Alden Estates Of Countryside, Inc

Based on observations, policy review, and interviews, the facility failed to ensure that staff performed hand hygiene before and after wearing gloves during blood glucose checks for five of five resident (Resident (R) 5, R6, R7, R8, and R9) observed during blood glucose checks. This failure had the potential to place residents at risk for the spread of infection and cross-contamination.Findings include: The following was observed during observation of blood sugar administration starting on 10/03/25 at 7:07 AM with Licensed Practical Nurse (LPN)1. LPN1 was observed performing hand hygiene at her cart. LPN1 picked up a previously cleaned glucometer from the cart, before going into R5's room. LPN1 entered R5's room, donned a pair of gloves, and performed a fingerstick glucose check on R5. LPN1 exited R5's room still wearing gloves and discarded her gloves and lancet at the medication cart on 10/03/25 at 7:10 AM. LPN1 performed hand hygiene.On 10/03/25 at 7:11 AM, LPN1 donned a pair of gloves without performing hand hygiene and cleaned the glucometer. LPN1 performed hand hygiene at the cart, picked up the previously cleaned and disinfected glucometer, a lancet, and a testing strip. and proceeded to R6's room.There was an Enhanced Precautions sign on R6's room and a supply cart at the door. The sign indicated gloves and gown were to be worn during high contact resident care activities. LPN1 donned a gown and gloves from the cart and entered R6's room. LPN1 accidentally dropped the lancet on the R6's floor. LPN1 took off gown and gloves and placed them on the supply cart outside the room. LPN1 returned to her cart to retrieve a fresh lancet and returned to R6's room. On 10/03/25 at 7:16 AM, LPN1 picked up a new gown and pair of gloves from the supply cart. No hand hygiene was performed before donning gloves. LPN1 picked up the glucometer and performed the blood glucose check. LPN1 took off her gown and gloves and added them to the ones already on the supply cart. LPN1 stated she needed to get a garbage bag to dispose of the gowns. When asked why she did not place them in the trash can in the resident's room, she had no response. LPN1 wheeled R6 back to the breakfast area and then performed hand hygiene at her medication cart on 10/03/25 at 7:19 AM. On 10/03/25 at 7:20 AM, LPN1 donned a pair of gloves and cleaned the glucometer, removed the gloves, and performed no hand hygiene. LPN1 documented on her computer, touched the keyboard and mouse, reached into her pocket for cart keys, opened cart, and retrieved a lancet and testing strip. LPN1 picked up the previously cleaned glucometer and went to R7's room. On 10/03/25 at 7:21 AM, LPN1 performed hand hygiene and donned gloves. LPN1 checked R7's blood sugar and removed her gloves. LPN1 did not perform hand hygiene before applying a fresh pair of gloves to apply a topical medication on R7. After applying the topical, LPN1 removed her gloves and performed hand hygiene. On 10/03/25 at 7:26 AM, LPN1 picked up the glucometer and returned it to her medication cart. LPN1 donned a pair of gloves, cleaned the glucometer, and took off the gloves. LPN1 did not perform hand hygiene and touched the cart, the computer, and mouse. LPN1 reached into her pocket for cart keys and retrieved a lancet and testing strip.On 10/03/25 at 7:28 AM, LPN1 picked up the clean glucometer and headed to R8's room. R8's room had an enhanced precaution sign on the door. LPN1 wore a gown and gloves from the supply cart outside the room, no hand hygiene, and entered R8's room. LPN1 performed blood sugar check on R8. On 10/03/25 at 7:31 AM, LPN1 discarded the gown and gloves in the trash. LPN1 held the glucometer in one hand and placed the other hand to collect some hand sanitizer from the wall dispenser in R8's room. LPN1 cupped the sanitizer in her hand but did not use it, until she stepped out of R8's room into the hallway and reached her mediation cart. LPN1 placed the glucometer on the cart and then brought her hand together to rub the sanitizer.On 10/03/25 at 7:32 AM, LPN1 donned a pair of gloves and proceeded to document on her computer with gloves on. When she finished documenting, LPN1 cleaned the glucometer. LPN1 doffed her gloves and did not perform hand hygiene.On 10/03/25 at 7:34 AM, LPN1 went to R9's room. LPN1 performed hand hygiene, performed the blood glucose check and discarded the gloves when done, without performing hand hygiene. LPN1 wheeled R9 back to the dining area.On 10/03/25 at 7:37 AM, LPN1 performed hand hygiene, wore a pair of gloves to clean the glucometer. LPN1 doffed her gloves and did not perform hand hygiene. She proceeded to document on the computer and put hands in her pocket.On 10/03/25 at 7:43 AM, LPN1 wheeled R10 back to the dining area. LPN1 donned a pair of gloves, performed no hand hygiene, and cleaned the glucometer. LPN1 doffed her gloves and did not perform hand hygiene.During an interview on 10/03/25 at 7:47 AM, the foregoing observations were discussed with LPN1. LPN1 acknowledged she had failed to perform hand hygiene before and after wearing gloves.During an interview on 10/03/25 at 1:40 PM, Infection Preventionist (IP) stated it was her expectation that staff perform hand hygiene before and after entering resident's rooms and before wearing gloves and after taking gloves off.Review of the policy titled Infection Prevention and Control Manual General Policies dated 2023 revealed:Cleaning and Disinfecting Blood Glucose Meters Policy:It is the policy of the facility to clean and disinfect multi-patient use blood glucose meters. Resident-to-resident transmission of blood-borne pathogens is a well-known risk when using lancets, needles, and syringes. Blood glucose monitors that are shared among residents must be cleaned and disinfected between each use.Procedure:1. Apply gloves before performing a blood glucose test. Glucose monitoring, administration of insulin, and any other procedure that involves potential exposure to blood or body fluids.2. Do not carry meter, supplies or medications in pockets.3. Unused supplies and medications taken to a patient's bedside during fingerstick monitoring or insulin administration should never be used on another resident .5. Remove gloves and perform hand hygiene.6. Apply new gloves.7. Thoroughly clean all visible soil or organic material (e.g., blood) from glucometer before disinfection.8. Perform hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other residents.9. Follow manufacturers' guidelines for cleaning and disinfecting glucose meters. Specific guidelines for glucose meters may vary with the manufacturer.10. In the absence of manufacturer's recommendations, the glucometer is considered a semi-critical device, follow policy for cleaning semi-critical devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents are free of any significant medication errors for 1 of 3 residents (R2) reviewed for medication errors.R2 was prescribed Levetiracetam (Keppra) (a medication used to treat seizures) for 7 days as a seizure prophylaxis. The facility failed to clarify, transcribe, and follow the physician order. R2 continued to receive the medication. This resulted in actual harm when R2 experienced a decline and was readmitted to the hospital, for Acute metabolic encephalopathy - Multifactorial at this point including continued use Keppra (serious condition characterized by diffuse brain dysfunction due to metabolic disturbances, often leading to confusion, memory loss or loss of consciousness; it's critical to identify and treat the underlying cause, it's often reversible with prompt treatment) requiring intravenous fluids, monitoring, and the discontinuation of the medication. The facility did not thoroughly investigate this medication error. This is evidenced by:Facility policy, titled Medication Errors, dated 09/2020, states in part, Policy: A medication error is defined as: any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional or resident. Such events may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling; packaging; compounding; dispensing; distribution; administration; education; monitoring, and use.On 11/25/25 at 11:13 AM, Surveyors interviewed DON B (Director of Nursing). DON B indicated the facility had no medication errors since 10/4/25.R2 admitted to the facility on [DATE] after being discharged from the hospital. R2 had been admitted to the hospital from [DATE] to 10/8/25 after falling at home and was diagnosed with a traumatic subdural and subarachnoid hemorrhage (bleeding between the brain's outermost covering and the brain and bleeding between the space between the brain and its second outermost layer) and diffuse traumatic brain injury with loss of consciousness status unknown (widespread brain injury). R2 also has diagnoses that include, in part: chronic kidney disease stage 3 (moderate kidney damage where the kidneys are not filtering blood as effectively as they should be), chronic combined systolic and diastolic heart failure (the heart's inability to pump blood and fill with blood properly), and dysphagia (difficulty swallowing). R2's admission Minimum Data Set (MDS) dated [DATE] indicates R2 has a Brief Interview for Mental Status (BIMS) of 10 out of 15, indicating he is moderately cognitively impaired.R2's facility progress note, dated 10/8/25 at 2:30 PM, states, Arrived to unit in w/c (wheelchair). Denies pain. Very hard of hearing even with hearing aids in. Pivot transfer with one assist.R2's hospital Discharge summary, dated [DATE], states in part, Hospital Course: (including consults and procedure details) .Keppra was initiated for 7 days for seizure prophylaxis per neurosurgical and neurology recommendations.Discharge Medications and Allergies.Start taking these medications.Levetiracetam (Keppra) 500 mg tablet - Disp (dispense)-2 tablet, R (refills)-0, Take 1 (one tablet by mouth 2 times daily, ePrescribe.R2's transfer orders for receiving facility, dated 10/8/25, states in part, Current Discharge Medication List.Start taking these medications.Levetiracetam 500 mg tablet, commonly known as Keppra, Quantity dispensed: 2 tablet / Instructions: Take 1 (one) tablet by mouth 2 times daily.R2's health facility transfer chart, dated 10/8/25, states in part, Assessment and Plan.Traumatic brain injury with intracranial hemorrhage (ICH): -Admit to ICU -CCM (chronic care management) consulted by ED (emergency department) MD (medical doctor) -Neurosurgery consulted, appreciate recs. (recommendations) -Keppra 500 mg BID (two times per day) for 7 days from injury for seizure ppx (prophylaxis). Hospital MAR (medication administration record): .Levetiracetam (Keppra) tablet 500 mg, Dose: 500 mg, Freq: 2 times daily, Route: PO (oral), Start: 10/04/25 1015, End: 10/10/25 0759.According to an article published by the University of Texas Health Science Center at Houston in 8/2005 and last reviewed 7/2024, titled, Post-Traumatic Seizure Prophylaxis in Patients with Traumatic Brain Injury Clinical Practice Guideline, post-traumatic seizures can occur following a traumatic brain injury (TBI) and levetiracetam is one of the top two commonly used anti-epileptic drugs for prophylaxis. The article states, Based on the American Academy of Neurology (AAN) and Brain Trauma Foundation (BTF) recommendations, using anti-seizure drugs during the first seven days after an injury has become the standard of care for PTS prophylaxis in severe TBI patients (https://med.[NAME].edu/surgery/post-traumatic-seizure-prophylaxis-in-patients-with-traumatic-brain-injury-clinical-practice-guideline/). According to the Epilepsy Foundation, Levetiracetam (Keppra) is a seizure medication. The website provides the following precautions and side effects, in part: How does the body digest Levetiracetam? .The body gets rid of the drug through the kidneys. This may affect how much levetiracetam a person with kidney problems takes and how often they take it. Who should not take Levetiracetam? . People with kidney disorders need to be extra careful, however. Levetiracetam may be given at a lower dose to prevent build up to a high level. What are the effects of Levetiracetam on Seniors? A very low dose of levetiracetam may need to be used when starting it in older adults. The dose of medicine would then be increased more slowly.Seniors may be more sensitive to the side effects of this medicine.What are the most common side effects of Levetiracetam? .Some side effects may include: dizziness, headache, irritability, loss of strength and energy, mood and behavior changes, sleepiness. (https://www.epilepsy.com/tools-resources/seizure-medication-list/levetiracetam). R2's October 2025 MAR included the following order: Levetiracetam oral tablet 500 mg - Give 1 tablet by mouth two times a day for 1 week. Order date: 10/08/25. R2 received the levetiracetam at 8:00 AM and 5:00 PM from 10/08/25 to 10/22/25. Note: On 10/08/25, R2 only received the 5:00 PM dose and on 10/22/25, R2 only received the 8:00 AM dose. R2's Nurse Practitioner (NP) Note, dated 10/17/25, includes the following, in part: (NP D) Neurological history with traumatic brain injury and subdural hemorrhage. Patient is receiving physical, occupational, and speech therapy to support functional recovery and is on Keppra for seizure prevention. Daughter was concerned the Keppra was causing patient to be lethargic and not want to participate in therapy, etc., wanted the dose lowered. Spoke with daughter and explained this is a common side effect but typically goes away over time. Daughter verbalized understanding. Continue Keppra at current dose.R2s Progress Notes, dated 10/22/25 at 11:00 AM, include in part:DON B: Late Entry - Note Text: Writer and social services met with family, family inquiring about keppra and if medication could be contributing to residents [sic] decreased appetite, decline in mobility and flat affect. Writer spoke with NP (Nurse Practitioner). Received new orders to taper Keppra to 500 mg daily x 7 days then discontinue. Writer confirmed with medical records that CT (computerized tomography) and neurology follow up is in the process of being scheduled. Writer updated POA (power of attorney) and daughter. Family in agreement with plan. On 11/25/25 at 4:05 PM, Surveyors interviewed NP D via telephone about R2's Keppra order. NP D indicated a brief review of the discharge summary is completed for new patients. NP D indicated she did not recall reading anything about the Keppra order for R2 except the start and continue information. NP D indicated R2's family had noted a decline with R2 - specifically being more sleepy - and had brought it up. NP D indicated she was not familiar with the long-term effects of this medication, but had looked it up and told the family it was a typical effect that usually subsides. NP D stated, I don't really mess with the Keppra, and had noted R2 had an upcoming neurology appointment and felt more comfortable letting neurology adjust the medication. R2's October 2025 MAR included the following order change: Levetiracetam oral tablet 500 mg - Give 1 tablet by mouth one time a day for 1 week. Order date: 10/22/25 / Discontinue Date: 10/27/25. R2 received the levetiracetam at 8:00 AM on 10/23/25 and 10/24/25.R2s Progress Notes, dated 10/24/25, include in part: -1:25 PM - Interdisciplinary Team Note: Note Text: Resident has triggered for a weight loss of 5.4 percent in 3 weeks since admissions. Residents [sic] PO intake is poor with less then 25 percent. Resident has supplements in place. Resident is more lethargic during daytime. Labs ordered and waiting results and plan of DON to consult with NP and family regarding plan of care.-3:21 PM - Nurse's Note: Note Text: Family at resident's bedside and had concerns r/t (related to) decreased LOC (level of consciousness) and audible lung sounds. Family called 911 to take resident to hospital. EMS (emergency medical services) took resident around 1515 (3:15 PM).-9:13 PM - NP D Progress Note - Note Text: Service Date: 10/23/25. Current Level of Function: PT (Physical Therapy) 10/23. Therapist participated in care conference with pt (patient) family and facility staff with pt not present per family request. Pt is incapacitated and has a recent medical decline.Staff reporting increased difficulty with transfers. Pt has demonstrated a decline in mobility. Pt instructed in use of EZ stand. Pt completed x 3 stands with pt unable to maintain standing position. After 10 seconds demonstrates hanging in machine. Pt notes 'no I can't' when cued to stand erect. Pt downgraded to a hoyer for transfers with caregiver training completed.(of note: R2 has had a decline from being able Pivot transfer with one assist to now needing to be transferred with a Hoyer (full body lift) and experience weight loss in approximately 2 weeks.)R2's Progress Notes, dated 10/31/25 at 2:23 PM, indicate R2 was readmitted to the facility. R2's hospital discharge documentation, dated 10/31/25, indicates R2 was admitted to the hospital from [DATE] to 10/31/25. Final diagnoses for his hospital stay include, in part: acute metabolic encephalopathy, aspiration pneumonia, and AKI (acute kidney injury). R2's treatment included, in part, being started on IV fluids and discontinuing Keppra. The documentation includes the following hospitalist notes, in part:-10/24/25 at 6:49 PM: Assessment/Plan: 1. Acute metabolic encephalopathy - Multifactorial at this point including continued use Keppra, UTI and probably pneumonia. Manage underlying problems. Supportive care.-10/27/25 at 2:28 PM: Subjective: .On admission Keppra was not continued. Assessment/Plan: 1. Acute metabolic encephalopathy: Resolving, has been hydrated, has been taken off chronic diuretic and for now Entresto (chronic heart failure medication) is on hold, Creatinine (level to measure how well the kidneys are filtering waste) has normalized from 2.6 down to 1.1.(Of note: The reference range for creatinine is 0.6-1.30 mg/dL in the hospital discharge paperwork. A number above 1.3 indicates the kidneys may not be filtering waste efficiently.)-10/29/25 at 12:18 PM: Subjective - [R2].was at [hospital] between October 2 to October 8, was started on Keppra to avoid posttraumatic seizures which was planned for 7 days total, but was continued at [nursing home facility] longer.On 11/25/25 at 1:53 PM, Surveyor interviewed PT H (Physical Therapist). PT H indicated she had worked with R2 from his admission to the facility on [DATE] to his hospital stay on 10/24/25. PT H indicated R2 had started making progress, plateaued, then declined.On 11/25/25 at 1:55 PM, Surveyor interviewed PT Supervisor E. PT Supervisor E reviewed R2's PT and OT (occupational therapy) notes from 10/08/25 to 10/23/25. The notes indicated the following, in part: -10/9/25 (PT): Ambulated 10 feet with therapist and walker with moderate assistance-10/13/25, 10/14/25 (PT): Worked on transfer training with minimal to moderate assistance-10/15/25 (OT): Hand strength near normal range, (PT): Ambulated 20 feet-10/20/25 (PT): Ambulated 10 feet-10/21/25 (OT): Not feeling good, declined therapy. Reported to nursing.-10/23/25 (PT): Unable to stand for required amount of time (1-3 minutes) for EZ stand for transfers, so was downgraded to a Hoyer lift. PT Supervisor H indicated R2 participated on and off in therapy during this time, and there was no noticeable decline until 10/23/25. PT Supervisor H reviewed PT notes from 10/31/25 to 11/14/25, when R2 was readmitted to the facility following his hospital stay. PT Supervisor H indicated R2 was very willing to participate in PT upon his return to the facility. Notes indicate the following, in part:-11/05/25 (PT): Able to stand on own-11/06/25 (PT): Walked 22 feet with minimal assistance On 11/25/25 at 2:15 PM, Surveyor interviewed CNA F (Certified Nursing Assistant). CNA F worked with R2 while he was at the facility. CNA F indicated R2 was up and down with being willing to participate in ADLs (activities of daily living) before he was admitted to the hospital on [DATE]. CNA F indicated R2 had more weakness, needed more help with transfers, and his appetite declined before being admitted to the hospital on [DATE]. When R2 returned to the facility on [DATE], CNA F indicated he was back to his normal self. He was more willing to get up and his appetite was good - he wanted to eat again.On 11/25/25 at 2:20 PM, Surveyor interviewed CNA G. CNA G worked with R2 while he was at the facility. CNA G indicated R2 displayed progressive weakness and a decreased appetite before he was admitted to the hospital on [DATE]. When R2 returned from the hospital on [DATE], CNA G indicated he was like a different person. He had a happier personality, was more talkative, and his appetite increased.Surveyor reviewed R2's power of attorney form and noted it was activated on 10/16/25 and inactivated on 11/11/25.On 11/25/25 at 2:43 PM, Surveyors interviewed DON B and RNC C (Corporate RN) regarding how medication orders are entered for new admissions to the facility. DON B indicated a nurse receives a resident's discharge summary and orders, calls a physician to verify the orders, then enters the orders into the facility's system. RNC C indicated the discharge medication list is verified by a nurse with a physician or NP, then the nurse is given the okay to process the orders. DON B indicated a second or third nurse then checks the order to verify it is correct. The order is initially pended and then must be confirmed by a second person. This may also be done by a remote nurse who audits medication orders. DON B indicated floor nurses, nurse leadership, the MDS coordinator, and interdisciplinary teams looks over the hospital discharge paperwork. Surveyors asked DON B and RNC C about R2's Keppra orders and pointed out the discharge paperwork indicated only two tablets should be dispensed. DON B indicated the dispense amount indicates how many tablets are in the current prescription and does not affect medications going forward. (Of note: The order had indicated 0 refills for the prescription.) Surveyors asked DON B and RNC C about the discrepancy on the hospital transfer discharge summary report that indicated the end date for the Keppra prescription was 10/10/25. RNC C indicated this information cannot be used for facility orders, as it is a hospital MAR. Surveyors asked if the end date of 10/10 would warrant further clarification. RNC C answered yes. Surveyors asked if a dispense amount of two tablets would prompt the facility to call the hospital to clarify the order. RNC C indicated this issue could be seen from two angles - someone should have called to clarify the order, but the hospital discharge paperwork should also indicate exactly what should happen with medications. There had been no end date listed for the Keppra order. Surveyors pointed out the discharge summary mentioned the Keppra was only for a 7-day time span multiple times. RNC C indicated the facility should not have to scan through the H&P (history and physical) notes and summary to obtain this information. DON B indicated NP D had tapered the dose and decided to continue it until R2's neurology review date. DON B was unsure when the neurology review date was scheduled for. Surveyors asked if the neurologist was ever consulted if NP D wasn't comfortable with stopping the medication without tapering it. RNC C indicated they could not speak to that and said the neurologist did not order the Keppra to begin with. (Of note: The hospital discharge summary indicated neurology had been consulted and had given recommendations.)RNC C indicated the facility had investigated the discrepancy with the hospital orders and the facility orders when it was brought to their attention. They were unable to provide documentation of the investigation.R2 was prescribed Levetiracetam (Keppra; a medication used to treat seizures) for 7 days as a seizure prophylaxis. The facility failed to clarify, transcribe, and follow the physician order. R2 continued to receive the medication. This resulted in actual harm when R2 experienced a decline and was readmitted to the hospital, for Acute metabolic encephalopathy - Multifactorial at this point including continued use Keppra requiring intravenous fluids, monitoring, and the discontinuation of the medication. The facility did not thoroughly investigate this significant medication error.

Based on observation, interview, and record review, the facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect 111 of 111 residents dining in the facility.
Staff did not wear beard restraints consistently in the kitchen.
Findings include:
The facility policy and procedure titled, Hair Covering dated 5/24, states in part:
Policy
Hair will be covered when in the kitchen operations areas.
Purpose
To prevent physical contamination of food
Procedure
1. While in the kitchen operations area staff will cover hair to prevent physical contamination of food .
3. Staff with facial hair, with the exception of eyebrow and eyelashes, will wear a beard cover. Mustache or beard restraints shall be used for any facial hair exceeding half (1/2) inch in length.
On 06/09/25, at 10:30 AM, Surveyor observed Dietary Director-C preparing rue with beard net not pulled up over mustache.
On 06/09/25, at 10:36 AM, Surveyor observed Dietary Director-C stirring pots on stove with beard net not pulled up over mustache.
On 06/09/25, at 10:48 AM, Surveyor observed Cook-W enter kitchen and start prepping food without donning a beard net.
On 06/10/25, at 10:46 AM, Surveyor observed Cook-W prepping food with no beard net.
On 06/10/25, at 10:51 AM, Surveyor interviewed Dietary Director-C regarding expectations for facial hair coverings. Surveyor relayed concern to Dietary Director-C of two observations of no beard net on Cook-W. Also, observations of Dietary Director-C with mustache exposed.
On 06/10/25, at 03:13 PM, during the end of day meeting, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that observations were made during food preparations of beards and mustaches not covered.
On 06/11/25, at 11:47 AM, NHA-A asked Surveyor to swap out the policy for hair covering that had been given previously, stating that a newer version was found. The new policy states mustache or beard restraints shall be used for any facial hair exceeding half (1/2) inch in length.
Surveyor noted that the first policy given stated mustache or beard restraints shall be worn, without a length specified.
On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor discussed with NHA-A and DON-B that the State of Wisconsin regulation is 1/2 inch, but the federal regulation is that no facial hair can be exposed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect all 111 residents residing in the facility.
Staffing information for Quarter 2 ([DATE] - [DATE]) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.
Findings include:
The CMS Electronic Staffing Data Submission Payroll-Based Journal, Long-term Care Facility Policy Manual, dated [DATE], indicates: Chapter 1: Overview, 1.1 introduction .(U) mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS .1.2 Submission Timelines and Accuracy. Direct care staffing and census data will be collected quarterly and is required to be timely and accurate .Report Quarter: staffing and census data will be collected for each fiscal quarter. Staffing data includes the number of hours paid to work by each staff member each day within a quarter. Census data includes the facility's census on the last day of each of the three months in a quarter. The fiscal quarters are as follows: Fiscal Quarter, Date range: (quarter) 1 [DATE]-[DATE], (quarter) 2 [DATE]-[DATE], (quarter) 3 [DATE]-[DATE], (quarter) 4 [DATE]-[DATE] .
Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2025 (run on [DATE]) which indicated the Facility had excessively low weekend staffing and a one star staffing rating for the 2nd Quarter ([DATE]-[DATE]).
Surveyor reviewed the Facility's weekend schedules from [DATE] to [DATE]. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules included call ins, agency staff and staff who picked up shifts. Surveyor noted there did not appear to be excessive call-ins.
On [DATE], at 10:47 AM, Surveyor interviewed Scheduler-X regarding staffing. Per Scheduler-X the lowest number staffed, per 24-hour period, is 20 aides and 12 nurses scheduled. The goal for a 24-hour period is 27 aides and 14 nurses/medication technicians.
Surveyor reviewed the Facility Assessment and noted for Licensed Nurses/Medication Aides the minimum is 11 and Certified Nursing Assistants the minimum is 20 per 24-hour period, this was compared to the provided schedules. No discrepancies were found.
On [DATE], at 12:16 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding how the facility functions when at the minimums for nursing staff per the Facility Assessment. Per NHA-A ideally, they would like more staff than those minimums, but you cannot account for call ins. The numbers in the Facility Assessment are the absolute minimum to run the facility. Surveyor stated that the facility triggered for one star staffing and low weekend staffing, was there an issue with how the data was reported to CMS. NHA-A stated they were confused because don't get much info from CMS, NHA-A got a report from CMS and quickly went through it. NHA-A thought there was a reporting error, then went back through and then figured out it was ancillary staff. Surveyor asked if it was the ancillary staff then why not trigger every quarter and NHA-A didn't know. Corporate sends information from payroll department and agency hours pull in as well, all hours get sent. NHA-A then stated that there was one error with reporting. A Licensed Practical Nurse graduated in December and got licensed in December or early January. The nurse was still being reported as an aide. This was just changed a couple weeks ago so will be fixed for second quarter.
On [DATE], at 01:47 PM, Surveyor interviewed Scheduler-X regarding each unit having multiple residents that use the mechanical lift. If a NOC shift person calls in, then the remaining aides split a unit. Surveyor asked how the unit is covered. Per Scheduler-X the nurse oversees the unit, and the remaining two aides watch the call lights and switch off on answering. All residents still get the regular two-hour rounds. Surveyor asked if residents were safe with staffing at the minimum numbers. Scheduler-X replied that residents aren't not (sic) being attended to, they aren't not (sic) getting care. Per Scheduler-X some staff will come in early to help when there are call ins. Surveyor asked if Scheduler-X had access to call light logs and was told no. Surveyor stated there are 35 residents who have elected full code, how can two nurses on NOC handle that. Scheduler-X stated that there are two full time night shift aides that took the cardiopulmonary resuscitation (CPR) class. The Medication Technicians have taken CPR class as well.
On [DATE], at 02:14 PM, Surveyor spoke with NHA-A regarding the data regarding staffing not being accurately submitted. No additional information was provided.
On [DATE], at 07:25 AM, Per NHA-A they spoke with corporate, and the payroll system being used was changed to a new vendor. The reporting was supposed to be fixed for 1st quarter, but it was not. NHA-A stated this has been taken care of.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (R32, R74) of 6 residents observed.
*R32 was readmitted to facility on 5/13/25 with a hospital acquired stage 3 pressure injury. R32 was placed on Enhanced barrier precautions (EBP) on 5/13/25. Surveyor observed on 6/9/25 R32 had no indication that R32 was on EBP. Care Plan documents R32 continued EBP until 6/12/25 when the facility discontinued EBP for a stage 3 pressure ulcer not yet healed. Surveyor observed R32's wound care on the stage 3 coccyx pressure ulcer on 6/11/25 with nurse not following EBP during R32's treatment.
*R74 was observed by Surveyor on 6/9/25 [NAME] with drainage on R74's bandaged leg wounds and not in Enhanced Barrier Precautions (EBP) until 6/10/25. R74's care plan has no documentation of R74 being on EBP for R74's 4/25/25 hospital readmission to the facility with a hospital acquired stage 3 coccyx pressure injury.
Findings include:
Facility policy titled ENHANCED BARRIER PRECAUTIONS dated 12/24
POLICY:
Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device.
GUIDELINES:
1. EBP involves gown and gloves use during high-contact resident care activities for residents known to be infected or colonized with MDROs when contact precautions do not otherwise apply. As well as residents with a chronic wound and/or indwelling medical device.
2. The facility will use a risk-based approach (critical thinking} to determine which type of precautions, if any, are warranted. After completing the risk based assessment (critical thinking) the facility will determine if residents with more common MDROs (MRSA, VRE, and ESBL-producing Enterobacterales) need EBP.
3. A subset of targeted MDROs is considered an extensively drug resistant organism (XDRO). ALL those infected or colonized with an XDRO will require EBP for the duration of their stay at the facility, unless contact precautions are warranted.
a. Candida auris (CA).
b. Carbapenemase-producing Enterobacteriaceae (CRE).
c. Carbapenemase-producing Acinetobacter baumannii (CRAB).
d. Carbapenemase-producing Pseudomonas aeruginosa (CRPA).
PROCEDURE:
1. High-Contact Resident Care Activities include the following:
a. Dressing.
b. Bathing/Showering.
c. Transferring.
d. Changing linens.
e. Providing hygiene.
f. Changing briefs or assisting with toileting.
g. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.
h. Wound care.
2. Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP.
a. Some examples may include central vascular line (including hemodialysis catheter), urinary catheter, feeding tube, tracheostomy, and ventilator (excludes peripheral IVs).
b. Devices that are fully embedded within the body (e.g., pacemakers) would not be an indication for ESP.
c. Other devices such as a colostomy, ileostomy, or a Jackson Pratt (JP) drain would not require EBP.
3. Residents that have a wound requiring a dressing, regardless of [NAME] status, will require ESP.
a. Types of wounds where ESP would be indicated include, but are not limited to: pressure ulcers, diabetic foot ulcers, arterial, chronic wounds (e.g., wound vacs) a wound that is not well-approximated (not healing as intended) and chronic venous stasis ulcers.
b. Fresh/healing surgical wounds is not an indication for EBP.
c. Residents with draining wounds that cannot be contained (e.g., residents who cannot maintain adequate hygiene), or the resident has an infection or condition listed in CDC's (Centers for Disease Control) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007).
d. Post the CDC EBP sign outside of the resident's room.
e. Gown and gloves use prior to the high-contact care activity (change PPE before caring for another resident).
f. Eye protection may be needed if performing activity with risk of splash or spray (e.g., wound irrigation).
4. Make PPE available and accessible outside of the resident's room (each room does not need their own set-up).
5. Ensure that alcohol-based hand rub is accessible for hand hygiene as needed.
6. Provide a trash receptacle at the exit of the resident's room for discarding PPE after removal and before exiting the room, or before providing care to another resident in the same room.
7. When entering the resident's room for reasons other than to provide high contact resident care activities, use of gown and gloves are not required. Instead, perform hand hygiene prior to entering and exiting the room.
8. Residents are not restricted to their rooms or from group activities when EBP is in place.
9. EBP does not replace existing guidance for the use of contact precautions for other pathogens. Contact precautions still need to be used for infected or colonized residents in certain situations, including but not limited to, C. difficile, norovirus, scabies, shingles (until the lesions are dry), etc.
10. EBP can be discontinued when chronic wounds heal or indwelling medical devices are removed.
Memorandum QSO-24-08-NH on 3/20/24 from the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group documents:
Subject: Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs).
EBP are indicated for residents with any of the following:
o Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply; or
o Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO.
Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid®) or similar dressing. Examples of
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chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers.
Document/Room Signage titled, (STOP) Enhanced Barrier Precautions documents:
Everyone Must:
Clean their hands, including before entering and when leaving the room.
Providers and Staff Must Also:
Wear gloves and a gown for the following activities.
Dressing, Bathing/Showering, Transferring, Changing Linens, providing hygiene, changing briefs or assisting with toileting.
Device care or use: central line, urinary catheter. Feeding tube, tracheostomy.
Wound Care: any skin opening requiring a dressing.
Do not wear the same gown and gloves for the care of more than one person.
1.) R32 was initially admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive pulmonary Disease (lung disease that stops air flow), Congestive Heart Failure (Chronic condition causing heart to not pump blood efficiently), Polyneuropathy (central nervous system disorder causing numbness, weakness, pain primarily in distal parts of the arms and legs).
R32's significant change in condition Minimum Daily Set (MDS) with an assessment reference date of 3/24/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 15 indicating R74 has intact cognition. Under section M Skin Conditions documents R74 as having 0 pressure injuries.
R32's (name of a wound physician group) wound consultation completed 5/13/25, the day of R32's readmission from hospital, documents
R32's stage 3 coccyx wound:
Wound Size (L x W x D): 3 x 1 x 0.2 cm
Surface Area: 3.00 cm²
Exudate: Moderate Sero - sanguineous
R32's (name of a wound physician group) wound consultation day of R32's readmission from hospital dated 6/03/25 documents
R32's stage 3 coccyx wound:
Wound Size (L x W x D): 2 x 0.7 x 0.1 cm
Surface Area: 1.40 cm²
Exudate: Light Sero - sanguineous
Granulation tissue: 100 %
Wound progress: Improved evidenced by decreased surface area
R32's Nursing Note dated 5/13/25, at 08:19 AM, documents Late Entry:
Day of Antibiotic Therapy: DAY 1. What day if beyond 14: Temperature: T 98.8 - 5/13/2025 04:43 Route: Forehead (non-contact) What antibiotic being used for: Other. Other Type: Sepsis
Antibiotic & Delivery Method: Ertapenem Sodium 1 GM IV via midline x 2 days
Reaction to Medication: NO Sign and Symptoms of Infection: NO Signs or Symptoms of infection
Exhabiting {SIC} the following signs & symptoms: Precautions: Contact
Summary (if applicable): Enhanced Barrier Precautions r/t (related to) midline and wound
R32's Alteration in Skin integrity care plan documents: Pressure ulcer(s) on coccyx present on admission date initiated 05/13/25. Intervention section documents: Enhanced Barrier Precautions will be implemented during high contact resident care activities for chronic wounds including, but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis
Ulcers Date Initiated: 05/13/2025 Resolved Date: 06/12/2025.
R32's physician's order dated 05/13/25 at 09:33 AM and discontinued 6/3/25 at 01:13 PM, documents: Maxorb II 2 X 2, Apply to coccyx topically every day shift, every Tue, Thu, Sat for Skin Condition
CLEANSE AREA W/NS, AND APPLY medihoney, f/b alginate and a foam border.
R32's physicians order dated 6/3/25, at 01:12 documents: Zinc Oxide Ointment 20 % Apply to coccyx topically every shift for Skin Condition.
On 6/9/25, at 0936 AM, Surveyor interviewed R32. Surveyor asked R32 if R32 had any concerns. R32 informed Surveyor that R32 has a big sore on R32's bottom. Surveyor asked R32 how R32 developed that sore on her bottom. R32 informed Surveyor R32 had a stay in the hospital and that R32 went for my heart a couple months ago. Surveyor asked R32 if R32 ever had people care for R32 in the last month wearing gowns, masks and gloves and a little cart outside of the room or heard the word precautions or isolation. R32 informed Surveyor that R32 did not recall that happening.
On 06/10/25, at 12:44 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-M R32 was placed into placed into EBP after R32's readmission in mid-May 2025. LPM-M informed Surveyor that LPN-M could not recall if R32 was in EBP since May 2025. Surveyor asked LPN-M if LPN-M could find out if R32 was placed in EBP. LPN-M informed Surveyor that LPN-M would find out for the Surveyor.
On 06/10/25, at 12:55 PM, Surveyor was approached by LPN-M. LPN-M informed Surveyor that LPN-M spoke to Director of Nursing DON-B and DON-B informed LPN-M that the infection control-Assistant Director of Nursing (ADON)-D makes the decision which residents go into EBP.
On 06/10/25, at 01:17 PM, Surveyor interviewed ADON-D about the facilities enhanced barrier precaution procedures. Surveyor asked ADON-D why if R32 placed into EBP after R32's readmission from the hospital. ADON-D informed Surveyor the ADON-D could not recall off hand if R32 was placed in EBP, but could check with DON-B. ADON-D informed Surveyor we have no wound nurse currently, so DON-B is the acting wound nurse, and she sees residents on wound rounds with the wound doctor weekly. Surveyor asked ADON-D when ADON-D should place a resident in EBP. ADON-B informed Surveyor any chronic wounds, wounds needing dressings to contain drainage, Foley catheters, Multi Drug Resistant Organisms) MDRO's, PICC (long term intravenous) lines, tube feeding, pressure ulcers, and diabetic ulcers. Surveyor asked ADON-D if all stage 3 pressures ulcers would be placed into EBP. ADON-D informed Surveyor that stage 3 pressure ulcers would be placed into EBP. Surveyor asked ADON-D if a resident still some drainage from a wound had (Surveyor noted the wound note for R32's stage 3 coccyx documented on 6/3/25 light serosanguineous drainage), and especially if it was a stage 3 pressure ulcer would the resident typically be in EBP. ADON-D informed Surveyor stage 3 pressure ulcers are typically placed in EBP.
On 06/11/25, at 07:19 AM, interviewed Occupational Therapist (OT)-J about R32's therapy. Surveyor noticed therapies went into R32's room. Surveyor asked OT-J if OT-J remembered any EBP that R32 was may have been in recently when therapy worked with R32. OT-J informed Surveyor that OT-J couldn't recall if R32 was in EBP or not.
On 06/11/25, at 09:21 AM, Surveyor interviewed R32 about R32's pressure injury of the coccyx. R32 informed Surveyor that R32's bottom getting better and that the cushion in R32's chair helped with R32's comfort.
On 06/11/25, at 01:52 PM, Surveyor observed Therapy working with R32 with no personal protection equipment.
On 06/11/25, at 01:59 PM, Surveyor observed R32's wound care with DON-B. DON-B informed Surveyor that the wound has epithelial tissue closing around wound and R32's wound was getting close to being closed. Surveyor observed good hand hygiene with gloves with no other enhanced barrier precautions (EBP) being followed. Surveyor noted R32's care plan documents R32 is still in EBP. Surveyor noted small area in middle of R32's stage 3 pressure area is still open and R32 was wearing a disposable brief.
On 06/11/25, at 02:11 PM, Surveyor interviewed DON-B following R32's treatment by DON-B. Surveyor asked DON-B if DON-B found the information Surveyor requested on basing pressure ulcers as chronic wounds must be over 30 days and if pressure ulcers had to have a traditional dressing. DON-B informed Surveyor that DON-B and corporate are still looking for that information. DON-B informed Surveyor that R32's wound was not draining and that it had no dressing so R32 should not be in EBP any longer. Surveyor asked DON-B while R32's wound is almost closed it is not completely closed and DON-B could not provide when R32's EBP ended. Surveyor informed DON-B that as of today R32's care plan indicates that R32 is still in Enhanced barrier precautions. DON-B replied to Surveyor oh.
On 06/11/25, at 09:57 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B Surveyor asked DON-B you would agree with the ADON-D that stage 3 pressure ulcers should be in EBP. Surveyor asked DON-B why R32 did not have an EBP sign and cart outside R32's room when R32 was in EBP and had a stage 3 pressure ulcer. DON-B informed Surveyor that yes stage 3 pressure wounds should be in EBP, but that any wound that no longer needing a dressing did not require EBP and that DON-B was checking with corporate for the information to verify that.
2.) R74 was initially admitted to the facility on [DATE] with diagnosis that included Chronic Obstructive pulmonary Disease, Type 2 Diabetes Mellitus, and Congestive Heart Failure.
R74's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 4/29/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 15 indicating R74 has intact cognition. Under section M Skin Conditions documents R74 as being readmitted on [DATE] with a stage 3 pressure ulcer.
R74's (name of a wound physician group) wound consultation dated 4/29/25 documents
R74's stage 3 coccyx wound:
Wound Size (L x W x D): 1.5 x 1 x 0.2 cm
Surface Area: 1.50 cm²
Exudate: Moderate Sero - sanguineous
Slough: 20%
Granulation tissue: 80%
R74's (name of a wound physician group) wound consultation dated 6/3/25 documents
R74's stage 3 coccyx wound:
Wound Size (L x W x D): 0.3 x 0.3 x 0.1 cm
Surface Area: 0.09 cm²
Exudate: Light Sero - sanguineous
Granulation tissue: 100%
Wound progress: Improved evidenced by decreased depth, decreased necrotic tissue, decreased surface area
R74's nursing noted dated 6/4/25, at 06:12 PM, documents, Day of Antibiotic Therapy: DAY 5
What day if beyond 14: Temperature: T 98.2 - 6/4/2025 09:32 Route: Tympanic
What antibiotic being used for: Cellulitis Other Type: Antibiotic & Delivery Method: Cephalexin Tablet 500 MG q (every) 12 hrs (hours) x (for) 7 days Reaction to Medication: NO Sign and Symptoms of Infection: Signs and Symptoms of infection are present (Describe below)
Exhibiting the following signs & symptoms: skin is red, warm, swollen, and draining
Precautions: Not Applicable
Summary (if applicable):
R74's physician's order dated 04/30/25, at 10:53 PM, discontinued on 06/03/25 at 08:36 PM documents: Maxorb II 2 X 2, Apply to left buttock/coccyx topically every day shift for Skin Condition
CLEANSE AREA W/NS (with normal saline) apply Maxorb and foam border,
R74's physician's order dated 06/02/25, at 02:25 PM, discontinued on 06/04/25 at 02:23 PM, documents: Clean & dry BLE (bilateral lower extremities). Apply ABD (abdominal) pads to weeping areas & cover with Kerlix & tubigrips. every day shift for SKIN CARE.
R74's physician's order dated 06/08/25, at 02:05 PM, discontinued on 06/15/25 at 03:53 PM, documents: Vaseline Petrolatum Gauze External Pad (Wound Dressings) Apply to BLE topically every morning and at bedtime for Wound Therapy
On 6/9/25, at 10:45 Surveyor interviewed R74. Surveyor asked R74 how R74 was doing today. R74 informed Surveyor that R74 was doing fair. Surveyor asked R74 if people ever had taken care of R74 with gowns and a cart outside of R74's for R74's wound on their bottom or leg. R74 informed Surveyor that R74 thought that when R74 was sick a while back but doesn't remember. (Surveyor did note in the medical record that R74 was in contact and droplet precautions when R74 returned from hospital on 4/25/25 and removed from precautions on R74's care plan on 4/28/25 for Metapneumovirus).
CNA-MM entered R74's room during the interview. Surveyor asked CNA-MM if R74 was ever in EBP or is in EBP. CNA-MM informed Surveyor that CNA-MM did believe that R74 was on precautions recently.
On 6/10/25 Surveyor noted R74 was placed in EBP.
On 06/10/25, at 12:44 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-M on why R74 was placed into EBP today, 6/10/25. LPN-M informed Surveyor LPN-M's guess was that Director of Nursing (DON)-B placed R74 in Enhanced Barrier precautions because of R74's bilateral wounds to R74's lower legs but was not sure. LPN-M shared they would find out for the Surveyor. Surveyor asked LPN-M if LPN-M recalls if R74 was in EBP after R74's return from the hospital in late April 25 or Early May 25. LPN-M informed Surveyor that LPN-M did not recall if R74 was in EBP prior to 6/10/25.
On 06/10/25, at 12:55 PM, Surveyor was approached by LPN-M. LPN-M informed Surveyor that LPN-M spoke to Director of Nursing DON-B and DON-B informed LPN-M that the infection control-Assistant Director of Nursing (ADON)-D makes the decision which residents go into EBP.
On 06/10/25, at 01:45 PM, Surveyor observed CNA-Q discussing with another CNA outside of R74's door that CNA-Q wasn't aware of why EBP was started on 6/10/25 for R74.
On 06/10/25, at 01:17 PM, Surveyor interviewed ADON-D about the facility's enhanced barrier precaution procedures. Surveyor asked ADON-D why was R74 placed into EBP. ADON-D informed Surveyor R74 had closed, acute wounds that are now chronic and weeping. ADON-D informed Surveyor that DON-B noted during wound rounds this morning with the wound doctor that R74's legs were weeping and draining. Surveyor asked ADON-D about nursing notes documenting R74 had drainage back on 6/4/25. ADON-D informed Surveyor we have no wound nurse currently, so DON-B is the acting wound nurse, and she sees residents on wound rounds with the wound doctor weekly. Surveyor asked ADON-D when ADON-D should place a resident in EBP. ADON-B informed Surveyor any chronic wounds, wounds needing dressings to contain drainage, Foley catheters, Multi Drug Resistant Organisms) MDRO's, PICC (long term intravenous) lines, tube feeding, pressure ulcers and diabetic ulcers. ADON-D informed Surveyor that residents with stage 3 pressure ulcers would be placed into EBP.
Surveyor asked if the wounds on R74's legs were chronic before today. ADON-D informed Surveyor ADON-D did not believe R74's legs were chronic. ADON-D informed Surveyor that with R74's lymphedema that it was unlikely they would heal quickly. Surveyor asked ADON-D if R74 was ever in EBP for R74's hospital acquired pressure injuries and when were those precautions removed. ADON-D informed Surveyor that ADON-D was not sure if R74's pressure injuries were chronic or if R74 was ever on EBP or if R74 was ever removed from EBP. Surveyor asked ADON-D if R74 had a stage 3 pressure injury. ADON-D informed Surveyor that R74 had a stage 3 pressure injury but it was resolved today 6/10/25. Surveyor asked ADON-D if a resident has some drainage from a wound and if it was a stage 3 pressure injury would the resident typically be in EBP. ADON-D informed Surveyor resident with stage 3 pressure injuries are typically placed in EBP. (Surveyor noted the wound note on 6/3/25 documents R74's stage 3 coccyx pressure injury had light drainage).
Surveyor asked ADON-D which staff can place a resident on EBP. ADON-D informed Surveyor that ADON-D will place a resident on EBP, but that the floor nurses can place a resident on EBP for the same reasons ADON-D gave Surveyor earlier.
On 06/11/25, at 09:57 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and DON-B concerning observing wound treatments for R74. Surveyor asked DON-B why R74 was not placed into EBP until 6/10/25. DON-B informed Surveyor that in DON-B's research a chronic wound is anything greater that 30 days. DON-B informed Surveyor R74 had started with leg wounds with fluid filled blisters but the leg wounds did not start draining until over the weekend of 6/7/25; and that is why we started EBP on 6/10/25. DON-B informed Surveyor R74's wounds were dry last week. Surveyor asked DON-B why the delay until 6/10/25 placing R74 on EBP when drainage started over the weekend. DON informed Surveyor DON-B did not see R74's wounds until 6/10/25 during wound rounds with the wound doctor. DON-B informed Surveyor R74 was on EBP for R74's stage 3 pressure injury but does not know when R74's EBP precautions came down because, no one informed DON-B that R74's EBP had been removed. DON-B Informed Surveyor that DON-B put R74 back on EBP on 6/10/25 after DON-B saw R74 on wound rounds and noted R74's leg drainage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents Pneumococcal immunizations were offered, or refused, as eligible. This was observed with 3 (R19, R109, and R163) of 5 residents whose immunization records were reviewed.
*R19, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records, then a verbal consent was obtained from R19's Power of Attorney (POA)
* R109, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records.
* R163, is [AGE] years old, admitted on [DATE] and did not have documentation of Pneumococcal vaccine being offered until 6/11/25, after Surveyor asked for records.
Findings include:
The facility's policy and procedure titled, Pneumococcal Vaccination, dated 01/2025 was reviewed. The policy documents in part:
Policy:
It is the policy of this facility that residents will be offered immunizations against pneumococcal disease in accordance with The Advisory Committee on Immunization Practices (ACIP) recommendations.
Procedure:
1. The pneumococcal vaccine as recommended by the CDC and ACIP varies by resident's age.
2. Vaccination Age Categories per Center for Disease Control (CDC):
a. age [AGE] years or older who have:
i. Not previously received a dose of PCV13 (Pneumococcal Conjugate Vaccine), PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 .
b. age [AGE]-64 years with certain underlying medical conditions or other risk factors who have:
i. Not previously received a PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 or 1 dose PCV20 .
3. If consented or declined, it will be documented in the residents' medical records. Historical information will be entered if available.
1.) R19 was admitted to the facility on [DATE] with pertinent diagnoses that include pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), lobar pneumonia (a type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung), acute and chronic respiratory failure with hypoxia (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and chronic systolic (congestive) heart failure (occurs when the left ventricle can't pump blood efficiently).
R19's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/21/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating that R19 is cognitively intact.
R19 is over [AGE] year. There isn't documentation of any pneumococcal vaccinations being offered or refused upon admission to facility. The Wisconsin Immunization Registry (WIR) does not have any pneumococcal vaccine administration on record.
R19 would be eligible for the PCV15, or PCV20.
On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date.
On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R19 was not offered the pneumococcal vaccination until today, after evidence of the vaccination was requested.
Surveyor noted no further evidence of documentation of R19 being offered or refusing the pneumococcal vaccine upon admission to the facility was provided.
2.) R109 was admitted to the facility on [DATE] with pertinent diagnoses that include enterocolitis (an inflammation that occurs throughout your intestines), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).
R109's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/26/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R109 is cognitively intact.
R109 is over [AGE] year. There isn't documentation of any pneumococcal vaccinations being offered being offered or refused upon admission to facility. The Wisconsin Immunization Registry (WIR) does not have any pneumococcal vaccine administration on record.
R109 would be eligible for the PCV15, or PCV20.
On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date.
On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R109 was not offered the pneumococcal vaccination until today, after evidence of the vaccination was requested.
Surveyor noted no further evidence of documentation of R109 being offered or refusing the pneumococcal vaccine upon admission to the facility was provided.
3.) R163 was admitted to the facility on [DATE] with pertinent diagnoses that include cellulitis of right and left lower limb (a bacterial infection of the skin and underlying tissues, commonly caused by bacteria like streptococcus or staphylococcus), and sepsis (a life-threatening condition that arises when the body's response to an infection spirals out of control, damaging its own tissues and organs).
R163's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 6/3/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R163 is cognitively intact.
R163 is [AGE] years old. There is no documentation of any pneumococcal vaccinations being offered being offered or refused upon admission to facility. The Wisconsin Immunization Registry (WIR) does not have any pneumococcal vaccine administration on record.
R163 would be eligible for the PCV15, or PCV20 per PneumoRecs VaxAdvisor.
On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date.
On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R163 was not offered the pneumococcal vaccination until today, after evidence of the vaccination was requested.
Surveyor noted no further evidence of documentation of R163 being offered or refusing the pneumococcal vaccine upon admission to the facility was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 immunizations for 3 (R19, R109, and R163) of 5 residents reviewed for immunizations.
*R19's medical record does not contain any documentation as to whether R19 was offered, received, or declined the COVID-19 immunization.
* R109's medical record does not contain any documentation as to whether R109 was offered, received, or declined the COVID-19 immunization.
* R163's medical record does not contain any documentation as to whether R163 was offered, received, or declined the COVID-19 immunization.
Findings include:
The facility's policy and procedure titled, Covid-19 Vaccinations, dated 02/2025 was reviewed. The policy documents in part:
Policy:
When recommended vaccines are available, the facility will ensure COVID-19 vaccines are readily accessible to both residents and staff. COVID-19 vaccinations can be administered to residents and staff at the facility by a contractor provider, or the facility can assist staff in finding an offsite pharmacy provider. The facility will not cover any expenses related to vaccines.
General Guidelines
1. Information will be posted for families, visitors, residents and staff that encourages them to be vaccinated.
2. The facility will actively encourage all residents and healthcare personnel to receive COVID-19 vaccinations, particularly before the peak of fall respiratory season. All recommended doses will be offered in a timely manner to ensure protection during peak infection periods .
4. Before offering the COVID-19 vaccine, all staff members, residents or their representative will be provided with education regarding the benefits and risks and potential side effects associated with the vaccine .
6. The resident, resident representative, or staff member has the opportunity to accept or refuse a COVID-19 vaccine and change their decision .
Resident Documentation Guidelines
1. The residents medical record includes documentation that indicates, at a minimum the following:
a. That the resident or resident representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine; and
b. Each dose of COVID-19 vaccine administered to the resident; or
c. If the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal.
1.) R19 was admitted to the facility on [DATE] with pertinent diagnoses that include pulmonary embolism (occurs when a blood clot gets stuck in an artery in the lung, blocking blood flow to part of the lung), lobar pneumonia (a type of pneumonia characterized by the infection and inflammation of one or more lobes of the lung), acute and chronic respiratory failure with hypoxia (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and chronic systolic (congestive) heart failure (occurs when the left ventricle can't pump blood efficiently).
R19's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/21/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 14, indicating that R19 is cognitively intact.
Surveyor reviewed R19's electronic medical record and was unable to locate whether R19 was offered, received, or declined the COVID-19 immunizations.
On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date.
On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R19 was not offered the COVID-19 vaccination until today after evidence of the vaccination was requested.
Surveyor noted no further evidence of documentation of R19 being offered or refusing the COVID-19 vaccination at admission to the facility was provided.
2.) R109 was admitted to the facility on [DATE] with pertinent diagnoses that include enterocolitis (an inflammation that occurs throughout your intestines), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed) and heart failure (occurs when the heart muscle doesn't pump blood as well as it should).
R109's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 5/26/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R109 is cognitively intact.
Surveyor reviewed R109's electronic medical record and was unable to locate whether R109 was offered, received, or declined the COVID-19 immunizations.
On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date.
On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R109 was not offered the COVID-19 vaccination until today after evidence of the vaccination was requested.
Surveyor noted no further evidence of documentation of R109 being offered or refusing the COVID-19 vaccination at admission to the facility was provided.
3.) R163 was admitted to the facility on [DATE] with pertinent diagnoses that include cellulitis of right and left lower limb (a bacterial infection of the skin and underlying tissues, commonly caused by bacteria like streptococcus or staphylococcus), and sepsis (a life-threatening condition that arises when the body's response to an infection spirals out of control, damaging its own tissues and organs).
R163's Medicare 5 day Minimum Data Set (MDS) with an assessment reference date of 6/3/25, documents a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating that R163 is cognitively intact.
Surveyor reviewed R163's electronic medical record and was unable to locate whether R163 was offered, received, or declined the COVID-19 immunizations.
On 06/11/25, at 01:44 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D who stated they thought they didn't have to ask about vaccinations for short term residents. ADON-D got consents today. ADON-D wasn't aware about asking at admission. Facility just had a vaccination clinic in April, ADON-D is catching up now. ADON-D will be working with pharmacy for another clinic date.
On 06/11/25, at 03:33 PM, during the end of day meeting, Surveyor shared concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R163 was not offered the COVID-19 vaccination until today after evidence of the vaccination was requested.
Surveyor noted no further evidence of documentation of R163 being offered or refusing the COVID-19 vaccination at admission to the facility was provided.

Based on observation, interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 (R25) of 1 residents reviewed for a mechanically-altered diet.
R25 has a mechanical soft diet order, R25 was served a regular diet meal.
Findings include:
The Facility Policy titled Regular Ground/Mechanical Soft dated 7/2023, documents (in part):
Purpose
The regular mechanical soft diet is for adults who have difficulty chewing. This diet is similar to the regular diet with some modifications to hard to chew foods. This diet is not intended to be used for modifications required by the National Dysphagia Diets.
Rationale
Foods that are difficult to chew are replaced with foods that have been altered into a form that can be easily swallowed. Food that may be modified because they are tough and difficult to chew include meats, poultry, fish, raw vegetables, and other fibrous foods .
According to Healthline.com A mechanical soft diet is a texture-modified diet that restricts foods that are difficult to chew or swallow. It's considered Level 2 of the National Dysphagia Diet in the United States. Foods can be pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew. It differs from a pureed diet, which includes foods that require no chewing.
Surveyor observed lunch being served in the 600 unit. Aide-V prepared one plate with food that was to be a mechanical soft consistency and serve the plate to a resident. Aide-V later plated a second mechanical soft meal, which the Dietary Director-C declined taking. The plate was set to the side.
The mechanical soft meal included minced ham, soft cooked broccoli, macaroni and cheese, and a dinner roll.
On 06/09/25, at 12:01 PM, Surveyor interviewed Aide-V and asked how many residents on the unit were prescribed a mechanical soft diet and was told two. Surveyor stated that only one was served, the other plate was set to the side. Aide-V walked over to the table where the two residents prescribed mechanical soft diets sat and removed the regular diet plate that was served incorrectly to R25.
R25's physician order with a start date of 1/14/25 documents Mechanical Soft texture, Thin Liquids consistency.
On 06/10/25, at 10:51 AM, Surveyor discussed the concern of the mechanical soft meal not being served to R25 with Dietary Director-C.
On 06/10/25, at 03:13 PM, during the end of day meeting, Surveyor informed Nursing Home Administrator-A and Director of Nursing-B of the concern that R25 had a regular diet meal served instead of a mechanical soft meal.
No further information was provided as to why the wrong diet was served to R25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not provide adaptive eating equipment to 1 (R95) of 1 sampled resident reviewed for assistive eating devices.
Surveyor observed R95 did not receive therapy recommended assistive eating devices needed to maintain or improve R95's ability to eat or drink independently during 2 out of 3 Surveyor observed meals.
Finding include:
Facility Clinical Practice Guidelines titled; Feeding a Resident dated 09/20.
Policy:
Residents who need assistance will be fed a well-balanced meal, by a nurse, C.N.A. (certified nursing assistant), or an individual who has completed a state approved feeding course
Procedure:
3. Check the tray before serving the meal to make sure everything is on the tray and it is accordance with the resident's diet. Correct anything wrong
9. Use appropriate utensil and adaptive equipment to feed the resident
R95 was initially admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and judgment), Vitamin D deficiency (nutritional deficiency of vitamin D), and Deficiency of other specified group B vitamins (nutritional deficiency of B vitamins).
R95's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 3/13/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 6 indicating R95 having severe cognitive impairment. Under section GG Functional abilities and goals documents R95 as being independent with eating.
R95's GG (functional abilities and goals) screener dated 6/10/25 documents for eating, R95 completes activity. Assistance may be provided throughout the activity or intermittently.
R95's Occupational Therapy note dated 5/29/25. At 04:20 PM documents, This OTA (occupational therapy assistant) spoke with OTR (occupational therapist registered) on 5/28/25 about patient's recent right-hand wrist drop issue. Right hand appears to have a small bruise on right wrist area. Patient stated I don't even know how I hurt my hand. Right versus left measurements are as follows hand grip is 2#/30#, and 3-point pinch is 1#/2#. This OTA provided patient instruction on how to use built up handled spoon with left hand to inc (increase) her I (independence) while feeding herself. OTR plans on S/U (setting up) goals for self-feeding d/t (due to) recent issue.
R95's Occupational Therapy note dated 5/30/25, at 11:31 AM documents, Staff were instructed in wear and care of right hand WHO (wrist hand orthotic) and use of tubigrip under for skin integrity management. Patient reported comfort with use. Discussed lack of active wrist extension and digit extension with floor nurse, as well as lean to right side this morning. Nursing agreed with change of condition and was communicating with appropriate medical team. OT (occupational therapist) spoke with kitchen and requested 2 handle cups with lids and built-up utensils on trays. Therapeutic activities: dynamic balance activities during sitting and fine motor coordination training.
Review of R95's CNA Task: GG-Eating indicates: built up handles on silverware, 2 handled cups with lid and cut food into small pieces during meals had daily documentation by certified nursing assistants on R95's functional ability every meal since 5/30/25, when these adapted utensils were implemented by therapy.
On 06/10/25, at 08:28 AM, Surveyor observed R95 sitting bent over, with R95's head in their lap, sleeping at a table during the breakfast meal. Surveyor observed R95's cereal all over table surrounding R95's cereal bowel. Surveyor observed there were no staff by R95's table helping R95. Surveyor observed R95 had no adaptive spoons or 2 handled cups to assist in R95's meal as recommended by occupational therapy on 5/30/25.
On 06/10/25, at 0829 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I about R95's current condition. Surveyor asked LPN-I if R95 needed help in the dining room. LPN-I informed Surveyor that they are speaking today and that the family is looking at hospice for R95. LPN-I informed Surveyor that R95 has declined in abilities recently. Surveyor asked LPN-I if R95 needed help eating. LPN-I informed Surveyor it depends on R95's cognitive abilities for the day, but often R95 will still feed still herself with set up. LPN-I informed Surveyor that R95 is weaker today.
On 06/10/25, at 12:20 PM, Surveyor observed lunch on the unit where R95 resides. Surveyor observed Certified Nursing Assistant (CNA)-N initially helping R95 eat and drink. Surveyor observed CNA-N was standing over R95 while helping R95 eat the meal. (Cross-reference F550). Surveyor observed that CNA-N was the only staff helping in the dining area.
On 06/10/25, at 12:24 PM Surveyor observed R95 feeding self with the built-up adaptive spoon but no 2 handled cups.
On 06/10/25, at 12:25 PM, Surveyor observed CNA-N came over to sit by R95 because R95 started to fall asleep. Surveyor observed CNA-N give R95 verbal cues to eat.
On 06/11/25, at 08:36 AM Surveyor observed breakfast on the unit where R95 resides. Surveyor observed R95 eating cereal with a regular spoon and a regular single handle cup was in front of R95. Surveyor observed R95 feeding self very slowly with regular spoon. Surveyor observed R95 had no adaptive spoon or 2 handled cups.
On 06/11/25, at 11:32 AM, Surveyor interviewed LPN-I about R95's adaptive eating equipment and R95's ability to feed herself. LPN-I informed Surveyor R95 was more independent the early part of June 2025 but now R95 often needs more encouragement and set up from staff. Surveyor asked LPN-I if staffing for meals was adequate because Surveyor noted one staff available to help during one of the meals. LPN-I informed Surveyor staffing is good, we get our stuff done. Surveyor asked LPN-I why the adaptive spoon and cups were not always being used for R95. LPN-I informed Surveyor that it must been accidentally overlooked by staff because R95 needs to use the built-up spoon. Surveyor asked where staff would find the information about the adaptive eating equipment. LPN-I informed Surveyor that LPN-I doesn't really know where the CNA's would find that information because the CNA's charting is different than nursing's charting.
On 06/12/25, at 09:12 AM Surveyor interviewed Occupational Therapist (OT)-J about R95's therapy and use of special equipment for meals. Surveyor asked OT-J when R95 started using the adaptive utensils at meals to facilitate independence with R95 feeding herself. OT-J informed Surveyor that OT-J believed it was sometime after 5/30/25, maybe 6/2/2025. OT-J informed Surveyor that OT-J spoke with kitchen to have built up handles on the spoons and 2 handle cups with a lid. OT-J informed Surveyor the OT-J would have to look at OT-J's notes to confirm and get back to the Surveyor.
On 06/12/25, at 02:06 PM, OT-J gave Surveyor therapy notes indicating that OT-J had seen R95 on 5/30/25 and implemented the adaptive eating utensils for R95 because of R95's contractures and that OT-J informed the unit staff and the kitchen staff of R95's need for adaptive utensils at meals. OT-J informed Surveyor that it was OT-J that implemented these adaptive eating utensils for R95 on 5/30/25. Surveyor asked OT-J why these items had not made it to R95's care plan yet. OT-J informed Surveyor that OT-J gives the facility education sheet to the restorative nurse and doesn't keep a copy. OT-J informed Surveyor the restorative nurse puts these types of interventions in the resident's care plan. OT-J informed Surveyor that OT-J had spoken to staff and the kitchen and that they were made aware of the adaptive eating equipment for R95.
On 06/12/25, at 09:31 AM, Surveyor interviewed Registered Nurse (RN)-G and CNA-T about R95's care plan not showing the adaptive eating equipment. RN-G informed the Surveyor that restorative will place it in the task section of the certified nursing assistants charting but that restorative is not allowed to place dietary interventions into the resident's care plan. RN-G informed Surveyor that interventions for the dietary care plan will come from an order. RN-G informed Surveyor that restorative doesn't get dietary orders because it is the dietary managers responsibility to get dietary orders.
On 06/12/25, at 09:42 AM, Surveyor interviewed Dietary Supervisor-C about R95's recommendation for adaptive eating utensils. Dietary Supervisor-C informed Surveyor that nursing needs to put in the order and then it comes into the nutrition management program and then Dietary Supervisor-C will update the resident care plan. Dietary Supervisor-C informed Surveyor R95's order for adaptive equipment has not come through the nutrition management system yet so the care plan has not been updated.
On 06/12/25, at 11:03 AM, Surveyor interviewed Corporate-AA, Assistant Administrator-F, Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A about R95's adaptive eating equipment not being used in 2 out 3 meals Surveyor observed. Surveyor asked who should have placed the order for R95's therapy's recommendation for R95 having adaptive eating equipment to maintain independence for self-feeding. NHA-A informed Surveyor that would be restorative nurse responsibility. NHA-A informed Surveyor Restorative is responsible to place that order. Surveyor expressed concern about the resident not having adaptive utensils on 2 or 3 meals and that the 5/30/25 recommendation had not been ordered or put in the care plan as of today (6/12/25). Surveyor informed NHA-A the CNA's task section had the adaptive eating equipment listed and documented by the CNA's. NHA-A informed Surveyor that the restorative nurse was new and may not have realized that these orders were the responsibility of the restorative department. NHA-A informed Surveyor the facility would make sure R95's order for adaptive eating equipment would be addressed.
On 06/16/25, at 08:12 AM, NHA-A gave Surveyor a training done for R95's built up silverware done on 6/13/25 with only 4 staff signatures on the sheet. The sheet was done by a speech language pathologist. Surveyor noted on the training sheet, R95's adaptive eating equipment was documented as now being used as needed.
On 06/16/25, at 08:52 AM, Surveyor interviewed OT-J on why R95's adaptive equipment was changed to being used as needed. OT-J informed Surveyor this training sheet is not from OT-J. Surveyor asked when this became an as needed intervention because in previous interviews OT-J and LPN-I informed Surveyor R95 needed the adaptive eating equipment. OT-J informed Surveyor OT-J doesn't know why the speech language pathologist wrote this as needed because OT-J was the one addressing that area. Physical Therapist (PT)-K informed Surveyor that the speech language pathologist informed PT-K that hospice asked Speech Language Pathology to reevaluate R95's need for the adaptive eating equipment on 6/13/25 because R95 was admitted to hospice on 6/13/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R64 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Chronic Kidney Disease, encounter for fitting and adjustment of Urinary Device.
R64's comprehensive Minimum Data Set (MDS), dated [DATE], indicates a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. R64 has an indwelling catheter and no trial of a toileting program.
R64's Care Plan, date initiated 5/13/25, documents, a focus area of Bowel and Bladder support is required. The goal is R64 will maintain current of bowel incontinence and R64 will show no complications secondary to catheter use. Interventions document, in part, .Keep drainage bag covered to promote privacy.
R64's Physician orders, dated 5/12/25, documents, CATHETER: INDWELLING URINARY CATHETER CARE DAILY AND PRN (as needed) every night shift related to ENCOUNTER FOR FITTING AND ADJUSTMENT OF URINARY DEVICE AND as needed related to ENCOUNTER FOR FITTING AND ADJUSTMENT OF URINARY DEVICE (sic).
On 06/09/25 at 10:15 AM, Surveyor observed R64 in her room, resting in her recliner, with the door open. R64 has an indwelling catheter, and the catheter bag attached to walker did not have a privacy cover. R64's catheter bag could be seen from the hallway.
On 06/10/25 at 12:37 PM, Surveyor observed R64 in her room, resting in her recliner, with the door open. R64's catheter bag was attached to walker and did not have a privacy cover. R64's catheter bag could be seen from the hallway.
On 06/11/25 at 08:01 AM, Surveyor observed R64 eating breakfast in the dining room with other residents. R64's catheter bag was attached to her wheelchair and did not have a privacy cover.
On 06/11/25 at 08:07 AM, Surveyor interviewed Registered Nurse (RN)-FF, asking what is the practice for privacy covers. RN-FF stated that drainage bags should always be covered with a blue privacy covering. Surveyor stated that R64 does not have a privacy cover on her catheter drainage bag and RN-FF stated, she should. RN-FF immediately notified Certified Nursing Assistant (CNA)-QQ and CNA-QQ wheeled R64 back to R64's room and placed a privacy cover on R64's catheter drainage bag.
On 06/11/25 at 08:11 AM, Surveyor interviewed R64 and asked R64 about the cover on the catheter bag. R64 stated, if she goes out of out or if she goes to therapy or other places in facility. R64 stated her drainage bag it is not always covered wherever she goes in the building but sometimes it is.
On 06/12/25 at 03:09 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concern regarding R64's dignity due to no privacy cover on R64's catheter drainage bag, observed on three different occasions.
Based on observation and interviews, the facility did not ensure each Resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 3 (R95, R94, R64) of 23 Residents reviewed for dignity.
*R95 was observed by Surveyor to be fed by staff while standing over resident. R95 was observed in dining area sleeping face down in lap with food noted all around R95's bowl on the table while seated with other diners, in dining room.
*Surveyor observed staff call across dining room referring to R94 as a feeder. Surveyor observed R94 alone at a table with R94's food still sitting in front of R94.
*R65 was observed by Surveyor with catheter bag exposed without privacy cover for 3 days.
Finding include:
Facility Policy titled; Dignity dated 06/23.
A. Policy:
The facility will promote care for residents in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and esteem.
B. Procedure:
1. Residents should be treated with dignity and respect.
2. The facility's culture supports dignity and respect by honoring resident goals, choices, preferences, values and beliefs.
3. Individual needs and preferences are assessed upon admission and quarterly thereafter on the activity assessment.
4. Residents may exercise their rights without interference or coercion, discrimination or reprisal from any person or entity associated with the facility.
5. When assisting with care, residents are supported in exercising their rights.
6. Residents' private space and property should be respected, unless there is a reasonable suspicion to believe there is property that may pose a risk of harm to the resident or others in the facility.
7. Residents' rights to personal privacy will be respected.
8. Residents will be dressed in a manner that preserves dignity, which includes wearing garments that are not over revealing.
1.) R95 was initially admitted to the facility on [DATE] with diagnoses (dx) that included Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and judgment), Vitamin D deficiency (nutritional deficiency of vitamin D), and Deficiency of other specified group B vitamins (nutritional deficiency of B vitamins).
R95's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 3/13/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 6 indicating R95 having severe cognitive impairment. Under section GG Functional abilities and goals documents R95 as being independent with eating.
R95's GG (functional abilities and goals) screener dated 6/10/25 documents that R95's eating ability as resident completes activity. Assistance may be provided throughout the activity or intermittently.
R95's hearing loss care plan documents: R95 is noted to have hearing loss in the right ear. Date Initiated: 03/05/2025. R95's intervention section documents: Face R95 when speaking. Date Initiated: 03/05/2025.
R95's impaired cognition care plan documents R95 has Impaired cognition due to dx of dementia. Date Initiated: 11/30/2024. R95's intervention section documents: When speaking to resident, establish and maintain eye contact, reduce environmental distractions, and use resident's preferred name to maintain attention. Date Initiated: 12/03/2024.
On 06/10/25, at 08:28 AM, Surveyor observed R95 sitting bent way over with their head in R95's lap sleeping at a table during the breakfast meal. Surveyor observed other diners around R95 including residents seated at R95's table. Surveyor observed R95's cereal all over table surrounding R95's cereal bowl. Surveyor observed there were no staff by R95's table helping R95. Surveyor observed R95 had no adaptive spoons or 2 handled cups to assist in R95's meal as recommended by occupational therapy on 5/30/25.
On 06/10/25, at 0829 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I about R95's current condition. Surveyor asked LPN-I if R95 needed help in the dining room. LPN-I informed Surveyor that R95 is not speaking much today and that the family is looking at hospice for R95. LPN-I informed Surveyor that R95 has declined in abilities recently. Surveyor asked LPN-I if R95 needed help eating. LPN-I informed Surveyor it depends on R95's cognitive abilities for the day, but often R95 will feed herself with set up. LPN-I informed Surveyor that R95 is weaker today.
On 06/10/25, at 12:20 PM, Surveyor observed lunch on the 400 unit. Surveyor observed Certified Nursing Assistant (CNA)-N initially helping R95 eat and drink. Surveyor observed CNA-N was standing over R95 while helping R95 eat the meal. Surveyor observed that CNA-N the only one helping in the dining area.
On 06/11/25, at 09:09 AM, Surveyor interviewed Resident Care Coordinator (RCC)-E about what education the staff receive on dignity and assisting the residents with eating. Surveyor asked RCC-E if RCC-E did the education for the certified nursing assistants (CNA). RCC-E informed Surveyor the RCC-E did the education for the CNA's and other staff. Surveyor asked if it was appropriate for staff to stand over residents while they are assisting to feed them or should staff sit next to them at eye level. RCC-E informed Surveyor the staff need to be at eye level and sit by them to maintain dignity. Surveyor asked RCC-E who does the training on feeding assistance for residents. RCC-E informed Surveyor that RCC-E does the training for staff regarding feeding assistance and that staff are taught by RCC-E to sit at Resident level. RCC-E clarified to Surveyor definitely at the eye level of the resident. RCC-E informed Surveyor that is what RCC-E teaches.
On 06/11/25, at 11:26 AM, Surveyor interviewed R95. Surveyor attempted to question R95 about R95 needing assistance eating. R95 became teary and informed Surveyor I am okay. R95 provided Surveyor no other information.
On 06/11/25, at 03:20 PM, Surveyor informed NHA-A, DON-B, of Surveyors concerns with dignity issues of staff standing over a resident while assisting in feeding, leaving food in front of resident who is unable to feed themselves. Surveyor informed NHA-A during an interview, RCC-C informed Surveyor that this was appropriate resident treatment. NHA-A informed Surveyor the NHA-A agreed it was not appropriate resident treatment.
2.) R94 was initially admitted to the facility on [DATE] with diagnosis that included Cerebral Infarction (a condition where blood flow to the brain is blocked causing brain tissue damage), Aphasia (a language disorder from damage to areas of the brain), Dysphagia oropharyngeal phase (difficulty swallowing that occurs in the mouth or throat).
R94's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 4/25/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of unable to complete assessment rarely or never understood indicating R94 has severe cognitive impairment. Under section GG Functional abilities and goals documents R94 as being completely dependent on staff with eating (Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident).
R94's restorative eating care plan documents R94 is in a program secondary to requiring assistance to eat meals. Difficulty focusing on task. Date Initiated: 04/11/25. R94's intervention section documents: Position resident at the dining room table. Provide napkin or other clothing protection per resident reference. Date Initiated: 04/11/2025. Prompt and cue resident to remain seated throughout the meal.
Date Initiated: 04/11/2025. Prompt and encourage resident to maintain intake. Date Initiated: 04/11/2025.
R94's activities of daily living (ADL) care plan documents that R94 has an ADL Functional
Performance Deficit r/t (related to) cerebral infarction, expressive and receptive aphasia, poor
cognition, weakness, is unable to follow direction of staff, and is in need of extensive assist with cares. Res has dentures however does not utilize and Family is in agreement that this is fine, collaboration with Hospice to ensure that resident is comfortable, and Hospice CNAs visits occur as well. Uses Broda chair for comfort Date Initiated: 10/22/2024. R94's intervention section documents: Assist/prompt resident to bring cup to mouth for drinking during meals. Date Initiated: 11/04/2024. Assist/prompt resident to bring food to mouth during meals. Date Initiated: 11/04/2024
On 06/10/25, at 12:38 PM, Surveyor observed during the lunch meal Licensed Practical Nurse (LPN)-M calling across the room to Certified Nursing Assistant (CNA)-P asking if there were any feeders the staff still needed help with. Surveyor observed CNA-P reply to LPN-M
she's a feeder over here pointing to R94. LPN-M walked over to table and sat down by R94.
On 06/10/25, at 12:58 PM, Surveyor returned to dining room and observed R94 sitting at the table alone with R94's food set out in front of R94. Surveyor asked CNA-Q if R94 was supposed to be alone at a table with food in front of R94. CNA-Q informed Surveyor R94 is a total assist with feeding and dependent on staff to eat. CNA-Q informed Surveyor CNA-Q did not know why the food is placed it in front of R94 and why R94 was left alone. CNA-Q stated R94 sitting alone with food was not appropriate because R94 cannot feed herself and R94 needs supervision and assistance at meals. Surveyor observed CNA-Q sit down to finish assisting R94 to eat the lunch meal. Surveyor observed that R94 continued to eat R94's meal with CNA-Q's help.
On 6/16/25, at 11:55 AM, Surveyor observed R94 at the dining table with a family member waiting for lunch.
On 06/11/25, at 09:09 AM, Surveyor interviewed Resident Care Coordinator (RCC)-E about what education the staff receive on dignity and assisting the residents with eating. Surveyor asked RCC-E if it was appropriate that staff should call across the room and ask if there are feeders over there. RCC-E informed Surveyor it is not appropriate to call residents who need assistance to be fed by staff as feeders. RCC-E asked Surveyor what staff did that and that RCC-E would talk to them because that was inappropriate for staff to refer to residents in that manner. RCC-E informed Surveyor that is not what we teach the staff, we teach them to maintain dignity and respect.
On 06/11/25, at 03:20 PM, Surveyor informed NHA-A and DON-B, of staff leaving food in front of resident who is unable to feed themselves, calling residents feeders across the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents were free from abuse affecting 2 (R67 and R513) of 3 residents reviewed for abuse concerns.
R513 had behaviors of agitation, wandering, and physical behaviors toward others. On 4/5/2025, R513 entered R67's room and was hitting and kicking R67 after R67 had fallen to the ground. Supervision of R513 was not increased with the heightening of behaviors to prevent abuse to R67.
Findings include:
The facility policy and procedure titled Abuse Policy dated 9/2020 documents: POLICY: . This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals.
ABUSE PREVENTION PROGRAM . 3. Prevention: The facility desires to prevent abuse, neglect and theft by establishing a resident sensitive and resident secure environment. d. As part of the social service assessment, staff will identify residents with increased vulnerability for abuse or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis.
R67 was admitted to the facility on [DATE] with diagnoses of congestive heart failure, adjustment disorder with mixed anxiety and depressed mood, atrial fibrillation, hypertension, and mitral valve insufficiency.
R67's Annual Minimum Data Set (MDS) assessment dated [DATE] documented R67 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10 with no behaviors. R67's Activities of Daily Living Care Plan initiated on 3/4/2024 documented R67 was independent with ambulation and R67's At Risk for Falls Care Plan initiated on 3/4/2024 documented R67 was at risk for falls due to weakness and a history of falls. R67 had an activated Power of Attorney (POA).
R67's At Risk for Abuse Care Plan was initiated on 3/12/2024 due to R67's incapacitated status, impaired cognition, and mental health diagnosis of adjustment disorder with depressed and anxious mood with the following interventions:
-At onset of behavior, calmly and firmly attempt to redirect to socially acceptable behaviors.
-Check and assure physical comfort.
-Compliment (R67) for appropriate social interactions.
-Consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents.
-Consider possible antecedents: fear, fatigue, loss of control over a situation.
-Determine preferred setting and approach and then offer health care accordingly.
-Encourage (R67) to participate in activities.
-Encourage/reassure/redirect/repeat as needed.
-Investigate accusation.
-Maintain a calm soothing approach/environment and smile/pay compliments to promote feelings of belonging and importance with (R67).
-Monitor and report signs/symptoms of abuse.
-Remind other to try to let comments/loud repetitive noises go in one ear and out the other, to ignore, to move away from.
-Respond with reassurance; do not argue.
-Simplify tasks, reduce stimulation, give more time or space if showing signs of feeling too challenged.
R513 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, severe dementia with other behavioral disturbance, major depressive disorder, anxiety disorder, and cognitive communication deficit.
R513's Annual MDS assessment dated [DATE] documented R513 was severely cognitively impaired with a BIMS score of 3 and had the following behaviors during the 7-day lookback period: delusions, physical behaviors toward others daily, verbal behaviors toward others 1-3 days, rejection of care 4-6 days, and wandering daily. R513's Cognitive Loss/Dementia Care Area Assessment (CAA) and Behavioral Symptoms CAA documented R513 has diagnoses of Alzheimer's Disease and Dementia with behavioral disturbance. R513 has mental health diagnoses as well that could contribute to behaviors. A care plan would be developed to address cognition and behaviors. R513 had an activated POA.
R513's Psychotropic Medication Care Plan was initiated on 7/10/2021 for the use of the antipsychotic quetiapine and antidepressant duloxetine with the following pertinent interventions in place on 4/5/2025:
-Attempt dosage reduction gradually as able.
-Delusions interventions: 1. Redirection. 2. One-on-one interaction. 3. Encouragement from staff.
-Hallucinations interventions: 1. Redirection. 2. One-on-one interaction. 3. Encouragement from staff. 4. Reality orientation to things in the present and in the environment.
-Physically resistive to care interventions: 1. Redirect. 2. Reapproach. 3. Anticipate needs. 4. Two staff to provide cares as able.
R513's At Risk for Abuse Care Plan was initiated on 7/12/2021 due to R513's major depressive disorder and dementia as well as behaviors with the following interventions in place on 4/5/2025:
-At onset of behavior, calmly and firmly attempt to redirect to socially acceptable behaviors.
-Check and assure physical comfort.
-Compliment (R513) for appropriate social interactions.
-Consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents.
-Consider possible antecedents: fear, fatigue, loss of control over a situation.
-Determine preferred setting and approach and then offer health care accordingly.
-Encourage (R513) to participate in activities.
-Encourage/reassure/redirect/repeat as needed.
-Investigate accusation.
-Maintain a calm soothing approach/environment and smile/pay compliments to promote feelings of belonging and importance with (R513).
-Monitor and report signs/symptoms of abuse.
-Regularly assess (R513) for possible thoughts of self-harm.
-Remind other to try to let comments/loud repetitive noises go in one ear and out the other, to ignore, to move away from.
-Respond with reassurance; do not argue.
-Simplify tasks, reduce stimulation, give more time or space if showing signs of feeling too challenged.
Surveyor noted R513's At Risk for Abuse Care Plan interventions were the same as R67's interventions and not personalized to the individual.
R513's At Risk for Elopement Care Plan was initiated on 4/1/2024 due to exit-seeking and wandering behavior with the interventions:
-Check and assure physical comfort.
-Consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents.
-Consider potential variables: boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation.
-Determine preferred setting.
-Encourage/reassure/redirect/repeat as needed.
-For wandering: 1. Redirection. 2. Check and ensure (R513) safety. 3. Calmly and positively guide (R513) back to (R513's) room/unit or towards whichever activity (R513) may be currently attending. 4. Assess (R513's) mood and address any mood related issues that may be occurring. 5. Provided one-on-one interaction with encouraging, uplifting comments.
-If (R513) shows agitation regarding the Wanderguard, remind (R513) it is in place for safety due to night terror and sleepwalking.
-May initiate frequent checks and supervision.
-Monitor behaviors.
-Offer alternative activities of daily living that may be engaging.
-Utilize Wanderguard as appropriate.
-Wanderguard on wheelchair for exit seeking behaviors; check for placement and function as required.
Surveyor noted R513 did not have a care plan to address the aggressive behaviors exhibited by R513 towards staff and potentially other residents.
On 3/29/2025 at 2:06 PM in R513's progress notes, a Registered Nurse (RN) documented R513 opened a fire door and was redirected immediately back into the facility. Management and R513's POA was notified.
On 3/30/2025 at 7:58 PM in R513's progress notes, a Licensed Practical Nurse (LPN) documented R513 was agitated throughout the shift. R513 went to the front desk often stating R513 was waiting for a cab and leaving, many times trying to go outside. When the LPN was called, the LPN offered to take R513 outside. R513 would refuse, get upset, and raise voice at the LPN. The LPN called R513's POA after three separate incidences and the POA told the LPN to sit in a chair in R513's way and wait for R513 to get tired. On the fourth attempt at R513 trying to leave, the LPN sat next to R513 in a chair and R513 immediately hit the LPN, began to kick the LPN, and attempted to push the chair over that the LPN was sitting in. R513 was very agitated that the LPN would not leave R513 alone and get R513 a cab to go home. The LPN attempted to reorient R513 without success, informing R513 that it was Sunday and that the cabs stop running at 7:00 PM and it was now 7:45 PM. Eventually R513 got tired and went back to the room with another nurse.
On 4/3/2025 at 10:16 PM in R513's progress notes, an LPN documented R513 was increasingly combative with staff while wandering. Management was notified and was advised to call the on-call physician. An order for Trazadone 50 mg to be given one time was received. Trazadone is an antidepressant used to treat depression and anxiety. R513 refused the medication and was currently calm and sleeping.
On 4/5/2025 at 5:17 PM in R513's progress notes, RN-KK documented R513 was behavioral at that time. Attempts were made to call R513's POA and R513's son but was unsuccessful. An order was received to give R513 the scheduled dose of Seroquel 50 mg, an antipsychotic, at that time instead of in the evening as ordered.
On 4/5/2025 at 5:40 PM in R513's progress notes, the on-call physician documented R513 was agitated and trying to elope out of the facility. R513 was trying to bite other residents and refusing to take medications. The physician documented the restlessness and agitation were worsening due to progressive dementia and ordered the Seroquel to be given early.
On 4/5/2025 at 9:42 PM in R513's progress notes, the on-call physician documented per the facility nurse, R513 went into another resident's room, hit the resident on the back of the left shoulder and kicked the other resident. Per the nurse, the other resident (R67) does not have any injuries, and the resident denies being hit or kicked by R513. R513's POA was with R513 at that time and R513 is more calm.
On 4/5/2025 at 10:35 PM in R513's progress notes, RN-KK documented R513 was very combative throughout the shift this afternoon/evening. R513 would not be redirected by staff despite many attempts to do so. R513 wheeled about the facility, going onto every unit. R513 would kick, hit, and even pull staff members' hair when they attempted to take R513 back to R513's unit. R513 also made several unsuccessful attempts to leave the facility. R513 required continuous monitoring from staff. Several attempts had been made by RN-KK to contact R513's POA to come to the facility to be with R513. R513's POA would come to the facility whenever asked. R513's POA was not answering the phone. Finally, R513's POA answered the phone and arrived at the facility at 8:00 PM and stayed with R513 until R513 went to sleep.
On 4/5/2025 at 10:38 PM in R67's progress notes, the on-call physician documented R67 lost their balance while attempting to get another resident to leave R67's room. Per the nurse, R67 got up independently and was sitting on the bed when staff arrived. R67 sustained a skin tear to the left shin. Per the nurse, another resident came into R67's room and hit R67 on the back of the left shoulder and kicked R67. R67 did not recall where R67 was kicked. No signs of injury were found post altercation.
On 4/6/2025 at 3:18 PM in R67's progress notes, an LPN documented R67 was telling staff that a resident came into R67's room and was kicking R67. R67 stated three staff members came in when R67 yelled for help and took the other resident out of R67's room. R67 stated R67 was fine and was talking with peers and laughing.
On 4/7/2025 at 11:01 AM in R67's progress notes, RN-Y documented the interdisciplinary team (IDT) met to review R67's incident on 4/5/2025. The root cause of R67's fall was most likely R67 stood up and lost balance and fell. R67 was startled as another resident entered R67's room. The immediate intervention was to ensure R67 was safe and remove the other resident from R67's room. R67's care plan was updated.
R67's Impaired Cognitive Functioning Care Plan was revised on 4/7/2025 with the intervention to remind R67 that R67 is safe when feeling anxious or scared. Surveyor noted the IDT met and the care plan was updated two days after the incident.
R513 continued to have agitation, elopement attempts, and physical behaviors until R513 was transferred to a memory care facility on 5/12/2025. R513's care plan was not revised with any interventions after the physical altercation with R67. Supervision was not increased to protect other residents from R513.
The facility reported the incident to the State Agency. The facility investigation of the event included a recap of the incident and interviews with staff members that were working in the facility on 4/5/2025. Nursing Home Administrator (NHA)-A wrote the recap of the event: R513 wandered into R67's room and when R67 stood up to redirect R513, R67 lost their balance and fell. While R67 was on the ground, R513 wheeled over and began hitting and kicking at R67. The residents were immediately separated and R67 was assessed for the fall and incident. R513 was supervised until R513's POA was able to come and sit with R513 to assist with calming R513 down. After some time, R513 did settle down and went to sleep.
The staff statements showed R513 had been agitated all day with wandering into other resident rooms.
-CNA-LL's statement indicated after 6:00 PM, a family member of a resident on the 300 unit told CNA-LL there was someone in the resident's room. CNA-LL went in and attempted to redirect R513 out of the room. CNA-LL touched R513's shoulder and R513 immediately tried to scratch CNA-LL. CNA-LL called for the nurse to assist. The nurse came and grabbed the back of the wheelchair while CNA-LL moved things out of the way so R513 could not throw anything. Together they removed R513 from the unit and called the 600 unit to come and retrieve R513. At about 7:30 PM or 8:00 PM, CNA-LL was in the hallway about to put someone in bed when CNA-LL heard R67 yell out for help. R513 was in R67's room at the foot of R67's bed. CNA-LL asked R513 to leave and R513 started to kick at CNA-LL. R513 followed CNA-LL to the doorway where CNA-LL was able to grab the front of the wheelchair to pull R513 out of the room. CNA-LL shut the door behind R513 and R513 followed CNA-LL towards the kitchen. CNA-LL attempted to make a phone call to the 600 unit. When CNA-LL turned to see if R513 was behind CNA-LL, R513 was not there. CNA-LL ran to R67's room and found R67 on the floor with the feet by the closet and the face facing the bed. R513 was in front of R67 attempting to kick R67. CNA-LL could not see if R513 kicked R67. CNA-LL grabbed R513's chair and again got R513 out of R67's room. CNA-LL ran and grabbed the nurse and DON-B. They helped get R513 off the unit and contacted the 600 unit to get R513.
-An LPN statement indicated R513 was wandering the facility and entered the 300 unit and into another resident's room. The LPN had to assist a Certified Nursing Assistant (CNA) to get R513 out of that room and was brought to the community wing area. While continuously trying to redirect R513, R513 was hitting, kicking, grabbing, and pulling at the nurses and CNAs. R513 wandered into the conference room and the LPN returned to the unit. The CNA from the 600 unit was with R513 and requested assistance as R513 was throwing trash, the trash can and pulling cords. R513 wandered to the outside of the 400 unit. The LPN contacted the charge nurse and the 600 unit nurse to come help redirect R513. There were four staff attempting redirection. R513 was kicking and swinging arms and grabbed the 600 unit CNA's ponytail. After the situation deescalated, the LPN returned to their unit. Later in the shift around 7:30 PM, R513 was again wandering the facility and ended up entering the 300 unit with staff at 7:40 PM unsuccessfully redirecting R513.
-A CNA statement indicated R513 was seen on the 200 unit around 4:00 PM entering resident rooms. Staff redirected R513 into the dining room where R513 attempted to open the patio door. Staff tried to redirect but R513 was able to open the door and set off the alarm. The 600 unit staff was called to come and get R513. Later in the shift the 600 staff came over to the 200 unit to ask if they had seen R513. The 200 unit staff had not seen R513 and asked if they should call a code for a missing resident. R513 was found with no code needing to be initiated.
-A CNA statement indicated the CNA had worked a 16-hour shift and during about 14 of those hours, R513 attempted to bite the CNA as well as other CNAs. The CNA witnessed R513 display high aggression at other CNAs. R513 ran over the CNA with the wheelchair, kicked several times, punched, scratched, had hair pulled, and was grabbed in the groin area. R513 was also destructive to the facility property. R513 was found in other resident rooms often. R513 tried to get outside and would check every door handle to see if they were unlocked as R513 went down the hallway.
-A CNA statement indicated a resident on the 400 unit called at 3:00 PM to get R513 out of their room. R513 attempted to bite the CNA's arm and then kicked the CNA. At 4:30 PM, R513 came back to the 400 unit with a CNA walking behind R513 and R513 tried to kick the CNA. After dinner at about 5:30 PM, R513 was back on the 400 unit and the CNA assisted another CNA to take R513 back to the 600 unit.
-A CNA statement indicated around 4:30 PM on the 400 unit, R513 was very agitated, kicking, trying to bite, pulling shirts and arms of staff. The CNA walked R513 back to the 600 unit holding R513's hand because R513 would not let go and gave R513 a doll to hold. After 30 minutes, R513 was back on the 400 unit, making statements that R513 had to get out of there because they want me dead. R513 was very agitated as before. R513 became more agitated with redirection. R513 tried to leave the building through the front door and then again on the 600 unit causing the alarm to go off.
-An LPN statement indicated R513 was seen wandering the halls in the wheelchair. R513 came onto the 200 unit around 4:00 PM and began attempting to enter other residents' rooms. R513 attempted to open the patio door initiating the alarm. Staff tried to redirect R513 but was unsuccessful and R513 continued to wander. The 600 unit staff came looking for R513 eventually. Around 9:00 PM, the LPN saw R513 with R513's POA. R513 was becoming combative with R513's POA so the LPN offered assistance. The LPN allowed R513's POA to wheel R513 around the 200 unit as long as R513 stayed out of residents' rooms.
Surveyor noted with all the interviews, R513 had been agitated all day with physical aggression and going into multiple resident rooms with no initiation of continuous supervision to keep other residents safe.
In an interview on 6/10/2025 at 4:04 PM, RN-KK stated R513 did not have the behaviors when first admitted but as the dementia progressed, R513 became very difficult to handle. RN-KK stated R513 would try to get out of doors that were locked and had hitting behaviors before R513 was discharged from the facility. RN-KK stated R513 would give a staff member a hug and then would kick the staff member. RN-KK stated R513 kept going to the other side of the building and that is where stuff happened. Surveyor clarified with RN-KK that stuff referred to R513 hitting and kicking R67. RN-KK stated yes. RN-KK stated R513 needed to be one-on-one constantly because R513 was not safe for themselves or other people around them. RN-KK stated RN-KK would wait as long as possible to call R513's POA to come in, but that was the only avenue they had to keep a constant eye on R513. Surveyor asked RN-KK how the one-on-one staff member was assigned. RN-KK stated RN-KK was the one-on-one while still doing all the other nursing duties that were required. RN-KK stated the facility does not have sitters or a single staff member assigned just for the one-on-one. RN-KK stated the facility accepts new admission residents that need one-on-one for safety, and it is upsetting to the staff and the family of the resident when they cannot provide one-on-one. Surveyor noted the facility did not get a statement from RN-KK for the incident on 4/5/2025.
In an interview on 6/11/2025 at 3:52 PM, Surveyor asked CNA-LL if CNA-LL recalled R513. CNA-LL stated R513 wandered quite a bit, constantly trying to elope, and came to the other side of the facility all the time. CNA-LL stated R513 was aggressive, kicking and hitting. CNA-LL stated CNA-LL was always trying to remove R513 from other residents' rooms so no one would get hurt. Surveyor asked CNA-LL if CNA-LL was working with R67 on 4/5/2025 when R513 came into R67's room. CNA-LL stated CNA-LL was working on R67's unit that day and did not know R513 was in R67's room until CNA-LL went into R67's room, saw R67 on the floor and R513 was in a wheelchair kicking towards R67. CNA-LL stated CNA-LL could not see if R513 made contact with R67 or not. Surveyor asked CNA-LL if R513 had ever been a one-on-one. CNA-LL stated R513 was never a one-on-one; no one was assigned to specifically watch R513. CNA-LL stated, Should (R513) have been? Yes. Surveyor asked CNA-LL what would happen when R513 was on the opposite side of the facility from R513's room/unit. CNA-LL stated the staff would have to call R513's unit or bring R513 back to the unit themselves. CNA-LL stated R513 was really hard to watch, but the family came in to watch R513 and walk around with R513. CNA-LL stated it would have been nice to have someone assigned to R513. CNA-LL stated there are a few residents currently that would benefit from having a one-on-one. CNA-LL stated staff are pulled in different directions, so it is hard to watch those residents with behaviors and keep everyone safe.
In an interview on 6/16/2025 at 10:49 AM, Surveyor asked DON-B about the resident to resident altercation on 4/5/2025 between R513 and R67. DON-B stated DON-B was with R513 from 6:00 PM until 8:00 PM on 4/5/2025. DON-B stated DON-B had taken R513 back to R513's unit where R513 had calmed down. DON-B stated DON-B was getting ready to leave the facility and found out R513 had gone back into R67's room where the incident occurred. Surveyor asked DON-B if R513 ever had one-on-one supervision to keep R513 safe as well as other residents. DON-B stated R513 never had a specific CNA assigned to do one-on-one with R513. DON-B stated there is a float CNA that would take that role, but otherwise nursing staff would take turns watching R513 and activities would help as well. DON-B stated it became line of sight monitoring because R513 would get more agitated if someone was right next to R513. DON-B stated on 4/5/2025, R513's behaviors would go away once R513 was resting; they did not anticipate R513 getting back up and being agitated again. DON-B stated R513 did not always have behaviors, R513 would just wander around the building. Surveyor shared with DON-B the concern R513 had been having behaviors all that day and there was no increased supervision to protect R67 from physical abuse. Surveyor shared R513's care plan indicated R513 was to have one-on-one with wandering and behaviors that was not implemented at any time. Surveyor shared interviews with staff said R513 never had one-on-one supervision and that would have been very effective. Surveyor shared with DON-B the concern that staff removed R513 from R67's room without any incident on 4/5/2025, but with the behaviors R513 was exhibiting and not increasing supervision, R513 was able to return to R67's room where R67 fell and was potentially physically assaulted by R513.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure 2 (R97, R39) of 5 residents reviewed were free from chemical restraints.
*The facility has no evidence of Abnormal Involuntary Monitory Scale (AIMS) monitoring prior to administrating R97's psychotropic medications.
* The facility has no evidence of Abnormal Involuntary Monitory Scale (AIMS) monitoring prior to administrating R39's psychotropic medications.
Findings Include:
The facility's policy titled Psychotropic Medications - Use of, dated 09/2020, documents the following: .A baseline AIMS assessment will be initiated when receiving antipsychotic medications. (A re-assessment will be completed every six months.) .
1.) R97 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks) and dementia (memory loss).
Surveyor reviewed R97's Electronic Medical Record (EMR) including current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R97 is prescribed Quetiapine Fumarate (Seroquel) Tablet 25 mg, an antipsychotic medication for Alzheimer's disease, Rivastigmine Tartrate (Exelon) Capsule 1.5 mg, a cholinesterase inhibitor (medication to improve memory function) for Dementia and Memantine HCl (Namenda) Oral Tablet 10 mg, a medication used to treat Dementia.
On 6/11/25, Surveyor notes R97's EMR did not include an Abnormal Involuntary Movement Assessment (AIMS) score.
On 6/11/25 at 3:15 PM, Surveyor requested an AIMS assessment for R97 from the facility.
On 6/12/25 at 9:10 AM, Surveyor followed up with the facility regarding R97's AIMS assessment. The facility was unable to provide Surveyor with R97's AIMS assessment. On 6/12/25 at 12:55 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A that R97 is receiving psychoactive medications, including Quetiapine Fumarate, an antipsychotic medication. No additional information was provided by the facility at this time.
2.) R39 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R39's diagnoses include pulmonary embolism (blood clot in the lungs), paraplegia (a type of paralysis that affects the lower half of the body), Parkinson's Disease (a progressive nervous system disorder that affects movement), Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (memory loss), mood disturbance and anxiety, depression, and anxiety disorder. R39's Quarterly Minimum Data Set (MDS) completed on 5/27/25, documents R39 as having a Brief Interview for Mental Status (BIMS) score of 14, indicating R39 is cognitively intact.
Surveyor reviewed R39's Electronic Medical Record (EMR) which documents R39's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Memantine HCL ER (Namenda) 28 mg by mouth in the morning related to Alzheimer's Disease ordered on 4/4/25, at 7:14 AM. R39 is prescribed Mirtazapine (Remeron) 15 mg by mouth at bedtime for sleep disturbance ordered on 4/3/25, at 6:55 PM. Surveyor notes R39's EMR did not include an AIMS assessment.
On 6/12/25, at 9:38 AM, Surveyor requested an AIMS assessment for R39 from the facility. Surveyor was provided a copy of R39's AIMS report dated 5/25/25.
On 6/12/25, at 3:18 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concerns with R39 taking psychotropic medications without having an AIMS assessment performed. Surveyor acknowledged the AIMS assessment dated [DATE] however, notified the facility of concerns with no AIMS assessment being performed prior to R39 taking psychotropic medications (Mirtazapine and Memantine). NHA-A and DON-B acknowledged the concern. Surveyor requested additional information if available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R91 was admitted to the facility on [DATE] with diagnoses that included gout, congestive heart failure, obesity, type 2 diabetes mellitus, chronic kidney disease and inflammation of right lower extremity.
The most recent Annual MDS (minimum data set), dated [DATE], documents that R91 has a BIMS (brief interview for mental status) of 13 indicating R91 is cognitively intact. R91 is at risk for developing a pressure injury and at the time did not have any unhealed areas of skin impairment.
Surveyor conducted a review of R91's individual plan of care and noted the following:
R91 is with actual alteration in skin integrity r/t (related to) red groin, and MASD (moisture associated skin damage), immobility and incontinence. Res (resident) refusing air mattress and prefers to have a foam pressure reducing mattress. Hx (history): edema and diabetic and stasis ulcers to bil (bilateral) lower extremities. Skin tears to RLE (right lower extremity) noted. Resident takes off own dressings at times if dressings on and prefers not re-dressed at times.
Date Initiated: [DATE]
o Skin will remain grossly intact thru next review. Date Initiated: [DATE]
o Absorbent to wick up moisture. Date Initiated: [DATE]
o Barrier cream to areas exposed to moisture/incontinence. Date Initiated: [DATE]
o Bathe with mild soap. Date Initiated: [DATE]
o Elevate heels off bed (non-arterial). Date Initiated: [DATE]
o Engage resident and/or family in risk reduction interventions. Date Initiated: [DATE]
o Inspect skin daily with care. Date Initiated: [DATE]
o Monitor labs, weight and/or intake. Date Initiated: [DATE]
o Monitor nutritional status. Date Initiated: [DATE]
o monitor RLE skin tears for s/s (signs/symptoms) of infection, until healed. Date Initiated: [DATE]
o Pericare after incontinent episodes. Date Initiated: [DATE]
o Position body with pillows/support devices. Date Initiated: [DATE]
o Pressure reduction support on wheelchair. Date Initiated: [DATE]
o Teach resident to shift weight in the wheelchair. Date Initiated: [DATE]
o Treatment as ordered Date Initiated: [DATE]
o Use assistive devices to decrease friction (Hoyer lift, draw sheet). Date Initiated: [DATE]
o Weekly wound progress assessment by nurse. Date Initiated: [DATE]
Nursing note dated [DATE] at 1:27 PM; Pressure injury to left buttocks and blood blister to right great toe reported by CNA's this AM. NP (nurse practitioner), VA (Veteran's Administration), family notified. Treatments in place.
Nursing note dated [DATE] at 1:31 PM; Pressure injury to left buttock measuring 4 x 4 cm.
Further review of R91's medical record did not provide evidence that a comprehensive assessment had been completed for the pressure injury to the left buttocks or blood blister to the right great toe.
On [DATE] at 4:00 PM a physician order was obtained as the following: Betadine to right great toe 2 x (2 times) daily until healed, two times a day.
An additional review of the individual plan of care was completed and it was noted it was not updated to reflect the pressure injury to the left buttocks or the blood blister to the right great toe. No additional interventions were put into place to aide in healing these areas.
On [DATE] at 8:00 AM; a physician order was obtained for zinc oxide to left buttock, cover with mepilex until healed. one time a day for Skin Condition
Nursing note dated [DATE] at 1:26 PM; Notified NP, that wound on buttocks is not improving and needs to be evaluated, notified management at morning nurse's meeting of the same.
Surveyor continued the review of the medical record for R91 and did not see any further documentation regarding the NP's response, if a further comprehensive assessment had been completed to the wound on the buttocks or that the plan of care was updated with interventions to prevent the worsening of the area or aide in healing.
On [DATE], a NP progress note was written (no time of visit/assessment documented) indicating R91 is receiving ongoing care for bilateral lower extremity wounds at the VA wound clinic. R91 wears compression stockings on both legs to manage swelling, which is noted in his bilateral lower extremities. Additionally, R91 has wounds on his right great toe and left buttock, which is being managed by the facility wound team. Physical Examination: Skin- wound to great toe and left buttock.
On [DATE], the facility completed a Braden Scale for Pressure Injury Risk indicating that R91 is at mild risk for pressure injuries.
On [DATE] at 11:45 AM, Surveyor interviewed DON (Director of Nursing)-B regarding R91's areas of skin impairment. Surveyor requested to review any comprehensive assessment of R91's pressure injury to the left buttocks or blister to the right great toe. DON-B stated that she had conducted a skin sweep starting 6/16-[DATE] to identify any new areas of skin impairments. DON-B stated that this information had not been uploaded into the medical record yet. Surveyor asked DON- B if there was any follow-up to the nursing note dated [DATE] that documents the wound to the left buttocks was worsening and needed further evaluation. DON- B stated that R91 does not have a pressure injury, it's a moisture area.
On [DATE], DON- B did provide a copy of the skin sweep documentation, dated [DATE] for R91. The skin notes state that 4 x 2 (does not indicate whether centimeter of milimeter) thickness area of MASD (moisture associated skin damage) to the left buttocks area has no signs/ symptoms of infection noted. R91 was previously using urinal and now calls for assistance and more episodes of incontinence. Right great toe stable eschar measuring 1 x .5 centimeters. Betadine continues. NP updated. This documentation was written by DON- B. Surveyor noted the skin sweep documentation does not include additional details to help distinguish if the area on R91's buttock is MASD vs (versus) a pressure injury such as whether the shape is irregular, inflamed, etc.
On [DATE] at 12:15 PM, Surveyor interviewed Agency Licensed Practical Nure (LPN)- RR regarding the completion of the treatments for R91 to the buttocks and right great toe. Agency LPN- RR stated she didn't see the area to the buttocks because the CNA's (Certified Nursing Assistants) do the Zinc applications. Agency LPN- RR stated that she only did a treatment to R91's toe. Surveyor asked why she had signed out on the Treatment Medication Administration Record for [DATE] that she did the treatment for zinc oxide to left buttock, cover with mepilex. Agency LPN- RR stated she signed it as completed because she will make sure the CNA applied it.
On [DATE] at 12:22 PM, Surveyor interviewed DON- B regarding R91's treatment to the left buttocks being completed by a CNA. DON- B stated that the CNA's definitely are not supposed to being doing any treatments and that she will immediately talk with Agency LPN- RR about this. Surveyor asked DON- B if she was able to find any follow-up to the [DATE] nursing note about the worsening area to R91's buttocks. DON- B stated she was not able to find any follow-up, but the area did not worsen. It once measured 4 x 4 and now it is 4 x 2, clean and healthy. Surveyor asked if there had been any comprehensive assessment of this area and the right great toe. DON- B stated that she had only done a skin sweep of all of the residents and was only looking for new areas. DON-B stated that she has another week (to meet requirement of weekly comprehensive skin assessments) to address these areas. DON- B confirmed that she is the facility's Wound Nurse.
On [DATE] at 2:15 PM, Surveyor requested to review the weekly skin check that was signed out as completed on [DATE]. DON- B stated that the nurse's don't document anything when they complete the weekly skin assessment unless there is a new area. Surveyor asked DON-B how the staff would know if there was a new area or not. DON-B stated that they would know because there would be a treatment in place. Surveyor then asked why there had not been a comprehensive assessment of R91's buttocks a right great toe wounds and why the plan of care had not been updated. DON- B was unable to provide any additional information at this time.
2.) R51 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, diabetes, heart failure, legal blindness, bilateral hearing loss, adjustment disorder with mixed anxiety and depressed mood, and mild cognitive impairment.
R51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R51 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and had impairment to the left arm and left leg.
R51's Activities of Daily Living Care Plan, initiated on [DATE], documented R51 used a full body mechanical lift for transfers.
R51's At Risk for Skin Breakdown Care Plan was initiated on [DATE] with the following interventions in place on [DATE]:
-Absorbent to wick up moisture.
-Barrier cream to areas exposed to moisture/incontinence.
-Bathe with mild soap.
-Inspect skin daily with care.
-Monitor for signs/symptoms of infection.
-Monitor labs, weight, and/or intake.
-Monitor nutritional status.
-Monitor wound related pain and administer pain medication as appropriate.
-Peri care after incontinent episodes.
-Position body with pillows/support devices.
-Pressure reduction support on wheelchair.
-Turn and reposition every two hours and as needed.
-Use assistive devices to decrease friction.
-Weekly wound progress assessment by nurse.
-Wound care consultation as ordered.
On [DATE] at 4:50 AM in the progress notes, nursing documented the nurse requested an air mattress due to R51's decline in condition to avoid pressure wounds. Surveyor noted R51's Care Plan was not revised to include an air mattress at that time.
R51 was seen weekly by the wound physician for diabetic ulcers to the left ankle and the right big toe prior to [DATE] when R51 was admitted to the hospital due to altered mental status. R51 was readmitted to the facility on [DATE].
On [DATE] on the Initial Nursing Assessment form, nursing documented R51 had a new pressure injury to the coccyx and the outer left great toe; the ulcer to the left heel remains. A Wound and Skin Assessment (WASA) form was completed at the same time documenting the right buttock pressure injury measured 0.2 cm x 0.1 cm with 50% epithelial tissue and 50% granulation tissue. Surveyor noted the pressure injury was not staged and had no depth measurement. Surveyor noted no treatments for the wounds were obtained.
On [DATE], R51 was seen by the wound physician who documented R51 had a Deep Tissue Injury (DTI) of the left medial foot that was present on readmission. The DTI measured 1 cm x 1 cm with intact purple/maroon discolored skin. A treatment of skin prep to the left medial foot was ordered at that time. No documentation was found by the wound physician of the coccyx pressure injury that was documented on [DATE]. In an interview on [DATE] at 11:02 AM, Director of Nursing (DON)-B stated DON-B thought the coccyx/right buttock wounds that were noted on readmission on [DATE] were moisture associated dermatitis and not pressure so were not assessed by the wound physician.
R51 was seen by the wound physician weekly and the left medial foot was comprehensively assessed with treatment changes as indicated.
On [DATE], R51 started hospice services with an admitting diagnosis of cerebral infarction.
On [DATE], R51 was seen by the wound physician who documented the left medial foot pressure injury was Unstageable measuring 1.5 cm x 1.4 cm x not measurable with 100% thick adherent devitalized necrotic tissue.
R51's At Risk for Skin Breakdown Care Plan was revised on [DATE] with the intervention of a pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed.
On [DATE] at 9:34 AM, Surveyor observed R51 sitting in a Broda chair in R51's room with a cloth heel boot on the left foot and a sock on the right foot. An air mattress was in place on R51's bed. R51 stated R51 had a bad sore on the left foot. Surveyor noted R51 had documentation of a diabetic ulcer to the left outer ankle and a pressure injury to the left medial foot. No dressings could be observed due to the cloth heel boot on R51's left foot.
On [DATE] at 3:52 PM, Surveyor observed R51 in bed lying on an air mattress. A cloth heel boot was in place to the left foot and a gripper sock was on the right foot. R51's left leg was bent at the hip and knee with outward rotation. The outer left foot was resting on the heel boot which ended mid foot and the left fifth toe was resting on the mattress.
On [DATE] at 10:41 AM, Surveyor observed R51's wound care performed by Licensed Practical Nurse (LPN)-BB and assisted by Certified Nursing Assistant (CNA)-CC. R51 was lying in bed with egg crate heel boots on that covered the heel only. The left medial foot Unstageable pressure injury was located on the bunion area of the foot. LPN-BB was unsure of how the wound developed. Surveyor noted DTIs to the left lateral foot and the left fifth toe. Surveyor asked LPN-BB if LPN-BB was aware of those areas. LPN-BB stated there was no treatment to those areas that LPN-BB was aware of and had not seen those pressure wounds before. CNA-CC stated CNA-CC worked two days ago, [DATE], and that was when CNA-CC first saw those areas of concern. CNA-CC stated the pressure areas came from R51's shoes because they stopped having R51 wear shoes last week. LPN-BB stated R51's regular boot is in the laundry and LPN-BB pulled the cloth boot out of the laundry basket in R51's closet. LPN-BB stated the pressure wound to the left outer foot came from that boot because the edge of the boot, with the stitched seam, lines up with the edge of the foot where the pressure injury is. LPN-BB stated the egg crate boots must have come from hospice, but LPN-BB would get R51 some new boots. LPN-BB stated LPN-BB would let DON-B know about the new areas as well as notify the Nurse Practitioner and the wound physician.
On [DATE] at 5:10 PM in the progress notes, LPN-BB documented R51 had new skin alterations to the left lateral foot and the fifth digit of the left foot that was noted during wound treatment that morning. The DON/wound nurse was notified, and the wound physician was updated. A daily treatment order was obtained and completed that morning.
On [DATE], DON-B documented comprehensive assessments of the DTI to the left fifth digit and the left medial foot.
On [DATE], the wound physician documented the left foot pressure wounds noted are related to R51's spasticity and inability to adequately offload the wounds despite pressure offloading boots and repositioning by the facility. R51 has attempted to be compliant with this but unfortunately due to underlying medical factors, R51 is unable to maintain offloading position. Surveyor noted R51's care plan did not address the floating of heels or address R51's tendency to position the left leg with outward rotation to prevent the development of pressure injuries.
On [DATE] at 9:28 AM, Surveyor observed R51 sitting in a Broda chair. R51 had socks on both feet that were resting directly on the foot board/footrest. Surveyor noted the eggcrate heel boots were on the windowsill in R51's room. R51's left foot was rotated slightly so the side of the foot was touching the foot board where the new DTI areas were discovered on [DATE]. No pillows or heel boots were in place.
On [DATE] at 11:02 AM, Surveyor shared with DON-B the concerns that R51's skin was not comprehensively assessed when readmitted to the facility on [DATE], the DTI to the left medial foot was not discovered or assessed until [DATE] when R51 was seen by the wound physician, and R51's care plan did not address R51's positioning with the outward rotation of the left leg to prevent pressure injuries. R51 developed two DTI's that were discovered during wound care on [DATE] when Surveyor was observing, and CNA-CC stated those areas were present two days prior. DON-B stated hospice provided the eggcrate heel boots, and the wound physician said the wounds were unavoidable because of contractures and positioning, the air mattress, and the boots should help and not hinder pressure areas. Surveyor shared with DON-B the concern R51 had known positioning challenges and those were not addressed through assessment or care planning.
3.) R93 was admitted to the facility on [DATE] with diagnoses of dementia, diabetes, congestive heart failure, and anemia. R93's admission Minimum Data Set (MDS) assessment dated [DATE] documented R93 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 5 and was dependent for dressing, personal hygiene, transferring, and bed mobility. The Pressure Ulcer Care Area Assessment (CAA) from R93's Significant Change MDS dated [DATE] documented R93 was at risk for the development of a pressure injury.
R93's Potential for Alteration in Skin Integrity Care Plan was initiated on [DATE] with the following interventions:
-Barrier cream to areas exposed to moisture/incontinence.
-Bathe with mild soap.
-Daily foot check as (R93) will allow.
-Elevate heels off bed as (R93) will allow; (R93) declines frequently.
-Inspect skin daily with care.
-Moisturize dry skin.
-Monitor nutritional status.
-Pericare after incontinent episodes.
-Position body with pillows/support devices; (R93) will decline use of these.
-Pressure reduction support on wheelchair.
-Treatment as ordered.
-Use of equipment for fragile skin.
On [DATE], R93's Potential for Alteration in Skin Integrity Care Plan was revised with the following interventions:
-Absorbent to wick up moisture.
-Dietary referral as needed; encourage acceptance of supplements.
-Educate (R93) and/or family regarding pressure injury management.
-Monitor/manage diabetes, assess lower extremities for arterial insufficiency and/or appropriate foot and nail care.
-Pressure reduction foam mattress or pressure redistribution support (low air or alternating air) in bed.
Surveyor noted no documentation was found for R93's Potential for Alteration in Skin Integrity Care Plan to be revised on [DATE]; no alteration in skin documentation was found or skin assessments documenting any new pressure injury concerns.
On [DATE] at 3:37 PM in the progress notes, nursing documented R93 had a large intact blister to the left heel. A new treatment for skin prep to the left heel every shift was initiated.
On [DATE] on the Wound and Skin Assessment (WASA) form, Director of Nursing (DON)-B documented the left heel Deep Tissue Injury (DTI) presented as a fluid filled blister that measured 8.5 cm x 11 cm. Surveyor noted this was the first comprehensive assessment after the discovery of the pressure injury three days prior.
On [DATE] on the WASA form, DON-B documented the DTI measured 8.5 cm x 9 cm and presented as a deflated blister with exposed dermis. Surveyor noted the exposed dermis was not a characteristic of a DTI but the development into a Stage 3 pressure injury or Unstageable.
DON-B assessed R93's left heel pressure injury weekly with the wound evolving into a stable heel cap with 100% eschar on [DATE] and progressing to an Unstageable pressure injury on [DATE] with 100% eschar. Surveyor noted the pressure injury was staged as a DTI while there was 100% eschar from [DATE] until [DATE]. The left heel pressure injury was Unstageable from [DATE] until [DATE] when the wound bed was 100% granulation and staged at a Stage 3. Surveyor noted no wound depth was documented from the development of the wound until [DATE].
On [DATE] at 1:55 PM, Surveyor observed Licensed Practical Nurse (LPN)-BB complete wound care with R93. Surveyor observed LPN-BB apply skin prep to bilateral heels. Surveyor noted R93 did not have any open areas on either heel at that time.
In an interview on [DATE] at 10:56 AM, Surveyor asked DON-B what the facility process was for a resident that developed a pressure injury while at the facility. DON-B stated the nurse on the floor would either complete a comprehensive assessment at that time or if it was an LPN that discovered the wound, a Registered Nurse (RN) that was in-house would be notified to come and assess. DON-B stated it would be situational about when the wound would be assessed. DON-B stated the wound physician is in the building weekly and they may wait until the wound round day to have the resident seen by the wound physician. DON-B stated the wound physician would then see the resident weekly for the weekly assessments. Surveyor shared the concern R93 developed a pressure injury to the left heel on [DATE] and was not comprehensively assessed until [DATE]. DON-B stated the facility had an Assistant DON (ADON) that was a wound nurse, but DON-B could not recall if the ADON saw R93 at all during that time. Surveyor shared the concern with DON-B the wound measurements did not include a depth measurement until [DATE]. DON-B stated the wound was superficial, but agreed a depth should have been documented.
5.) R79 was admitted to the facility on [DATE] with pertinent diagnoses that include type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood) and chronic diastolic (congestive) heart failure (occurs when the heart's left ventricle becomes stiff and doesn't relax properly, hindering its ability to fill with blood).
Surveyor noted R79 has a physician order dated [DATE] documenting cleanse right fourth toe with soap and water and change band aid daily every day shift for Wound cleansing.
R79's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE], documents a Brief Interview for Mental Status (BIMS) assessment score of 12, meaning moderate cognitive impairment. The MDS documents that R79 was not assessed to have any behaviors during the look back period. The MDS documents that R79 is at risk of pressure injuries, however no skin concerns were documented.
R79's most recent Braden Scale for Predicting Pressure Score Risk evaluation dated [DATE] documented that R79 was assessed to have a score of 15, indicating R79 is at mild risk of developing a pressure injury.
R79's care plan documents R79 is with actual alteration in skin integrity r/t (related to) DM (diabetes mellitus), incontinent, moisture, decreased activity, assistance needed with ADL's(activities of daily living). Swelling. Resident is with rashes to skin at times. Right lower extremity
Date Initiated: [DATE]
The care plan documents the following interventions:
o Educate resident and/or family about risk for pressure ulcer/injury
Date Initiated: [DATE]
o Inspect skin daily with care
Date Initiated: [DATE]
o Moisturize dry skin
Date Initiated: [DATE]
o Pressure reduction foam mattress or pressure redistribution support (low air or alternating air) in bed
Date Initiated: [DATE]
o Treatment as ordered
Date Initiated: [DATE]
R79's Nursing Weekly Summary dated [DATE] documents No New Skin Conditions.
R79's Nursing Weekly Summary dated [DATE] (no time indicated) documents No New Skin Conditions.
R79's progress note written on [DATE], at 9:18 pm, documents Resident has a small open area on his RLE (right lower extremity). Area was washed with warm water and patted dry. Writer applied an oil emulsion dressing, ABD (abdominal) and secured with rolled gauze. Resident tolerated well. NP (Nurse Practitioner) notified. Surveyor noted there is not a comprehensive assessment of this small open area on R79's RLE. The progress note does not specify where the area is located on R79's RLE.
R79's Nursing Weekly Summary dated [DATE] documents both Skin intact and No New Skin Conditions.
The sections If Skin Condition present - Document Site, type of condition, TX (treatment), and progress and Additional comments are left blank on the three Nursing Weekly Summary reports reviewed.
Surveyor noted [DATE] R79's open area was found, and it was not documented on the [DATE] Nursing Weekly Summary and on the next week's [DATE] Nursing Weekly Summary documents R79's skin was intact.
Surveyor noted no update to R79's care plan after the open area was discovered to the right lower extremity on [DATE].
R79's physician order dated [DATE] documents Clean area with warm soapy water, cover with oil emulsion dressing, ABD, and wrap with rolled gauze every day shift for Skin Condition.
R79's physician order dated [DATE] documents SKIN CHECK COMPLETED, every day shift every Tue (Tuesday). This was not marked as completed on [DATE].
R79's Skin Sweep form was completed on [DATE], by Director of Nursing (DON)-B that documents 1 x 1 full thickness opened blister, tx (treatment) order in place with the 4th right toe circled on the body chart. Surveyor noted the documentation of a full thickness wound would indicate the pressure injury is either an unstageable, stage 3 or stage 4 pressure injury based upon being a full thickness wound. There is no staging noted by the facility.
On [DATE], at 11:40 AM, Surveyor interviewed DON-B regarding the progress note written on [DATE] related to the right lower extremity open area found on R79. Surveyor asked if an assessment was completed. Per DON-B there is probably a paper assessment that was done during the skin sweep.
Surveyor noted that R79's 4th right toe was the only skin concern documented on the Skin Sweep form.
On [DATE], at 11:56 AM, Surveyor interviewed Registered Nurse (RN)-PP about R79's treatment. RN-PP stated the treatment had already been done for the day. Surveyor stated it was not marked as administered under treatments and RN-PP replied that they write down what need to do then cross off on the paper, R79's treatment is crossed off. RN-PP will document the administration at the end of the shift. Surveyor asked RN-PP to describe the wound to R79's right lower extremity and was told it is a skin tear that the scab came off. When RN-PP did the treatment, the wound was dry with no drainage. The wound bed was pink.
On [DATE], at 12:20 PM, Surveyor was provided R79's Skin Sweep form and Surveyor noted only the 4th right toe was documented. There is no reference to the RLE wound receiving a treatment.
On [DATE], at 12:27 PM, Surveyor interviewed DON-B regarding the right lower extremity open area not being on R79's Skin Sweep form and was told when DON-B saw R79 on the evening of 17th there was nothing there. Surveyor stated a treatment was in place and should have been seen during sweep. DON-B stated she needs to look into this.
Surveyor noted being unable to locate documentation of an assessment of R79's right lower extremity open area. Surveyor noted there was a treatment order that was charted on [DATE] through [DATE]. Surveyor noted the care plan was not updated after discovery of the open area.
On [DATE], at 02:52 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, DON-B and Corporate-AA that the extended survey has been completed, the immediate jeopardy has not been removed due to concerns with two additional residents that were reviewed. R79's progress note written [DATE] identified an open area on the right lower extremity. A physician order was obtained and documented. Surveyor was unable to locate assessment information, and the care plan was not updated. This area should have been identified on the skin sweep as there was an active order for a treatment in place.
No further information was provided at the time of write up regarding an assessment of R79's open area on the right lower extremity.
Based on observation, interview, and record review, the facility did not ensure 5 of 7 residents (R) reviewed (R17, R51, R93, R91 and R79) had a comprehensive assessment and care plan to prevent and heal pressure injuries.
* R17 was admitted to the facility on [DATE]. Upon Minimum Data Set (MDS) admission assessment and subsequent MDS assessments, R17 was assessed to be at risk for pressure injuries. R17 had admitting left and right anterior shin open areas. On [DATE], R17 developed a left toe and left ankle venous wounds. On [DATE], R17 was readmitted to the facility following a hospitalization with a venous wound left ankle, diabetic wound left dorsal foot, and diabetic left 4th toe wound. On [DATE], R17 developed a skin tear to the left shin and on [DATE], R17 developed a skin tear to the left leg. On [DATE], Occupational Therapy advised R17 that he should no longer self-propel his wheelchair with his arms and hands due to shoulder, pain and begin to self-propel with his legs and heels. On [DATE], R17 developed a non-pressure wound to the left great toe and on [DATE], the etiology changed from non-pressure wound to arterial wound to the left great toe. On [DATE], R17 developed an arterial wound to the right great toe. On [DATE], R17 had an appointment at the Wound Clinic and the wound Medical Doctor (MD) discovered a new unstageable left heel pressure injury. The wound MD wrote orders that R17 cannot self-propel with his heels and would need staff to push him in wheelchair. The care plan does not indicate use of an air mattress, heel offloading or pressure reducing boots as interventions prior to [DATE] when R17 developed the unstageable left heel pressure injury. There is no care plan for diabetic foot assessment or monitoring. The facility does not have evidence of any discussion with R17 regarding risk and benefits of self-propelling in his wheelchair with his legs and heels. On [DATE], R17 had left great toe amputated. On [DATE], R17's left heel was debrided and now presents as a Stage 4 pressure injury. On [DATE], R17 had a Magnetic Resonance Imaging (MRI) with results R17 has osteomyelitis (inflammation of the bone causing infection) with edema (swelling caused by excess fluid) enhancement of left heel. R17 was scheduled for a partial left heel removal on [DATE], however this did not occur as R17 was hospitalized on [DATE] and expired on [DATE].
The facility's failure to assess R17's risk for the development of pressure injuries and to establish preventative interventions to address R17's risk led to R17 developing a facility acquired, avoidable stage 4 pressure injury with osteomyelitis. The facility did not establish a care plan to assess R17's diabetic feet daily. The facility encouraged R17 to propel himself using his legs and heels to improve mobility but neglected the likelihood of R17 developing pressure injuries based on his extensive comorbidities and frail skin by using the same repetitive motion causing friction and pressure on the heels. R17 self-propelled with his legs and heels from [DATE] until the pressure wound developed, consequently, discovered by the wound physician on [DATE]. These failures created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility's failure to prevent the development of a facility acquired stage 4 pressure ulcer with osteomyelitis by ensuring assessment, prevention, and treatment in accordance with current standards of practice created a finding of immediate jeopardy (IJ) that began on [DATE] and has not yet removed by closure of survey on [DATE].
On [DATE] at 03:27 PM, Surveyor notified facility of the IJ. Facility staff present include Nursing Home Administrator (NHA)-A, Assistant Nursing Home Administrator (Assistant Administrator)-F, Senior Leader-H, Assistant Nursi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility did not ensure 2 out of 6 residents (R92 & R95) reviewed for being at high risk for falls, received adequate supervision and assistance devices to prevent accidents.
R92 is at high risk for falls and had 4 unwitnessed falls at the facility. The facility did not ensure they thoroughly investigated each fall to determine the root cause and to assure that all interventions were in place at the time of the fall and were effective.
R95 is at high risk for falls and has experienced several falls while at the facility. The facility did not ensure that they followed R95's toileting plan, which would reduce the chance that R95 would try to toilet herself and potentially fall. In addition, Surveyor observed R95 being transferred with a gait belt and 1 staff member when the plan of care indicates she needs a hoyer lift for transfers.
Findings include:
Policy Review Fall Management Program, dated 08/2020
The facility is committed to minimizing resident falls and/or injury as to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment.
Procedure:
1.) Complete a fall risk assessment upon admission, re-admission, with significant change, post fall, quarterly and annually.
2.) Educate patient, family or responsible party related to:
a. fall prevention
b. Call, don't fall for cognitive residents
3.) Educate staff members to check during room rounds the 4 P's
a. pain
b. positioning
c. placement of personal items
d. personal needs
4. Plan of care reviewed and updated at time of occurrence, quarterly and as needed in order to minimize risk for fall incidents.
5. Use standard fall/ safety precautions for all residents:
a. All staff will be trained on the Fall Management Program
b. At the time of admission, and in accordance with the plan of care the resident will be orientated to, use the nurse call device. The nurse call device will be placed within the residents reach.
c. Call lights to be answered promptly.
d. The bed will be maintained in a position appropriate for resident transfers.
e. The bed locks will be checked to assure they are in locked position.
f. Personal possessions will be within reach when possible. Assistive devices will be within reach if resident is capable of using independently.
g. The resident's environment will be kept clear of clutter. Lighting will be appropriate for the time of day.
1.) R92 was originally admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Lewy body Dementia, congestive heart failure and tremors.
The most recent quarterly MDS (Minimum Data Set), dated 5/15/25 documents R92 has a BIMS (brief interview for mental status) score of 15 (intact cognitive function). R92 has experienced falls at the facility since admission, 2 or more without injury. There has been no falls with major injury.
The facility conducted falls assessments on 5/6/25, 5/14/25, 6/5/25 and 6/10/25. These assessments all indicated R92 is at high risk for falling.
On 10/10/24, the facility initiated a plan of care documenting R92 is at Risk for falls r/t (related to) weakness, Parkinson's disease, and neurocognitive disorder, use of assistive device and need for staff assistance. (R92) is unaccepting of his limitations. Parkinson's, acute encephalopathy
(R92) prefers wife not be notified of falls to avoid causing her and himself emotional distress.
(R92) continues to transfer self w/o (with out) staff and needs reminders that he is a HOYER (sic).
Interventions included:
Will accept interventions to help prevent falls through next review. Date Initiated: 01/26/2025. Assist resident to get up and out of bed during the night when resident is not feeling sleepy.
Date Initiated: 10/10/2024.
Dycem to wheelchair. Date Initiated: 01/26/2025.
Encourage and offer rest periods when walking. Date Initiated: 10/10/2024.
Encourage resident to Call, don't fall. Date Initiated: 10/10/2024.
Encourage resident to keep room free of obstacles. Date Initiated: 05/04/2024.
Encourage use of and provide a Reacher as needed to assist resident with getting
items from hard-to-reach areas. Date Initiated: 02/24/2025.
Ensure adequate lighting for tasks. Date Initiated: 05/04/2024.
Keep bed in lowest appropriate position. Date Initiated: 01/26/2025.
Keep frequently used items within reach in room. Date Initiated: 10/10/2024.
Surveyor conducted a review of R92's medical record and noted the following falls:
4/7/2025 at 02:45 a.m., Post Occurrence Documentation Description of occurrence: Nurse called to (R92's) room to observe resident lying in the supine position on the floor next to his bed. (R92) stated, I tried getting out of bed by myself, slid out of bed on the floor. I was told that I could do this by myself. (R92) denies any pain, resident denies hitting his head. (R92) did not want nurse to call his wife, and stated, Do not wake her up at 0300, I will tell her when she comes to see me today. (R92) was educated on the importance of using his call light for help, and that he still needs the assistance of staff to transfer. Resident verbalized understanding. Charge nurse was called. VS (vital signs) obtained and stable. Neuro checks started. RN completed a head-to-toe assessment. Resident was assisted back to bed via hoyer and 3 staff members.
On 4/7/2025 at 11:43 a.m, Interdisciplinary Team (IDT) Note Text: IDT met to review R92's fall incident on 4/7. Root cause is most likely self-transfer. No pain, no injury. Care plan updated.
Surveyor conducted a review of the facility's fall investigation dated 4/7/25. Immediate intervention was to re-educate on calling for assistance and placing call don't fall signs in his room. Surveyor verified that the intervention for CALL DON'T FALL sign in room was added to the plan of care back on 10/10/24. In addition, on 4/7/25 the intervention was to continue to remind (R92) to call when needing assistance with transfers. The facility's fall investigation includes a staff statement that documents that R92's call light was turned on. The investigation does not include how long the call light was activated prior to staff finding R92. The investigation does not indicate what other interventions were in place at the time of the fall; for example; was bed in lowest position. Surveyor noted if R92's call light was on R92 did what was expected by R92 to prevent a fall, the investigation does not include a review on if staff implemented the care plan to prevent falls after R92 requested assistance with the call light.
On 4/25/2025 at 11:45 p.m., Post Occurrence Documentation: Description of occurrence: (R92) had unwitnessed fall in his room. Found lying on the floor by the door, w/c (wheelchair)and walker by the bathroom door. (R92) was ambulating independently using a walker. Slipped d/t (due to) wet floor and fell. Res. (resident) was in regular socks. No injuries noted. Denied discomfort and hitting his head.
On 4/28/2025 at 11:00 a.m., Interdisciplinary Team Note Text: Clinical IDT met to review (R92's) fall from 4/25. No injury noted. R92 slipped on ice chips he dropped on the floor while attempting to walk to obtain a soda. Administrator to provide education with R92 and family regarding asking for assistance and calling for help.
Surveyor conducted a review of the facility's falls investigation for the fall that occurred on 4/25/25. R92 did not have gripper socks on due to resident prefers to go to bed around 9:30 p.m. Fall happened approximately 8:45 p.m. 45 minutes prior to R92's preferred bedtime. The investigation did not indicate if the other falls interventions were in place at the time ( i.e. call light in reach). The fall investigation did not include review of whether this was a usual pattern for R92 or steps staff could take to help ensure R92's safety.
On 5/3/2025 at 10:17 p.m., Nurses Note Text: (R92) had a fall while self-transferring from recliner to w/c. Educated resident on need to ask for assistance to remain safe. Intervention: ensure w/c is locked so that when resident decides to self-transfer, he is able to do so.
On 5/5/2025 at 10:52 a.m., Interdisciplinary Team Note Text: IDC (interdisciplinary clinical) Team reviewed fall on 5/4/25 ([sic] documentation is wrong date, fall was 5/3/25). The goal of the facility is resident safety. R92 continues to be noncompliant with safety education on not (sic) self-transferring. A new intervention was implemented. Family notified.
Review of R92's care plan includes the following added interventions: Encourage resident to keep room free of obstacles. Date Initiated: 05/04/2024. Ensure adequate lighting for tasks. Date Initiated: 05/04/2024. Surveyor noted the initial recommendation was to ensure R92's wheelchair was locked for safety, this was not added to the care plan.
5/6/2025 at 03:00 a.m., Post Occurrence Documentation; Description of occurrence: CNA reported (R92) called on call light and as she entered room to answer call light resident was noted to be sitting on floor. Writer entered room and noted resident sitting on floor in front of his recliner. (R92) stated while he was trying to grab his blanket he slipped out of his recliner chair onto floor in sitting position. Resident denies hitting head. Resident denies pain or discomfort. Resident was assessed. VSS (vital signs stable). No injuries noted. MAE's (mobility assessment of extremities) per his norm. Assisted up x2 (with 2 staff) via hoyer lift into recliner. Resident instructed to call for assistance and voiced understanding.
Surveyor conducted a review of the facility's fall investigation for the 5/6/25 fall - (R92) and wife were educated regarding fall management program and following interventions. Staff stated (R92) put on call light at approximately 3:00 a.m Staff stated she was doing rounds, finished what she was doing and went to R92. The light was not on long, estimates just a few minutes. A review of the facility's investigation documents (R92) had activated the call light and CNA did enter the room and found R92 to be sitting on the floor. (R92) says he tried to grab his blanket, he slipped out of his recliner chair on to the floor. The investigation did not indicate why R92 was sleeping in recliner and not his bed and how long the call light was activated before staff arrived in R92's room. Surveyor noted R92 again did follow the care plan by activating the call light as instructed by the facility however, a fall still occurred. The facility did not review the effectiveness of this intervention.
5/12/2025 at 02:15 a.m., Post Occurrence Documentation: Description of occurrence: Nurse was entering (R92's) room to check his oxygen saturation and observed R92 laying on the floor between his bed and recliner, (bare) feet under the bed and head near recliner. Resident was rolled slightly onto his left side and had a blanket under him; he was not yelling for help. (R92) states he was reaching for a blanket and that he was in his bed (there were multiple blankets in his bed). He denies hitting his head or having any pain. Head to toe assessment complete with full range of motion and no signs of injury, vital signs and neuro check also complete. Resident was transferred into his recliner via hoyer, call light was clipped to his shirt, and he was reeducated about calling for assistance and not attempting to self-transfer for his safety.
Surveyor conducted a review of the facility's investigation for the fall that occurred on 5/12/25. (R92) likes to be warm but not hot and will kick off coverings/socks if he is hot. The facility's falls investigation did not include information if the falls interventions were in place at the time of the fall such as the call light being in reach, low bed etc. Surveyor note this the the second fall R92 experienced reaching for a blanket, care plan interventions initiated 10/10/24 included to keep frequently used items within reach in room.
On 5/12/2025 at 11:30 a.m., Interdisciplinary Team Note Text: Clinical IDT met to review fall from 5/12. The goal of the facility is resident safety. A new intervention was implemented. All parties notified. Review of R92's fall care plan does not indicate what the new intervention is that has been implemented.
06/12/25 03:16 PM Surveyor interviewed Nursing Home Administrator (NHA)- A and Director of Nursing (DON) -B regarding the fall investigations for R92. Surveyor asked if the facility had investigated the call-light response times on the occasions were R92 activated the call light for assistance and still was found to have an unwitnessed fall. In addition, Surveyor asked if the facility, included in their investigations, whether all falls care planned interventions were in place at the time of the falls for R92. As of the time of the exit, no additional information had been provided.
2.) Facility Policy titled Transfer dated 3/10/2022 documents:
Definition:
Transfer refers to activities provided to improve or maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record.
General Transfer Guidelines:
1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe transfers of residents.
2. Manual lifting or residents should be eliminated when feasible.
3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan Such assessment shall include:
b. Resident's mobility (degree of dependency)
d. Weight bearing ability
e. Cognitive status
4. Staff responsible for direct resident care with be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices .
General Transfer Procedure:
9. Use a transfer/gait belt .
R95 was initially admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, and judgment), and history of falling.
R95's Quarterly Minimum Daily Set (MDS) with an assessment reference date of 3/13/25 documents Under Section C cognitive patterns a Brief Interview for Mental Status score of 6 indicating R95 having severe cognitive impairment. Under section GG Functional abilities and goals assesses R95's toileting hygiene as: needing supervision or touching assistance. Helper provides verbal cues or touching/steadying assistance as resident completes activity. Under section GG Functional abilities and goals assesses R95's toileting transfer as: set up or clean up: resident completes activity.
R95's Care Area Assessment (CAA) with assessment reference date of 12/7/24 identified R95 as a fall risk. CAA section analysis of finding documents: R95 is admitted following a fall at home with pelvis fracture. Pt (patient) with right subdural hematoma (brain bleed) right scalp hematoma, right posterior rib fractures and left symphysis pubis and inferior pubic ramus fracture (pelvic fracture) . Resident since admission fell resulting in injury Resident requires assistance from staff for activities of daily living (ADLS), transfers.
R95's Physical Therapy treatment note dated 6/9/25 at 01:55 PM, documents R95 dependent with squat pivot transfer x 2 assist. R95 demonstrated increased agitated behavior. Nursing informed and R95 downgraded to Hoyer (full body mechanical lift) for transfers at this time.
R95's Mechanical Lift care plan documents R95 requires the use of a mechanical
lift for transfers. Date Initiated: 06/09/2025. The interventions section documents: Resident will tolerate total body (Hoyer) lift transfers from surface to surface with staff assistance. Date Initiated: 06/09/2025 Target Date: 09/10/2025. Instruct resident prior to transferring him/her. Date Initiated: 06/09/2025. Never leave the resident unattended when in the lift. Date Initiated: 06/09/2025. Provide 2 staff assistance for transferring. Date Initiated: 06/09/2025. Use total body (Hoyer lift) when transferring resident. Date Initiated: 06/09/2025.
R95's fall care plan documents R95 is at RISK for falls r/t (related to) history of falls, poor safety awareness r/t dementia, impaired balance, (R95) will self-transfer, resident is impulsive with self-transfers.
Family is aware of fall risk Date Initiated: 11/20/2024. R95's interventions section documents: Toilet Use prompt voiding upon waking up, before or after meals and before bed Date Initiated: 02/18/2025.
Call don't fall sign initiated for visual reminders Date Initiated: 05/05/2025. Encourage resident to be out of her room when she is awake. Date Initiated: 05/20/2025. enc (encourage) use of grip nonskid socks when in bed for safety Date Initiated: 05/30/2025. Encourage resident to Call, don't fall. Date Initiated: 02/18/2025. Surveyor note call do not fall is a duplicated intervention with two dates of initiation on R95's care plan.
R95's Interdisciplinary team (IDT) review on 2/18/25, after R95 had a fall, documents: Root cause of incident was resident attempting to self-transfer to go to the bathroom. Immediate intervention was resident was assisted to the toilet. RN assessed prior to movement. Vitals WNL (within normal limits), neuros (neurological checks) initiated, provider, family notified. Obtained swelling and small bump on head. Physician aware. NNO (no new order). Resident last fall was in December 2024. BIMS (Brief interview for Mental Status) score is 7. Will do prompted voiding with resident. Care plan updated.
R95's Nursing Note on 6/9/25 at 9:00 PM, charted by LPN-I documents Note Text: Resident resides at (name of facility) for LTC (long term care) w/dxs (with diagnosis) of dementia, COPD (chronic obstructive pulmonary disease), HTN (hypertension), polyneuropathy, fall hx (history), anxiety, sleep disorder, chronic pain and hearing loss, A&O x 1 (alert & oriented times 1), meds (medications) whole w (with)/water, self-transfers, mobilizes in wheelchair which she self-propels, Gen (general) diet/Reg tex (texture)/Thin liquids, feeds self, APAP (acetaminophen) for pain control, penicillin allergy, bowel/bladder continent usually, calm, polite and cooperative, HOB (head of bed) elevated due to SOB (shortness of breath) while lying flat. Resident's transfer status has been changed to a Hoyer due to decline in condition. Resident is a DNR (do not resuscitate), incapacitated.
Review of R95's Certified Nursing Assistant (CNA) care Kardex located during the survey in the resident care binder: Toileting: Toilet Use prompt voiding upon waking up, before or after meals and before bed Date Initiated: 02/18/2025. Transfer: Provide 2 staff assistance for transfer. TRANSFER: HOYER (mechanical lift).
On 06/11/25, at 11:03 AM, Surveyor asked LPN-I if R95 was in R95's room. Surveyor followed LPN-I into R95's room after knocking to check on R95. LPN-I asked Surveyor to step back because LPN-I had to get R95 off toilet. Surveyor stepped back to door then came back in to ask are you transferring R95 off the toilet. LPN-I informed Surveyor yes LPN-I needed to get R95 to the wheelchair. Surveyor observed LPN-I placing R95 back into a wheelchair with no gait belt. LPN-I informed Surveyor R95 had transferred herself to the toilet and LPN-I helped R95 back to the wheelchair. LPN-I informed Surveyor R95 is not safe to transfer on her own but will impulsively self-transfer to the toilet without informing staff. Surveyor observed LPN-I explain to R95 to ask for help and to be safe. LPN-I informed Surveyor we have signs on the wall to remind R95 to not transfer without asking for help. LPN-I informed Surveyor we keep providing education to turn R95's light on. LPN-I informed Surveyor there is nothing we can do about it because R95 just transfers when R95 wants to transfer. Surveyor asked LPN-I if R95's cognition and transfer ability had declined recently. LPN-I informed Surveyor R95 has declined physically and mentally but was not always compliant before the decline. LPN-I again informed Surveyor there not much we can do because R95's impulsiveness. Surveyor asked if R95 was on a prompted toileting program would that help decrease R95's self-transfers. LPN-I informed Surveyor R95 would self-transfer even if R95 was placed on a toileting program.
On 06/11/25, at 11:26 AM, Surveyor interviewed CNA-S. Surveyor asked CNA-S if R95 is taken to the bathroom by staff. CNA-S informed Surveyor usually the staff recently but, R95 used to be independent up until about a week ago. CNA-S informed Surveyor R95 is more confused now. Surveyor asked CNA-S when does staff take R95 to the bathroom. CNA-S informed Surveyor that CNA-S didn't usually work the morning shift, and that CNA-S usually worked on the PM shift. Surveyor asked CNA-S what the toileting schedule was for R95 on the PM shift. CNA-S informed Surveyor that when CNA usually works the PM shift, R95 will stay in dining room on the PM shift. Surveyor asked CNA-S if R95 ever needed to go to the bathroom when she was in the dining room on the PM shift. CNA-S informed Surveyor if CNA-S sees R95 in R95's room then CNA-S will ask R95 if R95 needs to go to the bathroom. CNA-S informed Surveyor that is when CNA-S will help R95 to the bathroom. Surveyor asked CNA-S why wouldn't staff follow R95's toileting schedule. CNA-S informed Surveyor the staff will toilet R95 when the staff thinks R95 needs to go to the toilet, that R95 is not on a toileting schedule.
Surveyor asked CNA-S if the staff on PM shift use a one assist to transfer R95 to the toilet. CNA-S informed Surveyor that yes, staff did need to use 1 assist for R95 more recently with R95's recent decline in health. Surveyor asked CNA-S if R95 continues to toilet herself, as of the last few days. CNA-S informed Surveyor R95 has continued to toilet herself recently but that R95 was more independent until R95's recent decline in health. Surveyor asked how CNA-S and other staff were transferring R95 now. CNA-S informed surveyor what CNA-S was doing and thought others, probably, were transferring R95 with one assist also. Surveyor asked CNA-S where CNA-S could get information on R95's transfers and toileting schedules. CNA-S informed Surveyor CNA-S wasn't sure where that information was kept. Surveyor asked CNA-S if the facility had more staff could CNA-S toilet R95 more frequently. CNA-S informed Surveyor staff really don't have a chance on PMs to take R95 to the bathroom.
Surveyor asked CNA-S how the staff knew what toileting programs residents might be on and how to care for the residents, especially if a staff member was new. CNA-S informed Surveyor staff just know how to care for the residents. Surveyor asked CNA-S if the staff knowledge came just from their experience. CNA-S informed Surveyor yes, staff just know and that R95 has recently just declined and needs 1 assist of staff to transfer now but, R95's decline is still new to us. Surveyor asked CNA-S to explain what R95's decline is new to us meant. CNA-S informed Surveyor that R95 was more independent until very recently and R95 has just become a 1 assist transfer recently.
On 06/11/25, at 11:32 AM, Surveyor interviewed with Licensed Practical Nurse (LPN)-I about R95's interventions to prevent falls including R95's toileting schedule. Surveyor asked LPN-I to explain the CNA charting which shows R95 self-toileting, especially in early June of 2025, while R95 needed staff assistance for transfers, noting as of 2/18/25 R95 was to transfer using a hoyer lift. LPN-I informed Surveyor that R95 was more able to self-toilet back early part of June 2025. LPN-I informed Surveyor R95 just recently declined. LPN-I pointed out in the task charting that staff have been helping R95 more in the later weeks of June of 2025. Surveyor asked LPN-I if R95 required staff assistance and a mechanical lift for transfers why R95 would be self-toileting and be on a toileting program since 2/18/25. LPN-I informed Surveyor that R95 was impulsive and transferred herself no matter how much staff prompted R95 not to self-transfer. Surveyor asked the LPN-I where CNAs get their information for resident care and toileting programs like the one R95 is on related to falls. LPN-I informed Surveyor that LPN-I did not really know where the CNA would find the toileting programs for residents. LPN-I informed Surveyor that LPN-I just knew the nursing end of the charting and LPN-I has little familiarity with that (referring to CNA documentation) charting.
RN-G called over to Surveyor from RN-G's office that R95 was recently made a Hoyer (sic)(mechanical lift) and the family doesn't want anything else done for R95 and the doctor thinks R95 had a stroke recently.
On 06/11/25, at 12:39 PM, Surveyor interviewed Occupational Therapist (OT)-J. OT-J informed Surveyor that R95 was being discharged from therapies because R95 is not tolerating therapy at this time. OT-J informed Surveyor the facility is a no lift facility, so therapy makes recommendations for safe staff transfers. OT-J informed Surveyor therapy will turn in a care giver training plan to restorative and RN-G implements that transfer status. Physical Therapist (PT)-K came into the office and informed Surveyor that R95 was downgraded to a Hoyer lift from a 1 assist transfer because of R95's recent decline. OT-J informed Surveyor therapy will train the facility staff and on 6/9/25 nursing was informed that R95 was downgraded to using a Hoyer lift for all transfers.
On 06/11/25, at 03:20 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Senior Leader-H of concerns with LPN-I transferring R95 alone, without a gait belt despite R95's care plan going back to February indicating a hoyer lift and two staff were to be used. Surveyor informed NHA-A that staff Surveyor interviewed were not aware of R95's prompted toileting fall intervention placed on the care plan on 2/18/25 to prevent falls and that R95 required the use of a Hoyer with 2 staff for transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 (R51) of 8 residents reviewed for mood concerns.
R51 told a Certified Nursing Assistant (CNA) they did not want to live. No documentation was found that a suicidal evaluation was completed, the physician was notified, or a Care Plan was developed to address R51's depression.
Findings include:
The facility policy and procedure titled Suicidal Ideation dated 10/2024 documents: POLICY: Facility staff will accurately assess, differentiate, and respond appropriately to individuals expressing suicidal ideation or passive death wishes, ensuring safety, appropriate intervention, and documentation.
DEFINITIONS:
Suicidal Ideation (SI): Thoughts of ending one's life, which may include a plan, intent, or means to act.
Passive Death Wish (PDW): A desire to be dead or not wake up, without an active plan, intent, or behavior to end one's life.
PROCEDURE: 1. Residents will be screened for mood disturbances using the PHQ-9 upon admission and, at minimum, quarterly thereafter. 2. If resident expresses passive death wishes, resident will be offered psychosocial support, which may include a referral to the psychologist. 4. If resident does not express a feasible plan with intention, suicidal ideation should be considered passive and care plan should be developed.
R51 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following a cerebral infarction, diabetes, heart failure, legal blindness, bilateral hearing loss, adjustment disorder with mixed anxiety and depressed mood, and mild cognitive impairment.
R51's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R51 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and did not have any symptoms of depression with a PHQ-9 (patient health questionnaire) score of 0.
R51 had received psychological services from an outside provider that came to the facility for visits. R51 had discontinued services in February 2024 due to stabilization of depressed mood.
Surveyor noted no Care Plan was initiated to address R51's depression to include how depression was manifested for R51 or interventions to address those manifestations.
On 4/7/2025, R51 was seen by a psychologist to evaluate R51 for depression. The psychologist conducted a PHQ-9 and R51 scored 8 indicating mild depression. R51 displayed depressed mood, loss of interest, fatigue, poor concentration, difficulty relaxing and fears. The psychologist documented R51 denied having a poor appetite however was having a difficult time staying awake during meals due to hypersomnia. R51 denied any suicidal ideation. The treatment plan was to have individual psychotherapy 2-4 times per month to remediate symptoms of mental health such as depressed mood, anxious mood, and pain management through use of evidence-based adaptive coping strategies and skill. R51 agreed to the psychological consult and treatment.
On 4/14/2025 at 11:21 PM in the progress notes, Registered Nurse (RN)-Y documented a CNA reported to RN-Y that R51 was refusing cares and meals. R51 does not want to live. RN-Y advised the CNA to report this to Social Services. At 11:38 PM in the progress notes, RN-Y documented Nursing Home Administrator (NHA)-A was updated on R51's status.
No documentation was found indicating an assessment was completed after R51 verbalized the desire not to live. No Care Plan was initiated to address R51's statement of not wanting to live. No documentation was found indicating R51's psychologist was informed of R51's statement of not wanting to live.
On 5/2/2025, R51 was admitted to the hospital with altered mental status and was readmitted to the facility on [DATE].
On 5/14/2025, R51 was admitted to hospice services with an admitting diagnosis of cerebral infarction. A Hospice Care Plan was initiated at that time and addressed discussion and acceptance of impending end of life.
R51's Significant Change MDS assessment dated [DATE] documented R51 was cognitively intact with a BIMS score of 13 and was moderately depressed with a PHQ-9 score of 10. The Care Area Assessment (CAA) for Mood documented R51 had moderate depressive symptoms, and a care plan should be developed to address R51's mood. Surveyor noted no mood care plan was initiated.
On 5/27/2025, R51 was seen by the psychologist and the psychologist documented R51 was receiving hospice services and may benefit from psychiatric treatment as opposed to psychotherapy at this point. No documentation of follow up to a psychiatrist was found.
In an interview on 6/11/2025 at 11:16 AM, Surveyor asked RN-Y if RN-Y could recall the event on 4/14/2025 and the conversation with a CNA stating R51 did not want to live. RN-Y reviewed the progress notes from 4/14/2025 and recalled being told R51 was refusing cares and meals and made the statement R51 did not want to live, but could not recall which CNA had approached RN-Y. RN-Y stated RN-Y told the CNA to let the social worker know but was not sure who the social worker was at that time. RN-Y was not sure what happened with R51 after the statement was made. RN-Y stated RN-Y informed NHA-A because that is what RN-Y documented but did not have any further information. RN-Y stated RN-Y did not follow up with R51 as to R51's state of mind at that time. RN-Y stated something should have been implemented but did not know what that would be. RN-Y stated R51 had recently been put on hospice.
In an interview on 6/11/2025 at 11:37 AM, Surveyor asked Director of Social Services (DSS)-Z when DSS-Z started working at the facility. DSS-Z stated DSS-Z started working at the facility in March 2025. Surveyor asked DSS-Z if DSS-Z was aware of R51's statement on 4/14/2025 of not wanting to live. DSS-Z read R51's progress notes from 4/14/2025 out loud so NHA-A, who was in the room, could hear what the progress note said. DSS-Z stated R51 is not suicidal. DSS-Z stated R51 was failure to thrive and declining in condition, so they had a conversation about hospice and R51 was admitted to hospice services. DSS-Z stated the verbiage of not wanting to live is not suicidal. DSS-Z stated they have parameters that they would put in place at that time if someone was suicidal. Surveyor asked how the facility would determine if a resident was suicidal or not. DSS-Z stated they would do a depression assessment, the PHQ-9, to show that. Surveyor asked DSS-Z if the facility did a PHQ-9 at that time. DSS-Z stated R51 was not suicidal. Surveyor noted no assessment was completed to determine if R51 was or was not suicidal or what was meant by R51's statement of not wanting to live. No documentation was found indicating anyone approached R51 at that time to determine R51's state of mind. Surveyor stated to NHA-A that RN-Y documented NHA-A was told of R51's statement of not wanting to live. NHA-A had no recollection of being informed of R51's statement.
In an interview on 6/12/2025 at 1:16 PM, Surveyor shared with DSS-Z the concern R51 did not have a care plan to address depression. DSS-Z stated behaviors and depression are addressed in different sections of the care plan. Surveyor shared with DSS-Z the concern R51's manifestations of depression are not documented and there are no interventions to address the depression. Surveyor noted the care plan with behavioral symptoms are for agitation but not for depression.
On 6/12/2025 at 3:01 PM, Surveyor shared with NHA-A and Director of Nursing (DON)-B the concern R51 refused cares and meals on 4/14/2025 and stated R51 did not want to live. The statement was never followed up on with an assessment to determine the degree of depression, no call was made to psych services that R51 already had in place, and no mood or depression care plan was created even after the Significant Change MDS assessment triggered the Mood CAA where it was documented a care plan would be initiated to address mood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action was taken to address them, for 1 (R39) of 5 residents reviewed.
R39 did not have regular monthly reviews performed by the pharmacist.
Findings include:
The facility's policy titled, Medication Regimen Reviews (MMR) Scheduled and Interim and dated 01/2022, documents the following:
The consultant pharmacist will review the medication regimen, as required by State and Federal regulations. This review should include a review of the resident's medical record.
The consultant pharmacist's MMR report or the interim MMR report will be given to the director of nursing (or designee), upon completion of all medication regimen reviews.
The facility nursing staff will follow up with the prescribing physician and record the response on the report and/or the interim review and make changes as ordered by this physician, within a reasonable time frame.
The completed original reports and/or interim reviews will be kept at the facility.
R39 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R39's diagnoses include pulmonary embolism (blood clot in the lungs), paraplegia (a type of paralysis that affects the lower half of the body), Parkinson's Disease (a progressive nervous system disorder that affects movement), Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (memory loss), mood disturbance and anxiety, depression, and anxiety disorder.
R39's Quarterly Minimum Data Set (MDS) completed on 5/27/25, documents R39 as having a Brief Interview for Mental Status (BIMS) score of 14, indicating R39 is cognitively intact.
Surveyor reviewed R39's Electronic Medical Record (EMR) which documents the Registered Pharmacist (RPh) performed the following monthly medication reviews:
5/12/25 - no recommendations after review from RPh
3/11/25 - no recommendations after review from RPh
2/3/25 - no recommendations after review from RPh
12/20/24 - no recommendations after review from RPh
Surveyor notes R39's EMR did not include monthly medication reviews in January 2025 and April 2025.
On 6/12/25, at 12:55 PM, Surveyor notified Nursing Home Administrator (NHA)-A that R39's EMR did not include monthly medication reviews in January 2025 and April 2025 and requested documentation if available.
On 6/12/25, at 3:18 PM, Surveyor notified NHA-A and Director of Nursing (DON)-B of concerns with R39 not having a monthly pharmacy review performed in January 2025 and April 2025. NHA-A and DON-B acknowledged the concern. DON-B stated R39 was hospitalized in April and did not trigger again for the pharmacist to review after R39 had returned from the hospitalization. Surveyor requested additional information if available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R94 was admitted to the facility on [DATE]. R94's diagnoses include Atrial Fibrillation (a heart condition that causes an irregular pulse rate) and Hypertension (High blood pressure). R94's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25 documents R94 as being rarely to never understood. R94's Quarterly MDS with an ARD of 4/25/25 documents that R94 received an anticoagulant (a medication that thins ones blood to prevent clotting) medication during the 7 day assessment period.
Surveyor reviewed R94's Electronic Medical Record (EMR) which documents R94's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Eliquis 5 mg two times a day for Atrial Fibrillation, last ordered on 10/25/24. Surveyor reviewed R94's MAR and TAR. Surveyor noted there is no documented monitoring of R94's Eliquis, an anticoagulant medication, for potential signs and symptoms of an adverse effect from this medication, such as bleeding, bruising, or fatigue.
On 6/12/25 at 12:45 PM, Surveyor notified Nursing Home Administrator (NHA)-A of R94 receiving Eliquis, an anticoagulant medication, with no documented monitoring for signs and symptoms of potential side effects. No further information was provided by the facility at this time.
Based on record review and interview the facility did not ensure 2 (R39 and R94) of 5 residents drug regime reviewed was free from unnecessary medications.
*R39 receives an anticoagulant (Eliquis) in which the facility did not adequately monitor.
*R94 receives an anticoagulant in which the facility did not adequately monitor.
Findings include:
1.) R39 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R39's diagnoses include pulmonary embolism (blood clot in the lungs), paraplegia (a type of paralysis that affects the lower half of the body), Parkinson's Disease (a progressive nervous system disorder that affects movement), Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (memory loss), mood disturbance and anxiety, depression, and anxiety disorder. R39's Quarterly Minimum Data Set (MDS) completed on 5/27/25, documents R39 as having a Brief Interview for Mental Status (BIMS) score of 14, indicating R39 is cognitively intact.
Surveyor reviewed R39's Electronic Medical Record (EMR) which documents R39's current physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR). R39 is prescribed Eliquis 5 mg two times a day for history of pulmonary embolism, last ordered on 4/3/25. Surveyor reviewed R39's MAR and TAR, and notes there is no monitoring of R39's Eliquis for potential signs and symptoms of an adverse effect from this medication, such as bleeding, bruising, fatigue, dizziness, etc.
On 6/12/25, at 12:54 PM, Surveyor interviewed Registered Nurse (RN)-U who indicates staff monitor residents who are taking an Anticoagulant such as Eliquis for potential side effects. RN-U states staff look for bleeding or bruising and document in the MAR or TAR. RN-U states if a resident has a fall and is taking an Anticoagulant, the resident will be sent out to the emergency room (ER) for evaluation.
On 6/12/25, at 3:18 PM, Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of concerns with R39 taking Eliquis with no monitoring for signs and symptoms for potential side effects. NHA-A and DON-B acknowledged the concern. Surveyor requested a policy for Anticoagulant monitoring if available. DON-B notified Surveyor the facility does not have a policy for Anticoagulants such as Eliquis or Xarelto however, the facility has a policy for Warfarin monitoring. No further information was provided by the facility at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents were seen by a physician or physician extender for 2 (R3 & R1) of 3 residents reviewed for physician services.
* R3 did not have alternating visits between the physician and physician extender.
* R1 was not seen by a physician every 60 days following 90 days after admission.
Findings include:
The facility's policy titled, Medical Care Services and dated 9/2020 documents under policy Residents will receive medical care and services which meet their individual needs and ensure adequate health care. Under procedures documents 4. Residents will be seen by a physician or delegated physician's assistant or nurse practitioner at least once every thirty (30) days for the first 90 days after admission and at least once every 60 days thereafter. A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required. 5. After the initial physician visit in SNF (skilled nursing facility) a qualified Nurse Practitioner NP or PA (physician assistant) may make every other required visit.
1.) R3 was admitted to the facility on [DATE] with diagnoses which includes cerebrovascular accident, hypertension, peripheral vascular disease, and dementia.
Surveyor reviewed R3's medical record and noted the following Physician/Nurse Practitioner visits:
11/8/24 & 11/13/24 by Advanced Practice Registered Nurse (APRN)-II, 11/14/24 by Physician-KK, 11/21/24 by APRN-II, 12/2/24 by Family Nurse Practitioner (FNP)-I, 12/13/24 by Adult Gerontology Primary Care Nurse Practitioner (AGPCNP)-JJ, 12/16/24 by FNP-I, 12/18/24 by APRN-II, 12/24/24 & 1/10/25 by AGPCNP-JJ, 1/16/25 by FNP-I, 1/24/25 &1/28/25 by AGPCNP-JJ, and 2/6/25, 2/17/25, 2/20/25, 2/24/25, 3/10/25, 3/27/25, & 4/7/25 by FNP-I.
Surveyor noted there has been only one visit by Physician-KK on 11/14/24 since R3's admission.
On 4/14/25, at 1:55 p.m., Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor informed NHA-A and DON-B since R3's admission on [DATE] there has been only one physician visit by Physician-KK on 11/14/24. Surveyor inquired if there are any additional physician visits. DON-B informed Surveyor she would look into this and get back to Surveyor.
On 4/14/25, at approximately 3:00 p.m., DON-B provided Surveyor with a copy of Physician-KK's note dated 11/14/24. Surveyor was not provided with any other physician visits for R3.
Surveyor was not provided with any additional information as to why there were not alternating Physician/NP for R3.
2.) R1 was admitted to the facility on [DATE], with diagnoses that include, Parkinson's Disease, Dysphagia, Chronic Kidney Disease, Congestive Heart Failure, Aneurysm, Old Myocardial Infarction, and Dysphagia.
R1's medical record documents:
R1 was seen by physician-KK on 7/25/24 and the next visit completed by physician-KK did not occur until 12/21/24. R1 had not been assessed by a physician for 128 days.
R1's Progress Note, dated 7/25/24, documented, an in person visit with assessment and medication review by physician-KK.
R1's Progress Note, dated 12/21/24, documented, an in person visit with assessment and medication review by physician-KK.
R1 does not have any physician visits following 12/21/24 to exit survey date on 4/14/25. R1 had not been assessed by a physician for 114 days.
On 4/14/25 at 4:15 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of lack of physician visits for R1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being. This deficient practice has the potential to affect all 109 residents residing at the facility.
Surveyor conducted interviews with residents and staff in which they expressed concerns regarding challenging staffing levels.
Surveyor conducted a record review of the Facility's staff schedules and verified the Facility is not providing staffing levels that meet the Facility identified staffing needs documented in the Facility Assessment.
Findings include:
*R4 was admitted to the facility on [DATE]. R4's Quarterly Minimum Data Set (MDS) assessment documents that R4 is cognitively intact.
On 4/2/25 at 2:10 PM, Surveyor interviewed R4. R4 stated R4 does use the call light when R4 needs help. Surveyor asked what the average wait time is for R4's call light to be answered. R4 stated that it depends on the time of day. R4 stated that sometimes the call light will be answered immediately but R4 has waited an hour to an hour and a half in the past. R4 stated R4 can understand if staff is busy but R4 stated R4 would like staff to at least acknowledge R4's call light is on and let him know they will be with R4 as soon as they can. R4 stated R4 requires a Hoyer lift for transfers which requires 2 staff members to help. R4 stated R4 is typically the last one on the list for morning cares because of this. R4 stated the longer wait times occur when there is not enough staff. R4 indicated R4 feels the facility does have staff shortages.
*R2 was admitted to the facility on [DATE]. R2's admission Minimum Data Set (MDS) assessment dated [DATE] which documents R2 is cognitively intact.
On 4/2/24 at 11:27 AM, Surveyor interviewed R2. Surveyor asked if R2 uses their call light. R2 stated R2 does use the call light. Surveyor asked what the average time frame is for staff to answer the call light. R2 stated it depends on the time of day. R2 stated getting help around mealtimes can be more difficult. Dinner time is the longest. R2 stated R2 will sometimes have to wait an hour for help. R2 stated R2 gets concerned with longer wait times and stated it is not a way to live. R2 stated R2 always requires oxygen and fears they would not get help in time if R2 had an issue with his oxygen. R2 stated the facility does not have enough staff on the floor to help.
Staff interviews
On 4/1/25 at 9:40 AM, Surveyor interviewed Anonymous Staff-N. Surveyor asked what staffing levels are like at the facility. Anonymous Staff-N stated facility staff were told by management to say that staffing is wonderful. Anonymous Staff-N stated management does try but call-ins really hurt. Anonymous Staff-N stated weekend staffing is the worst.
On 4/1/25 at 10:15 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-E. Surveyor asked what staffing levels are like at the facility. CNA-E stated that weekends are harder. CNA-E indicated call-ins on the weekend are a regular occurrence. CNA-E indicated that CNA-E is pulled in multiple directions but does make sure that residents are cared for safely. CNA-E stated not having enough staff on the weekends have made CNA-E emotional. CNA-E stated sometimes not all of CNA-E's charting is complete by the end of CNA-E's shift. CNA-E will either have to stay later or complete the rest of CNA-E's charting the next day.
On 4/2/25 at 9:22 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-J. Surveyor asked what the staffing goal is for the unit. LPN-J stated the goal is to have one nurse and 2 CNAs on the unit. LPN-J stated that is the goal, but it does not always work like that. LPN-J stated they do have float staff that will be assigned to a group of units to help. LPN-J stated the weekends are a hot mess. LPN-J stated multiple staff usually call in on the weekends. LPN-J stated LPN-J is still able to get everything LPN-J needs to do completed. LPN-J indicated that LPN-J stays late often but it is by choice. LPN-J stated that LPN-J stayed late yesterday because the facility had a new admit. LPN-J stated it would be hard for the nurse following LPN-J to complete the admit and get all the other work completed. LPN-J stated the facility should have an admission nurse. LPN-J stated an admission nurse would help a lot. LPN-J stated LPN-J is happy at the facility and stated that LPN-J's supervisors are good and supportive.
Staff Schedule Review
The Facility Assessment with a review date of 3/20/25 documents the Facility identified staffing requirements for a 24-hour day. The requirements include: 14 Licensed nurses, 26 CNAs for a census of 109-114 residents, and 27 CNAs for a census of 115 to 120 residents.
Surveyor noted that Medication Technicians (MT) are not identified in the staffing requirements in the Facility Assessment.
On 4/1/25 at 1:30 PM, Surveyor interviewed Staff Scheduler (SS)-M. Surveyor asked what the staff schedule was based on. SS-M stated the schedule is guided by the Facility Assessment and resident acuity. Surveyor asked how resident acuity affects the schedule. SS-M stated that acuity is reviewed by SS-M and Director of Nursing (DON)-B weekly, and it will guide where staff are scheduled at the facility. SS-M indicated that it does not change the number of staff allowed to be scheduled, but again guides where the staff will be scheduled to work in the facility. SS-M stated SS-M always schedules the same number of nurses, but CNAs are based off the census. According to SS-M, MTs count as nurses on the schedule. SS-M indicated call-ins are filled by staff that are at the facility or by contacting other staff members to come in. SS-M stated both SS-M and the Restorative aid are also able to fill in gaps as needed. SS-M stated nurse call-ins are also able to be posted to agency staff boards to fill in those gaps. Surveyor asked if staff on the schedule who are orienting count toward the total number. SS-M stated No. Surveyor asked if the schedule is reviewed with management. SS-M stated the schedule is given to DON-B before posting the schedule. Surveyor asked SS-M to count the number of CNA staff working on each day of February. SS-M counted with Surveyor.
On 4/1/25 at 2:53 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked what staffing for the facility is based on. NHA-A and DON-B indicated that staffing is based on the facility assessment and resident acuity. Surveyor asked if resident acuity affects the number of CNAs on the schedule or if it guides where CNAs are working within the facility. NHA-A and DON-B indicated both. Surveyor asked what MTs are counted as in the staffing plan since they are not listed on the facility assessment. DON-B indicated technically they are CNAs but are able to pass medications. Surveyor confirmed with NHA-A and DON-B the staffing schedule should include 14 licensed nurses and CNAs based on census. NHA-A confirmed that is the staffing plan. Surveyor asked if the schedule is reviewed prior to posting. DON-B stated the schedule is reviewed multiple times a day. DON-B stated the facility has had enough staff to meet the residents needs and is not short staffed. DON-B indicated that DON-B would come in and staff if that was the case.
Surveyor noted MTs would be included in the CNA count on the staff schedules.
Surveyor reviewed the census and staffing schedules with SS-M for the month of February 2025.
-2/1/25: For a census of 118, the facility scheduled 12 licensed nurses, 23.5 CNAs and 3 MTs. Surveyor noted that the facility was down 2 licensed nurses and 0.5 CNAs.
-2/2/25: For a census of 118, the facility scheduled 11 nurses 26 CNAs and 4 MTs. Surveyor noted that the facility was down 3 licensed nurses.
-2/3/25: For a census of 118, the facility scheduled 13 nurses, 24 CNAs and 2 MTs. Surveyor noted that the facility was down 1 licensed nurse and 1 CNA.
-2/4/25: For a census of 118, the facility scheduled 12 nurses (one nurse was being oriented), 26 CNAs and 4 MT. Surveyor noted the facility was down 2 licensed nurses.
-2/5/25: For a census of 116, the facility scheduled 13 nurses, 23.5 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse and 2.5 CNAs.
-2/6/25: For a census of 116, the facility scheduled 11 nurses, 27 CNAs and 2 MTs. Surveyor noted the facility was down 3 licensed nurses.
-2/7/25: For a census of 114, the facility scheduled 13 nurses and 23.5 CNAs. Surveyor noted the facility was down 1 licensed nurse and 2.5 CNAs.
-2/8/25: For a census of 114, the facility scheduled 13 nurses, 24 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse and 1 CNA.
-2/9/25: For a census of 114, the facility scheduled 14 nurses and 24 CNAs. Surveyor noted the facility was down 2 CNAs.
-2/10/25: For a census of 116, the facility scheduled 14 nurses and 26 CNAs. Surveyor noted the facility was down 1 CNA.
-2/11/25: For a census of 114, the facility scheduled 12 nurses, 25 CNAs and 2 MTs. Surveyor noted the facility was down 2 licensed nurses.
-2/12/25: For a census of 115, the facility scheduled 13 nurses, 23 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse and 3 CNAs.
-2/13/25: For a census of 117, the facility scheduled 12 nurses, 25 CNAs and 2 MTs. Surveyor noted the facility was down 2 licensed nurses.
-2/14/25: For a census of 118, the facility scheduled 13 nurses and 21.5 CNAs. Surveyor noted the facility was down 1 licensed nurse and 5.5 CNAs.
-2/15/25: For a census of 118, the facility scheduled 12 nurses, 22 CNAs, and 2.5 MTs. Surveyor noted the facility was down 2 licensed nurses and 2.5 CNAs.
-2/16/25: For a census of 119, the facility scheduled 13 nurses, 22 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse and 4 CNAs.
-2/17/25: For a census of 115, the facility scheduled 14 nurses and 25 CNAs. Surveyor noted the facility was down 2 licensed nurses and 2 CNAs.
-2/18/25: For a census of 115, the facility scheduled 13 nurses, 25.5 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse and .5 CNAs.
-2/19/25: For a census of 117, the facility scheduled 12 nurses, 25 CNAs and 2 MTs. Surveyor noted the facility was down 2 licensed nurses.
-2/20/25: For a census of 116, the facility scheduled 13 nurses, 24 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse and 2 CNAs.
-2/21/25: For a census of 115, the facility scheduled 13 nurses, 21 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse and 5 CNAs.
-2/22/25: For a census of 113, the facility scheduled 14 nurses and 23.5 CNAs. Surveyor noted the facility was down 2.5 CNAs.
-2/23/25: For a census of 112, the facility scheduled 14 nurses and 26 CNAs.
-2/24/25: For a census of 111, the facility scheduled 12 nurses, 22 CNAs and 2 MTs. Surveyor noted the facility was down 2 licensed nurses and 2 CNAs.
-2/25/25: For a census of 113, the facility scheduled 11 nurses, 23 CNAs and 3 MTs. Surveyor noted the facility was down 3 licensed nurses and 1 CNA.
-2/26/25: For a census of 113, the facility scheduled 13 nurses, 25 CNAs and 1 MT. Surveyor noted the facility was down 1 licensed nurse.
-2/27/25: For a census of 112, the facility scheduled 12 nurses, 27 CNAs and 2 MTs. Surveyor noted the facility was down 2 licensed nurses.
-2/28/25: For a census of 113, the facility scheduled 12 nurses, 24 CNAs and 2 MTs. Surveyor noted the facility was down 2 licensed nurses.
Surveyor noted the facility is consistently short on staff based on the Facility assessment.
On 4/2/25 at 4:20 PM, Surveyor informed NHA-A and DON-B of the concerns that both residents and staff have concerns with staffing and that the Facility is not providing staffing levels that meet the Facility identified staffing needs documented in the Facility Assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the Facility did not implement their policies and procedures for reporting allegations of abuse, neglect or injuries of unknown origin for 1 (R1) of 1 residents reviewed with allegations of abuse.
R 1 complained of 10/10 left knee pain following a pivot transfer with assist of 1 the evening of 2/7/25. R1 was assessed to require an EZ stand and assist of 1 for transfers. R1 informed Facility staff in the early morning hours of 2/8/25 the 10/10 left knee pain began after the incorrect transfer method was used on 2/7/25. It was later determined R1 sustained a left distal femur fracture. The Facility did not implement their Abuse Prevention policy and procedure as evidenced by not reporting the incorrect transfer resulting in, significant pain, bruising, and swelling to the Nursing Home Administrator or the State Agency. The Facility did not report R1's major injury of the left distal femur fracture following an incorrect transfer and not following R1's care plan to the State Agency.
Findings include:
The Facility policy entitled, Abuse Policy, dated 9/20, documents, in part, . Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. This will be done by: . Identifying occurrences and patterns of potential mistreatment; Immediately protecting residents involved in identifying reports of possible abuse: Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences; Filing accurate and timely investigative reports.Neglect is the failure of the facility, its employees, or service providers to provide good and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Serious Bodily Injury is an injury involving extreme physical pain, involving substantial risk of death: involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty: or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.
3. Prevention: This facility desires to prevent abuse, neglect and theft by establishing a resident sensitive and resident secure environment. a. Resident and family concerns will be recorded, reviewed, addressed and responded to using the facility's concern/ grievance procedure.
4. Identification: Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or administrator.The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruising or unknown origin, lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instruction.
6. The final investigation report will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts.
7. Initial reporting of allegations are reported immediately. Centers for Medicare and Medicaid Services (CMS), defines immediately as not later than 2 hours after forming the suspicion of abuse which results in serious body injury or not later than 24 hours if no serious bodily injury. A written report shall be sent to the Wisconsin Division of Quality Assurance (DQA). Please see policy regarding local law enforcement agency. a. The administrator or designee will also inform the resident's representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted. b. If there is a finding of abuse by a certified nurse's aide or licensed staff, the Wisconsin Division of Quality Assurance will notify the Nurse Aide Registry or the Department of Professional Regulations. the Wisconsin Division of Quality Assurance will also notify the State Police, for further investigation of the employee. c. Five Day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Wisconsin Division of Quality Assurance. d. Informing the resident's representative. The administrator or designee will inform the resident or resident's representative of the conclusion of the investigation. e. Report to the state nurse aide registry or licensing authorities regarding any allegations of abuse. f. report to the Social Security Administration (SSA) and Local Law Enforcement Agency. g. Review findings to determine if further training or other corrective action is needed to prevent future occurrences. h. If the events that cause the reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but no later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming suspicion.
R1 was admitted to the facility on [DATE], with diagnoses that include, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors.), and Old Myocardial Infarction (heart attack).
R1's Minimum Data Set (MDS) quarterly assessment, dated 2/4/25, documents R1 has a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition, a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions.
R1's Care Plan, dated 6/13/23, documents in part, Focus: R1 has an ADL (Assistance with Daily Living) Self Care Performance Deficit r/t (related to) Parkinson's, weakness and the need for staff to assist with ADL's. Interventions/Tasks: . Transfers: EZ stand, 1 assist, all with date initiated of 6/12/23.
R1's Facility Incident Report dated 2/8/25, at 3:40 am documents, in part, .Nursing Description: Certified Nursing Assistant (CNA) called nurse into room d/t (due to) resident complaining of left knee pain. R1 was laying (sic) in bed with a pillow under her knees. Resident Description: Resident stated that the CNA on PMs (evening shift) did not use the EZ stand (sit to stand) to transfer her to bed and that her left knee is now hurting. When asked if she fell stated she had not and when asked if she had hit her knee on anything she again stated she had not.
R1's Facility Nurses Note dated 2/8/25, at 4:19 am, Registered Nurse (RN-G) documents, TEH (Telehealth) consulted for evaluation of pain to left knee and swelling-new onset, pain rated 10/10. she is on tramadol 50 mg (milligrams) po (by mouth) q (every) 6 hours PRN, she has tylenol scheduled. R1 uses easy stand, noted to be x 1 (assist 1) transfer last evening. No falls or injury known, but she does have left lateral knee ecchymosis blue-ish discoloration. R1 has restriction in her mobility and flexion in her left knee. R1 states pain started post transfer last night. Review of Systems: ROS (Review of Systems) as per HPI (History of Present Illness), all other systems reviewed and are negative PMH (Past Medical History) and SH (Social History). Reviewed PMH and SH and Medications Source. Vital Signs: T (Temperature): 98.4 F (degree Fahrenheit), HR (Heart Rate): 68 BP Sys (Blood Pressure Systolic): 167 mm/Hg (millimeters of mercury)/ bmp (beats per minute), / (over) D (Diastolic): 85 mm/Hg, RR (Rate Respirations): 20 rpm (rate per minute), O2 (Oxygen): 94%.
On 3/31/25, at 8:05 am, Surveyor requested to view the Facility Grievance log and any Facility Reported Incidents (FRI) submitted over the last 3 months. Surveyor noted the FRIs provided do not include concerns related to the care and treatment of R1.
On 3/31/25, at 1:00 pm, Surveyor interviewed Medical Examiner (ME)-U, who states, she typically does not order autopsy's except if abuse, neglect or injury is suspected. She ordered an autopsy for R1. ME-U states she had a phone conversation with NHA-A and DON-B on 2/12/25 which revealed the following: NHA-A states R1 was transferred from chair to bed via pivoting and not EZ stand. ME-U states the preliminary results of the autopsy on 2/14/25, reveal the primary reason for R1's death is Fracture of the Distal Left Femur, and the secondary reason is natural occurring diseases. ME-U asked the physician who completed the autopsy, Medical Doctor (MD)-X, if the injury was from a pivot transfer or a blunt fall injury and MD-X states, this would be consistent with a fall/drop and much less consistent with her hitting the side of the bed or something like that with transfers.
On 4/1/25, at 8:39 am, Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Corporate Consultant (CC)-S, provided the Survey Team with a binder containing the Facility investigation into R1's bruising, swelling of the left knee which was eventually identified as a left distal femur fracture. NHA-A stated the Facility completed an investigation into R1's bruised knee. NHA-A stated R1's Responsible Party called NHA-A with a concern R1 was dropped on her head. NHA-A stated R1 did pass away after the incident. NHA-A stated the Facility did not submit a FRI to the State Agency related to the incident because they followed an abuse reporting algorithm and the situation did not meet the willful intent part of the algorithm so it wasn't reported to the State Agency. Surveyor notes the Facility used an abuse reporting algorithm for assisted living facilities and Skilled Nursing Facilities do not have such an algorithm. NHA-A stated initially R1 told staff she was dropped but later into the investigation R1 was no longer able to be interviewed. DON-B stated R1's physician (Nurse Practitioner) didn't say R1 had a fall in their evaluation. DON-B stated R1's physician felt the bruising and swelling was related to a soft tissue injury. DON-B stated the on call physician didn't want an x-ray completed and R1 was on hospice. DON-B stated she wanted Certified Nursing Assistant (CNA)-W, who transferred R1 on 2/7/25, to come to the Facility to demonstrate how they transferred R1 however CNA-W never returned to the Facility. NHA-A stated she did not report the incident with R1 to the State Agency because there was no definite drop of R1 and the Facility is trying to clear up the word dropped with the investigation. NHA-A stated the Facility was trying to investigate the situation due to the conflicting stories.
On 4/1/25, at 2:21 pm, Surveyor interviewed NHA-A, DON-B, Regional Director (RD)-V, and CC-S, Surveyor asked, if the care plan was not followed, and an injury occurred, shouldn't the incident be reported to the State Agency. DON-B stated, the Facility did not know of concerns until 2/10/25 and then they began an investigation. Surveyor informed NHA-A, DON-B, RD-V and CC-S of the concerns although administration may not have known until 2/10/25, several staff members knew of multiple concerns regarding R1 on 2/8/25 and 2/9/25, including a transfer completed not according to R1's assessed needs and care plan, resulting in bruising, swelling and 10/10 pain, continued physical and cognitive decline and subsequent death and the facility did not implement their abuse prevention policy and procedure of reporting the incident to the NHA and the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure 1 (R1) of 1 residents reviewed for allegations of abuse, suspected neglect, and/or injury of unknown origin were reported to the Nursing Home Administrator and the State Agency during the required timeframe.
On [DATE] R1 was transferred by a pivot transfer and assist of 1 when R1 was assessed to require an EZ stand and assist of 1 for transfers. Following the transfer R1 complained of 10/10 pain, swelling and bruising to the left knee. R1 informed staff the pain started after staff transferred her without the EZ stand. R1 declined physically and cognitively following the incorrect transfer and passed away at the Facility on [DATE]. R1's Responsible Party expressed concern to the Facility they believed R1 was dropped during the transfer. The Facility did not report the incident to the Nursing Home Administrator or State Agency.
Findings include:
The Facility policy entitled, Abuse Policy, dated 9/20, documents, in part, .Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. This will be done by: . Identifying occurrences and patterns of potential mistreatment; Immediately protecting residents involved in identifying reports of possible abuse: Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively and making the necessary changes to prevent future occurrences; Filing accurate and timely investigative reports.Neglect is the failure of the facility, its employees, or service providers to provide good and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Serious Bodily Injury is an injury involving extreme physical pain, involving substantial risk of death: involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty: or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.
4. Identification: Employees are required to report any occurrences of potential mistreatment they observe, hear about, or suspect to a supervisor or administrator.The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruising or unknown origin, lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator or designee. If the resident complains of physical injuries or if resident harm is suspected, the resident physician will be contacted for further instruction.
6. The final investigation report will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files and interview of witnesses. The final investigation shall also include a conclusion of the investigation based on known facts.
7. Initial reporting of allegations are reported immediately. Centers for Medicare and Medicaid Services (CMS), defines immediately as not later than 2 hours after forming the suspicion of abuse which results in serious body injury or not later than 24 hours if no serious bodily injury. A written report shall be sent to the Wisconsin Division of Quality Assurance (DQA). Please see policy regarding local law enforcement agency. a. The administrator or designee will also inform the resident's representative of the report of an occurrence of potential mistreatment and that an investigation is being conducted. b. If there is a finding of abuse by a certified nurse's aide or licensed staff, the Wisconsin Division of Quality Assurance will notify the Nurse Aide Registry or the Department of Professional Regulations. the Wisconsin Division of Quality Assurance will also notify the State Police, for further investigation of the employee. c. Five Day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Wisconsin Division of Quality Assurance. d. Informing the resident's representative. The administrator or designee will inform the resident or resident's representative of the conclusion of the investigation. e. Report to the state nurse aide registry or licensing authorities regarding any allegations of abuse. f. report to the Social Security Administration (SSA) and Local Law Enforcement Agency. g. Review findings to determine if further training or other corrective action is needed to prevent future occurrences. h. If the events that cause the reasonable suspicion result in serious bodily injury, the report must be made immediately after forming the suspicion (but no later than two hours after forming the suspicion). Otherwise, the report must be made not later than 24 hours after forming suspicion.
R1 was admitted to the facility on [DATE], with diagnoses that include, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors.), and Old Myocardial Infarction (heart attack).
R1's Minimum Data Set (MDS) quarterly assessment, dated [DATE], documents R1 has a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition, a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions.
R1's Care Plan, dated [DATE], documents, Focus: R1 has an ADL (Assistance with Daily Living) Self Care Performance Deficit r/t (related to) Parkinson's, weakness and the need for staff to assist with ADL's. Date initiated: [DATE]. Interventions/Tasks: . Transfers: EZ stand, 1 assist, all with date initiated of [DATE]. Focus: R1 is at risk for falls r/t (related to) Parkinson dx (history), weakness and limited mobility. Res (sic) is dependent on staff for transfers and mobility needs.
R1's Facility Incident Report dated [DATE], at 3:40 am documents, in part, .Nursing Description: Certified Nursing Assistant (CNA) called nurse into room d/t (due to) resident complaining of left knee pain. R1 was laying (sic) in bed with a pillow under her knees. Resident Description: Resident stated that the CNA on PMs (evening shift) did not use the EZ stand (sit to stand) to transfer her to bed and that her left knee is now hurting. When asked if she fell stated she had not and when asked if she had hit her knee on anything she again stated she had not.
R1's Facility Nurses Note dated [DATE], at 4:19 am, Registered Nurse (RN-G) documents, TEH (Telehealth) consulted for evaluation of pain to left knee and swelling-new onset, pain rated 10/10. she is on tramadol 50 mg (milligrams) po (by mouth) q (every) 6 hours PRN (as needed) she has tylenol scheduled. R1 uses easy stand, noted to be x 1 (assist 1) transfer last evening. No falls or injury known, but she does have left lateral knee ecchymosis blue-ish discoloration. R1 has restriction in her mobility and flexion in her left knee. R1 states pain started post transfer last night.
On [DATE], at 8:05 am, Surveyor asked Nursing Home Administrator (NHA)-A for the Facility grievance log and any Facility Reported Incidents (FRI) submitted over the last 3 months. Surveyor noted the Facility did not have a FRI related to R1 and the transfer without the EZ stand.
On [DATE], at 11:01 am, Surveyor interviewed R1's Responsible Party who states, he could not visit R1 on [DATE] due to a snowstorm and this is the only day either himself or someone from his family has not been to the Facility to see R1 in 1 year and 7 months. On [DATE], when one of his family members visited R1, R1 could not even tell family what was wrong. The family had to try to feed her, and she could barely talk. The family member went to ask the nurse what was wrong, and she just replied with, she is having a bad day. On [DATE], Responsible Party went to see R1 early morning. R1 could not eat, could barely talk and was just making noises. He went up to a nurse and asked her what was wrong with R1 and she said she has been this way since night staff dropped her. Responsible Party spoke with NHA-A and expressed his concerns by telling her R1 was dropped, and no one has done anything about it for days and now she is comatose. NHA-A states, she did not know of any incident and would investigate it and get back to him. Responsible Party states NHA-A never called him back. Responsible Party states R1's legs were all bruised.
Surveyor notes R1 passed away at the Facility on [DATE].
On [DATE], at 1:00 pm, Surveyor interviewed Medical Examiner (ME)-U, who states, she typically does not order autopsy's except if abuse, neglect or injury is suspected. She ordered an autopsy for R1. ME-U states she had a phone conversation with NHA-A and DON-B on [DATE] which revealed the following: NHA-A states R1 was transferred from chair to bed via pivoting and not EZ stand. ME-U asked NHA-A for a Fall Report and NHA-A states, they did not have one as CNA-W states she did not drop her, nor did R1 fall and did not have complaint of pain during transfer. ME-U asked if anyone was called and NHA-A states, Hospice was called.
NHA-A states, Family was not called because R1 was her own decision maker. NHA-A states, there was a telehealth visit made around 4:00 am in the morning on [DATE] because of R1's knee. Voltaren gel and ice packs were ordered. NHA-A states, R1 had a soft tissue injury and not a bone injury and no x-rays were ordered at this time. R1 was bed bound the remainder of the weekend. NHA-A states, R1 was minimally responsive on [DATE] and needed Oxygen. DON-B, states, she specifically looked at R1's knee and noticed bruising with nothing else noted. Prior to knee injury, R1 was baseline. R1 did not need Morphine and used Tramadol as needed.
ME-U states the preliminary results of the autopsy on [DATE], reveal the primary reason for R1's death is Fracture of the Distal Left Femur, and the secondary reason is natural occurring diseases. ME-U asked the physician who completed the autopsy, Medical Doctor (MD)-X, if the injury was from a pivot transfer or a blunt fall injury. MD-X states, the injury would be consistent with a fall/drop and much less consistent with her hitting the side of the bed or something like that with transfers.
On [DATE], at 8:39 am, NHA-A, Director of Nursing (DON)-B, and Corporate Consultant (CC)-S, provided the Survey Team with a binder containing the Facility investigation into R1's bruising, swelling, pain and eventual identification of a left distal femur fracture. NHA-A stated R1 initially stated she was dropped then reported to the physician and RN she was not dropped. NHA-A stated the physician stated the left leg swelling, bruising and pain were related to soft tissue damage. NHA-A also stated CNA-W did not know where to find the information on how to transfer R1. NHA-A stated the Facility identified this issue and reeducated the staff on where to find resident care cards. NHA-A stated R1's Responsible Party called NHA-A with a concern R1 was dropped on her head. NHA-A stated R1 did pass away after the incident. NHA-A stated the Facility did not submit a FRI to the State Agency related to the incident because they followed an abuse reporting algorithm and the situation did not meet the willful intent part of the algorithm so it wasn't reported to the State Agency. Surveyor notes the Facility used an abuse reporting algorithm for assisted living facilities and Skilled Nursing Facilities do not have such an algorithm. NHA-A stated initially R1 told staff she was dropped but later into the investigation R1 was no longer able to be interviewed. DON-B stated R1's physician (Nurse Practitioner) didn't say R1 had a fall in their evaluation. DON-B stated R1's physician felt the bruising and swelling was related to a soft tissue injury. DON-B stated the on call physician didn't want an x-ray completed and R1 was on hospice. DON-B stated she wanted Certified Nursing Assistant (CNA)-W, who transferred R1 on [DATE], to come to the Facility to demonstrate how they transferred R1 however CNA-W never returned to the Facility. NHA-A stated she did not report the incident with R1 to the State Agency because there was no definite drop of R1 and the Facility is trying to clear up the word dropped with the investigation. NHA-A stated the Facility was trying to investigate the situation due to the conflicting stories.
On [DATE], at 2:21 pm, Surveyor interviewed NHA-A, DON-B, RD-V, and CC-S, Surveyor asked, if the care plan was not followed, and an injury occurred why was the incident not reported to NHA-A and the State Agency. DON-B stated, the Facility did not know of concerns until [DATE] and then they began an investigation. Surveyor expressed concern although administration may not have known until [DATE], several staff members knew of concerns regarding R1 on [DATE] and [DATE], to include an alleged fall, not following R1's care plan related to transfer, bruising, swelling and 10/10 pain in the left leg, subsequent decline and death on [DATE], and the notification of the fracture of the left distal femur that were not reported to the State Agency.
On [DATE], at 3:05 pm, Survey Team, notified NHA-A, DON-B, Assistant Nursing Home Administrator (ANHA)-C, ANHA-T, CC-S and, RD-V, of the concerns Administration was not informed of the incorrect transfer and injury to R1 and a Facility Reported Incident was not submitted to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R1) of 3 residents reviewed received care and services based on a comprehensive assessment, person centered care plan, and resident's and/or responsible party's choices.
The evening of [DATE], Certified Nursing Assistant (CNA)-W transferred R1 with assist of 1 and a pivot transfer. R1's care plan documents R1 was assessed to require an EZ-stand and assist of 1 for transfers. Early morning of [DATE], R1 complained of left knee pain at a 10/10 which R1 stated began after the transfer the night before with CNA-W. A telehealth visit was completed the morning of [DATE] and Voltaren gel and ice packs were ordered. No imaging was ordered as R1 was receiving hospice services and comfort focused measures were implemented. R1 did have prior PRN (as needed) orders for Morphine and Tramadol. R1 continued to report pain levels of 10/10, 9/10, and 7/10. R1 began to refuse assistance with cares, to get out of bed, and meals. A thorough assessment of R1 including vitals was not completed after the telehealth visit which occurred the early morning hours of [DATE]. R1 continued to decline after the telehealth visit and the facility did not consult with R1's physician or responsible party to discuss the potential need to alter R1's plan of care. R1 experienced another change of condition on [DATE] requiring oxygen due to pursed lip breathing. R1 passed away at the facility on [DATE]. An autopsy was conducted which identified the primary reason for R1's death was a fracture of the distal left femur.
The facility's failure to complete ongoing, thorough assessments and communicate assessment results to R1's physician, hospice, and responsible party to allow for consultation, collaboration, and informed decisions to be made related to R1's plan of care created a finding of immediate jeopardy that began on [DATE].
On [DATE], at 2:50 PM, Nursing Home Administrator (NHA)-A, Assistant Nursing Home Administrator (ANHA)-C, ANHA-T, Director of Nursing (DON)-B, Regional Director (RD)-V, and Corporate Consultant (CC)-S were notified of the immediate jeopardy.
The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a scope and severity (s/s) level of E (potential for more than minimal harm/pattern) as the facility continues to implement their action plan.
Findings include:
The facility policy titled, Change in Condition (Resident), dated 9/20, documents, Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the residents change in condition. Policy: The attending physician/physician on call/NP and responsible party will be notified with changes in the resident's condition.
Procedure:
1.
Attending physicians or physicians on call/NP and responsible party will be notified of all changes in condition.
2.
Follow framework for reporting changes in vital signs or laboratory values based on
AMDA (American Medical Directors Association) Guidelines.
3.
Follow suggested guidelines for reporting clinical problems based on AMDA guidelines.
4.
Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received.
5.
Place call to responsible party to notify them of the resident's change in condition.
History: Gather details about the injury's cause, pain characteristics, functional limitations, and any associated symptoms. Physical Examination: Perform inspection, palpation, range-of-motion tests, and stability assessments to identify potential injuries. Gently palpate the knee to identify areas of tenderness, swelling, or abnormalities.Assess for joint effusion by checking for fluid accumulation around the patella. Imaging and Tests: Use X-rays to detect fractures and MRIs (Magnetic Resonance Imaging) for soft tissue injuries and to rule out or confirm fractures, dislocations, or degenerative changes.
R1 was admitted to the facility on [DATE] with diagnoses that include, Parkinson's Disease, Dysphagia, Chronic Kidney Disease, Congestive Heart Failure, Aneurysm, Old Myocardial Infarction, and Dysphagia.
R1 was admitted to Hospice Care on [DATE] with a primary diagnosis of atherosclerotic heart disease and other co-morbidities.
R1 has a Power of Attorney for Health Care (POA-HC), dated [DATE]. R1's POA-HC was not activated.
R1's Minimum Data Set (MDS) quarterly assessment, dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition, a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions. R1 was assessed to require substantial/maximum assistance for the activities of sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting, and toilet transfer.
R1's MDS annual assessment, dated [DATE], documents R1 required the same level of assistance, substantial/maximum for the activities of sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting, and toilet transfer.
R1's Care Area Assessment (CAA), dated [DATE], documents R1 is triggered for self-care mobility, psychotropic drug use, urinary incontinence, falls, nutritional status, and pressure ulcer/injury.
R1's Care Plan, dated [DATE], documents Focus: R1 has an ADL (Assistance with Daily Living) Self Care Performance Deficit r/t (related to) Parkinson's, weakness and the need for staff to assist with ADLs. Is currently enrolled in [Name] Hospice for end-of-life comfort care related to ASHD (Atherosclerotic Heart Disease). Continued collaboration between Hospice staff and [Facility] staff for the continuance of care and Hospice staff visits for assistance in cares provided. Date initiated: [DATE]. Interventions/Tasks: Allow enough time for completion of ADL tasks. Do not rush the resident, lock wheelchair brakes for transfers, provide needed level of assistance and support to complete Activities of Daily Living, Transfers: EZ stand, 1 assist, all with date initiated of [DATE].
R1's Facility Incident Report dated [DATE], at 3:40 AM documents:
Bruise:
Resident: [R1], Incident Location: Resident's room, Person Preparing Report: [RN-G.]
Incident Description:
Nursing Description: CNA (Certified Nursing Assistant) called nurse into room d/t (due to) resident complaining of left knee pain. R1 was laying (sic) in bed with a pillow under her knees.
Resident Description: Resident stated that the CNA on PMs did not use the EZ stand to transfer her to bed and that her left knee is now hurting. When asked if she fell stated she had not and when asked if she had hit her knee on anything she again stated she had not. Was the incident witnessed: No.
Immediate Action Taken:
Description: Focused assessment findings: swelling to left knee and hematoma to lateral aspect of left knee. Localized pain of 10/10 reported and resident was given PRN (as needed) tramadol at 3:48 AM. After speaking with the on-call provider an ice pack was applied to her left knee for 20 minutes.
Injuries Observed at Time of Incident:
Injury Type: No Injuries observed at time of incident
Injury location: No documentation
Level of Pain:
Level of Consciousness: No documentation
Mobility: No documentation
Mental Status:
(Check Box)
Oriented to Person: unchecked
Oriented to Time: unchecked
Oriented to Place: unchecked
Injuries Report Post Incident:
Injury Type: No injuries Observed Post Incident
Injury Location: No documentation
Level of Pain:
No documentation
R1's Physician Orders document on [DATE], at 3:48 AM, by RN-G, Tramadol HCI Tablet 50 mg (milligrams), Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Left knee pain 10/10. Elevated on Pillows.
On [DATE], at 4:17 AM, R1's telehealth visit written by Advanced Practice Nurse (APN)-H documents (service start time 3:58 AM) Exam findings per nurse and video observation Physical Exam- Notes: GEN (General): alert, NAD (nothing abnormal detected), R1 is alert, flat affect, simple responses. Left knee effusion, no erythema or warmth, left knee pain and effusion noted, swelling left (greater than) right, pain with flexion and mobility, left lateral knee with ecchymosis no noted fall, Tramadol available PRN, Morphine PRN available, Tylenol scheduled. Will add voltaren 1% topical gel TID (three times per day), ice TID, no imaging at this time as comfort focused measures. This is an acute new problem. Condition is stable. Orders: Voltaren 1% topical gel TID PRN, Ice to left knee TID 20 minutes x 48 hours. Notify a clinician of any change in condition. Disposition: Stay at Facility. Technology used: Audio and video with patient and nurse present.
On [DATE], at 4:19 AM, R1's medical record documents TEH (Telehealth) consulted for evaluation of pain to left knee and swelling-new onset, pain rated 10/10. Patient is on Hospice, she is on tramadol 50 mg (milligrams) po (by mouth) q (every) 6 hours PRN, she has Tylenol scheduled. R1 uses easy stand, noted to be x 1 (assist 1) transfer last evening. No falls or injury known, but she does have left lateral knee ecchymosis blue-ish discoloration. R1 has restriction in her mobility and flexion in her left knee. R1 states pain started post transfer last night. Review of Systems: ROS (Review of Systems) as per HPI (History of Present Illness), all other systems reviewed and are negative PMH (Past Medical History) and SH (Social History). Reviewed PMH and SH and Medications Source. Vital Signs: T (Temperature): 98.4 F (degree Fahrenheit), HR (Heart Rate): 68 BP Sys (Blood Pressure Systolic): 167 mm/Hg (millimeters of mercury)/ bmp (beats per minute), / (over) D (Diastolic): 85 mm/Hg, RR (Rate Respirations): 20 rpm (rate per minute), O2 (Oxygen): 94%. Progress note written by Registered Nurse (RN-G).
R1's February 2025 Physician Orders document:
-Aspirin oral tablet chewable 81 mg (Milligrams), give 1 tablet by mouth at bedtime for DVT (Deep Vein Thrombosis) Prophylaxis, date ordered, [DATE],
-Acetaminophen Tablet 500 mg, give 1 tablet by mouth three times a day related to Parkinson's disease, date ordered, [DATE],
-pain evaluation every shift, date ordered [DATE],
-Hyoscyamine Sulfate oral tablet 0.125 MG, give 1 tablet by mouth every 2 hours as needed for respiratory symptoms related to Dysphagia, crush and use syringe,
-Morphine Sulfate tablet 15 MG, give 1 tablet by mouth every 1 hours as needed for pain or trouble breathing, date ordered, [DATE],
-Tramadol tablet 50 MG, give 1 tablet by mouth every 6 hours as needed for pain management for 14 days for server pain, date ordered, [DATE],
-Voltaren external gel 1%, apply to left knee topically every 8 hours as needed for left knee pain related to Rheumatoid Arthritis for 14 days, date ordered, [DATE],
-Skin Check every evening shift every Thursday, date ordered, [DATE],
-Ice Cold therapy and apply cold pack to left knee for 20 minutes TID (three times a day) every shift for 2 days, date ordered, [DATE].
R1's Facility Nurses Note on [DATE] at 4:30 AM, RN-G documents, R1 is complaining of new onset of left knee pain 10/10, swelling and hematoma to lateral aspect of left knee. Contacted on call (APN-H), who saw R1 and gave new orders for ice pack to left knee 20 minutes TID for 2 days and voltaren gel TID PRN. Called Hospice and left a detailed message for her case manager.
R1's Hospice Progress Note on [DATE] at 4:27 AM, documents, TC (Telephone Call) from facility staff, [RN-G] wanting to report an update on patient. Patient having more pain to left knee. [RN-G] got new orders from [APN-H] for Voltan (sic) TID and ice for 20 minutes BID (two times a day). [RN-G] reported that patient has dx (diagnosis)) of arthritis and that when staff assisted her to bed they did a pivot transferred (sic) instead of a mechanical lift.
R1's Facility Orders Note on [DATE] at 7:30 AM, Registered Nurse (RN)-R documents, Tramadol HCI Tablet 50 mg (milligrams) PRN (as needed), Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. PRN Administration was ineffective.
R1's Facility Order Note on [DATE], at 7:37 AM, RN-R documents, Morphine Sulfate Tablet 15 mg, Give 1 tablet by mouth every 1 hours as needed for Pain or Trouble Breathing. Surveyor notes there was no documentation if this medication was effective.
R1's Facility Order Note on [DATE], at 12:13 PM, RN-R documents, Morphine Sulfate Tablet 15 mg, Give 1 tablet by mouth every 1 hours as needed for Pain or Trouble Breathing. PRN Administration was: Effective.
R1's Facility Nurses Note, on [DATE], at 1:38 PM, documents, Able to make needs known. Soft spoken/slow to respond. Continues with cares. Extensive assist with ADLs (Assistance with Daily Living). EZ stand for transfers and wc (wheelchair) for mobility.
R1's Hospice Progress Note on [DATE], at 2:04 PM, documents, Check in call to facility to assess patients knee pain after injury. Spoke with charge nurse [Hospice staff] patient was having pain and received Tramadol and staff is obtaining Volteren (sic) gel to apply as well.
R1's Facility Order Notes on [DATE], at 1:21 AM, RN-G documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Left knee pain 6/10, elevated and ice packs applied.
R1's Facility Order Notes on [DATE], at 2:24 AM, RN-G documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain.
PRN Administration was: effective.
R1's Facility Order Notes on [DATE], at 7:29 AM, RN-R documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. L (Left) knee pain.
R1's Facility Order Notes on [DATE], at 12:28 PM, RN-R documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. PRN Administration was: effective.
R1's Facility Order Notes on [DATE], at 3:18 PM, Licensed Practical Nurse (LPN)-Z documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Resident complains of pain her left knee.
R1's Facility Order Notes on [DATE], at 3:55 PM, LPN-Z documents, Tramadol 50 mg, Give 1 tablet by mouth every 6 hours as needed for Pain Management for 14 Days for severe pain. Resident complains of pain her left knee.
R1's February 2025, Medication Administration Record (MAR) documents, Acetaminophen tablet 500 MG was administered three times a day as ordered, from [DATE] to [DATE].
R1's February 2025 MAR documents, Morphine Sulfate tablet 15mg was administered as needed and per order, on [DATE] at 7:37 AM.
R1's February 2025 MAR documents, Tramadol tablet 50 mg was administered as needed and per order, on [DATE] at 11:01 AM, [DATE] at 9:07 AM, [DATE] at 3:48 AM and 12:14 PM, [DATE] at 1:21 AM, 7:29 AM and 3:18 PM, and [DATE] at 11:19 AM.
R1's February 2025 Treatment Administration Record (TAR) documents, Voltaren External gel 1%, with order to apply to left knee topically every 8 hours as needed for left knee pain was not signed as having been applied at anytime after the order was given.
R1's February 2025 TAR documents, ice cold therapy pack to left knee for 20 minutes twice a day was administered as ordered on [DATE] and [DATE].
R1's February 2025 TAR documents, pain evaluation for every shift recorded as ordered, from [DATE] to [DATE]. Surveyor notes pain level is scored from 0 to 10 scale with 10 being the worst.
-[DATE]
Days: 0
Evening: 0
Night: 0
-[DATE]:
Days: 0
Evening: 0
Night: 0
-[DATE]
Days: 0
Evening: 3
Night: 0
-[DATE]
Days: 4
Evening: 4
Night: 0
-[DATE]
Days: 0
Evening: 3
Night: 0
-[DATE]
Days: 0
Evening: 0
Night: 0
-[DATE]
Days: 9
Evening: 7
Night: 0
-[DATE]
Days: 10
Evening: 10
Night: 0
-[DATE]
Days: 10
Evening: 10
Night: 0
-[DATE]
Days: 7
Evening: 0
Night: 0
-[DATE]
Days: 1
Evening: 9
Surveyor notes there are no nurses' notes documented on [DATE], only medication administration documentation.
R1's meal intake monitoring documents:
-On [DATE], 0-25% consumption for breakfast, 0-25% consumption for lunch, and 26%-50% for dinner.
-On [DATE], 0-25% consumption for breakfast, resident refused for lunch, and no documentation for dinner.
-On [DATE], resident refused for breakfast and lunch, and 51% - 75% for dinner.
-On [DATE], 0-25% for breakfast and, resident unavailable for lunch and dinner.
R1's Facility Nurses Note on [DATE] at 8:16 AM, LPN-F documents, R1 had swelling of the outer aspect of her left knee over weekend. Staff got order for Voteran (sic) Gel to knee prn and ice pack to knee every shift for 3 days. Knee remains swollen and warm to touch, R1 declined ice pack or pain medication at this time, R1 is also less cognitive today than last week.
R1's Facility Nurses Note on [DATE] at 11:20 AM, LPN-F documents, R1 has been doing some pursed lip breathing, O2 (Oxygen) at 76%, R1 was started on Oxygen at 2L (Liters), recheck 1/2 hour later O2 at 91%. Hospice was notified of this change.
R1's Hospice Progress Note on [DATE] at 12:00 PM documents, Call received from [LPN-F] at [Facility] reporting, I found out this morning that over the weekend, staff attempted to transfer patient without a lift and dropped her on the floor. She has significant swelling to her L (left) outer knee and is complaining of pain. Looks like the nurse over the weekend got an order for voltaren gel, but nothing was mentioned regarding the fall. My management will investigate we are counting it as a fall. They also got an order for an ice pack to use every shift for the next 3 days. When I gave her (R1) scheduled Tylenol this morning, she did say her pain level was fine. I think someone should look at it as it is quite swollen, and I think it's more than arthritis. Call log reviewed and no mention of a fall but did report increased pain with new orders. MAR (Medication Administrative Record) reviewed, and no tramadol order is listed. We do have an active order on our end. [LPN-F] aware RN will make a visit today to complete fall assessment, and writer will update MAR with tramadol order.
R1's Hospice Progress Note on [DATE] at 1:26 PM documents, Return call received from facility nurse [LPN-F] who reports, I went in to check her pain level, and I noticed her lips were blue. I checked her oxygen and it was 78% on RA (Room Air). I did apply oxygen at 2L (liters) via NC (nasal cannula), and saturations increased to 92%. [LPN-F] aware RN will be seeing patient today.
R1's Hospice Progress Note on [DATE] at 2:13 PM, [R1's] [Responsible Party] called with concern that [R1] needs a visit today. He reports staff dropped her on her head and didn't tell anyone until my son was here today and now she is unresponsive. Writer updated [Responsible Party] that facility did contact [name of hospice] hospice today that a nurse is scheduled to see her. The RN (registered nurse) will call him with an update if he is no longer present at the facility. He was very upset with her condition. Visit RN [Responsible Party] updated to call him during visit if he is not present.
R1's Facility Nurses Note on [DATE] at 3:47 PM, late entry, Assistant Nursing Home Administrator (ANHA)-C, documents, [Responsible Party] stated that he is convinced that someone dropped R1. He stated that Responsible Party was in on Saturday morning, and all was normal with R1. The Responsible Party then again visited on Sunday morning and stated they noticed a change in condition from the previous day. He stated he thinks she was dropped on her knee and head and has facial swelling. At the time, I was only aware that her knee was swollen. I stated that we will be doing a thorough investigation as to what happened and that we are still unclear as to what had happened. I then had the nurse [LPN-F] go look at her face, and LPN-F stated that her eye did not seem swollen, just droopy.
R1's Hospice Progress Note on [DATE] at 7:03 AM documents, Call from facility staff [LPN-F] updating that minimal responsiveness continues today. Some terminal congestion present and no hyoscyamine ordered. Refill queued up in wise [sic] and orders faxed over. BP (Blood Pressure) 98/56, 90% P (Pulse) 86. [LPN-F] aware that [Hospice staff] will be seeing patient today.
R1's Hospice Progress Note on [DATE] at 10:01am documents, per RNCM (Registered Nurse Case Manager), RN visits increased to daily. Recurring schedule updated.
R1's Hospice Collaboration Note on [DATE] at 11:05 am documents, Writer received a call from [DON- B] following writer's message to facility that she would like to update PCP (Primary Care Physician). [PCP-I] per [name of hospice] hospice protocol following fall visits. [DON-B] called and wished to clarify with writer that the incident was currently under investigation. Writer acknowledged that the form she is currently completing is an occurrence report, and that in the report it was uncertain what happened and that staff nurse [LPN-F] had informed writer that the incident was under investigation. [DON-B] was able to inform writer that [PCP-I] was off over the weekend when the incident occurred but that she had been informed as of Monday, yesterday. Writer thanked [DON-B] for letting her know that [PCP-I] was aware.
R1's Hospice RN Comprehensive Assessment Visit Nursing on [DATE] at 2:21 pm documents, [R1] is in bed with eye's slightly open and unresponsive. She does not respond to touch or sounds. [LPN-F] reports that Sat (Saturday) am around 2:30 CNA (Certified Nursing Assistant) from [Facility] was doing pivot transfers and dropped patient. [R1] is sit to stand for transfers. Large bruise to left side of knee and knee is swollen during assessment today. Unknown if patient hit her head. No bumps or bruising to head noted at visit today. Unknown if patient had medical episode at time of fall. Patient did not go to ER (Emergency Room) per [LPN-F]. She reports that HCPOA (Health Care Power of Attorney) had not been contacted by the night staff. An order was obtained to apply ice to left knee and voltaren cream to left knee. [LPN-F] reports that she found patient Monday morning and lips were blue and she was gasping for air. [LPN-F] placed [R1] on oxygen at that time. Writer contacted [Responsible Party]. [Responsible Party] reports he was not contacted the morning of the fall. [Responsible Party] reports family member contacted him Sunday to come see [R1], as she was minimally responsive at that time. RN had seen [R1] on Monday for follow up visit d/t (due to) change in condition. [Responsible Party] was offered to have patient be seen in ER (Emergency Room) if he wishes. [Responsible Party] denied the need at this time for patient to go to the ER. Writer discussed holding her other medications and putting patient on comfort medications at this time. [Responsible Party] was in agreement and writer contacted NP to get order to DC (discontinue) all meds except comfort medications. Team updated on change in condition.
R1's Facility Nurses Note on [DATE] at 2:42 pm, LPN-F documents, Hospice aide here for cares, during cares, R1 passed. [name of hospice] Hospice informed and on the way. PCP-I and management aware.
R1's Hospice Progress Note on [DATE] at 3:07 pm, documents, Call received from HHA (Home Health Aide) [Name] who is currently at facility and reporting, [R1] has died. No family present at this time.
R1's Hospice Progress Note on [DATE] at 3:09 pm, documents, Call placed to [Responsible Party] HCPOA, to notify of death. Okay, we will head back to the facility. Will be about an hour or so. Condolences provided over the phone and told [Responsible Party] to take his time. [Responsible Party] aware PM (evening) nurse starts at 4:30pm and writer will have PM nurse star (sic) at [Facility]. Okay thank you.
R1's Facility Nurses Note on [DATE] at 4:42 pm, ANHA-C documents, I spoke with [Responsible Party] prior to him seeing R1 before she passed away, . He stated he thinks it is clear, cut and dry that she was dropped on her head due to someone transferring her without the EZ stand and he was not contacted for two days and now she is dead. I stated I understood. He then thanked me again .
R1's Hospice Visit Information on [DATE], documents, Reportable death due to patient fall with injury: Reported a fall on [DATE] and head strike may have occurred. Patient did have a change in condition following the fall including increased swelling to left knee, decreased verbal communication and inability to feed self.
R1's Hospice Visit Information on [DATE], documents, Death Visit Note Narrative: Triage received a phone call stating patient has passed away. No response to physical stimuli. Pupils fixed and dilated. No auscultated bilateral respirations or heart tones for a complete minute. Patient pronounced at 1655 (4:55pm). Family coping: Family coping well considering frustration with rapid decline following fall. Left leg has bruising from thigh to knee. Right leg has bruising on shin to foot.
The facility completed an investigation related to R1's left knee swelling and bruising. Staff statements document:
Staff Statement dated [DATE], RN-G documented, I was called into R1's room on Saturday [DATE] around 3:40 am d/t (due to) left knee pain. After a focused assessment I noted swelling and hematoma to the lateral aspect of her left knee, which was new. R1 was clearly communicating with me and speaking in full sentences at this time-she usually doesn't say much or will respond with single words. When I asked her if she knew what happened to her knee she said the CNA on PM shift did not use the EZ stand when transferring her to bed. I asked her if she hit it on something or fell and she said that neither of those things had happened. I administered PRN Tramadol at 3:48am and contacted the on-call physician APN-H immediately. She saw resident through the iPad and gave me new orders for ice pack to left knee 20 minutes TID x (for) 2 days as well as voltaren gel TID PRN. I then called [name of hospice] Hospice and left a detailed message with the on call nurse who said she would update her case manager. I explained that the on call provider didn't order x-rays because she believed it was tissue related and that the resident was on hospice-the on call hospice nurse agreed and said that they wouldn't be ordering an x-ray either. New orders were followed and R1 was checked on frequently over the next two nights I was here. Saturday night [DATE] I administered PRN Tramadol at 1:21am and R1 was back to her of not saying much or responding with more than one word at a time. Sunday night she was sleeping whenever I was in her room to check on her and she did not wake up when I put an ice pack on her knee. There were no signs over the weekend that she was declining or would pass away within the next couple of days.
LPN-Z's statement dated [DATE] documents, On Friday, [DATE]. I worked the pm shift. At approximately 2130 (9:30pm), I noted that resident in [room number] was still up. I requested the CNA to assist resident to bed. The CNA responded Ok. I was not aware of any incidents that occurred during the CNA/resident interaction. On Saturday [DATE], I worked the PM shift. I was told in report that R1 had a swollen knee and it was unsure how it happened. I went and observed resident first, I noted swelling to bruising to the L (Left) knee. I asked resident what happened, and resident reported, I hit my knee on the ground. I also asked if the EZ stand was used and resident responded, No. Resident received prn pain medication per her request. Resident remained in her bed throughout the shift. On Sunday, Resident continued to stay in bed throughout the shift. Resident continued to request prn medication which were administered. I applied iced and observed her knee. Resident continued to have bruising and swelling.
LPN-F's statement dated [DATE] documents, I, LPN-F got report Monday morning from (RN-G). It was reported that she was called to [R1's] room early in the morning on Saturday morning because resident was complaining of knee pain. After assessment was completed she notified [Telehealth] and received orders for ice packs and voltaren gel for her left knee. It was discussed the CNA had pivot transferred her and not used the EZ stand. It was noted that the resident had left knee pain, swelling, hematoma was getting ice pack q (every) shift and the ordered (sic) ended 7:59 this morning. At approximately 7:30am writer went to administer medications. Resident was not opening her mouth enough to administer medications she had pursed lip breathing and had bluish lips, O2 (Oxygen) was checked and at 76%, 2 L (Liters) of O2 was administered and rechecked in 30 mins (minutes) she was at 88%, rechecked 30 min later and she had dropped to 82%, O2 increased to 3L. Hospice notified spoke with triage nurse [Name]. Writer reported O2 was not maintaining and bumped it up to 3L, discussed the knee pain, swelling, and warmth. Writer reported, I was unaware of how the injury happened but management was aware and investigating. Informed that on call nurse would call back and be out for visit. [Responsible Party] was notified during in person visit between 8:00am and 9:00am. Writer asked if family was aware of bruising and swelling to left knee. [Responsible Party's Family] stated he was unaware of any changes. Updated on complaint of knee pain over the weekend and change of condition. [Responsible Party] came approx. 9:30am, I reported that I had spoke with hospice and updated on condition, he (responsible party) reported that she had swelling and bruising to her head. The [Responsible Party] and I went to room, writer assessed and did not note any swelling, bumps or abrasions to head I asked resident, when the incident happened over the weekend, did you hit your head at all. She responded, no, I was dropped. [Responsible Party] had made statements about resident getting transferred to the hospital. Nurse encouraged [Responsible Party] to reach out to hospice number. PRN medications were offered around lunch time and resident indicated she was not in any pain.
[Responsible Party] was in and out throughout shift, hospice nurse on call come at approximately 2:30pm. On 2/11, during shift to shift report, I was updated that resident ate a couple of bites for dinner, was unable to drink out of straw, was minimally responsive. Resident was noted to not be taking medications well, gurgling noted. Hospice updated, orders to hold all non-comfort medications and new order for hyoscyamine. Resident was comfortable, hospice nurse [Name] was in for a visit. Approximately 2pm hospice CNA was assisting with cares and notified nurse that resident was no longer breathing. Charge Nurse notified and assessed, Hospice Nurse updated.
CNA-P's statement, not dated, documents, I, [CNA-P] Sat morning noticed [R1] [room] was restless in her bed, when normally she sleeps most all nights. I went to her and asked if she was all right, I said your (sic) not sleeping yet is everything okay, this was around 1:00 AM. She told me her knee was hurting her. I looked at it n (sic) it was all swollen. I ask [R1] what happened, [R1] said she dropped me, I asked [R1] now, did she use the easy (sic) stand, R1 said No! She picked me up! I asked her if she needs an ice pack, and then she said n (sic) a pain

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure 1 (R1) of 3 resident reviewed for accidents had adequate supervision, and associative devices to prevent accidents.
Certified Nursing Assistance (CNA)-W transferred R 1 with assist of 1 and a pivot transfer. R1's care plan documents R1 is assessed to require assist of 1 and an EZ stand for transfers. R1 complained of pain at a level of 10/10 with swelling and bruising noted following the transfer. R1 experienced a change of condition following the transfer and passed away four days after the transfer. An autopsy was conducted and it was determined R1 suffered a fracture of the left distal femur related to the transfer. The Medical Examiner determined the femur fracture was the cause of R1's death.
Findings include:
The Facility policy titled, Fall Management Program, dated 8/20, documents, .Policy: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial wellbeing. While preventing all resident falls is not possible, it is the facility's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Procedure: . 4. Plan of care reviewed and updated at time of occurrence, quarterly and as needed in order to minimize risk for fall incidents. 5. Use standard fall/safety precautions for all residents: a. All staff will be trained on the Fall Management Program.d. The bed will be maintained in a position appropriate for resident transfers. e. The bed will be checked to assure they are in locked position at all times.
The Facility policy titled, Management of Falls, dated 8/20, documents, .Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident.
Procedure:
Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually.
Orient resident to room, call light, unit and location of the nurse's station upon admission to the facility.
Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's (Assistance with Daily Living), gait/transfers/balance issues, Behaviors, and/or cognitive status.
Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident.
Conduct Care Plan Meetings with the Resident, Responsible Party, and Facility Interdisciplinary Team quarterly and as needed.
Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.
The Facility policy titled, Change in Condition (Resident), dated 9/20, documents, Purpose: To ensure that the resident's physician/physician on call/NP (Nurse Practitioner) and responsible party is kept informed regarding the residents change in condition. Policy: The attending physician/physician on call/NP and responsible party will be notified with changes in the resident's condition.
Procedure:
Attending physicians or physicians on call/NP and responsible party will be notified of all changes in condition.
Follow framework for reporting changes in vital signs or laboratory values based on AMDA (American Medical Directors Association) Guidelines.
Follow suggested guidelines for reporting clinical problems based on AMDA guidelines.
Document time of call, physician or nurse practitioner or other person spoken to; reason for call and result or orders received.
Place call to responsible party to notify them of the resident's change in condition.
R1 was admitted to the facility on [DATE], with diagnoses that include, Parkinson's Disease (A disorder of the central nervous system that affects movement, often including tremors.), and Old Myocardial Infarction (heart attack).
R1 was admitted to Hospice Care on 6/15/23 with a primary diagnosis of atherosclerotic heart disease and other co-morbidities.
R1 has a Health Care Power of Attorney and it was not activated.
R1's Minimum Data Set (MDS) quarterly assessment, dated 2/4/25, documents R1 has a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition, a Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions. Sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting and toilet transfer are with substantial/maximum assist.
R1's MDS annual assessment, dated 5/9/24, R1 was assessed to require the same level of assistance as the 2/4/25 Quarterly MDS, substantial/maximum assistance sit to stand, chair/bed to chair transfer, sit to lying, lying to sitting and toilet transfer.
R1's Care Area Assessment (CAA), dated 5/9/24, documents, triggered for self-care mobility, psychotropic drug use, urinary incontinence, falls, nutritional status, and pressure ulcer/injury. Resident is 1 assist with assistance with daily living (ADL's) and transfers with EZ stand.
R1's Care Plan, dated 6/13/23, documents, Focus: R1 has an ADL Self Care Performance Deficit r/t (related to) Parkinson's, weakness and the need for staff to assist with ADL's. Is currently enrolled in [Name] Hospice for end-of-life comfort care related to ASHD (Atherosclerotic Heart Disease) Date initiated: 6/13/23.
Interventions/Tasks: Allow enough time for completion of ADL tasks. Transfers: EZ stand, 1 assist, all with date initiated of 6/12/23. Focus: R1 is at risk for falls r/t (related to) Parkinson dx (diagnosis), weakness and limited mobility. Res (Resident) is dependent on staff for transfers and mobility needs.
R1's Facility Incident Report dated 2/8/25, at 3:40 AM documents: Bruise:
Resident: R1, Incident Location: Resident's room, Person Preparing Report: Registered Nurse (RN)-G.
Incident Description:
Nursing Description: Certified Nursing Assistant (CNA) called nurse into room d/t (due to) resident complaining of left knee pain. R1 was laying (sic) in bed with a pillow under her knees.
Resident Description: Resident stated that the CNA on PMs (evening shift) did not use the EZ stand (sit to stand) to transfer her to bed and that her left knee is now hurting. When asked if she fell stated she had not and when asked if she had hit her knee on anything she again stated she had not. Was the incident witnessed: No.
Immediate Action Taken:
Description: Focused assessment findings: swelling to left knee and hematoma to lateral aspect of left knee. Localized pain of 10/10 reported and resident was given PRN (as needed) tramadol at 3:48 AM. After speaking with the on-call provider and ice pack was applied to her left knee for 20 minutes.
Injuries Observed at Time of Incident:
Injury Type: No Injuries observed at time of incident
Injury location: No documentation
Level of Pain:
Level of Consciousness: No documentation
Mobility: No documentation
Mental Status:
(Check Box)
Oriented to Person: unchecked
Oriented to Time: unchecked
Oriented to Place: unchecked
Injuries Report Post Incident:
Injury Type: No injuries Observed Post Incident
Injury Location: No documentation
Level of Pain:
No documentation
R1's [Telehealth Health] Physical Exam dated 2/8/25, at 4:17 AM, Advanced Practice Nurse (APN)-H documents, (service start time 3:58 AM) Exam findings per nurse and video observation Physical Exam- Notes: GEN (General): alert, NAD (nothing abnormal detected), R1 is alert, flat affect, simple responses. Left knee effusion, no erythema or warmth. Left knee effusion, no erythema or warmth, left knee pain and effusion noted, swelling left (greater than) right, pain with flexion and mobility, left lateral knee with ecchymosis no noted fall, Tramadol available PRN, Morphine PRN available, Tylenol scheduled. Will add voltaren 1% topical gel TID (three times per day), ice TID, no imaging at this time as comfort focused measures. This is an acute new problem. Condition is stable. Orders: Voltaren 1% topical gel TID PRN, Ice to left knee TID 20 minutes x (for) 48 hours. Notify a clinician of any change in condition. Disposition: Stay at Facility. Technology used: Audio and video with patient and nurse present.
R1's Facility Nurses Note dated 2/8/25, at 4:19 AM, Registered Nurse (RN)-G documents, TEH (Telehealth) consulted for evaluation of pain to left knee and swelling-new onset, pain rated 10/10. Patient is on Hospice, she is on tramadol 50 mg (milligrams) po (per oral) q (every) 6 hours PRN, she has tylenol scheduled. R1 uses easy stand, noted to be x 1 (assist 1) transfer last evening. No falls or injury known, but she does have left lateral knee ecchymosis blue-ish discoloration. R1 has restriction in her mobility and flexion in her left knee. R1 states pain started post transfer last night. Review of Systems: ROS (Review of Systems) as per HPI (History of Present Illness), all other systems reviewed and are negative PMH (Past Medical History) and SH (Social History). Reviewed PMH and SH and Medications Source. Vital Signs: T (Temperature): 98.4 F (degree Fahrenheit), HR (Heart Rate): 68 BP Sys (Blood Pressure Systolic): 167 mm/Hg (millimeters of mercury)/ bmp (beats per minute), / (over) D (Diastolic): 85 mm/Hg, RR (Rate Respirations): 20 rpm (rate per minute), O2 (Oxygen): 94%.
R1's Facility Nurses Note dated 2/8/25, at 4:30 AM, RN-G documents, R1 is complaining of new onset of left knee pain 10/10, swelling and hematoma to lateral aspect of left knee. Contacted on call APN (APN-H), who saw R1 and gave new orders for ice pack to left knee 20 minutes TID for 2 days and voltaren gel TID PRN. Called Hospice and left a detailed message for her case manager.
R1's Hospice Progress Note, dated 2/8/25 at 4:27 AM, documents, TC (Telephone Call) from facility staff, [RN-G] wanting to report an update on patient. Patient having more pain to left knee. [RN-G] got new orders from [APN-H] for Voltan (sic) TID and ice for 20 minutes BID (two times a day). [RN-G] reported that patient has dx (diagnosis) of arthritis and that when staff assisted her to bed they did a pivot transferred instead of a mechanical lift.
R1's Hospice Progress Note, dated 2/8/25, at 2:04 PM, documents, Check in call to facility to assess patients knee pain after injury. Spoke with charge nurse [Hospice staff] patient was having pain and received Tramadol and staff is obtaining Volteren (sic) gel to apply as well.
Surveyor notes, there are no nursing notes documentation on 2/9/25.
R1's Facility Nurses Note, dated 2/10/25, at 8:16 AM, Licensed Practical Nurse (LPN)-F documents, R1 had swelling of the outer aspect of her left knee over weekend. Staff got order for Voteran (sic) Gel to knee prn and ice pack to knee every shift for 3 days. Knee remains swollen and warm to touch, R1 declined ice pack or pain medication at this time, R1 is also less cognitive today than last week.
R1's Facility Nurses Note, dated 2/10/25, at 11:20 AM, LPN-F documents, R1 has been doing some pursed lip breathing, O2 (Oxygen) at 76%, R1 was started on Oxygen at 2L (Liters), recheck 1/2 hour later O2 at 91%. Hospice was notified of this change.
R1's Hospice Progress Note, dated 2/10/25, at 12:00 PM, documents, Call received from [LPN-F] at [Facility] reporting, I found out this morning that over the weekend, staff attempted to transfer patient without a lift and dropped her on the floor. She has significant swelling to her L (left) outer knee and is complaining of pain. Looks like the nurse over the weekend got an order for voltaren gel, but nothing was mentioned regarding the fall. My management will investigate we are counting it as a fall. They also got an order for an ice pack to use every shift for the next 3 days. When I gave her scheduled Tylenol this morning, she did say her pain level was fine. I think someone should look at it as it is quite swollen, and I think it's more than arthritis. Call log reviewed and no mention of a fall but did report increase pain with new orders. MAR (Medication Administrative Record) reviewed, and no tramadol order is listed. We do have an active order on our end. [LPN-F] aware RN will make a visit today to complete fall assessment, and writer will update MAR with tramadol order.
R1's Hospice Progress Note, dated 2/10/25, at 2:13 PM, [R1's] [Responsible Party] called with concern that [R1] needs a visit today. He reports staff dropped her on her head and didn't tell anyone until my son was here today and now she is unresponsive. Writer updated [Responsible Party] that facility did notify [Name of Hospice] hospice today that a nurse is scheduled to see her. The RN (registered nurse) will call him with an update if he is no longer present at the facility. He was very upset with her condition. Visit RN [Responsible Party] updated to call him during visit if he is not present.
R1's Facility Nurses Note, dated 2/10/25, at 3:47 PM, late entry, Assistant Nursing Home Administrator (ANHA)-C, documents, [Responsible Party] stated that he is convinced that someone dropped R1. He stated that Responsible Party was in on Saturday morning, and all was normal with R1. The Responsible Party then again visited on Sunday morning and stated they noticed a change in condition from the previous day. He stated he thinks she was dropped on her knee and head and has facial swelling. At the time, I was only aware that her knee was swollen. I stated that we will be doing a thorough investigation as to what happened and that we are still unclear as to what had happened. I then had the nurse LPN-F go look at her face, and LPN-F stated that her eye did not seem swollen, just droopy.
R1's Hospice Collaboration Note dated 2/11/25, at 11:05 AM, documents, Writer received a call from [DON- B] following writer's message to facility that she would like to update PCP (Primary Care Physician). [PCP-I] per [name of hospice] hospice protocol following fall visits. [DON-B] called and wished to clarify with writer that the incident was currently under investigation. Writer acknowledged that the form she is currently completing is an occurrence report, and that in the report it was uncertain what happened and that staff nurse [LPN-F] had informed writer that the incident was under investigation. [DON-B] was able to inform writer that [PCP-I] was off over the weekend when the incident occurred but that she had been informed as of Monday, yesterday. Writer thanked [DON-B] for letting her know that [PCP-I] was aware.
R1's Hospice RN Comprehensive Assessment Visit Nursing dated 2/11/25, at 2:21 PM, documents, R1 is in bed with eye's slightly open and unresponsive. She does not respond to touch or sounds. [LPN-F] reports that Sat (Saturday) am (morning) around 2:30 CNA (Certified Nursing Assistant) from Facility was doing pivot transfers and dropped patient. [R1] is sit to stand for transfers. Large bruise to left side of knee and knee is swollen during assessment today. Unknown if patient hit her head. No bumps or bruising to head noted at visit today. Unknown if patient had medical episode at time of fall. Patient did not go to ER (Emergency Room) per [LPN-F]. She reports that HCPOA (Health Care Power of Attorney) had not been contacted by the night staff. An order was obtained to apply ice to left knee and voltaren cream to left knee. [LPN-F] reports that she found patient Monday morning and lips were blue and she was gasping for air. [LPN-F] placed R1 on oxygen at that time. Writer contacted [Responsible Party]. [Responsible Party] reports he was not contacted the morning of the fall. [Responsible Party] reports family member contacted him Sunday to come see R1, as she was minimally responsive at that time. RN had seen R1 on Monday for follow up visit d/t (due to) change in condition. [Responsible Party] was offered to have patient be seen in ER (Emergency Room) if he wishes. [Responsible Party] denied the need at this time for patient to go to the ER. Writer discussed holding her other medications and putting patient on comfort medications at this time. [Responsible Party] was in agreement and writer contacted NP to get order to DC (discontinue) all meds except comfort medications. Team updated on change in condition.
R1's Facility Nurses Note dated 2/11/25, at 2:42 PM, LPN-F documents, Hospice aide here for cares, during cares, R1 passed. Hospice informed and on the way. PCP-I and management aware.
R1's Facility Nurses Note dated 2/11/25, at 4:42 PM, Assistant Nursing Home Administrator (ANHA)-C documents, . [Responsible Party] stated he thinks it is clear, cut and dry that R1 was dropped on her head due to someone transferring her without the EZ stand and he was not contacted for two days and now she is dead.
R1's Hospice Visit Information dated 2/11/25, documents, Reportable death due to patient fall with injury: Reported a fall on 2/8/25 and head strike may have occurred. Patient did have a change in condition following the fall including increased swelling to left knee, decreased verbal communication and inability to feed self.
R1's Hospice Visit Information dated 2/11/25, documents, Death Visit Note Narrative: Triage received a phone call stating patient has passed away. No response to physical stimuli. Pupils fixed and dilated. No auscultated bilateral respirations or heart tones for a complete minute. Patient pronounced at 1655 (4:55 PM). Family coping: Family coping well considering frustration with rapid decline following fall. Left leg has bruising from thigh to knee. Right leg has bruising on shin to foot.
Facility's investigation staff statements:
RN-G's Staff Statement dated 2/11/25, documents I was called into R1's room on Saturday 2/8/25 around 3:40 AM d/t (due to) left knee pain. After a focused assessment I noted swelling and hematoma to the lateral aspect of her left knee, which was new. R1 was clearly communicating with me and speaking in full sentences at this time-she usually doesn't say much or will respond with single words. When I asked her if she knew what happened to her knee she said the CNA on PM shift did not use the EZ stand when transferring her to bed. I asked her if she hit it on something or fell and she said that neither of those things had happened. I administered PRN Tramadol at 3:48 AM and contacted the on-call physician Advanced Practice Nurse (APN)-H immediately. She saw resident through the iPad and gave me new orders for ice pack to left knee 20 minutes TID (three times a day) x (for) 2 days as well as voltaren gel TID PRN. I then called [name of hospice] Hospice and left a detailed message with the on call nurse who said she would update her case manager. I explained that the on call provider didn't order x-rays because she believed it was tissue related and that the resident was on hospice-the on call hospice nurse agreed and said that they wouldn't be ordering an x-ray either. New orders were followed and R1 was checked on frequently over the next two nights I was here. Saturday night 2/9/25 I administered PRN Tramadol at 1:21 AM and R1 was back to her baseline of not saying much or responding with more than one word at a time. Sunday night she was sleeping whenever I was in her room to check on her and she did not wake up when I put an ice pack on her knee. There were no signs over the weekend that she was declining or would pass away within the next couple of days.
LPN-Z's Staff Statement dated 2/12/25, documents On Friday, 2/7/25. I worked the pm shift. At approximately 2130 (9:30 PM), I noted that resident in [room number] was still up. I requested the CNA to assist resident to bed. The CNA responded Ok. I was not aware of any incidents that occurred during the CNA/resident interaction. On Saturday 2/8/25, I worked the PM shift. I was told in report that R1 had a swollen knee and it was unsure how it happened. I went and observed resident first, I noted swelling to bruising to the L (Left) knee. I asked resident what happened, and resident reported, I hit my knee on the ground. I also asked if the EZ stand was used and resident responded, No. Resident received prn pain medication per her request. Resident remained in her bed throughout the shift. On Sunday, Resident continued to stay in bed throughout the shift. Resident continued to request prn medication which were administered. I applied iced and observed her knee. Resident continued to have bruising and swelling.
LPN-F's Staff Statement dated 2/12/25, documents I, [LPN-F] got report Monday morning from [RN-G]. It was reported that she was called to R1's room early in the morning on Saturday morning because resident was complaining of knee pain. After assessment was completed she notified Telehealth and received orders for ice packs and voltaren gel for her left knee. It was discussed the CNA had pivot transferred her and not used the EZ stand. It was noted that the resident had left knee pain, swelling, hematoma was getting ice pack q (every) shift and the ordered (sic) ended 7:59 this morning. At approximately 7:30 am writer went to administer medications. Resident was not opening her mouth enough to administer medications she had pursed lip breathing and had blueish lips, O2 (Oxygen) was checked and at 76%, 2 L (Liters) of O2 was administered and rechecked in 30 mins (minutes) she was at 88%, rechecked 30 min later and she had dropped to 82%, O2 increased to 3L. Hospice notified spoke with triage nurse, [Name]. Writer reported O2 was not maintaining and bumped it up to 3L, discussed the knee pain, swelling, and warmth. Writer reported, I was unaware of how the injury happened but management was aware and investigating. Informed that on call nurse would call back and be out for visit. [Responsible Party] was notified during in person visit between 8:00 AM and 9:00 AM. Writer asked if [Responsible Party] was aware of bruising and swelling to left knee. [Responsible Party] stated he was unaware of any changes. Updated on complaint of knee pain over the weekend and change of condition. [Responsible Party] came approx. (approximately) 9:30 AM, I reported that I had spoke with hospice and updated on condition, he reported that she had swelling and bruising to her head. The [Responsible Party] and I went to room, writer assessed and did not note any swelling, bumps or abrasions to head I asked resident, when the incident happened over the weekend, did you hit your head at all. She responded, no, I was dropped.
CNA-P's Staff Statement, not dated, documents, I, [CNA-P] Sat (Saturday) morning noticed R1 [room number] was restless in her bed, when normally she sleeps most all nights. I went to her and asked if she was all right, I said your (sic) not sleeping yet is everything okay, this was around 1:00 AM. She told me her knee was hurting her. I looked at it n (sic) it was all swollen. I ask R1 what happened, R1 said she dropped me, I asked R1 now, did she use the easy stand, R1 said No! She picked me up! I asked her if she needs an ice pack, and then she said n (sic) a pain pill. She is very soft spoken and she clearly asked for a pain pill, she never asks for a pain pill. I called the nurse and told her R1 said she dropped me and would like a pain pill. [RN-G] came and assed (assessed) her knee and called another nurse and gave her pain pill and ice pack. Sunday morning R1 said she didn't want to get up n (sic) in to her chair. Same on Monday morning when I would change her. She would just say ouch softly. I reported to both am nurses and that R1 is in pain n (sic) doesn't want to get up today.
On 3/31/25, at 11:01 AM, Surveyor interviewed [Responsible Party] who states, he could not visit R1 on 2/8/25 due to a snowstorm and this is the only day either himself or someone from his family has not been to the Facility to see R1 in 1 year and 7 months. On 2/9/25, when one of his family members visited R1, she could not even tell family what was wrong. Family had to try to feed her, and she could barely talk. Family member went to ask nurse what was wrong, and she just replied with, she is having a bad day. On 2/10/25, Responsible Party went to see R1 early morning. R1 could not eat, could barely talk and just making noises. He went up to a nurse and asked her what was wrong with R1 and she said she has been this way since night staff dropped her. Responsible Party spoke with Nursing Home Administrator (NHA)-A and expressed his concerns by telling her R1 was dropped, and no one has done anything about it for days and now she is comatose. NHA-A states, she did not know of any incident and would investigate it and get to him. Responsible Party states NHA-A never called him back. Responsible Party states R1's legs were all bruised and he took pictures.
On 3/31/25, at 1:00 PM, Surveyor interviewed Medical Examiner (ME)-U, who states, she typically does not order autopsy's except if abuse, neglect or injury is suspected. She ordered an autopsy for R1. ME-U states she had a phone conversation with NHA-A and DON-B on 2/12/25 which revealed the following: NHA-A states R1 was transferred from chair to bed via pivoting and not EZ stand. ME-U asked NHA-A for a fall report and NHA-A states, they did not have one as CNA-W states she did not drop her, nor did R1 fall and did not have complaint of pain during transfer. ME-U asked if anyone was called and NHA-A states, Hospice was called.
NHA-A states, Family was not called because R1 was her own decision maker. NHA-A states, there was a telehealth visit made around 4:00 AM in the morning on 2/8/25 because of R1's knee. Voltaren gel and ice packs was ordered. NHA-A states, R1 had a soft tissue injury and not a bone injury and no x-rays were ordered at this time. R1 was bed bound the remainder of the weekend. NHA-A states, R1 was minimally responsive on 2/10/25 and needed Oxygen. DON-B, states, she specifically looked at R1's knee and noticed bruising with nothing else noted. Prior to knee injury, R1 was baseline. R1 did not need Morphine and used Tramadol as needed.
ME-U states the preliminary results of the autopsy on 2/14/25, reveal the primary reason for R1's death is fracture of the distal left femur, and the secondary reason is natural occurring diseases. ME-U asked the physician who completed the autopsy, Medical Doctor (MD)-X, if the injury was from a pivot transfer or a blunt fall injury and MD-X states, this would be consistent with a fall/drop and much less consistent with her hitting the side of the bed or something like that with transfers.
On 4/1/25 at 8:39 am, Surveyor was provided a timeline of events dated 2/10/25, no author, documents, in part, .Writer contacted CNA-W regarding statement. CNA-W reported she does not work that unit often and could not remember resident. Writer attempted to explain the resident and CNA-W continued to state she could not remember. Writer asked CNA-if she knew how residents transfer. CNA-W reported that it was listed in the book and she would take report from the previous shift. CNA-W also stated that if she was un-sure she would ask the nurse. CNA-W reported she would not deviate from what was care-planned for resident.
Tuesday, February 11, 2025, Writer spoke with CNA-W, . asked if she could recall any additional information. CNA-W then reported that she asked the nurse how the resident transferred and she stated 1 assist, so she transferred R1 as a 1 assist. CNA-W denied R1 falling or any known incidents during transfer. Writer requested to have aide come give demonstration of how R1 was transferred and to obtain a written statement. Writer contacted [Name] Hospice RN (Registered Nurse) [Name], Writer reported to Hospice RN [name] that facility was investigating reports of a fall and at this time facility has ruled out a fall based off statements obtained from staff. Writer reported that resident was transferred incorrectly. Writer assessed resident on 2/11/25 approximately 1 PM. Resident was unresponsive in her room, appeared comfortable, no swelling, lumps or bruising noted to her head or face. Writer assessed Left knee to have increased swelling and bruising to the lateral side of the knee. Resident did not have any indicators of pain at this time.
On 4/1/25, at 9:57 AM, Surveyor interviewed Hospice RN-HH, who states, she knew R1 was transferred via a pivot transfer when she should have been a sit to stand transfer. The Facility did not tell Hospice R1 fell. If Facility would have told Hospice R1 fell, Hospice would have gone out right away for a follow up visit. Hospice RN-HH stated hospice would have approved an x-ray only if family requested and then decide if they wanted something done about the results.
On 4/1/25, at 9:00 AM, Surveyor interviewed CNA-D who states, she knows how to care for the residents by reviewing their care cards located in a binder that tells them everything about the residents. CNA-D stated they would never use a different transfer method other than what is stated on the care plan or per therapy direction.
On 4/1/25, at 12:08 PM, Surveyor interviewed telehealth APN-H who states, she remembers R1 to have side of the knee bruising. She was told R1 uses an EZ stand and a pivot transfer as completed. APN-H did not order an x-ray because she is just addressing the urgent needs which was pain and swelling. APN-H stated after that the primary team can change the Plan of Care or diagnose. APN-H was not aware if family was updated or what family wishes were as it was not discussed during the visit. APN-H states she is called during off hours when the primary team is unavailable. She is not there to diagnose, just to address the acute need until the primary team is back to address issues.
On 4/1/25, at 1:58 PM, Surveyor interviewed, Medical Examiner (ME)-U who states, during the autopsy, Medical Doctor (MD)-X, indicates R1 did have severe cardiac disease and remote infarct (prior stroke) but no signs of an acute (new) cardiac event or stroke.
On 4/1/25, at 3:37 PM, Surveyor interviews LPN-F who states, she did not work the weekend on 2/8/25 or 2/9/25 and when she came in on Monday, 2/10/25, the night shift RN provided very little information to her regarding R1's condition. She did administer medication for R1's pain due to bruising but did not know how she was bruised. A family member approached LPN-F with concerns regarding R1's condition and LPN-F informed family member it may be because of her pain from bruising. LPN-F states family member did not know she was bruised. LPN-F and family member went into R1's room and LPN-F asked R1 how she got her bruises and R1 states, she was dropped. LPN-F reported this information during morning stand up meeting to NHA-A and DON-B. LPN-F reports R1's knee was bruised, red, swollen from mid-thigh all the way down to calf.
On 4/2/25 at 3:05 PM, the Survey Team, notified NHA-A, DON-B, ANHA-C, ANHA-T,Corporate Consultant (CC)-S, and Regional Director (RD)-V of the concerns R1 was transferred with assist of 1 and pivot and not with an EZ stand and assist of 1 as documented on R1's care plan. R1 complained of left knee pain at 10/10, bruising and swelling following the transfer. R1 told staff she was dropped, her knee hit the ground, and she was transferred without the EZ stand. R1 continued to physically and cognitively decline following the incorrect transfer and passed away on 4/11/25. An autopsy was performed and the preliminary cause of death was identified as a left distal femur fracture.

Based on observation, interview, and record review, the facility did not ensure sufficient nursing staff was provided to allow residents to maintain or attain their highest practicable physical, mental, and psychosocial well-being This deficient practice has the potential to affect all 113 residents residing at the facility.
Surveyors conducted interviews with residents and staff in which both expressed concerns regarding low staffing levels.
The survey team had observations of resident call lights not being answered for extended periods of time. Surveyors interviewed residents who expressed concerns regarding extensive call light wait times.
Surveyors conducted a record review of Facility's nursing schedules and daily staff postings and verified the Facility is not providing staffing levels that meet the Facility identified staffing needs documented in the Facility Assessment.
Findings include:
* R3's quarterly MDS (minimum data set) with an assessment reference date of 11/21/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.
On 12/2/24, at 9:35 a.m., R3 informed Surveyor they don't have enough help. R3 explained today they have two CNAs (Certified Nursing Assistants) but all weekend long there was only one CNA. R3 stated it's ridiculous, there's not enough staff to take care of the patients and they have to do the dishes, silverware, set the table, its awful. R3 informed Surveyor sometimes have to wait 45 minutes to an hour for the call light to be answered. R3 informed Surveyor they are suppose to have a float but they don't always have one and there wasn't a float this weekend. Surveyor asked R3 when there's not enough staff is there anything that staff isn't able to do for her. R3 replied no because I make them do it. R3 informed Surveyor they have complained at resident council and nothing ever gets done, we complain & complain and nothing gets fixed, nothing gets done.
* R5's quarterly MDS (minimum data set) with an assessment reference date of 9/4/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.
On 12/2/224, at 10:07 a.m., Surveyor spoke with R5. During this conversation, Surveyor asked R5 if he attends therapy. R5 replied I'm done, they were suppose to walk me but they don't have time. Surveyor asked if staff ever walks him. R5 replied no. Surveyor asked how often he is suppose to be walk. R5 replied at least three times a week.
* On 12/2/24, at 10:14 a.m., Surveyor asked CNA (Certified Nursing Assistant)-J, who was on the 300 unit, if the normal staffing is one CNA and a float on the unit. CNA-J replied yes I would say for the weekend, during the week there is normally two. CNA-J explained they take from this unit first as there is only one hoyer transfer. Surveyor asked CNA-J if she is able to complete everything with how staffing is. CNA-J replied I come in very early to get everything done. If I didn't come in early there is no way. Surveyor asked CNA-J if she isn't able to come in early what doesn't get done. CNA-J informed Surveyor she generally leaves the laundry, dishes, things like that but sometimes last rounds don't get done if she can't stay late.
* On 12/2/24, at 10:25 a.m., Surveyor asked CNA (Certified Nursing Assistant)-I about the facility's call light system. CNA-I explained on the ceiling at the beginning of each hall there is a light and the computer screen has the room number. CNA-I explained if the call lights are answered the screen is green and if not the screen is red. CNA-I then showed Surveyor the computer screen which at this time showed all lights had been answered as the background is green.
On 12/2/24, at 11:58 a.m., Surveyor observed the call light computer screen on the 200 unit. Surveyor observed R10's room number is listed with the call light being activated at 11:54 a.m. and there is a red background for R10's room indicating the call light has not been responded to. Surveyor observed R10's call light was not answered until 12:19 p.m. when RCC (Resident Care Coordinator)-K entered R10's room and shut off the call light. This was 25 minutes after R10 placed on the call light.
At 12:21 p.m. Surveyor asked RCC-K why R10 placed the call light on. RCC-K informed Surveyor the resident thought she had a BM (bowel movement).
* R6's annual MDS (minimum data set) with an assessment reference date of 10/16/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.
On 12/2/24, at 10:33 a.m. Surveyor asked R6 if there is enough staff to take care of him. R6 replied no, they focus on the Hoyer's, got a routine with Hoyer and left alone. R6 pointed to his facial hair and stated he had not had a beard trim since fall.
* R8's annual MDS (minimum data set) with an assessment reference date of 11/5/24 has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact.
On 12/2/24, at 10:45 a.m. Surveyor asked R8 if there is enough staff. R8 replied no, constantly running behind schedule. R8 explained when the call light is placed on it takes an hour, an hour and a half to get answered.
On 12/3/24, at 3:55 p.m. Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Nurse Consultant-C and Assistant Administrator-D were informed of the above.
On 12/03/2024, at 9:50 AM, Surveyor interviewed R11 who stated, the staffing is just terrible. She also stated, Call light wait times are sometimes over an hour to be answered. R11 stated, there are not nearly enough people to care for us. R11 stated that she is an active member of Resident Council, and she has brought up the concern regarding lack of staffing many times at the monthly meetings.
On 12/03/2024 at 9:57 AM, Surveyor interviewed R12 who stated the staff are awesome but there is just not enough staff to properly care for everyone. R12 reported they feel the staff shortage is more apparent on nights and weekends.
On 12/03/2024, at 10:00 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-S, who stated staffing is not good at the facility. CNA-S stated she is alone again today with no one to float to her assigned unit (700 unit) to help. CNA-S stated she feels like the facility is always short .there is only me for 17 residents today. CNA-S stated she came in today for her shift at 6:30 AM to find many of the residents very incontinent and soiled as there was no one on the unit past 2:30am, leaving a four-hour gap in time.
On 12/03/24, at 10:10 AM, Surveyor interviewed LPN (Licensed Practical Nurse) -R, who stated, staffing is terrible. She stated she only has one primary CNA each day who almost always works alone. LPN-R stated, Eight out of ten times the float (CNA) calls in and there won't be another replacement. LPN-R stated other units get two CNA's but her unit never does. Surveyor asked why she thinks this is and LPN-R stated the Facility supposedly basis staffing on acuity of residents, but she does not feel that makes sense as she has residents who require constant supervision and attention.
On 12/03/24, Surveyor reviewed Resident Council meeting minutes for the past six months (June-November 2024). Resident Council meeting minutes documents staffing and long call light wait times during the last three months (August, September, and October 2024).
On 12/02/2024 at 8:18 AM, Surveyor interviewed SC (Scheduling Coordinator)-T, who stated she staffs the facility based upon acuity and census. SC-T stated she is made aware of the facility census via a morning email and by the daily staffing report posted in the facility's front lobby. SC-T stated if she cannot provide the appropriate staffing levels with facility employees, she uses Clipboard, a staffing agency to fill in the open shifts. SC-T told Surveyor there is typically less staff on weekends due to more facility call-ins. Surveyor asked SC-T if any incentive programs are utilized for staff retention. SC-T responded the facility does not offer bonuses to staff.
On 12/03/224, Surveyor reviewed the Facility Assessment tool which documents the Facility identified staffing requirements for a 24-hour day to include 26 CNA's for a census of 109-113 residents and 27 CNA's for a census of 114-120 residents.
On 12/03/24, Surveyor reviewed the census and staffing for 10/19/24-10/21/24. Surveyor notes on 10/19/24 there was a census of 118 residents and the Facility was staffed with 24 CNAs. Sunday, 10/20/2024 there was a census of 116 residents and the Facility was staffed with 22 CNA's. Monday, 10/21/2024 there was a census of 119 residents and the Facility was staffed with 23 CNA's. Based on the facility assessment tool, the assessed need for CNAs from 10/19/24-10/21/24 is 27 CNA's. Surveyor notes the Facility did not have maintain staffing levels met their assessed need and had a deficit of 3 CNAs on 10/19/24, 5 CNAs on 10/20/24, and 4 CNAs on 10/21/24.
Surveyor additionally reviewed the census and staffing for the month of November 2024 and 17 out of 30 days the Facility did not meet the staffing requirement for CNAs.
On 12/3/24, at 3:33 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Nurse Consultant-C and Assistant Administrator-D of the above staffing concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not have evidence all alleged violations of mistreatment were thoroughly investigated for 1 (R1) of 1 residents.
R1's allegation of being yelled at and handled roughly was not thoroughly investigated.
Findings include:
The facility's policy titled, Abuse Policy (For Wisconsin Facilities) and dated 9/20 under policy documents This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: .6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences;.
Under 6. Investigation documents a. Appoint an Investigator. Once an allegation has been make, the administrator or designee will investigate the allegation and obtain a copy of any documentation related to the incident.
R1 was admitted to the facility on [DATE] and discharged on 11/27/24.
R1's diagnoses includes hemiplegia and hemiparesis following cerebral infarction affecting left non dominate side, diabetes mellitus, congestive heart failure, aphasia, and epilepsy. R1 does not have an activated power of attorney for healthcare.
The admission MDS (minimum data set) with an assessment reference date of 10/28/24 has a BIMS (brief interview mental status) score of 11 which indicates moderate cognitive impairment.
On 12/2/24, at 2:46 p.m., Surveyor reviewed the facility's grievance report during the period R1 was a resident at the facility. Surveyor noted there is one grievance dated 10/21/24 for R1 regarding a missing phone which was found on 10/22/24.
On 12/3/24, at 9:45 a.m., Surveyor spoke with R1's family member-N on the telephone. During this conversation, Surveyor asked how staff treated R1. R1's family member-N informed Surveyor there was a CNA (Certified Nursing Assistant) who yelled and was rough with her R1. R1's family member-N stated it was reported to the Assistant Director. Surveyor asked who this was. R1's family member-N stated it was reported to [the first name of AA (Assistant Administrator)-E]. R1's family member-N informed Surveyor R1 told her that blonde with a pony tail she's not nice, always mean, yelling at me, and anytime she handles her she is rough. R1's family member-N informed Surveyor R1 told AA-E she's mean to her, yelled at her, and handled her rough and that was [first name of CNA-I]. Surveyor asked R1's family member-N what did AA-E say to her & R1. R1's family member-N informed Surveyor he (AA-E) would retrain her and asked R1 if she wanted the aide not to work with her anymore. R1's family member-N informed Surveyor she (R1) said she didn't want her (the CNA) to lose her job, she wanted her to treat her nice. Surveyor asked R1's family member-N if she knew the date when she & R1 were in AA-E's office informing him of being yelled at and treated roughly. R1's family member-N could not provide Surveyor with the date and informed Surveyor her R1 hadn't been there a month.
On 12/3/24, at 10:43 a.m., Surveyor interviewed AA-E regarding R1. Surveyor asked AA-E if he had any contact with R1's family. AA-E informed Surveyor he did, meeting with R1's daughter and another family member about the [NAME], getting it set up in R1's room. Surveyor asked AA-E if the family brought any concerns to him. AA-E replied no then stated they had mentioned about R1's blood sugar. AA-E explained anything clinical he brings to the clinical team's attention. Surveyor asked AA-E if there were any concerns about staff. AA-E replied not that I can remember. Surveyor asked AA-E if there were any concerns about a CNA being rough or yelling. AA-E replied yes there was. Surveyor asked AA-E to tell Surveyor about this. AA-E replied what I remember blonde CNA thinks during transfer, when in recliner feet were elevated and didn't like the way the pillow was placed under the leg. Surveyor asked who was the blonde CNA. AA-E replied believe [first name of CNA-I]. Surveyor asked AA-E who told him about this. AA-E informed the daughter. Surveyor asked AA-E if R1 or R1's family member-N informed him the CNA yelled at R1. AA-E replied I don't believe yelling, she's hard of hearing. Surveyor asked AA-E if R1 or R1's daughter informed him the CNA was mean to R1. AA-E replied I would say that is all inclusive, don't know if she said mean verbatim. Surveyor asked AA-E if R1 or R1's family member-N informed him the CNA handled R1 rough. AA-E replied same thing with cares. AA-E informed Surveyor within the same shift he spoke with [first name of CNA-I] who had no idea. AA-E informed Surveyor he told CNA-I he was giving her a heads up to be extra conscientious when doing cares. Surveyor asked AA-E if he asked R1 if she wanted CNA-I to continue to care for her. AA-E replied I don't remember. Surveyor asked AA-E if he has an investigation. AA-E replied not to my knowledge, no I would have to double check. Surveyor asked AA-E to check to see if there is an investigation and let Surveyor know. Surveyor informed AA-E Surveyor had reviewed the grievance log and didn't see any grievance regarding R1 except for a missing phone which was located. Surveyor asked AA-E if any education was provided to staff. AA-E replied I did a formal talking to her.
On 12/3/24, at 11:26 a.m., AA-E informed Surveyor he doesn't have anything on paper that he spoke with CNA-I. Surveyor asked AA-E if there was any investigation. AA-E replied in terms of a formal investigation we don't have anything, no. Surveyor asked AA-E why there isn't an investigation. AA-E replied it was on the shift. They just said blonde CNA. I spoke with two CNAs who were blonde, gave heads up to them may have an issue with how giving cares and be more conscientious.
On 12/3/24, at 3:33 p.m. NHA (Nursing Home Administrator)-A, DON-B, Regional Nurse Consultant-C and Assistant Administrator-D were informed of the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R3) of 3 residents were free from unnecessary psychotropic medications ordered on an as needed (PRN) basis.
On 11/10/24 R3 was prescribed an anti-anxiety medication, Lorazepam 0.5 mg every four hours PRN without an end date.
Findings include:
The facility's policy titled, Psychotropic Medications - Use Of and dated 9/2020 does not address stop dates for PRN (as needed) psychotropic medications.
R3's diagnoses includes multiple sclerosis, chronic inflammatory demyelinating poly neuritis, diabetes mellitus, paraplegia, depressive disorder and anxiety disorder.
R3 was readmitted to the facility on [DATE]. Hospital discharge documentation dated 11/10/24 includes under new medications lorazepam (LORazepam 0.5 mg (milligrams) oral tablet) 1 Tabs Gastrostomy tube/PE (percutaneous endoscopic) every 4 hours as needed anxiety.
On 12/2/24, at 11:29 a.m., Surveyor reviewed R3's physician orders and noted an order dated 11/10/24 for Lorazepam 0.5 mg. Give 1 tablet via G (gastrostomy) tube every 4 hours as needed for anxiety. Surveyor noted there is not an end date.
On 12/3/24, at 7:19 a.m., Surveyor asked Med Tech-F who is responsible to ensure there is a stop date for PRN psychotropic medications. Med Tech-F informed Surveyor she believes the RN's (Registered Nurse) are.
On 12/3/24, at 7:32 a.m., Surveyor rechecked R3's physician orders and noted there is now an end date for R3's Lorazepam 0.5 mg of 12/2/24.
On 12/3/24, at 11:01 a.m., Surveyor asked DON (Director of Nursing)-B who is responsible to ensure there is a stop date for resident's PRN psychotropic medication. DON-B replied the nurse who puts in the order. Surveyor informed DON-B on 12/2/24 Surveyor had reviewed R3's physician orders and there was not an end date for R3's Lorazepam 0.5 mg and when Surveyor rechecked R3's physician orders today there is now an end date dated 12/2/24. Surveyor asked DON-B who placed the end date in R3's physician orders. DON-B informed Surveyor Regional Nurse Consultant-C was reviewing R3 record and put it in.
On 12/3/24, at 3:33 p.m. NHA (Nursing Home Administrator)-A, DON-B, Regional Nurse Consultant-C and Assistant Administrator-D were informed of the above.

Based on interview and observation, the facility did not ensure water was consistently being passed to Residents. This has the potential to affect R3, R4, R5, R6, R7, R9, and other residents residing in the facility who would like water to drink in their rooms.
Findings include:
The facility's policy titled, Water Passing and dated 9/2020 under purpose documents To maintain fresh drinking water accessible to resident's around the clock. Procedure documents 1. Wash hands. 2. Gather supplies. 3. Fill clean water pitchers/cups with ice and water every shift and as necessary. Resident's on thickened liquids or fluid restrictions will be identified. 4. Knock before entering room. 5. Distribute cups to resident's room. Leave on bedside table with a straw (if able to have straw). 6. Water will not be left at bedside on the dementia unit unless appropriate. 7. Offer each resident a drink. Record on I & O (intake and output) sheet (if applicable). 8. Discard used supplies in appropriate manner.
* R3's quarterly MDS (minimum data set) with an assessment reference date of 11/21/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.
On 12/2/24, at 9:35 a.m., Surveyor asked R3 if staff pass water. R3 replied yes, I ask for it. Surveyor asked how often staff passes out water. R3 replied just when I ask for it.
* R4's annual MDS (minimum data set) with an assessment reference date of 9/13/24 has a BIMS (brief interview mental status) score of 2 which indicates severe cognitive impairment.
On 12/2/24, at 9:54 a.m., Surveyor observed R4 in bed wearing dark glasses. Surveyor did not observe a water glass in R4's room. Surveyor asked R4 if staff passes out water. R4 replied no.
* R5's quarterly MDS (minimum data set) with an assessment reference date of 9/4/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.
On 12/2/24, at 10:07 a.m., Surveyor observed R5 sitting in a wheelchair in his room. Surveyor asked R5 if staff provides water to him. R5 replied yes. Surveyor asked R5 how often he receives water. R5 replied when ever I request it. Surveyor asked R5 if he doesn't request it does staff provide him with water. R5 replied no maybe at night.
On 12/2/24, at 10:22 a.m., Surveyor asked CNA (Certified Nursing Assistant)-J & CNA-I, who were in the dining room on the 300 unit if they pass out water to residents. CNA-J replied no. CNA-I stated on the other side of the building, they do on 600.
* R6's annual MDS (minimum data set) with an assessment reference date of 10/16/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.
On 12/2/24, at 10:33 a.m., Surveyor asked R6 if staff passes out water. R6 replied no they give me water with my pills. Surveyor asked R6 if staff passed out water would he drink the water. R6 replied yes.
* On 12/2/24, at 10:36 a.m. Surveyor asked R7 if staff passes out water. R7 replied no.
* R9's quarterly MDS (minimum data set) with an assessment reference date of 11/13/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.
On 12/2/24, at 11:45 a.m., Surveyor observed R9 sitting in a wheelchair in the room. Surveyor did not observe a water glass. Surveyor asked R9 if staff brings her water. R9 replied no, the CNAs don't have time. Surveyor asked R9 if staff brought her water would she drink it. R9 replied sure.
* On 12/2/24, at 1:46 p.m., Surveyor asked CNA-M, who is the day float CNA for units 500, 600, & 700 units, if they pass out water to residents. CNA-M replied when we can and explained sometimes they can get to it if they have help.
* On 12/2/24, at 1:55 p.m., Surveyor asked CNA-L, who was on the 600 unit, if they pass out water to residents. CNA-L replied no we don't.
* On 12/2/24, at 3:24 p.m., Surveyor asked CNA-H, who is the evening float CNA for units 500, 600, & 700 units, if they pass out water to residents. CNA-H replied yes should be every two hours.
* On 12/2/24, at 3:41 p.m., Surveyor asked CNA-G who was on the 400 unit if they pass out water. CNA-G replied yes if we have enough cups and explained there are maybe three cups up there. Surveyor asked if this was unusual to not have cups. CNA-G informed Surveyor it's not unusual to not have mugs.
On 12/3/24, at 1:11 p.m., Surveyor asked DON (Director of Nursing)-B how water is passed to residents. DON-B informed Surveyor they have water cups in their room and they are filled as needed. DON-B informed Surveyor anyone can fill water cups. Surveyor asked DON-B if staff passes water once a shift. DON-B replied as needed, at least once a shift they are getting water. Surveyor informed DON-B of the multiple interview from residents and staff that water is not consistently being passed and Surveyor did not observe water being passed.
On 12/3/24, at 3:33 p.m., NHA (Nursing Home Administrator)-A, DON-B, Regional Nurse Consultant-C and Assistant Administrator-D were informed of the above. No information was provided to Surveyor as to why water wasn't being passed to residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R2 was admitted to the facility on [DATE] with primary diagnoses of cerebral infarction due to embolism of left middle cerebral artery (stroke), aphasia, abdominal aortic aneurysm, moderate protein-calorie malnutrition, encounter for attention to gastrostomy, unsteadiness on feet, muscle weakness and age-related physical debility.
R2's admission MDS (Minimum Data Set) assessment dated [DATE], documented R2 is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 0 with both short- and long-term memory problems. MDS section GG, documents R2 is dependent with oral hygiene, toileting, shower/bathing, upper/lower body dressing and putting on footwear. R2 needs substantial to maximum assistance with eating and personal hygiene. MDS section H, documents R2 is frequently incontinent of both urine and bowel. MDS, section K, documents R2 has a feeding tube and is on a mechanically soft diet requiring change in texture of food or liquids.
Record review of R2's Falls Risk assessment dated [DATE] documents a score of an 8, indicating R2 is at risk for falls. The assessment documents for mobility R2 has an unsteady gait and/or use of ambulatory device. Predisposing conditions documented, include CVA, (cerebral vascular accident) and visual deficit. R2's assessed mentation documents, R2 has impaired memory. R2 has had no falls in the past 3 months.
Record review of R2 care plan dated 10/19/24 documents resident is at risk for elopement related to cognitive impairment and will attempt to walk and wander on her own. A Wanderguard was implemented for safety. Interventions include determine preferred setting, consider potential variables such as boredom, thirst, hunger, need for toileting, pain, exercise, companionship, exhaustion and over stimulation. Staff is directed to redirect, calmly and positively guide back to her room, provide 1:1 interaction with encouraging, uplifting comments and attempt to address any agitation. Additionally, staff is to initiate frequent checks and supervision.
Record review documents R2's falls occurred on 10/21/2024, 11/05/2024 and 11/24/2024.
Review of R2's progress notes dated 10/21/2024 at 11:18 am, documents a post occurrence with a complete body check completed with no injuries. Description of occurrence was [R2] was noted on her knees in from of her closet. [R2] unable to give reason.
On 10/21/2024 a Falls Investigation Report was completed which documented, under incident description, CNA (Certified Nursing Assistant) called nurse to resident's room to note resident on her knees in front of her closet. Resident unable to give description. Immediate action taken documented, resident assessed for injuries and pain, neuros completed and assisted off the floor. Resident taken to the dining room for supervision. NP (Nurse Practitioner) guardian, DON, Administrator notified. No injuries observed at time of incident and no hospitalization. Pain is documented at a score of 0. Level of consciousness documented as alert. The following was not documented, mental status, predisposing environmental factors, predisposing physiological factors, and predisposing situation factors to include no known time last seen or last time toileted. There were no staff statements documented nor was a root cause analysis completed.
The Falls Risk assessment dated [DATE] following R2's first fall, documents a score of 11, indicating R2 is at risk for falls. R2's mobility includes unsteady gait and/or use of ambulatory device and decreased mobility. Predisposing conditions documented for R2 include, CVA and no visual deficit. R2's mentation assessment is documented as confused. R2 has a history of 1-2 falls in the past 3 months. Documented under medications assessed as risk factors is drugs that have a diuretic effect or increased GI (gastrointestinal) motility. Drugs that affect the thought process. Drugs that create a hypotensive effect.
R2's care plan fall interventions documented the following additions post first fall on 10/21/2024:
Offer resident to be in common areas while awake. Date initiated, 10/22/2024.
Monitor for changes in ability to navigate the environment. Date initiated, 10/23/2024.
Keep frequently used items within reach in room. Date initiated, 10/23/2024.
Ensure adequate lighting for tasks. Date initiated, 10/23/2024.
Encourage resident to report falls. Date initiated, 10/23/2024.
Encourage resident to keep room free from obstacles. Date initiated, 10/23/2024.
Encourage resident to call, don't fall. Date initiated, 10/23/2024.
Encourage participation in activities to keep resident focused and on task. Date initiated, 10/23/2024.
Review of R2's progress notes dated 11/05/2024 at 12:06 pm document a post occurrence with a complete body check completed with no injuries. No description of occurrence.
On 11/05/2024 a Falls Investigation Report was completed which documented under incident description, Summoned to resident room to observe resident sitting by her doorway by the white trash can. Resident was fully clothed with shoes and socks on Resident unable to give description. Immediate action taken documented, neuros taken No injuries observed at time of incident and no hospitalization. Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as lethargic (drowsy). Predisposing environmental factors documented, wheelchair. Predisposing physiological factors documented incontinent, confused, weakness, gait imbalance, impaired memory, and poor safety awareness. Predisposing situation factors documented, resident last toileted is checked but does not specify a time and resident last observed indicated, staff reports just checking on her prior to event and she was in recliner. There were no staff statements documented nor was a root cause analysis completed.
Revised care plan fall interventions for R2 documented the following additions post second fall on 11/05/2024:
Medication adjustment and reviews. Resident also likes to crawl/place self in doorway and repeat hi at staff. Date initiated: 11/06/2024.
Aromatherapy to promote calmness and relaxation. Date initiated: 11/06/2024.
On 11/05/2024 a Falls Investigation Report was completed which documented under incident description, Summoned to resident room to observe resident sitting by her doorway by the white trash can. Resident was fully clothed with shoes and socks on Resident unable to give description. Immediate action taken documented, neuros taken No injuries observed at time of incident and no hospitalization. Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as lethargic (drowsy). Predisposing environmental factors documented, wheelchair. Predisposing physiological factors documented incontinent, confused, weakness, gait imbalance, impaired memory, and poor safety awareness. Predisposing situation factors documented, resident last toileted in a check box but does not specify a time and resident last observed indicated, staff reports just checking on her prior to event and she was in recliner. There were no staff statements documented nor was a root cause analysis completed. Surveyor noted following the 10/21/24 fall R2's care plan indicates to offer to R2 to be in a common area. There is no documentation to indicate if this was offered to R2 and R2 refused or if the care plan had not been implemented to prevent this fall.
Record review of R2's Falls Risk Assessment documented on 11/5/24, following second fall, assessed R2 to have a of 10, indicating R2 is at risk for falls. Mobility documented includes unsteady gait and/or use of ambulatory device. Predisposing conditions documented, CVA with no visual deficit. R2's mentation is documented as confused. History of falls documents R2 has had 1-2 falls in the past 3 months. Medications documented includes drugs that have a diuretic effect or increased GI motility. Drugs that affect the thought process. Drugs that create a hypotensive effect.
Care plan fall interventions documented the following additions post second fall on 11/05/2024:
Medication adjustment and reviews. Resident also (patterns herself) likes to crawl/place self in doorway and repeat hi at staff. Date initiated: 11/06/2024.
Aromatherapy to promote calmness and relaxation. Date initiated: 11/06/2024.
Surveyor noted the fall risk assessment dated [DATE] references medication effects that could increase R2's risk for falls. However, it is not documented or individually assessed what specific medications R2 takes in the risk categories and how they may impact R2's falls.
On 11/24/2024 at 8:43 pm, progress notes document a post occurrence with a complete body check completed with injury, bruising and hematoma over right eye. Description of occurrence was [R2] was noted on her knees in front of her closet. [R2] unable to give reason. Note text documented, CNA notified writer that resident was noted to be sitting on the floor, near the door of her room. Writer notified RN to come assess, as well as notify the charge RN. When asked what happened resident repeated, no Hello. Hello! I don't know. I don't know. Resident noted to be alert and oriented only to self. It is noted that this is her mental base line for orientation. Upon assessment it was noted that an approximately 5 x 4 cm (centimeter) hematoma was over her R (right) eye, on her forehead. No deformities noted upon head-to-toe assessment. ROM (range of motion) in BUE (bilateral upper extremities) and BLE (bilateral lower extremities) to baseline, able to bear weight. Non-slip socks noted on her feet. Neuro checks immediately initiated and noted to be baseline. Resident is PERLLA, (pupils are equal, round and reactive to light and accommodation). Resident refused to have her blood pressure taken repeatedly. Gathered vitals noted to baseline. Resident not showing any signs of SOB, (shortness of breath). Resident noted to be restless and very challenging to redirect. Writer educated resident to please remain still and remain in the same place until further assessment could be completed, however she continued to move around and even scooted across the floor and placed herself onto the edge of the bed. Staff continued to attempt to attempt to redirect without success. (Name of) , (Medical Doctor), (name of tele-medical group) contacted and provided order to send this resident to the ER (Emergency Room). Writer reached out to residents Son/POA, (Power of Attorney) (name of) , conveying the situation to him and the Doctor's orders to send her to the ER, which he agreed with and stated he would meet her at the ER. EMS (Emergency Medical Service) activated and transported resident to the ER. Management updated by charge RN. Writer called (name of hospital) ER and provided a verbal report of resident. EMS was handed transfer papers for continuity of care. Care plan updated with a new intervention for fall prevention. Discuss with family or visitors if needed to notify staff when they leave.
On 11/24/2024 a Falls Investigation Report was completed which documented under incident description an exact copy of the progress note dated on 11/24/2024 at 8:43 pm. Resident unable to give description. Immediate action taken documented, RN assessed, vitals taken as able, neuros initiated, MD notified, POA/family notified, EMS activated, report given to ER. Resident taken to hospital with a hematoma top of scalp. Pain is documented at a score of 0. Mental status documented as orientated to person. Level of consciousness documented as alert and ambulatory with assistance. Predisposing environmental factors documented, other. Predisposing physiological factors documented, confused, gait imbalance and impaired memory, weakness and poor safety awareness. Predisposing situation factors documented, resident last toileted is checked but does not specify a date/time and resident last observed is checked but does not specify a date/time. There were no staff statements documented nor was a root cause analysis completed.
Record review of R2's Falls Risk assessment dated [DATE] documented following R2's third fall, on 11/24/2024 a risk score of 15, indicating R2 is at high risk for falls. Mobility is documented as, unsteady gait and/or use of ambulatory device, decreased mobility and decreased muscular coordination. Predisposing conditions are documented as, CVA and visual deficit. Mentation is documented to be, confused. History of falls documents R2 has had 3 or more falls in the past 3 months. Medications contributing to risk are documented to include drugs that have a diuretic effect or increased GI motility. Drugs that affect the thought process. Drugs that create a hypotensive effect. Surveyor noted despite care plan intervention to review R2's medications, the specific medications R2 receives are not assessed to show how they may impact R2's fall risk.
The care plan fall interventions for R2 post the third fall documented the following additions:
Discuss with family or visitors if needed to notify staff when they leave. Date initiated, 11/24/2024.
Sound machine placed in resident room for comfort and inhibit agitated behaviors at HS (hours of sleep) and during the night. Date initiated, 11/25/2024. Surveyor noted this is the third fall R2 has had where R2 is found on their knees with this being the second by the doorway. The facility noted in the plan of care R2 likes to be by the door and say hi but did not create an intervention to assist R2 to do this and keep R2 safe from falls.
On 11/25/2024 at 2:58 am, progress note documented, Resident medically cleared to return from ER.
On 12/03/2024 at 9:24 am, surveyor interviewed R2's family member-V who stated, she was told by Director of Nursing (DON)-B that R2 is known to be a crawler. DON-B says R2 gets out of their wheelchair and crawls on the floor. Family member-V feels like R2 is falling more frequently and the facility is telling her R2 is found on floor due to crawling and not actually falling. Family member-V stated she is concerned about the interventions put in place to mitigate falls.
Family member-V stated, my [R2] had a fall with a major bruise on her head and was told the intervention was a sound machine was placed in room. Family member-V does not feel this is an adequate intervention.
On 12/3/24, at 3:33 p.m. NHA (Nursing Home Administrator)-A, DON-B, Regional Nurse Consultant-C and Assistant Administrator-D were informed of the above. Surveyor asked if there is any additional information regarding all areas investigated. As of 12/05/24, at 1:15 pm, Surveyor did not receive any additional information.
Based on interview and record review, the facility did not ensure 2 (R3 & R2) of 2 residents received adequate supervision and assistance devices to prevent accidents.
* On 5/25/24 while the night Certified Nursing Assistant (CNA) was providing incontinent cares to R3, R3 indicated she couldn't hold onto the transfer device and rolled out of bed sustaining a laceration to the forehead and a right femur fracture. According to CNA-Q's statement she guided R3 out of bed however, when Surveyor spoke to R3, R3 informed Surveyor the CNA watched her roll out of bed. The facility did not conduct a thorough investigation, as there isn't a statement from the nurse who assessed R3 or a statement from R3, there are no details as to what the position of the bed was in relation to where R3 fell, and whether care plan interventions were in place at the time of the fall. R3's care plan does not address the air mattress on the bed.
* R2 sustained multiple falls with one fall resulting in injury. A thorough investigation after every fall was not completed to determine root cause analysis. Some Interventions established were not specific to prevent further falls.
Findings include:
The facility's policy titled, Management of Falls and dated 8/2020 under Policy documents The facility will assess hazards and risk, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident.
Under Procedure documents .3. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following: Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, Incontinence, Medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's (activities daily living), gait/transfer/balance issues, Behaviors, and/or cognitive status.
1.) R3 was originally admitted to the facility on [DATE].
R3's diagnoses includes multiple sclerosis, chronic inflammatory demyelinating polyneuritis (disorder that involves nerve swelling & irritation that leads to a loss of strength or sensation), contracture of muscle of right & left hand, hypertension, paraplegia, diabetes mellitus, depressive disorder, and anxiety disorder. R3 was admitted with a Stage 3 right gluteal pressure injury.
Review of R3's care plans document: The [R3's first name] has an ADL (activities daily living) functional performance deficit r/t (related to) paraplegia, MS (multiple sclerosis), atrophy, contractures, impaired AROM (active range of motion) and DM2 (diabetes mellitus). Has need to assist with mobility and repositioning with use of bilateral quarter assist rails to bed initially initiated 4/18/24 & last initiated date of 10/4/24 documents the following interventions:
* Enhanced Barrier Precautions will be implemented during high contact resident care activities. Initiated 4/18/24.
* Assist with ADL tasks as needed. Initiated 4/18/24.
* Allow enough time for completion of ADL tasks. Do not rush the resident. Initiated 4/29/24.
* Ask resident if room temperature is okay. If not contact Maintenance. Initiated 4/29/24.
* Assist resident with oral care daily as needed. Initiated 4/29/24.
* Assist resident with set up for supplies of bathing as needed. Initiated 4/29/24.
* Assist with locomotion as needed. Initiated 4/29/24.
* Assist with personal hygiene as needed. Initiated 4/29/24.
* Assist with toileting needs as necessary. Initiated 4/29/24.
* Assist with transfers as needed. Initiated 4/29/24.
* Barrier cream with incontinence care. Initiated 4/29/24.
* Check skin for changes during bathing. Initiated 4/29/24.
* Encourage to eat slowly. Initiated 4/29/24.
* Encourage use of call light for assistance when needed. Initiated 4/29/24.
* Encourage use of positioning device for bed mobility as needed. Initiated 4/29/24.
* Prompt and use hand over hand assist as needed to enable increased independence with bed mobility and repositioning with aide of bilateral assist rails to bed. Use of bed ladder was not effective. Initiated 4/30/24.
* Provide needed level of assistance and support to complete Activities of Daily Living. Document in POC (plan of care). Initiated 11/12/24.
* Transfers: Hoyer. Initiated 4/29/24.
The at risk for falls care plan initiated 4/18/24 and last revised 10/4/24 documents the following interventions:
* Encourage appropriate use of wheelchair. Initiated 4/18/24.
* Promote placement of call light with in reach. Initiated 4/18/24.
* Encourage resident to keep room free of obstacles. Initiated 4/29/24.
* Ensure adequate lighting for tasks. Initiated 4/29/24.
* Fall risk assessment quarterly and as needed. Initiated 4/29/24.
* Keep frequently used items within reach in room. Initiated 4/29/24.
* Monitor resident for tolerance and endurance. Schedule tasks accordingly. Initiated 4/29/24.
* Notify family and MD (medical doctor) of any new fall. Initiated 4/29/24.
* Provide an environment clear of clutter. Initiated 4/29/24.
* Apply pillow/pillows to side when doing cares to prevent rolling out of bed. Initiated 5/28/24.
R3's fall risk assessment dated [DATE] has a score of 4 which indicates at risk for falls.
The admission MDS (minimum data set) with an assessment reference date of 4/26/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 is assessed as not having any behavior. R3 is assessed as being dependent for chair/bed to chair transfer & toileting hygiene and substantial/maximal assistance for roll left and right. R3 is assessed as being frequently incontinent of urine and bowel. R3 is assessed as not having any falls prior to admission or since admission. R3 is 5 feet 10 inches in height & 179 pounds.
The falls CAA (care area assessment) dated 5/1/24 under analysis of findings for nature of problem/condition documents Resident came to [NAME] long term transfer from nursing home in NC (North Carolina). Resident has MS, G-tube that receives fluids and meds (medication) through. Also treatment in place for PU (pressure ulcer) Stage 3 to gluteal fold right. Res (Resident) pain assessment completed. Res is noted to have c/o pain at times occasionally and is noted to be utilizing both PRN (as needed) and scheduled pain medications via G tube. Res is alert and is able to make her needs known and can alert staff about her discomfort. Res does not utilize glasses for vision and is able to see without them. Res is noted to have upper dentures. Res receives a mechanical altered diet and also tube feeding according to the amount that is eaten. Resident is incontinent of bowel and bladder. Resident requires assistance from staff for ADLs/IADLS. Under care plan considerations documents Staff will ensure room is well lit and free from clutter. Staff will follow policies and procedures for bed mobility and transferring a dependent patient utilizing equipment appropriately.
The occupational therapy note for date of service of 4/29/24 and written by OTR (Occupational Therapist Registered)/DOR (Director of Rehabilitation)-O documents Physician's order received, chart reviewed, hx (history) noted, evaluation completed and POT (program of treatment) developed on this date. Due to mm (muscle) atrophy, contractures and impaired AROM (active range of motion) throughout B UE's (bilateral upper extremities), all joints, ulnar nerve symptoms B L including (bilateral left including) hyperextension of MCPs (metacarpophalangeal joint) (knuckle joint of the finger) and flexion of PIPIs (proximal interphalangeal joint) (middle joint of finger), throughout B (bilateral) hands, pt (patient) is unable to roll or reposition herself in bed when needed/desired. She is able to make weak fists B L in order to pull herself over onto her sides. Due to OA (open area) buttock pt is only up for 4 hours in her wc (wheelchair) and spends the rest of her day in bed, and must be repositioned side to side each time by staff. With assist rails pt is able to participate in mobility and reposition in bed to reach items as she chooses, which may not be anticipated prior. Diagnoses which make I (independent) use of body difficult included: paraplegia, chronic inflammatory demyelinating polyneuritis, unspecified pain and MS. Recommend B (bilateral) assist rails. Pt trialed use of wc (wheelchair) next to bed to pull over using arm rests on w/c which was difficult and additionally required mod (moderate) A (assist) to roll R (right) when supine. However wc will be plugged in at night to charge in another room. She attempted reaching to L by grabbing window sill, which was ineffective, and pulling self over with bed ladder however it didn't position high enough to reach and pull.
The CNA (Certified Nursing Assistant) Kardex dated 5/25/24 under the category for bed mobility documents Bilateral assist rails to bed to enable participation in bed mobility and repositioning. Prompt and use hand over hand assist as needed to enable increased independence with bed mobility and repositioning with aide of bilateral assist rails to bed. Use of bed ladder was not effective. Under the category for safety documents Elevate the head of the bed while napping or sleeping to avoid shortness of breath while lying flat. Encourage appropriate use of wheelchair. Monitor and report signs/symptoms of abuse.
The nurses note dated 5/25/24, at 0735 (7:35 a.m.), by Nursing-P includes documentation of Patient had a fall this AM (morning) witness out of bed, she had a laceration above her left eye pain rated 10/10 to her right leg. Per RN (Registered Nurse) her right knee had a deformity sent out prior to page d/t (due to) urgency.
The incident report dated 5/25/24 under incident description for nursing description documents Paged on the radio for help in resident room, on arrival found resident on the floor. Under resident description documents I couldn't hold the rail anymore, I let go. Under the section immediate action taken for description documents Assessed v/s (vital signs) and skin for abrasions and lacerations. Applied pressure to laceration to the forehead. called 911.
Under other info (information) documents CNA providing incontinent cares in bed. [R3's first name] was unable to continue holding onto rail and began to slide out of bed to floor.
Under statements CNA-Q's statement documents @ (at) 5:00 I entered [R3's first name] room [number] to do her cares. I got all of her essentials needed to perform them as I did proceed to talk with her to let her know that I was going to start cares on her. [R3's first name] replied Ok [NAME]! I asked [R3's first name] to turn as I helped her into the position she was propped up on her left side as I cleaned her bottom, and when doing so she said was slipping out of bed, I tried to ease ger (sic) to the floor as safe as possible without her harming herself. I then proceeded to call for help. Surveyor noted CNA-Q is not listed as a current employee on the staff list provided by the facility.
Under the note section dated 5/28/24 by Assistant Administrator (AA)-E documents IDC (interdisciplinary care) Team reviewed fall on 5/25/24. The goal of the facility is resident safety. The root cause was resident was holding onto side rail during cares, let go and fell. Resident was sent to hospital post fall. The interventions will be a larger bed for positioning during cares and pillow placement if necessary for positioning during cares. Staff member was also educated by DON (Director of Nursing) [Regional Nurse Consultant-C's first name]. [R3's first name] notified and in agreement.
Under the note section dated 5/31/24 by RNC (Regional Nurse Consultant)-C documents [R3's name] is a 73 y/o (year old) that admitted on [DATE] for LTC (long term care) from out of state SNF (skilled nursing facility). She has the following medical conditions: chronic inflammatory demyelinating polyneuritis, paraplegia, type 2 diabetes mellitus, with polyneuropathy, multiple sclerosis, major depression, copd (chronic obstructive pulmonary disease), pressure injury stage 3, chronic pain, hypertension, anxiety disorder and achalasia. [R3's first name] is alert and oriented to person, place, time and situation and has a BIMS score of 15. She is able to assist with turning side to side with use of the bilateral transfer bed rails and 1 assist. She is non-ambulatory, and a total lift is required for transfers. On 5/25 @ approx (approximately) 0500 (5:00 a.m.) [R3's first name] was on her left side for peri-care following incontinence, was unable to hold onto transfer rail and slipped off her bed. Due to c/o (complaint of) right leg discomfort and laceration to head she was transferred to the hospital and admitted with right femur fracture.
The hospital Discharge summary dated [DATE] under chief complaint documents Fall out of bed while doing bed change at [NAME] this morning. Head injury, no LOC (loss of consciousness). Under admission information documents Patient is a [AGE] year-old female nursing home resident who is wheelchair-bound from numerous medical issues and who was being helped in bed and ruled (sic) out and fell on the floor. Patient sustained significant pain and deformity of the right leg and was brought in for evaluation. In the ER (emergency room) patient is found to have a right hip fracture causing 8/10 pain and worse with movement. Under physical exam for Musculoskeletal documents Right leg in cast from upper thigh to toe, does not have sensation in feet at baseline, but is able to wiggle toes, and feet are equal warmth.
On 12/2/24, at 9:35 a.m., Surveyor observed R3 using the electric wheelchair in the hallway. R3 asked Surveyor who Surveyor was. After Surveyor identified self, R3 informed Surveyor she would like to speak with Surveyor. During this conversation, Surveyor asked R3 if she has had any falls at the facility. R3 replied oh sure she rolled me out of bed and I broke my femur. R3 explained she told them she needed a wider bed, they did put rails on and she rolled over the rail. R3 informed Surveyor she was in a cast for 8 weeks. Surveyor asked if she had any falls after this fall. R3 replied no. R3 informed Surveyor she had to wait until her insurance to kick in to get a wider bed which was June 1st. R3 informed Surveyor she is now on hospice and has a hospice bed. R3 informed Surveyor she transfers with a hoyer lift and has never fallen out of the hoyer lift.
On 12/2/24, at 11:08 a.m., Surveyor observed R3 in her electric wheelchair going down the hallway from the front entrance.
On 12/2/24, at 12:09 p.m., Surveyor observed R3 sitting in her wheelchair with an over bed table across and her lunch on the over bed table.
On 12/2/2, at 1:59 p.m., Surveyor observed R3 sitting in her wheelchair in her room with visitors.
On 12/3/24, at 7:17 a.m., Surveyor observed R3 on her back with the head of the bed elevated sleeping in bed. There are two quarter side rails up and there is an air mattress on the bed.
On 12/3/24, at 11:03 a.m., Surveyor asked DON (Director of Nursing)-B who Surveyor should speak with regarding R3's fall on 5/25/24. DON-B informed Surveyor she thinks RNC (Regional Nurse Consultant)-C was the acting DON at that time.
On 12/3/24, at 11:35 a.m., Surveyor observed R3 reclined slightly back in her wheelchair in the room. Surveyor asked R3 if Surveyor could talk to her again about her fall in May when she fractured her femur. Surveyor asked R3 if she could tell Surveyor what happened again. R3 replied she rolled me off the bed. She purposely turned me. I told her I wouldn't be able to hold on. Surveyor asked if there was one or two staff in the room. R3 replied one. Surveyor asked R3 if the CNA rolled her away from her (the CNA). R3 replied yes. R3 informed Surveyor at the time of the fall she had smaller bars on her bed than she has now. R3 stated I just rolled, she didn't put the bed against the wall as I asked her. I rolled right out. Surveyor asked R3 before rolling out of the bed was she holding onto the bar. R3 replied yes. Surveyor asked R3 what did the CNA do when she started to roll off the bed. R3 replied watched me go to the floor. Surveyor asked R3 if anyone spoke to her about the fall. R3 replied there was a lot of people. Surveyor asked if she remember who spoke with her. R3 replied no was after I came back, probably not even here.
On 12/3/24, at 12:14 p.m., Surveyor met with RNC-C to discuss R3's fall on 5/25/24. RNC-C informed Surveyor she thought R3's fall was on the day shift but when she spoke with the day shift CNA, the night CNA was already gone. RNC-C explained CNA-Q from nights was changing R3 & cleaning her up as R3 was incontinent and when R3 has a BM (bowel movement) it is usually large. R3 was holding on the transfer rail, just said she can't hold on and slide down. RNC-C indicated CNA-Q tried to guide her with the sheet and went to the floor. The nurse came in and assessed her. Surveyor inquired who was the nurse. RNC-C informed Surveyor it was a [name of agency] nurse. Surveyor asked RNC-C if she spoke with R3. RNC-C replied afterward, after she came back from the hospital. Surveyor asked

Based on interview and record review, the facility did not ensure 1 (R1) of 3 residents received prescribed medication as ordered by the physician to meet residents needs.
* R1 did not receive the scheduled Oxycodone 5mg on 7/12/24, 7/13/24, 9/8/24, 9/13/24, 10/8/24, 10/18/24, 10/28/24 and on 11/6/24 at different prescribed times.
Findings include:
The facility's policy titled, Reordering Medications (Facilities Ordering Refills on Demand) and dated 01/2022 under Policy/Purpose documents Medications are reordered in advance so as not to have lapses in therapy. Under Procedure documents 1. The nursing staff is responsible for reordering medications. 2. Medications should be reordered when, in the judgment of the nurse, a 2-day supply of medication remains. 3. Reorders should be submitted by one of the following methods: a. Using the re-order function in the facility's e-MAR (electronic medication administration record) system (only if there is a pharmacy interface), or b. Removing the barcode label, affixing it to the reorder sheet, and faxing it-in a fax document carrier-to the pharmacy. c. Using the facility port at [pharmacy website] to request reorders directly in the pharmacy's information system.
R1's diagnoses includes chronic pain syndrome, polyosteoarthritis, and anxiety disorder.
R1's physician orders includes an order with an order date of 1/24/24 that documents: Oxycodone HCI Tablet 5 mg (milligrams); Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for fracture with routine healing.
The pain CAA (care area assessment) dated 5/8/24 under analysis of findings for nature of the problem/condition documents Resident with polyosteoarthritis, COPD (chronic obstructive pulmonary disease), hx (history) of stroke, a-fib (atrial fibrillation), CHF (congestive heart failure), malignant neoplasm of lung, anxiety, GERD (gastroesophageal reflux disease), and hx of falls. Resident is alert and oriented x (times ) 4. Able to make needs known and use call light appropriately. Resident is on a general diet with regular texture and thin liquids Tolerates well. No swallowing issues noted/observed. Takes medications whole with water. Resident is independent with transfers and ADLs (activities daily living). WC (wheelchair) and walker for mobility. Resident interacts well with other residents and staff. HOB (head of bed) elevated for SOB (shortness of breath). Pain Managed with scheduled pain medications. residents pain is controlled with pain regimen. Resident is missing teeth. Resident denies swallowing issues or mouth pain. Resident has glasses and is able to read.
Under care plan considerations documents Staff will provide medications as ordered. Staff will assess pain every shift and PRN (as needed). Staff will follow up with MD (medical doctor) if current pain strategies are ineffective. Pain will be addressed in the care plan.
The quarterly MDS (minimum data set) with an assessment reference date of 9/12/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. Yes is answered for scheduled pain medication regimen. No is answered for PRN (as needed) pain medication and non medication interventions for pain. Yes is answered for pain or hurting at any time in the last 5 days. Pain frequency is assessed as frequently, pain effect on sleep is assessed as occasionally, and pain interference with day to day activities is assessed as frequently. Numeric rating for pain intensity is assessed at 8.
R1's eMAR (electronic medication administration record) note dated 7/12/24, at 2335 (11:35 p.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) med (medication) not available according to pharmacy because NP (nurse practitioner) did not send orders. This eMAR note was written by RN (Registered Nurse)-D.
R1's eMAR note dated 7/13/24, at 04:22 (4:22 a.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) pending delivery. This eMAR note was written by LPN (Licensed Practical Nurse)-E.
R1's nurses note dated 7/13/24, at 9:44 a.m., includes documentation of Other pain assessment: Resident needs his scheduled 5 mg Oxycodone refilled to get him through until Monday evening. He takes the oxy (Oxycodone) every 6 hours. Our NP does not come to our facility until this coming Monday in the afternoon. He has missed his last 2 doses . This nurses note was written by LPN-C.
R1's nurses note dated 7/13/24, at 12:10 p.m., documents [Name of off hours medical group] contacted requesting 5 mg Oxycodone refill after writer called pharmacy and was told there was no active order. In total 1 call made to [Name of off hours medical group] and 2 to pharmacy to get issue resolved. This nurses note was written by LPN-C.
R1's nurses note dated 7/13/24, at 13:32 (1:32 p.m.), documents waited for order from [Name of off hours medical group]. This nurses note was written by LPN-C.
R1's nurses note dated 7/13/24, at 14:38 (2:38 p.m.), documents Scheduled Oxycodone due at 1600 (4:00 p.m.) was administered @ (at) 1430 (2:30 p.m.) due to pharmacy not approving removal from cubex until 1430 (2:30 p.m.). This nurses note was written by LPN-C.
Surveyor reviewed R1's July 2024 MAR and noted R1 did not receive the scheduled Oxycodone 5mg on 7/12/24 at 2200 (10:00 p.m.), and on 7/13/24 at 0400 (4:00 a.m.), 1000 (10:00 a.m.), and 1600 (4:00 p.m.).
R1's eMAR note dated 9/13/24, at 20:07 (8:07 p.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) unavailable, on the way from pharmacy - cubex unavailable earlier. This eMAR note was written by RN-G.
R1's eMAR note dated 9/14/24, at 12:00 p.m., documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) awaiting authorization from NP to pharmacy. This eMAR note was written by LPN-F.
R1's eMAR note dated 9/14/24, at 17:14 (5:14 p.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) Enroute from pharmacy. Medication will arrive with next pharmacy delivery per pharmacist. This eMAR note was written by RN-G.
Surveyor reviewed R1's September 2024 MAR and noted R1 did not receive the scheduled Oxycodone 5mg on 9/8/24 at 0400 (4:00 a.m.), 9/13/24 at 1600 (4:00 p.m.) & 2200 (10:00 p.m.), 9/14/24 at 0400 (4:00 a.m.), 1000 (10:00 a.m.), & 1600 (4:00 p.m.).
R1's eMAR note dated 10/18/24, at 04:14 (4:14 a.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) non avail (available) to ogive sic (give). This eMAR note was written by RN-H.
R1's eMAR note dated 10/18/24, at 14:31 (2:31 p.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) awaiting new script. This eMAR note was written by LPN-I.
R1's eMAR note dated 10/23/24, at 17:21 (5:21 p.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) Medication unavailable. Awaiting arrival from pharmacy. This eMAR note was written by LPN-J.
Surveyor reviewed R1's October 2024 MAR and noted R1 did not receive the scheduled Oxycodone 5mg on 10/8/24 at 2200 (10:00 p.m.), 10/18/24 at 0400 (4:00 a.m.) & 1000 (10:00 a.m.) and 10/28/24 at 2200 (10:00 p.m.).
R1's eMAR note dated 11/6/24, at 21:22 (9:22 p.m.), documents Oxycodone HCI tablet 5 mg (milligram) Give 1 tablet by mouth four times a day related to wedge compression fracture of second thoracic vertebra, subsequent encounter for the fracture with routine healing (S22.020D) Medication unavailable. None left in cubex. Awaiting arrival from pharmacy. This eMAR note was written by LPN-J.
Surveyor reviewed R1's November 2024 MAR and noted R1 did not receive the scheduled Oxycodone 5mg on 11/6/24 at 2200 (10:00 p.m.).
On 11/18/24, at 8:58 a.m., Surveyor asked RN (registered nurse)-K if there are times when a resident's narcotic medication is not available to administer. RN-K informed Surveyor she has had that happen. Surveyor asked RN-K for residents, who are not new admissions, how is their narcotic medication reordered. RN-K informed Surveyor in the MAR can check & order their medication or the sticker can be faxed to the pharmacy.
On 11/18/24, at 10:28 a.m., Surveyor asked R1 if he has ever had problems with not having his narcotic pain medication. R1 informed Surveyor they have ran out of his medication. R1 explained one time the nurse followed up when he didn't have his medication and was told there was no prescription. R1 informed Surveyor the NP (Nurse Practitioner) has a habit of not calling in the prescriptions. R1 informed Surveyor this had happened three or four times. R1 informed he is on Oxycodone four times a day and was on the Oxycodone before he was admitted to the facility. R1 informed Surveyor when asked he rates his pain at 8. Surveyor asked R1 when he doesn't receive his Oxycodone how would he rate his pain. R1 replied I'd say it was off the chart. Surveyor asked R1 if he has problems with running out of his other medications. R1 replied never had a problem with them. R1 informed Surveyor he doesn't have any other complaints, the biggest thing is getting the medication, referring to the Oxycodone.
On 11/18/24, at 12:54 p.m., Surveyor interviewed LPN (licensed practical nurse)-C regarding how medication is reordered. LPN-C informed Surveyor she knows her residents and when they have three or four days left she reorders the medication from the pharmacy as the pharmacy is out of Chicago. LPN-C informed Surveyor if the medication is a narcotic and needs a script she will get a hold of the NP or will place the request in writing and place this written request in the folder at the nurses station which the NP grabs when they come in. Surveyor asked LPN-C how does she know if the medication would require a new script. LPN-C explained on the card it has the number of refills left. Surveyor asked if there are any concerns with the NP not sending a prescription in. LPN-C replied yes and explained she doesn't know if its the NP not doing it or there a glitch in the computer. LPN-C stated don't always get the medication when I need it. Surveyor asked LPN-C if there was a problem with R1 not having his Oxycodone. LPN-C informed Surveyor there was an issue of getting his refilled and doesn't know if it was a computer glitch or not. LPN-C informed Surveyor she did her part by getting it ordered. LPN-C informed Surveyor she can't pull from the cubex (contingency) unless there is a valid order.
On 11/18/24, at 1:09 p.m., Surveyor interviewed DON (Director of Nursing)-B regarding how medication is reordered at the facility. DON-B informed Surveyor when the medication is low, usually around 5, the nurses will reorder the medication. DON-B explained there is a button in PCC or the sticker can be pulled out and faxed to the pharmacy. Surveyor asked DON-B if there has been any complaints regarding residents not having their medication. DON-B informed Surveyor she has been at the facility for 3 months and has not been a big concern. Surveyor informed DON-B there were days when R1 did not receive his Oxycodone 5 mg during July, September, October, and November. DON-B informed Surveyor sometimes there's a struggle when it comes to getting a script. DON-B explained they are working with a NP and their hands are tied until they receive the script from the MD or NP.
On 11/18/24, at 2:40 p.m., NHA (Nursing Home Administrator)-A, Assistant Administrator-L, Assistant Administrator-M, DON-B, and Regional Nurse Consultant-M were informed of the above findings.
No additional information was provided to Surveyor as to why the facility did not ensure that R1 received routine prescribed medications on the above dates to meet R1's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did implement effective infection prevention measures. This included N95 mask fit testing for staff with the potential to effect all 115 residents in the facility. This includes Foley bag maintenance in 1(R85) of 4 residents observed with Foley bags.
* The facility did not ensure all staff exposed to COVID-19 were properly fit tested for a N95 mask to prevent the spread of infection.
* The facility did not ensure R85's Foley bag was maintained in a sanitary manner.
Findings include:
The facility policy and procedure for Management of Residents with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact, dated 1/5/24, was reviewed by Surveyor. The section: Residents with Confirmed COVID-19 documents: .
3. Isolate using Transmission-Based Precautions, .
10. Staff must wear full PPE (Personal Protective Equipment) (N95 respirator, gown, gloves, eye protection) when providing care.
The facility did not have a specific policy and procedure for Foley bag infection prevention.
1.) On 3/11/24 upon entering the Facility for the Recertificaiton and Complaint Survey the Facility identified R65 as having COVID and on the appropriate isolation precautions in place. This was verified through observation by Surveyor. There was no concerns identified with staff donning and doffing PPE (personal protective equipment) when caring for R65.
On 3/13/24 at 9:00 AM, Surveyor interviewed, and reviewed, the Facility's Infection Control program with NC-F (Nurse Consultant) and IP-H (Infection Preventionist). Surveyor asked to review the staff list for N95 mask fit testing due to the facility having COVID positive residents. NC-F indicated several staff perform the mask fit testing. Surveyor was informed that MR-N (Medical Records) performs the N95 mask fit testing and keeps the records. The facility has an investigation summary for March COVID tracking. This tracking indicates R65 was positive for COVID on 3/4/24 and contact tracing did not reveal any positive COVID. There has been no staff with positive COVID.
On 3/13/24 at 1:44 PM, Surveyor spoke with MR-N and Nursing Home Administrator-A. The facility was trying to fit test staff in coordination with their anniversary date. They got behind and do not know who is currently up to date with N95 fit testing. Nursing Home Administrator-A indicated they keep the same staff assigned to care for a COVID positive resident. They are doing all staff N95 fit testing in March and will do it annually every March. All staff were fit tested originally. Surveyor notes not all staff are up to date with their N95 fit testing. The Facility stated they would provide a list of staff that are up to date on the N95 mask fit testing and that have cared for R65.
On 3/14/24 at 8:16 AM, Surveyor received N95 mask fit testing for staff that have worked with COVID positive residents. There were 30 staff listed with 10 of the staff up to date on their fit testing. The facility line list for COVID indicates 1 resident tested positive on 3/4/24 and 1 resident on 3/10/24 and one on 3/12/24. A total of 3 residents total tested positive for COVID in March.
On 3/14/24 at 9:33 AM, Surveyor spoke with ANHA-C (Assistant Nursing Home Administrator) and Nursing Home Administrator-A whom stated there are no COVID positive staff. The staff list provided to Surveyor was staff that worked on R65's unit that were not up to date on N95 fit testing and this March all staff that come in to pick up paychecks will be fit tested. The facility issues paper pay checks so all staff come to the facility. They will track staff and follow-up with those who need to be re-tested.
2.) The facility policy entitled, Indwelling Catheter dated 9/2020, states: Indwelling catheters will be utilized to facilitate urinary drainage when medically necessary.
#4. Secure catheter tubing as appropriate to minimize movement of catheter.
#8. Utilize Standard Precautions when manipulating catheter site.
On 03/11/24, at 11:54 AM, during the initial screening of residents, R85 informed Surveyor they have a catheter.
On 03/12/24, at 08:11 AM, Surveyor observed R85 in their bedroom. R85 was sitting in the wheelchair next to the bed. Surveyor observed the entire catheter bag and some tubing laying on the floor under the wheelchair.
On 03/12/24, at 08:18 AM, Surveyor observed Certified Nursing Assistant (CNA)-L enter R85's room to provide cares and shut the door. At 08:23 AM, CNA-L open R85's bedroom door and transports R85 to the dining room. Surveyor observed a covered catheter bag drag on the floor under the wheelchair during the transport.
R85's physician orders document to change catheter every 30 days, active date of 2/28/24 and may use indwelling urinary catheter Foley, 18F size 10cc (cubic centimeters) balloon size due to urinary retention, active date 1/15/24.
R85's electronic, and paper medical record, did not contain a comprehensive plan of care with individualized interventions for bowel and bladder or an indwelling catheter.
Surveyor reviewed a hospital Discharge summary dated [DATE] which documents, Patient had urinary retention for which he was initially straight catheterize. They had recurrent urinary retention for which an indwelling Foley catheter was placed. Patient was initially significantly confused with the acute urinary retention. Confusion has resolved completely following placement of indwelling Foley catheter .Planned follow-up with Urology in 2 weeks for further evaluation of urinary retention.
On 03/12/24, at 08:25 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-L who informed Surveyor she was trained on catheter care which would include checking the tubing for any kinks, keeping the bag covered when outside of the bedroom and keeping the bag below hip level and off of the floor. CNA-L stated she typically emptied the bag in the morning when getting resident out of bed and then will empty it again later in the afternoon. Surveyor asked CNA-L if she observed the catheter bag to be on the floor when she went in to provide cares. CNA-L confirmed the catheter bag was on the floor and that it must have fallen. CNA-L also confirmed the catheter bag should not be dragged on the floor during transport. She stated she was not aware that the bag was dragging earlier when she transported R85 from the bedroom to dining room for breakfast.
On 03/13/24, at 10:34 AM, Surveyor interviewed Registered Nurse (RN)-J who informed Surveyor catheter bags should not touch the floor and they should never be dragged across the floor. RN-J confirmed R85 does have a history of UTI's (urinary tract infections) and R85 has been assessed by the urologist who plans on keeping the catheter in long term due to urinary retention.
On 03/14/24, at 08:23 AM, Surveyor interviewed Director of Nursing (DON)-B who informed Surveyor all staff are trained on catheter care as it is part of orientation as well as yearly competency. DON-B confirmed catheter bags should not be touching the floor which would include laying on the floor and being dragged on the floor during transport.
On 03/14/24, at 03:28 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Nursing Home Administrator (ANHA)-C, Surveyor shared concerns regarding two observations of R85's catheter bag touching the floor.
No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that staff promptly consulted with a physician when 1 of 1 resident (R414) experienced a significant change in condition.
R414 had unwitnessed falls on 10/27/23 and 10/29/23. After each fall, R414 experienced a significant change in condition with signs that are consistent with a head injury. Despite these changes, the Hospice nurse assigned to R414's case declined to send R414 to the emergency room for evaluation. The facility did not consult with the Hospice provider, R414's primary physician, or the Medical Director regarding R414's continued decline. R414 subsequently passed away.
The facility's failure to promptly consult with the MD regarding R414's significant change in condition and for failing to get direction from the MD as to whether the resident should be sent out for further evaluation created a finding of immediate jeopardy that began on 10/27/23. Surveyor notified the Director of Nursing (DON)-B of the Immediate Jeopardy on 3/18/24 at 10:09 am. The immediate jeopardy was removed on 3/19/24. The deficient practice continues at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement their action plan.
Findings include:
The facility's policy titled Change in Condition (Resident) dated 9/2020 states:
Purpose: to ensure that the resident's physician/physician on call/Nurse Practitioner (NP) and responsible party is kept informed regarding the resident's change in condition.
Policy: The attending physician or physician on call/NP and responsible party will be notified with changes in a resident's condition.
Procedure: 1. Attending physicians or physicians on call/NP and responsible party will be notified of all changes in condition. 2. Follow framework for reporting changes in vital signs or laboratory values based on AMDA Guidelines. 3. Follow suggested guidelines for reporting clinical problems based on AMDA guidelines. 4. Document time of call, physician or NP or other person spoken to; reason for call and result or orders received. 5. Place call to responsible party to notify them of the resident's change in condition.
R414 was admitted to the facility on [DATE] with diagnosis of dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, urine retention, Gilbert Syndrome, and failure to thrive. R414 was his own person at the time of admission. R414's admission Minimum Data Set (MDS) assessment completed on 8/24/23 indicates a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment.
R414 requires extensive assistance with one person and physical assistance with bed mobility, transferring, dressing, and toileting. R414 is not steady and is only able to stabilize himself with staff assistance while moving on and off the toilet. R414 has an indwelling urine catheter and is always continent of his bowels. R414's care plan indicates he is at high risk for falls related to limited mobility and impaired balance, dated 8/17/23.
R414's Care Plan indicates R414 is at high risk for falls related to limited mobility and impaired balance dated 8/17/23.
R414 was admitted to hospice due to Monoclonal Gammopathy (condition in which abnormal proteins are found in the blood.). R414's medical record indicates R414 had a prescreening for a possible discharge from hospice due to ineligibility on 10/17/23 as R414's health status was stable.
On 3/18 /24 at 9:17 am, Surveyor interviewed Hospice Director of Social Work (SW)-P who indicated there was a pre-discussion of possible ineligibility for R414 due to showing improvement. The Hospice Director of Social Work-P stated a pre-discussion of hospice care takes place when recertification time is approaching. The Hospice Director of SW-P indicated once a resident is deemed ineligible for hospice, the hospice staff have 2 days to develop a plan of care for discharge. Hospice Director of SW-P indicated R414 had continued hospice care due to the change in condition after the unwitnessed falls.
On 10/27/23 at 1730 (5:30 pm), the facility documentation indicates the CNA found R414 on the bathroom floor. R414 had an elevated blood pressure (BP) and was noted to have altered mentation; R414 was unable to convey where he was, day of the week, nor the month. R414's baseline orientation is fully oriented to person, place, time, and event. The facility charge nurse and Hospice were notified of the unwitnessed fall. R414 had an improvement with his vital signs and mentation after Hospice arrived at the facility at 6:45 pm.
On 10/27/23 at 5:34 pm, the facility documentation indicates R414 was found lying on his back flat on the bathroom floor and R414 had hit his head. R414 had complaints of pain in his upper back between his shoulder blades, altered mentation, and high blood pressures and low pulse rates. R414 had a brown emesis while being transferred with a Hoyer lift back to his bed. Documentation states hospice was updated. Hospice instructed the facility to administer Zofran for vomiting. There is no evidence the facility and/or hospice staff identified vomiting as a sign/symptom of a head injury. The facility documentation indicates family was informed of R414 having a change in condition by the hospice staff. Facility documentation states the resident hit his head. There is no evidence this was relayed to the hospice staff or MD at the time of the change in condition and it is unclear if family was updated on R414 hitting his head along with symptoms of altered mentation. It is unclear if the power of attorney was given the option for R414 to seek evaluation for the significant change in condition that is unrelated to R414's hospice diagnosis.
Surveyor reviewed the hospice visit note from the hospice RN dated 10/27/23 at 6:45 pm. Documentation indicates R414 is fully oriented with pupils being equal and reactive to light. Documentation reports R414 denies hitting his head. R414 was provided Tylenol and reports his last bowel movement being 3 days ago. Hospice changed R414's MiraLAX from every other day to every day during this visit. Documentation indicates the MD on call and POA were notified of updates however, Surveyor notes there is no documentation indicating what was discussed with the MD at the time of the update from hospice staff. Surveyor notes R414 denying hitting his head however, R414 was noted to have altered mentation at the time of his fall and was unable to recall place and time while being evaluated. There is no evidence the facility increased monitoring of R414's bowel pattern or need for assistance with toileting.
Neuro check documentation dated 10/28/23 at 3:47 am indicates R414 was having rambling speech with a weak right-hand grasp. This is not R414's baseline. There is no evidence that hospice or the MD were notified or consulted with regarding this significant change in condition with R414 having weak right-hand grasps and rambling speech.
Facility documentation dated 10/28/23 at 9:58 am indicates the facility nurse notified hospice with a significant change in condition. R414 was feeling off, hands were shaky, he was lethargic, and he needed assistance with eating breakfast. R414 did not previously require assistance with eating. Documentation indicates R414 indicated to the nursing staff he hit his head and acknowledged he notified hospice on 10/27/23 that he did not hit his head. This was relayed to the hospice staff by the facility staff via phone call. Surveyor notes the MD was not consulted after R414 notified staff he hit his head and his having a significant change in condition.
On 10/28/23 at 10:28 am, hospice was contacted again when R414 was hunched over in his wheelchair with increased fatigue. The facility staff requested hospice evaluation. There is no evidence the facility staff or hospice staff consulted with R414's MD to discuss R414's continued decline and changes in condition after the fall.
On 10/28/23 at 2:19 pm, the documentation from hospice indicates R414 was having poor coordination, increased sleep, lethargy, and Foley draining concentrated clear urine. There is no evidence the MD was notified of the significant change in condition and no evidence new interventions were placed after hospice was notified of R414 hitting his head.
Surveyor reviewed the Neuro check performed on 10/28/23 at 4:00 pm which indicates R414 had a change in condition with having slurred speech. R414 has a strong right-hand grasp, and the left hand was not documented as assessed. There is no evidence facility staff consulted with the MD about the ongoing decline in R414's condition.
Surveyor reviewed the post fall documentation on 10/28/23 at 8:00 pm which indicates R414 is alert with confusion and fatigue is noted. R414 can answer questions appropriately but did mumble stories about siblings that were nonsensical. Documentation reports R414 hit his head on 10/27/23 and Surveyor notes there is no evidence the MD was consulted with regarding this change in condition at the time of the post fall documentation.
Documentation from 10/29/23 at 9:10 pm indicates R414 was found on the floor lying on the left side of the bed with the call light and nightstand base under him. R414 was moaning in pain with c/o (complaints of) pain in his back, left arm and left shoulder. R414 had a head injury with blood present on the floor. R414 was noted to have cognitive impairment, intermittent nonsensical verbalization, pinpoint eyes, eyes wrenching, a left forehead hematoma measuring 4 cm x 3 cm with a 2 cm laceration to the middle of the hematoma, and no urine output in the urine Foley bag. The charge nurse and hospice were notified. Hospice instructed the facility staff to not send R414 out for evaluation prior to hospice doing an evaluation. The facility nurse applied pressure to R414's head injury site and remained with R414 in the fall position until hospice arrived for evaluation. There is no evidence the MD was consulted regarding the significant change in condition.
Documentation from Hospice Progress notes dated 10/29/23 at 9:34 pm indicates R414 had an unwitnessed fall and sustained a head injury. R414 denied pain but was observed to be wincing with movement. Notes indicate an as needed (PRN) pain medication was given due to R414 likely being sore and probably having a headache. R414 was observed to be alert and oriented and tolerating changing his shirt without the facility staff in R414's room. Hospice reports facility staff chose to leave R414 on the floor with a pillow under his head until hospice arrived for evaluation. R414 was assisted back to bed using a Hoyer lift. Hospice attempted to contact R414's POA who was unavailable and a message was left. The hospice nurse applied steri strips to R414's head wound and a new Foley catheter was inserted with 2400 cc of dark amber urine and large amounts of thick fibrous tan drainage was noted. There is no evidence the MD was consulted related to R414's significant change in condition with R414's fall and his retaining large amounts of urine or the discrepancies in the facility and the hospice notes and recommendations.
Surveyor interviewed Licensed Practical Nurse (LPN)-S on 3/14/23 at 11:00 am. LPN-S indicated R414 was typically alert and oriented and able to make his needs known. LPN-S reported R414 was weak and requires assistance of one with ambulation, toileting, and transferring. LPN-S stated the facility staff had to frequently remind R414 to contact staff when needing to transfer as R414 frequently ambulated independently without calling for assistance. LPN-S indicated she could clearly tell R414 had a head injury on 10/29/23 at 9:10 pm after R414 had a second unwitnessed fall from his bed while reaching for the call light that was out of reach. LPN-S indicated she applied pressure to R414's head to help control bleeding and stayed with R414 for approximately 30-40 minutes in the fall position while she waited for hospice to come and evaluate R414. LPN-S stated she thought residents had the option to be sent out for evaluation with a significant change in condition even though they are receiving hospice care. LPN-S indicated R414's change in condition was not related to his hospice diagnosis but she was told by hospice to not send R414 out for evaluation. LPN-S stated she did not feel comfortable with this decision as she knew R414 clearly had a brain injury with R414's eyes being dilated and changed. LPN-S was unsure if R414's POA was contacted to discuss the significant change in condition and whether the POA was given the option to send R414 out for evaluation. LPN-S indicated she was fearful of the head and neck injury R414 sustained. LPN-S indicated she noticed no urine output in R414's urine Foley catheter bag while holding pressure on R414's head injury and notified hospice upon arrival. LPN-S indicated she does not recall if the MD was notified by the hospice nurse.
Surveyor interviewed DON-B on 3/18/24 at 10:09 am. DON_B indicated facility staff are to contact hospice regarding any residents receiving hospice care and experiencing a change in condition. Surveyor reviewed with DON-B that facility staff were interviewed and reported not feeling comfortable with coordination and care being provided to R414 by hospice staff on 10/29/23 at the time of R414 having a second unwitnessed fall. DON-B indicated staff are to contact clinical leadership if they do not feel comfortable with orders given by the hospice staff. DON-B indicates she was not aware of the facility staff not feeling comfortable with orders being provided by hospice indicating R414 is to not be evaluated due to being on hospice. DON-B indicated clinical leadership should have been notified with this significant change on 10/29/23 and the facility staff not feeling comfortable with hospice recommendations to not send resident out for evaluation.
Surveyor reviewed the facility fall investigation dated 10/29/23 at 9:10 pm. The investigation indicated R414 sustained a hematoma and laceration to the face along with a skin tear to the left hand. R414 is oriented to person, the facility NP was notified on 10/30/23 at 3:53 pm, and POA was notified on 10/30/23 at 3:29 pm. This is over 18 hours after the fall occurred. There is no documentation as to what information was shared with the NP and the POA. There is no evidence the MD was consulted after the fall with a significant change in condition.
On 3/18/24 at 8:57 am, Surveyor spoke with Medical Director (MD)-O of the facility. Surveyor reviewed the change in condition with R414 that occurred on 10/29/23. MD-O indicated he does not recall being notified of the change in condition with R414 on 10/29/23. MD-O stated, if the facility does not agree with hospice recommendations, the facility is to reach out to the MD to discuss the change in condition with the resident. MD-O indicated the resident has the option to go to the emergency room for further evaluation while receiving hospice services.
Surveyor reviewed the facility neuro check documentation on 10/30/23 at 1:00 am which indicates R414's pupils not being equal in size, with the right pupil being fixed, left pupil being sluggish, and R414 being unable to grasp hands. There is no evidence of MD consultation regarding this change in condition.
Surveyor reviewed the facility neuro check documentation on 10/30/23 at 2:00 am which indicates R414 is aphasic (a person who is unable to communicate), right pupil is fixed, left pupil is sluggish, and unable to grasp hands. There is no evidence of MD consultation regarding this change in condition.
Facility progress note dated 10/30/23 at 2:59 am indicates the facility placed a call to hospice with an update on R414's neuro checks and R414 being unresponsive. Hospice advised the facility to continue with keeping R414 comfortable and provided no additional interventions. There is no indication clinical leadership and the MD were notified of these changes.
Facility progress note dated 10/30/23 at 3:04 am indicates the facility contacted R414's POA with an update. There is no documentation as to what was discussed with R414's POA and if options to send R414 out for evaluation were provided. There is no evidence clinical staff and the MD were updated of the significant changes in condition with R414.
Surveyor reviewed facility progress note dated 10/30/23 at 3:13 am which indicated the facility contacted hospice with updates on neuro checks and R414 being non-responsive. Hospice stated if R414 had a brain bleed that there is nothing that can be done for his condition. There is no evidence MD and clinical leadership were updated at this time.
Surveyor reviewed hospice progress note dated 10/30/23 at 9:15 am which indicated R414 requires meals set up, has decreased appetite, increased dysphagia, choking and coughing with thinned liquids, increased pain, total dependence with bathing, and is bedbound with assistance of a Hoyer lift after two unwitnessed falls on 10/27/23 and 10/29/23. R414 is requiring head support with a rolled towel to prevent neck pain and is unable to move his own head/neck. Urine is noted to be dark concentrated with sediment in Foley catheter tubing.
Surveyor reviewed the Interdisciplinary Team (IDT) note dated 10/30/23 at 11:42 am which indicated the 10/27/23 fall for R414 was reviewed for safety and a new intervention was placed. Surveyor notes the 2nd fall from 10/29/23 was not reviewed, the MD was not consulted with regarding the significant changes in condition, and there was one change to the care plan to include medication adjustments per hospice for R414 being a high risk of falls. Surveyor also notes it is unclear if clinical leadership was present for the IDT meeting.
Surveyor reviewed the Hospice Comprehensive Review Assessment note dated 10/30/23 at 11:21 pm which indicates hospice sent an email to the POA and DON-B regarding R414 having an increase in lethargy, rambling speech, reduced appetite, and trouble swallowing post falls.
Facility progress note dated 10/31/23 at 12:30 am indicates the facility contacted hospice with concerns of R414 having a low-grade fever, elevated BP and R414 complaints of neck pain. Hospice instructed the facility to administer Morphine for pain and apply a cool cloth to reduce the fever. There is no indication the MD was notified of this change.
Surveyor reviewed the facility progress note dated 10/31/23 at 2:05 pm which documented the POA was visiting with R414 and expressed concerns with hearing cracks in R414's neck when he moves. The facility progress note indicates Morphine was administered to R414 for neck pain and the charge nurse and hospice were contacted with an update. There is no indication the MD was consulted regarding this significant change.
Hospice Progress note dated 10/31/23 at 3:30 pm indicates R414 is in pain, increased sleeping, withdrawn, minimal responsiveness, barely opening his eyes, abdominal respirations, slow capillary refill in his nail beds, pallor, crackles in his lungs (fluid building up in the lungs), skin cool to touch, skin mottled in areas (lack of blood flow to the skin), and unable to respond to tell staff how he feels.
Surveyor reviewed the Hospice Progress Note dated 11/1/23 at 10:00 am which document R414 is unresponsive, having irregular heart rates, breathing through his mouth, eyelids barely opening, shallow respirations, crackles to his lungs, coughing to clear his airway, unresponsive to touch or voice however, R414 jerks and gasps when the hospice nurse swabs R414's lips. Documentation indicates the hospice nurse noted no PRN medications (Lorazepam and Morphine) given since last visit on 10/31/23 at 3:30 pm. Hospice updated the POA however, Surveyor notes documentation does not indicate what was discussed with POA.
Surveyor notes the facility documentation on 11/2/23 at 2:48 am indicates R414's POA contacted the Nursing Home Administrator (NHA)-A regarding R414's current condition. The POA expressed concerns with R414 needing to eat more. NHA-A educated the POA on the risk of intake when R414 is not alert and oriented. The NHA-A suggested the POA reach out to hospice for additional support. Surveyor notes the POA is not comprehending the severity of R414's current prognosis and significant change in condition and the NHA-A advised POA to contact hospice.
Hospice Progress Note dated 11/2/23 at 11:00 am notes R414 to have an elevated pulse, rapid respiratory rate (RR) of 36 (normal RR is 16), gasping for air, abdominal respirations, using accessory muscles with breathing, coughing, short of breath, and moderate discomfort with breathing. Documentation indicates hospice updated the POA and administered 1 dose of Morphine for shortness of breath.
Facility progress note dated 11/2/23 at 10:50 pm states a CNA called the nurse into R414's room. R414 was pulseless and not breathing. Hospice and the facility charge nurse were notified by the facility staff.
On 3/18/24, at 10:09 AM Surveyor notified Nursing Home Administrator-A and Director of Nursing-B of the above concerns.
The immediate jeopardy was removed on 3/19/24 when the Facility complete the following
-All Residents were reviewed for changes in condition, falls, and hospice services and the care plan were updated as indicated.
-The Nurse Consultant educated the Director of Nursing when to notify the physician when a change of condition occurs with a resident, notifying the resident's representative when a change in condition occurs, proper care coordination with the hospice provider regarding when it would be appropriate to discuss a change in the treatment/care plan of the residents based on residents's needs, properly assessing the patient, including hospice patients, and when a patient should be transferred out to the hospital.
- All nursing staff and clinical managers were reeducated by the Director of Nursing or designee when to notify the physician when a change of condition occurs with a resident, notifying the resident's representative when a change in condition occurs, proper care coordination with the hospice provider regarding when it would be appropriate to discuss a change in the treatment/care plan of the residents based on residents's needs, properly assessing the patient, including hospice patients, and when a patient should be transferred out to the hospital.
-All professional nursing staff were competency tested by the Director of Nursing or designee on hospice coordination of care and notification requirements.
-The Facility Director of Nursing, Nursing Home Administrator, Nurse Consultants and Medical Director reviewed policies and procedures on the change in condition and comprehensive care plan.
-Audits for compliance related to notification to the physician and resident representative were conducted. The audits will be conducted 4 times a week for 4 weeks, 3 times a week for 4 weeks and monthly for three months.
-Results of the audits will be reviewed monthly by the Facility Interdisciplinary Team and QAPI (Quality Assurance and Performance Improvement) team to determine any necessary changes.
-An emergency QA (Quality Assurance) meeting was held 3/18/24 by the Nursing Home Administrator with the Interdisciplinary Team and Medical Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure 1 out of 1 allegations of an injury of unknown source (R38) were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. In addition, the facility did not ensure they reported the results of the investigation, within 5 working days to the State Survey Agency for 1 out of 1 allegations of an injury of unknown source (R38).
R38 experienced pain in the left knee although no injury had been reported. An X-ray was obtained and it was noted R38 had suffered a left distal femur fracture and was admitted to the hospital and underwent surgical repair. The facility did not report the injury within 2 hours of being aware of the femur fracture, to the State Survey Agency, when they were not able to determine the cause of the fracture. In addition, the facility did not report, within 5 working days, the outcome of their investigation of the injury of unknown source for R38 following the diagnosis of the left femur fracture.
This is evidenced by:
Policy Review:
Abuse Policy (for Wisconsin facilities) dated 09/2020 documents,
Serious Bodily Injury is an injury involving extreme physical pain, involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.
7.) Reporting-Initial reporting of allegations are reported immediately. CMS (Centers for Medicare and Medicaid Services) defines immediately as not later than 2 hours after forming the suspicion of abuse which results in serious body injury or not later than 24 hours if no serious bodily injury. A written report shall be sent to the Wisconsin Division Of Assurance (DQA). (Please see policy regarding contacting local law enforcement).
c.) Five-day final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Wisconsin Division of Quality Assurance.
R38 was originally admitted to the facility on [DATE] and the last readmission to the facility was on 11/10/23. R38 has diagnoses that include: epilepsy, muscle weakness, anxiety disorder, dysphagia, history of falling and hemiplegia.
Surveyor conducted a review of R38's individual plan of care which indicated R38 is at risk for abuse related to:
psychosis, impaired cognition. Date Initiated: 09/20/2021. Interventions included:
- R38 will remain safe, calm and free from abuse through next review. Date Initiated: 09/20/2021
- Check and assure physical comfort. Date Initiated: 09/20/2021
- Consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents. Date Initiated: 09/20/2021.
- Consider possible antecedents: fear, fatigue, loss of control over a situation. Date Initiated: 09/20/2021.
R38 was seen by the Nurse Practitioner on 11/6/23 for routine maintenance. The progress note indicates R38 has been complaining of left knee pain, no reported injury. X-ray ordered. No other concerns reported by R38 or nursing staff.
Nursing note dated 11/7/2023 at 7:09 p.m., R38 c/o (complaint of) left knee pain new order to x-ray left knee and pelvis. X-Ray tech arrived approx. 1900 (7:00 p.m.) awaiting results.
Nursing note dated 11/7/2023 at 10:53 p.m.: Xray results came back that R38 has fx (fracture) to distal femoral rod. Call placed to 3rd eye Dr (doctor) and orders received to send R38 out to hospital. Call also placed to POA (Power of Attorney) message left to call us back, call placed to 2nd emergency contact person, and he was updated on info. Ok with the transfer. Ambulance called at 10:58 p.m., report called to triage nurse at ER (Emergency Room) .
Surveyor conducted a review of the emergency room preliminary reported, dated 11/7/23 at 11:40 p.m. The report indicates R38 is presenting from [facility name] with reported left leg pain and was found to have a left distal femur fracture based on their x-ray. There is no reported fall or illness .
Surveyor conducted a review of the history and physical- final report dated 11/8/23 from the hospital. The report states that the chief complaint was R38 arrived with EMS from [facility name]. Left distal femur fracture around rod. Unknown cause of injury. R38 poor historian. Facility staff stated that she started to complain of pain yesterday (11/7/23).
Nursing note dated 11/10/2023 at 3:43 p.m., ;72 Hour admission Note #1. R38 returned from hospital today. R38 was hospitalized post fall with L (left) femur/knee fracture. R38 underwent surgery to repair fracture. R38 is here for LTC (Long Term Care) with dx (diagnoses): hemiplegia, hemiparesis, epilepsy, hx falls, glaucoma, cognitive deficit, and weakness and LLE (Left Lower Extremity) Fracture. R38 is awake, alert and oriented x 3. Able to make needs known. Generally pleasant and cooperative. Does have periods of acute anger with outbursts as well as periods of tearfulness.
On 3/13/24 at 7:40 a.m., Surveyor interviewed Director of Nursing (DON)- B regarding the investigation into R38's injury of unknown source. DON- B stated she did obtain staff statements but is unable to locate at this time. Surveyor asked if the facility submitted a self-report investigation regarding the injury of unknown source. DON- B stated that they did not because the fracture was pathological, so it was not necessary.
Surveyor conducted further review of R38's medical record and hospital record and there was no documentation that the fracture was pathological in nature.
On 03/13/24 at 01:31 p.m., Surveyor interviewed DON- B regarding R38. DON- B stated the Nurse Practitioner saw R38 on 11/6/24 and R38 reported she was having some pain and she was given Tylenol. R38 was having more pain the next day. DON- B stated she spoke with R38 on 11/7/23 and R38 reported it had been hurting since she put herself on the toilet. DON- B reminded her not to transfer herself. Surveyor discussed the medical record review that was conducted and the lack of evidence supporting the fracture was pathological. DON- B stated that she also couldn't find anything about pathological fracture either, but she was sure she was told that it was. DON- B stated the only thing she could find was R38 has Osteoporosis. Surveyor reviewed the nursing note that indicated R38 was hospitalized post fall. DON- B stated that there was no fall and she started questioning staff because R38 said it was from transfer herself. DON- B stated she had staff report that R38 bumped her knee in the dining room. Surveyor stated to DON- B there is no documentation of either situation in the medical record. Surveyor asked DON- B if she was able to state how the injury occurred to R38. DON- B was unable to provide any additional information that the injury was thoroughly investigated and then reported to the state survey agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Surveyor reviewed R38's medical record. It was noted on 9/2/23, R38 was transferred to the hospital due to hypoxic and very large bleeding external hemorrhoid.
The facility eINTERACT transfer form and Bed Hold information was provided, except information on how to appeal a transfer and Ombudsman contact information was not included. The medical record did not contain all the required information at the time of transfer.
On 11/7/23, R38 was transferred to the hospital due to a change of condition.
The facility eINTERACT transfer form and Bed Hold information was provided, except information on how to appeal the transfer and Ombudsman contact information was not included. The medical record did not contain all the required information at the time of transfer
On 3/13/24 at 11:11 AM, Surveyor spoke with ANHA-D (Assistant Nursing Home Administrator) regarding resident transfer notices. ANHA-D indicated nursing staff will open the Interact tool in the electronic medical record (EMR). The bed-hold form that should be used is dated 12/22. ANHA-D stated there were old transfer summary forms in the nurses stations and the facility replaced all the forms yesterday. The bed-hold form is not updated to include any other information. ANHA-D was not aware of any other notice information requirements besides bed-hold. ANHA-D indicated the Corporation is in the process of developing the notice requirements. The facility does not have a policy and procedure related to transfer notice requirement.
Based on record review and interview, the facility did not ensure resident's received the required written notice information related to their transfers out of the facility. This was observed with 7 (R108, R38, R25, R77, R54, R85 and R65) of 7 resident reviewed transfers.
*R108, R38, R25, R77, R54, R85 and R65 were transferred to the hospital from the facility. A transfer notice including the following information was not provided:
-A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; .
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
Findings include:
On 3/13/24 at 11:11 AM, Surveyor spoke with ANHA-D (Assistant Nursing Home Administrator) regarding resident transfer notices. ANHA-D indicated nursing staff will open the Interact tool in the electronic medical record (EMR). The bed-hold form that should be used is dated 12/22. ANHA-D stated there were old transfer summary forms in the nurses stations and the facility replaced all the forms yesterday. The bed-hold form is not updated to include any other information. ANHA-D was not aware of any other notice information requirements besides bed-hold. ANHA-D indicated the Corporation is in the process of developing the notice requirements. The facility does not have a policy and procedure related to transfer notice requirement.
1.) R108 medical record was reviewed by Surveyor. R108 had a fall in the facility and was sent out to the hospital on [DATE] for further evaluation. A Progress Note dated 1/4/24 indicates R108 went from the hospital to their home. R108 did not return back to the facility per their choice.
R108's medical record did not contain evidence R108 received the required written notice information with their transfer to the hospital.
On 3/13/24 at 3:12 PM, at the Facility exit meeting Surveyor shared with Nursing Home Administrator-A and Director of Nursing-B the concern R108 did not receive a transfer notice when transferred to the hospital. No additional information was provided.
3) R25 admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following Cerebral Infarction, Dysarthria, Dysphagia, Spondylosis lumbar region, Adult Failure to Thrive, Hypertension, Anemia, Polyosteoarthritis and Depression.
Facility progress notes document:
On 2/11/24 at 9:12 AM, Nurses Note Text: Resident c/o (complained of) not feeling well earlier this morning, light cough noted, while up in wc (wheelchair) he became somewhat diaphoretic with slow reaction with verbal and tactile stim (stimulation), cold compresses applied, and vitals obtained. Resident is a dnr (do not resuscitate) status, when I asked him if he wanted to go to the hospital or stay here, he said stay here. Call placed to son and poa (power of attorney), updated him on all the above. Son requested for him to stay and have labs done here at (facility). Update to NP (Nurse Practitioner) with all the above and orders received. Resident is resting back in bed and labs obtained left forearm. He seems more alert now. No cough. Rapid for Covid negative.
On 2/11/24 at 1:49 PM, Nurses Note Text: Return labs note high liver enzymes. Call placed to NP and to pt's (patient) POA. POA aware of options for comfort cares, Hospice cares or hospitalization for further eval (evaluation). Family to consult with each other and get back to staff. Res has been comfortable in bed at this time with no intake this shift.
On 2/11/24 at 2:30 PM, Nurses Note Text: Family returned call and want resident send to the hospital for further eval. NP notified. Surveyor noted R25 was admitted to the hospital.
Surveyor was unable to locate evidence a transfer notice with the required information was provided to R25 or his POA. The facility was unable to provide evidence the transfer notice was provided. No additional information was provided.
4) R77 admitted to the facility on [DATE] and has diagnoses that include Acute Kidney Failure, Hydronephrosis, Chronic Kidney Disease stage 3, Obstructive and Reflux Uropathy, Alcohol-Induced Chronic Pancreatitis, Epilepsy, Anemia, Benign Prostatis Hyperplasia, Hypertension, Cholelithiasis and Depression.
Facility progress notes document:
On 7/1/23 at 11:33 AM, Nurses Note Text: Resident states he hasn't felt good since yesterday and that it burns when i pee update to NP with orders for labs, drawn and sent. Resident is afebrile and vitals are stable.
On 7/2/23 at 1:44 PM, Nurses Note Text: Resident continues to state he's not feeling well, call to (hospital) for labs which returned critical. Consulted with NP and with resident, he is full code and will be sent to (hospital) for evaluation. 911 called and update to (hospital) ER (emergency room). Surveyor noted R77 was admitted to the hospital.
Surveyor was unable to locate evidence a transfer notice with the required information was provided to R77 or his POA. The facility was unable to provide evidence the transfer notice was provided. No additional information was provided.
On 3/13/24 at 3:11 PM during the daily exit meeting, the facility was notified of concern regarding transfer notice not provided.
5) R54 was admitted the facility on 2/26/2020 with diagnoses that include, acute and chronic respiratory failure, chronic obstructive pulmonary disease, cerebral infarction, and bipolar. R54 signed onto hospice on 2/21/2024.
On 1/21/2024, at 11:15 AM, in the nursing progress notes nursing documented, went into R54's room resident was not responsive. R54 sent to ER (emergency room) for evaluation and treatment.
On 2/6/24, at 02:28 AM, in the progress notes, nursing documented staff spoke with hospital staff and R54 is being admitted to the ICU (intensive care unit).
On 2/20/24, at 03:30 AM, in the progress notes, nursing documented staff spoke with ER (emergency room) nurse who stated that R54 would be admitted with a diagnosis of hypercapnia.
Surveyor requested evidence of a bed hold and transfer notice for transfers that occurred on 1/21/24, 2/5/24 and 2/19/24.
The facility provided a copy of the Bed Hold Notice and eINTERACT Transfer Form dated 1/21/24, 2/5/24 and 2/19/24. Surveyor noted the documents do not contain any information about appeal rights to the State Agency.
On 03/13/24, at 03:28 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Nursing Home Administrator (ANHA)-C, Surveyor shared concerns regarding the transfer notice not including required information including the appeal to the State Agency for R54's three transfers.
No additional information was provided.
6) R85 was admitted to the facility on [DATE] with diagnoses that include acute and chronic respiratory failure, congestive heart failure, encephalopathy, narcolepsy and type 2 diabetes.
On 1/12/2024, at 15:36 (3:36 PM), in the progress notes, nurse documented, resident in respiratory distress, orders to send to ER (Emergency Room) for evaluation and treatment.
On 2/3/2024, at 21:50 (9:50 PM), in the progress notes, nurse documented resident had an unwitnessed fall with no injury. Resident weak due to COVID, will send to ER for IV (Interavenous) treatment.
Surveyor requested evidence of a bed hold and transfer notice for R85's transfers that occurred on 1/12/24 and 2/3/24.
The facility provided a copy of the Bed Hold Notice and eINTERACT Transfer Form dated 1/12/24 and 2/3/24. Surveyor notes the documents do not contain any information about appeal information to the State Agency.
On 03/13/24, at 03:28 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Nursing Home Administrator (ANHA)-C, Surveyor shared concerns regarding the transfer notice not including required information including the appeal to the State Agency for the two transfers.
No additional information was provided.
7) R65 was admitted to the facility on [DATE]. R65 is responsible for self.
On 03/13/24 at 01:34 PM, the Surveyor reviewed R65's electronic medical record which indicated R65 was transferred to the hospital on [DATE] and admitted to the hospital for severe sepsis, catheter associated urinary tract infection. R65 returned to same room in the facility on 12/26/2023. On 1/19/2024, R65 was admitted transferred to the hospital due to neck swelling and dental pain, R65 returned to the same room at the facility on 1/19/2024.
Surveyor requested evidence from the facility that notice of bed hold and transfer was provided to R65 and to R65's responsible party when R65 was hospitalized on [DATE] and 1/19/2024. The facility provided copies of the Facility Bed Hold and re-admission Policy Notice paperwork dated 12/22/2023 and 1/19/2024. Surveyor noted the information on the forms did not have contact information, including address, phone number and email address for the State Agency, Ombudsman, or Disability Rights agency.
On 03/13/24 at 11:11 AM, Surveyor interviewed ANHA (Assistant Nursing Home Administrator)-D regarding the process of paperwork for transfer notice. ANHA-D reports the Ombudsman is notified by the facility monthly of all hospitalizations through an e-mail. ANHA-D stated yesterday they found Facility Bed hold and re-admission Policy Notice paperwork on the units that was old and replaced it with paperwork that includes the current ombudsman contact information. When Surveyor asked if the information for the state agency to appeal to was included ANHA-D stated the facility put in a request with corporate staff yesterday for an updated form with appeal information included on the form.
On 03/13/24 at 03:11 PM, during the end of day meeting the concern about R65's transfer notice not being given on 12/22/2023 and 1/19/2024 was shared. Additional information was requested if available. None was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility did not ensure residents had an individualized comprehensive plan of care. This was observed with 2 (R85 and R81) of 23 resident comprehensive care plan reviews.
1. R85 was admitted to the facility with an indwelling catheter after a short stay in the hospital and there was no comprehensive plan of care with individualized interventions to address catheter care.
2. R81 was admitted to the facility on anticoagulant medication and there was no comprehensive plan of care with individualized interventions to address monitoring of the anticoagulant.
Findings include:
The facility policy entitled, Comprehensive Care Plans, dated 11/2017 states: An individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet Resident physical, psychosocial and functional needs, is developed and implemented for each Resident.
#4. Care plan interventions are initiated based on an analysis of information collected throughout the comprehensive assessment process.
#8. Assessment of the Resident is ongoing and care plans are revised based on the Resident condition, preferences, treatments and goals change.
1.) R85 was admitted to the facility on [DATE] with diagnoses that include acute and chronic respiratory failure, congestive heart failure, encephalopathy, narcolepsy and type 2 diabetes.
R85's Quarterly MDS (Minimum Data Set) assessment completed on 2/13/24 indicates R85 is cognitively intact and has an indwelling catheter and is always continent of bowel.
R85's physician orders document to change catheter every 30 days, active date of 2/28/24 and may use indwelling urinary catheter Foley, 18F size 10 cc (cubic centimeters) balloon size due to urinary retention, active date 1/15/24.
R85's electronic, and paper medical record, did not contain a comprehensive plan of care with individualized interventions for bowel and bladder or an indwelling catheter care and treatment.
On 03/13/24, at 10:34 AM, Surveyor interviewed Registered Nurse (RN)-J who stated when a resident is admitted to the facility the admitting nurse will complete a baseline care plan and then the Resident Care Coordinator will complete the comprehensive care plan. Should the care plan require any updates, anyone can update it like the floor nurse or Resident Care Coordinator. RN-J confirmed that should a resident return from a stay in the hospital with an indwelling catheter that should be identified in the hospital discharge paperwork and added to the care plan.
On 03/13/24, at 10:55 AM, Surveyor interviewed Resident Care Coordinator-T who confirmed that floor nurses are responsible to complete baseline care plans for new admissions, and she is responsible for completing the comprehensive care plan. Resident Care Coordinator-T explained it is all staffs' responsibility to update the care plan as needed. She also confirmed that if a resident has an indwelling catheter that should be reflected in their care plan.
On 03/14/24, at 08:23 AM, Surveyor interviewed Director of Nursing (DON)-B who informed Surveyor that if a resident has an indwelling catheter, then that should be part of their care plan. Surveyor informed DON-B that R85 returned from a hospital stay on 1/15/24 with an indwelling catheter and no bowel and bladder care plan could be located in R85's care plan as well as no indwelling catheter care plan. DON-B stated that typically when a resident returns from the hospital their discharge paperwork is reviewed by a nurse in admissions to check for any new physician orders. DON-B stated that this must have been an oversight.
On 03/14/24, at 03:28 PM, during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Assistant Nursing Home Administrator (ANHA)-C, Surveyor shared concerns regarding the lack of a bladder and bowel care plan for R85 including interventions for an indwelling catheter.
No additional information was provided.
2.) R81 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, generalized anxiety disorder, post-traumatic stress disorder (PTSD), cognitive communication deficit, essential tremor and absence of right leg above knee.
R81's quarterly MDS (minimum data set) dated 2/20/24 indicates a BIMS (brief interview for mental status) score of 15, which indicates cognitively intact. R81's MDS indicates he is taking an antidepressant, opioids, and anticoagulant. No antipsychotics were received. Active diagnosis include amputation, type 2 diabetes, hyperlipidemia, anxiety disorder, and PTSD. R81 uses a wheelchair for ambulating, is independent with eating and toileting, and requires partial to moderate assistance with bathing.
R81's November 2023 Medication Administration Record (MAR) documents:
Eliquis 5 mg (milligrams) - Give one tablet by mouth two times a day, ordered on 11/27/23.
R81's comprehensive care plan contains the following significant focused problems, initiated on 12/16/22 and resolved on 12/16/22: R81 has the potential for hemorrhage/bruising due to use of anticoagulant; initiated 12/16/22, resolved 12/16/22. Surveyor notes this care plan was initiated and resolved on the same day dated 12/16/22.
R81 will show no complications related to anticoagulant use; initiated 12/16/22, resolved 12/16/22
Interventions include:
-Encourage R81 to get out of bed and move about per plan of care to help prevent blood clots, monitor labs if ordered,
-Monitor R81 for and encourage to report any side effects of anticoagulant use such as pain, swelling, hot/cold sensations, skin changes, or discolorations on the body, sudden and severe leg or foot pain, foot ulcers, circulation issues, sudden headache, dizziness or weakness, unusual bleeding, pain in stomach, back or side, urinating less than usual or not at all, flu-like symptoms; initiated 12/16/22, resolved 12/16/22.
Surveyor notes there is not an active care plan to monitor the use of or side effects of Eliquis (anticoagulation therapy) for R81.
Surveyor interviewed Resident Care Coordinator-T on 3/14/24 at 8:01 am who indicated the nurses on the floor will get a new admit and complete an admission baseline care plan. Resident Care Coordinator-T indicated the facility then has 21 days to complete a comprehensive care plan. Resident Care Coordinator-T indicates residents are to have a care plan while taking anticoagulation therapy. Resident Care Coordinator-T reviewed R81's medical records and noted there was no care plan for anticoagulation therapy and notes there should be one included in R81's chart. Resident Care Coordinator-T indicates she has a new partner who is working with her and currently training. Resident Care Coordinator-T reports her previous partner was the individual responsible for including the anticoagulation therapy care plan for R81. Resident Care Coordinator-T indicated, had he been her resident, she would have included an anticoagulation therapy care plan for R81
On 3/14/24 at 8:36 am, Surveyor notified Director of Nursing (DON)-B of concerns with R81 taking anticoagulation and not having a current care plan. Surveyor requested additional information if available. None was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure they provided the necessary care, consistent with professional standards of practice, to prevent the development of pressure ulcers for 1 out of 5 residents (R38) reviewed who were at high risk.
R38 returned to the facility following surgical repair to the left knee. R38 was to wear an immobilizer to the left lower extremity for 6 weeks after the surgery. The facility did not provide monitoring of R38's skin under the immobilizer and R38 developed a stage 4 pressure ulcer to the back of her left lower leg.
This is evidenced by:
R38 was readmitted to the facility on [DATE] following an acute left distal femoral fracture with surgical repair.
Hospital discharge instructions included, wound/skin care: may reinforce left knee dressing; otherwise leave in place until ortho follow-up. Stage #3 coccyx pressure injury - silicone boarded foam change 3 times a week, offload from pressure.
Surveyor conducted a review of the physician orders for November 2023. R38 had an order that stated, may reinforce left knee dressing; otherwise leave in place until ortho follow-up. As needed for wound healing. Start date 11/10/23. (d/c date 12/27/23).
A review of the plan of care for R38 indicates: R38 Requires an immobilize to LLE (Left Lower extremity) secondary to Limitation in ROM (Range of Motion) from recent surgery. Date Initiated: 11/17/2023.
Interventions include:
o Will tolerate splint use through next review. Date Initiated: 11/17/2023
o Apply splint/brace per MD (Medical Doctor) order to affected area. Date Initiated: 11/17/2023
o Monitor splint for cleanliness, need for refitting, repair, or fit as needed. Date Initiated: 11/17/2023
o Report any changes in ability to use the affected area. Date Initiated: 11/17/2023
R38 has alteration in skin integrity r/t (related to) non-removable medical device stg (stage) 4 to LLE, Left thigh/knee wound near surgical incision, decreased mobility, need for staff assistance for ADLs (Activities of Daily Living) and transfers, diagnosis of lymphedema, hemiplegia and hemiparesis, epilepsy, anemia, hx of falls, poly osteoarthritis. Recurrent shingles/zoster, rashes, dx (diagnosis) atopic neurodermatitis. Non-compliance with repositioning/chair time. Date Initiated: 09/05/2023
Interventions include:
o Skin will show s/s (signs/symptoms) of healing thru next review Date Initiated: 09/05/2023
o Absorbent to wick up moisture. Date Initiated: 06/25/2023
o Barrier cream to areas exposed to moisture/incontinence. Date Initiated: 09/26/2021
o Bathe with mild soap. Date Initiated: 09/18/2021
o Inspect skin daily with care Date Initiated: 09/05/2023
o LAL (Low Air Loss) mattress to bed. Date Initiated: 11/10/2023
o Moisturize dry skin Date Initiated: 09/26/2021
o Monitor nutritional status Date Initiated: 09/26/2021
o Monitor wound related pain and administer pain medications as appropriate. Date Initiated: 06/25/2023
o Position body with pillows/support devices Date Initiated: 09/26/2021
o Pressure reduction support on wheelchair with LLE calf support in W/C (wheelchair) Date Initiated: 09/26/2023
o Remind of importance of frequent position changes. Explain risks of prolonged sitting in her w/c. Date Initiated: 11/27/2023
o Treatment as ordered Date Initiated: 09/18/2021
R38 had a follow up Orthopedic consult on 11/22/23. The progress note indicates there is a slow stable fracture alignment. Staples removed today. May allow running water over incision. No soaking under water. Steri strips may be removed after 1 week. Continue non-weight bearing on left lower extremity. No rx (prescription) changes.
The facility conducted a comprehensive assessment on 12/19/23 for R38's development of a pressure ulcer to the left lower leg (rear). Pressure Ulcer is unstageable. 5.0 centimeters in length by 2.0 centimeters in width and depth is less than 0.1 centimeters. Area described as superficial. 25% granulation, 75% slough, and 0 eschar. Margins are irregular, peri-wound is intact. Comments: Unstageable pressure ulcer noted to left lower extremity. New orders received. Low air loss mattress in place. Education on importance of repositioning with R38, who verbalized understanding.
On 12/18/2023 at 6:01p.m., Physician progress note: DATE OF SERVICE: 12/19/2023
CHIEF COMPLAINT: Mobility and ADL dysfunction secondary to h/o (history of) of CVA (Cerebral Vascular Accident) with left ORIF (Open Reduction and Internal Fixation) distal femur with removal of hardware. REASON FOR RE EVALUATION: R38 was discharged on 11/07 and was re admitted in the facility due patient undergone left ORIF distal femur with removal of hardware. HOSPITAL COURSE: R38 is a [age and sex of R38] who is a LTC (Long Term Care) resident with h/o of CVA with left ORIF distal femur with removal of hardware in the presence of multiple medical comorbidities leading to a functional decline. Patient admitted to the SNF (Skilled Nursing Facility) on 09/16/2021 for skilled nursing and rehab. Patient asked to be seen by primary team to optimize therapy, pain control and discharge planning. Patient's plan and progress was discussed with nursing staff and therapy. HPI (History of Present Illness): R38 seen and examined. R38 is going out for an appointment today. Unfortunately, R38 has a pressure injury from rubbing from knee immobilize brace which she has had at all times located on that left LE (left extremity). She does not feel a lot of pain there which she states she has not report it to nursing. She does have PRN (as needed) pain medication available. Spoke with nursing and will follow-up with her team today. Hopefully will get the immobilizer switch (sic) out to something that will allow for relief. Pain is a 0/10 today at rest. Pain is well controlled on pain medications. No reported side effects.
On 12/19/2023, the facility conducted an Unavoidable Pressure Injury or Condition Review of clinical Manifestations. The progress note states R38 has a non-removable brace to LLE. Does not like to reposition. Chooses not to drink nutritional supplement to aide in healing.
Nursing note dated 12/19/2023 at 4:36 p.m.: R38 returned from ortho appointment with orders for NWB (Non Weight Bearing) x (for) 6 more weeks to dc (discontinue) immobilizer, follow up in 6 weeks, to also consult with [name of doctor] for the wound on her left calf and heel noted and carried out.
On 12/26/23, the facility conducted a weekly comprehensive assessment of R38's pressure ulcer to the left lower extremity (rear). Stage is assessed to be a stage 4 measuring 5.5 cm in length by 2.5 cm in width by 0.1 cm in depth. 25% epithelization, 25% granulation, and 50% slough. Margins are irregular. Moderate exedute. This area is offloaded with pillow. R38 complains of pain with washing, subsides when completed. Wound is healing. NP (Nurse Practitioner) updated and continue treatment.
On 1/2/24, the facility's weekly skin assessment indicates R38 has a stage 4 pressure ulcer to the left lower extremity-rear measuring 5.6 cm by 2.3 cm by 0.1 cm. This area is offloaded with pillow. Wound bed is 25% epithelization, 50% granulation and 25% slough. No eschar present. Continue treatment.
On 1/9/24, the facility's weekly skin assessment indicated R38 had a stage 4 pressure ulcer to the left lower extremity-rear measuring 4.5 cm by 2.0 cm and depth is unable to measure. 10% slough and 90% eschar. Continue treatment.
On 1/16/24, the facility's weekly skin assessment indicates R38 has a stage 4 pressure ulcer to the left lower extremity-rear measuring 3.4 cm by 1.0 cm by 0.4 cm. Description - cavity or crater.
On 1/23/24, the facility's weekly assessment indicates that R38 has a stage 4 pressure ulcer to the left lower extremity measures 3.5 cm by 1.1 cm by 0.5 cm depth. 100% granulation. This area is offloaded with pillow. NP updated. Continue treatment, improved.
Continued weekly assessments were completed by the facility. The pressure ulcer continued to improve towards healing which was indicated by decrease in size of the area.
On 3/5/24, the weekly skin assessment indicated that the pressure ulcer to R38's left lower extremity is noted to be healed.
On 03/13/24 at 1:31p.m., Surveyor interviewed Director of Nursing (DON) - B regarding R38's acquired pressure ulcer to her left lower extremity-rear. Surveyor asked DON-B if the staff should have been monitoring R38's skin underneath the leg immobilizer. DON-B stated Nursing should have been looking at the skin and typically this would have been conducted each shift. DON-B stated she would need to investigate this further and get back to Surveyor to confirm skin assessments. Surveyor asked DON-B how the pressure ulcer was discovered. DON-B stated that I went to conduct a skin check, I was just doing random skin checks and I found the area. DON-B confirmed that no other staff had reported discovering the pressure ulcer prior to her finding it. DON B stated staff reported looking at the skin under the immobilizer and that CNAs would wash the left lower leg and put lotion on it. Surveyor reviewed with DON-B the facility's assessment that the pressure ulcer development was unavoidable because the brace R38 was wearing was non-removable and how did the facility staff wash and apply lotion if the immobilizer was not to be removed. DON-B was unable to provide additional information at this time and stated she would follow-up.
On 03/13/24 at 03:11 p.m., Surveyor shared concerns about the development of the stage 4 pressure ulcer that developed under R38's immobilizer on her left lower extremity-rear. Surveyor shared concerns the facility staff were not checking R38's left lower extremity daily knowing that R38 was at high risk for developing a pressure ulcer. The facility did provide evidence R38's skin was checked weekly, every day shift on Mondays with her shower however, the information did not document if the staff removed the immobilizer during the skin checks. In addition, the facility provided discharge documentation from 11/7/23 stating R38 is non-weightbearing to her left lower extremity for at least the next 6 weeks. Knee immobilizer to remain in place. Surveyor noted the order did not indicate if the skin under the immobilizer should or should not be checked and there is no documentation this was clarified with R38's physician.
No additional information has been provided as of the time of exit from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to identify and eliminate all known and foreseeable accident hazards in 1 (R414) of 1 resident reviewed with a significant change in condition.
The facility had assessed R414 as being at high risk for falls. On [DATE], R414 had an unwitnessed fall. Facility charting on [DATE] at 5:30 pm indicates the CNA found R414 on the bathroom floor.
R414 was noted to have hit his head and was experiencing altered mentation with being only oriented to self. R414's baseline orientation is to person, place, time, and event.
The facility did not do a post-fall investigation on this date to determine the circumstances surrounding the fall to analyze what occurred and what could be done to prevent further falls.
On [DATE], R414 sustained a second unwitnessed fall while reaching for his call light that was not within reach (contrary to the care plan, which directed staff to keep the call light within reach). R414 was found on the floor lying on his left side next to the bed lying over the call light and nightstand base. R414 sustained a head injury, was moaning in pain, and in and out of cognition with intermittent nonsensical verbalization. The facility did not do a post-fall investigation to analyze what occurred and what could be done to prevent further falls.
R414 died on [DATE].
The facility's failure to prevent accidents to the extent possible created a finding of immediate jeopardy that began on [DATE]. Surveyor notified the Director of Nursing (DON)-B of the Immediate Jeopardy on [DATE] at 10:09 am. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of an E as the facility continues to implement their action plan.
Findings include:
The facility policy titled Management of Falls dated 8/2020 states:
Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's plan of care in order to minimize the risks for fall incidents and/or injuries to the resident.
Procedure: 1. Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post fall, quarterly, and annually. 2. Orient resident to room, call light, unit, and location of the nurse's station upon admission to the facility. 3. Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following; Contributing diagnoses/disorders/disease processes/active infections/other comorbidities, history of fall incidents, incontinence, medications (Narcotics, Antihypertensives, etc.), assistance required with Activities of Daily Living (ADL's), gait/transfer/balance issues, behaviors, and/or cognitive status. 4. Provide assistive devices for mobility, hearing and vision as appropriate for the resident. 5. Assess appropriateness for resident to participate in skilled therapy or restorative programming in order to maintain or improve physical function of resident. 6. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. 7. Monitor for changes in medical condition and notify physician as necessary to manage changes in status of the resident. 8. Conduce care plan meetings with resident, responsible party, and facility interdisciplinary team quarterly and as needed. 9. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.
R414 was admitted to the facility on [DATE] with diagnoses of dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, urine retention, Gilbert Syndrome, and failure to thrive. R414 is his own person.
R414's admission Minimum Data Set (MDS) assessment completed on [DATE] indicates a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. R414 requires extensive assistance with one-person and physical assistance with bed mobility, transferring, dressing and toileting. R414 is not steady and is only able to stabilize himself with staff assistance while moving on and off the toilet. R414 has an indwelling urine catheter and is always continent of his bowels.
R414's Care Plan indicates R414 is at high risk for falls related to limited mobility and impaired balance dated [DATE]. Interventions include; 1. Assist R414 resident get up and out of bed during the night when resident is not feeling sleepy, Date Initiated: [DATE], 2. Encourage R414 to call, don't fall, Date Initiated: [DATE], 3. Complete frequent checks, Date Initiated [DATE], 4. Keep frequently used items within reach in room, Date Initiated [DATE], 5. Monitor for changes in ability to navigate the environment, Date Initiated [DATE], 6. Notify family and MD of any new fall, Date Initiated [DATE], 7. Promote placement of call light within reach, Dated Initiated [DATE].
On [DATE] at 1730 (5:30 PM), the facility documentation indicates the CNA (Certified Nursing Assistant) found R414 on the bathroom floor. R414 had an elevated BP (Blood Pressure) and noted to have altered mentation with being unable to convey where he was, day of the week nor the month. R414's baseline orientation is fully oriented to person, place, time, and event. The facility charge nurse and Hospice were notified of the unwitnessed fall. R414 had an improvement with his vital signs and mentation after Hospice arrived at the facility at 6:45 pm.
On [DATE] at 5:34 pm, the facility documentation indicates R414 was found lying on his back flat on the bathroom floor and R414 hit his head. R414 had complaints of pain in his upper back between his should blades, altered mentation, along with high blood pressures and low pulse rates. R414 had a brown emesis while being transferred with a Hoyer lift back to his bed. Hospice instructed the facility to administer Zofran for vomiting. There is no documentation of a post-fall investigation to determine the circumstances that led to R414's fall and to determine what changes might be made to the care plan to prevent further falls.
Surveyor reviewed the facility Neuro check documentation dated [DATE] at 3:47 am indicating R414 having rambling speech with a weak right-hand grasp. Surveyor notes there is no documentation indicating hospice or the MD were notified of this significant change in condition with R414 having weak right-hand grasps and rambling speech.
Facility documentation dated [DATE] at 9:58 am indicates the facility nurse notified hospice with a significant change in condition. R414 was feeling off, hands being shaky, lethargic, and needing to be fed for breakfast. R414 did not previously require assistance with eating.
Documentation indicates a second call was placed by the facility to hospice on [DATE] at 10:28 am indicating R414 is hunched over in his wheelchair with increased fatigue.
Surveyor reviewed the post fall documentation on [DATE] at 8:00 pm which indicates R414 is alert with confusion and fatigue is noted. R414 can answer questions appropriately but did mumble stories about siblings that were nonsensical. Documentation reports R414 hit his head on [DATE] and surveyor notes the MD was not notified of this change in condition at the time of the post fall documentation.
Documentation from [DATE] at 9:10 pm indicates R414 was found on the floor lying on his left side of the bed with the call light and nightstand base under him. R414 was moaning in pain with c/o pain in his back, left arm and left shoulder. R414 had a head injury with blood present on the floor. R414 was noted to have cognitive impairment, intermittent nonsensical verbalization, pinpoint eyes, eyes wrenching, a left forehead hematoma measuring 4 cm x 3 cm with a 2 cm laceration to the middle of the hematoma, and no urine output in the urine Foley bag. The charge nurse and hospice were notified. Hospice instructed the facility staff to not send out R414 for evaluation prior to hospice doing an evaluation. The facility nurse applied pressure to R414's head injury site and remained with R414 in the fall position until hospice arrived for evaluation.
Documentation from Hospice Progress notes dated [DATE] at 9:34 pm indicate R414 had an unwitnessed fall and sustained a head injury. R414 denied pain but was observed to be wincing with movement. Documentation from Hospice indicates as needed (PRN) pain medication was given due to R414 likely being sore and probably having a headache. R414 was observed to be alert and oriented and tolerating changing his shirt without the facility staff in R414's room. Hospice reports facility staff chose to leave R414 on the floor with a pillow under his head until hospice arrived for evaluation. R414 was assisted back to bed using a Hoyer lift. Hospice attempted to contact R414's POA who was unavailable, and hospice left a message. The hospice nurse applied steri strips to R414's head wound and a new Foley catheter was inserted with 2400 cc of dark amber urine and large amounts of thick fibrous tan drainage was noted.
Surveyor interviewed Licensed Practical Nurse (LPN)-S on [DATE] at 11:00 am. LPN-S indicated R414 is typically alert and oriented and able to make his needs known. LPN-S reported R414 being weak and requires assistance of one with ambulation, toileting and transferring. LPN-S stated the facility staff had to frequently remind R414 to contact staff when needing to transfer as R414 frequently ambulated independently without calling for assistance. LPN-S indicated she could clearly tell R414 had a head injury on [DATE] at 9:10 pm after R414 had a second unwitnessed fall from his bed while reaching for the call light that was out of reach. LPN-S applied pressure to R414's head to help control bleeding and stayed with R414 for approximately 30-40 minutes in the fall position while she waited for hospice to come and evaluate R414. LPN-S stated she knew R414 clearly had a brain injury with R414's eyes being dilated and changed.
Surveyor reviewed the facility fall investigation dated [DATE] at 9:10 pm indicating R414 sustained a hematoma and laceration to the face along with a skin tear to the left hand. R414 is oriented to person, the facility NP was notified on [DATE] at 3:53 pm, and POA was notified on [DATE] at 3:29 pm. Surveyor notes the MD was not notified of the significant change in condition. Surveyor also notes the facility NP and POA were notified the following day approximately 18+ hours after the significant change in condition. Surveyor notes documentation does not state was what discussed with the facility NP and POA at that time of phone call and if it the option for R414 to seek further evaluation was discussed.
Surveyor reviewed the facility neuro check documentation on [DATE] at 1:00 am indicating R414's pupils not being equal in size, with the right pupil being fixed, left pupil being sluggish, and R414 being unable to grasp hands.
Surveyor reviewed the facility neuro check documentation on [DATE] at 2:00 am indicating R414's is aphasic (a person who is unable to communicate), right pupil is fixed, left pupil is sluggish, and unable to grasp hands.
Surveyor reviewed hospice progress note dated [DATE] at 9:15 am indicating R414 requires meals set up, decreased appetite, increased dysphagia, chocking and coughing with thinned liquids, increased pain, total dependence with bathing, and is bedbound with assistance of a Hoyer lift after two unwitnessed falls on [DATE] and [DATE]. R414 is requiring head support with a rolled towel to prevent neck pain and is unable to move his own head/neck. Urine is noted to be dark concentrated with sediment in Foley catheter tubing.
Surveyor reviewed the Interdisciplinary Team (IDT) note dated [DATE] at 11:42 am indicating the [DATE] fall for R414 was reviewed for safety and a new intervention was placed. Surveyor notes the 2nd fall from [DATE] was not reviewed, the MD was not notified of the significant changes in condition, and there was one change to the care plan to include medication adjustments per hospice for R414 being a high risk of falls.
Hospice Progress note dated [DATE] at 3:30 pm indicates R414 is in pain, increased sleeping, withdrawn, minimal responsiveness, barely opening his eyes, abdominal respirations, slow capillary refill in his nail beds, pallor, crackles in his lungs (fluid building up in the lungs), skin cool to touch, skin mottled in areas (lack of blood flow to the skin), and unable to respond to tell staff how he feels.
Surveyor reviewed the Hospice Progress Note dated [DATE] at 10:00 am indicating R414 is unresponsive, having irregular heart rates, breathing through his mouth, eyelids barely opening, shallow respirations, crackles to his lungs, coughing to clear his airway, unresponsive to touch or voice however, R414 jerks and gasps when the hospice nurse swabs R414's lips. Documentation indicates the hospice nurse noted no PRN medications (Lorazepam and Morphine) given since last visit on [DATE] at 3:30 pm.
Surveyor reviewed the Hospice Progress Note dated [DATE] at 11:00 am indicating R414 is noted to have an elevated pulse, rapid respiratory rate (RR) of 36 (normal RR is 16), gasping for air, abdominal respirations, using accessory muscles with breathing, coughing, short of breath, and moderate discomfort with breathing. Documentation indicates hospice updated the POA and administered 1 dose of Morphine for shortness of breath.
Facility progress note dated [DATE] at 10:50 pm indicating the CNA called the nurse into R414's room. R414 was pulseless and not breathing. Hospice and the facility charge nurse were notified by the facility staff.
On [DATE], at 10:09 AM, Surveyor notified the Nursing Home Administrator-A and Director of Nursing-B of the concerns with the following:
~ No root cause analysis performed for [DATE] and [DATE] unwitnessed falls to minimize future falls or harm.
~ Lack of determining what may have caused or contributed to the fall, including what R414 was trying to do before he fell.
~ Revising R414's plan of care to reduce the likelihood of another fall. Including no additional monitoring after increasing Miralax on [DATE].
~ Call light was not within reach on [DATE]. R414 was reaching for his call light and sustained a fall on [DATE].
~ MD indicated R414 was not to ambulate independently. R414 was noted to be in the bathroom independently on [DATE] at the time of his unwitnessed fall.
The facility's failure to keep R414 free from hazards, reduce the risk of all known and foreseeable accident hazards that cannot be eliminated, provide appropriate and sufficient supervision to R414 to prevent an avoidable falls increased a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy.
The Immediate Jeopardy was removed on [DATE] when the Facility completed the following:
-All residents were reviewed for changes in condition, falls, and hospice services and the care plans were update as indicated.
-All nursing staff were educated by the Director of Nursing, Nurse Consultant or designee regarding assessing for changes in condition post fall and notifying the primary care provider of those changes in condition.
-All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's fall prevention policy.
-All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on the facility's change in condition policy.
-All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on conducting a root cause analysis post fall to further assess resident's needs, addressing risk factors such as the resident's medical condition(s), facility environmental issues and/or staffing issues.
- All nursing staff were educated by the Director of Nursing, Nurse Consultant, or designee on ensuring interventions were established to prevent further falls based on the root cause analysis/assessment.
-The facility Nursing Home Administrator, DON, and Nurse Consultants reviewed policies and procedures on falls, change in condition, and comprehensive care plan with the Medical Director.
-The Nursing Home Administrator and Director of Nursing conducted a review of compliance using a Quality Assurance audit tool for falls, changes in condition post fall, and root cause analysis post fall. Interventions were established and included in the comprehensive plan of care based on the root caused analysis/assessment to prevent further falls.
-Audits well be completed three times a week for four weeks, then weekly for four weeks, then monthly for 3 months, then randomly by the Nursing Home Administrator, DON, Assistant Director of Nursing/designee until compliance is maintained.
-The results of the audits will be reviewed monthly by the Facility QAPI team to determine any necessary changes.
-An emergency QA meeting was held on [DATE] by the Nursing Home Administrator with the Interdisciplinary Team and Medical Director. The meeting included discussion of a fall resulting in a change in condition, root cause analysis post fall, and implementation of a comprehensive care plan with interventions reflective of the root cause analysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and observation, the facility did not ensure a resident with an indwelling catheter received consult services. This was observed with 1(R22) of 4 residents reviewed with an indwelling catheter.
* R22 was admitted without an indwelling catheter. R22 went out to the hospital due to a change in condition and an indwelling catheter was placed in the hospital due to urinary retention. There was no follow-up with a Urology to determine long term needs of the catheter.
Findings include:
The facility's policy and procedure Indwelling Catheter, dated 9/20, was reviewed by Surveyor. The procedure includes under 15: A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible.
On 03/11/24 at 1:08 PM, Surveyor observed and spoke with R22. R22 was observed to have an indwelling Foley bag hanging below their wheelchair. R22 did not know why they had an indwelling catheter.
R22 was admitted to the facility on [DATE] for rehabilitation services. R22 had a fall at home and fractured their hip.
R22's admission MDS (minimum data set) assessment completed on 12/11/23, indicates: No indwelling catheter and frequently incontinent of urine.
Per Progress Note on 12/29/2023 at 11:07 AM, R22 Went out to Ortho (orthopedic) appointment this morning. Message received that she will be admitted to hospital for debridement of left hip. R22 returned to the facility on 1/4/24 with a indwelling catheter for their bladder.
The Hospital Discharge Notes from 1/4/24, indicate R22 was straight cathed x (times) 3 and then a Foley was placed for having over 500 ML (milliliters) of urine in the bladder after voiding. R22 has chronic overflow incontinence symptoms. R22 instructions include: Maintain Foley on rehab discharge; Urology follow-up for voiding trial to be arranged in the coming weeks.
R22's Nurse Practitioner progress notes dated 1/22/24, indicates under Assessment #6: Urinary retention with failed voiding trial, Foley replaced. Start Tamsulosin (medication for urinary retention) today. Monitor and consider a second voiding trial in 2 weeks or follow-up outpatient urology.
R22's Nurse Practitioner progress notes dated 2/6/24, indicates under Assessment #6: Urinary retention with failed voiding trial, Foley replaced. Start Tamsulosin today. Monitor and consider a second voiding trial in 2 weeks or follow-up outpatient urology.
On 3/12/24 at 11:07 AM, Surveyor spoke with ADON-H (Assistant Director of Nurses) regarding the concern R22 is experiencing urinary retention, Foley trial removals have been attempted and failed, and Surveyor was unable to locate documentation the outpatient urology follow up took place.
On 3/12/24 at 2:45 PM, at the facility exit meeting with Nursing Home Administrator-A, Director of Nursing-B Surveyor shared the concerns with R22's Foley use.
On 3/13/24 at 11:09 AM, ANHA-D (Assistant Nursing Home Administrator) spoke with Surveyor. ANHA-D indicated R22 was in the hospital and the hospital indicated the Urology referral was canceled due to the hospital stay. The skilled nursing facility will be managing the Foley. R22 had bladder voiding trials and failed to urinate on their own. After the canceled Urology referral, the facility did not request another referral to a Urologist. On 1/4/24, the hospital ordered a Urology referral for urine retention. ANHA-D provided a plain white paper that was dated 3/13/24 at 10:27 AM, indicates a telephone encounter from 1/30/24 states R22 is still in the hospital and catheter to be managed at the care facility. Referral closed. Surveyor notes R22 went out to the hospital on 1/29/24 for a respiratory illness. Prior to this hospital transfer there was no urology consult set up for R22.
On 3/13/24 at 3:12 PM at the Facility Exit Meeting Surveyor shared the urology follow-up concerns. DON-B (Director of Nurses) indicated R22 was admitted to the facility with the indwelling catheter. Surveyor provided R22 admission MDS assessment completed on 12/11/23 that indicates R22 is frequently incontinent of the bladder. R22 was not admitted to the facility with an indwelling catheter for bladder. DON-B did not validate the MDS information. Surveyor requested any additional information. As of 3/18/23 no additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure 1 Resident (R82) of 1 resident was properly assessed for the use of bed rails and the facility did not have evidence that risks and benefits were discussed with the resident and/or representative.
R82's was assessment to not be appropriate for the use of bed rails. R82's bed was observed to have grab bars.
Findings include:
The facility's policy entitled, Side Rail Assessment, dated 9/2020 states: It is the policy of this facility to properly assess a resident's needs for side rail use. The side rail assessment form will be completed upon admission, readmission, with significant change and annually thereafter.
R82 was admitted to the facility on [DATE] for short term rehabilitation with diagnoses that include fracture of unspecified part of neck of left femur, presence of left artificial hip joint, lack of expected normal physiological development in childhood, schizophrenia, moderate intellectual disabilities and history of traumatic brain injury.
R82's admission MDS (Minimum Data Set) dated 2/28/24 documents R82 as being severely cognitively impaired. R82 is assessed to have impairment on one side of his upper and lower extremity. R82 requires partial to moderate assistance when rolling left to right and sit to lying position and supervision/touching assistance for bed to chair transfers.
On 03/11/24 at 09:31 AM, during the initial tour, Surveyor observed R82 laying in a low bed with regular mattress and black grab bars on both sides of the bed. The grab bars were in a fixed position and did not move up and down.
Surveyor reviewed R82's medical record. A side rail assessment for R82 was completed on 2/21/24 which documents that the resident is not able to make decision regarding safety and is not able to get in and out of bed without staff assist. The decision regarding the use of side rails documented in this assessment is no use of side rails.
A review of R82's ADL (Activities of Daily Living) Functional Performance Deficit care plan created 2/21/24 documents the intervention, Cue resident to grasp side rail and pull self-up to a sitting position or to the side of bed, Date Initiated: 02/21/2024.
On 03/12/24, at 09:45 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-I who informed Surveyor that typically the nurse on the floor will complete a side rail assessment. She confirmed that enabler bars are considered side rails and explained that all residents have an assessment completed upon admission and then quarterly if they have a side rail otherwise yearly if they did not. ADON-I was unsure how the results of the side rail assessment are communicated other than just being in the resident medical record. Surveyor and ADON-I walked to R82's room and ADON-I confirmed the black bars attached to R82's bed were enabler bars which are considered side rails.
On 03/12/24, at 11:09 AM, Surveyor interviewed Registered Nurse (RN)-J, who stated typically the floor nurse will complete side rail assessments upon admission and at times therapy will complete them as well.
On 03/12/24, at 01:26 PM, Surveyor spoke with Therapy Director-K who explained therapy may complete a side rail assessment if they think a resident would benefit from having them. Therapy Director-K confirmed therapy did not make any recommendations for side rails to be used for R82.
On 03/12/24, at 01:34 PM, Surveyor observed R82 laying in the bed and observed the black enabler bars were removed from the bed. Surveyor spoke with Certified Nursing Assistant (CNA)-L who confirmed that maintenance came about an hour earlier and removed the bars. CNA-L stated the resident didn't need them anymore.
On 03/12/24, at 02:51 PM, at the end of the day meeting with Nursing Home Administrator-A and Director of Nursing (DON)-B, Surveyor explained concerns regarding enabler bars on R82's bed when the side rail assessment assessed R82 to not use side rails. Requested side rail policy and procedures.
On 03/12/24, at 03:19 PM, Surveyor spoke with Building Manager-M who confirmed he did remove the enabler bars from R82's today. Building Manager-M stated they do complete bed rail audits yearly as well as when a resident is discharged . Surveyor asked if he recalled a request to put the bed rails onto the bed for R82 and he stated he didn't remember and did not keep a log to check. Building Manager-M stated he also could not verify the enabler bars were removed from the bed prior to R82 being assigned to that bed and room.
No additional information provided.

Based on observation, interview, and record review, the facility did not ensure sufficient nursing staff was available to provide nursing and related services to assure residents attained or maintained the highest practicable physical, mental, and psychosocial well-being as determined by the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment potentially affecting 115 of 115 residents in the facility.
Residents voiced concerns there were not enough staff to care for their needs.
The facility was identified as having consistently low weekend staffing on the Staffing Data Report submitted to CMS (Centers for Medicare and Medicaid Services) from 10/1/23 through 12/31/23.
Staff indicated there were not enough staff on the unit to assist with residents' cares and needs.
Findings include:
The Facility Assessment stated the following for Licensed Nurses and Certified Nurse Aides (CNA) staffing coverage: Evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs. Total number needed or average or range of staff are 14 Licensed Nurses and 24 CNAs. Staffing may be adjusted based on resident needs.
The facility uses a documented algorithm dated 6/18/23 to determine the number of CNAs needed based on total census. The determination of staff based on the census is as follows:
85-90 residents = 22 CNAs
91-96 residents = 23 CNAs
97-102 residents = 24 CNAs
103-108 residents = 25 CNAs
109-114 residents = 26 CNAs
115-120 residents = 27 CNAs
The facility's algorithm indicates 14 Licensed Nurses are required throughout the facility with a total of 112 daily hours.
Surveyor reviewed the resident council notes from the facility which indicate the following staffing concerns:
-On 10/30/23 Resident council notes document - Re-visited staffing concerns on the weekends. Discussed what the facility is doing to bring in new staff, and what the facility is doing to retain the staff they have. Residents expressed they would like to see more staff.
-On 11/20/23 Resident council notes document - The facility spoke again to residents about staffing and incentives given when employees take on extra tasks.
-On 12/26/23 Resident council notes document - Staffing concerns were addressed. The facility indicated since the last resident council meeting the facility has hired a new Licensed Practical Nurse (LPN) and two new CNAs.
In an interview on 3/13/24 at 11:37 am, Scheduling Coordinator-V stated the facility's daily schedule is determined by following the facility's staffing algorithm to determine the number of CNAs and Licensed Nurses based on the number of residents within the facility. The staffing algorithm supports 27 CNAs and 14 Licensed Nurses per day based on a census of 115-120 residents. Scheduling Coordinator-V indicated weekend staffing requires the same number of staff as weekday staffing requirements. Scheduling Coordinator stated the facility has struggled with low weekend staffing and the facility does not always have the 27 CNAs that are required by the facility. Scheduling Coordinator-V reports about half of the weekends in the last month have not been fully staffed with the required 27 CNAs based on a census of 115-120 residents. Scheduling Coordinator-V reports about half of all weekend staffing has not met the staffing requirements in the last 6 months. Scheduling Coordinator-V stated the facility meets every Monday and every Thursday of the week to discuss scheduling concerns and requirements. Scheduling Coordinator-V report Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Assistant Nursing Home Administrator (ANHA)-C and Scheduling Coordinator-V are in attendance for the Monday and Thursday staffing meetings. Scheduling Coordinator-V indicates NHA-A and DON-B are aware of consistently low weekend staffing and this has been discussed in the Monday and Thursday weekly staffing meetings. Surveyor noted the acuity of the residents was not figured in when calculating the staffing needs.
On 12/31/23, the Facility census was 114 residents. The daily staffing schedule reports the following staff: Day shift had 6 nurses and 9 CNAs, evening (PM) shift had 6 nurses and 7 CNAs, night (NOC) shift had 2 nurses and 6 CNAs. The facility reports the daily nursing schedule with 17 nurses for the day and a total of 19 CNAs for the day. Surveyor notes the facility is short a total of 7 CNAs for the day. This is determined based on a census of 114 by the facility algorithm used by the facility and requiring 26 CNAs.
On 12/30/23, the Facility census was 117 residents. The daily staffing schedule reports the following staff: Day shift had 6 nurses, 2 Med Techs, and 10.5 CNAs, evening (PM) shift had 6 nurses and 8 CNAs, night (NOC) shift had 2 nurses and 6 CNAs. The facility reports the daily nursing schedule with 17 nurses for the day and a total of 16 CNAs for the day. Surveyor notes the facility is short a total of 11 CNAs for the day. This is determined based on a census of 117 by the facility algorithm used by the facility and requiring 27 CNAs.
On 12/24/23, the Facility census was 112 residents. The daily staffing schedule reports the following staff: Day shift had 6 nurses and 7.5 CNAs, evening (PM) shift had 5 nurses and 7.8 CNAs, night (NOC) shift had 2 nurses and 6 CNAs. The facility reports the daily nursing schedule with 16 nurses for the day and a total of 21 CNAs for the day. Surveyor notes the facility is short a total of 5 CNAs for the day. This is determined based on a census of 112 by the facility algorithm used by the facility and requiring 26 CNAs.
On 12/23/23, the Facility census was 112 residents. The daily staffing schedule reports the following staff: Day shift had 6 nurses and 8.5 CNAs, evening (PM) shift had 6 nurses and 9 CNAs, night (NOC) shift had 2 nurses and 6 CNAs. The facility reports the daily nursing schedule with 16 nurses for the day and a total of 23 CNAs for the day. Surveyor notes the facility is short a total of 3 CNAs for the day. This is determined based on a census of 112 by the facility algorithm used by the facility and requiring 26 CNAs.
On 12/17/23, the Facility census was 115 residents. The daily staffing schedule reports the following staff: Day shift had 4 nurses and 9 CNAs, evening (PM) shift had 6 nurses and 7 CNAs, night (NOC) shift had 2 nurses and 6 CNAs. The facility reports the daily nursing schedule with 17 nurses for the day and a total of 20 CNAs for the day. Surveyor notes the facility is short a total of 7 CNAs for the day. This is determined based on a census of 115 by the facility algorithm used by the facility and requiring 27 CNAs.
On 12/16/23, the Facility census was 112 residents. The daily staffing schedule reports the following staff: Day shift had 6 nurses and 11 CNAs, evening (PM) shift had 5.5 nurses and 8 CNAs, night (NOC) shift had 2 nurses and 6 CNAs. The facility reports the daily nursing schedule with 17 nurses for the day and a total of 24 CNAs for the day. Surveyor notes the facility is short a total of 2 CNAs for the day. This is determined based on a census of 112 by the facility algorithm used by the facility and requiring 26 CNAs.
In an interview on 3/13/24 at 1:27 pm, CNA-W stated CNAs are typically assigned 11 residents on their shift. CNA-W indicated the facility is short staffed and estimated about twice a month, she will be assigned to 22 residents which is over the recommended amount of residents assigned to a CNA. CNA-W stated staffing is based on resident needs indicating the facility will consider the number of residents requiring hoyer lifts and requiring more time when determining how many CNAs are on each unit when short staffed. CNA-W gave the example of the facility assigning one CNA to a unit that doesn't have as many hoyer lifts if they are short staffed for that day. CNA-W stated call lights are activated by the resident and can be visible to staff by looking at the call light monitors on the wall. Call light monitors are located on each unit that include when the call light was activated and for how long the call light has been on.
On 3/13/24 at 9:57 am, Surveyor observed the call light monitoring system on the wall. Surveyor noted a resident on the 500 unit with an active call light for a total of 15 minutes. Two other call lights were initiated within that 15 minutes and answered within a few minutes.
On 3/14/24 at 3:47 pm, Surveyor shared with NHA-A and DON-B the concerns with consistently low weekend staffing triggering on the Staffing Data Report to CMS, residents expressing concerns with low staffing consistently during resident council, and staff indicating low staffing is consistent and ongoing. The scheduling coordinator did not take acuity of the residents into account when scheduling nurses and CNAs. NHA-A and DON-B notified Surveyor a performance improvement plan (PIP) was started at the Facility 3/5/24 to address the facility's low staffing concerns. Surveyor reviewed the PIP and noted the identified task of rounding education with the leadership team was the only action item with an estimated completion date identified, which was documented as 3/29/24. Surveyor notes 8 other action items did not have a start or completion date documented. Surveyor also noted the action item of a meeting scheduled for 3/12/24 was documented to have been rescheduled to 3/20/24 due to the State Survey team being in the building. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on comprehensive assessment of a resident, the facility did not ensure that residents were not given psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; residents who use psychotropic drugs received gradual dose reductions, unless clinically contraindicated; and PRN (as needed) orders for psychotropic drugs were limited to 14 days for 3 of 5 residents (R25, 103, and R81) reviewed for unnecessary medications.
R25 did not have required gradual dose reduction for Mirtazepine (antidepressant medicaiton).
R103 was prescribed PRN Lorazepam (sedative/antianxiety) without documentation of rationale by the Physician to extend beyond 14 days.
R81 was prescribed Primidone (Anticovulsant) without clear indication of use.
Findings include:
R25 admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following Cerebral Infarction, Dysarthria, Dysphagia, Spondylosis lumbar region, Adult Failure to Thrive, Hypertension, Anemia, Polyosteoarthritis and Depression.
R25's Care plan documented: (R25) is receiving Mirtazapine psychotropic medication. Noted to have diagnosis of Depression, unspecified. POA (Power of Attorney) has declined psych (psychiatric) services at this time.
R25's Physician's Order included: Mirtazapine Tablet 15 mg (milligrams) give 1 tablet by mouth two times a day related to depression - start date 12/8/22.
R25's February 2023 MAR (Medication Administration Record) documented: Mirtazapine Tablet 15 mg Give 1 tablet by mouth two times a day related to Depression, unspecified.
Facility progress note dated 3/15/23 at 1:08 PM, documented: Psychotropic Note Text: GDR (Gradual Dose Reduction) meeting: GDR recommended; pharmacist recommends 15 mg once daily at bedtime.
R25's March 2023 MAR documented: Mirtazapine Tablet 15 mg Give 1 tablet by mouth at bedtime related to depression - order Date 3/15/23.
Facility progress note dated 1/24/24 at 1:14 PM, documented: Type: Psychotropic Note Author: Social Worker (SW)-E Social Services - Behavior management team reviewed psychotropic medication. GDR recommended for Mirtazapine from 15 mg to 7.5. Nursing will follow up with family to obtain consent for GDR. Surveyor noted a copy of this progress note was signed by the NP (Nurse Practitioner) on 1/25/24.
On 3/13/24 at 9:42 AM, Surveyor spoke with SW-E who reported the facility has monthly meetings, but reviews GDR's quarterly so as not do the same unit too close together. Surveyor asked why R25's recommended GDR on 1/24/24 was not completed. SW-E reported she would have to check with nursing to see who followed up on it.
On 3/13/24 at 11:52 AM, SW-E advised Surveyor that Director of Nursing (DON)-B called R25's son/POA on 1/31/24 and he did not want the GDR. SW-E informed Surveyor DON-B had an emergency that day and left the building, and that she documented the information in the notebook but didn't do a progress note. Surveyor clarified with SW-E: A GDR wasn't done because R25's son didn't want it? SW-E replied: Correct. Surveyor asked if the facility allows residents' families to dictate resident care. SW-E stated: Well, he is the POA and has the right to refuse GDR. Another Surveyor present asked SW-E where she obtained this information. SW-E reported she was not sure and would get more information.
Surveyor was provided a copy titled Psychotropic Behavior Management Program last update 2/8/24 by (SW-E)/700 unit reviewed by behavior management meeting 2/21/24.
(R25) Mirtazapine 15 mg. GDR recommended on 1/24/23, POA declined GDR 1/31/24.
On 3/13/24 at 3:15 PM, during the daily exit meeting the facility was advised of concern regarding the lack of GDR reduction recommended for R25's Mirtazepine.
On 3/14/24 Surveyor was provided a copy of an NP note for a visit on 2/1/24 which documented: GDR of Mirtazepine recommended by pharmacy, however, upon discussion with family, they would like to continue his current dose as he has been doing well and they are concerned that a dose reduction would be detrimental to his health. Continue current dose and will continue to monitor, will reassess for potential GDR again at a future date.
Surveyor noted the NP progress note provided to Surveyor is not located in R25's medical record. Subsequent NP progress notes are noted in medical record for 2/15/24 and 2/26/24 with no mention of the recommended GDR.
On 3/14/24 at 9:15 AM, Surveyor asked DON-B where the NP progress note for 2/1/24 came from, as it is not in R25's medical record. DON-B reported she called the clinic, and the NP sent it over to be scanned in. Surveyor advised concern still exists due to GDR not attempted in 2 separate quarters within the first year. R25 admitted to the facility on [DATE] with the first GDR 3/15/23, and no subsequent GDR attempt until recommendation on 1/24/24 that did not occur. DON-B reported she understood.
2) R103 admitted to the facility on [DATE] and has diagnoses that include Depression, Parkinson's Disease, Epilepsy, Encephalopathy, Orthostatic Hypotension, Dementia and Dysphagia. R103 signed on to Hospice on 2/22/24.
R103's care plan documented: He is also receiving Lorazepam as part of a hospice comfort care package for nausea, restlessness, and moderate agitation - date initiated 2/12/24. Visual hallucinations Interventions: 1. Ensure his safety 2. Create calm atmosphere in his room [ROOM NUMBER]. Give him a little space 4. Talk in a slow, calm, soft tone 5. Redirect conversation. Yelling out/restless Symptoms Interventions: 1. Check and make sure he's ok 2. Talk in a calm, soft tone 3. Ask what we may help with
4. Offer fluids or food 5. See if he'd like to be repositioned.
R103's Physician Orders documented: Lorazepam Tablet 0.5 mg Give 1 tablet by mouth every 2 hours as needed for Nausea may take by mouth or under the tongue for moderate agitation or restlessness or nausea - order date 2/22/24. Surveyor noted there was no stop date for the as needed Lorazepam.
Surveyor notes the 14 day end date would be 3/7/24.
On 3/13/24 at 3:15 PM, during daily exit meeting, the facility was advised of concern regarding R103's PRN (as needed) Lorazepam order extending beyond 14 days without a stop date. No additional information was provided.
On 3/14/24 Surveyor noted a new Physician's order for R103 entered on 3/13/24 for Lorazepam Tablet 0.5 mg give 1 tablet by mouth every 2 hours as needed for Nausea for 14 Days may take by mouth or under the tongue for moderate agitation or restlessness or nausea active 3/13/24, end date 3/27/24.
R81 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, generalized anxiety disorder, post-traumatic stress disorder (PTSD), cognitive communication deficit, essential tremor and absence of right leg above knee.
R81's quarterly MDS (minimum data set) dated 2/20/24 indicates a BIMS (brief interview for mental status) score of 15, which indicates cognitively intact. R81's MDS indicates he is taking an antidepressant, opioids, and anticoagulant. No antipsychotics were received. Active diagnosis on R81's MDS include amputation, type 2 diabetes, hyperlipidemia, anxiety disorder, and PTSD. R81 uses a wheelchair for ambulating, is independent with eating and toileting, and requires partial to moderate assistance with bathing.
R81's comprehensive care plan contains the following significant focused problems with interventions:
R81 experiences periods of depressive symptoms related to physical disability and inability to return to home independently, initiated 11/16/23. Goal: R81 will have improved mood state through the review date, initiated 11/16/23. Interventions include: Behavioral health consults as needed, encourage R81 to maintain as much independence and control as possible, monitor/record mood to determine if problems seem to be related to external causes, monitor/record/report to Medical Director (MD) as needed acute episode feelings or sadness; loss of pleasure and interest in activities; feelings of worthlessness or guilt; change in appetite; change in sleep patterns; diminished ability to concentrate; change in psychomotor skills; initiated 11/16/23.
R81 is at risk for abuse related to diagnosis of PTSD (related to traumatic accident and amputation of leg). R81 does not currently report any trauma/traumatic symptoms affecting his daily life, initiated 12/8/23. Goal: R81 will remain safe, calm, and free from abuse through next review, initiated 1/15/24. Interventions include: At onset of behavior, calmly and firmly attempt to redirect to socially acceptable behaviors; check and assure physical comfort; compliment resident for appropriate social interactions; consider past patterns, personal and medical/psych history, interests, family/friends accounts to past incidents; consider possible antecedents: fear, fatigue, loss of control over a situation; determine preferred setting and approach and then offer health care accordingly; encourage R81 to participate in activities; encourage/reassure/redirect/repeat as needed; investigate accusation; maintain a calm soothing approach/environment and smile/pay compliments to promote feelings of belonging and importance with R81; monitor and report signs/symptoms of abuse; and simplify tasks, reduce stimulation, give more time or space if showing signs of feeling too challenged, initiated 1/15/24.
Surveyor reviewed R81's Medication Administration Record (MAR) for March 2024 which includes Primidone 150 mg (milligrams) by mouth two times daily for seizures. Surveyor notes R81 does not have a diagnosis of seizures.
Surveyor interviewed Assistant Director of Nursing (ADON)-H on 3/13/24 at 10:44 am who indicates seizures is listed as a reason for R81 taking Primidone according to the MAR. ADON-H then acknowledged R81 does not have seizures listed on his diagnoses and states she will be getting clarification on why R81 is receiving Primidone.
On 3/13/24 at 1:36 pm, ADON-H notified Surveyor R81 was taking Primidone for essential tremors and not seizures. ADON-H indicated seizures was listed incorrectly on R81's medication order for Primidone. ADON-H provided documentation that R81's Nurse Practitioner (NP) was contacted for clarification on reason for taking Primidone. The NP indicated R81 is taking Primidone for essential tremors which is a current and accurate diagnosis.
On 3/14/24 at 8:36 am, Surveyor notified DON-B of concerns with R81 having an order for Primidone to take for seizures and R81 not having a diagnosis of seizures. Surveyor notified DON-B of interview with ADON-H on 3/13/24 who received clarification of R81 taking Primidone for essential tremors and the order for Primidone had been modified after clarification with facility NP. Surveyor requested additional information if available. None was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 (R414) of 1 resident.
The facility did not consistently update the physician or the power of attorney (POA) with changes in R414's condition; in failing to do so, the facility did not ensure collaboration of care between hospice, the facility, the physician, and the power of attorney.
R414 had a change in condition with an unwitnessed fall on 10/27/23. R414 was noted to have hit his head, to have altered mentation, vomiting while being transferred to his bed using a Hoyer lift and fluctuating unstable blood pressure (BP) readings (BP 158/84, 80/40 and 200/94) at the time of the fall.
On 10/28/23, R414 presented with further changes with confusion, rambling and slurred speech, weak hand grasp, poor coordination, being hunched over in wheelchair, lethargy, hands shaking, and needing assistance with eating.
On 10/29/23, R414 sustained a second unwitnessed fall while reaching for his call light. R414 was found on the floor lying on his left side next to the bed lying over the call light and night stand base. R414 sustained a head injury, was moaning in pain, and in and out of cognition with intermittent nonsensical verbalization. R414 was left in this fall position for approximately 30-40 minutes until Hospice Registered Nurse (RN) arrived for evaluation. The facility nurse contacted hospice and was instructed not to send resident out for evaluation. The facility nurse indicated she did not agree with recommendations from hospice. The facility nurse did not contact clinical leadership with for further evaluation and to discuss discrepancies of recommendations between hospice and the facility at this time.
Facility failure to coordinate care to the resident provided by the facility staff and hospice staff in collaboration with the MD and resident/family to ensure that the needs of the resident are addressed are met 24 hours per day, created a finding of immediate jeopardy that began on 10/27/23. Surveyor notified the Director of Nursing (DON)-B of the immediate jeopardy on 3/18/24 at 10:09 am. The immediate jeopardy was removed on 3/19/24. The deficient practice continues at a scope and severity of a D potential for harm/isolated as the facility continues to implement their action plan.
Findings include:
The Nursing Facility Services Agreement between [name of] Hospice Care and [Name of] Facility dated 7/18/2013 states:
Definitions:
Facility Services means those personal care and room and board services provided by facility as specified in the Plan of Care for a hospice patient including, but not limited to; 1. Contacting family/legal representative for purposes unrelated to the terminal condition; 2. Arranging for the provision of medications not related to the management of the terminal illness.
Hospice Physician means a duly licensed Doctor of Medicine or osteopathy employed or contracted by hospice who, along with the hospice patient's attending physician (if any) is responsible for the palliation and management of a hospice patient's terminal illness and related conditions.
Hospice Services means those services provided to a hospice patient that are reasonable and necessary for the palliation and management of such hospice patient's terminal illness and are specified in a hospice patient's plan of care.
Responsibilities of Facility:
Facility shall comply with hospice patient's plan of care and shall ensure hospice patients are kept comfortable, clean, well-groomed, and protected from negligent and intentional harm including, but not limited to, accident, injury, and infection. Facility's primary responsibility is to provide facility services. It is facility's responsibility to provide facility services that meet the personal care and nursing needs that would have been provided by a hospice patient's primary caregiver at home, and facility shall perform facility services at the same level of care provided to each hospice patient before hospice care was elected.
Coordination of Care:
Facility shall immediately inform hospice of any change in the condition of a hospice patient. This includes, without limitation, a significant change in a hospice patient's physical, mental, social, or emotional status, clinical complications that suggest a need to alter the plan of care, a need to transfer the hospice patient to another facility, or death of a hospice patient.
Term and Termination:
Notwithstanding the above, either party may immediately terminate this agreement if a party fails to perform its duties under this agreement and the other party determines in its full discretion that such failure threatens the health, safety, or welfare of any patient.
R414 was admitted to the facility on [DATE] with diagnoses of dementia, depression, panic disorder, anxiety, a-fib, obstructive uropathy, urine retention, Gilbert Syndrome, and failure to thrive. R414 is his own person.
R414's admission Minimum Data Set (MDS) assessment completed on 8/24/23 indicates a Brief Interview for Mental Status (BIMS) of 9 indicating moderate cognitive impairment. R414 requires extensive assistance with one-person and physical assistance with bed mobility, transferring, dressing and toileting. R414 is not steady and is only able to stabilize himself with staff assistance while moving on and off the toilet. R414 has an indwelling urine catheter and is always continent of his bowels.
R414's Care Plan indicates R414 is at high risk for falls related to limited mobility and impaired balance dated 8/17/23.
Surveyor reviewed R414's medical records which indicate, Hospice performed a prescreening of possible discharge from hospice due to ineligibility on 10/17/23. Hospice social work will continue to support R414 and be evaluated 1-2 times per month and on an as needed basis.
On 3/18/24 at 9:17 am Surveyor interviewed Hospice Director of Social Work (SW)-P who indicated there was a pre-discussion of possible ineligibility for R414 due to showing improvement. Pre-discussion of hospice care starts to take place when recertification time is approaching. The Hospice Director of SW-P indicated once a resident is deemed in eligible for hospice, the hospice staff have 2 days to develop a plan of care for discharge. Hospice Director of SW-P indicated R414 had continued hospice care due to the change in condition.
On 10/27/23 at 1730 (5:30 pm), the facility documentation indicates the CNA found R414 on the bathroom floor. R414 had an elevated BP and was noted to have altered mentation with being unable to convey where he was, day of the week nor the month. R414's baseline orientation is fully oriented to person, place, time, and event. The facility charge nurse and Rainbow Hospice were notified of the unwitnessed fall. R414 had an improvement with his vital signs and mentation after Hospice arrived at the facility at 6:45 pm.
On 10/27/23 at 5:34 pm, the facility documentation indicates R414 was found lying on his back flat on the bathroom floor and R414 hit his head. R414 had complaints of pain in his upper back between his should blades, altered mentation, along with high blood pressures and low pulse rates. R414 had a brown emesis while being transferred with a Hoyer lift back to his bed. Documentation states hospice was updated however, it is unclear as to whether hospice was updated on R414 hitting his head. Hospice instructed the facility to administer Zofran for vomiting. The facility documentation indicates family was informed of R414 having a change in condition by the hospice staff. Surveyor notes the resident hit his head and it is uncertain if this was relayed to the hospice staff or MD at the time of the change in condition and it is unclear if family was updated on R414 hitting his head along with symptoms of altered mentation. It is unclear if the power of attorney (POA) was given the option for R414 to seek evaluation for the significant change in condition that is unrelated to R414's hospice diagnosis.
The hospice visit note from the hospice RN dated 10/27/23 at 6:45 pm. indicates R414 is fully oriented with pupils being equal and reactive to light. Documentation reports R414 denies hitting his head. R414 was provided Tylenol and reports his last bowel movement being 3 days ago. Hospice changed R414's Miralax from every other day to every day during this visit. Documentation indicates the MD on call and POA was notified of updates however, Surveyor notes there is no documentation indicating what was discussed with the MD at the time of the update from hospice staff. Surveyor notes R414 denying hitting his head however, R414 was noted to having altered mentation at the time of his fall and was unable to recall place and time while being evaluated.
Facility Neuro check documentation dated 10/28/23 at 3:47 am indicates R414 had rambling speech with a weak right-hand grasp. Surveyor notes there is no documentation indicating hospice or the MD were notified of this significant change in condition with R414 having weak right-hand grasps and rambling speech.
Facility documentation dated 10/28/23 at 9:58 am indicates the facility nurse notified hospice with a significant change in condition. R414 was feeling off, hands being shaky, lethargic, and needing to be fed for breakfast. R414 did not previously require assistance with eating. Documentation indicates R414 indicated to the nursing staff he hit his head and acknowledged he notified hospice on 10/27/23 that he did not hit his head. This was relayed to the hospice staff by the facility staff at the time of phone call to hospice. Surveyor notes the MD was not notified of R414 notifying staff he hit his head and having significant change in condition.
Documentation indicates a second call was placed by the facility to hospice on 10/28/23 at 10:28 am indicating R414 is hunched over in his wheelchair with increased fatigue. The facility staff requested hospice evaluation.
On 10/28/23 at 2:19 pm the documentation from hospice indicates R414 having poor coordination, increased sleep, lethargy, and urine Foley draining concentrated clear urine. Surveyor notes there is no documentation that the MD was notified of the significant change in condition and no new interventions were placed after hospice was notified of R414 hitting his head. There is no collaboration between the facility, hospice, MD, and family to discuss treatment options.
Surveyor reviewed the Neuro check performed on 10/28/23 at 4:00 pm which indicates R414 with a change in condition with having slurred speech. R414 has a strong right-hand grasp, and the left hand was not documented as assessed. Surveyor notes the MD was not notified of the significant change in slurred speech.
Surveyor reviewed the post fall documentation on 10/28/23 at 8:00 pm which indicates R414 is alert with confusion and fatigue is noted. R414 can answer questions appropriately but did mumble stories about siblings that were nonsensical. Documentation reports R414 hit his head on 10/27/23 and surveyor notes the MD was not notified of this change in condition at the time of the post fall documentation.
Documentation from 10/29/23 at 9:10 pm indicates R414 was found on the floor lying on his left side of the bed with the call light and nightstand base under him. R414 was moaning in pain with c/o pain in his back, left arm and left shoulder. R414 had a head injury with blood present on the floor. R414 was noted to have cognitive impairment, intermittent nonsensical verbalization, pinpoint eyes, eyes wrenching, a left forehead hematoma measuring 4 cm x 3 cm with a 2 cm laceration to the middle of the hematoma, and no urine output in the urine Foley bag. The charge nurse and hospice were notified. Hospice instructed the facility staff to not send out R414 for evaluation prior to hospice doing an evaluation. The facility nurse applied pressure to R414's head injury site and remained with R414 in the fall position until hospice arrived for evaluation.
Documentation from Hospice Progress notes dated 10/29/23 at 9:34 pm indicates R414 had an unwitnessed fall and sustained a head injury. R414 denied pain but was observed to be wincing with movement. Documentation from Hospice indicates as needed (PRN) pain medication was given due to R414 likely being sore and probably having a headache. R414 was observed to be alert and oriented and tolerating changing his shirt without the facility staff in R414's room. Hospice reports facility staff chose to leave R414 on the floor with a pillow under his head until hospice arrived for evaluation. R414 was assisted back to bed using a Hoyer lift. Hospice attempted to contact R414's POA who was unavailable. Hospice left a message. The hospice nurse applied steri strips to R414's head wound and a new Foley catheter was inserted with 2400 cc of dark amber urine and large amounts of thick fibrous tan drainage was noted. Surveyor notes there is no documentation of collaboration of care between the facility, hospice, the MD or the POA to discuss treatment options for R414's significant change in condition with R414's fall and retaining large amounts of urine nor discussing the option of evaluation after this significant change.
Surveyor interviewed Licensed Practical Nurse (LPN)-S on 3/14/23 at 11:00 am. LPN-S indicated R414 is typically alert and oriented and able to make his needs known. LPN-S reported R414 being weak and requires assistance of one with ambulation, toileting and transferring. LPN-S stated the facility staff had to frequently remind R414 to contact staff when needing to transfer as R414 frequently ambulated independently without calling for assistance. LPN-S indicated she could clearly tell R414 had a head injury on 10/29/23 at 9:10 pm after R414 had a second unwitnessed fall from his bed while reaching for the call light that was out of reach. LPN-S applied pressure to R414's head to help control bleeding and stayed with R414 for approximately 30-40 minutes in the fall position while she waited for hospice to come and evaluate R414. LPN-S described herself as being old school and thought residents had the option to be sent out for evaluation with a significant change in condition even though they are receiving hospice care. LPN-S indicated R414 wasn't dying from his hospice diagnosis and was told not to send out R414 for evaluation by hospice. LPN-S stated she did not feel comfortable with this decision as she knew R414 clearly had a brain injury with R414's eyes being dilated and changed. LPN-S was unsure if R414's POA was contacted to discuss the significant change in condition and whether the POA was given the option to send R414 out for evaluation. LPN-S indicated she was fearful of the head and neck injury R414 sustained. LPN-S indicated she noticed no urine output in R414's urine Foley catheter bag while holding pressure on R414's head injury and notified hospice upon arrival. LPN-S indicated she does not recall if the MD was notified by the hospice nurse.
Surveyor interviewed DON-B on 3/18/24 at 10:09 am who indicates facility staff are to contact hospice with any residents having a change in condition. Surveyor reviewed with DON-B that facility staff were interviewed and reported not feeling comfortable with coordination and care being provided to R414 by hospice staff on 10/29/23 at the time of R414 having a second unwitnessed fall. DON-B indicated staff are to contact clinical leadership if they do not feel comfortable with orders given by the hospice staff. DON-B indicates she was not aware of the facility staff not feeling comfortable with orders being provided by hospice indicating R414 is to not be evaluated due to being on hospice. DON-B indicated clinical leadership should have been notified with this significant change on 10/29/23 and the facility staff not feeling comfortable with hospice recommendations to not send resident out for evaluation.
Surveyor reviewed the facility fall investigation dated 10/29/23 at 9:10 pm indicating R414 sustained a hematoma and laceration to the face along with a skin tear to the left hand. R414 is oriented to person, the facility NP (Nurse Practitioner) was notified on 10/30/23 at 3:53 pm, and POA was notified on 10/30/23 at 3:29 pm. Surveyor notes the MD was not notified of the significant change in condition. Surveyor also notes the facility NP and POA were notified the following day approximately 18+ hours after the significant change in condition. Surveyor notes documentation does not state was what discussed with the facility NP and POA at that time of phone call and if it the option for R414 to seek further evaluation was discussed. There is no collaboration of care between the facility, hospice, the MD or the POA.
On 3/18/24 at 8:57 am, Surveyor spoke with Medical Director (MD)-O of the facility. Surveyor reviewed the change in condition with R414 that occurred on 10/29/23. MD-O indicated he does not recall being notified of the change in condition with R414 on 10/29/23. MD-O stated, if the facility does not agree with hospice recommendations, the facility is to reach out to the MD to discuss the change in condition with the resident. MD-O indicated the resident has the option to go to the emergency room for further evaluation while receiving hospice services. Surveyor notes, facility documentation does not reflect the change in condition with R414 being discussed with MD-O.
Surveyor reviewed the facility neuro check documentation on 10/30/23 at 1:00 am indicating R414's pupils not being equal in size, with the right pupil being fixed, left pupil being sluggish, and R414 being unable to grasp hands.
Surveyor reviewed the facility neuro check documentation on 10/30/23 at 2:00 am indicating R414's is aphasic (a person who is unable to communicate), right pupil is fixed, left pupil is sluggish, and unable to grasp hands.
Facility progress note dated 10/30/23 at 2:59 am was reviewed by the surveyor and notes the facility placed a call to hospice with an update on R414's neuro checks and R414 being unresponsive. Hospice advised the facility to continue with keeping R414 comfortable and provided no additional interventions. Surveyor notes clinical leadership and the MD were not notified of these changes. There was no collaboration of care between the facility, hospice, the MD, and the POA.
Facility progress note dated 10/30/23 at 3:04 am indicates the facility contacted R414's POA with an update. Surveyor notes the facility did not document what was discussed with R414's POA and if options to send out R414 for evaluation was provided. Surveyor also notes clinical staff and MD were not updated of the significant changes in condition with R414.
Surveyor reviewed facility progress note dated 10/30/23 at 3:13 am indicating the facility contacted hospice with updates on neuro checks and R414 being non-responsive. Hospice stated if R414 had a brain bleed that there is nothing that can be done for his condition. Surveyor notes MD and clinical leadership were not updated at this time.
Surveyor reviewed hospice progress note dated 10/30/23 at 9:15 am indicating R414 requires meals set up, decreased appetite, increased dysphagia, choking and coughing with thinned liquids, increased pain, total dependence with bathing, and is bedbound with assistance of a Hoyer lift after two unwitnessed falls on 10/27/23 and 10/29/23. R414 is requiring head support with a rolled towel to prevent neck pain and is unable to move his own head/neck. Urine is noted to be dark concentrated with sediment in Foley catheter tubing.
Surveyor reviewed the Interdisciplinary Team (IDT) note dated 10/30/23 at 11:42 am indicating the 10/27/23 fall for R414 was reviewed for safety and a new intervention was placed. Surveyor notes the 2nd fall from 10/29/23 was not reviewed, the MD was not notified of the significant changes in condition, and there was one change to the care plan to include medication adjustments per hospice for R414 being a high risk of falls. Surveyor also notes it is unclear if clinical leadership is present for the IDT meeting.
Surveyor reviewed the Hospice Comprehensive Review Assessment note dated 10/30/23 at 11:21 pm indicating hospice sent an email to the POA and DON-B with R414 having an increase in lethargy, rambling speech, reduced appetite, and trouble swallowing post falls.
Facility progress note dated 10/31/23 at 12:30 am indicates the facility contacted hospice with concerns of R414 having a low-grade fever, elevated BP and R414 complaining of neck pain. Hospice instructed the facility to administer Morphine for pain and apply a cool cloth to reduce the fever. Surveyor notes the MD was not notified of this change.
Surveyor reviewed the facility progress note dated 10/31/23 at 2:05 pm indicating the POA was visiting with R414 and expressed concerns with hearing cracks in R414's neck when he moves. The facility progress note indicates Morphine was administered to R414 for neck pain and notified the charge nurse and hospice with an update. Surveyor notes the MD was not notified of this significant change.
Hospice Progress note dated 10/31/23 at 3:30 pm indicates R414 is in pain, increased sleeping, withdrawn, minimal responsiveness, barely opening his eyes, abdominal respirations, slow capillary refill in his nail beds, pallor, crackles in his lungs (fluid building up in the lungs), skin cool to touch, skin mottled in areas (lack of blood flow to the skin), and unable to respond to tell staff how he feels.
Hospice Progress Note dated 11/1/23 at 10:00 am indicates R414 is unresponsive, having irregular heart rates, breathing through his mouth, eyelids barely opening, shallow respirations, crackles to his lungs, coughing to clear his airway, unresponsive to touch or voice however, R414 jerks and gasps when the hospice nurse swabs R414's lips. Documentation indicates the hospice nurse noted no PRN medications (Lorazepam and Morphine) given since last visit on 10/31/23 at 3:30 pm. Hospice updated the POA however, Surveyor notes documentation does not indicate what was discussed with POA.
Surveyor notes the facility documentation on 11/2/23 at 2:48 am indicates R414's POA contacted the Nursing Home Administrator (NHA)-A regarding R414's current condition. The POA expressed concerns with R414 needing to eat more. NHA-A educated the POA on the risk of intake when R414 is not alert and oriented. The NHA-A suggested the POA reach out to hospice for additional support. Surveyor notes the POA is not comprehending the severity of R414's current prognosis and significant change in condition and the NHA-A advised POA to contact hospice.
Hospice Progress Note dated 11/2/23 at 11:00 am notes R414 is having an elevated pulse, rapid respiratory rate (RR) of 36 (normal RR is 16), gasping for air, abdominal respirations, using accessory muscles with breathing, coughing, short of breath, and moderate discomfort with breathing. Documentation indicates hospice updated the POA and administered 1 dose of Morphine for shortness of breath.
The facility progress note dated 11/2/23 at 10:50 pm indicates the CNA called the nurse into R414's room. R414 was pulseless and not breathing. Hospice and the facility charge nurse were notified by the facility staff.
Surveyor interviewed RN-U with Hospice on 3/14/24 at 11:42 am. RN-U indicated if a resident has a significant change in condition the MD is notified by hospice staff. RN-U indicated the whole care team including hospice and the facility MD are notified with any significant change in condition. RN-U reported the family and/or POA are contacted to discuss possible hospital evaluations and options for care after a significant change in condition. RN-U stated hospice can have portable x-rays performed in the facility for residents with suspected changes in conditions related to a fall. RN-U indicated these options such as portable x-rays and emergency room (ER) evaluation are to be discussed with the MD with any significant changes in condition. Surveyor notes portable x-rays and ER evaluation were not documented that they were discussed with R414 or his POA after the changes in conditions related to his head and neck injuries.
Surveyor interviewed Hospice DON-Q on 3/14/24 at 1:21 pm who indicated hospice documentation did not reflect that hospice was aware of R414 hitting his head on 10/27/23. Hospice DON-Q indicated hospice will talk with the family and the POA to give options to seek treatment with any significant changes in condition. Hospice DON-Q reported it is a collaborative effort with the facility and hospice staff to discuss changes in condition and treatment options. Hospice DON-Q indicated hospice documentation does not state R414 was offered to be evaluated in the ER. Hospice DON-Q indicated the facility and hospice are to discuss all options with R414 and the POA after the significant change occurred on 10/27/23. Hospice DON-Q reports there is no documentation from hospice indicating further treatment was discussed with R414 or R414's POA on 10/27/23 through 11/2/23.
On 3/18/24, at 10:09 AM, Surveyor notified Nursing Home Administrator-A and Director of Nursing-B of concerns with the following:
~ Assessments between the facility and hospice being contradictory.
~ Interview with facility staff not being comfortable with recommendations provided by hospice staff.
~ The lack of education for facility staff on how to move forward if facility staff are not in agreement with resident care.
~ The failure of coordination of care between hospice and the facility. The facility documented the assessments with the significant change in condition with R414 and R414 continued to decline.
~ The failure of the facility designating a member of the interdisciplinary team who is responsible for collaborating with hospice representatives and coordinating facility staff in the significant change in condition for R414.
~ MD not being updated with R414's significant changes in condition on 10/28/23, 10/29/23, 10/30/23, 10/31/23, and 11/1/23 for possible alterations in treatment.
~ Interview with MD-O indicated he was unaware of the change in conditions occurring with R414. DON-B notified MD-O would have discussed the options for further evaluation should he have been updated. MD-O indicated the facility is to contact him should there be a conflict between hospice and facility recommendations.
~ Facility staff did not contact clinical leadership on 10/29/23 when not agreeing and feeling uncomfortable with recommendations from hospice for R414 to not receive further evaluation after significant changes.
The facility's failure to establish a communication process to ensure that the needs of R414 are addressed/met, designate a member of the facility's interdisciplinary team who is responsible for working with hospice to coordinate care for R414, and ensure a plan of care to attain and maintain R414's highest practicable well-being delayed medical intervention for R414 and increased a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy.
The Immediate Jeopardy was removed on 3/19/24 when the Facility completed the following:
-All residents receiving hospice care were reviewed for changes in condition, falls and hospice service and care plans were updated as indicated.
-All nursing staff and clinical managers were educated by the Director of Nursing or designee to notify the physician when a change of condition occurs with a resident.
-All nursing staff and clinical managers were educated by the Director of Nursing or designee on proper collaboration with the hospice provider. This education included when it would be appropriate to discuss a change in the treatment/care plan of the residents based on the resident's needs.
-All nursing staff and clinical managers were educated by the Director of Nursing or designee on hospice collaboration and the need to ensure resident choice is honored while providing the care and treatment to their highest practicable level of care.
-A meeting with the hospice company in question was held. All other hospice companies were contacted to improve collaboration and responsibilities of both the facility and the hospice company.
-The Nursing Home Administrator, Director of Nursing, Nurse Consultant, and Medical Director reviewed policies and procedures as it related to the hospice service.
-The DON or designee is responsible for coordinating services between the hospice provider and the facility.
-A review for compliance using a Quality Assurance audit tool was completed and will be conducted 4 times a week for 4 weeks, and monthly for three months.
-The results of the audits will be reviewed by the Facility QAPI team including the Medical Director to determine and necessary changes.
-An emergency QA meeting was held on 3/18/24 by the Nursing Home Administrator with the Interdisciplinary Team and Medical Director. In the meeting the team discussed collaboration between the Facility and the hospice agency.

Based on observation and interview, the facility did not ensure the required posted information was displayed. This was observed in main areas and all 6 units, This had the potential to effect all 117 residents in the facility.
The facility did not display the following information:
-A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives.
Findings include:
1.) On 03/14/24 at 11:34 AM Surveyor observed the main entrance and lobby area. There was no display of the required posting information.
On 03/14/24 at 11:35 AM Surveyor observed the 200 unit. There was no display of the required posting information.
On 3/14/24 at 11:37 AM Surveyor observed the 300 unit. There was no display of the required posting information.
On 3/14/24 at 11:38 AM Surveyor observed the 400 unit. There was no display of the required posting information.
On 03/14/24 at 11:41 AM Surveyor observed the 500 unit. There was no display of the required posting information.
On 03/14/24 at 11:42 AM Surveyor observed the 600 unit. There was no display of the required posting information.
On 03/14/24 at 11:43 AM Surveyor observed the 700 unit. There was no display of the required posting information.
On 3/14/24 at 11:47 AM, Surveyor spoke with ANHA-C (Assistant Nursing Home Administrator), and Administrator-A, they were not aware postings of information were not displayed. They indicated the Ombudsman just dropped off posters, however the Ombudsman for the facility was not listed on the posters. The (Director of Nurses) DON-B came into the interview, and thought the postings were not up anywhere due to remodeling. Surveyor shared there are no postings in the facility lobby, or on all 6 units. The F-tag posting requirements were reviewed and Nursing Home Administrator-A indicated they will take care of it. Nursing HomeAdministrator-A is newer to the facility and thought the postings were displayed.
On 3/14/24 at 12:27 PM, Nursing Home Administrator-A provided Surveyor with a sheet of paper for the required postings. The State Survey Agency information was not correct, there was no statement related to complaints, abuse, advanced directives, nor the right State Agency office listed. Nursing Home Administrator-A indicated they are working on it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interview, and record review, the facility did not review and revise the plan of care for 5 Residents (R) (R5, R10, R2, R12, and R4) of 6 residents reviewed.
R5 had a history of wandering and wandered into several residents' rooms. Following an incident on 10/3/23, the facility did not update R5's care plan with interventions to keep R5 and other residents safe. In addition, stop sign banners were placed across the doorways of R10, R2, R12 and R4 after R5 wandered into their rooms. The intervention was not added to R10, R2, R12, and R4's plan of care.
Findings include:
The facility's Review of Care Plans policy, dated 11/2017, indicated: The Interdisciplinary Team is responsible for periodic review and adjustments of the plan of care: d. When there is a change to the plan of treatment goals or interventions.
On 12/8/23, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance. R5's Minimum Data Set (MDS) assessment, dated 10/16/23, contained a Brief Interview for Mental Status Score (BIMS) score of 4 out of 15 which indicated R5 had severe cognitive impairment. The MDS also indicated R5 was independent with ambulation. A care plan, initiated on 8/4/23, indicated R5 was at risk for elopement related to cognitive impairment .and wandering behavior.
On 12/8/23 at 11:04 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who confirmed R5 wandered into several residents' rooms. When asked if interventions were put in place to help prevent R5 from wandering into other rooms, LPN-E indicated several residents had a stop sign banner placed across their doorway, including R10, R2, R12, and R4. LPN-E could not recall when the banners were put in place. LPN-E also indicated it was the responsibility of the staff who put the intervention in place to add the intervention to the resident's care plan.
On 12/8/23 at 1:30 PM, Surveyor interviewed R10 who confirmed there was a stop banner placed across R10's doorway. R10 could not recall when the stop banner was placed. R10 indicated R5 was confused and meant no harm. R10 stated R5 entered R10's room several times and R10 learned to keep R10's door closed. R10 stated R2, who resided across the hall, also had a stop banner.
On 12/8/23 at 1:32 PM, Surveyor interviewed R2 who confirmed staff placed a stop banner across R2's doorway. R2 could not recall when the stop banner was placed. R2 indicated R5 frequently wandered up and down the hallway and entered R2's room occasionally, but didn't do anything that made R2 fearful. R2 indicated R2 told R5 to leave and R5 left. R2 indicated staff thought R2 should have a stop banner across R2's doorway because R5 frequently wandered the hallway and entered a couple of other rooms on the unit.
On 12/8/23 at 1:38 PM, Surveyor interviewed R12 who confirmed staff placed a stop banner across R12's doorway to prevent R5 from entering R12's room. R12 could not recall when the stop banner was placed, but indicated it was after the last time R5 entered R12's room. R12 stated R5 usually stopped at R12's door, however, the last time R5 entered R12's room and leaned over R12's walker near the bed while R12 was sleeping. R12 indicated staff redirected R5 out of the room and put up the banner. R12 stated R5 was moved off the unit later that day.
On 12/8/23, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] with diagnoses including dementia. R4's MDS assessment, dated 9/6/23, contained a BIMS score of 6 out of 15 which indicated R4 had severe cognitive impairment. R4 was not available for interview related to the stop banner on R4's doorway.
A progress note in R4's medical record, dated 10/3/23 at 6:10 AM, indicated: (R4) was very upset and emotional because (R5) was in (R4's) room again last night .
On 12/8/23, Surveyor reviewed a facility-reported incident regarding the incident on 10/3/23. Surveyor noted R5 also wandered into R12's room on the same night. After the incident, R5 was moved to a different unit. Activity staff assessed R5 in an attempt to provide additional activities to keep R5 busy.
On 12/8/23, Surveyor reviewed R10, R2, R12, and R4's plans of care which did not indicate stop banners were placed across their doorways to prevent R5 from entering their rooms. Surveyor also reviewed R5's plan of care (including R5's activities care plan) and noted no interventions were added after the incident on 10/3/23.
On 12/8/23, Surveyor interviewed Certified Nursing Assistant (CNA)-D who worked on R5's current unit and was unsure why R5 was moved to the unit. CNA-D indicated R5 wandered and exit sought, but CNA-D was not aware R5 was moved because R5 wandered into residents' rooms. CNA-D stated R5 liked coffee and snacks and CNA-D used those things to distract R5. When asked how CNA-D knew what approaches to use with R5 or how CNA-D knew if new interventions were added to a resident's care plan, CNA-D showed Surveyor a [NAME] (an abbreviated care plan used by nursing staff) binder. CNA-D and Surveyor reviewed R5's [NAME] and noted the [NAME] did not indicate R5 had a history of wandering into residents' rooms. The [NAME] also did not contain activities or approaches staff could use to distract or redirect R5 when R5 wandered.
On 12/8/23 at 2:06 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R10, R2, R12, and R4's care plans should have been updated to reflect the stop banner intervention. DON-B also verified R5's care plan should have been updated following the incident on 10/3/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not thoroughly investigate an injury of unknown origin for 1 Resident (R) (R6) of 10 residents reviewed.
On 10/25/23, R6 had an injury of unknown origin that was reported to the State Agency (SA). The facility did not thoroughly investigate the injury of unknown origin when they did not interview residents regarding abuse concerns following the unwitnessed injury.
Findings include:
The facility's Abuse Policy for Wisconsin Facilities, dated 9/20, indicated: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: 3. Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment. 4. Identifying occurrences and patterns of potential mistreatment. 5. Immediately protecting residents involved in identifying reports of possible abuse 6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences.
R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and dementia. R6's Minimum Data Set (MDS) assessment, dated 8/15/23, indicated R6 was rarely or never understood.
On 10/25/23, staff observed R6 sitting in a wheelchair in R6's room and guarding R6's right arm. R6 was sent to the emergency room (ER) and diagnosed with a right humerus fracture. The facility immediately reported the incident to the SA and began an investigation.
On 12/8/23, Surveyor reviewed the facility's investigation. When Surveyor asked if other resident interviews were completed as part of the investigation, Surveyor received a typed word document signed by Assistant Nursing Home Administrator (ANHA)-C. The document contained 4 sentences (one sentence for each resident interviewed). Each sentence was from an interview with a different resident and all of the statements were worded the same: (Resident name) said that did not witness (R6) fall or any incident that would result in a fracture. Surveyor noted the resident interviews did not indicate if the residents were asked about abuse concerns and/or if they witnessed abuse.
On 12/8/23 at 12:05 PM, Surveyor interviewed ANHA-C who indicated ANHA-C completed most of the investigation for R6's injury of unknown origin. When asked if residents were also asked if they had concerns with abuse or witnessed abuse, ANHA-C indicated if ANHA-C noticed odd body language or hesitation, ANHA-C would have probed further.
On 12/8/23 at 2:15 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed the statements provided from the resident interviews did not indicate if the residents were asked about abuse concerns, but indicated the question should have been asked during the interviews.

Based on observations, interviews, record review, and facility policy review, the facility did not ensure 2 Resident (R8 & R11) of 8 sampled residents were assessed and had physician orders to self administer respiratory treatment medications and to keep the medications bedside.
Findings included:
A review of a facility policy titled, Self-Administration of Medications, dated August 2023, revealed, Policy: Residents may be allowed to self-administer medication according to physician's order unless such practice for the resident is deemed unsafe.
1. A review of R8's admission Record revealed the facility admitted the resident on 06/06/2022.
A review of R8's Medical Diagnosis document revealed the resident had diagnoses that included chronic obstructive pulmonary disease (COPD) and need for assistance with personal care.
A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2023, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.
A review of R8's care plan initiated on 06/13/2022, indicated the resident had a potential for respiratory difficulty secondary to emphysema. An intervention directed nursing staff to administer medications for management of COPD symptoms as ordered. The care plan did not address self-administration of medications.
A review of an Order Summary Report revealed R8 had an order dated 06/10/2022, for albuterol sulfate nebulizer treatments four times a day related to COPD, and an order dated 10/17/2022, for sodium chloride nebulizer treatments every 12 hours as needed for respiratory symptoms related to COPD. The Order Summary Report did not reflect any orders for the resident to self-administer medications.
Observation on 10/23/2023 at 10:04 AM, revealed R8 in bed and a nebulizer machine at the bedside with the nebulizer mask on top of the machine. R8 stated they would get their nebulizer treatment again at noon.
During an interview on 10/24/2023 at 10:30 AM, R8 stated the nurse gave the resident medication for their nebulizer, they put the mask on, and when it was empty, R8 stated they removed the mask.
During an interview on 10/24/2023 at 2:13 PM, Certified Nurse Aide (CNA) N stated R8 came to the dining room in their wheelchair to have the nurse set up their nebulizer with medication, and the resident then went back to their room to take the medication.
During an interview on 10/26/2023 at 1:57 PM, Licensed Practical Nurse (LPN) P stated the nurse was supposed to stay and watch residents take medication and not walk away after giving medications to the residents.
During an interview on 10/26/2023 at 2:19 PM, LPN Q stated nurses should watch residents take their medications to ensure they took them. She stated some residents took their own medications, but she thought to do so, the residents needed an order for it.
During an interview on 10/26/2023 at 2:42 PM, LPN D stated the nursing team decided if a resident was able to administer their own medications. She stated that when she administered a resident's medication, she watched the resident take the medication. LPN D stated that for R8 she took the medication to the resident's room, filled the nebulizer, and planned her time so she could stay in the area to look in on the resident during the nebulizer treatment.
During an interview on 10/26/2023 at 3:12 PM, LPN E stated that when she administered medication, she watched the resident take it to make sure nobody else took the medication. LPN E stated residents could not administer their own nebulizer medication without a physician's order to do so.
Observation on 10/27/2023 at 3:31 PM, revealed R8 in bed asleep, with the nebulizer mask on and the nebulizer machine running.
During an interview on 10/27/2023 at 3:35 PM, LPN O stated she took the nebulizer medication to R8's room, filled the nebulizer, and the resident put the mask on. She stated she did not stay in the resident's room while the nebulizer was on because it took about 15 minutes, but usually she stayed in the hallway. LPN O stated R8 must have fallen asleep with the nebulizer running.
During an interview on 10/27/2023 at 4:07 PM, the Director of Nursing (DON) stated she expected staff to fill the resident's nebulizer with the medication and watch while the resident took it. She stated otherwise the nurse would not know if the resident was getting all the medication. The DON stated there were no notes from the IDT related to an assessment of R8's ability to self-administer medications, and there were no physician's orders for the resident to self-administer medications.
During an interview on 10/27/2023 at 5:03 PM, the Administrator stated he expected the nursing staff to give residents their medications and watch them take it.
2. A review of R11's admission Record revealed the facility admitted the resident on 12/21/2021 with diagnoses that included dementia, atrial fibrillation, and obstructive sleep apnea.
A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2023, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.
A review of R11's care plan initiated on 08/23/2023, indicated the resident had a potential for respiratory difficulty secondary to sleep apnea. The care plan did not address self-administration of medications.
A review of an Order Summary Report revealed R11 had an order dated 03/11/2023, for ipratropium-albuterol nebulizer treatments every six hours as needed for respiratory symptoms. The Order Summary Report did not reflect any orders for the resident to self-administer medications.
Observation and interview on 10/23/2023 at 11:47 AM, revealed R11 in their room. A plastic cup with seven full vials of ipratropium-albuterol nebulizer solution was noted on the resident's bedside table. R11 stated staff filled the cup with the medication, and the resident administered the nebulizer treatment themself about every other day.
Observation on 10/24/2023 at 10:28 AM, revealed seven vials of ipratropium-albuterol nebulizer solution on the table in R11's room.
Observation on 10/25/2023 at 2:35 PM, revealed six vials of ipratropium-albuterol nebulizer solution in the cup in R11's room. R11 stated they administered a nebulizer treatment earlier that day.
During an interview on 10/26/2023 at 2:42 PM, Licensed Practical Nurse (LPN) D stated the nursing team decided if a resident was able to administer their own medications. She stated that when she administered a resident's medication, she watched the resident take the medication. LPN D stated she did not know R11 had nebulizer solution in their room.
During an interview on 10/27/2023 at 3:35 PM, LPN O stated she did not know who placed the vials of nebulizer solution in R11's room.
During an interview on 10/27/2023 at 4:07 PM, the Director of Nursing (DON) stated she expected staff to fill the resident's nebulizer with the medication and watch while the resident took it. She stated otherwise the nurse would not know if the resident was getting all the medication. The DON stated there were no notes from the IDT related to an assessment of R11's ability to self-administer medications, and there were no physician's orders for the resident to self-administer medications. The DON explained, if R11 needed a nebulizer treatment, the resident should ask the nurse for the medication, and the nurse should administer it.
During an interview on 10/27/2023 at 4:53 PM, the Administrator stated he expected the nursing staff to give residents their medications and watch them take it.

Based on observations, and interviews the facility did not ensure proper infection control measures were completed during medication administration for 1 (R16) of 4 residents observed.
During medication administration a Licensed Practical Nurse (LPN) was observed to handle medications with bare hands.
Findings included:
On 10/24/2023 at 7:57 AM, Licensed Practical Nurse (LPN) T was observed preparing R16's medications for medication administration. LPN T placed the medications into a medication cup and touched the medications with her ungloved hands. At 8:05 AM, LPN T counted the medications in the medication cup by tipping the cup toward a second medication cup and using an ungloved finger to move the medication from one cup into the other. At 8:06 AM, LPN T then moved all crushable medication tablets back into the first medication cup and held the medication that could not be crushed with her ungloved fingers.
During an interview on 10/24/2023 at 8:14 AM, LPN T stated she should not have put fingers into the medication cup because it could contaminate the cup and medications from dirty fingers and said she should have used a spoon to move the medications instead.
During an interview on 10/26/2023 at 2:19 PM, LPN Q stated nurses should not touch medications with their bare hands because their hands may not be clean, and it was an infection control concern. LPN Q stated nurses should use a spoon or gloves to touch medications.
During an interview on 10/26/2023 at 3:12 PM, LPN E stated nurses should use a spoon to touch medications and not their bare hands due to infection control concerns.
During an interview on 10/27/2023 at 4:11 PM, the Director of Nursing (DON) stated nurses should not touch medications with bare fingers, because it was an infection control concern.
During an interview on 10/27/2023 at 5:05 PM, the Administrator stated nurses should not touch medications with their bare hands because of infection control concerns and the risk of contamination.

Based on observations, interviews, record reviews, and review of manufacturer's information the facility failed to ensure they followed appropriate infection control procedures for the storage of oxygen tubing and nasal cannula's and the storage and cleaning of CPAP equipment for 3 (R3, R8, and R11) of 4 sampled residents reviewed for respiratory care.
Findings include:
1.) A review of R3's admission Record revealed the facility admitted the resident on 06/24/2023 with diagnoses that included obstructive sleep apnea.
A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/29/2023, revealed the R3 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact.
A review of R3's care plan initiated on 06/26/2023, indicated the resident had a potential for respiratory difficulty secondary to sleep apnea. Interventions directed staff to assist the resident with their CPAP machine as ordered.
A review of R3's Order Summary Report revealed an order dated 06/30/2023 to apply the resident's CPAP machine at bedtime every evening related to obstructive sleep apnea. The Order Summary report did not reflect any orders related to the cleaning and storage of the resident's CPAP machine.
During an interview on 10/23/2023 at 10:12 AM, R3 stated staff did not clean their CPAP machine. R3 stated they purchased their own equipment cleanser for the machine and tried to clean it on their own because staff never cleaned the machine or the filter. Observation at that time revealed a bottle of distilled water and a bottle of disinfectant for CPAP machines on the floor of the room near the resident's bedside table. The resident's CPAP mask was laying on top of the CPAP machine, not bagged. R3 stated staff left the mask like that after they took the mask off, and staff did not place it in a bag or covering.
During an interview on 10/27/2023 at 4:12 PM, the Director of Nursing stated CPAP masks should be placed in a bag, and the CPAP machine should be cleaned according to manufacturer's directions.
During an interview on 10/27/2023 at 5:03 PM, the Administrator stated the CPAP mask should be placed in a bag for infection control purposes, and the CPAP machine should be cleaned according to manufacturer's directions.
A review of the undated manufacturer's information for R3's CPAP machine revealed, Cleaning You should clean the device weekly as described. Refer to the mask use guide for detailed instructions on cleaning your mask. 1. Wash the water tub and air tubing in warm water using mild detergent. Do not wash in a dishwasher or washing machine. 2. Rinse the water tub and air tubing thoroughly and allow to dry out of direct sunlight and/or heat. 3. Wipe the exterior of the device with a dry cloth.
2. A review of R8's admission Record revealed the facility admitted the resident on 06/06/2022.
A review of R8's Medical Diagnosis document revealed the resident had diagnoses that included chronic obstructive pulmonary disease (COPD).
A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/28/2023, revealed R8 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident was moderately cognitively impaired. The MDS indicated the resident received oxygen therapy while residing in the facility.
A review of R8's care plan initiated on 06/13/2022, indicated the resident had a potential for respiratory difficulty secondary to emphysema. Interventions directed nursing staff to administer oxygen per physician's orders.
A review of an Order Summary Report revealed R8 had an order dated 07/10/2023 that indicated the physician approved for staff to administer one to three liters of oxygen as needed to keep the resident's oxygen saturation above 88%.
During an interview on 10/23/2023 at 10:04 AM, R8 stated they used oxygen at night and if needed during the day. A portable oxygen tank was observed on the back of the resident's wheelchair with uncovered, unbagged tubing and a nasal cannula.
Observation on 10/24/2023 at 10:30 AM, revealed R8 was in their room in their wheelchair. A portable oxygen tank was observed on the back of the resident's wheelchair, with the tubing and nasal cannula not bagged. R8's oxygen tubing was not dated.
During an interview on 10/26/2023 at 1:57 PM, Licensed Practical Nurse (LPN) P stated oxygen tubing and nasal cannula's should be placed in a bag, so they did not get contaminated.
During an interview on 10/26/2023 at 2:19 PM, LPN Q stated oxygen tubing should be dated, and the tubing and nasal cannula should be placed in a bag, so they did not come into contact with the ground or harbor bacteria.
During an interview on 10/27/2023 at 4:12 PM, the Director of Nursing (DON) stated the oxygen tubing and cannula's should be placed in a bag, and the tubing should be dated and changed every 30 days.
During an interview on 10/27/2023 at 5:03 PM, the Administrator stated the oxygen tubing and cannula's should be placed in a bag and protected from debris.
3. A review of R11's admission Record revealed the facility admitted the resident on 12/21/2021 with diagnoses that included heart failure.
A review of an annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/19/2023, revealed R11 had a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident had moderate cognitive impairment.
A review of R11's care plan initiated on 02/24/2023, indicated the resident required as needed oxygen therapy related to congestive heart failure.
A review of an Order Summary Report revealed R11 had an order dated 04/05/2023, for oxygen per nasal cannula at two to five liters per minute as needed for shortness of breath.
Observation on 10/23/2023 at 11:47 AM, revealed R11 in their room with a portable oxygen tank hanging on the door with the tubing and nasal cannula uncovered and undated. An oxygen concentrator was observed in the resident's bathroom with the tubing and nasal cannula unbagged and undated.
Observation on 10/25/2023 at 2:35 PM, revealed R11's oxygen tubing and nasal cannula's for their portable oxygen and oxygen concentrator were not bagged or dated.
During an interview on 10/26/2023 at 1:57 PM, Licensed Practical Nurse (LPN) P stated oxygen tubing and nasal cannula's should be placed in a bag, so they did not get contaminated.
During an interview on 10/26/2023 at 2:19 PM, LPN Q stated oxygen tubing should be dated, and the tubing and nasal cannula should be placed in a bag, so they did not encounter the ground or harbor bacteria.
During an interview on 10/27/2023 at 4:12 PM, the Director of Nursing (DON) stated the oxygen tubing and cannula's should be placed in a bag, and the tubing should be dated and changed every 30 days.
During an interview on 10/27/2023 at 5:03 PM, the Administrator stated the oxygen tubing and cannula's should be placed in a bag and protected from debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) Surveyor reviewed R20's medical record. R20 was transferred to the hospital on [DATE] for further evaluation and treatment due to change of condition and moderate respiratory distress.
On 12/1/22 at 3:00 p.m., Surveyor Interviewed Administrator -A and Director of Nursing- B and requested to review the documentation provided to R20 and the legal representative at the time of transfer on 11/30/22.
On 12/5/2022 , DON-B provided to Surveyor the Behold and re-admission Policy Notice that was provided to R20 and the Interact Change of Condition Evaluation form which is generated through information entered into the electronic medical record. Surveyor asked DON- B if there was any additional information provided to R20 and the legal representative such as the location to which R20 was being transferred to, a statement of the resident's appeal rights and the name and address and telephone number of the Office of the State Long- Term Care Ombudsman. No additional information was provided other than DON- B stating that a pamphlet regarding the Ombudsman program is included in the transfer packet that goes with a resident upon transfer to the hospital.
Based on record review and interview, the facility did not notify the resident or resident's representative in writing of the transfer including the location to which the resident is transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form for 3 (R29, R72, and R20) of 3 residents reviewed for transfer to the hospital.
R29 was transferred to the hospital on [DATE]. No written transfer notification was provided to R29's representative that included the location R29 was being transferred to and information regarding appeal rights and how to obtain them.
R72 was transferred to the hospital on [DATE]. No written transfer notification was provided to R72 or R72's representative that included the location R72 was being transferred to and information regarding appeal rights and how to obtain them.
R20 was transferred to the hospital on [DATE]. No written transfer notification was provided to R20 or R20's representative that included the location R20 was being transferred to and information regarding appeal rights and how to obtain them.
Findings include:
The facility policy and procedure entitled Discharge or Transfer dated 6/2013 states: 1. Should it become necessary to make a transfer or discharge to a hospital or other related institution, the facility will implement the following procedures: a. Notify the resident's attending physician and/or obtain order to send to hospital or other related institution; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for the transfer; d. Complete a transfer form to send with the resident, make a copy for the resident record; e. Notify the representative or other family member; f. Assist in obtaining transportation for resident; g. Document in the nurse's notes the events that lead up to the emergency/non-emergency discharge or transfer with the time they were transferred and by whom.
1.) R29 was admitted to the facility on [DATE].
On 11/29/2022, R29 was transferred to the hospital due to unresponsiveness, lethargy, altered mental status, and a blood pressure of 64/42.
On 12/1/2022 at 2:57 PM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B documentation that was provided to R29's representative at the time of R29's transfer.
On 12/5/2022 at 12:47 PM, DON-B provided to Surveyor the Bedhold and re-admission Policy Notice that was provided to R29's representative and the Nursing Home to Hospital Transfer Form, both dated 11/29/2022. Surveyor asked DON-B if the Transfer Form was provided to R29's representative or was given to the hospital. DON-B stated DON-B was not sure. Surveyor asked DON-B if there was any other paperwork provided to R29's representative that stated where R29 was being transferred to and paperwork that included appeal rights with addresses and phone numbers for those appeal rights. DON-B provided pamphlets with Ombudsman information that DON-B stated were included in the information given to a resident when being transferred. No documentation was provided that included the location to which the resident was transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form. No further information was provided at that time.
2.) R72 was admitted to the facility on [DATE].
On 11/9/2022, R72 was transferred to the hospital due to altered mental status, possible seizure, and decreased level of consciousness.
On 12/1/2022 at 2:57 PM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B documentation that was provided to R72 or R72's representative at the time of R72's transfer.
On 12/5/2022 at 12:47 PM, DON-B provided to Surveyor the Bedhold and re-admission Policy Notice that was provided to R72 and the Nursing Home to Hospital Transfer Form, both dated 11/9/2022. Surveyor asked DON-B if the Transfer Form was provided to R72 or was given to the hospital. DON-B stated DON-B was not sure. Surveyor asked DON-B if there was any other paperwork provided to R72 that stated where R72 was being transferred to and paperwork that included appeal rights with addresses and phone numbers for those appeal rights. DON-B provided pamphlets with Ombudsman information that DON-B stated were included in the information given to a resident when being transferred. No documentation was provided that included the location to which the resident was transferred, a statement of the resident's appeal rights with the name, address, and telephone number of the entity which receives the request and information on how to obtain an appeal form. No further information was provided at that time.

Based on record review and staff interview, the facility did not ensure resident's with mental health disorders, and intellectual disabilities, were appropriately screened. This was discovered with 1 (R42) of 3 residents reviewed for PASARR (preadmission screening and resident review) screening.
*R42 has a diagnosis of intellectual disability and his PASARR Level I did not indicate this diagnoses upon admission to the facility. The facility's failure to identify R42's diagnoses of intellectual disability on the PASARR resulted in inaccurate completion of R42's PASARR Level 1 Screen. If R42's PASARR was completed correctly a positive Level 1 screen would have been documented. The facility did not identify R42's positive Level 1 screen which would have required the facility to refer R42 for an in-depth evaluation by a state-designated authority, known as a Level 2 screen. Since R42 was not referred for a Level 2 screen it allowed for the potential for R42 to be placed in an inappropriate environment and/or not receive the necessary specialized services related to the diagnoses of intellectual disability.
Findings include:
The facility's policy and procedures Preadmission Screen And Review dated 4/2022 was reviewed by Surveyor. The procedure includes: Prior to or upon admission and with any status change, facility will obtain completed PASARR Level I screen. A Level screen that includes Intellectual/Developmental Disabilities will be referred for a Level II screen.
1.) R42's medical record was reviewed by Surveyor. R42 has a PASARR (preadmission screening and resident review) Level I completed on 9/17/22 that indicates R42 does not have a diagnoses of developmental/intellectual disabilities.
R42's facility diagnosis list indicates a diagnoses of intellectual disability and R42's hospital discharge paperwork, from 9/17/22, documents a diagnoses of developmental delays.
A diagnoses of developmental/intellectual disabilities would be identified as a positive Level 1 screen, indicating further screening take place with a state-designated authority, known as a Level 2 screen.
R42's admission MDS (minimum data set) assessment, completed 9/24/22, indicates a diagnoses of ID/DD (Intellectual Disabilities/Developmental Disabilities).
On 11/30/22, at 1:08 PM, Surveyor spoke with AA-C (Administrative Assistant) who completed R42's PASARR Level 1 on 9/17/22. AA-C did not have additional information.
On 12/01/22, 1:37 PM, Surveyor received a copy of R42's Level I PASARR with a updated completion date of 12/1/22, documenting R42 had diagnoses that include ID/DD. This diagnoses was not documented as being present upon R42's admission to the facility on 9/17/22. The PASARR Level I on admission indicates R42 was not suspected to have any mental illness or ID/DD concerns.
On 12/05/22, at 8:25 AM, Administrator-A and DON-B (Director of Nurses) provided additional information to Surveyor. R42's PASARR Level I was updated on 12/1/22 to indicate ID/DD diagnoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received care consistent with professional standards of practice in the development and healing of pressure injuries for 1 (R72) of 3 residents reviewed for pressure injuries.
R72 developed deep tissue injuries (DTI) to the left heel and the left outer ankle on 7/28/2022, the right heel on 9/27/2022, and the right and left buttocks on 11/22/2022. The left heel DTI healed on 9/20/2022. The left outer ankle DTI was recategorized as a diabetic ulcer and then reclassified as a DTI with eschar. The definition of a DTI by the National Pressure Injury Advisory Panel (NPIAP) is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. A DTI is not open, covered by eschar, or have any other type of tissue present. The right heel DTI developed eschar and the staging of the pressure injury did not reflect the new tissue type. R72 was readmitted to the facility on [DATE] with an Unstageable pressure injury to the left lateral heel.
Findings include:
R72 was admitted to the facility on [DATE] after hospitalization for right shoulder surgery with diagnoses of hemiplegia and hemiparesis following cerebral infarction, seizures, diabetes, heart failure, chronic kidney disease, depression, anxiety, anemia, and history of myocardial infarction.
On 7/7/2022 on the Initial Nursing Assessment form, nursing charted in the skin section of the form R72 had a healing incision to the right shoulder and a small abrasion from glasses to the right side of the nose. Nursing charted in the additional notes section R72 did not have any open areas to the skin.
On 7/7/2022, R72's Braden scale was 17 indicating mild risk for skin breakdown.
R72's Skin Integrity Care Plan was initiated on 7/8/2022 with the following interventions:
-Absorbent to wick up moisture.
-Bathe with mild soap.
-Encourage mobility and/or ambulation.
-Inspect skin daily with care.
-Monitor for signs/symptoms of infection.
-Monitor nutritional status.
-Monitor wound related pain and administer pain mediation as appropriate.
-Pericare after incontinent episodes.
-Pressure reduction support on wheelchair.
-Treatment as ordered.
Surveyor noted there are no interventions for heel/foot protection or offloading. There also are no individualized interventions for repositioning despite R72 having hemiplegia and and hemiparesis.
R72's admission Minimum Data Set (MDS) dated [DATE] indicates R72 is cognitively intact with a Brief Interview of Mental Status (BIM) score of 14. R72 is identified as needing extensive assistance of two plus staff for bed mobility. R72 was identified as being at risk for pressure injuries and did not have any pressure injuries. The MDS also indicated R72 did not demonstrate any behaviors including refusal of cares.
On 7/14/2022, R72's Braden score was 14 indicating moderate risk for skin breakdown.
On 7/21/2022, R72's Braden score was 15 indicating mild risk for skin breakdown.
On 7/28/2022, R72 developed a DTI to the left outer ankle. The facility uses a form entitled WASA to document wounds. On the WASA form, nursing charted the left outer ankle DTI measured 1.5 cm (centimeters) x 1.4 cm x 0 cm that was maroon/purple and not open or draining. In the additional comments section of the form, nursing charted R72 had two new areas to the left foot both maroon/purple non-blanching: one area to the outer ankle bone and one area to the outer heel. Nursing charted R72 stated they sleep mostly on the left side and spends most time in bed. Surveyor noted the left heel did not have any measurements documented. Surveyor noted there were no changes to R72's care plan.
On 8/4/2022, on the WASA form, nursing charted the left outer ankle DTI measured 1.2 cm x 1 cm that was purple in color. In the additional comments section nursing charted R72 wears heel boots to prevent further or new skin conditions.
On 8/4/2022 on the WASA form, nursing charted the left heel DTI measured 1 cm x 0.6 cm that was purple in color. In the additional comments section nursing charted R72 wears heel boots to prevent further or new skin conditions. Surveyor noted this was the first comprehensive assessment of the left heel DTI.
R72's left outer ankle DTI and left heel DTI were comprehensively assessed weekly from 8/4/2022 through 9/7/2022.
On 9/7/2022 on the WASA form, nursing charted R72's left outer ankle DTI measured 1.4 cm x 1.5 cm x unknown depth with 100% eschar. Surveyor noted a DTI does not have eschar and the pressure injury was now Unstageable. In the additional comments section, nursing charted R72 had a low air mattress in place.
On 9/7/2022 on the WASA form, nursing charted R72's left heel DTI measured 1 cm x 0.5 cm and was dry and intact.
On 9/13/2022 on the WASA form, nursing charted R72's left outer ankle wound was a diabetic ulcer that measured 2 cm x 2 cm x unknown depth with 100% eschar. Surveyor noted no explanation was documented as to the change from a pressure injury to a diabetic ulcer.
On 9/13/2022 on the WASA form, nursing charted R72's left heel DTI measured 0.8 cm x 0.4 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the pressure injury was now Unstageable. In the additional comments section, nursing charted the DTI was intact with treatment in place.
On 9/20/2022 on the WASA form, nursing charted R72's left outer ankle diabetic ulcer measured 1.8 cm x 1.8 cm with 100% eschar.
On 9/20/2022 on the WASA form, nursing charted R72's left heel DTI had healed.
On 9/27/2022 on the WASA form, nursing charted R72's left outer ankle wound was a DTI that measured 2.0 cm x 2.8 cm x 0 cm with 100% granulation and the wound was no longer covered with eschar. Surveyor noted a DTI does not have granulation tissue and the wound should have been staged if it was a pressure injury.
On 9/27/2022 a new pressure area was discovered on R72's right heel. On the WASA form, nursing charted the right heel DTI measured 2.5 cm x 4.0 cm x 0 cm.
On 10/4/2022 on the WASA form, nursing charted the left outer ankle DTI measured 1.8 cm x 2.8 cm x 0 cm with 100% granulation. Surveyor noted a DTI does not have granulation tissue and the wound should have been staged.
On 10/4/2022 on the WASA form, nursing charted the right heel DTI measured 2.5 cm x 3.8 cm x 0 cm.
On 10/9/2022 on the WASA form, nursing charted the left outer ankle DTI measured 1.6 cm x 2.6 cm x 0.1 cm with 100% eschar. In the additional comments section, nursing charted the wound bed was a mix of white and black soft tissue with no slough identified and R72 had an appointment scheduled at the wound clinic on 10/10/2022 for evaluation and treatment. Nursing charted R72 was immobile and required turning every 1-2 hours, R72 gets up to chair after breakfast, and heels floated with pillows due to refusal of the Prevalon boots. Surveyor noted a DTI does not have eschar and should have been documented as Unstageable.
On 10/9/2022 on the WASA form, nursing charted the right heel DTI measured 2 cm x 3.6 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted the wound bed was black, dry, and intact with margins peeling up from the peri wound. Nursing charted the total dry area measured 4.6 cm x 4 cm x 0 cm with the eschar being in the center measuring 2 cm x 3.6 cm x 0 cm. Nursing charted R72 was immobile and required turning every 1-2 hours, R72 gets up to chair after breakfast, and heels floated with pillows due to refusal of the Prevalon boots. Surveyor noted a DTI does not have eschar and should have been documented as Unstageable.
R72's Skin Integrity Care Plan was revised on 10/10/2022 with the following intervention: float heels as tolerated and to comfort. Surveyor noted the interventions documented in R72's nurses notes are not included in the care planned interventions to ensure implementation.
R72's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R72 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and coded R72 as needing extensive assistance with all activities of daily living including bed mobility and was always incontinent of bowel and bladder. The MDS indicates R72 has two unstageable-deep tissue injuries and is at risk for pressure injuries. Review of the behavior section indicated R72 did not demonstrate any behaviors including refusal of cares.
R72's left outer ankle wound and right heel wound were measured weekly from 10/14/2022 through 11/7/2022. The wounds were charted as being DTIs with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable.
R72 was in the hospital from [DATE] through 11/14/2022.
On 11/15/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.9 cm x 0.1 cm with 50% granulation, 25% slough, and 25% clean non-granulation tissue. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged.
On 11/15/2022 on the WASA form, nursing charted the right heel DTI measured 3.2 cm x 3.3 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted R72 continued to refuse heel boots and would kick pillows away; R72 was re-educated on the risks of continued pressure to areas such as wound deterioration, infection, pain, loss of feet and to potential death. R72 verbalized understanding. R72 was to have a follow up appointment at the wound clinic. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable.
On 11/15/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.0 cm x 2.0 cm x 0 cm with 100% eschar. In the additional comments section, nursing charted R72 returned from the hospital with this wound.
On 11/22/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.1 cm x 0.2 cm with 50% granulation and 50% slough. In the additional comments section, nursing charted R72 was noncompliant with heel lift boots and risks of not following recommendations were discussed. Nursing charted the wound edges had epiboly. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged.
On 11/22/2022 on the WASA form, nursing charted the right heel DTI measured 3.0 cm x 3.4 cm x 0 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable.
On 11/22/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.0 cm x 3.5 cm x 0 cm with 100% eschar.
On 11/22/2022, R72 developed a DTI to the right buttock and the left buttock.
On 11/22/2022 on the WASA form, nursing charted the right buttock DTI measured 3.5 cm x 0.5 cm x 0 cm with red/purple non-blancheable area that was not open.
On 11/22/2022 on the WASA form, nursing charted the left buttock DTI measured 1.0 x 1.8 cm x 0 cm with red/purple non-blancheable area that was not open. In the additional comments section, nursing charted education was provided to R72 on the importance of allowing staff to reposition side to side while in bed; R72 verbalized understanding and agreed on allowing staff to reposition. Nursing charted R72 had a low air loss mattress in place.
On 11/28/2022, an Unavoidable Pressure Injury or Condition form was completed indicating comorbidities and risk factors. The physician and wound nurse Registered Nurse (RN)-I completed the form and determined the pressure injuries were unavoidable and all preventative measures had been in place.
R72's Skin Integrity Care Plan was revised on 11/28/2022 with the following interventions:
-Pressure reduction foam mattress or pressure redistribution support (low air or alternation air) in bed. (Surveyor noted this intervention had been in place prior to putting it in the Care Plan.)
-Turn and reposition every two hours and as needed.
On 11/29/2022 on the WASA form, nursing charted the left outer ankle DTI measured 2.5 cm x 1.2 cm x 0.1 cm with 50% granulation and 50% slough. Surveyor noted a DTI does not have granulation, slough, or any other type of tissue in the wound bed and the wound should have been staged.
On 11/29/2022 on the WASA form, nursing charted the right heel DTI measured 3.2 cm x 3.4 cm x 0 cm with 100% eschar. Surveyor noted a DTI does not have eschar and the wounds should have been documented as Unstageable.
On 11/29/2022 on the WASA form, nursing charted the left lateral heel Unstageable pressure injury measured 5.2 cm x 3.5 cm x 0 cm with 100% eschar.
On 11/29/2022 on the WASA form, nursing charted the right buttock DTI measured 3.3 cm x 0.5 cm x 0 cm that was purple/red in color.
On 11/29/2022 on the WASA form, nursing charted the left buttock DTI measured 2.0 cm x 1.6 cm x 0 cm that was purple/red in color.
On 11/29/2022, R72 developed a pressure injury to the back of the left ankle. On the WASA form, nursing charted the Unstageable pressure injury measured 3.0 cm x 1.0 cm x 0 cm with 100% eschar.
Surveyor reviewed R72's medical record and multiple refusals of pressure reducing devices and non-compliance were noted.
On 11/29/2022 at 9:31 AM in the progress notes, nursing charted a return call was received from the wound clinic and the etiology of wounds were discussed; the wound physician stated the wound to bilateral lower extremities were pressure ulcers however they are worsened by ischemia as evidenced by the ankle-brachial index on the right and left that indicated severe resting ischemia. R72 failed a stent and has a return appointment to the vascular clinic on 12/2/2022. The wound clinic was updated by the facility that R72's family was considering hospice services.
On 11/29/2022 at 2:32 PM, Surveyor observed R72 sleeping in bed on an air mattress with feet elevated off the mattress.
On 11/30/2022 at 3:26 PM, Surveyor observed R72's wound treatments by RN-I and assisted by Certified Nursing Assistant (CNA)-H. R72 had heel boots on both feet that were removed by CNA-H. Both feet were wrapped in Kerlex. Surveyor observed the following wounds: the left outer ankle wound measured approximately 3 cm x 3 cm with slough in the center and eschar on the outer edge of wound, the right heel had an eschar cap that measured approximately 4 cm x 4 cm, the left lateral foot by the base of the fifth toe measured approximately 2 cm x 1 cm with eschar, the left posterior heel by the Achilles tendon had 2 areas each measuring approximately 1 cm x 1 cm with eschar, the left buttock had an open area measuring approximately 1 cm x 1 cm with light pink tissue, and the right buttock had no pressure areas. RN-I stated the right buttock had healed and the left buttock had opened since last observation. Treatments were completed to all areas and heel boots were put back on R72 before leaving the room. Surveyor noted the locations of wounds observed did not correlate with the locations of wounds that had been documented on. The facility documented on the left lateral heel and the back of the left ankle. Surveyor noted wounds to the left lateral foot and two wounds to the back of the left heel at the Achilles tendon.
In an interview on 12/5/2022 at 9:38 AM, Surveyor asked RN-I why wounds were charted as DTI with eschar present. RN-I stated RN-I did not have an answer; the nurses that charted those assessments were no longer employed at the facility. Surveyor showed RN-I the charting completed by RN-I on 11/15/2022 where DTI was listed as the status of the pressure injury even when eschar or other tissue types were observed. RN-I stated the wounds should have been charted as Unstageable with eschar present and with other tissue types, they should have been staged a Stage 3. RN-I stated RN-I had just started working at the facility and did not know what previous nurses had been instructed to chart when it came to wounds.
In an interview on 12/5/2022 at 10:20 AM, RN-I stated RN-I talked to Nurse Consultant-D and was told not knowing the depth, even if it has eschar, they do not change the staging from a DTI. RN-I stated the wound with eschar wound be an Unstageable pressure injury and not a DTI at that point. RN-I stated wound education needs to be done so that will be RN-I's focus. RN-I stated some education had been done regarding wounds, but the nurses may not be retaining it. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure each resident received adequate assistance to prevent accidents for 1 (R5) of 4 residents reviewed for falls.
R5 was transferring with the use of a sit-to-stand lift (EZ lift) on 9/3/2022 when R5 slipped out of the sling and sustained a fall. The facility did not do a thorough investigation as to the cause of the fall to prevent future falls. R5 had contradicting transfer statuses: R5's Care Plan stated R5 was a Hoyer lift transfer and the Certified Nursing Assistant (CNA) Care Card stated R5 was an EZ lift transfer.
Findings include:
The facility policy and procedure entitled Management of Falls dated 9/2020 states: 3. Develop a plan of care to include goals and interventions which address resident's risk factors. 9. Review and/or modify the resident's plan of care at least quarterly and as needed in order to minimize risk for fall incidents and/or injury.
The facility policy and procedure entitled Fall Risk Assessment dated 8/2020 states: 5. If a residents fall [sic], the nurse will complete an Occurrence Report and initiate Post-occurrence documentation. 6. With each fall the care plan interventions will be reviewed for their effectiveness and modified as appropriate to reduce hazards and risk to the residents.
R5 was admitted to the facility on [DATE] with diagnoses of osteoarthritis, dementia, diabetes, lymphedema, morbid obesity, gout, hypothyroidism, hypertension, chronic kidney disease, and venous insufficiency. R5's Power of Attorney (POA) was activated on 3/30/2021. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R5 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4 and coded R5 as needing extensive assistance with transfers, toilet use, dressing, and hygiene.
Surveyor reviewed R5's Activities of Daily Living (ADL) Care Plan and R5's CNA Care Card and found the following discrepancies:
-The ADL Care Plan was initiated on 10/17/2013 with the transfer status of Hoyer lift initiated on 9/2/2021 and the Care Plan indicated that status had not changed since that date.
-The CNA Care Card transfer status was EZ lift initiated on 11/25/2020.
On 9/3/2022 at 10:30 PM on the Post Occurrence Documentation form, nursing charted R5 was being moved in the EZ lift from the bathroom to the bed and R5 slid out of the sling. The fall was witnessed by the CNA and no injuries were sustained. In the Witnesses section of the form, nursing charted no witnesses were found.
Surveyor reviewed the fall investigation completed by the facility interdisciplinary team (IDT) that was conducted on 9/6/2022, 9/7/2022, and 9/8/2022. The IDT determined the root cause of the fall was due to R5 transferring in the EZ lift and slid out of the sling. The intervention determined by the IDT was to temporarily decrease R5 to a Hoyer lift transfer. Surveyor did not find any documentation of an interview with the CNA that was present when R5 slid from the sling to understand how the fall occurred or an investigation into the mechanics of the fall, such as review of the transfer procedure, inspection of the lift and/or sling to determine if there was frayed material or if the sling was put on the lift correctly, or any follow up with staff to determine if there was a potential for another fall due to faulty equipment.
On 9/6/2022, R5's transfer status on the CNA Care Card was changed to Hoyer lift. On that same day, the transfer status on the CNA Care Card was changed back to EZ lift.
On 9/6/2022, R5's Falls Care Plan was revised with the intervention: decrease in transfer status. Surveyor noted the ADL Care Plan continued to read Hoyer lift for transfers.
On 9/7/2022, Therapy screened R5 for transfer status and determined EZ lift was appropriate for R5 with a reminder to staff that R5 was not to stand longer than two to two-and-a-half minutes. Surveyor did not see that time recommendation on R5's CNA Care Card or ADL Care Plan.
On 10/15/2022 at 3:00 PM on the Post Occurrence Documentation form, nursing charted R5 was seen seated on the floor in front of the toilet with the left leg stretched straight in front of R5 and the right leg in front bent at a 90-degree angle pointed outward to the right from the right knee. R5 complained of severe pain when the leg was attempted to be moved. R5 was sent to the emergency room for evaluation and treatment.
On 10/15/2022 at 10:10 PM in the progress notes, nursing charted R5 returned from the emergency room with a diagnosis of a right femur fracture and was non-weight bearing for two to four weeks.
On 10/17/2022 at 10:26 AM in the progress notes, nursing charted the IDT note for the review of R5's fall on 10/15/2022. Nursing charted the CNA was assisting R5 to the toilet with the EZ lift when R5's leg gave out and sustained a fracture to the right femur. The intervention put in place was R5 would be a Hoyer lift transfer.
On 11/29/2022 at 9:58 AM, Surveyor observed R5 in R5's room. R5 was seated in a wheelchair with footrests elevated. Surveyor asked R5 if R5 had any falls while at the facility. R5 stated R5 had falls at home and that was why R5 was at the facility. R5 denied having any falls at the facility. R5 stated as soon as the leg heals, R5 will go back to using the EZ lift.
In an interview on 11/30/2022 at 1:32 PM, Surveyor asked CNA-J how is R5 transferred. CNA-J stated R5 had always transferred with an EZ lift with one CNA assist, but R5 was currently a Hoyer lift with two CNAs due to R5's broken leg.
In an interview on 12/1/2022 at 1:59 PM, Surveyor asked Occupational Therapy Supervisor (OTS)-K if R5 was seen by therapy after the fall on 9/3/2022 and if OTS-K had any information on R5's transfer status prior to 10/15/2022. Surveyor explained the conflicting transfer status for R5 on the ADL Care Plan compared to the CNA Care Card. OTS-K stated R5 was in therapy from 6/17/2022 through 8/17/2022 because of decline in transfers and they worked on getting R5 to use the EZ lift for transfers. Surveyor asked OTS-K if R5 was evaluated after the fall on 9/3/2022. OTS-K looked to see if there was any documentation in the therapy department but stated OTS-K did not have any personal notes associated with that fall and there was no screening request written up in the therapy book. OTS-K stated there was a binder that was kept with Nursing Home Administrator (NHA)-A or Administrative Assistant-C that had all the resident falls in it and were reviewed for interventions. OTS-K stated the falls are reviewed initially and then again in three days to see if the interventions were appropriate. Surveyor asked OTS-K if therapy is involved with determining resident transfers if there is a change in status. OTS-K stated nursing contacts therapy for a change in transfer status, but staff can downgrade a resident transfer if there was an issue. Surveyor shared with OTS-K the conflicting ADL Care Plan and the CNA Care Card with R5's type of transfer: Hoyer lift on the ADL Care Plan and EZ lift on the CNA Care Card. OTS-K stated the MDS nurse would be able to clarify that more that OTS-K so OTS-K called Registered Nurse (RN)-G. RN-G came to OTS-K's office and Surveyor asked RN-G if RN-G could clarify the timeline for R5's transfer status as well as what was meant by decrease in transfer status that was added to the Falls Care Plan on 9/6/2022. RN-G reviewed R5's electronic medical record. RN-G stated a decrease in transfer status would be to change R5 to a Hoyer lift on 9/6/2022. Surveyor shared with RN-G the conflicting transfer status from the Care Plan to the CNA Care Card. RN-G stated R5 was an EZ lift for a long time and maybe the Care Plan did not get changed. RN-G looked at the CNA Care Card information and stated the transfer status was changed on 9/6/2022 to Hoyer lift, but then the floor nurse changed it back on the same date to EZ lift.
In an interview on 12/1/2022 at 2:41 PM, Director of Nursing (DON)-B stated DON-B talked to the floor nurse that changed R5's transfer status from Hoyer lift to EZ lift on 9/6/2022 and the floor nurse said R5 needed to use the toilet, so they changed R5 back to an EZ lift. DON-B stated the IDT met after the fall on 9/3/2022 and decided they need to upgrade R5 to a Hoyer, but when the floor nurse worked on 9/6/2022, she changed it back to EZ lift and did the documentation. DON-B stated the floor nurse could not completely remember making the change. DON-B stated R5's daughter was unhappy about the Hoyer lift because she wanted R5 to use the toilet.
On 12/3/2022 at 11:06 AM in the progress notes, nursing charted on 9/6/22 spoke to residents [sic] family regarding residents [sic] preference to use the EZ stand vs the Hoyer Lift. Family verbalized that they indeed would prefer the use of the EZ stand instead of the Hoyer as this assists with the residents continence and dignity with use of toilet vs bed pan. resident is aware of her toileting habits and verbalizes to staff and family preferences on wanting EZ stand use vs Hoyer. Risk vs Benefits explained to the family, with them verbalizing understanding. Surveyor noted this progress note was entered into R5's medical record after Surveyor brought the concern of the nurse changing R5's transfer status with no assessment to determine the safety of R5 using an EZ lift for transfers to the facility.
In an interview on 12/5/2022 at 11:13 AM, DON-B stated DON-B was not employed at the facility on 9/3/2022 but talked to other staff members and was told R5 did not like the Hoyer lift because of being suspended in the air. DON-B stated the Hoyer would have been safer because R5's knees give out. DON-B stated DON-B could see the transfer status of EZ lift and Hoyer lift went back and forth and knows the family requested the EZ lift. Surveyor asked DON-B if an investigation was done to determine how R5 fell out of the sling on 9/3/2022. DON-B asked, Out of the sling? You're asking tough questions. DON-B stated when DON-B started working at the facility, NHA-A asked DON-B to review R5's fall on 10/15/2022 but did not review R5's fall on 9/3/2022. DON-B stated DON-B and RN-G went through R5's Care Plan and tried to come up with a timeline for transfer status and was not able to follow when transfer statuses changed. DON-B stated the Hoyer lift transfer should have come off of the Care Plan to match the CNA Care Card. DON-B stated DON-B understands these processes need to be streamlined.
In an interview on 12/5/2022 at 1:20 PM, DON-B stated therapy was working with R5 from 6/17/2022 to 8/17/2022 and R5 was able to stand 2 to 2-1/2 minutes; R5 had not had any declines since therapy discontinued. DON-B stated R5 was evaluated on 9/7/2022 for the use of the EZ lift. Surveyor shared the concern with DON-B that R5 had conflicting transfer statuses in the Care Plan and CNA Care Card, no investigation was done after the 9/3/2022 fall to determine the cause of R5 to slip from the sling and to put an intervention in place to prevent future falls, the CNA involved in the transfer on 9/3/2022 was not interviewed, the EZ lift and sling were not inspected to determine if the lift or sling was faulty, and R5's transfer status was changed by the floor nurse with no assessment to determine if R5 was safe to transfer with an EZ lift. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 of 5 residents reviewed for medications (R20).
The facility was administering psychotropic medications to R20, but no behaviors were being monitored to assure the medications effectiveness.
Findings include:
R20 was originally admitted to the facility on [DATE] with diagnoses that included Anxiety Disorder, Depression, Dementia without behavioral disturbance.
A review of R20's Individual plan of care noted:
R20 is receiving antidepressant medications, Lexapro and Imipramine, antipsychotic medication, Aripiprazole to manage depressive symptoms and anxiousness related to diagnosis of Depression and Anxiety Disorder, unspecified. Date Initiated 11/4/2022.
Interventions included:
o Will show no adverse side effects of psychotropic medication regimen through next review.
o Will show a decrease in depressive symptoms and anxiety through next review.
o Assess/record effectiveness of drug treatment.
o Monitor and report signs and symptoms of side effects to physician as needed.
On 11/5/22, the facility completed the Psychotropic Assessment Form- admission and indicated that R20 is being administered the following medications: Name of Psychotropic Medication Escitalopram Diagnosis/Indication for Use Depression
Resident stable on current dose of medications, no plan on reduction at this time.
A review of the admission Minimum Data Set (MDS) dated [DATE] stated that R20 has received the following during the 7 day reference period prior to the completion of the assessment. 7 days antipsychotic medications, 2 antianxiety medications and 7 days antidepressant medications. The MDS indicates that; yes- antipsychotic's were received on a routine basis only.
On 11/30/22 at 3:00 p.m., Surveyor interviewed Administrator- A and Director of Nursing- B and requested to review any behavior monitoring that the facility was conducting on R20 for the use of the antidepressant and antipsychotic and antianxiety medications.
On 12/1/22 at 10:00 a.m. Surveyor again asked DON- B if the facility was conducting any monitoring of specific, targeted behaviors in order to determine the effectiveness and necessity of the medications was effective. DON- B stated that she would have to look into this.
On 12/1/22 at 2:00 p.m., Surveyor was provided with a copy of the Psychological Diagnostic Interview and Psychotherapy Progress Note dated 11/7/2022. The treatment plan review states; We will continue to meet with patient (R20) to manage her symptoms of dysphoria (generalized dissatisfaction with life) and anhedonia (lack of pleasure). R20 is prescribed the following psychotropic's: Aripiprazole 10 milligrams, Escitalopram 20 milligrams, Imipramine 100 milligrams and Ativan 0.5 milligrams twice daily for anxiety. DON- B included a note on top of the copies of this progress note stating Behavior Monitoring- No behaviors as documented by psychologist.
On 12/1/22 at 3:00 p.m., Surveyor again interviewed DON-B asking if the facility was monitoring specific targeted behaviors to assure the effectiveness of the above medications. DON- B stated she would again look into this. As of the time of exit on 12/5/22, no additional information was provided as to why the facility was not monitoring R20's behaviors daily.

Based on observation, interviews and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect 7 residents residing on the 200 unit of the facility.
The facility utilizes a shared glucometer between residents. The glucometer was not cleaned according to manufacturer's recommendations between residents.
Findings include:
The facility policy titled Assure Platinum Blood Glucose Monitoring dated 5/28/20 documents (in part) .
.12. After each use clean/disinfect outside of the meter with disinfectant wipes.
a. All surfaces of Blood Glucose Monitoring Machine if visibly soiled need to be physically cleaned to remove gross soil with one wipe and then a second wipe to disinfect the surface.
c. If using Super Sani wipes for treated surface of the blood glucose monitoring machine for Covid 19 should remain wet for 2 minutes.
Surveyor review of the Super Sani Cloth Plus germicidal disposable wipe with the purple top and label read (in part) .
.Bactericidal, tuberculocidal, and virucidal in 2 minutes. To disinfect non-food contact surfaces, unfold clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry.
Special instructions for cleaning and decontamination against Human Immunodeficiency Virus (HIV-1), Hepatitis-B, Hepatitis C of surfaces/objects soiled with blood/body fluids: Contact time: Allow surface to remain wet two (2) minutes, let air to dry.
On 12/1/22 at 7:45 AM Surveyor observed Licensed Practical Nurse (LPN)-L during medication pass. LPN-L reported she has a student going around taking vital signs and blood sugars. Surveyor asked if residents have their own glucometer's or if they are shared between residents. LPN-L reported glucometer's are shared and cleaned between residents.
Surveyor observed the nursing student leave a residents' room carrying a white plastic bin containing a glucometer. The nursing student placed the bin on the medication cart and LPN-L reminded her to clean it, handing her a container with a purple top labeled Super Sani Cloth Plus. While standing next to LPN-L, the nursing student removed 1 wipe and proceeded to wipe the glucometer for 5 seconds before placing it back in the white plastic bin. The student then picked up the bin containing the glucometer and started to walk away.
Surveyor stopped the student and asked if she was going to take more residents' blood sugars, to which she replied Yes. Surveyor advised of the nursing student and LPN-L of the observation regarding the cleaning of the glucometer for 5 seconds. Surveyor advised the student and LPN-L of the cleaning instructions requiring a 2 minute wet contact time. LPN-L reported she interpreted the directions to mean the glucometer needed to dry for 2 minutes and was not aware it needed to remain wet for 2 minutes.
Surveyor received a list of residents on unit 200 that required blood sugar testing utilizing the shared glucometer. Electronic Health Record review of the 7 residents that utilize the shared glucometer on unit 200 revealed no residents with bloodborne pathogens.
On 12/1/22 at 3:00 PM during the daily exit meeting, Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the above concern regarding cleaning of the shared glucometer.
On 12/5/22 at 9:00 AM NHA-A advised Surveyor all staff were immediately inserviced on the 2 minute contact time required for cleaning of the glucometer's. NHA-A reported on Friday, 12/2/22 the facility provided all residents with their own glucometer's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not have evidence that allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 3 (R15) residents reviewed for abuse/neglect.
R15's nursing progress notes on 10/2/22 documented an allegation of neglect that was not thoroughly investigated.
Findings include:
R15 admitted to the facility on [DATE] and has diagnoses that include Dementia, severe protein- calorie malnutrition, Chronic Kidney Disease and Major Depressive Disorder.
R15's Significant Change MDS (Minimum Data Set) dated 10/25/22 documents a Brief Interview for Mental Status Score (BIMS) score of 7, indicating severe cognitive impairment.
The facility policy titled Abuse Policy dated 9/20 documents (in part) .
.The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. This will be done by:
4. Identifying occurrences and patterns of potential mistreatment;
5. Immediately protecting residents involved in identifying reports of possible abuse;
6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences;
7. Filing accurate and timely investigative reports.
Neglect is the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
The facility policy titled Abuse Prevention Program dated 9/20 documents (in part) .
.4. Identification
Employees are required to report any occurrences of potential mistreatment the observe, hear about, or suspect to a supervisor or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate and incident investigation.
The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruising of unknown origin, lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible to assessing the resident, reviewing the documentation and reporting to the administrator or designee.
5. Protection of Residents
The facility will take steps to prevent mistreatment while the investigation is underway.
c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee.
e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents.
6. Investigation
a. Appoint an investigator. Once an allegation has been made, the administrator or designee will investigate the allegation and obtain a copy of any documentation related to the incident.
c. The final investigation report will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files and interview of witnesses's The final investigation shall also include a conclusion of the investigation based on known facts.
7. Reporting
Initial reporting of allegations are reported immediately. CMS defines immediately as not later than 2 hours after forming the suspicion of abuse which results in serious body injury or not later than 24 hours if no serious body injury. A written report shall be sent to the Wisconsin Division of Assurance (DQA).
c. Five Day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Wisconsin Division of Quality Assurance.
g. Review findings to determine if further training or other corrective action is needed to prevent future occurrences.
While reviewing R15's medical record, Surveyor located a nurse note dated 10/2/2022 at 13:49 which documented: Resident was found by CNA (Certified Nursing Assistant) this morning in soaked sheets from head to toe, resident still lying in same clothes from yesterday, and now right hip has an open area with bleeding. Optifoam ordered.
The facility was asked if there were any self report investigations for R15. None were provided.
On 11/30/22 at 11:31 AM Surveyor spoke with Licensed Practical Nurse (LPN)-E. Surveyor and LPN-E reviewed the progress note together. Surveyor asked LPN-E when she was notified of R15 lying in soaked sheets from head to toe and in the same clothes from previous day what did she do. LPN-E reported she let the charge nurse know. LPN-E reported she could not remember who the charge nurse was, as it's not always the same charge nurse every day. LPN-E reported she also did an assessment, called the Nurse Practitioner and got an order for Optifoam for the open area.
Surveyor confirmed LPN-E informed the charge nurse that R15 was found lying in soaked sheets from head to toe in the same clothes from the previous day. LPN-E stated: Yes, I told her everything. Surveyor asked why she informed the charge nurse. LPN-E stated: Because I was mad. I felt (R15) should have been checked on and changed during the night. Surveyor confirmed with LPN-E that she has had abuse and neglect training. Surveyor asked LPN-E if she considered this neglect. LPN-E paused and stated: Well, honestly I was just venting in frustration. I was mad. She (R15) should have been checked and changed during the night.
Surveyor asked LPN-E if anyone spoke to her after she reported the allegation to the charge nurse. LPN-E stated: No, not really. We discussed it on Monday morning during nurse to nurse report. Surveyor asked if there was an investigation into what happened. LPN-E stated: Not that I know of. Surveyor asked LPN-E if she was interviewed to discuss the allegation after she reported it to the charge nurse. LPN-E stated: No. But like I said, I really was just venting and angry.
Facility provided the schedule for Sunday, 10/2/22 which listed Registered Nurse (RN)-F as the Charge Nurse.
On 11/30/22 at 1:30 PM Surveyor spoke with RN-F. RN-F reported when assigned as charge nurse, she is responsible to help if a nurse needs assistance or if there's a fall or change in condition, but is also assigned to work a unit. Surveyor advised RN-F of the progress note documentation on 10/2/22 and asked if she remembered anyone reporting this to her. RN-F stated: No, not that I remember. But I can't say I'd remember something from that far back in October. Surveyor read the progress note documentation to RN-F and asked if that helped her recollect. RN-F stated: No, I'm sorry, I don't remember being told about that. Surveyor asked RN-F if she had been notified of this situation, what she would have done. RN-F stated: Well, we wouldn't have been able to speak to the aides working the night before, because they would've been gone for the day, so I probably would have told the DON (Director of Nursing) about in on Monday, so she could follow up and talk to that staff on night shift.
Surveyor again read the progress note documentation aloud to RN-F and asked if this was reported to her, would she consider this neglect. RN-F paused for a long time and stated: I hadn't really thought about it like that. I guess if it really did happen, I guess it could be considered neglect, now that you mention it. RN-F reported she was not aware of any investigation regarding the allegation.
On 11/30/22 at 3:24 PM during the daily exit meeting with Nursing Home Administrator (NHA)-A and DON-B, Surveyor advised of concern regarding the documented allegation of neglect. Surveyor confirmed no self report was filed in regards to the allegation. The facility reported they would look for additional information.
On 12/1/22 at 10:13 AM Surveyor spoke with DON-B who provided a file containing a typed Summary of Documentation 10/2/22 which was not signed or dated. DON-B reported she was not sure who completed the form. The typed summary documented 10/3/22 , Spoke with LPN-E about the documented entry. Spoke with NOC (night) shift nurse and CNA to verify that rounds had been completed, that the resident had been toileted and that she was in clean night clothes. Surveyor asked DON-B if a self report was filed. DON-B stated: No. I don't think it was considered as abuse or neglect. DON-B reported the MDS nurse pointed out the charting the next day and Nurse Consultant-D would have more information regarding the 10/2/22 documentation. DON-B reported NHA-A was aware of this situation. Surveyor noted the file provided also contained documentation of staff education on abuse on 10/5/22 (which did not include all staff) and education on skin program policy and procedure, pressure injury, assessment, treatment education on 10/4/22.
On 12/0/22 at 10:30 AM Surveyor spoke with Nurse Consultant-D. Surveyor showed Nurse Consultant-D the summary of documentation form which was not signed or dated and asked who completed the form. Nurse Consultant-D stated: The previous DON and I guess myself. Surveyor advised Nurse Consultant-D of interview with LPN-E who reported no-one spoke to her or asked her about the events documented on 10/2/22.
Surveyor advised Nurse Consultant-D the summary form was not dated and asked when it was completed. Nurse Consultant-D stared at Surveyor and did not answer. Surveyor asked if the form was just completed or if it was done in October. Nurse Consultant-D stated: Back then. Surveyor asked why a self report was note filed. Nurse Consultant-D stated: We did not consider it abuse or neglect. After talking to staff she said the aid often exaggerates stuff and was probably just mad she had to do a complete bed change.
Surveyor advised the summary documentation form indicates staff interviews were completed and asked if an investigation was done. Nurse Consultant-D stated: Well, not officially, but because of what was charted, we had to find out what happened. It was determined it was not neglect and we decided education was needed regarding charting.
Surveyor advised the file contained some staff education on abuse on 10/5/22 and asked if the education was related to the documentation involving neglect on 10/2/22. Nurse Consultant-D stated: Not necessarily. The training was due anyway, so we figured we might as well just do it.
On 12/1/22 at 1:47 PM Surveyor asked for copies of the file provided. DON-B advised surveyor she printed the the documentation regarding CNA point of care charting yesterday. When we were talking about this yesterday, I asked if anyone looked at the CNA charting from that night. NHA-A said I don't know, so I went in to check and printed it. It shows that the resident was checked and changed during the night. When asked who completed the summary of documentation form and when it was completed, DON-B stated: The previous DON did the form and had a bad habit of not signing and dating things.
On 12/5/22 at 9:02 AM Surveyor spoke with NHA-A and DON-B. DON-B reported Nurse Consultant-D noted the charting from 10/2/22 the following day and thought it was not appropriate charting. That's why we did education and inservice on documenting appropriately. DON-B provided Surveyor statements written by LPN-E and the CNA regarding allegation. Surveyor noted the statements were not included in the file previously given to Surveyor and were not dated. Surveyor asked when the statements were completed. DON-B reported the statements were written the next day (Monday) when Nurse Consultant-D noticed the charting. Surveyor advised DON-B of of interview last week with LPN-E reporting she did not talk to anyone about it the incident. DON-B stated: Well, she obviously did, she wrote the statement.
On 12/5/22 at 9:18 AM Surveyor spoke with LPN-E and asked about the written statement regarding her charting on 10/2/22. Surveyor asked who spoke to her about the charting, to which LPN-E reported it was the previous DON. LPN-E reported the previous DON spoke to her the next day She told me I can't be charting something like that and wanted me to write down and explain exactly what happened. Surveyor advised the statement was not dated and asked when it was written. LPN-E reported she wrote the statement the next day when the previous DON talked to her. Surveyor reminded LPN-E of interview last week in which she stated no-on spoke to her after she reported the incident to the charge nurse and was not aware of an investigation. LPN-E stated: I know, I must have forgot. When they they (DON-B and Nurse Consultant-D) were asking me about it last week, I remembered.
On 12/5/22 at 9:22 AM Surveyor spoke with NHA-A and DON-B. DON-B reiterated the facility did not consider the events documented on 10/2/22 as neglect, It was inappropriate charting. Surveyor advised the nursing note documented R15 was found by CNA in the morning in soaked sheets from head to toe, still lying in same clothes from yesterday, and now right hip has an open area with bleeding. Surveyor advised the documentation alleged neglect which should have been thoroughly investigated. DON-B reported she did not understand, It was determined it was not neglect, just inappropriate charting from a nurse who was angry at the time. Surveyor advised the allegation was not thoroughly investigated. There was only 2 statements from the nurse and CNA and no other staff interviews were completed. There were no interviews completed with other residents to determine if cares were not done or if neglect occurred, and CNA charting was not reviewed. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure that alleged violations involving neglect were reported to the State Survey Agency within the required time frame for 1 of 3 (R15) residents reviewed for abuse/neglect.
R15's nursing progress notes on 10/2/22 documented an allegation of neglect that was not reported to the State Agency.
Findings include:
R15 admitted to the facility on [DATE] and has diagnoses that include Dementia, severe protein- calorie malnutrition, Chronic Kidney Disease and Major Depressive Disorder.
R15's Significant Change MDS (Minimum Data Set) dated 10/25/22 documents a Brief Interview for Mental Status Score (BIMS) score of 7, indicating severe cognitive impairment.
The facility policy titled Abuse Policy dated 9/20 documents (in part) .
.The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. This will be done by:
4. Identifying occurrences and patterns of potential mistreatment;
5. Immediately protecting residents involved in identifying reports of possible abuse;
6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences;
7. Filing accurate and timely investigative reports.
Neglect is the failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress.
The facility policy titled Abuse Prevention Program dated 9/20 documents (in part) .
.4. Identification
Employees are required to report any occurrences of potential mistreatment the observe, hear about, or suspect to a supervisor or the administrator. Supervisors shall immediately inform the administrator or designee of all reports of potential mistreatment. Upon learning of the report, the administrator or designee shall initiate and incident investigation.
The nursing staff is additionally responsible for reporting on a facility incident report the appearance of bruising of unknown origin, lacerations or other abnormalities as they occur. Upon report of such occurrences, the nursing supervisor is responsible to assessing the resident, reviewing the documentation and reporting to the administrator or designee.
5. Protection of Residents
The facility will take steps to prevent mistreatment while the investigation is underway.
c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee.
e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents.
6. Investigation
a. Appoint an investigator. Once an allegation has been made, the administrator or designee will investigate the allegation and obtain a copy of any documentation related to the incident.
c. The final investigation report will be completed within five working days of the reported incident. The final report shall include facts determined during the process of the investigation, review of medical records, personnel files and interview of witnesses's The final investigation shall also include a conclusion of the investigation based on known facts.
7. Reporting
Initial reporting of allegations are reported immediately. CMS defines immediately as not later than 2 hours after forming the suspicion of abuse which results in serious body injury or not later than 24 hours if no serious body injury. A written report shall be sent to the Wisconsin Division of Assurance (DQA).
c. Five Day Final Investigation Report. Within five working days after the report of the occurrence, a complete written report of the conclusion of the investigation, including steps the facility has taken in response to the allegation will be sent to the Wisconsin Division of Quality Assurance.
g. Review findings to determine if further training or other corrective action is needed to prevent future occurrences.
While reviewing R15's medical record, Surveyor located a nurse's note dated 10/2/2022 at 13:49 which documented: Resident was found by CNA (Certified Nursing Assistant) this morning in soaked sheets from head to toe, resident still lying in same clothes from yesterday, and now right hip has an open area with bleeding. Optifoam ordered.
The facility was asked if there were any self report investigations for R15. None were provided.
On 11/30/22 at 11:31 AM Surveyor spoke with Licensed Practical Nurse (LPN)-E. Surveyor and LPN-E reviewed the progress note together. Surveyor asked LPN-E when she was notified of R15 lying in soaked sheets from head to toe and in the same clothes from previous day, what did she do. LPN-E reported she let the charge nurse know. LPN-E reported she could not remember who the charge nurse was, as it's not always the same charge nurse every day. LPN-E reported she also did an assessment, called the Nurse Practitioner and got an order for Optifoam for the open area.
Surveyor confirmed LPN-E informed the charge nurse that R15 was found lying in soaked sheets from head to toe in the same clothes from the previous day. LPN-E stated: Yes, I told her everything. Surveyor asked why she informed the charge nurse. LPN-E stated: Because I was mad. I felt (R15) should have been checked on and changed during the night. Surveyor confirmed with LPN-E that she has had abuse and neglect training. Surveyor asked LPN-E if she considered this neglect. LPN-E paused and stated: Well, honestly I was just venting in frustration. I was mad. She (R15) should have been checked and changed during the night.
Surveyor asked LPN-E if anyone spoke to her after she reported the allegation to the charge nurse. LPN-E stated: No, not really. We discussed it on Monday morning during nurse to nurse report. Surveyor asked if there was an investigation into what happened. LPN-E stated: Not that I know of. Surveyor asked LPN-E if she was interviewed to discuss the allegation after she reported it to the charge nurse. LPN-E stated: No. But like I said, I really was just venting and angry.
Facility provided the schedule for Sunday, 10/2/22 which listed Registered Nurse (RN)-F as the Charge Nurse.
On 11/30/22 at 1:30 PM Surveyor spoke with RN-F. RN-F reported when assigned as charge nurse, she is responsible to help if a nurse needs assistance or if there's a fall or change in condition, but is also assigned to work a unit. Surveyor advised RN-F of the progress note documentation on 10/2/22 and asked if she remembered anyone reporting this to her. RN-F stated: No, not that I remember. But I can't say I'd remember something from that far back in October. Surveyor read the progress note documentation to RN-F and asked if that helped her recollect. RN-F stated: No, I'm sorry, I don't remember being told about that. Surveyor asked RN-F if she had been notified of this situation, what she would have done. RN-F stated: Well, we wouldn't have been able to speak to the aides working the night before, because they would've been gone for the day, so I probably would have told the DON (Director of Nursing) about in on Monday, so she could follow up and talk to that staff on night shift.
Surveyor again read the progress note documentation aloud to RN-F and asked if this was reported to her, would she consider this neglect. RN-F paused for a long time and stated: I hadn't really thought about it like that. I guess if it really did happen, I guess it could be considered neglect, now that you mention it.
On 11/30/22 at 3:24 PM during the daily exit meeting with Nursing Home Administrator (NHA)-A and DON-B, Surveyor advised of concern regarding the documented allegation of neglect. Surveyor confirmed no self report was filed in regards to the allegation. The facility reported they would look for additional information.
On 12/1/22 at 10:13 AM Surveyor spoke with DON-B who provided a file containing a typed Summary of Documentation 10/2/22 which was not signed or dated. DON-B reported she was not sure who completed the form. The typed summary documented 10/3/22 , Spoke with LPN-E about the documented entry. Spoke with NOC (night) shift nurse and CNA to verify that rounds had been completed, that the resident had been toileted and that she was in clean night clothes. Surveyor asked DON-B if a self report was filed. DON-B stated: No. I don't think it was considered as abuse or neglect. DON-B reported the MDS nurse pointed out the charting the next day and Nurse Consultant-D would have more information regarding the 10/2/22 documentation. DON-B reported NHA-A was aware of this situation.
On 12/0/22 at 10:30 AM Surveyor spoke with Nurse Consultant-D. Surveyor showed Nurse Consultant-D the summary of documentation form (which was not signed or dated) and asked who completed the form. Nurse Consultant-D stated: The previous DON and I guess myself. Surveyor advised Nurse Consultant-D of interview with LPN-E who reported no-one spoke to her or asked her about the events documented on 10/2/22. Nurse Consultant-D implied that staff can get crazy & exaggerate stuff.
Surveyor advised Nurse Consultant-D the summary form was not dated and asked when it was completed. Nurse Consultant-D stared at Surveyor and did not answer. Surveyor asked if the form was just completed or if it was done in October. Nurse Consultant-D stated: Back then. Surveyor asked why a self report was not filed. Nurse Consultant-D stated: We did not consider it abuse or neglect. After talking to staff she said the aid often exaggerates stuff and was probably just mad she had to do a complete bed change.
Surveyor advised the file contained some staff education on abuse on 10/5/22 and asked if the education was related to the documentation involving neglect on 10/2/22. Nurse Consultant-D stated: Not necessarily. The training was due anyway, so we figured we might as well just do it.
On 12/5/22 at 9:22 AM Surveyor spoke with NHA-A and DON-B. DON-B reiterated the facility did not consider the events documented on 10/2/22 as neglect, It was inappropriate charting. Surveyor advised the nursing note documented R15 was found by CNA in the morning in soaked sheets from head to toe, still lying in same clothes from yesterday, and now right hip has an open area with bleeding. Surveyor advised the documentation alleged neglect which should have been reported to the state agency. DON-B reported she did not understand, It was determined it was not neglect, just inappropriate charting from a nurse who was angry at the time. Surveyor advised the facility is required to report any suspicion or allegations of neglect within the required timeframe before an investigation or conclusions are made. No additional information was provided.