Does LUTHER MANOR have any serious inspection findings?

Yes, LUTHER MANOR has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 47 total deficiencies from recent inspections.

What are the staffing levels at LUTHER MANOR?

LUTHER MANOR has a four-star staffing rating from CMS with 0.72 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is LUTHER MANOR located?

LUTHER MANOR is located in MILWAUKEE, WI. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does LUTHER MANOR have?

LUTHER MANOR has 99 certified beds.

Who owns LUTHER MANOR?

LUTHER MANOR is a non profit - corporation facility and operates independently (not part of a chain).

What questions should families ask when visiting LUTHER MANOR?

Families visiting LUTHER MANOR should ask about staff retention and training programs, what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does LUTHER MANOR compare to other nursing homes?

LUTHER MANOR has a 1-star overall rating, which is below average compared to other nursing homes in WI. Families should carefully review inspection findings and consider alternatives.

LUTHER MANOR

Name: LUTHER MANOR
Address: 4545 N 92ND ST, MILWAUKEE, WI, 53225, US
Telephone: (414) 464-3880
Rating: 1.0

4545 N 92ND ST, MILWAUKEE, WI 53225 · (414) 464-3880

Non profit - Corporation 99 Beds Independent Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#292 of 321 in WI

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Last Inspection: September 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Luther Manor has received a Trust Grade of F, indicating poor quality and significant concerns about care. It ranks #292 out of 321 nursing homes in Wisconsin, placing it in the bottom half of facilities in the state, and #24 out of 32 in Milwaukee County, meaning only a few local options are worse. While the facility shows an improving trend, reducing issues from 34 in 2024 to 3 in 2025, it still faces serious challenges, including $170,666 in fines, which is higher than 87% of Wisconsin facilities, signaling ongoing compliance problems. Staffing is a relative strength with a 4/5 star rating, but a 60% turnover rate is concerning as it exceeds the state average, indicating staff instability. There have been critical incidents, such as a resident developing a severe pressure injury due to inadequate care and assessments, and another resident suffering significant weight loss without proper nutritional support, which raises serious alarms about the quality of care provided. Overall, while there are some positive aspects, families should weigh the serious deficiencies against the strengths before making a decision.

Trust Score: F
In Wisconsin: #292/321
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $170,666 in fines. Higher than 71% of Wisconsin facilities. Some compliance issues.
Skilled Nurses: Each resident gets 43 minutes of Registered Nurse (RN) attention daily — more than average for Wisconsin. RNs are trained to catch health problems early.
Violations: 47 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 34 issues

2025: 3 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below Wisconsin average (3.0)

Significant quality concerns identified by CMS

Staff Turnover: 60%

14pts above Wisconsin avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $170,666

Well above median ($33,413)

Significant penalties indicating serious issues

Staff turnover is elevated (60%)

12 points above Wisconsin average of 48%

The Ugly 47 deficiencies on record

3 life-threatening 3 actual harm

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff members timely reported an allegation of suspected abuse to the Administrator for 4 (Residents #1, #2, #3, and #4) of 4 sampled residents related to 2 incidents (01/12/2025 and 07/01/2025) of 3 sampled for abuse. The facility also failed to ensure the facility timely reported an allegation of suspected abuse to the state agency for 2 (Resident #1 and Resident #2) of 4 sampled residents related to 2 incidents (05/20/2025 and 07/01/2025) of 3 sampled for abuse.Findings included:The facility's policy titled, Abuse, Neglect, Misappropriation, and Exploitation, implemented June 2025, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed the section titled, Policy Explanation and Compliance Guidelines, included, 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The policy revealed the section titled, VII. Reporting/Response, included, A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, Nurse Manager, Director of Nursing Services, state agency, adult protective services and to all other required agencies (e.g. [exempli gratia, for example], law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.1.) Resident #1 was admitted to the facility on [DATE] with a medical history that included diagnoses of dementia without behavioral disturbance, generalized anxiety disorder, and major depressive disorder.Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/16/2025, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated the resident used a wheelchair and propel it 50 feet with two turns independently. The MDS also indicated the resident had no behaviors during the assessment's lookback period and required set-up and clean-up assistance with eating.Resident #1's Care Plan Report, included a problem statement initiated on 12/11/2024, that indicated the resident had episodes of forgetfulness and confusion related to dementia. Interventions directed staff to ask yes/no questions in order to determine the resident's needs. Resident #2 was admitted to the facility on [DATE] with a medical history that included diagnoses of dementia with mood disturbance and anxiety disorder.Resident #2's quarterly MDS, with an ARD of 06/30/2025, revealed Resident #2 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. The MDS indicated the resident utilized a wheelchair and required substantial to maximum assistance to propel the wheelchair 50 feet with two turns. The MDS also indicated the resident had verbal behaviors during the assessment's lookback period and could eat independently. Resident #2's Care Plan Report, included a problem statement initiated on 09/18/2024 and revised on 07/11/2025, that indicated the resident had actual physical aggressiveness toward harming others related to anger, dementia, and poor impulse control, and on 07/03/2025 the resident was offered a new dining room experience in relation to a facility reported incident. Interventions directed staff that for communication provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated. The interventions instructed staff that the resident's triggers for physical aggression were related to loud noises/sensory overload towards other and the resident's behaviors were de-escalated by removing the resident from heightened situations to avoid conflict. A facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 05/20/2025 at 1:29 PM, revealed that on 05/20/2025 at 1:08 PM Resident #2 attempted to push themselves in their wheelchair through the dining room where other residents were. The report revealed Resident #2 could not get through and became frustrated and made contact with Resident #1. The report did not indicate the police or state authorities were notified.A document titled, Physical Aggression Received, dated 05/20/2025 at 12:45 PM, for Resident #2, revealed Certified Nursing Assistant (CNA) A reported that after lunch Resident #2 was trying to move away from the table and bumped into another resident. The document revealed the other resident yelled at Resident #2 and then Resident #2 hit the other resident on the left side of their face. The document did not indicate the police or state authorities were notified.A document titled, Physical Aggression Received, dated 05/20/2025 at 12:45 PM, for Resident #1, revealed CNA A reported that after lunch another resident was trying to move away from the table and bumped into Resident #1. The document revealed Resident #1 yelled at the other resident and the other resident hit Resident #1 on the left side of their face. The document did not indicate the police or state authorities were notified.During an interview on 07/30/2025 at 4:27 AM, regarding the incident on 05/20/2025, the Administrator stated she reported the incident to the state on 05/20/2025 at 1:29 PM. She stated they did not call the police or adult protective services. A facility Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 07/03/2025, revealed that the Administrator was made aware on 07/03/2025 that on 07/01/2025 at 6:50 PM, Resident #1 backed their wheelchair into Resident #2 and Resident #2 made contact with Resident #1's back area. The report indicated the Administrator submitted the report to the state agency on 07/03/2025 at 10:55 AM. The document did not indicate the police were notified. A document titled, Physical Aggression Received, dated 07/01/2025, for Resident #1, revealed CNA A reported that Resident #1 was involved in a physical altercation after Resident #1 ran into another resident's wheelchair and that resident punched Resident #1's back. The document did not indicate the Administrator or the police were notified.A document titled, Physical Aggression Received, dated 07/01/2025, for Resident #2, revealed CNA A reported that Resident #2 was involved in a physical altercation after another resident ran into Resident #2's wheelchair and then Resident #2 punched that resident in the back. The document revealed Resident #2 was unable to recall the incident. The document did not indicate the Administrator or the police were notified.During a telephone interview on 07/28/2025 at 5:00 PM, CNA A stated that she was standing there and Resident #1's chair got caught up in Resident #2's chair. She stated she separated the residents and reported it to LPN B.An undated Licensed Practical Nurse [LPN] Statement, indicated LPN B reported that she did not see the incident (on 07/01/2025) and that CNA A told her about it. The statement revealed LPN B indicated they separated Resident #1 and Resident #2, and they were fine.During an interview on 07/28/2025 at 3:22 PM, LPN B stated she did not witness the incident (on 07/01/2025), but that CNA A said Resident #2 hit Resident #1 in the back and she assisted with moving the residents. She stated she reported this to her supervisor, Registered Nurse (RN) C, not the Administrator.During an interview on 07/28/2025 at 3:33 PM, RN C stated they were to report abuse as soon as possible, and the same expectation was for the CNAs to report abuse to the nurses.During an interview on 07/29/2025 at 10:49 AM, the Director of Nursing Services (DNS) stated she received a text related to the 07/01/2025 incident from RN C. She stated he let her know Resident #1 and Resident #2 had an altercation and were separated and were okay. She stated RN C described it as the residents were trying to pass by each other and ran into each other unintentionally. She stated it seemed as though it frustrated Resident #2, and Resident #2 lashed out and punched Resident #1 in the back. She stated the incident was not a serious situation where she had to come in because both residents were safe and unharmed. She stated she did not look at the situation as an abuse situation. She stated she did not report it to the Administrator because she did not think it was abuse. She stated if the situation were considered abuse, her expectation would be that the Administrator would be notified. During an interview on 07/28/2025 at 4:38 PM, the Administrator confirmed the incident between Resident #1 and Resident #2 that occurred on 07/01/2025 was not reported to her until 07/03/2025. She said she believed staff did not think reporting resident-to-resident incidents needed to be reported immediately to her. She confirmed she did not notify the police or adult protective services for that facility-reported incident. During an interview on 07/29/2025 at 8:30 AM, the Administrator stated she did not remember who reported the incident on 07/03/2025 to her for the incident involving Resident #1 and Resident #2 on 07/01/2025. She stated her expectation was that the nurse and nurse supervisor should tell her about an allegation of abuse, but that at least one of them should have told her.2.) Resident #3 was admitted to the facility on [DATE] with a medical history that included diagnoses of degenerative disease of the nervous system, Alzheimer's disease, and dementia agitation. Resident #3's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) scare of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had physical and verbal behaviors during the assessment's lookback period. Resident #3's Care Plan, included a problem statement initiated 08/10/2021 and revised on 01/20/2025, that indicated the resident had an alteration in neurological status related to Alzheimer's dementia with behavioral disturbance and degenerative disease of the nervous system. The interventions directed staff to cue and reorient as needed. The Care Plan Report also included a problem statement initiated on 01/16/2025 that indicated the resident had a potential to be verbally aggressive related to dementia. The interventions directed staff that when the resident became agitated to intervene before agitation escalated and guide away from the source of stress. Resident #4 was admitted to the facility on [DATE] with a medical history that included diagnoses of degenerative disease of the nervous system, vascular dementia without behavioral disturbance, and anxiety disorder. Resident #4's admission MDS, with an ARD of 11/13/2024, revealed Resident #4 had a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had no behaviors during the assessment's lookback period. Resident #4's Care Plan Report, included a problem statement initiated on 11/22/2024, that indicated the resident could be verbally aggressive towards staff related to dementia. Interventions directed staff to assess and anticipate resident's needs to include food, thirst, toileting needs, comfort level, body positioning, and pain. The Care Plan Report included a problem statement initiated on 01/16/2025 that indicated the resident had a potential to be physically aggressive related to dementia. The interventions directed staff to assist with verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff member when agitated and when the resident became agitated to intervene before agitation escalates and guide away from the source of distress.An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report, dated 01/13/2025, revealed that the Administrator was made aware on 01/13/2025 that on 01/12/2025 at 4:38 PM Resident #3 attempted to spit toward Resident #4 and at that time Resident #4 made contact with Resident #3. The report indicated the Administrator submitted the report to the state agency on 01/13/2025 at 10:26 AM.During an interview on 07/29/2025 at 12:18 PM, Certified Nursing Assistant (CNA) D stated Resident #3 always acted like the resident was going to spit but never did. She stated that Resident #4 was the aggressor during the 01/12/2025 incident. She stated she reported this to the nurse at the nurses' station. She could not remember who. She stated that the next day, the Administrator called her into her office to make a statement. During an interview on 07/29/2025 at 11:04 AM, the Director of Nursing Services (DNS) stated she could not remember when she was notified by staff about the incident between Resident #3 and Resident #4. She stated if there was abuse the staff should notify her in a reasonable amount of time. The DNS stated that she and the supervisor should report abuse to the Administrator, and it should be reported to the Administrator that day. During an interview on 07/28/2025 at 4:50 PM, the Administrator stated the incident occurred on 01/12/2025 and was discovered by her on 01/13/2025. She stated she believed the delay in reporting to her was that the staff was not aware to call her right away. During an interview on 07/29/2025 at 2:40 PM, the Administrator stated her expectation was to report abuse the same day. She stated her expectation was to report abuse to the police and state authorities, and her expectation would be that the social worker or nurse in charge would call the police if there was an allegation of abuse if she was not available or if she delegated the task.No additional information was provided.

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility did not address and resolve grievances conveyed on behalf of 1 (R1) of 5 residents reviewed for grievances. * On 12/11/2024, a grievance was initiated for R1 regarding R1 requesting to be transferred to bed from R1's wheelchair. R1's grievance stated that a Certified Nursing Assistant (CNA), refused to transfer R1due to the request being too close to the shift change. The refusal resulted in R1 having to wait one hour to be transferred into bed. The grievance packet involving the above grievance was missing information and did not have a clear resolution. Findings include: The facility's policy, titled Grievance Policy, with the last reviewed date of 2/2020 documents: G. Response Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within the role and authority. If a complaint cannot be immediately resolved employee shall escalate the complaint to their supervisor and the facility grievance official . The investigation will consist of at least the following: a review of the completed complaint report, on interview/statement with the person or persons reporting the incident if applicable, interviews/statements with any witnesses to the incident or concern, . An interview with staff members having contact with the resident during the relevant periods or shifts of the alleged incident. 1.) R1 was admitted to the facility on [DATE] with diagnoses that include fracture of T9-T10 vertebra, multiple fracture of ribs (left side), displaced fracture of lower end of left humerus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R1's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 15, indicating R1 is cognitively intact. The MDS documents R1's mobility as dependent, as the helper does all the effort, as R1does none of the effort to complete this activity. R1's grievance, dated 12/11/2024, with an occurrence date of 12/10/2024documents that R1 requested from a CNA to get transferred into bed from a wheelchair. The response from the CNA is documented as: it was too close to shift change to move R1. It is documented that R1 had to wait for one hour to be transferred into bed. The resolution is documented in part as: Residents were educated on call light process, call response times, and provided with the social workers contact information for questions and concerns. It is not indicated on the form if R1 was notified of resolution, this portion was left blank. The next page in the grievance packet was to be signed by grievance official and reviewed by the Director of Nursing (DON) and Nursing Home Administrator (NHA) to ensure the grievance was addressed and resolved, but Surveyor noted that this page was left blank. On 5/13/2025, at 10:50 AM, Surveyor interviewed Social Worker (SW)-C, who indicated being the one the staff member who worked on this grievance. SW-C stated not being able to remember the grievance, but SW-C stated SW-C would have to look at the soft files for more information on the grievance and get back to the surveyor. On 5/13/2025, at 12:14 PM, SW-C informed Surveyor that she could not locate any more information on this grievance. On 5/13/2025, at 12:36 PM, Surveyor interviewed SW-C, who stated SW-C did not have any statements from the CNA alleged in the grievance and could not recall if the CNA was interviewed or if an interview as conducted. SW-C stated that all grievances should be brought to NHA-A to review, but that did not occur with R1's grievance. SW-C stated that NHA-A would have signed the grievance if it was brought to NHA-A. SW-C indicated that with this grievance a CNA interview should have been conducted. On 5/13/2025, at 12:44 PM, Surveyor informed NHA-A of the concern with the grievance that was submitted to SW-C on 12/11/2024, regarding R1. Surveyor informed NHA-A that after interview with SW-C, there was no evidence that a complete investigation of the grievance occurred. Surveyor informed NHA-A, of the concern that SW-C did not speak with or could not recall speaking with the alleged CNA. SW-C also indicated not being able to recall if the results of the resolution were reported to R1 or NHA-A. NHA-A indicated an understanding of the concern mentioned above. No additional information received as to why R1 was not informed of resolution or NHA-A. There was no additional information as to why the staff involved in the grievance for R1 were not interviewed.

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of hospital discharge summary, interview, and facility document review, the facility failed to ensure orders were transcribed correctly for one of three residents (Resident (R) 4) reviewed for medication orders out of 13 sample residents to ensure medications were administered as ordered. This had the potential for the residents to have unmet health care needs. Findings include: Review of R4's admission Record located in the electronic medical record (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with a diagnosis of cytomegaloviral disease (CMV/common virus). The resident discharged from the facility on 12/23/24. Review of R4's hospital After Visit Summary, dated 11/26/24 to 12/11/24 and located in the EMR under the Misc tab, revealed the resident was to continue to receive ganciclovir (antiviral medication to treat viruses) 2.5 milligrams (mg/kg [kilogram]) = 250 mg in dextrose 100 ml (milliliter) bag by intravenous (IV) route two times a day. There was no stop date indicated. Review of R4's Care Plan, initiated 12/11/24 and located in the EMR under the Care Plan tab, revealed the resident was on an antiviral therapy ganciclovir related to CMV infection. Interventions included administering the antiviral medication as ordered by the physician. Review of R4's Progress Note, dated 12/12/24 located in the EMR under the Progress Note tab, revealed an order was received from the Infectious Disease Clinic to change the ganciclovir to once a day. There was no stop date indicated. Review of R4's Medication Administration Record (MAR), located in the EMR under the Orders tab, revealed an order for ganciclovir, intravenous solution. Use 250 mg IV one time a day for CMV infection until 12/18/24. Start date 12/13/24. The MAR documented the resident received the ganciclovir everyday with the last dose given on 12/18/24. Review R4's Progress Note, dated 12/23/24 and located in the EMR under the Progress Note tab, revealed a call was received from the Registered Nurse (RN) from the Infection Disease Clinic who wanted to know who gave authorization for the resident's ganciclovir to stop on 12/18/24. The RN indicated she gave specific instructions that the anticipated completion date would be 12/23/24 dependent on the repeat antiviral levels and his follow up appointment. A Risk Management was completed for the medication error. Review of the facility's investigation provided by the facility revealed at the time of admission, the resident was to receive IV antiviral daily infusion through 12/23/24. When he went to his appointment on 12/23/24 it was noted that there was a discrepancy in medication administration regarding the IV antiviral stopping on 12/18/24. In conclusion, although there was a medication administration error, the error did not cause a negative outcome to the resident. Licensed nurses were involved in education of the five rights of medication administration as well as order clarification. During an interview on 03/26/25 at 1:00 PM with the Administrator, she confirmed RN1 transcribed R4's orders received from the Infectious Disease Clinic incorrectly and put a stop date for the ganciclovir on 12/18/24 and the resident should have received the medication until his next appointment on 12/23/24. During an interview on 03/26/25 at 1:20 PM, the Director of Nursing (DON) confirmed a medication error occurred for R4 when RN1 put a stop date on his ganciclovir of 12/18/24. She confirmed the resident was to receive the medication until 12/23/24 and he missed five doses of the antiviral medication. She confirmed licensed nurses were educated on medication errors and order transcription. She confirmed all residents' orders were not reviewed after the medication error was found by the Infection Disease Clinic to ensure there were no other medication errors. She confirmed a Performance Improvement Plan (PIP) had not been developed. During an interview on 03/26/25 at 1:40 PM with RN1, she confirmed she put a stop date on the ganciclovir of 12/18/24 and the resident should have received the medication through 12/23/24, until his follow up appointment with Infectious Disease. Review of the undated document titled, How do you ensure accuracy of physician order transcription? provided by the facility revealed, Physician order transcription is a crucial step in the delivery of quality patient care .1. Understand the order: You need to pay attention to the details, such as .duration .3. Check for errors .check for errors and inconsistencies. You need to proofread you transcription and compare it with the original order.

Oct 2024 9 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 of 1 Residents reviewed (R58). * R58 was prescribed Seroquel, 12.5 mg (milligrams) 2 times daily, an antipsychotic medication for agitation related to Delusional Disorder diagnosis on 9/27/24. On 10/8/24, Seroquel was increased to 12.5 mg 3 times daily. The facility did not have a written, signed consent explaining the risks and benefits of Seroquel by R58's activated power of attorney (POA). Findings Include: 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor noted the facility was not able to provide Surveyor with documentation of the competency evaluation for R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there are 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's admission Minimum Data Set (MDS) dated [DATE] documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's admission MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58 has not been assessed for a new MDS assessment since admission. On 8/9/24, R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On 9/27/24, Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On 10/1/24, Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's physician orders document that R58 was prescribed Seroquel 12.5 mg tablet two times a day with a start date of 9/27/24. On 10/8/24 R58's Seroquel was increased to 12.5 mg three times a day and remains currently at that dose. Surveyor reviewed R58's electronic health record (EHR) and could not locate a written consent for the reason for the antipsychotic medication, alternative modes of treatment, the risks of taking the medication and the benefit of taking the medication. On 10/30/24, Surveyor requested documentation for signed consent of R58's Seroquel from Nursing Home Administrator (NHA)-A. On 10/30/24 at 3:07 PM, Surveyor shared the concern with NHA-A, that there is no documentation that R58's consent for Seroquel which includes the reason for the antipsychotic medication, alternative modes of treatment, the risks of taking the medication and the benefit of taking the medication. NHA-A stated the facility will look for R58's signed consent. On 10/31/24 at 11:36 AM, Medical Records (MR)-I was interviewed by Surveyor. MR-I confirmed that MR-I is responsible for making sure consents are signed either by the Resident or responsible party. MR-I stated the nurse reviews the medication and gets the signature either at admission or when a new medication is prescribed that requires consent. MR-I informed Surveyor that MR-I spoke to R58's activated HCPOA this morning and R58's activated HCPOA had further questions but gave verbal consent for the Seroquel. MR-I stated 're-training' needs to be completed. On 10/31/24 at 12:04 PM, MR-I informed Surveyor that MR-I was further able to answer R58's activated HCPOA questions and gave verbal consent for the Seroquel and will come in to the facility and sign the consent. Surveyor shared the concern that the consent for the Seroquel should have been obtained back on 9/27/24, when the Seroquel was first prescribed to R58. MR-I agreed the consent should have been obtained and signed. On 10/31/24 at 1:58 PM, Surveyor reviewed the concern with NHA-A that R58's Seroquel consent had not been obtained when first prescribed on 9/27/24. NHA-A acknowledged the concern and has no additional information. NHA-A informed Surveyor there is no facility policy and procedure for obtaining consents for required medications. No additional information was provided as to why the facility did not ensure that R58 had written consent explaining the risks and benefits of psychotropic medications that were prescribed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** UNCORRECTED ON VERIFICATION VISIT Based on record review and staff interviews, the facility did not ensure that 3 allegations of abuse involving 2 residents (R2 and R58) and 1 Resident to Resident (R3 and R4) altercation were reported to the State Survey Agency within the required reporting timeframe . * R2's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a bruise of unknown origin was submitted to the State Survey Agency on 9/3/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. * R58's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of rape was submitted to the State Survey Agency on 9/26/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report and a Misconduct Incident Report to the State Survey Agency. * An Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting Resident to Resident abuse involving R3 and R4 was submitted to the State Survey Agency on 9/19/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/29/24. Findings Include: The facility Policy titled Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation revised 2/2020, documents: .Purpose -Facility will prohibit and prevent abuse, neglect, exploitation, mistreatment, injuries of unknown sources and resident to resident altercations. -Facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) -All alleged incidents of abuse, neglect, exploitation, and misappropriation must be reported and investigated in a timely manner per program code requirements. Special Key Points 2. An initial review of the allegation prior to reporting to DQA/OCQ may be conducted to determine whether or not the incident needs to be reported to DQA/OCQ. All alleged violations involving mistreatment (including abuse, neglect, exploitation, injuries of unknown source, misappropriation of property, resident-to-resident abuse, and mistreatment by family members, visitors, volunteers or other individuals) must be reported to the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) as soon as possible, but not to exceed 24 hours from the discovery. Guidelines 1. Protect the Resident a. The safety of the resident(s) is the first priority. The resident(s) must be protected from possible subsequent injury or incidents of misconduct. b. After ensuring the safety of the resident(s), all employees are to immediately report any alleged incidents of abuse, neglect, and mistreatment to the Supervisor to ensure that appropriate notification and a timely investigation are initiated. c. The Supervisor immediately assesses the resident's personal safety and potential of harm to other residents. d. The Director of Nursing/Director of Resident and Patient Services and/or designee is to be contacted immediately for all allegations of caregiver misconduct or Resident-to-Resident abuse. The Administrator/CCO will be notified immediately . 1.) R2 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Essential Hypertension, Paroxysmal Atrial Fibrillation, and Depression. R2 has an activated Health Care Power of Attorney(HCPOA). R2's Quarterly Minimum Data Set (MDS) completed 10/4/24 does not assess R2's cognitive status. R2's MDS documents R2 has no range of motion impairment, R2 requires substantial/maximum assistance for showers, upper body dressing, and mobility. R2 is dependent for transfers, lower body dressing, and sit to stand. R2 is independent with eating. On 7/5/24, R2 had a significant change MDS completed which documents R2's Brief Interview for Mental Status(BIMS) score to be 15, indicating R2 was cognitively intact for daily decision making at that time. R2's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a bruise of unknown origin was submitted to the State Survey Agency on 9/3/24. On 9/4/24, R2's nurse practitioner diagnosed R2 with cellulitis to the right eye and started her on an antibiotic. The facility determined this was the cause of the discoloration to the right eye. However, the facility did not submit the Misconduct Incident Report to the State Survey Agency until 10/16/24 with a summary explaining the quick conclusion to the investigation. On 10/29/24 at 2:45 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R2's Misconduct Incident Report to the State Survey Agency was not submitted until 10/16/24. NHA-A stated this report was during the transition time of the former Director of Nursing (DON) no longer being an employee at the facility. Surveyor shared that the investigation was over a month late. NHA-A agreed R2's Misconduct Incident Report to the State Survey Agency was late. The facility provided no additional information as to why the report was not submitted until 10/16/24. 2.) R58's admission Minimum Data Set (MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. R58's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of rape was submitted to the State Survey Agency on 9/26/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Survey Agency and did not submit a Misconduct Incident Report. On 10/15/2024, in R58's electronic medical record (EMR) it is documented that R58 contacted the police and reported that R58 was assaulted over the weekend and that management has been made aware. On 10/29/24 at 2:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to R58's allegations. NHA-A stated these allegations occurred during transition time. NHA-A stated Department of Human Services (DHS) called and informed NHA-A that a complete investigation had not been received. NHA-A stated NHA-A had to complete an investigation all over again. NHA-A wanted to send a complete investigation in. NHA-A was unaware of R58 calling the police and alleging an assault on 10/15/24. NHA-A believes NHA-A may have triggered R58 when questioning and then R58 called the police. Surveyor shared the concern of the 9/26/24 allegation of rape Misconduct Incident Report not being submitted to the State Survey Agency within the required timeframe. Surveyor also shared the concern that R58's allegation of assault on 10/15/24 did not get reported to the State Survey Agency. On 10/30/24 at 3:07 PM, Surveyor shared the concern again with the facility reporting R58's allegations of rape and assault within the required reporting timeframes. NHA-A responded, We always screw up self reports. No additional information has been provided by the facility at this time in regard to R58's self reports being submitted. 3.) R3 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Severe, with Other Behavioral Disturbance, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation, and Unspecified Protein-Calorie Malnutrition. R3 has an activated Health Care Power of Attorney(HCPOA). R3's Quarterly Minimum Data Set (MDS) completed 8/14/24 documents R3's BIMS score to be 0, indicating R3 is severely cognitively impaired for daily decision making. R3 has no behaviors. R3 has range of motion impairment on one side of upper and no impairment on lower. R3 needs supervision for eating. R3 is dependent for showers, upper and lower dressing, mobility, and transfers. R4 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, with Mood Disturbance, Anxiety Disorder, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. R4 has an activated HCPOA. R4's Quarterly MDS completed 10/4/24 documents R4's BIMS score is 3, indicating R4 is severely impaired for daily decision making. R4's MDS documents that R4 has had physical behaviors for 1-3 days and verbal behaviors for 4-6 days. R4 has no range of motion impairment. R4 is independent with eating. R4's MDS documents that R4 requires substantial/maximum assistance for showers and mobility. R4 requires partial/moderate for upper body dressing. R4 is dependent for lower body dressing, transfers, and sit to stand. R3 and R4's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a Resident to Resident altercation where R4 wheeled up and punched R3 in the face on the right side and started cursing at R4 was submitted to the State Survey Agency on 9/26/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/29/24. On 10/29/24 at 2:45 PM, Nursing Home Administrator (NHA)-A informed Surveyor that NHA-A did not know the Misconduct Incident Report was not submitted to the State Survey Agency for R3 and R4's Resident to Resident Altercation. NHA-A understands the concern that Surveyor communicated that R3 and R4's Resident to Resident altercation Misconduct Incident Report was not submitted to the State Survey Agency until 10/29/24. No additional information was provided by the facility.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** UNCORRECTED ON VERIFICATION VISIT Based on record review and staff interview, the facility did not ensure all allegations involving potential abuse (R58) and Resident to Resident altercation (R3 and R4) were thoroughly investigated for 3 of 3 reviewed self reports. * R58's Facility Reported Incident (FRI) dated 9/12/24 documents an allegation of R58 being raped along with R58 sustaining blunt force trauma to the chest. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. The FRI does not contain an investigation of the blunt force trauma. Facility Reported Incident (FRI) dated 10/16/24 documents an allegation of R58 being raped by a male caregiver. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report and a Misconduct Incident Report to the State Survey Agency. Consequently, the facility did not complete a thorough investigation of this allegation. * R3 and R4's Facility Reported Incident (FRI) dated 10/29/24 documents an allegation of R4 wheeling up and punching R3 on the right side of the face and cursing at R3. The FRI does not contain other resident statements, all staff statements, the reasoning for why the local law enforcement was not notified, or a root cause analysis of the circumstances of the allegation. Staff statements were not obtained prior to the incident to evaluate both R3 and R4's pattern of behavior/agitation prior to Resident to Resident altercation. Findings Include: Surveyor reviewed the facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation policy and procedure last revised 2/2020 and notes the following in regards to a thorough investigation: Thorough investigation and corrective action ensures that the safety of the Resident has not been jeopardized. Purpose -Facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) -Thorough investigation and corrective action ensures that the safety of the Resident has not been jeopardized. -Corrective action will be taken when appropriate. Guidelines 2. Assess the Effect on the Resident a. The Resident(s) must be interviewed and a body assessment completed as necessary. b. An assessment for psychosocial changes will be completed and document findings. c. Physician is made aware, as needed. Family is made aware if appropriate. Case management organizations notified as needed. d. Follow-up Resident interviews should be conducted. 2. Investigate the Allegation a. Contact law enforcement or other regulatory authority if appropriate. b. Obtain written, signed statements from all witnesses or persons with information. c. Obtain a written, signed statement from the accused individual. 4. Conclude the Investigation a. Review all components of the investigation. b. Inform accused caregiver that a report to another agency has been submitted. If the accused is a Resident, inform Resident and responsible party of the report to DQA has occurred. c. The conclusion must be written on the Investigation Summary form once employee interviews and a chart review have been completed. 5. Follow-up a. All the completed forms must be submitted to the Director of Nursing/designee. b. Contact the person who reported the incident. c. Reassure the Resident and family if the caregiver. e. If Resident to Resident abuse has occurred, Social Services will work with Residents and their responsible parties to determine if relocation/other interventions are needed. 1.) R58's admission Minimum Data Set (MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 requires partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. Surveyor reviewed the Misconduct Incident Report submitted to the State Survey Agency dated 9/12/24. On 9/3/24, R58 voiced an allegation of being raped and punched in the chest. The facility did not obtain all staff statements. The facility did not obtain any resident statements to determine if there was a pattern. R58's emergency room documentation dated 9/4/24 documents a diagnosis of blunt force trauma. The facility's Misconduct Incident Report summary does not document a thorough investigation of the R58's diagnosis of blunt force trauma was completed. Surveyor reviewed the Misconduct Incident Report submitted to the State Survey Agency dated 10/16/24. On 9/26/24, R58 made an allegation that R58 had been raped by a male caregiver. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. On 10/15/2024, it is documented in R58's electronic medical record (EMR) that R58 contacted the police department and stated R58 was assaulted over the weekend. Management has been made aware. On 10/15/24, R58 called the police alleging an assault had taken place over the weekend. The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report and a Misconduct Incident Report to the State Survey Agency. The facility did not complete a thorough investigation of this allegation. On 10/29/24 at 2:45 PM, Surveyor shared the concern that thorough investigations had not been completed with R58's allegations. Nursing Home Administrator (NHA)-A was not aware of R58's allegation of assault on 10/15/24. NHA-A stated maybe NHA-A triggered R58 to say that when NHA-A had questioned R58 about the 9/26/24 allegation of being raped by a male caregiver. On 10/30/24 at 3:07 PM, Surveyor shared the concern again with NHA-A that a thorough investigation has not been completed in regards to R58's allegations. NHA-A agreed and stated that NHA-A did not like how the investigation was completed. No further information was provided by the facility at this time. 2.) R3 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Severe, with Other Behavioral Disturbance, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Unspecified Atrial Fibrillation, and Unspecified Protein-Calorie Malnutrition. R3 has an activated Health Care Power of Attorney (HCPOA). R3's Quarterly Minimum Data Set (MDS) completed 8/14/24 documents R3's Brief Interview for Mental Status (BIMS) score to be 0, indicating R3 is severely cognitively impaired for daily decision making. R3 has no behaviors. R3 has range of motion impairment on one side of upper and no impairment on lower. R3 needs supervision for eating. R3 is dependent for showers, upper and lower dressing, mobility, and transfers. R4 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia, Unspecified Severity, with Mood Disturbance, Anxiety Disorder, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. R4 has an activated HCPOA. R4's Quarterly MDS completed 10/4/24 documents R4's BIMS score to be a 3, indicating R4 is severely impaired for daily decision making. R4's MDS documents that R4 has had physical behaviors for 1-3 days and verbal behaviors for 4-6 days. R4 has no range of motion impairment. R4 is independent with eating. R4's MDS documents that R4 requires substantial/maximum assistance for showers and mobility. R4 requires partial/moderate for upper body dressing. R4 is dependent for lower body dressing, transfers, and sit to stand. On 9/18/24, R4 wheeled up to R3 and punched R3 on the right side of the face and started cursing at R3 in the dining room while both were waiting for dinner. A staff statement documented that R4 did not like how loud R3 had been during the day. The facility did not obtain staff statements from the day shift to establish a pattern of behavior or possible increased agitation from either R4 or R3. The facility did not obtain any resident statements and the facility did not notify the police of the Resident to Resident altercation. The facility did not complete a Misconduct Incident Report until 10/29/24, when Surveyor brought it to the facility's attention. The Misconduct Incident Report does not include a thorough investigation of the Resident to Resident altercation. On 10/29/24 at 2:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to R3 and R4's Resident to Resident altercation. NHA-A informed Surveyor that NHA-A was not aware that a Misconduct Incident Report had not been submitted. NHA-A stated the former Director of Nursing made that decision. NHA-A stated that R3 can be vocal and stated that R3's Broda chair is up higher than R4 in the wheelchair and does not think R4 could have caused any injury to R3. NHA-A did inform Surveyor that R4 hit R3 with an open hand. On 10/30/24 at 3:07 PM, Surveyor shared the concern with NHA-A that R3 and R4's Resident to Resident altercation was not thoroughly investigated. Surveyor asked NHA-A why the police had not been notified. NHA-A stated, That's a good question. NHA-A understands the concern of the facility not completing a thorough investigation and provided no further information at this time. No additional information was provided.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R58) of 1 Resident reviewed with PASARR level 2 recommendations. *R58's PASARR dated 10//21/24 determination states R58 requires specialized psychiatric rehabilitation services to address R58's mental illness. Findings Include: The facility's policy Resident Assessment-Coordination with PASARR Program dated 10/22/21 documents: Policy: This facility coordinates assessments with the preadmission screening and resident review(ASA) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level 1-Initial pre-screening that is completed prior to admission i. Negative Level 1 Screen-permits admission to proceed with and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level 1 Screen-necessitates PASARR Level 11 evaluation prior to admission b. PASARR Level 11-a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 5. If a Resident who not screened due to an exception above and the Resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level 1 screening process and refer to any Resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level 11 PASARR evaluation and determination. b. The Level 11 Resident review must be completed within 40 days of admission. 6. The Social Services shall be responsible for keeping track of each Resident's PASARR screening status, and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level 11 determination and/or PASARR evaluation report will be incorporate into the Resident's assessment, care planning, and transitions of care. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there is 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's admission Minimum Data Set(MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58 has not been assessed for a new MDS since admission. On 8/9/24, R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On 9/27/24, Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On 10/1/24, Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's current physician orders documents R58 is prescribed: -Buspar 9/24/24 -Duloxetine 7/16/24 -Remeron 10/22/24 -Seroquel 10/8/24 R58's original Level 1 PASARR screen dated 7/15/24 documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level 1 PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level 1 PASARR screen was re-submitted on 10/16/24 documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. R58's Level 11 PASARR Evaluation Summary dated 10/21/24 documents: .R58 was referred due to R58's diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, Delusional Disorder, and Adjustment Disorder with Mixed Disturbance of Emotions. R58 currently receives Buspar, Duloxetine, Remeron, Seroquel and Gabapentin for Neuropathy. R58 is in need of specialized psychiatric rehabilitation services(SPRS). The focus of SPRS is to maintain or improve current level of functioning. SPRS should include a thorough assessment of this individual's unique capabilities, psychiatric symptoms, and behaviors, if any, by a Qualified Mental Health Professional(QMHP). -frequently refuses care -displays paranoid and accusatory behavior towards others -frequent yelling out, threatening behavior noted -consulting psychiatrist completing medication review notes that: SNRI clinicians to monitor for worsening depression and suicidal ideation; Gabepetin history has been reportedly associated with rare cases of depression and suicidal ideation. R58 may benefit from group therapy, 1:1 talk therapy, medication management, coping skill/problem solving techniques, behavioral management, and therapy for building self esteem. R58's comprehensive care plan is noted not to be person-centered and does not incorporate the need for specialized psychiatric rehabilitation services with person-centered interventions. All interventions except for one were implemented prior to the determination on 10/21/24 that R58 required specialized psychiatric rehabilitation services. R58's care plan documents with interventions: -Alteration in mood evidenced by intermittent episodes of anxious demeanor/verbalizations 8/1/24 No interventions have been updated since 10/22/24 -Resident has behavior problem due making untrue accusations of harm/abuse 9/5/24 No interventions have been updated since 9/5/24 -R58 experiences loneliness and/or isolation 9/6/24 No interventions have been updated since 9/6/24 -R58 is resistive to care bedside cares due to adjustment to nursing home 9/6/24 No interventions have been updated since 9/18/24 -R58 is at risk for signs/symptoms of resident relocation stress syndrome 9/25/24 No interventions have been updated since 9/25/24 -R58 has potential to be verbally aggressive due to ineffective coping skills, mental/emotional illness 10/15/24 No interventions have been updated since 10/15/24 -Potential for anxiety due to traumatic life event due to sexual assault 10/15/24 No interventions have been updated since 10/18/24 Surveyor notes there have been no updated person centered interventions for R58 since 9/5/24. Surveyor notes that R58's comprehensive care plan is concentrated on R58's behaviors and what is perceived as R58's negative responses to facility interventions. The facility has not examined why R58 may be responding to triggering situations or boundaries in what the facility perceives as 'behaviors', thus the facility has not facilitated R58 to increase self independence physically and emotionally or promote physical and emotional health overall. On 10/30/24, at 10:26 AM, Surveyor interviewed Social Worker (SW)-C in regards to R58's Level 11 PASARR determination for the need for specialized psychiatric rehabilitation services. SW-C informed Surveyor that Psychologist (Psych)-D would continue to see R58 for the next 30 days. SW-C is not aware of any other services that are being provided to R58. SW-C confirmed that SW-C is not a QMHP. SW-C also confirmed that the IDT has not worked together to develop a person-centered care plan to include the need for specialized psychiatric rehabilitation services. On 10/30/24, at 11:20 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who cares for R58 on a regular basis. LPN-G informed Surveyor that LPN-G is not aware that R58 requires specialized psychiatric rehabilitation services and has not been oriented to person-centered interventions to help decrease and approach R58's behaviors. On 10/30/24, at 12:45 PM, Surveyor interviewed Psych-D. Psych-D stated that R58's behavior has deteriorated since being admitted to the facility. R58 is very angry, anxious, and depressed. R58 has had limited episodes of delusions and paranoia. Psych-D was notified about a week ago that R58 required specialized psychiatric rehabilitation services, however, the plan was for Psych-D to see R58 on a weekly basis for 4 weeks at a time. Psych-D stated Psych-D was already treating R58 and stated nothing will change for treatment for R58. Psych-D also informed Surveyor that Psych-D has not been asked to be a part of any IDT discussion of R58's need for specialized psychiatric rehabilitation services. On 10/30/24, at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58's Level 11 PASARR determination found R58 requires specialized psychiatric rehabilitation services. Surveyor shared there is no documentation that specialized psychiatric rehabilitation services has been developed and implemented through R58's assessment, care planning, and transitions of care. NHA-A stated NHA-A is not familiar with specialized psychiatric rehabilitation services and questioned if the facility could provide specialized psychiatric rehabilitation services. NHA-A understands the concern and has no further information at this time. On 10/31/24, at 1:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J. CNA-J does not know what specialized psychiatric rehabilitation services and how it relates to R58. CNA-J stated it would be good to have an IDT meeting to discuss R58's behaviors and how to approach R58. CNA-J stated R58 is not motivated to do anything at this time. On 10/31/24, at 2:57 PM, Surveyor interviewed Psychiatrist (Psych)-E. Psych-E confirmed Psych-E has evaluated R58 for medication review. Psych-E was not notified that R58 requires and would benefit from specialized psychiatric rehabilitation services. On 10/31/24, LPN-F informed Surveyor of the following: I wish R58 would get a mental health evaluation and treatment. I wish R58 would get help. The facility assessment reviewed 6/13/24 documents that the facility is capable of caring for Residents with Major Depressive Disorder, Single Episode. Of all the Residents, 56% have a psychiatric diagnosis. Psychology services are provided. Quarterly IDT behavior management meetings are held to discuss both non-pharmacological and pharmacological interventions to assist with achieving the Resident's highest practical mental well being. The facility has a comprehensive process to assess Resident needs. The facility utilizes a comprehensive admission, readmission, and required assessment process in which the IDT identifies individualized Resident care needs. On 10/30/24, at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58's Level 1 PASARR screen which documented R58 was admitted to the facility on a 30 day exemption should have re-submitted no later that 8/25/24. Surveyor shared that a new Level 1 PASARR screen for R58 was not submitted until 10/16/24, which determined that R58 requires specialized psychiatric rehabilitation services. NHA-A understood the concern. No additional information was provided.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder for 1 (R58) of 1 residents reviewed for PASARR screening. * R58 was admitted on [DATE] and the Level I PASARR was completed indicating R58 would be in the skilled nursing facility for less than 30 days. R58 is currently a Resident in the facility. A Level I PASARR was not resubmitted/updated indicating R58 was going to be at the facility longer than the 30 exemption period triggering a Level II PASARR to be completed until 10/16/24. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. Findings include: The facility's policy Resident Assessment-Coordination with PASARR Program dated 10/22/21 documents: Policy: This facility coordinates assessments with the preadmission screening and resident review(ASA) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receive care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level 1-Initial pre-screening that is completed prior to admission i. Negative Level 1 Screen-permits admission to proceed with and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. Positive Level 1 Screen-necessitates PASARR Level 11 evaluation prior to admission b. PASARR Level 11-a comprehensive evaluation by the appropriate state-designated authority that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 5. If a Resident who not screened due to an exception above and the Resident remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level 1 screening process and refer to any Resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level 11 PASARR evaluation and determination. b. The Level 11 Resident review must be completed within 40 days of admission. 6. The Social Services shall be responsible for keeping track of each Resident's PASARR screening status, and referring to the appropriate authority. 7. Recommendations, such as any specialized services, from a PASARR level 11 determination and/or PASARR evaluation report will be incorporate into the Resident's assessment, care planning, and transitions of care. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there is 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's admission Minimum Data Set(MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58 has not been assessed for a new MDS since admission. On 8/9/24, R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On 9/27/24, Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On 10/1/24, Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's current physician orders documents R58 is prescribed: -Buspar 9/24/24 -Duloxetine 7/16/24 -Remeron 10/22/24 -Seroquel 10/8/24 R58's original Level 1 PASARR screen dated 7/15/24 documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level 1 PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level 1 PASARR screen was re-submitted on 10/16/24 documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. On 10/30/24, at 9:29 AM, Surveyor interviewed Admissions Director (AD)-H who confirmed AD-H is responsible for the Level 1 and Level 11 PASARR screens. AD-H explained that the Level 1 PASARR screen is completed at time of admission. Once the results of the screen is forwarded from the state agency, social services is notified of the determination. AD-H was notified by MDS Coordinator (MDS)-O that R58 needed a new Level 1 PASARR screen completed. AD-H stated, R58's Level 1 PASARR screen may have been over the 30 day exemption period. On 10/30/24, at 10:26 AM, Social Worker (SW)-C confirmed that SW-C is alerted of Level 11 PASARR determinations. SW-C stated SW-C believes the breakdown in the process was that R58's HCPOA was being activated. On 10/30/24, at 10:37 AM, Surveyor interviewed MDS-O who stated MDS-O checked the status of R58's Level 1 PASARR screen determination because the Interdisciplinary Team(IDT) was discussing R58's behaviors. I looked to see R58's Level 1 PASARR screen and noticed R58's Level PASARR screen was past the 30 day exemption. I sent AD-H an email right away which was on 10/16/24. On 10/30/24, at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58's Level 1 PASARR screen which documented R58 was admitted to the facility on a 30 day exemption should have re-submitted no later that 8/25/24. Surveyor shared that a new Level 1 PASARR screen for R58 was not submitted until 10/16/24, which determined that R58 requires specialized psychiatric rehabilitation services. NHA-A understood the concern. No additional information was provided as the facility did not complete a Preadmission Screening and Resident Review (PASARR) for R58.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** UNCORRECTED ON VERIFICATION VISIT Based on interview and record review, the facility did not update the person-centered care plan and ensure the comprehensive care plan was implemented to meet a resident's psychosocial needs for 1 (R58) of 1 resident. * R58's comprehensive care plan has not been updated with person-centered interventions including incorporating Level II PASARR recommendations of requiring 'specialized psychiatric rehabilitation services'. Findings Include: The facility policy titled Comprehensive Care Plans revised 9/23, documents: .Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The facility policy Care Plan Revisions Upon Status implemented 9/21 documents: .Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those Residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a Resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a Resident experiences a status change: b. The MDS Coordinator and the the IDT(Interdisciplinary Team) will discuss the Resident condition and collaborate on intervention options. c. The team meeting discussion will be documented in the nursing progress notes. d. The care plan will be updated with the new or modified interventions. e. Staff involved in the care of the Resident will report Resident response to new or modified interventions. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the Resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all Residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect Resident needs. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney (HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there are 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's admission Minimum Data Set (MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. R58's original Level I PASARR screen dated 7/15/24 documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level I PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level I PASARR screen was resubmitted on 10/16/24 documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. R58's Level 11 PASARR Evaluation Summary dated 10/21/24 documents: R58 was referred due to R58's diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, Delusional Disorder, and Adjustment Disorder with Mixed Disturbance of Emotions. R58 currently receives Buspar, Duloxetine, Remeron, Seroquel and Gabapentin for Neuropathy. R58 is in need of specialized psychiatric rehabilitation services(SPRS). The focus of SPRS is to maintain or improve current level of functioning. SPRS should include a thorough assessment of this individual's unique capabilities, psychiatric symptoms, and behaviors, if any, by a Qualified Mental Health Professional(QMHP). -frequently refuses care -displays paranoid and accusatory behavior towards others -frequent yelling out, threatening behavior noted -consulting psychiatrist completing medication review notes that: SNRI clinicians to monitor for worsening depression and suicidal ideation; Gabapentin history has been reportedly associated with rare cases of depression and suicidal ideation. R58 may benefit from group therapy, 1:1 talk therapy, medication management, coping skill/problem solving techniques, behavioral management, and therapy for building self esteem. R58's comprehensive care plan is noted not to be person-centered and does not incorporate the need for specialized psychiatric rehabilitation services with person-centered interventions. All interventions except for one were implemented prior to the determination on 10/21/24 that R58 required specialized psychiatric rehabilitation services. (Cross Reference F644 and F645) R58's admission MDS completed 7/22/24 documents that active discharge planning is in the process. R58's comprehensive care plan includes the following documentation: R58 would like to discharge home-Initiated 7/16/24 On 8/1/24, R58's care plan was revised and documented R58 would like to discharge to the most appropriate level of care. Interventions: Encourage R58 to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. 7/16/24. Evaluate R58's motivation and ability to safely return to the community 7/16/24 : Evaluate/record R58's abilities and strengths, with family/caregivers/Interdisciplinary Team(IDT). Determine gaps in abilities which affect discharge. Address gaps by making community referral, pre-discharge PT/OT(physical/occupational therapy) or internal referral 7/16/24 Surveyor notes R58's discharge plans have not been updated since 7/16/24 and per documented care plan interventions it has not been updated at a minimum of every quarter. (Cross Reference F660) R58's care plan documents with interventions: -Alteration in mood evidenced by intermittent episodes of anxious demeanor/verbalizations 8/1/24 No interventions have been updated since 10/22/24 -Resident has behavior problem due making untrue accusations of harm/abuse 9/5/24 No interventions have been updated since 9/5/24 -R58 experiences loneliness and/or isolation 9/6/24 No interventions have been updated since 9/6/24 -R58 is resistive to care bedside cares due to adjustment to nursing home 9/6/24 No interventions have been updated since 9/18/24 -R58 is at risk for signs/symptoms of resident relocation stress syndrome 9/25/24 No interventions have been updated since 9/25/24 -R58 has potential to be verbally aggressive due to ineffective coping skills, mental/emotional illness 10/15/24 No interventions have been updated since 10/15/24 -Potential for anxiety due to traumatic life event due to sexual assault 10/15/24 No interventions have been updated since 10/18/24 Surveyor noted there have been no updated person centered interventions for R58 since 9/5/24. Surveyor noted that R58's comprehensive care plan is concentrated on R58's behaviors and what is perceived as R58's negative responses to facility interventions. The facility has not examined why R58 may be responding to triggering situations or boundaries in what the facility perceives as 'behaviors', thus the facility has not facilitated R58 to increase self independence physically and emotionally or promote physical and emotional health overall. On 10/30/24 at 10:26 AM, Surveyor interviewed SW-C. SW-C stated SW-C is responsible for discharge, mood, behavior, cognition, and code status care plans. SW-C confirmed the expectation is to make revisions. On 10/30/24 at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA-A) that R58's comprehensive care plan has not been revised with person-centered interventions to assist R58 in reaching the highest practicable psychosocial well-being, receiving 'specialized psychiatric rehabilitation services', discharge planning, and achieving emotional health. NHA-A understands the concern. No additional information was provided as to why the facility did not update the person-centered care plan and ensure the comprehensive care plan was implemented for R58.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop and implement an effective discharge planning process focusing on resident discharge goals, and preparation for transition for 1 (R58) of 1 residents reviewed for discharge planning. * R58 was admitted to the facility on [DATE] with a Left Femur Fracture with the goal to discharge home and/or a lesser restrictive environment. R58 has not had consistent and active discharge planning since admission. Findings Include: The facility's policy Transfer and discharge date d 10/21 documents: .The comprehensive, person-centered care plan shall contain the Resident's goals for admission and desired outcomes and shall be in alignment with the discharge. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor notes the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred 9/27/24, however, there is 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's admission Minimum Data Set(MDS) completed on 7/22/24 documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS since admission. R58's care plan documents: R58 would like to discharge home-Initiated 7/16/24 On 8/1/24, R58's care plan was revised and documented R58 would like to discharge to the most appropriate level of care. Interventions: Encourage R58 to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. 7/16/24. Evaluate R58's motivation and ability to safely return to the community 7/16/24 : Evaluate/record R58's abilities and strengths, with family/caregivers/Interdisciplinary Team(IDT). Determine gaps in abilities which affect discharge. Address gaps by making community referral, pre-discharge PT/OT(physical/occupational therapy) or internal referral 7/16/24 The following is documented is regards to R58's discharge planning: 7/19/24 Care Conference Note documented by Social Worker (SW)-C: R58's goals are to move back in R58's apartment independently. 7/31/2024 IDT Medicare A Meeting documented by Registered Nurse (RN)-Q: Goal to discharge home with son. Plan B looking into assistive living facility. SW-C documented on 10/9/24 that HCPOA was contacted in regards to goals of care for discharge. On 10/11/2024, SW-C documented that R58 was informed that no assistive living facility appropriate then SW-C will work to find a long term care placement at another facility that fits R58's needs. At this time, R58 will remain in the facility until the next care conference and decision on long term care placement. On 10/15/2024, SW-C documented that SW-C will make referrals for long term care at another facility per R58's request. Surveyor notes there is no other documentation that referrals have been made in regards to whether or not R58 is assistive living appropriate or that referrals have been made to other long term care facilities per R58's request. On 10/29/24 at 11:40 AM, Surveyor interviewed R58. R58 informed Surveyor that R58 wishes to be discharged . R58 stated: I can't take it. I just lay in bed and watch the leaves come off the trees. Its pure misery. No one gives a crap. I can't stay here. Its making me crazy. Surveyor observed R58 crying throughout the interview. On 10/30/24 at 10:26 AM, Surveyor interviewed SW-C. SW-C informed Surveyor that no one will take R58 because of R58's behaviors. SW-C stated referrals have been sent to other facilities. On 10/30/24 at 12:45 PM, Surveyor interviewed Psychologist (Psych)-D. Psych-D stated that R58 has told Psych-D multiple times that R58 does not want to be at the facility. On 10/31/24, Surveyor reviewed R58's electronic medical record(EMR) again and notes there is no documentation that SW-C has sent out referrals to other facilities. On 10/30/24 at 1:10 PM, Surveyor interviewed R58 again. R58 informed Surveyor: I don't know what to do anymore. I hate it here. I want to leave desperately. Surveyor observed R58 crying throughout the interview. On 10/30/24 at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that documentation of active discharge planning has not occurred for R58. Surveyor reviewed that R58's discharge care plan is not person-centered and has not been updated with interventions to ensure R58 has a safe discharge to the most appropriate placement. NHA-A stated that NHA-A believed SW-C was finding a place for R58, but no one will take R58 because of R58's behaviors. Surveyor shared the concern that R58 clearly does not want to be at the facility, and R58's psychosocial well being continues to be at risk. SW-C has not actively assisted R1 to identify and prepare for alternate placement. NHA-A acknowledged the concern. On 10/31/24, at 10:29 AM, Surveyor interviewed SW-C again in regards to R58's discharge planning. SW-C stated that an outside agency completed a referral blast, however, there is no documentation of this. SW-C does not recall when this was completed and stated, if there is no documentation, then its not there. No additional information was provided.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R150) of 8 residents reviewed for ADL's (Activity of Daily Living). On 10/29/24, R150 was not provided with incontinence care every two hours and was observed with a saturated incontinence product. Findings include: The facility's policy titled, Incontinence and dated 10/21 under Policy Explanation and Compliance Guidelines documents 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. 1.) R150's was admitted to the facility with a diagnosis that includes diabetes mellitus, chronic kidney disease, history of malignant neoplasm of prostate, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side, quadriplegia and depression. The functional bladder incontinence care plan initiated 1/4/24 & revised 1/5/24 documents the following interventions: * Clean peri-area with each incontinence episode. Initiated 1/4/24. * Encourage fluids during the day to promote prompted voiding responses. Initiated 1/4/24. * INCONTINENT: Check Q (every) 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. Initiated 1/4/24. The Urinary Incontinence and Indwelling Catheter CAA (care area assessment) dated 1/16/24 under analysis of findings for nature of the problem/condition documents During the look back period, [150's first name] was incontinent of urine. He requires assistance with bed mobility, sit up at edge of bed, and transfers. Currently using EZ stand to transfer. He also requires assistance with toileting cares, dressing and bathing/showering. He was admitted following long hospitalization for sepsis associated MSSA (methicillin resistant staphylococcus aureus) bacteremia d/t (due to) poor source control from previous cellulitis leading to infective endocarditis, and complicated by GI (gastrointestinal) bleeding and acute ischemic septic emboli associated infarcts involving L (left) caudate and R (right) cerebellum. Has residual L sided hemiplegia/hemiparesis. Other diagnosis includes Polyneuropathy, cramps and spasms, acute posthemorrhagic anemia, HTN (hypertension), CKD (chronic kidney disease), PDM (personal diabetes manager) with diabetic nephropathy, hyperlipidemia, depression and GERD (gastroesophageal reflux disease). He receives daily scheduled antihypertensives, antiplatelet, statin, antidepressant, diuretic, PPI (proton pump inhibitors), oral hypoglycemic, insulin, and multivitamin and potassium supplements. The Quarterly MDS (minimum data set) with an assessment reference date of 10/11/24 has a BIMS (brief interview mental status) score of 15 which indicates that R150 is cognitively intact. R150 is assessed as not having any behavior including refusal of care. R150 is assessed as requiring partial/moderate assistance for toileting hygiene, and supervision or touching assistance for chair/bed to chair transfer & toilet transfer. R150 is frequently incontinent of urine and bowel. The CNA (Certified Nursing Assistant) Visual/Bedside [NAME] Report as of 10/29/24 under the Bladder/Bowel section documents * INCONTINENT: Check Q 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes. Under the Toileting section documents * Check resident every two hours and assist with toileting as needed. * Clean peri-area with each incontinence episode. * Provide pericare after each incontinent episode. * TOILET USE: The resident requires min (minimal) assist. On 10/29/24 at 9:45 a.m., Surveyor spoke with R150 who was sitting in a wheelchair in his room. R150 informed Surveyor his progress is slow as he had a massive stroke. R150 informed Surveyor he can pivot out of bed with staff and a gait belt. R150 informed Surveyor he uses the toilet in his room and uses the call light. R150 informed Surveyor staff used to answer his call light right away but now it takes a minute. On 10/29/24 at 10:47 a.m., Surveyor observed R150 sitting in the wheelchair in his room with his cell phone in his hand. On 10/29/24 at 1:07 p.m., Surveyor observed R150 sitting in the wheelchair in his room with his cell phone in his hand. On 10/29/24 at 1:48 p.m., Surveyor observed R150's call light on. Surveyor asked R150 why he placed his call light on. R150 informed Surveyor to go to the bathroom as he wants to go to a therapy group. On 10/29/24 at 1:49 p.m., Surveyor observed CNA (Certified Nursing Assistant)-K enter R150's room stating sorry I was with someone else. R150 informed CNA-K he wants to go to the bathroom. CNA-K placed a gait belt around R150, shut R150's room door, and removed the foot rests from R150's wheelchair. R150 wheeled himself into the bathroom. CNA-K placed gloves on, R150 placed his hands on the grab bar and assisted R150 to stand, lowered the incontinence product & shorts, and sit on the toilet. CNA-K removed R150's incontinence product which Surveyor observed was saturated with urine. CNA-K removed her gloves, asked R150 if he was going to be awhile, and washed her hands. R150 informed CNA-K about 5 minutes. CNA-K closed the bathroom door indicating she would give R150 privacy. Surveyor asked CNA-K what is R150's routine for toileting. CNA-K informed Surveyor R150 usually let us know. Surveyor informed CNA-K Surveyor observed R150's incontinence product was pretty saturated with urine. CNA-K informed Surveyor she usually checks R150 every two hours but that didn't happen today. CNA-K informed Surveyor R150 dribbles urine and usually puts his call light on. Surveyor asked CNA-K why she didn't check R150 every two hours. CNA-K replied this is my fault, I should of ask if he was wet or has to go. On 10/29/24 at 1:57 p.m., R150 placed on his call light & CNA-K entered the bathroom. On 10/30/24 at 11:09 a.m., Surveyor asked R150 yesterday when Surveyor observed [name of CNA-K] assist him with going to the bathroom prior to going to group therapy had he been to the bathroom before this time. R150 informed Surveyor once when he got up. Surveyor verified with R150 he was taken to the bathroom when he first got up and then when Surveyor observed prior to going to the group therapy. R150 replied yes. On 10/31/24 at 11:43 p.m., Surveyor asked LPN/UM (Licensed Practical Nurse/Unit Manager)-L what is the expectation if a Resident's care plan has they should be checked every two hours. LPN/UM-L informed Surveyor they should be changed every two hours. Surveyor informed LPN/UM-L of the observation on 10/29/24 with R150's incontinence product being saturated with urine and was not checked every two hours. On 10/31/24, at 12:21 p.m., NHA (Nursing Home Administrator)-A & DON (Director of Nursing)-B were informed of R150's incontinence product being saturated with urine and not being check & changed every two hours according to the care plan and [NAME]. No additional information was provided to Surveyor as to why R150, whom is unable to carry out activities of daily living, received the necessary services to maintain good grooming.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review, the facility did not ensure 1 (R58) of 4 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being. * R58 has a history of trauma as identified in a trauma assessment completed on [DATE]. The facility social worker (SW)-C did not establish an individualized plan of care to address R58's trauma. On [DATE], a Level II PASARR screen determined that R58 requires specialized psychiatric rehabilitation services to promote the highest practicable psychosocial well-being for R58. The facility did not update R58's comprehensive care plan with person-centered interventions. SW-D has not actively assisted R58 to identify and prepare for alternate placement. Findings include: 1.) Surveyor requested a medically related social service policy and procedure and the facility was not able to provide a policy to Surveyor. The facility's assessment review completed [DATE] documents: .The facility is capable of caring for Residents with Major Depressive Disorder, Single Episode. Of all the Residents, 56% have a psychiatric diagnosis. Psychology services are provided. Quarterly IDT behavior management meetings are held to discuss both non-pharmacological and pharmacological interventions to assist with achieving the Resident's highest practical mental well being. The facility has a comprehensive process to assess Resident needs and determine required care and services. The facility utilizes a comprehensive admission, readmission, and required assessment process in which the IDT identifies individualized Resident care needs. Over the past year, the facility has developed numerous customized assessments, such as a Behavioral Intervention Summary, a GPEP Behavioral Assessment, and a Smoking Assessment. Due to out patient population and facility workflow, we also developed facility-specific Baseline Care Plans and Discharge Instructions. R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). Surveyor noted the facility was not able to provide Surveyor with documentation of the competency evaluation of R58 that determined R58 was no longer able to make health care decisions for herself. It appears activation of the HCPOA may have occurred [DATE], however, there are 3 different activation forms with different activation dates. The facility was not able to clarify the activation date to Surveyor at time of survey. R58's admission Minimum Data Set(MDS) completed on [DATE] documents R58's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R58 is cognitively intact for daily decision making. At the time of the assessment, R58 had no behaviors and was demonstrating minimal depression. R58's MDS documents R58 has range of motion impairment on one side of upper and lower extremities. R58 is independent with eating. R58 requires substantial/maximum assistance for showers/bathing and lower dressing. R58 is supervision for upper dressing and R58 is requiring partial/moderate assistance with mobility and transfers. R58's MDS also documents that R58 is to be discharged to the community, a referral has been made, and R58 has a discharge plan. R58 has not been assessed for a new MDS assessment since admission. On [DATE], R58 was evaluated by Psychologist (Psych)-D who diagnosed R58 with Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent, Moderate. On [DATE], Psych-D documents a diagnosis of Psychotic Disorder with Delusions for R58 after a regular psychology visit. On [DATE], Psychiatrist (Psych)-E agreed with the Adjustment Disorder with Depressed Mood and Major Depressive Disorder, Recurrent Diagnoses and added Generalized Anxiety Disorder and Unspecified Dementia, Unspecified Severity with Mood Disturbance as a diagnosis. R58's current physician orders documents R58 is prescribed: -Buspar [DATE] -Duloxetine [DATE] -Remeron [DATE] -Seroquel [DATE] Surveyor reviewed R58's Medication Administration Record(MAR). The MAR is directed to record behaviors in relation to medications. However, Surveyor notes that R58's MAR were not accurately completed. R58's MAR based on documentation indicates that R58 has had no behaviors since admission to the facility. R58's electronic medical record(EMR) does not document frequent behaviors or interventions applied to R58's behavior. R58's original Level 1 PASARR screen dated [DATE] documents R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. R58's Level 1 PASARR screen documents R58 is only expected to be at the facility 30 days or less. A new Level 1 PASARR screen was re-submitted on [DATE] documenting R58 has a major mental disorder and is receiving psychotropic medications for symptoms or behaviors of a major mental illness. On [DATE], it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness. R58's Level II PASARR Evaluation Summary dated [DATE] documents: R58 was referred due to R58's diagnoses of Major Depressive Disorder, Generalized Anxiety Disorder, Adjustment Disorder with Depressed Mood, Delusional Disorder, and Adjustment Disorder with Mixed Disturbance of Emotions. R58 currently receives Buspar, Duloxetine, Remeron, Seroquel and Gabapentin for Neuropathy. R58 is in need of specialized psychiatric rehabilitation services(SPRS). The focus of SPRS is to maintain or improve current level of functioning. SPRS should include a thorough assessment of this individual's unique capabilities, psychiatric symptoms, and behaviors, if any, by a Qualified Mental Health Professional(QMHP). -frequently refuses care -displays paranoid and accusatory behavior towards others -frequent yelling out, threatening behavior noted -consulting psychiatrist completing medication review notes that: SNRI clinicians to monitor for worsening depression and suicidal ideation; Gabepetin history has been reportedly associated with rare cases of depression and suicidal ideation. R58 may benefit from group therapy, 1:1 talk therapy, medication management, coping skill/problem solving techniques, behavioral management, and therapy for building self esteem. R58's comprehensive care plan is noted not to be person-centered and does not incorporate the need for specialized psychiatric rehabilitation services with person-centered interventions. All interventions except for one were implemented prior to the determination on [DATE] that R58 required specialized psychiatric rehabilitation services. (Cross Reference F644 and F645) R58's care plan documents with interventions: -Alteration in mood evidenced by intermittent episodes of anxious demeanor/verbalizations [DATE] No interventions have been updated since [DATE] -Resident has behavior problem due making untrue accusations of harm/abuse [DATE] No interventions have been updated since [DATE] -R58 experiences loneliness and/or isolation [DATE] No interventions have been updated since [DATE] -R58 is resistive to care bedside cares due to adjustment to nursing home [DATE] No interventions have been updated since [DATE] -R58 is at risk for signs/symptoms of resident relocation stress syndrome [DATE] No interventions have been updated since [DATE] -R58 has potential to be verbally aggressive due to ineffective coping skills, mental/emotional illness [DATE] No interventions have been updated since [DATE] -Potential for anxiety due to traumatic life event due to sexual assault [DATE] No interventions have been updated since [DATE] Surveyor notes there have been no updated person centered interventions for R58 since [DATE]. Surveyor notes that R58's comprehensive care plan is concentrated on R58's behaviors and what is perceived as R58's negative responses to facility interventions. The facility has not examined why R58 may be responding to triggering situations or boundaries in what the facility perceives as 'behaviors', thus the facility has not facilitated R58 to increase self independence physically and emotionally or promote physical and emotional health overall. (Cross-reference F657). Discharge Planning: R58's admission MDS completed [DATE] documents that active discharge planning is in the process. R58's comprehensive care plan includes the following documentation: R58 would like to discharge home-Initiated [DATE] On [DATE], R58's care plan was revised and documented R58 would like to discharge to the most appropriate level of care. Interventions: Encourage R58 to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress. [DATE]. Evaluate R58's motivation and ability to safely return to the community [DATE] : Evaluate/record R58's abilities and strengths, with family/caregivers/Interdisciplinary Team(IDT). Determine gaps in abilities which affect discharge. Address gaps by making community referral, pre-discharge PT/OT(physical/occupational therapy) or internal referral [DATE] Surveyor notes R58's discharge plans have not been updated since [DATE] and per documented care plan interventions it has not been updated at a minimum of every quarter. (Cross Reference F660) R58's social history completed on [DATE] was completed 35 days after admission to the facility. The social history does not evaluate any psychosocial information pertinent to R58 maintaining the highest practicable physical, mental, and psychosocial well-being. A Brief Trauma Questionnaire was completed on [DATE]. The Trauma assessment documents R58 has had trauma that has impacted R58. Surveyor notes that this was not addressed by Social Worker (SW)-C and incorporated into R58's person-centered care plan with interventions. In response to R58's allegations of sexual misconduct, the facility developed a behavior problem outlining R58 making untrue accusations of harm/abuse on [DATE]. On [DATE], a care plan was implemented documenting R58 has the potential for anxiety due to traumatic life event due to sexual assault after the facility learned of past sexual traumatic events in R58's life. A new trauma assessment was not completed and a person-centered care plan was not implemented. On [DATE], Social Worker (SW)-C documented in R58's EMR that R58 continues to have behaviors and that R58 appears depressed. On [DATE] at 11:40 AM, Surveyor interviewed R58. R58 was at times crying during the interview and Surveyor observed facial grimacing. R58 stated R58 wants to be discharged . Its been pure misery. I can't take it. I just lay in bed and watch the leaves come off the trees through the window. What a life to wake up and count the leaves falling all day. No one gives a crap. I can't stay here. Its making me crazy, crazier than I've ever been. On [DATE] at 10:26 AM, Surveyor interviewed SW-C. SW-C informed Surveyor that SW-C would not complete a new trauma assessment even after learning of new identified trauma. SW-C stated SW-C is responsible for discharge, mood, behavior, cognition, and code status care plans. SW-C stated that R58 is so complex and a sad case. SW-C stated that R58 is accusatory, depressed, and has refusals of cares. SW-C stated R58 has mental health issues and is stuck in a mental health crisis. SW-C believes R58 just wants to be heard. On [DATE] at 11:20 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G regarding R58. LPN-G stated LPN-G frequently takes care of R58. LPN-G stated that R58 requires a lot of reassurance and benefits from physical comfort touch. LPN-G also shared that R58 enjoys compliments. LPN-G confirmed that R58 has not gotten out of bed in a long time. On [DATE] at 12:45 PM, Surveyor interviewed Psychologist (Psych)-D. Psych-D has been treating R58 on a weekly basis. Psych-D stated that R58 shared with Psych-D that there was an incident from the past but will not elaborate at this time. Psych-D recommended to the facility that staff complete cares with the 'buddy system'. On [DATE], at 1:10 PM, Surveyor interviewed R58 again. R58 shared that R58 attempted to speak to daughter on the phone this morning, but was not able to finish the conversation because R58 was crying so much. R58 shared that R58 woke up thinking about R58's oldest son who died of COVID. R58 stated, Who would think retirement would be like this. I hate it here. On [DATE] at 1:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J. CNA-J confirmed that R58 is on the buddy system for cares. CNA-J stated that R58 is not motivated to do anything and is not getting out of bed. On [DATE] at 2:57 PM, Surveyor interviewed Psychiatrist (Psych)-E who has evaluated R58 two times. Psych-E described R58 as being very irritable. On [DATE], at 3:07 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R58 has not been provided medically related social services in order for R58 to maintain the highest practicable physical, mental, and psychosocial well-being. NHA-A informed Surveyor that a new trauma assessment should have been completed upon learning that R58 has past sexual trauma. NHA-A informed Surveyor that NHA-A believes the buddy system is triggering to R58 and NHA-A stated that it is clear that R58 does not want to be at the facility. NHA-A stated, I am concerned about R58. On [DATE], at 9:35 AM, Surveyor interviewed LPN-F. LPN-F informed Surveyor that LPN-F wished R58 would get a mental health evaluation and treatment. LPN-F stated that R58 is constantly on the call light and needs reassurance. On [DATE] at 9:54 AM, NHA-A explained how the licensed staff should be filling out the MAR in regards to behavior monitoring. NHA-A agreed that R58's MAR detailing R58's behaviors has not been filled out correctly thus it appears R58 has had no behaviors. Surveyor shared the concern with NHA-A that non-pharmalogical interventions have not been implemented in order for R58 to maintain the highest practicable physical, mental, and psychosocial well-being. NHA-A understands the concern and at this time, the facility did not provide any additional information.

Sept 2024 14 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Pressure Ulcer Prevention (Tag F0686)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], [NAME] Based on observation, record review and interviews, the facility did not ensure that 1 (R62) of 5 residents reviewed received care, consistent with professional standards of practice to prevent the development of pressure injures and or to promote healing, prevent infection and prevent additional pressure injuries from developing. * R62 developed a pressure injury on the right buttock on 6/30/24 that was not comprehensively assessed and did not have physician notification for a treatment until 7/10/24. R62's pressure injury declined during this time, and on 7/10/24, the wound physician assessed the pressure injury as unstageable. The wound physician ordered a debriding treatment. On 7/17/24, the pressure injury was mechanically debrided to a stage 4 pressure injury. R62 was not assessed for weight loss prior to this pressure injury development. Cross reference F692. The failure of the facility to provide services to prevent pressure injury development and to ensure prompt treatment created a finding of immediate jeopardy that began on 7/17/24. Surveyor notified the (Nursing Home Administrator) NHA-A on 9/04/24 at 9:11 AM. The immediate jeopardy was removed on 9/11/24. The deficient practice continues at a scope of severity of D (potential for harm/isolated) as the facility continues to implement its action plan. Findings include: The facility's policy and procedure dated 6/14/24 and titled Treatment/Services to Prevent/Heal Pressure Ulcer documents: Intent-The facility will ensure that based on a comprehensive assessment of a resident: a.) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and b.) A resident with pressure ulcers receives necessary treatment and services, consistent with a professional standards of practice, to promote healing, prevent infection and prevent new ulcers on developing. The (National Pressure Injury Advisory Panel) NPIAP 2019 Prevention and Treatment of Pressure Ulcers/Injuries state; Recommendations and Good Practice Statements: - Consider the impact of impaired nutritional status. - Develop and implement a risk-based prevention plan for individuals identified as being at risk for pressure injuries. - Develop and implement an individualized nutrition care plan for individuals with, or at risk of, of a pressure injury who are malnourished or who are at risk of malnutrition. - Conduct a comprehensive initial assessment of the individual with a pressure injury. 1.) R62 was admitted to the facility on [DATE] with diagnoses that included severe protein malnutrition, dysphasia and severed dementia. R62 has a (Power of Attorney for Healthcare) POA-HC that is activated. R62 admission (minimum data set) MDS assessment dated [DATE] documents that R62 is at risk for pressure injury. The assessment does not encompass the diagnosis of severe protein malnutrition for preventative interventions. R62 requires staff assist with mobility, transfers, incontinence care and assist with activities of daily living. R62's Significant Change in Status MDS dated [DATE] documents changes with eating and swallowing. R62 is at a risk for pressure injuries and Surveyor noted that there were no changes made to the plan of care for preventative measures. R62 Quarterly MDS assessment dated [DATE] does not encompass malnutrition and swallowing concerns. There are no changes to the pressure injury risk treatments as documented in the quarterly MDS. R62 had a severe weight loss of 13% from 3/13/24 to 3/20/24. There was not a comprehensive assessment for the development of a pressure injury. On 3/13/24, R62 weighed 125 lbs and 108 lbs on 3/20/24. R62 had a severe weight loss of 28% from 6/6/24 to 7/10/24. R62 on 6/6/24 weighed 102 lbs and on 7/10/24 weighed 73 lbs. R62 Braden Skin Assessments were reviewed. The Braden Skin scale is from 6- 23. The lower the number the higher the risk for pressure injury development. R62's Braden assessments document the following scores: - 2/13/24 a 15 a mild risk. - 2/20/24 a 14 a moderate risk. - 3/11/24 a 13 a moderate risk. - 4/7/24 a 13 a moderate risk. - 6/7/24 a 12 a high risk R62's plan of care Potential impairment to skin integrity related to nutrition, Alzheimer's dementia and decreased mobility date as initiated 2/13/24 documents under the interventions section: - 2/13/24 Encourage good nutrition and hydration in order to promote healthier skin. - 2/13/24 Turn and reposition every 2 - 3 hours and as needed while in bed. The next intervention initiated on 2/27/24 documents: - Apply house barrier cream every shift and/or with incontinence episodes; Keep skin clean and dry. Use lotion on dry skin. This intervention was added a week after R62's skin risk assessment changed from a mild risk to a moderate risk for skin ulcers. The following interventions were subsequently added: - 3/18/24 Use a draw sheet or lifting device to move resident. There is no change to the plan of care to prevent skin impairment with the severe weight loss on 3/20/24. - 6/14/24 Apply heel boots in bed. - 6/14/24 The resident needs pressure reducing EquaGel cushion to protect the skin while up in chair. (There is not documentation of what preventative measure was used in the chair prior to this intervention.) -6/18/24 The resident needs an air mattress to protect skin while in bed. (There is not documentation of the type of mattress.) On 8/28/24 at 2:48 PM, Surveyor interviewed NHA-A. NHA-A indicated the facility changed R62's wheelchair cushion to an EquaGel but stated that NHA-A did not have information on what had been in place prior to this. NHA-A changed the air mattress. NHA-A indicated that they will get the exact dates. NHA-A provided on paper that on 6/28/24 an alternating air mattress was added to the resident for a pressure prevention related to weight loss and poor nutritional intake and that an EquaGel cushion was ordered for the wheelchair. NHA-A stated that on 7/11/24, a Panncea low air loss mattress was put in place and a EquaGel II cushion was added. R62's Progress Note on 6/30/2024 documents: Writer called into room regarding right buttock skin issue. Area is 0.4 cm x 0.4 cm. Wound bed is white with no drainage. Surrounding skin has erythema. Area is on bony prominence. Placed Allevyn for protection until seen by wound care team for further assessment and treatment. R62's Skin Only Evaluation dated 6/30/2024 documents: Skin: Skin warm & dry, skin color WNL (with in normal limits), mucous membranes moist, turgor normal. Resident has current skin issues. Skin Issue: Pressure Ulcer / Injury. Skin Issue Location: right buttocks Pressure Ulcer / Injury Stage: Unstageable. Length: 0.4 cm Width (cm): 0.4 cm Depth: 0.1 Wound Bed: Epithelial. Wound Exudate: None. Peri Wound Condition: Erythema. Dressing Saturation: None. No wound odor. No tunneling. No undermining. Area found on right buttocks. Area is 0.4 cm x 0.4 cm. Wound bed is white with no drainage. Surrounding skin has erythema. Area is on bony prominence. Placed Allevyn for protection until seen by wound care team. Clinical Suggestions: Evaluated for pain, discomfort. Dressing changes/treatments performed as ordered. Resident is turned, ambulated, moved at least every 2 hours. PRN (as needed) medication administered and effectiveness evaluated. There is no documentation the physician was contacted for treatment on 6/30/24. The description of the wound bed is white with no percentage of coverage. The definition of a white wound bed is necrotic tissue. The necrotic tissue would need to be removed to promote healing of the wound. There is not a comprehensive assessment on 6/30/24 to identify possible causative factors. There were no changes in interventions to promote healing upon discovery. R62's progress note dated 7/2/2024 documents: Skin/Wound Note. This is a late entry from 7/16/24 from NHA-A. The 7/2/24 documents : The (interdisciplinary team) IDT met to discuss the resident's new skin injury. The resident has a diagnosis of Dementia and dysphasia. Due to her diagnosis, she is only consuming 25% of her meals. The resident has a consult for speech therapy and is followed by the dietician. It was recognized that her Braden score moved from a moderate risk to a high risk. An air mattress was in place d/t (due to) the change. The resident was on a turning schedule and had a pressure reduction cushion on her wheelchair. Other skin prevention interventions in place were incontinence care and feeding assistance. Based on the interventions in place, the wound is classified as unavoidable. The IDT team recommends adding heel boots as an extra level of protection. R62 plan of care for ADL (activity of daily living) self-care performance deficit related to Alzheimer's dementia initiated date of 2/13/24. The interventions on 2/13/24 include: - Provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or mug where appropriate. - The resident requires physical assistance by 1 staff to eat. There is no changes to the ADL plan of care related to obtaining appropriate nutrition and assistance to promote wound healing. R62's plan of care Has an unstageable pressure ulcer right buttock. Now a stage 4 (7/17/24) initiated date 6/30/24. This plan of care does not include any preventative interventions related to positioning and nutrition. Surveyor noted that there is not a nutrition assessment until 7/16/24. This assessment by (Registered Dietician) RD- N documents a significant weight loss and severely underweight. A prosource protein supplement was added twice a day. There was no documentation of interventions to increase oral intake. This could include favorite foods, high caloric foods, or other individualized needs. Surveyor also noted that there was not a comprehensive assessment of R62 nutritional needs to implement an individual plan of care to promote wound healing on 6/30/24. On 7/3/2024, a Skin Only Evaluation for R62 was completed by NHA-A as a late entry on 7/16/24. The evaluation documents an increase in the pressure injury with a necrotic wound bed. There is not a percentage of necrotic tissue and is classified as an unstageable wound. The assessment documents Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. New. Issue type: Pressure ulcer/ injury. Location: Right buttock. Length (cm): 2.6 Width (cm): 2.9 Depth (cm): 0.9 Wound bed: Necrotic. Wound Exudate: Serosanguineous - thin, watery, pale, red/pink drainage. Peri wound: Normal. Dressing saturation: None 0%. Wound odor: No. Tunneling: No. Undermining: No. Treatment schedule: Daily. Pressure ulcer staging: Unstageable pressure ulcer / injury - obscured full thickness skin and tissue loss. Painful: No. Skin tissue: Warm. Skin note: Weekly skin assessment There is no documentation the physician was notified of this decline in the wound to implement an appropriate treatment. R62's initial wound physician assessment dated [DATE] documents: The type of wound is a pressure injury. It is assessed as a unstageable wound due to necrosis. The duration of wound is greater than 10 days. The wound size is 2.4 x 2.7 x 0.8 cm (centimeters). There is light serous sanguineous drainage. The characteristics are thick adherent devitalized necrotic tissue: 60 %; Slough: 30 %; Granulation tissue: 10 %. R62's wound physician assessment dated [DATE] is the first comprehensive assessment of this pressure injury since discovery on 6/30/24. The wound physician ordered Santyl apply once daily and as needed; recommended to off-load wound, reposition and group II mattress. Also recommended sharp debridement. The factors complicating wound healing is malnutrition. R62 had a severe weight loss that was discovered on 7/10/24 however, there was no nutritional assessment until 7/16/24. The additional measures were to add prosource protein supplement twice a day. A low air loss alternating mattress was added on 7/11/24. There were no changes in turning/positioning times. There were no additional nutritional interventions to promote oral intake. R62 was admitted to hospice on 7/16/24 with a primary diagnosis of severe protein malnutrition. The 7/17/24 wound physician assessment documents the wound has been debrided. The pressure injury is now a stage 4. There is no change in the treatment plan. R62 pressure injury has been assessed weekly from this point by the wound physician. On 8/28/24 at 2:17 PM, Surveyor observed R62 pressure injury treatment by Wound (Registered Nurse) RN-D. RN-D stated they do not do anything with the care plans. RN-D was not aware how R62 developed the pressure injury or any changes in the mattress. RN-D completed the treatment as ordered by the physician. The pressure injury was observed to be a stage 4 wound. R62 was positioned with pillows off the area. R62 was on the appropriate air mattress. On 8/28/24 at 2:48 PM, Surveyor interviewed NHA-A. NHA-A stated they noticed a change in R62 before the development of the pressure injury on 6/30/24. NHA-A stated they were rotating time up in the chair with laying down. They put heel boots in place at this time. NHA-A stated the skin is an organ, and with end stage of life there will be deterioration. NHA-A did not know the origin of pressure for the pressure injury. NHA-A did not indicate what nutritional interventions were started when the pressure injury was discovered 6/30/24. On 8/29/24 at 10:40 AM, Surveyor interviewed RN (Registered Nurse Unit Manager) RN UM-E. RN UM-E started this position in May 2024 and is still getting to know the residents. RN UM-E is not sure what was in place prior to weight loss, and pressure injury discovery. RN UM-E stated that towards the end of June R62's appetite decreased, and they would pick at their food. R62 was getting nutritional supplements. RN UM-E does not know anything about air mattress changes. RN UM-E stated that if R62 is not eating they are offered an additional supplement, and that sometimes R62 will drink this. The IDT meeting on 7/2/24 discussed the new pressure injury and to have Speech Therapy assess for not eating. RN UM-E did not have any additional information related to positioning or origin of the pressure injury. On 8/29/24 at 11:22 AM, Surveyor interviewed RD-N. RD-N they were aware of the weight loss right away. RD-N stated they were doing reweighs and could not believe the severe weight loss. R62 is up and down with eating. RD-N stated R62 is affected by their dementia and will eat food at times. R62 was already getting supplements 3 x a day. R62 is in the dining room for meals. On 7/16/24 pro-source supplement was added twice a day. RD-N increased the pro-source today to 3 x a day because the pressure injury is declining. This week R62 has been eating more with fingers. They also added finger foods this week. R62 varies in eating abilities, will use utensils, however, uses hands more. RD-N feels R62 has advanced dementia and has been eating less. RD-N stated they are in the facility 5 days a week. RD-N did not indicate any other nutritional approaches were attempted to promote nutrition. RD-N does not know how the severe weight loss occurred. RD-N was aware of the new wound, however, did not implement any changes in nutritional management until 7/16/24. The new wound was discovered on 6/30/24. R62's nutritional status is a factor in skin integrity. On 8/29/24, at 11:47 AM, Surveyor interviewed Wound (Medical Doctor) MD-O. MD-O stated that R62's pressure injury is an area that can be off-loaded. The facility and hospice take care of the air mattress ordering. R62 is off loaded most of the time. R62's main issue is their decline in health. R62 would develop wounds much faster with poor nutritional status and infections. R62 wound would not improve if they continue to medically decline. On 9/03/24 at 09:57 AM, Surveyor interviewed (Nurse Practitioner) NP-Q. NP-Q stated R62 has dementia and would eat on and off. R62 had a fall, with a hip fracture in February 2024 that was a factor in their decline in health. NP-Q felt R62 dementia behaviors were affecting their eating. R62 behaviors are crying and repetitive statements. They were trying to address the behaviors with medication. R62 had speech therapy on and off for swallowing and coughing. The coughing was more from bronchitis. NP-Q stated a person with dementia, can progress in the disease, for weight loss. The POA-HC did not want any artificial nutrition. NP-Q could not recall if they were notified of the pressure injury discovered on 6/30/24. NP-Q stated the wound MD drives the treatments. NP-Q stated that they can order a wound treatment, however the wound MD oversees it. NP-Q did not have any additional treatment information for the unstageable wound from 6/30/24 - 7/10/24. On 9/03/24, at 1:33 PM, Surveyor shared R62 concerns with NHA-A. NHA-A stated they notified the Nurse Practitioner and were using the Allevyn dressing until the Wound MD saw the resident. NHA-A stated they changed to an air mattress in June right before the pressure injury developed. Then they changed to a stronger air mattress after the wound MD saw the resident. NHA-A did not have additional information related to the actual cause of the pressure ulcer and what interventions were revised/implemented to promote skin integrity. On 9/03/24 at 3:00 PM, NHA-A spoke with Surveyor. NHA-A stated they did not actually see R62's pressure injury on 7/3/24. NHA-A was aware it was necrotic through review. The wound MD was off that week. Surveyor queried about the wound being larger on 7/3/24, from 6/30/24, with no changes in treatment or physician notification. On 9/03/24 at 3:15 PM, NHA-A spoke with Surveyor. NHA-A stated they did assess R62's pressure injury on 7/3/24. There was a question on wound bed. NHA-A stated the wound bed was necrotic and needed debridement. The Wound MD-O was off the first week of July and did not assess the wound until 7/10/24. The wound was debrided on 7/17/24 after permission from R62's POA-HC. NHA-A stated there was no change in treatment from 6/30/24 until 7/10/24. On 9/04/24 a 2:01 PM, Surveyor interviewed Wound MD-O in person at the facility. MD-O stated they debrided R62's wound to prevent infection. The goal is to keep infection risk down. The necrotic tissue removal helps with pain as well. MD-O stated that removing the necrotic also resolves inflammation. Surveyor noted that R62 was at high risk for pressure injury due to malnutrition with decreased mobility. The facility did not comprehensively assess R62's risk factors to develop an individualized treatment plan. R62's pressure injury was not comprehensively assessed upon discovery to provide prompt treatment. There were no changes in R62's nutritional, ADL and skin plan of cares. The failure of the facility to provide services to prevent pressure injury development, and prompt treatment created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 7/17/24. The immediate jeopardy was removed on 9/11/24 when the facility implemented the following: 1) All nursing staff (including agency staff) currently working will be re-educated on the facility wound prevention policy, which includes a comprehensive assessment that should include the following: staging of Pressure injuries, location, size, color, type of wound tissue, exudate or drainage amount and type, odor, and peri-wound condition completed by a registered nurse on all newly identified wounds and residents admitted with wounds. 2) All nursing staff currently working (including agency staff) will be re-educated on pressure injury skin prevention and proper notification of changes with skin injury. They will also be educated on the use of proper pressure prevention interventions. 3) All residents with pressure injuries will be seen by the wound physician and a comprehensive assessment will be completed. Based on his wound round notes the resident will be assessed for the proper skin prevention equipment i.e air mattress and heel boots. The care plan will be adjusted to reflect the pressure injury and pressure prevention equipment. 4) All residents and braden that are high risk for pressure injury care plan will be reviewed and and necessary adjustment will be made to reflect pressure prevention interventions. 5) All training noted above is to be completed by non-working staff by the beginning of the working shift. Any nurses who do not complete the competency will not be scheduled until completed. Competencies and education will be conducted by the DON, NHA, or Staff Development department. 6) RD was re-educated on the dietician responsibilities to assess residents with risk and pressure injuries for nutritional statues and interventions. 7) On 9/6/2024 the wound program and wound prevention policy were reviewed with the medical director and wound physician to ensure the policy meets current standards of practice. No additional information was provided as to why the facility did not ensure that R62, received care, consistent with professional standards of practice, to prevent the development of pressure injures and or to promote healing, prevent infection and prevent additional pressure injuries from developing.

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0692 (Tag F0692)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that 1 of 3 residents (R62) reviewed, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. * R62 was admitted with severe protein malnutrition. R62's nutritional assessments did not include actual weights that were obtained by facility staff and/or individualized interventions to provide adequate nutrition. R62 developed two periods of severe weight loss (130 lbs to 69.2 lbs, a 46.7% weight loss) that factored into the development of a stage 4 pressure injury and R62 being placed on hospice services. The facility's failure to conduct comprehensive assessments, to develop an individualized plan of care, and to provide adequate nutrition created a finding of immediate jeopardy that began on 3/20/24. Surveyor notified the (Nursing Home Administrator) NHA-A on 9/04/24 at 9:11 AM. The immediate jeopardy was removed on 9/9/24, however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement its removal plan. Findings include: The facility's policy and procedure dated October 2021 and titled Weight Monitoring documents: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. 1.) R62 was admitted on [DATE] with diagnoses to include severe protein malnutrition, dysphasia, and severe dementia. R62 has an activated Power of Attorney for Healthcare (POA-HC.) R62's admission MDS (minimum data set) assessment dated [DATE] documents that R62 requires set-up for eating and has had a recent weight gain. The MDS documents that the assessment weight for R62 is 130 lbs. R62's documented weights at the facility for February were as follows: - 2/13/24 130 lbs - 2/14/24 130.4 lbs - 2/15/24 130 lbs R62's Nutrition/Dietary admission assessment dated [DATE] and written by (Registered Dietician) RD-N documents: R62 is on a mechanical soft diet, consuming ~ (approximately) 35% of meals since admit. Weight is 130 lbs on 2/15 (question accuracy of the weights obtained & requested another weight), was 95.7 lbs in the hospital, and R62's niece said R62 is typically ~95# and Froedtert MyChart had a weight of 106 lbs and she was surprised to see a weight that high. BMI (body mass index): 23.8, WNL (within normal limits) - however, R62 appears closer to underweight and weight of 130 lbs does not seem accurate. R62 has her own teeth, which are in poor condition. No oral sores nor pain with chewing noted. Appears to be tolerating mechanical soft diet but ST (Speech Therapy) is ordered with history of dysphasia. Discussed Boost and R62 said chocolate or vanilla would be okay. Can feed self but assist and encouragement/cues are helpful. No pressure injuries noted. Braden: 15, at risk. R62 diagnosis: Alzheimer's dementia, HTN (hypertension), asthma, dysphasia, protein-calorie malnutrition Meds (medications): sertraline, quetiapine. Estimate nutrition needs based on UBW (usual body weight) of 95 lbs: 1295 kcal (kilocalorie) (30 kcal/kg (kilogram) for wt gain), 43 g (grams) protein (1 g/kg), and 1080-1295 mL (milliliter) of fluids (25-30 mL/kg). Nutrition diagnosis: Inadequate oral intake related to poor-fair po (oral) intake, dementia as evidenced by consuming ~35% of meals, Alzheimer's. Intervention: add Boost/house supplement 240 ml BID (twice a day) for 480 kcal, 20 g protein/day. Goals: consume 25%+ of meals/supplement, skin will not break down, no significant wt triggers, no s/s (sign/symptoms) of dehydration. Surveyor noted that R62's nutritional assessment calculations were not based off the weights obtained by facility staff. This assessment did not include vitamins or mineral supplements that could be provided to R62 to maintain R62's nutritional status. This assessment did not include alternate high calorie food choices, fortified foods, favorite foods or snacks, or any other foods that could be offered as part of R62's personalized diet plan. R62's care conference note dated 2/27/24 and written by RD-N documents: R62's family does not believe R62's weight at the facility. R62 was around 100 lbs at home and do not believe R62 gained 30 lbs. R62 only eats 30 % of their meals and nutritional supplement twice a day. R62 family does not want tube feeding, however they do want R62 to be provided assistance at meals, given cues and encouragement to eat, to keep weight above 95 lbs. The family did not want an appetite stimulant medication unless absolutely necessary. (Note: Despite the family's belief that the resident's weight was probably around 100 lbs., repeated weights at the facility thus far had shown R62's weight to be 130 lbs.) R62's nutritional plan of care dated as initiated on 2/16/24 documents: Resident is at nutritional risk related to need for mech (mechanical) soft diet, need for nutritional supplement, poor-fair po intake, Alzheimer's dementia, dysphasia, pro-cal malnutrition, risk for dehydration and risk for malnutrition. Under the interventions section it documents that on 2/16/24 the following interventions were initiated: - Staff to assist with meal set up and eating prn (as needed). - Allow adequate time for R62 to consume food served. - Monitor oral intakes and record in the electronic record. - Offer a minimum of 1400 ml of fluids at meals/day. R62 mainly prefers milk, juice, water and coffee. - Offer house supplements as ordered. - Provide mechanical soft diet. - Weigh monthly and PRN (as needed) as ordered. R62's plan of care dated as initiated on 2/13/24 documents: ADL (activity of daily living) self-care performance deficit related to Alzheimer's dementia. Now on Hospice care. The interventions section documents the following interventions for eating were in place on 2/13/24: - 2/13/24 R62 requires physical assistance of 1 staff to eat. - 2/15/24 an intervention was initiated to provide milkshakes or liquid food supplements when the resident refuses or has difficulty with solid food or provide nutritious foods that can be taken from a cup or a mug where appropriate. R62's documented weights at the facility continued as follows: - 2/19/24 130.2 lbs - 2/21/24 130.2 lbs - 3/6/24 128.6 lbs - 3/12/24 125.9 lbs - 3/12/24 125.9 lbs R62's Significant Change in Status MDS dated [DATE] documents that R62's weight was 126 lbs and there are coughing and swallowing concerns when eating for R62. R62's Nutritional Nutrition/Dietary Note dated 3/12/24 documents: R62 is downgraded to mildly thick liquids per ST (Speech Therapy) recommendation. R62 with swallowing difficulty and working with ST. R62 received ST for an evaluation one time on 3/11/24 for swallowing concerns by (Speech Therapist) ST-P. R62's speech therapy assessment recommendations are: Mechanical soft textures; nectar thick liquids; close supervision; to facilitate safety and efficiency. It is recommended R62 use the following strategies and/or maneuvers during oral intake: alternate liquid/solids, rate modification and bolus size, upright posture during meals and 30 minutes after eating. No further consult or exam indicated. The results would not change clinical management of R62. R62's nutritional plan of care revised on 3/12/24 documents: mildly thick liquids as ordered. The ST recommendations were not documented in R62's plan of care. R62's documented weights at the facility continued as follows: - 3/12/24 125.9 lbs - 3/13/24 125 lbs - 3/20/24 125 lbs - 3/20/24 108.2 lbs Surveyor noted that from 3/13/24 to 3/20/24, R62 experienced a 13% weight loss. This would be considered severe weight loss. R62's Nutrition/Dietary Note dated 3/28/24 and written by RD-N documents: Weights ranged 125-130 from 2/13/24 to 3/20/24 but weight also obtained at 108.2 on 3/20/24. Weights now 103.2-103.8 for past week. Continues on mechanical soft with nectar liquids. Sertraline increased on 3/22/24. Needs varying level of assistance at meals. Acceptance of meals and supplements somewhat decreased this past week, about 25%. Visited with R62 before dinner, R62 appeared hydrated but frail. Aide noted R62 seemed unchanged, accepted fluids well. RD-N spoke with R62 POA-HC. R62 had swallow study this week, existing diet/liquids was the recommendation. Discussed weights and POA-HC agreed 103 pounds was more consistent with R62 usual body weight recently as an elderly person. The POA-HC said R62 may have gotten up to 120-125 lbs in their younger adulthood. The POA-HC said R62 got as low as 89 pounds in the past few years but would like to see R62 stay above 100 pounds. The POA-HC was agreeable to increasing house supplement to TID (three times a day) and continuing to monitor weight. Boost/Ensure TID will provide 720 kcals and 30 g protein/day. Updated (Nurse Practitioner) NP-Q. Surveyor noted that R62's above nutritional assessment does not include any snacks, favorite foods, fortified foods, high calorie or other food choices that can be offered as part of R62's personalized diet plan. R62's additional documented weights were as follows: - 3/20/24 108.2 lbs - 3/21/24 103.8 lbs - 3/26/24 103.8 lbs - 3/27/24 103.2 lbs - 4/1/24 102.2 lbs - 4/2/24 102.2 lbs - 4/10/24 101.4 lbs - 4/14/24 99.8 lbs - 5/10/24 101.8 lbs - 5/10/24 101.2 lbs - 6/6/24 102.3 lbs R62's Nutrition/Dietary quarterly assessment dated [DATE] and written by RD-N documents: R62 is on a mech soft diet with mildly thick liquids, consuming ~45% of meals over the last 7 days. Wt: 102.3 lbs on 6/6, 101.2 lbs on 5/10, 130 lbs obtained at facility on 2/13, but the POA-HC reported all R62 doctor appointments and regular weights were ~95-100 lbs so her current weight is about where it usually had been. BMI: 18.7, WNL (within normal limits). R62 has their own teeth, which are in poor condition. No oral sores nor pain with chewing noted. Appears to be tolerating mech soft diet. R62 is offered house supplement 240 mL TID for ~720 kcal, 30 g protein/day to help maintain weight. Can feed self but assist and encouragement/cues are helpful, and at times she is fed at meals depending on her level of engagement. No pressure injuries noted. Estimated nutritional needs: 1162-1395 kcal (25-30 kcal/kg), 47 g protein (1 g/kg), and 1162-1395 mL of fluids (25-30 mL/kg). Fluid intake averages ~1230 mL of fluids/day, which should be meeting est. needs. Nutrition diagnosis: Inadequate oral intake related to poor-fair po (oral) intake, dementia as evidenced by consuming ~45% of meals, need for encouragement/cues/occasionally needs to be fed, Alzheimer's, need for supplements, low BMI of 18.7. Intervention: continue current POC (plan of care). Goals: consume 25%+ of meals/supplement, skin will not break down, maintain weight above 95 lbs. R62's next documented weight on 7/10/24 was 73.2 lbs. Surveyor noted that from 6/6/24 to 7/10/24, R62 suffered a severe weight loss of 28%. Surveyor noted that there were no revisions in the individualized plan of care to provide nutritional support for R62. Surveyor noted that there is no comprehensive assessment to identify causative factors for R62's severe weight loss. Surveyor also noted that there is not a comprehensive assessment to identify additional nutritional measures to provide nutrition for R62. On 7/10/24, R62 was prescribed an antibiotic for bronchitis. R62 was experiencing coughing prior to this being ordered. R62 was placed in droplet isolation for 5 days. Surveyor noted that there were no changes in the plan of care for additional nutritional support with an infection. R62's Nutrition/Dietary assessment dated [DATE] and written by RD-N documents: Weight/wound note - R62 is on a mech soft diet with mildly thick liquids, consuming ~30% of meals over the last 7 days. Wt: 66.8 lbs on 7/15, 68.4 lbs on 7/12, 75.4 lbs on 7/11, 73.2 lbs on 7/10, 102.3 lbs on 6/6, 101.2 lbs on 5/10, 130 lbs obtained at facility on 2/13, but POA-HC reported all R62 doctor appointments and regular weights were ~95-100 lbs so 130 lbs was likely incorrect. Significant wt loss from 6/6 to 7/10, not desirable. BMI: 12.2, severely underweight. R62 has increased difficulty chewing and swallowing per staff and ST (Speech Therapy) consult ordered. ST recommends VSS (video swallow study). Per therapy director R62 POA- HC does not want R62 sent out for VSS. Writer notified IDT (interdisciplinary team) on 7/11 that R62 needed a reweigh due to significant wt loss from the previous month. Reweigh obtained but requested another reweigh just to confirm due to the amount of weight lost in 1 month. Notified NP-Q regarding the weight loss and that reweighs were requested to confirm. NP-Q recommends discussing goals of care/hospice with POA-HC. R62 is offered house supplement 240 mL TID for ~720 kcal, 30 g protein/day. R62 needs assist with eating, has poor attention and needs encouragement to eat. No pressure injuries noted. Estimated nutrition needs: 1162-1395 kcal (25-30 kcal/kg), 47 g protein (1 g/kg), and 1162-1395 mL of fluids (25-30 mL/kg). Fluid intake averages ~1230 mL of fluids/day, which should be meeting est. needs. R62 is assisted with eating, receiving nutritional supplements, working with ST. Nutrition diagnosis: Increased nutrient needs related to demands of wound healing as evidenced by unstageable PI (pressure injury) to right buttock. Secondary Nutrition diagnosis: Involuntary weight loss r/t dementia, decline, poor po intake as evidenced by skin breakdown, need for assist with meals, need for supplements, working with ST, severely underweight with BMI of 12.2. Intervention: working with ST, add Prosource 30 ml BID for 200 kcal, 30 g protein/day to aid in wound healing. Goals: consume 25%+ of meals/supplement, skin will not break down, no further wt (weight) loss. Surveyor noted that there is no documentation that includes R62's poor nutritional intake with severe weight loss and how it was assessed. The assessment did not include any increased staff assistance with eating, finger foods, drinkable fortified snacks, or high calorie foods. There is not documentation of food likes or dislikes for R62. There is no assessment that includes vitamins or minerals for added nutritional support for R62. R62 had speech therapy from 7/11/24 to 7/15/24. The speech therapy assessment on 7/11/24 by (Speech Therapist) ST-P documents under the Recommendations section: Mechanical soft textures; nectar thick liquids; close supervision; to facilitate safety and efficiency. It is recommended R62 use the following strategies and/or maneuvers during oral intake: alternate liquid/solids, rate modification and bolus size, upright posture during meals and 30 minutes after eating. On 8/29/24 at 1:24 PM, Surveyor interviewed ST-P. ST-P stated there were variances in R62's oral intake. R62 has no physical barriers to eating. R62 has dementia and does not understand how to eat. ST-P assessed R62 due to more swallowing and coughing concerns. R62 had bronchitis and that would cause more coughing. R62 would take additional liquid supplements. R62 would at times take finger foods. Encouragement did not change R62's intake. ST-P felt R62's dementia was the main reason for not eating. R62 developed an unstageable pressure injury on 6/30/24. This pressure injury evolved into a stage 4 pressure injury on 7/17/24. The primary factor is severe protein malnutrition. Cross reference F686. R62's Nutrition/Dietary note dated 7/16/2024 and written by RD-N documents: Writer spoke with POA-HC regarding the weight loss d/t multiple reweighs confirming the weight loss. POA-HC is adamant that R62 is not 66 lbs and does not believe that R62 has lost that much weight. The POA-HC feels the scales are inaccurate. The POA-HC was just visiting R62 2 weeks ago and would've noticed if R62 had lost that much weight. Writer discussed all the reweighs obtained and that R62 continues with poor po (oral) intake. Discussed that R62 is working with ST (speech therapy) for swallowing, discussed R62 new unstageable wound to right buttock and that Prosource 30 ml BID was added. The POA-HC agreed ProSource is a good idea. The POA-HC is agreeable to hospice for R62 and feels that is what R62 would want, The POA-HC is noticing R62 decline as well. R62's progress note dated 7/17/24 and written by RN UM (Registered Nurse Unit Manager)-E documents: Writer contacted POA-HC regarding requested reweigh of R62 to ensure accuracy. Writer weighted resident today at 69.4 lbs and noted that resident's pants were very loose with at least 4 inches of extra space. Writer provided these updates to POA-HC. On 8/29/24 at 10:40 AM, Surveyor interviewed RN UM-E. RN UM-E stated they started their position in May and are still learning about the residents. RN UM-E was not sure what interventions were in place prior to May regarding R62's weight loss. RN UM-E stated that when R62's weight loss was identified, the POA-HC did not believe it. RN UM-E stated that R62's appetite was decreased and R62 would pick at their food and that this occurred at the end of June. RN UM-E stated that R62 was on house supplements and Boost. RN UM-E stated that if R62 is not eating, R62 is offered another liquid supplement and sometimes drinks it. R62 was not consuming meals and speech therapy was consulted. R62 is also followed by the RD. RN UM-E did not have information on various methods to provide nutrition related to R62's dementia. Surveyor did share there were no changes in the plan of care, no additional information was provided. R62 was admitted to hospice services on 7/19/24 with a primary diagnosis of severe protein-calorie malnutrition. At that time of the survey, R62's weight continues to decrease: - 7/11/24 75.4 lbs - 7/12/24 68.4 lbs - 7/15/24 66.8 lbs - 7/17/24 69.4 lbs - 7/26/24 69.4 lbs - 8/1/24 69.2 lbs On 8/28/24 at 2:48 PM, (Nursing Home Administrator) NHA-A spoke with Surveyor. NHA-A stated that R62 has advanced dementia and that the hospital weight for R62 was different than R62's admission weight. The facility admission weight was 130 lbs and the family said, No way. NHA-A stated that the facility had calibrated the scales and that R62's weight on 3/6/24 was 128.6 lbs. NHA-A stated that the RD did a reweigh on 3/12/24 of 125.9 lbs and that the RD indicated that R62 was losing weight and RD ordered supplements. The supplements that were added were Pro-cal upon admission for at risk for malnutrition. NHA-A stated that R62's weight on 3/13/24 was 125 lbs and that R62 was on weekly weights. NHA-A stated that on 3/20/24, R62's weight was 125 lbs and R62 was reweighed the same day and found to weigh 108 lbs. Then on 3/21/24, R62 was 103.8 lbs and kept going down in weight. On 7/10/24, there was a significant weight loss. NHA-A stated at that time, the RD did not believe R62 had that much of a weight loss. NHA-A stated that R62 was weighed on 7/10/24 and found to have weighed 73.2 lbs. On 7/11/24, R62 weighed 75.4 lbs. NHA-A stated that the RD was in contact with R62's POA-HC. NHA-A indicated that at the time, the facility needed to complete a significant change assessment as R62 was also having trouble swallowing. NHA-A stated that R62 did not have a change in intake prior to the significant weight loss and that speech therapy notes indicated R62 was not swallowing properly. NHA-A stated that facility staff met with R62's family to pursue hospice services at the time. NHA-A did not have any additional causative factors, or interventions, for the severe weight loss. On 8/29/24 at 11:22 AM, Surveyor interviewed RD-N. RD-N stated they were aware of R62's weight loss right away as a resident weight loss would show as a PCC (Point Click Care) alert. At the time, RD-N stated they wanted a reweigh to confirm the weight loss in R62 and that R62's POA-HC did not believe the weight loss. RD-N stated that R62 is very up and down with oral intakes and that sometimes R62 will drink fluids. RD-N stated that R62 does not want to touch food at times and will eat when they want. RD-N felt R62's dementia affected their eating and that R62's POA-HC did not want any tube feeding put in place. RD-N does not know how someone could lose that much weight and stated that NP (Nurse Practitioner)-Q recommended hospice. RD-N stated that R62 was already getting supplements 3 x a day and that R62 would be in the dining room for mealtimes. RD-N stated on 7/16/24, they added ProSource supplements twice a day and that this morning (8/29/24) the ProSource was increased to 3 times a day due to R62's pressure injury declining. RD-N stated that this week R62 has been eating more with their fingers and that the facility added finger foods. RD-N stated that R62 varies in eating and that R62 will use utensils at times, however uses hands more and that due to R62's advanced dementia, R62 has been eating less. RD-N is at the facility 5 days a week and stated that they have facility meetings every day. RD-N stated that R62's POA-HC does not want any further workup and that on 7/19/24, R62 started hospice services for severe protein malnutrition. RD-N did not have any additional information regarding R62's severe weight loss. There were no revisions to the plan of care to provide resident nutrition related to their dementia diagnosis. On 9/03/24 at 9:57 AM, Surveyor interviewed NP-Q. NP-Q stated R62 had weight loss in the hospital and eating was an issue. NP-Q stated that R62 had dementia and that R62 would eat on and off. NP-Q stated that R62 sustained a hip fracture just after admission to the facility that contributed to R62's decline. NP-Q indicated that R62 had a lot of crying and repetitive behaviors and that the hospital did adjust medication to address behaviors to assist with eating, and that the facility wanted to treat the behaviors first. NP-Q stated that R62 was seen by speech therapy on and off and that R62 was coughing was more related to a bronchitis. NP-Q felt that R62's dementia contributed to the weight loss and that the POA-HC did not want artificial nutrition. NP-Q stated that the RD will send an email to notify them about a weight loss. NP-Q indicated they were notified of the weight loss on 7/3/24 via email. The RD increased the nutritional supplements on 7/15/24. NP-Q did not have any information related to R62's severe weight loss. NP-Q requested a care conference to discuss hospice. No additional information was provided. On 9/03/24 at 1:33 PM, Surveyor spoke with NHA-A regarding concerns with R62's weight loss. Surveyor informed NHA-A that R62's plan of care was not revised with changes in their clinical status and that there was not a comprehensive assessment to determine potential factors contributing to the severe weight loss, along with individualized interventions to address R62's severe weight loss. On 8/27/24 at 9:23 AM, Surveyor observed R62 in a wheelchair at the dining room table. R62 was drinking from a glass on their own. There were no staff assisting R62 with eating. On 8/28/24 at 8:40 AM, Surveyor observed R62 in a wheelchair at the dining room table. R62 had a breakfast tray in front of them. R62 had thickened liquids. R62 was holding the glass themselves and drinking from it. There was no staff feeding R62. When staff cues R62 to eat solid food, R62 said no no no. R62 continued to talk non-sensical out loud. Surveyor noted that R62 was admitted with known malnutrition with eating concerns. R62's admission assessment did not calculate the resident's actual weight. Surveyor noted that R62's speech therapy recommendations were not implemented in a plan of care. Surveyor noted that R62's dementia, with behaviors, was not encompassed in the nutritional assessments to develop an individualized approach. R62 was noted to not being eating, along with having loose clothing, in June. There were no changes in the plan of care until mid-July when the nutritional supplement was added. This was also due to a new pressure injury development on 6/30/24. The nutritional assessments do not include a personalized plan to promote nutrition. No additional information was provided as to why the facility did not ensure that R62, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. The facility's failure to conduct comprehensive assessments, to develop an individualized plan of care, to provide adequate nutrition, created a finding of immediate jeopardy 3/20/24. Surveyor notified the (Nursing Home Administrator) NHA-A on 9/04/24 at 9:11 AM. The immediate jeopardy was removed on 9/9/24 when the facility completed the following: 1) RD (Registered Dietician), DON (Director of Nursing), and IDT (interdisciplinary team) members were reeducated on the facility's weight loss policy, which includes a nutritional assessment. 2) The RD reassessed all residents at risk for weight loss and applied the necessary nutritional interventions according to best practices. 3) Current residents with weight loss were reassessed and care plans were reviewed and/or updated to reflect those interventions. 4) The facility will validate that weights are accurate. Licensed staff will assist with obtaining and verifying the weights and ensure scales are calibrated by manufacture's recommendation. 5) During the nutritional assessment, residents' food preferences and assistance level will be identified and communicated to the caregivers. 6) DON, QA (Quality Assurance) nurse, and NHA will audit residents that trigger for weight loss using PCC (point click care) daily Monday - Friday to ensure proper interventions are applied and care planned. No additional information was provided as to why the facility did not ensure that R62, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not report 2 (R5 and R77) of 3 allegations of abuse or neglect to the State Survey Agency during the required timeframe. A report of abuse or neglect was not reported to the Nursing Home Administrator (NHA)-A for 1 (R77) of 3 allegations during the required timeframe. * An accusation of abuse was made involving R77 which was not reported to the NHA-A during the required timeframe. * The Facility did not report a resident-to-resident altercation involving R77 to the State Survey Agency. * On 7/9/24, R5 returned to the facility from a hospitalization on 7/3/24 - 7/9/24. R5 was discovered to have a femur fracture and the facility did not conduct an investigation or report the injury of unknown origin to the State Agency. Findings include: The Facility Policy titled Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation revised 2/2020, documents: Purpose -Facility will prohibit and prevent abuse, neglect, exploitation, mistreatment, injuries of unknown sources and resident to resident altercations. -Facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) . -All alleged incidents of abuse, neglect, exploitation, and misappropriation must be reported and investigated in a timely manner per program code requirements . Special Key Points . 2. An initial review of the allegation prior to reporting to DQA/OCQ may be conducted to determine whether or not the incident needs to be reported to DQA/OCQ. All alleged violations involving mistreatment (including abuse, neglect, exploitation, injuries of unknown source, misappropriation of property, resident-to-resident abuse, and mistreatment by family members, visitors, volunteers or other individuals) must be reported to the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) as soon as possible, but not to exceed 24 hours from the discovery . Guidelines 1. Protect the Resident a. The safety of the resident(s) is the first priority. The resident(s) must be protected from possible subsequent injury or incidents of misconduct. b. After ensuring the safety of the resident(s), all employees are to immediately report any alleged incidents of abuse, neglect and mistreatment to the Supervisor to ensure that appropriate notification and a timely investigation are initiated. c. The Supervisor immediately assesses the resident's personal safety and potential of harm to other residents. d. The Director of Nursing/Director of Resident and Patient Services and/or designee is to be contacted immediately for all allegations of caregiver misconduct or Resident-to-Resident abuse. The Administrator/CCO will be notified immediately . 1.) R77 was admitted to the facility on [DATE] with diagnoses that includes degenerative disease of nervous system, unspecified dementia with agitation and anxiety, generalized anxiety disorder, major depressive disorder and wandering. R77's Quarterly Minimum Data Set (MDS) dated of 6/19/24 documents a Brief Interview for Mental Status (BIMS) score of 00, indicating that R77 has severe cognitive impairment. R77's MDS documents no impairment to R77's upper and lower extremities. The MDS documents that R77 uses a walker for mobility and is incontinent of both bowel and bladder and that R77 has an elopement alarm. On 08/28/24 at 02:10 PM, Surveyor reviewed the Facility Reported Incident regarding an accusation of abuse that occurred on 8/14/24. Per a written statement from the Nursing Home Administrator (NHA)-A, the facility was aware of the event on 8/15/2024 around 10:30 AM. Surveyor noted that the NHA-A was not notified of the incident until 8/15/24, a day later. On 08/29/24 at 01:55 PM, Surveyor interviewed NHA-A and asked why the delay in reporting the incident to the NHA. NHA-A stated it was because the supervisor on duty at the time of the incident believed it was retaliation between two Certified Nursing Assistants who had a disagreement and the supervisor saw no signs of abuse. On 9/3/24 at 3:23 PM, during the daily exit meeting, Surveyor informed NHA-A and the Director of Nursing (DON)-B know of the above concern related to this incident not being reported timely to the NHA. No additional information was provided. 2.) R77 was admitted to the facility on [DATE] with diagnoses which include degenerative disease of nervous system, unspecified dementia with agitation and anxiety, generalized anxiety disorder, major depressive disorder and wandering. R77's Quarterly Minimum Data Set (MDS) dated of 6/19/24 documents a Brief Interview for Mental Status (BIMS) score of 00, indicating that R77 has severe cognitive impairment. R77's MDS documents no impairment to R77's upper and lower extremities. The MDS documents that R77 uses a walker for mobility and is incontinent of both bowel and bladder and that R77 has an elopement alarm. R77's progress note dated 7/16/2024 at 21:26 (9:26 PM) documents, Behavior Note. Subjective: The CNA was attempting to take the resident into the room. He did not want to go in his room so he grabbed ahold of the railing to remain in the hallway by his door. Once she got him to let go then he saw another resident go by that tried to help him and then he bit his arm. Objective: The pt. did not appear to have any bleeding gums. The pt. once seen had stopped being aggressive to the other resident and the CNA. Assessment: The pt. was given his HS medications a little later then normal and because of it the other staff stated that they feel this is why he became aggressive. Plan: To redirect the pt. to return to room to deescalate the situation with less sensory stimulation. Assist the pt. to the chair or bed to help him calm down. To make sure he takes his night time medications and give any ativan and/or morphine if he is due. Intervention: The pt. was given Ativan per the nurse and his night time medications. The light was turned off in his room and only the lamp was left on. The door was closed to decrease the noise from the hall. Evaluation: The pt. appears to be calm lying on his right side in the bed. Staff will continue to talk in a calm manner and not disrupt his sleeping while in the bed. R77's progress note written on 7/17/2024 at 09:58 AM documents, IDT Note. Note Text: IDT reviewed resident to resident altercation on 07/16, further investigating root cause and circumstances surrounding the incident, if it meets guidelines to report to DHS, and subsequent interventions. Surveyor noted that the Department of Health Services Form, F-62617, was not submitted to the State Survey Agency regarding this resident-to-resident altercation. On 09/03/24 at 01:54 PM, Surveyor interviewed Director of Nursing (DON)-B who stated that a certified nursing assistant was trying to get R77 into room, R77 was combative, and another resident tried to help to redirect R77. R77 then bit the other resident. The other resident stated no pain, and no mark was left. DON-B and the Nursing Home Administrator (NHA)-A looked at the Department of Health Services algorithm and determined that the incident did not need to be reported. On 9/3/24 at 3:23 PM, during the daily exit meeting, Surveyor asked the NHA-A and the DON-B if this incident had been reported. It was acknowledged that it was not. Surveyor let them know of the above findings. No additional information was provided. 3.) R5 was admitted to the facility on [DATE] with a diagnosis that includes pressure ulcer of sacral region, end stage renal disease (ESRD), hypotension of hemodialysis, anemia, convulsions, vascular dementia, left femur fracture, rheumatoid arthritis and type 2 diabetes. R5's Significant Change MDS (Minimum Data Set) dated 5/24/24 documents that R5 is dependent with toileting, showering, dressing, and transferring. R5 was documented as having a BIMS (Brief Interview for Mental Status) score of 10, indicating R5 has moderate cognitive impairment. R5's care plan documents: ~ R5 has an Activities of Daily Living (ADL) self-care performance deficit related to weakness due to end stage renal disease, chronic pain, and dementia (date initiated 5/20/22, revised 12/29/23). Interventions include: 1. Turn and reposition every two hours and as needed while in bed (date initiated 5/20/22, revised 12/29/23). 2. R5 is dependent on one staff to provide weekly shower and as necessary (date initiated 1/8/24). 3. R5 is dependent on two staff for repositioning and turning in bed (date initiated 9/28/22, revised 1/8/24). 4. R5 is dependent on one staff for dressing (date initiated 1/8/24). 5. R5 requires weekly skin inspections on shower day. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse (date initiated 5/20/22, revised 9/28/22). 6. R5 is dependent on two staff for toilet use. R5 uses a bedside commode (date initiated 1/8/24). 7. R5 requires a Hoyer lift and assistance of two staff for transfers (date initiated 5/2022, revised 5/31/24). ~ R5 has episodes of forgetfulness and confusion related to dementia (date initiated 8/22/22). Interventions include: 1. Ask yes/no questions in order to determine R5's needs (date initiated 8/22/22). 2. Cue and supervise R5 as needed (date initiated 8/22/22). ~ R5 has bowel incontinence related to impaired mobility, requires assistance with transfers and toileting (date initiated 6/8/23, revised 3/3/24). Interventions include: 1. Check and change every 2-3 hours (date initiated 5/31/24). 2. Provide a bedpan as able or requested (date initiated 3/3/24, revised 5/31/24). 3. Provide pericare after each incontinent episode (date initiated 6/8/23, revised 3/3/24). ~ R5 has potential impairment to skin integrity related to mobility, incontinence, ESRD, and morbid obesity (date initiated 5/20/22, revised 4/8/24). Interventions include: 1. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short (date initiated 9/28/22). 2. Heel lift boots on when in bed (date initiated 9/28/22). 3. Identify and document potential causative factors and eliminate/resolve where possible (date initiated 9/28/22). 4. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc to provider (date initiated 9/28/22). 5. R5 Requires pressure reducing cushion to protect the skin while up in chair (date initiated 6/5/24). 6. R5 Requires pressure relieving/reducing mattress to protect the skin while in bed (date initiated 6/5/24). 7. Turn and reposition every two hours and as needed while in bed (date initiated 5/20/22). 8. Use a draw sheet or lifting device to move R5 (date initiated 9/28/22). 9. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (date initiated 9/28/22). Surveyor reviewed R5's medical records which documents a hospitalization on 7/3/24 - 7/9/24. R5 was discharged to the facility on 7/9/24. Hospital discharge documents dated 7/9/24, document a left distal femoral fracture. Hospital records indicate R5 had complaints of left knee pain and imaging was obtained. Imaging revealed a displaced impacted distal femoral periprosthetic fracture. Hospital records indicate R5 does not recall any falls or trauma. Palliative care was consulted, and no surgical intervention took place. R5 was discharged to the facility on 7/9/24 with no immediate surgical plan and instructions to be non-weight bearing (NWB). On 8/29/24 at 3:14 PM, Surveyor requested the facility self-report and investigation into R5's left distal femoral fracture from Nursing Home Administrator (NHA)- A. NHA- A indicated R5 did not fall at the facility and the facility Nurse Practitioner (NP) indicated R5 had an idiopathic fracture due to age. Surveyor requested any facility investigation documentation into R5's left distal femoral fracture and documentation of investigation being submitted to the State Agency. None was provided. On 9/3/24 at 3:21 PM, during daily exit meeting, Surveyor notified NHA- A and Director of Nursing (DON)- B of concerns with no investigation into R5's left distal femoral fracture and injury of unknown origin not being submitted to the State Agency. NHA- A indicated the facility did not investigate into R5's femoral fracture due to it not occurring within the facility. Surveyor expressed concerns of R5 obtaining an injury of unknown origin and the facility not reporting to the State Agency. NHA- A acknowledged the facility is required to report injuries of unknown origin to the State Agency and states the facility did not complete the investigation for R5's left distal femoral fracture or report to the State Agency. Surveyor requested additional information if available. No additional information was provided.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R77 was admitted to the facility on [DATE] with diagnoses which include degenerative disease of nervous system, unspecified dementia with agitation and anxiety, generalized anxiety disorder, major depressive disorder and wandering. R77's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/19/24 documents a Brief Interview for Mental Status score of 00, indicating that R77 has severe cognitive impairment. The MDS documents no impairment to R77's upper and lower extremities. R77 uses a walker for mobility and is incontinent of both bowel and bladder. R77 has a wander elopement alarm. On 08/28/24 at 02:10 PM, Surveyor reviewed the Facility Reported Incident regarding an accusation of abuse that happened on 8/14/24. Per a written statement from the Nursing Home Administrator (NHA)-A they were informed of the event on 8/15/2024 around 10:30 am. At that time the NHA-A interviewed the Certified Nursing Assistant accused of hitting R77 and afterwards ended their shift. NHA-A then interviewed the supervisor on duty when the incident occurred. The supervisor stated that a quick investigation was done, and it was determined the allegation was not true and was made a couple hours after the accused Certified Nursing Assistant was reprimanded for not helping with cares. Surveyor notes there was a significant delay in the prevention of further abuse by allowing the Certified Nursing Assistant to remain in contact with residents for the remainder of the shift the allegation occurred and the start of a new shift the next day. On 08/29/24 at 01:55 PM, Surveyor interviewed the NHA-A and asked about education for staff after the incident. The NHA-A stated that one on one education to that supervisor regarding the abuse policy was completed, none to other staff. Surveyor asked if interviews with other residents were completed and was told the NHA-A would look for that information. The next day a sheet of paper was provided to the Surveyor labeled with R77's name. The next line states Resident Interview:, after which 3 residents names are typed each with a statement about not hearing anything and feeling safe/no concerns. Surveyor notes there are no dates, times or resident signatures provided on the paper. On 9/3/24 at 3:23 PM, during the daily exit meeting, Surveyor let the NHA-A and the Director of Nursing-B know of the concern related to this incident not being investigated thoroughly. No additional information was provided. 3. ) R77 was admitted to the facility on [DATE] with diagnoses which include degenerative disease of nervous system, unspecified dementia with agitation and anxiety, generalized anxiety disorder, major depressive disorder and wandering. R77's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/19/24 documents a Brief Interview for Mental Status score of 00, indicating that R77 has severe cognitive impairment. The MDS documents no impairment to R77's upper and lower extremities. R77 uses a walker for mobility and is incontinent of both bowel and bladder. R77 has a wander elopement alarm. Surveyor was reviewing R77's Electronic Medical Record and discovered a progress note dated 7/16/2024, written at 21:26 (9:26 PM). Behavior Note. Subjective: The CNA was attempting to take the resident into the room. He did not want to go in his room so he grabbed ahold of the railing to remain in the hallway by his door. Once she got him to let go then he saw another resident go by that tried to help him and then he bit his arm. Objective: The pt. did not appear to have any bleeding gums. The pt. once seen had stopped being aggressive to the other resident and the CNA. Assessment: The pt. was given his HS medications a little later then normal and because of it the other staff stated that they feel this is why he became aggressive. Plan: To redirect the pt. to return to room to deescalate the situation with less sensory stimulation. Assist the pt. to the chair or bed to help him calm down. To make sure he takes his night time medications and give any ativan and/or morphine if he is due. Intervention: The pt. was given Ativan per the nurse and his night time medications. The light was turned off in his room and only the lamp was left on. The door was closed to decrease the noise from the hall. Evaluation: The pt. appears to be calm lying on his right side in the bed. Staff will continue to talk in a calm manner and not disrupt his sleeping while in the bed. A second progress note was written on 7/17/2024, at 09:58 AM. IDT Note. Note Text: IDT reviewed resident to resident altercation on 07/16, further investigating root cause and circumstances surrounding the incident, if it meets guidelines to report to DHS, and subsequent interventions. Surveyor noted that the Department of Health Services Form, F-62617, was not submitted to the State Survey Agency regarding this resident-to-resident altercation. On 9/3/24 at 3:23 PM, during the daily exit meeting, Surveyor asked the NHA-A and the Director of Nursing-B if this incident had been reported. It was acknowledged that it was not. Surveyor requested any investigation records that were compiled as this is a concern. No additional information was provided. Based on interview and record review, the facility did not ensure 2 (R5 and R77) of 3 residents reviewed had thorough investigations into allegations of abuse or injuries of unknown origin. * On 7/9/24, R5 returned to the facility from a hospitalization. R5 was discovered to have a femur fracture and the facility did not conduct an investigation into R5's femur fracture. * An accusation of abuse was made involving R77 which was not investigated thoroughly * A resident-to-resident altercation took place involving R77 which was not investigated thoroughly Findings include: The facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment Reporting and Investigation policy dated August 1995, last revised on February 2020 documents: ~ The facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the Division of Quality Assurance (DQS)/Office of Caregiver Quality (QOC). ~ All alleged incidents of abuse, neglect, exploitation, and misappropriation must be reported and investigated in a timely manner per program code requirements. 1.) R5 was admitted to the facility on [DATE] with a diagnoses that includes pressure ulcer of sacral region, end stage renal disease (ESRD), hypotension of hemodialysis, anemia, convulsions, vascular dementia, left femur fracture, rheumatoid arthritis, type 2 diabetes, spondylosis, and chronic pain syndrome. R5's Significant Change MDS (Minimum Data Set) completed on 5/24/24 documents that R5 is dependent with toileting, showering, dressing, and transferring. R5 was documented as having a BIMS (Brief Interview for Mental Status) score of 10, indicating R5 has moderate cognitive impairment. R5's care plan documents: ~ R5 has an Activities of Daily Living (ADL) self-care performance deficit related to weakness due to end stage renal disease, chronic pain, and dementia (date initiated 5/20/22, revised 12/29/23). Interventions include: 1. Turn and reposition every two hours and as needed while in bed (date initiated 5/20/22, revised 12/29/23). 2. R5 is dependent on one staff to provide weekly shower and as necessary (date initiated 1/8/24). 3. R5 is dependent on two staff for repositioning and turning in bed (date initiated 9/28/22, revised 1/8/24). 4. R5 is dependent on one staff for dressing (date initiated 1/8/24). 5. R5 requires weekly skin inspections on shower day. Observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse (date initiated 5/20/22, revised 9/28/22). 6. R5 is dependent on two staff for toilet use. R5 uses a bedside commode (date initiated 1/8/24). 7. R5 requires a Hoyer lift and assistance of two staff for transfers (date initiated 5/2022, revised 5/31/24). ~ R5 has episodes of forgetfulness and confusion related to dementia (date initiated 8/22/22). Interventions include: 1. Ask yes/no questions in order to determine R5's needs (date initiated 8/22/22). 2. Cue and supervise R5 as needed (date initiated 8/22/22). ~ R5 has bowel incontinence related to impaired mobility, requires assistance with transfers and toileting (date initiated 6/8/23, revised 3/3/24). Interventions include: 1. Check and change every 2-3 hours (date initiated 5/31/24). 2. Provide a bedpan as able or requested (date initiated 3/3/24, revised 5/31/24). 3. Provide pericare after each incontinent episode (date initiated 6/8/23, revised 3/3/24). ~ R5 has potential impairment to skin integrity related to mobility, incontinence, ESRD, and morbid obesity (date initiated 5/20/22, revised 4/8/24). Interventions include: 1. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short (date initiated 9/28/22). 2. Heel lift boots on when in bed (date initiated 9/28/22). 3. Identify and document potential causative factors and eliminate/resolve where possible (date initiated 9/28/22). 4. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc to provider (date initiated 9/28/22). 5. R5 Requires pressure reducing cushion to protect the skin while up in chair (date initiated 6/5/24). 6. R5 Requires pressure relieving/reducing mattress to protect the skin while in bed (date initiated 6/5/24). 7. Turn and reposition every two hours and as needed while in bed (date initiated 5/20/22). 8. Use a draw sheet or lifting device to move R5 (date initiated 9/28/22). 9. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (date initiated 9/28/22). Surveyor reviewed R5's medical records which documents a hospitalization on 7/3/24 - 7/9/24. R5 was discharged to the facility on 7/9/24. Hospital discharge documents dated 7/9/24, document a left distal femoral fracture. Hospital records indicate R5 had complaints of left knee pain and imaging was obtained. Imaging revealed a displaced impacted distal femoral periprosthetic fracture. Hospital records indicate R5 does not recall any falls or trauma. Palliative care was consulted, and no surgical intervention took place. R5 was discharged to the facility on 7/9/24 with no immediate surgical plan and instructions to be non-weight bearing (NWB). On 8/29/24 at 3:14 PM, Surveyor requested the facility self-report and investigation into R5's left distal femoral fracture from Nursing Home Administrator (NHA)- A. NHA- A indicated R5 did not fall at the facility and the facility Nurse Practitioner (NP) indicated R5 had an idiopathic fracture due to age. Surveyor requested any facility investigation documentation into R5's left distal femoral fracture. On 9/3/24 at 3:21 PM, during daily exit meeting, Surveyor notified NHA- A and Director of Nursing (DON)- B of concerns with no investigation into R5's left distal femoral fracture. NHA- A indicated the facility did not investigate into R5's femoral fracture due to it not occurring within the facility. Surveyor expressed concerns of R5 obtaining an injury of unknown origin and the facility not completing an investigation. NHA- A acknowledged that the facility is required to investigate injuries of unknown origins and states the facility did not complete the investigation for R5's left distal femoral fracture. Surveyor requested additional information if available. No additional information was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R34 was admitted to the facility on [DATE]. R34's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/6/2024 indicated R34 had a Brief Interview for Mental Status score of 15 (cognitively intact). R34 has an activated power of attorney. On 08/29/24 at 01:43 PM, Surveyor reviewed R34's electronic medical record which documented that R34 was transferred to the hospital on 4/26/2024 and admitted for sepsis and transverse colitis. R34 later returned to the same room in the facility on 4/30/2024. Surveyor requested evidence from the facility that a transfer notice was provided to R34 and or R34's responsible party when R34 was hospitalized on [DATE]. On 9/3/2024 at 8:04 am, Surveyor reviewed a note from the Nursing Home Administrator (NHA)-A stating that R34 was not given a transfer form when sent to the hospital on 4/26/2024. On 09/03/24 at 11:25 AM, Surveyor interviewed NHA-A about the transfer notice and was told the Facility has no transfer notices as nurses are to do them and have not been providing them to residents upon transfer to the hospital. On 9/3/24 at 3:22 PM, during the daily exit meeting, Surveyor let the NHA-A and the Director of Nursing-B know of the concerns related to no transfer notices being provided to R34 or R34's responsible party. No additional information was provided.Based on interview and record review, the facility did not ensure 3 (R5, R34, and R32) of 3 residents reviewed that required hospitalizations were given written reason for transfer to the hospital and the facility did not send this notification to the Ombudsman. R5 was transferred to the hospital on 8/23/24, 8/12/24, 7/3/24, 5/24/24, and 5/15/24 for changes in condition. R5 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R34 was transferred to the hospital on 4/6/24 while residing in the facility and evidence was not provided R34 or their representative were given the required transfer notice information including appeal rights. On 8/12/24, R32 had a change in condition and was sent to the hospital. R32 was admitted to the hospital and a bed hold notice was given. R32 did not receive a transfer notice for the hospitalization on 8/12/24. Findings include: The facility's policy Transfer and discharge date d 10/2021 documents: the facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: ~ The specific reason and basis for transfer or discharge. ~ The effective date of transfer or discharge. ~ The specific location (such as the name of the new provider or description and/or address if the location is a resident) to which the resident is to be transferred or discharged . ~ An explanation of the right to appeal the transfer or discharge to the State. ~ The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. ~ Information on how to obtain an appeal form. ~ Information on obtaining assistance in completing and submitting the appeal hearing request. ~ The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. ~ For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and email addresses and phone number of the state agency responsible for the protection and advocacy of these populations. 1.) R5's medical record documents that R5 was transferred to the hospital on 8/23/24, 8/12/24, 7/3/24, 5/24/24, and 5/15/24 due to changes in condition. Surveyor was unable to locate any transfer notices for the above transfers in R5's medical record. On 9/3/24 at 11:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)- A and asked who is responsible for providing written documentation of transfer to the hospital for R5 or R5's representative. NHA-A informed Surveyor that the facility nursing staff are responsible for providing this documentation and stated that nursing staff have not been completing the written documentation of transfer to the hospital. Surveyor notified NHA-A of concerns with R5 not having written documentation of transfer to the hospital for R5's hospitalizations on 8/23/24, 8/12/24, 7/3/24, 5/24/24, and 5/15/24. NHA-A indicated that there are no written documentation of transfers to the hospital for R5 due to the facility not completing them. Surveyor requested additional information if available. No additional information was provided. 3.) R32 was transferred to the hospital on 8/12/24 after experiencing a change in condition. R32's nursing note dated 8/12/24 documents that R32 had a change in condition that required to R32 to be transported to the hospital. The medical record indicates R32 was admitted to the hospital and a bed hold notice was provided to R32. Surveyor could not locate any documentation that a transfer notice was given to R32 or R32's representative after R32 was transferred to the hospital on 8/12/24. On 9/3/24 at 11:25 a.m., Surveyor interviewed NHA-A regarding R32's transfer notice on 8/12/24. NHA-A stated nurses are responsible for the transfer notice and that it has not been completed for R32 on 8/12/24. No additional information was provided as to why R5, R34, and R32 of were not given written reason for transfer to the hospital and why the facility did not send this notification to the Ombudsman.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure the Minimum Data Set (MDS) accurately reflected the resident's status at the time of the assessment for 1 (R77) of 24 residents reviewed. R77's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/19/24, did not accurately reflect R77's occurrence of behaviors. Findings include: The Facility Policy titled MDS 3.0 Completion implemented 10/21, documents (in part): Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Policy Explanation and Compliance Guidelines: 1. According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State. 4. Care Plan Team Responsibility for Assessment Completion: . ii. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections . b. Coding of Assessment: . i. All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment . d. Care Area Assessment (CAA's): . iii. Based on the CAA review, key findings regarding a resident's status are documented, including the nature of the condition, complications and risk factors that affect the care planning decision . 1.) R77 was admitted to the facility on [DATE] with diagnoses which include degenerative disease of nervous system, unspecified dementia with agitation and anxiety, generalized anxiety disorder, major depressive disorder and wandering. R77's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/19/24 documents a Brief Interview for Mental Status score of 00, indicating that R77 has severe cognitive impairment. The quarterly MDS documents that R77's upper and lower extremities have no impairment. R77 uses a walker for mobility and is incontinent of both bowel and bladder. R77 also has a wander elopement alarm. On 09/03/24, at 11:12 AM, Surveyor conducted a further review of the Quarterly MDS with an assessment reference date of 6/19/24 and noted the behaviors listed below were all coded in section E as Behavior not exhibited by R77: Physical behavioral symptoms directed towards others Other behavioral symptoms not directed towards others Did the resident reject evaluation or care Has the resident wandered? A review of progress notes during the look back period indicated that these behaviors did occur: *6/18/2024, at 23:04, Activity Note Note Text: Some BX's (behaviors) noted near end of shift. PRN given; effect *6/18/2024, at 04:50, Daily Skilled Note Note Text: Behavior update: CNA T.L. completed adl rounds on the resident. Resident did not want to stay in bed. Resident up wandering on the unit. Attempting to go into 2801 room several times. He removed the Stop velcro sign. When placed back up resident attempted to go under the sign. Resident challenging to be redirected. Reproach with another staff. Resident was non compliant with the redirection. No agitation, but some resistiveness noted. Noc supervisor on the unit to assist. Resident given fluids but does not want to leave from the hallway between his room and 2801. CNA S.O. and Supervisor able to direct resident into his room and placed back in his bed. No PRN was given. No further attempts to get up and out of bed. *6/16/2024, at 21:48, Nurse to Nurse Report Note Text: PT (patient) was given a PRN he was wondering around unit going through things and going into others room PT was trying to push other residents around no aggressive behaviors. *6/15/2024, at 22:05, Nurse to Nurse Report Note Text: No behaviors noted on first shift. after dinner PT was wondered unit. Pt was a little agitated PT was give PRN lorazepam. lorazepam was effective. *6/15/2024, at 02:10, Daily Skilled Note Note Text: Bx: Resident restless and agitated in his room. He was incontinent of stool and urine. Tensed and stiffened body when attempting to guide him into the toilet to be cleaned up. Resident snatch back his hand. Re approach effective. Resident was pacing and wandering. PRN MSIR and ativan given at 2330 with effectiveness noted during follow up. *6/13/2024, at 19:11, Orders - Administration Note Note Text: Lorazepam Tablet 0.5 MG .increased anxiety *6/12/2024, at 22:14, Daily Skilled Note Note Text: PRN administered for increased agitation and wandering episodes, Medication was effective. No instances of striking out. Medication taken without issue . *6/12/2024, at 21:56, Orders - Administration Note Note Text: Weekly skin and shower check performed .Not completed due to increased behaviors *6/12/2024, at 19:26, Orders - Administration Note Note Text: Lorazepam Tablet 0.5 MG .given for increased agitation Surveyor noted that the above progress notes document behaviors that occurred and were treated with PRN medication as necessary during this period. On 09/04/24 at 08:45 AM, Surveyor interviewed MDS Coordinator-I regarding R77's quarterly MDS. MDS Coordinator-I informed Surveyor that she did not complete R77's quarterly MDS. For the behaviors section Surveyor was directed to talk to the social worker. MDS Coordinator-I stated that to complete section E, the individual should look at the progress notes and assessments located in the electronic medical records. On 09/04/24 at 08:56 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and was told that the social worker was not working and so Surveyor was unable to interview them. Surveyor asked NHA-A about the discrepancies found in section E of R77's MDS. NHA-A informed Surveyor that she doesn't know why the social worker didn't answer correctly, other than the social worker did not complete it correctly. NHA-A stated the need to do some training about MDS completion. Surveyor conveyed to the NHA-A that this is a concern. No additional information was provided as to why the facility did not ensure the Minimum Data Set (MDS) accurately reflected R77's behaviors.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not update the comprehensive person-centered care plan for 3 (R29, R49, and R64) of 24 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R64's care plan was not updated when foley catheter was removed. * R49's care plan was not updated to address condom catheter use. * R29's care plan was not updated for compression sleeve use. Findings include: The Facility Policy titled Comprehensive Care Plans revised 9/23, documents: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The Facility Policy titled Care Plan Revisions Upon Status Change revised 9/23, documents: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. Procedure for reviewing and revising the care plan when a resident experiences a status change: . f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change of status, at the time the change of status is identified, to ensure care plans have been updated to reflect current resident needs . 1.) R64 was admitted to the facility on [DATE] with diagnoses that includes type 2 diabetes mellitus. R64's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/25/2024 documents a Brief Interview for Mental Status score of 10, indicating that R64 has moderate cognitive impairment. The MDS no impairment to the upper and lower extremities for R64. R64 uses a walker for mobility. R64 does not have a catheter and is always continent of bowel and bladder. R64 has a care plan diagnosis of Enhanced Barrier Precautions (EBP) for high contact resident care activities r/t (related to) Indwelling Foley catheter. At high risk for multidrug-resistant organisms (MDRO) transmission. Date Initiated: 07/11/2024 Revision on: 07/11/2024 Interventions: o Dedicate daily care equipment as much as possible. Clean & disinfect nondedicated equipment after use, before using on another resident & before removal from the resident's room. Date Initiated: 07/11/2024 o EBP for high contact resident care activities. Perform hand hygiene & apply personal protective equipment (PPE) gloves, gown and/or goggle/face shield worn if risk of splash/spray. Remove PPE & perform hand hygiene prior to exiting room. Date Initiated: 07/11/2024 o EBP will remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical devices. Date Initiated: 07/11/2024 o Educate resident's family members and visitors on helping resident understand the importance of personal hygiene and enhanced barrier/standard precautions. Date Initiated: 07/11/2024 Surveyor noted that as of the 7/25/2024 MDS R64 had no foley catheter. Surveyor notes several observations of R64 on the unit with no foley catheter in place. On 09/03/24 at 10:27 AM, Surveyor interviewed Licensed Practical Nurse Unit Manager (UM)-J about R64 having a foley catheter and was told R64 does not have one. UM-J stated the care plan must not have been updated after the removal of the foley catheter. On 09/03/24 at 01:54 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about the care plan for R64 documenting a foley catheter being in place. DON-B responded that it needs to be cleaned up and updated. On 09/3/24 at 3:23 PM, during the daily exit meeting, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to a foley catheter in R64's care plan not being updated. No additional information was provided. 2.) R29 was admitted to the facility on [DATE] with a diagnosis that includes hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cognitive impairment, gout, osteoarthritis, and macular degeneration. R29's Quarterly MDS (Minimum Data Set) dated on 5/23/24 documents that R29 has impairment of one side for both her upper and lower extremities, is dependent for toileting, dressing and transferring, and requires substantial/maximal assistance with bathing. R29 was documented as having a BIMS (Brief Interview for Mental Status) score of 12, indicating that R29 has moderate cognitive impairment. R29's care plan documents: ~ R29 has a self-care performance deficit related to stroke with left sided paralysis (date initiated 2/14/23, revised on 11/26/23). Interventions include: 1. R29 requires max/total assistance with bathing (date initiated 6/4/24). 2. R29 requires total assistance of 2 staff to turn and reposition in bed as necessary (date initiated 2/14/23, revised 6/19/23). 3. R29 requires a mechanical lift with 2 staff assistance for transfers (date initiated 2/14/23, revised 6/8/23). 4. R29 requires total assist with 2 staff with personal hygiene and 1 staff with oral care (date initiated 2/14/23, revised on 6/19/23). Surveyor reviewed R29's orders which include: Tenashape compression sleeve to be applied to left arm in the AM and take off at bedtime every day. And evening shift for edema to left upper extremity applied in the AM and remove at bedtime. R29's Tenashape compression sleeve was ordered on 6/18/24. Surveyor noted R29's care plan was not updated after her Tenashape compression sleeve was ordered on 6/18/24. On 9/3/24, at 11:52 AM, Surveyor interviewed Nursing Home Administrator (NHA)- A. Surveyor asked NHA- A who is responsible for making changes to the care plan if a compression sleeve is ordered. NHA- A indicated that the unit managers are responsible for making changes to the resident's care plan with any new therapies, including a compression sleeve. Surveyor notified NHA-A of concerns with R29 having a Tenashape compression sleeve ordered on 6/18/24 and how R29's care plan was not updated. Surveyor requested additional information if available. No additional information was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R64) of 1 residents reviewed were free from significant medication errors. *R64 had a physician order to receive Plavix Oral Tablet 75mg (anticoagulant) one time a day. R64 did not receive 6 administrations of Plavix between 7/28/2024 and 8/11/2024. Findings include: The Facility Policy titled, Unavailable Medications last reviewed 6/23, documents: Policy: This facility shall use uniform guidelines for unavailable medications. Policy Explanation and Compliance Guidelines: 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn, and emergency medications. 2. A STAT supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify physician if inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold . 5. If a resident missed a scheduled dose of medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report and monitoring the resident for adverse reactions to omission of the medication. 1.) R64 was admitted to the facility on [DATE] with diagnoses that includes type 2 diabetes mellitus, unspecified atrioventricular block, atherosclerotic heart disease of native coronary artery without angina pectoris, and essential hypertension. R64's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/25/2024 documents a Brief Interview for Mental Status (BIMS) score of 10, indicating that R64 has moderate cognitive impairment. R64's MDS documents that R64 has no impairment to R64's upper or lower extremities. The MDS documents that R64 uses a walker for mobility and that R64 does not have a catheter and is always continent of bowel and bladder. R64 has a physician order that started 7/24/2024 for Plavix Oral Tablet 75mg, Give one tablet by mouth one time a day related to atherosclerotic heart disease of native coronary artery without angina pectoris and essential hypertension. On 08/28/24, at 09:04 AM, Surveyor reviewed R64's Medication Administration Record (MAR) and saw that Plavix was not given on August 2 with reason of on order and also August 6, 10, and 11 with reason of await pharmacy delivery. Surveyor looked at the July MAR and saw it was not given the 28 th and 30 th. Surveyor noted that there was a total of 6 missed administrations between 7/28/2024 and 8/11/2024 out of 15 opportunities. On 08/28/24, at 10:43 AM, Surveyor interviewed Certified Medication Assistant (CMA)-K and asked about the procedure when a medication is not available in the cart to give to a resident. CMA-K stated they would call the pharmacy and check with them on what is going on. CMA-K would then ask a nurse to help get medication out of contingency. Surveyor noted that the facility has an Omnicell which nurses can access but CMAs cannot. On 08/29/24, at 08:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-K and asked when passing pills if a medication is not there what should staff do. LPN-K stated to go to the Omnicell. Should also call the pharmacy to make sure they got the order, otherwise do a clarification order. LPN-K would also call the Nurse Practitioner to let know the resident did not receive, even if just one dose. On 09/03/24, at 10:25 AM, Surveyor interviewed LPN Unit Manager (UM)-J and asked what staff should do if a medication is unavailable to administer. UM-J stated nurses can get medications from the Omnicell. If it is a CMA they should get a nurse and go to Omnicell to pull, then notify the pharmacy. On 09/03/24, at 01:54 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the protocol when a medication is unavailable to administer. DON-B confirmed Plavix is available in the Omnicell. DON-B stated staff should get it from Omnicell. If it is agency worker, they should go to supervisor for help and if it is a CMA they should get a nurse. DON-B will look into why not given on those days and whether it was staff or agency for training purposes. On 09/3/24, at 3:23 PM, during the end of day meeting, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to Plavix not being administered. No further information was provided as to why the facility did not ensure that R64 was free from this significant medication error.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility did not ensure 1 of 5 Certified Nursing Assistants (CNAs) reviewed received the required 12 hours of continuing competence training. This deficient practice has the ability to affect 90 residents whom could receive care from the CNA. CNA-M was hired on 10/31/22 and received only 4.5 hours of continuing competence training. Findings include: 1.) On 9/10/24, Surveyor obtained a sample of 5 CNAs to review for their 12 hours of continuing competence training. Surveyor reviewed CNA-M's training record. CNA-M was hired on 10/31/22 and her training hours indicate she only received 4.5 hours of continuing competence training. On 9/10/24 at 11:45 a.m., Surveyor interviewed DON (Director of Nursing)-B regarding CNA-M's continuing competence training. Surveyor asked DON-B if this the in-service hours provided for CNA-M were accurate. DON-B stated yes there isn't any other in-service hours for CNA-M. On 9/10/24 at 11:49 a.m., Surveyor interviewed NHA (Nursing Home Administrator)-A. Surveyor asked NHA-A who is responsible for ensuring CNAs attain their required continuing competence training hours. NHA-A stated their training department is responsible and emails her with CNAs who need to do their in-services. NHA-A stated CNA-M must have fell through the cracks and did not have the required 12 hours of continuing competence training complete. No additional information was provided as to why the facility did not ensure that CNA-M received the required 12 hours of continuing competence training.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) R49 was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure, unspecified arterial fibrillation. R49's Minimum Data Set (MDS) dated [DATE] documents R49 receives an anticoagulant. R49 Physicians orders dated 1/6/23 documents: Apixaban Oral Tablet 5 MG (Milligrams). Give 1 tablet by mouth two times a day for A-Fib. (Atrial Fibrillation). Anticoagulant medication-monitor for discolored urine, black tarry stools, sudden severe headache, N&V (Nausea/Vomiting), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or V/S (Vital Signs), SOB (Shortness of breath), nose bleeds. R49's care plan dated 8/23/23 does not include the anticoagulant. Surveyor noted R49's care plan did not address the need for an anticoagulant medication, or the monitoring and care associated with anticoagulant use. On 8/29/24 at 10:41 AM, Surveyor interviewed Registered Nurse Unit Manager (RN UM)-E. Surveyor asked RN UM-E how a resident's admission assessment was completed. RN UM-E stated admission assessments were completed by the Unit Nurse when a Resident first arrives at the facility. When the assessment is completed by the Unit Nurse, it is then reviewed by the Nursing Manager. Surveyor questioned RN UM-E about R49's ordered anticoagulant and if the anticoagulant use should be addressed the care plan. RN UM-E stated she did not see the anticoagulant use documented in the care plan. On 9/4/2024, at the daily exit conference, the NHA-A and DON-B were informed of no care plan for R49's anticoagulant. No additional information was provided as to why the facility did not have an anticoagulant care plan in for R49. CONDOM CATHETER USE R49 was originally admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure, unspecified arterial fibrillation. R49's Quarterly review Minimum Data Set (MDS) dated [DATE] documents an external (condom) catheter, R49 is always incontinent, not on a toileting program, and R49 is dependent for all toileting needs. On 8/28/24 at 1:30 PM, Surveyor requested R49's care plan from Director of Nursing (DON)-B. Surveyor received R49's care plan dated 08/23/24. Surveyor noted R49's care plan did not include the R49's use of a condom catheter or the care and treatment of the condom catheter. On 8/29/24 at 10:41 AM, Surveyor interviewed Registered Nurse (RN) Unit Manager (UM)-E (RN UM-E) regarding R49's condom catheter. Surveyor asked RN-UM-H how it was determined R49 required the use of a condom catheter. RN UM-E stated it was a preference of the R49 and R49's Power of Attorney (POA). RN UM-E was unable to locate any documentation for such request. RN UM-E stated she didn't understand why the condom catheter was not on R49's care plan. On 9/4/2024, at the daily exit conference, Surveyor informed NHA-A and DON-B of the above findings. No additional information was provided as to why the facility did not have a comprehensive care plan for the use of a condom catheter for R49. Based on observation, interview, and record review, the Facility did not develop and implement a comprehensive person-centered care plan for 5 (R34, R49, R59, R64 and R72) of 24 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R34 was assessed to be an independent smoker and did not have a care plan in place with relevant interventions. * R64 has chronic nose bleeds and is a diabetic, there was no care plan created for either condition with interventions for managing the conditions. * R72 does not have a comprehensive person-centered care plan for the use of an antipsychotic and antianxiety medication. * R59 does not have a comprehensive person-centered care plan for specialized communication needs. * R49 does not have a comprehensive person-centered care plan for the use of an anticoagulant medication or the use of a condom catheter. Findings include: The Facility Policy titled Comprehensive Care Plans revised 9/23, documents: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines: . 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed . 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The Facility Policy titled Care Plan Revisions Upon Status Change revised 9/23, documents: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: . f. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. g. The Unit Manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change of status, at the time the change of status is identified, to ensure care plans have been updated to reflect current resident needs . 1.) R34 was admitted to the facility on [DATE] with diagnoses that includes Parkinson's disease without dyskinesia, dementia, anxiety disorder, depression, chronic obstructive pulmonary disease and personal history of nicotine dependence. R34's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/6/2024 documents a Brief Interview for Mental Status score of 15, indicating that R34 is cognitively intact. The MDS documents impairment to one side of the upper extremity and on one side and lower extremities have no impairment. R34 uses a walker or wheelchair for mobility and has an indwelling catheter. On 08/29/24 at 01:17 PM, Surveyor reviewed R34's medical record due to being identified as a smoking resident at the Facility. On 7/11/24 a smoking assessment was completed by the Facility. The smoking status was identified as Resident uses tobacco products. Resident follows the facility's policy on location and time of smoking. Surveyor reviewed R34's care plan and noted there was no person-centered comprehensive care plan to indicate smoking safety needs and interventions. On 09/03/24 at 10:29 AM, Surveyor interviewed Licensed Practical Nurse Unit Manager (UM)-J about having a care plan related to smoking and UM-J stated that she would review R34's medical record and get back to Surveyor. On 09/03/24 at 01:54 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about care planning for residents who smoke and was told that smoking should be care planned. On 9/03/24 at 3:23 PM, during the daily exit meeting, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to R34 not having a smoking care plan being in place. No additional information was provided. 2.) R64 was admitted to the facility on [DATE] with diagnoses that includes diabetes mellitus type 2. R64's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/25/2024 documents a Brief Interview for Mental Status score of 10, indicating that R64 is moderately cognitive impaired. R64's MDS documents that R64's upper and lower extremities have no impairment. R64 uses a walker for mobility and is always continent of bowel and bladder. NOSE BLEEDS On 08/28/24 at 09:12 AM, Surveyor reviewed R64's electronic medical record (EMR) progress notes. Three progress notes referred to R64 having nose bleeds and interventions being available. On 5/12/2024, at 11:51 PM, a change in condition progress note documents: Resident has nose bleeding can be prevented, resident is non-compliant refused Supervisor and writer to apply nose clip. On 5/12/2024, at 11:00 PM, a transfer to hospital summary progress note documents: Resident has Hx of Nose bleeding. Bell ambulance here to transport resident to St [NAME] Hosp. for Evaluation. Resident is self . On 5/12/2024, at 10:11 PM, a transfer to hospital summary progress note documents: Unit nurse informed writer that resident is experiencing a noise bleed. Writer attempted interventions to stop bleeding. Resident refused all interventions. Resident is insisting to go out to St. [NAME]'s. Bell Ambulance phoned for transport. NPP (Nurse Practitioner) made aware. While reviewing the EMR an order was found from 4/18/24: Afrin Nasal Spray Nasal Solution 1 application in both nostrils as needed for Nosebleed. If patient has nosebleeds apply Afrin to Cotton ball insert into nares and apply pressure. In review of R64's comprehensive care plan, Surveyor was not able to locate a care plan with interventions to address R64's nose bleeds or interventions to use in the event of a nosebleed. On 09/03/24 at 10:27 AM, Surveyor interviewed Licensed Practical Nurse Unit Manager (UM)-J about having a care plan related to nose bleeds. UM-J stated that she would reviewe if having an order for the Afrin is sufficient or if it should be care planned. On 09/03/24 at 01:54 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about care planning for residents who have chronic nose bleeds and was told that the chronic nosebleeds should be care planned. On 9/03/24 at 3:23 PM, during the daily exit meeting, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to no nosebleed care plan in place. No additional information was provided. DIABETES MANAGEMENT Surveyor reviewed R64's medication orders in the electronic medical record and noted R64 was prescribed Lantus SoloStar Subcutaneous Solution Pen. (Start: 4/21/2024) R64 has a diagnosis of Diabetes. On 08/28/24 at 09:36 AM, Surveyor reviewed the EMR and could not locate a care plan with interventions in place for diabetes and monitoring. On 09/03/24 at 10:27 AM, Surveyor interviewed Licensed Practical Nurse Unit Manager (UM)-J about having a care plan related to diabetes for R64. UM-J reviewed R64's medical record and stated that UM-K did not see one, but would check with DON (Director of Nursing)-B. On 09/03/24 at 01:54 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about care planning for residents with diabetes and was told that diabetes management should be care planned. On 09/03/24 at 3:23 PM, during the daily exit conference, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to no diabetes care plan in place. No additional information was provided. 3.) R72 was admitted to the facility on [DATE] with diagnoses which include degenerative disease of nervous system, adult failure to thrive and vascular dementia with agitation and psychotic disturbance. R72's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/5/2024 indicated R72 did not have a Brief Interview for Mental Status done due to resident rarely/never being understood. R72's MDS documents that R72's upper and lower extremities have no impairment. R64 uses a walker for mobility and is always incontinent of bowel and bladder. ANTIPSYCHOTIC R72's medical record was reviewed for unnecessary medications. R72 is taking Olanzapine 2.5 mg at bedtime (antipsychotic) for restlessness. Surveyor was unable to locate a care plan for R72's antipsychotic medication to address individualized targeted behaviors for continued use of an antipsychotic medication and non-pharmacological interventions. On 09/03/24 at 10:28 AM, Surveyor interviewed Licensed Practical Nurse Unit Manager (UM)-J about having a care plan related to antipsychotic medication. UM-J informed Surveyor that she would review R72's medical record and would inform Surveyor of any findings. On 09/03/24 at 01:54 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about care planning for residents with antipsychotic medication and was told that the use of antipsychotic medication use should be care planned. On 09/3/24 at 3:23 PM, during the daily exit conference, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to no antipsychotic medication care plan in place. No additional information was provided. ANTIANXIETY R72's medical record was reviewed for unnecessary medications. R72 is taking the antianxiety medication lorazepam on an as needed basis. R72's care plan does not address the use of the antianxiety medication, side effects to monitor for, or non-pharmacological interventions used to assist with alleviating feelings of anxiety. On 09/03/24 at 10:28 AM, Surveyor interviewed Licensed Practical Nurse Unit Manager (UM)-J about having a care plan related to antianxiety medication. UM-J informed Surveyor that she would review R72's medical record and let Surveyor know of any findings. On 09/03/24 at 01:54 PM, Surveyor interviewed the Director of Nursing (DON)-B and asked about care planning for residents with antianxiety medication and was told that the use of antipsychotic medication use should be care planned. On 09/3/24 at 3:23 PM, during the daily exit meeting, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to no antianxiety medication care plan in place. No additional information was provided. 4.) R59 was admitted to the facility on [DATE] with a diagnoses that includes chronic kidney disease, anemia, osteoarthritis, and constipation. R59's Quarterly MDS (Minimum Data Set) dated 8/19/24, documents that R59 has short and long-term memory problems, impairments to both upper extremities, and is dependent with toileting, dressing, and transferring. R59 was documented as not having a BIMS (Brief Interview for Mental Status) evaluation due to R59 is rarely/never understood. R59's care plan, dated 12/15/23, documents: ~ R59 has an Activities of Daily Living (ADL) self-care performance deficit related to impaired mobility and osteoarthritis (date initiated 12/15/23, revised on 8/23/24). Interventions include: 1. Provide appropriate level of assistance for ADL care needs to R59 (date initiated 12/15/23). 2. R59 requires a set up for eating (date initiated 5/22/24). 3. R59 requires max assistance with upper body dressing and is dependent with lower body dressing (date initiated 5/22/24). 4. R59 requires total assistance with bed mobility and bathing (date initiated 5/22/24). 5. Encourage R59 to use bell to call for assistance (date initiated 12/15/23). ~ R59 has limited physical mobility related to osteoarthritis (date initiated 12/15/23, revised on 8/23/24). Interventions include: 1. Provide appropriate level of assistance for ADL care needs (date initiated 12/15/23). 2. R59 is weight-bearing (date initiated 12/15/23). 3. R59 requires assistance by 1 staff member for locomotion using wheelchair (date initiated 8/7/24). ~ R59 has episodes of forgetfulness and confusion related to difficulty making decisions (date initiated 4/25/24). Interventions include: 1. Ask yes/no questions to determine R59's needs (date initiated 4/25/24). On 8/28/24 at 9:01 AM, Surveyor interviewed R59. Surveyor notes R59 has a left-hand contracture with her left fingertips contracted and touching into her palm. R59 is dressed in her personal clothes and is up in her wheelchair with her side table in front of her, eating breakfast. Surveyor notes a pad of paper and pen on the side table within reach of R59. Surveyor asked how breakfast was, and R59 gave Surveyor a thumbs up. R59 was pointing to her feet and Surveyor noted heel boots on both feet while up in her wheelchair and R59's right foot was off the wheelchair foot pedal. Surveyor asked if she needed help and R59 continued to point at her feet and gave a slight moan. Surveyor notified R59 that staff will be requested to come in her room for assistance and Surveyor immediately notified a staff member. On 8/28/24 at 3:17 PM, Surveyor interviewed R59 who was up in her wheelchair and appeared comfortable. Surveyor asked R59 how she was feeling and R59 gave a thumbs up to Surveyor. R59 did not offer any additional information or hand gestures during interview. On 9/3/24 at 1:33 PM, Surveyor interviewed R59 who was up in her wheelchair in her room. Surveyor asked how she was doing and R59 consistently put her right hand up to her mouth as if she needed something but was unable to communicate her needs. Surveyor noted a pad of paper and a pen on the sink counter which was out of reach from R59. Surveyor was unable to communicate with R59 and unable to understand what her needs were through hand gestures. On 9/3/24 at 1:34 PM, Surveyor interviewed Certified Nursing Assistant (CNA)- G who indicated that R59 communicates by using a pen and paper and writing down her needs. CNA-G indicated R59 will also point at things for communication but pen and paper works best for communication. CNA-G reported R59 has good handwriting and R59's handwriting is legible for proper communication. Surveyor reviewed R59's medical record which included a Care Conference dated 6/12/24. Surveyor noted that R59 was present for the care conference on 6/12/24 and was communicating with facility staff via pen and paper and writing down her needs. On 9/3/24 at 3:21 PM, during the daily exit meeting, Surveyor notified Nursing Home Administrator (NHA)- A and Director of Nursing (DON)- B of concerns with R59 having communication deficits that are not indicated on her Care Plan. Surveyor notified NHA-A and DON-B that Surveyor was unable to locate a comprehensive communication care plan for R59. Surveyor requested additional information if available. No additional information was provided.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 2 of 2 medication storage rooms did not have expired stock medication and expired & not dated insulin for R11. * Expired 0.9 sodium chloride irrigation 500 ml (milliliter) bottle, stock Systane lubricant eye drops and tear eye drop advanced were observed in the 2900 unit medication storage room. * Expired stock tear eye drop advance and a bottle of Lantus insulin was expired for R11. A second bottle of Lantus, which was open & used, was not dated when opened. This has the potential to affect 9 residents residing on the 2700 unit and 14 residents residing on the 2900 unit who may have eye drops ordered. Findings include: 1.) On [DATE], at 9:35 a.m., Surveyor observed the 2900 unit medication storage room with Med Tech (Medication Technician)-F. On the wire rack Surveyor observed a bottle of 0.9% sodium chloride irrigation usp 500 ml with the expiration date of 02-01-2024. In the cabinet to the left there is a stock bottle of Systane lubricant eye drops with the expiration date of 8/2024. In the same cabinet there are two stock bottles of tear eye drop advanced 15 ml with the expiration date of 7/2024 On [DATE], at 9:40 a.m., Surveyor asked Med Tech-F who is responsible for checking for expired medication. Med Tech-F replied we all do. 2.) On [DATE], at 9:51 a.m., Surveyor observed the 2700 medication storage room with DON (Director of Nursing)-B. In the cabinet to the left of the sink, 4th section down there are two bottles of stock tear eye drop advance 15 ml with the expiration date of 7/2024. On [DATE], at 9:56 a.m., Surveyor observed a gray plastic bin in the refrigerator located in the 2700 medication storage room. In the gray bin is a bottle of Lantus 100 ml insulin for R 11 which is opened & used and not dated when open. There is a second used bottle of Lantus 100 ml expired with an open date of [DATE]. On [DATE], at 9:59 a.m., DON-B stated to Surveyor I see 4 items on there, referring to the expired/not dated items on Surveyor's table. Surveyor asked DON-B who is responsible for checking for expired medication. DON-B informed Surveyor everyone is responsible for checking for expired medication and is mainly the night shift but all nurses and med techs are responsible. Surveyor asked after Lantus is open when is it considered expired. DON-B informed Surveyor always go by 28 days and if not sure verify with the pharmacy, that's the protocol we teach nurses as well. Surveyor asked DON-B if insulin should be dated when opened. DON-B replied always should be dated. Surveyor showed DON-B the expired medication On [DATE], at 10:03 a.m., Surveyor informed DON-B of the expired medication observed in the 2900 medication storage room. No additional information was provided as to why the facility did not ensure that medication storage rooms did not have expired medication.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) R49 was originally admitted to the facility on [DATE] with diagnosis of Post Traumatic Stress Disorder. R49's Quarterly Minimum Data Set (MDS) dated [DATE] documents antipsychotic medications were received on a routine basis only. Has a gradual dose reduction (GDR) been attempted? No is checked. Surveyor reviewed R49's physician orders which include the following: Seroquel Oral Tablet 25 MG (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for nightmares. Surveyor reviewed the pharmacy notes from 8/1/24: Pharmacy Review: Note Text: Pharmacy review. No new irregularities noted. On 9/4/2024 at 10:46 AM, Surveyor requested information from DON-B regarding R49's Seroquel use and a gradual drug reduction being completed. Surveyor requested any psychiatric and or physician notes pertaining to R49's Seroquel use for the last three months. On 9/4/24 at 2:11 PM, Infection Preventionist (IP-C) advised Surveyor that the facility had no gradual dose reduction or a psychiatric consult for R49's Seroquel use. On 9/4/24, at the daily exit meeting, NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were informed of no gradual dose reduction or psychiatric consult for R49's Seroquel use. No additional information was provided as to why the facility did not ensure residents on psychotropic medications received monitoring, and dose reductions, to minimize use of these medications. 3.) R38 receives Cymbalta and Sertraline once daily for depression. The facility has no evidence of AIMS (abnormal involuntary monitory scale) monitoring and no evidence of an attempted dose reduction. R38 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R38's diagnoses include multiple sclerosis, depression, post laminectomy syndrome, cramp and spam, chronic pain syndrome, neuromuscular dysfunction of bladder, morbid obesity, and dependence on wheelchair. R38's Annual MDS (Minimum Data Set) completed on 5/31/24 documents that R38 always socially isolates, has daily verbal behaviors, behaviors that interfere with cares and social interactions, and rejection of care that occur 4-6 days within a week. R38's MDS indicates she is taking an Antidepressant. R38 was documented as having a BIMS (Brief Interview for Mental Status) score of 13, indicating that R38 is cognitively intact. R38's physician orders documents: ~ Cymbalta oral capsule delayed release particles 30 mg (Duloxetine HCL). Give 1 capsule by mouth one time a day for depression. Cymbalta was ordered on 8/18/23 with a start date of 8/19/23. ~ Sertraline HCl tablet 100 mg. Give 1 tablet by mouth one time a day for depression. Sertraline was ordered on 8/18/23 with a start date of 8/19/23. Surveyor was unable to locate in the medical record where a dose reduction for Cymblata was attempted. On 9/4/24 at 10:11 AM, Surveyor interviewed Director of Nursing (DON)- B and asked where attempted medication dose reductions would be documented. DON- B indicated attempted dose reductions are mentioned in psychiatric notes. Surveyor notified DON- B of concerns with no documentation of R38 having an attempted dose reduction for Cymbalta and Sertraline. DON- B indicated she will contact the psychiatric provider to discuss attempted dose reductions for Cymbalta and Sertraline. Surveyor requested additional information if available. No additional information was provided for R38. Surveyor reviewed R38's medical record which includes an AIMS, dated 8/30/24. Surveyor is unable to locate any additional AIMS documentation in R38's medical record. On 9/4/24 at 8:30 AM, Surveyor interviewed Nursing Home Administrator (NHA)- A. Surveyor noted the AIMS documentation for R38, dated 8/30/24, and requested additional AIMS documentation. NHA- A indicates AIMS are completed on residents quarterly. NHA- A states AIMS were not being triggered on residents within the facility. NHA- A indicates the facility noticed AIMS were not being performed on residents which prompted the facility to perform an AIMS sweep, and AIMS was performed on all appropriate residents including R38. NHA- A indicated there were not additional AIMS documentation for R38 except for the AIMS on 8/30/24. Surveyor notified NHA- A of concerns with R38 receiving Cymbalta and Sertraline, and R38 does not have side effect monitoring with AIMS consistently. Surveyor requested additional information if available. No additional information was provided for R38. Based on record review and interview, the facility did not ensure residents on psychotropic medications received monitoring, and dose reductions, to minimize use of these medications. This was observed with 4 (R50, R62, R38 and R49) of 6 resident medication reviews. - R50 receives an antipsychotic medication, and did not have a AIMS (abnormal involuntary movement scale) assessment, to monitor for side effects. - R62 receives an antipsychotic medication, and did not have a AIMS assessment, to monitor side effects. - R38 receives Cymbalta and Sertraline once daily for depression. The facility has no evidence of AIMS (abnormal involuntary monitory scale) monitoring and no evidence of an attempted dose reduction. - R49 receives an psychotropic medication that was not reviewed for a gradual dose reduction. Findings include: The facility's policy and procedure Use of Psychotropic Medication dated 10/22. The procedures include: 6.) Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. 8.) Residents who receive an antipsychotic medication will have an Abnormal Involuntary Movement Scale (AIMS) test performed on admission, semi-annual, with a significant change in condition, change in antipsychotic medication, as needed or as per facility policy. 1.) R50 was admitted to the facility with a diagnosis of schizoaffective, borderline personality disorder and dementia. The Annual (minimum data set) assessment completed on 1/2/24 documents routine antipsychotic medication use by R50. The Quarterly MDS assessment completed on 4/2/24 documents routine antipsychotic medication use by R50. The Quarterly MDS assessment completed on 7/2/24 documents routine antipsychotic medication by R50. R50's nursing note dated 8/27/24 documents: COMMUNICATION - with Family Note Text: LM (left message)with POA (power of attorney) regarding recommendation to increase R50's Effexor XR to 75 mg (milligrams) po (by mouth) daily +37.5 mg Effexor XR daily=112.5 mg daily for depressed mood and trouble sleeping, awaiting call back. R50's medical record did not have documentation of an AIMS assessment being completed for R50's antipsychotic medication use. On 8/28/24, at 3:26 PM, at the facility exit meeting with (Nursing Home Administrator) NHA-A. Surveyor requested any AIMS assessment that was completed for R50's antipsychotic medication use. On 8/29/24 at 3:15 PM, NHA-A spoke with Surveyor. NHA-A stated there was not an AIMS assessment completed for R50's antipsychotic medication use that was completed prior to 8/28/24. NHA-A provided an AIMS assessment completed 8/29/24. No additional information was provided. 2.) R62 was admitted to the facility with a diagnosis of Alzheimer's dementia with agitation. The Significant Change in Status (minimum data set) assessment completed on 3/12/24 indicates routine antipsychotic medication use. The Quarterly MDS assessment completed on 6/10/24 indicates routine antipsychotic medication use by R62. The Significant Change in Status assessment completed on 7/26/24 indicates routine antipsychotic medication use by R62. R62's physician orders documents Seroquel use by R62. R62 medical record did not have documentation of an AIMS assessment being completed for R62's antipsychotic medication use. On 9/04/24, at 8:24 AM, Surveyor interviewed (Nursing Home Administrator) NHA-A. NHA-A stated that an AIMS assessment was not triggering in Point Click Care. for R62's antipsychotic medication use. and that the AIMS assessment was not completed. No additional information was provided.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure the Covid 19 outbreak reflected accurate data, the surveillance of infections were not identified on the infection line list and the monthly infections rates did not accurately identify infections. Visual alerts such as signs at the entrance to notify everyone of the current outbreak and instructions about current recommendations was not done. * CNAs (Certified Nursing Assistants) were observed not using hand hygiene appropriately during meal service. These deficient practices have the ability to affect all 90 residents residing at the facility at the time of the survey. Findings include: 1.) A Covid 19 outbreak was identified on 8/6/24 when two facility staff members developed symptoms and tested positive for Covid 19. The outbreak line list identified two residents that tested positive for Covid on 8/12/24. The last person that tested positive with Covid was a staff member on 8/14/24. On 8/20/24, R65 tested positive for Covid and was placed in isolation but was not identified on the outbreak line list. On 8/25/24, R36 tested positive for coronavirus and was not identified on the outbreak line list. Surveyor noted that the surveillance of infections in the facility was not accurate. The infection line list identified residents prescribed antibiotics without an indication of the type of infection being treated or any signs or symptoms that required the use of the antibiotics. Due to the inaccurate identification of infections, the monthly infection rates within the facility were found to not be accurate. During the survey, R65 was still in isolation due to Covid and there were no signs posted indicating the facility was experiencing an outbreak. 2.) During the meal service, Surveyor observed CNA's not using hand hygiene appropriately. The facility's Coronavirus Prevention and Response policy (not dated) documents: 5. The facility will establish a process to identify and manage individuals with suspected or confirmed SARS-CoV-2 infection including: a. Ensuring that everyone is aware of the recommended IPC (infection prevention and control) practices in the facility by posting visual alerts (e.g., signs, posters) at the entrance and in strategic places to include instructions about current IPC recommendations. The facility's Infection Surveillance policy dated 9/23 documents: 6. The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: a. Data to be collected, including how often and the type of data to be documented, including: i. infection site, pathogen (if available), signs and symptoms, and resident location, including summary and analysis of the number of residents (and staff, if applicable) who developed infections: ii. Observations of staff including the identification of ineffective practices, if any; and iii. The identification of unusual or unexpected outcomes, infection trends and patterns. b. How the data will be used and shared and with appropriate individuals (e.g,. staff, medical director, director of nursing, QAA committee) when applicable, to ensure that staff minimize spread of the infection or disease. 7. The facility will communicate via (specify how e.g. written reports, staff meetings, etc.) to staff and/or prescribing practitioners information related to infection rates and outcomes in order to revise interventions/approaches and/or re-evaluate medical interventions as indicated. 8. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. 9. All resident and infections will be tracked. Separate, site-specific measures may be tracked as prioritized from the infection control risk assessment. Outbreaks will be investigated. On 8/27/24 at 1:28 p.m. Surveyor observed R65 door to the room closed with a sign indicating droplet and contact precautions to be used. There was a storage container with PPE (personal protective equipment). Infection preventionist-C indicated R65 is in isolation due to Covid. Surveyor did not observe any signage indicating the facility is experiencing a Covid outbreak. Surveyor observed staff using appropriate PPE when entering R65 room. During the Survey, Surveyor was made aware R36 tested and was positive for coronavirus on 8/25/24. R36 was on hospice and experiencing a health decline prior to being tested for Covid and expired on 8/26/24. Surveyor reviewed the facility's Infection Surveillance Monthly Report. The August 2024 report indicates a total of 8 residents receiving antibiotics without any signs or symptoms noted and without an infectious diagnosis for the use of the antibiotics. The August infection rates indicate 22 residents with other for an infection. The July 2024 report indicates a total of 23 residents receiving antibiotics without any signs or symptoms noted and without an infectious diagnosis for the use of the antibiotics. The July infection rates indicate 38 residents with other for an infection. The June 2024 report indicates 24 residents receiving antibiotics without any signs or symptoms noted and without an infectious diagnosis for the use of the antibiotics. The June 2024 infection rates indicate 34 residents with other for an infection. The Covid outbreak line list was reviewed. The outbreak line list did not include R36 that tested positive for coronavirus on 8/25/24 and it did not include R65 who tested positive for Covid on 8/20/24. R65 was in the August 2024 Infection Surveillance Monthly Report as testing positive for Covid on 8/20/24 and receiving Paxlovid. R36 is not in the August 2024 Infection Surveillance Monthly report for testing positive for coronavirus. On 8/29/24 at 10:02 a.m. Surveyor interviewed Infection Preventionist (IP)-C. Surveyor asked IP-C why does the Infection Surveillance Monthly Report have residents being prescribed antibiotics and there aren't any signs or symptoms listed and there aren't diagnoses listed for the antibiotics. IP-C stated it's the PCC (point click care) program that does this and she is not sure why it doesn't completely fill it out. Surveyor asked IP-C who is responsible for filling the report out in PCC and she stated she is responsible. Surveyor asked IP-C what does Other mean in the infection rates. IP-C stated she wasn't sure. Surveyor explained to IP-C there isn't an Other infection so the infection rates data isn't not accurate and doesn't reflect the actual infections in the facility. Surveyor asked IP-C why wasn't R65 and R36 reflected on the outbreak line list. IP-C stated R36 was positive for coronavirus on a weekend and died on a weekend. IP-C stated she wasn't in the facility during the weekend and because R36 died she didn't think to add her on the outbreak line list or even the monthly surveillance report. IP-C stated she did not correlate R36 testing positive for corona virus to the current outbreak. Surveyor asked IP-C why is R65 not reflected in the outbreak line list. IP-C stated she didn't correlate R65 positive Covid to the current outbreak because the last person to be positive was on 8/14/24. Surveyor asked IP-C if any signage was put up near the entrance or near the entrance to the affected unit (s). IP-C stated the individual residents had isolation signs but those were the only signs posted. On 8/29/24 at 1:30 p.m. Surveyor interviewed NHA (nursing home administrator)-A regarding the infection control program. Surveyor explained the concerns regarding the Surveillance Monthly report and infections not listed when a resident is prescribed an antibiotic. Surveyor explained the infection rates indicate an infection of Other and the infection rates are then inaccurate. Surveyor explained the concern with the documentation of the current Covid outbreak. Surveyor explained R36 and R65 are not reflected on the line list because IP-C did not see the correlation between the current outbreak and these two residents so they were not placed on the outbreak line list. Surveyor also explained there is no signage explaining there is a current Covid outbreak in the facility. NHA-A stated she understood the concerns. NHA-A stated IP-C has been in this position 4 months and is still learning. No additional information was provided. Surveyor: [NAME], [NAME] L. 2.) The Facility's Policy titled, Hand Hygiene dated 10/21 documents: Policy Explanation and Compliance Guidelines: . 2. Hand Hygiene is indicated and will be performed under conditions listed in, but not limited to, the attached hand hygiene table . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Hand Hygiene Table . Either Soap and Water or Alcohol Based Hand Rub (ABHR is preferred) . Between resident contacts After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . Surveyor observed breakfast service in the second-floor home dining room. On 08/29/24, at 08:22 AM, Surveyor observed Certified Nursing Assistant (CNA)-H with gloved hands touch a resident on the shoulder to wake her then pick up toast to put jelly on with both gloved hands. CNA-H was then observed to get another tray and touch another resident on the arm with gloved hands while serving them. On 08/29/24, at 08:23 AM, Surveyor observed CNA-H change gloves without washing hands or using alcohol based hand rub. On 08/29/24, at 08:24 AM, Surveyor observed CNA-H touch another resident on the shoulder then put clothing protector on the resident. CNA-H then took lids off drinks, cut food up, picked up toast to put jam on toast. CNA-H then took gloves off and used alcohol based hand rub. Surveyor noted that CNA-H did not wash her hands or changed gloves before touching ready to eat food and after touching non-sanitized food surfaces. On 09/03/24, at 01:54 PM, Surveyor interviewed Director of Nursing (DON)-B and asked about the expectation for hand hygiene related to meal tray passing in the dining room. DON-B stated the expectation is for gelling (alcohol based hand rub) before move onto next person and that staff should wear gloves if assisting with food. DON-B stated that staff should wash hands after 3-5 gels. On 9/3/24, at 3:23 PM, during the daily exit meeting, Surveyor let the Nursing Home Administrator-A and the DON-B know of the concern related to hand hygiene during tray passing in the dining room. No additional information was provided.

Jun 2024 5 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Pressure Ulcer Prevention (Tag F0686)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R2 was admitted to the facility on [DATE]. R2's diagnoses included Chronic Kidney Disease, Heart Failure and Diabetes Mellitus. R2's Quarterly MDS dated [DATE] documents R2 is at risk for pressure injuries. On 3/5/24 a Braden assessment was conducted for Resident with a score of 16 indicating R2 is at risk for pressure injuries. On 3/9/24, R2 was discharged to the hospital. R2 returned from the hospital to the facility on 3/20/24. On 6/3/24 at 11:15 AM, Surveyor observed R2 in their room lying in bed. R2 had a pressure relieving air mattress in place at this time. R2's left heel was floated on a pillow to provide pressure relief. Surveyor attempted to conduct interview with R2 at this time. R2 declined interview with surveyor at this time responding, I am in no mood to talk with anyone any time soon. Surveyor reviewed R2's medical record including hospital records, physician orders, progress notes, TAR (Treatment Administration Record) and comprehensive care plans Unstageable Right heel pressure injury Surveyor reviewed R2's progress notes. On 4/2/24, Agency RN-FF documented CNA removed R2's boots while getting dressed and saw discharge on bed. R2 had discoloration to the right heel. Heel is leaking minimal serosanguinous (sic) fluid. Unable to measure. No complaint of pain, placed dressing to area. RN supervisor, MD Wound MD and Son aware. On 4/2/24, Surveyor could not identify an assessment of R2's right heel wound, including measurements or wound characteristics. On 4/3/24, R2's skin was evaluated by Wound Physician-I. Documentation reads Unstageable DTI (Deep Tissue Injury), right heel, full thickness 7.8 x 6.7 x 0.1 cm, 100% granulation tissue, light serosanguineous drainage. On 4/10/24, Wound Physician-I documents Unstageable DTI, right heel, 7.8 x 6.7 x 0.1 cm, 80% necrotic, 20 % granulation tissue. On 4/17/24, Wound Physician-I documents Unstageable DTI, right heel, full thickness, 7.2x 6.5 x 0.1 cm, 80% necrotic, 20 % granulation tissue. R2's right heel unstageable DTI pressure injury was surgically debrided at this time. On 4/24/24, Wound Physician-I documents Unstageable DTI, right heel, full thickness, 7.2 x 8.2 x 0.1 cm, 80% necrotic, 20 % granulation tissue. R2's right heel unstageable DTI pressure injury was surgically debrided at this time. On 5/1/24, Wound Physician-I documents Unstageable DTI, right heel, full thickness, 14.3 x 13.5 x 0.1 cm, light serosanguinous drainage, 50% necrotic, 10 % slough tissue, 40% granulation tissue. Note that the pressure injury has increased significantly in size. On 5/8/24, Wound Physician-I documents Unstageable DTI, right heel, full thickness, 10.8 x 11.3 x 0.1 cm, odor, serosanguineous drainage, 50% necrotic, 10 % slough tissue, 40% granulation tissue. Wound Physician-I noted R2's right heel Unstageable DTI as infected, looks like NF (Necrotizing Fasciitis) and recommended R2 be evaluated at the emergency room. R2 was transferred to the emergency room on 5/8/24. Surveyor reviewed R2's patient Discharge summary dated [DATE]. Discharge summary documents Reason for Hospitalization: necrotic right heel wound status post right AKA (Above Knee Amputation) 5/12/24 .discharge diagnoses: PAD (Peripheral Artery Disease) with necrotic right heel wound status post right AKA .stage 2 sacral pressure ulcer .hospital course: presented with a chief complaint of right heel wound, suspected NSTI (Necrotizing soft tissue infection) .Presented from facility with necrotic and draining wound to right heel .vascular surgery performed right above ankle amputation on 5/9, uncomplicated .now status post right AKA. Stage 3 right buttock pressure injury On 3/20/24, R2's admission skin only evaluation indicates the following: skin tear, right buttock, 1.0 x 0.6 x 0.0 cm. No depth. Epithielial-boggy tissue. There was no change to the care plan. There was no assessment or evaluation of the wound until two weeks later, 4/3/24, by which time the wound had increased significantly in size, as noted by wound Physician-I: Stage 3 pressure injury, right buttock, full thickness, 4.2 x 4.8 x 0.1 cm, light serosanguineous drainage, 80 % necrotic tissue, 20% slough tissue. Surgical debridement was provided to R2's stage 3 right buttock pressure injury at this time. On 4/10/24, Wound Physician-I documented Stage 3 pressure injury, right buttock, full thickness, 4.4 x 4.6 x 0.1 cm, moderate serosanguineous drainage, 80 % necrotic tissue, 20% slough tissue. Surgical debridement was provided to R2's stage 3 right buttock pressure injury at this time. On 4/17/24, Wound Physician-I documented Stage 3 pressure injury, right buttock, full thickness, 2.9 x 3.5 x 0.1 cm, light serosanguineous drainage, 80 % necrotic tissue, 20% granulation tissue. Surgical debridement was provided to R2's stage 3 right buttock pressure injury at this time. On 4/24/24, Wound Physician-I documented Stage 3 pressure injury, right buttock, full thickness, 2.9 x 3.5 x 0.1 cm, light serosanguineous drainage, 70 % necrotic tissue, 30% granulation tissue. No surgical debridement was provided to R2's stage 3 right buttock pressure injury at this time. On 5/1/24, Wound Physician-I documented Stage 3 pressure injury, right buttock, full thickness, 2.1 x 3.5 x 0.2 cm, moderate serosanguineous drainage, 60 % necrotic tissue, 30% granulation tissue. Surgical debridement was provided to R2's stage 3 right buttock pressure injury at this time. On 5/8/24, Wound Physician-I documented Stage 3 pressure injury, right buttock, full thickness, 2.1 x 3.5 x 0.3 cm, light serosanguineous drainage, 60 % necrotic tissue, 30% granulation tissue. Surgical debridement was provided to R2's stage 3 right buttock pressure injury at this time. R2 was hospitalized from [DATE] to 5/20/24. On 5/20/24, R2's re-admission skin assessment documents coccyx, skin tear, 3.0 x 4.0 x 0.5 cm. No additional wound characteristics were documented, including description of wound bed or drainage amount. R2 was hospitalized [DATE]-[DATE]. R2's discharge-return anticipated MDS with ARD 5/22/24 does not indicate that R2 has current pressure injuries at the time of discharge to hospital on 5/22/24. Surveyor did not note any documented skin assessments for R2 upon their return to the facility on 5/24/24. On 5/29/24, R2's skin was evaluated at facility by wound physician-I. Wound Physician-I documented Stage 3 pressure injury, right buttock, full thickness, 2.1x 3.3 x 0.7 cm, light serosanguinous drainage, 60 % necrotic tissue, 30% slough tissue, 10 % granulation tissue. Surgical debridement was provided to R2's stage 3 right buttock pressure injury at this time. R2 was transferred to the emergency room on 5/8/24. Stage 3 left buttock pressure injury On 5/29/24, R2's skin was evaluated at facility by wound physician-I. Wound Physician-I documented Stage 3 pressure injury, left buttock, full thickness, 2.5 x 1.6 x 0.1 cm, light serosanguinous drainage, 80 % granulation tissue, 20 % slough tissue. Surgical debridement was provided to R2's stage 3 left buttock pressure injury at this time. R2 was hospitalized from [DATE] to 5/20/24. On 5/20/24, R2's re-admission skin assessment documented coccyx, skin tear, 3.0 x 4.0 x 0.5 cm. R2 was hospitalized from [DATE] to 5/24/24. R2's discharge-return anticipated MDS with ARD 5/22/24 does not indicate that R2 has current pressure injuries at the time of their discharge to hospital on 5/22/24. On 6/4/24, Surveyor reviewed R2's skin integrity care plan with an initiation date of 11/2/21 and a revision date of 6/4/24. R2's care plan documents: The resident has a potential and actual impairment to skin integrity r/t immobility, a history of pressure injuries, incontinence, and refusal of repositioning at times. The following interventions were documented: Apply house barrier cream every shift and/or with incontinence episode(s). Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Float Left heel while in bed, Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Resident needs pressure reducing EquaGel cushion to protect the skin while up IN CHAIR. The resident needs pressure relieving/reducing mattress to protect the skin while IN BED. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Surveyor notes all of the above interventions had been listed on R2's comprehensive care plan with an initiation date of 6/3/24. On 6/3/24 at 2:08 PM, Surveyor conducted a phone interview with Agency RN-FF. Surveyor asked Agency RN-FF if a resident is admitted with pressure injuries whether or not an RN should assess the pressure injury, including staging of the wound and characteristics of the wound (measurements, description of wound bed and drainage amount). Agency RN-FF responded that they believed that an RN should conduct assessments on any skin issues upon admission to the facility and that the Wound Physician-I would see residents with pressure injuries on weekly rounds. Agency RN-FF added that their normal protocol as a nurse would be to assess the resident, measure the wound, complete an incident report and a pain skin assessment in the electronic medical record. Surveyor asked Agency RN-FF if they recalled assessing R2's heel on 4/2/24. Agency RN-FF responded that they work on different units when they come to the facility so they were unable to recall any specific instance regarding R2's heel. On 6/4/24 at 11:20 AM, Surveyor conducted Interview with LPN MDS-M. Surveyor asked LPN MDS-M who would be responsible for the initiation and revision of resident care plans. LPN MDS-M responded that the completion of the MDS would trigger which care plans should be initiated and that nurse managers would be responsible for updates to the care plans thereafter. Surveyor asked LPN MDS-M if resident pressure injuries should be coded on the MDS assessments. LPN MDS-M responded that pressure injuries should be coded on MDS assessments. Surveyor asked LPN MDS-M if they could explain why R2's discharge-return anticipated MDS with ARD 5/22/24 did not code R2's pressure injuries. LPN MDS-M told Surveyor that they would need to look into this. On 6/4/24 at 12:45 PM, LPN MDS-M told Surveyor that R2's discharge-return anticipated MDS with ARD 5/22/24 did not have R2's pressure injuries coded. LPN MDS-M told Surveyor that R2's MDS was going to be modified and resubmitted to reflect R2's pressure injuries. Surveyor asked LPN MDS-M if a resident is admitted with pressure injuries whether or not an RN should assess the pressure injury, including staging of the wound and characteristics of the wound including measurements, description of wound bed and drainage amount. LPN MDS-M responded that they believed that an RN should conduct assessments on any skin issues upon admission to the facility and that the Wound Physician-I would see residents with pressure injuries on weekly rounds. On 6/4/24 at 11:06 AM, Surveyor conducted interview with Physician-GG. Physician-GG is R2's Primary Medical Physician who visits R2 at the facility. Surveyor asked Physician-GG if they have had any involvement with management of R2's wounds while they have resided at the facility. Physician-GG responded that R2 is followed by Wound Physician-I who conducts weekly rounds at the facility to manage resident's wound care. Surveyor asked if Physician-GG had seen any of R2's pressure injuries prior to their hospitalization on 5/8/24. Physician-GG responded that they had not seen any of R2's pressure injuries prior to their hospitalization. Physician-GG told Surveyor that they knew that R2 had a right heel wound that was wrapped but that they had never removed the wrap. Surveyor asked Physician-GG if R2's vascular status had ever been discussed as a concern previous to R2's hospitalization on 5/8/24 when they were hospitalized with a diagnosis of PAD and a right AKA. Physician-GG told Surveyor that they had been focused lately on R2's gastrointestinal status due to a previous bowel obstruction that led to hospitalization in March 2024. Physician-GG told Surveyor that they didn't recall any discussion regarding R2's vascular status previous to R2's hospitalization on 5/8/24. Physician-GG told Surveyor that they were shocked when they learned that R2 had undergone surgical intervention for R2's right heel pressure injury including an AKA. Surveyor asked Physician-GG if a resident is admitted to the facility with pressure injuries if an RN should conduct a skin assessment including staging of wound and wound characteristics. Physician-GG responded that they think that would be the standard for nursing protocol. Surveyor reviewed R2's face sheet. Surveyor noted a diagnosis of PAD with an initiation date of 5/20/24. Surveyor could not identify any previous diagnoses related to R2's vascular status prior to 5/20/24. On 6/4/24 at 2:45 PM, Surveyor conducted interview with Wound Physician-I. Wound Physician-I conducts weekly rounds at the facility, usually on Wednesdays. Surveyor asked Wound Physician-I if R2's vascular status had ever been discussed as a concern previous to R2's hospitalization on 5/8/24 when they were hospitalized with a diagnosis of PAD and a right AKA. Wound Physician-I told Surveyor that they had been monitoring R2's pressure injuries weekly including measurements and debridement of pressure injuries as necessary. Wound Physician-I told Surveyor that they remembered seeing R2 on 5/8/24 and assessing their right heel pressure injury. Wound Physician-I told Surveyor that R2's right heel was very infected and that they recommended that R2 go to the emergency room for evaluation. Wound Physician-I told Surveyor that previous to that day, there hadn't been any discussion related to R2's vascular status that they could recall. Surveyor asked Wound Physician-I if a resident is admitted to the facility with pressure injuries if an RN should conduct a skin assessment including staging of wound and wound characteristics. Wound Physician-I responded that the nurses should comprehensively assess all resident wounds when they arrive at the facility and throughout the resident's stay. Surveyor asked Wound Physician-I if nurses should wait to assess resident wounds until Wound Physician-I is in the building. Wound Physician-I responded, Absolutely not. Wound Physician-I added that there should not be a delay in assessing wounds as residents are admitted to the facility on days that Wound Physician-I is not conducting wound rounds. On 6/4/24 at 3:20 PM at the daily exit meeting, NHA-A told Surveyor that they had spoken to Agency RN-FF regarding discovery of R2's right heel skin condition on 4/2/24. NHA-A told Surveyor that Agency RN-FF had told them that they did not feel comfortable conducting any measurements of R2's right heel on 4/2/24 as there were many layers to R2's heel wound. Agency RN-FF had referred R2's right heel wound to Wound Physician-I, who ended up conducting an assessment of R2's right heel pressure injury on 4/3/24. NHA-A told Surveyor that they have had mandatory in-services regarding wound care and assessments of pressure injuries. NHA-A added that they have very little faith in the facility's nurses' abilities to assess pressure injuries, including staging and assessment of wound characteristics. NHA-A told Surveyor at this time that the facility's solution to current wound assessments will be to delegate staging and assessment of wound characteristics to Wound Physician-I on a weekly basis. Surveyor shared multiple serious concerns with NHA-A and DON-B at this time regarding R2 including inconsistent MDS coding of R2's pressure injuries, missing weekly documentation of R2's right buttock pressure injury from 3/21/24 to 4/3/24 then again from 5/20/24 to 5/29/24, development of a facility acquired stage 3 pressure injury to the left buttock and R2's right heel unstageable facility acquired pressure injury becoming infected and leading to hospitalization and a right AKA. On 6/5/25 at 12:15 PM, Surveyor conducted interview with Medical Director-K. Medical Director-K told Surveyor that they were not R2's primary physician but that NHA-A and DON-B had made Medical Director-K aware of R2's case. Surveyor asked Medical Director-K if a resident is admitted to the facility with pressure injuries if an RN should conduct a skin assessment including staging of wound and wound characteristics. Medical Director-K responded that an RN should comprehensively assess all resident wounds when they arrive at the facility and as necessary there after. Surveyor asked Medical Director-K if pressure injuries should be assessed on a weekly basis. Medical Director-K responded that pressure injuries should be assessed weekly at a minimum. Surveyor asked Wound Physician-I if nurses should wait to assess resident wounds until Wound Physician-I is in the building. Medical Director-K responded that nurses at the facility should absolutely not wait to assess wounds until a physician is in the facility. Medical Director-K added that there may be times where Wound Physician-I is unavailable and may not be able to assess resident wounds every week. Medical Director-K told Surveyor that it is the facility's responsibility to ensure resident wounds are comprehensively assessed and that it is not appropriate to wait for a physician to measure and assess wound characteristics as it could delay treatment of the resident. The facility's failure to ensure R7 & R2 received appropriate care and treatment of their pressure injuries created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 6/7/24 when the facility implemented the following action plan: * All nursing staff (including agency staff) currently working will be re-educated on the facility wound prevention policy, which includes a comprehensive assessment that should include the following: staging of Pressure injuries, location, size, color, type of wound tissue, exudate or drainage amount and type, odor, and peri-wound condition completed by a registered nurse on all newly identified wounds and residents admitted with wounds. * All nursing staff currently working (including agency staff) will be re-educated on pressure injury skin prevention and proper notification of changes with skin injury. They will also be educated on the use of proper pressure prevention interventions. * All residents with pressure injuries will be seen by the wound physician and a comprehensive assessment will be completed. Based on his wound round notes the resident will be assessed for the proper skin prevention equipment i.e. air mattress and heel boots. The care plan will be adjusted to reflect the pressure injury and pressure prevention equipment. * All residents and Braden that are high risk for pressure injury care plan will be reviewed and necessary adjustment will be made to reflect pressure prevention interventions. * All training noted above is to be completed by non-working staff by the beginning of the working shift. Any nurses who do not complete the competency will not be scheduled until completed. Competencies and education will be conducted by the DON, NHA, or Staff Development department. * On June 5, 2024 the wound program and wound prevention policy were reviewed with the medical director and wound physician to ensure the policy meets current standards of practice. * Nurses Manager, DON, QA nurse, NHA, and nursing supervisors will conduct audits daily for 90 days, weekly for 3 months, and monthly for 6 months of newly admitted residents, residents with current pressure injuries, residents at risk, and residents with new skin injuries for a proper document including comprehensive assessments, care plan changes, and treatment administration record (TAR). The deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by: 3.) R5 was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, Alzheimer's disease, and diabetes. R5 started hospice services on 6/12/2023. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R5 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 1 and was assessed to be frequently incontinent of bowel and bladder. R5 had an activated Power of Attorney. R5's Activities of Daily Living (ADL) Care Plan initiated on 8/9/2022 indicated R5 needed extensive assistance by two staff to turn and reposition in bed and should be turned and repositioned every two hours and as needed. R5 needed staff to check and change R5 every two to three hours for incontinent needs. R5 required the assistance of two staff to transfer R5 using a Hoyer lift. R5's Skin Integrity Care Plan was initiated on 8/9/2022 and had the following interventions in place since 12/13/2022: -Encourage good nutrition and hydration in order to promote healthier skin. -Keep skin clean and dry; use lotion on dry skin. -Monitor for side effects of antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury. -Obtain blood work such as CBC with Diff, blood cultures and C&S (culture and sensitivity) of any open wounds as ordered by the physician. -Pressure relieving/reducing mattress to protect the skin while in bed. -Heel lift boots on while in bed at night. -Pressure relieving/reducing cushion to protect the skin while up in chair and air mattress on bed. -Turn and reposition every two hours and as needed while in bed. -Use a draw sheet or lifting device to move R5. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On 4/30/2024, on the Skin Only Evaluation form, Registered Nurse (RN)-G charted R5 had a Stage 2 pressure injury to the sacrum that measured 0.5 cm x 0.3 cm with granulation in the wound bed. The wound had minimal serous drainage. RN-G charted R5 had excoriation that measured 3.0 cm x 2.5 cm. RN-G charted RN-G completed a comprehensive skin assessment, a treatment was in place, the wound physician would reassess the wound on wound rounds, and the care plan was updated. Surveyor noted the pressure injury did not have a depth measurement or a percentage of granulation indicated in the documentation and the excoriation did not have a location or description of the wound. Surveyor noted no changes to the Care Plan were made to address the new pressure injury and no documentation was found indicating the dietician was notified of the new pressure injury; no changes to supplements or increase in protein was ordered. On 5/1/2024, on the Skin Only Evaluation form, a Licensed Practical Nurse (LPN) charted R5 had an open area to the sacrum. No other documentation was on the form. On 5/15/2024, on the Skin Only Evaluation form, an LPN charted R5 did not have any current skin issues. R5's Progress Notes had daily charting from 4/30/2024 to the time of the survey (6/5/2023) that a sacral wound was present, the dressing was clean, dry, and intact, and the treatment had been completed as ordered. On 5/22/2024, R5 was seen for the initial visit by Wound Physician (WP)-I. WP-I documented R5 had an Unstageable pressure injury to the sacrum that measured 1 cm x 0.8 cm x 0.2 cm with 20% slough and 80% granulation tissue. The wound had light serosanguineous drainage with no signs of infection. WP-I documented the wound was greater than 2 days old. Surveyor noted this was the first comprehensive assessment of the pressure injury, 22 days after the wound was discovered. On 5/29/2024, on the Skin Only Evaluation form, an LPN charted R5 did not have any current skin issues. On 5/29/2024, R5 was scheduled to be seen by WP-I. WP-I documented R5 visit had been rescheduled. No documentation was found indicating R5's Unstageable sacral pressure injury was comprehensively assessed on 5/29/2024. On 6/3/2024 at 12:00 PM, Surveyor observed R5 sitting in a Broda chair in R5's room sleeping. R5 was dressed appropriately and had heel boots on both feet. A call light was on the overbed table in front of R5's Broda chair. On 6/4/2024 at 8:30 AM, Surveyor observed R5 sitting in a Broda chair in R5's room. R5 was dressed appropriately and had heel boots on both feet. R5 stated R5 was comfortable and had no concerns. An air mattress was noted to be in place on R5's bed. In an interview on 6/4/2024 at 10:03 AM, Certified Nursing Assistant (CNA)-H stated CNA-H takes care of R5 regularly and was familiar with R5 and R5's cares. Surveyor asked CNA-H if R5 was incontinent and how often incontinence care was done. CNA-H stated CNA-H cleans R5 up real well before breakfast and then gets R5 up into the Broda chair. CNA-H stated R5 is put back to bed after lunch and will do incontinence cares at that time. CNA-H stated CNA-H checks on R5 again for incontinence care before leaving at the end of the shift. Surveyor noted R5's care plan intervention was to provide incontinence care every two hours and turn and reposition every two hours which were not being done as observed and per CNA-H's statement. On 6/4/2024 at 12:56 PM, Surveyor observed incontinence care being provided to R5 by CNA-H and CNA-V. R5 was incontinent of both bowel and bladder. Cares were provided with no concerns identified. R5 had a dressing to the sacral/left ilium area dated 6/3. The pressure injury was not observed. Treatment to the pressure injury was scheduled for Monday, Wednesday, and Friday evening shift. On 6/4/2024 at 2:36 PM at the daily exit with the facility, Nursing Home Administrator (NHA)-A stated an RN should do a comprehensive assessment of a new wound when it is discovered. NHA-A stated Director of Nursing (DON)-B would review the assessment to make sure it was complete and then the resident would be followed on a regular basis by WP-I. NHA-A stated there was a mandatory staff meeting on 5/31/2024 about wound assessments and documentation. NHA-A stated nursing staff should classify the wound as other and then describe the wound, but not say the etiology of the wound. NHA-A stated a certified professional, whether a Nurse Practitioner or the wound physician, would stage the wound if it was pressure. NHA-A stated the nurses do not know the difference between a skin tear and a pressure injury so had been documenting inaccurately and the wound physician would have to correct the type of wound. NHA-A stated a new resident may be admitted with a pressure injury from the hospital and the hospital may not have staged it accurately so it is best that they wait until their would physician classifies the wound. NHA-A stated the description of the wound should be in the narrative section of the assessment form. Surveyor shared with NHA-A the concern R5 had a Stage 2 pressure injury that was discovered on 4/30/2024 that was not comprehensively assessed until R5 was seen by WP-I on 5/22/2024, three weeks later and the wound had deteriorated to an Unstageable pressure injury that had doubled in size. Surveyor shared the care plan had not been revised and no documentation was found that the dietician was notified of the new pressure area. Surveyor shared the observation of R5 in a Broda chair throughout the survey and the interview with CNA-H stating incontinence cares were done before breakfast, after lunch, and at the end of first shift which was not what was care planned for R5. NHA-A stated incontinence cares should not have been done like that. In a phone interview on 6/4/2024 at 2:53 PM, WP-I stated WP-I had seen R5 on 5/22/2024. Surveyor asked WP-I if WP-I knew when WP-I was informed R5 had a pressure injury and needed an evaluation. WP-I could not recall when WP-I was informed that R5 needed to be added to the weekly wound rounds. WP-I stated WP-I will document on the initial assessment the duration of the wound greater the two or three days old because if a wound is five days old, the statement of it being greater than two or three days is still accurate. Surveyor shared with WP-I that WP-I had documented the wound had a duration of greater than two days on the 5/22/2024 assessment. Surveyor asked WP-I if WP-I was aware that R5's pressure injury was discovered on 4/30/2024. WP-I stated no, WP-I was not aware. WP-I stated WP-I would have documented the wound duration was greater than two weeks if WP-I had known that. Surveyor asked WP-I why R5 was not seen on 5/29/2024; the documentation stated the visit had to be rescheduled. WP-I stated WP-I will document that if the resident does not want to lay down in the bed, if the resident refuses to have an assessment or treatment, or if the resident is out at an appointment or something. WP-I did not know the circumstances as to why R5 was not seen on 5/29/2024. WP-I stated WP-I did not write down the reason R5 was not seen because WP-I did not think it was important. In an interview on 6/4/2024 at 3:40 PM, Surveyor asked RN-G what the facility process was for a resident that was discovered to have a new open area. RN-G stated as the supervising nurse, the unit nurse would let RN-G know there was a new wound, especially if it is an LPN. RN-G stated the unit nurse would open the risk management tool and then that tool would be reviewed by either DON-B or NHA-A. Surveyor asked RN-G how a wound was assessed. RN-G stated the wound would be measured by getting the length and the width and then describe what it looks like. RN-G stated the nurse should get witness statements to help determine the cause of the wound. Surveyor asked RN-G if the depth of a wound was measured in addition to the length and width. RN-G stated RN-G hardly ever measures the depth of a wound because RN-G only has basic knowledge of wounds and did not feel comfortable doing that. Surveyor shared with RN-G that RN-G had documented on R5's Skin Only Evaluation form on 4/30/2024 that R5 would be assessed by the wound physician on wound rounds. Surveyor asked RN-G if RN-G had notified WP-I about R5's new pressure injury. RN-G stated RN-G adds the wound physician's name to R5's profile in the computer, but RN-G did not call or notify WP-I. RN-G stated the unit manager will check all the documentation for a resident with a new skin issue and RN-G thought the unit manager would contact WP-I. Surveyor shared with RN-G that RN-G had documented R5's care plan was updated. RN-G stated RN-G would add the new pressure injury and date it was found to the first column (the problem) and then would put something new in the intervention column. Surveyor noted R5's care plan had the new addition of the sacral pressure injury on 4/30/2024 but no new interventions were documented. Surveyor shared with RN-G that R5 was not seen by WP-I until 5/22/2024 for the initial assessment. RN-G stated, Someone dropped the ball. In an interview on 6/4/2024 at 3:51 PM, Surveyor asked RN Manager-J how WP-I knows what residents to do wound rounds on. RN Manager-J stated the interdisciplinary team has a spreadsheet that is updated by the unit managers, DON-B, NHA-A, and maybe the supervisors that lists each resident with room number, location of the pressure injury, the stage, and when and where it was discovered. Surveyor asked RN Manager-J when R5 was added to the spreadsheet to help determine when WP-I was notified of R5's pressure injury. RN Manager-J stated they would look to see and would get that information to Surveyor. Surveyor did not receive any further information from RN Manager-J. On 6/5/2024 at 10:00 AM,[TRUNCATED]

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor reviewed the facility's policy and procedure last reviewed 4/23 and notes the following in regards to falls: .Policy: Each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a Resident's fall risk. a. The risk assessment categorizes Residents according to low, moderate, or high risk. b. For program identification purposes, the facility utilizes high risk and low/moderate risk, using the scoring method designated on the risk assessment. 2. Upon admission the nurse will complete a fall risk assessment along with the admission assessment to determine the Resident's level of fall risk. 3. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of Resident falling, including but not limited: i. A clear pathway to the bathroom and bedroom doors ii. Bed is locked and lowered to a level that allows the Resident's feet to be flat on the floor when the Resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. iv. Adequate lighting. v. Wheelchairs and assistive devices are within reach b. Implement routine rounding schedule. c. Monitor for changes in Resident's cognition, gait, ability to rise/sit and balance. d. Encourage Residents to wear shoes or slippers with non-slip soles when ambulating. e. Ensure eye glasses, if applicable, are clean and the Resident wears them when ambulating. f. Monitor vital signs in accordance with facility policy. g. Complete a fall risk assessment every 90 days and as indicated when the Resident's condition changes. 4. High Risk Protocols: a. The Resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan b. Implement interventions from Low/Moderate Risk Protocols c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the Resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. Scheduled ambulation or toileting assistance viii. Family/caregiver or Resident education ix. Therapy services referral 5. When a Resident who does not have a history of falling experiences a fall, the Resident will be placed on the Facility's Fall Prevention Program. 6. Each Resident's risk factors and environmental hazards will be evaluated when developing the Resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 7. When any Resident experiences a fall, the facility will: a. Assess the Resident b. Complete a post-fall assessment c. Complete an incident report d. Notify physician and family e. Review the Resident's care plan and update as indicated f. Document all assessments and actions g. Obtain witness statements in the case of injury 2) R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Psychotic Disturbance, Generalized Anxiety Disorder, Essential Hypertension, Type 2 Diabetes, Pulmonary Fibrosis, and Type 2 Diabetes Mellitus. R3 has a legal guardian. R3's Quarterly Minimum Data Set(MDS) dated [DATE] documents that R3's Brief Interview for Mental Status(BIMS) could not be assessed as well as the Patient Health Questionnaire(PHQ-9). R3's delusions and hallucinations are not documented. R3's MDS documents that R3 has physical and verbal symptoms which occurred 1-3 days, wandering 1-3 days, and rejection of care 4-6 days during the assessment period. R3 has no range of motion issues. R3 utilizes a walker and wheelchair. The MDS also documents that R3 requires supervision for upper and lower dressing and chair/bed-to-chair transfer. R3 is independent with mobility and transfers. Surveyor reviewed R3's [NAME] as of 6/3/24 only documents to ensure R3 has unobstructed path to the bathroom. The following care plans related to falls for R3 are in place: Problem 1. R3 is at risk for falls due to bladder and bowel incontinence, cognitive impairment, anxiety, medication regimen. -12/16/23 Unwitnessed Fall with injury Date Initiated: 09/25/2022 Revision on: 12/18/2023 Interventions in place o Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Date Initiated: 09/25/2022 o Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 09/25/2022 o Ensure that the resident is wearing appropriate footwear Date Initiated: 09/25/2022 o Follow facility fall protocol. Date Initiated: 09/25/2022 Problem 2. R3 has impaired physical mobility due to right intertrochanteric fracture, status post trochanteric nailing. Also has Alzheimer's dementia, Cardiac conditions, Anxiety and Osteoarthritis. Date Initiated: 09/25/2022 Revision on: 04/02/2024 Interventions in place o The resident is WEIGHT-BEARING Date Initiated: o LOCOMOTION: The resident uses wheelchair for locomotion. Assist as needed. Date Initiated: 12/27/2023 o PT, OT referrals as ordered, PRN. Date Initiated: 09/25/2022 Surveyor notes that no new interventions were put in place after the 12/16/23 unwitnessed fall resulting in a right intertrochanteric fracture. R3's fall assessment dated [DATE] documents a score of 18, which indicates that R3 is high risk for falls. Surveyor reviewed an investigation dated 12/16/23 which documents R3 was found at 3:30 PM by a certified nursing assistant(CNA) laying on left side, screaming of pain pointed to right hip. Reluctant to move or wiggle right foot due to pain. Observed R3's right foot wearing left shoe and left foot wearing right shoe. Floor notes no debris, dry, small bag full of own personal things on floor next to R3. R3 was transported to the emergency room for evaluation. Surveyor notes that both physician and guardian were notified. Surveyor notes the investigation of R3's unwitnessed fall does not document a head to toe assessment, staff statements, and a root cause analysis. Surveyor reviewed R3's hospital Discharge summary dated [DATE] which documents that R3 had a right intertrochanteric femur fracture status post insertion of trochanteric femoral nail. On 6/3/24 at 11:33 AM, Surveyor observed R3 in normal height bed sleeping. R3's call light was hanging down at the end of the bed not within reach of R3. On 6/3/24 at 1:47 PM, Surveyor again observed R3 in normal height bed sleeping, in same position as the morning. R3's call light was hanging down at the end of the bed not within reach of R3. On 6/5/24 at 10:05 AM, Surveyor observed R3 in normal height bed sleeping. R3's call light is on the floor in the corner of the room, far from head of bed where R3 was located. On 6/4/24 at 2:47 PM, Director of Nursing(DON-B) stated that there should be staff statements attached to the incident fall report. Statements should include last seen, last toileted, type of footwear, interventions in place etc. DON-B stated the statements should be very detailed. The interdisciplinary team(IDT) meets the next day to review the Resident falls. DON-B stated that routine rounding is defined as every 2-3 hours staff should be checking on Resident at a minimum by eyesight. Surveyor reviewed that R3's fall incident report did not have staff statements with the above details, and no documentation of an IDT meeting to discuss the root cause analysis of R3's fall. Surveyor also shared there have been new interventions since the fall which resulted in a fracture. Surveyor pointed out per policy, and based on R3's fall assessment indicating R3 is high risk for falls, R3 should be in a low bed. Nursing Home Administrator(NHA-A) explained the facility is in the process of changing all Resident beds to have the capability of being a low bed, however, NHA-A informed Surveyor that R3's unit has not been done yet. Surveyor shared the concern about R3's fall, no statements with details, no physical assessment, no care plan interventions updated, and no root cause analysis. NHA-A stated, Your aren't telling us anything we don't know already. No additional information was provided as to why the facility did not ensure that R3's fall on 12/16/23 was thoroughly investigated as to the root cause and why no care plan interventions were implemented to prevent future falls. Based on observation, record review, and interview, the facility did not ensure care plans were implemented for residents determined to be at risk for falls and did not ensure residents were comprehensively assessed after a fall to implement preventive measures based on the assessment for 2 (R1 and R3) of 4 residents reviewed for falls. *R1 was admitted to the facility after sustaining a fractured left hip from a fall in the community. R1 was assessed to be a high risk for falls and no care plan was developed to address the fall risk. On 4/22/2024, R1 fell from bed and sustained a fracture to the right hip. *R3 fell on [DATE] and sustained a fractured to the right hip. The fall was not thoroughly investigated as to the root cause and no care plan interventions were implemented to prevent future falls. Observations were made during the survey of fall interventions not in place per care plan. Findings include: 1.) R1 was admitted to the facility on [DATE] with diagnoses of fractured neck of the left femur, post hemorrhagic anemia, encephalopathy, Alzheimer's disease, and anxiety. R1's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R1 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 6 and assessed as being dependent for toileting hygiene and transferring, and maximal assistance with dressing and bathing, and moderate assistance for bed mobility. R1's Fall Care Area Assessment with the admission MDS indicated falls were to be addressed in a care plan to minimize risks. R1 had an activated Power of Attorney (POA). On 3/7/2024, R1's admission Data Collection and Baseline Care Plan Tool was completed by Licensed Practical Nurse (LPN)-N. LPN-N documented in the Physical and Functional Status section of the form that R1 was at risk for falls. Interventions were listed as possible fall prevention measures and no fall planning interventions were selected on the form. On 3/7/2024, R1's Fall Risk Evaluation form was completed by LPN-N. LPN-N documented R1 was a t risk for falls with a score of 13. The top of the form in the computer charting system indicates any score above 10 indicates the resident is at high risk for falls. Surveyor reviewed R1's comprehensive Care Plan. The Care Plan did not include any fall risk or interventions to prevent future falls. On 3/9/2024 at 2:19 AM, in the progress notes, nursing charted R1 did not attempt to self-transfer or get out of bed. On 3/9/2024 at 11:39 PM, in the progress notes, nursing charted the call light was within reach and the bed was locked and at lowest position. On 3/10/2024 at 9:48 PM, in the progress notes, nursing charted the call light was within reach and the bed was locked and at lowest position. On 3/12/2024 at 7:40 AM, in the progress notes, nursing charted R1 was alert to self, confused to time and place. R1 had been removing the linen off the bed and had undressed in bed. R1 had a nervous laugh as R1 rubbed the left hip and leg. Pain medication was administered along with one-on-one and position changes. R1 denied pain when asked but showed nonverbal pain such as the nervous laugh, rubbing the hip, restlessness, and moaning. R1 had poor safety awareness. Decreased stimuli was provided. On 4/9/2024 at 4:55 AM, in the progress notes, nursing charted R1 had made several attempts to get out of bed unassisted. R1 was weight-bearing as tolerated but at that time was not ambulating. R1 calls out for help and has a laughter that resembles that of a nervous laugh. Even when nurses or Certified Nursing Assistants (CNAs) did some one-on-one with R1, that did not stop R1 from calling out help, help, oh no. R1 had been changed and is dry, fluids and a snack were provided. Diminished stimuli was provided. R1 continued with anxiety and restless ness. CNA/nurse provided a safe environment so that R1 would not fall or injure themselves. On 4/10/2024 at 5:32 AM, in the progress notes, nursing charted R1 was restless and called out help me, help me, help me. Staff in with R1 to anticipate and assist with R1. R1 made several attempts to get out of bed unassisted. R1 remained restless even after toileting. Due to safety, R1 was washed up and got ready for the morning. R1 was brought to the common area and given a magazine to look at and a sandwich and apple juice to eat. R1 continued to be anxious and restless. On 4/14/2024 at 5:50 AM, in the progress notes, nursing charted R1 called out help, help, help. The CNA went into the room and R1 was sitting at the edge of the bed. When asked what R1 was doing, R1 did not know and then had a nervous laughter. R1 asked the CNA to please help and when the CNA asked what R1 would like the CNA to do, R1 did not know. R1 had poor safety awareness at night. On third shift R1 does not walk independently; R1 is a max assist of two to transfer to the wheelchair. Safety checks were done related to R1 attempting to get out of bed. Despite being taken care of, R1 continued to demonstrate anxiety and restlessness. On 4/15/2024 at 2:59 AM, in the progress notes, nursing charted R1 had been up since the change of shift. R1 was repetitive, restless, and anxious. Decreased stimuli was provided, one-on-one was given when able, and snacks and fluids were given. All interventions provided short-term relief for restlessness, but it was not effective for the anxiety. The Nurse Practitioner was notified. On 4/22/2024 at 10:07 PM, in the progress notes, LPN-L was informed by the Supervisor that R1 was on the floor. LPN-L and the Supervisor went to R1's room and observed R1 sitting on the floor with legs straight leaning with R1's back on the recliner chair facing the bed. Range of motion was within normal limits to all extremities. Neurological checks were initiated and were negative. R1 could respond to questions but could not remember what happened as R1 has impaired memory and is forgetful. This was normal for R1 as R1 had diagnoses of dementia with anxiety. No changes in consciousness or conditions were noted. No acute distress was observed. Scheduled Tylenol was administered for complaints of pain. R1 had a skin tear with hematoma to the right arm that measured 11 cm x 6.5 cm. The area was cleansed with normal saline and a wet to dry dressing was applied followed by Kerlix. A cold pack was placed on the area. R1 was put back in bed with a Hoyer lift by two CNAs and the assigned CNA. Vital signs were stable and remained with baseline. Interventions were put in place: a bed bolster placed on the left side of R1 under the fitted sheet. The bed was at low level and call light was in place. R1 is forgetful and reminded to call for assistance. The POA, Nurse Practitioner, Director of Nursing (DON) were updated and aware of the fall. On 4/22/2024 at 11:01 PM, in the progress notes, the LPN Nursing Supervisor charted R1 was sitting on the floor facing the bed with the back against the recliner. R1 had gripper socks on, and the call light was on the bed. R1 had scabbing along the right lateral arm with bleeding and a bruise. The unit nurse measured the wound 11 cm x 6.5 cm and cleaned the wound and applied a dressing. A cold pack was placed on the arm and a bed booster was placed on the left side of R1 under the fitted sheet. The Supervisor notified the Nurse Practitioner and the POA of the situation. The POA requested an x-ray. (Surveyor attempted to interview the LPN Nursing Supervisor, but they were unavailable for interview.) On 4/23/2024 at 8:00 AM, in the progress notes, nursing charted the nurse was called into R1's room by the CNA at 7:45 AM. R1 was lethargic and screaming with complaints of excruciating pain in the right leg. R1 had a hematoma to the right arm. Blood pressure 96/56, temperature 98.1, pulse 95, oxygen saturation 95% on room air, and respirations 18. R1 was unable to move lower extremities per baseline. The nurse contacted R1's POA and explained it would be in the best interest if R1 was sent to the hospital for further evaluation. R1 was sent to the hospital and communication between the hospital and the facility showed R1 had a right hip fracture. At 1:42 PM in the progress notes, nursing charted R1 went to the hospital at 8:30 AM. The AM shift CNA stated that when the CNA tried to get R1 dressed, R1 complained of severe pain and the AM shift nurse sent R1 to the hospital where R1 was diagnosed as having a right femur fracture and waiting for possible surgery. No documentation was found of an RN doing an assessment of R1 after the fall on 4/22/2024. R1 did not return to the facility and was not a resident at the time of the survey. In an interview on 6/3/2024 at 3:35 PM, Surveyor asked LPN-L to describe the events of 4/22/2024 when R1 fell in R1's room. LPN-L stated R1 was found on the floor and was not sure if R1 fell from the bed or from the recliner in the room. LPN-L stated R1 had a skin tear and bruising to the upper arm. LPN-L stated R1's legs were straight and R1 did not complain of any pain to the legs. LPN-L stated R1 was lifted back to bed using a Hoyer lift and did not complain of any pain to the leg when R1 was moved. LPN-L stated the LPN supervisor came to R1's room after R1 fell. LPN-L stated if there is no RN in the building, the facility assigns an LPN to be the supervisor. Surveyor asked LPN-L if an RN came to assess R1 after the fall. LPN-L could not recall if any other nurse came to the room. LPN-L reiterated R1 did not complain of any pain to the leg or have any range of motion problems at the time of the fall. In an interview on 6/4/2024 at 10:34 AM, Surveyor asked LPN MDS-M what the facility process was for completing the MDS assessments and creating care plans. LPN MDS-M stated LPN MDS-M works with a Registered Nurse (RN) to complete all the MDS assessments for the facility. LPN MDS-M stated each discipline completes the appropriate section of the MDS and then if a Care Area Assessment (CAA) is triggered, that discipline would complete the CAA to address the triggered area. Surveyor asked LPN MDS-M who initiates care plans for new residents. LPN MDS-M stated the nurse on the floor opens a baseline care plan and then the MDS nurses make sure all areas are completed on the care plan. LPN MDS-M stated the baseline care plans are part of the admission assessment. Surveyor shared with LPN MDS-M the concern R1's Fall CAA was triggered, was assessed to be at risk for falls, the CAA documented falls were to be addressed in the care plan to minimize risks, and no falls care plan was initiated. LPN MDS-M stated a fall care plan should have been initiated and would look to see if one could be located. At 11:35 AM, LPN MDS-M stated R1 did not have a fall care plan on file. LPN MDS-M stated the RN supervisor helps the floor nurse with the baseline care plan. LPN MDS-M stated the MDS nurse, when completing the Fall CAA, should have caught R1 did not have a fall care plan. In an interview on 6/4/2024 at 2:21 PM, DON-B stated an RN is always called in to assess a resident after a fall. Surveyor reviewed the staff schedule for 4/22/2024 and an RN was listed as being on the second shift at the time of R1's fall. DON-B stated the RN on the schedule was an agency RN and the agency staff do not always chart even though they are instructed to do so. DON-B stated the RN should have charted an assessment and agreed no documentation was found indicating R1 was assessed by an RN after the fall. On 6/4/2024 at 2:36 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B R1 was assessed on admission to be at risk for falls per the Fall Risk Assessment and no Falls Care Plan was initiated on the baseline care plan. R1 triggered the Fall CAA on the admission MDS, and no Fall Care Plan was initiated at any time while R1 was a resident at the facility by either the nurse unit manager, supervisor, or MDS nurse. Surveyor shared the concern when R1 fell on 4/22/2024, R1 was not assessed by an RN at the time of the fall and R1 sustained a right hip fracture requiring hospitalization. At 3:16 PM, NHA-A stated fall care plan interventions include low beds, and all beds are low beds except for ones that have not been swapped out as the building is being renovated so R1 would have had a low bed even without a care plan in place for falls. NHA-A stated each new admission is reviewed to make sure care plans are addressed. NHA-A stated NHA-A looked at the admission checklist for R1 and the Fall Care Plan was checked as being completed. NHA-A agreed R1 did not have a Fall Care Plan in place at any time while a resident of the facility. On 6/5/2024 at 9:37 AM, Surveyor interviewed LPN-N. LPN-N was the nurse that admitted R1 to the facility on 3/7/2024. Surveyor asked LPN-N what the process was for a newly admitted resident. LPN-N stated the electronic charting system generates all the admission forms that need to be completed including the admission Data Collection and Baseline Care Plan Tool. Surveyor asked LPN-N if that tool is what creates the baseline care plan with interventions. LPN-N was not sure. Surveyor showed LPN-N R1's admission Data Collection and Baseline Care Plan Tool that LPN-N had completed with the possible fall interventions not selected. LPN-N stated LPN-N does not do anything with care plans per facility policy because LPN-N is an LPN. Surveyor shared with LPN-N R1 did not have a Fall Care Plan in place even after being assessed at risk for falls. LPN-N was not aware R1 did not have a Fall Care Plan. In an interview on 6/5/2024 at 10:05 AM, Surveyor asked CNA-O what CNA-O could recall of R1's fall on 4/22/2024. CNA-O stated CNA-O had put R1 to bed and then R1 was on the floor after hearing yelling coming from R1's room. CNA-O did not know how R1 fell. CNA-O stated R1 had a bruise and was bleeding from the arm. CNA-O stated nothing else was wrong or injured. CNA-O stated an LPN and one other nurse came to look at R1. Then R1 was put back in bed using a Hoyer lift. CNA-O stated R1 did not complain of any pain and remembered the nurse moving R1's legs without any difficulty. CNA-O stated when R1 was put back in the bed, they put pillows on the side to protect R1 from falling again. No additional information was provided as to why R1 was assessed to be a high risk for falls and no care plan was developed to address the fall risk. On 4/22/2024, R1 fell from bed and sustained a fracture to the right hip.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure that an allegation of abuse involving 1 (R3) of 2 residents reviewed for allegations of abuse were reported immediately to the State Survey Agency. *On 4/17/24 an allegation of R3 being choked by a certified nursing assistant(CNA) was not reported to the state survey agency within 2 hours and local law enforcement was not notified of the allegation immediately. Findings Include: Surveyor reviewed the facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation policy and procedure last revised 2/2020 and notes the following in regards to reporting: .Purpose .Facility is in compliance with the reporting and investigation guidelines specific to each program area governed by the State Survey and Compliance Agencies(Division of Quality Assurance(DQA)/Office of Caregiver Quality(OCQ)). .All alleged incidents of abuse, neglect, exploitation, and misappropriation must be reported and investigated in a timely manner per program code requirements. Special Key Points 2. An initial review of the allegation prior to reporting to DQA/OCQ may be conducted to determine whether or not the incident needs to be reported to DQA/OCQ. All alleged violations involving mistreatment(including abuse, neglect, exploitation, injuries of unknown source, misappropriation of property, resident-to-resident abuse, and mistreatment by family members, visitors, volunteers or other individuals) must be reported to the DQA/OCQ as soon as possible, but not to exceed 24 hours from the discovery. The initial report is not to exceed 2 hours from discovery if serious bodily injury has occurred. 3. If the injury/incident was a result of a suspected crime, law enforcement must also be notified. 2. Assess the Effect on the Resident a. The Resident(s) must be interviewed and a body assessment completed as necessary. b. An assessment for psychosocial changes will be completed and document findings. c. Physician is made aware, as needed. Family is made aware if appropriate. Case management organizations notified as needed. d. Follow-up Resident interviews should be conducted. 1.) R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Psychotic Disturbance, Generalized Anxiety Disorder, Essential Hypertension, Type 2 Diabetes, Pulmonary Fibrosis, and Type 2 Diabetes Mellitus. R3's Quarterly Minimum Data Set(MDS) dated [DATE] documents that a Brief Interview for Mental Status(BIMS) could not be assessed as well as the Patient Health Questionnaire(PHQ-9). R3's delusions and hallucinations are not documented. R3's MDS documents that R3 has physical and verbal symptoms which occurred 1-3 days, wandering 1-3 days, and rejection of care 4-6 days during the assessment period. R3 has no range of motion issues. R3 utilizes a walker and a wheelchair. The MDS also documents that R3 requires supervision for upper and lower dressing and chair/bed-to-chair transfer. R3 is independent with mobility. R4 reported an allegation that R4 overheard verbal and physical abuse between R3 and a CNA at about 3:00 AM on 4/17/24. R4 reported that R4 heard R3 choking and then R3 was overheard to be going up and down the hallway yelling she choked me. The facility submitted to the State Survey Agency an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report on 4/17/24 at 4:30:58 PM. Surveyor notes the report does not document what time the facility was made aware of the incident or what time the administrator was notified of the allegation. The report was not submitted with-in the 2 hour required reporting time-frame for allegations of serious bodily injury. The facility submitted the Misconduct Incident Report on 4/24/24 at 8:06:45 PM. The report does not document that the local law enforcement was notified of the allegation that R3 was choked by a CNA. Surveyor notes this report is 1 day past the 5 day required reporting time-frame. On 6/3/24 at 11:35 AM, Surveyor interviewed R4 regarding the allegation that R4 overheard verbal and physical abuse between R3 and a CNA at about 3:00 AM on 4/17/24. R4 also reported that R4 heard R3 choking and then R3 was overheard to be going up and down the hallway yelling she choked me. R4 stated that R4 put R4's call light on immediately to report it, however, R4 stated that R4's call light was not answered until about 5 to 7:00 AM, by the next shift. R4 stated R4 informed a CNA whom no longer is employed at the facility. R4 informed Surveyor that R4 heard a nurse tell R4 she says she didn't choke you, but R4 does not know who that nurse was. On 6/5/24 at 7:44 AM, Surveyor interviewed Social Worker (SW-C) regarding the submitted reports to the State Survey Agency. SW-C confirmed that SW-C prepared, completed, and submitted the Facility Reported Incident(FRI) involving R3 and the allegation that R3 was verbally and physically abused including an allegation of R3 being choked. SW-C does not recall why SW-C did not report within 2 hours, why the local law enforcement was not notified, and why the Misconduct Incident Report was not submitted within the 5 day reporting time-frame. SW-C stated SW-C would need to look into the details and get back to Surveyor. On 6/5/24 at 8:37 AM, SW-C informed Surveyor that SW-C did not notify the local law enforcement because R3 could not say what happened. SW-C was not able to provide information as to why SW-C did not report within 2 hours and why the FRI was not submitted within the required time-frame. On 6/5/24 at 8:45 AM, Surveyor shared with Nursing Home Adminstrator (NHA-A)of the allegation of verbal and physical abuse including an allegation of R3 being choked was not reported with-in 2 hours, was not submitted with-in the 5 days required reporting time frame, and that the local law enforcement was not notified. NHA-A acknowledged the concern and was not able to provide any additional information at this time.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure all allegations involving potential abuse, neglect and misappropriation of Resident property were thoroughly investigated for 2 (R3 and R4) of 2 sampled residents. *R3's Facility Reported Incident(FRI) dated 4/17/24 documents an allegation of R3 being choked. The FRI does not contain other Resident statements, all staff statements, the reasoning for why the local law enforcement was not notified and a root cause analysis of the circumstances of the allegation. *R4's Facility Reported Incident(FRI) dated 4/1/24 documents an allegation of R3 being choked. The FRI does not contain other Resident statements, all staff statements, and a root cause analysis of the circumstances of the allegation. Surveyor reviewed the facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation policy and procedure last revised 2/2020 and notes the following in regards to a thorough investigation: Thorough investigation and corrective action ensures that the safety of the Resident has not been jeopardized. Guidelines 2. Assess the Effect on the Resident a. The Resident(s) must be interviewed and a body assessment completed as necessary. b. An assessment for psychosocial changes will be completed and document findings. c. Physician is made aware, as needed. Family is made aware if appropriate. Case management organizations notified as needed. d. Follow-up Resident interviews should be conducted. 2. Investigate the Allegation a. Contact law enforcement or other regulatory authority if appropriate. b. Obtain written, signed statements from all witnesses or persons with information. c. Obtain a written, signed statement from the accused individual. 4. Conclude the Investigation a. Review all components of the investigation. b. Inform accused caregiver that a report to another agency has been submitted. If the accused is a Resident, inform Resident and responsible party of the report to DQA has occurred. c. The conclusion must be written on the Investigation Summary form once employee interviews and a chart review have been completed. 5. Follow-up a. All the completed forms must be submitted to the Director of Nursing/designee. b. Contact the person who reported the incident. c. Reassure the Resident and family if the caregiver. R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Psychotic Disturbance, Generalized Anxiety Disorder, Essential Hypertension, Type 2 Diabetes, Pulmonary Fibrosis, and Type 2 Diabetes Mellitus. R3's Quarterly Minimum Data Set(MDS) dated [DATE] documents that R3's Brief Interview for Mental Status(BIMS) could not be assessed as well as the Patient Health Questionnaire(PHQ-9). R3's delusions and hallucinations are not documented. R3's MDS documents that R3 has physical and verbal symptoms which occurred 1-3 days, wandering 1-3 days, and rejection of care 4-6 days during the assessment period. R3 has no range of motion issues. R3 utilizes a walker and a wheelchair. The MDS also documents that R3 requires supervision for upper and lower dressing and chair/bed-to-chair transfer. R3 is independent with mobility. R4 reported an allegation that R4 overheard verbal and physical abuse between R3 and a CNA at about 3:00 AM on 4/17/24. R4 reported that R4 heard R3 choking and then R3 was overheard to be going up and down the hallway yelling she choked me. The facility submitted to the State Survey Agency an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report on 4/17/24 at 4:30:58 PM. The facility submitted the Misconduct Incident Report(FRI) on 4/24/24 at 8:06:45 PM to the State Survey Agency. Surveyor reviewed all of the documentation describing the allegation, and statements. The facility obtained only 4 staff statements. There are 4 additional staff statements that are blank. The facility obtained R4's statement and another Resident's statement that overheard the commotion. No other Resident statements were obtained to determine if any other Resident had been affected by the CNA. The local enforcement were not notified of the allegation of R3 being choked. The summary written by Social Worker(SW-C) states that R4 reported that R4 did not see any staff before or after the alleged incident but R4 could hear the sound of someone being hit and then the CNA was overheard to say to R3 don't put your m f . hands on me. R4 then heard R3 choking and the CNA was heard to say I told you not to touch me. R4 reported that R3 then yelled she choked me and repeatedly said this as R3 went up and down the hallway. Another Resident statement reported they heard R3 in the hallway going back and forth stating that R3 was calling the police and stating you had me by my throat. The summary identifies CNA-F as the CNA that provided cares to R3. CNA-F statement consists of answering no to the following questions: 1. Did you provide cares to R3 on 4/17/24? 2. Are you aware of an altercation between R3 and a staff member? 3. R3 report any abuse allegations to you? 4. Did you witness any physical or verbal abuse towards R3? The summary also documents the nurse assigned to R3 was unable to be reached to obtain a statement. On 6/3/24 at 11:35 AM, Surveyor interviewed R4 regarding R4 reporting that R4 heard sounds of someone being hit, verbal abuse from CNA-F, and hearing R3 stating that R3 had been choked by CNA-F. R4 stated R4 never saw the staff member because CNA-F never came into R4's room on that shift. R4 stated that R3 was going up and down the hallway yelling R3 had been choked by CNA-F. R4 stated R4 overheard the nurse tell R3 she said she didn't choke you. R4 was not able to identify the nurse. R4 put R4's call light on and informed Surveyor that the call light was not answered until around 5 to 7:00 AM by the first shift CNA who no longer works at the facility. R4 informed that CNA of what R4 had overheard and asked the CNA to check R3. According to R4, that CNA checked R3's neck and reported to R4 there were red marks on R3's neck. Surveyor notes that R4's statement that R4 reported the allegation to that CNA, and the CNA had checked out R3's neck is not included in the documentation in the facility's FRI. Surveyor notes there is no documentation of a head to toe physical assessment of R3 included in the facility's FRI. There is no nurse statement that according to R4, R4 overheard the nurse speaking to R3 about the allegation of R3 being choked. On 6/5/24 at 7:44 AM, Surveyor interviewed SW-C regarding the 4/17/24 FRI. SW-C confirmed that SW-C completed the investigation for the allegation that R3 was choked. SW-C stated SW-C follows the same method of investigating a grievance but administration is notified and written staff statements are obtained. The accused employee is suspended pending the investigation. Sometimes SW-C will have to take verbal over the phone from staff. SW-C also obtains Resident statements. SW-C completes a BIMS and PHQ-9 on the affected Resident. SW-C pulls reports from the unit. SW-C consults with the Administrator if the local law enforcement should be notified. SW-C is not able to recall why local law enforcement was not notified of R3's allegation of being choked, why only 4 staff statements were obtained, no other Resident statements were obtained, and why a BIMS and PHQ-9 were not completed on R3. SW-C will get back to Surveyor. On 6/5/24 at 8:37 AM, SW-C informed Surveyor that a BIMS and PHQ-9 was not completed on R3 because R3 would have gotten agitated with all the questions. SW-C stated the police were not notified because R3 could not remember the incident. SW-C is not able to provide any additional information as to why CNA-F's statement was not obtained, the CNA that the allegation was reported to by R4, or the nurse's statement as well as other staff statements and Resident statements not being obtained. On 6/5/24 at 8:45 AM, Surveyor informed Nursing Home Adminstrator (NHA-A) that a thorough investigation had not been completed in regards to R3's FRI dated 4/17/24. Surveyor shared there is no documentation that a head to toe physical assessment had been completed on R3. Surveyor also shared there are no Resident statements documenting if there was any issues with abuse, and the FRI is missing several staff statements, and the FRI is missing documentation that the local law enforcement had been notified. NHA-A acknowledged the concern and provided no additional information at this time. 2.) R4's diagnoses includes hypertension, atrial fibrillation, morbid obesity, and left above knee amputation. The quarterly MDS (minimum data set) with an assessment reference date of 2/24/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R4 is assessed as being dependent for chair/bed to chair transfers. On 6/3/24 at 1:35 p.m., Surveyor spoke with R4 and asked how staff treats her. R4 replied ok because I advocate for myself. R4 explained she does a lot for herself and doesn't have staff do something she could do for herself. R4 informed Surveyor she has had problems in the past and explained to Surveyor she needed to get up at 5:00 a.m. as she was going to [name of hospital] for her leg. R4 explained the ride was picking her up at 8:00 a.m. and wanted to get up early to get washed and dressed. R4 informed Surveyor first shift gets here at 7:00 a.m., sometimes they don't know which area they are assigned and may not be starting until 7:10 or 7:15 a.m. R4 informed Surveyor she ask nurse to get CNA (Certified Nursing Assistant)-E. R4 informed Surveyor CNA-E was cursing in the hallway, just going off saying she was sick of this place, they are short, sick of R4 and has to get R4 up. R4 informed Surveyor she's not sure why CNA-E said she was sick of her as all she asks CNA-E for is ice. R4 informed Surveyor LPN (Licensed Practical Nurse)-D came in and told her she didn't think there was time to get her up as they were very short & very busy. R4 informed Surveyor she told LPN-D its their job to help her. R4 informed Surveyor at 5:00 a.m. she placed her call light on. R4 informed Surveyor CNA-E answered her light, came in and stated what do you want then told her she was busy. R4 indicated CNA-E did come back and helped her into her chair. R4 informed Surveyor she told CNA-E she was going to report her. R4 informed Surveyor she reported it to name of NHA (Nursing Home Administrator)-A and name of DON (Director of Nursing)-B. R4 informed Surveyor SW (Social Worker)-C spoke with her. R4 informed Surveyor CNA-E does not take care of her anymore. LPN-D is still working on the unit and she's alright with this. R4 informed Surveyor she thinks they handled it pretty well. On 6/4/24 at 1:52 p.m., Surveyor reviewed the Facility's reported Incident for date of incident 4/1/24 involving R4 and CNA-E. Surveyor noted R4's concern was written up as a grievance/concern but was escalated to a self report. Surveyor noted the Facility protected R4 & other Residents as CNA-E was suspended during the investigation. The Facility interviewed CNA-E, LPN-D, and two other staff members who were not aware of the incident. Surveyor noted on the staff interview form for incident date of 4/1/24 there is a note with handwritten notation of no answer no call back for five staff. There is no indication as to when calls were placed, whether the Facility attempted to call these five employees back or have staff come to the Facility to be interviewed. Surveyor also noted there are no Resident statements or which Residents were interviewed to determine if there were concerns with CNA-E prior. On 6/4/24 at 2:36 p.m., during the daily exit meeting, Surveyor informed NHA-A and DON-B Surveyor would like to speak with SW (Social Worker)-C the next morning. On 6/5/24 at 7:44 a.m., Surveyor met with SW-C to inquire about investigation process for Resident's concerns. SW-C informed Surveyor for grievances she takes the statement & completes the grievance form. After completing this she starts to investigate by using who, what, where method. SW-C informed Surveyor she also informs NHA-A and DON-B. Surveyor inquired what happens when it's a concern that is self reported. SW-C informed Surveyor she follows the steps she explained in the grievance process and expedites it so that it's reported in the 2 hour window and the accused employee is suspended during the investigation. SW-C indicated she takes staff statements which are written unless it's third shift staff then takes verbal statements over the phone. Surveyor asked SW-C if she calls an employee & they don't answer does she call them back. SW-C indicated she does. Surveyor inquired if she speaks with Residents. SW-C replied yes. SW-C informed Surveyor she also will do a Resident's BIMS (brief interview mental status) & PHQ (patient health questionnaire) and update the family. Surveyor informed SW-C Surveyor did not note any Resident statements in the Facility's investigation regarding R4 & CNA-E on 4/1/24. SW-C informed Surveyor she doesn't recall and would have to look. Surveyor inquired for staff that didn't call back, could SW-C show Surveyor when she called staff back. SW-C informed Surveyor she could look in the file to see if there is any information and get back to Surveyor. On 6/5/24 at 8:26 a.m., SW-C informed Surveyor she doesn't have any information to provide Surveyor regarding staff. SW-C informed Surveyor and stated [name of resident] heard but couldn't make out who was taking but heard R4's name. SW-C informed Surveyor she doesn't have a list of residents who she spoke to and what they said. On 6/5/24 at 11:20 a.m., Surveyor informed NHA-A and DON-B the Facility's reported incident regarding R4 and CNA-E was not thoroughly investigated as there were five staff who were initially called, did not call back and there is no evidence the Facility attempted to contact them again to obtain their statements. In addition there are no Resident's statements. NHA-A informed Surveyor she went back & interviewed staff. Surveyor asked NHA-A to provide Surveyor with any additional information she may have to show the Facility completed a thorough investigation of the incident on 4/1/24. Surveyor was not provided with any additional information regarding the incident on 4/1/24 involving R4 & CNA-E.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 1 (R3) of 1 residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. *R3's hospital discharge paperwork dated 12/20/23 has instructions for R3 to follow-up for an orthopaedic consult to be scheduled within 6 weeks after discharge. R3 did not have a consult until 3/11/24. The consult documented that R3 was to return in 1 month for repeat x-rays. R3 did not have that appointment. R3 was scheduled for an orthopaedic appointment on 5/7/24 which R3 did not attend. Findings Include: 1.) On 6/5/24 at 11:54 AM, Administrator(NHA-A) informed Surveyor the facility does not have a policy and procedure for Resident appointments. R3 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dementia with Psychotic Disturbance, Generalized Anxiety Disorder, Essential Hypertension, Type 2 Diabetes, Pulmonary Fibrosis, and Type 2 Diabetes Mellitus. R3's Quarterly Minimum Data Set(MDS) dated [DATE] documents that R3's Brief Interview for Mental Status(BIMS) could not be assessed as well as the Patient Health Questionnaire(PHQ-9). R3's delusions and hallucinations are not documented. R3's MDS documents that R3 has physical and verbal symptoms which occurred 1-3 days, wandering 1-3 days, and rejection of care 4-6 days during the assessment period. R3 has no range of motion issues. R3 utilizes a walker and wheelchair. The MDS also documents that R3 requires supervision for upper and lower dressing and chair/bed-to-chair transfer. R3 is independent with mobility and transfers. Surveyor reviewed an investigation dated 12/16/23 which documents R3 was found at 3:30 PM by a certified nursing assistant(CNA) laying on left side, screaming of pain pointed to right hip. Reluctant to move or wiggle right foot due to pain. Observed R3's right foot wearing left shoe and left foot wearing right shoe. Floor notes no debris, dry, small bag full of own personal things on floor next to R3. R3 was transported to the emergency room for evaluation. Surveyor notes that both physician and guardian were notified. Surveyor reviewed R3's hospital Discharge summary dated [DATE] which documents that R3 had a right intertrochanteric femur fracture status post insertion of trochanteric femoral nail. The discharge summary has instructions for R3 to follow-up with orthopaedic trauma surgery in 6 weeks after discharge. R3 did not have a follow-up examination until 3/11/23 according to an after visit summary dated 3/11/24. Instructions were for R3 to return in one month for an x-ray. There is no documentation that R3 returned in one month for the repeat x-ray at the orthopaedic clinic. The after visit summary dated 4/29/24 where R3 was evaluated at the heart and vascular center documents that R3 has an appointment scheduled on 5/7/24 at the orthopaedic clinic. There is no documentation that R3 went to the 5/7/24 appointment. On 6/5/24 at 10:29 AM, Surveyor spoke with Health Information Manager(HIM-X) in regards to R3's missed appointments. Surveyor asked why the delay in and missed appointments for R3. HIM-X suggested there was an issue with openings or the facility being able to provide an escort. HIM-X will get back to Surveyor. On 6/5/24 at 11:41 AM, HIM-X stated to Surveyor that HIM-X found discrepancies with R3's appointments. HIM-X explained that it was discovered that appointments were not being followed up in a timely manner and Health Unit Secretory(HUC-Y) was disciplined. HIM-X stated there was a training in March of 2024 in regards to not scheduling appointments in a timely manner. HIM-X suggested that R3 refused the appointment in April, but agreed there is no documentation that R3 actually refused the appointment. On 6/5/24 at 11:54 AM, Nursing Home Adminstrator (NHA-A) was made aware of R3's missed appointments for the follow-up to R3's fracture. No additional information was provided as to why the facility did not ensure that R3 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Feb 2024 6 deficiencies 2 Harm

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interview, the facility did not ensure that all treatments and care was provided to 1 (Resident 8) of 1 sampled residents in accordance with professional standards of practice. * R8 presented with an open area to the right, superior buttocks. The open area was not assessed by a Registered Nurse (RN), nor was the treatment consistently completed as ordered. R8 was to be repositioned every 2 hours to relieve pressure on the open area and repositioning was not consistently completed. R8 was also incontinent of bladder. R8 had a toileting problem which was not consistently followed. As a result of R8 not receiving physician ordered wound treatments and not relieving pressure and moisture from the open wound, the wound declined from a scratch like appearance with granulation tissue in the wound bed to an open area that contained 40% slough (necrotic tissue). Findings include: According to the electronic admission Record, R8 was admitted to the facility on [DATE] with diagnoses of Dementia, Lumbago with sciatica (right side), Morbid Obesity, and Anemia. The Progress Notes dated 12/23/23 documented at 04:10, indicated R8 has a small open area to the right waist and back, 1.5 centimeters (cm) X 1.0 cm. It looks like a small scar scratched by her. No bleeding, surrounding skin normal, no signs/symptoms of infection. Writer cleaned the area with wound wash solution (WWS), dried and small allevyn dressing applied for protection. Nurse Practitioner (NP), unit manager and supervisor notified via software system. (Entry was written by a Licensed Practical Nurse (LPN) and no follow up assessment by a RN was completed). A comprehensive assessment of the initial discovery of the open area was not completed. The NP directed staff to cleanse the effected area with WWS, pat dry, and apply Allevyn dressing one time a day every 3 days. A review of the Treatment Administration Record (TAR) indicated the treatment had not been completed on 01/08/24. A review of the Medical Record and TAR had indicated a comprehensive assessment was not completed until a wound physician assessed R8's open area on 01/10/24. The Initial Wound Evaluation and Management Summary dated 01/10/24, indicated R8 was oriented to person, place, time and situation and was not in any acute distress. The summary indicated R8 had a Stage 3 pressure wound, sacrum full thickness with wound measurements of 1.1 cm X 0.7 cm X 0.2 cm with light sero-sanguinous draining and 100% granulation tissue. The physician changed the treatment to apply leptospermum honey apply once daily for 30 days, and to place a gauze island with border every day for 30 days. The summary record indicated anemia and morbid obesity as factors complicating wound healing. The January 2024 TAR was reviewed and it was noted that on 01/11/24, the treatment for the open area was not indicated to be completed, so the treatment that was ordered by the wound physician on 01/10/24, was not completed. The treatment was also not completed on 01/12/24, 01/13/24 and 01/16/24. The TAR was not indicating the treatment was not done on 01/10/24, 01/17/24 and 01/24/24. On 02/01/24 at 11:00 AM, Surveyor interviewed LPN Unit Manager (UM) C. LPN UM C stated she accompanies the wound physician on rounds when in the facility. LPN UM indicated she does not sign out the TAR as the treatment can change and would have to change it on the TAR. LPN UM stated she did not put the new order from 01/10/24 into the computerized software system, which in turns adds the treatment to the TAR, until after 3:30 PM on 01/11/24. LPN UM C stated that triggered the software system to start the treatment on 01/12/24. LPN UM stated she does not enter the new orders right away as the wound physician has given verbal orders on the day of the assessment and then when the facility gets the written note the following day, the order is sometimes different and then LPN UM C has to call to clarify the order so now she just waits for the written note before changing treatment orders. LPN UM C stated she entered the daily treatment order to be completed on the PM shift as R8 would be in bed more and it would be easier to do the treatment at that time. LPN UM C indicated someone changed the treatment to be done on the day shift and it appears that change was made on 01/12/24 and to start on 01/13/24. LPN UM verified the treatments had not been completed on 01/11/24, 01/12/24, 01/13/24, and 01/16/24. LPN UM C stated R8 was confused and not reliable. LPN UM indicated that R8 was dependent on staff for repositioning and toileting. LPN UM stated repositioning and toileting should be done every 2-3 hours. The Wound Evaluation and Management Summary dated 01/17/24, indicated R8 continued with a stage 3 pressure wound sacrum full thickness which measured 1.1 cm X 0.7 cm X 0.2 cm with 40 % slough and 60% granulation tissue. The wound continues with light sero-sanguineous drainage and the wound progress was at goal. The wound physician indicated surgical excision debridement procedure was completed and after the procedure the slough in the wound bed decreased from 40% to 0%. Treatment was changed to apply a hydrocolloid dressing and to apply 3 times per week. Recommendations were to offload wound and to reposition per facility policy. The Progress Notes dated 01/18/24 documented at 11:10 am indicated R8 was alert and responsive. The Progress Notes dated 01/21/24 documented at 13:47 (1:47 pm) indicated R8 was alert and oriented Xs 2.Toilets per requests Encouraged to shift weight side to side while up in own recliner chair. Agreeable. The Wound Evaluation and Management Summary dated 01/24/24, indicated the wound physician changed the cause of the open area to a non pressure wound of the right sacrum full thickness because of a note dated 12/23/23, that was written by a nurse that indicated this wound was a result of scratching, so I'm changing the etiology to trauma. The evaluation indicated the wound measures 1.1. cm X 0.7 cm X 0.2 cm with light sero-sanguineous drainage, contained 40% slough and 60% granulation tissue and the wound progress was at goal. The wound physician completed surgical excisional debridement procedure and when the procedure was done the non viable tissue decreased from 40% to 0%. Treatment continued with hydrocolloid dressing to be applied every 3 days. The facility developed a care plan which included: The resident has actual impairment to skin integrity of the sacrum related to fragile skin. Care plan initiated on 12/28/23 and revised on 01/15/24. All interventions were listed to be implemented on 01/15/24. The following were listed interventions: ~ Educate resident/family/caregivers of causative factors and measures to prevent skin injury. ~ Encourage good nutrition and hydration in order to promote healthier skin. ~ Identify/document potential causative factors and eliminate/resolve where possible. ~ Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etc to Medical Doctor (MD). ~ The resident needs to protect the skin when up in chair. ~ Turn and reposition every 2 hours and as needed (prn) when in bed (does not address repositioning when in wheelchair (w/c) . The Medical Record contained a plan of care for the potential for pressure ulcer development, dated 01/13/22. An intervention directs staff that R8 needs monitoring/reminding/assistance to turn/reposition at least every 2 hours, more often as needed or requested. On 01/31/24 at 12:15 PM, Surveyor interviewed Agency Certified Nursing Assistant (CNA) M. CNA M stated that R8 has intermittent confusion and staff need to reposition R8 every 2 hours as she is unable to reposition herself. CNA M indicated R8 was incontinent of bowel and bladder and is dependent on staff for all activities of daily living (ADLs) except R8 is able to feed herself. On 01/31/24 at 12:20 PM & 1:50 PM, Surveyor interviewed LPN UM C. LPN UM C verified the initial assessment, which included the wound bed, pain, and drainage was not completed by an RN. LPN UM C stated the nurse indicated she notified the UM, NP, and supervisor, but the supervisor was not always an RN. LPN UM C stated there was a pain note dated 01/02/24 that indicated R8 was having pain to the back and leg but the note was not specific to where the pain was located on the back. LPN UM C stated the first comprehensive assessment was completed on 01/10/24 by the wound physician. LPN UM C indicated the wound looked like an ingrown hair and wanted the wound physician to look at it. On 01/31/24 at 2:00 PM, Surveyor observed R8 lying directly on her back in bed. The Surveyor interviewed R8 while in bed. R8 stated she had a bedsore and does not know how she got it or what she should do. R8 stated she had never scratched the area. R8 indicated staff do not assist her with repositioning and due to her obesity she was unable to do herself. R8 says the area on her bottom is a little sore. On 01/31/24, Surveyor interviewed MD H. MD H stated he changed the cause from pressure to trauma due to a note that was written on 01/23/23 indicating the open area looked like a scratch. The Surveyor asked MD H if not doing the treatment for 4 days out of 7 between 01/10/24 to 01/17/24 could contribute to the deterioration of the open area. MD H stated he could not say that. On 01/31/24 at 3:30 PM, Surveyor accompanied MD H and LPN UM C to observe R8's wound and the treatment. MD H stated the wound measured 1.2 cm X 0.7 cm with 50% slough. MD debrided the area slightly. R8 was saying ouch during the treatment. When asked LPN UM C if R8 was medicated prior to the treatment, LPN UM C stated she did not know. The Medication Administration Record (MAR) did not show R8 was premedicated prior to debridement. LPN UM C completed the treatment as directed. On 02/01/24, Surveyor made a continuous observation from 7:45 AM to 10:50 AM. R8 was not assisted with repositioning or toileting. On 02/01/24 at 8:05 AM, Surveyor interviewed CNA N. CNA N stated she had gotten R8 out of bed at 7:10 AM and brought R8 to the dining room. CNA N stated R8 was dependent on staff for all ADLs except R8 was able to feed self. CNA N verified R8 has been sitting in her w/c since 7:10 AM. On 02/01/24 at 9:50 AM, Surveyor observed R8 sitting in her w/c in her room and CNA N asked R8 if she would like to use the bathroom and to let CNA N know when she needs to use the bathroom. R8 was not assisted to use the bathroom and was not checked to see if R8 had been incontinent. On 02/01/24 at 10:15 AM, Surveyor observed CNA N ask R8 if she was doing ok and R8 replied yeah. On 02/01/24 at 10:50 PM, Surveyor observed CNA N and O assist R8 onto the commode. CNA N removed R8's incontinent brief. Surveyor asked CNA N if the brief was wet and CNA N replied saying a little damp. Surveyor assessed the incontinent brief and the brief was saturated with urine. On 02/01/24 at 11:00 AM, Surveyor interviewed CNA N. CNA N stated R8 was up in her w/c before breakfast and stays in her w/c. CNA N indicated that R8 can not reposition on her own, but staff assist only at night and not during the day. CNA N stated staff assist with toileting but only toilet R8 when she asks.

SERIOUS (G) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice to prevent pressure ulcers from developing for 3 (R11, R1, and R7) of 4 residents reviewed for pressure injuries. * R11 was admitted with excoriation to the coccyx extending to the bilateral buttock which developed into an unstagable pressure injury to the sacrum that was never comprehensively assessed. R11 was admitted on [DATE] with excoriation to the coccyx extending to the bilateral buttocks, with treatment obtained. On [DATE] the Skin Only Evaluation documented open wounds to the coccy with no comprehensive assessment conducted. On [DATE] R11's care plan was initiated to include in part the provision of pressure relieving devices, mattress, chair cusion, along with weekly measurements. On [DATE] R11's care plan was revised to include in part turn and repositon every 2 hours while in bed, check incontinence every 2-3 hours. On [DATE] the Nurse Practioner (NP) E charted an active diagnosis list which included a Stage 3 pressure injury to the left buttock and a Stage 3 pressure injury to the right buttock with no other documentation. On [DATE] nursing reported an overall improvement and NP documented R11 had an air mattress in place and a wound clinic appointment. On 12/20 and [DATE] there was no documentation found from the wound clinic addressing R11's coccyx with the wound clinic addressing R11's bilateral lower extremety wounds on [DATE]. On [DATE] the progress note indicates the sacral wound worsened with measurements of 9 cm X 11.5 cm., with new treatment orders noted. This is the first time measurements of the area were documented however no comprehensive assessment was conducted at this time nor weekly thereafter. On [DATE] R11's coccyx /sacrum was assessed as 100% eschar/slough present with a new treatment for Santyl. On [DATE] the area measured 2 cm X 2.4 cm. with no depth documented. No characteristics of the wound was documented. A Foley catheter was inserted to protect the sacral wound. On [DATE] Surveyor observed R11's air mattress was deflated. As of [DATE] the pressure injury on the coccyx/sacrum has not been comprehensively assessed. * R1 did not have a comprehensive assessment after the development of a stage 3 pressure injury to the left heel on [DATE] by an RN until the wound was assessed by the wound physician on [DATE], almost 2 weeks after the discovery of the pressure injury. R1 was admitted on [DATE] and was identified at moderate to high risk for the developement of pressure injuries. R1 was assessed not to have any skin issues. A care plan initiated on [DATE] addresssed turning and repositionining every 2 hours and as needed, inspect skin weekly, pressure relieving wheelchair cushion and air mattress. On [DATE] R1 was found to have an open blister on R1's left heel measuring 3 cm X 3 cm, was cleansed with normal saline and Medihoney applied along with island border dressing. The wound was not assessed by an RN and there was no depth noted and no percentage of tissue type documented. On [DATE] the Treatment Administration Record (TAR) had an order to use heel lift boots when in bed and to sign off the treatment every shift. On [DATE] The Wound Physician conducted an initial assessment of the left heel documenting it was a Stage 3 pressure injury measuring 3.0 cm x 2.2 cm x 0.1 with 10% slough and 90% granulation, with recommendations to off load the heels and float heels when in bed. The Wound MD continued to see R1 weekly until R1 expired on [DATE]. *R7 was admitted with a Stage 4 pressure injury to the sacrum that was not comprehensively assessed for five days after admission. Findings: The facility policy and procedure entitled Treatment/SVC to Prevent/Heal Pressure Ulcer dated [DATE] states: PURPOSE: The facility's policy is to ensure it identifies and provides needed care and services that are resident-centered, per the resident's preferences, goals for care, and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. GUIDELINES: 1. The facility will ensure that based on the comprehensive assessment of a resident: a. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they are unavoidable; and b. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers om [sic] developing. PROCEDURE: 1. Upon admission, the resident will receive a head-to-toe skin check to identify any skin issues. 2. All residents will have a Braden Scale evaluation completed at the time of admission, in conjunction with each quarterly and annual assessment, with any significant change assessment and as deemed necessary by the Interdisciplinary Team. 3. Interventions will be implemented in the resident's plan of care to prevent pressure injury development. 4. When the resident is admitted with a pressure ulcer(s), the admitting nurse will document the size, location, odor (if any), drainage (if any). 5. Interventions will be implemented in the resident's plan of care to prevent deterioration and promote healing of the pressure injury. 6. The admitting nurse will notify the attending physician or wound physician to obtain a treatment order. 7. The pressure ulcer(s) will be evaluated weekly by a Registered Nurse or Wound Physician, and the following will be documented in the resident's electronic medical record: the size, location, odor (if any), drainage (if any), and current treatment ordered. 8. The nurse will notify the physician anytime the pressure injury shows signs of non-healing or infection and request treatment order changes. 9. The resident or the resident's representative will be notified of any changes related to the improvement, deterioration, and/or treatment changes on an ongoing basis. 1. R11 was admitted to the facility on [DATE] with diagnoses of venous insufficiency, non-pressure chronic ulcers of the right and left lower legs and feet, lymphedema, chronic kidney disease, anxiety, osteoarthritis, and morbid obesity. R11's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R11 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R11 as needing maximal assistance with rolling in bed. R11's hospital discharge instructions included a treatment to a wound to the coccyx extending to bilateral buttocks. Review of the hospital documentation indicated R11 had excoriation to the coccyx extending to bilateral buttocks. On [DATE] on the admission Data Collection and Baseline Care Plan Tool, Licensed Practical Nurse (LPN) Unit Manager (UM)-C charted in the Skin section of the form R11 had open lesions on the feet and bilateral lower extremity lymphedema was present. LPN UM-C did not document any skin integrity concerns for the coccyx or buttocks. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE], R11 had a treatment order to the coccyx extending to the buttocks: cleanse with Puracyn, no not rinse, Cavilon barrier to the peri wound, and cover with Mepilex daily. On [DATE] at 3:58 AM in the progress notes, nursing charted a treatment had been ordered for the coccyx. On [DATE], R11 was seen by Nurse Practitioner (NP)-E. NP-E charted R11 had a sacral plaque-like wound and irritant contact dermatitis and was followed by wound care while in the hospital. NP-E did not document any current concerns with R11's coccyx or bilateral buttocks. On [DATE] on the Skin Only Evaluation form, a Registered Nurse (RN) charted R11 had open wounds to the coccyx. In the Narrative Notes section of the form, the RN charted the RN and the unit nurse completed the initial admission skin assessment, R11 was aware of skin issues, treatment orders were in place and the Wound Physician would follow up on wound round day. Surveyor noted no measurements, characteristics, or etiology of the wound or wounds was documented. R11's Skin Impairment Care Plan was initiated on [DATE] with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocols for treatment of injury. -Monitor/document location, size and treatment of skin injury; report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc. to physician. -Provide pressure relieving devices: mattress, chair cushion -Weekly documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. On [DATE], R11 had an order for House Supplement 240 ml twice daily. On [DATE], R11 had an order for Prosource 30 ml daily. On [DATE], R11 had an order for Multivitamin daily. On [DATE] on the Skin Only Evaluation form, nursing charted R11 had old non-healing wound to the sacrum and no new skin issues at that time. Surveyor noted no measurements, characteristics, or etiology of the coccyx wound was documented. R11's Skin Impairment Care Plan was revised on [DATE] with the following interventions: -Turn and reposition every two hours and as needed while in bed -Clean peri area with each incontinence episode. -Incontinent: check every 2-3 hours and as required for incontinence; wash, rinse and dry perineum; change clothing as needed after incontinence episodes. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE], R11 was seen by NP-E. NP-E charted the active diagnosis list included a Stage 3 pressure injury to the left buttock and a Stage 3 pressure injury to the right buttock. No other documentation was found regarding the coccyx or bilateral buttocks. On [DATE] at 7:42 PM in the progress notes, LPN UM-C charted the Wound Physician attempted to see R11, but R11 refused to be seen by the Wound Physician. R11's Skin Impairment Care Plan was revised on [DATE] with the following interventions: -Treatment as ordered. -Wound physician consult and follow up as needed. -Brief use: R11 uses disposable briefs; change as needed. On [DATE] at 7:19 PM in the progress notes, LPN UM-C charted the Wound Physician attempted to see R11 but R11 was not agreeable to see the Wound Physician. R11 continued to be argumentative about how the wounds should be treated and R11 stated they would be following up with an outside wound clinic. On [DATE], R11 had an order for Ensure Clear of Boost 240 ml three times daily. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE] on the Skin Only Evaluation form, nothing was documented; the form was blank. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE] on the Skin Only Evaluation form, nursing did not document any information on the coccyx or bilateral buttocks. On [DATE], R11's Braden score was 12 indicating high risk for pressure injury. On [DATE], R11 was seen by NP-E. NP-E documented R11 had frequent refusals at facility and has declined labs and wound treatments. NP-E documented R11 was not being followed by the facility Wound Physician. NP-E documented the facility would try to coordinate care at the wound clinic for R11's bilateral lower extremity non-pressure wounds. NP-E did not document anything regarding the coccyx or bilateral buttocks wound. On [DATE], R11 was seen by NP-E. NP-E documented R11 had a sacral plaque-like wound and irritant contact dermatitis and was followed by wound care while in the hospital. NP-E did not document any current concerns with R11's coccyx or bilateral buttocks. On [DATE], R11 was seen by NP-E. NP-E documented R11 had a sacral plaque-like wound and irritant contact dermatitis and was followed by wound care while in the hospital. NP-E documented the current treatment to the coccyx wound that extended to bilateral buttocks that had been in place since admission on [DATE]. NP-E documented the active problem list included a Stage 3 pressure injury to the left buttock and a Stage 3 pressure injury to the right buttock. On [DATE], R11 was seen by NP-E. NP-E documented R11 was seen for a follow up of the sacral skin issue; nursing staff reported overall improvement and R11 did not want to continue with the dressing that had been in place. NP-E documented R11 had an air mattress in place and a wound clinic appointment the following week. NP-E visualized the sacral area indicating the etiology to be incontinence associated dermatitis and changed the treatment to Desitin every shift and as needed, continue offloading pressure, and will re-evaluate the following week. No measurements or characteristics of the skin were narratively charted. No re-evaluation of the wound was found for the following week. On [DATE] at 11:38 PM in the progress notes, nursing charted R11 had an appointment at the Wound Clinic that day. No documentation was provided of the consult. On [DATE], R11 was seen at the Wound Clinic. Documentation from the Wound Clinic on the Consult Sheet addressed R11's bilateral lower extremity wounds. No documentation was found addressing R11's coccyx. On [DATE] at 11:41 PM in the progress notes, an LPN charted R11's sacral wound got worse and measured 9 cm x 11.5 cm. The LPN charted NP-E was notified and a new order for Medihoney and cover with Allevyn instead of the Desitin cream was obtained. Surveyor noted this was the first time any measurements of the area had been documented. No wound characteristics were documented. On [DATE], R11 was seen by NP-E. NP-E documented R11 was seen for evaluation of the sacrum wound. NP-E documented staff had been applying Medihoney and Allevyn dressing to area with R11 refusing the dressing changes at times. NP-E documented R11 was incontinent of bowel and bladder at baseline, is on an air mattress, has overall poor appetite refusing meals at times and has had a ten-pound weight loss over the past month. NP-E documented R11's coccyx wound with 100% eschar/slough present and determined the etiology to be an Unstageable pressure injury. NP-E changed the wound treatment to Santyl to the wound bed instead of the Medihoney every other day. NP-E ordered a dietitian evaluation, lab work, and follow up by the Wound Clinic. On [DATE] at 1:42 PM in the progress notes, LPN-D charted the treatment to the sacrum was completed and the area measured 2 cm x 2.4 cm. LPN-D charted a Foley catheter was inserted to protect the sacral wound due to R11's functional incontinence status. Surveyor noted no depth of the wound was measured and no characteristics of the wound bed were documented. On [DATE], R11 was seen by NP-E. NP-E documented R11's coccyx pressure injury wound care was in progress with R11 refusing cares and resistant to changing positions and pressure relief. NP-E documented R11 was being followed by the Wound Clinic. No documentation was found that the Wound Clinic was evaluating or managing treatment to the coccyx. Surveyor noted R11's coccyx excoriation was not comprehensively assessed on admission or weekly and it developed into an Unstageable pressure injury at some point between admission and [DATE] when NP-E determined it was an Unstageable pressure injury. Documentation on [DATE] indicated a change to the wound, but a comprehensive assessment was not done at that time or weekly thereafter. In an interview on [DATE] at 2:00 PM, LPN UM-C stated LPN UM-C does rounds with Wound Physician-H weekly and if the resident is not seen by Wound Physician-H, then the nurses on the floor do the weekly assessment. On [DATE] at 11:22 AM, Surveyor observed R11 lying in bed. When Surveyor entered the room, Surveyor noted the air mattress to the bed was deflated. Surveyor asked LPN-G to come into R11's room and assess R11's air mattress. LPN-G saw the air mattress and went to get Certified Nursing Assistant (CNA)-F to assist moving R11's bed and reinflating R11's air mattress. CNA-F lowered R11's bed and LPN-G and Surveyor discovered the tubing for the air mattress had been crimped on the chair at the end of the bed, not allowing air to flow from the regulator to the air mattress. CNA-F stated the air mattress was not deflated when CNA-F was in the room earlier. Surveyor asked CNA-F how long ago CNA-F had been in R11's room. CNA-F could not recall the exact time but thought it had been within the last 30-45 minutes. R11's air mattress reinflated after being moved away from the chair at the end of the bed. In an interview on [DATE] at 3:15 PM, Surveyor asked LPN-D what the facility process was for a resident with a newly discovered open area on the skin. LNP-D stated an RN or RN supervisor needs to assess the wound and a treatment order needs to be gotten from the physician or NP. LPN-D stated all the wounds are monitored by the Wound Physician. Surveyor asked LPN-D what is done for a resident that is not seen or does not want to be seen by the Wound Physician. LPN-D stated that is tricky. LPN-D stated they encourage the resident to be seen by the Wound Physician, but sometimes they want their own wound doctor, or they go to a wound clinic. Surveyor asked LPN-D who would do the weekly measurements if not done by the Wound Physician. LPN-D stated an RN or RN supervisor does an assessment if there is a change to the wound. On [DATE] at 4:45 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R11 has not had a comprehensive skin assessment since admission on [DATE] and developed an Unstageable pressure injury that currently still has not been comprehensively assessed. Surveyor shared with NHA-A and DON-B the observation of R11 lying in bed with the air mattress deflated. Surveyor asked NHA-A and DON-B to provide any documentation showing a comprehensive assessment had been completed for R11 at any time since admission. On [DATE] at 10:00 AM, NHA-A and DON-B met with Surveyor to discuss R11's Unstageable pressure injury. NHA-A agreed R11 did not have a comprehensive assessment on admission or since. NHA-A stated NHA-A asked the nurses on the unit why R11 did not have any skin assessments completed and staff told NHA-A that R11 refused to let them measure the wound. NHA-A stated R11 requests Wound Physician-H stand at the doorway and look from afar. NHA-A stated they have had outside case managers come in to talk to R11 to educate R11 on appropriate evaluations and treatment, but R11 refuses. NHA-A stated the staff have been educated that even with refusals, they should get measurements of all wounds. In an interview on [DATE] at 11:29 AM, Surveyor asked NP-E how much involvement NP-E has had with R11's coccyx pressure injury. NP-E stated it took a while for R11 to trust NP-E enough to allow NP-E to look at R11's skin. NP-E stated the first time NP-E saw R11's coccyx area was on [DATE] and that was when R11 had contact dermatitis from incontinence. NP-E stated on [DATE], NP-E did not see R11's wound but was told by nursing staff that the treatment needed to be changed because the wound deteriorated. NP-E stated the floor nurses individually contact NP-E if a treatment needed to be changed, but there is not one nurse that is responsible for R11's wounds. NP-E stated LPN UM-C accompanies Wound Physician-H when doing rounds, but there is no system in place if a resident is not seen by Wound Physician-H. NP-E stated R11 is seen by a Wound Clinic, but they only manage wound treatments to the lower extremities and not the coccyx. No further information was provided at that time. 2. R1 was admitted to the facility on [DATE] with diagnoses of degenerative disease of the nervous system, dementia, malnutrition, fracture of the sacrum, compression fracture of the T7-T8 vertebra, congestive heart failure, chronic obstructive pulmonary disease, polyneuropathy, and spinal stenosis. R1's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R1 had moderate cognitive impairment per staff assessment and needed extensive assistance with bed mobility. R1 was admitted on Hospice services and had an activated Power of Attorney (POA). On [DATE], R1's Braden score was 14 indicating moderate risk for pressure injury. On [DATE] on the admission Data Collection and Baseline Care Plan Tool, nursing indicated R1 did not have any skin issues. R1's Activities of Daily Living Care Plan was initiated on [DATE] with the following interventions: -Turn and reposition every 2 hours and as needed. -Bed Mobility: R1 requires moderate assistance of one staff to turn and reposition in bed. -Skin Inspection: R1 requires skin inspection weekly and as needed; observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. R1's Potential for Impairment to Skin Integrity Care Plan was initiated on [DATE] with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Provide pressure relieving devices: wheelchair cushion, air mattress. -Turn and reposition every 2 hours and as needed while in bed. On [DATE], R1 had orders for Chocolate Pudding twice daily and Ensure 240 ml three times daily after meals. On [DATE], R1's Braden score was 10 indicating high risk for pressure injury. On [DATE], R1's Braden score was 12 indicating high risk for pressure injury. On [DATE], R1's Braden score was 11 indicating high risk for pressure injury. On [DATE] at 11:03 PM in the progress notes, a Licensed Practical Nurse (LPN) charted while providing cares, the nurse found an open blister on R1's left heel that measured 3 cm x 3 cm. The area was cleansed with normal saline and Medihoney was applied and dressed with an island border dressing. On [DATE] on the Skin Only Evaluation form, an LPN documented a blister to the left heel measured 3 cm x 3 cm with granulation tissue to the wound bed. NP-E was notified, and a treatment was obtained. Surveyor noted no depth and no percentage of tissue type was documented. The wound was not assessed by a Registered Nurse (RN). On [DATE] on the Treatment Administration Record (TAR), R1 had an order to use heel lift boots when in bed and to sign off the treatment every shift. On [DATE] on the Skin Only Evaluation form, an LPN documented R1 did not have any current skin issues. On [DATE], R1's Braden score was 12 indicating high risk for pressure injury. On [DATE], R1 was seen by Wound Physician-H. R1 had been monitored by Wound Physician-H on a previous admission and Wound Physician-H documented R1 no longer had a pressure injury to the right buttock. Wound Physician-H did not document on the left heel. On [DATE], R1 was seen by Wound Physician-H for an initial assessment of the left heel. Wound Physician-H documented the Stage 3 pressure injury to the left heel measured 3.0 cm x 2.2 cm x 0.1 cm with 10% slough and 90% granulation with light serosanguinous drainage. Wound Physician-H recommended off-loading the heels and float heels when in bed. On [DATE], R1 had an order for Prosource 30 ml twice daily. R1 was seen weekly by Wound Physician-H until [DATE] when R1 expired. In an interview on [DATE] at 3:15 PM, Surveyor asked LPN-D what the facility process was for a resident with a newly discovered open area on the skin. LNP-D stated an RN or RN supervisor needs to assess the wound and a treatment order needs to be gotten from the physician or NP. LPN-D stated all the wounds are monitored by the Wound Physician. On [DATE] at 4:45 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R1 did not have a comprehensive assessment after the development of a Stage 3 pressure injury to the left heel on [DATE] by an RN until Wound Physician-H assessed the left heel on [DATE], almost two weeks after the discovery of the pressure injury. Surveyor asked NHA-A and DON-B if there were any more assessments that had not been provided. On [DATE] at 10:00 AM, NHA-A and DON-B met with Surveyor to discuss R1's Stage 3 pressure injury to the left heel. NHA-A agreed R1 did not have a comprehensive assessment after the open blister was discovered on the left heel until R1 was seen by Wound Physician-H. NHA-A stated weekly skin checks are done for each resident and the order can be found on the TAR so administration can see that the skin checks were done. NHA-A stated if there are any new finding, the nurses have to do an incident report and that is followed up by an RN and the resident is gone through risk management. NHA-A provided an incident report for R1 dated [DATE]. Surveyor shared the concern that even with the incident report completed, R1 was not comprehensively assessed at that time. No further information was provided at that time. 3. R7 was admitted to the facility on [DATE] with diagnoses of osteomyelitis of the vertebra, sacral, and sacrococcygeal region, Stage 4 pressure ulcer of the sacral region, encephalopathy, convulsions, polyneuropathy, hemiplegia and hemiparesis of the right side, and dysphagia requiring a gastrostomy tube for nutrition. R7's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R7 was severely cognitively impaired per staff assessment and was dependent on staff for all cares and bed mobility. R7 had a Guardian. R7's hospital records indicated R7 had a Stage 4 pressure injury to the sacrum that was being treated with a negative pressure wound therapy device (wound vac). On [DATE] on the admission Data Collection and Baseline Care Plan Tool, Licensed Practical Nurse (LPN)-D charted in the Skin section of the form R7 had bilateral foot dryness. No documentation was found of the Stage 4 pressure injury to the sacrum. On [DATE], R7's Braden score was 13 indicating moderate risk for developing a pressure injury. On [DATE] on the Skin Only Evaluation form, LPN-D charted R7 had a Deep Tissue Injury to the sacrum that was a Stage 4 pressure injury. Surveyor noted two different categories of pressure injuries were documented. No measurements were documented, and the wound bed had granulation. Surveyor noted no percentage of tissue type was documented. LPN-D charted R7's wound treatment had been completed with pain medications administered prior to the treatment. Surveyor noted the Stage 4 pressure injury to the sacrum was not comprehensively assessed by a Registered Nurse (RN) and the data collected by LPN-D was not complete. R7's Potential/Actual Skin Impairment Care Plan was initiated on [DATE] with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Provide pressure relieving devices. -Turn and reposition every 2 hours and as needed while in bed. On [DATE], R7 had orders for: -Vitamin C 500 mg daily. -Cefepime 2 Gm/1000 ml IV every eight hours for osteomyelitis. -Osmolite 1560 ml daily per gastrostomy tube (G tube) for daily nutrition. -Treatment to Sacrum: cleanse with quarter strength Dakins, pat dry with gauze, apply 3M Cavilon barrier to peri wound, apply quarter strength Dakins Kerlix to wound bed, cover with ABD and Medipore tape daily and as needed until wound vac arrives. R7's Potential/Actual Skin Impairment Care Plan was revised on [DATE] with the intervention to provide a pressure relieving device: air mattress. On [DATE] at 12:20 PM in the progress notes, LPN-D charted LPN-D called a durable medical company and left a message stating an air mattress was needed for R7. On [DATE], R7 had an order for Prosource 30 ml twice daily. On [DATE], R7's nutritional order increased the Osmolite to 500 ml four times daily per G tube totaling 2,000 ml per day. On [DATE], R7 was seen by Wound Physician-H for the initial evaluation. The Stage 4 pressure injury to the sacrum measured 10.8 cm x 7.3 cm x 7.5 cm with 20% slough and 80% granulation. This was the first comprehensive assessment of the pressure injury since admission 5 days ago. On [DATE], R7's treatment to the sacrum changed to: cleanse with normal saline, skin prep to peri wound, apply drape to the surrounding peri wound, cut black foam to fit and apply wound vac 125 mmHg continuous; change three times per week Monday, Wednesday, and Saturday. R7's Potential/Actual Skin Impairment Care Plan was revised on [DATE] with the following interventions: -Apply house barrier cream every shift and/or with incontinence episodes. -Use a draw sheet or lifting device to move R7. R7's Stage 4 Pressure Ulcer Care Plan was initiated on [DATE] with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing; measure length, width, and depth at least weekly; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Assist to turn/reposition at least every two hours, more often as needed or requested. -Monitor nutritional status; serve diet as ordered, monitor intake and record. -Obtain and monitor lab/diagnostic work as ordered; report results to the physician and follow up as indicated. -Treat pain as per orders prior to treatment/turning etc. to ensure R7's comfort. -Wound physician follow up as needed. R7 was seen by Wound Physician-H weekly for a comprehensive assessment and treatment changes as determined by Wound Physician-H. On [DATE], R7's wound treatment to the sacrum changed to include collagen powder to the wound bed prior to placement of the black foam and wound vac. On [DATE] at 4:00 PM, Surveyor discussed R7's wound progression with Wound Physician-H. Wound Physician-H stated R7 is seen weekly and is accompanied on rounds by Licensed Practical Nurse (LPN) Unit Manager (UM)-C. Surveyor asked Wound Physician-H what would be the expectation of a newly admitted resident that is known to have a pressure injury. Wound Physician-H stated the expectation would be to have the wound measured and described within the first 24 hours of admission. Surveyor shared with Wound Physician-H that no documentation was found of any assessment of the Stage 4 pressure injury to the sacrum until Wound Physician-H met with R7 on [DATE], five days after admission. Surveyor observed Wound Physician-H and LPN UM-C assess R7's sacral Stage 4 pressure injury. R7 had heel boots on both feet. R7's wound measured approximately 6 cm x 6 cm x 6 cm with tunneling and undermining all the way around the wound. LPN UM-C stated LPN UM-C was told R7 had some new open areas to the peri wound. Surveyor observed approximately six small open areas that were attributed to the wound vac dressing. Wound Physician-H debrided the Stage 4 pressure injury and the small open areas with a scalpel. LPN UM-C then completed the dressing change and applied the wound vac. On [DATE] at 4:45 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R7 did not have a comprehensive assessment of a Stage 4 pressure injury to the sacrum on admission until Wound Physician-H assessed the sacrum on [DATE], five days after admission when the facility was aware R7 was being admitted with an infected Stage 4 pressure injury. Surveyor asked NHA-A and DON-B if there were any more assessments that had not been provided. On [DATE] at 10:00 AM, NHA-A and DON-B met with Surveyor to[TRUNCATED]

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility did not report the results of abuse/neglect investigations to the state agency within 5 working days for 1 (Resident 2) of 5 sampled investigations. The facility reported an initial allegation of abuse/neglect to the state agency but did not report the full investigation within five working days as required by state law. Findings include: The facility's policy and procedure for Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and investigation, with a revision date of 02/20020, indicated for every report submitted, a follow report detailing the Investigation must be submitted to Division of Quality Assurance/Office of Caregiver Quality within 5 working days even if it is determined that a violation did not occur. The facility received a concern from R2's family member indicating that R2 was sent to a doctor's appointment without an escort. R2 was nonverbal and has severe cognitive deficits. Registered Nurse (RN) allowed R2 to leave the facility unattended and was aware that R2's family member was not at the facility to accompany R2. On 01/30/2023, the Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated she had submitted a facility reported incident on 12/14/2023, but did have the full investigation but had not submitted the report until 01/30/2024.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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Based on record review and staff interview, the facility did not have evidence that alleged violations were thoroughly investigated for 3 (Residents 3, 4 and 6 ) of 5 sampled allegations of abuse/neglect. The facility submitted allegations of abuse/neglect for Residents (R) 3, 4 and 6, but there was not evidence that the allegations were thoroughly investigated nor did the facility complete training to staff to ensure they should not take money for any residents in attempt to prevent exploitation. Findings include: The facility's policy and procedure for Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and investigation, with a revision date of 02/20020, directed the following: ~ Obtain written statements from all witnesses or persons with information. ~ Obtain a written, signed statement from the accused individual ~ Contact law enforcement or other regulatory agency if appropriate. 1. On 10/28/2023, the facility submitted a Facility Reported Incident (FRI), that indicated Certified Nursing Assistant (CNA) L had received money via a cash app to purchase items for R3. On 01/30/2023 at 10:45 AM, the Surveyor interviewed Nursing Home Administrator (NHA)A. NHA A stated it was an outside person who had sent money to CNA L through a cash app to purchase items for R3. NHA A indicated the facility had not completed training to staff regarding staff are not allowed to take money from residents to prevent exploitation. 2. On 10/24/2023, the facility submitted an investigation regarding an allegation of neglect. The allegation indicated R4 received bad care and was not receiving any cares. The investigation did not contain any information regarding any cares that were completed. The investigation did not contain any interviews from other residents to see if there was a systemic problem, nor did the investigation contain interviews from staff regarding R4's care needs and if they are being met. On 01/31/2024 at 10:25 AM, the Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A verified the FRI was not thoroughly investigated. NHA A indicated other residents and staff should have been interviewed. NHA A stated the previous Social Worker (SW) received the allegation but did not thoroughly investigate the allegation. NHA A indicated the previous SW no longer is employed at the facility. NHA A stated she had not been aware of this allegation. 3. On 09/18/2023, the facility submitted a FRI that indicated R6 reported missing $600.00. The report indicated the police were notified but the investigation had not contained any interviews from other residents to ensure the facility does not have a systemic problem in missing money. The report also had not contained interviews from staff to assess if anyone has knowledge of missing money. The report indicated R6's brother had given R6 money, but the facility also did not interview R6's brother in attempt to verify if money was actually given. On 01/31/2024 at 10:30 AM, the Surveyor interviewed NHA A. NHA A verified the facility should have interviewed R6's brother, other residents and staff to achieve a thorough investigation. NHA A verified the additional interviews had not been completed.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, the facility did not ensure that 1 (Resident 8) of 1 sampled residents received appropriate treatment and services to restore continence to the extent possible. * R8 was incontinent of bladder. The facility did not complete a comprehensive assessment for bladder incontinence. The facility did not complete a voiding study in attempt to determine a voiding pattern and develop a toileting schedule based on the voiding study. The facility developed a toileting schedule but was not based on a voiding study. The plan of care directed staff that R8 was to be checked and change every 3 hours during the AM and PM shift. This was not consistently followed. Findings include: The facility's policy and procedure for Continence Management with a revision date of 06/2020 indicated that a resident who is incontinent of bladder will receive appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. The policy and procedure indicated the stops to achieve this plan are as follows: ~ Bladder assessment in the electronic medical record (EMR) ~ 3 day baseline voiding pattern ~ Determine the cause and type of incontinence present, if any ~ If incontinent of bladder, may refer to Occupational Therapy for evaluation and treatment for retraining ~ Develop a person-centered nursing care plan that includes the findings and individualizes the resident's needed interventions and incorporates the resident's choice in order to maintain continence to the extent possible, prevent UTIs and restore bladder incontinence to the extent possible ~ Based on the nursing assessment and resident's ability to benefit from a bladder plan, implement one or more of the following programs: a. bladder management program b. bladder rehabilitation/bladder training program ~ Evaluate effectiveness of interventions, making adjustments as needed ~ Reassess/revise the program quarterly, annually or with a change in condition to maintain effectiveness ~Complete or review the following quarterly, annually and with a change in condition a. Bladder assessment in EMR b. 3 day baseline voiding pattern According to the electronic admission Record, R8 was admitted to the facility on [DATE] with diagnoses of Dementia, Lumbago with sciatica (right side) Morbid Obesity and history of Urinary Tract Infections (UTIs). A Minimum Data Set (MDS) with an Assessment Reference Date (01/02/24) indicated R8 had mild cognitive impairment, was frequently incontinent of bladder and was dependent on staff for transferring to the toilet. The Surveyor could not locate a 3 day voiding study in the medical record. A bladder assessment was completed on 01/12/24, which indicated R8 was occasionally aware of the urge to void, had mixed incontinence and treatment options that were utilized was prompted voiding, check and change, bedside commode, personal hygiene and incontinent products. The summary indicated R8 was incontinent of bladder, but transfers to a bariatric bedside toilet with the use of an EZ stand and 2 assist. Care plan was reviewed. The facility developed a plan of care, The resident has mixed bladder incontinence .related to impaired mobility and use/side effects of medication. The plan of care had a revision date of 04/12/23. The following were listed interventions: ~ Toileting plan is check and change every 3 hours in the AM and PM shifts The Certified Nursing Assistant (CNA) bladder elimination record from 01/03/24 to 02/01/24 documentation indicated R8 had multiple episodes of bladder incontinence daily and had only twice documentation when R8 was continent at a specific time. On 02/01/24 the Surveyor made a continuous observation from 7:45 AM to 10:50 AM. R8 was not assisted with repositioning or toileting. On 02/01/24 at 8:05 AM, the Surveyor interviewed CNA N. CNA N stated she had gotten R8 out of bed at 7:10 AM and brought R8 to the dining room. CNA N stated R8 was dependent on staff for all ADLs except R8 was able to feed self. CNA N verified R8 has been sitting in her w/c since 7:10 AM. On 02/01/24 at 9:50 AM, the Surveyor observed R8 sitting in her w/c in her room and CNA N asked R8 if she would like to use the bathroom and to let CNA N know when she needs to use the bathroom. R8 was not assisted to use the bathroom and was not checked to see if R8 had been incontinent. On 02/01/24 at 10:15 AM, the Surveyor observed CNA N ask R8 if she was doing ok and R8 replied yeah. On 02/01/24 at 10:50 PM, the Surveyor observed CNA N and O assist R8 onto the commode. CNA N removed R8's incontinent brief. The Surveyor asked CNA N if the brief was wet and CNA N replied saying a little damp. The Surveyor assessed the incontinent brief and the brief was saturated with urine. On 02/01/24 at 11:00 AM, the Surveyor interviewed CNA N. CNA N stated R8 was up in her w/c before breakfast and stays in her w/c. CNA N indicated that R8 can not reposition on her own, but staff assist only at night and not during the day. CNA N stated staff assist with toileting but only toilets R8 when she asks. On 02/01/24 at 11:10 AM, the Surveyor interviewed Licensed Practical Nurse (LPN) Unit Manager (UM) C. LPN UM C stated R8 was dependent on staff for toileting needs and toileting should be completed every 2-3 hours. LPN UM C stated the facility does not complete 3 day voiding studies in attempt to determine if a voiding pattern was present. LPN UM C stated the toileting schedule is based on the resident's elimination record, but it was standard policy to place any resident that was incontinent of bladder to be toileted or checked and changed before and after meals.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail enabled an accurate reconciliation affecting 1 unit of 2 units. * Licensed Practical Nurse Unit Manager (LPN UM)-K diverted narcotic medications from discharged and expired residents. LPN UM-K did not follow the procedure to have two nurses sign the narcotic record form when narcotics were destroyed and shredded narcotic record forms so narcotic medications could not be reconciled. Findings: The facility policy and procedure entitled Medication Administration: Destruction of Controlled Schedule II Medications dated 9/2023 states: Purpose: 1. The destruction of controlled substance Schedule II Medications is required by Wisconsin Administrative Code HFS 132.65(6)(c)2. 2. All controlled substance Schedule II medications must be destroyed once the order is discontinued or upon the death or permanent discharge of a resident. Guidelines: 1. Schedule II medications are those that are kept in a locked drawer on the medication cart on each unit. 2. All unused doses of Schedule II medications that are no longer needed by a resident are to be destroyed by two licensed nurses, per policy and recorded on the Controlled Drug/Receipt/Record/Disposition form that is provided by the Pharmacy with all controlled substances. Note: Refer to (facility) policy, Destruction of Medication. 3. The Controlled Drug/Receipt/Record/Disposition forms will be maintained in the facility for 1 year. The facility submitted a Facility Reported Incident to the State Agency on [DATE] that contained the following information; On [DATE], an anonymous letter was placed on the Human Resource's door stating LPN UM-K misappropriated residents' pain medication. An investigation was started by the facility and LPN UM-K did not work at that time. The facility interviewed all the nurses and residents on the unit LPN UM-K was assigned to, which was the short-term rehab unit. None of the residents had any complaints of not receiving pain medications. The nurses reported LPN UM-K would obtain the narcotics from discharged residents, either from the nurse on the unit or would get the keys to the medication cart and narcotic drawer from the nurse on the unit and get the narcotics from the narcotic drawer. The nurses had been instructed by LPN UM-K to keep the narcotics of discharged residents in the locked narcotic drawer until LPN UM-K could get them and told the nurses LPN UM-K would destroy all discharged residents' narcotics in LPN UM-K's office. LPN UM-K would then take the narcotics into LPN UM-K's office without another nurse to witness the destruction of the narcotics. The facility interviewed LPN UM-K. LPN UM-K validated the nurses' statements. The facility asked LPN UM-K if LPN UM-K was aware of the policy of requiring two nurses to dispose of unused narcotics. LPN UM-K stated LPN UM-K was aware of this procedure and did not know why LPN UM-K swayed away from this procedure. During the investigation, the facility discovered LPN UM-K shredded all the narcotics record sheets of the medications LPN UM-K had in LPN UM-K's possession. When the facility asked LPN UM-K why the narcotic record sheets had been shredded, LPN UM-K did not know. The facility determined LPN UM-K had been diverting narcotic medications from discharged residents that should have been destroyed by two nurses at the time of the discharge. LPN UM-K was no longer employed at the facility at the time of the survey and not available for interview. In an interview on [DATE] at 2:30 PM, Nursing Home Administrator (NHA)-A stated LPN UM-K would only take the narcotics from residents that had either been discharged from the facility or residents that had expired. NHA-A stated LPN UM-K would instruct the nurses on the unit to save the narcotic medications in the narcotic drawer after a resident discharged so LPN UM-K could dispose of the narcotic medications. NHA-A stated LPN UM-K would either have the nurse hand over the narcotic medications from the medication cart or LPN UM-K would get the keys for the medication cart from the nurses and retrieve the narcotic medications of those residents that had discharged . NHA-A stated LPN UM-K instructed the nurses that any resident discharged over the weekend should have their narcotics kept in the narcotic drawer and LPN UM-K would take care of those narcotic medications on Monday when LPN UM-K was there. NHA-A stated when the nurses on the floor were asked about LPN UM-K directing them to give the narcotics to LPN UM-K, they knew this procedure was wrong but were afraid of retaliation and it was not until someone anonymously put a note on the Human Resource door that NHA-A was made aware of the situation. NHA-A stated LPN UM-K and the Director of Nursing (DON) at that time were very close friends and staff were aware of that relationship so felt they could not approach the DON to resolve the situation. NHA-A stated that DON is no longer employed at the facility and not available for interview. On [DATE] at 2:44 PM, Surveyor observed LPN-I and LPN-J count the narcotic cards and medications at the change of shift. No discrepancies were found. Surveyor asked LPN-I and LPN-J in what situations were narcotic medications needed to be destroyed. LPN-I and LPN-J stated if a resident expires and still has narcotics in the card or if an order changes and the resident no longer has the order for that narcotic, then those narcotics need to be destroyed. LPN-I and LPN-J stated two nurses are needed to destroy the narcotics and sign the narcotic record sheet. LPN-I and LPN-J showed Surveyor where the bottle was the narcotics were to be placed for destruction and where the signatures would go on the narcotic record sheet for destroyed medication. In an interview on [DATE] at 3:48 PM, Surveyor asked NHA-A what the procedure was for residents that were being discharged from the facility with narcotic medications still available in the facility. NHA-A stated for a resident that was in subacute rehab, narcotic medications are destroyed by the facility unless the resident for some reason cannot get to a pharmacy, then the narcotics are sent with the resident, and they are scanned into the chart so the facility can account for them. Surveyor asked NHA-A if education was done by the facility to review the policy of needing two nurses to destroy narcotics. NHA-A stated the previous DON did some education with the nurses and they had a townhall meeting with staff because there were a lot of issues to discuss with staff needing to trust the process and follow that process. NHA-A stated the situation was brought to QAPI (Quality Assurance and Performance Improvement), but they are still working through the process, and they are not there yet. NHA-A stated the policy and procedure has been reviewed but NHA-A wants to streamline it some more and would like the pharmacy to have a little more ownership of the process. NHA-A stated when the narcotic sheets were completed, they were retained for one year by the facility; they are working on reconciling with the pharmacy and then scanning that sheet into the resident record. NHA-A stated they cannot get into agreement with the pharmacy on the process. NHA-A stated the nurses know the policy and if they know something is wrong, they have administration to go to. NHA-A stated in the past, the DON and LPN UM-K were friends and staff did not want to snitch. NHA-A stated the staff have been educated that there will be no retaliation if any issues are brought forward. Surveyor asked NHA-A if there had been any narcotic diversion in the past or since this incident. NHA-A stated not that NHA-A was aware of. In an interview on [DATE] at 3:15 PM, Surveyor asked LPN-D if LPN-D had witnessed or been involved with LPN UM-K obtaining narcotic medications from discharged residents. LPN-D stated LPN-D witnessed LPN UM-K take narcotics to LPN UM-K's office once and did not know what LPN UM-K did with the medications. Surveyor asked LPN-D what the procedure was for destroying narcotic medication. LPN-D stated two nurses must destroy the medications together and sign the narcotic record sheet. LPN-D stated the documentation is kept in the narcotic book. Surveyor asked LPN-D if any education about how to destroy medications had been provided in the last five months. LPN-D stated LPN-D got that education during orientation but nothing since then. On [DATE] at 1:11 PM, Surveyor shared with NHA-A and DON-B the concern LPN UM-K took narcotic medication from discharged residents to LPN UM-K's office to destroy the narcotics without another nurse witnessing the destruction and LPN UM-K shredded the narcotic record sheets so there was no accounting for how many narcotic medications were in LPN UM-K's possession. Surveyor shared with NHA-A and DON-B the facility is working on getting a system to reconcile all narcotics but does not have a system in place currently to prevent future medication diversion. No further information was provided at that time.

Jul 2023 7 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure allegations of abuse involving 2 residents (R138 and R76) of 3 residents reviewed for abuse were reported in accordance with regulatory time frames. The facility did not ensure R138's allegation of abuse was reported immediately, but no later than 2 hours, to the Administrator and to the State Agency. The facility did not ensure the results of their investigation involving R76's allegation of abuse was reported to the State Agency within 5 working days of the incident. *R138 reported to Licensed Practical Nurse (LPN)-D on the evening of 4/12/23, that R138 was physically assaulted during a shower. LPN-D did not report the alleged allegation of abuse to the Administrator. The Administrator was notified of the alleged abuse on 4/13/23 when on 4/13/23, R138 reported the allegation to Receptionist-C during discharge from facility. This alleged abuse was then reported to the State Agency. *R76 was named in a facility self-report alleging an allegation of abuse against a Certified Nursing Assistant during cares. The facility did not submit the results of their investigation within 5 working days (Monday-Friday excluding legal holidays.) The facility submitted the results of their investigation (Misconduct Incident Report (F62447) to the State agency on 7/13/2023. Findings include: The facility policy entitled, Alleged incidents of Abuse, Neglect, Exploitation and Mistreatment - Reporting and Investigating, revised 2/2020, states: Special Key Points: 1. The resident and responsible parties are to be kept up to date on progress of the investigation. 2. An initial review of the allegation prior to reporting to DQA/OCQ may be conducted to determine whether or not the incident needs to be reported to DQA/OCQ. All alleged violations involving mistreatment (including abuse, neglect, exploitation, injuries of unknown source, misappropriation of property, resident-to-resident abuse, and mistreatment by family members, visitors, volunteers or other individuals) must be reported to the Division of Quality Assurance (DQA)/Office of Caregiver Quality (OCQ) as soon as possible, but not to exceed 24 hours from the discovery. The initial report is not to exceed 2 hours from discovery if serious bodily injury has occurred. i. This is reported online at: https://www.dhs.wisconsin.gov/caregiver/complaints.htm ii. For every report submitted, a follow-up F-62447 detailing the investigation MUST be submitted to DQA/OCQ within 5 working days even if it is determined that a violation did not occur. The day the F-62617 is filed is counted as day zero of the investigation period. 3. If the injury/incident was a result of a suspected crime, law enforcement must also be notified. (See [NAME] Manor Administrative Policy and Procedure-Reporting Reasonable Suspicion of a Crime in a Long-Term Care (LTC) Facility.) Guidelines: g. The Director of Nursing/Director of Resident and Patient Services and/or designee is to be contacted immediately for all allegations of caregiver misconduct or Resident-to-Resident abuse. The Administrator/CCO will be notified immediately. 1. R138 was admitted to the facility on [DATE] with diagnoses that include hypertensive heart disease with heart failure, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, bipolar disorder, depression, and lower back pain. R138 was discharged to home on 4/13/23 at 10:13 AM. R138's admission Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15 indicating R138 is cognitively intact. R138 is assessed as limited assist, one-person physical assist for transfers, bed mobility, dressing, and personal hygiene. R138 is assessed for bathing as physical help in part of bathing activity, one-person physical assist and not steady, only able to stabilize with staff assistance for walking. Surveyor reviewed a facility Misconduct Incident Report dated 4/20/23 which documents that on 4/13/23, R138 reported to facility security that R138 was physically assaulted the night of 4/12/23. R138 reported that R138 did call Wauwatosa Police at approximately 8:40 PM and they had come to the facility. According to the facility camera the police were onsite from 8:50 PM - 9:30 PM. R138 had a planned discharged from the facility after reporting this. Surveyor reviewed the Misconduct Incident Report which was completed within the 5 days. The investigation summary documents that staff were interviewed, police were notified, resident interviewed as well as other residents. Surveyor notes that the alleged incident occurred on the evening of 4/12/23 and staff who were aware of the allegation of abuse did not report the incident immediately (not to exceed 2 hours) to the Administrator. This alleged incident of abuse was reported to Administration on 4/13/23 when R138 was discharging from the facility. The facility then reported the allegation to the State Agency on 4/14/23. The delay in reporting this allegation of abuse to the administrator caused a delay in the facility immediately (not to exceed 2 hours) reporting the allegation of abuse to the state agency. Surveyor reviewed R138's medical record and did not find any documentation regarding the incident in the shower on the evening of 4/12/23 being reported and no documentation of any behaviors that R138 may have been having. Surveyor reviewed the grievance log for March and April 2023 and there were no grievances documented for R138. On 07/26/23, at 12:39 PM, Surveyor interviewed Receptionist-C regarding her interaction with R138 on the morning of 4/13/23. Receptionist-C explained that R138 was being discharged and was waiting in the front lobby for a ride. R138's ride arrived and R138 walked out the front door. R138 then walked back inside and approached Receptionist-C. R138 then stated that R138 wanted to tell her something and to pass it on to whomever needed to know. R138 then proceeded to say that R138 was physically assaulted while taking a shower the previous evening. Receptionist-C stated that she asked R138 to clarify what they meant and R138 stated that someone grabbed R138 by the arms and pushed R138 up against the wall. R138 gave Receptionist-C their name and room number and then left the facility. Receptionist-C stated she tried to get R138 to stay until she found someone to talk with however R138 stated they needed to leave. Receptionist-C said she immediately found Lead Social Worker-E and reported the conversation to her. On 07/26/23, at 02:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D regarding R138 and the incident on 4/12/23. LPN-D stated he was familiar with R138 and recalled the incident on 4/12/23. LPN-D explained he heard screaming from the shower room and he went in. He observed Certified Nursing Assistant (CNA)-H in front of R138. LPN-D stated CNA-H explained she was trying to help R138 shower and R138 was trying to get up independently. CNA-H was trying to assist and R138 thought the CNA-H was trying to push her. R138 was screaming at CNA-H. LPN-D explained he then told the CNA to leave and that he would continue to give R138 the shower. LPN-D informed Surveyor that when he was with R138 they (R138) stated that CNA-H hit R138 however LPN-D did not see any markings. LPN-D explained R138 has some psych issues and behaviors with making accusations. He explained that R138 is very particular about how R138 wants things done and that he (LPN-D) did not feel CNA-H did anything to R138. LPN-D stated after the shower R138 was calm and went back to R138's room. LPN-D could not recall if he spoke to police but stated he did tell the RN Supervisor-G what happened and indicated that R138 was just upset. LPN-D stated he did not report the incident as abuse because he did not think there was any real abuse happening by the CNA On 07/27/23, at 08:29 AM, Surveyor interviewed the Nursing Home Administrator (NHA)-A who informed Surveyor that she was made aware of the incident on 4/13/23 after R138 discharged from the facility. NHA-A stated that R138 informed the receptionist on her (R138's) way out the door and did not stay to speak to facility staff. The receptionist reported the conversation to Lead Social Worker-E who informed the Director of Nursing (DON) and Assistant Director of Nursing. The DON then notified the NHA-A by phone. NHA-A stated she told them to start a facility self-report. NHA-A explained that at this time she was not made aware that the police were in the building the previous night. NHA-A stated she spoke to security, and they informed NHA-A that the police were in the building however they were not aware as to why the police arrived. NHA-A stated she then spoke to RN Supervisor-G who stated that the police were in the building, and she did speak to the police however she didn't really think there was any allegation of abuse. NHA-A then spoke to LPN-D who stated that he did speak to police, however he didn't feel that any abuse occurred, so he told the police that nothing happened. LPN-D said it was more of a customer service issue. NHA-A explained that the police did speak with the resident as well, however the police could not determine if any abuse occurred, so they left the facility. Surveyor asked NHA-A if determining if abuse occurred was a determination that LPN-D was able to make. NHA-A stated, no, the incident should have been reported immediately so that we could start an investigation. NHA-A explained that she then talked to RN Supervisor-G and told her that any time a resident reports abuse and/or the police are in the building we need to escalate that concern up to administration. NHA-A stated that she did a 1:1 in service retraining for RN Supervisor-G. NHA-A stated that there were breaks all the way through. She stated that they needed to go back and reeducate LPN-D and RN Supervisor-G on reportable incidents. NHA-A explained that she only retrained the two staff because she has done multiple abuse prevention training over the past year and therefore did not do an all staff training after this incident. Surveyor relayed concerns to NHA-A regarding the facility staff not immediately (within 2 hours) reporting an allegation of abuse to the Administrator and to the State Agency. This delay in reporting caused a delay in starting an investigation into the allegation. NHA-A was in agreement with these concerns. No additional information was provided. 2. R76 was admitted to the facility 6/8/23 with diagnoses that include Fracture of Right Femur, Fracture of Left Femur, Fracture of Shaft of Right Humerus, Fracture of Lower End of Left Humerus, Fracture of Head of Left Radius, Fracture of Lower End of Left Radius, Fracture of Upper End of Left Ulna, Fracture of Right Forearm, Fracture of Olecranon Process, Fracture of Trapezium, Fracture of Right Patella, Fracture of Left Patella, Bimalleolar Fracture of Left Lower Leg, Multiple Fractures of Ribs, Fracture of Sternum, Acute Pain Due to Trauma, and Bipolar Disorder. Surveyor reviewed the Facility Reported Investigation for R76 with a date of 6/30/23. The Facility Reported Incident involved an allegation of abuse during cares occurring on 6/30/23 at 4:00 pm. Surveyor reviewed the Misconduct Incident Report (F62447) submitted to the State Agency. Surveyor noted the investigation was submitted to the Office of Caregiver Quality on 7/13/23 outside of the regulated 5 business day window. On 7/26/23 at 10:30 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked why the report was not turned in until 7/13/23. NHA-A stated Social Worker (SW)-E was his Social Worker and prepared the report. NHA-A stated SW-E had an emergency was out on leave.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure all allegations of abuse was thoroughly investigated for 1 (R138) of 3 self-reports reviewed for abuse, neglect, and mistreatment. The facility did not have evidence of preventing further abuse while the investigation was in progress. * On 4/12/23, R138 reported to Licensed Practical Nurse (LPN)-D that Certified Nursing Assistant (CNA)-H was physically assaulting her during a shower. On 4/12/23, LPN-D reported to Registered Nurse (RN) G that R138 was upset but did not specify the allegation of abuse. The facility did not prevent the potential for further abuse from occurring as the accused CNA-H continued performing resident cares after the allegation was first made on 4/12/23. The facility did not initiate an investigation into this allegation of abuse until the following day on 4/13/23. CNA-H was allowed to conduct resident cares once the investigation was initiated on 4/13/23. Findings include: The facility policy, entitled Alleged incidents of Abuse, Neglect, Exploitation and Mistreatment - Reporting and Investigating, revised 2/2020, states: Special Key Points: 1. The resident and responsible parties are to be kept up to date on progress of the investigation. Guidelines: 2. Protect the Resident: a. The safety of the residents is the first priority. The residents must be protected from possible subsequent injury or incidents of misconduct. b. After ensuring the safety of the residents, all employees are to immediately report any alleged incidents of abuse, neglect and mistreatment to the Supervisor to ensure that appropriate notification and a timely investigation are initiated. c. The Supervisor immediately assesses resident's personal safety and potential of harm to other residents. d. If an individual is named, the Supervisor immediately removes the accused from the resident care area. An employee, after a written statement is obtained, will be suspended pending the completion of the investigation. f. If another resident is named, staff immediately separates the two. Staff ensures that other residents are safe. g. The Director of Nursing/Director of Resident and Patient Services and/or designee is to be contacted immediately for all allegations of caregiver misconduct or Resident-to-Resident abuse. The Administrator/CCO will be notified immediately. R138 was admitted to the facility on [DATE] with diagnoses that include hypertensive heart disease with heart failure, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, bipolar disorder, depression and lower back pain. R138 was discharged on 4/13/23 at 10:13 AM to home. R138's admission Minimum Data Set (MDS) dated [DATE] document a Brief interview for Mental Status (BIMS) of 15 indicating R138 is cognitively intact. R138 is assessed a limited assist, one-person physical assist for transfers, bed mobility, dressing, and personal hygiene. R138 is assessed for bathing as physical help in part of bathing activity, one-person physical assist and not steady, only able to stabilize with staff assistance for walking. Surveyor reviewed a facility Misconduct Incident Report dated 4/20/23 which documents that on 4/13/23 R138 reported to facility security that R138 was physically assaulted the night of 4/12/23. R138 reported that R138 did call Wauwatosa Police at approximately 8:40 PM and they had come to the facility. According to the facility camera the police were onsite from 8:50 PM - 9:30 PM. R138 had a planned discharged from the facility after reporting this. Surveyor reviewed the Misconduct Incident Report (F-62447) which was submitted on 4/13/23 and completed within the 5 days. The investigation summary documents that staff were interviewed, police were notified, resident interviewed as well as other residents. Surveyor notes that the incident occurred on the evening of 4/12/23 and was reported to LPN-D. LPN-D did not report the allegation of abuse to a supervisor. This delayed the start of an investigation until the next day, 4/13/23, when administration was made aware. The facility did not follow their policy and procedures to protect further abuse as the alleged CNA continued to work and provide resident cares. On 07/26/23, at 12:39 PM, Surveyor interviewed Receptionist-C regarding her interaction with R138 on the morning of 4/13/23. Receptionist-C explained that R138 was being discharged and was waiting in the front lobby for a ride. R138's ride arrived and R138 walked out the front door. R138 then walked back inside and approached Receptionist-C. R138 then stated that R138 wanted to tell her something and to pass it on to whomever needed to know. R138 then proceeded to say that R138 was physically assaulted while taking a shower the previous evening. Receptionist-C stated that she asked R138 to clarify what they meant and R138 stated that someone grabbed R138 by the arms and pushed R138 up against the wall. R138 gave Receptionist-C their name and room number and then left the facility. Receptionist-C state that she tried to get R138 to stay until she found someone to talk with however R138 stated they needed to leave. Receptionist-C said that she immediately found Lead Social Worker-E and reported the conversation to her. On 07/26/23, at 02:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D regarding R138 and the incident on 4/12/23. LPN-D stated that he was familiar with R138 and recalled the incident on 4/12/23. LPN-D explained that he heard screaming from the shower room and he went in. He observed Certified Nursing Assistant (CNA)-H in front of R138. LPN-D stated that CNA-H explained that she was trying to help R138 shower and that R138 was trying to get up independently. CNA-H was trying to assist and R138 thought the CNA-H was trying to push her. R138 was screaming at CNA-H. LPN-D explained that he then told the CNA to leave and that he would continue to give R138 the shower. LPN-D informed the Surveyor that R138 alleged CNA-H hit R138 however LPN-D did not see any markings. LPN-D explained that R138 has some psych issues and behaviors with making accusations. He explained that R138 is very particular about how R138 wants things done and that he did not feel CNA-H did anything to R138. LPN-D stated that after the shower R138 was calm and went back to R138's room. LPN-D could not recall if he spoke to police but stated that he did tell the RN Supervisor-G what happened and indicated that R138 was just upset. LPN-D stated that he did not report the incident as abuse because he did not think there was any real abuse happening by the CNA. LPN-D stated that CNA-H continued to work her shift. Surveyor reviewed the time punch cards for CNA-H from 4/12/23 through 4/17/23. CNA-H worked 4/12/23 from 2:30 PM - 10:00 PM, 4/13/23 from 3:00 PM - 10:00 PM and 4/17/23 from 2:30 PM - 4:10 PM. On 07/27/23, at 08:29 AM, Surveyor interviewed the Nursing Home Administrator (NHA)-A who acknowledged that there was a delay in starting an investigation into the alleged abuse as administration was not notified of the allegation until the morning of 4/13/23 when R138 reported it to Receptionist-C. They than began investigating. NHA-A explained that at this time she was not made aware that the police were in the building the previous night. NHA-A stated she spoke to security, and they informed NHA-A that the police were in the building however they were not aware as to why the police arrived. NHA-A stated she then spoke to RN Supervisor-G who stated the police were in the building, and she did speak to the police however she didn't really think there was any allegation of abuse. NHA-A then spoke to LPN-D who stated that he did speak to police, however he didn't feel that any abuse occurred, so he told the police that nothing happened. LPN-D said it was more of a customer service issue. NHA-A explained that the police did speak with the resident as well, however the police could not determine if any abuse occurred, so they left the facility. Surveyor asked NHA-A if determining if abuse occurred was a determination that LPN-D was able to make. NHA-A stated, no, the incident should have been reported immediately so that we could start an investigation. NHA-A explained that she then talked to RN Supervisor-G and told her that any time a resident reports abuse and/or the police are in the building we need to escalate that concern up to administration. NHA-A stated that she did a 1:1 in service retraining for RN Supervisor-G. NHA-A explained that during the investigation they interviewed CNA-H and obtained her statement. This did not occur until the evening on 4/13/23 which is why the staff member was in working status and was still providing resident care. Surveyor asked NHA-A why LPN-D and RN Supervisor-D did not remove CNA-H from the floor when allegations of abuse were reported the evening of 4/12/23 and NHA-A explained that neither of them thought it was abuse. The RN Supervisor thought that the police were handling it and did not feel a need to escalate it up to administration when she was made aware on the evening of 4/12/23. NHA-A stated that there were breaks all the way through. NHA-A stated they needed to go back and reeducate LPN-D and RN Supervisor-G on reportable incidents. The DON did interview other residents who had interactions with CNA-H and no one reported any concerns. NHA-A explained that she only retrained the two staff because she has done multiple abuse prevention training over the past year and therefore did not do an all staff training after this incident. Surveyor relayed concerns to NHA-A regarding the delay in reporting the alleged incident of abuse by R138 during the evening of 4/12/23 by LPN-D and RN Supervisor-G. A delay in reporting the incident then cause a delay in notifying the State Agency of an alleged abuse of a resident and starting an investigation. During this delay in starting an investigation an alleged CNA was allowed to continue working with residents. The facility could not provide documentation that residents were safe guarded during this investigation. NHA-A was in agreement with these concerns. No additional information was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 3 Residents (R20, R29, and R26) of 4 residents reviewed for hospitalization received a transfer notice to include date of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the State Long-Term Care Ombudsman of hospital transfers for 3 Residents (R20, R29, and R26) of 4 residents reviewed for hospitalization. R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. The facility did not provide R20, their representative, and the Ombudsman notice of transfer. R29 was transferred to the hospital on 4/18/23 and 5/23/23. The facility did not provide R29, their representative, or the Ombudsman notice of transfer. R26 was transferred to the hospital on 5/7/23. The facility did not provide R26, their representative, and the Ombudsman notice of transfer. Findings include: The facility could not provide a resident transfer notice policy. 1. R20 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypercapnia, chronic respiratory failure with hypoxia, tracheostomy status, and congestive heart failure. R20 is on hospice. R20's Quarterly Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 11 indicating R20 was moderately cognitively impaired. R20 does have an activated Power of Attorney (POA.) Review of R20's medical chart documents R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. Surveyor was unable to locate information as to whether a transfer notice was provided to R20, their representative, and to the Ombudsman. R20 was readmitted into the facility upon hospital discharges. 2. R29 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease with acute lower respiratory infection, and mild cognitive impairment. R29's Quarterly Minimum Data Set (MDS) dated [DATE], documents a BIMS (Brief Interview for Mental Status) of 8 indicating R29 is moderately cognitively impaired. R29 does have an activated POA. Review of R29's medical chart documents R29 was transferred to the hospital on 4/18/23 and 5/23/23. Surveyor was unable to locate information indicating whether a transfer notice was provided to R29, their representative, and the Ombudsman. On 7/26/23, at 11:00 AM, Surveyor spoke with Social Worker-F regarding resident transfer notices. Social Worker-F stated that she did not participate in this process and did not know who does. On 7/26/23, at 2:11 PM, Surveyor spoke to Director of Nursing-B (DON) who stated that they did not have transfer notices for R20 and R29, as they have had a break in our process and we need to fix that. On 7/26/23, at 3:05 PM, Surveyor interviewed Nursing Home Administrator-A (NHA) who informed Surveyor that currently there is no process in place to notify the Ombudsman. NHA-A stated that since she has been at the facility, she has not been aware of anyone contacting the Ombudsman. NHA-A stated that she would investigate this and get back to Surveyor. R29 was allowed readmission into the facility upon hospital discharge. No additional information was provided at this time. 3. On 7/25/23, review of R26's medical record indicated R26 was transferred to the hospital on [DATE]. R26's medical record did not include documentation that a transfer notice had been given to the resident and/or representative for the hospitalization. On 07/26/23 at 2:13 PM, DON-B was interviewed and indicated the facility has a break in their bed hold process that needs to be fixed. DON-B indicated she could not find a transfer notice for R25's discharge to the hospital on 5/7/23. On 7/27/23 at 9:07 AM, NHA-A was interviewed and indicated no evidence could be found that the Ombudsman was notified of R26's discharge to the hospital on 5/7/23. NHA-A indicated she called the Ombudsman and no call has been returned as of yet. R26 was allowed readmission into the facility upon hospital discharge. The above findings were shared with NHA-A and DON-B on 7/26/23 at 3:00 PM at the daily exit meeting. Additional information was requested if available. The only additional information was from the above interview on 7/27/23 at 9:07 AM.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not provide written notice of the facility bed-hold policy for 3 (R20, R29, R26) of 4 residents reviewed for hospital transfers. R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. A bed hold notice was not provided to R20 and their resident representative. R29 was transferred to the hospital on 4/18/23 and 5/23/23. A bed hold notice was not provided to R29 and their representative. R26 was transferred to the hospital on 5/7/23. A bed hold notice was not provided to resident and their resident representative. Findings include: The facility policy, entitled Health Care Center Bed Hold and Return, revised 6/2018, states: It is the policy of [NAME] manor that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. 1. R20 was admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease with acute exacerbation, chronic respiratory failure with hypercapnia, chronic respiratory failure with hypoxia, tracheostomy status and congestive heart failure. R20 is on hospice. R20's Quarterly Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) of 11 indicating R20 was moderately cognitively impaired. R20 does have an activated Power of Attorney (HCPOA). Review of R20's medical chart documents R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. Surveyor was unable to locate in R20's medical record whether a bed hold notice was provided to R20 and their representative. 2. R29 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypertensive heart disease with heart failure, chronic obstructive pulmonary disease with acute lower respiratory infection, and mild cognitive impairment. R29's Quarterly MDS dated [DATE], documents a BIMS of 8 indicating R29 is moderately cognitively impaired. R29 does have an activated POA. Review of R29's medical chart documents R29 was transferred to the hospital on 4/18/23 and 5/23/23. Surveyor was unable to locate in R29's medical record whether a bed hold notice was provided to R29 and their representative. On 7/26/23, at 11:00 AM, Surveyor spoke with Social Worker-F regarding resident bed holds. Social Worker-F stated that she did not participate in this process and did not know who does. On 7/26/23, at 2:11 PM, Surveyor spoke to Director of Nursing-B who stated that they did not have bed hold notices for R20 and R29, as they have had a break in our process and we need to fix that. On 7/26/23, at 3:05 PM, Surveyor interviewed Nursing Home Administrator-A (NHA) who informed Surveyor that currently the floor nurse is responsible to give the bed notice to residents when they are leaving the facility. NHA-A stated that staff may be confused if all residents need to receive a bed hold prior to leaving the facility and that they would look into resolving this issue. No additional information was provided at this time. 3. On 7/25/23 R26's medical record was reviewed and it indicated R26 was transferred to the hospital on 5/7/23. R26's medical record did not include documentation that a bed notice had been given to the resident and/or representative for the hospitalization. On 07/26/23 at 2:13 PM Director of Nurses (DON)-B was interviewed and indicated the facility has a break in their bed hold process that needs to be fixed. DON-B indicated she could not find a bed hold notice for R25's discharge to the hospital on 5/7/23. On 2/9/22 at 9:30 AM Director of Nurses -B was interviewed and indicated no bed hold notices could be found for R89's hospitalizations on 10/12/21 and 12/7/21 and they should have been provided.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0742 (Tag F0742)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility did not ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 1 (R76) residents reviewed with a history of trauma. * R76 was admitted to the facility on [DATE] after a prolonged hospital stay from multiple fractures and complications related to a gunshot wound (GSW) and a fall out of a window from a 4th story building and bipolar disorder. R76 had multiple complications and was admitted to the facility with identified trauma and related behaviors. The facility completed a Brief Trauma Questionnaire Assessment with R76. Information gathered through this assessment was not incorporated into R76's care plan in order to reduce stressors triggering trauma induced behaviors and to decrease R76's exposure for re-traumatization. Additionally, the facility did not implement behavioral health services during his stay at the facility as planned. On 6/12/23 R76 agreed to psychological and psychiatry services. On 6/13/23 a referral was submitted to the psychiatrist/psychologist's office. On 6/30/23 a facility self-report investigative summary documents the team would like to mover forward with implementing supports such as psychological services. Psychological Services was not followed up on until 7/7/23 when there was a referral to eval (evaluate) and treat. R76 was discharged from the facility on 7/13/23 without receiving psychological services. Findings include: Surveyor reviewed the facility's Trauma Informed Care policy with an implementation date of 4/2023. Documented was: Policy: It is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Definitions: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. Common sources of trauma may include, but are not limited to: a. Natural and human caused disasters b. Accidents c. War d. Physical, sexual, mental, and/or emotional abuse (past or present) e. Rape f. Violent crime g. History of imprisonment h. History of homelessness i. Traumatic life events (death of a loved one, personal illness, etc.) Trauma-Informed Care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma. A trauma- informed approach to care delivery recognizes the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . Policy Explanation and Compliance Guidelines: . 2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, and others . 6. The facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan. While most triggers are highly individualized, some common triggers may include, but are not limited to: a. Experiencing a lack of privacy or confinement in a crowded or small space. b. Exposure to loud noises, or bright/flashing lights. c. Certain sights, such as objects that are associated with their abuser. d. Sounds, smells, and physical touch. 7. Trauma-specific care plan interventions will recognize the interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety. These interventions will also recognize the survivor's need to be respected, informed, connected, and hopeful regarding their own recovery. 8. The facility will evaluate whether the interventions have been able to mitigate (or reduce) the impact of identified triggers on the resident that may cause re-traumatization. The resident and/or his or her family or representative will be included in this evaluation to ensure clear and open discussion and better understand if interventions must be modified . Surveyor reviewed facility's Behavior Management policy with a reviewed date of 2/2021. Documented was: PREFACE [The facility] promotes and supports a resident centered approach to care. The purpose of this policy is to define and set expectations regarding mood and behavioral health services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, therefore an individualized approach to care is essential. POLICY It is the policy of [the facility] that each resident must receive and [the facility] must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment (483.20) and plan of care. The interdisciplinary team will utilize information from the Preadmission Screening and Resident Review (PASRR) process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life history and preference using the resident assessment instrument (RAI) specified by CMS. OBJECTIVE OF THE MOOD AND BEHAVIOR POLICY AND PROCEDURE The objective of the Mood and Behavior Policy and Procedure is to provide a plan of care that is individualize to the residents needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well-being. R76 was admitted to the facility 6/8/23 with diagnoses that include Fracture of Right Femur, Fracture of Left Femur, Fracture of Shaft of Right Humerus, Fracture of Lower End of Left Humerus, Fracture of Head of Left Radius, Fracture of Lower End of Left Radius, Fracture of Upper End of Left Ulna, Fracture of Right Forearm, Fracture of Olecranon Process, Fracture of Trapezium, Fracture of Right Patella, Fracture of Left Patella, Bimalleolar Fracture of Left Lower Leg, Multiple Fractures of Ribs, Fracture of Sternum, Acute Pain Due to Trauma, and Bipolar Disorder. R76 was hospitalized [DATE] through 6/8/23 after a gunshot wound and fall out a window of a 4 story building. Surveyor reviewed R76's Minimum Data Set (MDS) admission assessment with an assessment reference date of 6/15/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Surveyor reviewed R76's Progress Notes. Documented on 6/11/2023 at 8:30 PM was Resident has behavior issues of being disrespectful and cursing staff out. Calling staff and writer with F word. He said, Get your F anus out of my room and go home. After asking writer to put urinal between his thigh so he can urinate, because urinal touched his penis and he got so mad. Writer told resident you don't have to be rude and mad if anyone makes a mistake just correct the person and tell her or him what to do or turn your call light on for other help that's why you have call light, I touch infront of you. instead of cursing staff out and calling staff with F word. Also, at the beginning of the shift, he told his brother I am not a nurse later he said he does not understand what I tell him, I have un-accent. He doesn't want me any more to be his nurse. Surveyor reviewed R76's Progress Notes. Documented on 6/12/2023 at 10:22 AM was [R76] admitted to [facility] on 6/8/23, following a hospitalization for GSW, and other traumas. [R76] is alert and oriented, and able to make his needs known at this time. He remains [non-weight bearing (NWB)] to all of his extremities. [R76] admitted to [hospital] on 3/18/23 following successful resuscitation of [R76] in the trauma bay. He was admitted for multiple open fractures including bilateral femurs, R. Humerus, L olecranon. It was noted that upon admission there were obvious deformities of all four extremities. [R76] admitted to [facility] for long standing recovery efforts. He would like to engage in therapy, as his body heals, and reports that discharge disposition is unknown at this time. [R76] reports an okay relationship with his sister, that he is hoping to rekindle as he heals. He reports that nobody in the hospital had asked him about mental health needs, and reports that he has nightmares daily, and reports feeling subsequently depressed. Writer did share about psychology and psychiatry services, he was agreeable to this, although he cannot sign due to status of extremities, he provided verbal consent. Writer will submit referral for Psychology and psychiatry. An initial care conference has been set up for 6/13 @ 10:15am, writer will invite sister per [R76's] request. [R76] had no questions or concerns at this time. [Social Worker] will follow for support, [interdisciplinary team (IDT)] will continue to monitor. Surveyor reviewed Brief Trauma Questionnaire assessment with a date of 6/12/23. Documented was: A. Events .8. Have you ever been in any other situation in which you were seriously injured, or have you ever been in any other situation in which you feared you might be seriously injured or killed? a. Yes. 8a. If the event happened, were you seriously injured? a. Yes . B. IMPACT and Symptomology a. If the resident answered yes to any of the brief trauma questions, ask the resident to indicate the impact the event or trauma has had on their present day physical, emotional and social wellbeing: Answer: 2. Large - difficulty functioning and/or coping with emotions or daily life b. Check all of the physical symptoms of trauma that the resident indicates are present, (the following was checked): 1. Headaches, backaches or stomachaches 3. Heart palpitations 4. Changes in sleep or eating patterns c. Check all of the emotional symptoms of trauma that the resident indicates are present (the following was checked): 1. Being easily startled 3. Emotional swings 4. Fear, depression, and anxiety 6. Survivor guilt 7. Shame 8. Nightmare d. Check all of the social symptoms of trauma that the resident indicates are present (the following was checked): 2. Feelings of detachment or betrayal 3. Difficulty trusting . Surveyor reviewed R76's Comprehensive Care Plan with an initiation date of 6/12/23. Documented was: Focus: Potential for anxiety, depression, PTSD r/t traumatic life event GSW, and fall from 4th floor window, which left significant deformities to all extremities. Goal: Identify anxious feelings and report feeling control over factors contributing to fear Interventions: o Reduction in highest phase of anxiety reached o Will be free from injury o Will use appropriate coping strategies o Administer medications appropriately and monitor the side effects or dependence o Assess anxiety level to determine severity of condition and course of treatment or therapy. o Determine other psychological effects, change in mood/affect o Establish trust with the resident; listen to what the residents is saying and behave in a calm manner. o Provide calming and reassuring environment to help lessen or relieve anxiety and promote a feeling of safety. o Provide extra time for care and allow resident extra time to respond to questions. Surveyor noted the facility did not incorporate knowledge about R76's trauma and behaviors gathered from the Brief Trauma Questionnaire assessment dated [DATE] into R76's care plan. The Brief Trauma Questionnaire dated 6/12/23 indicates R76 has physical symptoms of traumas such as changes in sleep or eating patterns, heart palpitations. The Brief Trauma Questionnaire indicates R76's emotional symptoms of traumas as being easily startled, having survivor guilt, shame, nightmares. The Brief Trauma Questionnaire indicates R76 has social symptoms of trauma such as feelings of detachment or betrayal, difficulty trusting etc. however R76's care plan does not identify any stressors that may trigger these behaviors and that may re-traumatize R76. R76's care plan does not identify ways to mitigate or decrease the effect of those stressors. Surveyor reviewed Progress Notes for R76. Documented on 6/13/2023 at 9:43 AM was Psych referral submitted to [psychiatrist/psychologist's office]. Medical Records aware of referral being sent, and IDT also notified. Documented at 9:47 AM was Writer communicated with [psychiatrist/psychologist's office] regarding PASSR Screen. Writer did share that psychology will see [R76] when here next week, and Psychiatry will be in later this week . Surveyor reviewed R76's Electronic Medical Record. There was no documentation of psychology or psychiatry seeing R76. There was no documentation of monitoring of behaviors related to trauma identified. Surveyor reviewed the Facility Reported Investigation for R76 with a date of 6/30/23. Documented was: [R76] was admitted to [facility] on 06/08/2023, with a diagnosis of multiple fractures with Non-weight bearing to all extremities. [R76] is alert and oriented and able to make his needs known. He does require additional assistance for his care, based on his diagnoses and corresponding comorbidities. Outside of the diagnoses of multiple fractures and non-weight bearing to all extremities', [R76] has known mental health diagnosis of Bipolar Disorder. [R76] reported on June 30th, 2023, that he was pushed into a wall by [CNA-I]. He reported to [Police] that [CNA-I] was providing incontinence cares in bed. [R76] had soiled himself. During cares, [R76] claimed that [CNA-I] shoved him hard where he hit the wall. [R76] did indicate that he was not injured and wanted the incident documented. It is important to note that the [CNA-I] needed to move the resident towards the wall to give proper cares. [Police] spoke with [CNA-I] who reported that she was moving [R76] to clean him after he soiled himself. [CNA-I] reported she did not intentionally push to harm him, she had to move resident for proper cares .No injuries and this was referred to the Manager. No further police action was taken at this time. Writer interviewed [R76] and [R76] reported he immediately struck up a conversation with [CNA-I] to get under her skin. [CNA-I] continued to complete her cares with [R76]. It is imperative to note that [R76] was looking for [CNA-I] to not want to complete cares as he intentionally had a negative conversation with [CNA-I] as soon as she came into the room. In the past [R76] has had behaviors of not wanting certain caregivers in his room to complete cares. In further investigation by Social Worker, [CNA-I] reported that [R76] light was on, she went in to assist him. [R76] stated that he needed to be cleaned. [CNA-I] cleaned [R76] and prepped him for lunch time. While [CNA-I] was assisting [R76] he requested for her to scratch his head. [CNA-I] scratched his head twice, then she got a cold towel to rub around his head. Afterwards [CNA-I] asked [R76] to get ready to turn so she could clean him up. As [CNA-I] was assisting [R76] asked again to scratch his head, [CNA-I] explained to [R76] that she would ask the Nurse for cream to rub on his head. [R76] got upset, was rude, called the [CNA-I] out of her name, and told her to get out of his room. [CNA-I] walked out of [R76] room. Writer interviewed the other residents that are on the same group as [R76]. Residents reported that [CNA-I] is a good CNA, attentive, and a hard worker; There were no concerns with completed cares. Residents interviewed are alert and oriented. Based on the information obtained in the investigation, the facility is unable to substantiate any form of caregiver misconduct, based on the information reported above. Although the investigation is being closed at this time, the facility will continue to monitor [R76]. [R76] has not presented with any changes to his baseline mood or behaviors, and based on this, this writer will reach out to [R76's] brother who is his primary support system to meet and discuss the outcomes of this investigation to see how the team can best support [R76]. Social Services recognizes that [R76] struggles with frustration and anger with not being able to move around and do the small things for himself. The team would like to move forward with implementing supports to help [R76] cope, such as psychology services. Should any new information be obtained that enhances or alters this report, an addendum will be submitted to DQA with further information. Surveyor reviewed R76's Electronic Medical Record. There was no documentation of psychology or psychiatry seeing R76. There was no documentation of monitoring of behaviors related to trauma. Surveyor reviewed R76's Comprehensive Care Plan with a revision date of 7/6/23. Documented was: Focus: The resident is verbally aggressive, yelling and cursing at staff [related to (r/t)] Ineffective coping skills, Mental / Emotional illness, Poor impulse control Goal: The resident will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions: o Administer medications as ordered. Monitor/document for side effects and effectiveness. o Assess resident's coping skills and support system o Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. o Give the resident as many choices as possible about care and activities. o Monitor behaviors [every (Q)] shift. Document observed behavior and attempted interventions. o Psychiatric/Psychogeriatric consult as indicated. o Staff to maintain resident's safety by ensuring that the call light is within reach, the bed is in the lowest position and personal belonging are also within reach, when demonstrating escalating behaviors prior exiting room to give resident time to de-escalate. o When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Surveyor reviewed R76's Progress Notes. Documented on 7/7/2023 at 2:15 AM was Behavior Note. Subjective: [follow up (F/U)] Behavior. Objective: [BLANK]. Assessment: No behavior issues during the night shift . Surveyor reviewed facility referral to psychology and psychiatry consult with a date of 7/7/23. Documented was Eval and treat. There was no documentation of psychology or psychiatry seeing R76. R76 discharged from the facility on 7/13/23. On 7/26/23 at 10:30 AM Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked if there was a formal assessment done for R76 and his behaviors and trauma. NHA-A stated Social Worker (SW)-E would do that. Surveyor asked if R76 ever saw psych services based on documentation. DON-B stated a referral was sent on 7/11/23. Surveyor asked about the documentation on admission and if he was ever seen. DON-B stated she will look into that. Surveyor asked what was put in place for R76 after the incident on 6/30/23. NHA-A stated R76's only request was that he does not have CNA-I again. Surveyor noted the investigation noted monitoring and a psych referral that was supposedly already in place. DON-B stated they were supposed to document any behaviors or problems R76 was having. Surveyor noted there is no documentation until 7/7/23. DON-B stated they use the 24 hour boards to document as well. Surveyor requested the 24 hour boards for review. On 7/26/23 at 2:12 PM Surveyor reinterviewed DON-B. DON-B stated a referral was sent for psych services on 6/13/23 but it got missed. DON-B stated on 6/30/23 the facility found out that the referral was not followed up on and it was resent on 7/7/23. DON-B stated R76 was not seen by any psych services during his stay at the facility. DON-B also stated there was nothing charted on the 24 hour boards about R76 to monitor him after the 6/30/23 incident. No other additional information was provided.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure it maintained a medication error rate below 5 percent during observations of medication administration affecting 1 (R36) of 4 residents observed. Two medication errors were observed out of twenty-eight opportunities, for a total error rate of 7.14%. * R36 was administered 2 medications whole with applesauce that should not be chewed. R36 was observed chewing Januvia and Memantine ER (extended release) and drug manufacturers recommendations are not to chew the medication. Findings include; On 07/27/23 the facility's policy and procedure titled, Medication Administration dated 03/21 read: Crushing oral medication. Non-crushable medications cannot be without a specific medical doctor order documented on the medical record for a specific resident and specific medication. Long acting or enteric coated dosage forms should generally not be crushed: an alternative should be sought. R36 was admitted to the facility on [DATE]. On 07/26/2023 at 8:10 AM, Licensed Practical Nurse (LPN)-J was observed administering medication to R36. LPN-J placed Memantine ER 28 milligrams (mg) which was in a capsule form and Januvia 25 mg in a medication cup along with other medication. LPN-J mixed the whole pills in applesauce before giving them to R36. R36 was observed to chew the medication and indicated the medication tasted terrible and pieces of the medication were visible on her teeth. On 7/26/23 at 12:13 PM LPN-J was interviewed and indicated that sometimes R36 takes her medication whole and sometimes she gets it crushed. LPN-J reported she did not ask R36 how she would like to take her medication before administering it to her this morning. LPN-J stated R36 did not chew the Memantine ER capsule. LPN-J was asked how she new if R36 did not chew the capsule and indicated she did not know if R36 chewed the capsule (R36 was observed chewing all of the medication). LPN-J indicated that she did not instruct R36 not to chew the medication. LPN-J indicated she did not know that Januvia could not be chewed but she knew the capsule should not be chewed. On 7/26/23 R36's current physician orders were reviewed and read: Memantine ER capsule 28 mg one time a day. Sitagliptin Phosphate (Januvia) tablet 25 mg one time a day. No orders to crush or chew R36's medication could be found. On 7/27/23 The Website accessdata.fda.gov was reviewed and read: Januvia should be swallowed whole. The tablets must not be split, crushed or chewed before swallowing. The tablets are enteric coated with a film. On 7/27/23 the Website Drugs.com was reviewed and read: Memantine ER can not be divided, chewed or crushed. The above findings were shared with Administrator A on 7/27/23 at 9:07 a.m. Additional information was requested if available. None was provided.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R76 was admitted to the facility 6/8/23 with diagnoses that include Fracture of Right Femur, Fracture of Left Femur, Fracture of Shaft of Right Humerus, Fracture of Lower End of Left Humerus, Fracture of Head of Left Radius, Fracture of Lower End of Left Radius, Fracture of Upper End of Left Ulna, Fracture of Right Forearm, Fracture of Olecranon Process, Fracture of Trapezium, Fracture of Right Patella, Fracture of Left Patella, Bimalleolar Fracture of Left Lower Leg, Multiple Fractures of Ribs, Fracture of Sternum, Acute Pain Due to Trauma, and Bipolar Disorder. Surveyor reviewed R76's Minimum Data Set (MDS) admission assessment with an assessment reference date of 6/15/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Documented under Medications was .Medications Received: Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Enter 0 if medication was not received by the resident during the last 7 days. A. Medication received: Days: Antipsychotic: 7 . Surveyor reviewed R76's Progress Notes. Documented on 6/11/2023 at 8:30 PM was Resident has behavior issues of being disrespectful and cursing staff out. Calling staff and writer with F word. He said, Get your F anus out of my room and go home. After asking writer to put urinal between his thigh so he can urinate, because urinal touched his penis and he got so mad. Writer told resident you don't have to be rude and mad if anyone makes a mistake just correct the person and tell her or him what to do or turn your call light on for other help that is why you have call light, I touch Infront of you. instead of cursing staff out and calling staff with F word. Also, at the beginning of the shift, he told his brother I am not a nurse later he said he does not understand what I tell him, I have un-accent. He doesn't want me any more to be his nurse. Surveyor reviewed R76's Progress Notes. Documented on 6/12/2023 at 10:22 AM was [R76] admitted to [facility] on 6/8/23, following a hospitalization for GSW, and other traumas. [R76] is alert and oriented, and able to make his needs known at this time. He remains [non-weight bearing (NWB)] to all of his extremities. [R76] admitted to [hospital] on 3/18/23 following successful resuscitation of [R76] in the trauma bay. He was admitted for multiple open fractures including bilateral femurs, R. Humerus, L olecranon. It was noted that upon admission there were obvious deformities of all four extremities. [R76] admitted to [facility] for long standing recovery efforts. He would like to engage in therapy, as his body heals, and reports that discharge disposition is unknown at this time. [R76] reports an okay relationship with his sister, that he is hoping to rekindle as he heals. He reports that nobody in the hospital had asked him about mental health needs, and reports that he has nightmares daily, and reports feeling subsequently depressed. Writer did share about psychology and psychiatry services, he was agreeable to this, although he cannot sign due to status of extremities, he provided verbal consent. Writer will submit referral for Psychology and psychiatry. An initial care conference has been set up for 6/13 @ 10:15am, writer will invite sister per [R76's] request. [R76] had no questions or concerns at this time. [Social Worker] will follow for support, [interdisciplinary team (IDT)] will continue to monitor. Surveyor reviewed MD Orders for R76. Documented with a start date of 6/12/23 and end date of 6/13/23 was Quetiapine Fumarate Tablet 50 MG, Give 1 tablet by mouth at bedtime for PTSD. Documented with a start date of 6/13/23 and end date of 6/20/23 was Seroquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 1 tablet by mouth at bedtime for anti-psychotic for 7 Days. Documented with a start date of 6/21/23 and end date of 6/28/23 was SEROquel Oral Tablet 25 MG (Quetiapine Fumarate), Give 0.5 tablet by mouth at bedtime for antipsychotic for 7 Days give 1\2 tab to equal 12.5 mg. Surveyor reviewed R76's Comprehensive Care Plan with an initiation date of 6/12/23. Documented was: Focus: Potential for anxiety, depression, PTSD r/t traumatic life event GSW, and fall from 4th floor window, which left significant deformities to all extremities. Goal: Identify anxious feelings and report feeling control over factors contributing to fear Interventions: o Reduction in highest phase of anxiety reached o Will be free from injury o Will use appropriate coping strategies o Administer medications appropriately and monitor the side effects or dependence o Assess anxiety level to determine severity of condition and course of treatment or therapy. o Determine other psychological effects, change in mood/affect o Establish trust with the resident; listen to what the residents is saying and behave in a calm manner. o Provide calming and reassuring environment to help lessen or relieve anxiety and promote a feeling of safety. o Provide extra time for care and allow resident extra time to respond to questions. Surveyor reviewed R76's Comprehensive Care Plan with a revision date of 7/6/23. Documented was: Focus: The resident is verbally aggressive, yelling and cursing at staff [related to (r/t)] Ineffective coping skills, Mental / Emotional illness, Poor impulse control Goal: The resident will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions: o Administer medications as ordered. Monitor/document for side effects and effectiveness. o Assess resident's coping skills and support system o Assess resident's understanding of the situation. Allow time for them resident to express self and feelings towards the situation. o Give the resident as many choices as possible about care and activities. o Monitor behaviors [every (Q)] shift. Document observed behavior and attempted interventions. o Psychiatric/Psychogeriatric consult as indicated. o Staff to maintain resident's safety by ensuring that the call light is within reach, the bed is in the lowest position and personal belonging are also within reach, when demonstrating escalating behaviors prior exiting room to give resident time to de-escalate. o When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Surveyor reviewed R76's Progress Notes. Documented on 7/7/2023 at 2:15 AM was Behavior Note. Subjective: [follow up (F/U)] Behavior. Objective: [BLANK]. Assessment: No behavior issues during the night shift . Surveyor noted there was no documentation of monitoring of behaviors related to antipsychotic medications. R76 discharged from the facility on 7/13/23. On 7/26/23 at 10:30 AM Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked about R76's behaviors starting on 6/11/23. DON-B stated staff told her that he was cussing them out and she directed them to chart that if it is occurring. Surveyor asked DON-B what the process was if a resident had behaviors. DON-B stated if R76 was cussing and swearing it should be care planned. NHA-A stated the staff should ensure he is safe with his call light within reach and give him time to calm down. Surveyor asked why the care plan for behaviors was not implemented until 7/6/23 and behavior monitoring was not put in place until 7/7/23 even though resident showed behaviors on 6/11/23. Surveyor asked if another behavioral incident happened 7/6/23. DON-B was unsure. DON-B stated they were supposed to document any behaviors or problems R76 was having in the Progress Notes. Surveyor noted there is no documentation until 7/7/23. DON-B stated they use the 24 hour boards to document as well. Surveyor requested the 24 hour boards for review. On 7/26/23 at 2:12 PM Surveyor reinterviewed DON-B. DON-B stated there was nothing charted on the 24 hour boards about R76 to monitor him. No other additional information was provided. 4. R20 was admitted to the facility on [DATE] with diagnoses that include Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Respiratory Failure with Hypercapnia, Chronic Respiratory Failure with Hypoxia, Tracheostomy Status and Congestive Heart Failure. Surveyor reviewed R20's Minimum Data Set (MDS) admission assessment with an assessment reference date of 7/11/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 11 which indicated cognitively impaired. Documented under Medications was .Medications Received: Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Enter 0 if medication was not received by the resident during the last 7 days . B. Medication received: Days: Antianxiety: 7. C. Medication received: Days: Antidepressant: 7 . Surveyor reviewed MD Orders for R20. Documented with a start date of 6/26/23 was Buspirone HCl Oral Tablet 5 MG (Buspirone HCl), Give 1 tablet by mouth three times a day for anxiety. Documented with a start date of 6/26/23 and an end date of 7/26/2023 was Divalproex Sodium Oral Tablet Delayed Release 125 MG (Divalproex Sodium), Give 1 capsule by mouth two times a day related to ANXIETY DISORDER, UNSPECIFIED (F41.9). Documented with a start date of 7/14/23 and an end date of 7/26/2023 was Lorazepam Oral Tablet 0.5 MG (Lorazepam), Give 0.5 tablet by mouth every 8 hours as needed for anxiety for 30 Days. Surveyor reviewed R20's Comprehensive Care Plan with an initiation date of 4/12/23. Documented was: Focus: Resident has a behavior problem of calling the EMT [related to (r/t)] anxiety. Goal: The resident will have fewer episodes of anxiety weekly by review date. Interventions: o Administer medications as ordered. Monitor/document for side effects and effectiveness. o If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. o Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. There is no other care plan addressing interventions to prevent anxiety or to address resident specific interventions. Surveyor reviewed R20's Electronic Medical Record and noted there was no documentation of monitoring behaviors related to antianxiety medications. On 7/27/23 at 9:33 AM Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked for behavior monitoring and individualized behaviors and interventions for R20 related to her medications. NHA-A stated besides the EMT calls, there was no behavior monitoring for R20; only the medication side effects monitoring. NHA-A stated it is a lesson learned and they will be implementing behavior monitoring and care plans for the residents related to antipsychotics. Based on record review and interview the facility did not ensure 4 of 5 Residents (R48 R61, R76, and R20) reviewed for psychotropic medications were adequately monitored for indications for use for the psychotropic medication. This is evidenced by: Policy Review : Use of Psychotropic Medications, date implement 5/20 Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medications). Policy Explanation and Compliance Guidelines: ( Includes) 12. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: a. Upon physician evaluation (routine and as needed), b. During the pharmacist's monthly medication regimen review, c. During MDS review (quarterly, annually, significant change), and d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 13. The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. 1. R48 was admitted to the facility on [DATE] with diagnosis that included Depression. Surveyor conducted a review of R48's physician orders and noted that R48 had a order for Sertraline HCl Tablet 100 MG, give 1 tablet by mouth one time a day for depression This order was written on 5/30/2021. Surveyor conducted a review of the annual MDS (Minimum Data Set), dated 6/2/23. The MDS states R48 received antidepressant medication during the last 7 days of the assessment reference period. A review of R48's individual plan of care states R48 has depression r/t Disease Process, date Initiated: 06/10/2021. Interventions include to administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 06/10/2021 Further review of R48's medical record did not show evidence that the facility was qualitatively monitoring R48's behaviors for the use of the Sertraline medication. On 7/26/23 at 11:00 a.m., Surveyor interviewed Administrator - A and Director of Nursing- B regarding the behavior monitoring for R48's daily use of Sertraline for depression. Both Administrator- A and DON- B stated that they were unable to provide information that the facility was monitoring R48's behaviors . As of the time of exit, the facility did not provide any additional information as to why R48's behaviors were not monitored to ensure the effectiveness of the medications used. 2. R61 was originally admitted to the facility on [DATE] with diagnosis that included Alzheimer's disease, Dementia and Depression. Surveyor conducted a review of R61's physician orders and noted that R61 has an order for Quetiapine Fumarate Oral Tablet 25 MG, give 3 tablets by mouth three times a day for Depression. This order was written on 3/31/2023. In addition, R61 is receiving Fluoxetine HCl Oral Capsule 20 MG, Give 1 capsule by mouth one time a day for Depression. This order was written on 4/1/2023. A review of the significant change MDS (Minimum Data Set), dated 7/8/23 states that R61 has received antipsychotic and antidepressant medication for the seven days of the reference period for this assessment. The antipsychotics were received on a routine basis. R61's plan of care states that R61 is/has potential to be physically aggressive r/t Dementia, Depression. Interventions include to administer medications as ordered. Monitor/document for side effects and effectiveness. The plan of care also states that R61 uses fluoxetine daily r/t depression. Interventions include to administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Further review of R61's medical record did not show evidence that the facility was quantatively monitoring R61's behaviors for the use of the Quetiapine and Fluxetine medications. On 7/26/23 at 11:00 a.m., Surveyor interviewed Administrator - A and Director of Nursing- B regarding the behavior monitoring for R61's daily use of Quetiapine and Fluoxetine for depression. Both Administrator- A and DON- B stated that they were unable to provide information that the facility was monitoring R61's behaviors. As of the time of exit, the facility did not provide any additional information as to why R61's behaviors were not monitored to ensure the effectiveness of the medications used.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, record review and staff interview, the facility did not ensure a resident received assistance to eat their meal. This was observed with 1 (R1) of 10 residents with ADL (activity of daily living) dependence. R1 requires staff assistance to eat and was not provided that service timely. Findings include: R1's medical record was reviewed by Surveyor. R1's most recent Quarterly MDS (Minimum Data Set) assessment completed 3/4/23 indicates R1 requires extensive assist of 1 staff with eating. R1 is non-verbal and has a diagnosis of quadriplegia. Surveyor noted R1 was not responsive to Surveyor's interactions. R1's plan of care ADL self-care performance deficit related to impaired mobility, non-verbal, quadriplegia and epileptic syndrome revised on 3/7/23. Indicates for Eating: (R1) requires total assistance by staff to eat. On 4/5/22 at 8:22 AM, Surveyor observed R1's breakfast meal tray delivered to R1's room by dietary staff. R1 was in bed and the meal tray was placed on the bedside table. The meal contained 1 pancake and 2 sausage links and was covered. This meal remained untouched until 9:00 AM when CNA-D (Certified Nursing Assistant) began prepping the pancake and sausage with butter and syrup. CNA-D was not receptive to an interview with Surveyor in order to question as to why R1 had to wait 38 minutes to receive assistance with their breakfast. Surveyor noted R1 ate their breakfast with the assistance provided. R1 did not receives their meal until 38 minutes after it was placed on R1's bedside table in their room. The meal was not heated up before serving after being on the bedside table for 38 minutes. On 4/5/23 at 11:33 AM Surveyor shared this observation with Administrator-A, DON-B (Director of Nurses) and ADON-C (Assistant Director of Nurses). Surveyor shared with Administrator-A, DON-B and ADON-C that CNA-D was not receptive to an interview with Surveyor. There was no additional information provided.

Apr 2022 2 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure a newly admitted resident was monitored to determine nutritional status for 1 (R79) of 3 residents reviewed for nutrition. R79 was admitted on [DATE] and did not have a weight taken until 3/17/2022. The facility weight on 3/17/2022 was 9.7 pounds less than the hospital weight. R79 had a 5.88% weight loss in six days. Findings: The facility policy and procedure entitled Hydration and Nutrition dated 7/2020 states: Purpose: For ongoing monitoring of weight status and identification of residents with a significant weight change so interventions can be initiated. Guidelines: 1. The Resident is weighed on the day of admission/readmission, weekly times four and then monthly, within the first week of the month on the resident's bath day. a. The Nurse directs the CNAs (Certified Nursing Assistants) in shift report of the need to obtain weights as outlined above and other weights as ordered more frequently by a physician order or nursing order. 4. The CNAs record the weight in the EMR (Electronic Medical Record). 5. The Nurse will know if there has been a significant weight change from Alerts in the EMR. 6. The Dietitian (RD (Registered Dietitian)/DTR (Dietetic Technician, Registered) will be responsible for identifying significant weight changes as well as weight trends and of notifying the Nurse Manager. 8. The primary physician/designee must be notified and orders received as needed for weight changes using the following criteria: a. A 3-pound weight change (increase or decrease) if the resident is less than 100 pounds. b. A 5-pound weight change (increase or decrease) if the resident is more than 100 pounds. R79 was admitted to the facility on [DATE], with diagnoses of abdominal aortic aneurysm, gastro-esophageal reflux disease, lung cancer with metastases to the bone and brain, and convulsions. Hospital records were reviewed. On 3/2/2022, R79 weighed 171 pounds. On 3/11/2022, the day of discharge from the hospital and admission to the facility, R79 weighed 74.8 kg, or 164.9 pounds. Surveyor reviewed R79's nursing Clinical admission Evaluation on 3/11/2022; no documentation of R79's weight was found. R79 had the following physician's order upon admission to the facility: weight upon admission/readmission and every seven days for four weeks. On 3/15/2022, at 10:59 AM, Registered Dietician (RD)-C documented R79 was on a general diet and was eating approximately 35% of meals since admission. RD-C documented R79 had stated their appetite was ok and did not have any dislikes; R79's dental partials were not at the facility. RD-C documented a supplement was discussed with R79 and R79 would like one Ensure at breakfast and dinner. RD-C documented: admission weight pending. Note hospital weights of 164.9# and 171.2#. RD-C charted per R79, the usual body weight was 165 pounds, R79's skin was intact, and listed R79's diagnoses. RD-C estimated R79's nutritional needs based on R79's usual weight of 165 pounds. RD-C charted R79's nutritional diagnoses to be inadequate intake related to reduced appetite status after surgery as evidenced by 35-40% meal intake. RD-C added the intervention of chocolate Ensure twice daily and stated: Will monitor intake and weight trend. Goals: maintain weight without triggers, consume adequate fluids to avoid s/s (signs/symptoms) dehydration, consume >50% of meals/supplement and no skin breakdown. Will f/u (follow up) prn (as needed). Ensure twice daily was added to R79's daily regimen on 3/15/2022. R79's Nutritional Risk Care Plan was initiated on 3/15/2022 stating R79 was at nutritional risk related to status post vascular surgery, fair meal intake, and history of lung cancer with metastases and chemotherapy. On 3/17/2022, R79 was weighed for the first time at the facility. R79 weighed 155.2 pounds. On 3/11/2022, R79 weighed 164.9 pounds. On 3/17/2022, R79 weighed 155.2 pounds. R79 had a weight loss of 9.7 pounds, or 5.88% in six days. R79's Treatment Administration Record (TAR) had the weight of 155.2 pounds entered on 3/17/2022. On 3/24/2022, nursing documented a 2 indicating the weight was refused. No other documentation was found regarding R79 refusing to be weighed on 3/24/2022 or what the staff did to try and obtain a weight such as reapproaching the resident and explaining the risks and benefits of not being weighed. CNA documentation for R79 was reviewed. No data found was displayed on the EMR for the weight task in the CNA point of care charting. Amount, Resident Not Available, Resident Refused, and Not Applicable were options available for CNAs to use to document what occurred when a weight was attempted. None of the options were used. On 3/28/2022, at 10:37 AM, Surveyor observed R79 lying in bed. R79 talked softly with their eyes closed. R79 appeared weak and tired. R79's spouse was in the room with R79 and answered Surveyor's questions as R79 laid quietly in bed. R79's spouse stated R79 was getting therapy and that left R79 with little energy. In an interview on 3/30/2022 at 8:54 AM, Surveyor asked RD-C what the facility process was for a new admissions regarding monitoring weights. RD-C stated their policy is to get a weight on admission and then weekly times four weeks. RD-C stated if there was no weight in the computer on admission, RD-C would bring it up at the daily morning meeting. RD-C reviewed the progress note on 3/15/2022 and saw the admission weight was pending. RD-C recalled having a conversation with R79 and R79's spouse and they requested a supplement due to R79 not feeling well and not eating well. Surveyor shared with RD-C R79's weight on 3/17/2022 or 155.2 pounds was almost a ten-pound weight loss. RD-C stated RD-C was not aware of the weight loss but had started R79 on a twice daily supplement on 3/15/2022 and R79's BMI ( ) (no BMI value was documented) was still in normal range, so RD-C was keeping an eye on the weights to monitor R79. Surveyor shared the concern no other weights had been taken for R79 since 3/17/2022 and could not see how R79's nutritional status was being monitored. RD-C was not aware no other weights had been obtained on R79 for the last couple of weeks. In an interview on 3/30/2022 at 9:21 AM, RD-C informed Surveyor R79 had refused to have a bath or shower on 3/24/2022 so no weight was obtained on that day as scheduled. RD-C stated the refusal was documented in the EMR. On 3/30/2022 at 9:29 AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R79 did not have a weight obtained on admission and when R79 was weighed on 3/17/2022, six days after admission, had a weight loss of almost 10 pounds compared to the hospital discharge weight on 3/11/2022. Surveyor shared with NHA-A the interview with RD-C of R79's refusal to be weighed on 3/24/2022 and the lack of documentation that staff tried alternative methods of getting R79's weight. Surveyor shared the concern with NHA-A that RD-C stated R79 was being monitored for nutritional status yet did not know R79 had not been weighed. NHA-A stated R79 should have been weighed on admission and had documentation of refusals when that was the case. No further information was provided at that time.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 serving kitchens. * Dietary Aide-F, Dietary Aide-G and Dietary Aide-H were observed touching ready to eat food with gloved hands after touching non-sanitized food surfaces. This food was then observed being served to residents to eat. * The dish machine, responsible for washing and disinfecting all of the dishes and utensils for the nursing home facility, was observed not to be reaching the minimum disinfecting temperatures during the rinse cycle. This deficient practice has the potential to affect 89 of 89 residents who receive food the main serving kitchen at the facility. Findings include: 1. Food Handling On 3/30/22, at 8:06 a.m., Surveyor observed Dietary Aide-F setting up breakfast trays for one unit of the facility. Surveyor observed Dietary Aide-F wearing gloves on both hands and touching the top of the metal counter and then with her right gloved hand grabbing a plastic top plate cover. Surveyor then observed Dietary Aide-F use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-F did not remove their gloves or wash their hands after contaminating their gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:07 a.m., Surveyor observed Dietary Aide-F wearing gloves on both hands and touching the metal food cart and countertop with both gloved hands. Surveyor then observed Dietary Aide-F use her right gloved hand to grab a peeled, ready to eat boiled egg and remove it from a plate and place it back into the container containing all the peeled, ready to eat boiled eggs that were being served to all of the residents at the facility. Surveyor noted that Dietary Aide-F did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:08 a.m., Surveyor observed Dietary Aide-F wearing gloves on both hands and touching the top of the metal counter, touching the metal food cart and then with her right gloved hand grabbing a plastic top plate cover. Surveyor then observed Dietary Aide-F use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-F did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:09 a.m., Surveyor observed Dietary Aide-F wearing gloves on both hands and touching the top of the metal counter and touching the metal food cart. Surveyor then observed Dietary Aide-F use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-F did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:11 a.m., Surveyor observed Dietary Aide-F wearing gloves on both hands and touching the top of the metal counter and moving the metal food cart. Surveyor then observed Dietary Aide-F use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-F did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:15 a.m., Surveyor observed Dietary Aide-F wearing gloves on both hands and touching the metal countertop with both gloved hands. Surveyor then observed Dietary Aide-F use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-F did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:18 a.m., Surveyor observed Dietary Aide-H setting up breakfast trays for another unit of the facility. Surveyor observed Dietary Aide-H wearing gloves on both hands and touching the metal food cart with both gloved hands. Surveyor then observed Dietary Aide-H use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-H did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:20 a.m., Surveyor observed Dietary Aide-H wearing gloves on both hands and touching the top of the metal counter, touching the metal food cart and then with her right gloved hand grabbing a plastic plate top cover. Surveyor then observed Dietary Aide-H use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-H did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:23 a.m., Surveyor observed Dietary Aide-G setting up breakfast trays for another unit of the facility. Surveyor observed Dietary Aide-G wearing gloves on both hands and touching the outside of her pants with both gloved hands. Surveyor then observed Dietary Aide-G use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-G did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:25 a.m., Surveyor observed Dietary Aide-G wearing gloves on both hands and grabbing a plastic food wrap container with both gloved hands. Surveyor then observed Dietary Aide-G use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-G did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 8:26 a.m., Surveyor observed Dietary Aide-G wearing gloves on both hands and touching the top of the metal countertop with both gloved hands. Surveyor then observed Dietary Aide-G use her right gloved hand to grab a piece of ready to eat toast and place it on a plate for a resident to eat. Surveyor noted that Dietary Aide-G did not remove her gloves or wash her hands after contaminating her gloves after touching non-sanitized food surfaces and before touching ready to eat food. On 3/30/22, at 10:30 a.m., Surveyor informed Dietary Director-D of the above findings. Surveyor asked Dietary Director-D if dietary staff should be washing their hands and changing their gloves after touching non-sanitized food surfaces or items and before touching ready to eat food. Dietary Director-D informed Surveyor that staff should be using tongs to handle ready to eat food and should be washing their hands before handling ready to eat food. No additional information was provided as to why food was not distributed, and served in accordance with professional standards for food service safety. 2. Dish Machine Temperatures On 3/29/22, at 11:30 a.m., Surveyor observed the dish machine, responsible for washing and disinfecting all of the dishes and utensils for the nursing home facility, reach a final rinse cycle temperature of 178 degrees Fahrenheit. Surveyor noted that on the dish machine, over the final rinse thermometer gauge it stated, Minimum Temperature: 180 (degrees Fahrenheit). Surveyor observed that as the dish machine final rinse temperature read 178 degrees Fahrenheit, a tray containing food bowls was removed from the clean side and put away by dietary staff. On 3/29/22, at 11:32 a.m., Surveyor observed the dish machine running and the final rinse temperature read 178 degrees Fahrenheit. During this time, Surveyor observed food bowls, food trays and plates be removed by dietary staff from the clean side of the dish machine. Surveyor informed Dietary Manager-E of the above findings. Surveyor asked Dietary Manager-E if she had a temperature probe to run through the dish machine to verify whether or not the core temperature of the dish machine reached 180 degrees Fahrenheit. Dietary Manager-E then placed what appeared to be a Sanitizer Chlorine Test Paper in the dish machine to test the temperature. When the Sanitizer Chlorine Test Paper tray emerged from the dish machine, Surveyor noted that the probe had disappeared inside the dish machine and did not emerge from the clean side of the dish machine. On 3/29/22, at 11:33 a.m., Surveyor observed the dish machine running and the final rinse temperature read 178 degrees Fahrenheit. During this time, Surveyor observed a tray of silverware be removed by dietary staff from the clean side of the dish machine. On 3/29/22, at 11:36 a.m., Surveyor observed the dish machine running and the final rinse temperature read 178 degrees Fahrenheit. During this time, Surveyor observed food bowls, food trays and plates continued to be removed by dietary staff from the clean side of the dish machine. On 3/29/22, at 11:38 a.m., Dietary Manager-E again placed what appeared to be a Sanitizer Chlorine Test Paper in the dish machine to test the temperature. When the Sanitizer Chlorine Test Paper tray emerged from the dish machine, Surveyor noted that the test paper had disappeared inside the dish machine and did not emerge from the clean side of the dish machine. At this time, Surveyor observed the final rinse temperature of the dish machine to read 178 degrees Fahrenheit. On 3/29/22, at 11:41 a.m., Surveyor observed Dietary Manager-E bring a waterproof thermometer to run through the dish machine. On 3/29/22, at 11:46 a.m., Surveyor observed the waterproof thermometer emerge from the dish machine and observed the temperature of the thermometer to be 131.4 degrees Fahrenheit. Dietary Manager-E informed Surveyor that the thermometer was inaccurate and informed Surveyor that she would go obtain another one. On 3/29/22, at 11:55 a.m., Dietary Director-D arrived with a waterproof thermometer and ran it through the dish machine. Surveyor noted that at the time, the final rinse on the dish machine temperature gauge read 170 degrees Fahrenheit. On 3/29/22, at 11:55 a.m., Surveyor observed the waterproof thermometer emerge from the dish machine and observed the temperature of the thermometer to be 169 degrees Fahrenheit. Dietary Director-D informed Surveyor that he would rerun the thermometer through the dish machine. On 3/29/22, at 11:58 a.m., Dietary Director-D again placed the waterproof thermometer through the dish machine. Surveyor noted at the time, the final rinse on the dish machine temperature gauge read 178 degrees Fahrenheit. On 3/29/22, at 11:58 a.m., Surveyor observed the waterproof thermometer emerge from the dish machine and observed the temperature of the thermometer to be 169 degrees Fahrenheit. Dietary Manager-D informed Surveyor that he would stop running dishes through the dish machine and call the dish machine company for repairs. On 3/30/22, at 10:30 a.m., Surveyor informed Dietary Director-D of the above findings. Surveyor asked Dietary Director-D if the final rinse temperature of the dish machine should reach a minimum of 180 degrees Fahrenheit to ensure that dishware gets sanitized. Dietary Director-D informed Surveyor that the final rinse temperature of the dish machine should reach a minimum of 180 degrees Fahrenheit to ensure that dishware gets sanitized. No additional information as to why food was not prepared, distributed, and served in accordance with professional standards for food service safety.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 3 life-threatening violation(s), 3 harm violation(s), $170,666 in fines, Payment denial on record. Review inspection reports carefully.
• 47 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $170,666 in fines. Extremely high, among the most fined facilities in Wisconsin. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.

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About This Facility

What is Luther Manor's CMS Rating?

CMS assigns LUTHER MANOR an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Wisconsin, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Luther Manor Staffed?

CMS rates LUTHER MANOR's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Wisconsin average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 68%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Luther Manor?

State health inspectors documented 47 deficiencies at LUTHER MANOR during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 41 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Luther Manor?

LUTHER MANOR is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 99 certified beds and approximately 94 residents (about 95% occupancy), it is a smaller facility located in MILWAUKEE, Wisconsin.

How Does Luther Manor Compare to Other Wisconsin Nursing Homes?

Compared to the 100 nursing homes in Wisconsin, LUTHER MANOR's overall rating (1 stars) is below the state average of 3.0, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Luther Manor?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Luther Manor Safe?

Based on CMS inspection data, LUTHER MANOR has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Wisconsin. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Luther Manor Stick Around?

Staff turnover at LUTHER MANOR is high. At 60%, the facility is 14 percentage points above the Wisconsin average of 46%. Registered Nurse turnover is particularly concerning at 68%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Luther Manor Ever Fined?

LUTHER MANOR has been fined $170,666 across 6 penalty actions. This is 4.9x the Wisconsin average of $34,786. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Luther Manor on Any Federal Watch List?

LUTHER MANOR is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 99
Avg. Residents: 94
Occupancy: 95.8%
Ownership: Non profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
3 Immediate Jeopardy citations: -36
3 Actual Harm citations: -15
47 Deficiencies: -10
Fines ($170,666): -15
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 525588