Every finding on record at Abbotsford Health Care Center

Based on observation, interview, and record review, the facility did not ensure residents received services in the facility with reasonable accommodation of needs for 2 of 3 residents (R1, R5) reviewed from a sample of 5 residents.-R1 did not have a wheelchair available at all times and did not have the ability to get out of bed during those times.-R1 did not have assistance in obtaining eyeglasses replaced or fixed causing skin injuries.-R5 was unable to get out of bed at times due to the Hoyer lift not working properly.Findings include:The facility policy titled, Resident Rights Policy, dated 01/05/26, reads in part: The resident has a right to be treated with respect and dignity, including.the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.Example 1R1 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke affecting the right dominant side, and history of heart attack. On 06/02/26, R1's Minimum Data Set (MDS) noted a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment.R1's care plan initiated on 01/15/26 indicated a focus of physical functioning deficit related to mobility impairment with interventions that includes R1 requires assist of 1 for wheelchair mobility. Staff must push resident in a manual wheelchair.On 06/29/26 at 11:09 AM, Surveyor interviewed R1 about their Broda chair. R1 stated the Broda chair they were using broke and had to be fixed. R1 stated it was gone for about a week and the staff had to borrow one to use from another resident. R1 reported Family Member (FM)E comes to visit and R1 likes to be up, and a couple times R1 was not able to because R1 did not have a chair available.On 06/29/26 at 1:32 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D about R1's Broda chair. CNA D stated the chair had been sent out to be fixed and had since returned. CNA D reported the chair was gone about a week. CNA D was unsure about the sharing of wheelchairs.On 06/29/26 at 1:41 PM, Surveyor interviewed CNA G about R1's Broda chair. CNA G stated R1's chair did not steer right and had to be fixed. CNA G was unsure about the sharing of wheelchairs and stated R1 mostly just stayed in bed.On 06/29/26 at 1:49 PM, Surveyor interviewed FM E about R1's Broda chair. FM E stated FM E spoke with R1 about coming to visit. R1 told staff R1 wanted to be up when FM E arrived. FM E stated R1 was still in bed when FM E arrived at the facility and did not have the Broda chair available. FM E reported observing staff taking another resident to their room in a Broda chair, removed that resident from the chair, and then brought the same chair to R1's room.On 06/29/26 at 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about R1's Broda chair. NHA A stated R1's Broda chair had a hydraulic issue and had been sent out to be fixed. NHA A was notified on 05/23/26 about it being broken and it was sent out to be repaired on 05/26/26 and returned to the facility on [DATE]. NHA A stated R1 and another resident had shared the other resident's Broda chair during that time period. When asked if a schedule was in place for use by each resident or what to do in case of emergency, NHA A stated, Well I wasn't going to make a care plan for that short time. NHA A stated R1 did not get out of bed often, so it wasn't necessary.Example 2On 06/29/26 at 11:09 AM, Surveyor interviewed R1 about R1's glasses. R1 stated the nose piece of R1's glasses was broken since just after admission and R1 has reported it to staff and nothing was done. R1 stated the glasses were hurting R1's nose and causing sores. Surveyor observed a sore/reddened area to the left side of R1's nose. R1 reported staff were not applying any treatment for this skin injury.On 06/29/26 at 1:32 PM, Surveyor interviewed CNA D. CNA D stated R1 has a sore area on the left side of R1's nose from the glasses rubbing. CNA D stated this happened once before and there had been a previous treatment. CNA D reported CNA D has not seen any kind of treatment to R1's nose for a while. CNA D was unsure about if the facility was addressing the broken glasses.On 06/29/26 at 1:49 PM, Surveyor spoke with Family Member (FM) E regarding R1's glasses. FM E stated R1 required a new eye appointment in order to be eligible for new glasses. FM E stated they had previously spoken with Medical Records (MR) F staff regarding an eye appointment needed. MR F stated they had previously contacted R1's managed care organization and let them know R1 needed the appointment. FM E informed MR F that R1's managed care organization had changed. FM E stated MR F was going to follow up.On 06/29/26 at 3:15 PM, Surveyor interviewed NHA A about R1's glasses. NHA A stated FM E had complained to MR F and MR F was working on it. NHA A stated NHA A was not completely aware of the entire situation.On 06/29/26 at 4:51 PM, Surveyor interviewed MR F about R1's glasses. MR F stated they have only been with the facility for 3 months and are unsure what happened previously. MR F stated FM E had contacted MR F with concern of needing an eye appointment for R1 in order to get new glasses. MR F stated both the old managed care organization and the current one were contacted, and MR F was unaware if any appointment had yet been made.Example 3R5 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, morbid obesity, anxiety disorder and acute respiratory failure. R5's MDS assessment on 05/01/26 notes a BIMS score of 14/15 indicating no cognitive impairment.On 06/29/26 at 11:17 AM, Surveyor interviewed R5 regarding the Hoyer lift. R5 stated the Hoyer left has been broken down a few times since being admitted to the facility. R5 stated the reasons told to R5 included dead batteries and the charger not working. R5 stated the Hoyer lift is the only way they can be transferred and they had to remain in bed during the times it wasn't working. R5 stated there is only one bariatric lift in the facility to accommodate R5's weight.On 06/29/26 at 1:32 PM, Surveyor interviewed CNA D regarding Hoyer lifts. CNA D reported there have been issues with the special Hoyer lift for R5. CNA D reported the battery does not charge. Surveyor observed the bariatric Hoyer lift and noted it was plugged in and not charging. CNA D stated that when the lift is not working, R5 is unable to get out of bed.On 06/29/26 at 3:15 PM, Surveyor interviewed NHA A regarding Hoyer lifts not working. NHA A stated a back-up battery and charging cords had been ordered and delivered as there were previous concerns, but they should be in working order at this time. Assistant Nursing Home Administrator (ANHA) C was present for this interview and stated the Hoyer lifts should be working. ANHA C left to find maintenance and check the bariatric Hoyer lift due to Surveyor's observation and R5's report. Upon returning to the room, ANHA C stated the outlet the Hoyer lift had been plugged into was not working and the lift was not charging. The Hoyer lift was then plugged into another outlet and was now charging. NHA A reported R5 doesn't often get out of bed, and it shouldn't be a concern. Surveyor made NHA A aware of R5's concerns.

Based on interview and record review, the facility did not revise a comprehensive person-centered care plan for each resident, consistent with the resident rights, for 1 of 3 residents reviewed from a sample of 5 residents (R1).-R1's care plan did not include the use of a Broda chair or interventions related to sharing a Broda chair with another resident.Findings include:The facility policy titled, Comprehensive Care Plans, dated 10/01/22, reads in part: The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .resident specific interventions that reflect the resident's needs and preferences.On 06/29/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with R1's personal motorized wheelchair. On 02/15/26, R1 was noted to be unsafe and was recommended to be placed in a Broda wheelchair for safety and positioning. R1's care plan did not indicate R1 was to use a Broda chair. There were no interventions noted related to R1 sharing a wheelchair with another resident including a plan for times of use or what to do in case of an emergency.On 06/29/26 at 11:09 AM, Surveyor interviewed R1 about R1's Broda chair. R1 stated the Broda chair R1 was using broke and had to be fixed. R1 stated that it was gone for about a week and the staff had to get a different one to use. R1 was not aware R1 was sharing a Broda chair with another resident.On 06/29/26 at 3:15 PM, Surveyor interviewed Nursing Home Administrator (NHA) A about R1's Broda chair. NHA A stated R1's Broda chair had a hydraulic issue and had been sent out to be fixed. It had since been returned. NHA A stated R1 and another resident had shared the other resident's Broda chair during that time period. When asked if a schedule was in place for which Resident used it, or anything was care planned regarding this, NHA A stated, Well I wasn't going to make a care plan for that short time. NHA A stated R1 did not get out of bed often, so it wasn't necessary.

Based on interview and record review, the facility did not ensure the facility designated one or more individuals as the Infection Preventionist, who has completed specialized training in infection prevention and control. This has the potential to affect all 39 residents.-The facility does not have a certified infection preventionist. Findings include:The facility policy titled, Infection Prevention and Control Program, last revised 07/2025 includes: The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious disease.On 05/31/26 at 11:23 AM, Surveyor interviewed Nursing Home Administrator (NHA) A about who oversees the infection control program. NHA A indicated the previous Infection Preventionist (IP) had terminated employment recently and that Director of Nursing (DON) B and Licensed Practical Nurse (LPN) C would be working on the program together.On 06/01/26 at 1:35 PM, Surveyor interviewed DON B about the infection control program. DON B indicated they were not taking on the role of IP, and LPN C had recently started working at the facility and would be assisting in the role of IP.On 06/02/26 at 8:35 AM, LPN C reported to Surveyor that they had previously completed the training, but it was many years prior and was attempting to contact someone to assist with retrieving proof of completion.On 06/02/26 at 9:32 AM, Surveyor interviewed LPN C about the infection preventionist certification. LPN C reported they were unable to obtain proof of certification for IP training as it had been over 15 years. LPN C stated they would be taking the training in the upcoming days.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, which has the potential to affect all 39 residents.-The facility's infection control surveillance was incomplete and missing pertinent information to help prevent the spread of infection.-A wet/soiled incontinence brief was observed on the nightstand of a resident's room (R32).Findings include:The facility policy titled, Infection Prevention and Control Program, last revised 07/2025 includes: A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon a facility assessment and accepted national standards.Example 1On 05/31/26 at 9:08 AM, Surveyor observed a heavily saturated incontinence brief on the nightstand next to R32's bed. R32 is on enhanced barrier precautions in relation to wound on buttock and history of multi drug-resistant organisms (MDRO). Nursing staff were unavailable for interview at this time.On 06/02/26 at 8:51 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D about incontinence briefs. CNA D indicated incontinence briefs should immediately be placed in a garbage bag after removal from a resident. Surveyor asked CNA D if it would be appropriate to place a soiled incontinence brief on the nightstand next to the bed and CNA D stated no, never.On 06/02/26 at 9:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C about soiled incontinence briefs. LPN C stated it would be their expectation that soiled briefs would be placed into a garbage bag and disposed of properly. LPN C acknowledged Surveyor's observation and stated they had witnessed a similar situation on this date. LPN C stated they encouraged CNAs to carry garbage bags in their pockets or make sure a garbage can was near prior to performing incontinence care.Example 2On 06/02/26, Surveyor reviewed the infection surveillance line lists for residents, staff, and most recent outbreak. The lists were not complete and were missing the dates the symptoms resolved. Surveyor was unable to determine if staff returned to work on an appropriate date or if residents were in isolation for the correct amount of time.On 06/02/26 at 9:34 AM, Surveyor interviewed LPN C about infection surveillance. LPN C stated they were unable to locate the surveillance information from previously employed infection preventionist. LPN C stated the line list provided to the Surveyor was written in on the day prior and filled out the best it could be. There was no line list ready upon survey entrance. LPN C acknowledged some information was missing and the line lists were incomplete. LPN C showed Surveyor a form the facility may implement which has the required information.

Based on interview and record review, the facility did not ensure the Infection Prevention and Control Program included an Antibiotic Stewardship Program monitoring antibiotic use which has the potential to affect all 39 residents.-The facility does not currently have an antibiotic stewardship program in place.Findings include:The facility policy titled, Antibiotic Stewardship Program, last revised November 2017, includes: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infection while reducing the adverse events associated with antibiotic use.The program includes antibiotic use protocols and a system to monitor antibiotic use.On 06/02/26 at 9:43 AM, Surveyor interviewed Licensed Practical Nurse (LPN) C about the antibiotic stewardship part of the infection control program. LPN C stated the previous Infection Preventionist (IP) did not leave the information for the facility or did not complete the documentation for the facility's antibiotic stewardship monitoring upon employment termination. LPN C acknowledged contact would have to be made with the medical director regarding antibiotic use. LPN C reported there was no current monitoring in place which they could locate and would be working on that as soon as possible.

Based on staff interview and record review, the facility did not ensure a Significant Change Minimum Data Set (MDS) assessment was completed for 1 resident (R) (R6) of 17 sampled residents.The facility did not complete a Comprehensive Significant Change MDS assessment when R6 revoked Hospice services. This is evidenced by:The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual (October 2025) indicates: If a nursing home resident elects the hospice benefit, the nursing home is required to complete an MDS Significant Change in Status Assessment (SCSA). The nursing home is required to complete an SCSA when the resident comes off the hospice benefit (revoke). An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill.Record review of R6 documented an admission date of 05/23/25. R6's current diagnoses of orthopedic prosthetic devices, acute kidney failure, type 2 diabetes mellitus, depression, anxiety, and mood affective disorder.On 04/09/26, the Minimum Data Set (MDS) significant change assessment documented R6's Brief Interview for Mental Status (BIMS) score of 15/15, meaning intact cognition. Hospice care was elected. The 04/09/26 MDS assessment was the last completed MDS.On 04/09/26, R6 signed a hospice election form.On 04/22/26, R6 signed a hospice revocation form to be effective on 04/22/26 with the reason for revoking the hospice benefit was hospice philosophy.On 06/02/26 at 3:03 PM, Surveyor interviewed Director of Nursing (DON) B asking if a MDS significant change was completed when R6 revoked hospice services. DON B stated it would be expected an MDS be completed when hospice services ended. This would have been at the time when there were staff changes and there were no MDS personnel in the building and was overseen by corporate MDS H nurse.On 06/03/26 at 11:04 AM, Surveyor interviewed MDS H asking if a significant change MDS when R6 revoked hospice services. MDS H stated they were overseeing the completion of the MDS during this time when there were staffing changes. MDS H stated they weren't notified R6 was coming off hospice services. MDS H would have expected to be notified and a significant change MDS completed.

Based on observation, interview, and record review, the facility did not ensure a level II PASARR was completed for a resident (R) with a mental health disorder, within 40 calendar days of admission for 1 of 3 residents reviewed. (R25) -R25 was admitted with mental health diagnoses on 02/06/26 and no level II PASARR screen was completed.Findings include:Per regulation S483.20(k)(1)-(3), a level II PASARR is a comprehensive evaluation conducted by a state-designated authority that determines whether an individual has mental disorder (MD), determines the appropriate setting for the individual, and recommends what, if any, specialized services and/or rehabilitative services the individual needs. Under 42 CFR 483.106(b)(2)(ii), If an individual who enters a nursing facility as an exception is later found to require more than 30 days of nursing facility care, the State mental health authority must conduct a Level II resident review within 40 calendar days of admission. R25 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD), anxiety, depression, personality disorder, and mood (affective) disorder. On R25 day of admission, the facility completed a brief interview of mental status (BIMS) assessment that determined a score of 15/15 meaning R25 has intact cognition. Surveyor observed R25 throughout the survey and found R25 is able to walk, eat, toilet and transfer independently.Surveyor reviewed R25's electronic health record and discovered a Level I PASARR was completed on 2/10/26. It identified R25 was admitted under a 30-day exemption, has a major mental disorder, displayed symptoms that may suggest the presence of a major mental illness, and is receiving psychotropic medications to treat symptoms or behaviors of a major mental disorder. No other PASARR screens were found following the admission date. This was due no later than 03/18/2026. On 06/02/2026 at 11:05 AM, Surveyor interviewed Social Services (SS) E and asked about the PASARR II screens. SS E confirmed being new to the role. SS E ran an audit today, and there was no follow up PASARR II completed following the exemption for R25. SS E stated they started a calendar to ensure this is addressed timely and completed training with DHS. SS E states the plan is to reach out to the state for advice on what to do with other residents' PASARR II screens which were not correct prior to taking the position.

Based on interview and record review, the facility did not complete an accurate assessment on residents (R) Minimum Data Set (MDS) that reflects the resident's status for 1 of 17 residents reviewed. (R25) -R25 had an admission MDS dated [DATE]. The facility coded the MDS, in section A, indicating R25 does not meet the federal definition of a serious mental illness and the PASARR I, diagnoses, and medications indicate otherwise.Findings include: Centers for Medicare and Medicaid Services (CMS) program identified R25 had no PASARR II completed for a serious mental health disorder for R25. According to federal definition and the Diagnostic and Statistical Manual of Mental Disorder, 3rd edition, revised in 1987, states major mental disorders includes mood disorder, paranoid disorders, severe anxiety disorders, and personality disorders, other psychotic disorders, or other mental disorders that may lead to a chronic disability. R25 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, post-traumatic stress disorder, personality disorder, mood (affective) disorder, and altered mental status. R25's physician orders include the following: 02/06/26Amitriptyline 10mg every day for depression.02/06/26 Duloxetine 60mg 2 caps once a day for depression.04/04/26 Hydroxyzine 50mg three times a day for anxiety.02/06/26 Lamotrigine 200mg once a day for mood stabilizer.02/06/26 Melatonin 3mg at bedtime to help sleep.04/28/26 Olanzapine 15mg once a day for depression.04/04/26 Prazosin 2mg once a day for PTSD.02/06/26 Trazodone 100mg once a day for depression. R25's care plan, initiated on 02/06/2026, indicates:I have diagnosis/exhibit signs of a mood disorder related to: anxiety, depression, PTSD, mood and personality disorder, paranoia, delirium. R25's preadmission level I PASARR screen indicates R25 has a major mental disorder, displayed symptoms that suggest the presence of a major mental illness, and received psychotropic medication to treat the symptoms or behaviors of a major mental disorder. Surveyor reviewed R25's MDS, dated [DATE], section A, and found the facility checked the box indicating R25 does not meet the federal definition of a serious mental illness. Section M identifies R25 received antipsychotic medications on a regular basis, and section I indicates R25 has depression, anxiety, PTSD, personality disorder, mood (affective) disorder and altered mental status. On 06/02/2026, Surveyor interviewed Social Services (SS) E who reviewed the MDS for R25 and confirmed the coding was inaccurate and the error occurred from the previous social worker.

Based on interview and record review, the facility did not assess a resident using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 1 of 17 residents (R7).-R7's Quarterly MDS assessment was completed 40 days late and not submitted to CMS until survey was in process.Findings include:The facility policy titled, Resident Assessments, last revised October 2025, states the resident assessment coordinator (RAC) is responsible for ensuring the interdisciplinary team conducts timely and appropriate resident assessments.R7 was admitted to the facility on [DATE].R7's Minimum Dat Set (MDS) assessments indicated an assessment with an Assessment Reference Date (ARD) of 04/19/26 was completed and locked on 05/24/26 but had not been submitted.On 06/02/26 at 12:38 PM, Surveyor interviewed Regional Minimum Data Set (RMDS) Coordinator H about quarterly and comprehensive assessments. RMDS H stated that about halfway through the month, RMDS H runs a report to see what assessments are coming due and opens the ones that need to be started. RMDS H stated the information then imports to a calendar for the interdisciplinary team (IDT) to review. RDMS H stated annual assessments are to be completed within 366 days and quarterly assessments within every 92 days. When asked about R7's late quarterly assessment, RMDS H stated R7's assessment had been missed, and RMDS H could see this in the computer. RMDS H exported the assessment to CMS while on the phone with Surveyor.

Based on interview and record review, the facility failed to ensure each resident's medication regimen was free from medications used in excessive duration and without adequate indications for use for 1 of 5 sampled residents (R) reviewed for unnecessary medications (R5). R5 is a resident with dementia who has a physician's order for an antipsychotic medication. R5 has been on the same dose of the medication for over a year and has not had any behaviors for the past three months. This medication has not been reviewed by a physician for possible reduction in the past 9 months. This is evidenced by:The facility's policy titled Psychotropic Medication Use dated revised February 2026 states, Psychotropic medication management is an interdisciplinary process that involves the resident, family and/or the representative and includes a. determining adequate indications for use; .d. determining appropriateness for gradual dose reduction.R5 was admitted to the facility in 2024 with diagnoses including dementia, muscle wasting, diabetes, cognitive impairment, traumatic brain injury, and dysphagia. R5's physician orders dated 04/04/26 state Olanzapine 5 MG (an antipsychotic medication) Give 0.5 tablet by mouth one time a day every Mon, Wed, Fri, Sat and give 1 tablet by mouth one time a day every Tue, Thu, Sun related to dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; personal history of traumatic brain injury. This is the same dosage that has been in place since 05/18/25. On 09/18/25, a pharmacy review recommended a dose reduction. The physician responded by checking a box which states previous dose reduction attempt while in the facility failed. Current dose is required/appropriate and required for this patient and a further dose reduction at this time is clinically contraindicated. (Please note previous outcomes/prior to reduction/contraindication or other relevant patient specific information.) Review of R5's medical record did not reveal a previous failed dose reduction at the facility or clinically indicated contraindications.R5's medical record states R5 receives antipsychotic medication. Staff is to document number of times resident exhibits any of these behaviors: suspiciousness, suicidal ideations, hallucinations, paranoia, or verbal/physical aggression.Review of behavior monitoring for March, April and May of 2026 reveals no behaviors. On 06/02/2026 at 4:05 PM, Surveyor's interview with Director of Nursing (DON) B revealed the following information. When asked if R5 has had any behaviors, DON B stated, R5 has not had any behaviors since I've been here. R5 does frequently say, I'm tired. When asked if a dose reduction should have been tried with R5, DON B stated, the time medication is given was moved to PM instead of in the AM because R5 is always tired, but medication dose reduction hasn't been looked at. DON B stated an implementation of a new behavior dose reduction of psychotropic medications will be started. DON B stated the physician will be contacted this week to inquire about reduction of the medication.

Based on interview and record review, the facility did not immediately report to the physician on call of R22's decline of a groin wound for 1 of 2 residents (R) reviewed for pressure injuries (R22).R22's groin pressure injury (PI) increased in size on 05/30/26, and the facility did not notify the physician of the change. This is evidenced by:R22 was admitted to the facility on [DATE]. R22's current diagnoses include progressive multiple sclerosis, spinal stenosis of the lumbar region, and venous insufficiency (chronic peripheral). On 04/16/26, Minimum Data Set (MDS) documented R22 was independent with cognitive skills for daily decision making. R22 had impairment on both sides of lower extremities. R22 is dependent on staff assistance for toileting hygiene, lower body dressing and transfers. R22 requires maximum assistance of staff for personal hygiene and bed mobility. On 05/23/26, facility's assessment of R22's left groin wound was documented as a stage 3 PI measuring 0.1cm x 0.5cm x 0.1 cm. On 05/29/26, a new wound physician assessment documented R22's left groin as inguinal wound and measured 2.1 x 5.5 x 0.1 cm, partial thickness. Note, this physician assessment did not document a debridement was performed to this area to cause an increase in size. On 05/30/26, facility's assessment of R22's left groin wound was documented as stage 3 PI measuring 3.5cm x 6 cm x 0.2 cm with moderate amount of serosanguineous exudate, 100% granulation tissue, and wound status is worsening. The notes documented Wound went from being almost closed last week to being wipe (sic) open today. No signs or symptoms of infection, no pain noted from resident. No foul order (sic). The medical record did not document a physician was notified of the continued increase in size. On 05/31/26 at 1:09 PM, Surveyor interviewed R22 asking about healing of wounds. R22 stated all wound areas are now healing and R22 is so happy.On 06/01/26 at 8:45 AM, Surveyor observed Licensed Practical Nurse (LPN) K complete wound care. Surveyor asked LPN K what the area is to R22's groin area. LPN K stated the area is a slit. Surveyor observed R22's left groin area and there was an open slit at the base of the groin between the abdomen and thigh folds. The open area was clean with bright red tissue and appeared to be more of a skin tear slit. Surveyor asked LPN K how the area started. LPN K stated LPN K had just recently started at the facility and the wound was present at that time and did not know how the wound started. On 06/02/26 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B asking if the wound nurse updated the physician when R22's groin wound increased in size. DON B stated Medical Doctor (MD) L is the new wound physician and just started on Friday 05/29/26. Surveyor reviewed with DON B of MD L noting the groin wound size to be 2.1 x 5.5 x 0.1 cm. This is larger than previous facility wound assessment. The facility wound assessment that was conducted on 05/30/26, which is the day after MD L's assessment, and now the wound is larger. The facility's assessment documented the wound is worsening and did not document the physician was notified of the change. DON B stated they will look for further documentation.On 06/02/26 at 3:03 PM, Surveyor interviewed DON B asking about physician notification. DON B stated they are unable to find documentation where the MD was notified of the increase in the groin wound size. DON B stated the wound nurse is unavailable to interview. Surveyor asked what DON B's expectation is when a change in wound size. DON B stated DON B would have expected the physician to be updated with the change.

Based on interview and record review, the facility did not provide routine and emergency drugs and biologicals for the facility residents for 1 of 17 residents (R) reviewed (R37).-R37 did not have one routine medication available for 12 days with no interventions, alternatives, or monitoring.Findings include:On 06/02/26, Surveyor reviewed R37's medical record. R37 was admitted to the facility on [DATE].R37's Physician orders include Modafinil Oral Tablet 100 MG.give 1 tablet by mouth two times a day for sleep apnea which was ordered on 05/12/26.Surveyor reviewed R37's Medication Administration Record (MAR) for May 2026. The MAR indicated that from 05/12/26 through 05/23/26, R37's Modafinil was not given.R37's nursing progress notes documented:On 05/12/26 at 10:29 AM, Modafinil was not available from pharmacy.On 05/12/26 at 11:27 PM, Modafinil had a hold order for that day as the pharmacy would be sending the medication the next morning.On 05/13/26 at 8:19 AM, Modafinil was not available from pharmacy.On 05/13/26 at 7:22 PM, Modafinil was not yet available.On 05/14/26 at 8:03 PM, Modafinil was on order.On 05/15/26 at 7:43 AM, Modafinil was awaiting pharmacy.On 05/17/26 at 7:24 PM, Modafinil was not available from pharmacy.On 05/19/26 at 1:53 PM, Modafinil was on order.On 05/20/26 at 7:09 PM, Modafinil was not available.On 05/21/26 at 7:26 PM, Modafinil was waiting for delivery.On 05/22/26 at 8:10 PM, Modafinil was not available.On 05/23/26 at 8:12 PM, R37's progress note indicated staff called pharmacy and requested medication to be sent. Pharmacy confirmed that medication will be sent for arrival tomorrow if they have product on hand. Provider updated and stated it was okay to hold until available from pharmacy.On 06/02/26 at 7:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G about medications unavailable from pharmacy. LPN G stated if medications were not available, LPN G would look to see if it is available in contingency, call the pharmacy to confirm why the medication isn't available, and update the provider for further instruction. LPN G stated monitoring may be put in place depending on the type of medication. When asked if the medication was related to sleep apnea, LPN G stated sleep monitoring or change in activity/mood monitoring would most likely happen.On 06/02/26 at 10:24 AM, Surveyor interviewed LPN K about concerns with obtaining medications from pharmacy. LPN K stated they don't know if it is a delay in the system or something else, but yes there have been concerns. LPN K stated if a medication was unavailable, they would see if the medication was available in contingency, update the Director of Nursing (DON), update the provider, and update the guardian or power of attorney if applicable. LPN K stated they would possibly obtain a hold order for the medication until it was available depending on the provider's order.On 06/02/26 at 11:11 AM, Surveyor interviewed DON B regarding medications unavailable from pharmacy. DON B stated if medications are unavailable the provider should be contacted for a hold order or other instructions and check contingency to see if the medication is available there. DON B stated they would possibly talk to the family if applicable and have them bring in a home supply. When asked about monitoring related to sleep apnea medication being unavailable, DON B indicated that yes, monitoring would be appropriate. DON B acknowledged R37 was without Modafinil from 05/12/26 through 05/23/26 without monitoring and appropriate notification and follow up.

Based on observation, interview, and record review, the facility did not develop or implement a person-centered dialysis care plan to ensure the highest practicable physical well-being for 1 of 1 resident (R) reviewed for dialysis. (R42) -R42 receives dialysis. R42's care plan did not identify the dialysis company, provider, nephrologist, or contact number, days or times R42 attends dialysis, type (fistula/graft/catheter) of dialysis access used, identify which arm not to obtain BP, blood draws or administer IV. Findings include: R42 was admitted to the facility on [DATE] with diagnoses that include end stage renal disease. The facility conducted a Brief Interview of Mental Status (BIMS) assessment on 05/05/2026 that indicated a score of 14/15 meaning R42 had intact cognition. Surveyor reviewed R42's dialysis care plan dated 05/04/2026, that states, Alteration in Kidney Function Due to End Stage Renal Disease (SDRD), evidenced by hemodialysis. Interventions include check access site daily fistula/graft/catheter for signs of infection (Does not indicate what type or where R42's access site is.) Do not take blood pressure, blood samples, or insert IV in arm with access site and encourage patient not to sleep on arm with access site. (Does not indicate which arm has the access site.) Emergency Protocol - if bleeding occurs, apply pressure with clean gauze for 10-15 minutes. If bleeding is not controlled, call 911. Notify physician if edema, chest pains, elevated blood pressure, or shortness of breath occurs. (Does not specify on care plan or face sheet which physician or dialysis company manages R42's dialysis plan). Monitor thrill and bruit daily and document findings: report abnormal findings to physician. (Review of progress notes since R42's admission. No notes included thrill/bruit assessments or pre and post dialysis fistula assessment were completed.) On 06/02/2026 at 1:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked where R42's dialysis site is and does she have a fistula or a central line. LPN G stated, It is ln the left arm, that is where I had to put the lidocaine. Surveyor asked LPN G who is responsible to assess the arm and how often. LPN G stated the nurse working the floor each day. Surveyor asked LPN G what do you assess for. LPN G stated bleeding or infection. Surveyor asked LPN G to look in R42's medical record and locate where this information is documented. LPN G looked in R42's medical record, treatment record, and progress notes and stated it should be there but looks like no one is documenting. Surveyor asked LPN G which dialysis company does R42 attend, how often, and what physician handles any dialysis concerns. LPN G stated they were unsure and would have to look it up and get back to Surveyor. LPN G did not get back to Surveyor with any information. On 06/02/2026 at 4:02 PM, Surveyor interviewed Director of Nursing (DON) B and discussed the above information and offered to provide any proof that R42's care plan was implemented. DON B agreed the care plan needs to be more person centered and expects monitoring especially after dialysis. On 06/02/2026 at 4:26 PM, DON B informed Surveyor there was no information to show the assessments were being implemented.

Based on interview and record review, the facility did not review/revise the resident's person-centered comprehensive care plan for 1 resident (R6) of 17 resident's care plans reviewed. The facility did not update/revise R6's care plan after R6 revoked hospice services. The care plan was not revised to reflect R6's current goals and interventions according to R6's needs. This is evidenced by:Record review of R6's medical record documented an admission date of 05/23/25. R6's current diagnoses include orthopedic prosthetic devices, acute kidney failure, type 2 diabetes mellitus, depression, anxiety, and mood affective disorder.On 04/09/26, the Minimum Data Set (MDS) significant change assessment documented R6's Brief Interview for Mental Status (BIMS) score of 15/15 meaning intact cognition. Hospice care was elected. On 04/09/26, R6 signed a hospice election form.On 04/22/26, R6 signed a hospice revocation form to be effective on 04/22/26 with the reason for revoking the hospice benefit was hospice philosophy.Surveyor reviewed R6's current care plans. On 04/10/26, R6's care plan was initiated for Patient is on Hospice care related to: End of life care. Interventions included .Coordinate Care Plan with Hospice. Note, this care plan was not revised to reflect R6 is no longer receiving hospice services, and no new interventions and goals were implemented to reflect R6's current status. On 06/02/26 at 3:03 PM, Surveyor interviewed Director of Nursing (DON) B asking if R6's active care plan for hospice services needed to be revised after R6 revoked hospice services. DON B stated the hospice care plan should not be active and expected it to be updated when hospice ended.

Based on observation, interview and record review, the facility did not ensure residents (R) who are trauma survivors receive care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 of 1 resident with post-traumatic stress disorder (PTSD). (R25). -R25 is diagnosed with PTSD. Care plan does not identify type(s) of trauma, triggers, or interventions to prevent re-traumatization.Findings include: R25 was admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder (PTSD), anxiety, depression, personality disorder, mood (affective) disorder and altered mental status. R25 was admitted for therapy and monitoring following frequent falls at home and a fire with smoke inhalation. On [DATE] at 12:07 PM, Surveyor observed R25 sitting at a table in a small area next to the dining room. The door between the kitchen and dining room slammed shut causing a loud noise. R25 jumped in her seat, had frightened look on face, and put her hand over her chest. R25 told peer and Surveyor, That scared me. I have PTSD and loud noises like slamming doors and people approaching me from behind triggers me. On [DATE] at 1:51 AM, Surveyor and R25 along with other residents were in a resident council meeting. Surveyor observed R25 jump in her seat when another resident, who was sitting slightly behind R25, started talking. Surveyor reviewed R25's trauma informed care assessment dated [DATE], which identifies R25 had traumatic events that cause nightmares and guilt. Surveyor reviewed R25's care plan, dated [DATE], and there is no mention of guilt or nightmares. There were no triggers identified or interventions in place on how to mitigate or attempt to eliminate triggers for R25.On [DATE] at 3:26 PM, Surveyor interviewed R25 who openly shared she endured abuse of every kind. One sibling committed suicide, R25 was hit on the head with farm equipment when younger, was sexually abused throughout childhood, has a child and grandchild who live close, but they do not visit and she has not even gotten to meet the grandchild. R25 continued that both parents are deceased , she had a pet for 9 years that she had to give up after admission to the nursing home/fire in the apartment. R25 stated she feels so alone and that family does not seem to understand her mental illness and feels she does not really understand it either. R25 reported that she had counseling and attended a grief group prior to admission and feels it would still help. R25 was tearful throughout the interview. On [DATE] at 8:42 AM, Surveyor interviewed Social Services (SS) E and asked what type of trauma R25 endured, what the triggers are, and what R25's preferred services are because of the diagnosis of PTSD on the care plan. SS E stated they didn't know. It definitely needs work. I have only been here a couple weeks and am trying to fix these issues as they become due.

Based on observation, interview, and record review, the facility did not ensure residents receive proper treatment and assistive devices to maintain vision and hearing abilities for 1 of 1 resident (R) reviewed for hearing (R47).-R47 has a severe hearing deficit and has not had working hearing aids for a long period of time. This has not been addressed, and assessments do not reflect accurate information.Findings include:The facility policy titled, Resident Assessments, last revised October 2025, includes information in the Minimum Data Set (MDS) assessment will consistently reflect information in the progress notes, plans of care, and resident observation/interviews.R47 was admitted to the facility on [DATE].On 05/31/26 at 9:49 AM, Surveyor interviewed R47 about the care R47 receives at the facility. R47 emphasized the need for Surveyor to speak very loudly as R47 is very hard of hearing. R47 stated they have hearing aids, but the hearing aids stopped working a while back when they remained in while showering. R47 stated they have not had working hearing aids since, and no one has said anything about getting new ones or fixing the broken ones. R47 stated they are not sure on how long ago the hearing aids were broken, but when asked about months, R47 stated, Oh longer than that. Surveyor observed that R47 did not have hearing aids in during the interview.On 06/01/26, Surveyor reviewed R47's most recent MDS assessment, which indicated R47 had minimal difficulty hearing and currently had hearing aids.On 06/01/26, Surveyor reviewed R47's progress notes from the most recent audiology appointment dated 10/08/25. Recommendations include the importance of checking the hearing aids daily and being charged every night. The notes also indicate the hearing aids should be visually inspected for cleanliness and cleaned when needed, as well as assisting R47 with insertion.Surveyor reviewed R47's physician order, which did not include any care or monitoring of hearing aids.Surveyor reviewed R47's care plan which states R47 does have hearing aids which are placed in AM and removed at bedtime (last revised 02/27/26). Store hearing aids in nurse's station. Care plan also includes very hard of hearing, lip reads (last revised 02/27/24).On 06/02/26 at 7:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G about R47's hearing aids. LPN G stated LPN G was not aware of R47 having any hearing aids and would not know where they would be if R47 had them. LPN G stated R47 is very hard of hearing, and you must talk loudly and R47 also tries to read lips. LPN G looked in the medication cart and did not see any hearing aids for R47.On 06/02/26 at 7:45 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J about R47's hearing aids. CNA J stated they believe R47 has hearing aids but that they are broken. CNA J did not know where they are located. When asked about how long they've been broken, CNA J said quite some time.On 06/02/26 at 8:51 AM, Surveyor interviewed CNA D about R47's hearing aids. CNA D stated R47 did not have any that they were aware of.On 06/02/26 at 11:11 AM, Surveyor interviewed Director of Nursing (DON) B about R47's hearing aids. DON B stated they were not aware of any concerns with R47's hearing aids and was not aware R47 had not been wearing any. Surveyor asked DON B how often resident assessments are completed regarding hearing. DON B stated daily skilled charting should be completed, and long-term assessments are completed either weekly or monthly. DON B acknowledged a recent assessment had not been completed by nursing staff, and the most recent MDS assessment was not accurate with R47's current condition.

Based on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (R32) reviewed for non-pressure skin injuries.-R32 has moisture-associated skin damage (MASD) to buttocks and weekly skin assessments do not reflect monitoring.-Weekly wound rounds indicate only one evaluation completed since wound provider last evaluated in March 2026 that indicated the wound had worsened. Findings include:The facility policy titled, Wound Care, last revised April 2026, includes The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.assess and measure the wound.clean the wound.document the type of wound care given, the date and time wound care was given, and change in the resident's condition.report other information in accordance with facility policy and professional standards of practice.Surveyor reviewed R32's medical record. R32 was admitted to the facility on [DATE].On 05/31/26 at 9:08 AM, Surveyor interviewed R32 about any skin concerns. R32 reported R32 has sores on R32's buttocks that the staff put cream on. R32 was unable to describe what type of sores were present.On 06/01/26, Surveyor reviewed R32's physician orders which include buttock/groin maceration - zinc oxide to be applied twice a day with cares and as needed for moisture-associated skin damage (MASD) which started on 03/06/26.Surveyor reviewed R32's care plan which includes a focus of actual altered skin integrity related to: Impaired mobility, incontinence (09/26/25). Interventions include conduct weekly skin inspection, monitor for signs and symptoms of infection such as swelling, redness, warm, discharge, odor notify physician of significant findings, notify practitioner if symptoms worsen or do not resolve, provide thorough skin care after incontinent episodes and apply zinc oxide (09/26/25), and weekly wound evaluation (03/06/26).On 06/01/26, Surveyor reviewed R32's wound care assessments. R32 was previously followed by a wound care provider that indicated on 03/20/26 the wounds were healed and wound care services with that provider ended. The facility wound nurse then took over weekly monitoring.On 06/01/26, Surveyor reviewed weekly skin assessments:03/26/26 R32 has MASD to buttocks-not evaluated04/02/26 R32 has MASD to buttocks-not evaluated04/16/26 R32 has MASD to buttocks-not evaluated04/23/26 R32 has MASD to buttocks-not evaluated04/27/26 R32 has MASD to buttocks-evaluated and indicated wound worsening05/07/26 R32 has MASD to buttocks-not evaluated05/28/26 R32 has MASD to buttocks-not evaluated On 06/02/26 at 7:34 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G about wound care. LPN G stated weekly skin checks are done on shower/bath days but did not know what the facility protocol was for wound assessments. LPN G stated each weekly skin check should involve a full head-to-toe skin evaluation. LPN G stated that if a new skin impairment is noted or a wound has worsened, the provider and the Director of Nursing (DON) should be notified.On 06/02/26 at 10:24 AM, Surveyor interviewed LPN K about wound care. LPN K stated wounds are evaluated weekly by the wound nurse, Registered Nurse (RN) N or wound provider depending on what orders the resident has. LPN K stated that if a wound is noted to be worsened, the provider, DON, and Power of Attorney if applicable, should be updated. LPN K stated a risk management event should be completed.On 06/02/26 at 11:11 AM, Surveyor interviewed DON B about wound care expectations. DON B stated weekly skin checks are performed initially by the CNAs on shower days and sheets are filled out. Those sheets then go to the nurse on duty for review. If any concerns are noted DON B and RN N are updated. DON B stated a risk management evaluation should also be completed. DON B acknowledged R32's weekly skin assessments did not show monitoring of MASD and the provider had not been updated on the changes.On 06/02/26, Surveyor requested contact information for RN N from DON B which was not obtained. Surveyor gave Surveyor's contact information to DON B to have RN N call Surveyor. No call received from RN N.

Based on interview and record review, the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 5 residents (R) (R32).-R32 did not receive consistent restorative care.-R32's medical record had incomplete and incorrect documentation for restorative care. Findings include:The facility policy titled, Restorative Nursing Services, last revised July 2025, includes: Residents will receive restorative nursing care as needed to help promote optimal safety and independence.Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care.R32 was admitted to the facility on [DATE].R32's medical record documents R32 has a program that includes passive range of motion to bilateral lower extremities every shift.Surveyor noted 14 days in March 2026, 17 days in April 2026, and 28 days in May 2026, the task was documented as not applicable. 19 days in March 2026, 16 days in April 2026, and 9 days in May 2026, had no documentation.On 06/02/26 at 7:45 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J about restorative care. CNA J stated they believe therapy completes most of the restorative programs for the residents.On 06/02/26 at 8:51 AM, Surveyor interviewed CNA D about the restorative program. CNA D stated CNA F is the restorative CNA and completes the tasks. When asked who completes restorative tasks when CNA F is not working, CNA D stated they were not positive, but possibly therapy.On 06/02/26 at 8:54 AM, Surveyor interviewed CNA F about the restorative program. CNA F stated they were the restorative CNA and work with therapy. CNA F stated they complete the restorative tasks and chart them in the computer. When asked who completes the tasks when CNA F is not working, CNA F was unsure if anyone else did. When asked when it would be appropriate to mark the task as not applicable, CNA F stated they weren't sure but maybe if the resident was sick.On 06/02/26 at 11:11 AM, Surveyor interviewed Director of Nursing (DON) B about R32's restorative program. DON B stated they have a restorative CNA who is CNA F. DON B stated if CNA F is not working, the floor CNAs are to complete the tasks, or the facility will assign someone. Suveyor informed DON B, R32's restorative program documentation was incomplete and documentation was inaccurate.

Based on staff interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 of 1 resident (R) (R5) reviewed.The facility did not provide evidence of resident interviews and staff training on misappropriation.The facility's policy titled, Abuse/Neglect/Exploitation, read in part, Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .Training staff on changes made and demonstration of staff competency after training is implemented.On 02/06/26, the facility reported R5 returned from the hospital on [DATE] and it was reported R5 had $200 missing. Staff had observed a $50 bill in R5's room on 02/05/26.The facility completed an investigation which included: -Interview with R5.-Search for the missing money, which was not found.-Contacting law enforcement.-Staff interviews.-Facility reimbursed R5 $50 that had been verified by staff.-The facility submitted their investigation to the State Agency on 02/12/26.On 03/11/26 at 1:00 PM, Surveyor interviewed R5. R5's Brief Interview for Mental Status (BIMS) was 15/15, indicating intact cognition. R5 stated he was missing $200 and the facility reimbursed him $50. When Surveyor asked him questions about the missing money, R5 was not always clear in his responses and was cursing. R5 stated he had $200, then he stated he asked the transportation driver to stop at the tobacco outlet. When Surveyor asked him if they stopped, R5 stated, I had $200, and they only reimbursed me $50. Surveyor was unable to obtain additional information from R5.On 03/11/26, Surveyor interviewed Certified Nursing Assistant (CNA) I. CNA I was aware of R5's missing money. CNA I stated R5 was offered to keep his money locked and had declined. CNA I confirmed staff searched for the money and were unable to locate it. CNA I stated she did not remember any staff education or training related to misappropriation after R5's money was allegedly missing.On 03/11/26 at 1:27 PM, Surveyor interviewed Social Services Director (SSD) J. SSD J stated she was the grievance officer for the facility. SSD J confirmed the facility was unable to locate any missing money for R5 and staff could not confirm how much was missing, except for $50 that was observed in R5's room. SSD J provided Surveyor with the facility's investigation and evidence of R5 being reimbursed $50 via check.Surveyor asked SSD J if resident interviews were conducted, and SSD J reported the facility conducts daily Angel Rounds. Angel Rounds are where each department head is responsible for checking in with assigned residents on a daily basis and asking specific questions to confirm resident satisfaction or concerns.SSD J provided Surveyor with a blank copy of Angel Rounds. SSD J stated she knows the document is not dated with a revision date, but on 02/07/26, the facility added the question, Do you have any missing money or items? SSD J provided Surveyor with a typed two-page document titled, Resident interviewed about missing items, dated 02/07/26. The document listed a room number, a resident name, and indicated yes or no after the resident name. There were 26 residents listed on the document. R5 was the only resident who reported missing money.Surveyor asked SSD J if staff education was provided, and she stated NHA or DON would provide staff education.Surveyor interviewed R3 and R6, who did not have concerns related to missing items or money. R3 and R6 did not report if the facility had interviewed them after R5's money was allegedly missing.On 03/11/26 at approximately 2:30 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported resident interviews were conducted. NHA A stated a staff in-service, and education was completed on misappropriation.On 03/12/26, the facility provided evidence staff training related to misappropriation was completed on 02/12/26, six days after the incident. There was no evidence immediate education was completed to protect residents from misappropriation. Based on the Surveyor's investigation, the facility was unable to determine the amount of money R5 was allegedly missing, and the facility did reimburse R5 for the amount of money that was observed by staff. Surveyor determined the facility did not complete a thorough investigation due to lack of evidence of resident interviews and staff training.

Based on interview and record review, the facility did not ensure 1 of 3 residents (R7) reviewed for discharge process received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (mailing and email) with telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the facility did not ensure R7 and/or their representative received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility.Based on the Surveyor's investigation, there was no evidence of the following:-R7's admission to the facility.-R7's fall and incident at the facility.-R7's discharge from the facility.-Evidence the facility could not meet R7's needs.-R7 was provided with discharge notices and bed hold notice, with appeal rights upon discharge.-Communication with current hospital to assess transfer status and agreement to re-admit R7 to the facility.-A hoyer sling was ordered for R7.The facility's policy titled Transfer and Discharge, read in part,1. The facility will evaluate and determine the level of care needed for the resident prior to admission to ensure the facility's ability to meet the resident's needs.2. Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions:a. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.3. When a resident exercises his or her rights to appeal a transfer or discharge, the facility will not transfer or discharge the resident while the appeal is pending, unless failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility.4. 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: a. The specific reason and basis for transfer or discharge. b. The effective date of the transfer or discharge. c. The location to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address, and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, address, and phone number of the representative of the Office of the State Long-Term Care Ombudsman.10. For a transfer to another provider, for any reason, the following information must be provided to the receiving provider:a. Contact information of the practitioner who was responsible for the care of the resident;d. All other information necessary to meet the resident's needs.11. Non-Emergency Transfer or Discharges-initiated by the facility, return not anticipate.a. Document the reason for transfer or discharge in the resident's medical record, and in the case of necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the specific resident needs that cannot be met, facility attempts to [NAME] the resident's needs, and the service available at the receiving facility to [NAME] the resident's needs. Document any danger to the health or safety of the resident or other individuals that failure to transfer or discharge would pose.On 02/10/26, Complainant G reported R7 was admitted to the facility, and within 15-30 minutes, R7 fell and was sent to the emergency room for evaluation. Complainant G reported the facility was refusing to re-admit R7, stating they were unable to meet R7's needs.On 03/11/26 at 8:56 AM, Surveyor interviewed Complainant G. Complainant G stated when R7 arrived in the emergency room on [DATE], after falling at the facility, emergency medical services (EMS) told hospital staff the facility would not accept R7 back to the facility as R7's transfer status was not what the hospital had told the facility. Complainant G stated when she spoke with the facility staff she was told the facility did not have the equipment to care for R7, such as bariatric hoyer lift or sling. Complainant G was unaware R7 suffered any injury from the fall. Complainant G stated R7 had been transferred to a different hospital.On 03/11/26, Surveyor reviewed R7's electronic health record in the facility. Surveyor noted R7's record contained pre-admission scanned records, such as Advanced Directives, hospital discharge summary, insurance and payment information, but was unable to find any other documentation to support R7 was in the facility.The facility did not provide evidence of progress notes, assessments, incidents, or documentation of R7's admission or discharge to and from the facility.On 03/11/26 at 11:11 AM, Surveyor called R7. R7 did not answer, and Surveyor received an automated message there was no voicemail set-up on this phone.On 03/11/26 at 11:12 AM, Surveyor attempted to call R7's emergency contact, and received an automated message there was no voicemail set up on this phone.On 03/11/26 at 12:16 PM, Surveyor interviewed Admissions Coordinator (AC) G. AC G reported R7 was not admitted to the facility. AC G stated the referring hospital reported R7 was a pivot transfer and when R7 arrived she could not transfer. AC G stated R7 traveled approximately two hours from the referring hospital to the facility and had been placed in a wheelchair that was too small for R7.AC G stated shortly after R7 arrived, R7 was seated in her wheelchair and reached down to pick up something and slid out of her chair and onto the floor. AC G reported EMS were called, as the facility was unable to get R7 up from the floor. AC G reported she was unsure if R7 suffered any injury. R7 was transported to the emergency room.AC G stated she did receive a phone call from the emergency room discharge planner asking if the facility would re-admit R7. AC G stated, Our lifts only hold so much and we did not have the appropriate sling.AC G stated she has been in contact with hospital discharge planners, and the facility had agreed to re-admit R7. AC G stated, I believe she [R7] is still in the hospital.On 03/11/26 at 12:46 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated the facility had accepted R7 as an admission to the facility on [DATE]. NHA A reported the facility was told R7 could pivot transfer, and when R7 arrived at the facility staff were unable to transfer her out of her wheelchair as R7 could not pivot transfer. NHA A stated she asked for therapy to assess R7 and when returning to R7's room, R7 had fallen out of the wheelchair. NHA A stated no admission paperwork for R7 had been done.NHA A stated the facility called an ambulance to have R7 transferred to the emergency room. NHA A stated R7's wheelchair was too small and there was a long travel time, and asked, Is that why she couldn't pivot transfer? NHA A stated she called the referring hospital and was told R7 should be sent to the referring hospital's sister hospital, which was located approximately 30 minutes away from the facility. NHA A reported the sister hospital called the facility asking the facility what they wanted them to do with R7. NHA A reported the facility did not have the equipment to care for R7 as she could not pivot transfer.The facility did not provide evidence they communicated with the receiving hospital the reason for R7's discharge.NHA A reported she had been in contact with Bureau of Nursing Home Resident Care (BNHRC) Interim Regional Field Operations Director (RFOD) and was told to remain in contact with the current hospital. NHA A stated she had been in contact with the discharge planner at the current hospital and stated, We will take her back when she can pivot transfer. I haven't heard anything back.Surveyor asked if R7 suffered any injury and NHA A was not sure as staff were unable to move R7 from the floor.Surveyor asked why R7 was transferred to the hospital and NHA A stated because staff were unable to get R7 off the floor and R7 was unable to pivot transfer.Surveyor asked if R7's transfer status has been assessed at the current hospital and if R7's transfer status was a mechanical (hoyer) lift, and NHA A stated, That is a good question.The facility did not provide evidence R7 was assessed at the facility to determine what her transfer status was. The facility did not provide evidence of communication with current hospital to determine R7's transfer status and re-admission to the facility.Surveyor spoke with BNHRC Interim RFOD. BNHRC Interim RFOD stated the facility stated they would be ordering the correct hoyer sling for R7 and once received would be re-admitting R7.On 03/11/26 at approximately 2:30 PM, Surveyor asked NHA A if they had ordered and received hoyer lift sling for R7. NHA A was unsure and asked other staff. Staff reported the former Director of Nursing (DON) had been working on that and they would have to check to see.The facility did not provide evidence that a hoyer sling was ordered for R7.Surveyor requested documentation to verify contact with the hospital and agreement to re-admit R7.The facility provided the Surveyor with an email chain of communication between the facility's admission coordinator and the referring hospital discharge planner, which read as follows:-02/09/26, AC G, Yes we will accept her on [MCO]. Could you have her get here by noon tomorrow?-02/10/26, AC G, So we had issues when [R7] got here. She could not transfer like we were told and then slid onto the floor. Was taken down to hospital via ambulance. We were under the understanding that [R7] was pivot transferring, but she said she couldn't.The facility did not provide evidence of communication with the hospital after R7 was discharged from the facility.The facility provided Surveyor with a discharge summary from the receiving hospital dated 02/10/26. The discharge summary read in part, Resume normal activity. PT/OT eval and treat. Post-hospital discharge follow-up deconditioning, weakness, ankle and knee instability, bariatric management, and UTI.The facility did not provide evidence of R7's pre-admission assessment indicating her transfer status.The facility was unable to provide evidence the discharge process was followed for R7's discharge.

Based on interview and record review, the facility failed to ensure a resident utilizing a Hoyer lift for transfers received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R1) reviewed. Certified Nursing Assistant (CNA) transferred R1 utilizing a Hoyer lift from the bed to the chair without assistance from another staff member. Facility policy states all mechanical lift transfers require 2 people. R1 slipped out of the Hoyer lift sling, fell to the floor, and struck R1's head sustaining a subarachnoid hemorrhage, subdural hematoma, a right posterior scalp laceration and hematoma, and required hospitalization . R1's condition declined as a result. R1 was verbal, but nonsensical prior to the fall, and is now nonverbal. R1's code status changed from Full Code to Do Not Resuscitate (DNR). R1 is now residing in a hospice facility. The facility's failure to follow the policy for 2 staff assistance for Hoyer lift transfers created a finding of immediate jeopardy that began on 07/02/24. Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were notified of the immediate jeopardy on 07/17/24 at 9:30 a.m. The facility took steps on 07/02/24, immediately after the incident, to correct the deficient practice and ensure compliance. The immediate jeopardy was removed on 07/07/24 and corrected on 07/07/24. Based on this determination, the citation issued is past non-compliance. Findings include: The facility policy titled, Mechanical Lift Transfers, not dated, states in part: Policy: 8. Position the sling extending from the resident's shoulder to the thigh. 19. The other nursing assistant should hold the sling back in the hip area and help lower the resident slowly into the position in the chair while you slowly release the hydraulic and lower the lift. Monitor the location of the resident's feet and arms when lowering the lift. The facility policy titled, Mechanical Lift Transfers: Sit to Stand, not dated, states in part: Policy: 2. All mechanical lift transfers require 2 persons. On 07/16/24 at 9:58 a.m., Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including unspecified dementia-unspecified severity with other behavioral disturbance and anxiety disorder-unspecified. R1's Minimum Data Set (MDS) discharge assessment, dated 07/02/24, indicated R1 required total assistance with all activities of daily living (ADLs.) R1 is a fall risk with a score of 13. A score over 10 indicates at risk for falls. R1's Brief Interview for Mental Status (BIMS) score was 99, which indicates nonsensical responses. Facility documentation states R1 is disoriented to person, place, and time always. R1 has a Guardian (Guardian-P.) R1's code status is Full Code. R1's care plan: FOCUS Resident has diagnosis of Alzheimer's or related dementia. Due to cognitive loss, diminished decision-making capabilities and safety and security issues, placement in the secure Alzheimer's Care unit with programs designed for this population is needed as evidenced by: Vascular dementia. Date Initiated: 11/03/2021. GOAL Resident will maintain cognitive level as long as possible within the disease process as measured by the BIMS. Date Initiated: 11/03/2021 Revision on: 01/10/2024 Target Date: 09/24/2024. INTERVENTIONS: I have a physical functioning deficit related to: Mobility impairment. Date Initiated: 11/03/2021. Hoyer lift for transfers. Date Initiated: 06/08/2023. Resident to have a high back, reclining wheelchair, and calf pad. Date Initiated: 11/04/2021. On 07/02/24 at 6:00 a.m., CNA C was transferring R1 from the bed to the wheelchair using a Hoyer lift. CNA C lifted the sling with R1 in it, turned the Hoyer to pivot toward the wheelchair. CNA C lowered the sling and R1 started to slide forward out of the sling. CNA C was unable to stop R1 from sliding and R1 fell on the floor and struck R1's head. R1's medical record progress note dated 07/02/24 at 6:45 a.m. documents Registered Nurse (RN) D was called to R1's room and when RN D entered the room, R1 was on the floor next to the bed. R1 had slid out of the mechanical lift during transfer from the bed to the chair. R1 hit R1's head, and a laceration was noted on the back of R1's head. R1's physician was updated and ordered to send R1 to the emergency room (ER) for evaluation and treatment. Facility notified DON B and R1's guardian. R1's vital signs after the incident: blood pressure 139/78, pulse 83, respirations 12, temperature 97.4, and O2 (oxygen) saturation was 92% at room air. Facility documentation states an investigation was initiated immediately. Facility documentation states the following: R1 was sent to the ER for an evaluation and treatment. The facility contacted the police department to file a report. CNA C was suspended pending investigation. Facility investigation concluded the following factors: CNA C did not request a second person for the lift transfer. A nurse was available nearby. Facility had conducted an education on Hoyer use on 04/29/24. Care plan did not state to cross the straps between the legs. CNA C used the appropriate size sling for R1. CNA C had no complaints from staff or residents about CNA C's care, and had no similar events happen, and was not in a current disciplinary process. Facility had recently purchased and implemented the use of walkie talkies for the purpose of allowing CNAs to request assistance when needed. Facility had recently adjusted staffing up to ensure that enough staff are available for the safe, timely, and effective provision of care. Facility documentation includes an interview with CNA C. CNA C stated CNA C was transferring R1 from the bed to the wheelchair and had placed the sling and connected it to the Hoyer in an uncrossed fashion. CNA C stated the sling was raised up and CNA C turned the Hoyer lift to move it toward the wheelchair. As the sling was lowered, R1 began to slide out of the sling and fell out onto the floor. CNA C stated it happened so quickly that CNA C was unable to stop it. CNA stated the nurse was called immediately. NHA A interviewed CNA C and CNA C's responses were as follows: NHA A: Was it normal to complete the lift with the straps uncrossed? CNA C: The straps were not crossed between R1's legs because it was the normal way to lift R1. NHA A: What sling was used? CNA C: The sling used was the sling that was kept in R1's room for R1's individual use. NHA A: Was the Hoyer functioning normally? CNA C: Hoyer was functioning properly. NHA A: Did the Hoyer wheel hit anything? CNA C: Hoyer wheels did not hit anything. NHA A: Was there anyone else in the room at the time? CNA C: No one else was in the room at the time of the transfer/incident. NHA A: Was assistance requested? CNA C: CNA C did not ask for assistance. NHA A: Did CNA C know that all lifts required 2 people? CNA C stated CNA C knew. NHA A: Was the floor nurse nearby? CNA C stated a nurse was nearby for assistance. NHA A: Was the nurse asked to assist with the lift? CNA C stated the nurse was not asked to assist. On 07/17/24, Surveyor reviewed the hospital documentation from 07/02/24. Hospital performed a CT scan of the head which revealed a small multifocal acute subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), a new small subdural hematoma (blood collection between the skull and the surface of the brain) overlying the right frontal lobe anteriorly and new ill-defined subdural blood products (old collection of blood and blood breakdown products) anterior and medial to the anterior frontal lobes found on the second CT performed, and right scalp hematoma (collection of blood) with overlying skin staples. A CT of the chest/abdomen/pelvis was performed, and the results were negative. Documentation states given resident's (R1's) age (95), neurosurgery does not recommend any acute surgical interventions. On 07/16/24 at 11:51 a.m., Surveyor called R1's elder care agency to speak with R1's guardian. Representative of elder care agency (ECA) T stated Guardian-P was out of the office. Surveyor asked if agency received any information on R1 from the hospital as to R1's condition. Representative stated R1 was residing in a hospice facility. On 07/16/24 at 12:05 p.m., Surveyor interviewed RN D and asked about R1's incident. RN D stated CNA C came out of R1's room and called RN D. RN D stated R1 fell out of the Hoyer lift sling. RN D stated R1 was assessed and found to have a laceration on the back the head. RN D stated RN D took R1's vital signs. RN D stated R1's physician was called, guardian was called, ambulance was called and transported R1 to the ER. Surveyor asked if CNA C asked for assist to transfer with the Hoyer lift. RN D stated CNA C had not asked for assistance. Surveyor asked what the facility policy is regarding Hoyer lift transfers. RN D stated all lift transfers are to be done with 2 people. Surveyor asked what type of sling was used for R1's transfers. RN D stated RN D was unsure. On 07/17/24 at 10:00 a.m., Surveyor interviewed DON B and asked about R1's fall out of the Hoyer lift sling. DON B stated an in-service had been completed 04/29/24 on Hoyer lift transfers. DON B stated staff was aware that Hoyer lifts/all mechanical lifts require 2 people to operate. DON B stated staff have walkie talkies to call other staff for assistance when needed and the licensed nursing staff know they are required to assist the CNAs if needed. DON B stated R1's care plan wasn't updated until 07/02/24 stating straps were to be crossed in between R1's legs. Surveyor questioned the type of sling used for R1's transfers. DON B stated DON B would clarify. Surveyor asked what the facility plan is to ensure this type of incident does not reoccur. DON B stated the facility is going to continue to do spot check audits with lift transfers, and care plans of residents who use mechanical lifts have been reviewed and updated as needed. On 07/17/24 at 10:22 a.m., Surveyor called the police department and inquired about the facility calling regarding R1's fall from a Hoyer lift. Police department representative (PD) S stated the police department has documentation of the facility calling, but the officer has not written a report as of this date and time. On 07/19/24 at 10:52 a.m., Surveyor received a phone call from R1's guardian. Surveyor asked about R1's incident at facility, and current condition. Guardian P stated the last time Guardian P saw R1 was on 06/24/24 and R1 was verbal but nonsensical, which was R1's normal. Guardian P stated since the incident of falling from the Hoyer lift at the nursing home facility, R1 has been nonverbal. Guardian P stated R1's condition has declined, is considered in a vegetative state. Guardian P stated R1's code status has been changed to Do Not Resuscitate (DNR). Guardian P stated per R1's living will, R1 did not want tube feedings or any heroic measures if in a vegetative state. Guardian P stated the decision was made for no feeding tube. Guardian P stated R1 is currently residing in a hospice facility. On 07/22/24 at 3:52 p.m., Surveyor reached out to NHA A with an email to clarify the size and type of sling the facility used for R1's transfers. Surveyor received no reply from NHA A. The facility's failure to ensure a resident utilizing a Hoyer lift for transfers received adequate supervision and assistance devices to prevent accidents created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 07/02/24. On 07/02/24, the facility identified the deficient practice that occurred when the facility staff did not follow facility policy for 2 staff to be present during all mechanical lift transfers and R1 fell out of Hoyer lift sling sustaining a major head injury. The facility took steps to correct the deficient practice and ensure compliance starting on 07/02/24. The immediate jeopardy was removed on 07/07/24 and corrected on 07/07/24 when the facility completed the following: The facility completed resident care plan reviews for the residents who require mechanical lift transfers. The facility provided reeducation on mechanical lift use, requirement for 2 staff to be present during the entire transfer, and use walkie talkies to ask for assistance, and if unsure how to transfer a resident, staff is to seek clarification from a nurse. Licensed nursing staff educated on updating a resident care plan if the straps are to be crossed for the transfer. CNA C's employment with the facility was terminated 07/08/24. Based on this determination, the citation is issued as past non-compliance.

Based on interviews and record reviews, the facility did not identify the need to seek further medical treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was admitted after transmetatarsal amputation. R1's dressing was not changed, nor was the surgical wound assessed on a regular basis. R1 developed infection in the wound along with dehiscence of the wound that required hospitalization . This was evidenced by the following: R1, a [AGE] year-old, was admitted to the facility on [DATE] from the hospital with history of a right great toe amputation. Past history of infections. R1 made their own medical decisions. R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Admission MDS (Minimum Data Set) indicated that R1 had a BIMS (Brief Interview for Mental Status) score of 13. This would have indicated that R1 was cognitively intact. R1 required extensive assistance with ADLs (activities of daily living) due to amputation and inability to bear weight. On 8/30/2022, R1 had the following orders regarding the amputation site: Leave dressing to right foot dry, clean, and intact. Dressing care to be performed by provider during follow up at the podiatry clinic. R1 was to see podiatry one week after discharge from the hospital. R1 was discharged from the hospital to the facility on [DATE]. On 10/05/2022, Surveyor reviewed R1's comprehensive medical record. Findings include the following: 8/30/2022 R1 was admitted with orders to leave dressing to R foot dry and intact until seen by podiatry one week after discharge from the hospital. 9/10/2022 R1's Ex-wife called to let the staff know that R1 had open areas to left lower leg (LLE). Nursing did an assessment and found that R1 had picked open 4 areas on left ankle, shin, and knee. These were open but not draining. Nursing cleansed with Normal Saline, applied [MEDICATION(S)], and wrapped with Kerlix and Ace wraps. R1 was in agreement with the plan to change daily. A note was left in the MD book. There was no mention of the dressing to the R foot. 9/11/2022 Skin Evaluation was done. Documentation mentioned open areas to LLE, no mention of dressing to R foot. 9/19/2022 R1 pulled surgical dressing completely off right lower extremity. RN redressed the area as similarly as possible to how it had been. RN called podiatry to let them know. RN was notified that podiatry had no F/U appointment scheduled because when they reached out to R1 to try and schedule, they had to tell R1 that R1's insurance was not accepted by the provider and that R1 would have to have follow up elsewhere, and R1 hung up on them. No podiatry F/U had been scheduled. The RN informed the provider that the edges of the surgical wound were not approximated and that there was a wide gap where a couple of staples had come undone on one side. This provider stated that R1 should be seen somewhere within R1's insurance network to have it checked out as soon as possible. RN tried to discuss with R1 but R1 was interrupted by a cell phone call and was unable to continue the conversation during that RN's shift. RN did pass this information on to the next shift, and stated they would consult with the DON or Social Worker regarding the next steps. 9/21/2022 RN notes R1 removed dressing. There is no assessment or description of wound. 9/21/2022 There was a care conference held. Attendees were Social Worker, Director of Rehab, manged care staff, R1 and his ex-wife. They reviewed the non-weight bearing status. Talked about encouraging RI to elevate legs throughout the day. They reviewed the dressing changes for the left lower extremity and the need for supplements to promote wound healing. There is no mention of discussion of right foot wound dressing or assessment and needed follow up. 9/25/2022 R1 was complaining of severe pain to R foot. The note by RN states that this dressing was supposed to be left alone until F/U appointment but due to insurance coverage issues, resident had still not had a F/U appointment to check the surgical site. R1 had removed the dressing himself on 9/19 and 9/21. At those times the RN had cleansed it with normal saline, painted it with [MEDICATION(S)] and redressed as close to the way it had been after surgery as could be done with the supplies on hand. The RN noted that the incision line had dehisced (opened) and was not approximated. On inspection of dressing RN noted it was soaked through with yellow/green foul smelling pus, RN removed dressing to assess. Wound had dehisced more since the last time the RN had seen it and was now exuding foul smelling pus. RN cleansed the wound with normal saline, packed it with gauze-soaked [MEDICATION(S)], covered with border foam and wrapped with kerlix before applying an ACE wrap. The RN then informed another nurse on the shift as well as DON B and MD C. MD C gave orders to culture swab and test for sensitivities. To start on [MEDICATION(S)] 300mg QID (4x a day) with meals and at HS. R1 is to be seen by either wound clinic or general surgeon regarding post op infection ASAP. Due to RN packing the wound with [MEDICATION(S)] a culture would be contaminated. The RN removed the current dressing, cleansed [MEDICATION(S)] away with normal saline and redressed with a plain clean dry dressing. To collect culture in the AM when specimen can be transported to the lab ASAP. 9/25/2022 Note in chart at 6:18PM. That RN was not able to carry out orders received from MD C. RN had received a call from R1's ex-wife stating the facility should pack up R1's belongings because they were coming to get R1 to take to the Marshfield ER. The swab was not obtained and the RN did not start the course of [MEDICATION(S)] due to R1 going to the ER. Assisted R1 with getting dressed and got belongings packed up. Assisted R1 to wheelchair. Pulled paperwork together to send along. 9/25/2022 Note in chart at 7:05PM that R1 left in a personal vehicle that had a mattress in the back where R1 was sitting/lying during transport. No safety restraints. The facility W/C was left at facility. R1 had taken all personal belongings. R1 was accompanied by ex-wife and daughter. On 10/5/2022, Surveyor reviewed R1's TAR (Treatment Administration Record). It was also noted that there were no treatment orders for the right foot other than to keep it clean, intact, and undisturbed until seen by Podiatry. This was signed for 3x a day. On 10/5/2022, Surveyor reviewed R1's medical record for communications to the MD. On 9/6/2022 there is a Physician note when MD C was in house. Stating R1 was a new admission, R1's problem list having been reviewed. R1 was at [CONDITION(S)] so was not seen. There were no new orders. On 9/8/2022, RN sent a communication fact to MD C regarding insulin schedule and needing order for [CONDITION(S)] settings. There is no request for further clarification on R foot dressing. On 9/11/2022, RN got telephone order for treatment to open areas on left lower extremity. No request regarding right foot. On 10/5/2022 at approximately 10:10AM, Surveyor interviewed DON B (Director of Nursing) regarding R1. Surveyor asked who was responsible in the facility to make appointments. DON B stated they had been doing it up until about one week ago, when they handed it off to another employee. Surveyor requested the notes regarding R1's Podiatry appointment. DON B stated that they had thrown notes away as they were leaving the job and cleaning the office out. DON B stated that R1 had refused to go back to [NAME] for a podiatry appointment, so DON B called [name of clinic] orthopedics. DON B stated the physicians refused to see R1 until they got medical records and a doctor could review them. DON B stated they then called the other provider back with the fax number to send medical records. DON B stated on 9/6/2022 they had done rounds with MD C (Medical Director) who was also the MD following R1's care. DON B stated they told MD C that they were still waiting for records so that R1 could be seen by podiatry. MD C indicated that they would help to facilitate this. DON B stated they then had received a phone call from podiatry in Wausau stating they would call to set up an appointment as soon as they received R1's medical records. DON B stated there was an appointment set up for 9/23/2022, but R1 canceled that appointment. DON B stated this was not documented in the medical record. On 10/5/2022 at approximately 11:09AM, Surveyor interviewed DON B again regarding R1 and the lack of a dressing change or follow up. Surveyor asked if it was the expectation that a wound should be observed. DON B stated yes. Surveyor asked how often, and DON B stated per MD orders, or at least weekly. DON B then stated the staff had seen the wound at least 4x as R1 had removed the dressing themselves. Surveyor asked if it was the expectation that the nursing staff should have called the MD regarding this dressing change when they saw R1 had not seen Podiatry and had not had a dressing change. DON B stated yes it was a nursing judgement, so they should have gotten clarification. Surveyor asked if any MD or NP (Nurse Practitioner) had ever removed the dressing to observe it and DON B stated no. On 10/5/2022 at approximately 11:55AM, Surveyor spoke to MD C by phone regarding R1. MD C stated that R1 was a new admit who had come to the facility from [NAME]. R1 was to have follow up in [NAME] a week later but refused to go. MD C stated that DON B wanted R1 to be seen locally by orthopedics. MD C spoke to Orthopedics who thought R1 should be seen by podiatry. MD C sent over a referral to podiatry. Surveyor asked MD C if they had actually seen R1 while in house on 9/6/2022 as the note indicated R1 had been at [CONDITION(S)] and that MD C would see them when they returned. MD C stated they could not remember if they had seen R1. Surveyor asked MD C if given the fact that R1 had not been seen by podiatry and had not had a dressing change since admission, what MD C would expect from the nursing staff. MD C stated the nurses should have called to get orders regarding the dressing change. MD further stated they would not want a dressing to be on for that length of time without a dressing change. On 10/5/2022 at approximately 12:25PM, Surveyor interviewed RN D regarding dressings. RN D had worked at the facility for one year. Surveyor asked if RN D saw an order to not disturb a dressing, but dressing had not been changed for a few weeks what would RN D do. RN D stated they would call the provider, explain that there were no orders to address the dressing change and get appropriate orders. RN D stated they felt this was the expectation for most nurses. Hospital notes in part: 9/25/22 73 y.o. male with medical history significant for poorly controlled diabetes, diabetic foot ulcer status post [MEDICAL RECORD OR PHYSICIAN ORDER] . He reports that his wound was not evaluated for the last 6 weeks and he has the same dressing since discharge as he could not follow up with the podiatry and the nursing home staff refused to open/change it because they did not have the orders, because of worsening pain, his dressing was opened last night .There was no leukocytosis, lactic acidosis, or electrolyte abnormalities. Patient was given [MEDICATION(S)] for antibiotic coverage . Diabetic foot infection s/p amputation complicated with wound dehiscence . Patient had no follow up and/or dressing changes since discharge from outside facility. He now presented because of worsening symptoms and concerns of developing infection and wound dehiscence. X-ray did not show any evidence of [CONDITION(S)] or [CONDITION(S)]. Continue broad spectrum antibiotics and [MEDICATION(S)] because of history of [CONDITION(S)] colonization based off outpatient records. On 10/5/2022, Surveyor reviewed the facility policy entitled Wound Management. To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Under the heading Policy Explanation and Compliance Guidelines, bullet point number 2, it states: In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse. The facility did not provide dressing changes or seek follow up orders from an MD until the wound became infected with yellow foul smelling exudate and the wound was dehisced requiring hospitalization .

Based on observation, interview, and record review, the facility did not ensure the necessary treatment and care to prevent pressure ulcers and promote healing of pressure ulcers for 2 of 2 Residents (R40, R30). This resulted in R40 sustaining a left ischial stage IV pressure ulcer with 6 cm tunneling to the bone with subsequent VRE ([MEDICATION(S)] Resistant Enterococcus) in bone, causing [CONDITION(S)] to pelvis, [CONDITION(S)], Intravenous antibiotic therapy for 3 weeks, wound vacuum therapy, and multiple surgical interventions. The facility did not implement a ROHO cushion or pressure mapping as ordered for R40 on 7/7/21 and again on 9/17/21. The facility did not add these to the care plan or update the care plan from 6/30 - 9/30/21. Facility staff charted on one pressure injury, identifying the wound as being to the left scrotum, when there were actually two pressure injuries. The facility did not consult with the resident's primary physician, did not involve dietary until after the resident was hospitalized , and did not have regular communication with the wound clinic. When staff identified tunneling on 9/23/21 or when they identified the wound had increased in size or depth, the facility did not consult with a physician, did not change the care plan, or get a change in treatment. Facility failure to prevent pressure ulcers and promote healing of pressure ulcers created a finding of immediate jeopardy that began on 09/23/21. NHA (Nursing Home Administrator) was notified of the immediate jeopardy on 12/14/21 at 2:00 PM. The immediate jeopardy was removed on 12/14/21. However the deficient practice continues at a scope/severity level of G as evidenced by the following example: R30 was admitted with one pressure injury (PI) on the left heel. The left heel was a stage 2 on admission and progressed to a stage 3. R30 had 5 additional PIs develop in the facility that were identified by the wound clinic. The facility did not consistently or accurately assess the PIs. Despite the development and worsening of the PIs, the facility did not update R30's care plan with interventions to promote the healing of existing PIs or to prevent the development of new PIs. This is evidenced by: R40 was admitted to the facility on [DATE] after hospitalization for hypothermia and a fall from wheelchair. He has a BIMS (Brief Interview of Mental Status) score of 15, indicating an intact cognitive response. R40 is his own responsible party. R40 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R40 has a regular 2 gm sodium diet with regular texture and thin consistency liquids. R40 eats 75-100% of all meals and takes in an average of 2,000 ml of fluid daily. Weights reviewed are stable. On 12/13/21, at 8:00 AM, Surveyor reviewed R40's Weekly Wound Evaluations, Physician orders, hospital documentation, wound clinic notes, dietary notes, care plan, nurses' notes, and labs. Weekly Wound Evaluation dated 06/17/21 states that R40 had sustained an injury to the left side of scrotum due to Hoyer sling. This area is described as other open. No measurement is documented. Nurse Practitioner was updated and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Weekly Wound Evaluation was not performed for the week of 06/20 through 06/26/21. Weekly Wound assessment dated [DATE] shows a left scrotal open lesion measuring 2.5 x 1.5 x 0.5 cm. Nurse Practitioner was updated and an order was received for a Wound Clinic Referral. Progress notes from the Wound Clinic dated 07/07/21 identifies 2 pressure injuries. Wound #1 is located on the scrotum and is staged at a 2, partial thickness skin loss with exposed dermis, with measurement of 0.5 x 0.7 x 0.1 cm. Wound #2 is located on the left ischium and is staged at a 3, full-thickness skin loss, with measurement of 2.0 x 1.0 x 2.0 cm. Plan states: 1. Swab cultures taken today. Patient will start wet to damp dressing changes twice a day with TAB (Triple Antibiotic) solution, 2. Prealbumin lab draw will be ordered, 3. Pressure mapping should be done to ROHO cushion and bed, 4. Follow up with Wound Physician in 1 week. There is no evidence that the ROHO cushion was ever mapped or that a ROHO cushion was placed on R40's care plan. Weekly Wound Assessments from July through September 2021 refer to one wound only. The facility identifies the wound on the left scrotum, but the depth of the wound, varying between 2 and 3 cm, makes the documented location of the wound questionable. Weekly Wound Assessments July through September 2021 state: 06/30/21: Left scrotum described as open lesion with measurement of 2.0 x 1.0 x 1.0 cm. There is no evidence of Physician notification and care plan was not updated. 07/08/21: Left scrotum described as other with measurement of 1.5 x 1.0 x 1.0 cm. 07/08/21: Lab shows R40's Prealbumin as 13 mg/dl with normal range being between 20-40 mg/dl. There is no evidence of another prealbumin lab until R40 is hospitalized on [DATE]. There is no dietary intervention until 11/09/21. 07/14/21: Left scrotum described as other with measurement of 2.0 x 1.0 x 2.0 cm. There is no evidence of Physician notification or care plan update even though the wound has increased in size and depth. 07/21/21: Left scrotum described as other with measurement of 1.0 x 1.0 x 2.0 cm. 07/28/21: Left scrotum described as other with measurement of 1.0 x 1.0 x 2.0 cm. 08/04/21: Left scrotum described as other with measurement of 1.0 x 1.0 x 3.0 cm. There is no evidence of Physician notification or care plan update even though the depth of the wound has increased. The facility did not perform a Weekly Wound Assessment for the week of 08/08 through 08/14/21. R40 went to a Wound Clinic appointment on 08/11/21 with wound treatment order change. On 08/06, 08/09, and 08/10, nurses notes show description of wound drainage as brown/tan. There is no evidence of Physician notification. 08/18/21: Left scrotum described as open lesion with measurement of 1.5 x 1.5 x 3.0 cm. There is no evidence of Physician notification or care plan update. 08/25/21: Left scrotum described as open lesion with measurement of 1.0 x 1.0 x 2.5 cm. 09/01/21: Left scrotum described as open lesion with measurement of 1.5 x 1.5 x 2.5 cm The facility did not perform a Weekly Wound Assessment for the week of 09/05 through 09/11/21. On 09/07/21, an order was received from Wound Clinic Physician that states, Referral being made to wheelchair clinic for ROHO cushion with pressure mapping. When issued, he should use this at all times while sitting to relieve pressure. There is no evidence that this was done and ROHO cushion was not placed on care plan. On 09/08/21, R40 went to a Wound Clinic appointment. 09/15/21: Left scrotum described as open lesion with measurement of 1.0 x 1.5 x 2.5 cm. On 09/17/21, R40 went to a Wound Clinic Appointment and orders received for change in wound care treatment. 09/23/21: Left scrotum described as open lesion with measurement of 1.0 x 1.2 x 2.5 cm with 2 cm tunneling at 12:00. There is no evidence of Physician notification or care plan update despite the new development of tunneling. 09/30/21: Left scrotum described as open lesion with measurement of 1.5 x 1.5 x 2.0 cm. On 09/30/21, R40 underwent an every 6 month routine CT (Computed Tomography) scan of chest, abdomen, and pelvis at Urology appointment for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There is new [CONDITION(S)] in the left ischial tuberosity, suspicious for developing [CONDITION(S)]. Nurses' note, dated 10/01/21 at 7:08 PM, states, Received phone call from wound care Physician office with recommendation to send Resident to the ER for evaluation following scan done on 09/30/21 with suggestions of possible [CONDITION(S)]. Notified Resident, DNS, and [name] granddaughter of recommendation. In agreement to transfer to [name] ER, sent by non-emergent transport, with report called to ER RN at time of transfer. Hospital physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no evidence of R40 using a ROHO cushion and ROHO cushion was not added to care plan. physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan to obtain bone debridement and culture in OR (operating room) tomorrow. On 10/04/21, R40 underwent bone debridement and culture. Surgical Progress note, dated 10/04/21, states, Operation: 1. Excisional debridement of left buttock involving subcutaneous tissue and bone, and 2. Veraflo wound vac placement, left buttock <50 cm2. 10/05/21 Prealbumin is noted at 13 mg/dl. Surgical Progress note, dated 10/11/21, states, Operation: 1. Excisional debridement of left buttock involving subcutaneous tissue and bone-9.6 cm . Veraflo wound vac placement, left buttock <50 cm2. Surgical Progress note, dated 10/15/21, states, Operation: 1. Preparation of wound bed requiring excision for placement of skin substitute of left buttock-7.8 cm . Wound vac placement, left buttock <50 cm2. Infectious Disease Physician's Order, dated 10/18/21, states, Diagnosis/Site: Left ischium stage 4 decubitus, Organism: VRE in bone on 10/11, on wound vac therapy now, and Medications/IV Antibiotics: [MEDICATION(S)] 600 mg IV daily last dose 11/08/21 then PICC (Peripherally Inserted Central Catheter) can be removed. 10/20/21 Prealbumen is noted at 22 mg/dl. 10/28/21 Prealbumen is noted at 24 mg/dl. On 10/29/21, R40 returned to the facility with PICC line and IV antibiotic therapy with last dose being 11/08/21. PICC line was removed on 11/10/21. Weekly wound assessments after hospitalization : 10/29/21: Left ischium described as Deep Tissue Pressure Injury stage 3 with measurement of 1.5 x 3.5 x 4.5 cm. No Weekly Wound Assessment was performed the week of 10/31 through 11/06/21. Physician order, dated 11/08/21, states, d/c prn apap, schedule APAP 650 mg PO QID for pain, and will send order for [MEDICATION(S)] 50 mg up to TID prn for pain. Nurses' notes indicate R40 was having increasing aching pain from left ischial wound. Physician Order, dated 11/09/21, states, Proheal 30 ml BID po, House Supplements BID, [MEDICATION(S)] 220 mg 1 po q d x 14 days per RD recommendation. This is the first nutritional intervention to promote the healing of R40's pressure injury that was identified and staged by the wound clinic on 07/07/21. Nurses' notes dated 11/9, 11/10, and 11/11/21 show wound exudate described as purulent. There is no evidence of physician notification. 11/11/21: Left ischium described as surgical wound with measurement of 2.0 x 2.0 x 4.0 cm. No Weekly Wound Assessment was performed the week of 11/14 through 11/20/21. On 11/17/21, R40 went to a Wound Clinic appointment. Nurses' notes dated 11/18 and 11/25/21 show wound exudate described as purulent. There is no evidence of Physician notification. 11/25/21: Left ischium described as surgical wound with measurement of 1.0 x 1.0 x 3.2 cm. 12/02/21: Left ischium described as surgical wound with measurement of 1.0 x 1.0 x 2.5 cm. Nurses' note dated 12/02/21 shows wound exudate described as purulent. There is no evidence of Physician notification. Surgical Progress note, dated 12/06/21, states, Operation: 1. Preparation of wound bed requiring excision for placement of skin substitute of left buttock, and 2. Placement of skin substitute. Nurses' note dated 12/08/21 shows wound exudate described as purulent. There is no evidence of Physician notification. On 12/13/21, at 10:35 AM, Surveyor observed R40's left ischial wound. Left ischial wound is covered with a Meplex dressing. ADON-C was in the room and explained to Surveyor that left ischial wound had an [NAME]-Silk skin substitute and sponge sutured in place inside wound that cannot be removed. Observation is made by Surveyor of ROHO cushion in room. On 12/13/21, at 11:00 AM, Surveyor interviewed R40. R40 states that he is capable of turning and repositioning on his own, but that the CNA staff do help with placing pillows. R40 states that staff do remind to turn and reposition and that he has been provided education on that. R40 states that he never refuses to turn and reposition. R40 states that since he has been on bed rest he can no longer perform usual ADL (Activities of Daily Living) tasks like he used to. R40 states he used to get transferred by lift to the bathroom, but now has to use a bed pan. R40 states that he is going mentally crazy and that he has begged staff to sit him on the side of the bed, which they have done, but don't tell the doctor. R40 states, When I eat, it's not very pleasant. I am feeding my face instead of my stomach, I like to sit in a chair when I eat. R40 states that he does exercises on his feet because of constant laying and It gets to me. R40 states that he has J. Bavet brandy with soda because it, brings my morale up. On 12/13/21, at 12:30 PM, Surveyor interviewed WCS-E. WCS-E stated that they first started treating R40's left ischial wound on 07/07/21 and started a topical antibiotic solution for a dressing treatment. WCS-E states that the ischial wound is from sitting and did not come from the scrotal wound. WCS-E states that scrotal wound is from a shear injury. WCS-E stated that a ROHO cushion was recommended at R40's 07/07/21 appointment. WCS-E stated that R40's wound was initially staged at a 3, but continued to progress into October. WCS-E stated that when R40 was admitted to the hospital on 10/01/21, the measurement taken was 2.0 x 1.5 x 6.0 cm tunneled to the bone. On 12/13/21, at 1:40 PM, Surveyor interviewed ADON-C regarding R40 being on strict bed rest, no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON-C stated that R40 had told them that the Wound Clinic Physician had stated that he should remain in bed. There is no evidence that the Wound Clinic Physician stated strict bed rest and this has been denied by WCS-E. On 12/14/21, DON-B informed Surveyor's that it is unknown if ROHO cushion has ever been mapped, so facility staff cannot get R40 out of bed until ROHO cushion is mapped. Physician order was received by DON-B on 12/14/21 at 9:43 AM which states, Patient should be on bed rest until ROHO cushion can be obtained and pressure mapped. Facility failure to prevent pressure injuries and promote healing of pressure injuries led to serious harm and created a finding of immediate jeopardy. The facility removed the immediate jeopardy on 12/14/21 when it completed the following: A facility wide skin sweep was completed to ensure the facility was aware of all open areas. All residents with open areas were reviewed to ensure pressure reducing devices were in place as ordered. An audit for nutritional interventions in place, missed wound assessments, and missed physician notifications was completed. Facility ensured that all wound clinic visit reports were obtained. All nursing staff educated on pressure injury prevention, management, and physician notification. This will include pressure reducing devices either per order or per current standards of practice, nutritional supplementation, weekly wound assessments and measurements. Nursing and medical records educated on follow through continuity of care by obtaining visit notes from wound clinic visits. The deficient practice continues at a scope/severity of G, based on the following example. Example 2 R30 was admitted to facility on 10/20/2021; pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R30's Admission Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 14, meaning R30 is cognitively intact. MDS also indicated R30 required extensive staff assistance for bed mobility, transfers, locomotion, toileting, and personal hygiene. MDS indicated R30 is at risk for developing pressure injuries (PI), but does not indicate any current unhealed pressure injuries. MDS indicated other open [CONDITION(S)] of foot and surgical wounds. Skin treatments indicated are: surgical wound care and application of dressings to feet. R30's Care Plan titled, Pressure ulcer actual or at risk due to: Assistance required in bed mobility, Braden Score 18 or less than, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Conduct weekly skin inspection. Monitor vital signs as needed. Referral to Therapy. Treatments as ordered. All interventions were initiated on 10/20/2021; no additional interventions were added to the care plan. R30's Care Plan titled, .Pressure ulcer actual: (blank) date initiated: 10/21/2021 included interventions: Heel boots. Monitor skin under braces, prosthetics, splints, cast for breakdown. Treatments as ordered. Weekly Wound assessment. All interventions were initiated on 10/21/2021; no additional interventions were added to the care plan. R30's Braden Scale Assessment completed 10/20/2021 showed a score of 12, which indicated a high risk for skin breakdown. On 12/06/2021, at 3:20 PM, Surveyor interviewed R30. R30 was lying on his back in bed; head of bed slightly elevated, and R30 had pressure-reducing boots on both feet. R30 stated he had PI on heels and buttocks, to which dressing changes are completed multiple times per day. R30 denied pain. R30 stated he was able to turn himself from side to side if he needed to, but did not do so often. R30's medical record revealed Facility completed skin/wound assessments on the following dates: 10/21/2021, 10/30/2021, 11/1/2021, 11/18/2021, and 11/25/2021. R30 was seen by the Wound clinic on the following dates: 10/19/2021, 10/28/2021, 11/4/2021, 11/11/2021, 11/17/2021, and 11/29/2021. Following is a timeline of R30's wound progression: 10/19/2021 (1 day prior to admission) Wound Clinic Progress Note Wound #2: Left Heel PI stage 2, partial-thickness skin loss with exposed dermis. Size: Length 5.2cm x Width 4.4cm x Depth 0.4cm 10/20/2021 R30 admitted to facility; no skin assessment was documented upon admission. 10/21/2021 20:24 Facility assessment: Weekly Skin Impairment and Wound Evaluation Wound location: Left heel. Description: Heel ulcer with necrosis and epithelial tissue. Pressure ulcer Stage 3. Length 6cm Width 4cm Depth 0.1cm. Note: This was a progression from stage 2 PI that was present upon admission. No Physician notification was made when wound progressed from stage 2 to stage 3 PI. 10/28/2021 R30 assessed by Wound Clinic: Wound #2: Left Heel PI stage 3. Size: Length 7.5cm x Width 4.0cm x Depth 0.3cm Wound #4: Right Lateral Lower Leg PI stage 2. Size: Length 0.5cm x Width 0.3cm x depth 0.1cm NOTE: Wound clinic noted increased size of Wound #2 and Wound #3, and identified additional stage 2 PI (Wound #4) at visit. 10/30/2021 21:30 Facility assessment: Weekly Skin Impairment and Wound Evaluation (9 days since previous facility assessment) Wound location: Left heel. Description: Pressure ulcer to L heel on admission. Pressure ulcer Stage 3. Length 6cm Width 4cm Depth 0.1cm. NOTE: Recorded measurements are the exact same as previous facility wound assessment, however, are not consistent with Wound Clinic measurements from 10/28/2021. No additional areas of impaired skin were documented including the PI newly identified by the wound clinic on 10/28/21. 11/4/2021 R30 assessed by Wound Clinic: Wound #2: Left Heel PI stage 3. Size: Length 9.0cm x Width 4.0cm x Depth 0.3cm Wound #4: Right Lateral Lower Leg PI stage 2. Size: Length 2.0cm x Width 2.0cm x depth 0.1cm Wound #5: Left 5th MTH (Metatarsal) Unstageable PI, obscured full-thickness skin and tissue loss. Size: Length 1.3cm Width 1.0cm Depth 0.0cm. NOTE: Wound clinic noted increased size of Wound #2, Wound #4, and identified additional unstageable PI (Wound #5) at visit. 11/11/2021 R30 assessed by Wound Clinic: Wound #2: Left Heel PI stage 3. Size: Length 9.2cm x Width 4.0cm x Depth 0.3cm Wound #4: Right Lateral Lower Leg PI stage 2. Size: Length 5.2cm x Width 2.2cm x depth 0.1cm. Pressure ulcer on proximal aspect of wound. Wound #5: Left 5th MTH (Metatarsal) Unstageable PI, obscured full-thickness skin and tissue loss. Size: Length 0.6cm x Width 0.5cm x Depth 0.0cm. Wound #6: Right Lateral Foot Unstageable PI. Size: Length 1.6cm x Width 1.5cm x Depth 0cm. Wound #7: Left Lateral Foot Unstageable PI. Size: Length 1.4cm Width 1.0cm Depth 0cm Plan: .6. I called (Facility Name) after patient had left to update then on Patient's wound care. They asked if we had looked at Patient's sacral wound. Patient and Patient's wife did not mention sacral wound so it was not examined. (Facility Name) was notified that Dr .will assess sacral wound at next appointment . NOTE: Wound clinic noted increased size of Wound #2, Wound #4, and identified additional unstageable PIs (Wounds #6 and #7) at visit. The facility did not make the wound clinic aware of the sacral wound prior to the appointment or send information with the resident about the sacral area. 11/11/2021 19:07 Facility assessment: Skin Only Evaluation (12 days since previous facility assessment) Skin Issue #2: Open lesion (other than ulcers, rashes and cuts). Location: Right lateral lower leg. Length: 3cm Width: 2cm Depth: 0cm. Skin Issue #3: Pressure Ulcer/Injury. Location: Left heel Stage 3. Length: 4cm Width: 3cm Depth: 0.1cm NOTE: Facility measurements of wounds are inconsistent with Wound Clinic measurements from the same day. Wound Clinic identified 7 areas of skin impairment; facility only documented on 3 areas. Facility did not document anything regarding a sacral wound. 11/17/2021, R30 underwent surgical debridement of all wounds. Surveyor requested notes from debridement procedure; none were provided. 11/18/2021 Facility assessment: Skin Only Evaluation (7 days since previous facility assessment) Skin Issue #2: Open lesion (other than ulcers, rashes and cuts). Location: Right lateral lower leg. Length: 4cm Width: 3cm Depth: 0.1cm. Skin Issue #3: Pressure Ulcer/Injury. Location: Left heel Stage 3. Length: 5cm Width: 5cm Depth: 0.1cm Skin Issue #4: Diabetic Foot Ulcer. Location: left foot Length: 1cm Width: 0.5cm Depth: 0.1cm NOTE: Facility does not identify wounds on right lateral lower leg and left foot as PI, despite Wound Clinic assessments of areas. 11/25/2021 Facility assessment: Skin Only Evaluation (7 days since previous facility assessment) Skin Issue #3: Pressure Ulcer/Injury. Location: Left heel Stage 3. Length: 3cm Width: 3cm Depth: 0.2cm 11/29/2021 R30 was assessed by Wound Clinic: Wound #2: Left Heel PI stage 3. Size: Length 8.5cm x Width 7.5cm x Depth 0.6cm Wound #4: Right Lateral Lower Leg/calf PI stage 2. Size: Length 3.7cm x Width 3cm x depth 0.3cm. Pressure ulcer on proximal aspect of wound. Wound #5: Left 5th MTH (Metatarsal) Unstageable PI, obscured full-thickness skin and tissue loss. Size: Length 2.8cm x Width 2.3cm x Depth 0.2cm. Wound #6: Right Lateral Foot Unstageable PI. Size: Length 1.6cm x Width 1.5cm x Depth 0cm. Wound #7: Left Lateral Foot Unstageable PI. Size: Length 1.6cm Width 1.0cm Depth 0.3cm Wound #8: Sacrum PI Stage 2. Size: Approx. Length 3cm x Width 2.5cm x Depth 0.1cm NOTE: Wound clinic noted increased size Wound #2, Wound #4, Wound #5 and Wound #7, and identified additional Stage 2 PI (Wound #8) at visit. Surveyors entered facility on 12/6/2021 (11 days since previous facility assessment); no additional skin or wound assessments had been completed by facility. On 12/07/2021, at 2:32 PM, Surveyor interviewed Assistant Director of Nursing (ADON) C; ADON C is wound certified and serves as the facility's wound care nurse. Surveyor asked how wounds are tracked to determine improvement vs. deterioration. ADON C stated she did not really pay attention to measurements, she mostly determined improvement by looking at the wound. Surveyor asked when the wound on R30's sacrum was first identified and who it was reported to. ADON C was unsure if R30 had a sacral wound. Surveyor referred to Wound Clinic note dated 11/11/2021 in which wound clinic documented not being aware of R30's sacral wound. ADON C stated she was unsure who they spoke to from the facility, but would find the information. ADON C stated the wound clinic is documenting on multiple skin areas, but the facility is only documenting on 3 areas. Surveyor asked why the discrepancy? ADON C gave no explanation for this discrepancy in assessments. On 12/07/2021, at 3:26 PM, ADON C told Surveyor that the Wound Clinic had assessed the sacral wound at R30's next visit (which was 11/29/2021). Surveyor asked if a Physician had been notified or assessed the wound any time between 11/11/2021 and the following appointment 11/29/2021. ADON C stated, no, and unfortunately we have not documented anything on the sacral wound here either. Surveyor clarified that facility had no documentation of sacral wound; ADON C confirmed. On 12/08/21, at 7:52 AM, ADON C approached Surveyor and stated she wanted to clarify R30 did not currently or ever have a PI on sacrum. ADON C stated facility staff only asked the wound clinic to check R30's sacrum on 11/11/2021 because they were concerned due to R30's high risk for PI. ADON C stated she examined R30's sacral area yesterday (12/7/2021) and there is no PI, skin was intact and blanchable; the dressing is just for protection of the area. On 12/8/2021, at 10:16 AM, Surveyor observed ADON C and Registered Nurse (RN) G perform wound care for R30. Surveyor observed several areas of skin impairment as noted below: Right lateral foot: black eschar, Right lateral lower leg: facility called open lesion; Wound Clinic called PI stage 2, Right heel: Intact skin; reddened with deep purple center, Right lateral ankle: discoloration; blanchable, Left lateral foot: black eschar, Left heel PI stage 3, Sacrum: reddened, small areas open presenting as stage 2 PI. Surveyor asked ADON C and RN G to describe sacral wound. RN G stated she would call the area a stage 2 PI. RN stated the area looks, better now than it did last week. On 12/13/2021, at 1:47 PM, Surveyor interviewed RN G. Surveyor asked RN G to describe history and origin of R30's sacral wound. RN G stated the wound started as excoriation and maceration. At first facility was using [MEDICATION(S)], but it became open at one point so RN G stated she notified wound clinic. RN G confirmed the wound clinic did not look at it that day, but looked at it the following appointment. RN G stated, the first treatment to the area was actually [MEDICATION(S)], and then it was switched to [MEDICATION(S)] because R30 didn't like the sticky honey. RN G couldn't remember exactly, but thought the area started at about 0.3 x 0.3cm, and then it cleared up. Of note the most recent wound clinic measurement on 11/29/21 is, Size: Approx. Length 3cm x Width 2.5cm x Depth 0.1cm. RN G stated she had been off work for a long stretch of time and when she returned, the area had reopened again. It was about that time R30 returned to wound clinic and new orders were received to place a [MEDICATION(S)] dressing to area. Surveyor asked RN G where wound assessments are documented. RN G was unsure; stated ADON C is the only one who measures wounds, and RN G believed ADON C kept the documentation in her office. Surveyor asked if RN G recorded any of her observations or assessments of R30's skin in the medical record; RN G stated no. RN G stated she assumed someone had already documented on the sacral area because there was already a treatment ordered. R30 had Physician's order dated 11/9/2021 for ProHeal 300cc by mouth twice daily to aide in wound healing per RD (Registered Dietician) recommendations. The nutritional intervention was added weeks after the PI had been identified. R30 had Phone order for Small amount of Medahoney (sic) to buttock wound once daily and when soiled. [MEDICATION(S)] Oxide to buttocks PRN (as needed) to prevent further excoriation dated 11/5/2021. It is unclear where order originated from, as facility is unable to provide physician notification or nursing progress notes related to identification of skin impairment to sacral area per Surveyor request. On 12/08/2021, at 12:38 PM, Surveyor placed call to Wound Clinic and spoke to RN F who oversees R30's wound care. RN F confirmed R30 was seen on 10/19/2021, the day before admitting to the facility, and at that time R30 had two surgical wounds and one Stage 2 PI. Since that time, the Stage 2 PI has progressed to Stage 3, and R30 has developed multiple other pressure-related injuries.