Every finding on record at Avina of Kenosha

Based on observations, record review, policy review, and interviews, the facility failed to ensure effective interventions were implemented to prevent 1 of 12 residents who smoked (Resident (R)14) from a sample of 22 residents, from repeatedly smoking inside the facility. A 12/12/25 smoking assessment determined that R14 could smoke outside, in the designated smoking area, unsupervised. Between 01/19/26 and 07/02/26, R14 was found smoking in his room [ROOM NUMBER] times. The facility failed to implement additional interventions after each of these incidents and continued to allow R14 to hold his smoking materials. A 07/13/26 smoking assessment continued to identify R14 as being able to smoke outside unsupervised and added that staff were to keep R14's smoking materials in their possession. Observations during survey revealed R14 continued to hold his smoking materials after coming inside from smoking. The facility's failure to implement appropriate safety measures and/or interventions after R14 was found smoking in his room [ROOM NUMBER] times and failure to retrieve R14's smoking materials from him when he returned into the building after smoking as per his smoking assessment created a finding of immediate jeopardy that began on 02/14/26. Surveyor notified Director of Nursing (DON) and Regional Nurse Consultant (RNC) of the immediate jeopardy on 08/19/26 at 11:50 AM. The immediate jeopardy was removed on 08/20/26, however, the deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's policy titled Resident Smoking, dated 03/21/25, includes: Residents are to be assessed for smoking safety, supervised as indicated by the care plan, reassessed when changes in condition or smoking behaviors occur, and provided additional safety measures when smoking policies are not followed. The policy further includes that smoking is prohibited in all areas except the designated smoking area, smoking materials for residents requiring supervision are to be maintained by nursing staff, and care plans are to include and communicate all safe-smoking measures and required supervision. The policy also includes that when residents do not comply with smoking policies, the plan of care may be revised to include additional safety measures. The undated Smoking List provided by the facility included 12 residents who smoked, including R14. R14's admission Record included an admission date of 06/03/25 with a diagnosis of brain dysfunction. R14's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/26 revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderate cognitive impairment. R14's Smoking assessment dated [DATE] indicated R14 required supervision for smoking, including receiving cigarettes and a lighter from nursing staff. R14's Smoking assessment dated [DATE] indicated R14 could smoke outside unsupervised. R14's Progress Notes included documentation that R14 was found smoking in his room inside the facility on 01/19/26, 02/14/26, 02/20/26, 03/16/26, 04/25/26, 04/28/26, 05/15/26, and 07/02/26. On 01/19/26, the odor of cigarette smoke was coming from R14's room and staff found R14 smoking in his bathroom. On 02/14/26, R14 was found smoking in his bathroom. On 02/20/26, the odor of cigarette smoke was coming from R14's room and R14 was found smoking in his bathroom. On 03/16/26, the odor of cigarette smoke was coming from R14's room, the room was filled with cigarette smoke, and smoking materials were found on R14's person. On 04/25/26, R14 was caught smoking a cigarette in his bathroom, his bedroom door was blocked with the bathroom door, and he had a lighter on his person. On 04/28/26, R14 was caught smoking in his bathroom and cigarettes, and a lighter were removed from his room. On 05/15/26, R14 was caught smoking in his room, and a lighter was obtained from him. On 07/02/26, the odor of cigarette smoke was coming from R14's room, the door was blocked, R14 admitted smoking in his room, and cigarettes and a lighter were found in his bathroom. During an interview on 08/19/26 at 1:05 PM, Licensed Practical Nurse (LPN)1 stated she had personally observed R14 smoking in his room on one occasion. LPN1 stated she removed his smoking materials and reported the incident to the Social Services Director (SSD), DON, and charge nurse. LPN1 stated she educated R14 regarding smoking safety and reported, We keep his materials locked up. It's hard to monitor him because he barricades the door with the bathroom door and we can't always get into his room right away. Review of R14's Care Plan revealed no documentation of additional interventions being implemented following each incident of R14 being found smoking in his room. During an interview on 08/18/26 at 5:55 PM, the DON confirmed there were no interventions implemented after each time R14 was found smoking in his room inside the facility. During an interview on 08/19/26 at 8:43 AM, the Regional Nurse Consultant (RNC) confirmed there were no additional care plan interventions implemented following the documented incidents of R14 smoking in his room. During an interview on 08/19/26 at 8:48 AM, Housekeeper (HK)1 stated she cleaned R14's room and emptied his trash. When asked whether she had ever found cigarette butts in R14's trash can, HK1 stated, No, but reported she had found cigarette butts on the floor several months earlier that were not lit. When asked whether she reported finding the cigarette butts, HK1 stated, No, just to the CNAs. HK1 stated the cigarette butts may have fallen out of R14's pocket after he returned from outside because she had never smelled cigarette smoke in his room. R14's Smoking assessment dated [DATE] documented R14 could smoke unsupervised outside. The assessment indicated that upon returning from smoking, R14 was to give his cigarettes and lighter to nursing staff. During an interview on 08/18/26 at 9:00 AM, the DON stated the designated smoking area for residents was the west courtyard outside the building. During observations on 08/18/26 at 10:25 AM, from 1:18 PM to 1:28 PM, and at 2:43 PM, R14 was observed in the courtyard with other residents. No staff were observed supervising smoking activities. Numerous cigarette butts were observed in the grass although there is a receptable present for proper disposing of the butts. During an observation on 08/18/26 at 4:04 PM, numerous cigarette butts were observed on the ground throughout the designated smoking area. At that time, Certified Nursing Assistant (CNA)1 confirmed the large number of cigarette butts present on the ground. During an interview on 08/18/26 at 4:12 PM, Registered Nurse (RN)4 stated that staff do not give R14 a whole pack of cigarettes or a lighter. RN4 stated R14 receives two cigarettes and is expected to ask another resident to light his cigarette. During an observation and interview on 08/18/26 at 4:16 PM, R14 entered the facility from the courtyard with a pack of cigarettes and a lighter in his shirt pocket. There were seven cigarettes remaining in the pack. During an interview at that time, R14 stated the Business Office Manager (BOM) brought him cigarettes. R14 was then observed wheeling himself toward his room. No staff were present at the smoking area doors, and no one retrieved his smoking materials. During an interview on 08/18/26 at 4:28 PM, the Activity Director (AD) confirmed she purchased cigarettes for R14 the previous week but did not purchase a lighter. The AD stated R14 likely obtained a lighter from another resident because staff do not routinely monitor residents while smoking. During an interview on 08/18/26 at 4:41 PM, the DON stated staff should have removed R14's cigarettes and lighter when he reentered the building and that he should not have had smoking materials in his room. During an observation and interview on 08/18/26 at 4:44 PM, the DON attempted to enter R14's room and was initially unable to open the door because the bathroom door obstructed it. When asked if he still possessed his cigarettes and lighter, R14 stated he did and handed them to the DON. R14 stated he had retained the items because he wanted to smoke again. The DON reminded R14 that he was expected to request his smoking materials before smoking and return them afterward. The DON confirmed nursing staff were responsible for securing R14's cigarettes and lighter on a locked treatment cart and retrieving the items when he returned from smoking. DON stated residents were allowed to smoke as often as they desired. She confirmed residents who smoked were given the code to enter and exit the building without staff assistance. The DON stated staff did not supervise smoking activities because residents had been assessed as able to smoke unsupervised. The DON also confirmed residents were expected to discard cigarette butts in the designated receptacle. During an interview on 08/19/26 at 9:12 AM, RN1 stated residents who smoked were not continuously monitored. During an interview on 08/19/26 at 9:13 AM, the AD stated residents were not continuously monitored while smoking in the courtyard. During an interview on 08/19/26 at 11:46 AM, the DON stated she did not know who was responsible for monitoring cigarette butt accumulation in the courtyard. The DON stated incidents involving R14 smoking in his room were routinely discussed during interdisciplinary team meetings and leadership was aware R14 continued to violate the smoking policy. DON was asked how R14 continued to be assessed as safe to smoke unsupervised despite repeated incidents of smoking inside the facility and failure to demonstrate responsible smoking behavior. The DON stated that if the smoking activity itself was assessed as safe, residents were permitted to smoke unsupervised. The DON confirmed that R14's smoking rights could not supersede the safety of other residents. The DON further confirmed there was no documentation of ongoing audits of R14's smoking safety between assessments. During an interview on 08/19/26 at 12:50 PM, RN2 stated R14 had been instructed to return his smoking materials; however, it was unrealistic to expect him to do so consistently, and staff should have retrieved the items. RN2 stated that any staff member could check for smoking materials and acknowledged residents frequently share smoking materials despite instructions not to do so. RN2 further stated staff typically reported smoking incidents involving R14 during shift report or interdisciplinary team meetings. During an observation on 08/19/26 at 1:18 PM, dozens of cigarette butts were observed in the grass surrounding the smoking area. During an observation on 08/20/26 at 12:42 PM, R14 was observed smoking in the courtyard. When finished, he discarded a still-lit cigarette into the grass. The facility's failures to implement interventions after each of the 8 times R14 was found smoking cigarettes in his room and failure to retrieve R14's smoking materials from him after he returned inside from smoking unsupervised created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The facility removed the immediate jeopardy on 08/20/26, however, the deficient practice continues at a scope/severity level of E (potential for more than minimal harm/pattern) as the facility continues to implement the following action plan: An acceptable Plan of Removal (POR) was received on 08/20/26 at 3:19 PM and included identifying residents requiring supervision while smoking, re-educating staff regarding monitoring requirements for residents who require smoking supervision and updating residents' care plans. The survey team validated implementation of the POR through observations, interviews, and record review.

Based on observation, interview, record review, and policy review, the facility failed to follow menus for two of two days and for two (Resident (R)13, R22) of three residents reviewed for menus in the sample of 22 residents. This failure could cause exacerbation of health conditions and/or weight loss or weight gain. Findings include: 1. Review of R22's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 07/31/26 located in the electronic medical record (EMR) under the MDS tab revealed an admission date 10/28/24 and a Brief Interview for Mental Status (BIMS) score of nine out of 15 indicating R22's cognition was moderately impaired, received a therapeutic diet, has weight loss, and had diagnoses of chronic kidney disease, stage 3 (CKD3) unspecified, diabetes mellitus, and acquired absence of other right and left toes. Review of R22's Physician orders dated 08/26 located in the EMR under the Order tab revealed NAS (No Added Salt) diet, Regular texture, Regular (Thin Liquids) consistency. Observation on 08/18/26 at 1:00 PM, R22 was served the lunch meal in bed which included a chicken burger, peas, French fries, fruit, milk, and lemonade. Review of the facility's dietary 2026 Menus Week 4 extensions, provided by the facility, showed the planned lunch meal for 08/18/26 was breaded pork cutlet, brown gravy, rice, zucchini, and cake. Observation on 08/19/26 at 5:10 PM, R22 was served the supper meal in bed which included chili, cornbread, and fruit. Review of the facility's dietary 2026 Menus Week 4 extensions, provided by the facility, showed the planned supper meal for 08/19/26 was tuna noodle casserole, carrots, fruit cup, and garlic Texas toast. 2. Review of R13's quarterly MDS with an ARD date of 05/21/26 located under the MDS in the EMR revealed an admission date 08/11/25 with a BIMS score of 15 out of 15 indicating R13's cognition was intact, received a mechanically altered diet, and had diagnoses of diabetes mellitus, gastro-esophageal reflux disease, and schizophrenia. Review of R13's Orders located in the EMR under the Order tab in the revealed the Medication Administration Report (MAR) dated 08/2026 revealed, LCS [ Low Concentrated Sweets] diet Regular texture, Regular (Thin Liquids) consistency. Review of R13's nutritional assessment dated [DATE] located in the EMR under the Form tab revealed LCS, regular, nectar thick liquids.stage 3 PI [pressure injury] to R [right] buttock, laceration to L [left] lateral calf per 8/17 [wound company] note. Observation on 08/18/26 at 12:53 PM, R13 was served the lunch meal in bed which included a chicken burger, peas, French fries, fruit, milk, and lemonade. R13 confirmed the meal. Review of the facility's dietary 2026 Menus Week 4 extensions, provided by the facility, showed the planned LSC lunch meal for 08/18/26 was breaded pork cutlet, brown gravy, rice, zucchini, and cake. Observation on 08/19/26 at 5:15 PM, R13 was served the supper meal in the dining room which included chili, cornbread, fruit, and a beverage. Review of the facility's dietary 2026 Menus Week 4 extensions, provided by the facility, showed the planned supper meal for 08/19/26 was breaded tuna noodle casserole, carrots, fruit cup, and garlic Texas toast. 3. Observation on 08/18/26 at 10:00 AM, the Week At A Glance menus were posted in the dining room. The menus revealed that on 08/18/26, the lunch meal indicated: breaded pork cutlet, brown gravy, rice, zucchini, and cake was to be served. On08/19/26 the document indicated that for the supper meal: tuna noodle casserole, carrots, fruit cup, and garlic Texas toast was to be served. Observation on 08/18/26 at 12:50 PM, residents in the dining room were served a chicken burger, peas, French fries, fruit, milk, and lemonade. Observation on 08/19/26 at 5:25 PM, towards the end of meal service, residents in the dining room were served chili, corn bread and fruit. At the time of the observation, the Human Resources Coordinator (HRC), who was assisting in the dining room on 1 South, confirmed the meal. During an interview on 08/20/26 at 2:25 PM, the Dietary Manager (DM) was asked why the planned menu was not followed for lunch on 08/18/26 and supper on 08/19/26. The DM stated the kitchen substituted a chicken burger for the pork entrée at lunch on 08/18/26 because the delivered pork was not suitable. When asked why the vegetables and sides also differed from the menu, the DM stated they should not have been changed and said that he, missed it. When asked why the planned supper menu was not served on 08/19/26, the DM stated he switched the 08/19/26 supper menu to the 08/20/26 supper menu. When asked why coleslaw was not served since it was included on the 08/19/26 supper menu. The DM stated it was an oversight by the cook. The DM stated the facility keeps a substitution log, and the dietitian signs off on substitutions when she visits. The DM was unable to locate the substitution log. During a follow-up interview on 08/20/26 at 2:45 PM, the DM provided a substitution log he stated he just created after the interview on 08/20/26 at 2:25 PM to record the changes in the menus. The DM stated he recognized the log should have been filled out at the time of the meal changes. Review of the facility's Substitution Log provided by the facility revealed on 08/18/26 Pork entrée was substituted for an unidentified meal and on 08/19/26 the supper meal was switched with another unidentified supper meal. Review of the facility's policy titled Menu Planning and Approval dated 03/12/26 provided by the facility revealed, The facility shall ensure that menus are planned, reviewed, approved, and implemented in a manner that meets resident nutrition needs, considers resident preferences and special diets, The approved menu and its extensions are signed and dated by the RD [Registered Dietitian] and dietary manager and becomes the official menu cycle for implementation. Any deviations or substitutions require prior RD/dietary manager approval. Review of the facility's policy titled Menu Substitutions, dated 02/19/24 provided by the facility revealed, Menu substitutions will be made after discussion with the RDN [Registered Dietitian Nutritionist], and/or Regional Culinary Services Manager. Last-minute substitutions may need to be made for uncontrollable situations (i.e., inventory emergency when a food item is temporarily unavailable).

Based on observations, interviews, record review, document review, and policy review, the facility failed to ensure a resident grievance was documented, investigated, tracked through resolution, and followed up on in accordance with facility policy. Specifically, the facility failed to ensure a grievance was filed regarding concerns reported by one of one sampled resident (Resident (R)11) regarding another resident's behavior. As a result, the grievance was not documented, investigated, resolved, or communicated to the resident. This failure had the potential for resident grievances throughout the facility to remain unaddressed. Findings include: Review of the undated facility Smoking List provided by the facility revealed the following smokers were listed: R14, R17, R20, R19, R13, R11, and R16. During an interview on 08/18/26 at 9:00 AM, the Director of Nursing (DON) revealed the designated smoking area for facility residents was the west courtyard outside of the building. During an observation of the west courtyard on 08/18/26 at 10:00 AM, R11, R14, R16, R17, R18, R19, and R20 were smoking cigarettes. No staff were present or observed monitoring the area. During an interview on 08/18/26 at 10:17 AM, R11 stated R14 frequently urinates in the west courtyard with his genitals in plain view of other residents. R11 stated she reported R14's behavior to the Social Services Director (SSD) and the charge nurse; however, no facility staff had followed up with her regarding her concern. R11 reported the most recent occurrence that happened a couple of days earlier. Review of R11's admission Minimum Data Set (MDS) located under the RAI tab with an Assessment Reference Date (ARD) of 07/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R11 was cognitively intact. During an observation on 08/18/26 at 2:43 PM, R14 wheeled himself out the door to the smoking area after entering the code on the keypad. He lit a cigarette and remained in the concrete area. R18 and R11 were also smoking outside. No staff were present or observed supervising residents in the courtyard. Record review of R14's admission Record located under the Profile tab of the EMR revealed an admission date of 06/03/25 with a diagnosis of brain dysfunction. Record review of R14's quarterly MDS with an ARD of 07/15/26 revealed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. During an interview on 08/19/26 at 1:05 PM, Licensed Practical Nurse (LPN)1 reported she notified the SSD and the DON that R14 was urinating in the courtyard in view of other residents on 08/02/26. During an interview on 08/18/26 at 1:29 PM, the Social Services Director (SSD) stated no grievance had been initiated regarding R11's complaint about R14. During an interview on 08/18/26 at 2:27 PM, R17 stated R14 urinates in the courtyard and exposes himself to her and other residents. R17 stated the most recent occurrence she was aware of was three days earlier and reported the behavior made her feel embarrassed. During an interview on 08/18/26 at 2:31 PM, R18 confirmed R14 urinates outside and exposes himself to other residents while they are smoking. R18 stated the most recent episode occurred the previous week. During an interview on 08/18/26 at 2:33 PM, R16 stated she observed R14 urinating outside the previous day and exposing himself while other residents were present in the courtyard. R16 stated the behavior bothered her and made her feel violated. During an interview on 08/18/26 at 2:34 PM, R13 confirmed R14 exposes himself in the courtyard when other residents are present. During an interview on 08/18/26 at 2:35 PM, R19 stated R14 urinates outside and exposes himself to other residents. R19 stated, the ladies shouldn't have to see that. During an interview on 08/18/26 at 4:05 PM, Certified Nursing Assistant (CNA)5 confirmed R14 urinates in the courtyard in plain view of other residents and reported she had notified the charge nurse. During an interview on 08/18/26 at 4:06 PM, CNA4 stated she observed R14 urinating in the courtyard a few days earlier and reported R17 and R11 were upset because he exposed himself to them. During an interview on 08/19/26 at 3:51 PM, LPN2 stated R11 told her R14 was urinating in the courtyard in plain view of other residents and his genitals were exposed. LPN2 stated she documented the incident and notified the charge nurse. During an interview on 08/20/26 at 1:45 PM, the DON confirmed a grievance should have been initiated when R11 reported that R14 had exposed himself in the courtyard. Record review of the facility's Grievance Log from 03/05/26 through 08/13/26 revealed no documentation that a grievance had been filed regarding R11's concern about R14's behavior. Review of the facility's policy titled Grievance, dated 10/01/25, revealed grievances may be filed orally or in writing, all grievances are to be entered into the grievance log, investigated, tracked through resolution, and residents are to receive follow-up regarding the disposition of their grievance. The policy further directed staff to notify the Grievance Officer upon receipt of a resident grievance and required efforts toward resolution within seven days.

Based on interview, record review, and policy review, the facility failed to ensure medication administration was documented in a timely manner and in accordance with professional standards of practice and facility policy for one of three residents reviewed for professional standards (Resident (R)13) in a sample of 22 residents. Specifically, multiple medication administration entries were blank during review of the August 2026 Medication Administration Record (MAR) and were subsequently completed days later. The Director of Nursing (DON) confirmed medication administration documentation should be completed in real time. This failure had the potential to obscure the resident's medication administration history and leave the healthcare team without accurate information regarding medication administration.Findings include:Review of R13's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/26 located in the Electronic Medical Record (EMR) under the MDS tab revealed R13 received anticoagulant, antipsychotic, and antianxiety medications.Review of R13's August 2026 Medication Administration Record (MAR) located in the EMR under the Order tab revealed blank medication administration entries for the following medications:Amlodipine besylate on 08/15/26, with no systolic blood pressure documented;Bumex (bumetanide) on 08/15/26;Trazodone HCl on 08/03/26 and 08/16/26;Divalproex Sodium on 08/03/26 at 9:00 PM, 08/15/26 at 6:00 AM, and 08/16/26 at 9:00 PM;Eliquis 5 mg on 08/03/26 at 9:00 PM and 08/16/26 at 9:00 PM; andAlbuterol Sulfate inhalation nebulization solution on 08/03/26 at 10:00 PM, 08/15/26 at 6:00 AM, and 08/16/26 at 10:00 PM.During an interview on 08/19/26 at 10:23 AM, the DON was asked why R13's August 2026 MAR lacked documentation for specific days and shifts for Eliquis, trazodone, amlodipine, and divalproex. The DON reviewed the MAR and confirmed there should have been a corresponding code to indicate why R13 did not receive the medications on 08/03/26, 08/15/26, and 08/16/26. The DON stated R13 may have been in the hospital and she would review the record; however, she stated there still should have been a corresponding code if R13 had been out of the facility. The DON subsequently confirmed, based on review of the nurses' notes in the EMR, that R13 was not in the hospital on those dates.Record review on 08/20/26 of R13's August 2026 MAR revealed the previously blank entries for amlodipine besylate, Bumex, trazodone HCl, Divalproex Sodium, Eliquis, and Albuterol Sulfate had been completed with staff initials.During a follow-up interview on 08/20/26 at 4:22 PM, the DON was asked about the blank entries in R13's August 2026 MAR that were subsequently completed with staff initials, specifically the previously incomplete Divalproex, Eliquis, and trazodone entries. The DON stated the entries were acceptable because [EMR program] allows staff to go back 30 days and add entries. When asked whether it was the facility's practice for nurses to return and complete MAR entries at a later date, the DON stated, No, documentation should be completed in real time.Review of the facility's policy titled Medication Administration, dated 01/26, revealed, .ensure that the six rights of medication administration are followed: . Right documentation . Sign MAR after administration. For those medications requiring vital signs, record vital signs onto the MAR.

Based on interview and record review, the facility failed to ensure family was informed of a change in condition for one resident (Resident (R) 6) of 20 residents reviewed. The facility failed to inform family when R6 developed a stage 3 heel pressure ulcer (full thickness loss of skin). Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R6 was admitted to the facility on [DATE] and was discharged home on [DATE]. R6 had diagnoses that included cancer with metastasis to the bone, and a stroke.Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an assessment reference date (ARD) of 10/24/25 revealed R6 had a Brief Interview of Mental Status (BIMS) score of 13 out of 15 which indicated R6 was cognitively intact.Review of a 10/28/25 Wound Care Note located in the Progress Notes tab of the EMR revealed, Stage 3 pressure ulcer on left heel, measures 5.0 x 5.0 x 0.2 cm [centimeters] had 100% Sanguineous drainage. Wound care physician to see. There was no documentation to show a family member was updated on the newly identified heel ulcer.Review of a 10/28/25 Order Summary located in the Orders tab of the EMR revealed, Cleanse left heel with normal saline, pat dry, apply Medi honey to wound bed and cover with ABD pad [a highly absorbent wound dressing] and kerlix [used to hold the wound dressing in place] daily and PRN [as needed].During an interview on 01/12/26 at 12:59 PM, Family Member (FM) 1 was asked if he was notified of R6's newly identified heel ulcer. FM1 stated, I was not notified of any wound.During an interview on 01/12/26 at 2:34 PM, Registered Nurse (RN) 1 was asked if she notified R6's family when the heel wound was identified. RN1 stated, R6 was his own person, and he did not specify who or if he wanted family notified of the wound. He had just three emergency contacts and no resident representative. RN1 was asked if she had documented in the EMR that R6 was asked and he declined to have family updated. RN1 acknowledged that the documentation was not in the EMR.Review of the facility policy titled, Notification of Change in Condition, dated 10/06/23 revealed, .Competent individuals .The facility must still contact the resident's physician and notify resident's representative, if known .A family that wishes to be informed would designate a member to receive calls .When a resident is mentally competent, such [sic] a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally .

Based on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R3) of 3 residents reviewed for falls.R3 has a history of falls and is assessed to be at a high risk for falls. R3 has an active care plan intervention for Dycem (a versatile, non-slip material used for various applications, including wheelchair use) to be in place in R3's wheelchair to prevent falling. On 8/30/25, R3 slid out of R1's wheelchair and fell on the floor. R3 did not have Dycem in R3's wheelchair at the time of the fall. Findings include:The facility policy dated 1/30/23 and titled, Accidents/Fall Prevention Program, documents, in part: The facility strives to promote safety, dignity, and overall quality of life for its residents by providing an environment that is free from any hazards for which the facility has control and by providing appropriate supervision and interventions to prevent avoidable accidents. An immediate/initial care plan for fall risk will be developed for any newly admitted residents whose assessment indicated the resident was at greater risk for falls/accidents. This plan of care is communicated to all appropriate staff. Each incident/accident or fall must be investigated and/or assessed using a root cause analysis process to determine the cause of the episode to prevent any further injury. A resident's individual care plan is to be updated with any changes or new interventions post fall, incident, and accident, communicated to appropriate staff and implemented.R3 was admitted to the facility on [DATE] with diagnoses that include Severe vascular dementia with mood disturbance, Type 2 Diabetes, and Generalized Osteoarthritis.R3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents that R3 is severely cognitively impaired. R3 requires partial/moderate assist for hygiene and transfers. R3 has had 2 falls without injury since the last MDS assessment. R3's Annual Fall Care Area assessment dated [DATE] documents, in part: The resident has an [Activity of Daily Living (ADL)] self-care performance deficit [with] risk for falls. [related to] activity intolerance, musculoskeletal impairment [with] associated pain limiting mobility, respiratory failure, cognitive impairment, presence of intermittent incontinence of bladder.R3's fall risk assessment dated [DATE] documents a score of 15, indicating R3 has a high risk of falls.R3's fall risk care plan initiated 10/17/2024 documents the following pertinent interventions: Encourage the resident to use bell to call for assistance (initiated 1/29/25). Dycem in wheelchair (initiated 7/14/25), Grip strips on left side to left side of the bed (initiated 10/28/23). Pommel cushion added to [wheelchair] for pelvic alignment (initiated 6/23/23). Keep commonly used items within reach (initiated 1/5/25).R3's Certified Nursing Assistant (CNA) Kardex documents, in part: Dycem in wheelchair.R3's progress note entered by Licensed Practical Nurse (LPN)-H dated 8/30/25 at 5:30 PM, documents, in part: Writer notified [R3] had [unwitnessed fall] was found on bilateral buttocks. Fall appears to result from new [wheelchair] cushion which caused [R3] to slide out [wheelchair]. Neuro [checks] initiated. No presenting [signs/symptoms] impairment or changes to baseline [ADL] functions/mental status.On 9/3/25 at 1:04 PM, Surveyor attempted to reach LPN-H by telephone. Surveyor left a voicemail message but was unable to interview LPN-H.On 9/3/25 at 10:30 AM, Surveyor requested the facility's fall investigation into R3's fall on 8/30/25.R3's Interdisciplinary (IDT) note created on 9/3/25 at 10:51 AM and an effective date of 9/2/25 at 3:30 PM, documents, in part: IDT met to review unwitnessed fall that occurred on 8/30/2025 at approximately [5:30 PM]. Staff found resident on the floor seated on bilateral buttocks near [R3's] wheelchair. No injuries identified. [R3] has a history of self-transferring without asking for assistance [related to] impaired cognition and memory. Fall appears related to absence of Dycem in wheelchair at the time of incident, allowing resident to slide from the seat. Staff were re-educated on following Kardex interventions, specifically ensuring Dycem placement to reduce risk of slipping. Care plan reviewed and updated to reflect interventions for continued fall prevention.Surveyor noted that R3's IDT note was created on 9/3 at 10:51 AM, after Surveyor asked for R3's fall investigation.R3's facility fall investigation dated 8/30/25 documents, in part: R3 was wearing shoes at the time of the fall. R3 was assisted to the bathroom at 5 PM, 30 minutes before the fall. R3 was seen sitting in R3's wheelchair just prior to R3's fall. R3's fall risk care plan documents the following intervention with a creation date of 9/3/25 and an initiation date of 9/2/25: Educate staff on following Kardex and interventions.Included in the fall investigation is a CNA Education Note dated 9/3/25. Surveyor noted there is not a time documented on the CNA Education Note. The note documents, in part: Topic-Following resident care plans-fall prevention interventions. Date-9/3/25. Staff Educated- CNA-G. Education provided- Reviewed importance of following the individualized resident care plan at all times. Discussed the resident's risk of falls related to impaired cognition and history of self-transferring. Reinforced need to check wheelchair setup each shift, including cushion, Dycem, and bed height if transferring. Reviewed prompt reporting to nurse if care plan interventions cannot be followed or if equipment is missing/needs replacement. Included in the Education note was a Signature of staff receiving education. Documented in the space is: Over the phone. Signature of Educator. Documented in the space is [Registered Nurse (RN), Unit Manager (UM)-D]. The signature section was dated 9/3/25.Surveyor noted that the education was completed on 9/3/25 which was a day later than the documented IDT note and fall intervention which the facility documented was initiated on 9/2/25. Surveyor noted the education was completed after the Survey had started. Surveyor noted that no other CNAs were educated in relation to this investigation.On 9/3/25 at 1:15 PM, Surveyor interviewed UM-D, who investigated R3's fall on 8/30/25. UM-D stated that through investigation, UM-D found that R3 had the correct Pommel cushion on the wheelchair at the time of the fall, but Dycem was not under the cushion to prevent R3 from falling. UM-D stated that UM-D was aware that LPN-H documented that it was a new cushion but again stated that it was not a new cushion and that it was the correct cushion used. UM-D stated that the root cause of the fall was due to the missing Dycem on R3's wheelchair. UM-D stated that the primary CNA working with R3 at the time of the fall was CNA-G. UM-D confirmed that UM-D completed education with CNA-G today before CNA-G's scheduled PM shift. UM-D indicated that if R3's CNA Kardex would have been followed the fall could have been avoided, that is why education was completed. UM-D stated that CNAs are to check at the beginning of every shift to assure that resident's interventions are in place. On 9/3/25 at 2:23 PM, Surveyor interviewed CNA-G. Surveyor asked where to find fall interventions for residents. CNA-G stated that they are listed on the Kardex. Surveyor asked when CNAs check to make sure that interventions listed are in place. CNA-G stated that CNA-G is supposed to make sure interventions are in place at the beginning of each shift. Surveyor asked what happened on 8/30/25 when R3 fell. CNA-G stated that CNA-G was working to pass dinner trays. CNA-G stated that CNA-G had just been in R3's room to make sure R3 had everything needed for R3's dinner tray. CNA-G left the room and was passing other resident's trays when CNA-G heard R3 yelling for staff. CNA-G found R3 sitting on the floor in R3's room. Surveyor asked if R3's wheelchair was checked at the beginning of R3's shift. CNA-G stated that it is supposed to be checked. CNA-G stated that R3 can be difficult because R3 will put things in R3's wheelchair and will mess up R3's room and R3 can get very confused. Surveyor asked what CNA-G believed the cause of the fall was. CNA-G stated that R3's correct wheelchair cushion was on R3's wheelchair but the Dycem was not on the wheelchair.On 9/3/25 at 2:28 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the concern that R3 has a history of falls, and it is at high risk for falls. R3 has an active fall intervention for Dycem to be on R3's wheelchair. On 8/30/25, R3 fell out of R3's wheelchair when Dycem was not on R3's wheelchair. NHA-A acknowledged the concern. No further information was provided.

Based on observation, record review, and interview the facility did not ensure that food was stored, prepared and served under sanitary conditions in 1 of 1 kitchens.* On 7/22/25 , Surveyor observed Cook-D not wearing a facial hair restraint that completely covered his hair from contacting exposed food while pureeing a lunch item.* On 7/22/25, Surveyor observed Dietary Aide- E handling exposed foods without all of his hair under the hair restraint. Cook- D did not have his facial hair restrained while handling exposed foods preparing the lunch meal trays.* On 7/22/25, Surveyor observed Cook- D not clean the thermometer probe between different foods as Cook-D took the temperature of several food items.These deficient practices have the potential to affect 90 of 90 residents who reside in the facility at the time of survey and who receive their meals from the main kitchen. All of the food for the facility is stored, prepared and served from the main kitchen.Findings include:The facility's policy with no date titled, Employ Sanitary Practices documents under the Policy section: All food and nutrition services employees will practice good personal hygiene and safe food handling procedures.Under the Procedures section it documents:1.) Wear hair restraints ( hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food. 2.) Wash hands before handling food, using posted hand-washing procedures.On 7/22/25 at 10:55 AM, Surveyor observed [NAME] -D prepare puree cornbread for the lunch meal. Cook- D was observed to have a surgical mask that sat below on his chin, leaving his mustache hair exposed and not restrained. Cook-D's mustache was exposed for the entire observation while Cook-D made purred cornbread. On 7/22/25 at 11:25 AM, Surveyor observed Cook-D take temperatures of the prepared food for the lunch meal. Cook-D remained with his mustache hair exposed to the foods and not restrained. Cook-D was also observed to not clean the thermometer probe between each different type of food on the steam table. On 7/22/25 at 11:28 AM, Surveyor observed Dietary Aide- E assisting with plating ready to eat foods on lunch meal trays that were being served to residents. Surveyor observed Dietary Aide-E to have hair that rested just above his shoulders. Dietary Aide- E was observed to not have all of his hair underneath the hair restraint while plating ready to eat foods. Surveyor noted that Cook- D was also assisting to plate ready to eat foods while Cook-D had his mustache hair exposed. During this observation, Dietary Manager- C asked Surveyor how the observation was going. Surveyor stated that both Dietary Aide- E and Cook- D did not have their hair properly restrained while working with exposed foods. Dietary Manager- C stated that he also observed that but did not want to call the staff out in front of the Surveyor.On 7/23/25 at 2:05 PM, Surveyor interviewed Dietary Manger-C regarding sanitary practices in the kitchen. Dietary Manager- C stated that all hair must be tucked underneath the hair restraints and that beard nets are also to be used to restrain all facial hair, including mustache hair. On 7/24/25, during the daily exit meeting, Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. Surveyor requested any additional information. No additional information was provided as to why dietary staff did not always prepare and serve food under sanitary conditions.

Based upon interview and record review, the facility did not ensure the mandatory staffing data, submitted for the second quarter of 2025 (January 1- March 31) was accurate, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid Services). During review of the payroll-based-journal (PBJ) staffing data for the facility, the facility was triggered for excessively low weekend staffing. This had the potential to affect all 90 residents. Findings include: The facility's assessment dated [DATE] was reviewed, including staffing hours and acuity levels of care being provided. The facility's assessment documented staffing needs in the facility and triggered for low weekend staffing for the second quarter of 2025 Surveyor reviewed nursing schedules, along with the nurse staff posting hours and noted that there were no documented trends or gaps in weekend staff coverage. On 7/23/2025, at 9:09 AM, Surveyor interviewed Scheduler-J, and reviewed the nurse schedules, during this interview. Scheduler-J stated they have been in this role for about 7 months and that the facility does not use agency staff and have a lot of log-term staff to fill any absences. Scheduler-J stated they over staff on weekends for call-ins and that the facility had no staffing concerns as the facility has a consistent number of staff nurses working at the facility. On 7/23/2025, at 10:37 AM, Surveyor interviewed Director of Recruitment (DOR)-H via phone. DOR-H submits the PBJ staffing reports to CMS for the facility. DOR-H stated they pull from the timecards from the period and they input staff time into the computer system. DOR-H stated that the system will alert you for staffing concerns and if there is, an alerts will come up, and that DOR-G will notify the Nursing Home Administrator (NHA)-A of the alert. DOR-H informed Surveyor that there was an alert that came up from the software that you're at the bottom 20th percentile for staffing and that this alert came up for all of the company's facilities. DOR-H informed Surveyor that DOR-H did not investigate further what caused the alert for all of the company's facilities. DOR-H stated that the facility hasn't changed staffing patterns and did not understand why this was triggered. On 7/23/2025, at 1:16 PM, Surveyor interviewed NHA-A regarding any PBJ alerts. NHA-A informed Surveyor that NHA-A was not aware of any staffing alerts and was not aware of having low staffing on the weekends. No additional information was provided as to why the facility did not ensure that mandatory staffing data, submitted for the second quarter of 2025 (January 1- March 31) was accurate, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS.

Based on interview and record review, the facility did not ensure admission and annual comprehensive Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 6 (R35, R10, R75, R79, R87, and R34) of 8 residents reviewed for late MDS assessments.*R35's admission MDS assessment dated [DATE] was completed after the specified timeframe.*R10's Annual MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/21/2025.*R75's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/21/2025.*R79's admission MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/21/2025.*R87's admission MDS assessment dated [DATE] was completed after the specified timeframe.*R34's Annual MDS assessment dated [DATE] was in progress and had not been completed at the time of survey, 7/21/2025.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: The admission assessment is a comprehensive assessment for a new resident . that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA or an SCPA has been completed since the most recent comprehensive assessment was completed. The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date) (ARD + 14 calendar days). This date may be earlier than or the same as the CAA(s) (Care Area Assessment) completion date, but not later than. The CAA(s) completion date (item V0200B2) must be no later than 14 days after the ARD (ARD + 14 calendar days). This date may be the same as the MDS completion date, but not earlier than.1.)R35 was admitted to the facility on [DATE]. Per the RAI Manual, R35's admission MDS assessment must be completed by 6/27/2025. R35's admission MDS assessment was completed on 7/21/2025, 24 days after it was due to be completed.2.)R10's Annual MDS assessment dated [DATE], per the RAI Manual, must be completed by 7/4/2025. On 7/21/2025, R10's Annual MDS assessment was In Progress and not completed.3.)R75 was admitted to the facility on [DATE]. Per the RAI Manual, R75's admission MDS assessment must be completed by 7/4/2025. On 7/21/2025, R75's admission MDS assessment was In Progress and not completed.4.)R79 was admitted to the facility on [DATE]. Per the RAI Manual, R79's admission MDS assessment must be completed by 7/10/2025. On 7/21/2025, R79's admission MDS assessment was In Progress and not completed.5.)R87 was admitted to the facility on [DATE]. Per the RAI Manual, R87's admission MDS assessment and CAAs must be completed by 6/24/2025. R87's admission MDS assessment was completed on 7/11/2025, 17 days after it was due to be completed, and the CAAs were completed on 7/18, 24 days after it was due to be completed.6.)R34's Annual MDS assessment dated [DATE], per the RAI Manual, must be completed by 7/8/2025. On 7/21/2025, R10's Annual MDS assessment was In Progress and not completed.On 7/23/2025 at 8:24 AM, Surveyor asked Licensed Practical Nurse (LPN)-K how many MDS nurses were employed at the facility. LPN-K stated LPN-K works full time and another LPN works part time as MDS nurses. LPN-K stated LPN-K had been out of the facility on medical leave for three months and returned to work full time on 6/30/2025. Surveyor asked LPN-K if there was anyone covering LPN-K's workload while LPN-K was gone. LPN-K stated a couple MDS coordinators from sister facilities assisted with MDS assessments but was not sure of the extent of coverage. Surveyor shared with LPN-K the concerns R35, R10, R75, R79, R87, and R34 had late comprehensive assessments. LPN-K was aware of the late assessments and agreed they were behind schedule.On 7/23/2025 at 10:26 AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concerns with resident comprehensive MDS assessments not being completed timely. NHA-A stated LPN-K made NHA-A aware of the concern and agreed staffing of the MDS coordinators was difficult for a period of time making assessments late.No additional information was provided.

Based on interview and record review, the facility did not ensure admission, quarterly, and discharge Minimum Data Set (MDS) assessments were completed and transmitted in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 5 (R102, R35, R79, R87, and R69) of 8 residents reviewed for late MDS assessments.*R102's Discharge Return Anticipated MDS assessment dated [DATE] was not completed or transmitted by the specified timeframe.*R35's admission MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R79's Discharge Return Anticipated MDS assessment dated [DATE] and R79's Entry tracking record dated 7/11/2025 were not completed or transmitted by the specified timeframe.*R87's admission MDS assessment dated [DATE] was not transmitted by the specified timeframe.*R69's Quarterly MDS assessment dated [DATE] was not transmitted by the specified timeframe.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . The MDS completion date (item Z0500B) must be no later than day 14. This date may be earlier than or the same as the CAA(s) (Care Area Assessments) completion date, but not later than. The CAA(s) completion date (item V0200B2) must be no later than day 14. The care plan completion date (item V0200C2) must be no later than 7 calendar days after the CAA(s) completion date (item V0200B2) (CAA(s) completion date + 7 calendar days). Transmission Date No Later Than: Care Plan Completion Date + 14 calendar days. (The Quarterly assessment) MDS must be transmitted (submitted and accepted) electronically no later than 14 calendar days after the MDS completion date (Z0500B + 14 calendar days). The Entry tracking record is the first item set completed for all residents. Must be completed within 7 days after the admission/reentry. Must be submitted no later than the 14th calendar day after the entry (entry date (A1600) + 14 calendar days). OBRA Discharge assessments consist of discharge return anticipated and discharge return not anticipated. Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days). Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days).In an interview on 7/23/2025 at 8:24 AM, Surveyor asked Licensed Practical Nurse (LPN)-K how many MDS nurses were employed at the facility. LPN-K stated LPN-K works full time and another LPN works part time. LPN-K stated LPN-K had been out of the facility on medical leave for three months and returned to work full time on 6/30/2025. Surveyor asked LPN-K if there was anyone covering LPN-K's workload while LPN-K was gone. LPN-K stated a couple MDS coordinators from sister facilities assisted with MDS assessments but was not sure of the extent of coverage. Surveyor shared with LPN-K the concerns R102, R35, R79, R87, and R69 had entry tracking records, discharge assessments, quarterly assessments, and admission assessments that had not been transmitted in the timeframe allotted. LPN-K was aware of the late assessments and agreed they were behind schedule.1.) R102 was discharged from the facility on 5/23/2025. Per the RAI Manual, R102's Discharge Return Anticipated MDS assessment must be completed by 6/6/2025 and transmitted by 6/20/2025. R102's Discharge Return Anticipated MDS assessment was completed on 6/20/2025, 14 days late, and transmitted on 6/27/2025, 7 days late.2.) R35 was admitted to the facility on [DATE]. Per the RAI Manual, R35's admission MDS assessment must be transmitted by 7/18/2025. R35's admission MDS assessment had not been transmitted at the time of survey, 7/21/2025.3.) R79 was discharged from the facility on 7/8/2025. Per the RAI Manual, R79's Discharge Return Anticipated MDS assessment must be completed by 7/10/2025. On 7/21/2025, R79's Discharge Return Anticipated MDS assessment was In Progress and not completed.R79 was readmitted to the facility on [DATE]. Per the RAI Manual, R79's Entry Tracking Record must be completed by 7/18/2025. On 7/21/2025, R79's Entry Tracking Record was In Progress and not completed.4.) R87 was admitted to the facility on [DATE]. The facility combined R87's admission MDS assessment with R87's Discharge Return Anticipated MDS assessment. Per the RAI Manual, R87's admission MDS assessment and Discharge Return Anticipated MDS assessment must be transmitted by 7/15/2025. On 7/21/2025, R87's admission MDS assessment and Discharge Return Anticipated MDS assessment had not been transmitted at the time of survey.5.) R69's Quarterly MDS assessment dated [DATE], per the RAI Manual, must be transmitted by 7/16/2025. On 7/21/2025, R69's Quarterly MDS assessment had not been transmitted at the time of survey.On 7/23/2025 at 10:26 AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concerns with resident MDS assessments not being completed and transmitted timely. NHA-A stated LPN-K made NHA-A aware of the concern and agreed staffing of the MDS coordinators was difficult for a period of time making assessments and transmissions late.No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 4 of 4 ( R15, R49, R58, R106) residents residing at the facility whom receive a puree diet.*Cook-D was observed not following a recipe for preparing texture and modified consistency food for puree diets. Findings include:The facility's undated policy titled, Standardized Recipes documents under the Policy section: Standardized recipes will be used when preparing menu items.Under the Procedure section it documents: 1.) Standardized recipes ( in appropriate portion sizes) for each set of cycle menus will be maintained in the facility.2.) The director of dining services or designee will be responsible for adjusting and recording the recipes for the needed yield.3.) Cooks/chefs are expected to use and follow the recipes provided.On 7/22/25 at 10:55 AM, Surveyor observed [NAME] -D prepare pureed cornbread for the lunch meal. Cook- D stated that there are currently 5 residents who receive puree meals ( facility list provided had 4 residents listed). Surveyor observed Cook- D place several pieces of cooked cornbread into a commercial blender and then pour a small amount (not measured) of whole milk from a milk carton into the blender. Cook- C then closed the blender and activated the blender for approximately 10 seconds. The top of the blender was removed and then Cook- D poured thickening powder (unmeasured) into the blender. Surveyor asked if he was following a recipe or how Cook-D knew when the food is the correct puree consistency. Cook-D stated that he is looking for a certain consistency, but he was unable to indicate what that consistency would be like( i.e. pudding like). Cook-D showed Surveyor the contents of the blender and Surveyor noted that the puree food in the blender had a consistency that was thinner than pudding. Cook-D then emptied the pureed corn bread into a holding metal container, scrapped the sides of the blade for the remaining cornbread into the container and moved onto the next task.On 7/23/25 at 2:05 AM, Surveyor interviewed DM (Dietary Manager)- C regarding the process for pureeing foods. DM-C stated that there is a recipe for each food item that is to be pureed before the meal service. Surveyor shared the observation of Cook-D not following a recipe when pureeing the cornbread for the lunch meal on 7/22/25. DM-C stated that Cook-D should have followed the recipe to ensure that the right texture is achieved for puree.On 7/24/25, during the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A of the above findings. No additional information was provided as to why Cook- D did not follow the recipe for the lunch item on 7/22/25 to ensure the appropriate texture for pureed meal.

Based on observation, interviews, and record review the facility did not address and resolve grievances conveyed on behalf of 1 (R7) of 1 resident reviewed for grievances. * On 7/21/2025, Surveyor interviewed R7, regarding grievances that were reported to staff. R7 indicated reporting concerns with portion sizes of meals to R7's caring partner. R7's meal ticket didn't show double portions. R7 voiced concerns about getting double portions with every meal. Findings include:The facility's policy, titled Resident and Family Grievances, with implemented date of 3/4/2025 documents: Policy Explanation and Compliance Guidelines: .10. Procedure:a. This facility will not retaliate or discriminate against anyone who files a grievance or participates in the investigation of the grievance.b. Staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form.c. Forward the grievance form to the grievance official as soon as practicable.R7 was admitted to the facility on [DATE] with diagnoses that include intertrochanteric fracture of left femur, chronic obstructive pulmonary disease, type II diabetes malleolus, chronic systolic congestive heart failure, hyperglycemia, presence of automatic cardiac defibrillator.R7's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 15, indicating R7 is cognitively intact. The MDS documents R7's eating as, setup or clean-up assistance, Helper sets and cleans up, and then resident completes activity.R7's (nutritional) care plan, dated 5/7/2025, with a target date of 8/22/2025, under the intervention section it is documented as: Provide, serve diet as ordered. Surveyor could not locate any documentation of double portions in the care plan. On 7/21/2025, at 2:21 PM, Surveyor interviewed R7, who indicated that concerns were not being addressed and resolved with reporting. R7 stated giving complaints to R7's caring partner, this was Certified Nursing Assistant (CNA) Scheduler-J. A Caring Partner is a program at the facility that involves all residents to have an employee in management to report concerns to. R7 stated that the resolution was to have double portions with meals, R7 stated this doesn't happen with all meals. On 7/22/2025, at 8:32 AM, Surveyor observed R7's meal size and ticket. R7 stated that R7 will have to call down to kitchen to ask for a larger portion. Surveyor observed the meal ticket for breakfast and no size or preferences were documented on R7's meal ticket. Surveyor reviewed the grievance log from April 2025 to current. There were no documented grievances for R7.On 7/23/2025, at 9:52 AM, Surveyor interviewed CNA Scheduler-J, who stated that there was a concern from R7 related to portion size. CNA Scheduler-J stated there is a form to be filled out regarding concerns or grievances. CNA-Scheduler-J indicated that the form would be turned into the social worker upon completion. CNA Scheduler-J indicated that a form would only be fill out if the concern was something serious. CNA Scheduler-J stated that R7's meal size concern was addressed with Dietary Manager-C when reported a month ago. CNA Scheduler-C indicated that a form didn't need to be filled out for this concern as it was addressed verbally.On 7/23/2025, at 10:32 AM, Surveyor interviewed Dietary Manager (DM)-C, who stated DM-C remembers addressing the concern of portion size from R7 and that it was addressed with double portions. DM-C indicated that the concern was reported to him verbally and addressed verbally after, no documentation of R7's concern. DM-C stated the meal ticket should show R7's preferences on them, and that double portions was missed with R7's meal tickets, but that DM-C will be adding it to the tickets right away.On 7/23/2025, at 10:09 AM, Surveyor interviewed Social Services Director (SSD)-I, who stated that with any concern, a grievance form needs to be filled out. SSD-I stated that SSD-I wasn't aware of any concerns from R7. SSD-I stated that SSD-I will be following up with R7 today to address any concerns. On 7/24/2025, at 7:40 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated CNA Scheduler-J is a newer employee, to not only this company but also long-term care. DON-B indicated that CNA Scheduler-J, didn't know how to address the concern as a caring partner as CNA Scheduler-J is a newer employee. On 7/24/2025, at 8:24 AM, Surveyor informed Nursing Home Administrator (NHA)-A, of the concern with R7's grievances being addressed. Surveyor informed NHA-A that R7's caring partner didn't report grievances to social services or fill out a grievance form. NHA-A indicated that training would occur with CNA Scheduler-J on how to handle grievances. NHA-A indicated an understanding of the concern mentioned above.No additional information received as to why R7's grievance for double portions were not documented and addressed and or resolved.

Based on interview and record review, the facility did not ensure quarterly Minimum Data Set (MDS) assessments were completed in the timeframe prescribed in the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual for 1 (R69) of 8 residents reviewed for late MDS assessments.* R69's Quarterly MDS assessment dated [DATE] was completed after the specified timeframe.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual dated 10/2024 documents: The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (Assessment Reference Date) (ARD + 14 calendar days).R69's Quarterly MDS assessment dated [DATE], per the RAI Manual, must be completed by 7/2/2025. R69's Quarterly MDS assessment was completed on 7/22/2025, 20 days after it was due to be completed.In an interview on 7/23/2025 at 8:24 AM, Surveyor asked Licensed Practical Nurse (LPN)-K how many MDS nurses were employed at the facility. LPN-K stated LPN-K works full time and another LPN works part time. LPN-K stated LPN-K had been out of the facility on medical leave for three months and returned to work full time on 6/30/2025. Surveyor asked LPN-K if there was anyone covering LPN-K's workload while LPN-K was gone. LPN-K stated a couple MDS coordinators from sister facilities assisted with MDS assessments but was not sure of the extent of coverage. Surveyor shared with LPN-K the concern R69 had a late quarterly assessment. LPN-K was aware of the late assessment and agreed it was behind schedule.On 7/23/2025 at 10:26 AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R69's Quarterly MDS assessment was not completed timely. NHA-A stated LPN-K made NHA-A aware of the concern and agreed staffing of the MDS coordinators was difficult for a period of time making assessments late.No additional information was provided.

Based on interview and record review the facility did not revise care plans or complete a care conference for 2 (R61, R9) of 18 residents care plans that were reviewed. *R61 did not have hearing or depression focus areas added to R6's initial care plans. R61’s comprehensive care plan was not completed timely after admission to the facility. *R9 did not have a care conference after the MDS assessment 6/2025. Findings include: The facility's policy, titled Comprehensive Care Plans, with implemented date of 3/25/2025 documents: “Policy Explanation and Compliance Guidelines: …1. The care planning process will include an assessment of the resident’s strengths and needs and will incorporate the resident’s personal cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent in trauma-informed care as indicated.2. The Comprehensive Care plan will be developed within 7 days after the completion of the comprehensive MDS assessment. …3. Comprehensive Care plan will describe, at a minimum, the following: a. The services that are to be furnished to obtain or maintain a resident’s highest practicable physical, mental, and psychosocial well-being.” 1.) R61 was admitted to the facility on [DATE] and has diagnoses that include pneumonia, acute respiratory failure, hypertension, dysphasia, depression and anxiety. R61's discharge Minimum Data Set (MDS), dated [DATE], documents a Brief Interview of Mental Status (BIMS) of 11, indicating R61 is cognitively intact. The MDS started on 6/13/2025, was not completed and surveyor could not locate a completed BIMS score, or comprehensive care plan. R61's PHQ9 (PHQ-9 (Patient Health Questionnaire-9 that objectifies and assesses degree of depression severity via questionnaire) documented a score of 10, indicating moderate depression. Surveyor noted that at the time of the assessment, a referral for psychiatric services for R61. Surveyor noted that despite the facility completing R61's PHQ9 assessment for depression, an initial care plan with a focus on depression was not developed or implemented for R61. R61's care plan initiated on 6/13/2025, did not have a focus area for hearing deficit or depression. The initial care plan was started, and no revisions were made for the comprehensive days until 40 days post admission. On 7/21/2025, at 10:39 AM, Surveyor observed a sign posted on R61’s back wall, in R61’s personal room. This sign documented to speak up, as resident is hard of hearing. R61 stated having 1 hearing aid, that is at home, and not at the facility. R61’s stated that family will be bringing it in, but currently R61’s family is in bad health, and can’t bring it to the facility. R61 indicated not being able to give a time frame of when family will be able to bring in the hearing aid. On 7/23/2025, at 10:25 AM, Surveyor interviewed Social Services Director (SSD)-I, who informed surveyor that the floor nurse would start the initial care plan for residents. SSD-I stated not knowing about the hearing deficit and will be following up on this with R61. SSD-I stated the admitting nurse would be expected to add the focus areas (hearing and depression) to the care plan. Surveyor asked about the depression care plan and if SSD-I would address the care plan for depression. SSD-I stated that SSD-I wouldn’t add information until after the initial psych visit. On 7/23/2025, at 10:37 AM, Surveyor interviewed SSD-I, who indicated that SSD-I will be adding all focus areas to the care plan and that the floor nurses should be addressing depression, hearing and refusals on the initial care plan. SSD-I stated that the MDS not being completed timely caused the initial care plan to also be late. On 7/23/2025, at 1:24 PM, Surveyor interviewed Unit Manager (UM)-F, who stated that nurses on the floor can update and start the care plan, and then after that the Unit managers will go through the care plan and check for accuracy. UM-F indicated not being the unit manager that reviewed R61’s admission and believes UM-F was on vacation when R61 was admitted . UM-F indicated the whole nursing team knows how to enter focus areas into the care plan and they would all be aware of what areas should be in the care plan. The following focus area care plan was initiated on 7/23/2025: -Communication deficit related to hearing loss-R61 has a mood problem related to diagnosis of anxiety and depression. Surveyor noted that the focus areas were added to R61’s care plan after Surveyor informed the facility that R61 did not have these focus areas in the current care plan. On 7/24/2025, at 7:49 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated that DON-B would expect the floor nurse to complete the initial care plan with all concerns, like hearing and depression. DON-B indicated that the unit managers would go through and clean up and add more information if needed to the care plan. Surveyor informed DON-B that Unit Manager-F indicated being on vacation at the time R61 was admitted and didn’t do this for R61. DON-B indicated that the nursing staff had monitoring for behaviors in place, and we were doing all the interventions as we should, it just didn't make it into the care plan. On 7/24/2025, at 8:24 AM, Surveyor informed Nursing Home Administrator (NHA)-A of concern with R61’s care plan, focus areas that did not include hearing and depression. Surveyor also informed NHA-A of comprehensive care plan being late. NHA-A indicated that this is a concern and NHA-A indicated that she will be talking with nursing staff to ensure that care plans are updated and accurate. No additional information was provided as to why R61's care plans were initiated and updated to include R61's depression and hearing deficit. 2.) R9 was admitted to the facility on [DATE] with diagnoses chronic obstructive pulmonary disease, asthma, morbid obesity, diabetes, congestive heart failure, bipolar disorder, anxiety, depression, panic disorder, and post-traumatic stress disorder. R9’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R9 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. On 7/21/2025 at 10:32 AM, Surveyor observed R9 in bed in R9’s room. Surveyor asked R9 if R9 participated in Care Plan meetings or Care Conferences. R9 was not sure what Care Conferences were. Surveyor shared with R9 meetings should be held every three months to discuss R9’s preferences and goals so a personalized Care Plan could be either developed or revised and the meetings usually consisted of nursing staff, social services, dietary, and any other disciplines pertinent to the resident’s care. R9 was not aware of any meetings and stated R9 would like to have a meeting. On 3/18/2025 at 3:01 PM in the progress notes, a social worker documented an annual Care Conference was held with R9, the social worker, the nursing unit manager, and R9’s Case Manager and Registered Nurse from the managed care service. No documentation of a care conference was found after 3/18/2025. In an interview on 7/23/2025 at 8:57 AM, Surveyor asked Social Services Director (SSD)-I how often care conferences are held for residents. SSD-I stated for long term care residents care conferences are offered quarterly. Surveyor asked SSD-I when was the last time R9 had a care conference. SSD-I stated R9 had been in and out of the hospital in June, 2025 so that last care conference was March, 2025. SSD-I stated SSD-I met with R9 at the beginning of July 2025 so needs to schedule a care conference. Surveyor asked when care conferences should be scheduled. SSD-I stated they follow the MDS assessment schedule. Surveyor noted R9 had a Quarterly MDS assessment completed 6/7/2025 and had been in the facility from 6/3/2025-6/23/2025 with no care conference scheduled. On 7/23/2025 at 9:04 AM in the progress notes, SSD-I documented SSD-I reached out to R9’s case management team to schedule a quarterly care conference. Surveyor noted this was done after Surveyor’s conversation with SSD-I. On 7/23/2025 at 3:03 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R9 did not have a care conference since 3/18/2025 and R9 would like to attend a care conference meeting. Surveyor shared with NHA-A and DON-B the conversation with SSD-I and the progress notes in R9’s medical record that a care conference will be scheduled. No additional information was provided.

Based on observations, document review, interviews, and facility policy review, the facility failed to ensure proper dishwasher temperature and sanitizer levels, failed to thaw liquid eggs in a safe manner; failed to ensure food in the refrigerator and dry storage was labeled, dated, and not past the use by date; failed to ensure food on the steam table was held at a safe temperature level; and failed to ensure utensils and dishes were clean in one of one kitchen and one of one rehabilitation unit. This had the potential to result in the spread of infections and food born illness for 86 of the 87 residents consuming food in the facility. Findings include: Review of the undated facility's policy titled, Sanitation of Dishes/Dish Machine revealed the low temperature dish machine should have a water temperature of 120 degrees F [Fahrenheit] and the sanitizer level should be 50 PPM [parts per million]. Review of the safe thawing Practice section of the undated facility's policy titled, General HACCP [Hazard Analysis Critical Control Point] Guidelines for Food Safety revealed food could be thawed out by completely submerging the item in clean running water that was running fast enough to agitate and float particles off. Review of the undated facility's policy titled, Food Safety and Sanitation under food storage, revealed all refrigerated foods should be labeled, covered, and dated when stored. Perishable food should be used prior to the use by date on the package. Review of the facility's undated policy titled, General HACCP Guidelines for food safety revealed hot foods should be held at 135 degrees F or greater. 1. During an observation and interview on 05/08/25 at 8:53 AM, Dietary Aide (DA) 2 and DA1 were observed washing the breakfast dishes in the low temperature dishwasher. The chlorine sanitizer level of the rinse cycle was checked using the chlorine test strips. The strip did not change color, indicating the sanitizer level was zero PPM. According to the gauge on the bottom front of the dishwasher the water temperature was 105 degrees F. DA1 verified the sanitizer was zero PPM. After verifying it, she continued to run the soiled dishes through the dishwasher without making any adjustments or informing anyone. She stated she did not know how to check the dish washer sanitizer because she had never been trained. DA2 continued removing the dishes from the clean end of the dishwasher and putting them away in the kitchen. During an observation and interview on 05/08/25 at 9:04 AM, the sanitizer level and temperature of the water was checked again with the assistance of the Certified Dietary Manager (CDM). The sanitizer again measured zero PPM, and the water was 105 degrees F. A sign on the front of the dishwasher stated if the water was colder than 120 F or hotter than 140 F to contact maintenance. Review of the Dish Machine Log- Low Temp located on a clip board on the top of the dish washer indicated the water temperature and the sanitizer level had not been checked the evening prior nor the morning of 05/08/25. The log contained blanks for supper for all days in May and all the areas were blank for 05/03/25 and 05/04/25. On 05/08/25 at 9:24 AM the staff continued to run the dishes through the dishwasher and put them away. At that time, the CDM was queried about the dishwasher and verified the staff were continuing to use the dishwasher after they became aware it was not sanitizing the dishes. Review of the document titled, Customer Service Report, dated 05/08/25, revealed the technician came out to check the dish machine and found worn out squeeze tubes on the sanitizer and rinse agent and wrote maintenance turned up the water temperature. The technician wrote that the dish machine was fully functional at this time. 2. During an observation and interview on 05/08/25 at 8:53 AM, a five-gallon plastic container full of water and containing three one-gallon bags of eggs was sitting in the sink across and to the side of the food service area. Water was not running into the container of water, and the eggs were sitting in the water. Cook1 stated he placed the frozen bags of eggs in the water to thaw out between 7:15 AM and 7:30 AM. He stated he thawed too many and planned on placing them back in the refrigerator. He verified the water was not running over the container of water containing bags of eggs. At 9:23 AM, the CDM checked the temperature of the water and the eggs. The water was 53.1 degrees F, and the eggs were 32 to 51 degrees F depending on where the thermometer was stuck in the bag. The CDM verified the eggs were not being kept at a safe temperature level. During an interview on 05/08/25 at 12:01 PM, with the Director of Nursing/Infection Preventionist and review of the infection control line list and tracking and trending back to January 2025 revealed there was no outbreak of diarrhea, vomiting or gastrointestinal infections. 3. During an observation and interview on 05/08/25 at 9:07 AM, there was a pan of mashed potatoes and a pan of hamburgers from the steam table, in the walk-in refrigerator that was not dated or labeled. In a box there were four pork roasts that were completely thawed out and were not dated to indicate when it was thawed out. The CDM stated he would have expected the items to be dated when they were placed in the refrigerator. During an observation and interview on 05/08/25 at 9:10 AM, there was a gallon container of cottage cheese with an opened date of 05/06/25 written on it with a black marker. The use by date stamped on the container by the manufacturer was 04/28/25. The CDM stated the 05/06/25 date was the date the staff opened the container. The CDM verified the dates and stated they should not have been using the cottage cheese because it was past the use by date. During an observation and interview on 05/08/25 at 9:20 AM, there was an unlabeled undated plastic bag of raisin bran dried cereal in the food storage room. The bag was open to air and was not sealed. The CDM stated it was not supposed to be in there and should have been thrown out. 4. On 05/09/25 at 7:01 AM Cook2 was observed placing the food on the steam table. At 7:05 AM she began serving breakfast meal without first taking the temperature of the food items on the steam table. At 7:13 AM after Cook2 finished serving all the trays for the first food cart the CDM took the temperature of the foods on the steam table at the request of the surveyor. The puree sausage was 118 degrees F, and the ground sausage was 120 degrees F. Cook2 verified she had not taken the temperature of the food items on the steam table prior to starting the service and stated they did have residents on puree and mechanical soft diets on the cart that had received the puree sausage and ground sausage. 5. During an observation and interview on 05/08/25 at 9:20 AM seven of seven food serving utensils inspected in the clean utensil drawer were soiled with dried food residue. The CDM verified the utensils were soiled and removed them from the drawer. During an observation and interview on 05/09/25 at 7:28 AM, the staff on the rehabilitation unit were observed serving resident juice in 8-ounce clear plastic cups. Seven of the cups were soiled with a white residue on the inside surface. When the white substance was rubbed it came off on the finger. During the observation, Certified Nurse Aide (CNA) 8 was observed pouring cranberry juice in the glasses and taking them to the residents. She was asked if the glasses always had a white film in them and she stated they did. The CDM was present and verified the cups were not clean and should not have been used.

Based on observation, record review, and interviews, the facility failed to ensure food was served and received at palatable food temperatures for nine of nine residents (Resident (R) R2, R11, R8, R13, R15, R16, R17, R18, and R19) reviewed for palatability of 19 sample residents. This had the potential to result in residents not eating the food and resulting in weight loss. Findings include: Review of R2's quarterly Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 04/03/25 revealed she had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating she was cognitively intact. During an interview on 05/08/25 at 8:25 AM, R2 stated the food was sometimes cold. Review of R11's quarterly MDS located in the MDS tab of the EMR with an ARD of 03/06/25 and revealed he had a BIMS score of 10 out of 15 which indicated he had moderately impaired cognition. During an interview on 05/09/25 at 5:31 AM, R11 stated the food was not always good and it was cold. During an interview on 05/09/25 at 8:00 AM, R8 stated the food could be warmer. During an interview on 05/09/25 at 8:05 AM, R13 stated the eggs he received were cold and hard. 1. During an observation and interview on 05/09/25 at 7:01 AM Cook2 was observed placing the food on the steam table. At 7:05 AM she began serving breakfast meal without first taking the temperature of the food items on the steam table. At 7:13 AM after Cook2 finished serving all the trays for the first food cart the Certified Dietary Manager (CDM) took the temperature of the foods on the steam table at the request of the surveyor. The puree sausage was 118 degrees Fahrenheit (F), and the ground sausage was 120 degrees F. Cook2 verified she had not taken the temperature of the food items on the steam table prior to starting the service and stated they did have residents on puree and mechanical soft diets on the cart that had received the puree sausage and ground sausage. Review of a list of residents whose trays were placed on the cart along with their diets revealed R15 and R16 received puree diets and therefore received the pureed sausage and R17, R18, and R19 received a mechanical soft diet and therefore received the ground sausage. 2. During an observation and interview on 05/09/25 a test tray was placed on the cart for the rehabilitation unit at 7:28 AM after all the residents' meals were served from the steam table/tray line. The cart arrived at the rehabilitation unit at 7:32 AM and at 7:50 AM after all the trays were delivered to the residents on the unit the food temperatures of the test tray were obtained. The two hard boiled eggs were 105.3 degrees F. The eggs did not taste hot. The CDM felt the egg and verified it was not at a palatable temperature and stated it should have been warmer.

Based on interviews, record review, and review of facility policy, the facility failed to ensure the Medication Administration Record (MAR) and/or treatment administration record (TAR) was complete and accurate for two of 12 sample residents (Resident (R) 10 and R7) reviewed for accurate documentation. - R10's MARs were not accurately documented to show medications werev administered according to physician orders. -R7's TARs were not accurately completed to show consistent application of ordered treatments to R7's pressure injuries. Findings include: Review of the facility's policy titled, Medication Administration-General Guidelines, revised January 2018, revealed .The individual who administers the medication dose records the administration on the resident's MAR/eMAR [electronic medication administration record] directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR/eMAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R10 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease (ESRD), dementia, and diabetes. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/24/24 revealed R10 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R10 was moderately cognitively impaired. Review of the December 2024 eMAR revealed the following medications were not signed out as having been administered to R10: 1. Amoxicillin-Pot Clavulanate Oral Suspension Reconstituted [an antibiotic] 250-62.5 MG [milligram]/5ML [milliliter]. Give 10ml by mouth in the morning for PNA/UTI [pneumonia/urinary tract infection] for 5 days-Start Date 12/18/24. There was no documentation to show that R10 was administered the antibiotic on 12/22/24, as ordered. 2. Donepezil HCL [hydrogen chloride] Oral Tablet 5 MG. Give 5mg by mouth at bedtime for Dementia-Start Date 12/17/24. There was no documentation to show the medication was administered on 12/19/24, as ordered. 3. Famotidine Oral Tablet 20 MG. Give 20mg by mouth at bedtime for GERD [gastric esophageal reflux disease]-Start Date 12/17/24. There was no documentation to show that R10 was administered the medication on 12/19/24, as ordered. 4. Ferrous Sulfate [an iron supplement]. Give 650mg by mouth three times a day for supplement-Start Date 12/18/24. There was no documentation to show the medication was administered at 12:00 PM and 8:00 PM, as ordered. 5. Guaifenesin-DM [Dextromethorphan] Oral Syrup 100-10MG/5ML. Give 5ml by mouth three times a day for cough-Start Date 12/18/24. There was no documentation to show the medication was administered at 12:00 PM on 12/19/24, as ordered. 6. Renvela Oral Packet 0.8GM. Give 800mg by mouth three times a day for CKD/Dialysis [chronic kidney disease]-Start Date 12/18/24. There was documentation to show the medication was administered at 12:00 PM on 12/19/24, as ordered. 7. Ipratropium-Albuterol Inhalation Solution [a breathing medication] 0.5-2.5 (3) MG/3ML. 3ml inhale orally four times a day for SOB [shortness of breath]-Start Date 12/27/24. There was no documentation to show this was administered at 8:00 PM on 12/19/24, as ordered. During an interview on 01/17/25 at 2:15 PM, the Director of Nursing (DON) stated that she contacted Registered Nurse (RN) 5 regarding the blanks in documentation. The DON stated that RN5 was to have administered the 6:00 AM dose on 12/22/24 but was passed onto the day shift nurse, RN4 who stated that she did give the medication, however she did not document this on the MAR. In addition, the DON stated that Licensed Practical Nurse (LPN) 3 told her that the medications were administered on 12/19/24, however, she did not document this on the eMAR. The DON stated, My expectation is the medications are to be documented on the eMAR after being administered. 2.) Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of two limbs), morbid obesity, and a sacral pressure ulcer. Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 09/24/24 revealed R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 was cognitively intact and had one Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) on his sacrum (tailbone area). Review of the Physician Orders, dated 10/24, located in the Orders tab of the EMR, revealed the following wound care orders for R7's pressure ulcers: -Cleanse wound to left buttock with normal saline, pat dry, skin prep to peri wound, apply Iodosorb gel, followed by calcium alginate, and cover with bordered gauze, daily and PRN [as needed]. Start Date: 09/24/24 Review of the Treatment Administration Record (TAR) revealed there was no documentation to show that the treatment for R7's left buttock was administered on 10/04/24 and 10/31/24. -Cleanse wound to right lateral ankle with normal saline, pat dry, skin prep to peri wound, apply Iodosorb to wound bed, followed by calcium alginate, and cover with bordered gauze daily and PRN. Start date: 10/22/24. Review of the TAR revealed there was no documentation to show that the treatment for R7's right ankle wound was administered on 10/31/24. -Cleanse wound to right lateral hip with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, and cover with bordered gauze daily and PRN. Start Date: 09/24/24. Review of the TAR revealed there was no documentation to show that the treatment for the right hip was administered on 10/04/24. -Cleanse wound to sacrum with normal saline, pat dry, skin prep to peri wound, apply Iodosorb gel to wound bed, followed by calcium alginate, and cover with ABD [large pad dressing] and tape daily and PRN. Start Date: 09/24/24. Review of the TAR revealed there was no documentation to show that the treatment to R7's sacrum was administered on 10/04/24 and 10/31/24. -Cleanse wound to right lateral ankle with normal saline, pat dry, skin prep to peri wound, apply collagen powder to wound bed, followed by calcium alginate, and cover with bordered gauze daily and PRN. Start Date: 10/26/24. Review of the TAR revealed there was no documentation to show that the treatment for R7's right ankle wound was administered on 10/04/24. Review of the Physician Orders, dated 11/24, located in the Orders tab of the EMR, revealed the following wound care orders for R7's pressure ulcers: -Cleanse wound to left buttock with normal saline, pat dry, skin prep to peri wound, apply Iodosorb gel, followed by calcium alginate, and cover with bordered gauze, daily and PRN [as needed]. Start Date: 09/24/24 Review of the TAR revealed there was no documentation to show that the treatment to R7's left buttock was administered on 11/04/24. -Cleanse wound to sacrum with normal saline, pat dry, skin prep to peri wound, apply Iodosorb gel to wound bed, followed by calcium alginate, and cover with ABD [large pad dressing] and tape daily and PRN. Start Date: 09/24/24. Review of the TAR revealed there was no documentation to show that the treatment to R7's sacrum was administered on 11/04/24. Cleanse wound to right lateral ankle with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, followed by calcium alginate, and cover with bordered gauze daily and PRN. Start Date: 11/05/24. Review of the TAR revealed there was no documentation to show that the treatment to R7's right ankle was administered on 11/15/24. -Cleanse wound to left buttock with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, and cover with bordered gauze daily and PRN. Start Date: 11/12/24. Review of the TAR revealed there was no documentation to show that the treatment to R7's left buttock was administered on 11/15/24. -Cleanse wound to right upper lateral leg with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, and cover with bordered gauze daily and PRN. Start Date: 11/12/24. Review of the TAR revealed there was no documentation to show the treatment for R7's right upper leg was administered on 11/15/24. -Cleanse wound to sacrum with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, followed by calcium alginate, and cover with ABD and tape daily and PRN. Start Date: 11/05/24. Review of the TAR revealed there was no documentation to show the updated treatment to R7's sacrum was administered on 11/15/24. Review of the Physician Orders, dated 12/24, located in the Orders tab of the EMR revealed the following wound care orders for R7's pressure ulcers: -Cleanse wound to left buttock with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, and cover with bordered gauze daily and PRN. Start Date: 11/05/24. Review of the TAR revealed there was no documentation to show that the treatment to R7's left buttock was administered on 12/05/24, 12/06/24, 12/07/24. -Cleanse wound to right lateral ankle with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, followed by calcium alginate, and cover with bordered gauze daily and PRN. Start Date: 11/05/24. Review of the TAR revealed there was no documentation to show the treatment for R7's right ankle was administered on 12/05/24, 12/06/24, 12/07/24, 12/19/24, 12/20/24, 12/21/24, and 12/22/24. -Cleanse wound to sacrum with normal saline, pat dry, skin prep to peri wound, apply medihoney to wound bed, followed by calcium alginate, and cover with ABD and tape daily and PRN. Start Date: 11/05/24. Review of the TAR revealed there was no documentation to show that R7's treatment to his sacrum was administered on 12/05/24, 12/06/24, 12/07/24, 12/19/24, 12/20/24, 12/21/24, and 12/22/24. During an interview on 01/07/25 at 12:20 PM, R7 was asked if he was receiving wound care daily. R7 stated, Yes. R7 was asked if he left the facility often to go out into the community. He stated, Yes. R7 was asked if wound care was done before he left the facility. He stated, Well, if I don't get it, then they are supposed to make up for it later, but not sure. I do think it's healing though. During an interview on 01/07/25 at 1:22 PM, the Director of Nursing (DON) stated, If [R7] is out [of the facility] on a shift and not back by the end of the shift, then the nurses are to pass on the information to the next shift on what needs to be done. The DON further stated that she tried to call [Registered Nurse (RN) 3] to ask why the treatments were not documented as administered but RN3 was not available. The DON stated, My expectation is that medications and treatments are to be documented as administered at the time that it was done or document that the resident was out of the facility at the time the treatment was to be administered. The next shift nurse would then use a PRN order for the particular wound treatment and document that it was administered. During a follow-up interview on 01/27/25 at 2:15 PM, the DON stated that she was able to contact RN3 and ask about the missing documentation regarding R7's treatments. The DON stated that RN3 said, I get too busy, I forget to sign out for medications and treatments.

Based on observations, interviews, and record review, the facility failed to ensure appropriate door closure with an operating door latch for one of six residents (Resident (R) 4) reviewed for privacy of 12 sample residents. This failure resulted in the potential to affect resident safety, security, and privacy. Findings include: Review of the Admission Record located under the Profile tab in the electronic medical record (EMR) revealed R4 was admitted on [DATE] with diagnoses that included bilateral primary osteoarthritis of knee. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R4 was cognitively intact. During an interview on 01/07/25 at 11:22 AM, R4's door was observed to have a towel and pillowcase draped over the inside corner of the door. R4 stated, That's to keep it shut because it doesn't stay closed. It's been like that since September. A CNA [Certified Nurse Aide] came up with the idea of putting the linens up there and it works. The biggest problem I had was when the door didn't stay closed, others could see me on the commode. When the resident was asked if she had reported the problem with the door, R4 stated, Yeah, I think, they all know about it. During an observation on 01/07/25 at 11:30 AM, the door upon closing revealed the latch did not engage with the strike plate. During an interview on 01/07/25 at 2:15 PM, the Administrator confirmed that the door did not remain closed in its frame stating, It's probably related to the weather, expanding and contracting. During an interview on 01/07/25 at 3:30 PM the Unit Manager/Registered Nurse (RN1) discussed where the maintenance work orders were located and how the orders were submitted. RN1 said she was not aware of the problem with R4's door not staying closed.

Based on interviews, record review, and review of the facility policy, the facility failed to ensure a fingerstick blood sugar test (FSBS), and insulin was documented as administered, per the physician's order for one of three residents (Resident (R) 3) reviewed of 12 sample residents. This failure placed the resident at risk for serious medical consequences. Findings include: Review of the facility's policy titled, Medication Errors, revised February 2023, revealed .Medication errors, once identified, will be evaluated to determine if considered significant or not by utilizing the following three general guidelines .Resident's Condition .If the resident's condition requires rigid control .or monitoring of lab values .Drug Category .If the medication is from a category that usually requires the resident to be titrated to a specific blood level .To prevent medication errors and ensure safe medication administration, nurses should verify the following information .Right medication, dose, route, and time of administration, right resident and right documentation . Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R3 was admitted to the facility on [DATE] with diagnoses that included type one diabetes (juvenile diabetes) with ketoacidosis and coma (a process which forms toxic acids known as ketones in the blood or urine which can lead to a coma due to high levels of ketones.) Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/02/24 revealed R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R3 was cognitively intact and had been administered insulin during the seven-day observation period. Review of the December 2024 Medication Administration Record (MAR) located in the Orders tab of the EMR, revealed the following medications were not documented as having been obtained or administered for R3: 1. Insulin Lispro [fast-acting insulin] 100 UNIT/ML [Unit/Milliliter] Solution pen-injector. Inject 4 units subcutaneously three times a day for DM [diabetes mellitus] Start Date-12/05/24. There was no documentation that R3 was administered this medication on 12/7/24 at 8:00 AM or 12:00 PM. 2. Insulin Lispro Subcutaneous Solution Pen-injector 100 UNIT/ML. Inject as per sliding scale: if 150-199 = 1 unit; 200-249 = 2 units; 250-299 = 3 units; 300-349 = 4 units; 350-400 = 5 units over 400 administer 6 units, subcutaneously three times a day for DM. Start Date 12/05/24. There was no documentation to show that an FSBS was obtained or insulin administered on 12/07/24 at 8:00 AM and 12:00 PM. Review of the Nursing Progress Notes located in the Progress Notes tab of the EMR did not show any documentation on 12/07/24 that R3 had been assessed for the FSBS or insulin administered. During an interview on 01/07/24 at 2:15 PM, the Director of Nursing (DON) stated she had contacted Registered Nurse (RN) 3 regarding the blank documentation on the MAR for the insulin and FSBS. The DON stated, When I spoke to [RN3] on 01/07/24 regarding the identified blanks for the insulin and FSBS, [RN3] stated, 'I get so busy I forget to document' but did not indicate whether the insulin or FSBS had been obtained or administered for [R3]. The DON further stated, It is my expectation that medications are to be administered, as ordered, by the physician and is documented on the MAR.

Based on observations, menu review, and interviews, the facility failed to ensure the menu was followed for all the diets listed on the menu spreadsheet for 81 of 81 residents who receive food from the facility. Failure to follow the spread sheet had the potential to result in weight loss and for residents to feel hungry. Findings include: Review of the Client List Report dated 10/22/24 and provided by the facility, revealed the facility had 60 residents on regular consistency diets, 13 residents on mechanical soft consistency diets, and eight residents on puree consistency diets. The facility did not have any residents who were on tube feedings and did not receive their meals from the dietary department. During lunch observations on the north, south and west units on 10/22/24 from 11:50 AM to 12:40 PM, three unidentified residents stated they often did not get enough food during the meals. During an observation and interview on 10/22/24 at 11:29 AM, the [NAME] was observed serving the noon meal from the steam table in the kitchen. She stated she was serving the residents on all the regular consistency diets and mechanical soft diets a #6 (5.3 ounce) scoop of Chicken Cacciatore and 3-ounces of carrots. The pasta was mixed in with the chicken Cacciatore. She stated she was giving the residents on the puree diet a 4-ounce scoop of puree chicken and a 4-ounce scoop of puree carrots. She stated she did not serve the purees chicken cacciatore because a lot of them did not like tomato, so she just gave all the purees a 4-ounce scoop of puree chicken instead. She was observed serving these portions to all residents on regular consistency diets, mechanical soft consistency diets, and puree consistency diets unless they received alternate food items. Review of the paper menu spreadsheet titled Daily Spreadsheet .Week 4 Tuesday provided by the facility, revealed the residents on all regular and mechanical soft texture diets were supposed to receive 6-ounces of Chicken Cacciatore, 4-ounces of Penne pasta, and 4-ounces of butter carrots. Per the menu the residents on puree textured diets were supposed to receive 8-ounces of puree chicken cacciatore, 4-ounces of puree penne pasta, and 4-ounces of puree carrots. During an interview on 10/22/4 at 11:39 AM, the Dietary Manager (DM) verified the cook was not following the menu for any of the diets. The DM verified the cook should have been serving 4-ounces of penne pasta and 6-ounces of chicken cacciatore and she was only serving 5.3-ounces of the pasta and chicken cacciatore mixed together to the residents on regular and mechanical soft diets. The DM verified she should have been serving 4-ounces of carrots and was only serving 3-ounces of carrots to residents on regular and mechanical soft consistency diets. The DM verified she should have been serving 8-ounces of puree chicken cacciatore and 4-ounces of puree penne pasta and she was only serving 4-ounces of puree chicken to the residents on puree consistency diets. During an interview on 10/22/24 at 1:03 PM, the Administrator stated she would have expected the menu to be followed.

Based on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 8 (R50, R64, R65, R67, R70, R73, R78 and R235) of 9 residents reviewed for pressure injuries. * R78 developed a stage 4 pressure injury to the right posterior ankle despite the Facility knowing the resident was at risk for pressure injuries because the resident wore PRAFO boots. The Facility failed to perform checks each shift to monitor the skin under the boot to prevent skin issues from developing. The Facility failed to obtain written orders on length of time the PRAFO (contractor/LE (lower extremity) braces) boots should be worn. The resident's plan of care did not include interventions related to the PRAFO boots and was not updated for over a month regarding right posterior heel pressure wound after the discovery of the wound. A comprehensive assessment of the wound was not documented until the wound doctor saw R78 on 2/5/2024. This created a finding of Immediate Jeopardy (IJ) at a scope and severity of a J (immediate jeopardy/isolated) that began on 1/30/2024. On 04/24/24 at 09:37 AM the Surveyor notified the Director of Nursing (DON)-B, Nursing Home Administrator (NHA)-A and Facility Consultants about the immediate jeopardy. The immediate jeopardy was removed on 4/24/24 when the facility implemented their action plan. The deficient practice continues at a scope and severity of a G (actual harm/isolated) for the following examples regarding Residents R65, R235 and R64. * R65 was admitted to the facility from the hospital with an unstageable pressure injury on the coccyx. The pressure injury was not assessed on the day of admission. The pressure injury deteriorated to a stage 4 pressure injury with multiple courses of antibiotics after R65's admission. The resident developed multiple infections related to possible soiled dressing from stool that were not addressed in the treatment record to change dressings as needed. R65's air mattress was observed set to a higher weight load than what R65 weighed. Additionally, the wound physician indicated part of the issue with R65's wound involved offloading pressure. The facility did not establish a clear, individualized plan of care regarding repositioning for R65. * R50's air mattress was set to 550 pounds on several observations during the survey and R50's most recent weight is 185.9 pounds. * R235's guardian filed a grievance requesting R235 have an established repositioning schedule to prevent the development of a pressure injury. The facility did not establish an individualized repositioning schedule, and R235 developed a facility acquired, stage 3 pressure injury. * R70's air mattress was set to 550 pounds on several observations during the survey and R70's most recent weight is 152.2 pounds. * R64 was admitted to the facility with a sacral pressure injury and a chronic left heel pressure injury. The left heel was healed and then reopened on 11/11/23. The wound was not comprehensively assessed by a Registered Nurse (RN) until 11/13/23 when it was unstageable. On 2/7/24 through 2/13/24 R64 was hospitalized and underwent an incision to the bone with partial resection of left calcaneus and incision and drainage of left Achilles abscess. The resident was readmitted [DATE] and the wound was not comprehensively assessed by a RN until 2/19/24. During survey, R64 was observed on day 1 and day 2 without offloading interventions in place. *R67's air mattress was observed to be set to 210 pounds on multiple days of the survey despite R67 weighing 144 pounds. R67 is at risk for pressure injuries. *R73 was observed during multiple days of the survey to have their feet resting against the foot board of the bed and expressing discomfort from the pressure/position. R73 is at risk for pressure injuries. Findings include: The Facility Policy and Procedure titled Pressure Ulcers/Skin Integrity/Wound Management implemented 1/30/2023, revised 1/24/2024 documents (in part) . Policy: A system is in place for the prevention, identification, treatment and documentation of pressure and non-pressure wounds . Procedure . 2. Assessment and Treatment It is important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that may have influenced its development, the potential for development of additional ulcers, or for the deterioration of the pressure ulcer(s) be recognized, assessed, and addressed as follows: a. Differentiate the type of ulcer (pressure-related versus non-pressure-related) because interventions may vary depending on the specific type of ulcer. b. Determine the ulcer's stage. c. Describe and monitor the ulcers characteristics. d. Monitor the progress toward healing and for potential complications. e. Determine if infection is present. f. Assess, treat, and monitor pain, if present; and g. Monitor dressings and treatments. 3. Treatment/Management a. Residents with risk for or who have a loss of skin integrity will receive the appropriate treatment/services, and residents who are determined to be at risk for or who have loss of skin integrity will receive appropriate treatment/services . 4. Documentation a. Assessment i. Assessment information should identify specific factors that might increase the risk of pressure ulcer development or affect healing of a pressure ulcer such as: 1. Decreased mobility . 4. Use of restraints . 6. Non-compliance or history of non-compliance. 7. Altered sensory perception . 10. History of pressure ulcers . ii. For a resident who was admitted with a pressure ulcer or who developed one may include the following documentation. 1. Ulcer site and characteristics at the time of admission or onset, including measurements . b. Care Planning . iii. The care plan should address prevention of any skin breakdown, including sheering or friction, repositioning or off-loading; pressure relief equipment; and the care and treatment to be provided to the resident for a pressure ulcer or non-pressure wound behaviors and preferences. iv. If a resident refuses or resists staff interventions, the care plan should reflect efforts to seek alternatives as well as education to resident and/or family regarding the risks. This education should be documented. v. Care plan interventions should be revised if there is recurring skin breakdown, a lack of progress toward healing, or if the resident acquires a new ulcer . 1.) R78 was admitted to the facility on [DATE] from (name of hospital in Illinois) where they had been since 11/9/2023. R78 has diagnoses that include acute cystitis without hematuria, fusion of spine-thoracic region, paraplegia, morbid (severe) obesity due to excessive calories, muscle weakness, need for assistance with personal care, depression, and anxiety disorder. Braden assessment on 12/1/24 indicates R78 is at mild risk for pressure injuries. Review of the discharge paperwork from the hospital R78 discharged from indicates R78 Occupational Therapy was working with R78 on the use of bilateral lower extremity PRAFO orthotics to prevent plantar flexion contractures. The orthosis wear schedule is noted to be 4 hours on/off with R78 being dependent in a supine position to don/doff orthotics. Precautions noted: If redness, swelling, numbness or tingling occurs, please remove splint, and notify OT. The documentation indicates orthotics were donned throughout session. The paperwork indicates R78 has a wound on their buttocks. There was no order for the PRAFO orthotics on admission on 12/1/23. On 04/23/24 at 10:42 AM Surveyor spoke with DON-B and requested a physician order for the PRAFO orthotic and to talk to therapy about monitoring of the PRAFO orthotic for effectiveness. Surveyor was told will try to find if someone is still here from therapy to help with that. No order to the PRAFO orthotic was provided to Surveyor. On 04/23/24 at 03:32 PM DON-B told Surveyor there is no actual order for the PRAFO orthotics. On 12/1/23 the facility initiated a care plan with a focus area the resident is resistive to care AEB refusing scheduled medications, wound treatments and occasional therapy services r/t anxiety with new admission and debilitating comorbidities causing immobility and decreased independence. The Focus indicates it was revised on 12/18/23. Goals indicate: the resident will participate in care by performing/participating in self-care needs (ostomy care, med management, and therapy) w/less than 2-3 refusals by the next review date. Initiated 12/1/23, revised 1/2/24, target date 5/30/24. Interventions/Tasks include: - Allow the resident to make decisions about treatment regime, to provide sense of control, Date Initiated: 12/1/23. - Encourage as much participation/interaction by the resident as possible during care activities, Date Initiated: 12/1/23. - Give clear explanation of all care activities prior to an (sic) as they occur during each contact, Date Initiated: 12/1/23. - If possible, negotiate a time for ADLs so that the resident participates in the decision-making process. Return at the agreed upon time, Date Initiated: 12/1/23. - Praise the resident when behavior is appropriate, Date Initiated: 12/1/23 - Provide resident with opportunities for choice during care revision, Date Initiated: 12/1/23. Surveyor noted this plan of care was not updated to address if R78 was refusing to remove the PRAFO orthotics or not allowing staff to check R78's skin under the PRAFO. There is no intervention on the care plan to discuss risks and benefits with R78 regarding decisions to refuse care. R78's skin was assessed on 12/4/23 (3 days after admission) by the facility. The skin impairment wound form dated 12/4/23 indicates R78 has a pressure injury on their sacrum that is an unstageable pressure injury. Measurements of wound indicate wound measured by (name of wound physician practice) wound MD. See note. The assessment for wound tissue bed, to indicate tissue percentages, is blank along with details regarding pain and treatment. R78 is noted to have a second wound on the right buttock that is a stage 3. The measurement of the wound also indicates wound measured by (name of wound physician practice) wound MD. See note. The assessment for wound tissue bed to indicate tissue percentages is blank along with details regarding pain and treatments. The skin evaluation indicates there is a stage 2 pressure injury to the left ankle that is documented as resolved. The notes indicate for skin ulcer/injury treatments: pressure reducing device for bed, turning/repositioning program, nutrition, or hydration to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings (with or without topical medications) other than to feet, applications of ointments/medications other than to feet. Barriers to wound healing include paraplegia, HTN (hypertension), obesity. Current wound/skin integrity interventions indicate: Resident assessed by (name of wound physician practice) wound MD and wound team. Resident admitted to facility with preexisting pressure wounds to sacrum, R (right) buttock, and L (left) posterior ankle resolved. Resident wears bilateral ankle contractor braces, foam dressings continued for bilateral posterior ankles and R lateral foot where there is blanchable redness. Resident requires extensive assistance of two with repositioning in bed, off-loading positioning wedges are being used. Bilateral half side rails in place to allow resident to assist with repositioning. Air mattress in place. Currently eating 51-100% of meals. Wound physician (MD)-Q's wound evaluation dated 12/4/23 indicates wound present on back and buttock. Left and right lower extremity normal. The sacrum wound is unstageable measuring 2.5 x 2.2 x 0.7 40% necrotic tissue, 30% slough, 30% granulation tissue. Recommendations were to offload wound, reposition per facility protocol, group 2 mattress. This area was debrided by MD-Q. The right lower buttock, stage 3 measured 3.5 x 4.5 x 0.1. 10% slough, 60% granulation tissue, 30% skin. Recommendations to off load wound, reposition per facility protocol. There was no evaluation noted of R78's bilateral ankles. Surveyor noted orders for-Foam dressing to R lateral foot for protection. Every day shift every Mon, Wed, Fri - start 12/6/2023, d/c 2/23/2024. -Foam dressing to R/L posterior ankles for protection. Every day shift every Mon, Wed, Fri - start 12/6/2023, d/c 2/23/2024. On 04/24/24 at 08:38 AM Surveyor spoke with Director of Nursing (DON)-B to confirm where the order for Foam dressing to R/L posterior ankles for protection. Every day shift every Mon, Wed, Fri. came from. DON-B shared the wound doctor looked at the posterior heels after resident was admitted and during that initial assessment these recommendations were given verbally. The foam was an intervention, not an order from Wound Doctor-Q. -Check skin integrity under ankle contractor braces. Every, day shift - start 12/5/2023, d/c 2/23/2024. Review of R78's treatment administration record indicates the time for this treatment order is 6:15 AM. Facility documentation shows that staff monitored the skin only once daily from 12/5/23 to 2/23/24. On 12/8/24 a treatment order was added to complete nursing assessment skin observation tool every day shift every Friday for shower day skin monitoring. Surveyor noted there were no physician orders for R78 to wear the PRAFO orthotics or documentation the physician was consulted with regarding the wearing of the braces. Further, none of the recommendations that were noted in the discharge paperwork from occupational therapy regarding a donning and doffing schedule and signs and symptoms to monitor for with the use of the PRAFO orthotic for R78 were recorded. Review of the physical therapy evaluation dated 12/2/24 does not include reference or assessment of R78's PRAFO orthotics. On 12/4/24 the physical therapy summary of daily skilled services references passive stretches BLE (bilateral lower extremities) with PRAFO boot removal, ankle, knee, and hip ROM (range of motion) practiced with hold at the end of each movement to provide stretch, managed well. Repositioned in bed with roll side to side with max a (assist) x 2, placed PRAFO boots, wedges to deweight (sic) the sacral area and scooted up in bed with max a x2 with pts (patients) support with the headboard. On 12/8/23 R78 expressed concerns with positioning schedule. With physical therapy noting R78 is to be positioned Q (every) 2 hours for skin breakdown prevention. R78's interdisciplinary team conference was held on this date. Review of R78's physical therapy notes from 12/2/23-1/29/24 indicate occasional reference to R78 wearing the PRAFO orthotics however, the use of the orthotics do not appear to be documented as an ongoing part of the physical therapy evaluations. On 1/11/24 physical therapy notes: splint and brace program established/trained: PRAFO boot donning and doffing and skin check - nursing able to manage. The note also references a restorative program being established. On 04/24/24 at 12:07 PM Surveyor spoke to the Rehab Director-FF at the Facility about a discharge recommendation made by one of the physical therapists on 1/11/2024 that states splint and brace program established/trained: PRAFO boot donning and doffing and skin check-nursing able to manage. Rehab Director-FF shared they did not know what that means, will try to reach out to the Physical Therapist that made the note. Surveyor noted no additional information was provided and Surveyor was not able to speak to Therapist. On 1/25/24 physical therapy references R78 is taking the PRAFO boots off for a couple of hours when the wife visits and performs skin check. Review of the Skin impairment/Wound evaluation assessment completed on 1/29/2024 documents presence of a pressure injury to the sacrum. Surveyor notes there is no assessment of documentation on the skin impairment/wound evaluation of the bilateral areas on R78's ankles. only the one wound, no documentation of skin concerns to the bilateral lower extremities. A progress note written on 1/30/2024 at 9:03 pm indicates writer approached by pts spouse with skin concerns to bilateral Achilles. Upon assessment pressure injury noted to right Achilles and 2 small abrasions noted to left Achilles. NP (nurse practitioner) updated, NOR (new order) for medihoney daily to right Achilles and skin prep BID (twice daily) to left Achilles. txs (treatments) placed. pt tolerated well no complaints of pain or discomfort noted at this time. A Facility Skin Impairment/Wound Evaluation assessment was completed on 1/30/2024 that identifies a new stage 4 pressure injury to R78's right Achilles. The wound is measured as 1.5 by 2.0; no depth and no tissue description are included. On 04/23/24 at 11:32 AM Surveyor placed call to Licensed Practical Nurse (LPN)-U who was there when Family Member-V reported the skin change. LPN-U remembers Family Member-V telling them about it. They measured the area, and the other LPN updated the Nurse Practitioner. They got an order and let the supervisor know. Surveyor asked if LPN-U remembered what the wound looked like, LPN-U does not remember just knows they measured it and put a dressing on. On 04/23/24 at 11:34 AM Surveyor left a message for the other LPN who was there when Family Member-V reported the wound, a call back was not received. On 04/23/24 at 11:30 AM Surveyor called the charge nurse on duty when the skin change was reported on, 1/30/2024, no call back was received. The following orders were entered into the Treatment Administration Record (TAR) Cleanse Right Achilles with NS, pat dry apply medihoney and cover with dry gauze one time a day, start 1/31/2024, d/c (discontinue) 2/6/2024. Surveyor notes the treatment obtained from the Nurse Practitioner was entered and first signed out on 1/31/2024 the day after the Stage 4 pressure injury was identified. There is no description of the wound to identify the tissue type and if the tendon was visible at this time. On 04/23/24 at 12:34 PM Surveyor spoke with Family Member-V who would take the boots off. Family Member-V did not know how long the boots should be off daily, there was no order they knew of. When asked how often Family Member-V looked at R78's feet leading up to the discovery, Family Member-V stated being at facility five days a week Monday through Friday for a couple hours in the evening. The boots would be removed then and [NAME] lotion was put on R78's feet by Family Member-V. On 1/30/2024 when Family Member-V took the boots off, the dressing was 1/2 off and there was drainage on it, Family Member-V indicated they saw the wound and got the nurse. Surveyor asked Family Member-V about other opportunities when R78's feet could be observed. Family Member-V stated R78 should get a shower once a week and they should be cleaning R78 up other days. R78 was seen on 2/5/2024 by (name of wound physician practice) Wound Doctor-Q and the right posterior Achilles was added as a 3rd pressure wound. The wound was classified as a stage 4 of the right, posterior, Achilles tendon ankle. Etiology: pressure. Additional wound detail provided by Wound Doctor-Q states it is a medical instrument (boot) pressure sore. The wound size was (L x W x D): 2.6 x 3.1 x 0.6 cm. Exudate: Light Sero - sanguineous Thick adherent devitalized necrotic tissue: 40 % Slough: 20 % Other viable tissues: 40 % (Tendon) DRESSING TREATMENT PLAN Santyl apply once daily with Gauze island w/ bdr (border) over Recommendations: Off-Load Wound; Float Heels in Bed; Pressure Off-Loading Boot DEBRIDEMENT PROCEDURE completed. Review of R78's record indicates the intervention. On 2/5/24 the TAR was updated to include apply bilateral prevlon (sic) boots. Document refusals every shift. Surveyor noted this did not get added to R78's care plans until 3/1/24. On 04/23/24 at 11:00 AM Surveyor spoke with the (name of wound physician practice) Wound Doctor-Q via telephone and clarified that the tendon was visible before debridement procedure was completed on 2/5/2024. Wound Doctor-Q stated it was visible right away. R78 is then seen weekly by the (name of wound physician practice) Wound Doctor-Q. Notes each week 2/12/24 - 4/15/24 indicate that the wound decreased in size and continued to improve. The final note stated: Wound Size (L x W x D): 1.4 x 0.9 x 0.1 cm Granulation tissue: 100 % Wound progress: Improved evidenced by decreased surface area. Dressing(s) same Same recommendations No treatment needed by wound doctor, assessment only. On 4/22/24 at 11:49 AM Surveyor observed wound assessment provided by Wound Doctor-Q. Upon entering R78's room resident was wearing Prevalon boots on both feet, had a pressure relieving wedge under hip and another at upper back area. Wound Doctor-Q assessed right posterior ankle wound as smaller than last measurement, stated that no treatments needed, Facility should continue same dressing. Surveyor noted when the doctor asked if R78 needed lidocaine for pain management during wound evaluation R78 replied that resident does not feel pain from sternum down due to paralysis. On 04/22/24 at 12:44 PM Surveyor interviewed R78 about the orthotics R78 wore before developing the stage 4 pressure wound and those R78 is wearing now. R78 stated being admitted to Facility with a different type of boot meant to prevent drop foot, they had a hard sole with kick stands. R78 stated being in them for quite some time. R78 brought the boots which R78 got from (name of rehabilitation hospital program/lab) and continued to use them to prevent foot drop. R78 said that the boots had added padding where pressure wound started and thinks that the padding wore down and that was the problem. R78 states that Family Member-V pointed the skin change out to staff on 1/30/2024 in the evening. R78 stated that staff were not taking boots off and assessing feet daily. Family Member-V would take boots off in the evening and put lotion on feet. That is when the pressure wound was found on the back of the heel area. Per R78 they never refused any precautions, recommendations, or treatments. On 04/23/24 at 09:05 AM Surveyor spoke with Director of Nursing (DON)-B who confirmed R78 had the contractor boots (PRAFO orthotics) since admission and that two-nursing staff were in with R78 when Family Member-V informed them of the skin change. Surveyor asked DON-B for additional documentation or progress notes about the checking of skin integrity up to 1/30/2024. On 04/23/24 at 09:54 AM Surveyor spoke with Registered Nurse (RN)-W. RN-W signed the Treatment Administration Record (TAR) on 1/30/2024 for Check skin integrity under ankle contractor braces every, day shift. When RN-W was asked if staff checked under braces every day, RN-W replied yes, especially shower days. Surveyor noted 1/30/24 was not R78's Friday shower day. RN-W stated that if they signed it out on TAR then they did it and does not remember any skin impairment at that time. If a skin impairment was found, RN-W would complete a skin impairment eval and the unit manager is alerted. On 04/23/24 at 11:18 AM Surveyor followed up with R78 regarding the pressure wound. Per R78 Family Member-V was cleaning up feet and noticed that the callus on back of heel had turned to a wound. R78 states he was getting a shower once a week and made no refusals, actually wanted more showers that's why Family Member-V would give bed baths and clean up. When asked about daily skin checks, R78 shared he does not remember anyone from Facility taking boots off and looking at skin every day. R78 could not remove boots by himself, Family Member-V took them off nightly to give R78 a break from wearing them. On 04/23/24 at 01:59 PM Surveyor informed DON-B, Nursing Home Administrator (NHA)-A and the consultants that there was a very serious concern related to R78's facility acquired pressure injury. Surveyor shared concerns with R78 developing an avoidable, facility acquired stage 4 pressure injury when the facility did not get physician orders for R78's wearing of the PRAFO orthotics and assessed how long R78 should be wearing the orthotics daily to prevent possible skin breakdown. On 4/24/24 a progress note dated 4/23/2024 at 6:13 pm, signed by the facility therapy Physiatrist-GG was provided to the Surveyor stating Discussed with DON and leadership. Patient had arrived here in Dec from previous facility with rigid PRAFO boots, which (R78) had worn until developed some skin breakdown on back of distal leg/ankle. The use of these boots, which was well-tolerated at the previous facility, was reasonable to help prevent soft tissue injury and plantar flexion contracture for the patient. Surveyor noted that there are no details about how long to wear the boots or interventions to prevent skin breakdown and this was obtained by the Facility after they were informed of the serious concern. There is no documentation provided to the Surveyor to indicate Physiatrist-GG had assessed or consulted on R78's use of the PRAFO orthotics prior to R78 developing the stage 4 pressure injury to the right ankle. On 4/24/24 the Facility provided a late entry progress note to Surveyor stating LATE ENTRY FOR 1/31/24 Writer and (LPN-O) went to assess resident skin concerns to right achilleas (sic). Wound observed and assessed. Skin appears slightly open 0.2 cm x 0.2 x 0.1cm with slight purple hue periwound (sic). Total wound measured at approximately 1.5 cm x 2 cm. NP updated on wound. Orders to continue current treatment until seen by wound MD. Resident offered additional education on offloading and given offloading device options to try. At this time feels most comfortable offloading with pillows as (R78) directs staff to adjust, resident was urged to use device that would effectively float heels to relieve any pressure, and educated to ensure that heels are not touching surface because from what (R78) showed as preference pillows did not offer effective offloading. (R78) also decline to stop utilizing PRAFO boots despite education of prevelon (sic) boot benefits. We did confirm that (R78) had extra padding in the PRAFO boot. (R78) clarified wants them on at all times and Family Member-V will remove for a couple hours in the evening. On 04/24/24 at 09:58 AM Surveyor called LPN-U and asked about the PRAFO boots being worn after the pressure injury was discovered. LPN-U stated (R78) requested to continue to wear the PRAFO boots then switched on 2/5/2024 to the Prevalon boots after the wound doctor educated on the risks and benefits. Surveyor noted there is no indication facility staff discussed the risks and benefits of wearing the PRAFO with R78 at any time prior to Wound Doctor-Q's assessment of R78's right ankle, facility acquired pressure injury. On 04/24/24 at 10:05 AM Surveyor asked R78 when he started to wear the Prevalon boots and R78 can't remember, just knows switched to Prevalon boots at some point. Surveyor notes that Facility did not get physician orders on when or how long to wear the PRAFO boots only a recommendation for foam dressing to posterior ankles for protection every mon, wed, fri. R78's skin was only assessed daily not per shift. The Facility did not clarify with physicians' orders at admission for wearing the PRAFO orthotics. R78 continued to wear the orthotics after the pressure wound developed, Facility provided no evidence of risk analysis given to R78. There was no plan of care intervention for the PRAFO boots for Certified Nursing Aides (CNAs) even though the Facility recognizes resident wore from admission and had a pressure wound to the left posterior heel upon admission. On 4/25/24 the facility submitted additional documentation to review/consider regarding R78's Right Achilles Pressure Injury. Submitted was a pamphlet regarding a Pressure Relieving Ankle Foot Orthosis Instructions for wearing your Pressure Relieving Ankle Foot Orthosis (PRAFO) Surveyor noted this pamphlet is from a Prosthetic and Orthotic Department in a hospital in [NAME] Canada and it is not from the hospital or physician who originally ordered the PRAFO prior to admission. The facility highlighted the section asking When should the PRAFO be worn? A PRAFO should ideally be worn at all times, only being removed for wound care and showering, unless otherwise indicated by your doctor. Surveyor noted it is not even clear if the pictured PRAFO boot is the model R78 was using. Additionally, it is noted the facility did not give the doctor the opportunity to indicate otherwise when wearing the PRAFO as it was never assessed on discussed with a facility physician for orders for use. The facility also submitted an investigational summary indicating despite R78's many risks, the stage 4, facility acquired pressure injury should be considered unavoidable. The facility indicates in this information R78 had previously had a stage 4 pressure injury on this Achilles area necessitating the need to restage the area as a stage 4. There is no indication in R78's facility record R78 was admitted with a healed stage 4 pressure injury to the right Achilles and was assessed for the risk of redeveloping a stage 4 pressure injury to that ankle. The facility contends the occupational therapy notes included in the facility admission documents was not an order to be followed, was just a recommendation and the right of the resident to self-direct care and wear the braces continuously without specific wearing and removal orders relieves the facility of culpability. There is no indication the facility evaluated R78 for the wearing of the PRAFO orthotics, instituted ongoing evaluations of R78's tolerance of the devices post admission and present R78 with the risks and benefits of wearing such devices based upon an assessment of the devices for R78. The Facility's failure to provide care necessary to prevent the development and the deterioration of a pressure injury created a reasonable likelihood for serious harm, leading to a finding of immediate jeopardy. The Facility removed the immediate jeopardy on 4/24/24 when the Facility implemented the following: * R78 no longer uses his PRAFO boots. The pressure injury to his right Achilles is healing. His plan of care has been reviewed and is appropriate. * Any resident who wears a splint/brace has the potential for skin breakdown. Splint/brace orders will be obtained by Qualified Therapist or Physiatrist. * Orders for splint/brace and skin integrity checks will be reviewed by nursing and initiated. * Care plans have been reviewed and reflect the use of the splint/brace.? * Any new or worsening skin integrity issues will require a documented comprehensive RN assessment. This will include physician notification and care plan review. * Nursing staff to be educated on identifying a splint/brace along with the risk for skin breakdown related to the device. * Nursing staff to be educated on following the wearing schedule for splint/braces and completing skin integrity checks according to the plan of care. * Nursing staff will receive education on the need for an RN assessment when any new or worsening wound is found. * Education will begin April 24, 2024, for nursing staff and will continue and be provided prior to the start of their next shift for nursing staff. * Facility reviewed the policy for prevention of pressure injuries. * Medical Director is aware and involved in plan. * DON/designee will audit all brace/splint monitoring orders and wearing schedules three times per week to ensure completion. * DON/Nurse Managers will audit skin checks for braces/splints three times weekly to ensure compliance. * Results of audits will be reviewed through the QAPI process and make changes as necessary. The deficient practice continues at a scope and severity of a G (actual harm/[NAME][TRUNCATED]

Based on observation, record review, and interview, the facility did not ensure that residents received adequate assistance devices to prevent accidents for 2 (R65 and R67) of 7 residents reviewed for accidents. *R65 was transferred using a pivot transfer when R65's Care Plan indicated R65 transferred using a sit-to-stand lift. R65 sustained a broken tibia and fibula. *R67 was observed to not not have a fall mat in place per Care Plan. Findings include: The facility policy and procedure entitled Fall Prevention Program dated 5/2023 states in part: Procedure: 1. A care plan for fall prevention will be implemented and maintained to assure the safety of residents who are at risk. The program will be inclusive of measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate staff interventions to assure adequate supervision is provided, and that assistive devices are utilized when necessary. Fall Incident Reports will be reviewed, and quality issues identified to assure the on-going effectiveness of the prevention program. 6. Fall prevention strategies will be utilized for residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. 1.) R65 was admitted to the facility on [DATE] with diagnoses of malnutrition, anorexia receiving the majority of nutrition through a gastrostomy tube, diabetes, polyneuropathy, adult failure to thrive, and depression. R65's Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated R65 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R65 did not have an activated Power of Attorney. R65's Activities of Daily Living Care Plan was initiated on 6/23/2023 and had the following interventions in place on 3/11/2024: -Bed mobility: 1 assist extensive with bilateral side rails. -Eating: Setup and clean up assist/cue and encourage for meals. Offer alternative if R65 declines meal. Enteral nutrition via pump overnight. -Transfer: 2 assist with sit-to-stand mechanical lift On 3/11/2024 at 3:45 PM in the progress notes, nursing charted R65 complained of pain to the right leg and when asked if R65 could lift the leg, R65 started to scream. Tramadol was given at 2:58 PM and an ambulance was contacted for transfer to the hospital. The Emergency Department Provider Note dated 3/11/2024 documented R65 presented to the emergency department complaining of right leg pain. R65 stated R65 was being transferred from the wheelchair to the bed when during the transfer the right leg became trapped between the left leg and the bed. R65 felt a pop and extreme pain in the leg. X-rays were taken of the right leg and knee with results showing a fracture of the right tibia and fibula. On 3/15/2024 at 3:09 PM in the progress notes, nursing charted R65 was readmitted to the facility after being treated for a right tibia/fibula fracture and has an external fixation device to the right lower extremity. The device is not to be touched and to only lift the leg from the bottom for repositioning. R65 is non-weight bearing to the right lower leg. Surveyor reviewed the facility investigation of R65's right tibia and fibula fracture. The investigation was started by Registered Nurse Supervisor (RN Sup)-AA. The investigation form stated RN Sup-AA was approached by staff on 3/11/2024 to assess R65 due to R65 being transferred from the wheelchair to the bed when R65 started crying out in excruciating pain from the right knee down to the right foot. R65 told RN Sup-AA that R65 was in the wheelchair and wanted to go to bed. R65 told RN Sup-AA the Certified Nursing Assistant (CNA) wanted to get the lift and R65 told the CNA R65 did not want to use the lift as R65 had been doing pivot transfers with therapy. R65 told RN Sup-AA during the transfer R65's left leg crossed behind the right leg and R65 heard a pop snap-like noise and immediately felt severe pain from the right knee down to the ankle. CNA-X completed a statement on the investigation form which stated CNA-X answered R65's call light where R65 requested to be transferred back to bed from the wheelchair. CNA-X told R65 it would be a minute because CNA-X needed to get the lift. R65 told CNA-X that R65 was being transferred by pivot transfer. CNA-X knew that R65 was being transferred in therapy by a pivot transfer so CNA-X decided that CNA-X could do a pivot transfer with R65. During the transfer, CNA-X positioned CNA-X in front of R65 with a gait belt around R65's waist. CNA-X stated R65 stood up and transferred towards R65's right side which was R65's dominant side and R65's leg moved during the transfer crossing behind R65's right leg and when R65 was lowered to the bed, R65 started to yell out in pain. CNA-X immediately notified the RN to assess R65. The investigation was continued by Director of Nursing (DON)-B. DON-B wrote up a summary of the event. CNA-X was suspended pending an investigation on 3/11/2024. Statements were obtained from R65, CNA-X, and RN Sup-AA. It was determined by the facility that CNA-X did not follow R65's plan of care. In an interview on 4/21/2024 at 10:33 AM, R65 stated a caregiver was transferring R65 from the wheelchair to the bed and instead of using the sit-to-stand lift, the CNA lifted R65 by herself. R65 stated R65's right leg went under the bed which the CNA could not see and put R65 in bed. R65 stated both bones below the knee broke. Surveyor asked R65 to clarify how the CNA moved R65 from the wheelchair. R65 stated the CNA physically picked R65 up. R65 stated R65 used to weigh a lot less but had been gaining weight so the CNA would have been able to pick up R65 but not at that time. Surveyor observed R65's right leg with external fixators in place. In an interview on 4/23/2024 at 9:22 AM, Surveyor asked RN Sup-AA to review the incident on 3/11/2024 where R65 sustained a fractured tibia and fibula. RN Sup-AA stated RN Sup-AA did the investigation of the incident and interviewed CNA-X to find out what happened. RN Sup-AA stated CNA-X said CNA-X was going to transfer R65 and was going to get the lift when R65 said no, R65 had been doing pivot transfers in therapy and R65 could transfer that way. RN Sup-AA stated CNA-X said CNA-X gave in to R65 and R65's legs got twisted in the turn. RN Sup-AA stated when R65 was talked to, R65 said R65 wanted to do a pivot transfer and thought R65 had broken the leg. RN Sup-AA stated R65 was in a lot of pain even after Tramadol was given so RN Sup-AA went to the Nurse Practitioner (NP) and the NP agreed to send R65 out without getting an x-ray first. RN Sup-AA stated the hospital said R65 had a fracture and a history of osteoporosis. RN Sup-AA an investigation was competed. RN Sup-AA stated RN Sup-AA got CNA-X's statement and R65's statement as part of the investigation. On 4/24/2024 at 11:56 AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern CNA-X transferred R65 with a pivot transfer rather than using the sit-to-stand lift that was in R65's Care Plan and R65 sustained a fractured tibia and fibula during the transfer. NHA-A stated CNA-X did not follow R65's Care Plan. 22692 2.) R67 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction. On 4/22/24, Surveyor reviewed R67's care plan for risk for falls with a start date of 3/26/23 and noted the intervention floor mat to the right side of the bed was initiated 1/24/24. On 4/22/24, Surveyor reviewed R67's current Certified Nursing Assistant care card and noted under safety, it indicates floor mat at right side of bed. On 4/22/24, Surveyor reviewed R67's last fall risk assessment dated [DATE] and noted it indicated R67 was at high risk for falls. On 4/21/24 at 10:30 AM, R67 was observed in bed and no fall mat was observed on the right side of R67's bed. On 4/21/24 at 1:30 PM, R67 was observed in bed and no fall mat was observed on the right side of R67's bed. On 4/22/24 at 8:30 AM, R67 was observed in bed and no fall mat was observed on the right side of R67's bed. On 4/22/24 at 11:30 AM, R67 was observed in bed and no fall mat was observed on the right side of R67's bed. On 04/22/24 at 2:41 PM, Surveyor took Licensed Practical Nurse (LPN)-O into R67's room. LPN-O looked for R67's floor mat and did not find it. LPN-O indicated R67 should have a floor mat on the right side of his bed. The above findings were shared with Administrator-A and Director of Nurses-B on 4/23/24 at 3:00 PM. Additional information was requested if available. None was provided.

Based on record review and interview, the facility did not ensure a resident with an indwelling catheter was assessed for removal of the catheter as soon as possible for 1 (R65) of 3 residents reviewed with indwelling catheters. *R65 was admitted to the facility with a urinary catheter and the catheter was not removed due to resident convenience with no conversation of risks or benefits documented. R65 was hospitalized [DATE] and 1/6/2024 with sepsis due to a catheter associated urinary tract infection. Findings include: R65 was admitted to the facility on [DATE] with diagnoses of malnutrition, anorexia receiving the majority of nutrition through a gastrostomy tube, diabetes, polyneuropathy, adult failure to thrive, and depression. R65's Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated R65 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, had a Stage 4 pressure injury to the coccyx, and had an indwelling urinary catheter. R65 did not have an activated Power of Attorney. On 4/5/2024 at 8:23 PM in the progress notes, nursing charted R65 was admitted to the facility with diagnoses of failure to thrive, weakness, and urinary tract infection (UTI). R65 had a Foley catheter in place. R65's Urinary Catheter Care Plan was initiated on 4/5/2023 with the following interventions: -Monitor for signs/symptoms of catheter complications such as leaking, obstruction, etc. -Monitor/document for pain/discomfort due to catheter. On 4/6/2024 at 2:46 AM in the progress notes, nursing charted R65 was currently on cephalexin 500 mg four times daily for UTI with the last date of antibiotic on 4/11/2024. On 4/6/2023, R65 had a diagnosis of urinary retention. On 4/11/2023, R65 had a Urology consult. The Urologist charted R65 was seen for an inpatient consultation on 3/24/2023 for urinary retention. While R65 was in the hospital, R65 was unable to urinate, and a Foley catheter was placed. The Urologist charted R65 wants to continue with a chronic Foley catheter due to limited mobility and the Foley catheter makes R65's life easier. The Urologist charted R65 was to follow up with the Urologist in a month for a symptom check and discuss a possible voiding trial. On 5/11/2023, R65 had a Urology consult. The Urologist charted R65 was seen one month ago. The Urologist charted R65 wanted to continue with the Foley catheter. The catheter was exchanged and will come back in four weeks for the next catheter change. The Urologist discussed with R65 bladder management options and R65 wanted to continue with the chronic Foley catheter due to limited mobility and the Foley catheter makes R65's life easier. The Urologist charted R65 was to follow up with the Urologist in a month for a symptom check and discuss a possible voiding trial versus a catheter exchange. On 6/13/2023 at 6:15 AM in the progress notes, the Nurse Practitioner (NP) documented R65 had a diagnosis of urinary retention with a plan to attempt a voiding trial. No documentation was found that R65 had the catheter removed to attempt a voiding trial. On 6/16/2023 at 11:21 AM in the progress notes, Licensed Practical Nurse (LPN)-Z charted R65 was being sent to the emergency room due to altered mental status verbalizing wanting to harm self with no identified plan. R65 was currently being treated for an infection to the sacral wound and the physician would like further work up. The NP was updated and agreed to sending R65 to the hospital. The hospital Discharge Summary dated 6/23/2023 documented R65 was admitted with a diagnosis of sepsis due to UTI and osteomyelitis. The infective organism of the UTI was Escherichia coli and was catheter related. Escherichia coli is a bacteria found in fecal matter. R65 received intravenous antibiotics for the UTI as well as osteomyelitis of the Stage 4 sacral pressure injury. On 6/23/2023, R65's Urinary Catheter Care Plan was revised to include the catheter was maintained for wound treatment. Surveyor did not find any documentation by the Wound Physician that the indwelling urinary catheter was recommended for wound healing. On 8/1/2023, R65's diagnosis of urinary retention was removed from the diagnosis list. On 1/6/2024 at 9:34 PM in the progress notes, nursing charted R65 had nausea and vomiting twice and complained of pain in bilateral hands. Vital signs were blood pressure 69/41, pulse 122, oxygen saturation 96% on room air, temperature 98.2, and respirations 18. R65 was showing signs of being lethargic and was slow to answer questions. R65 tested negative for COVID-19. R65 stated they were not feeling well. 911 was activated and R65 was taken to the hospital. The hospital Discharge Summary dated 1/15/2024 documented R65 was admitted to the hospital for septic shock due to Escherichia coli in the urine with a catheter in place. R65 received intravenous antibiotics for the UTI. On 3/15/2024, R65 had an order for the antibiotic cephalexin 500 mg four times daily for five days for a UTI. On 4/5/2024, R65 had an order for the antibiotic Bactrim DS 800-160 mg twice daily for six administrations for a UTI caused by proteus mirabilis. On 4/21/2024 at 10:28 AM, Surveyor talked to R65 about having the Foley catheter. R65 stated R65 has had the catheter for a year because of urinary retention. R65 had fractured the right tibia and fibula with external fixators in place and stated R65 was unable to get up to go to the bathroom with the broken leg. R65 stated the catheter plugs up and then leaks into an incontinence product and when that happens, the catheter is changed out which sometimes can take a while for staff to change it. Surveyor asked R65 if R65 has had any infections with the catheter. R65 stated yes. In an interview on 4/23/2024 at 9:32 AM, Surveyor asked Registered Nurse Supervisor (RN Sup)-AA about R65's urinary catheter. RN Sup-AA stated R65 had a history of urinary retention so has had a chronic Foley catheter with chronic UTIs caused by lots of microorganisms. Surveyor asked RN Sup-AA if R65 had ever had a voiding trial to see if R65 still needed the catheter. RN Sup-AA did not know and stated LPN-Z was the unit manager recently and may know if a voiding trial was done. RN Sup-AA stated R65 has a large sacral wound and now has the external fixators on the leg so it would be appropriate for R65 to have a catheter. RN Sup-AA stated R65 sees the Urologist regularly. Surveyor shared with RN Sup-AA that no documentation was found showing R65 was given the risks and benefits of having a catheter. Surveyor asked RN Sup-AA if there had ever been that conversation. RN Sup-AA did not know but thought they had been trying to get the catheter out. RN Sup-AA stated R65 has had problems with clogging of the catheter which should be flushed when that happens. RN Sup-AA stated R65 was good about saying if the catheter was leaking and they try to irrigate the catheter and will change it out if it will not flush. In an interview on 4/23/2024 at 9:43 AM, Surveyor asked LPN-Z if R65 ever had a voiding trial to see if R65 could have the catheter removed. LPN-Z stated the facility had done a trial to get rid of R65's catheter but was not sure when that was done. Surveyor shared documentation was found of a voiding trial being done in the hospital discharge notes but no documentation was found of the facility attempting to remove the catheter. LPN-Z stated it was R65's preference to keep the catheter and it is for better healing of the wound as well. On 4/24/2024 at 11:59 AM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern R65 had not had an attempt to remove the urinary catheter in the last year since admission and R65 developed sepsis twice requiring hospitalization and intravenous antibiotics; R65 had oral antibiotics twice for a UTI as well. Surveyor shared with NHA-A the concern no documentation was found of a conversation with R65 of the risk versus benefits of having an indwelling urinary catheter. No documentation was found that the catheter was in place due to wound healing. On 4/29/24 the facility provided additional information indicating a formal diagnosis of neurogenic bladder was obtained for R65. Surveyor reviewed and noted the information provided by the facility.

Based on interview and record review, the facility did not ensure staff provided basic life support to 1 (R37) of 1 Residents who required Cardiopulmonary Resuscitation (CPR.) The facility currently has 50 out of 92 residents who desire CPR (Full Code.) The failure of staff to immediately call a code for R37 on the overhead page system, failure to call 911, the failure to not start CPR immediately, the failure to bring the crash cart & AED (Automated External Defibrillator) into R37's room during the code, and RN-NN instructing LPN-MM to stop CPR created a finding of immediate jeopardy that began on [DATE]. Administrator-A, DON (Director of Nursing)-B, Corporate Consultant-C, & Regional Clinical of Operations-D were notified of the immediate jeopardy on [DATE] at 12:18 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of E (potential for more than minimal harm/pattern) as the facility continues to implement and monitor their action plan. Findings include: The Cardiopulmonary Resuscitation-CPR policy & procedure with an effective date of [DATE] documents under guidelines: This facility will provide basic life support including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advanced directives. Under CPR Procedure it is documented: 1. Employee to verify safety of the scene/environment. 2. Check for resident response. Tap or shake shoulder of resident asking, Are you okay? 3. Simultaneously assess the resident for breathing and pulse for 10 seconds. If necessary, open the airway: Head-tilt/chin-lift technique. If a head, neck, or spinal injury is suspected, utilize the modified jaw-thrust maneuver. 4. Shout for nearby help or pull the call light for assistance. Activate emergency response System by announcing overhead, 3 times CODE BLUE and LOCATION. 5. Staff immediately instructed to retrieve emergency cart/equipment. If collapse was witnessed and staff member alone, leave resident to activate the emergency response system and retrieve emergency cart (unless another staff member is able to retrieve device) before beginning CPR. 5. Identify code status/advance directive preferences. If the resident has a valid advance directive, indicating Do Not Resuscitate, DO NOT PERFORM CPR: ILLINOIS - a POLST (Physician Orders for Life-Sustaining Treatment Form that indicates that resuscitation is not desired.) WISCONSIN - a POST (Physician Orders for Scope of Treatment form that indicates that resuscitation is not desired). 6. If a DNR order/Advanced Directive does NOT exist or if Advance Directive does not indicate DO Not Resuscitate, begin resuscitation efforts. 7. If Resident does not exhibit normal breathing and has a pulse, begin rescue breathing. 1 breath every ,d+[DATE] seconds (,d+[DATE] per minute) using face mask or Resuscitator Bag. If resident is presenting with agnal breaths, continue as if resident is not breathing. 8. Check pulse approximately every 2 minutes. 9. If no pulse, begin CPR. Place backboard under resident in bed or assist resident to a firm, flat surface if possible. Compress chest compressions at a rate of ,d+[DATE] per minute (place 2 hands on the lower half of the sternum). Compress to a depth of at least 2 (inches). Ensure full recoil following each compression. Minimize any pauses in compressions. Ventilate 2 breaths after 30 compressions, each breath to be delivered over 1 second, causing chest to rise (30:2 Ration for both 1 or 2 rescuers). Use face mask or resuscitator bag. 10. Continue resuscitation efforts until one of the following occurs: Resident presents with effective, spontaneous circulation. Care is transferred to emergency responders to provide advanced life support. The rescuer is not able to continue due to exhaustion, dangerous environmental hazards or efforts to resuscitate places others in danger. Reliable and valid criteria that indicates irreversible death are met, criteria of obvious death are identified or criteria for termination of resuscitation is met. 11. Turn CPR over to emergency personnel upon arrival and prepared to take over. The Automated External Defibrillator (AED) Policy dated [DATE] documents Purpose: The purpose of this policy is to provide information regarding the use of the AED. The use of the AED: The AED is to be applied to a victim if indicated, during a code blue response. R37 was readmitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, COPD (chronic obstructive pulmonary disease,) panlobular emphysema, diabetes mellitus, hypertension, depression, aphasia, and anxiety disorder. R37 was his own person. Resident's care plan notes Resident has advanced directive CPR - Full Code which was initiated [DATE]. Interventions are: * Code status will be reviewed on a quarterly basis and PRN (as needed) initiated [DATE]. * Resident has decided to remain a full code initiated [DATE]. The physician order dated [DATE] documents Full Code - (Provide CPR.) The orders administration note dated [DATE] at 3:54 p.m. documents Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours as needed for SOB (shortness of breath)/Wheezing Audible wheezing noted. The orders administration note dated [DATE] at 5:51 p.m. documents Albuterol Sulfate HFA Aerosol Solution 108 (90 Base) MCG/ACT 2 puff inhale orally every 4 hours as needed for SOB/Wheezing PRN (as needed) Administration was: Effective. The next nurses note is dated [DATE] at 4:59 a.m. and documents The Resident passed away at 04:50 am. The CPR initiated. Doctor was notified. [Name] called and notified via voice mail. Then author called his daughter [name] and notified the time of death. The Resident was unresponsive to the treatment. No pulse, BP (blood pressure)/heart rate were absent. The only vital signs documented on [DATE] were at 12:53 a.m. for 94% oxygen via nasal cannula. The nurses note dated [DATE] at 5:11 a.m. documents Nurses note Time of Death Resident observed with no pulse, respirations or audible heart tones. Time of death: The Resident passed away at 04:50 am. The CPR initiated. Doctor was notified. The Resident was unresponsive to the treatment. No pulse, BP/heart rate were absent. Second nurse confirming death. (If needed): The charge nurse evaluated ETD (estimated time of death) announced. Family Notification: Then author called his daughter [name] and notified the time of death. Physician Notification: The physician [name] notified. Coroner Notification: Other Notification (Describe): The Resident was unresponsive to the treatment. No pulse, BP/heart rate were absent. CPR performed. Authorization received to release body to funeral home. Post mortem care performed.: Notification that death is a coroner case, post mortem care deferred.: Funeral home notification: Requested documents faxed to coroner office: Time of transport to funeral home/coroner office: Belongings transported with body: Disposition of belongings to family. (Be specific): Eligible medications returned to pharmacy. Others to be destroyed.: Other notes: The Resident passed away at 04:50 am. The CPR initiated. Doctor was notified. [name] called and notified via voice mail. Then author called his daughter [name] and notified the time of death. The Resident was unresponsive to the treatment. No pulse, BP/heart rate were absent. On [DATE] at 1:51 p.m., Surveyor asked RN (Registered Nurse)-BB if there are AED machines in the facility. RN-BB replied we do. Surveyor inquired where they are located. RN-BB stated on the crash cart and he will show Surveyor. RN-BB then showed Surveyor the crash cart with an AED on top of the cart and stated if someone is unresponsive you should bring it with you. On [DATE] at 1:58 p.m., Surveyor asked RN-O if each unit has a crash cart. RN-O replied yes. Surveyor then asked if there are AEDs in the Facility. RN-O replied yes. On [DATE] at 3:19 p.m., Surveyor asked Administrator-A what time night shift staff leave. Administrator-A informed Surveyor they are here until 6:00 a.m. unless schedule says they are leaving early. Surveyor informed Administrator-A Surveyor needs to speak with two night shift staff, LPN (Licensed Practical Nurse)-MM and CNA (Certified Nursing Assistant)-LL. Administrator-A informed Surveyor LPN-MM was here today for a CPR class as he could not come back to work until he completed the CPR class. On [DATE] at 5:45 a.m., Surveyor met with CNA-LL. Surveyor asked CNA-LL to explain what occurred on [DATE] with R37. CNA-LL explained he walked into R37's room for routine change, R37 was coughing a little, he asked R37 if he needed a break and R37 could speak. After CNA-LL got the brief on, R37 started having a major coughing fit, seemed pretty bad. CNA-LL stated he then went to get LPN-MM. Surveyor asked if LPN-MM went to R37's room. CNA-LL replied yes. CNA-LL informed Surveyor he assumed R37 was like this because his oxygen was not on. CNA-LL informed Surveyor LPN-MM placed R37's oxygen back on, R37 seemed to be doing okay, LPN-MM told him to continue with his rounds and check R37 frequently. CNA-LL informed Surveyor he would take care of a resident and when finished would go back and check R37. CNA-LL stated during the third time of checking R37, R37 was not responsive. CNA-LL informed Surveyor he called R37's name & rubbed his chest to try to wake him. CNA-LL informed Surveyor he went to get LPN-MM. LPN-MM came in, looked at R37 & checked his vital signs. CNA-LL informed Surveyor he stayed with R37 while LPN-MM went to get the other nurse. CNA-LL indicated while he was in R37's room he continued to try to wake R37 up by calling his name, rubbing his chest, and trying to get his attention. CNA-LL informed Surveyor the two nurses came in and LPN-MM started CPR. Surveyor asked CNA-LL if the nurses had the AED with them. CNA-LL replied no, and stated they didn't get the crash cart either. CNA-LL informed Surveyor the two nurses took turns doing CPR and after a couple rounds of doing CPR they pronounced him dead and called the family. Surveyor asked if a code was announced on the overhead page. CNA-LL informed Surveyor he doesn't remember. Surveyor asked if 911 was called. CNA-LL replied no. Surveyor asked CNA-LL how R37 was at the start of his shift. CNA-LL replied he was fine, nothing wrong with him. CNA-LL informed Surveyor R37 always had respiratory issues but not that bad. Surveyor asked what R37's respiratory issues were. CNA-LL informed Surveyor R37 frequently coughed and always wore oxygen. Surveyor asked CNA-LL if R37 could tell him what was wrong with him. CNA-LL replied R37 was coughing too much to tell him what was wrong. Surveyor asked CNA-LL if he has received any recent in-services. CNA-LL replied yes, this past Friday on what to do during a code blue. On [DATE] at 6:01 a.m., Surveyor met with LPN-MM. Surveyor asked LPN-MM to explain to Surveyor what occurred on [DATE] with R37. LPN-MM informed Surveyor he was working on the north & south units that night. CNA-LL came and told him R37 was uncomfortable, went there, R37 did not have the nasal cannula on and was having difficulty breathing. LPN-MM informed Surveyor he put R37's nasal cannula on, checked his pulse & breathing. Surveyor asked when CNA-LL came to get him was he on R37's unit? LPN-MM explained he was on the South unit, the other unit. LPN-MM indicated this was not the way R37 used to look and went to get the charge nurse RN-NN. LPN-MM indicated he told RN-NN there was something wrong with R37, was still breathing. Surveyor asked if RN-NN came back with him to R37's room. LPN-MM replied yes, saw R37 was a little more uncomfortable and started CPR. Surveyor asked LPN-MM if CNA-LL informed him R37 was coughing. LPN-MM replied no he didn't tell me that got the charge nurse and started CPR. Surveyor informed LPN-MM, CNA-LL had informed Surveyor CNA-LL went to get him when R37 was coughing bad, you went in placed R37's oxygen back on and told CNA-LL to check R37 frequently. CNA-LL indicated after the third time of checking R37, he went and got you and this is when you went to get RN-NN. LPN-MM informed Surveyor he doesn't remember the time line. LPN-MM informed Surveyor R37 couldn't be revived. LPN-MM informed Surveyor he asked if he should call a code and RN-NN told him no, he's dead, she's in charge so I went with her. LPN-MM informed Surveyor he called the Kenosha police as he didn't have the coroner's phone number, called the POA (power of attorney) sister in law, the daughter, & director when charge nurse pronounced R37 dead. Surveyor asked LPN-MM if he took R37's vital signs would this be documented? LPN-MM replied he didn't know how many times he went in R37's room. Surveyor asked LPN-MM if he brought the crash cart or AED in R37's room? LPN-MM replied no. Surveyor asked why not? LPN-MM replied because I was doing CPR, she told me to give CPR. Surveyor asked LPN-MM how he was doing CPR? LPN-MM replied chest compressions. Surveyor asked LPN-MM if he is CPR certified? LPN-MM replied yes and went through the CPR class yesterday. Surveyor asked if 911 was called? LPN-MM replied no and that he asked the charge nurse and she said no need. Surveyor asked LPN-MM who pronounced R37? LPN-MM replied the charge nurse. Surveyor asked who was doing CPR? LPN-MM replied I was. Surveyor asked if RN-NN also did CPR? LPN-MM replied no. LPN-MM informed Surveyor while he was performing CPR he asked RN-NN to call 911 and she said no need. Surveyor asked LPN-MM why he stopped CPR? LPN-MM said R37 was not responding so declared him dead. Surveyor asked how many rounds of CPR were performed? LPN-MM replied 3, 3 to 4. Surveyor asked LPN-MM if he had an ambu bag? LPN-MM replied no, did CPR for 15 to 20 minutes. Surveyor asked LPN-MM to explain how he did CPR. LPN-MM stated he did 30 compressions then checked for respirations and RN-NN stated carry on, carry on. Surveyor asked LPN-MM if a code was called on the overhead paging? LPN-MM replied No, I asked her and she said no. Surveyor asked LPN-MM where he would find a Resident's code status? LPN-MM informed Surveyor in the patient's chart & PCC (pointclickcare.) Surveyor asked how he knew R37 was a full code? LPN-MM informed Surveyor when he gives medication it's there. Surveyor asked LPN-MM on the night of [DATE] did he check R37's code status? LPN-MM replied no, then stated he rechecked the code status. Surveyor asked LPN-MM if there was anything else he wanted to tell Surveyor? LPN-MM informed Surveyor it was a very particular situation, never came up with this situation, what he was told was strange. Surveyor asked LPN-MM what he meant by what he was told was strange? LPN-MM informed Surveyor not to call the code, 911, and declaring dead by the charge nurse. LPN-MM informed Surveyor he asked RN-NN what needs to be documented and she was not able to give him information on what to document. Surveyor asked LPN-MM when he called the doctor did he speak with the doctor? LPN-MM replied yes. Surveyor asked LPN-MM what he told the doctor? LPN-MM said R37 was not responding and he's dead. Surveyor asked LPN-MM if he informed the doctor R37 had been coughing and CPR was performed? LPN-MM replied no, it was a short conversation and put the phone down. On [DATE] at 9:35 a.m., Surveyor spoke to RN-NN on the telephone. Surveyor asked RN-NN to explain to Surveyor what occurred on [DATE] with R37. RN-NN informed Surveyor she was working on another unit and first name of LPN-MM came up to her at 4:40 a.m. and told her R37 didn't have a pulse. RN-NN informed Surveyor she went to the room, the patient was cold to touch, didn't have a pulse, and began CPR. Surveyor inquired who started CPR. RN-NN replied first name of LPN-MM. Surveyor inquired if CPR was on the bed or floor. RN-NN replied left R37 on the bed. RN-NN informed Surveyor we did another round of CPR, there was still no pulse and called the doctor that R37 passed away and did CPR. Surveyor asked who made the decision to stop CPR? RN-NN stated there were no pulses present and I said to stop it. Surveyor asked RN-NN if she called a code or called 911? RN-NN replied no. Surveyor asked RN-NN why didn't she call a code or call 911? RN-NN replied I was thinking he was a DNR (do not resuscitate.) Surveyor asked RN-NN if they brought the crash cart & AED into R37's room? RN-NN replied no, and stated the patient was new to me, didn't know the patient. The facility's failure to provide R37 with CPR in accordance with current standards of practice and the facility's policies, the failure to call an overhead code blue 3 times and to immediately start CPR, the failure to call 911, the failure to retrieve the emergency cart/equipment such as the crash cart, AED, Ambu bag in order to provide CPR, and the failure to continue resuscitation efforts until care is transferred to emergency responders to provide advanced life support created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when it had completed the following: * All departments received reeducation on basic life support including the CPR policy in the form of verbal education with verification of competency. Training was provided by the NHA, DON, and Nurse Managers. Training was initiated on [DATE] and was completed on [DATE]. The training occurred both individually and in small groups. Staff received reeducation prior to beginning of their next shift. * This training has been incorporated into the orientation process for all new hires. Education includes: Facility policy on CPR and how to respond in the event someone is found unresponsive. Location of the crash carts. Use of AED. Activation of Emergency Response Calling 911. Identification of code status. Once you initiate CPR you cannot stop until 911 arrives and assumes responsibility for the code. * CPR drills have been conducted on each shift and will be ongoing. * Review of CPR Policy on [DATE] by NHA, DON, Medical Director, and Corporate Nurse Consultant. * The CPR Policy was revised on [DATE] to reflect the use of an advanced directive form that indicates full code or DNR status. * Crash Cart Inventory audit in place [DATE] to be completed daily. * Facility has developed a process for internal review of code status events to be completed by IDT team following a Code Event. * Process in place to ensure CPR certification is current. * The facility has established a system to ensure that staff provide care and treatment related to code status based upon resident wishes, standards of practice, and policy and procedures. * Facility has established a system to ensure that advanced directives/code preferences are reflected accurately and timely in the resident's medical record in conjunction with physician consultation. * Hospice providers have been informed of facility policy for obtaining code status. In the event there is a request for a change in code status for a hospice patient, the hospice providers have been instructed to inform the Nurse manager assigned to the unit. If it is outside of normal business hours, the staff nurse will contact the nurse manager on call to facilitate the request immediately. * Facility has developed a process for internal review of code status events to be completed by IDT following a code. IDT team will Audit Post Code Forms following each code event. This will be ongoing. * Crash Cart Inventory Form will be audited by Unit Managers Weekly and following a code event. This is ongoing. Review of audits will be part of the ongoing QAPI (quality assurance performance improvement) process.

Based on interview and record review, the facility did not ensure 1 of 1 resident (R87) with a significant change in condition had a comprehensive assessment performed. On [DATE] at approximately 5:30 a.m., R87's husband asked RN (Registered Nurse) T for assistance because R87 was not feeling well. RN T did not perform a comprehensive assessment into the change in condition. On [DATE] at approximately 6:00 a.m., R87 became unresponsive, 911 was called, and CPR (cardiopulmonary resuscitation) was initiated. On [DATE], R87 was transferred and admitted into the hospital with a diagnosis of cardiac arrest. R87 subsequently passed away while in the hospital on [DATE]. The facility's failure to perform a comprehensive assessment into a change in condition created a finding of immediate jeopardy that began on [DATE]. Surveyor notified NHA (Nursing Home Administrator) A of the immediate jeopardy on [DATE] at 12:30 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope/severity of D (potential for harm/ isolated) as the facility continues to implement its action plan. Findings include: R87 was admitted to the facility on [DATE] with diagnoses of internal prosthetic of right shoulder, type 2 diabetes, CHF (congestive heart failure,) and anxiety. The medical record indicates R87 had moderate cognitive impairment and R87's husband was the APOAHC (Activated Power of Attorney for Health Care.) The nurses note dated [DATE] at 5:42 a.m. documents Resident has been awake all shift calling several family members including her husband. Husband came in this morning around 5:30 am yelling at CNA (Certified Nursing Assistant) because resident is having what he has called anxiety attacks and was requesting anxiety medication for his wife. Writer went and spoke with husband in regard to resident and informed him that at this time there is nothing I can administer to resident. Writer also informed husband that we would request something during office hours of the dr. Husband then stated that wife was taking something at home for anxiety and didn't understand why writer couldn't just give her something because she is in distress. Writer assessed resident and saw no signs of distress. Resident was laying in bed not speaking. Writer again informed husband that I would pass it along in morning report to request something to assist resident with her anxiety. Husband then stated resident has more anxiety pills at home and he himself will bring them in and administer them to wife. Writer advised husband that he can bring in the medication but he could NOT administer the medication to the resident and the facility still needs to have an order to administer the medication. Husband then stated that he will bring it in and administer the medication and what you don't know won't hurt you. Writer informed husband that will be documented. The nurses note dated [DATE] at 8:08 a.m. indicates, Writer walked onto the rehab floor at 0600 (6:00 am) and was called down the hall by NOC (night) nurse to call 911 for a resident who did not have a pulse and was not breathing, writer called 911, and they (911) informed me that they had received a call for room [ROOM NUMBER], it was later clarified that the husband had made the call (to 911) from the room, RN confirmed resident's code status, writer hung up with 911 and took crash cart to the room. Chest compressions were in progress by RN when writer entered with crash cart, writer turned on AED and placed pads on patient, Another RN assisted with giving rescue breaths via ambu bag, no shock was advised for patient and AED (automated external defibrillator) gave instructions to continue CPR (Cardiopulmonary resuscitation), writer took over compressions until EMS arrived, EMS worked on resident in room for approximately another 10 minutes and transported resident to the hospital, directions were given to resident's spouse via EMS. The next nurses note dated [DATE] at 8:32 a.m. indicates, Writer was with resident at about 5:30am resident was alert, talking, moving, and watching TV. Writer was called back to room at 5:54am because husband called facility from room to have wife checked. Writer went back to room to check residents vital signs and assess resident. At that time writer applied blood pressure cuff and obtained glucometer. Writer noticed resident wasn't breathing and was unable to obtain a pulse. Writer began CPR. Writer called out for assistance. Other nurses came to assist. The other nurses took over so that I could print transfer documents, then EMS arrived and took over care. EMS then transferred resident to (name of hospital) ER. The nurses note dated [DATE] 11:33 am states, called ER for update, Resident admitted into ICU (Intensive Care Unit). The nursed note dated [DATE] 15:30 (3:30pm states, spoke to hospital ICU, admitting DX (diagnosis) cardiac arrest. The nurses note dated [DATE] 10:33 am states, reported to facility that resident passed away at the hospital. The hospital record dated [DATE] indicated R87 had a cardiac arrest and was intubated. The documentation indicated R87 may have anoxic brain injury and there was discussion with the family regarding aggressive life support. R87 was taken off life support on [DATE]. On [DATE] at 3:00 p.m., Surveyor asked NHA (nursing home administrator) A if there was an investigation into R87's unresponsive episode on [DATE]? NHA A stated she was not working at the facility during this time but would look for any information. On [DATE] at 9:30 am, NHA A gave Surveyor a statement from RN T. NHA A stated she had no other information for Surveyor other than RN T's statement. Additionally NHA A informed Surveyor RN T no longer works at the facility. On [DATE], Surveyor reviewed a statement dated [DATE], written by RN T, which indicates At about 5:30 a.m. I was called to Rehab for resident in (R87) husband. Her husband came in because resident was having what he called an anxiety attack. He said resident had been calling him all night. I spoke with husband in regards to resident not having anything for anxiety available for me to give and that we will be requesting something when the Drs office opens. Her husband informed me that she normally takes something at home and give them to her himself and what we don't know wont hurt us (conversation documented in progress note). I talked with resident's husband until roughly 5:40 a.m. While I was in the room speaking with the husband the resident was alert, talking, moving and breathing. She did not appear to be in any kind of distress or having any complications at that time. After this conversation I returned to West unit to complete my work on that hall. At 5:54 a.m. I received a call from the North hall CNA that the husband had called the facility from (R87 room) stating someone needed to come check his wife's vital signs because she didn't look good and if we didn't hurry up he was calling 911. At that time I went to rehab obtained the vital sign cart and proceeded to the room. As I approached the room I overheard the husband on the phone with 911. I approached the resident to start assessing her and her vital signs. At that time I noticed the resident was limp and wasn't responding. I attempted to call for help from my cell phone to the facility but didn't get an answer and attempted to overhead page from the room but was unsuccessful. I ran up the hall to get the code status, glucose machine and to overhead page for help. I returned to the room and resident and couldn't feel a pulse and resident wasn't breathing. I paused to look in the hall for help. I saw a day shift nurse who I called out for help. The day shift nurse from rehab and north came in the room to help. We continued with CPR and attached the AED to resident. Shortly after EMS arrived and took over. I called the on call manager to inform her of what happened. On [DATE] at 11:44 a.m., Surveyor interviewed R87's husband. R87's husband stated on [DATE], R87 called him around 4:00 a.m. and told him she doesn't feel good and he needed to come to the facility. R87's husband stated he told R87 to put her call light on and he would call the facility to get R87 assistance. R87's husband stated he hung up with R87 then called the facility and spoke to whoever picked up the phone and reported R87 needed assistance because she didn't feel well. R87's husband stated after a few minutes R87 called him again and stated no one showed up and she still doesn't feel well. R87's husband stated he told R87 that he was going to come in. R87's husband stated he called the facility before leaving his house and no one picked up the phone, it just rang and rang. R87's husband stated between leaving his house and getting to the facility, R87 called him at least ten times. R87's husband stated when he arrived at R87's room he found R87 gasping for breath and looking gray. R87's husband stated R87's call light was on. R87's husband stated he didn't see anyone in the hallway so he called the nurses station and asked for someone to come to R87's room. R87's husband stated a nurse did eventually showed up and he stated he thought R87 was having an anxiety attack and needed assistance. R87's husband stated he did have a conversation with RN T regarding him bringing in R87's medications from home. Surveyor asked R87's husband if RN T performed an assessment on R87, such as listening to her heart, obtaining vital signs, or touching her at any point. R87's husband stated RN T did not perform an assessment. R87's husband stated RN T came in and talked with him then looked at R87 and walked out. R87's husband stated R87 continued to not feel well so he called again to the nurses' desk asking for assistance. R87's husband stated after a few minutes, when they didn't show up to R87's room, he called 911. R87's husband stated after he called 911, RN T showed up and looked at R87 and went out and came back with a crash cart. Surveyor asked R87's husband at any point did R87 stop breathing? R87's husband stated he seems to remember R87 struggling to breath until the paramedics arrived. Surveyor asked R87's husband if RN T performed CPR on R87? R87's husband stated the paramedics arrived right when RN T was going to perform CPR. On [DATE] at 3:00 p.m., Surveyor discussed with NHA A the concern there is no comprehensive assessment of R87's change in condition. In addition, Surveyor shared concerns regarding lack of staff response to R87's husband's telephone call to the facility reporting R87 not feeling well, the facility not answering the phone after R87's husband tried calling the facility back several times prior to arriving at the facility, and the lack of timely response to R87's call light. Surveyor explained the concern R87's husband's view of the incident from [DATE] is different than RN T's statement. Surveyor explained the concern R87 had a change in condition that required CPR and there is no investigation into the incident. On [DATE], NHA A stated LPN P worked the north/south unit on [DATE] on NOC shift and still works at the facility. NHA A stated she talked with LPN P and wrote up a statement. LPN P's statement dated [DATE] indicates LPN P was working north/south unit on [DATE]. LPN P indicates she remembers R87's husband calling (unknown time) and stated he was trying to reach the rehab nurse because his wife was anxious and had her call light on. LPN P indicates she then went to rehab and found RN T and told her what R87's husband said. RN T told LPN P that RN T had been in and out of R87's room all night and that as soon as they leave the room R87 puts the call light on again. LPN P then states around 6:00 a.m. she heard a page that stated, all nurses to rehab. LPN P stated she went to rehab unit and saw RN T coming out of R87's room yelling call 911 because this lady is coding. LPN P stated she got the crash cart, a med tech (unknown name) called 911, and RN T initiated CPR until paramedics arrived and took over. Surveyor explained to NHA A the concern R87 was experiencing a change in condition and RN T did not perform a comprehensive assessment which then R87 became unresponsive and needing CPR. Surveyor also explained the nurses notes and RN T's statement along with LPN P's statement do not coordinate with each other. The facility's failure to perform a comprehensive assessment when R87 was experiencing a change in condition created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE], when the facility completed the following: - Nursing staff will receive re-education on detecting change in condition and conducting proper nursing assessments in the event of identifying a change of condition. - Nursing staff will receive re-education on physician notification policy. - Staff will receive re-education on call lights and responding to grievances (family concerns.) - Staff will receive re-education on resident adjustment post new admission including education on responding to reports of anxiety. - Education for licensed nurses will be done in person by NHA, DON (Director of Nursing,) or nurse managers. Education began on [DATE] with licensed nurses on the schedule. Education will continue and be provided prior to the start of next shift for those not in attendance on [DATE]. Education for staff began on [DATE] and was done by NHA, DON/nurse manager, or HR. Education will continue and will be provided prior to the start of the next shift for those not in attendance on [DATE]. - The Facility reviewed the policy and procedure on [DATE] for physician notification including the definition of a change of condition and timing of notification in conjunction with current standards of practice. - The Facility reviewed the policy on call lights. - The Facility reviewed the grievance policy (family concerns) - The Facility reviewed the policy for caring partners which outlines a process to address resident adjustment post admission and includes addressing mental health needs. - The Medical director has reviewed and provide input regarding the above policies. - Nursing managers / DON will conduct audits during morning clinical review to identify potential change of condition and ensure that an assessment has been completed, physician/family notified as needed and care plan updated as indicated. - Results of audits will be reviewed at QAPI (Quality Assurance Performance Improvement) meeting for further recommendations.

Based on observation, record review, and staff interviews, the facility did not always ensure that 3 out of 9 residents (R29, R68, and R72) reviewed for being at risk for elopement and falls were provided with adequate supervision and assistance devices to prevent accidents. The facility did not evaluate and analyze residents' falls and elopement attempts to determine a root cause analysis. The facility did not implement resident centered care plan interventions to reduce future risk of falls and elopements, The facility did not monitor interventions for effectiveness and modify interventions to provide additional supervision to mitigate the risk of another accident/elopement from occurring. *R29 was assessed to be at high risk for falls and elopement due to having impaired gait and mobility, impaired cognition, and being difficult to redirect. R29 experienced 16 falls from [DATE] through [DATE]. Although some of these falls did not cause injury to R29, several falls did send R29 to the hospital for further evaluation and treatment. R29 suffered a hematoma to her forehead, laceration to her nose, skin tear to her elbow, a laceration to the top of the head requiring stitches, a fracture to her right hip, 2 additional ER visits after the hip fracture to assure the hardware to repair the hip remained intact, another laceration to the face requiring stitches and the last fall, R29 suffered a large hematoma and subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain.) In addition, R29 had several incidents of wandering about the facility, in and out of other resident rooms, and was even found with only a brief and socks on trying to crawl into a male resident's bed. Many residents were upset by the many incidents in which R29 was yelling and wandering about the units and common areas. The facility failed to provide additional supervision to prevent R29 from wandering and R29 was able to elope from the facility where she fell on the sidewalk suffering a laceration to her face. The facility did not conduct a comprehensive evaluation after each fall/wandering/elopement incident so they could implement additional interventions that were both effective and reduced the risk for R29 to suffer further injuries from falls. *R68 was determined to be an elopement risk on [DATE] and at that time a wanderguard was placed on R68. An Elopement Risk Care Plan was initiated on [DATE]. On [DATE], the wanderguard was removed, and the Elopement Risk Care Plan was resolved after a risk assessment was completed determining R68 was no longer at risk for elopement. On [DATE], R68 punched in the code to an outer door and eloped into the parking lot. Staff brought R68 back into the building. On [DATE], R68 ran over the receptionist's foot leaving the building. R68, in a wheelchair, went through the parking lot and across a heavily trafficked four-lane divided street with a curbed median with turning lanes and down two blocks before nursing staff were able to reach R68. Staff brought R68 back into the building. On [DATE], R68 went out the door into the parking lot causing the alarm on the door to sound activated by the wanderguard. Staff brought R68 back into the building. The physician and emergency contact were not notified, and the Elopement Risk Care Plan was not reinstated after any of the three elopements. No investigations or root cause analyses were completed on the elopements and the Elopement Risk Care Plan was not reinstated until [DATE] when the survey team was in the facility. The facility's failure to not evaluate and analyze residents' falls and elopement attempts to determine a root cause analysis, the failure to implement resident centered care plan interventions to reduce future risk of falls and elopements, the failure to monitor interventions for effectiveness and modify interventions to provide additional supervision to mitigate the risk of another accident occurring, and the failure to provide the supervision necessary to prevent falls and elopement for both R29 and R68 created a finding of immediate jeopardy that began on [DATE]. Surveyor notified Nursing Home Administrator-A, Director of Nursing-B and Nurse Consultant-C of the immediate jeopardy on [DATE] at 12:20 p.m. The immediate jeopardy was removed [DATE], however the deficient practice continues at a scope/severity of E, potential for harm/pattern as the facility continues to implement and monitor its action plan and as evidenced by: R72 had multiple falls with no root cause analysis with lack of staff education after the [DATE] fall. There was no evidence that the Interdisciplinary team (IDT) met to review R72's falls on [DATE] and [DATE] in order to develop care planned interventions to prevent future falls. Findings include: Policy Review: Elopement Risk Assessment, Effective date: [DATE], Review/revisions ,d+[DATE]. Purpose: To identify residents who may be potentially at risk for elopement and at risk for harm. To use a baseline to maintain a secure resident environment. Policy: An elopement risk assessment will be performed during the admission process; reviewed/updated quarterly and when there are documented changes in mood or behavior which indicate the potential for elopement. Procedure: 1. The elopement assessment will be completed during the admission process, when there is a significant change in mood or behaviors,) and quarterly. 2. Risk factors that will be assessed include the following: a. Independent ambulation with or without assistance b. Pre-admission or history of elopement c. Purposeful exit seeking d. Restless, aimless pacing e. Verbalization of wanting to leave the facility and/or go home f. Grabbing doorknob or pushing on exit door g. A cognitive impaired individual who is a follower h. Inability to differentiate safe from unsafe situations i. Diagnosis of Alzheimer's, Dementia, Schizophrenia, Brain Injury j. Inability or refusal to follow instructions 3. Should an elopement risk be determined; interventions will be immediately initiated to protect the resident in a reasonable manner and as approved by the physician. 4. The physician and family/POA will be notified as needed of the resident assessment findings, and suggested interventions to protect the resident. 5. Interdisciplinary care plans of those at risk of elopement will address specific interventions that are unique to the risk factors assessed. 6. Interventions may include, however, are not limited to the following: a. Relocation b. Use sign in/sign out record observations c. Psychological Consultation d. Personal Alarm Arm or Ankle e. 15 minutes to 1 Hour f. One-on-one observation 7. The assessment will be maintained in the permanent medical record with other assessment tools. 8. In the event the assessment was initiated because of an elopement (where the resident's whereabouts were unknown,) the elopement will be reported in accordance with the facility's Accident/ Incident Policy. 9. The individual determination of Elopement Risk will be based on the overall assessment of the resident status at the time the assessment is performed. Policy Review: Resident Elopement Plan: Revised [DATE] DEFINITION: Elopement is defined as a situation where a resident with cognitive impairment who cannot recognize normal danger and hazards outside the facility leaves the facility without staff knowledge. This does not include alert residents who handle themselves outside the facility and are choosing to leave the facility, even if against medical advice. An elopement also includes a situation in which a resident with decision-making capacity leaves the facility and the facility is unaware of the resident's departure and/or whereabouts. Procedure: In the event a resident is discovered missing, the following procedures shall be followed: o Determine if the resident is out on an authorized leave or pass. If not; o Make a thorough search of the building and premises including basement and all stairwells. If not located; o Notify administrator and the director of nursing. The administrator or designee shall coordinate a search of the immediate vicinity surrounding the facility and interview all potential witnesses regarding the whereabouts of the resident; o Notify the resident's authorized representative and the resident's physician; Should a thorough search for the resident prove unsuccessful, notify the local law enforcement emergency response system; o Provide search teams and law enforcement officials with resident identification information; o Make an extensive search of the surrounding area. o Until the resident is located and returned to the safety of the facility, the Administrator or designee shall serve as a liaison between the law enforcement officials, the resident's authorized representative, the physician, and the facility. In the event the resident is located and returned to the facility, the following procedures shall be followed: o Examine the resident for injuries; o Contact the attending physician and report findings and the condition of the resident. Follow any physician orders received; o Notify the resident's authorized representative; o Notify search teams that the resident has been located; o Complete and file an incident report; o Make appropriate entries into the resident's medical record; Policy Review: Fall Prevention Program. Effective Date: [DATE]. Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. Fall Incident Reports will be reviewed, and quality issues identified to assure the on-going effectiveness of the prevention program. Guidelines: The Fall Prevention Program includes the following components: o Methods to identify risk factors o Methods to identify residents at risk o Assessment time frames o Use and implementation of professional standards of practice o Immediate change in interventions that were successful o Notification of physician, family/legal representative o Communication with direct care staff members o Documentation requirements o Adherence to manufacturer's recommendation in use of alarm and medical devices and special care equipment. o Care plan incorporates: o Identification of all risk/issue Interventions are changed based on RCA (root cause analysis) following a fall, as appropriate Care plan is updated if fall risk changes o Preventative measures Periodic quality assurance audit activities of records relating to falls that exhibit adherence to facility policies and implementation of the plan of care. IDT will be responsible for reviewing residents falls, monitoring the effectiveness of fall prevention strategies, and for recommending individualized safety interventions. Procedure: A Care plan for fall prevention will be implemented and maintained to assure the safety of residents who are at risk. The program will be inclusive of measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate staff interventions to assure adequate supervision is provided, and that assistive devices are utilized when necessary. Fall Incident Reports will be reviewed, and quality issues identified to assure the on-going effectiveness of the prevention program. 2. The IDT will meet to review all resident falls that have occurred. Fall Incident Reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies that may be indicated. 3. The Director of Nursing (DON) and nurse managers and/or designee will be responsible for implementing and communicating resident-specific recommendations from the IDT to the nursing staff assigned to the resident. The nursing staff will be responsible for assuring the recommendations are followed through. 4. The DON and/or Designee will be responsible for communicating any significant safety issues identified through the Fall Risk Committee to the Quality Assurance Committee for further review or corrective action plans as indicated. 5. A Fall Risk Assessment will be completed initially, quarterly, and with any significant change in condition. Residents found to be at risk of falling will have a care plan implemented to address the need for additional safety precautions. The interdisciplinary care plan will include the risk of falls, reasonable goals, and appropriate interventions to prevent falls and/or injury from falls. 6. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. 7. Residents will be evaluated after a fall has occurred in an attempt to identify any causative factors that need correction. 8. Nursing staff will complete an Incident Report in risk management for each fall to determine factors contributing to the fall and interventions to reduce the risk of further falls. 1. R29 was originally admitted to the facility on [DATE] with diagnoses that included major depressive disorder, Dementia, anxiety disorder, visual hallucinations, insomnia, and cognitive communication deficit. Surveyor conducted a review of R29's most recent Significant Change Minimum Data Set (MDS) dated [DATE]. R29 was assessed to have both long and short-term memory problems. R29 has moderately impaired cognitive skills for daily decision making. R29 is assessed to have disorganized thinking, inattention, and an altered level of consciousness that fluctuates (comes and goes, changes in severity.) R29 needs extensive assistance with activities of daily living. R29 is said to use both a walker and wheelchair for mobility. R29 has had 1 fall since admission without injury. R29 has had surgery to repair a fracture of the pelvis, hip, leg, knee, or ankle. R29 has received antipsychotic medications over the past 5 days (assessment reference period,) 6 days received Antidepressants, and 6 days received antibiotics. A gradual dose reduction of the Antipsychotic was attempted [DATE]. The facility conducted a falls risk assessment on [DATE] in which it was determined that R29 is at high risk for falls. The facility also conducted assessments on [DATE] and [DATE] in which R29 remained at high risk for falls. R29's individual plan of care stated that she is at risk for falls due to weakness, impaired gait, and mobility. This was initiated on [DATE]. On [DATE], the plan of care was revised to say that R29 is at risk for falls due to weakness, impaired gait, and mobility, cognitively impaired, unable to redirect. Interventions included: anti-roll back for wheelchair, bilateral pillows on while in bed, encourage appropriate footwear, offer ambulation after lunch, and assist to bed for a nap, prefers to be seated at dining table in front of nurses station when awake, R29 to be encouraged to ambulate to the bathroom once daily with an extensive assist of one with a walker, gait belt and wheelchair for safety, early morning get-up by the night shift and put down to bed between ,d+[DATE] p.m. to encourage healthy sleep patterns. Fall #1: Nurse's note dated [DATE] at 10:24 p.m., R29 continues to yell and scream Help, when asked what she needs help with she stays quiet. Resident had an unwitnessed fall today in the hall by the nurse's station. R29 is unable to state if she was hurt. No apparent injury noted at the time, able to move all extremes and no visible injury to head. POA (Power of Attorney) was notified. MD was notified, no new orders, DON was also notified. Surveyor conducted a review of the facility's falls investigation dated [DATE] at 5:09 p.m. R29 tried to get up and slipped out on wheelchair onto the floor, slippers on at time of fall. R29 unable to describe what happened. No injuries observed. No witnesses found. The investigation did not indicate if new interventions were put into place nor did the facility conduct a root cause analysis. Fall #2: Nurse's note dated [DATE] at 2:39 p.m., R29 was found on the floor by the left side of her wheelchair at north dining room, resident was unable to describe what happened resident was repositioned on her wheelchair full body assessment done no injury noted during assessment resident able to move all extremities with no issues denied pain during assessment neuro check initiated and within normal limit [DATE] at 4:37 p.m., Interdisciplinary Team Note Late Entry: reviewed fall occurring ,d+[DATE] approx. 1:45 p.m. R29 fell from wheelchair (WC) in north unit lobby/dining area. R29 has history of falls. All interventions in place at time of fall. Upon further investigation resident was irritable / restless prior to fall - attempting to self-mobilize WC (wheelchair); as R29 scoots she brings buttocks closer to edge of seat. Root cause of fall appears to be poor safety awareness d/t WC positioning. Therapy to evaluate for proper WC mechanics / proper fitting WC - WC was replaced w/WC that has lower floor to seat height to assist is weight distribution when scooting in WC. Further review showed that it was not until [DATE] that R29's fall care plan was updated to have a new wheelchair with lower seat to floor height to encourage better body mechanics/weight distribution to prevent scooting to edge of wheelchair seat to decrease risk of falls due to poor awareness. On [DATE], the plan of care was updated with the intervention to assist R29 with family video calls when increased restlessness or anxiety noted. Nurse's note dated [DATE] at 1:31 p.m., this writer called POA regarding R29's fall on ,d+[DATE] and ,d+[DATE] also updated POA about resident increased behavior episode lately, POA requested medication list to be faxed to her. medication faxed to POA as requested. will continue to monitor Nurse's note dated [DATE] at 9:42 p.m., R29 was screaming most of PM shift continue to get out of wheelchair redirected her most of PM shift put her in bed at her request and as soon as Certified Nursing Assistant (CNA) walk out of room patient started screaming, I want to get up went in room and stated you don't have to go to sleep but you must rest, reposition patient got her comfortable then she was quiet and fell asleep. [DATE] 1:02 a.m., Behavior Note Describe behavior, notifications: Yelling out periodically during shift. Becomes verbally aggressive with staff swearing and threatening physical harm. Then her mood changes on a dime and she's sweet and speaks kindly, then the flip again. Requires a 1:1 staff member to watch her as she's a high fall risk and does not listen when attempting to educate her on safety. Will continue to monitor. *It was noted that the plan of care was not updated to reflect the need for 1:1 supervision due to increased fall risk. Fall #3: Nursing note dated [DATE] 8:55 p.m., R29 was wheeling herself along the hallway, writer was down the hall passing meds and on looking back, writer saw resident on the floor at west nursing station close to the dining. Resident was yelling help me, when asked some questions, she said she hit her head and her arm hurt. Writer and the resident's nurse called RN (supervisor) to the scene. R29 was assessed. R29 said she hit her head and her arm hurt. There was hematoma on R side of forehead and also laceration along the left side of the nose. It bled and the nurse cleansed it. Vitals were within normal range. The nurse called MD, MD said to send resident to ER. Resident was transferred to ER (emergency room ) via ambulance. Nurse called POA, no answer nurse left a message. Nursing note dated [DATE] at 3:34 a.m., R29 returned from ER @ 3:36 a.m., contusion of face & blunt head trauma. CT scan done, given NaCl (sodium chloride) continue to monitor next 24 hrs. [DATE] 09:28 a.m., Interdisciplinary Team Note Text: IDT reviewed unwitnessed fall that occurred on [DATE]. R29 was found down on the floor in the corridor on the west unit. Injuries noted - resident stated her arm hurt, also received a laceration to nose and hematoma to forehead. No change of consciousness noted. R29 sent to ER for evaluation due to hitting head. R29 has advanced dementia with behavioral disturbance. History of falling. History of pacing, anxiousness, and at times aggressive behavior. Resident is under services of psych for behaviors, however POA will not consent to medication regime for behaviors. Staff will initiate an ambulation program for strengthening as resident presently frequently attempts to get up and walk unassisted. Further review of the medical record showed that the falls care plan was updated on [DATE] to add the intervention of staff to ambulate R29 between meals. No further direction given. [DATE] at 10:17 a.m., Interdisciplinary Team Note Text: IDT reviewed fall that occurred on [DATE]. R29 was sitting in dining area, attempted to get up and fell . R29 is confused, restless at times and has dx of dementia with behavioral disturbance. Resident was scooting in chair and scooted to front of chair and wind up scooting out of chair onto floor. No injuries noted secondary to fall. Difficult to redirect at times. Will continue to monitor and provide with distraction activities as necessary. Physician progress note dated [DATE] indicates that R29 was seen in theER on [DATE] after a fall and suffering a head injury with left forehead hematoma. CT C-spine/ facial bones / head and Xray of chest and pelvis were performed and negative for acute changes. Of note: R29 is consistently agitated and getting up out of her chair and as such has a high fall risk. R29's POA will only allow Risperidone at bedtime. Cymbalta for depression. Otherwise declining all other medications prescribed by the Psych Nurse Practitioner. Plan of care discussed with the nurse reports R29 had no acute injuries after the fall and remained stable which, for the patient, remains being agitated especially at night and consistently needing one-on-one observation to reduce fall risk. Assessment and plan: Risperidone dose decreased from 0.5 milligrams twice daily to only at bedtime on [DATE], now has been increased agitation as of early July. On [DATE] at 11:00 a.m., the facility had a Care Conference meeting. Reason for Conference (Admission, Quarterly, Annual, Focused): Request by staff Social Service Review (Mood/Affect/Behavior/Cognition/Communication, D/C Plans, Concerns & Goals: not on any anxiety meds - see psych, informed that (POA) chose to discontinue psych meds for anxiety. Reported to nurse that (POA) felt R29 was over medicated. Was on Zoloft, Buspar before. POA would like to get R29 to be started on something for her anxiety. Nurse to update appropriate party. Psychotropic Regimen (if applicable). Med/Dose/Purpose/Efficacy/Side Effects: Nursing - General Health, Diagnoses and Medications Reviewed. Concerns/Goals: agitation, moving around (impatient, restless), falls, getting up out of w/c alone, trying to walk, transfer by self, yelling out, anxious. Safety Plan of Care (Concerns/Goals): (remained blank) Nurse's note dated [DATE] 8:45 p.m., R29 has been tearful, restless and agitated since start of PM shift. Self-transferring from WC and self-ambulating in halls. Gait unsteady, education and redirection provided. Resident screaming in halls, attempting to enter other resident's rooms. Toileting has been provided, ate 100% dinner and an additional sandwich. Assisted to bed, dozed off for 15 minutes and started screaming again. Bed in low position. Call light within reach. Will continue to monitor. Nurse's note dated [DATE] at 1:57 p.m., R29 start screaming and yelling from the top of her lungs while physical therapist was trying to help her to sit on her wheelchair R29 got up from her wheelchair ambulating without assistance R29 was pushing door 2 trying to open it, R29 was redirected to the nurse station and sat on her wheelchair resident sat on her chair for a few minutes then got up and continued ambulating without assistance. will continue to monitor. [DATE] at 6:58 p.m., Behavior Note Describe behavior, notifications: R29 was up and down all evening, walking to west, south and all over north (units) in and out of other residents' rooms yelling and screaming. R29 also stated,it's too hot down here! Tried taking her to bathroom, food, music, TV, giving her activity box and blowing the fan on her nothing worked, very,very,very hard to redirect. R29 is very disruptive to the other residents with some of them yelling at her to Shut up! Nurse's note dated [DATE] at 2:09 p.m., R29 is being monitored for behavior, ambulating without assistance during first shift, refusing assistance while ambulating. will continue to monitor Fall #4: Nursing note dated [DATE] a 4:13 p.m., Alert Note, fall unwitnessed: R29 observed on the floor on her right side near her w/c. R29's roommate states R29 got up from w/c to use the bathroom, when completed R29 was going back to her w/c which was near her bed and lost balance and fell . Head to toe assessment completed no obvious injuries found. Vitals: ,d+[DATE], 97.8T, 96% SpO2 RA, 18R, 100P. R29 states she has no pain and wants help to go back to her w/c. Resident placed in bed till nurse on the floor can observe the resident. This nurse reminded R29 to use her call light to get assistance to the bathroom. R29 placed on neuro-checks due to nature of fall. POA and NP on call contacted with no further orders. Surveyor conducted a review of the facility's falls investigation, dated [DATE] at 4:09 p.m. The document states that R29's mobility is wheelchair only, room was dark and R29 was walking without staff assistance. [DATE] note states that R29 has a history of dementia with behaviors, cognitively impaired, unaware of safety to her surroundings. Further review did not show that any further interventions were put in place to keep R29 safe and there were no staff statements to determine when the last time R29 was assisted with toileting per the plan of care or if any other interventions were put into place. Nursing note dated [DATE] at 10:08 a.m., R29 ambulating and screaming from the top of her lungs difficult to redirect refusing assistance whenever offered by staff, R29 ambulating pushing her wheelchair, was found on rehab unit sitting in one of the rooms. The resident is ambulating around the north unit at this time. Will continue to monitor [DATE] at 8:47 p.m., Behavior Note Describe behavior, notifications: R29 was up walking to west, south and back to north (units.) Going in other residents' rooms redirected several times. Nursing note dated [DATE] at 8:29 p.m., R29 agitated ambulating without assistance resident was pushing back door on north unit, resident redirected to her room and repositioned in bed. resident is sleeping at this time. will continue to monitor. Fall #5: [DATE] at 06:49 a.m., Event Note Situation: R29 found on knees approx. 6:10 a.m. R29 was hugging her pillow w/ her torso on the bed. R29 does not appear to be in distress, she was sleeping at time of finding. R29 was last checked on 5:45 a.m. she was sleeping in bed. No injuries / skin abnormalities to note. Background: R29 did not sleep approx. ,d+[DATE].5hr. Assessment (RN)/Appearance (LPN): Bed in lowest position. Fall mat was at bedside, bed against wall, call light was in reach but not in use. Neuro Checks WNL (within normal limits), assisted to bed, POA MD updated. VS - BP: ,d+[DATE] HR 84 T: 97.9 spo2 96 rm air resp 16. Room assessed, there is an air mattress in place for unknown reason will have replaced w/ regular. Recommendations (Document who was Notified and any New orders): POA & MD updated. NNO (no new orders.) Cont neuros. Recommendations: NNO, will have maintenance replace mattress. Surveyor conducted a review of the facility's falls investigation dated [DATE] at 6:24 a.m. R29 was assisted back to bed, POA and MD updated. Room assessed, there is an air mattress in place for unknown reason. Will address replacement with regular mat. No injuries observed. *Further review of this fall noted that Maintenance Department had put the air mattress on the wrong resident's bed. It was not said how long this type of mattress had been in place for R29's bed. Nursing note dated [DATE] at 2:47 p.m., R29 ambulating without assistance self-transferring from her wheelchair to a regular chair during first shift. will continued to monitor. [DATE] at 9:16 p.m., Behavior Note: R29 was yelling, screaming and wandering into other residents' rooms for most of the evening. Took her to the bathroom she had a Lg (large) BM (bowel movement), resident then came out of her room and took her clothes off in the hallway. R29 is currently in bed and quiet. Nurse's note dated [DATE] at 2:43 a.m., on alert charting for Behaviors and elopement. No issues this shift. R29 was up earlier in shift but was calm and cooperative with staff. Fall #6: Nurse's note dated [DATE] at 9:03 p.m., R29 had a unwitnessed fall in another resident's bathroom. Writer answered the call light in the other resident's room and saw R29 in the resident's bathroom, sitting on the floor naked. Writer called RN to the scene. No injury. R29 was assisted into the wheelchair. vitals were within normal range. MD and POA notified. Surveyor conducted a review of the facility's falls investigation dated [DATE]. R29 was unable to give description of what happened. Writer answered call light in the other resident's room and saw R29 sitting naked in other resident's bathroom. R29 was assisted into wheelchair, vitals were within normal range. No injuries observed at time of incident. R29 has history of dementia with behaviors, unable to redirect, severely cognitively impaired. Encouraged R29 to wear bilateral hipsters (hip protectors) for safety. R29 to be toileted during cares and after meals. *The investigation did not contain any staff statements about when the last time they had seen or cared for R29. Surveyor noted that the plan of care was not updated for the use of the hipsters and instead was revised on [DATE] to offer toileting during cares and after meals. Nursing note dated [DATE] at 11:48 a.m., this writer received a report from Dietitian-R that he witnessed R29 falling while she was self-transferring from one chair to another chair by north nurse station dining tables. Skin tear noted on left elbow measuring 2 cm x 0.5 cm area was cleaned and covered with a dressing bp ,d+[DATE] hr 61 resp 18 temp 97.3 02 96% RA. No other injury noted during assessment. R29 not complaining of pain or discomfort at this time. Will continue to monitor Fall #7: Surveyor conducted a review of the facility's falls investigation dated [DATE] at 12:13 p.m. R29 was unable to describe what happened during the incident. Injury - skin tear to left elbow. R29 has a history of Dementia with behaviors, R29 hard to redirect at times. R29 is cognitively impaired and unaware to safety of her surroundings. Removed extra chairs from the breezeway. Fall #8: Nursing note dated [DATE] at 3:25 p.m., R29 had a witnessed fall (2nd fall on this date) in the north dining/common area. Staff witnessed R29 ambulating backwards utilizing her wheelchair as a walker. R29 lost her balance and fallen on her buttocks. R29 did not hit her head. No injuries. Denies pain/discomfort. R29 was assisted into her wheelchair. Encouraged resident not to walk backwards. MD and POA updated. Surveyor conducted a review of the facility's falls investigation, dated [DATE] at 3:22 p.m. R29's description: I lost my balance. [DATE] note indicates that R29 is to be evaluated by occupational therapy for a wheeled walker. Further review of the medical reco [TRUNCATED]

Based on observation, record review, and interview, the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to prevent new ulcers from developing for 1 of 6 residents (R56) reviewed for pressure injuries. R56 developed multiple pressure injuries while in the facility with some of them healing. R56 developed a Stage 3 pressure injury to the left clavicle due to the head contracting to the left on 10/20/2022 that was last assessed on 11/15/2022. No weekly assessment was completed on 11/22/22. R56 was hospitalized from 11/24/2022 to 11/28/2022. No documentation was found regarding the left clavicle pressure injury on readmission. On the Skin Integrity Care Plan, the intervention of a neck pillow was initiated on 12/20/2022. Observations were made on 1/23/2023 and 1/24/2023 of R56 without the neck pillow in place. On 1/24/2023, R56 developed an unstageable pressure injury to the left clavicle. R56 had incomplete documentation with missing assessments, conflicting staging of pressure injuries, or no staging of pressure injuries for the following areas: right lateral ankle, left mandible, right elbow, sacrum, chest region, right ear, back of the right ear, right posterior shoulder, right heel, and right lateral ankle. Findings: The facility policy and procedure entitled, Pressure Injury and Skin Condition assessment dated [DATE] states: Purpose: To establish guidelines for assessing, monitoring and documenting the presence of skin breakdown, pressure injuries and other ulcers and assuring interventions are implemented. Pressure and other ulcers (diabetic, arterial, venous) will be assessed and measured at least every seven (7) days by licensed nurse, and documented in the resident's record. 1. A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. 2. Residents identified will have a weekly skin assessment by a licensed nurse. 3. A wound assessment will be initiated and documented in the resident chart when pressure and/or other ulcers are identified by licensed nurse. 7. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes. 10. Pressure injuries and other ulcers (arterial, diabetic, venous) will be measured at least weekly and recorded in centimeters in the resident's clinical record. 11. A wound assessment for each identified open area will be completed and will include: a. Site location b. Size (length x width x depth) c. Stage of Pressure ulcer d. Odor e. Drainage f. Description g. Date and initials of the individual performing the assessment 12. Measure length vertically in relation to head-to-toe position. Measure width horizontally in relation to hip-to-hip. Measure depth straight down into the deepest part of the wound. *If the wound is necrotic and the base of the wound bed is not visible or tunneling, the stage cannot be measured and must be recorded as non-stageable with a undetermined depth. 14. Dressings which are applied to pressure ulcers, skin tears, wounds, lesions or incisions shall include the date of the licensed nurse who performed the procedure. Dressing will be checked daily for placement, cleanliness, and signs and symptoms of infection. 18. Physician ordered treatments shall be initialed by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses noted [sic]. R56 was admitted to the facility on [DATE] with diagnoses of malignant neoplasm of the lung with secondary malignant neoplasm of the brain, hemiplegia affecting the left side, and seizures. R56 was hospitalized from 8/28/2022 through 9/8/2022 with a cerebral infarction resulting in a persistent vegetative stage diagnosed on [DATE]. On 9/8/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56's skin was intact. R56's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R56 was not understood and could not understand with severe cognitive impairment per staff assessment. R56 was totally dependent for all activities of daily living including bed mobility. R56 had an indwelling urinary catheter and received all nutrition through a gastrostomy tube (G tube). R56 was admitted to the hospital on 9/28/2022 until 10/3/2022. On 10/3/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56's skin was intact with edema. R56's Skin Integrity Care Plan was initiated on 12/21/2018 and the following interventions were in place on 10/18/2022: -Alternating pressure mattress and wheelchair cushion. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin. -Float heels as able. -Identify/document potential causative factors and eliminate/resolve where possible. -Monitor for side effects of the antibiotics and over-the-counter pain medications: gastric distress, rash, or allergic reactions which could exacerbate skin injury. -Monitor and document location, size and treatment of skin injury; report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to physician. -Turn and reposition as necessary. On 10/18/2022, R56 developed a Stage 3 pressure injury to the sacrum. This assessment was completed by the wound physician. On 10/20/2022 at 1:48 PM in the progress notes, nursing charted R56 presented with new open areas to the left mandible, the left collar bone, the right shoulder, the right elbow, and the coccyx. The nurse charted staff were interviewed, and the areas began as blister-like areas to the skin raised approximately 0.1 cm and were uniform with the skin tone. The physician was notified, and treatments were ordered. The assessment was completed by Licensed Practical Nurse (LPN)-I. No Registered Nurse (RN) assessment was documented. On 10/20/2022, comprehensive wound assessments were completed by LPN-I on each open area and were documented as follows: -Sacrum: Stage 3 pressure injury -Right posterior shoulder: Stage 3 pressure injury -Right elbow: Stage 3 pressure injury -Left mandible: Stage 3 pressure injury -Left clavicle: Stage 3 pressure injury R56 was admitted to the hospital from 10/24/2022 until 10/29/2022. On 10/29/2022, on the Admission Data Collection and Baseline Care Plan Tool, RN-K documented R56 had the following skin issues: an indwelling catheter, a G tube to the left upper quadrant of the abdomen, and a bandage to the right side of the neck from an intravenous line placement. A comprehensive assessment of the 5 pressure injuries noted prior to hospitalization was not completed on this date. On 10/29/2022, the Certified Nursing Assistant (CNA) Care Card indicated R56 was to be turned and repositioned and the heels offloaded. On 11/1/2022, three days after readmission, comprehensive wound assessments were done by an RN on each open area and were documented as follows: -Sacrum: Unstageable pressure injury -Right shoulder: trauma (had been a Stage 3 pressure injury) -Right elbow: Unstageable -Left clavicle: Unstageable On 11/15/2022, the wound assessments were completed by LPN-I. No RN assessment was documented. R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, Director of Nursing (DON)-B documented R56 had skin issues to the following 9 areas: chest, right elbow, back of the right ear, mid right ear, coccyx, anterior right thigh, outer right ankle, right heel, and posterior right shoulder. A Skin Impairment/Wound Form was completed by DON-B for each area and documented the following: -Chest: pressure injury with no staging -Right elbow: pressure injury with no staging -Back of the right ear: Stage 3 pressure injury -Mid right ear: Stage 4 pressure injury -Coccyx: Stage 2 pressure injury (downgraded from assessment prior to hospitalization ) -Anterior right thigh: pressure injury with no staging -Outer right ankle: pressure injury with no staging -Right heel: Unstageable pressure injury -Posterior right shoulder: pressure injury with no staging R56's Significant Change MDS dated [DATE] indicated in the Pressure Ulcer Care Area Assessment that R56 had Unstageable pressure injuries to the sacrum and the right heel, a Deep Tissue Injury to the left chest, and a Stage 4 pressure injury to the right ear related to a history of stroke with left-sided weakness (addressing 4 areas). Surveyor noted the right elbow, back of the right ear, anterior right thigh, outer right ankle, and posterior shoulder (5 areas) were not included in the Care Area Assessment. On 12/6/2022, the wound assessments were completed by LPN UM-H. No RN assessment was documented. On 12/20/2022, R56's Skin Integrity Care Plan was revised with the intervention: neck pillow. R56 was admitted to the hospital from 1/4/2023 until 1/9/2023. On 1/9/2023, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56 had skin issues to the following areas: right upper ear and right heel. A comprehensive assessment of the areas of concern were not completed on this date. On 1/16/2023, seven days after readmission, R56 was seen by the wound physician and a Skin Impairment/Wound Form was completed by LPN UM-H for each area and documented the following: -Right posterior upper ear: Stage 3 pressure injury -Right posterior heel: Unstageable pressure injury On 1/24/2023, R56 developed an Unstageable pressure injury to the left clavicle. Each pressure injury site will be addressed individually. SACRUM PRESSURE INJURY On 10/18/2022, on the Skin Impairment/Wound Form, nursing documented R56 had a Stage 2 pressure injury to the sacrum measuring 2.3 cm x 1.9 cm x 0.1 cm with 100% epithelial tissue. R56 was seen by the wound physician on 10/18/2022. The wound physician's documentation indicated R56 had a Stage 3 pressure injury to the sacrum measuring 2.13 cm x 1.95 cm x 0.1 cm with 100% granulation tissue. The wound physician ordered a treatment to cleanse the wound with half strength Dakin's solution, apply skin prep to the peri wound, and cover the wound with a foam dressing every Tuesday, Thursday, and Saturday and as needed. Surveyor noted the facility and the wound physician had different staging of the wound, slightly different measurements, and different tissue types in the wound bed. On 10/20/2022, on the Skin Impairment/Wound Form, nursing documented the sacrum pressure injury was a Stage 3 measuring 2.3 cm x 1.9 cm x 0.1 cm with 100% granulation tissue. This staging reflected the same staging as the wound physician on 10/18/2022. The Treatment Administration Record (TAR) had the wound treatment to be started on 10/20/2022 as ordered by the wound physician. The treatment was not initialed as completed on 10/20/2022. The TAR had the sacrum wound treatment changed to be completed every other day starting on 10/21/2022. The treatment was not initialed as completed on 10/23/2022. R56 was admitted to the hospital from 10/24/2022 until 10/29/2022. On 10/29/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56 had the following skin issues: an indwelling catheter, a G tube to the left upper quadrant of the abdomen, and a bandage to the right side of the neck from an intravenous line placement. No documentation of assessments of the skin were found on readmission to the facility. On 10/31/2022 on the TAR, the treatment to the sacrum was restarted. On 11/1/2022, on the Skin Impairment/Wound Form, the sacrum pressure injury was Unstageable and measured 2.15 cm x 1.09 cm x 0.1 cm with 1-25% granulation tissue and 51-75% slough. R56 was seen by the wound physician on this date and the wound physician documentation was the same for the sacrum Unstageable pressure injury. R56's sacral wound was comprehensively assessed weekly from 11/1/2022-11/15/2022. The pressure injury continued to be Unstageable, progressively getting smaller in size. No weekly assessment was completed on 11/22/2022. R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the coccyx that measured 2.0 cm x 2.0 cm. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted the coccyx was a Stage 2 pressure injury that measured 2 cm x 2 cm. No depth was documented. The wound base was 100% granulation tissue. Surveyor noted prior to the hospitalization , the wound was Unstageable and the staging cannot be downgraded to a Stage 2. Surveyor noted the use of sacrum and coccyx were used interchangeably for the same area. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the sacrum was an Unstageable pressure injury that measured 1.5 cm x 1.5 cm x 0.1 cm with 100% granulation tissue. Surveyor noted with 100% of the wound base exposed, the wound was stageable as a Stage 3 pressure injury due to the previous presence of slough in the wound bed. On 12/12/2022, R56 was seen by the wound physician. The wound physician was new to the resident and no documentation was found of the sacrum. In an interview on 1/26/2023 at 9:04 AM, Licensed Practical Nurse (LPN) Unit Manager (UM)-H stated the area must have healed on 12/12/2022 because there is no more documentation on the area and the wound physician was thorough in looking at all the areas since this was the first assessment by this wound physician. RIGHT SHOULDER PRESSURE INJURY/TRAUMA On 10/20/2022, on the Skin Impairment/Wound Form, nursing documented the right shoulder had a Stage 3 pressure injury that measured 2.5 cm x 3.2 cm x 0.1 cm with 40% granulation, 50% slough, and 10% eschar. On 10/20/2022 on a second Skin Impairment/Wound Form, the same nurse documented the right shoulder had a Stage 4 pressure injury with the same measurements as the previous assessment. The wound base had 50% granulation, 40% slough, and 10% eschar. Surveyor noted the pressure injury had different staging, Stage 3 and Stage 4, and different percentages describing the wound base. R56 was admitted to the hospital from 10/24/2022 until 10/29/2022. On 10/29/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56 had the following skin issues: an indwelling catheter, a G tube to the left upper quadrant of the abdomen, and a bandage to the right side of the neck from an intravenous line placement. No documentation of assessments of the skin were found on readmission to the facility. On 11/1/2022, on the Skin Impairment/Wound Form, nursing charted the right shoulder had a wound caused by trauma and measured 1.22 cm x 1.21 cm x 0.1 cm with no description of the wound base. R56 was seen by the wound physician on this date and documented the left shoulder, not the right shoulder, was caused by trauma and had the same measurements. The wound base had partial granulation, but the rest of the wound base was not described. On 11/8/2022, on the Skin Impairment/Wound Form, nursing charted the right shoulder trauma wound measured 1.05 cm x 0.81 cm x 0.1 cm with no description of the wound base. The wound physician documents the same measurements for the left shoulder, not the right shoulder. The wound base had partial granulation, but the rest of the wound base was not described. On 11/15/2022, on the Skin Impairment/Wound Form, nursing charted the right shoulder trauma wound measured 0.8 cm x 0.8 cm x 0.1 cm with no description of the wound base. No weekly assessment was completed on 11/22/2022. R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the right posterior shoulder that measured 3.0 cm x 2.0 cm with 100% granulation tissue. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted R56 had a pressure injury to the right posterior shoulder that measured 3.0 cm x 2.0 cm with no depth and 100% granulation. The pressure injury was not staged, and Surveyor was not able to determine if the right posterior shoulder was the same area that had been documented on (10/20/22) prior to hospitalization . In an interview on 1/26/2023 at 9:04 AM, LPN UM-H was not able to clarify where on the right shoulder the wound was or if the right shoulder and the right posterior shoulder were the same areas being documented on. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the right posterior shoulder wound had healed. On 12/12/2022, on the Skin Impairment/Wound Form, nursing charted the right shoulder had an Unstageable pressure injury measuring 1 cm x 1 cm x 0.1 cm with no wound base description. R56 was seen by the new wound physician on 12/12/2022 and the wound physician documented the Unstageable pressure injury to the right posterior shoulder had the same measurements with 100% necrotic tissue. The right posterior shoulder Unstageable pressure injury was comprehensively assessed and documented on weekly from 12/12/2022 until 1/2/2023 when the wound healed. RIGHT ELBOW PRESSURE INJURY On 10/20/2022, on the Skin Impairment/Wound Form, nursing documented the right elbow had a Stage 3 pressure injury that measured 1.2 cm x 1.2 cm x 0.1 cm with 100% granulation tissue. On 10/20/2022 on a second Skin Impairment/Wound Form, the same nurse documented the same information regarding the right elbow pressure injury. R56 was admitted to the hospital from 10/24/2022 until 10/29/2022. On 10/29/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56 had the following skin issues: an indwelling catheter, a G tube to the left upper quadrant of the abdomen, and a bandage to the right side of the neck from an intravenous line placement. No documentation of assessments of the skin were found on readmission to the facility. On 11/1/2022, on the Skin Impairment/Wound Form, nursing charted the right elbow was an Unstageable pressure injury measuring 0.68 cm x 0.9 cm x 0.1 cm with no wound base description. R56 was seen by the wound physician on this date and documented the right elbow was Unstageable and had the same measurements. The wound base had eschar. R56's right elbow Unstageable pressure injury was comprehensively assessed on 11/8/2022 and 11/15/2022. No weekly assessment was completed on 11/22/2022. R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the right elbow that measured 1.0 cm x 1.0 cm with 100% granulation tissue. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted R56 had a pressure injury to the right elbow that measured 1.0 cm x 1.0 cm with no depth and 100% granulation. The pressure injury was not staged. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the right elbow pressure injury had healed. LEFT MANDIBLE (Jawbone) PRESSURE INJURY On 10/20/2022, on the Skin Impairment/Wound Form, nursing documented the left mandible had a Stage 3 pressure injury that measured 1.0 cm x 1.5 cm x 0.1 cm with 100% epithelial tissue. On 10/20/2022 on a second Skin Impairment/Wound Form, the same nurse documented the left mandible had a Stage 2 pressure injury with the same measurements and description of the wound base. Surveyor was unable to determine if the pressure injury was a Stage 2 or a Stage 3. A neck pillow was recommended to keep the pressure off the area. R56 was admitted to the hospital from 10/24/2022 until 10/29/2022. On 10/29/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56 had the following skin issues: an indwelling catheter, a G tube to the left upper quadrant of the abdomen, and a bandage to the right side of the neck from an intravenous line placement. No documentation of assessments of the skin were found on readmission to the facility. No further documentation of a pressure injury to the left mandible was found. LEFT CLAVICLE (Collarbone) PRESSURE INJURY On 10/20/2022, on the Skin Impairment/Wound Form, nursing documented the left clavicle had a Stage 3 pressure injury that measured 0.5 cm x 0.7 cm x 0.1 cm with 100% granulation tissue. On 10/20/2022 on a second Skin Impairment/Wound Form, the same nurse documented the left clavicle had a Stage 2 pressure injury with the same measurements with 100% epithelial tissue. Surveyor was unable to determine if the pressure injury was a Stage 2 or a Stage 3 or what type of tissue was in the wound base. A neck pillow was recommended to keep the pressure off the area. R56 was admitted to the hospital from 10/24/2022 until 10/29/2022. On 10/29/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing documented R56 had the following skin issues: an indwelling catheter, a G tube to the left upper quadrant of the abdomen, and a bandage to the right side of the neck from an intravenous line placement. No documentation of assessments of the skin were found on readmission to the facility. On 11/1/2022, on the Skin Impairment/Wound Form, nursing charted the left clavicle was an Unstageable pressure injury measuring 1.63 cm x 1.13 cm x 0.1 cm with 1-25% granulation and 51-75% slough. R56 was seen by the wound physician on this date and the wound physician documentation was the same for the left clavicle Unstageable pressure injury. R56's left clavicle Unstageable pressure injury was comprehensively assessed and documented on 11/8/2022 and 11/15/2022. No weekly assessment was completed on 11/22/2022. R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had multiple wounds, but there was no documentation of a wound to the left clavicle. The wound may have healed while in the hospital. On 12/20/2022, R56's Skin Integrity Care Plan was revised with the intervention: neck pillow. On 1/23/2023 at 10:42 AM, Surveyor observed R56 lying in bed on an air mattress with no neck pillow in place. The head of the bed was slightly elevated and R56's head was leaning down and forward to the left with the side of the face resting on the left clavicle. On 1/24/2023 at 12:16 PM, Surveyor observed R56 lying in bed on an air mattress with no neck pillow in place. The head of the bed was slightly elevated and R56's head was leaning down and forward to the left with the side of the face resting on the left clavicle. On 1/24/2023, on the Skin Impairment/Wound Form, nursing charted R56 had a Stage 2 pressure injury to the left clavicle that measured 2 cm x 2.5 cm with no depth. The wound base had 60% granulation and 40% slough. The form was revised to state the pressure injury was Unstageable. In an interview on 1/25/2023 at 2:20 PM, LPN UM-H stated R56 had a pressure injury to the left clavicle in the past and thought it looked like the area reopened. Surveyor observed LPN UM-H and Registered Nurse (RN)-K complete the wound treatment to the left clavicle. R56 had a neck pillow in place. LPN UM-H stated the wound to the left clavicle was probably from the head leaning down on it; R56 leans to the left. RN-K removed the dressing from the clavicle. The dressing did not have a date or initials on it for when it was placed. LPN UM-H stated the wound measured 2 cm x 2.5 cm and the wound base was pink. RN-K washed the wound with normal saline and applied a border foam dressing. On 1/27/2023 on the TAR, the following orders were initiated: -Check skin integrity around back of neck and neck pillow area; keep skin dry and clean every shift for monitoring. -Place neck pillow on resident for protection every shift. -Cleanse wound to left clavicle with normal saline, apply medi honey, and cover with foam bordered gauze daily. CHEST REGION PRESSURE INJURY R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the chest that measured 4.0 cm x 2.0 cm with 100% granulation. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted the chest region had a pressure injury. The wound measured 4.0 cm x 2.0 cm with 100% granulation. The wound was not staged and the location on the chest was not specified. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the chest pressure injury measured 3.5 cm x 1.9 cm x 0.1 cm with 100% granulation tissue. The wound was not staged and the location on the chest was not specified. No further documentation was found regarding the chest pressure injury. In an interview on 1/30/2023 at 2:07 PM, LPN UM-H and LPN-I were unable to recall where the wound was on R56's chest. Surveyor shared the concern there was no more documentation of the chest wound after 12/6/2022. LPN-I looked on the electronic medical record and agreed there was no more documentation on the chest wound after 12/6/2022 and could not give a reason why an assessment was not completed. RIGHT ANTERIOR THIGH PRESSURE INJURY R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the right anterior thigh that measured 1.0 cm x 1.0 cm with 100% granulation. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted the right anterior thigh had a pressure injury. The wound measured 1.0 cm x 1.0 cm with 100% granulation. The wound was not staged and did not have a depth measurement. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the right anterior thigh wound had healed. MID RIGHT EAR PRESSURE INJURY R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the mid right ear that measured 3.0 cm x 1.0 cm with 100% granulation. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted the right ear had a pressure injury. The wound measured 3.0 cm x 1.0 cm with 100% granulation. The wound was not staged and did not have a depth measurement. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the mid right ear had a pressure injury that measured 2.0 cm x 0.7 cm x 0.1 cm with 100% granulation. The wound was not staged. On 12/12/2022 on the Skin Impairment/Wound Form, nursing charted the right ear Stage 4 pressure injury measured 1.4 cm x 1.0 cm x 0.1 cm with 60% granulation and 40% slough. R56 was seen by the wound physician on the same date and had the same documentation. This was the first time the wound had been staged since 11/28/22. The mid right ear Stage 4 pressure injury was comprehensively assessed weekly from 12/12/2022 until R56 was hospitalized on [DATE]. R56 returned to the facility on [DATE] and the wound had healed. The wound physician saw R56 on 1/16/2023 and documented the wound had resolved. BACK OF RIGHT EAR PRESSURE INJURY R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the back of the right ear that measured 2.0 cm x 1.0 cm with 100% granulation. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted the back of the right ear had a pressure injury. The wound measured 2.0 cm x 1.0 cm with 100% granulation. The wound was not staged and did not have a depth measurement. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the back of the right ear had a pressure injury that measured 1.2 cm x 0.8 cm x 0.1 cm with 100% granulation. The wound was not staged. The back of the right ear pressure injury was not comprehensively assessed weekly after 12/6/2022 until 1/2/2023. On 1/2/2023, on the Skin Impairment/Wound Form, nursing charted the posterior upper right ear Stage 3 pressure injury measured 1.2 cm x 0.6 cm x 0.1 cm with 100% granulation. R56 was seen by the wound physician on this date and recognized this area as a new wound. The wound physician's documentation of the Stage 3 pressure injury was the same as the facility documentation. R56 was admitted to the hospital from 1/4/2023 until 1/9/2023. On 1/9/2023, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the right upper ear that measured 0.5 cm x 0.5 cm x 0.1 cm. The pressure injury was not staged and did not have any description of the wound base. On 1/16/2023, on the Skin Impairment/Wound Form, nursing charted the right posterior upper ear Stage 3 pressure injury measured 0.4 cm x 0.3 cm x 0.1 cm with 100% granulation. R56 was seen by the wound physician on the same date and had the same documentation. On 1/23/2023, on the wound physician notes, the right posterior upper ear Stage 3 pressure injury had healed. RIGHT HEEL PRESSURE INJURY R56 was admitted to the hospital from 11/24/2022 until 11/28/2022. On 11/28/2022, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the right heel that measured 10.0 cm x 10.0 cm with 100% necrotic tissue. On 11/28/2022, on the Skin Impairment/Wound Form, nursing charted the right heel had a pressure injury. The wound measured 10.0 cm x 10.0 cm with 100% eschar. The wound was not staged and did not have a depth measurement. On 12/6/2022, on the Skin Impairment/Wound Form, nursing charted the right heel had a pressure injury. The wound measured 9.8 cm x 8.7 cm x 0.1 cm with 100% eschar. The wound was not staged. On 12/12/2022, on the Skin Impairment/Wound Form, nursing charted the right heel Unstageable pressure injury measured 5.5 cm x 0.7 cm x 0 cm with no wound base description. R56 was seen by the wound physician on the same date. The wound physician documentation states the right posterior heel Deep Tissue Injury (DTI) measured 5.5 cm x 7.0 cm x not measurable depth due to intact skin. Surveyor noted the facility and the wound physician had a difference in measurements and a difference in staging. Surveyor noted R56 was comprehensively assessed weekly by the wound physician on 12/19/2022, 12/26/2022, and 1/2/2023. The facility documented the pressure injury to be Unstageable while the wound physician documented the wound to be a DTI. The measurements were the same for both the facility and the wound physician. R56 was admitted to the hospital from 1/4/2023 until 1/9/2023. On 1/9/2023, on the Admission Data Collection and Baseline Care Plan Tool, nursing charted R56 had a wound to the right heel that measured 5.0 cm x 7.5 cm. The pressure injury was not staged, did not have a depth, and did not have any description of the wound base. On 1/16/2023, on the Skin Impairment/Wound Form, nursing charted the right posterior heel Unstageable pressure injury measured 4.5 cm x 7.2 cm with no depth measured and no wound base description. R56 was seen by the wound physician on the same date. The wound physician documentation states the right heel DTI measured 4.5 cm x 7.2 c [TRUNCATED]

UNCORRECTED AT THE VERIFICATION VISIT Based on observation, record review and interview, the facility did not ensure that 2 Residents (R) (R6 and R1) of 3 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent accidents. R1 was at risk for falls. R1 had interventions on the plan of care for two staff assist with bed mobility and Hoyer lift for transfer. R1 was changed and repositioned in bed by one staff. R1 rolled out of bed, hit head, and had a head laceration that required staples. R6 was at high risk for falls. R6 had an intervention on the plan of care to keep bed in the lowest position to ensure resident safety. R6's bed was observed not in the lowest position. Findings include: The facility policy entitled Fall Prevention Program with a print date of 12/8/21, indicated the facility must ensure that the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision and assistive devices to prevent accidents. Individual needs of each resident will be determined by assessing the risk of falls and implementation of appropriate staff interventions to assure adequate supervision is provided, and that assistive devices are utilized when necessary. A fall risk assessment will be completed. Residents found to be at risk of falling will have a care plan implemented to address the need for additional safety precautions. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. 1. On 12/7/21, the Surveyor reviewed the medical record for R1. R1 was admitted to the facility with diagnoses to include functional [CONDITION(S)] (complete immobility due to severe physical disability or frailty), [CONDITION(S)], hematuria, diabetes mellitus, [CONDITION(S)], and dementia. R1's quarterly MDS (Minimum Data Set) assessment, dated 11/8/21, indicated R1 had short-term and long-term memory problems, R1's cognition was severely impaired, and R1 was rarely/never understood. R1 was totally dependent on staff for bed mobility, transfers, ADLs (activities of daily living), R1 did not ambulate, and did not have any falls since admission. On 12/7/21, the Surveyor reviewed R1's current plan of care. R1's plan of care with a revision date of 10/3/19, indicated R1 was at risk for falls related to impaired mobility and weakness. An intervention initiated on 7/19/21, indicated staff education provided regarding proper body mechanics and important safety guidelines to follow. R1's plan of care with a revision date of 10/3/19, indicated R1 had an ADL self-care performance deficit related to dementia as evidenced by impaired mobility, bowel incontinence, bilateral hand contractions, and weakness. Interventions with a revision date of 7/5/19, included R1 required extensive assistance of two staff for bed mobility and transfers with two assist and Hoyer lift. On 12/7/21, the Surveyor reviewed a facility self-report submitted to the State Agency. The self-report indicated on 11/3/21, CNA (Certified Nursing Assistant)-T was assisting R1 alone with changing and repositioning in bed as there were not any other staff members available to assist with the cares. R1 rolled out of bed, fell on the floor and hit head. R1 was bleeding from the back of the head. After R1 fell out of bed, CNA-T panicked and transferred R1 back to bed per self even though R1 was a Hoyer lift with two staff assist and had not been assessed by the nurse. R1 was assessed by the nurse and sent to the emergency room for evaluation. R1 had a CT (computed tomography) scan completed which was negative. R1 returned to the facility with nine staples to the head laceration. On 12/7/21 at approximately 3:00 PM, the Surveyor interviewed DON (Director of Nursing)-B regarding the self-report for R1. DON-B verified the self-report occurred as documented, R1 had a CT scan that was negative for a bleed, and had a head laceration that required staples that occurred when R1 was changed and repositioned by one staff rather than two staff. DON-B confirmed R1 required a Hoyer lift for transfer with the assistance of two staff. Additionally, DON-B verified R1 was currently at the hospital for another diagnosis. The facility had an accepted plan of correction for F689 which was accepted on 11/15/21 by the State Agency. This fall occurred on 11/3/21 when the facility did not have an accepted plan of correction and there was current non-compliance during the verification visit with R6 as indicated below. 2. On 12/7/21 and 12/8/21, the Surveyor reviewed the medical record for R6. R6 was admitted to the facility with diagnoses to include cerebral infarction (stroke) due to embolism (blood clot)of left middle cerebral artery (largest artery that brings fresh blood to the brain), uterine cancer, secondary lung cancer, acute [CONDITION(S)] with [CONDITION(S)] (low tissue oxygen), vascular dementia (describes problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain), diabetes mellitus, muscle weakness, abnormalities of gait (walking) and mobility (to move with ease and without restriction), and anxiety. R6's quarterly MDS (Minimum Data Set ) assessment, dated 11/16/21, indicated R6's cognition was 7 out of 15, indicating R6 had severe cognitive impairment. R6 required extensive assistance from two plus staff for bed mobility, was totally dependent on two plus staff for transfer, required extensive assistance from staff for dressing and toilet use, R6 did not ambulate, and did not have any falls. The Surveyor reviewed R6's Fall Risk Scoring Tool, dated 12/7/21. Per the assessment, R6's fall risk score was 16, indicating R6 was at high risk for falls as R6 was disoriented x 3 at all times, had 1 - 2 falls in the past 3 months, and was chair bound. To evaluate the resident's gait/balance, have the resident stand on both feet without holding onto anything; walk straight forward; walk through a doorway, and make a turn. R6 was not able to perform the above function. R6 did not have a noted drop between lying and standing blood pressure. R6 took 3 - 4 medications currently and/or within the last 7 days that cause lethargy or confusion. R6 had 3 or more predisposing diseases present including a history of falls. The Surveyor reviewed R6's current plan of care. The plan of care with a revision on 9/3/21 with a target date of 2/7/22, indicated R6 was at risk for falls related to weakness and an activity intolerance with abnormal gait and mobility. An intervention/task indicated R6 was non-weight bearing. Additionally, an intervention in place for R6 was for the bed to be placed in the lowest position to ensure resident safety. Another intervention, indicated the resident, family and caregivers were to be educated about safety reminders and what to do if a fall occurs. R6 was to have a 2 person assist while transferring at all times related to activity intolerance and increased risk of falling. R6 had a medication review due to three new medications to rule out possible cause of fall with an initiated date of 9/15/21. Another intervention was initiated on 10/8/21 for a service request for bed/breaks to prevent future falls. The plan of care with a revision on 8/27/21 with a target date of 2/7/22, indicated R6 had an ADL self-care performance deficit related to increased weakness and an unsteady gait with impaired cognition. Interventions included R6 was max assist of 2 staff to turn and reposition with bed rails provided to promote independent repositioning. R6 required max assist by 2 staff for toileting and required the use of a Hoyer lift assisted by 2 staff for transfer. R6's Bedside Kardex Report used by the CNAs (Certified Nursing Assistants) indicated R6 required max assist by 2 staff to turn and reposition in bed, bed rails were provided to promote independent repositioning, R6 was non-weight bearing, staff were to transfer with Hoyer lift with 2 staff assisting, and a service request for bed/breaks was completed to prevent future falls. On 12/7/21 at 5:53 PM, the Surveyor observed R6 in bed with no mats on the floor and the bed not in the lowest position. On 12/7/21 at 7:02 PM, the Surveyor observed R6 in bed with no mats on the floor and the bed was not in the lowest position. CNA-E came in R6's room, verified R6 did not have mats on the floor, had not had mats on the floor during the entire shift on the floor next to the bed, and should have mats on the floor because the mats are on the care plan. CNA-E verified the bed was not in the lowest position and stated the bed will go down to the lowest position once R6 finished eating. On 12/7/21 at 7:30 PM, the Surveyor observed CNA-F going in R6's room to put mats on the floor next to the bed. CNA-F verified R6's bed was now in the lowest position as indicated in R6's plan of care. On 12/8/21 at 12:56 PM, the Surveyor observed R6 in bed without the bed being in the lowest position. R6 did not have mats on the floor next to the bed. On 12/8/21 at 1:12 PM, the Surveyor interviewed LPN (Licensed Practical Nurse)-J. LPN-J is the unit manager. LPN-J stated the care plan was reviewed last night and updated to indicate R6 no longer needed the mats on the floor because R6 had not had any recent falls. LPN-J verified the bed was not in the lowest position and lowered the bed to the lowest position because the bed needs to be in the lowest position. The low bed was not discontinued like the fall mats. R6 was in bed and stated to the Surveyor and LPN-J feels like can't zone, feels like (R6 is) floating, can't explain it. On 12/14/21 at 11:25 AM, the Surveyor interviewed R6's FM (Family Member)-K via telephone. FM-K stated R6 forgets to ask for help because R6's memory is not any better than when R6 was admitted . R6 still calls FM-K five times daily to ask the same question. FM-K stated FM-K was R6's activated POA (power of attorney). The Surveyor asked FM-K if FM-K had the POA paperwork. FM-K indicated FM-K would call the hospital for the paperwork and get back to the Surveyor. FM-K stated R6 has attempted to get out of bed, has fell out of bed at the facility and could attempt to get out of bed again which could result in a fall. On 12/14/21 at 12:06 PM, the Surveyor interviewed R6's FM-L via telephone. FM-L verified R6 continues to be a fall risk. FM-L stated R6 fell out of bed at the facility two to three times. The mattress was changed after a fall and after another fall, permission was given to put side rails on R6's bed. R6 has attempted to push the button to lower or raise the bed, but is unable to push the buttons because of R6's cognition. FM-L then stated R6 says R6 is going to get out of bed and tries to get out of bed while being advised not to get out of bed by family members visiting. On 12/14/21 at 12:36 PM, the Surveyor interviewed FM-K via telephone. FM-K stated FM-K talked to the case manager at the hospital. The case manager indicated the POA was not activated as the hospital was still waiting for the second physician to sign the paperwork. The case manager will get the signature and the POA will be activated today for medical. The POA should have been activated prior to leaving the hospital per FM-K as R6 was not able to make good medical decisions due to memory problems.

Based on observation, record review, and interview, the facility did not provide treatment and services, consistent with professional standards of practice, to promote healing of pressure injuries for 1 (R98) of 7 residents reviewed with pressure injuries. R98 was admitted the facility on 3/17/21. R98 was determined to be at risk for the development of a pressure injury. R98's care plans did not address offloading R98's heels or preventative devices to prevent pressure injuries. On 5/19/2021, R98 developed an unstageable pressure injury to the right heel. Wound assessments did not include percentages of tissue type. From 6/24/2021 to 7/8/2021 (14 days), there was no comprehensive assessment conducted of the right heel pressure injury. On 7/8/21 the unstageable wound was now identified as a Stage 3 pressure injury. From 7/8/2021 to 7/22/2021 (14 days), there was no comprehensive assessment conducted of the right heel pressure injury. On 7/22/21 R's Stage 3 pressure injury regressed to Unstageable. The wound description did not include percentages of tissue type. From 7/22/2021 to 8/12/2021 (21 days) there was no comprehensive assessment conducted of the right heel pressure injury. On 8/12/2021 the right heel was identified as a Stage 3 with no percentages of tissue type were documented. From 8/12/2021 to 8/23/2021 (11 days) there was no comprehensive assessment conducted of the right heel pressure injury. Assessments completed from 8/23/2021 through 9/16/2021 and 9/23/2021, 9/28/2021 did not include percentages of tissue type. From 10/1/2021 until 10/20/2021, R98 did not have a treatment to a Stage 3 pressure injury. On 10/20/2021, the wound measured 2 cm x 2.8 cm and was black in color. A new treatment was put on the TAR 10/20/2021 with a start date of 10/21/2021. On 10/21/2021 the Wound Physician assessed the pressure injury which measured 0.7 cm x 0.34 cm with 100% granulation. The Wound Physician stated the measurements of 10/20/2021 did not correlate with today's measurements. The Wound Physician was not aware treatments were not being completed from 10/1/2021 through 10/20/21. Findings include: The facility policy and procedure entitled Management of Wounds dated 10/16/2015 states: Policy: Our mission is to facilitate resident independence, promote resident comfort, and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective wound management program, allowing our residents a means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve this goal through utilization of the following pertinent aspects of wound care: -Assessing the resident to include ongoing skin assessment and assessment of risk factors for pressure ulcer development; -Assessing the local wound condition; -Determining the wound etiology; -Managing tissue loads; -Providing local wound care; -Managing bacterial colonization and infection; -Optimizing medical conditions and general systemic function; -Promoting the prevention of pressure ulcer development; -Promoting the healing of pressure ulcers that are present; -Providing education to residents, families and caregivers; and -Improving the quality of care and clinical outcomes through quality improvement programs. The facility policy and procedure entitled, Wound Assessment Policy and Procedure undated states: Procedure: 1. The presence of wounds, ulcers, and/or other skin abnormalities will be indicated on the admission nursing assessment. 2. Wound/wound dressing status will be monitored daily using the Daily Wound Status Sheet or documenting on the Treatment Administration Record. 3. A complete wound assessment will be done weekly by a licensed nurse or Attending Certified Wound Specialist for all wounds and ulcers. 4. The comprehensive or complete wound assessment will be documented on the 'Wound Assessment Flow Sheet' form during the initial admission skin assessment and weekly thereafter. The wound assessment will contain the following information: a. Wound classification (Wound Type) b. Wound location c. Pressure ulcer staging OR description of the extent of tissue damage d. Description of the wound bed, drainage, margins/surrounding skin, and odor e. Wound measurements f. Wound related pain 5. The wound assessment and documentation will follow the guidelines established in the 'Guidelines for Wound Assessment and Documentation' found on the back of the 'Wound Assessment Flow Sheet.' R98 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Potential for Impairment to Skin Integrity Care Plan was initiated on 3/17/2021 with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin -Follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Provide pressure relieving devices as needed -Turn and position as necessary R98's discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] indicated R98 needed extensive assistance of 2 plus staff with bed mobility, transfers, toilet use. The MDS indicates R98 is at risk for pressure injuries and has no unhealed areas. The MDS indicates pressure reduction devices for chair and bed should be present. The Brief Interview for Mental Status (BIMS) was unable to be completed due to R98's [CONDITION(S)] and was deemed severely cognitively impaired per staff. R98 did not have an activated Power of Attorney. The Potential for Impairment to Skin Integrity Care Plan was revised on 3/26/2021 with the removal of the intervention to turn and position as necessary. R98's Quarterly MDS dated [DATE] indicates R98 is totally dependent upon two staff for bed mobility and transfer. The MDS indicated R98 has limitations on one side for range of motion. The MDS indicates R98 is at risk for pressure injuries and has no open areas. The MDS indicates R98 did not exhibit any behaviors related to refusal of care. The Potential for Impairment to Skin Integrity Care Plan was revised on 5/10/2021 with the intervention to identify/document potential causative factors and eliminate and resolve where possible. On 5/19/2021 at 10:26 PM in the progress notes, nursing charted R98 had an area to the right heel measuring 3 cm x 3 cm that was completely covered with eschar. The area was left open to the air and elevated on pillows. R98 refused to have a Prevalon boot placed to the right heel. The family and physician was informed. The wound physician was to be notified in the morning of the new area. Surveyor noted there was no specific intervention in place to prevent development of the area until R98 developed a pressure injury. On 5/19/2021 on the Skin Impairment/Wound Form, nursing documented the right heel had an Unstageable pressure injury measuring 3.0 cm x 3.0 cm with 100% eschar. The Potential for Impairment to Skin Integrity Care Plan was revised on 5/25/2021 with the following interventions: -Air mattress for pressure relief -Trapeze to assist with self-positioning Surveyor noted the 5/8/21 indicated R98 was completely dependent upon 2 staff for bed mobility and had limitations on one side related to range of motion. On 5/27/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Unstageable pressure injury was debrided. The wound had two measurements: 3.49 cm x 3.30 cm x 0.20 cm and 4.70 cm x 4.43 cm x 0.10 cm. Surveyor was unable to determine which measurement was pre-debridement and which measurement was post-debridement. The wound base was described as Early/Partial granulation. No percentages of tissue type were documented. With an Unstageable pressure injury, the wound base would be obscured by slough and/or eschar tissue. Neither of these tissue types were documented. On 5/27/2021 at 6:24 PM in the progress notes, nursing charted R98's right heel pressure injury was debrided by Wound Physician-R at the bedside and a new order was obtained for Santyl to the right heel for further debridement. On 6/3/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Unstageable pressure injury measured 3.98 cm x 4.20 cm x 0.10 cm with early/partial granulation. No percentages of tissue type were documented. With an Unstageable pressure injury, the wound base would be obscured by slough and/or eschar tissue. Neither of these tissue types were documented. On 6/10/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Unstageable pressure injury measured 3.11 cm x 3.00 cm x 0.10 cm before debridement. The Unstageable pressure injury measured 3.37 cm x 3.48 cm x 0.50 cm after debridement with early/partial granulation. No percentages of tissue type were documented. With an Unstageable pressure injury, the wound base would be obscured by slough and/or eschar tissue. Neither of these tissue types were documented. On 6/17/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Unstageable pressure injury measured 1.79 cm x 2.46 cm x 0.40 cm with early/partial granulation. No percentages of tissue type were documented. With an Unstageable pressure injury, the wound base would be obscured by slough and/or eschar tissue. Neither of these tissue types were documented. On 6/18/2021, the Potential for Impairment to Skin Integrity Care Plan was changed to an Unstageable Pressure Ulcer to the Right Heel Care Plan. On 6/24/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Unstageable pressure injury measured 2.10 cm x 2.14 cm x 0.10 cm with early/partial granulation. No percentages of tissue type were documented. With an Unstageable pressure injury, the wound base would be obscured by slough and/or eschar tissue. Neither of these tissue types were documented. The right heel pressure injury was not comprehensively assessed from 6/24/2021 to 7/8/2021, for 14 days. On 7/8/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Stage 3 pressure injury measured 1.98 cm x 1.67 cm x 0.10 cm with early/partial granulation. No percentages of tissue type were documented. The right heel pressure injury was not comprehensively assessed from 7/8/2021 to 7/22/2021, for 14 days. On 7/22/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Unstageable pressure injury measured 2.56 cm x 2.15 cm x 0.10 cm with early/partial granulation. No percentages of tissue type were documented. With an Unstageable pressure injury, the wound base would be obscured by slough and/or eschar tissue. Neither of these tissue types were documented. The wound had been a Stage 3 pressure injury on 7/8/2021 and regressed to Unstageable on 7/22/2021. The right heel pressure injury was not comprehensively assessed from 7/22/2021 to 8/12/2021, for 21 days. Review of R98's 8/5/21 Quarterly MDS indicates R98 requires extensive assistance of one staff person for bed mobility. The MDS indicates R98 is at risk for pressure injuries and indicates R98 has one unstageable area. The 8/5/21 MDS indicates R98 did not demonstrate any rejection of care as a behavior. On 8/12/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Stage 3 pressure injury measured 1.39 cm x 0.91 cm x 0.10 cm with early/partial granulation. No percentages of tissue type were documented. Registered Nurse (RN)-J documented on the Skin Impairment/Wound Form the Stage 3 pressure injury with the same measurements as Wound Physician-R. The tissue type was partial granulation with no percentage given of the wound base. The right heel pressure injury was not comprehensively assessed from 8/12/2021 to 8/23/2021, for 11 days. On 8/23/2021 on the Skin Impairment/Wound Form, RN-J documented the Stage 3 pressure injury measured 1.39 cm x 0.91 cm x 0.1 cm with partial granulation. No percentage of tissue type was documented. On 8/26/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Stage 3 pressure injury measured 0.95 cm x 1.30 cm x 0.10 cm with early/partial granulation. No percentages of tissue type were documented. On 9/2/2021 on the Skin Impairment/Wound Form, RN-J documented the Stage 3 pressure injury measured 1.3 cm x 0.95 cm x 0.1 cm with partial granulation. No percentage of tissue type was documented. The 9/8/21 Quarterly MDS for R98 indicates R98 requires extensive assistance of two staff for bed mobility. The MDS indicates R98 is at risk for pressure injuries and had 1 stage 3 area. The MDS indicates R98 did not demonstrate rejection of care behavior. Surveyor noted progress notes dated during the assessment reference period look back period indicated R98 refused wound care as ordered. On 9/9/2021 on the Tissue Analytics form, Wound Physician-R documented the right heel Stage 3 pressure injury measured 1.30 cm x 0.93 cm x 0.10 cm with early/partial granulation. No percentages of tissue type were documented. RN-J documented on the Skin Impairment/Wound Form the Stage 3 pressure injury with the same measurements as Wound Physician-R. The tissue type was partial granulation with no percentage given of the wound base. On 9/16/2021 on the Skin Impairment/Wound Form, RN-J documented the Stage 3 pressure injury measured 1.3 cm x 0.93 cm x 0.1 cm with partial granulation. No percentage of tissue type was documented. On 9/23/2021 at 9:25 AM in the progress notes, RN-J charted R98 refused to have Wound Physician-R and the wound staff assess and treat the right heel pressure injury. On 9/28/2021 on the Skin Impairment/Wound Form, RN-J documented the Stage 3 pressure injury measured 1.3 cm x 0.93 cm x 0.1 cm with partial granulation. No percentage of tissue type was documented. On 9/30/2021 at 2:50 PM in the progress notes, RN-J charted R98 refused to be seen by the physician and wound team. The family and nurse practitioner was notified of the refusal. Review of the 10/6/21 Quarterly MDS for R98 indicates R98 requires extensive assistance of two staff for bed mobility, is at risk for pressure injuries. The MDS indicates R98 has a stage 1 or greater area not healed however, the MDS indicates R98 has no pressure injuries. Review of the behavior assessment section indicates R98 did not demonstrate rejection of care behavior. On 10/8/2021 at 1:50 PM in the progress notes, RN-J charted R98 had been non-compliant with wound care and the family member was contacted to enlist their help with encouraging R98 to comply with wound care. On 10/12/2021 on the Skin Impairment/Wound Form, Director of Nursing (DON)-B charted R98 did not have a pressure injury; R98 had a skin alteration that was a scab on the right heel that measured 0.1 cm x 0.1 cm with 100% granulation tissue. Skin prep was the treatment in place. In an interview on 10/21/2021 at 8:29 AM, DON-B stated RN-J was not available to do wound rounds on 10/12/2021. DON-B stated when DON-B looked at R98's right heel on 10/12/2021, it was only a scab and that it was not pressure anymore. (Once a wound is caused by pressure, it continues to be a pressure injury.) On 10/19/2021 at 2:00 PM in the progress notes, Licensed Practical Nurse (LPN)-K charted R98 refused wound care and was re-approached three times with refusals each time. Surveyor noted there is no indication education was provided to R98 on the risks and benefits of refusing wound care with the rejection. On 10/20/2021 at 11:47 AM, Surveyor observed RN-J and LPN-K provide wound care to R98 right heel pressure injury. R98 was resting in bed with a heel boot to the right heel. LPN-K held up R98's right leg while RN-J removed the heel boot and sock. RN-J measured the right medial heel wound; RN-J stated the wound measured 2 cm x 2.8 cm and was black in color. RN-J stated the treatment order was to clean the area with saline, apply skin prep and place foam over the wound for comfort. RN-J stated R98 refused to have the wound measured or treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-J stated the wound was about to completely heal and then R98 refused to have the treatment done. RN-J stated the wound physician may have to put in a new treatment order because of what the wound looks like today. R98 stated R98 would have to wait and see how R98 feels tomorrow if R98 will let the wound physician look at the wound. Surveyor observed R98's left foot resting on the bed. Surveyor asked RN-J if R98 had a heel boot for the left foot. RN-J stated no, just a boot for the right heel. RN-J stated R98 refuses to wear a boot on the left foot. RN-J stated RN-J called the family member to try and have them talk to R98 and convince R98 to have treatments completed on the right heel. The Unstageable Pressure Ulcer to the Right Heel Care Plan was revised on 10/20/2021 with the intervention: -R98 is noncompliant with dressing changes to the wound, frequently refusing scheduled treatments. Surveyor noted this change to the care plan was during the survey after concerns were shared regarding R98's wound care. The Treatment Administration Record (TAR) was reviewed. A treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Surveyor did not see any treatment to the right heel in place 10/1/2021 through 10/20/2021. A new treatment was put on the TAR 10/20/2021: Cleanse Right heel site with normal saline, apply skin prep on surrounding tissue and cover with comfort foam every Tuesday, Thursday, and Saturday and as needed for soiling with a start date of 10/21/2021. In an interview on 10/20/2021 at 3:25 PM, Surveyor asked RN-J if R98 had a treatment to the right heel in place from 10/1/2021 until 10/20/2021 when Surveyor asked see the treatment completed on R98's right heel. RN-J stated R98 had a treatment order for every fourteen days and then would get renewed by Wound Physician-R. RN-J stated R98 refused to see Wound Physician-R on 9/30/2021 and the treatment was not renewed at that time. RN-J stated RN-J was unaware the treatment was not in the TAR after that date. Surveyor asked RN-J how the treatment order was obtained today. RN-J stated RN-J went in to see R98 this morning to see if RN-J could do wound care and R98 refused. RN-J called Wound Physician-R to get an order just in case R98 agreed to have the treatment completed when it was being observed by Surveyor. Surveyor clarified with RN-J that no treatments were completed or attempted to be treated from 10/1/2021 until today, 10/20/2021. RN-J stated yes. RN-J stated R98 would refuse to have the weekly measurements done. Surveyor asked RN-J how R98 would refuse treatments when no treatments were ordered for 20 days. RN-J did not have an answer. In an interview on 10/21/2021 at 8:29 AM, Surveyor shared with DON-B the concern R98 did not have a treatment to a Stage 3 pressure injury to the right heel from 10/1/2021 until 10/20/2021. DON-B agreed a treatment should have been in place. In an interview on 10/21/2021 at 9:49 AM, Wound Physician-R stated R98 was being seen every two weeks and then R98 started to refuse to be assessed and treated by Wound Physician-R. Wound Physician-R stated R98 was assessed that morning and the pressure injury measured 0.7 cm x 0.34 cm with 100% granulation. Surveyor shared the measurements RN-J had obtained the day before: 2 cm x 2.8 cm with black discoloration. Surveyor had reviewed wound documentation that morning and RN-J had not documented any assessment or treatment on 10/20/2021. Wound Physician-R stated those measurements did not correlate with today's measurements and could not say what RN-J was measuring. Wound Physician-R stated the lower area of the heel was discolored, but it was not a deep tissue injury. Surveyor shared with Wound Physician-R no treatments had been ordered or completed from 10/1/2021 until 10/20/2021. Wound Physician-R was not aware treatments were not being completed. On 10/21/2021 at 1:36 PM, Surveyor shared the concerns with Nursing Home Administrator (NHA)-A and DON-B that R98's right heel pressure injury was not comprehensively assessed weekly with wound base tissue type or documented when assessments were refused, and R98 did not have any treatment to the Stage 3 pressure injury from 10/1/2021 until 10/20/2021 when Surveyor asked to see the treatment completed with R98. On 10/26/21 the facility provided additional information for Surveyor to review regarding R98's pressure injury. This information was reviewed by the Surveyor.

Based on observation, record review, and interview, the facility did not ensure residents receive adequate supervision and fall interventions to prevent falls for 2 (R106 and R4) of 4 residents reviewed for falls. R106 fell on [DATE] and [DATE] with no root cause analysis completed to determine the cause of the falls and the care plan was not revised to prevent future falls. Subsequently, R106 fell on [DATE] that resulted in a laceration to the right forehead and a fractured pelvic bone. R4 fell on [DATE] with no root cause analysis completed to determine the cause of the fall and the care plan was not revised to prevent future falls. R4 fell [DATE] and [DATE] in similar circumstances and did not sustain any injuries. Findings: The facility policy and procedure entitled Fall Prevention Program dated [DATE] states: 2. A Fall Risk committee will be responsible for reviewing resident falls, monitoring the effectiveness of fall prevention strategies, and for recommending individualized safety interventions. 3. The Fall Risk Committee will meet a minimum of weekly at a designated time to review all resident falls that have occurred since the last meeting. Fall Incident Reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies that may be indicated. 4. The Restorative nurse will be responsible for implementing and communicating resident-specific recommendations from the Fall Risk Committee to the nursing staff assigned to the resident. The nursing staff will be responsible for assuring the recommendations are followed through. 8. Residents will be evaluated after a fall has occurred in an attempt to identify any causative factors that need immediate correction. 9. Nursing staff will complete an Incident Report for each fall to determine factors contributing to the fall and interventions to reduce the risk of further falls. The facility policy and procedure entitled Fall Risk Assessment and Identification dated [DATE] states: 5. Any resident who experiences a fall will be reassessed and interventions will be implemented and evaluated by the Fall Committee. Recommendations and referrals will be made as determined by the Fall Committee. 6. Fall Committee interventions will be care planned and communicated to the nursing staff providing care by the Restorative nurse. The facility policy and procedure entitled Fall Prevention undated states: Review of a fall: -Review incident/accident report for details, completeness and corrective actions. -Review Nurses' Notes regarding fall. -Review clinical record for any changes in condition, medication .that could contribute to the fall. -Gather additional fall data (i.e. staff interviews, resident interviews .) -Complete the Fall Investigation Report. -Update Fall Risk Assessment. -Review potential for pain from fall. -Conduct Fall Committee Meeting. Fall Risk Committee Meetings: -Conduct meetings when a fall has occurred upon conclusion of daily morning meeting. -Review incident report and fall details. -Implement a new intervention or plan to prevent recurrence. -Review and revise fall care plan. -Carry out any Committee recommendations (implementation of alarm .communicating resident specific recommendations to direct care staff .) -Complete any physician orders indicated. -Document review in narrative form in the Restorative Section of the resident's medical record. Do not document staff interventions in a resident's chart. Fall Care Plans: . -Update fall care plans with new interventions after a fall . Date each new intervention. 1. R106 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances, auditory and visual hallucinations, anxiety, depression, malnutrition, [CONDITION(S)], and cochlear implant for hearing loss. R106 had an activated Power of Attorney. R106's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R106 needed extensive assistance with transfers, toilet use, and hygiene. A Fall Care Plan was initiated on [DATE] with the following interventions: -Call light in reach and encourage to use -Educate R106, family, and caregivers about safety reminders and what to do if a fall occurs -Ensure R106 is wearing appropriate footwear -Follow facility fall protocol -Keep commonly used articles within reach On [DATE] at 6:50 PM, R106 had an unwitnessed fall in the room next to the bed. The interdisciplinary team (IDT) met to determine the cause of the fall. The Fall Care Plan was revised to assist R106 back to bed after all meals. On [DATE] at 6:00 AM, R106 had an unwitnessed fall out of bed. The IDT met to determine the cause of the fall. The Fall Care Plan was revised to hang signs to remind R106 to call for assistance. On [DATE] at 4:20 PM, R106 had an unwitnessed fall in the room trying to get out of wheelchair. The IDT met to determine the cause of the fall. The Fall Care Plan was revised to remove R106's wheelchair from the room to dissuade R106 from self-transferring. On [DATE] at 2:47 PM, R106 had an unwitnessed fall in the bathroom when R106 was trying to charge the cell phone in the bathroom. The IDT met to determine the cause of the fall. Staff had observed R106 family members who insisted R106 needed to walk and be independent. The Fall Care Plan was revised to educate family members of the need for R106 to have assistance when ambulating. On [DATE] at 7:14 AM, R106 had an unwitnessed fall in the room trying to toilet self. The IDT met to determine the cause of the fall. The Fall Care Plan was revised to have R106 toileted before and after meals. On [DATE] at 9:38 AM, R106 had an unwitnessed fall due to R106 wanting to go to bed and self-transferring. The IDT met to determine the cause of the fall. The Fall Care Plan was revised to have medications reviewed for potential cause of the fall. On [DATE] at 6:52 PM in the progress notes, nursing charted R106 had an unwitnessed fall. The progress note 18:52 (6:52 PM) states .Writer heard resident calling for help. Writer ran to resident and found her on the floor. Writer called RN to the scene. Resident was assessesed no injury, no bumbs on head. Resident was assisted into the w/c per care plan. Wrier called ambulance when resident reported headache, hip pain and knee pain. Writer gave resident PRN 650 mg of Tylenol but didn't help. Resident was sent to . for evaluation. Son and MD has been notified of the situation. The progress note does not indicate where the fall occurred. R106 returned to the facility. No medical intervention was required. No documentation was found indicating the IDT met to determine the root cause analysis (continence status, when R was last seen and if R was in the w/c prior to being found on the floor, if R was able to share what she was trying to do, etc) and the Fall Care Plan was not revised. On [DATE] at 9:50 PM in the progress notes, nursing charted R106 had fall in the dining room next to the nurses' station. The progress note does not indicate if the fall was witnessed or unwitnessed. R106 was trying to get up from the wheelchair and fell on the left side. A bruise was noted to the left hip. No documentation was found indicating the IDT met to evaluate the root cause analysis (such as R's continent status when found, when R106 was last seen, if R106 was able to share what R106 was trying to do) and the Fall Care Plan was not revised. Surveyor noted during the survey that the Director of Nursing was not aware of this fall until Surveyor informed the DON of the fall documentation in the progress notes. On [DATE] at 6:00 PM, The progress notes states R fell out of wheelchair hitting head on floor causing laceration to right forehead with active bleeding, pressure applied. No verbal response due to resident poor hearing quality, eyes closed, responds to sternal rub with moaning. Bilateral arms bent at elbows and rigid. Complaining of right hip pain with movement .R106 had a witnessed fall in the dining room next to the nurses' station. R106 was sent to the emergency room for evaluation and treatment. R106 was diagnosed with a pelvic fracture from the fall. The IDT met to determine the root cause of the fall. The Fall Care Plan was revised with verbal cuing of R106 to remain seated. Surveyor noted R106 has cochlear implant due to [CONDITION(S)]. On [DATE] at 8:30 PM, R106 had an unwitnessed fall out of bed. Staff reports of family members instructing R106 to get up and walk. The IDT met to determine the cause of the fall. The Fall Care Plan was revised to have a care conference with the family to educate on R106's current functional abilities and the need for staff assistance with transfers. On [DATE] at 5:20 PM, R106 had and unwitnessed fall in the dining room next to the nurses' station sustaining a laceration to the right side of the head. R106 was sent to the emergency room for evaluation and treatment. R106 received stitches to the laceration. The IDT met to determine the cause of the fall. The Fall Care Plan was revised to keep R106 in high traffic areas due to lack of safety awareness and impulse control while awake. On [DATE] at 12:55 PM, Surveyor observed R106 sleeping in bed after lunch. The bed was in a low position and the call light was in reach. In an interview on [DATE] at 10:01 AM, Nursing Home Administrator (NHA)-A stated R106's family member encourages R106 to walk without assistance. NHA-A stated when the family member comes in, staff have tried to approach to educate on how much assistance R106 needs, but the family member does not listen to anybody. Director of Nursing (DON)-B stated during window visits, R106's family member calls R106 over to the window and tells R106 to get up and walk. DON-B stated R106 transfers with the assistance of one and is now getting weaker and needs to have another evaluation done to see what level of transfers is the most appropriate now. In an interview on [DATE] at 10:29 AM, Surveyor asked Social Worker (SW)-D and SW-C who was part of the Falls Committee. SW-D stated DON-B, Assistant DONs, Social Workers, therapy, and NHA-A are all part of the fall IDT. SW-D stated falls are reviewed as part of the morning meeting and the nurses will change the care plan with revisions and type up what was discussed in the meeting. On [DATE] at 11:07 AM, Surveyor observed R106 sitting in a wheelchair in the dining room next to the nurses' station in view of a nurse doing charting at the computer. In an interview on [DATE] at 8:04 AM, Certified Nursing Assistant (CNA)-E stated staff keep R106 out in the TV room to keep an eye on R106 so R106 is in sight of everyone. Surveyor asked CNA-E if R106 was ever put on one-to-one supervision to prevent falls. CNA-E stated R106 had never been supervised one-on-one, but will do one-on-one activities with the activity staff every day. In an interview on [DATE] at 8:56 AM, Surveyor asked DON-B what was the facility process when a resident has a fall. DON-B stated an RN assesses the resident before moving them to make sure there is no injury. Vital signs are obtained and neurological checks are done if the fall was unwitnessed. DON-B stated the resident is then transferred with a lift or gait belt. DON-B stated there is a charge nurse on every shift and falls are reported to them so the falls can be looked at during morning meeting. Surveyor asked DON-B who is responsible for updating the care plan. DON-B stated the care plan is updated by the MDS nurse. Surveyor shared the concern with NHA-A and DON-B R106 did not have an IDT meeting or Care Plan revision after the falls on [DATE] or [DATE] and the next fall R106 had on [DATE] R106 sustained a laceration to the right forehead and a fractured pelvic bone. Surveyor shared the concern the progress notes for the fall on [DATE] did not indicate where the fall occurred. DON-B agreed the location of the fall was not documented and the Fall Care Plan was not revised as it should have been. Surveyor shared the concern DON-B was not aware of the fall on [DATE] until the progress note on [DATE] was brought to the attention of DON-B. No further information was provided at that time. 2. R4 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], arthritis, [CONDITION(S)], [CONDITION(S)], depression, dementia, and anxiety. R4's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R4 needed extensive assistance with transfers, toilet use, and hygiene, and limited assistance for walking. R4's Brief Interview for Mental Status (BIMS) score was 5 indicating severe cognitive impairment. R4 had a guardian. The At Risk for Falls Care Plan was initiated on [DATE]. On [DATE] at 8:40 PM, R4 had an unwitnessed fall in the room sustaining no injuries. The Fall Care Plan was revised to include toileting R4 after meals. On [DATE] at 7:00 AM, R4 had an unwitnessed fall in the room on the right side of the bed. No injury was sustained during the fall. No documentation was found indicating the interdisciplinary team met to determine the cause of the fall. The Fall Care Plan was not revised. R4 had unwitnessed falls on [DATE], [DATE], and [DATE] with no injuries. The IDT met after each fall to determine the cause of the fall and the Fall Care Plan was revised with appropriate interventions. On [DATE] at 2:49 PM, Surveyor observed R4 in bed after lunch. The bed was in a low position and the call light was within reach. In an interview on [DATE] at 8:21 AM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R4 had a fall on [DATE] that was not reviewed by the IDT and the Fall Care Plan was not revised with an intervention addressing the cause of the fall. DON-B stated DON-B was not employed at the facility at that time and had no knowledge of the incident. DON-B agreed the fall should have been reviewed by the IDT and the Fall Care Plan should have been updated. No further information was provided at that time.

Based on observation, interview, and record review the facility did not promote the healing of existing pressure injuries for 1 (R17) of 3 sampled residents. R17 was noted to have an open area to his buttocks on 4/19/21. An assessment of the area is not documented as being completed when the area was first noted on 4/19/21, the physician is not documented as being notified, and a treatment is not documented as being initiated to the area. On 4/22/21 R17 was noted to have a stage 3 pressure injury to his sacrum with a new treatment initiated. On 4/27/21 R17 was observed without his ordered dressing being in place and was noted to be incontinent of stool. During observations of treatment to his wound, staff was observed not washing their hands after cleansing the wound and before applying the treatment and dressing to the area. R17 was observed with multiple layers of linen between R17 and his low pressure air mattress. Findings include: The facility's Wound Cleaning Policy and Procedure, dated, 10/17/08, states, .5. Cleanse hands and put on clean gloves. 6. Remove the soiled dressing and pull soiled gloves off over the dressing and dispose of in moisture-proof bag. 7. Cleanse hands and put on clean gloves. 8. Cleanse the wound with the prescribed solution. The wound is cleaned from the top to the bottom or with outward strokes from the least contaminated to the most contaminated. For the irregular wounds, such as a decubitus, cleanse from the center outward using circular strokes .9. Remove soiled gloves and cleanse hands. The facility Wound Assessment Policy and Procedure, undated, states, .3. A complete wound assessment will be done weekly by a licensed nurse or Attending Certified Wound Specialist for all wounds and ulcers. 4. The comprehensive or complete wound assessment will be documented on the 'Wound assessment Flow Sheet' form during the initial admission skin assessment and weekly thereafter. The wound assessment will contain the following information: 1. Wound classification (Wound type) b. Wound location c. Pressure ulcer staging OR description of the extent of tissue damage d. Description of the wound bed, drainage, margins/surrounding skin, and odor e. Wound Measurement f. Wound related pain. R17 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R17 has a history of pressure injuries. R17's plan of care includes a focus area for the resident has area of skin impairment r/t [related to] impaired mobility, history of PI [pressure injuries] bowel incontinence and hand contactors initiated on 7/3/19. Interventions on the plan of care include; identify/document potential causative factors and eliminate/resolve where possible and Monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD, and Provide pressure relieving device(s) i.e. air mattress, offloader boots, etc. A Skin Observation Tool, dated 3/13/21, documents No to Skin Intact. The Skin observation tool does not document where or how the skin is not intact. R17's progress notes do not document how the skin is not intact or that the physician was notified R17's skin was not intact. On 4/19/21 a Skin worksheet documents R17's skin as abnormal. On the diagram on the worksheet under If ABNORMAL circle affected area(s) R17's sacrum is circled. The bottom of the sheet documents Open bleeding sore on his butt. Scab on his leg. R17's medical record does not document an assessment of the open bleeding sore, does not document that the physician was notified of the bleeding sore, does not document a treatment in place to the area, and does not document any updates to R17's plan of care. On 4/22/21 a skin worksheet documents R17's skin as normal documenting okay. A wound evaluation on 4/22/21 documents a stage 3 pressure injury to the sacrum measuring 0.91cm x 0.69cm x 0.1cm, fully granulated. On 4/22/21 a treatment was ordered to Cleanse wound with saline, Protect periwound with Skin Prep, Apply Collagen with silver to wound bed, Cover wound with Foam, Change Tues/Thur/Sat and PRN [as needed]. Review of R17's Treatment Administration Records document this is the first time a treatment is started to the area. On 4/27/21 at 2:12 pm the surveyor spoke with LPN (licensed practical nurse)-D. LPN-D informed the surveyor she usually does R17's treatment after supper, but could do it earlier when the surveyor requested to see the dressing. At 2:33 pm the surveyor observed LPN-D and LPN-H in R17's room to observed R17's dressing. R17 had been incontinent of bowel, and had no dressing in place. LPN-D confirmed there was no dressing in place to R17's wound stating R17 must have had a bowel movement earlier. LPN-D stated she would have a CNA (certified nursing assistant) clean R17 up and put a dressing in place. At 2:56 pm the surveyor observed ADON (assistant director of nursing)-C and LPN-D in R17's room to do the treatment. The surveyor observed R17 had a wound to his right buttock approximately the size of a pencil eraser with red tissue observed in the wound bed The surveyor observed ADON-C cleanse R17's wound with normal saline. ADON-C removed his gloves and applied new gloves after cleansing the wound. ADON-C did not wash his hands after cleansing the wound and removing his gloves. Following the treatment the surveyor asked ADON-C about not washing his hands after cleansing the wound. ADON-C informed the surveyor sometimes he just changes his gloves. The surveyor observed R17 was on a low air loss mattress. The surveyor observed between R17 and the mattress was a fitted sheet, a lift sheet, and a blue soaker pad. The surveyor informed ADON-C of the observation of R17 having multiple linens between himself and the mattress. ADON-C informed the surveyor he had been working with the DON (Director of Nursing) about that, and knows there shouldn't be all the layers in between. On 4/27/21 at 3:12 pm the surveyor asked DON (Director of Nursing)-B if nurses should wash their hands after cleansing a wound. DON-B stated yes. The surveyor informed DON-B of the observation of ADON-C not washing his hands after cleansing R17's wounds and R17 having multiple layers between himself and the low air loss mattress. The surveyor informed DON-B of the skin worksheet on 4/19/21 documenting an open area to R17's bottom with no documented assessment or MD notification of the area and asked for any additional information related to the area first noted on 4/19/21. No additional information was provided.

Based on observation, interview and record review the facility did not ensure 4 ( R83, R84, R10 and R53) received care and services to promote the prevention and treatment of [REDACTED]. * A LPN (licensed practical nurse) observed an open area on R83 on 9/3/19. There is no documentation of a RN (registered nurse) assessment, MD notification, and a new treatment plan to the area until 9/9/19 when the area was noted to be unstageable with 75% slough, 25% granulation tissue measuring 8cm x 1.5cm with an island of intact tissue in between. * R84's pressure injury on the left buttock was not noted by staff until the wound was unstageable. A Wound Care Consultation Visit note on 9/10/19 documents the wound as being 2.5cm x 1cm unstageable pressure injury with 100% slough. * R10 did not have a wound assessment on 5/4/19 upon discovery of a pressure injury to the left heel. The left heel wound assessment was completed on 5/5/19, which was documented as a pressure injury to left heel with black, firmly attached eschar measuring 3.0 cm (centimeter) by 2.0 cm. As of 9/12/2019 the wound is described as 100% granulation tissue, measuring 1.2cm x 0.8cm x 0.8cm. * R53 did not have a documented wound assessment on 3/4/19 upon discovery of a pressure injury to the left heel. The hospice wound assessment, which was not in R53's medical record, dated 3/5/19 indicates the left heel was a deep tissue pressure injury with small amount of serous exudate, measuring 2 cm by 1.8 cm by 0.01 cm. The facility completed an assessment of the left heel on 3/6/19, which was documeted as unstageable with soft yellow slough scattered throughout the wound bed, 2.2 cm x 2.0 cm x 0.1. As of 9/12/2019 the wound is described as 100% granulated tissue, measuring 0.5cm x 0.3cm. Examples 1 and 2 rise to as scope and severity level of a G (harm/isolated). Findings include: 1. A Skin Observation Form, documented as completed by LPN (licensed practical nurse)-O on 8/30/19 documents R83's skin as being intact. A Skin Observation Form, documented as completed by LPN-O on 9/3/19 documents 2 OA's (open areas) on left butt cheek. Z0gaurd applied. OA #1: 1.5cm x 2cm, OA #2: 2cm x 1cm. The surveyor noted no documentation of a RN (registered nurse) assessment of the area in R83's medical record until 9/9/19. The surveyor noted no documentation of MD notification of a new open area in R83's medical record until 9/9/19. The surveyor noted no documentation of a new treatment plan related to a new open area in R83's medical record until 9/9/19. A Skin Observation Form, documented as completed by LPN-O on 9/6/19 documents 2 OA's on left butt cheek z-guard applied OA #1: 1.5cm x 2cm, OA #2: 2cmx1cm. Progress notes on 9/9/2019 at 11:35 AM document Health Status Note Text: un-stageable pressure ulcer noted to residents buttock this AM, resident is alert, non-verbal due [MEDICAL CONDITION](stroke), dependent on staff for mobility. Resident also receives tube feeding overnight and HOB (head of bed) is elevated at this time. MD and family updated on area. Care plan revised and updated as well. Treatment in place for santyl daily. Resident will follow-up with wound Dr. (Wound Dr.) on 09/12/19. Staff will continue to monitor resident. On 9/9/19 ADON (Assistant Director of Nursing)-D documents an unstageable pressure injury to R83's buttock with 75% slough, 25% granulation tissue measuring 8cm x 1.5cm with an island of intact tissue in between. On 09/17/19 at 09:45 AM the surveyor observed ADON-D and ADON-D administer a treatment to R83's pressure injury. The surveyor observed the pressure injury had not healed as of 9/17/19. On 09/17/19 at 02:31 PM the surveyor interviewed DON (Director of Nursing)-B. The surveyor shared the concern related to R83's pressure injury not being noted prior to it becoming unstageable. DON-B stated I am wondering that myself, it (pressure injury) should have been noted prior, absolutely. On 09/18/19 at 04:00 PM DON-B informed the surveyor LPN-O had noted the area on 9/3/19. DON-B informed the surveyor LPN-O was educated when the area was noted as an unstageable pressure injury on 09/10/19. DON-B provided the surveyor an Employee Education Record documenting LPN-O was educated on 9/10/19 that When a new skin issue is found, MD and Family need to be updated. Need treatment orders and a pain assessment, risk management and Braden Scale need to be completed. On 9/30/19 DON-B provided the surveyor the following information Timeline for (R83) 8/30/19: skin observation sheet done; skin intact. 9/03/19: skin observation sheet done noted open area to left buttock with measurements, resident had order for barrier cream to buttock every shift in place (the surveyor noted this intervention was in place prior to the area developing), 9/06/19: skin observation sheet done noted same area to left buttock with measurements. 9/09/19 nurse informed management of skin alteration, wound care consultation visit done, MD and family updated, new orders received, care plan revised and updated. Nurse educated on 9/9/19 in writing on proper procedure on skin alterations. 2. R84's Admission Data Collection and Baseline Care Plan Tool assessment, from an admission date of [DATE], documents R83's skin as being reddened and dry. R84's care plan includes a focus area for (R84) is at risk for alteration in skin integrity related to: Diabetes, impaired mobility. Chooses not elevated (sic) heels and reposition; preferring to lay on his back for long periods of time, chooses not to receive showers at times. Includes interventions to Observe skin condition with ADL care daily; report abnormalities initiated on 6/20/19. R84's Skin Observation Form, signed 8/22/19 by LPN (Licensed Practical Nurse)-O documents, Groin/buttocks/scrotum redness noted. R84's Skin Observation Form, signed 8/29/19 by LPN-O documents, Groin/buttocks/scrotum redness noted. R84's Skin Observation Form, signed 9/1/19 by LPN-O documents, Groin/buttocks/scrotum redness noted. R84's Skin Observation Form, signed 9/5/19 by LPN-O documents, Groin/buttocks/scrotum redness noted- treatments/ creams in place. The surveyor reviewed R84's plan of care. The surveyor noted the intervention for Barrier cream to peri area/buttocks as needed was initiated on 6/20/17. The surveyor noted no new treatments or interventions implemented related to R84's goin/buttocks/scrotum redness. R84's Skin Observation Form, signed 9/10/19 by LPN-O documents, Left buttock open area measuring 2cm x 0.5cm. On 9/10/19 LPN-O documents, Writer was notified by CNA (certified nursing assistant) that resident had an open area noted to left buttocks measuring 2cm x 0.5cm. Slough noted to wound bed. Surrounding tissue slightly red. No s/s (signs/symptoms) of infection noted. C/o (complained of) slight discomfort) PRN (as needed) [MEDICATION NAME] administered. MD updated. Resident and wife updated . A Wound Care Consultation Visit note on 9/10/19 by ADON (Assistant Director of Nursing)-E, documents the wound as being 2.5cm x 1cm unstageable pressure injury with 100% slough. Santyl and a dressing were ordered. On 09/17/19 at 09:32 AM the surveyor observed ADON-D and ADON-E administer a treatment to R84's pressure injury. The surveyor observed a pressure injury with slough on R84's left buttock. On 09/17/19 at 02:11 PM the surveyor asked ADON-E why R84's wound was not noted until it was an unstageable pressure injury. ADON-E stated I am not sure. On 09/17/19 at 02:31 PM the surveyor interviewed DON (Director of Nursing)-B. the surveyor shared the concern related to R84's pressure injury not being noted prior to it becoming unstageable. DON-B stated I am wondering that myself, it (pressure injury) should have been noted prior, absolutely. On 09/18/19 at 04:04 PM DON-B informed the surveyor LPN-O had previously noted a reddened area. The surveyor asked what is the expectation when a reddened area is noted. DON-B stated to notify us and start a treatment. DON-B informed the surveyor LPN-O was a new grad and education was completed with her. 3. R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (minimum data set) dated 6/17/19 indicates R10 is cognitively impaired and needs extensive assistance with bed mobility and transfers. The care plan for actual skin impairment to skin integrity to left heel with a initiated date 5/4/19 indicates interventions: -Encourage good nutrition and hydration in order to promote healthier skin -float heels while in bed -follow facility protocols for treatment of [REDACTED].>-implement pressure reducing devices i.e. w/c (wheelchair)cushion, air mattress, off-loading heels, etc. -keep skin clean and dry. Use lotion on dry skin. Do not apply on left heel. -Monitor/document location, size and treatment of [REDACTED]. to MD (medical doctor). -provide Prostat QD (daily) The nurses note dated 5/4/2019 at 2:38 p.m indicate (R10) noted this am to have skin issues left heel writer did update Hospice nurse (MD) also updated and resident's daughter made aware new order in place from Hospice daughter aware of orders of orders. On 5/4/19 there is not a documented assessment of R10 left heel skin issues. On 5/5/19 there is documented wound assessment which indicates R10 has a pressure injury to left heel with black, firmly attached eschar measuring 3.0 cm (centimeter) by 2.0 cm. The most current wound assessment date 9/12/2019 10:58 a.m. Wound Care Consultation Visit Wound Location: Left Heel Wound Type: Pressure injury unstageable Wound Bed: 100% granulation tissue Peri-Wound Area: Surrounding skin is macerated (apply skin prep) Drainage: Small amount of serous drainage Odor: Normal odor Wound Measurements: 1.2cm x 0.8cm x 0.8cm Tunneling: None Undermining: None Wound Pain: None reported or observed Other Assessments: Attached wound edges Barriers to Wound Healing: Resident is on hospice care for terminal illness Current Treatment and Interventions: Cleanse wound with Dakins solution, Apply Skin prep to peri wound, lightly pack with Dakins soaked gauze and cover with bordered gauze daily and PRN (as needed) for saturation. Pressure redistribution mattress, off loading as tolerated, nutritional supplements Recommendations: Continue with current treatments and interventions Education Provided: Importance of nutrition and off loading in wound healing Other Comments: On 9/17/19 at 9:28 a.m. Surveyor observed R10 in her wheelchair in the lounge area. Surveyor observed R10 have a pressure reducing cushion in the wheelchair and R10 had slippers on her feet. On 9/18/19 at 8:35 a.m. Surveyor observed R10 in bed with her heels offloaded. Surveyor observed the daily wound treatment. Surveyor observed the left heel to have a small pressure injury with no odor or slough and granulation tissue was observed. On 9/18/19 at 2:30 p.m. during the daily exit meeting with DON (Director of nursing) B and Interim NHA A, Surveyor explained the concern there wasn't a wound assessment on 5/4/19 upon discovery of the wound. On 9/23/19 at 12:30 p.m. Surveyor interviewed DON B regarding pressure injuries. DON B stated in (MONTH) the QAPI (quality assurance performance improvement) committee developed a PIP (performance improvement plan) regarding offloading of heels. DON B stated she noticed heels were not being offloaded. DON B states QAPI is still monitoring this concern. DON B had no additional information as to why there wasn't a wound assessment on 5/4/19. 4. R53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R53 is alert and oriented and able to make her needs known. The nurses note dated 3/4/2019 at 2:18 p.m. indicates R53 was noted with am shower by hospice cna (certified nursing assistant) to have skin area present to left heel hospice nurse updated and tx (treatment) of meplix applied to area resident aware of area denied any disc (discomfort). There is not a documented wound/skin assessment until 3/6/19. The wound assessment dated [DATE] at 1:46 p.m. indicates, Wound Care Consultation Visit Wound Location: Left heel Wound Type: Pressure injury unstageable Wound Bed: Area is covered with soft yellow slough scattered throughout the wound bed Peri-Wound Area: Clean, dry, intact Drainage: Small serous Odor: Normal odor Wound Measurements: 2.2 cm x 2.0 cm x 0.1 Tunneling: none Undermining: none Wound Pain: none reported or observed Other Assessments: Attached edges Barriers to Wound Healing: Resident is on Hospice Care Current Treatment and Interventions: [MEDICATION NAME] to area after cleaning wound with saline, cover with Foam dressing daily and PRN. Alternating air mattress, off loading of heel. Recommendations: Resident was wearing tennis shoes which is not the kind of shoes that she was wearing at home. Resident will no longer wear tennis shoes. Education Provided: Importance of off loading her heels Other Comments: The most recent documented wound assessment was on 9/12/2019 2:36 p.m. Wound Care Consultation Visit Wound Location: Left heel Wound Type: Pressure injury unstageable Wound Bed: 100% granulated tissue Peri-Wound Area: clean dry intact Drainage: Small serous drainage Odor: Normal Odor Wound Measurements: 0.5cm x 0.3cm Tunneling: None Undermining: None Wound Pain: None reported or observed Other Assessments: Attached wound edges Barriers to Wound Healing: Resident is on hospice care for terminal illness Current Treatment and Interventions: Cleanse wound with NS, skin prep to peri wound, Iodosorb to wound bed and cover with bordered gauze every other day. Pressure redistribution mattress, off loading of the heels and nutritional supplement Recommendations: Continue with current treatment and interventions Education Provided: Importance of nutrition and off loading in wound healing Other Comments: The care plan actual impairment to skin integrity pressure injury to left heel unstageable, redness to left toe. The date initiated for this care plan was 1/29/19 with revision date of 5/22/19. The interventions are: -Elevate heels off the mattress-date initiated 4/23/19 -Encourage good nutrition and hydration in order to promote healthier skin-date initiated 1/29/19 -Follow facility protocols for treatment of [REDACTED]. -Implement pressure reducing devices i.e. w/c cushion, air mattress, off-loading heels, etc-date initiated 3/7/19 -Provide protein supps as ordered to encourage wound healing-date initiated 7/31/19 -Resident (R53) refuses to use air mattress-encouraging off loading-date initiated 1/29/19 revision 5/30/19 -Turn and position as necessary-date initiated 3/7/19 -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations-date initiated 3/7/19 On 9/17/19 at 1:26 PM Surveyor observed R53 in her wheelchair with a pressure reducing cushion in the chair. R53 was observed in her room with gripper socks on and no shoes. On 9/18/19 at 8:56 AM Surveyor observed R53 in bed with her heels off loaded on a pillow. Surveyor observe daily wound treatment and notice a small wound with slough in the wound bed. No odor was observed. On 9/18/19 at 2:30 p.m. during the daily exit meeting with DON B and Interim NHA A, Surveyor explained the concern there wasn't a documented wound assessment on 3/4/19 upon discovery of the wound. On 9/19/19 at 9:34 AM DON B provided surveyor with hospice assessment of wound on 3/5/19. DON B confirmed the hospice wound assessment dated [DATE] was not in R53 medical record. DON B confirmed the hospice wound nurse printed out a screenshot of documented assessment that was done on 3/5/19 by hospice. The hospice wound assessment dated [DATE] at 2:30 p.m. indicate the left heel was a deep tissue pressure injury with small amount of serous exudate. The wound bed is intact appearing pink, purple and red in color. The pressure injury measured 2 cm by 1.8 cm by 0.01 cm. Foam silicone dressing was applied. On 9/23/19 at 12:30 p.m. Surveyor interviewed DON B regarding pressure injuries. DON B stated in (MONTH) the QAPI (quality assurance performance improvement) committee developed a PIP (performance improvement plan) regarding offloading of heels. DON B stated she noticed heels were not being offloaded. DON B states QAPI is still monitoring this concern. DON B had no additional information as to why there wasn't a wound assessment on 3/4/19.

Based on observation, interview, and record review the facility did not promote and prevent the development of pressure injuries for 1 (R1) of 2 residents reviewed. R1 was admitted to the facility with 2 pressure injuries. On 7/24/18 R1 was noted to have 5 pressure injuries. On 7/31/18 R1 was noted to have 8 pressure injuries. On 8/7/18 R1 was noted to have 9 pressure injuries. On 8/14/18 R1 was noted to have 10 pressure injuries. During observation on survey R1 was noted to have 14 pressure injuries. During observations R1 was observed with care planned interventions not in place. The facility did not always document on wounds assessed by the wound clinic, did not accurately assess R1's wounds by not always staging the wounds, improperly staging wounds, not assessing wound depth, and not documenting assessment of the wound bed. The facility did not document assessments of new wounds the day first observed during surveyor observation. R1's care plan was not updated to include specific interventions and recommendations from the wound clinic, the care plan did not specify how often staff were to reposition R1, and did not instruct staff on interventions if R1 declines being repositioned. R1 had a [DIAGNOSES REDACTED]. The facility did not develop non-pharmacological interventions to assist R1 with his depression impacting upon wound care. Findings include: R1 has [DIAGNOSES REDACTED]. Surveyor noted upon review of R1's medical record that R1 has multiple [DIAGNOSES REDACTED]. Surveyor noted during the investigation into R1 that at the time and prior to the survey R1 did not have a [DIAGNOSES REDACTED]. R1 was admitted to the facility on [DATE]. Progress notes on 6/8/18 document The plan is for him to return home and he will need to be able to ambulate about the home to return. Progress notes on 5/29/18 document .Upon admission unstageable pressure ulcer noted to right hip. Lower right hip by buttock measures 15.0 cm x 19.0 cm and upper right hip measures 4.0 cm x 12.2 cm. Wound bed is 85% nacrotic (sic) tissue and 15% slough tissue to wound edges. Care plan and interventions in place to promote healing and prevent further breakdown include specialty mattress/cushion, daily body audits, re-positioning and foley catheter to promote healing .The surveyor noted the progress note does not include a documented description of the type of necrotic tissue to the resident's wound bed. A pressure ulcer assessment form, with an effective date of 5/29/18, documents extrinsic risk factors as requires staff assistance to move, confined to bed/chair all or most of time, immobility, and cognitive loss. The form does not check the option of Requires regular schedule for turning. R1's Minimum Data Set assessment, with an assessment reference date of 6/1/18, documents R1 requires extensive assistance of 2 plus staff for bed mobility. The surveyor reviewed R1's care plan for the goal to Decrease/minimize skin breakdown risks with an initiation date of 5/27/18. The surveyor noted interventions include Encourage to reposition as needed; use assistive devices as needed initiated on 5/27/18. The surveyor noted R1's care plan does not instruct staff on how often R1 needs to be repositioned. On 10/9/18 at 4:26 pm the surveyor interviewed Director of Nursing (DON)-B. The surveyor asked DON-B if the facility specifies how often a resident should be repositioned. DON-B stated the facility does not put time frames unless needed. The surveyor asked how often DON-B expects staff to reposition R1. DON-B stated every 2 hours. The surveyor asked how staff knows that. DON-B stated they are taught that when they become a CNA and during orientation. The surveyor noted R1 had no resident specific intervention for being repositioned. Progress notes on 6/5/18 document Wound Rounds: Unstageable pressure ulcer remains to right hip. Lower right hip by buttock (Right Glutinous) (sic) measuring 14.0 cm x 18.0 cm, wound bed is 75% Narcotic (six) tissue, 20% slough present around narcotic (sic) and 15% red vascular tissue present to wound edges. PUSH score of Surrounding skin intact, no macarction (sic) noted. No s/sx (signs/symptoms) of infection noted. Right hip measure 3.0 cm x 11.0 cm. Wound bed is 80% slough to middle of wound bed and 20% red vascular tissue to edges of wound. Surrounding skin intact, no maceration noted, no s/sx of infection. Mild odor present with removal of old dressing .Care plan and interventions in place to promote healing and prevent further breakdown include specialty mattress/cushion, daily body audits, re-positioning and foley catheter to promote healing . On 6/11/18 a new order was received for [MEDICATION NAME] 7.5 mg every day for appetite stimulant. On 6/11/18 R1 was seen by an outpatient wound clinic. The outpatient wound care progress notes document .Reports he is rotating himself to avoid pressure to right side Since last evaluation from hospitalization wounds have now opened up and are full thickness. The surveyor noted the wound clinic documented a depth of 0.3 cm to R1's right hip by buttock/buttock right upper and 0.2 cm to R1's right anterior/lateral hip. The surveyor noted the facility did not document assessment of wound depth during their measurements of R1's wounds. The wound clinic notes instruct to Limit sitting to 1 hour three times a day with meals, change position in chair every 15 min, change positions when lying down every one to two hours .[MEDICAL CONDITION]: Elevate your extremities as much as possible. Heel above hip when sitting and heel above heart when sleeping. The surveyor noted these recommendations were not included on R1's plan of care. Progress notes on 6/12/18 document Wound Rounds: Unstageable pressure ulcer remains to right hip. Right hip by buttock measuring 15.0 cm x 15.0 cm, wound bed is 50% scattered slough and 50% red granulation tissue. Wound was debrided by wound clinic on 6/11. PUSH score 14. Surrounding skin intact, no macarction (sic) noted. No s/sx of infection noted. Right hip measures 2.1 cm x 11.0 cm. Wound bed is 80% slough to middle of wound bed and 20% red vascular tissue to edges of wound .extensive assist of one with ADL's (activities of daily living), transfers and bed mobility. Wheelchair used for mobility around unit. Care plan and interventions in place to promote healing and prevent further breakdown include specialty mattress/cushion, daily body audits, re-positioning and foley catheter to promote healing . Progress noted on 6/19/18 document Wound Rounds: Healing pressure ulcer right hip (posterior) measures at 13.9 x 18.5 with minimal slough noted. 90 percent beefy red granulation tissue and 10 percent of necrotic tissue was noted to the wound bed. Wound bed remains moist with edges intact and well defined. No odor and min drainage noted. Second wound to the right hip (Anterior/lateral) Measures at 2.5 x 10 with 95 percent slough and 5 percent granulation tissue noted to the wound bed. Edges remain intact and well defined. The wound has no odor and moderate amount of drainage .The wounds are healing slowly with the interventions put in place. Appetite has been poor upon admission and an appetite stimulant has been initiated with some positive results. The patient also has nutritional supplements in place with the increase of protein for wound healing. The patient will continue with all interventions and preventatives as they remain appropriate at this time. MD and family are aware of the current wound status with his P[NAME] (plan of care).The surveyor noted the weekly wound rounds assessment does not stage R1's pressure injuries. Progress notes on 6/26/18 document Healing pressure ulcer right hip (posterior) measures at 14.5 cm x 11.0 cm with minimal slough noted. 90 percent beefy red granulation tissue and 10 percent of necrotic tissue was noted to the wound bed. Wound bed remains moist with edges intact and well defined. No odor and minimal drainage noted. Second wound to the right hip (Anterior/lateral) Measures at 2.3 cm x 10 cm with 95 percent slough and 5 percent granulation tissue noted to the wound bed. Edges remain intact and well defined. The wound has no odor and moderate amount of drainage noted with removal of bandage . Appetite remain poor, encourage given at meals times, resident also has nutritional supplements in place with the increase of protein for wound healing. The patient will continue with all interventions and preventatives as they remain appropriate at this time. MD and family are aware of the current wound status. Will continue current P[NAME]. The weekly wound assessment does not stage the wounds. The weekly wound assessment does not describe the type of necrotic tissue noted to the wound bed. On 6/27/18 R1 was seen by an outpatient wound clinic. The surveyor noted the wound clinic documents R1's pressure injuries to his right lateral depth as 0.4 cm and the right posterior hip/buttock as having a depth as 0.3 cm. The surveyor noted the facility had no documented depth in their assessment of R1's wounds. Clinic notes state the wound dimensions were unchanged post debridement. Wound clinic notes include instructions stating Offloading was reviewed and discussed with patient and daughter today. Patient needs to offload wound area as much as possible in order to allow the healing process to occur more efficiently. Low air loss mattress. Limit sitting to 1 hour three times a day with meals, change position in chair every 15 min (minutes), change position when lying down every one to two hours .[MEDICAL CONDITION] Elevate your extremities as much as possible. Heel above him when sitting and heel above heart when sleeping. The surveyor reviewed R1's plan of care and noted it still contained the intervention to Encourage to reposition as needed; use assistive devices as needed initiated on 5/27/18. The surveyor noted R1's plan of care was not updated to include the recommendations for offloading from the wound clinic. The facility provided the surveyor with documentation of repositioning for the month of (MONTH) (YEAR). The surveyor noted no documentation of refusals of repositioning. Per the facility starting in July, repositioning was no longer documented on under its own documentation category. Progress notes on 7/1/18 at 10:36 am, by LPN (licensed practical nurse)-C, document Patient had open area to right buttock measuring 1.4 cm x 1 cm, 0 cm depth, no complaint of pain, cleansed with NS (normal saline) and applied [MEDICATION NAME]. Faxed (physician) for treatment orders requesting use of [MEDICATION NAME] AG, will follow up on AM shift. There is no documentation of a RN (registered nurse) assessment on 7/1/18 or 7/2/18 of the wound to the right buttock. There is no documented description of the open areas wound bed. On 7/2/18 R1 went to the hospital overnight for a procedure. An Admit/Readmit progress note on 7/3/18 documents .Noted several skin alteration including a 12 x 12.5 x .1 cm wound to right hip, 1.5 x 1 x .1 cm wound to right hip, 1.5 x .9 x .1 cm wound to right buttocks, 1.2 cm x 1 x .1 cm wound to left buttocks, 1.2 x 1 x .1 cm wound to left buttocks, redness to scrotum approx. 6 x 6 cm and a red area to outer right ankle [MEDICAL CONDITION] x .5 cm that is left OTA (open to air). Resident has multiple scabs throughout his lower extremities . The progress note does not contain a description of the wound beds. A pressure ulcer assessment form, with an effective date of 7/4/18 documents extrinsic factors as confined to a bed/chair all or most of time, needs special mattress/seat cushion, immobility, and cognitive loss. The assessment does not check the option of Requires regular schedule for turning. A skin progress note on 7/5/18 documents Resident was readmitted to facility on 07/03 pressure ulcer right hip (posterior) noted measures at 11.6 cm x 14.3 cm with scattered slough and red beefy granulation tissue. Wound bed remains moist with edges intact and well defined. No odor and minimal drainage noted. Second wound to the right hip (Anterior/lateral) Measures at 1.5 cm x 8. cm with 80 percent slough and 20 percent granulation tissue noted to the wound bed . Appetite remains poor, encouragement given at meal times, resident also has nutritional supplements in place with the increase of protein for wound healing. The patient will continue with all interventions and preventatives as they remain appropriate at this time. MD and family area ware of the current wound status. Will continue current P[NAME]. Progress notes on 7/5/18 document resident received dressing changes to bilateral buttocks and also right hip .appetite continues to be poor . Wound round notes on 7/10/18 document pressure ulcer right hip (posterior) noted measures at 10.5 cm x 12.5 cm wound bed 100% red beefy granulation tissue .Second wound to the right hip (Anterior/lateral) measures at 0.9 x 7.1 cm with 75% slough and 25 percent granulation tissue noted to the wound bed .Will continue current P[NAME]. The weekly wound assessment does not stage the wounds. On 7/10/18 a progress not documents call received from (MD-E's) office this am. Updated them on residents continued weight loss, very poor appetite and increased s/s of depression new orders received to start [MEDICATION NAME] increase [MEDICATION NAME] dosage to 15 mg and psych services to eval and tx writer received call from residents daughter (Daughter-G) at this time and she does not want psych eval and tx related to cost okay with increase in [MEDICATION NAME] and starting [MEDICATION NAME]. A behavioral symptoms assessment form, with an effective date of 7/11/18, does not check Resistance to ADL's as an identified behavioral symptom. The assessment does not document R1 as having behaviors of declining to be repositioned. The assessment does document depression as an identified behavioral symptom. Additional comments state [MEDICATION NAME] increased to 15 mg daily and [MEDICATION NAME] started due to poor appetite and repression. Will continue to monitor resident. The surveyor reviewed R1's plan of care. The surveyor noted a care plan for At risk for adverse effects related to: use of antidepression medication ([MEDICATION NAME] for appetite stimulant) with an initiation date of 6/12/18. The surveyor noted interventions include Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs and Report to physician signs of adverse reaction such as decline in mental status, decline in positioning/ambulation ability, lethargy, complaints of dizziness, tremors, etc. The surveyor noted R1's plan of care did not include non-pharmacological interventions to assist him with his depression. The surveyor reviewed R1's minimum data set assessment with an assessment date of 7/31/18 and noted that R1 had had an increase in mood symptoms to 4 symptoms compared to his previous assessment, with an assessment reference date of 6/1/18 of 1 symptom. Wound round notes on 7/17/17 document pressure ulcer right hip (posterior) noted measures at 8.5 cm x 11.0 cm wound bed 100% red beefy granulation tissue .Second wound to the right hip (Anterior/lateral) Measures at 0.6 cm x 5.6 cm, wound bed is 100% red beefy tissue .The patient will continue with all interventions and preventatives as they remain appropriate at this time. MD and family are aware of the current wound status. Will continue current P[NAME]. The weekly assessment does not stage either wound. On 7/18/18 R1 was seen by an outpatient wound clinic. The wound clinic instructs to Limit sitting to 1 hour three times a day with meals, change position in chair every 15 min, change position when lying down every one to two hours .[MEDICAL CONDITION]: Elevate your extremities as much as possible. Heel above hip when sitting and heel about heart when sleeping. Wound notes on 7/19/18 document writer spoke with (physician's) office updated them on redness present to bilateral ankle areas see new tx. A pressure ulcer assessment with an effective date of 7/19/18 documents extrinsic risk factors as confined to a bed/chair all or most of time, Needs special mattress/seat cushion, and immobility. The form does not check the option of requires regular schedule for turning. The note documents Resident was admitted with two pressure ulcer to his right hip that are unstageable. A new area was identified to the sacrum-DTI measuring at 1 x 1.5 skin intact and remains dark purple. MD and family are aware with a foam dressing for treatment. Patient has had multiple interventions in place that remain appropriate at this time. Will continue to monitor and P[NAME]. On 7/24/18 R1 is now documented as having 5 pressure injuries. Wound round notes on 7/24/18 document pressure ulcer right hip (posterior) noted measures at 6.6 cm x 11.5 cm wound bed 100% red beefy granulation tissue .second wound to the right hip (Anterior/lateral) Measures at 1.0 cm x 2.0 cm, wound bed is 100?% red beefy tissue .DTI (deep tissue injury) noted to right (sic) measuring 2. cm x 1.6 cm .DTI noted to left ankle measuring 1.5 cm x 1 cm .DTI noted to left buttock measuring 1.5 cm x 1 cm . Appetite remains poor, encouragement given at mealtimes, resident also has nutritional supplements in place to help increase wound healing. The patient will continue with all interventions and preventatives as they remain appropriate at this time. MD and family are aware of the current wound status. Will continue current P[NAME]. The wounds to R1's hips were not staged. Progress notes on 7/25/18 document writer spoke with residents daughter .and updated her on the decrease dose of amimodone (sic) to daily also made aware that reddened skin area present to bilateral feet ankle area with tx of marathon and specialized cushion being utilized while in bed. Progress notes on 7/26/18, by LPN-D document during txs (treatments) noted DTI to left and right calf areas. Left calf measures 7.0 cm x 2.0 cm and right calf measures 8.0 cm x 2 cm. DTI noted to left outer heel measuring 3.5 cm x 2.5 cm and DTI noted to right inner aspect of ankle measuring 2.0 cm x 1.5 cm. Specialized pressure relieving cushion removed and pillows place to float heels .Marathon treatments put in place labs for pre-[MEDICATION NAME] and [MEDICATION NAME] level ordered and scheduled for 7/27. Resident denies pain or discomfort to areas. Assist with re-positioning. There is no documentation of a RN assessment to the areas until 7/31/18. Progress notes on 7/29/18 document staff continue to reposition and float residents heels dressing changes and tx done appetite continues to be poor took meds as ordered . On 7/31/18 R1 is documented as having 8 pressure injuries. Wound round notes on 7/31/18 document Pressure ulcer to right hip (posterior) noted measures at 11.5 cm x 6.0 cm wound bed 100% red beefy granulation tissue . Second wound to the right hip (Anterior/lateral) Measures at 0.5 cm x 0.4 cm, wound bed is 100% red beefy tissue. Edges remain intact and well defined .DTI noted to right ankle measuring 1.5 cm x 1.5 cm .DTI noted to right calf measuring 11.0 cm x 3.0 cm .DTI noted to left ankle measuring 3.5 cm x 3.0 cm .DTI noted to left calf measuring 7.5 cm x 2.5 cm .DTI to left heel measuring 4.5 cm x 2.3 cm .Stage 2 to left buttock measuring 1.0 cm x 2.0 cm .Will continue current P[NAME]. R1's right hip wounds are not staged. The surveyor reviewed R1's care plan and noted no new documented interventions were put into place on the care plan from 7/19/18 (when R1 was noted to have new pressure injuries) to 7/31/18 (at which time R1 is documented as having 8 pressure injuries. On 7/31/18 the intervention to use a friction reducing transfer sheet and pressure redistributing support surface were added. The care plan still did not address the frequency that staff should attempt to reposition R1. Progress notes on 8/1/18 document .His kidney function is low, and his skin is breaking down as resident remains in bed all day per his choice. His appetite is poor. Doctor has started him on appetite stimulants. Resident enjoys fruits, therefore more will be offered. On 8/7/18 R1 is documented as having 9 pressure injuries. Wound rounds on 8/7/18 document Stage 2 pressure ulcer to right hip (posterior) noted to measure at 10.5 cm x 0.6 cm wound bed 100% red beefy granulation tissue .Second wound to the right hip (Anterior/lateral) healed. [MEDICATION NAME] in place for protection. DTI noted to right ankle measuring 1.4 cm x 1.2 cm .DTI noted to right calf measuring 5.8 cm x 1.5 cm .DTI noted to left ankle measuring 1.8 cm x 1.3 cm .DTI noted to left calf measuring 6.5 cm x 2.5 cm .DTI to left heel measuring 4.0 cm x 4.0 cm .DTI to left out heel measuring 4.4 cm x 2.0 cm . Stage 2 to left buttock measuring 2.5 cm x 2.0 cm .DTI noted to middle of back measuring 4.5 cm x 3.4 cm .Appetite remains poor, encouragement given at meal times, resident also had nutritional supplements in place to help increase wound healing. The patient will continue with all interventions and preventatives as they remain appropriate at this time. MD and family area aware of the current wound status. Wound Clinic updated on wound status. Will continue current P[NAME]. The surveyor noted R1's pressure injury to his right hip is incorrectly staged as a stage 2 due to the present of granulation tissue. He surveyor noted the stage 2 pressure injury to R1's left buttock does not document assessment of the wound bed. The surveyor noted no description of color of the wound bed to R1's 7 deep tissue pressure injuries. Outpatient wound care progress notes on 8/8/18 document Since 7/18/18 visit, pt now presents with multiple new wounds for evaluation on 8/8/18 visit. Daughter reports she feels pt has developed some wounds from pressure in his wheelchair and from medical device on his back. The wound clinic documents a 0.8 cm x 1.1 cm x 0 cm wound to R1's left great toe. The surveyor noted the facility's wound round notes do not document an assessment of this wound until 8/17/18. The surveyor noted the wound clinic documented two wound on R1's back, a 4 cm x 3.8 cm wound to the [MEDICATION NAME] left lateral and a 1.9 cm x 2 cm wound to the vertebrae distal. The surveyor noted the facility only documented 1 wound to middle of R1's back until 8/17/18. The wound clinic documents Pt. needs to have prevalon offloading boots for legs, ankles, and heels whenever sitting or lying down. Limit sitting to 1 hour three times a day with meals, change position in chair every 15 min, change position when lying down every one to two hours [MEDICAL CONDITION] Elevate your extremities as much as possible. Heel above hip when sitting and heel above heart when sleeping. On 8/14/18 R1 is documented as having 10 pressure injuries. Wound rounds on 8/14/18 document Stage 2 pressure ulcer to right hip (posterior) noted measures at 9.0 cm x 6.0 cm wound bed 100% red beefy granulation tissue .DTI noted to right ankle measuring 0.8 cm x 0.8 cm, PUSH score of 5, wound bed 100% red beefy tissue .DTI noted to right calf measuring 1.5 cm x 0.5 cm .wound bed 100% red beefy tissue .DTI noted to left ankle measuring 1.5 cm x 0.5 cm .DTI noted to left calf measuring 5.0 cm x 2.0 cm. DTI to left heel measuring 2.8 cm x 2.0 cm, DTI to left outer heel measuring 2.3 cm x 3.0 cm .Stage 2 to left buttock measuring 0.5 cm x 0.2 cm, PUSH score of 1. Surrounding skin intact with some redness noted. No maceration present. DTI noted to middle of back measuring 4.0 cm x 4.0 cm. DTI noted to outside of left foot by pinky toe measuring 2.0 x 1.0 . Appetite remains poor encouragement given at meal times, resident also has nutritional supplements in place to help increase wound healing. The patient will continue with all interventions and preventatives as they remain appropriate at this time. MD and family are aware of the current wound status. Will continue current P[NAME]. The surveyor noted the wound to R1's right hip is staged as a stage 2 pressure injury despite the wound bed being described as granulation tissue. The surveyor noted R1's DTI to his right ankle and right calf are documented as a deep tissue injury despite the wound bed being documented 100% red beefy tissue. R1 was hospitalized [DATE]-8/16/18 for a kidney stone removal procedure. R 1 was readmitted to the facility on [DATE]. An admission assessment, signed 8/17/18 documents skin integrity issues as Right trochanter (hip) 10 x 9.0, left buttock 2.2 x 1.2, right lower leg (rear) right calf 5.0 x 2.0, left lower leg (rear) left calf 6 x 2.5, right ankle (inner) 5 x .8, left ankle (outer) 1.5 x 1.5, left heel 3.5 x 3.0, left heel outer aspect 3.3 x 1.2, right toe right hallux (large toe bunion area) 1 x 1, left toe left hallux 1 x 1, lumbar spine 4.9 x 2.5, right lower lateral back 5.0 x 7.0, and [MEDICATION NAME] spine 3.5 x 3.0. The assessment does not document a description of the wound bed, wound depth, or wound stage. Progress notes on 8/17/18 document writer did speak with resident (daughter-G) and updated her that resident did acquire several new areas on back while in hospital and also of his refusal of meds last pm is concerned for his poor appetite. On 8/20/18 on a pressure ulcer assessment tools the facility checked Requires regular schedule for turning as an extrinsic risk factor. The assessment documents New DTI found to right lower lateral knee. Skin intact. Current intervention remain appropriate at this time call out to the MD, wound clinic and family to update. Resident continues to have a poor appetite and is on appetite stimulants. Will continue to monitor and P[NAME]. The surveyor reviewed R1's plan of care and noted no documented intervention of a regular schedule for turning. On 8/21/18 R1 had 13 pressure injuries. Wound rounds on 8/21/18 document Patient readmitted S/p (status [REDACTED]. Rt (right) lateral knee is a DTI dark purple and closed measures at 0.5 x 1.0, LT BTX (left buttock)/Sacrum area is now closed and healed will continue preventatives to area, unstageable to the [MEDICATION NAME] spine aspect measures at 3.5 x 3.0 with 100 percent yellow slough and a small area of necrotic tissue in the center minimal drainage of serosanguineous noted without odor. Edges area attached and surrounding tissue intact. Lumbar spine aspect is unstateable (sic) and measures at 2.5 x 2.5 with the wound bed being 100 percent covered with slough, edges are attached, minimal drainage without odor. Rt lateral back (rib area) is a DTI and measures at 8.0 x 8.0 with dark purple and closed. Lt lateral calf is unstageable currently measures at 5.8 x 2.0 the wound bed remains 100 percent black eschar with edges being attached, no S/sx of infection, and without purulent drainage. LT outer ankle remain unstageable with stable eschar measuring 1.5 x 3.0. Edges are attached, without odor, and there is minimal drainage noted. LT lateral (outer) heel remains unstageable and measures at 3.0 x 3.0 the wound bed is 100 percent covered with an eschar cap. Edges are attached without odor and no drainage noted. LT medial heel is a DTI dark color in purple measuring at 3.0 x 2.4. The wound remains closed with the edges being attached without odor or drainage. RT calf is unstageable measuring 4.0 x 1.5 with the wound bed having 75 percent of yellow slough and 25 percent beefy red tissue present. The edges are attached without odor and there is minimal drainage noted. The surrounding tissue is intact. Rt pinky toe remains as a DTI measuring at 2.0 x 1.4 and Is closed with a purple appearance in color. RT hip unstageable measures at 10.2 x 5.5 with 90 percent beefy granulation tissue to the wound bed and 10 percent [MEDICATION NAME] tissue noted to the edges. All edges are intact and attached, minimal drainage noted without odor. The wound to the right hip is improving. RT inner malleolus is unstageable and measures at 0.9 x 0.9 with the wound bed being 100 percent dry thick black eschar. The edges are attached and well defined. The wound has no drainage without odor present. LT hallux is unstageable and measures at 1.0 x 1.0 with the wound bed being 100 percent dry stable eschar. The edges are attached and well defined. The wound has no odor or drainage noted. (R1) remains to be followed very closely by the wound clinic. He is incontinent of bowel function and continent of bladder function with a catheter and nephrostomy tube. The patient is re-positioned frequently but can choose not re-position or get into his W/C. Appetite remains poor. The staff has tried appetite stimulants without success, supplements for wound healing that he chooses not to consume and he is highly encouraged by staff to eat for meals. The family has also visited and attempted to get him to eat and has not been successful. The MD had been informed and has declined TPN (Total [MEDICATION NAME] Nutrition). The facility has scheduled a family meeting for next week to look at different approaches or to change is P[NAME]. The facility has multiple interventions in place for preventatives and wound healing that remains appropriate at this time. (R1) has an upcoming appointment this week and the wound clinic we re-evaluate wounds upon arrival. Staff will continue to encourage patient follow the P[NAME] and recommendations. MD, family and the wound clinic are aware of the current wounds status and the facility's P[NAME]. The surveyor noted the right hip wound is documented as being unstageable despite the wound being documented as 90 percent beefy granulation tissue and 10% [MEDICATION NAME] tissue. A progress note on 8/21/18 documents Addendum Wounds Rounds: A family meeting is schedule for 08.28.18 to discuss (R1's) P[NAME]. (R1) wounds are not expected to improve d/t (due to) his co-morbidities, poor oral intake, and is choosing to not re-positioning or get up anymore. His wounds have declined in the couple of days he was hospitalized along with acquiring new pressure ulcers even with all the preventatives in place it is most likely his wounds are going to continue to worse. The wound clinic, MD and family area aware of the above declines. Progress notes on 8/24/18 document .Per CNA, refused to be re-positioned. He yelled and denies pain . Progress notes on 8/25/18 document .no refusals of cares, resident offered fluids Q2H (every 2 hours) with repositioning . Progress notes on 8/26/18 document .resident allowed ADL's . Progress notes on 8/27/18 document Resident refuse cares and repositioning at this time . Wound round notes on 8/28/18 document Rt lateral knee is a DTI dark purple and closed measures at 0.8 cm x 1.0 cm .DTI noted to left buttock, DTI dark purple and closed measuring 2.1 cm x 1.5 cm .Unstageable pressure ulcer to the [MEDICATION NAME] spine aspect measures at 3.0 x 3.0 with 100 percent yellow slough present, minimal drainage of serosanguineous noted without odor. Edges are attached and surrounding tissue intact .Lumbar spine aspect is unstateable (sic) and measures at 2.1 cm x 2.5 cm with the wound bed being 100 percent covered with slough, edges are attached, minimal drainage without odor . LT lateral calf is unstageable currently measures at 3.7 cm x 2.0 cm .The wound bed remains 100 percent black eschar with edges being attached, no S/sx of infection, and without purulent drainage. LT outer ankle remains unstageable with stable eschar measuring 2.5 cm x 3.0 cm .Edges are attached, without odor redness noted to surrounding skin and there is minimal drainage noted. Lt lateral (outer) heel remains unstageable and measures at 2.5 cm x 1.0 cm .The wound bed is 100 percent covered with a eschar cap. Edges are attached without drainage noted. LT medial heel is a DTI dark color in purple (sic) measuring at 3.2 cm x 2.5 cm The wound remains closed with the edges being attached without odor or drainage. RT calf is unstageable measuring at 4.0 cm x 2.0 cm .The wound bed having 50 percent of yellow slough, 25 percent narcotic (sic) tissue and 25 percent beef red tissue present. The edges are attached without odor and there is minimal drainage noted. The surrounding tissue is int

Based on a complaint, interview and record review, the facility did not always ensure that 2 out of 3 (Resident #1 and #7) residents reviewed with urinary catheters were given appropriate treatment and services to prevent clinical complications of catheter use. * Resident #1 had an indwelling catheter into his bladder upon admission that was new during hospitalization prior to the nursing home admission on 3/18/16. Resident #1 had a known history of urinary tract infections prior to admission to the hospital and the facility. On 3/24/16 an attempt to remove the indwelling catheter was unsuccessful due to [MEDICAL CONDITION] and the catheter was re-inserted on 3/25/16. Resident #1 did not have a [DIAGNOSES REDACTED]. Resident #1 continued with the indwelling urinary catheter from 3/25/16 to 4/18/16 and developed a urinary tract infection on 4/18/16. The physician ordered the removal of the catheter on 4/18/16. Resident #1 had the catheter reinserted on 4/22/16 by facility staff following contact with the physician office nurse. Several hours after Resident #1 had the catheter reinserted, Resident #1 began to bleed from his penis. For some unknown reason, trauma occurred to Resident #1's urinary tract which necessitated hospital care. Resident #1 was transferred to the hospital for care of the bleeding (hematuria) to his urinary tract and admitted for observation for 2 days. Evidence presented does not indicate that a comprehensive assessment of Resident #1's urinary problem, justified the re-insertion of the urinary catheter on 4/22/16. There is no evidence a comprehensive assessment of resident's inability to urinate or if resident was retaining urine was conducted prior to calling the physician office and receiving an order to re-insert the urinary catheter. For the time period following the removal of the catheter on 4/18/16 to the re-insertion of the catheter on 4/22/16, there was lack of evidence that resident was retaining urine and was experiencing an inability to urinate. There is lack of evidence that the bladder scans were conducted during this time period routinely or following an emptying of the bladder. There is no evidence resident was having abdominal distention, pain/discomfort or inability to urinate following the removal of the catheter on 4/18/16. Evidence presented indicated Resident #1 had confusion demonstrated by symptoms of self-transferring to the bathroom without assistance and Resident #1 forgetting he had an indwelling urinary catheter. Evidence presented indicated Resident #1's medical record did not specify catheter or balloon size to insert on 4/22/16 or a written order to re-insert the catheter on 4/22/16. Evidence presented indicated the nurse that re-inserted the urinary catheter spoke over the telephone with a physician office nurse to get the order to re-insert the catheter. It is unknown if the physician evaluated the status of the resident to determine if re-insertion of the catheter on 4/22/16 was necessary. There is no evidence the facility nurse spoke with a physician to relay a comprehensive assessment of Resident #1 inability to urinate or evidence there was [MEDICAL CONDITION] before getting the order to re-insert the catheter on 4/22/16. Evidence presented indicated Resident #1 was passing urine without difficulty following catheter removal on 4/18/16 and no signs or symptoms of [MEDICAL CONDITION] or pain/discomfort prior to the re-insertion of the urinary catheter on 4/22/16. Resident #1 had a successful discontinuation of the indwelling catheter on 5/5/16 without any evidence of [MEDICAL CONDITION] and was discharged from the facility on 6/14/16 without the use of an indwelling urinary catheter and fully continent of bladder. * Resident #7 was in a trial for discontinuing a urinary catheter. Resident #7 was retaining urine which meant the urinary catheter needed to be reinserted. There is no evidence that there was a physician order [REDACTED].#1 and after education had been provided to staff. Example #1 regarding Resident #1 rises to a scope and severity level of a G (harm/isolated.) Findings include: 1. Resident #1 was admitted to the facility on [DATE] following hospitalization for altered mental status. Hospital documentation from 3/18/16 indicated that resident did have urinary frequency and urgency. There was no other [DIAGNOSES REDACTED]. On 3/18/16, nursing home documentation indicated Resident #1 was admitted with an indwelling urinary catheter following hospitalization . Admitting [DIAGNOSES REDACTED].#1 having a [DIAGNOSES REDACTED]. On 3/22/16, nursing home documentation indicated an evaluation for the indwelling catheter which indicated resident was alert and able to make needs known with a Foley catheter in place. There is documentation that the physician office would be called for a trial discontinuation of the catheter. On 3/25/16, nursing home documentation indicated telephone orders for a urinalysis with culture/sensitivity one time only for monitoring/retention for 2 days. On 3/25/16, nursing home documentation indicated telephone orders for 16 French, 30 cc (balloon size), indwelling foley catheter for [MEDICAL CONDITION]. Change prn (as needed) for [MEDICAL CONDITION] as needed for retention. On 3/26/16, nursing home documentation indicated a catheter evaluation was being completed and that resident had a failed attempt at Foley discontinuation as resident was retaining urine and the Foley catheter was replaced per physician order. On 4/10/16 at 4:35 AM, nursing home documentation indicated Resident #1 was up and wandering into other rooms looking for the toilet, Foley in place, draining dark amber with 100 cc output noted at this time. Documentation indicated that the catheter was flushed by Registered Nurse (RN)-F and a new Foley was placed and a bladder scan done had results of 35cc urine On 4/18/16 at 3:05 PM, Licensed Practical Nurse (LPN) - K documented that Foley was discontinued as ordered by the physician. The Foley is intact and balloon intact. No complaints of pain or injury noted. Resident urinating without complaint. On 4/18/16 at 7:57 PM, Licensed Practical Nurse (LPN)- K documented a telephone order to discontinue the catheter for a urinary tract infection and to repeat a urinalysis after the antibiotic is completed for antibiotic clearance post urinary tract infection. On 4/19/16 at 4:47 AM, RN-F documented resident to be alert, responsive with some confusion and had no complaints after a witnessed fall with no new problems noted. RN-F also documented at this time that Resident #1 did not void at this time and a bladder scan was done with a result of 12cc only, fluids were encouraged and will continue to monitor. On 4/19/16 at 5:36 AM, RN-F documented resident to be incontinent of urine in small amount, resting in bed at this time. On 4/19/16 at 4:47 PM, LPN- L documented resident to have a bladder scan done post Foley removal with less than 199 cc. Resident had no complaints of pain or discomfort. Abdomen was non tender and no distention was noted. Resident stated not having the urge to urinate at this time and will continue to monitor. On 4/19/16 at 8:41 PM, LPN-L documented that resident remains [MEDICATION NAME] mg twice daily for urinary tract infection with no adverse reactions noted with medication. Resident had no complaints of pain or discomfort with urination. Foley has been removed. Resident has not voided on PM shift, does not complain of pain or discomfort to abdomen area. Resident does not have the urge to urinate at this time. Will continue to monitor. Temperature is 97.1. On 4/19/16 at 9:52 PM, LPN-L documented that resident was ambulated to the bathroom and voided in the toilet. No complaints of pain or discomfort with urination. Post void bladder scan was less than 50 cc. No complaints of abdomen discomfort. Daughter was present and updated. Will continue to monitor. On 4/20/16 at 1:33 AM, RN-R documented that resident was alert, responsive with confusion present and remains on antibiotic for urinary tract infection .resident denies any urinary complaints. Fluids encouraged, drinks independently. Has not voided yet this shift, will continue to monitor that. Frequently checked upon. Resting quietly at this time, has not offered any complaints of pain or discomfort and does not exhibit any signs or symptoms of same. Blood pressure 132/84, pulse 86, Temperature 97.2, SpO2 (oxygenation) 95% on room air. An undated written statement was given to Surveyor to review on 6/14/16 by the facility Director of Nursing. The undated, written statement, was signed by RN-R and it indicated at approximately 2:30 AM on 4/20/16 as resident had Foley recently dc'd (discontinued) and had not voided yet, I went in to prompt him with urination, he was cont (continent) of urine and used the toilet, I heard a strong urine flow into toilet (he was sitting on the toilet) for approximately 30-45 seconds. On 4/20/16 at 5:41 AM, RN-R documented that resident did void by end of shift, was continent of urine with prompting. On 4/20/16 at 2:06 PM, LPN- E documented that Resident #1 did void during shift, bladder scan later on during the shift. Denies any pain or discomfort at this time. States he does not have the urge to urinate at this time. Resident in on [MEDICATION NAME] mg orally twice daily for urinary tract infection. Encourage to drink more fluids. Temperature 98.3. Will continue to monitor. On an undated witness statement provided to Surveyor by the Facility Director of Nursing on 6/14/16, LPN-E wrote that On 4/20/16, I bladder scan resident and noted bladder contained 176cc of urine at that current time resident denied any pain or urge to urinate. Resident did void that shift. (no documentation that the bladder scan was done after emptying of the bladder). On 4/21/16 at 5:11 AM, LPN-N documented resident remains on antibiotic for urinary tract infection with no adverse reactions noted. Offers no complaints of pain or discomfort. will continue to monitor. On 4/21/16 at 10:18 AM, LPN-K documented resident remains on frequent checks and takes self to bathroom, staff continue to remind resident to ask for help and to stay in his wheelchair. Resident continues to be confused and needs reminders of where his bathroom is located. On 4/21/16 at 10:29 AM, LPN-K documented that resident offers no complaints of pain or adverse effects related to antibiotic therapy for urinary tract infection. LPN-K indicated not able to view urine as resident self toilets. On 4/21/16 at 7:35 PM, RN-S documented that resident continues on antibiotic for urinary tract infection with no adverse effects states no signs/symptoms of urinary tract infection, clear yellow urine in adequate amounts. Temperature of 97.7. On 4/21/16, the health care power of attorney statement of incapacity to make health care decisions was activated that Resident #1's daughter would make health care decisions for Resident #1. On 4/22/16 at 3:30 AM, LPN-T documented that resident continues [MEDICATION NAME] mg for urinary tract infection. No adverse reactions noted. Fluids at bedside and encouraged. No complaints of pain or discomfort. Will continue to monitor. On 4/22/16 at 9:30 PM, LPN-J documented that patient was in his room, visited with family for last couple hours. On 4/22/16 at 10:34 PM, LPN-J documented that 14 FR foley cath placed per MD office order. Appliance placed using sterile technique, pt (patient) tolerated well. On 4/23/16 at 1:35 AM, RN-M documented that Resident's Foley bag was noted no urine output but small amount, less than 100cc fresh blood in Foley bag since HS (hour of sleep) around 12:45 AM. There was at least 30ml length Foley cath exposed outside penis. Resident complained genitally pain earlier which was relieved by Tylenol. Foley cath balloon was deflated and was tried forward inside bladder but blood gushed out from penis. Approximately over 300ml blood was noted. Resident started complaining of feeling cold. 911 was called. BP (blood pressure) was 122/79 at 12:50 AM, 116/64 at 1:10 AM and 105/64 before paramedic got here. P 98, Spo2(oxygen level) 96% on RA (room air). Family POA (power of attorney) were around beside since PM (evening) shift at all the time. KMH ER (hospital) was informed, Dr. (name) was called as well. Blood spill kit was used for clean up after resident left. Surveyor reviewed the hospital record from the facility medical record. The hospital record indicated that Resident #1 was evaluated at the hospital by a urologist on 4/23/16 at 3:27 AM. The urologist documented the following . This is a [AGE] year old man referred by his nursing home because of inability to replace his catheter and gross hematuria. I cannot obtain a history from the patient. He does have dementia. Apparently he had a chronic catheter in and an order was there to change the catheter. The nursing home could not get the catheter in. He started bleeding. He was brought to the hospital emergency room . The nursing staff could not place a catheter. Upon my seeing the patient he had gross blood coming from his meatus. I attempted to place a 22 French 3 way catheter with a Coude tip. I was unable to get the catheter in due to a probably false passage in the urethra. I then used a Van Buren sounds, and I was able to get the sound in the bladder. I then used a catheter guide and a 22 French 3 way Coude tipped catheter. I was able to get the catheter in the bladder. I irrigated out multiple clots from the bladder. I kept irrigating until it was clear. I started CBI (continuous bladder irrigation) with saline. The irrigant eventually cleared. Impression: This is a patient who had a Foley catheter for unknown reasons at a nursing home. The nursing staff was unable to change the catheter and apparently blew up the balloon in the urethra. He then developed gross blood coming from the meatus. I was able to get a three-way catheter in. Recommendations: for now we will leave the 3-way catheter with CBI running. I will start him on IV antibiotics. I will follow along with you. The hospital discharge summary, dated 4/25/16, 9:47 AM, documented by another physician indicated: Discharge Diagnosis: [REDACTED].History: The patient is a [AGE] year old white male sent from Nursing Home (name) by ambulance after a Foley catheter insertion was attempted at the nursing home due to reported [MEDICAL CONDITION] and subsequently the patient developed gross hematuria and bleeding from the meatus .patient was admitted to hospitalist service. By that time, his urine was clear. There continued to be some slow leakage of blood around the meatus. The patient subsequently had an uneventful hospital stay. His vital signs initially showed some lower blood pressures, although not hypotensive, and this gradually increased with some fluid resuscitation. By his second hospital day, he was looking and feeling better and his blood pressures medicines were able to be resumed . On 4/25/16 at 9:50 PM, the Nursing home documented that resident returned to the facility via ambulance and accompanied by the daughter has a 22FR Foley inserted by urologist in place and staff are not to remove/replace, only urologist. No complaints of pain or discomfort at this time .Foley output clear yellow at this time. Will continue to monitor. Surveyor was given an internal facility investigation into concerns raised by the family to the facility on [DATE] following Resident #1's hospitalization . A review of the internal investigation revealed that education was provided to LPN-J on 4/28/16 regarding lack of documentation and assessment of need for indwelling foley catheter and needs to be documented along with MD notification/order. Documentation post catheter insertion needs to include assessment of procedure, any complications, size of catheter /balloon, urine return. The education was given verbally and signed by the employee, LPN-J. The investigation signed by the Director of Nursing on 4/26/16 indicated that on 4/22/16 LPN-J received in report that Resident #1 had a couple of bladder scans that noted some retention and we were calling the MD to update and see if there were any parameters to re-insert the Foley catheter. LPN-J spoke with the nurse from the physician's office to insert a 14 FR catheter and update later on any changes with resident. LPN-J said when he went to put a catheter in Resident #1, a girlfriend was in the room and he asked her to step out. LPN-J then inserted the 14FR catheter using sterile technique until he had urine flow in the catheter and advanced it up about an inch then finishing by inflating the balloon. LPN-J stated he had no complaints of pain or discomfort after insertion and left the room. The night shift nurse came in and during her shift around 12:45 AM-1:00 AM, noted some gross hematuria in the Foley bag. The nurse attempted to deflate the balloon and advance the catheter up but had a large amount of hematuria return and stopped. The nurse then decided to send resident out for evaluation. The conclusion to this investigation was that facility was unable to substantiate improper technique as evidence by the nurse was able to verbalize and demonstrate proper technique, Resident #1 does have a history of self-transferring and pulling at catheter, and has history of urinary tract infections. Writer did do education with licensed staff and return validation of the skill for insertion of a Foley catheter. Writer did follow up with Resident #1's family member to let her know the findings and facilities plan for her concen she responded well and was happy with resolution. A statement was obtained on 4/26/16 with LPN-K as part of the facility internal investigation. LPN-K indicated that on 4/22/16 she had received the F/U (follow up) list for North (unit) and on they were to update MD regarding getting possible parameters for [MEDICAL CONDITION] and Foley Catheter re-insertion. LPN-K indicated in this statement that she did not call the MD and passed it on to LPN-J and he spoke to the MD and relayed the message that resident was having 150-200cc of [MEDICAL CONDITION] (last bladder scan done on 4/20/16) and received orders to re-insert the foley catheter. LPN-K indicated the resident was voiding during her shift and she personally took resident to the bathroom twice. On 6/14/16 at 10:55 AM to 11:10 AM, Surveyor interviewed the Director of Nursing regarding physician parameters as to when to re-insert a catheter. The Director of Nursing told the surveyor that the physicians give the parameters as to when to re-insert the catheters. The Director of Nursing acknowledged that there is no written order for the Foley re-insertion for Resident #1 and LPN-J said he did not write the order and that education was given to LPN-J regarding this. The Director of Nursing indicated she has not spoken with the physician office about this and whether or not the physician was given an appropriate assessment and if he had given the order to re-insert the catheter or not. On 6/14/16 at 11:52 AM, Surveyor interviewed LPN-J by telephone as LPN-J no longer works at the facility. LPN-J told the surveyor that he recalled Resident #1 and recalled speaking with the nurse at the physician office. LPN-J indicated he could not remember who the nurse or the physician was, but would have been on the face sheet of the resident's chart. LPN-J told the surveyor that LPN-K was seated right next to him when he made the call and LPN-K asked him to call the physician because Resident #1 was still retaining urine. LPN-J indicated he told the physician office nurse that resident was still retaining urine and the doctor's office nurse told him to go ahead and insert one and call us back on Monday and give us a status. The surveyor asked LPN-J if he told the physician's nurse about bladder scan results or any other assessments and LPN-J said he could not recall, all he remembered was the nurse telling him to put in the catheter. LPN-J indicated he never spoke with the physician, only the physician's nurse who knew the patient. The surveyor indicated to LPN-J that he inserted a 14FR sized catheter into the resident when Resident #1 had previously had a 16 FR catheter with a 30CC balloon. The LPN told the surveyor that the nurse must have told him what size to put in because how else would he know what to insert in the resident as there are many sizes available. The LPN could not recall if the physician office nurse asked him what size catheter and balloon Resident previously had. The LPN acknowledged that he did not write an order with these details in it and thought LPN-K was assisting in documentation of this order since she heard the conversation. Surveyor interviewed RN Manager - O on 6/14/16 at 12:05 PM. RN-O told the surveyor that she gave education to LPN-J using a male model, a Foley catheter and a sterile kit and that she also inservices all the licensed nurses in the building about catherizing male residents. RN-O indicated she had the nurses demonstrate to her the procedure and also when it is necessary to use a bladder scan and what to do if there is resistance/complications to catherization. RN-O indicated LPN-J had demonstrated the procedure okay. The surveyor asked RN-O what types of catheters are available in the building and RN-O told the surveyor that there are #14 FR to #22 FR with 10-30cc balloons available. RN-O indicated that inside the kit is also a pre-filled syringe with probably 30 cc in it. The surveyor then asked RN-O questions about the Bladder Scan machine and indications when to use this machine. RN-O said that it is to be used when a resident has not voided, or not voiding very much, or if the physician gives an order for [REDACTED]. Surveyor interviewed LPN-K on 6/14/16 at 3:15 PM. LPN-K told the surveyor that bladder scan results are charted in nursing progress notes. LPN-K indicated there was information that was on the 24 hour sheet that is a worksheet between nurses. LPN-K recalled LPN-J speaking with the physician office nurse who said to re-insert the catheter. The surveyor asked about the physician office nurse giving the order and LPN-K indicated that it was not uncommon for a call to the MD office and have nurse's telling us to reinsert a catheter, and that nursing home nurses hardly ever talk directly to the doctor. LPN-K indicated she wasn't sure if they would have the hospital record there to check on that or not. LPN-K could not recall what MD was called that day by LPN-J. LPN-K indicated she could not recall if this was an initial call versus a follow up call to the MD office. LPN-K indicated she did not feel a need to do a bladder scan as Resident #1 was voiding okay that day two times for her. On 6/15/16 at 8:06 AM, Surveyor interviewed the Director of Nursing(DON) who told the surveyor that the physician office called that day was the primary physician office who knew resident well and that the Director of Nursing was piecing information together about details of what transpired prior to this interview. The DON acknowledged the documentation wasn't the best and that is why she did the education. The DON indicated she started the investigation right away after the family brought it to the facility attention and asked why the catheter had been put back in. The DON indicated that in order to assess somebody they do have the ability to scan, which requires only a nursing order to do, like taking a blood pressure. At this time, Surveyor also was shown the different catheters used in the facility. It was observed that the 14 FR catheter has a 10cc balloon, while the 16 FR and 22 FR have 30cc balloons. On 6/15/16 at 9:00 AM, Surveyor interviewed LPN-E who remembered Resident #1 and told the surveyor that Resident #1 fidgeted with his catheter alot and when he would self transfer and go to the bathroom, he would pull his pants down and catch the cath strap. LPN-E also indicated he would say he would have to urinate despite having a catheter in and staff would have to remind him he had a catheter. LPN-E indicated Resident #1 wore a bed bag at night and had heard he would stand up, but never saw him do that. LPN-E indicated that for Resident #1, it was hard for staff to tell if he was voiding, and she was watching for abdominal distention. She recalled asking him on her shift 3 times and he said he had already voided. LPN-E indicated that before the end of her shift, she did a bladder scan just to make sure and he had 176 cc in his bladder. LPN-E indicated there were no signs of discomfort, pain and no urge to urinate. LPN-E indicated resident did not complain of difficulty voiding. The facility did not have evidence that resident required the re-insertion of a urinary catheter. The facility had evidence of some urine in the bladder on 4/20/16 when the bladder was scanned (176cc), but it is unknown if this was a post void residual amount or not. There was no documented or known complaints of resident not being able to pass urine in the days after the catheter was removed on 4/18/16. There is no evidence resident was having bladder distention following removal of the catheter on 4/18/16. There is no evidence that a comprehensive assessment of all of these factors was relayed to the physician prior to the catheter re-insertion on 4/22/16 that warranted the necessity of this indwelling urinary catheter for a resident who had chronic urinary tract infections and who had no evidence of recent [MEDICAL CONDITION]. There is no evidence as to why a different size catheter (14 FR, balloon size unknown) was placed on 4/22/16 than what resident previously had in place (16 FR, 30 cc balloon). There is no evidence what balloon size of the catheter was placed upon re-insertion of the catheter on 4/22/16. The placement of the catheter created a situation requiring Resident #1 to be hospitalized with hematuria requiring IV antibiotics. On 6/15/16 at 3:15 PM, the concerns about the lack of adequate assessment and justification for catheter re-insertion for Resident #1 was shared with the facility Nursing Home Administrator, the Corporate Nurse Consultant and the Director of Nursing. Additional information received from the facility administration was in disagreement with surveyor findings. 2. Surveyor # reviewed Resident #7's medical record on 6/15/16. Resident #7 was originally admitted to the facility on [DATE] and had a most recent readmission to the facility on [DATE]. Resident #7 has [DIAGNOSES REDACTED]. On 5/18/16, Resident #7 was seen by Urologist-U at his office, and returned to the facility with the following Physician orders [REDACTED].>1. Keep Foley Catheter out 3 . Check post-void residual in 8 hours to make sure he is able to void. If greater than 300cc, straight catheterize him 5 . If after 48 hours patient still requires intermittent straight catheterization, place chronic indwelling Foley catheter. The physician orders [REDACTED].#7 required placement of a chronic indwelling catheter. On 5/18/16, Urologist-U removed Resident #7's urinary catheter which was 16 French in size. Resident #7's Nursing Progress Notes indicate that the indwelling urinary catheter was reinserted on 5/23/16 after a failed trial to discontinue the urinary catheter. The following notes are contained within Resident #7's nursing notes: 5/23/2016 at 4:49 A.M., resident did not use the urinal and stated that he went urinated (sic) in toilet, bladder scan done with a result of 450cc ((milliliters)), resident was okay with indwelling cath, Foley cath was reinserted with a result of 450 cc clear, pale yellow colored urine, resident resting comfortably in bed at this time. 5/23/2016 at 10:18 A.M., Note Text: MD ((Urologist-U)) aware of Foley catheter being reinserted. Surveyor # reviewed Resident #7's Primary Care Provider (PCP)'s orders, and the following orders were given for Resident #7 related to the Foley catheter size: 5/09/2016 at 6:54 P.M., 16 French 10 cc balloon inflate indwelling Foley catheter for [MEDICAL CONDITION]. Change PRN ((as needed)) as needed for retention. The order indicates this order was obtained via phone. 5/18/2016 at 12:05 P.M., 16 French 10 cc balloon inflate indwelling Foley catheter for [MEDICAL CONDITION]. Change PRN ((as needed)) as needed for retention. HOLD 05/18/2016 12:05- 05/20/2016 18:03 ((6:03 P.M.)) trial d/c ((discontinue)) of Foley. This order indicates this order was obtained via phone. 5/21/2016 at 10:17 A.M., 16 French 10 cc balloon inflate indwelling Foley catheter for [MEDICAL CONDITION]. Change PRN ((as needed)) as needed for retention. Discontinue 05/21/2016 at 10:17. This order indicates this order was obtained via phone. 5/23/2016 at 6:18A.M., 14 French Foley cath 10 cc balloon. This order indicates that the order was obtained via phone. This order was obtained after the 4:49 A.M. nursing note on 5/23/2016 which indicates that the Foley Catheter had been replaced. On 6/15/16, at 11:07 A.M., Surveyor # interviewed Registered Nurse (RN) Unit Manager-D regarding urinary catheter placement. RN Unit Manager-D indicated that staff talked to Urologist-U on 5/23 and reinserted the urinary catheter at that time. Surveyor showed RN Unit Manager-D the documentation which shows the urinary catheter was inserted before the doctor was called to obtain catheter size on 5/23/16. RN Unit Manager-D was not sure why the documentation showed the urinary catheter being placed before the doctor was called, and stated RN Unit Manager-D would ask the nurse (LPN-C) about the documenting time. Surveyor # requested to speak to nurse who called the doctor (LPN-C). On 6/15/16, at 11:34 A.M., Surveyor # interviewed Licensed Practical Nurse (LPN)-C regarding Resident #7's catheter placement and LPN-C calling the Doctor to obtain an order for [REDACTED]. The Doctor said yes. LPN-C indicated to Surveyor # that LPN-C told the Doctor that the trial had failed at that time. Surveyor # asked LPN-C if a catheter had to be inserted during the day on first shift how would LPN-C know what size of catheter to insert. LPN-C stated to Surveyor # that LPN-C would look in the progress notes and call the doctor if the size was not found. There is no evidence in Resident #7's record that an order for [REDACTED]. The above information was shared with the Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B on 6/15/16 at 3:25P.M. No additional information was provided.

Based on record review, observation and staff interview the facility did not ensure that 2 of 20 residents ( Resident #3 and #11) at risk for falls had the appropriate interventions in place to prevent falls from occurring. * Resident #3 was being given care in bed by one certified nursing assistant (CNA) instead of two; the CNA rolled Resident #3 away from them instead of toward them. Resident #3 rolled out of bed and fractured her ankle. * Resident #11 was observed to be transferred without a gait belt. Findings include: 1.) Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #3's quarterly minimum data set (MDS) with a reference date of 6/24/13 indicated Resident #3 required extensive assist of 2 for bed mobility and had a Brief Review for Mental Status that scored 13 (Mild impairment). On this MDS Resident #3 was recorded as having a weight of 270 pounds. On 8/6/13 at 11:00 a.m. Surveyor # interviewed Resident #3 who stated on 6/22/13 Certified Nursing Assistant (CNA)-F rolled her out of bed and fractured her ankle. Resident #3 stated this event halted her progress in therapy. Resident #3 stated she was supposed to have 2 CNA's to help her in bed. Resident #3 stated CNA-F rolled her toward the wall and not toward the CNA. On 8/6/3 Surveyor # reviewed Resident #3's emergency room report dated 6/22/13 which read: There is pain and swelling over the right medial malleolus (ankle). Discharge prescription Oxycodone 5 milligrams every 4 hours for 3 days then as needed. On 8/8/13 Surveyor # reviewed Resident #3's x-ray report dated 6/22/13 which read: Right ankle films. 2 views of the ankle demonstrate diffuse osteopenia. There is a minimally displaced medial and posterior malleolar fracture tibia. On 8/7/13 at 1:43 p.m. Surveyor # interviewed CNA-F who stated she rolled Resident #3 away from her to clean her up and Resident #3 rolled out of bed. CNA-F stated only half of Resident #3's body was on the floor. CNA-F stated she should have waited for the second CNA to come back and help her but she didn't. CNA-F stated Resident #3 did not help at all with the turning in bed and CNA-F had to do it herself. On 8/7/13 at 9:40 a.m. Surveyor # interviewed Registered Nurse (RN)-H who stated when she responded to Resident #3's fall on 6/22/13 she saw Resident #3 half on the bed. RN-H stated she immediately called the doctor and sent Resident #3 to the emergency room where she was diagnosed with [REDACTED]. On 8/7/13 at 2:15 p.m. Surveyor # interviewed CNA-G who helped CNA-F get Resident #3 into bed right before Resident #3 rolled out of bed. CNA-G stated she helped CNA-F Hoyer Resident #3 to bed and then left the room. CNA-G stated that CNA-F did not ask her to stay and help clean up Resident #3. CNA-G stated she assisted Resident #3 by herself all the time but rolled the resident toward her not away from her. On 8/6/13 Surveyor # reviewed the investigation the facility completed after Resident #3's roll out of bed. The interview with CNA-F read: When I was doing care I rolled Resident #3 to her left side towards the window, she used her right hand on the wall for support. I put her right leg over her left leg. She lost balance. I saw both her legs sliding off the bed and rushed to hold them, but they were too heavy. I started to scream for help meanwhile lower her legs to floor on knees with her upper body still on the bed. Co-worker came in right away to help. On 8/12/13 Surveyor # reviewed the personnel file of CNA-F which included a one on one in-service dated 6/24/13 with a topic of turning a resident. The education consisted of never turning a resident away from you unless there is another caregiver on the opposite side. An all-staff in-service was completed on 6/23/13 with the topic and content written as: Staff never roll resident way from you when you are turning resident alone. Always roll resident toward you or have 2 staff on each side of the bed. On 8/7/13 Surveyor # reviewed Resident #3's physical therapy summary dated 6/25/13 which read: Resident #3 sustained a right ankle fracture this week during being changed by CNA and rolling out of bed. Resident #3 has had increased pain since then and decreased time out of bed. The summary for Resident #3 dated 7/2/13 read: Resident #3 has been limited by right ankle, lower extremity pain secondary to fracture. The above findings were shared with the Administrator and Director of Nurses on 8/8/13 at 3:00 p.m. at the daily exit meeting. Additional information was requested if available. None was provided. 2.) On 8/06/13 Surveyor # reviewed Resident #11's medical record. The record indicates Resident #11 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident #11 has a Brief Interview for Mental Status Score of 4 (severe cognitive impairments) and requires extensive assistance of two staff for transfers. The annual Minimum Data Set (MDS), dated [DATE], indicates Resident #11 has modified independence in cognition (decisions poor; cues/supervision required) and requires extensive assistance of two staff for transfers. Resident #11's plan of care for Self Care Deficit related to impaired mobility includes the intervention to transfer with one assist with the use of a gait belt. The Certified Nursing Assistant care card for Resident #11, dated 8/07/13, includes the approach to transfer with assist of one and a gait belt. On 8/06/13, at 3:15 p.m., Surveyor # observed Certified Nursing Assistant (CNA)-C and CNA-D transfer Resident #11 from the wheelchair into the bed. CNA-C and CNA-D grabbed the back of Resident #11's pants and assisted the resident from the wheelchair to the bed by pulling on the back of Resident #11's pants. CNA-C and CNA-D did not use a gait belt. On 8/07/13, at 3:00 p.m., and 8/12/13, at 1:30 p.m., Surveyor # spoke with the Administrator and the Director of Nursing who indicated Resident #11 should be transferred with assist of one CNA with the use of a gait belt and one CNA for stand by assistance. The Administrator and the Director of Nursing indicated CNAs should use a gait belt when assisting Resident #11 with transfers.