Every finding on record at Barron Care and Rehabilitation

Based on interview and record review, the facility did not complete a performance review of every nurse aide at least every 12 months and provide 12 hours of regular in-service education based on the outcome of for 6 of 6 CNAs reviewed. This has the potential to affect all 47 residents.This is evidenced by:On 01/06/26, a sample of CNAs employed by the facility was selected for review for the completion of annual performance reviews. The facility provided the following information:CNA D has a hire date of 06/10/24. The annual performance review is dated 06/19/25. No documentation of in-service education based on performance review is noted.CNA K has a hire date of 04/24/24. The annual performance review is dated 08/12/25. No documentation of in-service education based on performance review is noted.CNA L has a hire date of 10/22/21. The annual performance review is dated 11/06/25. No documentation of in-service education based on performance review is noted.CNA M has a hire date of 04/15/24. The annual performance review is dated 08/12/25. No documentation of in-service education based on performance review is noted.CNA N has a hire date of 04/12/23. The annual performance review is dated 08/12/25. No documentation of in-service education based on performance review is noted.CNA O has a hire date of 09/20/21. The annual performance review is dated 11/06/25. No documentation of in-service education based on performance review is noted.On 01/06/26 at 3:12 PM, Surveyor interviewed Director of Nursing (DON) B regarding performance reviews and in-service education. DON B stated she did not have any documentation for training because it hadn't been done. DON B stated that she is aware this is a concern and will be working on this. Surveyor asked DON B if the facility had a Performance Improvement Plan in place to resolve this issue. DON B stated no.

Based on interview and record review, the facility did not complete the required annual 12 hours of in-service training for nurse aides for 6 of 6 CNAs reviewed. This has the potential to affect all 47 residents.This is evidenced by:On 01/06/26, a sample of CNAs employed by the facility was selected for review for 12 hours of in-service training. The facility provided the following documentation:CNA D has a hire date of 06/10/24. No documentation of required annual 12 hours of in-service training.CNA K has a hire date of 04/24/24. No documentation of required annual 12 hours of in-service training.CNA L has a hire date of 10/22/21. No documentation of required annual 12 hours of in-service training.CNA M has a hire date of 04/15/24. No documentation of required annual 12 hours of in-service training.CNA N has a hire date of 04/12/23. No documentation of required annual 12 hours of in-service training.CNA O has a hire date of 09/20/21. No documentation of required annual 12 hours of in-service training.On 01/06/26 at 3:12 PM, Surveyor interviewed Director of Nursing (DON) B regarding required annual in-service training. DON B stated that this has not been completed for any CNAs other than random nursing care topics discussed at monthly staff meetings. Surveyor asked DON B if she was aware of this annual requirement. DON B stated yes and the facility was working on fixing it. Surveyor asked for documentation of completed dementia training as a high percentage of the facility residents have dementia. DON B provided Surveyor with education that was last completed on 09/26/24. Surveyor asked DON B if she was aware this needed to be completed annually. DON B stated yes that this is being worked on. Surveyor asked DON B if there was a Performance Improvement Plan in place documenting their plan to fix this issue. DON B stated no.

Based on observation, interview and record review, the facility did not provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections.-The facility did not ensure proper hand hygiene during water pass for 4 of 4 residents observed (R35, R18, R46, & R16).-The facility did not ensure appropriate personal protective equipment (PPE) was donned during wound care for 1 of 1 resident observed (R34).-The facility did not ensure appropriate PPE was donned while administering eye drops to 1 of 1 resident observed (R21).Findings include: Facility Policy titled, Infection Prevention and Control Manual, dated 2023, reads in part: Personal Protective Equipment (PPE) required for contact precautions includes a gown and gloves when entering the room. The facility's nursing education sheet, dated 8/7/25, states in part, Infection Control- .Hand sanitizer is be used as entering, leaving (R's room) . On 1/5/26 at approximately 1:00 PM, Surveyor observed Certified Nursing Assistant (CNA) N exit R35's room carrying an almost empty water cup by the handle with her bare hands. CNA N set it on lower shelf of cart, grabbed a new water cup from top of the cart and proceeded in R18's room without practicing hand hygiene. Surveyor heard CNA N telling R18 she was bringing her fresh water and asked to take used water cup. Surveyor observed CNA N come out of R18's room with used water cup, place it on bottom shelf of the cart and grab another clean water cup from top of cart and proceeded into R16's room, returned with an empty cup and placed on the cart. CNA N again, did not practice hand hygiene before taking a clean water cup into R46's room and returning with used water cup. Surveyor immediately interviewed CNA N, who stated hand hygiene was done after completing that hall. CNA N stated her hands get cracked from hand sanitizer and she was unaware that she should use after touching contaminated surfaces such as residents' used water cups. On 1/7/26 at approximately 12:00 PM, Surveyor observed wound care provided for R34. Surveyor noted Registered Nurse (RN) W did not wear a gown and assisted provider with R34's wound care. R34's sign outside her door indicated contact precautions. RN W participated in R34's wound care by gathering supplies, applying skin prep and dressings to R34's open skin areas. On 1/7/26 at 12:25 PM, Surveyor interviewed RN W, who stated she didn't wear a gown when performing wound care for R34 because she wasn't at risk for splashing. Surveyor interviewed Director of Nursing (DON) B who was also present and stated that it was DON B's misunderstanding as DON B had told RN W a gown was only needed if there was a risk for splashing. Surveyor did review the CDC signage on R34's door, which indicated contact precautions, with DON B. DON B verbalized R34's signage should have been changed to Enhanced Barrier Precautions and states an understanding that gown should be worn with wound care with either of the two precautions for R34. DON B also verbalized agreement that hand hygiene needs to be performed when exiting a resident's room, after contact with resident's items, and prior to entering another resident's room. Findings include: Facility Policy titled, Personal Protective Equipment (PPE) dated 2023, reads in part: Gloves are worn when contact with blood or other potentially infections materials, mucous membranes, or contact with non-intact skin is anticipated .Contact precautions are intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or environment .and requires the use of appropriate PPE, including a gown and gloves before or upon entering the room. On 01/06/26 at 7:22 AM, Surveyor observed Licensed Practical Nurse (LPN) F administer medications to R21. LPN F administered 1 drop of artificial tears to each of R21's eyes. LPN F was not wearing gloves during administration. On 01/07/26 at 12:44 PM, Surveyor interviewed LPN G. LPN G stated that it would be appropriate to wear gloves when feeding a resident medication when your hand may touch the resident's mouth. LPN G stated it would be appropriate to wear gloves when administering patches, eye drops, and insulin. On 01/07/26 at 12:50 PM, Surveyor interviewed Registered Nurse (RN) H. RN H stated gloves would be appropriate when administering eye drops, creams, and patches. On 01/07/26 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated DON B's expectation for wearing gloves during med pass would include anything potentially hazardous, when administering eye drops, cleaning nebulizers, any time something is inserted, and when administering creams and ointments.

Based on observation, interview and record review, the facility did not ensure that 4 of 4 residents reviewed for falls (R5, R7, R10, and R26), received adequate supervision and assistance to prevent accidents.Findings: -The facility staff did not immediately respond to R7's wanderguard alarm, and R7 eloped from the facility. -The facility did not add a new intervention to R7 and R10's care plan after an accident. -The facility's documentation does not support R7 was 1:1 supervision.-The facility did not assess R26 for appropriate sling size based on manufacturer's recommendations.-The facility did not complete a thorough investigation after R5 had a fall with major injury to determine root cause and implement safety interventions.Example 1 The facility's policy titled, Elopement Prevention and Response, read in part, It is the policy of this facility to ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. d. Adequate supervision will be provided to help prevent accidents or elopements. R7 was admitted to the facility on [DATE], with diagnoses including dementia with behavioral disturbance. R7 propelled wheelchair independently. R7's Power of Attorney (POA) was activated to assist with decision making. R7's Minimum Data Set (MDS) assessment, completed on 09/08/25, confirmed R7 scored 08/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R7's MDS assessment revealed R7 presented with wandering behaviors placing R7 at significant risk of getting to a potentially dangerous place. R7's care plan included: -Resident will not leave building unattended Date Initiated: 08/27/2025 Revision on: 12/11/2025 -One on one supervision. Date Initiated: 11/10/2025 -Resident is at risk for elopement r/t to hx of wandering and exit seeking behaviors, impaired safety awareness. Date Initiated: 08/27/2025 -Attempt to engage resident in pleasant, meaningful, purposeful enjoyable, resident centered activities, during episodes of constant wandering. Date Initiated: 08/27/2025 -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 08/27/2025 -Document wandering behavior and attempted interventions to provide resident with meaningful activities, validation, and relationship-based redirection in behavior note. Date Initiated: 08/27/2025 -Provide structured activities: toileting, walking inside and outside with supervision, orientation strategies including signs, pictures and memory boxes. Date Initiated: 08/27/2025 -WANDER ALERT: Wander guard on L wrist Check device for placement every shift. Check function daily. Date Initiated: 08/27/2025 On 10/06/25 at 4:42 PM, the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse report, identifying R7's elopement from the facility on 10/05/25 at 8:00 AM. The facility's report stated R7's wanderguard alarm worked properly at the time of the elopement but staff did not respond to the alarm either due to not hearing the alarm or were busy with other residents preparing for breakfast. Staff located R7 outside the front doors of the facility on the sidewalk, sitting in his wheelchair. R7 stated he was getting some fresh air. R7 was brought back into the facility, and there were no injuries. Review of the temperatures on 10/05/25 at 8:00 AM, were approximately 70 degrees . Staff reported the incident to Director of Nursing (DON) B. On 10/05/25 at 9:17 AM, R7's progress notes read, Advised CNAs [Certified Nursing Assistants] to do an increased monitoring. Note, this was not added to R7's care plan until 11/10/25, 1:1 supervision was added to R7's care plan. Surveyor reviewed R7's progress notes and noted: -10/15/25, resident is just wandering the hallways. He is still on q15 min checks. He will be started on increased supervision. -10/16/25, Resident required increased supervision today. He was exit seeking most of the day today. -10/20/25, Resident needs increased supervision d/t exit seeking behaviors. -10/31/25, Resident stated being angry that he had to stay here. He stated he wanted to leave and walk out the door and wants to go home. -11/03/25, Later after supper he was trying to get out of the main door. But the door was locked. He was just pushing the door. -11/11/25, Resident does require increased supervision on all shifts d/t behaviors. -11/28/25, Resident requires increased supervision this shift. Resident was doing a lot of wandering/exit seeking this shift. -12/04/25, Resident did require increased supervision today, for wandering. Note, Surveyor was unable to find documentation to support R7's supervision was increased or R7 was placed on 15-minute checks or 1:1 from 10/05/25. On 11/24/25, an order was added to R7's Treatment Administration Record (TAR); Take report from CNA doing 1:1 supervision every shift. Document EVERY SHIFT on resident's mood and behavior. Note any behaviors and interventions tried and whether they are successful or not. Document things that bother resident or set off behavior, every shift for behavior charting. Be specific including anything preceding his behavior and interventions tried and whether they are successful or not. D/c date 01/06/26. Note, 1:1 was added to R7's care plan on 11/10/25. Surveyor was unable to find documentation to support R7 was 1:1 from 11/10/25-11/24/25. Note, R7's nursing progress notes do not support documentation was completed daily and every shift on R7's mood and behaviors. Progress notes do not support R7 was 1:1 each day or shift. Surveyor reviewed Certified Nursing Assistant tasks and noted a 1:1 task for R7. Surveyor noted CNA staff documented 1:1 on: -12/11/25 -12/18/25 -12/23/25 -12/25/25 -12/31/25 During the survey period from 01/05/26-01/07/26, Surveyor did not observe R7 to have 1:1 supervision. On 01/05/2026 at 12:46 PM, Surveyor interviewed CNA C. CNA C was working on 10/05/25, and reported she heard the alarm going off, but the alarms are hard to hear. CNA C was not sure how long the alarm was going off but responded as soon as she could. CNA C reported she found R7 outside of the front doors of the facility, without injury. CNA C reported this to the nurse right away. CNA C stated she could not remember if she was interviewed or provided a written statement. CNA C stated R7 is 1:1 when it is needed, when [R7] has more behaviors or is exit seeking. CNA C stated staff know when R7 is 1:1 because it is given in shift report. CNA C did confirm R7 is not always a 1:1 supervision. On 01/07/2026 at 7:28 AM, Surveyor interviewed DON B. DON B stated R7 was 1:1 on PM shift M-F, and AM and PM shift on weekends, as there are more staff M-F to provide supervision during the AM shift. Surveyor discussed with DON B that documentation and staff interviews did not indicate 1:1 was consistently completed. DON B stated she would look, but did acknowledge there was lack of documentation. On 01/07/25 at 11:56 AM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A stated he reported the incident on 10/06/25 due to lack of supervision to prevent R7 from exiting the facility. Example 2 The facility's policy titled, Falls Management, read in part, Add to temporary plan of care-include interventions that are implemented. 5. Interventions must be put into place after any fall and documented in nurse's notes and care plan to prevent further incident. Interventions used must be different each time and if already in therapy cannot use them as an intervention. Falls will be discussed at morning meeting to ensure that all departments are aware of safety needs and interventions that are put into place to prevent future falls if appropriate. R10 was admitted to the facility on [DATE], diagnoses included Alzheimer's disease and history of falls. R10's MDS assessment completed on 05/02/25, confirmed R10 scored 06/10 during BIMS, indicating severely impaired cognition. R10 uses a wheelchair for mobility and requires assistance from staff with all transfers. R10's care plan included: The resident is at risk for further falls recent fall r/t weakness, deconditioning, hx of falls and unaware of safety needs. Date Initiated: 09/27/2021 Revision on: 11/19/2022 -Resident will have no serious injury from a fall Date Initiated: 09/27/2021 Revision on: 08/01/2025 -Pressure alarms in W/C and recliner. Date Initiated: 01/29/2025 -Ensure that the resident is wearing appropriate-fitting clothing and footwear that fits well when ambulating or mobilizing in w/c. Date Initiated: 09/27/2021 Revision on: 11/06/2024 -Auto locks applied to W/C. Date Initiated: 10/02/2024 -Dycem cushion in wheelchair to prevent from sliding forward. Date Initiated: 10/07/2024 -Encourage participation in activities that will increase strength and mobility. Date Initiated: 09/27/2021 -Evaluate, interview and document resident physical condition and cognitive status. Observe environment to identify any potential factors that could contribute to a fall, such as lighting, uneven/slippery/cluttered floor surfaces, improper footwear, failure to use assistive devices, etc. Remove any potential causes or hazards, if possible. Educate resident and caregivers of potential fall hazards for the resident. Date Initiated: 09/27/2021 -Invite, encourage, and assist resident to activities of preference. Date Initiated: 09/27/2021 -Invite, encourage, and assist the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility and balance. Date Initiated: 09/27/2021 -Make sure that brakes on bed are locked when resident is in bed. Date Initiated: 09/27/2021 -Provide resident with safe environment: clutter free; support/assistive devices are available and in good repair; personal items and call device within reach; non-glare soft lighting at night, etc. Date Initiated: 09/27/2021 -PT to evaluate and treat as ordered. Date Initiated: 09/27/21 -Remind resident to use assistive devices and to use call device for assistance. Date Initiated: 09/27/21 On 06/15/25, R10 sustained a witnessed fall in her room. R10 was evaluated in the emergency room and determined to have no injuries. R10's progress notes read, Nurse was called into room when entered room resident and CNA where they were tangled up laying on the floor CNA was able to get repositioned and move away from the resident when attempted to help her she became vocal about her Ass hurting and when nurse questioned her she became verbally abusive. attempted to straighten out left leg and she screamed in pain noted left leg was shorter than right leg it was assisted that she would be transferred to the Hospital ER. placed call to POA and left message called Poa Alt and she said it was OK to send her and she wanted a bed hold for her room Called 911 and Hospital and updated them. placed call to DON and updated her Ambulance arrived and transported resident to ER. Surveyor noted R10's care plan was not updated after the fall, to help prevent further falls or accidents. On 01/07/26 at 7:28 AM, Surveyor interviewed DON B. Surveyor noted to DON B that R10's care plan did not reflect interventions after the fall. DON B did not have additional statements related to this. Example 3 R26 was admitted to the facility on [DATE] with pertinent diagnoses of vascular dementia severe with anxiety, Alzheimer's disease, fibromyalgia, weakness, contracture of muscle right thigh, contracture of muscle left thigh, contracture of muscle left lower leg, and contracture of muscle right lower leg. R26's most recent quarterly Minimum Data Set (MDS) assessment, dated 12/21/25, noted a Brief Interview of Mental Status (BIMS) score not completed due to resident rarely/never understood. R26 has ROM impairment of upper extremity on one side and impairment of lower extremities on both sides. R26 is dependent assist with all ADLs. R26's care plan, dated 03/04/21, with a target date of 12/23/25, states: Resident has ADL self-care deficit with interventions of transfer: hoyer and assist of 2. Of note: care plan does not indicate what size sling should be utilized for Hoyer lift. Surveyor reviewed Certified Nursing Assistant (CNA) Kardex and noted for R26 transfer assist with Hoyer. No sling size noted. Surveyor reviewed R26's therapy notes and noted no indication for sling size for use with Hoyer transfers. On 01/05/26 at 1:09 PM, Surveyor observed 2 staff assisting R26 with Hoyer lift transfer from broda chair to bed. R26 was observed in sling with black handles. Surveyor observed Volaro Hoyer lift used for transfers had a sizing chart attached to machine. The sizing chart noted that color of sling handles indicate size and black handles were a size large and intended for patients weighing 200-325 lbs. Surveyor reviewed R26's weights and noted between 10/16/25 – 01/06/26, R26 weighed between 159 – 164 lbs. Surveyor reviewed the Volaro manufacturer's guidelines for choosing sling size and noted, .to determine the proper sling size, lay a sling across the persons chest. If it's the proper size sling, you will note 2-8 inches of extra material extended past the side of each arm. Additionally, the sling size chart noted that each size sling had a corresponding weight, shoulder and hip measurement to determine sizing. Of note: no documentation was noted in R26's medical record to indicate shoulder and hip measurements to determine sling size. On 01/06/26 at 1:10 PM, Surveyor interviewed CNA D regarding R26's sling size. CNA D stated she thinks R26 uses an XL sling size. Surveyor asked CNA D how staff know which size sling to use. CNA D stated they look at the size of the resident or are told by the nurse. Surveyor asked CNA D if staff receive education on choosing the appropriate sling size for Hoyer lifts. CNA D stated no she couldn't remember any training. On 01/06/26 at 3:25 PM, Surveyor interviewed Registered Nurse (RN) E regarding R26's sling size. RN E stated he thought it was a medium. Surveyor asked RN E how staff know what size sling to use. RN E stated they go by weight and the positioning of the sling with resident's body. Surveyor asked RN E if staff receive training on choosing appropriate sling size. RN E stated there is a chart in the utility closet where the slings are stored that tells which size sling to use based on weight but couldn't recall any formal education or training. On 01/07/26 at 8:06 AM, Surveyor interviewed Director of Nursing (DON) B regarding sling sizes. Surveyor asked DON B if training and education is completed with staff regarding sling sizing. DON B stated inability to recall specific training for slings but that Hoyer transfer lift safety training is completed. Surveyor asked DON B if she was aware of manufacturer's guidelines for sling sizes. DON B stated no. Example 4 R5 was admitted to the facility on [DATE] with pertinent diagnoses of Alzheimer's disease with late onset, dementia with anxiety, dependence on supplemental oxygen, long-term use of anticoagulants, atrial fibrillation, and weakness. R5's most recent significant change Minimum Data Set (MDS) assessment, dated 11/07/25, noted a Brief Interview for Mental Status (BIMS) score was not assessed due to resident rarely/never understood and had no memory/recall ability. R5 had impaired ROM on one side of lower extremity and dependent assist with all ADLs related to transfer and hygiene. R5 had one fall with major injury. R5's care plan, dated 07/24/25, with a target date of 02/18/25, states: Resident has ADL self-care deficit with interventions of encourage resident to use call light to request assistance and provide reminders as needed (07/24/25) R5's care plan, dated 07/24/25, with a target date of 02/18/26, states: Resident is at risk for falls with interventions of ALARM: pressure alarm to chair and bed (08/18/25), ensure resident is wearing appropriate-fitting clothing and footwear that fits well when ambulating or mobilizing in w/c (07/24/25), remind resident to use assistive devices and to use call device for assistance as needed (07/24/25). Of note: no revisions to care plan interventions were noted after 08/18/25. R5's fall assessments: 07/24/25 19: at risk 08/07/2517: at risk 08/21/25 15: at risk 11/07/25 17: at risk Surveyor reviewed R5's falls: On 10/30/25 at 8:24 AM, R5 had an unwitnessed fall in room; res had fallen onto floor w/head looking up toward ceiling out of recliner chair. R5 did have mild pain to R leg/hip area. No wounds. Res stated she was trying to get up and her slippers slipped. Family, DON, provider notified. Sent to ER via ambulance for eval. ER documentation: 10/30/25 – CT abdomen w/IV contrast – Impression: 1. Acute comminuted fracture of the greater trochanter of right proximal femur. CT head w/o contrast – No acute infarct, hemorrhage, or mass effect. Surveyor reviewed facility's investigation of incident and noted no determination of root cause of incident and no new safety interventions were implemented. On 01/07/26 at 8:01 AM, Surveyor interviewed DON B regarding R5's fall. DON B stated she believed the new intervention of an additional chair alarm was added to alert staff quicker if R5 attempted to transfer self without assist but acknowledged this wasn't updated in R5's care plan. Surveyor asked DON B for additional documentation that this incident was fully investigated and reviewed by IDT. DON B stated no additional documentation was available, and it was not documented.

Based on observation, interview and record review, the facility did not ensure 1 of 2 residents reviewed (R7), received the necessary services to carry out Activities of Daily Living (ADLs). -The facility identified R7 had a decline in transfer status and did not follow up with the recommended therapy evaluation. R7's Minimum Data Set (MDS) assessment, completed on 12/08/25, confirmed R7 scored 04/15 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R7's MDS assessment revealed R7 requires assistance with all transfers.R7's care plan included:-Resident has ADL Self Care deficit r/t alteration in functional abilities, altered cognition, dementia with behaviors, low back pain. Date Initiated: 08/27/2025 Revision on: 12/12/2025.-Resident will improve in ADL function. Date Initiated: 08/27/2025 Revision on: 12/11/2025.-Transfer: The resident is A2 with EZ stand. Date Initiated: 08/27/2025 Revision on: 12/11/2025R7's progress notes included: 12/11/25, IDT met to review change in res transfers. Staff have been using A2 with EZ stand. Will change res toileting plan to eliminate urinal as res no longer standing. Res is nearly always incontinent of urine. Discussed asking for a change to something other than po [by mouth] medication as res refuses and/or spits out meds or refuses to swallow them. Also discussed topical pain medications for the same reason. Changes to medications that res will not take are not effective. Will request PT/OT orders to address decline is functional abilities. Staff offer support to res during periods of tearfulness and withdrawal. Efforts are made to limit crowded areas that may set res off or put others at risk when res becomes agitated.During the survey period from 01/05/26-01/07/26, Surveyor observed staff assist R7 with transfers using mechanical sit-to-stand lift. On 01/05/26 at 12:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C confirmed R7 was assist of one for transferring, but staff have been using the sit-to-stand lift due to R7 being weak. On 01/07/26 at 12:26 PM, Surveyor asked Director of Nursing (DON) B if R7 had been referred to therapy after 12/11/25, when staff identified a change in R7's transfer status. DON B stated she didn't know about a therapy referral but would look into it. DON B asked Surveyor if the referral was made in December, and Surveyor responded it was. On 01/07/26 at 1:46 PM, DON B gave Surveyor a signed physician order for therapy evaluation related to transfers for R7, dated 01/07/26. DON B stated, I just got the order today. We discussed it but never got it.

Based on observation, interview and record review, the facility did not ensure a medication error rate of less than 5% for 2 of 3 residents observed (R21, R22).-Facility had a medication error rate of 11.54%.-R21 received the wrong dose for two medications (artificial tears and Citalopram).-R22 received the wrong medication. R22 received Calcium with Vitamin D 500mg tab and the physician order was for Calcium Carbonate 1250 (500 Ca) and to give 2 tablets by mouth one time a day.Findings include:Facility policy titled, Medication Administration, last revised 11/25, states in part: Medications are administered to residents by qualified personnel in compliance with federal and state laws and standards of professional practice.to ensure the safe, appropriate, and accurate administration and handling of medications in a dignified manner.Licensed Nurses will . observe the seven rights of proper medication administration.right drug.right dose. On 01/06/26 at 7:22 AM, Surveyor observed Licensed Practical Nurse (LPN) F administer medications to R21. LPN F administered 1 drop of artificial tears to both R21's eyes and disposed of the one-dose vial into the garbage can. LPN F was not wearing gloves and did not follow the order for 2 drops in each eye. Surveyor observed LPN F administer oral medications to R21. LPN F administered 10mg of Citalopram to R21. Physician order states to give 30 mg by mouth one time a day for depression.On 01/06/26 at 7:46 AM, Surveyor observed LPN F administer medications to R22. LPN F administered Calcium with Vitamin D 500mg 1 tab. The physician order is for Calcium Carbonate 1250 (500 Ca) mg give 2 tablets by mouth one time a day for low amount of calcium in the blood.Surveyor reviewed orientation checklist and professional nurse orientation checklists for LPN F. Skill for using the electronic medication administration record (MAR) checked off and initialed complete on 08/15/25. Medication Pass: observation/independent pass with Nurse available, marked completed on 08/20/25.On 01/07/26 at 12:44 PM, Surveyor interviewed LPN G. LPN G stated LPN G would check the order in the MAR, check the order on the medication card, and could ask the resident their name, to ensure the proper medications were given. LPN G also stated that LPN G could check the orders if there was a discrepancy. LPN G stated that if there was an over-the-counter medication that was not clear, LPN G would clarify it with the Director of Nursing (DON) or look at the order in the chart. LPN G stated that it would be appropriate to wear gloves when feeding a resident medication when your hand may touch the resident's mouth. LPN G stated it would be appropriate to wear gloves when administering patches, eye drops, and insulin.On 01/07/26 at 12:50 PM, Surveyor interviewed Registered Nurse (RN) H. RN H stated RN would check the MAR to ensure the correct medications were given. RN H stated if RN H did not know what a medication was, RN H would look it up in the drug book. RN H stated gloves would be appropriate when administering eye drops, creams, and patches.On 01/07/26 at 2:00 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated if the nurses had an over-the-counter medication they were unsure of, they should look it up to see if there is another name for it. If it is out of stock, designated staff could run out and get it or management such as DON B or Nursing Home Administrator (NHA) A could give the pharmacy approval to send it. DON B stated the expectation is nurses should be wearing gloves with med pass, which would include anything potentially hazardous, when administering eye drops, cleaning nebulizers, any time something is inserted, and when administering creams and ointments.

Based on observations, interview and record review, the facility did not ensure that a resident (R) who requires dialysis receives such service, consistent with professional standards of practice for 1 of 1 sampled resident (R3) reviewed for dialysis.The facility failed to provide ongoing assessment of R3's condition and monitoring for complications before and after dialysis treatments.Findings include:R3 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, stage 4 (severe) and dependence on renal dialysis.R3 is transported to hemodialysis off site on Mondays, Wednesdays, and Fridays. R3's orders as of 10/21/25, indicate to take a full set of vitals and weight post dialysis treatment one time a day every Monday Wednesday, and Friday. Post vital signs were not taking on 11/28/25 and on 12/1/25 after R3's hemodialysis. R3's care plan states R3 requires dialysis related to renal failure with a goal to have no signs and symptoms of complications from dialysis. Interventions state in part. Check access site for bruit and thrill per nursing order on treatment assessment record, fistula/graft access site: If bleeding occurs to fistula/port site, using gauze apply pressure for 10 minutes if stops apply new gauze and tape. If does not stop send to ER. Observe and report to Nurse and/or MD as needed any signs/ symptoms of infection to access site.On 1/5/26 at 1:02 PM, Surveyor interviewed R3 who reported R3 did not have a fistula but R3 has a peripherally inserted central catheter (PICC) line. Surveyor asked R3 if staff ever observed or flushed R3's PICC line, and R3 stated the facility staff has not looked at it since R3's admission.In review of R3's medical record there are no orders, assessments, documentation, or care plan interventions in relation to R3's PICC line. R3's care plan indicates interventions for a fistula (Arteriovenous Fistulas are common in hemodialysis patients). R3 does not have a fistula.On 1/7/26 at 8:30 AM, Surveyor interviewed Registered Nurse (RN) W, who reported RN W assesses R3's fistula and then later stated RN W had R3 confused with another resident. Surveyor asked if RN W assesses R3's PICC line port. RN W stated the PICC line is covered, and dialysis takes care of the PICC line. Surveyor aske RN W if RN W documents anywhere about R3's PICC port site condition, and if the PICC line is monitored for signs of an infection or bleeding. RN W stated not that RN W is aware of.On 1/7/26 at 10:30 AM, Surveyor interviewed DON B, who verified post dialysis vital signs were missed on two days, and R3's care plan did not adequately identify or address interventions for the care of R3's PICC line.

Based on observation, interviews and record review, the facility did not ensure pain management interventions were provided for 1 out of 2 residents (R) reviewed for pain management.The facility did not assess and provide non-pharmacologic interventions to R6 as ordered for pain management.This is evidenced by:The facility policy titled, Pain Assessment & Scale dated 4/12/2001, reads in part. 3. Consider alternative pain relief measures such as: distraction, massage, cold or warm packs, repositioning, or backrub.R6 was admitted to the facility on [DATE]. Diagnoses include fracture of upper end of left humerus. R6's Minimum Data Set (MDS) assessment completed on 12/4/25 indicated R6 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R6's care plan updated 12/16/25 indicated resident has acute pain related to humerus fracture, chronic pain related to kyphosis and history of spinal fractures. Goal, pain will be managed at a level of comfort. Interventions include, offer non-pharmacological interventions such as: repositioning, toileting, offering food or drink, massage, cold packs, relaxation techniques, activities, TV, 1:1. current pain management interventions, pharmacological and non-pharmacological interventions, timeframes, and approaches for monitoring the status of the resident's pain, including the effectiveness of the interventions.On 1/05/2026 at 12:25 PM, Surveyor interviewed R6, who reported R6 has almost constant pain. R6 states R6 does take pain medication but mostly at night because R6 does not like taking too much medication. R6 also reported R6 is often uncomfortable due to anxiety. R6 does not want to take anything for anxiety. Surveyor asked R6 if staff offer alternative methods such as cold packs, conversation, or massage. R6 stated staff does not offer and they do not have time.R6 stated pain is on left side, includes shoulder arm, and entire leg. Pain comes and goes in intensity. R6 stated pain is worse at night because R6 cannot reposition self in bed and staff does not come in to reposition R6. R6's orders dated 12/4/25 include:Non-Pharmacologic Interventions used before, as needed (PRN) pain medication and/or before PRN pain analgesic. Document number corresponding to interventions attempted in supplementary documentation. As needed for non-pharmacological pain interventions PRN (as needed) Non-pharmacological pain interventions 1. Reposition 2. Warm pack 3. Ice pack 4. Dimmed lighting 5. Massage 6. Music 7. Television 8. Distraction 9. 1:1 communication 10. Education provided 11. Other--Add to progress note. Measurable goals for pain management, current pain management interventions, pharmacological and non-pharmacological interventions, timeframes, and approaches for monitoring the status of the resident's pain, including the effectiveness of the interventions. R6's treatment administration record indicated there were no non-pharmacologic interventions offered from 12/4/25 until 12/25/25, then again not offered on 12/27/25, 12/29/25, 12/31/25, and 1/2/26 through 1/6/25.R6's medication administration record indicated R6 received Hydrocodone- Acetaminophen 5/325 milligrams (mg) tablet orally every 12 hours as needed and R6 was given this daily from 12/4/25 until 12/8/25. However, R6's pain assessments were only documented for 12/5/25 and 12/7/25 and were both rated at a pain level of 7 on a scale of 1-10.R6's Hydrocodone- Acetaminophen 5/325 mg tablet was discontinued on 12/8/25, and R6 was prescribed Oxycodone 5 mg every 6 hours for pain. This was given as scheduled with pain assessments that ranged from 0 to 6 and change to Oxycodone 5 mg every 6 hours as needed on 12/20/25.Starting on 12/20/25, R6's pain assessments were not done every shift and when pain assessments were completed, the pain ranged from 5 to 10 on a scale of 1-10. During survey 1/5/25 through 1/7/25, Surveyor did not observe staff offer any non-pharmacologic interventions to R6.On 1/7/26 at 10:21 AM, Surveyor interviewed Director of Nursing (DON) B about R6's pain assessments and non-pharmacologic interventions not being consistently provided. DON B stated the expectation would be R6's pain be consistently assessed and nursing interventions be documented and this was not done.

Based on interview and record review, the facility did not ensure residents (R) with intermittent catheterization received care and treatment consistent with professional standards of practice to prevent complications or urinary tract infections (UTI) for 1 of 1 resident (R)(R4) reviewed.R4 completed self-catheterization without facility assessment and indication of need. R4 developed a UTI on 12/02/25 and 12/31/25.This is evidenced by:Facility policy titled, Catheterization of a Male, with a date of 2025, states in part: Policy: Urinary catheterization will be performed in accordance with current standards of practice to minimize risk for bacterial contamination or urethral trauma.Centers for Disease Control and Prevention (CDC) states that current standards of practice to prevent UTI and complications, intermittent catheterizations should be completed with clinical indications at regular intervals of 4-6 times daily and consider using a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume to reduce unnecessary catheter insertions and prevent bladder overdistension.R4 was admitted to the facility on [DATE] with pertinent diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms and retention of urine.R4's most recent quarterly Minimum Data Set (MDS) assessment, dated 11/16/25, noted a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition is intact. R4 has no impairment in upper range of motion and is dependent assist with toileting hygiene. R4 uses intermittent catheterization.R4's care plan, initiated 07/22/25, with a target date of 02/18/26, states: Resident has ADL self-care deficit with interventions of toilet use: resident needs assistance with peri hygiene and pad changing.R4's care plan, initiated 04/12/23, with a target date of 02/18/26, states: R4 requires intermittent straight catheterization and will do himself with interventions of monitor and document intake and output as per facility policy and monitor for signs & symptoms (s/sx) of discomfort on urination and frequency.R4's physician orders:12/31/25 May straight cath up to 3 times per day for urinary retention.12/31/25 Levaquin 750 mg daily for 5 days.12/02/25 Bactrim 800-160 mg daily for 7 days.R4's provider notes:04/05/23 H&P: Urinary retention - R4 had an indwelling Foley catheter placed because of chronic urinary retention. He normally does straight catheterization at home and there was large and output, over 2 L, each time he catheterized himself.11/21/25 INTERVENTIONS TO MANAGE BOWEL INCONTINENCE: Res straight catheterizing 2-3 times a day to manage bladder r/t obstructive uropathy r/t prostate. Urine output is monitored TID and documented by CNA.12/08/25 - PA visit - UA on 12/02/2025 showed large blood, positive nitrite, large leukocyte esterase, trace protein, greater than 100 WBCs, greater than 100 RBCs, and bacteria present. A urine culture was not done.12/31/25 NP ASSESSMENT: Patient is being seen today for recurrent urinary tract infections. He currently self-catheterizes twice daily which he has done for the past approximately 3 years. He reports recurrent UTI symptoms with occasional stinging during urination, thick urine especially in the morning, and foul-smelling urine. He has self-catheterized for almost six years after a prolonged indwelling catheter in a nursing home. He catheterizes twice a day with 950 to 1200 mL each time and does not urinate between catheterizations. He recalls one episode of slight bleeding with thick urine and difficult catheterization. He has not seen urology since 2022, when he was evaluated for urinary retention and kidney stones. He reports careful cleaning of catheter equipment. ASSESSMENT/PLAN: Infection and Inflammatory Reaction Due to Other Urinary Catheter Subsequent Encounter Retention Urinary tract infection associated with chronic urinary retention and indwelling catheter Recurrent UTI likely due to infrequent self-catheterization, increasing retention and infection risk. - Prescribed Levaquin 750 mg once daily for 5 days due to multiple morphologies based on culture report. - Increase self-catheterization to three times daily. The fact that he only self-catheterizes twice daily could likely be contributing to his recurrent infections. - Referred to urology for further evaluation and management. Appointment scheduled for 02/12/26.Of note: no urology consult or assessment was documented since admission on [DATE]. No documentation from urologist indicating need for catheter was documented.Surveyor reviewed R4's nursing assessments and noted on 12/03/25, nursing completed assessment of R4 demonstrating ability to complete self-catheterization using clean technique. No other assessments were completed prior to this.Of note: no bladder assessments were documented to address number of times R4 actually completed self-catheterization, bladder scanning results, bladder training program, or characteristics of urine output.On 01/05/26 at 1:35 PM, Surveyor interviewed R4 regarding self-catheterization. Surveyor asked R4 why he needed to self-catheterize. R4 stated it was because he had an indwelling catheter in a long time ago that messed him up and now, he can't go on his own. Surveyor asked R4 if the facility has ever attempted a bladder training program. Surveyor asked R4 if he had been seen by a urologist since admitting to the facility. R4 stated no. Surveyor asked R4 how many times a day he self-catheterizes. R4 stated 3 times a day. Surveyor asked if he ever urinates without self-catheterizing. R4 stated no. Surveyor asked if the facility has ever used a bladder scanner to see how much urine is retained or assess the bladder. R4 stated no.On 01/06/25 at 1:10 PM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding R4's catheter care. CNA D stated that she thinks R4 self-catheterizes 3 times a day and the CNAs document the amount. Surveyor asked if CNAs inform the nurse regarding color, odor, or consistency. CNA D stated no, they only keep track of the output.On 01/06/25 at 3:25 PM, Surveyor interviewed Registered Nurse (RN) E regarding R4's catheter. RN E stated that R4 has self-catheterized since admission but wasn't sure exactly why he had to do this. RN E stated he thought it was due to retention. Surveyor asked RN E how often bladder assessments are completed on R4. RN E stated this is only completed if it is a task assigned in the TAR and then a progress note would be made but didn't think R4 had regular assessments completed. Surveyor asked RN E if nurses assess how often R4 is self-catheterizing. RN E stated they don't ask R4 this but know that he does it 3 times a day. Surveyor asked RN E if they ever use a bladder scanner to assess urine retention on R4. RN E stated no.On 01/07/26 at 7:29 AM, Surveyor interviewed Director of Nursing (DON) B regarding R4's catheter. Surveyor asked DON B if R4 had any evaluations completed by a urologist to state need for self-catheterization. DON B stated, she could not find anything. Surveyor asked DON B if an assessment had been completed on R4 prior to 12/03/25 for capability of R4 to complete self-catheterization. DON B stated no. Surveyor asked DON B if this should have been completed to determine any risk that could lead to UTIs or complications. DON B stated yes. Surveyor asked DON B if bladder assessments are completed regularly on R4 to monitor for complications. DON B stated no and that they probably should have. Surveyor asked DON B why R4 had an order to self-catheterize 3 times a day. DON B stated that was what R4 stated he did, so that was what they asked the provider to order.

Based on observation, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for one of one resident (R) reviewed for pressure injuries (R34).The facility did not provide, document, or evaluate interventions to prevent the development of multiple pressure injuries and/or promote healing of R34's pressure injuries.Facility did not have orders or documentation to perform daily skin assessments to assess R34's skin of R34's left foot, which had a post-operative shoe due to amputaion of left great toe. The facility's lack of skin assessments of R34's left foot lead to development of a stage 2 pressure injury on toip of R34's left foot because facility did not observe that there was no cushion between the skin on R34's left foot and the post-operative shoe.Wrong Hoyer sling used on R34, which caused stage 2 sacral ulcer. No new interventions provided to promote healing.This is evidenced by:The facility's policy titled, Pressure Injury Prevention and Management, revised 10/24, states in part, .4. Interventions for Prevention and to Promote Healing . c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include . iv. Provide non-irritating surfaces . f. Interventions will be documented in the care plan and communicated to all relevant staff. g. Compliance with the interventions will be documented in the weekly summary charting.R34 was admitted to the facility on [DATE], with diagnoses including cutaneous abscess of buttock, peripheral vascular disease, venous insufficiency, acquired absence of other right toes, muscle weakness, and difficulty in walking.Skin assessment completed by the facility on 1/10/25 indicated pressure ulcer/injury (PU/PI), stage 2 of the left shin, present on admission, onset unknown. Measured 2cm long, 0.5 cm wide, and 0.1 cm deep. Foam dressing intact. Other skin issue included cellulitis.Comprehensive Minimum Data Set (MDS), dated [DATE], indicated R34 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. R34's MDS indicated a Brief Interview for Mental Status (BIMS) of 15/15 indicating intact cognition.R34's hospital discharge summary included a diagnosis of pressure injury/ulcer of right heel, stage 3, and amputation of great right toe. Other issues included cellulitis of the left lower leg. Braden score completed on 1/11/25 by facility, determined R34 was at low risk for pressure ulcer development.R34 was receiving weekly skin evaluations and wound treatment at the facility by Doctor of Osteopathic Medicine (DO) U. Documentation indicated the PU/PI of R34's left shin had healed; however, R34 had developed other wounds, including a wound to the left great toe, which resulted in amputation on 10/3/25.On 9/17/25, R34 developed a new non-pressure wound of the right sacrum measured 1.2 cm long, 3.5 cm wide, and 0.1 cm deep, with moderate serous drainage, etiology documented as moisture associated skin damage and was treated by wound care provider. Daily wound care orders as follows: Right buttock wound cleanse with normal saline, apply collagen sheet to wound bed, then apply calcium alginate, use skin prep on peri wound, cover with gauze island dressing, change once dailyOn 10/29/25, DO U changed etiology of the sacral wound to trauma/injury, as it was believed to have been caused by shearing of R34's Hoyer sling. DO U also changed the location from right sacrum to the right buttock. The wound measured 1.0 cm long, 1.8 cm wide, and 0.2 cm deep (stage 2), with moderate serous drainage.On 10/3/25, R34 had amputation of appendage of left foot. R34's left foot was bandaged and R34 wore a post operative shoe per orders.On 10/13/25, R34 was seen for a post operative evaluation with orders to keep dressing intact but ok to change dressing as needed and continue with post operative shoe.On 10/17/25, Braden Scale assessment showed R34 scored 18, indicating R34 is at risk for PU/PI.On 10/27/25, R34's bandage to left foot was removed, post operative shoe was continued. The facility did perform an evaluation to determine fitting of shoe. Daily nursing skin assessment was not ordered or documented to assess skin with device use.On 10/29/25, R34 developed a new stage 2 pressure ulcer to the top of the left foot, measuring 1.8 x 2.0 x 0.1 cm, open areas with exposed dermis and with light serous drainage. DO U's wound evaluation note indicated, Approach stated off-loading and close monitoring.On 10/30/25, summary note indicated a new pressure area to top of left foot. Area was discovered after R34's wraps to the left foot were discontinued. Root cause analysis identified that not having something between her skin and the boot was the cause of the area. Orders to have R34 not wear this boot at this time to allow area to heal. Staff to float heels when R34 is in bed. Check skin under removable devices every shift.On 10/30/25, an order was received to discontinue use of postsurgical shoe for R34.Facility could not provide evidence of any new interventions provided with the sacral wound, even though Director of Nursing (DON) B reported it was believed to be from using and sitting on the Hoyer sling with the hole in it, which is used for toileting. DON B stated the intervention was to use the sling that was flat, as that was supposed to be used, however this was not documented anywhere or in R34's care planR34's care plan was not updated. There was no documentation of daily skin checks with use of device prior to ulceration provided.On 1/5/26 at 3:00 PM, Surveyor interviewed R34, who reported the pressure ulcer on top of her foot was from the strap of her post-surgical shoe rubbing and the wound on her sacral area is from the Hoyer lift sling. R34 showed surveyor the Hoyer sling underneath her while sitting in the wheelchair and stated it was uncomfortable at times and the need to adjust it and/or the hem where the hole is would rub where her current buttock wound is.Surveyor noted R34 had a butterfly shaped dressing approximately 10 cm x 15 cm on the sacral/buttock area and a Hoyer sling used for toileting with a hole around buttock area, was underneath R34 as she was sitting in the wheelchair. R34 stated that is the sling that is typically used and left under her,On 1/7/26 at 6:45 AM, Surveyor interviewed DON B who reported R34's sacral/buttock wound was originally identified as a moisture associated wound on R34's sacrum and then on 10/22/25, after wound DO U had a conversation with the Certified Nursing Assistants (CNA). The documentation was updated to identify the sacral wound as being on the right buttock and caused from trauma from using the wrong sling (a sling with a hole for toileting). It was identified that the CNAs were using a sling with a hole in the center for use of toileting. DON B stated once this was identified, the facility started using the correct Hoyer lift sling (without a hole). DON B reported there is no documentation the staff had been provided education on using the correct Hoyer sling after it was determined to be the cause of the PU/PI. R34's care plan was not updated with this interventionSurveyor asked DON B how the CNAs know what Hoyer sling to use and/or leave under R34. DON B stated because we told them, and they are not supposed to leave the sling with the hole in it under the resident. Interventions are not in R34's care plan, the CNA Kardex, or orders.Surveyor asked DON B for any documentation of an evaluation by a nurse or provider of R34's post-surgical shoe fitting properly, for documentation addressing an assessment of the skin under the device, and/or plan to assess R34's skin under the device (boot) on a daily basis by qualified staff. DON B reported there was not any documentation to support this.On 1/7/26 at 8:12 AM, Surveyor observed CNA V and Registered Nurse (RN) W, provide incontinence cares for R34 in bed after toileting. After providing incontinence cares in bed, staff used same sling with hole to transfer R34 back into wheelchair leaving Hoyer sling with hole in it under R34.On 1/7/26 at 8:18 AM, Surveyor interviewed CNA V asking how to determine what sling to use for R34. CNA V replied the tag on the sling indicates the size and they go by how big the resident looks. CNA V also stated they keep the sling with the hole under R34 when she is up in the wheelchair so it's easier to put R34 on the toilet.On 1/7/25 at 8:22 AM, Surveyor interviewed RN W about R34's wounds. RN W reported there is an area of concern they are watching on R34's right buttocks and top of left foot. Surveyor asked if daily wound assessments are then being documented for these areas. RN W reported daily dressing changes are being done. RN W stated they are not documenting a daily skin assessment for R34's wounds, as wound provider does it weekly.On 1/7/26 at 9:15 AM, Surveyor asked DON B to meet in R34's room. R34 was sitting in wheelchair with Hoyer sling with hole in buttock area. R34 verbalized to DON B sitting on that sling was more uncomfortable than sitting on the flat Hoyer sling, that the hem of the hole rubs on R34's sacral area and R34 thinks that may have been what caused the wound. DON B stated R34 should not have the sling with the hole in it under her when in wheelchair. DON B reported interventions to stop using the Hoyer lift sling and to no longer use surgical shoe should have been updated in R34's care plan and were not.On 1/7/26 at 11:50 AM, Surveyor interviewed DO U. DO U stated it was determined R34's wound to the sacrum/buttocks was due to an injury suspected from the sling. Provider stated this was determined because the wound had worsened and involved deep granulation tissue, then it was suspected to be in injury resulting from the Hoyer sling.DO U stated R34's original wounds to foot were arterial, which worsened and became infected leading to R34's surgical amputation of the great left toe. DO U stated the wound to the top of R34's foot was most likely caused from the strap of the boot worn and is considered a trauma. Surveyor asked DO U if the wounds on R34's buttock/sacral area and on top of R34's L foot could have been prevented. DO U stated she would have to check with her Medical Director prior to answering that question.On 1/7/26 at 11:57 AM, Surveyor observed wound care provided for R34's wound on the right buttock (formally referred to as the sacral wound) and for the wound to the top of R34's right foot. Wound to R34's right buttock measured 0.2 x 1.0 x 0.1 cm. R34's wound to the top of the foot measured 2.1 x 2.6 x 0.1 cm.On 1/7/26 at 6:00 PM, DO U called Surveyor. After discussion of R34's wounds, DO U stated she cannot say if wounds could have been prevented because DO U Is not there 24/7.

Based on observation, interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice that would meet each resident's physical, mental, and psychosocial needs.-The facility did not obtain and enter orders for 1 of 1 resident reviewed (R51).-The facility did not update provider related to new skin impairment for 1 of 1 resident reviewed (R10).-The facility did not implement interventions to assess skin under immobilizer to prevent skin breakdown for 1 of 1 resident reviewed (R26). Findings include: Facility Policy titled, Provision of Physician Ordered Services, implemented in 2025, reads in part: The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality.Qualified nursing personnel will submit timely requests for physician ordered services (laboratory, radiology, consultations) to the appropriate entity.Documentation of consultation, diagnostic tests, the results, and date/time of Physician notification will be maintained in the resident's clinical record. Facility Assessment titled, Resident Profile, last reviewed on 09/01/25, reads in part: Specific Care or Practices for Skin Integrity includes pressure injury prevention and care, skin care, wound care.Management of Medical Conditions includes Assessment, early identification of problems.Therapy includes management of braces, splints.Provide person-centered care includes identify hazards and risks for residents. R51 was admitted to the facility on [DATE] with a high humerus fracture to the right arm. R51 was admitted with an immobilizer to right arm. On 01/05/26 at 10:41 AM, Surveyor interviewed R51. R51 was observed wearing an immobilizer around the chest with two arm straps to the right arm. R51 stated the right arm was broken and the immobilizer holds it in place. Surveyor reviewed R51's medical record and found no order in place for the immobilizer, no brace care, no weight bearing status, and no skin care associated with the brace. Care plan in place for pain related to humerus fracture, but no mention of immobilizer or skin care/impairment prevention interventions related to the immobilizer. Occupational therapy notes from hospital, dated 12/29/25, stated R51 was to be non-weight bearing to right upper extremity and to wear immobilizer to right upper extremity at all times. Physical therapy notes from hospital, dated 12/29/25, stated, Non-weightbearing right upper extremity, shoulder immobilizer at all times. Orthopedic surgery notes from hospital, dated 12/24/25, reads in part, Follow up.in one week with repeat radiographs of his shoulder.immobilizer on his right upper extremity. On 01/06/26 at 1:46 PM, Surveyor interviewed Health Unit Coordinator (HUC) S. HUC S stated there was no follow up appointment scheduled with new x-rays. HUC S stated the facility only follows the After Visit Summary (AVS) for appointments. On 01/06/26 at 1:48 PM, Surveyor interviewed HUC T. HUC T stated the facility follows the AVS and at times they check the hospital portal for upcoming appointments. On 01/06/26 at 2:23 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated HUC S and HUC T enter the appointments upon admission and at times, HUC S may help enter orders. DON B stated as of 12/01/25, there is an admission nurse that will usually enter orders, otherwise the floor nurses or herself enter them. DON B stated the nurses then double check the orders. DON B stated the facility uses the AVS only for appointment follow ups and admission orders because it is the most current. DON B stated the skin is checked weekly by the Certified Nursing Assistants (CNA)s on shower day. On 01/07/26 at 7:11 AM, Surveyor interviewed DON B. DON B stated after looking over the documentation, DON B was unable to locate any orders related to weight bearing status, the immobilizer, and there was no daily skin assessment in place for the resident. DON B stated none of the previous orders were added to the care plan. DON B stated the only papers that come with residents upon admission from the hospital are the AVS and discharge summary. Both documents did not have orders for a follow up appointment, the immobilizer, or weight bearing status. DON B acknowledged upon admission, orders regarding the immobilizer and weight bearing status should have been clarified. DON B reported there is now a follow-up appointment scheduled for R51. Example 2 R26 was admitted to the facility on [DATE] with pertinent diagnoses of vascular dementia severe with anxiety, Alzheimer's disease, fibromyalgia, weakness, contracture of muscle right thigh, contracture of muscle left thigh, contracture of muscle left lower leg, and contracture of muscle right lower leg. R26's most recent quarterly Minimum Data Set (MDS) assessment, dated 12/21/25, noted a Brief Interview of Mental Status (BIMS) score not completed due to resident rarely/never understood. R26 has ROM impairment of upper extremity on one side and impairment of lower extremities on both sides. R26 is dependent assist with all ADLs. R26's care plan, dated 03/04/21, with a target date of 12/23/25, states: Resident has ADL self-care deficit with interventions of LUE immobilizer on at all times except bathing or dressing. Report any redness or skin irritation to charge nurse (initiated 01/06/26). R26's orders: 01/06/25 Monitor skin under L shoulder immobilizer AM/PM. Note any redness or irritation and report to DON or wound nurse two times a day for skin monitoring. 12/09/25 Wear left shoulder immobilizer at all times (other than hygiene cares) and avoid movement of the shoulder. Wear immobilizer until cleared by orthopedic surgery every shift for shoulder dislocation. 11/18/25 Weekly Summary - Skin Condition V2 on bath days (under Assmnts) one time a day every Tue Weekly Summary - Skin Condition V2 on bath days (under Assmnts) Surveyor reviewed R26's skin assessments between 12/09/25 – 01/06/26 and noted no documentation of skin assessment under LUE immobilizer. On 01/06/26 at 3:25 PM, Surveyor interviewed Registered Nurse (RN) E regarding R26's skin assessments. RN E stated that CNAs look at R26's skin and inform the nurse if there are concerns. Surveyor asked RN E if the nurses remove the immobilizer and assess the skin at any time. RN E stated only if the CNAs report a concern. Surveyor asked RN E when skin assessments are completed. RN E stated only when it is assigned or ordered in the TAR. On 01/07/26 at 7:43 AM, Surveyor interviewed DON B regarding R26's skin assessments. DON B stated this should be assessed at least once a day under the device, and they would fix this issue as it could lead to skin impairment. Example 3 R10 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease. R10's MDS assessment completed on 05/02/25, confirmed R10 scored 06/10 during BIMS, indicating severely impaired cognition. R10 uses a wheelchair for mobility and requires assistance from staff with all transfers. R10's care plan included: Impaired skin integrity; Interventions: -Observe skin. Report any skin alterations to the charge nurse, 09/20/21. -Observe/document/report location, size, and treatment of skin injury and/or any new or worsened alterations in skin integrity, 09/20/21. On 01/03/26, R10's progress notes included, Open area to right buttock cleansed with NS, mepilex dressing applied.Surveyor was unable to find evidence of notification to provider, or a treatment order for new skin concern. On 01/06/26 at 3:33 PM, Surveyor interviewed Licensed Practical Nurse (LPN) J. LPN J stated when a new skin concern is identified, staff should update Director of Nursing and the provider. LPN J did not have knowledge of R10's new skin concern. On 01/07/26 at 7:38 AM, Surveyor interviewed DON B. DON B stated Registered Nurse (RN) H identified R10's new open area to right buttocks. DON B stated RN H is new and did not update provider. On 01/07/26 at 1:15 PM, Surveyor interviewed RN H. RN H stated she had not had training from the facility but has had from her agency. RN H stated she just started last Tuesday. RN H confirmed she observed a new open area on R10's buttocks on 01/03/25 and used standing order to apply mepilex (on Saturday). RN H did not call provider as the standing order was for 3 days and she knew she would be on in Monday morning to ask for clarification. RN H stated it did not get done on Monday morning.

Based on record review and interview, the facility must ensure each resident is free from unnecessary drugs as evidenced by completing adequate drug monitoring for 2 of 5 residents (R5 and R7) reviewed for unnecessary medication reviews.-The facility is not accurately monitoring resident-specific targeted behaviors for R7's psychotropic medication use. -The facility is not accurately monitoring resident-specific targeted behaviors for R5's psychotropic medication use. The facility policy titled, Psychotropic Medication, read in part, 4. Nursing will document daily on behaviors treated by antipsychotics/antianxiety/hypnotic. 8. PRN psychotropics and anti-anxiety medications will have behaviors to watch for and interventions to use prior to administration of medication. All behaviors and interventions used are to be documented. Example 1 R7 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance, depression, and anxiety. R7's Power of Attorney (POA) was activated to assist with decision making. R7's Minimum Data Set (MDS) assessment, completed on 12/08/25, confirmed R7 scored 04/15 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R7's MDS assessment revealed R7 exhibited physical, verbal, and wandering behaviors. R7's care plan included: -Resident has a diagnosis of anxiety, target behavior: pacing, 12/18/25. -Potential to demonstrate verbally and physically abusive behaviors related to dementia: analyze key times, places, circumstances, triggers, and what de-escalates behaviors and document. Document behavior and attempted interventions in behavior log, 10/07/25. -Diagnosis of depression and potential for decline in mood. Resident is prescribed an anti-depressant, 10/07/25. -Resident is at risk for elopement related to history of wandering and exit seeking behaviors, 08/27/25. R7's physician orders included the following psychotropic medications: -09/13/25-09/15/25, olanzapine 5 mg every 12 hours for agitation. -09/16/25-10/07/25, escitalopram 5 mg daily for depression. -10/08/25-12/17/25, fluoxetine 20 mg daily for depression. -10/21/25-11/04/25, olanzapine 5 mg two times daily for dementia with agitation. -11/15/25-11/20/25, Rexulti 0.5 mg at bedtime for anxiety. -11/20/25-12/17/25, Rexulti 1 mg at bedtime for anxiety. -12/17/25-12/20/25, Rexulti 0.5 mg at bedtime for anxiety. -12/20/25-12/22/25, Rexulti 0.25 mg at bedtime for anxiety. -12/20/25-current, Depakote Sprinkles 125 mg, twice daily for dementia related agitation. -12/24/25-current, Celexa 10 mg daily for anxiety. R7's Treatment Administration Record (TAR) included: -Monitor anti-anxiety target behaviors: Document corresponding number that reflects the behavior presented: 0-None, 1-Hitting, 2-Kicking, 3-Pushing, 4-Scratching, 5-Grabbing, 6-Threatening, 7-Screaming, 8-Cursing, 9-Rummaging, 10-Pacing, 11-Restlessness, 12-Fidgeting, 13-Other, see nurse's note. Every shift. -Monitor Antidepressant target behaviors: Document corresponding number that reflects the behavior presented: 0-None, 1-Negative statements, 2-Decreased interaction with others, 3-withdrawl from activities, 4-Poor sleep, 5-crying, 6-sad effect, 7-change in eating habits, 8-self isolation, 9-Other-see nurses note. Surveyor reviewed R7's October TAR and noted: -Monitor antianxiety target behaviors. A check mark was placed daily for each shift. The TAR did not reflect corresponding number reflecting the behaviors presented. -Monitor antidepressant target behaviors. October 2025, all days marked 0 except for 10/26/25 and 10/31/25 marked with a 1-(negative statements). Surveyor reviewed R7's October progress notes and noted: -10/04/25, took the fire extinguisher and used it on the door, setting off the smoke alarm. -10/05/25, eloped from the facility. -10/07/25, swearing. -10/08/25, crying. -10/14/25, set off fire alarm. Swinging gait belt and hitting CNA. Police were called. -10/15/25, wandering. -10/16/25, exit seeking most of the day. -10/26/25, shouting. -10/30/25, verbal aggression towards staff. -10/31/25, verbal aggression towards staff, swearing, statements of elopement. Surveyor reviewed R7's November TAR and noted: -Monitor antianxiety target behaviors, A check mark was placed daily for each shift. The TAR did not reflect corresponding number reflecting the behaviors presented. -Monitor antidepressant target behaviors. All days marked 0 except for 11/02/25, marked with 9-other. Surveyor reviewed R7's November progress notes and noted: -11/02/25, there were no behaviors documented in progress notes. -11/03/25, yelling, swearing, verbally aggressive towards staff, attempts at physical aggression towards staff, attempts to elope, awake most of the night. -11/08/25, yelling. -11/18/25, swearing. -11/22/25, nurse noted resident will spit out medications if taking whole. -11/27/25, wandering. One outburst. -11/28/25, a lot of behaviors. Yelling at staff. Surveyor reviewed R7's December TAR and noted: -Monitor antianxiety target behaviors. A check mark was placed daily for each shift. The TAR did not reflect corresponding number reflecting the behaviors presented. -Monitor antidepressant target behaviors. All days marked 0 except 12/28/25 and 12/29/25. Surveyor reviewed R7's December progress notes and noted: -12/01/25, physically aggressive with staff, punching CNA. -12/04/25, wandering. -12/08/25, yelling and swearing. -12/10/25, crying and yelling. -There were no behaviors documented in progress notes on 12/28/25 or 12/29/25. On 01/05/26 at 12:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C confirmed R7 requires 1:1 supervision at times due to behaviors. CNA C stated R7 has had several medication changes related to behaviors of wandering and verbal and physical aggression. On 01/07/26 at 7:28 AM, Surveyor interviewed Director of Nursing (DON) B. Surveyor discussed with DON B that R7's behaviors were not documented with corresponding number in TAR and were not consistent with progress notes. Surveyor asked DON B if there was additional documentation or evidence R7's behaviors were being tracked and monitored to ensure medications were appropriate and effective. Surveyor did not receive any additional information. Example 2 R5 was admitted to the facility on [DATE] with pertinent diagnoses of Alzheimer's disease with late onset, and dementia with anxiety. R5's most recent significant change Minimum Data Set (MDS) assessment, dated 11/07/25, noted a Brief Interview for Mental Status (BIMS) score was not assessed due to resident rarely/never understood and had no memory/recall ability. R5's care plan, dated 08/01/25, with a target date of 02/18/26, states: Resident uses anti-anxiety medications with interventions of give anti-anxiety medications ordered by physician. Monitor/document side effects and effectiveness. R5's orders: -clonazepam Oral Tablet 1 MG (Clonazepam) Give 1 mg by mouth two times a day for anxiety -Lorazepam oral tablet 0.5 mg Give 0.5 mg by mouth every 2 hours as needed for terminal agitation. -Monitor Antianxiety target behaviors: Document corresponding number that reflects the behavior presented: 0-None, 1-Hitting, 2-kicking, 3-pushing, 4-scratching, 5-grabbing, 6-threatening, 7-screaming, 8-cursing, 9-rummaging, 10-pacing, 11-restlessness, 12-fidgeting, 13-Other-see nurses note. every shift for Anti-Anxiety Med Monitoring every shift Surveyor reviewed R5's Treatment Administration Record (TAR) and Medication Administration Record (MAR) for 11/01/25 – 01/07/25 and noted: 11/01/25 – 11/30/25: all scheduled doses of clonazepam were given as ordered; 12 PRN doses of lorazepam were administered. Behaviors documented: -11/10/25 AMs – restlessness. -11/23/25 NOCs – restlessness. -11/28/25 NOCs – noted 'Other' with no additional note stating what behaviors were observed. *All other dates note no behaviors. 12/01/25 – 12/31/25: all scheduled doses of clonazepam were given as ordered; 7 PRN doses of lorazepam were administered. Behaviors documented: -12/01/25 NOC – noted 'Other' with no additional note stating what behaviors were observed. -12/08/25 PMs – no documentation. -12/10/25 PMs – no documentation. -12/25/25 NOCs – restlessness. -12/30/25 PMs – no documentation. *All other dates note no behaviors. 01/01/26 – 01/07/25: all scheduled doses of clonazepam were given as ordered; 2 PRN doses of lorazepam were administered. Behaviors documented: None.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 4 sampled residents reviewed.-The facility staff did not immediately respond to R7's wanderguard alarm, and R7 eloped from the facility.-The facility did not report R7's elopement within two hours, as the allegation involved potential neglect.-The facility did not submit the misconduct incident report within five business days of discovery of the incident.The facility's policy titled, Elopement Prevention and Response, read in part, It is the policy of this facility to ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner.d. Adequate supervision will be provided to help prevent accidents or elopements.Surveyor requested the facility's policy of reporting requirements but was not provided with this.R7 was admitted to the facility on [DATE]. Diagnoses included dementia with behavioral disturbance. R7 propelled wheelchair independently. R7's Power of Attorney (POA) was activated to assist with decision making.R7's Minimum Data Set (MDS) assessment, completed on 09/08/25, confirmed R7 scored 08/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R7's MDS assessment revealed R7 presented with wandering behaviors placing R7 at significant risk of getting to a potentially dangerous place.R7's care plan included:-Resident will not leave building unattended Date Initiated: 08/27/2025 Revision on: 12/11/2025-One on one supervision. Date Initiated: 11/10/2025-Resident is at risk for elopement r/t to hx of wandering and exit seeking behaviors, impaired safety awareness. Date Initiated: 08/27/2025-Attempt to engage resident in pleasant, meaningful, purposeful enjoyable, resident centered activities, during episodes of constant wandering. Date Initiated: 08/27/2025-Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Date Initiated: 08/27/2025-Document wandering behavior and attempted interventions to provide resident with meaningful activities, validation, and relationship-based redirection in behavior note. Date Initiated: 08/27/2025-Provide structured activities: toileting, walking inside and outside with supervision, orientation strategies including signs, pictures and memory boxes. Date Initiated: 08/27/2025-WANDER ALERT: Wander guard on L wrist Check device for placement every shift. Check function daily. Date Initiated: 08/27/2025On 10/06/25 at 4:42 PM, the facility submitted an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse report, identifying R7's elopement from the facility on 10/05/25 at 8:00 AM. The facility's report stated R7's wanderguard alarm worked properly at the time of the elopement but staff did not respond to the alarm either due to not hearing the alarm or were busy with other residents preparing for breakfast.Staff located R7 outside the front doors of the facility on the sidewalk, sitting in his wheelchair. R7 stated he was getting some fresh air. R7 was brought back into the facility, and there were no injuries. Review of the temperatures on 10/05/25 at 8:00 AM, were approximately 70 .Staff reported the incident to Director of Nursing (DON) B. DON B reviewed the facility's elopement policy and determined the elopement was not reportable.On 10/06/25 at 9:00 AM, Nursing Home Administrator (NHA) A reviewed the incident and determined it reportable, due to lack of supervision. NHA A reported the incident to the State Agency (SA) at 4:42 PM, outside of the regulatory timeframe for reporting of incidents.On 10/16/25, the Office of Caregiver Quality (OCQ) contacted NHA A via email requesting the facility's misconduct incident report, required within five business days of the incident.On 10/20/25, NHA A responded to OCQ via email, stating he submitted the misconduct incident report on 10/10/25, and stating the system did not work properly. NHA A did not use the email system available when there are issues submitting reports to the Misconduct Incident Reporting (MIR) system.On 10/21/25, NHA A submitted the misconduct incident report to the SA.On 01/05/2026 at 12:46 PM, Surveyor interviewed Certified Nursing Assistant (CNA) C. CNA C was working on 10/05/25, and reported she heard the alarm going off, but the alarms are hard to hear. CNA C was not sure how long the alarm was going off but responded as soon as she could. CNA C reported she found R7 outside of the front doors of the facility, without injury. CNA C reported this to the nurse right away. CNA C stated she could not remember if she was interviewed or provided a written statement.On 01/07/2026 at 7:28 AM, Surveyor interviewed DON B. DON B stated she did review the elopement policy on the day of the incident and determined she did not think it was reportable as R7 did not leave the property. DON B stated on 10/6/25, NHA A changed his mind and reported the incident because the resident was an elopement risk and did leave the facility.On 01/07/25 at 11:56 AM, Surveyor interviewed NHA A. NHA A stated he reported the incident on 10/06/25 due to lack of supervision to prevent R7 from exiting the facility. NHA A stated the initial report was probably not submitted timely. NHA A stated he did submit the misconduct incident report within five days but had difficulty with the system.

Based on interview and record review, the facility did not complete a thorough investigation of an injury for unknown origin for 1 of 1 resident (R)(R26) reviewed.On 12/06/25, R26 was noted to have an injury of unknown origin. Facility did not complete education for all staff on all potential causations of injury.This is evidenced by:R26 was admitted to the facility on [DATE] with pertinent diagnoses of vascular dementia severe with anxiety, Alzheimer's disease, fibromyalgia, weakness, contracture of muscle right thigh, contracture of muscle left thigh, contracture of muscle left lower leg, and contracture of muscle right lower leg.R26's most recent quarterly Minimum Data Set (MDS) assessment, dated 12/21/25 noted a Brief Interview of Mental Status (BIMS) score not completed due to resident rarely/never understood. R26 has ROM impairment of upper extremity on one side and impairment of lower extremities on both sides. R26 is dependent assist with all ADLs.R26's care plan, dated 03/04/21, with a target date of 12/23/25, states: Resident has ADL self-care deficit with interventions of transfer: hoyer and assist of 2.Of note: care plan does not indicate what size sling should be utilized for hoyer lift.Surveyor reviewed facility's self-report and noted:On 12/06/25, Registered Nurse (RN) E was notified by Certified Nursing Assistant (CNA) of bruises on R26's left arm and left breast and was noted to be pale in color and didn't eat breakfast. RN E notified Director of Nursing (DON) of findings and began investigation of injury of unknown origin and to monitor R26 for further changes. Interviews with staff and residents were completed. Provider and Power of Attorney (POA) were notified. On 12/08/25, R26 was noted to have worsening hematoma under left arm and left breast. Provider was notified and R26 was sent to ER for evaluation. ER determined R26 had an anterior left shoulder dislocation. ER contacted local police and Adult Protective Services. ER completed a shoulder reduction and R26 returned to facility with a left shoulder immobilizer in place until further orthopedic evaluation. Facility determined cause of injury was related to improper technique during upper body dressing of R26. Education was completed with CNA staff only on proper technique for dressing with impaired range of motion. Electronic total lift competency was completed with all nursing staff.Included in facility's investigation file was a disciplinary form for CNA D, dated 12/11/25. It noted improper transfer of resident with Hoyer lift. No additional information noted on what resident this was associated with. No additional education or training was documented for CNA D regarding safe transfers.Surveyor reviewed R26's hospital notes:12/08/25 Patient found to have a left shoulder dislocation. I do suspect that this was the cause to her left shoulder and arm ecchymosis.talked with nursing facility and they report the patient has had no falls or injuries. Patient is a hoyer lift. They suspected that she may have developed the bruising while they were transferring her. Spoke with patient's nephew her POA. He reports that he was not told of any injuries. I discussed with him my concern for potential abuse versus neglect as the patient is not ambulatory and has had no falls recently but has a dislocated shoulder. Adult protective Services and police were contacted to make a report.A police report was filed due to concern for possible elder neglect given the suspicious nature of the injury and delay in bringing her to care. However, this may have been sustained during a transfer or it could be related to her contractures and not related to overt abuse or neglect.Surveyor reviewed police report and noted:12/09/25: Officer spoke with facility staff and DON B regarding R26. DON B completed investigation and stated, they were not able to figure out how R26 obtained a dislocated shoulder and bruising on her elbow area. At this time, there is still no explanation to how R26 was injured. ER advised a report was generated and would be sent to appropriate agencies for follow-up. Facility was also advised of this information.Of note: no additional information was documented from police or other agencies.Surveyor reviewed facility's completed education and noted all CNAs were educated on proper techniques for dressing residents with limited range of motion. No education was completed with licensed nursing staff. Hoyer lift competencies were completed with all nursing staff. No abuse prevention education was completed.Surveyor reviewed R26's mobility assessments and noted that on 12/17/24, 03/18/25, 06/16/25, and 09/20/25 no impairment to upper extremity range of motion was documented.Surveyor reviewed R26's therapy noted and noted:09/10/25 OT: Reason for referral - patient presents to therapy due to contractures, difficulty with staff completion of ADLs including bathing and dressing. Cause of functional change: deficits with ROM contractures in BUEs with difficulty of staff completing ADLs including bathing and dressing.11/04/25 OT: Discharge from services. R26 goal to improve left elbow extension to 20 degrees for increased ease of dressing and bathing.-09/10/25 (baseline) can't extend L elbow past 40 degrees.-10/22/25 25 degrees extension passive ROM L elbow.-11/04/25 full extension with tendon pressure applied.OT goal: Patient will improve L shoulder flexion to 105 degrees PROM/AROM for increased ease of bathing and dressing.-09/10/25 (baseline) 85 degrees L shoulder flexion-10/01/25 met goalOT goal: Patient will improve L shoulder flexion PrOM to 110 degrees for increased ease of bathing and dressing tasks.-09/10/25 (baseline) 105 degrees-10/22/25 105 degrees, increased spasticity/tone on L side compared to R side.-11/04/25 110 degrees PROM L shoulderDischarge instructions: Patient will complete PROM/AROM as able all joints BUEs 3x/week for development of appropriate RNP/FmP for contracture management, ease of caregiver self care tasks, skin hygiene.Surveyor reviewed R26's weekly summary skin condition assessments:11/05/25 no skin impairments; no contractures present11/12/25 no skin impairments; no contractures present11/17/25 no skin impairments; no contractures present11/25/25 no skin impairments; no contractures present12/02/25 no skin impairments; no contractures present12/09/25 no skin impairments; no contractures presentOn 01/06/26 at 1:10 PM, Surveyor interviewed CNA D regarding R26's incident. CNA D stated that on 12/06/25 she did not complete upper body dressing as she worked 6 AM - 2 PM that day and the overnight shift from prior completed this task. Surveyor asked CNA D if any bruises or skin changes were observed. CNA D stated not looking at R26's upper body at all that day. CNA D stated she reported to the nurse that day of R26 acting differently and looking pale but had no awareness of a bruise on the left side. Surveyor asked CNA D if R26 had difficulty putting on shirt due to contractures. CNA D stated sometimes, but it wasn't usually a problem. Surveyor asked CNA D if R26 had any falls or concerns with equipment malfunctioning. CNA D stated no. Surveyor asked CNA D if she received any training or education on proper sling sizing and Hoyer lift use. CNA D stated yes, for Hoyer lift, but could not recall appropriate sling size education being completed.On 01/06/26 at 3:25 PM, Surveyor interviewed RN E regarding incident. RN E stated he was notified by CNA on PM shift on 12/06/25 about a bruise on R26's left arm. RN E stated he assessed a small bruise on the back side of R26's arm and nothing else. RN E then notified the DON of bruise and stated he was told to monitor it for worsening. Surveyor asked if RN E if he documented the size and location. RN E stated he thought so, but wasn't sure. Surveyor asked RN E if daily skin assessments are completed by the nurse. RN E stated that CNAs inform the nurse if there are any changes in skin condition. Surveyor asked RN E if R26 had any recent falls or injuries he was aware of. RN E stated no. Surveyor asked if R26 had any upper extremity contractures that would make dressing difficult. RN E stated no, that prior to the incident R26's arms moved really good and he didn't notice any difficulties.On 01/07/26 at 7:43 AM, Surveyor interviewed DON B regarding incident. Surveyor asked how the facility determined the cause reported as improper technique with upper dressing. DON B stated it was an assumption based on the ER report stating it could be from contractures and their interviews did not uncover any falls or equipment misuse. Surveyor asked DON B to show documentation of R26 having contractures prior to this incident. DON B was unable to provide documentation. Surveyor showed DON B the previous nursing documentation noting no contractures present. DON B stated being unaware of this. Surveyor asked DON B why a disciplinary form on CNA D was included in the facility's investigation file for the incident. DON B stated that during interview with CNA D, CNA D admitted to transferring R26 with the Hoyer lift by herself, and R26 was supposed to have 2 people assisting. Surveyor asked DON B if re-education on Hoyer lift transfers was completed with CNA D. DON B stated no because Hoyer lift competency had been completed and she did just fine. Surveyor asked DON B if it was possible that without noted contractures present in the upper extremities, was it then possible that actual neglect or some other action may have caused R26's injury. DON B stated yes that was why they completed education on dressing techniques with CNAs and did Hoyer lift competencies. Surveyor asked DON B if sling size education was completed with staff. DON B stated no, that a chart is in the utility room with the slings.

Based on interview and record review, the facility did not ensure a baseline care plan contained the minimum information to meet resident's immediate needs for 2 of 2 residents reviewed (R51 and R6).-Baseline care plan did not include weightbearing status related to broken humerus (R51)-Baseline care plan did not include immobilizer instructions/care (R51)-Baseline care plan did not include skin monitoring related to immobilizer (R51)-Baseline care plan did not include pain monitoring and interventions (R6) Findings include: Facility Policy titled, Care Plan Process, last revised on 11/17/23, reads in part: It is the policy of [name of facility] to develop an initial baseline care plan addressing the major area of risk within 48 hours of admission. Example 1 Occupational therapy notes from hospital, dated 12/29/25, stated R51 was to be non-weight bearing to right upper extremity and to wear immobilizer to right upper extremity at all times. Physical therapy notes from hospital, dated 12/29/25, stated, Non-weight bearing right upper extremity, shoulder immobilizer at all times. R51 was admitted to the facility on [DATE] with a right broken humerus. R51 was admitted to the facility with an immobilizer for the right upper extremity. On 01/05/26 at 10:41 AM, Surveyor interviewed R51. R51 stated the immobilizer R51 was wearing was to hold the right arm in place as it was broken. R51 stated the immobilizer was to stay on all the time. Surveyor reviewed R51's care plan. The care plan did not include any information regarding the use, care, or purpose of the immobilizer. The care plan did not include the non-weight bearing status to the right upper extremity. The care plan did not include skin monitoring related to wearing the immobilizer at all times. On 01/06/26 at 2:10 PM, Surveyor interviewed Certified Nursing Assistant (CNA) I. CNA I stated the immobilizer was on R51 to support R51's shoulder. CNA I stated R51 had a fall, and R51's arm got messed up prior to admission. CNA I stated the brace is taken off for cares with two people for stabilization and then placed back on. CNA I stated those instructions were given verbally from nursing staff. On 01/06/26 at 2:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN) G. LPN G stated LPN G would have to look in the chart for information or speak with management for instruction on R51's immobilizer. LPN G was unaware of the purpose of the immobilizer. On 01/06/26 at 2:19 PM, Surveyor interviewed LPN J. LPN J stated R51 had a brace related to a broken shoulder. LPN J stated the brace only gets taken off to wash arm and then goes back on. LPN J stated LPN J understood the brace would stay on until R51 goes back to the doctor and was unaware of when that would be. LPN J stated normally information regarding the brace would be found in the care plan. On 01/06/26 at 2:23 PM, Surveyor interviewed Director of Nursing (DON) B. DON B stated the orders for the immobilizer and weight bearing status had not been included on the after-visit summary upon admission. DON B stated the nursing staff should have clarified both the use of the immobilizer and the weight bearing status upon admission and added it to the care plan. DON B stated nursing staff performs weekly skin checks on bathing days but did acknowledge this should have been more frequently and added to the care plan. Example 2 R6 was admitted to the facility on [DATE]. Relevant diagnoses include fracture of upper end of left humerus, low back pain, chronic pain syndrome, unspecified pain. R6's Minimum Data Set (MDS) assessment completed on 12/4/25 indicated R6 scored 14/15 during Brief Interview for Mental Status (BIMS), indicating intact cognition. R6's orders dated 12/4/25 include: Hydrocodone- Acetaminophen 5/325 milligrams (mg) tablet orally every 12 hours as needed for pain. Non-pharmacologic interventions used before, as needed (PRN) pain medication and/or before PRN pain analgesic. Document number corresponding to interventions attempted in supplementary documentation. R6's medication administration record indicated R6 received Hydrocodone- Acetaminophen 5/325 milligrams (mg) tablet orally every 12 hours as needed and R6 was given this daily from 12/4/25 until 12/8/25. However, R6's pain assessments were only documented for 12/5/25 and 12/7/25 and were both rated at a pain level of 7 on a scale of 1-10. R6's Hydrocodone- Acetaminophen 5/325 mg tablet was discontinued on 12/8/25, and R6 was prescribed Oxycodone 5 mg every 6 hours for pain. This was given as scheduled with pain assessments that ranged from 0 to 6 and change to Oxycodone 5 mg every 6 hours as needed on 12/20/25. On 1/5/26, Surveyor reviewed R6's care plan. On 12/16/25, twelve days after R6 was admitted , a focus area of acute and chronic pain were added to R6's care plan. R6's care plan updated on 12/16/25 indicated R6 has acute pain related to humerus fracture, chronic pain related to kyphosis and history of spinal fractures. Goal, pain will be managed at a level of comfort. Interventions include, offer non-pharmacological interventions such as: repositioning, toileting, offering food or drink, massage, cold packs, relaxation techniques, activities, TV, 1:1. current pain management interventions, pharmacological and non-pharmacological interventions, timeframes, and approaches for monitoring the status of the resident's pain, including the effectiveness of the interventions.On 1/05/2026 at 12:25 PM, Surveyor interviewed R6, who reported R6 has almost constant pain. R6 states R6 does take pain medication but mostly at night because R6 does not like taking too much medication. R6 also reported R6 is often uncomfortable due to anxiety. R6 does not want to take anything for R6's anxiety. Surveyor asked R6 if staff offer alternative methods such as cold packs, conversation, or massage. R6 stated staff does not offer and they do not have time. R6 stated pain is on left side, which includes shoulder arm, and entire leg. Pain comes and goes in intensity. R6 stated pain is worse at night because R6 cannot reposition self in bed and staff does not come in to reposition R6. On 12/17/25, R6's provider note states in part, .Patient was seen today at the request of staff due to concerns regarding pain control and anxiety . Her pain is not well controlled . On 7/7/26 at 10:25 AM, Surveyor interviewed DON B about R6 pain not being in initial baseline care plan. DON B stated the expectation would be to have R6's pain and interventions in the initial base line care plan.

Based on interview and record review, the facility did not ensure care plans were revised to reflect residents' current needs and to provide the needed direction to staff in providing necessary care and services. The facility practice affected 1 of 13 resident care plans reviewed (R10).-R10's care plan was not revised after a fall. The facility policy titled, Care Plan Revision Upon Status Change, read in part, 1. The comprehensive care plan will be reviewed and revised as necessary, when a resident experiences a status change. D. The care plan will be updated with new or modified interventions.R10 was admitted to the facility on [DATE], diagnoses included Alzheimer's disease and history of falls. R10's Minimum Data Set (MDS) assessment completed on 05/02/25, confirmed R10 scored 06/10 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R10 uses a wheelchair for mobility and requires assistance from staff with all transfers. R10's care plan included: The resident is at risk for further falls recent fall r/t weakness, deconditioning, hx of falls and unaware of safety needs. Date Initiated: 09/27/2021 Revision on: 11/19/2022 -Resident will have no serious injury from a fall Date Initiated: 09/27/2021 Revision on: 08/01/2025 -Pressure alarms in W/C and recliner. Date Initiated: 01/29/2025 -Ensure that the resident is wearing appropriate-fitting clothing and footwear that fits well when ambulating or mobilizing in w/c. Date Initiated: 09/27/2021 Revision on: 11/06/2024 -Auto locks applied to W/C. Date Initiated: 10/02/2024-Dycem cushion in wheelchair to prevent from sliding forward. Date Initiated: 10/07/2024 -Encourage participation in activities that will increase strength and mobility. Date Initiated: 09/27/2021 -Evaluate, interview and document resident physical condition and cognitive status. Observe environment to identify any potential factors that could contribute to a fall, such as lighting, uneven/slippery/cluttered floor surfaces, improper footwear, failure to use assistive devices, etc. Remove any potential causes or hazards, if possible. Educate resident and caregivers of potential fall hazards for the resident. Date Initiated: 09/27/2021 -Invite, encourage, and assist resident to activities of preference. Date Initiated: 09/27/2021 -Invite, encourage, and assist the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility and balance. Date Initiated: 09/27/2021 -Make sure that brakes on bed are locked when resident is in bed. Date Initiated: 09/27/2021 -Provide resident with safe environment: clutter free; support/assistive devices are available and in good repair; personal items and call device within reach; non-glare soft lighting at night, etc. Date Initiated: 09/27/2021-PT to evaluate and treat as ordered. Date Initiated: 09/27/21-Remind resident to use assistive devices and to use call device for assistance. Date Initiated: 09/27/21 On 06/15/25, R10 sustained a witnessed fall in her room. R10 was evaluated in the emergency room and determined to have no injuries. R10's progress notes read, Nurse was called into room when entered room resident and CNA [Certified Nursing Assistant] where they were tangled up laying on the floor CNA was able to get repositioned and move away from the resident when attempted to help her she became vocal about her Ass hurting and when nurse questioned her she became verbally abusive. attempted to straighten out left leg and she screamed in pain noted left leg was shorter than right leg it was assisted that she would be transferred to the Hospital ER. placed call to POA [Power of Attorney] and left message called Poa Alt and she said it was OK to send her and she wanted a bed hold for her room Called 911 and Hospital and updated them. placed call to DON [Director of Nursing] and updated her Ambulance arrived and transported resident to ER.Surveyor noted R10's care plan was not updated after the fall, to help prevent further falls or accidents. On 01/07/26 at 7:28 AM, Surveyor interviewed DON B. Surveyor noted to DON B that R10's care plan did not reflect interventions after the fall. DON B did not have additional statements related to this.

Based on observation, interview, and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for two of three residents (R) reviewed for pressure injuries (R29 and R18.) R29 was admitted to the facility with no skin impairments and developed a stage 3 pressure injury to the coccyx area (tailbone) which remains unhealed, due to lack of comprehensive assessments, lack of timely care plan interventions, and lack of repositioning. This example is being cited at actual harm. Facility did not complete comprehensive assessment on admission of R18's present PIs and did not implement care plan interventions timely or follow the repositioning schedule to prevent a stage 2 pressure injury from occurring. Findings include: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, A pressure injury is defined as localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. Pressure injuries usually occur over a bony prominence but may also be related to a device or other object. Facility policy and procedure entitled Pressure Injury Prevention and Management, dated 08/02/24, states in part, .Assessments of pressure injuries will be performed by a licensed nurse, and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [Minimum Data Set] . R29 was admitted to the facility on [DATE] with the following diagnoses, in part, spina bifida (congenital disorder of the nervous system), morbid obesity, adult failure to thrive, changes in skin texture, history of diseases of the skin and subcutaneous tissue, and generalized muscle weakness. On 10/07/24 at 9:08 AM, Surveyor interviewed R29, who reported he had a sore on his bottom that the nurses are changing a bandage on daily. R29's admission MDS assessment, dated 12/05/23, stated R29 was completely dependent on caregivers for all Activities of Daily Living (ADLs) and all mobility. The MDS assessment also identified R29 was at risk for the development of pressure injuries but had no current unhealed pressure injuries. Under the skin and ulcer treatment section of the MDS assessment, no was marked for pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, and nutrition or hydration program to manage skin problems. There were no refusals or rejection of cares documented on the MDS. R29's MDS assessment, dated 08/12/24, identified R29 had one stage 2 pressure injury and one stage 4 pressure injury. Under the skin and ulcer treatment section of the MDS assessment, no was marked for pressure reducing device for chair, pressure reducing device for bed, and turning/repositioning program. Yes was marked for nutrition or hydration program to manage skin problems. There were no refusals or rejection of cares documented on the MDS. R29 had a Braden risk assessment score of 12 on 11/29/23. This identified R29 was high risk for developing pressure injuries. R29's Braden score was 9 on 08/09/24, which indicated R29 was very high risk for developing pressure injuries. R29's baseline care plan, dated 11/28/23, had nothing checked under current or history of skin integrity issues. R29 had the following care plan: The resident has potential for pressure ulcer development r/t [related to] Immobility, incontinence, weakness, diagnoses/medications that can/may affect skin integrity. Coccyx. Date initiated: 12/06/23. Revision on: 10/07/24 Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date initiated: 10/07/24 Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 12/06/23 Administer treatments as ordered and monitor for effectiveness. Date initiated: 12/06/23 APM [Alternating Pressure Mattress] on Bed to Alleviate Pressure. Date initiated: 10/07/24 Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date initiated: 12/06/23 Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date initiated: 12/06/23 Instruct and assist as needed to shift weight in W/C [wheelchair] q [every] 15 minutes. Date initiated: 12/06/23, revision on: 02/29/24 Monitor for s/sx [signs or symptoms] of infection: Redness, swelling, purulent drainage, warmth, tenderness or pain, Date initiated: 09/25/24 Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date initiated: 12/06/23 Nutrition Supplements Liqua Cell for wound healing. Date initiated: 10/07/24 Patient goes to wound clinic. Date initiated: 09/25/24 Roho W/c [wheelchair] Cushion. Date initiated: 09/25/24 Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date initiated: 12/06/23 The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned q4h per his request. Date initiated: 01/17/24 Surveyor identified a Weekly Summary-Skin Condition document, dated 02/07/24, that indicated R29 had no skin impairments. The only preventative measure currently in place was barrier cream, and R29 required the assist of two for repositioning. The Weekly Summary-Skin Condition document, dated 02/21/24, indicated R29 had no skin impairments. Preventative measures in place were turning/repositioning program, heels elevated when in bed, and barrier cream. The Weekly Summary-Skin Condition document, dated 03/13/24, indicated R29 had open lesions to the back of knees from sling. The only preventative measure currently in place was barrier cream, and R29 required assist of two for repositioning. There was a communication sent to the provider updating about the open areas. R29's skin integrity care plan was not updated. A physician's orders sheet from a Nurse Practitioner (NP), dated 03/21/24, identified R29 had unstageable pressure injuries to both lateral knees. The order sheet included Pad wheelchair sides where knees meet w/c to offload pressure. PT [physical therapy] involved to reduce pressure areas. R29's skin integrity care plan was not updated. The Weekly Summary-Skin Condition document, dated 03/22/24, identified R29 had pressure injuries to right and left lateral knees. Skin preventative measures checked included: special pressure relieving mattress, pressure relieving cushion in chair, pillows for repositioning, and barrier cream. R29's skin integrity care plan or treatment orders were not updated to reflect these interventions. There is no further documentation of assessments with description or measurements of the pressure injuries until 04/04/24. A Skin Only Evaluation document, dated 04/04/24, identified R29 had a newly identified stage 3 pressure injury to the coccyx measuring 2 centimeters (cm) long by 2 cm wide by 0.5 cm deep. The wound had undermining of 0.5 cm at 5 to 7 o'clock. There was a physician's order sheet dated 04/04/24 from the NP with orders for treatment of the new pressure injury to the coccyx. The orders also included: Dietician eval and treat for diet to enhance wound healing yet decrease caloric intake. There is no documentation of an evaluation by a dietician until 06/11/24. R29's skin integrity and nutrition care plans were not updated to reflect interventions for the new pressure injury to the coccyx to promote wound healing and prevent further breakdown. There was no documentation of assessments of R29's pressure injuries with staging, description of wounds, or measurements between 04/05/24 to 04/26/24. The next documentation of assessment of R29's pressure injuries was dated 04/26/24. The documentation identified the coccyx wound as a stage 4 pressure injury with measurements of 3 cm long by 3 cm wide by 3 cm deep. The documentation indicated the wound had tunneling and undermining 1 cm around 1 o'clock and 2 cm at 7 o'clock. It is of note that on 10/09/24 at 1:18 PM, Surveyor interviewed Registered Nurse (RN) C, who was the first nurse to document that R29's coccyx wound was a stage 4 pressure injury on 04/26/24. Surveyor asked RN C what they based that assessment on. RN C stated they labeled R29's coccyx wound stage 4 based on assessment by a wound care NP who made wound rounds in the facility on that date. RN C searched the medical record and found a handwritten order from the NP that documented Coccyx ulcer stage III . RN C stated they were in error and mistakenly documented R29's coccyx wound a stage 4. All weekly wound documentation between 04/26/24 through 09/13/24 labeled the coccyx wound stage 4. There was weekly documentation of assessment of the wounds with description and measurements that were essentially unchanged from 04/26/24 through 06/07/24. Surveyor identified a nutritional assessment completed by the dietician dated 06/11/24. The note identified R29 had several wounds and made recommendations for increasing a liquid protein supplement to three times per day and adding liquacel protein supplement twice per day. R29's skin and nutrition care plans were not updated to reflect these recommendations. The weekly wound documentation on 06/14/24 identified R29's coccyx wound had increased in size to 4 cm by 4 cm by 2.5 cm with undermining. There was weekly documentation with assessments and measurements of wounds that were essentially unchanged from 06/14/24 through 07/05/24. There was no documentation of wound assessments between 07/05/24 and 07/19/24. The weekly wound assessment documentation of R29's coccyx wound from 07/19/24 through 09/13/24 was essentially unchanged. All other pressure injuries were resolved by 09/13/24. Beginning 09/18/24, the facility began using a new system for documenting wounds and all weekly wound documentation and summaries were complete on the medical record from that date. The coccyx wound from that date going forward was staged as a stage 3 pressure injury. On 10/07/24, Surveyor observed R29 seated in wheelchair from 10:45 AM through 4:00 PM. On 10/08/24 at 10:26 AM, Surveyor observed RN C provide wound care for R29's coccyx wound. No concerns were identified with infection control or wound care procedure. The wound was observed to be a deep crater in the center of coccyx area. The wound bed appeared clean with minimal slough and no signs of infection. RN C stated Interim Director of Nursing (IDON) H would do wound care tomorrow with a full assessment of the wound with measurements. On 10/08/24, Surveyor observed R29 seated in wheelchair from 10:45 AM through 4:00 PM. On 10/09/24 at 9:33 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D and asked if they did any special turning or repositioning for R29. CNA D stated when R29 was in bed they offered to turn R29 about every 4 hours, but R29 spent most days up in the wheelchair all day from the time they got R29 up which was mid-morning today. On 10/09/24 at 10:42 AM, Surveyor interviewed IDON H who took over as interim DON in July. IDON H stated a different nurse was managing wound care at that time. IDON stated they did not discover there was a problem with wound assessments and documentation until September. Surveyor reviewed the documentation of R29's wound care described previously with IDON H. IDON H agreed the facility staff did not care for or document R29's wound appropriately to prevent development of pressure injuries and promote healing. 48793 Example 2: R18 was admitted to the facility on [DATE] with diagnoses including in part, vascular dementia, hemiplegia and hemiparesis cerebral infarction, dysphagia, osteomyelitis left elbow, pressure ulcer stage 4 left elbow, type 2 diabetes mellitus, heart failure, and benign prostatic hyperplasia with lower urinary tract infections. R18 was admitted with 3 PIs and facility did not identify location, sizes, or stages and is unclear determining the condition of the pressure injuries at admission. R18's Minimum Data Set (MDS) assessment, dated 01/11/24, identified on admission that R18 had a Brief Interview for Mental Status (BIMS) score of 08. This indicated R18 had moderate cognitive impairment. The MDS assessment also identified R18 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, eating, and for transfers. MDS also indicated that R18 was determined to be at risk for PIs and currently had one stage 4 PI. Surveyor reviewed R18's right gluteal and left buttock pressure injury care plan initiated on 04/25/24 and revised 10/07/24, in part: -Educate and encourage good nutrition and hydration in order to promote skin integrity initiated on 04/25/24. -Observe/identify/document potential causative factors for alterations in skin integrity. Eliminate/resolve where possible initiated on 04/25/24. -Reposition resident every 1-2 hours initiated on 04/25/24. -Wound dressing treatments per provider initiated on 04/25/24 and revised on 10/07/24. -Roho cushion in wheelchair initiated on 09/25/24. -APM for pressure reduction and prevent sheering initiated on 09/25/24. -Monitor for signs and symptoms of infection: increased warmth, redness, swelling, purulent drainage, pain or tenderness initiated on 09/25/24. -Nutrition supplement three times a day to promote wound healing initiated on 09/25/24. -Resident will not develop any further skin breakdown, redness, blisters, or discoloration initiated on 10/07/24. Surveyor reviewed R18's physician orders, which state in part: -On 02/08/24: position resident on his side for 1 hour post meals three times a day. -On 04/04/24: . MEASURE EACH WOUND WIDTH, LENGTH, DEPTH, AND DOCUMENT WOUND DESCRIPTION (DRAINAGE, COLOR, ODOR, ETC.), tunneling, and what wound care was provided. -On 09/05/24: Check inflation of high low ROHO cushion every day and adjust as necessary to limit pressure while up in w/c or recliner every morning and at bedtime for Pressure Ulcer. Two times a day for wound prevention. - On 09/25/24: Check Alternating Air Mattress for proper functioning every shift. Surveyor reviewed Braden score assessment dated [DATE] incomplete. Surveyor did not find R18's score to determine the risk of PIs and skin breakdown. Surveyor reviewed admission nurse progress notes, which state in part: -On 01/04/24, R18 has Deep tissue injury to the left elbow, stage 4, 2x1x1.2cm, open lesions in 4 places on left buttock. No thorough assessment including documentation of location of PI, PI measurements, or description of condition of PIs noted on admission. -On 01/27/24, R18 has left buttock open lesion 4cmx2cm, left buttock open lesion 3.5cmx2cm, left buttock open lesion 3cmx1cm, left buttock open lesion 6cmx3cm, left elbow pressure injury 2.5cmx1x0.5cm. The open areas on the buttocks are not called PIs, or staged. R18 was hospitalized [DATE] and returned on 1/29/24. -On 01/29/24, nurses note in part, R18 has left buttock open lesion 6cmx3cm left buttock open lesion 3.5cmx2cm, left buttock open lesion 3cmx1cm, left buttock open lesion 6cmx3cm, left elbow pressure injury stage 4 2.5cmx1x0.5cm. No new interventions were put into place for R18's pressure injuries. -On 02/15/24, R18's left buttock is assessed as stage 2 PI 1.7x1.1x0.1cm, left buttock is assessed as stage 2 PI 1x0.5x0.1cm, right buttock is assessed as stage 2 PI 3.5x2x0.1cm, new right buttock stage 2 PI 0.6X0.6cm., right posterior thigh PI stage 3, 4x1x0.2cm. Facility did not identify exact locations on left and right buttocks and is unclear determining the condition of the pressure injuries. No new interventions were put into place for R18's pressure injuries. -On 05/09/24, R18's Right posterior thigh PI stage II, 1x0.3cm. New right posterior thigh PI at stage 2 measures 3x5cm. This contradicts documentation in note on 2/15/24. Surveyor interviewed Interim DON H about this entry. Interim DON H stated they were stage 2 on admission, just not clearly documented. Facility did not identify wounds by numbers and is unclear determining the condition of the pressure injuries. No new interventions were put into place for R18's pressure injuries. -On 10/09/24, R18 has PI noted to the right gluteal fold buttock measures 0.3x1.1x0.1cm. Provider will be updated of new area assessed. Observations: On 10/07/24 at 9:28 AM, Surveyor observed R18 lying in bed. R18 appeared to be sleeping, but Surveyor observed R18 to have contracted hands bilaterally. Surveyor observed R18's bed positioned high and R18 lying supine on back in bed. On 10/07/24 at 9:56 AM, Surveyor observed R18 yelling for assistance from R18's room. On 10/07/24 10:07 AM, Surveyor observed Certified Nurse Assistant (CNA) F enter R18's room. R18 indicated R18 was cold and needed a blanket. CNA F gave R18 a blanket and exited R18's room. Surveyor observed R18 lying supine on back in bed. On 10/07/24 at 10:20 AM, Surveyor observed R18 yelling for assistance from R18's room. On 10/07/24 at 10:23 AM, Surveyor observed CNA D enter R18's room and ask R18 what R18 needed. R18 stated that R18 wants to get up out of bed. CNA D indicated to R18 that staff just laid R18 down in bed and would get R18 up before lunch. Surveyor observed R18 lying supine on back in bed. On 10/07/24 at 11:35 AM, Surveyor observed CNA D and CNA J transfer R18 via Hoyer lift to wheelchair. Surveyor did not observe R18 repositioned on side post meal for an hour or repositioned every 1-2 hours as the care plan instructs. Observations on 10/08/24: On 10/08/24 at 6:48 AM, Surveyor observed R18 sitting in wheelchair in dining room. On 10/08/24 at 8:00 AM, Surveyor observed R18 sitting in wheelchair in dining room. Surveyor did not observe R18 repositioned as ordered. On 10/08/24 at 9:05 AM, Surveyor observed R18 in wheelchair in room with call light attached. R18 utilized call light for assistance. CNA D entered and asked R18 what was needed. R18 indicated that R18 wanted to lie down in bed. CNA D exited R18's room. Surveyor did not observe R18 repositioned as ordered. On 10/08/24 at 9:08 AM, Surveyor observed CNA J and CNA D enter R18's room to transfer with Hoyer. On 10/08/24 at 9:18 AM, Surveyor observed R18 on back lying in bed. Surveyor did not observe R18 repositioned on side post meal for an hour as ordered. On 10/08/24 at 9:39 AM, Surveyor interviewed LPN G and RN C about R18's wound dressing changes. RN C indicated that LPN G would be doing wound rounds with Interim DON H tomorrow on Wednesdays. RN C indicated that R18's wounds are on both buttocks and left side opened is a stage 2. On 10/08/24 at 10:26 AM, Surveyor observed CNA J and CNA D enter R18's room and reposition R18 to right side slightly with pillow under left side. On 10/08/24 at 1:23 PM, Surveyor observed R18 lying in bed on back. R18's wife in visiting R18. Surveyor did not observe R18 repositioned on side post meal for an hour as ordered. On 10/08/24 at 2:12 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned on side post meal for an hour as ordered. On 10/08/24 at 2:43 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned every 1-2 hours as ordered. On 10/08/24 at 3:04 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned every 1-2 hours as ordered. On 10/08/24 at 3:33 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned every 1-2 hours as ordered. On 10/09/24 at 7:02 AM, Surveyor observed Interim DON H perform wound dressing change on R18. Interim DON H indicated through assessment and wound cleaning, R18 has a stage 2 PI, 1.6x1x1.0 cm of the left gluteal inferior area. On 10/09/24 at 10:20 AM, Surveyor interviewed CNA D and asked about repositioning R18. CNA D indicated that R18 is repositioned every 2 hours and as needed. Surveyor asked CNA D if R18 was repositioned every 2 hours for the past 3 days. CNA D indicated that R18 should be repositioned every two hours and has an air mattress in place. Surveyor asked CNA D if CNA D follows physician orders that indicates R18 should be repositioned onto side post meals for an hour three times a day. CNA D indicated that CNA D is unaware of this order and that staff make sure R18 is repositioned every 2 hours from side to side. On 10/09/24 at 10:24 AM, Surveyor interviewed Interim DON H and asked about repositioning R18. Interim DON H indicated that R18 is to be repositioned every 1-2 hours. Surveyor indicated to Interim DON H that R18 was not repositioned every 2 hours for the past 3 days. Surveyor did not observe R18 positioned off back and buttocks but twice in the last 3 days. Interim DON H indicated that R18 should be repositioned every 1-2 hours. Interim DON H indicated to Surveyor the physician order for repositioning on side for one hour post meals is a dumb order but will update care plan after verifying order is correct. On 10/08/24 at 3:09 PM, Surveyor interviewed Interim DON H and asked about wound documentation for R18. Interim DON H indicated that wound documentation has not been being recorded accurately and is in 4-5 different skin assessment sections throughout the electronic health record. Surveyor asked Interim DON H if R18 had pressure injuries on admission. Interim DON H was not here at that time. Interim DON H indicated that Interim DON H could not specify if R18's right posterior thigh was from admission or acquired in facility. Surveyor asked Interim DON H to clarify open areas. Interim DON H stated, [R18] has pressure injuries on buttocks that is being staged at a 2 and wound rounds weekly. Interim DON H indicated that once Interim DON H observed that wound care was not going the best, Interim DON H started a full facility skin sweep and implemented a PIP in September.

Based on interview and record review, the facility failed to ensure that written bed hold notice required for facility-initiated transfers was given to the residents or resident representatives for 5 of 6 residents reviewed for hospitalization (R10, R14, R25, R8, R15) This is evidence by: The facility's policy titled Bed Hold & Return to Facility with revised date of 05/03/24 documented, in part: It is the policy of this facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer. Example 1 R10 was admitted to the facility on [DATE]. R10's medical record documented diagnoses in part, dementia with behavioral disturbance, Alzheimer's, Parkinson's, UTI, sepsis, infectious gastroenteritis, dysphagia, and CVA. R10 was transferred to the emergency department on 04/26/24 for right lower quadrant pain and was admitted to the hospital. Surveyor requested a copy of the bed hold notice that was given to R10's legal representative. Director of Nursing (DON) B indicated no notice was given. Example 2 R14 was admitted to the facility on [DATE]. R14's medical record documented diagnoses in part: fracture part of neck of right femur, dislocation of internal right hip prosthesis, muscle weakness, chronic lymphocytic leukemia of b-cell type not having achieved remission, peripheral venous insufficiency, dementia mild with behavioral disturbance, pain, repeated falls, dizziness and giddiness, and anxiety. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07. This indicated R14 had severe cognitive impairment. The MDS documented R14 had inattention and disorganized thinking. R14's medical record documented transfer to the emergency roiagnom on [DATE], 06/25/24, and 07/03/24. The medical record did not document a written bed hold notice was given to R14's legal representative. Surveyor requested a copy of the bed hold notice that was given to R14's legal representative. Director of Nursing (DON) B indicated no notice was given. On 10/08/24 at 1:30 PM, Surveyor interviewed Interim Director of Nursing (DON) H about the written bed hold notices not being done. Interim DON H stated he talked with Social Services (SS) K and asked if SS K was doing the notices. SS K told Interim DON H that she was not doing the notices and DON B was doing the notices. Interim DON H indicated the social worker should be following up with the notices. On 10/08/24 at 2:32 PM, Surveyor interviewed SS K about the written bed hold notice being given to residents or representatives. SS K stated she had not given residents or representatives written bed hold notices. SS K stated nursing had done the portion of giving the notices and the last DON was doing the notices and following up. 40181 Example 3 Record review identified R25 had a change in condition with shortness of breath and chest pain noted on 06/08/24. An on-call provider was notified and R25 was transferred to the emergency room and later admitted to the hospital. R25 remained in the hospital until 06/11/24. On further record review, Surveyor was unable to find a written bed hold notice provided to R25's representative. 48793 Example 4 R8 was hospitalized from 07/30/24 to 08/07/24 for kidney stone blockage. R8 was hospitalized from 08/22/24 - 08/30/24 due to urosepsis. No written notice of bed hold policy was identified during review of R8's medical record. Surveyor requested a copy of the written notice of bed hold policy. On 10/09/24 at 2:16 PM, Interim DON H reported they did not do a written notice of transfer form for bed hold. DON B stated they are starting a process to fix this non-compliance. 49353 Example 5 R15 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus, atrial flutter, and congestive heart failure. R15's Minimum Data Set (MDS) assessments indicate that R15 was discharged to the hospital on 09/05/24 and returned to the facility on [DATE]. Nurse note dated 09/05/24 stated that R15 was sent to the Emergency Department (ED) via ambulance for vomiting. Nurse note dated 09/07/24 stated that R15 was admitted to the hospital for pneumonitis due to inhalation of food/vomit. On 10/08/24 at approximately 1:00 PM, Surveyor requested bed hold notice documentation for R15 provided to the resident and/or representative at the time of the transfer or within 24 hours of the transfer. Interim Director of Nursing (DON) H stated inability to locate bed hold notification provided to the resident and/or representative at the time of the transfer or within 24 hours of the transfer.

Based on interview and record review, the facility did not notify the resident/representative in writing of the reason for the transfer/discharge for 5 of 6 residents reviewed who were discharged (R10, R14, R25, R8, R15). This is evidenced by: The facility's policy titled Resident [NAME] of Rights documented, in part: 14. Transfer and Discharge .Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident, of the transfer or discharge and the reasons, proposed date and location of transfer; record the reasons in the resident's clinical records; and include in the notice . Example 1 R10 was admitted to the facility on [DATE]. R10's medical record documented diagnoses in part, dementia with behavioral disturbance, Alzheimer's, Parkinson's, UTI, sepsis, infectious gastroenteritis, dysphagia, and CVA. R10 was transferred to the emergency department on 04/26/24 for right lower quadrant pain and was admitted to the hospital. Surveyor requested a copy of the notice for reason of transfer that was given to R10's legal representative. Director of Nursing (DON) B indicated no notice was given. Example 2 R14 was admitted to the facility on [DATE]. R14's medical record documented diagnoses in part: fracture part of neck of right femur, dislocation of internal right hip prosthesis, muscle weakness, chronic lymphocytic leukemia of b-cell type not having achieved remission, peripheral venous insufficiency, dementia mild with behavioral disturbance, pain, repeated falls, dizziness and giddiness, and anxiety. The Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07. This indicated R14 had severe cognitive impairment. The MDS documented R14 had inattention and disorganized thinking. R14's medical record documented transfer to the emergency roiagnom on [DATE], 06/25/24, and 07/03/24. The medical record did not document a written reason for transfer notice was given to R14's legal representative. Surveyor requested a copy of the notice for reason of transfer that was given to R14's legal representative. Director of Nursing (DON) B indicated no notice was given. On 10/08/24 at 1:30 PM, Surveyor interviewed Interim Director of Nursing (DON) H about the written notices of transfer not being done. Interim DON H stated he talked with Social Services (SS) K and asked if SS K was doing the notices. SS K told Interim DON H that she was not doing the notices and DON B was doing the notices. Interim DON H indicated the social worker should be following up with the notices. Surveyor explained the facility's notices include the reason for transfer along with the bed hold notice and asked if the reason for transfer was provided in another manner. Interim DON H indicated was not aware of the written notification of transfer. On 10/08/24 at 2:32 PM, Surveyor interviewed SS K about the written notice of transfer. SS K stated she had not given residents or representatives written notices of transfers. SS K stated nursing had done the portion of giving the notices and the last DON was doing the notices and following up. 40181 Example 3 Record review identified R25 had a change in condition with shortness of breath and chest pain noted on 06/08/24. An on-call provider was notified and R25 was transferred to the emergency room and later admitted to the hospital. R25 remained in the hospital until 06/11/24. On further record review, Surveyor was unable to find a written notice of reason for transfer provided to R25's representative. 48793 Example 4 R8 was admitted to the facility on [DATE] with the following diagnoses in part, diabetes mellitus type 2, candidal sepsis, acute pyelonephritis, chronic kidney disease, and muscle weakness. Record review identified R8 was hospitalized on [DATE] - 08/30/24 due to urosepsis. Surveyor was unable to locate a written notice of discharge/transfer form for this hospitalization on R8's medical record. On 10/09/24 at 9:29 AM, Surveyor requested a copy of the written notice of discharge or transfer and documentation of ombudsman notification for R8's transfer to the hospital on 08/22/24. On 10/09/24 at 2:16 PM, Interim DON H reported they did not do a written notice of transfer form for R8's hospital transfer. DON B stated they are starting a process to fix this non-compliance. 49353 Example 5 R15 was admitted to the facility on [DATE] with pertinent diagnoses of diabetes mellitus, atrial flutter, and congestive heart failure. R15's Minimum Data Set (MDS) assessments indicate that R15 was discharged to the hospital on 09/05/24 and returned to the facility on [DATE]. Nurse note dated 09/05/24 stated that R15 was sent to the Emergency Department (ED) via ambulance for vomiting. Nurse note dated 09/07/24 stated that R15 was admitted to the hospital for pneumonitis due to inhalation of food/vomit. On 10/08/24, Surveyor was unable to locate a written notice of discharge/transfer form for this hospitalization . On 10/08/24 at approximately 1:00 PM, Surveyor requested a transfer notice from Interim Director of Nursing (DON) B for R15's transfer to the hospital on 09/05/24. Interim DON B stated inability to locate a transfer notice.

Based on observation, interview and record review, the facility did not ensure residents (R) were treated with respect and dignity and cared for in a manner to enhance their quality of life. Facility staff used clothing protector to wipe resident's face while assisting to eat. This affected 3 of 3 residents observed. (R13, R18, and R17) This is evidenced by: Example 1 Facility's policy titled Resident [NAME] of Rights documented in part: Quality of Life, 19. Dignity, The facility must promote and care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. R13's medical record documented current diagnoses including in part, Alzheimer's disease, major depressive disorder, dysphagia following cerebrovascular disease, CKD stage 3A, dementia, and mild protein-calorie malnutrition. R13's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented R13 having severe impaired cognition and dependent on staff for meal assistance. On 10/08/24 at 8:48 a.m., Surveyor observed Certified Nursing Assistant (CNA) I assist R13 with breakfast meal. R13 receives meal pureed in cups and staff assist R13 to drink the meal. While CNA I was assisting R13 with breakfast meal, CNA I used R13's clothing protector to clean R13's mouth. This continued for the entire breakfast meal. Surveyor observed an unused napkin on the table that was provided with R13's meal. Example 2 R18's medical record documented current diagnoses including in part, vascular dementia, hemiplegia and hemiparesis cerebral infarction, dysphagia, osteomyelitis left elbow, pressure ulcer stage 3 left elbow, type 2 diabetes mellitus, heart failure, and benign prostatic hyperplasia with lower urinary tract infections. R18's MDS assessment, dated 01/11/24, identified on admission that R18 had a Brief Interview for Mental Status (BIMS) score of 08. This indicated R18 had moderate cognitive impairment. The MDS assessment also identified R18 required total dependent assistance for eating. On 10/08/24 at 8:52 a.m., Surveyor observed CNA E assisting R18 with breakfast meal. While CNA E was assisting R18 with the breakfast meal, CNA E was using R18's clothing protector to clean R18's mouth. Surveyor observed an unused napkin on the table that was provided with R18's meal. Example 3 R17 was admitted to the facility on [DATE] with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and dysphagia. R17's MDS assessment, dated 08/17/24, identified that R17 had a BIMS score of 12. This indicated R17 had moderate cognitive impairment. The MDS assessment identified R17 had impairment to one side of the upper extremities and required supervision and touching assistance with eating meals. On 10/08/24 at 8:56 a.m., Surveyor observed CNA D approach R17 and asked if R17 was completed with breakfast. CNA D assisted taking off R17's clothing protector and wiped R17's mouth with the clothing protector. Surveyor observed R17 had a paper tissue and napkin in lap which R17 had used prior to wipe mouth. On 10/09/24 at 10:53 AM, Surveyor interviewed R17 about the observation of staff wiping her face with the clothing protector. R17 stated she did not like when staff use the clothing protector to wipe her face. R17 indicated she uses a napkin or tissue to wipe her face and it was not dignified to use the clothing protector. On 10/09/24 at 12:30 p.m., Surveyor interviewed Interim Director of Nursing (DON) H and asked if staff are to use clothing protector to wipe residents' mouths. Interim DON H indicated staff should be using a napkin. Education will be provided to staff.

Based on interview and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 3 of 3 residents (R) reviewed who smoke (R1, R2, and R3). R1 was given smoking materials and exited the building to smoke. Nursing staff did not turn off or remove R1's oxygen before R1 exited the building. R1 received first and second degree burns to the face as a result of attempting to light a cigarette while receiving oxygen therapy via nasal cannula. There was a reasonable likelihood for even more serious harm given the dangers of smoking in an oxygen-enriched environment. Facility failure to assess R1's safety to smoke independently or implement a plan to ensure R1's smoking safety, and failure to remove R1's oxygen prior to allowing R1 to exit the building to smoke created a finding of immediate jeopardy that began on 06/10/23. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 07/05/23 at 3:05 PM. The immediate jeopardy was removed on 06/13/23; however, the deficient practice continues at a scope/severity of D as the facility continues to implement its action plan and as evidenced by facility failure to conduct recent smoking assessments for R2 and R3: Findings include: According to the [NAME] Point Fire Department, there is no safe setting for smoking with oxygen on. The United States has approximately 70 deaths and 1200 injuries per year due to smoking with oxygen. https://www.facebook.com/stevenspointfire/videos/deadly-the-effects-of-smoking-with-home-oxygen-[NAME]-point-fire-demonstration/646055859856441/ According to information from OSHA, a normal environment is one that is comprised of 16.5 - 23% oxygen. This level changes to one of oxygen-enrichment both around the oxygen tank, because of the venting that occurs, and around the nasal cannula. An oxygen-enriched environment makes the air highly combustible and makes burning more efficient. A spark from a match, a lighter, or a cigarette, could cause lit materials to combust and burn more vigorously and hotter (between 1500 - 3000 degrees F.) This could cause serious burns to an individual's skin, throat and lungs. As a result, various sources advise keeping flames five to six feet away from anyone receiving oxygen. One oxygen concentrator supplier writes: We always advise against smoking while using an oxygen concentrator, or any oxygen therapy equipment, because if a spark catches the oxygen and has a fuel source, it will ignite and spread extremely fast. The fuel source can be anything from a small patch of dry grass, a carpet, or your clothing or hair. When a fire comes in contact with pure oxygen, like that from an oxygen concentrator, it will burn much hotter because fire needs oxygen to burn. When more oxygen is present, it can become out of control in the blink of an eye. Please be safe and do not smoke at all while you are using your portable oxygen concentrator if you are indoors or outdoors. We advise you to keep at least a 10-foot radius from others who are smoking, or from campfires or other open flames. https://www.oxygenconcentratorstore.com/blog/user-question-can-smoking-outside-with-a-portable-oxygen-machine-be-dangerous/ The facility policy, entitled Smoking/Clean Air/Use of Tobacco and Related Products, dated March 2023, states: .The use of tobacco products (smoking or chewing), is prohibited in the building and on campus. There are no designated smoking areas on campus, so smokers must go to the public sidewalk to smoke .If a resident desires to smoke, A. A smoking assessment will be done to determine safety issues. If deemed safe to be independent, a smoking plan will be developed .V. ALL smoking/e-nicotine/vaping/tobacco supplies will be kept at nurse station. A. Resident/resident representative must check in with nursing prior to leaving on a smoking outing to receive any necessary safety training, to include but not limited to: Need for smoking apron, ash tray and removal of Oxygen tank if applicable . R1 was admitted to facility on 03/09/23 and had diagnoses including in part: congestive heart failure, chronic obstructive pulmonary disease with dependence on oxygen, hypertension, shortness of breath, muscle weakness, and unsteadiness on feet. R1's admission Minimum Data Set (MDS) assessment, dated 03/14/23, indicated R1's Brief Interview for Mental Status (BIMS) score was 14. This score indicated R1 was cognitively intact. The MDS assessment also indicated R1 had current use of tobacco products. R1's medical record identified a physician order for oxygen continuously via nasal cannula at 2 liters per minute to keep oxygen saturation levels greater than 90%. Review of R1's medical record showed no smoking safety evaluation was completed at the time of R1's admission to the facility. There was no smoking plan to address R1's safety with smoking added to R1's comprehensive care plan at the time of admission. A nursing progress note, dated 06/10/23, indicated at approximately 11:00 PM, R1 went outside to smoke a cigarette. Nursing staff gave R1 smoking materials and a call pendant and assisted R1 out of the building. R1 propelled self in wheelchair to the public sidewalk. A few minutes later R1 called for help and told staff they forgot to take the oxygen off before lighting a cigarette and started a fire. R1 denied pain but reported shortness of breath. The note indicated R1 had soot inside throat and both nostrils, and eyebrows, facial hair, and hair on forehead were singed. The note also indicated R1 had superficial burns on the face where the oxygen tubing touched skin. Emergency Medical Services was called and R1 was transported to the local emergency department for evaluation. The emergency room (ER) note identified a final diagnosis of facial burns, first and second degree burns to both cheeks. R1 was evaluated in the ER for approximately one hour and had no intraoral swelling and denied shortness of breath or difficulty breathing. R1 was discharged back to the facility with orders for bacitracin ointment to facial burns. The witness statement from Licensed Practical Nurse (LPN) C, who cared for R1 on the evening of 06/10/23, stated in part, .[R1] is also reminded to take oxygen off when smoking. I have attempted to take off oxygen previously for [R1], but [R1] stated that he needs to catch his breath before smoking. This is the usual process for when he would like to go outside to smoke .I also told [R1] before I left to take off his oxygen . Surveyor attempted to interview LPN C but did not receive a call back. On 07/05/23 at approximately 8:10 AM, Surveyor interviewed NHA A who reported the facility became a no-smoking campus approximately one year ago. R1 was informed of that when admitted to the facility and agreed to the no-smoking policy. NHA A stated some time after admission R1 began to request to go out for a cigarette late in the evenings after a bath. NHA A did not know for sure but assumed a safe smoking evaluation was completed to determine R1 was safe to smoke independently on the public sidewalk in front of the building. NHA A stated nursing staff was supposed to turn off R1's oxygen before R1 went outside to smoke. On 07/05/23 at 9:10 AM, Surveyor interviewed R1 about the smoking accident on 06/10/23. R1 stated prior to the accident R1 smoked 1 or 2 times per day in the evening. R1 was told the facility was a no-smoking facility but residents could smoke independently on the sidewalk across the parking lot. R1 did not remember any staff doing a smoking safety assessment prior to allowing R1 to smoke independently. R1 stated the nurse would give R1 a cigarette and lighter and usually a Certified Nursing Assistant (CNA) would assist R1 out of the building. Staff would give R1 a button to push when ready to come back in. R1 stated R1 would take the oxygen off when out on the sidewalk because could not tolerate having the oxygen off while propelling self to the sidewalk in the wheelchair. R1 did not remember nursing staff ever turning off the oxygen or removing the oxygen tubing prior to R1 leaving the building to smoke. R1 stated the nurse would just remind R1 to remove the oxygen before smoking. R1 stated R1 forgot to do that before lighting the cigarette on 06/10/23 and there was a flash of fire in R1's face. R1 stated they went to the ER for evaluation and had minor burns to the face, but nothing more. R1 stated they quit smoking after that accident. On 07/05/23 at 9:40 AM, Surveyor interviewed Registered Nurse (RN) D about R1's smoking accident. RN D stated they were not working when the accident happened but were aware of the incident. RN D was aware that R1 smoked and said R1 was alert and independent and went out to the sidewalk to smoke independently. RN D was unsure if a safe smoking evaluation was completed prior to allowing R1 to smoke independently. RN D was unsure if R1 had a smoking care plan in place prior to the accident on 06/10/23. RN D stated nursing staff was supposed to make sure R1 took off the oxygen before smoking. RN D stated after the accident all staff were required to watch an educational video about the dangers of smoking with oxygen on and complete a quiz. Staff were also required to review and sign off on the revised facility smoking policy. RN D stated the new policy requires all residents who smoke to wear a protective smoking apron when smoking. If the resident requires oxygen, staff need to remove the oxygen tank and tubing from the resident's wheelchair and make them wait 10 minutes before smoking. If they cannot tolerate having the oxygen off that long, they will not be allowed to smoke. On 07/05/23 at 10:08 AM, Surveyor interviewed DON B about the facility's smoking policy and R1's incident on 06/10/23. DON B stated if a resident was alert and oriented and determined to be independent, they would be allowed to go out to the public sidewalk to smoke. Surveyor asked if R1 had a safe smoking evaluation done or a smoking care plan in place prior to his being allowed to go out to smoke independently. DON B stated no safe smoking assessment was done for R1 and no smoking care plan was in place prior to R1's smoking incident on 06/10/23. DON B stated R1's smoking materials were kept in the nurse station and nursing staff would turn off R1's oxygen when they gave the smoking materials to him. DON B stated on the evening of 06/10/23, R1 refused to let the nurse turn off the oxygen prior to leaving the building and the nurse reminded R1 to turn off the oxygen prior to smoking. DON B stated R1 forgot to turn off the oxygen prior to lighting the cigarette. DON B stated after the accident R1 decided to quit smoking. DON B stated they have revised the facility smoking policy, which all staff were required to read and sign off. They provided an educational video on the dangers of smoking with oxygen with a follow-up quiz that all staff were required to complete on 06/13/23. The failure to assess R1's safety to smoke independently or implement a plan to ensure R1's smoking safety, and the failure to remove R1's oxygen prior to allowing R1 to exit the building to smoke created a reasonable likelihood for serious harm and led to a finding of Immediate Jeopardy. The facility removed the jeopardy on 06/13/23 when it had completed the following: 1. Revised facility policy and procedure Smoking/Clean Air/Use of Tobacco and Related Products to include: Anyone who smokes and is on oxygen has to have oxygen off for at least 10 minutes before smoking. Oxygen device and tubing must be removed and placed 6-10 ft away from resident while smoking. 2. Educated all staff on revised policy and procedure. 3. Educated all staff on dangers of smoking with oxygen with a video and printed materials followed by a quiz to verify competency. Revised facility policy entitled Smoking/Clean Air/Use of Tobacco and Related Products, last revised June 2023. The policy states in part, .If a resident desires to smoke, A. A smoking assessment will be done to determine safety issues. If deemed safe to be independent, a smoking plan will be developed to include but not limited to: .6. If someone uses oxygen and insists on smoking, use the Ten Minute Rule. a) Turn off the oxygen supply and wait at least 10 minutes for high oxygen concentrations of oxygen to dissipate before going outside to smoke. This will reduce risk of fire or serious burns to the face or body if clothing ignites. It is the RN or LPN's responsibility to monitor at least 10 minutes have passed. 1. If a resident is unable to be without oxygen for 10 minutes, he/she cannot be given smoking materials due to the danger of residual high concentrations of oxygen that may still be on the resident and his/her hair, clothing, etc. b) The oxygen tank/concentrator must be removed before the resident is handed his/her cigarettes and lighter. C) Keep oxygen at least 10 feet away from possible ignition sources like cigarettes, matches, lighters. 7. WARNING: Only after the resident has had the oxygen removed for 10 minutes and the oxygen tank/concentrator is at least 10 feet away, then the staff may give the resident the cigarette and lighter . The record identified R1 had a Smoking Safety Evaluation completed on 06/13/23, after the incident occurred. The evaluation noted the following abnormalities: Balance problems while sitting or standing and follow the facility's policy on location and time of smoking. The clinical suggestions stated Resident deemed unsafe to smoke. Refer to Interdisciplinary team. A use of tobacco products focus was added to R1's comprehensive care plan on 06/13/23, after the incident. The care plan stated in part, .[R1] can smoke SUPERVISED only after oxygen has been removed for at least 10 minutes and oxygen tank/concentrator and tubing are at least 6-10 feet away from [R1]. If [R1] cannot tolerate being off oxygen for 10 minutes prior to and during smoking, then [R1] will not be able to smoke due to dangers of fire. [R1] decided to completely quit smoking 06/12/23 . The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) based on the following examples: Surveyor reviewed two other residents in the facility who smoke. R2 was admitted to the facility on [DATE] with diagnoses including in part heart failure and chronic obstructive pulmonary disease. R2's BIMS score on 05/23/23 was 14, indicating R2 was cognitively intact. R2 had orders for oxygen as needed. The most recent Smoking Safety Evaluation on R2's medical record was dated 07/15/21 and R2 was deemed safe to smoke independently. R2 had a care plan initiated on 06/14/21 which stated R2 was able to use tobacco products independently without adaptations or supervision off facility property. The care plan had the following intervention initiated 06/14/23: .Staff will review smoking assessment quarterly at care conference to ensure resident safety with smoking. On 07/05/23 at 9:05 AM, Surveyor interviewed R2 who reported they only smoke a cigar on Sundays. R2 stated they can go outside independently to smoke. Surveyor observed a half-smoked cigar on the bedside table. R2 stated they bring the unlit cigar back to the room to chew on for a while after smoking. R2 stated all other smoking supplies were kept locked at the nurse station. R2 stated they only use the oxygen as needed and it always stays in the room when R2 goes outside to smoke. R3 was admitted to the facility on [DATE] with diagnoses including in part heart failure and chronic obstructive pulmonary disease. R3's BIMS score was 15 on 03/22/23, indicating R3 was cognitively intact. Record review identified the most recent Smoking Safety Evaluation was completed on 08/30/22. R3 had a smoking care plan which was initiated on 06/13/23. On 07/05/23 at 12:48 PM, Surveyor interviewed R3 who reported they were only allowed to smoke 2 cigarettes per day and had smoked those prior to returning from dialysis center. R3 said all smoking materials were kept locked at nurse station. R3 stated a staff member gives R3 cigarette and lighter, helps R3 outside and puts a protective apron on R3 before R3 smokes. R3 did not know if anyone did a safe smoking assessment for him. On 07/05/23 at 1:42 PM, Surveyor interviewed DON B who stated no Safe Smoking Evaluation had been completed for R2 since 07/05/21 and no Safe Smoking Evaluation had been completed for R3 since 08/30/22. Surveyor asked how often the Safe Smoking Evaluation should be completed for residents who smoke. DON B stated the Safe Smoking Evaluation should be reviewed at least quarterly. Surveyor asked DON B if R3 had a smoking safety care plan in place prior to 06/13/23. DON B stated there was no smoking safety care plan in place for R3 prior to 06/13/23. Surveyor asked DON B if they were doing any formal audits or keeping any documentation to ensure staff were following revised smoking procedures since the smoking policy was updated on 06/13/23. DON B stated they were not doing any formal audits of procedures when residents smoked.

Based on observation, interview and record review, the facility did not ensure a resident who entered the facility without a pressure injury did not develop a pressure injury; and a resident with a pressure injury receives the necessary treatment to promote healing and prevent infection. This occurred for two of six residents with pressure injuries (Residents (R) 13 and 195). 1. R13 is at high risk for developing pressure injuries and developed an unstageable pressure injury to the left heel. The facility did not follow current standards of practice to prevent pressure injuries from occurring with repositioning, and offloading. The facility did not assess and measure the wound every seven days, and did not made a podiatry referral in a timely manner. The resident's care plan was not updated to identify the location of the resident's pressure injury, and to include all current interventions to prevent further skin breakdown. 2. R195 is a high risk for developing pressure injuries. The resident developed an infected pressure injury to the outer right foot, which resulted in an amputation of the resident's fifth toe. There is no documentation the resident's feet were inspected daily, or the padded boots were applied at all times. The facility did not assess and measure the wound every seven days. The resident's care plan was not updated to identify the resident required a toe amputation due to a pressure injury, and to include all current interventions to prevent further skin breakdown. This is evidenced by: According to the National Pressure Ulcer Advisory Panel (NPUAP) standard of practice, .Repositioning for Preventing Heel Pressure Ulcers 1. Ensure that heels are free of the surface of the bed Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf . (NPUAP Heel Pressure Ulcers: 2014 International Pressure Ulcer Prevention & Treatment Guidelines, 2014). 1. On 05/14/18, Surveyor reviewed R13's medical record. The resident has [DIAGNOSES REDACTED]. The resident's most recent Brief Interview for Mental Status (BIMS) score, dated 03/19/18, was a 11 out of 15 total points. According to the BIMS assessment, a score of 11 indicates the resident has moderately impaired cognition. R13 is able to make his own healthcare decisions. The medical record indicates R13 requires assistance with bed mobility, transfers, personal hygiene, and requires the assistance of two staff members with ambulation. The resident was admitted to the facility on [DATE] with a femur fracture. R13's 4 Day Admission assessment form, dated 12/20/18, identifies the resident had no skin breakdown on the feet or heels. The assessment indicates R13 had 3+ [MEDICAL CONDITION] (by pressing a finger for five seconds into a person's skin causing an indentation, it takes approximately 30 seconds for the skin to rebound back) to the left foot from the knee to the foot. R13's initial Minimum Data Set (MDS), dated [DATE], identifies the resident is at risk for developing pressure injures. The assessment indicates the resident has no current unhealed pressure injuries. Surveyor reviewed the resident's nurses' and wound notes from 12/20/17 to 05/16/18. The notes state the following, in part: -12/20/17: .Resident is transferred with contact guard assist of two and walker. Up per wheelchair with elevated foot rests .LOWER EXTREMITY CONCERNS .[MEDICAL CONDITION] .Resident is at risk for alteration in skin integrity due to decreased mobility secondary to left hip fx (fracture). Resident requires two assist for transfers .Resident will be assisted with .position changes while in bed and wheelchair. Legs elevated due to hip fx and [MEDICAL CONDITION]. Family state [MEDICAL CONDITION] has been chronic. Skin is monitored for breakdown with AM and PM cares including feet . There is no documentation or care plan which indicates how often R13 is being repositioned by staff in the bed or wheelchair. -12/25/17: .Upset this am as he stated to staff that he was left in his wheel chair all night. Staff did am cares this am and got him to breakfast, resident did lay down and elevate his legs once he was through . There is no investigation or documentation in the resident's medical record if the resident was in fact up in the wheelchair all night. -12/26/17: Note: Bed positioning; as client tolerates- 1 pillow for head, elevated head of bed as client feels comfortable. Keep lower bed flat if tolerated for hip and knee position at neutral .(name of Physical Therapy Assistant) There is no documentation in the medical record R13's heels were being floated at this time, since admission. -12/29/17: .INCIDENT TYPE .fluid filled blister to left heel. Assessment of Skin incident: resident had a hip surgery prior to admission and to maintain hip precautions resident is on his back most times. This am during his bath the bath aid called writer in to assess and found a 4 cm (centimeter) in diameter fluid filled blister to posterior (back) left heel. A heel dressing was placed for protection under his tubi grip and blue boots will be applied when in bed .INTERVENTION: blue boot to be worn while in bed to relieve any possible pressure .RESIDENT .Cognitive-Alert JUDGEMENT: Good judgement COMMUNICATION: Makes needs known .physician notified .instructed resident on wearing blue boots in bed . Surveyor reviewed a facility Skin Report form, dated 12/29/17, with nursing staff witness statements. The form and witness statements state the following, in part, .Incident Type .fluid filled blister to left heel .resident had a hip surgery prior to admission and to maintain hip precautions resident is on his back most times .POSSIBLE CAUSE .laying on back in bed .Witness Interview Form (Completed by Registered Nurse (RN) H) .Why did this occur (if known): laying (illegible) on back due to hip repair . -01/03/18: .Weekly Assessment ONSET/DISCOVERY DATE: 12/29/2017 .Late entry for: 01/02/2018 WOUND TYPE: Pressure (Injury) Stage 2 .left heel .dry hardness/indurating entire rim is raised and hard .EXUDATE (drainage): Scant-very moist in appearance Drainage < (less than) 25% on dressing EXUDATE TYPE: Sero-sanguineous (usually contains blood and the liquid part of blood/serum) .LENGTH (cm): 4.8 cm WIDTH (cm): 4.8 cm DEPTH: 0.1 .granulation (tissue) .WOUND BED: at the inferior aspect at 6 O'clock is a pinpoint open area .ODOR: slight offensive odor detected TREATMENT: area is cleansed with normal saline calcium alginate with AG is applied to wound bed then telpha wrapping with kling then foam heel dressing is applied to protect tissue Resident also wears blue boots to off load pressure He wears the blue boots at all times with exception of transfers and bathing . -01/09/18: .Weekly Assessment ONSET/DISCOVERY DATE: 01/03/2018 .Late entry for: 01/02/2018 WOUND TYPE: Pressure Stage 2 .left heel .Tissue: dry rough and dark in color .EXUDATE: Scant-very moist in appearance Drainage < 25% on dressing .EXUDATE TYPE: brown .WOUND BED: superficial open with tissue the same color as the periphery .LENGTH (cm): 4.8 cm WIDTH (cm): 4.8 cm DEPTH: 0.0 .granulation .ODOR: none .TREATMENT: area was cleansed with normal saline calcium alginate with AG then telpha a foam heel dressing then secured with kling .area is drying with no evidence of infection . -01/12/18: BEHAVIOR: Resident was with therapy and made mention that he is not getting repositioned during the night. Therapy did bring it to the nurse attention and he was placed on a every 2 hour repositioning schedule . A facility repositioning document identifies R13 was not placed on a two-hour repositioning schedule until 01/12/18. There is no documentation in the medical record how often the resident was repositioned by staff before this date. -01/19/18: ASSESSMENT TYPE: Follow-up assessment WOUND TYPE: Stage 2 .left heel .intact .EXUDATE: Scant-very moist in appearance Drainage < 25% on dressing EXUDATE TYPE: Other bloody .WOUND EDGES: Flush with wound bed LENGTH (cm): 7 cm WIDTH (cm): 4.5 cm .MOST SEVERE TYPE: Necrotic/Eschar (dark scab of dead skin) Necrotic (dead tissue) % (No percentage identified) .TREATMENT: cleaned applied calcium alginate, heel protector applied and wrapped with kerlix every 3 days . The wound has worsened, and there is no documentation if signs of infection are present. There is no documentation the wound was assessed and measured for ten days, from 01/09/18 to 01/19/18. -01/30/18: .Weekly Assessment WOUND TYPE: Stage 3 .left heel .Tissue: dry .EXUDATE: Scant-very moist in appearance Drainage < 25% on dressing EXUDATE TYPE: Other bloody .WOUND EDGES: Flush with wound bed .LENGTH (cm): 7 cm WIDTH (cm): 14 cm DEPTH: (0).2 .Necrotic Eschar .%50 WOUND BED: soft eschar .HEALING PROGRESS becoming larger becoming deeper . The wound has now worsened to a stage III pressure injury. There is no documentation if signs of infection are present. There is no documentation the wound was assessed and measured for eleven days, from 01/19/18 to 01/30/18. -02/06/18: Note: Resident signed refusal for skin interventions form; as resident refusing to utilize blue boots to help protect his heels. Writer explained to resident why these interventions were put into place to help prevent skin breakdown of his heals (sic), verbalized understand, but continues to refuse blue boots. Form signed and in chart . There is no documentation in R13's medical record, including the care plan, the resident was refusing to wear the blue boots, prior to 02/06/18. The Refusal of Skin Care Interventions Risk & Benefit Form, signed by R13 on 02/06/18, identifies the facility offered other interventions of floating heels, blue boots, and adding sheep skin to the resident's wheelchair foot pedals. There is no documentation in the record these alternative interventions to prevent skin breakdown were offered to R13 prior to 02/06/18, or if these alternatives were ever attempted. -02/13/18: .new orders received and noted .okay for wound care referral . -02/19/18: RETURNED FROM APPOINTMENT .(wound clinic nurse) new orders received and noted .left heel bkack (sic) eschar unstageable pressure ulcer 3x3 cm 100% black .Left heel swab with [MEDICATION NAME] 3 (times per week) and cover with foam non-bordered or heel (sic) foam pad. Wrap with gauze .D/C (Discontinue) [MEDICATION NAME] AG .Try pillow under calf to suspect heel in recliner and bed . There is no documentation in R13's record the facility attempted to place a pillow under the resident's left calf. -02/21/18: R13 was receiving eight ounces of a K2 nutritional supplement, three times a day. On this day, the resident's physician ordered an additional 30 cubic centimeters of liquacel nutritional supplement, three times a day to promote wound healing. R13's nurses' notes continue, in part: -03/13/18: .Weekly Assessment ONSET/DISCOVERY DATE: 01/30/18 .WOUND TYPE unstageable .left heel .Tissue: intact and dry .EXUDATE: None . LENGTH (cm): 2.6 WIDTH (cm): 2.6 .100% stable eschar .ODOR: no offensive odor detected HEALING PROGRESS: immediate periphery has a thin brown scab present No evidence of infection of other concerns . -03/20/18: .Weekly Assessment WOUND TYPE unstageable .left heel .bottom of left heel .Tissue: intact and dry .EXUDATE: None . LENGTH (cm): 2.5 WIDTH (cm): 2.5 .100% stable eschar .ODOR: no offensive odor detected HEALING PROGRESS: slow to heal Has a return appointment with .wound nurse .March 26th for debridement . -03/27/18: .Weekly Assessment WOUND TYPE unstageable .left heel .bottom of left heel .Tissue: tissue is dry and rough to the touch .EXUDATE: None . LENGTH (cm): 2.5 WIDTH (cm): 2.8 .Necrotic/Eschar Necrotic % 100 .ODOR: no offensive odor detected .Resident refuses to comply with interventions presented to prevent further deterioration and promote healing Writer spoke with resident and discussed consequences of his refusals Resident reports he understands. Resident is his own person and signed refusal of skin care form. Staff will continue to offer interventions . It is noted, there is no documentation in R13's medical record and care plan, except a nurses' note on 02/06/18, the resident was refusing interventions to promote wound healing, prior to 03/27/18. The Refusal of Recommended Medical Intervention Risk and Benefit Form, signed by R13 on 03/29/18, identifies the facility offered other interventions, such as placing a pillow under the resident's calf, and having a foot cradle and a bolster at the end of the bed. There is no documentation in the record these alternative interventions to prevent skin breakdown were offered to R13 prior to 03/27/18, or if these alternatives were ever attempted. -04/03/18: Wound notes identify R13 has an unstagable left heel wound which measures 2.5 cm by 2.8 cm. -04/09/18: .RETURNED FROM APPOINTMENT (with primary physician) .new orders received and noted .Podiatry to evaluate heel ulcer. (Called clinic and Podiatry will call once in system) Podus boot to left foot while in chair/bed may remove for .ambulation . -04/12/18: RETURNED FORM APPOINTMENT .new orders received and noted .Left Heel Healing. Debrieded to 50% black, 40% yellow, 10% red. 2.2 x 2.5 cm with 0.2 cm deep. Change dressing every other day . A facility fax, sent to R13's primary physician on 04/24/18, states the following, in part, Resident requires two assist with walking and typically denies heel pain but does c/o (complain of) knee locking or giving out. Resident wheels self in wheelchair. Resident appears more depressed then (sic) painful. Likes to isolate to room and will visit with wife but typically does not attend activities and watches TV in room. Flat affect .Resident verbalizes wanting to go home and does not want to be in the nursing home .MD (Doctor of Medicine) Response/New Orders: Podiatry referral requested after his last appointment with me 4/9/18-no note that this has been done .If heel ulcer still present, please schedule podiatry referral . There is no documentation the facility followed-up and made an appointment for R13 with a podiatrist. Surveyor reviewed the wound nurse's progress note, dated 04/19/18. The note states the following, in part, .Assessment .Wound healing compromised by decreased mobility, age, and postsurgical procedure for left hip and [MEDICAL CONDITION] . R13's nurses' notes continue, in part: -04/26/18: .Weekly Assessment WOUND TYPE unstageable .left heel .Tissue: dry intact .EXUDATE: Medium/Moderate-wound tissue is wet drainage involves < 75% on the dressing EXUDATE TYPE: Sero-sanguineous .LENGTH (cm): 2.5 WIDTH (cm): 2.0 .Slough % 40 .HEALING PROGRESS: improving . -05/10/18: Wound notes identify R13 has an unstagable left heel wound which measures 2.2 cm by 2.0 cm. -05/14/18: PHYSICIAN VISIT: Attending physician .examined client 05/14/2018 .new orders received .Continue wound care nurse management. Have podiatry consult. (Appointment for podiatry) schedule (sic) on (MONTH) 8 . This is the third time R13's physician has ordered the facility to make a referral to the podiatrist for the left heel wound. -05/16/18: Wound notes identify R13 has an unstagable left heel wound which measures 2.2 cm by 2.0 cm. The wound notes state in part, .Comments: resident continues to refuse to sleep in his bed so he is in his recliner or W/C (wheelchair) 24 hours a day. MD did start resident on [MEDICATION NAME] (a diuretic) .due to the +2/+3 [MEDICAL CONDITION] .Diet does not consist of much protein, resident often leaves the meat on the plate at meals . Surveyor reviewed R13's care plan. The care plan states the following, in part: PROBLEM: I have potential for Comfort .in pain .RELATED TO: heel ulcer .APPROACH: soft blue booties in bed bilateral feet .Please check my skin with cares and report any concerns to my nurse .please keep good padding around my bony areas . The care plan does not identify the resident is at risk for skin breakdown, or identify the location of the heel ulcer. The care plan does not include the interventions of repositioning, or to offload the resident's heels by using pillows, or the Podus boot. On 05/14/18 at 9:23 a.m., Surveyor interviewed the resident. R13 stated the resident lived at home prior to being admitted to the facility, and the resident stated he wants to return home to live with his spouse. R13 stated he has a sore on his left foot, the resident has a poor appetite and he does not participate in group activities. The resident said to Surveyor, .I'm just giving up .you keep fighting but there's just no use. During this interview, R13 was observed to be looking down at the floor, had a pained facial expression, did not make much eye contact with Surveyor, and was crying. During this interview, the resident was wearing a heel-suspending boot on the left foot, and had gripper socks on both feet. Both of R13's feet were resting on the metal and plastic foot rests of the wheelchair. Neither footrest had sheepskin, or other type of padding. There was no pillow beneath either of the resident's calves. At 11:05 a.m., Surveyor observed R13 sitting up in the wheelchair, in the resident's room. The resident was wearing the heel-suspension boot on the left foot, and gripper socks were on both feet. Neither metal/plastic footrest had sheepskin, or other type of padding, and no pillows were beneath R13's calves. At this time, both of the resident's feet were resting on the floor. On 05/16/18 at 1:40 p.m., Surveyor interviewed Certified Nursing Assistant (CNA) K. CNA K stated prior to R13's heel wound, the resident's heels were not floated. CNA K stated the blue boots were applied to the resident's heels, after the heel wound was discovered. At 2:08 p.m., Surveyor interviewed R13. The resident stated prior to obtaining the left heel wound, staff did not float the resident's heels while in bed or in the recliner. R13 stated he wore gripper socks and did not wear any type of boots or have pillows behind his legs while up in the wheelchair. R13 stated there were times in which the resident's heels would get sore, prior to the discovery of the left heel ulcer. During the interview, the resident was wearing a heel-suspending boot on the left foot, and had gripper socks on both feet. Both of R13's feet were resting on the metal/plastic foot rests of the wheelchair. Neither footrest had sheepskin, or other type of padding, and there was no pillow beneath either of the resident's calves. On 05/17/18 at 10:00 a.m., Surveyor interviewed the Director of Nursing (DON) and RN B. RN B stated R13's left heel pressure injury was unavoidable, due to the facility following standard hip precautions to the resident's left leg, staff was repositioning the resident every two hours, and the resident used a pressure relieving mattress. Surveyor asked when R13's two-hour repositioning schedule was implemented. At this time, the DON reviewed a facility repositioning binder and located a form identifying R13 was started on a two-hour repositioning schedule, on 01/12/18. RN B reviewed this form and stated R13 was started on the repositioning schedule on 01/12/18, fourteen days after the heel pressure injury was discovered. During the continued interview, Surveyor asked if the facility considered obtaining an air mattress for R13. RN B stated the resident does not have and has never had an air mattress. The DON and RN B stated the facility has historically had an issue with falls due to air mattresses, and some residents have not found the air mattresses comfortable. The DON additionally stated a wound consultant company, Genteel, has recommended the facility get rid of air mattresses. It is noted, some residents in the facility were observed to have air mattresses at the time of survey. Surveyor discussed the lapses in R13's wound measurements/assessments, from 01/09/18 to 01/19/18 and from 01/19/18 to 01/30/18. RN B stated the facility wound nurse was ill during these dates, so a facility RN completed the wound assessments during these times, which were late. RN B and the DON stated the facility policy is to measure and assess wounds every seven days. Surveyor discussed the resident's heel measurements. RN B stated the resident's left heel ulcer, dated 02/19/18, should measure 3 cm by 3 cm; and the wound should measure 7 cm by 4 cm, on 01/30/18. During the continued interview, Surveyor discussed the resident's nurses' notes and care plan do not identify R13 was refusing to wear the blue boots until the facility had the resident sign the risk/benefits forms on 02/06/18 and 03/29/18. RN B confirmed there is no documentation in R13's record of the resident's refusals. Surveyor asked why the facility did not make a podiatry appointment until 05/14/18, when the physician ordered an initial podiatry referral on 04/09/18. RN B replied she is not sure why it took so long to make a podiatry appointment for R13, but confirmed the appointment for podiatry was made on 05/14/18. 2. On 05/14/18, Surveyor reviewed R195's medical record. The resident has [DIAGNOSES REDACTED]. The resident's most recent BIMS score, dated 02/26/18, was a 08 out of 15 total points. According to the BIMS assessment, a score of 08 indicates the resident has moderately impaired cognition. The medical record indicates R195 requires assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident does not ambulate and requires a Hoyer lift (a full-body mechanical lift) for transfers. R195's MDS, dated [DATE], identifies the resident is at risk for developing pressure injures. The assessment indicates the resident has no current unhealed pressure injuries or areas of skin breakdown as of this date. Surveyor reviewed the resident's nurses' notes, from 03/01/18 to 05/16/18. The notes state the following, in part: -03/29/18: ASSESSMENT TYPE: Initial assessment 03/29/2018 ONSET/DISCOVERY DATE: 03/29/2018 .WOUND TYPE: Pressure at site of previous bunion (which has been long term) Note: resident also has [DIAGNOSES REDACTED].outer edge of right foot .red and warm to touch THICKNESS: Full EXUDATE: Scant-very moist in appearance Drainage < 25% on dressing EXUDATE TYPE: Other brown .well defined wound edges .LENGTH (cm): 2.8 cm WIDTH (cm): 2.8 DEPTH: 0.2 cm .TREATMENT: area was cleansed and padded to protect fragile tissue resident wears blue boots at all times .POA (Power of Attorney for Healthcare) updated writer suggested MD consult for possible wound infection . writer and POA felt that this required attention today POA in agreement to ER (emergency room ) visit .temp 97.5 Pulse 92 Respirations 22 B/P (Blood Pressure) 111/60 Staff assessed this area on 3/28/2018 and noted that area was slightly reddened and closed at that time areas was then redressed with a [MEDICATION NAME] dressing for protection . Surveyor reviewed a facility Skin Report form, dated 03/29/2018. The form states the following, in part, .Incident Type .Pressure ulcer .Assessment .Writer noted that the site was open and the entire 1/2 portion of the top of the foot and along the side toward the ankle was red and warm Scant amount of brown drainage noted on the dressing .Resident admitting that area is painful which is a new complaint .POSSIBLE CAUSE .rubbing foot against cradle .INTERVENTION: to monitor daily and apply more padding to the foot to protect from possible rubbing against a hard surface .staff instructed on correct positioning while in bed and in the chair ensuring that pressure is minimized with the use of the blue boots and cradles (bed/chair) . -04/02/18: A physician ordered the antibiotic [MEDICATION NAME] 875/125 milligrams (mg) every twelve hours for ten days, for a foot infection. -04/03/18: .Weekly assessment .WOUND TYPE: pressure .outer edge of right foot .THICKNESS: Full EXUDATE: Scant-very moist in appearance Drainage < 25% on dressing EXUDATE TYPE: Sero-sanguineous .LENGTH (cm): 3.0 cm WIDTH (cm): 3.0 DEPTH: 0.1 cm .WOUND BED: brown rough tissue color of [MEDICATION NAME] .ODOR: no offensive odor detected .TREATMENT: right lateral foot is cleansed with Acretic Acid then [MEDICATION NAME] applied to wound bed and cover with gauze and ABD and wrapped with kerlix . -04/05/18: .Wound continues with a foul odor, dressing changed per MD orders . Lab work on this date identified R195 had an elevated white blood cell count of 10.4. According to the lab results, a normal range for a resident's white blood count should be between 4.1 and 10.9. An elevated white blood count may indicate the resident has an infection. -04/06/18: .SPOKE WITH .physician on call .sensitivity of organism grown from foot wound .new orders received .stop [MEDICATION NAME] and start [MEDICATION NAME] (an antibiotic) 1 gram IM (intramuscular injection) daily x10 days . -04/12/18: .Follow-up assessment .WOUND TYPE: pressure (previous bunion site) .outer edge of right foot .intact Unstageable .EXUDATE: Scant-very moist in appearance Drainage < 25% on dressing EXUDATE TYPE: Sero-sanguineous .LENGTH (cm): 3.0 cm WIDTH (cm): 4.5 DEPTH: 0.1 cm .MOST SEVERE TYPE: Necrotic/Eschar Necrotic % 50 WOUND BED: soft eschar .ODOR: no offensive odor detected .TREATMENT: cleaned with acetic acid and rinsed .HEALING PROGRESS: no change . -04/13/18: .Foot wound continues to be monitored by wound nurse at Mayo clinic . -04/16/18: .Temp is 98.2 .He has been sleeping most of shift .Resident received last dose of IM [MEDICATION NAME] this am for his wound infection. Wound continues to be treated and dressed daily, odor is gone .SCHEDULED APPOINTMENT .CT (Computerized Tomography) Scan .04/17/2018 . -04/18/18: RETURNED FROM APPOINTMENT .new orders received and noted .Please continue with current dressing change orders .MRI (Magnetic Resonance Imaging) pending to evaluate extent of osteomyeitis (sic, a bone infection) . -04/26/18: .Weekly assessment .WOUND TYPE: Pressure at previous bunion site, seeing MD this shift for MRI to rule out osteo[DIAGNOSES REDACTED] .EXUDATE: Scant-very moist in appearance Drainage < 25% on dressing EXUDATE TYPE: Sero-sanguineous .LENGTH (cm): 2.5 WIDTH (cm): 3.5 .MOST SEVERE TYPE: Necrotic/Eschar Necrotic % 75 WOUND BED: soft eschar .ODOR: no offensive odor detected .HEALING PROGRESS: no change . There is no documentation the wound was assessed and measured for fourteen days, from 04/12/18 to 04/26/18. -04/27/18: .new orders received and noted .due to osteo[DIAGNOSES REDACTED] and infection will begin planning for amputation/5th ray resection of right foot date of surgery 05/02/2018 . Surveyor reviewed R195's hospital discharge summary, dated 05/04/18. The report states, in part, .admitted : 5/2/2018 .DETAILS OF HOSPITAL STAY .He also has type 2 diabetes with [MEDICAL CONDITION] and nonhealing ulcer in the webbing between the right 4th and 5th toes. Recently had had an MRI which suggested a possible osteo[DIAGNOSES REDACTED] in the 5th metatarsal head and proximal 5th phalanx .He was admitted to the hospital for ongoing IV antibiotic wound care until results of the bone biopsy and intraoperative wound cultures are available . The resident's nurses' notes continue, in part: -05/04/18: .ADMISSION NOTE: Resident readmitted from (name of hospital) where he was hospitalized for [REDACTED]. Resident is alert to self and recognizes wife, Is not aware of time. Resident very sleepy on return .Resident will be repositioned by staff minimum of every two hours . -05/09/18: Wound notes identify the resident's surgical wound to the outer right foot measures 8.7 cm by 1.7 cm. The note states, in part, .Comments: resident had a surgical procedure on (MONTH) 2, (YEAR) due to DX of osteo[DIAGNOSES REDACTED], area was opened and a 5th ray resection was performed. the fifth toe was removed as well as the affected pressure area. 16 stitches are intact down the outer edge of right foot . Surveyor reviewed the resident's comprehensive care plan, which states, in part, PROBLEM: I have Impairment of skin integrity .RELATED TO: diabetes, dementia, depression, incontinence, [MEDICAL CONDITION], hx (history) of [MEDICAL CONDITION] .MANIFESTED BY: recurring venous scabs to both feet 3rd and 4th digits decreased sensory perception .nutritionally at risk .GOAL: Improve Skin Integrity, heal scabbed areas with no complications .prevent skin breakdown secondary to mobility and moisture concerns .APPROACH .(09/2016) to wear blue boot heel protectors at all times .bolster at end of bed in between mattress and foot board .Assess skin condition daily and note any changes . The care plan does not identify R195 had a fifth toe amputation due to a pressure injury, nor does it identify how often the resident is to be repositioned, or the foot cradle on the wheelchair was padded to protect the outer foot to prevent further breakdown of this area. R195's Certified Nursing Assistant (CNA) care plan, states the following, in part, .(No date identified) HYGIENE .Please inspect my lower legs and feet daily with cares . There is no documentation on the CNA care plan the resident is to wear blue heel boots, or when the boots are to be worn. Surveyor reviewed R195's Treatment Administration Record (TAR) for (MONTH) (YEAR) through (MONTH) (YEAR). There is no documentation on the TAR or in the medical record staff was checking the resident's feet daily, or ensuring the resident was wearing the blue boots at all times, each shift. The resident's physician's orders [REDACTED]. -05/04/18: Apply Prevalon boots bilateral foot/feet when in bed every shift AM PM N[NAME] (night) -05/04/18: Bilateral (both) Prevalon boots on when in bed and/or off load heels. AM PM N[NAME] On 05/14/18 at 11:32 a.m., Surveyor observed R195 sitting up in a Broda-type, padded wheelchair in the resident's room. The resident was wearing a blue boot to the left foot, and a blanket was covering up the majority of the resident's right foot. A black, vinyl, foot cradle was located on the foot rest of the wheelchair, in which both of the resident's feet were located inside of this cradle. On 05/16/18 at 9:50 a.m., Surveyor observed the resident sitting up in a Broda-type wheelchair in the resident's room. R195 was wearing padded blue boots on both feet, and both feet were securely inside the black foot cradle on the wheelchair foot rest. According to the Surveyor's observation, it appears as if the resident is not able to move his feet side-to-side in the foot cradle but would only be able to move his feet up and down. The right edge of the foot cradle appears to be touching the right outer edge of the resident's foot (if the blue boot were not present), just below where the fifth toe would be located. At 1:40 p.m., Surveyor interviewed CNA K. Surveyor asked if the CNA inspected R195's foot, daily, prior to the discovery of the resident's right foot wound. CNA K replied the resident's feet were usually wrapped with [MEDICATION NAME] for [MEDICAL CONDITION], so CNA K was not able to inspect the resident's feet daily. On 05/17/18 at 10:00 a.m., Surveyor interviewed the DON and RN B. RN B stated R195 has been wearing the blue, padded boots to both feet since (YEAR), and the foot cradle to the wheelchair was applied in (YEAR). RN B further stated the wound documentation indicates the pressure injury is due to the resident rubbing his right foot on the side of the wheelchair foot cradle. Surveyor asked how the resident was able to rub the side of the foot on the wheelchair foot cradle, if R195 was supposed to be wearing the padded boots at all times. RN B replied the facility added extra padding to the f (TRUNCATED)

Based on observation, interviews, record review, and a review of the facility's policy and procedure related to pressure ulcers, the facility did not ensure that 5 of 7 sampled residents having pressure ulcers or were at risk for pressure ulcers, received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Resident #1 was admitted with a pressure ulcer which was not healing and was at risk of developing subsequent pressure ulcers. Resident #1's pressure ulcer deteriorated, required treatment by the wound clinic including sharp debridement, and became infected. A wound vac was initiated and Resident #1 developed new pressure ulcers from the wound vac tubing. Resident #1 was observed during survey to spend most of his day in bed. The facility did not: ~Accurately and/or consistently assess skin integrity; ~Develop a complete and accurate care plan related to the presence of pressure ulcers and a specific repositioning schedule; ~Develop a care plan that addressed the resident's resistance to turning and his preference to remain on his back; ~Promptly implement nutritional measures such as additional calories, increased protein, and/or vitamin and mineral supplements to prevent deterioration of the existing pressure ulcer and to prevent new pressure ulcers from developing; ~Promptly notify and provide complete information to the physician/nurse practitioner regarding pressure ulcer deterioration and/or weight loss; ~Provide accurate and complete documentation related to pressure ulcer assessments and treatment; ~Promptly implement revision of the repositioning schedule to prevent delayed healing and infection of the right buttock pressure ulcer and/or to prevent new pressure ulcers from developing. Resident #2 had surgical repair of a left [MEDICAL CONDITION] and developed a facility-acquired pressure ulcer. The pressure ulcer became infected and developed increased drainage and odor with a wound vac initiate for further treatment. The facility did not: ~Provide accurate and complete documentation related to pressure ulcer assessments and treatment; ~Develop a complete and accurate care plan related to the presence of the pressure ulcer; ~Promptly notify the physician/nurse practitioner regarding increased drainage with odor of the pressure ulcer; ~Apply relevant policies and procedures for pressure ulcer treatment and prevention. (3), (4), (5) Residents #4, #5, and #6 were all at risk for pressure ulcers. The facility did not develop a complete and accurate care plan related to the risk of pressure ulcers and an appropriate repositioning schedule, and did not provide appropriate positioning for the residents as observed during survey. Findings include: At various times during [DATE] to [DATE] Surveyor reviewed records and policies related to Resident #1 including the facility medical record, hospital/wound clinic records, and the facility's "Pressure Ulcers Treatment and Prevention" dated [DATE] with the following noted: The facility's "Pressure Ulcers Treatment and Prevention" dated [DATE] includes the following: preventative and appropriate treatment measures for pressure ulcers are to be provided according to the AHCPR and NPUAD guidelines; RISK is identified using the Braden scale and the Resident Assessment Instrument (RAI) process; PREVENTION includes positioning..."Establish and record an individualized turning and repositioning schedule if the resident is immobile...Frequency of position changes is titrated for the individual resident. (Educate on 15 min pressure relief)...Boney prominence susceptible to pressure will be protected...Elevate heels off bed as indicated..." and nutrition..."Obtain order for nutritional supplements and use of protein supplements as indicated..."; TREATMENT includes, "Notify physician if any evidence of deterioration is noted or no improvement...The diet of the resident with a pressure ulcer should contain nutrients adequate to support healing. Adequate protein and fluids, and vitamin with minerals...Avoid positioning the resident on a pressure ulcer. Use positioning devices to a raise a pressure ulcer off the support surface...Update care plan as needed...Documentation In the nurse notes and on the weekly wound progress sheet at a minimum weekly, to include specific wound description: date, stage, size, depth...tissue appearance, periwound appearance, character of drainage (odor, type, amount, color), wound pain, response to treatment, nurses signature." Resident #1 was admitted to the facility on [DATE] with diagnoses/conditions on the hospital discharge summary that included a recent [MEDICAL CONDITIONS] resulting in right [MEDICAL CONDITION] and [MEDICAL CONDITION], severe dysphagia with gastrostomy tube placement, [MEDICAL CONDITIONS] with [MEDICAL CONDITION] and pneumonia, [MEDICAL CONDITIONS] and anticoagulation with [MEDICATION NAME], diabetes mellitus, [MEDICAL CONDITION] (CAD), [MEDICAL CONDITIONS] disk disease and history of [MEDICAL CONDITION] arthritis, and a "decubitus" ulcer on the right buttock. Facility documentation confirmed the presence of a Stage II right buttock pressure ulcer with the development of a new Stage II pressure ulcer in the same area. On [DATE], the resident was hospitalized with pneumonia and possible aspiration and was readmitted to the facility on [DATE]. Pain medications included Tylenol 650 milligrams (mg) and [MEDICATION NAME] 50 mg both to be given every 4 hours as needed and a 50 microgram (mcg) [MEDICATION NAME] to be changed every 3 days. The resident has a legal guardian and is a full code. On [DATE], nurses' notes identified Resident #1 was readmitted with an unstageable deep tissue injury (DTI) to the right buttock measuring 4.2 by 1.2 (cm) with "100% yellow firmly adhered slough," indicating that the pressure ulcer was open. The notes identified the resident had a Braden skin assessment score of 12 (high risk), was incontinent of bowel with a catheter in place, required 2 staff assist for mobility, was currently on an air overlay mattress, and frequently slid down in bed requiring frequent repositioning. The Weekly Wound Documentation (WWD) Form dated [DATE] was consistent with the nurses' notes and identified the DTI as a "Pressure" wound. It also identified the wound edges had [DIAGNOSES REDACTED] (redness) and that a [MEDICATION NAME] (foam) dressing was applied. A skin and body assessment form dated [DATE] stated the resident had a DTI, "wound bed black - not open," with measurements consistent with the nurses' notes and the WWD Form. The picture on the skin and body assessment form showed a large area circled which included approximately half of the buttocks crease and several cm above the crease and stretched across almost the entire left and right buttocks area. Staff did not complete accurate and complete skin assessments related to the location of the pressure ulcer, the description of the wound base, and whether or not the skin was intact or open. Staff did not obtain an order for [REDACTED]. The care plan dated [DATE] related to skin integrity identified Resident #1 had no open areas and no skin impairment but did have a DTI with a "Braden Risk" score of 12 (high risk). The care plan included the following risk factors: cognitive impairment at times; head of the bed elevated the majority of the day (required during the tube feeding administration); resident attempted to assist with ADL's (removed pillows and repositioned self to back); fragile skin due to [MEDICAL CONDITION]; pain due to [MEDICAL CONDITION] arthritis; and, [DIAGNOSES REDACTED]. Interventions included an air mattress in bed but no cushion to the Broda chair, repositioning every 2 hours, side to side in bed, with the head of the bed no more than 30 degrees, inspecting the skin daily and assessing weekly, and wound care consultation and treatment as ordered. It was stated the resident refused a pillow and heel protectors in the past so this was not placed as an intervention at that time. Staff did not accurately identify the DTI as skin impairment. Staff identified the resident was chairfast but did not put an intervention in place for a pressure relief cushion in the chair. Staff did not identify how offloading would be accomplished when positioned on the affected side. Staff stated the resident removed pillows placed for repositioning but did not address risk factors with the resident or attempt an alternate plan. On [DATE], the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Staff still did not obtain an order for [REDACTED]. On [DATE], a dietary note written by the dietary manager stated the resident had a pressure ulcer and required 92 grams of protein daily which was being provided with his [MEDICATION NAME] tube feedings. On [DATE], a dietary note written by the Registered Dietician (RD) stated, "Does have open area on right buttock. Protein needs for healing are 95 grams per day, tube feeding does provide 91.8 grams per day. Recommend doing [MEDICATION NAME] level to establish protein status and to determine if there is a need for increased nutritional intervention..." Staff did not obtain an order at that time to draw the [MEDICATION NAME] level. On [DATE] the readmission Minimum Data Set (MDS) assessment was consistent with the discharge MDS assessment with no significant changes (moderate cognitive impairment, extensive assistance needed for bed mobility, presence of a catheter with no bowel incontinence, and 2 Stage II pressure ulcers) thus there was not a full assessment completed at that time. The CAA related to pressure ulcers that was completed in association with the admission MDS stated only that the resident required ADL assistance with bed mobility and was at risk for developing pressure ulcers with no risk factors identified. Staff identified the pressure ulcer was intact on the skin and body assessment on [DATE] but that it was a Stage II pressure ulcer on [DATE]. Staff did not consistently identify if the pressure ulcer was a Stage I with intact skin or a Stage II with an open area. On [DATE], the WWD Form identified a Stage II pressure ulcer with 100% slough and intact wound edges and that a [MEDICATION NAME] dressing was applied. On [DATE], a nurse's note identified that Resident #1 had pain with repositioning and, "Wound is beginning to darken around previously open area...continuing to break down again. Dressing applied and attempted to reposition." Staff did not obtain an order for [REDACTED]. On [DATE], the physician ordered a [MEDICATION NAME] dressing to Resident #1's right buttock to be changed every 3 days. Nurses' notes and the WWD Form identified on [DATE] that the pressure ulcer had increased in size to 5 by 2 cm with 100% slough and reddened wound edges and by [DATE] that it had increased in size to 6 by 3.5 cm with 100% slough, pink wound edges, and a scant amount of tan drainage with [MEDICATION NAME] as the continued treatment. On [DATE], the WWD Form identified the pressure ulcer measured 5 by 4.5 cm with 100% slough, a scant amount of serosanguinous drainage, and [DIAGNOSES REDACTED] of the wound edges. It was stated the pressure ulcer had increased to a Stage III and treatment was changed to [MEDICATION NAME], covered with [MEDICATION NAME]. According to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Nurses' notes on [DATE] identified the resident's weight was 196.5 which was a 7 pound loss in 1 week. On [DATE], nurses' notes identified the physician was notified because Resident #1 had a weight loss (over 10 pounds in 1 month) and because the right buttock pressure ulcer was "getting worse" with orders received for PT involvement as well as a wound consult. Staff did not promptly obtain a physician order [REDACTED]. On [DATE], wound clinic notes identified Resident #1 arrived at the wound clinic for an initial evaluation with a medication list and "notes just to check the wound." It was stated the resident arrived sitting in a Broda chair with a ROHO cushion in place but on top of that had the Hoyer lift sheet, could answer nonverbally to yes/no questions asked, had right side [MEDICAL CONDITION] and could not assist at all with his care, and had [MEDICATION NAME] covering a right buttock pressure ulcer measuring 4.5 by 1.9 cm with 50% black eschar and 50% yellow slough. Following sharp debridement, the wound was identified as 50% dull red tissue and 50% adipose subcutaneous tissue. The final assessment was a "Probable stage III pressure ulcer on the right buttock" measuring 4.5 by 1.9 cm with a depth of 0.8 cm and treatment changed to [MEDICATION NAME] to enzymatically debride the wound covered with an Allevyn or [MEDICATION NAME] dressing to be changed every 3 days or as needed for drainage. The notes identified the resident received tube feedings and that a ROHO cushion was used to offload the area. Staff did not provide complete information to the wound clinic including the recent weight loss. On [DATE], an initial assessment by PT identified "wound noted on sacrum, reported by nursing to open on [DATE]st 2011." The pressure ulcer was described as measuring 5 by 2.4 cm and 0.2 cm deep with "Significant necrosis noted with slough present throughout wound. No granulation tissue present...complaints of pain in area of wound...electrical stimulation (Estim), plan on use next visit." On [DATE], the WWD Form identified the pressure ulcer measured 5 by 4.7 cm with a depth of 1.0 cm and 100% slough, a scant amount of serosanguinous drainage, and [DIAGNOSES REDACTED] of the wound edges. Despite the increase in size, there is no evidence to indicate that the facility notified the physician or initiated a change in treatment. On [DATE], nurses' notes identified the resident required an increase in pain medication but it was advised by the on call physician to wait for the attending physician to return. Estim was performed on [DATE] and [DATE] with pain medication increased on [DATE] (Duragisic 100 mcg). The PT notes on [DATE] identified the resident was "not happy" with the PT aide "verbally asking me to leave room loudly..." Staff did not immediately notify the physician and discuss alternate treatment when the pressure ulcer was noted with significant necrosis and an increase in size with the area of the wound painful and possibly interfering with adequate repositioning. On [DATE], nurses' notes identified the pressure ulcer measured smaller, 4.5 by 1.75 cm with a depth of .08 cm, but the area around the wound was red and "indurated completely around wound" and the inner wound "appears [MEDICAL CONDITION]." It was stated the pressure ulcer was "odiferous" with a moderate amount of "green" drainage and 100% "adherent" slough that was also "green." Despite the presence of odor, the facility did not notify the physician or initate a change in treatment. The WWD Form on [DATE] identified the resident had "Heavy...Green" drainage and odor present with an order for [REDACTED]. Resident pushes back when attempting to do wound care. Resident also refuses repositioning and staff attempts to get him up in Broda chair. Wound has green/yellow wound bed with heavy exudate..." The care plan was not updated related to repositioning. The MAR indicated [REDACTED]. Staff did not revise the care plan to ensure the resident received appropriate repositioning. On [DATE], wound clinic notes identified Resident #1's pressure ulcer measured 4 by 1.9 cm with a depth of 1 cm. Sharp debridement of the pressure ulcer was performed and the plan was to continue on an antibiotic with the same treatment of [REDACTED]." It was stated the resident complained of pain in the area of the pressure ulcer and that family members present stated that at the facility, "...he can lie in one position for an extended period of time...Some days he is up in his chair the whole day and sometimes he is in bed for the whole day." Part of the plan included, "I would like him to be repositioned every 2 hours in bed, for 2 hours on his side, and then up in the Roho recliner chair for 2 hours during the day..." It was not clear if the Nurse Practitioner's recommendation was that the resident should be repositioned every 2 hours including his affected side, or if the repositioning included only placement on the unaffected side. The assessment identified a "Probable" Stage III pressure ulcer. Staff did not provide complete information to the wound clinic including any problems with repositioning in bed due to noncompliance that would prevent offload of the area in bed. Staff did not clarify the wound clinic plan for repositioning and update the care plan accordingly. The PT notes identified Resident #1 received Estim to the pressure ulcer on [DATE], [DATE],and on [DATE]. On [DATE], the WWD Form identified little change in the size of the pressure ulcer. The section related to drainage and wound edges was left blank. Staff did not document whether there was any drainage or redness. On [DATE], a dietary note written by the RD identified that Resident #1 was seen due to a referral from the physician to evaluate the tube feeding to improve the low [MEDICATION NAME] of 2.7 and to improve wound healing. It was stated that protein needs for healing were 111 - 120 grams of protein per day with the current tube feeding of "[MEDICATION NAME] 1.5" providing 91.8 grams of protein per day. It was recommended to change the tube feeding formula to "Impact 1.5" which would provide 120.96 grams of protein per day. Staff did not assure that the resident consistently received an adequate amount of protein for healing. On [DATE], a nurse's note at 7:54 p.m. identified, "Throughout dressing change resident appeared to be in pain..." On [DATE], a nurse's note during the night stated, "Is repositioned off of buttocks as resident will allow." Staff did not explain adequately why risk factors were not addressed with the resident when he was uncooperative with repositioning. Staff did not revise the care plan with an alternate plan for repositioning. On [DATE], nurses' notes and the WWD Form identified the pressure ulcer had increased in size to 4.5 by 3 cm and a depth of 2 cm with moderate brown drainage and a thick layer of adherent slough debrided by PT, "Area does not appear to be responding to current RX (treatment). It was stated the wound clinic Nurse Practitioner was updated and a new order to discontinue the current treatment and initiate a wound vac was received. On [DATE], a dietary note written by the RD stated the resident was seen again to evaluate the tube feeding regimen to increase protein due to the low [MEDICATION NAME] and for wound healing. It was stated that due to the unavailability of the Impact formula, it was recommended to continue with the [MEDICATION NAME] and add "Prostat" twice a day via the tube which would provide an additional 30 grams of protein per day or a total of 121.8 grams (111 - 120 grams needed for healing). On [DATE], a fax was sent to the physician requesting a protein supplement which was then ordered to be administered daily via the gastrostomy tube. Staff did not provide the required amount of protein needed for healing until the pressure ulcer deteriorated to the point that a wound vac was required. On [DATE], Resident #1's care plan identified repositioning was to be done every 1 to 2 hours and the head of the bed was to be elevated at 30 degrees. The WWD Form dated [DATE] identified the depth of the pressure ulcer as 2 cm with tunneling present and that the wound vac had been initiated. A nurse's note on [DATE] identified the resident was uncooperative with repositioning. On [DATE], wound clinic notes identified the resident was currently on Bactrim and that the wound vac was appropriate "since the wound had become much larger in depth and tunneling." The depth of the pressure ulcer was identified as 3.5 cm with undermining present and the wound base was identified with 80% yellow slough with an odor. Sharp debridement was completed and the assessment was "Right buttock stage III pressure ulcer." Staff did not specify how long the resident could be positioned on his back with the head of the bed up or how long he could be positioned on the affected side. Staff identified the resident was uncooperative with repositioning but did not address risk factors with the resident or attempt an alternate plan. Nurses' notes and the WWD Form identified that on [DATE] the pressure ulcer continued with a moderate amount of serosanguinous/tan drainage with tunneling present. Nurses' notes on [DATE] stated the resident winced with repositioning and on [DATE] that the resident tended to put himself on his back when in bed. On [DATE], nurses' notes and the WWD Form identified the resident's pressure ulcer had increased in depth to 5 cm and in the amount of slough with 100% undermining around the ridge of the wound bed. It was identified there was a moderate amount of odorous tan drainage and the wound clinic was called to change the type of foam used with the wound vac to a grey silver foam. Nurses' notes on [DATE] stated the resident was positioned off the site, "but tends to straighten self onto back" and on [DATE], "Resident grimacing with repositioning. Swatting at CNAs." Staff did not specify how long the resident could be positioned on his back with the head of the bed up or how long he could be positioned on the affected side. Staff identified the resident was uncooperative and/or had pain with repositioning but did not address risk factors with the resident or attempt an alternate plan. On [DATE], wound clinic notes identified Resident #1's right buttock stage III pressure ulcer had decreased in size with increased granulation tissue but had a new area of tunneling. It was stated, "There has been no asking if we would consider the silver black foam for the pressure ulcer." Wound care was completed using black foam. Staff did not clarify with the wound clinic what type of foam was to be used for the pressure ulcer and revise the care plan to ensure the proper treatment. On [DATE], a nurse's note identified Resident #1's behaviors included persistent anger such as hitting at staff with cares and resisting when staff attempt repositioning. On [DATE], a quarterly review note identified the resident was noted to slide down in his Broda chair causing friction and shear currently spending most of his time in bed and was totally dependent on staff for bed mobility, was incontinent of bowel, and currently had a Stage III pressure ulcer on the left buttock (the correct location is the right buttock). A quarterly MDS dated [DATE] identified these significant changes. Staff did not complete a significant change assessment to ensure a complete and accurate care plan. On [DATE], a nurse's note identified Resident #1 continued to hit at staff, "especially during repositioning." On [DATE], a nurse's note identified a 5 by 0.3 cm abrasion with some small pinpoint open areas on the right buttock caused by the wound vac tubing. It was stated that it was communicated to staff to monitor where the resident's wound vac tubing was "so as not to cause pressure/friction/injury to skin." It was stated that staff would continue to reposition the resident onto his side with a pillow, trying to wedge (the pillow) where the resident could not fully turn himself onto his back. On [DATE], a nurse's note stated, "...facial grimacing and moaning with repositioning at this time." On [DATE], wound clinic notes identified the wound had significant undermining but the wound base had 100% red granulating tissue. It was identified the wound vac had moderate serosanguinous drainage and the pressure of the wound vac was increased from 125 to 150 millimeters of mercury (mmHg), "This is a large cavity wound. This should help the granulation tissue progress faster." Staff did not update the care plan to ensure appropriate repositioning off the affected area and clear of the wound vac tubing. On [DATE], a nurse's note identified the quarterly care conference was held with concerns by family including that all staff did not properly position Resident #1's affected (right) arm on a pillow when he was repositioned and family also requested to get the resident up into the Broda chair at times during the day. It was stated these things were communicated to all staff. The care plan was not updated to include when and for how long the resident could be up in the Broda chair. On [DATE] and [DATE], nurses' notes identified a urinary tract infection [MEDICAL CONDITION] treated with antibiotics. On [DATE] and on [DATE], nurses' notes identified the resident had facial grimacing and moaning and moaning with repositioning ([MEDICATION NAME] increased to 125 mcg on [DATE]). On [DATE], the WWD Form identified the pressure ulcer was deeper because nurses had difficulty getting the foam into the tunneling which was 3.5 cm deep. On [DATE], a nurse's note identified abrasions were noted to the resident's right side that appeared to be from the wound vac tubing. It was stated that it appeared the tubing had "stuck" to the resident's side and, "when tubing was moved it sheared his skin in 3 places on right side. This is not first abrasion from this, thus, will need to keep side covered with ABD (abdominal dressing) or similar for protection." The areas measured 3 by 1.5 cm, 1 by 0.6 cm, and 5 by 2.5 cm. It was stated the resident confirmed the areas were "sore." The care plan was not updated. Staff did not update the care plan to ensure appropriate repositioning when in the Broda chair and when in bed, especially the importance of protecting the resident from pressure related to the wound vac tubing. On [DATE], wound clinic notes identified the wound vac screen was not working (possible problem with the pump per nurses' notes), a repeat [MEDICATION NAME] was needed because [MEDICATION NAME] (low [MEDICATION NAME]) might be slowing up the wound healing ([MEDICATION NAME] was identified to still be low at 3.0), and the treatment directly on the wound was changed as well as the wound vac pressure increased to stimulate granulation formation. On [DATE] at 9:18 a.m., 10:27 a.m., and 1:40 p.m., Surveyor observed Resident #1 in bed, laying directly on his back with the only pillows in bed noted to be that under his head and supporting his right arm. The resident's heels were pressed into the mattress without a positioning device to offload them from the mattress. Staff did not reassess and revise the care plan to prevent new pressure ulcers from developing. A nurse's note for [DATE] identified the resident was repositioned every 2 hours, "to keep pressure off site as much as possible." It was stated the resident tended to scoot himself down in bed and (lay) on his back with pillows used to try to keep him on his side. Staff did not update the care plan related to how long the resident could be positioned on the affected side. Surveyor observed CNA B and CNA C reposition Resident #1 onto his right (affected side with the pressure ulcer) on [DATE] at 9:10 a.m. It was observed the CNA's did not check the placement of the wound vac tubing during the repositioning. A pillow was placed behind the resident's back but no device was used to offload the heels. The lateral side of the right foot and the left heel were noted to be pressed into the mattress. The CNA's stated the resident was repositioned every 2 hours. On [DATE] at approximately 2:30 p.m., Surveyor observed Resident #1 laying directly on his back with the only pillow in bed noted to be that under his head. There was no pillow supporting the resident's dependent right arm. Staff did not consistently offload the heels and support the resident's right arm on a pillow as directed on the current care plan. Staff did not update the care plan to include checking the placement of the wound vac tubing during repositioning to ensure there would be no further development of pressure areas from the tubing. Surveyor interviewed CNA B on [DATE] at 1:10 p.m. CNA B stated that Resident #1 was repositioned every 2 hours and he should have heel protectors on bilaterally with his feet elevated on a pillow so his heels were off the bed. When CNA B and Surveyor checked Resident #1's positioning, it was noted he had thin, tight fitting heel protectors on bilaterally and that his feet had moved off the pillow and were positioned on the mattress with his heels pressing into the mattress. CNA B repositioned the resident's feet on the pillow with his heels off the bed. Surveyor was unable to observe Resident #1's right buttock pressure ulcer as the dressing change was not scheduled during the days of survey. Surveyor did not observe the status of the abrasions/pressure ulcers identified on [DATE] due to the resident's resistance to staff when approached for cares. Surveyor interviewed the Nursing Home Administrator (NHA) and the DON on [DATE] at 1:25 p.m. at which time concern that Resident #1 was readmitted with a pressure ulcer on [DATE] which then worsened was discussed. The DON identified she had been in her new role as DON for less than 1 week and added that the previous DON had been the wound nurse. The DON identified that another nurse had been doing wound measurements but was not wound certified. The NHA and the DON confirmed there was no one currently in the facility who was wound certified. Surveyor interviewed the Director of Nursing (DON) and RN A on [DATE] at 4:50 p.m. during the exit meeting and encouraged the DON and RN A to submit any and all additional information related to pressure ulcer prevention and treatment provided for Resident #1. There was insufficient evidence provided to ensure the facility had provided appropriate and consistent assessments, care planning, treatments, notification, and documentation related to Resident #1's right buttock pressure ulcer and his risk for developing subsequent pressure ulcers. The following record was reviewed as a closed record. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to nurses' notes on the day of admission, the Braden score was 18 which indicated a low risk for pressure ulcers and the skin assessment identified numerous bruises and/or skin tears to the upper extremities bilaterally and to the lower left extremity, "...left buttocks is all bruised purple in color." There was no documentation of any skin impairment to the right lower extremity or right buttock area. Resident #2's admission MDS dated [DATE] identified no cognitive impairment; the need for limited staff assistance with ADL's including bed mobility and transfers; no bowel or bladder incontinence; frequent pain; and risk for pressure ulcers but no documentation of a current pressure ulcer. Skin treatments included pressure-relieving devices for the chair and bed and a turning/repositioning program. The associated Care Area Assessment (CAA) related to pressure ulcers identified there were no pressure ulcers at that time but that a care plan would be developed due to the resident's risk for impairment of skin integrity. It was stated the resident had decreased ability to participate in ADL's due to