Every finding on record at Christian Community Home

Based on observation and interview, the facility failed to distribute food under sanitary conditions. Gloves were not used appropriately, and food was handled without proper hand hygiene. This has the potential to affect all 35 residents who reside in the facility. The facility policy and procedure titled: General Food Preparation and Handling last reviewed on 05/2025 states under section 3 of policy, Food Preparation,*g. Bare hands should never touch ready to eat raw food directly/ Disposable gloves are a single use item and should be discarded after each use. Employees should wash hands prior to putting gloves on and after removing gloves. *h. Food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. * .f. Tongs or other serving utensils will be used to serve breads or other items to avoid bar hand contact with food. On 04/07/2026 at 11:22 AM, Surveyor conducted observation of [NAME] H with gloved hands. [NAME] H, without removing gloves and conducting hand hygiene, proceeded to do the following until all resident meals were served: *Held the handle of deep-fryer basket, tipped the basket, and dropped a piece of deep-fried fish into a wired tray. *Held the piece of deep-fried fish, placed on prep table and while holding one end of the fish, used a knife to cut the fish into bite size pieces. *Picked up the cut pieces of fish and placed them on a serving plate.*Used a sanitized wet cleaning cloth to wipe down prep table crumbs into a metal container. *Turned the knob on stove with frying pan on top to make an omelet.*Opened the fridge door and removed a container of shredded cheese, grabbing a handful of cheese and putting it into frying pan. *Picked up a squeeze bottle of oil and drizzled into frying pan. *Opened a bag of bread, grabbed a slice of bread and placed in toaster pushing down toaster knob. *Opened the fridge door taking out containers of ham and liquid eggs.*Poured the liquid eggs into pan. *Reached into container of ham taking a handful and placed into frying pan. *Opened the fridge and put away the containers of ham and liquid eggs. *Picked up a slice of toast and placed on prep table, holding onto one end of the toast, buttered toast with a knife and picked up buttered toast and placed on a serving plate. *Turned back to making omelet on stove and reached into the container of shredded cheese for a handful of more cheese and sprinkled on top of the omelet. On 04/07/2026 at 11:40 AM, Surveyor conducted observation of Lead [NAME] I. Lead [NAME] I, with gloved hands and without removing and conducting hand hygiene, proceeded to do the following: *Took out a frying pan and placed it on stove. *Picked up a squeeze bottle filled with oil and drizzled into frying pan. *Opened the fridge door and removed separate containers of ham, green peppers, onions, and shredded cheese. *Grabbed a handful of each content and placed in frying pan. On 04/07/26 at 11:43 AM, Surveyor interviewed [NAME] H and Lead [NAME] I regarding observation of meal prep tasks and expectations of removing gloves, conducting hand hygiene and touching food. Both [NAME] H and [NAME] I confirmed observation of not conducting proper hand hygiene/removal of gloves and touching food with contaminated hands. Both [NAME] H and Lead [NAME] I indicated the expectation would be to not touch foods at any time with contaminated gloves/hands. On 04/07/2026 at 12:24 PM, Surveyor interviewed Dietary Manager (DM) J regarding observations of lack of hand hygiene and glove removal with food contact during meal service tasks. DM J stated the expectation would be staff should not touch food with contaminated gloves and to conduct hand hygiene between each task.

Based on interview and record review, the facility did not evaluate care plans for effectiveness and revise following each required assessment for 6 residents (R3, R5, R7, R21, R26, R28) of 12 resident care plans reviewed for care plan timing and revisions in a sample of 12 residents. Resident care plans were tagged as overdue in electronic medical records with no revision dates or updated target dates. Resident care plans did not have updated interventions in place and/or interventions between comprehensive care plans and certified nursing assistant (CNA) care plans for same resident had discrepancies for cares. This could result in physical, mental and psychosocial harm to residents because care plans were not revised in a timely manner to reflect current goals and interventions according to residents' needs. Findings include: The facility policy, titled Resident Assessment and Care Plan Policy, last revised 01/2025, states in part: It is the policy of the facility that the Interdisciplinary Team (IDT) in collaboration with the resident and/or representative will complete a comprehensive assessment and develop a comprehensive care plan for each resident.the care plan will be reviewed at least every 3 months and as often as changes occur in the resident's condition and will be revised to maintain accuracy. Example 1 R3 was admitted to facility on 04/28/2022 and has medical diagnosis that includes multiple sclerosis, neuromuscular dysfunction of bladder, cognitive communication deficit, dementia. R3 has a Brief Interview for Mental Status (BIMS) score of 7/15, severe cognition impairment, chronic pain. Review of R3's care plan had goals and target dates which were not updated or revised during IDT reviews as follows:- Alteration in/potential for alteration in comfort. Resident will experience relief of pain as evidenced by verbal report of relief of pain. Date initiated: 04/28/2022, target date 07/31/2025. No revision dates indicated. Interventions initiated 01/16/2025. - [R3] has a psychosocial well-being problem related to diagnosis of multiple sclerosis and poor coping skills. [R3] will continue to use coping mechanisms. Date initiated: 05/09/2022, target date 01/28/2026. No reviewed/revised dates since target date. - [R3] has urinary dysfunction related to multiple sclerosis, urinary retention, neurogenic bladder as manifested by need for indwelling catheter. Goal. is to minimize risk for septicemia. Date initiated: 08/01/2024. Target date 01/31/2026. Interventions include indwelling catheter as ordered with initiation date of 10/27/2025. On 01/14/2026, R3 had a suprapubic catheter (a tube placed directly into the bladder which helps drain bladder of urine. Used for long-term, chronic retention of urine. Tube exits body slightly above the pubic region) inserted to replace the Foley catheter (tube place into bladder through the urethra to drain bladder of urine) R3 previously had. R3's comprehensive care plan was not updated to reflect placement of suprapubic catheter with emphasis on goals and interventions. On 03/16/2026, a physician order from urology stated R3 could proceed with tub baths. To note: R3 was not permitted to have a tub bath/shower up to this date because of post operative instructions, dated 01/14/2026, to not submerge surgical wound in water. The certified nursing assistant (CNA) care plan, last updated on 03/24/2026, states, Foley Cath=no baths/showers. CNA care plan was not updated to reflect physician order for R3 to have baths/showers, or presence of a suprapubic catheter instead of a regular Foley catheter. Suprapubic catheter care requires additional assessments for signs of insertion site infection, as well as precautions to be in place to reduce risk of catheter occlusion, accidental removal and replacement by urology when needed. - [R3] has neurological impairment related to multiple sclerosis. Goal is [R3] will remain free of complications or discomfort.through review date. Date initiated: 08/01/2024. Target date: 01/20/2025. No revised/reviewed dates since target date. - IDT quarterly review dates for the past year for R3 were 04/16/2025, 07/09/2025, 10/15/2025, 01/14/2026. Example 2 R21 was admitted to the facility on [DATE] with diagnoses that include repeated falls, dementia, aphasia following cerebral infarction (brain stroke), congestive heart failure, arthritis. Review of R21's care plan had goals and target dates which were not updated or revised during IDT reviews as follows: - [R21] has assisted with daily living (ADL) dysfunction related to congestive heart failure, dementia, and arthritis. Goal is [R21] will continue to participate in ADLs as able through review date. Date initiated: 01/24/2024. Target date: 05/04/2025. No revisions have been made since 2025. Most recent intervention indicates date of 02/11/2025. - [R21] has a mobility impairment and is at risk for falls due to history of falls, dementia.Goal is [R21] will remain safe in her environment. Date initiated 07/21/2023. Target date: 05/04/2025. No revisions have been done since target date. - [R21] has bladder incontinence related to dementia.Goal is risk for septicemia will be minimized. Date initiated 01/20/2025. Target date 10/31/2025. No revisions since target date. - IDT quarterly reviews for R21 done on 07/09/2025, 10/08/2025, 01/07/2026 and 04/07/2026. Example 3 R28 was admitted to the facility on [DATE] and has diagnoses that include repeated falls, Parkinson's disease, incontinence and skin breakdown. Review of R28's care plan had goals and target dates which were not updated or revised during IDT reviews as follows: - [R28] is at high risk for falls.Goal is [R28] will follow her care plan and ask for assistance. Date initiated 05/22/2024 with target date 02/19/2025. No review or revisions since target date. Last intervention implemented was dated 02/07/2025. R28 has had 17 fall incidents documented in medical record since last target date. - The resident experiences urinary and bowel incontinence.Goal is resident will remain free from skin breakdown due to incontinence. Date initiated 12/09/2025 with target date 11/26/2025. R28 has a sacral ulcer being treated, as documented by registered nurses performing wound care in R28's medical record. - R28's CNA care plan, last updated 03/24/2025, indicated R28 is a Hoyer lift (mechanical device used for transferring persons unable to transfer selves) transfer. R28's comprehensive care plan does not have interventions in place for transferring and/or utilizing the Hoyer lift device. On 04/07/2026 at 10:45 AM, Surveyor asked Director of Nursing (DON) B what the process was for implementing and revising resident care plans. DON B stated all staff can fill out a care plan update form kept at the nurses' station. This form is then placed into a binder, also at the nurses' station. Nurse manager (NM) Q and Restorative coordinator (RC) L update the resident care plans accordingly. DON B stated no other staff can make electronic revisions to the care plans. CNA care plans are updated at least weekly, and copies are at nurses' station for CNA to use as a reference. On 04/08/2026 at 10:23 AM, Surveyor asked Nurse Manager (NM) K how often resident care plans are revised. NM K stated at least quarterly. Surveyor asked NM K why the care plans did not have revisions done since initiation dates. NM K stated all care plan interventions were reviewed and updated to the best of IDT's knowledge. NM K acknowledged care plans did not indicate revision dates or updated target dates by the IDT reviews. Example 4 R7 was admitted to the facility on [DATE] with unspecified dementia with psychotic disturbance. R7's care plan, dated 02/24/25, with a target date of 12/10/25, states: [R7] has a history of making sexually inappropriate comments towards female staff with a goal to have fewer than 1 episode per week of sexually inappropriate comments towards others by the next review date. Surveyor reviewed R7's behavior monitoring and noted no sexually inappropriate behaviors documented after the target date. No additional revisions or updates to this care plan noted. Example 5 R7 was admitted to the facility on [DATE]. R7's most recent therapy assessment, dated 09/19/25, noted use of EZ stand for transfers. No additional therapy assessments documented. R7's care plan, dated 12/24/24, with a target date of 12/31/25, states: [R7] has impaired mobility and a low falls risk with a goal to be free from falls through review date. Interventions include Ambulation: Does not walk. Bed Mobility: See CNA care plan. Cue to stand tall when using EZ stand. Ok to leave on EZ-stand while on toilet. Transfers: See CNA care plan. On 03/11/26, R7's hospice care plan noted transfer assist with EZ stand. R7's CNA care plan, with an updated date of 03/24/26, noted R7's transfer status as a Hoyer lift and EZ stand for toileting. Surveyor reviewed R7's medical chart and noted: On 03/31/26 at 4:46 AM, the facility nurse documented a skin/wound note stating staff reported two new large bruises on R7's right upper chest/axillary region. Upper bruise measured 12 cm x 12 cm and lower bruise measured 12 cm x 4 cm. R7 stated unsure of how bruises occurred but agreed with nurse the EZ stand may be the possible cause. Staff did not see the bruises on R7 during previous day. No documentation of pain assessment or range of motion (ROM) assessment completed. No documentation from the hospice provider notified of new bruises at this time. No documentation of request to have R7's transfer ability assessed by therapy. On 03/31/26 at 4:27 PM, as needed (PRN) pain medication was administered for pain rated at 10/10 (severe pain). At 6:11 PM, follow-up pain score of 10/10 and medication was ineffective. Nursing note states R7 is in excruciating pain whenever being lifted in EZ stand due to bruising. No documentation of notifying facility provider or hospice provider of increased pain with use of EZ stand during transfers. On 03/31/26 at 10:14 PM, a nursing note documented R7 having a lot of pain in area of new bruises. CNAs used the Hoyer lift rather than the EZ stand because the EZ stand caused R7 too much pain and R7 would scream/yell the whole time. No documentation of communicating change of transfer status noted or notifying hospice provider in change of transfer status. On 04/02/26 at 5:37 AM, the facility contacted the hospice provider. Hospice notes document facility reporting new onset of pain after recent transfer using EZ stand. The facility nurse reported assessing R7's shoulder after multiple doses of pain medication and noted a significant asymmetrical appearance to R7's left shoulder and concerned it may be dislocated. Hospice provider orders a hospital transfer for evaluation. Hospice provider was not notified of bruising or change in transfer status at this time. Surveyor reviewed R7's hospital after visit summary and noted no acute fracture or dislocation and pain was likely due to an old shoulder surgery. On 04/07/26 at 2:05 PM, Surveyor interviewed Director of Nursing (DON) B regarding communicating changes in transfer status. DON B stated a care plan update is filled out and placed in the communication binder at the nursing station. Then, Restorative Coordinator L updates the CNA care plan with changes. On 04/07/26 at 2:22 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F regarding how staff are updated with transfer status changes. CNA F stated during shift report, in the communication binder at nursing station, and on the CNA care plan. Surveyor asked CNA F what R7's transfer status is currently. CNA F pulled a CNA care plan from his pocket and stated R7 is a Hoyer lift. Surveyor asked CNA F what it meant on R7's transfer status under toileting where it said EZ stand. CNA F stated he was unaware of that transfer status as aides only look at the mobility section. CNA F stated during the past month, he thought R7's transfer status was always a Hoyer lift assist. On 04/07/26 at 2:56 PM, Surveyor interviewed CNA G regarding how staff are informed of changes in transfer status. CNA G stated during shift report and on CNA care plan. Surveyor asked CNA G if the CNA care plans currently at the desk were current. CNA G stated yes. Surveyor showed CNA G the date of 03/24/26 of the CNA care plan currently at the desk and asked if this was the current care plan. CNA G stated yes. Surveyor asked CNA G what is R7's current transfer status. CNA G stated R7 is a Hoyer lift. Surveyor asked CNA G for clarification of the toileting mobility as stated for the EZ stand lift. CNA G stated aides do not look at that because it didn't make sense anyway because if a resident is a Hoyer lift for transfers, then they use a Hoyer lift for all transfers – including toileting. Surveyor asked CNA G if she knew about the incident documented on 03/31/26 resulting in R7's bruising. CNA G stated she wasn't working that day but knew about it. CNA G thought the RN supervisor on-duty changed the status from EZ stand to Hoyer lift because R7 was having pain with transfers. On 04/07/26 at 3:11 PM, Surveyor interviewed DON B regarding R7's transfer status and findings during interviews. Surveyor showed DON B the CNA care plan which was at the nursing station with the date of 03/24/26 and asked DON B if the date noted was accurate. DON B stated it was. Surveyor asked DON B if this would be the most up-to-date care plan for staff to use to identify transfer assistance needed. DON B stated yes. Surveyor asked DON B what the expectation would be for staff to communicate changes in transfer status. DON B stated the expectation would be to communicate the changes in the communication binder, verbally update staff on-duty, and likely get therapy involved for further assessments. DON B stated it would also be expected for some kind of progress note to be entered into the resident's chart if this were to happen. On 04/08/26 at 8:28 AM, Surveyor interviewed Nurse Manager K regarding R7's transfer status and incident which occurred on 03/31/26. Nurse Manager K stated he was not in the facility last week when this occurred and did not become aware of it until 04/06/26. Nurse Manager K stated he was confident at the time of the incident on 03/31/26, R7 was an EZ stand transfer, and this wasn't changed to a Hoyer lift until after the incident but unable to state when the change in transfer status occurred or when it was communicated to staff. On 04/08/26 at 10:50 AM, Surveyor interviewed DON B regarding R7's transfer status and the incident on 03/31/26. DON B stated she spoke with the Restorative Coordinator L and R7's CNA care plan was updated on 04/01/26 but was unsure how or when this was communicated to all nursing staff. DON B stated recognition having both the Hoyer lift transfer assist and EZ stand assist for toileting with the date of 03/24/26 is confusing and hard to determine when this change occurred. Surveyor asked DON B if hospice should have been contacted to evaluate R7's transfer status. DON B stated yes. On 04/08/26 at 12:30 PM, Surveyor interviewed Restorative Coordinator L, who stated that she is responsible for updating the CNA care plan for all residents. Restorative Coordinator L stated that she recalls specifically updating R7's care plan on 04/02/26 as that was the day R7 went to the ER to be evaluated. Restorative Coordinator L provided Surveyor with the care plan communication form, dated 04/02/26, updating R7's transfer status to a Hoyer lift with transfers and EZ stand for toileting. Restorative Coordinator L stated prior to 04/02/26, no one had communicated any other transfer status changes. Example 6 R26 was admitted to the facility on [DATE] with mononeuropathy of left lower limb. R26's care plan, dated 10/24/25, with a target date of 10/24/25, states: [R26] has general chronic pain managed with medications and a goal that [R26] will not have an interruption in normal activities due to pain through review date and resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through review date. No additional updates were made to care plan to indicate review of goals by target date or revision of interventions were documented. Example 7 R5 was admitted to the facility on [DATE] with the following pertinent diagnosis; encounter for palliative care, cerebrovascular disease, type 2 diabetes mellitus with diabetic neuropathy, and atherosclerotic heart disease. R5's care plan initiated 1/5/26 with a target date of 4/5/26, indicated focus area of skin integrity: Alteration or potential for alteration in skin integrity with a goal of no skin breakdown throughout stay. Interventions included, daily skin observation with cares, report new or worsening concerns to nurse immediately, float heels, house lotion to dry skin with cares as needed, skin risk assessment per facility policy, and turn and reposition q (every) 2-3 hours. R5 developed open wounds on 2/5/26. No updates or interventions were added to R5's care plan and target date indicated R5's care plan was not reviewed or revised.

Based on 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 form 1 of 1 resident (R1) reviewed for dialysis.R1 did not have current physician orders for dialysis, physician ordered fluid restrictions were not monitored, care plan did not include transportation logistics, and the facility did not establish regular communication with R1's dialysis provider.This is evidenced by:Facility policy titled, Care for residents with Hemodialysis, with a reviewed date of 01/2026 states in part: Policy: It is the policy to ensure the safe and efficient coordination of off-site hemodialysis services for residents requiring such treatment. The facility assists with arranging transportation, maintaining communication with the dialysis center, and monitoring the resident's condition before and after treatment. All staff involved must ensure adherence to physician orders, resident rights, and continuity of care. Procedure: 2. Residents receiving hemodialysis will have a care plan incorporating dialysis treatment days, potential side effects, transportation logistics, dietary needs, and psychosocial support. 4. Facility will send updated information with resident to appointment which will include: a. Facesheet b. H&P and DC summary c. POA documentation d. Current medication and treatment list e. Transfer Form f. Recent Vitals g. Any other pertinent information.Facility policy titled, Fluid Restrictions and Sample Distribution of Fluids, with no date, states: Policy: Fluid restrictions will be followed per physician's orders and following the procedures below. Procedure: 1. The amount of fluid allowed per 24-hour period will be specified in a written physician's order.Facility policy titled, Intake and Output, with a reviewed date of 08/2023, states in part: Policy: The nursing staff maintains an intake and output record when needed to monitor residents for adequate fluid balance and to prevent dehydration. Intake and/or output may be initiated for, but not limited to: g. Residents with fluid restrictions.R1 was admitted to the facility on [DATE] with diagnoses of hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, type 2 diabetes mellitus with diabetic polyneuropathy, dependence on renal dialysis.R1's care plan, dated 02/27/23, with a target date of 04/16/26, states: [R1] has a renal impairment related to end-stage renal disease and needing hemodialysis with a goal to have immediate intervention should any s/sx of complications from dialysis occur through the review date. Interventions include: Encourage [R1] to go for the scheduled dialysis appointments. [R1] receives dialysis 3x/week. Fluid restriction per MD order. Monitor intake and output. R1's CNA care plan, updated 04/03/26, states: General: Dialysis M-W-F; Must be ready by 5:20 AM up front to leave; 1500ml fluid restriction.-Of note: care plan does not include where R1's dialysis occurs or who provides transportation.R1's physician orders:07/02/24 Fluid restriction per day 1080mL allotted for meals, 420mL for nursing with meals every shift no water mugs at water pass.Surveyor reviewed R1's fluid intake:November 2025:-11/02/25 1560 ml-11/04/25 1530 ml-11/06/25 2000 ml-11/15/25 1560 ml-11/18/25 no documentation for evening entered.-11/19/25 no documentation for days entered.-11/23/25 1680 mlDecember 2025:-12/04/25 1680 ml-12/07/25 1520 ml-12/27/25 1680 mlJanuary 2026:-01/03/26 no documentation for nights entered.-01/04/26 1850 ml-01/06/26 1530 ml-01/21/26 no documentation for evening entered.-01/23/26 no documentation for days entered.-01/25/26 1920 ml-01/29/26 1580 mlFebruary 2026:-02/01/26 no documentation for evening entered.-02/07/26 1680 ml-02/08/26 no documentation for days entered.-02/17/26 no documentation for evening entered.-02/18/26 no documentation for evening entered.-02/28/26 1580 mlMarch 2026:-03/01/26 1770 ml-03/05/26 1560 ml-03/08/26 no documentation for days entered.-03/22/26 1560ml-03/31/26 1560mlOf note: fluid intake does not include a daily tally for review. No documentation of review of daily fluid intake noted. No provider notification of R1 exceeding 1500 ml intake documented.On 04/06/2026 at 12:22 PM, Surveyor interviewed R1 regarding dialysis. R1 stated that he receives dialysis on Monday, Wednesday, and Friday. Surveyor asked R1 how dialysis communicates with the facility after appointments. R1 said, What communication? Dialysis doesn't give me anything to bring back. Surveyor asked R1 if any information from the facility is taken to dialysis to communicate. R1 stated no.On 04/07/26 at 10:32 AM, Surveyor interviewed Registered Nurse (RN) C regarding R1's dialysis communication. RN C stated they send R1 to dialysis with a patient packet containing recent vitals, meds, and any necessary info. Surveyor asked how the facility receives communication from the dialysis unit. RN C stated the dialysis unit will either fax or call the facility with any concerns or changes, but do not typically send any other communication with R1 after dialysis appointments. Surveyor asked RN C where the communication from the dialysis unit is kept. RN C stated in R1's paper chart under physician orders. RN C showed Surveyor R1's paper chart and noted one communication from dialysis unit on 03/03/26 for a medication order. No other dialysis communication was noted. Surveyor asked RN C how R1's fluid restriction was monitored. RN C stated that it is documented by CNAs during meals how much fluid was drank 3 times a day, but was unable to state who monitors the total 24 hour intake. Surveyor asked RN C what would be expected of the nurse if R1 goes over the fluid restriction. RN C stated she wasn't sure, but probably notify the provider.On 04/07/26 at 12:23 PM, Surveyor interviewed RN D regarding R1's dialysis. Surveyor asked RN D about communication with the dialysis unit. RN D stated a patient packet gets sent with R1. Surveyor asked RN D if the facility receives any communication from the dialysis unit after appointment. RN D stated yes and that it is kept in R1's paper chart under the dialysis tab. RN D showed Surveyor R1's chart and noted no tab for dialysis. RN D then stated that she wasn't sure where the dialysis communication was kept as she doesn't care for R1 very often, but thought it was in there. Surveyor asked RN D how R1's fluid restriction is monitored. RN D stated R1's intake is documented with meals by CNAs, but the day nurse does not tally or review intake.On 04/07/26 at 12:27 PM, Surveyor interviewed Health Unit Coordinator (HUC) E regarding dialysis. HUC E stated, I guess if it isn't in the chart. HUC E then explained to Surveyor that the dialysis unit rarely contacts the facility anymore. Surveyor asked HUC E for more information. HUC E stated that she couldn't remember when, but quite a while ago, the dialysis unit asked the facility to stop sending a patient pack with R1 to dialysis appointments. Surveyor asked if R1 returns to the facility with any communication from dialysis appointments. HUC E stated no, not for a long time, unless they update orders or have a concern - otherwise nothing comes back with R1.On 04/07/26 at 2:22 PM, Surveyor interviewed Certified Nursing Assistant (CNA) F regarding R1's fluid restriction. CNA F stated that aides only enter the intake during meals but do not tally the total intake for a 24-hour period.On 04/08/26 at 10:13 AM, Surveyor interviewed Director of Nursing (DON) B regarding R1's dialysis care. Surveyor asked DON B if there were current physician orders for R1's dialysis. DON B stated no that they were still using the original admission orders from 01/15/23. DON B stated being unsure how they were never renewed but should have. Surveyor asked DON B about the facility's process for communicating with the dialysis unit. DON B stated she just became aware that R1 was no longer taking a resident packet with to dialysis and that dialysis does not send back a daily communication form. DON B stated this should have been documented but wasn't. Surveyor asked DON B how staff monitor R1's fluid restriction. DON B stated that each shift enters the fluid intake, and the expectation is for the night nurse to review the 24-hour total. DON B stated she just became aware this was not being reviewed and monitored daily.

Based on observation, interview, and record review, the facility did not ensure that residents (R) received treatment and care in accordance with professional standards of practice for 2 out of 3 residents reviewed for hospice care (R5, R7).The facility did not ensure weekly wound assessments and did not assess wound treatment plan for effectiveness or provide interventions for R5's arterial wound.The facility did not immediately update R7's hospice provider when bruising was discovered, change in transfer status, and new/worsening pain.Findings include: Example 1 The facility's policy titled, Skin Alteration Policy and Procedure, not dated, states in part, .Skin Alteration/Wound Assessment/Documentation .F. Document the description of the skin alteration including: 1. Location 2. Size -record in centimeters (cm's) from wound edge to wound edge using head to toe 12-6/3-9 techniques.3. Record reddened or denuded skin surrounding the wound as a separate component. 4. Identify the type of skin alteration: a. All other wounds are identified as partial or full thickness b. Acute wounds are identified as less the 12 weeks oldc. Chronic wounds are greater than 12 weeks a. Pressure Injury (only pressure injuries are staged) b. Arterial Ulcer c. Venous/Vascular Ulcer d. Diabetic e. Mixed Lower Extremity Ulcer f. Surgical Wound g. Skin Tear h. Abrasion i. Other (rashes, cancerous lesions, herpes zoster, shingles, etc.) 5. Measurement: i. Length.ii. Width. iii. Depth. iv. Irregular shaped wounds. v. undermining and/or tunneling6. Staging.7. Drainage. a. amount. b. Type. c. Color. d. Odor.8. Wound Bed a. Necrotic/ Eschar. b. Slough. c. Granulation.9. Surrounding Skin.10. Signs of Infection.11. Pain. Skin Alteration/Wound Management and Treatment.A. Eliminate or reduce cause of pressure.G. Notify the Director of Nursing (DON) to incorporate into weekly skin rounds.I. Review/Update the residents Plan of Care (POC), Certified Nurse Assisitant (CNA) assignment sheet.J. Re-evaluate with each dressing change and update residents attending health care provider if area worsens.L. Continually re-evaluate/revise POC as necessary. Skin Alteration Documentation. B. Initial wound assessment and weekly updates are documented in the Medical Record via Electronic Health Record (EHR)Weekly Skin Rounds/ Quality Assurance ReviewPolicy: Weekly wound rounds are completed to determine the progress of healing, the presence of possible complications'. and the status of the area and the area surrounding. Procedure: .2. Wound rounds are done by Certified Wound Nurse. R5 was admitted to the facility on [DATE] with diagnoses including encounter for palliative care, cerebrovascular disease, type 2 diabetes mellitus with diabetic neuropathy, and atherosclerotic heart disease. The Minimum Data set (MDS) dated [DATE] indicates R5 had a Brief Interview for Mental Status (BIMS) of 15/15, which indicated R5 is cognitively intact. R5's MDS indicated R5 was at risk for pressure injuries, had no wounds present, and to have pressure reducing devices for bed. R5's care plan initiated 1/5/26 indicated focus area of skin integrity: Alteration or potential for alteration in skin integrity with a goal of no skin breakdown throughout stay. Interventions included, daily skin observation with cares, report new or worsening concerns to nurse immediately, float heels, house lotion to dry skin with cares as needed, skin risk assessment per facility policy, and turn and reposition q 2-3 hours. On 4/07/26 at 8:10 AM, Surveyor observed Certified Nursing Assistant (CNA) T perform morning cares for R5. Surveyor observed on R5's left foot, a bandage below big toe on outer edge of foot with approximately 1 to 2 cm drainage noted though back of bandage. There was nothing (no date) written on the bandage. CNA T stated she was unsure of when bandage was placed on R5's left foot. On 4/07/26 at 8:32 AM, Surveyor interviewed Registered Nurse (RN) C, who reported R5's dressing change is done on PM shift. RN C also informed Surveyor, R5 was no longer on Hospice as of 4/3/26. Record review indicated R5 had a scab on the L (left) MTP (Metatarsophalangeal) as of 2/3/26. On 2/5/26, a physician's order note indicated hospice order change reads in part, . 1. Left MTP joint: Cleanse with NS, apply NSB, cover with mepilex q (every) 3days and PRN (as needed) until resolved. Resident/family/responsible party notified of change: On 2/7/26, R5's progress note indicated right foot on the MTP joint area measured 1cm by 0.75cm and included the following description of alteration: Reddened area, condition of surrounding tissue: WNL (with in normal limits), treatment initiated: Float feet when in bed, notifications: MD. R5's records indicated dressing changes continued as ordered and every 3 days. R5 did not have new interventions put in place for R5's wound. R5's wound assessments were incomplete and there was no indication that wound status was reviewed. R5's wound documentation includes in part, On 3/13/26 at 5:01 PM, . Residents L MTP joint is pail in color with no redness. The joint has a circular wound that has progressively been tunneling deeper into the foot in the middle with serious purulent weeping out. The resident's MPT dressing was changed as ordered. On 3/25/26 at 11:11 PM, . Left MTP joint dressing changed per poc (Plan of Care) Moderate serous drainage to old dressing, no foul odor present. Wound is circular in shape, wound bed in center is pencil-eraser sized with tan, white and yellow tissue. This center is surrounded by a white epidermis approximately 2mm. Surrounding skin is normal for resident. No c/o (complaints of) pain or discomfort during dressing change. On 3/31/26 at 11:09 PM, . Left MTP joint dressing changed per poc Skin concern is circular in shape, white/yellow in color, serous drainage noted to previous dressing, no foul odor noted, no c/o pain. On 4/6/26, . Left MTP joint had small amount of drainage to old dressing. No c/o pain during procedures. Record review indicated R5's last dressing change was documented on 4/5/26 at 3:47 PM by Licensed Practical Nurse (LPN) S. Documentation reads in part, . L (left) MTP (Metatarsophalangeal) joint dressing was changed d/t (due to) wound drainage visible through previous dressing. Area is white centered, slightly macerated in appearance. Skin surrounding wound is pink and dry with no signs of infection. On 4/07/26 at 2:27 PM, Surveyor asked Director of Nursing (DON) B for documentation for R5's wound assessments. DON B stated hospice must have been taking care of the wound assessments, and the facility has not completed a wound assessment with measurements on R5's wound. DON B stated she just went down and measured the wound and sent for a new wound care order. On 4/08/26 at 7:11 AM, Surveyor interviewed DON B, who stated the expectation would be that weekly skin assessments be completed by a wound care nurse and evaluated to ensure improvement. DON B agreed that new wound care interventions were not put in place before today. On 4/08/2026 at 8:40 AM, Surveyor interviewed CNA R, who reported R5 has her own personal mattress. CNA R is unaware of any interventions added to R5's cares to prevent further skin breakdown/worsening of the wounds. On 4/08/26 at 8:42 AM, Surveyor questioned DON B about documentation of wound tunneling. DON B stated the documentation was completed by a new nurse. R5 does not have any tunneling and education on wound assessments will be provided. Example 2 R7 was admitted to the facility on [DATE] On 02/24/26, R7 was admitted to hospice services. Surveyor reviewed R7's medical record and noted: On 03/31/26 at 4:46 AM, facility nurse documented a skin/wound note stating staff reported two new large bruises on R7's right upper chest/axillary region. Upper bruise measured 12 cm x 12 cm and lower bruise measured 12 cm x 4 cm. R7 stated unsure of how bruises occurred but agreed with nurse that EZ stand may be the possible cause. Staff did not see the bruises on R7 during previous day. No documentation of pain assessment or range of motion (ROM) assessment completed. No documentation of hospice provider notified of new bruises. On 03/31/26 at 4:27 PM, as needed (PRN) pain medication was administered for pain rated 10/10. At 6:11 PM, follow-up pain score of 10/10 and medication was ineffective. Nursing note states R7 is in excruciating pain whenever being lifted in EZ stand due to bruising. No documentation of notifying hospice provider of increase in pain and ineffective interventions. On 04/02/26 at 12:30 AM, R7 was administered PRN pain medication for pain rated 9/10. No documentation of pain location noted. At 4:20 AM, follow-up pain assessment noted as unknown. On 04/02/26 at 5:00 AM, R7 was administered PRN pain medication for PAINAD score 9/10. No documentation of pain location noted. At 5:40 AM, follow-up pain assessment noted as unknown with nursing note stating R7 appeared comfortable, respirations even and unlabored. On 04/02/26 at 5:37 AM, hospice notes document facility reporting new onset of pain after recent transfer using EZ stand. Facility nurse reported assessing R7's shoulder after multiple doses of pain medication and noted a significant asymmetrical appearance to R7's left shoulder and concerned it may be dislocated. Hospice provider orders a hospital transfer for evaluation. Hospice provider was not notified of bruising or change in transfer status at this time. -Of note: this assessment of change in R7's asymmetrical left shoulder appearance is not documented in R7's facility medical chart. On 04/08/26, Surveyor attempted to interview nurse who documented bruising, change in transfer status, and new worsening pain and was unable to reach them. On 04/08/26 at 10:50 AM, Surveyor interviewed DON B regarding R7's incident on 03/31/26. Surveyor asked DON B what would be expected of staff when changes are assessed in residents. DON B stated that after R7's bruises were discovered and staff felt they were from the EZ stand, hospice should have been updated with the changes right away. DON B stated that with R7's new pain, this should have been communicated right away with hospice for reassessment of care plan.

Based on observation, interview and record review, the facility did not develop and implement a comprehensive care plan for 2 residents (R21, R26) of 2 residents reviewed for wandering/elopement in a sample of 12 residents. R21 and R26 were identified by the facility to have be at risk for elopement and had Wanderguard bracelets (an alarm system to warn the facility if a resident attempts to elope from the facility) in place to alert staff to attempts by R21 and R26 to elope from facility. R21 and R26 do not have care plans with interventions in place to identify and reduce risk for elopement which could result in physical harm to residents in the event of actual elopement. Findings include: Example 1 R21 was admitted to the facility on [DATE] with diagnoses that include repeated falls, dementia, aphasia following cerebral infarction (brain stroke). R21 does not have a Brief interview for Mental Status (BIMS) score indicated, as per facility documentation, unable to obtain. On 04/06/2026 at 12:27 PM, Surveyor observed R21 transfer self from wheelchair to bed. No staff were present in room. A Wanderguard bracelet was attached to metal frame of R21's wheelchair. On 04/07/2026 at 7:45 AM, Surveyor asked Certified Nursing Assistant (CNA) Q about R21's mobility status. CNA Q stated R21 was able to transfer self between wheelchair and bed and occasionally to the bathroom. CNA Q stated R21 never ambulated outside of her room but did propel self around the facility in wheelchair. CNA Q was aware of Wanderguard placement for R21 but did not know of any actual attempts by R21 to elope from facility. Surveyor asked CNA Q how staff were made aware of R21's risk of elopement and CNA Q stated the CNA care plan has her listed as a wanderer. Surveyor asked CNA Q how staff managed R21 if attempting to leave the facility, and CNA Q stated they would redirect her back to room. R21's medical record had several documentations by nursing of R21 coming out during night hours to the nurses' station, propelling self in wheelchair, asking for snacks or when breakfast was being served. R21 had no elopement risk assessment documentation in medical record since admission. R21's CNA care plan, dated 03/24/2026, noted R21 is identified as Wanderguard/Risk for Elopement. R21's comprehensive care plan did not have goal, target date or intervention in place for wandering or elopement type behaviors. On 04/08/2026, Surveyor observed a list of residents, which included R21 and R26 on it, with wandering/elopement tendencies and pictures of those residents hanging at nurses' stations and at front entrance to facility. On 04/08/2026 at 9:45 AM, Surveyor asked health unit coordinator (HUC) E, whose workstation is located at front entrance, if R21 made attempts to elope from facility. HUC E stated R21 often came to front entrance area in wheelchair to look out the windows and HUC E was aware R21 was at identified by facility as at risk for elopement. On 04/08/2026 at 9:58 AM, Surveyor interviewed director of nurses (DON) B and asked how residents are determined to be at risk for wandering/elopement behaviors requiring the placement of a Wanderguard bracelet. DON B stated elopement assessments are based off resident cognition, mobility status and/or verbal intentions made by residents to leave facility. These assessments are done by the interdisciplinary team (IDT) upon admission in the admission Data Base and then during quarterly IDT reviews. DON B was not aware of an actual elopement risk assessment tool in the electronic medical record that was done for residents. DON B stated care plans are updated at the IDT quarterly reviews and should have interventions in place for residents at risk of elopement. On 04/08/2026 at 10:23 AM, Surveyor asked nursing manager (NM) K, who participates in IDT reviews, how a resident is assessed to be at risk for wandering/elopement type behaviors. NM K stated residents with dementia, or tendencies to go near an entrance were at risk for elopement. NM K was not aware of an elopement risk assessment for residents needing to be done and documented in medical record. NM K acknowledged R21 did not have comprehensive or CNA care plan interventions in place for elopement. Example 2 R26 was admitted to the facility on [DATE] with vascular dementia moderate without behavioral psychotic disturbance. R26's physician order, dated 05/08/25, check Wanderguard daily for placement and function. R26's most recent quarterly Minimum Data Set (MDS) assessment, dated 01/28/26, noted a Brief Interview for Mental Status (BIMS) score of 05/15, indicating severely impaired cognition. R26 has a wander alarm used daily. R26's CNA care plan, dated 03/24/26, noted R26 is identified as Wanderguard/Risk for Elopement. No additional care plan to include goal, target date, or interventions noted. Surveyor reviewed R26's medical record and no elopement risk assessment documented at any point after admission.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation were thoroughly investigated for 1 of 1 resident (R7) reviewed.On 03/31/26, R7 was assessed with 2 new bruises of unknown origin. The facility did not complete a thorough investigation to determine cause of injury. This is evidenced by:Facility policy titled, Abuse, Neglect, Misappropriation, & Exploitation Policy, with a revised date of 11/08/22, states in part: The Nursing Home Administrator or designees will report 'abuse' to the state agency per State and Federal requirements. g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: i. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; ii. The injury is suspicious because of the extent of the injury or the location of the injury, or the number of injuries observed at one particular point in time or the incidence of injuries over time.E. Investigation Components.It is the policy of this facility that reports of 'abuse'.are promptly and thoroughly investigated. Procedure: The facility will immediately begin a thorough investigation of any reported incidence, collect information that corroborates or disproves the incent and document the findings for the incident.The designated facility personnel will begin the investigation immediately. A root cause investigation and analysis will be completed. A thorough investigation is an investigation that adequately addresses the circumstances of the allegation.b. Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out potential abuse.R7 was admitted to the facility on [DATE] with unspecified dementia.R7's most recent significant change Minimum Data Set (MDS) assessment, dated 03/02/26, noted a Brief Interview for Mental Status (BIMS) score of 04/15, indicating severely impaired cognition.Surveyor reviewed facility's self-reported incidents and investigations and noted no investigations completed during the year 2025.On 04/06/26, shortly after entrance conference, Surveyor verified with Nursing Home Administrator (NHA) A that no incidents or investigations were completed regarding abuse, injuries of unknown origin or misappropriation during 2025. NHA A stated no reportable or unreportable events occurred and no investigations were completed during 2025.On 04/07/26, Surveyor reviewed R7's medical record and noted:On 03/31/26 at 4:46 AM, facility nurse documented a skin/wound note stating staff reported two new large bruises on R7's right upper chest/axillary region. Upper bruise measured 12 cm x 12 cm and lower bruise measured 12 cm x 4 cm. R7 stated unsure of how bruises occurred but agreed with nurse that EZ stand may be the possible cause. Staff did not see the bruises on R7 during previous day. Facility provider notified of new bruises with request to monitor until resolved. No documentation of incident reported to the Nursing Home Administrator (NHA).On 04/08/26 at 8:28 AM, Surveyor interviewed Nurse Manager K regarding R7's incident on 03/31/26. Nurse Manager K stated he was not at the facility during the week the incident occurred and did not return until 04/06/26, which is when he became aware of the incident. Surveyor asked Nurse Manager K what the facility's procedure is when a resident with impaired cognition is found to have bruises or injury that was not witnessed. Nurse Manager K stated the nurse on duty would begin an incident investigation and report to Nurse Manager K or DON B right away. Surveyor asked Nurse Manager K if an investigation was initiated to determine the root cause of R7's injury. Nurse Manager K said no. Surveyor asked Nurse Manager K how the facility knows R7's injury was not due to negligence or abuse. Nurse Manager K was unable to answer and stated this incident hasn't been discussed yet in the Interdisciplinary Team (IDT) meeting.On 04/08/26 at 10:33 AM, Surveyor interviewed DON B regarding R7's incident on 03/31/26. DON B stated that she was out of the facility most of the week that this occurred and did not return to the facility until 04/06/26. Surveyor asked DON B when she became aware of the incident. DON B started on 04/06/26. Surveyor asked DON B if an investigation had been initiated to determine the root cause of R7's injuries. DON B stated yes that this definitely should have been investigated or at least started by now.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation 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 policy and procedures for 2 of 2 residents (R7 and R26) reviewed.On 03/31/26, R7 was assessed with 2 new bruises of unknown origin. Facility staff did not immediately report this finding to the Nursing Home Administrator (NHA).On 04/04/26, R26's hearing aids were documented as missing. Facility staff did not report this finding of potential misappropriation of resident's property to leadership.This is evidenced by:Facility policy titled, Abuse, Neglect, Misappropriation, & Exploitation Policy, with a revised date of 11/08/22, states: The Nursing Home Administrator or designees will report 'abuse' to the state agency per State and Federal requirements.Procedure: Internal Reporting: a. Employees must always report any 'abuse' or suspicious of 'abuse' immediately to the Administrator. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law.Facility policy titled, Lost, Stolen, Missing Items, with a revised date of 09/01/21, states: Procedure: Any person may report an incident where the person has information that the resident has a lost, stolen or missing item. Upon learning of a missing item, the staff member notified of the missing item is to immediately fill out the Lost/Stolen/Missing Item form and complete a search of the resident room or area it was last seen in. In addition, this same staff member is to report the lost/missing item to the designee, Social Services .Example 1R7 was admitted to the facility on [DATE] with pertinent diagnoses of unspecified dementia with psychotic disturbance, COPD, malignant neoplasm of unspecified part of right bronchus or lung, mature T/NK-cell lymphomas intrathoracic lymph nodes.R7's most recent significant change Minimum Data Set (MDS) assessment, dated 03/02/26, noted a Brief Interview for Mental Status (BIMS) score of 04, indicating severely impaired cognition.On 04/07/26, Surveyor reviewed R7's medical record and noted:On 03/31/26 at 4:46 AM, facility nurse documented a skin/wound note stating staff reported two new large bruises on R7's right upper chest/axillary region. Upper bruise measured 12 cm x 12 cm and lower bruise measured 12 cm x 4 cm. R7 stated unsure of how bruises occurred but agreed with nurse that EZ stand may be the possible cause. Staff did not see the bruises on R7 during previous day. Facility provider notified of new bruises with request to monitor until resolved. No documentation of incident reported to the NHA.On 04/08/26, Surveyor attempted to contact the nurse who documented the bruising and was unable to reach them.On 04/08/26 at 7:48 AM, Surveyor interviewed Certified Nursing Assistants (CNA) N and O regarding abuse reporting. Surveyor asked CNA N and O when they would be expected to report concerns of abuse. Both CNA N and O stated immediately to Social Services (SS) and Nurse Manager.On 04/08/26 at 7:52 AM, Surveyor interviewed Registered Nurse (RN) P regarding abuse reporting. Surveyor asked RN P when concerns of abuse should be reported. RN P stated immediately to SS and Nurse Manager.On 04/08/26 at 8:02 AM, Surveyor interviewed SS M regarding the injury documented on 03/31/26. SS M stated not being aware of this injury, but the DON is usually the one who handles those kinds of abuse reports.On 04/08/26 at 8:28 AM, Surveyor interviewed Nurse Manager K regarding R7's incident on 03/31/26. Nurse Manager K stated he was not at the facility during the week the incident occurred and did not return until 04/06/26, which is when he became aware of the incident. Nurse Manager K stated that abuse concerns should be directly reported to the DON.On 04/08/26 at 10:50 AM, Surveyor interviewed DON B regarding R7's injury that occurred on 03/31/26. DON B stated that the first she became aware of this injury was on 04/06/26, as she was not in the facility during the week it happened. Surveyor asked DON B what the expectation is for staff in reporting abuse or injuries of unknown origin. DON B stated staff are expected to report all concerns about abuse immediately and this should have been done with R7's injuries. Example 2R26 was admitted to the facility on [DATE] with sensorineural hearing loss bilateral.R26's most recent quarterly Minimum Data Set (MDS) assessment, dated 01/28/26, noted a Brief Interview for Mental Status (BIMS) score of 05, indicating severely impaired cognition. R26's hearing is noted as moderate difficulty and has hearing aids.R26's care plan, dated 05/15/24, with a target date of 02/19/25, states: Focus of hearing with a goal to hear adequately at level of conversation to allow communication to meet needs. Interventions include Hearing Aides: Right / Left / Bilateral Place in AM and remove at HS.R26's orders:01/23/26 Hearing aids to be put in by nurse in AM and collected at bedtime and charged in Med room. (nursing order, per POA).Surveyor reviewed R26's MAR:04/02/26 at 9:00 AM, no documentation.04/04/2026 at 10:20 PM, Medication Administration Note: Not able to locate.04/05/2026 at 9:07 AM, Medication Administration Note: Missing at the moment.04/05/2026 at 9:55 PM, Medication Administration Note: Still missing.04/06/2026 at 9:17 AM, Medication Administration Note: Not available.-Of note: No documentation notifying Administrator of hearing aids missing noted. No other documentation noted.On 04/06/26 at 10:50 AM, Surveyor observed R26 in her room visiting numerous families. Surveyor attempted to interview R26 but R26's family stated R26 was deaf without her hearing aids, and they went missing over the weekend. R26's family stated they were found this morning and were on the charger because the batteries were dead. Family did not have any additional information on exactly when they went missing or when they were found.On 04/08/26 at 7:48 AM, Surveyor interviewed Certified Nursing Assistants (CNA) N and O regarding missing hearing aids. Both CNA N and O stated that staff will look in resident's room, in clothing and in common areas to try to find them. Surveyor asked CNA O and N when this incident would be reported. Both CNA N and O stated if they can't find the hearing aids in those areas, then it would be reported to Social Services (SS) immediately.On 04/08/26 at 7:52 AM, Surveyor interviewed Registered Nurse (RN) P regarding missing hearing aids. RN P stated staff will look in the resident's room and in common areas. If the hearing aids aren't found by the end of the shift, then it gets reported to SS and the Nurse Manager.On 04/08/26 at 8:02 AM, Surveyor interviewed SS M regarding R26's missing hearing aids on 04/04/26. SS M stated not being aware of this and no one reported R26's hearing aids missing. Surveyor asked SS M if staff would be expected to report this. SS M stated yes.On 04/08/26 at 10:50 AM, Surveyor interviewed DON B regarding R26's hearing aids being documented as missing on 04/04/26. DON B stated not being aware and no one reported this. Surveyor asked DON B if staff would be expected to report this. DON B stated yes.

Based on observation, interview, and record review, the facility did not ensure that 1 of 4 residents (R16) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent potential skin breakdown and promote healing of existing PIs. R16 was at risk for PI on admission having no PIs, weekly PI assessments were not completed consistently, physician was not notified with changes in the PI, alternate support surfaces were not provided when skin issues were noted. The PI care plan was not developed until 2 months after the identification of the stage 3 PI. Offloading of the PI was not observed by Surveyor. This is cited at actual harm. Findings include: The facility policy, titled Prevention of skin breakdown, revised [DATE], states: .D. Repositioning: a. Reposition bed-bound persons at least every two hours and chair bound persons every hour to hour and half consistent with overall goals of care . The facility policy titled Weekly skin rounds/Quality Assurance Review, revised [DATE], states: .Weekly wound rounds are completed weekly to determine the progress of healing, presences of possible complications, presence of pain and the status of the area and the area surrounding the pressure injury . R16 was admitted to the facility on [DATE]. R16's diagnoses included cauda equina syndrome (when a bundle of nerves at the bottom of spinal cord is compressed or damaged), sepsis, unspecified, malignant neoplasm of prostate, muscle weakness, unsteadiness on feet, diabetes mellitus type 2, and pulmonary hypertension. R16's Minimum Data Set (MDS), dated [DATE], confirmed R16 scored 10 during Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R16 was admitted with at risk for skin breakdown, and no current PIs. Surveyor reviewed R16's skin integrity alteration care plan initiated on [DATE], which states in part: - Daily skin observation with cares. Report new or worsening concerns to nurse immediately initiated [DATE]. - House lotion to dry skin with cares as needed initiated [DATE]. - Treatment as ordered. Observe for changes and report concerns to MD/NP as warranted initiated [DATE]. - Inform resident/family/caregivers of any new area of skin breakdown initiated on [DATE]. - Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises or Discoloration noted during bath or daily care initiated on [DATE]. - Pressure reducing/relieving mattress initiated [DATE]. - ROHO to seated positions initiated on [DATE]. - Turn and reposition q (every) ,d+[DATE].5 initiated on [DATE]. - Encourage side to side positioning when in bed initiated on [DATE]. - Enhanced Barrier Precautions in place due to chronic wound initiated on [DATE]. - Float heels initiated on [DATE]. Surveyor reviewed R16's pressure ulcer stage 3 to coccyx area care plan initiated on [DATE], which states in part: -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing (weekly). Measure length, width and depth where possible. --Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. -Monitor dressing (daily) to ensure it is intact and adhering. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -ROHO to seated positions. Surveyor reviewed R16's physician orders, which state in part: -On [DATE], Reposition every 2 hours to off load buttocks every shift. -On [DATE], Protein gel cup one time a day. -On [DATE], Monitor open area to coccyx daily, until resolved every evening shift. -On [DATE], Cleanse wound, and peri wound tissue with wound cleaner. Apply 2x2 (2 by 2) collagen on the wound base (use all of it on the wound only). Place bordered super absorbent 5x5 dressing diagonally. change daily. Date and time dressing. Surveyor reviewed R16's nurse progress notes, which state in part: R1's skin/wound note dated [DATE] states in part . Location: R gluteal fold, Stage if pressure injury: MASD Measurements (in cm's (in centimeters)) length/width/depth: 5x4x0.1, Description of alteration: partial thickness skin/tissue loss with wound bed granular with maceration throughout wound bed. wound edges ill defined. mod (moderate) amt (amount) of serosanguious drainage noted. peri wound per resident's usual. no odor or s/sx (signs or symptoms) of infection. no complain of pain or discomfort. Additional Comments (if needed): ROHO added to seated positions, change pad Q 2h (every 2 hours). Will request catheter placement until wound healed. R16's skin/wound note dated [DATE] states in part . Location: Right post thigh, L (left) butt, coccyx, Stage if pressure injury: MASD, Measurements (in cm's) length/width/depth: R (right) post (posterior) thigh: 2x1.8x0.1, L butt: 1.5x0.7x0.1, Coccyx: 2.8x1x0.1, Description of alteration: wound bed covered in red granular tissue. Wound edges macerated. Peri wound per resident's usual. No odor or s/sx of infection. No c/o (complaints of) pain or discomfort. Of note: Surveyor found no documentation that R16's provider was notified of skin changes. Of note: Surveyor found no weekly wound measurements or description of wound bed for [DATE]. R16's skin/wound note dated [DATE] states in part . Location: coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 2.8x1x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in pink granular tissue. Wound edges oval and intact. Peri wound per resident's usual. Small amt of serosanguinous drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Location: Left buttock. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 1.5x0.7x0.1. Description of alteration: Partial thickness skin/wound tissue loss with wound bed covered in light red granular tissue. Wound edges irregular and intact. Small amt of serosanguinous drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Peri wound per resident's usual. Location: Right gluteal fold. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 3x4x0.1. Description of alteration: partial thickness skin/tissue loss with wound bed covered in light red granular tissue. sm (small) amt of serosanguinous drainage noted. Peri wound per resident usual. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 1.5x2x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in ,d+[DATE]% granular tissue. wound edges oval and intact. No drainage noted. Peri wound per resident's usual. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. Location: Left buttock. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 4x3.5x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in ,d+[DATE]% granular tissue and ,d+[DATE]% slough. Wound edges irregular and intact. Peri wound per resident's usual. Scant amt of serosanguinous drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. Location: R gluteal fold. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 1.5x2x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in ,d+[DATE]% granular tissue. No drainage noted. Peri wound per resident's usual. No odor or s/sx of infection. Autolytic debridement performed. Of note: Surveyor reviewed left buttock wound deteriorating and facility did not implement any new pressure relieving interventions. Facility missed [DATE] weekly skin assessment, no measurements noted. Facility missed [DATE] weekly skin assessment related to gluteal and buttock wounds; no measurement noted. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: stage 3. Measurements (in cm's) length/width/depth: 4.2 x 2 x 0.2. Description of alteration: Wound bed has ,d+[DATE]% pink granulated tissue with ,d+[DATE]% slough present. No tunneling or undermining. Moderate serosanguineous drainage noted. Periwound moist but intact. Concern for deep tissue at 6 o'clock w/in wound bed. Of note: Facility assessed R16's wound to be a PI stage 3 on [DATE]. Provider was not notified of PI deterioration, and no new interventions were put into place. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 2.8x2x0.1. Description of alteration: Wound bed covered in pink, granular tissue. Peri wound per resident's usual. No drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. Of note: Facility incorrectly labeled R16's PI back to MASD versus assessment of PI stage 3 from [DATE]. Surveyor reviewed Skin/wound notes from [DATE], [DATE], and [DATE] and coccyx wound decreases in size to on [DATE]- measures 0.5x0.5x0.1cm. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Measurements: 3x3x0.1cm. Of note: R16's PI has increased in size; facility did not implement any new interventions. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 4.5 x 5. Description of alteration: Partial tissue loss. Minimal serous drainage. Surrounding tissue per normal skin tone. No pain. Autolytic debridement. No signs or symptoms of infection. Of note: Facility is calling this MASD instead of a PI. Facility did not implement a PI care plan for R16 until [DATE]. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 3.5 x 1.5 x <.01. Description of alteration: Epithelial cell noted in wound bed. Minimal serous drainage. Surrounding tissue per normal skin tone. Autolytic debridement. Denies pain or discomfort. Observations and interviews: On [DATE] at 9:59 AM, Surveyor interviewed R16 and asked how R16's care is at the facility. R16 indicated no concerns noted at this time. Surveyor observed wheelchair insert in recliner and asked R16 about the cushion in recliner. R16 indicated that R16 has a pressure injury from sitting too long on buttocks but the facility dresses it every evening on night shift. R16 indicated that R16 had a sore at home for a while, but it healed. Then when R16 was admitted about 1.5 months ago sitting around too long caused R16's buttocks to break open. On [DATE] at 12:19 PM, Surveyor observed R16 in recliner sitting at a 45-degree angle watching TV. Surveyor observed pressure relief pad insert in recliner. On [DATE] at 2:05 PM, Surveyor observed staff in room and laying R16 down. Surveyor walked in and did not see pillows underneath R16 to off load the bottom while lying in bed. Surveyor observed R16 lying flat on back in bed at a 90-degree angle. Surveyor asked R16 if R16 should have pillows underneath to off load the PI on coccyx. R16 stated, Yes I should, but I will have to call for assistance as I cannot do it myself. R16 rang call light. Of note: Surveyor observed no repositioning for 2 hours. On [DATE] at 2:17 PM, Surveyor observed Certified Nurse Assistant (CNA) I enter R16's room and assist R16 with placing pillow underneath R16. Surveyor interviewed CNA I and asked what are R16's repositioning needs. CNA I indicated that R16 should be repositioned every 1.5 hours and to off load bottom. CNA I indicated that R16 is pretty good with it so CNA I just does what R16 asks CNA I to do when R16 is ready. On [DATE] at 6:55 AM, Surveyor observed CNA K enter R16's room. Surveyor observed R16 lying supine on back in bed. Surveyor did not see any pressure relief on coccyx. On [DATE] at 7:11 AM, Surveyor observed R16 sitting in recliner leaned slightly right at a 90-degree angle. Surveyor observed roho cushion insert in recliner. On [DATE] at 8:25 AM, Surveyor observed Registered Nurse (RN) E deliver breakfast tray to R16. Surveyor observed R16 sitting in recliner leaned to right side slightly at a 90-degree angle. Surveyor observed roho cushion insert in recliner. On [DATE] at 8:54 AM, Surveyor observed R16 sitting in recliner leaned to right side slightly at a 90-degree angle. Surveyor observed roho cushion insert in recliner. On [DATE] at 9:13 AM, Surveyor observed RN E go into R16's room and grab breakfast tray. Surveyor observed R16 still in recliner but reclined slightly less than 90-degree angle backwards in recliner. On [DATE] at 9:40 AM, Surveyor observed R16 place call light on. Surveyor observed R16 ask CNA H if R16 could get into bed. On [DATE] at 9:45 AM, Surveyor observed CNA H assist R16 out of recliner with gait belt, and dycem mats on floor. Surveyor observed two pillows on bed located on each side of bed. R16 sat on top of the pillows and swung legs over to lay down. R16 directed CNA H to place pillow under heels. Surveyor observed left heel still touching mattress, right heel elevated. Surveyor observed R16 lying on back. Surveyor observed R16 place head of bed up to a 90-degree angle and CNA H stated, That is high, is that how you do your bed? R16 responded and stated, Yes. Surveyor observed CNA H exit R16's room. Of note: Surveyor did not observe CNA H encourage or offer to lay R16 on side to off load coccyx area. On [DATE] at 11:50 PM, Surveyor observed R16 lying in bed on back. Surveyor observed R16 at a 90-degree angle, lying directly on coccyx area watching tv. On [DATE] at 1:35 PM, Surveyor observed R16 lying in bed on back with head of bed about 90-degree angle with left side pillow down near feet and heel pillow not under feet. On [DATE] at 1:37 PM, Surveyor interviewed R16 and asked who moved pillows. R16 indicated that R16 removed the left side pillow due to R16 being uncomfortable. Surveyor asked R16 and Family Member L if R16 can reposition self. R16 indicated not in this bed. R16 indicated that at home R16 could move around in bed but not in R16's bed at the facility. R16 indicated that R16 must ring call light if R16 wants to be repositioned. R16 stated, I don't want to bother them, so I wait for them. Surveyor asked Family Member L if staff come in every 1 or 2 hours to reposition. Family Member L indicated that sometimes I will come in, in the morning around 9 AM to visit R16 and nothing has been done until lunch time. Family Member L is concerned with PI getting worse. Surveyor asked R16 and Family Member L if facility offered an air mattress for R16 or did R16 refuse the air mattress. R16 indicated that no one has offered an air mattress. R16 asked Surveyor if air mattress would help with R16's wound. Family Member L indicated that Family Member L did not know air mattress was an option. Of note: Surveyor did not observe air mattress in place as care planned. On [DATE] at 2:20 PM, Surveyor interviewed CNA H and asked CNA H what CNA H's process is for R16's repositioning care plan. CNA H indicated that R16 can reposition self in bed and sometimes is on R16's side. Surveyor indicated to CNA H that Surveyor has not seen R16 off back and coccyx [DATE] or today. CNA H indicated that R16 was up in recliner this morning for breakfast. Surveyor indicated to CNA H that R16 has been sitting in recliner for over 3 hours this morning on [DATE]. CNA H indicated that CNA H thought that was fine since R16 has pressure relieving cushion in recliner. Surveyor asked CNA H if CNA H repositioned R16 while lying in bed after breakfast, before lunch, or after lunch since R16 has been in bed since 9:45 AM. CNA H indicated that when I placed R16 in bed I propped R16 with two pillows on each side. Surveyor indicated that when Surveyor was observing the offloading the pillows placed under R16's hips on each side was adequate for pressure relief of coccyx off the bed. Surveyor asked CNA H if CNA H could place hand underneath R16's coccyx and feel the space between mattress and R16's coccyx. CNA H indicated that CNA H did not test if there was space. Surveyor indicates that care plan is to encourage R16 to be off back and reposition unto sides often. Surveyor indicated to CNA H that Surveyor did not observe CNA H offer to reposition R16 on side. CNA H indicated that CNA H did not offer or encourage to reposition R16 on side because R16 will usually ask if R16 wants to be on sides. On [DATE] at 2:41 PM, Surveyor interviewed Director of Nursing (DON) B and asked what is DON B's expectation of R16's repositioning care plan in place. DON B indicated that R16 should be encouraged to get off R16's coccyx and reposition side to side every ,d+[DATE].5 hours. Surveyor indicated that Surveyor has not observed R16 repositioned every ,d+[DATE].5 hours and at one-point R16 sat in recliner on coccyx for over 3 hours and in bed over 3 hours without being repositioned. DON B indicated that staff should be repositioning every ,d+[DATE].5 hours as care planned. Surveyor asked DON B if R16's wound on coccyx was a pressure injury and why R16 did not have a PI care plan in place until [DATE]. DON B indicated there were two wound nurses who thought Moisture Associated Skin Damage (MASD) and the other thought stage 3 PI. DON B reached out to a wound care specialist who confirmed that R16's wound on coccyx is a stage 3 PI. DON B confirmed to Surveyor that R16 should have had a PI care plan implemented back in September when the PI was discovered but was not put into place until [DATE]. Surveyor asked DON B where is R16's air mattress. DON B indicated that DON B was unaware that R16 did not have an air mattress in place. Surveyor confirmed with DON B that R16's mattress was observed to be a basic Direct Supply Panacea foam mattress. On [DATE] at 8:01 AM, Surveyor interviewed DON B and asked expectation of how long R16 should be up for meals. DON B indicated it is R16's right to sit up for however long R16 would like but that DON B's expectation would be that staff still reposition R16 every ,d+[DATE].5 hours while sitting as well. Surveyor asked DON B if R16 had any nutritional interventions to assist healing with R16's PI deterioration. DON B indicated that on [DATE], Pro gel was implemented to help with PI healing, but there were no other interventions for nutrition before [DATE]. Surveyor asked DON B when was the first official date R16's PI was found. DON B indicated that [DATE] was the first alteration in skin integrity and identified as a PI on [DATE]. Surveyor asked DON B if R16's development of a stage 3 PI in the facility was avoidable or unavoidable. DON B stated, Well with the observations of lack of repositioning of [R16] off of [R16's] buttocks and no air mattress in place, I feel it could have been avoided if those measures were in place. On [DATE] at 10:40 AM, Surveyor interviewed previous wound care RN J and asked about education in wound care. RN J indicated that RN J took skin and wound management 9 years ago but did not pass the exam to become certified. Surveyor asked how RN J assessed that R16's wound was related to MASD versus PI. RN J indicated that now that RN J looks back on R16's case, R16's wound should had been labeled PI as R16 had a lot of issues like immobility and incontinence but there was a lot going on on R16's back side from back surgery. On [DATE] at 10:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for RN F's (current wound nurse) training. NHA A indicated that RN F let RN F's wound certification lapse, but facility is trying to figure out how she can retest. NHA A provided Surveyor with Wound Care Certified certification which expired on [DATE].

Based on observation, record review and interview, the facility failed to ensure the chemical sanitation used in the 3-compartment sink for dishwashing was the correct concentration per manufacturer's guidelines. This had the potential to affect all 36 residents who are served food from the facility's kitchen. This is evidenced by: Facility policy titled, Resource: Sanitation of Dishes/Manual Washing, dated 2021, states in part: Manual washing using chemical to sanitize: - An exposure time of at least 10 seconds for a chlorine solution of 50mg/L that has a pH of 10 or less and a temperature of at least 100 degrees Fahrenheit; -Or a pH of 8 or less and a temperature of at least 75 degrees Fahrenheit; - An exposure time of at least 30 seconds for other chemical sanitizing solutions per manufacturer. Quaternary Ammonium Compound Solutions - Minimum 75 degrees Fahrenheit - Concentration as indicated by manufacturer - Used only in water with 500 mg (milligrams)/L (Liter) hardness or less, or in water with a hardness no greater than specified by the manufacturer. The facility did not have a policy/procedure in place to document quaternary concentration testing results. On 02/11/25 at 10:00 AM, Surveyor observed kitchen staff using the 3-compartment for manual dishwashing prior to lunch meal service. On 02/11/25 at 10:22 AM, Surveyor interviewed Dietary Director (DD) C. Surveyor asked what kind of disinfection is used for dishwashing in the 3-compartment sink. DD C stated that a quaternary solution is used. Surveyor asked DD C how the concentration was measured for appropriate levels. DD C stated that prior to January 2025, there was not a process in place to check and a new process was initiated to use the quaternary strips. Surveyor asked DD C to demonstrate use of the quaternary strip testing. DD C stated that they currently did not have any strips to do this. Surveyor asked DD C how long they have been out of quaternary strips. DD C stated since 01/26/25, but they are currently waiting for an order. Surveyor then asked DD C for the documentation logs of measuring the quaternary concentration for the last 30 days. DD C stated that they do not keep track of this. DD C then stated that after review of kitchen procedures for infection control a new practice was recently initiated for monitoring quaternary concentrations for each meal service and would start as soon as the shipment of strips arrived. DD C stated no recent food-borne illness has occurred but recognized the risk this produced by not ensuring the chemical solution was at the recommended level to sanitize dishes.

Based on observation, interview and record review, the facility did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, administering and disposal of all drugs and biologicals. The facility did not ensure controlled medications were disposed of timely for 11 out of 11 residents (R) observed during medication storage observation. (R1, R2, R289, R290, R291, R292, R293, R294, R295, R296, R298). The facility did not ensure proper dose of topical medication was administered for 1 out of 1 resident (R9). Findings include: Example 1 The facility policy titled Controlled Substance Accountability, dated June 2023, states in part: .Disposing of Narcotics 1. All narcotics will be destroyed according to Pharmacy and Regulatory timelines . The Statute DHS 132.65 Pharmaceutical Services refers to the handling of medication in Wisconsin facilities, including hospitals and nursing homes. It states in part: .(c) Destruction of medications. 1. 'Time limit.' Unless otherwise ordered by a physician, a resident's medication not returned to the pharmacy for credit shall be destroyed within 72 hours of a physician's order discontinuing its use, the resident's discharge, the resident's death or passage of its expiration date. No resident's medication may be held in the facility for more than 30 days unless an order is written every 30 days to hold the medication . On 02/12/25 at 8:34 AM, Surveyor observed the medication room with Director of Nursing (DON) B. DON B opened a locked cabinet that had a basin with 11 prescription (RX) prefilled medication cards and a vial of a liquid narcotic waiting to be destroyed. There were 188 pills and 25 ml of controlled substance. Surveyor observed the following list of prescription prefilled cards in the basin belonging to the following residents, R1, R2, R289, R290, R291, R292, R293, R294, R295, R296, and R298. Medications observed in bin for destruction include: Hydromorphone 2mg was for R295. Per documentation 2 tablets were signed out for administration leaving 10 tablets to be destroyed when placed in bin on 12/2/2024. This is reconciled with the receipt of card originally containing 12 tablets. Oxycodone 2.5 mg was for R298. Per documentation the unused card of 16 tablets was placed in bin to be destroyed 11/13/24. APAP/Codeine Tab 300-30mg was for R1. Per documentation the unused card of 12 tablets was placed in bin to be destroyed 11/20/24. Oxycodone 5mg was for R296. Per documentation 16 tablets were signed out for administration leaving 14 tablets to be destroyed when placed in bin on 11/20/24. This is reconciled with the receipt of card originally containing 30 tablets. Oxycodone 5mg was for R294. Per documentation the unused card of 10 tablets was placed in bin to be destroyed 12/3/24. Oxycodone 5mg was for R291. Per documentation the unused card of 30 tablets was placed in bin to be destroyed on 12/17/24. Oxycodone 5mg was for R293. Per documentation the unused card of 10 tablets was placed in bin to be destroyed 12/22/24. Oxycodone 2.5mg was for R292. Per documentation 14 tablets were signed out for administration leaving 16 tablets to be destroyed when placed in bin on 1/2/25. This is reconciled with the receipt of card originally containing 30 tablets. Oxycodone 5mg was for R289. Per documentation the unused card of 10 tablets was placed in bin to be destroyed on 1/1/7/25. Oxycodone 5mg was for R290. Per documentation the unused card of 30 tablets was placed in bin to be destroyed 1/17/25. Morphine 100mg/5ml (30ml bottle) was for R2. Per documentation 5. signed out for administration and Surveyor noted the line on side of bottle was filled to just over 25 was placed in the bin to be destroyed on 1/28/25. Zolpidem 5mg 30 was for R289. Per form the full card of 30 tablets was placed in bin to be destroyed 2/4/2025 after pharmacy returned it reporting they do not take back and destroy medications. On 02/12/25 at 8:38 AM, Surveyor interviewed DON B and asked DON B's process for destruction of controlled medications. DON B indicated there are two licensed staff that destroy the controlled substances. DON B indicated that destruction of medications should be destroyed at least weekly, but facility has been so busy that the controlled substances noted back to November 2024 have not been destroyed and needs to be. DON B indicated the process for destroying controlled substances is two licensed staff count and verify that correct amount is there and coincides with the controlled substances sheets and then placed in a biohazard bag with kitty litter and thrown in the garbage. Example 2 The facility policy, titled Medication Administration, dated January 2014, states: Purpose: To ensure an accurate and effective medication administration process that is in compliance with state and federal regulations. Medications must be administered in accordance with the written orders of a physician. Manufacturer's directions, titled Voltaren The [NAME] of Movement, states: The amount of gel applied (2g (gram) for each application) should be measured using the dosing card supplied in the product carton. For each application the gel should be squeezed from the tube and measured up to the 2gm line on the dose card. The generic name for Voltaren is Diclofenac. R9 was admitted to the facility on [DATE] and has the diagnoses that include but are not limited to presence of right artificial shoulder joint, personal history of healed traumatic fracture, and mild cognitive impairment of unknown etiology. R9's Minimum Data Set (MDS) assessment, dated 10/30/24, indicated that R9's Brief Interview of Mental Status (BIMS) score was 15 out of 15 and is cognitively intact. R9 has minimal range of motions and needs substantial/maximum assist to dependent for assistance for movement and cares. R9 has pain in her left shoulder and right knee that she rates as a 9 out of 10 but verbally states as mild. R9's care plan states: R9 has potential for pain r/t (related to) arthritis, bilateral arthroplasty. Apply topical analgesics per MD (Medical Doctor) order. Monitor for effectiveness and adverse effect and notify MD as necessary. MD order dated 1/22/2024 states, Diclofenac Sodium External Gel 1% (Diclofenac Sodium (Topical)) Apply to Left shoulder topically two times a day for pain 2 grams. On 02/11/25 at 8:32 AM, Surveyor observed Registered Nurse (RN) D take Diclofenac 1% topical, squirt some in RN D's hand and apply to patient's left shoulder. On 2/11/25 at 8:35 AM, Surveyor interviewed RN D regarding dosing of Diclofenac. RN D stated, I just put some in my hand. (pause) Less than a quarter. RN D then looked at the label and reported it says 2 grams. When asked how she knew she gave 2 grams, RN D stated I don't know, she does not need a lot. On 2/11/25 at 2:24 PM, RN D stated to Surveyor, I found the measurement thing in the drawer. Surveyor clarified the statement RN D made to Surveyor that RN D meant the Diclofenac measurement card. RN D stated, Yes, I should have used the measuring device.

Based on observation, interview and record review, the facility did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 1 out of 2 sampled residents (R7). R7 was not ambulated per recommendation of Physical Therapy (PT) or receive restorative exercises per recommendation of PT. This is evidenced by: R7 was admitted to the facility on [DATE]. R7's diagnoses included cerebral infarction unspecified, type 2 diabetes mellitus, history of falling, essential hypertension, and unspecified diastolic congestive heart failure. R7's Minimum Data Set (MDS), dated [DATE], confirmed R7 scored 12 out of 15 during Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R7 understands and is understood by others, and he can make his needs known. R7 needs partial to moderate assistance with toileting, sit to stand, and ambulation. Surveyor reviewed R7's PT recommendations titled, Restorative Program, dated on 12/06/24, which states in part: -Walking program; gait belt, contact guard assist, 100-150 feet with front wheel walker. - Nu Step or Sci Fit level 3 for 10-15 minutes as tolerated. Surveyor reviewed R7's care plan, which states in part . -R7 has restorative nursing program in place initiated on 01/14/25. -Ambulation assist of one with two-wheel walker with wheelchair to follow. Surveyor reviewed Certified Nurse Assistant (CNA) care plan tasks that indicated: -Nursing rehab: Active Range of Motion (ROM): document number of minutes spent providing ROM (active). Of note: Surveyor did not find documentation from 02/07/25-02/11/25. -Nursing rehab: Walking (Specify): document distance walked in (ft). Of note: Surveyor did not find documentation from 02/07/25-02/11/25. - Nursing rehab: Walking (Specify): document number of minutes spent training and skill practice in walking. Of note: Surveyor did not find documentation from 02/07/25-02/11/25. On 02/10/25 at 10:14 AM, Surveyor interviewed R7 and asked if R7 had any physical concerns with mobility and Activities of Daily Living (ADL)s. R7 indicated that facility is not really working with R7 on PT or exercises enough. R7 indicated that facility offers simple little arm exercises but nothing with R7's legs that will make R7 stronger so R7 doesn't lose independence. On 02/11/25 at 8:03 AM, Surveyor observed R7 self-propelling back to room after breakfast. R7 wheeled into R7's room and decided to stand up and self-transfer. R7 was standing up from wheelchair and started walking to bathroom. On 02/11/25 at 8:04 AM, Surveyor observed CNA K enter R7's room. CNA K immediately asked R7 to hang on while CNA K grabbed wheelchair to assist R7. R7 stated, No I need to go to bathroom, and I want to walk there. CNA K grabbed wheelchair anyway and had R7 sit down in wheelchair. CNA K then propelled R7 to bathroom. CNA had R7 stand up and stand pivot to toilet. On 02/11/25 at 8:15 AM, Surveyor interviewed CNA K and asked why CNA K did not allow R7 to ambulate to bathroom since the care plan indicated R7 could ambulate with one assist. CNA K indicated that CNA K is with agency staff and did not know what R7's care plan stated. On 02/11/25 at 10:07 AM, Surveyor interviewed PT M and asked if R7 was on PT. PT M indicated that R7 use to be on PT but no longer is due to not improving in function ability. PT M indicated that R7 was placed on a restorative program for ROM and walking. PT M indicated to Surveyor that PT M would gather information from Restorative Coordinator (RC) G and find copies. On 02/11/25 at 10:10 AM, Surveyor interviewed RC G and asked what RC G's process was for R7's restorative program and to provide the documentation as Surveyor could not find the documentation since 02/06/25 of completion of R7's restorative ROM and walking. RC G stated, Honestly, we are the first to get 'pulled' out of restorative and unto the floor when we are short. I was pulled all last week, and my other help was pulled over the weekend. Surveyor asked RC G if anyone has completed restorative with R7 since 02/06/25. RC G indicated that RC G knows that R7 did not receive restorative exercises this last weekend, and RC G will need to review notes in office and get back to Surveyor about other dates. On 02/11/25 at 11:04 AM, RC G delivered restorative charting from missing documentation not in the EHR (electronic health record). Surveyor reviewed documentation and noted that it was late charted. Surveyor asked RC G if this was just entered. RC G indicated that RC G did just document the missed documentation in the EHR. RC G indicated that she does not chart this on a day-to-day basis. Surveyor asked RC G how RC G remembers what to document from weeks ago. RC G indicated that CNAs or RC G checks off on a paper with all who are on restorative plans and then writes how far and how long R7 walks or when exercises were completed. Surveyor requested documentation of the notes that RC G charted as a late entry. On 02/11/25 at 3:20 PM, RC G delivered paper copies of restorative program for all residents in the building. RC G indicated that if Surveyor reviews and finds the exercise labeled 'resident not available' it means 1 of 4 things; Resident at an activity, therapy, out of building for appointments, or staff did not get to the 'said' resident. Surveyor asked RC G if the documentation specifies which reason the resident was unavailable. RC G stated, No it does not, just resident unavailable. Surveyor reviewed restorative schedule documentation paper forms from 02/01/25-02/11/25. -On 02/01/25 and 02/02/25, no documentation on paper forms. -On 02/05/25, resident not available. -On 02/07/25, no documentation on paper forms. -On 02/08/25, resident not available. Restorative Coordinator G was pulled to floor and did not complete restorative program for any residents. -On 02/09/25, resident not available. Restorative Coordinator G was pulled to floor and did not complete restorative program for any residents. On 02/12/25 at 8:01 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for R7's restorative program. Surveyor indicated that PT recommended R7 ambulate daily and complete ROM on the Nustep machine. Surveyor indicated to DON B that through observation, record review, R7's complaint of no exercise, and interview with RC G, R7 had not been receiving restorative exercises on a consistent basis. DON B indicated that it is DON B 's expectation that R7 receive R7's exercises and is walked often to keep R7's body strong. Surveyor indicated to DON B that through interview with RC G, RC G gets pulled from the floor and then is not able to complete restorative programs for all residents. DON B indicated to Surveyor that RC G has not been pulled that much. Surveyor indicated to DON B that RC G has been documenting Resident not available and that means many things such as resident at an activity, therapy, out of building for appointments, or staff did not get to the said resident. Surveyor asked DON B if the documentation was appropriate or did it need more detail as to why R7 did not receive restorative. DON B indicated the vague documentation is not acceptable, and that documentation needs to specify why R7 did not receive restorative exercises.

Based on interview and record review, the facility did not provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 1 of 1 sampled resident being reviewed for heart failure with increased edema, Resident (R) R17. R17 had no edema in lower extremities on admission. R17 was observed to have 3+ pitting edema in left lower extremity on 02/12/25. The facility did not assess or add interventions to decrease increasing edema for R17. Facility did not complete weekly assessments for heart failure inlcuding missed weights weekly. This is evidenced by: According to the National Institutes of Health (NIH) Congestive Heart Failure (CHF): Nursing Diagnosis, 2023, indicates nurse assessment of CHF is to assess current symptoms such as dyspnea, fatigue, orthopnea, peripheral edema, vital signs, cardiovascular examination such as (abnormal heart sounds, jugular venous distention), respiratory examination such as (auscultate lung sounds for crackles or wheezing and assess respiratory effort), daily weights, edema assessments, dietary habits, weight changes, medication adherence and any side effects related to diuretics or blood pressure medications, and assess emotional well-being related to potential anxiety or depression related to the chronic nature of CHF. R17 was admitted to the facility on [DATE]. R17's diagnoses included Heart Failure (HF) unspecified, anemia, old myocardial infarction, paroxysmal atrial fibrillation, and localized edema. R17's Minimum Data Set (MDS), dated [DATE], confirmed R17 scored 10 out of 15 during Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R17 was admitted with a diuretic for HF. Surveyor reviewed R17's cardiac impairment related to HF, hypertension, and Hyperlipidemia care plan initiated on 01/14/25, which states in part . -Administer antilipemic per MD (Medical Doctor) order. Monitor for effectiveness and adverse effects. Notify MD as necessary. -Administer diuretics per MD order. Monitor for effectiveness and adverse effect and notify MD as necessary. -Monitor/document/report to MD PRN (as needed) signs and symptoms of Congestive Heart Failure: dependent edema of legs and feet, periorbital edema, SOB (shortness of breath) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate (Tachycardia) lethargy and disorientation. -Monitor/document/report to MD PRN any signs and symptoms of hypokalemia in residents receiving diuretic therapy: Fatigue, muscle, weakness, diminished appetite, nausea and vomiting and dysrhythmias. Monitor potassium levels. Surveyor reviewed R17's physician orders, which state in part . -On 09/06/24 Furosemide Oral Tablet; Give 40 mg by mouth one time a day related to HF, unspecified. Surveyor reviewed R17's completed assessments, which state in part . .-On 09/05/24 admission assessment indicates no edema noted on admission. Of note: Surveyor could not find any assessments of R17's edema in lower extremities. Surveyor reviewed R17's physician notes, which state in part: -On 09/09/24 no edema noted to lower extremities, continue Furosemide 40mg tablet daily. -On 10/02/24 no edema noted to lower extremities, continue Furosemide 40mg tablet daily. -On 11/06/24 weight is up 8 pounds in the last month, trace pitting edema noted to [R17's] left lower extremity. [R17] states [R17] sits with his feet dependent for most of the day. No compression stockings in place. Plan: Order Tubi grips for bilateral lower extremity edema. No changes to medications at this time. Surveyor reviewed R17's nurse progress notes, which state in part . -On 09/05/24 [R17] had no edema skin issues noted. -On 11/06/24 [R17] seen provider today, follow up in 2 months, start Tubi grip sleeves, lower extremities, off at night. -On 12/16/24 provider discontinued Tubi grips, resident request. Surveyor reviewed R17's tasks in Electronic Health Record, which state in part . -On 01/14/25, Monitor for s/s of CHF (congestive heart failure) exacerbation: shortness of breath, coughing or wheezing, swollen ankles or legs, weight gain, fatigue, and heart palpitations. -On 01/14/25, Monitor for s/s of fluid imbalance related to CHF/diuretic use: BP changes, SOB, confusion, fatigue, N/V (nausea/vomiting), irregular heartbeat, weakness, change in urination. -On 01/14/25, Monitor for s/s of hypertension, dull headache, vertigo, increased B.P (blood pressure), fluid retention, blurring of vision, epistaxis. Of note: Surveyor did not find any documentation that the tasks were checked off for monitoring fluid retention and edema. Of note: R17 did not have a cardiac care plan put in place until 01/14/25. Surveyor reviewed R17's history of weights from 09/06/24-02/12/25, which state in part . -On 09/06/24-173.0 lbs. -On 09/10/24- 172.4 lbs. -On 10/07/24-176.4 lbs. -On 10/18/24- 175 lbs. -On 10/27/24- 178.8 lbs. -On 11/25/24- 177.8 lbs. -On 12/01/24- 174.0 lbs. -On 12/04/24- 176.8 lbs. -On 12/17/24- 178.0 lbs . Of note: Surveyor reviewed R17's weight and found facility not following weekly weights per facility protocol. Observations and Interviews: On 2/10/25 at 9:51 AM, Surveyor interviewed R17 and asked how R17's care is at the facility. R17 indicated no concerns noted other than R17 stated, My leg is so swollen, do you know why? Surveyor observed swelling and edema in left leg from ankle up to the left knee. R17 indicated that R17's left leg has been swollen for a long time now and unsure if facility is doing anything about it. Surveyor asked R17 if he sits with his legs up at all. R17 indicated that R17 sits on edge of bed most of the day but will lay down periodically in bed. On 02/12/25 at 10:17 AM, Surveyor interviewed Registered Nurse (RN) E and asked about process for assessing HF. RN E indicated that usually if a resident is newly admitted with HF, RN E would assess lungs, edema, heart, and vitals. Surveyor asked RN E if RN E has assessed any increase in edema in R17 since admission. RN E indicated that RN E was unsure if it has increased but R17 does have quite a bit of swelling in the left lower extremity. Surveyor indicated to RN E that R17 had no edema on admission and then in November weekly weights were missed. R17 had a provider appointment 11/26/24 and provider noted 8lbs increase and trace-1 pitting edema. Surveyor asked RN E what R17's edema is today on 02/12/25. RN E indicated that RN E is unsure but knows it is swollen. Surveyor asked RN E if RN E could take Surveyor into R17's room and assess R17's left lower extremity for edema. RN E assessed R17 and found that R17 has 3+ pitting edema in left lower extremity and will be notifying the physician right away. RN E indicated that usually if there is an increase in edema it is documented in the EHR and provider and DON B are notified right away. RN E indicated that RN E is surprised there has been no documentation of R17's increase in edema in the left lower extremity. On 02/12/25 at 10:35 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B what is expectation for monitoring and assessing HF in R17. DON B indicated that if any resident has HF it is expectation that vitals, weights, and assessing for Shortness of Breath (SOB), and edema, are monitored. Surveyor asked DON B if DON B had a policy for assessing HF. DON B indicated the facility does not have a specific HF policy. Surveyor asked how often weights are to be completed for R17. DON B indicated the facility has standing orders to complete weights weekly for all residents unless specific parameters are ordered from provider. DON B indicated that if R17 does not have a specific order in EHR then standing orders need to be weekly weights. DON B's expectation is that any increase in edema needs to be assessed and reported to provider right away. DON B indicated that all residents who have HF need to be continuously monitored and assessed for increased in fluid retention or edema. Surveyor indicated to DON B that Surveyor reviewed R17's care plan which indicates that nursing staff should be monitoring for signs and symptoms of HF exacerbation: shortness of breath, coughing or wheezing, swollen ankles or legs, weight gain, fatigue, and heart palpitations. Surveyor asked DON B where is the documentation in R17's EHR. DON B indicated that DON B could not find documentation of the monitoring and it must not be being completed. DON B indicated that it is DON B's expectation that nursing staff are assessing for the signs and symptoms of HF decline and R17's diuretic medication. Facility did not have evidence of asuculatation of lungs, daily weights, and edema assessments completed per standard of practice for HF. Surveyor indicated to DON B that at one point in November the facility went a month without weighing R17 and R17 had a provider visit where the provider assessed an 8lb increase and trace-1 pitting edema in lower left extremity. Provider ordered Tubi grip to be applied in day and off at night. DON B indicated the staff should have been weighing R17 at least weekly and not sure how that got missed for the 8lb increase. DON B indicated that R17 was refusing the Tubi grips for about a week after provider ordered the Tubi grips to be applied so the provider discontinued the Tubi grips but had no other orders put into place. Surveyor asked DON B about the vagueness in R17's HF care plan that did not include any specific interventions to prevent the swelling other than administering diuretic medication. DON B indicated the care plan should be updated to encourage R17 to elevate lower extremities often, weight R17 weekly, and other specific interventions.

Based on observation, interview and record review, the facility did not ensure that 1 of the 4 residents reviewed for falls (R7), received adequate supervision and assistance to prevent accidents. The facility did not follow R7's care plan: -CNA did not apply gait belt to R7 during transfer to toilet as care planned. -CNA did not lock R7's wheelchair brakes during transfer from wheelchair to bed. -Staff did not apply pressure alarm in recliner as care planned. -R7 was observed self-transferring to toilet without staff assistance for 2 different events. This is evidenced by: R7 was admitted to the facility on [DATE]. R7's diagnoses included cerebral infarction unspecified, type 2 diabetes mellitus, history of falling, essential hypertension, and unspecified diastolic congestive heart failure. R7's Minimum Data Set (MDS), dated [DATE], confirmed R7 scored 12 out of 15 during Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R7 understands and is understood by others, and he can make his needs known. R7 needs partial to moderate assistance with toileting, sit to stand, and ambulation. Surveyor reviewed R7's Physical Therapy (PT) recommendations titled, Restorative Program dated on 12/06/24, which states in part . -Walking program; gait belt, contact guard assist, 100-150 feet with front wheel walker. Surveyor reviewed R7's impaired mobility and high risk for falls care plan, which states in part . -Alarms in place. Pressure seated areas, laser in bed, recliner, and bathroom. - Ambulation assist of one with two-wheel walker with wheelchair to follow . R7's physician orders state in part . -Alarms in place; see CNA care plan every shift, ordered on 12/12/2024. Surveyor reviewed fall risk assessments which state in part . .-On 10/22/24- Fall risk assessment completed: Scored High risk 18.0 -On 01/21/25- Fall risk assessment completed: Scored High risk 11.0 . Surveyor made the following observations: On 02/10/25 at 10:13 AM, Surveyor observed floor alarm on R7's bedside table near recliner. Floor alarm was not turned on. Surveyor observed recliner alarm attached to recliner but not on. On 02/10/25 at 10:34 AM, Surveyor observed R7 get out of recliner and use R7's walker to walk to bathroom. Of note: Surveyor did not hear recliner alarm go off. On 02/10/25 at 10:37 AM, Surveyor observed Restorative Coordinator G walk by R7's room and observed R7 walking in bathroom. Restorative Coordinator entered R7's room to assist R7. On 02/10/25 at 10:49 AM, Surveyor interviewed CNA K and asked about R7's pressure alarm in recliner and floor alarm in room. CNA K indicated that R7 sometimes will turn alarms off himself and transfer. Surveyor indicated to CNA K that Surveyor observed floor alarm turned off and on bedside table next to R7's recliner. CNA K indicated that a staff member probably put it on bedside table and turned it on and R7 probably turned it off. CNA K indicated that staff need to put floor alarm down on the floor and not in reach of R7. CNA K indicated that R7 is unstable while walking alone and becomes wobbly. Surveyor indicated to CNA K that Surveyor observed R7 transferring out of recliner and into bathroom for two minutes before Restorative Coordinator G was walking by and caught R7 up walking to bathroom. Surveyor indicated to CNA K that Surveyor did not hear the recliner pressure alarm go off either. CNA K indicated that R7 should not be ambulating by R7's self and that R7 needs assistance of one to transfer. On 02/11/25 at 7:00 AM, Surveyor observed R7 sitting in recliner sleeping. Surveyor did not observe recliner pressure alarm attached to recliner. Recliner alarm was located across room on R7's wheelchair. On 02/11/25 at 8:03 AM, Surveyor observed R7 self-propelling back to room after breakfast. R7 wheeled into R7's room and decided to stand up and self-transfer. R7 was standing up from wheelchair and started walking to bathroom. Surveyor did not observe wheelchair alarm go off. On 02/11/25 at 8:04 AM, Surveyor observed CNA K enter R7's room. CNA K immediately asked R7 to hang on while CNA K grabbed wheelchair to assist R7. R7 stated, No I need to go to bathroom, and I want to walk there. CNA K grabbed wheelchair and had R7 sit down in wheelchair. CNA K then propelled R7 to bathroom. CNA K had R7 stand up and stand pivot to toilet. Surveyor did not observe CNA K utilize a gait belt around R7. On 02/11/25 at 8:07 AM, Surveyor observed CNA K grab a gait belt after R7 sat down on toilet and placed it on R7. CNA K stated, We should probably have gait belt on when we get up off toilet. Surveyor observed CNA K propel R7 in wheelchair to bed. CNA K did not lock brakes on wheelchair before transferring R7 to bed. On 02/11/25 at 8:18 AM, Surveyor interviewed CNA K and asked what CNA K's process is for transferring R7 from chair to toilet, to toilet to chair and chair to bed. CNA K indicated that CNA K is aware that CNA K did not apply a gait belt to R7 as CNA K should have. Surveyor asked CNA K why R7's recliner alarm has not been placed on recliner when R7 is in recliner and why when it was placed it was not on. CNA K indicated that CNA K did not realize R7's alarms were not on. On 02/12/25 at 11:10 AM, Surveyor interviewed Director of Nursing (DON) B and asked DON B's expectation for R7's pressure alarms and gait belt usage. DON B indicated that R7's care plan states pressure alarms are to be applied to seated areas such as recliner, and wheelchair when R7 is seated. DON B indicated that floor alarm should be on floor anytime R7 is in R7's room. DON B indicated that all staff are to use a gait belt during R7's transfers.

Based on interview and record review, the facility did not ensure each residents' drug regimen was free from unnecessary medications for 1 of 13 sampled residents (R4). R4 was prescribed a prophylactic antibiotic without adequate indications for use. R4 at times was prescribed excessive dose (duplicate drug therapy) when two antibiotics were given at the same time. This is evidenced by: R4 was admitted to the facility in 2022 with diagnoses including chronic kidney disease, urinary retention, multiple sclerosis, prostate cancer, neurogenic bladder, and reoccurring urinary tract infections (UTIs). R4's physician orders dated 06/18/24, state in part: Macrodantin 100 mg daily for reoccurring UTIs. R4's physician had changed his orders from Doxycycline prophylactically for recurrent UTIs to Macrodantin. R4 had been on Doxycycline since admission. R4 was last seen by urology in 2022. The urology note from 2022 makes no mention of the use of prophylactic antibiotics, at that time, even though R4 was receiving daily Doxycycline prophylactically. R4 was diagnosed with a UTI on 12/06/24 and treated with Cipro 500 MG two times a day for 7 days. R4 received the last dose of Cipro on 12/12/24. During this time R4 also received Macrodantin 100 MG daily prophylactically for recurrent UTIs. R4 received 7 days of duplicate drug therapy. R4 was diagnosed with a UTI again on 02/08/25 and treated with Cipro 500 MG two times a day for 7 days. During this time R4 also received Macrodantin 100 MG daily on 02/08-10/25. On 02/10/25, an order was received by the physician to hold the Macrodantin until the completion of the Cipro order and then to re-start the Macrodantin. R4 received 3 days of duplicate drug therapy. On 02/11/25 at 2:22 PM, Surveyor interviewed Director of Nursing (DON) B, who is also the Infection Preventionist (IP). DON B stated that she had taken the IP role in December 2024 and noticed immediately that an effective antibiotic stewardship program was not in place to monitor, track, and follow-up on antibiotic use. DON B acknowledged residents being administered antibiotics without appropriate indication. DON B stated she is working with administration and QAPI to improve this process as it has the potential of harm to residents. On 02/11/25 at 3:30 PM, Surveyor requested the facility's policy on prophylactic antibiotic use, and on duplicate antibiotic therapy from DON B. None was provided. On 02/12/25 at 10:03 AM, Surveyor interviewed DON B related to R4's antibiotic use. DON B stated that R4's antibiotic use in December was before she was at the facility, so she could not speak to that. When asked about R4's current antibiotic treatment, DON B stated the antibiotic was started for the UTI on Friday, and she noticed it when she arrived on Monday, so she contacted the physician and got the hold order for the prophylactic antibiotic on Monday. DON B acknowledged R4 did receive both antibiotics on a few days. DON B stated she understands concerns about duplicative antibiotic use, and that one antibiotic should have been stopped prior to the start of the other one. Surveyor asked about R4 having a history of sepsis or other complications that may justify prophylactic antibiotic use, as a clear reason for use was not located within the medical record. DON B stated she would prefer it if they were to discontinue the prophylactic antibiotic as it is proven not to be effective. DON B added that R4 used to straight cath himself, with staff assistance, and did not have the best technique. DON B stated that R4 recently switched to an indwelling catheter and the hope is to discontinue the prophylactic antibiotic use as DON B was unable to locate a clear indication for use.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety by not wearing hairnets appropriately, and did not ensure proper hand hygiene with food handling. This has the potential to affect all 26 of 26 residents residing in the facility. Findings include: The facility policy, entitled Company Dress Code, dated December 2023, states in part: All those in the kitchen must wear hair restraint (i.e., Hairnet, CCHS ball cap, chef's hat, bonnet). On 01/02/24 at 9:08 AM, Surveyor observed Dietary Aide (DA) K wearing a hat that had their ponytail protruding from the cap. The ponytail was not restrained with a hair net and was exposed to the kitchen area. On 01/02/24 at 11:48 AM, Surveyor observed DA J not wearing a hair net while dishing up food from serving area. Surveyor noted hair was noticeable on DA J's head and could be seen from across the dining room; no hair net was observed. On 01/02/24 at 11:55 AM, Surveyor interviewed DA J regarding the lack of a hair net. DA J said they usually don't wear a hair net due to shaving their head, and the hair net gets itchy. DA J said this is the longest their hair usually gets, and they planned to shave their head but did not before coming to work. On 01/03/24 at 7:52 AM, Surveyor observed DA J taking their glasses off, rubbing their forehead, and then placing their eyeglasses back on their head. DA J did not perform hand hygiene after and continued preparing and serving residents food. On 01/03/24 at 8:03 AM, Surveyor observed DA J walk out of the kitchen with an apron on and enter the restroom near the facility's entrance. At 8:06 AM, DA J left the bathroom with an apron still on. DA J walked back into the kitchen at 8:08 AM; no hand hygiene was performed when entering the kitchen, gloves were donned, and the apron was not changed before preparing food. While serving food, DA J was observed touching the surgical mask they wore with gloved hands, then continuing to serve food without changing gloves or performing hand hygiene. On 01/03/24 at 1:15 PM, Surveyor interviewed Dietary Manager (DM) I regarding concerns observed. DM I said they would expect that aprons that were worn in the kitchen were not worn out of the kitchen or were replaced if the apron had left the kitchen. DM I would expect that all hair is restrained when dietary aides are in the kitchen and that hair is restrained under hats. DM I would expect hand hygiene to be followed per policy.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections; the facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to affect 26 of the 26 residents reviewed. Improper hand hygiene occurred for 5 of 26 residents. (R21, R15, R23, R8, and R12.) Improper use of PPE for 2 of 2 resident observations (R181, R183). Findings: Example 1 The facility policy entitled, Water Management for Legionnaires' Disease, states in part: Facility will identify and manage the risks arising from exposure to Legionella bacteria in water systems, and complete flow diagrams for proper control measures to avoid infections. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system in the policy and in a flow diagram of the system to include an assessment of the facility's water system to identify all locations where Legionella could grow and spread. - Identify where control measures should be applied. - Include a process to confirm the WMP was being implemented and was effective. - Document and communicate all the activities. - Include a water management team that reviews processes. Surveyor noted the flow diagram was generic and did not specify any distinguished locations or areas where Legionella could grow, spread, or any measures to control the possible spread. The section of the policy entitled, monitoring risk measures to avoid Legionella infections contained maintenance will complete monthly monitoring, water sampling, and documentation. Surveyor noted the above monitoring measures documentation was not completed. Surveyor noted the facility's WMP did not document specific names, contact information or assignments of the individuals on the team, and the plan did not contain all the control points or measures taken to reduce Legionella. The above policy/WMP did not address dead legs throughout the facility. On 01/03/24 at 2:00 PM, Surveyor interviewed Director of Nursing (DON)/Infection Preventionist (IP) B and Nurse Manager C about the WMP. DON B indicated that the facility policy is not detailed, and they do not have a formal diagram of exactly where the facility is preventing the risk of Legionella in the water systems. DON B indicated that they do not have the best system in place. On 01/03/24 at 2:35 PM, Surveyor interviewed Director of Maintenance G and asked about WMP and the control measures that identify and control the spread of Legionella. Director of Maintenance G indicated that the WMP policy is very vague and any unoccupied wings in the facility are flushed every two weeks by Director of Maintenance G, but this procedure is not being documented that it was completed. Example 2 The facility policy entitled, COVID-19, states in part: a. residents who are confirmed to have COVID-19 will be placed on Airborne precautions, b. Staff will wear gowns, gloves, N95 masks, and goggles/face shields when working with residents. On 01/02/24 at 10:05 AM, Surveyor observed a Droplet/Contact precautions sign outside R181's room. Surveyor observed a side table located outside R181's door which contained four paper bags with used N95s in the brown paper bags. Surveyor observed Certified Nursing Assistant (CNA) E exit R181's room with N95 on and goggles. CNA E placed the goggles on the side table and then took the N95 mask off. CNA E placed the N95 mask and goggles into a brown paper bag and then pulled out a regular surgical mask from the brown paper bag. CNA E placed the surgical mask on and ambulated down the hall. CNA E placed hands in pockets feeling for hand sanitizer. CNA E could not find any so CNA E walked to the wall and used hand sanitizer on the wall. Surveyor observed CNA E enter R27's room and answer the call light. Surveyor observed the same surgical mask when entering R27's room. On 01/02/24 at 11:35 AM, Surveyor interviewed CNA E on the process for donning and doffing Personal Protective Equipment (PPE) in isolation rooms. CNA E indicated the facility instructed and educated staff on changing N95 masks once a day. CNA E indicated at the end of the day CNA E discards the N95 mask, and then sanitizes the goggles and places them in the bin. CNA E indicated the process for donning PPE by placing a regular surgical mask in the brown paper bag and then pulling out the used N95 to enter R181's room. CNA E takes the goggles out of the brown paper bag and places them on. CNA E then dons a gown and gloves and walks into R181's room. CNA E indicated when care is completed, CNA E doffs all PPE except the goggles and N95 mask. CNA E exits R181's room, sanitizes hands and then places the goggles and N95 mask back in the used brown paper bag. CNA E indicated that CNA E grabbed the regular surgical mask out of the brown paper bag and placed it back on the face. CNA E indicated this is the process CNA E was taught by the facility. On 01/02/24 at 11:40 AM, Surveyor observed CNA E start donning PPE before entering R181's room. CNA E set down iPad/tablet device on a side table outside of R181's room. CNA E took off the regular surgical mask and laid it on the side table. CNA E grabbed the N95 mask out of the brown paper bag and donned the mask and goggles. CNA E then proceeded to take the regular surgical mask and place it in the brown paper bag. CNA E grabbed the gown and put it on, then placed gloves on and entered R181's room. On 01/02/24 at 11:47 AM, Surveyor observed Registered Nurse (RN) D push EZ-stand in the doorway for CNA E to grab. RN D started donning PPE before entering R181's room. RN D placed safety glasses on the face, took off the regular surgical mask, and laid it on the side table. RN D grabbed the N95 mask out of the brown paper bag and donned the mask. RN D then adjusted the nose band to fit the face and then readjusted the safety glasses. RN D took the glasses off and rubbed the glasses on the scrub top then placed the glasses back on the face. RN D then took the regular surgical mask and placed it in the brown paper bag. RN D grabbed the gown and put it on, then placed gloves on and entered R181's room. On 01/02/24 at 12:00 PM, Surveyor observed RN D come out of R181's room. RN D's N95 mask was below the nose and covering the mouth. RN D walked to the side table, took the mask off and placed it in the brown paper bag. RN D took the regular surgical mask out of the brown paper bag and placed it on the face. RN D proceeded to walk down the hallway feeling in pockets and all over scrubs. RN D stated, Oh, I forgot these, and threw eye protection safety glasses onto the med cart and kept walking. RN D went into the unoccupied dining room and washed hands with soap and water, then she exited the dining room. On 01/02/24 at 12:04 PM, Surveyor observed CNA E pop head out of R181's room and was looking for assistance with lift transfer. Surveyor observed goggles on top of CNA E's head touching CNA E's hair. On 01/02/24 at 12:08 PM, Surveyor observed RN D grab the goggle safety glasses off the med cart and place them in RN D's scrub pocket. RN D then went to the side table, took goggles out of pocket and put them on the side table. RN D took the regular surgical mask off and placed it in the brown paper bag. RN D took the N95 mask out of the brown paper bag and donned the N95 mask. RN D donned a gown and then RN D dug in her pockets again and then remembered she placed goggles on the side table. RN D grabbed the goggles and placed them on the face. RN D then gloved and entered R181's room. On 01/02/24 at 12:13 PM, Surveyor observed CNA E come out of the room with only goggles and an N95 mask on. CNA E took off the N95 mask and the goggles and placed them in the brown paper bag on the side table. CNA E took a regular surgical mask out of the same brown paper bag and placed it on the face. On 01/02/24 at 12:16 PM, Surveyor observed RN D come out of R181's room with goggles and an N95 mask on. RN D took the goggles off and laid on the side table then walked away down the hall with the same N95 mask on talking to Director of Nursing (DON) B. RN D finished talking to DON B, sanitized her hands and then walked back to the side table and took off contaminated N95 mask and placed mask and goggles into the same brown paper bag as earlier. RN D then grabbed the regular mask out of the brown paper bag and placed the regular mask on. RN D walked to the med cart and continued to open drawers and gather medications. Surveyor did not observe any hand hygiene performed by RN D after touching contaminated PPE. RN D went into R183's room, conversed for a while, and then exited with a pitcher of water to refill for R183. CNA E started talking to RN D, and RN D placed the pitcher on the med cart where goggles were previously observed to be sitting. Surveyor did not observe any sanitizing of the med cart or hands washed before or after touching the water pitcher and delivering R183's water pitcher to R183. On 01/02/24 at 12:55 PM, Surveyor interviewed DON B on what expectations are for donning and doffing PPE with COVID-19-infected residents. DON B indicated that there are no contingency plans, no shortage of N95 masks and staff should be throwing N95 away after each use. DON B indicated unaware that staff were utilizing the same N95 mask for the whole day instead of throwing it out and changing it every time. Example 3 The facility policy entitled, Standard care routines-nursing services, states in part: Wash hands before serving food, offer wipes, washcloth, or sanitizer to residents for handwashing before and after meals, and assist as needed. On 01/04/24 at 7:43 AM, Surveyor observed R21 enter the dining room, sit at the table, and order breakfast fluids. On 01/04/24 at 7:55 AM, Surveyor observed a breakfast tray delivered to R21 at the table. Surveyor observed no hand hygiene offered to R21. On 01/04/24 at 11:25 AM, Surveyor observed R15, R23, R8, and R12 enter dining room. Clothing protectors were applied by the staff. Surveyor did not observe hand hygiene being offered to residents. Surveyor did not observe any hand sanitizer bottles or wipes on the dining room tables. On 01/04/24 at 11:41 AM, Surveyor observed Speech Therapist (ST) F serve a lunch tray to R8. Surveyor did not observe hand hygiene being offered to R8. On 01/04/24 at 11:43 AM, Surveyor observed ST F serve lunch tray to R12. Surveyor did not observe hand hygiene being offered to R12. On 01/04/24 at 11:44 AM, Surveyor observed ST F serve lunch tray to R15. Surveyor did not observe hand hygiene being offered to R15. On 01/04/24 at 11:47 AM, Surveyor observed ST F serve lunch tray to R23. Surveyor did not observe hand hygiene being offered to R23. On 01/04/24 at 11:49 AM, Surveyor interviewed ST F and asked what the process is for sanitizing resident hands before meals. ST F indicated usually offer hand hygiene before meals are served. ST F indicated that this was not performed, and staff is inconsistent with the process of hand hygiene. On 01/04/24 at 11:53 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked what expectations are for hand hygiene for residents before meals. NHA A indicates that hand hygiene is offered to all residents before they leave their rooms and enter the dining room.

Based on interview, medical record review and facility document review, the facility did not have a comprehensive system for ensuring residents received influenza immunizations, for 1 of 5 sampled residents, (R181). This is evidenced by: The CDC Influenza Vaccine Timing for Adults reads, in part: One dose of Influenza vaccine is recommended for adults each flu season . Surveyor requested a list of current residents and their influenza, pneumococcal, and COVID-19 immunization dates. R181's immunization record stated influenza immunization last received was on 11/02/22. On 12/13/23, influenza vaccination was listed as being: Historical. No actual dates of these immunizations had been obtained to verify R181 was up to date with his influenza immunization. Surveyor reviewed a consent form signed on 12/12/23 titled, Consent to administer Influenza vaccine, signed by R181 which indicated the desire to receive the influenza vaccination from the facility. Surveyor reviewed the physician's order dated 12/12/23 which stated in part, Administer influenza vaccine upon admission one time at bedtime. On 01/03/24 at 10:00 AM, Surveyor interviewed Social Services H and asked about the process for admission and up-to-date on current immunizations. Social Services H indicated it is the nursing department that handles the admission of current immunizations and forms. On 01/03/24 at 10:48 AM, Surveyor interviewed Director of Nursing (DON) B and asked about the process for admission and up-to-date on current immunizations. DON B indicated the process for following up with vaccinations after residents are admitted is a working process at this time. DON B indicated that this task had fallen through the cracks. DON B indicated that the staff did not administer influenza vaccination as requested by R181.

Based on interviews and record review, the facility did not ensure the right of a resident to receive visitors at the time of their choosing for 1 (R181) of 1 resident reviewed for visitation rights. The facility restricted R181's family's immediate access to R181 during a decline in health conditions related to COVID-19 infection. Findings include: R181 was admitted on [DATE] with diagnoses of fall with T8-T9 spinal fractures, atrial fibrillation, heart failure, neurogenic bladder, diabetes mellitus, and arthritis. Surveyor reviewed R181's Admission Minimum Data Set (MDS) dated [DATE] which documents R181's Brief Interview for Mental Status (BIMS) score to be a 13, indicating R181 was cognitively intact for daily decision-making. The facility provided Surveyor with a copy of a progress note regarding R181. The progress notes document in part, on 12/28/23 at 3:04 pm, R181's daughter called and asked about coming to visit R181. R181's daughter was informed by the Director of Nursing (DON) B that R181 should not have visitors while in isolation for COVID-19. R181's daughter was denied access to R181 and was told the facility would update accordingly. On 01/02/24 at 10:05 AM, Surveyor observed R181 yelling in the room asking for his daughter. On 01/02/24 at 11:40 AM, Surveyor observed R181 talking in the room to self-asking, Can I see my daughter? On 01/02/24 at 12:08 PM, Surveyor observed R181 talking to a Certified Nursing Assistant (CNA) E. R181 stated, I don't understand what is happening and I want to see my family. CNA E indicated to R181 that everything would be ok and R181 was in a safe environment. On 01/03/24 at 10:48 AM, Surveyor interviewed DON B about the facility's visitor policy and visitations during the isolation period. DON B indicated that the facility doesn't have a policy in place, but the facility is not allowing visitors to visit when a resident is in isolation. DON B indicated that visitors for other residents who are not in isolation will wear masks when ambulating through halls and then remove them once in the resident's family's room, but COVID-positive residents don't get visitors at this time. On 01/03/24 at 2:30 PM, Surveyor shared the concern with Nursing Home Administrator (NHA) A and DON B that the facility did not provide immediate access to R181, at the time of R181's choosing. No further information was provided by the facility at this time.

Based on observation, interview and policy review, the facility failed to distribute food under sanitary conditions. This has the potential to affect 30 of the 30 residents that reside at the facility. Staff was observed to be working with food without a hair restraint in place to cover all hair. During dishwashing, Staff was observed to touch a item that fell on the floor and then remove dirty gloves and replace gloves without hand washing. During meal service, Staff was observed to touch a resident's foot and slipper and then return to serving food without hand washing. The Cook was observed to serve food at tray line with his facial mask below his nose or chin. This is evidenced by The facility policy entitled Hair Restraints dated October 2011 states in part; Hair .must be secured and pulled up, must wear hair restraint (i.e. Hairnet, .). The facility policy entitled Handwashing dated October 2011 states in part; When to wash hands . After handling soiled equipment or utensils after engaging in other activities that contaminate the hands. The facility policy entitled Bare Hand Contact with Food and Use of Plastic Gloves dated October 2011 states in part; Remember gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed . Wash hands after removing the gloves. Observations on 11/08/22 beginning at 9:19 AM Hair Restraints Dietary Assistant (DA) E was observed in the main dining room handling juice and maple syrup. DA E was also observed wiping down all juice machines, counters and refrigerator doors. DA E wears a hair net that does not cover all of her hair. The hair on top of DA E's head is totally uncovered. She has long hair pulled back into a pony tail; the hair net covers only a part of the bottom of DA E's pony tail, the rest of her long brown hair is sticking out of net. When asked about her hair net DA E stated, My hair is so long that the hair net doesn't cover it all. Glove use/Handwashing DA F was observed washing dishes. A pitcher fell off of the counter onto the floor. DA F picked up the pitcher off of the floor, and placed it on counter on the dirty side of dish machine. DA F then took off her dirty gloves and put on clean gloves. DA F did not wash her hands between glove changes. Observations on 11/09/22 at 11:30 AM, DA F was observed serving residents lunch in the main dining room. DA F brought bowls of fruit to the table for R16. R1 was just arriving to the table and her slipper fell off of her foot. R1 requested assistance. DA F was observed to approach R1, pick up the slipper off of the floor and place it onto R1's foot. DA F then walked back to R16's food and took the plastic wrap off of his bowls of fruit. DA F then continued to plate Mess Cake and take it to other residents. DA F did not wash her hands following touching something contaminated. Mask use at tray line Cook C was observed on each day of survey to wear a N-95 or a surgical mask below his nose and at times below his chin while at tray line and other times. Cook C was observed in the kitchen with his mask down during the following times 11/08/22 at 10 AM in kitchen , 11/09/22 11:05 AM at steam table with mask below nose and mouth, 11/09/22 11:20 AM talking with other staff in Kitchen over steam table with mask under his nose and mouth. 11/10/22 8 AM at the steam table and tray line. Interview on 11/10/22 at 8:37 AM with Dietary Director (DD) D the surveyor reviewed the above observations. DD D stated that at this time due to the county's high covid positivity rate all staff are to wear masks covering their nose and mouth while at work. DD D stated that hair restraints need to cover all hair, that hand washing needs to be completed any time hands are contaminated. DD D also provided facility policies and procedures at this time.

Based on interviews and facility record review, the facility failed to prevent or contain the spread of COVID-19 by not having procedures for addressing staff, including individuals providing services under arrangement and volunteers who refuse COVID testing or are unable to be tested . This has the potential to affect all 32 residents that reside in the facility. The facility did not have procedures in place for addressing staff that refuse COVID testing or are unable to be tested . During outbreak testing, 61 facility staff members that refused testing, or were unable to be tested , were not restricted from the building until the procedures for outbreak testing had been completed. This is evidenced by: On 12/01/20 at 9:21 a.m., Surveyor interviewed Certified Nursing Assistant (CNA) C about facility COVID-19 testing for staff. CNA C indicated the facility is testing 2 times a week. Surveyor asked if COVID-19 testing is required. CNA C indicated it is not required but is highly recommended and especially if showing symptoms. On 12/01/20 at 9:35 a.m., Surveyor interviewed Registered Nurse (RN) D about facility COVID-19 testing for staff. RN D indicated the facility is testing twice a week and is optional and most staff are doing one time a week. Surveyor asked if staff refuse to test if they are able to work. RN D indicated staff are able to work. Surveyor is unable to determine RN D's last testing date due to no system in place to track this. On 12/01/20 at 2:00 p.m., Surveyor interviewed Director of Nursing (DON) B and RN E about the infection control program and staff COVID testing. RN E and DON B indicated the COVID outbreak started on 11/11/20. RN E indicated staff and residents are tested two times a week on Monday and Thursday. Surveyor reviewed the CMS.gov website that documents the data for the county positivity rate. The facility county has been a red county since 10/21/20, requiring staff to be tested twice a week. Surveyor asked what happens when staff refuse to be tested for COVID. RN E indicated staff are to sign a form for refusal not to test. RN E indicated having not seen anything that states that staff have to test. Surveyor asked when staff refuse COVID testing are they able to continue to work. RN E indicated staff can continue to work and if they show signs and symptoms and refuse to test the staff are off for the 10 days. Surveyor asked for COVID test tracking of staff. Surveyor reviewed the list provided of staff refusing testing and identified 61 different staff members refusing testing. Surveyor was unable to determine what time frame as the facility has no tracking system with dates. On 12/01/20 at 3:30 p.m., Surveyor interviewed DON B asking about testing days, if the facility is tracking staff refusals or those who did not attend testing. DON B indicated some staff don't get tested and some are refusing to test and we don't go through to see which staff don't test. Surveyor reviewed 12/01/20 staffing schedule and identified License Practical Nurse (LPN) F is on the schedule and is also on the list of staff refusing to test. Surveyor can not determine the last test date for LPN F as there is no system to track this for LPN F. CNA G is listed on the staffing schedule and the last documented COVID testing date was 11/19/20. Review of CNA G's schedule identified CNA G worked on 11/23/20, 11/24/20, 11/25/20, 11/26/20, 11/30/20 and 12/01/20. CNA G was not tested [DATE], 11/26/20 or 12/1/20 on the testing dates established by the facility. CNA G was allowed to continue working. Surveyor asked DON B when staff are unable to make it to the scheduled testing dates is the facility using the rapid testing before staff start their next shift. DON B indicated they are not tested until the next scheduled testing date. Surveyor asked if there is a system to track staff testing. DON B indicated they don't keep track of who doesn't get tested . Surveyor reviewed with DON B the 11/30/20 staff testing list and identified CNA G and RN H were not on the list and were working today. DON B indicated CNA G and RN H were not on the testing list and were working today. Surveyor asked DON B where CNA G usually works. DON B indicated CNA G is usually the restorative aide and works with residents throughout the building. On 12/01/20 at 3:45 p.m., Surveyor reviewed the information above with Nursing Home Administrator (NHA) A to verify the facility does not have a system for tracking staff refusal to participate with facility COVID testing on scheduled testing days. The facility's policy does not address refusal of COVID testing during an outbreak and does not address testing of staff when missing the scheduled testing date. Surveyor reviewed the QSO-20-38-NH memo documenting 483.80(h) COVID-19 Testing. The LTC facility must test resident and facility staff, including individuals providing services under arrangement and volunteers, for COVID-19. At a minimum, for all residents and facility staff . (5) Have procedures for addressing residents and staff, including individuals providing services under arrangement and volunteers, who refuse testing or are unable to be tested *For outbreak testing, all staff and resident should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases . Refusal of Testing: If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. NHA A and DON B indicated understanding and are starting a tracking system.

Based on medical record reviews, policy review, observation, and interview, the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers, ulcers and receives the necessary treatment to promote healing, prevent infection, and prevent new pressure ulcers from developing for 2 of 4 residents reviewed with pressure ulcers (Resident #3, #2). Resident #3 and #2 developed stage III pressure ulcers in the facility, where interventions to prevent the pressure ulcers, and promote healing did not occur. This is evidenced by: The facility policy titled, Skin integrity - Pressure sores includes in part: "Procedure: 1. Assessment Process: Initial and weekly b. If pressure sore is evident a written description of the pressure sore characteristics which includes: Location, stage, depth, measurement, description of exudate, tissue description, site infection evidence, condition of skin surrounding the ulcer, appropriate treatment, and resident's response to treatment. 2. f. Initiate and implement appropriate measure in care plan... 4. c. Turn/reposition every 2 hours while in bed and reposition frequently when in chair. e. Evaluate the need for pressure reduction surface for bed/chair and the need for elbow/heel protectors." 1. Resident #3 has [DIAGNOSES REDACTED]. Resident #3 has severe cognitive impairment. The MDS also documents that Resident #3 has one unhealed stage III or IV pressure Ulcer or Eschar, measuring 0.5 length x 0.5 width, and is at risk of developing pressure ulcers. The MDS does not have anything marked for skin and ulcer treatments, such as pressure reducing device for chair, pressure reducing device for bed, or turning and repositioning program. The MDS does identify that Resident #3 is receiving pressure ulcer care. Physician orders: "Left hip reddened area- cover with foam border dressing to be changed every 3 days, 02/22/15 Mid back open area: cleanse with NS (normal saline), apply no sting barrier, and cover with foam border. 02/18/15. Open area midback - pressure redistribution 02/18/15" Comprehensive nursing care plan in part: "Potential for skin breakdown related to decreased mobility, incontinence, mid spine pressure ulcer. Date initiated 02/12/2012. Goal: Resident's skin will remain free of breakdown through review date. Pressure ulcer will resolve without complications. Interventions: Air mattress date initiated 02/08/12, Monitor skin with cares..., provide peri care following incontinence episodes, socks only, no shoes, treat any areas per CCH protocol." (All dated 02/12/2012). According to Registered Nurse (RN) A (02/26/15, 2:45 PM) "Our system reverts back to the admitted , so the 2012 dates are not correct." The Certified Nursing Assistant (CNA) assignment sheet in part: "A-2 (assist of 2) hoyer, incontinent. Lie down after lunch. Trial tilt-n-space recliner, tilt all the way back between 30 min in a.m. and 30 min p.m., pillow between legs bed, reclining wheelchair." The care plan does not identify a repositioning schedule for the resident, or have any changes to offload pressure, after the areas opened on the mid spine area. The care plan does not identify interventions to float the heels or to wear protective heel boots. Nurses' notes show that Resident #3 has a history of a left heel ulcer. 07/30/14 "Left heel assessed. Wound is intact, boggy, purple in color...order for left flex boot until healed, float heels in bed..." 09/10/14 "Left heel wound bed is beefy red, scant amount of serosang (serosanguinous) drainage to old dressing..." 09/29/14 "Dressing change to left heel. ..purple non viable tissue 0.5 cm x 1 cm..." 02/04/15 "...left heel ulcer resolved..." Despite this history, there is nothing on the care plan to prevent reoccurrence. Nursing notes document the current pressure ulcers as follows: 02/13/15 "Three superficial open area in a 2 cm diameter reddened areas on center of mid-back. Treatment started. MD (Medical Doctor) updated." A skin assessment of wound bed, drainage, wound stage, tissue description, surrounding skin description is not done the day the area is identified. 02/18/15 "Mid spine wounds assessed...cluster of 3 open areas to mid spine 0.8 cm x 0.5 cm, 0.5 cm x 0.5 cm, and 0.5 cm x 0.5 cm. Wound beds are pale, wound edges dark pink, peri wound pink and firm. Scant amount of serosang drainage to old dressing..." Skin/wound weekly report (The wound assessment is completed five days after the area was noted.) 02/18/15 "Site 13, vertebrae (upper-med) Type: pressure length 0.8 cm x 0.5 cm, Stage III. Comments: Cluster of 3 open areas to mid spine. 0.8 x 0.5, 0.5 cm x 0.5 cm, and 0.5 cm x 0.5 cm..." Nurses' note in part: 02/22/15 "CNAs reported a reddened area to left hip noted this am. when got up this morning...measured reddened area appprox 2.8 cm in width x 3 cm in length. ...foam border dressing applied...update written to MD..." 02/25/15 "...left hip wound is 0.2 cm x 1 cm, dark red and non blanching..." Skin/wound weekly report 02/25/15 "Site 13 (upper-mid) type: pressure length 4 cm x 1.2 cm depth 0, unstageable site 22 Left iliac crest (rear) type: pressure 0.2 length x 1 cm width, depth 0. Stage I Comments: Site 1 -wound bed is covered with drak non-viable tissue, peri wound dark red and soft. Small amount of serosan drainage to old dressing. Comments site 2 - wound is non blanching, no open area noted." The Pressure Ulcer Scale for Healing (PUSH) tool scores were reviewed by Surveyor and are as follows: Directions for the PUSH tool in part: "A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing." 01/29/15 Left heel =2 02/19/15 Spine = 5 02/25/15 Spine =12 Iliac crest =1 Observations on 02/26/15: 10:30 a.m., Surveyor observed Resident #3 in her room sitting in her broda chair. There were no pillows or cushions on the seat or back of the chair to prevent pressure on the open areas. Resident #3's feet had socks on them with no protective boots or pillows in place to protect the recently healed heel ulcer. 12:10 p.m., Surveyor observed CNA B and CNA C assist Resident #3 into bed, using the hoyer lift. Surveyor observed a dressing on the left ischial crest, and dressings to the left of Resident #3's spine. When Resident #3 was turned onto her left side, Surveyor could see a very red circular area on the right ischial tuberosity. Surveyor asked CNA C to touch the area with her gloved hands; the area did not blanch. Surveyor asked CNA C about Resident #3's positioning schedule. CNA C stated, "We lay her down between meals, she is up at 7 a.m., lies down at 9:30 a.m., then up at 11:00 a.m., and lies down at 1:00 to 1:30 p.m." Surveyor asked if Resident #3 had a specific repositioning schedule. CNA C stated, "I think every two hours is standard for all residents." Resident #3's heels were not floated while in bed. 12:22 p.m., Surveyor requested the Nurse Manger for the unit, Registered Nurse (RN) A, view the area on the right ischial turbrosity. RN A turned Resident #3 onto her left side and looked at the area. RN A checked for blanching, and the area did blanch at this time, but remained discolored. RN A said, "Hospice was here yesterday and checked on her. I will have to let them know." RN A left Resident #3 lying on her left side, where the pressure ulcers are located. 1:15 p.m. to 2:35 p.m., Surveyor observed that Resident #3 continued to lie on her left side. 2:35 p.m., Surveyor observed CNA E assist Resident #3 with getting out of bed. Surveyor asked what Resident #3's usual afternoon schedule was like. CNA E stated, "We get her up about this time, then she goes to music and memory activity, then she has supper at 5:00 p.m., and we put her to bed at 6:30 p.m." Surveyor asked what her repositioning schedule is during that time. CNA E stated, "We will change her every two hours or so, and then recline her chair for a while." Resident #3 was placed in the broda chair, in an upright position, with no cushions in the chair to prevent pressure. 3:35 p.m., Resident #3 continues to sit upright in her broda chair. 3:50 p.m., Resident #3 is lying in bed, on her left side, with no offloading for the pressure ulcers. At 2:45 p.m. Surveyor interviewed RN A, who is the facility wound care nurse. Surveyor asked what standard of practice the facility follows for pressure ulcer prevention. RN A was not sure, but indicated they have policies that they follow. Surveyor asked what interventions had been put in place when the pressure ulcers were identified on 02/13/15. RN A said, "We started to lay her down between meals." Surveyor asked how often that is. RN A stated, "We reposition every two hours." -Surveyor asked about Resident #3's pressure ulcer history. RN A stated, "She had a heel ulcer in July that just healed 02/04/15." -Surveyor asked if the broda chair provided any offloading for the pressure ulcers. RN A stated, "I have been told that it is a pressure redistribution chair." -Surveyor asked if that is the same as offloading a current pressure ulcer. RN A stated, "No." -Surveyor asked when the air mattress was added. RN A stated, "Since the area was larger in size yesterday, we added the air mattress yesterday." -Surveyor asked for verification of any updates to the care plan. RN A provided Surveyor with a piece of paper that verified the air mattress intervention was updated 02/26/15. Surveyor asked what stage the wound was when assessed by RN A on 02/18/15. RN A stated, "It was a stage III, because I could visualize the wound bed, and it had slough." -Surveyor asked when the assessment of the wound should be done. RN A stated, "The nurse who identifies it should do a completed assessment of the area. I do them on a weekly basis on my rounds once I am aware of it." -Surveyor asked if the pressure ulcer was avoidable. RN A said, "All pressure ulcers are avoidable, but if the resident is compromised they happen." -Surveyor asked if Resident #3 developed three stage III areas on her back, and a stage I on her ischial crest with two hour repositioning, why that was not reevaluated. RN A stated, "We just recently got some information on tissue tolerance testing that we plan to start using." -Surveyor asked if she had more information on the standard of practice the facility follows. RN A said, "Yes, we use NPUP, (National Pressure Ulcer Advisory Panel)." -Surveyor asked if RN A knew what positioning schedule is needed when a resident has a pressure ulcer on their bottom. RN A did not know. Surveyor stated every one hour repositioning when in direct contact with an existing pressure ulcer to offload the area. Surveyor shared the observation that Resident #3 was showing lack of tissue perfusion on the right ischial tuberosity area today, and she had only been in the broda chair for 1 hour and 40 minutes. RN A stated, "She needs to be repositioned more often." On 02/26/15 at 3:15 p.m., Surveyor interviewed the Director of Nursing (DON) about the concerns of no updates on the care plan for repositioning for pressure ulcer prevention and healing when Resident #3 had developed three stage III areas on her back and a stage I on her iliac crest. The intervention of an air mattress was added three days after the fourth pressure ulcer developed on 02/22/15. 2. Resident #2's current [DIAGNOSES REDACTED]. The MDS, dated [DATE], documents Resident #2 is total dependence of two person physical assist for bed mobility, transfers, toilet use, personal hygiene, and bathing. The MDS documents Resident #2 is always incontinent of bowel and bladder. The MDS also documents Resident #2 is at risk for developing pressure ulcers and does not have one or more unhealed pressure ulcers. The MDS documents no pressure ulcers were present on the prior MDS assessment. The MDS documents for skin and ulcer treatments that are used are pressure reducing device for chair and bed. The turning/repositioning program and nutrition or hydration intervention were not identified as being utilized to prevent future skin breakdown. Review of the comprehensive nursing care plans read in part: "Unable to bathe, dress, groom self independently, potential for skin breakdown r/t (related to) H/O (History Of) [MEDICAL CONDITIONS] as evidenced by unsteady on wet surfaces (shower/tub) Date Initiated: 02/07/12". Goal: "Skin will remain free of breakdown through review date. Date Initiated: 02/07/12." Intervention: "Lie down in bed after each meal. Date Initiated: 09/29/13". "Pressure reducing mattress for bed. Date Initiated: 02/07/12'. "Provide peri-care following episodes of incontinence. Date Initiated: 02/07/12." Review of the CNA care plans read in part: "Lay flat after meals, pillow under head, recline up at meals, and elevate legs often." Review of the medication review report: "Reposition every 2 hours" Order date: 03/14/14, Start date: 03/14/14. Review of nurses' notes read in part: 01/08/15 "Resident is turned and repositioned every two hours..." 01/16/15 2:10 p.m., "Open area noted to coccyx during cares. Wound bed is pale, wound edges dark pink. Peri wound pale and firm. No drainage or odor noted. MD updated." 01/16/15 10:17 p.m., "Area on coccyx cleaned with NS (Normal Saline), no sting and covered with replicare." 01/28/15 9:03 a.m., "Coccyx wound resolved." 02/05/15 10:26 a.m., Dietary Note: "4. Aware of skin abrasions (buttock / coccyx) with not nutrition intervention (additional protein/fluids/etc) desired for her comfort as intake is now so poor and she is not interested in eating and deceasing (sic) interest in drinking these interventions likely will irritate her. Noted is so poor her elimination patterns are scant to none." 02/18/15 4:00 p.m., "CNA reported res. has a superficial open slit to buttocks crease below coccyx. No visible drainage noted. Writer updated Wound Nurse & barrier cream applied. SBAR update sent to Dr. to inform of new open area." 02/20/15 1:46 p.m., "Coccyx wound bed is dark red, peri wound dark red and non blanching. No drainage noted. MD updated." 02/20/15 4:36 p.m., Dietary Note: "NUTRITION NOTE - alerted to new skin area on coccyx as a stage 3. (Resident name) has had a comfort focus and has been eating progressively less r/t dementia with a continual and noted progression in weight down to 103#. She is up 4# to 107# in the past month and drinks better than she eats. She lays down between meals. Will begin a nutrition supplement (might shake) for comfort to aid in healing for comfort approach for wound healing...." 02/21/15 3:40 a.m., "Res. has been repositioned every 2 hrs. per usual..." 02/23/15 1:20 p.m. "MD reviewed fax noted and agreed on dressing change to coccyx wound, cleanse with n/s, apply no sting, and cover with replicare, change x 3 days and PRN until resolved." 02/23/15 3:01 p.m., "Dressing changed to coccyx wound. Wound bed is beefy red, peri wound light red. Scant amt of serosang drainage to old dressing. no tunneling or undermining noted. No c/o pain during dressing change." Review of the Braden Scale for Predicting Pressure Sore Risk, dated 11/05/14, has a score of 13 indicating a moderate risk for developing pressure sore and on 02/03/15 has a score of 14 indicating a moderate risk for developing a pressure sore. Review of PUSH tool results dated: 01/21/15 Coccyx = 5 01/29/15 Coccyx = 5 02/18/15 Coccyx = 4 02/25/15 Coccyx = 4 Review of the Skin/wound-weekly report: 01/16/15 Site 23) Coccyx, Type: Pressure, Measurements: 0.4 cm by 0.2 cm, Stage: II 01/21/15 Site 23) Coccyx, Type: Pressure, Measurements: 0.4 cm by 0.2 cm, Stage: II (Note: There are no changes to the care plan to prevent the pressure ulcer from worsening.) 02/20/15 Site 23) Coccyx, Type: Pressure, Measurements: 1 cm by 0.4 cm by 0.1 cm, Stage: III 02/23/15 Site 23) Coccyx, Type: Pressure, Measurements: 1.5 cm by 0.4 cm by 0.1 cm, Stage: III Surveyor interviewed CNA F about Resident #2's positioning schedule. CNA F indicated Resident #2 is up for each meal and then is to lie back in bed after the meals. Surveyor asked how often Resident #2 is to be repositioned in bed. CNA F stated "Every resident is to be repositioned every two hours." At 3:00 p.m., Surveyor interviewed RN A, who is the facility wound care nurse. Surveyor asked RN A if the area that opened on 02/20/15 is the same area that was open on 01/16/15. RN A stated it is the same area on the coccyx. Surveyor asked RN A if the nurse that discovered the open area on 02/18/15 should have started wound documentation of the open area. RN A indicated the nurse who discovered the area should assess it. RN A indicated she does weekly treatments and assessment once she is made aware of it. Surveyor asked RN A if barrier cream was an appropriate treatment of [REDACTED]. RN A stated, "By nurse charting, seemed o.k. if a slit." Surveyor asked when the area first opened what was changed to prevent future pressure areas to Resident #2. RN A indicated she now implemented Resident #2 is to be lying down more frequently and up for meals only, and side to side positioning. On 02/21/15 started on mighty shakes for meals. Surveyor reviewed the comprehensive care plan and the CNA care plan with RN A and identified the care plans were not updated with any new intervention to promote healing and prevent future pressure ulcers. RN A stated, "Wrote care plan updates this morning for up for meals only." Surveyor asked RN A since the pressure ulcer reoccurred as a stage III if it was preventable. RN A indicated all pressure ulcers are preventable, but unfortunately they can happen quickly. On 02/26/15 at 3:15 p.m., Surveyor interviewed the DON about the concerns of Resident #2 having a reoccurring stage III pressure ulcer to the coccyx, having no new interventions initiated to promote healing and prevent future pressure ulcers, the care plans not being updated, and having a repositioning schedule of every two hours for a resident with a reoccurring stage III pressure ulcer.