Every finding on record at Christian Community Home of Osceola, Inc

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This had the potential to affect all 37 residents (R).-Infection Control (IC) surveillance logs for the month of January to August 2026 had data missing. -No Enhanced Barrier Precautions (EBP) in place for R33 who has open wounds.-Clean Resident clothing observed uncovered in hallways and touching the floor.-Staff are not aware why R36 is on Enhanced Barrier Precautions (EBP).-Enhanced Barrier Precautions (EBP) posted for R36 are not being followed.-Staff did not perform proper hand hygiene per standards of practice during medication administration and personal cares. Findings Example 1 On 08/12/2026 10:05 AM, Surveyor interviewed Infection Preventionist (IP) C regarding the facility's infection and prevention program. Surveyor asked IP C why surveillance logs were missing the type of test ordered, specimen collected, and date specimen collection was received. Surveyor asked IP C if surveillance logs should include the type of isolation residents needed to be on and when the precautions were implemented. IP C stated they are new to the IP role and were following the previous line lists from the previous IP designee. IP C stated isolation, start/stop dates, and full scope of symptoms need to be tracked on line list going forward to decrease the spread of infection. Surveyor asked IP C how staff know which resident needs to be placed on transmission based precautions (TBP) including when to initiate and stop TBP. IP C stated nurses on the floor write in a binder to keep eye on and/or implement isolation precautions but that is not efficient for tracking the infection and preventing further spread. Example 2 The facility policy titled Infection Control Policies and Procedures: Enhanced Barrier Precautions (EBP), last revised July 20206, states in part: .Examples of resident care activities that require EBP include: dressing, bathing/showering, transferring, providing hygiene, changing linen, changing briefs or assisting with toileting,. wound care: any skin opening requiring a dressing. R36 was admitted to the facility on [DATE] with diagnoses that include malignant neoplasm of breast. R36's Brief Interview for Mental Status (BIMS), dated 10/4/25, scored a 13/15 indicating R36's cognition is intact. On 8/10/26 at 11:26 AM, Surveyor observed Enhanced Barrier Precaution poster and personal protective equipment (PPE) supplies outside of R36's room. ~ At 11:28 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D regarding the Enhanced Barrier Precaution sign posted for R36. LPN D stated they are not sure why R36 has EBP. ~ At 1:30 AM, Surveyor interviewed LPN E who stated LPN E does not know why R36 has EBP outside their room. It is usually because of a wound, catheter, COVID-19, or some infection. ~ At 1:02 PM, Surveyor and Registered Nurse (RN) P observed the EBP related PPE and a posting outside of R36's room. RN P stated that R36 is on EBP based on the posting outside her door. RN P stated they had not had time to look into why R36 had EBP posted. RN P stated R36 had COVID and thinks that is why. RN P stated R36 is outside the window and does not need it anymore. ~ At 1:26 PM, Surveyor interviewed Director of Nursing (DON) B regarding R36 having EBP posted outside their room. DON B stated they are not certain why and will check with the Infection Control nurse. ~ At 1:33 PM, DON B returned and stated R36 is on EBP because they have a lesion on their left breast that hospice is treating and assessing. Example 3 On 8/10/26 at 12:45 PM, Surveyor observed Certified Nursing Assistant (CNA) H and CNA F assist R36 to the commode with EZ stand mechanical lift. CNA H and CNA F did not have on the gown required by EBP standards. On 8/10/26 at 1:00 PM, Surveyor interviewed CNA H and CNA F and asked if the EBP poster and supplies outside the room were for R36 or the neighboring room. CNA F stated oh that was for R36. R36 had Covid. They don't need it anymore. We were just helping her to the bathroom. Surveyor reviewed R36's medical record. R36 has an open lesion (sore) on R36's left breast. R36's orders state: Left breast raised lesions if open cleanse w/(with) warm soapy water or saline and pat dry. Cover w/ bordered foam. Change weekly and PRN (as needed). Date- 07/15/2026 0600 Surveyor observed the Nursing Assistant Assignment Sheets/Care Plan dated 8/11/26. Under column related to R36 it states EBP for wounds. On 8/11/26 at 6:41 AM, Surveyor observed CNA F coming out of R36's room. Surveyor asked if CNA F knows why R36 has EBP posted. CNA F stated it was left over from COVID and R36 did not need it anymore. CNA F stated they just need to take it down. Surveyor asked CNA F when EBP is posted and PPE is outside the resident's room, is it not always necessary to follow the EBP. CNA F stated they know it has been there since COVID. CNA F stated that if CNA F needed to wear it again, the nurse would tell CNA F. CNA F stated that if they saw new stuff outside a resident's room and they were not told about it, CNA F would ask. CNA F stated they work 8 days a pay period and are considered full time. CNA F stated they know when there are new things they need to do. On 8/11/26 at 10:44 AM, Surveyor interviewed LPN E who stated EBP requires hand washing and a gown to be worn when you are doing catheter care or wound care. LPN E stated anytime you are touching a resident who has a wound or catheter. On 8/11/26 at 1:16 PM, Surveyor observed CNA G and CNA H use the EZ stand mechanical lift to transfer R36 to the toilet. Neither CNA completed hand hygiene nor donned a gown prior to assisting R36. Both CNAs put on gloves when they entered the room without hand hygiene first. On 8/11/26 at 1:43 PM, Surveyor interviewed CNA F regarding when EBP is needed. CNA F stated we do not need to wear gowns and gloves very often. CNA F stated CNA F chooses to put on a gown and gloves when they help R5 dress because they put on R5's tubi-grips but R5 can dress himself pretty much. CNA F stated they only must put on the gown when dealing with R5's catheter really because the wound is always covered. On 8/11/26 at 1:52 PM, Surveyor interviewed LPN P regarding when EBP is required. LPN P stated if we are exposing the dressing or what is underneath it. LPN P stated we also wear gowns when working with the catheter. We do not need to wear gowns when wounds and catheters are covered or passing meds or trays. On 8/12/26 7:19 AM, Surveyor observed LPN P while administering cream to R36's breast. LPN P was not wearing a gown. On 8/12/26 7:20 AM, Surveyor interviewed LPN P who stated R36 is on EBP due to a lesion on her left breast. LPN P stated they did not need to wear EBP because they were only putting cream on the breast and the wound was covered. On 8/12/26 at 10:31 AM, Surveyor interviewed CNA F about the Nursing Assistant Assignment Sheets/Care Plan. CNA F stated they get one every day to guide them. Surveyor asked CNA F to look under R36's column. CNA F stated oh it says EBP for wound care. I don't do anything with her wound so not sure why it says EBP. CNA F stated the wound is on her left breast. Surveyor asked if PPE should be worn because R36 has a wound. CNA F stated only when the wound is uncovered and we don't do anything with that so not really. On 8/12/26 at 2:05 PM, Surveyor interviewed RN C, the infection control nurse, regarding EBP procedures. RN C stated any nurse can set up EBP or transmission based precautions; the posters and supplies are kept on the units. RN C stated staff should not wait for RN C to do it. Surveyor asked RN C what some instances could be where EBP is needed. RN C stated if there is an open wound, catheter, g-tube, or lab comes back with an infection; well some infections require other precautions. Surveyor asked how new interventions and EBP orders are communicated to floor nurses and CNAs. RN C stated the care plan and Nursing Assistant Assignment Sheets. Surveyor asked expectation of staff when EBP is posted outside a room. RN C stated they should wear a gown and gloves with all resident cares, goggles if something might splash. Surveyor asked if this is only when they work with the wound or catheter, or if the wound or catheter is covered, do staff still need to wear PPE. RN C stated yes that they need to wear PPE any time they are touching the patient. RN C stated we just had a skills fair and that was covered with everyone. The training covered a lot of topics that included EBP, isolation precautions, and hand hygiene. It was offered on two different days so everyone could participate. Example 4 On 08/10/26, Surveyor reviewed R33's medical record. R33 was admitted to the facility on [DATE]. R33's most recent Minimum Data Set (MDS) assessment showed a Brief Interview for Mental Status (BIMS) score of 6/15 indicating severe cognitive impairment. On 08/10/26 at 9:45 AM, Surveyor observed R33 had a bandage to the left forearm. Surveyor observed there were no precaution signs in place and staff entered the room to perform cares with no personal protective equipment (PPE) on. R33's treatment administration record (TAR) indicated R33 has an ordered treatment to the left forearm for an open area with documented drainage present. On 08/12/26 at 8:07 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K about enhanced barrier precautions (EBP). CNA K stated they believe EBP is when a resident has an illness with symptoms, but it is manageable with hand hygiene and gloves. When asked if a resident with wounds would be on EBP, CNA K stated yes. Surveyor asked CNA K if R33 has open wounds. CNA K stated R33 has open wounds to the left forearm. When asked if R33 was on EBP, CNA K stated R33 should be but is not. On 08/12/26 at 8:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L about EBP. LPN stated residents that have a Foley catheter, tube feeding, and anything that splashes, should be on EBP. LPN L stated any of the nurses can place signs and PPE bins by a resident room if EBP is warranted. LPN L indicated a resident with an open wound with drainage should be on precautions. When asked if R33 has open wounds, LPN L stated yes to the left forearm. LPN L acknowledged R33 should be on precautions and is not. On 08/12/26 at 8:22 AM, Surveyor interviewed Registered Nurse (RN) C about EBP. RN C stated open wounds, catheters, and other sores are examples of what would warrant a resident being on EBP. RN C stated any nurse can place the signs and bins and that either RN C or Director of Nursing (DON) B will follow up to make sure they are in place. RN C indicated that a resident with an open wound with drainage present should be on EBP. Surveyor informed RN C that R33 is not currently on precautions. RN C acknowledged R33 should be on EBP. On 08/12/26 at 8:28 AM, Surveyor interviewed DON B about EBP. DON B stated catheters, wounds and feeding tubes would be examples of when EBP would be in place. Surveyor informed DON B of R33's open wound with no EBP in place. DON B acknowledged R33 should be on EBP. Example 5 Per facility policy titled Hand Hygiene, last revised June 2026, states in part: The procedure must be followed by all staff to prevent cross- contamination, including hand washing, sanitizing hands with Alcohol-Based Hand Sanitizer (ABHS) or changing gloves after providing personal care, or when performing tasks among individuals which provide the opportunity for cross contamination to occur. Appropriate hand washing or using ABHS (alcohol based hand sanitizer) must be performed under the following conditions: Before and after duty. Before and after resident cares-make sure to take off dirty gloves, wash hands and don on clean gloves before and after any resident care/contact. Before performing invasive procedures. Before medication and food handling. Before and after gloving for procedures. After personal body functions (eating, toileting, etc.) After any situation involving microbial contamination. Whenever in doubt. On 8/11/26 at 7:28 AM, Surveyor observed LPN E administer daily scheduled medication to R5. LPN E did not complete hand hygiene or hand washing prior to prepping, administering, or after medication pass. On 8/11/26 at 7:33 AM, Surveyor observed LPN E administer daily scheduled medication to R28. LPN E did not complete hand hygiene or hand washing prior to prepping, administering, or after medication pass. On 8/11/26 at 7:58 AM, Surveyor observed LPN E administer PRN (as needed) medication to R39. LPN E did not complete hand hygiene before donning gloves and opening the new container of morphine sublingual. LPN E proceeded to take off gloves and take medication to R39's room. LPN E did not complete hand hygiene prior to entering or administering medication, after administration or upon leaving R39's room. On 8/11/26 at 8:21 AM, Surveyor observed LPN E administer daily scheduled medications to R39. LPN E did not complete hand hygiene or hand washing prior to prepping, administering, or after medication pass. On 8/11/26 at 9:36 AM, Surveyor observed LPN E administer daily scheduled medication to R38. LPN E did not complete hand hygiene or hand washing prior to prepping, administering, or after medication pass. On 8/11/26 10:44 AM, Surveyor interviewed LPN E regarding hand washing or hand hygiene requirements. LPN E stated LPN E washes LPN E's hands all the time. LPN E stated they never use hand sanitizer because it bothers their skin. LPN E stated hand hygiene is needed any time you are doing wound care or catheter care, or before and after you enter a resident's room. LPN E stated they do not need to wear gloves to just pass medication unless it is topical. LPN E stated that gloves do not replace the need for hand hygiene. You should do hand hygiene before you put on gloves or after you take them off. Surveyor shared the observation of LPN E not completing hand washing or hand sanitizing multiple times. LPN E stated no, I always wash. On 8/11/26 at 1:16 PM, Surveyor observed CNA G and CNA H use the EZ stand mechanical lift to transfer R36 to the toilet. Neither CNAs completed hand hygiene prior to assisting R36. Both CNAs put on gloves when they entered the room without hand hygiene first. On 8/11/26 at 1:43 PM, Surveyor interviewed CNA F who stated that hand hygiene is needed before you come in the room, after you leave the room, when providing cares and moving to a clean task. CNA F stated gloves do not replace the need to complete hand hygiene. CNA F stated hand hygiene should be completed between glove changes, that is why they carry this little hand sanitizer. On 8/12/26 at 11:12 AM, Surveyor interviewed CNA G who stated that hand hygiene is important all the time, before you work with residents and afterwards. CNA G stated gloves do not replace hand hygiene. CNA G stated you are supposed to use hand sanitizer before you put gloves on and if you change them. CNA G stated when they leave a resident's room they try to wash their hands. On 8/11/25 at 3:22 PM, Surveyor interviewed Director of Nursing (DON) B regarding hand hygiene. DON B stated she expects hand hygiene before and after care, before entering a resident's room to take care of the patient, or changing from one area to another when doing cares. DON B stated they also expect staff to wash their hands after taking the trash out. Surveyor asked if gloves replace the need for hand hygiene. DON B stated no they do not. Staff should complete hand hygiene before they put them on and when they change them. Surveyor shared their observations of lack of hand hygiene and asked DON B if they saw missed opportunities for hand hygiene. DON B stated yes that they should have completed hand hygiene before entering a resident room or before putting on gloves. DON B stated we just had a skills fair. Example 6 On 08/11/26 at 6:50 AM, Surveyor observed clean resident personal laundry hanging on the railing outside R6's room. The bottom of the clothing was touching the floor. Surveyor observed next to the hanging clothing was a basketd of folded resident clothing that was not covered. On 08/11/26 at 6:54 AM, Surveyor observed a basket of resident clothing sitting in the hallway outside of R13's room uncovered. On top of the basket of clothing was one shirt on a hanger that was draped over the basket with the sleeves touching the floor. On 08/11/26 at 6:55 AM, Surveyor observed a basket of resident clothing sitting in the hallway outside of R33's room uncovered. On 08/11/26 at 11:26 AM, Surveyor interviewed Certified Nursing Assistant (CNA) M about resident laundry. CNA M stated the evening shift CNAs collect the resident hampers with personal clothing and take it to the laundry room. The overnight shift CNAs then wash, dry, and fold the laundry. CNA M stated the overnight shift CNAs leave the clothing outside the resident rooms for the day shift CNAs to put away. On 08/12/26 at 8:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L about resident personal laundry. LPN L stated CNAs do the laundry. LPN L stated the laundry is always left in the hallway uncovered for the dayshift CNAs to put away. On 08/12/26 at 8:22 AM, Surveyor interviewed Registered Nurse (RN) C, who also oversees the infection control program in the facility, about laundry. RN C stated the procedure for resident personal laundry includes making sure the laundry does not touch staff clothing and carrying the items in a container/basket. When asked if the laundry should be covered while transporting to the resident rooms, RN C stated that RN C did not think that was standard of practice. Surveyor informed RN C all laundry must be covered in the hallway and RN C acknowledged understanding. RN C stated the laundry should never touch the floor. On 08/12/26 at 8:28 AM, Surveyor informed Director of Nursing (DON) B about the observed laundry concerns. DON B acknowledged understanding.

Based on observation, interview and record review, the facility did not prepare, distribute and serve food in a manner that prevents foodborne illness to 37 out of 37 residents reviewed.Surveyor observed dirty fan attached to wall located above serving steam table where kitchen staff serve residents' meals.Findings include: On 08/11/26 at 11:23 AM, Surveyor observed a fan mounted in the kitchen above the serving steam table. Surveyor observed lint hanging from the fan on the wall above residents' serving plates. Surveyor interviewed [NAME] R and asked how often the fan is used in kitchen. [NAME] R stated kitchen staff use it sometimes when it is extremely hot in the kitchen. Surveyor asked [NAME] R how often the fan is cleaned. [NAME] R stated that Maintenance Technician T is supposed to clean the fan often. [NAME] R stated to Surveyor [NAME] R just doesn't use the fan at this time. [NAME] R stated, I have told [Maintenance Technician T] about the uncleanliness of the fan and [Maintenance Technician T] reports cleaning it twice already. On 08/11/26 at 12:06 PM, Surveyor interviewed Dietary Manager (DM) S and asked about kitchen fans and how often the fans are cleaned. DM S reported there is one kitchen fan on the wall, and one located on the floor in the kitchen. DM S stated Maintenance Technician T is supposed to be responsible for the kitchen fans and the cleaning. DM S stated Maintenance Technician T cleans kitchen fans at least quarterly. Surveyor informed DM S the kitchen fan was observed to have lent hanging from the fan above the resident serving plates and the steam table. DM S stated the kitchen fans should not have lint or debris on the fan at all. On 08/11/26 at 12:12 PM, Surveyor interviewed Maintenance Technician T and asked how often kitchen fans are cleaned. Maintenance Technician T stated kitchen fans are cleaned monthly. Surveyor explained the observation of the kitchen fan on wall in kitchen above the steam table was found to have lint and debris hanging from the fan over the resident serving plates and steam table. Maintenance T acknowledged the fans should be clean.

Based on interview, medical record review and facility document review, the facility did not have a comprehensive system for ensuring residents receive influenza and/or pneumococcal immunizations, for 2 of 5 sampled residents, (R8 and R9) out of a total sample of 15.R8 did not receive influenza immunization.R9 did not receive influenza and pneumococcal immunization.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 . The CDC Pneumococcal Vaccine Timing for Adults reads, in part:Administer 1 dose of PCV13 at least 1 year after the most recent pneumococcal vaccine dose. Administer a second dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the previous dose of PPSV23 . Example 1R8 was admitted on [DATE]. R8's immunization record stated that influenza immunizations were recommended. There was no documentation the facility offered or educated R8 regarding the influenza immunization. There was no evidence in R8's record of the influenza immunizations being declined. R8 did not have an up to date influenza immunization.Example 2R9 was admitted on [DATE]. R9's immunization record stated that influenza and pneumococcal vaccinations were recommended. There was no documentation the facility offered or educated R9 regarding the influenza and pneumococcal vaccinations. There was no evidence in R9's record of the influenza and pneumococcal immunization being declined. R9 had signed a consent form on 05/15/25, requesting the pneumococcal immunization. The facility did not administer pneumococcal immunization. On 08/12/26 at 9:54 AM, Surveyor interviewed Infection Preventionist (IP) C and asked for the process for administering immunizations to residents. IP C stated it is part of the admission process, if residents would like immunizations facility will administer immunizations, and if residents are offered immunizations and the resident declines then the declinations are filled out with education of risks versus benefits. IP C reported the [NAME] Data Set (MDS) nurses have 5 days to go in and look up current immunizations then nurses will fill out a physician standing order and administer immunizations. IP C reported facility completes annual flu immunizations every year during the flu season October-March. On 08/12/26 at 12:17 PM, Surveyor interviewed Director of Nursing (DON) B and asked if DON B was aware R8 and R9 were missing influenza immunizations and/or pneumococcal. DON B stated pharmacy faxed Wisconsin Immunization Record (WIR) to DON B and R8 and R9 have immunizations. Surveyor reviewed the WIR for R8 and R9 and found immunizations were not up to date. DON B stated pharmacy told DON B the immunizations were up to date. DON B stated to Surveyor R8 and R9's declinations were not filled out. DON B reported R8 did not receive influenza immunization. DON B reported to Surveyor R9 did not receive influenza and pneumococcal as requested.

Based on observation, interview and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 2 of 2 residents (R14 and R5) reviewed for catheters out of a total sample of 15. R14's catheter drainage bag touching and dragging on the floor.R14 had an incomplete care plan directing nursing staff on catheter care.R14 had no doctor's orders specific to size of catheter and when to change the catheter. Findings:R14 was admitted to the facility on [DATE] with a Brief Interview of Mental Status Score of 13/15 which indicated R14 was cognitively intact. R14 had diagnoses of polyneuropathy and retention of urine.Doctor's orders included catheter care every shift for retention and outputs every shift.R14's nursing care plan included the following interventions: Catheter: Check for patency and urinary output ___x per shiftDate Initiated: 05/01/2026 Empty catheter bag every shift.Date Initiated: 05/01/2026 Indwelling catheter: Date inserted:4/29/26___ size:___ change: q___. Ensurecatheter is taped to leg.Date Initiated: 05/01/2026On 08/10/2026 at 10:40 AM, Surveyor noted that R14's catheter drainage bag was hanging on the garbage can and the bag was sitting on the floor.On 08/11/2026 at 8:54 AM, Surveyor asked Certified Nursing Assistant (CNA) K about the positioning of R14's catheter when R14 is in his room. CNA K indicated R14 likes the catheter hooked to the garbage can. Surveyor asked CNA K, Is the catheter supposed to be lying against the floor? CNA K replied, No, it is hanging from the garbage can so that it doesn't touch the floor. Surveyor informed CNA K that R14's catheter was observed hanging from the garbage can lying against the floor. CNA K then escorted Surveyor to R14's room. CNA K stated, That's not right. CNA K then took R14's walker, put it next to R14's recliner and attached the drainage bag for the catheter to the lower bar on the walker so that it was not touching the floor.On 08/11/2026 at 7:22 AM, R14 was brought into the dining room in R14's wheelchair. R14's catheter drainage bag was hanging underneath the wheelchair dragging on the floor.On 08/11/2026 at 8:54 AM, Surveyor asked CNA K should the catheter bag be hanging underneath the wheelchair. CNA K then explained to Surveyor that the bag needs to hang under the wheelchair but not drag on the floor.On 08/11/2026 at 9:48 AM, Surveyor asked Director of Nursing (DON) B about the plan of care not having directions for the nursing staff to follow to care for R14's catheter. DON B replied, There should be specific orders for when to change the catheter and what size the catheter should be. Surveyor informed DON B of the observations of R14's drainage bag sitting on and dragging on the floor. DON B replied, The catheter bag should not be touching the floor.

Based on observation, interview, and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed for non-pressure skin injury (R22) out of a total sample of 15.-R22 has multiple lesions on bilateral legs, abdomen, arms, and shoulders with no plan of care or treatment in place to address them. Findings include:R22 was admitted to the facility on [DATE]. R22's most recent Minimum Data Set (MDS) assessment shows a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment.R22's progress notes indicate on 07/26/26, R22 had open areas to R22's torso. No further progress notes or follow up documented. No wound assessments present for review.On 08/12/26 at 7:57 AM, Surveyor observed numerous lesions on R22's bilateral legs, abdomen, bilateral arms, and bilateral shoulders. R22 reported the lesions come and go in different areas on R22's body and this began prior to admission. R22 reported at times the lesions weep and when scratched, may bleed. Surveyor observed several of the lesions had thick scabs present and some areas appeared open but dry. R22 stated R22 used to be followed by dermatology but is not currently. R22 stated since admission to the facility, no one is addressing the condition or trying to treat it. R22 reported that the facility gave R22 lotion for the dry skin only.Surveyor reviewed the previous 3 months of shower forms that contain skin checks:-On 05/10/26 the shower form indicated R22 had a scab to the left shin and redness to the right upper arm.-On 05/17/26 the shower form indicated no skin concerns.-On 05/24/26 the shower form indicated dry skin and red blotchy areas to the right knee.-On 07/26/26 the shower form indicated open areas from itching all over and very tight scaley skin. The shower form also indicated the areas included bilateral upper arms, bilateral front thighs, abdomen, and left lower back.-On 08/06/26 the shower form indicated very dry skin all over.On 08/12/26 Surveyor reviewed R22's care plan which did not include the skin condition and interventions to correspond.On 08/12/26 at 8:07 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K about R22's skin. CNA K stated that R22 has open sores on her body from dry skin. CNA K stated there is lotion available for R22 to apply. CNA K stated the lesions were there since prior to admission.On 08/12/26 at 8:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L about R22's skin. LPN L stated R22's skin gets checked on shower days and that R22 has scratches on R22's body that lotion gets applied to. LPN L was not aware of any open wounds.On 08/12/26 at 8:25 AM, Surveyor interviewed Wound Registered Nurse (RN) N about R22's skin. Wound RN N stated nursing staff has not filled out a wound form regarding any skin concerns for R22, and Wound RN N has not personally observed R22's skin for a long time. RN C was present during the interview and stated RN C was not aware of any skin concerns with R22. Wound RN N acknowledged nursing staff should be following up and reporting skin concerns timely and consistently.On 08/12/26 at 12:15 PM, Surveyor informed Director of Nursing (DON) B about observations and concerns of no skin treatment regarding R22's skin. DON B acknowledged.

Based on interview and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 of 15 sampled residents (R22).-R22 has Diabetes Mellitus with no care plan including interventions in place.Findings include:The facility policy with the subject titled, Resident Assessment and Care Plan Policy, last reviewed in January 2026, includes: This assessment will include resident's needs, strengths, goals, life history, and preferences, as well as determine expected outcome of stay and discharge goals and plans.The assessment and (Minimum Data Set) MDS 3.0 information will be used, with input from the resident and representative, to develop a comprehensive, person-centered care plan.R22 was admitted to the facility on [DATE]. R22's most recent MDS assessment showed a Brief Interview for Mental Status (BIMS) score of 12/15 indicating moderate cognitive impairment.R22's diagnoses which include Diabetes Mellitus Type 2. R22 has orders for glipizide and insulin glargine. Orders are present for diabetic foot checks and blood glucose checks.On 08/11/26, Surveyor reviewed R22's care plan which includes a diabetic diet in the nutrition care plan but no diabetic care plan that includes monitoring for hypoglycemia and hyperglycemia.On 08/12/26 at 8:07 AM, Surveyor interviewed Certified Nursing Assistant (CNA) K about diabetic residents. CNA K stated CNA K could ask the nurse if a resident is diabetic, or it should be on their meal ticket. CNA K was unsure if it was on the Kardex. When asked about R22, CNA K stated CNA K would have to ask if R22 was diabetic.On 08/12/26 at 8:17 AM, Surveyor interviewed Licensed Practical Nurse (LPN) L about care plans. LPN L stated care plans are updated by any nurse or nurse manager. When asked about residents that are diabetic, LPN L stated those residents should have a diabetic care plan.On 08/12/26 at 8:28 AM, Surveyor interviewed Director of Nursing (DON) B about care plans. DON B stated care plans are part of the resident assessment and are created by the nurse doing the admission. DON B stated each department adds to the care plan more specific details and interventions. DON B stated the dietary department puts information regarding diets for diabetic residents. When asked if the care plan includes an actual diabetic section with interventions for monitoring, DON B stated no. DON B stated the monitoring would be in the medication administration or treatment administration records. Surveyor informed DON B that R22's orders did not include monitoring. DON B stated the facility has a standard protocol for all diabetic residents that is kept in a folder. DON B acknowledged there was no resident-centered care plan for R22 related to diabetes. On 08/12/26, Surveyor reviewed previous 3 months of shower forms for R22. Staff documented on 7 of 12 forms, that R22 is not diabetic. Surveyor informed DON B about this discrepancy. DON B acknowledged.

Based on record review and interview, the facility did not ensure as needed (PRN) orders for psychotropic medications are limited to 14 days or provide an appropriate rationale to extend the medication on 2 of 5 residents (R9 and R8) reviewed for unnecessary medications out of a total sample of 15. R9's order for psychotropic medications end date was indefinite in the Medication Administration Record (MAR).R9's rationale for use was Hospice. R8's order for psychotropic medications end date was blank or indefinite in the Medication Administration Record (MAR).R8's rationale for use was Hospice. Example 1 Findings: Facility policy titled, Psychotropic Use last reviewed on October 2025, stated in part:.3. All PRN (as needed) psychotropics will have an automatic stop date after 14-days unless other duration length is ordered, with the exception of PRN antipsychotics which will always have a stop date after 14 days. R9 was admitted to the facility on [DATE] with diagnosis of dementia with agitation. R9 had a doctor's order for lorazepam dated 07/09/2026 for 0.5 milligram (mg) every 4 hours as needed. The order in the Electronic Medical Record (EMR) had an end date of indefinite. On 08/11/2026 at 9:45 AM, Surveyor informed Director of Nursing (DON) B of R9 having no end date in the EMR and Surveyor was unable to find appropriate rationale to continue a psychotropic medication beyond 14 days. DON B informed Surveyor that all PRN psychotropic medication should have an end date of 14 days. On 08/11/2026 at 11:32 AM, DON B provided Surveyor with a note sent to the provider which states:Note To Attending Physician/Prescriber dated 07/14/2026 stated in part:Rationale for PRN use beyond 14 days: HospiceDURATION FOR ORDER THRU: 07/16/2027. Example 2 R8 was admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, with agitation. R8 has a doctor's order dated 3/26/26 for lorazepam oral concentrate 2 MG/ML -Give 0.25 ml by mouth every 4 hours as needed. The order in the Electronic Medical Record (EMR) had no end date. On 8/11/26 at 11:32AM, DON B provided Surveyor with the Health Direct Pharmacy (HDP) Note to Attending Physician/Prescriber dated 4/14/26. Physician/Provider response to pharmacy's request was Rationale for PRN use beyond 14days: Hospice. DURATION FOR ORDER THRU: 4/16/27. On 08/11/2026 at 11:35 AM, Surveyor informed DON B of R8 having no end date in the EMR. DON B stated that all PRN psychotropic medication should have an end date of 14 days unless there are clinical indications. DON B stated I suppose it should have the indication for SOB (shortness of breath) or anxiety and not just the word hospice.

Based on observation, interview, and record review, the facility did not ensure the resident has a right to a dignified existence, self-determination, and the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 1 resident (R8) reviewed from a total sample of 15.R8 has a care plan intervention to sleep in, in the morning if up late at night. Staff are not promoting R8's quality of life and respecting R8's choice to sleep in.Findings include: Per the facility admission Handbook, Exhibit E Resident Rights, date unknown, reads in part: The resident has a right to a dignified existence, self-determination, . 6. Self Determination and Participation. A resident has the right to, and the facility must promote and facilitate resident self- determination through support of resident choice including but not limited to the residents right to: . (c) Make choices about aspects of his or her life in the facility that are significant to the resident. R8 was admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, with agitation. R8's Brief Interview Mental Status (BIMS) from the Minimum Data Set Assessment (MDS), dated [DATE], resulted in a score of 1 out of 15. This indicates that R8 is cognitively impaired. Per admission progress note, dated 12/18/24, R8 worked night shift most her life. R8's care plan intervention states: Allow resident to sleep late in the morning if resident was awake all night. Date Initiated: 07/23/2026 R8's cognition does not allow for Surveyor to interview R8 and determine R8's wishes. Surveyor was unable to reach the Power of Attorney for Healthcare (POA-HC). On 8/10/26 at 11:18 AM, Surveyor observed R8 slouched to the left in her wheelchair in the dining room. R8 was bent over with their head almost touching their arm rest. R8's eyes were closed and they did not arouse when Surveyor attempted to greet them. On 8/10/25 at 12:08 PM, Surveyor observed R8 in dining area. R8's meal tray was in front of them. R8 was slouched over with their eyes closed. R8 did not arouse when Surveyor attempted to greet them. On 8/10/26 at 1:12 PM, Surveyor observed R8 in the recliner in the TV area of the community room. R8 was slouched to the left, with their eyes closed. R8 did not arouse when Surveyor attempted to greet them. On 8/11/26 at 6:28 AM, Surveyor observed Certified Nursing Assistant (CNA) G say to Licensed Practical Nurse (LPN) E that R8 was up until 4:00 AM again, should we let her sleep. LPN E was heard to say you should get her up; everyone should be up for breakfast. LPN E made eye contact with Surveyor and stated residents should not be in bed all day, they should get up for a meal. LPN E stated they just need to get up; they should not stay in bed. On 8/11/26 6:50 AM, Surveyor observed CNA H pushing R8 in their Broda chair out to the lounge area. R8 was slouched down with their eyes closed, appearing asleep. On 8/11/26 at 8:19 AM, Surveyor observed R8 sleeping in her chair next to recliner in the TV room. R8 was observed to be slouched to the left. R8's head was almost touching the arm rest.On 8/11/26 at 8:40 AM, Surveyor observed R8 sleeping in her Broda chair, slouched to the left. R8 did not respond to Surveyor when Surveyor attempted to interview them. On 08/11/26 at 9:38 AM, Surveyor observed R8 sitting at dining room table with a food tray in front of R8. Surveyor did not observe any staff present to assist R8 with R8's meal. Surveyor observed an adaptive tray with toast, sausage cut up, and eggs on tray. R8 was slouched to the left, with their head bent almost resting on the arm rest. R8's eyes were closed, and R8's neck pillow was hanging off the chair. On 8/11/26 at 10:07 AM, Surveyor observed CNA F and CNA H at the sink washing their hands. CNA F stated we could lay R8 down. CNA H stated we have to lay down R3 and R9 first. CNAs left the area and R8 continued sitting at dining room table with their food in front of them. R8 continued to be slouched to the left with their arm now out of chair boundaries.On 8/11/26 at 10:14 AM, Surveyor interviewed LPN E, asking why staff got R8 up this morning. LPN E stated that R8 sleeps all the time and leaving her in bed will cause problems, it is neglectful. LPN E stated if we don't get her up and try to keep her from sleeping, she won't sleep again at night. On 8/12/26 at 10:31 AM, Surveyor interviewed CNA F regarding how the facility incorporates resident's lifestyle and habits into their life at the facility. CNA F stated they know that R8 worked nights. R8 is often up all night and if she is not ready to go to bed, she tries to climb out. CNA F stated it is in her care plan that R8 should sleep in when up late at night. Surveyor asked if R8 was up late Sunday or Monday night. CNA F stated yes, but the problem is there are a lot of nurses that tell you residents must get up. CNA F stated the nurse Monday and yesterday made us get R8 up. CNA F states it says on her plan to let her sleep in, but nurses want them up. Surveyor asked if there is any action CNAs can take to let R8 sleep in bed. CNA F stated we have told management, but we must follow what the nurse wants. On 8/12/26 at 11:35 AM, Surveyor interviewed Director of Nursing (DON) B regarding how they are accommodating R8's choice to sleep in if up late at night. DON B stated we let her stay up later, but it is often 4:00 AM before she goes to bed. The doctors said she spent her life working nights there is no way we are going to change her now. DON B stated it is care planned that she be able to sleep in, in the morning if she was up all night. Surveyor shared observations of R8 sleeping in her chair after being pushed out her room at 6:50 AM and staff sharing she was up until 4:00 AM the previous night. DON B stated R8 should have been able to sleep in. Surveyor asked if staff followed the care plan and respect R8's choice to sleep in. DON B stated no.

Based on interview and record review, the facility did not ensure that falls were thoroughly investigated to determine root cause, new safety interventions implemented, staff education, and monitoring of effectiveness of interventions for 1 of 3 residents (R4) reviewed.-On 12/03/25, R4 sustained a fall. Facility determined root cause of fall was that staff did not follow R4's care plan interventions of:Pressure alarms in place on bed and chair (10/02/25). Pressure and laser alarm (10/02/25). Tab alarm (10/02/25).-After fall on 12/03/25, new intervention of checking R4 every 2 hours at bedtime for alarm placement was implement. No documentation on staff education following fall and new intervention.-On 12/23/25, R4 had a fall. No new interventions were implemented. No documentation on staff education. Interventions implemented after -On 02/02/26, R4 had a fall. No new interventions were implemented. No documentation on staff education.-On 03/19/26, R4 had a fall. Care plan was not updated after fall. No documentation on staff education.This is evidenced by: Facility policy titled, Fall/Injury Reporting, with a revised date of 11/2025, states: Policy: Falls.will be documented in the resident medical records. Nurses are responsible to document any reports, investigations and assessments relating to the falls.IDT representatives are responsible for investigating any needed areas to assure no abuse or neglect was suspect and for ensuring interventions are implemented.Appropriate investigations, follow-up and reporting to state and deferral agencies will be accomplished per Administrator/designee if deemed necessary. Procedure: 11. The IDT will then evaluate the fall and recommend intervention. The change in plan will then be documented in the resident care plan and CNA care plan. R4 was admitted to the facility on [DATE] with neurocognitive disorder with Lewy bodies. R4's comprehensive Minimum Data Set (MDS) assessment, dated 04/15/26, noted a Brief Interview for Mental Status (BIMS) score of 0/15, indicating severe cognitive impairment. R4 had one fall without injury. R4's care plan, dated 10/01/25, with a target date of 08/17/26, states: [R4] has had an actual fall with unsteady gait with a goal to resume usual activities. Interventions include Pressure alarms in place on bed and chair (10/02/25). Pressure and laser alarm (10/02/25). Tab alarm (10/02/25). Rounding every 2 hours when in bed and overnight (12/10/25). Gripper socks in place (12/26/25). Check with resident for preference to go to bed before 8 PM (05/26/26). Assist of 2 with 2WW (05/26/26). R4's fall investigations state: On 12/03/25 at 7:20 PM, R4 had an unwitnessed fall in room. Certified Nursing Assistant (CNA) found R4 lying on the floor and R4's floor alarm was found sitting on tray table in OFF position. No injuries noted. Immediate follow-up interventions include gripper socks. On 12/10/25, IDT (Interdisciplinary Team) reviewed fall and noted root cause to be self-transfer and confusion. New intervention to check on R4 every 2 hours. -Of note: Surveyor reviewed R4's medical record and was unable to find documentation for 2-hour checks being completed. No documentation on staff training after incident was provided. No review of why the alarm was off. On 12/23/25 at 11:20 AM, R4 had an unwitnessed fall in room. CNA found R4 lying on floor with no shoes or gripper socks on. No injuries noted. On 12/24/25, IDT reviewed fall and determined root cause to be self-transfer. New intervention implemented was gripper socks in place. -Of note: immediate interventions implemented after 12/03/25 fall included gripper socks. No new interventions were implemented. On 02/02/26 at 4:00 PM, R4 had an unwitnessed fall in bathroom. CNA found R4 lying on floor. No injuries noted. On 02/03/26, IDT reviewed fall and noted root cause to be self-transfer, confusion and communication deficit. New intervention noted for Physical Therapy (PT) assessment. -Of note: Fall investigation did not include interviews with staff to determine how resident got to bathroom or last time toileted. Surveyor reviewed PT note, dated 02/04/26, noted R4's mobility is variable and Contact Guard Assist (CGA) to minimal/moderate assistance without 2 wheeled walker recommended. R4's care plan was not updated to reflect PT's recommendation. On 03/19/26 at 8:00 PM, R4 had an unwitnessed fall in Great Room. Nurse heard R4's alarm and found R4 lying on ground. No injuries noted. On 03/20/26, IDT reviewed fall and determined root cause to be R4 being up at 8:00 PM and self-transferred. New intervention of discussing with resident preferred bedtime and putting to bed at that time. Note: R4's care plan not updated until 05/26/26. On 05/27/26 at 12:00 PM, Surveyor interviewed Director of Nursing (DON) B and Clinical Nurse Manager (CNM) J regarding R4's falls. DON B stated all the documentation provided to Surveyor included the complete investigations of each incident. Surveyor asked DON B and CNM J how they ensure interventions are in place and effective. Both DON B and CNM J were unable to provide an answer. Surveyor asked DON B and CNM J if there was any documentation of staff completing 2-hour checks as stated in care plan. CNM J stated no.

Based on interview, observation and record review, facility did not implement professional standards of practice to ensure a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 residents (R1) reviewed.R1 was assessed as high risk for PI development. The facility failed to implement interventions to prevent PI development, ensure treatment orders were completed as ordered, and failed to complete a comprehensive assessment upon discovery of a new avoidable PI on R1's buttocks. This is evidenced by:Facility policy titled, Skin Alteration Policy and Procedure, with no date, states: Purpose: To establish a comprehensive facility program to maintain optimal skin condition for the residents.Policy: Nursing assessment will be utilized to identify residents at risk for the development of pressure injuries and appropriate plans of care for these residents will be established. Through the use of a skin protocol, all pressure areas will be identified and treatment begun immediately. All other skin alterations will be assessed and treated immediately. D. Repositioning. a. Reposition residents at least every two hours consistent with overall goals of care. c. Care plan the resident specific repositioning schedule.Skin Alteration/Wound Assessment/Documentation: B. Licensed nurses will evaluate skin plan, institute treatment methodologies specific to the resident.Weekly skin checks are documented in PCC.Skin Alteration Documentation: B. Initial wound assessment and weekly updates are documented in the Medical Record via EHR. C. A temporary care plan is initiated upon identification of an open area or added to the care plan if a skin alteration care plan already exists.R1 was admitted to the facility on [DATE] with abnormalities of gait and mobility.R1's quarterly Minimum Data Set (MDS) assessment, dated 02/24/26, noted a Brief Interview for Mental Status (BIMS) score of 04/15, indicating cognition is severely impaired. R1 requires substantial/maximum assistance with rolling left to right and dependent assist with lying to sitting and chair/bed transfers. R1 did not have a PI present, was assessed to be at risk for PIs, and skin treatments implemented included a turning/repositioning program and application of ointments/medications other than to feet.R1's care plan, dated 05/05/25, with a target date of 05/05/26, states: Skin integrity: Alteration or potential for alteration in integrity with a goal of no skin breakdown through review date. Interventions include Pressure relieving mattress (05/27/26). Pressure relieving cushion in recliner (05/27/26). Pressure relieving cushion in w/c (05/27/26). Reposition Q [every] 2-3 hours. R1 often refuses this (05/27/26). R1's nursing orders, dated 05/05/25, include turning and repositioning every shift.-Of note: turn and reposition order does not specify frequency to be completed during each shift.Surveyor reviewed R1's Certified Nursing Assistant (CNA) Kardex for completion of turning and repositioning R1. Surveyor noted the following:-On 05/05/26 and 05/21/26, no turning and repositioning was documented as completed.-On 05/03/26, 05/04/26, 05/07/26, 05/08/26, and 05/16/26, turning and repositioning were documented as completed only once.-On 05/01/26, 05/02/26, 05/06/26, 05/09/26, 05/10/26, 05/11/26, 05/13/26, 05/14/26, 05/15/26, 05/20/26, 05/22/26, 05/23/26, 05/25/26, and 05/26, turning and repositioning were documented as completed twice.-On 05/12/26, 05/18/26, 05/19/26, and 05/24/26, turning and repositioning were documented as completed three times.R1's progress notes state:-04/16/26 Skin/Wound Note - right buttock; no staging; 2.2 x 2 cm; denuded area on buttock related to (r/t) sheering; is dried; does have chronic skin breakdown on buttock.No additional skin assessment documentation completed until 05/11/26.-05/11/26 Skin/Wound Note - coccyx red, cleaned, and barrier cream applied.No additional skin assessment documentation completed until 05/26/26.-On 05/26/26 at 5:43 AM - weekly skin check with bath yesterday on evening shift. No new skin concerns noted per RN, who was completing RN's shift. R1's weekly bath skin evaluation sheets state:-On 05/04/26 - noted a skin tear was present on R1's buttocks. No additional skin assessment was documented. No documentation notifying the wound nurse noted.-On 05/11/26 - noted, bottom open/red,; nursing progress note entered. No additional skin assessment noted. No documentation notifying the wound nurse noted.-On 05/18/26 - noted concern on R1's bottom by circling the buttock area; the indication for concern is marked under Other (specify below) with no additional comments entered. No additional skin assessment documented. No documentation notifying the wound nurse noted.-On 05/25/25 - noted no skin concerns present. On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding R1's skin and cares. CNA D stated she noticed R1 had some skin concerns in the beginning of April this year and reported it to the nurse. Surveyor asked CNA D what interventions were implemented after the new finding of skin impairment. CNA D stated nothing, just to continue applying ointment. Surveyor asked CNA D if there were any standard protocols used to help prevent skin breakdown for residents. CNA D stated yes staff should be rounding on residents at least every 2-3 hours and checking incontinent briefs, but this is not always done by some staff. Surveyor asked CNA D if staff document when residents are repositioned or if incontinence briefs are changed. CNA D stated only on the CNA shift report sheets, but not everyone does it. Surveyor asked CNA D if R1 had any current skin breakdown. CNA D stated yes, on R1's buttocks.On 05/26/26 at 2:39 PM, Surveyor interviewed Wound Nurse C regarding R1's skin assessments. Surveyor asked Wound Nurse C about the documentation on 04/16/26 of a new skin concern on R1's right buttock. Wound Nurse C stated that was the only assessment completed regarding skin concerns as R1 has chronic maceration skin issues. Surveyor asked if chronic concerns should be observed more closely. Wound Nurse C stated yes, but during weekly bath checks and not with wound assessments. Surveyor asked Wound Nurse C about the skin issue documented on 05/11/26. Wound Nurse C stated it was reported to her as a fungal issue, so she did not assess the area. Surveyor asked Wound Nurse C about the expectations for nursing staff regarding skin assessments and reporting concerns. Wound Nurse C stated Certified Nursing Assistants (CNA) are supposed to look at the skin on bath day weekly, document areas of concern on the bath sheet, and report any concerns to the nurse. The nurse is then supposed to complete a communication sheet form and submit it to the Wound Nurse for review. Surveyor asked Wound Nurse C who reviews the bath sheets for concerns. Wound Nurse C stated she believed the DON (Director of Nursing) did this.On 05/26/26 at 4:16 PM, Surveyor interviewed DON B regarding skin assessments and reporting new skin concerns. DON B stated the expectation is for CNAs and the nurse to look at the skin weekly on bath day and report new concerns to the wound nurse for review. Surveyor asked DON B if anyone would review the weekly bath sheets for completion or concerns. DON B stated the nurse should be doing this.On 05/26/26 at 4:26 PM, Surveyor interviewed CNA E and CNA F regarding R1's skin. Both CNA E and CNA F stated not being aware of any skin breakdown on R1.On 05/26/26 at 5:02 PM, Surveyor requested DON B and Wound Nurse C assess R1's skin. Upon entering R1's room, Surveyor observed R1 lying on left side in bed. R1's mattress was a static mattress with no additional pressure relieving devices in place. Surveyor observed R1's recliner to have a gel cushion, approximately 1 inch thick, sitting on the seat with a moisture-wicking pad on top of it. Wound Nurse C removed R1's incontinent brief and Surveyor observed on R1's left inner gluteal fold/sacral area. The area was dark red, non-blanchable area measuring approximately 1 inch in width and diameter. On R1's right inner buttock were 2 small red, blanchable marks which were intact. The peri-wound area was reddened, blanchable and intact. Surveyor asked Wound Nurse C if this was a new wound. Wound Nurse C stated yes. Surveyor asked Wound Nurse C how this new wound would be documented. Wound Nurse C stated it would be stage 1 PI. Surveyor asked Wound Nurse C about R1's current mattress. Wound Nurse C stated R1 has a standard mattress. Surveyor asked Wound Nurse C if any other mattresses were tried to help alleviate pressure. Wound Nurse C stated no and R1 typically preferred to sit in the recliner or wheelchair. Surveyor asked Wound Nurse C about the gel cushion sitting in the recliner. Wound Nurse C stated it was a typical cushion that would be used. Surveyor asked Wound Nurse C if any other pressure relieving device had been used to help prevent PIs in R1's wheelchair or recliner. Wound Nurse C stated no, she didn't think so.On 05/27/26 at 8:26 AM, Surveyor interviewed Physician Assistant (PA) H regarding R1's new stage 1 PI. PA H stated not being aware of this new PI at this time. Surveyor asked PA H if R1's new PI was preventable. PA H stated PA H's belief is all PIs should be preventable. Surveyor asked PA H if any alternative interventions were attempted to prevent PIs for R1. PA H stated no, but that another outside resource was used by the facility to assist with additional interventions. Surveyor asked PA H if this resource was used regarding R1. PA H stated no the Wound Nurse handles it.On 05/27/26 at 9:54 AM, Surveyor interviewed Licensed Practical Nurse (LPN) I regarding skin assessments. LPN I stated CNAs fill out a skin sheet on each resident once a week on bath day and report any concerns to the nurse. Surveyor asked LPN I if the nurse is expected to assess the skin with the CNA on bath day. LPN I stated no, only the CNAs do it. Surveyor asked LPN I if nurses are expected to complete a weekly skin assessment. LPN I stated no, unless the CNA reports a concern. Surveyor asked LPN I if the nurse reviews the completed weekly bath sheets. LPN I stated no, not unless the CNA says there is a concern.On 05/27/26 at 11:55 AM, Surveyor interviewed Clinical Nurse Manager (CNM) J regarding skin assessments and preventative measures for breakdown. CNM J stated the expectation would be for nurses to document at least weekly on skin condition after the bath sheet is completed. Surveyor asked CNM J if anyone is reviewing or monitoring if the weekly skin checks are documented or if the bath sheets are completed. CNM J stated no. Surveyor asked CNM J how staff document when residents are repositioned or if incontinence briefs are checked/changed. CNM J stated there is no current practice in place for staff to document this, but staff are expected to turn and reposition residents frequently. Surveyor asked CNM J how they monitor residents at risk for PIs or currently have PIs are being turned and repositioned frequently. CNM J stated no process is currently in place to do this.On 05/27/26 at 12:01 PM, Surveyor interviewed Wound Nurse C regarding the additional resource for PIs. Wound Nurse C stated that this resource is a wound specialty provider that comes onsite monthly to review residents with PIs and other skin issues. Surveyor asked Wound Nurse C if this resource was contacted regarding R1. Wound Nurse C stated no.

Based on interview and record review, the facility did not complete a thorough investigation after being made aware of a concern of neglect for 1 of 1 resident (R1) reviewed.On 05/10/26 at 10:56 PM, Director of Nursing (DON) B was notified via email by Certified Nursing Assistant (CNA) D of a neglect concern regarding R1. The facility did not immediately begin a thorough investigation of reported neglect, collect information that corroborates or disproves the incident, and document the findings.This is evidenced by: On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B regarding concerns of neglect. CNA D stated upon starting her PM shift, CNA D entered R1's room and found R1's incontinent brief to be overly saturated with urine and R1's legs and chest were wet with urine. CNA D stated she checked the CNA report sheet, and no one had documented changing R1's incontinent briefs since 8:15 AM. Surveyor asked CNA D if the DON had followed up with her after sending the email. CNA D stated no. Surveyor asked CNA D if a copy of the email could be accessed. CNA D forwarded the email to Surveyor. On 05/26/26 at 8:58 AM, CNA D forwarded the email was sent to DON B (Director of Nursing) to Surveyor. Surveyor noted the original email was time and date stamped as 05/10/26 at 10:56 PM. The email stated: .[R1] was completely soaked in urine that seeped through the pad.soaker completely wet.and went down [R1's] leg. While completing cares, [CNA K] entered room, and [CNA D] asked [CNA K] the last time [R1] was changed. [CNA K] stated having no time. [CNA D] stated this was unacceptable and felt this was neglect. R1 was admitted to the facility on [DATE]. R1's care plan, dated 05/05/25, states: Vulnerabilities: Potential for abuse/neglect from self or others. No goals or interventions documented. No additional care plan interventions were implemented after allegation of neglect was reported on 05/10/26. Surveyor reviewed R1's progress notes: Surveyor reviewed R1's medical record and noted no behavior monitoring implemented after allegation of neglect was reported on 05/10/26. No documentation of allegation of neglect was documented. No documentation notifying R1's Power of Attorney of neglect allegation was noted. Surveyor reviewed the facility's complaint/grievance log and noted no reported allegations of neglect. On 05/27/26 at 7:30 AM, Surveyor interviewed DON B regarding investigation of reported allegation of neglect with R1. DON B stated receiving the email from CNA D on 05/10/26 but did not see the wording alleging neglect. DON B stated she attempted on 5 different occasions to interview CNA D and CNA K but they did not show up for the interviews. Surveyor asked DON B if any documentation for an investigation being completed. DON B stated only having what she had documented on her computer. DON B stated as of 05/27/26, no interviews had been completed with R1, CNA D, CNA K or any other staff or residents regarding the allegation of neglect.

Based on interview and record review, the facility did not report an allegation of neglect to the State Survey Agency or local law enforcement within 24 hours after being made aware of the allegation for 1 of 1 resident (R1) reviewed.On 05/10/26 at 10:56 PM, Director of Nursing (DON) B was notified via email by Certified Nursing Assistant (CNA) D of a neglect concern regarding R1. DON B did not submit a Misconduct Incident Report to the State Survey Agency after being made aware of concern.This is evidenced by:On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B (Director of Nursing) regarding concerns of neglect. CNA D stated upon starting her PM shift, CNA D entered R1's room and found R1's incontinent brief to be overly saturated with urine and R1's legs and chest were wet with urine. CNA D stated she checked the CNA report sheet, and no one had documented changing R1's incontinent briefs since 8:15 AM. Surveyor asked CNA D if the DON had followed up with her after sending the email. CNA D stated no. Surveyor asked CNA D if a copy of the email could be accessed. CNA D forwarded the email to Surveyor.On 05/26/26 at 8:58 AM, CNA D forwarded the email that was sent to DON B to Surveyor. Surveyor noted the original email was time and date stamped as 05/10/26 at 10:56 PM. The email stated: .[R1] was completely soaked in urine that seeped through the pad.soaker completely wet.and went down [R1's] leg. While completing cares, [CNA K] entered room, and [CNA D] asked [CNA K] the last time [R1] was changed. [CNA K] stated having no time.[CNA D] stated this was unacceptable and felt this was neglect.Surveyor reviewed the facility's complaint/grievance log and noted no reported allegations of neglect.On 05/26/26 at 3:23 PM, Surveyor interviewed Nursing Home Administrator (NHA) A regarding incident reporting. Surveyor asked NHA A if any allegations of neglect had been reported in the last 3 months. NHA A stated no.On 05/26/26 at 5:02 PM, Surveyor interviewed DON B regarding allegations of neglect. Surveyor asked DON B if any allegations of neglect had been reported in the last 3 months. DON B stated no. Surveyor clarified with DON B no allegations of neglect or concerns with quality of care from staff had been reported in person, email, or other written communication. DON B stated being positive no concerns like that had been brought to her attention. On 05/27/26 at 7:30 AM, Surveyor interviewed NHA A and DON B. DON B stated after our initial conversation, DON B reviewed emails and found the email from CNA D on 05/10/26. Surveyor asked DON B why this allegation of neglect was not reported. DON B stated CNA D frequently makes unvalidated complaints about co-workers, is not credible, and did not see the word 'neglect' when initially reviewing the email. NHA A stated in retrospect, regardless of who made the allegation, this should have been reported to the State Agency within 24 hours.

Based on observation, interview, and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. The kitchen cooler contained a variety of foods not labeled with open or use-by dates. Cook Q had personal beverages on the food prep table. Findings include: Surveyor reviewed the policy titled, Food Safety and Sanitation, which states in part, .#4: All time and temperature control for safety (TSC) foods (including leftovers) should be labeled, covered, and dated when stored. Surveyor reviewed the policy titled, Personal Hygiene and Health Reporting, which states in part, .#1: Street clothing, coats, purses, packages, and other personal effects will be stored in employee lockers or designated storage areas and not in the kitchen . Example 1 On [DATE] at 9:12 AM, Surveyor toured kitchen area with [NAME] Q. Surveyor observed in kitchen cooler #10; Pulled pork opened with date of ,d+[DATE], red Jello in a container opened with no label, crushed pineapple in a container labeled ,d+[DATE], red tomato sauce in a container with no label. Surveyor observed refrigerator under prep table to have ham in a container labeled [DATE] when it was frozen, and then pulled to thaw on [DATE]. Ham was still sitting in the refrigerator. Surveyor interviewed [NAME] Q and asked what the timeframe is for food items to stay in a refrigerator after being opened, thawed, or expired. [NAME] Q stated typically it is around 5 days or so. [NAME] Q stated [NAME] Q was not working all weekend, so [NAME] Q is fixing all items expired or unlabeled today. Surveyor observed refrigerator #3 which had ham salad labeled [DATE]. [NAME] Q stated the ham salad should be tossed as well. [NAME] Q stated [NAME] Q is finding some expired foods in the storage areas from the weekend that should have been discarded, and [NAME] Q will make sure these items are discarded. Example 2 On [DATE] at 11:40 AM, Surveyor observed kitchen staff prepping and serving food. Surveyor observed 3 containers (soda can, water bottle, and milk) located on the prepping table near the rolls and bowl of lemons which were being served for lunch. Surveyor asked [NAME] Q what the containers sitting on the prep counter were. [NAME] Q immediately said to Surveyor that the items were not open but that the 3 containers were [NAME] Q's personal beverages located on the prep table. Surveyor asked [NAME] Q if storing [NAME] Q's personal beverages on the prep table was a normal process. [NAME] Q stated [NAME] Q probably should not have the personal beverages on the prep table but not sure where they would be good to go as [NAME] Q's break room is at the other end of kitchen. On [DATE] at 11:48 AM, Surveyor interviewed Dietary Manager (DM) P and asked DM P what the expectation is for storage in refrigerator with labeling foods when opened. DM P stated all foods opened need to have the open date on them when storing and need to be discarded within 5 days of open date, if not frozen. Surveyor asked DM P's expectation for personal beverages and where these items should be stored in the kitchen. DM P stated personal items and beverages should not go into the food prep and cooking area. DM P stated that [NAME] Q's personal beverages should not be on the prep table in the kitchen but left in the storage break room area where staff keep their belongings.

Based on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases. The facility was not tracking infection surveillance accurately. These failures have the potential to affect 31 of the 31 residents. LPN L was observed touching medications with bare hands for 2 of 2 residents (R133 and R1) during medication pass. Improper hand hygiene observed for 2 of 4 residents (R8 and R23). Findings: The facility policy titled Nosocomial Infection Surveillance/Antibiotic Stewardship Program, states in part: The infection Preventionist is responsible for monitoring; investigating and setting forth a control plan to prevent unnecessary infections. The IP is responsible for monitoring and trending the facility infection incidence rates and this information is reviewed quarterly assurance committee with the interdisciplinary team and medical director each at least quarterly . .Procedure: - #1. An infection Control Log sheet/daily surveillance will be kept for each hallway/unit and updated by nursing staff when suspected/actual infections occur. See Infection Criteria list-reference McGeer's infection Criteria. -#2. The IP will confer with the licensed nurse/nurse manager/DON for each resident group and maintain an updated list of suspected/actual residents exhibiting signs and symptoms of an infection. -#3. The interdisciplinary team will review infections weekly. -#4. The list of residents with infections will be reviewed at the Quality Assurance meeting with the interdisciplinary team and Medical Director each quarter. -#5. The IP verifies the signs and symptoms/dx are documented in the resident medical record. -#6. The IP will evaluate each resident for: a. Adequate/inadequate antibiotic use -monitor for urine analysis/urine culture results and if lab results are negative or mixed will notify MD to DC antibiotics if ordered. b. Proper follow-up care. c. Lab/Xray results. d. Causative agent. e. Improvement in resident signs and symptoms. f. Determination if infection is pre-existing of nosocomial. g. Risk factors for infection. h. Need for hospitalization . i. Preventative measures for residents' risk of future infection. -#7. The IP is responsible for keeping a monthly list of infections and completing the cumulative nosocomial infection data. -#8. Infection incident rates are calculated monthly and compared to the previous month and trended over the year. -#10. On-going audits/real-time surveillance will be completed . Example 1 Surveyor reviewed the resident monthly infection control log line lists from March 2024-March 2025. Surveyor found missing data for all months. Facility was not tracking what the organism was for all infections, what test was utilized to determine infection, the well date of the resident or staff member, was not tracking isolation precautions and when each infected resident or staff members were placed or stopped isolation. On 05/06/25 at 2:35 PM, Surveyor reviewed infection surveillance logs and found missing data needed to prevent the spread of infection for an Influenza outbreak that occurred in February and March of 2025. Surveyor did not find what type of outbreak occurred, the location of the outbreak, what testing was determined for the outbreak, the well date of residents and staff members who were infected, and when and what precautions/isolations staff and residents were placed on. On 05/06/25 at 2:48 PM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked NHA A about missing data on infection surveillance logs. Surveyor stated to NHA A infection logs were missing data needed to prevent the spread of infection for an Influenza outbreak that occurred in February and March 2025. Surveyor did not find location of outbreak, what testing was determined for outbreak, well date of residents and staff members, and when and what precautions and isolations staff and residents were placed on. NHA A stated facility was using the spreadsheet the county sent over and didn't realize that more data was needed to monitor infections. Surveyor asked NHA A how NHA A monitors staff infections. NHA A stated staff are screened and must fill out a form. Staff does not always complete form. NHA A stated it is something NHA A and DON B, once DON B is trained into Infection Control (IC), will be fixing. Example 2 Facility policy titled, Handwashing, reviewed December 2024 states in part: .The procedure must be followed by all staff to prevent cross-contamination, including hand washing or changing gloves after providing personal care, or when performing tasks among individuals which provide the opportunity for cross contamination to occur. All staff and volunteers must wash their hands before and immediately after coming in direct contact with each resident, and after contact with material that may be contaminated and/or potentially infectious. It is essential after contact with a source of body fluids, mucous membranes and after removing gloves. Appropriate 10-15 second handwashing must be performed under the following conditions: *Before and after duty. *Before and after resident cares *Before performing invasive procedures *Before medication and food handling *Before and after gloving for procedures . On 05/06/25 at 7:52 AM, Surveyor observed Licensed Practical Nurse (LPN) L prep R133's medications. LPN L popped medications into medication cup and realized one medication was discontinued. LPN L placed bare fingers inside R133's medication cup and pulled the medication out. LPN L then administered medications to R133. Surveyor did not observe LPN L sanitize hands before touching R133's pills in medication cup. On 05/06/25 at 8:03 AM, Surveyor observed LPN L prepping R1's medications. Surveyor observed LPN L drop Furosemide on the contaminated medication cart. LPN L grabbed the medication tablet with bare contaminated hands and placed back in R1's medication cup. Surveyor observed LPN L administer R1's medications. On 05/06/25 at 8:16 AM, Surveyor interviewed LPN L and asked what normal process is when a pill falls onto top of contaminated medication cart. LPN L stated LPN L should have disposed of medication and got a new medication, but medications are so expensive. Surveyor asked LPN L if it is normal for LPN L to stick fingers in medication cup and pull a medication out of the medication cup. LPN L stated LPN L should have sanitized hands and donned gloves before picking medication out of the medication cup. 46694 Example 3 R8 was admitted to the facility on [DATE] with a Brief Interview for Mental Status score of 5/15, indicating R8 had severely impaired cognition. R8's diagnoses include multiple sclerosis (a disease that causes breakdown of the protective covering of nerves and can cause numbness, weakness, trouble walking, vision changes, and other symptoms), neuromuscular disorder of the bladder, and artificial opening of the urinary tract. R8's quarterly minimum data set (MDS) dated [DATE] indicated R8 had an indwelling catheter including suprapubic catheter and nephrostomy tube. R8's doctor's orders included the following: -Suprapubic Catheter twice a day flush with sterile saline solution (30cc) once after lunch and once after dinner/before bed. -Renacidin Irrigation Solution Use 30 milliliters (mls) via irrigation every day shift for catheter care Instill 30mL into catheter, clamp catheter for 10 minutes and unclamp and allow to naturally drain into foley bag. -Change Suprapubic Catheter one time every month as well as PRN clogging (use 18 French 5 cubic centimeter (cc) balloon foley when changing). -Suprapubic catheter care daily- cleanse around insertion site with saline, cleanse catheter with alcohol wipe, cover insertion site with T-drain sponge. Monitor for signs of skin breakdown and report to provider/hospice if noted. -Enhanced Barrier Precautions due to indwelling catheter and wound. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. On 05/06/25 at 7:49 AM, Surveyor observed CNA M perform cares for R8. Proper personal protective equipment (PPE) was utilized for enhanced barrier precautions (EBP). CNA M washed R8's suprapubic catheter insertion site, then the catheter tube, then R8's penis, and then scrotum. CNA M did not change gloves or wash hands. CNA M used same soiled gloves to open sterile drain sponge and placed it over the catheter insertion site. On 05/07/25 at 10:09 AM, Surveyor interviewed Director of Nursing (DON) B and Nursing Home Administrator (NHA) A regarding observation of R8's personal cares. DON B replied, This CNA should have changed gloves and performed hand hygiene when moving from a dirty location to a clean location during cares like the suprapubic catheter site, especially with this dressing. Example 4 On 05/06/25 at 2:21 PM, Surveyor observed suprapubic catheter flush performed by Licensed Practical Nurse (LPN) L for R8. Proper PPE was utilized for EBP. LPN L was unable to flush catheter due to some obstruction. LPN L then changed the suprapubic catheter. After changing the suprapubic catheter LPN L noted there was no urine coming out of the new catheter. LPN L removed the sterile glove used for insertion of the catheter from LPN L's right hand and placed a non-sterile single use glove on the right hand without performing any hand hygiene with this glove change. LPN L then aspirated 10mls from R8's foley catheter balloon, then attempted to pull the catheter back. LPN L replied, The tip of the catheter may be against the bladder wall. LPN L then inserted the catheter back into R8 while wearing the non-sterile gloves. LPN L then replied, Oh shoot, I did not perform hand hygiene between my glove changes. On 05/07/25 at 10:20 AM, Surveyor interviewed DON B about the observation made of LPN L while performing catheter procedures with R8. DON B replied, This LPN should have washed her hands and put on sterile gloves when manipulating this catheter. 51804 Example 5 R23 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke) affecting the left side, hemiplegia and hemiparesis (partial paralysis), absence of part of digestive tract, history of urinary tract infections, and vascular dementia with psychotic disturbance. R23's Minimum Data Set (MDS) assessment, dated 1/7/2025, indicates that R23 is cognitively intact, has clear speech, and understands others. R23's physical abilities are limited, requiring substantial assistance for position changes, transfer from bed to chair, and transfers to toilet. On 5/5/25 at 10:38AM, Surveyor observed CNA F provide cares to R23. CNA F did not complete hand hygiene before entering the room or in the room and put on gloves with contaminated hands. CNA F managed EZ stand, assisted with R23 taking off soiled pants and soiled brief and took off gloves. CNA F left room to get new washcloths, came back in put on new gloves (no hand hygiene observed being completed in the room), pulled new pants back up, used lift to raise resident, transferred R23 to the chair and adjusted R23's clothes with same contaminated gloves. CNA F took off gloves in room and left the room. CNA F was not observed to use hand hygiene while in room or after leaving the room; CNA F went to the next room with contaminated hands. Note: Surveyor asked other Surveyor in the hall who stated 2nd Surveyor noticed CNA F coming out of R23's room, so she continued observation for initial Surveyor. 2nd Surveyor observed CNA F leaving the room, did not perform hand hygiene, watched her get clean washcloths and go back into R23's room without performing hand hygiene. On 5/6/25 at 9:05 AM, Surveyor observed CNA F provide cares to R23. CNA F completed no hand hygiene prior to entering room and putting on gloves. CNA F used EZ stand, assisted with R23's pants and soiled brief, pulled pants back up, used EZ stand to put resident back in R23's chair and went to turn on R23's radio with contaminated gloves. R23 did not want radio on, so CNA F turned it off while still wearing contaminated gloves. CNA F took off her gloves, did not perform hand hygiene and radio was not wiped off. CNA F left the room, wiped down EZ stand, and walked across the TV room, looked at iPad call screen on CNA's desk, and went into another's room. No hand hygiene observed. On 5/6/25 at 2:12 PM, Surveyor interviewed CNA F. CNA F stated, I probably use hand hygiene more than I need to. CNA F indicated she is always using hand gel. Surveyor asked when CNA F uses hand hygiene. CNA F replied hand hygiene should be done anytime you go in a room, out of room, provide cares, or do anything with the resident. Surveyor asked CNA F if she carried hand gel in her pocket. CNA F replied no, it is all over the place on hall walls. CNA F was informed Surveyor did not see her use hand hygiene during cares. CNA F stated, No, I used hand gel. I wash my hands anytime I work with the catheter or bowel and use alcohol gel before I go in their room. Surveyor stated that CNA F was not observed to use hand gel or wash their hands. CNA F did not make further comments. On 5/6/25 at 3:11 PM, Surveyor interviewed DON B. DON B indicated the expectation is for staff to wash their hands before they enter and exit a room, before donning (putting on) and doffing (taking off) gloves, and anytime they provide cares with a resident. On 5/7/25 at 11:30 AM, Surveyor reviewed findings with NHA A, since NHA A is the Infection Preventionist (IP). NHA A indicated the expectation for hand hygiene is before entering, before gloves, after gloves, changing gloves after care, and leaving a room.

Based on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 5 of 5 residents (R) reviewed (R8, R14, R232, R11, R4). -Medication storage room had 2 opened unlabeled bottles of Lorazepam for resident (R8 and R14) with unknown expiration date. -Medication storage room had 1 opened and expired bottle of Amoxicillin for R232 stored in refrigerator that expired on 04/24/25. -Medication cart had R11's Morphine Sulfate liquid bottle opened unlabeled with unknown expiration date. -Observation of prescribed Nystatin powder left unattended in R4's room during 1 observation. Findings include: Facility policy titled, Storage of Medications, dated 05/2018 states in part: .Procedures: J. Medication storage conditions are monitored monthly basis by the consultant pharmacist or pharmacy designee and corrective action taken if problems are identified. K. Refrigerated medications are kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Expiration Dating (Beyond use dating): D. When the original seal of a manufacturer's container or vial is initially broken, the container of vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (Note: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be 30 days unless the manufacture recommends another date or regulations/guidelines require different dating. G. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. The medication will be destroyed in the usual manner. Facility policy titled, Bedside Medication Storage, dated 05/2018 states in part: .A. A written order for the bedside storage of medication is present in the resident medical record. B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medications. Surveyor reviewed Medication Storage Review monthly pharmacy reviews for 02/25/25-04/21/25. .-On 02/25/25- E fridge has one expired Lorazepam concentrate and one undated Lorazepam concentrate. -On 03/27/25-E fridge has one undated Lorazepam concentrate. -On 04/21/25- E medication cart has 3 undated Morphine Sulfate solution and on D medication cart 2 undated Morphine Sulfate solution . On 05/05/25 at 10:20 AM, Surveyor toured medication storage room on E-115 hall at the nurse's station. Surveyor observed one bottle of lorazepam for R8 dispensed on 02/28/25 and opened. Surveyor could not identify when the bottle was opened. Surveyor interviewed Licensed Practical Nurse (LPN) N and asked process for when medications are opened. LPN N stated there was no open date label on the bottle. Upon opening the medication, and before giving the first dose, open date label should be placed on bottle. Surveyor observed one bottle of lorazepam for R14 dispensed on 01/17/25. Open label on the bag opened 02/02/25 but no label on the bottle. LPN N stated all bottles opened are to be labeled with open date, so staff know when to discard. On 05/05/25 at 10:57 AM, Surveyor toured medication storage room on D-115 hall at the nurse's station. Surveyor observed R232's bottle of amoxicillin expired in refrigerator with label showing an expired date of 04/24/25. Surveyor asked Registered Nurse (RN) O why the expired medication is still located in the refrigerator. RN O stated it needs to be discarded right away. RN O discarded medication. RN O stated expired medications should be disposed of when it expires. On 05/05/25 at 11:08 AM, Surveyor toured RN O's medication cart during medication administration. Surveyor observed R11's morphine sulfate liquid bottle opened, with a date on narcotic sheet 04/11/25 but no label on bottle. RN O stated RN O would label it now going off the narcotic sheet as the open date. RN O stated this is not best practice. RN O stated that whoever opened the bottle should have labeled once it was opened with the date, so staff knew when it would expire. On 05/05/25 at 11:13 AM, Surveyor observed prescribed Nystatin powder on R4's bedside table. On 05/05/25 at 11:29 AM, Surveyor interviewed R4 and asked about the prescribed Nystatin powder located on R4's bedside table. R4 indicated the CNAs apply this powder to R4's groin area after showers. On 05/05/25 at 12:10 PM, Surveyor interviewed Director of Nursing (DON) B and asked expectation for open date labels on bottle of lorazepam. DON B said staff should be placing an open date label on the lorazepam bottles once opened. Surveyor asked DON B who regulates the refrigerator medications. DON B stated each shift's nurse should be monitoring refrigerators for temperature and any expired medications. DON B stated pharmacy reviews refrigerator medications monthly. DON B asked RN O when pharmacy last visited the facility. RN O stated pharmacy was present at facility recently. Surveyor asked DON B who manages monthly pharmacy recommendations for residents. DON B stated DON B reviews the pharmacy recommendations monthly and fixes issues as needed. On 05/05/25 at 12:53 PM, Surveyor interviewed Director of Nursing (DON) B if storage of prescribed nystatin powder was proper at R4's bedside table. DON B stated, Storage of prescribed Nystatin powder at bedside is ok if [R4] can self-administer medications. Surveyor did not find any assessment for self administration of medications.

Based on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards possible and each resident receives adequate supervision and assistance devices to prevent accidents. Facility did not assess residents for safe use of the EZ sit to stand lift for 5 out of 5 residents (R) (R23. R9, R21, R12, R17). Facility does not have a procedure in place to assess appropriate EZ Way Smart Stand mechanical lift (sit to stand) slings for accurate size and fit for each resident requiring use of the EZ stand lift for transfers. Certified Nursing Assistants (CNA) are determining what size sling to use for each resident. Findings include: EZ Way Smart Stand Manufactures Guidelines, dated10/24/24, states: To determine the correct sling size for an EZ Way Smart stand, consider the patient's weight, height, and girth. A proper sling size will comfortably support the patient and prevent any portion of them from overlapping the edges of the sling. Harness Color Coding System states there a small, medium, large, x-large, xx-large and xxx-large sling sizes available for the EZ Way Smart Stand. Medium sling is for 90 -220# with a torso circumference of 34- 46 Large sling is for 190 - 320# with a torso circumference of 40-56 XL sling is for 280-450# with a torso circumference of 50-64 Sling size is to be determined by both weight and circumference of individuals torso (chest) due to how individuals are shaped different and can carry their weight differently. Slings fit around one's torso (chest.) Example 1 R23 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke) affecting the left side, and hemiplegia and hemiparesis (partial paralysis). R23's Minimum Data Set (MDS) assessment, dated 1/7/2025, indicates that R23 is cognitively intact, has clear speech, and understands others. R23's physical abilities are limited, requiring substantial assistance for position changes, transfer from bed to chair and transfers to the toilet. R23's care plan states: Can use EZ stand if not comfortable with pivot transfer. CNA care guide from today 5/7/25, states, A2 EZ stand prn. No care plan or CNA care guide for sling size to use for R23 with the sit to stand. R23's weight is 127.6 pounds on 5/2/25. No assessment of torso circumference was completed to determine appropriate fit of sit to stand device sling. R23 is assisted with the EZ stander using the medium sling. Based on R23's torso circumference, R23 could need a small or medium sling. On 5/5/25 at 10:38 AM, Surveyor observed R23 cares requiring the assist of 2 and use of the sit to stand lift. CNA I grabbed the sling on the top of the lift and CNA F stated, No she is smaller, we should use the other one. CNA I grabbed the other sling with the lift, the medium sling. There were only two slings available, medium and XL. CNA I attached the sling to R23. R23 was lifted, transferred to toilet, lifted again and transferred to R23's chair. Sling was removed and wiped off. Surveyor observed R23 hanging from her armpits while being transferred by the sit to stand lift. On 5/06/25 at 12:56 PM, Surveyor interviewed CNA F, who stated I have been here 6 years. I had training a long time ago. CNA F indicated staff use the sling which fits each resident's size. CNA F replied sling size not on their care guide. CNA F stated, Nurses do not tell us what size, I just know. On 5/7/25 at 10:57 AM, Surveyor interviewed Occupational Therapist (OT) E, who indicated Physical Therapy (PT) is not available today. OT E replied she can speak to the question. OT E indicated therapy does the assessment, usually it is PT. OT E indicated PT or OT will assess residents for abilities, what is needed for transfer, how many staff are needed, and determine if they need a lift or stander. OT E stated, We do not determine the sling to use. I think the nurse does that. On 5/7/25 at 11:19 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D who stated, nurses can help with the mechanical lifts if needed. LPN D stated, Not sure who determines which sling is used. I think it goes by size. There is a small, medium (med) and large (L) size. After a pause, LPN D replied, I think there is extra-large (XL). LPN D indicated CNAs determine based on body size. On 5/7/25 at 12:15 PM, Surveyor interviewed Director of Nursing (DON) B, who stated the sling size should be on their care guide (CNA plan of care). Surveyor and DON B reviewed the current CNA care guide together. DON B replied it is not on this care guide for R23. Surveyor asked if DON B could show Surveyor a resident who does have it listed. DON B looked and then replied it is not listed for anyone. DON B stated, I'm not sure who does it [assigns sling size]. DON B offered to check. DON B indicated extra slings in laundry room on each unit. On 5/7/25 at 12:47 PM, Surveyor interviewed CNA H, who showed Surveyor the sling being used for R23 and stated sling size is a medium. On 5/7/25 at 12:49 PM, DON B stated DON B Can't figure it out. DON B does not know who is determining sizes of slings. DON B indicated facility will put a plan into place. Example 2 R9 was admitted on [DATE] with the diagnoses of deep venous thrombosis (clots), and history of stroke with partial paralysis. R9's Minimum Data Set, dated dated [DATE], indicates R9 is cognitively intact and requires substantial to maximal assistance with personal hygiene, and showering, and dependent with position changes, transfers and mobility. R9's care plan, dated 4/15/25, states, Transfers: EZ stand A2 staff, if sitting on edge of bed, needs trunk support, use medium sling, make sure left leg/knee is fully in green support, use support strap on legs, do not leave alone in EZ stand for toileting. CNA care guide from today 5/7/25, states, Transf: EZ stands A2, EZ stand for toileting No care plan or CNA care guide for sling size to use for R9 with EZ Stander (sit to stand device). R9's weight is 238.8 pounds on 5/5/2025. CNAs are using a medium size sling. Surveyor did not find documentation of an assessment for torso circumference for appropriate fitting of sling size. On 5/7/25 at 1:07 PM, Surveyor interviewed CNA G, who stated the sit to stand lift is used with R9 with a medium sling. When asked, CNA G indicated no residents have slings in their room. (E wing) Example 3 R21 was admitted on [DATE], with the diagnoses of cardiac history, diabetes, history of stroke with partial paralysis. R21's Minimum Data Set (MDS), dated [DATE], indicates R21 is cognitively intact and requires substantial to maximal assistance with toileting, showering, personal hygiene, position changes, and mobility and transfers. R21's care plan, updated 8/9/24 states, Ok to use EZ stand when she [R21] struggles with freezing or difficulty pivoting with transfers. She [R21] typically can recognize when she's off and is ok with lift prn. CNA care guide from today 5/7/25, states, A2 Ez stand. No care plan or CNA care guide for sling size to use for R21 with EZ Stander (sit to stand device). R21's weight is 242.9 pounds on 3/7/2024. No assessment of torso circumference done to determine appropriate fit of sit to stand device sling. On 5/7/25 at 12:49 PM, Surveyor interviewed CNA H, who stated we use the XL size with R21. When asked, CNA H replied no one has a sling in their room. (D wing) Example 4 R12 was admitted on [DATE] with diagnosis of Parkinson's disease. R12's Minimum Data Set, dated dated [DATE], indicates R12 is cognitively intact and requires assistance of one with cares and is dependent to substantial assistance needed for position changes, transfers and mobility. R12's care plan updated 1/14/25 states: Transfers: Assist of 1-2 1/4/25 OK for EZ stand if needed with A2. CNA care guide from today 5/7/25, states, EZ stand PRN. No care plan or CNA care guide for sling size to use for R12 with EZ Stander (sit to stand device). R12 's weight is 117.5 pounds on 5/7/2025. No assessment of torso circumference done to determine appropriate fit of sit to stand device sling. On 5/7/25 at 1:07 PM, Surveyor interviewed CNA G, who stated sit to stand is used with R12. CNA G stated they use the medium sling with R12. Example 5 R17 was admitted on [DATE] with diagnoses of dementia, hypertension and thyroid disorder. R17's Minimum Data Set, dated dated [DATE], indicates R17 is cognitively intact and needs substantial/ maximal assistance with toileting hygiene, shower/bathing, and personal hygiene and substantial assistance to dependent with position changes, transfers and mobility. R17's care plan, dated 4/28/24, states, Toilet Use: assist of 2 to toilet with EZ stand . Transfer utilize the EZ stand if able. Most often hoyer lift is required for transfer. CNA care guide from today 5/7/25, states, A2 Ez stand and Trans: A2/ez stand. No care plan or CNA care guide for sling size to use for R17 with EZ Stander (sit to stand device). R17's weight was 179.6 pounds on 5/5/2025. No assessment of torso circumference done to determine appropriate fit of sit to stand device sling. On 5/7/25 at 1:07 PM, Surveyor interviewed CNA G, who indicated the sit to stand is used with R12. CNA G showed Surveyor the sling used. CNA G confirmed the medium sling is what they use with R12. CNA G stated it is the only one we need on this side. (R9 is on this side.) On 5/7/25 at 12:03 PM, Surveyor and CNA H confirmed the sling sizes for the sit to stand device on D unit. There was a med and XL sling with the sit to stand device. CNA H indicated use of slings is determined by resident's size. CNA H indicated CNA H thinks facility has the same sizes on the other side. CNA H stated, I would not think to call them to find a different size. CNA H confirmed R21 and R23 are the only residents on D unit that use the sit to stand. On 5/7/25 at 12:47 PM, Surveyor and CNA H went through the inventory in the D wing laundry for other sizes. CNA H stated she knew there were other slings in laundry and the other side, but the two we have work fine. Surveyor and CNA H confirmed there is one more sling for the sit to stand device in the D wing laundry, it is large in size. The D side has 1 XL, 1 medium, and 1 large sling On 5/7/25 at 1:07 PM, Surveyor interviewed CNA G, who stated they use the sit to stand with R12, R9 and R17. CNA G stated no one has a sit to stand sling in their room. CNA G indicated if a sling is dirty CNAs would have to wash it before it could be used again. CNA G stated if a resident needed something before that we would get one from the other side. CNA G and Surveyor looked at inventory of sit to stand slings in the E wing laundry. There were 2 more medium slings, 1 XL sling, and no large slings available in the E wing laundry area. (Only one large sling was found in the facility, and it was in the laundry room on the D wing.)

Based on record review, observation and interview, the facility did not ensure a resident who required substantial assistance for repositioning and toileting received timely assistance for 1 of 12 residents (R) reviewed for Activities of Daily Living (ADLs) (R23). R23 requested to use the bathroom and waited 36 minutes before being assisted into restroom, resulting in clothing change, feeling embarrassed and like she is a burden. Findings include: R23 was admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke) affecting the left side, hemiplegia and hemiparesis (partial paralysis), absence of part of digestive tract, history of urinary tract infections and vascular dementia with psychotic disturbance. R23's Minimal Data Set (MDS) assessment, dated 1/7/2025, indicates that R23 is cognitively intact, has clear speech, and understands others. R23's physical abilities are limited, requiring substantial assistance for position changes, transfer from bed to chair and transfers to the toilet. R23's care plan had the following focus area: TOILETING/CONTINENCE: Requires assistance/potential to restore function to maximum self-sufficiency for the physical process of toileting. Will ask for and receive the necessary assistance On 5/5/25 at 10:03 AM, R23 asked CNA I to use the bathroom. CNA I replied to R23 that she needed to find a 2nd person to help, she might have to wait a bit. On 5/5/25 at 10:38 AM, Surveyor observed R23's cares requiring the assist of 2 and use of the EZ Way Smart Stand mechanical lift (sit to stand). CNA I and CNA F attached sling, assisted R23 to bathroom, assisted R23 into new pants and socks, completed peri-cares and assisted back to her wheelchair. While clothing was being changed, R23 stated, I am sorry. I know you're busy. I don't mean to be such a problem. CNA I reassured R23. R23 waited 36 minutes for the assistance. On 5/6/25 at 8:22 AM, Surveyor observed R23 being pushed back from dining room. Dining room staff member told R23 they would let the CNAs know R23 asked to use the bathroom. Surveyor observed dining staff member go straight over to CNA F and talk with her. At 8:52 AM, CNA F and CNA H came to assist R23 to the bathroom. R23 had waited 30 minutes for assistance. On 5/5/25 at 11:03 AM, Surveyor interviewed R23. R23 stated R23 would not recommend this place, primarily because of how long you have to wait to get care. Primarily for that reason I wouldn't come here again. R23 indicated R23's son is trying to have R23 moved to another nursing home. R23 stated, It is embarrassing when I am incontinent. On 5/5/25 at 11:20 AM, Surveyor interviewed R23's Family Member (FM) J. FM J stated that R23 has complained about that before. FM J indicated that R23 reports she waits a long time for assistance as the norm. FM K stated it is typical to wait 36 minutes or more. FM K indicated R23 complains of them taking long. FM J confirmed R23 is on a waiting list at another nursing home. On 5/6/25 at 2:12 PM, Surveyor interviewed Registered Nurse (RN) C. Surveyor asked RN C if R23 was on a toileting program. RN C replied that everyone is on a toileting program basically; we get everyone up every 2 hours or so. RN C indicated R23 does not have a formal program. R23 is not always incontinent, but frequently. R23 does not always require clothing changes when she is incontinent. RN C stated she did not hear a radio call to help R23 yesterday, nor did she know R23 waited 36 minutes. RN C replied she did not notice a call light on that long. Surveyor informed RN C that R23 had told CNA verbally she needed to use the bathroom; there was no call light. On 5/7/25 at 11:23 AM, Surveyor interviewed CNA F regarding 36-minute wait. CNA F stated that was when she went on break. When CNA F came back, CNA I told CNA F that R23 needed to go to the bathroom. CNA F indicated when your partner is on break you can always ask the nurse or call for another CNA on E Wing to help. CNA F stated she would have asked RN C; she is more than willing to help. Surveyor asked CNA F about the 30-minute wait on Tuesday. CNA F replied we were in the middle of things; I do not think R23 waited that long. On 5/7/25 at 12:12 PM, Surveyor interviewed Director of Nursing (DON) B who indicated DON B's expectation is to answer call lights and respond to resident requests within 5 minutes. Sometimes they (CNAs) get stuck in a room. DON B indicated she does not expect resident care to stop or residents to wait because staff go on break. DON B stated staff are to do a room check of all for needs before they go on break. The staff left on a unit shouldn't get stuck. If they need to, there is a walkie to use to call for help. Surveyor asked how staff know they can call for help. DON B replied staff have orientation and then when they come on the floor, staff shadow and spend time with a restorative aide. On 5/8/25 at 8:54 AM, CNA I returned call to Surveyor. CNA I stated R23 waited because we need 2 people to transfer with the EZ stand. CNA I stated her partner, CNA F, was on break. CNA I stated she did not get a chance to ask the nurse for help. Surveyor asked CNA I if she works only with those on her unit or if she could have called for help. CNA I replied CNA I could have used the walkie to call for help, and it would have been a good solution. CNA I indicated she assumed everyone was busy on the other side. CNA I stated in the future she should think more about other resources so the residents don't have to wait so long.

Based on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff for 1 of 8 residents (R) observedduring medication administration (R4). -Surveyor observed prescribed Nystatin powder at R4's bedside table. During medication administration, Registered Nurse (RN) O stated Certified Nursing Assistant (CNA) I applied prescribed Nystatin powder to resident (R4)'s skin earlier in the AM. Findings include: R4 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure without coma. Review of R4's medical record identified the following physician orders: -On 03/31/25, Nystatin external powder 100000 unit/GM, Apply to Skin topically three times a day for skin infection due to candida yeast. Apply 1 application to folds/under breasts. On 05/05/25 at 11:13 AM, Surveyor followed RN O into R4's room. Surveyor observed prescribed Nystatin powder on R4's bedside table. RN O indicated that Nystatin didn't need to be administered because CNAs completed Nystatin powder administration this morning after R4's shower. Surveyor interviewed RN O and asked RN O if this is a normal process for CNAs to administer Nystatin to R4's folds. RN O indicated that CNAs are good on this unit so CNAs will apply Nystatin to affected areas. On 05/05/25 at 11:29 AM, Surveyor interviewed R4 and asked about the prescribed Nystatin powder located on R4's bedside table. R4 indicated the CNAs apply this powder to R4's groin area after showers. R4 indicated that R4 received a shower this morning and CNA I applied the Nystatin powder to R4's groin folds. On 05/05/25 at 11:58 AM, Surveyor interviewed CNA I and asked if CNA I showered R4 this morning. CNA I indicated that CNA I did shower R4 this morning. Surveyor asked CNA I if CNA I applied prescribed Nystatin powder to R4's folds. CNA I stated CNA I did apply Nystatin powder under R4's groin folds after R4's shower. CNA I stated that CNA I always applies R4's Nystatin powder when needed. CNA I stated it is always a hassle trying to find the nurse to administer when it is shower day. On 05/05/25 at 12:53 PM, Surveyor interviewed Director of Nursing (DON) B and asked if it was normal for R4 to receive prescribed Nystatin powder to groin folds by CNA I and if storage of prescribed nystatin powder was proper at R4's bedside table. DON B stated, Storage of prescribed Nystatin powder at bedside is ok if [R4] can self-administer medications. Surveyor asked DON B if it was DON B's expectation that CNAs can apply Nystatin powder to R4's groin folds. DON B stated it is not ok for CNAs to apply prescribed medication, and it is the nurses' job to apply this. The resident may apply if a successful assessment of safe administration of medications is completed.

Based on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was not obtained before employee started working at facility. (RN O). Findings include: The facility policy, titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, revised November 2022 states in part, Employee screening and training: a. Before new employees are permitted to work with resident's board registrations and certifications regarding prospective employee's background will be checked. d. A criminal background check will be conducted on all prospective employees as provided by the facility's policy on criminal background checks. On 05/06/25 at 8:14 AM, Surveyor reviewed 8 random staff Background Information Disclosures (BID). Registered Nurse (RN) O was hired on 02/04/25. Surveyor found no BID, Department of Justice (DOJ), or Integrated Background information System (IBIS) completed for RN O. On 05/06/25 at 11:42 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked where RN O's BID, DOJ, and IBIS were. NHA A indicated that somehow RN O was missed and will be completed today right away. NHA A indicated when old DON had left facility, facility called RN O who is a contracted staff member and did not complete a background. Surveyor asked NHA A to reach out to contracted company for the contracted company's BID. NHA A indicated that NHA A already reached out to contracted company and there was no BID completed upon RN O's hire. NHA A indicated that NHA A will complete right away.

Based on observation, interview and record review, the facility did not notify the physician on call of R4's refusal of insulin for 1 of 1 resident (R) reviewed for insulin administration (R4). Findings include: R4 was admitted to the facility on [DATE] with diagnoses including in part, type 2 diabetes mellitus with diabetic neuropathy, metabolic encephalopathy, chronic kidney disease stage 4, and acute and subacute hepatic failure without coma. Review of 4's medical record identified the following physician orders: - Insulin Aspart Injection Solution, inject 6 unit subcutaneously before meals for diabetes mellitus type 2 related to diabetes mellitus type 2 with hyperglycemia. Do not give insulin if Blood Glucose (BG) is less than 100. Observations: On 05/05/25 at 11:13 AM, Surveyor observed Registered Nurse (RN) C go into R4's room to check BG for insulin administration. R4's BG was 169. RN C indicated R4 is on sliding scale but does not require any insulin since BG is adequate. RN C indicated that R4 has been refusing R4's insulin due to hypoglycemic episodes in the past. On 05/06/25 at 9:52 AM, Surveyor interviewed RN C and asked RN C when R4 refuses insulin lispro what does RN C do afterwards. RN C indicated that RN C documents the refusal and kind of keeps an eye on R4 throughout the day. RN C indicated that RN C feels R4 knows R4's self very well that R4 can make that decision. Surveyor asked RN C if RN C is supposed to notify physician of R4's refusal of R4's insulin lispro order for base of 6 units to be given before meals. RN C indicated that RN C probably should be notifying physician of refusals so facility can readjust medications or discontinue altogether. RN C indicated to Surveyor that RN C has not been notifying the provider. Surveyor reviewed R4's progress notes and found no documentation that provider was contacted regarding R4's refusal of insulin on 05/05/25. On 05/06/25 at 11:25 AM, Surveyor interviewed Director of Nursing (DON) B and asked expectation if R4 refuses insulin. DON B indicated that RN C is to notify provider every time there is a refusal for insulin. DON B indicated that nurses should be notifying physician about refusals of insulin so that the insulin can be readjusted if not needed as often.

Based on record review and interview, the facility did not ensure adequate supervision and assistive devices were provided to prevent accidents for 1 of 5 residents (R22) reviewed for falls. R22 was identified as a fall risk upon admission and sustained seven documented falls at facility between [DATE] and [DATE]; the last fall, on [DATE] resulted in a right [CONDITION(S)] and R22 required a 5 day hospitalization before returning to facility. The facility did not implement a comprehensive care plan to address or implement interventions to reduce R22's risk of falls. Findings include: R22 was reviewed as a Closed Record during the facility's Recertification Survey. Surveyor requested R22's entire closed medical record, including Comprehensive Care Plan and Incident Investigation Reports; Surveyor reviewed all documentation provided by facility. R22 admitted to facility on [DATE], and had diagnoses that included: Cerebral Amyloid Angiopathy (a progressive neurological condition in which proteins build up on the walls of arteries in the brain), Neurologic Neglect Syndrome, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] with Behavioral Disturbance, and Other Symptoms and Signs Involving Cognitive Functions Following Non-Traumatic Intracerebral Hemorrhage. R22's Admission assessment dated [DATE] stated R22 had sustained a fall at her previous care facility. R22's Admission MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 6, indicating R22 had severe cognitive impairment. MDS also indicated R22 had a history of falls and required extensive assistance with transfers, mobility, and activities of daily living (ADLs). A Fall Risk Assessment was completed [DATE]; R22 scored 17, which indicated she was at High Risk for falling. No Care Plan was found for R22's identified fall risk. R22 sustained a fall on [DATE]. R22 was found sitting in her laundry basket by her door. Fall Note dated [DATE], read: .Immediate Action Taken: Laser alarm to floor. Resident is blind and confused. R22 sustained a fall on [DATE]. R22 was found on the floor in her room. Fall Note dated [DATE], read: .Environmental Factors: Alarm did not sound until she had already fallen .Fall prevention interventions instituted: Alarm repositioned . Health Status Note dated [DATE], read: Follow up note to fall that occurred on [DATE] .Resident has alarm in their room which sounded after the fall due to being placed on the dresser. Resident assisted back to bed and alarm placed in proper location to alarm staff if resident is attempting to get out of bed . R22 sustained a fall on [DATE]. R22 was found sitting on floor by bed. Fall Note dated [DATE], read: .Fall prevention interventions instituted: alarms were not in place, spoke with CNAs about following care plans . Health Status Note dated [DATE], read: Follow up note to fall that occurred on [DATE] .Alarms were not in place at time resident was found on the floor. Staff educated on the importance of following resident's care plan by floor nurse and reminded staff to have resident's bed in low position . R22 sustained a fall on [DATE]. R22 was found laying on the floor next to bed. Fall Note dated [DATE], read: .Immediate interventions provided: 1:1 until husband could arrive and sit with resident, called MD for medication to help with sundowning . Health Status Note dated [DATE], read: Follow up note to fall that occurred on [DATE] .1:1 initiated for safety until resident's spouse could be with her .no new orders placed. R22 sustained a fall on [DATE]. R22 was found kneeling on floor next to bed. Fall Note dated [DATE], read: .Fall prevention interventions instituted: Keeping laser alarm on the floor . Health Status Note dated [DATE], read: Follow up note to fall that occurred on [DATE] .Staff continued with the use of laser alarm on the floor of resident's room . R22 sustained a fall on [DATE]. R22 was found laying on floor. Health Status Note dated [DATE], read: .res (resident) bare footed .gripper socks applied .writer educated res on using call light; res acknowledged . R22 sustained a fall on [DATE]. Health Status Note dated [DATE], read: Writer alerted to res room by staff; upon entering room observed res sitting in recliner; staff standing by res; res self transferring self from recliner 'going upstairs'; staff reported res was getting very agitated being on floor; staff unable to console res; staff transferred res x2 to recliner; VS/Neuros/ROM WNL for res; res c/o slight right hip discomfort; PRN pain med administered .res educated to use call light for assistance; res acknowledges. Dr. notified Health Status Note dated [DATE], read: Follow up note to fall that occurred on [DATE] at approximately 0000 .At approximately 0200 on this same date, staff assisting resident to the bathroom, however resident was not able to bear weight on the RLE (right lower extremity) due to pain. Unable to complete ROM a (sic) this time due to pain. MD was notified again of findings and resident was sent to (hospital emergency department) .At approximately 0440 staff was notified .that resident had sustained a right [CONDITION(S)] .Resident returned .to unit on [DATE] at approximately 1500 following the repair of her right [CONDITION(S)]. R22 was sent to the emergency room following a fall on [DATE] for complaint of right lower extremity pain and unable to bear weight. R22 was diagnosed with a right [CONDITION(S)] and was hospitalized for 5 days. R22 returned to facility on [DATE], and later expired on [DATE] due to unrelated comorbidities. On [DATE] at 12:09 PM, Surveyor asked Director of Nursing (DON-B) if there was any additional information that would show R22 had a care plan alerting staff to R22's risk for falling, or any documentation of fall interventions that were put in place after each fall to prevent R22 from falling again. DON-B stated, if it wasn't in the packet we gave you, then there probably wasn't anything. No additional information was provided. There is no evidence that R22 had a care plan in place alerting staff to her increased risk of falling.

Based on interview and record review, the facility did not ensure a resident received care, consistent with professional standards of care, to prevent the development of a pressure injury. This occurred for 1 of 2 residents (R) reviewed for pressure injuries (R1). R1 was at risk for development of pressure injuries and developed a stage 3 pressure injury while at the facility. R1 did not have appropriate staging, monitoring, assessment, or a care plan for prevention or care of a pressure injury. Findings include: Record review identified R1 was admitted to the facility on [DATE] for therapy following a [MEDICAL CONDITION]. R1's [DIAGNOSES REDACTED]. R1's Brief Interview for Mental Status score was 08, indicating moderate cognitive impairment. R1's Minimum Data Set Assessment ((MDS) dated [DATE] section G (functional status) indicated R1 required extensive assistance of 2 persons for bed mobility and transfers. Functional limitation identified R1 had an impairment of the left lower extremity. Section M (skin conditions) of the MDS assessment identified R1 was at risk for development of pressure injuries. Section M also indicated R1 had no unhealed pressure injuries. A skin condition assessment dated [DATE] identified no skin conditions or open wounds. Record review identified R1 was re-hospitalized with pneumonia from 11/20/20 through 11/23/20. A skin condition assessment dated [DATE] identified a circle around the tailbone area of a body diagram with an arrow to the word redness. Review of R1's medical record did not identify any other documentation describing R1's skin condition, or the presence of any open wounds upon return from the hospital. Review of R1's comprehensive care plan did not identify any skin or wound problems. The care plan did not contain any goals or interventions for the prevention of pressure injuries, or for the care of any open wounds. A nursing progress note dated 11/29/20 stated, in part: resident requires 2 staff assist for transferring with an EZ stand .rests in (R1's) bed most of the shift . A nursing progress note dated 12/01/20 stated, in part: .R1's buttocks have small open areas and is reddened. Did fax MD (medical doctor) for Calaseptine (SIC) (skin barrier cream) order. It was noted there was no description of the location or size of the open areas, and no description of the wound bed. A nursing progress note dated 12/03/20 stated, in part: resident requires 2 staff to transfer with an EZ stand .rests in (R1's) bed most of the day . A nursing progress note dated 12/03/20 stated, in part: .open area on right buttock cleansed, island dressing applied, as reported to nurse on 11/30. no s/s (signs or symptoms) of infection are noted at this time . It was noted there was no description of the wound bed, no measurement of the open area, and no description of any drainage or odor from the wound. Review of physician orders [REDACTED]. The next noted documentation of R1's wound was on 12/10/20, noted as a late entry on 12/14/20. The note stated: Resident has area on (R1's) left buttock. Measuring 3 1/2 X (by) 2 3/4, with no noticeable depth. Reported to writer by CNA (Certified Nursing Assistant). Area washed, air dried, skin prep applied to the outer edges and skin protectant applied to reddened area. Covered with padded [MEDICATION NAME] (dressing). Reported to next shift and DON (Director of Nursing). It was noted there was no order for a padded [MEDICATION NAME] dressing on R1's physician orders. Review of a physician progress notes [REDACTED]. A nursing progress note dated 12/16/20 stated: While changing catheter rolled resident over and noted a stain of putrid smelling drainage from OA (open area) on buttocks. Center of stain is grey in color then turning red on the outside of stain. Stain is circular and about 10+ cm (centimeters). [MEDICATION NAME] applied and DON notified of worsening of area. A nursing progress note dated 12/16/20 stated: Open area on L (left) side of buttocks assessed. Open area is red and moist measuring 6x6 cm with 2x2 cm at the center darker greyish color. No depth to area with no soft bogginess present. Resident had recently bathed and not (SIC) odor present at this time. [MEDICATION NAME] tx (treatment) remains appropriate. Review of R1's medical record did not identify any notification to the physician about the worsening condition of R1's open wound with odorous drainage. The record indicated R1 was then discharged to return to an assisted living facility. Surveyor interviewed nurse practitioner (NP) F who reported NP F took over as R1's primary care provider when R1 returned to the assisted living facility. NP F stated NP F did not receive any report from the facility that R1 had an open wound that had odorous drainage. NP F stated the staff from the assisted living facility informed NP F that R1 had an open wound on the buttocks with no dressing or bandage on it when R1 arrived at the facility on 12/16/20. The staff at the assisted living facility informed NP F the discharging facility did not inform them that R1 had an open wound, or provide any orders for wound care. NP F assessed R1 on 12/21/20 and reported R1 had a stage 3 pressure injury to the left buttocks. NP F stated R1 is currently hospitalized [MEDICAL CONDITION] due to the pressure injury. Surveyor interviewed DON B about R1's skin condition. DON B stated R1 had been incontinent of loose stools from antibiotic therapy, and developed irritation to the buttocks from that. Surveyor asked DON B if the wound described on 12/16/20 sounded like irritation from stool or a possibly infected pressure injury, DON B agreed the wound sounded like a possible pressure injury. When asked what interventions were in place to prevent the development of a pressure injury, DON B stated R1 had a gel cushion in R1's wheel chair. DON B stated R1 was resistant to getting out of bed or working with therapy, and did not want to move. Surveyor asked if R1 was considered at risk to develop a pressure injury due to immobility and weight loss, DON B stated R1 was at risk. When asked if there was a care plan and interventions to address this, or any skin integrity or wound care plan on R1's chart, DON B stated there was no skin integrity or wound care plan on R1's record, but the clinical coordinator should have initiated a wound care plan. When asked if [MEDICATION NAME] is an appropriate treatment for [REDACTED]. DON B stated a physician should have been notified of the wound condition, or R1 should have been sent to a physician for evaluation of the wound. When asked if a report about the open wound was given to the receiving facility when R1 was discharged , DON B stated the physician orders [REDACTED]. DON B provided documents titled Discharge Summary and Medication review report sent to the receiving facility. Review of these documents did not identify any mention of the open wound to R1's left buttocks, or orders for treatment of [REDACTED].