Every finding on record at Clairidge House

Based on record review, interview, and facility policy review, the facility failed to implement the abuse policy and ensure alleged violations involving sexual abuse, exploitation, misappropriation of resident property, and/or a reasonable suspicion of a crime against a resident (R) were reported to the State Survey Agency and, when applicable, law enforcement within required timeframes for one of three reportable incidents reviewed affecting (R6). These failures had the potential to delay protective oversight, law enforcement involvement, and required external oversight of allegations affecting residents in the facility. Findings Include: Review of the facility's reportable incident documentation for R6 revealed the Administrator received an anonymous text message on 06/16/26 at 11:48 AM, alleging a staff member was involved in an inappropriate relationship with R6, including allegations of kissing, consuming alcohol, and having sex with the resident in the smoking area. The facility report documented the incident was discovered on 06/16/26. The Administrator prepared the initial report on 06/17/26 at 11:37 AM, approximately 24 hours after receiving the allegation. The five-day report was completed on 06/23/26 instead of 06/22/26. During an interview on 07/23/26 at 3:20 PM, the Administrator stated he received the text message on his personal cell phone on 06/16/26 at 11:48 AM while sitting at his desk and immediately interviewed R6 with the Director of Nursing. The Administrator stated R6 denied the allegation and was a fairly credible witness. The Administrator stated he did not report the allegation within two hours because he did not believe it happened, did not view it as abuse, and considered it misconduct. The Administrator stated, I reported it on 06/17/26 at 11:37 AM, because I didn't believe it happened, and further stated, I had a four-hour Dementia training the afternoon of the 16th, so that's why the reporting portion was pushed off until the next day. I did what I felt was best after investigating the situation. I could have just deleted the text and never reported it. During an interview on 07/23/26 at 4:16 PM with the Administrator, Director of Nursing (DON), and Regional staff, the Administrator stated the allegation involved kissing, alcohol consumption, and sex. The Administrator stated he did not believe the allegation was abuse after interviewing R6. Regional staff stated an original abuse allegation would require reporting within two hours; however, after review, Regional staff stated they did not believe it was abuse. During an interview with R6, on 07/22/26 at 3:45 PM, he stated he had never been abused. Although R6 denied the allegation, the facility had received an allegation involving potential staff-to-resident sexual misconduct and alcohol use. The facility investigated before reporting and used its credibility determination to delay reporting until the next day. The facility failed to report the allegation to the State Survey Agency within two hours after the allegation was made. A review of the facility policy titled Real Property Resident Safety Abuse Policy, last revised 02/22, revealed the policy required the Administrator to report a reasonable suspicion of a crime against a resident to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. The policy required reporting immediately, but not later than 2 hours after forming the suspicion, if the events resulted in serious bodily injury, or not later than 24 hours if the events did not result in serious bodily injury. The policy further required all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property to be reported immediately, but not later than two hours after the allegation was made if the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the allegation did not involve abuse and did not result in serious bodily injury. The policy required the results of all investigations to be reported to other officials, including the State Survey Agency, within five working days of the incident.

Based on record review, interview and observations, the facility did not ensure residents received comprehensive assessments, interventions and treatment, to prevent and heal, pressure injuries. This was observed with 4 (R3, R9, R1 and R16) of 4 residents reviewed with pressure injury. *R3 was at high risk for a pressure injury, developed a facility acquired stage 3 pressure injury, that was not comprehensively assessed upon discovery. R3 did not have interventions revised to promote healing. This resulted in actual harm to R3. *R9 had facility acquired pressure injuries to the left upper posterior thigh area and left medial thigh. On 3/03/2026, Surveyor observed R9's wound treatment which was not completed per the order. R9's pressure injuries were determined to be due to R9 being provided with the incorrect size brief causing medical device related pressure injuries. R9's stage 2 left medial thigh pressure injury was not assessed, and treatment was not put into place until Surveyor questioned the treatment. This resulted in actual harm to R9. *R1 had a Deep Tissue Injury to the left heel when admitted to the hospital on [DATE]. R1 was readmitted to the facility on [DATE] and the left heel pressure injury was not comprehensively assessed until 2/12/2025, one week later. *R16 has a Stage 3 pressure wound on right heel and was observed to not have heels floated during survey process. Review of R16's Treatment Administration Records (TARS) documented missing treatments. R16 has a history of MASD and pressure wound to left heel. Findings include: The facility's policy and procedures Skin Care Treatment, dated 2/25, was reviewed. The Policy documents: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of pressure injury and other skin integrity concerns.Protocol:1. Within 4 hours of admission a complete body check is completed by the nurse, using the skin and body assessment form. If any issues are found on this comprehensive body check, documentation will be entered into the pressure injury assessment (for any pressure injuries) or non-pressure wounds (for all other wound types) of folder in ECS (Electronic Chart System). A Braden scale will also be calculated at this time.2. Proactive pressure injury and skin care integrity interventions will be considered and implemented at the time of admission and care planned accordingly this includes but is not limited to pressure relieving support services for bed and chairs wheelchairs frequent repositioning and offloading skin inspection and early detection of issues moisture and incontinence management nutrition and hydration interventions mobility and exercise encouragement and appropriate selection and use of skin care products and equipment3. All resident beds are equipped with pressure reducing relieving or redistributing mattresses all resonant wheelchairs are equipped with pressure reducing you're leaving or redistributing cushions advanced treatment level mattresses and wheelchair cushions are issued to residents with assessed need per the skin treatment management guidelines policy.9. When a resident is admitted with or develops a pressure injury or any other open area, immediate treatment will be initiated.a. Initial wound documentation will be entered into the pressure injury assessment folder for any pressure injuries or non-pressure wounds folder for all other wound types in ECS.b. Comprehensive assessment of pain and implementation of pain control measures prior to treatment is the priority and wound care management.c. Measurements of the area will be done using a wound measuring guide.d. A weekly assessment will be done by the nurse, and all ongoing wound documentation will be entered into the pressure injury assessment folder or non-pressure wounds folder in ECS.e. The treatment protocol will be initiated using the skin treatment management guidelines protocol and the intending physician order.f. The nurse will notify the residents responsible party of any skin integrity issues and or changes in treatment and document this in the nursing progress notes. 1.) R3 was admitted on [DATE] with a diagnosis of stroke. R3's admission Minimum Data Set (MDS) assessment completed on 7/7/25 assesses R3 as non-verbal, tube feeding, totally dependent on staff for positioning, at risk for pressure injury, along with stage 1 pressure injury. R3's Care Area Assessment (CAA) was triggered for Pressure Ulcer but the CAA does not include where the pressure injury is located or risks for pressure injury development for R4. R3's Braden Scale performed on 6/25/25 documents a score 11, indicating that R3 is at high-risk for developing pressure injuries. R3 Plan of Care (POC) Care plan, dated 6/20/25, for Tissue integrity impairment documents under the Interventions section: assess skin status, keep physician informed, medical plan for treatment, reposition every 1.5 hours. Keep skin clean and dry.REVISED on 7/1/25 with ensure floating boots while in bed. R3's New Impairment of skin Integrity, dated 8/18/25, documents the following interventions: Assess skin daily and note any changes, Monitor use of skin protective devices. Bandage as appropriate. Keep clean and dry, check skin under elbow protectors every shift. REVISED 8/26/25 float bilateral elbows with pillows. R3's nursing note written by Wound Nurse-G and dated 8/18/25 documents: A facility acquired pressure injury, stage 3 on the right elbow. The discovery date is 8/15/25. The area measures 2.5 centimeters (cm) by 1.5 by 01. The wound has a moderate amount of drainage. The MD (medical doctor) was notified, and a treatment was ordered. The new interventions include elbow protectors. R3's Skin POC 8/18/25, by WN-G, that the elbow protectors are too tight. The right elbow was elevated with a bath blanket, and the left elbow is also elevated with repositioning. There is no documentation for a comprehensive wound assessment, along with interventions and treatment, to promote healing on 8/15/25. The documentation of the discovery of the wound on 8/18/25 documents that the area was not comprehensively assessed until 8/21/25 by Nurse Partitioner (NP) -Q on 8/21/25. On 3/05/26, at 8:00 AM, Surveyor interviewed WN-G. The WN-G is a Licensed Practical Nurse (LPN) with wound care certification. The WN-G stated when they reviewed the 24-Hour Reports on 8/18/25 (Monday), they noticed on 8/15/25 (Friday) R3 had a wound on their elbow. The Floor Nurse should have let WN-G know about a wound. The WN-G does assessments weekly with the NP-Q. The 24-hour Report Sheet documents on 8/15/25 an old wound reopened on the right elbow. There is no additional documentation related to this open area discovery until 8/18/25. On 8/21/25, NP-Q documented an assessment of a stage 3 pressure ulcer on the right elbow. Measuring 1.5 cm by 1.3 by 0.1. With scant serosanguinous drainage and 100% granulation. The intervention includes, to float elbows in bed. R3's Skin POC had a entry on 8/26/25 of: pressure ulcer correlated to contact wedge pillow used for positioning. Staff instructed to reposition every 1.5 hours and to float elbows with pillows in bed. This was documented by WN-G. On 3/04/2026, at 10:23 AM, Surveyor interviewed the WN -G. The WN-G stated the elbow protectors were black and elastic and too tight. They ordered a larger size. These were ordered after the elbow wound was discovered. The WN-G states the positioning wedge may have caused a wound on the elbow. R3 is not mobile at all. On 8/28/25 the NP-Q documented an assessment of the right elbow. R3 was experiencing a change in their clinical condition and was going to be sent out to the hospital. The elbow wound measures 1.5 cm by 2.8 by 0.1. There is moderate serosanguinous drainage and 100% slough. R3's nursing note documents that R3 returned from the hospital on 9/2/25. The right elbow wound is larger. Wound Nurse-G was documented on the area. This documentation is not in the medical record. Surveyor noted that there was not a comprehensive assessment of the right elbow upon R3's readmission to the facility from the hospital on 9/2/25. R3's right elbow was not assessed until 9/4/25 by NP-Q. On 9/4/25, NP-Q documented an assessment of the right elbow. The elbow is a stage 3 pressure injury with improvement. Measures 1.2 cm by 2.8 by 0.1. There is 50% slough and 50% granulation. No changes in treatment or plan of care. On 9/11/25, NP-Q documented an assessment of the right elbow. The right elbow is deteriorating. Measures 1.8 cm by 2.5 by 0.3. With 50% slough and 50% granulation. The Treatment was changed. There was no change in the POC. On 9/18/25, NP-Q documented an assessment of the right elbow. The right elbow is deteriorating. A Dietary Consult for glucose management. Given the location of the wound and deterioration present this week will order work up for osteomyelitis. Ordered wound culture and lab work. R3 was prescribed Levaquin (antibiotic) on 9/18/25 for wound infection for 7 days. The wound work-up did not show osteomyelitis. The wound culture did not show an infection. On 9/25/25, NP-Q documented an assessment of the right elbow. The right elbow has improved. The wound is unstageable with 80% slough and 20% granulation. Measures 2.5 cm by 2.5 by 0.4. The POC is the same On 10/2/25, NP-Q documented an assessment of the right elbow. The right elbow is improving. The right elbow is a stage 3 with 10 % slough and 90% granulation. There is moderate amount of serosanguinous drainage. Measures 2.5 cm by 2.5 by 0.3. No change in treatment or POC. On 10/9/25, NP-Q documented an assessment of the right elbow. The right elbow is unchanged from the previous week. No changes in treatment or POC. On 10/16/25, NP-Q documented an assessment of the right elbow. The wound has improved. It is a stage with 10% slough and 90% granulation. Measures 1.7 cm by 1.5 cm by 0.2. There is no change to the treatment or POC. On 10/23/25, NP-Q documented an assessment of the right elbow. The measurements unchanged from the week before. There is 100% granulation. There is no change in treatment or the POC. On 10/30/25, NP-Q documented an assessment of the right elbow. The measurements are unchanged from the prior week. There is 40% granulation and 60% epithelial. There is no change in treatment or POC. On 11/6/25, NP-Q documented an assessment of the right elbow. The area is improving. There is 90% granulation and 10% slough with moderate serosanguinous drainage. Measures 1.5 cm by 1.5 by 0.1. The treatment was changed. There was no change to the POC. On 11/14/25, NP-Q was not at the facility. The facility Wound Nurse-G documented on the right elbow. The right elbow measured 1.5 cm by 1.5 by 0.1. with 90% granulation and 10% slough. There was no change in treatment or POC. On 11/20/25, NP-Q documented an assessment of the right elbow. The area has declined, and Bactrim DS 800 mg BID(twice a day) for 10 days was ordered. The area is a stage 3 with purulent drainage and 90% granulation and 10% slough. Measures 2.2 cm by 2.8 by 0.1. The treatment was changed. There was no change in the POC. On 11/26/25, NP-Q documented an assessment of the right elbow. The area is improving. It is a Stage 3, and has moderate serosanguinous drainage, with 90% granulation and 10% slough. Measures 1.9 cm by 1.6 by 0.1 There is no change in the treatment or POC. On 12/4/25, NP-Q documented an assessment of the right elbow. The area is improving. There is moderate serosanguinous drainage with 100% granulation. Measures 1 cm by 1.5 by 0.1. No change to the treatment or POC. On 12/11/25, NP-Q documented an assessment of the right elbow. The area is stable. There is moderate serous drainage with 100% granulation. Measures 1 cm by 1.5 by 0.2. No change in treatment or POC. On 12/18/25, NP-Q documented an assessment of the right elbow. The wound has stalled and concerns for infection. Labs and wound culture ordered. There is moderate serosanguinous drainage with 100% granulation. Measures 1.5 cm by 1.5 by 0.3. There is no change in treatment or POC. There were no infections discovered with wound culture or labs. On 12/30/25, NP-Q documented an assessment of the right elbow. The wound is stable. There is moderate serosanguinous drainage with 90% granulation and 10% slough. Measures 1.5 cm by 1.5 by 0.3. The treatment was changed. There was no change to the POC. On 1/1/26 the facility WN-G documented on the right elbow. The area is a stage 3 with moderate serosanguinous drainage with 90% granulation and 10% slough. Measures 1.5 cm by 1.5 by 0.3. The treatment and POC is unchanged. On 1/15/26, NP-Q documented an assessment of the right elbow. The area has deteriorated. A stage 3 with heavy serosanguinous drainage with 100% granulation. Measures 2 cm by 2.5 by 0.1, No change to the treatment or POC. On 1/22/26, NP-Q documented an assessment of the right elbow. The area is improving. It is a stage 3 with moderate serosanguinous drainage with 100% granulation. Measures 1.8 cm by 2 by 0.1. There is no change in treatment or the POC. On 1/29/26, NP-Q documented an assessment of the right elbow. The area is improving. A stage 3 with heavy serosanguinous drainage with 100% granulation. Measures 1.5 cm by 1.5 by 0.2. There was no change in the treatment or POC. On 2/5/26, NP-Q documented an assessment of the right elbow. The area is improving. A stage 3 with moderate serosanguinous drainage and 100% granulation. Measures 1 cm by 1 by 0.1. There was no change in the treatment or POC. On 2/12/25, NP-Q documented an assessment of the right elbow. The area is improving. Stage 3 with heavy sanguineus drainage and 100% granulation. Measures 0.8 cm by 0.8 by 0.1. There is no change in treatment or the POC. Surveyor noted that there was no comprehensive assessment between 2/12/26 and 2/26/26. On 2/26/26, NP-Q documented an assessment of the right elbow. The area is stable. A stage 3 with moderate serosanguinous drainage and 100% granulation. Measures 1 cm by 1 by 0.1. The treatment was changed. There was no change on the POC. On 3/04/2026, at 7:34 AM, Surveyor observed R3 wound care by WN-G. The treatment was followed. The pressure injury appeared as assessed. The intervention measures were in place. On 3/4/25, at 3:00 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A and Director of Nurses (DON) -B, Surveyor shared the concerns that R3was missing comprehensive assessments, infection that was treated with antibiotics and updates to R3's plan of care. On 3/05/2026, at 10:50 AM, Surveyor interviewed NP-Q. The NP-Q is an outside Consultant that comes to the facility once a week. WN-G will contact the facility with any concerns or new areas. WN-G will look at the wounds when they are not in the facility. NP-Q stated they had pillows and elbow protectors. R3 has respiratory issues, receives tube feeding, bed bound with contractures. There were no concerns about wound cultures or labs. The NP-Q thinks the elbow is slow to heal due to R3 clinical condition. There have been no concerns about dressing changes or missed treatments. On 3/5/25, at 1:02 PM, Surveyor shared with NHA-A regarding R3's pressure injury concerns. R3 right elbow was not comprehensively assessed upon discovery. It was assessed as a stage 3 pressure injury and was treated with antibiotics. No additional information was provided. 2.) R9 was admitted to the facility on [DATE], with diagnoses including acute kidney failure (sudden, often reversible loss of kidney function), acquired absence of right foot, and urine retention (the inability to fully or partially empty the bladder). R9's annual MDS (Minimum Data Set) dated 1/21/2026, indicates R9 has a BIMS score of 14, indicating R9 is cognitively intact, does not exhibit rejection of care behaviors, has no impairment in upper extremities, has impairment in lower extremities, is dependent for toileting, dependent on lower body dressing, requires partial/moderate assistance rolling left to right, frequently incontinent of urine, always incontinent of bowels and has an unhealed stage 3 pressure injury. On 03/02/2026, at 9:29 AM, Surveyor interviewed R9. R9 informed Surveyor that R9 has wounds on his butt and thigh that were acquired while at the facility. R9's Facility provided untitled document, dated 12/26/2025 documents: Initial Assessment- Area 1- left posterior thigh; Onset- 12/26/2025; Origin- Facility Acquired; Stage- 3 ; Wound Base- 10% epithelial scab wound edges, 80% granulation, 10% dermis; Measurement in centimeters (cm) (length x width x depth)- 4.2 x 4.8 x 0.1; Exudate- serosanguinous ; Exudate color- bloody; Amount- moderate; Treatment- skin sealant to peri wound, cover with calcium alginate, cover with foam boarded bandage daily. Interventions: support surfaces for bed: Medline advantage select PE support surfaces for w/c: cushion, geo-mat PRT monitor skin integrity and tissue tolerance; minimize risk for sheer and friction; teaching redistributing pressure, reposition and offloading; risk and benefits. Surveyor reviewed R9's Physician orders and noted a treatment for R9's left posterior thigh, initiated 12/26/2025. Surveyor reviewed R9's Skin Integrity care plan initiated on 8/6/24 that documents: R9 has potential for impairment to skin integrity with no current breakdown; Interventions include: Weekly skin assessments; Monitor stumps for presence of edemas and skin integrity; Encourage to wear stump shrinkers; Keep legs elevated on cushion in chair; Assure incontinent cares are complete in timely manner; Encourage to shift body weight when up in chair; Provide moisture barrier if needed; Update wound nurse if impaired skin develops; Monitor dietary intake. Surveyor noted no added interventions to care plan and that R9's skin integrity care plan was discontinued on 1/7/2026. Surveyor noted R9's Care Plan, initiated an intervention on 1/7/2026 that documents: Ensure R9's brief is fitted properly to prevent excessive friction. Surveyor noted R9 was admitted to the hospital for unrelated medical concerns on 1/10/2026 and returned to the facility on 1/14/2026. R9's Integrated Wound Care document, dated 1/15/2026, indicates: R9 is being seen for evaluation and treatment recommendation regarding a stage 3 pressure injury to the left posterior thigh. R9 was recently hospitalized and upon return stage 3 pressure injury noted to posterior thigh. Measurement- 2 x 1 x 0.1 100% dermis; Treatment recommendations: Apply Thera honey to wound bed, cover with alginate and boarder foam, change daily and as needed. R9's Integrated Wound Care document, dated 1/22/2026, indicates: Wound is improving, new trauma to left medial thigh observed. Pressure Injury left posterior thigh- measurement- 1 x 1 x 0.1 cm; Trauma medial left thigh- measurement 2 x 4 x 0.1; Treatment recommendations: Pressure Injury left posterior thigh- Apply Thera honey to wound bed, cover with alginate and boarder foam, change daily and as needed; Trauma medial left thigh- Thera honey to wound bed, cover with boarder foam, change daily and as needed. R9's Facility provided untitled document, dated 1/23/2026 documents: Area 2- left medial thigh; Onset- 1/22/2026; Origin- Facility Acquired; Stage- 2 medial device related pressure injury (brief); Wound Base- 100% dermis; Measurement in centimeters (cm) (length x width x depth)- 2 x 4 x 0.; exudate- serous; Exudate color- pale red; Amount- small/minimal; R9 went up in brief size to prevent further injury to inner thighs Surveyor noted that R9's stage 3 left posterior thigh stage 3 pressure injury left posterior thigh pressure injury increased in size based on the facility's measurements and a new stage 2 pressure injury to R9's left medial thigh developed on 1/22/2026. R9's Care Plan indicated R9's left medial thigh pressure injury was added to the care plan as a care area on 1/23/2026, indicating R9 has impairment of skin with current pressure injuries to upper left posterior thigh and a medical device related pressure injury to inner thigh with no added interventions. Surveyor noted R9's medical device related pressure injury to R9's left medial thigh, was not assessed by the facility and the treatment was not initiated until 1/23/2026. On 1/29/26, the facility documents that both of R9's pressure injuries healed, and the action plan is to monitor for four weeks. Surveyor noted, 2/6/2026 through 2/20/2026 the Facility continued to observe R9's healed pressure injuries with no changes indicated. R9's Facility provided untitled document, dated 2/23/2026 documents: Area 1- left posterior upper thigh; Facility Acquired; Onset date 2/22/2026; Measurement- 1 x 5 x 0.1 cm; Wound Base- 100% granulation; Medical device related pressure injury; Exudate- serosanguinous; Exudate color- pale red; Amount- moderate; Reoccurred; Stage 3 ; Treatment- Thera Honey to wound base, cover with foam border bandage daily and as needed. R9's Facility provided document, titled Treatments, initiated on 2/23/2026, indicates: Left posterior upper thigh pressure injury- apply Thera Honey to wound base, cover with boarder foam dressing daily. On 03/02/2026, at 9:47 AM, Surveyor observed CNA-R and CNA-I assist R9 with getting undressed and perform a partial bed bath for R9, including incontinence cares. During this time. Surveyor noted dressings in place of R9's left posterior thigh pressure injury and noted a scant amount of red matter, consistent with the appearance of blood, to R9's brief around R9's left thigh area. Surveyor observed a large open wound to R9's left medial thigh. R9's left posterior thigh wound did not appear to be open but was left uncovered. R9's brief was changed and appeared to fit snug on R9's body. During conversation with R9, R9 indicated that the wounds are from scratches, some scratches are from R9 on the backside, others are from the staff putting the pamper too tight. R9 indicated sometimes R9 uses the urinal and sometimes is incontinent of urine. Surveyor asked R9 if R9 can feel when the brief is too tight, R9 indicated yes and has mentioned it but most of the time they leave it and do not readjust it. Surveyor observed an open area to R9's left medial thigh, which was not documented in R9's chart. R9's medical chart was reviewed, and Surveyor could not locate any documentation regarding any open area to R9's left medial thigh. On 03/03/2026, at 1:22 PM, Surveyor observed Registered Nurse (RN)-T perform a wound treatment for R9. Surveyor noted R9 did not have a dressing in place to R9's stage 3, posterior left thigh pressure injury. Surveyor observed the open area to R9's left medial thigh, which was open with a small amount of blood visible and no covering over the wound. RN-T applied zinc oxide to R9's inner thighs, posterior thighs, and scrotum. Surveyor asked RN-T if RN-T was providing wound care to R9's pressure injury, RN-T informed Surveyor that RN-T is only performing R9's morning treatment to the denuded areas and the PM shift does the pressure injury wound treatment. RN-T indicated she would call Wound Nurse-G to come up to do the afternoon treatment for R9's pressure wounds. RN-T then went to the computer to verify R9's order and discovered R9's left posterior thigh wound has a different order than the zinc oxide. Surveyor observed R9's left posterior thigh, stage 3, pressure injury uncovered, without the ordered foam dressing in place. Surveyor observed RN-T provide incorrect treatment to R9's left posterior thigh, stage 3, pressure injury by applying Zinc Oxide over the wound, which is not the order for R9's left posterior thigh, stage 3, pressure injury. On 03/03/2026, at 1:41 PM, Wound Nurse-G came to R9's room. Wound Nurse-G informed Surveyor that R9's left posterior upper thigh should have Thera Honey and cover with foam dressing and not zinc oxide applied to it. Wound Nurse-G and Surveyor observed the stage 3 left posterior thigh wound, Wound Nurse-G indicated it looks healed but will do treatment as ordered. Wound Nurse-G informed Surveyor the wound is currently uncovered and that R9 has an order to have a foam boarder dressing in place and the zinc oxide for the denuded areas should be around the not on the wound. Wound Nurse-G informed Surveyor R9's left medial thigh wound has reopened and is new, and called out loud the following measurements, 7 x 1 x 0.1cm. Surveyor informed Wound Nurse-G that Surveyor observed the left medial thigh wound yesterday. Wound Nurse-G indicated Wound Nurse-G was not made aware and expect staff to notify the nurse when it was discovered and the nurse should have notified Wound Nurse-G call the wound Nurse Practitioner (NP)-Q, get an assessment and begin treatment. Wound Nurse-G indicated since that was not done, it caused a delay in R9's wound treatment. Surveyor observed the open wound to R9's left medial thigh on 3/02/2026 and noted the significant size of the wound. Surveyor noted R9's left medial thigh wound was not assessed and no treatment was ordered until 3/03/2026, when Surveyor brought it to Wound Nurse-G's attention. On 03/04/2026, at 3:01 PM, Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Clinical Nursing Officer-C, were informed of the concerns. On 03/05/2026, at 8:13 AM, Surveyor interviewed DON-B regarding R9's wound care and pressure injuries. DON-B indicated wounds that are pressure injuries would generally be followed by the outside wound care provider. Surveyor asked DON-B how DON-B oversees wound care information gathered, DON-B indicated DON-B has conversations with Wound Nurse-G to see how things are, if there is anything getting worse or improving and will co-sign the plan of care. DON-B indicated DON-B will do the initial assessments of wounds and Wound Nurse-G will monitor and update R9's care plan. DON-B indicated interventions would be reassessed once recurrence of the wound happened and if not improving an order for ProSource for wound healing would be put in place. DON-B included weekly skin checks were completed by Wound Nurse-G and DON-B, and it is reviewed as a team. When Surveyor informed DON-B of Surveyors observations of improper wound treatment for R9's stage 3 left posterior thigh wound and the delay in reporting a stage 2 pressure injury to R9's left medial thigh, DON-B did not give a response and indicated Wound Nurse-G was tasked with gathering further information and DON-B would look further into everything. Surveyor noted that R9 was not seen by the Wound NP once R9's pressure injuries reopened, and no additional information was provided to Surveyor regarding the delayed reporting, assessment and treatment of R9's left medial thigh pressure injury. On 03/05/2026, at 8:27 AM, Surveyor interviewed Wound Nurse-G. Wound Nurse-G Informed Surveyor that R9's left posterior thigh pressure injury was caused by R9 wearing the incorrect brief size, causing friction. Wound Nurse-G increased R9's brief size and would look more into when exactly it was identified. Wound Nurse-G indicated R9 developed the stage 3 left posterior thigh wound on 12/26/2025 and healed 1/30/2026, was monitored for 4 weeks and was caused by positioning of R9's brief. R9 had the flu in January, which caused R9 to be in bed more and had increased incontinence. Wound Nurse-G noticed R9 wearing 2x briefs and changed them to 3x. Surveyor noted that the root cause of R9's pressure injuries was identified as R9's brief size. On 03/05/2026, at 9:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-P and CNA-V. CNA-P indicated R9 was wearing a green, size 2x briefs but they cut into R9 so R9 was switched to 3x briefs but does not remember when. CNA-V indicated the brief size goes based on weight and by seeing if the brief is too snug or too tight. CNA-V informed Surveyor there used to be list in clean hold of all resident sizes but not here anymore, so staff will just look at the person, and based on that, determine what size. On 03/05/2026, at 12:42 PM, Clinical Nursing Officer- C provided Surveyor with a document titled FITRIGHT How to use the FITRIGHT tape measure and indicated they typically use height and weight to determine brief sizing. For R9 brief size is determined by hip measurement and weight due to R9 having bilateral leg amputations. Surveyor noted could not locate R9's hip measurements in R9's electronic health record. Surveyor noted the last weight documented in R9's electronic health record was on 1/15/2025 under the vitals tab and indicated R9 weighed 258 pounds. R9's weights are documented as: 8/18/2025, 256 pounds; 11/11/2025, 270 pounds; 1/19/2026, 270 pounds; 1/21/2026, 255 pounds. Surveyor noted that R9 is a bilateral lower extremity amputee. The facility did not addressR9's weight differences and how it could potentially mislead the facility's choice in brief size causing R9 to develop pressure injuries. On 03/05/2026, at 11:06 AM, Surveyor interviewed Wound Nurse Practitioner (NP)-Q. Wound NP-Q indicated she was supposed to start seeing R9 again last week but R9 was unavailable and will be going to see R9 today. Wound NP-Q indicated R9's left upper posterior thigh stage 3 pressure injury has reoccurred and they have now tried different briefs, which seemed to be a benefit and will evaluate effectiveness when seen today. No additional information was provided. 3.) R1 was admitted to the facility on [DATE] with diagnoses of idiopathic aseptic necrosis of the left toe, pneumonia, peripheral vascular disease, nicotine dependence, Type 1 diabetes mellitus, bipolar disorder, insomnia, and neuromuscular dysfunction of the bladder requiring an indwelling urinary catheter. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and had impairment to both arms and legs requiring assistance with all activities of daily living. The MDS documented R1 had one Deep Tissue Injury (DTI) on admission. On 1/29/2026, R1 was assessed by Nurse Practitioner (NP)-Q assisted by MDS/Wound Nurse-G. NP-Q documented R1 had a DTI to the left heel that measured 1 cm x 1 cm x 0.1 cm with 100% epithelial tissue that was dry and maroon in color. A treatment to apply Skin Prep to the area and cover with bordered foam daily and as needed was ordered. On 2/1/2026, R1 was sent to the hospital for evaluation and treatment of kidney pain. R1 was admitted to the hospital at that time. On 2/5/2026, R1 was readmitted to the facility. No documentation of a skin assessment was located. Treatment of the DTI to the left heel continued with Skin Prep and a bordered foam dressing daily and as needed. On 2/12/2026, R1 was assessed by NP-Q assisted by MDS/Wound Nurse-G. NP-Q documented R1's DTI to the left heel measured 3 cm x 3 cm x 0.1 cm with 100% epithelial tissue that was dry and maroon in color. The treatment continued as prior to hospitalization with the exception of the wound was covered by Optiview instead of a bordered foam dressing. On 3/2/2026 at 10:02 AM, Surveyor observed R1 lying in bed on an air mattress. R1 was covered in multiple blankets and had towels under the arms and sides. R1 stated the towels relieved pain to the back and preferred them to be placed there. Surveyor asked R1 if R1 had any wounds or daily treatments

Based on interview and record review, the facility did not ensure the physician was consulted with regarding a possible change in condition for 1 (R20) of 1 sampled Residents.On 2/19/26 R20's recorded weight was significantly less than their previous weight. The facility did not consult with R2's physician regarding the possible weight loss.Findings include:The facility's Physician Notification-Consultation Parameters last revised 1/22 documents:Definitions:1. Immediate Notification/Consultation: A physician should be informed and consulted at the time the event occurs (but not later than 1 hour after the condition is identified) directly or via an electronic or telephone call system.2. Non-immediate Notification: The attending physician should be informed of the event during normal office hours, and generally no later than the next regular office day. Consultation with the physician may be required if clinically warranted. If a non-immediate event occurs on a weekend or holiday, licensed nurses must determine if the notification can wait until the next office day or the on-call physician notified during day time hours.Unexplained Weight Loss or Weight Gain-5% or more within 30 days, 10% or more within 6 months.R20 was admitted to the facility on [DATE] with diagnoses of Alzheimer's (progressive disease that destroys memory and other important mental functions), Vascular Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) with Behavioral Disturbance, Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Hypothyroidism (underactive thyroid), Hyperlipidemia (high levels of fat particles in blood), Chronic Kidney Disease (progressive damage and loss of function in the kidneys), and Hypertensive Heart Disease (long term conditions developed from chronic high blood pressure).R20's Significant Change Minimum Data Set (MDS) with an assessment reference date of 12/3/25 assesses R20 has both short- and long-term memory impairments and demonstrates severely impaired skills for daily decision making. R20's MDS assesses R20 has no range of motion impairment, requires set-up for eating. R20's MDS assesses R20 holds food in mouth, no current weight loss, and is on a mechanically altered diet.Surveyor reviewed R20's monthly weights. On 12/17/25, R20's documented weight was 141 pounds. On 2/19/26, R20's documented weight was 118 pounds. The calculated weight loss from 12/12/25 to 2/19/26 is 16.31%.On 2/25/2026, at 6:54 PM, Registered Dietician (RD)-K documented R20 has a significant weight loss of 17 pounds. RD-K discussed with Registered Nurse (RN) who will obtain a re-weight to assess weight accuracy as previously weight has been stable.On 3/04/2026, at 7:53 AM, Surveyor completed a thorough review of R20's electronic medical record (EMR) and paper chart. Surveyor was unable to locate any documentation that R20's physician had been consulted with regarding R20's significant weight loss of 16.31% from 12/12/25 to 2/19/26. R20's re-weight was never obtained. Surveyor reviewed R20's nutrition care plan and notes R20's nutrition care plan has not been updated since 12/9/25.On 3/04/2026, at 12:14 PM, Surveyor spoke to RD-K via telephone. RD-K stated that if R20 had a significant weight loss, RD-K would implement high protein and high calorie added to daily meals. RD-K does not know who notifies a physician of a significant weight loss.On 3/04/2026, at 3:00 PM, Surveyor shared the concern with NHA-A, DON-B, and Clinical Nursing Officer (CNO)-C that R20's physician had not been consulted with regarding R20's significant 16.31% weight loss.On 3/05/2026, at 12:14 PM, Surveyor interviewed Director of Nursing (DON)-B and asked when a physician should be notified. DON-B stated that it would be for weight loss, chance of condition, falls, abnormal labs, etc. DON-B stated there is a form at each nurse's station that states when a nurse should contact a physician either for immediate notification or non-immediate notification.On 3/09/2026, CNO-C sent additional information to review indicating R20 was re-weighed during the survey and R20's weight was 140 pounds. CNO-C stated the facility believes the 2/19/26 weight was wrong. Surveyor shared Surveyor still has a concern that this was not addressed as requested by the registered dietitian (RD)-K and there is no physician notification.

Based on record review and interview, the facility did not ensure employees were screened for abuse prior to working at the facility. This was observed in 4 (M, N, O and P) of 8 staff reviewed.*Certified Nursing Assistant (CNA)-M was hired on 6/27/25 and worked out of state. The other state background check was not completed by their hire date.*Dietary Manager (DM) - N was hired on 1/9/25. Their Background Information Disclosure (BID) was not signed and dated. The Departement of Justice (DOJ) was not completed until 3/2/26. The Integrated Background Information System (IBIS) was not completed until 3/2/26.*CNA-O was hired on 1/19/26 and worked out of state. The other state background check was not completed by their hire date.* CNA-P was hired on 6/17/25. The DOJ was not completed until 7/2/25. The IBIS was not completed until 7/2/25.Findings include:The facility policy and procedure Resident Safe Abuse Policy dated 3/24 was reviewed. Protocol: 3. Procedures:a. ii. All Employees shall have a criminal background check.1. Initial and any required future background checks will be conducted in accordance with applicable state and federal laws checks may include criminal history, state caregiver registry, Office of the Inspector General (O IG), and exclusion lists. The type, frequency, and timing of checks will be in accordance with applicable state and federal law.1.) Surveyor reviewed the criminal background checks for CNA-M. CNA-M was hired on 6/27/25 and works as needed in the facility. CNA-M completed a BID upon hire and disclosed they worked in another state within the last 3 years. The other state background screening was not completed.On 3/03/2026, at 9:30 AM, Surveyor interviewed the Nursing Home Administrator (NHA) -A, who has been completing the employee background screenings. The NHA-A stated they did not run an out of state background check on CNA-M. 2.) Surveyor reviewed the criminal background checks for DM-N. DM-N was hired on 1/9/25 and works full-time in the facility. DM-N completed a BID and did not sign, or date, the document. DM-N DOJ, and IBIS, was completed on 3/2/26 after their hire date.On 3/03/2026, at 9:30 AM, Surveyor interviewed the Nursing Home Administrator (NHA) -A, who has been completing the employee background screenings. The NHA-A stated there have been changes in staff and they identified the screenings were not being completed.3.) Surveyor reviewed the criminal background checks for CNA-O. CNA-O was hired on 1/19/26 and works part-time in the facility. CNA-O disclosed on a BID upon hire they worked in another state within the last 3 years. The out of state background screening was not completed.On 3/03/2026, at 9:30 AM, Surveyor interviewed the Nursing Home Administrator (NHA) -A, who has been completing the employee background screenings. The NHA-A stated they did not run an out of state background check on CNA-O.4.) Surveyor reviewed the criminal background checks for CNA-P. CNA-P was hired on 6/17/25 and works part-time in the facility. CNA-P's DOJ, and IBIS were completed on 7/2/25, after their hire date.On 3/03/2026, at 9:30 AM, Surveyor interviewed the Nursing Home Administrator (NHA) -A, who has been completing the employee background screenings. The NHA-A stated there have been changes in staff and they identified the screenings were not being completed.

Based on observation, interview, and record review, the facility did not ensure the environment remained free of accident hazards with smoking materials for 3 (R1, R2, and R16) of 4 residents reviewed for smoking and residents received adequate supervision to prevent accidents for 1 (R20) of 4 residents reviewed for falls. *R1 was observed to be vaping while lying in bed. R1 did not have smoking assessments completed on a quarterly basis. *R2 was observed to have smoking materials in the room; R2's Care Plan documented R2 may not possess any smoking materials including a lighter and all smoking materials were to be kept with the nurse for distribution as requested. R2 did not have smoking assessments completed on a quarterly basis. *R16 did not have smoking assessments completed on a quarterly basis. *R20 had three falls that were not thoroughly investigated including identifying a root cause analysis. Observations of interventions of call light within reach and to be laid down after lunch were not implemented during the survey. Findings include: The facility policy and procedure titled Smoking, Vaping and Tobacco Free Policy dated 6/2025 documents: Protocol: 1. The facility prohibits smoking, vaping and tobacco use on all company premises in order to provide and maintain a safe and healthy environment for all. a. Company premises is defined as up to the property boundaries* of all facilities. *With the exception of the southeast corner of the courtyard on the east side of the building. Prior to resident smoking, a smoking assessment shall be completed in the electronic charting system. 2. The company defines smoking and tobacco use as the 'act of lighting, smoking or carrying or using a lighted or smoldering cigar, cigarette, pipes of any kind, smokeless or electronic cigarettes/vaping materials, dipping tobacco, or chewing tobacco.' 3. The smoke and tobacco free policy applies to: a. All areas of buildings occupied by residents and employees. b. All vehicles owned or leased by the facility. c. All visitors (customers, vendors and volunteers) on facility premises. d. All contractors and consultants and/or their employees working on facility premises. e. All residents. 5. Employees are not allowed to assist residents in smoking or chewing as they are not allowed to leave the campus property while working. Families that wish to assist residents may do so after signing the resident out of the Resident Sign Out Form and leaving campus property. 6. Residents who violate this smoke and tobacco use policy may be subject to discharge per the facility admission agreement. 1.) R1 was admitted to the facility on [DATE] with diagnoses of idiopathic aseptic necrosis of the left toe, pneumonia, peripheral vascular disease, nicotine dependence, Type 1 diabetes mellitus, bipolar disorder, insomnia, and neuromuscular dysfunction of the bladder requiring an indwelling urinary catheter. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and had impairment to both arms and legs requiring assistance with all activities of daily living. The admission MDS dated [DATE] documented R1 smoked. On 11/6/2025, R1 had an admission smoking assessment completed that documented R1 was able to verbalized understanding of the policy, follows directions well, cooperative, participative, alert and oriented times four, is able to recall the long past, is able to make decisions which are consistent and reasonable, can hold cigarettes safely, lights and extinguishes cigarettes safely, and is physically capable of managing smoking materials. The assessment determined R1 needed assistance by staff to bring R1 in and out of the facility when R1 goes for a cigarette. No other smoking assessments were documented. R1's Alteration in Health Maintenance Care Plan initiated on 11/14/2025 has the following nursing interventions: -Nurses will perform safe smoking assessment. -(R1) will be educated on facility smoking protocols and designated smoking areas. -(R1) is aware there is to be no smoking in rom and no smoking in proximity of oxygen. -The nurse will assist (R1) with obtaining smoking cessation material if requested. (R1's) Alteration in Health Maintenance Care Plan initiated on 11/14/2025 has the following Certified Nursing Assistant (CNA) interventions: -CNA will assess (R1) for safe smoking and following of facility protocol with routine cares. -All staff will observe (R1) is safely smoking with interactions and following facility protocols. -Any suspected or observed noncompliance will be reported immediately to the nurse. -If (R1) expresses desire for cessation, report to the nurse. On 3/2/2026 at 10:04 AM, Surveyor entered R1's room. R1 was lying in bed on an air mattress, covered in multiple thick blankets. Surveyor asked R1 general questions regarding the care R1 had been receiving and any concerns with that care. As Surveyor was talking to R1, R1 took out from below the covers an electronic cigarette and began smoking. Surveyor asked R1 if R1 was vaping. R1 said yes. Surveyor asked R1 if that was allowed in resident rooms. R1 stated no, but if they do not see it, they cannot take it away. In an interview on 3/3/2026 at 12:35 PM, Surveyor asked CNA-L what the facility policy was for smoking or vaping. CNA-L stated residents are supposed to go outside in the smoking area. CNA-L stated most residents are independent, so they go out on their own. Surveyor asked CNA-L what would be done if a resident was smoking or vaping in their room. CNA-L stated CNA-L would tell the nurse and the nurse would relay it to whomever needed to know. In an interview on 3/3/2026 at 12:40 PM, Surveyor asked Registered Nurse (RN)-D what the facility policy was for smoking or vaping. RN-D stated the residents cannot smoke in their room; there is a designated area in the front with ash trays. RN-D stated if they are caught smoking in their room, the cigarettes are taken away and they are put in the nurse's cart. RN-D stated the residents can ask for their cigarettes on their way outside. Surveyor asked RN-D if there had been any problems in the past with R1 smoking or vaping in their room. RN-D stated R1 and R1's husband are in the room together visiting and you can smell smoke, but they have never been caught smoking in the room. RN-D stated the resident has to be caught in the act of smoking, then they can confiscate the smoking materials, but they must be caught actively vaping. Surveyor shared with RN-D the observation of R1 vaping in the bed the previous morning. RN-D stated RN-D cannot act on hearsay to do anything with R1 and R1's smoking materials. In an interview on 3/3/2026 at 12:49 PM, Surveyor asked Social Service Designee (SSD)-H what the facility policy was for smoking or vaping. SSD-H stated residents cannot smoke in their rooms, they have to be able to take care of their smoking on their own, such as lighting, holding, and extinguishing the cigarette. SSD-H stated a smoking assessment is completed when the resident is admitted where the resident is watched while they smoke to make sure they can be independent. SSD-H reiterated residents cannot smoke in their rooms, they have to be deemed a safe smoker through the assessment, and they must not require any assistance from staff in any way while smoking. Surveyor asked SSD-H what would happen if a resident is caught smoking or vaping in their room. SSD-H stated Nursing Home Administrator (NHA)-A says it cannot be hearsay, someone has to actually see them smoking; it cannot just be the smell of cigarettes or a cigarette butt on the floor. SSD-H stated a letter was distributed to all residents and resident representatives about the smoking policy that stated if a resident is caught smoking somewhere other than the designated smoking area, they will be given a 30-day notice. SSD-H stated the resident has to be physically seen, not just gossip. SSD-H stated NHA-A put smoke detectors in some resident rooms to alert them if someone is smoking in the room. Surveyor asked if the policy applied to vaping as well. SSD-H stated yes. SSD-H stated they will remove smoking materials or vaping materials if the resident is observed doing either in their room. Surveyor shared the observation of R1 vaping during a conversation the day before. SSD-H stated SSD-H will report that to NHA-A. Surveyor shared with SSD-H that Surveyor had reported to RN-D the same observation and RN-D's response of not accepting hearsay and needing to actively see R1 vaping. Surveyor shared with SSD-H R1's response when asked about vaping: R1 admitted to vaping and if facility staff do not see R1 vaping, they cannot do anything about it so R1 does not vape in front of any staff but continues to vape in bed with no one observing. SSD-H stated RN-D should have reported R1 vaping in bed and would do so at that time. On 3/4/2026 at 3:00 PM, Surveyor shared with NHA-A and Director of Nursing (DON)-B the concern R1 was actively vaping in bed while Surveyor was in the room talking with R1. Surveyor shared with NHA-A RN-D's response and the conversation with SSD-H. NHA-A stated SSD-H had communicated the concern with NHA-A and NHA-A would address the issue. Surveyor shared with NHA-A and DON-B the concern R1 had not had a quarterly smoking assessment following the initial admission assessment. 2.) R2 was admitted on [DATE] with diagnoses of Schizoaffective Disorder (mental health condition with hallucinations, delusions, and other mood disorders like depression – this affects how people think, act and feel which can greatly hinder day to day activities), Nicotine Dependence – cigarettes, and Left Hemiballismus (severe movement disorder characterized by involuntary, violent, flinging movements of the left arm and leg). R2's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated R2 is cognitively intact. R2 has no limb impairment. R2 is independent for eating, oral hygiene, toileting, bed mobility; R2 requires set up assist for showering, and personal hygiene, transferring; R2 requires supervision for upper body dressing; R2 requires partial assist with lower body dressing, footwear. R2's care plan initiated 3/27/24 documented the following an Alteration in health maintenance, R2 is a long term smoker. Initiated 1/28/26 – nurses will perform safe smoking assessment is educated on facility smoking protocols and designated smoking areas. (R2) may not possess any smoking materials including lighter. All smoking materials are to be kept with the nurse for distribution to (R2) as requested. (R2) is aware no smoking in room and no smoking in proximity of oxygen, nurse to assist (R2) with obtaining smoking cessation material if requested. Initiated 3/27/2024 - nurse aid will assess (R2) for safe smoking and following a facility protocol. Update nurse with suspected noncompliance. R2's Certified Nursing Assistant (CNA) assignment sheet, which indicated to CNA staff how to care for R2, documented (R2) is a smoker, report any safety or health concerns related to smoking to nurse. Resident may not have in his possess any smoking materials such as cigarettes/cigars/lighters. These items must be kept in the nurses station/Med room and (R2) must ask for materials to go outside to smoke and return them to the nurse when returns to floor. No exceptions. Staff to report any smells/ signs of smoking in room to nurse immediately and document on CNA lineup sheets and 24 hour boards. Nurse is to notify administration of any incidents of observing students smoking in the facility or having smoking materials in room. R2's quarterly Smoking assessments documented: 6/6/25 (R2) is able to Verbalize understanding of policy dims equals 13 cooperative participative oriented to time oriented to person oriented to place oriented to situation. Short term memory OK long term memory OK. Able to make decisions which are consistent and reasonable. Hold cigarettes safely yes, lights and extinguishes cigarettes safely yes, physically capable of managing smoking materials yes, residents smoking history our 2 has smoked for many years, expressed desire to quit smoking no, requires assistance to quit no. Independent with all aspects of smoking. 11/3/25 Resident is able to verbalize understanding of policy bims is 13 cooperative participative oriented to time oriented to person oriented to place oriented to situation. Short term memory OK long term memory OK. Able to make decisions which are consistent and reasonable. Physically capable of managing smoking materials 1/23/26 Smoking assessment: extreme cold weather education to resident provided education regarding risks of smoking outdoors and temperatures below freezing. Discussed increased risk of vasoconstriction, elevated blood pressure, and potential for rapid hypothermia/ frostbite due to smoking induced reduced circulation. Patient advised to wear thermal layers, hat, and gloves, and to limit outdoor time to less than 5 minutes. Patient verbalized understanding of risks. Educated patient on safety precautions when leaving to smoke during extreme cold advisory. Advised using a buddy system or notifying staff/ family before going out. Recommended having a warm drink immediately upon returning. Residents stated he will follow all suggestions and if possible he will limit his smoking for today due to extreme cold weather. A progress note written by Director of Nursing (DON)-B dated 1/28/26 at 1:05 PM documented: Nurses will perform safe smoking assessment, resident is educated on facility smoking protocols and designated smoking areas. Resident may not possess any smoking materials including lighter. All smoking materials are to be kept with the Nurse for distribution to resident as requested. Resident is aware no smoking in room and no smoking in proximity of oxygen, nurse to assist resident with obtaining smoking cessation material if requested. On 3/2/26, at 9:36 AM, Surveyor interviewed R2 who informed surveyor that R2 was smoking in R2's room and was caught by the facility. R2 stated R2 has to give the nurse R2's smoking materials. R2 stated R2 cannot have smoking materials in R2's room. Surveyor observed a lighter in R2's pocket and multiple cigarettes of various lengths in R2's pocket. Surveyor observed multiple cigarettes of various lengths on R2's windowsill by R2's bed. On 3/2/26, at 3:17 PM, Surveyor interviewed DON-B. DON-B stated all residents are considered independent, some we will collect smoking materials. There are no supervised smokers as the facility cannot force staff to be near cigarette smoke. DON-B stated assessments are done quarterly or if there is a change in smoking status. On 3/3/26, at 9:20 AM, Surveyor interviewed Registered Nurse (RN)-N. RN-N stated R2 is on the list of residents who cannot have smoking materials. RN-N stated RN-N only takes R2's lighter and does not take R2's cigarettes. RN-N stated RN-N should probably take R2's cigarettes as well, but R2 can't smoke without R2's lighter. On 3/3/26, at 11:54 AM, Surveyor observed R2's room. There was 1 cigarette on R2's windowsill and a green lighter in R2's bed. On 3/3/26, at 3:13 PM, Surveyor interviewed DON-B. DON-B stated nurses are to complete the smoking assessments quarterly. DON-B stated the assessments can be completed anytime within the quarter, as long as the assessment is completed. On 3/4/26, at 3:13 PM, Surveyor observed a cigarette on R2's windowsill in R2's room. On 3/4/26, at 3:49 PM, Surveyor informed DON-B that R2 has 3 missing quarterly assessments. January 2025 through March 2025, July 2025 through September 2025, January 2026 through March 2026. Surveyor informed DON-B R2 was observed to have smoking materials in R2's room and possession while not smoking or going to smoke. On 3/5/26, at 7:47 AM, DON-B informed Surveyor all smoking materials are to be collected for R2. This includes cigarettes, vapes, lighters, cigars, chewing Tobacco, and more. The Facility did not have any additional information regarding R2's smoking assessments. 3) R16 was admitted to the facility on [DATE]. R16's Quarterly Minimum Data Set (MDS) completed 1/22/26 documents R16's Brief Interview for Mental Status (BIMS) score to be 11, indicating R16 demonstrates moderately impaired skills for daily decision making. R16's comprehensive care plan for alteration in health maintenance effective 4/7/25 indicates: , R16 is a long term smoker. Interventions effective 4/7/25 include: -nurses will perform safe smoking assessment, resident will be educated on facility smoking protocols and designated smoking areas. Resident is aware there is to be no smoking in room and no smoking in proximity of oxygen, nurse will assist resident with obtaining smoking cessation material if requested. CNA (Certified Nursing Assistant) will assist resident for safe smoking and following of facility protocol with routine cares, all staff will observe resident is safely smoking with interactions and following of facility protocols. Any suspected or observed noncompliance will be reported immediately to nurse. If resident expresses desire for cessation-report to nurse On 1/23/26, there is a note in R16's record indicating Director of Nursing (DON)-B documented that they provided education to R16 regarding risks of smoking outdoors in temperatures below freezing. Review of R16's smoking assessments indicate the most recently completed assessment is dated 4/7/25. This assessment indicates R16 is independent with smoking. No other assessments were noted in R16's medical record. On 3/02/2026, at 3:09 PM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were interviewed about the facility's smoking policy. NHA-A explained there is no supervised smoking. The policy is that residents will manage smoking materials independently in the smoking area. NHA-A stated the expectation is that smoking assessments are completed quarterly and updated as needed. NHA-A explained if a resident cannot handle their smoking materials, it is handled case by case. NHA-A stated, we can't provide assistance due to the clean air act. Surveyor asked what other options for smoking the facility provides. NHA-A stated the facility would provide gum or the patch. On 3/03/2026, at 3:04 PM, Surveyor interviewed DON-B about R16's smoking assessments and that one has not been completed since 4/7/25 despite R16 still smoking. DON-B shared that either themselves or the Minimum Data Set nurse (MDS)-G completes the smoking assessments, and the expectation is that the smoking assessments are to be completed on a quarterly basis. On 3/04/202, at 3:00 PM, Surveyor shared the concern with NHA-A, DON-B, and Clinical Nursing Officer (CNO)-C that R16's smoking assessment had not been completed on a quarterly basis. On 3/05/2026, at 8:00 AM, Surveyor was provided a completed smoking assessment dated [DATE] documenting R16 is independent with all aspects of smoking. 4) R20 was admitted to the facility on [DATE] with diagnoses of Alzheimer's (progressive disease that destroys memory and other important mental functions), Vascular Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) with Behavioral Disturbance R20's Significant Change Minimum Data Set (MDS) with an assessment reference date of 12/3/25 documents for assessment R20 has both short- and long-term memory impairments and demonstrates severely impaired skills for daily decision making. R20's MDS documents R20 has no range of motion impairment and is always incontinent of bowel and bladder. R20 is dependent on toileting hygiene, showers, upper and lower dressing and requires substantial/maximum assistance for mobility and transfers. R20's MDS also documents that R20 has had falls since the last assessment. The following completed fall assessments document: 6/2/25-continue current care plan for risk of falls 9/8/25-is at risk for falls due to unstable gait, continue current plan of care 11/25/25-is at risk for falls and prefers to nap and will be transferred to bed after lunch for a rest period 12/3/25- is at risk for falls and will revise fall care plan 2/12/26- is at risk for falls and staff to follow care plan transfer to bed following lunch for a rest period R20's comprehensive care plan documents: Potential for Trauma-falls injury manifested by history of falls 10/18/22 Interventions in place: -Nurses-observe, record, and report all unsafe conditions and situations, assess change in level of consciousness, encourage to ask for assistance, assure resident is wearing proper fitting shoes 7/30/24 -CNA (Certified Nursing Assistant) -ensure footwear properly fitting or wearing gripper socks 9/9/23 -CNA-call light in reach, encourage to ask for assistance, monitor whereabouts, report wandering behavior to nurse on unit, monitor for presence of wanderguard every shift, report to nurse if not present, update nurse if shoes are not fitting 7/30/24 -CNA-resident can be assisted to room after lunch meal for rest period in bed 11/25/25 R20's CNA Assignment Sheet documents there should be a pool noodle on the headboard of the bed. Assist resident to bed after lunch for afternoon nap. Ensure that resident's head is away from footboard/headboard to prevent accidental bump. R20 Resident assist of 1 at times, assist of 2 if resident is weak. R20 has had 4 falls since 11/25/25: Review of R20's record indicates on 11/25/2025, R20 had an unwitnessed fall sometime during NOC (night) shift. R20 was found about 7:30 AM on the ground. R20 sustained 0.1 x 3.5 x 0.1 laceration at right eyebrow. Documentation indicates: intervention applied immediately is to have R20 in day room during the day, to watch for behaviors, and decrease risk of R20 hitting head on headboard. Surveyor requested the full fall investigation for this fall which was not provided by the facility during the survey On 11/25/2025, at 2:30 PM, R20 had a 2nd fall. This fall was a witnessed fall in the living room. The documented intervention applied immediately was for R20 to be taken to room and made comfortable in bed for afternoon rest period. The facility's 11/25/25 fall investigation documents that Certified Nursing Assistant (CNA)-P was in the living room with R20 but did not see R20 fall. CNA-W and Nurse Manager (NM)-E stated that they observed R20 stand from couch, lean forward, and reach for the second couch when R20 fell. The intervention post fall is to assist R20 to bed after lunch. On 1/04/2026, at 7:10 PM, R20 had an unwitnessed fall and was found on the ground in R20's room. The documented intervention applied immediately post fall is gripper socks/appropriate footwear. The facility's fall investigation dated 1/4/26 does not document a root/cause analysis. The fall investigation has no documented staff statements. The fall investigation documents R20's care plan will not be updated. Post fall despite recommended immediate interventions suggested for R20 to wear gripper socks/appropriate footwear. On 2/12/2026, at 2:00 PM, R20 had an unwitnessed fall and was found on the ground in the television room. The documented intervention applied immediately post fall was to assist R20 to bed for rest period after lunchSurveyor noted that after the 11/25/25 fall, the intervention for safety was for R20 to be assisted to bed after lunch for a rest period. R20 fell again in the living room area at 2:00 PM at which time R20 should have been in bed resting according to their recommended post fall interventions documentation. The facility's fall investigation dated 2/12/26 does not document a root/cause analysis. The fall investigation has no documented staff statements. On 3/02/2026, at 11:44 AM, Surveyor observed R20 in bed sleeping and noted a pool noodle on the top of R20's headboard. Surveyor observed R20's call light on the floor, not within reach. On 3/02/2026, at 1:43 PM, Surveyor observed R20 sitting in a high back chair in the left hand corner of R20's room. R20 had an overbed table in front of them. R20's call light was on the floor, not within reach. On 3/03/2026, at 7:07 AM, Surveyor observed R20 in bed sleeping, and the call light was observed to be on the floor. On 3/03/2026, at 9:29 AM, Surveyor observed R20 sitting in a high back chair with the overbed table in front of R20. Surveyor observed the call light was on the floor, not within reach of R20. On 3/03/2026, at 12:59 PM, Surveyor observed R20 sitting in a high back chair in same spot as earlier with the overbed table in front of them. Surveyor observed the call light was on the floor not within reach. On 3/03/2026, at 1:01 PM, Surveyor interviewed CNA-I. CNA-I informed Surveyor that R20 can use the call light and has used it in the past. CNA-I stated that R20 used the call light a lot in the past. On 3/03/2026, at 3:31 PM, Surveyor observed R20 in bed sleeping. R20's call light was observed to be on the floor. On 3/04/2026, at 7:15 AM, Surveyor observed R20 in bed sleeping. R20's call light was observed to be on the floor. On 3/04/2026, at 12:46 PM, Surveyor observed R20 sitting on the edge of the bed with the overbed table in front of R20. Surveyor observed the call light on the floor, not within reach. Surveyor then observed R20 lay down on the bed from a sitting position. R20's call light remained on the floor out of R20's reach. On 3/03/2026, at 3:04 PM, Surveyor interviewed Director of Nursing (DON)-B about the facility fall assessments. DON-B stated that it is the responsibility of the staff nurse to complete the facility fall investigations along with the incident report. There is a checklist that they are to use to review the elements of care plan changes, including making changes to interventions. The falls are reviewed by the IDT (interdisciplinary team). DON-B stated that the CNA assignment sheet should also be updated with changes in fall interventions.

Based on record review and interviews, the facility did not ensure allegations of misappropriation of funds and neglect for two (R19 and R10) of 2 sampled residents were not reported as required. *R19 informed staff of missing money on 1/21/26 and this allegation was not reported to the State Survey Agency. *An allegation of neglect directly affecting R10 was not reported to the State Survey Agency. Findings include: The facility's Resident Safety Abuse Policy last revised 2/22 documents: Purpose: It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental, or sexual), neglect, corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms, exploitation and misappropriation of resident property. Providing a safe environment is one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents, makes ethical and professional behavior essential. Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors, friends, or other individuals. This system cannot guarantee that abuse will never occur. It can only assure that the facility is doing all that is within its control to prevent occurrences. 8. Reporting Suspected Violations: a. The supervisor on duty shall IMMEDIATELY safeguard the resident(s) and immediately report all alleged violations involving abuse, neglect, mistreatment, exploitation, including injuries of unknown source and misappropriation of resident property to the facility administrator. The administrator will notify the director of nursing and/or others as appropriate. b. The administrator will report a reasonable suspicion of a crime against any individual who is a resident of, or is receiving care from the facility to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located. c. The administrator shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. f. The administrator shall also report the results of all investigations to other officials in accordance with state law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 1.) R19 was admitted to the facility on [DATE]. R19's Quarterly Minimum Data Set (MDS) completed 2/10/26 documents R19's Brief Interview for Mental Status (BIMS) score to be 5 indicating R19 demonstrates severely impaired skills for daily decision making. On 3/02/2026, at 9:28 AM, R19 informed Surveyor that R19 does not know what is happening with R19's money. On 3/03/2026, at 9:22 AM, R19 greeted Surveyor by name as Surveyor approached R19. R19 was able to provide the current day, month and year to surveyor. R19 informed Surveyor that R19 recalls withdrawing $110 and reported approximately $60 missing to a staff member downstairs. R19 shared it was about 7 days after they took the money out. R19 called her Red because she had red hair, white, bigger girl, still works here and would go to the store for me. Not sure if it was her. R19 reported being left $13. R19 reported it but does not know if the facility did an investigation. On 3/03/2026, at 12:25 PM, Surveyor interviewed R19's Guardian via telephone. (Guardian)-U informed Surveyor that Guardian-U is unaware of R19 having any missing money. On 3/03/2026, at 1:41 PM, Surveyor was provided with a withdrawal slip dated 1/17/26 documenting R19 signed for $110 received. On 3/04/2026, at 10:20 AM, Surveyor interviewed Social Services Designee (SSD)-H. SSD-H had no knowledge of R19 alleging money was taken. On 3/04/2026, at 10:44 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and asked about R19's allegation of funds being taken. NHA-A confirmed NHA-A was aware of that R19 alleged they were missing money. NHA-A informed Surveyor that NHA-A did not report R19's allegation of missing money because R19 is confused and uncertain as to exactly how much was actually missing. NHA-A shared R19 has a history of false accusations, and it is care planned. NHA-A also stated, Doesn't it matter that the guardian doesn't think anything happened? Surveyor shared it is a concern that there was an allegation of misappropriation of funds, and a facility reported incident (FRI) was not submitted. 2.) R10 was readmitted to the facility on [DATE]. R10's Quarterly MDS, dated [DATE], indicates R10 has a Brief Interview for Mental Status (BIMS) score of 14 with intact cognition, no behaviors or rejection of care, requires supervision or touching assistance to sit to stand, supervision or touching assistance with transfers, able to walk 10 feet with supervision or touching assistance, takes high risk medications and had 2 or more falls since admission/reentry. The Facility provided document, titled Grievance Investigation, dated 11/25/2025 indicates the following: Summary Statement: Adult Protective Services (APS) received an anonymous complaint regarding (R10) having a fall on 10/26/2025 and staff refused to send (R10) to the hospital. The complaint also indicates (R10) had a fall on 11/1/2025 and staff did not come to assist (R10) after putting on the call light. Name and title of person(s) interviewed: APS attempted to interview R10 but was unable to answer questions. APS discussed competency evaluation and guardianship referral. Steps taken to investigate grievance: APS visited R10 again on 12/3/2025, no new concerns expressed. Summary of Investigation findings and conclusion: -file/incident review- no incident on 11/1/2025 -10/26/2025- observed on floor, daughter was called and was not at the Facility -readmit 10/16 post psych inpatient stay -10/31 hip pain while in therapy, spoke with daughter, no verbal complaints. On 11/1/2025 R10 went to target with daughter, daughter took R10 to hospital for evaluation then R10 returned to the Facility via ambulance. Per daughter, R10 was placed in car funny and complained of left hip pain. Was grievance confirmed or not confirmed? Not confirmed Signed by Nursing Home Administrator (NHA)-A on 12/3/2025. On 03/05/2026, at 12:05 PM, Surveyor interviewed NHA-A. NHA-A indicated APS reached out to him regarding a complaint involving R10 falling on 10/26/2025 and allegations staff refused to send R10 to the hospital. After APS reached out, NHA-A began to look at the fall history for R10 and piece things together. NHA-A indicated the allegation was staff refused to send R10 to the hospital, but NHA-A did not see that occurred during the investigation. NHA-A indicated he did not interview staff but did a record review and could see in the record that R10 did not go out to the hospital and what NHA-A found is that the incident on 11/1/2025 occurred while R10 was with R10's daughter from a nurse's note. NHA-A does not believe this allegation should have been sent to the State Agency because the allegation could not be verified and questioned the validity of the allegation.

Based on record review and interviews, the facility did not ensure allegations involving potential misappropriation of funds and neglect were thoroughly investigated for 2 Residents (R19 and R10) of 2 sampled Residents. *R19 informed staff of missing money on 1/21/26 and this allegation was not thoroughly investigated by the facility. *An allegation of neglect directly affecting R10 was not thoroughly investigated by the facility. Findings include: The facility's Resident Safety Abuse Policy last revised 2/22 documents: Purpose It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, physical, mental, or sexual), neglect, corporal punishment, involuntary seclusion, physical or chemical restraints not required to treat the resident's medical symptoms, exploitation and misappropriation of resident property. Providing a safe environment is one of the most basic and essential duties of the facility. Employees have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents, makes ethical and professional behavior essential. Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents have the right to be free from abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors, friends, or other individuals. This system cannot guarantee that abuse will never occur. It can only assure that the facility is doing all that is within its control to prevent occurrences . 9. Procedure For Investigation: a. All alleged violations will be thoroughly investigated, and all investigations are conducted by or coordinated through facility administration. d. The supervisor will ensure that resident(s) is/are protected from further potential abuse, neglect, mistreatment while the investigation is in progress. e. An incident report and investigation must be completed for any violations of this policy using the facility incident report in ECS or narrative statements. i. All witnesses or involved parties will be interviewed giving their own description of the incident and will be recorded by QAPI Leader and/or supervisor on duty. These records will become part of the permanent investigation file. -The QAPI Leader and/or supervisor on duty will interview the residents as well as any nursing, housekeeping, laundry, dietary, activity, or social service staff, any visitors or other who may have knowledge of the occurrence or who may have been in the vicinity at the time the incident happened. l. The Administrator will be the custodian of all documents generated during the course of the investigation. m. The facility must have evidence that all alleged violations are thoroughly investigated. n. These documents will be identified as QAPI documents and will be reviewed by the QAPI Committee for re-evaluation of the policies and procedures and for revision of the same policies and procedures if warranted to prevent further occurrences. 1.) R19 was admitted to the facility on [DATE]. R19's Quarterly Minimum Data Set (MDS) completed 2/10/26 documents R19's Brief Interview for Mental Status (BIMS) score to be 5 indicating R19 demonstrates severely impaired skills for daily decision making. On 3/02/2026, at 9:28 AM, R19 informed Surveyor that R19 does not know what is happening with R19's money. On 3/03/2026, at 9:22 AM, R19 greeted Surveyor by name as Surveyor approached R19. R19 was able to provide the current day, month and year to surveyor. R19 informed Surveyor that R19 recalls withdrawing $110 and reported approximately $60 missing to a staff member downstairs. R19 shared it was about 7 days after they took the money out. R19 referred to the person they gave the money to as Red because she had red hair, white, bigger girl, still works here and would go to the store for me. Not sure if it was her. R19 reported being left $13. R19 reported it but does not know if the facility did an investigation. On 3/03/2026, at 12:25 PM, Surveyor interviewed R19's Guardian via telephone. (Guardian)-U informed Surveyor that Guardian-U was unaware of any missing money from R19. On 3/03/2026, at 1:41 PM, Surveyor was provided with a withdrawal slip by the facility dated 1/17/26 documenting R19 signed for $110 received. On 3/04/2026, at 10:44 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A confirmed NHA-A was aware that R19 had communicated an allegation of missing money. NHA-A informed Surveyor that NHA-A did not report or investigate R19's allegation of missing money because R19 is confused and R19 was uncertain as to exactly how much was actually missing. NHA-A shared R19 has a history of false accusations, stating it is care planned. Surveyor reviewed documentation provided by NHA-A indicating R19 did submit an allegation of missing money on 1/21/26 and Social Services Designee (SSD)-H submitted the Missing Item Notification Form. Surveyor noted there is 1 staff statement and another statement from R19's guardian. There are no other staff statements and no statements obtained from other Residents. 2.) R10 was readmitted to the facility on [DATE]. R10's Quarterly MDS, dated [DATE], indicates R10 has a Brief Interview for Mental Status (BIMS) score of 14 with intact cognition, no behaviors or rejection of care, requires supervision or touching assistance to sit to stand, supervision or touching assistance with transfers, able to walk 10 feet with supervision or touching assistance, takes high risk medications and had 2 or more falls since admission/reentry. The Facility provided document, titled Grievance Investigation, dated 11/25/2025 indicates the following: Summary Statement: Adult Protective Services (APS) received an anonymous complaint regarding R10 having a fall on 10/26/2025 and staff refused to send R10 to the hospital. The complaint also indicates R10 had a fall on 11/1/2025 and staff did not come to assist R10 after putting on the call light. Name and title of person(s) interviewed: APS attempted to interview R10 but was unable to answer questions. APS discussed competency evaluation and guardianship referral. Steps taken to investigate grievance: APS visited R10 again on 12/3/2025, no new concerns expressed. Summary of Investigation findings and conclusion: -file/incident review- no incident on 11/1/2025 -10/26/2025- observed on floor, daughter was called and was not at the Facility -readmit 10/16 post psych inpatient stay -10/31 hip pain while in therapy, spoke with daughter, no verbal complaints. On 11/1/2025 R10 went to target with daughter, daughter took R10 to hospital for evaluation then R10 returned to the Facility via ambulance. Per daughter, R10 was placed in car funny and complained of left hip pain. Was grievance confirmed or not confirmed? Not confirmed Signed by NHA-A on 12/3/2025. On 03/05/2026, at 12:05 PM, Surveyor interviewed NHA-A. NHA-A indicated APS reached out to him regarding a complaint involving R10 falling on 10/26/2025 and allegations staff refused to send R10 to the hospital. After APS reached out, NHA-A began to look at the fall history for R10 and piece things together. NHA-A indicated the allegation was staff refused to send R10 to the hospital, but NHA-A did not see that occurred during the investigation. NHA-A indicated he did not interview staff or other residents but did a record review and could see in the record that R10 did not go out to the hospital and found that the incident on 11/1/2025 occurred while R10 was with R10's daughter from a nurse's note. NHA-A was not able to show details to indicate staff and other residents were interviewed regarding the allegations of neglect.

Based on record review and interview, the facility did not document a summary of information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS) for 2 (R3, and R1) of 5 sampled residents. * R3's admission MDS, completed 7/7/25, Pressure injury Care Area Assessment (CAA) does not contain a comprehensive summary of triggered areas. *R1 had 10 Care Area Assessments (CAAs) triggered to be completed for the admission Minimum Data Set (MDS) assessment dated [DATE]. Documentation of summary information of the ten CAAs was not completed. Findings include: The facility's policy and procedure Resident Assessment Instrument and Person -Centered Care Planning, dated 4/25, was reviewed. The Purpose documents:The RAI (Resident Assessment Instrument) is an OBRA (Omnibus Budget Reconciliation Act of 1987) required process for conducting initial and periodic standardized, reproducible assessments of the functional capacity of all nursing home residents. It consists of the MDS (Minimum Data Set), CAA (Care Area Assessment) process and Utilization Guidelines. It is to be completed by the IDT (Interdisciplinary Team) per RAI guidelines to identify the strengths, goals, life history and preferences of the resident to develop a person-centered care plan, to provide the appropriate care and services for each resident and to modify the care plan and care services based on the resident's status.The Protocol:2. Completion of the CAAs.a. The Care Area Assessments systematically interpret the information recorded on the MDS and trigger areas of concern (CAT).b. Using evidence based clinical resources (in [ECS-name of electronic medical record system]) each IDT assessor will assess potential problems in their completed sections that trigger the CAA and determine whether to proceed to the care plan.c. The CAA summary (section V of the MDS) provides the location of areas that have triggered and decision as to whether to proceed to care plan. 1.) R3 was admitted to the facility on [DATE]. R3 is non-verbal and dependent on staff for all Activities of Daily Living (ADL). The admission MDS was completed on 7/7/25 and the Pressure Injury CAA (care area assessment) was triggered. The CAA documents, through checked boxes R3 is at risk for pressure injury, is totally dependent on staff, non-verbal, and has a stage 1 pressure injury. The CAA Summary documents: R3 triggered CAA due to requiring full cares related to pressure ulcer present on admission. The CAA Summary does not document the analysis of the information or the rationale on whether to proceed with care planning and why the decision was made for R3. On 3/04/2026, at 1:34 PM, Surveyor interviewed MDS Nurse-G. The MDS Nurse -G stated they were trained in completing CAAs by the previous MDS Nurse. MDS Nurse-G has not had any training on specifically completing the MDS CAA. MDS Nurse-G shared they do not conduct any additional assessments/analysis for the triggered CAA separate from the MDS assessment. On 3/4/26, at 3:00 PM. At the facility exit meeting with Nursing Home Administrator (NHA) -A and Director of Nurses (DON) -B, Surveyor shared the concerns regarding R3's CAA Summary. 2.) R1 was admitted to the facility on [DATE] with diagnoses of idiopathic aseptic necrosis of the left toe, pneumonia, peripheral vascular disease, nicotine dependence, Type 1 diabetes mellitus, bipolar disorder, insomnia, and neuromuscular dysfunction of the bladder requiring an indwelling urinary catheter. R1's admission Minimum Data Set (MDS) assessment dated [DATE] triggered Care Area Assessments (CAAs) for Activities of Daily Living, Urinary Incontinence and Indwelling Catheter, Falls, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, Pressure Ulcer, Psychotropic Drug Use, Pain, and Return to Community Referral. No documentation of summary information, including the rationale to proceed to care planning or not for each CAA triggered area was found. In an interview on 3/4/2026 at 1:34 PM, Surveyor asked MDS/Wound Nurse-G about the CAAs for residents. MDS/Wound Nurse-G stated MDS/Wound Nurse-G was trained by the staff to complete the MDS assessments but had not been trained on writing CAAs. MDS/Wound Nurse-G stated the information that was clicked on the triggered area is put in the care plan; no additional assessments were done to complete the CAAs and assist with determining the plan of care. On 3/4/2026 at 3:00 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R1 did not have any CAAs completed with the admission MDS assessment.

Based on interview and record review, the facility did not ensure they notified the state mental health authority promptly for a resident review after a significant change in mental condition for 1 (R10) of 1 resident reviewed for PASARR. *R10 demonstrated increased mood related symptoms which required an extensive inpatient psychiatric stay. Following the hospitalization R10 was prescribed psychotropic medication to treat symptoms. R10 was readmitted to the facility and a new PASARR (Preadmission Screening and Resident Review) was not completed and submitted to the state authority to ensure R10 received care and services in the most appropriate setting. Findings include:R10 was admitted to the facility on [DATE] and has diagnoses that include general anxiety disorder, bipolar disorder, and current episode of depression, severe, with psychotic features. R10's Quarterly Minimum Data Set (MDS), dated [DATE], indicates R10 has a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition, no behaviors concerns, receives antipsychotic medication, antianxiety medication, and antidepressant medication. R10 was readmitted to the Facility in June 2025, after a psychiatric hospitalization related high anxiety, panic attacks, decreased appetite, and significant depression with suicidal ideation. R10's hospitalization included medication adjustments with orders for Invega 117 mg (milligrams) (antipsychotic medication) injection monthly, Depakote DR 250 mg (anticonvulsant and mood -stabilizing medication) three times a day, and trazadone 50 mg (antidepressant medication) at bedtime. R10's medical record documents, Psychiatric Follow up, dated 7/17/2025, documents R10 reports depression is not good and getting worse every day. R10 was previously at a psychiatric facility for manic symptoms of bipolar and had during hospitalization, R10's lithium, buspirone, and hydroxyzine were discontinued. Depakote 250 milligrams (mg) was increased to 3 times per day and Trazodone 50 mg at bedtime was added. R10's Invega 117mg monthly injection did not change. R10's medical record documents, Psychiatric Follow up, dated 9/18/2025, documents R10 having lots of depression, expressing wanting to give up, feels suicidal and indicated wanting to save medications to overdose. Plan reviewed with staff and staff have been watching R10 take R10's medications to ensure swallowing. R10's Psychiatric evaluation dated 2/27/26, documents a Risk Assessment: [R10] Reports chronic episodes of suicidal thoughts. States she does not have a plan or access to means. Denies homicidal ideation. Plan and Assessment: Bipolar disorder, current episode depressed, severe, with psychotic features. Status: Inadequately Controlled. Chronicity Level: Chronic. Patient presents with severe depressive episode with psychotic features, reporting delusional thoughts and visual and auditory hallucinations. Reports chronic episodes of suicidal thought; currently denies active plan or access to means. Continue close safety monitoring at facility given history of suicidal ideation and current severe depressive symptoms. On 03/05/2026, at 2:02 PM, Surveyor interviewed Social Services Designee (SSD)-H, who indicates PASSAR's are done on admission and is the only time SSD-H completes them. SSD-H indicated SSD-H only completed 1 PASSAR for R10, which was done on R10's initial admission but will look if one was done after readmission and medication changes. On 03/05/2026, at 3:25 PM, Nursing Home Administrator (NHA)-A was informed of the concern the facility did not notify the state mental health authority promptly after R10 experienced a significant change in mental condition and psychotropic medications were prescribed.

Based on observation, interview, and record review, the facility did not ensure 1 (R20) of 1 resident reviewed for diminishing abilities in activities of daily living, received the appropriate treatment to maintain or improve the ability to carry out activities of daily living.Findings include: The facility did not provide a policy and procedure for maintaining or improving activities of daily living (ADL(S)). R20 was admitted to the facility on [DATE] with diagnoses of Alzheimer's(progressive disease that destroys memory and other important mental functions), Vascular Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) with Behavioral Disturbance, Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Hypothyroidism(underactive thyroid), Hyperlipidemia(high levels of fat particles in blood), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), and Hypertensive Heart Disease(long term conditions developed from chronic high blood pressure). R20 currently has an activated Health Care Power of Attorney (HCPOA).R20's Quarterly Minimum Data Set (MDS) completed 9/25/25/25 documents R20 has both and short and long term memory impairments and demonstrates severely impaired skills for daily decision making. R20 has not range of motion impairment. R20 requires set-up for eating. R20 requires substantial/maximum assistance for toileting hygiene, showers, and lower dressing. R20 requires partial/moderate assistance for upper dressing. R20 is independent for mobility and transfers and is always incontinent of bowel and bladder. There is no documented weight loss for R20 and R20 has a regular diet. R20 is documented as walking 150 feet with assistance. R20's Significant Change Minimum Data Set (MDS) with an assessment reference date of 12/3/25 assesses R20 has both short- and long-term memory impairments and demonstrates severely impaired skills for daily decision making. R20's MDS documents R20 has no range of motion impairment, requires set-up for eating, and is always incontinent of bowel and bladder. R20 is dependent on toileting hygiene, showers, upper and lower dressing and requires substantial/maximum assistance for mobility and transfers. R20's MDS documents R20 holds food in mouth, no current weight loss, and is on a mechanically altered diet. R20's MDS also documents that R20 has had falls since the last assessment. Walking R20 was not attempted due to medical condition.Surveyor notes that documentation and comparison of R20's MDS from September to December states that R20 had a significant decline in ADL status. In September, R20 was independent in mobility and transfers and required partial/maximum assistance for other ADLS. R20 was not pocketing R20's food when eating and R20 was able to walk 150 feet with assistance. In December, R20 required substantial/maximum assistance for mobility and transfers, was pocketing food when eating and changed to a pureed diet and walking R20 with assistance was not attempted. R20's Annual Nutrition Care Area Assessment (CAA) dated 12/9/25, is blank with no documentation. R20's Annual CAAs dated 12/9/25 for Falls, Activities of Daily Living (ADL), Cognitive and do not document a comprehensive summary of triggered symptoms and interventions to be put in place.Surveyor reviewed R20's comprehensive care plan which documents:On 1/23/23, R20 has a self-care deficit manifested by incomplete ADL's, ADL functional deficit, increased need for ADL assistance effective 12/9/25. The only interventions updated on 12/9/25 was to assess functional level, administer medications, observe for side effects and effectiveness, note changes in functional level, reorient as able, calm, gentle approach, offer simple instructions to encourage to participate, explain procedures, speak clearly. Surveyor notes that R20's comprehensive care plan do not document person-centered interventions to address R20's increased need for ADL assistance. On 2/27/26, Physician (MD)-X documents R20 had a decrease in mobility and has had multiple falls. On 10/16/2025, at 3:00 PM, documentation states that Psych Nurse Practitioner (Psych NP)-Y increased R20's Depakote 125 mg from 2 times a day to 3 times a day. On 11/25/2025, at 12:33 PM, documentation states that R20's diet changed from regular to pureed due to R20 pocketing food and holding food in mouth, delayed swallowing.On 12/03/2025, at 2:54 PM, documentation states that staff have reported to writer that R20 has required more assistance with ADLs. R20 is chair fast now, dressing, transfer and bed mobility ability has decreased, and R20 tires easily. Surveyor observed R20 throughout the survey process. R20 was either laying in bed or sitting in a high back chair with an overbed table in front of R20. R20 was not observed ambulating at all during the survey process. Surveyor only observed R20 eating independently. Surveyor did not observe R20 leave R20's room. On 3/03/2026, at 9:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who has been employed at the facility for 27 years. CNA-I informed Surveyor that CNA-I knows R20 really well. CNA-I states that R20 has had a need for increased assistance. CNA-I states R20 is incontinent of bowel and bladder and has always been as long as CNA-I has known R20. On 3/03/2026, at 9:38 AM, Surveyor interviewed Registered Nurse (RN)-D. RN-D informed Surveyor that R20's ADL assistance decreased around the time R20's medications were being played with due to R20's behavior of playing with feces. RN-D then starting falling, and R20's medications were reduced back down. RN-D acknowledged that R20's ADL status has changed significantly but believes R20's dementia has progressed. On 3/04/2026, at 8:35 AM, Surveyor was informed by the facility that there are no therapy notes or referrals for R20. On 3/04/2026, at 10:21 AM, Surveyor interviewed Social Worker Designee (SSD)-H. SSD-H informed Surveyor that R20 is not doing much. SSD-H states that R20 definitely has had a change. SSD-H used to take her outside almost daily and walk around the facility with R20. SSD-H states SSD-H is a CNA and will help R20 with ADLs. SSD-H states SSD-H was helping CNA-I the other day with R20's ADLs and it was difficult for R20 to stand. SSD-H informed Surveyor that SSD-H asked CNA-I if this was normal and CNA-I informed SSD-H that it was normal and R20 does not do much. On 3/04/2026, at 12:59 PM, Surveyor interviewed Nurse Manager (NM)-E. NM-E confirmed that R20 is weaker. NM-E thinks R20's change is medication provoked due to medication changes. NM-E states that R20 couldn't stay calm unless R20 was in bed. NM-E states that a therapy referral was not discussed or attempted. On 3/04/2026, at 1:10 PM, Director of Nursing (DON)-B informed Surveyor, we probably discussed therapy but therapy was never attempted. DON-B does not believe R20 would be able to follow directions for therapy. On 3/04/2026, at 3:00 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, DON-B, and Clinical Nursing Officer (CNO)-C that R20 has had a significant decrease in ADL abilities and the facility has not implemented interventions to improve R20's ADL abilities. Surveyor shared the concern that once R20's diminished ADL abilities was identified by staff, a therapy evaluation was not initiated in order to attempt to improve R20's ADL abilities. The facility has not provided at this time additional information as to why the facility has not implemented interventions in an attempt to restore and/or improve R20's ADL abilities.The facility provided a Rehabilitation Referral dated 2/25/26 that documents: staff reports R20 was ambulatory previously, caregiver staff reports decline in functional mobility with increased assistance required for bed mobility and transfers. The facility also provided a Therapy Payer Verification/Communication Form dated 3/3/26(one day after survey started) listing R20 has Medicare B and Medicaid.

Based on interview and record review, the facility did not ensure resident (R20) maintained acceptable parameters of nutritional status for 1 (R20) of 1 sampled residents with weight loss.R20's medical record indicated a deviation in R20's weight that reflected the potential for a severe weight loss. The facility did not reweigh R20 or requested assessment by the registered dietitian with the documented weight changes. The facility did not ensure R20's intake was monitored as care planned. Findings include:The facility's Weight Management policy and procedure last reviewed 9/25 documents:Purpose:An accurate body weight obtained at individually assessed intervals is one of the most reliable, inexpensive and non-invasive ways to identify when a resident is not obtaining adequate nutrition and/or hydration.6. Resident's weight information is reported by Certified Nursing Assistant (CNA) to licensed nurse then recorded in the medical record by the licensed nurse in the electronic medical record.7. The licensed nurse will determine if an additional (third) reweight is required and accompany the CNA to monitor the process.8. The licensed nurse notifies the Dietary Director/Registered Dietitian (RD) of residents with a significant/severe weight change.10. The Dietary Director/RD assesses each resident with a significant or severe weight change as soon as practicable, makes appropriate recommendations to physicians and updates the residents' plan of care.The facility's Persons at Risk Program (PAR) last revised 2/22 documents:Purpose:It is the policy of this facility to proactively and holistically address the status of residents who are considered to be at risk.Weight Lossi. Definition of PAR Residents1.Residents who have lost or gained 10% or more of their body weight over a six month period which was undesired or unplanned.ii. Areas of Review1. Review weight-current and trends2. Review nurse's notes3. Review medications4. Review labs5. Review supplement use and acceptance6. Review diagnosis listing7. Review RD and dietary manager documentation8. Review intake and output documentation, if applicable9. Review speech therapy documentation, if applicable10. Develop interventions, consider all possible consequences of weight loss and care plan for prevention of associated problems12. Update care plan13. Complete nursing note14. Document changes on 24 hour report sheet15. Update CNA assignment sheetsR20 was admitted to the facility on [DATE] with diagnoses of including Alzheimer's (progressive disease that destroys memory and other important mental functions), Vascular Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) with Behavioral Disturbance, and Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar).R20's Significant change Minimum Data Set (MDS) with an assessment reference date of 12/3/25assesses R20 has both short- and long-term memory impairments and demonstrates severely impaired skills for daily decision making. R20 has no range of motion impairment and requires set-up for eating. R20 holds food in mouth, has no current weight loss, and is on a mechanically altered diet.R20's CNA Assignment Sheet during the survey documents pureed diet, thin liquids. Encourage (R20) to drink fluids during day to stay hydrated; (R20) likes juice vs plain water.R20's comprehensive care plan documents:10/18/22 Potential for weight fluctuation potential for alteration in nutrition 12/9/25 related to disease process, psychological factors, Alzheimer's, or other dementia, recent diet texture change, taking thyroid replacement medication potential for weight gain or loss manifested by fluctuation in weight gain or loss, diet change from regular to pureed.-11/28/23 Monitor weights, high protein supplement, administer medications as ordered, observe for side effects and effectiveness, monitor food intake-12/9/25 Record food intake, offer snacks, assist with eating as needed, encourage rest periods, monitor fluid intake with meals, in between meals, set up meal for (R20)-10/18/22 Provide ordered diet, determine food likes, provide pleasant meals, offer extra snacks, RD consult at neededThe 12/9/25 care plan for Potential for altercation in nutrition related to change in chewing/swallowing regular texture food manifested by (R20) observed holding/pocketing food in mouth, unable to swallow food due to not chewing thoroughly-12/9/25 Record food intake, provide snacks, ensure (R20) is set up for meals and that current diet order of puree is followed, report to nurse any chewing/swallowing/episodes of chokingReview of R20's medical record indicates R20's diet was changed from regular to pureed texture due to R20 pocketing food, holding in mouth and delayed swallowing 11/25/25.Review of R20's weights documents R20's weight on 12/17/25 was 141 pounds. On 2/6/26 and 2/19/26 R20's weight was recorded as 118 pounds. This would be a 16.31% weight loss.Surveyor reviewed R20's intake records for December of 2925 and January 2026. Surveyor noted: December has 15 meal intakes with no documentation. January has 46 meal intakes with no documentation.On 2/25/2026, Registered Dietitian (RD)-K documented in their Quarterly Assessment, R20 has a significant weight loss of 17 pounds times 3 months. Discussed with Registered Nurse [(RN)-D] who will obtain a re-weight to assess weight accuracy as previously weight had been stable. Will continue to monitor. Encourage MedPass three times daily.Surveyor notes a re-weight was not obtained.On 3/04/2026, at 12:14 PM, Surveyor interviewed RD-K via telephone. RD-K stated RD-K discussed with RN-D the concern of R20's weight loss. RD-K stated RD-K asked for a re-weight. When asked about assessments, RD-K indicated they would assess R20's intake. Surveyor asked RD-K about care plan revisions and goals. RD-K stated they are not part of the care plan process so any goals and interventions related to nutrition would be documented in a note. RD-K stated if R20 has a weight loss, RD-K would add high protein and high calorie items to R20's meals. When asked about the change in consistency to R20's diet, RD-K stated that it was a physician's decision to downgrade R20's regular diet to pureed. RD-K indicated they were not a part of that decision.On 3/04/2026, at 12:59 PM, Surveyor interviewed Nurse Manager (NM)-E. NM-E did not know about the need for a reweight for R20.On 3/04/2026, at 3:00 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Clinical Nursing Officer (CNO)-C that R20 has had a documented 16.31% weight loss, and a re-weight was not completed per RD-K's request. Surveyor shared that the facility has not had any follow-up including person-centered interventions regarding R20's weight loss. Surveyor shared staff are not monitoring R20's intake at meals as care planned.

Based on interview and record review, the facility did not provide necessary treatment and services to 1 (R16) 1 sampled residents with a history of substance abuse.R16 has a diagnosis of alcohol abuse and had sustained falls following episodes of drinking. The facility did not review and offer necessary supports toR16 to address substance abuse and to ensure R16's safety when drinking.Findings include:R16 was admitted to the facility on [DATE] with diagnoses including Alcohol Abuse (pattern of drinking that interferes with day to day activities), and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities).R16's Quarterly Minimum Data Set (MDS) assessment completed 1/22/26 documents a Brief Interview for Mental Status (BIMS) score for R16 of 11, indicating R16 demonstrates moderately impaired skills for daily decision making. R16's MDS documents minimal depressive symptoms and no behaviors.R16's comprehensive care plan initiated 4/7/25 Resident (R16) has a history of alcohol abuse and misuse due to a diagnosis of alcohol dependence with withdraw, resident continues to drink alcohol. Interventions dated 4/7/25:-Monitor/report to MD for suspected resident intoxication and use of alcohol, re-educate on risks of continued alcohol abuse, manage appropriate medications to decrease adverse effects-Report behaviors, changes in mental status, behaviors, slurred speech, lethargy, respiratory failure to nurse promptly, provide for safety and wellbeing of resident, staff, yourself and other residentsSurveyor notes that R16's care plan for alcohol abuse has not been updated with interventions since 4/7/25.On 12/6/25 R16 had a fall the facility determined was related to R16's drinking alcoholic beverages and intoxication. The post fall intervention was for R16 to not drink. Surveyor noted there were no supports or interventions to try and implement R16 not drinking.On 12/13/25 R16 fell again with the facility documenting drinking alcohol was a causal factor. Changes to R16's care plan and offered support continued to not be assessed or addressed by the facility regarding R16's drinking.Review of R16's medical record indicates there was an order dated 2/20/26 for Psychiatric services to evaluate and consult regarding R16.Surveyor was not able to locate any psychiatric evaluation in R16's electronic medical record or paper chart to indicate the consult was scheduled/completed as ordered.On 3/05/2026, at 10:34 AM, Surveyor interviewed Social Service Designee (SSD)-H regarding R16 and R16's continued consumption of alcohol. SSD-H informed Surveyor that SSD-H only completes the discharge care plan for residents. SSD-H does not know who completes the psychosocial, behavior, mood, etc. care plans. SSD-H informed Surveyor that SSD-H has no training other than leadership training. SSD-H recalls offering Alcoholic Anonymous (AA) one time to R16 but didn't document offering that service. SSD-H confirmed that SSD-H did not implement any other interventions. SSD-H understands and agrees with Surveyor concerns that R16 has not been offered any services or implemented interventions to address R16's continued consumption of alcohol beverages.On 3/9/26 the facility sent additional information for consideration regarding R16. The information indicated SSD-H spoke to R16 on 3/6/25 asking if R16 was interested in alcohol treatment programs and R16 did not want services. The facility also sent information stating on 3/6/25 R16 knows he is an alcoholic. The facility also indicated R16 has a history of poor health decisions. Surveyor noted this does not address the recent concerns of falls due to intoxication and not following through on physician orders for a psychiatric consult.

Based on interview and record review the Facility did not provide appropriate treatment and services for 1 (R20) of 1 sampled residents with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.* R20 was observed during the survey to not receive activities or stimulation based upon individual preferences and identified interests with a diagnosis of dementia. R20 was observed engaging in behaviors of repeatedly tapping and banging objects on tables without redirection or encouragement to do participate in an activity.Findings include:The facility's Dementia Management policy and procedure last revised 9/22 documents:Purpose:To ensure that facility staff members understand the needs of resident who display or are diagnosed with dementia and provide appropriate treatment and services to meet the highest practicable physical, mental, and psychosocial well-being of these individuals.Protocol:2. Staff will understand the expectation to observe residents condition throughout the shift they work and report to the nurse immediately any sudden change or worsening from baseline in the residents' expressions or actions.4. Every effort will be made to complete a preferences for Everyday Living Inventory (PELI) with the resident to help inform the person-centered care plan.5. The management team will complete routine observations of care and activities of daily living to ensure staff members are consistently implementing the person-centered care plan that reflects the resident's goals and maximizes the resident's dignity, autonomy, privacy, socialization, independence, and choice.6. The effectiveness of interventions will be monitored and adjustments to interventions based on effectiveness, as well as any adverse consequences related to treatment will be discussed with Interdisciplinary Team (IDT) and made as needed throughout each shift.8. Upon admission to the facility and routinely throughout the course of the resident's stay, they IDT will gather and review information from medical records, observations, and resident/resident representative interviews to determine:a. Resident's usual and current cognitive patterns, mood, and behaviorb. Any underlying root causes of behavioral expressions or indications of distressc. How the resident typically communicates an unmet need such as pain, discomfort, hunger, thirst9. The IDT will develop and implement a comprehensive resident-centered care plan from this evaluation and assessment that includes specific targeted behaviors and expressions of distress, measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, the resident's goals, desired outcomes, and preferences.10. The nursing staff will update the resident-centered care plan as changes and maintain a current copy which will identify changes in condition and dementia care approaches.11. Dementia care interventions may include the following:a. Identifying unmet needs or root causes such as pain/hunger/thirst/boredom/lonelinessb. Underlying behavioral expressions such as restlessness, anxiety, aggression, screamingc. Using a soft, low voice and speaking facing resident so lips can be read and face can be seen clearlyd. Not approaching resident from behind so you do not startle them.e. Providing adequate time during resident care and meals.g. Encouraging maximal independence that resident could perform themselvesh. Encouraging time outdoors in engaged activity or relaxation.i. Encouraging meaningful resident-centered physical activity.j. Providing meaningful stimulation (to avoid boredom).k. Ensuring an adequate number and type of activities on all shifts.n. Assess for sensory deficits and how it impacts cognition, provide adaptive equipment if needed.o. Assess and evaluate if appropriate for music-memory program and implement according to resident interest.R20 was admitted to the facility on [DATE] with diagnoses including Alzheimer's (progressive disease that destroys memory and other important mental functions), Vascular Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) with Behavioral Disturbance.R20's Significant Change Minimum Data Set (MDS) with an assessment reference date of 12/3/25 assesses R20 has both short- and long-term memory impairments and demonstrates severely impaired skills for daily decision making. R20 no range of motion impairment.Surveyor reviewed R20's comprehensive care plans which documents:(R20) has potential for impaired adjustment related to dementia, confusion, perpetual motion manifested by walking in hallways and room tapping on various surfaces, and anxiety. 10/9/24-12/5/23 Social Service-1:1 (one on one) visits, involve family, reorient as needed, (R20) wanders at times.-12/5/23 Activities-1:1 visits, (R20) enjoys [NAME] music. Engage in activities. Enjoys playing cards, singing and Christmas music. (R20) is Catholic and engages in Mass. Enjoys pet visits when LPN (licensed practical nurse) brings cats.(R20) has potential for disruptive interaction 10/18/22 related to Dementia 12/9/25 manifested by digging in brief, spreading contents of soiled brief, difficult to redirect at times.-10/18/22 Provide calm environment, offer diversion, provide 1:1, redirection-10/18/22 1:1 visits, encourage activity participation-10/18/22 Provide activities of choice for (R20)12/9/25 Maintain safety of (R20) and other residents, and other staff. Praise positives.On 11/24/25, Psychiatric Nurse Practitioner (Psych NP)-Y documented that R20 was recently started on risperidone by primary physician for continued tapping behaviors and playing with R20's feces.R20's current physician orders document the following medications:3/21/25 Sertraline 50mg for depression and anxiety12/10/25 Depakote Sprinkles 125mg 2 times daily for dementia with mood disorder1/15/26 Risperidone .25mg 2 times daily for behavioral disorders associated with dementia was increasedSurveyor reviewed R20's Medication Administration Records (MARS) from November to March and notes that nursing staff are documenting that R20 is displaying no targeted behaviors.Staff identified a significant change in R20's activities of daily living (ADL) functional abilities in December 2025 and attributed the significant change to R20's medications. R20's medications were decreased at that time.On 3/02/2026, at 11:44 AM, Surveyor observed R20 in bed sleeping.On 3/02/2026, at 1:43 PM, Surveyor observed R20 sitting in a high back chair in the left-hand corner of R20's room. R20 had an overbed table in front of R20. R20 was continuously tapping their hand on the overbed table. Surveyor observed there were no items on the overbed table. There was no music playing or television on to provide stimulation.On 3/03/2026, at 7:07 AM, Surveyor observed R20 in bed sleeping.On 3/03/2026, at 9:29 AM, Surveyor observed R20 sitting in the high back chair with the overbed table in front of R20. Surveyor observed R20's call light is on the floor; not within reach of R20.On 3/03/2026, at 12:59 PM, Surveyor observed R20 sitting in the high back chair in same spot with overbed table in front. Surveyor observed R20 banging R20's water cup on the overbed table. Surveyor noted there was no music playing or television on to provide stimulation.On 3/03/2026, at 3:31 PM, Surveyor observed R20 in bed sleeping.On 3/04/2026, at 7:15 AM, Surveyor observed R20 in bed sleeping.On 3/04/2026, at 7:55 AM, Surveyor observed R20 awake in R20's room. Surveyor noted they have not observed R20 out of R20's room during the survey. R20's care plan states R20 enjoys music and playing cards. Surveyor has not observed R20 participating in any activities. On 3/04/2026, at 12:46 PM, Surveyor observed R20 sitting on the edge of the bed with the overbed table in front of R20. Surveyor again noted there is no music or television on providing stimulation.On 3/04/2026, at 7:28 AM, Surveyor interviewed Activity Director. (AD)-F regarding R20's activities. AD-F stated R20, on occasion, will attend online church and movies but needs 1:1 monitoring when in an activity. AD-F stated, I am one person, so it is hard to bring (R20) to activities. AD-F stated they only provide 1:1 visits 1 time a week and usually it is to read R20 a devotion.On 3/05/2026, at 10:34 AM, Surveyor spoke to Social Services Designee (SSD)-H. Surveyor asked SSD-H if the facility has programs and activities for residents with dementia. SSD-H informed Surveyor the facility does not have a dementia program and believes that dementia training is very important. SSD-H stated hospice came in awhile ago and provided dementia training. SSD-H stated that dementia care is very important and understands Surveyor's concern that the facility has not been providing dementia care to R20.On 3/05/2026, at 1:45 PM, Surveyor interviewed AD-F again. AD-F confirmed that AD-F does not provide dementia activity programming for the residents with diagnoses of dementia or demonstrating signs/symptoms of dementia.R20 has a diagnosis of Alzheimer's Disease and Dementia. R20's MARS for daily behavior monitoring per shift does not document any targeted behavior. There has been no comprehensive assessment with individualized interventions of R20's behaviors and implementing person-centered interventions focusing on dementia care. The facility does not conduct dementia assessments.On 3/04/2026, at 3:00 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Clinical Nursing Officer (CNO)-C that Surveyor observed R20 not being provided person-centered interventions for dementia care during the survey.

Based on interview, and record review the facility did not ensure 1 (R10) of 1 resident reviewed received medically related social services to attain their highest practicable mental and psychosocial well-being.* On 1/14/2025, R10 was committed for 6 months on a locked unit at a psychiatric facility for Suicidal Ideation (SI), mania and psychosis with substantial probability of physical harm to self, manifested by overt attempt or threat. R10 readmitted to the facility without a suicidal care plan put into place and no person-centered interventions specific to SI prevention in R10's care plan. Social Service Designee (SSD)-H was not aware of R10's history of SI and was not involved in R10's psychosocial care planning or follow up.Findings include:R10 was admitted to the facility on [DATE] with diagnoses including Major depressive disorder and generalized anxiety disorder.R10's Quarterly MDS, dated [DATE], indicates R10 has a Brief Interview for Mental Status (BIMS) score of 14 with intact cognition, no behaviors or rejection of care, Patient Heath Questionnaire (PHQ)9 total severity score of 1 indicating minimal depression.R10's health records document that R10 was committed to a psychiatric facility due to suicidal ideation.R10's court order commitment dated 01/14/2025 and indicates that the court found grounds for commitment and documents: The subject is mentally ill, dangerous because of substantial probability of physical harm to him or herself under statute 51.20(1)(a)2.a. As manifested or shown by: a recent overt act, attempt or threat to act under statute 51.20(1)(a)2.a. or b. Wis. Statute. The court orders the subject is committed for 6 months from 1/14/2025.R10's Facility provided document titled Care Plan dated 8/11/2024 indicates the following: Bipolar disease, major depression and anxiety disorderSocial Services: 1:1 visit; Allow to vent; Teach relaxation techniques; Involve family; Make referral for counseling if needed; Inform of activities4/01/2025- Potential for Alteration in thought process related to psychotropic medications, history of bipolar and major depression, interventions include:Surveyor noted that R10 does not have an identified suicidal ideation care plan with person centered interventions to manage and prevent suicide attempts. R10's Psychiatric note, dated 7/17/2025, documents: R10 seen today for follow up of bipolar disorder, generalized anxiety disorder, insomnia, and mild cognitive impairment. R10 recently returned from psychiatric hospitalization within the past month. Mental Status Evaluation- thinks about harming self, denies having a plan or access but states I wish I could. Assessment and plan: continue to monitor mood/behaviors, symptoms of anxiety, sleep status and encourage socialization with peers.R10's Psychiatric note, dated 9/18/2025, documents: Mental Status Evaluation- Suicidal Ideation- R10 reports significant depression, wants to give up, expresses a plan to save up medications to overdose. Assessment and plan: Staff reports they have been watching R10 take medications and will continue to monitor and observe R10 while taking R10's medications to prevent R10 from hoarding medications. Will continue current medication regimen, will closely monitor R10's mood, behaviors and SI. Encourage activities to improve mood.Surveyor noted no documented monitoring of SI or medication hoarding in R10's Medication Administration Record (MAR), Treatment Administration Record (TAR), orders, Care Plan or Certified Nursing Assistant Care Card.Surveyor reviewed R10's electronic health record and noted R10 was admitted to a psychiatric facility on 10/2/2025 and readmitted back to the facility on [DATE], following an inpatient psychiatric stay for SI.R10's discharge summary titled, SBH-Discharge Summary and dated 10/16/2025 documents:Reason for admission: R10 was seen at an outside Emergency Department for SI with no plan or intent. Discharge plan: to return to Facility with medication adjustments.Surveyor reviewed R10's Psychiatric note, dated 11/24/2025, which indicates: Chief Complaint: Follow up psychiatric visit sadness, isolation, SI, nervousness and difficulty sleeping. Mental Status Evaluation: Suicidal Ideation- not assessed during visit.R10's Psychiatric note, dated 1/15/2026, which documents: Chief Complaint: Psych follow up for difficulty sleeping, nervousness, bipolar disorder, and psychotropic medication management. R10 indicated having bad depression, indicating R10 does not want to live anymore at first denied a plan, but then indicated R10 will take pills. R10 denied having access to pills or having pills in R10's room. Suicidal Ideation: present, reports depression is bad and severe, states she does not want to liveanymore, initially denied having a plan then states will take pills. Denies having access to pills or pills in room.Assessment and plan: continue close safety monitoring at facility, including supervised medication administration/observed swallowing and on-going monitoring for worsening suicidality.R10's Psychiatric note, dated 2/27/2026, which documents: Chief Complaint: follow up, bipolar disorder Goal 2: Maintain safety and monitor for suicidal ideation with on going risk assessment. Initial completed. Currently denying plan. Continues to require close safety monitoring at facility level given history. Suicidal Ideation: chronic episodes, deny current plan, denies means.On 03/05/2026, at 10:36 AM, Surveyor interviewed Social Service Designee (SSD)-H. SSD-H informed Surveyor that the admission nurse will do the initial care planning for behaviors and psychiatric services. SSD-H stated that Psych Nurse Practitioner (NP) will send SSD-H the follow up vist information, and SSD-H will put the documentation in residents charts. SSD-H indicated SSD-H does not review the notes and stated that she will scan the documents and will only work on discharge planning. SSD-H indicated that SSD-H is not aware of R10 being or ever being suicidal. SSD-H indicated that, if R10 would tell SSD-H that R10 is suicidal SSD-H would contact crisis and visit R10 more frequently. SSD-H informed Surveyor that R10 does not have history of SI but was living in a car and ended up going to the hospital, then came to the facility for therapy. SSD-H stated that R10 does have bipolar but nothing in R10's medical chart documents anything about suicide, and if there were a history of SI, R10 would absolutely have a care plan and SSD-H would be involved.On 03/05/2026, at 10:54 AM, Surveyor interviewed DON-B. DON-B informed Surveyor that SSD-H oversees all social services related behaviors, psych, care planning and DON-B will review, Psych NP will discuss with us prior to leaving facility. DON-B indicated that R10 has history of suicidal ideation and indicated that it should be in R10's care plan. DON-B informed Surveyor DON-B does not see personalized interventions in R10's care plan relating to SI or prevention. DON-B informed Surveyor there is no monitoring of R10 for SI and medication administration observations. On 03/05/2026, at 3:25 PM, Surveyor notified the facility of the lack of a SI care plan and interventions to prevent and manage SI for R10. No additional information was provided.

Based on interview and record review, the facility did not ensure pharmaceutical services were provided to 1 (R10) of 1 sampled residents receiving pain medications. R10 was seen in the emergency room (ER) on 11/1/25 for hip pain. R10 returned to the facility with recommendations to take Tylenol 650mg 3 times per day with or without ibuprofen 600mg twice a day, as needed for pain. There is no indication this recommendation was reviewed with R10's physician or medication orders at the time were adjusted to implement this recommendation for pain management. Additionally, R10 received multiple doses of as needed (PRN) Tramadol for pain management without a rating of R10's pain prior to administration or documentation of the effectiveness of the medication. Findings Include:The facility's policy, titled Pain Recognition and Management, last revised 4/2025, documents: . 8. Quality Assurance/Performance Improvement Considerations: a. For residents experiencing ongoing/unresolved moderate to severe pain, review the resident's current pain medication regimen to determine if changes in the regimen are necessary. i. Chart the resident's daily pain level in ECS (name of facility electronic medical record software), using an appropriate care planned pain scale. ii. Reassess medication's effectiveness and work with medical provider to adjust dosage to best meet the resident's pain goals. Monitor for repeated PRN requests, which may indicate the need to reevaluate the current medication regimen. Iii. Search for causes, location and severity of the pain, the potential benefits of pain medication, risks and adverse consequences, and the resident's desired level of relief and tolerance for adverse consequences. R10 was admitted to the facility on [DATE] with diagnoses including fracture of fourth lumbar vertebra, chronic anal fissure (a small, painful tear in the lining of the anus), and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R10's Quarterly Minimum Data Set(MDS) completed 1/28/2026 documents R10's Brief Interview for Mental Status(BIMS) score to be 14 indicating R10 is cognitively intact for daily decision making. R10's MDS documents no mood or behavior symptoms during the assessment period. R10 has no range of motion impairment on either side. R10 requires supervision or touching assistance rolling left to right, partial/moderate assistance with dressing, is on a scheduled pain regimen and received non-medication interventions for pain. R10's comprehensive care plan documents:Problem: Potential for alteration in comfort related to pain not of recent onsetInitiated 7/22/2025 Interventions Initiated 1/9/2024:Nurses ----Assess physical symptoms-Administer pain meds-Monitor/record: med effectiveness, med side effects, Teach pain relievers: Document pain level, Notify MD prn-Minimize/relieve pain: Discuss exacerbation of pain with resident stressors, Nurse Aide ----Encourage rest periods-Offer diversion-Assist with repositioning-Encourage self-care-Assist with Activities of Daily Living (ADL)'s as needed-Promote rest, provide quiet dark environment-Report pain to nurse Social Services ----1:1 visits-Allow to vent-Teach relaxation techniques-Involve family Surveyor reviewed R10's Electronic Health Record (EHR) and noted the following progress note, dated 11/1/2026:(R10) was out on pass with a family member, and after shopping at (name of store) (R10) complained of pain to (R10's) left hip after getting into the car. (R10) requested to go to ER for evaluation and treatment. (R10) had no injuries and will be coming back to the Facility with no new orders except, to continue with current pain medications. Surveyor reviewed R10's After Visit Summary, dated 11/1/2025 and indicates the following:Instructions: Take Tylenol 650mg 3 times per day with or without ibuprofen 600mg twice a day, as needed for pain. Surveyor reviewed R10's current physician orders with discontinued entries and documents:-Tramadol 50mg- by mouth twice a day as needed (PRN) for pain. start date 5/21/2025-Acetaminophen (Tylenol) 325mg- 2 tablets by mouth every 6 hours as needed for pain and/or fever. Start date 2/19/2026 Surveyor noted Tylenol at the recommended dosage from November 2025 was not added to R10's medication orders until 2/19/2026. Surveyor reviewed R10's Facility provided pain assessments and noted the following: 11/3/2025- PRN Tamadol given at 3:21 PM- no pain level before given, no description of pain and no location of pain. 11/4/2025- PRN Tamadol given at 5:36 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/5/2025- PRN Tamadol given at 3:19 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/7/2025- PRN Tamadol given at 7:44 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/8/2025- PRN Tamadol given at 6:55 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/9/2025- PRN Tamadol given at 3:25 AM - no pain level before given, no description of pain, no location of pain and no follow up pain level of effectiveness.PRN Tamadol given at 7:05 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/10/2025- PRN Tamadol given at 7:04 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/12/2025- PRN Tamadol given at 8:33 AM - pain unchanged no indication anything further was done.PRN Tamadol given at 7:44 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/13/2025- PRN Tamadol given at 7:02 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/14/2025- PRN Tamadol given at 7:14 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/18/2025- PRN Tamadol given at 7:01 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/21/2025- PRN Tamadol given at 11:22 AM - no pain level before given, no description of pain and no follow up of effectiveness.PRN Tamadol given at 6:27 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/22/2025- PRN Tamadol given at 3:05 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/23/2025- PRN Tamadol given at 7:36 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/24/2025- PRN Tamadol given at 10:02 AM - no pain level before given, no description of pain, and no follow up of effectiveness.PRN Tamadol given at 6:53 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/26/2025- PRN Tamadol given at 7:57 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/27/2025- PRN Tamadol given at 3:22 PM - no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/28/2025- PRN Tamadol given at 6:56 PM- no pain level before given, no description of pain, no location of pain and no follow up of effectiveness. 11/29/2025- PRN Tamadol given at 8:34 AM - no pain level before given, no description of pain, and no follow up of effectiveness.12/1/2025- PRN Tamadol given at 12:10 PM - no follow up of effectiveness assessment. 12/2/2025- PRN Tamadol given at 4:06 PM - no description of pain, and no follow up of effectiveness assessment. 12/3/2025- PRN Tamadol given at 7:13 PM - no pain level before given, no description of pain, and no follow up of effectiveness assessment. 12/4/2025- PRN Tamadol given at 7:13 PM - no pain level before given, no description of pain, and no follow up of effectiveness assessment. 12/5/2025- PRN Tamadol given at 7:37 AM - no pain level before given, no description of pain, and no follow up of effectiveness assessment.PRN medication given at 7:10 PM - no pain level before given, no description of pain, and no follow up of effectiveness assessment. 12/6/2025- PRN Tamadol given at 3:21 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/7/2025- PRN Tamadol given at 3:22 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/10/2025- PRN Tamadol given at 8:10 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/11/2025- PRN Tamadol given at 3:41 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/12/2025- PRN Tamadol given at 7:32 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/15/2025- PRN Tamadol given at 11:32 AM - no follow up of effectiveness assessment.PRN Tamadol given at 7:14 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/16/2025- PRN Tamadol given at 3:24 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/17/2025- PRN Tamadol given at 3:41 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment.PRN Tamadol given at 9:00 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/19/2025- PRN Tamadol given at 3:28 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/20/2025- PRN Tamadol given at 7:50 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/21/2025- PRN Tamadol given at 7:32 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/22/2025- PRN Tamadol given at 1:15 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment.PRN Tamadol given at 7:36 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/24/2025- PRN Tamadol given at 8:34 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/25/2025- PRN Tamadol given at 10:37 AM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/26/2027- PRN Tamadol given at 3:13 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/27/2025- PRN Tamadol given at 8:45 AM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/28/2025- PRN Tamadol given at 3:41 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/29/2025- PRN Tamadol given at 7:26 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/30/2025- PRN Tamadol given at 1:09 PM - no follow up of effectiveness assessment.PRN Tamadol given at 7:26 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 12/31/2025- PRN Tamadol given at 7:00 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 1/2/2026- PRN Tamadol given at 3:26 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 1/3/2026- PRN Tamadol given at 3:30 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment.1/4/2026- PRN Tamadol given at 7:28 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 1/5/2026- PRN Tamadol given at 4:46 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 1/7/2026- PRN Tamadol given at 7:02 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 1/8/2026- PRN Tamadol given at 8:01 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 2/20/2026- PRN Tamadol given at 3:24 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 2/23/2026- PRN Tamadol given at 3:24 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 2/27/2026- PRN Tamadol given at 3:11 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. 2/28/2026- PRN Tamadol given at 6:58 PM - no pain level before given, no description or location of pain, and no follow up of effectiveness assessment. Surveyor noted, 23 out of 43 pain evaluations were not thoroughly completed for November and on 11/12/2025- PRN Tamadol given at 8:33 AM - pain unchanged no indication anything further was done, 30 of 40 pain assessments were not thoroughly completed in December 2025, 6 of 7 pain assessments were not thoroughly completed in January 2025 and 4 of 5 pain assessments were not thoroughly completed in February 2026. On 03/03/2026, at 11:59 AM, Surveyor interviewed R10, R10 indicated R10 is not currently having pain and pain has been managed at the Facility as of recently.On 03/05/2026, at 1:55 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B indicated the expectation is R10 should have a pain evaluation, including location, numerical pain value, description/location and follow up for R10's PRN pain medication administrations. DON-B was unsure of why R10's Tylenol order was not implemented until 2/19/2026 following R10's ER visit on 11/1/2025. DON-B indicated will look further into it. On 03/05/2026, at 3:25 PM, Surveyor informed the Facility of the above concerns regarding R10 not having pain assessments completed prior to administration of PRN pain medication, no follow up pain assessments post PRN pain medication, incomplete pain assessments and the recommendation for R10 to receive Tylenol not being addressed until about 3 months later.

Based on record review and interview, the facility did not ensure a resident received an antibiotic medication with adequate indications for use for 1 (R5) of 6 sampled residents.*R5 was prescribed, and administered, the antibiotic (Macrobid) without adequate indications of an infection.Findings include: R5 was admitted to the facility on [DATE] and is currently receiving hospice services. The Nurses Note dated 2/11/2026, at 5:29 PM, By Registered Nurse (RN)-D documents: (R5) complained of burning sensation to her vagina area. RN-D called the hospice nurse and received orders to start Macrobid 100 mg (milligram) Po (oral) BID (twice a day) times 7 days. RN-D faxed order to primary and (name of) pharmacy. RN-D placed R5 on alert charting times 7 days.R5's February 2026 Medication Administration Record documents Macrobid 100 mg was administered, BID from 2/12 - 2/17/26, for a Urinary Tract Infection (UTI).R5's medical record does not have documentation of clinical indications for the antibiotic or Physician documentation, to support the administration of antibiotic medication.On 3/03/2026, at 10:55 AM, Surveyor interviewed the Director of Nursing (DON)- B who is also the facility Infection Preventionist. Surveyor requested clinical information for R5's antibiotic medication use.On 3/04/2026, at 8:31 AM, DON-B spoke with Surveyor. The DON-B was not aware of hospice ordering the antibiotic. DON-B informed Surveyor the antibiotic medication R5 received did not meet the clinical definitions of use. DON-B shared there is no further clinical information regarding the UTI or antibiotic. On 3/4/26, at 3:00 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A and DON-B, Surveyor shared R5's medication concern.

Based on observations, interviews, 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 for 1 (R9) of 5 residents observed with Enhanced Barrier Precautions (EBP).*R9 has a Facility acquired pressure injury to the left upper posterior thigh area and left medial thigh. On 3/02/2026, Surveyor observed R9's incontinence care and on 3/03/2026, observed R9's wound treatment. The Facility staff did not wear the proper Personal Protective Equipment (PPE) while performing R5's wound treatment or incontinence cares.Findings include:The Facility's police, titled Standard and Transmission-Based Precautions, with a last revised date of 2/2024, indicated, . 11. Enhanced Barrier Precautions . a. When required, Enhanced Barrier Precautions are used IN ADDITION TO Standard Precautions. i. Enhanced Barrier precautions are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. They are indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: 1. Wounds or indwelling medical devices, regardless of MDRO colonization status, . 1. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include:DressingB. Bathing/showeringC. TransferringD. Providing hygieneE. Changing linensF. Changing briefs or assisting with toiletingG. Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilatorH. Wound care: any skin opening requiring a dressing . R9 was admitted to the facility on [DATE], with diagnoses including acute kidney failure (sudden, often reversible loss of kidney function), acquired absence of right foot, and urine retention (the inability to fully or partially empty the bladder).R9's Quarterly Minimum Data Set (MDS), dated [DATE], indicates R9 was a Brief Interview for Mental Status (BIMS) score of 14 indicating R9 is cognitively intact, has no impairment in upper extremities, has impairment in lower extremities, requires partial to moderate assistance rolling left to right, requires substantial/maximal assistance with toileting, is occasional incontinent of urine, always incontinent of bowels, does not have any skin conditions, and is at risk for developing pressure injuries.R9's most recent comprehensive MDS, dated [DATE], indicates R9 has a BIMS score of 14, indicating R9 is cognitively intact, does not exhibit rejection of care behaviors, has no impairment in upper extremities, has impairment in lower extremities, is dependent for toileting, dependent on lower body dressing, requires partial/moderate assistance rolling left to right, frequently incontinent of urine, always incontinent of bowels and has an unhealed stage 3 pressure injury.On 03/02/2026, at 9:29 AM, Surveyor interviewed R9. Surveyor noted there was no EBP sign on R9's door and there was no Personal Protective Equipment (PPE) in or near R9's room. R9 informed Surveyor that R9 has wounds on his butt and thigh that were acquired while at the Facility. Surveyor asked R9 if R9 is ok with Surveyor watching staff preform cares for R9, R9 indicated yes.On 03/02/2026, at 9:47 AM, Surveyor observed Certified Nursing Assistant (CNA)-R and CNA-I enter R9's room without EBP PPE. Surveyor observed CNA-R and CNA-I assist R9 with getting undressed and perform a partial bed bath for R9, including incontinence cares. During this time, Surveyor observed R9 to have 2 square adhesive dressings to R9's right and left buttock. Surveyor noted no other dressings in place and noted a scant amount of red matter, consistent with the appearance of blood, to R9's brief around R9's left thigh area. Surveyor noted a large open wound to R9's left medial thigh. CNA-R and CNA-I finished cleaning R9 and assisted R9 with getting dressed, used a Hoyer lift to transfer R9 into R9's wheelchair. Surveyor noted CNA-R and CNA-I did not use EBP PPE while performing cares and transfers for R9.On 03/03/2026, at 1:22 PM, Surveyor observed CNA-S and CNA-P assist R9 with getting undressed and prepare R9 for Registered Nurse (RN)-T to perform a wound treatment for R9. Surveyor noted R9 still had 2 adhesive dressings in place to R9's right and left butt cheeks. Surveyor observed the open area to R9's left medial thigh. Surveyor noted that CNA-S and CNA-P were only wearing gloves and were not wearing EBP PPE while providing cares. RN-T then came into R9's room and provided a treatment to R9's denuded areas, while doing this, RN-T provided treatment to R9's stage 3 left posterior thigh pressure injury not as ordered. (please see F686 for further information). Surveyor asked RN-T if RN-T was providing wound care to R9's pressure injury, RN-T informed Surveyor that RN-T is only performing R9's morning treatment to R9's denuded areas and was unsure but thinks all the wounds are the same. RN-T indicated she would call Wound Nurse-G to come up to do the afternoon treatment for R9's other wounds.On 03/03/2026, at 1:41 PM, Wound Nurse-G came to R9's room. Wound Nurse-G indicated R9 did not have PPE available by R9's room and did not have a EBP sign on R9's door. Wound Nurse-G informed Surveyor that R9 should have EBP in place and staff should be using EBP PPE due to R9's pressure injuries.On 03/04/2026, at 3:01 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Clinical Nursing Officer-C made aware of concerns regarding no EBP and no PPE for R9.On 03/05/2026, at 8:09 AM, Surveyor observed R9 to now have EBP sign on door and PPE available.On 03/05/2026, at 8:13 AM Surveyor interviewed DON-B. DON-B indicated EBP is used for any open wounds or indwelling medical devices and R9 requires EBP to be in place. DON-B believes R9 was on EBP at one point but must have healed and was not put back into place.

Based on record review and interview, the facility did not offer the influenza immunization for 2 (R16 and R5) of 5 residents reviewed for immunizations.R5 and R17 were not offered the influenza (flu) immunization on admission to the facility and the facility did not document if the immunizations were offered and declined.Findings Include:The facility policy titled Influenza Immunization - Resident Reviewed 2/25, Revised 2/21 documented:All residents will receive vaccination annually between October 1st and mid November, at the direction of the facility medical director and Q API committee.Residents admitted during the winter months (October 1st through March 31st) will receive influenza vaccination at admission, if they have not already received it unless there is a medical contraindication.If a resident refuses vaccination, the refusal is to be documented in the nurse's notes of the residence record, and his statement included which states that the resident was made aware of the risks of refusing the vaccination. Risk information is contained in the VIS. Any refusal will be placed on the MAR to ensure follow up within 30 days following the initial refusal of the vaccine and document.On 3/5/26, at 10:23 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R5 and R16 not being offered the influenza vaccine and there was no documentation of refusal. DON-B stated the Facility will try to locate correspondence that R5 was offered an influenza vaccine. DON-B stated R16 was not offered the influenza vaccine, as R16 was admitted after the Facility's influenza vaccine clinic. Surveyor noted the Facility's policy for Influenza vaccines stated if the resident is admitted [DATE]st to March 31st the resident will receive the influenza vaccine on admission.1.) R5 was admitted to the facility on [DATE] with diagnoses of Acute Respiratory Failure With Hypoxia (the lungs cannot properly get oxygen to the body) and Unspecified asthma (chronic inflammation and swelling of the airways and lungs causing shortness of breath),On 3/4/26, at 12:49 PM, Surveyor reviewed R5's Electronic Medical Record (EMR). Surveyor was unable to locate any information pertaining to R5 receiving the influenza vaccination. There was no documentation that R5 received education regarding the benefits and potential side effects of the influenza immunization. There was no documentation in R5's medical record that R5 either received the influenza immunization or did not receive the influenza immunization due to medical contraindication or refusal.2.) R16 was admitted to the facility on [DATE] with diagnoses of dyspnea (difficulty breathing), Emphysema (chronic progressive lung disease that causes shortness of breath), and Chronic respiratory failure with hypoxia (the lungs cannot properly get oxygen to the body).On 3/4/26, at 12:49 PM, Surveyor reviewed R16's Electronic Medical Record. Surveyor was unable to locate any information pertaining to R16 receiving the influenza vaccination. There was no documentation that R16 received education regarding the benefits and potential side effects of the influenza immunization. There was no documentation in R16's medical record that R16 either received the influenza immunization or did not receive the influenza immunization due to medical contraindication or refusal.No additional information was provided from the Facility regarding R5's and R16's influenza vaccine status.

Based on record review and interview, the facility did not offer the COVID-19 immunization for 1 (R16) of 5 residents reviewed for immunizations.R16 was not offered the COVID-19 immunization on admission to the facility and the facility did not document if the immunizations were offered and declined.Findings Include:The facility policy titled Coronavirus (COVID-19) Vaccination - Resident. Last reviewed 3/24, last revised 4/25 documented:Coronavirus vaccination is strongly recommended and applies to all the residents. When COVID-19 vaccination is available to the facility, each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident has already been immunized.Before offering COVID-19 vaccine, each resident or the resident representative is provided with education regarding the benefits and risks and potential side effects associated with the vaccine. In situations where COVID-19 vaccination requires multiple doses, the resident or resident representative is provided with current information regarding those additional doses, including any changes in the benefits or risks and potential side effects, associated with the COVID-19 vaccine, before requesting consent for administration of any additional doses.Any resident (or resident representative) the declines to be vaccinated against coronavirus must sign the coronavirus COVID-19 vaccine declination form, which serves as proof of education of the risks and benefits of the vaccine and encouragement to receive vaccination. The refusal will also be documented in the nurse's progress notes of the residence's medical record.The resident's medical record includes documentation that indicates the following: that the resident or resident representative was provided education regarding the benefits and the potential risks associated with COVID-19 vaccine by way of the coronavirus COVID-19 vaccine declination form. R16 was admitted to the facility on [DATE] with diagnoses of dyspnea (difficulty breathing), Emphysema (chronic progressive lung disease that causes shortness of breath), and Chronic respiratory failure with hypoxia (the lungs cannot properly get oxygen to the body).On 3/4/26, at 12:49 PM, Surveyor reviewed R16's Electronic Medical Record. Surveyor was unable to locate any information pertaining to R16 receiving the COVID-19 vaccination. There was no documentation that R16 received education regarding the benefits and potential side effects of the COVID-19 immunization. There was no documentation in R16's medical record that R16 either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindication or refusal.On 3/5/26, at 10:23 AM, Surveyor shared concerns with Director of Nursing (DON)-B that R16 was not offered the COVID-19 vaccine and there was no documentation of refusal. DON-B stated R16 was not offered the COVID-19 vaccine, as R16 was admitted after the Facility's vaccine clinic. Surveyor noted the Facility's policy titled 'Coronavirus (COVID-19) Vaccination - Residents stated before offering the vaccine, the resident or representative is provided with education. Surveyor noted there is no documentation of education provided.No additional information was provided from the Facility regarding R16's COVID-19 vaccine status.

Based on record review, document review, and staff interview, the facility failed to designate a person to serve as the Director of Food and Nutrition Services. Failure to designate a person had the potential to result in food not being prepared, stored, or served in a sanitary manner with the potential to result in food borne illness. This had the potential to affect all 41 of 41 residents residing in the facility. Findings include: On 10/15/24 at 10:34 AM, during the initial tour of the dietary department, Cook1 and Dietary Aid (DA)1 were working in the kitchen and when asked who the Dietary Manager/Director of Food Services was they both stated they did not have one. Cook1 stated she used to be the interim supervisor until they hired one. They stated a Director of Dietary was hired and then quit and they have not had a supervisor since he left. Interview on 10/15/24 at 4:10 PM, the Corporate Clinical Consultant and the Administrator stated the facility had a consultant Dietitian who provided consulting services once a week. They stated they did not have a person designated as the Director of Food and Nutrition Services. Per interview they were actively recruiting for a Certified Dietary Manager (CDM) and were having problems finding a qualified person. The Corporate Clinical Consultant provided a document titled (name of facility) Dietary Manager Recruitment and interview with the Administrator and Corporate Clinical Consultant revealed Cook1 was designated as the interim Director of Dietary on 11/01/22 when the last CDM was terminated. They stated that they continued to advertise and interview potential candidates without any success. Per the document and review of [NAME] 1's personnel file, Cook1 was enrolled in the CMS course on 06/2023. On 05/2024, she decided not to complete the course and additional advertising was conducted. Per the report they hired a CDM on 07/15/24 and he terminated his employment on 08/23/24. The interview revealed they had not designated a Director of Food and Nutrition Services since 08/23/24 and they continued to place ads, and had interviewed two candidates in September 2024. Review of Cook1's personnel file revealed she did not meet the requirements to be designated as the Director of Food and Nutrition Services. On 10/18/24 at 10:45 AM, telephone interview was conducted with the Registered Dietitian (RD) who stated that she only does the clinical side of nutrition services and did not inspect the kitchen for potential sanitation problems. She stated she provides services about once a week and often she completes her visits virtually. Review of a list of hours she worked since 09/01/24 revealed she worked one hour on 09/07/24, two hours on 09/13/24, 3.25 hours on 09/17/24, four hours on 09/26/24, and two hours virtually via computer on 10/10/24. Review of the facility's Job Description for the Food Service Manager revealed for the Qualification section, the Food Service Manager must be a Certified Dietary Manager.

Based on record review and interview, the facility did not ensure that staff promptly consulted with a physician when residents experienced significant changes of condition. This was observed with 3 (R36, R40 and R32) of 12 residents reviewed. * R36 is dependent on staff for fluid and meal intakes. R36 also was on a scheduled diuretic, 20mg of [MEDICATION(S)] each day for [CONDITION(S)]. On 11/10/21, R36 experienced a change in condition. R36 ate only 25% at each meal and took in approximately 120 cc fluid at each meal. Charting on the 24- hour board indicates she was somewhat lethargic. There was no consultation with the physician regarding R36's lethargy, decreased intake and for facility to get direction as to whether they should continue to administer [MEDICATION(S)] considering R36's poor intake. The physician indicated staff should have made contact. On 11/11/21, R36 ate only 25% at each meal and took in a total of 489 cc's for all 3 meals combined. On 11/12/21, R36 did not eat supper. On 11/13/21, Resident did not eat breakfast or lunch and ate 25% supper. On 11/14/21, nothing is recorded for intake. The 24-hour board indicated R36 was not herself that she is lethargic and barely opens her eyes. No one consulted with the physician. On 11/15/21, R36 was hospitalized via 911 when staff found her unresponsive. On 11/15/21, R36 admitted into the hospital for severe dehydration that required aggressive fluid resuscitation in the emergency room . R36 was diagnosed with hypovolemic shock and severe dehydration. R36 remained hospitalized until 11/23/21 when she return to the facility. The facility's failure to consult with the physician regarding R36's lethargy, decreased intakes and for failing to get direction as to wether they should continue administering [MEDICATION(S)] considering R36's poor intake created a finding of immediate jeopardy that began on 11/10/21. Surveyor notified Director of Nursing (DON)-B and Vice President (VP)-U of the Immediate Jeopardy on 4/19/22 at 11:00 AM. The immediate jeopardy was removed on 4/19/22 and continues at a scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy, pattern) as the facility continues to implement and monitor the immediate jeopardy removal plan and as evidenced by the following noncompliance; *R40 physician was not notified of resident refusing wound treatments. *R32 physician was not notified regarding a burn wound on their leg. Findings include: The facility's policy and procedures for Physician Notification revised 1/22 was reviewed by Surveyor. The policy identifies immediate notification and non-immediate notification. The Immediate notification column under Infection includes changes in ability to perform activity of daily living; intake of food or fluids; increasing confusion or lethargy. The immediate notification definition is: A physician should be informed and consulted at the time the event occurs (but no later then 1 hour after the condition is identified) directly or via an electronic or telephone system. 1. R36's medical record was reviewed by Surveyor. R36 has an activated POA (Power of Attorney) and requires total assist from staff. R36's Annual MDS (minimum data set) assessment completed 9/10/21 indicates severe cognitive impairment; requires extensive assist of 1 for eating. R36's meal/fluid intake reports were reviewed for November 2021. They indicate the following: -11/7/21 Breakfast 75%/fluids 240 cc; Dinner 50%/fluids 360 cc; Supper 50%/fluids 360 cc -11/8/21 Breakfast 75%/fluids 120 cc; Dinner 50%/fluids 300 cc; Supper 50%/fluids 360 cc. -11/9/21 Breakfast 50%//fluids 120 cc; Dinner 25%/fluids 240 cc; Supper 50%/fluids 290 cc. -11/10/21 Breakfast 25%/fluids 120 cc; Dinner 25%/fluids 120 cc; Supper 25%/fluids 120 cc. -11/11/21 Breakfast 25%/fluids 240 cc; Dinner 25%/fluids 120 cc; Supper 25%/fluids 100 cc. -11/12/21 Breakfast 25%/fluids 240 cc; Dinner 25%/fluids 120 cc; Supper 0%/fluids 120 cc. -11/13/21 Breakfast 0%/fluids 60 cc; Dinner 0%/fluids 100 cc; Supper 25 %/fluids 200 cc. -11/14/21 indicates Hospital (R36 did not go to the hospital until mid morning on 11/15/21) R36 received [MEDICATION(S)] 40 mg a day for diuresis. This was administered November 1st up to the 15th when R36 went out to the hospital. The facility's 24 hour report sheets were reviewed for this this time period which reflected; On 11/10/21 AM shift it indicates R36 is somewhat lethargic and vital signs are stable. There is no documentation the physician was consulted with regarding R36's change in condition, with noted lethargy, decreased intake and consultation regarding continued use of R36's diuretic. The night shift documentation up to 11/13/21 AM shift documents R36 is not themselves. There is no documentation the physician was consulted with regarding R36's change in condition, not being themselves, noted lethargy of 11/10/21, decreased intake and consultation regarding R36's diuretic Then the next notation is on 11/14/21 AM shift that indicates R36 is not themselves; doesn't eat well; barely opens their eyes; speech is soft; please evaluate R36. There is no documentation the physician was consulted with regarding R36's change in condition, decreased intake and for consultation regarding R36's diuretic R36 nurses note on 11/15/21 at 11:01 AM indicates R36 had hypertension with change in condition, increase in lethargy, and loss of appetite over the weekend. 911 was called for transport to the emergency room . R36's Hospital note on 11/15/21 indicates an assessment of hypovolemic shock with concern for [CONDITION(S)]. R36 presented to emergency room with lethargy for 2 days. R36 meets the criteria for hypothermia, hypotensive and concern for septic shock. R36 was unresponsive to 3 liters of fluid administered in the emergency room . They will administer an additional 1 liter of fluids. R36 also had a femoral line placed in the emergency room if R36 did not respond to fluid resuscitation and pressors (to raise blood pressure). R36 did start to respond after receiving 4 liters of fluid in the emergency room . R36 was significantly uremic with a BUN (blood urea nitrogen) of 117. Upon further chart review R36 appeared to be more lethargic the past several days with decreased intakes. R36 was transferred to a different hospital for further management. R36 remained in the hospital from 11/15/21- 11/23/21. On 04/18/22 at 10:43 AM Surveyor spoke with MD-P (Medical Doctor). MD-P indicated the staff usually call me with changes. If there is no documentation they called me then it was not done. MD-P interventions would be on a patient-to-patient basis. On 04/18/22 at 10:58 AM Surveyor spoke with DON-B regarding changes in condition with intake monitoring. DON B stated they should have contacted the physician with changes. They would follow the COC (Change of Condition) parameters the policy and procedure. The Nurses should be reviewing the fluid/appetite intake on a daily basis and discuss if there is any concerns. The policy directs the process for intakes and when to notify the physician. DON-B has no additional information. The facility's failure to promptly consult with the physician about R36's lethargy and decreased intake and for failing to get direction as to whether they should continue to administer [MEDICATION(S)] considering R36's poor intake delayed medical intervention and created a reasonable likelihood for serious harm, thus creating a finding of Immediate Jeopardy. On 4/19/22, the immediate jeopardy was removed when the facility implemented the following; 1. All resident records were reviewed to identify any other residents with a change of condition not previously identified and if found completed notification to MD and implemented interventions. Director of Nursing and MDS coordinator reviewed all nurses' notes and 24- hour reports for the past 7 days to identify any other residents requiring monitoring or MD notification of any change of condition. All resident nutritional assessments will be reviewed or updated. 2. The facility management reviewed the facility Resident Change in Condition and Physician Notification policies. On 4/19/22, the facility DON and MDS Coordinator reviewed the policies and procedures for nutrition and hydration monitoring and change of condition. 3. The facility policy on physician notifications and change of condition policies were reviewed to ensure which information will be communicated to the MD related to changes in change in condition. The facility does use an SBAR (Situation, Background, Assessment, Recommendation) tool to be completed with each change in condition to allow for a thorough and documented assessment and communication between the facility and MD. 4. All facility nurses have been retrained on change of condition and notification policies. Prior to working the next scheduled shift, staff were: * Re-educated on change of condition, fluid and nutrition monitoring policies and process and physician notification policies and parameters. * Educated on resident specific care plans and nurse orders for fluid and nutritional monitoring documentation. * Educated on the specific Care Plan MD notification parameters for these residents including changes in condition. * Educated on change of condition policies and documentation requirements. * All nursing staff and the Interdisciplinary Team were educated on monitoring and reporting of change of condition of all residents. * Management nurses will be educated on monitoring of nurses' documentation of nutrition, hydration and physician notification. 5. The facility will review facility implementation of the plan via the facility QAPI (Quality Assurance Performance Improvement) committee. The survey also identified noncompliance at the level of potential for more than minimal harm that is not immediate jeopardy, as evidenced by the following: 3. R40 was admitted to the facility on [DATE] and discharged [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses note dated 11/19/21 documents, skin problems: has open lesion(s) present in past 7 days location: abdomen length: 24.0 cm (centimeter), width: 9.0 cm depth 0.2 cm, tissue type 90% granulation tissue 10% slough, drainage heavy exudate serous sang (sanguineous) no odor present action: will continue to monitor and assess weekly general skin condition: skin problems: open area location: left and right lower leg comments: writer attempted to complete tx (treatment) and measure wound when resident refused and requested pain tx be administered prior to BLE (bilateral lower extremity) tx, no c/o (complaint of) pain during abdominal tx, floor nurse notified and tx scheduled to be completed this shift will continue to monitor. The nurses note dated 11/20/21 documents behavior 11/19/21 refused dressing changes to bi-feet; today 11/20/21 refuses again but eventually allowed tx. The nurses note dated 11/21/21 under comments documents writer completed abdominal treatment without incident or c/o pain, resident refused to have bilateral leg dressings completed due to potential pain resident does have scheduled analgesic and PRN (as needed) analgesic every 8 hours. resident stated I do not want anyone else to do my dressing, but a nurse practioner; writer explained to resident that the orders provided does not state it needs to be completed by NP, resident has hx of non compliance with wound care, risk and benefit counseling provided on infection control and importance of adhering to MD (medical doctor) order, no change in decision writer respected resident's wishes and notified the floor nurse and DON (Director of Nursing) of the above, will continue to monitor. The nurses note dated 12/1/21 documents skin problems: open area location: to abdomen and bilateral anterior shins, teaching done: risk and benefit counseling provided to resident in regards to allowing staff nurses to complete wound treatments on scheduled days. resident voiced understanding. comments: will continue to monitor. behavior: resident argumentative with writer in regards MD order for ACE wraps to BLE, resident demanding writer use the 2 step wrap system copy of MD orders for wound care provided to resident and order explained. after multiple attempts to redirect resident was cooperative with the ACE bandage per MD order. will continue to monitor. The nurses note dated 12/6/21 documents offered to do treatments that are ordered for bil-lower legs and abd'l (abdominal) area, but she's been refusing them and also refuses them today. The nurses note dated 12/7/21 documents Continues to refuse dressing changes to wounds despite [NAME] efforts to persuade. Surveyor reviewed R40's November and December 2021 TAR (Treatment Administration Record) and noted: The skin treatment: soak soiled abdominal wound dressing with copious amount of NS (normal saline) and take care in removing, cleanse with Puracyn Plus or wound cleanser leave solution to wound bed, for 3-5 minutes or as long as tolerated, do not wipe off, pat dry with gauze, apply skin sealant to peri wound, apply petroleum impregnated gauze to wound bed, f/b (followed by) calcium alginate with silver over gauze, cover with ABD (abdomen), secure with secure with tape changed every other day. R40 refused the treatment on 11/26, 11/30 is not initiated as being completed, and 12/6 refused. The skin treatment: Cleanse open area to left lower leg with Puracyn Plus or equivalent wound cleanser, leave solution to wound bed, for 3-5 minutes or as long as tolerated, do not wipe off, pat dry with gauze, apply skin sealant to peri wound, apply petroleum infused gauze to wound bed, f/b (followed by) Calcium Alginate AG, cover with ABD, secure with Kerlix, wrap with ace wrap, change every other day. On 11/19, 11/21, 11/23 R40 refused her treatments, 11/24 is not initialed as being completed, 11/26 refused, 11/28 & 11/30 is not initialed as being completed and refused on 12/6. The skin treatment: Cleanse open area to right lower leg with Puracyn Plus or equivalent wound cleanser, leave solution to wound bed, for 3-5 minutes or as long as tolerated, do not wipe off, pat dry with gauze, apply skin sealant to peri wound, apply petroleum infused gauze to wound bed, f/b Calcium Alginate AG, cover with ABD, secure with kerlix, wrap with ace wrap, change every other day. The treatment was not completed on 11/19, 11/21, 11/23, 11/24 is not initialed as being completed, 11/26 refused, 11/28 & 11/30 are not initialed as being completed, not completed on 12/4, & refused 12/6. On 4/18/22 at 9:19 a.m. Surveyor asked MDS (Minimum Data Set)/Wound RN (Registered Nurse)-G when would a Resident's physician be notified of refusals. MDS/Wound RN-G informed Surveyor she would have to check the policy. Surveyor informed MDS/Wound RN-G R40 had multiple treatment refusals and Surveyor was unable to locate when the physician was notified of the refusals. On 4/18/22 at 10:48 a.m. Surveyor spoke with MD (Medical Doctor)-P on the telephone regarding R40. Surveyor informed MD-P R40 was admitted to the facility on [DATE] & discharged on [DATE]. R40 was admitted with bilateral open areas to her lower extremity and abdominal wound. Surveyor informed MD-P Surveyor had noted multiple refusals and asked MD-P if he was notified of R40's refusals. MD-P stated to be totally honest do not recall. MD-P explained a lot of times he goes in to examine patient and they don't want to see him because they want to go smoke. MD-P informed Surveyor he has 7 jobs and can't deny or confirm he was notified. On 4/18/22 at 11:18 a.m. Surveyor asked MDS/Wound RN-G if she was able to locate when R40's physician was notified of her refusals. MDS/Wound RN-G informed Surveyor she is still looking for the physician's notification. On 4/18/22 at 11:22 a.m. Surveyor informed DON (Director of Nursing)-B of Surveyor's concern regarding R40's physician not being notified of her treatment refusals. DON-B informed Surveyor MDS/Wound RN-G is looking into this. On 4/19/22 at 7:40 a.m. Surveyor asked MDS/Wound RN-G if she was able to find any information when the physician was notified regarding refusal of treatments. MDS/Wound RN-G informed Surveyor they are still looking. On 4/19/22 at 8:08 a.m. Surveyor asked DON-B if she was able to locate when R40's physician was notified of R40's treatment refusals. DON-B replied not exactly sure, I don't think so but let me check with [MDS/Wound RN-G]. DON-B then went to MDS/Wound RN-G's office, returned and stated no. 4. R32 was admitted to the facility on [DATE] and the quarterly MDS (Minimum Data Set) dated 1/26/22 indicates R32 has cognitive impairment, is dependent with bed mobility, transfers, locomotion on and off the unit, and has mobility issues with his upper and lower extremities. The nurses note dated 4/10/22 indicate open area on left knee. 1 by 0.5 granulation tissue no drainage or odor. Applied dressing to left knee. The nurses note does not indicate R32's physician and POA (power of attorney) were notified. The MAR (Medication Administration Record) and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses note dated 4/11/22 indicate New area has second or third degree burn (s) .superior to left anterior knee 1.0 cm by 0.5 cm by <0.1 cm UTA (unable to assess) wound bed to 100% dry tan exudate in place. Area circular in shape. resident stated I didn't mean to burn myself. The incident investigation dated 4/11/22 indicate writer discovered area of skin impairment at time of assessment. Other causal factors: resident smokes primarily with daughter. Physician and POA notified. The April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/13/22 at 3:30 p.m. during the daily exit meeting with Director of Nursing (DON) B, Wound Nurse G and Nursing Home Adminstrator (NHA) A, Surveyor asked how did R32 burn himself with a cigarette when R32 is dependent and cognitively impaired. Wound Nurse G stated R32 goes out to smoke with daughter when she visits. Wound Nurse G stated R32's daughter is not sure how the burn happened. R32's POA stated R32 doses off while smoking. On 4/14/22 at 10:02 AM Surveyor interviewed Wound Nurse G. Surveyor asked if R32's physician was notified and orders obtained. Wound Nurse G stated when she came in on 4/11/22 she discovered the cigarette burn and obtained orders for treatment from the physician. Surveyor asked if R32 POA was made aware of R32's burn on 4/10/22 and Wound Nurse G stated R32's POA was made aware of the burn on 4/11/22. On 4/14/22 at 3:30 p.m. during the daily exit meeting with DON B, Wound Nurse G and NHA A, Surveyor explained the concern R32 sustained a cigarette burn on 4/10/22 while he was outside with his daughter and R32's physician and POA were not made aware of it until 4/11/22. A treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . As of 4/18/22, Wound Nurse G had no additional information.

Based on observation, record review and interviews, the facility did not ensure residents' fluid intakes were assessed or monitored. This was observed with 3 (R36, R33 and R31) of 3 residents reviewed for hydration concerns. *R36 is dependent on staff for meal and fluid intakes. R36 was sent out to the hospital via 911 on 11/15/21 for severe dehydration and required aggressive fluid resuscitation. On 11/10/21, R36 started experiencing a change in condition becoming more lethargic with decreased intake. The facility did not involve the dietitian for reassessment of R36's food and fluid intake in order to develop an individualized care plan to ensure hydration. The facility continued giving R36 a [MEDICATION(S)] (diuretic) even though R36's fluid intake was less then usual and did not monitor R36's fluid intake. The facility does not have a system to monitor and assess fluid needs and ensure residents receive adequate fluids. *R33 is dependent on staff for meal and fluid intakes, along with supplemental gastronomy tube. R33 was sent to the hospital via 911 on 7/17/21 for severe dehydration and required aggressive fluid resuscitation. The facility does not have a system to monitor and assess fluid needs or to ensure adequate intake. Upon R33's return to the facility on [DATE], the hospital discharge summary orders stated if R33 eats less then 70% of their meal, R33 required 1 can of ensure. The facility was not monitoring R33's intake in order to determine if R33 was to receive the 1 can of ensure if consuming less than 70%. The facility's failure to involve the registered dietitian in assessing residents needs and developing individualized plans to ensure proper hydration, its failure to monitor intake for R36 or R33, both of whom are dependent on staff for eating, its failure to ensure each resident received proper nutrition and hydration to ensure hydration and health and its failure to intervene when intake was less then usual created a finding of immediate jeopardy that began on 11/10/21. Surveyor notified DON-B (Director of Nurses) and VP-U (Vice President) of the immediate jeopardy on 4/19/21 at 11:00 AM. The immediate jeopardy was removed on 4/19/22, however, the deficient practice continues at a scope and severity level of D (potential for more than minimal harm that is not immediate jeopardy, isolated) as the facility continues to implement and monitor the immediate jeopardy removal plan and as evidenced by the following noncompliance; * R31's mechanically altered diet care plan includes recording intake every shift. R31's nutritional assessment indicates R31's daily caloric needs is between 2413 to 2815 and total daily fluid intake is 2011 to 2413. The facility is not documenting and monitoring R31's intake every shift, by not consistently completing R31's intakes. R31's last annual dietary assessment was September 2020 and not done annually as indicated by the Registered Dietitian. Findings include: The facility's policy and procedure for Hydration Management dated 12/20 was reviewed by Surveyor. The policy indicates hydration management will be accomplished through an individualized plan to promote adequate hydration based on risk factor identification and assessment and to determine if intake and/or monitoring is indicated. The procedures include the following: -the nurse will complete the Dehydration/Fluid Balance Assessment under the nurse charting tab upon admission, quarterly and with significant changes. -The dietary manager or registered dietician will compare the resident's current monitored intake to their calculated need and make adjustments to food/fluids as necessary. -Fluids will be provided consistently throughout the day: approximately 75-80% at meals, 20-25% delivered during non-meal times The facility's policy and procedure for Intake and/or Output Monitoring dated 5/18 was reviewed by Surveyor. The policy indicates to obtain accurate daily totals of resident fluid intake as indicated. The procedures include: -intake and output is initiated by the Hydration Management policy. -The daily intake is calculated on the night shift. In the event of any 24 hour period a resident has less then 75% of their identified fluid needs consumed, the 24 hour report will be noted for appropriate intervention or follow-up. Nutrition Care Process (NCP) According t the Academy of Nutrition and Dietetics, the Nutrition Care Process is a systematic method to providing high-quality nutrition care. It was published as part of the Nutrition Care Model. Use of the NCP does not mean that all clients get the same care; the process provides a framework for the RDN (Registered Dietician) to customize care, taking into account the client's needs and values and using the best evidence available to make decisions. Other disciplines in healthcare, including nurses, physical therapists and occupational therapists have adopted care processes specific to their discipline. In 2003, the Academy's House of Delegates adopted the NCP in an effort to provide dietetics and nutrition professionals with a framework for critical thinking and decision-making. Use of the NCP can lead to more efficient and effective care, nutrition research, and greater recognition of the role of nutrition and dietetic professionals in all care settings. The Nutrition Care Process consists of distinct, interrelated steps: * Nutrition Assessment and Reassessment: The RDN collects and documents evidence such as food or nutrition-related history; biochemical data, medical tests and procedures; anthropometric measurements, nutrition-focused physical findings and client history. * Nutrition Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] .e., naming specific problems) terms. * Nutrition Intervention: The RDN then selects the nutrition intervention(s) that will be directed to the root cause (or etiology) of the nutrition problem(s) and/or aimed at alleviating the signs and symptoms of each diagnosis. * Nutrition Monitoring/Evaluation: The final step of the process is monitoring and evaluation, which the RDN uses to determine if the client has achieved, or is making progress toward, the planned goals. 1. On 04/11/22 at 10:16 AM Surveyor observed R36 in bed awake. There was no water next to the bed or in R36's room. R36 indicated they wanted water. On 04/11/22 at 01:32 PM Surveyor observed R36 in bed. There was no water visible near the bed. R36's medical record was reviewed by Surveyor. R36's Annual MDS (Minimum Data Set) assessment, dated 9/10/21, indicates a BIMS (brief interview of mental status) of 2 indicating severe cognitive impairment; eating is an extensive assist of 1 staff. The Quarterly MDS assessment completed on 3/15/22 indicates a 0 for BIMS (severely impaired); eats with supervision; impairment of bilateral lower extremities; 2 staff for bed mobility. R36 had a hospital stay from 11/15/21 to 11/23/21; per the nurses note on 11/17/21 R36 was sent out to hospital on 11/15/21 at 11:00 AM. R36 transferred (to the hospital) due to high blood pressure, lethargy and loss of appetite over the weekend. MD (Medical Doctor) and POA (Power of Attorney) aware of transfer. This was a 911 call. Resident returned to the facility on [DATE]. R36's Hospital note on 11/15/21 indicates an assessment of hypovolemic shock with concern for [CONDITION(S)]. R36 presented to emergency room with lethargy for 2 days. R36 meets the criteria for hypothermia, [CONDITION(S)] and concern for septic shock. R36 was unresponsive to 3 liters of fluid administered in the emergency room . They will administer an additional 1 liter of fluids. R33 also had a femoral line placed in the emergency room if R36 did not respond to fluid resuscitation and pressors (to raise blood pressure). R36 did start to respond after receiving 4 liters of fluid in the emergency room . R36 was significantly uremic with a BUN (blood urea nitrogen) of 117. Upon further chart review R36 appeared to be more lethargic the past several days with decreased intakes. R36 was transferred to a different hospital for further management. R36 remained in the hospital from 11/15/21- 11/23/21. R36 nutritional note on 11/23/21 indicates R36 was reviewed for weight gain. The nutritional note does not address fluid status. The previous note is a review from 8/17/21, which does not address fluid needs and did not contain any calculated fluid in the last 2 years. The last assessment dated [DATE] documents R36 needs 2613 ML fluid needs a day. There is no other comprehensive assessment after 10/10/2019 regarding R36's individualized fluid needs. R36' meal/fluid intake reports were reviewed for November 2021. They indicate the following: -11/07/21 Breakfast 75%/fluids 240 cc; Dinner 50 %/fluids 360 cc; Supper 50%/fluids 360 cc -11/08/21 Breakfast 75%/fluids 120 cc; Dinner 50%/fluids 300 cc; Supper 50%/fluids 360 cc. -11/09/21 Breakfast 50%//fluids 120 cc; Dinner 25%/240 cc; Supper 50%/fluids 290 cc. -11/10/21 Breakfast 25%/fluids 120 cc; Dinner 25%/fluids 120 cc; Supper 25%/fluids 120 cc. -11/11/21 Breakfast 25%/fluids 240 cc; Dinner 25%/fluids 120 cc; Supper 25%/fluids 100 cc. -11/12/21 Breakfast 25%/fluids 240 cc; Dinner 25%/fluids 120 cc; Supper 0%/fluids 120 cc. -11/13/21 Breakfast 0%/fluids 60 cc; Dinner 0%/fluids 100 cc; Supper 25 %/fluids 200 cc. -11/14/21 indicates Hospital (R36 did not go to the hospital until mid morning on 11/15/21). There is no current assessed fluid need, thus no way of knowing if fluid intake is meeting R36's need and, if not, how much fluid intake is below assessed need. If R36 still needed 2613 ml fluid each day, fluid intake was 63-86% less than need per day from 11/07 to 11/14/21. R36 weights were recorded as: -09/09/21 190# -10/26/21 202# -11/09/21 230# -11/23/21 233# -12/16/21 199# -12/20/21 199# R36's medical record does not indicate the physician, or the RD, was called with change in intakes. R36 received [MEDICATION(S)] 40 mg daily for diuresis from November 1 through November 15, 2022. R36 receieved the [MEDICATION(S)], scheduled diuretic for [CONDITION(S)] that was administered when fluid intake was minimal. There is no documentation that the RD was notified about R36's low intake and diuretic use. There is no a RD assessment that incorporates medications that could lead to risks of dehydration. R36's medical record does not contain any comprehensive fluid assessment after, or before, 11/15/21 hospital stay for dehydration other than the 10/10/2019 assessment documenting R needed 2613 ML fluids per day, with no indication of R36's fluids being monitored. On 04/18/22 at 12:23 PM Surveyor observed R36 in bed with meal tray set-up in R36's room. R36 has 1 glass of water (6 ounce cup), mashed potatoes, chopped chicken creamed corn and sherbet. R36 was attempting to eat their sherbert with a spoon, however R36 does not have use of their other hand to hold items in place. R36 was scooting the sherbet cup around the meal tray. R36 had a large mug of water on the nightstand and not in reach. Surveyor noted R36 cannot pick up an item to drink on their own. On 04/18/22 at 01:21 PM spoke with DM-K regarding meal tickets. R36' meal ticket shows water as the only beverage for lunch and dinner. DM-K stated they provide preference at meals of juice. DM-K talks with staff regarding if a resident refuses a certain beverage they will not put it on their tray. They have Milk, juice, coffee and water. The meal ticket indicates just the beverage and no amount of fluid. DM-K reported there is no way to put fluid ounces on ticket. DM-K stated residents drink all day long. DM-K stated for meal service we just give them these amounts: Breakfast 240 cc; 160 cc lunch and 240 cc for dinner. Between breakfast and lunch we send out a large mug of 500 cc of ice water. Have never done fluid ounces for meals. DM-K stated she does not know each resident's daily fluid needs. Surveyor noted DM-K does not incorporate an individuals fluid needs on the meal ticket to ensure adequate amounts of fluid are provided. On 04/18/22 at 3:08 PM at the Exit meeting with DON-B and VP-U Surveyor shared concerns with fluid monitoring and assessed daily fluid needs. 2. On 04/11/22 at 09:42 AM Surveyor observed R33 in their room. R33 had a covered cup with straw with water on a overbed table in front of them. On 04/11/22 at 12:03 PM Surveyor observed R33 in a Broda chair in their room eating a pureed diet independently with the same covered cup and straw. On 04/18/22 at 09:05 AM Surveyor observed R33 up in a Broda chair in the lounge area on unit. R33 had a bowl of possibly hot cereal in front of them and a large beverage cup with a lid and straw. R33 was not eating or drinking at this time. R33's medical record was reviewed by Surveyor. R33 has a facility acquired stage 4 pressure injury and receives tube feeding based on appetite consumption. R33 has an activated POA (Power of Attorney) and is dependent on staff for ADL's (activity of daily living). R33 is a full code status. R33's medical record included a hospital visit from 7/17/21 - 7/23/21. The Hospital Discharge Summary indicates R33 had Dehydration with acute kidney injury with elevated creatnine and was treated with fluid hydration as per shock protocol. R33 has suspected shock upon admission and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R33 was hypotensive and received fluid boluses. R33 had severe [CONDITION(S)] with septic shock. R33 was also diagnosed with a severe right renal hydroureteronephrosis secondary to a 8 mm calculus. R33 was also anemic. The Discharge orders include if R33 eats less then 70% of their meal they require 1 can of ensure; flushes of 150 cc 4 times a day through PEG (percutaneous endoscopic gastronomy) tube regardless. The Hospital History and Physical from 7/17/21 indicates R33 presented to the emergency room with altered mental status and largely non-verbal (has [CONDITION(S)]) so can nod. The Assessment includes severe [CONDITION(S)] with septic shock with a treatment to continue aggressive fluid resuscitation. The nursing home staff noted R33 to be less alert and hypotensive. The EMS (emergency medical service) reported on arrival to the facility R33 was somnolent, protecting their airway and hypotensive. R33 received 700 ml bolus prior to arrival at the emergency room from EMS. R33's fluid intake for meals in June and July 2021 were blank. The April 2022 intake only has the 1st and 2nd day fully documented. The rest of the days did not have 24 hour documented intakes. There is no documentation to indicate R33's daily fluid needs. April 1st and 2nd indicates 340 cc total for all 3 meal times a day. On 7/23/21 there is an MD order after R33's hospital stay. The order indicates to flush the gastronomy tube with 150 ml of water 4 times a day; and if R33 eats over 75% to hold [MEDICATION(S)] 1.5 355 ML feeding 3 times a day. The Medical record did not contain any meal intakes, fluid flushes or fluid intakes for July 2021. There was no documentation that resident's intake was being assessed to determine intake needs prior to hospitalization . There is no physician notification due to no ongoing monitoring of R33's intakes to identify a change before becoming severely dehydrated. On 04/18/22 at 10:07 AM Surveyor spoke with RD-Q (Registered Dietician) who indicated a comprehensive nutritional assessment is completed annually and on admission. These are kept in the yellow department notes in the electronic record. RD-Q indicated staff will let me know if someone isn't eating/drinking. The nurses look at the intake reports, if RD-Q was told of a concern they would do a full evaluation. RD-Q indicated they would want to be aware of concerns to monitor weight with extra fluids. RD-Q indicated they were not made aware of concerns if there is no assessment note. RD-Q is not made aware of resident hospital stays and indicated it would be nice if they were made aware. R33's medical record did not contain a comprehensive nutritional assessment related to dehydration. R33's weight documentation indicated: -6/17/21 172# -6/22/21 174# -7/06/21 188# -8/04/21 166# -9/23/21 is 168#/166# On 04/18/22 at 10:37 AM, Surveyor spoke with DM-K (Dietary Manager) who reported the RD does all the assessment. On 04/18/22 at 10:43 AM, Surveyor spoke with MD-P (Medical Doctor) who stated staff usually call me with changes, If there is no documentation they called me then it was not done. MD-P's interventions would be on a patient to patient basis. On 04/18/22 at 10:58 AM, Surveyor spoke with DON (Director of Nursing)-B regarding changes in condition with intake monitoring who stated they should have contacted the physician with changes. They would follow the COC (Change of Condition) parameters the policy and procedure. The Nurses should be reviewing the fluid/appetite intake on a daily basis and discuss if there is any concerns. The policy directs the process for intakes and when to notify the physician. DON-B has no additional information. On 04/18/22 at 12:14 PM Surveyor spoke with LPN-R (Licensed Practical Nurse) who indicated if there is a reason to look at intakes they do. They usually are monitored with new admission residents. The 3rd floor Intake Binder with intake forms were reviewed. All the resident intake sheets are blank for April 8 -11 and the fluid intakes are not calculated. On 04/18/22 at 12:18 PM Surveyor spoke with CNA-S (Certified Nursing Assistant)who reported they will put in intakes on certain people and not everyone. CNA-S did not elaborate on who was on intakes. They will let the nurse know if someone doesn't have any intake. On 04/18/22 at 12:22 PM Surveyor spoke with CNA-T who reported they document all their resident's intake and lets the Nurse know if someone refuses. On 04/18/22 at 01:21 PM Surveyor spoke with DM-K regarding meal tickets. DM-K stated they provide preference at meals of juice. DM-K talks with staff regarding if a resident refuses a certain beverage they will not put it on their tray. They have milk, juice, coffee and water. Meal tickets indicate just the beverage and no amount of fluid. DM-K stated there is no way to put fluid ounces on ticket. DM-K reported residents drink all day long. MD-K stated for meal service we just give them these amounts: Breakfast 240 cc; 160 cc lunch and 240 cc for dinner. Between breakfast and lunch we send out a large mug of 500 cc of ice water. DM-K stated she has never calculated fluid ounces for meals. DM -K does not know an individuals daily fluid needs. and does not incorporate the fluid needs on the meal ticket. On 04/18/22 at 3:08 PM at the Exit meeting with DON-B and VP-U Surveyor shared concerns with fluid monitoring and assessed daily fluid needs. The facility's failure to involve the registered dietitian in assessing the resident's needs and developing individualized plans to ensure proper hydration, its failure to monitor and assess intake and its failure to ensure each resident received proper nutrition and hydration created a reasonable likelihood for serious harm occurring (both residents were hospitalized via 911 with severe dehydration), thus leading to a finding of immediate jeopardy. On 4/19/22, the immediate jeopardy was removed what the facility implemented the following; * On 4/19/22 the contracted Registered Dietitian calculated fluid needs for residents R36 and R33. * A comprehensive nutritional assessment identifying individual parameters of nutritional status has been completed for R36 and R33. * Both residents' medication administration sheets were updated to include total daily fluid needs to ensure ongoing monitoring. * Care plans have been updated with nutritional interventions and meal consumption records implemented. * All Interdisciplinary Team members and nurses have or will be educated before their next worked shift on the interventions and the monitoring required. * The facility Registered Dietitian was re-educated on Policy and Procedure for completion of a comprehensive nutritional assessment on 4-19-22. * The facility has reviewed all other resident records to ensure completion of a comprehensive nutritional assessment on all residents and will identify residents that are nutritionally at risk and at risk for dehydration and updated care plans. * The facility has implemented the procedures to monitor food and fluid intake for residents found to be at nutritional risk and risk for dehydration. * The facility will summarize food and fluid intake for residents when found to be at risk, notify MD and implement interventions. * The facility has identified individual resident nutritional preferences and nutritional requirements that need to be provided at each meal. * The facility will review the facility implementation of the plan via the facility Quality Assurance Performance Improvement committee. The survey also identified noncompliance at the level of potential for more than minimal harm that is not immediate jeopardy, as evidenced by the following; 3. R31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS (Minimum Data Set) with an assessment reference date of 1/26/22 documents a BIMS (brief interview mental status) score of 5 which indicates severe impairment. R31 is coded as requiring extensive assistance with one person physical assist for eating. The need for mechanically altered diet care plan dated 12/7/2018 includes an approach dated 2/27/19 of Nurse Aide--Record intake every shift. Feed all meals Elevate head of bed Explain foods served. dietary supplement per MD (Medical Doctor) order. weekly weights., 5/22/19 of Nurse Aide--Record intake every shift Feed all meals Elevate head of bed Explain foods served. weekly weight. and 9/11/19 of Nurse Aide-- Record intake every shift Feed all meals Elevate head of bed Explain foods served. On 4/18/22 Surveyor reviewed R31's nutritional assessment and noted the last annual nutritional assessment is dated 9/8/20. Total calories are documented as 2413-2815 kcal (kilocalorie)/day based on 30-35kcal/kg (kilogram) CBW (current body weight), total protein 104--120 gPro/day (gram protein per day) based on 2.3-1.5 gPro/KG CBS and total fluids 2011-2413 ml/day (milliliters per day) based on 25-30 ml/kg CBW Under comments documents [resident] due for his annual review. Spoke with dietitian at [CONDITION(S)] for collaboration of care. Diet is Mechanical soft, double protein; Regular diet OK with family. Recent death of significant other and decrease in appetite. Overall intakes are still fair. Receives [MEDICATION(S)] (strawberry) 250 ml q (every) [CONDITION(S)] treatment and enjoys this and drinks it well . On 4/18/22 at 12:12 p.m. Surveyor asked CNA (Certified Nursing Assistant)-I if they record the amount of fluids Residents consume. CNA-I replied certain ones we do. Surveyor asked CNA-I how she is aware which Residents need to have their fluids monitored. CNA-I informed Surveyor if therapy or the nurse lets them know and thinks R31 is the only one. CNA-I then showed Surveyor the appetite book. On 4/18/22 at 12:14 p.m. Surveyor reviewed R31's April 2022 intake record and noted the following: Breakfast fluids 4/1 leave of absence, 4/2 240 cc (cubic centimeters), 4/3 to 4/10 are blank, 4/11 360cc, and 4/12 to 4/17 are blank. Dinner (lunch) fluids 4/1 leave of absence, 4/2 240 cc, 4/3 to 4/10 are blank, 4/11 OOP (out on pass) and 4/12 to 4/17 are blank. Supper fluids 4/1 240 cc, 4/2 240 cc, 4/3 is blank, 4/4 240 cc, 4/5 120 cc, 4/6 240 cc, 4/7 240 cc, 4/8 240 cc, 4/9 240 cc, 4/10 & 4/11 are blank, 4/12 240 cc, 4/13 & 4/14 R (refused), 4/15 240 cc, and 4/16 & 4/17 are blank. On 4/19/22 at 8:16 a.m. Surveyor spoke with RD (Registered Dietitian)-Q and inquired when does she complete nutritional assessments to determine a Resident's fluid and caloric intake. RD-Q informed Surveyor they should be done annually when the Resident has an annual MDS. Surveyor inquired about R31's fluid requirements. RD-Q informed Surveyor R31 receives [CONDITION(S)] and the [CONDITION(S)] center will let her know about fluids, his dry weight is a good indicator of whether R31 would need to be placed on a fluid restriction which he has not had to be placed on. RD-Q informed Surveyor she usually speaks to [CONDITION(S)] about once a quarter at least and then informed Surveyor she spoke with [CONDITION(S)] on 3/24/22, 2/25/22, 1/13/22, & 12/16/21, then stated usually once a month. Surveyor asked RD-Q when the last time an annual assessment was completed to determine R31's fluid needs. RD-Q replied September 2020 was the last annual assessment. Surveyor asked RD-Q if she reviews the Resident intake binder as Surveyor had noted multiple days when R31's fluids were not recorded. RD-Q informed Surveyor she rely's on staff to let her know as Surveyor had mentioned there are holes. RD-Q informed Surveyor the nurses review the intake and she speaks to the nurses and CNAs to see if there is anyone with decreased intake they want her to take a peek at. RD-Q stated that's how I know who is high risk. On 4/18/22 at 3:10 p.m. VP (Vice President)-U, DON (Director of Nursing)-B and MDS/Wound RN (Registered Nurse)-G were informed of the above.

Based on observation, record review and interview, the facility did not ensure the prevention, and healing of pressure injuries. This was discovered in 2 (R33 and R2) of 3 residents reviewed with pressure injuries. * R33 developed a fissure above the sacrum on 3/24/21. There was no further assessment of this area until 4/22 and 4/29/21. On 5/13/21, the fissure became larger and the MD was contacted for new treatment. On 6/10/21 the assessment indicated slough in fissure. On 7/17/21, R33 was admitted to the hospital where it was noted upon admission, R33 had a stage 3 pressure injury on the sacrum. The facility had not identified the fissure as a stage 3 pressure injury. Upon readmission from the hospital on 7/23/22, the facility did not notify the physician of the hospital discharge wound treatment recommendations for the use of 2 X 2 with Dakins, cover with wet to dry keep frequently turned. The facility continued to use the treatment to apply Santyl ointment until 7/29/21. There was no wound assessment of R33's stage 3 pressure injury upon readmission on 7/23/21, even though the hospital identified R33 as having a stage 3 pressure injury. On 10/4/21, the sacrum pressure injury was noted to be larger and deeper and on 10/7/21 the pressure injury was noted to have declined with tunneling. There was no MD consultation or change in R33's care plan with the deterioration of the wound. On 10/14/21 slough was noted in the wound with no MD consultation. On 10/27/21, the MD progress note indicated the wound is declining, encourage nutrition and continue with wound specialist. On 10/28/21, the pressure injury assessment indicated the area was noted to be a stage 4, with no MD consultation, no notification of the POA and no care plan revisions. The physician did not see R33's pressure injury. On 4/13/22, during a dressing change surveyor noted no date on the dressing. R33's care plan was not revised timely as the wound deteriorated. On 4/18/22, R33 was observed seated on a gel cushion when according to RN-G R33 is not to have a cushion with the Broda chair. Additionally RN-G indicated the removal of heel boots from R33's care plan. * R2 is a risk for pressure injuries. A weekly wound assessment for 3/31/22 indicates R2 had a suspected deep tissue injury to the left lateral foot. This weekly wound assessment for 3/31/22 was conducted 6 days after the podiatrist discovered the area on 3/25/22. On 4/12, 4/13 and 4/14/22, Surveyor observed R2 in bed with heels resting directly on the mattress. The facility did not implement the floating of R2's heels prior to the development of the suspected deep tissue injury. Findings include: The facility's policy and procedure for Skin Care Management dated 8/21 was reviewed by Surveyor. The policy indicates to provide skin care to residents that include assessment, prevention of skin breakdown, and management of pressure injury and other skin integrity concerns. The procedures include: A skin and body assessment form will be completed with admission; readmission; significant change in condition; acuity and alterations in skin. 1. On 04/11/22 at 09:43 AM Surveyor observed R33 sitting in a Broda chair in their room. R33 has gripper socks on with pillow under feet. R33 has a seat cushion in the Broda chair. On 4/11/22 at 12:15 PM Surveyor observed R33 eating their pureed lunch in their room. R33 was sitting in a Broda chair and had a seat cushion. On 04/13/22 at 08:03 AM Surveyor observed R33 in bed watching T.V. There was an air mattress on the bed. R33 was laying on their back. R33's medical record was reviewed as R33 had developed a facility acquired stage 4 pressure injury on the sacrum. R33 has a plan of care for skin impairment starting on 10/15/19. The identified concerns with correlating interventions; On 11/1/19 the interventions are; To use a lift sheet, Reposition every 2 hours, Float heels off bed. On 12/9/2020 R33 was identified as having a stage 2 ulcer to coccyx and ulcer to right heel with no corresponding revisions to the care plan. On 2/25/21 the interventions indicate to ensure the Convertible Alternating pressure mattress is on; Broda chair; elevate heels; prevalon boots to feet at all times. R33's Quarterly MDS (Minimum Data Set) assessment completed 6/13/21 indicates at risk for pressure injury and no current pressure injuries. R33 requires total assist from staff for bed mobility/positioning. The Brief Interview for Mental Status (BIMS) documented 00 indicating R33 was not able to complete the interview. The Quarterly MDS assessment completed on 9/10/21 indicates 1 stage 3 pressure injury and total assist from staff for bed mobility/ positioning. R33 has an activated POA (Power of Attorney) for healthcare. The Brief Interview for Mental Status (BIMS) documented 00 indicating R33 was not able to complete the interview. The wound assessments were reviewed. A Wound/Skin assessments dated 3/24/21 indicates fissure above sacrum reopened, MD (Medical Doctor) and POA updated. measured 2 cm (centimeter) x 0.5 cm depth 0.1 cm 25% epithelial tissue. The fissure sacrum wound was not assessed again for 3 weeks, it was not assessed the week of 3/27- 4/2/22, 4/3-4/9, and 4/10-4/16/22. There were no care plan revisions when the fissure reopened. The fissure above the sacrum was not assessed again until 4/22/21 and on 4/29/21. The 4/29/21 assessment documents 0.9 cm by 0.2 cm with a depth of 0.2 cm and 100% epithelial cells. On 5/13/21 an assessment indicated the fissure became larger measuring 1.5 cm by 2.8 cm by 0.1 cm importance of offloading and MD was called for new treatment. The new treatment was for foam dressing to be changed daily rather than every 3 days. On 5/27/21 the care plan identified fissure to sacrum; blister to left anterior foot; reddened areas and pressure ulcers. There are no care planned interventions that correlate with this date. On 6/10/21 an assessment indicated slough in fissure started. On 6/17/21 the Fissure continues to the superior sacrum. On 7/4/21 a care planned intervention of a cushion in the Broda chair was added. R33 had a hospital visit from 7/17/21 - 7/23/21 for an unresponsive episode. R33 received fluids and had a stage 3 pressure injury on the sacrum. The Hospital Discharge Summary on 7/23/21 indicates cleanse sacral wound 2 x 2 with Dakin's and cover with wet to dry keep frequently turned. Upon readmission into the facility on [DATE], the Nurses Notes do not indicate the MD was notified of the hospital discharge wound treatment recommendations. The facility continued using the previous treatment until 7/29/21. There was no wound assessment upon readmission into the facility on [DATE]. On 7/29/21, the facility's wound assessment indicates the fissure evolved to a stage 3 pressure injury. The change in the wound assessment to a stage 3 pressure injury correlates with a hospital stay (7/17-7/23/21). The hospital documents a stage 3 pressure injury upon admission into the hospital on 7/17/21. Surveyor noted R33's pressure injury was not assessed appropriately from a fissure that was actually a pressure injury. Upon return from the hospital stay on 7/23/21, R33 had a stage 3 pressure injury to the sacrum. The hospital discharge instructions had a treatment order. This treatment order was not relayed to the physician at the facility upon readmission on 7/23/21. R33 did not have a wound assessment upon return from the hospital. The Treatment Administration Record for July 2021 has a MD order starting on 7/1/2021. This order indicates to clean fissure to buttocks with normal saline, pat dry, apply skin sealant peri-wound, apply Santyl ointment topically nickel thick to wound bed, cover with foam dressing daily until healed. This was documented as being administered, except during the hospital stay, until discontinued on 7/29/21. A new treatment order started on 7/29/21 to cleanse open area to sacrum with normal saline, pat dry, apply skin sealant to peri-wound, apply Santyl ointment topically nickel thick to wound bed only, cover with foam dressing daily. This was administered and then discontinued on 9/3/21. On 8/10/21 there is a care plan intervention to limit time up to 60 minutes during meals. Wound/Skin assessments with changes from a stage 3 to a stage 4 pressure injury were noted on the following: On 10/4/21 the wound/skin assessment indicated sacrum pressure injury is a stage 3 measuring 3.0 cm by 1.5 cm by 1.5 cm wound worse becoming larger and deeper. On 10/7/21 the wound/skin assessment indicated pressure injury declined with tunneling noted. There is no correlation with MD notification or change in plan of care. On 10/13/21 the care plan identified fissure has evolved into a pressure injury to the sacrum. On 10/13/21 an intervention of a protein supplement was added. On 10/14/21 the wound/skin assessment indicated slough in wound, no MD notification The MD progress note dated 10/27/21 indicates wound declining. Encourage nutrition and continue with wound specialist. There is an MD order for a nutritional supplement twice a day for wound healing. The MD progress note indicate stage 3 afterwards. On 10/28/21 the sacrum progressed to a stage 4 pressure injury from a stage 3 pressure injury. The medical record does not contain any care planned intervention revisions, MD or POA notifications when on 10/28/21, the wound declined to a stage 4 pressure injury. On 2/8/22 the care plan identified a fissure evolved into a pressure injury to the sacrum. On 2/11/22 an intervention of a nutritional supplement was added. On 4/12/22 the care plan identified a chronic stage 4 pressure injury to sacrum. There is no updated intervention. On 4/12/22 the care plan identified non-compliance with repositioning at times; dependent on staff for repositioning; incontinent of bowel and bladder. There are no updated interventions. On 4/13/22 at 2:02 PM RN-G provided Surveyor with the CNA (Certified Nursing Assistant) plan of care. The plan of care indicates the following for Skin Care: CCC mattress with pump. Broda chair. Float heels off bed. Offloading boots to be worn in chair. Reposition every 2 hours and as needed. Avoid direct pressure to sacrum as much as possible using slip sheet. Encourage R33 to keep the maximum amount of time in their chair to 60 minutes during meals to promote healing. For Toileting R33 is a check and change every 2 hours for incontinence of bowel and bladder. R33 is a 2 person Hoyer lift for transfers. On 04/13/22 at 01:25 PM Surveyor spoke with RN-G (Registered Nurse). RN-G indicated [R33] has declined overall in nutrition and physical activity which has contributed to the pressure injury RN-G reported [R33] does not have pain with treatment to the pressure injury. RN-G does not know why there is a cushion in the Broda chair. The Broda chair has its own pressure relief. Surveyor observed R33's pressure injury at this time with RN-G. RN-G removed the dressing from the sacrum. There was no date on the dressing. RN-G indicated they have talked with MD-P about nutrition and possible bladder catheter. RN-G indicated R33 has not had any infection in the wound. R33 has barrier cream placed around the surrounding skin. Surveyor observed the surrounding skin to appear macerated and R33 is incontinent of bladder. R33's pressure injury has not been assessed /visualized by any physician or nurse practitioner since their hospital stay from 7/17-7/23/21. RN-G indicated this area started as a fissure (the fissure was not assessed accurately as a pressure injury) and has been in communication with R33's POA . The POA indicated they want R33 managed here in the facility. R33 has limited mobility and there are struggles with moving R33 for transportation. R33's stage 4 pressure injury has no odor or drainage. During the observation of treatment, RN-G applied Santyl with a q-tip to the wound bed, followed by calcium alginate. RN-G then covered the area with a foam dressing. RN-G could not find barrier cream in the room and indicated they will find some later. RN-G indicated R33 uses a heel manager and does not wear pressure relief boots. RN-G indicated they will verify why there was a seat cushion. RN-G indicated R33 does not like to be on positioned on their side. On 04/13/22 at 02:02 PM, RN-G spoke with Surveyor who stated [R33] is not supposed to have a cushion in the Broda chair. RN-G indicated they will remove the cushion. RN-G also stated they will remove the (2/25/21) heel boots from the care plan. RN-G stated [R33] should be using the heel manager or off-loaded device. RN-G stated she would look for when the pressure injury changed to a stage 4 pressure injury and what revisions were made (to the care plan). RN-G will find out more information related to wound changes and interventions. On 4/13/22 at 3:20 PM, Surveyor shared R33's wound concerns with Administration at the facility exit meeting. On 04/14/22 at 02:29 PM Surveyor spoke with RN-G. RN-G indicated on 10/13/21 (she), spoke with Wound NP (Nurse Practitioner) about worsening of the wound, vitamins and nutritional supplements. (There is no documentation of this discussion.) RN-G indicated the plan of care was revised to avoid pressure to sacrum; monitor intakes; encourage to be up un chair for just 60 minutes for mealtimes; protein and nutritional supplement. On 04/14/22 at 10:37 AM, RN-G told Surveyor they did communicate to MD-P the stage 4 change. However, the conversation is not documented reflecting any changes in the plan of care. On 4/14/22 at 3:30 PM Surveyor shared the concerns with R33's wound with Administration at the facility exit meeting. On 04/14/22 at 03:46 PM Surveyor spoke with MD-P who reported they did not see the wound and does not recall if they knew resident had a stage 4 (pressure injury). MD-P's progress notes do not indicate a stage 4 pressure injury. MD-P did not see the pressure injury. There is an MD order on 10/26/21 to switch the nutritional supplement from Prosource to [MEDICATION(S)], twice a day for wound healing. The MD progress note dated 10/27/21 indicates wound declining. Encourage nutrition and continue with wound specialist. Surveyor observed there was no indication in the record that R33 was being seen by a wound specialist. The wound assessment indicates on 10/28/21 the sacrum progressed to a stage 4 pressure injury from a stage 3 pressure injury. The medical record does not contain any intervention revisions, MD or POA notifications when wound deteriorated to a stage 4 pressure injury on 10/28/21 On 04/18/22 at 09:05 AM Surveyor observed R33 up in a Broda chair with a gel cushion on the seat. R33 also has a Hoyer sling behind R33's back while R33 was seated on the gel cushion. R33 was in the lounge area on unit. On 04/18/22 11:09 AM Surveyor spoke with DON-B (Director of Nurses) regarding R33 seat cushion in the Broda chair, R33's pressure injury concerns with the change of wound, and no care plan revisions/interventions with changes identified through the assessment. DON-B indicated the weekly wound assessments get reviewed by Corporate for interventions. The gel cushion information was provided to Surveyor. The gel cushion manufacturer indicates it is designed for users at moderate RISK for skin breakdown. On 04/18/22 at 03:27 PM, RN-G stated there should be no gel cushion in the Broda. RN-G reported the (pressure injury) area was originally assessed as a fissure. RN-G continued calling it a fissure. On 4/19/22 at 9:00 AM RN-G provided Surveyor with a fax to MD-P. The fax was dated 4/19/22 at 8:30 AM and requests a wound consult and a Foley catheter for bladder. This was just sent and no response noted from MD-P at this time. 2. R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The CNA (Certified Nursing Assistant) Assignment Sheet not dated under skin care includes Float feet off of bed with heel manager or equivalent device every shift. and DTPI (deep tissue pressure injury) to left lateral foot. The Impairment of skin integrity care plan dated 2/6/20 has the following approaches: * Assess skin condition daily and note any changes, Treat as ordered, Keep clean and dry, apply tubigrips per MD (medical doctor) order, monitor feet daily notify MD of any changes dated 2/6/20. * Assist with hygiene and general skin care, Reposition every two hours, and PRN (as needed) remove tubigrips at HS (hour sleep), elevate legs whenever possible Keep skin clean and dry, Use lift sheet when moving resident in bed dated 2/6/20 & 4/9/21. * Provide ordered diet, Offer replacement food, Determine food likes dated 2/6/20. * 1:1 visits, Encourage activity participation dated 2/6/20. * P.T. (physical therapy) Evaluate, Treat as indicated 2/6/20. * O.T (occupational therapy) Evaluate, Treat as indicated 2/6/20. * S.T. (speech therapy) Evaluate, Treat as indicated 2/6/20. * Assess skin condition daily and note any changes, Treat as ordered, Keep clean and dry, apply tubigrips per MD order, monitor feet daily notify MD of any changes skin assessment weekly due to at risk for skin breakdown due to immobility, diabetes, PVD (peripheral vascular disease), HX (history of) [CONDITION(S)] Braden scale completed every quarter dated 4/9/21. * Complete tx (treatment) per MD order dated 9/17/21. * Encourage [Resident's first name] to wear shoes when in his w/c (wheelchair) dated 12/1/21 * Administer oral ABT (antibiotics) per MD order dated 2/4/22. * Encourage [Resident's first name] to elevate BLE (bilateral lower extremity) while in bed, assist in trimming finger nails on shower days and PRN dated 2/4/22. * Assist with hygiene and general skin care, Reposition every two hours, and PRN float heels off of bed, tubigrips at HS, elevate legs whenever possible Keep skin clean and dry, Use lift sheet when moving resident in bed dated 3/8/22. * Report shower refusals to nurse promptly dated 3/8/22. * Tubi grips on in am (morning) off at HS, encourage [Resident's first name] to elevate his BLE while in bed dated 4/1/22. * Complete tx per MD order, update MD of any s/s (sign/symptoms) of infection dated 4/1/22. * Float feet off of bed with heel manager or equivalent device every shift NOC (night) AM (day) PM (evening) dated 4/1/22. * Encourage to reposition every 2 hours and PRN, report refusals to nurse dated 4/12/22. The annual MDS (Minimum Data Set) with an assessment reference date of 12/28/21 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R2 requires extensive assistance with two plus person physical assist for bed mobility & transfer, does not ambulate and is dependent with two plus person physical assist for toilet use. R2 is occasionally incontinent of urine and bowel. R2 is at risk for pressure injuries and is coded as not having any pressure injuries. The podiatry consult dated 3/25/22 under progress notes documents He states feet are mostly numb. Noticed a blood blister still full of blood lateral left foot I told his nurse to monitor, The weekly wound assessment dated [DATE], late entry for 3/31/22 documents Foot problem/care: **NEW AREA** Has 1+ foot problem eg. corn, callous, bunion, hammer toe, overlapping toe, pain structural problem. Suspected Deep Tissue Injury: Appearance of blood-filled blister, intact skin, Location: left lateral foot. Length: 0.5 cm (centimeters), Width: 0.5 cm, Depth <(less than) 0.1 cm, Drainage: none present clean and dry No odor present, Surrounding Tissue: [CONDITION(S)] +3, Healing process: new area discovered during podiatry visit per nurse interview, Teaching done: importance of floating feet off of bed, Skin Treatment: Receives turning/repositioning program. float heels off of bed with heel manager or equivalent. Receives application of dressings (with or without topical medications) other than to feet. Procedure done: area cleaned examined measured area off loaded from bed. Action: tx order pending. Surveyor noted this assessment is 6 days after the area was discovered during a podiatry consult on 3/25/22. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 4/2/22. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekly wound assessment dated [DATE] documents Suspected Deep Tissue Injury: Purple/maroon colored, localized area, intact skin, Appearance of blood-filled blister, Location: left lateral foot Length: 2.0 cm, Width: 1.0 cm, Depth: <0.1 cm Tissue Type: Closed, Wound Tissue: NA (nonapplicable), Drainage: none present clean and dry No odor present, Surrounding Tissue: [CONDITION(S)] Healing Progress: no change, Description: no s/s of infection present Teaching Done: importance of diet and [CONDITION(S)] control on skin condition Skin Treatment: skin sealant applied to area q (every) shift, [CONDITION(S)] control, diabetes management Procedure Done: area cleaned examined measured Skin tx done per order Procedure Result: treatment effective. On 4/11/22 at 1:25 p.m. Surveyor reviewed the Facility's pressure injury list and noted R2 is listed for a left foot DTPI. On 4/11/22 at 2:00 p.m. Surveyor observed R2 sitting on the edge of the bed. Surveyor asked R2 if he has any skin impairments on his feet. R2 replied they said while ago had a couple of blisters but I can't see them. R2 also informed Surveyor the Podiatrist said had a couple of bumps. R2 stated I don't know why I'm not walking and I have black velcro shoes which are not on my feet. R2 informed Surveyor he has diabetes. On 4/12/22 at 11:09 a.m. Surveyor observed R2 in bed on his back with the head of the bed elevated. Surveyor observed R2 heels are resting directly on the mattress and there is not a heels up device on the bed. Surveyor asked R2 if staff ever floats his heels. R2 replied no. On 4/13/22 at 1:01 p.m. Surveyor observed R2 in bed on his back with two transfer bars up. Surveyor observed R2's heels are resting directly on the mattress and there is not a heels up device on the bed. On 4/13/22 at 1:06 p.m. Surveyor observed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-D with gloves on removed R2's tubi grips & gripper sock from his left lower extremity, removed her gloves, washed her hands, and placed gloves on. RN-D opened the skin prep package and applied skin prep on R2's left lateral foot pressure injury. RN-D then completed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 informed RN-D they are in the box. RN-D removed her gloves telling R2 the pillows are for under his feet. RN-D placed gloves on, placed R2's tubi grips and gripper sock back on and placed a pillow under R2's legs to float his heels. RN-D removed her gloves and washed her hands. On 4/13/22 at 1:18 p.m. Surveyor spoke with RN-D regarding R2's deep tissue pressure injury. RN-D informed Surveyor the blood blister was caught by the podiatrist. Surveyor asked RN-D how this area developed. RN-D informed Surveyor R2's feet lay out like a frog and assumed the pressure injury developed from the bed. RN-D informed Surveyor R2 doesn't get up very often just for showers or doctors appointments and very rarely attends activities. Surveyor asked RN-D prior to R2 developing this pressure injury were staff floating his feet. RN-D replied I don't believe so. On 4/14/22 at 7:54 a.m. Surveyor entered R2's room with RN-D to observe RN-D administer insulin to R2. Surveyor observed R2 in bed on his back. After RN-D administered R2 his insulin, Surveyor asked RN-D if Surveyor could look at R2's feet. RN-D removed the bedding off R2. Surveyor observed R2's right foot is resting directly on the pillow and the left foot is on the mattress. RN-D informed Surveyor R2 must of kick off the pillow and readjusted the pillow so R2's feet were being offloaded. On 4/14/22 at 10:54 a.m. Surveyor met with MDS/Wound RN-G to discuss R2's pressure injury. Surveyor asked MDS/Wound RN-G what should be under R2's feet when he is in bed. MDS/Wound RN-G informed Surveyor they encourage R2 to use heel manager as long as R2's feet are offloaded and elevated. Surveyor informed MDS/Wound RN-G most of the time Surveyor observed R2 sitting on the edge of his bed but when R2 was laying in bed the only time Surveyor observed anything under his feet was with RN-D when she placed a pillow. Surveyor asked MDS/Wound RN-G how did R2's pressure injury develop. MDS/Wound RN-G informed Surveyor it's the strangest thing, the podiatrist saw it, thought maybe it was from his shoes being too tight but R2 barely wears them. MDS/Wound RN-G informed Surveyor R2 denied any injury to his foot, R2 does have diabetes and he could of bumped his foot on something. MDS/Wound RN-G informed Surveyor R2 has been wearing tubi grips to help manage [CONDITION(S)] and float heels off bed when possible. Surveyor asked where Surveyor would be able to find diabetic foot checks. MDS/Wound RN-G replied on the TAR (treatment administration record). Surveyor informed MDS/Wound RN-G Surveyor did not note diabetic foot checks on R2's TAR. MDS/Wound RN-G then looked at R2's electronic record and informed Surveyor she's not seeing it. MDS/Wound RN-G stated Usually diabetics have it, I'm still shocked. On 4/18/22 at 10:35 a.m. Surveyor asked CNA (Certified Nursing Assistant)-I if she knew how R2 developed the pressure injury on his left foot. CNA-I replied I sure don't. Surveyor asked if they float R2's feet. CNA-I informed Surveyor lately they have been putting them up on a pillow. Surveyor asked if they started floating R2's feet after he developed the pressure injury. CNA-I replied yes. Surveyor asked if they were floating his feet prior. CNA-I replied no.

Based on observation, interview, and record review, the facility did not ensure that 3 (R32, R38, R31) of Residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents and that the environment was free of accident hazards. * R32 was assessed as being unsafe with smoking 8/25/21. On 4/10/22, R32 was outside smoking with a family member. R32 sustained a second or third degree burn to the left anterior knee. R32 stated he did not mean to burn himself. R32 was allowed t smoke without staff supervision. *On 5/8/21, R38 fell in his room sustaining a laceration that required 13 sutures. R38's interviews reveals prior to the fall he had informed maintenance about a piece of wood sticking out from bed footboard. He asked for this to be fixed or for tape to fix it himself. R38 informed Surveyor he was told they (maintenance) were too busy. There is no evidence maintenance inspected R38's footboard prior to 5/8/21. R38 received the laceration when he fell against the protruding wood on the footboard. * R31 was observed without a mat on the floor next to the bed and the bed not in the lowest position according to R31's care plan interventions. Findings include: The facility smoking policy with revised date of 6/2020, indicates: . Protocol: 1. The facility prohibits smoking and tobacco use on all company premises in order to provide and maintain a safe and healthy environment for all. a. Company premises is defined as up to the property boundaries of all facilities. *with the exception of the southeast corner of the courtyard on the east side of the building . 3. The smoke and tobacco free policy applies to: a. All areas of buildings occupied by residents and employees. b. All vehicles owned or leased by the facility. c. All visitors (customers, vendors and volunteers) on facility premises. d. All contractors and consultants and/or their employees working on facility premises. e. All residents. f. All employees, including temporary employees. g. All student interns. 5. Employees are not allowed to assist residents in smoking or chewing as they are not allowed to leave the campus property while working. Families that wish to assist residents may do so after signing the resident out on the Resident Sign Out Form and leaving campus property. 1. R32 was admitted to the facility on [DATE]. R32's smoking assessment, dated 8/25/21, indicates R32 memory impaired oriented to person, has difficulty making decisions in new situations, makes decisions which are poor; requires cues and supervision when making decisions. Lights/extinguishes cigarette safely: no: someone to assist him Physically capable of managing smoking: needs assistance. Level of assistance required: needs assistance with: lighting cigarette. R32's quarterly MDS (minimum data set), dated 1/26/22, indicates R32 has cognitive impairment, is dependent with bed mobility, transfers, locomotion on and off the unit, and has mobility issues with his upper and lower extremities. R32's nurses note, dated 4/10/22, indicates open area on left knee. 1 by 0.5 granulation tissue no drainage or odor. Applied dressing to left knee. R32's nurses note, dated 4/11/22, indicates New area has second or third degree burn (s) .superior to left anterior knee 1.0 cm (centimeter) by 0.5 cm by < (less than) 0.1 cm UTA (unable to assess) wound bed to 100% dry tan exudate in place. Area circular in shape. resident stated I didn't mean to burn myself. R32's incident investigation, dated 4/11/22, indicates writer discovered area of skin impairment at time of assessment. Other causal factors: resident smokes primarily with daughter. Physician and POA (Power of Attorney) notified. R32's April 2022 MAR (medication administration record), indicates on 4/11/22 an order was obtained to Cleanse open area to left anterior knee with NS (normal saline) pat dry apply skin sealant to periwound apply [MEDICATION(S)] ointment to wound bed topical daily f/b (followed by) dry gauze secure with kerlix AM (morning) R32's smoking assessment, dated 4/13/22, indicate: Holds cigarette safely: no; burn discovered to left anterior left, resident admits he had burned himself with a cigarette, but didn't mean to. Level of assistance required: Needs assistance with entire smoking process. Resident noted to be an unsafe smoker. The above information reviewed with NHA (Nursing Home Administrator), DON(Director of Nursing), and SSD (Social Service Director). POA is aware of findings and agrees that resident is an unsafe smoker due to his ability to fall asleep quickly and frequently. pending further investigation. On 4/13/22, at 3:30 PM, during the daily exit meeting with DON-B, Wound Nurse-G and NHA-A, Surveyor asked how R32 burned himself with a cigarette when R32 is assessed to be dependent and cognitively impaired. Wound Nurse-G stated R32 goes out to smoke with daughter when she visits. Wound Nurse-G stated R32's daughter is not sure how the burn happened. R32's POA (Power of Attorney) stated R32 doses off while smoking. On 4/14/22, at 10:02 AM, Surveyor interviewed Wound Nurse-G. Surveyor asked if the cigarette burn was assessed and treated on 4/10/22. Wound Nurse-G stated when she came in on 4/11/22 she discovered the cigarette burn and obtained orders for treatment from the physician. On 4/14/22, at 3:30 PM, during the daily exit meeting with DON B, Wound Nurse G and NHA A, Surveyor explained the concern R32 sustained a cigarette burn on 4/10/22 while he was outside with his daughter. A treatment for the burn was not obtained until 4/11/22. Surveyor also explained the concern R32 is dependent for most ADLs (activities of daily living) yet was not monitored while outside smoking. As of 4/18/22, Wound Nurse G had no additional information. 2. R38's diagnoses include [CONDITION(S)], chronic [CONDITION(S)], diabetes mellitus, [CONDITION(S)], hypertension, and [CONDITION(S)]. R38's Annual MDS (minimum data set), with an assessment reference date of 1/21/22, documents a BIMS (brief interview mental status) score of 15 which indicates R38 is cognitively intact for daily decision making. R38 requires limited assistance and one person physical assist for bed mobility, transfer & toilet use. R38 requires supervision with set up only for ambulating in room and requires extensive assistance with one person physical assist for ambulating in corridor. R38 is incontinent of urine and continent of bowel. R38 is coded as not having any falls since prior assessment period. On 4/11/22, at 12:16 p.m. Surveyor observed R38 sitting in a wheelchair in his room. R38 showed Surveyor a scar on his right inner forearm. R38 informed he received this last year in May. Surveyor asked R38 what happened. R38 explained there was a piece of wood sticking out on his footboard and begged maintenance for a long time to fix it, but they said they didn't have time. R38 informed Surveyor he also asked for tape to cover the wood sticking out. R38 informed Surveyor one time he got up and ran into it and had to have stitches. R38's nurses note dated 5/8/21, documents incident type: resident reported a fall, date of incident: 5/8/21, location: resident's room; resident's condition prior: orientated; activity at the time: walking; equipment involved: wheelchair (was not using); injury: laceration; injury location: left forearm (should be right), injury; measurement: 10 cm (centimeters) x (times) 2.5 cm; first aid: DSD (dry sterile dressing) and kerlix; first aid: wrap to forearm transferred to emergency room vitals blood pressure 122/74, pulse 70, respiratory rate 18, temp (temperature) 98.0, neurochecks right hand grasp weak (r/t (related to) pain from laceration) left hand grip firm staff involved: nurse; witnesses: none R38's nurses note dated 5/8/21 documents Resident returned from ER (emergency room ) accompanied by 2 paramedic staff. Hospital sutured lac (laceration) on right forearm. Has order for suture removal on 5/18/21 [name of hospital] in emergency department. Resident drowsy but able to answer/ask questions. The after visit summary from hospital dated 5/8/21 documents laceration care. R38's nurses note dated 5/8/21, includes documentation of measurements right arm of 10.0 cm, 2.5 cm, 0.1 cm well approximated with 13 sutures. R38's nurses note dated 5/11/21 includes documentation of skin problems: laceration, drainage: none present no odor present, description: no s/sx (signs/symptoms) of infection noted, sutures intact. On 4/11/22, at 12:17 p.m., Surveyor asked R38 why he doesn't have a foot board on his bed. R38 informed Surveyor maintenance took it off. Surveyor asked why they didn't give him another one. R38 informed Surveyor they were afraid something would happen because he's so tall. R38 informed Surveyor they angled his bed so he could see the TV. R38 stated to Surveyor They haven't apologized for what happened referring to the scar on his right forearm. On 4/14/22, Surveyor reviewed R38's incident investigation for date of 5/8/21 at 1:10 a.m. Under description of incident for what resident stated regarding incident I slipped on the way from the toilet. For root cause identified documents resident not using w/c (wheelchair) For resident injury/outcome documents Laceration to right forearm; resident sent to ER for possible stitches or staples to area. There is a handwritten notation attached to R38's incident investigation which documents Return from hospital, resident stated he cut arm on footboard. Maint (maintenance) immediately addressed. On 4/14/22, at 11:04 a.m., Surveyor asked MDS/Wound RN (Registered Nurse)-G if she was involved with R38's fall on 5/8/21. MDS/Wound RN-G replied no and explained she wasn't the nurse for either fall but does recall the laceration and sutures. Surveyor asked MDS/Wound RN-G how R38 received the laceration. MDS/Wound RN-G informed Surveyor R38 wasn't using his wheelchair and was walking. Surveyor asked what R38 cut his forearm on. MDS/Wound RN-G informed Surveyor she thinks it may have been the footboard. On 4/14/22, at 11:14 a.m., Surveyor asked MS (Maintenance Supervisor)-E if he was involved with R38's fall on 5/8/21. MS-E informed Surveyor R38 fell on the weekend and he wasn't here. MS-E informed Surveyor he removed the footboard because it was cracked. Surveyor asked if R38 mentioned to him his footboard had sharp edges before the fall. MS-E replied I don't recall. On 4/18/22 at 12:07 p.m. MT (Maintenance Tech)-H informed Surveyor he saw R38's footboard after the incident. MT-H informed Surveyor he didn't see anything on their log regarding R38's footboard and does walk around Resident's room. Surveyor inquired if there are any maintenance logs when Resident's beds including headboard or footboards are inspected. MT-H informed Surveyor they do a walk around the room, has glanced in R38's room and doesn't recall anything on the footboard. MT-H informed Surveyor R38 does close his door. On 4/19/22 at 9:08 a.m. Surveyor asked R38 who in maintenance he spoke to regarding his footboard. R38 informed Surveyor last night after supper MT-H came to speak to him. R38 informed Surveyor he had spoken to MS-E. R38 informed Surveyor he told MT-H a piece of wood was sticking out of the footboard and MT-H told him it was a piece of plastic. R38 stated he told MS-E every day for a week before the accident but not on the weekend as there is no maintenance here on the weekend. MS-E told him he was too busy and the day before the accident he asked MS-E for tape to do it himself but MS-E said he had to do it but was too busy. R38 informed Surveyor his right arm got in contact with the object sticking out, must of hit his head as there was blood everywhere and a gash in his skin. R38 again showed Surveyor the scar on his right inner forearm and stated his sister hasn't seen it yet. 3. R31 was admitted to the facility on [DATE] with diagnoses that include dependence on [CONDITION(S)], acute & chronic respiratory failure, [CONDITION(S)], and [CONDITION(S)] disorder [CONDITION(S)] type. R31's potential for trauma-falls care plan, dated 12/1/18, includes the following approaches: * Observe, record, and report all unsafe conditions and situations, Anticipate fall times, Instruct on safety, dated 12/1/18; * Call light in reach, Toilet every 2 hours and as needed, Anticipate needs, Floor mat on floor beside bed when resident is in the bed, (the right side of bed), dated 12/1/18; * Call light in reach, Toilet every 2 hours and as needed, Anticipate needs, floor mat on both sides of [first name] bed, dated 12/12/18; * Observe, record, and report all unsafe conditions and situations, Anticipate fall times, Instruct on safety, dated 4/28/21; * Call light in reach, Toilet every 2 hours and as needed, Anticipate needs, floor mat on both sides of [first name] bed, dated 4/28/21. The last fall assessment was completed 11/30/20. The CNA (Certified Nursing Assistant) Assignment Sheet, not dated, under the safety Equipment section documents Floor mat on right side of bed in lowest position. Enabling bars on bed. R31's quarterly MDS (minimum data set), with an assessment reference date of 1/26/22, documents a BIMS (brief interview mental status) score of 5 which indicates severe impairment related to daily decision making. R31 is dependent with two plus persons for bed mobility, transfer, & toilet use and does not ambulate. R31 is always incontinent of bowel and bladder and is coded as not fallen since prior assessment period. On 4/12/22, at 11:06 a.m., Surveyor observed R31 in bed on his back with the head of the bed elevated and two transfer bars up. Surveyor observed R31's call light is on the floor and not within reach. Surveyor also observed there were no mats on the floor next to R31's bed. On 4/12/22, at 12:23 p.m,. Surveyor observed R31 in bed on his back with two transfer bars up. Surveyor observed R31's call light is now within reach. Surveyor observed there are still no mats on the floor next to R31's bed. On 4/14/22, at 8:01 a.m., Surveyor observed R31 in bed on his back with the head of the bed elevated with two transfer bars up. Surveyor did not observe a mat on the floor next to R31's bed. On 4/14/22, at 8:56 a.m., Surveyor observed R31 continues to be in bed on his back with the head of the bed elevated and two transfer bars up. Surveyor did not observe a mat on the floor next to R31's bed. On 4/14/22, at 1:30 p.m., Surveyor observed R31 in bed on his back with his eyes closed. Surveyor did not observe a mat on the floor next to R31's bed and R31's bed is not at the lowest position. On 4/14/22, at 1:32 p.m., Surveyor asked RN (Registered Nurse)-D if she knew which CNA (Certified Nursing Assistant) was assigned to R31. RN-D asked Surveyor if Surveyor needed something. Surveyor explained to RN-D Surveyor wanted to ask if R31 is suppose to have mats on the floor next to his bed. RN-D replied I believe he is. RN-D then reviewed the CNA assignment sheet, printed on 4/7/22, and informed Surveyor R31 is to have a mat on the right side of the bed, bed in lowest position and has enabling bars on the bed. At 1:34 p.m., Surveyor informed RN-D there is not a mat on the floor next to R31's bed and the bed is not at the lowest position. RN-D stated she will get right on it now. On 4/14/22, at 3:56 p.m., during the end of the day meeting Administrator-A and DON (Director of Nursing)-B were informed of the above. On 4/19/22, at 9:15 a.m., Surveyor observed R31 in bed on his back with the head of the bed up. Surveyor observed R31's bed is not at the lowest position and there is no mat on the floor next to R31's bed. Surveyor did observe a gray mat along the wall as you enter R31's room on the right side.

Based on observations, record review and staff interviews, the facility did not always ensure that they, based on a comprehensive assessment, provided the necessary care and treatment to 3 out of 3 residents (R5, R12 and R1) reviewed for pressure ulcer care and treatment. The facility did not always ensure that a resident with pressure ulcers received the necessary care and treatment to promote healing and prevent new ulcers from developing for 3 out of 3 sampled residents reviewed (R5, R12 and R1). * R5 was admitted to the facility with pressure ulcers to the right, left and medial sacrum. The facility did not always comprehensively assess these areas, update the plan of care with interventions to aid in the healing of these areas and provide treatments as ordered. R5 also developed a facility acquired unstagable pressure ulcer to the left heel. The facility did not comprehensively assess, update the plan of care and provide treatments as ordered. * R12 was readmitted to the facility with a pressure ulcer to the sacrum and a facility acquired pressure ulcer to the right heel. The facility did not ensure that R12 was comprehensively assessed, that the plan of care was updated with necessary interventions to assist in healing the pressure ulcers and to avoid the devlopment of further pressure ulcers and did not always provide the treatments as ordered by the physician. * R1 had seven pressure ulcers that were both present on admission and acquired at the facility. The wounds were not comprehensively assessed weekly, the Skin Integrity Care Plan was not revised to prevent future pressure injuries, the physician was not always notified when there was a change in the wound, and treatments were not administered as ordered. This is evidenced by: Policy Review: Skin Care Management last revised on 10/20 Purpose: It is the policy of this nursing home to provide skin care to residents that includes assessment, prevention of skin breakdown and management of pressure injury and other skin integrity concerns. Protocol: (includes) 1.) Within 4 hours of admission, a complete body check is completed by the nurse, using the Skin and Body Assessment Form. If any issues are found on this comprehensive body check, a Skin Care Flow Sheet (or electronic equivalent) will be completed. A Braden Scale will also be calculated at this time. 2.) The Skin and Body Assessment Form is to be completed as instructed above at the time of admission, quarterly, and if there is significant change in the resident's condition, acuity or alterations to skin. This form is always completed within 4 hours of readmission to the nursing home since a comprehensive new admission resident assessment is not completed for hospital readmissions. a.) If any pressure or other skin ulcers are found during the assessment, the Skin Care Flow Sheet or ( electronic equivalent) is to be completed and maintained until the area is healed and for 30 days after. If paper-based, all assessments are to be filed in the assessment section of the medical record when completed. 3.) The Braden Scale pressure injury risk assessment will be completed weekly in ECS (electronic record) for 4 weeks upon new admission. This assessment will also be completed to identify risk factors up readmission, quarterly and if there is a significant change in the resident's condition, acuity or alterations to their skin. 6.) When a resident is admitted with or develops a pressure injury or any other open area, immediate treatment will be initiated. a.) The Skin Care Flow Sheet (or electronic equivalent) will be initiated (if indicated) by the nurse. b.) Comprehensive assessment of pain and implementation of pain control measures prior to treatment if the first priority in wound care management. c.) Measurements of the area will be done using a wound measuring guide. d.) A weekly assessment and associated documentation will be done by the nurse using the Skin Care Flow Sheet (or electronic equivalent) If paper- based, this will be filed in the Assessment section of the resident's record upon completion. 7.) When a resident is transferred to the hospital or discharged , a complete body assessment is done by the nurse using the Skin and Body Assessment Form. This form is to be placed in the resident's record with the transfer/ discharge records. 1. R5 was originally admitted to the facility on [DATE] following a surgical amputation of the 3rd, 4th and 5th toes to the left foot. R5's [DIAGNOSES REDACTED]. Surveyor conducted a closed record review of R5's electronic medical record and the following was noted: Nursing note dated 11/2/20 stated that R5 was admitted to the facility 3:00 p.m. from . Hospital. The only note regarding R5's skin condition on the day of admission is that the general skin is dry and warm. Nursing note dated 11/3/20 states Pressure Ulcers on Admit. Partial thickness loss of skin layers that presents as an abrasion or blister ( stage #2) Left buttock approximately 7.0 cm by 7.0 cm. by >0.1 cm., irregular shape, periwound reddened, peeling, jagged shape. Wound base 50 % yellow, 50% pink. Small amount of serous drainage, no odor after cleaning. Fax to MD to update and to request orders. Second note indicates Stage #2 right buttock approximately 7.0 cm. by 6.0 cm. by <0.1 cm. irregular shape, periwound reddened, peeling, jagged in shape. Wound base 50 % yellow and 50 % pink. Small amount of serous drainage, no odor after cleaning. Fax to MD to update and request orders. Nursing note Weekly Skin assessment dated [DATE] states that R5 has a Stage #2 pressure ulcer to the medial sacrum. Length 1 cm. by 0.7 cm. width by 0.1 cm. depth. 100% [MEDICATION NAME] tissue, wound tissue is yellow/pink. Drainage is light exudate, no odor present, surrounding tissue is excoriated. Pressure ulcer edges are open and proliferative. Skin treatment indicates has pressure relieving device for chair and pressure relieving device for bed. Receives turning / repositioning program. Receives application of dressings other than to feet. Procedure done: cleaned, examined, measured and dressing applied. Action: continue to observe. It is noted that this area was not mentioned in the skin assessment conducted on 11/3/20. The weekly skin assessment, dated 11/5/20, states R5 has a Stage #2 right sacrum 3 cm. length by 3.2 cm. width by 0.1 cm depth with the tissue type being 100 % [MEDICATION NAME]. Wound tissue is pink and drainage noted to be light exudate. Surrounding tissue is excoriated, no undermining present. Procedure done: cleaned, examined, measured and dressing applied. Action: continue to observe. Weekly Skin Assessment, dated 11/5/20, states R5 had a Stage #2 pressure ulcer to the left sacrum, 3 cm. length by 3 cm. width by 0.1 cm. depth. Tissue type is 100% [MEDICATION NAME] tissue and the wound base is pink. Drainage: light exudate, surrounding tissue is excoriated. No undermining present. Pressure ulcer edges are open and proliferative. Procedure done: cleaned, examined, measured and dressing applied. Action: continue to observe. A review of the physician orders for November, 2020 showed that the facility did not obtain a treatment order for the Stage #2 pressure ulcers, noted on 11/3/20, until 11/5/20. The order was to clean areas to sacrum with soap and water wash, dry, apply medi-honey to wound base, cover with foam sacral dressing every 3 days in the morning. Start date 11/5/20. Surveyor conducted a review of the Skin Care Flow Sheet for R5. The flow sheet indicates that R5 has a pressure ulcer (stage #2) to the right sacrum, present on admission, date of origin 11/2/20. The flow sheet indicates the area measured 3cm. by 3.2cm. by 0.1cm., 100 % [MEDICATION NAME] wound base, scant serous exudate and pain is present. Healing progress noted that the wound base is pink, periwound is excoriated and wound margins intact. Foam dressing every 3 days. Surveyor conducted a review of the Skin Care Flow Sheet for R5. The flow sheet indicates that R5 has a pressure ulcer (stage #2) to the left sacrum, present on admission, date of origin 11/2/20. The flow sheet indicates the area measured 3cm. by 3cm by 0.1 cm, 100 % [MEDICATION NAME] wound base, scant serous exudate and pain is present. Healing progress noted that the wound base is pink, periwound is excoriated and wound margins intact. Foam dressing every 3 days. Surveyor conducted a review of the Skin Care Flow Sheet for R5. The flow sheet indicates that R5 has a pressure ulcer (stage #2) to the medial sacrum, present on admission, date of origin 11/2/20. The flow sheet indicates the area measured 3cm. by 3cm by 0.1 cm, 100 % [MEDICATION NAME] wound base, scant serous exudate and pain is present. Healing progress noted that the wound base is pink, periwound is excoriated and wound margins intact. Foam dressing every 3 days. It was noted that the Skin Care Flow Sheet refers to R5 having pressure ulcers to the right, left and medial sacrum. The initial skin assessment on 11/3/20 (day after admission) states R5 has Stage #2 pressure ulcers to the right and left buttock. There is no drawing of a diagram to indicate if this is the same areas described on 11/3/20 as 11/5/20. A review of R5's individual plan of care, developed 11/2/20, states that R5 has the problem: tissue integrity impairment, potential for increased skin alteration. Related to post operation to left foot surgery (amputation of toes), decreased mobility, diabetes, [MEDICAL CONDITION], previous [MEDICAL CONDITION]. Approaches are to assess skin status, assess nutrition status, keep physician informed, refer to dietician, follow medical plan for treatment. Nurse Aides are to keep skin clean and dry, avoid restricting clothing, encourage and assist to reposition, inspect skin each shift and report changes to nurse on the unit. It is noted that the plan of care did not contain the fact that R5 was admitted with pressure ulcers to his sacrum and would be at risk for further pressure ulcer development. The plan of care did not include approaches to assist in the healing of R5's current pressure ulcers and interventions to prevent further pressure ulcers from developing. A Braden Scale/ pressure injury risk assessment was conducted on 11/3/20. The assessment did not indicate if R5 was at risk or not at risk of developing pressure ulcers. Ii indicates R5 has slightly limited mobility, R5 is chair fast and can't bear weight or assist to chair or wheelchair. Some sliding with repositioning, occasionally slides down in bed/ chair. This was the only Braden assessment conducted by the facility. The policy indicates that a Braden Assessment is to be completed weekly for the first 4 weeks following admission. The Admission Minimum Data Set (MDS), dated [DATE], states that R5 needs extensive assistance / 2 person physical assistance for bed mobility. R5 has not transferred or has not had any locomotion on/ off the unit during this assessment reference period. The MDS states that R5 had 3- Stage #2 pressure ulcers present on admission as well as surgical wounds. It is noted that pressure device for chair and bed and turning and repositioning program is in place. Nursing note dated 11/15/20 indicates weekly skin assessment: good. There were no further comprehensive assessments of the pressure ulcers to the right, left and medial sacrum since 11/5/20. There is no indication if the areas are smaller or larger in size, if the wound base has changed and if the pain is still present. Weekly Skin assessment dated [DATE] states that R5 has open [MEDICAL CONDITION] on the foot (surgical wound from admission). Therapist request assessment to R5's left heel, blood noted on bed sheet, upon assessment pressure ulcer present, 2.5 cm. by 2.5 cm. overall, center area 1.5 cm by 1.5 cm. 90% necrotic tissue p, 10 % slough, surrounding skin red, unstageable due to necrotic tissue. Procedure done: left heel floated off mattress with pillow to relieve pressure to area. Action: MD notified of new area, fax request sent for treatment and follow up appointment made for 11/17/20. (Follow-up appointment is with surgeon involved in R5's care and surgery prior to facility admission.) The Skin Care Flow Sheet for R5 stated that R5 had an unstageable left heel pressure ulcer, date of origin- nothing noted, facility acquired or present on admission, noting indicated. The assessment indicates the same assessment of the wound noted in the weekly skin assessment dated [DATE]. The treatment is to cleanse area, [MEDICATION NAME], skin prep periwound. R5's medical record did contain a copy of a fax that was sent to R5's physician on 11/16/20 noting the new pressure ulcer to the left heel. A request was made for treatment to cleanse area to left heel ulcer with normal saline, pat dry, apply [MEDICATION NAME] to ulcer after applying skin prep to periwound, cover with dressing and secure with tape, change daily and as needed. If soiled or dislodged. It was noted the physician did sign the order on 11/16/20. A review of the treatment administration record (TAR) for November, 2020 did not show that the facility ever sent in the order request for this treatment to the pharmacy. There was no documentation that a treatment of [REDACTED]. A review of the December, 2020 TAR also did not show that the facility ever obtained the order for the [MEDICATION NAME] and skin prep for the heal ulcer and provided this treatment daily to R5, per physician order. On 11/17/20, R5 did see the surgeon for follow-up on the left foot surgery. A recommendation was made that R5 needs a boot to the left heel to off load. The physician orders indicated that on 11/17/20, a nursing order was obtained to apply Prevelon boot to left heel when in bed, am, pm and night time. Further review of R5's individual plan of care did not indicate that R5 now has an unstageable, facility acquired pressure ulcer to the left heel. There were no listed interventions for the use of the prevelon boot or the need to off load R5's heel from the mattress. Nursing note, Weekly Skin assessment dated [DATE] states that R5's pressure ulcer to the medial sacrum has been resolved. It was also noted that the area to the right sacrum has also been resolved. It is not apparent if this is the date both areas actually healed, as the last comprehensive assessment of these areas to R5's sacrum was on 11/5/20. The area to the left sacrum measures 1.5 cm. by 0.8 cm. by <0.1 cm. Noted to be improving and shallower. A review of the Skin Care Flow Sheet indicates the same measurements for the left sacrum and the medial and right sacrum. The Skin Care Flow Sheet for R5's unstageable pressure ulcer to the left heel indicates that an assessment of the area was conducted on 11/23/20. The area is 1.2cm. by 1.2 cm. by <0.1 cm. 75% necrotic and 25% slough. Pain is present. Periwound decreased redness 0.7 cm. by 0.7 cm. Treatment is to cover with dressing daily and as needed. Current treatment and boot to left heel. It was again noted that the TAR for November, 2020 and December, 2020 did not reflect that a treatment was being signed out daily for the left heel ulcer. The plan of care also remained unchanged and did not include interventions to assist in healing these areas or to prevent new areas from developing. Nursing note dated 11/29/20 states Skin Problem, partial thickness to coccyx area. Scant amount of bleeding to area. Skin surrounding area intact. No complaints of pain or discomfort. No foul odor. There is no indication if this is a new pressure ulcer that developed for R5 or referring to the area to the left sacrum. The left sacrum had not been assessed since 11/19/20. If this indeed a new area, the physician was not notified, a treatment was not obtained and the plan of care was not updated. R5 was discharged from the facility on 12/3/20. There was no discharge assessment of the areas that were present on discharge on 12/3/20 per policy. The unstageable pressure ulcer to the left heel had last been comprehensively assessed on 11/23/20. There was no further assessment of this area as of the time of discharge on 12/3/20. In addition, the area to the left sacrum had not been comprehensively assessed from 11/19/20 to the date of discharge on 12/3/20. On 2/18/21 at 3:00 p.m., Surveyor interviewed Director of Nursing (DON) B regarding R5's care and treatment of [REDACTED]. Surveyor asked DON why the facility did not comprehensively assess R5's pressure ulcers upon admission, noting 11/2/20 there was no skin assessment done and on 11/3/20, the assessment indicates areas only to the left and right sacrum. Surveyor also asked DON- B if the area to the medial sacrum was newly noted on 11/5/20 assessment, or present on 11/3/20. DON- B was not able to provide any additional information as to why a comprehensive assessment of R5's skin was not conducted on admission per policy. Surveyor asked DON- B why a treatment for [REDACTED]. DON- B was not able to provide any additional information. Surveyor asked DON- B about the development of the unstageable pressure area to R5's left heel that had been noted to already have 90% necrotic tissue present. Surveyor asked why the facility was not assessing R5's left foot daily both for the treatment of [REDACTED]. DON- B was unable to provide any additional information. Surveyor brought forth the concern that staff was to be providing a treatment to R5's surgical site on the left foot daily every morning. This treatment was not documented as being completed from, 11/12 to 11/16/20. If the treatment had been done daily, staff may have noted the area to left heel sooner. (See citation at F- 684). DON- B was not able to provide any information as to why the treatment to the left foot/ surgical site was not completed for the 4 days prior to the left heel ulcer development. DON- B was asked why the plan of care had not been updated to reflect that R5 had actual areas of skin impairment and was at risk for further developing pressure ulcers. It was also asked why the plan of care did not include the intervention of off-loading R5's heel from the bed prior to the development of the pressure ulcer or the use of the prevelon boot. DON- B was not able to provide any additional information. DON- B was asked why a treatment signed treatment order was obtained from the physician on 11/16/20 for the left heel ulcer but was never sent to pharmacy to be filled. It was also asked why the treatment was not on the TAR for November, 2020 and December 2020. DON- B was not able to provide any additional information. DON- B was asked why a discharge assessment was not completed for R5 to indicate the condition of his skin at the time of discharge. DON- B had no additional information to provide. 2. R12 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Surveyor conducted a review of R12's electronic medical record and noted that R12 was readmitted to the facility on [DATE] at 6:30 p.m. from at stay at an acute care hospital. Nursing note dated 11/11/20 states; pressure ulcer: no pressure ulcers. Nursing note dated 11/12/20 states; Skin Problems: Stage #2 pressure areas to coccyx. No active bleeding or drainage to area. No signs/ symptoms of infection. No pain. Action: Physician notified. Awaiting return call. Writer requesting [MEDICATION NAME] to area. The note continues to state: Skin Problems: Blister to left heel. 6.5 cm. by 5.5 cm. Skin intact. No active bleeding or drainage noted to area. No signs/ symptoms of infection. Skin surrounding blister intact and no maceration. R12 denies pain or discomfort. Action: Physician notified. Awaiting return call. Writer requesting order for skin prep to heel and heels to be floated when in bed. The Skin Care Flow Sheet indicates that R12 has a right heel- unstageable area that was facility acquired. The date is noted as 11/12/20. Area measures 6.5 cm. by 5.5 cm. by < 0.5 cm. No further description of area is noted on this form. The Skin Care Flow Sheet indicates that R12 has an unstageable area to the sacrum. There is no date of origin or if the area is facility acquired. Only indicates R12's readmission date of [DATE]. The form is dated 11/12/20 with measurements of 1.52 cm. by 1.5 cm. by <0.1 cm. 100% epitheal, no odor, no pain. Wound base is defined, peri-wound intact. Treatment is [MEDICATION NAME] daily and as needed. It was noted that there was no comprehensive skin assessment completed on R12 upon her re-admission to the facility on [DATE]. There is no indication that these areas were present at that time or developed over the 2 days before being assessed on 11/12/20. Surveyor conducted a review of the Physician Orders for November, 2020. The physician orders for treatment of [REDACTED]. A review of the Treatment Administration Record (TAR) for November, 2020 also did not show that a treatment was provided to R12 for either the sacrum wound or the right heel. R12 was to receive a treatment daily to these areas. Nursing Note dated 11/16/20 indicates that R12 had a 7 cm. by 7 cm. blister that is fluid filled to the right heel. R12 was also experiencing a change of condition at this time and family requested R12 be sent to the hospital for further evaluation. R12 was readmitted to the facility on [DATE] at 2:30 p.m. after being at the acute care hospital since 11/16/20. The electronic medical record did not contain a comprehensive assessment of R12's skin upon her re-admission to the facility on [DATE]. A review of the physician orders for R12 showed that on 12/8/20 a nursing order was added to elevate bilateral legs every shift, night morning and afternoon. Also noted to monitor right heel blister every shift, apply barrier cream to buttocks every shift and change positioning when in bed (off-loading of sacrum) every shift. Surveyor conducted a review of the TAR for December, 2020 and noted that a treatment order was obtained on 12/8/20 to cleanse pressure injury to sacral area with [MEDICATION NAME], then dry. Apply [MEDICATION NAME] daily in the evening. Start date 12/8/20. It was noted that the first time this treatment was signed out on the December, 2020 TAR was 12/11/20. The treatment was to be completed daily. There is no indication that a treatment was obtained or conducted to R12's right heel for the month of December, 2020. Nursing note dated 12/9/20 states Pressure Ulcer: partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stage #2). The note does not state where the pressure ulcer is located or any or information about the areas appearance. The significant change Minimum Data Set (MDS), dated [DATE] states that R12 is at risk for developing pressure ulcers and had 2- Stage #2 pressure ulcers present on admission. The MDS also indicates that R12 is totally dependent on staff for bed mobility, toileting, and dressing and that transferring and walking on/ off unit did not occur during the assessment reference period. A review of R12's individual plan of care noted that an update was made on 12/9/20 stating that R12 has problem: impairment of skin integrity, stage #2 ulcer to coccyx, ulcer to right heel. There were no updates to the interventions to assist in the healing of the ulcers or to prevent further development of pressure ulcers. The plan of care did not include the intervention to elevate bilateral heels each shift or include any type of repositioning schedule to off load pressure to R12's sacrum. Nursing note dated 12/10/20 indicates Skin Problems: open area to coccyx. The first comprehensive assessment of the pressure ulcer to R12's sacrum, after her readmission from the hospital on [DATE], was conducted on 12/11/20. The Skin Care Flow Sheet states that R12 has a Stage #2 pressure ulcer to the sacrum and measures 1.4 cm. by 1.6 cm. by < 0.1 cm. 100% epitheal wound base, no drainage, no odor, no pain. Wound intact and peri-wound intact. Treatment is [MEDICATION NAME]. Nursing note dated 12/14/20 states that there is full thickness of skin lost, exposing the SubQ tissues- presents as a deep crater (Pressure Stage #3.) There is no further assessment of the area noted on this date. Also the medical record did not contain information the physician was notified of the worsening pressure ulcer. Nursing note dated 12/18/20 at 9:32 a.m. states that [MEDICATION NAME] dressing on right heel removed, disrupted blister resolving, dry, no drainage, left open to air, pressure relief provided with towel roll to keep heel off mattress. Action: continue to observe per physician order. It was noted by Surveyor that the area to R12's heel should not have had a [MEDICATION NAME] dressing to it as there was no physician order for [REDACTED]. Procedure results: tolerated will. Action: Physician notified to request change in treatment continue to observe. Skin Problems: open area to sacral area, unstageable, 90 % yellow slough, 10 % black tissue. Nursing note dated 12/18/20 at 12: 39 p.m. states Procedure done: skin treatment done per order. Action: Physician notified to request change of treatment due to presence of slough, black tissue continue to observe. Skin Treatment: Receives turning/ repositioning program. Receives application of dressing (without topical medications) other than to feet. Peri-care. Pressure Ulcers on admit: Partial thickness loss of skin layers that present as an abrasion or blister (pressure stage #2). Tissue type: slough necrotic tissue. General Skin Condition: warm, dry, pale. Skin Problems: has open lesion(s) present in past 7 days. Receives application of dressings (with or without topical medication). Sacrum. Foot Problem/ care: has open [MEDICAL CONDITION] on the foot. Right heel. It was again noted by Surveyor that the facility staff had not obtained a treatment to R12's right foot. A review of TAR also noted that staff was not documenting that a treatment was conducted to the right foot for R12 for December 2020. The plan of care remained unchanged and did not contain any of the interventions about providing pressure relief to the right heel. Nursing note dated 12/21/20 states has persistent area of skin redness that does not disappear when pressure relieved (pressure stage #1). Purple/ maroon colored. It was noted that the nursing note did not indicate the location of the stage #1 and if this was a new area requiring additional treatment or not. Nursing note dated 12/22/20 states that dressing not on pressure ulcer, incontinent of bowel, CNA's present and incontinence care completed, wound cleansed and new dressing applied, CNA's informed to report to nurse on unit if dressing becomes dislodged or soiled. R12 tolerated treatment well, wound unstageable, yellow slough present 95%, no necrotic tissue noted, no drainage or signs/ symptoms infection noted. On 12/22/20 a nursing order is written to monitor dressing to sacrum each shift, am, pm, and noc, replace if dislodged or soiled. Nursing note dated 12/29/20 states, Pressure Ulcer: partial thickness loss of skin layers that presents as an abrasion or blister (stage #2). The nursing note did not identify the location of this stage #2 pressure ulcer or any further assessment of the area. Nursing note dated 1/3/2021 states, Pressure Ulcer: partial thickness loss of skin layers that presents as an abrasion or blister (stage #2). The nursing note did not identify the location of this stage #2 pressure ulcer or any further assessment of the area. The Skin Care Flow Sheet for R12's area to the right heel is updated on 1/13/21 stating that R12 now has an unstageable area to the right heel measuring 1.5cm. by 1.5 cm. by <0.1 cm. Wound base is necrotic tissue with no maceration, dry peri-wound skin. Treatment is skin prep 2 times daily. This is the first time a comprehensive assessment of the right heel had been completed since R12's re-admission to the facility on [DATE] and even at this point the only indication that R12 has an area to the right heel is on the individual plan of care. The care plan indicates ulcer to right heel, updated 12/9/20. A review of the physician orders indicates that the first time an order is written to apply skin prep to R12's right heel, twice daily, is on 1/14/21. A review of the January, 2021 TAR shows that on 1/14/21 the skin treatment: apply skin prep to right heel twice a day, am and pm was added. The treatment is not signed out as being completed in the p.m. from 1/14/21 through the end of the month 1/31/21. It is only documented that the skin prep is being applied in the morning. The Skin Care Flow Sheet for R12's pressure ulcer to the sacrum is updated on 1/13/21 stating the area to the sacrum is not unstageable. The area measures 1.0cm. by 1.0cm. by <0.1 cm. Wound base is 75% slough and 25% [MEDICATION NAME] tissue. Peri- wound intact. Treatment is [MEDICATION NAME] and cover with Meplex daily. It was noted that the last time the facility performed a comprehensive assessment of R12's pressure ulcer to the sacrum was on 12/11/20. The facility did obtain a physician order on 1/14/21 to cleanse pressure injury to sacral area with normal saline, pat dry. Apply [MEDICATION NAME] to wound base and cover with Meplix tape daily in the pm and as needed. A review of the January, 2021 TAR showed this treatment was updated but the facility staff had not signed out that treatment was completed from 1/15/21 to 1/21/21 when the treatment was changed to be performed by the am shift. 1/29/21 Nursing Note states Weekly Skin Assessment: R12 has small open area on coccyx which is healing well. Treatment is done daily. The nursing note did not contain any additional information about the size or appearance of the area to the coccyx. This weekly assessment also did not include assessment of R12's pressure ulcer to the right heel. Nursing note dated 2/2/21 states, Pressure Ulcer: partial thickness loss of skin layers that presents as an abrasion or blister (pressure stage #2) Location: coccyx. Nursing note dated 2/4/21 states, Procedure done: Skin treatment done per order. Fax to MD to update on improvement and request to discontinue [MEDICATION NAME] and change treatment to cleanse with normal saline and apply Meplix dressing daily and as needed. Healing Progress: improving, Description: becoming smaller, granulation occurring, appears more clean. Pressure Ulcer: Location: Coccyx 0.8cm. by 0.3cm. by < 0.1cm. [MEDICATION NAME] tissue 100%. Wound tissue pink, drainage: none present. (A review of the February, 2020 TAR shows that this particular treatment did not get changed and remained the same order that was obtained on 1/21/21.) On 2/4/21 The Skin Care Flow Sheet for R12's area to the right heel is updated. The right heel ulcer remains unstageable and measures 5.5cm. by 4 cm. by <0.1 cm. All necrotic tissue is gone, entire wound base is pink. Some wound edges appear as peeling. Peri-wound intact. Pink skin is soft/ boggy. Treatment: elevate heels. R12's individual plan of care remained unchanged for interventions to assist in healing the current pressure ulcers or to avoid new areas of skin impairment. The interventions did not state to elevate heels and what device would be used to do so. The Skin Care Flow Sheet for R12's area to the right heel is updated on 2/19/21. It states that the area is unstageab (TRUNCATED)

Based on observation, record review and interview, the facility did not not provide adequate supervision and assistive devices to prevent accidents for 3 (R3, R2 & R8) of 9 sampled residents identified by the facility as at risk for falls. Since 7/12/16, R3 has had 29 falls, eight that resulted in injuries and four (7/2/16, 11/25/16, 1/18/17 & 8/25/17) that resulted in sutures or staples. R3 was observed to be left unsupervised and not have fall interventions in place to prevent any further accidents and incidents as a result of a fall by R3. The Facility's failure to conduct root cause analysis of falls, the failure to establish and implement fall precautionary interventions and the failure to provide adequate supervision to prevent falls, created a finding of Immediate Jeopardy beginning on 3/14/17. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy finding on 8/30/17 at 2:47 p.m. The Immediate Jeopardy was removed on 8/30/17 however; the deficient practice continues at a scope/severity D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) as evidenced by the following: * R8 did not have fall interventions implemented to prevent future falls and accidents after experiencing two falls. * R2 did not have fall interventions implemented to prevent future falls and accidents per R2's plan of care. Findings include: The facility's fall policy dated as revised July 2017 and titled, Fall Assessment and Prevention Protocol documents in Purpose section, To ensure the appropriate actions are taken to assess, prevent and reduce resident falls. Under the After A Fall or Intercepted Fall section it documents, 6. Update the resident care plan with the appropriate intervention(s) to keep resident safe (including date, time, signature) until reviewed by interdisciplinary team the following business day. 7. Add any new interventions to the CNA assignment sheet and to the 24 hours report to communicate any new resident needs. 8. Assign responsibility to an appropriate staff person to implement any new resident safety equipment identified through this process. Under the Ongoing section it documents, 2. Any trends or patterns in falls will be evaluated through the facility QAPI (Quality Assurance and Performance Improvement) process on a monthly/quarterly basis. 3. All staff members are regularly inserviced on resident fall prevention and safety, including proper placement of safety devices, use of different kinds of available safety equipment, and daily surveillance of possible hazards. 1. Fall Investigations Surveyor reviewed R3's medical record from 8/24/17 to 8/30/17. R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R3's quarterly MDS (Minimum Data Set) dated 7/15/16 documents a BIMS (Brief Interview for Mental Status) score of 11, indicating that R3 is moderately cognitively impaired. Section G (Functional Status) documents that R3 requires extensive assistance and one person physical assist for his transfer and bed mobility needs. Section G0400 (Functional Range of Motion) documents that R3 has no impairment to both his upper and lower extremities. R3's Falls CAA (Care Area Assessment) with a reference date of 4/8/16 documents under the Problem section, Potential for Trauma-Fall Injury. Related to: History of falls. Parkinson's Disease. Under the Nurses section it documents, Observe, record and report all unsafe conditions and situations, remove resident from any unsafe conditions or situations, instruct of safety, assess change in level of consciousness instruct resident in use of adaptive equipment as needed, encourage resident to request help for difficult tasks, anticipate needs as appropriate, notify md (medical doctor) as needed. Under the Physical Performance Limits section it documents, Impaired strength, impaired fine motor coordination, impaired transfers/functional mobility, impaired safety awareness. Under the Description of Problem section it documents, At risk for falls. Causes and Contributing Factors: see above. Under the Risk Factors section is documents, See above injury from falls. Under the Care Plan section it documents, Will not develop care plan. Reason: Continue current plan. R3's Falls Care Plan dated 11/28/16 documents under the Problem section, Problem: Potential for Trauma-Falls Injury. Under the Approach section it documents interventions related to R3's falls begin with a start date of 4/25/17. Surveyor noted that R3's Falls Care Plan documents only 1 intervention related to R3's falls and accidents prevention prior to 2017. Under the approach section it documents, Nurse Aide- Call light in reach, anticipate needs, redirect resident to adaptive equipment when appropriate, update nurse with any decline noted, refer to care plan for interventions. R3's Falls assessment dated [DATE] documents under the Falls Assessment section; 10. Does resident have a history of a fall or multiple falls? Yes. Describe the Circumstances: Resident has had numerous falls this quarter. 11. Does resident have an unsteady gait? Yes. Describe: Resident requires assistance with transfers, ambulation, has Parkinson's and gait unsteady shuffle, uses assistive device for transfers, ambulation. Under the Summary of Findings section it documents, Resident continues to be a high risk for falls, has had numerous falls this quarter, 4/19, 4/22, 5/12, 5/20 had x (times) 2 (falls), 5/27, 5/30, 6/6, 6/19, 7/2. Resident requires assistance with transfers, ambulation uses assistive device, resident primary language is Spanish, does have communication board to assist with communication, resident does take antipsychotropic medications and has a history of dementia. Continue to follow current plan of care and update as needed. Surveyor reviewed R3's Incident Reports for R3's falls on 7/2/16, 7/20/16 and 8/3/16. Surveyor noted that R3's Incident Reports for the above falls were thoroughly investigated and contained a root cause analysis for each fall. R3's Incident Report for R3's fall on 8/6/16 documents under the Description of Incident section, Describe what happened: Resident was observed on the floor by writer. He was right in front of his recliner. Describe why it happened: Possibly recliner. Describe what caused incident: Recliner is a rocking recliner, dyson (dycem) should be in chair at all times. Injury: None. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Dyson (dycem) placed in recliner. Surveyor could not locate any documentation in R3's falls care plan or R3's medical record documenting that the above intervention was put in place on 8/6/16 after R3's fall. Surveyor noted that R3's falls care plan documented that the above intervention of dycem in recliner was first documented in R3's falls care plan on 9/13/16 and not after R3's fall on 8/6/16. R3's Incident Report for R3's fall on 8/7/16 documents under the Description of Incident section, Description what happened: Observed on floor next bed. Describe why it happened: Self transfer. Described what caused the accident: Left blank. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Left blank. Under the Actions section it documents, Order from vendor landing strip with alarm to alert staff to self-rise from bed and self ambulate. Under the Assessment Supporting Intervention section it documents, Resident a little more secure with dyson (dycem) but family should switch out recliner because it is a rocking recliner. Surveyor noted that R3's falls care plan documented that the above intervention of landing strip with alarm was first documented in R3's falls care plan on 8/14/16 and not after R3's fall on 8/7/16. Surveyor was unable to locate any documentation indicating when the facility contacted R3's family regarding switching R3's recliner per the above intervention of family should switch out recliner because it is a rocking recliner on 8/7/16. R3's nursing note dated 8/8/16 documents, Resident received a new recliner from his family. It is leather, rocking recliner and the resident has had some difficulty getting out of it. The resident's family plans to come in on 8/9/16 to make adjustments to the chair. If the resident continues to have troubles they plan to replace it. Will continue to monitor and update as needed. Surveyor could not locate any other documentation in R3's medical record that documented that R3's family replaced or modified R3's recliner after 8/8/16. R3's Incident Report for R3's fall on 8/11/16 documents under the Description of Incident section, Description what happened: Resident took dicem (dycem) out of his chair from home. Resident slip to the floor in a sitting position with back against the chair. No apparent injuries at this time. Describe why it happened: Resident took anti slip pad out of his chair. Standing unsteady gait dementia. Described what caused the accident: Resident taking anti slip pad out of chair or resident slid out of chair on purpose. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Family to buy new safer chair for resident. Under the Actions section it documents, Have family bring new chair that is safer for resident (pending). Under the Assessment Supporting Intervention section it documents, Resident a little more secure with dyson (dycem) but family should switch out recline because it is a rocking recliner. Family contacted re (regarding): this request possible cause. Surveyor was unable to locate any documentation in R3's medical record when the facility contacted R3's family regarding switching out R3's recliner as described in the Assessment Supporting Intervention for R3's previous fall on 8/7/16 and R3's nursing note dated 8/8/16. Surveyor noted that the intervention described in the Assessment Supporting Intervention for R3's previous fall of switching our R3's recliner chair because it's a rocking chair was not listed on R3's falls plan of care nor documented as completed per R3's 8/7/16 fall intervention and 8/8/16 nursing note. R3's Incident Report for R3's fall on 8/21/16 documents under the Description of Incident section, Description what happened: Found on floor with rt (right) shoulder resting on walker by heater with cord between legs of wheeled walker. Had no shoes or gripper socks on. Describe why it happened: Tripped, tangled over cord with walker, possibly. Not witnessed. Described what caused the accident: Cord was in the pathway to BR (bathroom) from his chair. Injury: Abrasion below rt knee. Oval mark on rt shoulder. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Keep cord under heater. Wear gripper socks when in bed and shoes when up. Under the Actions section it documents, Immediate Interventions Implemented: gripper sock on when in bed. Appropriate footwear when up. Heating unit cord under unit. Assist to bathroom approx (approximately) one hour past meals to avoid falls/incident. Under the Assessment Supporting Intervention section it documents, Tripped over cord (not witnessed). Surveyor could not locate any staff statements or documentation when R3 was last seen and if R3 had been in bed prior to having his fall at 9:00 p.m. Surveyor could not locate if R3's fall mat with an alarm was in place prior to R3's fall on 8/21/16. R3's Incident Report for R3's fall on 8/27/16 documents under the Description of Incident section, Description what happened: Pt. (patient) was found laying on his abdomen with his right arm underneath him. There was a large pool of blood underneath his head. Describe why it happened: Pt. was apparently transferring to and from his stationary chair. Describe what caused the accident: Pt. could not answer. Injury: Laceration to head. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Will do when he returns form ER (emergency room ). Under the Actions section it documents, Immediate Intervention Implemented: Sent to ER. Under the Assessment Supporting Intervention section it documents, Sent to ER. Surveyor could not locate any staff statements or documentation when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. R3's Patient Discharge Instructions from the emergency room dated 8/27/16 documents, Health Issues: Laceration of forehead. Discharge Orders: Sutures are absorbable, no need to remove unless bothersome after 10 days. Surveyor could not locate any documentation that listed any interventions that would prevent any future falls or incidents for R3. R3's Incident Report for R3's fall on 9/3/16 documents under the Description of Incident section, Description of Events: Resident's room. Resident was in room chair prior to incident. Activity at the Time: Transferring. Equipment Involved: Recliner. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Left Blank. Under the Actions section it documents, Immediate Intervention Implemented: Removed towel off of dyson (dycem) on the seat of the recliner. Under the Assessment Supporting Intervention section it documents, No further incident. Surveyor could not locate any staff statements or documentation when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor could not locate any documentation that the fall interventions of replacing R3's recliner as documented on R3's Fall Incident Reports on 8/7/16 and 8/11/17 had been implemented. There was no care plan approach directing staff to keep towels off the dycem in the recliner. Surveyor could not locate any documentation that listed any future interventions that would prevent any future falls or incidents for R3. R3's Incident Report for R3's fall on 9/9/16 documents under the Description of Incident section, Description what happened: Resident found down on right knee and left hand on recliner's arm rest. Describe why it happened: Due to Parkinson's and shuffled gait. Described what caused the accident: Due to Parkinson's and shuffled gait, dementia. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Remove towel from recliner, placed wheeled walker closer to resident, family requested to remove recliner. Under the Actions section it documents, Do frequent checks to make sure towels or other objects are not placed over dycem on recliner. Under the Assessment Supporting Intervention section it documents, No further incidents noted. Surveyor noted that the above intervention of do frequent checks to make sure towels or other objects are not placed over dycem on recliner was not documented as implemented on R3's care plan until 9/13/16 and not after R3's fall on 9/9/16. Surveyor could not locate any staff statements or documentation when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor could not locate any documentation that listed any interventions that would prevent any future falls or incidents for R3. R3's Incident Report for R3's fall on 9/17/16 documents under the Description of Incident section, Description what happened: Resident observed laying on his right side on the floor in front of his recliner. Describe why it happened: Unsteady gait at times. Described what caused the accident: Unsteady gait at times. Injury: None Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Frequent checks. Under the Actions section it documents, Monitor resident getting up from chair. Under the Assessment Supporting Intervention section it documents, No further incidents noted. Surveyor could not locate any staff statements or documentation when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor could not locate any documentation that listed any interventions that would prevent any future falls or incidents for R3 or any direction to staff as to what was meant by frequent checks. Surveyor noted that the intervention on Monitor resident getting up from chair was not documented as implemented on R3's falls care plan until 9/19/16 and not on 9/17/16 when R3 fell . R3's Incident Report for R3's fall on 10/5/16 documents under the Description of Incident section, Description what happened: Resident observed on floor in sitting position with side placed against recliner. Resident had previously been placed in recliner prior to fall, resident was incontinent at time of fall. Resident's shoes and slippers do not have appropriate tread (sic), resident was wearing slippers at time of fall. tread wearing off of footwear. Describe why it happened: Resident was transferring on own, walker was placed to side of him, tread on footwear wearing off, was incontinent of urine at time of fall, resident unable to communicate what he was doing or where he was going. Described what caused the accident: Resident getting up out of recliner and possible slipping d/t (due to) tread wearing off on footwear. Resident Comments Regarding Incident: None, resident unable to communicate cause of fall. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Requested different shoes with better tread on them. Under the Actions section it documents, Both sets of footwear do not have appropriate tread on them which may lead to resident slipping. Under the Assessment Supporting Intervention section it documents, Both sets of footwear do not have appropriate tread on them which may lead to resident slipping. Surveyor could not locate any staff statements or documentation indicating when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. R3's Incident Report for R3's fall on 10/15/16 documents under the Description of Incident section, Description what happened: Resident observed on floor. Describe why it happened: Unsteady gait. Described what caused the accident: Unsteady gait. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Resident moved to general population to be monitored. Under the Actions section it documents, When resident is up and down, bring resident closer to nurse's station (e.g (example) chair out side of resident's room) to keep closer eye on resident. Under the Assessment Supporting Intervention section it documents, No further incidents noted. Surveyor could not locate any staff statements or documentation when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor noted that the intervention of when R3 is up and down, bring closer to nurses's station or sit him in a chair outside of his room to keep a closer eye on R3 was documented as implemented on 10/17/16 and not on 10/15/16 when R3 fell . R3's Incident Report for R3's fall on 10/19/16 documents under the Description of Incident section, Description what happened: Resident observed on floor in room in front of brown recliner. Describe why it happened: Unsteady gait. Described what caused the accident: Unsteady gait. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Transfer to wheelchair and brought to nursing station to increase supervision. Under the Actions section it documents, Frequent checks when in room. Under the Assessment Supporting Intervention section it documents, No further incidents noted/resident put to bed shortly after. Surveyor could not locate any staff statements or documentation indicating when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor noted that the intervention of when R3 is up and down, bring closer to nurses's station or sit him in in chair outside of his room to keep a closer eye on R3 was not documented to be in place prior to R3's fall on 10/19/16. Surveyor noted that R3's fall on 10/19/16 may have been prevented if the intervention of when R3 is up and down, bring closer to nurses's station or sit him in in chair outside of his room to keep a closer eye on R3 was in place prior to R3's fall on 10/19/16. R3's Incident Report for R3's fall on 11/7/16 documents under the Description of Incident section, Description what happened: Resident self transfer from bed and noted on the floor near his bed. Describe why it happened: Resident self transferred from his bed. Described what caused the accident: Resident self transferred from his (bed). Had a shower at 930 PM. To bed after. Floor mat alarm was not checked for proper functioning. Found by bed with walker near, laying on left side on pillow on floor. Liquid substance on floor by bathroom door. It appears resident had transferred self and fell on way back to BR (bathroom). Injury: Skin tear: left elbow apprx (approximate) 0.5 cm (centimeters) wide and appx 1.5 cm long. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Make sure resident's mat near bed. Under the Actions section it documents, Educate CNA (Certified Nursing Assistant) staff to make sure mat is in place and to make sure floor is not wet. Under the Assessment Supporting Intervention section it documents, No further incidents noted/Resident put to bed shortly after. Surveyor located a staff statement from the staff on shift when R3's fall occurred on 11/7/16. The statement documents, She (CNA) states that whenever she had seen R3's fall mat by his bed, it was not alongside the bed, but long way at the head of the bed. She stated she did not ensure the alarm was in working order. Surveyor noted that R3's falls care plan did not document any interventions that were documented as in place to ensure R3's alarm was in working order. Surveyor could not locate any documentation indicating that the facility provided all direct care staff with training or an inservice to ensure that R3's alarm was in working order in order to prevent future falls and occurrences. Surveyor could not locate any root cause analysis that explained the cause of R3's fall on 11/7/16. R3's Incident Report for R3's fall on 11/24/16 documents under the Description of Incident section, Description what happened: Found on floor next to bed. May have rolled out bed or attempted to stand. Describe why it happened: Unknown. Described what caused the accident: Resident was up without walker. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Closer observation. The Actions section was left blank and did not contain any documentation. Under the Assessment Supporting Intervention section it documents, No further incidents noted/Resident put to bed shortly after. Possibly related to acute condition UTI (urinary tract infection). Surveyor could not locate any staff statements or documentation indicatingindicating when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor could not locate any documentation indicatingindicating that R3's fall mat alarm was in place prior to R3's fall on 11/24/16. Surveyor could not locate any documentation that listed any future interventions that would prevent any future falls or incidents for R3. R3's Incident Report for R3's fall on 11/25/16 documents under the Description of Incident section, Description what happened: Pt. (patient) was found on floor. Describe why it happened: Pt. was walking without walker. Described what caused the accident: Not using walker. Injury: Sent to ER (emergency room ) Laceration 2.5 by 2.5 cm. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Have pt. stay out of room more. Under the Actions section it documents, Sent to ER. Under the Assessment Supporting Intervention section it documents, Is @ (at) ER. Surveyor could not locate any documentation that explained how R3 fell on [DATE]. Surveyor could not locate any staff statements or documentation indicatingindicating when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor could not locate any documentation indicatingindicating that R3 was being closely monitored by staff prior to R3's fall on 11/25/16. Surveyor could not locate any documentation that listed any future interventions that would prevent any future falls or incidents for R3. R3's Incident Report for R3's fall on 1/18/17 documents under the Description of Incident section, Description what happened: When entering resident's room, resident was observed lying on floor with head towards bed, blood dripping on floor. Resident had been carrying a couple items when ambulating. Walker was positioned on an angle and close to plastic dresser. It appears that resident stepped over base of walker and lost balance while carrying items. Hit head on bed frame, scraped arm on bed side table next to bed. Describe why it happened: There was not enough room between walker and dresser to walk through so resident had to step over base of walker while carrying items in his hands. Dementia. Described what caused the accident: Stepping over walker base while holding items. Injury: Skin tear: left elbow, 2 lacerations to top of head and to left side of head. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Assist resident with carrying items. Under the Actions section it documents, Assist with caring items in room. Under the Assessment Supporting Intervention section it documents, Had arms full of items when found. Surveyor could not locate any staff statements or documentation indicatingindicating when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor could not locate any documentation indicatingindicating that R3 was being closely monitored by staff prior to R3's fall on 1/18/17. R3's emergency room Discharge Instructions dated 1/18/17 for R3' fall on 1/18/17 documents under the Health Issues section, Abrasion of scalp; Abrasion of left elbow; Laceration of scalp, initial encounter; Fall. Under the Patient Discharge Orders it documents, Procedure done in the emergency room : Laceration repair. Head injury. R3's Skin Note dated 1/19/17 documents, Skin problems: Staples dry and intact to top of head. R3's Skin Note dated 1/21/17 documents, Skin problems: Has 7 staples to top of head due to fall from 1/18/17. Surveyor could not locate any documentation that listed any future interventions that would prevent any future falls or incidents for R3. R3's Incident Report for R3's fall on 1/19/17 documents under the Description of Incident section, Description what happened: Tried to walk from w/c (wheelchair) to bed, fell and bumped back of head. LPN (Licensed Practical Nurse) thinks resident attempted to transfer self from w/c to bed. Describe why it happened: Unstable, but due to dementia tries to walk. Described what caused the accident: Unstable, but due to dementia still tries to walk. Injury: Abrasion back of head, 5 cm. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Try to keep an eye on resident. Under the Actions section it documents, Keep in w/c by nurses station when resident is restless. Under the Assessment Supporting Intervention section it documents, To keep him in w/c so he will not stand. Surveyor could not locate any staff statements or documentation indicatingdocumentation indicating when R3 was last seen, last toileted or a root cause analysis that explained the cause of R3's fall. Surveyor could not locate any documentation indicatingdocumentation indicating that R3 was being closely monitored by staff prior to R3's fall on 1/19/17. Surveyor also noted that the above intervention of keep in w/c by nurses station when resident is restless was documented as implemented on 1/20/17 and not on 1/19/17 when R3's fall occurred. R3's Falls assessment dated [DATE] documents, 10. Does Resident have a history of a fall or multiple falls? Yes. Describe Circumstances: Recently resident has had fall 1/18/17, 1/19/17. Does resident have unsteady gait? Yes. Describe: Resident does have unsteady gait, looses balance. Under the Summary of Findings section it documents, Resident having decline with mobility, loosing balance, gait unsteady, requires use of assistive device, needs reminders for use, therapy was informed and will screen and eval (evaluate) resident for decline, careplan changes were made, continue to follow current plan of care. No injury noted from this fall. Surveyor noted that per R3's Falls assessment dated [DATE], R3 continued to be at risk for falls. R3's Incident Report for R3's fall on 3/13/17 documents under the Description of Incident section, Description what happened: Statement of observation when resident was found: resident was found in the recovery position by his closet by CNA when passing room with another resident. What resident stated regarding incident: Resident said something, but unable to discern what it was due to being in Spanish. Described what caused the accident: Resident has not been walking much lately and most likely became fatigued and fell to the ground. Injury: No apparent injury. Under the Steps to Prevent Recurrence section it documents, Steps to prevent recurrence: Place resident in day room with CNA, place resident on 30 min (minute) checks while in room alone. Under the Actions section it documents, Placed on 30 minute checks, placed in day room. Consider discontinue walker- wheelchair only. Under the Assessment Supporting Intervention section it documents, If resident is in the day room it may serve as a reminder to stay in wheelchair and not try to walk. 30 minute checks to ensure resident isn't on the floor. Surveyor could not locate any staff statements or documentation indicatingdocumentation indicating when R3 was last seen or last toileted prior to R3's fall. Surveyor could only locate documentation of R3's 30 minute checks from 3/13/17 at 5:00 PM to 3/14/17 to 4:00 PM. Surveyor noted that R3's 30 minute checks were not documented as being completed or in place after 3/14/17 at 4:00 PM. Surveyor could not locate any documentation indicatingdocumentation indicating that R3 was being closely monitored by staff prior to R3's fall on 3/13/17. Surveyor noted that the above intervention of 30 minute checks to ensure resident isn't on the floor was not documented as being implemented in R3's plan of care until 8/17/17 and not on 3/13/17 when R3's fall occurred. Surveyor reviewed R3's Incident Report for R3's fall on 3/14/17 and noted that fall was thoroughly investigated and contained a root cause analysis. R3's Falls assessment dated [DATE] documents, 10. Does Resident have a history of a fall or multiple falls? Yes. Describe Circumstances: Attempting to self transfer. Does resident have unsteady gait? Yes. Describe: Shuffle. Under the Summary of Findings section it documents, Resident's dis