Every finding on record at Complete Care at Ridgewood LLC

Based on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder and notify the state authority of a significant change in mental illness for 1 (R1) of 2 residents reviewed for PASARR screening.*R1 had a completed PASARR with an admission date of 10/15/25, with a 30-day exemption. R1 remained in the facility and a new PASARR was not completed despite changes in R1's psychiatric diagnoses and medication changes. Findings Include:The facility's Resident Assessment-Coordination with PASARR Program policy and procedure reviewed/revised 1/26 documents:Policy:.This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.Policy Explanation and Compliance Guidelines:.1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening.5. If a resident who was not screened due to an exception above and the resident remains in the facility longer than 30 days:a. The facility must screen the individual using the State's Level 1 screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level 2 PASARR evaluation and determination.b. The Level 2 resident review must be completed within 40 calendar days of admission.6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred to the state mental health or intellectual disability authority for a Level 2 resident review.a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder.R1 was admitted to the facility on [DATE]. R1's Quarterly Minimum Data Set (MDS) completed 1/21/26 documents R1's Brief Interview for Mental Status (BIMS) score to be 3, indicating R1 demonstrates severely impaired skills for daily decision making. R1's Patient Health Questionnaire (PHQ-9) score is 13, indicating R1 is demonstrating moderate depressive symptoms. R1's MDS documents no behaviors at this time. On 4/2/26, at 9:40 AM, Surveyor reviewed R1's electronic medical record (EMR) and reviewed R1's PASARR. Surveyor noted R1's PASARR was completed with R1's 10/15/25 admission date, documenting a 30-day exemption.R1 has remained in the facility. A new Level 1 PASARR was not completed prior to the end of R1's 30-day exemption.On 12/9/25 R1 was diagnosed as having Unspecified Mood Affective Disorder. On 1/8/26 R1 was started on 10 mg of Paroxetine (Paxil) was added for anger and sexual inappropriateness. On 2/27/26 R1 was diagnosed with an Adjustment Disorder with Depressed Mood.On 3/27/26 Depakote Sprinkles 125 mg was ordered for R1 along with Ativan as needed for behaviors.With the significant changes in R1's mental illness diagnoses and treatments, the facility did not initiate the PASARR process and notify the state authority of the changes for R1 to determine the possible need for specialized services.On 4/6/26, at 1:19 PM, Surveyor interviewed Social Services Director (SSD)-F. SSD-F stated that SSD-F has nothing to do with the processing PASARRs. SSD-F does not know who completes a new Level 1 PASARR if a resident is remaining in the facility past 30 days or when new diagnoses and medications are added.On 4/6/26, at 1:31 PM, Director of Nursing (DON)-B confirmed the facility did not complete a new Level 1 when diagnoses and medications were initiated. DON-B informed Surveyor that a 30-day exemption Level 1 PASARR had been completed initially. DON-B stated the facility is completing a new Level 1 today. DON-B understood the concern that a new Level 1 PASARR was not completed for R1.

Based on interview and record review, the facility did not ensure 1 (R8) of 13 residents received treatment and care in accordance with professional standards of practice.R8 was re-admitted back to the facility from the hospital on [DATE] with a [NAME] monitor (a wearable battery powered device that continuously records the heart's electrical activity) in place and instructions that it needed to be worn for 7 to 14 days. Facility staff did not enter an MD order for the [NAME] monitor use. Facility staff did not enter a care plan intervention for the [NAME] monitor. Facility staff did not provide documentation that R8's [NAME] monitor was functioning and in place every shift from readmission on [DATE] until R8 was discharged from the facility on 12/15/25. Findings include:On 4/6/26, Surveyor asked Director of Nursing (DON)-B for the facility policy regarding admission orders/following MD orders. DON-B returned to Surveyor with the following policy regarding orders: The facility policy dated 2025 and titled, Medication Orders, documents, in part: The facility shall use uniform guidelines for the ordering of medication. Each medication order should be documented with the date, time, and signature of the person receiving the order. The order should be recorded on the physician order sheet, and the Medication Administration Record (MAR). Transcribe newly prescribed medications on the MAR or treatment record or ensure the order is in the electronic MAR. R8 was admitted to the facility on [DATE] with diagnosis that include syncope (fainting) and collapse, Pulmonary emboli (blood clot in the lung), Chronic Obstructive Pulmonary Disease (progressive lung disease that causes obstructed airflow, making it difficult to breath), Type 2 Diabetes, Dementia, Congestive heart failure, and Venous insufficiency (leg veins cannot efficiently return blood to the heart, causing blood to pool due to damaged valves). R8's Minimum Data Set (MDS) assessment dated [DATE] documents, in part: R8 is moderately cognitively intact. R8 depends on staff for showering, bathing, toileting and transfers. R8's progress note dated 12/8/25 at 10:24 AM, documents: [R8] left for two doctor's [appointments] today at 1015. R8 was alert and able to make needs known.R8's progress note dated 12/8/25 at 2:12 PM, documents, in part: Writer was notified at [1:50 PM] of resident having seizure at [R8's] doctor appointment today. [Writer] was told [R8] is going to Emergency Room.R8 was hospitalized from 12/8 through 12/11/25.R8's hospital After Visit Summary dated 12/11/25 documents, in part: . Your primary diagnosis was Atrial Flutter with Rapid Ventricular Response. Other instructions: [Cardiovascular] [NAME] Monitor Hosp/[Clinic] Placement more than 7 days up to 15 days. What is the duration of the event monitor study? 14 days. Where will the [NAME] be placed? Hospital/Clinic Placement. Will the monitor be hooked up today? Yes. Reason for exam? [Normal Sinus Ventricular Tachycardia]. Surveyor reviewed R8's MD orders for evidence that R8's [NAME] monitor was in place after re-admission to the facility. Surveyor noted that facility staff did not enter an order for R8's [NAME] monitor.R8's Impaired Cardiovascular status related to [hypertension, peripheral vascular disease, coronary artery disease. Care plan initiated on 9/25/25 documents the following interventions: Lab work or X-rays as ordered by physician. Medications as ordered by physician and observe use and effectiveness. Observe and report signs of chest pain, edema, [Shortness of breath], abnormal pedal pulse, restlessness and fatigue.Surveyor noted facility staff revised R8's Cardiovascular status care plan and added Atrial flutter to the care plan on 12/11/25. Surveyor noted that facility staff did not add an intervention of [NAME] monitor for 14 days when facility staff revised the care plan on 12/11/25. Surveyor reviewed R8's progress notes and noted the following documentation:R8's progress note dated 12/11/25 at 8:53 PM, documents, in part: . Readmit - [diagnosis] Atrial Flutter with rapid ventricular response . Breathing normal with [oxygen] . [Vital signs stable]. On [R8's] left chest Body Guardian Mini plus intact. Surveyor noted that on the night of admission, facility staff documented that R8's [NAME] monitor was intact. R8's Nurse Practitioner (NP) note dated 12/12/25 at 8 AM, documents, in part: New diagnosis of atrial flutter with rapid ventricular response from hospitalization. A [NAME] monitor (Body Guardian Mini plus cardiac monitor) was ordered for 7-15 days and is currently in place on the left chest for further rhythm evaluation. Plan: . maintain Body Guardian Mini plus [NAME] cardiac monitoring as ordered. Ensure completion of ordered [NAME] monitor (7-15 days from 12/11/2025 hospital discharge) and arrange timely review of results with cardiology/electrophysiology.Surveyor noted the morning after R8's re-admission to the facility, R8's NP documented that the [NAME] monitor was in place. Surveyor reviewed R8's progress notes for any additional documentation of R8's [NAME] monitor. Surveyor noted facility staff did not document R8's [NAME] monitor in progress notes after 12/12/25 at 8 AM.Surveyor reviewed R8's 24-hour board from 12/11/25 through 12/15/25 and noted the following documentation:On 12/11/25, Focus of Change: Came back, PM shift staff documented: [Left]chest body guardian monitor on.Surveyor noted facility PM staff documented that R8's [NAME] monitor was in place on readmission to the facility.On 12/12/25, Focus of Change: readmission [atrial fibrillation with] rapid ventricular response Night shift: No documentation noted.On 12/12/25, Day shift: [Vital signs stable], [oxygen] 99% [with] 2 Liters.On 12/12/25, PM shift: No documentation noted.Surveyor noted facility staff did not document R8's [NAME] monitor on 12/12/25.On 12/13/25, Focus of Change: readmission [atrial fibrillation with] rapid response Night shift: No documentation noted.On 12/13/25, Day shift: OK. [Vital signs stable] [within normal limit].On 12/13/25, PM shift: No documentation noted.Surveyor noted facility staff did not document R8's [NAME] monitor on 12/13/25.On 12/14/25, Focus of Change: readmission [atrial fibrillation with] [rapid ventricular response]. [NAME] monitor. Night shift: No documentation noted.On 12/14/25, Day shift: OK. Vital [within normal limits]. No pain.On 12/14/25, PM shift: [Please check] [NAME] monitor box at desk.Surveyor noted facility staff documented that R8's [NAME] monitor box was at the desk on 12/14/25.Surveyor noted that R8's 24-hour board had documentation regarding R8's [NAME] Monitor on 2 out of 10 shifts from 12/11 through 12/14/25.Surveyor reviewed all documentation on 12/15/25 and did not locate any documentation about R8's [NAME] Monitor.Surveyor noted R8 was discharged from the facility on 12/15/25 at 1:30 PM. Surveyor reviewed the facility staff schedule from 12/11/25-12/15/25. Surveyor noted Licensed Practical Nurse (LPN)-S, worked as the nurse on R8's unit on 12/11, 12/13, 12/14 and 12/15/25.On 4/2/26 at 1:55 PM, Surveyor interviewed LPN-S. Surveyor asked if a resident returns to the facility after a hospital admission with an order for a [NAME] monitor, how is that documented. LPN-S stated, That is a good question. LPN-S indicated that LPN-S was not sure. LPN-S stated that LPN-S would ask another nurse and ultimately the Unit Manager to get an answer. On 4/6/26 at 9:25 AM, Surveyor returned to LPN-S. Surveyor asked if LPN-S could recall R8 having a heart monitor from 12/11 through 12/15/25 when R8 was discharged from the facility. LPN-S indicated that LPN-S did not want to say yes, or no. LPN-S stated that LPN-S did not remember and that was a while ago. On 4/2/26 at 2:02 PM, Surveyor interviewed LPN-O. Surveyor asked if a resident returns to the facility after a hospital admission with an order for a [NAME] monitor, how is that documented. LPN-O stated that LPN-O would make sure that there was an order placed that would appear in the Medication Administration Record (MAR). That way staff would know that placement would need to be checked each shift. LPN-O stated that LPN-O would also make sure that it is written on the 24-hour board so all staff following LPN-O would know about it. Surveyor asked if the [NAME] monitor would appear on the care plan. LPN-O stated that LPN-O would have to ask about that.On 4/2/26 at 3:15 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-E. Surveyor asked what documentation is completed for a resident that returns from a hospital admission with a [NAME] monitor. ADON-E stated that staff would document in the other tab that the [NAME] monitor was in place and that follow up communication is needed regarding when the monitor is removed and where to send the monitor box and information after the study is completed. ADON-E stated that it would be an MD order so staff could check for placement each shift. Surveyor asked if the [NAME] monitor should be in the resident's care plan. ADON-E stated yes. Surveyor asked if ADON-E could recall if R8 was wearing a heart monitor from 12/11-12/15/26. ADON-E stated that ADON-E does not recall.On 4/6/26 at 3:12 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Consultant-C and Chief Compliance Officer-D of the concern that R8 was re-admitted back to the facility after a hospitalization with a [NAME] monitor. An MD order and a care plan intervention was not placed. There are multiple shifts from 12/11/25 through 12/15/25 that there is no documentation that the [NAME] monitor was functioning and was in place. No further information was provided.

Based on observation, interview and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R8 and R11) of 3 residents reviewed for pressure injuries. *R8 was admitted to the facility with an unstageable pressure injury. On 10/30/25, R8's pressure injury was assessed as a stage 3 pressure injury. On 11/6/25 and 12/11/25, R8 was readmitted to the facility after a hospital stay. Facility staff incorrectly staged R8's pressure injury as a stage 2 on these readmissions. In addition, R8's Wound MD changed R8's wound treatment on 11/20/25 and 12/4/25. Facility staff did not update R8's treatment order and R8 was treated with the incorrect treatment from 11/20 to 11/26/25 and 12/4 to 12/8/25. *R11 has an Unstageable pressure injury to the left heel. R11's Skin Integrity Care Plan has the intervention to have heel boots on when in bed. R11 was observed in bed with no heel boots on and the heels resting on the mattress. Findings include: The facility policy with a last reviewed date of 1/2026 and titled, Pressure Injury Prevention and Management, documents, in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. Licensed nurses will conduct a pressure injury risk assessment, using the Braden risk assessment, on all residents upon admission/re-admission, weekly x four weeks, then quarterly. The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include, but are not limited to: Impaired/decreased mobility and decreased functional ability, Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus. Resident refusal of some aspects of care and treatment, cognitive impairment. Under nutrition, malnutrition and hydration deficits and the presence of a previously healed pressure injury. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries and appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics. Compliance with interventions will be documented in the weekly summary charting. Monitoring- The [Registered Nurse (RN)] Unit manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing and compliance at least weekly. 1.) R8 was admitted to the facility on [DATE] with diagnoses that include syncope (fainting) and collapse, Pulmonary emboli (blood clot in the lung), Chronic Obstructive Pulmonary Disease (progressive lung disease that causes obstructed airflow, making it difficult to breath), Type 2 Diabetes, Dementia, Congestive heart failure, and Venous insufficiency (leg veins cannot efficiently return blood to the heart, causing blood to pool due to damaged valves). R8's Minimum Data Set (MDS) assessment dated [DATE] documents, in part: R8 is moderately cognitively intact. R8 requires substantial to maximum assistance to roll left and right in bed. R8 depends on staff for showering, bathing, toileting and transfers. R8 has an indwelling catheter and is always incontinent of bowel. R8 is at risk for pressure injuries and has 1 unstageable pressure injury present on admission. R8's Care Area assessment dated [DATE] documents, in part: [R8 was] admitted with an unstageable wound to sacrum. [R8] needs assist with ADLs due to weakness post treatment for [pneumonia], respiratory failure. [R8] is also on supplemental [oxygen] via nasal cannula and has an indwelling foley. R8's Braden/skin integrity assessment (an assessment completed to determine a resident's risk for developing pressure injuries) dated 9/24/25 documents a score of 17 indicating R8 is at low risk for developing pressure injuries. R8's admission skin assessment dated [DATE] documents, in part: Sacrum Pressure injury 3 centimeters (cm) x 2cm x < (less than) 0.1 Unstageable. R8's actual impairment to skin integrity care plan dated 9/24/25 documents the following pertinent interventions: Encourage good nutrition and hydration in order to promote healthier skin, Encourage/assist me with reposition as needed, My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment, The resident needs pressure low air-loss mattress to protect the skin while in bed, and The resident needs pressure relieving/reducing cushions to protect the skin while up in chair. R8's Wound MD assessment dated [DATE] documents R8 has a stage 3 pressure injury that measures 2.07cm x 1.68cm x 0.1cm. 75% granulation and 25% slough. Treatment order: Cleanse with 1/2 strength Dakin's, apply nickel-thick Santyl to wound, cover with bordered gauze, change daily and as needed. R8's MD order with a start date of 10/23/25 documents Cleanse with 1/2 strength Dakin's [followed by] Santyl and bordered gauze dressing. Every day shift and as needed. On 10/31/25, R8 experienced a change of condition and was sent to the emergency room. R8 was admitted to the hospital from [DATE] through 11/6/25. R8's hospital discharge summary documented R8's pertinent discharge diagnosis as Chronic hypoxic respiratory failure, Pulmonary embolism, and Colitis. R8's re-admission skin assessment dated [DATE] documents, in part: Coccyx Pressure injury 2cm x 2cm x 0.1cm. Stage 2. Surveyor noted R8's pressure injury was documented by the facility Wound MD on 10/30/25 as a stage 3 pressure injury. On readmission, R8's pressure injury was documented by facility staff as a stage 2 pressure injury. Surveyor noted that a stage 3 pressure injury cannot be down staged to a stage 2. Surveyor noted facility staff staged R8's pressure injury incorrectly on readmission. R8's Wound MD assessment dated [DATE], documents, in part: R8 has an unstageable pressure injury that measures 1.58cm x 1.11cm x 0.1cm. 25% granulation and 75% slough. Treatment order: Cleanse with 1/4 strength Dakin's, apply nickel-thick Santyl to wound, cover with bordered gauze, change daily and as needed. Surveyor noted R8's Wound MD changed part of R8's treatment from 1/2 strength to 1/4 strength Dakin's solution. Surveyor reviewed R8's MD orders and noted facility staff did not update R8's treatment order to reflect this change. Surveyor noted facility staff continued to treat R8's pressure injury with 1/2 strength Dakin's from 11/20/25 through 11/26/25. R8's Wound MD assessment dated [DATE], documents, in part: R8 has an unstageable pressure injury that measures 1.42cm x 1.11cm x 0.1cm. 25% granulation and 75% slough. Treatment order: Cleanse with 1/4 strength Dakin's, apply nickel-thick Santyl to wound, cover with bordered gauze, change daily and as needed. R8's MD order with a start date of 11/26/25 documents, in part: Cleanse with 1/4 strength Dakin's solution. apply nickel thick Santyl to wound bed, Cover wound with bordered gauze, change daily and as needed. R8's Wound MD assessment dated [DATE] documents, in part: R8 has an unstageable pressure injury that measures 3.02cm x 1.34cm x 0.2cm. 50% granulation and 50% slough. Treatment order: Cleanse with 1/2 strength Dakin's, apply nickel-thick Santyl to wound, cover with bordered gauze, change daily and as needed. Surveyor noted R8's Wound MD changed part of R8's treatment from 1/4 strength to 1/2 strength Dakin's solution. Surveyor reviewed R8's MD orders and noted facility staff did not update R8's treatment order to reflect this change. Surveyor noted facility staff continued to treat R8's pressure injury with 1/4 strength Dakin's from 12/4/25 through 12/8/25 when R8 was admitted to the hospital after an episode of unresponsiveness. R8 was hospitalized from 12/8 through 12/11/25. R8 was readmitted to the facility on [DATE]. R8's hospital After Visit Summary dated 12/11/25 documents the primary diagnosis as Atrial Flutter with Rapid Ventricular Response. R8's re-admission skin assessment dated [DATE] documents, in part: Sacrum Pressure injury 3cm x 4cm x 0.5cm. Stage 2. Surveyor noted on readmission, R8's pressure injury was documented by facility staff as a stage 2 pressure injury. Surveyor noted that a previous stage 3 pressure injury cannot be down staged to a stage 2. Surveyor noted facility staff incorrectly staged R8's pressure injury incorrectly on readmission. On 4/2/26 at 1:55 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-S. Surveyor asked what is completed and documented when a pressure injury is found on admission. LPN-S stated that the nurse will assess the wound, notify the MD and family as necessary, complete a risk assessment and get a treatment order. The assessment would include measurements and a description of the wound bed. LPN-S stated LPN-S does not stage the wound but can send a picture of the wound to the Wound MD. The Wound MD comes every Thursday to assess anyone with a wound. Surveyor asked who accompanies the Wound MD during wound rounds. LPN-S stated that if the resident is assigned to them, the floor nurse will accompany the Wound MD. LPN-S stated that sometimes the Unit Manager will accompany the Wound MD as well. Surveyor asked who updates the MD orders in a resident's medical record if the treatment is changed by the Wound MD. LPN-S stated that the Unit Manager will update the order. On 4/2/26 at 2:10 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what is expected when a nurse completes an admission skin assessment. DON-B stated that staff should assess the wound, including measurement and staging. DON-B indicated staff can send a picture to the wound MD to confirm staging of the wound. DON-B stated staff should inform the MD and family as appropriate and should get a treatment order. Surveyor asked how wound rounds work. DON-B stated that the resident's unit nurse will round with the Wound MD. If the treatment order is changed, the Unit Manager will change the MD order within the resident's medical record. On 4/6/26 at 9:25 AM, Surveyor informed DON-B of the concerns about R8's pressure injury care. When R8 returned to the facility after a hospital stay, on 11/6/25 and on 12/8/25, facility staff staged R8's sacrum pressure injury incorrectly. On 11/20/25 and 12/4/25, the Wound MD changed R8's treatment and R8's MD order was not updated. Surveyor asked if facility staff should follow the recommended treatment orders from the wound doctor. DON-B stated yes, those are MD orders and should be followed. DON-B indicated that the staging of wounds is something DON-B can do education on. On 4/6/26 at 3:12 PM, Surveyor informed Nursing Home Administrator (NHA)-A, DON-B, Regional Consultant-C and Chief Compliance Officer-D of the above concerns. 2.) R11 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, congestive heart failure, Alzheimer's disease, Type 1 Diabetes, and anxiety. R11's Annual Minimum Data Set (MDS) assessment dated [DATE] documented R11 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 3, was dependent on staff for activities of daily living (ADLs), and had an Unstageable pressure injury. The Pressure Ulcer Care Area Assessment (CAA) associated with the Annual MDS documented R11 had a new left heel Unstageable pressure injury, was always incontinent of both bowel and bladder, and depends on staff to assist with ADLs including bed mobility. R11 had an activated Power of Attorney (POA). R11's Skin Integrity Care Plan was initiated on 3/3/2025 with the following interventions in place on 4/2/2026: -Encourage R11 to off load heels. -Encourage/assist R11 with repositioning as needed. -Heel boots while in bed. -R11 needs pressure relieving/reducing mattress and pillows to protect the skin while in bed. On 4/2/2026 at 10:39 AM, Surveyor observed Wound Physician (WP)-X accompanied by Registered Nurse Unit Manager (RNUM)-W and Assistant Director of Nursing (ADON)-E provide wound care to R11's left heel pressure injury. R11 had been put back to bed for the assessment and treatment to be completed. R11 had on socks with no heel boots; heel boots were observed in the chair in the room. WP-X stated R11 has to keep the heels off of the mattress and asked RNUM-W if heel boots or a wedge cushion would be better for R11. RNUM-W stated a cushion may work better for R11 because R11 kicks off the heel boots. WP-X told RNUM-W R11 needs to keep the heels off the bed. In an interview on 4/6/2026 at 11:21 AM, Surveyor asked RNUM-W if R11 was active in bed and RNUM-W stated R11 kicks off the heel boots. Surveyor asked RNUM-W if staff go frequently to check and replace the heel boots if R11 had kicked them off. RNUM-W stated they were not aware of staff reapproaching or doing more frequent rounds to check on R11's heel boots. Surveyor repeated with RNUM-W the conversation with WP-X and RNUM-W about keeping R11's heels floated and the discussion whether a cushion or heel boots would be better for R11. RNUM-W stated R11 will not keep the boots on and does not think a cushion would be in place long. Surveyor asked RNUM-W why R11 needed assistance with bed mobility if R11 was mobile enough to kick off boots or a cushion. RNUM-W stated R11 requires staff assistance because R11 is resistant to cares. On 4/7/2026 at 7:34 AM, Surveyor observed R11 in bed. R11 had bare feet and a heel boot was in the bed next to R11's side. R11's knees were bent, and the heels were on the mattress. In an interview on 4/7/2026 at 7:38 AM, Surveyor asked Licensed Practical Nurse (LPN)-Y what R11 was like. LPN-Y stated R11 was resistive to cares so staff need to re-approach for R11 to cooperate. Surveyor asked LPN-Y if R11 is known to kick off the heel boots. LPN-Y stated R11 is usually up in a wheelchair during the day so does not wear heel boots and cannot speak as to what the staff does on the night shift with heel boots. Surveyor shared with LPN-Y the observation of R11 lying in bed at that time with no heel boots on. On 4/7/2026 at 8:15 AM, Surveyor shared with Regional Consultant-C the observation of R11 that morning lying in bed with the heel boot next to R11 and not on R11's feet. Regional Consultant-C stated Regional Consultant-C could not contest Surveyor's observation.

Based on observation, interview, and record review, the facility did not ensure residents with special dietary needs received the appropriate food for 1 (R12) of 4 residents reviewed on a mechanically altered diet.R12 was on a mechanically soft diet and was observed to have tortilla chips, not a mechanically soft diet food.Findings include:The facility policy and procedure titled Non-Compliance with Physician Order Diet/Thickened Liquids undated documents: POLICY: To manage those residents who consistently refuse to accept the physician-ordered diet. In long term care facilities, Diet orders must be followed. When the diet order is not acceptable to the resident, the facility attempts to obtain a different diet order, or to make acceptable substitutions to encourage adequate intake by the resident.PROCEDURE: 1. When residents insist on being served foods that are not allowed on their diets, Or refuse those foods that are on their diets, the dietary manager, with consultation from the Dietitian as necessary, will notify the physician, family, and care plan team of the problem. 2. The dietitian/ST (speech therapist) or designee explains to the resident and/or family the danger of substituting or rejecting food. 3. Nursing, Social Services, Therapy (ST), and dietary departments document in individual progress notes, document that the resident is consuming foods not recommended on their diet, or that the resident is rejecting foods that are on the diet, and that the resident and family is aware of the consequences of this action. Dietary notes also document that substitute foods are offered and accepted or rejected. 4. When a resident continues to refuse the diet, or continues to eat items not on the diet, the physician is notified and asked for his or her assistance in developing an alternative diet plan. 5. The dietary department continues to serve the diet as ordered until that order is changed by the physician. 6. Once the resident starts to lose their cognitive ability (BIMMS score < 13) and the risk for complications increases. The facility shall revert to the most restrictive diet order as necessary. 7. Plan of care must be developed indicating resident is at risk for aspiration for non-compliance to diet/liquid restrictions. 8. All signed waivers should be reviewed on a quarterly basis and/or as cognitive status changes.R12 was admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting the left side. R12's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R12 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and was on a mechanically altered diet. R12 did not have an activated Power of Attorney (POA).On 3/24/2023, R12 was ordered to have a regular diet with mechanical soft texture.R12's Activities of Daily Living (ADL) Care Plan was initiated on 6/10/2021 and had the intervention to provide set up and assistance at meals for a regular mechanical soft texture diet revised on 1/13/2022.On 4/2/2026 at 12:00 Noon, Surveyor observed R12 in bed waiting for lunch. Surveyor observed two unopened snack size bags of Doritos tortilla chips and one opened snack size bag of Dorito tortilla chips on R12's overbed table. Surveyor asked R12 if R12 was on a special consistency diet. R12 stated R12 was on a mechanical soft diet because R12 did not have any teeth or dentures. Surveyor asked R12 if the bags of Doritos were R12's. R12 stated staff bring R12 Doritos and as long as they bring Doritos and Pepsi, R12 is happy. Surveyor asked R12 if R12 ever choked when eating the Doritos. R12 said no, R12 is able to chew even though R12 does not have any teeth. Surveyor observed a multipack box of Dorito tortilla chips on a table on the far side of the room.In an interview on 4/2/2026 at 12:14 PM, Surveyor asked Cook-P what kind of diet R12 was on. Cook-P was serving the lunch meal at the kitchenette on the unit and had a stack of meal tickets for the residents on the unit. Cook-P found R12's meal ticket and stated R12 was on a mechanical soft diet as documented on the meal ticket.In an interview on 4/2/2026 at 2:14 PM, Surveyor asked Activity Director (AD)-G how activity staff are made aware of residents on a special diet, either nutritionally or consistency. AD-G stated a printout of all the residents with their diet is provided on a weekly basis from the dietician. AD-G stated the resident dietary list is also in the general store so the staff that are working in there know what the resident can purchase. AD-G stated there is always a list available. Surveyor asked AD-G if AD-G knew about R12 having Doritos. AD-G stated R12's family brings in the chips and the family says it is okay for R12 to have them. AD-G stated R12 gets $3 a day for two bags of chips, so Activities purchases the two bags of Doritos daily and gives them to R12. Surveyor asked AD-G if R12 was able to have the chips because R12 was on a mechanically soft diet. AD-G stated that would be a question for Registered Dietician (RD)-J.In an interview on 4/2/2026 at 2:21 PM, Surveyor asked RD-J if R12 could have Doritos. RD-J stated R12 was on a mechanically soft diet so Doritos would not be on that diet. Surveyor shared with RD-J the observation of R12 having Doritos and the conversation with AD-G that Activities and R12's family provide Doritos daily to R12. RD-J stated the facility has a diet waiver that has to be signed that states the risks of choking and aspirating so the resident has to assume the liability. RD-J stated RD-J works closely with Speech and Language Pathologist (SLP)-K when developing a diet that has an altered texture. RD-J looked in R12's medical record and could not find a dietary waiver for R12. RD-J stated SLP-K may have a waiver.In an interview on 4/2/2026 at 2:34 PM, Surveyor asked SLP-K if a resident on a mechanically soft diet could have Doritos. SLP-K stated no. SLP-K stated residents have a right to eat what they want but if they are on an altered diet, they would have a waiver in their record. Surveyor asked SLP-K if R12 was on the mechanical soft diet due to swallowing concerns or due to not having any teeth. SLP-K referred to R12's notes and R12 complained of pain with swallowing in 2023 and was put on the mechanical soft diet at that time. SLP-K could not find any risk/benefit charting for R12's desire to have Doritos.On 4/6/2026 at 10:26 AM, Director of Nursing (DON)-B stated the facility has started a performance improvement plan (PIP) to address residents on an altered consistency diet. DON-B stated R12 was given the risks and benefits of eating the Doritos on 4/3/2026 and R12 signed the waiver. DON-B provided Surveyor with the signed Non-Compliance with Physician Order Diet/Thickened Liquids for R12. The form was also signed by SLP-K and Registered Nurse Unit Manager (RNUM)-W. Surveyor noted the form was signed after Surveyor brought the concern to facility staff.

Based upon observation, interview and record review, the facility did not ensure 1 (R58) of 4 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being.R1 was admitted to the facility and started demonstrating sexually inappropriate behaviors. In December of 2025 R1 was diagnosed as having an Unspecified Mood Affective Disorder and was started on an antidepressant for anger and sexual inappropriateness. In February of 2026 R1 was diagnosed with an Adjustment Disorder with Depressed Mood. In March R1 started on Depakote Sprinkles along with Ativan as needed for behaviors. During this period of time staff and psychiatric practitioners documented on R1 sexual behavior. Individuals interacting with R1 expressed concern regarding his behaviors towards others; there were recommendation from the psychiatric nurse practitioner to supervise R1. These changes and recommendations were not further assessed or addressed for R1 until after R1 was engaged in a resident to resident sexual situation with a peer.Findings Include:The facility's Social Services policy and procedure implemented 2026 documented:Policy:.The facility will provide medically-related social services to each resident, to assist in attaining or maintaining the resident's highest practicable physical, mental, and psychosocial well-being.Policy Explanation and Compliance Guidelines:.2. The facility, regardless of size, will provide medically-related social services to each resident, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.4. The social worker, or social service designee, will pursue the provision of any identified need for medically related social services of the resident. Services to meet the residents' needs may include:j. Providing or arranging for needed mental and psychosocial counseling services.k. Identifying and seeking ways to support residents' individual needs through the assessment and care planning process.l. Encouraging staff to maintain or enhance each resident's dignity in full recognition of each resident's individuality.n. Identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident.6. The resident's plan of care will reflect any ongoing medically related social service needs, and how these needs are being addressed.7. The social worker, or social service designee, will monitor the resident's progress in improving physical, mental, and psychosocial functioning.The facility's Resident Assessment-Coordination with PASARR Program policy and procedure reviewed/revised 1/26 documents:Policy:.This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs.Policy Explanation and Compliance Guidelines:.1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening .6. The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.R1 was admitted to the facility on [DATE] with diagnoses including Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life. R1 has an activated Health Care Power of Attorney (HCPOA).R1's Quarterly Minimum Data Set (MDS) completed 1/21/26 documented R1's Brief Interview for Mental Status (BIMS) score to be 3, indicating R1 demonstrates severely impaired skills for daily decision making. R1's Patient Health Questionnaire (PHQ-9) score is 13, indicating R1 is demonstrating moderate depressive symptoms. R1's MDS documented no behaviors at this time.The following is documented in R1's progress notes:On 10/23/25, Registered Nurse (RN)-Z documented: .CNA called nurse into the room due to resident inappropriate gestures to nursing staff and CNA felt uncomfortable to be in room for transfer alone. Social work as well as Unit Manager were notified. Nursing staff will continue to monitor.On 10/24/25, Registered Nurse (RN)-AA documented: .Unit Manager discussed behavior.On 10/24/25, Cares in pairs is added as intervention to R1's comprehensive care plan, but staff interviewed did not know cares in pairs was to be implemented. Surveyor noted it is not listed as a 1/24/26 intervention on R1's Kardex.On 11/30/25, Registered Nurse documented: .Sexually inappropriate. Unit Manager aware Message left for Social Worker.Surveyor reviewed R1's treatment administration record (TARS) for October and November that documented no targeted behaviors.On 12/1/25, Social Services Director (SSD)-F documented SSD-F .discussed the staff's report of inappropriate behaviors sexual in nature with (R1's) wife who is (R1's) activated HCPOA.On 12/2/25, Licensed Practical Nurse (LPN)-U documented:.being monitored for inappropriate behaviors, there were a couple this shift.On 12/9/25, Psych Nurse Practitioner (NP)-H documented: .(R1) is being seen for initial psychiatric consultation for sexual inappropriateness towards female staff, physically grabbing for patient's breasts and genitals, and anger. Staff reports the patient can be physically and verbally aggressive especially during cares and will attempt to touch female staff inappropriately as well as making inappropriate comments. He will lie in his room naked without covering himself up even when his roommate has visitors. Chronicity Level: Chronic: Patient presents with sexual inappropriateness towards female staff, physically grabbing for breasts and genitals, and exhibiting anger.On 12/9/25 R1 was diagnosed as having an Unspecified Mood Affective Disorder. On 12/10/25, LPN-U documented: .(R1) is being monitored for inappropriate sexual behaviors. (R1) was being inappropriate with staff the housekeeper he was asking her to feel on butt and for her to get in bed with him.On 12/17/25, RN- E documented: .(R1) being monitored for behaviors. (R1) 'flashing' CNA this shift. Writer went and provided resident with education on appropriateness. R1 laughed and asked if writer 'wanted to see too'. Staff advised to do cares in pairs for (R1).On 12/18/25, RN-L documented: .(R1) told staff 'Come here, let me kiss'.Surveyor reviewed R1's treatment administration record (TARS) for December that documented no targeted behaviors.On 1/8/26 R1 was started on 10 mg of Paroxetine (Paxil) was added for anger and sexual inappropriateness.On 1/13/26, Psych NP-H-documented: .Staff reports patient continues to have sexual comments and attempts to inappropriately touch staff in a sexual manner. (R1) has stated he needs a woman in his bed and invite staff to join him in his bed. Any attempts to redirect (R1) are unsuccessful. (R1) can become physically verbally aggressive at times again with difficulty redirecting behaviors. (R1) will often be found in his bed naked and exposed to anyone who walks in. When asked about (R1's) pain he pointed to his groin and said 'I have a pain down there, and I need a woman to help me. (R1) continued with his inappropriate conversation, the writer dismissed herself. Continues to demonstrate sexually inappropriate behaviors toward female staff with attempts to touch and grab in a sexual manner. Makes inappropriate sexual comments including stating he needs a woman in his bed and inviting staff to join him in bed. Physically and verbally aggressive during cares and when redirected. Any attempts to redirect (R1) are unsuccessful. (R1) is often found in his room naked and exposed to anyone who walks in. During today's encounter, made inappropriate sexual comments to the provider. Ongoing behavior dysregulation by staff with continued sexually inappropriate comments/behaviors and intermittent physical/verbal aggression with difficulty redirecting. Inadequately Controlled, (R1) presented with sexual inappropriateness toward female staff and anger with poor impulse control, circumstantial thought process with loose associations, poor judgment/insight; oriented to person only with poor attention/concentration. Persistent behavioral disturbance with continued sexual disinhibition, frequent exposure/nudity and limited response to redirection; staff also reports intermittent physical/verbal aggression. No improvement on Paxil. Continue close behavioral monitoring and staff redirection/safety precautions.Surveyor reviewed R1's treatment administration record (TARS) for January that documented no targeted behaviors.On 2/4/26, Psychologist (Psych)-I documented: .Decreased impulse control with ongoing sexually inappropriate behaviors and grabbing.On 2/10/26, Psych NP-H documented: .Ongoing behavioral dysregulation reported by staff with continued sexually inappropriate comments/behaviors and intermittent physical/verbal aggression with difficulty redirecting. (R1) continues to state he wants a woman and is difficult to redirect from this conversation. Started on Paxil without any improvement in target sexual aggressive behaviors. Continue close behavioral monitoring and staff redirection/safety precautions.On 2/27/26, Psych-I documented: .During the interaction, (R1) made comments focused on woman and asked this writer personal questions. Prior encounters documented resistive behavior during assessment attempts and ongoing behavioral concerns including sexual inappropriateness toward staff, verbal and physical aggression, and difficulty with behavioral redirection. (R1) with established adjustment disorder presenting for psychotherapy. Today's session focused on social disinhibition and behavioral boundary concerns, with (R1) making comments focused on women, asking personal questions of this writer, acknowledging that (R1) at times attempted to touch staff. Continued monitoring is indicated to address social disinhibition, reinforce boundaries, and support adjustment to the long-term care environment.On 2/27/26 R1 was diagnosed with an Adjustment Disorder with Depressed Mood.Surveyor reviewed R1's treatment administration record (TARS) for February that documented no targeted behaviors.On 3/20/26, Psych-I documented: .During the session, (R1) made sexually inappropriate comments toward this writer. When asked about treatment goals, (R1) responded with statements focused on obtaining access to women. Previously, (R1) had demonstrated sexually inappropriate behaviors toward staff, including attempts to touch staff, and comments focused on women. (R1) demonstrated behavioral dysregulation with sexually inappropriate behavior, impaired judgement and impulse control, and limited insight into the impact of his behaviors. Minimal receptivity to intervention observed. Minimal progress noted. Made sexually disinhibited comments during session. (R1) expressed focus on obtaining access to women rather than appropriate social engagement. Inappropriate interpersonal behaviors toward staff and this writer noted during session. Continues to demonstrate sexually inappropriate behaviors toward female staff and made sexually inappropriate comments toward this writer. Makes comments focused on women and asks staff personal questions. Demonstrated poor impulse control and preoccupation with sexual themes during session. Behavior during session was inappropriate at times, including sexually disinhibited comments. Though content notable for preoccupation with sexual themes and inaccurate beliefs about environment. Behavioral concerns noted: sexually inappropriate behavior toward female staff, sexually inappropriate comments toward writer, inappropriate toileting behaviors, impaired judgment and poor impulse control, preoccupation with sexual themes, limited insight, minimal receptivity to intervention. Coordinate with interdisciplinary team regarding behavioral concerns and monitor for changes in behavior, impulse control, and level of insight.On 3/27/26, the facility completed a Misconduct Incident Report indicating there was alleged sexual inappropriate behavior between R1 and R2 on 3/22/26. The facility's summary documented that R2's hand was observed by multiple staff making the up and down motion by R1's lap. Staff provided statements that R1 was observed adjusting R1's pants, lean back and push R1's penis into R1's pants. The facility's summary also documented R1 has a history of sexually inappropriate behaviors towards female staff which now has turned to a new focus on female residents. This incident occurred during the lunch meal in the dining room with other residents present in the dining room. Surveyor noted despite frequent documentation of sexual inappropriate behavior directed towards staff psych practitioners who have worked with R1 have noted his sexual disinhibition and impulsive behavior and R1's desire for attention from females. Additionally, psych practitioners recommended monitoring and supervision of R1. These were not further assessed and incorporated into a care plan for R1 until after the resident to resident incident on 3/22/26.Surveyor reviewed R1's treatment administration record (TARS) for March that documented no targeted behaviors.On 3/27/26, R1 started on Depakote sprinkles and Lorazepam as needed every 8 hours for behaviors.Surveyor noted with the significant changes in R1's mental illness diagnoses and treatments, the facility did not initiate the PASARR process and notify the state authority of the changes for R1 to determine the possible need for specialized services. (Cross-reference F646).Surveyor reviewed R1's comprehensive care plan that documented:At times I feel sad and have no energy, Lonely, Not interested in things, Withdrawn. PHQ9 14/27.Sexual behaviors/verbalization towards female staff.Initiated 10/21/25I have made sexual comments to my peersRevised 3/23/26Interventions:1:1 with staff supervision 3/23/26Address inappropriate comments immediately and calmly, stating behavior is not appropriate 3/23/26Encourage me to get involved in activities related to my interests 10/21/25Help me to keep in contact with family and friends 10/21/25Introduce me to others with similar interests 10/21/25Offer me food and beverages I like 10/21/25Please tell my doctor if my symptoms are not improving to see if I need a change in my medication 10/21/25Redirect resident to neutral conversation 3/23/26Take the time to discuss my feelings when I'm feeling sad 10/21/25Surveyor reviewed R1's medical record to determine if an assessment to determine R1's ability to understand and process consent was completed as part of an assessment of R1's sexual behaviors. Surveyor was unable to locate one being completed for R1 prior to the 3/22/26 interaction with a peer despite frequent sexual behavior seeking out female interaction.The facility completed an Assessment of Resident Capacity to Consent to Sexual Activity for R1 on 3/23/26. The facility determined a score of not applicable due to R1's severely impaired cognitive skills for daily decision making and not being able to answer the assessment questions.On 4/6/26, at 1:19 PM, Surveyor interviewed Social Services Director (SSD)-F regarding R1. SSD-F stated SSD-F has only completed three Resident Capacity to Consent to Sexual Activity assessments since employment. One with a married couple, and now after the incident involving R1 and a female peer. SSD-F shared that SSD-F is very uncomfortable with completing the Resident Capacity to Consent to Sexual Activity assessments. When asked about the referrals for psych care SSD-F confirmed that SSD-F made a psychological referral due to R1's sexual inappropriateness. Surveyor asked SSD-F if they review the recommendations made by psych and make care plan revisions based upon the recommendations and SSD-F confirmed that SSD-F does not review the psych notes. Surveyor asked SSD-F about their role in the PASARR (Preadmission Screening and Resident Review) process including when a significant change in mental health diagnosis and treatment changes. SSD-F stated that SSD-F has nothing to do with processing PASARRs. SSD-F does not know who completes a new Level 1 PASARR if a resident is remaining in the facility past 30 days or when new diagnoses and medications are added.On 4/6/26, at 3:09 PM, Regional Consultant (RC)-C was informed of Surveyor's concerns regarding medically related social services provided to R1.

Based on interview, record review, and facility policy review, the facility failed to monitor fluids offered and consumed by a resident to ensure fluid intake was in accordance with a physician order for a 1500 milliliter (ml) fluid restriction for 1 (R4) of 2 sampled residents reviewed for dehydration.Findings included:A facility policy titled, Fluid Restriction, dated 2025, revealed It is the policy of this facility to ensure that fluid restrictions will be followed in accordance to (sic) physicians' orders. Policy Explanation: Fluid restrictions are basically the restriction of fluid intake. This may be due to underlying medical conditions that may cause fluid buildup such as congestive heart failure or end stage renal disease (ESRD), in addition to electrolyte imbalance disorders such as hyponatremia. Fluid restrictions amounts can vary according to the resident's condition and the physician's judgment.An admission Record indicated the facility admitted R4 on 10/03/2025. According to the admission Record, the resident had a medical history that included a diagnoses of chronic kidney disease and acute on chronic diastolic (congestive) heart failure. R4's Care Plan Report included a focus area initiated 10/03/2025, that indicated the resident was at nutritional risk. Interventions directed the staff to monitor meal intake percentage of food and fluids (initiated 10/04/2025) and provide a consistent carbohydrate diet with a 1500 milliliter (ml) fluid restriction (initiated 10/06/2025). R4's Order Summary Report for active orders as of 10/14/2025, revealed an order dated 10/03/2025, for a 1500 ml fluid restriction every shift.R4's Treatment Administration Record [TAR] for the timeframe 10/01/2025 - 10/31/2025, revealed documentation to indicate the resident consumed 910 ml of fluids on 10/05/2025, 1020 ml of fluids on 10/07/2025, 960 ml of fluids on 10/08/2025, 970 ml of fluids on 10/11/2025, and 1220 ml of fluids on 10/12/2025.R4's Meal Intake for the timeframe 10/03/2025 - 10/13/2025, revealed documentation to indicate the resident consumed 800 ml of fluids on 10/05/2025, 680 ml of 10/07/2025, 960 ml on 10/08/2025, 620 ml on 10/11/2025, and 620 ml on 10/12/2025.According to the R4's TAR and Meal Intake for 10/2025, the resident consumed 1710 ml of fluids on 10/05/2025, 1700 ml of fluids on 10/07/2025, 1920 ml of fluids on 10/08/2025, 1590 ml of fluids on 10/11/2025, and 1840 ml of fluids on 10/12/2025.During an interview on 10/14/2025 at 4:02 PM, the Registered Dietitian (RD) stated R4 admitted to the facility with a physician's order for a fluid restriction. The RD stated she calculated how much fluids nursing and dietary would provide. According to the RD, nursing would provide 780 ml per day and dietary would provide 720 ml per day. The RD stated she did not calculate or monitor the amount of fluids nursing provided but expected the nursing staff to monitor what they provided to the resident and make any necessary adjustments based on what the dietary staff provided. During an interview on 10/14/2025 at 5:17 PM, Registered Nurse Q stated she was aware R4 was on a fluid restriction, and she recorded what the resident received from nursing to include what the nurse aides reported to her the resident consumed during meals. During an interview on 10/15/2025 at 10:27 AM, Registered Nurse Unit Manager (RN UM) F stated when she administered medication during the day shift for residents on a fluid restriction, she documented the amount of fluids given to the resident on the resident's TAR. During an interview on 10/15/2025 at 11:59 AM, Licensed Practical Nurse (LPN) G stated when a resident was on a fluid restriction, she divided the total fluids allowed by three so that she would know how many ml of fluids could be provided per shift and recorded the amount of fluid provided during medication administration on the resident's TAR. LPN G stated she reminded the nurse aides to follow the fluids allowed as recorded on the resident's meal ticket. During an interview on 10/15/2025 at 1:15 PM, RN UM R stated for residents with fluid restrictions, the nurse was responsible for documenting on the resident's TAR the fluids given. RN UM R stated that he had not added up the total amount of fluids provided to R4 from medication administration and meals to make sure the fluid restriction was being followed. RN UM R stated he only monitored fluids a resident consumed if there was a change in the resident's condition, and his review only included the documentation on the TAR recorded by the nurse. RN UM R acknowledged his review did not include the documentation by the nurse aides of how much fluids the resident consumed during meals. During an interview on 10/15/2025 at 2:23 PM, the Director of Nursing (DON) stated because of the inconsistency and lack of monitoring, it was difficult to determine if staff provided R4 fluids per the physician's order. According to the DON, the nurse should monitor a resident's fluid intake to ensure their fluid needs were met per the physician's order.During a telephone interview on 10/14/2025 at 4:58 PM, the Medical Director (MD) stated R4 admitted to the facility with a physician's order for a 1500 ml fluid restriction. The MD stated based on the resident's medical history, he would not be concerned about the amount of fluids the resident consumed over the 1500 ml limit unless the resident had problems with shortness of breath, edema, or weight gain. The MD stated R4 had a potential for fluid overload, but the amount of fluids consumed by the resident was not of meaningful significance without some impact on the resident's laboratory values, shortness of breath, edema, or weight gain. The MD stated the staff should monitor fluid restrictions, but fluid restrictions could be difficult to manage especially in a resident who was cognitively intact, mobile, and could eat and drink independently. The MD stated he was not sure the resident required a fluid restriction since they did not receive dialysis. During an interview on 10/15/2025 at 5:11 PM, the Administrator stated the nurses and unit managers should both monitor a resident's fluid restrictions on a regular basis to validate any changes to the physician's order and to ensure the parameters for the fluid restriction was being followed.

Based on interview, observation, and record review the facility did not ensure 1 (R13) of 20 sampled residents care plans were revised accordingly.R13's care plan was not revised after R13 had a catheter re-inserted for urine retention.Findings include:The facility policy titled Care Plan Revisions Upon Status Change reviewed/revised 5/2025 documents: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change.Policy Explanation and Compliance Guidelines:1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change.2. Procedure for reviewing and revising the care plan when a resident experiences a status change: .b. The Minimum Data Set (MDS) coordinator and the Interdisciplinary Team (IDT) will discuss the resident condition and collaborate on intervention options.d. The care plan will be updated with the new or modified interventions. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.R13 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, major depressive disorder, chronic kidney disease stage 3, and Benign Prostatic Hyperplasia (prostate is larger than normal) with lower urinary tract symptoms. R13's admission Minimum Data Set (MDS) dated [DATE] indicated R13 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0. R13 was admitted to the facility on Hospice care and had a Foley catheter in place.On 8/6/2025, at 9:48 AM, Surveyor observed R13 lying in bed sleeping. Surveyor noted R13 had a catheter bag hanging from the right side of R13's bed.Surveyor reviewed R13's care plan and noted R13 had an indwelling foley catheter care plan initiated on 6/5/2025 that had been resolved on 6/27/2025.Surveyor reviewed R13's progress notes:On 6/26/2025, at 21:32 (9:32 PM), in the progress notes nursing documented (R13) removed catheter . order given to bladder scan (R13) each shift for 24 hours.On 6/27/2025, at 19:16 (7:16 PM), in the progress notes nursing documented . bladder scan for (R13) completed. 596 cc urine present, foley catheter replaced.Surveyor noted R13's foley catheter care plan never got revised/ re- initiated after R13 had R13's catheter re-inserted on 6/27/2025.On 8/12/2025, at 8:35 AM, Surveyor interviewed registered nurse unit manager (RNUM)-D who stated RNUM-D usually updates/ revises the care plans. RNUM-D stated that RNUM-D was not sure why R13's care plan was not revised on 6/27/2025 when R13 got the foley catheter re-inserted because RNUM-D was not employed with the facility at that time. RNUM-D stated care plans do get reviewed in the morning IDT (interdisciplinary team) meetings so it should have been noticed and must have been overlooked. Surveyor asked how often care plans get reviewed in the morning IDT meetings. RNUM-D stated the IDT meetings are every morning and discuss concerns, not all residents get reviewed unless something is happening or a resident is experiencing a change, so R13's should have been revised when the catheter got re-inserted in June.On 8/12/2025, at 11:47 AM, Surveyor shared concern with Director of Nursing (DON)-B that R13's catheter care plan was not revised on 6/27/2025 after R13 has a catheter re-inserted for retention. DON-B stated the care plan should have been revised when R13 had a foley catheter re-inserted and not resolved.

Based on observation and interview the facility did not ensure facility stock medications were not expired in 1 of 2 medication storage rooms.- 1 bottle of Calcium with Vitamin D 600 mg/400 IU with an open date of 11/22 and expiration date of 7/2025.- 2 unopened bottles of Aspirin 325 mg with an expiration date of 6/2025.- 1 bottle of Iron 27 mg with an open date of 1/23/2025 and an expiration date of 4/2025 and 2 unopened bottles of Iron 27 mg with an expiration date of 4/2025.Findings include:On 8/12/2025, at 8:18 AM, Surveyor observed in the 2nd floor medication room (2-East) in the stock medications cabinet the following expired medications:- 1 bottle of Calcium with Vitamin D 600 mg/400 IU with an open date of 11/22 and expiration date of 7/2025.- 2 unopened bottles of Aspirin 325 mg with an expiration date of 6/2025.- 1 bottle of Iron 27 mg with an open date of 1/23/2025 and an expiration date of 4/2025 and 2 unopened bottles of Iron 27 mg with an expiration date of 4/2025.On 8/12/2025, at 8:47 AM, Surveyor interviewed registered nurse unit manager (RNUM)-D who stated RNUM-D looked through the cabinets when RNUM-D started employment at the facility in July 2025 but must have missed those medications. Surveyor asked whose responsibility it is to go through the medications for expired medications. RNUM-D stated anyone can go through the medications to check for expired dates, but ultimately it is up to RNUM-D to make sure that is being completed and check to make sure it is being done. Surveyor asked how often the medications rooms are checked for expired medications. RNUM-D stated was not sure how often but would guess monthly.On 8/12/2025, at 11:47 AM, Surveyor shared concerns with director of nursing (DON)-B that Surveyor observed several expired medications in the 2-East medication room. DON-B stated that medication rooms should be checked often and expired medications should not be left in the medication rooms.

Based on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained to help prevent the development and transmission of infections during wound care for 1 (R7) of 1 residents observed during wound care. *R7 had a treatment to the right calf pressure injury and hand hygiene was not performed between dirty and clean aspects of the treatment. Findings include: The facility policy and procedure titled Hand Hygiene dated 4/2024 documents: Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The attached Hand Hygiene Table included, in part, hand hygiene in the following situations: after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE) including gloves, before and after handling clean or soiled dressings, after handling items potentially contaminated with blood, body fluids, secretions, or excretions, when during resident care moving from a contaminated body site to a clean body site, and when in doubt. R7 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, gastro-esophageal reflux disease with esophagitis with bleeding, protein-calorie malnutrition with a gastrostomy tube for all nutrition, anemia, and chronic embolism and thrombosis of deep veins. R7's Admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 and had impairment to both arms and legs requiring maximum to total assistance with all activities of daily living and bed mobility. The MDS documented R7 received all nutrition through the gastrostomy tube. The MDS documented R7 had a Deep Tissue Injury that was present upon admission and had a pressure reducing device for the chair and bed and received pressure ulcer care. R7's Skin Impairment Care Plan dated 6/26/2024 documented R7 had deep tissue injuries to the five toes on the left foot. R7's Quarterly MDS assessment dated [DATE] documented R7 did not have any pressure injuries. R7 had an activated Power of Attorney (POA). On 10/24/2024 at 10:24 AM in the progress notes, a Licensed Practical Nurse (LPN) documented a Certified Nursing Assistant (CNA) was giving R7 a bed bath and noticed R7 had a scabbed area on the right leg. The LPN documented the area is a dry, scabbed pressure area that measured 1.0 cm x 1.2 cm. On 2/18/2025 at 1:17 PM, Surveyor observed R7 in bed on an air mattress. R7 stated R7 was comfortable and agreeable to have Surveyor observe wound care. On 2/18/2025 at 3:57 PM, Surveyor observed LPN-F provide wound care to R7 with the assistance of CNA-G. R7 was observed in bed on an air mattress and to have heel boots on. LPN-F washed their hands in the bathroom with soap and water. LPN-F and CNA-G put on isolation gowns and gloves. LPN-F turned R7's feeding tube pump to hold. LPN-F moved the garbage can with gloved hands by grabbing the top edge of the garbage can with the fingertips inside the garbage can. LPN-F removed the lid and protective seal on a bottle of normal saline. LPN-F opened a 4x4 gauze, folded the gauze, and placed it over the open normal saline bottle. With two hands, LPN-F turned the bottle up-side-down so the gauze was on the bottom absorbing the normal saline and then placed the saline soaked gauze on the open gauze packet. LPN-F removed R7's heel boots. CNA-G held R7's right leg under the ankle and knee so LPN-F could access the wound site. LPN-F removed R7's dressing from the back of R7's calf and threw it in the garbage can. LPN-F picked up the saline soaked gauze and washed the wound bed with the gauze. LPN-F took a dry gauze and patted the wound dry. LPN-F removed the gloves and put on a new pair of gloves. LPN-F did not complete any hand hygiene between the use of gloves. LPN-F put manuka honey from a tube onto the middle of the foam gauze. LPN-F placed the foam gauze onto and covering the wound. LPN-F did not perform any hand hygiene after touching the garbage can and before putting normal saline on the gauze. LPN-F did not perform any hand hygiene after removing the heel boots and removing the old dressing. LPN-F did not perform any hand hygiene after removing the old dressing and cleansing the wound with normal saline. LPN-F did not perform any hand hygiene after removing gloves and putting on a new pair of gloves. LPN-F did not perform any hand hygiene after the wound care was completed. Surveyor asked LPN-F if LPN-F normally washes their hands while doing wound care. LPN-F stated LPN-F usually has hand gel (alcohol-based hand sanitizer) in their pocket but today LPN-F did not have any. Surveyor asked LPN-F when LPN-F would use the hand sanitizer. LPN-F stated LPN-F would use it between taking gloves off and putting gloves on. On 2/19/2025 at 7:57 AM, Surveyor shared with Director of Nursing (DON)-B the observation of R7's Unstageable pressure injury wound treatment completed by LPN-F on 2/18/2025. Surveyor shared the concerns with DON-B LPN-F did not perform hand hygiene at critical points throughout the treatment and touched multiple surfaces, such as the garbage can and R7's heel boots, without performing hand hygiene. DON-B agreed hand hygiene should have been performed throughout the wound treatment.

Based on observation, interview, and record review the facility did not ensure 2 (R6 and R7) of 3 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal the pressure injuries. * R6 was admitted to the facility on [DATE]. Upon admission, R6 had no open wounds or Pressure Injuries (PI). R6 was assessed to be at risk for pressure injuries and to need assistance with bed mobility upon admission. On 2/7/25, R6 developed a facility acquired Deep Tissue Injury (DTI) to his left heel. On 2/9/25, R6 developed a PI to his sacrum. The facility did not complete a comprehensive assessment of his wounds when discovered. R6 was transferred to the hospital on 2/13/25, with a change in condition and noted to have an unstageable sacral wound. * R7 developed an unstageable PI to the right calf on 10/24/2024. R7 did not have a comprehensive assessment of the wound when discovered, the weekly measurements did not include the measurement of depth, and the wound bed was never documented so staff could not determine if the wound was improving or declining. The unstageable PI has not ever been comprehensively assessed with all the components of a comprehensive assessment: stage, measurements of length, width, and depth, and a complete description of the wound bed. Registered Dietician (RD)-H was not aware of the pressure injury when it was discovered. Findings include: The facility's policy titled, Pressure Injury Prevention and Management, dated 2023, last reviewed/revised 04/2024, documents: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure injury, prevent infection and the development of additional pressure injuries. Avoidable means, that the resident developed a pressure injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable means, the resident developed a pressure injury even though the facility had evaluated the resident's clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Licensed nurses will conduct a pressure injury risk assessment, using the Braden risk assessment, on all residents upon admission. The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include but are not limited to: impaired/decreased mobility and decreased functional ability. Cognitive impairment. Exposure of skin to urinary and fecal incontinence. Under nutrition, malnutrition, and hydration deficits. The presence of a previously healed pressure injury. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse. The staging of pressure injuries will be clearly identified to ensure correct coding on the Minimum Data Set (MDS). Monitoring: The Registered Nurse (RN) unit manager will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly. 1.) R6 is an [AGE] year-old resident who was admitted to the facility on [DATE]. R6's diagnoses include bilateral osteoarthritis of the knee and left shoulder, pain in the left shoulder, Chronic Obstructive Pulmonary Disease (COPD), contusion of the left eyelid, difficulty walking, abnormalities of gait and mobility, lack of coordination, abnormal posture, cognitive communication deficit, and glaucoma. R6's Admission MDS completed on 2/3/25, documents R6 is dependent with toileting hygiene, dressing, and requires substantial/maximal assistance with showering and rolling left to right. R6 was documented as having a Brief Interview for Mental Status (BIMS) score of 8, indicating R6 has moderate cognitive impairment. The MDS assesses R6 as not demonstrating the behavior of refusing cares. R6's MDS documents no unhealed pressure injuries and is at risk for developing PI's. R6's Care Area Assessment (CAA) for PI documents, R6 has frequent bowel incontinence, is at risk for developing PI's, and requires assistance with Activities of Daily Living (ADL) for movement in bed. R6 requires assistance from rolling left to right. R6 requires assistance from sitting on the side of the bed to lying flat on the bed. R6 requires assistance to safely move from lying on his back to sitting on the side of the bed with feet flat on the floor, and with no back support. R6's CAA documents R6 does not have any pressure ulcers. R6 was admitted to the skilled nursing facility (SNF) after an inpatient stay, treatment for rib pain after a fall at home, and requires assistance with ADL's, including transfers. R6 is frequently incontinent of bowel. R6's care plan, dated 1/28/25, documents: (R6) has actual impairment to skin integrity of the face, hematoma below the left eye with a scab, scattered bruising to extremities related to fall prior to admission, 2/7/25 left heel ruptured blister, now appears unstageable, 2/9/25 moisture acquired skin damage (MASD) now appears unstageable, (dated 1/28/25 with revisions on 1/29/25, 2/8/25, 2/10/25 and 2/13/25). Interventions include: Encourage good nutrition and hydration in order to promote healthier skin (dated 1/28/25). Encourage (R6) to elevate heels (dated 1/28/25). Encourage/assist (R6) with reposition as needed (dated 1/28/25). Low air loss mattress to protect the skin while in bed (dated 1/29/25). (R6's) skin will be assessed on a weekly basis on his scheduled bath day and document findings on a weekly skin assessment (dated 1/28/25). Pressure relieving/reducing cushions to protect the skin while up in chair (dated 1/29/25). Report any skin redness/impaired integrity areas to my nurse (dated 1/28/25). Use barrier cream to prevent skin impairment issues, as needed (dated 1/28/25). Heel lift boots when in bed (dated 2/8/25). Bed rest per wound medical director (MD) (dated 2/13/25). Surveyor noted R6's care plan was not individualized to R6 until 2/13/25 when bedrest, specific to R6, was ordered by the wound MD-L. Surveyor reviewed R6's medical record which documents a Braden Score performed on 2/7/25 and documents a score of 19, indicating R6 is not at risk for pressure injuries. Surveyor notes R6 was assessed rarely being moist on his 2/7/25 Braden Score indicating skin is usually dry and linen only requires changing at routine intervals. R6's medical record documents a progress note on 2/7/25, at 8:56 PM, indicating R6's Certified Nursing Assistant (CNA) notified nursing staff of a ruptured blister on his left heel. There was no drainage, pain, swelling, or erythema noted, and nursing staff notified R6's Medical Director (MD) and facility nurse manager. Treatment orders were obtained and R6 was placed on the 24-hour board for monitoring. Surveyor reviewed R6's Treatment Administration Record (TAR) which documents an order placed on 2/7/25 to apply betadine to the left heel twice daily and apply heel boots when R6 is in bed. R6's medical record documents a Head-to-Toe Assessment completed on 2/7/25, that documents a ruptured blister to the left heel measuring 3 cm x 3 cm x 0 cm. Staging is documented as Not Applicable (N/A) and no further wound description or details are documented. Surveyor notes there is no comprehensive assessment to include staging, wound bed description or, surrounding skin assessment performed. R6's medical record documents a Pressure Ulcer/Skin Breakdown Unavoidable Investigation/Review completed on 2/7/25, by Registered Nurse (RN) Unit Manager (UM)- D documenting the ruptured blister to R6's heel as unavoidable. Documentation includes primary risk factors being immobility and urine and bowel incontinence. Clinical interventions in place on the care plan include daily skin observation, weekly skin observation, frequent turning and repositioning, heel/elbow protectors, protein supplements, pain management, wound MD consult. Comments on the investigation/review form document (R6) is at risk for skin breakdown due to decreased mobility from rib pain and knee pain status post fall prior to admission. The Root Cause portion of the form was blank. Surveyor noted information documented on the unavoidable investigation as clinical interventions in place such as frequent turning and repositioning, heel/elbow protectors were not included on R6's care plan as interventions specific to R6's assessed needs prior to the development of the pressure injuries. Primary risk factors identified to include immobility, and urine and bowel incontinence were not reflected as being addressed individually for R6's potential needs as the care plan, generically, stated encourage/assist with reposition as needed. R6's Braden assessment dated [DATE] did not identify wet/moist skin and linen (which is possible with urine incontinence) as a risk factor for R6. On 2/19/25, at 9:37 AM, Surveyor left a message on RN- I's voicemail to contact Surveyor to discuss the Head-to-Toe Assessment completed on 2/7/25. RN- I did not return the call to Surveyor. R6's medical record documents a Head-to-Toe Assessment completed on 2/9/25, that documents an open area on R6's coccyx measuring 1cm x 1 cm. Surveyor notes there are no descriptive details regarding the open area including possible measurement of depth, staging, wound bed description or surrounding skin description. This was completed by Licensed Practical Nurse (LPN)-N. Surveyor reviewed R6's Medication Administration Record (MAR) which documents an order placed on 2/9/25, that now identifies the open area as Moisture Associated Skin Damage (MASD) on coccyx to be cleansed with Normal Saline (NS) and apply border foam every shift on every Monday, Wednesday, and Friday. Surveyor reviewed R6's medical record which documents a Braden Score performed on 2/9/25 and documents a score of 20, indicating R6 is not at risk for pressure injuries. Surveyor notes R6 was documented as having slightly limited mobility and makes frequent though slight changes in body or extremity position independently, potential problem for friction and shear, moves freely or requires minimum assistance, skin probably slides to some extent against sheets during a move, maintains relatively good position in his chair or bed most of the time but occasionally slides down. Surveyor notes R6's MDS assesses R6 as requiring substantial/maximal assistance with rolling left to right and being dependent with toileting hygiene and dressing. R6's diagnoses include abnormalities of gait and mobility, abnormal posture, and lack of coordination. An interdisciplinary team (IDT) note written by RN UM-D on 2/10/25 at 18:06 (6:06 pm) documents: IDT note concerning MASD to sacral area measuring approx.1.0 cm x 1.0 cm with surrounding blanchable redness. Resident was not aware of new skin breakdown and denied pain. (Name of) physician notified, new tx (treatment) orders received for bordered foam 3x (times)/week. Resident has hx (history) of morbid obesity, COPD (chronic obstructive pulmonary disease) and osteoarthritis and bowel and bladder incontinence which predisposes him to skin breakdown. Resident requires assist of 1 for bathing, dressing, toileting, and incontinence cares. The IDT recommends a low air loss mattress to prevent further skin breakdown . Surveyor noted R6's care plan indicates a low air loss mattress was identified as an intervention that was to be in place for R6 going back to 1/29/25. R6's medical record includes a Weekly Skin Review performed on 2/12/25, which documents R6's alteration in skin condition to redness that is not checked to indicate if it is pre-existing or new. A bruise that is not checked whether it is pre-existing or new. Surveyor noted there is nothing checked or indicating R6 has an open area on the assessment. Under other it is documented: (R6) admitted with hematoma and scab below left eye and scattered bruising to extremities, new bruise on right side of face, redness and wound to buttocks noted, (R6) denies pain at the time of skin check, and dressing on buttocks replaced per treatment orders. Surveyor noted this was completed by LPN-O and there is no RN assessment despite the documented presence of a wound on R6's buttock. Surveyor notes there is no comprehensive assessment to R6's buttocks wound or left heel to include staging, wound bed description, or surrounding skin assessment. On 2/19/25, at 11:19 AM, Surveyor interviewed Licensed Practical Nurse (LPN)- J to discuss wound care treatments provided to R6 on 2/12/25. LPN- J states she does not recall R6 and works as a travel/agency nurse and typically works at the facility once every 2-3 months. On 2/19/25, at 2:32 PM, Surveyor interviewed Registered Dietitian (RD)- H who states she was notified that R6 developed a new PI after admission. RD- H does not recall how she was notified of R6 having a PI however, RD- H states she attends morning stand up meetings and may have been told at that time. RD- H indicates she reviews wound care documentation that is performed by Wound Physician (MD)- L on Thursdays. RD- H indicates Prostat supplement was ordered for R6 on 2/14/25 after she reviewed wound care documentation from MD- L. On 2/13/25, MD- L performed wound assessment and treatments which document the following: * Unstageable Sacrum Pressure Ulcer with attached edges, 1-25% slough, 51-75% eschar, small serous drainage, normal odor, and excoriated periwound measuring 5.23 x 3.47 x 0.10 cm, with a total area of 12.54 cm. Treatment orders include: Complete Blood Count (CBC) on 2/13/25 and 2/19/25, bed rest, protect periwound with skin prep, apply Santyl to wound bed, change daily, cleanse with 1/2 strength Dakin's solution, change as needed (PRN) for soiling and/or saturation, cover wound with bordered gauze, and discussed nutrition and its impact on wound healing. * Suspected DTI left heel Pressure Ulcer with attached edges, purple wound bed, no drainage, normal odor, and periwound is clean, dry, and intact measuring 4.76 x 2.59 x 0.10 with a total area of 7.57 cm. Treatment orders include: change PRN for soiling and/or saturation, discussed nutrition and its impact on wound healing. Surveyor notes this is the first comprehensive assessment completed for R6's left heel wound discovered on 2/7/25 and sacral wound discovered on 2/9/25. On 2/13/25, at 3:10 PM, Surveyor notes documentation from RN UM- D indicating MD- L was in house and saw (R6's) left heel and sacrum, both wounds have declined since initial finding, and both now present as unstable. (R6) remains on low air loss mattress, (MD- L) gave new treatment orders and bed rest as intervention. (R6) made aware. Call placed to daughter to update; she will update (R6's) wife. Care plan update, chart updated to reflect new orders. R6's medical record documents a Pressure Ulcer/Skin Breakdown Unavoidable Investigation/Review completed on 2/13/25 by RN UM- D documenting R6's heel wound as unavoidable. Documentation includes primary risk factors being immobility, urine and bowel incontinence and head of bed elevated most of the day. The unavoidable investigation/review documents as clinical interventions in place on the care plan include daily skin observation, weekly skin observation, frequent turning and repositioning, moisture barrier, heel/elbow protectors, pressure relieving chair cushion, protein supplements, pain management, and wound MD consult. Comments include (R6) is at risk for skin breakdown due to decreased mobility from rib pain and knee pain status post call prior to admission, recent diagnosis of COVID. The Root Cause portion of the form was blank. Surveyor noted R6's care plan for pressure still had not been updated by 2/13/25 to include frequent turning and repositioning or a frequency specifically assessed for R6's needs. The risk factors for possible skin breakdown when sick with COVID were not assessed or addressed with interventions on R6's care plan for skin concerns. On 2/13/25, at 5:00 PM, R6 was documented as having a change in condition related to a recent diagnosis of COVID and was sent out to the hospital for evaluation. R6's hospital documentation indicates post admission to the hospital, R6 arrived in the emergency room (ER) on 2/13/25, at 5:16 PM with generalized weakness, increased confusion, and positive COVID 3 days ago. R6's [NAME] Blood Cells (WBC) were documented as WBC 6.9 (normal) on 2/13/25, at 6:15 PM. The records indicate R6 was noted to have a suspected DTI to the sacrum measuring 6 x 4 cm with 100% slough. R6 was admitted to the inpatient floor. The hospital records do indicate a delay in treating R6 in the ER and admission to the floor post arrival. The records indicate R6's sacral wound was debrided in general surgery and R6 was started on Intravenous (IV) Antibiotics. On 2/18/25, at 3:01 PM, Surveyor interviewed Interim DON- B and RN UM- D who indicate wound care rounds are performed by MD- L weekly on Thursdays. RN UM- D stated floor nursing staff complete wound measurements and wound care evaluations with MD- L. RN UM- D attends wound care rounds with MD- L weekly on Thursdays. Surveyor asked what a Head-to-Toe Assessment is compared to the Weekly Skin Assessments in resident records. Interim DON- B and RN UM- D indicate the weekly skin assessments are more comprehensive than the Head-to-toe Assessments. Head-to-Toe Assessments are generated when risk management prompts a change in condition. On 2/19/25, at 3:02 PM, Surveyor interviewed RN UM- D who stated the floor nurse will complete wound measurements upon discovery of a new wound, notify the MD, get treatment orders, notify family, update the care plan, and contact maintenance for an air mattress if they don't already have one. Head to Toe Assessments are triggered and performed by the floor nurse and reviewed by the unit manager if a Licensed Practical Nurse (LPN) is completing the Head-to-Toe Assessment. Surveyor asked RN UM- D about the Pressure Injury Unavoidable forms and RN UM- D stated MD- L notifies staff to fill out the unavoidable form. RN UM- D stated R6 qualified as unavoidable because he has 2 or more risk factors, is non-compliant with turning and repositioning, pain from his previous fall at home, and immobile due to his pain after falling at home. Surveyor asked where documentation was of R6 being non-compliant with turning and repositioning. RN UM- D stated staff tell her, and she is not sure this is documented. RN UM- D stated the facility had things in place such as an air mattress, turning, incontinence care, toileting every two to three hours, prior to prevent skin breakdown and it still broke down. RN UM- D stated if all those things are happening and there's still breakdown then it's determined as being unavoidable. RN UM- D indicated the facility started using the pressure ulcer unavoidable investigation form around August or September of 2024. Surveyor notified RN UM- D of concerns with R6 developing an unstageable pressure injury to his sacrum and the suspected DTI to the left heel with no comprehensive assessment completed until MD- L saw R6 on 2/13/25. On 2/19/25, at 3:42 PM, Interim Director of Nursing (DON)- B requested to speak with Surveyor. Interim DON- B stated the facility completes daily skin monitoring for R6 which is documented on the TAR. Interim DON- B stated the comprehensive assessment is completed in the interdisciplinary team (IDT) note. Surveyor notified Interim DON- B there is no comprehensive assessment completed for R6's left heel DTI and unstageable sacral wound to include staging, wound bed description, and surrounding skin in the IDT notes. Interim DON- B acknowledged these concerns. On 2/25/25, at 10:49 AM, Surveyor interviewed MD- L who stated he recalls conversing with R6 at the time of his wound care assessment on 2/13/25. MD- L stated R6's wounds looked significantly worse than what the facility had initially notified him. MD- L stated he ordered bed rest for at least a week, blood work to rule out infection, and planned to follow up with another set of labs because the wound had progressed so much. MD- L indicated he ordered lab work to include a CBC to rule out a bacterial infection due to the worsening wounds. MD- L stated he would have started IV antibiotics right away if he was contacted with a positive CBC. MD- L stated he reviewed R6's hospital documentation and notes R6 did not have an elevated white blood cell count until 2/17/25. MD- L then stated R6's CBC was slightly elevated at 11.3 on 2/17/25 which is just out of range. MD- L stated he thinks this case was due to R6 being elderly, immunocompromised because of his age and very fragile due to COVID. MD- L indicated you have to look at it clinically because labs don't show everything or worsening infection, there's nothing we can go by, so I believe it was due to skin failure that was taken over with opportunistic bacteria that grew in an infected wound and that's why it had gotten so big so fast. MD- L indicated he could feel healthy tissue about 0.5 cm behind R6's sacral wound on 2/13/25, which is why he chose not to debride it. MD- L indicated he saw some excoriation that was kind of red around the area. MD- L notified staff to let him know if the sacral wound gets boggy and he would come by the facility. MD- L indicated there was no fluid leaking to the open area on R6's left heel at the time of the wound assessment on 2/13/25 which is why he chose to leave the blister alone. On 2/20/25 the facility submitted information provided to the Surveyor during the survey for additional review and consideration regarding R6. 38253 2.) R7 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, gastro-esophageal reflux disease with esophagitis with bleeding, protein-calorie malnutrition with a gastrostomy tube for all nutrition, anemia, and chronic embolism and thrombosis of deep veins. R7's Admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 and had impairment to both arms and legs requiring maximum to total assistance with all activities of daily living and bed mobility. The MDS documented R7 received all nutrition through the gastrostomy tube. The MDS documented R7 had a Deep Tissue Injury that was present upon admission and had a pressure reducing device for the chair and bed and received pressure ulcer care. R7's Skin Impairment Care Plan dated 6/26/2024 documented R7 had deep tissue injuries to the five toes on the left foot. R7's Quarterly MDS assessment dated [DATE] documented R7 did not have any pressure injuries. R7 had an activated Power of Attorney (POA). R7's Skin Impairment Care Plan, initiated 6/25/2024, had the following interventions in place on 10/24/2024: -Apply zinc barrier cream every shift and as needed with incontinence cares. -Encourage good nutrition and hydration in order to promote healthier skin. (Surveyor noted R7 did receive any nutrition orally.) -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Keep linen dry, clean, and free of wrinkles. -Skin will be assessed on a weekly basis on scheduled bath day and document findings on a weekly skin assessment. -Report any skin redness/impaired integrity areas to the nurse. -Use barrier cream to prevent skin impairment issues as needed. R7 was receiving enteral nutrition through a gastrostomy tube. R7 had an order for Osmolyte 1.2 at 75ml/hr from 2:00 PM to 10:00 AM, a total of 20 hours. On 10/24/2024 at 10:24 AM in the progress notes, a Licensed Practical Nurse (LPN) documented a Certified Nursing Assistant (CNA) was giving (R7) a bed bath and noticed (R7) had a scabbed area on the right leg. The LPN documented the area is a dry, scabbed pressure area that measured 1.0 cm x 1.2 cm. The LPN documented the physician, POA, Unit Manager, and the Wound Physician were notified. The LPN documented the area was cleaned with normal saline and was awaiting orders from the wound physician. On 10/24/2024 on the Head to Toe Skin Check form, the LPN documented R7 had a new Unstageable pressure injury to the back of the right lower extremity that measured 1.0 cm x 1.2 cm. On 10/24/2024 at 10:33 AM in the progress notes, Registered Nurse Unit Manager (RN UM)-C documented R7 had a pressure injury to the right calf and R7 was unaware of the breakdown. RN UM-C documented R7 requires extensive assist for bed mobility, total assist for incontinence cares, and total assist of two for Hoyer transfer. RN UM-C documented R7 had a history of cerebral palsy, dysphagia, protein calorie malnutrition, and unilateral osteoarthritis of the right hip. RN UM-C documented R7 would be seen in house by the Wound Physician during wound rounds. RN UM-C documented R7's legs were elevated at the knee to avoid pressure to the site. The POA was updated, and the Care Plan was updated. RN UM-C documented previous intervention in place included heel boots. Surveyor noted heel boots when in bed were on the Treatment Administration Record to be signed off every shift initiated on 6/25/2024. On 10/24/2024 on the Weekly Skin Review, RN UM-C documented R7 had a scabbed area to the right calf, the Wound Physician had been notified, and a treatment order was received. The form was signed by RN UM-C on 10/25/2024. A treatment order for the right calf was to cleanse the wound with normal saline and apply betadine daily. On 10/24/2024 on the Pressure Ulcer/Skin Breakdown Unavoidable Investigation/Review form, RN UM-C documented R7 developed on 10/24/2024 to the right calf, skin breakdown. Primary risk factors include immobility and failure to thrive. No treatments were indicated. No recent lab values were indicated. Clinical signs that increased risk were gradual weight loss, immobility, and total dependence. No non-compliant behavior risk factors were indicated. clinical intervention in place and on the care plan included weekly skin observation, moisture barrier, heel/elbow protectors, and tube feeding. Monitoring included vital signs and weight changes. Education was provided to the POA. The form indicated based on the above clinical findings the pressure ulcer was determined to be unavoidable. The Root Cause portion of the form was blank. Surveyor noted with the information documented on the form, the pressure injury was not unavoidable. R7's Skin Impairment Care Plan was revised on 10/24/2024 with the interventions: -Educate (R7)/family/caregivers of causative factors and measures to prevent skin injury. -Elevate knees with pillow to avoid pressure to calves. Surveyor noted R7 was not seen by the Wound Physician as indicated. On 10/30/2024 on the Head to Toe Skin Check form, RN UM-C documented R7 had an Unstageable pressure injury to the right lower leg (rear) that measured 1.0 cm x 1.2 cm. On 10/30/2024 on the Weekly Skin Review form, an LPN documented R7 had a scabbed area to the right calf. On 10/31/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 2.0 cm x 2.0 cm with no drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type or percentages were documented. On 11/8/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 2.0 cm x 2.5 cm with no drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type or percentages were documented. On 11/14/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 2.0 cm x 2.0 cm with no drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type or percentages were documented. On 11/21/2024, R7 was admitted to the hospital due to a large brown emesis indicating a gastrointestinal bleed. R7 was readmitted to the facility on [DATE]. On 11/22/2024 on the Admit/Readmit Assessment form, an RN completed the Skin Integrity portion of the assessment and documented R7 had a pre-existing open wound to the back of the right lower leg (rear) that measured 1.5 cm x 1.5 cm x 0.2 cm with slough present. Surveyor noted this was the first measurement of depth and description of the tissue in the wound bed. No staging of the pressure injury was documented, and the percentage of slough was not documented. The treatment was changed to cleanse with normal saline, apply betadine, and cover with a foam dressing daily. On 11/27/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.4 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 12/5/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.6 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the Wound Physician would be updated if the condition declines or changes. On 12/12/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.3 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the Wound Physician would be updated if the condition declines or changes. On 12/19/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.3 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the Wound Physician would be updated if the condition declines or changes. On 12/26/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.6 cm x 1.3 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the treatment was changed to manuka honey to the wound bed daily. On 12/26/2024, R7 was admitted to the hospital due to shortness of breath. R7 was readmitted to the facility on [DATE]. On 12/30/2024 on the Admit/Readmit Assessment form, an LPN completed the Skin Integrity portion of the assessment and documented R7 had a wound to the posterior right lower leg. No staging, measurements, or description of the wound was documented. The hospital nutrition orders were for Osmolyte 1.2 at 75ml/hr from 2:00 PM to 12:00 Noon, a total of 22 hours, which is the order continued on readmission to the facility. On 12/30/2024 on the Nutrition Initial/Quarterly/Annual Assessment form, Registered Dietitian (RD)-H documented R7 was a nutritional risk related to past me [T

Based on interview and record review the facility did not ensure 1 (R2) of 5 residents needing assistance with bathing received the necessary services for cares. R2 was admitted to the facility on [DATE] and discharged on [DATE]. R2 went from 1/25/25 until 2/7/25 without receiving a shower/bath. R2 should have received a shower/bath on 1/31/25 according to the plan of care. Findings include: R2 is a [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses of sepsis, Myasthenia [NAME], subdural hemorrhage, epilepsy, abnormal posture, and colostomy. R2's Admission Minimum Data Set (MDS) completed on 1/20/25 documents that R2 is dependent with toileting, showering, dressing and transfers. R2 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R2 has severe cognitive impairment. Surveyor reviewed R2's bathing documentation which documents R2 was to receive showers every Friday on the evening shift. The documentation indicates a shower was not completed for R2 on 1/31/25. Surveyor reviewed R2's nursing notes which documents R2 received a shower on 1/17/25, 1/20/25, 1/24/25, and 2/7/25. Surveyor notes R2 did not receive his scheduled shower on 1/31/25, making it two weeks without receiving a shower/bath per the plan of care. Surveyor interviewed Registered Nurse (RN) Unit Manager- D on 2/18/25, at 11:21 AM, who reviewed R2's shower records and indicated R2 did not receive a shower on 1/31/25. RN Unit Manager- D stated documentation looks like R2 missed his 1/31/25 shower. Surveyor notified RN Unit Manager- D of concerns with R2 missing his 1/31/25 shower and going two weeks without a shower. On 2/19/25, at 11:48 AM, Surveyor notified interim Director of Nursing (DON)- B of concerns with R2 going two weeks without a shower and missing his 1/31/25 shower. Interim DON- B acknowledged these concerns. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (R4 and R2) of 3 residents reviewed for falls. *R4 had unwitnessed falls on 1/17/2025, 1/19/2025, 2/4/2025, and 2/13/2025. The facility did not thoroughly investigate the falls to determine a root cause of each fall and develop personalized interventions to prevent future falls. *R2 had two unwitnessed falls on 1/17/2025 and 2/7/2025. The facility did not thoroughly investigate these falls. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and a thorough investigation to determine a root cause to determine necessary preventative interventions. Findings include: The facility policy and procedure titled Fall Prevention Program dated 4/2024 documents: Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 5. When any resident experiences a fall, the facility will: a. Assess the resident. b. complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments. 1.) R4 was admitted to the facility on [DATE] with diagnoses of urinary tract infection, chronic kidney disease, diabetes, polymyalgia rheumatica, dementia, depression, difficulty in walking, lack of coordination, and communication deficit. R4's Admission Minimum Data Set (MDS) assessment dated [DATE] documented R4 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9, wore glasses, was always incontinent of bladder, frequently incontinent of bowel, needed maximal assistance with toileting hygiene, and needed moderate assistance with transfers. R4's Fall Care Area Assessment with this MDS documented R4 had not had any recent falls, depends on staff to assist with activities of daily living including transfers, has dementia, and becomes confused at times and needs reorientation. R4 was taking psychotropic medication, insulin, and a diuretic which may increase the risk for falls due to side effects. R4 was at risk for falls due to impaired mobility and side effects of medication. R4 did not have an activated Power of Attorney. R4's At Risk for Falls Care Plan was initiated on 1/3/2025 with the intervention: -Be sure (R4's) call light is within reach and encourage (R4) to use it for assistance as needed; (R4) needs prompt response to all requests for assistance. R4 had a Bowel Incontinence Care Plan and a Bladder Incontinence Care Plan initiated on 1/3/2025. No toileting schedule or check and change protocol was initiated. On 1/17/2025 at 7:29 PM in the progress notes, a Registered Nurse (RN) documented a Certified Nursing Assistant (CNA) entered R4's room at 6:05 PM to pick up the dinner tray and found R4 laying on the floor next to the bed. R4 reported R4 had slipped off from the bed while trying to get self into bed. The call light was not activated. R4 did not hit the head. Range of motion was within normal limits, neuro checks were negative, and R4 did not have any injury. R4's spouse, PM supervisor, and physician were notified. The Fall Risk Management form was completed by the RN and documented R4 was oriented to person, place, and situation, predisposing physiological factors were confusion, incontinence, gait imbalance, and weakness/fainted, and predisposing situation factors were using a wheelchair. R4 had intermittent confusion. The Post Fall Assessment form was completed by the RN and documented the fall occurred on 1/17/2025 at 6:05 PM in R4's room. R4 had been up in a wheelchair prior to the fall. R4 did not have a history of falls. R4 had diabetes and unsteady gait. R4 took a diuretic and recently had a new medication of Kevzara injections (used to treat rheumatoid arthritis). R4's functional status included receiving rehab therapy, incontinent of bladder and bowel, unable to toilet self, and can use call light independently. The review of post fall findings documented R4 was attempting to self-transfer from the wheelchair to the bed and slipped off. A referral was made to therapy and the root cause was unsteady gait and did not use the call light. R4's At Risk for Falls Care Plan was revised on 1/17/2025 with the intervention to anticipate and meet R4's needs. R4's Actual Fall Care Plan was initiated on 1/17/2025 with the interventions: -Complete Post Fall Assessment. -Complete Risk Management in PCC (computer charting system). -Initiate neuro checks per facility protocol. -Initiate pain monitoring per facility protocol. -Update physician, nurse practitioner, and responsible party. On 1/19/2025 at 11:20 PM in the progress notes, a Licensed Practical Nurse (LPN) documented R4 had an unwitnessed fall at 9:30 PM. The CNA called the nurse into the room. R4 was found halfway on the bed with the torso bent forward and R4 kneeling on the floor. The wheelchair was unlocked and away from R4 about 3 feet. R4 stated R4 thought R4 locked the wheelchair and then leaned forward towards the bed to reach for the call light but the wheelchair slipped out from under R4 and R4 fell forward onto the bed. R4 stated R4 was there for 5 minutes before R4 was found. The charge nurse was called. Vital signs and neuro checks were obtained and normal. R4 did not have any injuries. R4 was transferred to bed. the physician was notified and R4 declined for emergency contact to be called. Education was provided about locking the wheelchair and process of how post-fall works. The Fall Risk Management form was completed by the LPN and documented R4 had predisposing physiological factors of incontinence, gait imbalance, and medication, and predisposing situation factors of using a wheelchair, on a diuretic, unlocked wheelchair, and lack of coordination. The Post Fall Assessment form was completed by the LPN and documented the fall occurred on 1/19/2025 at 9:30 PM in R4's room when R4 was reaching to get the call light off the bed and thought R4 had locked the wheelchair. Fall interventions in use at the time of the fall were lock wheelchair, call light in reach, and education to R4 about locking the wheelchair and use of the call light for assistance. R4 had 1-3 falls in the past three months. R4 had underlying diseases or conditions of psychiatric or cognitive conditions such as dementia, lack of coordination, and abnormal posture. R4 took hypoglycemic's and diuretics. R4's functional status included problems with mobility, standing and sitting balance, use of assistive/adaptive devices, receiving rehab therapy, incontinent of bowel and bladder, unable to toilet self, and can use call light independently. The new fall prevention intervention to be implemented as a result of the assessment was call light in reach, education about locked wheelchair, and call for assistance if they need to transfer to bed or to wheelchair. The root cause was unlocked wheelchair. On 1/20/2025 at 9:07 AM in the progress notes, RN Unit Manager (RN UM)-C documented the interdisciplinary team (IDT) met to review R4's fall on 1/17/2025 at 6:05 PM and determined R4 would benefit from a Call Don't Fall sign placed in R4's room. Surveyor noted the IDT met three days after the fall and the intervention was implemented after R4 had another fall. On 1/20/2025 at 10:08 AM, RN UM-C documented the IDT met to review R4's fall on 1/19/2025 at 9:30 PM and determined R4 would benefit from staff to ensure call light is within reach prior to leaving R4's room each time. Surveyor noted that intervention was in R4's initial At Risk for Falls Care Plan. R4's At Risk for Falls Care Plan was revised on 1/21/2025 with the intervention Call Don't Fall sign placed in R4's room. R4's At Risk for Falls Care Plan was revised on 1/22/2025 with the intervention to reeducate R4 on locking wheelchair prior to transfers with return demonstration. On 2/4/2025 at 11:17 AM in the progress notes, an LPN documented they heard someone screaming for help from the hallway. The LPN and two CNAs did a walk through and found R4 sitting up on the bathroom floor. R4 verbalized R4 needed to use the toilet and felt weak and out of balance during the self-transfer to the toilet. R4 was assessed for injury and R4 had minimal redness to the buttocks. The unit manager and physician were updated with no new orders. Therapy was updated. R4 was responsible to self. The Fall Risk Management form was completed by the LPN and documented R4 was oriented to person, place, and situation. Predisposing physiological factors were gait imbalance and impaired memory. Predisposing situation factors were improper footwear. The LPN documented R4 self-transferred without grip socks on. The Post Fall Assessment was completed by the LPN and documented the fall occurred on 2/4/2025 at 7:25 AM in R4's bathroom due to a self-transfer. The call light was within reach and the bed was in the lowest position. R4 had a history of 1-3 falls in the last three months. R4 took diuretics. R4's functional status included use of assistive/adaptive devices, receiving rehab therapy, incontinent of bowel and bladder, unable to toilet self, and can use call light independently. The new fall prevention intervention to be implemented as a result of the assessment was to check R4 often, call light within reach, and education provided to R4 about waiting for assistance to arrive prior to transferring self. The root cause was unsteady gait, not utilizing call light for assistance. Surveyor noted the documentation of the fall was unclear as to how R4 got to the bathroom, whether in a wheelchair or ambulating independently. Surveyor noted the fall risk management form does not document follow up or investigation into what type of footwear R4 should have on and whether it was included on the care plan or ask why R4 did not have on gripper socks as identified as a contributing factor in the fall. On 2/5/2025 at 9:56 AM in the progress notes, RN UM-C documented the IDT met to review R4's fall on 2/4/2025 at 7:25 AM and determined R4 would benefit from offering R4 to get up after blood glucose monitoring is completed. Review of the fall shows R4 was attempting to get out of bed unassisted in the early morning after being woken for glucose monitoring. R4's At Risk for Falls Care Plan was revised on 2/5/2025 with the intervention R4 to be offered to get up in the morning after blood glucose monitoring is completed. Surveyor noted R4's toileting care plan was not revised to address R4 needing to use the toilet at the time of the fall and the lack of proper footwear was not addressed. On 2/13/2025 at 12:15 AM in the progress notes, an RN documented the RN heard R4 yelling and found R4 on the floor sitting with no incontinent product on and with R4's walker nearby. R4 had taken the incontinent product off and it was lying on the bed. R4 stated R4 thought it was time to get up so R4 got up to go to the bathroom and slid down. R4 did not have any injuries. The physician and spouse were notified. The Fall Risk Management form was completed by the RN and documented R4 was confused and had impaired memory. R4 was ambulating without assist and had improper footwear. R4 was using a walker. The Post Fall Assessment form was completed by the RN and documented the fall occurred on 2/13/2025 at 12:15 AM in R4's room. R4 had been in bed sleeping prior to the fall. The bed was in low position and the call light was within reach. R4 had 1-3 falls in the last three months. R4 was diabetic. R4 took hypoglycemic's and diuretics. R4's functional status included problems with mobility, standing and sitting balance, use of assistive/adaptive devices, incontinent of bowel, unable to toilet self, and can use call light independently. The new fall prevention intervention to be implemented as a result of the assessment was for R4 to have gripper socks on when in bed. The root cause was confusion. R4's At Risk for Falls Care Plan was revised on 2/13/2025 with the intervention to have bed in low position and gripper socks on when in bed. Surveyor noted R4 did not have appropriate footwear on when R4 fell on [DATE] and was not addressed as an intervention at that time. On 2/14/2025 at 11:57 AM in the progress notes, RN UM-C documented the IDT met to review R4's fall on 2/13/2025 at 12:15 AM and determined R4 would benefit from a night light kept on for assistance with orientation if waking up in the middle of the night. Surveyor noted R4's toileting schedule was not reviewed or revised with R4's need to use the bathroom. R4's At Risk for Falls Care Plan was revised on 2/14/2025 with the intervention night light to be on at night for assistance with orientation in the middle of the night. On 2/17/2025 at 1:21 PM, Surveyor observed R4's room. R4 was not in R4's room at the time. Surveyor observed a Call Don't Fall sign on R4's bulletin board across the room from R4's bed. Surveyor noted multiple items were on the bulletin board such as cards and pictures making the sign very difficult to see. As a fall intervention, the sign was not in R4's line of vision whether in bed or transferring into or out of bed. Surveyor noted R4 required glasses for clear vision and only one sign was observed in R4's room. The call light was attached to R4's pillowcase at the edge of the bed. A walker was up against the wall opposite of the bed. Surveyor asked CNA-M where R4 would be located at that time. CNA-M stated R4's spouse comes regularly to see R4 and wheels R4 downstairs for activities. CNA-M stated R4 does not spend much time in R4's room. Surveyor observed R4 in a wheelchair on the first floor attending the BINGO activity. In an interview on 2/18/2025 at 1:31 PM, Surveyor asked RN UM-C what the facility fall protocol was. RN UM-C stated the CNA would let the nurse know if a resident had fallen and an RN must do the assessment before the resident is moved either to a chair or bed. RN UM-C stated the unit nurse does a skin assessment, a pain assessment, neurological checks, starts the 72-hour post fall follow ups, and does the post fall assessment. The unit nurse notifies the physician and the Power of Attorney or emergency contact. The fall is reported to the unit manager or shift supervisor or the on-call supervisor. RN UM-C stated falls are discussed in morning stand-up and at 1:30 PM stand-down. RN UM-C stated the floor nurse talks to all the staff to get details of the fall. RN UM-C stated if a fall happens on a weekend, therapy is here and can do an assessment at that time and then the IDT meets on Monday after the weekend to come up with interventions. RN UM-C stated the IDT has a group chat, so all are updated timely on any situations. RN UM-C stated for instance, R4 just decided to get out of bed and go to the other bed in the room. Surveyor noted that information was not in R4's fall investigation for the fall that occurred on 2/13/2025. Surveyor asked RN UM-C if the facility uses fall mats as an intervention because Surveyor had not noted any fall mats in use with residents. RN UM-C stated yes, they use fall mats. Surveyor reviewed with RN UM-C R4's four falls for clarification. Surveyor shared the concern with RN UM-C that the documentation does not always follow as to how the intervention is determined, such as the fall on 2/4/2025 did not have any information as to how R4 got into the bathroom, who had seen R4 last, and did R4 walk to the bathroom or was there a wheelchair in the vicinity of the fall. RN UM-C was unable to say how R4 got into the bathroom. Surveyor shared the concern with RN UM-C that R4 had fallen a few times trying to get to the bathroom and toileting was not addressed in any of the root cause evaluations. Surveyor shared with RN UM-C the intervention for R4's fall on 2/13/2025 was to have gripper socks on when in bed and improper footwear was listed in the fall on 2/4/2025 and not followed up on. Surveyor shared with RN UM-C the observation in R4's room of the Call Don't Fall sign; the sign was buried on the bulletin board and would not catch R4's eye to remind them to use the call light. Surveyor shared that Surveyor was actively looking for the sign as a fall intervention and it took a bit to find it. RN UM-C agreed that the interventions needed to be reviewed. On 2/19/2025 at 8:56 AM, Surveyor observed R4's room. R4 was not in the room at the time of the observation. The Call Don't Fall sign was still on the bulletin board covered with cards and pictures. A fall mat was on the floor next to R4's bed. The call light was on the bed under a pillow at the head of the bed. Surveyor noted R4, in a wheelchair, would not be able to get close to the bed to reach the call light to ask for assistance due to the fall mat being placed on the floor next to the bed. On 2/19/2025 at 9:23 AM, Surveyor shared with Director of Nursing (DON)-B the concerns with R4's falls not being thoroughly investigated to implement a personalized fall intervention based on the root cause analysis. Surveyor shared with DON-B the observations of R4's Call Don't Fall sign being buried on the bulletin board where R4 would not be able to see it as well as the need for R4 to have glasses on to see the sign, showing the intervention was not personalized to R4's needs. Surveyor shared with DON-B the observation that morning of a fall mat on R4's floor that was not assessed as a need or put on R4's At Risk for Falls Care Plan and the fact that the floor mat made it impossible for R4 to wheel up to the bed to reach the call light to ask for assistance. In an interview on 2/19/2025 at 10:24 AM, RN UM-C stated Nursing Home Administrator (NHA)-A had purchased fall mats and a nurse saw them and put one in R4's room. RN UM-C stated the fall mat should be put up off the floor when R4 is not in bed. RN UM-C stated RN UM-C added the fall mat to R4's care plan. RN UM-C agreed the Call Don't Fall sign was not placed well. In an interview on 2/19/2025 at 11:49 AM, DON-B agreed the Call Don't Fall sign should have been moved. DON-B stated a nurse on the floor saw the fall mats so put one in R4's room that morning. Surveyor shared with DON-B there was no assessment to show R4 needed a fall mat. DON-B stated the nurse saw it and thought it would be a good idea. DON-B stated the IDT meets and DON-B feels they do a very good job with falls. DON-B stated the sign would have been placed right away and there may not have been anything else on the bulletin board at that time. Surveyor shared with DON-B that interventions are not reviewed to see if they are still effective, such as the Call Don't Fall sign. DON-B agreed interventions need to be reevaluated. On 2/20/25 the facility submitted information provided to the Surveyor during the survey for additional review and consideration regarding R4. 48391 2.) R2 is a [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses of sepsis, Myasthenia [NAME], subdural hemorrhage, epilepsy, abnormal posture, and colostomy. R2's Admission Minimum Data Set (MDS) completed on 1/20/25 documents that R2 is dependent with toileting, showering, dressing and transfers. R2's MDS documents falls since admission to the facility on [DATE]. R2's MDS documents falls with injury in the last 2-6 months prior to admission. R2 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R2 has severe cognitive impairment. R2's care plan, dated 1/14/25, documents: (R2) is at risk for falls related to myasthenia gravis status post Cerebrovascular Accident (CVA) with right sided weakness (date initiated 1/14/25). Interventions include: Be sure (R2's) call light is within reach and encourage the resident to use it for assistance as needed. (R2) needs prompt response to all request for assistance (date initiated 1/14/25). Surveyor notes these are the only interventions for R2 who has a history of falls with injury, right sided weakness post CVA, and severe cognitive impairment prior to his fall on 1/17/25. R2 has an activities of daily living (ADL) self-performance deficit related to myasthenia gravis status post CVA with right sided weakness (date initiated 1/14/25) Interventions include: (R2) requires assistance by one staff with bathing as necessary (date initiated 1/15/25). (R2) requires assistance by one staff to turn and reposition in bed (date initiated 1/14/25). (R2) requires assistance by one staff to dress (date initiated 1/15/25). (R2) requires set up by one staff to eat (date initiated 1/14/25). On 1/17/25, at 1:30 PM, R2 sustained an unwitnessed fall and was found by facility staff sitting on his buttocks on the floor with his back and head against the side of the bed. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and thorough investigation to determine a root cause. Surveyor reviewed the facility fall investigation dated 1/17/25 for R2 which documents the following: (R2) fell in his room on 1/17/25 at 1:30 PM and was sitting in his wheelchair prior to the fall. (R2) sustained a red linear line to the back of his neck, however skin was not broken. (R2's) family, and physician were notified of his fall on 1/17/25. Fall interventions currently in place prior to his fall were documented to keep (R2's) call light within reach. Neuro checks were completed without significant findings. R2's post fall assessment documents R2 having problems with cognition, judgment, memory, and/or safety awareness. (R2) is a new admission to the facility; is alert and oriented but does have decreased safety awareness. There are no environmental factors that may have contributed to R2's fall. (R2) is alert, oriented; did not activate his call light to ask for assistance; (R2) wanted to get into bed and attempted to self-transfer which resulted in a fall due to weakness. New fall prevention interventions included, encourage (R2) to use his call light to ask for assistance into bed from wheelchair and notify therapy. The post fall assessment documents the root cause as weakness and lack of safety awareness. The fall investigation included an incident description which states staff was notified R2 had fallen in his room. Staff entered R2's room and noted him to be sitting on his buttocks, with his back and head against the side of the bed. R2's wheelchair was to the right of him, brakes unlocked. R2's call light was not activated, but within reach. R2 had gripper socks on both feet. No environmental factors noted. R2 is unable to fully verbally state what happened, but did indicate he was trying to get himself into bed. R2 indicated to staff he did not hit his head during the fall. R2's fall investigation indicates a Registered Nurse (RN) assessment was completed. R2 was placed on the 24-hour report board for monitoring. Surveyor notes the Interdisciplinary Team (IDT) met on 1/20/25 which documents (R2) would benefit from a call don't fall visual aid on the wall in his room. The IDT team documents the root cause of the fall being R2 self-transferring. Surveyor notes the fall investigation does not include when R2 was last seen, last toileted, location of where R2 was sitting in his wheelchair prior to his fall, staff statements, and whether R2's call light was within reach at the time of the fall. Surveyor notes the fall investigation did not identify a thorough root cause analysis. R2's care plan was updated after R2's 1/17/25 fall to include: Call don't fall visual aid on the wall in my room (date initiated 1/17/25). Encourage (R2) to use his call light to ask for assistance with transferring to bed from wheelchair, and to wait for assistance (date initiated 1/17/25). Surveyor notes care plan interventions are not personalized interventions for (R2) who has severe cognitive impairment and a BIMS of 3. Fall occurred with no injury (date initiated 1/17/25) Interventions include: Complete a risk assessment in point click care (PCC) (date initiated 1/17/25). If no apparent acute injury, determine and address causative factors of the fall (date initiated 1/17/25). Initiate neuro checks per facility protocol (date initiated 1/17/25). Initiate pain monitoring per facility protocol (date initiated 1/17/25). Complete post fall assessment (date initiated 1/17/25). Complete risk management in PCC (date initiated 1/17/25). Continue interventions on the at risk for falls care plan (date initiated 1/17/25). Update nurse manager, Director of Nursing (DON), Assistant Director of Nursing (ADON) of a fall with significant injury requiring emergency room evaluation (date initiated 1/17/25). Update physician, nurse practitioner, and responsible party (date initiated 1/17/25). On 2/7/25, at 10:15 AM, R2 sustained an unwitnessed fall and was found by facility staff sitting on the floor next to his bed with his back against the side of the bed facing the door. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and thorough investigation to determine a root cause. Surveyor reviewed the facility fall investigation dated 2/7/25 which documents the following: (R2) fell in his room on 2/7/25 at 10:15 AM with no apparent injury. (R2) was sitting prior to his fall. (R2's) family and physician were notified of R2's fall on 2/7/25. Fall interventions currently in place prior to his fall were documented to keep (R2's) call light within reach. Underlying diseases or conditions were documented as R2 having prior CVA and seizures. (R2) was documented as recently starting a new medication or having a change in medications. (R2) functional status is documented as being incontinent of bowel and bladder. (R2) was documented as having concerns with cognition, judgment, memory and/or safety awareness. There are no environmental factors that may have contributed to R2's fall. Post fall findings document (R2) is alert, oriented, able to use his call light independently, has a history of falls, and weakness. New fall interventions included a sidewall mattress to (R2) bed, notify therapy. The post fall assessment documents R2's fall root cause being weakness. The fall of investigation included an incident description documenting, staff was walking down the hallway and heard (R2) yelling out. Staff noted (R2) to be sitting on the floor next to his bed with his back against the side of the bed. (R2's) call light was not activated. (R2) had gripper socks on his feet and no environmental factors were noted. R2 is alert, oriented, though somewhat aphasic, and did not indicate if he was attempting a transfer or if he slid off the bed. (R2) was assisted back to bed. Vital signs and neuro checks were obtained with no significant findings. No injuries were noted and (R2) denied pain or discomfort. R2's provider, family, and DON were notified. (R2) was placed on the 24-hour board for monitoring. Surveyor notes the IDT team met on 2/7/25 which documents R2 sustained an unwitnessed fall without injury on 2/7/25. The IDT team progress note documents R2 was sitting at bedside when he slid off his mattress onto the floor. Interventions post fall were to place a side wall mattress to aid into finding the perimeter of the mattress. R2's care plan was updated, and the IDT team progress note documents nursing staff will continue to monitor and implement the intervention and evaluate the effectiveness. Surveyor noted the fall investigation does not include when R2 was last seen, last toileted, location of where R2 was sitting prior to the fall, staff statements, whether the call light was within reach at the time of the fall, and further investigation into new medications recently started for R2. Surveyor noted the documentation related to R2's 1/17/25 and 2/7/25 post fall documentation includes documentation to notify therapy. It is unclear if therapy was involved in reviewing R2 for safety as the facility documentation references weakness as a factor in the falls but does not address through investigation to help identify effective interventions to prevent falls for R2. On 2/18/25, at 8:39 AM, Surveyor observed unit one east. Surveyor noted every resident on 1 East having a low bed in the low position. Surveyor observed no fall mats being used throughout 1 East at the time of the observation. On 2/18/25, at 10:14 AM, Surveyor interviewed RN Unit Manager- D who indicates every resident has a low bed. RN Unit Manager- D stated the nurse assigned to the resident starts a fall investigation when a resident falls. The assigned nurse will talk with staff, talk with the resident, obtain a location of where the resident was last seen and when the resident was last seen. RN Unit Manager- D stated statements are verbally given to the nurse and documented in the post fall evaluation. RN Unit Manager- D indicated R2 was very forgetful and would self-transfer. RN Unit Manager- D described R2 as impulsive and indicated R2 told staff he was trying to get into bed at the time of his fall on 1/17/25. RN Unit Manager- D stated this is documented in a nursing progress note. RN Unit Manager- D indicated R2's progress notes document where R2 was last seen, however RN Unit Manager- D was unable to state when R2 was last seen. RN Unit Manager- D indicated the IDT team meets daily in the mornings Monday through Friday and will discuss falls the same day or following day. RN Unit Manager- D stated the default intervention after a resident falls, is to place a call don't fall sign in their room. The IDT team will discuss the fall and unit managers will determine if other interventions are warranted. Surveyor asked RN Unit Manager- D how the facility follows up with interventions placed post fall. RN Unit Manager- D stated, interventions are discussed in the IDT team if another fall occurs. On 2/19/25, at 9:28 AM, Surveyor notified Interim DON- B of concerns discussed above with the fall investigations for R2's unwitnessed falls on 1/17/25 and 2/7/25. Surveyor notified Interim DON- B the facility fall investigations did not determine when R2 was last seen, last toileted, exact location of where R2 was last seen prior to his falls, staff statements, and completion of a thorough investigation to determine a root cause to establish effective interventions to prevent future falls. On 2/19/25, at 11:48 AM, Interim DON- B requested to speak with Surveyor. Interim DON- B reviewed with Surveyor R2's facility progress notes, IDT notes, and post fall investigation. Surveyor notified Interim DON- B of concerns with the facility not completing a thorough fall investigation for R2's falls on 1/17/25 and 2/7/25. Surveyor noted to Interim DON- B the fall investigations lacked a thorough investigation to determine why R2 was attempting to self-transfer or possible causes for R2's falls. On 2/20/25 the facility submitted information provided to the Surveyor during the survey for additional review and consideration regarding R2.

Based on policy review, record review and interview, the facility failed to ensure the family member and Activated Responsible Party (FM1) of one Resident (R1) out of nine residents reviewed in the sample was provided with information required to make informed decisions about the residents health care. FM1 was not notified prior to rehabilitation services being discontinued for R1. This failure created the potential for the resident's rehabilitation services to be unnecessarily and/or prematurely discontinued. The findings include: Review of the facility's policy titled, Notification of Changes dated 01/2024 read, in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Review of R1's Admission Record, dated 12/06/24 and found in the Electronic Medical Record (EMR) under the Profile Tab, indicated the resident was admitted to the facility on [DATE]. The record indicated family member (FM1) was her activated Medical Power of Attorney (MDPOA)/ Responsible Party. Review of R1's quarterly Minimum Data Set (MDS) found in the EMR under the MDS Tab and with an assessment reference date (ARD) of 12/03/24, revealed the Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated the resident was cognitively intact. Review of R1's Power of Attorney for Health Care Statement of Incapacity documentation, dated 08/12/24, signed by two physicians, and found in the EMR under the Miscellaneous Tab, revealed the resident was not capable of making her own health care related decisions and indicated FM1 was activated as R1's legal health care representative. Review of R1's physician's orders found in the EMR under the Orders Tab, revealed an original order dated 09/03/24, for the resident to be evaluated and treated by Occupational Therapy (OT) and Speech Therapy (SLP), and with an original order dated 10/01/24, for the resident to be evaluated and treated by Physical Therapy (PT) under her Medicare B benefit. Review of R1's care plan, most recently dated 09/18/24 and found in the EMR under the Care Plan Tab, revealed the resident planned to remain in the facility for long-term care and indicated, POA- Keep in Contact with (FM1)/Activated Healthcare as needed/requested. Review of R1's skilled therapy documentation dated 09/03/24 through 11/11/24 and provided directly to the surveyor, revealed the resident received skilled OT and PT services consistently per physician's orders during that time period. Review of R1's Advance Beneficiary Notice (ABN) document, dated 11/11/24, signed by R1 herself, and found in the EMR under the Miscellaneous Tab, revealed the resident was provided notification her rehabilitation services were ending. Review of R1's EMR revealed no documentation to indicate FM1 was notified that R1's rehabilitation therapy services were ending or was given the opportunity to appeal to have R1 potentially continue to receive therapy. During an interview with FM1 on 12/04/24 at 1:47 PM, she confirmed she was R1's activated MDPOA and had not been notified that R1's therapy was ended or given an opportunity to appeal the discontinuation of therapy services. She indicated this had been upsetting to her as she felt R1 may have benefited from continued therapy. During an interview with Director of Rehabilitation (DOR) on 12/06/24 at 12:10 PM, she confirmed the ABN notice had been provided and signed by R1 rather than FM1. She stated she should have provided the notice to FM1. During an interview with the Director of Nursing (DON) on 12/06/24 at 2:00 PM, she stated her expectation was the ABN notice should have been provided to FM1 rather than R1 since FM1 was R1's activated MDPOA.

Based on record reviews, interviews, and facility policy review, the facility failed to ensure one of nine sample residents (Resident (R) 6) had her preferences honored. Findings include: Review of the facility's policy titled, Accommodation of Needs, provided by the facility, with a revised date of 02/24, revealed The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. The policy further revealed Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible. Review of R6's admission Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) revealed R6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated her cognition was intact. The MDS further revealed R6 was admitted to the facility on [DATE]. Review of R6's diagnoses under the Diagnosis tab of the EMR revealed R6 had diabetes and chronic kidney disease stage four. Review of R6's comprehensive Care Plan, dated 08/27/24 and located in the Care Plan tab of the EMR revealed a problem for an activity of daily living (ADL) self-care deficit. Review of the interventions for 08/29/24 included for bathing and showering R6 was totally dependent on one member of staff to provide bathing and showering weekly and as needed. The intervention included no male Certified Nursing Assistants (CNA) was to perform care. Review of the dressing intervention revealed R6 required assistance of one staff and no male CNAs for care. Review of the personal hygiene intervention revealed R6 was totally dependent on staff, but it did not reflect no male CNA to render care. Review of the toilet use intervention revised on 09/09/24 revealed R6 required assistance of two staff but did not specify no male CNA. Review of the problem for functional bladder incontinence revealed peri care was to be completed after each incontinent episode but did not include no male CNA. Review of the care plan with a revised date of 10/10/24 revealed R6 was to not have any male CNAs for any care. During an interview on 10/22/24 at 3:00 PM, CNA3 revealed he had taken care of R6 previously but only to pass her tray and water to her. CNA3 stated he had introduced himself to R6 and her family when she was admitted to the facility. CNA3 stated he was her CNA on 10/10/24 during the night and he had gone into her room around midnight to just check her brief to see if it was yellow or blue and if she needed to be changed, he would go get the female CNA on the other hall, but R6 was dry. CNA3 revealed he went back into R6's room around 4:00 AM to check if R6 was wet. CNA3 revealed R6 was awake, and he pulled the cover back and looked to see if the line on the brief was blue and it was yellow which meant she was still dry. CNA3 stated he knew R6 did not want a male CNA to do certain care. but that was for peri care, and he did not do peri care. CNA3 stated he was just checking R6 for wetness. CNA3 stated he did not go back into the room after Registered Nurse (RN) 2 told him not to. During an interview on 10/22/24 at 6:30 PM, R6 revealed she did not want any male to take care of her because men should not be in a profession where they wiped residents' butts. R6 revealed a male CNA, who she had never seen before, came into her room twice on 10/10/24 and she told the CNA to get out. During an interview on 10/22/24 at 7:15 PM, RN2 revealed she was not aware R6 was not to have a male aid taking care of her. RN2 stated she reviewed the care plan after R6 informed her she did not want a male taking care of her and saw where it was listed to not have a male CNA for peri care and bathing. RN2 stated Unit Manager (UM) 1 scheduled CNA3 to work that shift and she knew about R6 preferring to not have a male CNA. During an interview on 10/23/24 at 9:47 AM, the UM1 revealed CNA3 had taken care of R6 before but only passed water and meal trays to her and did not do peri care or bathing. UM1 stated the son had informed them on admission that R6 preferences was to not have any male CNAs to bathe or do peri care for R6. UM1 revealed she did the scheduling but the nurse on the unit could do the hall assignments. UM1 stated checking the brief was a part of peri care. During an interview on 10/23/24 at 2:09 PM, the Director of Nursing (DON) revealed R6 was care planned to not have a male CNA for bathing and peri care. The DON stated checking the brief for a yellow or blue mark was not a part of peri care. The DON stated CNA3 was just looking at the brief to see if R6 needed care. The DON revealed she had talked to R6, and the resident did not have an issue with a man passing water or a meal tray but did not want a male CNA seeing her nude. The DON stated RN2 should have known that R6 preferred to not have a male CNA because it was on her care plan and the care list.

Based on observations, record review, interviews, and review of the facility policy, the facility failed to follow enhanced barrier precautions (EBP) and infection control for one of nine sample residents (Resident (R) 4) reviewed for infection control precautions. The failure had the potential to put the residents at risk for the spread of an infection. Findings include: Review of the facility's policy titled, Clean Dressing Change, provided by the facility, with an implemented date of 11/23 and reviewed/revised on 09/24, revealed It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physicians' orders will specify type of dressing and frequency of changes. The policy further revealed to set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape) .e. Use no-touch techniques to remove ointments and creams from their containers (i.e. use tongue blade or applicator) .Wash hands and put on clean gloves .Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Loosen the tape and remove the existing dressing .Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on clean gloves .Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze .Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. Secure dressing. [NAME] with initials and date. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of R4's admission Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 10/02/24 revealed R4 was admitted to the facility on [DATE] with diagnoses of Parkinson's, diabetes with a foot ulcer, hypertension, and cerebral vascular accident (CVA). The MDS revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. Review of the comprehensive Care Plan located in the Care Plan tab of the EMR, initiated 09/27/24, revealed a problem listed for infection control with an intervention that R4 had to be on enhanced barrier precautions. A problem was identified for impaired skin integrity. Review of the Physicians Orders located under the Orders tab of the EMR, review date 10/16/24, revealed an order, dated 10/17/24, for enhanced barrier precautions due to wounds. The physician orders further revealed Santyl External Ointment 250 unit/grams was to be applied to the sacrum, dated 10/17/24. Another physician order revealed clean the sacrum with 1/2 Dakin's. Apply skin prep to the peri wound, apply Santyl to the wound base and it was to be followed up with a bordered gauze daily, dated 10/17/24. Another physician's order further revealed the left heel was to be cleansed with saline and skin prep was to be applied, dated 10/17/24. A wound care sacral treatment observation for R4, on 10/22/24 at 10:04 AM, with Licensed Practical Nurse (LPN) 2, revealed he gathered Dakin's Solution (an antiseptic used to treat and prevent infections in wounds), Santyl (an ointment used for debriding ulcers), skin prep, two gauze pads and a bordered gauze and took them into R4's room without washing or sanitizing his hands before entering the room which had a sign visibly posted on the door for enhanced barrier precautions which included washing or sanitizing the hands before going into the room and wearing a gown and gloves when doing care. During the entire observation LPN2 did not wear a gown while doing the wound treatments. During observation on 10/22/24 at 10:04 AM in R4's room, LPN2 did not clean the overbed table before putting the supplies on it and did not put a barrier on the table. Observation further revealed the overbed table had candy bars, Kleenex, a cup, a remote control, and a cell phone lying on it. Observation further revealed LPN2 put gloves on and removed the pillows from behind the resident and under his knees. LPN2 used the lift pad to turn the resident over to his left side and went to remove the brief when he realized R4 had a bowel movement. LPN2 provided appropriate peri care. Observation revealed R4 was not double briefed. The pad and the brief were folded under R4. The dirty washcloth was placed on the side of the garbage can that had a plastic bag in it. Observation revealed LPN2 did not change gloves or wash his hands before he removed the old bandage for the sacral wound. Observation of LPN2 revealed he removed his gloves and applied new gloves but did not wash or sanitize his hands. LPN2 wet the gauze with the Dakin's Solution and cleaned the wound. LPN2 applied Santyl to the wound with the same gloved finger that he had just cleaned the wound with. LPN2 removed the gloves, new gloves were put on, then he applied skin prep around the edges of the wound and applied the border dressing. LPN2 took a pen out of his pocket, signed the dressing, and put the pen back in his pocket. During observation on 10/22/24 at 10:30 AM, LPN2 removed the soiled brief and put it in the garbage can. Peri care to the groin area was completed and a new brief was put on R4. LPN2 removed the pad that was under R4 and placed it on the floor beside the bed and put the dirty washcloth in it. Observation revealed LPN2 removed his gloves and did not wash or sanitize his hands in the room. Observation further revealed LPN2 went down to the small dining room and washed his hands there. During the wound care left heel treatment observation on 10/22/24 at 10:30 AM in R4's room, LPN2 gathered supplies for the left heel wound treatment that consisted of skin prep, normal saline, and a gauze sponge. LPN2 went into R4's room and did not put a gown on. LPN2 placed the supplies on R4's bed. Observation revealed LPN2 removed the old bandage on the foot which did not have any drainage or blood noted. LPN2 placed the old bandage on the bed and did not change gloves. LPN2 cleaned the wound with normal saline and placed that gauze on the bed, put skin prep on the area and placed a sock on the foot. LPN2 removed his gloves but did not wash his hands before he left the room. LPN2 went to the dining area and washed his hands there. During an interview on 10/22/24 at 10:45 AM, LPN2 stated he had training on infection control but just missed it and did not notice that R4 was on enhanced barrier precautions. LPN2 read the enhanced barrier precautions on the door and stated he should have worn a mask, gown, and gloves which he did wear gloves. LPN2 stated he had never been told he had to clean the table off or put a barrier on the table before putting the supplies on the table. LPN2 stated he should not have put the pad on the floor, however he did put the dirty washcloth inside the pad, so it did not touch the floor. During the interview, LPN2 revealed he did change gloves, but he did not wash or sanitize his hands during the wound treatment. LPN2 revealed infection control was to prevent infection from being passed to someone else. During an interview on 10/22/24 at 1:00 PM, the Director of Nursing (DON) revealed for enhanced barrier precautions and doing a wound treatment the nurse should wear gowns and gloves when going into the room. The DON further revealed the surface should be cleaned off and the supplies should be opened there and laid out. The DON stated the old dressing should be removed and put in the garbage can. DON stated the nurses should remove their gloves, clean their hands, put on new gloves, and apply the new dressing after cleaning the wound. The DON stated the gown, and gloves should be removed and placed in garbage bags in the rooms and disposed of. The DON revealed staff should sanitize their hands before going into the room that had enhanced barrier precautions and when leaving the room. The DON revealed the overbed table should be cleaned and all items should be removed from the table. The DON stated the pad that had been under R4 should not have been put on the floor. The DON stated that anytime a staff member removed their gloves they should wash or sanitize their hands. The interview further revealed it was not appropriate for the dirty bandages to be placed on the bed and the bandages should be placed in the garbage. During the interview on 10/22/24 at 1:30 PM, the DON revealed they had a yearly skills fair and they went over enhanced barrier precautions. The DON stated staff were trained in enhanced barrier precautions for wound care, gastrostomy tube (G-tube) care, foley catheter care which consisted of donning a gown and gloves. The DON revealed infection control was utilized to prevent spreading infections. The DON stated the Santyl should have been applied with a Q-Tip and not the gloved finger of the nurse. The DON revealed they have not had any outbreak of infections.

Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure one comprehensive care plan for enhanced barrier precautions (EBP) was implemented for one of nine sample residents (Resident (R) 4) reviewed for care plans. This failure had the potential to put R4 and other residents at risk for infections. Findings include: Review of the facility's policy titled, Comprehensive Care Plans provided by the facility with a revised date of 02/24, revealed It was the policy of this facility to develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Resident specific interventions that reflect the resident's needs and preferences. Review of R4's admission Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 10/02/24 revealed R4 was admitted to the facility on [DATE] with diagnoses of Parkinsons, diabetes with a foot ulcer, hypertension, and cerebral vascular accident (CVA). The MDS revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. Review of the comprehensive care plan located in the Care Plan tab of the EMR, initiated 09/27/24, revealed a problem listed for infection control with an intervention that R4 had to be on enhanced barrier precautions. The care plan revealed a gown and gloves should be worn. A problem was identified for impaired skin integrity. Review of the Physicians Orders located under the Orders tab of the EMR, dated 10/16/24, revealed an order for enhanced barrier precautions due to wounds. A wound care treatment observation for R4, on 10/22/24 at 10:04 AM, with Licensed Practical Nurse (LPN) 2, revealed the nurse entered R4's room and did not wash or sanitize his hands before entering the room which had enhanced barrier precautions posted visibly on the door which was opened. During the entire observation on 10/22/24 at 10:15 AM, LPN2 did not wear a gown during the wound treatments to the left heel and buttock. Observation of the signage on the door for R4 revealed enhanced barrier precautions should be used which included hands were to be washed or sanitized before and after entering the room. The signage further revealed the staff must wear gloves and a gown when wound care was done that required a dressing. During an interview on 10/23/24 at 12:38 PM, the MDS Coordinator (MDSC) revealed if the care plan had enhanced barrier precautions on it then enhanced barrier precautions should have been utilized. The MDSC further revealed staff should have worn gloves and a gown if they did any kind of patient care such as wound care treatments. The MDSC stated enhanced barrier precautions helped to prevent transmission of germs to the next patient. During an interview on 10/23/24 at 12:45 PM the Administrator revealed care plans should have been followed and modified as needed. During an interview on 10/23/24 at 1:00 PM, the Director of Nursing (DON) revealed care plans should have been followed to meet the needs of the residents. DON stated the care plan for enhanced barrier precautions should have been implemented.

Based on observation, record review, and interview, the facility did not ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Medical equipment was not sanitized between resident use potentially affecting 3 (R36, R15, and R86) of 3 residents reviewed for monitoring of blood sugars and the handling of dirty laundry was not kept separate from the clean laundry potentially affecting all 92 residents in the facility. *An observation was made of Registered Nurse (RN)-K wiping off an EvenCare glucometer with an alcohol wipe. RN-K did not use a disinfectant wipe to clean the glucometer. RN-K had checked blood sugars on R36, R15, and R86 without disinfecting the glucometer between residents potentially exposing those residents to blood borne pathogens. *Observations were made of Laundry Aide-M handling dirty laundry while wearing a gown. The gown was not removed before Laundry Aide-M handled clean linen from the dryer. Findings include: 1.) The facility policy and procedure entitled Blood Glucose Monitoring dated 1/2024 states: Procedure: . 18. Clean and disinfect the glucometer as per manufacturer's instructions. The EvenCare Blood Glucose Monitoring System User's Guide dated 2023 states: Intended Use: . It is indicated to be used for multiple patients in a clinical setting by healthcare professionals, as an aid to monitoring levels in Diabetes Mellitus. Cleaning and Disinfecting Procedures for the Meter: The EvenCare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. Materials needed: EvenCare G3 Meter, Gloves, A validated disinfecting wipe . Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. On 5/1/2024 at 7:46 AM, Surveyor observed Registered Nurse (RN)-K clean off the glucometer with an alcohol pad. Surveyor asked RN-K if residents had their own glucometer or if they shared a glucometer. RN-K stated residents do not have their own individual glucometer's and RN-K uses one glucometer for the residents on that hallway. Surveyor asked RN-K how many residents had their blood sugar checked that morning. RN-K stated three residents, R36, R15, and R86, had their blood sugars checked that morning by RN-K. Surveyor asked RN-K how the glucometer was cleaned between residents. RN-K stated with an alcohol wipe. RN-K stated Surveyor had just watched RN-K clean the glucometer. Surveyor reviewed R36, R15, and R86 diagnosis lists and confirmed none of the affected residents had blood borne pathogens. On 5/1/2024 at 9:48 AM, Surveyor shared with Director of Nursing (DON)-B the observation of RN-K clean the glucometer with an alcohol wipe and not a disinfectant wipe. DON-B stated RN-K should have cleaned the glucometer with the disinfectant wipe. No further information was provided at that time. 25490 2.) Review of the facility's Standard Precautions: For Infection Control, sign posted on the entrance door of the laundry room revealed, .Handwashing, wash hands after touching body fluids .wear gloves before touching body fluids .Gown, wear gown during procedures that may cause splashes .handle linen soiled with body fluids to prevent personal contamination and transfer to other patients . Review of the document provided by the facility titled Attention Housekeeping and Laundry Staff, dated 09/25/19 indicated .LAUNDRY: 1. Wear gown, gloves, mask and goggles when sorting and loading machines .Wash your hands with soap and water. Review of the facility's Laundry Policy dated 01/2023 revealed, .The facility launders linens and clothing under current CDC guidelines to prevent transmission of pathogens .soiled laundry shall be kept separate from clean laundry at all times. During an observation on 05/02/24 at 8:59 AM with the Director of Housekeeping/Laundry (DHL)-L revealed Laundry Aide (LA)-M placed soiled laundry into a washing machine. LA-M was wearing PPE of a yellow gown and gloves. After LA-M placed the soiled clothes in the washer, DHL-L verbally reminded LA-M to remove her PPE before she went to the dryer to retrieve clean linen. LA-M spoke very little English, and DHL-L gestured to LA-M to remove her soiled PPE. Even though LA-M was reminded to remove her PPE, she walked to the dryer and removed the clean linen with the soiled PPE still on. During an interview on 05/02/24 at 9:03 AM, DHL-L stated LA-M did not follow proper PPE procedures related to preventing cross contamination. DHL-L stated it was her expectation LA-M should have removed her soiled gown and gloves before handling the clean laundry. DHL-L also stated it was her expectation LA-M would have followed proper hand hygiene per facility policies. DHL-L further stated that he expected all staff to follow facility policies to eliminate the spread of infections. During an interview on 05/02/24 at 9:41 AM, Administrator (NHA)-A revealed it was his expectation the facility's staff would have followed the facility's policies and procedures for the proper donning and doffing of PPE to prevent the spread of infectious diseases.

Based on observation, record review, and interview, the facility did not treat residents with dignity when administering insulin for 2 (R33 and R55) of 2 residents observed receiving insulin. Licensed Practical Nurse (LPN)-G administered insulin to R33 in the hallway by the nurses' station with other residents present. LPN-G checked R55's blood sugar and then administered insulin to R55 in the TV room with another resident present. No privacy was provided to R33 or R55. Findings include: The facility policy and procedure entitled Timely Administration of Insulin dated 1/2024 states: Policy Explanation and Compliance Guidelines: . 5. d. Explain procedure and provide privacy. On 5/1/2024 at 8:22 AM, Surveyor observed LPN-G standing at the medication cart next to the nurses' station. LPN-G dialed up the dose on the insulin pen for R33. R33 was in a wheelchair in the middle of the hallway next to the medication cart. Other residents were in the hallway and dining room getting ready for breakfast. The dining room was located across from the nurses' station. LPN-G administered R33's insulin in the right arm. LPN-G did not offer to take R33 to a private area to administer the insulin. LPN-G went into the TV room across from the nurses' station and next to the dining room and tested R55's blood sugar by drawing blood from the finger. R55 was sitting at a table with another resident. LPN-G then administered insulin to R55 in the left arm. LPN-G did not offer to take R55 to a private area to check the blood sugar or administer the insulin. Surveyor reviewed Resident Council minutes from 2/7/2023. A concern was identified at that meeting by residents. The concern was that insulin was being given to residents in the dining room. The recommendation/solution per the minutes was that staff would be educated on giving insulin in the dining room. On 5/1/2024 at 9:48 AM, Surveyor shared with Director of Nursing (DON)-B the observations of LPN-G taking R55's blood sugar in the TV room with another residents present and administering insulin to R33 and R55 in a public space. DON-B stated LPN-G had contacted DON-B after Surveyor had left the unit LPN-G worked on and informed DON-B of the observations. DON-B stated LPN-G was aware blood sugars and insulin should not be obtained or provided to residents in public spaces. No further information was provided at that time.

Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds for 2 (R188 and R190) of 2 residents reviewed with non-pressure injuries. R188's non-pressure injuries were not comprehensively assessed on admission. R190's non-pressure injuries were not comprehensively assessed on admission. Findings include: The facility policy and procedure entitled Skin assessment dated ,d+[DATE] states: Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. document if resident refused assessment and why. f. Document other information as indicated or appropriate. 1.) R188 was admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit, bacteremia, malnutrition, leukemoid reaction, anemia, anxiety, depression, and epilepsy. R188 had not been a resident of the facility long enough to have a comprehensive Minimum Data Set (MDS) assessment completed. R188 had an activated Power of Attorney (POA). R188's Activities of Daily Living Care Plan was initiated on 4/26/2024 and indicated R188 needed staff assistance of one for bathing/showering, bed mobility, dressing, personal hygiene, and toilet use and staff assistance of two for transferring using a mechanical lift. The Infectious Disease Physician Progress Note dated 4/26/2024 documented R188 had wounds on the dorsal aspect of the left foot and fifth metatarsal (toe) that measured approximately 2 cm x 2 cm and multiple small wounds scattered on bilateral legs and arms. R188's hospital Discharge Summary dated 4/26/2024 indicated no wound care was needed. On 4/26/2024, Registered Nurse (RN)-D completed R188's Admit/Readmit Assessment form and Skin & Wound Evaluation forms for the following open areas: -Left flank area skin tear measured 3.2 cm x 1.7 cm (on the Admit/Readmit Assessment form) and left iliac crest abrasion with the same measurements (on the Skin & Wound Evaluation form) with 100% granulation. Surveyor noted no depth of the wound was measured. -Left fourth toe Unstageable pressure injury measured 1.5 cm x 1.5 cm. Surveyor noted no depth was measured and no wound characteristics were documented. Surveyor noted the picture attached to the assessment showed the wound to be on the fifth toe and not the fourth toe. Surveyor noted no wound was documented to the left dorsal foot as noted on the Infections Disease Physician Progress Note dated 4/26/2024. R188's Skin Impairment Care Plan was initiated on 4/26/2024 with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Use barrier cream to prevent skin impairment issues, as needed. R188's Skin Impairment Care Plan was revised on 4/27/2024 with the following interventions: -Encourage to offload heels. -Heel boots on when in bed. -R188 needs an air mattress to protect the skin while in bed. -R188 needs pressure relieving/reducing cushions to protect the skin while up in a chair. On 5/1/2024, Licensed Practical Nurse (LPN)-P completed a Skin & Wound assessment form for the following open area: -Left iliac crest abrasion measured 3.0 cm x 1.9 cm x not applicable. No tissue type was documented for the wound bed and the wound was stable with no other characteristics. On 5/2/2024 at 11:09 AM, Surveyor accompanied Wound Physician-I and RN Unit Manager (UM)-E to assess R188's pressure injuries. RN UM-E stated R188 had a skin tear to the left flank. Wound Physician-I stated the wound to the left fifth toe was due to trauma and not a pressure injury. Surveyor clarified with Wound Physician-I that the wound was on the fifth toe and not the fourth toe as initially documented. Wound Physician-I agreed the wound was on the fifth toe. Surveyor observed a scabbed area to the left dorsal foot. Wound Physician-I stated that wound was caused by trauma. Surveyor observed an open area on the left iliac crest. Wound Physician-I stated the wound to the left iliac crest was possibly due to pulling on the sheets when R188 was repositioned in bed. Surveyor requested a copy of Wound Physician-I's wound assessments. Wound Physician-I's documentation of R188's non-pressure areas on 5/2/2024 had the following assessments: -Left fifth toe trauma measured 1.24 cm x 1.0 cm x 0.1 cm with eschar. -Left dorsal foot trauma measured 1.08 x 1.01 x 0.1 with eschar. -Right posterior superior iliac crest trauma measured 1.88 cm x 1.89 cm x 0.1 cm with 1-25% granulation and 51-75% slough. Surveyor noted the wound was located on the left iliac crest and not the right iliac crest. This was the first comprehensive assessment of the non-pressure areas, six days since admission. In an interview on 5/2/2024 at 3:22 PM, Surveyor asked RN-D what the facility process was when a new resident was admitted to the facility. RN-D stated the nurse on the floor does the initial skin assessment which includes looking at the resident's skin from top to bottom and documenting anything like a scab, bruising, scratches, checking under the breasts and folds for redness or excoriation, and any open areas or Deep Tissue Injuries (DTI) caused by pressure. RN-D stated for any open areas or DTIs, you put a sticker next to the wound and take a picture with the phone; that is connected to the electronic charting system, and it measures the length and width of the wound. RN-D stated the picture is sent to Wound Physician-I or to RN UM-E with the resident's name and what the wound is so they can get a treatment order. RN-D stated the wounds are monitored and they are evaluated weekly on Wednesday. RN-D stated if a treatment needs to be done right away, RN-D will do that and then make sure everything is charted. RN-D stated if the resident has mushy heels, RN-D will get heel boots or pillows if the resident hates the boots. Surveyor asked RN-D if pictures were taken of all skin impairments. RN-D stated scabs, bruises, and blanchable redness just get written into the assessment, but if it is an open area, then they get a picture on the phone. RN-D clarified an open area on the coccyx or anything that gets a deeper assessment will get a picture so Wound Physician-I can get a treatment in place. RN-D stated Wound Physician-I is available every day and answers quickly. RN-D stated RN UM-E and Assistant Director of Nursing (ADON)-C are really good with wounds, so they help with assessments. Surveyor noted the phone picture assessment does not measure depth. Surveyor asked RN-D if any wounds get depth measurements. RN-D stated it depends on the wound if a depth is measured. RN-D stated with a flap off, like a skin tear, the depth is estimated and if it something deeper, then they would take a cotton swab to measure the depth. On 5/6/2024 at 9:31 AM, Surveyor shared with DON-B the concern R188's non-pressure areas were not comprehensively assessed until 5/2/2024, six days after admission, when Wound Physician-I assessed R188's wounds. Surveyor shared with DON-B R188 had a wound to the left fifth toe that was documented as the left fourth toe and determined to be caused by trauma when Wound Physician-I assessed the wound, the left iliac crest wound did not have a depth measurement on admission, and the left dorsal foot wound was not documented on admission. 2.) R190 was admitted to the facility on [DATE] with diagnoses of diabetes, osteomyelitis of the right ankle and foot, chronic obstructive pulmonary disease, cholecystitis, congestive heart failure, diabetic polyneuropathy, coronary artery disease, and anemia. R190 had not been a resident of the facility long enough to have a comprehensive Minimum Data Set (MDS) assessment completed. R190 did not have an activated Power of Attorney. R190's Hospital Wound Care Note dated 4/17/2024 indicated the following non-pressure wounds: -Right lateral foot incision wound from a diabetic ulcer measured 9.9 cm x 3.5 cm x 2 cm with 10% epithelialization, 70% granulation, and 20% slough. -Right distal posterior Achilles leg venous ulcer measured 0.7 cm x 0.8 cm x 0.6 cm with 15% epithelialization, 80% granulation, and 5% slough. -Right foot dorsum incision wound measured 2 cm x 1.6 cm x 0.9 cm with 10% granulation and 90% slough. -Right plantar foot originally a blister measured 0.8 cm x 3 cm x 0.2 cm with 5% epithelialization, 25% slough and 70% eschar. -Bilateral buttocks Suspected Deep Tissue Injury (DTI) with the right buttock DTI measured 0.3 cm x 0.5 cm and the left buttock DTI measured 0.5 cm x 0.5 cm. -Right anterior lower leg Stage 2 pressure injury measured 3 cm x 9 cm with 5% epithelialization. Treatments were ordered for each area including a wound vac to the right lateral foot wound. The Hospital Discharge Summary dated 4/18/2024 documented R190 was hospitalized for cholecystitis with elevated liver enzymes. R190 had continuation of a previously treated diabetic foot infection with osteomyelitis of the metatarsal and was placed on intravenous antibiotics. R190's Skin Impairment Care Plan was initiated on 4/18/2024 with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Ensure pressure relieving cushion is used in dialysis chair when resident is in chair for dialysis session. Document if resident refuses to use cushion. (Surveyor noted R190 does not attend dialysis.) -Skin will be assessed on a weekly basis on scheduled bath day and document findings on a weekly skin assessment. -Report any skin redness/impaired integrity areas to the nurse. -R190 needs pressure relieving/reducing cushions to protect the skin while up in chair. -R190 needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. -Use barrier cream to prevent skin impairment issues, as needed. On 4/18/2024 on the Admit/Readmit Assessment form and on the Skin & Wound Evaluation form, Licensed Practical Nurse (LPN)-J documented R190 had the following skin integrity concerns: -Left lateral foot vascular wound measured 10.0 cm x 4.0 cm x 1.7 cm. (Surveyor noted the hospital documentation showed the wound to be on the right foot and not the left foot.) -Bottom of right foot diabetic ulcer measured 1.0 cm x 4.0 cm x 0.2 cm. No wound descriptors were documented. -Right dorsum foot vascular ulcer measured 1.0 cm x 4.0 cm x 0.2 cm. No wound descriptors were documented. -Left buttock Moisture Associated Skin Damage (MASD) measured 0.5 cm x 0.5 cm. No depth or wound descriptors were documented. -Right middle shin venous ulcer measured 4.25 cm x 2.14 cm with 100% granulation. No depth was documented. (Surveyor noted the hospital paperwork indicated this was a pressure area.) -Right medial calf venous ulcer measured 1.58 cm x 1.03 cm with 20% epithelialization and 20% slough. No depth was documented, and the wound descriptors did not equal 100%. -Right medial calf diabetic ulcer measured 1.99 cm x 0.94 cm with 20% granulation and 80% slough. No depth was documented. -Intergluteal cleft MASD measured 0.77 cm x 0.52 cm with 100% granulation. No depth was documented. (Surveyor was unable to determine if the intergluteal cleft MASD was the same area as the left buttock MASD though they did not have the same measurements. Surveyor noted the hospital paperwork indicated this was a pressure area.) -Right lateral midfoot surgical wound measured 9.46 cm x 3.84 cm with 80% granulation and 20% slough. No depth was documented. (Surveyor noted the area was now labeled right instead of left and the length and width measurements were similar.) On 4/25/2024 R190 was seen for the initial visit by Wound Physician-I. Wound Physician-I documented the following wounds: -Right lateral foot surgical wound measured 7.76 cm x 3.19 cm x 1.4 cm with early/partial granulation with the wound bed color descriptions denoted by centimeters squared: red, black, yellow, pink, and other. The tissue types were not documented nor the percentage of wound bed coverage. -Right dorsal foot venous ulcer measured 1.59 cm x 1.2 cm x 0.6 cm with 1-25% granulation and 51-75% slough. -Right plantar foot diabetic ulcer measured 1.49 cm x 2.98 cm x 0.1 cm with 76-100% slough before debridement and 1.25 cm x 2.93 cm x 1.6 cm with 1-25% granulation and 51-75% slough. -Right shin venous ulcer measured 4.63 cm x 2.69 cm x 0.1 cm with 26-50% granulation and 26-50% slough. -Right calf venous ulcer measured 0.87 cm x 1.1 cm x 0.1 cm fully granulated. On 4/25/2024 at 2:40 PM in the progress notes, Registered Nurse Unit Manager (RN UM)-E charted R190's left buttock had healed. On 5/2/2024 at 10:47 AM, Surveyor observed Wound Physician-I along with RN UM-E assess R190's wounds. RN UM-E stated R190's coccyx area had healed since admission and currently has wounds to the lower right leg. Surveyor observed R190's right foot with a Kerlix dressing wrapped around the foot. Yellow drainage had seeped through the bandage on the bottom of the foot. The wound to the bottom of the right foot was macerated. The right lateral foot wound had a wound vac connected which was removed for the assessment. Surveyor observed wounds to the right shin, the right dorsum of the foot, and the right Achilles. Wound Physician-I stated the right Achilles wound had hyper-granulation because of possible tendon involvement. R190 stated R190 had cellulitis to the right foot and because of neuropathy to R190's hands, R190 was unable to change the dressings while at home. R190 stated R190 left the dressing to the right foot on for two weeks and then was in a really bad state and ended up in the hospital. Surveyor requested a copy of Wound Physician-I's wound assessments for that day. Wound Physician-I's documentation of R190's non-pressure areas on 5/2/2024 had the following assessments: -Right lateral foot measured 6.84 cm x 3.11 cm x 0.5 cm with early/partial granulation with the wound bed color descriptions denoted by centimeters squared: red, black, yellow, pink, and other. The tissue types were not documented nor the percentage of wound bed coverage. -Right dorsal foot venous ulcer measured 1.63 cm x 1.12 cm x 0.5 cm with 1-25% granulation and 51=75% slough. -Right plantar foot diabetic ulcer measured 0.76 cm x 5.64 cm x 0.6 cm with 76-100% slough. -Right shin venous ulcer measured 1.03 cm x 0.84 cm x 0.1 cm with 76-100% granulation. -Right calf venous ulcer measured 1.54 cm x 1.57 cm x 0.1 cm with full granulation. In an interview on 5/2/2024 at 3:33 PM, Surveyor asked LPN-J what the facility procedure was for a newly admitted resident. LPN-J stated the majority of new admissions come on second shift, so the floor nurse does the assessment and admission note. LPN-J stated the Unit Manager or the unit secretary may help with orders and getting appointments into the computer system. LPN-J stated the floor nurse has to do the admission in addition to their normal duties and if there are multiple new admissions, then the two floor nurses will split up the admissions so it is an even workload. LPN-J stated the nurse has to get vital signs, do a skin assessment, an admission assessment, and write the admission note. LPN-J stated if the regular nurses are working when there are a lot of new admissions, it is not too bad, but if a nurse does not normally work on that unit, it can be very stressful. Surveyor asked LPN-J to explain what is meant by doing a skin assessment. LPN-J stated the nurse checks for bruising from IVs, open areas, redness, scars, tattoos, or anything else on the skin. LPN-J stated they normally know what they are looking at from the report that is given from the hospital. LPN-J stated the nurse gets measurements of the wounds and takes a picture of the wound that also gets measurements. LPN-J stated the Wound Physician will officially stage any pressure injuries. Surveyor asked LPN-J if the phone picture gets a depth measurement of the wound. LPN-J stated the phone gets a slight depth, but that is where the Wound Physician fills in. LPN-J stated LPN-J does not usually get a depth measurement but knows to use a disposable paper ruler to measure the depth. Surveyor asked LPN-J if LPN-J remembered doing the admission skin assessment for R190. LPN-J stated LPN-J was told to change the dressings that LPN-J could and that R190 was going to have a wound vac to one of the wounds and LPN-J was not going to do the wound vac. LPN-J did not remember getting a depth of the right lateral foot wound. LPN-J stated pictures are taken of the open wounds so the progression of healing can be seen. Surveyor asked LPN-J if any other areas of the skin would have pictures taken. LPN-J stated a picture of a large area of maceration on the buttocks was taken of R190. LPN-J stated LPN-J waits to have someone else look at the wound, so LPN-J does not describe the tissue. LPN-J stated after a picture is taken, the computer gives you option to specify the tissue type and other descriptors, so LPN-J clicks on whatever was seen. LPN-J stated the wound assessment is followed up by RN UM-E. On 5/6/2024 at 9:38 AM, Surveyor shared with Director of Nursing (DON)-B the concerns that R190's wounds on admission were very hard to follow with the documentation; either the wounds did not have a depth measurement, they did not have any description of the tissue type, or they labeled the same areas different names. DON-B stated on the Admit/Readmit Assessment form nurses are not able to add notes such as descriptions of the tissue type. Surveyor stated not all the wounds had Skin & Wound Evaluation forms completed which would allow the nurse to document more descriptors. DON-B stated Wound Physician-I comes after a resident has been in the facility for a few days and Wound Physician-I labels the wound to be at a different location than what the facility picked for the wound, so the facility has to take a new picture or relabel the wound and that makes it look like the wound is a new wound when really it is the same wound just relabeled with the location picked by Wound Physician-I. Surveyor shared the concern most wounds on admission did not have a depth measurement. DON-B stated the nurses will use the depth measurement from Wound Physician-I so they do not have a depth until then. No further information was provided at that time.

Based on observation, record review, and interview, the facility did not ensure residents with pressure injuries received care consistent with professional standards of practice to promote healing for 4 (R188, R62, R14, and R12) of 5 residents reviewed with pressure injuries. *R188 was admitted to the facility with pressure injuries that were not comprehensively assessed on admission and the air mattress was observed to be not set according to R188's weight. *R62, R14, and R12 had pressure injuries and observations were made of their air mattresses not to be set according to their weight. Findings include: The facility policy and procedure entitled Pressure Injury Prevention and Management dated 10/2023 states: Policy Explanation and Compliance Guidelines: . 3. Assessment of Pressure Injury Risk . c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. 4. Interventions for Prevention and to Promote Healing . c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: . iii. Provide appropriate, pressure-redistributing, support surfaces. The facility policy and procedure entitled Skin assessment dated ,d+[DATE] states: Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. document if resident refused assessment and why. f. Document other information as indicated or appropriate. 1.) R188 was admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit, bacteremia, malnutrition, leukemoid reaction, anemia, anxiety, depression, and epilepsy. R188 had not been a resident of the facility long enough to have a comprehensive Minimum Data Set (MDS) assessment completed. R188 had an activated Power of Attorney (POA). R188's Activities of Daily Living Care Plan was initiated on 4/26/2024 and indicated R188 needed staff assistance of one for bathing/showering, bed mobility, dressing, personal hygiene, and toilet use and staff assistance of two for transferring using a mechanical lift. The Infectious Disease Physician Progress Note dated 4/26/2024 documented R188 had wounds on the dorsal aspect of the left foot and fifth metatarsal (toe) that measured approximately 2 cm x 2 cm and multiple small wounds scattered on bilateral legs and arms. R188's hospital Discharge Summary dated 4/26/2024 indicated no wound care was needed. On 4/26/2024, Registered Nurse (RN)-D completed R188's Admit/Readmit Assessment form and Skin & Wound Evaluation forms for the following pressure injuries: -Coccyx/Sacrum Stage 3 pressure injury measured 8.1 cm x 6 cm x 0.2 cm with 20% granulation and 80% slough. An additional Skin & Wound Evaluation form was completed for the sacrum Stage 3 pressure injury measured 3.8 cm x 1.4 cm with no depth measurement with 20% granulation and 80% sough. The photos attached to the sacrum assessments revealed three open areas and measurements were for two areas with no description of what was being assessed. The location of the pressure injury was labeled coccyx on the Admit/Readmit Assessment form and was labeled sacrum on the Skin and Wound Evaluation form. -Left heel Unstageable pressure injury measured 2.9 cm x 1.9 cm with 100% eschar. -Left fourth toe Unstageable pressure injury measured 1.5 cm x 1.5 cm. Surveyor noted no depth was measured and no wound characteristics were documented. Surveyor noted the picture attached to the assessment showed the wound to be on the fifth toe and not the fourth toe. R188's Skin Impairment Care Plan was initiated on 4/26/2024 with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Use barrier cream to prevent skin impairment issues, as needed. R188's Skin Impairment Care Plan was revised on 4/27/2024 with the following interventions: -Encourage to offload heels. -Heel boots on when in bed. -R188 needs an air mattress to protect the skin while in bed. -R188 needs pressure relieving/reducing cushions to protect the skin while up in a chair. On 4/27/2024 on the Treatment Administration Record (TAR), R188 had an order to check the function of the low airloss mattress every shift. On 5/1/2024, Licensed Practical Nurse (LPN)-P completed a Skin & Wound assessment form for the following pressure injuries: -Sacrum Unstageable pressure injury measured 6.5 cm x 3.3 cm with 90% slough and 10% eschar. Surveyor noted no depth was measured and the photo attached to the assessment showed two open areas. -Sacrum Stage 3 pressure injury had no measurements and no wound description other than the wound was stable. The photo attached to the assessment showed three open areas and had measurements of 0 cm x 0 cm. Surveyor noted the sacrum had open areas and was unable to determine what was being assessed. On 5/2/2024 at 11:09 AM, Surveyor accompanied Wound Physician-I and RN Unit Manager (UM)-E to assess R188's pressure injuries. RN UM-E stated R188 had pressure injuries to the left fourth toe, the left heel and the sacrum. RN UM-E stated R188 had three areas on the sacrum that the picture documentation counted as one area. Surveyor observed R188 in bed on an air mattress. The air mattress setting was at 360 pounds. Surveyor shared the observation of the air mattress setting with Wound Physician-I. Wound Physician-I asked R188 how much R188 weighed. R188 stated R188 weighed 172 pounds the last time R188 was weighed. Wound Physician-I turned the setting on the air mattress down to R188's weight. RN UM-E stated they would reset that air mattress. R188 had bilateral heel boots on. Wound Physician-I stated the wound to the left fifth toe was due to trauma and not a pressure injury. Surveyor clarified with Wound Physician-I that the wound was on the fifth toe and not the fourth toe as initially documented. Wound Physician-I agreed the wound was on the fifth toe. Surveyor observed three open areas on the sacrum and one open area on the left iliac crest. Wound Physician-I stated the sacrum wounds were measured as one area because the tissue surrounding two of the open areas was darkened and had damage below the skin making it one wound with two open areas. Surveyor noted the third open area on the sacrum was not measured or assessed. Wound Physician-I debrided necrotic tissue from the middle and right open areas of the sacral wound. The left heel pressure injury had an eschar cap over the wound. Surveyor requested a copy of Wound Physician-I's wound assessments. Wound Physician-I's documentation of R188's pressure areas on 5/2/2024 had the following assessments: -Sacrum Unstageable pressure injury measured 5.4 cm x 4.51 cm x 0.2 cm with 1-25% granulation and 51-75% slough before debridement and measured 3.97 cm x 5.28 cm x 1.1 cm with 1-25% granulation and 51-75% slough after debridement. Surveyor noted the measurement included two open areas. Surveyor noted the third open area on the sacrum was not assessed. -Left heel Unstageable pressure injury measured 2.16 cm x 1.84 cm x 0.1 cm with eschar. In an interview on 5/2/2024 at 3:22 PM, Surveyor asked RN-D what the facility process was when a new resident was admitted to the facility. RN-D stated the nurse on the floor does the initial skin assessment which includes looking at the resident's skin from top to bottom and documenting anything like a scab, bruising, scratches, checking under the breasts and folds for redness or excoriation, and any open areas or Deep Tissue Injuries (DTI) caused by pressure. RN-D stated for any open areas or DTIs, you put a sticker next to the wound and take a picture with the phone; that is connected to the electronic charting system, and it measures the length and width of the wound. RN-D stated the picture is sent to Wound Physician-I or to RN UM-E with the resident's name and what the wound is so they can get a treatment order. RN-D stated the wounds are monitored and they are evaluated weekly on Wednesday. RN-D stated if a treatment needs to be done right away, RN-D will do that and then make sure everything is charted. RN-D stated if the resident has mushy heels, RN-D will get heel boots or pillows if the resident hates the boots. Surveyor asked RN-D if pictures were taken of all skin impairments. RN-D stated scabs, bruises, and blanchable redness just get written into the assessment, but if it is an open area, then they get a picture on the phone. RN-D clarified an open area on the coccyx or anything that gets a deeper assessment will get a picture so Wound Physician-I can get a treatment in place. RN-D stated Wound Physician-I is available every day and answers quickly. RN-D stated RN UM-E and Assistant Director of Nursing (ADON)-C are really good with wounds, so they help with assessments. Surveyor noted the phone picture assessment does not measure depth. Surveyor asked RN-D if any wounds get depth measurements. RN-D stated it depends on the wound if a depth is measured. RN-D stated with a flap off, like a skin tear, the depth is estimated and if it something deeper, then they would take a cotton swab to measure the depth. Surveyor asked RN-D how air mattresses were set for the amount of pressure. RN-D stated maintenance usually sets that up but was not sure how they determined the amount of pressure. RN-D stated you can tell who needs a mattress, like if the resident has a wound to the back or is frail skin and bones. Surveyor clarified with RN-D who set the pressure on the air mattress. RN-D stated maintenance sets the pressure; nurses never set the pressure. On 5/6/2024 at 8:55 AM, Surveyor observed R188 lying in bed. The air mattress was set to the correct weight and a sticker had been added to the control panel that listed R188's weight as 166.5 pounds. Surveyor reviewed R188's TAR and R188 had an order to check the function of the low airloss mattress every shift. Weight settings: 166.5 had been added on 5/4/2024 to the original order on the TAR. On 5/6/2024 at 9:31 AM, Surveyor shared with DON-B the concern R188's pressure areas were not comprehensively assessed until 5/2/2024, six days after admission, when Wound Physician-I assessed R188's pressure injuries. Surveyor shared with DON-B R188 had three pressure areas on the sacrum and only two open areas were assessed, and those areas were measured as one area even though they were two separate open areas. DON-B stated Wound Physician-I measured those two open areas together because it gets one treatment. Surveyor shared the third open area was never assessed. Surveyor shared with DON-B R188's left heel did not have a depth measurement until 5/2/2024 when Wound Physician-I assessed the left heel. Surveyor shared with DON-B that R188's air mattress was set to 360 pounds when R188 weighed 166.5 pounds. DON-B provided a table that was obtained from the air mattress distributor that gave pound to kilogram conversions for settings on an air mattress, but the settings did not correlate with the air mattress in place on R188's bed. DON-B stated the bed should be set to the resident's weight and the resident's comfort. Surveyor was unable to find any documentation in R188's medical record that a conversation was had about the setting on the air mattress and R188's comfort level. 20025 2.) R12 was admitted to the facility on [DATE] with diagnoses of dementia, type 2 diabetes and CVA (cerebral vascular accident). The significant change MDS (minimum data set) dated 3/22/24 indicates R12 has cognitive impairments and is dependent for hygiene, bed mobility and toileting. R12 has a stage 3 pressure injury to the sacral area. The physician order dated 4/27/22 indicating a low air loss mattress (settings by weight). On 4/22/24 R12 weight was 114 lbs. On 4/30/24 at 9:09 a.m. Surveyor observed R12 in bed and the low air loss mattress was set at 180 lbs. On 5/1/24 at 8:33 a.m. Surveyor observed R12 was in bed and the low air loss mattress was set at 180 lbs . On 5/2/24 at 11:48 a.m. Surveyor observed R12 receive pressure injury treatment and the low air loss mattress was set at 180 lbs. R12's low air loss mattress device is called Proactive. The operating instructions for the Proactive mattress indicates determine the patient's weight and set the control knob to that weight setting on the control unit. On 5/2/24 at 3:00 p.m. during the daily exit meeting with DON (director of nursing)-B and NHA(nursing home administrator)-A, Surveyor explained the concern R12 was observed to be on the low air loss mattress set at 180 lbs when R12 weighs 114 lbs. On 5/6/24 at 10:07 a.m. Regional Consultant-Q stated the mattress representative explained to her that the mattress should be set at the weight and/or resident's comfort level. Surveyor explained what the mattress should be set at is not documented in the medical record. There is no indication an assessment was completed to determine if R12's mattress setting should be set differently from R12's weight. 3.) R14 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, dementia, paraplegia and anxiety disorder. Significant change MDS dated [DATE] indicate R14 has cognitive impairments and is incontinent of bowel and bladder. R14 has a healing stage 3 pressure injury to the right buttock. The care plan indicates R14 has a low air loss mattress. On 5/2/24 at 12:22 p.m. Surveyor observed R14's pressure injury treatment and the mattress was set at 320 lbs. The mattress is a Proactive device. The operating instructions for the Proactive mattress indicates determine the patient's eight and set the control knob to that weight setting on the control unit. On 4/3/24 R14 weight was 163.5 lbs. On 5/2/24 at 3:00 p.m. during the daily exit meeting with DON (director of nursing)-B and NHA(nursing home administrator)-A, Surveyor explained the concern R14 was observed to be on the low air loss mattress set at 320 lbs when R14 weighs 163.5 lbs. On 5/6/24 at 10:07a.m. Regional Consultant-Q stated the mattress representative explained to her that the mattress should be set at the weight and/or resident's comfort level. Surveyor explained what the mattress should be set at is not documented in the medical record. There is no indication an assessment was completed to determine if R14's mattress setting should be set differently from R14's weight. 4.) R62 was admitted to the facility on [DATE] with diagnoses of dementia, type 2 diabetes and major depression. On 4/30/24 at 9:25 a.m. Surveyor observed R62 in bed and the low air loss mattress was set at 280 lbs. On 5/2/24 at 12:36 p.m. Surveyor observed R62's pressure injury treatment and observed the mattress set between 240 and 280 lbs. On 4/27/24 R62 weighed 190.5 lbs. On 5/2/24 at 3:00 p.m. during the daily exit meeting with DON (director of nursing)-B and NHA(nursing home administrator)-A, Surveyor explained the concern R62 was observed to be on the low air loss mattress set at 240-280 lbs when R62 weighs 190.5 lbs. On 5/6/24 at 10:07 a.m. Regional Consultant-Q stated the mattress representative explained to her that the mattress should be set at the weight and/or resident's comfort level. Surveyor explained what the mattress should be set at is not documented in the medical record. There is no indication an assessment was completed to determine if R62's mattress setting should be set differently from R62's weight.

Based on observation, interview, and record review, the facility did not ensure residents received care and services in accordance with professional standards of practice for 4 of 4 (R52, R82, R92, and R199) residents reviewed. R199 did not have a follow up assessment and monitoring of urinary symptoms following identified change in condition and physician orders were not followed. R199 was admitted to the hospital for a change in condition after orders were not followed to monitor R199 and push fluids. R52 did not have neurological assessments completed following falls according to facility policy. R82 did not have neurological assessments completed following falls according to facility policy. R92 did not have neurological assessments completed following falls according to facility policy. Findings include: 1.) R199 admitted to the facility on [DATE] and has diagnoses that include paraplegia, urinary elimination alteration due to neurogenic bladder secondary to paraplegia, history of renal mass and urinary tract infections (UTI.) The facility Clinical Management Policy titled Assessment Schedules dated revised 5/2022 documents (in part) . .Policy: It is the policy of the facility to complete appropriate assessments on residents on admission, quarterly, significant change, annually and at any assessment would be indicated. The purpose of assessments is to get an accurate picture/evaluation of the resident to ensure the development of an appropriate and comprehensive care plan. The facility policy titled Notification of Changes dated revised 10/2022 documents (in part) . .Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the residents representative when there is a change requiring notification. Definitions: Clinical Complications Examples: Recurrent UTIs. R199's Care Plan Focus area documents: Urinary elimination alteration due to neurogenic bladder secondary to paraplegia. History of blood tinged urine and bladder spasms. History of renal mass. History of UTIs. Diagnosis: Neurogenic bladder. Interventions include: Catheter care every shift - initiated 6/9/19. Change indwelling catheter per physician order - revised 10/1/18. Monitor urinary output every shift, advise nursing of changes in urine; cloudy or bloody urine, foul odor, or change in output amount - initiated 6/9/19. Surveyor review of facility progress notes documented: 1/5/23 at 3:08 PM Resident was noted to have very dark urine with odor, (Nurse practitioner group name) aware and asked for her Foley to be changed/push fluids and if symptoms persist update (Nurse practitioner group name). Surveyor noted this information to monitor R199 by the nurse practitioner was only noted in this progress note and did not get added to a 24 hour monitoring report or a treatment order. Progress note dated 1/8/2023 at 11:05 PM indicates: Writer was informed by CNA (Certified Nursing Assistant) that patient was going crazier than usual in her room. Writer entered the room and immediately noticed the patient was pale and diaphoretic. CNA was there trying to calm the patient. Vitals obtained, see charting for 8:39 PM. Charge nurse to evaluate patient with writer. Urine was dark red, almost purple in color. (Nurse practitioner group name) was called and informed. While on the phone with (Nurse practitioner group name), they were placed on a brief hold while a second set of vitals were obtained, charting for 9:26 PM. HR (heart rate) was elevated at 118 and BP (blood pressure) had dropped to 75/51. Writer immediately update (Nurse practitioner group name) and called 911. MD (Medical Doctor) was informed. (Nurse practitioner group name) RN (Registered Nurse) updated family. Ambulance arrived to pick up patient and departed at 9:39 PM. No updates at this time. The Hospital Discharge Summary dated 1/17/23 documented: Diagnosis Sepsis due to UTI. Hospital Course: [AGE] year old T4 spinal cord injury with paraplegia, chronic Foley admitted from memory care facility with sepsis due to UTI. In ED (Emergency Department) had temperature 100.5. Surveyor noted there was no documentation the facility was assessing or monitoring R199's urine or symptoms after this was conveyed by the nurse practitioner on 1/5/23 and there were no revisions made to R199's care plan. Surveyor noted R199's Medication Administration Record documented for extra 120 cc fluids every shift since 11/15/21. There was no evidence the facility was pushing additional fluids as ordered by the physician on 1/5/23, and there was nothing on the MAR or TAR (Treatment Administration Record) to alert staff of the nurse practitioner direction to monitor R199 to determine if symptoms persist, update (Nurse practitioner group name). Surveyor review of R199's vital sign record revealed no fever from 1/5/23 to 1/8/23. There was no blood pressure, pulse, or respirations documented from 1/5/23 until 1/8/23. On 1/8/23 at 8:39 PM blood pressure 179/90, respirations 19, pulse 104. On 1/8/23 at 9:26 PM blood pressure 75/51, respirations 22, pulse 118. On 1/25/23 at 10:45 AM, Surveyor spoke with Licensed Practical Nurse (LPN)-D who reported R199's Foley catheter was changed on 1/5/23 as ordered. Surveyor review of R199's TAR documented the Foley catheter signed out as having been changed on 1/5/23 at 12:34 PM. On 1/25/23 at 10:52 AM, Surveyor spoke with Nurse Manager (NM)-F. Surveyor reviewed R199's progress note on 1/5/23 with NM-F which documented dark urine with odor/(Nurse practitioner group name) aware, asked for Foley to be changed, push fluids, if symptoms persist update (Nurse practitioner group name). Surveyor asked how staff would be aware of this directive/order to monitor R199's urine and symptoms. NM-F stated: It would be on the 24 hour board. Surveyor asked where to find documentation or evidence staff was pushing fluids, monitoring symptoms, urine color, and odor as ordered. NM-F stated: If it's on the 24 hour board, it's expected the nurses should be charting in the progress notes. Surveyor advised NM-F there was no documentation in facility progress notes after 1/5/23. NM-F reported she would look for the 24 hour boards. On 1/25/23 at 11:52 AM NM-F informed Surveyor there was nothing on the 24 hour board regarding R199 or the order to push fluids and if symptoms persist update (Nurse practitioner group name). NM-F provided copies of the 24 hour board for 1/5/23 and 1/6/23, but was unable to locate the 24 hour board for 1/7/23. Surveyor review of the 24 hour boards revealed R199 was not on the 24 hour board and it included no information or orders to push fluids and if symptoms persist update (Nurse practitioner group name). On 1/26/23 at 9:11 AM, Surveyor advised Director of Nursing (DON)-B of concern R199 has a history of urinary tract infections and developed a change in condition regarding her urine color and odor on 1/5/23. The physician ordered to push fluids and if symptoms persist update (Nurse practitioner group name). There was no evidence the facility pushed fluids, monitored her urine and symptoms, and updated the physician as ordered. DON-B stated: I agree, she was not added to 24 board to push fluids and monitor symptoms and should have been. We did education on change of condition and monitoring for 72hrs. The only thing I can say is she didn't have a fever, those are the only vital signs I could find. Surveyor discussed with DON-B again the concern regarding the change in R199's urine color and odor with no continued monitoring, with the resident subsequently being sent to the hospital and admitted with sepsis due to UTI. DON-B stated: I understand, all I can say is that we have done education with all the nurses. Surveyor asked what is the expectation when a physician orders to push fluids and if symptoms persist, update? DON-B reported R199 should have been placed on the 24 hour board. DON-B reported the facility has a UTI monitoring form that could have been implemented. The nurse could have called the doctor back and asked if there was a specific amount of extra fluids he wanted, but we would normally add on the MAR to provide extra fluids. Surveyor advised the MAR already documented an extra 120 cc every shift since 2021. Surveyor asked DON-B if she would expect that amount to be increased if the doctor ordered to push fluids. DON-B stated: Yes, I take that to mean he wants us to push more fluids than she is already receiving. On 1/26/23 at 11:45 AM, DON-B reported she is unable to locate a specific policy and procedure regarding urine monitoring, only the Notification of Changes policy and procedure. DON-B stated: But we don't have a problem that the physician wasn't notified, the problem is they (staff) didn't follow up and monitor her afterward. DON-B provided add order set form which she stated should have been utilized. DON-B showed Surveyor there is a UTI protocol to click - which included: Assess the 3 day UTI protocol in three days on this date. Check and document vital signs for 3 days every shift. Encourage fluids. Urine/voiding characteristics. UTI stat. DON-B reported the nurse should have just clicked on the box and all would have been implemented on the MAR to follow. On 1/30/23 (after survey) the facility sent additional information - this included a statement by R199's Nurse Practitioner: From the last hospitalization on [DATE] the resident was found to have nephrolithiasis, kidney stones that are unpassable, will need outpatient urology follow up. Chronic indwelling catheter and the new nephrolithiasis will predispose resident to UTI and urosepsis and can happen fast. From my professional judgement, pushing fluids and obtaining vital signs will not prevent patient from developing urosepsis especially with the presence of kidney stones. This was discussed with POA (power of attorney)/son during care conference that the likelihood of resident getting septic again is high due to the presence of renal stones. Surveyor noted: The facility was not aware of the presence of kidney stones until after she was hospitalized on [DATE]. There was no evidence the facility followed the order on 1/5/23 of pushing fluids and monitoring resident, urine color, or odor - until she was sent to hospital and diagnosed with sepsis on 1/8/23. The fact that the resident was diagnosed with kidney stones (which according to the physician statement, increases the likelihood of sepsis) only reinforces the importance of increased monitoring of the resident. 38829 The Facility Policy and Procedure, entitled Falls Management, dated 5/2022, documents (in part) . .Post Fall/Injury Resident Management: .7. Obtain neurological checks for any unwitnessed fall or any fall with evidence of injury to head . 2.) R52 was admitted to the facility on [DATE] with diagnoses of Acquired Absence of Both Cervix and Uterus, Legal Blindness, Dysphagia, and Polyneuropathy. R52 has an activated Health Care Power of Attorney (HCPOA). Surveyor reviewed R52's Significant Minimum Data Set (MDS) dated [DATE] and notes R52's Brief Interview for Mental Status(BIMS) score of 11 indicating R52 demonstrates moderately impaired skills for daily decision making. R52 MDS documents R52 requires extensive assistance with bed mobility, transfers, dressing, toileting, and hygiene. R52's MDS documents R52 has no range of motion impairment on upper body extremities but has range of motion impairment on lower extremities. Surveyor reviewed R52's comprehensive care plan and notes the focused problem of fall occurred with no injury initiated 1/22/23 has the intervention in place to initiate Neuro Checks per facility protocol. R52 had two unwitnessed falls: 1/2/23 Per fall investigation dated 1/3/23, R52 slipped out of wheelchair onto buttocks in an attempt to reach the side table. Neuros at baseline and no pain noted. .1/2/2023 at 3:02 PM: *24 HR Report Note Text: Writer was informed that resident was sitting on her bedroom floor. Writer went in to find resident sitting in front of her chair. Resident stated she was trying to reach bedside table when she slipped out of her chair. Resident's vital signs 110/62 P 60 RR 18 temp 97.3 Neuro checks negative. Resident stated her back was bothering her. Resident currently in her bed with call light in reach. (Name of Hospice) and family was notified. Will continue to monitor. Surveyor reviewed the neuro checks provided by the facility which were completed for R52's 1/2/23 fall. Surveyor noted the first neuro check completed was on 1/2/23 at 12:00. The set of vitals do not match the initial set of vitals documented in the nurse's note at 3:02 PM. The vitals along with neuro checks is documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. The second neuro check is completed on 1/2/23 at 12:15. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The third neuro check is completed on 1/2/23 at 12:30. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor notes the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fourth neuro check is completed on 1/2/23 at 12:45. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fifth neuro check is completed on 1/2/23 at 5:00 PM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The sixth neuro check is completed on 1/2/23 at 8:34 PM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The seventh neuro check is completed on 1/3/23 at 10:00 AM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The eighth neuro check is completed on 1/3/23 at 2:20 PM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The ninth neuro check is completed on 1/3/23 with no time documented. The vitals along with neuro checks is documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The tenth neuro check is completed on 1/4/23 at 10:00 AM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The eleventh neuro check is completed on 1/4/23 at 5:10 PM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is one hour after the vitals and neuro checks are documented. Surveyor noted there is different documentation for the vitals. The twelfth neuro check is completed on 1/5/23 at 6:00 AM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The thirteenth neuro check is completed on 1/5/23 at 9:00 AM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fourteenth neuro check is completed on 1/5/23 at 4:00 PM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fifteenth neuro check is completed on 1/6/23 at 6:00 AM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The sixteenth neuro check is completed on 1/6/23 at 9:00 AM. The vitals along with neuro checks are documented they were obtained on 1/1/23 at 9:39 PM, which is one day prior to R52's 1/2/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. 1/22/23 fall: Per fall investigation dated 1/22/23, the report documents R52 fell out of bed and bumped right forehead on bar of over-bed table. Neuros at baseline and no pain noted. .1/22/2023 at 7:29 AM *24 HR Report Note Text: At 0645 CNA on duty informed writer that resident was on the floor. Writer assessed the resident and noted resident lying on her right side with right forehead on lower bar of over-bed table. States turned over right out of bed onto the floor. Staff on duty assisted resident off the floor via Hoyer back to bed. B/P 145/114 AP 50, R 16, T 97.8 O2 sat 95% room air. PEERL (pupils equal and equally reactive to light). Protrusion right forehead hairline 3.0 cm X 3.0 cm, scalp intact. ROM BUE and BLE (range of motion bilateral upper extremity and bilateral lower extremity) at baseline for resident. Hospice nurse (name of) called and informed and states will be in to assess on AM shift as well as call family and MD. MGR (manager) on duty informed. Resident in bed resting comfortably, with call light in reach. Will continue to monitor. Surveyor reviewed the neuro checks provided by the facility which were completed for R52's 1/22/23 fall. The first neuro check is completed on 1/22/23 at 6:45 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. The second neuro check is completed on 1/22/23 at 7:00 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The third neuro check is completed on 1/22/23 at 7:15 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fourth neuro check is completed on 1/22/23 at 7:30 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fifth neuro check is completed on 1/22/23 at 11:00 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The sixth neuro check is completed on 1/22/23 at 2:30 PM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The seventh neuro check is completed on 1/22/23 at 6:40 PM. The vitals along with neuro checks are documented they were obtained on 1/22/23 at 6:43 PM. The eighth neuro check is completed on 1/22/23 at 9:00 PM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The ninth neuro check is completed on 1/23/23 at 2:00 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The tenth neuro check is completed on 1/23/23 at 4:30 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The eleventh neuro check is completed on 1/23/23 at 12:30 PM. The vitals along with neuro checks are documented they were obtained on 1/23/23 at 11:58 AM. The twelfth neuro check is completed on 1/23/23 at 8:30 PM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The thirteenth neuro check is completed on 1/24/23 at 4:00 AM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fourteenth neuro check is completed on 1/24/23 at 1:00 PM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The fifteenth neuro check is completed on 1/24/23 at 9:00 PM. The vitals along with neuro checks are documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. The sixteenth neuro check is completed on 1/25/23 at 3:00 AM. The vitals along with neuro checks is documented they were obtained on 1/4/23 at 6:03 PM, which is 18 days prior to R52's 1/22/23 fall. Surveyor noted the vitals and neuro checks are exactly the same vitals documented as the previous set of vitals and neuro checks. Surveyor reviewed R52's active orders as of 1/24/23 and noted the following order Fall Follow up: 72 hours post fall assessment q (each) shift x 3 days every shift for 3 Days Other Active 1/22/2023 15:00 1/25/2023, 1/22/2023 Neuro Check every 4 hours x 24 hours then every 8 hours x 48 hours every 4 hours for Post fall for 1 Day AND every shift for 2 Days Other Active 1/22/2023 10:00 1/24/2023, 1/22/2023 On 1/25/23 at 1:42 PM, Surveyor interviewed Nurse Manager(NM-E) in regards to R52's neuro checks. NM-E stated that new neuro checks and vitals should be done for every unwitnessed falls. 4 every 15 mins, every 4 hours for 24 hrs, every 8 hrs for 48. NM-E confirmed the nurse should be getting completely new vitals and neuro checks NM-E stated the Resident would be on the 24 board. NM-E stated NM-E does not know why its pulling the same vitals and neuro checks for R52. On 1/25/23 at 3:50 PM, Surveyor shared the concern with Administrator (NHA-A) and Interim Director of Nursing (DON-B) that the neuro-checks completed for R52's two unwitnessed falls pulled vitals and neuro-checks information from the last set of vitals and no new vitals and neuro-checks were completed per facility policy and procedure. No further information was provided at this time by the facility. On 1/26/23 at 8:45 AM. DON-B agreed with Surveyor that not all the neuro-checks are complete for both of R52's falls. I want you to know that some of the nurse's did neuro-checks but it is not completed per facility policy. On 1/31/23 at 2:26 PM, the facility provided additional documentation. However, the documentation is that neuro checks are negative. Surveyor noted that if no new vitals or neuro checks were obtained, how can there be documentation that neuro checks are negative. The post fall assessments provided do not indicate new vitals and neuro checks were completed for both R52's 1/2/23 and 1/22/23 falls. 45647 3.) R82 was admitted to the facility on [DATE] with diagnoses of Epilepsy, Repeated Falls, Hypertension, and Edema. R82's Quarterly MDS (Minimum Data Set) assessment dated , 11/24/22, documents a BIMS (Brief Interview for Mental Status) score of 12, indicating R82 is moderately cognitively impaired for daily decision making. R82's fall investigation, dated 10/5/2022, documents R82 had an unwitnessed fall with possible head injury. Resident was sent out via ambulance and returned to the facility on [DATE]. Surveyor reviewed hospital documentation which indicated R82 did not have any injuries related to the fall on 10/5/22. Surveyor reviewed Neurological Checks, dated 10/5/2022. Documented under the date of 10/07/22 at 10:00 AM, Neuro Check documents blood pressure of 143/79, pulse of 78, respiration rate of 18, and temperature of 97.4. The date of the above vitals documented is 9/14/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/06/2022. Documented under the date of 10/07/22 at 2:00 PM, Neuro Check documents blood pressure of 143/79, pulse of 78, respiration rate of 18, and temperature of 97.4. The date of the above vitals documented is 9/14/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/06/2022. Documented under the date of 10/08/22 at 12:30 AM, Neuro Check documents blood pressure of 143/79, pulse of 78, respiration rate of 18, and temperature of 97.4. The date of the above vitals documented is 9/14/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/06/2022. Documented under the date of 10/08/22 at 8:15 AM, Neuro Check documents blood pressure of 143/79, pulse of 78, respiration rate of 18, and temperature of 97.4. The date of the above vitals documented is 9/14/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/06/2022. Surveyor noted that the same vitals were used for several neurological checks from 10/6/22 until 10/8/22. Surveyor noted staff using vitals from 9/14/22 when the fall occurred on 10/5/22. R82's fall investigation, dated 10/22/2022, documents R82 had an unwitnessed fall without injury. The resident was found in their room by another resident. Surveyor reviewed Neurological Checks, dated 10/22/2022. Documented under the date of 10/22/22 at 12:15 PM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Documented under the date of 10/22/22 at 12:30 PM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Documented under the date of 10/22/22 at 12:45 PM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Documented under the date of 10/23/22 at 12:00 AM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Documented under the date of 10/23/22 at 4:00 AM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Documented under the date of 10/23/22 at 8:00 AM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Documented under the date of 10/23/22 at 12:00 PM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Documented under the date of 10/24/22 at 9:00 PM, Neuro Check documents blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Surveyor noted the last two neurological checks, that should be completed every 8 hours for 48 hours, had the date and time left blank, but vital signs were completed. However, it is documented that R82's blood pressure of 130/72, pulse of 84, respiration rate of 18, and temperature of 98.3. The date of the above vitals documented is 10/8/22 for the blood pressure, pulse, and respirations. The date of the temperature is 10/22/2022. Surveyor noted that the same vitals were used for several neurological checks from 10/22/22 until 10/24/22. Surveyor noted staff using vitals from 10/8/22 when the fall occurred on 10/22/22. R82's fall investigation, dated 11/4/2022, documents R82 had an unwitnessed fall in their room while trying to turn off the television. Surveyor reviewed Neurological Checks, dated 11/04/2022. Documented under the date of 11/4/22 at 9:30 PM, Neuro Check documents blood pressure of 135/73, pulse of 72, respiration rate of 17, and temperature of 98.6. The date of the above vitals documented is 11/4/22 at 9:30 PM for the blood pressure, pulse, respirations, and temperature. Documented under the date of 11/4/22 at 9:45 PM, Neuro Check documents blood pressure of 135/73, pulse of 72, respiration rate of 17, and temperature of 98.6. The date of the above vitals documented is 11/4/22 at 9:30 PM for the blood pressure, pulse, respirations, and temperature. Documented under the date of 11/4/22 at 10:00 PM, Neuro Check documents blood pressure of 135/73, pulse of 72, respiration rate of 17, and temper [TRUNCATED]

Based on observation, record review and interview, the facility did not ensure that 3 (R12, R99 and R139) of 11 residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents. * R12 had 24 falls in his room over a 10-month period, one that resulted in a [MEDICAL CONDITION] vertebra and the need to wear a cervical collar for 8-12 weeks. The facility did not address the amount of supervision R12 required when in his room to prevent falls. * R139 did not have interventions in place for medication administration while being an a puree diet. * R99 did not have interventions in place to prevent R99 from eloping from the facility. Example number 1, R12 represents actual harm. Findings include: 1) R12 was admitted [DATE] and, following hospitalization , re-admitted on [DATE]. He has [DIAGNOSES REDACTED]. R12's Quarterly MDS (Minimum Data Set) dated 7/6/19 documents a BIMS (Brief Interview for Mental Status) score of 3, indicating that R12 is severely cognitively impaired. Section G (Functional Status) documents that R12 requires extensive assistance and two person physical assist for his transfer, toilet use and bed mobility needs. On 7/21/19, Surveyor reviewed R12's above fall investigation reports and noted that a majority of R12's falls occurred while in his room while unsupervised. Although the facility did make changes to the care plan, Surveyor noted that after the falls the facility did not assess the amount of supervision R12 required while in his room and did not address this on the plan of care. While R12 was encouraged to stay in areas where he (R12) was visible to staff, Surveyor also noted that the facility did not implement specific supervision interventions that detailed how often and in what manner R12 would be supervised while in his room to avoid further falls. 1. R12's IDT (Interdisciplinary team note) falls note documents, 9/19/2018 2:45- IDT (Interdisciplinary team) note concerning un-witnessed fall without injury on 9/19/18 without injury. The resident was attempting to self-transfer from the bathroom back to the bed. The resident was found on the floor by the bathroom. 2. R12's falls note documents, 9/29/2018 14:10- IDT note concerning un-witnessed fall on 9.29.18 without injury. The resident was attempting to self-transfer from the bed to the wheelchair. The resident had the call light at the bedside but it was not used. 3. R12's IDT (Interdisciplinary team note) falls note documents, 11/5/2018 14:44- IDT note concerning un-witnessed fall without injury on 11.5.18. The resident was attempting to ambulate independently holding on the furniture in his room. He fell to buttocks and denies hitting head. Plan of care was updated to include: 11/05/18- reminder signs to the bathroom to prompt the resident to request assist for all needs; 11/05/18- reminder signs to the room to prompt the resident to request assist for all needs 4. R12's IDT (Interdisciplinary team note) falls note documents, 11/10/2018 20:30- IDT note concerning un-witnessed all without injury on 11/10/18, transferred from the bed to the floor. The bed was in the low position. The facility updated the plan of care to include: 11/11/18- body pillow to be in the bed. 5. R12's IDT (Interdisciplinary team note) falls note documents, 11/23/2018 22:04- IDT note concerning fall on 11/23/18 without injury. The resident was found on the floor at 2100. The bed was in the low position, body pillow in place, and all interventions are present. The facility updated the plan of care to include: 11/23/18- provide bedside urinal. 11/25/18- enabler bars to the bed. 6. R12's IDT (Interdisciplinary team note) falls note documents, 11/26/18 14:45- IDT note concerning un-witnessed fall on 11/26/18 at 1400. The resident was attempting to self-transfer from wheelchair to toilet and fell . The resident was found by nursing staff sitting on the floor on his buttocks by the wheelchair. The resident was assessed and no injuries or pain is noted. The facility updated the plan of care to include: ; 11/26/18- staff to toilet daily at 1400; 12-4-18-change to scheduled toileting 7. R12's IDT (Interdisciplinary team note) falls note documents, 12/4/2018 09:15- IDT note concerning un-witnessed fall without injury on 12/4/18. the resident was found in the bathroom on the floor after breakfast. It appeared that the resident had gotten caught in between the wheelchair and toilet while trying to go to the bathroom. The resident was wearing gripper socks and shoes at the time of the fall. 8. R12's IDT (Interdisciplinary team note) falls note documents, 1/5/19 19:00- IDT note concerning un- witnessed fall with minor injury to the mid back (abrasion). The resident was found in his bathroom sitting on the floor on 01/05/19 at 0500. 9. R12's IDT (Interdisciplinary team note) falls note documents, 1/18/19 21:30- IDT note concerning unwitnessed fall without injury on 1/18/19. Nursing was notified by wife of the resident had sustained a fall. Nursing found resident laying on the floor beside the bed. The facility updated the plan of care to include: 01/19/19- therapy to eval (evaluate) related to fall; 10. R12's IDT (Interdisciplinary team note) falls note documents, 3/19/2019 13:50- IDT note concerning unwitnessed fall without injury on 3/19/19 at 1350. Resident was found on the floor sitting on his butt on the floor next to the bed. The resident stated I slid out of bed. Resident has no c/o pain or discomfort. The facility updated the plan of care to include: 3-19-19-Put facility bedspread and blanket on bed--not personal one that is slippery- R12 agrees. 11. R12's IDT (Interdisciplinary team note) falls note documents, 3/27/2019 21:30- IDT note concerning unobserved fall on 3/27/19 without injury. The resident was located in the bathroom at 2130 resident stated he was attempting to transfer from WC to toilet when he lost his balance. 12. R12's IDT (Interdisciplinary team note) falls note documents, 3/28/2019 11:15- IDT note concerning unobserved fall on 3/28/19 with injury, hematoma to the forehead, redden area to shoulder and skin tear to R hand 1st knuckle. The resident was located in the bedroom at 1115 resident stated he was attempting to transfer from WC to bed when he lost balance. R12's Hospital Discharge History and Physical notes document, Patient is an [AGE] year old gentleman who presents to the emergency department from Ridgewood Care Center for chief complaint of unwitnessed fall He experienced an unwitnessed fall today. It is speculated that he tried to get up from the wheelchair and fell forward hitting his head .He was brought to the emergency department where he was found to have a C1 fracture. Under the Radiology section it documents, Impressions: Minimally displaced fracture involving the left anterior and posterior arch of C1. Surveyor noted that R12's Significant Change in Status MDS (Minimum Data Set) dated 4/5/19 documents in section J1900 (Number of Falls Since Admission or Prior Assessment) that R12 has experienced 1 fall with major injury that included R12's fall resulting in a fracture on 3/28/19. The facility updated the plan of care to include: 3/28/19 PT to eval upon return from hospital. 13. R12's IDT (Interdisciplinary team note) falls note documents, 4/4/2019 22:34- IDT note concerning unwitnessed fall without injury on 4/4/19 at 2225. Resident found on the bathroom floor lying on his right side next to his w/c. Resident stated he was trying to get off the toilet and sit back in his w/c. The facility updated the plan of care to include: 4-4-19- Maintenance to assess w/c and anti-roll backs. 14. R12's IDT (Interdisciplinary team note) falls note documents, 4/9/2019 06:50- IDT note concerning unwitnessed fall without injury on 04/09/19 at 0650 AM in the resident room. The resident was located beside his wheelchair on the floor sitting on his buttocks when he was found and he states he slid out of his wheelchair. Nursing assessed the resident and noted no injury. Denies hitting head. The facility updated the plan of care to include: 4-9-19- all non-pharm (pharmacological) interventions in place- inc (included) in [MEDICATION NAME] and mood stabilizer. 4/9/19 encourage more activities and activities in dayroom, staff is close by for assistance. R12's Falls CAA dated 4/10/19 documents under the Analysis of Findings section, Recently hospitalized following fall and resulting in traumatic minimally displaced C1 cervical fracture, hx (history) of multiple falls, unsteady gait, balance problems during transitions, received antidepressant medications. On cervical collar 8-12 wks (weeks), is able to make needs known but confused at time, behavior combative, refuses cares, yelling out. Reported two episodes of falls since admission without injury, maintained safety measures, at risk for falls. Under the Care Plan Considerations section it documents, Will not experience any additional injury related falls. Will use call light for needs and wait for staff to respond, will demonstrate behaviors consistent with preventative measures, monitor risk for falls. 15. R12's IDT (Interdisciplinary team note) falls note documents, 5/7/2019 06:00- IDT note concerning unwitnessed fall without injury on 5-7-19. (R12) was located in his bathroom attempting to reach for his pull-ups and slide from his w/c to the floor without injury. He activated his call lite after the fall. The plan of care was updated to include: 5-7-19 provided a Reacher (able to return demo). 16. R12's IDT (Interdisciplinary team note) falls note documents, 5/31/2019 07:20- The IDT feels the resident would benefit from a room closer to the nurse's desk, but he declines as he wants his own room, no roommate at this time due to no one appropriate at this time. The facility updated the plan of care to include: 5-31-19 offered a closer room toward the desk-no. 17. R12's IDT (Interdisciplinary team note) falls note documents, 6/3/2019 01:00- IDT note concerning unwitnessed fall without injury on 6-3-19. The resident was located in his bathroom on the floor was just checked approx. 1 hour prior and was sleeping in bed. Stated he slipped off the toilet, no light activated. Has dementia feels he can do this himself. Nursing assessed the resident and noted no injury. The facility updated the plan of care to include: 6-3-19 Added a night time scheduled toileting, if awake. (see Urinary Care Plan). 18. R12's IDT (Interdisciplinary team note) falls note documents, 6/4/2019 17:10- IDT note concerning unwitnessed fall without injury on 6-4-19 at 5:10pm. (R12) was on the floor by his bed lying on a blanket was attempting to get up, had been napping. Had stated he was sleepy and didn't want to eat, when asked approx. 1/2 hour before. The body pillow was in place. The bed was in low position. The facility updated the plan of care to include: 6-4-19 Bring up to dining room approx. 4:30pm; 6-6-19 Urinalysis ordered. 19. R12's IDT (Interdisciplinary team note) falls note documents, 6/9/19 11:30- IDT note concerning unwitnessed fall without injury on 6-9-19. (R12) was on the floor attempting to get into bed. had grippy socks on and found with one shoe on. He was dry with no bathroom needs. The facility updated the plan of care to include: 6-9-19 Encouraged to be in a common area in view; 20. R12's IDT (Interdisciplinary team note) falls note documents, 6/10/2019 10:19- IDT note concerning unwitnessed fall without injury on 6-6-19. The resident was located in his room at 0800 and was found next to his bed on the floor stating he slipped. 21. R12's IDT (Interdisciplinary team note) falls note documents, 6/12/2019 14:25- IDT note concerning unwitnessed fall without injury on 6-12-19 in his room, was checked on 3 separate times and the last being 5 minutes prior to fall, was asked if he needed to use the bathroom, if he needed help as he was looking thru his bed side stand. No injury. Nursing assessed. 22. R12's IDT (Interdisciplinary team note) falls note documents, 7/7/2019 3:23- IDT note concerning unwitnessed roll form his bed at approx. 0315 on 7-7-19 without injury.(R12) stated he didn't fall he slid out of bed. Nursing assessed the resident and noted no injury. MD notified. 23. R12's IDT (Interdisciplinary team note) falls note documents, 7/10/2019 08:47- IDT note concerning unwitnessed fall without injury on 7-10-19 at [MEDICAL CONDITION]. The resident was located in the room next to his bed, said he slid off for no particular reason. The facility updated the plan of care to include: 7-10-19- Encouraged to get up out of bed earlier in the morning. Surveyor asked DON-B if the facility had additional information regarding if R12's bed was in the low position when R12 fell on [DATE], as the information was not documented in R12's 7/10/19 fall investigation. Surveyor informed DON-B that per R12's falls plan of care, R12's falls intervention on 3/26/18 documented that R12 was supposed to have a low bed while in bed, thus this intervention should be documented in R12's fall investigation. DON-B reviewed the fall investigation with Surveyor and informed Surveyor that she could not provide any additional information regarding 7/10/19 fall. 24. R12's IDT (Interdisciplinary team note) falls note documents, 7/19/2019 23:35- IDT note concerning unwitnessed fall without injury on 7-19-19 at 2335in his room slid form bed. (R12) stated he was attempting to get up and slid out of bed. Nursing assessed him and noted no injury occurred. The facility updated the plan of care to include: 7-19-19 sidewall mattress. In addition to the above documented falls, Surveyor also reviewed fall investigation reports for R12's falls that occurred on 9/21/18, 10/2/18, 3/3/19 and 6/6/19. On 7/23/19 at 10:47 a.m., Surveyor asked DON-B why R12 did not have any additional supervision interventions that were specific to how often and how frequently R12 should be supervised while in his room, as the majority of R12's falls occurred while in his room. DON-B informed Surveyor that due to R12's resident's rights, supervision was not added to R12's plan of care while in the room. On 7/25/19 at 11:24 a.m., DON-B added that R12's wife was frequently in his room supervising him and that while facility staff did frequent checks on R12, interventions were not well documented in R12's plan of care to prevent falls while R12 was in his room. DON-B informed Surveyor that she could not provide any additional information as to why R12 did not have adequate supervision while in his room to prevent falls and accidents. 2) R139 has [DIAGNOSES REDACTED]. R139 was hospitalized [DATE]-6/17/19 with discharge [DIAGNOSES REDACTED]. Progress notes prior to the hospitalization document 6/14/2019 13:55 (1:55 PM) SBAR (Situation, Background, Assessment, Response) - Change of Condition Situation: Resident had a hypoxic episode while taking his meds 1 by 1. refused to have them crushed. Resident did expel the pill on his own. Spo2 dropped to 30% applied o2 and spo2 went to 86%. Alert and could respond verbally. Background: History of [MEDICAL CONDITION] stricture Assessment: b/p 151/86 T 99.1 HR 71 86% 5L Response: Notified (nurse practitioner) received order to send to ER for Eval . R139 was hospitalized [DATE]-6/11/19 following a choking episode. Progress notes document 6/8/2019 13:30 (1:30 pm) Nurses Note Note Text: writer was called to resident room for a chocking/coughing episode, resident was sitting up and having a hard time breathing, resident vitals was checked , bp 102/68,pulse 58, o2 at 80% RA, oxygen was put on resident at 2 liters, after 2 mins o2 was 84%, at 3 liters of oxygen o2 was at 88%, at 4liters o2 at 90% stable at 90% at 4 liters of oxygen . R139's Admission Minimum Data Set Assessment, dated 6/7/19, documents R129 required supervision of 1 person's physical assistance for eating. R139's plan of care includes a focus area of Swallow (Impairment) Decreased Cognition Interventions include SWALLOW GUIDELINES: Thin liquids, Eat slowly, sit upright, sitting position, head & trunk in midline in wc (wheelchair) preferably. Alternate solids and liquids. Small bites/small sips. Take single sips with straw, double swallow every bite, Requires 1:1 supervision during meals with verbal cues initiated on 6/4/19 and revised 6/19/19. Speech therapy notes on 7/4/19 document .Pt (patient) safely swallowing pureed diet w/ (with) thin liquids under nursing supervision/cueing. On 07/17/19 at 12:43 PM the surveyor observed R139 in the dining room. The surveyor observed R139 had pureed peas, ham, and potatoes. The surveyor observed staff entering and leaving the dining room, at times with no staff in the dining room. The surveyor observed no staff sitting next to R139 while eating. On 7/23/19 at 9:18 AM the surveyor interviewed ST (speech therapist)-Z. the surveyor asked ST-Z what 1:1 supervision with meals means. ST-Z informed the surveyor when someone sits with the resident at meals. On 7/23/19 at 3:17 pm the surveyor informed Administrator-A and Director of Nursing B of the observation of R139 not being provided 1:1 supervision with meals. 3.) The facility policy and procedure entitled Elopement dated 9/16/2018 states: PURPOSE: 1. To identify residents at risk for unsafe wandering and exit seeking behavior. 2. To develop individualized prevention and management interventions based on Exit Seeking /Elopement evaluation. PR[NAME]EDURE: 1. Complete admission evaluations . 2. Review evaluations and risk factor data. 3. Determine if the resident is at risk for elopement. 4. Include resident and family/responsible party in development of the Plan of Care. 5. Develop individualized interventions . 9. Review and revise Plan of Care as needed. ELOPEMENT - MANAGEMENT: POLICY: The interdisciplinary team will re-evaluate cognitively impaired residents/patients who have attempted, unsuccessfully or successfully, to leave the facility without staff knowledge. With the assistance of the resident/patient and family/responsible party, individualized interventions will be developed and initiated to manage the elopement behavior. PR[NAME]EDURE: 1. Determine the following: a. Was the resident/patient trying to leave the facility? b. If yes, ask the resident/patient where and why they were trying to go. 2. Re-evaluations may include the following: a. Nursing Comprehensive Admission, Re-admission, Significant Change and Quarterly Evaluation. b. Exit Seeking/Elopement Risk Evaluation. c. Social Service Assessment. d. Activities Assessment. 3. Determine if there is a pattern to the exit seeking behavior. 4. Evaluate the risk factors identified on the Exit Seeking /Elopement Risk Evaluation. 6. Review and revise individualized interventions that may prevent further elopement attempts . 9. Evaluate and document effectiveness of revised interdisciplinary interventions. 10. Review and revise Plan of Care as needed. On 1/9/2019, R99 was admitted to the rehabilitation unit with [DIAGNOSES REDACTED]. On admission, R99 was assessed as being a high risk for wandering. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated R99 had a Brief Interview for Mental Status (BIMS) score of 06 showing severe cognitive impairment. R99 was not coded as having wandering behaviors. On 2/11/2019 at 12:03 PM in the progress notes, nursing charted R99's Power of Attorney (POA) was contacted regarding R99's wandering behavior and concerns for R99's safety. A wander guard safety device was placed on R99. A Wander Risk Assessment was completed with a score of 11 indicating R99 was at moderate risk for wandering. R99's wandering care plan was initiated on 2/11/19 with the following interventions: maintain safe environment and structured routine for R99; assess R99 for thirst, hunger, or pain and need for voiding assistance; assess R99 for presence of wandering behavior, noting time, place, and people whom they ambulate with; and assess specific reasons for wandering if R99 is able to verbalize motivation. The wander guard that was implemented on 2/11/2019 was added to the Treatment Administration Record (TAR) on 2/26/2019 to check for placement and function every shift. The wander guard was not added to R99's wandering care plan at that time. On 2/14/2019 at 12:07 AM in the progress notes, nursing charted R99 was found outside the building walking with a walker at the beginning of second shift on 2/13/2019. No time was documented of the elopement. R99 had exited the rehab unit door with the wander guard on. R99 did not sustain any injuries; R99 commented they were cold. R99 was placed on the 24-hour board and checked throughout the shift. A Wander Risk Assessment was not completed. A skin assessment was completed 2/14/2019 at 9:04 AM, eighteen hours after the elopement. The interdisciplinary team (IDT) investigation showed R99 exited through a secure door on 2/13/2019 at 2:30 PM. The alarm was activated and staff reacted immediately, bringing R99 back into the building. Staff statements were obtained and R99 was moved to a room closer to the nurses' station. R99's wandering care plan was not revised. On 2/15/2019 at 1:16 PM in the progress notes, nursing charted R99 had been wandering on and off the unit throughout the shift and exited the building through the rehab unit door with the wander guard in place. R99 was escorted back into the facility immediately and brought to the nurses' station for closer observation. No time was documented of the elopement. A Wander Risk Assessment was not completed. R99's wandering care plan was not revised. The IDT investigation stated R99 exited the facility through a secure door on 2/15/2019 at 1:15 AM, twelve hours before the nursing progress note was written. The alarm was activated and R99 was followed by a staff member and brought back into the facility. The nurse that entered the progress note was the only staff member interviewed. The documentation of action taken states R99 will be monitored for seven days and will adjust medications accordingly; see [MEDICAL CONDITION] medication assessment. The [MEDICAL CONDITION] Medication Assessment was completed on 2/22/2019 indicating R99's care plan was reviewed and updated. On 2/21/2019, six days after the most recent elopement, R99's wandering care plan was revised to include the following intervention: when wandering with out reason check and change, offer toileting and snacks. On 3/2/2019, a Wander Risk Assessment was completed with a score of 14 indicating R99 was at high risk for wandering. The wander guard, which had been placed on R99 on 2/11/2019, was added to R99's wandering care plan. On 3/14/2019 at 10:56 PM in the progress note, nursing charted R99 was returned to the unit at 4:30 PM by therapy staff after R99 attempted to exit the building through a secured therapy exit door. A statement from the therapist was obtained stating R99 comes to the therapy department daily between 3:30 PM and 4:30 PM, but no IDT documentation was provided. R99's care plan was not updated. No Wander Risk Assessment was completed. On 4/24/2019 at 8:53 PM in the progress notes, nursing charted R99 attempted to leave the building. R99 was seen packing clothes wanting to go home and asking staff which door R99 could go out. R99's wander guard was functioning and R99 was placed on one-to-one supervision and the nurse practitioner changed the dosing of [MEDICAL CONDITION] medications. No IDT documentation of an investigation was provided for the 4/24/2019 elopement attempt. R99's wandering care plan was not revised. On 6/29/2019 at 4:30 PM in the progress notes, nursing made a late entry stating at 4:30 PM a visitor came to the nurses' station inquiring if R99 was a resident at the facility. R99 was seen outside the facility. Staff left the building to locate R99. R99 was ambulating off the facility grounds with a wheeled walker. R99 was brought back to the facility without incident. A head-to-toe assessment was completed with no signs of distress. Food and fluids were offered. When asked where R99 was going, R99 stated, over to (name's) house, he lives right down the street. The secure door had not alarmed when R99 left through the main doors, but alarmed when R99 was brought back into the building indicating the wander guard was functioning. 15-minute checks were initiated. On 6/30/2019 an Elopement Risk Assessment was completed indicating R99 is at risk for elopement. The investigation of the elopement included statements from staff. On 6/30/2019, R99's wandering care plan was revised with the following interventions: 6/29/19-elopement response Md notified, POA notified, assessed for any injuries or changes in condition, 15 minute checks, checks completed to ensure the residents wander guard is functional as well as door being checked. 6/29/19 Offer to walk with resident prior to supper and offer discussion including but not limited to; hobbies, interests, music and memories with spouse. After walking, or if declines walking, offer for me to sit down at a table with coffee/drink and appetizer, prior to supper. On 7/1/2019, R99's wandering care plan was revised with the following interventions: 6/10/19 -Please request that the Guardian check in at nursing station after visiting to help the resident adjust to the guardian's departure and ensure safety and encourage distractions to reduce upset and exit seeking behaviors 05/21/19 New orders to document number of times resident request to go home or exit seeks 02/13/19 at 1430 attempted to leave facility/ staffed followed and guided resident back into the facility; Move resident to a room closer to nursing station; POA notified- consent obtained; NP aware; 02/15/19 attempted to leave facility grounds/ staff followed and guided resident back into building - continue to orientate resident to new room if continues to exit seek NP, in collaboration with psych MD, to review medications and adjust accordingly -; 2/22/19 N.O. to decrease ariprprazole to 5mg daily r/t (related to) [DIAGNOSES REDACTED]. After walking, or if declines walking, offer for me to sit down at a table with coffee/drink and appetizer, prior to supper. 02/13/19 If resident is exit seeking please re-direct. Resident loves to walk please walk with her to get out some of her energy and give her companionship and encourage her to socialize with peers. 6/10/19 POA visiting and upon departure resident had increased exit seeking behaviors- On 7/2/2019, R99's wandering care plan was revised to include: If resident is asking to go home and packing up belongings please remind her that this is her home and help her feels (sic) safe and secure in her home and assist her with unpacking. On 7/16/2019 at 9:36 AM, R99 was observed in a wheelchair self-propelling down the hallway toward R99's room using the hand rail on the wall to continue the forward motion. No staff was in the area at that time. R99 complained of having to use the bathroom frequently. On 7/18/2019 at 9:52 AM, R99 was observed coming out of the bathroom in R99's room. R99 self-transferred into the wheelchair and wheeled out of the room into the hallway. Registered Nurse (RN)-L was down the hall and did not observe R99 in the bathroom. On 7/22/2019 at 9:58 AM, Surveyor interviewed Receptionist-D regarding the secured main entrance doors. Receptionist-D stated the doors can only be unlocked by pushing a button under the reception desk or on the inside of the entrance door and cannot remain unlocked without either buttons being pushed. If a resident has a wander guard on, the door will not open even when the button is pushed. On 7/22/2019 at 10:02 AM, Surveyor interviewed Maintenance Director-E regarding the security system. Maintenance Director-E stated there is an antenna on the left side of the doorway and R99's wander guard was on the right side, missing the area covered by the antenna. Maintenance Director-E and Nursing Home Administrator (NHA)-A were able to intermittently duplicate the malfunction of the alarm system at the main entrance. The security company was contacted and the area covered by the antenna was increased to prevent any further elopements with the alarm not going off. The exit doors throughout the facility had been tested monthly and are now tested weekly as well as the monitors at the reception desk and at each of the four unit nurses' stations. Maintenance Director-E confirmed the main entry doors cannot be unlocked and remain locked. On 7/22/2019 at 10:52 AM, Surveyor interviewed Social Services (SS)-F regarding R99's wandering and elopements. SS-F stated R99 has wandering behavior and is involved with the behavior aspect of R99's care plans. Elopements are reviewed in the morning report, but the IDT does not meet specially for elopements. Elopement risks are reviewed quarterly for the MDS. SS-F does not review or revise the wandering care plan. On 7/22/2019 at 11:36 AM, Surveyor interviewed Activities-G regarding interventions in R99's care plan. Activities-G stated R99 is invited to activities and often participates. If R99 starts to wander away from the activity, the staff tries to redirect R99 as part of R99's care plan states. On 7/22/2019 at 11:54 AM, Surveyor interviewed RN Unit Manager (RN UM)-H regarding the process the facility uses when a resident elopes or tries to elope. RN UM-H stated the resident is assessed after an elopement for injury or pain. The Director of Nurses and the Administrator are notified of the elopement. Statements are obtained of all staff on the unit that would have knowledge of the incident or when the resident was last seen. The care plan is reviewed and revised with new interventions specific to that elopement. The physician and family are notified and the resident is monitored. When asked if elopements are discussed at an IDT meeting, RN UM-H stated the elopements are brought up in the morning stand up meeting. When asked specifically about R99, RN UM-H stated R99 is typically verbally redirected. R99 is always being watched by the staff on the unit and redirected as needed. R99 has a tendency to self-isolate and RN UM-H prefers R99 to be in the TV room on the unit for easy visualization. When asked if the intervention of having R99 in the TV room for close supervision was part of R99's wandering care plan, RN UM-H stated it should be. On 7/22/2019 at 12:22 PM, Surveyor interviewed Speech Therapist (ST)-I regarding R99's cognition and elopement attempts. ST-I stated R99 was on the speech therapy case load from 6/4/2019 to 7/1/2019 to help with safety when using the walker. R99 often forgot to lock the brakes on the walker increasing the risk for falls. When asked about R99's elopement on 6/29/2019, ST-I stated ST-I had heard about the elopement but wasn't consulted to help develop interventions to prevent elopements. On 7/22/2019 at 2:11 PM, Surveyor interviewed Licensed Practical Nurse Unit Manager (LPN UM)-J, the unit manager when R99 attempted to elope 4/24/2019. LPN UM-J stated the IDT meets and reviews the assessments for elopement and dementia to come up with interventions. R99 was put on one-to-one supervision tempor

Based on observation, interview, and record review, the Facility did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 3 (R63, R160 & R163) of 29 Residents at risk. * R63 developed pressure injuries on her right and left buttocks which were not assessed by an RN (Registered Nurse), the skin integrity care plan was not revised after development of these pressure injuries and the pressure injuries are not always staged. R63's heels were observed not being offloaded. * R160 & R163 are at risk for developing pressure injuries and were observed without their heels being offloaded. Findings include: 1.) R63's [DIAGNOSES REDACTED]. R63's power of attorney for healthcare was activated on 7/12/17. The skin integrity impairment actual or potential for immobility care plan initiated 12/17/17 has interventions also dated 12/17/17 of Assist with general hygiene and comfort measures., Clinical team will inspect skin q (every) shift and as needed, document condition and report changes., Dietary Consult, Keep linen dry, clean and free of wrinkles, Monitor nutritional intake; maintain adequate hydration, and Use preventative skin care devices as needed, foam/air mattress, chair cushions, pillows. The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. The nurses note dated 2/1/2018 documents Resident noted to have a 11cm area to right inner buttock, with a small intact blister to center at brief line. No s/s (signs/symptoms) discomfort noted, will continue with barrier cream , CHART PULLED FOR md. (medical doctor). The quarterly MDS (minimum data set) with an assessment reference date of 2/3/18 documents short & long term memory problems and severe impairment for cognitive skills for daily decision making. R63 requires extensive assistance with one person physical assist for bed mobility, extensive assistance with two plus person physical assist for transfer & toilet use, does not ambulate, and is always incontinent of bowel and bladder. R63 is at risk for pressure injuries and is coded as not having any pressure injuries. On 4/9/18 at 10:13 a.m. Surveyor asked RN/MDS (Registered Nurse/Minimum Data Set)-LL if R63's quarterly MDS with an assessment reference date of 2/3/18 should have been coded as a Stage 2 pressure injury. RN/MDS-LL replied yes, we will correct it and informed Surveyor the MDS nurse that completed this assessment is no longer employed at the Facility. The weekly skin review dated 2/7/18 documents for site right buttocks. Under description documents Area to right buttock measures 0.4 x (by) 1.2 x 0.1, wound bed red granulation tissue, surrounding skin pink and intact, no drainage noted, no c/o (complaint of) discomfort. Area to right inner thigh measures 0.3 x 1.3 x 0.1 wound bed pink granulation tissue, surrounding skin pink and intact, no drainage noted, no c/o discomfort. Surveyor noted R63 pressure injury is not staged and there is no revision in R63's care plan. The weekly skin review dated 2/14/18 documents for site right buttocks. Under description documents Area to right buttock measures -.3 x 1.1 x 0.1, wound bed red granulation tissue, surrounding skin pink and intact, no drainage noted, no c/o discomfort. Area to right inner thigh measures 0.3 x 1.2 x 0.1 wound bed pink granulation tissue, surrounding skin pink and intact, no drainage noted, no c/o discomfort. Surveyor noted this assessment was completed by LPN (Licensed Practical Nurse)-II. Surveyor noted there is no RN (Registered Nurse) assessment, the pressure injury is not staged and there is no revision in R63's care plan. Surveyor noted there is no assessment a week after the 2/14/18 for 2/21/18. The nurses note dated 2/28/18 documents Areas to right inner buttock are improving. No s/s of infection noted. Resident denies any pain or discomfort. Will continue to monitor. The weekly skin review dated 3/1/18 documents under site right buttock. Under description documents 1.5 cm (centimeter) x 1.0 cm dried stage 2 pink. Under site documents left buttock. Under description documents 0.5 cm x 0.6 cm dried stage 2, pink. Surveyor noted this assessment is 18 days later and there continues to be no revision in R63's care plan. The weekly skin review dated 3/7/18 under site documents Right buttock. Under description documents area to right inner buttocks is resolving. Area measures 0.5 cm x 0.3 cm and is light red in color. no s/s of infection noted. resident denies any pain or discomfort will continue to monitor. Surveyor noted there is no stage, there no assessment of the left buttocks, and no revision in R63's care plan. The weekly skin review dated 3/12/18 documents skin intact. The weekly skin review 3/18/18 only documents bruise right axilla. The weekly skin review dated 3/21/18 documents under site Right buttock. Under description documents Area measures 2 cm in length and 0.5 cm in width. Wound bed is red in color. No drainage noted. No s/s of infection noted. Chart pulled for MD to request a new Tx. Awaiting response from MD. Under site documents Left buttock Under description documents Area measures 2 cm in length and 1 cm in width. Wound bed is red. No drainage noted. No s/s of infection noted. Chart pulled for MD to request a new Tx. Awaiting response from MD. This weekly skin review was completed by LPN-JJ. Surveyor noted there is no stage and there is still no revision in R63's care plan. The nurses note dated 3/21/18 documents Physician-H here for med (medication) review, new orders obtained re (regarding) oas (open areas) to buttocks. The weekly skin review dated 3/25/18 under skin condition is checked for redness and open area. The site and description sections are blank. This assessment was completed by an RN. The weekly skin review dated 3/28/18 for site documents Right buttock. Under description documents OA (open area) remains red in color. No s/s (signs/symptoms) of infection noted. Area is 1.5 cm in length and 0.2 cm in width. No drainage or bleeding noted. Resident denies any pain or discomfort. Will continue with current Tx (treatment). Will continue to monitor. Under site documents Left buttock. Under description documents OA remains red in color. No s/s of infection noted. Area is 3 cm in length and 0.3 cm in width. No drainage or bleeding noted. Resident denies any pain or discomfort. Will continue with current Tx. Will continue to monitor. This was completed by LPN- JJ. Surveyor noted there is no RN assessment or stage and R63's care plan has not been revised. The weekly skin review dated 4/1/18 under site documents Right buttocks. Under description documents OA remains red in color. No s/s of infection noted. Area is 3.5 cm in length and 0.5 cm in width. No drainage or bleeding noted. Resident denies any pain or discomfort. Will continue with current Tx. Will continue to monitor. Under site documents Left buttock. Under description documents OA remains red in color. No s/s of infection noted. Area is 3.5 cm in length and 2.5 cm in width. No drainage or bleeding noted. Resident denies any pain or discomfort. Will continue with current Tx. Will continue to monitor. This was completed by LPN-II. Surveyor noted there is no RN assessment, stage and R63's right & left pressure injury declined without any revision to the care plan. On 4/5/18 at 7:44 a.m. Surveyor observed R63 in bed on her back with the head of the bed elevated. Surveyor observed R63's heels are resting directly on the mattress and are not being offloaded. On 4/5/18 at 8:23 a.m. Surveyor observed LPN-C place gloves on, placed soap & water on a wash cloth and inform R63 she was going to change her bottom. LPN-C unfastened the incontinence product and R63 was positioned on her side. Sruveyor observed the back of R63's right heel has a reddened area the approximate size of a half dollar. LPN-C removed the dressing from the left buttocks, wiped the pressure injury with the wash cloth and informed Surveyor she measured the open area yesterday which was 5.5 cm by 3 cm and the black part was 1 by 1 cm. At 8:29 a.m. LPN-C asked CNA (Certified Nursing Assistant)-D to keep an eye on R63 as she wants to measure the right side. LPN-C removed her gloves and left R63's room returning at 8:32 a.m. with UM (Unit Manager)-E. LPN-C showed UM-E the area on R63's right buttocks. UM-E informed LPN-C to measure the area and call the doctor. LPN-C measured the right buttocks area indicating 3.5 cm by 0.5 cm. LPN-C then completed the treatment according to physician orders. The weekly skin review dated 4/8/18 documents under other pre-existing o/a to coccyx. On 4/9/18 at 7:34 a.m. Surveyor observed in bed on back with heels resting directly on the mattress. On 4/9/18 at approximately 8:00 a.m. Surveyor asked CNA-HH if Surveyor could look at R63's heels with her. Surveyor entered R63's room with CNA-HH. CNA-HH removed the bedding from R63, Surveyor observed R63's heels were resting directly on the mattress. CNA-HH removed R63's socks. Surveyor observed R63's right heel had a redden area the approximate size of a half dollar. Surveyor asked CNA-HH if she could lightly press on R63's right heel with her finger which CNA-HH did. Surveyor asked CNA-HH if the area stayed red or turned white. CNA-HH informed Surveyor the area stayed red. On 4/9/18 at 11:35 a.m. Surveyor spoke with UM-E regarding R63's pressure injuries. Surveyor asked UM-E where the stage of R63's pressure injury would be on the weekly skin review. UM-E informed Surveyor the weekly skin review doesn't ask for staging so they probably didn't stage it. Surveyor informed UM-E Surveyor noted only one wound evaluation sheet dated 3/23/18 and asked when this form would be completed. UM-E replied That's a very good question. Surveyor inquired how often pressure injuries are assessed. UM-E informed Surveyor they are completed weekly normally on Wednesday by the nurse that is working that day. UM-E informed Surveyor the definition of skin assessment has changed in the past couple of months and sometime in (MONTH) or (MONTH) they found out there is a wound evaluation form in the computer that could be used to document wounds. UM-E informed Surveyor the only form that asks for staging is the wound evaluation form. Surveyor inquired if there is a wound team. UM-E replied no. UM-E explained that she tries to observe any pressure injuries Tuesday to Thursday so she knows if they get worse. UM-E informed Surveyor there is a wound nurse available if the wound is getting worse or for change in treatment. Surveyor inquired if the wound nurse who is employed at the Facility does rounds on UM-E's unit. UM-E replied no. Surveyor asked why she doesn't. UM-E replied I plead the fifth and explained they don't use the wound nurse here as other facilities do. Surveyor informed UM-E there wasn't any assessment on (MONTH) 21st and asked if R63's pressure injury was healed. UM-E replied yes, that's what I would assume, may have been real faint or light. UM-E looked into the computer then informed Surveyor she was looking at the wrong one and there is missing documentation. Surveyor informed UM-E the weekly assessment dated [DATE] indicates skin intact and asked if the pressure injuries were healed. UM-E replied no I know it wasn't. Surveyor asked UM-E when would an RN assess R63's pressure injuries. UM-E informed Surveyor she didn't think there is a policy that an RN has to assess. UM-E informed Surveyor she looks at the wounds. Surveyor inquired if makes any documentation. UM-E replied No, like I said there isn't a policy that I'm aware of that an RN has to assess. Surveyor informed UM-E Surveyor also noted there was no change in R63's skin integrity care plan after she developed the pressure injuries and asked who is responsible for updating the care plan. UM-E informed Surveyor the nurse on the unit who is caring for R63 is responsible. Surveyor informed UM-E of the observations of R63's heels not being offloaded. The Prevention and treatment of [REDACTED]. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Repositioning for preventing heel pressure ulcers include the following: Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure a state sometimes called 'floating heels'. Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Heel suspension devices are preferable for long term use, or for individual who are not likely to keep their legs on pillows. 2.) R160's [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The quarterly MDS (minimum data set) with an assessment reference date of 3/16/18 documents a BIMS (brief interview mental status) score of 9 which indicates moderately impaired. R160 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, and does not ambulate. R160 is at risk for pressure injury development and is coded as not having any pressure injuries. The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. On 4/3/18 at 12:33 p.m. Surveyor observed R160 in bed on his back with a pillow under R160's calves. Surveyor observed R160's heels are resting directly on the mattress and are not being offloaded. On 4/3/18 at 2:13 p.m. Surveyor observed R160 continues to be in bed on his back with his heels resting directly on the mattress. On 4/3/18 at 3:23 p.m. Surveyor observed R160 continues to be in bed and is on his right side. Surveyor observed R160's heels are resting directly on the mattress and are not being offloaded. On 4/4/18 at 8:08 a.m. Surveyor observed R160 in bed on his right side. There is a pillow under R160's calves but R160's heels are resting directly on the mattress and are not being offloaded. On 4/9/18 at 7:33 a.m. Surveyor observed R160 in bed on his back, the head of the bed is elevated and tube feeding is on. There is a pillow at the end of R160's bed and not under R160's calves. R160 right foot is crossed over his left and the left heel is resting directly on the mattress. On 4/9/18 at 11:12 a.m. Surveyor asked UM (Unit Manager)-E if R160's heels should be offloaded. UM-E informed Surveyor R160's heels should be floated by a blanket or pillow. Surveyor informed UM-E of the observations of R160's heels not being offloaded. 3.) R163's [DIAGNOSES REDACTED]. R163's Braden assessment dated [DATE] has a score of 15 which indicates low risk. The annual MDS (minimum data set) with an assessment reference date of 3/13/18 documents R163 has short and long term memory problems and is severely impaired for cognitive skills for daily decision making. R163 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, and does not ambulate. R163 is at risk for pressure injury development and is coded as not having any pressure injuries. On 4/3/18 at 1:38 p.m. Surveyor observed CNA (Certified Nursing Assistant)-HH and CNA-T enter R163's room with a hoyer lift. Staff connected the sling to the hoyer lift and R163 was transferred into bed. CNA-HH & CNA-T unhooked the sling from the hoyer lift. CNA-T placed a body pillow on the left side, covered R163 with bedding, and lowered R163's bed down. CNA-T removed her gloves, washed her hands, and left R163's room. Surveyor observed R163's heels were resting on the mattress and were not being offloaded. On 4/3/18 at 2:00 p.m. Surveyor observed R163's heels continue to be resting directly on the mattress. On 4/3/18 at 3:16 p.m. Surveyor observed R163 continues to be in bed with his heels resting directly on the mattress. On 4/9/18 at 11:22 a.m. Surveyor asked UM (Unit Manager)-E if R163's heels should be offloaded. UM-E informed Surveyor staff are using pillows. Surveyor informed UM-E of the observations of R163's heels not being offloaded. UM-E informed Surveyor she didn't think there is an order to offloaded R163's heels. Surveyor informed UM-E staff doesn't need an order to offload R163's heels to prevent pressure injuries.

Based on record reviews and interviews, the facility did not ensure that 1 (Resident #2) of 7 sampled residents, maintained acceptable parameters of nutritional status, specifically body weight, unless the resident's clinical condition demonstrates that this is not possible. Resident #2 had a history of [REDACTED]. Resident #2's weight had been stable between September 2013 until mid January 2014, ranging from 170-176. In mid January 2014, Resident #2's weight increased to 179 pounds. The increased weight was felt to be related to increased [MEDICAL CONDITION], and by 3/8/14, Resident #2's weight was 173 pounds. A dietary note written on 3/3/14, indicates that it was felt that the [MEDICATION NAME] Resident #2 was receiving was ineffective and the [MEDICATION NAME] was discontinued. The note indicated the Registered Dietitian (RD) and nursing will monitor for negative effects from the discontinuation of the [MEDICATION NAME]. Nursing staff documented on appetite daily until 3/15/14. These notes indicate Resident #2's appetite fluctuated, and he preferred snack foods brought by his wife. By 3/25/14, Resident #2 experienced a significant weight loss of 7.6%. On 3/8/2014, Resident #2's weight was 173 pounds and on 3/25/14, his weight was 160 pounds. The Nurse Practitioner (NP) was updated on 3/25/14, regarding Resident #2's weight. The dietitian did not assess Resident #2 after the weight loss, to determine if dietary adjustments were indicated. The care plan was not updated to reflect the weight loss and any new interventions. According to documentation of appetite percentages, Resident #2's appetite continued to decline after the weight loss was noted on 3/25/14. Nursing staff did not address Resident #2's appetite in the nursing notes after 3/25/14, but did address refusals for weekly weights. Resident #2 was hospitalized for [REDACTED]. Findings include: Surveyor # reviewed Resident #2's record as part of a complaint investigation on 4/29-5/1/14. Resident #2 had been admitted to the facility in November of 2012, with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set ((MDS) dated [DATE], indicates Resident #2 is independent with eating. An undated care plan identifies a problem of "inappropriate food choices related to heart failure and cognitive impairment as evidenced by many meal refusals, history of supplement refusals and instead eating snack foods brought in by wife; [MEDICAL CONDITION]." The goal date for this problem was 5/22/14, with the listed goals as: Oral/fluid intakes greater than 25%, no significant weight changes, maintain skin integrity, labs within normal limits, tolerate diet without gastrointestinal distress or chewing/swallowing difficulties, maintain independence with eating. A review of weights, printed from Resident #2's computerized medical record, reveals that between 9/28/13 and 1/5/14, Resident #2's weight stayed within a range of 170-175 pounds. On 1/18/14, Resident #2's weight was 179 pounds, then decreased to 173 pounds on 3/8/14. According to a Quarterly Nutritional Assessment written by Registered Dietitian (RD)-A and dated 2/18/14, Resident #2 had a current weight of 176 pounds, which was a 2% weight increase in 30 days, and a 10% weight increase in past 180 days. The note summarized Resident #2's refusal of 1-2 meals per day and eating 25-100% at other meals, and referenced nursing documentation of resident meal refusals but eats "junk" foods brought by wife. "Weight gain appears to be related to [MEDICAL CONDITION] and possibly increased snacking... Resident has a history of refusing supplements. Current diet regimen seems appropriate and the best we can do at the moment given the resident's acceptance of interventions." An Interdisciplinary Care Conference progress note dated 2/27/14, indicates weight increase attributed to recent LE (lower extremity) [MEDICAL CONDITION]. According to a dietary note dated 3/3/14, Resident #2's [MEDICATION NAME], which had been ordered as an appetite stimulant, was discontinued because Dietitian-A and the nursing staff felt it was ineffective on the appetite of Resident #2. The note states, "RD and nursing will monitor for negative effects resulting from this." A review of nursing documentation reveals that between 3/3/14 and 3/14/14, nursing staff documents daily on appetite, fluid intake and frequency of eating snacks provided by wife. Between 3/15 and 3/25/14, there is no documentation regarding appetite/fluid intake or snacks eaten with the following exceptions: On 3/18/14, at 11:36pm, nursing documents Resident #2's usual amount eaten is 0-25%. On 3/21/14, there is a note referencing a family telephone conference in which one of the subjects discussed is that Resident #2's appetite is unchanged following the discontinuation of the [MEDICATION NAME], and that his weight is fairly stable. This note mentions that the dietitian was notified of the need for a consult regarding likes and dislikes per Power of Attorney (POA) request. Nursing documentation on 3/25/14, indicates a reweigh was obtained and Resident #3's weight is 160 pounds. Surveyor # calculated Resident #2's weight loss using the monthly weight of 3/8/14 (173 pounds) and the reweigh of 3/25/14 (160 pounds). Between 3/8/14 and 3/25/14 (17 days), Resident #2 experienced a severe weight loss of 7.6% (13 pounds). Facility nursing staff monitored Resident #2's lower extremity [MEDICAL CONDITION] through measurements of the calf, ankle and instep. On 3/8/14, when Resident #2's weight was 173 pounds, Resident #2's measurements were: (All measurements in centimeters with 2.5 cm equaling 1 inch) Right calf 38, ankle 25, instep refused Left calf 35, ankle 25, instep refused. On 3/22/14, the day before Resident #2's weight was 161.2 pounds, Resident #2's measurements were: Right calf 35.5, ankle 26, instep 26cm. Left calf 36.5, left ankle 27, instep 25cm. The measurements of the right lower extremity revealed a decrease in [MEDICAL CONDITION], while the measurements of the left lower extremity revealed a slight increase in [MEDICAL CONDITION]. Changes in [MEDICAL CONDITION] could account for some weight loss. A review of the computerized documentation reveals the most recent dietary note was written on 3/25/14. The note commented that Resident #2's likes/dislikes had been discussed, and Resident #2 wanted no changes done except more coffee. "Request will be honored and food alternatives will continue to be offered to improve resident's appetite". The dietary note written 3/25/14, did not mention the 13 pound weight loss. On 5/1/14 at 3:05pm, Surveyor # spoke with RD-A regarding Resident #2's weight loss. When asked if RD-A had been notified of Resident #2's weight loss, RD-A explained that the computerized documentation system used by the facility automatically "triggers" the dietitian of any weight losses. RD-A stated she should have gotten a message of the weight loss when the data was entered into the system by nursing staff. RD-A stated she could not recall if she had received a message or not. RD-A stated she had been unaware that Resident #2 had experienced the severe weight loss. RD-A stated Resident #2 was on her "nutrition at risk" list and as such was reviewed monthly. The monthly review for March 2014, had been completed by RD-A prior to the documented weight loss on 3/25/14. RD-A stated she would have completed her monthly review in mid-April, but by that time Resident #2 had been hospitalized . RD-A stated she tries to complete assessments within a week of weights being entered into the system. RD-A stated she had not assessed Resident #2 after the weight loss in March 2014, but had reviewed the record when told that Surveyor # wanted to speak with her. RD-A stated that weekly weights had been recommended for Resident #2, and that Resident #2 had refused to have his weight taken after 3/25/14. RD-A stated Resident #2 had been refusing supplements, but dietary was providing fortified foods, whole milk and snacks. On 3/25/14, there is a progress note written by Nurse Practitioner (NP)-B, which acknowledges Resident #2's weight of 160 pounds. The note mentions anorexia (lack of appetite) and that Resident #2 was off of the [MEDICATION NAME], on [MEDICATION NAME] and "weight holding on FIS (foods instead of supplements)". A review of nursing documentation from 3/25/14 until 4/11/14, revealed no documentation of Resident #2's appetite or physical status related to weight loss. Nursing documentation revealed refusals of weekly weights on 3/29, 4/5 & 4/10/14. On 4/11/14, nursing documentation indicates the physician was faxed as a reminder of [MEDICATION NAME] being discontinued, and decreased appetite in thirty days with weight loss. On 4/12/14, Resident #2 refused a weekly weight. On 4/14/14, the physician restarted [MEDICATION NAME]. Surveyor # reviewed the data regarding the percentage of meal intake from 3/1 - 4/14/14. From 3/1/14 through 3/25/14, there was one day (3/2/14) in which Resident #2 refused all three meals in one day. This was 1 of 25 days. From 3/26/14 through 4/14/14, there were 5 days (3/26, 4/1, 4/2, 4/7 & 4/12/14) in which Resident #2 refused all three meals in one day. This was 5 of 20 days, demonstrating an increase in appetite decline. Although nursing staff attempted unsuccessfully to weigh Resident #2 after 3/25/14, there is no evidence that nursing staff conducted a physical assessment, with the exception of monitoring for lower extremity [MEDICAL CONDITION]. A review of Resident #2's plan of care reveals no revision to the care plan related to weight loss and decreasing appetite.

Based on record review, observation, and staff interview the facility did not ensure that 2 of 3 residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ulcers from developing. Resident #2 has facility acquired avoidable stage 2 pressure ulcers on both of the heels. Resident #2 is at risk for pressure ulcer development. Resident #2 has a plan of care to prevent the development of pressure ulcer. The plan of care includes the intervention to elevate the heels when in bed. On the night shift of 10/22/13, staff did not elevate Resident #2's heels off the mattress. As a result of positioning Resident #2's heels directly on the mattress, the resident developed avoidable stage 2 pressure ulcers to both of the heels. Resident #3 has a facility acquired, unstageable pressure ulcer on the left heel. On 11/12/13 Resident #3 was observed to be wearing a tight fitting pair of TED hose. (Compression stockings worn around the leg compressing the limb, exerting pressure against the legs. Unlike traditional socks, compression stockings use stronger elastics to create significant pressure on the legs, ankles and feet). In addition, on 11/12/13, Resident #3 was observed sitting in a wheelchair with the left foot positioned directly on the metal foot pedal of the wheelchair. Resident #3 did not have a pressure redistribution device on the left foot to reduce pressure to the left heel area when positioned in the wheelchair. Findings include: 1. On 11/12/13 Surveyor # reviewed Resident #2's medical record. The record indicates Resident #2 was admitted from the hospital to the facility, on 10/11/13, for aftercare status [REDACTED]. The record review indicates Resident #2 has [DIAGNOSES REDACTED]. The Admission Nursing Assessment, dated 10/11/13, indicates Resident #2 does not have impairment to the skin on the heels. The physician's orders [REDACTED]. The admission Minimal Data Set (MDS), dated [DATE], indicates Resident #2 has a Brief Interview for Mental Status score of 15 (cognitively intact), requires extensive staff assistance for bed mobility and transfers, is at risk for pressure ulcers, and has no pressure ulcers. The plan of care for skin integrity, dated 10/11/13, includes the approach to elevate heels off bed/chair. The Care Area Assessment (CAA) for Pressure Ulcers, dated 10/22/13, indicates Resident #2 is at risk for pressure ulcers due to requiring staff assistance to move sufficiently to relieve pressure over any one site, confined to a bed or chair most of the time. The Nursing Note, dated 10/23/13 at 7:51 a.m., indicates Resident #2 has a stage 2 pressure ulcer to the left heel measuring 3 centimeters (cm) by 4 cm. The note describes the pressure ulcer as a blister that had broken open. The Nursing Note, dated 10/23/13 at 7:54 a.m., indicates Resident #2 has a stage 2 pressure ulcer to the right heel measuring 5 cm by 4 cm. The note describes the pressure ulcer as a blister that is intact. The Nursing note indicates the physician was notified and treatment orders were obtained. The physician's orders [REDACTED]. The plan of care was updated on 10/23/13 to include the approach for a specialty low air loss stage 4 air mattress. The Nursing note, dated 10/30/13, indicates the left and right heel pressure ulcers had noted improvement with the left heel pressure ulcer measured 4.7 cm by 3.6 cm. and the right heel pressure ulcer measuring 3 cm by 4 cm. The Nursing note, dated 11/06/13, indicates the left and heel pressure ulcers had noted improvement with the left heel pressure ulcer measured 4.2 cm by 3.1 cm. and the right heel pressure ulcer measuring 2.8 cm by 3.6 cm. On 11/12/13, 11/13/13 and 11/14/13 the surveyor made observations of Resident #2 and his room environment. The resident had a specialty low air loss stage 4 mattress on his bed and a pressure redistribution device in his wheelchair. There were no foot petals on the wheelchair. On 11/12/13, at 10:00 a.m., the surveyor observed Resident #2's heels. The left heel had an approximate 4.0 cm by 3.0 cm stage 2 pressure ulcer and the right heel had an approximate 2.5 cm by 3.5 cm stage 2 pressure ulcer. On 11/14/13, at 10:10 a.m., Surveyor # spoke with Resident #2. Resident #2 indicated that prior to developing the pressure ulcer on the heels, staff were not elevating his heels off the mattress. Resident #2 indicated that since the development of the pressure ulcers, staff always put pillow under his legs to elevate the heels. On 11/14/13, at 10:35 a.m., Surveyor # spoke with Registered Nurse (RN)-E. RN-E indicated that on 10/23/13, at the beginning of the dayshift, Certified Nursing Assistant (CNA)-F, informed her that Resident #2 had open areas on the heels. RN-E indicated she went into the room to assess Resident #2's heels and noted the heels were not elevated off the mattress. RN-E indicated Resident #2 had stage 2 pressure ulcers on both heels. RN-E indicated that due to Resident #2's recent hip surgery, the resident could not move his lower extremities without staff assistance. RN-E indicated Resident #2 should have had his heels floated off the mattress with the use of pillows and they were not floated. On 11/14/13, at 10:35 a.m., Surveyor # spoke with CNA-F who indicated that when she came to work on the morning shift of 10/23/13, Resident #2 was lying in bed with both heels positioned directly on the mattress. CNA-F indicated she observed open areas on the resident's heels and informed the nurse immediately. On 11/14/13, at 10:45 a.m., Surveyor # spoke with the Director of Nursing who indicated all residents that are at risk for pressure ulcers to the heels, should not have heels positioned directly on the mattress. The DON indicated the heels should be elevated off the mattress with the use of pillow under the calves or the use of a pressure redistribution boot. 2. On 11/12/13 Surveyor # reviewed Resident #3's medical record. The record indicates Resident #3 was admitted from the hospital to the facility, on 10/21/13, for aftercare status [REDACTED]. The record review indicates Resident #3 has [DIAGNOSES REDACTED]. The Admission Nursing Assessment, undated, indicates Resident #3 does not have impairment to the skin on the heels. The admission Minimal Data Set (MDS), dated [DATE], indicates Resident #3 has a Brief Interview for Mental Status score of 13 (cognitively intact), requires extensive staff assistance for bed mobility and transfers, is at risk for pressure ulcers, and has no pressure ulcers. The plan of care for skin integrity, dated 10/21/13, includes the approach to elevate heels off bed/chair. The Care Area Assessment (CAA) for Pressure Ulcers, dated 10/31/13, indicates Resident #3 is at risk for pressure ulcers, requires staff assistance with bed mobility, has no pressure ulcers and wears TED hose to bilateral lower extremities. ( TED hose are anti-embolism stockings/compression stockings worn around the leg compressing the limb, exerting pressure against the legs. Unlike traditional socks, compression stockings use stronger elastics to create significant pressure on the legs, ankles and feet). The Nursing Note, dated 11/06/13 at 6:47 a.m., indicates Resident #3 has an unstageable pressure ulcer to the left heel measuring 2.0 centimeters (cm) by 0.5 cm. The note describes the pressure ulcer as a suspected deep tissue injury, irregular in shape and purple in color. The nursing note included interventions to offload pressure to the area. The nursing note indicates the physician was notified and orders were obtained for [MEDICATION NAME] to the left heel at hours of sleep. The plan of care was updated on 11/06/13 to include the approach to off load pressure to the affected area with pillows. The plan of care did not include the discontinuing of the TED hose to the right lower extremity. On 11/12/13, at 9:45 a.m., Surveyor # spoke with Resident #3 and observed Resident #3 sitting in a wheelchair in the room. Resident #3 was observed to be wearing a tight fitting pair of white TED hose and slipper socks. Resident #3's left foot was observed to be positioned directly on the wheelchair's medal foot pedal. Resident #3 indicated staff have been applying the TED stockings to both of her legs since admission. Resident #3 indicated staff do not elevate her heels off the wheelchair foot pedals and have not provided a pressure redistribution boot for her left foot. On 11/12/13, at 9:45 a.m., Nurse Manager Registered Nurse (RN)-D entered Resident #3's room. Surveyor # spoke with Nurse Manager Registered Nurse (RN)-D who indicated Resident #3 has an Deep Tissue Injury to the left heel and should not be wearing the TED hose as they could prevent the healing of the left heel pressure ulcer. Nurse Manager Registered Nurse (RN)-D indicated Resident #3's heels should be elevated off the wheelchair foot pedals with pillows under the calves or a pressure redistribution boot. On 11/12/13, at 11:00 a.m., Surveyor # and RN-C observed Resident #3's left heel. Resident #3 was observed to have an approximate 2.5 cm by 1.5 cm purple colored Deep Tissue Injury to the left heel. Resident #3 did not have a pressure ulcer to the right heel. The Nursing note, dated 11/13/13, indicates the left heel pressure ulcer had no improvement in the healing process and was measured to be 2.5 cm by 1.5 cm. On 11/13/13, at 8:40 a.m., and on 11/14/13, at 7:55 a.m., Surveyor # observed Resident #3 sitting in a wheelchair in the room. Resident #3 had a soft cloth boot on the left heel and the left foot was positioned on the wheelchair foot pedal. On 11/14/13, at 10:45 a.m., Surveyor # spoke with the Director of Nursing who indicated all residents at risk for the development of pressure ulcer to the heels, should not have heels positioned directly on the foot pedal of a wheelchair. The DON indicated the heels should be elevated off the foot pedals with the use of pillow under the calves or the use of a pressure redistribution boot. The DON indicated the soft cloth boot is used for comfort only and is not considered a pressure redistribution boot.