Every finding on record at Eastcastle PL Bradford Ter Conv CTR

Based on observation, interview, and record review the facility did not ensure residents with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent pressure injuries from developing for 1 (R38) of 4 residents reviewed with pressure injuries.R38 was admitted to the facility on [DATE] and was at risk for the development of pressure injuries. R38's admission assessment does not indicate R38 has pressure injuries. Hospital discharge paperwork dated 12/5/25 does not indicate R38 had pressure injuries or had treatment orders for pressure injuries. On 12/7/25 a registered nurse documents a list of skin concerns including scabbed areas on R38's bilateral heels. These areas are not comprehensively assessed. No treatment orders are obtained from a physician and the risks and care concerns of these areas are not addressed in R38's baseline plan of care. On 12/8/25 the facility Wound Licensed Practical Nurse (LPN)-I documented the bilateral heels to be unstageable. The areas are never comprehensively assessed by a Registered Nurse. During collection of data by Wound LPN-I R38 complains of pain that is not addressed on R38's plan of care. R38 refuses to wear bilateral blue boots however, R38's care plan including the Certified Nursing Assistant (CNA) care card does not include an alternative to address offloading of R38's heels with refusals. R38 self-propels their wheelchair with their feet/heels which is not addressed as a risk factor in the plan of care. On 2/16/26 R38 continued to complain of pain, expressing pain to their right heel during a meal. X-rays of R38's heel were obtained indicating findings suspicious for calcaneal osteomyelitis. Recommend MRI. On 2/18/26 R38 started receiving intravenous (IV) antibiotics.Findings Include:The facility's Prevention of Pressure Injuries dated as revised April 2020 documents:Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors.Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.Risk Assessment1. Assess the resident upon admission for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition.2. Use a standardized pressure injury screening tool to determine and document risk factors.3. Supplement the use of a risk assessment tool with assessment of additional risk factors.Skin Assessment1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge.2. During the skin assessment, inspect:a. Presence of erythemab. Temperature of skin and soft tissuec. Edema3. Inspect the skin on a daily basis when performing or assisting with personal care activities of daily living (ADLs)a. Identify any signs of developing pressure injuries. For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistencyb. Inspect pressure pointsc. Wash the skin after any episodes of incontinenced. Moisturize dry skin dailye. Reposition resident as indicated on the care planSupport Surfaces and Pressure Redistribution1. Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice.Monitoring1. Evaluate, report and document potential changes in the skin2. Review the interventions and strategies for effectiveness on an ongoing basisR38 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Right Side, Vascular Dementia (brain damage caused by multiple strokes), Atherosclerotic Heart Disease of the Native Coronary Artery (plaque buildup narrows the arteries that supply blood to the heart), Essential Hypertension (chronic condition of persistently high blood pressure), Insomnia (sleep disorder characterized by difficulty falling asleep), Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Depression (mood disorder that causes persistent feelings of sadness and loss of interest). Review of R38's hospital discharge documentation does not contain any documentation R38 had unstageable right and left heel pressure injuries in the hospital. There are no physician orders located in R38's hospital record for treatments to the right and left unstageable heel pressure injuries to be carried out upon discharge and admission to the facility.R38's facility Braden Scale for Predicting Pressure Ulcer Risk Evaluation completed 12/6/25 documents R38 is at risk for developing pressure injuries.R38's facility Skin Check completed 12/6/25 documents R38 has no skin issues.R38's facility Clinical admission completed 12/6/25 documents R38 has no skin issues. The Clinical admission does not document that a care plan needed to be initiated for pressure injuries and/or wound management.On 12/7/25, Registered Nurse (RN)-X documented:-Right lateral rib cage-Right outer hip region-Scabbed pinpoint wound to right posterior knee area-Scabbed wound to bilateral heels. Pressure relieving boots introduced but R38 will not keep on.-Left inner foot-Left gluteal and bilateral gluteal crease area-Skin turgor age appropriateSurveyor notes there isn't a comprehensive assessment (including measurements and characteristics of the wound/scab and surrounding tissue) of R38's bilateral heels.R38's undated and incomplete baseline care plan does not document if R38 had any skin issues, wound, or pressure injuries on admission. Areas are circled on the front view of the body image and nothing circled on the back body image; R38's bilateral heels are not identified as areas of concern. R38's baseline care plan has no other documentation related to any pressure injuries located on the right and left heels or need for interventions to address risk for pressure injuries.R38's history and physical data dated 12/8/25 documented by Nurse Practitioner (NP)-S contains no documentation that R38 has any skin issues, including right and left unstageable heel pressure injuries.On 12/8/25, 2 days after admission and same day as NP-S's history and physical, Licensed Practical Nurse (LPN) Wound Nurse (WN)-I assessed R38's right and left heel scabbed areas.Right Heel-First Observation - 12/8/251.3 x 1.0 x 1-Unstageable100% necrosis and/or slough in the wound bed. Surveyor noted it is not specified what type of tissue the necrosis is (scab/possible eschar or slough).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. Surveyor noted the detail of the discoloration still does not clearly identify if it is slough present, eschar/scab, or combination of tissue types. No drainage. Induration (abnormal hardening, thickening or firmness of the surrounding skin and tissue of the wound) of peri-wound tissue with well defined wound edges and shape. No inflammation. Surveyor noted there was no documentation or assessment indicating R38 had induration of the skin at the time of admission.Left Heel-First Observation - 12/8/250.9 x 1 x 1 -Unstageable100% necrosis and/or slough in the wound bed. Surveyor noted it is not specified what type of tissue the necrosis is (scab/possible eschar or slough).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. Surveyor noted the detail of the discoloration still does not clearly identify if it is slough present, eschar/scab, or combination of tissue types. No drainage. Induration (abnormal hardening, thickening or firmness of the surrounding skin and tissue of the wound) of peri-wound tissue with well defined wound edges and shape. No inflammation. Surveyor noted there was no documentation or assessment indicating R38 had induration of the skin at the time of admission.R38's admission Minimum Data Set (MDS) completed 12/12/25 assesses R38 with a Brief Interview for Mental Status (BIMS) score to be 0, indicating R38 demonstrates severely impaired skills for daily decision making. The MDS assesses: R38 has no depressive symptoms; R38 has range of motion (ROM) impairment on one side of upper extremity; No ROM impairment on lower extremities; R38's MDS assesses R38 demonstrates physical and other behaviors for 1-3 days. No refusals of care noted. R38 requires supervision for eating; R38 requires partial/moderate assistance for transfers, substantial/maximum assistance for upper dressing and mobility, and is dependent for showers and lower dressing; R38's MDS assesses R38 is at risk for pressure injuries and has unhealed pressure injuries. R38 has two unstageable pressure injuries that are indicated as being present upon admission.R38's Care Area Assessment (CAA) is triggered for pressure injuries and indicates to proceed to care plan. Surveyor noted there is no narrative documented to analyze R38's risk for pressure injuries and explanation/details regarding the care planning process as a result of the assessment.R38's comprehensive care plan dated initiated 12/8/25 addressing R38's risk for skin concerns indicates unstageable bilateral pressure ulcers due to immobility and weakness.Interventions included:-Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 12/8/25 -Administer treatments as ordered and monitor for effectiveness. Initiated 12/8/25-Assess/record/monitor wound healing every dressing change. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. Initiated 12/8/25-Blue boots on while in bed. Initiated 12/8/25-Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Initiated 12/8/25. Surveyor noted R38 is severely cognitively impaired.-Inform the resident/family/caregivers of any new area of skin breakdown. Initiated 12/8/25-Monitor dressing every shift/as needed to ensure it is intact and adhering. Report loose dressing to Treatment nurse. Initiated 12/8/25-Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 12/8/25-Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length X width X depth), stage. Initiated 12/8/25-Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Initiated 12/8/25-Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Initiated 12/8/25-(R38) requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. Initiated 12/8/25-Treat pain as per orders prior to treatment/turning etc. to ensure R38's comfort. Initiated- 12/8/25-Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Initiated 12/8/25The treatment order initiated 12/8/25 indicates: Clean Left and Right heel Unstageable w (with)/ wound cleanser, pat dry, skin prep peri wound. Moistened Aquacel dressing w/ Therahoney gel. Cover w/ Optifoam dressing. Change QD (each day)/prn (as needed) is (sic) soiled or off. Monitor for signs of infection. in the morning AND as neededR38's Wound Data (in centimeters):Surveyor noted there are no wound assessments for both the right and left heel pressure injuries for the week of 12/15/25. Surveyor noted with review of weekly wound documentation completed by LPN WN-I there is no comprehensive assessment or validation of data collected by LPN WN-I by a registered nurse.According to the Wisconsin Nurse Practice Act, N6.03(1), An R.N. (Registered Nurse) shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process:(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.s (Licensed Practical Nurse) or less skilled assistants.(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.Left Heel data: 12/23/250.9 x 1 x 1-Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. R38 complaining of pain during assessment to left heel. No changes noted.Right Heel data: 12/23/251.3 x 1.0 x 1-Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination)No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. R38 complaining of pain during assessment to left heel. No changes noted.Care plan revision -Observed R38 propel self in wheelchair using feet or heel, resident encouraged to refrain using heels to propel self, and use hands to propel self, also encouraged to avoid wearing leather shoes. Risk and benefits res states, oh well, I try, I think its fine, it does not hurt when I use my feet to move my chair, ok, ok Initiated 1/26/26Right Heel data:12/31/251.3 x 1.0 x 1-Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. R38 complaining of pain during assessment to left heel. No changes noted.Left Heel data: 12/31/250.9 x 1 x 1-Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. R38 complaining of pain during assessment to left heel. No changes noted.On 12/31/2025 R38's skin care plan was revised to include documentation indicating: Risk and benefits provided to R38 and HCPOA (healthcare power of attorney), refusing non pharmacological intervention blue boots to feet while in bed, will increase risk of skin breakdown and or worsen the current pressure ulcer's to bilateral heels, R38 states well, my feet gets hot, then it gets uncomfortable staff to encourage res to wear blue boots or offer alternative which is elevating legs with pillow. HCPOA states well, just encourage, I'm sorry Initiated 1/3/26Surveyor noted there are no wound assessments for both the right and left heel pressure injuries for the week of 1/5/26Right Heel data: 1/13/261.3 x 1.0 x 1-Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. Complaints of tenderness to area. R38 complaining of pain during assessment to left heel. No changes noted.Left Heel data 1/13/260.9 x 1 x 1-Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. R38 complaining of pain during assessment to left heel. No changes noted.Surveyor noted R38 initially complained of pain during the wound assessment on 12/31/25. There is no indication additional assessments of the pain was completed or addressed leading to R38 to continue to experience pain during additional assessments.R38's previous treatment to the right heel was discontinued on 1/13/26. The new treatment order starting 1/14/26 indicates: Clean wound to Right heel w/ wound cleanser, pat dry, skin prep peri wound. Apply quarter thick of Santyl to wound bed. Cover w/ Optifoam dressing. Change QD/PRN if soiled. Monitor signs of infection at bedtime.Right Heel data: 1/20/261.3 x 1.0 x 1-Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. Complaints of slight tenderness to touch. R38 complaining of pain during assessment to left heel. No changes noted. New treatment.Left Heel data: 1/20/260.9 x 1 x 1 -Unstageable100% necrosis and/or slough in the wound bed. Tissue type not specified (ie: eschar or slough or combination).No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. R38 complaining of pain during assessment to left heel. No changes noted. New treatment.Surveyor noted R38 continues to complain of pain during the assessment that is not addressed and now is indicating the right heel is also tender to the touch in addition to being painful during assessment.Right Heel data: 1/27/261.3 x 1.0 x 1- Unstageable90% necrosis and/or slough in the wound bed.No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. Complaints of slight tenderness to touch. R38 complaining of pain during assessment to left heel. Improving, no change with measurement, wound bed 10% red, 90% light brown brownish color resembles scab thinning, moist to exudate.Surveyor noted R38 continues to express pain with the right heel.Left Heel data: 1/27/260 x 0 x 0- UnstageableHealed. New treatment to cover left heel with optifoam dressing for protection. Change every 3 days and as needed. Left heel wound bed 100% epithelization.Right Heel data: 2/3/261.3 x 1.0 x 1-Unstageable90% of necrosis and/or slough in the wound bed.No exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation. Complaints of slight tenderness to touch. R38 complaining of pain during assessment to left heel. Improving, no change with measurement, wound bed 10% red, 90% light brown brownish color resembles scab thinning, moist to exudate.Left Heel data: 2/3/260 x 0 x 0-UnstageableHealed.Right Heel data: 2/10/260.9 x 0.8 x < (less than) 0.1 wound bed pinkish red moist, callused peri wound, no complaints of pain. No signs of infection.100% pinkish red wound bedNo exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation.Surveyor noted conflicting details in the data documentation regarding the details of the tissue type with statements indicating pinkish, red, moist wound bed and brown, tan, blackish discoloration in wound bed, wound bed dry.A new treatment order initiated 2/10/26 indicates: Clean wound to Right heel w/ wound cleanser, pat dry, skin prep peri wound. Apply Xeroform dressing. Cover w/ Optifoam dressing. Change QOD (every other day)/PRN if soiled or offRight Heel data: 2/18/260.6 x 0.7 x < 0.1 wound bed pinkish red moist, callused peri wound, no complaints of pain to surrounding area during palpation, slightly red. R38 complaint of pain to wound area itself during dressing change. New order.100% pinkish red wound bed, peri wound surrounded with thick callusNo exudate, no odor. Full thickness tissue loss in which the base of the ulcer's is covered by brown, tan, blackish discoloration in wound bed, wound bed dry. No drainage. Induration of peri-wound tissue with well-defined wound edges and shape. No inflammation.Surveyor noted conflicting details in the data documentation regarding the details of the tissue type with statements indicating pinkish, red, moist wound bed and brown, tan, blackish discoloration in wound bed, wound bed dry. R38 again is experiencing pain related to the wound that is not assessed.Observations of heels not floated/blue boots not on - expression of pain:R38's certified nursing assistant (CNA) care card reviewed by Surveyor during the survey instructing CNAs on the care of R38 documents R38 is to have blue boots on while in bed. Surveyor noted the alterative of offloading R38's heels with pillows is not included as directions for the CNAs for caring for R38.On 2/16/26, at 10:55 AM, Surveyor observed R38 in bed with no heel boots on and heels were observed to not be floated/offloaded of pressure.On 2/16/2026, at 12:12 PM, Surveyor observed the lunch meal in the dining room. Surveyor heard R38 inform Wound LPN -I that R38's right heel really hurts. Wound LPN-I informed R38 that Wound LPN-I will look at it after lunch. On 2/16/26, at 2:25 PM, Surveyor observed R38 in bed with no bilateral blue boots on.On 2/17/2026, at 6:59 AM, Surveyor observed R38's bilateral heels not floated or offloaded with boots or a pillow. Surveyor observed both heels on the bed.On 2/17/26, at 11:09 AM, Surveyor observed R38 in a low bed, gripper socks on, no bilateral heel boots on and no pillow floating/offloading pressure on R28's heels.On 2/17/2026, at 11:27 AM, Surveyor observed Wound LPN-I complete a treatment to R38's right heel. R38 stated no pain or discomfort this morning. Wound LPN-I explained the area around the wound bed was inflamed red on 2/16/26. Surveyor observed the area to be pinkish around the wound bed during the treatment. Wound bed present, area around is callous. Wound LPN-I informed Surveyor at this time that Wound LPN-I wanted to send R38 to a wound clinic for debridement, but HCPOA has refused and only wants treatments to be done at the facility. Wound LPN-I believes it will not heal without debridement. Wound LPN-I placed a pillow under R38's heels after completing the treatment. R38 has no problem with the pillow underneath R38's heels. Wound LPN-I did not complete any measurements.On 2/17/2026, at 12:19 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-N. CNA-N confirmed CNA-N is assigned to R38 today. CNA-N informed Surveyor that R38 does not like R38's bilateral heel boots on. Surveyor asked CNA-N what CNA-N would do if R38 refused to wear the bilateral heel boots. CNA-N stated that CNA-N will offer a pillow which R38 will allow. CNA-N will re-approach R38 several times and then tell the nurse R38 is refusing.On 2/17/2026, at 1:23 PM, Surveyor interviewed Wound LPN-I. Surveyor asked Wound LPN-I why R38's bilateral heel pressure ulcers were not assessed until 2 days after admission. Wound LPN-I stated it was because R38 came in on the weekend. Surveyor asked Wound LPN-I if R38 refuses the heel boots what staff should do. Wound LPN-I stated staff should encourage R38 to wear the bilateral heel boots and if R38 continues to refuse, staff should float R38's heels with a pillow.Surveyor noted that R38's Medication/Treatment Assessment Records (MARS/TARS) document R38 frequently refuses to wear heel boots. Surveyor noted R38's CNA care card do not indicate an alternative to the blue heel boots to offload pressure to R38's heels.On 2/17/26 (during the survey) R38's care plan for skin was resolved. A revised care plan dated 2/16/26 (during the survey) includes the revisions: addressing the continued unstageable pressure injury to the right heel; indicating the left heel had resolved. Surveyor noted the revised care plan included the same, previous interventions as R38's care plan initiated 12/8/25 but now with an initiated date of 2/16/26 (the first day of the survey).Possible Right Heel Osteomyelitis:On 2/16/26, the facility obtained an x-ray of the right heel. Results: Subtle heterogeneity of the calcaneus. Soft tissues appear swollen with ulceration.Conclusion: Findings suspicious for calcaneal osteomyelitis. Recommend MRI.On 2/18/26, The following was initiated and documented in R38's physician orders: Peripheral IV administration Cefepime via Peripheral IV (intravenous).On 2/18/2026, at 10:23 AM, Surveyor interviewed Wound LPN-I. Wound LPN-I informed Surveyor that Wound LPN-I believes R38's right heel is not healing due to non-compliance. Wound LPN-I shared R38 was wearing leather shoes at admission, Wound LPN-I asked family to bring soft shoes in. R38 agreed to wear softer shoes and most recently gripper socks. R38's HCPOA does not want aggressive treatment. Wound LPN-I shared they had a conversation with HCPOA, sometime in first week of January, but failed to document the conversation. Wound LPN-I had informed family that it is not healing due to the heel pressure ulcer needing debridement. Wound LPN-I shared R38 likes to hang right leg off the bed. Surveyor noted the possible risks for pressure and/or injury by wearing leather shoes, was not addressed in the care plan until 1/26/26. Surveyor also noted that the care plan does not address the risk factor of R38 using his feet/pressure on heels to self-propel their wheelchair. Regarding R38's pain, Wound LPN-I assessed R38's pain on Monday (2/16/26) and obtained an x-ray. Surveyor asked Wound LPN-I about R38's missing wound assessments of both the right and left heel pressure ulcers for the week of 12/15/25 and 1/5/26. Wound LPN-I stated, may have gotten away from me, I get a lot of admissions that have to be completed. Surveyor shared the concern that R38's bilateral right and left heel scabbed areas did not have data collected regarding the areas until 2 days after admission. Surveyor noted the areas have not been comprehensively assessed by an RN. Surveyor shared a care plan (baseline or comprehensive) to address R38's skin risks was not initiated until 12/8/25 and physician orders with a treatment were not initiated until 12/8/25.On 2/18/2026, at 1:20 PM, Surveyor spoke with Wound LPN-I regarding the timing of the data collection/assessment of #38's skin. Wound LPN-I stated, you can't expect me to complete assessments on the weekend. Wound LPN-I insisted an assessment was completed by RN-X. Surveyor shared there is no measurements, no characteristics until 2 days after admission with no treatment in place until 12/8/25.On 2/18/2026, at 1:27 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A regarding R38's pressure injury care. NHA-A stated they understood the concerns.On 2/18/2026, at 2:20 PM, NHA-A shared with Surveyor R38's baseline care plan has circles on the body image indicating R38 had pressure areas. Surveyor explained the circles are on the front body image and not on the back body image where the scabbed/unstageable bilateral heel pressure injuries would have been documented. NHA-A also stated Wound LPN-I documented the missing wound assessments (12/15/25 and 1/5/26) in Wound LPN-I's tracker but did not transfer to the formal wound assessment. NHA-A provided the tracker at this time.Surveyor reviewed the tracker and noted the details in the tracker indicate need to document.

Based on observation, interview and record review, the facility did not ensure food was served in accordance with professional standards for food service safety.* The 5th floor kitchen server for lunch was observed. The Cook-E used gloves for multiple tasks, including handling ready-to-eat foods. The food thermometer had a tethered string that was not maintained to prevent food contamination. This had the potential to affect all 20 residents on the 5th floor.Findings include:The facility policy and procedure Hospitality Department-Attendance, Conduct, and Safety Policy dated 9/12/2025 documents: The purpose of this policy is to give a hospitality employees clear direction regarding attendance, time-off requests, food handling, glove usage guidelines, kitchen safety, and grooming standards. Adherence to these guidelines protects employees, residents, and the reputation of [facility name].Procedures and Guidelines:5. Glove Usage documents under Changing Gloves:Gloves must be changed when switching tasks or workstations, after touching non-food surfaces (equipment handles, doors, trash lids, etc.).The following are not permitted: Wearing the same glove for multiple tasks.1.) On 2/16/2026, at 12:36 PM, Surveyor observed food service on the 5th floor with Cook-E. Cook-E removed the prepared food from the hot cart and placed items in the steam table. Cook-E washed their hands and donned gloves. Cook-E had a clipboard with a tethered thermometer on a string. Cook-E used the thermometer to take the temperature of the ravioli. During the observation, Surveyor observed the string was resting against the cooked ravioli.After Cook-E used the thermometer in the ravioli they used their gloved hand to mix cooked green beans. Surveyor noted that Cook-E did not wash their hands or changed gloves before touching and mixing the ready to eat cooked green beans with their gloves. Surveyor then observed Cook-E finish taking temperatures of the cooked food and then removed their gloves and washed their hands.Cook-E with their gloves, place bottom plate warmers on the device. The Cook-E took a plate from the plate warmer. The Cook-E used their gloved hand to place the cooked ravioli on it. The Cook-E used the same gloved hand for the tongs to serve cooked green beans. The Cook-E used the same glove to touch cooked ravioli, serving utensils and plates. This was observed with 2 plate services.Surveyor noted that Cook-E did not wash their hands or changed gloves before touching ready to eat food. Cook-E then removed their gloves and donned new gloves. Cook-E did not wash hands between glove changes. Cook-E then took a plate and a heated plate warmer. Cook-E used the same gloved hand to place the ravioli on the plate, used tongs for the green beans and pasta sauce ladle. Cook-E used their gloved hand to obtain 2 cooked raviolis. Cook-E placed the Ravioli on the server board. This board was used to place non-food items on. Cook-E used a knife to cut the ravioli and placed it on a plate. Cook-E used the same gloved hand to grab green beans and placed them on the same plate.Surveyor noted that Cook-E did not wash their hands or changed gloves before touching ready to eat food. On 2/16/26, at 12:56 PM, Surveyor interviewed Cook-E after observing several plates being served in a unsanitary manner. Cook-E stated they were aware of using food barriers however, the ravioli is sticky. Cook-E stated they were aware of glove use and did not have a response for touching multiple items with their gloves without washing their hands or changing gloves before touching ready to eat food. On 2/17/2026, at 10:22 AM, Surveyor interviewed Director of Hospitality (DOH) -D. The DOH-D stated that staff are aware of glove use with food handling. DOH-D did not have a response for the thermometer string being in the food or why Cook-E did not wash their hands or changed gloves before touching ready to eat food. On 2/17/26, at 3:03 PM, at the facility exit meeting, with Nursing Home Administrator (NHA)- A and Director of Nurses (DON) -B, Surveyor shared the kitchen sanitation concerns. No additional information was provided.

Based on interview and record review the facility did not ensure 1 (R52) of 12 residents reviewed received a completed Minimum Data Set (MDS). R52 was discharged to the hospital on 9/10/25 due to a change in condition. A discharge MDS was not completed.Findings include:R52 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, pneumonia and hypertension. On 9/10/25 R52 was discharged to the hospital due to a change in condition. The MDS information reveals a discharge MDS was not completed on 9/10/25. The medical record reveals the MDS is late.On 2/17/26 at 12:52 p.m., Surveyor interviewed MDS Coordinator-Q. Surveyor explained R52 was discharged to the hospital on 9/10/25 and a discharged MDS was not completed. MDS Coordinator-Q stated she was hired in October to be the MDS Coordinator but hasn't done much with MDSs because she's been training. Surveyor asked MDS Coordinator-Q if she knew why the discharge MDS wasn't completed. MDS Coordinator-Q stated she would investigate it.On 2/18/26 at 9:30 a.m. MDS Coordinator-Q stated an MDS correction was completed to document R52's discharge MDS. MDS Coordinator-Q stated it was an oversight.

Based on observation, interview and record review the facility did not ensure 1 (R2) of 12 residents reviewed received an accurate comprehensive Minimum Data Set (MDS) assessment. R2 was admitted on [DATE] and the admission MDS dated [DATE] assess R2 with the need for tracheostomy care. Surveyor notes R2 does not have a tracheostomy.Findings include:R2 was admitted to the facility on [DATE] with diagnoses of right lower leg fracture, asthma, hypertension and atrial fibrillation. The admission MDS dated [DATE] documents R2 has moderate cognitive impairment and is independent with eating. Section O0110 Special Treatments Procedures and Programs documents while a resident R2 was receiving tracheostomy care. On 2/16/26 at 9:44 a.m. Surveyor interviewed R2. Surveyor observed R2 did not have a tracheostomy.On 2/17/26 at 12:52 p.m. Surveyor interviewed MDS Coordinator-Q. Surveyor explained the concern the admission MDS dated [DATE] documents R2 is receiving tracheostomy care. MDS Coordinator-Q stated the facility does not accept residents with tracheostomy. Surveyor explained R2 was observed by Surveyor and does not have a tracheostomy. MDS Coordinator-Q agreed R2 does not have a tracheostomy. MDS Coordinator-Q stated this was a mistake.

Based on interview and record review, the facility did not complete neurological (neuro) checks in accordance with policy and procedure for 1 (R38) of 4 residents reviewed for unwitnessed falls.*R38 did not receive neurological checks in accordance with facility's policy and procedure for 1 of 3 unwitnessed falls.Findings Include:The facility's Falls policy and procedure revised 12/25 documents:2. In addition, the nurse shall assess and document/report the following:e. Neurological statusThe facility's process for completing neurological assessment is the following:-Time of incident-30 min post incident check-60 min post incident check-Following shifts for 72 hoursR38 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Right Side, Vascular Dementia(brain damage caused by multiple strokes), Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), Essential Hypertension(chronic condition of persistently high blood pressure), Insomnia(sleep disorder characterized by difficulty falling asleep), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R38's admission Minimum Data Set(MDS) completed 12/12/25 documents a Brief Interview for Mental Status(BIMS) score to be 0, indicating R38 demonstrates severely impaired skills for daily decision making. The MDS documents that: R38 has no depressive symptoms; R38 has range of motion (ROM) impairment on one side of upper extremity; No ROM impairment on lower extremities; R38 demonstrates physical and other behaviors for 1-3 days; R38 requires supervision for eating; R38 requires partial/moderate assistance for transfers, substantial/maximum assistance for upper dressing and mobility, and is dependent for showers and lower dressing; R38 has a pressure injury, currently has two unstageable, and is at risk for developing pressure injury and that R38 has had 2 or more falls since admission or previous assessment.Surveyor reviewed R38's three unwitnessed falls.R38 had an unwitnessed fall on 1/18/26 and there is no documentation that neuro-checks were completed per facility policy and process.On 2/18/2026, at 11:00 AM, Surveyor interviewed Director of Nursing (DON)- B in regard to the facility process for neurological checks to be completed. DON-B informed Surveyor that neuro-checks should be completed for any unwitnessed fall. Surveyor shared that R38 is missing a shift for R38's 1/17/26 unwitnessed fall and there are no documented neuro-checks for R38's 1/18/26 unwitnessed fall.On 2/18/2026, at 1:27 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R38 was missing a neuro-check for a shift following R38's 1/17/26 unwitnessed fall and that there are no documented neuro-checks following R38's unwitnessed fall on 1/18/26.No additional information has been provided by the facility at this time as to why R38 has missing documented neuro-checks following R38's unwitnessed falls.

Based on observation, interviews, and record review, the facility did not ensure a resident (R23) with hearing and vision impairment received proper treatment and assistive devices to maintain vision and hearing abilities.*Surveyor observed R23 to not be wearing R23's bilateral hearing aids and glasses during the survey process.Findings Include:The facility's Hearing Impaired Resident, Care of policy and procedure revised 2/18 documents:Policy Statement:Staff will assist hearing impaired residents to main effective communication with clinicians, caregivers, other residents and visitors.Policy Interpretation and Implementation:3. Staff will assist residents with care and maintenance of hearing devices.4. Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices.j. Evaluate resident's adaptive needs and progress at regular intervals.R23 was admitted to the facility on [DATE] with diagnoses of Paroxysmal Atrial Fibrillation (irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Essential Hypertension (chronic condition of persistently high blood pressure), Hyperlipidemia (high levels of fat particles in blood), Protein-Calorie Malnutrition Moderate (significant, but not severe, deficiency in nutrient intake), Gastro-Esophageal Reflux Disease (stomach contents leak backward from stomach into the esophagus (food pipe), Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities).R23's Significant Change MDS completed 11/19/25 documents a BIMS (Brief Interview for Mental Status) score of 0, indicating R23 demonstrates severely impaired skills for daily decision making. The MDS documents: R23 has no depressive symptoms; R23 demonstrates verbal and other behaviors 1-3 days; R23 has ROM impairment on one side of lower extremity and has no upper ROM impairment; R23 requires partial/moderate assistance for eating; R23's MDS also documents R23 requires substantial/maximum assistance for showers and upper dressing, and is dependent for lower body dressing, transfers, and mobility; R23's is dependent for sit to stand-the ability to come to a standing position from sitting on the bed; R23's MDS also documents that R23 has minimal difficulty for hearing and has hearing aids and that R23 has had 2 or more falls since admission or previous assessment.R23's current physician orders document to assist R23 with hearing aids' placement-on AM (morning) and off HS (hour of sleep), Effective 1/7/26. R23's certified nursing assistant (CNA) care card documents to offer assistance with bilateral hearing aids in AM or HS. Charge hearing aids in medication room. R23's comprehensive care plan documents to provide bilateral hearing aids and glasses. Initiated 12/2/25. Surveyor noted R23's comprehensive care plan does not address R23's vision and hearing loss including R23 wearing glasses and bilateral hearing aides. R23's care plan does not address if R23 refuses to wear R23's glasses and hearing aides and interventions to address refusals.On 2/16/2026, at 10:06 AM, Surveyor observed R23's purple glasses on the window ledge in R23's room. Surveyor observed R23 in a broda chair located at the nurse's station. Surveyor observed R23 not wearing glasses and bilateral hearing aides. On 2/17/26, the facility updated R23's physician orders to document if R23 refused hearing aid placement or takes them off and/or throws them two times a day.On 2/17/2026, at 3:39 PM, Surveyor observed R23 up in R23's broda chair not wearing glasses or bilateral hearing aides. On 2/17/2026, at 9:54 AM, Surveyor observed R23 in a broda chair located at the nurse's station. Surveyor observed R23 not wearing glasses and bilateral hearing aides. On 2/17/2026, at 12:12 PM, Surveyor interviewed both Certified Nursing Assistants (CNA)-M and CNA-N in regard to R23. Both CNA-M and CNA-N informed Surveyor that R23's hearing aides have been missing for awhile but does not know how long the hearing aides have been missing.On 2/17/2026, at 1:39 PM, Surveyor interviewed Nurse Manager (NM)-I regarding R23. NM-I stated that R23 does not wear glasses as much anymore and R23 wears R23's hearing aides on a regular consistent basis. NM-I explained the bilateral hearing aides are kept at the nurse's station and the nurse should be validating that R23 is wearing them. Surveyor shared the concern to NM-I that R23's glasses and hearing aides have not been in place. On 2/17/2026, at 1:52 PM, Surveyor confirmed that the bilateral hearing aides are not in and R23 is not wearing glasses. R23 is sitting in the broda chair in the dining room.On 2/17/2026, at 3:13 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R23 has not had R23's glasses on and bilateral hearing aides in during the survey process.On 2/17/2026, at 3:36 PM, at Licensed Practical Nurse (LPN)-L informed Surveyor that LPN-L attempted to place R23's bilateral hearing aides in, but R23 kept pulling at R23's ears and grabbing at them, so LPN-L had the CNA put back the bilateral hearing aides on the charger because R23 wouldn't wear the hearing aides. LPN-L stated LPN-L wrote a note but then struck it out. DON-B was present with LPN-L. Surveyor shared the concern that there is no documentation that R23 is refusing to wear the hearing aides or glasses. Surveyor shared that there are no interventions in place when R23 refuses to wear bilateral hearing aides and glasses documented on R23's comprehensive care plan. Surveyor shared the bilateral hearing aides are to be placed in, remains documented on R23's care card. Surveyor noted there is no documentation in R23's progress notes located in R23's electronic medical record(EMR) that R23's glasses and bilateral hearing aides were attempted to be placed on/in and interventions attempted.Surveyor reviewed R23's medication administration records(MARS) for January and February.January: There is 7 days with documentation that R23 was not wearing bilateral hearing aides.February: There is 10 days with documentation that R23 was not wearing bilateral hearing aides.Surveyor reviewed R23's progress notes and LPN-L did not document on 2/17/26 that R23 refused to wear R23's bilateral hearing aides. On 1/31/2026, LPN-R documented: Hearing Aides located and charged in 4th floor medication room. Document if R23 refused hearing aids placement two times a day. Hearing aids not working.Surveyor notes the 1/31/26 progress note is the only documented note in regards to R23's hearing aides. There is no documented follow-up to R23's hearing aides not working at this time.On 2/18/2026, at 10:08 AM, the facility did not provide any additional information in regards to R23 not wearing bilateral hearing aides and or glasses on during the survey process.

Based on observation, interview and record review, the facility did not ensure 3 (R23, R38 and R62) of 4 sampled residents received adequate supervision and assistance devices to prevent and be free of accidents. * On 2/2/26 R23 was evaluated by physical therapy, after the facility risk management team determined R23 was doing better, to assess changing R23's transfer status from the use of a mechanical lift to being transferred with a sit to stand or through a stand-pivot transfer. Following the evaluation R23 was upgraded to transfer with the assist of two staff using a sit to stand. R23's power of attorney for healthcare was not consulted with or notified of this change in care for R23. On 2/14/26 two Certified Nursing Assistants (CNAs) proceeded with transferring R23 using a sit to stand despite R23 showing resistance to sitting upright to position the sling and releasing staffs hand to hold onto the bar. The CNAs (U and V) proceeded with raising R23 up using the lift and discovered a cord was in the way of the lift impeding moving the lift. They turned their attention to move the cord and R23 slipped from the sling/lift hitting their head on the bed. R23 sustained an injury requiring transfer to the hospital to have staples placed related to the head injury. R38's assessments and facility care plans did not address all of R23's possible risk factors. Multiple staff indicated R23 should not have had their transfer modality changed as it was unsafe. * R38 sustained 3 avoidable falls following admission to the facility. The facility did not ensure post fall investigations were comprehensive to help determine a root cause analysis to determine effective interventions to prevent falls and possible injuries. During the survey, R38 was observed to not have safety interventions implemented. * On 11/27/25, R62 was found on the floor next to his bed. The fall investigation reveals R62's bed was left in a high position (a position higher than the baseline height of the average bed/height for caregivers to provide cares). The staff involved provided a statement post fall indicating the plan of care was not followed. The standard of practice for Nurse Aides was not followed prior to the fall. Findings include: The facility's Falls-Clinical Protocol dated September 2012 documents1. As part of the initial assessment, the Interdisciplinary team (IDT) will help identify individuals with a history of falls and risk factors for subsequent falling. a. Staff will ask the resident and caregiver or family about a history of falling.b. Staff to complete Fall risk EvaluationTreatment/Management1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risk of serious consequences of falling.a. Examples of such interventions may include calcium and vitamin D supplementation to address osteoporosis, addressing medical issues such as hypotension and dizziness and tapering, discontinuing, or changing problematic medications (for example, those that could make the resident dizzy or cause blood pressure to drop significantly on standing). Change to add fall mat, bed in lowest position, visual cue for call light etc. 1.) R23 was admitted to the facility on [DATE] with diagnoses of Paroxysmal Atrial Fibrillation (irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Essential Hypertension (chronic condition of persistently high blood pressure), Hyperlipidemia (high levels of fat particles in blood), Protein-Calorie Malnutrition Moderate (significant, but not severe, deficiency in nutrient intake), Gastro-Esophageal Reflux Disease (stomach contents leak backward from stomach into the esophagus (food pipe), Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R23's Significant Change Minimum Data Set (MDS) completed 11/19/25 assesses R23 with a BIMS (Brief Interview for Mental Status) score of 0, indicating R23 demonstrates severely impaired skills for daily decision making. The MDS documents: R23 has no depressive symptoms; R23 demonstrates verbal and other behaviors 1-3 days; R23 has Range of Motion (ROM) impairment on one side of lower extremity and has no upper ROM impairment; R23 requires partial/moderate assistance for eating; R23's MDS also documents R23 requires substantial/maximum assistance for showers and upper dressing, and is dependent for lower body dressing, transfers, and mobility; R23's is dependent for sitting to standing-the ability to come to a standing position from sitting on the bed; R23's MDS also assesses R23 a having minimal difficulty for hearing and has hearing aids and that R23 has had 2 or more falls since admission or previous assessment. Surveyor noted that R23's dependency on assistance for transfers and mobility established R23 requires substantial staff intervention for safe repositioning and movement, increasing the risk of injury if equipment selection for transfers was inconsistent or improperly implemented. Surveyor noted R23's Care Area Assessment (CAA) for falls was triggered as requiring further review and to proceed to a plan of care. The CAA did not include the details to demonstrate R23's risk factors and the details considered to develop a plan of care related to falls for R23. R23's Fall Risk Evaluation completed 11/19/25 documents R23 is high risk for falls with a score of 17. Surveyor noted that a high risk fall score, combined with cognitive impairment and mobility dependence, required staff to adhere to transfer protocols and verify safe transfers to prevent accidents for R23. R23's current certified nursing assistant (CNA) care card documents R23 is to be transferred using a mechanical lift with assistance of two staff. R23's comprehensive care plan documents R23 is at risk for falls due to deconditioning, and pain; secondary to L3 compression fracture. Dementia. No safety awareness. Initiated 9/19/25 Revised 12/2/25 Interventions: -Anticipate and meet (R23's) needs. Initiated 9/19/25 -Be sure (R23's) call light is within reach and encourage (R23) to use it for assistance as needed. (R23) needs prompt response to all requests for assistance. Initiated 9/19/25 -Educate (R23)/family/caregivers about safety reminders and what to do if a fall occurs. Initiated 9/19/25 -Ensure phone and items are close to (R23) for easy access. Initiated 10/29/25 -Physical Therapy evaluate and treat as ordered or as needed. Initiated 9/19/25 -(R23) needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items with reach. Initiated 9/19/25 -11/14/25 Staff re-education on rounding and incontinence care. Initiated 11/14/25 Revised 11/17/25 Surveyor reviewed R23's hospice care plan which documents: Hospice nurse to assess for fall risk factors: Abnormal gait/balance, Muscle weakness, Taking 4 or more medications, Vision deficits (poor visual acuity, reduced contrast sensitivity, decreased visual field, cataracts, glaucoma, macular degeneration, etc), Certain chronic diseases, such as Parkinson's Disease, arthritis, stroke, cognitive impairment, osteoporosis, etc., History of previous falls, Postural hypotension (dizziness, syncope), Cardiac arrhythmia, Use of restraints, Sleep problems, Alcohol consumption, Presence of pain, Peripheral neuropathy, Urinary frequency, urgency, incontinence, nocturia. -Hospice nurse to instruct facility on R23 and caregiver on safe and appropriate use of assistive devices.-Hospice nurse to instruct facility, patient/caregiver on fall prevention strategies.-Hospice nurse to instruct facility, patient/caregiver on safe transfers.-Hospice nurse to review care plan with facility, patient/family/caregiver. Surveyor noted the facility care plan for falls does include R23's diagnoses of postural hypotension as a possible risk factor during transfers as referenced in the hospice plan of care. MDS Coordinator (MDS)-Q documented the following: Initiated 11/13/25 TRANSFER: (R23) requires mechanical lift 11/28/2025 TRANSFER: (R23) requires sit to stand Assistance of two for transfers 2/2/2026 TRANSFER: (R23) requires mechanical lift assistance of two for transfers 2/16/2026 On 2/17/2026, at 1:46 PM, Surveyor asked LPN Wound Nurse-I about the changes in R23's transfer status. LPN Wound Nurse-I informed Surveyor that therapy would have made the decision to change R23's transfer status to a sit to stand. On 2/2/26, Physical Therapist (PT)-O documented: PT evaluation completed this date. R23 is being referred to therapy services to evaluate R23's transfer status. Sit to stand lift trialed with CNA present in room. R23 was able to complete 3 stands, each lasting about 30-45 seconds. Transfer completed to Broda chair with assist of two. Sit to stand trialed from Broda with R23 holding onto writer, maximum assistance of one required. R23 tolerated standing for about 15 seconds and then let go of writer to try and sit. Pivot transfer not safe to trial at this time. R23 is upgraded to use of sit to stand lift with assist of two on unit. Further skilled therapy is not warranted at this time due to R23 being on hospice care. Surveyor noted R23's care plan adjusting R23 to being able to transfer using a sit to stand with assist of two did not include factors to monitor for such as the length of time it may take to transfer R23 given R23 was only able to stand and hold on for limited lengths of time versus and extended period that may be required to complete a full transfer. On 2/14/26, at 8:50 AM, R23 was assisted by two CNAs utilizing the sit to stand. The fall investigation, with a statement written by Certified Nursing Assistant (CNA)-U, states when CNA-U was first trying to put the sling on R23, R23 was resisting sitting up straight but eventually got R23 to sit up straight. R23 also would not loosen up R23's hands to hold on to the bars, eventually getting R23 to loosen up and hold on. CNA-U's statement documents R23 let go of the handlebars on the sit to stand and fell out of the sling into a fetal position, hitting R23's head and both CNA-U and CNA-V noticed blood coming out. CNA-V stated R23 was up in the air when the pathway was unclear. With one hand on R23's back, CNA-V bent down to clear the way of the cords in the way, CNA-U began to pull out the sit to stand and R23 fell out of the sling. CNA-U's statement documents that R23 should never have been made a sit to stand transfer as it was not a good idea. Surveyor noted prior to initiating the transfer CNA-V and U did not ensure the pathway to complete the transfer in was clear and safe requiring them to turn their attention away from R23. On 2/14/2026, at 9:28 AM, Registered Nurse (RN)-T documented: Writer made aware by aides that they were attempting to transfer R23 to wheelchair with sit to stand at 8:50 AM. Aides reported that R23 was secured tightly in sling. One aide began to lift R23 by remote while the other removed a cord that was blocking the machine's pathway. Aides also reported that R23 held a tight grip before trying to have her hold the safety bars and that assisted R23 with loosen (sic) hands for proper placement. Once R23 was raised from bed, R23 released hands from safety bars and slipped out of the sling. Aides stated R23 hit head on foot of bed. Upon observation, R23's head was bleeding. Writer immediately called 911 for assistance and took vitals. R23 was awake and moaning in pain. R23 did not lose consciousness at any time while with R23. Writer kept talking to R23 and noted R23 squeezing writer's hand. Writer remained bedside with R23 until paramedics arrived to evaluate. Upon evaluation, it was determined that R23 should be sent to emergency room to evaluate head laceration. Ambulance arrived at 9:20 AM to transfer R23 to emergency room. Call to HCPOA (healthcare power of attorney) attempted with no success, callback number provided on voice mail. R23's fall documents that R23 became unstable while elevated in the sit to stand, resulting in an unprotected fall from the sling with an injury requiring staples to the head. On 2/14/2026, at 12:00 PM RN-T documented: Writer explained the fall and transfer to emergency room to HCPOA. HCPOA had questions about transfer status as she believed R23 was a mechanical lift. Writer explained that R23 was a mechanical lift transfer and writer was made aware that status was upgraded to sit-to-stand recently. HCPOA made writer aware that R23 is getting stitches and should be coming back to facility at some point. Surveyor reviewed R23's emergency room documentation dated 2/14/26. A CT (computed tomography scan) of head without contrast was completed and R23 sustained a laceration of scalp due to a fall and received staples to the back of R23's head. On 2/16/26 R23's falls care plan was revised stating: - 2/14/26 (R23) sent to (initials of hospital) for evaluation. (R23) downgraded to mechanical lift assistance of two. Initiated 2/16/26. On 2/16/2026, at 12:07 PM, Surveyor interviewed Anonymous individual (ANON)-P via telephone. Anon-P shared it was understood R23 was to be transferred with a mechanical lift but R23 was transferred with the use of a sit to stand. Anon-P expressed concern regarding why the change was made and that not everyone was aware of the change. Anon-P expressed concern that R23 was unnecessarily injured because of the unsafe change in transfers. On 2/16/2026, at 4:06 PM, Licensed Practical Nurse (LPN) Wound Nurse-I documented: IDT (interdisciplinary team) team (sic) met and discussed R23's witnessed fall, R23's plan of care was followed, including transfer status. The correct size sling was used for transfer. R23 was sent to the hospital. Upon return, R23 downgraded to mechanical lift transfer. Surveyor noted upon review of the interdisciplinary team note related to the fall the team did not take into consideration the CNAs initiated use of the lift despite resistance/reluctance from R23. CNA-U and V did not seek out guidance from a nurse prior to proceeding with the transfer to ensure R23's safety. Surveyor also noted the interdisciplinary team did not take into consideration the CNA did not ensure the pathway was clear of obstacles that required turning their attention away from R23 during the transfer leading to an unsafe transfer. On 2/18/2026, at 7:29 AM, Surveyor asked CNA-G about transferring R23. CNA-G informed Surveyor that CNA-G knows R23 very well. CNA-G stated that CNA-G used their judgment with R23 to continue to use the mechanical lift when R23 was changed to transfer with a sit to stand. CNA-G explained that R23 had good days and bad days where R23 appears to be weaker and more disoriented so CNA-G would use the mechanical lift to transfer R23. When asked about R23'a 2/14/26 fall. Both CNA-G and CNA-H shared that they both believe there was a lack of judgement due to R23 not being able to stand well that day contributed to R23 slipping out of the sling. CNA-G stated R23 will buckle R23's legs. Surveyor noted there are multiple indicators from staff presently and at the time of the fall that questioned the decision to change how R23 was to be transferred. Surveyor noted the assessment to change R23's transfer status did not seem to include facts from staff that work with R23 on a routine basis and assist R23 with transfers. On 2/18/2026, at 8:59 AM, Surveyor interviewed Physical Therapist (PT)-O who evaluated R23 and upgraded R23 to the sit to stand. PT-O was informed by nursing they wanted to do an evaluation because R23 was doing better. PT-O completed a couple of transfers with the sit to stand, and it went well so PT-O upgraded R23 to the sit to stand. PT-O stated R23 did not have any buckling of legs when the transfer was completed and R23 could tolerate standing for a period of time. PT-O stated the size of the sling is based on weight. PT-O stated something didn't go right, maybe they used the wrong size sling or it was too loose. On 2/18/2026, at 11:06 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R23's fall out of the sit to stand sling. DON-B explained that at the weekly risk meeting, it was discussed that R23 was stronger and that is how the upgrade from mechanical lift to sit to stand occurred. DON-B shared that both agency CNAs and new CNAs are provided education and policies on safe transfers. Surveyor shared the concern with DON-B that R23 slipped out the sling resulting in 4 staples. Surveyor shared that 'something' with the transfer process of R23 did not go according to facility procedure for a safe transfer. The facility's failure to ensure the real time clinical appropriateness of the sit to stand transfer resulted in the resident becoming unstable while elevated, slipping from the sling and sustaining actual harm in the form of scalp laceration requiring emergency treatment and staples. 2.) R38 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Right Side, Vascular Dementia (brain damage caused by multiple strokes), Atherosclerotic Heart Disease of the Native Coronary Artery (plaque buildup narrows the arteries that supply blood to the heart), Essential Hypertension (chronic condition of persistently high blood pressure), Insomnia (sleep disorder characterized by difficulty falling asleep), Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Depression (mood disorder that causes persistent feelings of sadness and loss of interest). R38's admission Minimum Data Set (MDS) completed 12/12/25 assesses a Brief Interview for Mental Status (BIMS) score to be 0, indicating R38 demonstrates severely impaired skills for daily decision making. The MDS documents: R38 has no depressive symptoms; R38 has range of motion(ROM) impairment on one side of upper extremity; No ROM impairment on lower extremities; R38's MDS documents R38 demonstrates physical and other behaviors for 1-3 days; R38 requires supervision for eating; R38 requires partial/moderate assistance for transfers, substantial/maximum assistance for upper dressing and mobility, and is dependent for showers and lower dressing; R38's MDS documents R38 has a pressure injury, currently has two unstageable, and is at risk for developing pressure injury and that R38 has had 2 or more falls since admission or previous assessment. Surveyor notes that R38's Care Area Assessment (CAA) for falls was triggered and not thoroughly completed to include a narrative describing the impact of the problem/need and the rationale for a care plan decision. R38's 12/5/25 hospital record documents: R38 with frequent falls and potential for impact trauma. R38's hospital record documents R38 had up to 15 falls in the past 2 weeks prior to admission to the hospital. Surveyor notes R38's high risk for falls are not documented on R38's baseline care plan with person-centered interventions upon admission. R38's Fall Risk Evaluation completed 12/6/25 documents a score of 11, indicating R38 is at high risk for falls. R38's Certified Nursing Assistant (CNA) care card documents R38 is to have bed in lowest position and a fall mat. R38's comprehensive care plan documents: R38 is at risk for falls due to weakness, confusion, gait/balance problems. History of falls. Initiated 12/6/25 Revised 12/18/25 Interventions: -1/16/26 Environmental assessment, provide education to staff member regarding proper positioning during cares. Initiated 1/16/26 Revised 1/21/26-1/18/26 Continence evaluation assessment to be completed. Initiated 1/21/26-1/19/26 Encourage R38 to be up for meals in dining room. Initiated 1/19/25 Revised 1/21/26-Bed in lowest position. Initiated 12/8/25-Encourage R38 to be up for meals in dining room. Initiated 1/19/26-Ensure that R38 is wearing appropriate footwear when ambulating or mobilizing in w/c. Initiated 12/8/25-Fall mat next to bed. Initiated 12/6/25 Revised 2/16/26-Medication review from pharmacy consultant. Initiated 12/8/25-R38 needs a safe environment with: floors free from spills and/or clutter a working and reachable call light. Initiated 12/8/25 On 12/8/25, Nurse Practitioner (NP)-S documented in R38's history and physical: R38 is here for a new patient history and physical for skilled rehabilitation, with the primary goal of strengthening. R38 has experienced 15 falls in the past two weeks and is described as alert and oriented to two spheres. Assessment: 1. Impaired mobility and frequent falls- R38 has reported multiple falls due to muscle weakness and impulsivity, requiring further strengthening and monitoring. 3. Cognitive impairment- Alert and oriented to two spheres, indicating potential cognitive challenges that need addressing. Plan 1. Impaired mobility and frequent falls -Proceed with strengthening therapies to enhance muscle function and reduce fall risk. -Implement close monitoring for safety due to impulsivity and mobility issues. 3. Cognitive impairment -Maintain regular assessment of cognitive status and adjust care plans as needed. -Ensure staff is aware of and accommodates cognitive deficits. On 2/17/2026, at 10:37 AM, Surveyor reviewed the investigations into R38's three unwitnessed falls. Fall 1. 1/15/26 at 6:20 PM. R38 was found lying on R38's back next to the wall. The CNA was changing the bed after the bed bath. The bed was pulled away from the wall and elevated to allow CNA to give a bed bath and change the sheets. Per CNA, R38 abruptly turned to R38's left side. The mattress was not properly placed on the bed frame, leaving the mattress unsupported from the bed frame and R38 rolled off the bed on to the floor. R38 sustained an abrasion to the right elbow. Per investigation, the CNA involved was re-educated on making sure the mattress is secured on the bedframe, make sure the resident is lying flat on the bed with weight evenly dispersed and CNA should be on the side the resident is lying and facing to act as a barrier from rolling off the bed. Surveyor noted R38's care plan documents R38 requires moderate assistance of one to turn and reposition in bed. Fall 2. 1/17/26 at 12:14 PM. R38 was found on the floor by family in a sitting position on the fall mat bedside. R38 stated, I was sitting at the edge of the bed and slipped to the floor about two feet onto the mat. R38 indicated R38 wasn't going anywhere when R38 slipped. The investigation does not document if the fall interventions of gripper socks and low bed was implemented. R38's continence status is not documented. The fall investigation does not have documented statements from possible witnesses or staff responsible for R38. Fall 3. 1/18/26 at 2:08 AM.R38 was found on the floor by CNA. R38 was wrapped in bed sheet. Bed was lowered. R38's head was near/under bed. R38 was incontinent of loose stool. Mat was in place. Surveyor noted there are no witness or staff statements documented as part of the fall investigation. The post fall intervention was to complete an incontinence evaluation which documents that R38 prefers check and change. Surveyor noted the intervention of check and change was not initiated on R38's comprehensive care plan regarding bowel and bladder continence. R38's certified nursing assistant (CNA) care card documents R38 to be checked and changed with rounds, as needed, and per R38's request. On 2/16/2026, at 10:55 AM, Surveyor interviewed R38 who informed Surveyor that R38 had 2 falls, one where R38 rolled out of bed and the other R38 believes something went wrong with the hoyer. R38 did not sustain any injuries. On 2/16/2026, at 2:25 PM, Surveyor observed R38 in bed resting. Surveyor observed R38's bed is against the wall. Surveyor observed regular socks on R38 and R38's right leg is dangling off the bed. R38's bed is not in the low position, and there is no mat down on the floor next to the bed. On 2/17/2026, at 11:10 AM, Surveyor observed R38 sleeping in a low bed, right leg is dangling off the bed. There is no mat on the floor next to the bed. Surveyor observed the mat in the corner, by the lamp, on the right side of the room. On 2/17/2026, at 11:44 AM, Surveyor observed Licensed Practical Nurse (LPN) Wound Nurse-I complete R38's treatment to R38's right heel. When LPN Wound Nurse-I finished R38's treatment, LPN Wound Nurse-I lowered R38's bed back into the low position. Surveyor observed LPN Wound Nurse-I did not place a mat down next to the bed. Surveyor observed the mat to still be in the corner of the room. On 2/17/2026, at 12:20 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-N regarding R38. Surveyor asked if R38 is supposed to have a mat down next to the bed. CNA-N informed Surveyor that R38 should always have the mat down when in bed. On 2/17/2026, at 1:45 PM, LPN Wound Nurse-I, who also is the unit manager, informed Surveyor that resident falls are reviewed the next day or the following Monday if the fall happened on the weekend and the interdisciplinary team (IDT) comes up with the best interventions. On 2/18/2026, at 11:00 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R38's three falls. DON-B stated the safest way to complete the bed bath is to ensure the resident is lying on their back to prevent a fall. The CNA should always roll a resident towards them when providing cares in bed. Surveyor shared the concern that R38's other 2 falls were not thoroughly investigated with an established root/cause analysis to facilitate implementing person-centered interventions to prevent future falls. Surveyor reviewed the facility's revised 3/21 bed bath policy and procedure which documents: Back: a. Instruct the resident to turn on his/her side with his/her back toward you.(Note: Be sure the side rail is up on the opposite side of the bed to prevent the resident from rolling out bed.) b. If the resident cannot turn by himself or herself, assist as needed. f. Remove the towel and reposition the resident on his or her back. 24.Lower the bed into lowest position and place the side rails in the appropriate position. On 2/18/2026, at 1:27 PM, Surveyor shared the concern of R38 rolling off the bed when CNA-H was performing a bed bath with DON-B. Surveyor shared that per facility procedure for safety, R38 should have been placed on back prior to completing the bed bath, and completed any rolling towards CNA-H. Surveyor also shared the observations of R38 not having fall interventions in place during the survey process like mat on the floor, bed in lowest position, gripper socks on. Surveyor shared R38's falls were not thoroughly investigated to establish a root/cause analysis to facilitate implementation of interventions to avoid future falls. NHA-A understands the concerns of R38's falls and did not provide additional information. 3.) R62 was admitted to the facility on [DATE] with diagnoses of parkinsonism, anxiety and hypertension. R62's fall risk assessment dated [DATE] documents R62 is at high risk for potential falls. R62's admission Minimum Data Set (MDS) dated [DATE] documents R62 has severe cognitive impairment and is dependent for bathing and rolling in bed. The MDS also documents R62 had a fall prior to admission. R62's Care Assessment Area (CAA) dated 11/16/25 documents a history of falls, confusion and weakness. R62's falls care plan, dated 11/13/25, documents the following interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Pt (physical therapy) evaluate and treat as ordered or PRN (as needed). The resident needs activities that minimize the potential for falls while providing diversion and distraction. The resident needs a safe environment with: floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach. The nurses note dated 11/27/25 documents R62 was found on the floor beside his bed with blood coming from the left side of his head. R62 was sent to the hospital and did not return to the facility. The fall investigation reveals a drawing of how R62 was found. The drawing reveals the bed was found to be high (in an elevated above normal baseline height used by caregivers during cares). The fall investigation documents interviews with staff involved when R62 was found on the floor. The statement from CNA-W, who was R62's CNA on 11/27/25, documents, she checked and changed R62 and remembers adjusting the bed but wasn't sure if it was at the lowest position as it should have been. CNA-W continues that she apologizes for the accident and should have been following the care card and should have known he was a fall risk. The facility provided documentation CNA-W was an agency CNA and is not allowed back to the facility. According to the State of Wisconsin Nurse Aide Candidate Handbook date November 2025 Version 74: all nurse aide competencies for providing care in bed include the expectations: .Leave the resident in a position of safety and .Lower the bed. On 2/18/26 at 10:00 a.m. Surveyor interviewed Director of Nursing (DON)-B regarding R62 fall. Surveyor explained the concern the investigation reveals R62 was left in a high bed and fell out of bed. Surveyor explained the concern R62 was dependent in bed. Surveyor explained the investigation doesn't reveal how R62 fell or if R62 is dependent for moving in bed. Surveyor asked if there is additional information to this fall investigation and if any education provided. DON-B stated she understood the concern and will asked NHA-A if there is any additional pieces to the investigation for R62. On 2/18/26 at 12:55 p.m. Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor explained to NHA-A the concern R62 was left in a high bed and fell out of bed. Surveyor explained R62 was dependent for bed mobility and the investigation doesn't reveal how R62 fell out of bed. Surveyor asked if there is additional information to the investigation and if any education was provided to staff. NHA-A stated she thinks there is more information to the investigation. On 2/18/26 at 1:35 p.m. NHA-A stated to Surveyor she did not have any additional information regarding the investigation. NHA-A stated education was provided to nursing staff. No additional information was provided.

Based on observation, interview and record review the facility did not ensure 1 (R6) of 3 residents observed during medication pass received medications without errors or that the medication error rate was not 5 percent or greater. The medication error rate was 33.33%.*On 2/17/26 at 9:00 a.m., Surveyor observed R6 receive his medications through his G (gastrointestinal) tube. Surveyor observed RN (Registered Nurse)- F dispense R6's morning medications into individual medication cups and then crush them individually. RN-F instilled all the medications at the same time without water flushes in between each medication. Findings include:The facility's Administering Medications through an Enteral Tube policy dated March 2015 documents: 3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately. 23. Dilute the crushed or split medications with 15-30 milliliter (ml) sterile or purified water (or prescribed amount).26. If administering more than one medication, flush with 15 ml (or prescribed amount) warm sterile or purified water between medications27. When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml of warm or purified water (or prescribed amount).On 2/17/26 at 9:00 a.m. Surveyor observed RN-F prepare R6 medications to be administered through G tube. RN-F dispensed each medication, which was ten medications in total, into individual cups. RN-F crushed nine tablets separately and poured one liquid medication. RN-F poured water into each crushed medication separately. RN-F checked placement then administered the water flush per facility policy. R6's family member explained to RN-F that it was easier to administer all the meds at the same time. RN-F then proceeded to mix all the medication in the same syringe and instill the medications into R6's G-tube. RN-F then flushed the G tube with water as per facility policy. On 2/18/26 at 10:08 a.m. Surveyor interviewed Director of Nursing (DON)-B. Surveyor explained the concern RN-F administered R6 medications through the G tube and did not follow the facility's policy. Surveyor explained RN-F carefully crushed all the tablet medications separately but when it came time to administer the medications, she instilled all the medications at the same time. Surveyor explained that R6 family member directed RN-F to administer the medications in this manner. DON-B stated R6 family member is particular when it comes to the care of R6. DON-B stated she agreed RN-F did not follow the facility's policy in regards to administering R6 medications through the G tube. No additional information was provided.

Based on interview and record review, the facility did not ensure a baseline care plan was developed and implemented within 48 hours of a resident's admission for 1 (R38) of 12 sampled residents reviewed for baseline care plans.*R38's baseline care plan was not thoroughly completed as every section of R38's baseline care plan was not completed. Findings Include:The facility did not provide a baseline care plan policy and procedure for review.R38 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Right Side, Vascular Dementia (brain damage caused by multiple strokes), Atherosclerotic Heart Disease of the Native Coronary Artery (plaque buildup narrows the arteries that supply blood to the heart), Essential Hypertension (chronic condition of persistently high blood pressure), Insomnia (sleep disorder characterized by difficulty falling asleep), Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Depression (mood disorder that causes persistent feelings of sadness and loss of interest). R38 has an activated Health Care Power of Attorney (HCPOA).R38's admission Minimum Data Set (MDS) completed 12/12/25 documents R38's Brief Interview for Mental Status (BIMS) score to be 0, indicating R38 demonstrates severely impaired cognitive skills for daily decision making. R38 has no depressive symptoms. R38 has range of motion (ROM) impairment on one side of upper extremity. No ROM impairment on lower extremities. R38's MDS documents R38 demonstrates physical and other behaviors for 1-3 days of the last 7 days. R38 requires supervision for eating. R38 requires partial/moderate assistance for transfers, substantial/maximum assistance for upper body dressing and mobility and is dependent for showers and lower body dressing. R38's MDS documents R38 has a pressure injury, currently has two unstageable areas, and is at risk for developing pressure injuries. R38 has had 2 or more falls since admission or previous assessment. Surveyor reviewed R38's undated baseline care plan provided by the facility. Surveyor notes the following sections of R38's baseline care plan contains no documentation:-admitted for :-Disease/Illness Management including interventions-Assistance of Daily Living (ADL)-Psychosocial well/Ill being care: including interventions-Other special care instructions-Physician order for therapy-Activity/mobility-Labs-There is no physician order for medication/treatment documentationSurveyor notes the front and back pictures of the body figures located under wound and/or pressure injury are circled on the front of the body figure. No further documentation on specific details of R38's skin impairment.Surveyor notes R38 had skin impairment on the back of the right and left heels on admission.R38's 12/5/25 hospital record documents R38 had frequent falls and potential for impact trauma. R38's hospital record documents R38 had up to 15 falls in the past 2 weeks prior to admission to the hospital.Surveyor notes both R38's pressure injuries and high risk for falls are not documented on R38's baseline care plan with person-centered interventions on admission.Surveyor notes R38's physician orders document to verify baseline care plan is complete and signed per responsible party one time only for one day filed under care plan tab in chart-leave open until complete. Start date of 12/6/25 and end date of 12/7/25.On 2/18/2026, at 12:44 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the facility procedure for resident baseline care plans. DON-B explained the baseline care plans are completed on a separate individualized care plan and are not included in the comprehensive care plan. Surveyor reviewed R38's incomplete baseline care plan with DON-B who agreed R38's baseline care plan was not complete, and all areas should have been addressed with immediate interventions on admission. DON-B understands the concern R38's baseline care plan was not thoroughly completed on admission.On 2/18/2026, at 1:27 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that R38's baseline care plan was not thoroughly completed, and two significant areas of pressure injury/wound, and falls was not completed and did not include person-centered interventions. NHA-A acknowledged the concern.

Based on observation, interview and record review the facility did not ensure 1 (R2) of 1 resident received the necessary assessment to self-administer medications. On 2/16/26 at 9:44 a.m. Surveyor interviewed R2. Surveyor observed an Advair inhaler on the table beside the bed. Surveyor asked R2 if she uses the inhaler independently. R2 stated she does and has been using that inhaler for many years. Surveyor asked R2 if the nurses leave the inhaler in R2 possession and R2 stated yes. Surveyor reviewed R2 assessments, and a self-administration of medications assessment was not completed.Findings include:The facility's self-administration of medications policy dated December 2016 documents1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident.2. In addition to general evaluation of decision-making capacity, the staff and practitioner will perform a more specific skill assessment, including (but not limited to) the resident's: a. Ability to read and understand medication labels.b. Comprehension of the purpose and proper dosage and administration time for his or her medicationsc. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication andd. Ability to recognize risks and major adverse consequences of his or her medications.6. For self-administering residents, the nursing staff will determine who will be responsible (the resident or the nursing staff) for documenting that medications were taken.8. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them. R2 was admitted to the facility on [DATE] with diagnoses of right lower leg fracture, asthma, hypertension and atrial fibrillation. The admission Minimum Data Set (MDS) dated [DATE] documents R2 has moderate cognitive impairment and is independent with eating. On 2/16/26 at 9:44 a.m., Surveyor interviewed R2. Surveyor observed an Advair inhaler on the table beside the bed. Surveyor asked R2 if she uses the inhaler independently. R2 stated she does and has been using an inhaler for many years. Surveyor asked R2 if the nurses leave the inhaler in R2's possession and R2 stated yes. Surveyor reviewed R2's medical record and there wasn't an assessment to determine if R2 is safe to self-administer the inhaler. R2's care plan does not address R2's self-administering the inhaler. On 2/17/26 at 3:00 p.m., during the daily exit meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor requested to see R2's self-administration of medication assessment.On 2/18/26 at 10:06 a.m., DON-B gave Surveyor a self-administration of medication assessment for R2. The assessment was dated 2/17/26. Surveyor asked DON-B why the assessment was not completed prior to 2/17/26. DON-B stated she wasn't sure why because she remembers having a conversation with nursing regarding R2 self-administering the inhaler. Surveyor explained the concern R2's inhaler is not secured somewhere that other residents don't have access to. DON-B understood the concern.

Based on record review and interview, the facility did not ensure a resident with psychotropic medications was comprehensively assessed for their use. This was observed with 1 (R38) of 5 resident medication reviews.* R38 was admitted [DATE] with Duloxetine (antidepressant), Bupropion (antidepressant) and Trazadone (antidepressant). The diagnosis for Duloxetine is for depression, Bupropion for dysthymia and Trazadone for insomnia. The medical record does not have documentation of a comprehensive assessment for the use of these medications. Findings include:The facility's policy and procedure Psychotropic Medication Use dated July 2022. Policy Interpretation and Implementation:1. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior.2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: b. Anti-depressants .3. Residents, families and/or the representative are involved in the medication management process. Medication management includes:a. indications for use;b. dose (including duplicate therapy);c. duration;d. adequate monitoring for efficacy and adverse consequences; ande. preventing, identifying and responding to adverse consequences.R38 was admitted to the facility on [DATE] with an activated Power of Attorney for Healthcare (POAHC). R38 has diagnosis of unspecified insomnia, unspecified depression and unspecified anxiety disorder. R38's medications upon admission to the facility are Duloxetine (antidepressant), Bupropion (antidepressant) and Trazadone (antidepressant). The diagnosis for Duloxetine is for depression, Bupropion for dysthymia and Trazadone for insomniaR38's admission Minimum Data Set (MDS) was completed on 12/12/25 and documents R38 is receiving antidepressant and antianxiety medications. The MDS Care Area Assessment (CAA) for Psychotropic Drug Use does not document a comprehensive assessment for depression, anxiety and insomnia. Surveyor notes R38's medical record does not have documentation of a comprehensive assessment related to depression medication indications for use and adequate monitoring.R38 Treatment Administration Record (TAR) for December 2025 documents a sleep study every hour for 12/8/25 - 12/10/25. This indicates yes or no for sleeping. The TAR for January 2026 documents a sleep study every hour for 1/1/26 - 1/3/26. This indicates yes or no for sleeping. There is no documentation related to this sleep study sleeping information. The sleep study documented if R38 was asleep or awake. There is no additional documentation related to a comprehensive assessment for insomnia including the sleep study information.On 2/18/2026, at 9:14 AM, Surveyor interviewed Director of Nurses (DON)-B. Surveyor reviewed R38's sleep study and psychotropic medications with DON-B. DON-B stated they were aware the MDS CAAs summary assessment is blank (no documentation of a comprehensive assessment). DON-B stated they will look for any additional assessments. DON-B stated there was no additional facility staff with information related to the assessment. R38's medical record was reviewed at this time. Surveyor notes there was no documentation of a comprehensive assessment for R38 3 antidepressant medications.On 2/18/2026, at 2:46 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A and DON-B, no further information was provided for R38's psychotropic medications.

Based on record review and interview, the facility did not document additional assessments for the Care Area Assessment (CAA) triggered by the Minimum Data Set (MDS) assessment information. This would include a summary of the information to complete a comprehensive assessment. This was observed with 3 (R38, R23, and R62) of 12 resident reviews. * R38 had an admission MDS assessment completed on 12/12/25. The MDS triggered CAAs for Falls, Pressure Injury, Psychotropic Drug Use, Psychosocial Well-Being and Behavioral Symptoms. The CAAs did not have an additional assessment summary analyzing the MDS data and need for an individualized care plan. * R23 had a Significant Change in Status (SCS) MDS assessment completed on 11/19/25. The MDS triggered a CAA for Falls. The CAA did not have an additional assessment summary analyzing the MDS data and need for an individualized care plan. * R62 had an admission MDS assessment completed on 11/16/25. The MDS triggered a CAA for Falls. The CAA did not have an additional assessment summary analyzing the MDS data and need for an individualized care plan . Findings include: The facility policy and procedure Care Area Assessments undated documents Policy: Care Area Assessments (CAAs) will be used to help analyze data obtained from the MDS and to develop individualized care plans. CAAs are the link between the assessment and care planning.Policy Interpretation and Implementation:5. CAA documentation explains the basis for the care plan. This documentation should include:a. Causes and contributing factors for the triggered care areas; b. The nature of the condition or issue (i.e., What exactly is the problem and why is it a problem?);c. Complications contributing to (or caused by) the care area;d. Risk factors related to the condition;e. Factors that should be considering in developing the care plan (including reasons to care plan or not to care plan particular findings);f. Any need for further evaluation by the physician or other health care provider;g. Resources and tools used for decision making;h. Conclusions that arise from the care area assessment process; [NAME]. Completion of section V of the MDS. On 2/18/2026, at 10:02 AM, Surveyor interviewed MDS Nurse-K via phone. MDS Nurse-K stated they do not write a long narrative in the CAA Summary. The electronic medical record Point Click Care (PCC) triggers the CAA by checked boxes. The PCC system triggers the areas of concern, and they check the boxes. MDS Nurse-K stated the residents are discussed and the care plan is an interdisciplinary development. MDS Nurse-K stated she does not document a summary of the triggered CAAs from the MDS assessment. 1.) R38 was admitted to the facility on [DATE] with an activated Power of Attorney for Healthcare (POAHC). R38 has diagnosis of unspecified insomnia, unspecified depression and unspecified anxiety disorder. R38's medications upon admission are Duloxetine (antidepressant), Bupropion (antidepressant) and Trazadone (antidepressant). The diagnosis for Duloxetine is for depression, Bupropion for dysthymia and Trazadone for insomnia The admission Minimum Data Set (MDS) was completed on 12/12/25 which documents R38 is receiving antidepressant and antianxiety medications. R38 has range of motion (ROM) impairment on one side of upper extremity. No ROM impairment on lower extremities. R38's MDS R38 requires partial/moderate assistance for transfers, substantial/maximum assistance for upper dressing and mobility, and is dependent for showers and lower dressing. R38's MDS documents R38 has a pressure injury, currently has two unstageable pressure injuries, and is at risk for developing pressure injury. R38 has had 2 or more falls since admission or previous assessment. R38's MDS Care Area Assessment (CAA) triggered additional assessment information for Psychotropic Drug Use, Psychosocial Well-Being, Behavioral Symptoms, Pressure Injuries and Falls. Surveyor notes these CAAs do not have documentation of an assessment summary analyzing the MDS data and need for an individualized care plan. Surveyor notes boxes that are checked on the CAAs, however, there is no narrative describing the impact of the problem/need and the rationale for a care plan decision. On 2/18/2026, at 9:14 AM, Surveyor interviewed Director of Nurses (DON)-B who stated R38's sleep study and psychotropic medications were reviewed. DON-B stated they were aware the MDS CAAs did not have a comprehensive assessment. On 2/18/2026, at 2:46 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A and DON-B, no further information was provided as to why the facility did not complete a summary analyzing R38's assessment information in the CAA. 2) R38 was admitted to the facility on [DATE] with diagnoses of Fracture of One Rib, Right Side, Vascular Dementia(brain damage caused by multiple strokes), Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), Essential Hypertension(chronic condition of persistently high blood pressure), Insomnia(sleep disorder characterized by difficulty falling asleep), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R38 has an activated Health Care Power of Attorney(HCPOA). R38's admission Minimum Data Set(MDS) completed 12/12/25 documents R38's Brief Interview for Mental Status(BIMS) score to be 0, indicating R38 demonstrates severely impaired skills for daily decision making. R38 has no depressive symptoms. R38 has range of motion(ROM) impairment on one side of upper extremity. No ROM impairment on lower extremities. R38's MDS documents R38 demonstrates physical and other behaviors 1-3 days. R38 requires supervision for eating. R38 requires partial/moderate assistance for transfers, substantial/maximum assistance for upper dressing and mobility, and is dependent for showers and lower dressing. R38's MDS documents R38 has a pressure injury, currently has two unstageable, and is at risk for developing pressure injury. R38 has had 2 or more falls since admission or previous assessment. Surveyor reviewed R38's pressure injury and falls care area assessment(CAA). There are boxes that are checked, however, there is no narrative describing the impact of the problem/need and the rationale for a care plan decision. 3) R23 was admitted to the facility on [DATE] with diagnoses of Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Essential Hypertension(chronic condition of persistently high blood pressure), Hyperlipidemia(high levels of fat particles in blood), Protein-Calorie Malnutrition Moderate(significant, but not severe, deficiency in nutrient intake), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), and Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R23 has activated Health Care Power of Attorney(HCPOA). R23's Significant Change MDS completed 11/19/25 documents R23's BIMS score is 0, indicating R23 demonstrates severely impaired skills for daily decision making. R23 has no depressive symptoms. R23 demonstrates verbal and other behaviors 1-3 days. R23 has ROM impairment on one side of lower extremity and has no upper ROM impairment. R23 requires partial/moderate assistance for eating. R23's MDS also documents R23 requires substantial/maximum assistance for showers and upper dressing, and is dependent for lower body dressing, transfers, and mobility. R23's is dependent for sit to stand-the ability to come to a standing position from sitting on the bed. R23's MDS also documents that R23 has minimal difficulty for hearing and has hearing aides. R23 has had 2 or more falls since admission or previous assessment. Surveyor reviewed R23's falls care area assessment(CAA). There are boxes that are checked, however, there is no narrative describing the impact of the problem/need and the rationale for a care plan decision. On 2/18/2026, at 10:02 AM, Minimum Data Set (MDS)-K was interviewed by Surveyor on the team. MDS-K confirmed MDS-K is responsible for each residents' CAA. MDS-K does not write much because the boxes are checked to identify areas. MDS-K stated MDS-K does not write long narratives due to the residents' electronic medical record(EMR) which pulls in information. MDS-K stated that MDS-K will start completing CAA narratives effective today. On 2/18/2026, at 1:27 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern that both R38 and R23 did not have triggered care area assessemts(CAA) completed for falls and R38 did not have a CAA completed for pressure injury. No further information has been provided by the facility as to why CAAs triggered have not been completed with a thorough narrative describing the impact of the problem, rationale for a care plan decision, and interventions implemented. 3) R62 was admitted to the facility on [DATE] with diagnoses of parkinsonism, anxiety and hypertension. The fall risk assessment dated [DATE] documents R62 is high risk for potential falls. The admission Minimum Data Set (MDS) dated [DATE] documents R62 has severe cognitive impairment and is dependent for bathing and rolling in bed. It also documents R62 had a fall prior to admission. The Care Assessment Area (CAA) dated 11/16/25 documents history of falls, confusion and weakness. The CAAs did not have an additional assessment summary analyzing the MDS data and need for an individualized care plan. On 2/18/2026, at 10:02 AM, Surveyor interviewed MDS Nurse-K via phone. MDS Nurse-K stated they do not write a long narrative in the CAA Summary. The electronic medical record Point Click Care (PCC) triggers the CAA by checked boxes. The PCC system triggers the areas of concern, and they check the boxes. MDS Nurse-K stated the residents are discussed and the care plan is an interdisciplinary development. MDS Nurse-K stated she does not document a summary of the triggered CAAs from the MDS assessment. On 2/18/2026, at 2:46 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A and Direction of Nursing (DON)-B, no further information was provided as to why the facility did not complete a summary analyzing R62's assessment information in the CAA.

Based on record review, observation and interviews, the facility did not ensure the required nurse staff posting information was posted. The facility did not document the total amount of hours for Certified Nursing Assistants (CNAs). This had the potential to affect all 39 residents in the facility.Findings include:The policy Titled Staffing Hours Posting Procedure, created 1/2020 documented:ResponsibilityThe nursing Scheduler creates/posts weekday BIPA sheets.Designee acts if scheduler is absent.Required informationNursing staff hours based on position for all 3 shifts.Compliance MonitoringNurse Manager/DON (director of nursing) and/or verifies presence and accuracy.Surveyor reviewed January 2026 and February 2026 nurse staff schedules along with the nurse staff posting information. The nurse staff posting did not document the total number of hours for CNAs.On 2/17/2026, at 2:05 PM, Surveyor spoke with Staffing Specialist (SS)-C who has been in the role for over a year. SS-C admitted they are responsible for filling out the staff posting information. SS-C was not aware that the required CNA staffing hours were not posted. SS-C stated it was an oversight.On 2/17/26, at 2:27 PM, Surveyor spoke with Nursing Home Administrator (NHA)-A who indicated the SS-C fills out the nurse staffing information. NHA-A was not aware of the missing CNA posting information. NHA-A stated the staff postings are made by hand and the CNA hours were missing. NHA-A stated either NHA-A or Director of Nursing (DON)-B are responsible for the daily postings if SS-C is absent.On 2/17/26, at 3:03 PM, Surveyor shared the concern of information missing from the nurse staff posting with NHA- A and DON- B. No additional information was provided.

Based on interview and record review, the facility did not ensure 1 (R1) of 1 facility reported incidents reviewed for an allegation of misappropriation, was reported to the local law enforcement agency.*On 6/26/25, facility staff was made aware of R1's missing narcotic pain medication. The facility did not report the incident to local law enforcement.Findings include: The facility policy with a revision date of November 2022, titled Controlled Substances documents, in part: . Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. The director of nursing services documents irreconcilable discrepancies in a report to the administrator. If a major discrepancy or a pattern of discrepancies occurs, or if there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. The administrator, consultant pharmacist and/or director of nursing services determine whether other action(s) are needed, e.g., notification of police or other enforcement personnel. The facility policy dated 9/22/23 titled Abuse Prevention Program documents, in part: . Employees are required to report any incident, allegation, or suspicion of potential abuse neglect or misappropriation of property they observe, hear about, or suspect immediately to the Administrator or the person in charge of the community, acting on behalf of the Administrator. If a crime is suspected, the Administrator will coordinate timely reporting to the state survey agency and local law enforcement on behalf of the employees involved. Any incident or allegation involving abuse, neglect, or misappropriation will result in an abuse investigation. If a reasonable suspicion of a crime has occurred, the resident's representative and the Department of Health and law enforcement shall be informed according to the following timeframes: Serious bodily injury- immediately but not later than 2 hours after forming the suspicion. All others- not later than 2 hours after forming the suspicion.R1 was admitted to the facility on [DATE]. R1 is currently on hospice care and has the following active MD order: Morphine Sulfate (Concentrate) Oral Solution 100 [milligrams (mg) per 5 milliliters (ml)]. Give 0.25 ml by mouth every 4 hours as needed for Pain - Moderate to severe pain.Surveyor reviewed the facility self-report regarding R1's Morphine medication. The self-report documents, in part: During narcotic count PM shift change on June 26, 2025, our two-nurse counting protocol identified an isolated discrepancy with [R1]'s morphine syringe bags. The two nurses counting were present. The physical count did not align with the documented record, resulting in a numerical variance from 19 vs. 20 syringes. Investigation initiated, and a comprehensive search of the designated medication storage and transport areas was performed. Nurse Educator contacted all relevant nursing staff who had been on duty since the discrepancy was identified. [R1] is on hospice services, who were also spoken to and did not administer. Pharmacy also contacted and confirmed that the 20 syringes were delivered on the refill on 6/25. The investigation concluded that there was no evidence of diversion or intentional misappropriation as the singular 0.25morphine syringe was not found through investigation and search. The self-report includes: all staff interviews and statements completed, the conclusion of the audits of medication carts, the pharmacy packing slip indicating the amount of Morphine delivered on 6/25/25, review of R1's Medication Administration record, Narcotic sheets and pain assessments, and Education provided to nursing staff. On 7/15/25 at 12:51 PM, Surveyor interviewed Registered Nurse (RN)-E who worked the night shift starting on 6/25/25 and went to the morning of 6/26/25. Surveyor asked what occurred on 6/25/25 through 6/26/25 regarding R1's Morphine medication. RN-E stated that on the evening of 6/25/25 RN-E received a delivery of R1's Morphine from the pharmacy. RN-E stated that RN-E took the bag of Morphine and counted the number of syringes twice to ensure the count was correct. RN-E stated that Licensed Practical Nurse (LPN)-C was witness to the count completed. RN-E stated there was 20 syringes. RN-E put the medication in the med drawer and locked the drawer. RN-E did not give any Morphine during that shift. RN-E stated that R1 was comfortable and did not display any signs or symptoms of pain during that shift. At the end of RN-E's shift, RN-E completed the narcotic count with LPN-D and the count remained at 20 syringes.On 7/15/25 at 12:46 PM, Surveyor interviewed LPN-C who worked the PM shift on 6/25/25 and the PM shift on 6/26/25. Surveyor asked what occurred on 6/25/25 through 6/26/25 regarding R1's Morphine medication. LPN-C stated that LPN-C witnessed the counting of R1's Morphine on 6/25/25 after it was delivered by pharmacy. LPN-C stated that RN-E counted the medication and got a count of 20. The next day when LPN-C returned to the facility for LPN-C's next shift, LPN-C completed the count of R1's Morphine with LPN-D, the count was 19. LPN-C stated that LPN-C reviewed the Medication Administration Record and Narcotic sheet, and nothing was documented that R1 received the Morphine. LPN-C stated that LPN-C immediately reported the missing narcotic medication to nursing leadership.On 7/15/25 at 12:03 PM, Surveyor interviewed LPN-D who worked the Day shift when the facility found that R1's Morphine syringe was missing. LPN-D indicated that LPN-D is very careful about counting narcotic pain medications. LPN-D indicated that when LPN-D started the shift on 6/26/25, the count of morphine was 20, at the end of LPN-D's shift, the count was 19. LPN-D stated that R1 was comfortable and did not require any Morphine during the shift. When the discrepancy was identified, nursing leadership was notified.On 7/15/25 at 1:32 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B stated that DON-B was made aware of the Morphine discrepancy by Assistant Director of Nursing (ADON) when DON-B was on vacation. When DON-B returned to the facility after vacation, DON-B reviewed the on-going investigation and wanted to continue to investigate to find out what happened. DON-B stated that in addition to all of what is included in the investigation, DON-B, the ADON and the nurse educator, took the time to sit and watch all video camera footage of when R1's Medication was delivered to the facility until the count was completed and a syringe was missing. DON-B stated that nothing concerning was found on the video footage. DON-B stated that the facility was unable to identify the cause of R1's missing Morphine.Surveyor concluded that despite not knowing what caused the count to be off, the facility did complete a thorough investigation into R1's missing Morphine syringe. Surveyor noted the facility did not contact local law enforcement to inform them of the misappropriation of R1's Morphine medication.On 7/15/25 at 12:40 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor asked if local law enforcement was notified of the misappropriation of R1's Morphine medication. NHA-A stated that contacting the police was discussed with the facility consultant, but the police were not notified. NHA-A indicated that they did not feel like this was a systemic issue as there was only one syringe missing. NHA-A stated that at one point, facility staff thought they had solved the discrepancy but that was not the case. Given that it was not a systemic issue the police were not notified. NHA-A asked Surveyor if the police should have been called. Surveyor stated that if there is reasonable suspicion of a crime, police should be notified. NHA-A stated that's on me. NHA-A indicated NHA-A did not suspect a crime because it was just one dose but did appreciate the feedback. Surveyor informed NHA-A of the concern that police were not notified after the misappropriation of R1's Morphine medication.No further information was provided.

Based on observation, interview, and record review, the Facility did not ensure staff followed infection control procedures for 3 (R13, R22 and R290) of 12 residents sampled. * Wound care preformed for R13- staff did not follow standard of practice for hand hygiene in between glove changes and did not sanitize scissors for wound treatment. *R290 noted to be on Enhanced Barrier Precautions (EBP), staff member observed not following standards of practice while providing high contact, incontinence care. *Incontinence cares observed for R22, staff member observed not changing soiled gloves and did not perform hand hygiene prior to applying lotion to R22. Findings include: The Facility's policy, titled Handwashing/Hand Hygiene, with a last revision date of October 2023, documents in part, Administrative Practices to Promote Hand Hygiene . 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene 1. Hand Hygiene is indicated: a. immediately before touching a resident; b. before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical device); c. after contact with blood, body fluids, or contaminated surfaces; d. after touching a resident; e. after touching a resident's environment; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. The Facility's policy, titled Enhanced Barrier Precautions, with a last revision date of October 2023, documents in part, Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multi drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gowns are applied before performing the high contact resident care activity (as opposed to before entering the room) . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) h. chronic wound care . 1.) R22 was admitted to the facility on [DATE]. R22's Admission Minimum Data Set (MDS), dated [DATE], documents R22's Brief Interview for Mental Status (BIMS) score is 06, indicating R22 has severely impaired cognition. R22's Admission MDS documents R22 has frequent urinary incontinence, always incontinent of bowel and dependent when performing toileting hygiene. R22's primary medical condition category is documented as medically complex conditions. On 11/26/2024, at 10:34 AM, Surveyor observed incontinence cares for R22. Surveyor observed Certified Nursing Assistant (CNA) CNA-F perform incontinence care for R22, with CNA-G and CNA-H assisting; all CNAs were wearing gloves to provide cares. Surveyor observed the CNA's assist R22 rolling onto R22's left side. CNA-F removed R22's brief, Surveyor observed a small bowel movement. Surveyor observed CNA-F wash the fecal matter off of R22's buttocks, CNA-F then grabbed a clean towel, dried R22's buttocks. CNA-F then grabbed a small bottle of lotion, squeezed lotion into CNA-F's hand and rubbed the lotion onto R22's buttock with unchanged gloves. CNA-F did not perform hand hygiene or change gloves after performing incontinence cares for R22. 2.) R290 was admitted to the facility on [DATE]. R290's BIMS score is 13 as documented in a progress note, on 11/13/2024 at 01:55 PM. R290 has a relevant medical diagnosis of urinary retention. Surveyor noted R290 has an indwelling catheter per R290's medical record. On 11/25/2024, at 12:33 PM, Surveyor observed R290 to have an enhanced barrier precautions (EBP) sign on door and a 3 drawer cart outside the room with personal protective equipment (PPE). On 11/25/2024 at 01:36 PM, Surveyor observed CNA-E and CNA-D assisting R290 into bed using a Hoyer lift. Surveyor noted CNA-E and CNA-D did not don gowns, but donned gloves. Once R290 was in bed, CNA-D removed R290's pants and brief to begin performing incontinence cares. CNA-D completed cares with R290 without concerns, Surveyor asked CNA-D if R290 was on any precautions, CNA-D informed Surveyor that R290 was not on any precautions. On 11/26/2024, at 01:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Infection Preventionist (IP)-C of above concerns. 21855 3.) On 11/26/24, at 9:55 AM, Surveyor observed wound care for R13 completed by Infection Preventionist (IP)-C. IP-C began by utilizing hand hygiene and donning gloves and a gown. IP-C dated two border foam dressings on the over bed table. IP-C removed the dressing on R13's mid back. IP-C removed their gloves with the used dressing and donned new gloves. IP-C did not utilize hand hygiene with the glove change. IP-C cleansed the wound and then removed their glove on their right-hand after washing the wound. IP-C then donned a new glove on their right hand. IP-C did not utilize hand hygiene with the glove change. IP-C then took scissors and cut through a package of Xeroform. IP-C cut out a section through the package. IP-C did not sanitize their scissors, nor open the package to access the dressing directly. IP-C applied the Xeroform to the wound bed via a Q-tip swab. IP-C then applied the border foam dressing. IP-C removed their gloves and utilized hand hygiene. IP-C then donned new gloves. IP-C removed the used dressing from the sacrum area. IP-C removed their gloves and donned new gloves. IP-C did not utilize hand hygiene after the glove change. IP-C cleansed the wound then removed their right hand glove. IP-C then donned a new right glove. IP-C did not utilize hand hygiene with the glove change. IP-C used their scissors to cut a section of Xeroform through the package. IP-C did not sanitize their scissors, nor open the package to access the dressing directly. IP-C applied the Xeroform to the wound bed via a Q-tip swab. IP-C then applied the border foam dressing. IP-C removed their gloves and donned new gloves. IP-C did not utilize hand hygiene with the glove changes. IP-C removed all the used dressing supplies and equipment IP-C then removed their gloves, and gown, in R13's bathroom. IP-C then washed their hands. Surveyor queried IP-C on hand hygiene and scissor use. IP-C stated they do not have anything to sterilize their scissors, so they cut through the packaging and they view each wound as its own contamination. They also did not think to utilize hand hygiene with glove removals. On 11/26/24 at 3:00 PM, at the facility exit meeting, Surveyor shared the infection control concerns with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and IP-C. No further information was provided.

Based on observation and interview the facility did not ensure the call light was within reach for 1 (R290) of 12 residents reviewed. *R290 was observed in R290's room without a call light within reach. Findings include: R290 was admitted to the facility on [DATE]. R290's BIMS score is 13 as documented in a progress note, on 11/13/2024 at 01:55 PM. R290's care plan documents in part, R290 has Activities of Daily Living (ADL) self-care performance deficit, related to activity intolerance, and anemia. R290 is completely dependent on staff assistance for bathing, dressing, toileting; and requires an assist of 2 staff, using a Hoyer lift for transfers. R290's care plan indicates R290 is at risk for falls, with an intervention documenting, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Surveyor notes R290's care plan does not indicate R290 prefers to call for assistance using the cordless phone, or that R290's call light does not have to be within reach. A progress note, dated 11/14/2024, at 11:46 AM, documents in part, R290 will be admitted to the Facility for long term care, R290 is able to makes needs known, R290 uses a Hoyer lift at baseline and is reliant on staff to meet Activities of Daily Living (ADL) needs. On 11/25/2024, at 12:23 PM, Surveyor observed R290 up in wheelchair, the bedside table was within reach, and the call light was attached to R290's bed, which was out of reach for R290. R290 indicated to Surveyor that the call light is normally attached to R290. Surveyor asked R290 how R290 would call for assistance. R290 informed Surveyor that R290 would need to yell. On 11/25/2024, at 01:27 PM, R290 informed Surveyor that R290 used R290's cordless phone to call down to the front desk around 12:50 PM, to ask for assistance being put into bed due to R290's buttock was painful. R290 informed Surveyor that a staff member came in and moved R290's bedside table containing the cordless phone, out of R290's reach, then left R290's room. R290 asked Surveyor to move R290's side table back over by R290 so that R290 can attempt to call for assistance again. Surveyor noted R290 was unable to move around the room without assistance. On 11/25/2024, at 01:36 PM, Surveyor observed Certified Nursing Assistant (CNA)-D and CNA-E enter R290's room to assist R290 into bed. On 11/26/2024, at 01:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of above concerns.

Based on observation, interview, and record review the Facility did not provide necessary treatment and services to prevent development of a pressure injury and promote healing for 1 (R4) of 3 Residents with pressure injuries. On 2/8/22 R4's significant change minimum data set indicated R4 was at risk for the development of pressure injuries. R4's plan of care for pressure injuries was not revised to include individualized interventions to prevent developing pressure injuries based upon assessment. On 3/6/22 nursing noted R4 developed a pea sized area on the sacrum and was called a stage 2. The area was not comprehensively assessed on this date. On 3/8/22 the Facility assessed the area and staged it as a stage 2 pressure injury despite the area being assessed to have 60% slough present. A Stage 2 pressure injury does not have slough in the wound bed. The Facility has continued to incorrectly stage R4's pressure injury. On 3/29/22 the wound assessment revealed the wound bed has epithelial & granulation tissue. The Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue and continued to incorrectly stage R4's pressure injury. During weekly assessments, it is indicated the pressure injury was increasing in size and there were no revision of the care plan with the last revision dated 4/17/22. On 5/17/22 R4 was observed to not be checked and/or changed for approximately 6 hours despite the facility indicating they believe the area originated as being from moisture related to incontinence. Findings include: The Pressure Injuries Overview, 2001 Med-Pass, Inc. (Revised March 2020) under Staging (National Pressure Injury Advisory Panel Classification System) for Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis includes Granulation tissue, slough and eschar are not present. R4 was admitted [DATE]. R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 is receiving hospice services. Minimum Data Set (MDS) assessment on 6/8/21 indicated R4 was at risk for developing pressure injuries. The potential for pressure ulcer development initiated 6/14/21 had the following interventions: *Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 6/14/21. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 6/14/21. * No brief at night in bed, resident choice. Initiated 8/25/21. * Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Initiated 6/14/21. * The resident needs assistance to turn/reposition with RDS, more often as needed or requested. Initiated 6/14/21. * Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Initiated 6/14/21. This potential for pressure ulcer development was resolved on 4/6/22. The significant change MDS (minimum data set) with an assessment reference date of 2/8/22 documents a BIMS (brief interview mental status) score of 4 which indicates severe impairment. R4 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use and does not ambulate. R4 is always incontinent of bowel and bladder. R4 is at risk for developing pressure injuries and is coded as not having any pressure injuries. On 2/8/22 R4's significant change minimum data set indicated R4 was at risk for the development of pressure injuries. Despite this risk, there were no individualized approaches in the care plan to prevent the development of a pressure injury. The nurses note dated 3/6/22 documents Patient has a small pea sized stage 2 pressure injury on sacrum. Skin prep applied around injury and [MEDICATION(S)] dressing applied and dated. The nurses note dated 3/7/22 documents Resident alert/responsive, NAD (no apparent distress). [MEDICATION(S)] dressing covers sacrum area. Resident repositioned side-to-side as tolerated. No expressions of pain. Will continue to monitor. Afebrile. The nurses note dated 3/7/22 documents New partial thickness lesion noted last night per NOC (night) shift-upon assessment wound is in intergluteal fold about 2 cm (centimeters) distal from bony prominence, wound edges diffuse and macerated, wound bed is moist with small amount serous drainage-reviewed w MD (with medical doctor) who states he will be present tomorrow morning for further evaluation to determine dx (diagnoses) pressure vs moisture-frosted w (with) zinc barrier cream in the interim. Spoke with POA (power of attorney) who verbalizes understanding and agrees with plan of care. The nurses note dated 3/8/22 documents Resident discussed by IDT this date r/t (related to) risk management. Resident is alert not oriented, not always able to make basic needs known. Remains on hospice services and is a DNR (no not resuscitate). Residents activated POA is her niece who is involved in her POC (plan of care). Resident has new stage 2 to coccyx. Area has been assessed by wound nurse. Treatment is in place and family aware. Appetite remains fair to good depending on residents mood. No other concerns noted at this time. Resident continues to get up daily in Broda and be in common areas and participate daily in activities. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.2, Width 0.6, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Granulation tissue present (beefy red) and Slough tissue present (yellow, tan, white stringy). For Describe the extent (%) of necrosis and/or slough in the wound bed documents 60. Surveyor noted Facility staff incorrectly Staged R4's pressure injury as a Stage 2 pressure injury does not have slough in the wound bed. Subsequent assessments, noted below, also incorrectly staged the pressure injury The resident has stage 2 pressure ulcer to medial intergluteal cleft initiated & revised on 3/8/22 has the following interventions: * The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 1 person assist and pillows. Initiated & revised 3/8/22 Surveyor noted R4 is assessed as requiring extensive assist of 2 staff for bed mobility. * Administer medications as ordered. Monitor/document for side effects and effectiveness. Initiated 3/8/22. * Avoid positioning the resident on back as she allows. Initiated 3/8/22 & revised 4/8/22. * Check air mattress QS (every shift). Initiated 4/17/22. * If the resident refuses treatment, confer with the resident, IDT (interdisciplinary team) and family to determine why and try alternative methods to gain compliance. Document alternative methods. Initiated 3/8/22. * Orange top barrier cream q shift (every shift) and PRN (as needed) with cares, remove top soiled layer and replace as needed. Initiated 3/8/22. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Initiated 3/8/22. Surveyor noted the interventions were not developed until after R4 developed a pressure injury with slough. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.2, Width 0.6, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Granulation tissue present (beefy red) and Slough tissue present (yellow, tan, white stringy). For Describe the extent (%) of necrosis and/or slough in the wound bed documents 60. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Granulation tissue present (beefy red) and Slough tissue present (yellow, tan, white stringy). For Describe the extent (%) of necrosis and/or slough in the wound bed documents 60. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 0.8, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 0.8, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 0.8, Width 0.4, Depth 0.1 and Stage II (2). Location small superficial wound to intergluteal fold. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue. The nurses note dated 4/16/22 documents Writer was called to room by care staff to assess wound on coccyx area. Wound is 1 cm in length x 1.4 cm in width and .5 cm depth. Area washed and cleansed thoroughly and barrier cream applied to area. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue. The Facility continues to incorrectly stage R4's pressure injury. Surveyor noted there was no revision in R4's plan of care after the pressure injury increased in size. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue. The wound assessment dated [DATE] documents for site 23) Coccyx, Type Pressure, Length 1.0, Width 0.6, Depth 0.2 and Stage II (2). Location pressure injury to coccyx. For visible tissue is checked for Epithelial tissue present (pink). and Granulation tissue present (beefy red). Surveyor noted the Facility did not comprehensively assess R4's pressure injury as the Facility did not document the percentage of epithelial & granulation tissue and continues to incorrectly stage R4's pressure injury. The Braden assessment dated [DATE] has a score of 14 which indicates moderate risk. The quarterly MDS (minimum data set) with an assessment reference date of 5/11/22 documents a BIMS (brief interview mental status) score of 3which indicates severe impairment. R4 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfers, and does not ambulate. R4 is always incontinent of bowel and bladder, is at risk for pressure injury development and is coded as having one Stage 2 pressure injury. On 5/17/22 at 7:26 a.m. Surveyor observed R4 sleeping in a Broda chair in the dining room. R4 is wearing gripper socks on her feet with a pillow under her feet. There is a Hoyer sling under R4 and the back of the chair is reclined slightly. Surveyor noted there is no care planned intervention regarding leaving the Hoyer sling under R4 when seated in the Broda chair. On 5/17/22 at 10:29 a.m. Surveyor noted R4 is not on the unit and is on another floor for an activity. On 5/17/22 at 12:09 p.m. Surveyor observed R4 sitting in a Broda chair at a table in the dining room with a red beverage in front of her. On 5/17/22 at 12:41 p.m. Surveyor observed R4 continues to be sitting at a table in the dining room. On 5/17/22 at 12:52 p.m. Surveyor observed RN (Registered Nurse) Manager-M wheeling R4 down the hallway stating to Surveyor she is going to let R4 sit up for a little as she had a magic cup. RN Manager-M wheeled R4 into her room informing Surveyor they are going to let her sit up then do her dressing and bed bath. On 5/17/22 at 1:10 p.m. Surveyor observed CNA-Q & CNA-P in R4's room with a Hoyer lift. Surveyor observed CNA-Q & CNA-P attached the Hoyer sling which was under R4 to the Hoyer lift, raise R4 off her chair, wheel R4 over to the bed and lower R4 onto the bed. At 1:14 p.m. RN (Register Nurse) Manager-M and RN-E entered R4's room. At 1:15 p.m. R4 was positioned side to side to remove the sling, lower the pants and R4's incontinence product was unfastened. CNA-Q washed R4's frontal perineal area and removed the wet incontinence product. After CNA-Q completed incontinence cares, RN Manager-M removed the dressing, measured the pressure injury indicating measurements of 1.0 cm (centimeter) length, 0.6 cm width and 0.2 depth stating there is a line of tissue growing in the wound bed. RN Manager-M completed R4's treatment according to physician orders. On 5/17/22 at 1:38 p.m. Surveyor asked CNA-P what she does for R4. CNA-P informed Surveyor the night shift gets R4 up, she helps her with breakfast & lunch and R4 goes to activities. R4 will lay down after lunch and rotate R4 every two hours. Surveyor inquired when incontinence cares are provided to R4. CNA-P informed Surveyor depends when night shift gets her up. Surveyor asked CNA-P if this was the first time incontinence cares were provided today to R4. CNA-P replied yes. Surveyor noted R4 who has a coccyx pressure injury has not been checked &/or changed for approximately six hours. On 5/17/22 at 1:46 p.m. Surveyor met with RN Manager-M to discuss R4. Surveyor asked RN Manager-M, who is the wound nurse for the Facility, how R4 developed the pressure injury. RN Manager-M informed Surveyor she thinks it started as moisture. RN Manager-M explained hospice was using a different brand of incontinence briefs and then they switched back to a high absorbency brief. RN Manager-M informed Surveyor once the skin was compromised the area opened up. RN Manager-M informed Surveyor they have since gotten a roho cushion for R4's Broda chair. Surveyor asked if R4 received the roho cushion after development of the pressure injury. RN Manager-M replied yes. Surveyor asked RN Manager-M why she staged the pressure injury as a Stage 2. RN Manager-M informed Surveyor the doctor said it was partial thickness loss. Surveyor informed RN Manager-M a Stage 2 pressure injury does not have slough in the wound bed and explained it would be a Stage 3 or unstageable depending on the percentage of slough. RN Manager-M informed Surveyor she would go in and fix it. Surveyor informed RN Manager-M of today's observation of R4 not being checked &/or changed for approximately 6 hours. On 5/18/22 at 3:18 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above. On 5/19/22 at 8:30 a.m. Surveyor asked RN Manager-M why her assessments don't include the percentage of granulation and epithelial tissue. RN Manager-M informed Surveyor she was informed she needs to do percentage of the wound bed when there is slough.

Based on interview and record review the facility did not ensure they completed COVID-19 testing of staff according to Center for Disease Control (CDC) recommendations for 1 of 3 staff with approved non-medical exception for the COVID-19 vaccination. There is no documentation Staff-L, who has a non-medical COVID-19 vaccination exemption, is being tested for COVID-19 according to CDC county transmission rates. This has the potential to affect all 35 Residents at the facility. Findings include: On 5/18/22, this Surveyor reviewed the facility policy titled Resident and Staff Testing Intervals for COVID-19, undated, which documents: Staff not up to date (COVID-19 vaccination) must routine test at a minimum according to CDC county transmission rate. 1. High to Substantial High (Rate)-2 times per week; 2. Moderate (Rate)-1 time per week 3. Low (Rate)-not recommended. On 5/18/22, this Surveyor reviewed the facility staff vaccination tracking log. Three staff with non-medical vaccination exceptions were reviewed. Staff-L had an approved non-medical COVID-19 vaccination exemption. Staff L's testing records were reviewed and no COVID-19 testing could be found from 3/26/22 to 5/18/22. Staff-L started employment with the facility on 9/21/21. On 5/18/22, the CDC county transmission rate for Milwaukee county was reviewed for the timeframe of 3/26/22 to 5/13/22. The county was documented to be in moderate or high spread for the entirety of that time, indicating Staff-L should have been tested for COVID-19 either 1 or 2 times per week. This Surveyor reviewed Staff-L's work scheduled during the time of 3/26/22 to 5/18/22. The facility schedule documented Staff-L worked on both resident living units for a total of 18 shifts. On 5/18/22, at 1:45 PM, Director of Nursing (DON)-B was interviewed and indicated that no documentation could be found that Staff-L was tested for COVID-19 between 3/26/22 and 5/18/22 and he should have been. The above findings were shared with Nursing Home Administrator-A and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM. Additional information was requested if available. None was provided.

Based on observation, interview, and record review the facility did not have an updated comprehensive assessment for repositioning/assist bars for 10 (R18, R234, R1, R17, R2, R23, R6, R9, R15 & R25) of 10 Residents observed with repositioning/assist bars. Further, the facility did not have evidence of the Interdisciplinary Team (IDT) involvement, no documentation of repositioning/assist bars being reviewed at care conference, and repositioning/assist bars were not documented on their Minimum Data Set (MDS) or comprehensive care plan. *R18, R234, R1, R17, R2, R23, R6, R9, R15, and R25 did not have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Their electronic medical record (EMR) did not have evidence that risks and benefits were discussed with the Resident and/or representative. Findings Include: Surveyor reviewed the facility's Proper Use Bed Assistive Device policy and procedure revised 12/16 and notes the following: Policy: Bed assistive devices will be assessed on an individual basis. Bed assistive devices will only be applied if manufactured for the specific bed. Facility does not use bedrails, siderails, or safety rails. Procedure: 1. If a Resident and/or responsible party requests a bed assistive device, Physical Therapy(PT) and/or nursing will assess, and the Registered Nurse(RN) manager will monitor the Resident's cognitive and functional ability for use. 2. If an assessment shows the Resident's ability is appropriate, the bed assistive device will be attached to the bed. 3. An assessment will be done quarterly, with a change of condition, and annually to determine if use of the bed assistive device continues to be appropriate. 1.) R18 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R18 is her own person. R18's Admission Minimum Data Set(MDS) dated [DATE] documents R18's Brief Interview for Mental Status (BIMS) score to be 15 indicating R18 is cognitively intact for daily decision making. R18's MDS also documents that R18 requires extensive assistance of 2 for bed mobility, transfers, dressing, and toileting. Bed rail is not documented on R18's MDS. On 5/16/22 at 10:38 AM, Surveyor observed 2 repositioning bars located on R18's bed. At 10:46 AM, R18 informed Surveyor that R18 does not use the repositioning bars. Surveyor was unable to locate an assessment for repositioning bars in R18's medical record. Surveyor notes that repositioning bars are not documented in R18's comprehensive care plan. Surveyor notes there is no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] 2.) R234 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R234 is her own person. Surveyor notes R234's 5/13/22 Admission MDS is in progress dated 5/13/22. A BIMS was completed on 5/9/22 and R234 has a score of 15 indicating R234 is cognitively intact for daily decision making. On 5/16/22 at 10:28 AM, Surveyor observed 2 repositioning bars located on R234's bed. On 5/18/22 at 8:45 AM, R234 informed Surveyor that R234 does not use the repositioning bars. Surveyor was unable to locate an assessment for repositioning bars in R234's medical record. Surveyor notes that repositioning bars are not documented in R234's comprehensive care plan. Surveyor notes there is no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] 3.) R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 is his own person. R1's Admission MDS dated [DATE] documents R1's BIMS score to be a 6, indicating R1 demonstrates severely impaired skills for daily decision making. R1 requires limited assistance for bed mobility, and extensive assistance for toileting, transfers, dressing, and hygiene. Bed rail is not documented on R234's MDS. On 5/16/22 at 10:32 AM, Surveyor observed R1 had 1 repositioning bar on left side of R1's bed. Surveyor was unable to locate an assessment for repositioning bars in R1's medical record. Surveyor notes that repositioning bars are not documented in R1's comprehensive care plan. Surveyor notes there is no physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/17/22 at 11:25 AM, Director of Nursing(DON-B) stated that therapy does an assessment for repositioning bars and should be in the Resident's chart. On 5/17/22 at 1:54 PM, Surveyor informed DON-B that Surveyor could not find assessments for the R18, R234, and R1. DON-B indicated they would check with therapy to see if they have the assessments. DON-B stated the facility has been back and forth with who is doing the assessments. On 5/17/22 at 2:41 PM, DON-B stated that all Residents in the facility have the repositioning bars on their beds. We use them for the remotes, call lights, and sometimes for positioning. We do not have assessments for any of the Residents for the repositioning bars. On 5/17/22 at 3:04 PM, Surveyor shared the concern with Administrator(NHA-A) and DON-B that R18, R234, and R1 did not have a completed assessment for their repositioning bars. Surveyor also shared there is no documentation that risks and benefits were explained to the Resident and there was no documentation of the repositioning bars on R18, R234, and R1's care, and there was no physician's order for the repositioning bars. No further information was provided at this time. On 5/18/22 at 11:46 AM, the facility provided an undated siderail assessment for R18, R234, and R1. On 5/18/22 at 3:07 PM, Surveyor again shared the concern with DON-B and NHA-A of R18, R234, and R1 not having an assessment for the repositioning bars including documentation that risks and benefits were acknowledged by R18, R23, and R1. DON-B confirmed the assessments provided by the facility were completed after Surveyor addressed the concern of no assessments for R18, R234, and R1. No further information was provided at this time. 4.) R2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly MDS (minimum data set) with an assessment reference date of 4/30/22 documents a BIMS (brief interview mental status) score of 00 which indicates severe impairment. R2 requires extensive assistance with one person physical assist for bed mobility and under the physical restraint section bed rails is coded as not used. On 5/16/22 at 3:28 p.m. Surveyor observed R2 propelling self in a wheelchair in her room. Surveyor observed there is a transfer bar up on left side of bed. On 5/17/22 at 7:30 a.m. Surveyor observed R2 awake in bed on her back. Surveyor observed the transfer bar on the left side of R2's bed is up. Surveyor reviewed R2's paper and electronic record and was unable to locate an assessment for R2's left transfer bar. On 5/17/22 at 3:34 p.m. Surveyor asked RN (Registered Nurse)-K where Surveyor would be able to locate side rail/transfer bar assessments. RN-K informed Surveyor he doesn't know if there is an assessment. On 5/17/22 at 3:50 p.m. Surveyor informed DON (Director of Nursing)-B Surveyor is unable to locate an assessment for the transfer bar on R2's bed and asked DON-B to provide Surveyor with any information. On 5/18/22 at 8:22 a.m. Surveyor observed R2 in bed on her back with a left transfer bar up. On 5/18/22 at 3:01 p.m. Surveyor informed Administrator-A and DON (Director of Nursing)-B Surveyor was unable to locate an assessment for R2's left transfer bar. On 5/19/22 Surveyor reviewed the left transfer bar assessment for R2 dated 5/17/22. 5.) R9's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's annual MDS (minimum data set) with an assessment reference date of 2/10/22 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R9 requires extensive assistance with two plus person physical assist for bed mobility and under the physical restraint section bed rails is coded as not used. On 5/16/22 at 11:13 a.m. Surveyor observed R9 in bed on her back with the head of the bed elevated. Surveyor observed two padded quarter side rails up on the bed. On 5/17/22 at 7:36 a.m. Surveyor observed R9 in bed on her back with the head of the bed elevated and two padded quarter side rails up on the bed. Surveyor asked R9 if she uses the side rail. R9 replied sometimes and explained she holds onto them to pull herself over in bed. On 5/18/22 at 10:30 a.m. Surveyor observed R9 in bed on her back with the head of the bed elevated and two padded quarter side rails up on the bed. Surveyor reviewed R9's paper and electronic record and was unable to locate an assessment for R9's padded quarter side rail. On 5/17/22 at 3:34 p.m. Surveyor asked RN (Registered Nurse)-K where Surveyor would be able to locate side rail/transfer bar assessments. RN-K informed Surveyor he doesn't know if there is an assessment. RN-K explained they assess the mattress on R9's bed but not the bars specifically as not every bed has bars. On 5/17/22 at 3:50 p.m. Surveyor informed DON (Director of Nursing)-B Surveyor is unable to locate a side rail assessment for R9's padded side rails and asked DON-B to provide Surveyor with any information. On 5/19/22 Surveyor reviewed the side rail assessment for R9 dated 5/17/22. 6.) R15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS (minimum data set) with an assessment reference date of 4/8/22 documents a BIMS (brief interview mental status) score of 13 which indicates cognitively intact. R15 requires extensive assistance with two plus person physical assist and under the physical restraint section bed rails is coded as not used. On 5/16/22 at 10:17 a.m. Surveyor observed R15 in bed on her back with the head of the bed elevated. Surveyor observed there is are two transfer bars up. On 5/16/22 at 3:31 p.m. Surveyor observed R15 in bed. Surveyor observed there are two transfer bars up on R15's bed. On 5/17/22 at 7:33 a.m. Surveyor observed R15 in bed asleep. Surveyor observed there are two transfer bars up on R15's bed. On 5/18/22 at 8:25 a.m. Surveyor observed R15 in bed on her back with two transfer bars up on R15's bed. Surveyor reviewed R15's paper and electronic record and was unable to locate an assessment for R15's bilateral transfer bars. On 5/17/22 at 3:34 p.m. Surveyor asked RN (Registered Nurse)-K where Surveyor would be able to locate side rail/transfer bar assessments. RN-K informed Surveyor he doesn't know if there is an assessment. On 5/17/22 at 3:50 p.m. Surveyor informed DON (Director of Nursing)-B Surveyor is unable to locate an assessment for the transfer bars on R15's bed and asked DON-B to provide Surveyor with any information. On 5/18/22 at 3:01 p.m. Surveyor informed Administrator-A and DON (Director of Nursing)-B Surveyor was unable to locate an assessment for R15 transfer bars On 5/19/22 Surveyor reviewed the left transfer bar assessment for R15 dated 5/17/22. 7.) R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/22 R6's Quarterly Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score to be 3 indicating R6 has severe cognitive impairment. R6's MDS also documents that R6 requires extensive assistance of one for bed mobility. Bed rail is not documented on R6's MDS. On 05/17/22 at 2:34 PM R6 was observed sleeping in bed with the left repositioning bar up. On 5/17/22 R6's medical record was reviewed and an assessment for repositioning bars was not found in R6's medical record. On 5/17/22 R6's care plan was reviewed and a care plan for repositioning bars was not found in R6's care plan. On 5/17/22 R6's physician orders were reviewed and no orders for repositioning bars were found in R6's medical record. On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R6's repositioning bars. The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided. 8.) R17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/22 R17's Quarterly Minimum Data Set (MDS) dated [DATE] documents R17's Brief Interview for Mental Status (BIMS) score to be 12 indicating R17 has mild cognitive impairment. R17's MDS also documents that R17 requires supervision with assistance of one for bed mobility. Bed rail is not documented on R17's MDS. On 05/16/22 at 9:54 AM R17 was observed sleeping in bed with a repositioning bar up on the left side of the bed. On 05/17/22 at 10:54 AM R17 was observed sleeping in bed with a repositioning bar up on the left side of the bed. On 05/18/22 at 8:55 AM R17 was observed sleeping in bed with a repositioning bar up on the left side of the bed. On 5/17/22 R17's medical record was reviewed and an assessment for repositioning bars was not found in R17's medical record. On 5/17/22 R17's care plan was reviewed and a care plan for repositioning bars was not found in R17's care plan. On 5/17/22 R17's physician orders were reviewed and no orders for repositioning bars were found in R17's medical record. On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R17's repositioning bars. The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided. 9.) R23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/22 R23's Significant Change in Status Minimum Data Set (MDS) dated [DATE] documents R23's Brief Interview for Mental Status (BIMS) score to be 0 indicating R23 has severe cognitive impairment. R23's MDS also documents that R6 requires extensive assistance of two for bed mobility. Bed rail is not documented on R23's MDS. On 05/17/22 at 2:57 PM R23 was observed in bed with both repositioning bars up. On 5/18/22 at 8:48 AM R23 was observed in bed with both repositioning bars up. On 5/17/22 R23's medical record was reviewed and an assessment for repositioning bars was not found in R23's medical record. On 5/17/22 R23's care plan was reviewed and a care plan for repositioning bars was not found in R23's care plan. On 5/17/22 R23's physician orders were reviewed and no orders for repositioning bars were found in R23's medical record. On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R23's repositioning bars. The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided. 10.) R25 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/17/22 R25's Quarterly Minimum Data Set (MDS) dated [DATE] documents R25's Brief Interview for Mental Status (BIMS) score to be 3 indicating R25 has severe cognitive impairment. R25's MDS also documents that R25 requires extensive assistance of two for bed mobility. Bed rail is not documented on R25's MDS. On 05/16/22 at 2:31 PM R25 was observed in bed with both repositioning bars up. On 5/17/22 at 3:00 PM R25 was observed in bed with both repositioning bars up. On 5/17/22 R25's medical record was reviewed and an assessment for repositioning bars was not found in R25's medical record. On 5/17/22 R25's care plan was reviewed and a care plan for repositioning bars was not found in R25's care plan. On 5/17/22 R25's physician orders were reviewed and no orders for repositioning bars were found in R25's medical record. On 5/18/22 at 9:02 AM Director of Nurses (DON)- B was interviewed and indicated that she could not find an assessment, order or care plan for R25's repositioning bars. The above findings were shared with the Administrator and DON-B at the daily exit meeting on 5/18/22 at 3:00 PM Additional information was requested if available. None was provided.

Based on interview and record review the Facility did not ensure 1 (R2) of 12 Residents reviewed for code status had their code status accurately documented in their medical record. R2's electronic medical record documented R2 is a full code [should receive CPR (cardiopulmonary resuscitation)] while the paper record documented R2 is a DNR (do not resuscitate). Findings include: The Advanced Directives policy 2001 Med-Pass, Inc (Revised [DATE]) under Policy Interpretation and Implementation documents 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. and 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive. R2 was admitted to the facility on [DATE]. The top portion of R2's electronic record documents CPR. The order summary report with active orders as of [DATE] includes a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician signed the order summary on [DATE] which includes a statement I have approved these orders for [R2's name]. Total pages 3. Surveyor noted this physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated & revised on [DATE] documents [R2] desires to be a Full Code. CPR. On [DATE] Surveyor reviewed R2's paper medical record and noted a pink (red) sheet of paper with large black letters DNR. The paper medical record also includes a Preference for Resuscitation form. NO Cardiopulmonary Resuscitation is checked. This form dated [DATE] is signed by R2's power of attorney for health care and witnessed by R2's daughter. The State of Wisconsin Emergency Care Do Not Resuscitate Order (DNR) is signed by R2's power of attorney on [DATE] and R2's physician on [DATE]. On [DATE] at 10:51 a.m. Surveyor asked RN (Registered Nurse)-E if she needed to find out a Resident's code status where would she find this information. RN-E informed Surveyor she would go to the hard (paper) chart and look at the paper which is either green for CPR or red for DNR. RN-E informed Surveyor she could also look under the advanced directive section and as the last report look in the computer. Surveyor asked RN-E if a Resident or their representative change the code status who is responsible for updating the Resident's medical record. RN-E informed Surveyor it is her understanding social service would update this. Surveyor inquired who would obtain the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-E indicated advanced directives is through social service. On [DATE] at 11:06 a.m. Surveyor asked SW (Social Worker)-C what is the process for Resident's code status. SW-C informed Surveyor the code status paper work is filled out by nursing upon admission and then if there are any changes. SW-C informed Surveyor they verify code status quarterly, annually, as well as during care conferences. Surveyor asked SW-C who would contact the physician for new orders if there is a change in code status. SW-C informed Surveyor the floor nurses or HSM (Health Services Manager)-D. Surveyor asked how HSM-D would become aware of a Resident's code status change. SW-C informed Surveyor HSM-D has the State DNR form and she has face to face interaction with the nurses. On [DATE] at 11:10 a.m. Surveyor asked HSM-D if she is involved in changes for Resident's code status. HSM-D informed Surveyor she is not directly involved with Resident's code status but will help out if the power of attorney lives out of state. HSM-D informed Surveyor on admission the nurse will ask about the code status and put the paper, either green or red, in the medical record. Surveyor asked what happens when there is a change in code status. HSM-D informed Surveyor the nurses have access to paper in the cabinet or can ask us. Surveyor asked HSM-D if she was involved with R2's change of code status. HSM-D replied not directly that I remember. Surveyor asked who is responsible for updating the care plan. HSM-D informed Surveyor she wasn't sure if it was SW-C, MDS (minimum data set) or the DON (Director of Nursing). On [DATE] at 11:14 a.m. Surveyor asked SW-C who would updates a Resident's care plan when there is a change in code status. SW-C informed Surveyor either nursing or social services and stated obviously that can change 24 hours a day and I'm not here. On [DATE] at 11:17 a.m. Surveyor asked RN (Registered Nurse) Manager-M to explain the process when a Resident's code status is changed. RN Manager-M explained a CPR or no CPR is signed by the responsible party and if the code status is changed to DNR there is a state form that has to be signed by the responsible party and the physician. Once the physician signs that form they can active the code status. RN Manger-M explained the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN Manager-M explained this is audited by the social service team. Surveyor asked RN Manager-M to open R2's medical record in the computer. Surveyor showed RN Manager-M R2's code status is CPR in the electronic record while the hard (paper) record is DNR. RN Manager-M stated it should not be different and informed Surveyor she is going to change R2's code status in the computer. On [DATE] at 3:03 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above.

Based on observation, record review and interview, the facility did not ensure that 4 of 10 residents (Resident #1, 3, 4 and 6) received adequate supervision and assistance devices to prevent accidents. The facility also did not ensure that 1 of 2 units kept chemicals locked and floors free of accident hazards. * Resident #1 is at risk for falls and requires extensive assistance of 2 staff with the use of a mechanical lift for transfers. On 5/07/14, Resident #1 was inappropriately assisted during 3 transfers; using assistance of 1 staff and/or without the use of the mechanical lift. Resident #1's knees buckled during one transfer and Resident #1 sustained a skin tear to the left forearm. On 5/08/14, Resident #1 was noted to have a left distal femur fracture, sustained during the inappropriate transfers that occurred on 5/07/14. * Resident #3 was observed to be transferred with a mechanical stand lift that had a broken strap and was utilized without it. The transfer was observed to be unsafe. * Resident #4 was assessed to need a wheelchair alarm and was observed not to have it on one day of the survey. * Resident #6 was assessed to need assist of 2 and a gait belt for transfer and was observed to be transferred with one assist and no gait belt on 8/4/14. Resident #6 was also observed not to have Dycem (non -slip rubber material) in his chair one day of the survey. * Hazardous chemicals were observed to be unlocked in 2 bathing areas and the dining room on the 5th floor unit. * A hole was observed in a high traffic area of the 5th floor dining room and posed a trip hazard. Example 1 involving Resident #1 is determined to be an example at the scope and severity of "G" actual harm/isolated. The remaining examples are determined to be severity 2, potential for more than minimal harm. Findings include: 1.) From 7/30/14 through 8/04/14, Surveyor # reviewed Resident #1's medical record. The quarterly Minimum Data Set (MDS), dated [DATE], indicates Resident #1 has Brief Interview for Cognitive Status (BIMS) score of 10 (moderately impaired cognitive skills), requires extensive assistance of 2 for transfers, is dependent on 2 staff for toilet use, and has had no falls. The Certified Nursing Assistant plan of care for transfers, (undated), indicates Resident #1 requires assistance of 2 staff and a sit to stand lift for transfers. The Incident Report, dated 5/07/14, at 9:25 p.m., indicates the Certified Nursing Assistant (CNA) -Q reported to Licensed Practical Nurse-J, that while transferring Resident #1 from a wheelchair to the toilet, Resident #1 stood and held herself up on the toilet rail, and then her knee buckled while the CNA pulled the pants/brief down for transfer to the commode. The report indicates the CNA was able to catch the resident underneath her arm and was able to put the resident on the commode. The report indicates the resident's left arm was bumped on the bathroom hand rail bar during the transfer resulting in a skin tear to the left forearm, approximately 8 centimeters (cm) in length. The report indicates the resident complained of left knee pain. The report indicates the physician was notified, the skin tear was treated and an x-ray of the left knee was ordered. The report does not include information that would indicate if Resident #1 was appropriately transferred with assist of 2 and a sit to stand, if the Administrator was notified, or if an investigation into the transfer was begun. The x-ray report, dated 5/08/14, indicates Resident #1 has an acute left femur fracture. The Nursing Note, dates 5/08/14, indicates the x-ray results were received and new orders were obtained for a left knee immobilizer to be worn at all times. On 5/09/14, the facility completed an investigation into the transfer that occurred on 5/07/14. The facility obtained witness statements from CNA - Q who transferred Resident #1 on the 5/07/14. The witness statement indicates that on the p.m. shift of 5/07/14, Resident #1 was incorrectly transferred by CNA-Q 3 times. The Witness Statement completed by CNA- Q, dated 5/09/14 at 8:13 a.m., indicates Resident #1 had her call light on to use the bathroom (the statement does not indicate the time of the toileting). The statement indicates CNA -Q positioned Resident #1 facing the handrails and told the resident to hold on and lift herself up. When the resident was standing up CNA- Q started pulling the resident's pants and brief down, the resident started " tilting " toward the wall, and CNA- Q caught the resident underneath her arms and transferred the resident on to the toilet. CNA- Q indicated Resident #1 obtained a skin tear to her left arm by hitting her hand on the toilet paper dispenser. The report does not indicate if Resident #1 was transferred correctly with assistance of 2 staff and the use of the sit to stand lift. The report indicates that after the resident completed using the toilet, CNA- Q transferred Resident #1 from the toilet to the wheelchair using a sit to stand lift. The report indicates Resident #1 complained of knee pain during the transfer. The report does not indicates if Resident #1 was transferred correctly with assistance of 2 staff while using the sit to stand lift. The report indicates Resident #1 was transferred into bed, at about 9:00 p.m., by CNA- Q with the use of a gait belt, and with CNA- Q placing her arms underneath the resident ' s underarms. A review of the report indicates Resident #1 was transferred incorrectly with assistance of 1 staff without the use of the sit to stand lift. On 5/09/14, at 4:18 p.m., the facility obtained a Witness Statement from LPN-J who indicated CNA - Q informed her on 5/07/14, Resident #1 had a skin tear to her arm. The statement indicates LPN-J inquired about the skin tear and was informed by CNA- Q that the skin tear occurred when CNA- Q stood resident #1 up and told her to hold onto the bathroom handrails. The statement indicates Resident #1's knee buckled during the transfer to the commode and CNA- Q was able to catch the resident underneath her arm and put her on the commode. The Neglect Investigation Tool, dated 5/09/14, indicates that on 5/07/14, during the p.m. shift, CNA -Q disregarded the plan of care while transferring Resident #1. The investigation tool indicates that during the interview with CNA- Q she indicated she was aware that Resident #1 was a sit to stand transfer (with assist of 2 staff) but choose to transfer the resident with one person (without the use of the sit to stand lift). On 7/30/14, at 12:00 p.m., Surveyor # spoke with LPN-J who indicated that on 5/07/14, when CNA- Q was transferring Resident #1 to the toilet, the resident's knee buckled, and the CNA caught the resident under her arms and put her on the toilet. LPN- J indicated that based on the information that CNA- Q provided, it appeared that the CNA did not assist Resident #1 with the transfer using a sit to stand and assist of 2 staff. On 5/07/14, Resident #1 was incorrectly transferred from the wheelchair to the commode, from the commode back to the wheelchair and from the wheelchair into bed. There was no evidence that on 5/07/14, when Resident #1 sustained a skin tear to her left arm and sustained a left femur fracture, that the resident was transferred according to her care plan, using a sit to stand lift and assistance of 2 staff. 2.) Resident #4 was originally admitted to the facility on [DATE]. His medical [DIAGNOSES REDACTED]. Surveyor # initiated a review of Resident #4's medical record on 7/28/14. The most recent fall risk assessment, dated 11/13/13, states that Resident #4 is at high risk for falls. A review of Resident #4's most recent plan of care, dated 11/13/13, states that Resident #4 is at high risk for falls due to confusion and gait/ balance problems. The listed interventions included that Resident #4 uses a chair and bed electronic alarm. Ensure the device is in place as needed, floor mat at bedside. On 7/30/14 at 7:42 a.m., Surveyor # made observations of Resident #4 up in his wheelchair in the dining room. At this time it was noted that there was not a chair alarm in place. On 7/30/14 at 8:55 a.m. Surveyor # made observations of Resident #4 propelling himself about the the unit in his wheelchair. At this time it was noted that chair alarm was still not in place in the wheelchair. On 7/30/14 at 8:59 a.m., Surveyor # interviewed Certified Nursing Assistant (CNA)- G in regards to Resident #4 not having his chair alarm in place. CNA- G verified that the alarm was not in place and that Resident #4 was to be using an alarm when he is up in his chair. Surveyor # asked CNA- G why the alarm was not in use. CNA- G responded she does not know, she did not get Resident #4 up and ready this morning, as he was already up in his chair when she started her shift. 3.) Resident # 3 was originally admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. According to the most recent plan of care for Resident #3, dated 9/5/13, Resident #3 is dependent on staff for meeting emotional, intellectual, physical and social needs due to physical limitations and cognitive deficits. The plan of care also states that Resident #3 had an activity of daily living self-care performance deficit due to Dementia. This is dated 6/5/14, and the listed interventions include that Resident #3 is totally dependent on staff for transfer and that 2 CNA's are to use the sit to stand lift to transfer Resident#3. On 7/30/14 at 1:50 p.m., Surveyor # made observations of CNA- G and CNA- N prepare Resident #3 to be transferred from his wheelchair to the bed using the sit to stand lift. It was noted that the sit-to- stand lift was model # 896 , serial # 4. The staff applied tennis shoes to resident #3's feet and also placed the sling behind Resident#3's back CNA- G brought the sit-to stand lift over to Resident #3, and at this time noticed that the shin pad strap was broken, missing the plastic buckle. CNA- G continued to position the sit-to-stand lift in front of Resident #3 as he was seated in his wheelchair. Resident #3 places his hands on the handles, and CNA- G helps put his feet on the foot plate and the sling was attached around Resident #3's upper body. The staff did not attach the shin pad strap around Resident #3's legs, as the buckle was missing. The staff began to lift Resident #3 from the wheelchair with the use of the lift. Resident #3's legs shifted completely off the foot plate as he was risen completely from his wheelchair, hanging from the sling under his armpits. CNA- G stated to Resident #3 to put his feet back on the base of the lift, Resident #3 was unable to do this on his own, and the staff continued to use the lift as Resident #3 was hanging from the sling, provided no standing support on his own. The staff moved Resident #3 over to the bed and assisted him to the sitting position and removed the sling. Surveyor # asked both CNA- G and CNA- N what happened to the shin pad strap. Both responded that the did not know and that is was broken and were not aware how long it had been broken. CNA- N pushed the sit-to stand lift out into the hallway and both CNA- G and CNA- N provided Resident #3 with cares. Surveyor # observed both CNA- G and CNA- H leave Resident #3's room and attend to other resident needs and left the sit- to -stand lift in the hallway, not alerting other staff that the lift was broken. Surveyor # immediately alerted administrative staff that the lift was broken. Surveyor # conducted a review of the " EZ way stand" operator's instructions manual. The listed instructions state to attach the harness by attaching the harness around the upper body of the patient sot he it is resting 2-3 inches below the underarm. The instructions state to position shin pad and foot plate, and position the EZ Way stand in front of the patient. It then states that if the caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the strap around the patient's legs. Then attach harness to EZ Way stand, raise the patient and stop lifting when the patient is in a standing position. Transfer the patient and lower patient to chair, toilet, bed or wheelchair and unhook harness. During the observation made by Surveyor # on 7/30/14, the facility staff did not attach the shin pad strap, as the buckle was broken. The staff continued to raise Resident #3 in the lift, even after Resident #3 had kicked both of his feet of the foot plate and was only supported by the harness under his armpits. Resident #3 never was safely standing on his own during the use of the sit- to stand and was unsafely transferred from the wheelchair to the bed. On 7/30/14 at 3:20 p.m., Surveyor # interviewed Administrator- A in regards to the staff using the sit- to stand lift to transfer Resident #3, even though the shin strap was broken and he was unable to stand safely with the lift prior to be transferred to the bed. Administrator- A stated that a nurse is able to determine if the leg strap needs to be used in order to safely transfer a resident. Administrator- A was unable to state if Resident #3 was ever assessed to be able to safely use the sit- to stand lift with out the use of the shin strap to keep his legs in place of the foot board. 4.) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/30/14 Surveyor # reviewed Resident #6's current care plan dated 5/23/14 which read: High risk for falls related to unaware of safety needs. Transfer assist of 2 with gait belt. Bed and chair alarm. Dycem (nonslip rubber material) in wheelchair. On 8/4/14 at 11:20 a.m. Surveyor # went into Resident #6's room and observed Resident #6 to only have a brief on sitting in his wheelchair. Resident #6's pants were at his ankles and he placed a pink pad between his legs. Resident #6's wheelchair alarm was disconnected and the non-slip material for the wheelchair was on the floor. Surveyor # put on the call light and Certified Nursing Assistant (CNA) -H responded. CNA-H transferred Resident #6 to the toilet by herself without a gait belt and removed Resident #6's wet pants and brief. CNA-H put on new pants, a brief and a shirt and had Resident #6 stand holding on to the wheelchair by herself without a gait belt. CNA-H pulled up Resident #6's brief and pants and transferred him to the wheelchair. CNA-H did not provide any perenial care/cleansing to Resident #6. The non-slip material for the wheelchair was left on the floor of Resident #6's room when he left his room to go to the dining room. The Above findings were shared with the Administrator-A on 8/4/14 at 12:30 p.m. Additional information was requested if available. None was provided. 5.) On 7/30/14 at 1:25 p.m. Surveyor # observed the 5th floor bathroom on the north hall. The door to the bathroom was propped open with a cart and no one was in the hall or bathroom. Inside an unlocked closet were 8 full bottles and 1 partially full bottle of Don-O-Mite cleaner. Immediately after the observation Surveyor # brought Registered Nurse (RN) P- to the bathroom and RN-P ensured the chemicals were locked and stated the bathroom door should be locked. On 7/30/14 at 1:40 p.m. Surveyor # observed the 5th floor bathroom on the south hall. The door was unlocked and in an unlocked cabinet were a partial bottle of Don-O-Mite cleaner and a bottle of Mastercare disinfectant. Immediately after the observation Surveyor # brought Registered Nurse (RN) -E to the bathroom and RN-E removed the chemicals and stated they should be locked. On 7/30/14 at 1:45 p.m. Surveyor # observed the dining area on the 5th floor. Under the sink in the dining area in an unlocked cabinet was a bottle of Liquid Assure silver presoak and bottle of Chlorigen bleach. Immediately after the observation Surveyor # brought Registered Nurse (RN) -E to the dining room and RN-E removed the chemicals and stated they should be locked On 8/4/14 Surveyor #2262 reviewed the Material Data Safety Sheets for the above chemicals which read: Don-O-Mite cleaner: moderately irritating to the eyes, harmful if absorbed through the skin, harmful if inhaled, Ingestion may cause nausea, vomiting and diarrhea. Mastercare disinfectant: Corrosive, if in eyes, inhaled, or ingested immediately call poison control. Liquid Assure: Eye, Skin, inhalation, and ingestion get medical attention immediately. Skin corrosion Chlorigen: if swallowed or eye contact call poison control center immediately, contact can cause chemical burns. The Above findings were shared with the Administrator-A on 7/30/14 at 3:00 p.m. at the daily exit meeting. Additional information was requested if available. None was provided. 6.) On 8/4/14 at 9:45 a.m. Surveyor # observed an approximate 3 inch diameter by ? inch deep circular hole in the dining room floor located in the main walking path at the entrance to the dining room. The hole could have cause a trip hazard. Administrator-A was immediately notified by Surveyor # and had maintenance come fix the hole promptly.

This deficiency remains uncorrected at the Verification Visit. Based on observations, interviews and record review, facility staff did not provide adequate supervision and assistive devices to prevent accidents for 3 of 6 residents reviewed. There were no foot pedals on Resident #3's Broda chair during transfer per the plan of care during four observations (three on 9/23/14 and one on 9/24/14); Resident #3 did not have an alarm on while in the Broda chair on 9/24/14; and the alarm box was placed next to the pillow on 9/24/14, not affixed to anything while Resident #3 was in bed-rendering the alarm ineffective. Resident #4 did not have the alarm on the wheel chair per plan of care, and the Dycem was not positioned properly in the wheel chair. The plan of care directs staff to place a piece of Dycem on top of and underneath Resident #4's wheel chair cushion. Resident #4 was observed with both pieces of Dycem to be on top of the wheel chair cushion. Resident #14 did not have a mat on the floor next to the bed while in bed on 9/23/14 per the Plan of Care; nor were foot pedals used on Resident #14's wheel chair during transport on 9/23/14 and 9/24/14 as direct on the Plan of Care. Findings include: 1.) Resident #3 has resided at the facility for several years and was recently hospitalized at the end of August and readmitted to the facility 9/8/14. On 9/24/14 at approximately 10:00 a.m., Surveyor # reviewed Resident #3's Morse Fall Risk Scale dated 9/8/14 which indicates Resident #3 is at high risk for falling due to a history of falls, multiple [DIAGNOSES REDACTED]. Surveyor # reviewed Resident #3's CAA (Care Area Assessment) dated 9/17/14 for Falls. The CAA "Nature of the Problem" states "Resident is at risk for falls. Resident has history of falls from chair and bed. Resident has reported falls during hospitalization . Resident had unwitnessed fall since previous admission which occurred on 9/11/14. Resident was observed crawling on floor. Resident has impaired cognition with periods of anxiety. Safety devices in place are low bed, mobility alarms, floor mats and Wanderguard. Staff to provide a safe environment and assistance with all mobility. Requires sit to stand lift for transfers due to knee contractures. Surveyor # reviewed Resident #3's care plan in the EMR (electronic medical record) which includes a care plan: Resident at risk for falls related to unaware of safety needs, confusion and wandering, dated 4/6/14 and revised on 9/12/14. The care plan states Resident #3 "uses chair and bed electronic alarms, ensure devices is in place as needed. Wanderguard to prevent elopement. Floor mat at bedside, low bed. Remind Resident to sit back in the chair (intervention for fall 1/24/14). Assist Resident into wheel chair and offer snacks when restless in bed (intervention for fall 9/11/14)." Surveyor # reviewed Resident #3's CNA (Certified Nursing Assistant) Care Card. Under the "Alarms" section, it states Resident #3 is to use bed and chair alarms; under "Notes" it states "Low bed, mat on right side. Remind Resident to sit back in chair. Apply foot rests with transport. Resident is HOH (hard of hearing), speak clearly and slowly..." Surveyor # observed numerous Nurses' Notes indicating Resident #3 frequently tries to remove his clothing. On 9/23/14 at 10:40 a.m., LPN (Licensed Practical Nurse)-J pushed Resident #3 in the Broda chair from the dining area to his room to be changed and lay down before lunch. Resident #3 had been dozing in the Broda chair. No foot rests were applied to the Broda chair for the transport. After Resident #3 was changed in bed, he no longer wanted to lay down so CNA (Certified Nursing Assistant)-H and CNA-G transferred Resident #3 back into the Broda chair. CNA-H took Resident #3 back out to the dining area in the Broda chair. No foot rests were applied to the Broda chair. Surveyor # did observe one foot rest in Resident #3's room. LPN-J stated Resident #3 is at risk for falling and they do not leave him in his room in his chair while awake. On 9/23/14 at 1:24 p.m., Surveyor # observed Resident #3 throw up in the dining room. CNAs H and G took Resident #3 back to his room, changed his pants, and brought him back out to the dining room. No foot rests were used of Resident #3's Broda chair during the transport to or from the dining room. On 9/23/14 at 1:49 p.m., Resident #3 again had a small emesis. CNA-H and CNA-G again took Resident #3 back to his room to change his pants, and then brought him back out to the dining room. No foot rests were applied to the Broda chair for transport. The one foot rest remained in sight in Resident #3's room. On 9/24/14 at 7:32 a.m., Surveyor # observed Resident #3's door to be closed. Surveyor # knocked on Resident #3's door, expecting staff to be assisting Resident #3 with morning cares. Resident #3 was not in the dining area or common areas of the unit. When there was no reply, Surveyor # cracked the door a little bit because Resident #3 is hard of hearing, said hello, explained reason for visit. Resident #3 was observed to be sitting in his Broda chair at the side of the bed, with his hospital-style gown on the floor near the right front wheel of the Broda chair, and a bath blanket covering part of his upper body and head. Resident #3's clip alarm box was attached to the back of the Broda chair, but the clip end was lying on the backrest of the Broda chair, not attached to Resident #3 in any way. Surveyor # immediately got LPN-J who came and observed Resident #3 without a gown or other pajamas or clothing on, so the clip alarm was not attached, making it useless. LPN-J put a shirt on Resident #3, and stated she would get help and have Resident #3 changed, put pants on him and bring him out to the dining room now that he is awake. Surveyor # asked why Resident #3 was in his chair, in his room with the door closed. (On 9/23/14, LPN-J stated they keep Resident #3 in supervised, common area when in his chair.) LPN-J stated she checked on Resident #3 at 7:00 a.m. Resident #3 was sleeping in his chair because he was restless in bed on night shift so they got him up in his chair. LPN-J stated she left the door partially open so they could hear Resident #3 and/or his alarm. LPN-J did not know who closed Resident #3's door. LPN-J stated Resident #3 frequently removes or tries to remove his clothes, and can remove the clip from his clothes. Surveyor # asked if Resident #3 frequently removes his gown, and the clip alarm is attached to the gown, how is that an effective fall prevention intervention. Surveyor # asked if they have tried other night wear such as pajamas, or if they tried other types of alarms. LPN-J stated she thought they tried a sensor pad alarm, but Resident #3 would pull the cord off it when he saw it. Surveyor # asked why they didn't position the cord to come out the back of the seat, so Resident #3 would not see it, or use motion detectors, if the clip alarm was known to be not effective. No further information was offered. On 9/24/14 at 8:01 a.m., Surveyor # observed LPN-J and CNA-W change Resident #3's brief, provide peri-care and put pants on Resident #3 to then take him out to the dining room where staff could supervise Resident #3 and assist him with breakfast. As Resident #3 was raised up using the EZ Stand, it was noted Resident #3's Broda chair cushion was soaked with urine. There was also a large amount of urine under the cushion. (Cross reference F315). LPN-J stated they would have to assist Resident #3 to bed until his wheel chair could be cleaned. LPN-J and CNA-W transferred Resident #3 to bed. LPN-J transferred the clip alarm box from the wheel chair to Resident #3's bed. LPN-J attached the clip end to Resident #3's shirt, and laid the alarm box next to Resident #3's pillow. If the alarm box is not securely attached to a fixed object, the alarm does not always sound because the alarm is triggered when the string attached to the clip is pulled too far (as when a resident tries to get up), and pops a magnet out of the alarm box, sounding the alarm. Often when the alarm box is not attached to the bed or chair, a Resident can get up and the alarm boxes moves with them, dangling at the end of the string. The magnet doesn't disengage so the alarm does not sound. On 9/24/14 at 10:25 a.m., Surveyor # observed Resident #3 in the dining area in his Broda chair. Resident #3 frequently set off the clip alarm because he repeatedly tried to remove his shirt to which the alarm was attached. On 9/2/414 at 11:59 p.m., LPN-J moved Resident #3 away from the dining room table where he had been sitting in his Broda chair. A puddle of urine was observed beneath the Broda chair. LPN-J directed CNAs G and N to change Resident #3. The two CNAs took Resident #3 to his room in the Broda chair, changed him, and brought him back to the dining room for lunch without applying foot rests on the Broda chair. On 9/24/14 at 2:00 p.m., Surveyor # interviewed RN (Registered Nurse)-E, who is now interim DON (Director of Nursing). Surveyor # asked interim DON-E why they continue to use the clip alarm if they know Resident #3 can remove the clip from his clothing, or removes the clothing the clip is attached to, rendering it ineffective. Interim DON-E stated sometimes when Resident #3 scoots forward to the edge of the seat of the Broda chair and triggers the alarm, he will listen to when staff tell him to sit back in his chair, so it does work sometimes. Surveyor # asked if they have tried or discussed other interventions, perhaps different placement of the clip, different types of clothing, different types of alarms or motion sensors, increased supervision, etc. Interim DON-E stated they would take a closer look at Resident #3's fall care plan. Interim DON-E stated she did not think Resident #3 used foot rests on the Broda chair because he can propel himself in the chair using his feet. Surveyor # pointed to the CNA Care Card that instructs staff to apply foot rests for transfer. Interim DON-E stated Resident #3 can usually hold his feet up when pushed/transferred in his chair by staff. Surveyor # asked why the intervention is on the CNA Care Card if it is not to be followed, and how staff would know they do not have to follow that intervention. This information was shared at the exit meeting on 9/24/14. No further information was provided. 2.) Surveyor # reviewed Resident #4's medical record on 9/23/14 & 9/24/14. The CNA (Certified Nursing Assistants) care card which is not dated for Resident #4 documents under the section alarms "Bed and chair alarms." The resident is high risk for falls r/t (related to) confusion and gait/balance problems care plan dated 11/13/13 includes an intervention revised on 8/12/14 of "The resident uses chair electronic alarm. Ensure the device is in place as needed. Floor mat at bed side. Dicem to wheelchair above and below seat cushion. P.T. (physical therapy) to evaluate for positioning in wheelchair (Intervention for fall 8/10/14)." The Morse fall assessment dated [DATE] has a total score of "60" which indicates high risk for falling. The annual MDS (minimum data set) with an assessment reference date of 9/15/14 documents a BIMS (brief interview for mental status) total score of "8" which indicates moderately impaired. Resident #4 does not ambulate, requires extensive assistance with transfers and has had one fall with no injury since prior assessment. The Falls CAA (care area assessment) dated 9/16/14 documents under analysis of findings "Resident at risk for falls. Resident has imbalance with post CVA (cerebral vascular accident) condition. Left sided weakness requiring assistance of two and w/w (wheeled walker) for balance. Resident calls for assistance and has had h/o (history of) impulsive behavior. Resident had fall on 8/9/14 when he slid out of w/c (wheelchair). Dicem to chair, mat at bedside and mobility alarms in place. Staff to provide a safe environment with call light in reach." On 9/24/14 at 7:20 a.m. Surveyor # observed Resident #4 dressed for the day sitting on the toilet with CNA (Certified Nursing Assistant)-W in the bathroom. CNA-W informed Resident #4 that she needed to get him another wheelchair cushion as she had washed his chair that night. At 7:22 a.m. while Resident #4 was sitting on the toilet, CNA-W placed a gait belt around Resident #4. At 7:29 a.m. CNA-W left to get a cushion and returned at 7:30 a.m. CNA-W placed the cushion in the wheelchair with two pieces of Dicem on top of the cushion (one piece was red and the second piece of Dicem was blue). At 7:31 a.m. CNA-W assisted Resident #4 to stand and had Resident #4 hold onto the bar with his right hand. While CNA-W was washing Resident #4's buttocks, Resident #4 stated "my legs are going numb." CNA-W replied "I know" and applied barrier cream. Resident #4 stated "I'm going to fall down." CNA-W replied "no you're not." CNA-W placed a product on Resident #4 and had Resident #4 sit back on the toilet. At 7:35 a.m. CNA-W placed the call light on and asked Resident #4 "want to try for me to stand" and assisted Resident #4 to stand holding on to the bar with his right hand. CNA-W attempted to fasten the incontinence product but Resident #4 needed to sit and sat Resident #4 in the wheelchair. At 7:37 a.m. Administrator/Executive Director-A entered Resident #4's room and informed CNA-W that she could help. CNA-W and Administrator/Executive Director-A stood Resident #4 up, CNA-W fastened the right side of Resident #4's incontinence product, and sat Resident #4 in the wheelchair. CNA-W and Administrator/Executive Director-A stood Resident #4 up fastened the left side of the incontinence product, pulled up his pants, and sat Resident#4 back in the wheelchair. Again CNA-W and Administrator/Executive Director-A stood Resident #4 up, zipped his pants, and Administrator/Executive Director-A straightened the two pieces of Dicem on top of Resident #4's wheelchair. At 7:42 a.m. Administrator/Executive Director-A washed her hands and left Resident #4's room. CNA-W removed the gait belt and washed her hands. CNA-W prepared mouth care items for Resident #4 and gathered the soiled towels and garbage. At 7:47 a.m. CNA-W left Resident #4's room. Surveyor # observed Resident #4 sitting in the wheelchair in front of the sink. Surveyor # did not observe a wheelchair alarm on Resident #4's wheelchair. On 9/24/14 at 7:54 a.m. Surveyor # observed Resident #4 propelling himself out of the bathroom towards the TV in his room. Surveyor # noted that Resident #4 still does not have an alarm on the wheelchair. On 9/24/14 at 8:05 a.m. Surveyor # observed CNA-N & CNA-G enter Resident #4's room. CNA-N asked Resident #4 to lean forward and then stated it's not on. CNA-G looked by Resident #4's TV and then handed CNA-N the wheelchair alarm which CNA-N placed the alarm box on the back of Resident #4's wheelchair and attached the alarm to the back of the shirt. On 9/24/14 at 8:57 a.m. Surveyor # observed Resident #4 sitting in the wheelchair at a dining room table with the wheelchair alarm on. On 9/24/14 at 9:33 a.m. Surveyor # observed Resident #4 sitting in the wheelchair in his room with the wheelchair alarm on. On 9/24/14 at 10:18 a.m. Surveyor # observed Resident # 4 was not on the unit. At 10:35 a.m. Surveyor # asked CNA-N if Resident #4 had gone off the unit for bible study. CNA-N replied "yes." On 9/24/14 at 11:12 a.m. Surveyor # observed CNA-N wheel Resident #4 into his room. CNA-N washed her hands, placed gloves on, placed a gait belt around Resident #4, and wheeled Resident #4 into the bathroom. CNA-N assisted Resident #4 to stand, pulled down his pants, unfastened the incontinence product, and sat Resident #4 on the toilet. Surveyor # checked Resident #4's wheelchair and observed two pieces of Dicem on top of the wheelchair cushion. Surveyor # then lifted up the cushion informing CNA-N that Surveyor # wanted to check to see if there was Dicem under the cushion. Surveyor # did not observe Dicem under the cushion. CNA-N asked Surveyor # "is there suppose to be." Surveyor # informed CNA-N according to Resident #4's plan of care there is suppose to be one piece on top and one underneath the cushion. CNA-N placed the blue piece of Dicem under the wheelchair cushion and the red piece of Dicem on top. On 9/24/14 at 1:43 p.m. Surveyor # asked RN (Registered Nurse) Manager/Interim Director of Nursing-E if the care plans in the computer are the most up to date. RN Manager/Interim Director of Nursing-E replied "yes." Surveyor # asked if the computer care plans and the CNA care cards are the total plan of care for the Residents and should staff be following these plans of care. RN Manager/Interim Director of Nursing-E replied "yes." Surveyor # informed RN Manager/Interim Director of Nursing-E of the observations of Resident #4 not having the wheelchair alarm on and two pieces of Dicem on top of the wheelchair cushion when according to his plan of care there is suppose to be one piece on top and one pieces under the cushion. On 9/24/14 at 3:35 p.m. during the exit conference Administrator/Executive Director-A, Health Care Administrator-B and RN Manager/Interim Director of Nursing-E were informed of the above. Administrator/Executive Director-A stated "I saw that" when Surveyor # shared the observation of two pieces of Dicem on top of the wheelchair cushion. 3.) Surveyor # reviewed Resident #14's medical record on 9/23/14 & 9/24/14. The resident is high risk for falls r/t (related to) Parkinson's disease care plan dated 10/18/13 includes an intervention dated 11/13/13 of "client to utilize foot pedals when staff is propelling w/c (wheelchair)" and an intervention revised on 9/4/14 of "Resident to have non-slip material on seat of w/c to prevent sliding forward. Mat at bedside, mobility alarm." The annual MDS (minimum data set) with an assessment reference date of 9/9/14 documents a BIMS (brief interview for mental status) total score of "5" which indicates severe impaired. Resident #14 requires extensive assistance with transfers and has not had any falls since prior assessment. The falls CAA (care area assessment) dated 9/4/14 under analysis of findings documents "Resident at risk for falls due to imbalance. Resident requires SBA (stand by assist) with transfers, can to use gait belt. Resident knows limits and does no attempt to self transfer. Floor mat at bedside." On 9/23/14 at 10:25 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-H wheeling Resident #14 into the dining room. Surveyor # observed the wheelchair alarm but did not observe foot pedals on Resident #14's wheelchair. On 9/23/14 at 12:56 p.m. Surveyor # observed the hospice nurse wheeling Resident #14 down the hall and into her room. Surveyor # observed there were no foot pedals on Resident #14's wheelchair. On 9/23/14 at 1:09 p.m. Surveyor # observed Resident #14 in bed on her back. Surveyor # observed an alarm was attached to the back of her sweater but did not observe a mat on the floor by Resident #14's bed. On 9/23/14 at 1:37 p.m. Surveyor # observed Resident #14 continues to be in bed and noted there is not a mat on the floor by Resident #14's bed. On 9/23/14 at 1:51 p.m. Surveyor # observed CNA-G wheeling Resident #14 out of her room. Surveyor # observed there were no foot pedals on Resident #14's wheelchair. On 9/23/14 at 2:34 p.m. Surveyor # observed CNA-H wheel Resident #14 into her room. Surveyor # observed there were no foot pedals on Resident #14's wheelchair. CNA-H placed a gait belt around Resident #14, assisted Resident #14 to stand, Resident #14 took a couple steps and sat on the edge of the bed. CNA-H removed the gait belt & shoes and swung Resident #14's legs so Resident #14 was laying on her back in bed. CNA-H covered Resident #14 with a blanket, attached the clip of the alarm to the left side of Resident #14's sweater and attached the alarm box to the cord on the bed frame. CNA-H washed her hands and left Resident #14's room. Surveyor # observed that CNA-H did not place a mat by Resident #14's bed. On 9/23/14 at 2:59 p.m. Surveyor # observed Resident #14 continues to be in bed and noted there is not a mat on the floor by Resident #14's bed. On 9/23/14 at 3:36 p.m. Surveyor # observed Resident #14 continues to be in bed and noted there is not a mat on the floor by Resident #14's bed. On 9/24/14 at 8:28 a.m. Surveyor # observed LPN (Licensed Practical Nurse)-J wheel Resident #14 into the dining room and placed Resident #14 at a table for breakfast. Surveyor # observed there were no foot pedals on Resident #14's wheelchair. On 9/24/14 at 9:16 a.m. Surveyor # observed LPN-J wheel Resident #14 away from the dining room table and place Resident #14 over by the television. Surveyor # observed there were no foot pedals on Resident #14's wheelchair. On 9/24/14 at 9:19 a.m. Surveyor # observed LPN-J wheel Resident #14 from the television area into Resident #14's room and transfer Resident #14 onto the toilet. Surveyor # observed there were no foot pedals on Resident #14's wheelchair. On 9/24/14 at 9:25 a.m. Surveyor # observed foot pedals in Resident #14's closet. On 9/24/14 at 9:30 a.m. Surveyor # observed LPN-J wheeling Resident #14 out of her room, down the hallway, and placed Resident #14 in the hallway near the television. Surveyor # observed there were no foot pedals on Resident #14's wheelchair. On 9/24/14 at 1:43 p.m. Surveyor # asked RN (Registered Nurse) Manager/Interim Director of Nursing-E if the care plans in the computer are the most up to date. RN Manager/Interim Director of Nursing-E replied "yes." Surveyor # asked if the computer care plans and the CNA care cards are the total plan of care for the Residents and should staff be following these plans of care. RN Manager/Interim Director of Nursing-E replied "yes." Surveyor # informed RN Manager/Interim Director of Nursing-E of the observations of Resident #14 not having the mat by Resident #14's bed on 9/23/14 and not having foot pedals on the wheelchair when staff was wheeling Resident #14 on 9/23/14 & 9/24/14. On 9/24/14 at 3:35 p.m. during the exit conference Administrator/Executive Director-A, Health Care Administrator-B and RN Manager/Interim Director of Nursing-E were informed of the above.

Based on record review and interview, the facility did not ensure that laboratory services and results were obtained timely to prevent a delay in treatment for 1 of 10 sampled residents. Resident #5 had an order for [REDACTED]. The urinalysis was reordered on [DATE]. On 9/1/13, the facility first contacted the laboratory for results. The physician ordered an antibiotic to treat a urinary tract infection [MEDICAL CONDITION], however Resident #5 had already been sent to the emergency room with a [DIAGNOSES REDACTED]. This is evidenced by: According to Resident #5's medical record the facility obtained a catheterized urine sample for Resident #5 on 8/21/13. The contracted laboratory did not pick up the specimen on time for testing. The physician again ordered a urinalysis and the facility obtained a second urine specimen on 8/27/13, 6 days after the first specimen was not picked up. On 9/1/13 (Sunday) at 7:25 p.m., the facility obtained the results from the lab and notified the physician of the findings. On 9/2/13, the physician ordered [MEDICATION NAME] (antibiotic) 50 mg, 4 times a day for 10 days. Before the first dose could be given, Resident #5 was sent to the emergency room and was admitted [MEDICAL CONDITION] (systemic disease caused by the multiplication of microorganisms in the circulating blood) secondary to Urinary Tract Infection/[MEDICAL CONDITION]. The hospital progress note indicated RN-F was on duty over the weekend and described the sequence of events prior to admission, "In brief, he had urine taken by cath 8/23, not picked up by lab on time, so couldn't be used, re-orded (sic) and re-cath'd (re-catheterized) on 8/28, but no report from lab for 4 days, when results sought by East Castle, and received on 9/1, MD ordered [MEDICATION NAME], but pt (patient) in ED (emergency department), so no time to give Abx. (antibiotic)." On 9/23/13 at 10:35 a.m., Surveyor # spoke with the Director of Nurses who stated the facility contracts laboratory services with St. Mary's Hospital. The facility obtains urine samples and the lab will pick up the specimen. The Director of Nurses stated Resident #5's urine specimen was not picked up by the lab on 8/23/13. On 8/28/13 is when the lab picked up the urine specimen. The results were sent on 9/2/13. When asked why it took so long, the Director of Nurses stated she called the lab and they did not know why.

Based on observation, interviews and record review, the facility did not ensure that 1 of 2 sampled residents reviewed for pressure ulcers receive necessary and appropriate care and treatment to prevent the development of pressure ulcers and/or to promote the healing of pressure ulcers. Resident #5 was determined to be at risk for pressure ulcer development. In June 2013, nursing documented a decline in Resident #5's mobility. The facility did not assess Resident #5's risk factors and did not develop a care plan to include approaches for pressure ulcer prevention. Resident #5 developed 3 pressure ulcers: ~7/3/13, unstageable pressure ulcer to the right heel which deteriorated to a Stage III. ~7/6/13, pressure ulcers to the left buttock which also deteriorated to a Stage III. ~7/6/13, Resident #5 developed a pressure ulcer to the right buttock which progressed to a Stage II. There were no approaches implemented to promote the healing of the pressure ulcers. On 8/22/13, the Stage II pressure ulcer to the right buttock was documented as healed. There were no approaches implemented to prevent recurrence of the pressure ulcer. On 9/12/13, the area was documented as a Stage II pressure ulcer. This is evidenced by: Resident #5 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 5/6/13, indicated Resident #5: ~Does not refuse care; ~Requires extensive assistance of 1 staff for transfers and bed mobility; ~Has range of motion limitations of both legs and both arms; ~Is frequently incontinent; ~Is at risk for pressure ulcer development; ~Has no current or healed pressure ulcers; ~has a pressure-reducing device for chair. The Care Area Assessments (CAA), dated 5/14/13, indicated pressure ulcer was triggered and stated, "...Resident is able to off load weight while in bed and his wheelchair per self. Pressure reducing devices present...Will continue to adjust the plan of care as needed to reflect the needs of the resident." Documentation in the nurse's notes on 6/8/13 and 6/10/13 indicated Resident #5 has had a decline in bed mobility and now requires 2 staff assistance with bed mobility. Despite this change in mobility, there were no changes to the care plan to assist with pressure relief and pressure ulcer prevention. On 7/3/13, nursing noted a golf ball sized, intact blister to the right heel, and documented the left heel was reddened. On 7/6/13, staff documented newly open areas on the right and left buttocks. On 7/7/13, the family requested an air mattress. On 7/10/13, the facility placed an air mattress on Resident #5's bed. There was no evidence that the care plan was updated with new interventions to promote healing of the current pressure ulcers. Review of the wound care flow sheets indicate measurements documented in centimeters and documented by length x width x depth are listed: RIGHT HEEL ~7/12/13, measures 5.0 x 5.0 intact blister. ~7/19/13, Stage II, measures 6.0 x 4.0 x 0 cm., Surrounding skin: pink/red. ~7/26/13, Stage II, measures 5.8 x 4.2 x 0 cm., Surrounding skin: pink/red. Wound bed: granulation. ~8/2/13, Stage II, measures 5.0 x 5.0 x 0 cm. O/A (open area) measuring 0.5 x 0.5 x 0 cm, Surrounding skin: pink/red. Wound bed: granulation. Response to treatment: Improved. ~8/8/13, Stage II, measures 0.5 x 0.5 x 0 cm., Surrounding skin: pink/red. Wound bed: granulation and [MEDICATION NAME]. "Improved." ~8/16/13, Stage II, measures 0.5 x 0.5 x 0 cm., Surrounding skin: pink/red. Wound bed: pink. "Improved." ~8/22/13, Stage II, measures 0.2 x 0.2 x 0 cm., Surrounding skin: pink/red. Wound bed: pink. Improved. ~8/29/13, Stage II, measures 0.2 x 0.2 x 0 cm., Surrounding skin: intact. Wound bed: pink. On 9/3/13, Resident #5 was seen by the wound care nurse in the hospital. Review of wound care nurse progress notes indicated the pressure ulcer on the right heel was a Stage III. Facility wound documentation continues: ~9/12/13, Stage II, measures 0.2 x 0.2 x 0 cm. Drainage: serous. Wound bed: Red. Pain: #3 on a scale of 1-10. LEFT BUTTOCK ~7/12/13, Stage II, measures 0.5 x 0.5 x 0.1 cm., Surrounding skin: intact. Wound bed: granulation. ~7/19/13, Stage II, measures 0.5 x 0.5 x 0 cm., Surrounding skin: Pink/red. Wound bed: granulation. ~7/26/13, Stage II, measures 0.6 x 0.4 x 0 cm., Surrounding skin: Pink/red. Wound bed: granulation. "Improved." ~8/2/13, Stage II, measures 0.5 x 0.3 x 0 cm., Surrounding skin: Pink/red. Wound bed: granulation. Improved. ~8/8/13, Stage II, measures 1.0 x 0.5 x 0 cm., Surrounding skin: Pink/red. Wound bed: pink, granulation and [MEDICATION NAME]. Deteriorated. ~8/15/13, Stage II, measures 0.5 x 0.5 x 0 cm., Surrounding skin: intact. Wound bed: pink. Last change in treatment: 7/6/13. ~8/22/13, Stage II, measures 0.5 x 0.5 x 0 cm., Surrounding skin: intact. Wound bed: pink. ~8/29/13, Stage II, measures 0.5 x 0.5 x 0 cm., Drainage: Serous. Drainage amount: scant. Wound bed: pink. Last treatment change: 8/23/13. Response to treatment: "Improved." The development of drainage would demonstrate a deterioration. On 9/3/13, Resident #5 was seen by the wound care nurse in the hospital. Review of wound care nurse progress notes indicated a Stage III pressure ulcer noted to the left superior buttock. Area measured 0.6 x 0.6 x 0.2 cm (centimeters). Facility wound documentation continues: ~9/12/13, Stage II, measuring 0.5 x 0.5 x 0 cm. Drainage: Serous. Drainage amount: scant. Wound bed: pink. Last change in treatment: 9/10/13. Response to Treatment: Improved. RIGHT BUTTOCK: ~7/12/13, Stage II measuring 0.5 x 0.8 x 0.1 cm. Wound bed: granulation. Improved. ~7/19/13, Stage II measuring 1.5 x 0.5 x 0 cm. Drainage: Serous. Drainage amount: scant. Surrounding skin: Pink/red. wound bed: granulation. Last change in Treatment: 7/6/13. Response to Treatment: "Improved." ~7/26/13, Stage II, measuring 1.6 x 0.6 x 0 cm. no drainage. Last change in treatment 7/10/13. ~8/22/13, Area healed. There were no interventions started to prevent redevelopment of the pressure ulcer. Wound notes indicate the pressure ulcer redeveloped: ~9/12/13, Stage II measuring 0.5 x 0.5 x 0 cm. Drainage: Serous. Drainage amount: Scant. Wound bed pink. On 9/17/13 at 2:15 p.m., Surveyor # spoke with Resident #5. He was sitting in his wheelchair with a special cushion since lunch. When asked if he had any sores on his bottom he stated, "Oh yes, yes they hurt...My seat hurts quite a bit..." On 9/17/13 at 2:40 p.m., Surveyor # observed Resident #5 being toileted, buttocks ruby color but no open areas seen. Nurse aides applied skin barrier repair cream to the area. On 9/19/13 at 2:00 p.m., Surveyor # spoke with the RN-F and asked why Resident #5 developed a pressure ulcer. RN-F stated because he sits in his chair and will not let the staff lay him down. When asked if this was documented anywhere, RN-F stated, "Probably not." Surveyor # inquired about Resident #5's heel pressure ulcer. RN-F stated she observed him in the wheelchair with legs crossed and his shoes were rubbing back and forth on his heels. RN-F stated, "Should have done something about it."

Based on interview and record review the facility did not ensure that 1 of 6 residents at risk for falls received adequate supervision to prevent further falls. Resident #7 was admitted to the facility on [DATE] with a history of falls and a non displaced fracture of her left hip. From 2/20/12-2/23/12, Resident #7 fell 3 times after independently getting out of bed. The facility did not assess for the effectiveness of current interventions in place and modify interventions to reduce the potential for further falls and injury to the Resident. On 2/23/12, Resident #7 experienced a third fall resulting in Resident #7 being sent to the emergency room due to left hip pain. Resident #7 returned to the facility on [DATE] after surgical repair of a displaced left hip fracture. Following readmission, Resident #7 continues to experience falls. Findings include: 1) On 6/19/12 at 9:20 a.m., Surveyor # observed Resident #7 during the initial tour of the unit. Surveyor #2005 observed Resident #7 in a Broda chair participating in an activity. During the initial tour, Director of Nursing (DON)- B stated that Resident #7 has dementia and vision impairment. On 6/20/12 and 6/21/12, Surveyor # reviewed Resident #7's medical record. Resident #7 was admitted to the facility on [DATE] for rehabilitation due to a non displaced fracture of the left hip. The hospital discharge summary dated 2/20/12 indicates the resident was admitted to the hospital confused, and suffered an impacted subcapital fracture of left hip due to frequent falls. It also indicates the left hip "appears to be a fairly stable fracture." A nurse's note dated 2/20/12 at 3:09 p.m. indicates the resident was admitted to the facility from the hospital. A nurse's note dated 2/20/12 at 9:45 p.m. indicates Resident #7 was "restless and agitation noted at 1800 this shift, ativan given at this time." A nurse's note dated 2/20/12 at 10:55 p.m. indicates the resident had a fall. Resident #7 was found in her room close to the door. The incident report dated 2/20/12 indicates that the resident was confused and had no injuries from the fall. The intervention was to "continue to observe" and "instructed resident on use of call light anytime in need." A nurse's note dated 2/21/12 at 2:10 p.m. indicates Resident #7 was "anxious, PRN (as needed) administered, noncompliant with safety precautions, screaming at others, continually asking the same questions." A nurse's note dated 2/22/10 at 6:15 a.m. indicates, Resident #7 "observed walking in hallway unassisted holding on to railing in hallway. Assisted to w/c (wheelchair), sat up in w/c for about 15 minutes has some juice. Assisted with a.m. cares." A nurse's note dated 2/23/12 at 10:19 a.m.resident had a fall. Resident #7 was found on the floor in her room doorway at 9:45 a.m. The incident report dated 2/23/12 indicates that the resident was confused and had no injuries from the fall. The intervention was to "continue to observe" and "instructed resident on use of call light." Surveyor # noted no assessment of the effectiveness of the interventions already in place which was to "continue to observe" and "instructed resident on call light." The facility continued with these same interventions and did not modify interventions to reduce the potential for further falls and injury to the Resident. A nurse's note dated 2/23/12 at 3:47 p.m. indicates Resident #7 had another fall. Resident #7 was found on the mat beside her bed at 3:10 p.m. The incident report dated 2/23/12 at 3:10 p.m. indicates the resident was disoriented, confused and forgetful. It also indicates the resident was complaining of pain to her left hip area. The intervention was to "continue to observe, PRN Vicodin administered. Use of call light." Surveyor # noted no assessment of the effectiveness of the interventions already in place which was to "continue to observe and "instructed resident on call light." The facility continued with these same interventions and did not modify interventions to reduce the potential for further falls and injury to the Resident. The nurse's note dated 2/23/12 at 3:47 p.m. indicates the resident had a fall from bed which resulted in pain and the resident was sent to the emergency room . A nurse's note dated 3/1/12 indicates Resident #7 returned to the facility from the hospital. The hospital history and physical report dated 2/24/12 indicates Resident #7 was at the facility "recovering from an impacted subcapital fracture of the left hip. She fell twice on the day of admission and after the second fall had a great deal of pain and therefore was sent to the emergency room . In the emergency room , it was determined that this was now displaced and would need additional evaluation and treatment in spite of her advanced age and multiple comorbidities." It also indicates the resident has advanced dementia and "clearly a fall risk." The operative procedure report dated 2/24/12 indicates Resident #7 had a left hip hemiarthroplasty procedure due to the displaced hip fracture. The nurse's notes indicate after the resident came back from the hospital on [DATE], Resident #7 continued to have many falls. From 3/1/12 until 6/9/12 Resident #7 had 11 falls. A comprehensive assessment was not completed upon the resident's admission to the facility or at anytime. The potential for injury-trauma care plan was dated 4/27/12 but was not based upon a comprehensive assessment. The care plan addresses the use of a low bed and mat on the floor. In June 2012, the resident continued to have 2 falls without injury after transferring self from bed. On 6/9/12, the facility implemented the use of a scoop mattress. On 6/20/12, during the daily exit meeting with the facility, Surveyor # shared the concern that Resident #7 was admitted with a history of falls and a [DIAGNOSES REDACTED]. Resident #7 suffered 3 falls from 2/20/12-2/23/12 without the facility re-assessing the effectiveness of current interventions and modifying interventions to to reduce the potential for further falls and injury, i.e. causing resident's fracture to become displaced and requiring surgery. On 6/21/12 at 2:00 p.m., Surveyor # spoke with DON B. DON B states the interventions used for the falls were to keep the resident at the nurses station to observe her. Surveyor # stated all 3 falls were when Resident #7 was in bed. DON B confirmed this fact. On 6/21/12 at 3:10 p.m. Surveyor # interviewed Licensed Practical Nurse (LPN) C. LPN C states she remembers Resident #7 being "very anxious" and confused upon admission and the few days after the initial admission. LPN C states she is not sure if an initial care plan for falls was initiated for Resident #7. On 6/21/12 during the daily exit meeting with the facility, Surveyor # shared the above concern regarding Resident #7's falls and subsequent injury which required surgery.