Every finding on record at Four Winds Manor

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the appropriate agencies for 1 of 3 sampled residents (R1).R1 voiced a concern regarding possible neglect, stating she did not receive care during the overnight shift. The facility staff failed to report the allegation to the Nursing Home Administrator and the facility failed to report the allegation to the state agency.Evidenced by:Facility policy, titled Alleged Incidents of Abuse, Neglect, Misappropriation, Injuries of Unknown Origin, and Exploitation, last reviewed 2/2026, includes: .All alleged incidents of mistreatment, neglect, exploitation or abuse of a resident. will be immediately reported to the Facility Administrator/designee and the Division of Quality Assurance. If the events that caused the allegation involve abuse or result in serious bodily injury, the Administrator/designee will report to the Division of Quality Assurance no later than 2 hours after the allegation is made. All other allegations that do not involve abuse and that do not result in serious bodily injury must be reported no later than 24 hours after the allegation is made. References: Centers for Medicare & Medicaid Services (CMS) regulations found in 42 CFR S 483.5: Under Centers for Medicare & Medicaid Services (CMS) regulations found in 42 CFR S 483.5 neglect is defined as the failure of a facility, its employees, or service providers to provide the goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. Involving regulatory authorities who may assist such as local law enforcement, elder abuse agency, adult protective services.R1 admitted to the facility on [DATE]. R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/6/26, indicates R1's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15.R1's Grievance/Concern Form, dated 4/13/26, includes: Date concern was received: 4/12/26. Concern: R1 expressed she didn't get cared for overnight Friday, 4/10/26 into Saturday, 4/11/26. Actions Taken: Resident interviewed regarding concern. Staff statements received from night shift staff and morning staff. Resident chart reviewed for documentation of aides caring for her. Resident care card reviewed and shows she is a check and change as she is incontinent of bowel and bladder. Call light report printed for past few days.Summary of Incident, dated 4/12/26, includes: AT APPROXIMATELY 9:57 AM writer received a call from RN I. regarding a concern that R1 had shared with her when she was delivering medications to her. RN I asked her for further information. R1 shared that she didn't get cared for at all overnight on Friday 4/10/26 into Saturday 4/11/26 and she knew this because when she was put to bed Friday evening her call light was down by her legs, and when she woke up on Saturday morning the call light was still down by her feet. She felt she had not been cared for all night. R1 went on to tell RN I that she had reported to CNA C. CNA C told R1 she needed to report this to NHA A. Per RN I, CNA C did not share this information with RN D. Education was done with CNA C regarding the need to report any resident complaint/concern right away.CNA C's Statement, dated 4/14/26, includes:. CNA C states that she was not in the room that night, she was assigned to (another location) and did not provide any cares to R1, on 4/10/26. She states that CNA E had her and she did not hear anything until it was mentioned to her the next night on 4/11/26 by R1. CNA C states that she did tell RN D about it.RN D Statement, dated 4/14/26, includes: Hi NHA A, I apologize for not responding yesterday to address your concerns about R1. I want to provide what I know. Last Sunday, while I was passing medications, CNA C informed me that R1 had complained that no one checked on her the previous night. I did observed [sic] CNA E entering the room Saturday morning, but I didn't see her provide care. After completing my medication, I went to check on R1 to talk about her complaint, but she was already asleep. Knowing her preference for not being disturbed while sleeping, I decided not to wake her. I completely forgot about the complaint until (a staff member) mentioned it the next shift. I regret not following up on this issue sooner.On 7/23/26 at 11:59 AM, MT/CNA G (Medication Technician/Certified Nursing Assistant) indicated if a resident reports she did not get cared for overnight that this could be an allegation of neglect and the facility should look into it. MT/CNA G indicated she would report this right away to a supervisor.On 7/23/26 at 12:19 PM, RN H (Registered Nurse) indicated neglect is when staff ignore the residents' needs. RN H indicated if a resident reports she did not get cared for overnight, this could be an allegation of neglect, and the facility should follow the abuse policy and procedures.On 7/23/26 at 12:31 PM, NHA A and DON B indicated a resident reporting that she did not receive care overnight and her call light was placed by her feet could be an allegation of neglect. NHA A indicated the facility should have reported this to the Division of Quality Assurance as they are a resource for the resident. NHA A indicated she was not called about this incident. NHA A stated, The Nurse took on the investigation. I wasn't called for this.(It is important to note staff did not report the allegation timely to NHA A and the facility did not report R1's allegation to the State agency.)

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are thoroughly investigated for 1 of 3 sampled residents (R1).R1 voiced a concern regarding possible neglect, stating she did not receive care during the overnight shift. The facility did not conduct a thorough investigation into the allegation. The facility did not put protections in place while completing their investigation. Evidenced by:Facility policy, titled Alleged Incidents of Abuse, Neglect, Misappropriation, Injuries of Unknown Origin, and Exploitation, last reviewed 2/2026, includes: .All alleged incidents of mistreatment, neglect, exploitation or abuse of a resident. The facility will thoroughly investigate, under the direction of the Administrator/designee. all alleged violations involving mistreatment, abuse, neglect, or exploitation. and in accordance with state and federal law. A thorough investigation may include: Conducting observations of alleged victim., interviewing alleged victim/s and witness/es. Interviewing accused individuals allegedly responsible for mistreatment to suspected. including staff, visitors, resident's relatives, etc. Interviewing other residents to determine if they have been abused or mistreated. Interviewing staff who worked the same shift as the accused to determine if they ever witnessed any mistreatment by the accused. Interviewing staff who worked the previous shifts.R1 admitted to the facility on [DATE].R1's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 7/6/26, indicates R1's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15.R1's Grievance/Concern Form, dated 4/13/26, includes: Date concern was received: 4/12/26. Concern: R1 expressed she didn't get cared for overnight Friday, 4/10/26 into Saturday, 4/11/26. Actions Taken: Resident interviewed regarding concern. Staff statements received from night shift staff and morning staff. Resident chart reviewed for documentation of aides caring for her. Resident care card reviewed and shows she is a check and change as she is incontinent of bowel and bladder. Call light report printed for past few days.Summary of Incident, dated 4/12/26, includes: At approximately 9:57 AM writer received a call from RN I. regarding a concern that R1 had shared with her when she was delivering medications to her. RN I asked her for further information. R1 shared that she didn't get cared for at all overnight on Friday 4/10/26 into Saturday 4/11/26 and she knew this because when she was put to bed Friday evening her call light was down by her legs, and when she woke up on Saturday morning the call light was still down by her feet. She felt she had not been cared for all night. R1 went on to tell RN I that she had reported to CNA C. CNA C told R1 she needed to report this to NHA A. Per RN I, CNA C did not share this information with RN D. Education was done with CNA C regarding the need to report any resident complaint/concern right away.CNA C's Statement, dated 4/14/26, includes:. CNA C states that she was not in the room that night, she was assigned to (another location) and did not provide any cares to R1, on 4/10/26. She states that CNA E had her and she did not hear anything until it was mentioned to her the next night on 4/11/26 by R1. CNA C states that she did tell RN D about it.RN D Statement, dated 4/14/26, includes: Hi NHA A, I apologize for not responding yesterday to address your concerns about R1. I want to provide what I know. Last Sunday, while I was passing medications, CNA C informed me that R1 had complained that no one checked on her the previous night. I did observed CNA E entering the room Saturday morning, but I didn't see her provide care. After completing my medication, I went to check on R1 to talk about her complaint, but she was already asleep. Knowing her preference for not being disturbed while sleeping, I decided not to wake her. I completely forgot about the complaint until (a staff member) mentioned it the next shift. I regret not following up on this issue sooner.On 7/23/26 at 11:59 AM MT/CNA G (Medication Technician/Certified Nursing Assistant) indicated if a resident reports she did not get cared for overnight that this could be an allegation of neglect and the facility should look into it. MT/CNA G indicated she would report this right away to a supervisor and they would investigate.On 7/23/26 at 12:19 PM RN H (Registered Nurse) indicated neglect is when staff ignore the residents' needs. RN H indicated if a resident reports she did not get cared for overnight, this could be an allegation of neglect and the facility should follow the abuse policy and procedures.On 7/23/26 at 12:31 PM NHA A and DON B indicated a resident reporting that she did not receive care overnight and her call light was placed out of reach could be an allegation of neglect. NHA A indicated the facility should have investigated this thoroughly and didn't. NHA A indicated the facility did not ask staff interviewed questions related to the placement of the call light. NHA A indicated no other residents were interviewed related to the allegation. NHA A indicated non-interviewable residents who were assigned to the same staff member as R1 for the time period in question were not assessed for signs of neglect. NHA A indicated accused staff were not removed from the schedule pending a thorough investigation. (It is important to note the facility did not look into R1's call light placement, did not conduct interviews or assessments with other residents, and did not protect residents pending a thorough investigation of the allegation.)

Based on interview and record review, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (R2) reviewed for falls.R2's fall interventions were not in place when R2 had a fall resulting in a bloody nose.This is evidenced by:The facility's policy Comprehensive Care Planning, dated 4/23, includes: .will create an Initial Resident Baseline Care plan upon admission. Within 21 days and periodically a comprehensive, accurate, standardized assessment of each resident's function capacity is completed. The comprehensive assessment describes the resident's capability to perform daily life functions, strengths, and significant impairments in functional capacity. The results of the assessments . are used to develop, review, and revise the resident's comprehensive plan of care.R2 admitted to the facility on [DATE] with a diagnosis of Parkinson's (a progressive movement disorder with symptoms that include problems with movement, tremor, stiffness and impaired balance).R2's comprehensive care plan, dated 9/30/25, includes: Problem: Potential for injury related to fallsInterventions: Ensure my call light is within my reach before leaving my room. I have a mat on the floor next to my bedR2's Incident report, dated 10/3/25, includes:Incident type: Fall/Found on floorDate of Incident: 10/2/2025Time of Incident: 11:15 PMDescription of incident: CNA (Certified Nursing Assistant), [Name] discovered the resident lying face down on the floor beside the bed. Upon assessment, a small amount of blood was observed coming from the resident's nose, and the resident reported pain upon nasal palpitation.How/Where Resident Was Found: lying on floor face downCurrent Fall Precautions in place at time of incident: No no floor mat, call light was not within reached [sic]On 11/6/25 at 10:18 AM, Surveyor interviewed CNA G regarding fall interventions. CNA G indicated fall interventions are found in the resident's care plan and on the CNA care cards. CNA G indicated the CNA care cards are located in the resident's closet. CNA G indicated all interventions should be followed.On 11/6/25 at 10:20 AM, Surveyor interviewed CNA H regarding fall interventions. CNA H indicated resident's at risk for falling has a star on their name plate outside their room. CNA H indicated fall interventions are in the resident's closets and sometimes there are things written on the resident's whiteboard in their room. CNA H indicated fall interventions should be in place.On 11/6/25 at 10:30 AM, Surveyor interviewed RN I (Registered Nurse) regarding fall interventions. RN I indicated fall intervention are on the resident's care plan and the CNA care cards. RN I indicated fall interventions should be in place for residents per their care plans.On 11/6/25 at 10:50 AM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding fall interventions. NHA A indicated staff should have the resident's fall interventions in place. Surveyor asked NHA A about R2's fall and not having her fall mat in place when she fell on [DATE]. NHA A indicated she expects staff to follow the resident's care plan and R2 should have had all her interventions in place but did not.

Based on interview and record review the facility did not ensure that all alleged violations involving injuries of unknown source, are reported immediately, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 reportable incidents.On 10/27/25, 2 CNAs (Certified Nursing Assistants) observed a large bruise on R1's left upper arm. The 2 CNAs did not report the bruise. Upon further investigation, R1 had a non-displaced left humerus fracture.This is evidenced by:The facility's policy For Alleged Incidents of Abuse, Neglect, Misappropriation, Injuries of Unknown Origin, and Exploitation, dated 8/25, includes: All injuries, [sic] of unknown origin.will be immediately reported to the Director of Nursing or the Administrator/designee, in person or by phone and an investigation will be completed. The Administrator/designee will report all alleged violations immediately. If the events that cause the reasonable suspicion resulted in serious bodily injury to a resident, the covered individual must report the suspicion immediately. When any employee discovers an injuring of unknown origin.the employee's first priority is to protect the resident, and ensure the resident is safe. After establishing the resident's safety, they immediately report the observation to the supervisor on duty. Individual state reporting requirements will be adhered to. All allegations will be reported to the DQA (Department of Quality Assurance) immediately or not to exceed 24 hours or within 2 hours if an incident involves serious bodily injury.On 10/27/25 on the evening shift, CNA C (Certified Nursing Assistant) and CNA D provided cares for R1. CNA C and CNA D was assisting R1 after dinner. CNA C and CNA D noted a large, dark bruise on R1's left upper arm. CNA C and CNA D did not report this injury of unknown origin to their supervisor. On 10/28/25 at approximately 4:00 AM, CNA E noted a large bruise to R1's left upper arm. CNA E reported this bruise to LPN F (Licensed Practical Nurse). LPN F followed facility protocol to report the injury of unknown origin.On 11/6/25 at 10:50 AM, Surveyor interviewed NHA A (Nursing Home Administrator) regarding R1's incident. NHA A indicated both CNA C and CNA D saw the bruise on 10/27/25 and did not report the bruise. NHA A indicated on 10/28/25, the night shift CNA (CNA E) reported the bruise to the nurse. NHA A indicated CNA C and CNA D should have reported the bruise immediately to their supervisor and did not.

Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (R4) reviewed for change of condition. R4 had experienced a change in condition with an elevated blood pressure (BP) and severe headache. The facility failed to perform a thorough assessment and notify physician. R4 continued to show signs of a change in condition over the next two days with signs of restlessness and change in usual routine. R4 was sent to emergency room (ER) two days after onset of headache and elevated BP and was diagnosed with a left occipital lobe subacute infarct (stroke in the posterior (back) left part of the brain that occurred days or weeks ago, not acutely (within hours). This type of stroke primarily affects vision, leading to a loss of the right-side visual field in both eyes. Symptoms can also include visual hallucinations, memory problems, or confusion and require immediate medical attention). Evidenced by:The facility's policy entitled Notification About Change of Condition, dated 7/2025, states, in part: . PURPOSE: A change of condition is a clinically important change from the resident's baseline in physical, cognitive, behavioral or functional domains. Without intervention these changes may result in complications or death. Examples include significant vital sign changes, new symptoms, possible infection and other care issues.POLICY: The attending physician/APP (Advanced Practice Provider) and activated HCPOA (Healthcare Power of Attorney) will be notified in a timely manner of a resident change of condition.PROCEDURE:1. All staff should report change of condition 2. Assess the resident:a. Reference: INTERACT SBAR COMMUNICATION FORMb. Assess overall condition, level of consciousness, and functionc. Take vital signs.g. Is the resident having pain? Determine description, location, severity, pattern i. Evaluate relevant systems: mental status, functional status, behavior, respiratory, cardiovascular, abdominal/GI (gastro-intestinal)/ urine, skin, neurologic, painj. Complete a head-to-toe physical assessment. 5. Notify appropriate contacts.b. The licensed nurse notifies the attending/APP.POA (Power of Attorney) .g. When calling physician/APP explain the degree of urgency of the situation and the anticipated timespan for return response.h. Determine with the physician/APP if the resident needs to be transported to the ER/hospital. or if they can be treated at the facility.i. If treatment and monitoring at the facility is planned determine appropriate interventions, monitoring and timeline of follow up with the physician/APP.8. Monitoring a. A nurse should evaluate the resident with a change of condition every shift for at least 3 days and document the resident's overall condition, the status of the change of condition. Interact' s Care Path for change in condition states, in part: . Change in Condition: When to report to the MD (medical doctor)/NP (nurse practitioner)/PA (physician assistant) Immediate Notification: Any symptom, sign or apparent discomfort that is:*Acute or Sudden in onset, and: *A marked change (i.e. more severe) in relation to usual symptoms and signs. Headache- Immediate: Abrupt onset of progression of severe headache with fever, change in mental status or focal neurological abnormalities(Note: the nurse did not do a thorough assessment or a neurological assessment to know if there was a change) . Pain: Immediate: New severe pain. Interact Stop and Watch Early Warning Tool states, in part: . If you have identified a change while caring for or observing a resident. please circle the change and notify the nurse.S Seems different than usual; symptoms of new illnessT Talks or communicates [NAME] Overall needs more helpP Pain- new or worsening.A Ate lessN.D.W.A Agitated or nervous more than usualT Tired. Weak, confused, or drowsyC.H. R4 admitted to the facility on [DATE] and has diagnoses that include encephalopathy (a general condition where the brain's function is impaired), cerebral infarction (occurs when blood flow to the brain is interrupted, leading to cell death and brain damage), and essential hypertension (chronic condition of persistently high blood pressure with no identifiable cause). R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] shows R4 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R4 is cognitively intact. R4's Care Plan, dated 5/07/2025, states, in part: . Problem: I have hypertension. 5/07/2025Approach: Interventions: Monitor my vital signs. Monitor me for headaches.Goal: I will have no exacerbations 5/07/2025. R4's Nurses Note, dated 8/24/25, at 8:45PM, states: resident complained of having a bad headache behind his eyes requested Tylenol which was given. His caretaker, PC P (Personal Caregiver) was here and requested a blood pressure be taken 146/105. Caregiver told him he should go to the emergency department to be checked out, but he refused. Writer called son to inform him, he asked that we call him back if it gets worse or we need him to talk to resident. I went back in an hour to recheck BP pt (patient) refused to allow me to take it he said his headache is gone he is fine. Phone call placed to NP (Nurse Practitioner) to inform. BP 146/105. (of note: this was a Sunday)On 9/3/25 at 10:59 AM, Surveyor interviewed PC M (Personal Caregiver) who indicated that Sunday 8/24/25 when he had come in that morning R4 was still in bed which was unusual for R4, and he was informed that R4 only ate half his breakfast that morning. PC M indicated R4 had called him at 3:45 that morning and informed him he wanted water. PC M indicated after speaking with the facility he had found R4 was not eating and only wanted water which was unusual. On 9/3/2025 at 2:00 PM, Surveyor interviewed LPN J (Licensed Practical Nurse) who indicated on Sunday 8/24/25 R4 had complained of a bad headache to PC P, who had come to LPN J and informed her. PC P requested LPN J check R4's BP. LPN J indicated it was high but could not recall offhand what it was at this time. PC P informed LPN J R4 should be sent out to ER but R4 refused. LPN J indicated she checked R4's BP and administered Tylenol for headache and did not perform any further assessment besides the BP. LPN J indicated she attempted to recheck R4's BP an hour later but R4 refused. Surveyor asked if LPN J notified the physician regarding an onset of severe headache and an elevated BP. LPN J indicated she had left a message on the NP (Nurse Practitioner) call line as R4's NP was currently on vacation. LPN J indicated she did not speak with a physician or NP; she never received a call back. On 9/3/25 at 4:24 PM, Surveyor interviewed MT G (Medication Tech) who indicated she had worked with R4 on Sunday 8/24/25. MT G indicated R4 did not want to get up out of bed that morning which was very unusual for R4 as usually R4 will be on his call light right at 6:00 AM wanting to get up every morning. MT G indicated that was a big change for R4 and the nurse was informed. MT G indicated she had gone in R4's room several times to see if he wanted to get up out of bed but R4 kept indicating no but was adamant about getting water to drink every time MT G entered room. MT G indicated when R4's caregiver came in that morning MT G went in R4's room with the caregiver and asked if R4 was ready to get up. R4 had indicated he has been wanting to get up all morning but that is not what R4 had been telling MT G. MT G indicated that was a change for R4 and she had notified the nurse. On 9/4/25 at 8:56 AM, Surveyor interviewed PC P who indicated when she came into the facility on Sunday 8/24/25 in the evening R4 complained of a pounding headache; R4 could not hold his eyes open due to the severe pain in his head. PC P indicated R4 was not acting his usual; he was different. PC P indicated she had reported that to the nurse and requested the nurse to check R4's BP which was high. Surveyor asked PC P if she was aware if the nurse phoned the physician and PC P was unaware but did know the son was phoned. On 9/4/25 at 11:35 AM, Surveyor interviewed CNA O (Certified Nursing Assistant) who indicated she worked with R4 on Sunday 8/24/25 on the PM shift. CNA O indicated R4 was a little off that shift as he would ask for the nurse or pain medication every 15 minutes. CNA O indicated R4 kept repeating I need the nurse. I need a lidocaine patch. I need the nurse. I am in pain. CNA O indicated R4 generally has a bit of general pain but never has repeatedly asked for nurse or indicate he was in pain like he did that shift. CNA O indicated that was not normal behavior for R4. CNA O indicated she would keep telling LPN K as R4 would ask and LPN K would say she will get to him. CNA O indicated R4 did not have a history of turning his call light on due to pain in the past. R4's Nurse Note dated 8/25/25 at 6:55 AM, states: Note 8/24/25 10:30PM BP- 108/68 Pulse- 88 O2 (oxygen) Saturation- 95 RA (Room Air). R4's Nurse Note dated 8/25/25 at 6:40 PM, states: BP- 153/92 Pulse- 66 Respirations- 14 Temperature- 97.2 O2 Saturation- 97 RA Resident appeared to be lethargic at dinner time; resident did not want to eat. VS (vital signs) take; WNL (within normal limits) as documented. Lung sounds CTA (clear to auscultation). Resident is responsive to stimulation. Will continue to monitor resident.(Of note: this is a change from R4's baseline - no RN assessment was completed and no evidence a provider was updated regarding R4's change in condition.)On 9/4/25 at 2:13 PM, Surveyor interviewed LPN K (Licensed Practical Nurse) who indicated that she worked with R4 on Monday 8/25/25 on the PM shift. LPN K indicated R4's caregiver had informed her that R4 is not wanting to eat and usually R4 eats. LPN K indicated she had gone in by R4 to talk with him and R4's eyes were closed. LPN K started rubbing on his arms and rubbed his sternum. Surveyor asked LPN K what made her rub his sternum and LPN K indicated R4 was lethargic but was responding. LPN K indicated based on his vital signs and talking to R4 she thought R4 had had a long day. LPN K indicated her judgement was not to send R4 out to ER right away. R4 did not eat supper that night and LPN K had made him a protein milkshake. LPN K indicated R4 usually eats at meals and as far as pain, R4 is touch and go with general pain. Surveyor asked LPN K if being lethargic where LPN K felt to rub R4's sternum and not eating would be a change of condition for R4. LPN K indicated R4 has a history of ups and downs in health. R4's Nurse Note dated 8/26/25 at 10:05 AM, states: Staff reported resident has not been at baseline for the last couple of days, VSS (vital signs stable) as charted. Resident told staff he was in pain and needed meds, writer attempted to give meds, he refused and stated, get out. Writer re-approached x 2 at [sic] after a brief period, he still refused. He was observed not making needs known per his usual. Order obtained from NP to send to ER for eval. Writer spoke with son and resident who were both in agreement with the plan. EMS transported resident to hospital at approximately 9:45 AM. On 9/03/25 at 2:41 PM, Surveyor interviewed RN L (Registered Nurse) who indicated that it had been reported to her by R4's caregiver and CNA N that R4 was off on the morning of 8/26/25 approximately 6:30 AM. RN L indicated R4 was talking and making statements that were not his normal conversation. CNA N had come to RN L and informed that R4 was in pain and needed something. RN L went in by R4 and R4 stated, I don't want those. Get out of here! RN L indicated she reapproached and checked vital signs on R4. RN L indicated R4 can usually make needs known so his behavior was a change for him. RN L called NP and received an order to send R4 out to ER. Surveyor asked RN L if she had received anything in report regarding a change in R4 and RN L indicated she worked with R4 Sunday and R4 was a little off. On 9/03/25 at 3:52 PM, Surveyor interviewed CNA N who indicated she worked with R4 the morning of 8/26/25 when R4 was complaining of pain in his back and asking for pain medication. CNA N indicated R4 never asked for pain medication so that was a change for R4. CNA N indicated that morning she had got in report that R4 was acting different. R4's Nurse Note dated 8/27/25 at 11:12 AM, states, Resident was admitted to hospital for observation, RN from hospital called to update on his condition and to gather information on his cares here. Plan at this time is to have him return when ready. R4's Nurse Notes, dated 8/27/25, at 5:42 PM, states, admit date : [DATE] Time: 5:05PM.Diagnosis: CVA (cerebrovascular accident) (stroke) in occipital lobe.Primary reason for admission: CVA. R4's BP recordings are as follows:7/8/25 11:23 AM- BP- 112/787/15/25 12:44 PM- BP-97/658/1/25 12:27 PM- BP-137/768/5/25 1:17 PM- BP- 105/708/12/25 9:22 AM- BP- 151/838/19/25 10:35 AM- BP-127/738/24/25 8:45 PM- BP-146/1058/24/25 10:30 PM- BP-108/688/25/25 6:40 PM- BP- 153/92 R4's Hospital Discharge, dated 8/27/25, states, in part: . admission Date: 8/26/25. discharge date : [DATE] Primary Discharge Diagnosis: Left occipital lobe subacute infarct (an area of brain tissue damage in the posterior (back) left part of the brain that occurred days or weeks ago, not acutely (within hours). This type of stroke primarily affects vision, leading to a loss of the right-side visual field in both eyes. Symptoms can also include visual hallucinations, memory problems, or confusion and require immediate medical attention) .Active Issues Requiring Follow-Up:Issue: Post-hospital follow up.What is needed: diabetes and hypertension management, evaluate for tolerance of new aspirin for stroke, moderate to severe aortic valve stenosis on TTE (transthoracic echocardiogram) .Issue: post-hospital follow upResponsible Individual: stroke neurology clinicWhat is Needed: stroke follow up, zio (cardiac monitoring patch for detecting irregular heart rhythms) ordered at discharge. Details of Hospital Stay:Initial Presentation and Hospital Course: . presented to ER from his nursing facility on 8/26/25 due to altered mental status for a few days. Initial neurologic exam notable for disorientation to time, reason for presentation, right temporal hemianopia (a condition where there is a partial or complete loss of vision in one half of the visual field), and at least antigravity strength (ability to resist gravity with bending or extending arm) of right upper extremity, bilateral lower extremities, and 1/5 left upper extremity strength. CT (Computed Tomography) head demonstrated new cytotoxic edema (excess accumulation of fluid in the intracellular or extracellular spaces of the brain. This typically causes impaired nerve function, increased pressure within the skull, and can eventually lead to direct compression of brain tissue and blood vessels) of the left occipital lobe likely representing a subacute infarct (a brain injury that occurs when blood flow to a part of the brain is reduced or blocked for a period of time, resulting in tissue damage) with gyriform areas of linear hyperdensity (a sign of brain damage caused by insufficient energy supply to the brain) potentially related to associated petechial blood products. Etiologic Investigation of Stroke: .1.MRI (Magnetic Resonance Imaging) head: Redemonstrated subacute infarct of the left occipital lobe. There is associated susceptibility artifact favored to represent petechial hemorrhage.2.] MR (Magnetic Resonance) Perfusion: Small area of elevated Tmax within the area of left occipital infarct (indicates tissue that is at risk of damage but still may be salvageable), though elevation is limited by technical factors. Etiology of infarct considered to be ESUS (Embolic Stroke of Undetermined Source) at this time. However, atherembolism (cholesterol embolism) is a consideration. Discharge Planning: Secondary stroke prevention treatment plan at discharge includes antiplatelet therapy (prevent blood clots). Ongoing BP management. Blood Pressure: Last 3 Readings:8/27/25 3:00AM- 167/748/27/25 7:50 AM- 122/558/27/25 11:30AM- 121/59. On 9/04/25 at 12:00 PM, Surveyor interviewed NP R and asked if she would expect to be notified of R4 complaining of a severe headache where R4 is unable to hold eyes open due to pain and elevated BP of 146/105 and NP R indicated yes. Surveyor asked NP R if R4 was refusing to go to the ER at this time of elevated BP and severe headache what would NP R expect nursing staff to do. NP R indicated notify physician/NP and follow directions. Surveyor asked at the time R4 was experiencing severe headache and elevated BP would NP R expect a thorough assessment by a nurse. NP R indicated yes with neurological assessment and repeat BP checks. NP R indicated with a significant change as that she would expect MD/NP notification immediately by phone, not voicemail. On 9/04/25 at 2:33 PM, Surveyor interviewed DON B (Director of Nursing) and asked on 8/24/25 R4 was experiencing a severe headache where he could not hold his eyes open the pain was so bad and an elevated BP of 146/105 would you expect physician notification immediately. DON B indicated yes. Surveyor asked if that would be a change of condition and DON B indicated yes. Surveyor asked if DON B would expect a thorough assessment to include a neurological assessment by an RN and DON B indicated yes. Surveyor informed DON B that Surveyor could not locate a thorough assessment for R4 on 8/24/25 and DON B and NHA A (Nursing Home Administrator) agreed after looking in R4's medical record there was no thorough assessment. Surveyor informed DON B and NHA A that LPN J indicated no NP or physician was notified; LPN J left a voicemail on the NP's line. Surveyor asked DON B with a change of condition would she expect physician notification and DON B indicated yes. Surveyor asked if voicemail would be acceptable and DON B indicated no. Surveyor went over the nurse notes from 8/25/25 when R4 did not eat supper and was lethargic with nurse rubbing R4's sternum. Vital signs charted in R4's medical record without a thorough assessment. DON B agreed a thorough assessment should have been completed and was not. Surveyor asked what standards of practice the facility follows for change of condition and DON B indicated Interact.R4 was not thoroughly assessed by an RN when he experienced a change in condition and R4's provider was not notified regarding his change in condition.

Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 1 of 3 supplemental residents (R29) and 22 residents eating in the main dining room out of a census of 31. R29 voiced concerns of cold food during screening. Surveyor conducted 1 test tray for the dining room which was not palatable. Evidenced by: Facility policy, entitled Standard Operating Procedures Serving Food dated 10/10/10 states, in part: .5. Hold potentially hazardous foods at the proper temperature. The 2022 Federal Food and Drug Administration (FDA) Food Code documents at 3-501.16: .Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone of 5 degrees Celsius (C) to 57 degrees C (41 degrees Fahrenheit (F) to 135 degrees F) too long. Example 1 On 9/3/25 at 12:39 PM, Surveyor conducted a test tray from the main dining room. Surveyor took the temperature of the items on the tray. The temperatures were as follows: Salisbury Steak– 124.2 degrees Fahrenheit Buttered noodles – 121.4 degrees Fahrenheit Vegetable medley (broccoli, squash, green beans, red pepper) – 126.9 degrees Fahrenheit Cheesecake – 64.9 degrees Fahrenheit Milk – 46.9 degrees Fahrenheit Surveyor tasted the food and drink on the tray. The Salisbury steak, noodles, and vegetables did not taste as hot as they should have been - the steak and noodles were lukewarm. The cheesecake tasted like it was room temperature and the milk was not as cold as it should have been. The tray was not palatable and at a safe and appetizing temperature. On 9/4/25 at 11:18 AM, Surveyor interviewed DM F (Dietary Manager) who indicated the hot food should have been above 135 degrees and the cold food should be below 41 degrees Fahrenheit. On 9/4/25 at 3:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator), ANHA E (Assistant Nursing Home Administrator), and DON B (Interim Director of Nursing) who indicated they would expect food to be served at the appropriate temperatures. Of note: 22 Residents dine in the dining room out of a census of 31. Example 2 R29 was admitted to the facility on [DATE] with diagnoses that include: hypertension (high blood pressure) and hyperlipidemia (high cholesterol). R29's Comprehensive Minimum Data Set (MDS), with Assessment Reference Date (ARD) 8/28/25, indicates R29 has a Brief Interview for Mental Status score of 15 out of 15, indicating that R29 is cognitively intact. On 9/2/25 at 11:44 AM, Surveyor interviewed R29. R29 stated to Surveyor that the food she receives is cold sometimes. On 9/4/25 at 3:15 PM, Surveyor interviewed NHA A (Nursing Home Administrator), ANHA (Assistant Nursing Home Administrator), and DON B (Interim Director of Nursing) who indicated they would expect food to be served at the appropriate temperatures.

Based on interview and record review, the facility did not ensure that before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 2 of 5 residents (R6, & R7) reviewed for immunizations. The facility did not offer R6 the pneumococcal vaccines, and the facility has no declination/education or consent for R6.The facility did not offer R7 the pneumococcal vaccines, and the facility has no declination/education or consent for R7.Evidenced by:The facility policy entitled Immunization Policy- Residents, dated 5/24/21, states, in part: . Policy: Four Winds Manor provides the following vaccinations to residents pursuant toa directive from CMS (Centers for Medicare & Medicaid Services) and an overall order from the Medical Director. These vaccinations are administered per this protocol at the appropriate time unless there is a medical contraindication for vaccination.the current Vaccination Information Sheet prepared by the Centers for Disease Control is provided in advance to the resident or responsible party. E. Immunization status of residents is reviewed annually. Current CDC (Centers for Disease Control) recommendation is considered. Example 1R6 admitted to the facility 2/26/2024.R6's vaccine documentation shows:R6 received the 23 Valent Pneumococcal Vaccine on 11/13/2017.R6 received the 13 Valent Pneumococcal Vaccine on 5/21/2015.R6 was not offered the PCV20 or PCV21 per CDC recommendations. There is no documentation that R6 was offered the next pneumococcal vaccine. Facility could not provide a declination or consent for R6.Per Pneumo Recs VaxAdvisor, the recommendation for R6 is to give one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Example 2R7 admitted to the facility on [DATE]. R7's vaccine documentation shows:R7 received the 13 Valent Pneumo on 11/11/2014.R7 received the 23 Valent Pneumo on 10/31/2018.R7 was not offered the PCV20 or PCV21 per CDC recommendations. There is no documentation that R7 was offered the next pneumococcal vaccine. Facility could not provide a declination or consent for R7.Per Pneumo Recs VaxAdvisor, the recommendation for R7 is to give one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose.On 9/4/25, at 1:45PM, DON B (Director of Nursing) handed Surveyor an email from the pharmacy regarding CDC's current guidance for pneumococcal vaccinations. DON B indicated the facility had been following the old CDC guidance and not the current guidance. The facility does not have declinations for R6 and R7.

Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 3 supplemental residents (R19 &R10)) reviewed for antibiotic stewardship. R19 was treated for a urinary tract infection (UTI) with no documentation for criteria being met. R19 was treated with ciprofloxacin for UTI and culture and sensitivity (C&S) showed resistance to ciprofloxacin.R10 was treated with antibiotic for cystitis with no documentation for criteria being met and with no documentation of urinalysis (UA) and C&S.Evidenced by:The facility policy entitled Antibiotic Stewardship Program, dated 2/2024, states, in part: . Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.Procedure: .4. The program includes antibiotic use protocols and a system to monitor antibiotic use. A. Antibiotic use protocols include: . ii. Laboratory testing shall be in accordance with the current standards of practice. iii. The facility uses McGeers Criteria to define infections. B. Monitoring antibiotic use: i. Antibiotic orders obtained upon admission, whether new admission or readmission to the facility will be reviewed for appropriateness. ii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. The facility policy entitled Infection Control Surveillance, dated 2/2024, states, in part: . Policy: It is the policy that surveillance is an integral component of an effective program to prevent, control, and treat infection among residents and staff. A system of surveillance is utilized for prevention, and controlling communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under contractual arrangement based upon a facility assessment and accepted national standards. Procedure: 1. An Infection Preventionist (IP) serves as the leader in surveillance activities, maintains documentation of incidents, finds any corrective actions made by the facility.9. Data to be used in the surveillance activities may include but are: . H. Documentation of signs and symptoms in clinical record monitoring includes a review of the current resident's medical status, risk factors, daily documentation, physician's orders, laboratory reports, culture findings, and residents known to have experienced multi-drug-resistant organisms. McGeer Criteria for Infection Surveillance Checklist, states, in part: . Urinary Tract Infection (UTI) Surveillance Definitions:Syndrome: UTI with indwelling catheter.Criteria: Must fulfill both 1 and 21. At least one of the following sign or symptom:-Fever, rigors, or new-onset hypotension, with no alternate site of infection-Either acute change in mental status or acute functional decline, with no alternate diagnoses and leukocytosis-New onset suprapubic pain or costovertebral angle pain or tenderness-Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis, or prostate2. Urinary catheter specimen culture with > 10 to 5th power cfu (colony forming units)/mL (milli-liters) of any organism.Syndrome: UTI without indwelling catheter.Criteria: Must fulfill both 1 and 21. At least one of the following sign or symptom.-Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate-Fever or leukocytosis, and > 1 of the following: -Acute costoverbral angle pain or tenderness -Suprapubic pain -Gross hematuria -New or marked increase in incontinence -New or marked increase in urgency -New or marked increase in frequency-If no fever or leukocytosis, then > 2 of the following: -Suprapubic pain -Gross hematuria -New or marked increase in incontinence -New or marked increase in urgency -New or marked increase in frequency 2. At least one of the following microbiologic criteria- > 10 to 5th power cfu/mL of no more than 2 species of organisms in a voided urine sample- > 10 to 5th power cfu/mL of any organism(s) in a specimen collected by an in-and-out catheter Example 1:R19 admitted to the facility on [DATE], and has diagnoses to include spinal stenosis (the spaces inside the bones of the spine get too small putting pressure on the spinal cord and the nerves that travel through the spine) and atherosclerotic heart disease (involves plaque buildup in artery walls and can cause a heart attack, stable or unstable angina, stroke, transient ischemic attack or aortic aneurysm).The facility's August 2025 Infection Control Line Listing shows for R19: . Infection Type: UTI. Date Lab: 8/11/25. Date Symptom: 8/10/25. Predisposing Factors: left blank. Date Treatment: 8/11/25. Antibiotic: Ciprofloxacin. Dose: 500 mg. Start Date: 8/11/25. Stop Date: 6 days. Date of Culture: left blank. Is organism sensitive to antibiotic? Left blank. Clinical signs of infection present? Left blank.R19's C&S, dated 8/15/25, states, in part: . >100,000 CFU (colony forming unit)/mL (milli-liter) Proteus mirabilis.>100,000 CFU/mL Pseudomonas aeruginosa. Susceptibility: .Cefuroxime - Susceptible.Ciprofloxacin - Resistant. R19's August 2025 Medication Administration Record (MAR) states, in part: . Entry Date: 8/11/25 Ciprofloxacin HCI (hydrochloride) 500 mg (milligrams) Tablet dose ordered: 1 tablet/500mg by mouth twice a day 0800/8pm x 6 days (Current Order) For: UTI.R19's August 2025 MAR shows R19 received Ciprofloxacin 500 mg at 8:00PM on 8/11/25 and twice a day at 8:00AM and 8:00PM on 8/12/25, 8/13/25, 8/14/25, 8/15/25 and 8/16/25. R19 received ciprofloxacin 500 mg at 8:00AM on 8/17/25.R19's August 2025 MAR states, in part: . Entry Date: 8/15/25 Cefuroxime Axetil 250 mg tablet dose ordered: (1 tablet/250mg) by mouth twice a day 8:00 AM/8:00PM. First Date: 8/16/25 through 8/27/25 for UTI.R19's August 2025 MAR shows R19 received Cefuroxime axetil 250 mg at 8:00PM on 8/15/25 and at 8:00AM and 8:00PM on 8/16/25 -8/20/25.On 9/4/25 at 10:20AM, Surveyor interviewed IP S (Infection Preventionist) and RN T (Registered Nurse). IP S indicated R19 had returned from a hospital stay on 8/11/25 on Ciprofloxacin for UTI. Surveyor asked IP S looking at the C&S is the organism resistant to Ciprofloxacin and IP S indicated yes. IP S indicated R19 received the ciprofloxacin for a few days and then started on cefuroxime which R19 was susceptible to. IP S indicated R19 should not have received Ciprofloxacin for UTI as R19's C&S showed resistance to the antibiotic. Surveyor asked IP S looking at line listing what were R19's symptoms and IP S indicated there are no symptoms listed. Surveyor asked IP S what the facility's process is for a resident coming from hospital or another facility on antibiotic. IP S indicated the facility is to be sure the resident and the labs meet criteria to treat infection, and the resident is on correct antibiotic according to C&S. IP S indicated it was missed in R19's case. Surveyor asked IP S what standards of practice the facility uses, and IP S indicated McGeers. Example 2:R10's last admission date to the facility from the hospital was 9/04/25 and has diagnoses that include cerebral infarction (occurs when blood flow to the brain is interrupted leading to cell death and brain damage) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe).The facility's August 2025 Infection Control Line Listing shows for R10: . Infection Type: left blank. Date Lab: 7/30/25. Date Symptom: 7/30/25. Predisposing Factors: left blank. Date Treatment: left blank. Antibiotic: Cefpodoxime. Dose: 200 mg. Start Date: 7/30/25. Stop Date: 7 days. Date of Culture: N/A. Is organism sensitive to antibiotic? Left blank. Clinical signs of infection present? Left blank. Comments: cystitis.R10's July MAR shows: Entry Date: 7/30/25. Cefpodoxime Proxetil 200 mg Tablet dose ordered: (1 tablet/200 mg) by mouth twice a day 8:00AM/5PM x 7 days. For: Infection.R10's July 2025 MAR shows R10 received Cefpodoxime Proxetil 200 mg at 5:00PM on 7/30/25 and at 8:00AM and 8:00AM and 5:00PM on 7/31/25.R10's August MAR shows: Entry Date: 7/30/25. Cefpodoxime Proxetil 200 mg Tablet dose ordered: (1 tablet/200 mg) by mouth twice a day 8:00AM/5PM x 7 days. For: Infection.R10's August 2025 MAR shows R10 received Cefpodoxime Proxetil 200 mg at 8:00PM and 5:00PM on 8/1/25- 8/5/25 and at 8:00AM and 8:00AM on 8/6/25.On 9/4/25 at 10:20 AM, Surveyor interviewed IP S and RN T. Surveyor asked IP S what were R10's symptoms and IP S indicated there are no symptoms listed on the line list. Surveyor asked if R10 met criteria and IP S indicated I wouldn't know looking at line listing. RN T indicated McGeers criteria would be in documentation. (Note: documentation was not provided).Surveyor asked if facility has UA and C&S for R10, and RN T indicated no. IP S indicated the UA and C&S should be in R10's medical record.

Based on observation, interview, and record review, the facility did not ensure residents are free of significant medication errors for 1 (R34) of 1 out of 5 sampled residentsR34 has an order for metoprolol succinate (medication used to lower blood pressure) ER (extended release) 25 MG (milligrams) Tablet Extended Release 24 Hour dose to be administered once a day by mouth. This medication is labeled and ordered as an extended-release medication, meaning it is designed to release the active ingredients slowly over time, and are not to be crushed. Additionally, the order required staff to assess a pulse prior to administration. Surveyor observed MT G (Medication Technician) crush R34's Metoprolol extended release and administer it to R34 without assessing a pulse. Evidenced by:The facility policy entitled, Preparation and General Guidelines IIA2: Medication Administration-General Guidelines, dated 8/2014, states, in part: . 7) Tablet Crushing/Capsule Opening:. a. Long-acting or enteric-coated dosage forms should not be crushed; an alternative should be sought.The facility policy entitled, Appendix 7: Medication Crushing Guidelines, dated 8/2014, states, in part: . Medications That Should Not Be Crushed or Chewed. When a resident's condition prohibits the administration of solid dosage forms (tablets, capsules, etc.), the nurse administering the medication should check to see that there is no contraindication to crushing the medications in question. If crushing is contraindicated, the nurse should consult the pharmacist for assistance in obtaining the medication in liquid form, if possible, and obtain a physician's order to change dosage forms and directions. The rational for not crushing some medications includes:. D. Timed Release Tablets are designed to release medication over a sustained period, usually 8 to 24 hours. These formulations utilized to reduce stomach irritation in some cases and to achieve prolonged medication action in other cases. In either case these tablets should not be crushed.The facility policy entitled, Specific Medication Administration Procedures IIB1: Administration Procedures For All Medications, dated 8/2014, states, in part: . I. Obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration.The facility policy entitled, Medication Error, dated 4/2023, states, in part: It is the policy of [Facility Name] to be free of significant medication error and error rates. Significant medication errors can cause the resident discomfort or jeopardizes his or her health safety.R34 was admitted to the facility on [DATE], with diagnoses that include, in part: Cerebrovascular Accident (Stroke), hypertension (high blood pressure), and hypothyroidism (Thyroid gland doesn't produce enough thyroid hormone).R34's Quarterly Minimum Data Set, with Assessment Reference Date (ARD) of 6/20/25, indicates R34 has a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating that she is cognitively intact.R34's Physician Orders indicate:Metoprolol Succinate ER (extended release) 25 MG (milligrams) Tablet Extended Release 24 Hour dose ordered: (1 tablet/25mg) by mouth daily 0800 (8:00 AM) FOR: Hypertension. Administration Instructions: hold for pulse <50. Start Date: 12/15/23. Active Order. R34's Nursing Notes indicate R34's pulse was not assessed prior to the Metoprolol Succinate administration.On 9/4/25 at 8:47 AM, Surveyor observed MT G prepare R34's medications. Surveyor observed MT G prepare and crush 4 medications, including the Metoprolol Succinate ER tablet. Surveyor stopped MT G and asked if she had completed all of her pre-administration medication checks. MT G states, yes, and that R34 likes to take her medications with pudding. Surveyor asked MT G if she was now going to administer the medications. MT G states, yes. Surveyor asked MT G if she knew what the ER label meant on medication labels. MT G indicates, that ER means extended release. Surveyor asked MT G if extended-release medications can be crushed. MT G states, no. Surveyor advised MT G that she was not able to give her direction on what to do, but if she wanted to speak with a nurse, physician, or pharmacy prior to administration, she could do what she felt was appropriate at this time since she had not yet administered the medication. MT G indicated that is how R34 takes her medication and Surveyor observed MT G administer the crushed medications, mixed with pudding, to R34. This resulted in one significant medication error.On 9/4/25 at 10:20 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B how staff who administer medications know which resident's medications are crushed, in pudding, or have special instructions. DON B indicates this information should be on the MAR (Medication Administration Record), and they should have crush or do not crush orders. Surveyor asked DON B what the ER stands for on medication labeling. DON B indicates, it means extended release. Surveyor asked DON B if extended-release medications should be crushed. DON B states, no. Surveyor asked DON B if crushing an extended-release medication would be considered a medication error. DON B indicates, yes, and that the facility has already started the procedure of notifying the physician, assessing the resident, and reaching out to their pharmacist for further instruction. On 9/4/25 at 1:37 PM, Surveyor interviewed DON B. Surveyor noted that R34's metoprolol physician order also requires R34 to have her pulse checked prior to medication administration. Surveyor asked DON B if she would have expected R34 to have her pulse checked prior to the metoprolol succinate medication administration. DON B states, yes.

Based on interview and record review, the facility must ensure the assessment accurately reflects the resident's status, this affected 1 of 16 sampled residents (R17).R17's comprehensive and quarterly Minimum Data Set (MDS) Assessments do not accurately reflect her bowel status. Evidenced by:The facility's policy titled MDS Completion last reviewed on 4/2024, states in part .Key Points: The RAI (Resident Assessment Instrument) is an interdisciplinary process in which input from the resident, family, care team staff as well as the medical record is used. It is intended that the assessment and interview process includes the resident's choices for care whenever possible.R17 was admitted to the facility on [DATE] with diagnoses that include type 2 Diabetes mellitus, hypertension (high blood pressure), and bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs).R17's most recent MDS dated [DATE] states that R17 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R17 is cognitively intact.R17's MDS Section H- Bowel and Bladder, since admission state the following:10/25/24- Occasionally incontinent of bowel- on toileting program.2/4/25- Frequently incontinent of bowel- on toileting program.4/30/25- Frequently incontinent of bowel- on toileting program.7/25/25- Always incontinent of bowel- on toileting program.R17's care plan dated 11/5/24 states in part .Problem: Potential for difficulty with self-cares r/t (related to) my impaired mobility. Approach: .Toileting: I need 2 people to help me to the bathroom. I am partially incontinent.On 9/2/25 at 4:13 PM, Surveyor interviewed R17. R17 reported to Surveyor that they have to Poop in bed. Surveyor asked R17 if staff have tried to transfer her to the toilet with the Hoyer, R17 stated np, they can't. Surveyor asked R17 if she knows when she has to have a bowel movement, R17 reported that she has full control of her bowels and knows when she has to have a bowel movement. R17 also reported that she is fully incontinent of her bladder.On 9/4/25 at 8:49 AM, Surveyor interviewed RN Q (Registered Nurse), who is also the MDS nurse. Surveyor asked RN Q What the process is for completing a MDS, RN Q stated that she has a worksheet that she fills out, reviews the documentation, and then enters the data into the computer system. Surveyor asked RN Q if she interviews the residents for the MDS, RN Q stated she interviews residents on admission and with quarterly assessments and looks at the documentation in the electronic health record. Surveyor asked RN Q if she spoke with R17 regarding her bowel continence, RN Q stated no, and that R17 is a Hoyer transfer and that the lift won't fit into the bathroom. RN Q reported that she is unsure if the CNAs (Certified Nursing Assistant) are offering R17 the bedpan. Surveyor asked RN Q if R17 cannot be transferred to the bathroom, does that automatically make her incontinent, RN Q stated no. RN Q reported that the CNA documentation states that R17 is incontinent. Surveyor asked RN Q if she has spoken with R17 about her bowel incontinence, RN Q stated no. Surveyor asked RN Q what the toileting program that R17 is on, RN Q stated R17 should be toileted upon rising, after breakfast, before and after lunch and supper, and at bedtime.It is important to note that Surveyor requested documentation of R17's toileting program and none was provided.On 9/4/25 at 10:11 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the information in the MDS should be accurate, DON B stated yes. Surveyor asked DON B if a resident is on a toileting program, should it be documented, DON B stated yes.

Based on interview and record review, the facility did not ensure that all staff had background checks completed every four years which is part of preventing abuse. This affected 2 of 8 staff reviewed.Housekeeper C did not have a background check completed every four years.LPN D (Licensed Practical Nurse) did not have a background check completed every four years.Evidenced by:The facility's policy titled Policies and Procedures last reviewed on 8/2025 states in part .Components of Abuse Policy: 1. Screening: .B. Employment Background Checks are completed on all employees through [county's health and family services department] and Department of Justice at hire and every 4 years thereafter.On 9/3/25, Surveyor reviewed 8 random staff members to ensure compliance with background checks.Surveyor reviewed the background check information for Housekeeper C and noted the date of the background check was 5/12/21, meaning that Housekeeper C was due for a background check on or before 5/21/25.Surveyor reviewed the background check information for LPN D and noted the date of the background check was 11/25/20, meaning that LPN C was due for a background check on or before 11/25/24.On 9/3/25 at 4:05 PM, Surveyor interviewed ANHA E (Assistant Nursing Home Administrator). Surveyor asked ANHA E how often background checks should be completed, ANHA E stated every 4 years. Surveyor asked ANHA E if Housekeeper C and LPN D should have had their background checks completed timely, ANHA E stated yes.

Based on interview and record review, the facility did not ensure that each resident is treated with dignity and respect in an environment that promotes maintenance or enhancement of his or her quality of life and recognizes each resident's individuality for 1 of 12 residents (R17) reviewed.R17 reported to Surveyor that they are continent of their bowels, but facility staff make them go to the bathroom in their depends.Evidenced by:The facility policy titled Rights of Residents, no date, states in part .As a basic premise, all residents have the right to a dignified existence, self- determination, and communication with and access to persons and services inside and outside of the facility.Quality of Life: This facility will care for each resident in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life.Dignity: We will promote your right to receive care and treatment in a manner and in an environment that maintains or enhances your dignity and respect in full recognition of your individuality.R17 was admitted to the facility on [DATE] with diagnoses that include type 2 Diabetes mellitus, hypertension (high blood pressure), and bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs).R17's most recent Minimum Data Set (MDS) dated [DATE] states that R17 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R17 is cognitively intact.R17's MDS Section H- Bowel and Bladder, since admission state the following:10/25/24- Occasionally incontinent of bowel- on toileting program.2/4/25- frequently incontinent of bowel- on toileting program.4/30/25- frequently incontinent of bowel- on toileting program.7/25/25- Always incontinent of bowel- on toileting program.R17's care plan dated 11/5/24 states in part .Problem: Potential for difficulty with self-cares r/t (related to) my impaired mobility. Approach: .Toileting: I need 2 people to help me to the bathroom. I am partially incontinent.On 9/2/25 at 4:13 PM, Surveyor interviewed R17. R17 reported to Surveyor that they have to Poop in bed. Surveyor asked R17 if staff have tried to transfer her to the toilet with the Hoyer, R17 stated no, they can't. Surveyor asked R17 if she knows when she has to have a bowel movement, R17 reported that she has full control of her bowels and knows when she has to have a bowel movement. R17 also reported that she is fully incontinent of her bladder. Surveyor asked R17 if given the option, would she prefer to go to the bathroom on the toilet, R17 stated yes. Surveyor asked R17 how it makes her feel to have to go to the bathroom in bed and in a Depends, R17 stated that it makes her feel icky and that she is above that and does not want it to continue.On 9/3/25 at 3:12 PM, Surveyor interviewed CNA H (Certified Nursing Assistant). Surveyor asked CNA H if R17 is aware when she has to have a bowel movement, CNA H stated yes. Surveyor asked CNA H if R17 gets transferred to the bathroom when she has to have a bowel movement, CNA H stated no, she has to go in bed, on the bedpan or in her Depends. CNA H stated that she is not sure how they would get the Hoyer in the bathroom due not having much room.On 9/4/25 at 8:58 AM, Surveyor interviewed CNA I. Surveyor asked CNA I if R17 knows when she has to have a bowel movement, CNA I stated that sometimes she does and sometimes she doesn't. Surveyor asked CNA I if they transfer R17 to the toilet when she has to have a bowel movement, CNA I stated that they have not put R17 on the toilet since she became a Hoyer transfer. Surveyor asked why they do not transfer R17 to the toilet, CNA I stated that it is physically impossible to get someone on the toilet with a Hoyer lift.On 9/4/25 at 10:11 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B what the expectation is for toileting residents that transfer with a Hoyer, DON B reported that residents can be evaluated by therapy, but if not cleared, they can use a commode or a bedpan. Surveyor asked DON B if residents should be expected to defecate in their Depends, DON B stated absolutely not. Surveyor asked DON B if she was aware that R17 is having to have bowel movements in her Depends, and occasionally on the bedpan, DON B stated no. Surveyor asked DON B if anyone had considered using a commode for R17, DON B stated that she was unsure.Cross reference F641.

Based on observation, interview and recird review the facility failed to follow appropriate infection control practices for hand hygiene before donning and after doffing gloves during indwelling urinary catheter care for 1 of 1 resident's (R9). Findings include: Review of the facility's policy titled INFECTION CONTROL HAND HYGIENE dated April 2023 provided by the facility revealed: It is the policy that hand hygiene is an integral component of an effective program to prevent, control, and treat infection among residents and staff. The hands of staff and those who are in contact with the care environment are potential for the spread of infection. Effective hand hygiene is a key component in preventing infection .The use of ABHR (alcohol based hand rub) is the preferred method in healthcare settings; however, hands must be washed with soap and water if visibly soiled. Avoid touching the face at all times as eyes, nose, and mouth are common sites for entry of infection. Avoid touching door knobs and handles with bare hands. Gloves are never worn from one resident to another, one room to another, or after leaving a resident care area. if in doubt, clean your hands C. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. During observation of R9's indwelling urinary catheter care on 01/24/25 at 7:00 AM, Certified Nurse Aide (CNA4) performed hand hygiene and donned a pair of gloves. CNA4 performed R9's peri-care with a towel and warm soapy water. CNA4 performed several glove changes during the peri-care due to the presence of fecal matter until R9 was clean. No hand hygiene was performed after doffing gloves and prior to donning new pair of gloves. At 7:30 AM, CNA4 changed gloves, touched her pocket, paper towel, and the door of R9's room, while calling for the nurse in the hallway for nystatin powder to apply to R9's peri-area. At 7:33 AM, CNA4 donned new gloves without performing hand hygiene, and applied the nystatin powder to R9's peri-area. At 7:37 AM CNA4 doffed nystatin-stained gloves and donned another pair of gloves without performing hand hygiene in between glove changes. CNA4 dressed R9 and with the assistance of CNA 2, moved R9 from the bed to the wheelchair. No hand hygiene was performed before glove changes. CNA4 doffed her gloves and performed hand hygiene for the first time since observation began at 7:00 AM. During an interview on 01/24/25 at 8:00 AM, CNA4 confirmed that she did not perform hand hygiene between gloves changes during R9's peri care. During an interview on 01/24/25, at 4:37 PM, the Director of Nursing (DON) stated it was her expectation that staff perform hand hygiene before and after each glove change.

Based on interview, record review, and review of facility policy, the facility failed to provide documentation of a person-centered baseline care plan within 48 hours of admission to ensure that 1 of 1 resident's (R8's) initial care needs would be provided. Findings include: Review of the facility's policy titled COMPREHENSIVE CARE PLANNING - COMPLETION OF RESIDENT assessment dated ,d+[DATE] revealed, .Facility will create an Initial Resident Baseline Care Plan upon admission . Review of R8's admission Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 10/22/24 revealed R8 was admitted to the facility on [DATE] with diagnoses that included orthostatic hypotension, atrial fibrillation, and hypertension. Review of the undated document titled Initial Resident Baseline Care Plan signed by RN2 and provided by Patient Care Advocate/Registered Nurse (RN)2 revealed hand-written entries indicating cares to be performed by the CNA. During an interview on 01/24/25 at 1:03 PM, RN2 stated this document was the patient's care card use as a tool for Certified Nurse Aides (CNAs) and would be in the resident's closet so the staff would have easy access to it and can see how to take care of that resident. When asked if this was the mandated baseline care plan that must be shared with the resident and/or their representative, RN2 stated, no. During an interview with the Administrator and the Director of Nursing (DON) on 01/24/25 at 4:37 PM, they both acknowledged that R8's baseline care plan could not be located, and it could not be determined if initial care expectations were addressed and a copy given to R8 and the resident representative.

Based on staff interviews and record review, the facility failed to ensure the rights of 1 of 1 resident's (R4) to be free from physical restraints imposed for the purposes of convenience. Findings: Review of the facility's policy titled For Alleged Incidents of Abuse, Neglect, Misappropriation, Injuries of Unknown Origin, and Exploitation dated 02/2024 provided by the facility revealed, .Definitions .The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms . Review of R4's Face sheet provided by the facility revealed she was admitted to the facility on [DATE] with diagnosis that included dementia. R4 was discharged from the facility on 10/30/24. Review of R4's quarterly Minimum Data Set (MDS) with assessment reference date (ARD) of 10/21/24 provided by the facility revealed R4 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated severe cognitive impairment. Review of R4's Care plan dated 07/24/24 provided by the facility revealed R4 had a Potential for Difficulty with self-cares r/t[(related to] impaired mobility . Potential for injury related to falls due to my impaired mobility . loss of memory, cognitive impairment, Alzheimer's/dementia, distractibility, and cognitive change. The care plan did not indicate the need for the use of a restraint as an intervention to prevent R4 from getting up out of her wheelchair. Review of R4's Physician orders dated 07/17/24 provided by the facility failed to reveal an order for a restraints to be used for R4. The investigative report revealed the facility reported the incident to the state survey agency (SSA) on 10/15/24 and the facility submitted a follow up report the SSA on 10/21/24 with the conclusion that the facility's investigation was inconclusive. The investigative report indicated, The morning of 10/14/24, it was reported to the D.O.N [ Director of Nursing] by the night nurse on duty Registered Nurse [RN1] that C.N.A. [Certified Nursing Assistant, CNA1] had used a bed sheet placed around the midsection of resident [R4] in her wheelchair at some point during the night shift to keep her safe and keep her from falling out of the wheelchair. The resident was able to move about in her wheelchair and throughout the facility, which is normal activity for this resident. The investigative report revealed the facility reported the incident to the state survey agency (SSA) on 10/15/24 and the follow up report on 10/21/24 with the conclusion that the facility's investigation was inconclusive. Administrator 2 provided the following staff interviews of the event concerning R4. Review of the written statement from CNA3 dated 10/15/24 indicated, .I [CNA3] noticed resident [R4] with a sheet around her in her wheelchair, tighted (sic) to the back of her chair. I told my co-worker, [CNA1], we cannot do this. She mumbled some words and walked away. So, I then reported what I saw to my supervisor. Administrator 2 provided the following statement dated 10/14/24 which indicated, This writer met with [CNA1's name] and the Assistant Director of Nursing [ADON] to discuss the incident that allegedly occurred during the night shift of 10/13/24 -10/14/24. Per reports to this writer, [CNA1] had used a bed sheet to secure R4 to her wheelchair during the night shift. While interviewing [CNA1], this writer asked [CNA1] to explain what she had done and to demonstrate how she had used a bed sheet on [R4's] wheelchair. [CNA1] explained that she was doing whole bed changes from the start of her shift [10 PM] on 10/13/24 due to some staffing issues that had occurred on the p.m. [evening] shift before she arrived at work. With her having to do all of these bed changes, she was not sure that she could check on resident [R4] every hour as is her customary practice. [CNA1] indicated that resident [R4] had fallen out of her wheelchair on the previous night [10/13/24] and she did not want her to fall from it again. [CNA1] stated that when she walked past resident [R4's] room while on her way to get linens, she did not state what time this was, she saw resident's briefs laying on the floor. [CNA1] indicated this is a daily occurrence with [R4], that she will often take her briefs off during the night and throw them on the floor. [CNA1] said that when she saw this, she knew that [R4] was going to try to get out of bed, because this is what she usually does. So [CNA1] stated that she went into R4's room, cleaned her up, reapplied a brief and pajamas, and got her up into her wheelchair, as this is many times what [R4] does/wants. Because [CNA1] was afraid [R4] was going to try to get up from the wheelchair which is also a common occurrence and that [CNA1] did not want her to fall again, she took a bed sheet, and wrapped it around the armrest of the wheelchair, across [R4's] lap, and around the other armrest of the wheelchair, with both ends ending up behind the wheelchair. [CNA1] stated she did not tie the bed sheet but rather crossed the two ends around each other and pushed the ends into the bottom of the wheelchair. She then stated that she put [R4's] notebook on her lap .[CNA1] indicated that [R4] was able to move from side to side in the wheelchair, and turn her body in the wheelchair, indicating the bedsheet was not tight up against [R4] or her midsection. She said that [R4] then proceeded to go out to the dining room, sat at a table, had a snack, and was writing in her notebook when she left her to continue doing her rounds [CNA1] would be off the schedule until a complete investigation could be conducted. This writer also indicated to [CNA1] that she needed to write a very complete, detailed statement on what she had done and re-educated [CNA1] that this type of use of a bed sheet is not ever allowed, [it] is not on the resident's care plan . Review of the statement by RN1 dated 10/14/24 indicated, At around 1:00 AM on 10/14/24, [CNA1] brought [R4] out in a wheelchair, due to the resident expressing inability to sleep. I told [CNA1] we need to supervise the resident, so she doesn't fall. The CNA wrapped a sheet around the resident in the wheelchair after bringing her to the dining room. [CNA1's] reason was so resident doesn't get up and fall. I said we shouldn't do that as could be considered a restraint; and the DON would say the same. The CNA disagreed and said she'd show the DON. [CNA1] explicitly refused my instruction to not wrap the resident with the sheet, expressing that the DON would observe later and be ok with it. Later in the morning, the ADON was on site, and [CNA1] claimed the ADON already saw the resident with the wrapped sheet, and didn't make any specific observation. This is my account of the of the event listed. Review of the statement by CNA1 indicated, . I took a conscious step by loosely laying a flat sheet on their (sic) [R4's] lap under their chip card, I allowed 10 of space in the front and twisted and tucked the excess behind their wheelchair. This was not done to restrain or punish her, but rather to provide additional safety should they attempt to stand up and have another fall. They (sic) remained fully able to move their limbs, roll around in their wheelchair and engage in their usual activities. At no point did [R4] express discomfort or attempt to remove the sheet. Nor did they exhibit any signs of distress, which is typically what she does when she is uncomfortable or restrained in any way. If this precaution had been a true restraint before R4 would have screamed and fought to remove it, as she does in other situations, such as when using the easy stand harness. In this instance, she was calm and fully mobile. It is important to note that no injuries occurred as a result of this incident. There were no injuries, bruising, chafing, or any of the sort and her ability to complete daily activities remained unimpaired. I want to emphasize that my actions were motivated purely by concern for [R4's] safety after her fall, and to prevent further harm. I would never restrain a resident for convenience, and the sheet was not used in any manner to restrict her freedom of movement. Review of CNA1's personnel record revealed she was hired on 08/26/24 and had passed the background check prior to employment. CNA1 completed all prerequisite initial training, including abuse training, and was still within the first 90 days of employment. During an interview with the Administrator 2 on 01/23/25 at 4:52 PM she stated on the morning of 10/14/24, when she came to work, the ADON and CNA3 had informed Administrator 2 of an allegation that CNA1 had used a bed sheet to tie R4 to the wheelchair. Administrator 2 stated she and the Assistant Director of Nursing (ADON) interviewed CNA1 who stated that R4 had been up during the night, was in her wheelchair and so CNA1 decided to take a bed sheet and set it across R4's lap in a wheelchair and draped the sheet around the handles of the wheelchair but did not tie the sheet to the back of the wheelchair. The resident could move and propel herself in her wheelchair. Administrator 2 stated she asked CNA1 why she did it, and CNA1 stated it was because she thought if the sheet was on R4 it would remind R4 not to stand. Administrator 2 stated she informed CNA1 that her actions were inappropriate and that she needed to leave. CNA1 was suspended pending an investigation. During an interview with ADON on 01/24/2025 at 4:37 PM she stated that the incident regarding R4 and CNA1 was brought to her attention when she came to work on 10/14/24, since it had occurred during the night shift. ADON stated she recalled CNA1 stated she placed a sheet over R4 to prevent R4 from getting up and did not seem to understand this was considered a restraint. CNA1 did not realize she could not use a sheet as a restraint and could not take corrective criticism. Education was provided for CNA1 and then was let go shortly after the incident. During an interview with Administrator 2 and DON on 01/23/25 at 6:37 PM, Administrator 2 and the DON admitted the incident occurred and that CNA1 did use a bed sheet as a restraint for R4, as confirmed by witness statements and CNA1's written account of the incident.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 33 residents. Surveyor observed food that had been removed from original containers and not labeled with an open date. Surveyor observed opened food without open dates and expired food in circulation in the facility's kitchenette. Evidenced by: Facility policy, entitled Food Dating-Procurement, revised [DATE], includes: All items are dated upon delivery. Expiration dates are monitored . All food service staff need to label items with open and use by dates as needed. They all need to monitor for dates to make sure food is still fresh and safe to serve . Any items that are expired, past use by date, or appear questionable will be discarded . Facility policy, entitled Food Storage and Handling of Food and Beverage Brought In For Residents, dated ,d+[DATE], includes, in part: . Food . should be covered and sealed, dated, and placed in proper storage area . should be labeled with resident name and the date . Facility refrigerators are checked twice daily by the Food and Nutritional Services department to ensure proper temperatures, food quality, and disposal of items past use by date. On [DATE] at 9:35 AM during initial tour of the kitchen, Surveyor observed food that was opened and did not have an open date, including coffee, noodles, and four different kinds of cereal. DM J (Dietary Manager) indicated she was unsure when the noodles, coffee, or cereal were opened and indicated food opened and/or removed from their original packaging should be labeled with an open date. On [DATE] at 10:21 AM Surveyor observed expired food in the facility's kitchenette, including coffee with expiration date of [DATE], 19 cartons of prune juice with expiration date of [DATE], thickened tomato juice with expiration date of [DATE], and cheerios with expiration date of [DATE]. Surveyor observed food that was opened and without an open date including, split top wheat bread, grape nuts, shredded wheat, corn flakes, and Wheaties. On [DATE] at 1:25 PM Surveyor observed 29 yogurts in the kitchenette refrigerator with expiration date of [DATE]. On [DATE] at 1:51 PM CNA K (Certified Nursing Assistant) indicated the residents can ask for snacks at any time and they are available in the kitchenette. CNA K indicated it is everyone's responsibility to throw expired items out. On [DATE] at 2:03 PM RN F (Registered Nurse) indicated there are always snacks available in the kitchenette and it is everyone's responsibility to discard expired items. On [DATE] at 1:08 PM Dietary Manager J indicated it is the responsibility of all staff to watch food dates and to discard expired food. It is all staff's responsibility to date and label food in the shared kitchenette. Dietary Manager J indicated food should have an open date once it is opened.

Based on observation, interview, and record review, the facility did not ensure snacks were offered at bedtime daily when there is more than 14 hours between the evening meal and breakfast. This has the potential to affect 33 of 33 residents and 3 of 3 units/hallways. R26, R185, R18, and R24 voiced concerns of snacks not being offered at bedtime. The facility is not offering all residents nourishing snacks at bedtime when their supper meal and breakfast meal are more than 14 hours apart. Evidenced by: The facility did not provide a policy related to meal frequency. Facility's posted meal times are as follows: Breakfast 8:00 AM . Lunch 12:00 PM . Supper 4:45 PM (It is important to note there are 15.25 hours between supper and breakfast.) On 7/31/24 at 1:00 PM during the Resident Council Task meeting, R26, R185, R18, and R24 voiced concerns of staff not offering snacks to them at bedtime. On 8/1/24 at 7:35 AM, CNA I (Certified Nursing Assistant) indicated staff do not offer all residents a snack at bedtime, but they have snacks available if a resident should ask. On 8/5/24 at 1:51 PM, CNA K indicated staff do not offer all residents a snack at bedtime, but snacks are available if a resident would ask. On 8/5/24 at 2:03 PM, RN F (Registered Nurse) indicated there is no snack cart that goes around to offer all residents a snack at bedtime, but snacks are available if a resident would ask for one. On 8/6/24 at 8:27 AM, DM J (Dietary Manager) indicated the staff do not offer snacks to all residents at bedtime, but snacks are available if residents were to get hungry. On 8/6/24 at 9:58 AM, NHA A (Nursing Home Administrator) indicated snacks should be offered to all residents at bedtime if there is more than 14 hours between supper and breakfast. On 8/6/24 at 10:39 AM, DON B (Director of Nursing) indicated staff do not offer snacks to all residents at bedtime, but snacks are available. DON B indicated snacks should be offered to all residents if there is more than 14 hours between supper and breakfast.

Based on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect the total census of 33 residents (3 of 3 hallways and 2 of 2 test trays.) Residents voiced concerns at Resident Council regarding hot food being served cold. 2 of 2 test trays were observed to not be palatable. Residents (R) from all three hallways voiced concerns of food not being served at a desirable temperature (R283, R19, R14, and R3.) Evidenced by: The facility policy, titled Food Temperature Policy, revised 8/6/24, includes in part: It is the policy of (the facility) to provide safe and sanitary food items to the residents and to ensure that hazardous food items are cooked to correct temperatures . Any cold food items, ready to eat at or below 41 degrees F (Fahrenheit) . minimum temperature for holding hot food and for ready to eat food - 135 degrees F . Steak/Roast, Pork/Ham/Bacon/Eggs/Seafood - 145 degrees F . Ground meat - 155 degrees F . Poultry, stuffed foods, reheated foods - 165 degrees F . (It is important to note the facility has three hallways where residents reside. These hallways are labeled A, B, and D.) Example 1: Resident Council Minutes, dated 5/21/24, include, Hall trays are cold. DM J (Dietary Manager) notified . Resident Council Minutes, dated 6/18/24, include, Hall trays are cold .Residents asked to meet with DM J (Dietary Manager,) NHA A (Nursing Home Administrator,) .to discuss food concerns .Residents would like DM J to attend monthly resident council meetings . Resident Council Minutes, dated 7/15/24, include, Fried eggs have been cold when serving . Example 2: R283 admitted to the facility on [DATE]. Her most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/29/24 indicates her cognition is intact with a BIMS (Brief Interview of Mental Status) score of 15 out of 15. On 7/31/24, R283 indicated her hot food is often served to her cold. (It is important to note R283 resides on the B hallway.) Example 3: R19 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 5/30/24 indicates his cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. On 7/31/24 at 1:03 PM, R19 indicated his food is not always served at a desirable temperature. (It is important to note R19 resides on the D hallway.) Example 4: R14 admitted to the facility on [DATE]. His most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 5/16/24 indicates R14's cognition is intact with a BIMS (Brief Interview for Mental Status) score of 15 out of 15. On 8/1/24 at 8:20 AM, R14 indicated his hot food is often served to him at a cold temperature. (It is important to note R14 resides on the B hallway.) Example 5: R3 admitted to the facility on [DATE]. Her most recent MDS with ARD of 7/17/24 indicates R3's cognition is intact with a BIMS score of 14 out of 15. (It is important to note R3 resides on the A hallway.) On 8/6/24 at 8:20 AM, R3 indicated her hot meals are served cold at times. Example 6: On 8/5/24 at 4:57 PM, Surveyor ordered a test room tray for B hallway, noting the plates for the room trays are set directly onto the tray and are covered by a thin metal cover that has a hole in the top center of it. On 8/5/24 at 4:58 PM, Dietary staff set up Surveyor's room tray with white milk, ice water, and watermelon. On 8/5/24 at 5:11 PM, Dietary Staff placed a plate of food onto Surveyor's room tray and put the tray into a four-sided uninsulated cart. Nursing Staff then pushed the cart to the hallway. On 8/5/24 at 5:16 PM, Surveyor was served the test tray. Surveyor and DM J (Dietary Manager) took a temperature reading of the food and beverages provided. They are as follows: milk 43.3 degrees F . water 37.7 degrees F . hot dog 119 degrees F . coleslaw and potato salad 48.0 degrees F. Surveyor noted the potato salad and the coleslaw were served on the plate with the hot dog. The hot dog was lukewarm, and the coleslaw and potato salad were cool, but not cold. DM J indicated the hot dog should be served hotter and the salads should be served colder. She was unsure why the cold food was served with the hot food and covered together. DM J indicated keeping food at a desirable temperature has been a concern for some time. DM J indicated staff are trying to serve them up as they are dished up, but the timing does not always work out. DM J indicated the covers help, but the heat does not stay in long enough to get the room trays down the hallway. Example 7: On 8/6/24 at 8:00 AM, Surveyor followed room trays out to the hallway and stayed with them. On 8/6/24 at 8:17 AM, DM J was going to deliver the last room tray to a resident on A hallway when Surveyor asked DM J to take a temperature reading of the food on the tray. DM J measured and recorded the following temperatures: fried eggs 104.9 degrees F and bacon 93.4 degrees F. DM J indicated the food is lukewarm and she would like to see the food at a hotter temperature. DM J indicated getting the food to stay hot until it gets to the end of the hallway has been a challenge. DM J indicated staff often have to reheat plates in the microwave due to the undesirable temperatures.

Based on interview and record review, the facility has not established an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 16 sampled residents (R9) and 3 of 5 supplemental residents (R24, R185, R186). The facility's resident infection control line lists do not include lab reports, and culture and sensitivity (C&S) reports. The facility failed to ensure that the residents were on the correct antibiotics. This is evidenced by: The facility policy titled Infection Control Surveillance last reviewed on 2/2024 states in part, .9. Data to be used in the surveillance activities may include but are: .B. Lab reports .H. Documentation of signs and symptoms in clinical record monitoring includes a review of the current resident's medical status, laboratory reports, culture findings, and residents known to have experienced multi- drug resistant organisms . Example 1 The facility's line list for May 2024 indicates that R9 and R186 were placed on antibiotics for a UTI (Urinary Tract Infection). On 5/1/24, R9 experienced a change of condition and was sent to the emergency department. R9 was diagnosed with a UTI and placed on an antibiotic. R9 returned to the facility on an antibiotic and the facility did not obtain R9's urine culture and sensitivity to ensure that he was on the correct antibiotic. On 5/14/24, R186 was sent to the emergency room and was diagnosed with a UTI. R186 returned to the facility on an antibiotic. The facility did not obtain R186's urine culture and sensitivity to ensure that she was on the correct antibiotic. Example 2 The facility's line list for June 2024 indicates that R24 was placed on an antibiotic for a UTI. R24 was admitted to the facility on [DATE] and was taking an antibiotic for a UTI. The facility did not obtain R24's lab results or culture and sensitivity to ensure that R24 was on the correct antibiotic. Example 3 The facility's line list for July 2024 indicates that R185 was placed on an antibiotic for a UTI. R185 was admitted to the facility on [DATE] and was taking an antibiotic for a UTI. The facility did not obtain R185's lab results or culture and sensitivity to ensure that R185 was on the correct antibiotic. On 8/1/24 at 2:00 PM, Surveyor requested urinalysis results, as well as culture and sensitivity results for the residents listed on the line lists. DON B (Director of Nursing), who is also the Infection Preventionist, reported to Surveyor that the request may take some time because she will have to look up the results and that the lab results do not come with the hospital paperwork. Surveyor asked DON B how she ensures that residents are on the correct antibiotics, DON B stated that she trusts the doctors. On 8/6/24 at 9:45 AM, Surveyor interviewed DON B. Surveyor asked DON B what the process is for obtaining lab results when a resident is admitted from or returns from the hospital, DON B stated that WN H (Wound Nurse), who also is the admissions nurse, takes care of that. On 8/6/24 at 10:43 AM, Surveyor interviewed WN H. Surveyor asked WN H what the process is for obtaining lab and culture and sensitivity results for a new admission or for a resident that is returning from the hospital, WN H stated that if the results are in the hospital paperwork she has them, if they are not in the paperwork, she does not reach out to get them.

Based on interview and record review the facility did not ensure that residents that are diabetic received routine diabetic foot checks in accordance with professional standards of practice for 4 of 4 residents (R9, R14, R84, R283) reviewed for diabetic foot checks. R9 has no documentation of diabetic foot checks. R14 has no documentation of diabetic foot checks. R84 has no documentation of diabetic foot checks. R283 has no documentation of diabetic foot checks. This is evidenced by: The facilities Policy and Procedure entitled Diabetic Foot Checks/Screens dated 9/2023 documents the following in part: .Residents with diabetes will be assessed upon admission and quarterly or upon significant change in condition. Procedure: 1. The Wound Nurse or designee will assess any current diabetic resident for skin impairment upon admission . The facilities form to complete diabetic foot checks is entitled Diabetes Foot Screen, undated includes pictures of both feet, top and bottom with specific areas circled that the Nurse would use a filament to determine if the resident has sensation in those areas. This procedure would allow the facility to take appropriate action if a diabetic resident doesn't have sensation in certain areas and be able to monitor the area (s) for concerns. Per ADA (American Diabetes Association), dated 2017, foot checks/screens should be conducted daily with a comprehensive exam conducted annually. Per AMDA (American Medical Director Association), dated 12/9/14, these foot checks/screens are vitally important for treatment of foot problems in patients with diabetes. Common foot problems in diabetic patients are broken down into three categories: at risk foot, current mild foot/ankle or heel infection or ulcer, and limb-threatening foot/ankle/heel ulcer. Example 1 R9 has a diagnosis of type 2 diabetes mellitus. R9's medical record was reviewed for documentation of diabetic foot checks. R9's medical record does not include any documentation of the facility completing diabetic foot checks. Example 2 R14 has a diagnosis of type 2 diabetes mellitus. R14's medical record was reviewed for documentation of diabetic foot checks. R14's medical record does not include any documentation of the facility completing diabetic foot checks. Example 3 R84 has a diagnosis of type 2 diabetes mellitus. R84's medical record was reviewed for documentation of diabetic foot checks. R84's medical record does not include any documentation of the facility completing diabetic foot checks. Example 4 R283 has a diagnosis of type 2 diabetes mellitus. R283's medical records was reviewed for documentation of diabetic foot checks. R283's medical record does not include any documentation of the facility completing diabetic foot checks. On 8/6/24 at 1:02 PM, Surveyor interviewed RN G (Registered Nurse). Surveyor asked RN G if diabetic foot checks are completed, RN G stated we are supposed to do them daily. Surveyor asked RN G where you chart diabetic foot checks, RN G said I don't know if we do chart it. Surveyor asked RN G should diabetic foot checks be done and documented, RN G replied we should be doing them and charting them daily. On 8/6/24 at 1:23 PM, Surveyor interviewed LPN N (Licensed Practical Nurse). Surveyor asked LPN N if diabetic foot checks are completed, LPN N asked like a skin check. I do not think we do them. On 8/6/24 at 2:45 PM, Surveyor interviewed RN E. Surveyor asked RN E if diabetic foot checks are completed here, RN E stated when they come in. Surveyor asked RN E if diabetic foot checks should be done more than just on admission, RN E said I'm not really sure, we are supposed to do it every day, the CNA's (Certified Nursing Assistants) check when they put them to bed. Surveyor asked RN E what the CNA's are checking, RN E stated they check to see if there are wounds, open areas, or bruising, or any skin changes. Surveyor asked RN E do you use a filament when you check their feet, RN E said no. RN E indicated they are not doing daily diabetic foot checks with a filament. On 8/6/24 at 2:48 PM, Surveyor interviewed RN F. Surveyor asked RN F if diabetic foot checks are completed here, RN F stated we are supposed to do them daily. Surveyor asked RN F do you use a filament when you do it, Rn F said we should be using a filament, it is supposed to be in the top drawer; RN F looked and did not find it. RN F then looked in the next med cart and did not find it there either. Surveyor asked RN F how often do you do diabetic foot checks, RN F replied we don't do it in this building daily. Surveyor asked RN F where do you document diabetic foot checks, RN F stated I would chart it under the MAR (Medication Administration Record) or TAR (Treatment Administration Record) if there was a space to do so. On 8/6/24 at 3:17 PM, Surveyor interviewed Wound Nurse H. Wound Nurse H brought the Facilities Policy and Procedure and their form in and stated the previous DON (Director of Nursing) had the CNA's doing foot checks daily and they documented it. Surveyor asked if a CNA could assess, Wound Nurse H said no. Surveyor asked Wound Nurse H if their Policy and Procedure would need some changes, Wound Nurse H stated yes. On 8/6/24 at 3:29 PM, Surveyor interviewed DON B. Surveyor asked DON B if she would expect diabetic foot checks to be completed here, DON B stated I thought they were. Surveyor asked DON B if she would expect the Nurses to be using a filament, DON B replied yes. Surveyor asked DON B how often would you expect diabetic foot checks to be done, DON B stated every day. Surveyor asked DON B if she would expect there to be documentation of the diabetic foot checks, DON B said yes, they should be documented in the TAR.

Based on observation, interview, and record review, the facility failed to ensure 2 of 3 (R1 and R2) residents reviewed for accidents received care and services to prevent accidents. On 8/3/23, CNA C (Certified Nursing Assistant) attempted to transfer R1 without a second person to assist as directed in R1's care plan. As R1 was transferring, the sling tilted sideways and R1 fell to the floor, causing R1 to receive a head laceration that required four staples. The facility completed a self-report and investigation; however, the facility failed to identify CNA C used an incorrect sling size. The facility does not have a process in place for identifying what size and style sling a resident should use. Surveyor observed R2 transferring with a lift and sling that were not compatible. Evidenced by: EZ Way Classic Lift manufacturers recommendations with a revision date of 5/15/19, state, in part; .Safety Notes .EZ Way slings are made specifically for EZ Way Lifts. For the safety of the patient and caregiver, only EZ Way slings should be used with EZ Way lifts . EZ Way Smart Lift manufacturers recommendations with a revision date of 6/14/23, state, in part; .Safety Notes .EZ Way slings are made specifically for EZ Way Smart Lifts. For the safety of the patient and caregiver, only EZ Way slings should be used with EZ Way lifts. EZ Way Sling Sizing Chart with revision date of 1/19/21, states, in part; .NOTE! The size/weight destinations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient. Invacare Reliant manufacturers recommendations with a date of 2018, state, in part; .Safety .ACCESSORIES WARNING Invacare products are specifically designed and manufactured for use in conjunction with Invacare accessories. Accessories designed by other manufacturers have not been tested by Invacare and are not recommended for use with Invacare products WARNING .Invacare slings and patient lift accessories are specifically designed to be used in conjunction with Invacare patient lifts. Slings and accessories designed by other manufacturers are not to be utilized as a component of Invacare's patient lift system . Invacare Patient Sling Reference Guide, states, in part; Complete instructions for lift usage and sling procedures are found in the Invacare Operating Manual. Only Invacare slings and accessories should be used on Invacare lifts .Note: Sling size and fit can vary significantly depending on patient weight and girth. These are general guidelines. Consult physician before sling selection . Example 1: R1 was readmitted to the facility on [DATE] with diagnoses including fracture of right fibula, diabetes, hyperlipidemia, stroke, dementia, anxiety disorder, and depression. R1's care plan states in part; 4/22/22 I have difficulty with my self cares r/t (related to) my stroke .TRANSFERS: I need 2 people to help me transfer with the EZ lift . R1's care card states in part; Transfers: 4/22/22 I need 2 people to help me transfer with the EZ lift . It is important to note there is no documentation in R1's care plan and care card indicating what size or style sling R1 should use to ensure safe transfers. The facility self-report to state agency states in part; .8/3/23 Briefly describe the incident .Resident was being transferred using Hoyer lift, from bed to wheelchair and resident fell out of Hoyer lift headfirst. Initially there were two CNAs involved in the resident's transfer. The two CNAs had the resident ready for transfer when one of the CNAs heard the resident across the hall, and saw resident across the hall, sitting on the edge of bed. At this point, one of the CNAs left to assist the resident in other room. The CNA helping the resident continued with the transfer without waiting for the second CNA to return. As the resident was being transferred the sling tilted sideways and the resident started to slip out of Hoyer sling. The CNA attempted to catch the resident but was unsuccessful. EMS (Emergency Medical Services) was contacted, and the resident was sent to the ER. The same day resident returned from the hospital with 4 staples to head laceration. No other injuries noted .Explain what steps the entity took upon learning of the incident .The facility suspended the CNA operating the Hoyer lift for 3 days, pending outcome of the investigation. On 8/3/23 CNA operating the Hoyer lift received education on the proper use of the Hoyer lift including sling use including proper placement, alignment, connection to lift. Lift use including 2-person assistance required, proper use of leg support, proper lifting procedure. Lowering resident to bed/chair-providing support and positioning. Removal of lift sling. A return demonstration was completed by all floor CNAs assuring proper use of Hoyer lift . On 8/22/23 at 11:23 AM, CNA C indicated on 8/3/23 CNA C and co-worker were assisting R1 in getting up. Co-worker left to assist another resident. CNA C indicated she kept assisting R1 in going from bed to wheelchair. R1 started to go sideways, before CNA C could get R1 back to bed, R1 slid right out of sling and fell to the floor. CNA C indicated CNA C immediately started yelling for co-worker. Co-worker stayed with R1 while CNA C ran to get a nurse. CNA C indicated she received education after incident. CNA C indicated she received education on the importance of following if someone needs 2 people assist for transfers, lift use, and properly placing the sling onto the lift. CNA C indicated she remembers using the mesh crisscross blue sling and that R1 uses a large sling. CNA C indicated staff know what sling residents should use based on the resident weight. CNA C indicated if she didn't know the resident weight, she would ask a nurse what sling a resident should use. On 8/22/23 at 12:12 PM, Surveyor asked Rehab Director D how do staff know what sling to use for residents? Rehab Director D indicated therapy doesn't have anything to do with slings or full body lifts. Rehab Director D indicated their job is to get people up. Rehab Director D indicated that would be a question for DON B (Director of Nursing.) On 8/22/23 at 12:14 PM, DON B indicated any nurse can complete measurements to determine what sling a resident should use. DON B indicated this is a new process. DON B indicated the facility has many different styles and sizes of slings. DON B indicated this is something she has been starting to work on and it is a work in progress. DON B indicated she started doing an audit just to determine how many different slings are in house. DON B indicated several slings have been pulled because they are worn and old. Surveyor asked DON B how do staff know what style and size of sling a resident should use? DON B indicated this is not written down anywhere and that right now it is just by word of mouth. On 8/22/23 at 1:36 PM, CNA C indicated on 8/3/23 she did not use the correct color loops on the sling when assisting R1 in getting up. CNA C indicated she used all the same color so R1 was not sitting up correctly when going from bed to chair. CNA C indicated she was provided education on how to place sling loops on lift. CNA C indicated she had a sling that was too small on 8/3/23 as well, but it was there so she just used it. CNA C showed Surveyor the Invacare full body lift that was used on 8/3/23 during R1's fall. CNA C indicated any sling can be used with either Invacare full body lift or the EZ Way Lift. On 8/22/23 at 2:44 PM, RN E (Registered Nurse) indicated she would assume that therapy or nursing would measure residents to determine the correct size and style of sling a resident should use. RN E indicated she has never measured someone for a sling, and this was not reviewed during training. Surveyor asked how does staff know what sling a resident should use? RN E indicated she would assume it would be written down somewhere or that maybe a resident has their own sling in their bedroom. On 8/22/23 at 2:50 PM, Surveyor asked LPN F (Licensed Practical Nurse) how do staff know what sling a resident should use? LPN F indicated she just asked this question the other day. Surveyor asked who is responsible for measuring residents to determine appropriate slings and sizes? LPN F indicated it would probably be best if therapy did that and that LPN F has never had to measure for slings since she has been at this facility. LPN F indicated she is unsure if there is anything documented on what sling a resident should use. On 8/22/23 at 2:55 PM, RN G indicated therapy probably would be the ones to measure and determine what sling a resident should use. RN G indicated therapy would probably be the ones to document this information somewhere as well. RN G indicated she does not know what sling a resident should use and that most of the time the CNA already has the sling hooked up to the lift and that RN G acts as that second staff person during transfers. On 8/22/23 at 3:19 PM, DON B indicated there is not a facility policy for sling measurements and process. DON B indicated they follow the manufacturers recommendations and size chart. On 8/22/23 at 3:40 PM, DON B indicated after the incident on 8/3/23 DON B asked staff, Where do you find what type of sling a resident should use? DON B indicated at that time she received all kinds of different answers and most staff said they didn't know. DON B indicated the blue slings can be used with both brands of full body lifts in house. DON B and Surveyor were unable to read the tag on slings to determine the name brand of the blue slings. Surveyor asked if using the blue slings universally would follow manufacturers recommendations? DON B stated they follow the manufacturer recommendations. Surveyor asked DON B to provide any additional information on the slings. No additional information was provided. On 8/22/23 at 4:10 PM, CNA H indicated he can determine what sling to use based on looking at the resident. CNA H indicated CNA H can do a visual of the person and if the person is larger than they would use a large sling. Surveyor asked if CNA H bases what size sling to use based on resident weight. CNA H indicated you can do that, but mostly it's just by looking at the resident. CNA H indicated he does not believe anything is written down as to what sling a resident should use. CNA H indicated he cannot always find the correct style of sling that works best for a person and when this happens, he uses what is available. CNA H indicated he will then transfer resident as quick and safely as possible. On 8/22/23 at 4:20 PM, CNA I indicated she determines what sling to use for a resident by the resident weight. CNA I indicated she will look to determine that the sling fits the resident and is covering them before lifting resident up. CNA I indicated this information should be documented somewhere. CNA I indicated for new staff the current staff will train them on what sling should be used for the resident. CNA I indicated the facility has many different sizes and styles of slings. On 8/22/23 at 4:25 PM, Surveyor asked CNA J how does she know what sling a resident should use? CNA J indicated this information is not written down anywhere and that they go off the resident weight. On 8/22/23 at 4:30 PM, CNA K indicated she was taught to go off the resident's weight and needs in determining the size and style of sling. CNA K indicated that current staff tell new staff or agency staff what sling a resident should use. CNA K indicated this information is not written down anywhere and there are many different styles and sizes of slings in house. CNA K indicated it would be helpful to have this information written in the care plan in the resident closets. CNA K indicated there are times the sling that works best for that resident is not available and that they make it work with different style of sling. CNA K indicated when this happens, she always tries to size up when choosing an alternate sling. She always tries to keep in mind the person's diagnosis as well. R1 required 2 staff to transfer using a full body lift. The staff failed to follow the care plan and failed to ensure each staff utilize the appropriate size and type of sling. R1 fell from the full body mechanical lift which resulted in a head laceration requiring staples. Example 2 is being cited at severity level 2. Example 2: R2 was admitted to the facility on [DATE] with diagnoses including fusion of spine, spinal stenosis, chronic pain, and respiratory failure. On 8/22/23 at 10:07 AM, Surveyor observed R2 being transferred from chair to shower chair by use of a full body lift and sling. Surveyor observed staff use the EZ Way full body lift however the sling used was not the EZ Way sling. Of note, the EZ Way slings are tan in color and contain the EZ Way logo; the sling observed was a blue mesh and did not contain the EZ Way logo. Per manufacturers recommendation EZ Way Slings should be the only sling used with the EZ Way lift. CNA L indicated there are many different styles and sizes of slings in the facility. CNA L indicated it can be difficult finding slings and that they will use what is available. CNA L indicated she goes by the resident weight to determine the size of sling that is used. CNA M also indicated she goes by the resident weight to determine the size of sling that is used as well. On 8/22/23 at 4:25 PM, CNA J indicated she believes that all slings can be used with both brands of full body lifts in house. The facility has 2 types of mechanical lifts. Manufacturers recommendations state the company's slings should be used with their lifts. The facility has a variety of slings that staff are using universally with both mechanical lifts. Facility staff are not aware the slings are not universal. Staff have not received a competency check off for the use of the full body lift.

Based on observation, interview, and record review, the facility did not ensure that a resident who entered the facility without pressure ulcers did not develop pressure ulcers, and a resident who has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing, for 4 of 6 sampled residents with pressure ulcers or interventions to prevent pressure ulcers (Resident 6, 7, 10, and 2). Resident 6 was admitted to the facility without a pressure ulcer (PU) and was identified to be at risk for PU development. Resident 6 has a history of a facility-acquired PU. Interventions were not put in place to prevent Resident 6 from developing a PU. Resident 6 developed an unstageable PU to the right heel that deteriorated to a stage 4 PU. Facility staff was observed flushing a pressure ulcer with exposed bone with tap water using a catheter irrigation kit syringe this treatment was not part of the physician orders. The resident was observed in bed with incorrect settings for air mattresses and the facility had no system to communicate the correct mattress settings to staff. Resident 6's heels were not offloaded and staff has not received education on the correct technique on how to offload a heel; weekly wound care assessments and measurements are not consistently completed. During observations of wound care, the nurse did not place a clean barrier under wound care supplies. The facility Director of Nursing (DON) who is currently responsible for wound care was unaware if the facility follows a Standard of Practice (SOP) for wound care and admits to having little wound care knowledge. Additional examples not at the G level include: Resident 7 had an air mattress on the bed and staff did not know what the correct settings were to be set at for the air mattress. Resident 10 was noted in his medical record to have ted hose on over his right heel pressure ulcer, and when assessed on 11/4/15 his wound was not measured. The facility did not ensure that Resident 2's air mattress was at the optimal setting to reduce the risk of pressure ulcer development. This is evidenced by the following: The facility's Wound Care Policy dated 1/14 and entitled Wound Care Policy states in part; C. Weekly Wound Rounds: 1. Weekly wound rounds will be the responsibility of the Director of Nursing (DON) or designated licensed nurse in conjunction with the wound care consultant. 2. All residents with pressure ulcers (PU) will be seen on the wound rounds weekly until the wound is resolved. 3. Documentation will be made on the appropriate form: Weekly Pressure Ulcer Record. 5. The wound care consultant or DON (or designated licensed nurse) will measure the wound, assess progress towards healing, assess response to current treatment, determine need for further interventions and communicate any changes to relevant staff. The physician will be updated and consulted regarding status of wound and need for interventions. 7. The Interdisciplinary Wound Care Team will review wounds on a weekly basis. Skin Risk Assessment: 4. All residents who have a score of 18 or less are at risk for the development of PU. These residents will be followed by the Interdisciplinary Wound Care Team who will initiate preventative measures and develop a care plan. Practice Guidelines: 1. Heels will be elevated with a pillow placed under the calves when the resident is in bed. Licensed nurses are responsible for monitoring that position changes are being performed. Preventative Protocols: Elevate heels by using a pillow underneath the calves to reduce pressure. High Risk Preventative Protocols: A resident who has a score of 10-12 (high risk) on the Braden scale will have their heels floated when in bed utilizing a heel float device. The DON currently completes the weekly wound assessments. Per interview with the DON the facility does not have a wound consultant. The Quick Reference Guide entitled Pressure Ulcer Prevention published by the National Pressure Ulcer Advisory Panel (NPUAP) in 2009 indicated to prevent pressure ulcers in individuals considered to be at risk for the development of pressure ulcers, ensure the heels are free of the surface of the bed. Heel protection devices should elevate the heels completely (offload them) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. Ensure the heels are free of the surface of the bed. Using a pillow under the calves so the heels are elevated (i.e., floating) will accomplish reduction of pressure on heels. According to <www.woundcareadvisor.com <http://www.woundcareadvisor.com <http://www.woundcareadvisor.com <http://www.woundcareadvisor.com>> May/June 2013 Volume 2, Number 3> an article entitled Best Practices Is your wound cleansing practice up to date? Potable (drinkable) tap water may be used if there is no other alternative. Check the quality of the water source. However, use normal saline solution instead of water for wounds with exposed bone or tendon. Example 1 Resident 6 has [DIAGNOSES REDACTED]. Resident 6 has a history of PU's including recent past history of stage IV right ankle PU (healed 11/6/15), stage 2 PU coccygeal region (healed approximate date 3/22/15), and is receiving hospice care. Resident 6's Braden assessment, dated 12/28/15, indicates Resident 6 scored a 12 indicating Resident 6 was at high risk for PU development. The Braden assessment indicating the following: Sensory Perception: very limited; Moisture: Occasionally moist; Activity: Bedfast; Mobility: very limited; Nutrition: probably inadequate; Friction or sheer: potential problem. Resident 6's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/17/15, indicates A Brief Interview for Mental Status (BIMS) was unable to be completed with Resident 6 indicating Resident 6 has severe cognitive impairment. Section M0150 of the MDS indicates Resident 6 is at risk for developing a PU. Section G0110, Activities of Daily Living (ADL's) indicates Resident 6 requires 2 staff and total assistance for bed mobility and transfers. (Of note Resident 6 is bed- ridden) A Care Area Assessment (CAA) worksheet dated 4/14/15 states in part; Extrinsic risk factors: requires staff assistance to move sufficiently to relieve pressure over any one site, confined to bed; [MEDICATION NAME] Factors: immobility, incontinence, poor nutrition, cognitive loss, limited mobility, status [REDACTED]. Resident 6's plan of care entitled Impairment of Skin Integrity dated 12/17/15 states in part; elevate lower extremities as tolerated when in bed, minimize pressure on bony prominences, pressure reducing air mattress, use pillow/positioning. Assess skin as needed, provide all treatments as ordered. Inform hospice/nurse practitioner (NP) of progress, monitor turning schedule, notify physician as needed with changes noted in skin integrity or if current treatment not effective. The following is a brief timeline history of Resident 6's right heel: Nursing notes dated 10/18/14 at 2:00 PM weekly skin check. Nursing notes dated 10/20/14 at 11:08 AM indicate a Braden scale of 14 which indicates a moderate risk. Intervention: reposition every 1 to 2 hours and as needed, right leg boot, weekly body audit. Of note, this is the first mention of a right leg boot. Nursing notes dated 10/21/14 at 3:00 AM state in part; skin prep applied to right heel; right boot on. Nursing notes dated 10/21/14 at 1:37 pm at 1:37 PM state in part; right foot heel examined by Advance Practice Nurse Practitioner (APNP) N no new treatment orders. Nursing notes dated 10/21/14 at 9:55 pm state in part right heel with darkened area and flaccid skin. Skin prep applied to heel and other red areas of foot. APNP progress notes dated 10/22/14 state in part; seeing (patient) Resident 6 today new report of a deep tissue injury to her right heel. Per nursing staff had noted a new area to the right heel of dark discoloration with a blister. APNP progress note dated 11/4/15 states in part; reviewed heel ulcer continues to improve blister resolved. Nursing notes 11/11/14 at 2:03 PM state in part; scabs to right heel. Nursing notes dated 11/29/14 at 6:44 PM state in part; Admission note: arrived at 2:15 PM from {hospital name}. Of note, Resident 6 returned from the hospital was transferred to hospital on [DATE] at 12:25 am for fever and returned to facility on 11/29/14 at 2:15 PM. Nursing notes dated 11/29/14 at 7:01 PM skin problems has abrasion/bruise present in the past 7 days. Right heel 0.7cm by 0.5 cm [MEDICATION NAME] dressing applied. Of note there is no further description of the right heel. Nursing notes dated 12/08/14 at 4:45 PM state in part open area to right heel. There is no further documentation on the right heel. Resident 6's Braden assessment dated [DATE] indicates Resident 6 scored a 13 indicating Resident 6 is at moderate risk for skin breakdown. APNP progress notes dated 1/8/15 state in part; Assessment/Plan: offload pressure absolutely as much as possible. APNP progress notes dated 2/18/15 state in part; reviewed booties to feet, previously (patient) Resident 6 had some soft thicker booties that seemed to protect her legs and feet better, she has new booties that have been provided by hospice which have little protection, they are just foam booties; reviewed that we will change back to the previous booties for better protection. Nursing notes dated 2/19/15 at 2:51 PM state in part; late entry for 2/18/15. Resident 6 has a dry yellow calloused area on her right heel. The area measures 1 cm by 0.7 cm; the area is not open. She is wearing pressure reduction boots at all times. APNP progress notes dated 2/24/15 states in part; we have noticed since we switched Resident 6 to an air mattress Resident 6 is fidgeting more in bed. Resident 6 stopped scooting in bed when she was on a foam mattress called hospice will provide a foam mattress. Utilizing booties to her feet, staff and family feel that part of the scooting around and wiggling is that Resident 6 tries to get the booties off of her feet she does quite dislike them. With Resident 6 disliking the booties we will stop using them Resident 6 has slippers on today and family brought in sheepskin that we can place under/between her legs for comfort. Of note, the facility has now removed the offloading booties as well as the air mattress. Resident 6 has been identified as at moderate risk for skin breakdown per Braden assessment and identified at risk per Resident 6's MDS with an ARD of 1/5/15. Section M0150 of the MDS indicates Resident 6 is at risk for developing a PU. Section G0110, ADL's indicates Resident 6 requires 2 staff and extensive assistance for bed mobility and transfers. (Of note Resident 6 is bed- ridden). Of note, there is no indication in the medical record that family was educated on the risk and benefits of discontinuing the heel boots or air mattress to include deterioration of PU's or new PU development prior to the discontinuation of these PU prevention devices. Nursing notes dated 2/27/15 at 11:16 AM state in part; dry, yellow calloused are on right heel, the area is not open. APNP progress note dated 3/10/15 states in part; has a callous to her right heel which has now opened with small area of eschar, minimal drainage at this time. Assessment/Plan: unstageable wound to heel with eschar and open area. Nursing notes dated 3/11/15 at 4:14 PM state in part; continues to have a calloused area on the right heel, today the area is open and dry it measures 1.5 cm by 1.5 cm and is 0.2 cm deep. The wound bed is dry/purple brown eschar. APNP notes dated 3/22/15 state in part; reviewed wounds on right foot we noted wounds are becoming worse the heel wound is larger with eschar and now has an odor. We had previously had patient (Resident 6) on an air mattress but family had requested that we stop air mattress. Spoke with Hospice they will provide an alternating air mattress spoke with family and reviewed the goal of course is to reduce pressure to all of her bony surfaces and without using an air mattress it's quite difficult to do. Right heel is 3.0 cm x 3.0 cm with malodorous drainage and eschar. APNP notes dated 4/1/15 state in part right heel open, significantly malodorous measures 5.0 cm x 5.0 cm. Assessment/Plan (A/P): unstageable right heel ulcer. Nursing notes dated 4/15/15 at 3:31 PM state in part; unstageable PU to the right heel measures 5.0 cm x 4.0 cm x 0.5 cm. APNP notes dated 4/22/15 state in part; heel wound considerably worse with exposure of tendons and bone-large amount of slough but eschar resolved. Right heel depth 0.7 cm, tendon and bone exposed. A/P: two wounds stage 4 right lateral malleolus and right heel. Nursing notes dated 4/22/15 at 3:23 PM state in part; full thickness PU on heel measures 4.5 cmx 4.5 cm x 1.0 cm. Nursing notes dated 5/28/15 at 12:30 PM indicated the right heel ulcer is now 6.5 cm x 4.5 cm x 1 cm. Nursing notes dated 6/3/15 at 12:40 PM state in part; right heel ulcer measures 6.6 cm x 4.0 cm x 0 cm. APNP Progress note dated 6/4/15 state in part; reviewed right heel wound measures 6.6 centimeters (cm) by 4 cm; central area measures 2.5.cm by 2 cm of granulation tissue, from 11 to 3 o'clock we notice slough, lower edge of wound still has area about 2 cm by 2 cm of eschar, we observed this wound has filled in, it did have significant depth a few weeks ago and now essentially no depth. Assessment/Plan: 2. Heel- unstageable wound has continued to fill in with granulation tissue, no depth. We will continue current wound care appreciate excellent care from {staff name} the wound care Registered Nurse (RN). Of note, the wound care RN is no longer at the facility. Currently the wound care is being completed by either the Director of Nursing (DON) B who admits to having little knowledge of wound care or the facility floor nursing staff. Nursing notes dated 7/8/15 at 2:42 PM state in part; continues to have a full thickness, unstageable PU on the right heel measuring 8.0 cm x 3.0 cm x 0 cm. APNP notes dated 7/8/15 state in part; Stage 4 right heel with necrosis. Nursing notes dated 8/27/15 at 3:38 PM state in part; healing full thickness unstageable PU on right heel measures 7.0 cmx 3.2 cm with 50 % slough and 50 % pink granulation tissue. Nursing notes dated 9/25/15 at 2:37 PM state in part; continues to have healing unstageable PU to right heel measuring 7.2 cm x 3.2 cm with no measurable depth. Social Services notes dated 9/30/15 at 3:38 PM state in part; resident is prone to skin breakdown due to being on bed rest and does have some wounds. There was concern that these wounds would never heal due to her poor circulation, but at this time they are healing and have greatly improved. Of note weekly wound measurements were not completed for the right heel the weeks of 10/7/15 and 10/29/15. Nursing notes dated 10/14/15 at 4:07 PM state in part; healing pressure area on right heel measures 3.1 cm x 3.8 cm with no depth. Nursing notes dated 10/22/15 at 12:23 PM state in part; continues to have healing pressure area on right heel measuring 2.5 cm x 3.5 cm the wound bed is 40 % slough/eschar and 60 % [MEDICATION NAME] tissue. Of note there is missing PU documentation for 11/18/15. Hospice skin assessment and wound care record dated 11/20/15 states in part; right heel unstageable 4.2 cm x 2.5 cm with slough and granulation. Nursing notes dated 11/25/15 at 3:45 PM state in part; right heel measures 3.0 cm x 4.0 cm. There is no odor and the wound bed appears pink, moist with white slough around the edges. Nursing notes date 12/2/15 at 5:12 PM state in part; right heel measurements unchanged however; the heel now has a dark red/black area of necrosis from 9:00 o'clock to 12:00 o'clock. There is a dime sized area of dark yellow slough at 2:00 o'clock. The wound bed is dark red in color. The ankle is healed. Nursing notes dated 12/9/15 at 5:56 AM state in part, the right heel has a small area of yellow slough an 8:00 o'clock. There is dark red/black necrotic are between 3:00 to 5:00 o'clock. The area measures 4.0 cm x 3.0cm. Social Services notes dated 12/11/15 at 2:10 PM state in part; staff continues with wound treatment though all of her wounds have or are very close to healing. Nursing notes dated 12/15/15 at 4:12 PM state in part; right heel measures 4.0 cm x 4.5 cm there is an area of black eschar from 3:00 to 5:00 o'clock and yellow slough at 7:00 o'clock. Nursing notes dated 12/23/15 at 5:55 PM state in part; hospice nurse assisted with the wound care to the right heel. The entire wound measures 4.5 cm x 3.5 cm. There is an area of slough between 3:00 and 5:00 o'clock. There is an area that is open and deep that measures 1.0 cm x 0.5 cm with 0.7 cm of depth. There is an area at the bottom of the wound that has a depth of 1.5 cm. Hospice clinical note dated 12/29/15 states in part; right heel stage 2 with small area of slough at 5:00 o'clock area pink/red and moist with a meaty odor. Large area of slough came away when old dressing removed. APNP progress note date 12/29/15 states in part; as a review patient (Resident 6) had a significant deep wounds to both her right lateral malleolus (ankle) and her heel, amazingly the wound to her right lateral ankle has completely filled in this was a stage 4 wound with exposure of muscle and tendons as was the heel wound, reviewed that the heel wound is currently about the size of a quarter, depth 2 millimeters (mm) but also has a 3 cm area of tunneling. A/P: PU right heel stage 3 with tunneling; continue to offload pressure. Patient Active Problem List: PU of heel Stage 4. Nursing notes dated 12/30/15 6:30 PM right heel measures 4.0 cm x 3.0 cm and has beefy red tissue to the wound bed with a small area of black eschar at periphery. The area of black eschar is noted between 3:00 to 5:00 o'clock. There is tunneling at approximately 8:00 o'clock that measures 3.0 cm in depth. Hospice Face to Face Encounter dated 12/31/15 states in part; currently and 6/2015 bed-bound, fully dependent for turning/positioning; patient (Resident 6) thin, bony prominences visible; wound on right heel. Nursing notes dated 1/6/16 at 3:09 AM state in part; Skin Ulcer Evaluation: right heel ulcer measures approximately 4 centimeters (cm) by 3.5 cm and has beefy red tissue to wound bed with areas of granulating pink tissue noted throughout; tunneling between area 0700 and 0800 and measures 4.3 cm in depth with bright red blood draining from tunneling area. An area of Eschar is noted between 0300 to 0500 o'clock there is no odor to wound. Of note, there is no mention of bone exposure in the nursing note dated 1/6/16 at 3:09 AM. Resident 6's Physician Order Sheet signed 12/31/15 states in part; wound treatment to right heel: cleanse wound with wound cleanser; apply skin prep to periwound; apply Santyl to slough; pack tunneling area with Calcium Alginate strips loosely. Continue placing foam over wound, then wrap with Kerlix dressing daily. Resident 6 has a Telephone Order dated 12/29/15 which states in part; same wound care but use [MEDICATION NAME] for odor. On 1/5/16 at 10:45 AM Surveyor observed Resident 6 lying in bed. Resident 6's heels were not offloaded off the mattress. On 1/5/16 at 2:00 PM Surveyor observed Resident 6 lying in bed. Resident 6's heels were not offloaded off the mattress. On 1/6/16 at 8:00 AM Surveyor observed Resident 6 lying in bed. Resident 6's heels were not offloaded off the mattress. On 1/6/16 at 9:00 AM Surveyor observed care being provided for Resident 6. Certified Nursing Assistant (CNA) D placed Resident 6's heel on a pink pillow, shaped like a donut, Resident 6's heel was directly touching the pillow and not offloaded. Surveyor asked CNA D if Resident 6's heel was to be offloaded or floated. CNA D stated Resident 6's heel was not touching the bed because it was on the pillow. Surveyor asked CNA D how she offloads a heel, CNA D stated to put something between the bed and the heel. CNA D did not appear to have accurate knowledge of offloading heels. On 1/6/16 at 9:30 AM Surveyor interviewed DON B regarding Resident 6's PU and wound care. Surveyor indicated to DON B that the PU documentation in the medical record was conflicting for example; a hospice note on 12/29/15 describes the heel ulcer as a stage 2. Nursing home documentation, which does not stage the wound, suggests from the description that the wound was a stage 3. The nurse practitioner, who saw and documented on the wound on 12/29/15 calls the wound a stage 4 in one place, but later refers to it as a stage 3. DON B stated that Resident 6 has a current Stage 3 PU to her right heel. Surveyor asked DON B if the facility completes weekly wound assessments. DON B stated that facility does complete weekly assessments and measurements and informed Surveyor that the wound documentation may be found in 3 separate locations in the medical record. Surveyor asked DON B if the facility follows a wound care SOP (Standard of Practice) DON B stated she was not aware of a wound care SOP. Surveyor asked DON B if the facility has a wound care certified nurse on staff; DON B stated the facility does not she completes weekly wound assessments and stated, I will be honest I know very little about wound care. Surveyor asked DON B about Resident 6's PU interventions. DON B stated they use pillows to separate bony prominences, reposition every 2 hours, we are very limited with Resident 6's contractures, pillow between legs, and a pillow under her foot to offload foot from touching the bed. Surveyor asked DON B how the pillow offloads the heel from the bed DON B stated the pillow is under the heel and separates the heel from the bed. Surveyor reviewed Resident 6's Treatment Record for November 2015 which states: Float Right Heel: This was not signed out for the following dates: 11/5, 11/7, 11/8, 11/16, 11/19, 11/20, 11/21 and 11/30. Resident 6's Treatment Record for December 2015 states Float Right Heel: This was not signed out for the follow dates: 12/1, 12/2, 12/3, 12/4, 12/5, 12/7, 12/9, 12/29, and 12/31. Resident 6's Treatment Record for January 2016 states Float Right Heel: This was not signed out for the follow dates: 1/1, 1/2, and 1/7. On 1/6/16 at 10:06 AM Surveyor observed wound care being provided to Resident 6 by Licensed Practical Nurse (LPN) C. LPN C removed the old dressing and left the old dressing lying in the bed directly under Resident 6's heel. Surveyor observed the wound and noted that a large egg shaped wound over the right heel. The wound bed appeared beefy red with 90 % of the wound bed having hyper-granulation tissue and 10 % with slough/eschar. In the center of the wound bed Surveyor noted a pea-sized white area, Surveyor asked LPN C to describe the white area. LPN C took the wooden end of a cotton tipped applicator and probed the white area when LPN C tapped the area the sound of bone could be heard. Surveyor questioned LPN C about the bone exposure and LPN C stated she had not completed the dressing change recently but the bone exposure was new. Once the wound was exposed LPN C removed packing from a tunneled area in the wound and placed it on the dirty dressing lying in the bed. LPN C measured the PU the area measured 3.8 cm x 2.5 cm with an area of tunneling that measured 3.5 cm deep. LPN C stated she wanted to irrigate the wound and left the room to obtain irrigation supplies. LPN C returned with a catheter irrigation tray and syringe and filled the irrigation bottle with tap water. LPN C returned to the bedside and flipped the dirty dressing which was lying in the bed upside down now the bloody drainage from the old dressing was touching Resident 6's pink pillow. LPN C irrigated the wound with tap water using a catheter irrigation syringe. During the irrigation of the wound LPN C directly touched the wound with the tip of the irrigation catheter. LPN C's elbows were resting in Resident 6's bed during the irrigation and dressing change procedure. Once the wound was irrigated LPN applied skin prep to the periwound then moved 4x4 dressings, cotton- tipped applicators, and [MEDICATION NAME] ointment into Resident 6's bed there was no barrier in Resident 6's bed to prevent the 4x4 dressing, cotton applicators or the [MEDICATION NAME] from contamination. During the dressing change LPN C leaned across Resident 6's bed LPN C's elbows were resting in the bed and LPN C's pigtails and stethoscope were touching Resident 6's bed. After completion of wound care LPN C placed Resident 6's right lower extremity on sheepskin which was directly lying on the bed Resident 6's heel was not offloaded off of the surface of the bed. After the completion of the wound care Surveyor walked to the foot of the bed to observe the pump for Resident 6's air mattress. Surveyor did not note a, typical, humming noise from the pump. Surveyor asked LPN C how the staff knows the air mattress is working. LPN C looked at the pump then pressed the switch on the pump and the pump immediately began to hum. Surveyor asked LPN C if the air mattress was off LPN C stated, Yes. Surveyor asked LPN C should it have been on. LPN C stated, Yes. On 1/6/16 at 11:04 AM Surveyor interviewed LPN C regarding the wound treatment for [REDACTED]. Surveyor asked LPN C if there was a physician's order to irrigate the right heel PU with tap water. LPN C stated there was not a physician order however; she felt it was a good idea. Surveyor asked LPN C if Resident 6 is to have her heels offloaded LPN C stated that the sheepskin does offload the heel. LPN C stated the sheepskin is soft and a barrier between the bed and the heel. Surveyor asked LPN C if she had a barrier in the bed when she moved the dressing supplies into the bed. LPN C stated she did not even realize she had moved the dressings into the bed. Surveyor asked LPN C if she would have noticed the bone exposure during the dressing change LPN C stated no, you have a good eye. Of note, LPN D did not appear to have accurate knowledge of offloading heels and deviated treatment from the physician orders and used poor infection control techniques. In addition, Surveyor noted bone exposure during this dressing change; this was not noted in the dressing change completed earlier on 1/6/15 or during the observed dressing change on 1/6/16. On 1/6/16 at 2:00 PM Surveyor interviewed DON B regarding the above observations regarding Resident 6's PU and wound care. DON B stated she would expect the staff to follow physician orders for wound care as written. DON B stated she was surprised that LPN C would flush a bone exposed wound with tap water that could introduce bacteria or who knows what into the wound. DON B stated she would except staff to free float Resident 6's heels and was able to describe accurate offloading of an extremity to Surveyor including that heels would be free from the surface of the bed. Surveyor stated to DON B that wound assessments were missing for 10/7/15, 10/29/15 and 11/18/15 for the right heel DON B stated she would expect there to be weekly wound measurements. Surveyor asked DON B about wound care protocols and DON B stated she would expect a barrier between dressings and another surface; DON B stated LPN C did not use proper infection control practices. Surveyor asked DON B if she would expect the air mattress to be On DON B stated; Absolutely. Surveyor asked DON B when she last observed the wound DON B stated 12/30/15 Surveyor asked DON B if there was bone exposed on 12/30/15 DON B stated no the wound was beefy red, with eschar between 3:00 to 5:00 o'clock and tunneling the wound bed was cleaner and smaller from the previous week. Surveyor asked DON B if the facility has completed PU education for the staff regarding offloading heels, mattress settings, wound care protocols including infection control practices. DON B was not certain if wound care education had been provided but stated that she had not provided PU education since she was hired in October 2015. When Surveyor asked DON B if the facility completed wound care audits or auditing of interventions in place, DON B stated she was not certain but she had not provided auditing since she was hired. When Surveyor asked DON B how staff would know the proper settings for an air mattress, DON B stated I am not sure. We do not have a physician order for [REDACTED]. On 1/6/16 at 3:53 PM Surveyor interviewed DON B and Nursing Home Administrator (NHA) A. NHA A stated the facility had spoken with the hospice provider and that the air mattress the Resident 6 utilizes has a non-powered and powered mode and that the bed provides pressure relief up to a stage 4 in both modes. Surveyor asked NHA A what setting the mattress should be on NHA A stated I do not know that answer. Surveyor asked NHA A how the staff would know what setting the mattress should be on DON B stated I believe with any air mattress we would obtain a physician order and coordinate with hospice. Hospice Interdisciplinary Plan of Care Problem Alteration in Skin Integrity dated 1/13/15 and states in part; air mattress with pump. Of note, the facility is using an Anatomic Concepts Reactive Air Pro mattress for Resident 6. Per manufacturer's guidelines the Reactive Air Pro can be used in the non-powered mode. Remove the connecting hose from the power unit to the mattress and the Reactive Air Pro will automatically adjust for patient movement. The mattress does not alternate air in the non-powered mode but adjusts to resident movement. Of note, LPN C turned the mattress on and the mattress began to fill as noted above. The air mattress had the connecting hoses attached to the pump and mattress. On 1/7/15 at 7:45 AM Surveyor observed Resident 6's heels offloaded and the air mattress remained on the power mode. On 1/7/16 at 9:15 AM Surveyor interviewed {company name} representative for Reactive Air Pro mattress. Representative Q stated that the mattress would function in the non-powered mode despite the hoses being connected there was just a potential for air leaking if the hoses were connected. Of note, the facility has no system in place to determine the correct mattress settings and whether the mattress should be set up either in a power mode or non-power mode. The facility has no system to communicate the appropriate mattress settings to the staff or an auditing system to ensure accurate air mattress settings. On 1/7/16 at 8:40 AM Surveyor interviewed APNP N regarding Resident 6's PU. Surveyor asked APNP N regarding Resident 6's PU history. APNP N stated that about a year ago Resident 6 had a Stage IV PU on her ankle and heel and that the heel had almost closed over and recently re-opened. Surveyor asked APNP N when she last observed Resident 6's PU. APNP N stated the PU was last observed on 12/29/15 APNP N stated the ulcer was egg shaped and resembled a burn with granulation tissue and tunneling. Tunneling was about 3.0 cm. Surveyor asked APNP N if there was bone exposed during the 12/29/15 observation APNP N stated there was no bone exposed and asked Surveyor Is there now? Surveyor asked APNP N if the facility had notified her with the change in PU status APNP N stated she had not been notified of the deterioration of the right heel PU. Surveyor asked APNP N if she would hav