Every finding on record at Franciscan Woods

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 3 of 3 residents (R5, R7, and R1) reviewed for falls. *R5 was transferred by mechanical lift by one Certified Nursing Assistant (CNA.) The CNA was not following R5's care plan to transfer residents with two staff members when using a mechanical lift. R5 slid out of the sling and sustained multiple rib fractures. *R7 was transferred from bed to a motorized scooter via a sling. The sling was left under R7 while R7 was in the motorized scooter. R7 slipped out of R7's scooter and R7 sustained a right leg fracture. After the fall with fracture, facility Physical Therapy (PT) staff informed Surveyor that the motorized scooter that R7 had been using was not safe for R7. R7 did not have a current, accurate PT assessment for the use of R7's motorized scooter. *R1 had multiple falls that were not thoroughly investigated. Care plan interventions were not always updated after a fall and Registered Nurse (RN) assessments were not always completed after a fall. Findings include: The facility policy with a last approved date of 1/2026 and titled Falls documents: The purposes of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall. The [NAME] Fall Risk Assessment form (or similar fall risk evaluation) should be utilized to complete the evaluation of the residents' potential for falls. If a resident sustains a fall or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated. Direct care associates shall evaluate the area where the fall occurred for possible contributors.The Licensed Nurse shall document the fall in the resident's clinical record. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record. 1.) R5 had diagnoses of malignant neoplasm of the frontal lobe and long term use of anticoagulants. R5's Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented R5 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. The MDS assessed R5 as needing moderate assistance with bed mobility and being dependent on staff for transfersR5 was admitted to hospice services on 2/7/2026. R5's Activities of Daily Living Care Plan was initiated on 11/19/2025 and documented under the intervention section to transfer R5 with maximum assistance of two people with a total lift assistive device. On 5/14/2026 at 3:00 PM in the progress notes, nursing documented a Certified Nursing Assistant (CNA) alerted them that R5 was on the floor and hit their head and back during the fall out of the full body mechanical lift at 2:10 PM. R5 was assessed and assisted off of the floor by three staff members and the full body mechanical lift. R5 was unable to follow commands fully and was nonverbal at baseline. R5's head was observed to have a red know on the back left side and the back had slight rednessR5's POA (power of attorney) requested R5 be sent to the hospital for evaluation. At 10:37 PM in the progress notes, nursing documented R5 returned to the facility with a new order for a lidocaine patch. On 5/15/206 at 1:29 PM in the progress notes, nursing documented R5 had a care conference that day with R5's POA and hospice. R5 had returned from the hospital the day before with three broken ribs on the left side of R5's chest and one broken rib on the right side. An Incident Witness Statement Form was completed by the CNA that transferred R5 in the full body mechanical lift. The CNA wrote they put R5 on a sling and had started to raise R5 up when R5 started to slide and slid out of the sling and onto the floor. The CNA tried to catch R5 as R5 was reaching out to the CNA as R5 fell. R5 hit their head on the nightstand with the body and back on the lift. The CNA went to get help and R5 was placed on the sling and put back to bed. The facility investigation into R5's fall from the sling showed R5 was transferred using a full body lift with one CNA. The investigation documented that R5 should not have been transferred with one CNA, as the correct procedure was to have two staff members assist for all R5's transfers. The CNA that performed the transfer independently was an agency staff and was no longer worked at the facility. The CNA was not able to be contacted for interview. In an interview on 7/21/2026 at 1:18 PM, Surveyor asked Licensed Practical Nurse (LPN)-D if they could recall the incident on 5/14/2026 when R5 fell. LPN-D stated they were the nurse caring for R5 that day. LPN-D stated the CNA transferred R5 by themselves, not with two people as they should have and R5 slipped out of the sling. LPN-D stated R5 had always been a full body lift transfer. On 7/21/2026 at 10:58 AM, R5 was observed to be sleeping in bed. On 7/22/2026 at 8:15 AM, R5 was observed in the dining room sitting in a Broda chair for breakfast. Surveyor asked CNA-E if R5 laid down after breakfast. CNA-E stated yes, they would be transferring R5 back to bed. CNA-E stated every transfer with a mechanical lift has to have two people. On 7/22/2026 at 3:38 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Clinical Operations (DOC)-C that R5 was transferred on 5/14/2026 with a full body mechanical lift by one CNA when two staff members are required for all full lift transfers and sustained multiple rib fractures. NHA-A agreed the fall was avoidable and there should have been two staff members present for the transfer. 2.) R7 was admitted to the facility on [DATE] with diagnoses to include Multiple Sclerosis (MS) and Morbid Obesity. R7's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents R7 is cognitively intact. The MDS documents that R7 was assessed to require substantial/maximum assistance from staff for toileting hygiene, partial/moderate assistance from staff for personal hygiene, and is dependent on staff for transfers. R7's Fall Care Area Assessment (CAA) dated 10/13/25 documents: Fall-proceed to care plan. R7's Potential for Falls care plan dated 12/26/25 documents the following interventions: Keep personal items within reach. Keep pathways clear and provide adequate lightening. Orient to room and call light. R7's Activities of Daily Living (ADL) care plan dated 12/26/25, documents the following pertinent interventions: Toileting: I need extensive assistance with 1 person staff support. Mobility: I need no assistance with no staff support. I use a motorized scooter independently (start date 4/24/25.) Surveyor noted that R7 was independent while using a motorized scooter listed on R7's ADL care plan dating back to April of 2025. R7's [NAME] Fall Risk assessment dated [DATE] documents [R7] is at moderate risk of falls. On 7/21/26 at 12:35 PM, Surveyor interviewed R7. R7 stated that about 3 months ago, R7 was sitting in R7's motorized scooter. R7's sling to transfer R7 from the bed to the scooter was underneath R7. R7 stated they began to feel themselves slipping. R7 stated they called for help but R7 fell in the doorway of R7's bathroom. R7 stated that facility staff wanted R7 to go to the hospital, but R7 refused. An x-ray was completed later at the facility and R7 did go to the hospital as it was found that R7 had a leg fracture. R7 stated that since the fall, R7 has been told that R7 cannot use R7's motorized scooter. In a follow up interview on 7/22/26 at 10:15 AM, R7 informed Surveyor that R7 had bought the motorized scooter a while ago but could not give Surveyor an exact date. On 7/22/26 at 11:37 AM, Surveyor interviewed Registered Nurse/Event Manager (RN)-S, who reviews all falls that occur at the facility. Surveyor asked when R7 started using the motorized scooter that was in place at the time of the fall. RN-S stated R7 bought it and has been using it since 2024. Surveyor asked if R7 was assessed for the safety of the scooter when it was first put into place. RN-S stated they could not find a physical therapy evaluation. On 7/23/26 at 10:05 AM, Surveyor interviewed Registered Nurse (RN)-F. Surveyor asked when R7 got the current motorized scooter that was in place at the time of R7's fall. RN-F stated that they were not sure about the date but found that R7 was first admitted to the facility with a motorized pink scooter and that a new blue motorized scooter was bought in 2024. On 7/22/26 at 3:38 PM, Surveyor asked Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B for evidence that R7's safety was evaluated after R7 received the current scooter in 2024. NHA-A and DON-B indicated that they would get back to Surveyor. On 7/23/26, NHA-A provided Surveyor with R7's clinical note and Occupational Therapy (OT) notes from 2025. R7's clinical note dated 5/28/25 documents in part: . [R7] also reported recent bruise on left knee from running into door frame. [R7] is agreeable to working with therapy for scooter positioning. R7's OT evaluation and plan of treatment note dated 6/5/25 documents: Reason for referral: [R7] referred to OT due to exacerbation of decrease in strength, decrease in range of motion and reduced balance indicating the need for OT to develop and instruct on compensatory strategies and facilitate sitting tolerance and postural control. Impressions: Alert, oriented, able to express needs and follow directions. [R7] has been having greater difficulty maneuvering electric scooter in small spaces due to positioning of [lower extremities] and inability to correct and maintain [left lower extremity] midline position on footrest . R7's OT encounter note dated 6/11/25 documents in part: . Instruction in proper body alignment in [scooter] to facilitate skin integrity. Reviewed possible options with saddle [scooter] cushion, attachable knee pads and strapping options. Due to structure of scooter, straps may be only viable option. Vemfoam strapping being ordered. R7's OT encounter note dated 7/3/25, documents: [R7] is able to apply knee positioning strap with [minimal] assist. Uses as needed for positioning to maneuver through narrow spaces. R7's OT Discharge summary dated [DATE] documents: Ability to control positioning of [left lower extremity] is inconsistent. Increased risk of bumping knee. Suggested using Velcro strap for positioning assist. [Patient] and Caregiver Training: Instructed [R7] and primary caregivers in compensatory strategies, positing/pressure relieving techniques, safety precautions and use of assistive device(s) in order to facility improved functional abilities with variable carryover demonstrated by caregivers, facilitating the need for further instruction and analysis of caregiver implementation of and patient response to instructions/techniques. Surveyor reviewed R7's comprehensive care plan and noted that the Velcro strap recommendation was not added to R7's care plan. Surveyor reviewed all therapy notes and noted that R7 only had an OT assessment completed and did not have a Physical Therapy assessment completed after R7 started using a new motorized scooter in 2024. On 7/22/26 at 10:48 AM, Surveyor interviewed Physical Therapy Assistant (PTA)- T. Surveyor asked if the PT department is contacted when a resident receives a new motorized scooter. PTA-T stated that facility staff will usually ask for a consultation when a resident starts using a new scooter. PTA-T stated that they would need to be called to assess the scooter to make sure that it is safe for the resident. R7's SBAR note dated 4/17/26 at 10:42 PM documents: Resident had an unwitnessed fall at [8:45 PM] in the bathroom. Resident was sitting up on the bathroom floor next to scooter in front of the door. [R7's] right leg was on the scooter. [Registered Nurse] called EMT to assist resident up and out of the bathroom. Neurological checks stable and [within normal limits]. A 7.5 [centimeter (cm)] x 7.5 cm bruise with pink and blue discoloration on [right lower extremity (RLE)] located on shin/calf noted. Resident rated pain a 10/10. Resident has trouble moving RLE stating, I cannot move this leg much because it hurts. RN administered Tylenol for pain. RN and EMT (Emergency Medical Technician) suggested resident to go to the emergency room for a check up and scan. Resident refused. RN educated resident about receiving timely and appropriate care after fall. Resident still refused. RN updated [provider]. Provider on call ordered STAT X-ray on RLE of tibia, fibula, and femur. R7's Fall investigation, Level 1 Root Cause Analysis document dated 4/17/26 documents in part: Time of incident [8:45 AM]. What was the surrounding area like-clean [and lighted.] What was the floor like? . Dry. What was resident's apparel. Non-skid socks. Was the resident incontinent at the time of the incident? No. When was the last time the resident had something to eat/drink? At dinner at 5 PM. When was the last time the resident was toileted? Before dinner. Based on the above information, what interventions are most appropriate? Appropriate position in scooter. R7's Fall investigation, Level 2 Root Cause Analysis documents in part: What human factors impacted the outcome? MS, weakness. R7's Fall investigation incident witness statement from RN-U dated 4/17/26, documents in part: Passing meds to a resident. Found [R7] on bathroom floor while passing meds. [R7] next to scooter with RLE on scooter. EMT called and assisted resident out of bathroom with a lift assist. Surveyor noted that facility staff did not document the last time R7 was seen prior to the fall. Surveyor noted that facility staff did not document whether the call light in the bathroom or R7's room was on or off. On 7/23/26 at 9:12 AM, Surveyor interviewed RN-U. RN-U stated they were passing medications when they found that R7 had fallen. RN-U stated R7 was going into the bathroom to start getting ready for bed. RN-U stated RN-U last saw R7 shortly before the fall. R7 was seen talking with other residents in the common area. Surveyor asked if R7's call light was on at the time of the fall. RN-U stated they did not remember. Surveyor asked where R7's sling, used for transferring, was at the time of the fall. RN-U stated they could not recall. Surveyor asked what staff would typically do with the sling after transferring R7 to the motorized scooter. RN-U stated most of the time they would leave the sling under R7 in the scooter. Surveyor asked how R7 was typically positioned in the motorized scooter. RN-U stated R7 had a history of being more slanted on the chair and was leaning to one side while going around the facility. Surveyor asked if PT was consulted to address R7's safety due to leaning to one side in the scooter. RN-U stated they could not remember. Surveyor asked what happened after the fall. RN-U stated they called 911 because of the position that R7 was found in and RN-U did not feel like it was safe to move R7 without EMTs. RN-U stated both RN-U and EMTs tried to talk R7 into going to the ER but R7 refused. RN-U stated R7 wanted x-rays completed at the facility. Surveyor noted RN-U stated that R7 had a history of leaning/slanting in the scooter prior to the fall and did not recall if PT was consulted for safety. Surveyor noted RN-U did not recall if the call light was on at the time of the fall. R7's Fall investigation incident witness statement from Certified Nursing Assistant (CNA)-V, dated 4/17/26, documents in part: Nurse came to the room that my coworker and I were in to let us know that [R7] had fallen out of [their] motorized chair in the bathroom in [their] room. [R7] was on the floor up on the wall entrance of [their] bathroom [with] [their] right leg stuck on the base of the motorized chair.EMTs were contacted. Surveyor noted that CNA-V's statement did not include when R7 was last seen by CNA-V and did not include if R7's call light was on or off at the time of the fall. On 7/22/26 at 11:17 AM, Surveyor called CNA-V. Surveyor was unable to leave a voicemail. Surveyor was unable to reach CNA-V for interview. R7's Fall investigation Safety event manager, titled Falls and Slips, documents in part: Occurred 4/17/26 [8:45 PM]. Submitter: Event Manager-[RN-S]. Affected Person [R7]. Description: Unwitnessed fall from power scooter in bathroom. Additional details: There was a deviation from Generally Accepted Performance Standards. There were preventable known complications. Event was preventable. Surveyor noted that facility documented that this fall was preventable. On 7/22/26 at 11:37 AM, Surveyor interviewed Event Manager-RN-S. RN-S indicated they are responsible for reviewing all fall events for the facility. RN-S stated R7 had a fall from their motorized scooter. Surveyor asked why R7 fell. RN-S indicated R7 is a larger resident and R7 has gained a significant amount of weight since being at the facility which could have played a part. RN-S stated the Hoyer sling used to transfer R7 to the motorized scooter was under R7 before the fall. RN-S stated it had been regular practice for facility staff to leave the sling under R7 because they felt it was not safe to remove it after transferring to the scooter and was not safe to place it under R7 in the scooter to be transferred back to bed. RN-S stated facility staff should have brought forward the concern of safety sooner so that physical therapy could have evaluated R7's safety on the motorized scooter. On 7/22/26 at 10:48 AM, Surveyor interviewed Therapy Director-W. Surveyor asked if a Hoyer sling should be left under a resident who was transferred to a scooter. Therapy Director-W indicated it would not be safe to leave the sling under a resident in the scooter. On 7/22/26 at 10:51 AM, Surveyor interviewed PTA-T. Surveyor asked if a Hoyer sling should be left under a resident who was transferred to a scooter. PTA-T stated it is not safe to leave the sling in the chair with the resident. PTA-T stated that it could cause the resident to slide out. Surveyor noted that through the facility fall investigation documentation and interviews, R7's transfer sling was left under R7. R7 slid out of the motorized scooter and fell. Multiple facility staff stated that it is unsafe to leave a transfer sling under a resident while in a scooter. R7 had an x-ray completed and was transferred to the hospital on 4/18/26. R7 was hospitalized until 4/22/26. R7's Hospital Discharge summary dated [DATE] documents: Closed fracture of right tibial plateau sustained after a mechanical fall. Orthopedics consulted, recommended non-operative approach, continue knee immobilizer. Surveyor noted that R7 had a fractured right tibial plateau (lower leg) as a result of this fall. On 7/22/26 at 10:51 AM, Surveyor interviewed PTA-T. PTA-T indicated they started working with R7 after their return from the hospital. PTA-T stated after R7's non-weight bearing status was lifted, PTA-T was trying different methods of transfers for R7 to safely be transferred from bed to the scooter and back so R7 can maintain their independence. PTA-T indicated they have tried the sliding board, sit-to-stand, and total mechanical lift. PTA-T stated that right now, R7 is a Hoyer transfer. PTA-T stated facility staff cannot leave the Hoyer sling in the motorized or manual scooter, and it is not safe for staff to remove or replace the sling while R7 is sitting in the motorized scooter. PTA-T indicated they were working with R7 to do the necessary maneuvers to remove the sling and replace the sling when ready to be transferred back to bed. In addition, PTA-T stated R7's motorized scooter is not safe for R7. PTA-T stated the seat is too small. The width and depth of the seat is not the correct size for R7's body size. PTA-T indicated there should be 1 to 2 inches of width left on each side of the seat in order to consider the motorized scooter safe. R7's chair seat does not have that when R7 is in the motorized scooter. PTA-T indicated they were not sure how long R7 had the motorized scooter but stated that, in general, they would recommend a custom scooter for R7's safety. PTA-T stated the company would come to the facility to complete measurements, assess posture, mobility, and comfort. PTA-T stated that right now, R7 is using a manual scooter for safety. PTA-T indicated R7 also has MS, which symptoms and strength can change quickly, so it is something that needs to be assessed often to make sure R7 is safe in whatever scooter they are in. Surveyor noted the facility PT staff stated that R7's motorized scooter seat, which was in use at the time of the fall, is unsafe and too small for R7. R7 is currently in a manual scooter for their safety. On 7/23/26 at 10:05 AM, Surveyor interviewed RN-F. Surveyor asked about R7's fall in April of this year. RN-F stated the fall happened right before they started working at the facility. RN-F stated they can only inform Surveyor of what they gathered. RN-F stated staff used the Hoyer lift to transfer R7 to the motorized scooter. The Hoyer sling was left under R7 and R7 slid out of the scooter. Surveyor asked why they think R7 fell. RN-F indicated R7's seat in the motorized scooter is curved down, and the sling was left under R7. RN-F indicated maybe a grippy or different cushion could have prevented the fall. On 7/23/26 at 1:20 PM, Surveyor asked DON-B if they had any additional information regarding R7's fall. DON-B indicated they did not hear of R7's fall until after they started working at the facility and they did not have any additional information. On 7/23/26 at 11:59 AM, Surveyor interviewed NHA-A. Surveyor informed NHA-A that R7 bought a motorized scooter in 2024, and the facility's Physical Therapy department did not evaluate the scooter for R7's safety. The facility's Occupational Therapy department recommended a foam leg strap for positioning in the motorized scooter in 2025. This was not added to R7's comprehensive care plan. R7's transfer sling was left under R7 in R7's scooter. R7 slipped out of the scooter, fell, and fractured R7's leg. PTA-T informed Surveyor that R7's motorized scooter that was in place at the time of the fall was unsafe for R7. NHA-A nodded. NHA-A stated R7 knows how R7 likes their things. NHA-A stated R7 likes things their way even if it is not the safest. 3.) R1 was admitted to the facility on [DATE] with diagnoses including Dementia, delirium and history of a fall prior to admission. R1's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 7, indicating severe cognitive impairment. The MDS documents that R1 was assessed to have no impairment to the upper or lower extremities, is dependent with sit to stand, requires substantial/maximal assistance with lying to sitting at side of the be, dependent with transfers from bed to chair/ chair to bed and incontinent of bowel and bladder. R1's fall risk assessments provided by the facility indicate the following: 3/18/2026- score 24, moderate fall risk 3/20/2026- score 31, moderate fall risk 3/21/2026- score 29, moderate fall risk 4/1/2026- score 48, significant fall risk 4/6/2026- score 31, moderate fall risk 4/10/2026- score 31, moderate fall risk 4/20/2026- score 27, moderate fall risk 5/12/2026- score 44, significant fall risk 5/19/2026- score 30, moderate fall risk 6/18/2026- score 34, moderate fall risk R1's care plan indicates R1 is at risk for falls, initiated 3/16/2026 with the following interventions: Keep pathways clear and provide adequate lighting; Keep bed at appropriate height; Keep personal items within reach; Transfer per intake information until seen by therapy, then follow therapy recommendations; Orient to room and call light. R1's progress note, dated 3/26/2026, indicates R1 experienced an unwitnessed fall around 9:50 PM in R1's room with noted swelling above R1's right eye and forehead. On 7/21/2026, Surveyor requested the fall investigation for R1's fall on 3/26/2026. R1's fall investigation titled, Safety Event Manager, dated 4/15/2026 documents: At approximately 9:50 PM on 3/26/2026, R1 was found on the floor of R1's room lying on their right side on the fall mat next to the bed. The bed was in the lowest position with call light resting on bed and not in use at time of incident. R1 was wearing grippy socks at the time of the incident. R1 indicated that they were attempting to go to the bathroom. R1's brief was noted to be dry at time of incident. Swelling noted above right eye and forehead, no other injuries noted. R1 was transferred to Broda chair using a mechanical lift and placed in common area near nurses station. Surveyor noted the Safety Event Manager was reported on 4/15/2026, about 3 weeks after the fall occurred, no root cause analysis was completed, and no staff statements were collected regarding R1's fall. On 7/22/2026, at 11:05 AM, Surveyor interviewed Event Manager/RN-S who indicated the nurse did not enter the incident report into the electronic health record which would have initiated a fall protocol in the system. If the nurse does not have access to the reporting system with an email, paper fall packets are available. When the nurse does not complete the fall packet Event Manager/RN-S will try to get the nurse to come back to the Facility or gather information herself to enter the report which causes a delay. Event Manager/RN-S tried to piece together the information she had to determine the root cause. R1's progress note, dated 4/1/2026, indicates R1 was found at approximately 7:55 AM in R1's room and appeared to have slid the top half of their body onto the floor as the bottom half (lower extremities) were still resting on the bed. The bed was in the lowest position, fall mat in place, call light within reach. Nurse was in room [ROOM NUMBER]-5 minutes prior, to offer medications. Nurse left the room and herd help and ran back in to find R1 half way on the ground. R1 was unable to answer questions and difficulty remembering at baseline. Hospice was notified with no new orders. It was suggested to management to consider moving R1's room closer to the nurses' station and also to have R1 get up on third shift. On 7/21/2026, Surveyor requested the fall investigation for R1's fall on 4/1/2026. The investigation contained a statement titled, Incident Witness Statement Form indicating R1 had a fall and was unwitnessed. Surveyor noted R1's care plan was updated with the following intervention on 4/1/2026, Up in Broda chair at nurses station when restless and unable to redirect. Surveyor noted that the fall investigation for R1's fall on 4/1/2026, does not have the time last toileted, no time last repositioned and does not address refusal of medications. Surveyor also noted that moving R1's room and getting up on third shift was not implemented in R1's plan of care. On 7/22/2026, at 11:05 AM, Surveyor interviewed Event Manager/RN-S who indicated that once a room was to become available, R1's room would be moved closer to the nurses station. Getting R1 up on third shift should be linked to the Certified Nursing Assistant care guide but it does not appear to have been implemented in the care plan or care guide. R1's progress note, dated 4/6/2026, indicates R1 experienced an unwitnessed fall around 4:00 AM in R1's room with no injuries. On 7/21/2026, Surveyor requested the fall investigation for R1's fall on 4/6/2026. On 7/23/2026, at 10:43 AM, Surveyor was informed by DON-B that there is no fall investigation for R1's fall on 4/6/2026. Surveyor noted that the facility did not provide evidence that a root cause analysis or interventions were in place to R1's progress note, dated 4/9/2026, indicates R1 experienced an unwitnessed fall around 10:40 PM in R1's room. On 7/21/2026, Surveyor requested the fall investigation for R1's fall on 4/9/2026. The investigation document titled, Safety Event Manager, reported 4/16/26 documents: Description- When coming on shift resident heard yelling in room. when doing walking rounds at 10:40 PM on 4/9/2026. R1 noted to be on the floor face first arms and legs straight on floor mat. Able to move extremities with no hip rotation. Assisted to bed via 2 staff members using lift. Older looking knot on left forehead. Also noted to have new swelling and redness around left eye and swelling about 180 degrees around left eye. No open areas noted. Assisted into chair and brought to common area. Hospice notified and visit requested. Pain and anxiety med offered but refused. Surveyor noted R1's care plan was updated with the following intervention on 4/12/2026, moved to room closer to nurses station. R1's experienced a fall on 5/11/2026, the Facility provided fall investigation contains the following: -A document titled Safety Event Manager -A document titled, Post Fall Form, indicating Resident stated she does not know how she fell out of her chair Witnessed- yes Environmental factors- none Resident factors- slid/fall from w/c, attempting to self-transfer Footwear at time of fall- gripper socks Mood prior to fall- confused/angry/upset Incontinent at time of fall- yes bowel and bladder Location of fall- dining room No injury Last observed prior to fall- 4:30 PM watching TV Food last offered- 12:30 Time fluids last offered- 3:00 PM -Witness- RN-U R1 was yelling in the dining room while watching TV with a resident. tried to give scheduled medication and offered a drink. R1 refused after multiple attempts and continued to yell. Tried to reassure R1 and calm R1 down. R1refused. -no recent changes to medication - no active infection - no injury -number of nurses RN/LPN on unit at time of fall- 1 -number of aids/CNAs working on the unit at time of fall- 1 -immediate new care plan/service plan interventions put into place- continue POC and fall precautions Surveyor noted there was no initial documentation of R1's fall on 5/11/2026, the root cause analysis was not completed for R1's fall. On 7/22/2026, at 11:05 AM, Surveyor interviewed Event Manager/RN-S who indicated a voiding trial was started as an intervention for R1's fall on 5/11/2026. On 7/23/2026, at 10:43 AM, Surveyor interviewed DON-B. DON-B indicated that the intervention implemented after R1's fall on 5/11/2026 was to use a wedge cushion but it was missed and not put into R1's care plan. R1 sustained a fall on 5/17/2026. As part of the fall investigation, R1's care plan was updated on 5/18/2026 to include a 3-day voiding trial. Surveyor asked the facility for the log of R1's voiding trial and noted only 1 day completed (5/19/2026). On 7/23/2026, at 10:43 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A, DON-B and Event Manager/RN-S. Surveyor informed NHA-A and DON-B that theR1's voiding trial was not completed. DON-B indicated that psych services were consulted to follow up with R1 and the voiding [NAME]

Based on interviews and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for 2 (R7 and R1) of 2 residents reviewed for unwitnessed falls. *R7 sustained an unwitnessed fall on 4/17/26. Facility staff did not document that neurological checks were completed per facility fall protocol and standards of practice. *R1 sustained multiple unwitnessed falls. No RN (Registered Nurse) assessment was completed after R1 experienced two falls. Facility staff did not document that neurological checks were completed per facility fall protocol and standards of practice for four falls. Findings include: On 7/23/26 at 12:15 PM, Surveyor asked Nursing Home Administrator (NHA)-A for the facility neurological (neuro) check policy. Surveyor was not provided with a neuro check policy. The American Association of Post-Acute Care Nursing dated August 2021 and titled, Post Fall Assessments documents: An assessment of neurological status, often called a neuro check, should be done when a resident hits his or her head or if it is unknown if they hit their head (unwitnessed fall) . A subdural hematoma may not show symptoms until several days after the fall. The facility policy with a last approved date of 1/2026, and titled, Falls documents: The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred. A Licensed Nurse shall observe clinical status for 72 hours after an observed or suspected fall, and document findings in the resident clinical record . R7 was admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis. R7's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents that R7 is cognitively intact. R7's SBAR note dated 4/17/26 at 10:42 PM, documents: Resident had an unwitnessed fall at [8:45 PM] in the bathroom. Neuro checks stable and [within normal limits] . Continuing to assess residents' neuro and vitals [every] 15, [every] 30 and every shift. Surveyor noted the fall occurred around 8:45 PM and noted facility staff documented that initial neuro checks were complete. Surveyor could not locate any documentation that facility staff completed additional neuro check were completed. On 7/23/26 at 10:25 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-D. Surveyor asked if neuro checks are completed after an unwitnessed fall. LPN-D indicated that it is facility protocol to do neuro checks if a resident hits their head and/or experiences an unwitnessed fall. Surveyor asked where the neuro checks are documented. LPN-D stated that they are documented in the electronic medical record. On 7/23/26 at 10:05 AM, Surveyor interviewed Registered Nurse (RN)-F. Surveyor asked when neuro checks are completed after a fall. RN-F stated they need to be completed after an unwitnessed fall. RN-F stated that neuro checks are completed every 15 min for 1 hour, every 30 min for 2 hours and there is more of a schedule after that. RN-F stated that the exact schedule is populated when a fall is documented in the electronic health record (EHR). RN-F stated that when the next neuro check is due, the EHR will automatically flag the nurse to complete the neuro check. Surveyor asked if R7 had neuro checks completed on 4/17/26 after an unwitnessed fall. RN-F stated they would look. RN-F looked in the EHR. RN-F indicated they did not see that all neuro checks were completed. On 7/23/26 at 11:59 AM, Surveyor informed NHA-A that facility staff informed Surveyor that neuro checks are supposed to be done and documented in the EHR after an unwitnessed fall. Surveyor informed NHA-A that R7 experienced an unwitnessed fall, and neuro checks were not documented per facility protocol. NHA-A stated that R7 is alert and oriented and is able to tell staff if there is something going on. NHA-A stated that R7 will frequently refuse assessments as well. Surveyor stated that if neuro checks are not completed and documented in the EHR, nursing staff that are from oncoming shifts would not know if something changed or was getting worse with R7. NHA-A stated that they understood. 2.) R1 was admitted to the facility on [DATE] with diagnoses that included Dementia, delirium and history of a fall prior to admission. R1's admission Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 7, indicating severe cognitive impairment. The MDS documents that R1 was assessed to not have upper or lower extremities impairment, is dependent with sit to stand, requires substantial/maximal assistance with lying to sitting at side of the be, is dependent with transfers from bed to chair/ chair to bed and incontinent of bowel and bladder. R1's fall investigation titled, Safety Event Manager, indicates R1's fall occurred on 3/21/2026 at 4:05 AM, and describes an unwitnessed fall from bed by R1. The investigation documents that R1 sustained a 1 cm laceration to left eyebrow. The event closed on 3/26/2026 by Event Manager/Registered Nurse (RN)-S indicating closed with increased monitoring of similar occurrences. R1's Level 1 Root Cause Analysis, dated 3/21/2026, documents that R1 rolled out of bed on to tile floor, face down, no clutter, proper lighting, had bare feet, does not use assistive devices, was repositioned mid-night shift, was not incontinent at time of fall and no recent changes to medications. Surveyor noted there was no documented RN assessment completed post R1's 3/21/2026 fall. On 7/22/2026, at 11:05 AM, Surveyor interviewed Event Manager/RN-S who indicated the nurse completes initial root cause and Event Manager/RN-S will follow up to ensure accuracy of completion and review/implement interventions. Event Manager/RN-S indicated that if the nurse is a Licensed Practical Nurse (LPN), they notify the on-call nurse who is always a RN, but the RN is not expected to complete an assessment. R1 is on hospice, hospice is notified and will send a RN to follow up and complete an assessment. Event Manager/RN-S informed Surveyor she would look for the hospice RN assessment. R1's progress note, dated 3/26/2026, indicates R1 experienced an unwitnessed fall around 9:50 PM in R1's room with noted swelling above R1's right eye and forehead. Surveyor reviewed R1's electronic health record and did not locate any neuro (neurological) checks were completed. Surveyor also could not locate any RN assessment that was completed for R1 after R1 experienced a fall on 3/26/2026. On 7/22/2026, Surveyor requested neuro checks for R1's fall on 3/26/2026 and was provided with 1 neuro check, completed on 3/26/2026 at 9:00 AM. On 7/22/2026, at 10:28 AM, Surveyor interviewed Unit Manager (UM) Registered Nurse (RN)-F. UM/RN-F stated that when a fall occurs, the nurse will initiate the fall protocol in the electronic health record, and the system will generate reminders to complete neuro checks. Neuro checks are only completed in the electronic health record. UM/RN-F went through R1's electronic health record with Surveyor and indicated for 3/26/2026, the initial neuro checks were not completed, indicating if they were completed, they would be in the electronic health record. On 7/22/2026, at 11:05 AM, Surveyor interviewed Event Manager/RN-S who indicated the nurse did not enter the incident report into the electronic health record which would have initiated a fall protocol in the system. If the nurse does not have access to the reporting system with an email, paper fall packets are available. Hospice was notified and will send out an RN to do an assessment when available. When the nurse does not complete the fall packet Event Manager/RN-S will try to get the nurse to come back to the Facility or gather information herself to enter the report which causes a delay. Event Manager/RN-S tried to piece together the information she had to determine the root cause. On 7/23/2026, at 10:43 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B informed Surveyor that neuro checks for R1's unwitnessed fall were incomplete. DON-B indicated that the facility had per-dem staff up until 5/1/2026 and were constantly providing reeducation regarding fall protocols, including neuro checks. The expectation is if a fall is unwitnessed, initial neuro checks can be completed in a progress note and then the nurse is to initiate neuro checks in the electronic health record, and the system will generate the times at which they need to be completed. R1's progress note, dated 4/6/2026, indicates R1 experienced an unwitnessed fall around 4:00 AM in R1's room. Surveyor could not locate any neuro checks that were documented a progress note. On 7/22/2026, Surveyor requested neuro checks for R1's fall on 4/6/2026. None were provided. On 7/22/2026, at 10:28 AM, Surveyor interviewed UM/RN-F who informed Surveyor that neuro checks were not documented or completed for R1's unwitnessed fall on 4/6/2026. On 7/23/2026, at 10:43 AM, Surveyor interviewed DON-B, who informed Surveyor that the facility could not locate any neuro checks for R1's fall on 4/6/2026. DON-B stated that the expectation is if a fall is unwitnessed, initial neuro checks can be completed in a progress note and then the nurse is to initiate neuro checks in the electronic health record, and the system will generate the times at which they need to be completed. R1's progress note, dated 4/9/2026, indicates R1 experienced an unwitnessed fall around 10:40 PM in R1's room with new swelling and redness around R1's left eye. On 7/22/2026, Surveyor requested neuro checks for R1's fall on 4/9/2026. None were provided. On 7/22/2026, at 10:28 AM, Surveyor interviewed UM/RN-F who informed Surveyor that neuro checks were not documented or completed for R1's unwitnessed fall on 4/9/2026. On 7/23/2026, at 10:43 AM, Surveyor interviewed DON-B, who informed Surveyor that the Facility could not locate any neuro checks for R1's fall on 4/9/2026. DON-B stated that the expectation is if a fall is unwitnessed, initial neuro checks can be completed in a progress note and then the nurse is to initiate neuro checks in the electronic health record, and the system will generate the times at which they need to be completed. R1's progress note, dated 4/21/2026, documents that R1 experienced an unwitnessed fall on 4/20/2026 in the dining room, noting a small knot to R1's right eyebrow. Surveyor noted there are no neuro checks documented in the progress note. On 7/22/2026, Surveyor requested neuro checks for R1's fall on 4/20/2026. None were provided. On 7/22/2026, at 10:28 AM, Surveyor interviewed UM/RN-F who informed Surveyor that neuro checks were not documented or completed for R1's fall on 4/20/2026. On 7/23/2026, at 10:43 AM, Surveyor interviewed DON-B, who informed Surveyor that neuro checks for R1's fall on 4/20/2026 were not completed and indicated the unit manager is responsible for ensuring neuro checks are being completed. On 7/23/2026 at 1:30 PM, Surveyor informed NHA (Nursing Home Administrator)-A and DON-B that neuro checks were incomplete or not completed for R1's falls on 3/26/2026, 4/6/2026, 4/9/2026, and 4/20/2026 and no RN assessment was completed after R1 fell on 3/21/2026 and 3/26/2026.

Based on record reviews and interviews, the facility did not ensure allegations of sexual abuse were reported to the State Survey Agency, within 5 working days of the incident. This was observed with 1 of 1 Facility Reported Incidents reviewed for alleged sexual abuse.* NHA-A did not submit an investigation of findings for allegations of sexual abuse involving R1 within 5 days to the State Agency.Findings Include:The Facility's policy, titled Abuse Prevention with a last revised date of 08/2025, indicates, in part, the following .The community will investigate and report any allegations of abuse within timeframes as required by federal, state, and local requirements.R1 was admitted to the facility on [DATE] and was sent out to the hospital on 5/18/2026 for unrelated medical concerns. On 5/20/2026, the facility was notified by the hospital that R1 expressed pain during a urine sample catch and expressed it felt like R1 was raped by a specific named, male staff. After the Facility was made aware of the allegation, an investigation was started. Surveyor noted there are no male staff employed by the facility matching the alleged name and description.R1 was discharged from the facility during time of survey.The hospital informed the facility (via email) that the allegation appeared to have occurred while R1 was in the hospital. The facility continued an investigation, and it was confirmed that R1 never had a catheter or urine sample catch that would have required insertion of a catheter while at the facility. Surveyor reviewed and verified the above findings based on review of R1's electronic health record and interview with NHA-A. Surveyor noted that Nursing Home Administrator (NHA)-A initially reported the allegation of sexual assault to the State Agency on 5/20/2026. The facility investigated the findings and discovered the allegation did not occur at the facility. The facility reported the findings to the State Agency on 6/1/2026, which is seven days after the initial allegation was submitted.Surveyor noted that the final report was submitted to the State Survey Agency, two days after the 5 working days reporting requirement.On 7/21/2026, at 3:02 PM, Surveyor interviewed NHA-A regarding the late reporting. NHA-A informed Surveyor that it was an error and NHA-A did not realize it was submitted late.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 (R2) of 3 allegations of abuse or neglect reviewed.*R2 was found with a bruise and new skin tears and the injuries were of unknown origin. The investigation was not thoroughly investigated as nursing documentation and staff statements were conflicting. Findings include:The Facility's policy, titled Abuse Prevention with a last revised date of 08/2025 documents: The community will investigate and report any allegations of abuse within timeframes as required by federal, state, and local requirements. R2 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, dementia, and cerebral infarction.R2's Quarterly Minimum Data Set (MDS), dated [DATE], indicated that R2 is sometimes understood by others and sometimes understands others. The MDS documents a Brief Interview for Mental Status (BIMS) score of 02, indicating that R2 has severe cognitive impairment. R2 was assessed as not exhibiting any behaviors.R2's pressure ulcer/skin prevention care plan, dated 10/24/2023, documents: R2 is at risk for pressure ulcers and bruises and other skin related injuries related to fragile skin. Interventions include: Observe skin for redness and breakdown during routine care. Start: 10/24/2023; Caregiver education: train caregivers on proper lifting techniques and how to reposition the patient safely without causing shear or friction. Start: 12/12/2024; Apply tubi grips to bil (bilateral) arms in am (morning) off at hs (bedtime) Start: 5/24/2025.The facility submitted a Facility Reported Incident to the State Agency on 4/2/2026 that documented under Summary of Incident section: When getting resident up for the day, staff noted a large bruise and some bleeding on resident's R (right) arm. Area cleaned and resident was assessed. Nurse and aide for evening shift called and suspended pending outcome of investigation. Police notified, Officer. came. Began investigation with interviewing staff, residents, doing skin assessments on all residents in the area. Investigation began, investigation to follow.Surveyor reviewed the summary provided by the Nursing Home Administrator (NHA)-A dated 4/9/2026, which documents: Conclusion: There were no other staff in the area at the time. Due to the fact that the resident is combative at times with care and he was combative that day, resident could have possibly incurred those injuries himself. The police did not feel the skin tears were made by another person's hands. We were unable to prove or disprove an allegation of abuse.Surveyor reviewed the investigation documentation that was provided. The two staff that worked with R2 on night shift before the bruise and skin tears were discovered each provided a written statement about R2 on the night shift. Licensed Practical Nurse (LPN)-H did not mention R2 exhibiting behaviors during the NOC shift. The Certified Nursing Assistant that worked with R2 on the NOC shift documented: I was doing my normal checks on the Residents every 2 hours and R2 was trying to climb out of the bed and I was just going in there every chance I got to check or when the nurse would say something about him. He would have half his body hanging off the bed at times and I was wondering why cause I never seen him do it but I did hear that he likes to try and get out of the bed at times, so I put 3 pillows on the side he was hanging out on and put his bed all the way down the floor and the fall mat down making sure he didn't fall.Surveyor reviewed R2's Medication and Treatment record for 4/1/2026 prior to skin tears being discovered.R2's physician order documents: Mood disorder behavior monitoring - complete ID note, 0 indicates none. On 4/1/2026, 0 was documented for the evening and night shifts.R2's physician order documents: Side effect monitor for antianxiety medication Lorazepam - monitor for SE (side effect) related to use of antianxiety medication. Document 1 if no SE observed and 2 if SE observed documents that on 4/1/2026, 1 was documented for eve (evening) and noc (night) shifts.Surveyor noted that per the documentation, it was unclear as to whether R2 was restless the night before the skin tears were discovered on 4/2/26 and or if R2 was experiencing behaviors.R2's progress note dated 4/2/2026 documents: Patient was found by aid at 07:00AM with skin tears to right antecubital and right forearm. Patient was not in any distress or didn't appear to be in any discomfort. Patient is unable to communicate any recent events as patient is limited with verbal communication and cognitive abilities. Management was contacted. Skin tears were cleaned, bleeding disrupted and wound dressed. Patient was found with blood on sheets, on right sleeve of long sleeve t-shirt and on brief. Management arrived to facility to assess. Management advised to send patient out.On 7/21/2026, at 2:13PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who was the nurse on shift when R2's skin tears were found. LPN-G stated that the aide found R2's skin tears on initial rounds for the shift. LPN-G called management to report and then cleaned and covered the skin tears. When asked how R2 could have gotten the skin tears LPN-G stated they looked at the room with the police and the only thing that was found to potentially tear the skin was the call light pin.On 7/22/2026, at 1:53PM, Surveyor interviewed LPN-H who worked the night shift before the skin tears were discovered. LPN-H stated that R2 slept through the night just fine and that R2 exhibited no restlessness. LPN-H stated that R2 was not trying to get out of bed. 3Surveyor asked if R2 exhibited any behaviors. LPN-H stated R2 sometimes sticks legs out to try and kick boots off feet. Surveyor asked if this behavior could have caused the skin tears and LPN-H stated that the aide who turned R2 could have bumped or grabbed R2's arm, causing the skin tears.Surveyor noted the CNA on night shift and the CNA that discovered the skin tears were not available for interview.On 7/23/2026, at 9:50AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about R2's behaviors not being documented for evening or night shift. NHA-A stated that behaviors were reported by the night Certified Nursing Assistant (CNA) that worked with R2. The CNA stated they had to keep going into R2's room to reposition R2, at one point R2's arm was hanging off the bed. Surveyor asked if training regarding injuries of unknow origin and or potential abuse was provided to facility staff after R2's incident and was told no. Surveyor asked if R2's care plan was updated to prevent future skin tears and NHA-A stated would need to review. Surveyor asked why the investigation did not thoroughly investigate if R2's behaviors or interactions with the CNA could have contributed to R2's bruise and skin tear on 4/2/26.Surveyor informed NHA-A that R2's pressure ulcer/skin prevention care plan was not updated with new interventions to prevent additional skin tears. Surveyor informed NHA-A that the investigation was not thoroughly investigated as nursing documentation and staff statements about R2's behaviors were conflicting and the investigation did not thoroughly investigate if R2's behaviors or interactions with the CNA could have contributed to R2's bruise and skin tear on 4/2/26.

Based on observation, interview, and record review, the facility did not establish and maintain an infection prevention and control program based upon current standards of practice, designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all 51 residents. The facility was not monitoring infections, tracking and trending infections and monthly infection rates were not completed in the facility for 2025. In November 2025, the facility did not have any documentation of monitoring infections, surveillance, tracking and trending of infections were not completed, and infection rates were not completed. The facility had a Covid 19 outbreak in September 2025, and the infectious outbreak was not thoroughly investigated. The facility does not have a sink in the laundry room and staff are using a sink located across the hallway. This prevents the laundry workflow from being free of cross contamination. R8 and R51 had an enteric precautions sign and supply cart outside of their room, staff was observed providing care to R8 and R51 without putting on proper personal protective equipment (PPE). Findings include: The facility's policy titled Infection Prevention and Control Program, dated 05/2018, last revised 06/2025, documents the following: The infection prevention and control program (IPCP) is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, interventions implemented to promote the prevention of infection, education and associate health and safety. The IPCP covers all residents, associates, contractors, consultants, volunteers, visitors, others who provide care and services to residents on behalf of the facility, and students in the facility's nurse aid training programs or from affiliated academic institutions. The IPCP Is designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The infection preventionist will conduct ongoing surveillance for health care associated infections and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The infection preventionist, at routine intervals, reviews Initiated surveillance tools to identify; Health care acquired infections Potential outbreaks Reportable infections Reportable diseases will be reported by IP per state and federal guidelines. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequencies, detecting outbreaks and epidemics, monitoring associate infections, and detecting unusual pathogens with infection control implications. Data gathered during surveillance is used to identify infections and trends. Data is analyzed by absolute number of cases reported, as well as by infection rate. Compare the rates to previous months in the current year and to the same month in previous years, to identify seasonal trends. Consider how increases or decreases might relate to recent process changes, events, or activities in the community. The infection preventionist and Director of Nursing services will be responsible for: Receiving surveillance information and tabulating data; Maintaining a line listing of identified cases on the appropriate line listing report; Notifying the Medical Director and the attending physicians; On 4/9/26, at 9:08 AM, Surveyor interviewed Laundry-P who stated she performs laundry services for resident's personal items only. Laundry-P stated all other linens are ordered daily and delivered to the facility. While touring the laundry facilities, Surveyor noted no sink in the laundry room. Surveyor asked Laundry-P how she prevents cross contamination and proper hand hygiene without a sink in the laundry room. Laundry-P stated she uses gloves when transporting and loading laundry in the washers and will run across the hallway to the bathroom to wash her hands. Surveyor observed the laundry room door closed and noted staff would need to use the door handle prior to performing hand hygiene. On 4/7/26, at 10:50 AM, Surveyor interviewed Quality Management (QM)-D who stated she is the Infection Preventionist for the facility. QM-D stated she was recently hired and has been in the Infection Preventionist role since January 2026. QM-D stated there were no infection surveillance logs prior to January 2026. QM-D stated she had asked Nursing Home Administrator (NHA)-A for surveillance logs and infection prevention documentation and NHA-A notified QM-D there were no logs or surveillance prior to QM-D starting her position in January 2026. QM-D stated infection tracking was not being performed. QM-D stated in January 2026, she started tracking infections every day and are working with staff about ensuring infections are reported to QM-D. QM-D stated it's an expectation for the facility to have a comprehensive and accurate infection prevention program and stated she is not sure why the facility was not previously implementing the infection prevention program. QM-D then stated staff turnovers was an issue which may have contributed to the infection surveillance not being performed. QM-D provided Surveyor infection prevention logs and surveillance from January 2026 to current. Surveyor notified QM-D of concerns with the facility not implementing and maintaining the infection prevention logs and surveillance prior to January 2026 and QM-D acknowledged these concerns. On 4/8/26, at 11:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated QM-D started in the Infection Preventionist role in January 2026. NHA-A stated the previous Director of Nursing (DON) was completing the Infection Preventionist task. Surveyor notified NHA-A of concerns with the facility was not monitoring infections, tracking and trending infections and monthly infection rates were not completed in the facility prior to January 2026. NHA-A acknowledged these concerns. On 4/8/26, at 1:24 PM, QM-D provided Surveyor an Infection Prevention binder dated 2025. QM-D notified Surveyor she had previously asked for documentation from 2025 and was not provided the information or notified the 2025 binder existed prior to today on 4/8/26. Surveyor reviewed the 2025 binder and noted the following: -The facility was not monitoring infections, tracking and trending infections and monthly infection rates were not completed in the facility for 2025. In November 2025, the facility did not have any documentation of monitoring infections, surveillance, tracking and trending of infections were not completed, and infection rates were not completed. -The facility had a Covid 19 outbreak in September 2025, and the infectious outbreak was not thoroughly investigated. On 4/8/26, at 3:26 PM, Surveyor notified NHA-A of the following concerns: -The facility was not monitoring infections, tracking and trending infections and monthly infection rates were not completed in the facility for 2025. In November 2025, the facility did not have any documentation of monitoring infections, surveillance, tracking and trending of infections were not completed, and infection rates were not completed. -The facility had a Covid 19 outbreak in September 2025, and the infectious outbreak was not thoroughly investigated. -The facility did not provide QM-D previous infection prevention documentation for the facility and QM-D to review to gather data and analyze data to identify infections and trends. NHA-A acknowledged these concerns and no additional information was provided. 2.) The facility policy titled Standard and Transmission-Based Precautions last revised 6/2025 documents: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Personal Protective Equipment (PPE) refers to specialized clothing or equipment worn by individuals to minimize exposure to hazards and prevent injuries or illnesses. Enhanced Barrier Precautions. A. Each community will fully implement EBP in accordance with CMS regulatory requirements. EBP in addition to standard and contact precautions shall be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring and/or transmitting a multidrug resistant organism (MDRO) such as a resident with wounds, indwelling medical devices and residents with colonization with an MDRO. B. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. C. EBP are indicated (when contact precautions do not otherwise apply) for residents with any of the following: 1. Wound that requires a dressing (not a skin tear/cut that would just require a band aid). 2. Indwelling catheter (foley, suprapubic) 3. Other indwelling medical device (ie., fistula for dialysis, etc.) 4. Enteral tube. 5. Enteral tube 6. Trach 7. Vent Examples of high-contact resident care activities requiring gown and glove use for EBP include device care or use, central line, urinary catheter, feeding tube, tracheostomy/ventilator. On 4/7/26 at 9:35 AM, Surveyor observed Registered Nurse (RN)-M prepare R8's medications that were ordered to be given via Gastrostomy tube (G-tube). RN-M sanitized her hands, applied gloves and entered R8's room. RN-M flushed R8's G-tube with water and administered the medications through the G-tube. Surveyor noted RN-M did not wear a gown during administration of R8's medications. Upon leaving R8's room, Surveyor asked why there was a sign for Enhanced Barrier Precautions (EBP) outside R8's room. RN-M stated, That's for her roommate, she has a wound. Surveyor clarified that R8 is not on EBP, RN-M stated No. Surveyor noted the EBP sign outside of R8's room documented: Everyone must wear gloves and a gown for the following high-contact resident care activities: Device catheter or use: Central line, Urinary catheter, Feeding Tube, tracheostomy. Wound care any skin opening requiring a dressing. On 4/9/26 at 11:48 AM, Nursing Home Administrator (NHA)-A was advised of the above observation and concern that appropriate PPE (gown) was not worn during administration of medications through gastrostomy tube. No additional information was provided. 3.) The facility's policy and procedure titled, Standard and Transmission-Based Precautions, last revised 6/2025, documents: Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Transmission-Based Precautions (TBP). D. When implementing transmission-based precautions, the facility will consider the following: 1. The identification of resident risk factors that increase the likelihood of transmission (such as uncontained secretions or excretions, non-compliance, cognition deficits, incontinence, etc.). 5. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility-wide. Additionally, either the CDC (Centers for Disease Control) category of transmission-based precautions (e.g., contact, droplet, or airborne) or instructions to see the nurse before entering will be included in the signage. 6. The facility will have PPE (Personal Protective Equipment) readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions . Surveyor noted per the CDC for Enteric Precautions the Personal Protective Equipment (PPE) staff and visitors must wear gowns and gloves when entering the room to prevent contact with contaminated surfaces. On 04/06/2026, at 9:55 AM, Surveyor observed two staff members, a nurse and a Certified Nursing Assistant (CNA) go into R51's room to help her sit up in bed. No Personal Protective Equipment (PPE) was put on by either staff member. There was an enteric precautions sign on R51's door frame advising to wear gloves and gown up. Surveyor heard the CNA say to R51 we will get you dressed then up in the chair; the staff then left the room to go find help. On 04/06/2026, at 9:59 AM, Surveyor observed two staff members use hand sanitizer then go into R51's room and shut the door, they did not stop to put on gowns from the cart in hallway. On 04/06/2026, at 10:03 AM, Surveyor observed Minimum Data Set (MDS)-Q exit room to look for a mechanical lift. Surveyor interviewed MDS-Q and was told no we did not put on gowns. The aid is actually getting R51 dressed, I did not touch R51. Surveyor noted the CNA was still in the room. On 04/06/2026, at 10:05 AM, Surveyor interviewed CNA-R regarding why no gown or gloves were worn inside R51's room. Surveyor pointed to sign on door frame and asked if the CNA was trained to know what the sign means. CNA-R replied yes, I just didn't see it or see precautions on R51's chart. I was just dressing R51. On 04/06/2026, at 10:10 AM, Surveyor observed MDS-Q and CNA-R wear gowns into the room to transfer R51 from bed to wheel chair. On 04/08/2026, at 3:11 PM, during end of day meeting with Nursing Home Administrator (NHA)-A Surveyor told of concern there were observations of staff going into R51's room that was posted for enteric precautions with no PPE being donned. No additional information was provided regarding PPE not being worn in a room posted for enteric precautions.

Based on interview and record review, the facility did not ensure they implemented an effective antibiotic stewardship program with the potential to affect all 51 residents in the facility. Review of the facility infection surveillance logs for residents on antibiotics, indicate antibiotic use without documentation of appropriate use, surveillance, and tracking information. Findings include: The facility's policy titled Antibiotic Stewardship, dated 01/2018, last revised 06/2025, documents: The Ascension Living antibiotic stewardship program's goals are to promote resident safety with the appropriate use of antibiotics, improve resident outcomes and reduce antibiotic resistance and adverse events.Antibiotics shall be prescribed and administered to residents under the guidance of the community's antibiotic stewardship program.The antibiotic stewardship program shall be incorporated in the overall infection prevention and control program and reviewed on an annual basis and as needed.The antibiotic stewardship program promotes appropriate use of antibiotics for quality of care, successful resident outcomes and reduction of potential adverse consequences related to antibiotic use.A collaborative effort between the resident, interdisciplinary team, prescribing practitioners, Medical Director, pharmacist, and leadership team is essential for success of the antibiotic stewardship program.The facility practices the core elements of antibiotic stewardship, outlined by the Centers for Disease Control and Prevention to optimize the treatment of infections while reducing the adverse events associated with antibiotic use including; leadership commitment, accountability, drug expertise, action, tracking, reporting and education. On 4/8/26, at 10:43 AM, Surveyor interviewed Quality Management (QM)-D who stated she is the Infection Preventionist for the facility. QM-D stated she was recently hired and has been the Infection Preventionist role since January 2026. QM-D stated there were no infection surveillance logs prior to January 2026. QM-D stated she had asked Nursing Home Administrator (NHA)-A for surveillance logs and antibiotic stewardship documentation and NHA-A notified QM-D there were no logs or surveillance prior to QM-D starting her position in January 2026. QM-D stated antibiotic tracking was not being performed. QM-D stated in January 2026, she started tracking antibiotics every day and work with staff about ensuring McGeer's criteria is being followed. QM-D stated when she first started, the facility's on call providers started antibiotics without asking questions and QM-D is now working with the providers on Urinary Tract Infection (UTI) protocols that were not previously being followed. QM-D stated it's an expectation to follow the antibiotic stewardship program and stated she is not sure why the facility was not previously following the program. On 4/8/26, at 11:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated QM-D started in the Infection Preventionist role in January 2026. NHA-A stated the previous Director of Nursing (DON) was completing the Infection Preventionist task. Surveyor notified NHA-A of concerns with the facility not completing surveillance logs for residents on antibiotics, indication of antibiotic use and tracking information. NHA-A acknowledged these concerns. On 4/8/26, at 1:24 PM, QM-D provided Surveyor an Infection Prevention binder dated 2025. QM-D notified Surveyor she had previously asked for documentation from 2025 and was not provided the information or notified the 2025 binder existed prior to today on 4/8/26. Surveyor reviewed the 2025 binder and noted there was no indication for antibiotic use throughout 2025, with the exception of August 2025. On 4/8/26, at 3:26 PM, Surveyor notified NHA-A of concerns with the facility not completing surveillance logs for residents on antibiotics, indication of antibiotic use and tracking information, except for August 2025. NHA-A acknowledged these concerns. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure 1 (R8) of 1 residents who is fed by enteral means received the appropriate treatment and services to prevent complication from enteral feeding.R8 received an enteral feed and a flush was not done prior to starting the feeding per R8's physician order. Findings:The facility policy and procedure titled Enteral Nutrition last approved 1/2026, documents: Policy Statement: Adequate nutritional support through enteral feeding should be provided to residents as ordered.C. The Dietitian, with input from the Physician and Nurse, should:1. Estimate calorie, protein, nutrient and fluid needs.4. Calculate fluids to be provided.The facility policy and procedure titled Enteral Tube Feeding Via Continuous Pump last approved 1/2026, documents, in part: PurposeThe purpose of this procedure is to provide nourishment to the resident who is unable to obtain nourishment orally.Steps in the Procedure.J. When correct tube placement has been verified, flush tubing with at least 30mL tap water (or prescribed amount) .R8 was admitted to the facility on [DATE], with pertinent diagnoses that include dysphagia (difficulty swallowing), aphasia (complete inability or refusal to swallow), vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and gastrostomy status (a surgically created opening in the abdomen that connects to the stomach, often for the purpose of feeding or administering medication).R8's Quarterly Minimum Data Set (MDS) with an assessment reference date of 2/13/2026 does not document a Brief Interview for Mental Status assessment. R8 is documented to rarely or never be understood and rarely or never understands others. During the look back period of the MDS, no behaviors were exhibited by R8. R8 is documented on the MDS for tube feeding. R8's average fluid intake per day by IV or tube feeding is documented as 501cc/day or more.R8's physician order dated 2/25/25 documents: Flush enteral tube with 150 mls water before and after each feeding - four times a day.On 04/09/2026, at 10:55 AM, Surveyor observed Registered Nurse (RN)-H prepare and administer R8's enteral tube feed. After the preparation steps were completed, RN-H attached the tube feeding line to the peg-tube. Surveyor asked if R8 gets a flush before the feeding is started and RN-H replied R8 gets flushes after medications and after feedings.On 04/09/2026, at 11:06 AM, Surveyor interviewed RN-G about when R8 should be receiving flushes. Per RN-G, R8 is supposed to get 150ml of water before and after the feeding. RN-G read the order to Surveyor. Surveyor let RN-G know that RN-H did not give R8 a flush before starting the feeding and when asked stated it is done after feeding and medications are given. Surveyor stated this is a concern. RN-G was going to follow up with RN-H immediately.On 04/09/2026, at 11:11 AM, Surveyor informed Nursing Home Administrator (NHA)-A that the tube feed set up was observed and RN-H did not flush before the feed was started and told Surveyor the flush is done after feed and after meds.No additional information was provided why the physician ordered flush was not done prior to starting the feeding for R8.

Based on interview and record review, the facility did not ensure that 3 (R5, R8 and R9) of 4 residents reviewed for transfers or discharges received the proper written notice of transfer, written bed hold policy with reserve bed payment identified and that proper notification was sent to the State Long-Term Care Ombudsman. * R5 was transferred to the hospital on 9/14/25 and 10/20/25, for evaluation due to a change in condition with no evidence of written bed hold notice and transfer notice provided to R5. The State Ombudsman was not sent a copy of the notices. * R8 was transferred and admitted to the hospital on [DATE], while residing in the facility and evidence was not provided that R8 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold, including reserve bed payment. * R9 was transferred and admitted to the hospital on [DATE], while residing in the facility and evidence was not provided that R9 or their representative were notified in writing of the reason for the transfer/discharge to the hospital. The Ombudsman was not notified of R9's transfer to the hospital. Findings include: The facility's policy titled Bed Holds and Returns, dated 12/2016, last revised 12/2017, documents: At the time of transfer for hospitalization or therapeutic leaves, the nursing facility must provide to the residents or resident representatives written notice which specifies the duration for the bed hold. Prior to a transfer, written information will be given to the residents and the resident representatives that explains in detail: The duration of the bed hold; The reserve bed payment policy as indicated by the state plan; and The details of the transfer (per the Notice of Transfer). The facility's policy titled Transfer or Discharge Notice, dated 12/2016, last revised 06/2020, documents the following: A resident and/or his/her representative will be given a 30-day advance notice of an impending transfer or discharge from our community. A copy of the notice will be sent to the office of the state long term care ombudsman. 1.) R5 was admitted to the facility on [DATE], with a diagnoses including chronic kidney disease (damaged kidneys that are unable to filter blood, waste and excess fluid), Heart Failure (heart muscle is too week to pump) and Type 2 Diabetes (the body resists insulin or fails to produce enough insulin resulting in elevated blood sugar levels). R5's Electronic Medical Record (EMR) documents R5 was transferred to the hospital on 9/14/25 and 10/20/25, for evaluation due to a change in condition. There is no documentation that R5 that was provided a written copy of transfer notice or bed hold rate for R5's hospitalization on 9/14/25 and 10/20/25. Surveyor notes the State Ombudsman was not sent a copy of the notices. On 4/9/26, at 12:06 PM, Surveyor interviewed Social Worker (SW)-O who stated she just started working at the facility recently and started doing bed holds at the facility and has completed one bed hold to dated. SW-O stated someone else was completing bed holds prior to her working at the facility. SW-O stated she has not received training to complete the transfer notices for residents. SW-O stated the facility is not doing notifications of discharges to the State Ombudsman yet. On 4/9/26, at 12:29 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated no paperwork is completed that is shared with the family prior to sending a resident out with a change in condition or discharge. LPN-F stated the nurses will call the managers and Director of Nursing (DON) with any residents experiencing a change in condition or discharge. On 4/8/26, at 3:33 PM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns that the facility did not provide R5 bed hold notices or transfers on 9/14/25 and 10/20/25. Surveyor notified NHA-A of concerns with the State Ombudsman not being notified of transfers on 9/14/25 and 10/20/25 for R5. NHA-A acknowledged these concerns. No additional information was provided. 2.) R8 was admitted to the facility on [DATE], with pertinent diagnoses that include dysphagia (difficulty swallowing), aphasia (complete inability or refusal to swallow), vascular dementia (a type of cognitive decline caused by damage to the blood vessels in the brain), type 2 diabetes mellitus (happens when the body cannot use insulin correctly and sugar builds up in the blood), and gastrostomy status (a surgically created opening in the abdomen that connects to the stomach, often for the purpose of feeding or administering medication). R8's Quarterly Minimum Data Set (MDS) with an assessment reference date of 2/13/2026 does not document a Brief Interview for Mental Status assessment. R8 is documented to rarely or never be understood and rarely or never understands others. During the look back period of the MDS no behaviors were exhibited by R8. R8 is documented on the MDS for tube feeding. R8's average fluid intake per day by IV or tube feeding is documented as 501cc/day or more. R8's Electronic Medical Record (EMR) documents R8 was transferred to the hospital on [DATE] for evaluation due to a change in condition. There is no documentation that R8 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold, including reserve bed payment. On 4/7/2026 and 4/8/2026, Surveyor requested bed hold and transfer documents for R8 from 11/12/2025 when R8 was admitted to the hospital. On 4/9/2026, at 12:06 PM, Surveyor interviewed Social Worker (SW)-O who started working at the facility at the end of February. SW-O just started doing bed hold notices. SW-O has completed one bed hold notice to date. SW-O stated someone else was completing bed hold notices before. SW-O stated has not received training to complete the transfer notices for residents yet. SW-O stated they are not doing notifications of discharges to the State Ombudsman yet. On 4/9/2026, at 12:29 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated no paperwork is completed that is shared with the family when sending a resident out with a change in condition or discharge. LPN-F stated the nurses will call the family to update when the resident is experiencing a change in condition. On 4/8/2026, at 3:00 PM, during the end of day meeting, Surveyor notified Nursing Home Administrator (NHA)-A of concern that the facility did not provide R8 or their representative the required bed hold or transfer notices on 11/12/2025. No additional information regarding bed hold or transfer notices was provided. 3.) R9 was admitted to the facility on [DATE] with pertinent diagnoses that include chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed), bipolar disorder (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), anxiety disorder (persistent, excessive fear or worry in situations that are not threatening), chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months), and nicotine dependence (a chronic, relapsing condition characterized by a compulsive need to use nicotine, resulting from physical and psychological addiction). R9's Comprehensive Minimum Data Set (MDS) with an assessment reference date of 2/25/2026 documents R9 had a Brief Interview for Mental Status score of 15 indicating that R9 is cognitively intact. R9 is documented to be understood and understands others. During the look back period of the MDS no behaviors were exhibited by R9. R9 is documented on the MDS as using oxygen. R9 is coded for the question of current tobacco use as no. R9's Electronic Medical Record (EMR) documents R9 was transferred to the hospital on [DATE] for evaluation due to a change in condition. There is no documentation that R9 or their representative were notified in writing of the reason for the transfer/discharge to the hospital. On 4/7/2026, Surveyor requested bed hold and transfer documents for R9 from 12/29/2025 when R9 was admitted to the hospital. Surveyor was given the Franciscan Place Bedhold Policy document dated 12/28/25 given Verbal to whom is not documented. Surveyor requested documentation of the December transfer/discharge residents being provided to the state ombudsman and received none. On 4/9/2026, at 12:06 PM, Surveyor interviewed Social Worker (SW)-O who started working at the facility at the end of February. SW-O just started doing bed hold notices. SW-O has completed one bed hold notice to date. SW-O stated someone else was completing bed hold notices before. SW-O stated has not received training to complete the transfer notices for residents yet. SW-O stated they are not doing notifications of discharges to the State Ombudsman yet. On 4/9/2026, at 12:29 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated no paperwork is completed that is shared with the family when sending a resident out with a change in condition or discharge. LPN-F stated the nurses will call the family to update when the resident is experiencing a change in condition. On 4/8/2026, at 3:00 PM, during the end of day meeting, Surveyor notified Nursing Home Administrator (NHA)-A of concern that the facility did not provide R9 or their representative the required transfer notice on 12/29/2025. Surveyor notified NHA-A of concern that the State Ombudsman was not notified of R9's transfer on 12/29/2025 to the hospital. No additional information regarding bed hold or transfer notices was provided.

Based on observation, interview, and record review, the facility did not ensure that a resident who is unable to carry out activities of daily living receive the necessary services to maintain good nutrition and assistance with meals for 1 of 15 (R1) residents observed during meals.R1's meal tray was not set up and R1 was not positioned upright to eat and R1 was not provided assistance with meals per R1's plan of care.Findings include:R1 admitted to the facility on [DATE] and has diagnoses that include progressive Multiple Sclerosis, quadriplegia, neuromuscular dysfunction of bladder, sepsis, hypertension, acute respiratory failure, history of pulmonary embolism, Gastroesophageal Reflux Disease, kidney calculus, obsessive compulsive disorder, kidney failure, pressure injuries stage 3, trigeminal neuralgia, adjustment disorder with mixed anxiety and depressed mood, Irritable Bowel Syndrome and anemia. The facility policy titled Assistance with meals revised 1/2025 documents: It is the policy of (facility) that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. A. Dining room residents:1. All residents are encouraged to eat in the dining room for socialization.4. Residents who require assistance with eating should be provided with self-help devices and/or provided help as needed.B. Room bound residents:1. Nursing associates should be responsible for delivering food trays to the residents' room.4. Resident's place setting should be prepared by nursing associates to enable the resident to consume food served.C. Room bound residents who must be fed:1. Nursing associates should be responsible for delivering food trays to the residents' room.2. Nursing services should be responsible for feeding the resident while the food is hot.3. Unless prohibited by medical condition, resident requiring active assistance to eat should be fed in a congregate setting.R1's Quarterly Minimal Data Set (MDS) dated [DATE] documents: Eating - the ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident: Substantial/maximal assistance - helper does more than half of the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R1's Activity of Daily Living (ADL) Functional/Rehab Potential Care Plan dated 3/9/26 documents: Needs assistance with daily ADL care due to impaired mobility. Eating: I need extensive assistance with 1-person staff support.R1's Certified Nursing Assistant (CNA) worksheet for Tuesday 4/7/26 all shifts documents: Eating - I need extensive assistance with 1 person staff support. Encourage eating in Broda chair and eating slowly. Provide assist at meals. Ensure (R1) has a good setup at meals and is positioned properly. On 4/6/26 at 9:59 AM, Surveyor observed R1 lying in bed with the head of bed elevated maybe 30 degrees but not positioned upright to eat. R1's breakfast tray was on the tray table in front of him and he was able to reach only some of the food and was eating independently with his left hand.On 4/8/26 at 9:05 AM, Surveyor observed R1 in bed with his breakfast tray on the tray table in front of him. R1 was not positioned upright to eat. Surveyor observed R1 struggling to reach items on the tray. Surveyor asked if he needed help. R1 stated, I can eat myself, but can you open the sugar for me. Surveyor observed R1's tray had not been set up for him to eat. The sugar packet was not opened/not placed in the hot cereal, the milk had a plastic cover on top, and the silverware was not within reach. R1 stated, I can't eat like this.Surveyor left the room to look for staff assistance. Surveyor advised CNA-I that R1 is asking for assistance opening sugar and can't reach the silverware. CNA-I stated, They didn't set him up? He needs to be set up to eat. CNA-I entered R1's room and said, I'm sorry, let me help you, you can't eat like this. CNA-I raised the head of the bed, opened the sugar, mixed it in the hot cereal and placed the tray in front of him with the utensils within reach. CNA-I stated, There's an agency aid working today, maybe she didn't know he needed to be set up. CNA-I told Surveyor she is contract staff working at the facility from March through May and she usually gets R1 up to eat, because he eats better in the chair, but he wanted to stay in bed this morning. Surveyor asked if the facility has care cards to review so that staff or agency staff know how to care for a resident. CNA-I showed Surveyor the binder on the unit containing the CNA worksheets. On 4/9/26 at 10:28 AM, Nursing Home Administrator (NHA)-A was advised of the above observations and concern R1 was not positioned upright to eat, his tray was not set up and the care plan indicates he needs extensive 1 person assistance with eating. No additional information was provided.

Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan for the followed for 1 (R10) of 5 residents reviewed.R10's physician order for daily weights every day and to notify provider if greater than 3 pound change in one day or greater than 5 pounds in a week was not implemented per R10's physicians order. occur. Findings include:The facility policy and procedure for the weight monitoring effective 07/2025, documents in part: Policy: It is the policy of [facility name] that appropriate nutritional care shall be provided to residents who have significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days.Procedure:A nursing or nutrition associate should notify the health care provider of any significant weight change that is unexplainable or in which the RD has requested a nutritional intervention.R10 was admitted to the facility on [DATE] with pertinent diagnoses that include Alzheimer's, chronic obstructive pulmonary disease, Hypertensive heart disease with heart failure, chronic diastolic (congestive) heart failure, schizophrenia, unspecified vascular dementia severe with agitation.R10's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/13/26, documents a Brief Interview for Mental Status (BIMS) score of 02, indicating that R10 has severe cognitive impairment.R10's physician order documents: Daily weights d/t CHF diagnosis. Every day notify provider if greater than 3 pound change in 1 day or greater than 5 pound change in a week, nurse to call [facility providers name] will be in contact with [physician provider name].Surveyor reviewed R10's Treatment Administration Record (TAR) for February, March and April 2026. Surveyor noted that R10's TAR documented missing weights for the following dates:February 2026: 4,10,12,17,19,25March 2026: 3,4,14,16,19,20,23,24,26,28April 2026: 4, 6,7.R10's progress note dated 2/20/26 documents: Obtain daily weights until further review by NP (nurse practitioner) for edema and fluid overload.On 4/9/26 at 10:30 AM, Surveyor asked CNA (Certified Nursing Assistant)-K regarding R10's missing weights from 4/5/26 to 4/7/26. CNA-K stated that she was not at the facility working on 4/6/26 and that on 4/7/26, CNA-K was working on both sides of the unit so R10's weight was not taken.Surveyor asked CNA-K if CNA-K notified the nurse that R10's weight was not taken. CNA-K informed Surveyor that CNA-K notified the nurse on R10's weight that R10's weight was not taken.On 4/9/26 at 1:18 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the above findings. NHA-A informed Surveyor that the lack of weight was identified and that education was provided to staff, but that NHA-A could not provide supporting documentation to Surveyor as to when the education took place or who was in attendance.No additional information was provided.

Based on interview and record review, the facility did not ensure residents received adequate supervision to prevent accidents for 1 (R9) of 1 residents reviewed for smoking.*R9 smokes and the facility lacked ongoing smoking supervision and assessments or a cessation program.The facility's policy and procedure titled, Smoking Policy-Residents, last revised 10/2025 documents in part: Policy Statement- This policy is established to maintain safe resident smoking practices in accordance with the fire safety regulations. Residents who wish to smoke on the community premises should comply with the requirements in the policy. Smoking is defined as a practice in which a substance, most commonly tobacco, is burned and the smoke is tasted or inhaled. This policy applies to the use of all smoking materials, consumed by cigarette, pipe, vaporizers, electronic cigarettes and other vapor devices.F. The resident should be evaluated on admission to determine smoking preference. If the resident prefers to smoke, the evaluation will include:1. Current level of tobacco consumption;2. Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe, etc.);3. Desire to quit smoking, if a current smoker; and4. The resident's capabilities and deficits to determine whether or not supervision is required while smoking (per a completed Safe Smoking Evaluation)G. The associates should consult with the Attending Physician and/or Nursing Leadership to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation.I. Smoking-related privileges, restrictions, and concerns are noted on the care plan.K. Smoking is not permitted while oxygen is in use.L. Resident agrees to the level of associate supervision indicated on the Safe Smoking Evaluation.R9 was admitted to the facility on [DATE] with pertinent diagnoses that include chronic obstructive pulmonary disease (lungs become inflamed, damaged and narrowed), bipolar disorder (mental health condition causes extreme mood swings that include emotional highs, called mania, and lows, known as depression), anxiety disorder (persistent, excessive fear or worry in situations that are not threatening), chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months), and nicotine dependence (a chronic, relapsing condition characterized by a compulsive need to use nicotine, resulting from physical and psychological addiction).R9's Comprehensive Minimum Data Set (MDS) with an assessment reference date of 2/25/26 documents R9 had a Brief Interview for Mental Status score of 15, indicating that R9 is cognitively intact. R9 is documented to be understood and understands others. During the look back period of the MDS, no behaviors were exhibited by R9. R9 is documented on the MDS as using oxygen. R9 is coded for the question of current tobacco use as no.R9's care plan Safety R9 is at risk for injury related to smoking started on 12/31/2025, has the following intervention: R9 seen outside smoking a cigarette and was educated on smoking cessation and the risks of continuing to smoke.R9's progress note written on 1/2/2026, at 11:06am, documents: at 0700 this am resident was found in bed smoking a cigarette, O2 (oxygen) on. Cigarette was extinguished, and removed from room with lighter, resident educated on the danger to her and others in facility of smoking with O2, DON (Director of Nursing) notified.Surveyor noted the care plan only addresses when R9 was seen smoking outside, there were no interventions to protect R9 from the safety concerns of smoking in bed and being on oxygen.R9's Smoking Assessment form was triggered on 3/1/26, this was not completed, nor on any other dates. Surveyor noted R9 admitted with the diagnosis of nicotine dependence and there is no documentation of a cessation program or safety assessments being completed.On 04/09/2026, at 7:54 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-I and was told that R9 was not a smoker. R9 can't get out of bed to smoke.On 04/09/2026, at 8:14 AM, Surveyor interviewed Registered Nurse (RN)-G who stated R9 doesn't go outside to smoke. Surveyor asked why after R9 smoked in R9's room, in bed with oxygen on, wasn't the incident added to the care plan. RN-G replied that the manager managing 1st floor is no longer here and that RN-G doesn't know why it was not added to the care plan. Surveyor asked what RN-G's expectation would be regarding R9s smoking. RN-G informed Surveyor that RN-G was told they took R9's cigarettes and educated R9 when it happened. RN-G would have followed up with frequent rounding and care planned the incident.On 04/09/2026, at 10:45 AM, Surveyor interviewed R9 and was told when I lit up, I wasn't even thinking about it. I pulled the pack out of my purse and I took 2 drags. I realized what I was doing and I put out the cigarette. I didn't mean to that do that. Surveyor asked if the facility had offered help for smoking cessation and was told R9 asked for it and nobody followed up. R9 learned to use meditation instead.On 04/09/2026, at 11:11 AM, Surveyor let Nursing Home Administrator (NHA)-A know of concern that R9 was smoking in bed with oxygen on and the lack of follow up from the facility. Surveyor let NHA-A know that R9 would have liked help with cessation and this was not followed up on.No additional information regarding supervision or assessments of R9 and care plan interventions to keep R9 and other residents in the facility safe was provided.

Based on interview and record review, the facility failed to provide pharmaceutical services for 1 (R55) of 15 residents reviewed.R55 was not provided multiple medications per physician orders and not signed out as given on the Medication Administration Record (MAR) dated January 2026 through April 2026.Findings include:The facility's policy titled Medication Administration, dated 6/21/17, documents: Medications will be administered by legally authorized and trained persons in accordance to applicable state, local and federal laws and consistent with accepted standards of practice.R55 was admitted to the facility on [DATE] with diagnoses that include Multiple Sclerosis (MS) (chronic autoimmune disease that attacks the nerve fibers affecting the brain, spinal cord, and optic nerves), Major Depressive Disorder (MDD) (a serious mental health condition characterized by persistent, intense feelings of sadness, worthlessness, and a loss of interest in activities), encephalopathy (damage or dysfunction that alters the brain's structure or function), constipation and chronic pain.R55's Minimum Data Set (MDS) dated [DATE], documents that R55 requires substantial/maximal assistance with toileting, showering, dressing, and rolling left to right. R55 is dependent with transfers and is documented as taking an antianxiety, antidepressant, hypnotic, anticoagulant and anticonvulsant. R55 was assessed as having a Brief Interview for Mental Status (BIMS) score of 15, indicating that R55 is cognitively intact.R55's care plan documents:R55 has a mood state problem related to diagnosis of depression, multiple sclerosis and unspecified mood effective disorder.Interventions include: Administer medication as ordered and observed for adverse side effects. If adverse side effects are noted, update MD with changes (start date 12/26/25); Observe effectiveness of mood enhancement medication (start date 12/26/25).R55's care plan documents:R55 has multiple sclerosis and has the potential for complications. Interventions include: Administer medications for symptom management or to treat disease progression. Observe for side effects and inform physician of concerns (start date 12/26/25).Surveyor reviewed R55's Medication Administration Record (MAR) which documents the following missed medications:January 2026:1/4/26 night shift - Baclofen 20 mg (milligrams) three times daily for muscle spasm1/6/26 night shift - Levothyroxine 100 mcg (micrograms) daily for hypothyroidism1/8/26 PM shift - Sucralfate 1 gram four times daily for acid reflux1/8/26 night shift - Sucralfate 1 gram four times daily for acid reflux1/14/26 AM shift - Clarithromycin 500 milligrams twice daily for H pylori1/26/26 PM shift - Nortriptyline 25 milligrams every 12 hours for polyneuropathy1/26/26 PM shift - Clonazepam 0.5 milligrams twice daily for anxiety and MS.1/26/26 PM shift - Gabapentin 600 milligrams, give two tablets for polyneuropathy.1/26/26 PM shift - Lactobacillus acidophilus 1 capsule every 12 hours.1/26/26 night shift - Sucralfate 1 gram four times daily for acid reflux1/26/26 night shift - Bisacodyl 10 mg for 3 days for constipation1/26/26 night shift - Baclofen 20 mg three times daily for muscle spasm1/27/26 PM shift - Clonazepam 0.5 milligrams twice daily for anxiety and MS.1/27/26 night shift - Bisacodyl 10 mg for 3 days for constipation1/28/26 night shift - Bisacodyl 10 mg for 3 days for constipation1/29/26 AM shift - Acetaminophen 325 mg four times daily for pain1/29/26 AM shift - Paxlovid 150 milligrams Twice daily for five days for COVID1/29/26 PM shift - Combivent inhaler one puff four times daily for congestion1/29/26 PM shift - Mucinex 600 mg every 12 hours for congestion1/29/26 night shift - Levothyroxine 100 mcg daily for hypothyroidism1/30/26 AM shift - Combivent inhaler one puff four times daily for congestion1/30/26 noon shift - Combivent inhaler one puff four times daily for congestion1/31/26 AM shift - Combivent inhaler one puff four times daily for congestion1/31/26 noon shift - Combivent inhaler one puff four times daily for congestionFebruary 2026:2/1/26 noon shift - Combivent inhaler one puff four times daily for congestion2/2/26 noon shift - Combivent inhaler one puff four times daily for congestion2/2/26 AM shift - Fingolimod 0.5 milligrams once daily for MS2/2/26 AM shift - Lactulose 15 milligrams once daily for constipation2/2/26 PM shift - Senna 15 mg twice daily for constipation2/2/26 PM shift - Molnupiravir 200 mg every 12 hours for COVID2/3/26 AM shift - Lactulose 15 milligrams once daily for constipation2/3/26 AM shift - Senna tab 15 mg twice a day for constipation2/3/26 AM shift - Molnupiravir 200 milligrams twice daily for COVID2/6/26 night shift - Acetaminophen 650 milligrams four times daily for pain2/8/26 AM shift - Fingolimod 0.5 milligrams once daily for MS2/10/26 AM shift - Lactobacillus acidophilus 1 capsule every 12 hours.2/10/26 AM shift - Vitamin D3 take 50 micrograms once daily for supplement2/10/26 AM shift - Baclofen 20 mg three times daily for muscle spasm2/10/26 AM shift - Bupropion 150 milligrams once daily for MDD2/10/26 AM shift - Ferrous Sulfate 325 milligrams once daily for anemia2/10/26 AM shift - Vitamin B12, take 1,000 micrograms once daily for supplement2/10/26 AM shift - Protonix 40 milligrams twice daily for acid reflux2/10/26 AM shift - Xarelto 20 mg once daily for Deep Vein Thrombosis (DVT) prophylaxis2/10/26 AM shift - Myrbetriq 25 milligrams daily for overactive bladder2/10/26 AM shift - Nortriptyline 25 milligrams every 12 hours for polyneuropathy2/10/26 AM shift - Cranberry 20 milligrams once daily for UT prevention2/12/26 PM shift - Nortriptyline 25 milligrams every 12 hours for polyneuropathy2/12/26 PM shift - Clonazepam 0.5 milligrams twice daily for anxiety and MS.2/12/26 PM shift - Gabapentin 600 milligrams, give two tablets for polyneuropathy2/12/26 PM shift - Lactobacillus acidophilus 1 capsule every 12 hours.2/12/26 PM shift - Senna tablet twice daily for constipation2/23/26 day shift - Modafinil 200 milligrams twice daily for chronic fatigue2/23/26 PM shift - Nortriptyline 25 milligrams every 12 hours for polyneuropathy2/23/26 PM shift - Clonazepam 0.5 milligrams twice daily for anxiety and MS.2/23/26 PM shift - Lactobacillus acidophilus 1 capsule every 12 hours.2/23/26 PM shift - Gabapentin 600 milligrams, give two tablets for polyneuropathy2/23/26 night shift - Sucralfate 1 gram four times daily for acid reflux2/23/26 night shift - Baclofen 20 mg three times daily for muscle spasm2/27/26 noon shift - Gabapentin 600 milligrams three times a day for polyneuropathy2/27/26 noon shift - Methylphenidate 10 milligrams once daily for fatigue2/27/26 day shift - Sucralfate 1 gram four times daily for acid refluxMarch 2026:3/6/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/7/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/8/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/9/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/9/26 noon shift - Sucralfate 1 gram four times daily for acid reflux3/12/26 noon shift - Gabapentin 600 milligrams, give two tablets for polyneuropathy3/12/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/13/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/29/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/30/26 noon shift - Methylphenidate 10 mg once daily for chronic fatigue3/31/26 PM shift - Modafinil 200 milligrams twice daily for chronic fatigueApril 2026:4/2/26 AM shift - Sucralfate 1 gram four times daily for acid reflux4/2/26 PM shift - Sucralfate 1 gram four times daily for acid reflux4/2/26 night shift - Sucralfate 1 gram four times daily for acid reflux4/3/26 AM shift - Sucralfate 1 gram four times daily for acid reflux4/3/26 PM shift - Sucralfate 1 gram four times daily for acid reflux4/3/26 night shift - Sucralfate 1 gram four times daily for acid reflux4/4/26 AM shift - Sucralfate 1 gram four times daily for acid reflux4/4/26 PM shift - Sucralfate 1 gram four times daily for acid reflux4/4/26 night shift - Sucralfate 1 gram four times daily for acid refluxOn 4/6/26, at 11:41 AM, Surveyor interviewed R55 who stated she has multiple missed medications. R55 expressed concerns with missing medications and having chronic diseases that require medications. R55 stated R55 has MS which causes chronic fatigue and will experience increased fatigue if staff do not administer medications as prescribed. R55 also stated R55 was recently hospitalized due to blood clots in the lungs and expressed concern if medications are not administered as prescribed with the history of having blood clots in the lungs.On 4/9/26, at 10:14 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated medications are delivered nightly and placed in the medication cart. LPN-F stated staff can use contingency medications or contact the pharmacy for next day delivery if medications are not available.On 4/8/26, at 3:25 PM, Surveyor notified Nursing Home Administrator (NHA)-A of concerns with R55 having multiple missed medications listed above. NHA-A acknowledged these concerns.No additional information was provided as to why the facility did not provide or administer the above medications to R55 per physician's orders.

Based on observation, interview, and record review, the facility did not ensure that drugs and biologicals used in the facility were be labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 2 of 2 medication carts reviewed.Medication carts contained insulin that was not dated when opened and/or was expired.Findings include:The facility policy titled Insulin Administration effective [DATE] documents:Insulin is a high-risk drug and warrants additional precautions for the safe and effective administration. Insulin administration is performed by licensed nurses. Facility nursing procedures supersede this procedure if present.6. Follow the manufacturer's instruction for storage and expiration. Ensure that the opened date is documented on the vial or pen.7. Check the expiration date prior to administration to ensure it is within the usage date. Expired insulin should be immediately discarded. Vials and pens without an open date recorded should be discarded.On [DATE] at 9:30 AM, Surveyor observed the 1st floor medication cart. In the top drawer, Surveyor located the following:2 Lantus insulin vials belonging to R16 which were open and used. The label on each vial documented: Expires 28 days after opening. One vial was dated 1/16 and the other was dated 1/17, indicating both vials were past the expiration date.On [DATE] at 10:34 AM, Surveyor observed the 2nd floor medication cart. In the top drawer, Surveyor located the following:A Humalog Kwik pen in a bag belonging to R5 which was open and used but not dated when opened. The label documented: Expires 28 days after opening.A Novolog insulin vial belonging to R25 which was open and used but not dated when opened. The label documented: Throw away any medication that remains 28 days after first use.Nursing staff were advised of the above insulin that was not dated and were expired.On [DATE] at 11:48 AM, Nursing Home Administrator (NHA)-A was advised of concern regarding residents' insulin that was not dated when opened and were expired. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure a resident's hospice notes were readily available for communication and collaboration of care in accordance with professional standards of practice for 1 (R11) of 1 residents reviewed for hospice services.Hospice visit notes were not updated in R11's medical record or in R11's hospice binder.Findings include:The facility's policy and procedure titled, Hospice Program, last approved 12/2025, documents, in part: Policy Interpretation and Implementation.D. When a resident participates in the hospice program, a coordinated plan of care between the community, hospice agency and resident/resident representative will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plan shall be revised and updated as necessary to reflect the resident's current status.The contract titled Nursing Facility Services Agreement (Basic, Respite and General Inpatient Care for Hospice Patients) signed on 1/25/2021, documents, in part: 1.8 Coordination of Care.Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice Patients are met 24 hours per day.R11 was admitted to the facility on [DATE], with pertinent diagnoses that include adjustment disorder with depressed mood (a strong emotional or behavioral reaction to stress or trauma), cognitive communication deficit (difficulty with communication that stems from impaired thinking skills, such as memory, attention, and problem-solving, rather than from physical speech problems), vascular dementia with mood disturbance (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety disorder (persistent, excessive fear or worry in situations that are not threatening), depression (a mental health condition characterized by persistent sadness, loss of interest or pleasure in activities, and other symptoms that significantly affect daily life), insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep), and chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months).R11's Quarterly Minimum Data Set (MDS) with an assessment reference date of 2/26/26, documents a Brief Interview for Mental Status (BIMS) score of 03, indicating that R11 has severe cognitive impairment. The MDS documents that R11 was assessed to have no behaviors exhibited during the look back period. R11 can make self understood and understands others. R11 was coded as being on hospice services.Surveyor reviewed R11's Hospice communication binder located in the nursing station. In the binder there was: Residential Communication Form dated 2/4/26 completed by a Licensed Practical Nurse, 3/4/26 completed by a home health aide and an additional dated 3/13/26 that looked like the Nurse Practitioner signed. There were also five forms completed by the chaplain with the most recent being 4/6/26.On 04/09/2026, at 8:25 AM, Surveyor interviewed Registered Nurse (RN)-G about the process of hospice staff and facility staff exchanging resident information. Per RN-G, the hospice staff check in with the floor nurse before they leave. Surveyor asked if the floor nurse should make a progress note to document the visit and was told no, hospice staff should be writing in the binder on the unit. Surveyor explained the lack of documentation in the binder.On 04/09/2026, at 11:11 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about the concern that Surveyor reviewed the hospice binder and there is a lack of communication when hospice staff visit.No additional information regarding why the facility did not have an effective system of communication between hospice staff and facility staff or why R11's hospice visit notes were not being updated in R11's medical record or in R11's hospice binder was provided.

Based on observation, interview, and record review, the facility did not ensure residents with pressure injuries or at risk for pressure injury development received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 1 (R12) of 4 residents reviewed for pressure injuries.* R12 was admitted to the facility with a sling to the left arm. There is no evidence of monitoring the skin under the sling and R12 developed an unstageable pressure injury that declined to a stage 4 pressure injury to R12's left elbow with exposed hardware. Interventions were not implemented timely to prevent R12's pressure injury from developing/ declining.Findings include:The facility policy titled Prevention of Pressure Injuries Protocol last approved 1/2026 documents: Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. General Guidelines: .C. Pressure can also come from splints, casts, bandages, and wrinkles in bed linen. If pressure injury are [sic] not treated when discovered, they quickly get larger, become very painful for the resident, and often become infected.J. Routinely assess and document the condition of the resident's skin per community wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury to the supervisor. Assessment: .D. Because a resident at risk can develop a pressure injury within 1 to 4 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches and interventions. Interventions and Preventative Measures: Residents with Risk Factors: .4. Place resident on a minimum of every 2 hour check/ reposition routine, complete more frequently if needed.7. Monitor the placement of splints, immobilizers, and casts to ensure they are not placing friction on the resident's skin.13. Protect bony prominences as needed.Additional Factors that Indicate Residents at Risk:A. Impaired/ decreased mobility and decreased functional ability .F. Cognitive impairment .The facility policy titled Pressure Injury Assessment/ Treatment last approved 1/2026 documents: Purpose: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries. General Guidelines: The pressure injury treatment program should focus on the following strategies: 1. Evaluation of the residents and the current status of pressure injuries2. Observe currently used support surfaces and/or pressure relieving devices, initiate as needed. 3. Resolution of current Pressure injuries and prevention of additional pressure injuries. Interventions/ Care Strategies: A. Eliminate or reduce source of pressure using positioning techniques .C. Preventative measures to reduce the risk of further tissue loss .G. Managing system issues (edema, venous insufficiency, etc.) .R12 was admitted to the facility on [DATE] with the following diagnoses left humerus fracture, UTI, Parkinson's disease, Dementia, severe protein-calorie malnutrition, cachexia (wasting syndrome/ involuntary weight loss), cognitive communication deficit, and weakness.R12's admission Minimal Data Set (MDS) dated [DATE] indicated R12 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0 and the facility assessed R12 being dependent on 1 staff member for repositioning, dressing, and hygiene care, R12 is dependent on 2 staff for transferring with gait belt and pivot with wheeled walker, and toileting/ toileting hygiene.R12 was admitted with a deep tissue injury to the coccyx that healed on 3/31/2026 and a fracture to the left humerus and an order for a sling to the left arm. R12 was assessed on 3/12/2026 to be high risk for pressure injury development with a Braden score of 10. R12's weight was documented as 77 pounds.R12's at risk for pressure ulcers and other skin related injuries care [plan was initiated on 3/12/2026 with the following interventions:- Braden scare to be completed- Do not use excess pads- Observe skin for redness and breakdown during routine care- use pressure relieving devices, cushion on wheelchair and off of heels as indicated- Follow community skin care protocol- Treatments, as indicated, see physician order sheet- Low air loss mattress at correct setting and functioning properly (initiated 3/17/2026)- Prevlon boots on when in bed (Initiated 3/19/2026)R12's fracture other than hip/ vertebra: (R12) has left humerus fracture care plan was initiated on 3/15/2026 with the following interventions:- Make sure (R12) is eating to ensure (R12's) fracture heals. If (R12) is not eating well, contact doctor about nutritional status. Provide snacks of (R12's) choice, including protein.- Administer pain medication as ordered by doctor. Notify doctor if pain medication is ineffective.- Make sure to administer pain medications at least 30 minutes prior to therapy appointments so pain is well controlled and able to progress with therapy.- Make sure (R12) has enough time to rest after therapy sessions.- Assist (R12) with following doctor orders regarding weight bearing status- (R12) is NON-weight bearing to left upper extremity (LUE).- Make sure (R12's) call light is in easy reach and answer it promptly.Surveyor noted there are no interventions regarding R12 left arm sling or monitoring of skin under the sling for R12's left arm. Surveyor noted interventions do not include repositioning of R12 or protection of R12's left arm or if R12's sling can come off at any time. Surveyor reviewed R12's physician orders and noted the following:1. Weekly skin check sheets on Thursday and Sunday (Start: 3/20/2026)2. Sling to arm every shift for fracture (Start 4/1/2026)Surveyor noted there is not an order to monitor R12's skin under the sling for R12's left arm fracture daily/ every shift to monitor R12's skin or if R12 is to wear sling at all times or if it can come off. Surveyor reviewed R12's progress notes and noted nursing documenting R12's sling on left arm in place, however, Surveyor notes nursing did not document if skin was intact under the sling or if the R12's skin was checked under R12's sling on the left arm. On 3/31/2026 R12's wound medical doctor (MD)-C assessment documented:- NEW CONCERN: Left Elbow Unstageable pressure injury- 3.0 X 1.0 X 0.1 (Length X width X depth)- 100% eschar (thick, dry, black layer of dead tissue (necrosis) that forms over wounds)- Treatment: wash area with normal saline, skin prep to area followed by foam border dressing. Change daily and as needed.- An X-ray was ordered for R12's left elbow to rule out osteomyelitis (infection to the elbow bone)R12's impaired skin integrity related to unstageable necrosis pressure injury to left elbow was initiated on 3/31/2026 with the following interventions:- Will follow wound MD- Will follow all treatment orders- Update nurse practitioner (NP)/ MD will [sic] concerns. worsening of areas, or signs/ symptoms of infection- Keep skin clean and dry- low air loss mattress at correct setting and functioning properly- Prevlon boots while in bed- Turn and reposition with rounds and as needed (PRN)- Offload elbowsOn 4/1/2026- R12's left elbow x-ray results document:- Osteoarthritis of left elbow- No acute fracture or dislocation- No osteomyelitisOn 4/7/2026 wound M-C assessment documented:- Unstageable pressure injury to left elbow exacerbated and is not a Stage 4 pressure injury with protrusion of prosthetic.- 4.0 X 2.0 X 0.1- 100% necrotic tissue, moderate serous (thin, clear, watery drainage- part of the healing process) drainage.- Area was debrided (medical removal of dead, damaged, or infected tissue/ biofilm from a wound to promote healing)-Treatment: Clean with normal saline, dry area, apply calcium alginate, followed by border foam dressing three times a week and as needed.- Continue current measures to prevent further skin breakdown: New: apply left elbow protector, Monitor skin under left arm sling for redness or breakdown.R12's impaired skin integrity related to unstageable necrosis pressure injury to left elbow was revised on 4/7/2026 with the following interventions:- Ensure left elbow protector is on- Monitor L arm under sling every (Q) shift for skin breakdownSurveyor noted monitoring of R12's left arm under sling was not initiated or documented as being completed until 4/7/2026.On 4/8/2023, at 12:03 PM, Surveyor observed R12 being assisted with lunch in the dining room. R12 had a blue fabric sling on the left arm. Surveyor was unable to observe if R12 was wearing an elbow protector on the left elbow.On 4/8/2026, at 12:03 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J who stated CNA-J often cares for R12. CNA-J was not sure if R12's left arm sling could come off and was told to make sure R12 had the left arm sling on. Surveyor asked CNA-J if the sling comes off during baths/ showers. CNA-J replied giving R12 a bed bath and did not remove the sling and that nursing would do the skin assessments. CNA-J stated if something was observed that was concerning CNA-J would tell the nurse, however CNA-J did not recall seeing anything concerning but sis not remove R12's left arm sling during the bed bath and was not sure if the nurse assessed R12's skin under the sling or not. Surveyor asked CNA-J if R12's left elbow protector was applied when getting R12 ready for the day. CNA-J was not aware of R12 having anything other than a treatment and sling applied to R12's left arm/ elbow area.On 4/8/2025, at 1:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who stated LPN-L assess R12's left arm prior to putting R12's sling on but could not speak for other nursing employees. Surveyor asked LPN-L how staff are aware that monitoring needs to be completed for R12's left arm. LPN-L stated usually it would be in the care plan and sign out on the medication/ treatment administration record (MAR/TAR) but for R12 it is not, LPN-L stated from experience and knowledge that skin gets checked under slings. LPN-L stated R12 had an area on the coccyx that was getting treatments and was not aware of any concerns to R12's left elbow until a treatment was ordered. LPN-L could not recall any concerns on R12's elbow during assessments. Surveyor asked LPN-L if R12 has an elbow protector on the left arm. LPN-L was not aware of an elbow protector for R12 but would look into it. Surveyor asked LPN-L who initiates or revises care plans. LPN-L stated being a LPN, LPN-L does not revise or initiate care plans, but nursing management usually takes care of the care plans.On 4/8/2026, at 1:50 PM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-G who stated RNUM-G completes wound rounds with wound MD-C on Tuesdays. RNUM-C stated will do wound assessments for residents that are admitted to the facility or if a new concern is noted if in the facility at the time, otherwise nursing will do assessments and RNUM-G will follow up. RNUM-G stated nursing staff can initiate, or revise care plans and the interdisciplinary team (IDT) gets together every morning, Monday through Friday so discuss new/ ongoing concerns for residents, at that time care plans are reviewed and initiated/ revised accordingly. Surveyor asked if residents come in with slings or braces what is expected for monitoring. RNUM-G stated monitoring of the skin under the appliance should be monitored for breakdown. Surveyor shared concern R12 did not have interventions implemented to monitor skin under R12's sling to the left arm. RNUM-G confirmed interventions were not implemented to monitor or prevent R12's left arm from breakdown under the sling. RNUM-G stated monitoring of skin under R12's sling on the left arm should have been added to the care plan and MAR/TAR for staff to document completion. RNUM-G stated the pressure injury to R12's left elbow was found by accident during wound rounds on 3/31/2026 with wound MD-C, when RNUM-G rolled R12 onto her side so wound MD-C could assess R12's coccyx pressure injury, (which had resolved on 3/31/2026), wound MD-C and RNUM-G noted R12's left elbow came out of the sling a little bit and both noted a black area to R12's left elbow. RNUM-G stated RNUM-G was not made aware or notified of any concerns to R12's left elbow area until RNUM-G observed it during wound cares on 3/31/2026. Surveyor asked how R12 could have developed the area on R12's left elbow. RNUM-G stated was most likely caused by pressure to that area, on 4/7/2026 when RNUM-G and wound MD-C assessed R12's elbow, both were surprised to see hardware on the left elbow on 4/7/2026, when the x-ray results to the left elbow were received, there was no mention of hardware to that area. RNUM-G stated interventions were put into place for a left elbow protector and to monitor the skin under the sling to R12's left arm, but those interventions should have been implemented and followed up that they were being completed prior to 4/7/2026. On 4/8/2026, at 3:03 PM, Surveyor interviewed wound MD-C who stated R12's left elbow pressure injury was first noted on 3/31/2026 during R12's wound assessment to the coccyx, which is now healed. Wound MD-C stated R12's left elbow was noted to have dry eschar to the tip of the elbow so wound MD-C ordered skin prep daily with foam border dressing for protection and also ordered an x-ray to rule out osteomyelitis. Wound MD-C stated the x-ray came back negative on 4/1/2026 and when R12's left elbow was assessed on 4/7/2026 the eschar was loosed a little so wound MD-C debrided the elbow area and that is when metal hardware was noted on the elbow. Wound MD-C was surprised because there was no mention of hardware to the left elbow on R12's x-ray results from 4/1/2026. Surveyor asked how the pressure injury could develop on R12's left elbow. Wound-MD stated pressure to the area could develop within 2 hours if there was no pressure relief. Wound-MD stated R12 is very thin, frail, and not able to move without assistance so something could develop rather quickly. Wound MD-C stated the pressure injury to R12's left elbow could also be secondary to the hardware resulting in medical induces pressure especially from the swelling that occurred from R12's left humerus fracture, hardware and swelling induced pressure versus pressure to that area, uncertain at this time. On 4/8/2026, at 3:10PM, Surveyor asked Nursing Home Administrator (NHA)-A what the expectations/ process was for monitoring skin of a resident that has orders for a splint or brace. NHA-A stated to follow physician orders, if no orders were received then nursing staff would be expected to call the physician for orders such as monitoring of area, if it can be removed, therapy orders, etc Surveyor asked NHA-A who would be overseeing if care plan initiation and revision were being completed with appropriate interventions. NHA-A stated on admission or new concern development, care plans would be initiated or revised and Monday through Friday the IDT meets to discuss to and ongoing concerns and review care plans at that time. Surveyors share concerns with NHA-A, R12 was admitted to the facility 3/12/2026 with sling to the left arm and there were no care plan interventions for the skin on R12's left arm to be monitored under the sling daily/ each shift and R12 developed an unstageable pressure injury to the left elbow on 3/31/2026 that declined to a stage 4 with exposed metal hardware on 4/7/2026. Surveyor shared concerns regarding no revisions were made to the care plan until 4/7/2026 to monitor the skin under R12's sling on the left arm. No additional information was provided.

Based on interview and record review, the facility did not ensure medical records contained documentation related to COVID-19 (Coronavirus disease 2019) immunizations for 1 (R10) of 5 residents reviewed for immunizations. R10's Electronic Medical Record (EMR) does not contain any documentation as to whether R10 was offered, received or declined the COVID-19 immunization. Findings include: The facility's policy titled COVID-19, dated 06/2020, last revised 06/2025 documents: Residents will be offered the COVID-19 vaccination to remain up to date with the most current Center for Disease Control (CDC) vaccination schedule. If a resident/resident legal representative wishes to receive the COVID-19 vaccination, the facility will obtain the consent and provide the vaccination to the resident as soon as it is available in alignment with the vaccination schedule. R10 was admitted to the facility on [DATE] with diagnoses that includes Alzheimer's Disease (progressive irreversible brain disorder that slowly destroys memory and thinking skills), Chronic Obstructive Pulmonary Disease (COPD) (lung disease that makes breathing difficult causing airflow obstruction) and Urinary Tract Infection (UTI) (bladder infection). Surveyor reviewed R10's EMR and was unable to locate whether R10 was offered, received or declined the COVID-19 immunization in 2023, 2024, 2025 or 2026. Surveyor noted R10 received the COVID-19 immunization on 10/29/2021. On 4/8/26, at 10:43 AM, Surveyor interviewed Quality Management (QM)-D who stated immunizations including COVID-19 are offered to the resident upon admission and during the flu season. QM-D stated documentation is scanned in the EMR if a resident declines the COVID-19 immunization. Surveyor reviewed R10's COVID-19 immunization record and noted R10 last received the COVID-19 immunization on 10/29/2021. QM-D stated the facility noted concerns with the previous infection control program and residents not receiving or being offered the COVID-19 immunization. QM-D stated the facility started a Performance Improvement Plan (PIP) at the end of February 2026/beginning of March 2026. QM-D stated there were staffing turnovers and challenges that contributed to R10 not receiving or being offered the COVID-19 immunization. On 4/8/26, at 11:11 AM, Surveyor informed Nursing Home Administrator (NHA)-A of concerns with R10 not receiving or being offered the COVID-19 immunization. NHA-A acknowledged this concern. On 4/8/26, at 1:24 PM, QM-D notified Surveyor, that QM-D looked into R10's EMR and was unable to locate documentation that R10 was offered or declined the COVID-19 immunization. Surveyor notified QM-D of concerns with R10 not receiving or being offered the COVID-19 immunization. QM-D acknowledge this concern. No additional information was provided.

Based on interview and record review, the facility did not ensure 1 (R10) of 5 residents reviewed were offered/administered the influenza vaccination. R10's Electronic Medical Record (EMR) does not contain any documentation as to whether R10 was offered, received or declined the influenza immunization. Findings include: The facility's policy titled Clinical Protocol: Influenza Vaccine, dated 09/2018, last revised 09/2022 documents: Residents who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. A resident's refusal of the vaccine shall be documented in the resident's medical record. R10 was admitted to the facility on [DATE] with diagnoses that includes Alzheimer's Disease (progressive irreversible brain disorder that slowly destroys memory and thinking skills), Chronic Obstructive Pulmonary Disease (COPD) (lung disease that makes breathing difficult causing airflow obstruction) and Urinary Tract Infection (UTI) (bladder infection). Surveyor reviewed R10's EMR and was unable to locate whether R10 was offered, received or declined the influenza immunization in 2025 or 2026. Surveyor notes R10 received the influenza immunization on 11/12/2024. On 4/8/26, at 10:43 AM, Surveyor interviewed Quality Management (QM)-D who stated immunizations including influenza are offered to the resident upon admission and during the flu season. QM-D stated documentation is scanned in the EMR if a resident declines the influenza immunization. Surveyor reviewed R10's influenza immunization record and notes R10 last received the influenza immunization on 11/12/2024. QM-D stated the facility noted concerns with the previous infection control program and residents not receiving or being offered the influenza immunization. QM-D stated the facility started a Performance Improvement Plan (PIP) at the end of February 2026/beginning of March 2026. QM-D stated there were staffing turnovers and challenges that contributed to R10 not receiving or being offered the influenza immunization. On 4/8/26, at 11:11 AM, Surveyor informed Nursing Home Administrator (NHA)-A of concerns with R10 not receiving or being offered the influenza immunization. NHA-A acknowledged this concern. On 4/8/26, at 1:24 PM, QM-D notified Surveyor that QM-D looked into R10's EMR and was unable to locate documentation that R10 was offered or declined the influenza immunization. Surveyor notified QM-D of concerns with R10 not receiving or being offered the influenza immunization. QM-D acknowledged this concern. No additional information was provided.

Based on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 2 (R10 and R11) of 5 Residents who's medication records were reviewed. *R11 was prescribed Lorazepam, a benzodiazepine that works in the brain to relieve symptoms of anxiety. The facility did not have a signed consent explaining the risks and benefits of Lorazepam. *R10 was prescribed Zyprexa, an antipsychotic medication that helps regulate mood, behaviors and thoughts. The facility did not have a signed consent explaining the risks and benefits of Zyprexa. Findings Include: The facility's policy and procedure titled, Medication Monitoring, effective date 6/21/2017, documents: Policy: A resident's medication regimen shall promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being, as identified by the resident and/or representative(s) in collaboration with the attending physician and facility staff. Procedure: 3. The involvement of residents family members (e.g. care conference or discussion group) in the development and adoption of guidelines relative to the use of psychotropic drugs in the facility is recommended. 1.) R11 was admitted to the facility on [DATE], with pertinent diagnoses that include adjustment disorder with depressed mood (a strong emotional or behavioral reaction to stress or trauma), cognitive communication deficit (difficulty with communication that stems from impaired thinking skills, such as memory, attention, and problem-solving, rather than from physical speech problems), vascular dementia with mood disturbance (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), anxiety disorder (persistent, excessive fear or worry in situations that are not threatening), depression (a mental health condition characterized by persistent sadness, loss of interest or pleasure in activities, and other symptoms that significantly affect daily life), insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep), and chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months). R11's Quarterly Minimum Data Set (MDS) with an assessment reference date of 2/26/26, documents a Brief Interview for Mental Status (BIMS) score of 03, indicating that R11 has severe cognitive impairment. The MDS documents that R11 was assessed to have no behaviors exhibited during the look back period. R11 can make self understood and understands others. R11 was coded as taking an antianxiety and a hypnotic medication. R11's physician order dated 11/18/25 documents: Lorazepam 0.5 mg tablet [generic] 0.5 mg by mouth every 12 hours for anxiousness, restlessness. Surveyor was provided the document Informed Consent dated 11/7/25 for the Psychotropic Medication Order of Lorazepam 1.5mg tab q 1 hour PRN. The Resident Name or Responsible Party's Signature line was left blank. Surveyor noted R11 does not have an active PRN order for Lorazepam, as of 11/18/25 the medication was scheduled every 12 hours and no consent was obtained. On 4/8/26, at 3:00pm, during the end of day meeting with Nursing Home Administrator (NHA)-A Surveyor let know of concern that there is no evidence of the informed consent being presented to R11's Representative. No additional information was provided as to why the facility did not ensure that R11 had written consent explaining the risks and benefits of psychotropic medications that were prescribed. 2.) R10 was admitted to the facility on [DATE], with pertinent diagnoses that include Schizophrenia, Alzheimer's disease, hypertensive heart disease with heart failure, acute kidney failure, unspecified, chronic diastolic (congestive) heart failure, Chronic Obstructive pulmonary disease, vascular dementia, severe with agitation. R10's Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/13/26, documents a Brief Interview for Mental Status (BIMS) score of 02 indicating that R10 has severe cognitive impairment. The MDS documents that R10 was assessed to have behaviors exhibited (hitting, kicking, pushing, scratching, grabbing) behavior of this type occurred 1-3 days during the look back period. R10 was coded as taking an antidepressant and an antipsychotic medication. R10's Abnormal Involuntary Movement Scale (AIMS) score of 0, which indicates the complete absence of abnormal movements in a specific area. R10's physician order dated 7/13/25 documents Olanzapine 7.5 mg tablet {generic} 7.5mg by mouth hours of sleep for schizophrenia/bipolar. Surveyor was provided the document Informed Consent dated 06/10/25 for the Psychotropic Medication management Zyprexa (Olanzapine) 2.5mg tab po daily at 0800 5mg PO daily at HS. The Resident Name or Responsible Party's Signature page was missing. On 4/8/26, at 2:43pm, Surveyor asked Nursing Home Administrator (NHA)-A if there was another page to go with the consent form that was provided. NHA-A stated that NHA-A did not have the second half of the missing consent signed page. On 4/8/26 at 3:00pm, during the end of day meeting, Surveyor informed Nursing Home Administrator (NHA)-A of the above concern that there is no evidence of the informed consent being presented to R10's Representative for the use of R10's Olanzapine. No additional information was provided as to why the facility did not ensure that R10 had written consent explaining the risks and benefits of psychotropic medications that were prescribed.

Based on interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 1 (R2) of 2 residents reviewed with pressure injuries. R2 was admitted to the facility on [DATE], with a diagnosis of Type 2 Diabetes. There is no documentation the facility was performing daily diabetic foot checks as documented in R2's care plan. R2's care plan does not document person centered interventions of turning and repositioning when R2 is assessed to be dependent on the staff for activities of daily living (ADLs). On 11/1/25, R2's family notified the facility of R2 having bilateral heel pressure injuries. The facility documented the size and location of a left heel pressure injury but did not complete an assessment of R2's right heel prior to R2's transfer to the hospital. R2 was sent to the emergency room (ER) for evaluation and the hospital documents bilateral heels with pressure ulcer with black scabs. R2 returned to the facility on [DATE]. R2's skin was not comprehensively assessed until 11/9/25, ordered treatments were not implemented until 4 days after they were ordered.Findings include:The facility's policy titled, Pressure Injury Assessment/Treatment and dated 12/2016, last reviewed 7/2024, documents:General Guidelines:The pressure injury treatment program should focus on the following strategies:*Evaluating the resident and the current status of the pressure injury.*Observe currently used support surfaces and/or pressure relieving devices; initiate as needed.*Resolution of current pressure injuries and prevention of additional pressure injuries.*Identification of additional nutritional needs to aide in wound healing.*Education and quality improvement.Pressure injury treatment requires a comprehensive approach, including and not limited to:*Elimination or reduce the source of pressure using positioning techniques.*Preventative measures to reduce the risk of further tissue loss.*Managing and reducing the risk of infections.*Interventions that increase the potential for healing.*Managing systemic issues. The facility's policy titled Nursing Care of the Resident with Diabetes Mellitus and dated 12/2016, last reviewed 11/2024, documents:Complications Associated with Diabetes:Foot complications - neuropathy, dry skin, calluses, poor circulation, and ulcers.Skin and Foot Care:Skin should be kept as dry and clean as possible.Apply lotion to dry skin as needed, unless contraindicated.Use aseptic technique in caring for any lacerations, abrasions or breaks in skin integrity, and report the condition immediately to your supervisor.Bathe feet in warm (not hot) water as necessary to keep clean.Keep feet dry, especially between toes.Encourage the use of non-constricting, well-fitting shoes, slippers and hose.Keep feet warm without the use of external heat sources.Toenails should only be trimmed by associates qualified to do so.Documentation:Assessment of the skin including color, moisture, temperature, any redness, ulcers, irritation, abrasions, and/or pruritus (itching).Assessment of the feet should include the following:Hygiene, temperature, color, circulation, any abrasions, sores and/or injuries. R2 was admitted to the facility on [DATE]. R2's diagnoses include cerebral infarct (part of the brain tissue dies), heart failure (weakened heart or stiff heart pumping), chronic kidney disease (CKD) (damaged kidneys), Diabetes (high blood sugar levels in the body), Chronic Obstructive Pulmonary Disease (COPD) (lung condition caused by damage to the lungs), Atrial Fibrillation (irregular heart beat), Peripheral Vascular Disease (PVD) (narrowed blood vessels to the legs causing reduced blood flow), dementia (memory concerns due to damaged brain cells), hemiplegia (weakness) affecting left side, and muscle weakness.Surveyor notes R2 discharged from the facility on 11/21/25. R2's admission Minimum Data Set (MDS) completed on 9/12/25, documents R2 is dependent with toileting, showering, dressing, and transfers. R2 was assessed as being at risk for pressure injuries with no unhealed pressure injuries. R2's Care Area Assessment (CAA) for pressure injuries documents, proceed to plan of care. Surveyor notes no further documentation in R2's pressure injury CAA.R2 was documented as having a Brief Interview for Mental Status (BIMS) score of 13, indicating R2 is cognitively intact.R2's readmission MDS completed on 11/11/25, documents R2 is at risk for pressure injuries with no unhealed pressure injuries, venous or arterial ulcers. R2's MDS documents R2 as having Diabetic foot ulcers.R2's Discharge MDS completed on 11/18/25, documents R2 having 2 unhealed unstageable pressure injuries with slough and/or eschar. Surveyor reviewed R2's Electronic Medical Record (EMR) which documents the following Braden Scales (a tool that assesses a resident's risk of developing pressure injuries):Braden Scale scoring:Score 15 - 18 indicates low risk with interventions to reposition regularly, keep positioned off bony prominences.Score 13 - 14 indicates moderate risk with interventions to initiate turning schedule every 2 hours.Score 10 - 12 indicates high risk with interventions to reposition every 1-2 hours with frequent small shift of position, use pressure reduction support surface per recommendations from wound clinician.9/12/25 - score 16- low risk for the development of pressure injuries9/19/25 - score 15- low risk for the development of pressure injuries9/26/25 - score 14- moderate risk for the development of pressure injuries10/3/25 - score 14- moderate risk for the development of pressure injuries10/14/25 - score 15 low risk for the development of pressure injuries10/17/25 - score 16 low risk for the development of pressure injuries11/10/25 - score 11- high risk for the development of pressure injuries11/14/25 - score 16- low risk for the development of pressure injuries R2's care plan documents:-R2 is at risk for pressure ulcers and other skin related injuries (date initiated 9/12/25).Interventions include:Braden Scale to be completed (date initiated 9/12/25).Keep bed linens wrinkle free and do not use excess pads (date initiated 9/12/25).Observe skin for redness and breakdown during routine care (date initiated 9/12/25).Use pressure relieving devices, cushion on wheelchair and off of heels, as indicated (date initiated 9/12/25).Follow community skin care protocol (date initiated 9/12/25).Treatments, as indicated, see physician order sheet (date initiated 9/12/25).Pressure reducing mattress on bed (date initiated 9/12/25).Float heels while in bed (date initiated 11/12/25).Tubigrips to bilateral lower extremities to help protect skin (date initiated 11/12/25). -R2 has potential for complications from Diabetes (date initiated 9/12/25).Interventions include:Observe feet daily for redness, breakdown or pain and report to MD. Keep feet dry and skin lubricated (date initiated 9/12/25). Surveyor notes R2's care plan was updated on 11/10/25 to include:-R2 has impaired skin integrity to right heel wound (date initiated 11/10/25).Interventions include:Provide treatment as ordered (date initiated 11/10/25).Assist with repositioning during rounding and cares (date initiated 11/10/25).Wound Medical Director (MD) to follow (date initiated 11/12/25).Float heels in bed (date initiated 11/12/25). -R2 has impaired skin integrity to left heel wound (date initiated 11/10/25).Interventions include:Provide treatment as ordered (date initiated 11/10/25).Assist with repositioning during rounding and cares (date initiated 11/10/25).Wound MD to follow (date initiated 11/12/25).Observe skin integrity and update MD with concerns (date initiated 11/12/25). Surveyor notes the following care plan concerns:*R2 was assessed to be at risk for the development of pressure injuries and R2's care plan does not document person centered interventions for turning and repositioning to prevent the development of pressure injuries.*R2's Diabetes care plan documents daily foot checks should occur which Surveyor notes this did not carry over to R2's orders and there is no evidence of the facility performing or documenting daily foot checks.*R2 returned to the facility on [DATE] with a right and left heel pressure injury. This was not documented on R2's care plan until 11/10/25 with interventions to float R2's heels added on 11/12/25. Surveyor notes R2's skin assessment on 11/1/25 documents a partial thickness pressure injury to the left heel measuring 3.5 cm x 0.4 cm x 0. Cause is pressure. The skin assessment does not address the concern for a right heel pressure injury which the family informed the facility of on 11/1/25. Surveyor reviewed R2's emergency room Provider Notes dated 11/2/25, at 1:48 AM, which document the following:R2 having bilateral heels with pressure ulcer with black scab, no erythema (redness) or discharge, hyperpigmentation to the toes (darker skin commonly seen with circulation problems), feet and ankles bilaterally, skin warm to the touch in the feet/legs, prolonged capillary refill in all toes 3-4 seconds (indicating poor circulation), weak palpable dorsalis pedis (DP) pulses (weak pulses in the feet) and doppler tones present.R2's family has noticed R2's legs seem more swollen as well, she has had pressure wounds to her feet but no current wound care being done at R2's facility. R2 has seen podiatry in the past. R2's family is unsure how long the current wounds have been there or if they are worse. R2 does complain of pain to R2's legs chronically, has been again complaining of worsening leg pain today.R2 has palpable DP pulses with intact Doppler tones through does have prolonged capillary refill at the toes. R2 has known peripheral vascular disease especially in the setting of R2's lower extremity edema and pressure wounds do feel R2 would benefit from seeing podiatry this admission.Surveyor notes R2 was not followed by podiatry for circulatory concerns while residing at the facility. Surveyor reviewed R2's EMR which documents the following skin assessments:-10/20/25 - no skin concerns noted.-11/1/25 - partial thickness pressure injury to the left heel measuring 3.5 x 0.4 x 0. Cause is pressure. R2 was sent to the ER for evaluation. Surveyor notes no comprehensive assessment documentation for left heel wound bed or documentation of a right heel pressure injury. Upon R2's return to the facility on [DATE] the first skin assessment was documented on 11/9/25.-11/9/25 - Left heel full thickness diabetic foot ulcer measuring 3.0 x 3.3 x 0 with eschar cap and even wound edge, caused by pressure. Treatment to cover with non adaptic dressing then wrap with kerlix daily. Surveyor notes left heel wound assessment completed 2 days after R2 returned from the hospital on [DATE]. Surveyor notes the care plan is not indicated as reviewed on R2's skin assessment. Surveyor notes orders for treatment did not carry over to R2's Medication Administration Record (MAR) or Treatment Administration Record (TAR), indicating there is no evidence or documentation R2 received wound care treatment as ordered.-11/9/25 - Right heel full thickness diabetic foot ulcer measuring 2.2 x 2.0 x 0 with eschar cap and even wound edge, caused by pressure. Treatment to cover with non adaptic dressing then wrap with kerlix daily. Surveyor notes right heel wound assessment completed 2 days after R2 returned from the hospital on [DATE]. Surveyor notes the care plan is not indicated as reviewed on R2's skin assessment. Surveyor notes orders for treatment did not carry over to R2's Medication Administration Record (MAR) or Treatment Administration Record (TAR), indicating there is no evidence or documentation that R2 received wound care treatment as ordered.-11/11/25 - Unstageable left heel partial thickness pressure injury measuring 3.0 x 4.0 x 0 with necrotic/eschar present, caused by pressure. Surface area measured at 12 cm with 100% black necrotic tissue present. Treatment to cleanse with normal saline, pat dry, followed by foam border dressing daily and as needed (PRN). Surveyor notes unstageable left heel pressure injury worsened in size and is no longer documented as a diabetic foot ulcer.-11/11/25 - Unstageable right heel partial thickness pressure injury measuring 3.0 x 4.0 x 0 with necrotic/eschar present, caused by pressure. Surface area measured at 12 cm with 100% black necrotic tissue present. Treatment to cleanse with normal saline, pat dry, followed by foam border dressing daily and PRN. Surveyor notes unstageable right heel pressure injury worsened in size and is no longer documented as a diabetic foot ulcer. -11/18/25 - Unstageable left heel full thickness pressure injury measuring 3.0 x 4.0 x 0 with necrotic/eschar present. Surface area measured at 12 cm with 100% black necrotic tissue present. Treatment to cleanse with normal saline, pat dry, followed by foam border dressing daily and PRN.-11/18/25 - Unstageable right heel full thickness pressure injury measuring 3.0 x 4.0 x 0 with necrotic/eschar present. Surface area measured at 12 cm with 100% black necrotic tissue present. Treatment to cleanse with normal saline, pat dry, followed by foam border dressing daily and PRN. Surveyor reviewed R2's TAR which documents the following:*Cleanse right heel with normal saline, pat dry, followed by foam border dressing daily and PRN (order date 11/11/25). Surveyor notes order for wound care treatment was placed 4 days after R2 returned to the facility on [DATE], with no further documentation indicating R2 received wound care treatment to R2's right heel prior to 11/11/25.*Cleanse left heel with normal saline, pat dry, followed by foam border dressing daily and PRN (order date 11/11/25). Surveyor notes order for wound care treatment was placed 4 days after R2 returned to the facility on [DATE], with no further documentation indicating R2 received wound care treatment to R2's left heel prior to 11/11/25.*Heels to be floated in boots while in bed for edema (order date 11/12/25). Surveyor notes order was entered on R2's TAR 5 days (11/12/25), after returning to the facility on [DATE]. Surveyor also notes edema as the reason for floating heels with no mention of facility acquired pressure injuries to R2's bilateral heels to protect bony prominences. On 12/17/25, at 2:15 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who states he completes a full head to toe assessment when a resident returns from a hospitalization. If skin is not intact or wounds are present, LPN-H will get another nurse to validate his assessment. LPN-H states he completes the skin flowsheet assessment form that is at the nursing station, that includes the type of wound, measurements, and wound bed descriptors. LPN-H then gives the skin flowsheet assessment to the DON (Director of Nursing) and will contact the provider for orders and send a request for the provider to visit the resident with wounds. On 12/18/25, at 9:59 AM, Surveyor interviewed LPN-D who states she is an agency nurse and worked with R2 one time on 11/1/25. LPN-D states R2's family notified her, they found new pressure injuries to R2's heels and requested R2 be sent out for evaluation of edema and new pressure injuries. LPN- D states she does not recall what R2's heels looked like but states she recalls starting a skin assessment but did not finish due to R2 being sent out to the hospital for evaluation. LPN-D states she notified the DON of the new facility acquired pressure injuries and was never told of skin concerns with R2 when getting report from the previous nurse. Surveyor asked LPN-D if daily foot checks would be expected for a resident who has diabetes. LPN-D responded yes, daily foot checks should be completed and that's a standard of practice for diabetes management. LPN-D also states it is a standard of practice to complete a comprehensive skin check including staging, measurements, and wound bed descriptors when a resident returns from the hospitalization. LPN-D states floor nurses are to enter orders for treatments and medication when a resident returns from the hospital, but unit managers will sometimes help enter in orders if the unit manager is available. On 12/17/25, at 2:07 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who states the facility had a wound care nurse but she is no longer works at the facility as of last week. NHA-A was unable to identify who the wound care nurse was and stated she was going to ask around to see who was doing wound care. Surveyor requested to speak with that nurse once NHA-A found out who was doing wound care rounds. On 12/17/25, at 2:44 PM, at end of day meeting, Surveyor asked if the facility knew who was performing wound care rounds. Corporate Consultant- G states Nurse-I who was an agency nurse was going to be doing wound rounds. NHA-A states Nurse-I was not available at the time for interview. Surveyor requested to speak with Nurse-I when available. Surveyor then asked what the process is for skin assessments and wound care treatments when a resident returns from the hospital. Corporate Consultant-G states, the resident is seen by the wound care physician at the next scheduled wound care rounds, the admitting nurse will perform a comprehensive skin assessment and enter in treatment orders with the wound care nurse. Corporate Consultant-G states the comprehensive skin assessment includes staging, measurements, and wound bed description that is to be completed the same day of admission/readmission. Surveyor asked if R2 was being followed by podiatry as stated by R2's EMR. Corporate Consultant-G states R2 did not follow podiatry during R2's admission at the facility from 9/12/25 - 11/21/25. On 12/18/25, at 10:54 AM, Surveyor interviewed Director of Nursing (DON)-B who states she was not at the facility at the time of discovery of R2's facility acquired bilateral heel pressure injuries on 11/1/25. DON-B stated the facility had a wound care nurse who previously worked at the facility and is no longer at the facility. DON-B then stated that is on her for these facility acquired pressure injuries and DON-B can't speak upon R2's pressure injuries as she was not working for the facility at that time. Surveyor asked who she could speak to regarding R2's facility acquired pressure injuries and DON-B stated she was not sure and directed Surveyor to Nursing Home Administrator (NHA)-A. Surveyor notified DON-B of concerns with R2 developing bilateral pressure injuries while at the facility on 11/1/25. Surveyor notified DON-B of the following concerns with R2's facility acquired bilateral heel pressure injuries:R2 is a diabetic with no documentation of daily diabetic foot checks being performed.Last documented skin assessment performed on 10/20/25, with new discovery of bilateral heel pressure injuries with eschar present on 11/1/25.R2 returned to the facility on [DATE], with no comprehensive skin assessment completed until 2 days later, on 11/9/25.R2's wound care treatment orders were entered on to R2's TAR on 11/11/25 which is 4 days after R2 returned to the hospital.R2's care plan was not updated with facility acquired pressure injuries until 11/10/25.R2 was assessed with being at risk for pressure injuries with no documentation of person-centered interventions of turning and repositioning to prevent pressure injuries.DON-B acknowledged these concerns.

Based on observation, interview and record review the facility did not ensure the medication error rate was below 5% during medication pass. Surveyor observed 20 out of 32 opportunities with a medication error rate of 62.5%. On 12/18/25, Surveyor observed Licensed Practical Nurse (LPN)- E stab 20 bubble packs with a pen for 2 (R8 and R9) of 4 residents during medication administration. Findings include: On 12/18/25, at 7:54 AM, Surveyor observed LPN-E administer medications to R9. R9 was administered 8 medication that included:Amlodipine 5 mg tabletCertravite (Multivitamin) 1 tabletFolic Acid 1 mg tabletHydrochlorothiazide 12.5 mg tabletTurmeric 500 mg tabletVitamin B complex 1 tabletThiamine 100 mg tabletVitamin C 500 mg tabletSurveyor observed each medication to be individually wrapped in a bubble packet and observed LPN-E lay out all 8 bubble packs on top of the medication cart and press the button on her pen to expose the ballpoint on the pen and stab each individual packet with the open ball point pen. LPN-E then placed each bubble pack over a medicine cup to push out the tablet into the medication cup. LPN-E then walked over to R9 who swallowed the medications whole with water. On 12/18/25, at 8:29 AM, Surveyor observed LPN-E administer medications to R8. R8 was administered 12 medications that included:Tamsulosin 0.4 mg (2 tablets)Losartan 50 mg tabletMemantine 5 mg tabletMetoprolol Extended Release (ER) 25 mg tabletThiamine 100 mg tabletVitamin K with D3 100 mcg tabletAspirin 81 mg tabletChlorthalidone 25 mg tabletCoQ10 100 mg tabletFolic Acid 1 mg tabletGabapentin 300 mg tabletGlimepiride 2 mg tabletSurveyor observed each medication to be individually wrapped in a bubble packet and observed LPN-E lay out all 12 bubble packs on top of the medication cart and press the button on her pen to expose the ballpoint on the pen and stab each individual packet with the open ball point pen. R8 overheard LPN-E stabbing the bubble packs from the hallway and yelled out to LPN-E, stating R8 did not want their medications crushed. LPN-E responded to R8 stating she did not have fake nails to open the bubble packs and was not crushing R8's medications. LPN-E then placed each bubble pack over a medicine cup to push out the tablet into the medication cup. LPN-E then walked over to R8 who swallowed the medications whole with water. On 12/18/25, at 10:54 AM, Surveyor notified Director of Nursing (DON)-B of concerns with performing observations of medication pass with 32 opportunities. Surveyor notified DON-B of Surveyor observing LPN-E stabbing 20 bubble packs open with a ball point pen exposed to break medication bubble packs which makes a 62.5% medication error rate with 20 out of 32 opportunities. DON-B acknowledged the concerns.

Uncorrected on Revisit Based on observation, interview, and record review, the Facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R6, R7, R8) of 3 residents reviewed for pressure injuries. *R6 developed a deep tissue injury (DTI) which was discovered on 2/19/25 by a Licensed Practical Nurse (LPN). There is no documentation that the DTI was evaluated by a Registered Nurse until the Wound Nurse Practitioner saw it on 2/27/25. Additionally, R6 did not have nutritional interventions attempted and R6's care plan was delayed in being updated. The DTI declined to a stage 3 pressure injury. *R8 developed a Stage 2 pressure injury to left buttocks on 3/10/25. The wound was not comprehensively assessed until 3/13/25. Treatment for the pressure injury was not obtained until 3/13/25 and R8's care plan was not updated until 3/13/25. *Facility staff documented R7 developed a new wound to R7's mid back on 3/9/25. The wound was not comprehensively assessed until 3/13/25 when the Wound Nurse Practitioner (NP)-M documented that the wound was a stage 2 pressure injury. R7's care plan was not updated with new interventions until 3/13/25, 4 days after the development of the pressure injury. On 3/16/25, R7's wound care was not documented as completed. Findings include: 1.) R6 was admitted to the facility on [DATE]with pertinent diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition and encounter for palliative care. R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating that R6 has severe cognitive impairment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was assessed to have a mechanically altered diet. The MDS assesses no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documents that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6 has an activated Power of Attorney (POA). R6's Significant Change MDS with an assessment reference date of 2/6/2025 does not document a BIMS assessment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was assessed to have a mechanically altered diet. The MDS assesses that Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months occurred and R6 was not on a physician prescribed weight loss regimen. The MDS assesses that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6 had multiple Braden Scale for Predicting Pressure Score Risk evaluations done. Braden evaluations dated 3/9/24, 8/20/24 and 1/31/25 documented that R6 was assessed to have a score of 10, indicating R6 is at very high risk of developing a pressure injury. R6's Braden evaluation dated 11/10/24 documents R6's risk of developing a pressure injury to be a moderate risk with a score of 16. R6's Pressure Ulcers/Skin Prevention care plan documents the following interventions: Follow community skin care protocol. Start 11/10/2021 Treatments, as indicated, see physician order sheet. Start 11/10/2021 Pressure reducing mattress on bed. Start 11/10/2021 Air mattress with bolsters, check for proper functioning Q (each) shift. Start 4/6/2022 Assist with repositioning when in bed and Broda chair during rounding and cares. Start 4/6/2022 cushion to w/c (wheelchair). Start 12/27/2022 Tubi grips on from hand to elbow in early am and off at bedtime. Hole cut for thumb. Start 8/9/2023 Prevalon Boots while in bed. Start 2/21/2025 (R6) has impaired skin integrity related to right lateral heel DTI (deep tissue injury) noted on 2/19/25 Goal: (R6) will be free from signs and symptoms of infection and will demonstrate optimal healing Interventions: Provide treatment as ordered. Start 3/11/25 Follow with wound APNP (Advanced Practice Nurse Practitioner). Start 3/11/25 Per wound rounds on 3/13/25, with wound APNP, wound is now classified as a stage III (3) pressure injury. Start 3/14/25 (R6) has impaired skin integrity related to right medial heel DTI noted on 3/6/25 Goal: (R6) will be free from signs and symptoms of infection and will demonstrate optimal healing Interventions: Provide treatment as ordered. Start 3/11/25 Follow with wound APNP. Start 3/11/25 R6's physician order dated 1/28/25 documents severe protein calorie malnutrition: hospice to eval (evaluate) and treat. R6's physician order dated 1/30/25 documents admit to (name of) Hospice Surveyor noted that R6's DTI was found on 2/19/25 and Prevalon boots were added on 2/21/25, which was 2 days after the DTI was identified. Surveyor noted that the rest of R6's care plan was updated 3/11/25 and 3/14/25. Surveyor noted that R6's the right medial heel has progressed to a stage 3 pressure injury, not the right lateral heel as documented in R6's care plan. R6's physician order dated 2/19/25 documents skin prep-topical every shift to be applied to right heel q (each) shift for protection and Heels to be elevated off bed with pillows-topical continuous for protection R6's progress note, written by Licensed Practical Nurse (LPN)-X dated 2/19/2025, at 3:39 pm, documents: bed bath given. A 5.2 cm (centimeter) x 4.5 cm darkened area was noted on right heel. On call RN (Registered Nurse) Supervisor aware and will assess. Heels elevated on pillows. Skin prep to be applied q shift R6's progress note, written by LPN-X dated 2/20/2025, at 2:52 pm, documents: on 2-19-25 a 1. cm x 2.0 cm, darkened area was found on resident's right heel during a bed bath and skin check. On call RN Supervisor was updated, (name of medical group) was updated, and POA (power of attorney) was updated. Skin prep ordered and a Prevalon boot to right foot. No pain to area Surveyor noted there was a discrepancy in R6's right heel measurements listed on 2/19/25 and on 2/20/25 when R6's medical doctor (MD) and POA were informed. On 2/19/25, a Skin Evaluation Form was completed for R6 by LPN-X. Documentation for the heel right is length 5.2 cm, width 4.5 cm, depth 0 cm. and the treatment of skin prep q shift, to be assessed by RN R6's physician order dated 2/20/25 documents Prevalon boot-topical every shift to be worn on right foot for protection On 2/20/25, a Skin Evaluation Form was completed for R6 by wound LPN-E. Documentation for the heel right is length 1.0 cm, width 2.0 cm, depth UTD (unable to determine) cm, cause is identified as pressure, tissue type is 0 = closed/resurfaced, exudate amount is 0 = none and stage is deep tissue injury The treatment section remained the same skin prep q shift, to be assessed by RN On 2/27/25, a Wound Care Assessment was completed by wound Nurse Practitioner (NP)-M, the right heel DTI documentation status is documented as new. Deep tissue pressure injury 0.9 x 2.5 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Surveyor noted this is the first documented comprehensive assessment of the wound by an RN. On 3/6/25, a Wound Care Assessment was completed by wound NP-M, the right heel DTI documentation is right lateral heel (DTI), deep tissue pressure injury 1 x 2 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- stable. A second pressure injury is discovered. Documentation is right medial heel (DTI), deep tissue pressure injury 0.5 x 1 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- new. On 3/13/25, a Wound Care Assessment was completed by wound NP-M, documentation is right lateral heel (DTI), deep tissue pressure injury 1 x 2 cm. Intact, purple, no drainage. Peri wound is dry, intact. No sign/symptom infection. Status- stable. Documentation for right medial heel (stage 3 pressure injury), full thickness wound measuring 1 x 1.5 cm. 100% granular tissue. Scant serosanguinous drainage. Peri wound is dry, intact. No sign/symptom infection. Status- decline. On 3/13/25, wound LPN-E completed the Skin Evaluation Form which documented the right lateral heel size is 1.0 cm x 1.5 cm x 0.1 cm and staged as a stage 3 pressure injury. The right medial heel size is 1.0 cm x 1.0 cm x UTD, and stage is deep tissue injury. Surveyor noted from 3/6/25 to 3/13/25 the DTI on the right medial heel declined to stage 3 as the measurements went from 0.5 x 1 cm to 1 x 1.5 cm. Surveyor noted wound LPN-E incorrectly documented the right lateral heel as the stage 3 pressure injury. Surveyor noted observing wound care on 3/19/25, at 8:38am, and the stage 3 pressure injury is on the right medial heel, as NP-M documented. Surveyor noted a delay in reporting of DTI to R6's physician and POA. Surveyor noted there was a delay in implementing R6's Prevalon boot as it was not added until 2/20/25, one day after R6's DTI was found. Additionally, Surveyor noted that there is no documentation that an RN assessed R6's heel until 2/27/25, seven days after it was initially discovered, and wound NP-M noted the DTI as new. Surveyor noted that on 3/6/25, a DTI to R6's right medial heel was also discovered. At the time, R6's wound documentation is changed from right heel to right lateral heel for the DTI found 2/19/25. On 3/13/25, the right medial heel DTI progressed to a stage 3 pressure injury per wound NP-M. R6's Interdisciplinary note, written by Registered Dietician (RD)-Y dated 1/29/25, documents: aware of current weight 107 pounds which reflects a significant weight loss of 10% in the past month. Intake appears to have decreased slightly but not significantly. Continues to accept 4oz ensure enlive TID between meals. Family has decided to proceed with hospice care. Will continue to monitor. R6's interdisciplinary note, written by RD-Y dated 3/18/25, documents monitoring wounds to RLE (right lower extremity) (venous ulcer-suspicious for cancerous lesion) and Right lateral heel (DTI). Both are stable. Patient admitted to hospice 1/30/25. Oral intake varies from poor to good although R6 has had an overall decrease as evidence by significant 13.85% weight loss in the past 6 months. R6 does receive 4 oz ensure enlive TID (three times per day) for additional calories/protein. Due to end stage diagnosis weight and wound changes unavoidable. Will continue to offer supplement and food/fluid as patient desires. Surveyor noted R6's RD note dated 3/18/25 was written a month after R6's right heel DTI was found and did not document that R6's right medial heel had progressed to stage 3. Surveyor noted R6 had a severe weight loss (more than 10%) over 6 months, not significant (less than 10%) as indicated in the 3/18/25 note. On 3/19/25, at 12:35pm, Surveyor interviewed RD-Y and asked about any intervention changes when R6's weight loss was detected, as Surveyor could not locate any in R6's medical record. RD-Y informed Surveyor that R6 was palliative care so RD-Y was not super aggressive in developing interventions for R6. RD-Y stated that in January RD-Y saw R6 and that R6 gets ensure. RD-Y stated that in January R6's family proceeded with hospice care. Surveyor asked if RD-Y updated R6's care plan and was told if a resident is losing weight the goal stays the same, to provide nutritional needs. RD-Y removed the part in the care plan about R6 not having a weight change. RD-Y stated the goal was to provide food and fluids to try to prevent further weight loss, this is for comfort. Surveyor asked about improving R6's nutrition and was told RD-Y did not implement further interventions because hospice was being discussed with the family. RD-Y saw a gradual decrease in R6's appetite, comfort was the goal. Surveyor noted R6 had no interventions that were attempted which could improve protein intake. Surveyor noted R6 had been on hospice previously from 9/30/21 to 9/14/22, 2 years ago. On 3/19/25, at 1:23pm, Surveyor interviewed Hospice RN-AA about weight loss and pressure injuries. Surveyor asked Hospice RN-AA about R6's pressure injury and who monitors it. Hospice RN-AA stated the facility cares for it and that pressure injuries are fairly common at the end of life, especially with R6's diagnosis due to the lack of protein. Surveyor asked if R6 needs a protein supplement or other interventions and was told not necessarily as pressure injuries are part of the decline. On 3/18/25, at 2:20pm, Surveyor interviewed wound LPN-E and was told the wound NP-M stages the wounds, LPN-E just puts in what NP-M says. If a skin issue is found and it is not by the wound rounding day with NP-M, LPN-E grabs a RN to stage and documents what they say. Surveyor asked if anyone was monitoring the right heel between 2/27/25 and 3/6/25 when the new DTI was discovered by wound NP-M. LPN-E stated yes, at the weekly bath skin check and when the skin prep was applied q shift. Surveyor asked if hospice followed the wound and was told no, they are aware and are given updates weekly, but they refer to the wound NP-M for treatments. Surveyor asked why there was no RN assessment on the 19th when the DTI was found and was told there were no managers here at that point, LPN-E believes they have 24 hours for RN to put eyes on it. On 3/18/25, at 3:20pm, Surveyor interviewed LPN-X, who found R6's right heel DTI. LPN-X informed Surveyor that R6's DTI was discovered during R6's skin check, 2/19/25, on bath day. LPN-X let the unit manager know over the phone and was told the wound team would look at it the next day. The wound was not open when it was found. On 3/19/25, at 10:25am, Surveyor interviewed wound LPN-E again after reviewing wound NP-M notes. Surveyor asked why the wound was found on 2/19/25, charted on by LPN-E on 2/20/25, and assessed by NP-M on 2/27/25 as new. LPN-E will look into the documentation. On 3/19/25, at 12:13pm, LPN-E got back to Surveyor that since wound NP-M was coming on the 20th, LPN-E printed wound rounds on the 19th before the DTI was found, so it was not on the sheet. After NP-M left, LPN-E remembered the DTI so took RN Unit Manager-C with to assess. Surveyor asked for documentation of the RN assessing the wound and was told it is noted in treatment section. Surveyor noted it reads to be assessed by RN in the treatment section. Surveyor asked about interventions to keep heels off bed before the DTI was discovered and LPN-E will look into. Surveyor noted no documentation was provided. On 3/19/25, at 12:47pm, Surveyor interviewed RN Unit Manager-C and was told they had been called the night before (2/19/25) about the new wound and took care of the assessment the next day. Surveyor noted no documentation was provided of the RN assessment. On 3/20/25, at 8:08am, Surveyor interviewed wound NP-M who stated the 2nd pressure injury developed because R6 always kicks boots off. Surveyor asked about interventions in place before the DTI was discovered and NP-M cannot speak to that. Surveyor reviewed the CNA Worksheet provided by Facility and R6 is a 2 person assist for transfers, bed mobility, dressing and bathing. It is not documented on the worksheet for R6 to be turned or repositioned on any schedule, float heels or wear Prevalon boots. On 3/20/25, at 10:18am, Surveyor interviewed R6's POA and asked if they had been notified of R6's weight loss. R6's POA responded that R6's weight loss had been mentioned casually. R6's POA stated they bring food in for R6 and R6 has no trouble eating the food. POA felt R6 gets lots of skin tears and feels the bad nutrition would affect skin integrity. On 3/20/25, at 2:06pm, Surveyor spoke with Director of Nursing (DON)-B about the concerns for R6 regarding the lack of RN assessment, lack of care plan interventions or nutrition supplementation that led to a DTI progressing to a stage 3 pressure injury. No further information was provided at the time of write up regarding no documentation that the DTI was evaluated by a Registered Nurse (RN) until the Wound Nurse Practitioner (NP) saw it on 2/27/25, R6 did not have nutritional interventions attempted and R6's care plan was delayed in being updated. Cross-reference F692. 48391 2.) R8 is a [AGE] year-old resident who was admitted to the facility on [DATE]. R8's diagnoses include osteoarthritis, polyneuropathy, basal cell carcinoma, stage 2 left buttocks pressure injury. R8's Quarterly Minimum Data Set (MDS) completed on 2/1/25 documents that R8 is a partial/moderate assist with toileting, showering, dressing, and transferring. R8 is occasionally incontinent of urine and always incontinent of bowels. R8 has one stage 2 unhealed pressure injury. R8 is documented as having a Brief Interview for Mental Status (BIMS) score of 13, indicating R8 is cognitively intact. R8's Care Area Assessment (CAA) for Pressure Ulcer/Injury dated 11/14/24, documents R8 was admitted on [DATE]. R8 was admitted to (name of) Hospital on 10/30/24 for weakness and falls. R8 has a past medical history for anxiety, depression, chronic pain, Chronic Obstructive Pulmonary Disorder (COPD), Gastroesophageal Reflux Disease (GERD), Hypertension (HTN), and shingles pain. R8 reports over the past few months she has had an increased number of falls. R8 has lived at an Assisted Living Facility (ALF) for the past 3 years. R8 is independent living until 3 weeks ago when she was moved to assisted living. R8 is having issues with falls and needed more help with medications and Activities of Daily Living (ADL)s. R8 has the following impairments: transfers, gait, balance, Range of Motion (ROM), strength, endurance/activity tolerance, safety awareness/judgment, fall risk, and pain in low back. Benefits for R8 at rehab will be additional physical therapy to address deficits. R8's care plan, dated 11/4/24, documents: R8 is at risk for pressure ulcers and other skin related injuries (dated 11/4/24). Interventions include: Braden Scale to be completed (dated 11/4/24). Keep bed linens wrinkle free and do not use excess pads (dated 11/4/24). Observe skin for redness and breakdown during routine care (dated 11/4/24). Use pressure relieving devices, cushion on wheelchair and off of heels, as indicated (dated 11/4/24). Follow community skin care protocol (dated 11/4/24). Treatments, as indicated, see physician order sheet (dated 11/4/24). Pressure reducing mattress on bed (dated 11/4/24). R8 has impaired skin integrity related to cancerous hyperpigmentation on old site from biopsy, present on admission (dated 11/11/24) Interventions include: Follows with wound Advanced Practice Nurse Practitioner (APNP) for monitoring (dated 11/11/24). R8 has stage 2 pressure ulcer buttock (dated 2/4/25) Interventions include: See Electronic Treatment Administration Record (ETAR) (dated 2/4/25). Follows with APNP for monitoring (dated 2/4/25). 2/20/25: left buttock pressure injury resolved: denuded fragile skin due to healed pressure area (dated 3/13/25). 3/13/25: left buttock pressure injury resurfaced, now stage 2 (dated 3/13/25). Provide treatment as ordered (dated 3/13/25). Assist with repositioning during rounding and cares (dated 3/13/25). Surveyor reviewed R8's medical recorder which documents the following: *Order placed on 11/6/24 to apply z-guard to coccyx every shift. *R8 received a bath on 3/10/25. Certified Nursing Assistant (CNA)- T performed the bath on R8 and documents R8 having a new reopened pressure wound to the left buttocks. *R8's Skin Evaluation form dated 3/12/25 documents, denuded fragile skin due to healed pressure area to the left buttocks. Treatment includes z-guard to coccyx every shift. *R8's Skin Evaluation form dated 3/13/25 documents, left buttocks denuded fragile skin due to healed pressure area. Treatment includes z-guard to coccyx every shift. *R8's Skin Evaluation form dated 3/13/25 documents, Stage 2 full thickness wound pressure injury to left buttocks. Resurfaced 100% smooth, red, granulation, serosanguineous drainage, and moderate exudate present. Cause is pressure. Treatment changed to cleanse with Normal Saline (NS), pat dry, followed by Foam Border Dressing (FBD) to be changed daily and as needed (PRN). Surveyor notes this was the second Skin Evaluation performed for R8 on 3/13/25 which was performed by Licensed Practical Nurse (LPN) Unit Manager/Wound Nurse- E who rounds with the wound care Nurse Practitioner (NP) on Thursdays. On 3/18/25, at 10:19 AM, Surveyor interviewed R8 who was sitting in the recliner on top of a pillow. R8 states she prefers to sit on a pillow due to pressure injuries developing on her buttocks. R8 states she spends most of her time in the recliner sitting on pillows and will occasionally go down to the dining room for meals in her wheelchair. Surveyor observed R8's wheelchair in the corner of the room with a cushion on it. Surveyor reviewed R8's medical record which includes a progress note dated 3/12/25, at 3:16 PM, that documents: R8 had a skin check completed on 3/11/25. R8 had a previous skin condition that had since closed on her left buttocks and is now reopened. Measurements were placed in the skin condition. Treatment was not changed and Wound NP- M will assess and change treatment on 3/13/25. Surveyor notes R8's left buttocks wound was identified on 3/10/25 during her bath and facility is documenting the wound was identified on 3/11/25 and documenting treatment be changed on 3/13/25 when Wound NP- M rounds, which is 3 days after R8 developed a left buttocks stage 2 pressure injury. On 3/18/25, at 1:23 PM, Surveyor interviewed CNA- U who indicates R8 spends all her time in the recliner. CNA- U indicates she has not seen R8 use her bed and staff offer to take R8 to the dining room for meals and sometimes R8 will go but most of her meals are in her room while sitting in the recliner. R8 does not attend facility activities. CNA- U states R8 is continent and will press her call light for assistance to go to the restroom. On 3/18/25, at 1:28 PM, Surveyor interviewed Registered Nurse (RN)- K who states she will complete a comprehensive assessment, notify the unit manager, family, and Medical Director (MD) if she is told by a CNA of a new wound or discovers a new wound on a resident during an assessment. RN- K states she is a Registered Nurse and can perform comprehensive assessments and many nurses on the floor are LPNs who are not able to perform comprehensive assessments. RN- K then stated she doesn't work at the facility very often and relies on the facility CNAs for skin checks and assessments since RN- K does not see resident's skin on a regular basis. RN- K indicates the facility offered R8 a cushion to use for her recliner and R8 declined, indicating R8 prefers to sit on pillows. On 3/18/25, at 1:49 PM, Surveyor interviewed CNA- T who found R8's new pressure injury on 3/10/25, during R8's bath. CNA- T states she notified the nurse on 3/10/25, after identifying a new pressure injury on R8. CNA- T does not recall who that nurse was and then states she always updates the nurse with any new skin finding during cares. On 3/18/25, at 1:49 PM, Surveyor interviewed LPN- P who states she will fill out the facility Skin Injury and Pressure Injury packet if a CNA notifies her of a resident having a new pressure injury. LPN- P states the Skin Injury and Pressure Injury packet has a checklist for nursing staff to complete and fill out. This check list is then placed in the gold basket in the nursing station for the unit manager to pick up and review. LPN- P states the unit managers round daily to pick up the Skin Injury and Pressure Injury packets. LPN- P states measurements and wound descriptions are completed and included in the Skin Injury packets. LPN- P also states measurements and wound descriptions should be obtained immediately and called in to the MD with updates and possible orders. On 3/18/25, at 2:01 PM, Surveyor interviewed LPN Unit Manager- D who states floor nursing staff will notify the unit manager, update family, and contact the MD with any new wounds or pressure injuries. LPN Unit Manager- D then stated Wound NP- M will then evaluate the resident on Thursdays during wound care rounds. LPN Unit Manager- D states the Skin Injury and Pressure Injury packet are completed by nursing staff when a new pressure injury is identified. LPN Unit Manager- D states if the floor nurse is an LPN, the LPN will get the unit manager or an RN to complete a comprehensive assessment to obtain measurements, depth, staging, and wound bed description. LPN Unit Manager- D acknowledged she will get the 1st floor unit manager who is an RN or the DON to complete a comprehensive assessment if she is contacted by nursing staff with a new pressure injury. LPN Unit Manager- D states the comprehensive assessment is completed on the day the pressure injury is identified. On 3/19/25, at 9:32 AM, Surveyor interviewed LPN Unit Manager- D who states the nurse will complete a comprehensive skin assessment to include measurements, depth, surrounding tissue and if there is any drainage, if a new pressure injury is identified. LPN Unit Manager- D then states the facility staff aim to complete the comprehensive assessment right away, but the facility has 24 hours to complete a full comprehensive assessment. LPN Unit Manager- D states Wound NP- M sees every resident in the facility with a pressure injury. Surveyor notified LPN Unit Manager- D of concerns with R8 having a pressure injury identified on 3/10/25 during her bath and the first comprehensive assessment completed in R8's medical record is documented on 3/13/25. Surveyor notified LPN Unit Manager- D R8 did not receive treatment orders until 3/13/25. LPN Unit Manager- D states she will investigate these concerns. On 3/19/25, at 9:56 AM, Surveyor reviewed R8's medical record and notes wound care was not performed on 3/15/25 and R8 declined wound care treatment on 3/16/25. Surveyor notes R8 went two days without receiving wound care treatment. On 3/19/25, at 10:24 AM, Surveyor interviewed LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E who state the facility performed a skin sweep on 3/12/25 and R8 was identified as having a new pressure injury to her left buttocks. Surveyor asked LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E if they were aware of R8 having documentation of a new pressure injury on her left buttocks on 3/10/25. LPN Unit Manager/Wound Nurse- E asked who documented the new wound on 3/10/25. Surveyor notified LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E of R8 having documentation of a new pressure injury on 3/10/25 during her bath. LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E then notified Surveyor that R8 had changed her bath day from Monday PMs to Wednesday AMs due to R8 wanting AM baths. LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E then states R8's wound was identified on 3/12/25 during the facility skin sweep. Surveyor notified LPN Unit Manager- D and LPN Unit Manager/Wound Nurse- E of concerns with R8 having a new pressure injury documented on 3/10/25 and no comprehensive skin assessment, wound care orders, care plan updates, or wound care provider notification until 3/13/25. LPN Unit Manager- D states the facility had orders already going for z-guard. LPN Unit Manager/Wound Nurse- E states FBD dressings were requested by R8 for additional padding. On 3/19/25, at 10:42 AM, LPN Unit Manager- D notified Surveyor skin checks with measurements were performed on 3/11/25 for R8 and is unsure why it is not documented in R8's medical record. On 3/19/25, at 1:06 PM, Surveyor interviewed Director of Nursing (DON)- B. Surveyor asked when an assessment of a new wound should take place. DON-B stated it should be assessed when found and reported to the Medical Director (MD) and Power of Attorney (POA). Treatment orders should be obtained. DON-B stated the facility wound nurse should be updated so the resident can be added to wound rounds which occur every Thursday. DON-B stated the nurse who finds the wound should complete a skin packet and incident report. Surveyor asked what should be included in the initial wound assessment. DON-B stated it should include the location, drainage, color of the wound, and measurement. DON-B stated that this information is documented in the skin packet and in the electronic medical record. Surveyor asked about the facility wide skin sweep. DON-B stated that the sweep was completed on 3/11/25. DON-B stated that it is a different electronic program than the facility's electronic health record. Surveyor asked if staff nurses would be able to see what is documented on the skin sweep. DON-B indicated that staff nurses would not be able to see the information from the skin sweep. Staff nurses need to use the facility's electronic medical record to view any documentation on residents. On 3/20/25, at 7:38 AM, Surveyor observed R8's wound care with LPN Unit Manager/Wound Nurse- E and Wound NP- M, Surveyor observed a Stage 2 pressure injury to the left buttocks approximately the size of a dime. No drainage was observed, wound bed was red and smooth and surrounding skin was observed to be dry and intact. Surveyor observed white cream on R8's buttocks and surrounding skin. Surveyor observed Wound NP- M notify LPN Unit Manager/Wound Nurse- E of R8's left buttocks pressure injury measuring 0.6 x 0.6 x 0.1. Wound NP- M asked R8 if she would sleep in her bed and R8 declined. Following wound care, Surveyor interviewed Wound NP- M who states she has offered R8 a cushion for her recliner in the past and R8 declines. Wound NP- M states R8 was previously using a donut shaped cushion to sit on and Wound NP- M asked R8 and family not to use the donut shaped cushion due to it putting pressure on R8's buttocks in certain spots. Wound NP- M has not seen the donut shaped cushion for a while and states she is unsure if R8's son took the cushion home. Wound NP- M acknowledged R8's left buttocks pressure injury measuring 0.6 x 0.6 x 0.1 and being larger than the previous wound care rounding performed on 3/13/25 measuring 0.2 x 0.2 x 0.1. Wound NP- M states the wound looks better but is probably bigger due to noncompliance. On 3/20/25, at 1:07 PM, Surveyor notified DON- B the following concerns for R8: a new stage 2 pressure injury to her left buttocks was identified on 3/10/25 and it was not assessed comprehensively until 3/13/25 when Wound NP- M assessed the area as a stage 2 pressure injury. The skin sweep completed on 3/11/25 was not documented in R8's medical record for all nursing staff to view. R8's care plan was not updated until 3/13/25 which was three days after the wound was found. R8's wound treatment was not completed on 3/15/25, and R8 declined wound care treatment on 3/16/25. Surveyor notes to DON- B that R8 went two days without receiving wound care treatments. DON- B acknowledge these concerns and states that she is familiar with the facility having 24 hours to complete a skin check for residents that are newly admitted . DON- B then stated she is not aware of what is the clock or timeframe for skin checks for newly identified pressure injuries. DON- B indicates her expectation for the nurse would be to contact the MD and complete the skin injury packet the same day. Surveyor asked DON- B if measurements and wound bed description are included in the assessment completed the same day by the nurse. DON- B stated (name of medical group) providers ask what the wound looks like but don't always ask for measurements. DON-B states she doesn't want the [TRUNCATED]

Based on observation, interview, and record review the Facility did not ensure residents maintained acceptable parameters of nutritional status for 1 (R6) of 1 resident reviewed for weight loss. R6 experienced severe weight loss over a period of 6 months, during which time R6 developed pressure injuries. The weight loss was not prescribed, and no new interventions were implemented to prevent R6's weight loss. Surveyor was unable to locate any documentation that the Facility updated the Power of Attorney or R6's physician. Findings include: The facility policy and procedure titled, Nutritional Screening, Assessment, and Monitoring and last revised 11/2022, documents, in part: Policy Statement It is the policy of Ascension Living that a comprehensive nutritional assessment is completed upon admission, annually, or when a significant change occurs for each resident. Policy Interpretation and Implementation A. The RD (Registered Dietician) should complete a comprehensive nutritional assessment on each resident according to the admitted and MDS (Minimum Data Set) schedule, and clinical nutrition need. B. A validated malnutrition screening tool will be utilized to determine malnutrition risk, as per community policy. C. The individualized plan of care will be written and reviewed regularly when changes are noted. The plan of care will be shared with and agreed upon by the resident and/or representative. D. A member of the food and nutrition services team will participate in the IDT (Interdisciplinary Team) care planning process and meetings according to the community's policy . F. The dietitian will monitor regularly to ensure residents maintain acceptable parameters of nutritional status. G. Residents are offered a therapeutic diet when it has been determined that there is a benefit . Procedures C. Interval assessment / Progress note will be completed for the following but are not limited to: 1. Resident with a confirmed significant change in weight will receive a re-assessment as soon as possible but no longer than 5-days after notification, and the follow-up note will be done a minimum of weekly until weight stabilization occurs or there is a determination in the plan of care to discontinue weekly weights. 2. Resident with insidious weight loss (gradual unintended progressive weight loss over an extended time). 3. Residents with a new pressure injury will receive a re-assessment as soon as possible, but no longer than 5 days after notification, and the follow-up note will be done minimally monthly - until pressure injury is resolved . The Facility Policy and Procedure titled, Procedure: Assistance with Meals and last revised 1/1/2025, documents, in part: Purpose Statement It is the policy of Ascension Living that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation A. Dining Room Residents 1. All residents are encouraged to eat in the dining room for socialization . 4. Residents who require assistance with eating should be provided with self-help devices and/or provided help as needed. 5. Residents who are unable to feed themselves should be fed with attention to safety, comfort, and dignity . R6 was admitted to the facility on [DATE] with pertinent diagnoses that include type 2 diabetes mellitus, cardiomyopathy, heart failure, cognitive communication deficit, mild cognitive impairment, and vascular dementia. On 1/30/25, the following diagnoses were added: unspecified severe protein-calorie malnutrition and encounter for palliative care. R6's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/16/2024, documents a Brief Interview for Mental Status (BIMS) score of 04, indicating that R6 has severe cognitive impairment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was coded to have a mechanically altered diet. The MDS documents no weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. The MDS documents that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6 has an activated Power of Attorney (POA). R6's Significant Change MDS with an assessment reference date of 2/6/2025 does not document a BIMS assessment. The MDS documents that R6 was assessed to have no behaviors exhibited during the look back period. R6 is always incontinent of bowel and bladder. No swallowing disorders were noted, R6 was coded to have a mechanically altered diet. The MDS documents that Weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months occurred and R6 was not on a physician prescribed weight loss regimen. The MDS documents that no pressure injury was present, but that R6 is at risk of developing pressure injuries. R6's care plan documents Nutritional Status, (R6) is at risk for impaired nutrition related to end stage diagnosis. Goal: (R6) will have nutritional needs met. (R6) is offered diet as prescribed, see physician order sheet. Start 11/10/21 Provide supplement as ordered. Start 11/10/21 Provide assist as needed. Start 12/27/22 Surveyor noted R6 had previously been on hospice from 9/30/21 to 9/14/22. R6 began hospice services again on 1/30/25. R6's care plan documents Dehydration/Fluid Maintenance. (R6) has a potential for fluid volume deficit related to . poor vision, may need staff assist with fluid intake use of diuretic for dx (diagnosis) of CHF (congestive heart failure). Goal: (R6) will be free from signs and symptoms of dehydration and will be well hydrated as evidenced by physical conditions. Keep fresh water, or beverage of preference, in reach. Start 4/4/22 Assess (R6's) preferred fluids and provide. Start 4/4/22 Offer 120 mL fluids with medication pass. Start 4/4/22 Staff to assist with all hot liquids and (R6) to drink hot liquids while sitting at table only. Start 4/4/22 Surveyor noted R6 did not have a diuretic currently prescribed. Surveyor noted there were no updates to R6's care plan when R6 was taken off hospice and when R6's diuretic was discontinued. Surveyor also noted that there were no new interventions when R6's weight loss was discovered. R6's physician order dated 10/21/22 documents Monthly weight - due on the first Wednesday of every new month. Document refusals . R6's physician orders dated 10/31/23 document diet: consistent carbohydrate, pureed diet . and diet: thin liquids. R6's physician order dated 1/28/25 documents severe protein calorie malnutrition: hospice to eval (evaluate) and treat. R6's physician order dated 1/30/25 documents admit to (name of) Hospice. While investigating a Facility Reported Incident Surveyor reviewed R6's electronic medical record (EMR) and found R6's weights progressively declined from 7/3/2024 to the last weight taken on 1/26/25. Prior to 7/3/24, R6's weight had been stable. On 7/3/24 R6's documented weight was 131.0 pounds. On 8/7/24 R6's documented weight was 124.2 pounds. On 9/4/24 R6's documented weight was 120.8 pounds. On 10/2/24 R6's documented weight was 119.4 pounds. On 11/6/24 R6's documented weight was 118.0 pounds. On 12/10/24 R6's documented weight was 119.0 pounds. On 1/15/25 R6's documented weight was 108.2 pounds. On 1/24/25 R6's documented weight was 105.9 pounds. On 1/26/25 R6's documented weight was 107.0 pounds. Surveyor noted that there is an active physician order for monthly weights. Despite this order, Surveyor noted that 1/26/25 was the last recorded weight for R6. Surveyor noted that R6 experienced a severe weight loss of 18.32% from 7/3/24 to 1/26/25 (6 months), 10.39% from 10/2/24 to 1/26/25 (3 months), and 10.8% from 12/10/24 to 1/26/25 (1 month). R6's annual Nutrition Risk assessment dated [DATE], completed by Registered Dietician (RD)-Y, documents under the food and nutrition history section 4 oz ensure enlive TID (three times daily). R6's feeding ability is marked as extensive assistance. Surveyor noted per staff interviews (which follow) it was determined that R6 is totally dependent on staff for eating and drinking, RD-Y did not mark R6 as total dependence on assessment. Meal intakes (average) was marked as 51-75%. R6 has chewing difficulty and no swallowing problems per assessment. Surveyor noted R6 is missing many teeth per an interview with staff. At the time of the assessment the current weight was noted as 120.8 pounds (recorded in September by Facility) and the weight trend for last 6 months was marked as stable. Comments/recommendations were Resident seen for annual review . Intake fair at meals. Mostly fed at meals. Weight 120.8 pounds, stable the past 6 months. No new interventions needed at this time. Currently free of pressure injury. Will continue to monitor. Surveyor noted the 7/3/24 weight was 131.0 pounds, and the weight used for assessment is 120.8 which is a loss, not stable. On 8/20/24, R6 had a compliance visit with R6's internal medicine doctor. The follow-up note reads monitor behaviors, dementia, progressive decline, right lower extremity wound. Continue ongoing plan of management/care with close monitoring. R6's quarterly Nutrition Risk assessment dated [DATE], completed by RD-Y, documents under the food and nutrition history section 4 oz ensure enlive TID remained and encourage fluids with medication pass was added. On 11/11/24 a nursing order was added to R6's physician orders to encourage fluids with medication pass - 3 times per day. Provide resident with 240ml with each medication pass. Surveyor noted in an interview with RD-Y it was indicated that this was added due to a nursing initiative. Feeding ability remained extensive assistance and meal intakes (average) were marked again as 51-75%. Chewing difficulty was indicated and no swallowing problems were noted. R6's current weight is recorded as 118 pounds and the weight trend in the last 6 months was marked as stable. Comments included resident seen for quarterly review . Intake fair at meals. Needs assistance at meals. Weight 118 pounds, stable the past 6 months. No new interventions needed at this time. Currently free of pressure injury. Will continue to monitor. Surveyor noted that R6's 7/3/24 weight was 131.0 pounds, and the weight used for assessment is 118.0 which is a loss, not stable. R6's monthly visit note from (name of NP group), written by the APRN-BC (Advanced Practice Registered Nurse-Board Certified) after a face-to-face visit on 11/20/24, documents (R6) is a [AGE] year-old . being seen today for a follow-up visit. Chart and medications reviewed. Patient and staff interviewed. (R6) is compliant with medication regimen. (R6) is transferred by Hoyer lift and enjoys spending time sitting in Geri chair with the other residents. Weight this month is 118.0 pounds, which is down from 125 pounds in June 2024 and down from 127.2 pounds in November 2023. Staff continue to assist with meals. Discussed weight loss with nurse manager. Voicemail left for daughter/POA. Will discuss potential hospice services with POA given weight loss. Surveyor noted that R6's weight is being recorded as trending down and the information is shared with Facility staff by (name of nurse practitioner (NP) group) APRN-BC. An email, written on 11/26/24, from Register Nurse (RN) Unit Manager-C to R6's POA was provided to Surveyor. The email documents .we did have a care conference last week, (name of NP group) was present as well. I attempted to reach out and contact you during the meeting. I left a message. I'm sorry to hear you didn't receive a notice prior to the meeting . Surveyor noted there is no mention of R6's weight loss. This email was provided when Surveyor requested documentation that R6's POA was updated by the Facility regarding R6's weight loss. R6's follow up visit note from (name of NP group), written by APRN-BC after a face-to-face visit with R6 on 12/9/24, documents (R6) is a [AGE] year old . being seen today for a follow-up visit. Chart and medications reviewed. Patient and staff interviewed. (R6) is compliant with medication regimen. (R6) is transferred by Hoyer lift and enjoys spending time sitting in Geri chair with the other residents. (R6's) most recent weight is 118.0 pounds, which is down from 125 pounds in June and down from 127.2 pounds in November 2023. Staff continue to assist with meals. Voicemail message left for daughter/POA to discuss potential hospice services with POA given weight loss. R6's clinical note written by the (name of NP group) APRN-BC on 12/18/24, which was communicated with POA and Registered Nurse at Facility documents .(R6) most recent weight is 119.0 pounds, which is down from 125 pounds in June 2024 and down from 127.2 pounds in November 2023. Staff continue to assist with meals and R6 drinks ensure. Discussed vascular dementia, weight loss/protein calorie malnutrition with daughter/POA and nurse manager. (R6) has a painful lower extremity venous ulcer full thickness wound and a chronic scab to the right side of nose. Daughter/POA notes that this area on right lower extremity has been an area of concern by dermatologist in the past - likely a skin malignancy. POA also reports she would like comfort goal of care for (R6). Plan for a hospice referral due to vascular dementia, weight loss and protein calorie malnutrition. POA is in agreement. Order given to Nurse Manager. R6's clinical note written by the (name of NP group) APRN-BC on 1/16/25, which was communicated with Nurse Manager at Facility documents Chart review completed. Met with (R6) who is resting comfortably in bed. (R6) states is tired and would like to sleep . Spoke with Nurse Manager and reviewed. Daughter had wanted dermatology consult for chronic wound on right shin and this was being scheduled. Called and spoke with daughter/POA. Discussed chronic wound to right shin and concern for its removal and biopsy which could possibly create an even larger wound area, and if grafting was needed would actually create 2 wounds. Also discussed weight loss, recorded weight show (R6) has lost another 10 pounds in the last month, current weight 108 pounds. POA under impression that biopsy could be completed at SNF (skilled nursing facility). Discussed that was not possible and (R6) would need to be sent for outpatient . POA has decided does not want dermatology referral and would like wound team at SNF to continue treating the wound as they have been. Discussed hospice referral . At the end of the conversation POA did agree to have a hospice evaluation for (R6) and have hospice contact her to discuss and answer all her questions. Called and spoke with 1st Floor Nurse Manager- who will cancel dermatology referral . (R6's) progress note, written by RN Unit Manager-C dated 1/17/2025, documents Writer spoke with (name of NP group), who had followed up with family regarding dermatology consult. POA has decided that is not the route she wants to go. POA stated would prefer to move towards hospice . Surveyor noted no documentation of the Facility discussing weight loss with POA or R6's physician was located. On 1/17/2025, R6 was seen by the APNP (Advanced Practice Nurse Practitioner) for a monthly follow up appointment. The Chief Complaint section documents APNP monthly compliance visit - dementia with decline, anxiety, plans for hospice. Surveyor noted was not able to find documentation of the weight loss being discussed with APNP in the evaluation or nursing concerns. R6's Interdisciplinary note, written by RD-Y, dated 1/29/25, documents aware of current weight 107 pounds which reflects a significant weight loss of 10% in the past month. Intake appears to have decreased slightly but not significantly. Continues to accept 4oz ensure enlive TID between meals. Family has decided to proceed with hospice care. Will continue to monitor. Upon admission to hospice the hospice provider completed a Hospice Interdisciplinary Group Comprehensive Assessment and Plan of Care Update Report which has the following pertinent orders dated 1/30/25. Skilled nursing to educate patient/family on dietary modification to improve overall nutrition as tolerated including Providing small, frequent meals, offer small amounts of fluids frequently, offer but do not force food/fluids. Skilled nursing to educate caregivers on offering, but not forcing food/fluids. Surveyor noted these hospice orders were not integrated into R6's care plan. On 3/19/25, at 1:23pm, Surveyor interviewed Hospice RN-AA about monthly weights. RN-AA stated that facilities in general do monthly weights, when on hospice, facilities can stop taking weights. Hospice can request for them to take weights though. Surveyor asked RN-AA what interventions were in place for R6 weight loss. Hospice RN-AA told Surveyor weight loss is a normal part of the process with R6's hospice diagnosis of unspecified severe protein calorie malnutrition with prognosis of 6 months or less if the disease runs its normal course. Per RN-AA even if R6 took in more calories R6 would lose weight due to the diagnosis. It is completely normal with R6's diagnosis and being on hospice in general for weight loss to occur. Surveyor asked about the Interdisciplinary Group orders for skilled nursing to educate patient/family on dietary modification to improve overall nutrition as tolerated including Providing small, frequent meals, offer small amounts of fluids frequently, offer but do not force food/fluids. Skilled nursing to educate caregivers on offering, but not forcing food/fluids. Per RN-AA skilled nursing refers to the hospice RN and they should educate staff how to offer food and fluids. This is part of the normal decline, a resident will not eat/drink as much because it is part of the dying process. Surveyor asked if resident is actively dying and was told no declining now. Surveyor asked if small frequent meals should be an order and was told no not necessarily. Staff should offer fluids at regular intervals and feed at mealtime, RN-AA was not sure if R6 gets snacks. RN-AA informed Surveyor it is fairly certain R6 is not eating much as that is part of R6's end of life diagnosis. Surveyor asked RN-AA about R6's pressure injury and who monitors it. RN-AA stated the facility cares for it and that pressure injuries are fairly common at the end of life, especially with R6's diagnosis due to the lack of protein. Surveyor asked if R6 needs a protein supplement or other interventions and was told not necessarily as pressure injuries are part of the decline. R6's significant change Nutrition Risk assessment dated [DATE], completed by RD-Y, documents under the food and nutrition history section 4 oz ensure enlive TID and encourage fluids with medication pass remained. Feeding ability remained extensive assistance and meal intakes (average) were changed to 26-50%. Chewing difficulty was indicated and no swallowing problems were noted. R6's current weight was recorded as 107 pounds and the weight trend in the last 6 months was recorded as significant weight loss. Comments/Recommendations are written as (R6) seen for significant change assessment . Intake fair-poor at meals. Needs assist at meals. Weight 107 pounds, weight loss of 9% times 1 month noted from December to January. Family has opted for hospice care. No new interventions needed at this time. Right shin venous/stasis wound noted. Will continue to monitor. On 3/19/25, at 12:35pm, Surveyor interviewed RD-Y and asked about any intervention changes when R6's weight loss was detected, as Surveyor could not locate any in R6's medical record. RD-Y informed Surveyor that R6 was palliative care so RD-Y was not super aggressive in developing interventions for R6. RD-Y stated that in January RD-Y saw R6 and that R6 gets ensure. RD-Y stated that in January R6's family proceeded with hospice care. Surveyor asked if RD-Y updated R6's care plan and was told if a resident is losing weigh the goal stays the same, to provide nutritional needs. RD-Y removed the part about R6 not having a weight change from the care plan. RD-Y stated the goal was to provide food and fluids to try to prevent further weight loss, this is for comfort. Surveyor asked about improving R6's nutrition and was told RD-Y did not implement further interventions because hospice was being discussed with the family. RD-Y saw a gradual decrease in R6's appetite, comfort was the goal. Surveyor noted R6 had no interventions attempted which could provide comfort for R6 and prevent further weight loss. Surveyor noted R6 had been on hospice previously from 9/30/21 to 9/14/22, 2 years ago. R6's progress note written by Licensed Practical Nurse (LPN)-X dated 2/19/2025, at 3:39pm, documents bed bath given. A 5.2cm (centimeter) x 4.5cm darkened area was noted on right heel. On call RN (Register Nurse) Supervisor aware and will assess. Heels elevated on pillows. Skin prep to be applied q shift. R6's progress note, written by LPN-X dated 2/20/2025, at 2:52pm, documents on 2-19-25 a 1.0cm x 2.0cm, darkened area was found on resident's right heel during a bed bath and skin check. On call RN Supervisor was updated, (name of medical group) was updated, and POA was updated. Skin prep ordered and a Prevalon boot to right foot. No pain to area. Surveyor noted there was a discrepancy in R6's right heel measurements listed on 2/19/25 and on 2/20/25 when R6's physician and POA were informed. Surveyor noted that on 3/6/25, a DTI to the right medial heel is also discovered and on 3/13/25, the right medial heel DTI progressed to a stage 3 pressure injury. Surveyor notes no documentation of nutritional interventions are found. R6's interdisciplinary note, written by RD-Y dated 3/18/25, documents monitoring wounds to RLE (venous ulcer-suspicious for cancerous lesion) and Right lateral heel (DTI) (Deep tissue injury). Both are stable. Patient admitted to hospice 1/30/25. Oral intake varies from poor to good although (R6) has had an overall decrease as evidence by significant 13.85% weight loss in the past 6 months. R6 does receive 4 oz ensure enlive TID for additional calories/protein. Due to end stage diagnosis weight and wound changes unavoidable. Will continue to offer supplement and food/fluid as patient desires. Surveyor noted R6's RD note dated 3/18/25 was written a month after R6's right heel DTI was found and did not document the R6's right medial heel had progressed to stage 3. Surveyor noted R6 had a severe weight loss (more than 10%) over 6 months, not significant (less than 10%) as indicated in the 3/18/25 note. Surveyor noted no further assessment completed related to R6 oral intake decreasing, for instance determination of what food R6 likes and may be more likely to consume. Surveyor noted was unable to locate any documentation why, with only a slightly decreased intake, R6 would suffer severe weight loss. Surveyor noted that R6 had no new interventions identified for R6's weight loss other than hospice services. On 3/18/25, at 1:50pm, Surveyor interviewed LPN-H who confirmed R6 is supposed to get monthly weights. On 3/18/25, at 2:20pm, Surveyor interviewed wound LPN-E who stated R6 has lots of issues. Regarding weight loss, R6 is on hospice so decline is expected. If resident is on hospice facility staff do not do weights unless hospice orders them. Surveyor noted an active physician order for monthly weights dated 10/21/22. On 3/18/24, at 3:20pm, Surveyor interviewed LPN-X regarding weight loss. LPN-X states that the unit nurse manager tracks weights. R6 is on hospice, is fed by staff and accepts food but is not a big eater. Weight loss was happening before R6 was on hospice. R6 has very few teeth so gets a soft diet. Prefers food warm and with coffee. Surveyor noted on 12/10/21 R6's POA elected eye care from the Facility provider, dental was not selected. On 3/19/25, at 1:54pm, Surveyor interviewed RN Unit Manager-C who stated that the RD monitors weights and then staff talk at the daily meetings about this information. On 3/20/25, at 8:08am, Surveyor interviewed Certified Nursing Assistant (CNA)-J about how R6 is set up for meals and was told R6 is a total assist of puree diet. Staff feed R6 every meal. Staff stop and give sips of water during the day. If R6 refuses or will not finish the whole meal it is entered in the charting as the percent eaten. R6 has been a total assist a long time, more than a year. On 3/20/2025, at 9:53 am, Surveyor interviewed RN Unit Manager-C and asked for evidence the Facility informed R6's POA or physician of the weight loss. Surveyor noted only (name of NP group) notes were provided that showed POA being updated by (name of NP group) APRN-BC. Surveyor asked for evidence R6 was being fed all 3 meals and was told the January intake forms were provided to Surveyor, RN Unit Manager-C knows there are holes in the documentation, however, assures Surveyor that they check whenever they work that everyone is being fed appropriately. Surveyor noted while reviewing the intake forms many time slots (holes) were left blank hence not documented if a meal was attempted. In 31 days, 44 meals were not recorded and 49 were documented on. Surveyor asked what happens with the hospice plan of care report and was told staff are to read it for reference. When asked if the small meals and snacks should have been added to the care plan the response was RN Unit Manager-C felt the ensure between meals was the snack and resident could eat as much of meal as wanted. On 3/20/25, at 10:00am, Surveyor interviewed RD-Y again. Surveyor asked why there is a difference in charting. The MDS reads R6 is totally dependent, Kardex reads max assistance, meal ticket has needs assist and RD assessments show extensive assistance. Per RD-Y extensive assistance has no set definition other than the resident needs someone with them the whole time. The meal ticket with needs assist means the resident needs to be fed. Surveyor asked why R6 had a puree diet and was told the altered diet had been in place even before the current order. Per RD-Y, R6 loves puree and has never complained. Surveyor asked why RD-Y referred to weight loss as significant when it is severe and was told it is the verbiage RD-Y uses, RD-Y does not use the severe category like Surveyors. Again, Surveyor clarified that no interventions were attempted in the last 6 months when weight loss occurred and was told none were added. On 3/20/25, at 10:18am, Surveyor interviewed R6's POA and asked if they had been notified of R6's weight loss. R6's POA responded that R6's weight loss had been mentioned casually. R6's POA stated they bring food in for R6 and R6 has no trouble eating the food. POA felt R6 gets lots of skin tears and feels the bad nutrition would affect skin integrity. On 3/20/25, between 12:40pm and 12:55pm, Surveyor observed R6 being assisted to eat by LPN-H. R6 stated help me multiple times during the observation, LPN-H would ask what can I help you with and R6 would reply food. R6 was assisted to drink coffee between bites of food. Surveyor requested labs from the RN Unit Manager-C and was provided labs done on 2/16/25 and 2/17/25. On 3/20/25, at 1:30pm, Surveyor asked RN Unit Manager-C for labs prior to the 2025 labs provided and was told labs had not been completed in quite a while because R6 was on hospice, off hospice and back on again, labs had not been done in over a year. On 3/20/25, at 2:45pm, Surveyor interviewed MD-Z and asked if there was a significant weight change in a resident should they be notified and was told not directly. MD-Z makes rounds at several facilities, staff should contact the on-site NP who will then contact MD-Z if there are concerns. Surveyor asked if MD-Z was aware R6 had weight loss and was told MD-Z last saw R6 in February and knows R6 lost 10 pounds in one month. Surveyor asked if any interventions should have been started and was told the family was thinking about hospice. With R6 having advanced dementia and the leg wound MD-Z would expect a decline, R6 gets ensure and was eating fair to good, MD-Z felt the RD could handle. On 3/20/25, at 2:06pm, Surveyor spoke with Director of Nursing (DON)-B regarding R6's weight loss. DON-B stated they were not aware of the issue. Surveyor stated no interventions being put in place is a concern and was told during daily clinical report significant changes are brought up, nursing would not be involved with nutrition interventions. Surveyor also stated that the RD charted R6's weight as stable in assessments when weight loss was occurring. Surveyor told DON-B they had requested documentation that R6's POA or MD had been updated about the weight loss by the Facility and none had been provided. Surveyor also discussed the intake forms not being charted on daily so there is no evidence R6 is being fed three meals a day. After the weight loss a pressure injury developed. No further information was provided at the time of write up regarding the severe weight loss R6 experienced that was not prescribed. No new interventions were implemented to prevent R6's weight loss.

Based on observations, interviews and record review, the facility did not ensure residents received care, consistent with professional standards of practice, and the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for that 1 (R3) of 3 residents reviewed for pressure injuries. * R3 did not receive pressure injury treatments for a pressure injury that was discovered during admission. There was no evidence that R3's physician was notified of R3's newly discovered pressure injury and there was a delay in implementing pressure relieving interventions and pressure injury treatments for R3. During this delay, R3's pressure injury increased in size and the condition deteriorated while they were not receiving treatment and interventions. Findings include: The facility procedure titled Pressure Injury Assessment/Treatment dated as last approved July 2024 documents (in part): .The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries . Interventions/ Care Strategies: Pressure injury treatment requires a comprehensive approach, including and not limited to: C. Preventative measures to reduce the risk of further tissue loss. E. Interventions that increase the potential for healing. 1.) R3 was admitted to the facility on [DATE] with a diagnoses that includes history of fall, open reduction and internal fixation surgical procedure for fracture intertrochanteric fracture to the femur, protein - calorie malnutrition, Parkinson's disease and neurocognitive disorder with Lewy bodies. R3's initial MDS (minimum data set) with an assessment reference date of 2/1/2025, documented a BIMS (brief interview mental status) score of 7 which indicates severely impaired cognition for R3. R3 is assessed as being substantial to maximal assist for rolling left and right and is dependent for chair/bed to transfers & toilet transfer. R3 is assessed as always being incontinent of urine and bowel. R3's pressure injury/skin prevention care plan dated 1/28/2025 documents under the interventions section: Observe skin for redness and break down during routine care, treatments- as indicated- see physician order sheet, pressure reducing mattress on bed. Use pressure relieving devices, cushion on wheelchair and off heals, as indicated. R3's discharge report from the hospital dated 1/28/2025 does not document any wound treatment or an open area to R3's heel. R3's initial skin assessment dated [DATE] and completed by RN-I documents: Pressure injury to left upper heel. Tissue type granulation. Light exudate. Measurements 0.2 x 0.3 x 0.1(centimeters); Under the stage it section it documents, further assessment required. Surveyor reviewed R3's electronic medical record and was unable to locate any evidence that R3 received treatment to R3's left upper heel pressure injury from 1/28/25 to 1/30/25. Surveyor also was unable to locate any interventions that were put in place to reduce pressure for R3's newly discovered pressure injury as documented on 1/28/25. Surveyor was unable to locate any evidence that R3's physician was notified and consulted of R3's pressure injury to the left upper heel as documented on 1/28/25. R3's initial visit document dated 1/29/25 and completed by a Nurse Practitioner (NP) documents: Skin-no masses, no rashes, no lesion on exposed skin, dressing to right hip, clean dry and intact. Surveyor could not find any documentation, related to a physician or NP being updated on the pressure injury observed on admission. The NP note dated 1/29/25 did not include any details on the pressure injury to R3's left upper heel as documented on 1/28/25. R3's MAR (Medication Administration Record) and TAR (Treatment Administration Record) does not document any wound treatment for R3 from 1/28/25 to 1/30/25. R3's skin assessment dated [DATE] documents: Full thickness wound/ pressure injury to left upper heel. Tissue type 100% slough. Moderate exudate. Measurements 0.8 x 0.5 x 0.1 under stage it documents, Unstageable slough and or eschar. R3's pressure injury care plan documents new interventions put in place as of 1/30/25 which included: Prevalon boots on while in bed, every shift; air mattress, Prevalon boots, repositioning, and provide treatment as ordered. R3's physician order dated 1/31/25 documents: Change dressing to left heel - once every day, cleanse with normal saline, pat dry, followed by Medi-honey, followed by dressing, change daily and as needed. Surveyor noted that from 1/28/25 to 1/30/25, no documented pressure relieving interventions were put in place. Surveyor noted that from 1/28/25 to 1/30/25, R3 did not receive any treatments to his left upper heel pressure injury. R3's left upper heel pressure injury showed a decline in wound health, as there was an increase in the wound size and a decline in the wound bed of the pressure injury. On 2/10/2025, at 11:56 AM, Surveyor interviewed Registered Nurse (RN)-G regarding pressure injuries. RN-G stated that if there was a new open area discovered, RN-G would measure the area, and call the MD (medical doctor) to update them. RN-G stated the expectations after finding a pressure injury would be to place orders received in the medical record. RN-G informed Surveyor that an update to the next shift would also be expected, as staff would place the concern on the follow up board, so upcoming shifts know to monitor and document on the new concern or condition. On 2/10/2025, at 1:41 PM, Surveyor interviewed Licensed Practical Nurse (LPN) Manager-C who stated that if a new area is discovered on admission, the floor nurse would contact the MD. The floor nurse would be expected to get new orders for treatment. LPN Manager-C stated the facility expects any new orders received to be started and to be documented in the resident's medical record. LPN-C stated the only way LPN Manager-C would know if there is a new pressure injury area is by going back and reviewing progress notes and assessments. LPN Manager-C informed Surveyor that there is nothing in the electronic health record that triggers or notifies LPN Manager-C of new pressure injuries. LPN Manager-C informed Surveyor that LPN Manager-C was the person that was responsible for reviewing residents on the third floor, but that LPN Manager-C does not review residents every day. Surveyor requested R3's wound documentation and was provided with R3's facility skin evaluations. Surveyor was advised that LPN Manager-C is the wound care nurse and was informed that LPN Manager-C is not wound certified and rounds with a wound nurse practitioner (NP) on a weekly basis. Surveyor was informed that the wound NP is the one who completed R3's wound assessments and measurements with LPN Manager-C. On 2/10/2025, at 1:53 PM, Surveyor informed LPN Manager-C of the above findings. Surveyor informed LPN-Manager-C that R3 had no treatment in place or MD update documented that Surveyor could locate in R3's medical record. LPN Manager-C stated no dressing was in place on 1/30/2025 when LPN Manager-C completed wound assessment. LPN Manager-C stated to have looked at R3's physician orders and stated that Prevalon boots were ordered. Surveyor explained to LPN Manager-C that this order wasn't started until after 1/30/2025. Surveyor explained there was a lack of documented updates to to R3's physician and no documented treatment completed from admission until 1/30/25. Surveyor verbalized the concern that during the days of no treatment or interventions there was documented decline to R3's pressure injury. On 2/10/2025, at 2:07 PM, Surveyor interviewed LPN Manager-C whom stated LPN Manager-C was not able to find any documentation that R3's physician was updated or that new treatment orders by RN-I (the nurse that completed initial wound assessment) that documented that R3 received treatment or had interventions in place for R3's left upper heel pressure injury were put in place after R3's pressure injury was discovered upon admission. On 2/10/2025, at 2:37 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked DON-B if three was any additional information regarding concerns that R3's physician was not updated and the noted delay in treatment to R3's left upper heel pressure injury. DON-B stated expectations of nursing staff is to update MD on new areas and to document any new orders received. DON-B stated that DON-B would need to look through R3's medical record and get back to surveyor. On 2/11/2025, at 10:15 AM, Surveyor observed wound care for R3. Surveyor was able to confirm the documentation of R3's left upper heel pressure injury. On 2/11/2025, during the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B, of the above findings. NHA-A and DON-B stated that the wound communication to management was being addressed. No additional information was provided as to why R3 did not get care, consistent with professional standards of practice, and the necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for residents reviewed for pressure injuries.

Based on observation, interview, record review, and policy review, the facility failed to ensure one out of two sampled residents (Resident (R)185) reviewed for tube feeding was provided with tube feeding administration in accordance with physician's orders. The facility failed to administer the prescribed formula and failed to ensure medication (pills) were crushed. R185 was hospitalized on [DATE] with a clogged feeding tube. The facility staff administered R185 medications in a pill form that were not sufficiently crushed which clogged the feeding tube. R185 was hospitalized and a surgical procedure was necessary to unclog the feeding tube due to the pill lodged in the tube. Findings include: Review of the facility's Enteral Nutrition (tube feeding) policy dated 01/2024 and provided by the facility revealed, Adequate nutritional support through enteral feeding should be provided to the resident as ordered . The nurse should confirm that there are appropriate orders for oral (PO) intake or restrictions for nothing by mouth (NPO), as appropriate . Review of the undated Profile Face Sheet in the Electronic Medical Record (EMR) under the Profile tab revealed R185 was admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the digestive tract, cellulitis (a bacterial infection that affects the deep layers of the skin and underlying tissue) of the abdominal wall, dysphagia (impaired swallowing), and with a gastrostomy tube (a tube inserted through the wall of the abdomen directly into the stomach). Review of the Physician's Orders from 11/04/24 - 11/12/24 in the EMR under the Orders tab revealed orders for: Nothing by mouth initiated on 11/06/24. Osmolite 1.2 tube feeding formula, 75 milliliters (ml) per hour continuous feeding, check for placement and function every shift dated 11/04/24; and May crush appropriate medications dated 11/04/24. Observations and interview revealed R185 was not administered the tube feeding formula ordered by the Physician, Osmolite 1.2, as follows: During an observation on 11/11/24 at 2:56 PM, R185 was lying in bed and was administered Jevity 1.2 tube feeding solution at 75 ml an hour. During an observation on 11/13/24 at 2:30 PM, there was a supply of Jevity 1.2 and Jevity 1.5 tube feeding formula in the kitchen storeroom. There was no Osmolite tube feeding solution in the storeroom. Review of the Manufacturer's website ([NAME] Nutrition), https://www.abbottnutrition.com/our-products/jevity-1_2-cal, Jevity 1.2 tube feeding formula provides 285 calories per 8 fluid ounces (237 mL), with 13.2 grams of protein, 9.3 grams of fat, 40.2 grams of carbohydrates, and 4 grams of dietary fiber per serving; it is considered a high-protein, fiber-fortified formula designed for tube feeding, and contains a full spectrum of vitamins and minerals to meet nutritional needs Review of the Manufacturer's website ([NAME] Nutrition), https://www.abbottnutrition.com/our-products/osmolite-1_2-cal, Osmolite 1.2 tube feeding formula provides feeding formula provides 285 calories per 8 fluid ounces (237 mL), with 13.2 grams of protein, 9.3 grams of fat, 37.5 grams of carbohydrates, and no dietary fiber per serving. The primary difference is the absence of fiber in Osmolite 1.2 versus Jevity 1.2. Review of the Medication Administration Record (MAR) dated November 2024 and provided by the facility documented Osmolite 1.2 was administered, when Jevity 1.2 was administered. During an interview on 11/13/24 at 2:20 PM, the Registered Dietitian (RD) stated she started R185's nutritional assessment on 11/05/24 and completed it on 11/08/24. The RD stated Jevity was the facility's house formula, and the facility did not have Osmolite in stock. The RD stated Jevity had fiber and was generally a better formula. The RD stated she assessed R185's tube feeding regimen of 75 ml/hour of Jevity 1.2 when completing her nutritional assessment. The RD stated this was a new feeding tube for R185 and the Jevity 1.2 formula at 75 ml/hour met his nutritional needs. The RD reviewed the EMR and physician's orders and confirmed the physician's order currently read Osmolite 1.2 was prescribed and not Jevity 1.2. The RD stated the order should have been changed. The RD stated nursing had consulted with her about administering Jevity instead of Osmolite and she told nursing Jevity would be okay. During an interview on 11/12/24 at 3:18 PM, Licensed Practical Nurse (LPN)3 stated R185 had been administered Jevity 1.2 since admission. LPN3 stated the current order called for Osmolite 1.2. LPN3 stated she was not sure if the formulas were comparable. During an interview on 11/13/24 at 10:16 AM, the Director of Nursing (DON) stated R185's tube feeding order called for Osmolite 1.2. The DON verified the order should have been corrected to reflect Jevity 1.2 Review of a nursing Interdisciplinary Note dated 11/11/24 at 9:11 PM, Resident's G-tube was occluded. Writer was unable to administer medication or tube feeding. Multiple attempts were made to unclog but were unsuccessful. Paged on-call provider through (name of medical practice) and spoke with NP (Nurse Practitioner) [name]. Writer was advised to flush with Coca-Cola; if it didn't work, then to send patient to [name] ER [emergency room ]. Attempts were unsuccessful. Writer contacted charge nurse [name] and on call manager, [name] to advise that patient was being sent out. [Name] ambulance arrived at approximately 1930 [7:30 PM] and patient was transported to [name] ER. Observations on 11/11/24 - 11/14/24 at 7:45 PM revealed R185 did not return to the facility from the hospital. During an interview on 11/12/24 at 3:18 PM, LPN3 stated she was informed in shift change report on this date that R185's G tube was clogged and he had been sent to the ER. LPN3 stated R185 had resided in the facility for a couple weeks and he came with staples down his abdomen for surgery due to a crimped colon. LPN3 confirmed R185 had been getting a continuous tube feeding regimen of Jevity 1.2 administered via a pump at 75 ml/hour. LPN3 stated she checked for placement and residuals on her shift and administered water flushes as ordered. During an interview on 11/13/24 at 10:16 AM, the DON stated R185's feeding tube was clogged, and he was sent to the ER. She stated there was no additional information regarding R185's status. Review of the hospital Gastroenterology Consult dated 11/12/24 at 7:49 AM revealed, Clogged G-tube etiology to clog not clear .Ct scan of the abdomen recommended to assess the G-tube site . This tube was placed surgically less than a month ago so the tract from the stomach to the wall is possible not quite mature for GI to feel comfortable about changing it at the bedside and even endoscopically (plus that puts him at risk for sedation with a procedure). Given that this was a surgically placed G-tube with sutures in place . we would feel more comfort having surgery . attempting to unclog or replace this G-tube given that it was surgically placed . Review of the hospital General Surgery Consult dated 11/12/24 at 2:18 PM and provided by the facility revealed, Chief Complaint: G tube issue . [R185] . was admitted to [name of hospital] from 09/25/24 to 11/04/24 and during his hospital stay he underwent exploratory laparotomy with lysis of adhesions and gastrostomy tube placement on 10/17/24 with [name of physician] for small bowel obstruction who presents today from [nursing home name] due to malfunctioning G tube . I attempted flushing the tube at the bedside and it did not flush. It appeared there was a blockage in the distal tube. The surgeon proceeded with the exchange of the feeding tube at the bedside. The surgeon documented, Ok to resume tube feeds at this time. Surgery will sign off. Please call for any questions or concerns. Please crush pills completely prior to administering as the tube was blocked by pill within the distal tube. During an interview on 11/14/24 at approximately 3:00 PM, the DON was shown the surgeon's report indicating a pill had not been crushed and that it was the source of the clogged feeding tube. The DON, who just obtained the report from the hospital, stated she had not read the report and was not aware of this. During an interview on 11/14/24 at 06:01 PM, the DON stated R185's pills should have been crushed; there was a physician's order to crush them. The DON stated she had not yet interviewed any of the nurses to find out what happened with the administration of his pills. The DON verified the tube became clogged in the facility; nursing staff passed all R185's medications via his feeding tube, and if a pill was not crushed, the facility was responsible.

Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for residents with non-pressure injuries and changes of condition for 2 (R1 and R46) of 2 residents reviewed. *R1 was admitted with gangrenous fingertips and the areas were not comprehensively assessed or treated on admission. The Nurse Practitioner (NP) applied a band aid to one finger that then became infected when it was not monitored for three days requiring antibiotics. *R46 was sent to the hospital and no documentation was found of an assessment describing the change of condition that occurred requiring hospitalization . Findings: The facility policy and procedure entitled Skin Identification, Evaluation and Monitoring dated 1/2022 states: Upon Admission: The Licensed Nursing Associate: A. Complete physical skin evaluation, document findings. If a skin condition is present on admission: 1. Initiate protective dressing; 2. Notify health care provider of findings and for further treatment orders; 3. Notification/Education of resident and resident representative of findings and physician orders; 4. Document evaluation in the medical record. B. Initiate preventative and/or treatment intervention, as indicated. D. Document findings, notifications and interventions. Weekly: A. Complete a General Skin Check to evaluate for changes in skin integrity. B. Document in medical record the finding of general skin check. 1. If wound is present and previously identified: a. Document integumentary findings. i. Appearance of the wound, including measurements; ii. Treatment applied/initiated per health care provider order in the medical record. 2. If new wound is identified: a. Initiate protective dressing; b. Notify health care provider of findings and for further treatment orders. 3. Notification/Education of resident and resident representative of finding and physician orders; 4. Document evaluation in the medical record. C. Update plan of care with each intervention. 1. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the admission Minimum Data Set (MDS) assessment dated [DATE], R1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. R1's Power of Attorney (POA) was activated while in the hospital. The arterial gangrenous wounds to the fingers were not coded on the MDS assessment. R1 needed extensive assistance with all activities of daily living and received all nutrition through a gastrostomy tube. The hospital discharge summary dated 6/30/2022 stated the hospital course was complicated by vasopressor-induced ischemia of bilateral fingers. R1 was seen by the wound care and surgical team and R1 refused amputation of fingers at that time. The discharge exam indicated the distal fingertips bilaterally appeared dusky and gangrenous with dry gangrene of the right fourth digit and loss of muscle bulk. The discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/30/2022 on the Skin Evaluation Form, nursing charted the right fingers 1 through 4 had dry gangrene with necrotic tissue on all four fingertips. No measurements or descriptors were documented for any of the fingertips. The treatment documented was open to air. On 6/30/2022 on the Skin Evaluation Form, nursing charted the left fingers 1 through 4 had dry gangrene with necrotic tissue on all four fingertips. No measurements or descriptors were documented for any of the fingertips. The treatment documented was open to air. On 7/1/2022 at 12:17 AM in the progress notes, nursing charted R1 arrived at facility in no apparent distress from the hospital. R1 was oriented to the room and call light. New orders were received. R1 was alert and oriented times three with no complaints of pain and gastrostomy tube was patent. The Nursing Comprehensive Admission Observation/Evaluation form was initiated on 7/1/2022 at 12:19 AM. The Skin/Nails section of the form indicated the fingernails were long. A separate Skin Condition Form for all Skin Documentation was to be completed and was documented on the Skin Evaluation Form on 6/30/2022. On 7/1/2022, R1 had a telehealth visit with the Physician Assistant (PA). The PA charted R1's extremities had no [CONDITION(S)], clubbing or cyanosis and the skin had no masses, rashes, or [CONDITION(S)] on exposed skin. The assessment and plan section of the documentation stated R1 had Gangrene, not elsewhere classified: Dry to fingertips, due to vasopressor induced ischemia. s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Consult hand surgery if patient becomes agreeable. On 7/2/2022 on the Skin Evaluation Form, nursing charted the site to be the Finger left #2 and the description stated, 8 of 10 finger tips have dry gangrene. No measurements or descriptions of the wounds were documented. On 7/2/2022 at 9:13 PM in the progress notes, nursing charted R1's fingers remain with black tips. On 7/5/2022, R1 had a telehealth visit with the PA. The PA charted R1 believes she had bleeding from the fingers last night, however none has been noted by nursing staff overnight or currently. R (1) states she has ongoing pain to the fingers, is made aware that recommendation is to consult with hand surgeon which patient has declined, nursing staff is made aware to f/u (follow up) with local wound cares. The PA charted R1's extremities had no [CONDITION(S)], clubbing or cyanosis, but had gangrene to fingertips. The assessment and plan section of the documentation stated R1 had Gangrene, not elsewhere classified: Dry to fingertips, due to vasopressor induced ischemia. s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Consult hand surgery if patient becomes agreeable. Continue local wound cares. On 7/5/2022, an order was entered to monitor for bleeding from gangrenous digits on hands every shift. On 7/6/2022 at 4:05 AM in the progress notes, nursing charted R1's fingers bilaterally remained discolored per usual, and the skin remained intact. On 7/6/2022, R1 had an order to paint the gangrenous tissue to the digits on the right and left hand with [MEDICATION(S)] daily. On 7/8/2022 on the Skin Evaluation Form, Registered Nurse (RN)-C charted the right fingers had gangrene with 100% eschar and bloody drainage. No measurements of the wounds were documented. The treatment was [MEDICATION(S)] paint to gangrenous tissue on digit number 1, 2, 3, and 4. On 7/8/2022 on the Skin Evaluation Form, RN-C charted the left fingers had gangrenous tissue on digits with 100% eschar. No measurements of the wounds were documented. The treatment was [MEDICATION(S)] paint to gangrenous tissue on digits 2, 3, 4, and 5. On 7/9/2022 at 9:11 PM in the progress notes, nursing charted: digit number 3 right hand. band aide is stuck to the eschar. An SBAR (Situation, Background, Assessment, Recommendation) was completed at that time. The nursing notes on the SBAR stated the resident reported that a band aid was placed on the finger 2-3 days ago and was hurting. The band aid was stuck and attached to the eschar. The current treatment was [MEDICATION(S)] to fingers. The digit number 3 is open, pink skin with white area, black eschar on the top side. R1 complained of pain and acetaminophen was given. The supervisor was notified for assist in examining and the director of nursing was notified and was contacting the wound care nurse. New orders were received for iodosorb, [MEDICATION(S)], and a 4x4 gauze to the digit. On 7/9/2022 at 10:38 PM on the Skin Evaluation Form, nursing charted the right finger #3 had eschar peeling off and was open and red with swelling. No measurements were documented. The treatment to the area was iodosorb, [MEDICATION(S)], and a 4x4. On 7/9/2022 at 11:00 PM on the Skin Evaluation Form, DON-B initially charted the right finger #2 was the location of the wound, but then amended the area and charted the right finger #3 had eschar lifting off of the finger that was dry gangrene. The wound measured 2 cm x 3 cm x 0.2 cm with eschar surrounding the wound. The wound had a moderate amount of purulent yellow foul-smelling drainage. The wound base was not described. The treatment order to the area was to cleanse with wound spray, pat dry, apply iodosorb and oil emulsion, cover with 4x4 and secure with tape daily and as needed. The treatment order in the Treatment Administration Record on 7/9/2022 stated Left second finger cleanse with wound spray, pat dry, and apply iodosorb and oil emulsion, cover with a 4x4 and secure with tape daily and as needed. Surveyor noted the finger that had the open area was the right middle finger. On 7/10/2022, R1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/10/2022 at 1:12 AM in the progress notes, nursing charted no weeping was observed from the right hand third finger. On 7/10/2022 at 1:01 PM in the progress notes, nursing charted no bleeding was noted to digits. On 7/10/2022 at 5:55 PM in the progress notes, nursing charted [MEDICATION(S)] was applied to bilateral fingers and the treatment was done to digit #3. On 7/11/2022, R1 had an in-person visit with the PA. The PA documented R1 was seen in the room resting in bed comfortably. The PA had been updated by the wound NP and DON that concern had been raised regarding infection to a finger and had been started on oral antibiotics for management. The PA charted R1's extremities had no [CONDITION(S)], clubbing or cyanosis; gangrene to fingertips, the right middle finger dressing was clean, dry, and intact. The Assessment and Plan section stated: Gangrene, not elsewhere classified: Dry to fingertips, due to vasopressor induced ischemia. s/p (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Consult Hand surgery if agreeable - family & patient are still discussing per recent care conference. Continue local wound cares; wound NP follows at facility. On 7/11/2022 at 5:36 PM in the progress notes, nursing charted [MEDICATION(S)] was applied to bilateral fingers and the treatment was done to digit #3. On 7/12/2022 at 10:12 AM, Surveyor asked R1 if R1 had any pain. R1 stated she had pain to her fingers. R1 held up both hands. Surveyor observed blackened eschar to the right second (pointer) finger, the right fourth (ring) finger, the left second (pointer) finger, the left fourth (ring) finger, and the left fifth (pinky) finger. The right third (middle) finger had a 4x4 gauze wrapped around it and the finger could not be visualized. On 7/12/2022 at 10:52 PM in the progress notes, nursing charted: bilateral fingers and dressing to the right completed and tolerated well. On 7/13/2022 on the Skin Evaluation Form, RN-C documented the fingers on the right hand had 100% eschar with bloody drainage. The documentation did not indicate how many fingers were bleeding or where they were bleeding from. The wounds were not measured or described. The treatment was [MEDICATION(S)] paint to the gangrenous tissue on digit numbers 1, 2, 3, and 4. On 7/13/2022 on the Skin Evaluation Form, RN-C documented the fingers on the left hand had 100% eschar. The treatment was [MEDICATION(S)] paint to the gangrenous tissue on digit numbers 2, 3, 4, and 5. The wounds were not measured. On 7/14/2022 at 12:36 PM in the progress notes, nursing charted R1 was seen by writer and wound care NP for gangrene to digits of bilateral hands. Continue current treatment orders at this time. On 7/14/2022 on the Skin Evaluation Form, RN-C documented the right finger #3 had eschar lifting off of the finger with dry gangrene. The area measured 2 cm x 3 cm with no depth and purulent yellow foul-smelling drainage. The wound where the eschar had lifted was not described. At the daily exit with the facility on 7/14/2022 at 3:01 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B R1 did not have a comprehensive assessment of the fingers that had gangrene, with no measurements of any of the areas until the right third finger had eschar pulled off when removing a band aid. Surveyor asked DON-B where the band aid come from and who put a band aid on R1's finger. DON-B thought R1's daughter put the band aid on but was not completely sure. DON-B stated R1 was told the fingers could not get wet. Surveyor requested NP-D's wound care notes. On 7/18/2022, Surveyor was given a copy of NP-D's wound care note dated 7/6/2022. On 7/6/2022, R1 had an initial wound visit by the wound NP. NP-D charted R1 developed vasopressor induced ischemia of fingers, refused amputation. Today patient is seen lying in bed, she asks what time it is repeatedly. She has some awareness of the condition of her fingers will need amputation, but pending her agreement. We will keep her as comfortable as able, and steer off infection as best as able. The Physical Exam section of the notes stated: left hand digits 1-2-3-4 -dry gangrene, paint with [MEDICATION(S)] daily. Right hand digit #3, ring finger, open area, will cover with Band-Aid at this point, observe daily. Left hand (sic) digits 2-3-4-5 -dry gangrene, paint with [MEDICATION(S)] daily. Hand-written on the printed copy of the Wound Care Assessment form provided to Surveyor was a statement indicating the second finger, not the ring finger, had the open area. No measurements of the affected fingertips were documented. On 7/18/2022 at 8:43 AM, Surveyor went to see R1 to get a better assessment of which fingers had gangrene. The documentation of the gangrenous areas was not easily understood or comprehensive. Surveyor made the following observations of R1's fingers: RIGHT HAND: -Second (pointer) finger had eschar from the tip of the finger measuring approximately 2.5 cm on the palm side of the finger. -Third (middle) finger had eschar from the tip of the finger to the first knuckle and an open area on the inner aspect below the first knuckle measuring approximately 3 cm x 2 cm. The wound did not look infected. -Fourth (ring) finger had eschar from the tip of the finger to the first knuckle all the way around the finger including the fingernail. LEFT HAND: -Second (pointer) finger had eschar from the tip of the finger to the first knuckle all the way around the finger including the fingernail. -Fourth (ring) finger had eschar from the tip of the finger measuring approximately 1 cm on the palm side of the finger and below the nail on the outer aspect of the finger. -Fifth (pinky) finger had eschar from the tip of the finger measuring approximately 1 cm on the palm side of the finger and a small amount of the fingernail. Surveyor noted the right first (thumb) finger, the right fifth (pinky) finger, the left first (thumb) finger, and the left third (middle) finger did not have any eschar. In an interview on 7/18/2022 at 9:47 AM, Surveyor asked RN-C what the expectation for wound charting was, such as how often and what should be documented. RN-C stated at the minimum, the floor nurses should document any treatment done and any signs or symptoms of infection or pain with treatment. RN-C stated weekly the wounds should have measurements and a wound description of each area. RN-C stated wound rounds are done weekly by RN-C and NP-D. RN-C stated NP-D does the treatment on rounds and RN-C takes notes. RN-C stated all wounds are looked at weekly except for surgical incisions. Surveyor asked RN-C why there were no measurements for each finger that had gangrene. RN-C stated they had not been measuring R1's wounds due to the extensiveness of it and R1's skin was not the best. RN-C stated he did not know how you would record all the different areas. Surveyor asked RN-C if a resident had a wound to the left knee, the right heel, and the right elbow, would each area be documented individually or would they all be put together in one Skin Assessment. RN-C stated each wound would be charted on individually. Surveyor asked RN-C why each finger would not be considered a separate area. RN-C stated he was not sure, and that he did not know he had to separate them out. RN-C stated he did not know how to chart the individual fingers in the computer charting system. RN-C stated the wounds were circumferential, so he did not know how to document that. Surveyor asked RN-C if RN-C could document the wounds were circumferential, just like RN-C had stated. RN-C said yes. RN-C stated the problem with the computer charting is that when they put the site description in, there is not enough space to put the information; the documentation is really hard to put in. RN-C stated he copied the descriptor from one of the nurses where she put digit #3 and RN-C did not know how she got that to be designated; RN-C stated he was still learning the charting system. Surveyor asked RN-C if RN-C had put the band aid on R1's finger. RN-C stated he thought NP-D had put the band aid on because R1 was trying to use a scissors to cut eschar off. RN-C stated he did not know NP-D had put the band aid on until he saw the NP note last week. (Surveyor had asked for the NP note dated 7/6/2022 on 7/14/2022 and it was provided on 7/18/2022. The NP note was not available prior to Surveyor asking for it.) In an interview on 7/18/2022 at 10:23 AM, Surveyor shared the concern with DON-B R1's gangrenous fingers were not comprehensively assessed on admission and have still not been individually documented on. Surveyor shared with DON-B the difficulty in following the wound documentation with digit numbers and finger names not matching. DON-B stated it was hard for her to follow the documentation as well. DON-B stated the nurses got confused as to what to call the fingers, like is it one thumb and four fingers? Surveyor asked DON-B why the fingers were not documented on individually. DON-B stated, I don't know. DON-B stated she looked at R1's fingers with the floor nurse when R1 was admitted but did not document anything at that time. DON-B stated the nurses are having a hard time with the computer program and RN-C does not know the program. DON-B stated Licensed Practical Nurses (LPNs) know not to stage things, but they have too many people putting notes in different places when it comes to skin. Surveyor shared with DON-B the observations made by Surveyor of R1's fingers with the description of each finger with approximate measurements. Surveyor shared the concern with DON-B that the documentation was very vague as to what fingers were affected by the gangrene and did not match the observations made by Surveyor of what fingers were affected and how many fingers were affected. DON-B stated the documentation of the assessments of the fingers was messy. In an interview on 7/18/2022 at 2:17 PM, NP-D stated on 7/6/2022, NP-D saw R1 had gangrenous fingers and did not want amputation so NP-D wanted to protect those fingers as best she could. NP-D stated R1 wanted to get scissors to cut off the black tissue. NP-D stated R1 was using the hand for writing so NP-D put a band aid on the ring finger to protect it because you do not want to lift the eschar off the finger. Surveyor clarified with NP-D which finger NP-D was referring to. NP-D held up the right hand and indicated the middle finger. NP-D stated NP-D does not wear rings so was not sure which finger was the ring finger. NP-D stated a little bit of the eschar lifted off the right middle finger and could see some viable tissue underneath and was hoping to save the fingers. NP-D stated R1 was getting [MEDICATION(S)] to eight digits on 7/6/2022 and when there was the change of condition on the right middle finger, NP-D made sure the treatment was different for that finger. NP-D stated gangrene stays pretty stable; if the finger became redder than what it was or if it started to open even more, that would be an emergent situation. NP-D stated you cannot measure the areas; you have to wait to have the gangrene dry up on its own and then take the scab off. NP-D stated [MEDICATION(S)] is used to dry it out. NP-D stated if there was an open ulcer, then they would measure it. Surveyor asked NP-D if an order was put in to change the band aid to prevent infection. NP-D stated she would assume someone would have noticed the band aid and changed it, but NP-D did not think the band aid caused the infection. Surveyor asked NP-D if NP-D had told anyone NP-D had put a band aid on R1's right middle finger. NP-D stated she felt someone would have seen it and changed the band aid. DON-B had been present for the interview with NP-D on 7/18/2022 at 2:17 PM. After NP-D left the interview, Surveyor asked DON-B if the band aid applied to R1's right middle finger should have had an order to change the band aid or remove the band aid on a specific date. DON-B stated no one knew NP-D had put a band aid on R1's finger and would not have known to remove it or change it. DON-B stated it was not until R1 complained of pain to the finger that the band aid was removed. Surveyor shared the concern with DON-B that R1's finger became infected after the band aid was applied and the area underneath was not monitored for three days. DON-B agreed the band aid should not have been applied with no follow up or knowledge by the rest of the staff. DON-B stated she totally understood Surveyor's concern. No further information was provided at that time. 2. The Facility Policy and Procedure Guidelines for Charting and Documentation last approved 01/2022 (which was the only policy the facility provided to Surveyor related to assessments) documented (in part) . .Purpose: The purpose of charting and documentation is to provide: A. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc (etcetera) and the progress of the resident's care. B. Nursing service personnel with a record of the physical and mental status of the resident. Nursing Summaries and/or Assessments: When charting nursing summaries or making assessments, include (as they may apply) the following information: P. Unusual Occurrence/Significant Events: Describe the condition(s). Indicate whether the condition(s) improved or worsened. Q. Vital signs: Indicate whether or not the resident's vital signs were fluctuating, elevated, or stable. R46 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R46's Quarterly Minimum Data Set (MDS) with an Annual Reference Date of 3/25/22 documented a Brief Interview for Mental Status score of 15, indicating R46 to be cognitively intact. Facility progress notes dated 5/12/22 at 2:21 PM documented: Resident is c/o (complaining of) SOB (shortness of breath), N/V (nausea and vomiting) and diarrhea. NP (Nurse Practitioner) aware. (named hospital) is hospital of choice, they have been called and given report. Surveyor noted there was no evidence or documentation a comprehensive assessment of R46 was completed to include a respiratory assessment, lung or cardiac assessment, bowel assessment or vital signs related to R46's complaints. There was no SBAR (Situation, Background, Assessment, Recommendation) completed. Facility progress notes dated 5/12/22 at 2:32 PM documented: Resident has been visibly unsatisfied and upset with the building not having air condition working. Building is very hot and unbearable for resident. Resident was non compliant with medications except for [MEDICATION(S)] and cancer medication. Resident refused all other medications. Resident felt very dizzy, overheated and thought she might have a heart attack. Staff at (facility) called ambulance per request from resident to be sent to (named hospital). Resident was sent out via ambulance at 2:10 PM. The nurse that entered the above progress note was an agency nurse and was not available for interview. Surveyor noted there was no evidence or documentation of an assessment of R46 to include a respiratory assessment, lung or cardiac assessment, bowel assessment or vital signs related to R46's complaints. There was no SBAR (Situation, Background, Assessment, Recommendation) completed. Facility progress notes dated 5/13/22 at 7:40 AM documented: Resident was aware that an ambulance had been called to take her to (named hospital) per her request. Resident became behavioral because she didn't want to wait, so she called 911 on her own. The police and ambulance arrived at the same time as the ambulance that had originally been called for transport. The nurse that entered the above note was on vacation, thus was not available for interview. Facility progress notes dated 5/13/22 documented: Spoke with RN (Registered Nurse) at (hospital). (R46) had a Cardiac work up which was negative. They are still running other tests and currently expect her to be there two more nights. Facility progress notes dated 5/16/22 documented: Spoke with RN at hospital. (R46) will be having more scans and a bone biopsy completed today. They are working on transferring her off the cardiac floor and to the oncology floor. CXR (chest X-ray) and nuclear medicine scan showed pulmonary nodules and metastasis to the spine. Cardiology has signed off. They expect her to be there at least 2 days yet. Facility progress notes dated 5/20/22 documented: Spoke with RN at hospital. (R46) has been moved to the oncology floor. Biopsy of the iliac crest was positive. Had US (ultrasound) of gallbladder, liver and pancreas today, no results as of yet. Testing and treatment is ongoing. SW (Social Worker) is involved. No planned discharge date at this time. R46 readmitted to the facility on [DATE]. The Hospital Discharge Summary documented (in part) . .Presented on 5/12/22 with c/o (complaints of) chest/abdominal pain. ED (Emergency Department) EKG (Electrocardiogram) and troponin negative. CT (Computed Tomography) abdomen and pelvis found to show extensive sclerotic foci t/o (throughout) visualized skeleton, liver [CONDITION(S)] concerning for metastatic disease. Metastatic [CONDITION(S)] consistent with primary [CONDITION(S)] with metastasis iliac crest and liver. Due to advanced age, multiple comorbidities, oncology did not feel patient was good candidate for [CONDITION(S)]. Followed by palliative medicine but not ready to transition to hospice at this time. On 7/14/22 at 9:39 AM Surveyor spoke with Director of Nursing (DON)-B regarding R46's discharge to the hospital on 5/12/22. DON-B stated: I was there the day she went out and was involved. She was insisting she wanted to go out, unfortunately she had done this several times before, and the hospital would send her back with no findings. That day, before she went out, she was not in any distress, she was sitting at the reception eating and drinking. Surveyor advised DON-B the facility progress notes documented R46 complained of SOB, N/V, diarrhea, and there was no evidence an assessment was completed on R46. DON-B stated: There should be an SBAR. DON-B reviewed R46's medical record and was unable to locate an SBAR. Surveyor advised DON-B of facility documentation indicating R46 reported feeling dizzy, lightheaded and though she might have a heart attack. Surveyor asked DON-B if she would you expect the nurse to do an assessment. DON-B stated: Yes. I would expect the nurse to do, and document an assessment. I was not aware of the statement she thought she might have a heart attack. She (R46) may have been exaggerating because she was upset about the heat. But I can tell you, she was not in any distress. I spoke to her several times that day and saw her in the cooling area. Before she was sent out, she was sitting at the reception desk eating and drinking, and was not in any distress. Surveyor advised DON-B of concern an assessment was not completed on R46 based on the residents' voiced complaints. DON-B stated: I understand what you're saying. The bottom line is yes, I expect an assessment to have been done. On 7/14/22 at 2:17 PM Surveyor advised DON-B of concern the facility did not complete an assessment on R46 prior to hospitalization . No additional information was provided.

Based on interview, and record review, the facility did not provide necessary treatment and services to promote healing for 2 (R45 & R27) of 3 reviewed for pressure injuries. * R45 was admitted to the facility on [DATE] without any pressure injuries. On 4/4/21, R45 was identified as having a Stage 3 to her midline buttocks/coccyx. Interview with Certified Nursing Assistant (CNA)-D revealed R45 had an area which was described as a scratch that looked like it was going to open. There is no documentation of this in R45's record. The facility first became aware of this pressure injury when the area had already become a Stage 3. On 4/7/21 Surveyor observed a blister on R45's right heel and a blister and scabbed area on R45's left heel. On 4/7/21, CNA-I observed this with Surveyor and did not report this. The Facility was unaware of R45's bilateral heel pressure injuries until the Surveyor brought this to the Facility's attention. R45's heels were observed not to be offloaded. * R27 was at risk for pressure injuries and had a healed area. The facility was aware of R27's resistance to repositioning or offloading pressure to prevent possible redevelopment of a pressure injury. However, the facility did not routinely speak to R27 about the the risks and benefits of offloading to prevent pressure until a month after R27 developed an unstageable pressure injury. Findings include: The skin identification, evaluation and monitoring policy and procedure last revised 1/2018 under the Certified Nursing Assistant (CNA) should: D. Report skin integrity changes to nurse. 1. R45 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The at risk for pressure ulcers care plan with a start date of 3/24/21 documents approaches of: Braden Scale to be completed with a start date of 3/24/21 Keep bed linens wrinkle free and do not use excess pads with a start date of 3/24/21 Observe skin for redness and breakdown during routine care with a start date of 3/24/21 Use pressure relieving devices, cushion on wheelchair and off of heels as indicated with a start date of 3/24/21 Follow community skin care protocol with a start date of 3/24/21 Treatments, as indicated, see physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Pressure reducing mattress on bed with a start date of 3/24/21 Float heels on pillow when in bed with a start date of 3/31/21 Assist with repositioning during rounds with a start date of 3/31/21 Cushion to wc (wheelchair) and recliner with a start date of 3/31/21 The Braden assessment dated [DATE] has a score of 16 which indicates mild risk for pressure injury development. The Braden assessment dated [DATE] has a score of 15 which indicates mild risk for pressure injury development. R45's admission MDS (Minimum Data Set) with an assessment reference date of 3/29/21 documents R45 has short term memory problems and is moderately impaired for cognitive skills for daily decision making. R45 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use and does not ambulate. R45 is coded as having an indwelling catheter and is always incontinent of bowel. Surveyor noted R45's indwelling catheter was removed on 3/31/21. R45 is at risk for pressure injury development and is coded as not having any pressure injuries. Under skin and ulcer/injury treatment is only checked for pressure reducing device for chair & pressure reducing device for bed. Surveyor noted turning/repositioning program is not checked. The pressure ulcer/injury CAA (care area assessment) dated 3/31/21 under description of problem documents Pt (patient) needs extensive assist with bed mobility, frequent bowel incontinence and is at risk for developing pressure injury. The Braden assessment dated [DATE] has a score of 12. According to the instructions a score of 12 or less consider him/her at high risk for pressure injury development. The nurses note dated 4/4/21 documents OA (open area) noted with incontinence care, new order for wound care and Z-guard obtained. Wound care consultant. Optum to see on 4/5/21. The skin evaluation form dated 4/4/21 with an origin date of 4/4/21 for site documents buttock midline, type pressure injury, description moderate open area to bidline (midline) buttocks and coccyx, cause pressure, length 5.2 cm (centimeters), width 0.5 cm, depth 0.3 cm tissue type slough, drain type purulent, color beige and stage further assessment required. Under nurses notes documents, Surrounding skin: CDI (clean dry intact), blanchable. Wound Edge: regular, soft, unapproximated. The skin evaluation form dated 4/5/21 with an origin date of 4/4/21 for site documents buttock midline, type pressure injury, description area located in midline, cause pressure, length 5.2 cm (centimeters), width 1.0 cm, depth 0.2 cm tissue type granulation, drain type serosanguineous, color pink and stage 3. Under nurses notes documents Excoriated, [CONDITION(S)]. The stage III (3) pressure ulcer to the coccyx area care plan with a start date 4/5/21 documents approaches of; Air mattress recommended at setting of 1. Check function q (every) shift with a start date of 4/5/21 Treatments per MD (medical doctor) orders with a start date of 4/5/21 Repositioning while in bed q.2 (every two) hours with start date of 4/5/21. The CNA worksheet for Monday 4/5/21 under the section appliances/safety/skin documents HOH (hard of hearing). Glasses to be kept at bedside. Float heels on pillow when in bed. Assist with repositioning during rounds. Cushion to wc and recliner. Encourage facemask when out of room and during cares. TV to be on when in room; enjoys the news. On 4/5/21 at 11:49 a.m. Surveyor observed R45 in bed on her right side with her bed down and call light within reach. Surveyor observed R45's heels are not being offloaded. On 4/6/21 at 8:02 a.m. Surveyor observed maintenance bringing an air mattress into R45's room. On 4/6/21 at 8:24 a.m. Surveyor observed R45 sitting in a wheelchair in the dining room. There is a black cushion in R45's wheelchair and R45 is wearing gripper socks on her feet. On 4/6/21 at 12:16 p.m. Surveyor observed R45 sitting in a wheelchair in her room by the door and is wearing gripper socks. The nurses note dated 4/6/21 documents Patient being monitored for increase to [MEDICATION(S)], no adverse reactions noted. VSS (vital signs stable). Patient ate less then 25% of meals. Dressing to buttocks CDI (clean dry intact). No s/s (signs/symptoms) of pain noted this shift. Surveyor reviewed R45's April 2021 MAR (Medication Administration record) and noted on 4/6/21 the Facility started monitoring R45 for decreased appetite, withdrawal, refuses of cares/therapies r/t (related to) [MEDICATION(S)] usage. On 4/7/21 at 7:16 a.m. Surveyor asked LPN (Licensed Practical Nurse)-E if he knew how R45 developed the Stage 3 pressure injury on her coccyx. LPN-E replied, I don't know and explained he had been off a few days. On 4/7/21 at 7:26 a.m. Surveyor observed R45's treatment with LPN-E and CNA-I. Surveyor observed R45 was in bed on towards her right side. R45 had a shirt partially on, pants towards her lower legs and socks with her heels resting directly on the mattress. CNA-I rolled R45 on her right side, LPN-E removed the foam dressing and handed the dressing to CNA-I. LPN-E removed his gloves and placed new gloves on. LPN-E placed no rinse foam cleanser on gauze and cleansed the wound bed. Surveyor observed the wound bed was red with yellow slough. LPN-E placed no rinse foam cleanser on gauze and cleansed R45's buttocks. LPN-E removed his gloves and placed new gloves on. With his gloved finger, LPN-E applied Z guard on the wound bed and around the wound bed. LPN-E removed his gloves and placed new gloves on. LPN-E placed a product under R45 and R45 was positioned side to side to straighten and fasten the incontinence product. LPN-E removed his gloves, washed his hands and left R45's room at 7:33 a.m. Surveyor then asked CNA-I if Surveyor could look at R45's feet. CNA-I removed R45's right sock. Surveyor observed a fluid filled blister on R45's right heel. Surveyor asked CNA-I if R45's heel was soft. CNA-I pushed her finger on R45's right heel and replied yes. CNA-I then placed the right sock back on and removed R45's left sock. Surveyor observed the left heel has a fluid filled blister with a smaller dark area. CNA-I placed R45's left sock on and pulled up her pants. At 7:36 a.m. Surveyor asked CNA-I when she came into R45's room to do morning cares what did R45 have on her feet. CNA-I replied blue gripper socks. Surveyor asked CNA-I if there was a pillow under R45's legs/heels. CNA-I replied no. On 4/7/21 at 8:12 a.m., Surveyor asked CNA-D how R45 developed the stage 3 pressure injury on her coccyx. CNA-D informed Surveyor she didn't know but R45 did have an area that looked like a scratch that looked like it was going to open from laying on her back. CNA-D informed Surveyor R45 lays down after breakfast and lunch if she is willing. On 4/7/21 at 9:50 a.m. Surveyor observed R45 in bed on her right side. There are pillows under R45's lower legs but the back of R45's heels are resting directly on the pillow. On 4/7/21 at 11:18 a.m. Surveyor asked LPN-E if anyone reported anything to him today regarding R45. LPN-E replied no didn't mention anything. Surveyor asked if anything was reported to him about R45's heels. LPN-E replied no and explained he went into R45's room and saw her heels were elevated. Surveyor asked if a CNA observes a pressure injury or any other skin impairment when should they report this. LPN-E replied immediately. Surveyor informed LPN-E of the pressure injuries on R45's heels and asked if he wanted to come with Surveyor to see them. LPN-E replied no, that's alright and explained he would start the process. Surveyor then asked LPN-E to ask RN Manager-H to come to the unit. On 4/7/21 at 11:27 a.m., Surveyor entered R45's room with RN Manager-H. Surveyor informed RN Manager-H Surveyor would like to look at R45's heels with her. Surveyor observed R45 was in bed on her back. R45's right heel was being floated but the left heel was resting directly on the mattress. RN Manager-H removed the pillows under R45's legs, and removed the gripper socks & socks. Surveyor showed RN Manager-H the fluid filled blister on R45's right heel and fluid filled blister with a small scabbed area on R45's left heel. RN Manager-H stated really wish that would of been brought to my attention. RN Manager-H informed Surveyor she is going to call the nurse so she can measure the area now and get a treatment started. At 11:39 a.m. RN Manager-H measured R45's right heel pressure injury. Surveyor asked what were the measurements. RN Manager-H informed Surveyor 6 centimeters by 6.8 centimeters. RN Manager-H wrote these measurements down with fluid filled surrounding skin intact. At 11:42 a.m. RN Manager-H measured R45's left heel. Surveyor asked RN Manager-H the measurements. RN Manager-H informed Surveyor 4.3 centimeters by 5 centimeters and the scabbed area is .5 by .5. RN Manager-H informed Surveyor she is going to get a heel riser for R45 and ask Wound Doctor-O if he wants R45 to wear socks in bed. The nurses note dated 4/7/21 documents, Resident presents with fluid filled sacs to bilateral heels, both areas are intact, NOR (new order received) from Wound MD (Medical Doctor)-O: [MEDICATION(S)] 2x (times)/day, f/b (followed by) tubigrips (on in am (morning)/off HS (hour sleep), NWB (non weight bearing) to bilateral heels until evaluated by wound MD on 04/09/2021, Daughter updated and in agreement with POC (plan of care), Optum NP (Nurse Practitioner)-P updated as well. The skin evaluation form dated 4/7/21 with an origin date of 4/7/21 documents for site heel right, type pressure injury, description fluid filled area to heel, cause pressure, length 4.3 cm (centimeter), width 5.0 centimeters, depth und (undetermined), and stage 2. Under nursing notes documents surrounding skin: intact, dry. Surveyor noted these measurements are not the same as Surveyor was informed of during the observation with RN Manager-H on 4/7/21 at 11:39 a.m. The skin evaluation form dated 4/7/21 with an origin date of 4/7/21 documents for site heel left, type pressure injury, description fluid filled area to heel, cause pressure, length 4.3 cm (centimeter), width 5.0 centimeters, depth und (undetermined), and stage 2. Under nurses notes documents surrounding skin: dry intact. The skin evaluation form dated 4/7/21 with an origin date of 4/7/21 documents for site foot left inner under description documents darkened area to lower medial foot, does not appear to be fluid filled, possible scab, length 0.5 cm, width 0.5 and depth 0, stage Inapplicable and nurses notes surrounding skin: intact dry. The April 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] = fluid filled area to bilateral heels. The April 2021 TAR (treatment administrator record) with a start date of 4/7/21 documents Ensure (sic) resident is turned side-to-side while in bed and float heels on heel riser Type NURS (nurse)-Nursing Initiative. On 4/7/21 at 11:54 a.m. Surveyor met with RN Manager-H to discuss R45's pressure injuries. Surveyor asked when the CNA saw R45's heels should she have report this immediately. RN Manager-H replied yes. Surveyor asked RN Manager-H how R45's pressure injury developed and wasn't noted until it was a Stage 3. RN Manager-H informed Surveyor she can't answer how it developed and doesn't know why it was not reported until it was a Stage 3. RN Manager-H informed Surveyor R45 had been getting up until more recently has been uncooperative with getting up and changing. RN Manager-H informed Surveyor she can't specifically say how the pressure injury developed. RN Manager-H informed Surveyor Wound Medical Doctor-O will see the area this week on Friday. Surveyor informed RN Manager-H, CNA-D informed Surveyor R45 had an area like a scratch that looked like it was going to open but Surveyor didn't note any documentation regarding this. RN Manager-H informed Surveyor she personally didn't hear anything and will have to educate on reporting skin even if they think its minor. RN Manager-H indicated it's not their (CNAs) job to assess and it's her job to have appropriate intervention in place. Surveyor informed RN Manager-H Surveyor is very concerned with the development of R45's coccyx pressure injury and the stage 2 pressure injuries on R45's right and left heel which the Facility was unaware of the stage 2 pressure injures on both heels until Surveyor brought it to their attention. RN Manager-H informed Surveyor this is very concerning to her as well. On 4/7/21 at 2:15 p.m. Administrator-A and DON (Director of Nursing)-B were informed of the above. No further information was provided to Surveyor. 2. The facility policy entitled, Prevention of Pressure Injuries Protocol, dated 12/2015, last approved: 12/2019, last revised: 1/2018, states: . A. Review the resident's care plan to assess for any special needs; B. Review current Braden Scale assessment tool. General Guidelines, A. Pressure injury are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Interventions and Prevention Measures: SKIN A. S-Surface Selection 1. Select surface based on resident/client assessment: a. Ensure all resident/clients at risk of developing pressure injuries are placed on a pressure reducing surface; b. Preventable surface/foam mattress for all residents, including Stage1 and Stage 2 wounds; c. Stage 3 and Stage 4 use low air loss or gel; d. Use pressure reducing chair pad for all at risk residents/clients. Refer resident to therapy services for seating evaluation and positioning plan; B. K-Keep Them Turning 1. Schedule regular and frequent repositioning for bed and chair bound resident: a. Identify risk factors for pressure injury development; b. For a person in bed: 1. Change position at least every two hours or more frequently if needed: 2. Determine if resident needs a special mattress per bed selection algorithm; and 3. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medically necessity. c. For a person in a chair: 1. Reposition resident per care plan; 2. Use foam, gel or air cushion as indicated to relieve pressure; 3. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging; 4. Do not use donut-shaped cushions; 5. Refer resident to rehabilitation program, or a restorative nursing program, as indicated; 6. Encourage the resident to participate in active and passive range of motion exercises to improve circulation. C. I-Incontinence Management 1. Consider etiology of urinary and fecal incontinence: a. Gently clean and dry the skin after every incontinent episode and use protective skin barriers to protect and maintain skin integrity; b. Avoid hot water and use mild cleaning agent to minimize irritation and drying of the skin; c. Minimize force and friction applied to the skin; d. Utilize properly fitted incontinence briefs that are absorbent and wick moisture away from the skin on incontinent residents. R27 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/5/21 at 10:45 AM, Surveyor observed R27 sitting up in bed, laying on his back with the head of the bed elevated, resting on an air mattress. R27's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/7/20 documents: a Brief Interview of Mental Status (BIMS) score of 15, indicating cognitively intact for daily decision making; Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms; rejection of evaluation or care behavior - not exhibited; total dependence of 2 staff for transfers, extensive assist 2 staff for bed mobility, dressing, toilet use, extensive assist of 1 staff for personal hygiene; not steady, only able to stabilize with staff assistance for surface to surface transfers and moving from seated to standing; requires wheelchair for mobility; catheter and always incontinent of bowel; at risk for development of pressure injuries with no unhealed stage 1 or greater pressure injuries; no venous or arterial ulcers, no other ulcers, wounds or skin problems, skin and ulcer treatments of a pressure reducing device for chair and bed and application of ointments or medication other than to feet and no turning or repositioning program. R27's Care Plan dated 7/15/20, documents: [R27] is at risk for pressure ulcers and other skin related injuries. Interventions include: Braden Scale to be completed, Start: 7/15/20; Keep bed linens wrinkle free and do not use excess pads, Start: 7/15/20; Observe skin for redness and breakdown during routine care, Start: 7/15/20; Use pressure relieving devices, cushion on wheelchair and off of heels as indicated, Start: 7/15/20; Follow community skin care protocol, Start: 7/15/20; Treatment as indicated by physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Air mattress to bed, check for inflation q (every) shift, Start: 7/15/20; Float heels when in bed, Start 7/15/20; R27's Care Plan dated, 7/15/20, also documents: [R27] has short term memory problems. [R27] is able to make his needs known to the staff. HCPOA (Health Care Power of Attorney) has been activated. Interventions include: Call resident by name, Start 7/15/20; Daily orientation to facility routines and activity schedules, Start: 7/15/20; Use environmental cues (e.g (example) pictures, signs, clocks, calendars, color coding of environment) to stimulate memory and promote appropriate behavior, Start: 7/15/20; Provide cues to promote independence, Start: 7/15/20; Provide consistent physical environment, Start: 7/15/20. Braden Scale- (Assessment scale used to assess a resident's risk for pressure injuries.) R27's Braden Scale score on 12/2/20 is documented at 11, indicating R27 is at risk for development of pressure injuries. On 12/23/20, R27's medical record documents excoriation on right and left buttock and open area to the left buttock. Cause: incontinence. Measures 1.3 cm (centimeters) x (by) 2.7.cm x 0.1 cm. Superficial open area left inner buttocks. No eschar, slough or granulation. Treatment: NS (Normal Saline) f/b (followed by) Allevyn foam dressing. No eschar and no slough or granulation. Stage: Inapplicable. Turning repositioning program: inapplicable, morning and afternoon nap: inapplicable. Surveyor noted there was no change to the care plan or notation of discussing risks & benefits or repositioning/offloading with R27. On 12/23/20, R27's care plan is updated and documents: Pressure injury stage 3 to left buttock; with interventions of: tx as per MD order; P (Problem): [R27] Pressure injury stage 3 to left buttock: Start: 12/23/20. Interventions include: Tx (treatment) as per MD (Medical doctor) order, Start: 12/23/20; [R27] is non-compliant with repositioning and up/down schedule given to him in order to relieve pressure even after staff education was given, Start: 12/23/20; [R27] is non-compliant with reposting and up/down schedule given him in order to relieve pressure even after staff education was given; Wound MD to follow; Resident encouraged to remain in bedrest; Resident is encouraged to lay side to side and not flat on his back. R27's care plan dated 7/15/20 and MDS with an ARD of 12/7/20, both prior to the newly identified left buttock stage 3 pressure injury being identified, do not document a turning and/or repositioning program or schedule as an intervention to prevent new pressure injuries. On 12/29/20, R27's medical record documents: Superficial open area left inner buttocks, partial thickness wound, no slough, eschar, or granulation. Cause: incontinence. Has pressure reducing chair and bed. Treatment: NS f/b Allevyn foam dressing: Measurements: 1.3 cm x 2.7.cm x 0.1 cm. No staging documented. Stage: Inapplicable. Turning repositioning program: inapplicable, morning and afternoon nap: inapplicable. On 1/5/21, R27's medical record documents: Superficial open area left inner buttocks, partial thickness wound, no slough or eschar, has granulation. Cause: incontinence. Has pressure reducing chair and bed. Treatment: NS f/b Allevyn foam dressing: Measurements: 0.8 cm x 0.8.cm x 0.1 cm. No staging documented. Surrounding skin is pink/red. Stage: Inapplicable. Turning repositioning program: inapplicable, morning and afternoon nap: inapplicable. R27's medical record documents the following regarding the left inner buttocks; On 1/8/21, R27's medical record documents: Partial thickness wound, pressure injury. Tissue type: granulation. Drain type: Serous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Treatment: Clean would with saline. Protect periwound with skin prep, apply zeroform gauze (cut to size) to wound bed, cover wound with ABD, secure dressing with Medi/[MEDICATION(S)], change daily, change PRN (as needed) for soiling and/or saturation. Eval (evaluation) and treat by [wound doctor]. Measurements: 4.1cm x 1.6.cm x 0.1 cm. Stage 3. Surrounding skin: purple and intact. Turning repositioning program: yes; morning and afternoon nap: yes. On 1/12/21, R27's medical record documents: Partial thickness wound, pressure injury. Tissue type: granulation. Drain type: Serous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Treatment: Clean wound with saline. Protect periwound with skin prep, apply zeroform gauze (cut to size) to wound bed, cover wound with ABD, secure dressing with Medi/[MEDICATION(S)], change daily, change PRN (as needed) for soiling and/or saturation. Eval (evaluation) and treat by [wound doctor]. Measurements: 0.8 x 1.6.cm x 0.1 cm. Stage 3. Surrounding skin: purple and intact. Turning repositioning program: yes; morning and afternoon nap: yes. On 1/19/21, R27's medical record documents: Partial thickness wound, pressure injury. Tissue type: granulation. Drain type: Serosanguineous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Treatment: Clean would with saline. Protect periwound with skin prep, apply zeroform gauze (cut to size) to wound bed, cover wound with ABD, secure dressing with Medi/[MEDICATION(S)], change daily, change PRN (as needed) for soiling and/or saturation. Eval (evaluation) and treat by [wound doctor]. Measurements: 3.0 x 1.4.cm x 0.2 cm. Stage 3. Surrounding skin: pink/red, intact. Turning repositioning program: yes; morning and afternoon nap: yes. On 1/26/21, R27's medical record documents: Partial thickness wound, pressure injury. Wound larger with 50% slough. No s/s (sings/symptoms) of infection. Resident is non-compliant with bedrest. Aware of risks. Tissue type: granulation. Drain type: Serosanguineous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. [Wound Doctor] updated with new orders received. Resident is aware wound may continue to decline if he doesn't stay off it. Measurements: 3.2 x 2.2 cm x 0.2 cm. Stage 3. Surrounding skin: pink/red, intact. Wound edge: Resident also when in bed won't turn side to side and lays flat on back. Again reviewed risks and does understand. Turning repositioning program: yes; morning and afternoon nap: yes. On 2/2/21, R27's medical record documents: Partial thickness wound, pressure injury. Wound larger with 50% slough. No s/s (signs/symptoms) of infection. Resident is non-compliant with bedrest. Aware of risks. Tissue type: granulation. Drain type: Serosanguineous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. [Wound Doctor] updated with new orders received. Resident is aware wound may continue to decline if he doesn't stay off it. Measurements: 3.2 x 2.2 cm x 0.2 cm. Stage 3. Surrounding skin: pink/red, intact. Wound edge: Resident also when in bed won't turn side to side and lays flat on back. Again reviewed risks and does understand. Turning repositioning program: yes; morning and afternoon nap: yes. On 2/9/21, R27's medical record documents: Partial thickness wound, pressure injury. Treatment: Cleanse with ½ strength Dakin's, skin prep to surrounding tissue. Santyl to slough apply nickel thick, calcium alginate cut to size, cover with Allevyn changed q (every) day and prn for soiling. Tissue type: granulation. Drain type: Serosanguineous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. [Wound Doctor] updated and new orders received. Resident is aware wound may continue to decline if he doesn't stay off it. Measurements: 4.0 cm x 2.2 cm x 0.1 cm. Stage 3. Surrounding skin: pink/red, intact. Wound edge: Resident also when in bed won't turn side to side and lays flat on back. Again reviewed risks and does understand. Turning repositioning program: yes; morning and afternoon nap: yes. On 2/12/21, R27's medical record documents: Partial thickness wound, pressure injury. Treatment: Cleanse with ½ strength Dakin's, skin prep to surrounding tissue. Santyl to slough apply nickel thick, calcium alginate cut to size, cover with Allevyn changed q (every) day and prn for soiling. Tissue type: granulation. Drain type: Serous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Eval and treat by {wound Doctor]. Measurements: 3.1 cm x 2.3 cm x 0.1 cm. Unstageable. Surrounding skin: pink/red, intact. Wound edge: Resident also when in bed won't turn side to side and lays flat on back. Again reviewed risks and does understand. Turning repositioning program: yes; morning and afternoon nap: yes. On 2/16/21, R27's medical record documents: Partial thickness wound, pressure injury. Treatment: Cleanse with ½ strength Dakin's, skin prep to surrounding tissue. Santyl to slough apply nickel thick, calcium alginate cut to size, cover with Allevyn changed q (every) day and prn for soiling. Tissue type: granulation. Drain type: Serous color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Wound showing signs of healing. Some decrease in size. Minimal drng (drainage). [Wound Doctor] updated, continue same tx. Measurements: 3.0 cm x 1.7 cm x 0.1 cm. Unstageable. Surrounding skin: pink/red, intact. Wound edge: Resident also when in bed won't turn side to side and lays flat on back. Again reviewed risks and verbalizes understanding. Sits up in wc (wheelchair) for many hours even though advised not to do so. Turning repositioning program: yes; morning and afternoon nap: yes. On 2/23/21, R27's medical record documents: Partial thickness wound, pressure injury. Treatment: Cleanse with ½ strength Dakin's, skin prep to surrounding tissue. Santyl to slough apply nickel thick, calcium alginate cut to size, cover with Allevyn changed q (every) day and prn for soiling. Tissue type: granulation. Drain type: Serous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Continues to show signs of healing. Some decrease in size. Minimal drng. Measurements: 3.3 cm x 1.5 cm x 0.1 cm. Unstageable. Surrounding skin: pink/red, intact. Wound edge: When in bed won't turn side to side and lays flat on back. Reviewed risks and verbalizes understanding. Sits up in wc for many hours even though advised not to do so. Turning repositioning program: yes; morning and afternoon nap: yes. On 3/2/21, R27's medical record documents: Partial thickness wound, pressure injury. Treatment: Cleanse with ½ strength Dakin's, skin prep to surrounding tissue. Santyl to slough apply nickel thick, calcium alginate cut to size, cover with Allevyn changed q (every) day and prn for soiling. Tissue type: slough. Drain type: Serous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Area slightly decreased in size. Kidney bean shaped wound. Slough has decreased to approximately 25%. No pain to site. Continues with non-compliance and aware of risks of not following bedrest. Measurements: 3.3 cm x 1.2 cm x 0.2 cm. Stage: Healing stage 3. Surrounding skin: pink/red, intact. Wound edge: Resident also when in bed won't turn side to side and lays flat on back. Reviewed risks and verbalizes understanding. Sits up in wc for many hours even though advised not to do so. Turning repositioning program: yes; morning and afternoon nap: yes. On 3/9/21, R27's medical record documents: Partial thickness wound, pressure injury. Treatment: Cleanse with NS, apply skin prep to periwound, apply [MEDICATION(S)] Blue (cut to size) to wound bed, cover with foam drsg. Change q T (Tuesday), TH (Thursday), Sat (Saturday), and prn for soiling. Significant improvement form last week to this. Wound has scar tissue formed in the middle of it (1.4 cm). Slough continues to decrease, minimal drng. Continues to be non-compliant with bed rest and repositioning order. Educated daily on this. Tissue type: slough. Drain type: Serous; color: yellow; odor: none. Cause: pressure. Has pressure reducing chair and bed. Measure [TRUNCATED]

Based on observation, interview and record review, the facility did not provide adequate supervision and assistive devices to prevent accidents for 1 (R3) 3 residents reviewed for falls. R3 had a fall from a Broda Chair, while in the day room. The Broda chair was in the upright position and R3 sustained a femur fracture. The facility Interdisciplinary Team (IDT) failed to assess conflicting care plan intervention of keeping R3 upright 30 minutes after meals due to swallowing concerns and reclining R3 in the Broda chair when unattended due to high risk for falls. Findings include: Facility policy, entitled Falls Policy, dated 12/2017, last revised 1/2018, states: Policy Statement/Overview. The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in the identification of potential causes of the fall. Policy Detail 1) The Henrich II Fall Risk form (or a similar fall risk evaluation) should be utilized to complete the evaluation of the resident's potential for falls during the admission process. The Henrich II Fall Risk form (or similar fall risk evaluation) should be completed quarterly, with significant change MDS (Minimum Data Set) Assessments and after every fall. 2) If a Resident sustains a fall, or is found on the floor without a witness to the event, associates shall evaluate for possible injuries and provide first aid or treatment as indicated. Direct care associates shall evaluate the area where the fall occurred for possible contributors. The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. The falls should be reviewed at the Daily Stand-up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls. R3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. R3's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 10/2/19, documents: R3 rarely/never understands other or is understood by others; has long and short term memory loss; totally dependent on two staff for bed mobility, transfers and toilet use, dependent on one staff for locomotion on and off the unit and personal hygiene, requires extensive assistance of two staff for dressing and extensive assist of one staff for eating; is unsteady, only able to stabilize with staff assistance with surface to surface transfers; limited range of motion on one side of upper and lower extremities; receives scheduled and as needed pain medication. R3's Care Plan, dated 10/22/19, documents: (R3) has the potential for falls r/t (related to) R (right) hemi ([MEDICAL CONDITION]), cognition, balance, depression, anxiety. Interventions include: Fall risk evaluation completed quarterly, (start 4/11/19); Check on resident with rounding, (start 4/11/19); Keep soft touch call light within reach, (start 4/11/19); Keep bed at the appropriate height for me, bed in the lowest position (low bed with landing mats), (start 4/11/19); Anticipate patient needs: thirst, hunger, pain, repositioning, boredom, (start 4/11/19); Scoop mattress on bed, (start 4/11/19); When unattended in Broda chair, tilt/recline chair, Resident to be in common area when not attended, (start 4/11/19); Resident to remain in common area until podiatry is ready to assess resident, (start 4/11/19); Increased size of Dycem, (start 4/11/19); Pummel cushion on top of Dycem in Broda chair, (start 4/11/19); Resident is Falling Star Program participant, (start 4/11/19); Staff to make sure front wheels to Broda chair are locked when by dining room table and in common area, (starts 4/11/19) R3's care plan, dated 10/22/19, documents: (R3) has impaired swallowing and requires nectar thick liquids. Interventions include: Thicken liquids to nectar consistency, (start 8/8/17); Resident to be upright at 90 degrees for all meals, (start 8/8/17); Resident to remain upright for 30 minutes after meals, (start 8/8/17); Monitor for appetite and weight loss, (start 8/8/17); Resident has preference for appropriate medications to be crushed, (start 11/16/18). Facility did not clarify conflicting care plan interventions of keeping R3 upright after meals for 30 minutes and for R3 to be reclined in the Broda chair when not attended when R3 was assessed to be a high fall risk. Review of the Broda operating manual indicates: Before the chair is put into service, this manual must be read thoroughly by the caregiver(s) directly responsible for the resident's care. After the chair is put into service, this manual must be read thoroughly by any new caregivers prior to operating or moving the chair. For the purpose of this manual, a resident's family member who shares responsibility for their care is considered a caregiver and is subject to the same competency before being permitted by the resident's primary caregiver to operate of move the chair. Prior to first use, the customer must arrange for an in-service on the operation and safety requirements in this manual, must be given to the resident's caregivers by the local BRODA representative who supplied the chair. The primary caregiver must maintain a list of caregivers who have read this manual and who they have authorized to operate and move the chair. The resident's primary caregiver is responsible for ensuring that anyone who is unfamiliar with, unwilling, or unable to adhere to the safety and operating instructions, is not permitted to operate or move the chair. The operations of the chair must be performed by the resident's primary caregiver who is responsible for seating. All The operations and adjustments performed should be done in a manner to ensure the overall safety, comfort and well-being of the resident, caregiver and third party. All operations and adjustments required for the resident should be determined by the resident's primary caregiver who is responsible for seating. The Broda Operating Manual states: Position of chair - 'Danger of Falling': After a resident is transferred into a chair, assess the amount of tilt required. We recommend that the chair's seat be tilted sufficiently to prevent the resident from sliding or falling forward off the chair. The amount of seat tilt used should be determined by the resident's caregiver who is responsible for seating. We recommend that the resident's feet be correctly positioned on the footrests and slightly too fully elevated to prevent the resident from sliding or falling forward off the chair. The amount of elevation used should be determined by the resident's caregiver who is responsible for seating. Improper Use: As outlined, the improper use of the chair is dangerous to the resident, caregivers, or third parties, and can consist of, but is not limited to the following: . 3) Inappropriate use of the chair for a resident who has not been assessed by a qualified caregiver responsible for their seating. 7) Leaving the resident unattended in the chair near other objects. 8) Leaving an agitated resident in the chair in an unsupervised area. 9) Leaving a resident unattended. R3's Hendrich II Fall Risk Model Assessment, dated 6/27/19, documents: R3 is at a high risk for falls with a score of 12. (A score of 5 or higher = High Risk.) Facility Reported Incident (FRI) report, dated 11/13/19, documents: R3 had a fall on 11/10/19 and was sent to the hospital for evaluation. All X-rays were negative and R3 was transferred back to the facility. On 11/13/19, resident complained of increased pain to her right lower extremity and was sent to the emergency room for x-rays which showed a [MEDICAL CONDITION] femur. The facility investigation records indicate: When R3 was sent to the hospital following the fall on 11/10/19 the hospital completed x-rays of R3's pelvis and hips. During the next few days R3 complained of intermittent pain and PRN (As Needed) pain medication was effective. On 11/12/19 R3 was seen by a physician who ordered Physical Therapy for right knee pain. On 11/13/19, R3 was noted to have increased pain to the lower extremity. Physician and family were made aware and R3 was sent to the hospital for further evaluation. A right femur fracture was diagnosed . Level I Root Cause Analysis form, dated 11/10/19 at 0900 (9:00 AM), documents R3 was unable to respond to the questions of: What were you trying to do at the time of the fall and what was different this time; R3 fell on her right side next to the Broda chair; the Broda chair was in the up position; R3 ate 15 minutes before the fall and was last toileted before breakfast; interventions that are most appropriate is documented as: res (resident) sent to hospital for eval (evaluation). The Root Cause Analysis form does not document if R3's care planned fall intervention of: pummel cushion and Dycem were in the Broda chair at the time of the fall. R3's Level I Root Cause Analysis form does not document new interventions put into place to prevent future falls. On 12/5/19, at 1:51 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-J, who stated: after breakfast CNA-J observed CNA-K take R3 from the dining room to the lounge area next to the dining room. CNA-K did not put R3's Broda chair in the reclined position and R3 was noted to rock back and forth, as she typically does, when holding a baby doll. R3's upper body was bent too far forward and she slid out of the Broda chair. CNA-J stated: normally staff will put the Broda chair in the laying position or back somewhat. CNA-J stated: all staff on the first floor are instructed to recline a Broda chair when a resident isn't at the dining room table. CNA-J stated: R3 was just taken from the breakfast table and moved to the lounge area by CNA-K and that is why R3's Broda remained in the upright position. Following the fall on 11/10/19, CNA-J recalled R3 being in pain and having to log roll R3 with a draw sheet so staff wouldn't pull on any part of R3's body. CNA-J stated: she believed R3 was left in the Broda chair in the upright position and was leaning too far forward, rocking her baby doll, when she fell forward most likely catching her right leg on the broad foot pedal breaking her leg. CNA-J stated: CNA-K does not normally work on the first floor so may not know about putting the Broda chair in the reclined position. CNA-K is an agency CNA that no longer works at the facility. CNA-K's Incident Investigation Statement, dated 11/10/19 does not document if R3's Broda chair was in the upright or reclined position or if the pummel cushion and Dycem were in the Broda chair at the time of the fall. The statement documents: CNA-K did not witness the fall and last assisted R3 with toileting needs at 7:30 AM and R3 had just finished breakfast. On 11/12/19, at 11:34 AM, R3's medical record documents an SBAR (Situation, Background, Assessment, Recommendation) form, which documents: (R3) has pain with movement, with moving RLE (right lower extremity), with ADL's (activity of daily living) with rolling back and forth in bed; new or worsening behavioral symptoms of demonstrating pain; R3 has been calling out in pain during am (morning) adl's when pt (patient) is moved from side to side and then again when was transferred with mechanical lift to Broda. Writer did not witness said actions at this time it was reported to writer after events occurred. College students were assigned to pt (patient) for cares today. Pt was sitting in Broda chair when writer was notified; pt was not demonstrating any discomfort at that time however did refuse oral cares. Writer does note a change in pt's mood pt appearing a bit more timid and not as accepting to those around her. Pt moaned when writer attempted ROM (Range of Motion) to RLE. PRN (as needed) apap (Tylenol) administered and pt is in proper position in Broda chair. No bruising noted to pt's body, no swelling to hips. Unit manager present and updated. NP (Nurse Practitioner) called and discussed, new order received for scheduled apap tid (three times a day) x 7 days, poa (Power of Attorney) called and updated. The facility did not obtain statements from the college students assigned to care for R3 on this day to determine if another incident could have occurred at this time. On 12/9/19, at 10:22 AM, Surveyor asked Nursing Home Administrator (NHA)-A if the facility completed training to all staff in regards to proper positioning of a Broda chair when a resident is not seated at a table. NHA-A informed Surveyor, no training was completed because the facility believed R3's care plan was followed. On 12/9/19, at 10:25 AM, Surveyor interviewed Director of Nursing (DON)-B, who stated he was in the building when R3 fell and was called to the area. DON-B observed R3 on the floor in front of the Broda chair on her left side. DON-B assessed R3 and noted R3 was in pain with any movement, R3 was left on the floor and 911 was called. R3 was transported to the hospital for evaluation. DON-B stated: the CNA in question was interviewed after the fall and it was determined the Broda chair was in the upright position per the dietary care plan. No further action was taken on part of the facility because the care plan was followed. R3 continued to complain of pain and was evaluated by her doctor who ordered physical therapy to address the pain. DON-B stated therapy was never started. R3 continued to complain of pain and further x-rays of R3's knee were ordered. DON-B informed Surveyor: the x-rays revealed a right femur fracture and the fracture was reported to the State Agency due to the time between the fall and the fracture being discovered. DON-B stated R3's care plan was updated after the fall to remove the intervention of keeping R3 upright for 30 minutes after meals. R3's care plan was updated on 11/18/19 to discontinue the intervention of keeping R3 upright for 30 minutes after meals. Surveyor asked DON-B why the conflicting care plan interventions were not clarified. DON-B did not provide an answer. On 12/9/19, at 1:36 PM, DON-B, informed Surveyor: R3 was not unattended in the dining room when the fall occurred. DON-B explained his definition of unattended would be if no staff were in the general area or if staff were unable to visualize R3. DON-B stated: R3 was attended because staff had just assisted R3 to the lounge area and she was sitting in the area closest to the nursing station and where staff do their charting and staff were in the dining room at the time of the fall. DON-B stated since R3 was not unattended, it was okay to follow the nutritional care plan interventions of keeping R3 in the upright position in the Broda chair. DON-B stated: he believes 100% the pummel cushion was still in the Broda chair when R3 slid out even though it was not documented on R3's Level I Root analysis form. Surveyor questioned DON-B as to how the staff should know what intervention to use for R3 when in the Broda chair after meals. DON-B stated the interventions could have been written better in the care plan. Surveyor asked DON-B if the Interdisciplinary Team (IDT) reviewed R3's plan of care to discuss the conflict of the two interventions and discussed the intervention of having R3 remain upright 30 minutes after meals in a Broda chair putting R3 at increased risk for falls. DON-B indicated he could not state the conflicting interventions were reviewed by the IDT. DON-B stated the facility does not have a policy for the safe use of Broda chairs. On 12/9/19, at 2:27 PM, Surveyor interviewed Therapy Department Manager (TDP)-L, who stated: R3 does become anxious after meals and it is hard to keep her safe when juggling her safety with eating and potential risk for falls. TDP-L, stated R3 has poor trunk control and she would be okay slightly tilted back in the Broda chair after meals to address the concern with swallowing and risk for falls. R3 was someone that was not safe fully upright due to her fall risk with poor trunk control. TDP-L stated the speech therapist that assessed R3 and made the recommendation of sitting right for 30 minutes after meals no longer works at the facility. On 12/9/19, at 3:35 PM, Surveyor informed Administrator-A and DON-B of the concern R3 was left upright in the broda chair in the lounge area and the facility Interdisciplinary Team did not review R3's conflicting care plan interventions of leaving R3 upright for 30 minutes after meals and for R3 to be reclined in the Broda chair when unattended after the facility assessed R3 to be at high risk for falls. On 12/16/19, additional information was provided to the Surveyor by DON-B, which included: 1. A timeline of the events around R3's fall and identification of a fractured right femur. This information was provided in the FRI supplied to the State Agency. 2. Additional information proved also included: the 11/14/18 Speech Therapy evaluation, which documented: The reason for the referral: R3 was referred for ST (Speech Therapy) evaluation and treatment after having a coughing and near choking episode with nectar-thick liquids when family was visiting. Aspiration Precautions: no straw; upright at 90 degrees during meals and upright for 30-45 minutes post meal. Supervision: 1:1 feeding-not to be left alone for meals; Positioning: As upright as possible for 20/30 minutes after meals. 3. Additional information also provided: Multiple Hendrich II Fall Risk Model assessment forms: (A score of 5 or greater = High Risk for Falls; Hendrich II Fall Risk Model assessment, dated 11/29/19, with a risk score of 11, indicating R3 is at high risk for falls; Hendrich II Fall Risk Model assessment, dated 11/16/19, with a risk score of 8, indicating R3 is at high risk for falls; Hendrich II Fall Risk Model assessment, dated 11/10/19, with a risk score of 12, indicating R3 is at high risk for falls; Hendrich II Fall Risk Model assessment, dated 4/6/19, with a risk score of 12, indicating R3 is at high risk for falls; Hendrich II Fall Risk Model assessment, dated 1/21/19, with a risk score of 11, indicating R3 is at high risk for falls; Hendrich II Fall Risk Model assessment, dated 1/3/19, with a risk score of 12, indicating R3 is at high risk for falls; Hendrich II Fall Risk Model assessment, dated 10/4/18, with a risk score of 12, indicating R3 is at high risk for falls; Hendrich II Fall Risk Model assessment, dated 9/11/18, with a risk score of 12, indicating R3 is at high risk for falls. On 12/17/19, at 12:25 PM, Surveyor interviewed DON-B, who stated: the Speech Therapy evaluation that was completed on 11/14/18, was completed before DON-B was hired at the facility. DON-B stated he could not say if he saw the Speech Therapy recommendation for R3 to remain as upright as possible for 20/30 min (minutes) after meal documented on the 11/14/18 Speech Therapy evaluation. DON-B stated had he seen the recommendation for R3 to remains as upright as possible he isn't sure that would have prompted him to change the care plan intervention from the intervention of keeping R3 upright 30 minutes after meals. DON-B stated that he met with the facility IDT and all agree the Broda chair remains the safest seating device for R3 and the risk of falls is greater than the risk of aspiration so the intervention of keeping R3 upright 30 minutes after meals has been removed from R3's care plan.

Based on observation, interview and record review the facility did not ensure residents received care consistent with professional standards of practice to prevent pressure injuries for 1 (R42) of 3 residents reviewed at risk for pressure injuries. R42 was admitted to the facility on [DATE] requiring extensive assist from staff for activities of daily living. R42 developed an unstageable pressure injury to the left heel on 4/12/19 and a blister/deep tissue injury to the right heel on 4/16/19. Interventions were not put into place upon admission to prevent pressure injuries. Findings include: R42 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. R42's Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 4/15/19, documents: Rarely makes self understood and rarely understands other, has the absence of spoken words, non verbal; Modified independence in cognitive skills for daily decision making; mild depressive symptoms using the staff assessment of residents mood (PHQ-9 OV); total dependency of one staff for locomotion on and off the unit, total dependence on two staff for toileting needs; extensive assistance of two staff for bed mobility, transfers, dressing and personal hygiene; limited range of motion to one side of the upper extremities and both sides of the lower extremities. R42's Nursing Comprehensive Admission Observation/Evaluation form, dated 4/8/19, documents: dependent on staff for upper and lower body dressing, requires substantial or maximal assistance to roll left and right in bed, to move from sitting to lying and is dependent on staff to move from sit to stand, chair/bed to chair transfer and toilet transfer and has limited range of motion of both sides related to arms, hands, legs and feet and uses anti-embolic stockings/wraps (TED stockings). R42's care plan, dated 4/8/19, with a target date of 7/12/19, states: (R42) is at risk for pressure ulcers and other skin related injuries r/t (related to) decreased mobility, hx (history) of SAH (Subarachnnoid Hemorrhage), nonverbal. Interventions include: Braden Scale to be completed (4/8/19); Keep bed linens wrinkle free and do not use excess pads (4/8/19); Observe skin for redness and breakdown during routine cares (4/8/19); Use pressure relieving devices, as indicated (4/8/19); Follow community skin care protocols (4/8/19); Treatments as indicated (4/8/19); Pressure reducing mattress on bed, speciality hi/lo air mattress (4/8/19) Heel lift utilized (4/16/19); wound consult (4/24/19); Bilateral lower feet pressure relief boots to be on at all times when out of bed (4/24/19). R42's admission skin check, dated 4/8/19, documents a small scratch to the base of the right knee and healing scratch on the left shin. Left heel: On 4/12/19, at 9:55 PM, R42's medical record documents: CNA (certified nursing assistant) notified writer that patient had a blister that popped, writer notified RN (Registered Nurse) Supervisor, area measures 4.4 cm (centimeters) x (by) 6.0 cm, with serosanguineous drainage to the L (left) heel, noted to have scant amount of drainage to tubi-grip sock. The doctor was notified and an treatment order was obtained. R42's care plan was not updated once the open blister was identified. R42's Skin Evaluation Forms Document: 4/12/19: Staff observed serous drainage from open blister measuring 6 cm by 4 cm by 0.1 cm blister cap intact to left heel. Treatment order for: [MEDICATION NAME] QD (every day) with skin prep. On 4/13/19, at 1:41 PM, R42's medical record documents: Nurse manager called to update this nurse r/t res (resident) left heel blister. A speciality high Hi/Lo air mattress needed to be order for pressure relief. The order was obtained by Dr on call. AM nurse supervisor was updated. Maintenance was updated. No in house air mattresses available at this time so a speciality mattress needs to be ordered. Nursing Supervisor is aware and will follow up . In the meantime res heels are elevated with a pillow when up in Broda chair and heels floated when in bed. Res [MEDICATION NAME] to left heel is CDI (Clean, Dry and Intact). No s/s (signs/symptoms) of pain. On 4/15/19, at 1:05 PM, R42's medical record documents: Speciality mattress ordered & (and) applied to bed, plan for resident to not wear shoes until heel is healed, foam dressing being applied to left heel daily, ordered heel lift boots for both feet/heels while in bed. Surveyor noted the mattress was indicated on the care plan as of 4/8/19 despite not obtaining the mattress until after areas developed. R42's Skin Evaluation Forms document: 4/16/19: Stage 2 O/A (Open Area) left heel with skin flap. Measures 5.3 cm by 4.5 cm by 0.1 cm. Bloody/Sanguineous drainage, red color. Previously this was a serous fluid blister that popped. Skin flap noted. No odor. Treatment order for: Allevyn life heel pad change q (every) 3 days. 4/22/19: Stage 2 pressure injury noted to left outer aspect of heel. Measures: 5.3 cm by 4.5 cm by 0.1 cm. Previously this was a serous fluid blister that popped. Skin flap noted. No odor, no c/o (complaint of) pain or discomfort. Cause: pressure. Treatment order for: Cleanse with NS (normal saline), cover with foam dressing and change Q 3 days and PRN (As Needed). 4/29/19: Unstageable pressure injury noted to the left outer aspect of heel. Measures: 3.0 cm by 2.1 cm by 0.1 cm. Previously this was a serous fluid blister that popped. Edges attached. No odor, no c/o (complaint of) pain or discomfort. Cause: pressure. Treatment: Cleanse with N/S, periwound, cover with foam dressing, change q 3 days and PRN. 5/1/19: Unstageable pressure injury noted to left outer aspect of heel. Previously this was a serous fluid filled blister that popped. Edges attached. Slough noted at base of wound. No odor, no c/o pain or discomfort. Cause: pressure. Measures: 2.6 cm by 1.8 cm by 0.1 cm. Treatment: Cleanse with saline, protect periwound with skin prep. Apply Santyl to wound bed, cover with bordered gauze, change daily and prn. 5/6/19: Unstageable pressure injury noted to the left aspect of heel. Previously this was a serous fluid filled blister that popped. Edges attached. Slough noted at base of wound. No odor, no c/o pain or discomfort. Cause: pressure. Measures: 2.2 cm by 2.0 cm by 0.1 cm. Treatment: cleanse wound with saline, protect periwound with skin prep, apply Santyl to wound bed, cover wound with bordered gauze and change daily and prn. 5/13/19: Unstageable pressure injury noted to the left aspect of heel. Previously this was a serous fluid filled blister that popped. Edges attached. Periwound macerated. Early/partial granulation at base of wound. No odor. no c/o pain. Cause: pressure. Measures: 3.8 cm by 2.6 cm by 0.1 cm. Treatment: cleanse wound with 1/2 strength Dakins, protect periwound with skin prep, apply Santyl to wound bed, cover wound with bordered gauze, change daily and prn for soiling. 5/20/19: Unstageable pressure injury noted to the left aspect of heel. Previously this was a serous fluid filled blister that popped. Edges attached. Periwound macerated. Early/partial granulation at base of wound. No odor. no c/o pain. Cause: pressure. Measures: 3.8 cm by 2.6 cm by 0.1 cm. Treatment: cleanse wound with saline, protect periwound with skin prep, apply Santyl to wound bed, cover would with bordered gauze, change daily and PRN for soiling. Right heel: On 4/16/19, at 11:20 AM, R42's medical record documents: General skin check completed on resident. Resident has new issue that were identified during skin check. See site specific note for full details of the new issues identified during the skin check. R42's Skin Evaluation Form document: 4/16/19: Blanchable intact blister area on the right heel. Measures: 2 cm by 2 cm. The doctor and family were notified. Cause: Pressure. Treatment: Allevyn life heel pad. Change Q 3 days. R42's care plan is updated to include the intervention of heel lift on 4/16/19. 4/22/19: Suspected deep tissue injury. Base of wound is purple in color. Measures: 2.7 cm by 2.4 cm by 0. Treatment: Cleanse with [MEDICATION NAME], daily and PRN followed by ABD and kerlix wrap secure with tape. 4/29/19: Suspected deep tissue injury. Base of wound is purple in color, no odor, no drainage, no c/o pain or discomfort noted. Cause: pressure. Measures: 2.0 cm by 1.9 cm by 0. Treatment: Cleanse with [MEDICATION NAME], daily and PRN followed by ABD (absorbent sterile dressing) and kerlix wrap secure with tape. 5/1/19: Suspected deep tissue injury Base of wound is purple in color, no odor, no drainage, no c/o pain or discomfort noted. Cause: pressure. Measures: 1.6 cm by 1.8 cm by 0. Treatment: cleanse with saline, skin prep area daily and PRN. 5/6/19: Area healed. Continue to cleanse with saline, skin prep area daily and prn. R42's care plan is not updated to include the pressure relief boots until 4/24/19 when the heel lift boots were ordered on [DATE] and after both heels have documented pressure injuries. On 5/22/19, at 8:29 AM, Surveyor observed the treatment to R42's bilateral heels. No concerns were observed. On 05/22/19, at 12:10 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated he wasn't certain when the facility obtained the speciality air mattress for R42 and was uncertain of what the facility's general use mattress is rated in relation to pressure injury stages but would look into it and let Surveyor know. On 5/22/19 at 12:52 PM, Regional Clinical Director of Operations-F, Provided Surveyor with an invoice documenting a speciality mattress was delivered to the facility on [DATE] for R42 even though the mattress is documented as an intervention on R42's care plan dated 4/8/19. The mattress was large and made it difficult for staff to move round the room so another speciality mattress was ordered and delivered on 4/15/19 and the other mattress was removed at this time. No further information was provided as to the pressure reducing rating of the facility general use mattress. On 5/22/19, at 12:10 PM, Surveyor interviewed DON-B, who stated: R42 was noted to be at high risk for the development of pressure injuries upon admission. DON-B stated, all residents at risk for pressure injures are expected to have their heels elevated, repositioning provided, a facility mattress and wheelchair pad that provide pressure relief per facility standard of practice to prevent pressure injures from developing. DON-B stated, he would expect to see heels floated and turning and repositioning documented as interventions on R42's care plan upon admission but if it is not on the care plan it is because it is the facility's standard of practice for all residents at risk for pressure injuries. On 5/22/19, Surveyor reviewed the facility policy and procedure, titled: Skin Identification, Evaluation and Monitoring. The facility policy did not include a facility standard of practice of floating heels and a turning and repositioning as interventions for all residents found to be at risk for the development of pressure injuries. On 5/22/19, Surveyor informed, Administrator-A, DON-B, Regional Clinical Director of Operations-F of the concern the facility did not implement interventions to prevent pressure injuries for R42 who was documented to be at risk for the development of pressure injuries upon admission. Regional Clinical Director of Operations-F provided Surveyor with a copy of the facility's Quality Assurance Plan related to pressure injures. The Quality Assurance Plan was reviewed by Surveyor. On 5/22/19 NHA-A sent to the regional office a statement regarding the F686 deficiency and the facility's QAPI plan developed regarding pressure injuries. NHA-A indicated: F686 The resident did have risk assessments in place upon admission. The origin is considered to be more friction than pressure, and his care plan was updated accordingly. Floating heels and wheelchair cushions are standard of practice upon admission for all of our residents in all of our communities. Surveyor reviewed the documentation regarding R42 and did not note any care planned interventions to reduce friction or sheering for R42 with the exception of a note to not wear shoes which is noted in a 4/15/19 note in the medical record. There is no assessment to indicate friction as a cause of R42's pressure injuries. Surveyor noted upon review of the facility submitted QAPI plan the plan does not clearly indicate the date the plan was initiated however the targeted goal dates are established for after the completion of the recertification survey.

Based on observation, interview and record review the facility did not ensure that 3 (R26, R20, and R29) of 7 residents reviewed for pressure injuries received the necessary care and services to prevent pressure injuries and to prevent developed pressure injuries from worsening. -On 5/31/18 R26's coccyx wound deteriorated and was noted to have a yellow wound bed. A RN (registered nurse) assessment was not documented as being completed, a physician was not documented as being notified, and there was no documented change in treatment or plan of care until 6/5/18 when the wound again deteriorated and became classified as an unstageable pressure injury with slough and necrotic tissue. R26 was observed on survey sitting in her wheelchair without her pressure relief cushion in place per her plan of care. R26's wound was also not consistently documented as being assessed by an RN during the duration of the wound. -R20 developed a pressure injury on his right ankle which wasn't identified until it was unstageable on 1/13/18. There is no RN assessment for 6 days after the development and care plan interventions for R20's lower extremities was not implemented until after the development. The Facility did not stage this pressure injury correctly when on 1/30/18 the wound bed was visible with 25% slough, continuing to stage the pressure injury as unstageable. On 3/28/18 the Facility incorrectly staged R20's pressure injury as a healing Stage 2. According to current standards of practice pressure injuries should not be back staged. The above resulted in actual harm to R20 -R29 who is at risk for developing pressure injuries was observed without his heels being offloaded. Findings include: 1.) On 2/5/18 R26 is documented as developing a 1cm x 2cm denuded area on coccyx. peritissue reddened scant amt. (amount) sanguinous drainage. The wound type is documented as other. On 2/14/18 the wound is documented as a 0.6cm x 0.4cm denuded area on coccyx. peritissue reddened. scant amt. sanguinous drainage. The wound type is documented as other. There is no documented assessment of the wound between 2/14 - 2/27/18 in R26's medical record. On 2/27/18 the wound is documented as increasing in size to 0.7cm x 0.6cm and is described as denuded area on coccyx. peritissue reddened. scant amt. sanguinous drainage. The wound type is changed to incontinence. Between 2/27 - 3/20/18 there is no documented RN assessment of the wound documented in R26's medical record. On 3/21/18 RN Manager-C documents a 0.4cm x 0.2cm denuded area on coccyx. peritissue reddened. scant amt. sanguinous drainage. The wound type is documented as incontinence. On 3/28/18 at 3:28 pm RN Manager-C documents a 0.4cm x 0.2cm denuded area on coccyx. peritissue reddened. scant amt. sanguinous drainage. The wound type is documented as incontinence. On 3/28/18 at 8:57pm LPN-Q documents the wound to have increased in size to 1cm x 0.7cm. The wound type is documented as incontinence. On 4/3/18 LPN-R documents a 1cm x 0.7cm denuded area on coccyx. peritissue reddened. scant amt sanguinous drainage. The wound type is documented as incontinence. On 4/11/18 LPN-D documents the wound to be 0.4cm x 0.4cm denuded area on coccyx. peritissue reddened. no drainage. Area improved. The wound type is documented as incontinence. On 4/18/18 LPN-Q documented the wound to be 0.4cm x 0.4cm denuded area on coccyx. peritissue reddened. no drainage. Area improved. The wound type is documented as incontinence. On 4/25/18 the wound increased in size. LPN-D documents the wound to be 2cm x 2cm. The wound description is documented as denuded area on coccyx. peritissue reddened. no drainage. There is no documented RN assessment of the wound in R26's medical record between 3/28 - 4/25/18. On 4/26/18 the wound increased in size. RN Manager-C documents the wound to be 2cm x 2.9cm. The wound description is documented as denuded area on coccyx. peritissue reddened. no drainage. The wound type is documented as incontinence. The treatment is documented as being changed to cleanse area with soap and water and cover with an Allevyn life dressing every 7 days. On 5/3/18 the wound increased in size to 3cm x 3cm. RN Manager-C documents the wound to be described as a denuded area on coccyx. peritissue reddened. no drainage. The wound type is documented as incontinence. On 5/9/18 LPN-D documents the wound as a 3cm x 3cm denuded area on coccyx with dark red center. peritissue reddened. no drainage. The wound type is documented as incontinence. The surveyor noted that this is the first time the wound is documented as dark red. There is no documentation that an RN was notified of the change in R26's wound. There is no documented change in treatment or plan of care. On 5/17/18 LPN-D documents the wound as 1.1cm x 0.6cm denuded dark red/purple area on coccyx. No drainage. Peritissue red and denuded. The wound type is documented as incontinence. The surveyor noted that this is the first time the wound is documented as dark red/purple. There is no documentation that an RN was notified of the change in R26's wound. There is no documented change in treatment or plan of care. On 5/23/18 LPN-D documents the wound as 1.1cm x 0.6cm denuded dark red/purple area on coccyx. no drainage. peritissue red and denuded. The type of wound is documented as incontinence. On 5/30/18 LPN-Q documents the wound as 1.1cm x 0.6cm denuded dark red/purple area on coccyx. no drainage. peritissue red and denuded. The facility's Pressure Injury Assessment/Treatment procedure last revised 1/2018 defines a deep tissue pressure injury as Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. On 5/31/18 LPN-D documents the wound as 1.8cm x 0.4cm. The wound is described as area on coccyx consist of yellow wound bed with dark red tissue adjacent to it. No drainage. peritissue red and denuded. This is the first time the wound bed is documented as yellow. There is no documentation that a physician was notified of the change in the wound bed. There is no documented change in treatment of [REDACTED]. There is no documented RN assessment of the wound between 5/3/18 - 6/5/18 The facility's Pressure Injury Assessment/Treatment procedure last revised 1/2018 defines slough tissue as Non-viable yellow, tan, gray or brown tissue, usually moist, can be soft stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. On 6/12/18 at 3:50 pm the surveyor interviewed LPN-D. LPN-D confirmed that she was familiar with R26 and her coccyx wound. The surveyor asked LPN-D about her documentation of the wound on 5/31/18 stating area on coccyx consist of yellow wound bed with dark red tissue adjacent to it. LPN-D stated it was a white yellow, and wasn't apparent enough that it was slough tissue. LPN-D stated it definitely turned out to be slough and was very recent that it changed. LPN-D stated sometimes it is hard to tell in the beginning if it is slough. The surveyor asked LPN-D if she had told anybody such as a physician or RN that R26's wound had a yellow wound bed. LPN-D stated she could not remember. The surveyor asked if that is something LPN-D would document. LPN-D stated yes, on the skin sheet. LPN-D stated R26's would change overnight. The surveyor asked LPN-D if she asked an RN to assess the wound. LPN-D stated she could not recall. LPN-D stated her general practice is to leave RN Manager-C a message. On 6/13/18 at 8:39 am the surveyor interviewed RN Manager-C. The surveyor asked what is the process for wound monitoring. RN Manager-C stated nurses are expected to evaluate on bath days, and nurse managers do weekly wound rounds that include measuring. RN Manager-C stated some nurses do measure on bath days, and nurse managers follow up with that. The surveyor asked if that is the same for an open area with incontinence. RN Manager-C stated any open area. The surveyor informed RN Manager-D of periods of time when R26 had no documented wound assessment by an RN. RN Manager-D stated at times if a LPN measures she (RN Manager-C) may not have measured but would have looked at the wound and document on the wound sheet. The surveyor noted the wound sheet that RN Manager-D provided to surveyor was not part of R26's medical record, did not contain documentation of the wound bed, and did not document who was completing the measurements. RN Manager-D stated that it was a tool the facility uses. The surveyor asked RN Manager-D if on 5/31/18 when R26's wound was noted to have yellow wound bed if she recalled being notified. RN Manager-C stated she did not recall being notified of that. The surveyor asked RN Manager-C if she would expect to be notified of that. RN Manager-C stated yes. The surveyor asked RN Manager-C if she would you expect the physician to be notified of that. RN Manager-C stated yes. On 6/5/18 RN Manager-C documented the wound as a partial thickness unstageable pressure ulcer. The area is documented as a 2cm x 1cm area on coccyx consist of yellow wound bed with dark red tissue adjacent to it. No drainage. peritissue red and denuded. The wound edge is documented as necrotic. Interdisciplinary notes document on 6/6/18 late entry for 6/5/18. Coccyx wound noted with slough in wound bed with necrotic area around perimeter of wound. (physician) aware . On 6/11/18 RN Manager-C documented the wound as a 2cm x 1cm pressure ulcer describing the wound as open area to coccyx, necrotic tissue resolved, slough remains 100% to wound bed. R26's care plan includes an area of concern for Potential for Impaired Skin Integrity r/t (related to) decreased mobility, severe Alzheimer's dementia, impaired vision. DX (diagnosis) of [MEDICAL CONDITION], hx (history) of frequent bruising related to clinical conditions, aging and resident's desire to self propel, coccyx MASD (moisture associated skin damage). Interventions on R26's plan of care includes Dycem under, cushion in broda chair with a start date of 3/15/18 and Air mattress on bed, pressure relieving cushion on chair when resident is up in chair with a start date of 6/5/18. R26's ADL (activities of daily living)/Daily Care card/sheet (not dated) that the CNAs (certified nursing assistants) utilize for implementing a resident's plan of care, received 6/7/18, states Air mattress on bed, pressure relieving cushion on chair when resident is up in chair. On 6/12/18 at 10:12 am the surveyor observed R26 in a transportation wheelchair. The surveyor observed there was no pressure relief cushion in the wheelchair. On 6/12/18 at 10:18 am, surveyor observed R26 being taken from her room down to the hair salon. The surveyor observed that there was no pressure relief cushion in R26's wheelchair. On 6/12/18 at 10:23 am the surveyor observed R26 in the hair salon. The surveyor observed that there was no pressure relief cushion in R26's wheelchair. On 6/12/18 at 10:44 am and 11:24 am the surveyor observed R26 remained in the hair salon in the wheelchair with no pressure relief cushion in place. The surveyor noted a removable pressure relief cushion in R26's broda chair in her room. On 6/13/18 at 8:39 am the surveyor interviewed RN Manager-C. The surveyor asked what interventions were currently in place related to R26's pressure injury. RN Manager- C stated R26 has an air mattress and a specialty cushion in her chair. The surveyor informed RN Manager-C of the observations of R26 being up in her wheelchair without a pressure relieving cushion in the chair. RN Manager-C stated staff should be putting the cushion in any wheelchair R26 is in in. The procedure for Prevention of Pressure Injuries Protocol last revised 1/2018 under general guidelines include; A. Pressure injury are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or decreased circulation (blood flow) to that area and subsequent destruction of tissue. B. The most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles and toes. Under Intervention and Preventative Measures: Resident with Risk Factors for E. Risk Factor - Immobility documents; 1. See bed-fast and chair-fast. 2. Use pillows, wedges or other off-loading devices to keep bony prominence such as knees or ankles from touching each other. Do not massage bony prominence. 3. When in bed every attempt should be made to float heels (keep heels off of the bed) by placing a pillow from knee to ankle or with other devices as recommended by clinical staff or by the physician. 4. Refer resident for a therapy evaluation and/or restorative nursing program (may include range of motion, transfer and ambulation programs). 2.) R20's [DIAGNOSES REDACTED]. The pressure ulcer/skin prevention care plan not dated documents interventions of; Braden Scale to be completed per facility protocols with a start date of 6/1/17, Rest Q mattress and w/c (wheelchair) cushion with a start date of 6/1/17, Inspect skin for signs and symptoms of breakdown with a start date of 6/1/17, Skin protectant to buttocks/groin after each incont (incontinent) episode with a start date of 9/1/17, Heel Riser in bed 1/13/17 with a start date of 1/19/18, Resident has Air mattress with a start date of 1/23/18, See eTar (electronic treatment administration record) for treatments as ordered with a start date of 3/18/18, Physician-T consult as needed with a start date of 3/18/18, Medix boot to right foot for protection related to wound with a start date of 3/19/18, Sheep skin to bilateral thigh and hip area during medi lift transfers with a start date of 5/22/18 and Encourage to wear sunscreen and a hat when outside. with a start date of 5/30/18. The annual MDS (Minimum Data Set) with an assessment reference date of 11/29/17 documents R20 has short & long term memory problems and is moderately impaired for cognitive skills for daily decision making. R20 requires extensive assistance with two plus person physical assist for bed mobility & transfer and does not ambulate. R20 is at risk for pressure injury development and is coded as not having any pressure injuries. The nurses note dated 1/13/18 documents, General skin check completed on resident. Resident has a new wound to right outer ankle as well as an old area to LLE (left lower extremity) on shin, and old area to LUE (left upper extremity) near bicep, that were identified during the skin check. Please see skin assessment in chart for further wound details. This nurses note was written by LPN (Licensed Practical Nurse)-E. The nurses note dated 1/13/18 documents, NP (Nurse Practitioner)-U and POA (Power of Attorney)-V updated on new wound to right outer ankle. Received order per NP-U for SWW (saline wound wash) to right ankle f/b (followed by) nickel thick santyl f/b [MEDICATION NAME] dressing daily to right ankle wound. The skin evaluation form dated 1/13/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents Pressure. Under Length documents 2.8 cm (centimeters), Width 2.5 cm, Depth 0 cm. Under Stage documents Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right inner ankle, surrounding skin red, wound bed 100% slough. Painful with movement or touch. This evaluation was completed by LPN-E. Surveyor noted there is no RN (Registered Nurse) assessment. The physician orders [REDACTED]. The next skin evaluation form is dated 1/19/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents 2.8 cm, Width 2.5 cm, Depth 0 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right inner ankle, surrounding skin red, wound bed 100% slough. Painful with movement or touch. Surveyor noted this evaluation was completed by RN-S, six days after R20's unstageable pressure injury was identified. The skin evaluation form dated 1/23/18 for site documents, ankle right outer, for type, Pressure ulcer, and under cause documents, Pressure. Under Length documents, 2.8 cm, Width 2.5 cm, Depth 0 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin red, wound bed 100% slough. Painful with movement or touch. The physician order [REDACTED]. The skin evaluation form dated 1/30/18 for site documents ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents 3.0 cm, Width 3.0 cm, Depth 0 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin red, wound bed 25% slough. Painful with movement or touch. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3 as the wound bed is now visible with 25% slough. The skin evaluation form dated 2/6/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents, 3.0 cm, Width 2.4 cm, Depth 0 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin red, wound bed 25% slough. Painful with movement or touch. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3 as the wound bed is now visible with 25% slough. The skin evaluation form dated 2/14/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents 2.8 cm, Width 2.6 cm, Depth 0 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin red, wound bed 25% slough. Painful with movement or touch. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3 as the wound bed is now visible with 25% slough. The skin evaluation form dated 2/19/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents 3.0 cm, Width 2.3 cm, Depth 0.1 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin red, wound bed 25% slough. Painful with movement or touch. Surveyor noted this evaluation was completed by LPN-E and the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3 as the wound bed is now visible with 25% slough. The quarterly MDS with an assessment reference date of 2/21/18 documents a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R20 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfer, and does not ambulate. R20 is at risk for pressure injury development and is coded as having one Unstageable pressure injury. The skin evaluation form dated 2/27/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents, 3.1 cm, Width 2.0 cm, Depth 0.1 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin red, wound bed 25% slough. Painful with movement or touch. Macerated skin to outer edges. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3 as the wound bed is now visible with 25% slough. The skin evaluation form dated 3/6/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents 2.0 cm, Width 2.3 cm, Depth 0.1 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin red, wound bed 25% slough. Painful with movement or touch. Macerated skin to outer edges. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3 as the wound bed is now visible with 25% slough. The skin evaluation form dated 3/13/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents 3.5 cm, Width 2.1 cm, Depth 0.1 cm. Under Stage documents Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin purple in color, wound bed less than 25% slough. Painful with movement or touch. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3. The nurses note dated 3/14/18 documents, Writer notified Physician-T regarding necrotic tissue surrounding wound bed on right ankle wound. Physician-T will come to facility on 3/15 to follow up with resident and wound care. The nurses note dated 3/15/18 indicates, Physician-T saw Resident. nor (new order received) to extend bactrim ds until 3/22/18., extend cefitn 500 mg (milligrams) bid (twice daily) until 3/22 add [MEDICATION NAME] to right ankle ulcer care waffle boot to right leg/foot POA-V updated on nor (new order received). The skin evaluation form dated 3/15/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents Pressure. Under Length documents, 2.0 cm, Width 2.0 cm, Depth 0.1 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin pink in color, wound bed less than 25% slough. Painful with movement or touch. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3. The physician order [REDACTED]. The skin evaluation form dated 3/22/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents 2.0 cm, Width 2.0 cm, Depth 0.1 cm. Under Stage documents, Unstageable Slough and or esch (eschar). Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin pink in color, wound bed less than 25% slough. Painful with movement or touch. Surveyor noted the Facility continued to Stage this pressure injury as unstageable but should have been staged as a Stage 3. The skin evaluation form dated 3/28/18 for site documents, ankle right outer, for type Pressure ulcer, and under cause documents, Pressure. Under Length documents, 2.0 cm, Width 2.0 cm, Depth 0.1 cm. Under Stage documents, Healing Stage 2 Under description documents, Pressure wound to bony prominence of right outer ankle, surrounding skin pink in color, wound bed less than Painful with movement or touch. Surveyor noted the Facility is incorrectly staging R20's pressure injury as a healing Stage 2. According to current standards of practice pressure injuries should not be back staged. Surveyor noted the Facility continued to complete weekly skin evaluations documenting the exact same description of Pressure wound to bony prominence of right outer ankle, surrounding skin pink in color, wound bed less than Painful with movement or touch and continued to stage R20's pressure injury as a healing stage 2. The last measurements dated 6/11/18 document length as 3.0 cm, width 2.0 cm, and depth 0.1 cm. The significant change MDS (Minimum Data Set) with an assessment reference date of 3/29/18 documents R20 as requiring extensive assistance with two plus person for bed mobility, is dependent with two plus person for transfers, and does not ambulate. R20 is at risk for pressure ulcer development and is coded as having one Stage 2 pressure ulcer. The Pressure Ulcer CAA (Care Area Assessment) dated 4/4/18 under causes and contributing factors documents, Res. (Resident) noted with pressure injury to his right outer ankle since 1/13/18. This started as unstageable due to slough and tx (treatment) and skin interventions were started to minimize risk of the wound getting worse and a mnimoze (minimize) further skin breakdown. Res. also being followed by a wound doctor. Since 3/28/18 (please refer to skin evaluation notes in AOD (answers on demand), res. right outer ankle wound has been stage 2. Staff will cont (continue) to monitor and will cont with the wound tx and skin interventions that is put in place. The nurses note dated 4/25/18 documents Writer noted surrounding skin warm to touch and redness with swelling, MD (medical doctor) notified, are outlined surrounding wound, wound bed granulated tissue, red in color. The nurses note dated 4/25/18 documents, writer took call from Physician-T new orders received for culture of right outer ankle wound due to warmth redness and swelling of surrounding tissue new order for abt (antibiotic) and [MEDICATION NAME] POA (power of attorney) updated regarding new orders. The nurses note dated 4/27/18 documents, continues abt (antibiotic) for right ankle wound infection no s/s (signs/symptoms) of adverse reaction to abt therapy resident is afebrile dressing c/d/i (clean/dry/intact) bilaterally remains in contact isolation for [MEDICAL CONDITIONS] all services are being provided to resident in his room at this time. The 1 West Report sheet updated 6/7/18 for R20 under skin prevention documents, skin protectant to buttocks/groin after each incont (incontinence) episode. The Resident ADL (activities of daily living)/Daily Care List provided to Surveyor on 6/7/18 at 11:08 for R20 under appliances/safety/skin precaution dated 6/1/17 documents, Has glasses and keeps them at the bedside. Has upper and lower dentures. Low bed. Staff to assist with transporting resident to and from the patio as resident requests and check frequently when outside. Medix boot to right foot for protection related to wound. Air mattress on bed. Heel riser used when in bed. Encourage to wear sunscreen and a hat when outside. On 6/7/18 at 10:52 a.m. Surveyor observed R20 sitting in a high back wheelchair wearing a pressure relieving black boot on his right foot. Surveyor asked R20 how he developed the pressure ulcer on his right ankle. R20 informed Surveyor he didn't know and that he's had it for a long time. Surveyor asked R20 when the nurse is going to do his treatment would it be alright if the Surveyor observed. R20 informed Surveyor the Surveyor would have to speak with the nurse. Surveyor then informed R20 Surveyor had noted he keeps his room door closed and asked if it would be alright if Surveyor periodically came in and when staff came into his room could the Surveyor observe staff. R20 replied, no. On 6/12/18 at 10:07 a.m., Surveyor entered R20's room with LPN-E & LPN-W. In the presence of staff Surveyor asked R20 if Surveyor could observe his treatment. R20 replied, ya. Surveyor observed R20 in bed on his back with his right leg flexed and his left leg extended. Surveyor did not observe a heels up pad. Surveyor observed the treatment for [REDACTED]. Surveyor observed a red wound bed and did not observe slough. There were no concerns identified with this observation. On 6/12/18 at 10:33 a.m. Surveyor asked LPN-E how R20 received the right ankle pressure injury. LPN-E replied, You saw his leg and explained she thinks it's from putting pressure on the bed. Surveyor asked LPN-E how long R20 has had the pressure injury. LPN-E informed Surveyor she thinks a couple of months; he had a couple bouts [MEDICAL CONDITION] which was treated, and the last culture came back clear. On 6/13/18 at 10:26 a.m. Surveyor spoke with LPN-E to inquire when R20 was identified with the unstageable pressure injury on 1/13/18 if she informed RN Manager-C. LPN-E informed Surveyor she lets RN Manger-C know if there are new skin concerns. Surveyor asked if RN Manager-C looked at R20's pressure injury. LPN-E informed Surveyor she would have to say RN Manger-C usually does but this was back in (MONTH) and couldn't say for sure. Surveyor again asked LPN-E how she thought R20 developed the unstageable pressure injury. LPN-E informed Surveyor it was from pressure on the bed or the outer aspect of his ankle would hit the wheel of his wheelchair. Surveyor asked LPN-E if R20 wore pressure relieving boot prior to developing the pressure injury. LPN-E replied, I don't believe so. On 6/13/18 at 10:58 a.m., Surveyor informed RN Manager-C Surveyor had noted an intervention of air mattress on R20's care plan but Surveyor did not observe an air mattress on R20's bed. RN Manager-C informed Surveyor she remembers that R20 didn't want the air mattress, his wife talked him into it and once he was on the air mattress he didn't want it again. Surveyor asked how R20 developed the right ankle pressure injury. RN Manager-C informed Surveyor R20's feet are deformed and pressure from when he's laying in bed is how she believes the pressure injury developed. RN Manger-C explained R20 can't really put his feet on the wheelchair foot rest so that's where the heel Medix boot came in from Physician-T. Physician-T felt something should be supporting the foot. Surveyor stated R20 received the boot and heels up pad after developing the pressure injury. RN Manager-C replied right. Surveyor asked RN Manager-C what the Facility was doing to prevent the development of R20's pressure injury. RN Manager-C informed Surveyor he should have had his feet elevated on pillows. RN Manager-C informed Surveyor R20 was more mobile, had a fall in December, and after this fall started to decline. RN Manager-C informed Surveyor heel risers were obtained for the facility and no one should have pillows. Surveyor informed RN Manager-C the skin evaluation on 1/13/18 was completed by LPN-E and didn't note an RN assessment until 6 days later on 1/19/18. Surveyor inquired if this was the first time she assessed R20's pressure injury. RN Manager-C looked at R20's electronic record and informed Surveyor the assessment on 1/19/18 was completed by RN-S and she didn't see the wound until the 23rd. Surveyor asked RN Manager-C why wasn't R20's pressure injury not identified until it was unstageable. RN Manager-C replied, I don't know. I can't tell you why. On 6/13/18 at 1:03 p.m., Surveyor informed DON (Director of Nursing)-B of the development of R20's right ankle pressure injury which was not identified until it was unstageable, no RN assessment for 6 days, and the Facility not staging this pressure ulcer correctly. DON-B asked Surveyor if Surveyor saw Physician-T's notes as he may have staged them. Surveyor info (TRUNCATED)

Based on observation and staff and resident interviews, the facility did not ensure that food was prepared and served in accordance with professional standards of safety for 2 of 2 residents who requested over-easy eggs (R19 and R7); these residents received non-pasteurized eggs that were not set and completely firm. The Facility's practice of cooking and serving non-pasteurized eggs that were not fully formed and set created a finding of Immediate Jeopardy beginning 4/5/17. Administrator-A was informed of the Immediate Jeopardy on 4/5/17 at 12:36 p.m. The Immediate Jeopardy was removed on 4/5/17, however the deficient practice continues at scope/severity of F (potential for harm/widespread) as evidenced by the observation that Dietary Manager-E was walking through the main kitchen that serves all residents not wearing a hair restraint that completely covered her hair from contacting exposed food. This deficient practice has the potential to affect 84 of 87 residents who receive their meals from the main kitchen. Findings include: 1. On 4/3/17 at 7:55 a.m., during the initial kitchen walk through, Surveyor observed a box of eggs in the facility's walk in cooler. Surveyor observed that the box of eggs was labeled Fresh Eggs and asked Dietary Manager-E if the box of eggs in the facility's walk in cooler contained pasteurized eggs. Dietary Manager-E informed Surveyor that the box did not contain pasteurized eggs and asked, Should they be? On 4/3/17 at approximately 10:30 a.m., Surveyor asked Dietary Aide-H if residents could order over easy or sunny side up eggs on demand during meal times. Dietary Aide-H informed Surveyor that residents on each unit could order over easy or sunny side up eggs on demand during meal times. On 4/5/17 at 7:35 a.m., Surveyor asked Dietary Aide-H if any residents currently on the 3 West unit ordered eggs over easy or sunny side up. Dietary Aide-H informed Surveyor that no residents currently on the 3 West unit ordered eggs over easy or sunny side up, but that R19 who used to reside on the 3 West and now currently resides on the 2 West unit orders 3 eggs over easy daily for breakfast. On 4/5/17 at 7:56 a.m., Surveyor asked Dietary Aide-F if residents could order over easy or sunny side up eggs on demand during meal times. Dietary Aide-F informed Surveyor that residents on each unit could order over easy or sunny side up eggs on demand during meal times. Surveyor asked Dietary Aide-F if any residents currently on the 1 West unit ordered eggs over easy or sunny side up. Dietary Aide-F informed Surveyor that currently on the 1 West Unit, R7 orders eggs sunny side up for breakfast. On 4/5/17 at 8:05 a.m., Surveyor interviewed R19 and asked R19 if he orders any eggs for breakfast and if he did, how he likes his eggs prepared. R19 informed Surveyor that he usually orders two eggs for breakfast and that he orders his eggs over easy with a runny or not set and not completely formed yolk. On 4/5/17 at 8:12 a.m., Surveyor observed in the 2 West unit refrigerator, a container containing eggs that was dated 4/4/17. Surveyor noted that the eggs in the container were white in color and did not contain any stamps or symbols indicating that the eggs were pasteurized. On 4/5/17 at 8:15 a.m., Surveyor interviewed Dietary Aide-G whom usually cooks R19's eggs on the 2 West unit. Surveyor asked Dietary Aide-G how R19 usually orders his eggs for breakfast. Dietary Aide-G informed Surveyor that R19 usually orders two eggs over easy with the yolk not fully formed, as R19 prefers his eggs have a runny or not set yolk. On 4/5/17 at 8:35 a.m., Surveyor observed Dietary Aide-G prepare two eggs for R19 on a skillet. Surveyor noted that Dietary Aide-G cracked open the eggs, let the eggs cook on the skillet and then flipped the eggs so that the side containing the yolk cooked over the skillet. At 8:37 a.m., Surveyor observed Dietary Aide-G place the two eggs on a plate with a spatula. Surveyor noted that when Dietary Aide-G placed the two eggs on the plate, Dietary Aide-G pierced a small part of the yolk with the spatula that revealed a runny, not set and not completely firm yolk. On 4/5/17 at 8:45 a.m., Surveyor observed R19 eat the two eggs prepared by Dietary Aide-G. Surveyor observed R19 cut open both eggs and noted that the egg yolks of both eggs were runny, not set and not completely firm. Surveyor informed Dietary Manager-E of the above findings. Surveyor asked Dietary Manager-E to confirm that the eggs served to R19 came from the box of eggs located in the walk in cooler that contained eggs that were not pasteurized. Dietary Manager-E and Surveyor walked into the walk in cooler and both confirmed that the eggs served to R19 came from the box of eggs located in the walk in cooler that contained eggs that were not pasteurized. Surveyor noted that the box of non-pasteurized eggs located in the walk in cooler documented, in bold lettering, on the side of the box, In order to prevent food borne illness, cook thoroughly until yolks are firm. Surveyor noted that the item number on the box of non-pasteurized eggs documented on the side of the box read 73. On 04/05/17 at 9:43 a.m. on 1 West, Surveyor observed DA-F (dietary aide) preparing breakfast for R7. One of the food items being prepared was an over easy egg. The egg was observed to be cooked on both sides and then placed on the plate at which time DA-F poked the egg to assess the temperature at which time yellow yoke begin to ooze out of the egg. When asked, DA-F stated that the temperature registered at 142 degrees. The resident's breakfast try was then observed to be delivered to the resident in his room by CNA-J (certified nurse aide) at 9:50 a.m. and Surveyor observed R7 cut into the egg with his fork commence eating the egg as the yolk spread over the plate. On 4/5/17 at 9:37 a.m., Surveyor asked Dietary Manager-E if residents could order over easy or sunny side up eggs on demand during meal times. Dietary Manager-E informed Surveyor that any resident could order over easy or sunny side up eggs on demand during meal times. Surveyor asked Dietary Manager-E why the facility did not serve pasteurized eggs as it served residents eggs that were not set and fully formed. Dietary Manager-E informed Surveyor that she could not provide a reason as to why the facility did not serve pasteurized eggs. Dietary Manager-E then informed Surveyor that it was an ordering mistake that caused the facility to purchase and serve non-pasteurized eggs to residents. Surveyor requested from Dietary Manager-E a copy of the facility's food invoice that documented that the facility previously purchased pasteurized eggs. On 4/5/17 at 11:05 a.m., Dietary Manager-E provided Surveyor a copy of the facility's food invoice documenting the eggs that the facility purchased. Dietary Manager-E informed Surveyor that the facility had not been ordering pasteurized eggs per the documentation on the food invoices and could provide no further information as to why the facility did not serve residents pasteurized eggs. The invoices dated 12/29/16, 2/20/17 and 3/23/17 document that the facility purchased 1 case of Whole Egg Shell Large White Grade A. Surveyor noted that the item number for the above purchase orders is documented as 73, which Surveyor noted matched the box that contained non-pasteurized eggs Surveyor observed be served to R19. On 4/5/17 at 11:21 a.m., Surveyor informed Administrator-A of the above findings. At the time no further information was provided. DQA (Division of Quality Assurance) Memo 10-022 documents: Food borne illness is a serious health issue for all persons, but persons who are elderly, have weakened immune systems, or suffer from chronic disease such as diabetes are at a higher risk of severe illness due to Salmonella Enteritis. The FDA 2009 Food Code defines highly susceptible populations as persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool children, or older adults. These individuals are most at risk for getting Salmonella Enteritis. The infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics (http://www.cdc.gov/Features/SalmonellaEggs/). The symptoms of Salmonella Enteritis include diarrhea, fever, nausea, vomiting, abdominal pain. The Centers for Disease Control and Prevention (CDC) Salmonella and Eggs documents: A person infected with the Salmonella enteritis bacterium usually has fever, abdominal cramps, and diarrhea beginning 12 to 72 hours after consuming a contaminated food or beverage. The illness usually lasts 4 to 7 days, and most persons recover without antibiotic treatment. However, the diarrhea can be severe, and the person may be ill enough to require hospitalization . The elderly, infants, and those with impaired immune systems may have a more severe illness. In these patients, the infection may spread from the intestines to the blood stream, and then to other body sites and can cause death unless the person is treated promptly with antibiotics. The facility's failure to serve eggs in accordance with professional standards for safety created a finding of immediate jeopardy. The facility removed the jeopardy on 4/5/17. On 4/5/17 at 11:54 a.m., Administrator-A informed Surveyor that the facility had discarded all of the non-pasteurized eggs and that the physicians of R19 & R7 were notified that each resident consumed eggs that were not pasteurized and not fully formed or set. Administrator-A informed Surveyor that R19 & R7 were each being monitored for signs and symptoms of food borne illness. Additionally, the facility implemented an action plan that trained dietary staff and only served pasteurized eggs to residents throughout the facility. The deficient practice continues at a scope/severity of F (potential for more than minimal harm/widespread) as evidenced by: 2. Hair Restraints The 2013 Food and Drug Administration (FDA) Food Code regulations state: 2-402.11 - (A) .Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food clean equipment, utensils, and linens. Hair restraints are to prevent contamination of food. Hair is not only a physical contamination, but can also be a biological contamination. According to Foodsafety.gov, Staphylococcus Aureus (or Staph Aureus) is a type of bacteria commonly found on the skin and hair as well as in the noses and throats of people and animals. One pathogen present in up to 25 percent of healthy food is Staphylococcus aureus. Centers for Disease Control and Prevention (CDC) states, Staphylococcus aureus is important because it has the ability to make several different toxins that are frequently responsible for food poisoning. The facility's hair restraints policy dated as revised in June 2014 titled Dress Code and Uniforms documents: 2. Hairnets must be work by all associates while working. All hair except up to two inches of bangs must be covered .Male associates with beards must wear bear guards. On 4/3/17 at 8:01 a.m., Surveyor observed Dietary Manager-E not wearing a hair restraint covering her hair as she walked through the main kitchen were all of the facility's food is prepared. On 4/4/17 at 2:26 p.m., Surveyor observed Dietary Manager-E not wearing a hair restraint covering her hair as she walked through the main kitchen were all of the facility's food is prepared. On 4/5/17 at 10:04 a.m., Surveyor observed Dietary Manager-E not wearing a hair restraint covering her hair as she walked through the main kitchen were all of the facility's food is prepared. On 4/6/17 at 9:25 a.m., Surveyor observed Dietary Manager-E not wearing a hair restraint covering her hair as she walked through the main kitchen were all of the facility's food is prepared. On 4/6/17 at 9:33 a.m. Surveyor informed Dietary Manager-E of the above findings. Surveyor asked Dietary Manager-E why she did not wear a hair restraint while walking through the main kitchen where all of the facility's food is prepared. Dietary Manager-E did not provide a reason as to why she did not wear a hair restraint while walking through the main kitchen where all of the facility's food is prepared. On 4/6/17 at 2:25 p.m., during the daily exit conference, Surveyor informed Administrator-A and Acting DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not ensure that food was prepared, stored and served under sanitary conditions in 1 of 6 serving kitchens.