Every finding on record at Greendale Park Nursing and Rehab

Based on interviews and observation, the facility failed to ensure a qualified individual was designated to serve as the director of food and nutrition services with the potential to affect 65 of 76 residents consuming food in the dietary department. This failure had the potential to contribute to improper kitchen sanitation practices. Findings include: The facility failed to provide a copy of the Dietary Manager (DM) job description when requested on 06/30/26 at 12:35 PM, on 06/30/26 at 4:30 PM, and on 07/01/26 at 10:15 AM. During observation of the kitchen on 06/30/26 at 11:00 AM, no certificates of training were observed in the kitchen or office area. During an interview on 06/30/26 at 12:35 PM, the DM stated, I've been in this position for about two months, I do not have any certifications. During an interview on 06/30/26 at 4:30 PM, the Administrator stated, The current DM does not have any certifications. I just hired a Certified Dietary Manager (CDM) who will be starting in two weeks.

Based on observation, interview, and facility policy review, the facility failed to ensure facial hair was properly restrained while serving food with the potential to affect 65 out of 76 residents consuming food in the dietary department. This had the potential for physical contamination of the food being served. Findings include: During an observation on 06/30/26 at 11:35 AM, the [NAME] (C) 1 was observed to have a goatee approximately 0.25-0.50 in length. C1 was working at the steam table, plating food for lunch service and was not wearing a beard restraint. During the same observation Dietary Aide (DA) 1 was observed to have a goatee approximately 1.00-2.00 inches in length. DA1 was prepping (placing drinks, silverware, and condiments) meal trays for service on the tray line and was not wearing beard restraint. During the same observation DA2 was observed to have a goatee approximately 0.25-0.50 inches in length. DA 2 was prepping (placing drinks, silverware, and condiments) meal trays for the service on the tray line and was not wearing a beard restraint. During an interview on 06/30/26 at 12:10 PM, the Dietary Manager (DM) stated, They are not wearing beard guards and they should be, hair is supposed to be restrained. Review of the facility's policy titled, Food Safety Requirements, dated 2026, revealed Policy: It is the policy of this facility to procure food from sources approved or considered satisfactory by the federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Policy Explanation and Compliance Guidelines . 7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. d. Dietary staff must wear hair restraints (e.g. hairnet, hat, and/or beard restraint) to prevent hair from contacting food.

Based on staff interviews, document review, and policy review, the facility failed to maintain a comprehensive water management program, including hot and cold-water temperature monitoring, a water system risk assessment, and a water distribution flow diagram. Additionally, the facility failed to provide an infection surveillance system to identify, track, trend, analyze, and respond to infectious illnesses within the facility. These deficient practices had the potential to contribute to the transmission of infectious diseases and adversely affect all 76 residents residing in the facility. Findings include: 1. During an interview on 07/01/26 at 9:10 AM, the Maintenance Director (MD) was asked to provide water temperature monitoring records for the previous three months. The MD stated that water temperature testing had not been conducted during that period. The MD further stated that no water treatment activities had been completed since the start of his employment and that he was unable to locate documentation of any previous water treatment program or monitoring activities. Specifically, the facility was unable to provide a written water management plan, hot and cold-water temperature monitoring logs, a documented water system risk assessment, a water distribution flow diagram, or documentation of corrective actions related to water system management. The MD stated he had not seen water temperatures and had not completed any. He stated he had not seen a written management plan nor water system risk assessment. He stated he did not have a distribution flow diagram of the water and was not aware that there was any corrective action noted. Review of the facility's policy titled, Legionella Surveillance, implemented 10/01/22, revealed 5. Primary prevention strategies.c. Physical controls: i. Cooling towers and potable water systems shall be routinely maintained.iii. Non-potable water systems shall be routinely cleaned and disinfected.d. Temperature controls: i. Cold water shall be stored and distributed below 68 degrees F [Fahrenheit]. ii. Hot water shall be stored above 140 degrees F and circulated at a minimum return temperature of 124 degrees F. 2. Review of the infection control tracking and trending documentation, dated from February 2026 through May 2026, provided by Licensed Practical Nurse (LPN) 7 and Assistant Director of Nursing (ADON) on 06/30/26 at 9:45 AM, revealed pages of unclear resident tracking. They both stated that they could not understand it by the way it was sent by the Director of Nursing (DON). They stated this was the first time seeing it written down. During an interview on 06/29/26 at 1:42 PM, the LPN7/ Supervisor revealed that the DON did not share the Infection Prevention (IP) information with her. LPN7 stated she had never seen a book, and the DON stated it was on her computer. LPN7 noted that by working the floor she was aware of who had infections and who was on antibiotics. LPN7 stated she was not aware of how the DON got that information. LPN7 stated was not aware of how DON did the tracking and trending. The DON was unavailable for interviews during the survey.

Based on interviews, and record review, the facility failed to provide a contract that they provided Medicaid services as required for one of one resident (Resident (R) 9) reviewed for admission contract of 18 sample residents. The facility's contract, signed by residents and/or their representatives, stated The Facility does NOT participate in the Medicaid program. This failure had the potential to affect payor source. Findings include: Review of the Face Sheet tab of the electronic medical records (EMR) revealed R9 was admitted on [DATE] with payer as Medicare A. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/26 revealed a Brief Interview for Mental Status (BIMS) score of zero out of 15 which indicated R9 was severely cognitively impaired. During an interview on 06/29/26 at 4:35 PM the Business Office Manager (BOM) revealed that R9 had been under Medicare services and back to private pay at this time. During an interview on 06/29/26 at 1:54 PM, R9's guardian revealed she was given a contract at the time of R9's admission that stated the facility did not accept Medicaid as payment. R9's guardian stated she had not attempted to apply for Medicaid because of the contract she signed. Record review of R9's facility's admission agreement, dated 01/23 and located under the Misc. tab of the EMR, revealed on page eight of 72 the following language: h) Medicaid Assistance. i) Medicaid Status Eligibility. The resident is considered a Medicaid beneficiary if the Resident receives benefits from a state Medicaid Program consistent with Title 42 CFR 483. Eligibility for Medicaid assistance is determined by applicable state law and is based on the Resident's financial resources. The Facility does NOT participate in the Medicaid program. During an interview on 06/29/26 at 4:35 PM, the Business Office Manager (BOM) revealed he completed Medicaid applications with residents' and family members on a regular basis. The BOM stated he had open forms on his desk that he was assisting family members with completing. The BOM stated R9's guardian had not asked him for assistance with completing a Medicaid application. The BOM stated he was not aware of the statement in the contract that read, The Facility does NOT participate in the Medicaid program. The BOM stated they participated in Medicaid, even if the contract said they did not. During an interview on 01/07/26 at 1:23 PM, the Assistant Director of Nursing (ADON) stated the facility had Medicaid residents and was not sure why the contract was different. During an interview on 07/01/26 at 1:23 PM, the Administrator stated the facility accepted Medicaid residents and was not sure why the contract was different.

Based on record review, staff interview, and facility policy review, the facility failed to notify the physician that medication (Arikayce - an antimicrobial) was not administered as ordered for one out of three residents (Resident (R) 1) reviewed for physician notification of 18 sample residents. This failure had the potential to delay physician evaluation and intervention and placed R1 at risk for worsening or progression of the underlying infection. (Cross Reference F755) Findings include: Review of R1's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with a diagnosis of mycobacterium avium complex (a chronic, sometimes progressive pulmonary infection). Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/26 and located under the MDS tab of the EMR, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 was moderately cognitively impaired. Review of R1's physician Orders located under the Orders tab of the EMR, dated 05/23/26 indicated the resident was prescribed Arikayce Inhalation Suspension 590 milligrams (mg)/8.4 milliliters (ml) (Amikacin Sulfate Liposome), 590 mg inhale orally one time a day for pulmonary infection. Review of R1's May 2026 Medication Administration Record (MAR) located under the Orders tab, indicated R1 was not administered Arikayce on 05/29/26, 05/30/26, and on 05/31/26. The medication could not be reordered through the pharmacy and noted that the family of the resident provided this medication. Review of R1's June 2026 MAR located under the Orders tab, indicated that R1 was not administered Arikayce on 06/03/26, 06/07/26, 06/17/26. The medication could not be reordered through the pharmacy and noted that the family of the resident provided this medication. Review of R1's clinical record failed to contain evidence that the resident's physician was notified that the Arikayce was not administered. During an interview on 06/30/26 at 2:48 PM, Licensed Practical Nurse (LPN) 7, who was also a supervisor and the Assistant Director of Nursing (ADON), stated that the physician should have been notified when the Arikayce was not administered. LPN 7 stated the Arikayce was in the complex refrigerator and had informed the nursing staff of its location. LPN 7 confirmed that the physician was not notified. Review of the facility's undated policy titled, Medication Administration Policy, indicated .Immediately assess residents following medication errors, notify the practitioner, monitor the resident complete required reports, and implement corrective actions.

Based on interview, record review, and facility policy review, the facility failed to ensure medications were available and administered as ordered for two of three residents (Residents (R) 2 and R1) reviewed for medication availability from a total sample of 18 residents. This failure had the potential to result in adverse health outcomes which could lead to ineffective treatment. Findings include: 1. Review of R2's admission Record located under the Profile tab of the electronic medical records (EMR) revealed R2 was admitted to the facility on [DATE] with a diagnosis of hereditary spastic paraplegia. Review of R2's physician Orders, dated 01/20/26 and located under the Orders tab of the EMR, revealed an order for diazepam (an antianxiety) 0.5 milligrams (mg) to be administered twice a day (7:30 AM and 12:00 PM) for anxiety. In addition, R2 had an order for metformin 500 mg twice a day (7:30 AM and 6:30 PM) for diabetes. Review of R2's January 2026 Medication Administration Record (MAR) located under the Orders tab of the EMR revealed on 01/21/26 the 7:30 AM and the 12:00 PM doses of diazepam were documented as not administered. On 01/22/26 the 7:30 AM dose of diazepam was documented as not administered. On 01/22/26 the 7:30 AM dose of metformin was documented as not administered. There were no corresponding progress notes to show why the medications were not administered to R2 on 01/21/26 and 01/22/26. Review of R2's Five-Day Medicare Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/22/26 and located under the MDS tab of the EMR, indicated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed R2 was cognitively intact. Review of a facility document titled Inventory Replenishment Report, provided by the facility, referred to as the Pyxis (an automated medication dispensing system), failed to identify diazepam as being available through this system. During an interview conducted on 06/30/26 at 12:26 PM, Pharmacist 2 stated that R2's metformin was ordered on 01/20/26 and sent back to the facility on the same date. Pharmacist 2 stated that the pharmacy never received the physician order for the diazepam. During an interview on 07/01/26 at 11:44 AM, Licensed Practical Nurse (LPN) 7/Supervisor confirmed that R2's diazepam was not ordered. LPN 7 stated the process was to ask the hospital to order medication if the hospital forgot to send the prescription. Review of a facility's undated policy titled, Medication Administration Policy, indicated .To ensure medications are ordered, prepared, administered, documented, stored,monitored, and disposed of safely in accordance with practitioner orders, resident rights,professional standards of practice, and applicable federal and state regulations. 2. Review of R1's admission Record located under the Profile tab of the EMR revealed R1 was admitted to the facility on [DATE] with a diagnosis that included mycobacterium avium complex (a chronic, non-contagious infection caused by bacteria naturally found in soil and water). Review of R1's admission MDS with an ARD of 05/21/26 and located under the MDS tab of the EMR, indicated R1 had a BIMS score of 12 out of 15 which revealed the resident was moderately cognitively impaired. Review of R1's physician Orders, dated 05/23/26 and located under the Orders tab of the EMR, revealed an order for Arikayce Inhalation Suspension 590 mg (milligram)/8.4 ml (milliliter) (Amikacin Sulfate Liposome) 590 mg to be inhaled one time a day for pulmonary infection. Review of R1's May 2026 MAR located under the Orders tab, indicated R1 was not administered Arikayce on 05/29/26, 05/30/26, and 05/31/26. For the month of June 2026, R1 was not administered Arikayce on 06/03/26, 06/07/26, and 06/17/26. During an interview on 06/29/26 at 3:52 PM, LPN5, stated R1 returned from an infectious disease appointment with the Arikayce medication orders. R1 stated she contacted R1's family member to bring the medication into the facility. LPN 5 stated she was unfamiliar with the Arikayce and the administration of the medication. LPN 5 stated respiratory therapy (RT) was to administer the Arikayce Monday through Friday and the floor nurses were to administer the inhaler on the other days of the week. LPN 5 stated R1 had to show her how to set up the Lamira nebulizer system (a drug delivery device that has a vibrating mesh nebulizer to deliver a fine mist of Arikayce directly into the lung). During an interview on 06/29/26 at 4:01 PM, the Respiratory Therapist (RT) stated R1 had mycobacterium avium complex (MAC) disease and received directions on how to set up the nebulizer system through the Arikayce manufacture website. During an interview on 06/30/26 at 2:48 PM, LPN 7 and the Assistant Director of Nursing (ADON) stated the directions for setting up the nebulizer system for the administration of Arikayce was in the medication area. ADON stated she would have expected competence of the safe administration of the Arikayce; therefore, training was important. LPN 7 confirmed there was no training for the nursing staff for the administration of the Arikayce. ADON stated she would expect a check-off list. Review of the Food and Drug Administration (FDA) manufacturer's instructions for Arikayce, dated 09/18 and located at https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/207356s000lbl.pdf, revealed the medication must be prepared and administered using the Lamira nebulizer system (vibrating mesh nebulizer system specifically designed to be used with Arikayce). The instructions indicated Arikayce should be brought to room temperature by removing it from the refrigerator at least 45 minutes before use. The instructions also indicated that the medication should not be used if it had been frozen. The instructions directed staff to shake the vial for at least 10 to 15 seconds until the medication looked the same throughout and was well mixed. The instructions then directed staff to remove the vial cap, metal band, and rubber stopper before pouring one vial of Arikayce into the medication reservoir. The instructions indicated staff should not use more than one vial for each treatment. The instructions directed staff to attach the medication cap to the medication reservoir, turn the cap clockwise until it stopped, and then turn on the Lamira device. The instructions indicated the resident should sit upright, place the mouthpiece in the mouth, close the lips around the mouthpiece, and breathe through the mouthpiece until the treatment was complete. The instructions indicated the treatment should take approximately 14 minutes but could take up to 20 minutes. Review of a facility's policy titled, Training Requirements, dated 10/01/22, indicated .It is the policy of this facility to develop, implement, and maintain effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles.All facility staff needs to be trained to be able to interact in a manner that enhances the resident's quality of life and quality of care and that they can demonstrate competency in the topic areas of the training program.The Staff Development Coordinator maintains a training schedule and documentation system for completed training by all staff, contracted staff, and volunteers. Review of a facility's undated policy titled, Medication Administration Record, indicated .Verify every medication order before administration and clarify questionable orders.Nursing staff shall follow this policy during every medication pass.

Based on interview and record review, the facility failed to prevent a significant medication error for 1 (R1) of 18 sampled residents reviewed for medications.R1 was prescribed the medication Arikayce, an antimicrobial medication related to a diagnosis of mycobacterium avium complex (a chronic, non-contagious infection caused by bacteria naturally found in soil and water - causing a pulmonary infection). R1 did not receive the medication as ordered on 6 different dates.Findings include:Review of R1's admission Record located under the Profile tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with a diagnosis of mycobacterium avium complex (a chronic, sometimes progressive pulmonary infection). Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/26 and located under the MDS tab of the EMR, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R1 was moderately cognitively impaired. Review of R1's physician Orders located under the Orders tab of the EMR, dated 05/23/26 indicated the resident was prescribed Arikayce Inhalation Suspension 590 milligrams (mg)/8.4 milliliters (ml) (Amikacin Sulfate Liposome), 590 mg inhale orally one time a day for pulmonary infection. During an interview on 06/29/26 at 3:52 PM, LPN5, stated R1 returned from an infectious disease appointment with the Arikayce medication orders. R1 stated she contacted R1's family member to bring the medication into the facility. LPN 5 stated she was unfamiliar with the Arikayce and the administration of the medication. LPN 5 stated respiratory therapy (RT) was to administer the Arikayce Monday through Friday and the floor nurses were to administer the inhaler on the other days of the week. LPN 5 stated R1 had to show her how to set up the Lamira nebulizer system (a drug delivery device that has a vibrating mesh nebulizer to deliver a fine mist of Arikayce directly into the lung). Review of R1's May 2026 Medication Administration Record (MAR) located under the Orders tab, indicated R1 was not administered Arikayce on 05/29/26, 05/30/26, and on 05/31/26. The medication could not be reordered through the pharmacy and noted that the family of the resident provided this medication. Review of R1's June 2026 MAR located under the Orders tab, indicated that R1 was not administered Arikayce on 06/03/26, 06/07/26, 06/17/26. The medication could not be reordered through the pharmacy and noted that the family of the resident provided this medication. Review of R1's clinical record failed to contain evidence that the resident's physician was notified that the Arikayce was not administered. During an interview on 06/30/26 at 2:48 PM, Licensed Practical Nurse (LPN) 7, who was also a supervisor and the Assistant Director of Nursing (ADON), stated that the physician should have been notified when the Arikayce was not administered. LPN 7 stated the Arikayce was in the complex refrigerator and had informed the nursing staff of its location. LPN 7 confirmed that the physician was not notified.

Based on observation, interview and record review the facility did not ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 4 (R41, R2, R60, and R10) of 6 residents reviewed for pressure injuries. R41 developed an avoidable left heel deep tissue injury that was not comprehensively assessed or measured since September 2025. No treatment has been implemented and Surveyor had observations while on survey of R41's care plan interventions of heel boots and turning from side to side and not laying on his back, not implemented. R10 admitted to the facility on [DATE] with a pressure injury to the right heel. A comprehensive assessment was not completed until 8/6/25 when it was then documented as unstageable. R2 was observed not wearing heel boots per the plan of care while on survey. R60 was observed not wearing heel boots per the plan of care while on survey. Findings include: The facility policy titled Pressure Injury Prevention Guidelines (which was not dated) documents (in part) . . Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and for tasks, the frequency for performing them. 7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record. a. For at risk residents: Treatment or medication administration records. b. For residents who have a pressure injury present: Treatment or medication administration records, weekly wound summary charting. Pressure relieving devices: . 3. Apply heel suspension devices according to the manufacturer's instructions. a. For prevention, stage 1 or stage 2: Use pillows or heel suspension devices. If using heel protectors, will still need to utilize pillows for floatation. b. For stage 3, 4, unstageable or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury. Check the skin each shift and PRN (as needed) for signs of redness or skin breakdown related to the boot. R41 admitted to the facility on [DATE] and has diagnoses that include Cerebral infarction, Hemiplegia and hemiparesis affecting right dominant side, Multiple Sclerosis, Monoplegia of upper limb, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Moderate protein-calorie malnutrition, osteomyelitis of vertebra, sacral and sacrococcygeal region, neuromuscular dysfunction of bladder, depression, epilepsy, paraplegia, pressure ulcer of sacral region and pressure ulcer of left heel. Surveyor notes R41's hospital discharge paperwork dated 12/31/24 documents lower extremity contractures are present. R41's Braden score on 1/16/26 documents a score of 15 indicating at risk for pressure injuries. R41's Quarterly Minimum Data Set (MDS) dated [DATE] documents: Roll left and right - the ability to roll from lying on back to left and right side and return to lying on back on the bed as substantial/maximal assistance. Section M - Skin Conditions documents: Current number of unhealed pressure ulcers/injuries at each stage - number of Stage 4 pressure ulcers 1. Number of these Stage 4 pressure ulcers that were present upon admission/entry or reentry - 1. No other pressure injuries were documented on the MDS. R41's care plan documents: -I am at risk for alteration in psychosocial well-being r/t (related to) new environment, refusing therapy, refusing care, refusing to get out of bed, refusing to go to appointments that are scheduled, refusing to wear protective boot. Interventions include: If I am refusing care and treatment, please reapproach me, explain the reason for the care or treatment and why it's important – date initiated 7/3/25. -Pressure ulcer actual or at-risk r/t decrease bed mobility, incontinence, HX (history) of wounds: Active: Coccyx stage 4 - present on admission. HX of left ischial wound, left heel wound, Superior left buttocks stage 3, left buttocks inferior stage 3, left thigh stage 3, left great toe Stage 3, Left heel-suspected DTI (deep tissue injury), Left buttock- fluid filled blister, right gluteal cleft, I sometimes scratch my left ischial wound area, refuses Prostat supplement - date initiated 2/12/25. Interventions include: Encourage Heel boots at all times – revision on 4/14/25. -I have a physical functioning deficit related to: Mobility impairment, Self-care impairment date initiated 2/11/25. Interventions include: I need assist x1 for bed - revision on 10/28/25. R41's Kardex as of 1/22/26 documents: Encourage Heel boots at all times. Provide pressure reduction/relieving mattress setting at 200. Reposition every 2 hours side to side, avoid back. Surveyor review of R41's hospital discharge summary and hospital records dated 2/10/25 which document: Chronic Stage 4 decubitus ulcer with osteomyelitis s/p (status post) surgical I&D (incision and drainage). Intravenous antibiotics through 2/5/25. Also, s/p debridement including bone debridement 10/19/24. CT (Computed Tomography) abdomen/pelvis showed large abscess associated with sacral ulcer and extending deep pelvis with question of rectocutaneous fistula involving sacral ulcer but nonobvious noted intra-op. History of wound vac sacrum. Left heel DTI with improvement continue to keep covered with padded band aid. Maroon, purple, dry, non-blanchable 4.4 x 5 cm (centimeters). On 1/20/26 at 10:54 AM, Surveyor observed R41 lying in bed on his back watching TV. Air mattress on bed and functioning at appropriate setting. Head of bed elevated 30 degrees, wearing Prevalon boot on left foot. R41 reported he had a sore on the side of his foot before, so they want him to wear the boot. Surveyor observed R41 was wearing a gripper sock on the right foot and not wearing a Prevalon boot on his right foot. His right foot was resting directly on the mattress. R41 was unable to lift either foot off the bed upon request, he reported he can't because he had a stroke. R41 reports he had 3 sores - 2 on each side of butt and one on the coccyx. On 1/22/26 at 9:30 AM, Surveyor observed R41 lying in bed with the head of bed elevated approximately 30 degrees. Surveyor observed R41 was not wearing a Prevalon boot on either foot and both feet were resting directly on the mattress. Surveyor observed one Prevalon boot on a chair across the room. R41 stated, My aide last night didn't put them on, and I only wear one because of a sore that I used to have on my left foot. R41 reported staff do come in to reposition him, but he mostly stays on his back where he is comfortable. On 1/22/26 at 12:00 PM, Director of Nursing (DON)-B provided Surveyor evidence of assessments and measurements of R41's sacral pressure injury. Surveyor advised R41 reported he had a history of a sore on his left foot and was given a boot to wear on that foot only. Surveyor asked if R41 should be wearing pressure relieving boots on both feet. DON-B stated, Yes, that would only make sense to give him boots for both feet. But he may refuse at times, he does refuse cares and repositioning at times. Surveyor advised DON-B of care plan intervention to encourage heel boots at all times and observations while on survey of R41 not wearing boots and feet resting directly on the mattress. Due to Surveyor observation of R41's heels not offloaded and history of foot pressure injury, Surveyor asked to view R41's feet. On 1/22/26 at 12:27 PM, the facility MDS nurse (unknown name) assisted Surveyor to view R41's feet. Surveyor noted R41 to be wearing Prevalon boots on both feet. Assessment of R41's right foot revealed no pressure injuries or signs/symptoms of skin breakdown. Assessment of R41's left foot revealed a darkened brown necrotic area approximately the size of a half dollar. Surveyor asked the MDS nurse to palpate the area. It was reported to be dry, no open skin and no drainage. The MDS nurse reported it looked like it was a deep tissue injury. Review of R41's medical record revealed R41 is followed by [name of company] wound physician. There was no documentation or evidence R41 currently has a pressure injury to his left heel. Surveyor located no assessments or measurements and no treatment of a left heel pressure injury. DON-B provided Surveyor documentation of R41's 2/10/25 admission assessment and measurements of the sacrum stage 3 pressure injury and left heel SDTI (Suspected Deep Tissue Injury) present on admission which measured 8 x 6 x 0.1 cm. Surveyor identified no concerns with R41's sacrum pressure injury. The pressure injury is chronic, dating back to at least 2024. Appropriate treatment is implemented and completed, and he is followed by the wound care physician. Current measurements as of 1/13/26 were 0.6 x 0.6 x 0.5 cm. 100% granulation tissue. Wound progress improved evidenced by decreased depth. No signs of infection. Surveyor advised DON-B of the observation of necrotic area on R41's left heel and there is no evidence of assessments/measurements or current treatment implemented. DON-B reported R41 is followed by the wound care physician. DON-B reported he does not have treatment, and the doctor does not document on it because it is to be left open to air and he assesses it weekly. The wound physician note dated 1/13/26 included documentation of the coccyx stage 3 pressure injury, however there was no documentation of an assessment or measurements of the necrotic left heel. R41 was hospitalized on [DATE] and readmitted on [DATE]. Facility documentation: Left heel Pressure ulcer/injury. Unstageable pressure injuries presenting as deep tissue injury. Wound was present on admission. Signs and symptoms of infection: None. Painful: No. Length (cm): 8 x 6 Depth (cm): 0.1. Eschar: 100%. On 3/17/25 the Advance Wound Care physician documents R41's left heel as healed. Surveyor noted there was no treatment, or assessment/measurements after 3/17/25 of R41's left heel. Surveyor had significant difficulty determining when the now observed left heel necrotic area developed. On 1/26/26 at 8:47 AM, Surveyor spoke with Wound Doctor-Z by phone. Surveyor asked about R41's left heel necrotic area and why there was no documentation in his wound progress notes and no treatment. Wound Doctor-Z reported if the area is dark black, he would use maybe betadine or if it was open maybe Medi honey. Surveyor described the area to Wound Doctor-Z and advised Wound Doctor-Z there is no documentation in his weekly wound note regarding the left heel. Wound Doctor-Z stated, I don't do a complete body assessment, I only look at the wound the patient has. If he has any other wounds, they (referring to the facility) need to tell me about it. Surveyor asked Wound Doctor-Z if he was aware of the left heel pressure injury. Wound Doctor-Z stated, If I didn't document on it then they didn't tell me about it. I'll be in tomorrow, have them remind me to look at it then. On 1/26/26 at 10:05 AM, Surveyor spoke with DON-B to clarify questions about R41's left heel pressure injury. Surveyor informed DON-B Surveyor observed R41 currently has an unstageable pressure injury with necrosis on his left heel. Surveyor is unable to determine when the pressure area developed due to no documentation of an assessment or measurements and no treatment implemented. DON-B stated, I will have to look into this. I think it's the same area as he admitted with, but even if there isn't a treatment and we're leaving it OTA (open to air) someone should be assessing it at least weekly. Surveyor informed DON-B that Wound Doctor-Z reported he has not been looking at R41's heel because he was not aware there was a pressure injury, and he will look at it tomorrow. On 1/26/26 at 11:30 AM, DON-B advised Surveyor R41's heel never opened. The wound team (Tissue analytics) saw R41 on 9/24/25 and signed off. Surveyor and DON-B viewed the picture taken by Tissue Analytics – R41's heel was not open and there was no necrotic area. DON-B stated, Prior to that, on 9/17/25 the facility wound nurse documented the area as non-blanchable. When [wound care company] took over on 10/28/25 it was not open, which is why he didn't address it. Surveyor informed DON-B of the concern – if R41's heel was healed on 9/24/25 and the wound physician said it was not open on 10/28/25, then why does the resident currently have a necrotic area on his heel and when did it develop? DON-B reported she is not sure and was not aware and will have to look into it. Surveyor review of facility progress notes documented: On 8/27/25 at 6:07 PM, N Adv (Nursing Advanced) Skin Check documents - Skin issue is resolved. Location: Left heel Pressure ulcer injury. Progress: Resolved: Wound healed and/or closed. Unstageable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 0 Width (cm): 0 Depth (cm): 0 Undermining: No. On 9/10/25 at 8:27 PM, pt (patient) seen by wound MD (Medical Doctor) continue current TX (treatment) orders. Blanchable redness noted to right heel during routine skin check. On 9/17/25 at 11:47 AM, N Adv Skin Check Late Entry documents: Suspected DTI left heel - new. On 9/17/25 at 4:15 PM, Seen by wound MD today, NOR (new order received) and transcribed. Pt does have blanchable redness to left heel. The Wound Tissue Analytics documentation on 9/24/25 documented: Left heel SDTI (Suspected Deep Tissue Injury) 1.53 x 1.68 wound bed assessment - purple. The Wound Tissue Analytics documentation on 10/1/25 included no documentation of R41's left heel pressure injury and there was no documentation thereafter of an assessment, measurements or treatment. Surveyor review of R41's (Treatment Administration Record) TAR documented an order for skin prep every evening completed 9/17/25 through 10/4/25 and was then discontinued, no further treatment was documented. R41 was hospitalized [DATE] - 10/16/25 and 10/20/25 -10/27/25. Surveyor was unable to locate documentation of a left heel pressure injury in those hospital records. R41 was hospitalized [DATE] – 12/10/25. Hospital records documented: Left heel pressure injury. DTI (deep tissue injury). Wound bed/tissue type: Intact; red; purple. Peri wound callus, dry. R41's readmission N ADV clinical admission note on 12/10/25 includes no documentation of a left heel pressure injury. Surveyor notes R41's left heel DTI declined between R41's hospitalization 12/7/25 - 12/10/25 when it was described as a DTI, intact red; purple compared to the current observation on 1/22/26 when Surveyor identified a darkened brown necrotic area approximately the size of a half dollar on R41's left heel. On 1/26/26 at 3:11 PM, during the daily exit meeting with Nursing Home Administrator (NHA)-A and DON-B, Surveyor shared concerns regarding R41's left heel pressure injury. Surveyor asked for additional information regarding Surveyors observation of R41's necrotic left heel. DON-B advised Surveyor that Wound Doctor-Z would be in tomorrow. Surveyor asked if the facility is or was aware R41 currently has a necrotic area to his left heel prior to identification by Surveyor. DON-B reported she spoke to the wound doctor, he said he was aware, and he has always had the area and will meet with Surveyor tomorrow. Surveyor informed DON-B of conversation with Wound Doctor-Z who reported to Surveyor – If I didn't document on it then they didn't tell me about it. On 1/27/26 at 11:10 AM, Surveyor met with Wound Doctor-Z. Wound Doctor-Z reported R41's left heel wound documentation was on the other (tissue analytics) documentation, and he does not have any documentation of the left heel wound. Wound Doctor-Z stated, If they don't tell me about a wound, then I don't know to look at it. Surveyor observed R41's left heel with Wound Doctor-Z. Surveyor observed the heel to have approximately 75% black necrotic tissue and approximately 25% tan necrotic tissue. The area was measured by Wound Doctor-Z's assistant as 3.5 cm x 3.2 cm. Wound Doctor-Z instructed his assistant the wound is a DTI and advised to order skin prep. Outside of R41's room Surveyor spoke with Wound Doctor-Z and DON-B. Surveyor informed DON-B of concern there is no evidence the facility was aware of R41's left heel pressure injury until Surveyor observed the area and notified the facility. Surveyor and facility are unable to determine when the pressure injury developed. There are no comprehensive assessments, measurements or treatment ordered for the pressure injury. DON-B stated, I have looked at everything as well and can't find anything related to the heel, I just don't know. On 1/27/26 at 11:41 AM, Surveyor spoke with Wound Doctor-Z. Wound Doctor-Z stated, Yes, he has a DTI. He's had one on that heel before too. It heals and reappears. Look at him, he has a lot of health problems. He's had pressure injuries for years. He has contractures, he refuses to get out of bed, he refuses care and treatment - it's his way or no way. I would say it was unavoidable with his compromised health; he's in and out of the hospital, sometimes refusing treatment he was arguing with me today about his treatment. We have the air mattress, heel boots, repositioning but he mostly won't get off his back. A normal person who would develop a DTI with say 70 mm (millimeters) pressure, he would probably need less than 30. But for someone like him all things you do can sometimes just make minimal difference. Surveyor confirmed with Wound Doctor-Z that if he was aware of the left heel pressure injury he would have assessed and documented on it weekly. On 1/27/26 at 3:15 PM, NHA-A and DON-B were informed of the concern Surveyor observed of R41's heels not offloaded while on survey. Surveyor observation of the left heel revealed a necrotic area which Wound Doctor-Z classified as a DTI. There is no evidence the facility was aware of the pressure injury until it was identified by Surveyor. Surveyor and DON-B were unable to determine when the pressure injury developed. There is no evidence of a comprehensive assessment or weekly assessments/measurements and R41 does not have a current treatment implemented. No additional information was provided. 3) R2 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis (a chronic disabling autoimmune disease of the central nervous system), Spastic Hemiplegia Affecting Right Dominant Side (one side of body experiences muscle stiffness and weakness), Neuromuscular Dysfunction of Bladder (nerves controlling bladder and urinary sphincter are damaged and not working correctly), Irritable Bowel Syndrome with Diarrhea (common chronic functional disorder of the large intestine), Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Chronic Obstructive Pulmonary Disease (lung disease that block airflow and make it difficult to breathe), Insomnia (sleep disorder characterized by difficulty falling asleep), and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R2 is currently his own person. R2's Quarterly Minimum Data Set (MDS) completed 12/29/25 documents R2's Brief Interview for Mental Status (BIMS) score to be 15 indicating R2 is cognitively intact for daily decision making. R2's Patient Health Questionnaire (PHQ-9) score of 6 indicates R2 is demonstrating mild depressive symptoms. R2's MDS documents R2 is not demonstrating behavior symptoms including refusal of cares/treatments. R2's MDS documents R2's primary method of locomotion is wheelchair. R2 has range of motion impairment (ROM) on one side of both upper and lower extremity. R2 requires set-up for eating. R2's MDS documents R2 requires substantial/maximum assistance with showers, upper dressing, and mobility. R2 is dependent on assistance for lower dressing and transfers. R2 has an indwelling catheter and is frequently incontinent of bowel. R2's MDS also documents R2 is at risk for developing pressure areas/injuries. R2's MDS does not document R2 has a splint. R2's Care Area Assessment (CAA) completed 4/16/25 documents pressure reducing devices are in place to minimize risks. R2's Kardex dated 1/22/26 documents care instructions for certified nursing assistants (CNAs) to place prevalon boot to left heel at all times while in bed. R2's is at risk for altered skin integrity relate bowel incontinence and impaired mobility comprehensive care plan was initiated on 8/16/25. History of shearing to buttocks and non-blanchable redness to right heel; initiated 8/16/25. The intervention prevalon boot to left heel at all times while in bed was initiated 12/23/25. Surveyor notes there is no comprehensive care plan documenting R2 refuses to wear the prevalon boot. Surveyor reviewed R2's January 2026 medication and treatment administration record (MAR/TAR) and notes there is no monitoring of the placement of R2's left heel boot at all times while in bed. R2's Braden scale for predicting pressure ulcer risk completed 1/6/26 documents a score of 17 indicating R2 is at risk for developing a pressure injury/ulcer. On 1/21/2026, at 7:35 AM, Surveyor observed R2 in bed with no heel boots on. Both heels are directly on the mattress. On 1/21/2026, at 12:57 PM, Surveyor observed R2 in bed with no heel boots on. Both heels are directly on the mattress. On 1/22/2026, at 7:44 AM, Surveyor observed R2 sleeping in bed with no heel boots on. Both heels are directly on the mattress. On 1/22/2026, at 9:51 AM, Surveyor observed R2 in bed with no heel boots on. Both heels are directly on the mattress on the footboard. On 1/26/26, at 7:24 AM, Surveyor observed R2 in bed with no heel boots on. R2's heels are directly on the mattress. On 1/26/26, at 11:21 AM, Surveyor interviewed certified nursing assistant (CNA)-CC in regard to R2. CNA-CC informed Surveyor that CNA-CC is not normally assigned to R2 but is familiar with R2. CNA-CC states that CNA-CC has seen R2 wearing heal boots in the past when assigned to R2. CNA-CC is not aware of anytime that R2 has refused to wear the heel boot when in bed. CNA-CC stated that CNA-CC would check a resident Kardex if taking care of a new resident or if assigned to another unit. On 1/26/2026, at 11:41 AM, Surveyor observed R2 in bed with no heel boot on. Surveyor interviewed R2. R2 stated they used to put it on him, he only has the one heel boot, and they haven't put it on in about a month. They used to put it on me when in bed. It goes on the leg that I can't move, my right leg. I never refused it. I sometimes ask to take it off for a couple of hours and then I'm ok with it being put back on. I would wear it. R2 gave permission for Surveyor to look in R2's closet. Surveyor observed R2's green heel boot which is located on the top shelf of R2's closet. On 1/26/2026, at 2:59 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the observation R2 was not wearing their heel boots to reduce the risk of developing a pressure injury as documented on the CNA Kardex and comprehensive care plan. On 1/27/2026, at 7:09 AM, Surveyor observed R2 in bed sleeping. R2 has a heel boot on the left heel. 4) R60 was admitted to the facility on [DATE] with diagnoses of Pressure Ulcer of Right heel, Unspecified Stage, Spondylopathy (disease or disorder affecting vertebrae of the spine) in Diseases Classified Elsewhere, Muscle Wasting and Atrophy, Hyperlipidemia, Depression (mood disorder that causes persistent feelings of sadness and loss of interest), and Generalized Anxiety Disorder (mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R60 is currently his own person for decision making. R60's Quarterly Minimum Data Set (MDS) completed 12/17/25 documents R60's Brief Interview for Mental Status (BIMS) score to be 15, indicating R60 is cognitively intact for daily decision making. R60's patient Health Questionnaire (PHQ-9) has a score of 1 indicating minimal depressive symptoms. R60 has range of motion (ROM) impairment on one side of upper extremity and no lower extremity ROM impairment. R60's main method of locomotion is by wheelchair. R60 requires set-up for eating. R60 is dependent for assistance with showers, upper and lower dressing, and transfers. R60 requires substantial/maximum assistance for mobility. R60's MDS documents R60 is always incontinent of bowel and bladder and is at risk for developing pressure injury/ulcers. R60's Pressure Ulcer/Injury Care Area Assessment (CAA) completed 6/18/25 documents pressure reducing devices in place and the goal is to have improvement and minimize risks. R60's Braden Scale for Predicting Pressure Ulcer Risk completed 12/9/25 documents a score of 16 which indicates R60 is at risk for developing a pressure injury. R60's Kardex dated 1/23/26, instructs certified nursing assistants (CNAs) to place heel boots while in bed. R60 will refuse at times when in bed. R60's current physician orders as of 1/23/26 document to ensure prevalon boots in place while in bed every shift, document refusals, effective 9/25/25. R60's comprehensive care plan documents the following targeted problem: Surveyor notes there is a comprehensive care plan documenting R60 is at risk for impaired skin integrity related to bowel incontinence, pressure ulcer history and impaired mobility, sling underneath at all times. History of right buttocks-unstageable, admitted , right heel: pressure ulcer stage 3 admitted , left heel: pressure ulcer-suspected deep tissue injury (DTI) admitted , initiated 6/25/25. Interventions include: -Heel boots while in bed. I refuse to wear my heel boots at times when in bed. Initiated 6/25/25 Revised 1/22/26. -I prefer to wear my heel boots only when I am in bed. Initiated 9/25/25 Revised 1/22/26. Surveyor notes there are no interventions in place when R60 refuses to wear the bilateral heel boots. Surveyor notes there is no documentation in R60's electronic medical record (EMR) that R60 refuses to wear the bilateral heel boots. On 1/21/2026, at 7:29 AM, Surveyor observed R60 sleeping in bed. R60's feet are at the footboard. R60 has no heel boots on. On 1/21/2026, at 9:45 AM, Surveyor observed R60 in bed and has no heel boots on. R60 informed Surveyor that some put the boots on, and some do not.On 1/22/2026, at 7:46 AM, Surveyor observed R60 lying in bed and has no heel boots on. R60's heels are directly on the mattress. R60 informed Surveyor they did not put them on him last night. Surveyor notes staff have been documenting R60 has had prevalon boots in place per treatment administration record (TAR) for January 2026. There is only one day in January, on the 13th, that R60 was documented as not wearing bilateral heel boots. Surveyor notes during the survey, R60 was observed to not have prevalon boots in place as documented on the TAR. On 1/22/2026, at 9:11 AM, Surveyor interviewed Assistant Director of Nurse (ADON)-E. ADON-E confirmed ADON-E was responsible for monitoring pressure injuries. ADON-E states the expectation is to re-approach R60 if refusing to wear bilateral heel boots. On 1/22/2026, at 9:36 AM, R60 states they frequently don't put the heel boots on, and my heels are sore right now. R60 states they wanted him to wear the heel boots 24 hours, but he didn't want the 'big things' on all the time. Surveyor asked: Do they float your heels with a pillow or offer a pillow. R60 stated he is not offered to float R60's heels with a pillow. On 1/26/2026, at 9:32 AM, Surveyor observed R60 in bed sleeping and is wearing bilateral heel boots. On 1/26/2026, at 2:21 PM, Surveyor interviewed (CNA)-I. CNA-I stated that if a resident refused cares, heel boots, etc., CNA-I would document it and report it to the nurse. CNA-I confirmed that CNA-I usually works PM shift. CNA-I states that R60 is agreeable to wear the bilateral heel boots. On 1/26/2026, at 2:59 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern R60 have not been wearing their heel boots to reduce the risk of developing a pressure injury as documented on the CNA Kardex and comprehensive care plan during the survey process. On 1/27/2026, at 7:09 AM, Surveyor observed R60 in bed sleeping. R60 has bilateral heel boots on. 4) R10 was admitted to the facility on [DATE] with diagnoses of repair of left femur fracture, muscle wasting, and type 2 diabetes. The admission Minimum Data Set (MDS) dated [DATE] documents R10 is cognitively intact and needs maximum assistance with dressing, bathing and bed mobility. The MDS also documents R10 does not have any unhealed pressure injuries. The Care Area Assessment (CAA) documents recent decline due to fall w fx (with fracture) hip and ORIF (open reduction and internal fixation). Daily topical skin care. Sched (scheduled) pain med.LE (lower extremity) bilat (bilateral) weakness. Skin and pain med (medication) monitored. Pressure reducing devices in place. On 1/20/26 Surveyor observed R10 dressed in grip slipper socks. R10 was unable to communicate with Surveyor due to language barrier. The admission note dated 7/25/25 documents R10 had a 1 (centimeter) cm hematoma to the right heel. Surveyor notes there is no other documentation regarding the assessment to F10's right heel until 8/6/25. A wound MD note dated 8/6/25 documents the right heel with an unstageable pressure injury with 1-25% granulation and 51-75% slough measuring 1.97 cm by 2.43 cm. The wound MD ordered a treatment to the right heel. The treatment documents, cleanse with 1/2 strength Dakin's solution and cover wound with bordered foam dressing daily. The at risk for skin alteration related to history of pressure ulcer, muscle wasting, type 2 diabetes and protein-calorie malnutrition care plan dated 8/6/25 documents the interventions: Educate the resident/representative on causes of skin breakdown; including: transfer/positioning, good nutrition and frequent repositioning, dated 8/6/25.Encourage resident to frequently shift weight, dated 12/23/25.Evaluate skin for areas of blanching or redness, dated 12/23/25.(R10) prefers to elevate heels with pillows while in bed, dated 9/16/25.Monitor bony prominences for redness dated, 12/23/25. There is no documented evidence R10's heels were offloaded p

Based on interview and record review the facility did not ensure the Payroll Based Journal (PBJ) was accurately submitted to the Centers for Medicare and Medicaid (CMS). The facility's fourth quarter (July 1st-September 30th) PBJ data triggered for excessively low weekend staffing. This deficient practice has the possibility of affecting all 74 residents residing at the facility. Findings include:The facility's PBJ staffing data report for quarter 4 2025 (July 1st-September 30th), triggers for excessively low weekend staffing. Surveyor reviewed the weekend staffing schedules for the 4th quarter and the facility assessment. The facility assessment documents the needs of the facility for staffing, and it coincided with the staffing levels on the provided schedules.On 1/26/26 at 1:14 p.m., Surveyor interviewed Scheduler-AA. Surveyor reviewed the weekend staffing schedules with Scheduler-AA and noted that the staffing schedule document that there is sufficient staff to meet residents' needs.On 1/26/26 at 2:00p.m., Surveyor interviewed BOM-L. BOM-L stated he is responsible for collecting the payroll data and inputting it into the facility's payroll system. BOM-L stated the corporate human resource (HR) payroll staff is responsible for documenting the data into the PBJ system. BOM-L stated they have not had a corporate HR staff since 8/1/25. Surveyor asked BOM-L if he knew the reason why the PBJ report triggered low weekend staffing. BOM-L looked at the data and stated the facility's cut point is 2.9 and the facility was at 2.7. On 1/26/26 at 3:15 p.m., during the daily exit meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, Surveyor explained the concern the facility's PBJ reporting triggered low weekend staffing for the 4th quarter and there is no follow-through as to the accuracy of the reporting.On 1/27/26 at 9:02 a.m. BOM-L provided Surveyor with additional information. BOM-L stated he looked at the payroll more in-depth to decipher the inaccuracy. BOM-L discovered on 8/10/25, RN-J is a salaried employee but worked extra and those hours on 8/10/25 that did not pull through into the payroll data. BOM-L also found RN-BB, who is also salaried, worked extra on 7/10/25 and her hours did not get pulled through into the payroll data. No additional information was provided.

The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This deficient practice had the potential to affect all residents residing in the facility. The facility does not have a current comprehensive water management plan that includes flow charts specific to the facility to determine areas of concern or interventions implemented to prevent the spread of opportunistic pathogens (Legionella) in the facility's water systems. R11 was documented as having loose stools and had a physician's order to check stool for Clostridium Difficile (C-diff). Transmission Based Precautions (TBP) was not implemented. In addition, R11 was sent to the emergency room after coughing up bloody sputum and returned to the facility on antibiotic for pneumonia. TBP was not implemented. Surveyor observed the laundry aid sorting dirty laundry not wearing appropriate PPE and did not perform hand hygiene after. During observation of medication administration for R39, the nurse did not perform hand hygiene. R34 was in EBP and Surveyor observed staff not following appropriate PPE during cares. R2 has indwelling catheter and Enhanced Barrier Precautions (EBP) was not implemented. R35 was in EBP and Surveyor observed staff not following appropriate PPE during cares. Staff did not wear a gown, change gloves and did not conduct hand hygiene. R75 received blood sugar testing, and the glucometer was not sanitized after use. Findings include: The facility policy titled Water Management Program dated 10/1/22 documents (in part) . . It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards. 1. A water management team has been established to develop and implement the facility's water management program, including facility leadership, the Infection Preventionist, maintenance employees, safety officers, risk and quality management staff, and Director of Nursing. 2. The Maintenance Director maintains documentation that describes the facility's water system. 3. A risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. 8. The water management team shall regularly verify that the water management program is being implemented as designed. Auditing assignments will reflect that individuals will not verify the program activity for which they are responsible. 9. The effectiveness of the water management program shall be evaluated no less than annually. Routine infection control surveillance data, water quality data, and rounding data shall be utilized to validate the effectiveness. 14. Documentation of all the activities related to the water management program shall be maintained with the water management program binder for a minimum of three years. The facility policy titled Infection Prevention and Control Program (which is not dated) documents (in part) . .It is the policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 4. Hand hygiene protocol: a. All staff shall wash their hands when coming on duty, between resident contacts, after handling contaminated objects and after PPE (personal protective equipment) removal. b. Staff shall wash their hands before and after performing resident care procedures. c. Hands shall be washed in accordance with our facility's established hand washing procedure. 5. Isolation protocol: b. A resident with an infection or communicable disease shall be placed on isolation precautions as recommended by the CDC guidelines for isolation precautions. 10. Linens: a. Laundry and direct care staff shall handle, store, process and transport linens so as to prevent spread of infection. e. Staff shall use PPE according to established facility policy governing the use of PPE. The facility policy titled Hand Hygiene (which is not dated) documents (in part) . .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Hand Hygiene Table documents (in part) . .Between resident contacts. After handling contaminated objects. Before performing invasive procedures. Before applying and after removing PPE, including gloves. Before preparing or handling medications. Before and after handling clean or soiled dressings, linens, etc. Before performing resident care procedures. Before and after providing care to residents in isolation. After handling items potentially contaminated with blood, body fluids, secretions or excretions. After assistance with personal body functions (e.g. elimination, hair grooming, smoking). The facility policy titled Transmission Based (Isolation) Precautions (which is not dated) documents (in part) . . It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogen's modes of transmission. 10. Contact precautions: c. Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning PPE upon room entry and discarding before exiting the room is done to contain pathogens. 11. Droplet precautions: a. Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory sections (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing or talking). e. Healthcare personnel will wear a facemask for close contact with an infected resident. Type and duration of transmission-based precautions recommended for selected infections and conditions: Clostridium difficile – contact precautions for duration of illness. Pneumonia, adenovirus – droplet, contact precautions for duration of illness. Pneumonia, mycoplasma – droplet precautions for duration of illness. Pneumonia streptococcus group A – droplet precautions until 24 hours after initiation of treatment. The facility policy titled Laundry (which is not dated) documents (in part) . The facility launders linen and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. 1. Aligning with principles of standard precautions, staff shall consider all previously work clothing and used linens as potentially contaminated. 2. The facility's laundry area will provide hand washing facilities and products as well as PPE. 4. Soiled laundry shall be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces and persons. On 1/20/26 at 10:00 AM, Surveyor asked Maintenance-W if the facility has a binder for the water management plan to review. Maintenance-W reported he has only worked at the facility for 3 weeks and does not think there is a binder and was not sure what happened to it after the other maintenance man left. Surveyor asked Maintenance-W if he oversees the water management plan or if he has any information regarding water management. Maintenance-W stated, Not really, I've only been working here for 3 weeks. 1.) On 1/26/26 at 12:54 PM, Surveyor spoke with Infection Preventionist/Assistant Director of Nursing (IP/ADON)-E and asked what her role in the water management plan is. IP/ADON-E reported (a named worker) from the state of Wisconsin came and did a tour of the facility in August 2025. She reported nothing was put in place at that time, but she gave suggestions. Surveyor advised IP/ADON-E that I have asked for the water management binder several times, but the facility is unable to locate it. IP/ADON-E reported there are no closed units at this time. She stated, I go in the biohazard room every couple of weeks to flush hopper and water. To my knowledge we don't use the hopper. IP/ADON-E reported she does not really know what the water management involves and is not aware of any mapping or flow charts specific to the facility. IP/ADON-E told Surveyor to speak with Nursing Home Administrator (NHA)-A. During review of infection control, no cases of Legionella was identified. On 1/26/26 at 1:29 PM, Surveyor spoke with NHA-A and asked about the facility water management plan. NHA-A stated, We have a fella in housekeeping who goes through building and turns on faucets and flushes toilets for rooms that aren't being used at the moment. He looks at aerators on faucets, checks shower heads and replaces them if needed or if they need to be descaled. Surveyor asked if there is a binder or anything to show evidence of the facility water management plan, for example a description or flow charts specific to the facility to determine areas of concern identified or if any external hazards have been identified. NHA-A stated, Unfortunately I don't have anything to show you. I know we had a system in place, but whether the other maintenance guy took it with him or threw it out, we just don't know. I know at one point we had the water flow schematic. Going forward I'll have to bring the new man up to speed and maybe find new schematic for external and internal water. Surveyor located no evidence the facility has a current comprehensive water management plan, and no additional information was provided. 2.) Surveyor review of R11's facility progress notes documented: 1/12/26 9:11 AM - Alert Note Resident stool consistency documented as loose/diarrhea. Physicians note dated 1/19/26 documented: Seen in follow-up for diarrhea and Lyrica refill. Has been having loose stool. Recently had antibiotic therapy. No other nursing concerns all interval events noted needed refill for Lyrica as well. Plan: Check stool for C-diff. Surveyor located a physician's order dated 1/19/26 which documented: Please send stool for C-Diff. Surveyor was unable to locate an order in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) to check stool for C-Diff. During initial interview with R11 and throughout the survey, Surveyor noted there was no TBP or PPE signage posted on the door and no PPE cart outside of her room. Surveyor review of R11's medical record documented she was sent to the ER (emergency room) on 1/14/26 after coughing up bloody phlegm. The hospital HPI (History of Present Illness) dated 1/15/26 documents: [AGE] year-old presenting to the emergency department for hemoptysis (the coughing up of blood or blood-stained mucous from the lungs or airways). Pt (patient) reports she felt fine today. Went to dialysis. Back to her rehab facility to take a nap. Started to cough and felt like she had phlegm. When she coughed it up, it was blood. She proceeded continue to cough and reports coughing clots and blood which amounted to half a trash bin of blood-soaked Kleenex. Has some shortness of breath when using her wheelchair but denies any current shortness of breath or chest pain. Denies any recent fevers or chills. The hospital After Visit Summary (AVS) dated 1/15/25 documents: Summary of discharging medications Amoxicillin-clavulanate 500-125 mg (milligrams) (Augmentin) last dose 1/15 4:19 PM. Take 1 tablet by mouth daily for 7 days. Next dose due 1/16 @ 5 PM. The facility physician note dated 1/16/26 documents: Patient hemoptysis was likely due to the left lower lobe pneumonia. There is some mucous plugging. At this time, we will attempt a conservative approach for mucociliary clearance. I will hold off on bronchoscopy at this time. Agree with antibiotics for 5–7-day course. Currently on Augmentin. Will repeat CT (Computed Tomography) of chest in 6-8 weeks. The physician order dated 1/17/26 documented: Augmentin Oral Tablet 500-125 MG -give 1 tablet by mouth one time a day for pneumonia for 7 Days. R11's January 2026 MAR documented the order for Augmentin Oral Tablet 500-125 MG - give 1 tablet by mouth one time a day for pneumonia. Surveyor noted R11 had received 3 doses thus far from 1/18-1/20/26. On 1/21/26 at 12:45 PM, Surveyor spoke with IP/ADON-E and asked what the expectation is if a resident is having loose stools. IP/ADON-E stated, Contact precautions. Surveyor asked what the expectation is if the doctor orders to check stool for C-Diff. IP/ADON-E stated, Definitely contact precautions. Surveyor asked how she would know if a resident were having loose stools or a doctor has ordered to check stool for C-diff. IP/ADON-E stated, The clinical dashboard should alert to any such orders or changes. If the nurse manager sees it first, she will send out a message to the manager group. Surveyor asked what the expectation is if a resident is diagnosed with pneumonia. IP/ADON-E stated, Droplet precautions. Surveyor provided scenario if a resident comes to the facility with pneumonia or has a new diagnosis of pneumonia and is on an antibiotic, what the expectation is. IP/ADON-E stated, Droplet precautions. Surveyor advised IP/ADON-E of concerns R11 was having loose stools and the physician ordered stool testing for C-diff, however precautions were not implemented. IP/ADON-E reviewed R11's medical record stating, That was just Monday, I didn't even know about it. Yes, she should have been placed on contact precautions if she was having loose stools or if the doctor ordered testing for C-Diff. Surveyor advised IP/ADON-E that R11 was sent to the ER due to coughing up bloody sputum on 1/14/26 and returned on 1/15/26 with orders for antibiotic for left lower lobe pneumonia, but droplet precautions were not implemented. IP/ADON-E reviewed the hospital discharge papers and stated, I think it's because I didn't see pneumonia diagnoses. Surveyor advised R11 was sent to the ER for coughing up blood and returned the next day with antibiotics ordered. IP/ADON-E stated, Yes, going forward she should have been on droplet precautions. On 1/22/26 at 10:01 AM, Director of Nursing (DON)-B advised Surveyor she remembered reading R11's hospital record that pneumonia was likely aspiration pneumonia and new lower lobe nodule and it may be inflammatory. DON-B reported she spoke with the Nurse Practitioner (NP) who agreed that the antibiotic treatment was conservative for likely aspiration pneumonia and inflammation. DON-B stated, Going forward we will review and document if precautions are warranted. Surveyor advised DON-B that R11 was sent to the ER due to coughing up bloody sputum and asked if that would alert the facility to implement droplet precautions. DON-B stated, I think that wasn't new for her, she's had that before. Surveyor advised DON-B there was no documentation in R11's medical record of any episodes of R11 coughing up bloody sputum since admission until 1/14/26. On 1/22/26 at 11:27 AM, DON-B advised Surveyor she spoke with the NP who reported she was not sure why the doctor ordered to check stool for C-Diff. She reported the NP believed R11's baseline is looser stool related to dialysis and discontinued the order. On 1/22/26 at 12:00 PM, Surveyor advised DON-B and IP/ADON-E of concern the facility documented R11 was having loose stools, an order was obtained to check stool for C-Diff, but precautions were not implemented. IP/ADON-E stated, Yes, we have a protocol. As soon as we are aware of loose stools and the nurse sees the order to check for C-diff, she should have been put on precautions. Surveyor advised of concern R11 was coughing up blood clots, was sent to the ER, returned the following day on antibiotics for pneumonia, but precautions were not implemented. IP/ADON-E stated, I understand. She should have been put on precautions if she was on an antibiotic and coughing. 3.) On 1/26/26 at 8:05 AM, Surveyor entered the 1st room laundry sorting area. Surveyor observed Laundry-X sorting dirty laundry (removing dirty laundry from one bin and placing it in another) wearing a mask and gloves, but no gown. Laundry-X then entered through the door to the washing machine and clean area wearing the same gloves. She removed her gloves, threw them in the garbage, but did not wash her hands. Housekeeping-Y entered the room and reported she can answer questions because Laundry-X does not speak English. Housekeeping-Y reported the process for laundry is to wear a gown, gloves and mask when sorting dirty linen, bring linen in the bin through the door and place it in the washer, remove PPE and wash hands. While talking with Housekeeping-Y, Surveyor observed Laundry-X remove clean laundry from the washer, place it in a cart and put it in the dryer. (Surveyor noted Laundry-X had still not washed her hands). Laundry-X then walked through the door to the dirty linen area and returned with a bin of dirty clothes wearing a gown, gloves and mask. She placed the clothes in the washer, removed the PPE and washed her hands. On 1/26/26 at 3:11 PM, during the daily exit meeting with NHA-A and DON-B, Surveyor shared the following infection control concerns: The facility does not have a current comprehensive water management plan; precautions were not implemented for infections including suspected C-Diff and pneumonia; and observations of staff sorting soiled linen without proper PPE and not washing their hands after. No additional information was provided. The facility's undated Enhanced Barrier Precautions (EBP) policy and procedure documents: Purpose: .To prevent the spread of multidrug-resistant organisms through the consistent use of EBP during high-contact resident care activities. Policy Statement: .The facility shall implement EBP for residents colonized or infected with MDROs as identified through laboratory testing or regional/state public health notification, and for residents with wounds, indwelling medical devices, or other high-risk conditions, in accordance with Centers Disease Control guidance. EBP is in addition to standard precautions and not as strict as contact precautions. Residents under EBP can participate in group activities and do not require room restriction. When to implement EBP: .Any resident with MDRO colonization or infection, regardless of symptoms Any resident with indwelling devices(central line, urinary catheter, feeding tube, tracheostomy) Any resident with chronic wounds or pressure injuries Continue EBP: Indefinitely for colonized residents For the duration of indwelling device or wound presence. Personal Protective Equipment(PPE) and Room Guidance: .Gown and gloves must be donned immediately before high-contact care activities. Remove PPE and perform hand hygiene before leaving resident care area. PPE may be stored in a dedicated clean area within the room. Resident is not restricted to room; may participate in communal dining and activities. Education: .All direct care staff will receive initial and annual education on EBP, including rationale, proper PPE use, donning/doffing technique, and documentation requirements. Documentation: .Staff must document implementation of EBP in the care plan and nursing notes, including reason and specific precautions used during care. Quality Assurance/Monitoring: .Infection Preventionist(IP) or designee will conduct routine audits for compliance with EBP, review infection logs, and present findings to QAPI committee monthly. 4.) R35 was admitted to the facility on [DATE] with diagnoses of Spastic Hemiplegia Affecting Right Dominant Side(one side of body experiences muscle stiffness and weakness), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Chronic Respiratory Failure(long-term condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Hyperlipidemia(high levels of fat particles in blood), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities). R35's Quarterly Minimum Data Set(MDS) completed 10/28/25 documents a Brief Interview for Mental Status(BIMS) score of 14, indicating R35 is cognitively intact for daily decision making. R35 has no behaviors. R35's Patient Health Questionnaire(PHQ-9) score is 7, indicating R35 demonstrates mild depressive symptoms. R35's MDS documents: R35 has an indwelling catheter and is frequently incontinent of bowel. On 1/20/2026, at 10:56 AM, Surveyor observed staff entering and exiting R35's room who is in EBP. Surveyor notes there is a sign on R35's room indicating R35 is in EBP, and the precautions needed. Surveyor observed through the open doorway, Licensed Practical Nurse (LPN)-U answer R35's call light without performing hand hygiene prior to entering room, with both hands lean on the end of the bed. LPN-U exited R35's room without performing hand hygiene. Surveyor asked LPN-U what R35 needed and LPN-U informed Surveyor that R35 was on the bedpan. On 1/20/2026, at 10:58 AM, Certified Nursing Assistant (CNA)-D entered R35's room without performing hand hygiene. CNA-D exited R35's room and performed hand hygiene. CNA-D informed Surveyor that R35 is getting ready for a shower. On 1/20/2026, at 11:01 AM, Surveyor observed CNA-V grab gloves out of the cart outside of R35's room and Surveyor observed CNA-V enter R35's room without performing hand hygiene. Surveyor observed CNA-V who does not don a gown on prior to entering the room. On 1/20/2026, at 11:05 AM, Surveyor observed CNA-V exit R35's room with gloves in left hand, put the gloves in CNA-V's pocket and perform hand hygiene. CNA-V was not observed to have removed a gown. Surveyor asked CNA-V what CNA-V did, and CNA-V stated that CNA-V took R35 off the bed and put the mechanical lift sling under R35. On 1/20/2026, at 11:07 AM, Surveyor observed CNA-D and CNA-V transfer R35 from bed to shower cot. R35 gave permission for Surveyor to watch the transfer. Surveyor observed CNA-D and CNA-V does not perform hand hygiene before entering R35's room. Both CNA-D and CNA-V put gloves on but did not don a gown. CNA-D and CNA-V completed the transfer utilizing the mechanical lift. At separate times, both CNA-D and CNA-V placed gloved hands on R35's indwelling catheter bag. CNA-D with same gloves on got a clean sheet to cover R35 up once on the shower cot, retrieved shampoo and body wash from closet and entered bathroom to get a bar of soap. Both CNA-D and CNA-V exited the room with R35 on the shower cot and remove their gloves. CNA-V performed hand hygiene; CNA-D did not perform hand hygiene. Neither CNA-D nor CNA-V wiped down the mechanical lift after use. On 1/22/2026, at 7:39 AM, Surveyor observed the PPE cart with 3 drawers outside of R35's room contains a box of surgical masks in the first drawer. There are no gowns or gloves in the cart. The other 2 drawers are empty. On 1/22/2026, at 9:52 AM, Surveyor observed Wound Nurse (WN)-T perform hand hygiene and don gloves and gown before entering room. 5.) R2 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis(a chronic disabling autoimmune disease of the central nervous system), Spastic Hemiplegia Affecting Right Dominant Side(one side of body experiences muscle stiffness and weakness), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Irritable Bowel Syndrome with Diarrhea(common chronic functional disorder of the large intestine), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Insomnia(sleep disorder characterized by difficulty falling asleep), and Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R2 is currently his own person. R2's Quarterly Minimum Data Set(MDS) completed 12/29/25 documents R2's Brief Interview for Mental Status(BIMS) score to be 15 indicating R2 is cognitively intact for daily decision making. R2's Patient Health Questionnaire(PHQ-9) score of 6 indicates R2 is demonstrating mild depressive symptoms. R2's MDS documents R2 is not demonstrating behaviors including refusal of cares/treatments. R2's MDS documents R2's primary method of locomotion is wheelchair. R2 has range of motion impairment(ROM) on one side of both upper and lower extremity. R2 requires set-up for eating. R2's documents R2 requires substantial/maximum assistance with showers, upper dressing, and mobility. R2 is dependent on assistance for lower dressing and transfers. R2 has an indwelling catheter and is frequently incontinent of bowel. R2's MDS also documents R2 is at risk for developing pressure areas/injuries. R2's MDS does not document R2 has a splint. On 1/20/2026, at 12:03 PM, Surveyor notes that R2 has an indwelling catheter and there is no sign on the door for EBP instructions, no cart with PPE supplies around R2's room. On 1/21/2026, at 7:33 AM, Surveyor observed no EBP instructions on or around R2's door. On 1/22/2026, at 7:41 AM, Surveyor observed no EBP instructions on or around R2's door. On 1/22/2026, at 9:26 AM, Surveyor interviewed Infection Preventionist (IP)-E. IP-E stated that anyone with a wound, g-tube, foley catheter, 'any open area of entry' requires EBP. IP-E stated that there are carts in the hallway containing PPE for use. All EBP residents should have a sign on the door indicating EBP, so all staff are aware in order to follow the correct precautions. On 1/22/2026, at 1:14 PM, Surveyor shared the concern that R2 has an indwelling catheter but does not have a sign on the door alerting staff to follow EBP when caring for R2. IP-E stated R2 had been in contact precautions and came out of precautions on 1/10/26. The contact precautions sign was removed from R2's door and a EBP sign should have been placed on the door at that time. IP-E acknowledges that EBP have not been in place since 1/10/26 and should have been. IP-E informed Surveyor that a sign instructing EBP would immediately be placed. Surveyor reviewed with IP-E; Surveyor's observations of care being provided to R35 on 1/20/26. IP-E confirmed that hand hygiene should be performed prior to entering the room and when exiting the room, before and after placing gloves on, no matter if a resident requires EBP or not. IP-E stated, I guess more education needs to be completed. IP- E understands the concern and shared that staff had last been re-educated 11/7-11/13/25. On 1/22/2026, at 3:37 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the infection control observations involving R35 and R2 who both are in EBP due to indwelling catheters. Surveyor shared that staff did not don PPE prior to performing cares to R35 and did not perform proper hand hygiene. Surveyor shared that there was no indication that R2 required EBP for staff to follow when providing cares to R2. No further information has been provided by the facility at this time. On 1/26/2026, at 11:30 AM, Surveyor observed CNA-CC enter R2's room without hand hygiene prior and brought R2's breakfast tray out. CNA-CC re-entered the room and placed gown and gloves on, did not perform hand hygiene prior to putting gloves on. Exited the room and informed Surveyor there was no sanitizer in R2's room. CNA-CC used the hand sanitizer in the hallway and performed hand hygiene. 6.) On 1/22/26, at 7:12 a.m., Surveyor observed Licensed Practical Nurse (LPN)-P prepare R39's medication which consisted of pro stat 30 cc (cubic centimeters), Amantadine 100 mg (milligrams) one capsule, Vitamin C 500 mg one tablet, Juven one packet, Levetiracetam 10 cc, Levothyroxine Sodium 25 mcg (micrograms) one tablet, Hiprex 1 gram one tablet, and Thiamine 100 mg one tablet. At 7:18 a.m., LPN-P placed gloves on, poured R39's pro stat, Levetiracetam, and Juven into individual plastic glasses, opened the Amantadine capsule and crush each medication individually. At 7:21 a.m. LPN-P picked up an article from the floor and threw the article in the garbage container on the medication cart. LPN-P removed her gloves but did not perform any hand hygiene. LPN-P removed spoons from a container and poured water into the plastic glasses. LPN-P placed a gown on, brought R39's medication into the room, removed a box from the medication cart and placed gloves on. LPN-P disconnected R39's tube feeding, checked placement, and flushed R39's tube with 20 cc of water. LPN-P added 20 cc of water to each cup containing Levetiracetam, pro stat and Juven. LPN-P administered each of these flushing with 20 cc of water in between. At 7:30 a.m. LPN-P removed her gloves, added 20 cc of water to each crushed medication and placed gloves on. LPN-P did not perform any hand hygiene after removing her gloves. LPN-P administered R39's medication individually flushing in between and then flushed R39's tube after the last medication. After administering R39's medication, LPN-P removed her gown & gloves and washed her hands. On 1/26/26, at 11:19 a.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-U if staff should perform hand hygiene after removing their gloves and before placing new gloves on. LPN/UM-U replied oh yes absolutely. Surveyor informed LPN/UM-U of the observation during R39's medication pass with LPN-P. The facility's policy titled, Glucometer Disinfection and not dated under policy documents The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devise to prevent transmission of blood borne disease to residents and employees. Under policy explanation and compliance guidelines documents 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instruction for multi-resident use. 7.) On 1/22/26, at 8:07 a.m., Surveyor observed Licensed Practical Nurse (LPN)-H place gloves, wipe R75's left index finger with an alcohol pad, wave to dry R75's finger, poke R75's finger and squeeze the finger to place a drop of blood on the strip. LPN-H informed R75 her blood sugar is 289 and removed her gloves. At 8:09 a.m. LPN-H cleansed her hands and then i

Based on interview and record review, the facility did not develop and implement policies and procedures to ensure that when Covid (Coronavirus)-19 vaccine is available to the facility, each resident is offered the vaccine unless the immunization is medically contraindicated or the resident has already been immunized for 4 of 5 (R2, R9, R35 and R54) residents reviewed for immunizations.Findings include:The facility policy titled COVID-19 Vaccination (which is not dated) documents (in part): It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from Covid-19 (SARS-CoV-2) by educating and offering our residents and staff the Covid-19 vaccine.10. Individuals should receive the recommended [NAME]-appropriate vaccine product and dosage-based o their age on the day of vaccination and follow the recommended dosing intervals.11. Covid-19 vaccinations will be offered to residents when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refused to receive the vaccine.14. The facility will educate and offer the Covid-19 vaccine to residents, resident representatives and staff and maintain documentation of such.17. Residents or their representatives will sign the consent form prior to administration of the Covid-19 vaccine. This information will be retained in the resident's medical record.On 1/22/26 at 11:52 AM, Surveyor asked Infection Preventionist/Assistant Director of Nursing (IP/ADON)-E about the facility's vaccination protocol. IP/ADON-E stated, Upon admit, there is a document nurses fill out asking about immunizations. If they want or consent, they are supposed to get an order, then normally I will see the order during morning meeting.R2 admitted to the facility on [DATE] with diagnoses that include Multiple Sclerosis, chronic obstructive pulmonary disease and protein calorie malnutrition.Review of R2's medical record revealed a consent for the Covid vaccine signed but not dated. Surveyor noted the consent was uploaded into R2's electronic health record on 12/26/25. Surveyor could not locate evidence that the Covid vaccine was offered or given.R9 admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, protein-calorie malnutrition, immunodeficiency, chronic obstructive pulmonary disease, malignant neoplasm of sigmoid colon and chronic congestive heart failure.Review of R9's medical record revealed a consent for the Covid vaccine signed 7/2/25. Surveyor could not locate evidence the Covid vaccine was offered or given to R9.R35 admitted to the facility on [DATE] with diagnoses that include chronic obstructive pulmonary disease, asthma and chronic respiratory failure with hypoxia.Review of R35's medical record revealed a consent for the Covid vaccine signed 8/26/25. Surveyor could not locate evidence the Covid vaccine was offered or given.R54 admitted to the facility on [DATE] and has diagnoses that include malignant neoplasm of colon, severe protein-calorie malnutrition, immunodeficiency, chronic congestive heart failure and adult failure to thrive. Surveyor could not locate evidence the Covid vaccine was offered or given.On 1/26/26 at 10:25 AM, Surveyor spoke with IP/ADON-E regarding the above immunizations. IP/ADON-E reported R2 did not receive the Covid vaccine, and the facility got an order 1/25/26 to administer it. R9 did not receive the Covid vaccine. IP/ADON-E spoke to the resident today and it was declined. R35 did not receive the Covid vaccine. IP/ADON-E spoke to the resident today and it was declined. R54 did not receive the Covid vaccine. IP/ADON-E stated that R54 wanted the vaccine, and it was ordered today.Surveyor advised IP/ADON of concern consents were signed to receive the Covid vaccine and there was no follow up until after Surveyor identified concern. IP/ADON-E stated, I understand the concern. On 1/26/26 at 3:11 PM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed of the concerns regarding the above immunizations. No additional information was provided.

Based on observations, interviews and record review, the facility did not ensure 1 (R2) of 1 residents reviewed for self-administration of medications had a physician order to self-administer and for the medication.*R2 was observed with Melatonin 5mg at the bedside and did not have a physician order for Melatonin 5mg or an order to self-administer medication.Findings include:The facility's policy titled Self-Administration of Medications effective 10/25/2014 documents:Policy:In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer.Procedures:A. If the resident desires to self-administer medications, an assessment is conducted by the inter disciplinary team of the resident's cognitive(including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process.C. For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition.5. The resident is asked to complete a bedside record indicating the administration of the medication.D. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notion that it may be self-administered.E. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted.G. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication card or medication room. The nurse records such self-administration on the medication administration record(MAR) by placing a check mark in the appropriate space and noting in the nursing comments and the initials of the nurse who obtained the information from the resident.R2 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis(a chronic disabling autoimmune disease of the central nervous system), Spastic Hemiplegia Affecting Right Dominant Side(one side of body experiences muscle stiffness and weakness), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Irritable Bowel Syndrome with Diarrhea(common chronic functional disorder of the large intestine), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Insomnia(sleep disorder characterized by difficulty falling asleep), and Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R2's Quarterly Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status(BIMS) score to be 15, indicating R2 is cognitively intact for daily decision making. R2's Patient Health Questionnaire(PHQ-9) score of 6 indicates R2 is demonstrating mild depressive symptoms. R2's MDS documents: R2 is not demonstrating behaviors including refusal of cares/treatments; R2's primary method of locomotion is wheelchair; R2 has range of motion impairment(ROM) on one side of both upper and lower extremity; R2 requires set-up for eating; R2's documents R2 requires substantial/maximum assistance with showers, upper dressing, and mobility; R2 is dependent on assistance for lower dressing and transfers; R2 has an indwelling catheter and is frequently incontinent of bowel; R2's MDS also documents R2 is at risk for developing pressure areas/injuries and does not document R2 has a splint.R2's physician orders as of 1/21/26 do not document a physician order for R2 to self-administer medications. Surveyor could not locate a physician order for Melatonin for R2. R2's comprehensive care plan documents R2 is able to safely administer R2's medications initiated 8/8/25. The only intervention initiated on 8/9/25 and revised 9/24/25 documents to complete self-administrated evaluation of R2's ability to self-administer medications.R2's self-administration of medications assessment completed 10/27/25 documents that R2 is approved for the self-administration of medications and R2 may keep medications at bedside.On 1/20/2026, at 11:53 AM, Surveyor observed a bottle of Melatonin 5mg gummies on R2's overbed table. R2 informed Surveyor that R2 takes 2 5mg every night. On 1/21/2026, at 12:57 PM, Surveyor observed the bottle of Melatonin on R2's overbed table. R2 informed Surveyor that R2 does not keep track of taking the Melatonin on a nightly basis. On 1/22/2026, at 7:43 AM, R2's Melatonin remained on R2's overbed table. On 1/22/2026, at 3:37 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R2 has Melatonin 5mg at bedside but has no physician order for the Melatonin and does not have a physician order to self-administer. DON-B confirmed that R2 should have a physician order for the Melatonin and to self-administer medications. On 1/26/2026, at 7:25 AM, Surveyor observed R2's Melatonin remain on R2's overbed table. On 1/26/2026, at 8:41 AM, DON-B informed Surveyor that R2 will not give up the Melatonin and R2's physician won't give the order for the Melatonin due to conflicts. Surveyor shared that R2's electronic medical record (EMR) progress notes documents R2 is having difficulty sleeping at night and reminded DON-B that R2 has a diagnosis of insomnia. Surveyor shared the concern that staff have not addressed the Melatonin at R2's bedside and observations of the Melatonin at R2's bedside. On 1/26/2026, at 9:41 AM, Surveyor noted there is no documentation in R2's EMR of the conversation with R2's physician concerning the Melatonin at bedside. On 1/27/2026, at 7:29 AM, Surveyor noted there is no documentation in R2's EMR that R2's Melatonin at bedside had been addressed with R2's physician. Surveyor observed R2's Melatonin still at R2's bedside. Surveyor noted the facility has not provided any additional information as to why R2 does not have a physician order to self-administer and does not have an order for Melatonin which R2 has been self-administering every night for R2's insomnia. No additional information was provided.

Based on observation and interview the facility did not ensure a clean environment for 1 (R67) of 1 Resident.*Food and debris were observed alongside and under the wheelchair cushion on 1/20/26, 1/21/26, & 1/22/26.Findings include:On 1/20/26, at 9:45 a.m., Surveyor observed R67 sitting in a wheelchair in R67's room with his head down. R67 looked at Surveyor and then put his head back down. Surveyor observed the right side of R67's wheelchair, between the cushion and the right side, has a large accumulation of food particles and other debris.On 1/21/26, at 12:59 p.m., Surveyor observed R67 sitting in the wheelchair with an overbed table in front of him in R67's room. Surveyor observed on the right side of R67's wheelchair, between the cushion and the right side there is a large accumulation of food particles, including scrambled eggs, and other debris.On 1/22/26, at 10:58 a.m., Surveyor observed Certified Nursing Assistant (CNA)-Q, CNA-O, and Licensed Practical Nurse/Wound Nurse (LPN/WN)-T in R67's room. CNA-Q placed the sit to stand lift in front of R67 and CNA-O placed R67's feet on the foot portion of the lift. CNA-Q & CNA-O placed the sling around R67, and the sling was attached to the sit to stand lift. R67 was raised off the wheelchair and R67's pants & incontinence product were lowered. LPN/WN-T and Surveyor checked R67's buttocks and did not observe any pressure injuries. While CNA-O washed R67's frontal perineal area, Surveyor lifted up R67's wheelchair cushion. Surveyor observed under R67's cushion covering the entire seat portion of the wheelchair there is a large accumulation of food, dirt, and other debris.On 1/22/26, at 11:05 a.m., Surveyor asked CNA-Q who is responsible for cleaning resident's wheelchairs. CNA-Q replied it's supposed to be third shift.On 1/22/26, at 11:07 a.m., Surveyor asked LPN/WN-T if she happened to see under R67's cushion when Surveyor lifted the cushion up. LPN/WN-T replied no why is there supposed to be dycem. Surveyor informed LPN/WN-T R67's wheelchair is extremely dirty with food particles and debris under R67's cushion. LPN-H who was in the hallway and heard Surveyor's conversation stated third shift is supposed to clean wheelchairs. LPN-H informed Surveyor the next time R67 is toileted CNA-O will clean the wheelchair.On 1/22/26, at 4:00 p.m. LPN-H informed Surveyor R67's was cleaned. Surveyor asked LPN-H if she saw the debris and food particles under R67's wheelchair cushion. LPN-H nodded her head yes and stated all wheelchairs will be done.

Based on observation, interview, and record review, the facility did not ensure 1 (R25) of 5 residents were free from chemical restraints.R25 was prescribed Seroquel 25 mg (milligrams) twice daily, an antipsychotic medication, on 11/5/25 after R25's family voiced concerns about R25 yelling and swearing. The facility did not attempt any nonpharmacological interventions and did not rule out any underlying medical conditions.Findings include:The facility's policy titled, Use of Psychotropic Medication(s) and not dated documents under policy It is the intent of this policy to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. Under police explanation and compliance guidelines include documentation of 5. The indications for initiating, maintaining, or discontinuing medication(s), as well as the use of non-pharmacological approaches, will be determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risk, and the preference and goals for treatment. 6. Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use of the lowest possible dose, or discontinue the medications.R25's diagnoses includes chronic kidney disease (kidneys are damaged and cannot filter blood & waste effectively), diabetes mellitus (high blood sugar), anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), depression (serious mood disorder that causes a persistent feeling of sadness and a loss of interest in activities interfering with daily life), and dementia (loss of cognitive function that interferes with a person's daily life and activities).R25 receives hospice services and has an activated power of attorney for healthcare.R25's at risk for alteration in psychosocial well being r/t (related to) depression and anxiety diagnosis I take Buspirone for Anxiety. I take Mirtazapine for Depression. I take Seroquel for agitation care plan. Initiated 1/3/25. Documents the following interventions:*Encourage me to openly express my feelings. Initiated 1/3/25.*Observe for and report any changes in my mental status to nursing and/or social services. Initiated 1/3/25.*Provide me with activities I can do alone (ex. Books, books on tape, movies, puzzles). Initiated 1/3/25 and revised 6/2/25.*Refer to social services PRN (as needed) for additional emotional support. Initiated 1/3/25.*Update me regularly to help put my mind at ease. Initiated 1/3/25.R25's I get nervous and anxious in new situations, in new surroundings. Monitor for anxiety, restlessness, agitation. Behaviors combative with cares at times kicking, grabbing and hitting, pushing. 5/30/25 I will frequently take out my dentures and put them in blanket, clothing, drop them on the floor care plan initiated 1/23/25. Documents the following interventions:*Approach me from the front and address me by name. Initiated 1/23/25.*Call me by name or touch/hold my hand. That makes me feel secure. Initiated 1/23/25 & revised 4/27/25.*If I don't like what I'm doing, let me choose something else. Initiated 1/23/25.*If I'm upset, please re-direct the conversation or task. Initiated 1/23/25.*Offer food/fluids, toileting, massage, repositioning, soft music, quiet environment, encourage deep breathing, provide reassurance, relaxation activities, dim lighting, cold compress, diversional activities. Initiated 1/23/25 & revised 4/27/25.*Offer things that are soothing to me. Initiated 1/23/25 & revised 6/2/25.*Please avoid things that make me more anxious. Initiated 1/23/25 & revised 6/2/25.*Please give me my medication that help me with my anxiety. Initiated 1/23/25.*When I am nervous offer me a stuffed animal to hold. Initiated 4/27/25.*Be mindful when removing items from my room that my dentures are not in blankets, clothing, garbage. Initiated 5/30/25.*Ensure I have my dentures during meals. Initiated 5/30/25.R25's quarterly MDS (minimum data set) with an assessment reference date of 9/11/25 assesses R25 as having short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making. R25 is assessed as not having any behavior and is marked no for antipsychotic medication.R25's quarterly MDS with an assessment reference date of 12/25/25 assesses R25 as having short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making. R25 is assessed as not having any behaviors and yes is marked for antipsychotic medication. R25 is assessed as requiring partial/moderate assistance for eating, and is dependent on rolling left and right, chair/bed to chair transfer, and toilet use. R25 is always incontinent of bowel and bladder.Surveyor reviewed R25's October 2025 & November 2025 MAR (medication administration record) and noted monitoring behavior symptoms starting 2/27/25. Surveyor noted 0=None Noted, 1=Frequent Crying, 2=Repeats Verbalization, 3=Repeats Movement, 4=Yelling/Screaming, 5=Kicking/Hitting, 6=Pinching/Scratching/Spitting, 7=Biting. 8=Wandering. 9=Abusive Language, 10=Threatening Behavior, 11=Sexually Inappropriate, 12=Rejection of Care, 13=Other (describe in progress note) every shift. Surveyor noted each shift has only a check mark documented and does not document any numbers listed.R25's social service note dated 10/17/25 and created on 10/21/25, written by Social Service Director (SSD)-R documents Behavior/GDR (gradual dose reduction) meeting held today. IDT (interdisciplinary team) reviewed resident medication, mood and behavior. Resident is stable at this time. Psych continues to follow. No changes recommended at this time.Surveyor noted the next progress note is dated 11/3/25 at 3:40 p.m.R25's nurses note dated 11/3/25, at 15:40 (3:40 p.m.), written by Licensed Practical Nurse (LPN)-H documents, Daughter contacted nurse in regard to pts (patient) new agitation with @ (at) times pt yelling out. Hospice contacted with call out to nurse and will contact facility at their earliest convenience.R25's nurses note dated 11/4/25, at 09:03 (9:03 a.m.), written by LPN-H documents, Nurse spoke to hospice nurse and stated she will contact pts daughter/POA (power of attorney) and will be in the facility for further assessment.R25's nurses note dated 11/4/25, at 12:02 p.m., written by LPN-H documents, no agitation AM (morning) shift with pt sleeping most of the morning, VSS (vital signs stable), attended dining room with 100% intake, no c/o (complaints of) pain or discomfort with pt sat near staff for comfort and close monitoring.R25's nurses note dated 11/4/25, at 20:53 (8:53 p.m.), written by LPN-HH documents, Resident continue to yell out at staff and peers when passing or near. Calling staff and peers names. Resident is easily redirected. Will continue to monitor.R25's nurses note dated 11/5/25, at 02:36 (2:36 a.m.), written by LPN-FF documents, No s/s (signs/symptoms) of agitation. Has been sleeping quietly. No complaints.R25's nurses note dated 11/5/25, at 08:56 (8:56 a.m.), written by LPN-H documents, Pt observed to have outbursts of yelling out during NP (Nurse Practitioner) [first name] assessment AM shift. NP reached out personally to hospice nurse for possible medication regime with NOR (new order received) for Quetiapine 25 mg (milligrams) BID (twice a day) as well as hospice nurse to reach out further to POA (power of attorney) for possible PRN (as needed) Lorazepam agreement. First dose administered with pt sat near staff and residents for comfort and close monitoring.R25's physician order with an order date of 11/5/25 documents Quetiapine Fumarate Oral Tablet 25 mg (milligrams) (Quetiapine Fumarate) Give 1 tablet by mouth two times a day for dementia with agitation.R25's nurses note dated 11/6/25, at 02:00 (2:00 a.m.), written by LPN-FF documents, Resident having occasional yelling out. When spoke with resident denies yelling out. Encouraged to rest.R25's nurses note dated 11/6/25, at 1748 (5:48 p.m.), written by LPN-HH documents, Resident continues being monitored r/t new medication Seroquel. No adverse reactions noted or reported. Resident continues to yell out to staff inappropriate comments but easily redirected. Will continue to monitor.R25's nurses note dated 11/10/25, at 10:48 a.m., written by LPN-H documents, Pt cont. (continue) close monitoring for new medication Seroquel with pt tolerating well with less agitation, pt exhibited some anxiousness and yelling out and easily calmed with attention and conversation. Pt sat near nurse for comfort and safety, good appetite with assistance needed, VSS, no s/s of pain with no further concerns at this time.R25's nurses note dated 11/12/25, at 20:05 (8:05 p.m.), written by LPN-H documents, Close monitoring cont. for new medication Seroquel as well as bx (behavior) with yelling noted throughout AM shift and calmed with attention and conversation, good appetite, VSS with no SOB (shortness of breath), no s/s of pain or distress noted with no further concerns at this time.R25's social service note dated 11/14/25, at 14:30 (2:30 p.m.), written by DSS-R documents Behavior/GCR meeting held today. IDT reviewed resident medications, mood and behavior. Resident is stable at this time. Psych continues to follow. No changes recommended at this time.R25's nurses note dated 11/22/25, at 9:07 a.m., written by LPN-H documents, Pt cont. close monitoring for new medication Seroquel 25 mg BID with pt tolerating well. Pt attending dining room with 100% intake with staff assistance. Pt sat near nurses' station for comfort, activities and safety with no outburst or bx, VSS, no s/s of pain or discomfort with q2 (every two) change and reposition in place and obtained with no further concerns at this time.On 1/21/26, at 12:55 p.m., Surveyor observed R25 sitting in a Broda chair with a CNA sitting on the right side of her.On 1/26/26, at 9:36 a.m., Surveyor asked LPN-H if she knew why R25 was prescribed Seroquel. LPN-H replied yes, I have a note in there she was yelling out. LPN-H explained R25 was normally really pleasant. R25 was yelling out to patients and her daughters were concerned about that. Surveyor asked what interventions were tried prior. LPN-H informed Surveyor R25 was already on Buspar, didn't want lorazepam, and wanted a little something to take the edge off. Surveyor asked LPN-H who wanted this. LPN-H replied her daughters. LPN-H then looked at her phone and informed Surveyor on November 3rd the daughters wrote we noticed mom had been irritable and fisty last couple of visits the staff and residents feel same think it's dementia. LPN-H informed Surveyor she said she was going to contact hospice for any recommendations. The daughter responded okay thanks been putting fists up and calling people assholes, that's not my mom. Surveyor asked LPN-H who recommended Seroquel. LPN-H informed Surveyor first name of Nurse Practitioner (NP)-JJ and hospice agreed. Surveyor asked LPN-H if Seroquel was ordered because R25's daughters were concerned. LPN-H replied yup, I contacted hospice, but they were taking a little bit that's why I contacted [NP-JJ first name]. LPN-H stated it wasn't like a hard narcotic, think we monitored for 15 days.On 1/26/26, at 9:58 a.m., Surveyor observed R25 sitting in a Broda chair with her legs down and covered with a blanket in the hallway outside the nurse's station. R25 has her eyes closed and appears to be sleeping.On 1/26/26, at 11:00 a.m., Surveyor observed R25 sitting in a Broda chair covered with a blanket on another unit with CNA-N sitting next to resident. R25's eyes are closed and appears to be sleeping.On 1/26/26, at 11:13 a.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-U why R25 was prescribed Seroquel. LPN/UM-U informed Surveyor at one-point R25 was yelling, screaming or calling out. R25's family didn't want her to be on a lot of medication, medication that would put her to sleep or zonked out like Ativan. The POA was very reluctant of certain medications. Surveyor asked LPN/UM-U what nonpharmacological interventions were tried prior to Seroquel being ordered. LPN/UM-U replied just a lot of redirection, talking to [R25's name], someone would come around and talk with her, she wants someone to hold her hand, kind of calm her down with conversation. Surveyor asked if they ruled out any underlying medical conditions or if any assessments were completed such as was R25 in pain. LPN/UM-U replied I'm not for sure and informed Surveyor she didn't think they did. Surveyor asked LPN/UM-U to look into this for Surveyor.On 1/26/26, at 12:29 p.m. Surveyor spoke with Hospice Registered Nurse (RN)-II on the telephone. Surveyor inquired about R25 being started on Seroquel in November. Hospice RN-II explained to Surveyor he took over as case manager in November but thought the medication was started a couple of weeks prior. Hospice RN-II informed Surveyor the first time he saw R25 was on 11/19/25. Hospice RN-II informed Surveyor per his notes she was started on Seroquel on 11/5/25 because of increased agitation, yelling out more resistive to cares, yelling at care givers and things like that.On 1/26/26, at 1:19 p.m., Surveyor asked Social Service Director (SSD)-R if she was aware and if she was involved with R25 being prescribed Seroquel. SSD-R informed Surveyor she thinks hospice put R25 on it and didn't think the psych provider did. Surveyor informed SSD-R psych hasn't seen R25 since June 2025. Surveyor informed SSD-R Surveyor needed to take a phone call and asked if Surveyor could meet with her after.On 1/26/26, at 1:21 p.m. Surveyor spoke with NP-JJ on the telephone. Surveyor asked NP-JJ why R25 was prescribed Seroquel. NP-JJ informed Surveyor R25 was having increased behavior with aggressive behaviors. Surveyor asked NP-JJ what R25's aggressive behaviors were. NP-JJ informed Surveyor she was verbally, doesn't use profanity and said to her daughter *itch and hospice agreed to put R25 on Seroquel. Surveyor asked NP-JJ what nonpharmacological interventions were tried prior. NP-JJ replied I would have to check with nursing on that. Surveyor asked NP-JJ if she assessed R25 for any underlying medical conditions, was she assessed for pain. NP-JJ informed Surveyor she saw R25 the day she started her on Seroquel and doesn't have any documentation of pain. Surveyor asked NP-JJ if R25's behavior were verbal or physical. NP-JJ replied they were verbal. Surveyor asked NP-JJ if there was any discussion about other medication other than antipsychotic medication. NP-JJ informed Surveyor she discussed it with her hospice team and that's the medication they decided on.On 1/26/26, at 1:29 p.m., Surveyor met with DSS-R again to discuss R25. DSS-R informed Surveyor if she remembers correctly R25 had increased agitation, yelling out hey you to anyone who would walk past. DSS-R informed Surveyor she doesn't remember name calling as nursing charted. DSS-R informed Surveyor they did call hospice, and it looks like their (the facility's) NP gave the orders. DSS-R then asked Surveyor if that's who Surveyor was speaking with. Surveyor informed DSS-R Surveyor had spoken with NP-JJ. Surveyor asked DSS-R if R25 had behavior of yelling out prior. DSS-R replied no, she would be anxious and likes someone to sit and hold her hand explaining it's a safety thing. Yelling out was new. Surveyor asked DSS-R if any non-pharmaceutical interventions were implemented prior to starting Seroquel. DSS-R stated let me take a look and informed Surveyor she would get back to Surveyor.On 1/26/26, at approximately 1:53 p.m., LPN/UM-U informed Surveyor they did a pain assessment back in February 2025 but did not do one in November.On 1/26/26, at 2:59 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were informed R25 was started on an antipsychotic, Seroquel, without nonpharmacological interventions being attempted, Surveyor was unable to locate where the facility ruled out any underlying medical conditions, and any assessments prior.On 1/27/26, at 8:50 a.m., Surveyor asked DON-B if there is any additional information regarding R25's Seroquel. DON-B informed Surveyor the only thing they have are progress notes [first name of Infection Preventionist/Assistant Director of Nursing-E] brought in before. DON-B informed Surveyor they didn't see anything.On 1/27/26, at 9:04 a.m., Surveyor met with SSD-R and Social Worker (SW)-S. Surveyor asked if there is any additional information regarding R25's Seroquel. SSD-R replied no. Surveyor asked what should have been done. SSD-R replied they should have attempted nonpharmacological interventions, further discussion of medications, and have them call psych before prescribing that.

Based on interview and record review the facility did not ensure 3 (R2, R35, and R34) of 3 residents and/or representative were notified of the reason for transfer/discharge in writing and the facility bed hold notice did not contain the required information for appeal rights. *R2 was discharged to the hospital on 8/6/25, 10/21/25, and 12/7/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R2 and/or R2's representative. The facility bed hold notice does not contain the email address for all 3 agencies listed and the ombudsman information does not include an address. The facility was not able to provide documentation that bed hold/transfer notice was provided to R2 and/or representative for R2's discharge on [DATE]. *R35 was discharged to the hospital on 8/19/25 and 12/2/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R35 and/or R35's representative. The facility was not able to provide documentation that a bed hold/transfer notice was provided to R35 and/or representative. *R34 was discharged to the hospital on 8/13/25, 9/1/25, 9/12/25,10/27/25, and 12/5/25. The facility's transfer and discharge notice was not provided in writing and in a language understood to R34 and/or 34's representative. The facility bed hold notice does not contain the email address for all 3 agencies listed and the ombudsman information does not include an address. Findings include: Upon request, the facility was not able to provide a bed hold and transfer notice policy and procedure. 1.) R2 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis (a chronic disabling autoimmune disease of the central nervous system), Spastic Hemiplegia Affecting Right Dominant Side (one side of body experiences muscle stiffness and weakness), Neuromuscular Dysfunction of Bladder (nerves controlling bladder and urinary sphincter are damaged and not working correctly), Irritable Bowel Syndrome with Diarrhea (common chronic functional disorder of the large intestine), Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Insomnia (sleep disorder characterized by difficulty falling asleep), and Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R2 is currently his own person. R2's Quarterly Minimum Data Set (MDS) completed 12/29/25 documents R2's Brief Interview for Mental Status (BIMS) score to be 15 indicating R2 is cognitively intact for daily decision making. On 8/6/25, R2 was discharged to the hospital. On 8/6/2025, at 1:57 AM, Licensed Practical Nurse (LPN)- FF documented: . Resident requesting to go to hospital. Call placed ambulance for transfer to hospital for evaluation. There is no documentation that a bed hold and transfer notice was provided to R2 and/or R2's representative. The facility was not able to provide documentation that a bed hold and transfer notice was provided in writing to R2 and that R2 acknowledged R2's appeal rights. On 10/21/25, R2 was discharged to the hospital. On 10/21/2025, at 11:00 AM, LPN-J documented: . Patient left facility via transport heading to hospital for laparoscopic resection on 10/22/25. Bed hold received at this time. R2's bed hold and notice of transfer indicates R2 was verbally informed of bed hold and transfer notice. The bed hold and notice of transfer is not acknowledged by a facility representative indicating a bed hold and notice of transfer rights was provided to R2 in a writing in a language R2 could understand. On 12/7/25, R2 was discharged to the hospital. On 12/7/2025, at 7:22 PM, LPN-H documented: . Patient complaining nausea earlier AM shift. New orders to send patient out due to poor intake and constant emesis with patient in agreement. Patient transferred with bed hold in place. R2's bed hold and notice of transfer indicates R2 was verbally informed of bed hold and transfer notice. The bed hold and notice of transfer is not acknowledged by a facility representative that bed hold and notice of transfer rights was provided to R2 in a writing in a language R2 could understand. On 1/20/2026, at 11:49 AM, R2 informed Surveyor that R2 has been out to the hospital a couple of times but never signed acknowledgment of bed hold and notice of transfer in writing. On 1/22/2026, at 10:00 AM, Surveyor interviewed LPN-H. LPN-H confirmed the nursing department handles the bed hold and transfer notice process when a resident is transferred to the hospital. LPN-H stated that if a resident can sign for self, then the resident signs, otherwise the representative gives a verbal over the phone. LPN-H confirmed that the nurse responsible for transferring a resident should acknowledge the bed hold and transfer notice by signing their name. The form is then sent with the hospital paperwork. On 1/22/2026, at 3:37 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R2 was not provided in writing a bed hold and transfer notice with the required appeal rights information. No further information was provided by the facility at this time. 2) R35 was admitted to the facility on [DATE]. R35 is currently her own person. R35's Quarterly Minimum Data Set (MDS) completed 10/28/25 documents R35's Brief Interview for Mental Status (BIMS) score of 14 indicating R35 is cognitively intact for daily decision making. On 8/19/25, R35 was discharged to the hospital. On 8/19/25, at 7:49 AM, LPN-J documented: . Patient admitted due to hyperglycemia and abscess on kidney. On 12/2/25, R35 was discharged to the hospital. On 12/2/25 LPN-H documented, Nurse Practitioner gave new orders: . send patient out for further assessment with patient relieved and in agreement. Bed hold in place. On 1/20/2026, at 11:28, R35 informed Surveyor that R35 has been out to the hospital and has not acknowledged bed hold or transfer notices in writing. As of 1/22/2026, at 7:18 AM, the facility has not provided bed hold and notice of transfer documentation indicating R35 was provided in writing a bed hold and notice of transfer and acknowledged appeal rights. On 1/22/2026, at 10:00 AM, Surveyor interviewed LPN-H. LPN-H confirmed the nursing department handles the bed hold and transfer notice process when a resident is transferred to the hospital. LPN-H stated that if a resident can sign for self, then the resident signs, otherwise the representative gives a verbal over the phone. LPN-H confirmed that the nurse responsible for transferring a resident should acknowledge the bed hold and transfer notice by signing their name. The form is then sent with the hospital paperwork. On 1/22/2026, at 3:37 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B R35 was not provided in writing a bed hold and transfer notice with the required appeal rights information. No further information was provided by the facility at this time. 3.) R34's diagnoses includes history of traumatic brain injury (brain dysfunction caused by outside force usually a violent blow to the head), encephalopathy (general brain dysfunction characterized by alteration in brain function or structure), and conversion disorder (condition in which a mental health issue disrupts how the brain works) with seizures (sudden burst of electrical activity in brain which can cause changes in behavior, movement and level of consciousness) or convulsions. R34 has an activated power of attorney or healthcare. R34's nurses note dated 8/13/25, at 8:20 a.m., written by Licensed Practical Nurse (LPN)-H documents Pt (patient) was assessed by NP (Nurse Practitioner) [Name] due to change in pts baseline. After assessment NOR (new order received) to send pt out for further assessment to [hospital's initials]. POA/Brother contacted with attempt to speak with pt and unable to communicate with pt at this time. No further questions or concerns, pt transferred via [ambulance name] with no issues. R34 was readmitted to the facility on [DATE]. On 1/27/26, at 7:42 a.m., Surveyor reviewed R34's electronic medical record for R34's bed hold policy and notice of transfer form for R34's transfer to the hospital on 8/13/25. Surveyor was unable to locate this form in R34's medical record and asked Nursing Home Administrator (NHA)-A for a copy. Surveyor was not provided with R34's bed hold policy and notice of transfer form for R34. R34's nurses note dated 9/1/25, at 14:02 (2:02 p.m.), written by LPN-H documents, Hospital reported pt became lethargic during dialysis late morning. Writer contacted [hospital initials] in regards to pts status stating pt currently has AMS (altered mental status), BP (blood pressure)-88/58 and awaiting on labs and other tests. [Name] POA contacted with message left. Will cont. (continue) to f/u (follow up) later PM (evening) shift. R34 was readmitted to the facility on [DATE]. On 1/27/26, at 7:43 a.m., Surveyor reviewed R34's electronic medical record for R34's bed hold policy and notice of transfer form for R34's transfer to the hospital on 9/1/25. Surveyor was unable to locate this form in R34's medical record and asked Nursing Home Administrator (NHA)-A for a copy. Surveyor was not provided with R34's bed hold policy and notice of transfer form for R34. R34's nurses note dated 9/12/25, at 13:50 (1:50 p.m.), written by LPN-H documents [Initials] Lab contacted facility for critical Glucose reading of 49. Writer contacted dialysis in regards to current bs (blood sugar) with reading of 103. Nurse also informed writer they were sending pt (patient) to [hospital initials] due to multiple emesis accompanied with AMS (altered mental status). Pts POA (power of attorney)/Brother contacted and aware of the situation with no further questions or concerns. Will f/u (follow up) later in the shift. R34's nurses note dated 9/12/25, at 14:41 (2:41 p.m.), written by LPN-H documents, Verbal Bed hold with POA stating he will sign when he comes to facility with email/fax unavailable. R34 was readmitted to the facility on [DATE]. On 1/27/26, at 7:45 a.m., Surveyor reviewed R34's electronic medical record for R34's bed hold policy and notice of transfer form. Surveyor noted under the miscellaneous tab there is a bed hold policy and notice of transfer form dated 9/12/25. Surveyor noted under the Appeal Procedure section for Department of Quality Assurance does not include their email address. The Long-Term Care Ombudsman does not include their mailing and email address. The Wisconsin Coalition for Advocacy does not include their email address. Surveyor noted the POA was notified verbally by LPN-H on 9/12/25. This bed hold policy and notice of transfer form does not include evidence the form was provided in writing. R34's nurses noted dated 10/27/25, at 15:50 (3:50 p.m.) written by LPN-H documents Pt sent to [hospital initials] d/t (due to) hypotension with low K+ (potassium). POA [Name] informed with questioning if bp (blood pressure) medication was sent with pt and confirmed with nurse that it was with dialysis reporting medication was administered with not much change to bp with reading from 79/47 with increase to 82/55. POA in understanding with no further questions or concerns at this time. F/U (follow up) to hospital later in the shift if pt is admitted . R34's nurses note dated 10/29/25, at 0925 (9:25 a.m.) documents Per [Name] POA bed hold in place with verbal consent via phone 10/27/25. R34 was readmitted to the facility on [DATE]. On 1/27/26, at 7:47 a.m., Surveyor reviewed R34's electronic medical record for R34's bed hold policy and notice of transfer form. Surveyor was unable to locate this form in R34's medical record and asked Nursing Home Administrator (NHA)-A for a copy. NHA-A provided Surveyor with R34's bed hold policy and notice of transfer form dated 10/27/25. Surveyor noted under the Appeal Procedure section for Department of Quality Assurance does not include their email address. The Long-Term Care Ombudsman does not include their mailing and email address. The Wisconsin Coalition for Advocacy does not include their email address. Surveyor noted the POA was notified verbally by LPN-H on 10/27/25. This bed hold policy and notice of transfer form does not include evidence the form was provided in writing. R34's nurses note dated 12/5/25, at 13:29 (1:29 p.m.), written by Licensed Practical Nurse/Unit Manager (LPN/UM)-U documents Received call from patients' dialysis at [dialysis's name], with information that they will be sending patient to the hospital for bright red blood from the rectum. No blood reported this morning prior to dialysis. All responsible parties notified. R34 was readmitted on [DATE]. On 1/27/26, at 7:48 a.m., Surveyor reviewed R34's electronic medical record for R34's bed hold policy and notice of transfer form. Surveyor noted under the miscellaneous tab there is a bed hold policy and notice of transfer form dated 12/5/25. Surveyor noted under the Appeal Procedure section for Department of Quality Assurance does not include their email address. The Long-Term Care Ombudsman does not include their mailing and email address. The Wisconsin Coalition for Advocacy does not include their email address. Surveyor noted the form indicates the POA was notified verbally on 12/5/25 but there is no facility signature as to whom provided the verbal notification. This bed hold policy and notice of transfer form does not include evidence the form was provided in writing. On 1/27/26, at 8:17 a.m., Surveyor asked LPN-H to explain the facility's process when a resident is transferred to the hospital. LPN-H explained they automatically contact the doctor, if the POA is activated they contact them to get clearance and ask if they want a bed hold. The POA gives them a verbal, and this is documented on the bed hold form. A transfer form is printed out and sent to the hospital and a copy of the bed hold policy is sent. They call the hospital to give report and inform the Director of Nursing (DON). Surveyor asked LPN-H if she was responsible for providing written notification of the bed hold policy and notice of transfer to the resident and/or their legal representative. LPN-H informed Surveyor if their POA is in the building she reads it to them and if the resident is their own person she reads it to them, and they sign. LPN-H informed Surveyor Unit Clerk (UC)-DD scans the bed hold policy and notice of transfer into the computer. On 1/27/26, at 8:54 a.m., Surveyor asked Director of Nursing (DON)-B to explain the process when a resident is transferred to the hospital. DON-B explained they put in an order to send to the hospital, contact the POA to update them on the situation, & tell the POA their bed hold policy. DON-B indicated sometimes they get a verbal or if they come in, they sign. A progress note, the e-interact change of condition form, and transfer form is completed. Surveyor asked DON-B if the POA doesn't come to the facility is the bed hold policy and notice of transfer form provided to the POA. DON-B informed Surveyor she's not sure. If they give a verbal the business office is notified the POA gave a verbal and the business office moves forward with that. On 1/27/26, at 11:15 a.m. Surveyor asked Business Office Manager (BOM)-L if he is involved with resident's bed hold policy and notice of transfers. BOM-L replied no, only if they want a bed hold then he will add it in the census. Surveyor asked if he sends the bed hold policy and notice of transfer to the resident representative. BOM-L replied to no.

Based on observation, interview, and record review the facility did not ensure 1 (R2) of 4 Residents reviewed with limited range of motion, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility.*R2 was observed not wearing a right hand splint to prevent further decrease in range of motion/mobility. Findings include:The facility's undated Use of Assistive Devices policy and procedure documents:Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity .Policy Explanation and Compliance Guidelines:2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care.4. Facility staff will provide appropriate assistance to ensure that the resident can sue the assistive devices. This may include education or therapy sessions for training on the use of the device, set up assistance, supervision, or physical assistance as needed.5. Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding the devices. Training will also include when to refer to other departments for changes in condition or problems with the device.6. A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed.R2 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis(a chronic disabling autoimmune disease of the central nervous system), Spastic Hemiplegia Affecting Right Dominant Side(one side of body experiences muscle stiffness and weakness), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Irritable Bowel Syndrome with Diarrhea(common chronic functional disorder of the large intestine), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Insomnia(sleep disorder characterized by difficulty falling asleep), and Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R2's Quarterly Minimum Data Set(MDS) completed 12/29/25 documents a Brief Interview for Mental Status(BIMS) score of 15, indicating R2 is cognitively intact for daily decision making. R2's Patient Health Questionnaire(PHQ-9) score of 6 indicates R2 is demonstrating mild depressive symptoms. R2's MDS documents that R2 is not demonstrating behaviors including refusal of cares/treatments. R2's also MDS documents:R2's primary method of locomotion is wheelchair; R2 has range of motion impairment(ROM) on one side of both upper and lower extremity; R2 requires set-up for eating; R2's documents R2 requires substantial/maximum assistance with showers, upper dressing, and mobility; R2 is dependent on assistance for lower dressing and transfers; R2 has an indwelling catheter and is frequently incontinent of bowel; R2 is at risk for developing pressure areas/injuries and the MDS does not document R2 has a splint.R2's functional abilities(self care and mobility) care area assessment(CAA) completed 4/16/25 documents: R2 has ROM impairment and the goal is minimize risks and demonstrate improvement.R2's current physician orders printed 1/21/26 documents: R2 is to have a right-hand resting splint on at night as tolerated, in the evening effective 12/30/25.Surveyor reviewed R2's January 2026 medication and treatment administration record(MAR/TAR) and notes that R2's right-hand resting splint is not being monitored for placement every evening.Surveyor reviewed R2's occupational therapy(OT) notes. On 4/14/25, Occupational Therapist (OT)-F documents R2 was provided with a right-hand splint to be worn during sleeping hours.On 6/20/25, OT-F documents R2 continues to tolerate right resting hand splint with good skin integrity. Staff demonstrates proper technique for donning/doffing splint.On 9/8/25, OT-F documents R2 wears resting hand splint to right upper extremity and continues to demonstrate good skin integrity and staff is able to assist with donning and doffing.On 1/7/26, OT-F documents R2 is currently wearing a right resting hand splint during sleeping hours and off during the day with no complaints of pain and with good skin integrity. Certified Nursing Assistants (CNAs) are helping with donning and doffing.R2's bedside Kardex as of 1/22/26 to assist CNAs in the care of R2, documents: R2 has a right resting hand splint on at night, as tolerated.R2's current comprehensive care plan documents: R2 has a physical functioning deficit related to mobility impairment and self-care impairment initiated 4/9/25. The intervention of right resting hand splint on at night as tolerated was initiated 4/16/25 and revised 12/30/25.Surveyor notes there is no comprehensive care plan documenting R2 consistently refuses the splint to be placed.On 1/20/2026, at 11:52 AM, Surveyor observed a black splint, when facing R2, on the left corner of the bedside table which is located next to R2's bed. Surveyor observed R2's right hand significantly contracted with all fingers bent into the palm of R2's right hand. Surveyor interviewed R2 at this time about the splint. R2 stated the splint was not placed on R2's right hand last night. R2 informed Surveyor that R2 would wear the splint every night if the staff would help R2 with putting the splint on.On 1/21/2026, at 7:33 AM, Surveyor observed R2 in bed sleeping and the splint is not on R2's right hand. Surveyor observed the splint to be in the same exact spot on the bedside table as on 1/20/26.On 1/22/2026, at 7:43 AM, Surveyor observed R2 sleeping in bed. R2's splint is not on. Surveyor observed the splint is located in the exact same spot on the left corner of the bedside table as 1/21/26.On 1/22/2026, at 8:15 AM, Surveyor reviewed R2's progress notes located in R2's electronic medical record(EMR). Surveyor noted there was no documentation of R2 refusing to wear the right resting hand splint at night. On 1/26/2026, at 7:24 AM, Surveyor observed R2 in bed sleeping. R2's splint is not on. Surveyor observed the splint is located in the exact same spot on the left corner of the bedside table as last week.On 1/22/2026, at 9:40 AM, Surveyor interviewed OT-F. OT-F confirmed OT-F has worked with R2 in therapy and that R2 should be wearing the right resting hand splint at night. OT-F stated OT-F has never been told R2 was refusing to wear the splint or that it was painful to wear. OT-F stated that R2 has mentioned to OT-F that R2 has had to consistently remind staff to put the splint on. OT-F stated that staff have to help R2 place the splint on. OT-F informed Surveyor that with any restorative program, staff are educated every time a resident is released from therapy. On 1/26/2026, at 11:21 AM, Surveyor interviewed (CNA)-CC. CNA-CC stated CNA-CC is not normally assigned to R2 but has helped to take care of R2. CNA-CC is unaware if R2 is supposed to be wearing a splint. CNA-CC would check a resident's Kardex for instructions when taking care of a new resident or when assigned to a different unit. On 1/26/2026, at 2:21 PM, Surveyor interviewed (CNA)-I. CNA-I informed Surveyor that if a resident refuses cares, heel boots, splints, etc, CNA-I would document it and inform the nurse. CNA-I consistent schedule is PMs and assists R2 on a regular basis. CNA-I is not familiar with R2 having a right-hand splint. On 1/26/2026, at 2:59 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R2 has not been wearing R2's right resting hand splint as documented on R2's Kardex and comprehensive care plan. Surveyor shared that staff indicated they were unaware R2 had a right-hand splint. No additional information was provided by the facility as to why R2 has not been wearing R2's right hand splint to decrease any further range of motion impairment.

Based on interview and record review, the facility did not ensure 2 (R25 & R34) of 6 residents received adequate supervision and assistance devices to prevent accidents.*R25 was observed without a fall mat and body pillow while in bed according to R25's plan of care.*R34's falls on 8/12/25, 10/24/25, 11/23/25, 12/13/25, & 1/3/26 were not thoroughly investigated and the root cause was not consistently determined to help prevent further falls.Findings include:The facility's undated policy titled, Fall Prevention Program documents: Each resident will be assessed for fall risk and will receive care and services in accordance with their individual level of risk to minimize the likelihood of falls.1.) R25's diagnoses includes chronic kidney disease (kidneys are damaged and cannot filter blood & waste effectively), diabetes mellitus (high blood sugar), anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life), depression (serious mood disorder that causes a persistent feeling of sadness and a loss of interest in activities interfering with daily life), and dementia (loss of cognitive function that interferes with a person's daily life and activities).R25's at risk for falls care plan initiated 1/3/25 documents the following interventions:*Assess me for pain. Initiated 1/3/25 & revised 1/18/25.*Clear and monitor environmental obstacles (tubing, cords, etc.). Initiated 1/3/25.*I need my call light and personal items available and in easy reach or provide reacher. Initiated 1/3/25 & revised 1/18/25.*Encourage meals in dining room, common space. Initiated 2/28/25.*Nonslip shoes/socks. Initiated 2/28/25 & revised 3/2/25.*Prompt toileting before meals. Initiated 2/28/25 & revised 3/2/25.*Staff will ensure that resident is in view when family leaves and staff will educate family to make sure that resident is brought back to the nurses station. Initiated 2/28/25.*Body pillows to be applied door side of bed. Initiated 5/28/25.*Floor mat applied to door side of bed. Initiated 6/2/25 & revised 6/6/25.*Staff to ensure that bed linens are tucked in at the foot of the bed. Initiated 6/2/25.R25's fall CAA (care area assessment) dated 6/11/25 under analysis of findings for nature of the problem/condition documents: Fall 6/1. Speech is weak and a few words at a time. Clear. Allow time to express self. IDDM (insulin dependent diabetes mellitus), ref (refuse) to wear dentures (upper). No obvious issues noted. Sched (scheduled) Tylenol. Fall 6/1 w (with) pain to knee. Taking antidepressant, antianxiety. On Hospice. Pressure reducing devices in place. Skin and pain monitored. Monitored for changes. Under care plan considerations for describe impact for this problem/need on the resident and your rationale for care plan decision documents Speech is weak and a few words at a time. Clear. Allow time to express self. IDDM, Ref to wear dentures (upper). No obvious issues noted. Sched Tylenol. Fall 6/1 w pain to knee. Taking antidepressant, antianxiety. On Hospice. Pressure reducing devices in place. Skin and pain monitored. Monitored for changes. R25's quarterly MDS (minimum data set) with an assessment reference date of 12/25/25 is assessed as having short- & long-term memory problems and is severely impaired for cognitive skills for daily decision making. R25 is assessed as being dependent for toilet use, roll left and right, and chair/chair to bed transfers. R25 is always incontinent of bowel and bladder. R25 is assessed as not having any falls since prior assessment.R25's Visual/Bedside Kardex Report as of 1/21/26 under the safety section includes *Body pillows to be applied to right side for positioning and *Fall mat applied to right side of bed.On 1/21/26, at 7:38 a.m., Surveyor observed R25 in bed sleeping on the left side. The call light is under R25's pillow and is not in reach. Surveyor observed there is not a body pillow on the right side of R25's bed and there is not a floor mat on the right side.On 1/21/26, at 8:31 a.m., Surveyor observed R25 continues to be in bed on the left side. Surveyor observed there is still not a body pillow on the right side and there is not a floor mat on the right side.On 1/21/26, from 8:54 a.m. to 9:17 a.m., Surveyor observed Certified Nursing Assistant (CNA)-N provide morning cares for R25. At 9:17 a.m. CNA-N informed R25 she was going to get the sling and someone to help her put her in the chair. CNA-N lowered the height of R25' bed down and at 9:18 a.m. CNA-N left R25's room. Surveyor observed prior to leaving R25's room, CNA-N did not place a body pillow on the right side of the bed or a fall mat on the floor.On 1/21/26, at 9:27 a.m. Surveyor observed CNA-N enter R25's room, place gripper socks on R25 and a sling under R25. CNA-N told R25 she would be right back, went into the bathroom, removed her personal protective equipment, washed her hands and left R25's room at 9:29 a.m. Surveyor observed CNA-N did not place a body pillow on the right side of the bed or a fall mat on the floor next to R25's bed.On 1/21/26, at 9:35 a.m., Surveyor observed CNA-N and CNA-CC enter R25's room, attach the sling to a Hoyer lift and R25 was transferred from the bed into the Broda chair.On 1/22/26, at 7:40 a.m., Surveyor observed R25 sleeping in bed on her back. Surveyor observed there is not a body pillow on the right side and there is not a mat on the floor next to R25's bed.On 1/22/26, at 9:55 a.m., Surveyor observed R25 sitting in a Broda chair in the hallway outside the lounge area with the soda machine, covered with a blanket.On 1/26/26, at 7:08 a.m., Surveyor observed R25 on the left side with her knees flexed. Surveyor observed there is a rolled item along the right side of R25's bed but there is not a floor mat on the right side according to R25's plan of care.On 1/27/26, at 7:20 a.m., Surveyor observed CNA-M in R25's room. R25 was sitting in a Broda chair and was dressed for the day. Surveyor asked CNA-M if she got R25 up this morning. CNA-M replied yes. Surveyor asked CNA-M when she went in R25's room was there a floor mat on the right side of R25's bed. CNA-M looked around R25's room and then stated no. Surveyor then pointed to two red rolls in the corner and asked CNA-M if these were on R25's bed. CNA-M replied yes.On 1/27/26, at 8:22 a.m., Surveyor asked Licensed Practical Nurse (LPN)-H if CNAs should follow a resident's plan of care. LPN-H replied absolutely. Surveyor asked how CNAs know what a resident plan of care is. LPN-H replied we have a Kardex and explained for extensive things she lets them know. LPN-H explained she lets them know who has weights, if their a high fall risk she tells them what interventions are in place as well as fluid restriction. Surveyor informed LPN-H of multiple observations of R25 not having a body pillow or floor mat according to R25's plan of care.On 1/27/26, at 8:48 a.m., Surveyor informed Director of Nursing (DON)-B of the multiple observations of R25 not having a body pillow or floor mat according to R25's plan of care.On 1/27/26, at 12:00 p.m., LPN-H informed Surveyor R25 didn't have the floor mat as when they moved R25's roommate to another room they moved the floor mat also.2.) R34's diagnoses includes history of traumatic brain injury (brain dysfunction caused by outside force usually a violent blow to the head), hypertension (high blood pressure), end stage renal disease (kidneys do not work to meet the body's needs), diabetes mellitus (high blood sugar), encephalopathy (general brain dysfunction characterized by alteration in brain function or structure), and conversion disorder (condition in which a mental health issue disrupts how the brain works) with seizures (sudden burst of electrical activity in brain which can cause changes in behavior, movement and level of consciousness) or convulsions. R34's fall CAA (care area assessment) with an assessment reference date of 5/13/25 under analysis of findings for nature of the problem/condition documents No recent falls. Inc. (incontinent) B & b (bowel and bladder). Toileted by staff approx. (approximately) q (every) 2 hrs. (hours). Substantial to total assist w (with) all care. Daily antidepressant, seizure med (medication), Betadine to arterial toe. Sometimes understands. Understood. Allow time to answer - Ask short questions. No glasses. Items in reach in a well-lit area. Dialysis. High back w/c (wheelchair). Skin and pain monitored. Pressure reducing devices in place. Under care plan considerations for describe impact of this problem/need on the resident and your rational for care plan decision documents Inc B & b. Toileted by staff approx. q 2 hrs. Substantial to total assist w all care. Daily antidepressant, seizure med, Betadine to arterial toe. Sometimes understands. Understood. Allow time to answer-Ask short questions. No glasses. Items in reach in a well lit area. R34's quarterly MDS (minimum data set) with an assessment reference date of 12/12/25 has a BIMS (brief interview mental status) score of 6 which indicates severe cognitive impairment. R34 is assessed as not having any behavior. R34 is assessed as requiring supervision for eating, is dependent for toileting hygiene, and requiring partial/moderate assistance for rolling left & right, chair/bed to chair transfer, and toilet transfer. R34 is frequently incontinent of bowel & bladder and is assessed as not having any falls since prior assessment period.R34's nurses note dated 8/12/25, at 0646 (6:46 a.m.) written by Licensed Practical Nurse (LPN)-FF documents Resident found lying on the floor on his left side. Incontinent of bowel. Resident states tried getting up and fell. Did not use call light. C/o (complained of) left knee pain. ROM (range of motion) WNL (within normal limits) to all extremities. Medicated with 650 mg (milligram) Tylenol. Hoyer lifted into bed. BP (blood pressure) 145/70, pulse 72, resp. 17, temp. (temperature) 97.2, pulse ox 96% room air. Neuro check negative. Resident denies hitting his head.On 1/27/26 at 10:15 a.m. Surveyor reviewed the facility's fall investigation provided by NHA (Nursing Home Administrator)-A. Surveyor noted the facility investigation consisted of an incident report dated 8/12/25, neuro checks, and one staff statement. The facility's investigation does not include a root cause, when was R34 last seen, when was R34 last toileted and were prior interventions in place. R34's nurses note dated 10/24/25 fall at 1934 (7:34 p.m.) written by LPN-H documents During HS (hour sleep) medication administration writer heard pt (patient) yell out for help, when Nurse approached pts room pt was observed attempting to reach his w/c (wheelchair) when his gait became unsteady and fell landing on his R (right) side w/out (without) hitting his head with gripper socks and fitted. Pt stated he was okay but that he needed to get to the restroom fast for he felt a bowel movement coming. Pt was last seen coming from dinner with CNA (Certified Nursing Assistant) for nightly ADLs (activities daily living) @16:30 (4:30 p.m.). Pt able to move all extremities with no vocal or facial c/o (complaint of) pain, no new skin issues with current drainage remaining to G-tube site, VSS (vital signs stable) with no SOB (shortness of breath) or distress, eyes PERRLA (pupils are equal, round, reactive to light and accommodation) with pt A&O (alert and orientated) with clear speech. Pt was explained the importance of using the call light for assistance for transferring with UM (Unit Manager) and Nurse ambulating pt with gait belt to the restroom and then safely transferred back to bed in the lowest position. NP (Nurse Practitioner) [Name] made aware with NNO (no new orders) with close monitoring. POA (Power of Attorney) [Name] informed with no further questions or concerns.On 1/27/26, at 10:20 a.m. Surveyor reviewed the facility's investigation for R34's fall on 10/24/25 provided by NHA-A. Surveyor noted the facility's investigation included an incident report, nurses note dated 10/24/25, and four staff statements. Surveyor noted a root cause but noted the facility did not conduct a thorough investigation as staff statements document staff did not witness, were unaware of the fall or did not provide care. The investigation does not include whether prior interventions were in place, who last observed R34 and what was R34 doing to help prevent further falls.R34's nurses note dated 11/23/25 at 22:29 (10:29 p.m.) written by Registered Nurse (RN)-EE documents Nursing assistant reported to writer that resident had fallen in the bathroom. Writer entered room and noted resident sitting on buttocks next to toilet with right side against the wall. Gown and gripper socks on. Wheelchair in front of resident facing toilet and locked. Denies pain/discomfort. Denies hitting head. ROM WNL. Resident stated, I fell. Vital signs taken. Writer assisted resident to wheelchair with cna and gait belt. Updated physician, nurse manager on duty, and POA.On 1/27/26, at 10:21 a.m., Surveyor reviewed the facility investigation for R34's fall on 11/23/25 provided by NHA-A. Surveyor noted this investigation consisted of an incident report, neuro checks, and two staff statements. Surveyor noted the facility did not determine a root cause to help prevent further falls and did not conduct a thorough investigation as the staff statements indicate they didn't provide cares and did not witness R34's fall. The facility investigation did not include who last observed R34, when was R34 last toileted and were prior interventions in place. R34's nurses note dated12/13/25 at 0350 (3:50 a.m.) written by LPN-FF documents CNA found resident lying on the floor. Resident was lying on his right side. Had a BM (bowel movement) on the floor. States needed to have a BM got out of bed fell. Denies hitting head. Alert, able to make needs known. Denies pain or discomfort. ROM WNL to extremities. Skin intact, no raised or open areas to head. Neuro check negative. Cares provided. Hoyer lifted into bed. BP 114/62, pulse 72, resp. (respirations) 16, temp. (temperature) 97.6, pulse ox 96% room air. Message left for manager [Name].On 1/27/26, at 10:23 a.m. Surveyor reviewed the facility's fall investigation for R34's fall on 12/13/25 provided by NHA-A. Surveyor noted the facility's investigation consisted of an incident report, one staff statement, and neuro checks. Surveyor noted a root cause but the facility did not conduct a thorough investigation as the facility investigation does not include who last observed R34, when was R34 last toileted and were prior interventions in place.R34's nurses note dated 1/3/26 at 1440 (2:40 p.m.) written by LPN-H documents Pt was observed sitting on his buttocks in front of his w/c with legs straight ahead, clothes on and fitted, not incontinent, denied hitting his head, call light not on but within reach with noted tennis shoes on and laced up correctly, wheelchair locked with cushion in place. Pt stated he was attempting to get into his electric new w/c to get to the restroom. Head to Toe WNL with pt able to move all extremities without vocal and or facial pain, VSS with no SOB or distress, no changes to skin or any other noted injuries. Pt was safely transferred back to w/c via Hoyer, reminded the importance of utilization of call light for safety with pt in understanding. Pt then was sat near nurses station for comfort and safety with electric w/c removed from room as well. POA/[Name]-phone not on with message left, NP [Name] made aware as well as DON (Director of Nursing). Neuros and close monitoring to continue.On 1/27/26, at 10:25 a.m., Surveyor reviewed the facility's fall investigation for R34's fall on 1/3/26 provided by NHA-A. Surveyor noted the facility's fall investigation consists of an incident report, neuro checks, and five staff statements. Surveyor noted a root cause, but the facility did not conduct a thorough investigation as none of the staff statements included when was R34 last observed & what time was R34 toileted. The investigation doesn't include whether prior interventions were in place at the time of R34's fall.On 1/27/26, at 11:49 a.m., Surveyor interviewed Director of Nursing (DON)-B regarding the facility's process after a resident has sustained a fall. DON-B explained the resident needs to be assessed by the nurse who checks for injuries, if there is a RN in the building, we want them to do an assessment. DON-B informed Surveyor if there is not an RN in the building the floor nurse will do the assessment, and the RN will do an assessment the following day. The resident is transferred back into bed, neuro checks are started and the MD (Medical Doctor) or NP (Nurse Practitioner), POA or guardian or emergency contact, if the resident wants, are contacted. The nurse puts an intervention in place and in the morning meeting they talk about the fall, if the intervention is appropriate or if we need to find another one. Surveyor asked about the investigation into a resident's fall. DON-B replied that's where we get statements from the CNAs and the nursing statement is usually in risk management. Surveyor asked who determines the root cause. DON-B informed this is done as an IDT (interdisciplinary team). Surveyor informed DON-B Surveyor reviewed the facility's investigation for R34's five falls and was unable to consistently find the root cause. Surveyor informed DON-B R34's falls involved R34 needing to have a BM, trying to get to the bathroom or found in the bathroom. Surveyor informed DON-B the facility's investigation was not thorough as staff statements did not include who last observed R34, what was he doing, when was he toileted, etc. to help prevent further falls and whether prior interventions were in place.No additional information was provided.

Based on interview and record review, the facility did not ensure ongoing communication with the dialysis center and monitoring for complications before and after dialysis treatment for 2 (R34 & R11) of 2 residents reviewed for hemodialysis. Findings include: The facility's undated policy, titled Hemodialysis documents: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: *The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. *Safe administration of hemodialysis at the bedside in the nursing home provided by qualified trained staff/caregivers, in accordance with State and Federal laws and regulations: (see home dialysis treatment policy). *Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices: and *Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. 1.) R34's diagnoses includes a history of traumatic brain injury (brain dysfunction caused by outside force usually a violent blow to the head), hypertension (high blood pressure), end stage renal disease (kidneys do not work to meet the body's needs), diabetes mellitus (high blood sugar), encephalopathy (general brain dysfunction characterized by alteration in brain function or structure), and conversion disorder (condition in which a mental health issue disrupts how the brain works) with seizures (sudden burst of electrical activity in brain which can cause changes in behavior, movement and level of consciousness) or convulsions. R34's alteration in kidney function care plan initiated 10/6/25 documents the following interventions: *Labs per Physician order and PRN (as needed) for change in condition/manifestation of clinical signs or symptoms. Initiated 10/6/25. *Monitor for edema in extremities and report any increase to Physician, pre-dialysis and post dialysis weights at dialysis center. Initiated 10/6/25. *Monitor thrill and bruit daily and document findings; report abnormal findings to Physician. Initiated 10/6/25. *Observe for signs and symptoms of bleeding, i.e. hematuria, bleeding gums, tarry stools, increase in bruising. Initiated 10/6/25. R34's quarterly MDS (minimum data set) with an assessment reference date of 12/12/25 has a BIMS (brief interview mental status) of 6, which indicates severe cognitive impairment. On 1/21/26, at 9:26 a.m., Licensed Practical Nurse (LPN)-H asked Surveyor if Surveyor wanted R34's dialysis binder as he is going to dialysis today. LPN-H explained R34 goes to dialysis on Monday, Wednesday, and Friday. Surveyor informed LPN-H Surveyor would review R34's dialysis binder at another time. On 1/21/26, at 12:57 p.m., Surveyor went to R34's room and noted R34 has not returned from dialysis. On 1/22/26, at 10:44 a.m., Surveyor observed R34 sitting in a high back wheelchair in R34's room. Surveyor asked R34 how his dialysis was yesterday. R34 replied good I think depending on who the instructor is. On 1/22/26, at 10:49 a.m., Surveyor heard R34 yelling out for Surveyor. Surveyor spoke with R34 who started to talk to Surveyor about his tube leaking. Surveyor asked R34 if his G-tube was leaking. R34 was unsure then showed Surveyor his dialysis port located on R34's right upper chest. Surveyor informed R34 Surveyor would ask LPN-H to see him. R34 stated oh first name of LPN-H is here? Surveyor spoke with LPN-H who then went to R34's room. On 1/26/26, at 8:12 a.m., Surveyor asked LPN-H where Surveyor could find R34's dialysis book. LPN-H showed Surveyor a thin white binder stating this is his little one, he had a thick binder. Surveyor asked LPN-H what happened to R34's thick binder. LPN-H explained R34 went to the hospital from dialysis and the hospital lost R34's binder. LPN-H informed Surveyor they called the hospital and they said they couldn't find it. On 1/26/26, starting at 8:14 a.m., Surveyor reviewed R34's dialysis binder and R34's medical record regarding dialysis communication and monitoring. Surveyor noted R34 was hospitalized on [DATE] and returned to the facility on [DATE]. Surveyor noted the following: *On 12/12/25 the bottom portion of the dialysis communication report sheet is not completed by the dialysis center and there is no post dialysis assessment. *On 12/15/25 the bottom portion of the dialysis communication report sheet is not completed by the dialysis center and there is no post dialysis assessment. *On 12/17/25 the bottom portion of the dialysis communication report sheet is not completed by the dialysis center and there is no post dialysis assessment. *On 12/19/25 there is no pre dialysis assessment, communication from dialysis center, and no post dialysis assessment. *On 12/21/25 the bottom portion of the dialysis communication report is not completed by the dialysis center and there is no post dialysis assessment. *On 12/24/25 there is no pre dialysis assessment, no communication from dialysis center, and no post dialysis assessment. *On 12/26/25 there is no pre dialysis assessment, no communication from the dialysis center, and no post dialysis assessment. *On 12/29/25 the bottom portion of the dialysis communication sheet is not completed by the dialysis center and there is no post dialysis assessment. *On 12/31/25 there is no pre dialysis assessment, no communication from the dialysis center, and no post dialysis assessment. *On 1/2/26 there is no pre dialysis assessment, no communication from the dialysis center, and no post dialysis assessment. *On 1/5/26 there is no pre or post dialysis assessment. *On 1/7/26 the bottom portion of the dialysis communication sheet is not completed by the dialysis center and there is no post dialysis assessment. *On 1/9/26 there is no pre or post dialysis assessment. *On 1/12/26 there is no post dialysis assessment. *On 1/16/26 there is no pre dialysis assessment, no communication from the dialysis center, and no post dialysis assessment. *On 1/19/26 there is no post dialysis assessment. On 1/26/26, at 9:41 a.m., Surveyor interviewed LPN-H to inquire about the facility's dialysis communication and monitoring for R34. LPN-H explained they do a pre and post dialysis assessment form. The pre assessment goes to the dialysis center then dialysis reads it and sometimes they send the form back. Surveyor informed LPN-H Surveyor noted in R34's binder dialysis communication forms where the facility completes the top portion and the bottom portion is completed by the dialysis center. Surveyor inquired about the top portion. LPN-H explained if they don't complete the dialysis pre assessment on the computer and print it out then they complete the top portion of the dialysis communication form. Surveyor inquired who is responsible for the post dialysis assessment. LPN-H replied the PM (evening) nurse for [R34's first name]. On 1/26/25, at 11:04 a.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-U to explain the facility's communication process with the dialysis center. LPN/UM-U explained there is a communication book, the nurses fill out pre and post assessment in the computer and they are supposed to send the pre assessment with the patient to dialysis so the dialysis center knows if there is any medication taken and also has a set of vitals. LPN/UM-U explained the pre assessment is completed by the nurse on the unit and then the post is completed by the floor nurse when they return. Surveyor informed LPN/UM-U Surveyor noted in R34's dialysis binder there is a communication form which has the facility completing the top portion and dialysis center the bottom section. Surveyor asked if the nurses complete this top portion. LPN/UM-U replied I've seen some of the forms and explained the form in the computer system has everything on the top portion. LPN/UM-U informed Surveyor she believes they have been doing the assessments on the computer. Surveyor asked LPN/UM-U who ensures the dialysis center is completing their section to communicate back to the facility. LPN/UM-U replied the nurse should because the binder should be coming back. LPN/UM-U explained the nurse should be looking at what dialysis says and then complete the post dialysis assessment in PCC. Surveyor informed LPN/UM-U there are multiple dates when the facility has not completed R34's pre or post dialysis assessment and there is no communication from the dialysis center. Surveyor asked LPN/UM-U to look into this, and Surveyor would meet with her the next day. On 1/26/26, at 2:59 p.m., during the end day meeting with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B, facility staff were informed of the multiple days when the facility did not complete R34's pre or post dialysis assessment and there is no communication from the dialysis center. On 1/27/26, at 8:53 a.m., Surveyor asked DON-B if there is any additional information regarding R34's pre & post dialysis assessment and communication with the dialysis center. DON-B replied no. On 1/27/26, at 12:05 p.m., Surveyor asked LPN/UM-U if she has any information for Surveyor regarding R34's pre/post dialysis assessments and communication with the dialysis center. LPN/UM-U replied I was looking and think we might of dropped the ball, I'm not finding anything else. No additional information was provided. 2.) R11 admitted to the facility on [DATE] and has diagnoses that include non-displaced condyle fracture of lower end of right femur, Type 1 Diabetes Mellitus and End Stage Renal Disease dependence on renal dialysis. R11's admission Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R11 is cognitively intact. R11's Care Plan documents: Alteration in Kidney Function evidenced by hemodialysis; date initiated 12/22/25. Interventions include: Written communication form with review of weights and any changes in condition between dialysis provider and living center. On 1/20/26 at 9:27 AM, Surveyor spoke with R11 who reported she goes to dialysis every Monday, Wednesday and Friday. R11 showed Surveyor the access port in her right chest and reported the facility does not do anything with the access site and that the dressing is changed at dialysis. 01/26/2026 9:02 AM Surveyor asked Director of Nursing (DON)-B how the facility communicates with the dialysis center. Surveyor was advised residents on dialysis have a binder with facility and dialysis communication sheets. Surveyor was unable to locate R11's dialysis binder. Surveyor was advised by the unit nurse (unknown name) the dialysis communication book goes with the resident to dialysis, and that R11 leaves at 5:30 am and should return around 11:00 am. Surveyor was unable to locate any facility/dialysis communication forms and reviewed R11's progress notes which included the following facility pre or post dialysis evaluations completed: 1/26/26 pre-dialysis, 1/19/26 post-dialysis, 1/14/26 post-dialysis, 1/12/26 post-dialysis, 1/9/26 pre-dialysis, 1/8/26 pre and post dialysis, 1/7/26 pre and post dialysis, 1/2/26 pre and post dialysis, 12/31/25 pre and post dialysis, 12/26/25 post-dialysis and 12/23/25 post-dialysis. Surveyor noted there was no assessment/evaluation for R11 documented before or after dialysis on 12/22/25, 12/24/25, 12/29/25, 1/5/26, 1/16/26, 1/21/26 or 1/23/26. In addition, facility documentation on 1/19/26, 1/14/26, 1/7/26, 1/2/26, 12/26/25 and 12/23/25 documented: Bruit – positive. Thrill – yes. R11 does not have a dialysis shunt to assess bruit and thrill. On 1/26/26 at 12:09 PM, Surveyor spoke with R11 while R11 was eating lunch in the dining room. Surveyor asked if she had the dialysis communication book she takes to dialysis. R11 stated, No, I don't have, and I've never had a book that I take with me. It depends on who's working, but I've only taken a piece of paper with me two time to dialysis. Someone here filled it out and then someone there wrote on it too. That has only happened twice. Surveyor confirmed R11 has a dialysis access port in her chest and no access shunt in either arm. R11 stated, They tried an access in my arm like 5 years ago, but it didn't take. On 1/26/26 at 3:11 PM, during the daily exit meeting with Nursing Home Administrator (NHA)-A and DON-B, Surveyor shared concern regarding the lack of communication between the facility and the dialysis center, and the facility not consistently assessing R11 before and after dialysis. Surveyor advised DON-B of documentation indicating assessment of bruit/thrill, though R11 does not have a shunt to assess bruit/thrill. No additional information was provided.

Based on observation, record review, and interview, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practical mental and psychosocial well being in accordance with a comprehensive assessment and plan of care for 1 (R69) of 1 resident received for mood concerns.R69 has a long history of suicidal ideations. On 9/3/25 and 1/19/26, R69 voiced suicidal ideations while in the dining room. R69 was not placed on a one to one according to R69's plan of care, R69's physician and/or psychological services were not notified, and social service staff was unaware of these suicidal ideations.Findings include:The facility's undated policy titled, Suicide Prevention documents: It is the policy of this facility to act quickly and appropriately if a resident expresses thoughts of suicide. Under policy explanation and compliance guidelines documents 1. All staff members will immediately report any suicidal ideation to the resident's charge nurse and facility social worker. 2. Immediately notify the resident's physician if the resident presents with suicidal ideation, even if he or she isn't specific about a plan or intent. 3. If applicable, notify the resident's responsible party of the resident's suicidal ideation and any orders received from the resident's physician. 4. The resident will not be left alone. One on one care will be provided until arrangements can be made for the resident to receive emergency psychiatric care, or until the resident's physician determines that the risk of suicide is no longer present. 5. Objectively and thoroughly document the resident's mood and behaviors, as well as all actions taken, in the medical record. 6. If the resident requires inpatient psychiatric services, State specific guidelines and requirements will be followed. 7. All staff will be trained annually on risk factors and warning signs of suicide, as well as how to respond to a resident with suicidal ideation.R69's diagnoses include bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood), hypertension (high blood pressure), diabetes mellitus (high blood sugar), major depressive disorder (serious mood disorder that causes a persistent feeling of sadness and a loss of interest in activities interfering with daily life), generalized anxiety disorder (group of mental health conditions characterized by excessive and persistent worry, fear and nervousness that can interfere with daily life), and obsessive-compulsive personality disorder (excessive thoughts that lead to repetitive behaviors).R69's PASRR (Pre-admission Screening and Resident Review) level II (2) dated 10/17/24 under reason for referral documents [R69's name] was referred to [Name] due to his diagnosis of bipolar disorder, major depressive disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Claustrophobia (extreme or irrational fear of confined spaces) is also noted in his records. He was originally diagnosed in the late 1970's and early 80's. Symptoms in the past have included fluctuation in mood, periods of depression, feelings of frustration, feeling overwhelmed, and suicidal ideation. He has had 2 psychiatric hospitalizations and suicide attempts in the 1980's. He has taken psychotropic medications since around that time. He continues to see a psychiatrist in the community.R69's at risk for alteration in psychosocial well-being related to bipolar disorder, depressive disorder, generalized anxiety disorder. I have episodes of increased irritability and aggressive verbalizations. I have a history of suicide attempt many years ago, related to a breakup with girlfriend. I sometimes have behaviors which include yelling, attention seeking. I sometimes refuse showers. I am taking Buspirone for my anxiety. I am taking Depakote for my anxiety. I am taking Seroquel for my Bipolar. 4/10/25 I am currently having episodes of increased anxiety that become overwhelming. I will make statements of not wanting to live anymore. 4/30/25 Voice suicidal thoughts, no plan care plan. Initiated 9/14/24 documents the following interventions:*Encourage me to openly express my feelings. Initiated 9/14/24.*Observe for and report any changes in my mental status to nursing and/or social services. Initiated 9/14/24 & revised 4/11/25.*Refer to social services PRN (as needed) for additional emotional support. Initiated 9/14/24.*Update me regularly to help put my mind at ease. Initiated 9/14/24.*If I am having increased anxiety or irritability, allow me to express my feeling, provide me validation and reassurance. Encourage me to socialize, offer things I enjoy; favorite music station, Sci-Fi tv shows, phone calls to family/friends. Initiated 4/10/25 & revised 10/23/25.*Approach me from the front and address me by name. Initiated & revised 4/11/25.*Don't leave me alone if I express any suicide ideation, initiate 1:1, inform nurse and call 911. Initiated & revised 4/11/25.*Please avoid things that make me more anxious. Initiated 4/11/25.*Please give me my medication that help me with my anxiety. Initiated 4/11/25.*Please refer me to my psychologist/psychiatrist as needed. Initiated 4/11/25.*Please tell me what you are going to do before you begin. Initiated 4/11/25.*Monitor me for any changes in my mood. Initiated 9/2/25.*Monitor me for medication side effects. Initiated 9/2/25.R69's physician orders include Buspirone HCI 5 mg (milligrams) three times a day for anxiety related to bipolar disorder, current episode depression, moderate with an order date of 8/21/25. Depakote Delayed Release 125 mg, 4 tablets four times a day related to generalized anxiety disorder with an order date of 11/18/24. Seroquel 300 mg, give 2 tablets in the evening related to bipolar disorder, current episode depressed moderate with an order date of 4/11/25 and Seroquel 50 mg in the evening related to bipolar disorder, current episode depressed, moderate with an order date of 9/19/25.Surveyor reviewed R69's August 2025, September,2025, & January 2026 MAR (medication administration record) and noted the following Order date 11/18/24 Monitor - Behavior Symptoms: 0=none noted, 1=frequent crying, 2=repeats verbalization, 3=repeats movement, 4=yelling/screaming, 5=kicking/hitting, 6=pinching/scratching/spitting, 7=biting, 8=wandering, 9=abusive language, 10=threatening behavior, 11=sexually inappropriate, 12=rejection of care, 13=other (describe in progress note) every shift. Surveyor noted there are only check marks with licensed nurse's initials.Surveyor reviewed R69's August 2025, September 2025 , & January 2026TAR (treatment administration record) and noted the following: Order date 11/18/24 Resident is prescribed an antianxiety medication. Document number of times per shift that resident exhibits any of these behavior: anxiety, restlessness, agitation. Non-Pharm interventions A=food/fluids, B=toileting, C=Massage, D=repositioning, E=soft music, F=quiet environment, G=deep breathing, H=reassurance, I=exercise/ambulating, J=relaxation no/visualization, K=dim lighting, L=cold compress, M=diversional activity, N=other. Place code in box when used, place N/A (non-applicable) every shift.Surveyor noted there are only check marks with the licensed nurse's initials and/or is blank and doesn't indicate if R69 has exhibited any of these behaviors listed.Order date 11/18/24 Resident receives an antidepressant. Document number of times per shift that any of these behaviors occur: states feeling sad or depressed, crying, tearfulness, social isolation. Non-Pharm interventions A=food/fluids, B=toileting, C=Massage, D=repositioning, E=soft music, F=quiet environment, G=deep breathing, H=reassurance, I=exercise/ambulating, J=relaxation no/visualization, K=dim lighting, L=cold compress, M=diversional activity, N=other. Place code in every shift. Surveyor noted there are only check marks with the licensed nurses' s initials and/or is blank and does not indicate if R69 has exhibited any of these behaviors. Order date 11/18/24 Resident receives antipsychotic medication. Document number of times resident exhibits any of these behaviors: suspiciousness, suicidal ideations, hallucinations, paranoia, or verbal/physical aggression. Non-Pharm interventions A=food/fluids, B=toileting, C=Massage, D=repositioning, E=soft music, F=quiet environment, G=deep breathing, H=reassurance, I=exercise/ambulating, J=relaxation no/visualization, K=dim lighting, L=cold compress, M=diversional activity, N=other. Every shift. Surveyor noted there are only check marks with the licensed nurses' s initials and/or is blank and does not indicate if R69 has exhibited any of these behaviors. R69's late entry nurses note dated 9/3/25, at 1900 (7:00 p.m.), and created on 9/4/25 at 11:37 a.m. written by Licensed Practical Nurse/Unit Manager (LPN/UM)-U documents Writer was informed by the nurse on the unit that the patient was talking in the dining room to the other residents and had mentioned that he wanted to slit his wrist. The nurse on duty reported that she had talked to the patient and asked him what was going on the patient replied to the nurse I was feeling a little depressed and needed to talk it out. Writer informed [NAME] (Director of Nursing) and Adon (Assistant Director of Nursing) about the situation. Writer also had the patient come in to talk with us regarding his remarks. the patient stated I did say that I want to slit my wrist which I have done in the past, but I was feeling a little depressed and just needed to talk it out and now I feel better and there is no need to worry.R69's social service note dated 9/4/25, at 1400 (2:00 p.m.), written by Social Worker (SW)-S documents Care conference held today. SW, SSD (Social Service Director), Resident were present. SSD discussed with the resident about the ADRC (Aging and Disability Resource Center). Resident shared his thoughts on it and agreed to enroll into a Family Care Program. SSD called the ADRC and shared this information with them after the meeting. Resident shared that he has been having some ups and downs with his mood. Resident shared at the end that he feels better talking with the SW and SSD. Resident shared that talking with others have always helped express his feelings and calm himself down. Resident denied any suicidal ideations. SW will continue to follow and provide support.R69's social service note dated 9/19/25, at 1430 (2:30 p.m.), written by Social Services Director (SSD)-R documents Behavior/GDR (gradual dose reduction) meeting held today. IDT (Interdisciplinary team) reviewed resident medications, mood and behavior. Resident is stable at this time. psych continues to follow. No changes recommended at this time.Advanced Practice Nurse Prescriber (APNP) Psych-KK's psychiatry follow up progress note dated 9/19/25 under review of systems for psychiatric documents no suicidal ideation, no homicidal ideation, no plan, fixating on rejections from females he is looking to be involved romantically with, no hallucinations, thought process organize, associations normal, judgment intact, insight intact, impulse control intact, no acute behavioral concerns, no apparent agitation, no aggression, no combativeness, cooperative demeanor, good eye contact, interacting with peers and staff, goes to activities sometimes. Under risk assessment for comments documents Patient reports having thoughts of suicide over the last 2 days but denies any plan or intent at this time. Patient will contract for safety. Patient reported talking to an RN (Registered Nurse) last night when having suicidal thoughts. Denies homicidal ideation, plans, intent, or access. Surveyor did not note any documentation from an RN regarding R69 having suicidal thoughts the night prior.R69's quarterly MDS (minimum data set) with an assessment reference date of 11/21/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R25's PHQ-9 (patient depression questionnaire) has a score of 11 which indicates moderate depression. Yes was answered for feeling down, trouble falling or staying asleep, feeling tired, poor appetite, and feeling bad about self. R69 is assessed as being independent for his ADLs (activities daily living) and is continent of bowel and bladder.There are psychiatry follow up progress notes written by APNP Psych-KK on 11/21/25 & 12/19/25.R69's nurses note dated 1/19/26, at 18:46 (6:46 p.m.), written by Nursing-LL documents: Resident said to a CNA (Certified Nursing Assistant) @ (at) 1730 (5:30 p.m.) in the dining room that he was having suicidal thoughts, and that he wouldn't harm himself, he needed to say it out loud. Resident also said he did not want to go to the hospital. Writer called on- call and resident spoke with nurse and verbalized not being happy with 3rd shift staff and was feeling defeated. On call nurse made sure no plan was in place to harm himself and there was not. On- call is to help investigate the issue and resident was feeling better and thanked the CNA for telling writer and not being upset. Resident reassured and now feeling fine. Writer told resident she was working tonight and to feel free to be in Complex area if he wanted too.On 1/20/26, at 9:53 a.m., Surveyor observed R69 lying in bed. Surveyor asked R69 how he is doing and if staff help with cares. R69 informed Surveyor he does all his own cares except he can't shower by himself because of safety. Surveyor observed multiple items around and in R69's bed. Surveyor inquired about these items. R69 informed Surveyor it makes him feel like he's home. R69 then stated to Surveyor he wanted to go on record and informed Surveyor he's having problems with one of Certified Nursing Assistants (CNAs). Surveyor asked R69 what's the problem. R69 explained he goes over to the other side's living room and watches a movie or listens to music. R69 informed Surveyor a CNA told him to keep the door closed because it was too loud. R69 explained he opened the door because he was getting warm and she got smart with him asking why he opened the door as she told him to keep it closed. Surveyor asked R69 if he reported this to anyone. R69 replied I sure did. Reported it to name of SW-S, name of SSD-R and the admissions clerk, kind of high up the totem pole people. Surveyor asked R69 if he knew the CNA's name. R69 replied no and then explained what the CNA looked at. R69 informed Surveyor another time, two or three nights ago he was watching a science fiction movie Aliens, asking Surveyor if Surveyor knew this movie. R69 stated I talk to the screen, I get into things. R69 informed Surveyor the CNA pounded on the glass of the living room. R69 stated he disregarded her. The CNA said to him when you get back to the 21st century, shut up. Surveyor asked R69 if he reported this. R69 replied yes but was unable to tell Surveyor who he reported this incident to. Surveyor asked if there is anything else he'd like to tell Surveyor. R69 informed Surveyor he's been depressed and yesterday he had thoughts of suicide. Surveyor asked R69 if he was still having thoughts about suicide. R69 no and then explained he doesn't like someone from the outside telling him what to do.R69's nurses note dated 1/20/26, at 10:19 a.m. created on 1/26/26 at 1655 (4:55 p.m.), written by Infection Preventionist/Assistant Director of Nursing (IP/ADON)-E documents: Note for conversation with resident on 1/19/26 @ (at) approx. (approximately)1800 (6:00 p.m.). Writer received phone call from nurse at facility d/t (due to) resident had expressed suicidal thoughts and was present with her at the time of the call. Writer received permission from resident to have discussion with him. Resident stated, you know that when I feel this way that if I say it out loud, put it out of me then I feel better. I am not going to hurt myself and I do not have a plan. And I refuse to go to the hospital. This is what I am allowed to say when I am feeling like this. Resident stated that he would stay with nurse. Resident stated that what 'got him going' was being told his phone was too loud, that people were sleeping. Writer told resident I would follow up with him this morning. Resident stated he is still upset but thanked writer for checking up on him.On 1/21/26, at 8:50 a.m., Surveyor observed R69 propelling his wheelchair down the hallway by moving his feet. R69 went into his room, sat in the doorway for a few seconds and then wheeled back down the hallway.On 1/21/26, at 1:02 p.m., Surveyor entered R69's room. Surveyor informed R69's roommate Surveyor was just going to check R69. The roommate informed Surveyor he's sleeping. Surveyor observed R69 in bed on his left side with his arms crossed and eyes closed.On 1/22/26, at 1:56 p.m., Surveyor met with SW-S and SSD-R. Surveyor asked if SW-S could tell Surveyor about R69. SW-S replied he's been fine; we have conversations in the morning. Surveyor asked if R69 has ever voiced suicidal ideations. SW-S informed Surveyor he had a couple but not recently; they are just thoughts. R69 doesn't have any plan or intent, when R69 is in a lower mood he expresses them. Surveyor asked SW-S what she does for R69. SW-S replied I talk with him about any plans, if he has a plan, any intent. SW-S indicated they go through why R69 is having these thoughts. Surveyor asked SW-S what nursing does. SW-S informed they assess him and if they feel he may harm himself they would send him out. SSD-R informed Surveyor in R69's care plan there are a lot of problem statements and interventions used. R69 is followed by psych, and he comes to their office pretty regularly about his thoughts, his past thoughts, things that have happened in the past. We talk with him, and he's followed by our psych team. SSD-R informed Surveyor they have a new psychologist who saw him on 12/19/25 and yesterday (1/21/26) but they may not have received these notes. Surveyor asked if R69 has voiced any concerns regarding staff. SSD-R informed Surveyor she knows R69 recently had episodes with staying up late at night and will go over to the family room on the other side. They have been addressing the tv's volume. R69 complained about staff telling him to turn the tv down. SSD-R informed Surveyor she has an open grievance. Surveyor asked if there were any other issues. SSD-R informed Surveyor the only thing R69 mentioned was staff telling him he can't go behind the nurse's station. SSD-R informed Surveyor she told R69 that is correct. SSD-R informed Surveyor they are going to do education on resident's rights, R69 has the right to be over in the lounge, and review interventions with behavior. SSD-R explained R69 becomes verbally aggressive, swears at staff when situations like that arise. Surveyor then informed SW-S and SSD-R what R69 had said to Surveyor regarding the Alien movie. Surveyor informed SW-S and SSD-R, R69 had stated to Surveyor he told a staff member and asked if they were aware. SW-S stated to Surveyor no one has reported that to us. Surveyor then informed SW-S and SSD-R R69 had informed Surveyor after the incident with the alien movie R69 said he had suicidal thoughts which according to the nurse's notes R69 did on January 19th. SSD-R informed Surveyor she just saw the note. Surveyor asked SW-S and SSD-R if they were aware of R69's suicidal ideations on 1/19/26. SW-S informed Surveyor R69 didn't talk to them, and no one reported it. SSD-R informed Surveyor R69 has a history of suicidal thoughts, they talk to him, ask him about going to the hospital but he doesn't want to go. SSD-R informed Surveyor they will speak with R69 and R69 said someone knocked on the window. SSD-R stated I want to reinterview him in case I'm missing anything. Surveyor asked SW-S and SSD-R to get back to Surveyor tomorrow after they have spoken with R69.R69's social services note dated 1/22/26, at 15:37 (3:37 p.m.), written by Social Service Director (SSD)-R documents: SW (Social Worker) and SSD made aware of resident recently voicing thoughts of suicide. Resident has a history of voicing thoughts of suicide without any plan or intent. SW and SSD met with resident 1:1to further discuss and provide psychosocial support. When asked what he is feeling when he is having these thoughts, resident states, 'I just don't feel right when I have those thoughts. SS asked what it feels like overall, and he stated he feels like he is just existing and depressed. Reviewed interventions that were discussed with resident in the past such as talking with other staff, writing things down/journaling, listening to music or watching movies. Resident states he still does these interventions. When asked if he had any plan to harm himself or if he currently has any plan to harm himself, resident sated, no and in the sixteen months I have been here I have not had a plan or looked for anything to harm myself with. Resident is happy with the plan in place for when he has these thoughts. Resident is followed by psych at facility and has declined the last two visit attempts by psychologist for two weeks in a row, 1/14/26 and 1/21/26. SS encouraged resident to accept visits from psychologist to help him with depression and negative thoughts. SS to continue to follow and provide support.On 1/26/26, at 2:59 p.m., during the daily exit conference with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B Surveyor informed staff R69 has two documented episodes of suicidal ideation on 9/3/25 & 1/19/26 and Surveyor was unable to locate evidence R69's physician, psych services were notified and unable to locate what interventions were implemented. On 1/27/26, at 8:58 a.m., Surveyor asked DON-B if she had any additional information regarding R69's documented suicidal ideations. DON-B informed Surveyor she was not here on 9/3/25 as she started working at the facility in November. DON-B informed Surveyor she became aware of R69's 1/19/26 suicidal ideations on 1/22/26. Surveyor asked DON-B how she became aware. DON-B replied I was told by social services. DON-B informed Surveyor she believes the nurse on 1/19/26 is an agency nurse. DON-B informed Surveyor that the plan is for social service to follow up, they were doing one on one after with him. Surveyor asked what nursing did after R69 voiced the suicidal ideations. DON-B informed Surveyor she would have to check with first name of Licensed Practical Nurse/Unit Manger (LPN/UM)-U as that's her unit.On 1/27/26, at 9:09 a.m., Surveyors met with SW-S and SSD-R. SSD-R informed Surveyor they were not aware of R69's September suicidal thoughts. They became aware of R69's suicidal thoughts on 1/19/26 when Surveyor spoke to them on 1/22/26. Surveyor asked after they became aware of what they did. SSD-R informed Surveyor they went and met with R69, and they have been checking on him daily. SSD-R informed Surveyor she was at the facility over the weekend and R69 didn't have any suicidal ideations. SSD-R informed Surveyor they should have initiated one on one, called the doctor, and R69 wouldn't want any family called but they should have asked him when this happened. SSD-R informed Surveyor they have tried to send him to the hospital, but he has refused anytime it is brought up. A Surveyor asked if they would have called the crisis team. SSD-R indicated in the past they have called them and R69 has also called the crisis team. Surveyor asked after they became aware by the Surveyor of R69's suicidal ideations did they call psychiatric services. SSD-R replied no. SSD-R informed Surveyors that the psychologist has tried to see R69 for the past two weeks, but he has refused. A Surveyor asked if there is a contact in place for R69's suicidal ideation/behavior. SSD-R replied no. On 1/27/26, at 12:06 p.m., Surveyor informed LPN/UM-U she had written R69's nurses note on 9/3/25 regarding R69's suicidal ideations and inquired what was implemented after. LPN/UM-U informed Surveyor R69 was placed on the 24-hour board. Surveyor asked LPN/UM-U if R69 was placed on one-to-one observation. LPN/UM-U informed Surveyor she thought 15-minute checks. Surveyor informed LPN/UM-U R69's care plan intervention is to place R69 on one to one. LPN/UM-U replied oh. Surveyor asked LPN/UM-U for R69's fifteen-minute checks. Surveyor was not provided with these checks.No additional information was provided.

Based on interview and record review, the facility did not ensure that each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period and each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized for 2 of 5 (R9 and R35) residents reviewed for immunizations. Findings include:The facility policy titled Influenza Vaccination (which is not dated) documents:. It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from influenza by offering our residents, staff members and volunteer workers annual immunization against influenza.2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine.7. Individuals receiving the influenza vaccine or their legal representative, will be required to sign a consent form prior to the administration of the vaccine. The completed signed and dated record will be filed in the individual's medical record.9. The resident's medical record will include documentation that the resident and/or resident's representative was provided education regarding the benefits and potential side effects of immunization and that the resident received or did not receive the immunization due to medical contraindication or refusal.On 1/22/26 at 11:52 AM, Surveyor asked Infection Preventionist/Assistant Director of Nursing (IP/ADON)-E about the vaccination protocol. IP/ADON-E stated, Upon admit, there is a document nurses fill out asking about immunizations. If they want or consent, they are supposed to get an order, then normally I will see the order during morning meeting.R9 admitted to the facility on [DATE] with diagnoses that include muscle wasting and atrophy, protein-calorie malnutrition, immunodeficiency, chronic obstructive pulmonary disease, malignant neoplasm of sigmoid colon and chronic congestive heart failure.Review of R9's medical record revealed a consent for the influenza and pneumonia vaccine signed 7/2/25. Per WIR (Wisconsin Immunization Records) pneumonia vaccine was completed. Surveyor could not locate evidence the influenza vaccine was offered or given.R35 admitted to the facility on [DATE] and has diagnoses that include chronic obstructive pulmonary disease, asthma and chronic respiratory failure with hypoxia.Review of R35's medical record revealed a consent for the influenza vaccine signed 12/18/25. Surveyor could not locate evidence the influenza vaccine was offered or given.On 1/26/26 at 10:25 AM, Surveyor spoke with IP/ADON-E about the above immunizations. IP/ADON-B reported she spoke with R9 today about receiving the flu vaccine and he refused. IP/ADON-E reported R35's flu vaccine was not given and will be given today. Surveyor advised IP/ADON of concern consents were signed in 2025 and there was no follow up until after Surveyor identified concern. IP/ADON-E stated, I understand the concern.On 1/26/26 at 3:11 PM, Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were advised of the concerns regarding the above immunizations. No additional information was provided.

Based on observation, interviews, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services to promote healing and prevent new injuries from developing for 1 of 2 (R3) residents reviewed for pressure injuries. R3's pressure injuries were not comprehensively assessed and treatment was not implemented timely. This deficient practice resulted in R3's development of a stage 3 pressure injury. Findings include: The facility policy titled Skin Assessment implemented 3/1/19 documents (in part) . . It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. 1. A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: Document type of wound. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). The facility policy titled Wound Management which was not dated, documents (in part) . .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. 5. Treatment decisions will be based on: Etiology of the wound, characteristics of the wound (pressure injury stage, size and volume/characteristic of exudate) and location of the wound. 7. Treatments will be documented on the Treatment Administration Record. R3 admitted to the facility on [DATE] and has diagnoses that include severe hypoxic ischemic encephalopathy, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with hypoxia, anoxic brain damage, Cerebral Infarction, Heart Failure, Major Depressive Disorder, spondylosis lumbosacral region, Hidradenitis Suppurativa, and Epilepsy. R3's Admission MDS (Minimum Data Set) dated 1/27/25 documents: Always incontinent of B&B (bowel and bladder) and dependent for toileting hygiene and bed mobility. The Care Area Assessment (CAA) documented: Is this resident at risk of developing pressure ulcers? Yes. Resident has one or more unhealed pressure ulcer(s) at stage 2 or higher, or one or more likely pressure ulcers that are unstageable at this time as indicated by: Number of stage 3 pressure ulcers = 1. Existing pressure ulcer/injury - assess location, size, state, presence and type of drainage, presence of odors, condition of surrounding skin. Extrinsic risk factors: Pressure, needs special mattress or seat cushion to reduce or relieve pressure. Maceration - Moisture Associated Skin Damage (MASD). Intrinsic risk factors: Altered mental status, cognitive loss, incontinence, poor nutrition. R3 has a care plan implemented for pressure injuries with appropriate interventions, but did not have an incontinence care plan implemented (Cross reference F690). R3's Clinical Admission note dated 1/23/25 documents: New skin issue. Location: Left gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 4 x 1.5 x 0 cm (centimeters). Left gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 2.5 x 1 x 0 cm. Left gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 1 x 1 x 0 cm. Left gluteus open lesion, present on admission 0.7 x 0 cm. Right gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 3.5 x 1 x 0 cm. Coccyx - Moisture Associated Skin Damage (MASD) 7 x 1 cm. Surveyor review of R3's January 2025 Treatment Administration Record (TAR) revealed no treatment was implemented for R3's pressure injuries or MASD when identified on 1/23/25 until 5 days later, after R3 was seen by the wound physician. On 1/27/25 (4 days after admission to the facility), R3 was seen by (name of medical group) Wound Physicians. The initial wound evaluation and management summary documented: Patient presents with wounds on her coccyx, bilateral buttocks. Focus wound exam site 1: Stage 3 pressure wound coccyx full thickness 5.7 x 0.8 x 0.1 cm. Moderate serosanguineous exudate. 20% thick adherent devitalized necrotic tissue. 40% slough. 40% granulation tissue. Surgical excisional debridement procedure: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 2.74 cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a dept of 0.2 cm and healthy bleeding tissue was observed. Dressing treatment plan: Leptospermum honey with foam border apply once daily. Focus wound exam site 2: Non-pressure wound of the bilateral buttock, partial thickness. MASD 14.3 x 13 x 0.1 cm. Surface area 185.90 cm. Light serosanguineous exudate. Open areas with exposed dermis. Dressing treatment plan: House barrier cream apply Q (every) shift (3 times a day) and as needed for 30 days. Surveyor noted R3's clinical admission note dated 1/23/25 documented several stage 2 pressure injuries and MASD to her coccyx. No treatment was implemented. On 1/27/25, the wound physician identified a stage 3 pressure injury to her coccyx which required mechanical debridement. R3 was hospitalized for a change in condition on 1/30/25 and readmitted to the facility on [DATE]. R3's Clinical Admission note (entered by a Licensed Practical Nurse that no longer works for the facility) dated 2/5/25 documents: Skin issues have not been evaluated. Surveyor noted the documentation and measurements of R3's open areas were the same as previously documented on R3's 1/23/25 Clinical Admission note, including coccyx MASD 7 x 1 cm, even though R3 had a stage 3 pressure injury to her coccyx identified on 1/27/25. Surveyor review of R3's February 2025 TAR revealed no treatment was implemented for R3's pressure injuries upon readmission to the facility on [DATE]. Only house barrier cream to sacrum/coccyx was implemented on 2/7/25, which is not an appropriate treatment for stage 3 pressure injury. On 2/10/25, (5 days after readmission to the facility), R3 was seen by (name of medical group) Wound Physicians. The wound evaluation and management summary documented: Patient has wounds on her coccyx, right buttock. Focus wound exam site 1: Stage 3 pressure wound coccyx full thickness. 5.6 x 7.4 x 0,1 cm. Moderate serosanguineous exudate. 20% thick adherent devitalized necrotic tissue. 40% slough. 40% granulation tissue. Wound progress exacerbated due to hospitalized . Surgical excisional debridement procedure: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 24.86 cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a dept of 0.2 cm and healthy bleeding tissue was observed. Dressing treatment plan: Leptospermum honey with foam border apply once daily. Focus wound exam site 2: Non-pressure wound of the left buttock partial thickness. MASD. Wound size 8 x 1 x 0.1 cm. Surface area 8.00 cm. Moderate serous exudate. Open areas with exposed dermis. Dressing treatment plan: Leptospermum honey with foam border apply once daily. Focus wound exam site 3: Non-pressure wound of the left buttock partial thickness. MASD. Wound size 7.5 x 4.5 x 0.1 cm. Surface area 33.75 cm. Moderate serosanguineous exudate. Open areas with exposed dermis. Dressing treatment plan: Leptospermum honey with foam border apply once daily. The wound physician notes on 2/10/25 documented R3's wound progress exacerbated due to hospitalization , however Surveyor noted R3's wounds were not comprehensively assessed and measured upon readmission to the facility on [DATE] and no treatment was implemented. R3's clinical admission note dated 2/5/25 documented R3's skin issues have not been evaluated and listed the same information and measurements as on the 1/23/25 clinical admission notes (including MASD to the coccyx even though she had a previously identified stage 3 pressure injury to her coccyx). On 2/7/25, house barrier cream was implemented and not the previously ordered treatment for the stage 3 pressure injury. On 2/10/25, when R3 was seen by the wound physician, the Stage 3 pressure injury to her coccyx had declined, was larger in size and required mechanical debridement. On 2/17/25, R3 was seen by (name of medical group) Wound Physician. The wound evaluation and management summary documented: Patient has wounds on her coccyx, right buttock, left buttock. Stage 3 pressure wound coccyx full thickness, non-pressure wound of left and right buttocks partial thickness. Surveyor noted there was no evidence of decline or increase in size of the wounds. The coccyx and right buttock wounds were debrided during this visit and appropriate treatment continued. On 2/24/25, (name of different medical group) physicians took over care of R3's wounds. Weekly assessments and appropriate treatments completed. As of 3/17/25, the coccyx stage 3 pressure injury measures 1.4 x 0.9 x 0.1 cm. Over 50% granulation with a scattered pattern of beefy red quality. Between 0-25% nonviable material of slough/fibrin. Bilateral buttocks red, blanchable, partial thickness skin breakdown to multiple small areas on bilateral buttocks. Improvement in overall surface area of wound openings and improvement to peri wound skin. On 3/17/25, Surveyor spoke with (different medical group name) Nurse Practitioner (NP)-F. NP-F reported R3 has a stage 3 pressure injury on her coccyx, which she was told was present on admission, and several partial thickness areas of MASD to bilateral buttocks. Surveyor asked what she thought was the cause of the MASD. NP-F stated, probably combination of wetness from incontinence and shearing. NP-F reported all areas are improving and she anticipates the coccyx to heal within the next couple of weeks. Surveyor asked if the facility implemented a check and change schedule related to incontinence. NP-F reported she did not know. Surveyor asked if R3's MASD is a result of wetness from incontinence, would she expect routine or more frequent checking/changing for incontinence. NP-F stated. Of course. I'm sure they have a protocol for weight shifting and skin care incontinence protocol. Surveyor asked if she has communicated the need for weight shifting and skin care/incontinence care. NP-F stated, I have, it would be in my notes. Surveyor confirmed NP-F's progress note dated 2/24/25 documents (in part) . HPI: The pressure ulcer is located on the coccyx and has been present for 5 weeks. The pressure ulcer was present on admission. According to the NPIAP (National Pressure Injury Advisory Panel) staging system, the pressure ulcer is classified as stage 3. Additional factors that contribute to non-healing include bed-bound status, bowel incontinence and bladder incontinence. Provider Comments document Prognosis: Guarded, dependent on offloading and moisture management. Discussed pressure relief and redistribution strategies. Patient is on an appropriate support surface for the patient to use when supine and should be on a weight shifting schedule and skin care/continence schedule per facility protocol. The balance of moisture is critical to wound healing. I have given caregivers instructions about managing skin moisture which include using a skin barrier and wicking agent. Patient wears an adult brief. Consider Foley catheter in future if urine management becomes a problem. R3 did not have an incontinence care plan implemented (Cross reference F690). On 3/18/25 at 9:00 AM, Surveyor met with Acting Director of Nursing (DON)-C to discuss concerns: R3 admitted to the facility with pressure injuries and MASD to her coccyx. Treatment was not implemented until 5 days later, after R3 was seen by the wound physician. At this time a stage 3 pressure injury was identified on her coccyx which required mechanical debridement of necrotic tissue and slough. R3 was readmitted following hospitalization on [DATE]. The facility did not complete a comprehensive assessment and measurements of R3's wounds and no treatments were implemented until 2 days later, which included only barrier cream and not the previously ordered (appropriate) treatment for stage 3 pressure injury. 5 days later, the wound physician documented R3's coccyx stage 3 pressure injury declined/was larger in size and required mechanical debridement of necrotic tissue and slough. Acting DON-C reported she will review information and see if there is any additional information to provide. No additional information was provided prior to survey exit. On 3/19/25 at 12:30 PM, Nursing Home Administrator (NHA)-A, Acting DON-C, and DON-B were advised of the above concerns.

Based on observation, interview, and record review the facility did not ensure 1 (R8) of 4 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal pressure injuries. R8 developed a facility acquired, unstageable pressure injury to their right great toe despite being at risk for the development of pressure injuries. R8's skin was not assessed upon admission and an individualized care plan was not developed based upon R8's risks and care needs. Assessments by the contracted wound care provider incorrectly identified the location of the wounds. Facility wound assessments were not comprehensive. Findings include: The facility's policy titled, Wound Management documents: . In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatment decisions will be based on: Etiology of the wound: Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous, diabetic, moisture or incontinence related skin damage. Surgical, Incidental, Atypical Characteristics of the wound: Pressure injury stage (or level of tissue destruction if not a pressure injury) Size - including shape, depth, and presence of tunneling and/or undermining. Volume and characteristics of exudate Presence of pain Presence of infection or need to address bacterial bioburden Condition of the tissue in the wound bed Condition of peri-wound skin Location of the wound Goals and preferences of the resident/representative Guidelines for dressing selection may be utilized in obtaining physician orders. The guidelines are to be used to assist in treatment decision making. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. The facility will follow specific physician orders for providing wound care. Treatments will be documented on the treatment administration record (TAR) The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: Lack of progression towards healing Changes in the characteristics of the wound. Changes in the residence goals and preferences, such as at end of life or in accordance with his/her rights. R8 was admitted to the facility on [DATE] and has diagnoses that include muscle wasting and atrophy, epilepsy, dysphagia, abnormalities in gait and mobility, dementia, adult failure to thrive, and peripheral vascular disease. R8's hospital discharge paperwork dated 11/27/24 documents R8 as having the following pressure injuries: Left great toe wound that is unstageable with eschar and necrotic tissue. Treatment orders include betadine on Monday, Wednesday, and Friday and to keep open to air. Right heel wound that is unstageable with eschar, skin intact, and necrotic. Treatment orders include paint with betadine, cover with gauze and secure with Kerlix dressing on Monday, Wednesday, and Friday. Surveyor notes the facility did not place treatment orders until 12/2/24. On 1/7/25, at 9:53 am, Surveyor interviewed Licensed Practical Nurse (LPN) - H who indicated nurses will typically get wound care orders from the hospital discharge paperwork with a newly admitted resident. LPN- H states they will call the hospital if they do not receive wound care orders and will also contact the facility provider for wound care orders. LPN- H states the facility nurse will contact the provider service (name of telehealth provider) for orders if it is after hours. LPN- H states every resident receives a comprehensive skin assessment by the facility nurse on the day of admission R8's facility admission medical records include a Clinical Admission assessment dated [DATE], identifying R8 as having a right heel wound present on admission that is painful. Surveyor notes there are no measurements, staging, or properties for the right heel wound on admission. Surveyor also notes the left great toe wound is not identified or documented by the facility on the Clinical Admission Assessment. Surveyor notes no comprehensive skin assessments being completed on admission on 11/27/24. R8's Admission Minimum Data Set (MDS) with an assessment reference date of 12/1/24 documents R8 is dependent with rolling left to right, chair and bed transfers, and shower/tub transfers. R8's MDS documents R8 as being at risk for pressure injuries and has one unstageable pressure injury and one Deep Tissue Injury (DTI). R8 was documented as having a Brief Interview for Mental Status (BIMS) score of 15 indicating R8 is cognitively intact. R8's care plan, dated 11/27/24, documents: A physical functioning deficit related to mobility impairment and self-care impairment (date initiated 11/29/24). Interventions include: (R8) requires a Hoyer lift with assistance of two for transfers (date initiated 11/29/24). (R8) requires total assistance for bed mobility (date initiated 11/29/24). (R8) has altered skin integrity with wounds to his left toe and right heel upon admission and wounds to his right toe. (R8) refuses to wear heel boots (date initiated 11/29/24). Interventions include: (R8) requires an air mattress (date initiated 11/29/24). Conduct weekly skin inspection (date initiated 11/29/24). (R8) will wear bilateral heel boots at all times. Staff will encourage (R8) to wear them (date initiated 12/19/24). Monitor for signs and symptoms of infection such as swelling, redness, warm discharge, odor, notify physician of significant findings (date initiated 11/29/24). Provide pressure reduction/relieving mattress (date initiated 11/29/24). Weekly wound evaluation (date initiated 11/29/24). Surveyor reviewed R8's Braden Scale's (a clinical tool used to assess a resident's risk for developing pressure injuries) which document the following: 11/27/24 R8 is high risk for developing pressure injuries. 12/4/24 R8 is at moderate risk for developing pressure injuries. 12/11/24 R8 is at high risk for developing pressure injuries. 12/25/24 R8 is at high risk for developing pressure injuries. 1/1/25 R8 is at moderate risk for developing pressure injuries. Surveyor noted R8's Braden Scales dated 12/4/24 and 1/1/25 document R8 is independent with rolling/moving in bed which is not reflected in R8's other assessments and impacted the overall score to assess R8's overall risk for developing pressure injuries with the Braden tool. Surveyor reviewed R8's medical record which documents a provider progress note dated 11/30/24, with wound care instructions to the right heel and left great toe. Surveyor notes orders were not present on R8's Medication Administration Record (MAR) or TAR until 12/2/24. On 12/2/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 6 cm x 3.8 cm x not measurable, with a surface area of 22.80 cm. 100% thick adherent black necrotic tissue (eschar) is present. Recommendations to apply betadine once daily and to off-load wound. *Unstageable right great toe DTI pressure injury that was noted on admission per staff. Measuring 1.3 cm x 1.8 cm x not measurable, with a surface area of 2.34 cm. Skin is intact with purple/maroon discoloration present. Recommendations to apply betadine once daily and off-load wound. Surveyor notes the hospital discharge documentation identified R8 as having unstageable pressure injuries on the right heel and left great toe at the time of discharge that were noted to have eschar present. There is no comprehensive assessment of the wounds by the facility to support the present upon admission statement. Additionally, it was not assessed upon admission that R8 had a pressure injury on their right great toe. Surveyor noted treatment orders were now initiated for R8 despite having recommended treatment orders since admission on 11/27/24. On 12/9/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 6 cm x 3.2 cm x not measurable, with a surface area of 19.20 cm. 100% thick adherent black necrotic tissue (eschar) present. Wound progress has improved evidence by decreased surface area. Recommendations to apply betadine once daily and to off-load wound. *Unstageable right great toe DTI pressure injury that was noted on admission per staff. Measuring 1.3 cm x 1.8 cm, x not measurable, with a surface area of 2.34 cm. Skin is intact with purple/maroon discoloration and wound progress at goal. Recommendations to apply betadine once daily and to off-load wound. Surveyor notes the wound care progress note for R8 documents the DTI was identified as the right great toe instead of the left great toe in error. *A new unstageable DTI of the right first toe pressure injury measuring 1.2 cm x 1.6 cm x not measurable with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Recommendations to apply betadine once daily and off-load wound. Surveyor notes this is a new facility acquired pressure injury for R8. Review of R8's care plan indicates no revisions were made to the care plan to help prevent further decline or development of pressure injuries to R8's toes. On 12/16/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 5.9 cm x 3.2 cm x not measurable, with a surface area of 18.88 cm. 100% thick adherent black necrotic tissue (eschar) present. Wound progress has improved as evidence by decreased surface area. Recommendations to apply betadine once daily and to off-load wound. Unstageable DTI of the right first toe pressure injury measuring 1.1 cm x 1.6 cm x not measurable, with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Duration of wound > 11 days. Recommendations to apply betadine once daily and off-load wound. *Unstageable left great toe DTI pressure injury that was noted on admission per staff. Surveyor notes the wound care progress note for R8 documents the DTI now being corrected to be the left great toe that was noted in the hospital discharge documents at the time of discharge from the hospital. This area measures 2 cm x 1.8 cm, x not measurable, with a surface area of 3.60 cm. Skin is intact with purple/maroon discoloration and wound progress is not at goal. Recommendations to apply betadine once daily and to off-load wound. Surveyor notes this wound is not at goal and measurements are greater than the previous week. The first facility wound assessment was completed on 12/18/24 by Licensed Practical Nurse (LPN)- O which documents R8 having a right heel wound that was present on admission. Surveyor notes there are no measurements or detailed characteristics assessed regarding the right heel wound. Surveyor also noted the left great toe and right first toe pressure injuries are not identified on the 12/18/24 facility skin assessment. Surveyor noted the facility skin assessment being completed by LPN- O with no registered nurse (RN) assessment. Surveyor noted this is the first facility wound assessment initiated by facility nursing staff despite R8 being admitted to the facility on [DATE]. Additional review of R8's medical record indicates the same assessment forms were documented dated 12/22/24, 12/29/24, and 1/5/25 which documented the same details as the 12/18/24 assessment completed by LPN-O. Surveyor noted the facility assessment sheets Surveyor noted these assessments were not completed upon current standards of practice and did not include a comprehensive assessment by an RN. Surveyor reviewed R8's TAR and noted missed wound care treatments on 12/19/24 and 12/20/24. On 12/23/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 5.9 cm x 3.2 cm x 0.1 cm, with a surface area of 18.88 cm. 90% thick adherent black necrotic tissue (eschar) and 10% granulation tissue present. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable DTI of the right first toe pressure injury measuring 1.1 cm x 1.6 cm x not measurable, with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Duration of wound > (greater than) 18 days. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable left great toe DTI pressure injury that was noted on admission per staff. Measuring 2 cm x 1.8 cm, x not measurable, with a surface area of 3.60 cm. Skin is intact with purple/maroon discoloration and wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. On 12/30/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 5.9 cm x 3.2 cm x 0.1 cm, with a surface area of 18.88 cm. 90% thick adherent black necrotic tissue (eschar) and 10% granulation tissue present. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable DTI of the right first toe pressure injury measuring 1.1 cm x 1.6 cm x not measurable, with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Duration of wound > 25 days. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable left great toe DTI pressure injury that was noted on admission per staff. Measuring 1.9 cm x 1.8 cm, x not measurable, with a surface area of 3.42 cm. Skin is intact with purple/maroon discoloration and wound progress is improved as evidenced by decreased surface area. Recommendations to apply betadine once daily and to off-load wound. On 1/7/25, at 8:32 am, Surveyor observed R8 laying on his back in bed with his head of the bed up approximately 45 degrees. R8 was sleeping and appeared to be comfortable with his heels resting directly on the bed and not off loaded. Surveyor observed R8's blankets to be resting directly on top of his toes and heel boots were observed on a shelf across the room. On 1/7/25, at 9:16 am, Surveyor interviewed R8 who stated he does not like wearing his heel boots due to pain. R8 indicates the heel boots cause him a lot of pain. R8 was noted to have his heels resting directly on his bed with his blankets directly on his toes. On 1/8/25, at 9:15 AM, Surveyor observed R8's wound care with LPN- D. Surveyor entered the room and R8 was observed lying in bed on his back with head of bed up approximately 45 degrees. R8's heels were observed to be floated with a pillow and blankets laying directly across R8's toes and feet. R8's right great toe revealed a dime size necrotic/black area on the tip of the toe, slightly medial, with no redness to the surrounding area and no odor. R8's left great toe revealed a nickel sized necrotic/black area on the tip of the toe with no redness to the surrounding area and no odor. R8's left heel displayed no redness and no signs or symptoms of pressure injury. R8's right heel revealed a large necrotic/black area on the back of the heel. The black area extended to the lateral side of the heel to the achilles area. Surveyor observed LPN- D applied betadine to R8's right heel, left great toe, and right great toe. On 1/8/25, at 9:46 am, Surveyor interviewed Director of Nursing (DON)- B and Assistant Director of Nursing (ADON)- C regarding concerns with R8's pressure injuries. Surveyor discussed R8 was admitted to the facility on [DATE], with no comprehensive skin assessment on admission, R8 did not have wound care treatment orders implemented until 12/2/24, and R8 developed a facility acquired DTI to his right first toe. Surveyor discussed R8's contracted wound care assessments documenting inaccurate pressure injury sites on 12/2/24 and 12/9/24. DON-B and ADON-C acknowledged the contracted wound care provider had inaccurately documented their assessment indicating the wrong toe/location on R8. Surveyor asked about R8's facility skin assessments not identifying R8's DTIs to his right great toe and left great toe, and all of R8's facility skin assessments being completed without an RN assessment. No additional information or clarification was provided at this time by DON-B or ADON-C. DON- B and ADON- C understood the concerns and had no additional information.

Based on interview and record review, the facility did not implement their written policies and procedures to prohibit and prevent abuse, for 1 CNA (Certified Nursing Assistant)-GG of 1 CNA reviewed who was involved in an allegation of sexual assault against 1 (R10) of 1 residents who alleged sexual assault. The deficient practice has the potential to affect a pattern of the 69 residents residing in the facility as the staff on night shift float to assist on other units. CNA-GG's BID (background information disclosure) form, completed by CNA-GG upon hire at the facility, was completed inaccurately as CNA-GG answered no for the question, Were you ever convicted of any crime anywhere including in federal, state, local, military and tribal courts? The facility did not verify the positive results of the DOJ (Department of Justice) background check (which identified a fourth-degree sexual assault conviction) against the results of the BID, completed by CNA-GG, to identify CNA-GG had inaccurately completed the BID form. The facility also did not obtain references for CNA-GG as part of the hiring process to accurately screen potential employees for a history of abuse, neglect, exploitation, or mistreatment of residents. The lack of thorough screening of CNA-GG by the facility before hiring allowed R10 to be cared for by CNA-GG resulting in R10 alleging CNA-GG sexually assaulted her. The facility failure to ensure CNA-GG's BID form was completed accurately by verifying the positive results of the DOJ background check against the results of the completed BID allowed CNA-GG to care for R10, subsequently resulting in R10 alleging sexual assault by CNA-GG. This created a finding of immediate jeopardy that began on 6/11/24. On 7/15/24, at 4:34 PM, Nursing Home Administrator-A was informed of the immediate jeopardy. The immediate jeopardy was removed on 7/17/24. However, the deficient practices continue at a scope and severity of an E (potential for harm/pattern) as the facility continues to implement and monitor its action plan. Findings include: The facility's policy titled, Abuse/Neglect/Exploitation and not dated under the components of the facility abuse prohibition plan are discussed herein for I Screening documents: A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency, or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. On 6/27/24, at 9:00 a.m., Surveyor reviewed CNA-GG's personnel file. Included in CNA-GG's personnel file was a BID (Background information disclosure) form completed by CNA-GG on 2/29/24. Under section A. Acts, Crimes, and Offenses that may act as a bar or restriction, No is checked for Were you ever convicted of any crime anywhere, including in federal, state, local, military, and tribal courts? State of Wisconsin Department of Justice (DOJ) report dated 3/1/24, includes a charge of 4th degree sexual assault with a conviction date of 10/17/94. There is no documentation in CNA-GG's personnel file as to why CNA-GG answered no to the aforementioned question and if he was questioned about not answering the question truthfully when he was convicted of 4th degree sexual assault. In addition, there are no references noted prior to hire or documentation as to where references were sent to in order to complete a reference check. On 6/27/24, at 1:57 p.m., Surveyor asked BOM (Business Office Manager)-KK if he was responsible for HR (Human Resources). BOM-KK replied, now I am and explained the previous person left the end of May. Surveyor asked about the hiring process. BOM-KK informed Surveyor with the application they will have the BID, DOJ (Department of Justice), and IBIS (Integrated Background Information System) checks. Surveyor inquired if they request references. BOM-KK informed Surveyor they do. BOM-KK looked in CNA-GG's personnel file and informed Surveyor it doesn't look like any were completed for him. Surveyor asked BOM-KK if references were completed would they be in the personnel file. BOM-KK replied they would. Surveyor asked BOM-KK for any hiring policies. One of the residents CNA-GG cared for was R10. R10's diagnoses include right and left above knee amputation, hemiplegia and hemiparesis following cerebral infarction affecting left non dominate side, anxiety disorder, and depression. The quarterly MDS (minimum data set) with an assessment reference date of 4/9/24 has a BIMS (Brief Interview for Mental Status) score of 13 which indicates cognitively intact. R10 is assessed as not having any behaviors. R10 is assessed as being dependent for toileting, hygiene, & chair/bed to chair transfer, and partial/moderate assistance for rolling left and right. R10 is always incontinent of bladder and bowel was not rated. R10's BIMS dated 6/18/24 has a score of 8 which indicates resident has a moderate cognitively impairment. Surveyor noted this is a decline in R10's cognitive status. The alleged nursing home resident mistreatment, neglect, and abuse report documents the date occurred as 06/11/2024, time occurred documents 08:00 PM, date discovered is documented as 6/12/2024. Brief summary of incident documents: Resident stated aide came into her room last night and sexually abused her. Resident stated he forced his hands inside her private area and forced her hand on his private area. Surveyor noted the investigation included an interview with R10 which documents: On 6/12/24 patient [R10's first name] Notified SW (Social Worker) that a staff member touched her inappropriately. SW asked patient to provide a bit more information. SW asked patient the following question, Can you tell me exactly what happened. Last night 6/12/24 a worker came in carrying towels, when he came into my room and he asked me did you miss me, [R10's first name] responded saying how can I miss you I don't know you. He came closer and started to touch my leg and then he put his finger in my private part pushing in and out. When he touched me, He said it feels good, you like it, you wanna ride that? He grabbed my hand and put it on his private part and rubbed it up and down. After he was done, he did not say anything he just walked out of the room. Patient reports that she yelled out for help, but nobody came in. He did not yell, he talked to me in a normal tone when this happened. For the question can you describe the person who did this? Patient responded that he was a Black guy, skinny guy he said his name was [CNA (Certified Nursing Assistant)-GG first name]. Did you report the alleged abuse? Patient states she attempted to notify staff after the alleged abuse, but staff did not come in. Patient reported the abuse to social worker at about 8:45 am on Wednesday morning: SW immediately notified DON (Director of Nursing), the police, and POA (Power of Attorney). The late entry note dated 6/12/24, at 11:00 (11:00 a.m.), documents: Met with resident to complete body check, check unremarkable. Resident cooperative without signs of distress, no emotional distress noted during conversation. Voiced wanting to eat lunch. Verbalized understanding why the body check was being performed and voiced being fine. No ill effects noted. Will continue to monitor. Resident being sent out for ER (emergency room ) evaluation per request of POA (power of attorney). Resident not avoiding conversations, no displays of fear, does not shy away from being touched, no angry outbursts, tearfulness or stress noted. This nurses note was written by DON (Director of Nursing)-B. The Social Services note dated 6/13/24, at 18:47 (6:47 p.m.) documents SW (Social Worker) completed daily check in, patient states she is doing well, but feeling a bit down. SW will follow up with BCS (Behavioral Care Solutions) to follow up with patient. SW provided patient with wash towel as to support with comfort as patient prefers to have 2 wash cloths. CNA (Certified Nursing Assistant) also readjusted patient position. Patient states she is comfortable and does not have any further needs at this time. This social services note was written by SS (Social Services)-E. The Social Services note dated 6/14/24, at 16:45 (4:45 p.m.), documents: SW completed daily check in, patient was sleeping most of the day. SW asked patient if she was feeling okay, patient reports feeling tired. Patient stated she is doing well and has no concerns at this time. This social service note was written by SS-E. Psychologist's note dated 6/18/24 under history of present illness includes documentation of . [R10's first name] is concerned that she might have nightmares, as a result of the alleged assault. [R10's first name] denies that she is currently having nightmares, and states Nothing is worrying me. [R10's first name] has a history of SI (suicidal ideation's) and attempts. All staff should be made aware of this. Suicidal ideation is not uncommon in survivors of sexual assault. Following our meeting, this writer met with the SW, the DON, and the ADON (Assistant Director of Nursing). Her care plan was amended at that time, to reflect current concerns. Staff should refer to case plan, dated 6/18/24. [R10's first name] is oriented times three, and continues to benefit from individual, supportive psychotherapy. The Social Service note dated 6/19/24, at 16:37 (4:37 p.m.), documents: SS check in - SW completed check in with patient; patient states she is doing well. patient appears calm and resting well. This social service note was written by SS-E. The Social Services note dated 6/24/24, at 11:43 (11:43 a.m.), documents: SW completed daily check in, patient states she is okay. Patient states she is comfortable and does not need anything at this time, SW will follow up with patient tomorrow. This social service note was written by SS-E. The Social Services note dated 6/25/24, at 16:16 (4:16 p.m.) documents: SS check in-SW completed check in with patient to discuss how she is feeling, patient states she is doing (sic) feeling a little sad today and was crying, patient states she had a bad dream. [Name] from BCS is aware of patient current mood. [Name] will visit again the following week as plan of care. [Name] has requested a call if patient needs follow up sooner. This social service note was written by SS-E. On 6/26/24, at 11:35 a.m., Surveyor observed R10 in bed on her back. Surveyor informed R10 Surveyor would like to talk with her and was sorry for the questions Surveyor may have to ask. R10 informed Surveyor, Surveyor was about the 10th person that has come in to talk to her. R10 informed Surveyor someone came in and touched her. Surveyor asked R10 if she remembers the name of the person. R10 replied I told them. R10 then informed Surveyor of CNA-GG's first name. Surveyor asked R10 why CNA-GG came into her room. R10 replied, I don't know why he wanted to touch me. Surveyor asked where CNA-GG touched her. R10 replied, in my private parts and then he put my hand between his legs in his pants and wanted me to go up and down. He said he enjoyed that. Surveyor asked R10 if CNA-GG had been in her room before. R10 replied, I don't remember, they don't have enough staff here. Surveyor asked when CNA-GG was in the room did anyone else come in? R10 replied, I don't think so, I called for help, and no one responded. Surveyor informed R10 Surveyor was terribly sorry for what she had to go through. R10 replied, what can I do, you can do nothing. On 6/26/24, at 12:26 p.m., Surveyor met with SS (Social Services)-E. Surveyor informed SS-E Surveyor had noted multiple notes she had written regarding daily checks with R10 and inquired about these daily checks. SS-E informed there was an incident that occurred, so she has been checking in on R10 to ensure she is not having ill effects from the incident that occurred. Surveyor inquired what the incident was. SS-E informed Surveyor an allegation of sexual assault. Surveyor inquired how she became aware of this. SS-E informed Surveyor R10 reported it to her. Surveyor asked SS-E when R10 reported this to her. SS-E informed Surveyor R10 has behaviors of yelling out so when R10 yells out she goes in and checks on R10 as her office is next to R10's room. SS-E informed Surveyor she went into R10's room and said Hey [first name of R10] what's going on. R10 said she was not well. SS-E indicated she asked R10 what do you mean? R10 said she had a terrible night. SS-E asked what happened. R10 informed her a worker put his fingers in her private parts and pushed his fingers in and out and then he grabbed her hand and had her rub his private parts up and down. SS-E informed Surveyor she immediately stopped R10 and asked R10 if she could give her a second as she needed to report this to the DON (Director of Nursing). DON-B informed her they needed to start an investigation and since R10 was comfortable with her DON-B gave her some questions to ask R10. SS-E informed Surveyor one of the follow up questions was could R10 give her a description of the person. SS-E informed Surveyor R10 actually gave her a name and description. SS-E informed Surveyor she went to DON-B who was with the scheduler to get the schedule and SS-E gave DON-B the name of the staff R10 had given her. SS-E informed Surveyor this person was on the schedule. Surveyor asked SS-E if R10 had ever voiced a concern like this in the past. SS-E replied no. Surveyor asked what she could tell Surveyor about R10. SS-E informed Surveyor she was born in [name of country] and her husband travels back & forth to this country, she has an activated POA (Power of Attorney,) if you ask R10 a question R10 will answer but is a very private person. SS-E informed Surveyor when this happened R10 was able to talk about the incident but when she told R10 she needed to call her son, the POA, SS-E stated R10 broke down & cried and said she was embarrassed. SS-E informed Surveyor R10 has been consistent in her story, thinks R10 is truthful but in her heart prays it wasn't true. SS-E informed Surveyor R10 does not complain or make up stories but will yell out. SS-E explained when R10 yells out she wants ice water, her call light fell on the floor, needs cough drops, or wants two washcloths. SS-E informed Surveyor R10 is very consistent with her needs. On 6/28/24, at 11:21 a.m., Surveyor observed R10 in bed on her back. Surveyor informed R10, Surveyor doesn't want to ask her about the details of what happened to her again but would like to ask her a couple more questions. R10 replied, you can ask whatever you like, that's your job, I don't have a problem, only problem is I don't have legs. R10 then informed Surveyor of the incident with CNA-GG repeating the same details as she had told Surveyor previously. Surveyor asked R10 if she feels safe here. R10 replied, yeah, they said they got the guy, he worked here, and they fired him. R10 then informed Surveyor the police were here with pictures asking if she recognized him. R10 stated, I'm scared he will come again. Surveyor asked R10 if she has felt sadder or upset. R10 replied no, just scared that will happen again because he said he would be back. On 7/1/24, at 7:08 a.m., Surveyor observed R10 in bed on her back. Surveyor spoke with R10 asking how she was doing. R10 stated, I want to kill myself. Surveyor informed R10 Surveyor would be back. Surveyor went out into the hallway and informed LPN (Licensed Practical Nurse)-K what R10 had said to Surveyor. LPN-K then went right into R10's room. On 7/1/24, at 9:36 a.m., BOM-KK informed Surveyor they don't have a hiring policy but use a new hire check-off list. BOM-KK provided Surveyor a copy of this new hire check-off list. Surveyor noted the check list includes application, offer letter, send BID check to HR resolution, review background check, background check if any convictions, administrator review, and reference check. On 7/1/24, at 10:52 a.m., Surveyor observed R10 wearing a hospital gown in bed. R10 informed Surveyor she just got back from the hospital and stated they took care of me. On 7/1/24, at 1:12 p.m., Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above. The facility's failure to implement their policies and procedures including ensuring CNA-GG's Background Information Disclosure (BID) form was accurate by verifying the positive results of the DOJ background check against the results of the completed BID allowed CNA-GG to provide cares for a vulnerable resident, resulting in that resident alleging sexual abuse by CNA-GG. This failure created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy. The immediate jeopardy was removed on 7/17/24 when the facility completed the following: -Education to Human Resources (HR) personnel regarding proper review of information submitted on BID and review of background checks along with reference checks are completed prior to staff being hired. Education will include interventions to be put into place for individual concerns. -All staff will be educated to ensure all staff know and respond to residents calling out for help, not just staff assigned to the resident. -Policies related to onboarding staff have been reviewed on 7/1/24 with the corporate HR Director. Policies reviewed include checking background information and reference prior to staff being hired. The nurses review with the CNA what their assignments are related to cares, showers, etc. Throughout the day the nurse verify that the duties were completed. -All nursing staff will be trained regarding their responsibility related to supervision on the unit and what it entails. Assignments will be made by the nurse on the unit and audited by the manager overseeing that unit weekly. Any supervision or education that is required as a result of the background check the administration will be responsible for education, training and assigning. -Abuse policy was reviewed, language related to staff calling out for help and expected response from staff to ensure not just staff assigned to the resident respond was added on 7/15/24 and reviewed with Regional Consultants. -Above reviewed with the Medical Director on 7/15/24. -The administrator will conduct audits on all staff hired for 3 months to ensure onboarding has been properly completed prior to staff being hired. -Random audits will be conducted by the DON and administrator or designee daily x 2 weeks then weekly x 8 weeks, then monthly x3 months to ensure staff can verbalize steps to take when residents are calling out for help. -Both audits will be reviewed at the QA meeting for further recommendations.

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 and the resident's choices for 1 (R6) of 3 residents. R6 did not have a CBC (complete blood count) & BMP (basic metabolic panel) during the week of 5/19/24 to 5/25/24 according to physician orders. CNAs (Certified Nursing Assistants) documented 14 episodes of loose, watery, diarrhea stools starting 5/25/24. On 5/28/24, Imodium 2 mg (milligram) was ordered every six hours as needed. Also on 5/28/24, NP (Nurse Practitioner) recommended Metamucil for R6. An order wasn't obtained until 5/30/24 two days later for psyllium husk powder (an ingredient in Metamucil.) The facility did not comprehensively assess R6's bowels and a stool sample was not obtained to rule out an infectious process. On 6/4/24, R6 was discharged from the facility to a family member. The family member transported R6 to the hospital where in the emergency room R6 was diagnosed with dehydration, C-Diff (Clostridioides difficile), and a Urinary Tract Infection (UTI). Findings include: R6 was admitted to the facility on [DATE] and discharged on [DATE]. R6 did not have an activated healthcare power of attorney. R6's diagnoses includes urinary tract infection, severe protein calorie malnutrition, hypertension, and rheumatoid arthritis. The physician orders include an order dated 5/15/24 which documents CBC (complete blood count), CMP (comprehensive metabolic panel) x (times) 1, CBC, bmp (basic metabolic panel) weekly. Surveyor noted a CBC and CMP was collected on 5/17/24 and a CBC and BMP was collected on 5/30/24. Surveyor was unable to locate a CBC & BMP was collected during the week of 5/19/24 to 5/25/24. On 7/1/24, at 9:47 a.m., Surveyor asked LPN/UM (Licensed Practical Nurse/Unit Manager)-F when the lab comes into the facility. LPN/UM-F informed Surveyor Tuesday and Fridays but labs can be ordered any day of the week. Surveyor informed LPN/UM-F Surveyor was unable to locate a CBC & BMP during the week of 5/19/24 to 5/25/24 according to physician orders. LPN/UM-F informed Surveyor R6 refused one lab. Surveyor informed LPN/UM-F Surveyor did not note any documentation regarding refusal of a lab. LPN/UM-F informed Surveyor it may be on the lab form. Surveyor asked LPN/UM-F to provide this form to Surveyor. On 7/1/24, at 11:01 a.m., LPN/UM-F informed Surveyor labs for the week (5/19-5/25/24) there was an issue with drawing labs as the lab didn't have staff. The NP (nurse practitioner) was made aware and ended up drawing labs the next week. Surveyor asked LPN/UM-F when was the NP notified as Surveyor did not note any documentation regarding this. On 7/1/24, at 11:06 a.m., Surveyor called [name of ] lab and spoke with LR (lab representative)-O on the telephone. Surveyor inquired during the week of 5/19/24 to 5/25/24 if they didn't have staff available to draw a CBC & BMP at [name of] facility. LR-O informed Surveyor they have staff 24-7 and informed Surveyor she knows a couple times they had a break of service as they did not pay their bills. LR-O asked Surveyor for the name of the resident who did not have their lab work, which Surveyor provided. LR-O informed Surveyor they had a break of service as the facility was not paying their bills and services were stopped. The admission MDS (minimum data set) for R6 with an assessment reference date of 5/18/24 has a BIMS (Brief Interview for Mental Status) score of 12 which indicates moderate cognitive impairment. R6 is assessed as requiring partial/moderate assistance for toileting, hygiene, chair/bed to chair transfer, and toilet transfer. R6 is assessed as always continent for urine and bowel. The functional abilities (Self-Care and Mobility) CAA (care area assessment) dated 5/20/24 under analysis of findings for nature of problem/condition documents: Res (Resident) recent decline due to UTI (urinary tract infection) and dizziness. Daily antianxiety, ABT (antibiotic)-UTI. SOB (shortness of breath) when flat per MAR (medication administration record), moisturizer to extremities. Therapy ppoc (per plan of care). Skin and pain monitored. Pressure reducing devices in place. Assist w (with) ADLs (activities daily living). The physician functioning deficit care plan initiated 5/16/24 includes an intervention of, I require mod (moderate) assist x (times) 1 to complete toileting. Initiated 5/16/24. The alteration in elimination of bowel and bladder Constipation, History of UTIs initiated 5/20/24 documents the following interventions: * Monitor and report S&S (signs and symptoms) of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain. Initiated 5/20/24. * Monitor bowel status frequency. Initiated 5/20/24. * Provide easy access to clothing. Initiated 5/20/24. APNP (Advanced Practice Nurse Prescriber)-R's note dated 5/17/24 under review of systems includes documentation of Gastrointestinal: Positive for diarrhea (last couple days.) Negative for abdominal distention and abdominal pain. APNP-R's note dated 5/22/24 documents 5/22 follow up visit with patient today, family at bedside. She had a care conference today. Plan is for patient to go home after rehab, ALF (assisted living facility) has been recommended by therapy. She denies pain, cp (chest pain), sob (shortness of breath) or other concerns. States diarrhea has resolved. Family trying to fix and get battery in to her hearing aid. She is anxious to go home. Denies new concerns at this time. APNP-R's note dated 5/28/24 documents: 5/28 follow up visit with patient today, states over the weekend had some diarrhea. Today it was loose so she felt it was getting better. States she thought she received something this am (morning), but didn't know what it was. No antidiarrheal on med (medication) list. Will add prn (as needed) imodium if needed, later received msg (message) from nursing stool loose, not watery and mucous noted. Will add Metamucil as well. Continue to monitor BMs (bowel movements). Patient is eating and drinking fluids ok . Under review of symptoms documents: Gastrointestinal: Positive for diarrhea (vs soft stools). Negative for abdominal distention and abdominal pain. Under assessment and plan documents: For loose stool plan to add Metamucil 1 packet daily and imodium 2 mg (milligrams) 4 times daily as needed for diarrhea. The physician order dated 5/28/24 documents Imodium A-D oral capsule 2 mg (Loperamide HCI) Give 1 capsule by mouth every 6 hours as needed for diarrhea and dated 5/30/24 Psyllium Husk Powder (Psyllium Husk (Bulk)) Give 1 Tbsp (tablespoon) by mouth one time a day for Digestive Health. Surveyor noted there was a 2 day delay in ordering Psyllium Husk (Metamucil) for R6. The initial cardiac progress note dated 5/29/24 by NP (Nurse Practitioner)-S under history of present illness includes documentation of: Resident was examined resting in her room in her wheelchair today. She is extremely hard of hearing and anxious. She reports a 3 day history of diarrhea with no other symptoms. She denied the following cardiac symptoms including dizziness, visual disturbances, chest pain, chest pressure or tightness, palpitations, shortness of breath, PND (paroxysmal nocturnal dyspnea), lower extremity edema or syncope. There are no nursing concerns at this time. The nurses note dated 5/30/24, at 12:18, under gastrointestinal includes documentation of: Date of last BM (bowel movement): 5/30/24 Bowel movement appearance: WNL (within normal limits). Gastrointestinal Note: Resident started on Metamucil for digestive health. Bowel sounds x 4 quads with soft non-dist (distended) ABD (abdomen). Resident denies constipation or pain upon palpation. Stools noted to be very soft. This nurses note was written by LPN/UM (Licensed Practical Nurse/Unit Manager)-F. APNP-R's note dated 6/3/24 documents: 6/3 visit with patient today. Denies cp, sob, or new concerns. She states she believes she is still having diarrhea, she pulled down her brief to look and there was a mix of loose stool and some formed, (incontinent) she had new underwear in room but requested pull ups. Stool appeared dark brown, darker than previous seen, writer did an poc (bed side) occult blood test which was negative. She denies abdominal pain, nausea/vomiting. Per nursing she is declining nutritional supplements. She states she has not received her Metamucil or imodium, writer discussed with nursing to make sure she gets this today. The nurses note dated 6/4/24, at 13:46 (1:46 p.m.), documents Pt (patient) d/c (discharged ) from facility about 1345 (1:45 p.m.) via private transportation with daughter and son. VSS (vital signs stable). No SS (signs symptoms) distress. Denies SOB. All remaining meds were provided. Discharge med list and paperwork all explained to Pt and family by writer and [Name]; daughter verbalized understanding in her own words. Pt left the facility alert, orientated, and stable. This nurses note was written by LPN-U. The hospital ED (emergency department) note dated 6/4/24 documents [R6's first name] is a nontoxic-appearing [AGE] year-old female who presents with concerns for diarrhea and generalized weakness. Vitals were AFVSS (afebrile vital signs stable) throughout care. Differential was broad and included but was not limited to C. difficile, UTI, electrolyte abnormalities, AKI (acute kidney injury) and many other etiologies. C difficile was positive and her UA (urinalysis) appeared infectious. CBC was remarkable for a leukocytosis without anemia. CBC showed normal electrolytes and kidney function. She was treated with a liter bolus, oral vancomycin, and ceftriaxone for her dehydration, UTI, and C. difficile. We attempted to ambulate her and she was only able to take a few steps without assistance. The patient, her daughter, and I discussed admission for UTI and C. difficile treatment in additional to potential PT/OT (physical therapy/occupational therapy) and help with finding a safe discharge plan for her as they noted she would be going home by herself with no one to help care for her long term. They were amenable to this plan and she was admitted to the medicine service without incident. On 6/26/24, at 2:27 p.m., Surveyor showed CNA (Certified Nursing Assistant)-Q R6's picture and asked CNA-Q if she remembered R6. CNA-Q replied yes. Surveyor asked CNA-Q if she assisted R6 with using the bathroom. CNA-Q replied yes. Surveyor asked CNA-Q if R6 had diarrhea when she was at the facility. CNA-Q informed Surveyor she didn't remember and then stated they all have diarrhea. On 6/27/24, at 7:50 a.m., Surveyor received R6's bowel records and noted the following: 5/25/24 day shift continent, medium, loose/watery/diarrhea. 5/26/24 day shift incontinent, large, loose/watery diarrhea and night shift continent, medium, loose/watery/diarrhea. 5/27/24 evening shift continent, medium, loose/watery/diarrhea. 5/28/24 day shift continent, large, loose/watery/diarrhea. 5/29/24 evening shift incontinent, medium, loose/watery/diarrhea. 5/30/24 day shift incontinent, large, loose/watery/diarrhea. 5/31/24 day shift incontinent, large, loose/watery/diarrhea and evening shift incontinent large loose/watery/diarrhea. 6/1/24 day shift continent, large, loose/watery/diarrhea and evening shift incontinent medium loose/watery/diarrhea. 6/2/24 day shift incontinent medium, loose/watery/diarrhea and evening shift incontinent medium loose/watery/diarrhea. 6/3/24 day shift incontinent, medium, loose/watery/diarrhea. Surveyor noted the CNAs documented 14 episodes of loose/watery/diarrhea bowel movements. On 6/28/24, at 11:07 a.m., Surveyor asked PTA (Physical Therapy Assistant)-T if R6 complained about diarrhea while in therapy. PTA-T informed Surveyor she would complain of loose stool at times and for a period of time her participation decreased because of it. PTA-T explained they would modify her treatment if she wasn't feeling well but R6 would still receive therapy. Surveyor inquired if she received therapy in the therapy department or in her room. PTA-T informed Surveyor R6 would come to the therapy aside from the time when she was having loose stools. PTA-T informed Surveyor R6 knew when she had to use the bathroom and they would take her back to her room. PTA-T informed Surveyor he believes the loose stool started about a week prior to R6 being discharged . On 6/28/24, at 1:34 p.m., Surveyor asked LPN/UM-F if she remembers R6. LPN/UM-F replied a little bit. Surveyor asked if they tested R6's stool for any infectious process. LPN/UM-F informed Surveyor they did attempt to test but the stool was never loose enough to submit it. LPN/UM-F explained the lab wouldn't accept it as they tried to test another resident at one time and the lab refused to test the sample. Surveyor informed LPN/UM-F Surveyor was unable to locate an order for a stool specimen or any documentation regarding a stool specimen. Surveyor asked LPN/UM-F to look into this and get back with any information. On 6/28/24, at 2:52 p.m., Surveyor spoke to LPN-U on the telephone regarding R6. Surveyor asked LPN-U if R6 was having diarrhea while she was at the facility. LPN-U informed Surveyor R6 had been having diarrhea which was ongoing. LPN-U informed Surveyor R6 was on Metamucil but the daughter stated it wasn't going to work. Surveyor asked LPN-U on the day of discharge does she remember R6 having diarrhea. LPN-U informed Surveyor she doesn't remember R6 having loose stool on the day she was discharged . Surveyor asked LPN-U if R6 could go to the bathroom herself. LPN-U replied not sure. On 7/1/24, at 9:12 a.m., Surveyor showed CNA-P R6's picture and asked CNA-P if she remembers R6. CNA-P informed Surveyor she didn't like to be disturbed if she was sleeping. Surveyor inquired if she assisted R6 with cares. CNA-P informed Surveyor she would offer but she wanted to do them herself. Surveyor asked if R6 had diarrhea. CNA-P informed Surveyor she thinks she had diarrhea and would report this to the nurse. CNA-P informed Surveyor a lot of times R6 took herself to the toilet. Surveyor asked when R6 took herself to the toilet could she clean herself. CNA-P informed Surveyor she didn't think she was supposed to and offered to help. Surveyor asked CNA-P if she remembers who she reported R6's diarrhea to. CNA-P replied no I don't, think they are no longer here. On 7/1/24 at 9:47 a.m., Surveyor met with LPN/UM-F to follow up on the date when a stool specimen was attempted for R6. LPN/UM-F informed Surveyor they did discuss collecting R6's stool but the sample was soft, mushy and the lab would reject it unless the sample was watery. Surveyor again asked for the dates of when this was attempted. Surveyor asked LPN/UM-F who reviews the CNA charting of residents' bowel movements. LPN/UM-F informed Surveyor a report comes up if a resident hasn't had a bowel movement for three days. Surveyor inquired who would review the bowel records for loose/watery/diarrhea and inquired if there is an alert for loose/watery/diarrhea. LPN/UM-F didn't answer Surveyor and informed Surveyor she knows she showed APNP-R or the doctor a picture of R6's stools. On 7/1/24, at 10:28 a.m., Surveyor asked DON (Director of Nursing)-B for any bowel policy the facility has. On 7/1/24, at 11:01 a.m., LPN/UM-F provided Surveyor with the following bowel policy. The facility's policy titled, Incontinence and implemented 3/26/23 under Policy Explanation and Compliance Guidelines includes documentation of : 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. LPN/UM-F then informed Surveyor she doesn't have a date as to when she showed the NP or MD a picture of R6's stools. On 7/1/24, at 11:24 a.m., Surveyor spoke to APNP-R about R6. APNP-R explained she is at the facility Monday to Friday and usually sees residents twice a week depending how stable they are and if they are stable then will see them once a week. Surveyor asked if there were any concerns with R6 having diarrhea. APNP-R informed Surveyor the only thing was the daughter would say R6 was having diarrhea but R6 did not complain of diarrhea to her. APNP-R informed Surveyor one time they said she had loose with some formed pieces, that's all she knows. Surveyor asked APNP-R if she reviews the bowel records which the CNAs chart. APNP-R informed Surveyor she doesn't look at this record unless there is a problem. Surveyor asked APNP-R if she recalls nursing informing her R6 was having loose stools/diarrhea. APNP-R informed Surveyor if they told her R6 was having diarrhea she would have ordered a specimen, it would have been a verbal order. Surveyor asked APNP-R if she was aware of the number of times loose, watery, diarrhea was being documented. APNP-R replied no and wasn't told it was diarrhea. Surveyor informed APNP-R of the 14 times it was documented R6 had loose, watery, diarrhea. APNP-R informed Surveyor when she saw R6's stools they were not watery. Surveyor asked APNP-R if she remembers when this was. APNP-R replied not off the top of my head. On 7/1/24, at 1:12 p.m., NHA (Nursing Home Administrator)-A and DON-B were informed of R6's CBC & BMP not being drawn during the week of 5/19/24 to 5/25/24 and R6 experiencing multiple episodes of what was documented by the CNAs as loose/watery/diarrhea without facility assessing R6's bowels and ordering a stool specimen to determine if there was an infectious process. DON-B informed Surveyor the provider ordered Metamucil on 5/30/24. Surveyor informed DON-B R6 continued to have loose/watery/diarrhea 7 times after the Metamucil.

Based on the comprehensive assessment of a resident, the facility did not ensure that residents received care, consistent with professional standards of practice, to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure injuries received necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing for 2 of 4 (R4 and R5) residents reviewed for pressure injuries. R4 was dependent for bed mobility and identified to be at high risk for pressure injuries. Care plan interventions to include offloading, turning, and repositioning were not implemented. R4 developed a stage 3 pressure injury to her buttock and the care plan was not revised to include increased offloading, turning, and repositioning. Initial assessment and measurements were not completed and treatment for the pressure injury was not immediately implemented. In addition, R4 developed a Deep Tissue Injury (DTI) to her left heel. There was no documentation of a comprehensive assessment or measurements. R5 required maximal assistance for bed mobility and was identified to be at risk for pressure injuries. Care plan interventions to include offloading, turning, and repositioning were not implemented. R5 developed a DTI to his right heel. A comprehensive assessment and measurements of the pressure injury were not completed. Findings include: The facility policy titled Pressure Injury Prevention Guidelines (which is not dated) documents (in part) . .To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency of performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses). 7. Interventions will be documented in the care plan and communicated to all relevant staff. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. c. Changes in the resident's goals and preferences, such as at end of life or in accordance with his/her rights. Repositioning: 1. Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition. 2. Routine repositioning schedule: Every two hours, using both side-lying and back positions. Reposition when in bed and out of bed. 5. Repositioning techniques: f. Ensure that heels are floated off the surface of the bed, using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Pressure Relieving Devices: 1. Support surfaces do not eliminate the need for turning and repositioning. 2. Pillows and wedges may be utilized to maintain proper positioning. 3. Apply heel suspension devices according to the manufacturer's instructions. a. For prevention, stage 1 or stage 2: Use pillows or heel suspension devices. If using heel protectors, will still need to utilize pillows for floatation. b. For stage 3, 4, unstageable or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury. Check the skin each shift and prn (as needed) for signs of redness or skin breakdown related to the boot. 1.) R4 admitted to the facility on [DATE]. Diagnoses include Respiratory Failure, Parkinson's Disease, Pulmonary Embolism, dysphagia, Alzheimer's Disease, orthostatic hypotension, and insomnia. R4 admitted to the facility with no pressure injuries. R4's Braden Score dated 3/26/24 documented a score of 12 indicating High Risk. R4's Admission Minimum Data Set (MDS) dated [DATE] documents: Is this resident at risk of developing pressure ulcers/injuries? Yes. Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed: Dependent - helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity. R4's CAA (Care Area Assessment) worksheet documents: Pressure Ulcer/Injury Potential. Bed mobility is impaired, and she had episodes of incontinence. At risk for functional decline and skin breakdown. Goal is to improve her functional status and to not develop skin impairment. R4's Care Plan Focus initiated 3/27/24 documents: Physical functioning deficit related to mobility impairment, self-care impairment. Interventions: Bilateral bed canes for bed mobility. I require Hoyer lift with assist x 2 to complete transfers. I require max assist x 2 to complete bed mobility. Pressure ulcer actual or at risk due to assistance required in bed mobility, bowel incontinence, Braden Score 18 or < (less) - initiated 4/3/24. Interventions: Complete Braden Scale per living center policy. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. Provide thorough skin care after incontinent episodes and apply barrier cream. Prevalon boots to bilateral feet initiated 4/12/24. Resident has an actual pressure ulcer left lateral upper buttocks, left inferior heel. Resident refuses to wear Prevalon boots. R&B (risks and benefits) were discussed with resident - initiated 4/9/24. Interventions: Evaluate need for pain reliever prior to cleansing or dressing changes. Notify practitioner if symptoms worsen or do not resolve. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. Treatments as ordered. Weekly wound assessment. Float heels initiated 5/6/24. R4's Physical Therapy Evaluation & Plan of Treatment start of care dated 3/27/24 documents: Bed Mobility roll left and right = Dependent. R4's Admission Skin assessment dated [DATE] documents blancheable redness to left buttocks, no wounds. Surveyor noted although R4 was identified to be at high risk for pressure injuries and was dependent on staff for bed mobility, there were no care plan interventions to include offloading, turning, or repositioning implemented. Facility Progress Notes document: 4/8/24 at 4:27 AM Skin tear was observed by CNA (Certified Nursing Assistant) during patient care. Upon observation is appeared to be a pressure sore on her left gluteal. Family is aware and NP (Nurse Practitioner) notified via text. Surveyor noted there was not a comprehensive assessment or measurements of the pressure injury documented, and no new treatment was ordered or implemented. 4/9/24 at 3:55 AM Pt (patient) monitoring r/t (related to) skin tear to left buttocks. Frequent repositioning encouraged. Barrier cream applied. 4/9/24 6:32 PM Patient seen by Wound Care for left lateral upper buttocks and left inferior heel. Patient had no c/o (complaints of) pain or distress during treatment, will follow current treatment regimen in place and continue to see patient weekly for wound rounds. Surveyor noted this was the first mention of a left heel wound. There was no documentation of an assessment or measurements of the wound. The Wound Pros progress reports document: 4/9/24 [AGE] year-old female presents with a chronic non-healing pressure ulceration of the left lateral upper buttocks. The wound has been present for approximately less than 30 days and is for initial evaluation. Previous treatments include off-loading and Advanced wound care dressings. Surveyor noted R4 did not have previous treatment orders for advance wound care dressings and the care plan did not include off-loading. Left lateral upper buttocks new stage 3 pressure ulceration. Length/Width/Depth measurements 5.39 x 3.81 x 0.2 cm (centimeters). 80% granulation, 10% fibrous tissue, 10% necrotic tissue. Sanguineous bright red exudate. Sharp debridement. Left inferior heel new Deep Tissue Injury 3.5 x 1.5 x 0.01 cm. Wound size medium. Surveyor noted although the facility identified a DTI to the heel and Stage 3 pressure injury to R4's buttocks, and R4 was dependent for bed mobility, the care plan was not revised to include frequent offloading, turning, and repositioning. Appropriate treatment was ordered and implemented. The wounds were followed weekly with periodic sharp and mechanical debridement of the buttocks wound. On 5/11/14 at 6:43 PM Facility progress notes document: Writer informed by the aides that pt's tx (treatment) came off and wound looks worse. Upon assessment wound appears worse, strong odor present. Writer contacted MD (Medical Doctor), NOR (new order received) for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) which was drawn earlier today, awaiting results. Start pt on Augmentin 875 mg (milligrams) BID (twice daily) x 7 days. Pending evaluation by wound team and obtain wound culture. Surveyor noted a comprehensive assessment and measurements of R4's buttock wound was not completed when the decline was noted on 5/11/24. On 5/14/24 R5 was seen by The Wound Pros: Left inferior heel healed. Left lateral upper buttocks stage 3 deteriorating. 6.4 x 4.6 x 3.5 cm. Moderate serosanguineous light red/pink exudate. Mild odor. 100% necrotic tissue. Undermining 4.5 cm from 9 to 6 o'clock. Sharp debridement. Appropriate treatment was ordered and implemented. R4 was hospitalized from 5/17/24 through 5/22/24 for change in condition - decreased food/fluid intake, functional decline, Covid, and Failure to Thrive. Upon readmission to the facility on [DATE], R4 continued to be followed by wound care weekly. Periodic sharp and mechanical debridement was performed. No further infection noted. R4 signed on to Hospice care on 5/28/24 and discharged home with Hospice care on 6/5/24. On 6/27/24 at 12:15 PM, Surveyor spoke with Licensed Practical Nurse (LPN) Unit Manager (UM)-D and Wound Care Nurse (WCN)-L. Surveyor advised of the above concerns. LPN UM-D reported she was unable to locate any facility assessments or measurements of R4's heel wound. LPN UM-D stated, I know there were issues before I came, I've been trying going forward, but I can't fix what happened. Basically, this is why the other WCN isn't here anymore. On 6/27/24 at 3:00 PM during the daily exit meeting, the facility was advised of the concern R4 admitted to the facility with no pressure injuries, was identified to be at high risk and was dependent on staff for bed mobility. No care plan interventions to include offloading or turning and repositioning were implemented. R4 developed a left heel deep tissue injury that was not comprehensively assessed or measured and a stage 3 pressure injury to her buttock. After the stage 3 pressure injury was identified, the facility did not revise the care plan to include frequent turning and repositioning and treatment for the stage 3 pressure injury was not immediately ordered and implemented. 2.) R5 admitted to the facility on [DATE]. Diagnoses include Right Femur Fracture, Polymyalgia Rheumatica, Atherosclerotic Heart Disease, Pulmonary Hypertension and Chronic Kidney Disease stage 3. R5 admitted to the facility with no pressure injuries. R5's Admission Minimum Data Set (MDS) dated [DATE] documents: Is this resident at risk of developing pressure ulcers/injuries? Yes. Functional Limitation in Range of Motion: Impairment on one side - lower extremity (hip, knee, ankle, foot). Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed: Substantial/maximal assistance - helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort. R5's CAA worksheet documents: Pressure Ulcer/Injury Potential. Resident does not have any pressure ulcer impairments at this time. Care plan considerations: Minimize risks. Care plan to address and to minimize the risk for pressure ulcer impairments. R5's Care Plan Focus initiated 3/14/24 documents: Physical functioning deficit related to mobility impairment, self-care impairment. Interventions: Bilateral bed canes for bed mobility. Max assist x 1 to complete toileting. Max assist x 1 to complete bed mobility. Pressure Ulcer at risk due to decreased mobility initiated dated 3/19/24. Interventions: Complete Braden scale per living center policy. Conduct weekly skin inspection. At risk of Pressure Injuries due to assistance required in bed mobility initiated 3/20/24. Interventions: Conduct weekly skin inspection. Heel boots. R5's Physical Therapy Evaluation & Plan of Treatment start of care dated 3/14/24 documents: Bed Mobility roll left and right = Substantial/maximal assistance (The patient will require bed rails for bed mobility performance and the use of pillows or A frame to maintain proper hip alignment with rolling, side lying and bed mobility). There was no evidence in R5's electronic health record (EHR) an admission skin assessment or Braden was completed. R5's skilled evaluations (skin section) in the EHR included no documentation of pressure injuries through 3/27/24. R5's Treatment Administration Record (TAR) documented: Skin prep R (right) heel two times a day - ordered 3/19/24. Prevalon boot on while in bed every shift - ordered 3/19/24. Apply non-adherent dressing to right heel every day shift - ordered 3/28/24. Surveyor noted a Physician's order dated 3/28/24 for wound care to evaluate and treat right heel. Surveyor was unable to locate any documentation of R5's right heel wound in the medical record. There was no evidence a comprehensive assessment or measurements were completed. On 6/25/24 at 3:00 PM, Surveyor advised the facility R5 had treatment orders for a right heel wound, however there was no documentation of the heel wound in R5's medical record. Surveyor asked the facility for all documentation regarding R5's right heel wound. On 6/26/24 at 9:00 AM, Director of Nursing (DON)-B provided Surveyor two (2) Wound Pros progress reports, stating: That's all we have. 3/26/24 Wound Pros Progress notes document: [AGE] year-old male last seen on March 26, 2024, as a consult for a skin issue on the right medial heel that was present for less than 30 days. Location: Right medial heel Blister. Skin Health Status: At Risk. Size: Medium. Orders/recommendations: Off-loading. Recommend heel protectors. Surveyor noted there were no measurements documented. The picture on the form appeared to be a large dark blister. Wound Pros Visit Details 4/2/24: Wound Evaluation right medial heel. Status unchanged. Pressure ulceration. Stage: Deep Tissue Injury. 3.0 cm (centimeters) x 2.5 cm x 0.01 cm. Wound size: Small. Necrotic tissue. Surveyor noted the picture showed the darkened area appeared smaller in size. On 6/26/24 at 9:50 AM, DON-B advised Surveyor the facility did not have evidence a skin assessment or Braden was completed on R5 upon admission to the facility and the facility did not have a comprehensive assessment or measurements of R5's right heel pressure injury when it was identified. DON-B reported the previous wound care nurse no longer works for the facility and new systems have been put in place since. Surveyor confirmed with DON-B there was no documentation of R5's heel pressure injury from the time treatment was implemented on 3/19/24 until he was seen by The Wound Pros on 3/26/24. On 6/27/24 at 10:55 AM, Surveyor spoke with Licensed Practical Nurse (LPN) Unit Manager (UM)-D who reported she remembered R5 had a pressure injury on his heel. Surveyor asked what the expectation for a resident is who admits to the facility with a hip fracture and requires maximal assistance with bed mobility for offloading and turning and repositioning. LPN UM-D stated: Really anyone with that should automatically have their heels floated or pressure relieving boots put on, that's just a given because they can't move their leg or turn themselves. Surveyor reviewed R5's TAR noting an order for skin prep to the right heel implemented 3/19/24. Surveyor advised there is no documentation of an assessment or measurement of the pressure injury when it was identified. LPN UM-D reported whichever nurse finds any wound they should document an assessment and measure it, then get a treatment order. LPN UM-D stated: I'm not making any excuses, but we had a lot of agency at one point and they sometimes are just here for the paycheck it seems, they don't do as good of job as the regular staff. If I find any wound, I document what it looks like, measure it and call for treatment orders. On 6/27/24 at 3:00 PM during the daily exit meeting, the facility was advised of concern R5 admitted to the facility with no pressure injuries, was identified to be at risk, and required max assist with bed mobility. No care plan interventions to include offloading or turning and repositioning were implemented. R5 developed a right heel Deep Tissue Injury that was not comprehensively assessed or measured until at least 1 week after it was identified. No additional information was provided at this time. On 7/1/24 at 10:15 AM, Assistant Director of Nursing (ADON)-C provided Surveyor a pressure injury Performance Improvement Plan (PIP). ADON-C reported it was created for the overall pressure injury program in general. ADON-C reported on 4/11/24 she noticed things were not matching up, such as measurements and treatments. An audit was completed which identified problems with assessments and treatments not being done and the prior WCN information not matching documentation or what was seen. ADON-C reported she and DON-B created a PIP on the whole wound process from beginning to end. ADON-C reported it's a work in progress and they have not yet done education with staff on prevention and assessments. Surveyor review of the PIP start date 4/14/24 documented key area for improvement: Wound process not timely, initial measurements missing, weekly measurements not always completed, wound round not organized, treatments not always completed, wound nurse not doing treatments. Surveyor noted the PIP did not address concern regarding pressure injury prevention and implementing interventions to assist with prevention of pressure injuries. No additional information was provided.

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 non-pressure injuries and neurological checks after a potential head injury for 4 (R247, R146, R97, and R38) of 6 residents reviewed for non-pressure injuries and 2 (R38 and R298) of 4 residents reviewed for neurological checks after potential head injury. *R247 was admitted with excoriation to the right and left buttocks with discharge orders from the hospital for a treatment to the area and to not have an incontinence brief on. Surveyor observed staff peel an incontinence brief from R247's right and left buttock causing R247 to cry out in pain and causing excessive bleeding from open wounds. The wounds were not comprehensively assessed until eleven days after admission. Documentation was conflicting as to where R247 had wounds and a surgical wound to the right hip with a wound vac was not comprehensively assessed for eleven days. R247 was on anticoagulant medication and no documentation was found that the physician was notified of the excessive bleeding with the wound treatment. *R146 sustained a skin tear to the right leg after a fall that was not assessed and a treatment was not provided as ordered. *R97 was admitted on [DATE] with diabetic foot ulcers to the right and left feet per the hospital discharge summary with treatments ordered to each foot. The right foot ulcer was not comprehensively assessed until 6/13/2023 and the left foot ulcer was not assessed at all through the time of the survey. *R38 had non-pressure injuries that were not comprehensively assessed weekly. *R38 had incomplete neurological checks after a fall with a potential head injury. *R298 did not have neurological checks after the discovery of an injury of unknown origin to the head. R247 is being cited at a severity level 3 (Actual harm that is not immediate jeopardy). R146, R97, R38, and R298 are cited at severity level 2 (No actual harm with potential for more than minimal harm). Findings include: The facility policy and procedure entitled Wound Management dated 10/28/2021 states: . 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: A. Feces has seeped underneath the dressing. B. The dressing has dislodged. C. The dressing is soiled otherwise, or is wet. 4. Dressings will be applied in accordance with manufacturer recommendations. 5. Treatment decisions will be based on: A. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesions, pyoderma, calciphylaxis). B. The characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including shape, depth, and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. C. Location of the wound. D. Goals and preferences of the resident/representative. 6. Guidelines for dressing selection may be utilized and obtaining physician orders (see attached). a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above). c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1) R247 was admitted to the facility on [DATE] with diagnoses of osteomyelitis to the right femur, Parkinson's disease, rheumatoid arthritis, diabetes, paraplegia, peripheral vascular disease, depression, heart failure, and gastroparesis. R247 had not been in the facility long enough to have a Minimum Data Set (MDS) assessment completed at the time of survey. The nursing assessment on 6/2/2023, at 8:00 PM, in the progress notes charted R247 needed total assistance with bed mobility, transferring, eating, toilet use, and hygiene. R247 had a suprapubic urinary catheter in place. R247 did not have an activated Power of Attorney. On the After Visit Summary - Transition hospital paperwork dated 6/2/2023, the Problem List included a pressure ulcer, a deep tissue injury (DTI,) a tear of the skin of the right buttock, and an open wound. Wound documentation was included in the paperwork for a right hip surgical wound and right anterior proximal thigh with a negative pressure wound vac in place and a Stage 2 pressure injury to the right buttock with a treatment of antifungal powder doing the crusting technique. The discharge treatment instructions for the buttock DTI and sheering wound was a crusting technique with antifungal powder and no sting times three layers and if unavailable, use remedy antifungal cream; do not use Depends. On 6/2/2023, at 8:05 PM, in the progress notes, Licensed Practical Nurse/Unit Manager (LPN/UM)-E charted R247's admission assessment. LPN/UM-E charted R247 had a pressure injury to the right hip with a wound vac in place, moisture associated skin damage (MASD) to the buttocks with entire buttock with open wounds and excoriation, open lesions of the right toes, open lesions of the left toes, and bilateral feet with scabbed areas. No measurements or descriptions of the wounds with tissue type, exudate, or odor were documented. On 6/2/2023, R247's treatment order for the buttocks was to apply Happy Butt Cream every shift. Surveyor reviewed R247's admission orders and noted the hospital discharge orders for the antifungal powder, no sting barrier, and not using Depends was not put in place. R247's Pressure Ulcer Care Plan was initiated on 6/2/2023 with the following interventions: -Complete Braden scale per facility policy. -Conduct weekly skin inspection. -Evaluate the need for pain reliever prior to cleansing or dressing changes. -Heel boots. -Monitor vital signs as needed. -Notify practitioner if symptoms worsen or do not resolve. -Provide pressure reduction/relieving mattress. -Provide thorough skin care after incontinent episodes and apply barrier cream. -Skin assessment to be completed per facility policy. -Treatments as ordered. -Weekly wound assessment. R247 was admitted to the facility with orders for warfarin 2.5 mg (milligrams) Tuesday, Wednesday, Thursday, Saturday, and Sunday and 5 mg Monday and Friday, aspirin 81 mg daily, venlafaxine 27.5 mg twice daily, and ceftriaxone 2 Gm intravenously daily. (Venlafaxine and Ceftriaxone may increase the effects of warfarin and cause bleeding more easily.) R247's INR (International normalisation ratio) was being monitored every Tuesday and Friday per physician orders. R247's At Risk for Complications related to Anticoagulant Care Plan was initiated on 6/2/2023 with the interventions: -Apply prolonged pressure to venipuncture sites. -Monitor dietary intake of foods high in Vitamin K (green leafy vegetables) -Monitor medication regime for medications which increase effects (NSAID (Non Steroidal Anti-Inflammatory Drug) such as aspirin, antidepressants, antibiotics, fish oil, etc.). -Observe for adverse reaction: fever, skin lesions, anorexia, nausea, vomiting, cramps, diarrhea, hemorrhage, hemoptysis. -Observe for signs/symptoms of bleeding such as tarry stools, blood in urine, bruising, petechiae. -Obtain and monitor lab/diagnostic work as ordered and report results to the physician and follow up as indicated. -Utilization of soft bristle toothbrush and inspect oral cavity for ulcerations or bleeding gums. On 6/6/2023, at 9:24 PM, in the progress notes, Director of Nursing (DON)-B charted R247 would not allow DON-B to look at buttock or use the wound app to take measurements. DON-B charted DON-B would attempt to assess R247 the next day. On 6/7/2023, at 11:41 AM, in the progress notes, LPN-G charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. On 6/7/2023, at 9:21 PM, in the progress notes, DON-B charted R247's wound vac to the right lateral thigh was no longer working and orders were obtained to remove the wound vac. DON-B charted new orders, cleanse with normal saline followed by a gauze island dressing, was completed. DON-B charted the wound looked clean, dry, and intact. Surveyor noted no measurements or description of the wound tissue was documented. DON-B charted R247 again refused to have DON-B look at the wounds on the buttocks and R247 was aggravated by DON-B asking to assess the buttocks. On 6/8/2023, at 9:29 PM, in the progress notes, DON-B charted R247 refused to have DON-B assess the buttock wound and R247 was informed of risks of not having the wound assessed. On 6/9/2023, at 11:43 AM, in the progress notes, LPN-G charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. Surveyor noted the wound vac had been discontinued on 6/7/2023 due to the vac no longer working and the progress note referred to the wound clinic appointment that had taken place the day before. On 6/9/2023, at 9:31 PM, in the progress notes, DON-B charted DON-B attempted to assess R247's buttock and R247 refused to be turned to have buttock assessed. DON-B charted R247 was aggravated by DON-B's attempts to assess the buttocks. On 6/10/2023, at 11:08 AM, on 6/11/2023 at 10:58 AM, and on 6/13/2023 at 10:55 AM in the progress notes, LPN-G charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. Surveyor noted the wound vac had been discontinued on 6/7/2023 due to the vac no longer working. On 6/12/2023, at 4:34 PM, in the progress notes, LPN-O charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. Surveyor noted the skilled evaluation note in the progress notes for R247's skin on 6/7/2023, 6/9/2023, 6/10/2023, 6/11/2023, 6/12/2023, and 6/13/2023 had the same areas of concern with the same descriptors of the wounds with no variation in the charting even when the wound vac had been discontinued and new treatment orders for the right hip had been implemented. This charting matched the initial admission assessment completed on 6/2/2023. On 6/13/2023, at 10:45 AM, Surveyor accompanied Regional Director of Wound Management (RDWM)-J and Nurse Manager-I into R247's room to observe the wound treatment and assessments of R247's wounds. RDWM-J stated RDWM-J had not seen R247's wounds before and commented that it appeared R247 had a treatment to the right lateral thigh and buttocks. Surveyor asked RDWM-J who assesses the skin of a new resident and who does the weekly wound rounds in the facility. RDWM-J stated RDWM-J was the wound nurse for seven facilities and therefore could not be in each building weekly, so Director of Nursing (DON)-B does the initial wound assessment when the resident is first admitted and the weekly wound rounds of all the residents with wounds. Certified Nursing Assistant (CNA)-H was asked to assist in positioning R247. R247 was lying in bed on an air mattress with bilateral heel boots on. R247 was turned onto the left side. R247 had a border dressing to the right hip/trochanter with a small amount of serous drainage when removed. The right hip incision was well approximated at the proximal and distal ends and measured approximately 10 cm in length. The center of the incision had a slight gap that measured approximately 0.2 cm. Surveyor was unable to see the wound bed. RDWM-J cleaned the incision with normal saline and applied a border foam dressing. R247 denied any pain to the right hip. R247 stated the pain was in my cheeks, referencing the buttocks. R247 had an incontinence brief in place. RDWM-J attempted to remove the brief, but the wounds were stuck to the brief and R247 yelled out in pain. RDWM-J continued to pull at the brief peeling it from the buttocks and once removed, rivulets of blood flowed from the open buttocks wounds. The right buttock had an open area that measured approximately 0.5 cm x 1.5 cm with active bleeding and a pink wound base. Nurse Manager-I was able to stop the bleeding of the right buttock wound by applying pressure with a wet washcloth. The left buttock had five open areas with four of the open areas in vertical orientation on the medial aspect of the left buttock and a single open area to the left of the four open areas. The four linear wounds each measured approximately 1 cm x 1 cm and the lateral wound measured approximately 3 cm x 1 cm. The wound bases were not visible due to the amount of blood present in the wounds. Nurse Manager-I placed pressure to the left buttock wounds with a wet washcloth and the washcloth was immediately saturated with blood. The skin to R247's right and left buttocks was discolored and macerated. RDWM-J applied Happy Butt Cream to the right and left buttocks. The cream was white in color before being applied to the buttocks and turned pink while being applied due to the extent of active bleeding from the left buttock wounds. A clean incontinence brief was placed on R247 by rolling R247 back and forth. Blood smeared onto the sides of the brief during the process of putting the brief on. R247 cried out in pain, held their breath, and inhaled quickly throughout the process of assessing and treating the buttocks wounds. Nurse Manager-I asked R247 to rate the pain to the buttocks. R247 stated the pain was a five-and-a-half that comes and goes. Nurse Manager-I told R247 that Nurse Manager-I would ask the nurse to bring in some pain medication to R247. R247 replied, Thank you. RDWM-J instructed R247 to stay off of the butt, turn side to side, and eat a good diet to promote wound healing. In an interview on 6/13/2023, at 11:42 AM, Surveyor asked CNA-H if CNA-H had ever seen R247's buttocks and if the amount of blood seen during the wound treatment that day was typical for R247. CNA-H stated R247 had always had that much bleeding. Surveyor asked CNA-H if the nurse was aware of the bleeding. CNA-H stated CNA-H thought so because they would let the nurse know about the need to apply the Happy Butt Cream and the nurse would come in to do that and see R247's buttocks. CNA-H stated sometimes the nurse would give the Happy Butt Cream to the CNA to apply so then they would not see it. Surveyor asked CNA-H if R247's wounds were getting better or worse since the last time CNA-H saw the wounds. CNA-H stated it was hard to say because the wounds were hard to see because of all the bleeding. Due to the amount of bleeding noted during the wound observation, Surveyor reviewed R247's H/H (Hemoglobin and Hematocrit) lab work. (13.7-17.5/40-51 is considered low.) 5/27/2023 (hospital lab) - 10.5/35.1 5/31/2023 (hospital lab) - 10.5/35.3 6/6/2023 - 9.8/33 6/13/23 - 9.2/31 On 6/13/2023 on the Skin and Wound Evaluation form, RDWM-J charted the right lateral thigh surgical wound measured 5.5 cm x 0.8 cm x 0.1 cm with 100% granulation with moderate serosanguineous drainage. On 6/13/2023 on the Skin and Wound Evaluation form, RDWM-J charted the right gluteus MASD measured 5.6 cm x 2.8 cm x 0.1 cm with 100% granulation with moderate serosanguineous drainage. The surrounding tissue was macerated. On 6/13/2023 on the Skin and Wound Evaluation form, RDWM-J charted the left gluteus MASD measured 7.0 cm x 4.8 cm x 0.1 cm with 100% granulation with moderate serosanguineous drainage. The surrounding tissue was blanching. Surveyor noted the assessments of the right and left gluteus did not correlate with the observations made during wound care on that date. In an interview on 6/13/2023, at 1:47 PM, DON-B stated when a new resident is admitted , the nurse on the floor is expected to measure the wounds and then DON-B would come in and measure the wound the following day. DON-B stated a treatment for any wounds that are noted on admission and do not have treatment orders from the hospital are told to the physician to get a wound treatment in place depending on what they find. R247's Care Plan was updated on 6/13/2023 to address refusals by R247 and on 6/14/2023 to incorporate no incontinence product to be used. In an interview on 6/14/2023, at 1:10 PM, LPN-G stated LPN-G charted on R247 every day shift that LPN-G worked. Surveyor asked LPN-G how the charting system was set up for daily charting, such as were sections of the charting pre-filled from previous shifts or were preset charting options selected each time charting was completed. LPN-G stated there were no pre-filled sections on the charting; the nurse had to click on the appropriate information in the charting system. Surveyor asked LPN-G if R247's buttock had been observed by LPN-G the day before, on 6/13/2023. LPN-G stated no, LPN-G had not seen R247's buttocks in a long time. Surveyor noted LPN-G had charted on R247 on 6/7/2023, 6/9/2023, 6/10/2023, 6/11/2023, and 6/13/2023. LPN-G could not recall when LPN-G last saw R247's buttocks. Surveyor noted LPN-G had charted information in R247's medical record without verifying that information. LPN-G stated LPN-G heard the previous day that R247's buttock was really red and they were getting a new treatment with nystatin to add to the Happy Butt cream. Surveyor asked LPN-G if R247's buttocks were bleeding the last time LPN-G observed R247's buttocks. LPN-G stated it was macerated and excoriated, but nothing was bloody, and the skin looked like it was peeling. Surveyor asked LPN-G if any CNAs had reported to LPN-G that R247 was bleeding from the buttock. LPN-G stated no. Surveyor asked LPN-G if the admitting nurse reviews the discharge summary from the hospital when a new resident comes in. LPN-G stated that would depend on what time the resident gets to the facility. LPN-G stated the After Visit Summary is looked at for the medications and the Unit Managers go through the charts the next day to make sure the orders are all in the charting system. In an interview on 6/14/2023, at 1:46 PM, Surveyor asked LPN/UM-E what LPN/UM-E could recall when R247 was admitted to the facility on [DATE]. LPN/UM-E stated R247 had a wound vac on the hip and that was to be left in place until R247 was seen by the wound clinic. LPN/UM-E reviewed the charting in the computer charting system and stated R247's bottom had open excoriation and got orders for Happy Butt Cream. LPN/UM-E stated the buttocks had bloody drainage. Surveyor asked LPN/UM-E if LPN/UM-E had seen the wound treatment discharge orders from the hospital for R247? LPN/UM-E stated there was an order for a cream that the facility did not have so they got an order from the physician for the Happy Butt Cream which was an equivalent. LPN/UM-E stated on admission, R247's buttocks wounds were pretty extreme with blood, so much so that LPN/UM-E did not know how to describe the wounds. Surveyor shared with LPN/UM-E the concern R247 was on warfarin, along with aspirin and an antibiotic that would increase the possibility of bleeding, and R247 had very active bleeding during wound care with an order from the hospital not to put incontinence briefs on. LPN/UM-E stated they were not aware of that order. In an interview on 6/15/2023, at 7:47 AM, Surveyor asked CNA-Q if CNA-Q had attended to R247 that morning? CNA-Q stated CNA-Q changed the bed linen, did all cares on the upper and lower body, and R247 requested to not have any clothes on when CNA-Q was done so that was how CNA-Q left R247. Surveyor asked CNA-Q if R247 had an incontinence brief on? CNA-Q stated yes, and CNA-Q changed the brief. Surveyor asked CNA-Q what CNA-Q observed when changing the brief? CNA-Q stated R247's buttocks had areas that were excoriated. CNA-Q stated there were no dressings to the open areas, so CNA-Q put a cream on which was basic skin protection. CNA-Q showed Surveyor the cream that had been applied. The cream was Periguard ointment. CNA-Q stated CNA-Q dabbed the area to get it clean and R247 complained of pain while CNA-Q was doing that. CNA-Q stated there was no active bleeding from the wounds. CNA-Q reiterated there were about three open areas with no dressing, so CNA-Q put the cream on. In an interview on 6/15/2023, at 8:05 AM, LPN-G stated LPN-G did the treatment yesterday and there was a little bit of blood but not like it was on 6/13/2023. LPN-G stated LPN-G would be doing the treatment again that day after lunch. On 6/15/2023, at 1:53 PM, Surveyor observed LPN-G with R247. R247 had an incontinence brief underneath the buttocks that was not fastened in the front. R247 was rolled to the side and R247 asked, Did it stop bleeding? pointing to R247's bottom. R247 stated they said it was really bleeding last night. R247 stated R247 had not gotten much sleep at night because of the pain to the bottom. R247 grimaced in pain when being turned and moved. R247's right hip dressing was removed. Serosanguineous drainage dripped down the leg from the open area in the incision. The wound was cleansed with normal saline and a border foam dressing was placed. Cream was visible on R247's buttocks and peri area. LPN-G cleaned off the cream with wipes and R247 had vocalizations of pain when the area was touched and held their breath for the majority of the process. The right buttock open area had improved since the observation on 6/13/2023 with no active bleeding noted and the left buttock, originally having five open areas, had changed to three open areas with four wounds merging to form two wounds. The left buttock wounds had minimal bleeding noted. R247's wife was in the room and stated when R247 was at home, there was a pad on the buttocks wounds so no stool would go on it and R247's wife would clean the area and put on a clean pad. R247's wife stated R247 had an appointment with the wound clinic on 6/22/2023. Surveyor asked R247 about R247's pain to the buttocks. R247 stated R247 could not sleep at night because of the pain. R247 stated R247 could take pain medications but the relief only lasts so long and the cream helps with the pain but only for a little while. In an interview on 6/19/2023, at 10:52 AM, Surveyor asked DON-B if R247 had any wounds to the toes of the right and left feet as documented repeatedly in the progress notes? DON-B adamantly stated R247 did not have any wounds to the feet or toes. DON-B stated R247's feet were contracted, but there were no wounds on them. DON-B stated DON-B could not figure out why that was continually charted. Surveyor discussed with DON-B the concern there was a lot of bleeding with wound care on 6/13/2023 and no documentation was found that the physician was notified of the extent of bleeding since R247 was on warfarin. DON-B agreed with the lack of documentation and could not determine if the physician had been told of the bleeding. Surveyor shared with DON-B the concern R247's wounds were not comprehensively assessed until 6/13/2023, eleven days after admission. DON-B stated R247 would not allow DON-B to assess R247's backside and that was documented. Surveyor shared with DON-B R247 had incontinence cares completed with bowel movements and had cares completed twice daily when R247's backside would have been exposed. DON-B agreed those would have been opportunities to see R247's skin. Surveyor shared with DON-B the concern the assessment documentation completed by RDWM-J on 6/13/2023 did not reflect the observations made at the same time by Surveyor regarding the amount of bleeding, RDWM-J documented moderate serosanguineous drainage when there was copious amounts of active bleeding, or in the description of the wounds to the left buttock, only charting the multiple wounds as one wound. 21855 2) The facility's policy and procedure for Skin Integrity-Skin Tears, dated 3/1/19 was reviewed by Surveyor. The policy indicates a systematic approach for the prevention and management of skin tears. This includes assessment, care planning, monitoring, and modification of interventions as appropriate. Surveyor reviewed R146's medical record which documents: Note on 11/1/22, at 5:23 AM, states R146 had an unwitnessed fall on 11/1/22, at 4:35 AM. R146 obtained a skin tear on the right lower leg. There is no documentation of an assessment or treatment of the skin tear in the medical record. On 11/1/23, at 5:16 AM, the Progress Note indicates R146 is confused and hallucinating. R146 obtained a minor skin tear to the right lower leg and right great toe. Due to R146's change in behavior with the fall they are sent out to the hospital. Surveyor notes R146's medical record does not have a documented assessment of the skin tear and abrasion R146 obtained from the fall. R146's hospital notes from 11/1/22 visit were reviewed by Surveyor. The hospital ER (emergency room ) assessment notes a skin tear on the right lower leg that does not require stitches. There is also an abrasion on the small right toe. The Hospital Summary for 11/1/22 indicates to keep skin tear clean, wash daily, and cover with a band aid. R146's Treatment Administration Record for 11/22 was reviewed, along with the physician plan of care. There is no treatment order documented for the right lower leg skin tear or the right small toe abrasion. On 06/14/23, at 9:07 AM, Surveyor spoke with DON-B (Director of Nurses). R146's medical record was reviewed during this interview. DON-B agreed there was no skin assessment nor treatment documented for the right lower leg and right small toe. There was no further information provided. On 6/14/23, at 9:31 AM, Surveyor spoke with LPN/UM-E (Licensed Practical Nurse) who is also the Unit Manager. R146's medical record was reviewed during this interview. There was no skin assessment nor treatment documented for the right lower leg and right small toe. On 6/14/23, at 2:50 PM, at the Facility Exit Meeting, Surveyor shared the concerns of no skin assessments and treatments documented for F146's right lower leg skin tear and right small toe abrasion. 20483 3) R97 was admitted to the facility on [DATE]. Diagnoses includes end stage renal disease, diabetes mellitus with foot ulcer, heart failure, hypertension, and dependence on renal dialysis. The hospital discharge summary dated 6/2/23 under principle diagnosis includes Bilateral diabetic foot ulcers without infection. The Clinical admission assessment dated [DATE] is checked for diabetic foot ulcer(s). The physician orders dated 6/3/23 documents, Left dorsal foot: Wash with soap/water, pat dry. Apply Iodosorb f/b (followed by) secondary dry dressing. Change daily and prn (as needed.) Every evening shift for wound care. Review of R97's June TAR (treatment administration record) reveals the treatment is not initialed as being completed on 6/6/23, 6/8/23, 6/9/23, 6/11/23, 6/12/23, & 6/13/23. The physician order dated 6/3/23 documents Right hallux (big toe): Wash with soap and water, pat dry. Apply Iodosorb f/b dry dressing. Change 3x's (three times)/week on AM (day shift) M-W-F (Monday-Wednesday-Friday) and prn (as needed) every evening shift every Mon, Wed, Fri for wound care. Review of R97's June TAR (treatment administration record) reveals the treatment is not initialed as being completed on 6/9/23 & 6/12/23. The Skin Only Evaluation dated 6/3/23 documents, Skin: Skin Issue: #001: New. Issue type: Erythema and warmth. Location: Chest - generalized. Painful: Yes - episodic pain. Erythema present on surrounding skin. Skin Issue: #002: New. Issue type: Other skin issue. Location: Right lower leg. Other skin issue description: Scattered dry wounds. Wound odor: No. Tunneling: No. Painful: No. Skin Issue: #003: New. Issue type: Other skin issue. Location: Right foot. Other skin issue description: mix of granular tissue and dry blood. Wound odor: No. Tunneling: No. Painful: No. Skin Issue: #004: New. Issue type: Other skin issue. Location: Left lower leg. Other skin issue description: Scattered dry wounds. Wound odor: No. Tunneling: No. Undermining: No. Painful: No. Skin Issue: #005: New. Issue type: Other skin issue. Location: Left foot. Other skin issue description: dry superficial wounds. Wound odor: No. Tunneling: No. Undermining: No. Treatment schedule: Other. Other treatment schedule: 3x's per week. Skin is dry / cracked. Skin is fragile. Decreased skin turgor. Completed Clinical Suggestions: Surveyor noted this skin only evaluation is not a comprehensive assessment of R97's right and left diabetic foot ulcers. The location is right & left foot but does not indicate where on the feet the ulcers are located, does not include measurements, whether there is exudate or infection, & description of periwound. The Skin Only Evaluation dated 6/4/23 documents Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Skin Issue: #001: No Change. Issue type: Other skin issue. Location: Right foot. Other skin issue description: mix of granular tissue and dry blood. Wound odor: No. Tunneling: No. Painful: No. Skin Issue: #002: No Change. Issue type: Other skin issue. Location: Left lower leg. Other skin issue description: Scattered dry wounds. Wound odor: No. Tunneling: No. Undermining: No. Painful: No. Skin Issue: #003: No Change. Issue type: Other skin issue. Location: Left foot. Other skin issue description: dry superficial wounds. Wound odor: No. Tunneling: No. Undermining: No. Treatment schedule: Other. Other treatment schedule: 3x's per week. Skin Issue: #004: No Change. Issue type: Erythema and warmth. Location: Chest - generalized. Length (cm) (centimeters): 0.8 Width (cm): 0.4 Depth (cm): 0.3 Painful: Yes - episodic pain. Erythema present on surrounding skin. Skin Issue: #005: No Change. Issue type: Other skin issue. Location: Right lower leg. Other skin issue description: Scattered dry wounds. Wound odor: No. Tunneling: No. Painful: No. Completed Clinical Suggestions: Surveyor noted this skin only evaluation is not a comprehensive assessment of R97's right and left diabetic foot ulcers. The location is right & left foot but does not indicate where on the feet the ulcers are located, does not include measurements, whether there is exudate or infection, & description of periwound. Surveyor noted the facility developed a pressure ulcer actual or at

Based on observations, interviews and record review the facility did not ensure that residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 6 of 7 (R197, R21, R199, R22, R245, R15) residents reviewed for pressure injuries. R197 admitted to the facility without pressure injuries and was identified to be at risk. No preventative care plan (CP) interventions to offload heels were implemented. The resident developed a Suspected Deep Tissue Injury (SDTI) to the right heel, which R197 described as hurts so bad. There was a delay in treatment and Surveyor had observations care plan interventions not in place while on survey. R21's pressure injury incurred a delay in treatment and observations on survey of care plan interventions not in place. R199's pressure injury incurred a delay in assessment and treatment. R22's pressure injury was missing comprehensive assessments, incurred a delay in treatment and documented conflicting staging of the pressure injury. R245's pressure injury was not comprehensively assessed upon admission. R15's pressure injury did not have weekly comprehensive assessments and observations on survey of care plan interventions not in place. R197 is being cited at severity level 3 (actual harm). Findings include: The facility Policy and Procedure titled Pressure Injury Prevention implemented 3/1/19 documented (in part) . Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel floatation devices, cushions, mattresses). 6. Guidelines for prevention may be utilized in obtaining physician orders. a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. When physician orders are present, the facility will follow the specific physician orders. 7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record. a. For at-risk residents: Treatment or medication administration records. B. For residents who have a pressure injury present: Treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changed in wound characteristics. c. Changes in the resident's goals and preferences, such as end-of-life or in accordance with his/her rights. The facility policy titled Wound Management dated 10/28/21 documents (in part) . Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 4. Dressings will be applied in accordance with manufacturer recommendations. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. c. Changes in the resident's goals and preferences, such as end-of-life or in accordance with his/her rights. 1.) R197 admitted to the facility on [DATE] and has diagnoses that include displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture, spondylosis without myelopathy or radiculopathy, cervical region and mild protein-calorie malnutrition. R197's Braden Scale for Predicting Pressure Sore Risk dated 5/26/23, documents a score of 15 indicating R197 is at risk for pressure injuries. R197's Braden score dated 6/3/23 documented a score of 14 - moderate risk for pressure injuries. R197's Clinical Admission skin assessment dated [DATE] documented: Skin baseline: Skin warm and dry, skin color WNL (within normal limits), turgor normal met. Surveyor noted there were no skin areas of concern marked on the picture of the body on the form. R197's skin only evaluations dated 5/26/23 and 5/31/22 had no documentation of pressure injuries. R197's Admission MDS (Minimum Data Set) dated 5/29/23 documents: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture - as extensive assistance 2 plus person physical assist. Transfer - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet) - as extensive assistance 2 plus person physical assist. Functional Limitation in Range of Motion: Upper extremity (shoulder, elbow, wrist, hand) impairment on 1 side, Lower extremity (hip, knee, ankle, foot) - impairment on 1 side. R197's Care Plan Focus area dated 5/29/23 documents: I have a physical functioning deficit related to: Mobility impairment, Self care impairment. Interventions include: - Bed mobility assistance of ( ) (Nothing entered) - Call bell within reach - I require mod (moderate) assist x 2 to complete transfers - I require total assist to complete personal hygiene Care plan Focus area dated 5/29/23 documents: Pressure ulcer actual or at risk due to: Right hip fracture s/p (status post) ORIF (Open Reduction Internal Fixation). Interventions include: - Complete Braden Scale per Living Center Policy - Conduct weekly skin inspection - Nutritional and Hydration support - Provide pressure reducing wheelchair cushion - Provide thorough skin care after incontinent episodes and apply barrier cream - Air mattress date Initiated: 6/9/23 - Heel boots date Initiated: 6/9/23 Care plan Focus area dated 6/8/23 documents: Pressure ulcer actual: DTI (Deep Tissue Injury) right heel. Interventions include: - Evaluate need for pain reliever prior to cleansing or dressing changes - Float heels - Provide pressure reducing wheelchair cushion - Provide pressure reduction/relieving mattress - Treatments as ordered - Turning and repositioning every 2-3 hours - Weekly wound assessment Surveyor noted R197 was identified to be at risk for pressure injuries and require extensive physical assistance of 2 persons for bed mobility, however, the care plan did not include interventions of turning and repositioning or offloading of heels until after the SDTI (Suspected Deep Tissue Injury) developed on the right heel. Review of R197's medical record revealed an E-interact form dated 6/3/23 which documented: Pressure ulcer/injury - New onset Grade 2 or higher pressure ulcer/injury. Right heel slightly purple in the center, reddened around the area is blanchable, no open skin noted. [She] has stage one to right heel 3 cm (centimeters) x 3 cm with purple in the center .8 x .3 skin prep to heel BID (twice daily). R197's Point Click Care wound evaluation dated 6/7/23 documented: Pressure - DTI right heel in house acquired. 1.9 x 2.2 cm. Wound bed: Purple tissue. Treatment: skin prep. Additional care: cushion, mattress with pump, other,specify: float heels. R197's June, 2022 Medication Administration Record (MAR) documented: Skin Prep wipes miscellaneous (ostomy supplies) Apply to Rt (right) heel topically one time a day for DTI - order date 6/9/23. Surveyor noted a 1 week delay in treatment of R197's right heel DTI. R197's right heel DTI was identified on 6/3/23 and no treatment was ordered until 6/9/23 and treatment was not started until 6/10/23. In addition, R197's care plan was not revised to include turning and repositioning every 2-3 hours and offload heels until 6/8/23, 5 days after the DTI was identified even though R197 was identified to be at risk for the development of pressure injuries upon admission to the facility on [DATE]. On 6/12/23, at 10:21 AM, Surveyor observed R197 lying in bed on her back. Surveyor noted an air mattress on the bed and R197 was wearing Prevalon boots on both feet. On 6/12/23, at 1:12 PM, Surveyor observed R197 lying in bed with the head of bed elevated and a meal tray on the tray table in front of her. Surveyor observed R197's heels were not offloaded, her heels were resting directly on the mattress and the Prevalon boots were on the dresser in the corner. Surveyor asked R197 if she is able to lift her right leg off the bed. R197 attempted to lift her leg off the bed, but was unable, stating: I just can't do anything anymore. R197 informed Surveyor she needed to be up higher to eat. Surveyor encouraged her to put the call light on, which she did. Within 30 seconds, the facility Social Worker (unknown name) entered the room to answer the light. R197 asked for chicken soup or broth. The Social Worker left the room, but did not turn the call light off. On 6/12/23, at 1:17 PM, Certified Nursing Assistant (CNA)-DD entered R197's room to answer the call light. Surveyor heard another staff member say someone is getting her some chicken soup. R197 informed CNA-DD she did not want anything else on her tray and CNA-DD removed the tray from her room. Surveyor noted although R197's heels remained resting directly on the mattress and the Prevalon boots were on the dresser, R197 was not repositioned to offload their heels. On 6/12/23, at 1:19 PM, The Social Worker returned to R197's room with soup/broth. The Social Worker advised another staff member R197 needed a spoon, as their tray had been removed. On 6/12/23, at 1:20 PM, CNA-DD brought R197 a plastic spoon and left the room. Surveyor observed R197 struggling to eat the soup stating: I can't reach it and I can't even keep the soup on this spoon. Surveyor asked CNA-DD (in hall) to accompany to R197's room. R197's told CNA-DD she needed to be up higher and couldn't reach her soup. CNA-DD left the room to find assistance. On 6/12/23, at 1:23 PM, Surveyor observed CNA-DD and another staff member enter R197's room. After the staff members left R197's room, Surveyor noted R197 to be positioned more upright to eat, however, Surveyor noted R197's heels remained resting directly on the mattress and the Prevalon boots were in the corner. On 6/12/23, at 1:28 PM, Surveyor observed R197 taking sips of the chicken broth. R197 remained positioned upright with the head of bed elevated. Surveyor noted R197's heels remained resting directly on the mattress and the Prevalon boots remained on the dresser. On 6/13/23, at 7:58 AM, Surveyor spoke with R197 and asked how they were feeling today. R197 stated: OK, but my right heel hurts so bad, I can't understand why. Surveyor observed R197 to be wearing Prevalon boots on both feet. On 6/13/23, at 11:44 AM, Surveyor observed R197 lying in bed on her back with her head on a pillow. Surveyor observed the Prevalon boots on the dresser. Surveyor observed R197 to be wearing socks and a pillow under R197's calves, however the pillow was flat and both of her heels were resting directly on the mattress. On 6/13/23, at 1:54 PM, Surveyor advised Director of Nursing (DON)-B of concern R197's DTI was identified on 6/3/23, but no treatment was implemented until 6/10/23. DON-B reported she would look and gather all information to review. No additional information was provided. On 6/13/23, at 2:35 PM, Surveyor observed R197's wound care with Nurse Manager-I and Regional Director of Wound Management-J. Nurse Manager-I removed R197's blanket revealing the flat pillow under R197's calves and heels resting directly on the mattress. Surveyor asked Nurse Manager-I if R197 should have their heels offloaded. Nurse Manager-I stated: Yes, she should be wearing her boots, I don't know why they're not on, they're right there (pointing at Prevalon boots on the dresser). Nurse Manager-I removed R197's right sock revealing a dark purple DTI to the right medial heel with redness surrounding the peri wound. Regional Director of Wound Management-J utilized her phone to obtain a picture and measurements of the pressure injury which measured 1.7 x 1.9 cm. Observation of R197's left heal revealed no signs or symptoms of pressure injury. On 6/14/23, at 10:26 AM, Surveyor observed R197 sitting up in her wheelchair, dressed, wearing regular socks. R197's heels were not offloaded, both feet were resting directly on the foot pedals. Surveyor observed the Prevalon boots on the dresser in R197's room. On 6/14/23, at 1:19 PM, Surveyor spoke with DON-B. Surveyor advised DON-B of the following concerns: R197 admitted to the facility with no pressure injuries, and was identified to be at risk. She was dependent for bed mobility and unable to lift her right leg off the bed. There were no care plan interventions for turning/repositioning or offloading of heels to prevent pressure until after the DTI developed. The DTI was identified on 6/3/23, however no treatment was implemented until 6/10/23. The initial assessment on 6/3/23 documented the area as stage 1 although listed as purple in center. Reddened surrounding skin documented as blanchable, but no mention of blanching of the purple area. Surveyor asked how she would expect the area to be staged. DON-B stated: It should have been documented as a SDTI. Surveyor advised DON-B of observations on survey: R197 not wearing Prevalon boots, heels not offloaded/lying directly on the mattress and resting directly on foot pedals. DON-B reported she understands the concerns and has already done education with nursing staff. 2.) R21 admitted to the facility on [DATE] with Hospice services and has diagnoses that include acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure and morbid obesity. R21's Braden Scale for Predicting Pressure Sore Risk dated 4/28/23 documented a score of 16 - at risk. R21's Admission Minimum Data Set (MDS) dated [DATE] documents bed mobility and transfer as limited 1 person assist. Functional limitation in ROM (range of motion) - no impairment. R21's Care plan Focus area dated 4/30/23 documents: Pressure ulcer actual due to: Pressure Ulcer Present on coccyx. Interventions include: - Float heels - Notify practitioner if symptoms worsen or do not resolve - Provide pressure reducing wheelchair cushion - Complete Braden Scale per Living Center Policy - Provide thorough skin care after incontinent episodes and apply barrier cream - Weekly Wound assessment R21's medical record indicated R21 was admitted to the facility with a stage 2 pressure injury to the coccyx. Progress notes document: 4/28/23, Resident arrived to facility @1140 (11:40 AM) via ambulance, resident is officially [Name of hospice provider] Hospice Care. She is A/O (alert and oriented) x 1/2 forgetful, denies pain at this time. Observed pressure ulcer injury to coccyx wound bed is pink and moist, linear in shape, has minimal serous drainage noted. 100% granulation and measurement is 2.0 x 1.5 x 0.1. R21's April 2022 Treatment Administration Record (TAR) documented wound care orders dated 4/30/23: Coccyx wound: Cleanse with NS (normal saline) F/B (followed by) medi honey F/B gauze island daily and prn (as needed) soiling as needed for wound care. Surveyor noted R21 admitted on [DATE] with a stage 2 pressure injury, however treatment orders were not obtained until 4/30/23. In addition, the treatment was entered on the TAR as PRN and not scheduled for a specific time or shift, thus the treatment was not signed out as having been completed on 4/30/23. R21's May 2022 TAR documented the coccyx treatment: Cleanse with NS F/B medi honey F/B gauze island daily and prn soiling in the evening for wound care scheduled for 8:00 PM. Surveyor noted several missing signatures indicating the treatment was either not completed or not documented. On 5/22/23 the treatment was changed to barrier cream every shift for wound care. Measurements on 5/25/23 were 1.0 x 0.6 no depth. On 6/4/23 measurements were 1.0 x 0.6 no depth. (The wound has decreased in size.) On 6/12/23, at 10:48 AM, Surveyor observed R21 sitting on a pillow in her wheelchair and not a pressure reducing cushion as indicated on her care plan. On 6/12/23, at 2:29 PM, Surveyor observed R21 sitting on a pillow in her wheelchair and not a pressure reducing cushion as indicated on her care plan. On 6/14/23, at 9:50 AM, Surveyor observed R21 sitting on a blue cushion in a wheelchair. Surveyor asked about the cushion. R21 stated: They just gave that to me. I had one awhile ago, but I don't know what happened to it, so I was using the pillow to sit on. On 6/14/23, at 1:19 PM, Surveyor advised Director of Nursing (DON)-B of concerns regarding R21 pressure injury: Resident admitted with stage 2 pressure injury to the coccyx on 4/28/23. No treatment was ordered until 2 days later on 4/30/23 and treatment was not implemented on the TAR until 5/1/23. Observations on survey of care plan interventions/pressure reducing cushion not on wheelchair, observed resident sitting on pillow. DON-B reported she understands the concerns and has already done education with nursing staff. 3.) R199 admitted to the facility on [DATE] receiving Hospice services and has diagnoses that include encephalopathy, secondary malignant neoplasm of brain, generalized idiopathic epilepsy and personal history of other diseases of the digestive system. R199's Braden Scale for Predicting Pressure Sore Risk dated 6/5/23 documented a score of 21 - not at risk, although R199 admitted to the facility with a stage 2 pressure injury. R199's Braden Scale for Predicting Pressure Sore risk dated 6/12/23 documented a score of 10 - high risk. R199's Care Plan Focus area dated 6/8/23 documents: Pressure ulcer at risk due to: Decreased mobility. Stage 2 to coccyx upon admit. Interventions include: - Float heels - Provide pressure reducing wheelchair cushion - Provide pressure reduction/relieving mattress - Turning and repositioning schedule per assessment R199's medical record indicated R199 was admitted with a stage 2 pressure injury to the coccyx. R199's Clinical Admission form dated 6/5/23 documented: Location - coccyx. Skin issue - Pressure ulcer/injury. Surveyor noted there was no description, staging, or measurements of the wound. R199's Point Click Care/Electronic Medical Record wound evaluation dated 6/7/23 documented: Stage 2 Pressure Injury coccyx present on admission. 3.7 x 1.9 cm (centimeters), 100% granulation. On 6/12/23, at 10:33 AM, Surveyor observed R199 lying in bed on their back, asleep. An air mattress was on the bed and their heels were offloaded on a pillow. On 6/13/23, at 8:59 AM, Surveyor observed R199 lying in bed on his back, asleep. Care plan interventions of air mattress and offloading heels were in place. R199's June 2022 Treatment Administration Record (TAR) documented wound care orders dated 6/8/23: Coccyx wound: Cleanse with NS (normal saline) F/B (followed by) medi honey F/B foam border every day shift for wound care, which was not signed out as completed - D/C (discontinue) date of 6/9/23. Coccyx wound: Cleanse with NS F/B medi honey F/B foam border every evening shift for wound care - order date 6/9/23. Surveyor noted R199 admitted on [DATE] with a stage 2 pressure injury, however treatment orders were not obtained until 6/8/23 and not implemented on the TAR until 6/9/23. On 6/13/23, at 1:47 PM, Surveyor advised DON-B of concerns regarding R199's pressure injury: R199 admitted to the facility on [DATE] with a pressure injury. There was no assessment, staging or measurements of the wound upon admission. Treatment for the pressure injury was not ordered until 6/8/23 and not implemented until 6/9/23. R199's admission Braden score indicated a score of 21- not at risk, although R199 admitted to the facility with a pressure injury. DON-B stated: Yeah, that's not right. DON-B looked at the TAR and stated: I see that, maybe they were just using barrier cream until a treatment was ordered. DON-B reported an LPN (Licensed Practical Nurse) identified the pressure injury on 6/5/23, but did not stage or measure the wound. I came in a couple of days later on the 7th and did my assessment and measurements and ordered a new treatment, but I see that it didn't get started until the 9th. DON-B reported she understands the concerns and has already done education with nursing staff. 20483 4.) R22 was admitted to the facility on [DATE]. Diagnoses includes diabetes mellitus, hypertension, heart failure, atrial fibrillation, chronic kidney disease, and depression. R22 was discharged on [DATE]. The hospital discharge summary dated 5/23/23 under primary discharge diagnoses includes Stage 4 pressure ulcer on coccyx, POA (present on admission). The Braden assessment dated [DATE] has a score of 21 which indicates not at risk for the development of pressure injuries. The clinical admitted d 5/23/23 includes documentation of Skin: Skin warm & dry, skin color WNL (within normal limit) and turgor is normal. Skin Issue: #001: New. Issue type: Pressure ulcer/ injury. Location: Coccyx (Back of body above buttocks). Skin Issue: #002: New. Issue type: Other skin issue. Location: Left shin. Other skin issue description: healed venous ulcer. Wound odor: No. Painful: No. Skin Issue: #003: New. Issue type: Pressure ulcer/ injury. Location: Right heel. Painful: No. Skin Issue: #004: New. Issue type: Bruising. Location: Left anterior elbow. Painful: No. Skin note: drsg (dressing) intact and dry to Rt (right) heel and coccyx, healed venous ulcer The physician's order with an order date of 5/24/23 documents, Coccyx wound: Cleanse with normal saline f/b (followed by) Acticoat f/b dry dressing 3x (times) a week and prn every day shift every Mon (Monday), Wed (Wednesday), and Fri (Friday) for wound care. Surveyor noted R22 was admitted on [DATE] and the treatment for R22's coccyx did not start until 5/26/23, 3 days later. Review of R22's May 2023 TAR (treatment administration record) reveals the treatment is not initialed as being completed on 5/29. Review of R22's June 2023 TAR reveals on 6/9 code 7 is documented. 7 is other/see nurses notes. The EMAR (electronic medication administration note) dated 6/7/23 documents, Patient not in her room. The physician's orders with an order date of 5/24/23 documents, Right heel wound cleanse with NS (normal saline) f/b (followed by) Acticoat f/b dry dressing 3x (times) a week and PRN every day shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound care. Surveyor noted R22 was admitted on [DATE] and the treatment for R22's right heel pressure injury did not start until 5/26/23, 3 days later. Review of R22's May 2023 TAR (treatment administration record) reveals the treatment is not initialed as being completed on 5/29. Review of R22's June 2023 TAR reveals on 6/9 code 7 is documented. 7 is other/see nurses notes. The EMAR (electronic medication administration note) dated 6/7/23 documents Patient not in her room. The physician's orders with an order date of 5/25/23 documents, Diabetic foot checks at hs (hour sleep) at bedtime. The admission MDS (minimum data set) with an assessment reference date of 5/25/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R22 is assessed as requiring extensive assistance with one person physical assist for bed mobility, transfer, ambulating in room, and toilet use. R22 is occasionally incontinent of urine and bowel was not rated. R22 is assessed as having a pressure injury, however, the MDS documents, no for the question is this resident at risk of developing pressure ulcers and is assessed as having one Stage 2 pressure injury present on admission and one Stage 4 pressure injury present on admission. The pressure injury CAA (care area assessment) dated 5/29/23 under analysis of findings documents, stage 4, stage 2- see skin sheets. Recent hospitalization for hyperkalemia, encephalopathy, stage 4 coccyx. Daily antidepressant, lasix, IDDM (insulin dependent diabetes mellitus), ABT (antibiotic), anticoag (anticoagulant). RD (Registered Dietitian) intervention, Nystatin to knee- rash. Barrier applied. Items in reach in well-lit area. Therapy ppoc (patient plan of care). Skin and pain monitored. Pressure reducing devices in place. Update MD (medical doctor) as needed. Assist w (with) ADLs (activities daily living) as needed. Monitor skin. Under care plan considerations documents Recent hospitalization for hyperkalemia, encephalopathy, stage 4 coccyx. Daily antidepressant, lasix, IDDM, ABT, anticoag. RD intervention, Nystatin to knee- rash. Barrier applied. Items in reach in well-lit area. Therapy ppoc. Skin and pain monitored. Pressure reducing devices in place. Update MD as needed. Assist w ADLs as needed. The pressure ulcer actual or at risk care plan initiated 5/29/23 has the following interventions: * Complete Braden Scale per Living Center policy initiated 5/29/23. * Conduct weekly skin inspection initiated 5/29/23. * Evaluate need for pain reliever prior to cleansing or dressing changes initiated 5/29/23. * Float heels initiated & revised on 5/29/23. * Monitor vitals signs as needed initiated 5/29/23. * Notify practitioner if symptoms worsen or do not resolve initiated 5/29/23. * Nutritional and Hydration support initiated 5/29/23. * Provide pressure reducing wheelchair cushion initiated 5/29/23. * Provide pressure reduction/relieving mattress initiated 5/29/23. * Provide thorough skin care after incontinent episodes and apply barrier cream initiated & revised 5/29/23. * Treatments as ordered initiated 5/29/23. The Braden assessment dated [DATE] has a score of 18 which indicates at risk. The skin only evaluation dated 5/31/23 documents, Skin Issue: Pressure ulcer/Injury Location: Coccyx (Back of body above buttocks). Skin Issue: Pressure ulcer / Injury Location: Right heel. Wound exudate: Sanguineous: bloody drainage Painful: No. Surveyor notes this skin only evaluation is not a comprehensive assessment as there is no staging of the pressure injuries, measurements, description of wound bed, whether the pressure injuries are infected and description of the surrounding tissue. Coccyx assessments The skin & wound evaluation dated 5/24/23 for type documents, pressure, Stage: Stage 2, location: Coccyx, & acquired, present on admission. Under wound measurements length is 1.2 cm (centimeters), width is 0.4 cm and depth is 0.1. Undermining & tunneling is not applicable. The wound bed and evidence of infection has not been completed. The exudate is light serosanguineous. The periwound section for edges and surrounding tissue have not been completed. Surveyor notes there is no assessment for R22's coccyx pressure injury during the week of 5/28/23 to 6/3/23. The skin & wound evaluation dated 6/7/23 for type documents: pressure, Stage: Stage 2, location: Coccyx, & acquired is present on admission. Under wound measurements length is 0.7 cm (centimeters), width is 0.4 cm and depth is 0.4 cm. Undermining & tunneling is not applicable. The wound bed is checked for granulation with 100% of wound bed filled and evidence of infection is checked for none. The exudate is moderate serous. The periwound section for edges is checked for rolled edges and surrounding tissue is checked for intact: unbroken skin & normal in color. Right heel assessments The skin & wound evaluation dated 5/24/23 for type documents: pressure, Stage is Stage 2, location: Right Heel, & acquired: present on admission. Under wound measurements length is 1.0 cm, width is 0.8 cm, depth is 0.1 cm and for undermining and tunneling not applicable is documented. Wound bed is checked for epithelial with 90% of wound covered. Surveyor notes there is no assessment of the other 10% of the wound bed. Evidence of infection is none & exudate is moderate serosanguineous. The periwound section for edges has not been completed and surrounding tissue is checked for macerated: Wet, white, waterlogged tissue. Surveyor notes there is no assessment for R22's right heel pressure injury during the week of 5/28/23 to 6/3/23. The skin & wound evaluation dated 6/7/23 for type documents: pressure, Stage: Stage 2, location: Right Heel, & acquired: present on admission. Under wound measurements length is 2.4 cm, width is 2.0 cm, depth is not applicable and for undermining and tunneling not applicable is documented. [Note: Wound has increased in size.] Wound bed is checked for epithelial with 100% of wound covered & granulation 10% of wound filled. Surveyor noted the wound bed is assessed as 110% not 100%. Evidence of infection is none & exudate is moderate serous. The periwound section for edges is attached and surrounding tissue is checked for normal in color. Surveyor noted there was no revision in R22's pressure injury care plan after the pressure injury increased in size. The IDT (interdisciplinary team) note dated 6/8/23 documents, Resident has a stage two to right heel and coccyx stage 2. Being followed by wound clinic Resident on Juven BID (twice a day), Magic cup BID, Mvi (multivitamin) with minerals. Prealbumin 17. Interventions remains appropriate. Will cont (continue) to monitor. On 6/12/23, at 11:03 a.m., Surveyor observed R22 sitting in a wheelchair in her room. R22 is wearing slippers and has her feet on the foot rests. Surveyor asked R22 if she has any skin concerns. R22 informed Surveyor she has a pressure ulcer on her butt and stated not much of a change, it's not better but not worse. R22 informed Surveyor she came in with the pressure ulcer. Surveyor asked R22 if she has a cushion in her wheelchair R22 replied yes. Surveyor asked permission to observe the treatment for her pressure injury, R22 gave Surveyor permission. On 6/13/23, at 7:18 a.m., Surveyor ob [TRUNCATED]

Based on observation, interview, and record review the Facility did not ensure 4 (R96, R38, R246, & R6) of 8 Residents reviewed for accidents received care and services to prevent accidents. * R96 transferred herself onto the toilet. CNA (Certified Nursing Assistant)-X entered the bathroom and did not place a gait belt on R96 according to R96's plan of care. CNA-X assisted R96 off the toilet, R96 washed her hands, R96 then reached for the walker and fell . R96 sustained a femur fracture. R96 was moved by CNA-X & CNA-KK prior to RN-AA assessing R96. * The Facility did not determine a root cause following R38's fall on 5/21/23, did not investigate or determine root cause of R38's fall on 5/27/23 and did not implement any interventions on R38's at risk for falls care plan. On 6/19/23, R38 was observed attempting to get out of bed. R38's call light was on the floor by the footboard of the bed & not within R38's reach. * R246 had 3 falls. There was no IDT (interdisciplinary team) review and the fall prevention interventions were not appropriate for the root cause of the falls. * R6's falls care plan has an intervention for a low bed. R6 was observed not in a low bed. R96 is being cited at severity level 3 (actual harm). Findings include: The Falls Management process policy dated 9/21/20 documents, . 1. In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present (fire, highway etc.). Remain with the resident while calling for assistance, if at all possible. 11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. The nurse will determine the most appropriate intervention, implement, and update care plan. The Use of Gait Belt Policy, not dated, documents, . It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Under Policy Explanation and Compliance Guidelines documents . 3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. 1) R96 was admitted to the facility on [DATE] and discharged on [DATE]. The Clinical Admission assessment dated [DATE] includes documentation of, Able to move all extremities. Upper extremity ROM (range of motion): No impairment. Lower extremity ROM: No impairment. Gait is unsteady. Balance is poor. The fall risk assessment dated [DATE] has a score of 11, which indicates at risk for falls. The at risk for falls care plan initiated 4/19/23 has an intervention of Gait belt with transfers, initiated & revised 4/19/23. The I have a physical functioning deficit related to mobility impairment, self care impairment care plan initiated 4/20/23 includes interventions of: * Gait belt with transfers, initiated & revised 4/19/23. * I require 2 ww (two wheeled walker), initiated & revised 4/20/23. * I require max (maximum) assist to complete toileting, initiated & revised 4/20/23. * I required mod (moderate) assist to complete transfers, initiated & revised 4/20/23. The admission MDS (minimum data set) with an assessment reference date of 4/21/23 has a BIMS (brief interview mental status) score of 00 which indicates severe impairment. R96 is assessed as requiring limited assistance with one person for bed mobility, transfer, & toilet use and does not ambulate. R96 is assessed as being occasionally incontinent of urine and continent of bowel. R96 has not had any falls prior to admission and has not fallen since assessment. The fall CAA (care area assessment) dated 5/3/23 under of analysis of findings documents [AGE] year old [gender] recently admitted after a hospital stay for UTI (urinary tract infection) and general weakness. Other dx (diagnoses) include but are not limited to dementia, arthritis, A fib (atrial fibrillation), CAD (coronary artery disease), CHF (congestive heart failure), and osteoporosis. [R96's first name] triggered the falls CAA because she has impaired mobility and poor balance. [R96's first name] is at risk for functional decline, falls, and related injury. Plan is for [R96's first name] to participate in MD (medical doctor) ordered therapy and to monitor fall risk. Goal is for [R96's first name] to improve her functional status and to not fall. Care plan in place The nurses note dated 5/10/23 documents, Resident sent out 911 due to witnessed fall and c/o (complaint of) pain to left hip and leg. [Physician's name] made aware as well as son. The EMAR (electronic medication administration record) note dated 5/10/23 documents, Resident sent to hospital at 1530, (3:30 p.m.) later admitted . The post fall evaluation dated 5/10/23, at 19:22 (7:22 p.m.) documents, Fall Details: Date / Time of Fall: 05/10/2023, 3:15 PM Fall was witnessed. Who witnessed fall: [CNA (Certified Nursing Assistant)-X's name] Fall occurred in the bathroom. Resident was reaching for item(s) at time of the fall. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: Resident was c/o pain in her left leg and hip. Did fall result in an ER (emergency room ) visit/hospitalization : Yes. ER Visit/hospitalization Details: 911 called. ER called to inform us of admit due to fracture of left femur. Provider: [Physician's name]. Time notified: 05/10/2023. Notified of: fall. Fall Details Note: resident fell in bathroom reaching for walker after washing her hands with CNA in attendance. Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: Yes. Footwear at time of fall: Shoes. Resident was using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Bedside call light on when Resident was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Medication Changes: Recent change to Resident's medications: No. Vitals: T (temperature) 97.8 - 5/10/2023 19:26 (7:26 p.m.) Route: Forehead (non-contact) BP (blood pressure) 173/120 - 5/10/2023 19:26 (7:26 p.m.) Position: Sitting r (right)/arm. P (pulse) 125 - 5/10/2023 19:26 (7:26 p.m.) Pulse Type: Regular Character: Normal. R (respirations) 18 - 5/10/2023 19:26 (7:26 p.m.) W (weight) 164.4 lb (pounds) - 5/9/2023 14:40 (2:40 p.m.) Scale: Wheelchair Pain: Indicators of pain: Vocal complaints of pain. Pain Issue: #001: New. Location: Left thigh - generalized. Pain score: 5. Sharp. Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Physical Findings: Change in diagnosis status: No. Recent diagnosis of stroke, TIA (transient ischaemic attack) or arrhythmia: No. Decrease in fluid intake: No. Change in blood glucose levels: No. Change in blood pressure: No. Change in mental status: No. Change in behaviors: No. Change in mobility status: No. Recent weight loss: No. Sensory impairment: No. Resident does not have orthostatic BP changes. Surveyor reviewed the Facility's investigation and noted the Facility self reported this incident according to regulations and the Facility obtained statements from CNA-X, RN (Registered Nurse)-AA and CNA-KK. CNA-X's handwritten statement dated 5/10/23 documents, [CNA-X's name] I was a witness to a resident fall [R96's name]. She was in the bathroom I transferred her from the toilet to the sink. She wanted to wash her hands reaching for her walker and lost her balance and felt [sic] (fell ) to the floor. Between the toilet and the wall in a sitting position. CNA-KK's handwritten statement dated 5/10/23 documents, At about 1515 (3:15 p.m.) I was walking past [room number], when my co-worker [CNA-X's first name] called my name. [CNA-X's first name] was hold up [room number] [R96's first name] in the doorway of the bathroom with [R96's first name] leaning on the door jamb and holding her walker. [R96's first name] wheelchair was outside the door (bathroom) and [CNA-X's first name] and I attempted to pivot [R96's first name] so she could get in her wheelchair, but her legs buckled and [CNA-X's first name] and I lowered [R96's first name] to the floor. RN-AA's statement in an email to Prior DON (Director of Nursing)-HH dated 5/11/23 documents, [CNA-KK's first name] came and got me to tell me [room number] was on the floor. When I came in the room the resident was sitting in the bathroom doorway with her butt in the bathroom and her feet on the doorway. I was told she fell in the bathroom and it was witness by [CNA-X's name]. I asked her and the resident if she hit her head. The resident said no and [CNA-X's first name] said she may have hit her head on the wall. I assessed her head and asked the resident what happened. She did not remember. I was told by [CNA-X's first name] that she was on the toilet. She stood up to wash her hands and lost her balance reaching for her walker. She fell between the wall and toilet. I asked how she got over by the door and was not given an answer. [CNA-KK's first name] proceeded to raise her right leg and then her left leg when she let out a scream in pain. I went and told [first name] she fell , text [Physician's name] and called 911. I also called her son. On 6/15/23, at 3:51 p.m., Surveyor asked RN-AA if she could tell Surveyor what she remembers about R96's fall on 5/10/23. RN-AA informed Surveyor she was at the nurses station when CNA-KK came and got her indicating they needed her help with a patient who had fallen. RN-AA informed Surveyor she went to R96's room and R96 had her feet up against the door frame. RN-AA indicated she asked the aide what happened and was told she (CNA-X) stood R96 off the toilet, R96 went to wash her hands then reached for her walker and fell . RN-AA informed Surveyor CNA-KK said R96 was not complaining of anything so lets get her up. A gait belt was placed on R96. RN-AA informed Surveyor she couldn't remember if she or CNA-KK placed the gait belt on. RN-AA informed Surveyor they went to put R96's left leg up and R96 hollered. RN-AA informed Surveyor she told CNA-KK not to move R96 and 911 was called. RN-AA informed Surveyor she called the doctor and R96's son. Surveyor asked RN-AA if she asked how R96 got over to the doorway. RN-AA informed Surveyor she never got a clear answer, doesn't want to accuse people of anything but she's not stupid. Surveyor inquired if CNA-KK was working. RN-AA informed Surveyor CNA-KK is on vacation. On 6/15/23, at 4:02 p.m., Surveyor asked CNA-X to tell Surveyor what she remembers about R96's fall on 5/10/23. CNA-X informed Surveyor she remembers she was walking down the hall and RN-AA asked her to go to the room because she didn't want R96 walking around. CNA-X informed Surveyor she went to the room and R96 was sitting on the toilet and she went to get her walker. CNA-X indicated R96 got up off the toilet & stated she wanted to wash her hands. CNA-X informed Surveyor she was standing a little behind her when R96 turn away and that's when she slipped and fell . Surveyor asked where R96 fell . CNA-X informed Surveyor she fell between the toilet and wall. Surveyor asked after R96 fell what did she do. CNA-X indicated she stuck her head out of the doorway and called for help. Surveyor asked if anyone came to help her. CNA-X replied yes [CNA-KK's first name]. CNA-X indicated after CNA-KK came in she doesn't know if they tried to get R96 up and that's when R96 complained of hip pain. Surveyor asked CNA-X how to explain how they tried to get R96 up. CNA-X informed Surveyor they asked R96 if anything hurt then stated I don't know it's been a minute, we couldn't get her all the way, when she complained of pain they laid her there and got the nurses. Surveyor asked CNA-X when R96 was on the toilet did she put a gait belt around R96. CNA-X replied no I didn't see a gait belt. On 6/19/23, at 7:20 a.m., Surveyor asked DON (Director of Nursing)-B if a Resident's care plan documents a gait belt to be used with transfers and a CNA observed a Resident who had placed themselves on the toilet, should the CNA place a gait belt on that Resident prior to getting the Resident off the toilet. DON-B informed Surveyor should always put a gait belt on unless independent. Surveyor informed DON-B the Resident is not independent. DON-B replied yes there should be a gait belt. On 6/19/23, at 7:53 a.m., Surveyor asked Administrator-A how the Facility found out R96 sustained a fracture femur. Administrator-A informed Surveyor from the hospital. Surveyor asked Administrator-A if she investigated R96's fall on 5/10/23. Administrator-A replied I believe I did, looked at the investigation and stated yes I did. Surveyor asked during the investigation did you find out if a gait belt was used. Administrator-A replied no this one self transferred to the bathroom, the aide went in to assist her, the resident had already been on the toilet. Surveyor asked Administrator-A if she asked CNA-X why she didn't put a gait belt on R96. Administrator-A informed Surveyor the resident was trying to get up. Surveyor informed Administrator-A of the concern R96's fall prevention interventions were not in place at the time of the witnessed fall and staff attempted to move R96 prior to the RN assessment after the fall. 2) R38 was admitted to the facility on [DATE]. The Clinical Admission assessment dated [DATE] includes documentation of Safety Note: patient is high fall risk. The fall risk assessment dated [DATE] has a score of 19 which indicates high risk for falls. R38's at risk for falls care plan, initiated 5/21/23, does not have any interventions documented. R38's physical functioning deficit care plan, initiated 5/22/23, includes an intervention also dated 5/22/23 of Call bell within reach. The nurses note dated 5/21/22, documents Pt (patient) had a fall and was found at 5:15 this morning Sunday May 21st. He has a new skin tears to his left arm. I called and left a message for his daughter [name]. [First name of DON (Director of Nursing)-B] is aware. The incident report dated 5/21/23, 05:00 (5:00 a.m.), under the section incident description for nursing description documents, resident heard calling out for help when staff entered room and observed resident out of bed and holding on to a chair in the room by the window blood observed in bed and to LUE (left upper extremity), skin tear noted, first aide provided neuro checks initiated, VS (vital signs) checked skin and neuro assessments completed. Under resident description documents, dementia. Under immediate action taken for description documents, first aide to injury vs (vital signs) taken, neuro/skin assessment. Under injuries observed at time of incident for injury type documents, skin tear and injury location is left antecubital. The incident report dated 5/21/23, at 16:45 (4:45 p.m.), under the section incident description for nursing description, documents, Writer observed resident in his room sitting on bathroom floor. Under resident description documents, dementia. Under immediate action taken for description documents, VSS (vital signs stable), skin assessment: skin tear noted to posterior of rue (right upper extremity) area clean and dried, currently on neuro checks. Under injuries observed at time of incident documents, for injury type skin tear and for injury location right elbow. The post fall evaluation dated 5/22/23, at 05:56 (5:56 a.m.), (for fall on 5/21/23 at 4:45 p.m.) documents, Fall Details: Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: unwitnessed. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: s/t (skin tear) anterior RUE (right upper extremity) Did fall result in an ER (emergency room ) visit/hospitalization : No. Provider: [Physician's name] Time notified: 05/21/2023 Notified of: fall/injury. Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: Yes. Footwear at time of fall: Non-skid shoes/socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Incontinent at time of fall: No. Bedside call light on when Resident was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Medication Changes: Recent change to Resident's medications: No. Vitals: W (weight) 181.0 lb - 5/21/2023 10:45 Scale: Wheelchair Pain: Indicators of pain: None. Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Skin note: skin tear to RUE Skin Issue: #001: Needs Review. Issue type: Skin tear. Location: Left forearm. Skin Issue: #002: Needs Review. Issue type: Pressure ulcer/ injury. Location: Left buttock. Wound odor: No. Tunneling: No. Undermining: No. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Physical Findings: Change in diagnosis status: No. Recent diagnosis of stroke, TIA (transcient ischaemic attack) or arrhythmia: No. Decrease in fluid intake: No. Change in blood glucose levels: No. The EMAR (electronic medication administration record) note dated 5/22/23 documents, Resident placed in view of staff and q (every) 15 min (minute) checks provided, is high risk for fall. Skin tear to RUE both clean and dry. Neuro checks wnl, incontinent cares provided by two staff. Resident restless and uncooperative with staff regarding laying down, was up wandering around unit most of shift. Fluids/snacks offered frequently, VSS (vital signs stable). No limitations noted during ROM (range of motion), no other injuries noted. AM (morning) shift to f/u (follow up) with MD (medical doctor). The admission MDS (minimum data set) with an assessment reference date of 5/22/23 has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R38 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility & transfer, extensive assistance with one person physical assist to ambulate in the room, does not ambulate in corridor, and extensive assistance with one person physical assist for toilet use. R38 is assessed as being occasionally incontinent of urine and frequently incontinent of bowel. R38 has fallen one month prior to admission, fallen 2 to 6 months prior to admission and since admission has fallen two or more times with no injury and two or more times with injury not major. The nurses note dated 5/26/23 documents 24 hour board monitoring: room change for increased supervision r/t (related to) fall risk. Adjusting to new room/environment well. No attempts made to self transfer. Stood with assist of two and gait belt, pivot transferred into w/c (wheelchair). Dined in main dining room for meals. Appetite good. Alert with confusion. Toileted every 2-3 hours for check and change. Continues to follow plan of care. Participated in therapies and tolerated well. The nurses note dated 5/27/23, at 21:32 (9:32 p.m.), documents, Pt (patient) slid out of w/c trying to pick something off the floor. pt wasn't hurt. pt put on neuro checks. daughter was informed and [Physician's name]. The fall CAA (care area assessment) dated 5/28/23 under analysis of findings documents Resident has had multiple falls since admission into the facility. He also had multiple falls prior to admission. Under care plan considerations Care plan to address and to minimize the risk for falls. On 6/12/23, at 1:56 p.m., Surveyor observed R38 propelling self in wheelchair by moving his feet. On 6/13/23, at 7:14 a.m., Surveyor observed R38 wearing a sweatshirt with pajama bottoms attempting to place the foot pedals on wheelchair. R38 has socks on his feet with black velcro shoes. On 6/13/23, at 7:44 a.m., Surveyor observed R38 sitting in the wheelchair in the hallway outside the nurses station. Surveyor observed there are no footrests on the wheelchair. On 6/13/23, at 7:48 a.m., Surveyor observed UC (Unit Clerk)-EE place foot rests on R38's wheelchair and wheel R38 towards the dining room. On 6/13/23, at 9:13 a.m., Surveyor observed R38 sitting in a wheelchair in his room. Surveyor asked R38 how he is doing. R38 replied not good. Surveyor asked R38 what was the matter. R38 informed Surveyor he can't get the foot pedals off the chair and he trips on them. On 6/13/23, at 12:39 p.m., Surveyor observed R38 sitting on the edge of the bed with the bedspread around his shoulders. R38 is wearing gripper socks and his feet are on the floor. On 6/13/23, at 1:06 p.m., Surveyor observed R38's call light on. CNA (Certified Nursing Assistant)-Z entered R38's room. R38 informed CNA-Z he didn't get his coffee. Surveyor observed CNA-Z return with coffee for R38. On 6/14/23, at 7:43 a.m., Surveyor observed a sign on bulletin board in R38's room Use your call light when you need help! and below bulletin board Do not stand up on your own! Use your call light button for help! On 6/14/23, at 9:04 a.m., Surveyor observed R38 sitting in a wheelchair in his room. Surveyor observed the call light is on. Surveyor asked R38 why he has his call light on. R38 informed Surveyor he's cold and wants a warm blanket. Surveyor asked if staff has taken him to the bathroom. R38 replied I don't need their help anymore. At 9:06 a.m. Surveyor observed staff answer R38's call light and at 9:08 a.m. R38 received a blanket. On 6/14/23, at 11:40 a.m., Surveyor observed R38 sitting in a wheelchair in the bathroom. On 6/14/23, at 11:43 a.m., Surveyor observed CNA-Q wheeling R38 down the hallway towards the dining room. On 6/14/23, at 12:52 p.m., Surveyor observed CNA-CC wheeling R38 out of the dining room and down the hallway. CNA-CC asked R38 if he wants to go to activities for bracelet making. Surveyor then observed CNA-CC wheel R38 towards activities. On 6/14/23, at 2:55 p.m., during the end of the day meeting with Administrator-A and DON (Director of Nursing)-B, Surveyor asked for all R38's fall investigations since date of his admission and informed Facility staff R38's fall care plan does not have any interventions documented. On 6/15/23, at 10:41 a.m., Surveyor informed DON-B Surveyor did not receive any information regarding R38's fall on 5/27/23 and asked DON-B if she could look into this and get back to Surveyor. On 6/15/23, at 12:21 p.m., Surveyor asked DON-B if she was able to find R38's fall investigation for the fall on 5/27/23. DON-B informed Surveyor she wasn't able to find an investigation and she wasn't notified of this fall. On 6/19/23, at 7:17 a.m., Surveyor observed R38 in bed with his legs toward the floor attempting to get up. Surveyor observed the room is dark, the positioning device is up and the call light is on the floor by the foot board. Surveyor approached R38 and R38 informed Surveyor he needs help. Surveyor informed R38 to stay in bed and Surveyor would get him help. Surveyor stayed in the doorway to observe R38 and informed UC (Unit Clerk)-EE who was at the nurses station R38 needs help. UC-EE called CNA-Z informing her R38's room number needs help. Surveyor observed CNA-Z then went into R38's room. On 6/19/23, at 7:24 a.m., Surveyor asked DON-B if R38 can use his call light. DON-B replied yes. On 6/19/23, at 11:08 a.m., Surveyor met with DON-B to discuss R38. Surveyor informed DON-B for R38's falls on 5/21/23 there are no root cause, there is no investigation or root cause for R38's fall on 5/27/23. Surveyor informed DON-B, R38's falls care plan does not have any interventions. DON-B replied really, looked at the care plans in the computer and stated lovely. DON-B informed Surveyor an intervention for a reacher was put in on 6/16/23 following a fall on 6/15/23. DON-B informed Surveyor normally what they do is they want an intervention implemented right away. Surveyor informed DON-B of today's observation with R38 attempting to get out of bed and his call light was on the floor near the foot board. 38253 3) R246 was admitted to the facility on [DATE] with diagnoses of compression fracture of the fourth lumbar vertebra, morbid obesity, anxiety, and Alzheimer's disease. R246 had not been in the facility long enough to have a Minimum Data Set (MDS) assessment completed at the time of survey. R246's At Risk for Falls Care Plan was initiated on 6/3/2023 with the following interventions: -Assess for pain. -Assess that the wheelchair is of the appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety. -Elevated toilet seat. -Encourage fluids. -Encourage rest periods of feeling fatigued. -Footwear to prevent slipping. -Gait belt with transfers. On 6/5/2023, at 4:12 AM, on the Post Fall Evaluation in the progress notes, nursing charted R246 had an unwitnessed fall on 6/4/2023 at 10:45 PM in R246's room when R246 was attempting to go to the bathroom. R246 had bare feet and was not using a cane or walker as instructed. R246 did not have oxygen on as ordered and the call light had not been activated. An incident report was initiated indicating R246 was found on the floor soaking wet and R246 stated R246 was coming back from the bathroom and fell . R246 was educated on using the call light and no self-transferring. On 6/5/2023, at 12:53 PM, on the Post Fall Evaluation in the progress notes, Licensed Practical Nurse (LPN)-F charted R246 had an unwitnessed fall on 6/5/2023 at 10:44 PM. In an interview with LPN-F on 6/14/2023 at 1:19 PM, LPN-F clarified the fall had occurred at 10:44 AM and not 10:45 PM as documented. R246 was attempting to go to the bathroom unassisted. R246 had bare feet and was not using a cane or walker as instructed. R246 did not have oxygen on as ordered and the call light had not been activated. An incident report was initiated by LPN-F indicating R246 was found sitting on the buttocks on the floor next to the bed and R246 stated R246 was trying to get up to go to the bathroom and slipped and fell . R246's At Risk for Falls Care Plan was revised on 6/5/2023 with the following interventions: -Offer toileting upon wakening, after meals, and before bed. -Offer activities of residents liking. On 6/7/2023, at 11:59 AM, on the Post Fall Evaluation in the progress notes, LPN-F charted R246 had an unwitnessed fall in the bathroom on 6/7/2023 at 11:00 AM when R246 self-transferred and tripped and fell . R246 was wearing shoes at the time of the fall. R246 was not using a cane or walker as instructed and did not have oxygen on as ordered. The call light had not been activated. An incident report was initiated by LPN-F indicating R246 was found sitting on the buttocks on the bathroom floor and R246 stated R246 got up to use the bathroom and tripped and fell . R246 was confused at baseline and did not use call light appropriately for needs per staff. R246's At Risk for Falls Care Plan was revised on 6/8/2023 with the intervention to have gripper socks at all times. Surveyor noted this intervention did not address the cause of the fall on 6/7/2023 as R246 was wearing shoes at the time of the fall. Surveyor reviewed R246's medical record. No interdisciplinary team (IDT) notes were found for R246's falls on 6/4/2023, 6/5/2023, or 6/7/2023 showing R246's At Risk for Falls Care Plan was reviewed for appropriate interventions and a root cause analysis was completed to determine what interventions should be initiated to prevent future falls. On 6/12/2023, at 11:13 AM, Surveyor observed R246 in R246's room. R246 was lying in bed with a gown on, which R246 stated was by choice. R246's bed was in a low position and the wheelchair was close to the bed. R246 stated R246 had to go to the bathroom. Surveyor asked R246 if R246 could push the call light for help. R246 located the call light and pushed the button. A Certified Nursing Assistant (CNA) came into the room and asked R246 if R246 needed anything. R246 could not recall that R246 had wanted to go to the bathroom. When the CNA asked R246 if R246 needed to use the bathroom, R246 was not sure. The CNA asked R246 if R246 wanted to use a bed pan. R246 said yes. When the bed pan was provided, R246 refused to use it and stated R246 wanted to go into the bathroom. The CNA assisted R246 to the bathroom. In an interview on 6/14/2023, at 1:19 PM, Surveyor asked LPN-F what the facility process was when a resident had a fall. LPN-F stated whoever finds a resident on the floor leaves them there and gets the nurse to do an evaluation. LPN-F stated the nurse would get vital signs, do neurological checks, check range of motion, and inspect the skin for bleeding or injury. LPN-F stated neurological checks are completed at the time the resident is found and then every 15 minutes for an hour, every 30 minutes for an hour, every hour for four hours, and then the resident is put on the 24-hour board to be monitored every shift. Surveyor asked LPN-F about R246's falls that LPN-F was involved with on 6/5/2023 and 6/7/2023. LPN-F stated R246 has Alzheimer's dementia and has had multiple conversations with the family to get ideas of what to do to keep R246 safe. LPN-F stated after the fall, LPN-F would bring R246 out to the nurses' station while doing all the vital signs and neurological checks to keep an eye on R246 and even then, R246 would walk away. Surveyor asked LPN-F who updates the Fall Care Plan after a resident has a fall. LPN-F stated as the nurse on the floor, they would look at the circumstances of the fall and decide what to do for the resident. LPN-F stated with R246 a very low bed and a fall mat would not be good interventions because R246 gets up and walks and you do not want to have a tripping hazard. LPN-F stated LPN-F tried to implement a lower bed, but R246 is not always compliant. LPN-F stated sometimes R246 does not like to wear shoes, so the gripper socks were an alternate choice for R246. Surveyor asked LPN-F if there is an IDT that meets to review falls. LPN-F stated falls are talked about every morning during the morning report and every Thursday there is an IDT for falls. In an interview on 6/14/2023, at 1:30 PM, Surveyor asked LPN Unit Manager (UM)-E if there is an IDT that reviews falls and how often the IDT meets. LPN UM-E stated the IDT meets every week to review falls. LPN UM-E stated they look at the reason for the fall: if the resident needed to use the bathroom, if the resident has confusion, or what the resident was wearing or not wearing. With that information they determine an intervention that is appropriate. Surveyor reviewed with LPN UM-E R246's falls. LPN UM-E stated after R246 fell on [DATE] the intervention was added to offer toileting after meals and before bed. LPN UM-E stated after the fall on 6/5/2023 the intervention was added to have gripper socks on because R246 had bare feet. Surveyor shared with LPN UM-E the intervention of having gripper socks on was not added to the Falls Care Plan until 6/8/2023, after R246 fell on [DATE] while wearing shoes. LPN UM-E could not recall any other information about the fall re [TRUNCATED]

Based on observation, interview, and record review, the facility did not: identify and seek ways to support resident's individual needs through the assessment and care planning process, make referrals and obtain needed services from outside entities, and provide and arrange for needed mental and psychosocial services related to difficulty coping with change in condition and loss of meaningful life, and need for emotional support for 1 of 1 Residents (R6) reviewed for medically related social services. R6 was not provided medical related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. *R6's electronic medical record (EMR) documents that R6 had suicidal ideation on [DATE], and was given a 30 day discharge notice on [DATE], 1 day after having suicidal ideation. There is no documentation that at any point, R6 was being monitored for any psychosocial symptoms, care plan interventions were not followed through with, and R6's mental health issues were not being addressed through medications, psychological services, non pharmacological interventions, or support from the Interdisciplinary Team (IDT.) Findings include: Surveyor reviewed the facility's Behavioral Health Services policy and procedure implemented [DATE], which states in part: .It is the policy of this facility to ensure all Residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. Policy Explanation and Compliance Guidelines: 1. Behavioral health encompasses a Resident's whole emotional ad mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma or post-traumatic stress disorders . 4. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 5. Conditions that are frequently seen in nursing home Residents and may require facility to provide specialized services and supports based upon Resident's individuals needs, include, but are not limited to: a. Depression b. Anxiety c. Schizophrenia d. Bipolar 6. The facility uses the comprehensive assessment process for identifying and assessing a Resident's mental and psychosocial status and providing person-centered care. This process includes, but is not limited to: a. PASRR (Preadmission Screening and Resident Review) screening b. Obtaining history from medical records, the Resident, and as appropriate the Resident's family and friends, regarding mental, psychosocial, and emotional health c. MDS (Minimum Data Set) and care area assessment d. Ongoing monitoring of mood and behavior e. Care plan development and implementation f. Evaluation 7. The Resident, and as appropriate the Resident's family, are included in the comprehensive assessment process along with the interdisciplinary (IDT) and outside sources, as indicated. The care plan shall: a. Have interventions that are person-centered, evidence-based, culturally competent, trauma informed, and in accordance with professional standards of practice. b. Provided for meaningful activities which promote engagement and positive, meaningful relationships. The facility will ensure that activities are provided to meet the needs of these Residents. c. Reflect the Resident's goals for care. d. Account for the Resident's experiences and preferences. e. Maximize the Resident's dignity, autonomy, privacy, socialization, independence, and safety. f. Use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated. g. Address any other individualized needs the Resident may have related to the mental disorder. h. Be reviewed and revised as needed, such as when interventions are not effective or when the Resident experiences a change in condition. 8. If a behavioral contract is used, it will only be used with Residents who have the capacity to understand it. A contract will only be used as a method of encouraging the Resident to follow their plan of care, and not as a system of reward and punishment . 10. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each Resident, which includes non-pharmacological interventions. Examples of individualized, non-pharmacological interventions to help meet behavioral health needs of all ages may include, but not limited to: a. Ensuring adequate hydration and nutrition b. Exercise c. Pain relief d. Individualizing sleep and dining routines f. Adjusting the environment to be more individually preferred or homelike g. Consistent staffing h. Supporting the Resident through meaningful activities that match his/her individual abilities, interests and needs i. Assisting the Resident outdoors in the sunshine and fresh air k. Assisting the Resident to participate in activities that support their spiritual needs l. Assisting with the opportunity for meditation and associated physical activity m. Focusing the Resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities, offering verbal reassurance, especially in terms of keeping the Resident safe; acknowledging that the Resident's experience is real to him/her o. Assisting Resident with substance abuse disorders to access counseling p. Assisting Residents with access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem solving q. Providing support with skills related to verbal de-escalation, coping skills, and stress management. The facility assessment last updated on [DATE] document the facility may accept Residents with anxiety, depression, schizophrenia, and post-traumatic stress disorder. The facility assessment also documents that the Director of Nursing (DON-B) would assess the referral and determine if the facility is able to meet the Resident's needs listed above and the staff would be educated in necessary clinical needs of the Resident. Currently, the facility assessment documents there are no Residents with behavioral health needs and active or current substance use disorders. Lastly, the facility assessment states the facility can manage the medical conditions related to the Resident's mental health: anxiety, depression, trauma, dementia, and other mental health disorders. R6 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left-Dominant Side, Sleep Apnea, Insomnia, Other Idiopathic Scoliosis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Other Obsessive-Compulsive Disorder, Unspecified Attention-Deficit Hyperactivity Disorder, and Other Psychoactive Substance Abuse. R6 is currently R6's own person. R6's Admission MDS dated [DATE] documents R6 has a BIMS (Brief Interview of Mental Status) score of 15 of 15 (cognitively intact) and requires limited assistance of 1 for bed mobility, dressing, toileting, and hygiene and limited assistance of 2 person plus assistance for transfers. R6 has no range of motion impairment and no behavior symptoms. R6 has a PHQ-9 score of 9 indicating mild depression. R6's 5-day Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R6 is cognitively intact for daily decision making. R6's MDS also documents that R6 requires extensive assistance with 2 for bed mobility and transfers. R6 requires extensive assistance of 1 for dressing and toileting and has range of motion impairment on 1 side for both upper and lower extremities. R6's MDS reflects a patient health questionnaire (PHQ-9) score of 9 indicating mild depression. There are no behavior symptoms documented. Surveyor notes that the most current MDS dated [DATE] documents that R6 is now requiring more assistance with activities of daily living (ADLs) than one month earlier. Surveyor notes R6's PASRR (Preadmission Screening and Resident Review) Level 1 dated [DATE] does not accurately document R6's status on admission on [DATE]. The PASRR also does not document that R6 is receiving Cymbalta and Fluvoxamine Maleate for depression. On [DATE], R6 was evaluated by psychiatric services and was diagnosed with Schizoaffective Disorder, Bipolar Type due to R6 having delusions and hallucinations. R6's PASRR Level 1 was not updated to accurately reflect R6's mental health status at time of admission on [DATE]; failure to identify mental health signs and symptoms impacted the facility's ability to formulate a person-centered approach to improve R6's quality of life. On [DATE] at 1:42 PM, Doctor (DR-MM) shared with Surveyor that R6 has multi-level pain issues and has recommended to the facility to get R6 to focus on hobbies and take the focus off of R6's pain. DR-MM stated, There is is a lot of psychosocial outcome that is related to the focus on R6's pain. R6 has no control over anything. R6 is focused on pain because it is the only thing R6 can try and be in control of. I would be in the same position if I was dealing with what R6 is. As noted later, in an interview on [DATE] at 10:49 AM, R6 stated her pain was not controlled, which led her to asking her son to bring in pain medication from home. R6's electronic medical record (EMR) has the following documentation: [DATE] 8:18 PM General Note Note Text: Patient arrived to facility via van service in wheelchair patient is alert, denies any pain or discomfort at this time patient wheelchair switched out for highback wheelchair. Patient and son has concerns in regards to social services and cares and plan of care writer left message for social services. patient requires no male caregivers or therapist upon per patient upon arrival. patient educated on call light system and is in bed resting comfortable. On [DATE] at 1:32 PM, Surveyor spoke to Social Worker (SW)-T about R6 not having male caregivers. SW-T states SW-T was not aware of this request. Surveyor notes no male caregivers is not on the care plan or R6's care card, and there is no other documentation that this was addressed. Surveyor reviewed R6's current physician orders. R6 is on the following medications: Melatonin 10 MG-Give 1 tablet at bedtime for sleep Alprazolam .25 MG-Give 1 tablet every 8 hours as needed for anxiety Cymbalata-60 MG-Give 1 capsule 1 time a day for depression Fluvoxamine Maleate-1 tablet 3 times a day for depression It also states for the anti-anxiety use to observe closely for significant side effects: sedation, abnormal thoughts, behavior confusion, agitation every shift. Surveyor reviewed R6's entire EMR and notes that it is documented that R6 consistently and frequently asked for the Alprazolam for anxiety. Surveyor reviewed R6's Medication Administration Records and Treatment Administration Records since admission and notes there is no documentation that R6 is being monitored for signs and symptoms of anxiety and depression. The facility is not monitoring R6's sleep pattern on a nightly basis and Surveyor notes 2 sleep studies (,d+[DATE] - [DATE] and ,d+[DATE] - [DATE]) were not completed fully. The following was documented in R6's EMR progress notes: [DATE] 21:43 (9:43 PM) General Note Note Text: patient day 5 new admit patient has vape pin in narc drawer and a second vape pin purple in color was retrieved and given administrator. staff reported she has another vape red in color, writer did go and speak to patient and patient stated she doesn't have another vape. patient called writer in room later in shift complaining of lightheadness and dizzy, writer did take vitals and blood pressure was ,d+[DATE] afebrile and hr 80 writer will let unit manager know patient will benefit from patch and MD should be updated in am. [DATE] 6:52 PM General Note Note Text: writer called to room patient not responding to staff as per usual. writer walked in to room and asked resident is she ok, resident stated take off socks please no socks was on patient, patient response speech is minimal slurred and patient is lethargic arousable for only a few seconds at a time. patient is not on any PRN (as needed) narcs at this time. MD gave order to send patient to ER to be evaluated and treated. Patient was in bed with vape pen in hand patient continued to sleep thru writer overall assessment. patient was verbal when asked about what hospital to go to. Patient will be transported to St. Luke's Hospital via Bell ambulance, writer called daughter and son and left message on voice mail to call facility for detailed updated in regards to patient. Surveyor notes that R6 returns from the hospital and no smoking cessation was offered. No smoking cessation was offered and implemented on R6's admission. On [DATE] at 1:21 PM, DON-B confirmed that no smoking cessation was offered to R6. Surveyor has concerns that R6's vape was taken, and no alternatives were offered to R6 along with smoking cessation which could potentially cause a higher level of anxiety. [DATE] 22:39 (10:39 PM) General Note Note Text: Writer was alerted by aide that the resident was found to have prescription opioids at her bedside. CNA brought a few pills to writer that she found. Writer and 2 CNAs went into resident's room and found a total of 18 oxycodones in tin container. Res appears sleepy and hard to arouse. VSS stable at this time. DON updated and suggests to have res sent out for evaluation. MD updated. 911 called and police arrived with paramedics. Res refuses to go to the hospital. Police and EMTs are not able to take resident and she is now more alert and vitals are still normal. Daughter was called and did not get an answer. DON and ADON aware of non transfer to hospital. On [DATE], R6 was evaluated by psychiatric services. It is recommended to consider switching from alprazolam to lorazepam .5 MG 2 times a day, longer acting buspiroren 5 MG twice a day. Schizoaffective Disorder, Bipolar type was added with the plan to consider depakote sprinkles 125 MG 2 times a day or seroquel 12.5 MG daily if hallucinations/delusions persist. Drug rehabilitation/social worker to help with family counseling/grief therapy and outpatient psychiatry/psychotherapy upon discharge as well. [DATE] 8:55 AM General Note Note Text: writer took a call from patient's daughter. Daughter reports that patient called her at least 4 time early this morning talking about suicide. writer went in and spoke to patient. writer asked patient if she is currently thinking of hurting herself. patient replied no but reports she was sad last night. writer looking into precautions for patient. Surveyor noted Suicidal ideation was not addressed on R6's care plan. On [DATE] at 1:32 PM, SW-T confirmed SW-T was not aware of R6 having suicidal thoughts. Surveyor was unable to interview the nurse who documented that R6 was having suicidal ideation due to no longer working at the facility. [DATE] 7:12 AM General Note Note Text: Resident continues to utilize call light system through out the night, resident continues to state she wants to get up and go outside to smoke and needs constant reminders this is a no smoking facility, resident is very agitated and angry on this writers shift, will continue to redirect and monitor. [DATE] 3:31 PM General Note Note Text: Writer, resident's assigned SW, BOM (business office manager), and Administrator met with resident in her room to review 30 Day Notice of IVD (Involuntary discharge notice). Writer and aforementioned team members spoke with resident about reasoning behind 30 Day IVD - Safety d/t use of non-prescription drugs in room and vaping/smoking in room - and resident verbalized understanding. Writer educated resident on appeal process and provided resident with information on how to appeal and timelines. Resident verbalized understanding and signed 30 Day IVD. Resident provided with original copies of documents alongside stamped and preaddressed envelope to Division of Hearings & Appeals. Physician and Ombudsman notified and received faxed copies of 30 day IVD. Discharge planning to commence to suitable transfer location. On [DATE] the facility developed care plans addressing substance abuse (which included an intervention to establish a verbal or written behavioral contract) and frequent complaints related to mood (which included an intervention to evaluate underlying factors leading to complaints). On [DATE], R6 was seen by psychiatry services for follow-up. R6 is complaining of anxiety, difficult sleeping, panic attacks regularly. States grieving loss of husband and mother. States pain is not controlled. States misses husband, passed away 5 years ago. It is recommended to consider switching from alprazolam to lorazepam .5 MG 2 times a day, longer acting buspiroren 5 MG twice a day. Consider increasing Cymbalta to 90 MG daily. Schizoaffective Disorder, Bipolar type was added with the plan to consider depakote sprinkles 125 MG 2 times a day or seroquel 12.5 MG daily if hallucinations/delusions persist. On [DATE] at 1:32 PM, Surveyor attempted to contact psychiatric services but did not receive a return call. [DATE] 2:48 AM General Note Note Text: patient awake most of the night. patient c/o anxiety. Tylenol given for HA. deep breathing done for anxiety. patient snacking on cookies. On [DATE] at 1:21 PM, Surveyor interviewed DON-B. DON-B states there is no behavior meeting to review medications. DON-B is not sure how psychiatric services communicates medication changes and agrees that recommendations of medication changes (,d+[DATE] & [DATE]) for R6 were never followed through with. On [DATE] at 2:17 PM, DON-B communicated the following in regard to R6: I am just seeing the pysch recommendations now. I had no idea. I do not know how psych communicates changes that need to be made. I don't know what the old DON-B was doing with recommendations prior to [DATE]. Surveyor reviewed R6's physician progress notes and there is no documentation of the physicians addressing R6's anxiety, depression, and substance abuse signs and symptoms. Surveyor reviewed R6's current comprehensive care plan, which indicates in part: 1. I would like to continue participating in the recreational activities I currently enjoy. Initiated [DATE] . Invite me to my favorite activities, and to try new things that I might be interested in. I enjoy bingo, board games, and crafts. R6's Resident Preferences Evaluation dated [DATE] at time of admission documents, it is very important for R6 to keep up on the news, listen to music, be around animals, do things with groups of people, to do favorite activities, and to get fresh air. On [DATE] at 11:11 AM, Surveyor observed R6 in bed, flat affect, answered questions appropriately. R6 stated R6 wanted to be up for lunch because R6 likes to be in the dining room with other residents and does not like to eat in bed. On [DATE] at 11:14 AM, R6 informed Surveyor that activities never come to R6's room. R6 would like to get R6's hair and nails done to feel better. R6 states not getting out of the room makes R6 sad, causes anxiety, wants to be involved with activities, and it would make a difference for R6. On [DATE] at 12:44 PM, Surveyor observed R6 up and in wheelchair, flat affect, and stated that R6 was able to get up and eat lunch in the dining room. On [DATE] at 9:13 AM, Surveyor observed R6 in bed eating breakfast in bed. R6 again stated that R6 wants to be up every day so R6 can eat meals in the dining room. On [DATE] at 10:49 AM, Surveyor observed R6 in bed with flat affect, and resident became tearful at times during the interview with Surveyor. R6 explained that R6 is very worried about the 30 day discharge notice and nothing has been communicated about the process with R6. R6 stated the 30 day is hanging over R6's head. R6 explained that R6 was not aware that vaping is included in the policy of being a smoke-free facility. R6 stated it was not explained to R6 that R6 could not vape. R6 stated the facility took all her vapes away and have offered no alternative or smoking cessation. R6 stated R6's pain was not being managed despite repeatedly asking for assistance, so R6 had R6's son bring in R6's purse which R6 knowingly knew there was pain medication in the purse. R6 stated R6 needed to manage R6's own pain. R6 has asked for 'talk therapy,' but no one has gotten back to R6. I feel my depression is getting worse. I have lot of stuff going on in my head. I felt so bad about the vaping and medication issue. R6 has not had a behavior contract and no referrals for mental health assistance or substance abuse. R6 stated, I asked for smoking cessation after they took everything away, never gave me anything. My anxiety is very high. Staff do not come around to ask or offer anything at bedside for anxiety. It would help. I cry every night because of all this stress. Especially with the 30 day notice. That's why I don't sleep. My husband committed suicide in 2018 on 4th of July, anniversary is coming up. My mom died in 2019 and then I had my stroke. It's been very painful for me and to deal with. Sometimes I have feelings of suicide, but I never have a plan. SW-T is aware but I have only seen SW-T 1 or 2 times, but has not been back in a month and has offered no support to me. Activities would help but is never offered. I want to be around people to take my mind off of everything. I really want to feel better, but I am so sad and miserable with everything. I really hope they do not retaliate against me for the vaping and the medication issue. On [DATE] at 1:32 PM, SW-T confirmed SW-T has done nothing for R6 other than to work on discharge plans due to the 30 day discharge notice given to R6. Surveyor notes there is no social service documentation from the day of R6's admission to the facility on [DATE] until today ([DATE]). Surveyor also acknowledges there is no documentation that R6 had any other behavior issues involving vaping and medications after the 1 enty documented on both issues. On [DATE] at 1:52 PM, Surveyor spoke with R6 who was up in a chair, watching TV. Surveyor interviewed R6 who was extremely happy to have gotten R6's nails and hair done and was very proud to show Surveyor R6's nails. R6 was smiling and engaging in conversation. On [DATE] at 9:41 AM, R6 reported to Surveyor that R6 got out of bed on Saturday but did not get out of bed on Sunday because of the pain. On [DATE] at 10:34 AM, Surveyor interviewed Administrator (NHA-A) who stated that NHA-A did not review R6's referral information as that is done by team members from corporate. NHA-A is unsure what standard of practice as far as the Trauma Assessment is being utilized by the facility. NHA-A is unaware that R6 had requested no male caregiver or had suicidal ideations. NHA-A is unaware that R6 has polysubstance abuse. Surveyor shared the concern that smoking cessation was not offered to R6 after staff took R6's vape away. Surveyor shared that mental health services and interventions have not been implemented to address R6's anxiety and depression. Surveyor shared that there has been no monitoring of R6's signs and symptoms with documentation including delusions/hallucinations and suicidal ideation. Surveyor shared that a structured activity program has not been implemented to reduce R6's pain, depression, and anxiety. Surveyor shared that R6 has been seen 2 times by psychological services for medication management with no follow-up and has not received 1:1 counseling and referrals for R6's polysubstance abuse. Surveyor shared the concern that R6's coping mechanisms were taken away with no interventions put into place. NHA-A understands the concern that R6 was not provided medically related social services to maintain the highest practicable physical, mental, and psychosocial well-being. No further information was provided by the facility at this time. On [DATE] at 1:55 PM, NHA-A shared with Surveyor that NHA-A has spoken to R6 about the 30 day discharge notice and has since rescinded the 30 day discharge notice because R6 has not had any further behavior issues at the facility.

Based on interview, record review and observation, the Facility failed to ensure that 2 (R7 & R3) of 2 Residents reviewed for anticoagulants was adequately monitored for therapeutic levels. * R7 was admitted to the facility on [DATE]. R7 had been on [MEDICATION(S)] 5 mg every night since prior to admission. The facility did not develop a base line care plan for [MEDICATION(S)] to address monitoring for signs/symptoms related to the use of [MEDICATION(S)]. R7's fall risk assessment placed R7 at 16, which is high risk for falls. On 9/15/21, R7 was found on the floor after falling out of bed. R7 indicated she hit her face on the floor and was observed to have an abrasion on her nose between her eyes. R7 was transferred to the hospital for an evaluation. The CT scan was unremarkable and R7 returned to the Facility. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The Facility did not develop a care plan for monitoring signs & symptoms of bleeding and did not complete neuro checks, even though R7 was at increased risk for bleeding from the fall that occurred the previous day. R7 had an order to receive [MEDICATION(S)] 5 mg at hour of sleep and a PT/INR (Prothrombin time/international normalized ratio) to be drawn every Tuesday and Friday with a starting date of 9/17/21. On 9/17/21 a PT/INR was to be drawn at 7:00 a.m. This lab was not drawn until approximately 7:00 p.m. R7's [MEDICATION(S)] 5 mg was administered at 8:30 p.m. per schedule of hour of sleep without the results of the lab and without first consulting with a physician for direction to give or to wait for the results. On 9/18/21 at 12:24 a.m., a critical lab was called to LPN-P with PT greater than 90 and INR greater than 10. R7's physician was contacted and an order was received for Vitamin K 10 milligrams which was administered at 2:30 a.m. The nurses note dated 9/18/21 at 5:30 a.m. documented R7 as being anxious, up most of the night and attempting to get out of bed. On 9/18/20 at 7:30 a.m. R7 was found unresponsive, respirations of 20 and using accessory muscles to breathe. R7 was hospitalized with altered mental status. The facility's failure to develop a care plan for monitoring the signs/symptoms related to the use of [MEDICATION(S)], the failure to contact the physician for further direction when PT/INR results were not known at the scheduled time of the [MEDICATION(S)] administration on 9/17/20 because the blood work was done 12 hours later than usual, and the lack of consistent neurological checks created a finding of immediate jeopardy that began on 9/17/21. Administrator-A, DON (Director of Nursing)-B and DOO (Director of Operations)-J were notified of the immediate jeopardy on 10/14/21 at 4:00 p.m. The immediate jeopardy was removed on 10/15/21, however the deficient practice continues at a scope and severity level of D (potential for more than minimal harm/isolated) and as the facility continues to implement & monitor the effectiveness of its removal plan and as evidenced by; * R3's physician was not notified of the high INR lab values on 8/3/21, 8/6/21, & 8/10/21. Findings include: The High Risk Medications - Anticoagulants policy implemented 3/1/19 documents under policy, This facility recognizes that some medications, including anticoagulants, are associated with greater risk of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Under policy explanation and compliance guidelines documents, Target symptoms (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulants shall be documented in the resident's medical record. Duration of use shall be appropriate to the resident's condition and indication of use. The resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include: a. Bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool). b. Fall in hematocrit or blood pressure. c. [CONDITION(S)]. The resident's plan of care shall include interventions to minimize risk of adverse consequences. Examples include (depending on medication); a. Limit venipunctures and injections as possible. Be aware of the need to apply pressure following these procedures. b. Use soft toothbrush and electric razors. c. Limit intake of foods high in vitamin K: broccoli, cabbage, collard greens, spinach, kale, turnip greens, and brussel sprouts. d. Avoid cranberry juice and cranberry products. e. Caution resident/family about alcohol use while taking anticoagulants. f. Educate resident/family on risk of bleeding, dietary modifications and symptoms to report to nurse/physician. g. Avoid (strenuous) activities that may lead to injury. 1. R7 was admitted to the facility on [DATE] and discharged on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The fall risk evaluation dated 9/14/21 has a score of 16 which indicates at risk. The laboratory order request dated 9/14/21 includes PT/INR q (every) Tuesday/Friday with a start date of 9/17/21. The physician orders with an order date of 9/14/21 includes [MEDICATION(S)] Tablet 5 mg (milligrams). Give 5 mg by mouth one time a day for monitoring. This order was discontinued on 9/15/21 with a new order dated 9/15/21 of [MEDICATION(S)] Tablet 5 mg Give 5 mg by mouth at bedtime for monitoring. Surveyor reviewed R7's care plans and noted the following care plans: * Physical functioning deficit initiated 9/16/21. * Pressure ulcer actual or at risk initiated 9/16/21. * Pain initiated 9/16/21. * Fall initiated 9/15/21. * At risk for falls initiated 9/16/21. * Swallowing difficulty initiated 9/17/21. The Facility did not develop a 48 hour baseline care plan for [MEDICATION(S)] with monitoring for signs and symptoms of bleeding. The nurses note dated 9/15/21 documents, At approximately 0630 (6:30 a.m.) CNA (Certified Nursing Assistant) found patient laying on the ground. Nurse then informed team including writer. Patient found laying on right side. When asked what she was doing writer mumbled but did not give clear response. Writer then noticed abrasion above bridge of nose between eyes. When asked if she hit her head patient replied my face hit the floor. Vital signs obtained are as follows: Temperature 97.7, Resp (respirations) 25, Pulse 101. Pulse ox 87% on 3 LPM (liters per minute) of O2 (oxygen). Blood pressure 143/70. [Name of physician] called and updated on patient's fall. MD (medical doctor) informed writer to send pt (patient) out to ER (emergency room ) for eval (evaluation). [Name of] ambulance contacted. Report given. Neurological assessments initiated. Staff present with patient at this time. Blanket applied to keep patient warm. Surveyor reviewed R7's neuro checks and noted 9/16 the AM (morning) shift is blank, 9/17/21 the PM (evening) shift is blank, and 9/18/21 the AM & PM shift are blank. The hospital after visit summary dated 9/15/21 under diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurses note dated 9/15/21 documents Pt returned from [name of hospital] ER at 1345 (1:45 p.m.) via ambulance. VS (vital signs): 148/85 98.6 P89 R24 91% 3L O2 per NC (nasal cannula) PRN (as needed) APAP (acetaminophen) given X (times) 1 upon return d/t (due to) pt having c/o (complained of) HA (head ache). Abrasion to FH (forehead)/nose OTA (open to air)/beefy red. No drainage. Pt's husband at bedside upon pt's return. Larger bed and air mattress ordered per unit secretary and awaiting delivery. Per ER nurse, CT (cat scan) of pt's head negative and all lab work WNL (within normal limits) as well. Will continue to monitor. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient found to have cerebral venous [MEDICATION(S)] [CONDITION(S)] with accompanying venous infarcts in bilateral frontal and left parietal regions and refused mechanical thrombectomy and was treated with anticoagulation. She was also later found to have a small right parietal SAH (subarachnoid hemorrhage). Was also worked up for [CONDITION(S)] and status epilepticus. Medications were adjusted due to concerns over opioid dependence. She was also treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient asked to be seen by primary team to optimize therapy, pain control and discharge planning. Patients' plan and progress was discussed with nursing staff and therapy. Under assessment/plan documents Subarachnoid hemorrhage - given recent history patient is at high risk of developing cerebral hemorrhage with injury. Reportedly after falling the other day in the ER imaging was negative for new hemorrhage though cannot completely rule out the development of slower venous blood accumulation. Discussed with primary team, nursing staff and therapists to have a very low threshold to transfer to ER for evaluation if mental status deteriorates further. The facility did not develop a care plan to monitor for signs and symptoms of bleeding and altered mental status. The physician orders with an order date of 9/16/21 includes Laboratory order summary PT/INR every Tuesday and Friday starting on 9/17/21. One time a day every Tuesday, Friday for on [MEDICATION(S)]. For scheduling: frequency one time a day, checked for Tuesday & Friday, once daily 0730 (7:30 a.m.) The nurses note dated 9/17/21 at 5:53 a.m. documents, Resident sleeping off and on during the night with one request for her prn (as needed) Oxycodone and Tylenol. Prn pain med (medication) were effective for resident. resident is alert/oriented with some confusion noted. resident can make some of her needs known the rest are anticipated per family and staff. resident was more anxious during the night tonight and just wanted someone to hold her hands and talk with her. The resident's scheduled blood draw was not completed at 7:00 AM on Tuesday 9/17/21. It was not drawn until approximately 7:00 PM, 12 hours later. At 8:30 PM the R7's [MEDICATION(S)] 5 mg was administered per schedule of hour of sleep without the results of the lab and without first consulting with a physician for direction as to whether to give or wait with the administration of the [MEDICATION(S)]. The nurses note dated 9/18/21 at 2:00 a.m. documents, Lab called [at 12:24 AM] with critical labs of her [MEDICATION(S)] being greater than 90 and INR being greater than 10 along with a chest X-ray that showe sic (shows) moderate CHF (congestive heart failure) and Cardiomegaly. Writer placed calls out to [Physician-U]. [Physician-U] called back and was updated on all of her labs and X-ray results. MD gave orders for Vit (vitamin) K 10mg now. repeat INR on 09-18-21 and 09-20-21. and hold her [MEDICATION(S)] until they draw her INR on Monday and we get the results and update MD with result and he will give further orders at that time. Vit K was given to resident at 0230 (2:30 a.m.). Labs were ordered and call in. Surveyor noted R7's laboratory report for PT/INR documents a collected date time of 9/17/2021 18:52 (6:52 p.m.) [MEDICATION(S)] result documents >90.0 H (high) (normal blood clotting level is 10-13 seconds) and INR > 10.0 (therapeutic range is generally 2-3). Under result comments documents, INR This critical value report to [LPN-P]. Date/Time: 09/18/21 00:24 (12:24 a.m.) by . This critical value was verbally repeated back: Y (yes). Review of R7's September 2021 MAR (Medication Administration Record) reveals R7 received [MEDICATION(S)] 5 mg on 9/15, 9/16, & 9/17/21 with time of administration at 2030 (8:30 p.m.) Surveyor noted R7 was at increased risk for bleeding from a fall resulting in R7 hitting her face sustaining an abrasion on her nose, which occurred the previous day. Surveyor noted the 9/17/21 8:30 p.m. dose of [MEDICATION(S)] was administered prior to receiving the results of the PT/INR and without first consulting with the physician for medical direction as to whether [MEDICATION(S)] should be given, given that the resident had had a fall and was at risk for the development of slower venous blood accumulation and given that lab results were not yet back. The nurses note dated 9/18/21 at 5:30 a.m. documents, resident up most of the night with one request for her prn Oxycodone and Tylenol at 0530 (5:30 a.m.). Prn pain med were effective for resident. resident is alert/orientated with confusion noted. resident can make some of her needs known the rest are anticipated per family and staff. resident was getting more anxious during the night and attempting to get out of bed. writer talk to resident that she can't get out of bed at this. when asked why she was trying to get out of bed resident was unable to tell. resident kept telling writer that she didn't want to fall. writer reassure that we had her positioned in middle of bed and that she will not fall out of bed with her being positioned there. writer held her hand and talk to her for a few minutes which help her relax and stop yelling out for help. Lung sounds are clear and diminished. No shortness of breathe, congestion or coughing was observed. Precautionary contact maintained during the night. Range of motion within normal limits for her. Cran checks were negative for resident. No new injuries were noted. Legs were elevated during the night. resident reposition during the night. resident vss (vital signs stable) are as follows T97.8 P86 R20 B/P 156/90 spO2 99% on oxygen. bed in low position with side rails up. staff watching resident closely during the night call light within resident reach. fluids are encourage when awake. The nurses note dated 9/18/21 at 7:30 a.m. documents Day nurse had gone into resident room and found that resident was unresponsive at this time. resident eyes were open but she was unresponsive and her skin was cool to touch. 911 was called at this time call husband [name] and updated husband on her being unresponsive. husband stated that she did this on Wednesday and she was sent out and by the time she arrived at the hospital she was responsive and [name of hospital] sent her back here. husband mentioned that he felt it was going to be the same thing again Writer told husband that it would be better to send her out in case something was going on with her and the hospital can treat her better then we can and if it was nothing she can come right back here writer gave paramedic report on resident due to paramedic wanted more of a report on resident. upon transferring resident onto the gurney. resident became alert and responsive again. writer talked to resident and told her that she was going to the hospital because she was unresponsive for a while and we wanted her to get checked out. resident stated ok. writer recall husband due to paramedic wanted husband to meet them there. Husband stated that he was getting ready to go to hospital. also updated husband that resident became alert and responsive before leaving facility. The nurses note dated 9/18/21 at 7:40 a.m. documents Went into resident room to give medications, resident was not alert. Resident would not respond to commands, and would not swallow. Resident was using accessory muscles to breath, and RR (respiration rate) were 20. The nurses noted dated 9/18/21 at 10:15 a.m. documents called [name of] hospital for update on resident and ER (emergency room ) nurse informed writer that resident is going to be admitted with dx (diagnosis) of AMS (altered mental status). On 10/14/21 at 10:34 a.m. Surveyor asked DON (Director of Nursing)-B when labs for PT/INR are drawn. DON-B informed Surveyor typically Tuesday and Friday unless the [MEDICATION(S)] clinic has other days. DON-B informed Surveyor the lab is typically drawn early in the morning. Surveyor asked DON-B what is the expectation if the PT/INR is not drawn and asked if [MEDICATION(S)] should be administered. DON-B asked Surveyor if she could get back to Surveyor. Surveyor asked DON-B if a resident falls, hits their head and goes to the hospital should neuro checks continue when they return from the hospital. DON-B replied we should. Surveyor informed DON-B of R7's neuro checks not being completed. On 10/14/21 at 10:54 a.m. Surveyor asked RN (Registered Nurse)-F if the PT/INR lab was not drawn in the morning what would she do regarding the Resident's [MEDICATION(S)]. RN-F informed Surveyor she would not give it (the [MEDICATION(S)]) until the results are received and would call the doctor. Surveyor informed RN-F R7's PT/INR was not drawn until around 7:00 p.m. and the Facility did not receive the results until the night shift. Surveyor asked RN-F why she administered R7's [MEDICATION(S)] on 9/17/21 prior to receiving the lab results and without first contacting the doctor. RN-F replied I don't have a logical answer for that. On 10/14/21 at 1:36 p.m. DON-B informed Surveyor when the PT/INR is not drawn they would not give the [MEDICATION(S)] and wait for an MD order. Surveyor informed DON-B of R7's PT/INR not being drawn in the morning but at approximately 7:00 p.m. Surveyor informed DON-B that R7's [MEDICATION(S)] 5 mg was administered prior to the results of the PT/INR results and without first consulting with a physician and that a critical lab value was called during the night shift for the INR. R7 then received Vitamin K. On 10/14/21 at 4:18 p.m. DON-B informed Surveyor R7 was transferred to the hospital early on 9/18/21 to the hospital so the morning and afternoon neuro checks would not have been completed. DON-B provided updated neuro checks for 9/16/21 morning shift and 9/17/21 evening shift with vital signs completed but is still not fully completed. On 10/18/21 the Facility submitted additional information stating in part, . there was no physician order to hold [MEDICATION(S)] without lab results and in fact Dr . the primary care physician for this patient and Medical Director (see attached statement) indicates he intended and would have directed for the [MEDICATION(S)] to have still been administered without the results on the evening of discussion. The suggestion to have held this patients [MEDICATION(S)] dose would have had the potential to be more harmful and of higher risk than the administration of it .The physician indicates that the facility should not have held the [MEDICATION(S)] dose in the case of this resident. If the physician would have been notified of the results not being received yet he would have still had the facility administer the [MEDICATION(S)] without the results. Additionally, Physician U submitted a statement which stated in part, she (resident) had a fall at Heritage Square on the night of admission and sent to .ER (emergency room ) for neurological evaluation. CT head showed no acute intracranial event and patient is sent back to Heritage Square. Her severe weakness and lethargy is due to central venous [MEDICATION(S)] [CONDITION(S)] and recent R parietal [CONDITION(S)]. She had her blood drawn on 9/17 for PT INR but due to lab facility drawing her blood in the evening, the result of the PT INR was not available at the time of [MEDICATION(S)] administration on 9/17. Given her medical conditions including central venous [MEDICATION(S)] [CONDITION(S)] and hypercoagulable state, it's reasonable practice to give [MEDICATION(S)] before the results are noted. Risk of not being anticoagulated appropriately on time is greater than withholding a dose in her case. Because the nurse did not first contact the physician, she did not have the above information or medical direction as to how to proceed. She gave the [MEDICATION(S)] without adequate monitoring and without medical direction. Surveyor noted according to the American Medical Directors Association (AMDA) Acute Change of Condition in the Long-Term Care Setting, Clinical Practice Guideline dated 2003, Table 14 documents: Framework for Reporting Changes in Vital Signs or Laboratory Values to a Practitioner, Report Immediately- Prothrombin Time (PT) International normalized ratio (INR)- >6 IUs (hold [MEDICATION(S)]), PT (in seconds) 3x control (hold [MEDICATION(S)].) Had the lab results been known, professional standards of practice would have indicated to hold the [MEDICATION(S)] ([MEDICATION(S)]). The facility's failure to develop a care plan for monitoring the signs/symptoms related to the use of [MEDICATION(S)], the failure to consult with the physician about giving [MEDICATION(S)] when the results of PT/INR lab were not yet known, the lack of consistent neurological checks, and the administration of [MEDICATION(S)] without lab results or physician consultation created a finding of immediate jeopardy that began on 9/17/21. The immediate jeopardy was removed on 10/15/21 when the facility implemented the following action plan: * All RN's, LPN's and Med Techs were educated on Facility policy and procedure regarding reporting of PT/INR results to MD/extender on day of lab work prior to giving scheduled [MEDICATION(S)]. * All RN's and LPN's were educated on timing of neuro checks and continuation of timing of neuro checks after ER visit as per policy. * All RN's and LPN's were educated on assessment of AMS (altered mental status) and s/s of bleeding post fall. * DON/nursing leadership were educated on necessity of baseline care planning to include at risk for injury for residents on [MEDICATION(S)]. * The Facility reviewed high risk medications - anticoagulant policy and procedure. Notification and care planning are covered in this policy. * The Facility reviewed neuro check policy and procedure. * DON/designee will conduct audits daily x (times) 2 weeks, weekly x 8 weeks and monthly x 3 months of resident receiving [MEDICATION(S)] to ensure all required components are in place. Results of the audits will be reviewed at the QAPI (Quality Assurance Performance Improvement) meeting monthly x 3 for further recommendations and determination of continuing need for audits. Facility assessment will be reviewed and updated as needed. The deficient practice continues at a scope and severity level of D as evidenced by the following; 2. R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Admission Minimum Data Set (MDS) reference assessment, dated 7/27/21, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R3 is cognitively intact. R3's MDS indicates R3 received an anticoagulant medication for 5 of the 7 MDS assessment dates. R3's comprehensive care plan states At risk for complications related to anticoagulant or antiplatelet medication due to: Heart Valve replacement. Target date of 8/2/21. Interventions include: Will remain without complications from bleeding or injury. Monitor medication regime for medications which increase effects. Observe for signs and symptoms of bleeding including tarry stools, blood in urine, bruising, petechiae. Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. On 7/23/21, a physician ordered Anticoagulant use: monitor for: Nosebleeds, bruising, bleeding that is severe or cannot be controlled, pink, red or brown urine, vomiting blood or coffee-ground emesis, red stools or black tarry stools, and coughing up blood or blood clots every shift. Surveyor noted R3's treatment administration record was checked off for every shift as ordered. On 7/23/21, the physician ordered [MEDICATION(S)] 3 mg by mouth at bedtime for one day (7/23/21). On 7/23/21, the physician ordered [MEDICATION(S)] 4 mg by mouth at bedtime for [MEDICATION(S)] therapy starting on 7/24/21. On 7/24/21, the physician ordered PT/INR every Tuesday and Friday starting on 7/27/21. One time a day every Tuesday and Friday for medication management. On 7/27/21, laboratory results for R3 indicate [MEDICATION(S)] result of 25.9 and (International normalized ratio) INR results of 2.6. The laboratory document states the INR guidelines for patients receiving [MEDICATION(S)] ([MEDICATION(S)]) therapy include: INR 2.0-3.0 conventional anticoagulation INR 2.5-3.5 intensive anticoagulation On 7/27/21, there is a progress note entry stating Doctor aware of lab results recheck BMP on 7/30/21 for elevated potassium. On 7/30/21, laboratory results for R3 indicate [MEDICATION(S)] results of 28.5 and INR results of 2.8. The laboratory document states the INR guidelines for patients receiving [MEDICATION(S)] ([MEDICATION(S)]) therapy include: INR 2.0-3.0 conventional anticoagulation INR 2.5-3.5 intensive anticoagulation On 7/30/21, there is a progress note entry stating Doctor aware of lab results. No new orders. On 10/14/21 at 11:00 AM, Surveyor informed DON-B of the inability to locate labs and notifications for 8/3 through 8/13/21 (8/3, 8/6, 8/10, 8/13/21). DON-B stated she would look for all of the lab results for R3 and will search for documentation of notification to the MD and the family for all of the dates between 7/27-8/17/21. On 10/14/21 at 1:28 PM, Surveyor interviewed DON-B. DON-B found the lab results for those not in the electronic health record; however, DON-B could not find any documentation that the MD or the family was contacted for the high INR lab values on 8/3, 8/6 and 8/10/21. DON-B states the expectation is not to give blood thinners until reviewed the labs. If the labs are out of the normal range, then the nursing staff should be talking to the doctor prior to giving the medication. DON-B was not sure who collected the labs from the computer or if anyone did. DON-B said it is not one specific nurses responsibility to look for the labs, but that they should all be doing it. Since Tuesday and Fridays are the normal lab days at the facility, nurses know to look on those days specifically. Otherwise, if the labs are due on other days, then it would be on the shift report normally. On 8/3/21, laboratory results for R3 indicated [MEDICATION(S)] results of 35.7 and INR results of 3.6. The laboratory document states the INR guidelines for patients receiving [MEDICATION(S)] ([MEDICATION(S)]) therapy include: INR 2.0-3.0 conventional anticoagulation INR 2.5-3.5 intensive anticoagulation *Surveyor noted there was no documentation of lab results or notification of results to the family or MD in the electronic health record. Surveyor noted an elevated INR result. On 8/6/21, laboratory results for R3 indicated [MEDICATION(S)] results of 38.6 and INR results of 4.0. The laboratory document states the INR guidelines for patients receiving [MEDICATION(S)] ([MEDICATION(S)]) therapy include: INR 2.0-3.0 conventional anticoagulation INR 2.5-3.5 intensive anticoagulation *Surveyor noted there was no documentation of lab results or notification of results to the family or MD in the electronic health record. Surveyor also noted an elevated INR result. On 8/10/21, laboratory results for R3 on 8/10/21 indicated [MEDICATION(S)] results of 43.4 and INR or 4.5. The laboratory document states the INR guidelines for patients receiving [MEDICATION(S)] ([MEDICATION(S)]) therapy include: INR 2.0-3.0 conventional anticoagulation INR 2.5-3.5 intensive anticoagulation *Surveyor noted there was no documentation of lab results or notification of the results to the family or MD in the electronic health record. Surveyor also noted an elevated INR result. From 8/3-8/12/21, Surveyor reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/13/21, laboratory results for R3 on 8/13/21 indicated [MEDICATION(S)] results of 64.4 and INR of 6.9 (flagged as critical). The laboratory document states the INR guidelines for patients receiving [MEDICATION(S)] ([MEDICATION(S)]) therapy include: INR 2.0-3.0 conventional anticoagulation INR 2.5-3.5 intensive anticoagulation On the lab document, it states result comments INR, reported to RN at 12:05. This critical value was verbally repeated back: yes. Surveyor noted on the lab document there is a notation of hold til Tuesday 8/17/21 From 8/13-8/16/21, Surveyor noted on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/17/21, laboratory results for R3 indicated [MEDICATION(S)] results of 16.8 and INR of 1.6. The laboratory document states the INR guidelines for patients receiving [MEDICATION(S)] ([MEDICATION(S)]) therapy include: INR 2.0-3.0 conventional anticoagulation INR 2.5-3.5 intensive anticoagulation On 8/17/21, there is a progress note stating RN updated MD on INR. RN received new order to start [MEDICATION(S)] 2 mg nightly. Continue plan of care. A communication form was completed on 8/18/21 stating: Family notified on 8/18/21. Surveyor noted from 8/17/21 until R3's discharge on 8/19/21, R3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/21 at 3:59 PM, Surveyor shared concern of R3's lab results not being reported to the MD and the family from 8/3/21-8/10/21. No further documentation or information was shared.

Based on observation, interview, and record review the facility did not ensure that 3 of 4 (R1, R4, R6) residents did not develop avoidable PI (pressure injuries), prevent current pressure injuries from worsening, or promote the prevention of pressure injury development for residents reviewed who were at risk for the development of pressure injuries including care plan interventions. * R1 was admitted into the facility with an unstagable Pressure injury to the sacrum, an unstagable pressure injury to the left shin, and a Deep tissue injury on the left heel. On 8/31/21 the MD changed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The change in treatment order was not carried out until 9/8/21. On 9/1/21, the wound area (buttock area) was dark in color with surrounding skin reddened. The facility did not measure or assess the wounds, contact the physician for possible new orders and did not notify the R1's representative. On 9/7/21, all three of R1's pressure injuries deteriorated. New treatment orders for up for therapy only and side to side repositioning was not added to R1's care plan. On 9/7/21, the MD ordered antibiotics for the left shin infection. On 9/8/21 R1 was admitted to the hospital for [CONDITION(S)] and blood clots. * On 9/22/21, R4 was admitted with a stage 4 pressure injury on the right heel, unstageable on left ankle and deep tissue injury of the right elbow. On 9/22/21, a skin evaluation was completed by a Licensed Practical Nurse (LPN). There was no Registered Nurse (RN) assessment and no comprehensive assessment of these areas including no measurements or description of the wound bed or wound exudate. These pressure injuries were not assessed until wound rounds on 9/28/21. R4's skin care plan was not initiated until 10/3/21. R4 was on an Invacare Glissando gliding mattress until 10/13/21 and there is no indications this mattress was appropriate for a Stage 4 pressure injury. On 10/13/21 a low air loss mattress was placed on R4's bed. From 9/28/21 to 10/10/21 nurses were initialing on the Treatment Administration Record (TAR) two treatments for each pressure injury (wet to dry dressings and Alginate Calcium with foam dressing). The Alginate Calcium was ordered on 9/28/21.The wet to dry dressing order had been discontinued on 10/10/21. The skilled evalution notes dated 9/28/21, 9/29/21, 9/30/21, 10/2/21 incorrectly staged R4's pressure injury to the right heel as a Deep Tissue Injury when on 9/28/21 the Wound MD-M assessed it to be a stage 4. The skilled evaluation notes dated 9/28/21, 9/29/21, 9/30/21, 10/2/21 incorrectly staged R4's pressure injury to the left ankle as a Deep Tissue Injury when on 9/28/21 Wound MD-M assessed to be unstagable due to necrosis. On 10/3/21 the skilled assessment note indicated a left heel deep tissue injury. On 10/7/21 the Left heel was noted with drainage. On 10/12/21, Wound MD-M assessed R4's left heel with a measurement of 4 X 4.5 and the left heel was debrided.After debridement the area was measured at 6 X 6 X 0.3. Alginate Calcium treatment was ordered. Wound MD-M indicated the pressure injury was unstageable, 70% slough & 30% granulation. On 10/12/21, Wound MD-M indicated he was not aware of R4's left heel pressure injury. On 10/13/21, R4 was observed with his heels resting directly on the mattress and not off loaded. On 10/13/21, a stage two pressure injury was observed during morning cares on 10/13/21 which the Certified Nursing Assistant (CNA) did not immediately report to the nurse or unit manager. * R6 was admitted into the facility with no pressure injuries however was assessed to be at moderate risk for the development of a Pressure injury. The facility did not develope a care plan with interventions to prevent the development of pressure injuries. On 9/3/21 the Treatment Administration Record indicated the start of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no comprehensive assessment of this wound to include the description of the wound bed etc. The physician was not consulted with as the Director of Nursing has a verbal standing order with the phyisician in regards to initiating treatment, until the MD is able to see the resident. There was no care plan with interventions developed in regards to pressure injuries as on 9/3/21. On 9/6/21 R6 developed another pressure injury to the right buttock with treatment ordered. There was no comprehensive assessment of this new area. No pressure injury care plan with interventions was developed. On 9/6/21 R6 was admitted into the hospital. The hospital after visit summary indicated R6 had 3 stage 2 pressure injuries at the time of admission into the hospital, located on the posterior coccyx, posterior left buttock, and right buttock. R6 was readmitted into the facility and on 9/14/21, the facility developed a pressure injury care plan. Findings include: The facility policy, Wound Management, no date, indicated: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders. Treatment decisions will be based on: Etiology of the wound, Characteristics of the wound, Location of the wound, Goals and preferences of the resident/representative. Treatments will be documented on the Treatment Administration Record. The effectiveness of treatments will be monitored through ongoing assessment of the wound. 1. Prior to admission, R1 was admitted to the hospital on 8/4/21 with a worsening left lower extremity wound and a sacral pressure injury. R1's Hospital Records on 8/5/21 indicated a Coccyx pressure injury at Stage 3 measuring 10 x 11 cm with non-viable tissue. R1's Left Posterior Calf measured 9.5 x 3 cm. R1's Hospital Records on 8/9/21 indicated the Left Posterior Calf measured 8.7 x 1 x 0.2 cm. R1's Hospital Records on 8/11/21 indicated a Coccyx pressure injury measured 9 x 7 x 0.1 cm with increased viable tissue and a Left heel wound measured 1 x 0.5 x 0.1 cm. R1's Hospital Discharge 8/17/21 Instructions indicated: Local Wound Care: Wash with mild soap and water. [MEDICATION(S)] to Left Lower Extremity followed by Allevyn daily. Apply Santyl to Sacral Pressure Injury followed by Allevyn daily. Moisturizer to Bilateral Lower Extremities. Foam to Left heel for protection. Aggressive offloading with Stage 4 mattress w/alt pressure pump, frequent repositioning/turning at least every 2 hours, gel chair cushion, Prevalon boots. R1 was admitted to the facility on [DATE] for physical therapy and strengthening with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 was due to discharge home on 9/8/21 but was transferred to the hospital on 9/8/21 and admitted for [CONDITION(S)] and DVT (Deep Vein [CONDITION(S)]-Blood Clots). R1 did not return to the facility. R1's Admission MDS (Minimum Data Set), dated 8/20/21, indicated R1 was cognitively impaired, required extensive assistance with 2 staff for bed mobility and toileting, total dependence for transfer, and had a functional impairment of the lower extremity on one side. Section M indicated R1 was admitted with 2 unstageable pressure injuries and 1 DTI (Deep Tissue Injury). R1 was noted to be at risk with bed and chair pressure relieving devices but no repositioning plan. When R1 was admitted to the facility on [DATE], R1 was seen by MD-M (Wound Physician). MD-M's progress notes on 8/17/21 indicated R1's Sacrum-Unstageable pressure injury measured 3 x 5 x 0.1 cm with 90% slough, 10 % granulation. Treatment ordered: [MEDICATION(S)] with Border Gauze. Left shin-Unstageable pressure injury measured 8 x 2 x 0.1 cm with 90% slough, 10% granulation. Treatment ordered: [MEDICATION(S)] with Border Gauze. Left heel-Unstageable DTI measured 6 x 6 cm. Treatment ordered: skin prep, boot. Braden scale score-17 *The facility and MD-M changed the hospital wound treatment discharge orders stopping the Santyl for debridement of the sacral pressure injury and antibiotic ointment to the left lower extremity. R1's facility Care plan was initiated on 8/17/21: Actual/at Risk Pressure Ulcer-Sacrum, Left heel, Left shin. Interventions: Conduct weekly skin inspections, Heel boots, Provide pressure relieving WC cushion, Provide pressure relieving mattress, Treatments as ordered, Turn/Repositioning per assessment. Initiated 8/17/21. R1's CNA (Certified Nurse Assistant) care card indicated for skin integrity the intervention: heel boots. MD-M's progress notes on 8/24/21 indicated R1's Sacrum-Unstageable pressure injury measured 3 x 5 x 0.1 cm with 90% slough, 10 % granulation. Wound progress no change, no change in treatments Left shin-Unstageable pressure injury measured 8 x 2 x 0.1 cm with 90% slough, 10 % granulation. Wound progress no change, no change in treatments. Left Heel-Unstageable DTI measured 6 x 6 cm, no exudate. Wound progress no change, No change in treatments. Braden scale score-13 MD-M's progress notes on 8/31/21 indicated R1's Sacrum-Unstageable pressure injury measured 3 x 5 x 0.1 cm with 90% slough, 10% granulation, with biofilm, debrided by MD-M. Left shin-Unstageable pressure injury measured by 8 x 2 x 0.4 cm with 90% slough,10% granulation, with biofilm, debrided by MD-M. Treatment changed to Calcium Alginate with foam border. Left heel-Unstageable DTI measured 6 x 6 cm. Wound progress no change, no change in treatments. Braden scale score-14 *According to documentation, the left shin change in treatment to Calcium Alginate with foam border was not carried out as ordered on 8/31/21 until 9/8/21. Unlike Calcium Alginate, [MEDICATION(S)] dressing does not have antibiotic properties. By 9/7/21, the left shin was infected. R1's progress note on 9/1/21 at 9:58 PM indicated: Note Text: Writer went in to complete wound tx. writer noted change in resident wound area is dark in color with surrounding skin redden no odor noted treatment needs updating supervisor made aware who came in took pic's of area and sent to MD for new orders current treatment completed till md gives new orders. skin prep applied to left heel Feet left floating will continue to monitor. On 10/13/21, at 1:53 PM, Surveyor interviewed RN-O (Registered Nurse) who was the PM nursing supervisor on 9/1/21. RN-O stated she did take pictures of R1's wounds on 9/1/21 with her personal cell phone because she had not rounded with MD-M during wound rounds on 8/31/21. RN-O stated she did not know if R1's wounds looked worse when LPN-T (Licensed Practical Nurse) called her to the bedside to assess R1 for worsening of the wounds. RN-O stated she had no formal wound care training and sometimes measures wounds upon a resident admission but only describes not staged. On 10/13/21, at 3:13 PM, Surveyor interviewed LPN-T who stated R1 had a wound on his butt and it had changed to being dark in color with notification of nursing supervisor who took pictures. LPN-T stated she did not know how to measure a wound and they don't have the tools available to measure a wound. On 10/13/21, at 10:57 AM, Surveyor interviewed DON-B who stated RN-O is just a physical body that goes with MD-M and changes the dressings. RN-O does not do any assessments or measurements. DON-B stated she was not notified of R1's 9/1/21 change in wound status by the nurses and that the nursing supervisor should have notified her as there were no further measurements or assessments. *Based on nursing observations of R1's worsening wounds on 9/1/21, the facility did not measure or assess the wounds, consult a physician for possible new orders or notify the resident representative. By 9/7/21 R1's wounds had deteriorated and become infected. MD-M's progress notes on 9/7/21 indicated R1's Sacrum-Unstageable pressure injury measured 10 x 6 x 0.1 cm with 50% slough, 10% granulation, 40% skin. Deteriorated pressure injury. Treatment orders: up for therapy only, side to side repositioning, Calcium Alginate daily with Border Gauze, debrided by MD-M. Left shin-Unstageable pressure injury measured 5 x 5 x 0.4 cm with 100% slough, Deteriorated pressure injury. Treatment orders: Doppler Ultrasound, Antibiotics for [CONDITION(S)] (skin infection)-[MEDICATION(S)] 500 mg 3 times/day x 10 days), Calcium Alginate with border gauze, debrided by MD-M Left heel-Unstageable DTI measured 6 x 7 100% necrotic Deteriorated, Alginate Ca with border gauze, debrided by MD-M. [Note: This wound is now infected.] MD-M added a new Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . *R1's care plan was not updated to reflect up for therapy only and side to side repositioning. R1 was admitted to the hospital on 9/8/21 with [CONDITION(S)] and blood clots. On 10/12/21, at 1:35 PM, Surveyor interviewed DON-B who stated the facility does not do their own wound notes, only MD-M documents weekly. MD-M stated if there is a new area then it is documented in assessments by nursing. On 10/12/21, at 2:41 PM, Surveyor interviewed MD-M who stated R1 wounds did deteriorate with scattered areas of new sacral pressure injuries on 9/7/21. MD-M stated all the pressure injury areas were included in the measurement which increased the area and size of the unstageable sacral pressure injury. On 10/14/21, at 2:00 PM, Surveyor interviewed MD-M regarding the delay in treatment from 8/31/21 to 9/8/21 with the change from [MEDICATION(S)] to calcium Alginate on left shin that was ordered on 8/31/21 and not carried out until 9/8/21 resulted in the area becoming infected. MD-M stated not necessarily as [MEDICATION(S)] can have some antimicrobial properties. MD-M ordered antibiotics for the left shin infection on 9/7/21. [Note: According to The Antimicrobial Spectrum of [MEDICATION(S)], While [MEDICATION(S)] [MEDICATION(S)], and [MEDICATION(S)] tribromophenate unbound to Xeroform® demonstrate antimicrobial activity, it appears that Xeroform® dressings do not. https://pubmed.ncbi.nlm.nih.gov/ 915/] R1 had pressure injuries that worsened without notification of the physician or family, new wound care orders on 8/31/21 were not carried out until 9/8/21, and R1's care plan was not revised. 2. R4 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital discharge summary dated 9/22/21 documents wound care to right lateral heel, left medial ankle and left 4th toe. * Apply Vashe to gauze and place on wound for 3-5 minutes and remove. Do not rinse. * Apply sure prep barrier to peri wound skin. * Apply Iodosorb. * Cover with gauze. * Secure with 2 x (by) 2 gauze and [MEDICATION(S)] tape. * Assess wound and change daily and PRN (as needed). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . These orders were discontinued on 10/10/21. The COMS Skin only evaluation dated 9/22/21 documents Skin warm & dry color WNL (within normal limits), mucous membranes moist, tugor normal. Resident has skin issues. Skin Issue: Deep Tissue Injury. Skin Issue Location: right elbow. Skin Issue: Bruising. Skin Issue Location: Bilateral arms. Skin Issue: Bruising: Skin Issue Location: left hand. Skin Issue: Laceration: Skin Issue Location: right knee. Skin Issue: Pressure Ulcer/Injury. Skin Issue Location: right heel Pressure Ulcer/Injury Stage: Stage IV (4) - Full thickness tissue loss. Skin Issue: Open Lesion (other than ulcers, rashes and cuts). Skin Issue Location: left inner ankle. Multiple bruises to bilateral arms elbow has o/a (open area), right knee has abrasion, right heel stage IV left inner ankle Stage II (2), no c/o (complaint of) pain or discomfort at this time, wounds need re-evaluated. * Surveyor noted the 9/22/21 Skin only evaluation was completed by an LPN (Licensed Practical Nurse) and not assessed by an RN (Registered Nurse). This skin evaluation is not a comprehensive assessment as there are no measurements of R4's pressure injuries, no description of the wound bed, and if there is any wound exudate. On 10/12/21 at 1:33 p.m. Surveyor asked DON (Director of Nursing)-B where Surveyor would be able to locate for Residents with pressure injuries a comprehensive assessment. DON-B informed Surveyor if Wound MD (Wound Doctor)-M is following the Resident they don't do an assessment as he has all the information. DON-B informed Surveyor if a Resident develops a pressure injury in the Facility there would be a COMS skin only evaluation completed. The Braden assessment dated [DATE] documents a score of 15 which indicates at risk for pressure injury development. The nurses note dated 9/23/21 documents Patient admitted with pressure injury. Treatments in place and completed as ordered. Wound MD (medical doctor) to follow. The admission MDS (minimum data set) with an assessment reference date of 9/25/21 documents a BIMS (brief interview mental status) score of 15. R4 requires supervision with one person physical assist for bed mobility, transfer, & toilet use and does not ambulate. R4 is occasionally incontinent of urine and continent of bowel. R4 is at risk for pressure injuries and is coded as having one Stage 4 pressure injury which was present upon admission, one unstageable slough/eschar pressure injury which was present upon admission, and one unstageable deep pressure injury which was present upon admission. The skilled evaluation note dated 9/27/21 under the skin section for skin location #1 right heel documents Issue type: Deep tissue pressure injury (DTPI). and for skin location #10 left ankle documents Issue type: Deep tissue pressure injury (DTPI). Wound MD-M's initial wound evaluation & management summary dated 9/28/21 documents Focused Wound Exam (site 1) Stage 4 Pressure wound of the right heel full thickness Etiology pressure, wound size 3 x (times) 3 x 0.2 cm (centimeter), exudate moderate serous and Slough 100%. Under dressing treatment plan documents Primary Dressing(s) Alginate calcium apply once daily for 30 days. Secondary Dressing(s) Foam with border apply once daily for 30 days. Focused Wound Exam (Site 2) Unstageable (due to necrosis) of the left, medial ankle full thickness. Etiology pressure, wound size 0.8 x 0.8 x 0.1 cm, exudate moderate serous and slough 100%. Under dressing treatment plan documents Primary Dressing(s) Alginate calcium apply once daily for 30 days. Secondary Dressing(s) Foam with border apply once daily for 30 days. * Surveyor reviewed the September and October TAR (treatment administration record) and noted two treatments of wet to dry dressing and alginate calcium with foam dressing are initialed as being completed from 9/28/21 to 10/10/21 for R4's right heel and left ankle pressure injuries. The skilled evaluation notes dated 9/28/21, 9/29/21, 9/30/21, 10/2/21 under the skin section for skin location #1 right heel documents Issue type: Deep tissue pressure injury (DTPI). and for skin location #10 left ankle documents Issue type: Deep tissue pressure injury (DTPI). * Surveyor noted these skilled evaluation notes have incorrectly staged R4's pressure injuries. The actual pressure ulcer care plan initiated 10/3/21 documents the following interventions: Evaluate need for pain reliever prior to cleansing or dressing changes. Initiated 10/3/21. Float heels. Initiated 10/8/21 and revised 10/13/21. Notify practitioner if symptoms worsen or do not resolve. Initiated 10/3/21. Provide pressure reducing wheelchair cushion. Initiated 10/3/21. Provide pressure reduction/relieving mattress. Initiated 10/3/21. Treatments as ordered. Initiated 10/3/21. * Surveyor noted this care plan was developed 11 days after admission and there was no baseline care plan developed for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The skilled evaluation note dated 10/3/21 under the skin section for skin location #1 right heel documents Issue type: Deep tissue pressure injury (DTPI)., for skin location #10 left ankle documents Issue type: Deep tissue pressure injury (DTPI). and for skin location #11 left heel documents Issue type: Deep tissue pressure injury (DTPI). Surveyor noted this is the first documentation of a left heel pressure injury. * Surveyor noted these skilled evaluation notes have incorrectly staged R4's right heel and left ankle pressure injuries. * Surveyor reviewed R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The skilled evaluation notes dated 10/4/21 & 10/5/21 under the skin section for skin location #1 right heel documents Issue type: Deep tissue pressure injury (DTPI)., for skin location #10 left ankle documents Issue type: Deep tissue pressure injury (DTPI). and for skin location #11 left heel documents Issue type: Deep tissue pressure injury (DTPI). * Surveyor noted these skilled evaluation notes have incorrectly staged R4's right heel and left ankle pressure injuries. * Surveyor reviewed R4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Wound MD-M's wound evaluation & management summary dated 10/5/21 documents Focused Wound Exam (site 1) Stage 4 Pressure wound of the right heel full thickness Etiology pressure, wound size 3 x 3 x 0.2 cm, exudate moderate serous, Slough 100% and wound progress no change . Under additional wound details documents patient stated being up all day. educated on elevating legs returning to bed often to keep legs up. Under dressing treatment plan documents Primary Dressing(s) Alginate calcium apply once daily for 24 days. Secondary Dressing(s) Foam with border apply once daily for 24 days. Focused Wound Exam (Site 2) Unstageable (due to necrosis) of the left, medial ankle full thickness. Etiology pressure, wound size 0.4 x 0.8 x 0.1 cm, exudate moderate serous, slough 100% and wound progress improved. Under dressing treatment plan documents Primary Dressing(s) Alginate calcium apply once daily for 24 days. Secondary Dressing(s) Foam with border apply once daily for 24 days. * Surveyor noted Wound MD-M's wound evaluation does not include any documentation regarding a deep tissue pressure injury on R4's left heel. The nurses note dated 10/5/21 documents Patient assessed by wound MD, see progress note in MISC (miscellaneous) tab. Treatments in place and completed as ordered. Wound MD to continue to follow while patient in facility. The COMS skin only evaluation dated 10/6/21 documents Skin warm & dry, skin color WNL, mucous membranes moist, tugor normal. Resident has current skin issues. Skin issue: Deep Tissue Injury. Skin issue location: right elbow. Skin issue: Bruising. Skin issue location: bilateral arms. Skin issue: Bruising. Skin issue location: left hand. Skin issue: Laceration. Skin issue location: right knee. Skin issue: Pressure ulcer/injury. Skin Issue Location; right heel pressure ulcer/injury Stage: Stage IV (4) - Full thickness tissue loss. No wound odor. No tunneling. No undermining. Skin issue: Open lesion (other than ulcers, rashes, and cuts). Skin issue location: left inner ankle. No wound odor. No tunneling. No undermining. Skin issue: Deep tissue pressure injury (DTPI). Skin issue location: left heel pressure ulcer/injury Stage: Suspected deep tissue injury - depth unknown. No wound odor. No tunneling. No undermining. Multiple bruises to bilateral arms elbow has o/a (open area), right knee has abrasion, right heel stage IV (4) & left heel left inner ankle stage II (2), no c/o (complaint of) pain or discomfort at this time, wounds need re-evaluated. The nurses note dated 10/6/21 documents Patient being treated by wound MD for pressure injury, see progress note in MISC (miscellaneous) tab. Treatments in place and completed as ordered. The skilled evaluation note dated 10/7/21 under the skin section for skin location #1 right heel documents Issue type: Deep tissue pressure injury (DTPI)., for skin location #10 left ankle documents Issue type: Deep tissue pressure injury (DTPI). and for skin location #11 left heel documents Issue type: Deep tissue pressure injury (DTPI). * Surveyor noted these skilled evaluation notes have incorrectly staged R4's right heel and left ankle pressure injuries. The late entry nurses note dated 10/8/21 documents Late entry: 10/7/21 pm shift. Dressing to Lt (left) heel changed r/t (related to) increased drainage. * R4's left heel Deep Tissue Injury was now noted with drainage. * Surveyor reviewed R4's October TAR (treatment administration record) and did not note a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The skilled evaluation note dated 10/8/21 under the skin section for skin location #1 right heel documents Issue type: Deep tissue pressure injury (DTPI). and for skin location #10 left ankle documents Issue type: Deep tissue pressure injury (DTPI). * Surveyor noted the left heel is not documented. The skilled evaluation notes dated 10/9/21, 10/10/21, 10/11/21 under the skin section for skin location #1 right heel documents Issue type: Deep tissue pressure injury (DTPI)., for skin location #10 left ankle documents Issue type: Deep tissue pressure injury (DTPI). and for skin location #11 left heel documents Issue type: Deep tissue pressure injury (DTPI). * Surveyor noted these skilled evaluation notes have incorrectly staged R4's pressure injuries. The nurses note dated 10/12/21 documents wound team to evaluate wounds today. The CNA (Certified Nursing Assistant) Kardex as of 10/12/21 under skin integrity documents ADL (activities daily living) - Bathing/Shower Mon (Monday) & Thurs (Thursday) A.M. (morning. and Float heels. On 10/12/21 at 10:22 a.m. Surveyor observed R4 sitting in a wheelchair in his room with gripper socks on his feet and his feet resting on the floor. Surveyor noted there are no leg rests on R4's wheelchair. Surveyor asked R4 if he has any pressure injuries. R4 informed Surveyor he has two sores on his feet and they don't heal because he retains water. Surveyor asked how the pressure injuries developed. R4 informed Surveyor he doesn't know but doesn't have any feeling on his feet because of [CONDITION(S)]. Surveyor asked if the nurses do any treatments for these sores. R4 informed Surveyor they change the bandages every other day and they were just placing bandages on but they were falling off so they started wrapping his feet with gauze. Surveyor asked R4 if he has a cushion in his wheelchair. R4 replied yes and explained his daughter brought it in. Surveyor asked R4 if he is able to turn himself in bed. R4 replied no and informed Surveyor he just sleeps on his back. Surveyor asked if staff floats his heels or does he wear boots. R4 informed Surveyor staff uses a pillow. R4 informed Surveyor before he came to the Facility at the hospital they put boots on his feet but he didn't like them. R4 informed Surveyor if they get bad he may have to do it. * On 10/12/21 at 11:44 p.m. Surveyor observed R4 sitting in a wheelchair wearing gripper socks with his feet resting directly on the floor. Surveyor noted R4's wheelchair does not have leg rests to elevate his legs. * On 10/12/21 at 1:14 p.m. Surveyor observed R4 sitting in a wheelchair with his feet resting on the floor. R4's lunch tray is on the over bed table and R4 is eating Oreo. On 10/12/21 at 3:04 p.m. Surveyor spoke with Wound MD (medical doctor)-M to inquire about wound rounds. Wound MD-M explained he comes to the Facility weekly on Tuesdays. Surveyor asked what is the system if a Resident is admitted after Tuesday with impaired skin integrity. Wound MD-M explained the Facility has Optum to see Residents, the wound nurse can call for recommendations, and he would see them the next Tuesday. Surveyor asked Wound MD-M if the first time he was involved with [R4] was on 9/28/21. Wound MD-M verified with Surveyor 9/28/21 was the first date he saw R4. On 10/12/21 at 3:50 p.m. Surveyor entered R4's room with Wound MD-M and RN/NS (Registered Nurse)/Nurse Supervisor-O. Wound MD-M & RN/NS-O washed their hands and placed gloves on. Wound MD-M removed R4's gripper sock from the right foot, cut the gauze and removed dressing. Wound MD-M then removed R4's left gripper sock, cut the gauze and removed the dressing from R4's left medial ankle and heel. Surveyor observed the dressing from R4's left ankle had serosanguineous drainage. Wound MD-M stated have bunch more wounds and toes too. Wound MD-M check his computer, indicated the left heel doesn't look so good and asked R4 what is he doing during the day and asked R4 if he lays in bed. R4 informed Wound MD-M he hasn't laid down today. Wound MD-M measured the areas on R4's toes, debrided the let medial ankle and then measured this area. Wound MD-M assessed R4's left heel, measured the left heel, with measurements of 4 x (times) 4.5 cm. Wound MD-M informed R4 his skin is wet and might get bigger if R4 doesn't lay down in bed. Wound MD-M debrided R4's left heel and re-measured obtaining measurements of 6 x 6 x 0.3 cm. Wound MD-M then measured & debrided R4's right heel. After Wound MD-M was finished assessing and measuring R4's pressure injuries, RN/NS-O completed R4's treatments according to physician orders. On 10/12/21 at 4:14 p.m. Surveyor asked Wound MD-M if anyone notified him of R4's left heel pressure injury. Wound MD-M replied, No I didn't know about it. Surveyor asked what about the stage and wound bed. Wound MD-M informed Surveyor the pressure injury is unstageable, 70% slough & 30% granulation. Surveyor asked Wound MD-M if Facility staff should have notified him about the left heel pressure injury. Wound MD-M informed Surveyor sometimes they tell him and sometimes they don't. Wound WD-M informed Surveyor he educated R4 about laying down in bed last week. On 10/12/21 at 4:18 p.m. Surveyor asked RN/NS-O how is the information Wound MD-M educated to R4 communicated to the nursing staff. RN/NS-O informed Surveyor it should be updated in the care plan to offer R4 to go to bed and will let the CNAs (Certified Nursing Assistants) know. Surveyor asked RN/NS-O if the nursing staff was informed of this as Surveyor did not note this information on the care plan or kardex. RN/NS-O informed Surveyor she's not sure. Wound MD-M's wound evaluation & management summary dated 10/12/21 documents Focused Wound Exam (site 1) Stage 4 Pressure wound of the right heel full thickness Etiology pressure, wound size 3.5 x 3 x 0.1 cm, exudate moderate serous, Slough 100% and wound progress deteriorated . Under additional wound detail documents Patient was reeducated on the importance of limit time up in chair, elevating legs and return to bed to elevate legs but has a history of noncompliance. Under dressing treatment plan documents Primary Dressing(s) Alginate calcium apply once daily for 30 days. Secondary Dressing(s) Foam with border apply once daily for 30 days. Focused Wound Exam (Site 2) Unstageable (due to necrosis) of the left, medial ankle full thickness. Etiology pressure, wound size 0.4 x 0.3 x 0.1 cm, exudate moderate serous, slough 100% and wound progress improved. Under dressing treatment plan documents Primary Dressing(s) Alginate calcium apply once daily for 24 days. Secondary Dressing [TRUNCATED]