Every finding on record at Hearthwood SNF Senior Living

Based on interview and record review, the facility failed to ensure adequate assistance and supervision were provided during a mechanical lift transfer for a resident with hemiplegia and hemiparesis due to history of stroke. This deficiency affects one (R1) of three residents in the sample of four reviewed for quality of care. This failure resulted in R1 sustaining a head injury resulting in a right face abrasion, bruise on the right temple area, and skin tear on the right lower arm after falling against an oxygen tank.Findings include:R1 is an [AGE] year-old male, initially admitted in the facility on 06/03/25 with the following diagnoses: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side; and Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Anterior Cerebral Artery.R1's MDS (Minimum Data Set) dated 05/29/26 documented R1 has BIMS (Brief Interview for Mental Status) score of 14, which means little to no impairment in cognition. MDS also indicated R1 has impairment on both sides on upper and lower extremities. R1 also uses a wheelchair. MDS also documented: chair/bed-to-chair transfer: 01 which means 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.R1's POS (Physician Order Sheet) dated 07/06/26 documented: Resident (R1) requires mechanical lift for transfers. Assist two for transfer with sit to stand mechanical lift using large/green sling.Incident Report dated 07/07/26 recorded: R1 was observed sitting on the floor. CNA (Certified Nurse Assistant) on duty is with resident (R1) at the time of fall. Neuro checks initiated. Vital signs within normal limits. Range of motion within normal limits. Bruising noted to right temporal area. Skin tear to right forearm. Skin tear cleansed with normal saline, patted dry, xeroform applied and covered with dry dressing. R1 denies pain. R1 is on anticoagulant. R1 refused to be sent out to hospital for evaluation.Progress notes dated 07/08/26, time stamped 10:57AM recorded: patient (R1) had a witnessed fall during the night causing right arm skin tear and right face abrasion.On 08/03/26 at 11:10 AM; R1 was observed in room, sitting in wheelchair. R1 is alert, oriented and able to verbalize needs and wants. A dressing was noted on his lower right arm. R1 was asked regarding the dressing. R1 showed surveyor dry and healing skin tear under the dressing. The bruise on R1's right temple area and face abrasion was no longer visible. R1 was asked about a fall incident on 07/07/26. R1 stated, It was 4:30 AM, I called for assistance to go to the bathroom. V4 (CNA) and V5 (CNA) came and they put me in the sit to stand machine. After that, V5 came back, only her, and brought me back to bed with the machine. I was sitting on the edge of the bed when she pushed the machine away and I fell on my right side. I hit my head with the oxygen tank, and I had the skin tear on my arm.On 08/03/26 at 12:13 PM, V5 was asked regarding R1's fall incident on 07/07/26. V5 replied, It was 4 AM, we took him to the bathroom, with V4. We toileted him using the sit to stand machine with one person behind him and one person guiding him. We gave him time and when it was time to come back, that was when the fall occurred. He was put to bed safely. He was sitting on the bed, and I was taking off the sling. He was kind of holding on the handrail of the sit to stand and I was telling him to let it go for a little bit and I was holding him. He has a right sided weakness. When I was taking off the sling on the left side, he was trying to put himself on the bed, he slid down and fell. He fell on his right side, on the floor between the bed and chair. I think he had a little blood on his wrist and forehead. He might have hit the top of his head with an oxygen tank, it was metal. I pulled the call button and alarm went off, the nurse happened to be nearby, and she heard and went to his room. V3 (Licensed Practical Nurse, LPN) was the nurse. She (V3) assessed him. V5 was asked if she was helped by another CNA at the time of R1's fall. V5 stated, I was the only one putting him back to bed. I came back by myself to put him back to bed. He needs two CNAs when he is transferred and using the sit to stand machine. I did his transfer using the sit to stand. I was in-serviced to use the sit to stand machine a couple of months ago. During the in-service, in general it needs one to two assists. But for R1, it should be two CNAs, I think.V4 was asked on 08/03/26 at 12:51 PM regarding R1 on 07/07/26. V4 verbalized, On 07/07/26 at around 4 AM, I remember I assisted V5 to take him to the bathroom. It was her (V5) resident, I helped her (V5) put him in the bathroom. We used the sit to stand machine on him. He needs two CNAs to help him with the sit to stand. After he was put into the bathroom, we left. V5 did not ask for any assistance afterwards. Later, I found out that he had a fall.On 08/03/26 at 12:58 PM, V3 was interviewed regarding R1. V3 stated, R1 is alert, oriented but sometimes forgetful. He had a stroke with right-sided weakness. He uses a wheelchair and uses the sit to stand machine to transfer to the bathroom, and to bed. If he is using the sit to stand machine, he needs two-person assistance. On 07/07/26 around 4 in the morning, R1 called to go to the bathroom. V5, the CNA assigned asked for help, V4 came and helped her (V5) to transfer him (R1) to the toilet safely. After that, I answered the call light from his room, I went there right away and saw him on the floor beside the bed. V5 was with him. I assessed R1, his vitals were within normal limits, no pain. I noticed a skin tear on his right forearm, with scanty bleeding. I put dressing foam. There was a bruise on the right temporal area. I notified V10 (Nurse Practitioner) and V11 (Family Member). He (R1) refused to be sent out. He needed 2 CNAs, but it was only V5 who transferred him back to bed.R1's care plan (date initiated 06/11/25) regarding potential for injury related to mechanical lift use (sit to stand) documented: Intervention (date initiated 06/11/25): 2 CNAs to assist resident (R1) with transfer using mechanical lift (sit to stand).On 08/04/26 at 10:35 AM, V13 (Physician) was interviewed regarding R1 and fall. V13 replied, I have been taking care of him since he's been admitted in the facility. He is alert, oriented, some expressive aphasia due to stroke. He has hemiparesis on the right side due to stroke and needs custodial care. He certainly is cognitively with it. Family is there all the time. He can use the sit to stand machine with two staff assist. I was notified about his recent fall, that same day they called me. I don't remember the circumstances. V13 was asked regarding expectations on facility staff related to fall prevention. V13 stated, Staff should do what they were trained to do in preventing falls. Certainly staff should follow the fall prevention set in the facility.V2 (Director of Nursing/Fall Coordinator) was also asked on 08/04/26 at 11:16 AM regarding R1 and expectations from staff in preventing fall. V2 verbalized, He is alert, oriented. He had a stroke and has hemiplegia on the right side. He is wheelchair bound, dependent on staff for ADLs (activities of daily living). He uses sit to stand machine with two-person assist. He had a fall on 07/07/26. Staff should be safe at all times with residents. We cannot prevent all falls but to make sure appropriate interventions are followed. If there are no injuries, monitor residents. If there are injuries, send them out to the hospital for further evaluation. If two-person assist is needed to transfer a resident using a sit to stand machine, there should be two persons assist for resident's safety. If there is an order for two persons assist during transfer, it should be followed by staff for resident safety.Facility's policy titled, Care plans, Comprehensive Person-Centered undated, documented in part but not limited to the following:Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to resident's physical, psychosocial and functional needs is developed and implemented for each resident.Facility's policy titled Falls-Clinical Protocol, undated, did not address safe use of mechanical lift/sit to stand machine on residents during transfer.

Based on interviews and record reviews, the facility failed to protect a resident with severe cognitive impairment from verbal abuse. This deficiency affects one (R2) of three residents in the sample of four reviewed for abuse.Findings include:R2 is a [AGE] year-old, male, admitted in the facility on 12/11/25 with the following diagnoses: Acute Kidney Failure with Tubular Necrosis; Altered Mental Status, Unspecified; Cognitive Communication Deficit; Anxiety Disorder, Unspecified; Alcohol Abuse, Uncomplicated; Personal History of transient ischemic attack (TIA), and Cerebral Infarction without Residual Deficits. MDS (Minimum Data Set) dated 01/05/26 recorded R1's BIMS (brief interview for mental status) score is 5, which means severe cognitive impairment.R2's incident report dated 01/28/26 documented: a staff member reported that a co-worker made an inappropriate comment regarding resident's eating habits. Resident was interviewed for safety and comfort; he did not have any concern regarding staff or care.According to V1 (Administrator), the staff involved was V7 (Certified Nurse Assistant, CNA).On 08/03/26 at 2:26 PM, V7 was asked regarding R2 and incident on 01/28/26. V7 replied, He is confused all the time and dependent on staff for care. He has a behavior of throwing food on the floor. On 01/28/26, I remember he was eating in the common area. The whole table has food and the floor as well. I was there and he was there, he was the only one. I made a comment about his eating habits that he is a messy eater, but not in front of him. I shouldn't make a comment on anybody, at any place. It was my fault, no excuse or whatsoever, that I shouldn't make a comment to any resident. I should keep it to myself. I was suspended for that. They said I have to be mindful of what I said. It was verbal abuse for saying that he (R2) was a messy eater. I admit that I made a comment about him being a messy eater. I made a comment after I cleaned up the mess, I was in the hallway.On 08/03/26 at 3:00 PM, V8 (CNA) was also asked regarding incident on 01/28/26 involving R2 and V7. V8 stated, On 01/28/26, it was like dinnertime, around 5:30 PM. R2 was in the common area, by the television. He was eating there. He needs assistance while eating; he has tremors in his hands. He has no control with his hands when he eats. The table within his space is full of food, not the floor. He eats by himself at the time. V7 was supposed to assist him during dinner. I was picking up the trays of my residents; I was rolling the food cart to the kitchen. He (V7) was with him (R2). V7 made a comment that it's not a pigsty to eat like this. He said that directly to R2. After that, I mentioned that to my nurse, V9 (Registered Nurse, RN) and I called V1 and reported the incident.V9 was asked on 08/03/26 at 3:16PM regarding R2's incident, stated, On 01/28/26, I was told by V8 that he heard V7 stated, Why are you doing this, this is not a pigsty, something like that. I talked to V7 and confirmed if he stated that. He answered as to why he said that. That there were a lot of mess and a lot of residents eating in that area and he did not like what he saw because it was a mess. He just explained why he said pigsty.On 08/04/26 at 10:10 AM, V1 was asked regarding abuse and R2. V1 verbalized, I was notified on the same day the incident happened, 01/28/26. It was V8 who notified me about the incident. V8 said that he was around the common area, northside and he overheard another coworker, V7 made a comment that the area was so messy. I clarified with V7 and he said that there was food on the floor, too messy. Said he might have used the word pig. He said he was referring to the area and not the resident (R2). When I spoke with R2, he was not able to recollect anything. I made sure that there was no harm done. He (R2) was assessed at the time. V7 was sent home and put on leave for two days. V7 agreed that he made that comment, he did not intend to direct it to R2.On 08/04/26 at 10:35 AM, V13 (Physician) was asked regarding abuse. V13 stated, We have a policy and procedures for abuse, and we review it multiple times over and we should follow it to a T.Facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated February 2024 stated in part but not limited to the following:Policy Statement:Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Policy Interpretation and ImplementationThe resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:1.Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to:a.Facility staff5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

Based on interview and record review, the facility failed to follow their water management plan by failing to establish control measures for the risk of Legionella growth within the facility's water system. This failure has the potential to affect the health and safety of all 55 residents currently residing in the facility. On 11/25/2025 at 1:12 PM, V1 (Administrator) said that the facility has never tested the facility's water for Legionella. The Facility signed a contract with a new water management services on 03/01/2025, following the last facility survey, and still had not yet conducted any Legionella testing. V1 said, I am not aware why the testing was not done, and the facility is expected to follow their policy and the water management plan and test for legionella annually.On 11/25/2025 at 1:10 PM, V11(Maintenance Director) said that the facility has not been tested for Legionella and showed the testing supplies in a box provided by the water management services dated 05/06/2025. V11 said the facility is expected to test annually for Legionella, and the test was not done as per the facility's water management plan.On 11/26/2025q at 2:29 PM V1(Administrator) presented policy titled: Water Management Plan dated 3/17/2025, which reads:2.3 Water Management Plan Creation and StrategyThe risk of a building can be assessed by determining if Legionella is present, the type of Legionella found (species and serogroup), the extent of positivity, and the opportunity for exposure. Risk management methods provide a process for hazard identification and mitigation. ASHRAE Standard 188: Legionellosis: Risk Management for Building Water Systems was developed to provide a standard approach to guide these risk management activities. ASHRAE Standard 188 provides a standard approach to implementation of water management programs, with the following seven key elements:1. Identify and describe the building water systems: Conduct a water systems survey, identity major processing steps, and develop flow diagrams.2. Conduct a hazard analysis: Among the water systems identified, determine the risk of Legionella growth and transmission.3. Establish control locations: Determine points or steps at which Legionella control measures can be applied.4. Establish and implement control measures: For each control location, determine control limits, monitor the performance, and take corrective action if a control measure is not within the control limits.5. Establish and implement verification procedures: Verify the WMP is being implemented.6. Establish and implement validation procedures: Show the effectiveness of the WMP in controlling the hazard (Legionella).7. Establish and implement documentation: The control measures, validation, and other WMP actions must be documented. 3. Water Management Plan Summary3.1 Summary Control validation and locationLegionella distal site testing-Monitoring Frequency-Annually.7. DocumentationA written record is required to document monitoring, compliance with control limits, performance of corrective actions, and WMP validation. Maintain water testing documentation to be retrievable for at least three years. A master document providing the location of all program documents shall be maintained.Maintain the following minimum documentation for this WMP. Logs required for normal operation and system maintenance shall continue to be maintained: Temperature (heaters, return, distal outlets, mixing valve logs) Maintenance and Operation Procedures Flushing Logs System service/modification records Bacteriological analysis records Episodic water event and action logs Corrective action records

Based on observation, interview, and record review, the facility failed to ensure staff and visitors wore corresponding PPE (Personal Protective Equipment) for resident isolation status, and failed to have measures to test for growth of Legionella and other opportunistic water borne pathogens in the building water system. This affects 3 out of 3 residents (R28, R54, R211) and all 54 residents in the facility. Facility's Long-Term Care Facility Application for Medicare and Medicaid dated 2/18/2025 to 2/21/2025 showed a census of 54 residents. Findings include: 1. On 2/18/2025 at 11:14 AM, R28 was on contact and droplet isolation. On 2/18/2025 at 12:10 PM, V8 (RN-Registered Nurse) was observed in front of R28's door when a visitor arrived. V8 stepped aside and let the visitor enter the room with only a surgical mask on. V8 did not educate or encourage visitor to wear appropriate PPE. Review of R28's EHR (Electronic Health Record) shows diagnosis of Covid-19. 2. On 02/19/25 at 02:00 PM, a visitor was observed inside R211's room. Visitor was not wearing any PPE. R211's EHR documents she is on contact isolation for Herpes Simplex. On 2/20/2025, V27 (IP-Infection Preventionist) said visitors are expected to follow facility policy when entering an isolation room. He said for droplet isolation, visitors are expected to wear gown, gloves, well fitted mask and eye protection. He said for contact isolation, visitors are expected to wear gown and gloves. He said he expects staff to educate visitors of what PPE to wear before going inside an isolation room. He said it is important for visitors to wear appropriate PPE to stop spread of infection. He said it is the responsibility of staff to provide education to visitors regarding use of proper PPE. Facility's undated Isolation - Categories of Transmission-Based Precautions Policy showed Transmission-based precautions are additional measures that protects staff, visitors, and other residents from becoming infected. The policy stated for contact isolation, staff and visitors will wear gloves and disposable gowns upon entering the room. Policy showed for droplet precautions, mask, gloves, gown, and goggles should be worn if there is a risk for spraying respiratory secretions. 3. On 02/19/25 at 08:43 AM, R54's wound care was observed. Wound care was done by V23 (Wound Care Nurse). R54 has pressure ulcer on her right buttock. All throughout providing wound treatment, V23 was only wearing gloves. After wound care, V23 said I forgot to wear a gown. R54's EHR documents she is on EBP (Enhanced Barrier Protection) due to wounds. On 2/20/2025, V27 (IP-Infection Preventionist) said residents are put on EBP when they have open wounds that require dressing. He said staff should wear gown and gloves when providing care to protect both staff and resident. Facility's Policy and Procedure on Enhanced Barrier Protection dated 4/1/24 documents that EBP precautions are defined as use of gowns and gloves during high contact care activities that generate opportunities for transfer of MDROs (Multidrug-resistant Organisms) in the form of blood or body fluids, onto the hands and/or clothing of the caregiver. Policy states that precautions are generally in place until there is resolution of the wound. Policy further documents dressing care/changes/management of dressings as an example of high contact resident care activity. 41384 4. On 02/20/25 at 10:38 AM V1 (Administrator) said that the facility has never tested the facility's water for Legionella or any other opportunistic waterborne pathogen. The facility's Water Management Plan dated 12/1/2017 showed, collect water samples from appropriate locations and have the samples tested for Legionella by a highly qualified laboratory that has certifications and approvals applicable to the facility's location - e.g., certified by the CDC's ELITE program in the US; certified per the Public Health England external quality assessment (EQA) Legionella isolation scheme in the UK; approved by the state environmental laboratory approval program (ELAP). Sample domestic water system and other drinking water (e.g. bottled water dispenser) at the following minimum frequencies initially, and then more frequently if indicated by test results: residential buildings occupied primarily by seniors nursing homes, health care facilities, and other buildings occupied by persons at high risk four times yearly.

Based on interview and record review, the facility failed to provide the mandatory 12 hours of annual training to their CNA's (Certified Nursing Assistants). This applies to all 54 residents in the facility reviewed for staff training. The findings include: On 2/18/2025, V1 (Administrator) submitted Form CMS (Centers for Medicare and Medicaid Services) 671: Long Term Care Facility Application for Medicare and Medicaid. It documents the facility has a current census of 54 residents. On 2/19/25 at 9:30 AM, V22 (CNA Supervisor/Staffing Coordinator) stated I don't have any record of the 12 hours of dementia and abuse training that CNA's are supposed to do. I think they do that in the skills fair. I will talk to human resources. On 2/20/25 at 10:02 AM, V2 (DON-Director of Nursing) stated, We don't have the 12 hours of training for the CNA's. We usually do it in our skills fair. Yes, CNA's are supposed to do the required 12 hours every year. Yes, it is required for my CNA's to do the dementia and abuse training. HR (Human Resources) was responsible for doing it at the skills fair. We had it 2 years ago in (2023) before our annual survey (4/25/24). We didn't have a skills fair in 2024. We are going through a transition with a new HR and new management. The skills fair is part of it. Competencies and inservices are done by (V22), me or my ADON (Assistant Director of Nursing). On 2/20/25 10:12 AM, V3 (HR-Human Resources Director) stated, I took over the role as HR Director in November 2024 very suddenly. We usually would have an annual skills fair encompassing all of that training. They did not do a skills fair in 2024. I'm unable to provide you any documentation that says my CNA's got 12 hours of training. The 12 hours are mandatory every year. On 2/20/25 at 10:50 AM, V3 came back to the conference room with a list of all her CNA's. The document shows the facility currently has 36 CNA's. She stated the skills assessment quiz doesn't show how many hours the subjects were. V3 stated that V16 (Former Director of Assisted Living) did an inservice on dementia in March 2024. However, she was unable to find the inservice sign in sheets at this time. The following five CNA's files were reviewed with V3: V14 (hire date of 6/22/22), V17 (hire date of 4/20/09), V18 (hire date of 5/23/16), V19 (hire date of 12/28/10), and V20 (hire date of 10/19/10). They did not have the required 12 hours of annual training. V3 showed a skills fair quiz from 2023 for the CNA's, but it did not specify the number of hours for each topic and V3 was unable to determine how many hours of presentation the skills fair was for. Facility's policy titled Nurse Aide Qualification and Training Requirements (August 2022) show the following: 6. Nurse aides will have a minimum of 16 hours of training in the following areas prior to direct contact with the residents: a. communication and interpersonal skills; b. infection control; c. safety/emergency procedures; d. promoting residents' independence; e. respecting residents' rights; f. basic nursing skills; g. personal care skills; h. mental health and social service needs; i. care of the cognitively impaired residents; j. basic restorative services; and k. resident rights.

Based on observation, interview, and record review, the facility failed to ensure resident medications were safely secured. This applies 6 to 6 residents (R3, R13, R26, R33, R34, and R115) reviewed for medications in a sample of 23. The findings include: 1. On 2/18/25 at 10:13 AM, there were bottles of Advil (Ibuprofen 200mg), DayQuil severe cold and flu (Acetaminophen, Guaifenesin, Phenylephrine HCL, Dextromethorphan), and Loperamide hydrochloride (1mg per 7.5mg) on top of R34's bedroom dresser. V30 (R34's husband) said the Loperamide was his; he said his son brought it for them. V30 said his wife does not talk much. On 2/19/25 at 9:36 AM, the medications were still noted on R34's dresser. Review of R34's Electronic Medical Record (EMR) showed diagnoses of atrial fibrillation and dementia. R34's Minimum Data Set (MDS) of 1/22/25 shows that R34's cognition is severely impaired. Review of R34's orders shows that R34 had an order for Loperamide HCL solution 1gm/7.5ml to give 15ml by mouth for times a day. R34 did not have an order for Advil (Ibuprofen) or DayQuil; R34 did not have an order for medications to be stored in resident's room. 2. On 2/18/25 at 10:51 AM, there was a bottle of Nystatin 100 000 USP powder on R13's bedside table. At 11:24 AM, R34 said the Nystatin powder was his. On 2/19/25 at 9:44 AM, the Nystatin powder was still noted on R13's bedside table. Review of R13's EMR showed diagnoses of heart failure, atrial fibrillation and personal history of urinary tract infection (UTI). R13's MDS of shows that R13's 12/11/24 cognition is severely impaired. Review of R13's orders shows that R13 had an order for Nystatin External Powder 100 000 unit, apply to groin and scrotum topically every day and evening shift for redness; R13 did not have an order for medication be stored in resident's room. 3. On 2/18/25 at 10:54 AM, there was a bottle of Nystatin 100 000 USP powder on R3's bedside table; R3 said it was hers, and staff uses it on her. On 2/19/25 at 9:50 AM the Nystatin powder was still on R3's bedside table. Review of R3's EMR showed diagnoses of polyosteoarthritis, lymphedema, rash and other nonspecific skin eruption. R3's MDS of 12/3/24 shows that R3's cognition is intact. Review of R3's orders shows that R3 had an order for Nystatin External Powder 100 000 unit, apply to vaginal skin every shift for redness; R3 did not have an order for medication be stored in resident's room. 31327 4. On 2/18/25 at 11:20 AM, during initial tour, surveyor went to R115's room. On her bedside table, there was saline nasal spray on top of her bedside table. R115 stated she brought it from home. On top of R115's dresser, there was a Fluticasone Propionate nasal spray. R115 stated she brought it from the hospital. R115's face sheet shows an admitted [DATE]. R115's POS (Physician Order Sheet) shows no order for the saline nasal spray. It indicates a physician order of Fluticasone Propionate Nasal Suspension 50 MCG (Micrograms)/ACT-2 sprays in each nostril at bedtime for nasal agent. There is no order for the medication to be stored at the bedside. R115's MDS (Minimum Data Set) dated 2/20/25 shows a BIMS (Brief Interview for Mental Score) of 14, which means she is cognitively intact. 5. On 2/18/25 at 12:58 PM, on R26's bedside table, there was Nystatin 100,000 units/GM powder. R26 stated that it's always kept in her room. R26 stated, The CNA (Certified Nursing Assistant) comes and cleans me. Then she puts the powder in my groin area and then she changes me and puts a new brief on me. R26's MDS dated [DATE] shows a BIMS score of 13 which indicates normal cognition and intact cognitive response. R26's POS shows an order for Nystatin External Powder 100000 unit/GM-Apply to groin topically everyday and evening shift for fungal infection. There was no order for the medication to be stored at the bedside. On 2/20/25 at 11:15 AM, V2 (DON-Director of Nursing) stated, All medications brought from home should be given back to the resident's family or be put in the medication cart. They should be not stored in the room. Specialty medications brought from home can be used but must need a doctor's order. All medications that residents take should have physician orders for it. Antifungal creams are medicated creams. They can be left at the bedside without a physician's order. Facility's policy titled Storage of Medications (Undated) showed The facility stores all drugs and biologicals in a safe, secure and orderly manner. 1. Drugs are biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. 41384 6. On 02/18/25 at 12:05 PM the following medications were found on R33's dresser: 2 medication cups half full of a white powder, 1 opened tube of Nystatin and Triamcinolone Acetonide cream, 2 opened tubes of Medihoney, and 1 plastic bag with 2 unopened tubes of Triamcinolone AC 0.5% cream inside the bag. R33's 2/12/25 MDS showed that R33's cognition is moderately impaired. A review of R33's electronic health record did not show any order to have medications at bedside. R33's physicians orders showed: 11/16/24 Desenex External Powder 2%, & 2/8/25 Triamcinolone Acetonide External cream 0.5%.

Based on observations, interviews, and record review, the facility failed to provide ADL (Activities of Daily Living) for residents who require assistance with ADL cares. This applies 3 of 8 residents (R10, R32, R33) reviewed for daily cares in a sample of 23. The findings include: 1. On 02/18/25 at 11:55 AM R32 was observed with her fingernails long and jagged. R32's 1/14/25 MDS (Minimum Data Set) showed her cognition is severely impaired and is dependent on staff for personal hygiene. R32's 1/22/25 care plan showed R32 has an ADL self-care performance deficit related to impaired balance, limited mobility, limited range of motion, and left sided weakness. The interventions include, check nail length and trim and clean on bath day and as necessary. R32 needs staff assistance in personal hygiene. 2. On 02/18/25 at 10:13 AM R10 was observed with facial hair on his chin and above his upper lip and said that he didn't recall the last time he was shaved, and his fingernails were long, jagged and with a brown substance under the nails. R10 said that his nails needed to be trimmed and he didn't recall the last time he received nail care. R10's 2/10/25 MDS showed that R10 needs substantial/maximal assistance for personal hygiene. R10's 2/4/25 care plan showed that R10 requires assistance with activities of daily living with interventions including set up assistance by staff for personal hygiene. 3. On 02/18/25 at 12:05 PM R33 was observed with her fingernails jagged with brown substances under the nails. R33 chin and upper lip was observed with hair. R33 said that the facial hair bothers her, and she would like for someone to help her with it. R33's 2/17/25 MDS showed her cognition is moderately impaired and that she needs partial/moderate assistance with personal hygiene. R33's 11/27/24 care plan showed that R33 has an ADL self-care performance deficit with interventions including check nail length and trim and clean on bath day and as necessary, and personal hygiene care she needs partial assistance from staff. On 2/20/25 at 1:40 PM V2 DON (Director of Nursing) said that the CNAs (Certified Nurses' Assistants) are responsible for shaving and nail care and ADLs are done as needed, there is no scheduled time. The facility's policy Activities of Daily Living (ADLs) dated March 2018 shows, residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, bathing, dressing, grooming, and oral care.

Based on observation, interview, and record review the facility failed to provide meaningful activities to residents. This applies to 3 residents (R25, R32, & R33) reviewed for activities in a sample of 23. Findings include: 1. On 02/18/25 at 11:05 AM R25, who was alert and oriented, denied attending any activities and said that staff does not bring activities to her room. R25 said that she would like to attend activities. R25's 12/26/24 care plan showed that R25 enjoys socializing with peers, watching TV gameshows, and doing word search puzzles and visiting with family. The interventions include the resident will express satisfaction with type of activities and level of activity involvement when asked through the review date. Assess the residents strengths and abilities. Evaluate the resident for participating in active and passive programs. Check in to see if the resident has any change in activity preferences. Continue assessment of activities enjoyed in the past that could be built upon to enhance current involvements. Encourage participants involvement and enjoyment of activities program; provide activities that resident can complete, has stated enjoyment. Encourage residents creativity and curiosity, encourage participant to try a new activity when they choose not be involved in programs. Offer individual activities designed to match the preference and resident goals. Offer recreational cart to increase independent leisure activities. Offer visits to ensure sufficient independent social and recreational contacts. Provide with calendar and identify time and place of recreational programs of assessed interests. Staff will encourage resident to attend programs of choice, offering escort and assistance with programs when resident agrees. Support preferences to spend time alone and introspectively. Validate feelings and emotions. 2. On 02/18/25 at 12:05 PM R33, who's cognition is intact, said that staff doesn't bring any activities to her room or come and visit or talk to her. R33's 11/27/24 care plan showed R33 prefers to spend duration of time in her room, relaxing in her bed, engage in informal room activities, reading novels, watching TV, listening to music, and taking short naps. Has good family support. The interventions including likes to talk about cats and animals in general. Allow freedom of choice of activity interests. Bring to R33's attention activity programs which coincide with past interests. During in room activities: ask resident where she would like staff to be seated. Express appreciation for willingness to try new activities. [NAME] rapport with frequent greetings without expectations; observe feeling of frustration. Introduce R33 to peers with similar interests. Ask resident and peers open-ended questions to promote opportunity for development of friendship. Observe R33 for signs of increased distress, anxiety or nervousness and positive signs of relaxation or calming and modify interventions accordingly. Offer brief visits as support and to keep open the opportunities for recreational pursuits. Offer individual activities designed to match the preference and resident goal. Offer simple explanation of programs contents. Offer to take R33 out of room for short period of time: a change of environment. Promote gradual exposure to alternate recreational setting as R33 becomes willing or comfortable. Remind of the open opportunity to decline recreational invitations without apologies. Remind to stay within her comfort zone. Respect residents right to refuse activities. Validate feelings and emotions. R33 prefers to socialize with staff about magazines that she enjoys reading, daily news, and family. 3. On 02/18/25 at 11:55 AM, R32 was observed in her room with V32 (R32's Private Care Giver) and V32 said that she is there every day, all day, Mondays through Fridays and the facility does not bring any activities to R32 room or come in and read or talk to R32. V32 said that the staff does nothing with R32. R32's 10/17/24 care plan showed that R32 enjoys in engaging in independent leisure activities with assistance. She will occasionally participate in facility recreational, spiritual, and social activities. She enjoys relaxing in her room after meals listening to music, watching TV, talking on the phone, and spending time with family. The interventions include assess strengths and ability, evaluate the resident for participating in activities and passive programs. Check in to see if resident has any change in activity preference. Community life will provide rosary beads as needed. Encourage and support the development of new interests, hobbies, and skills. [NAME] rapport with frequent greetings without expectations. Offer individual activities designed to match the preference and resident goal. Offer recreational cart to increase independent leisure activities. Offered visits to ensure sufficient independent social and recreational contacts. Provide a program of activities that is of interest and empowers the resident by encouraging allowing choice, self-expression, and responsibility. Staff will encourage R32 to attend programs of choice, offer escort and assistance with programs when resident agrees. Staff will visit resident in room for short durations based on resident's ability and acceptance of visits on a daily basis. On 02/19/25 at 10:15 AM V4 Activities Director provided the state surveyor a One on One Visits list updated 2-3-25 and it showed that R25, & R33 were on the list. V4 also provided a book with documentation showing when staff provided 1 to 1 activities for R25, & R33. V4 said that this was where the staff documents when they provide activities for the residents who stay in bed. R25's 1 to 1 Activities documentation showed that R25 only received activities for February 2025 on 2/5/25 and 2/13/25, and for January 2025 only received activities on 1/1/25, 1/3/25, 1/5/25, 1/5/25, & 1/16/25. R33's 1 to 1 Activities documentation showed that R33 only received activities for February 2025 on 2/3/25, 2/5/25, 2/11/25, 2/13/25, and January 2025 on 1/1/25, 1/4/25, 1/5/25, 1/7/25, 1/30/25, 1/31/25. On 02/19/25 at 02:08 PM a review of progress notes were done, and no notes were found showing R25, R32 or R33 refusing to attend or participate in activities. The Activities Participation Record [unit] book was also reviewed and there was no documentation in it for R25, R32 or R33. On 02/19/25 at 02:00 PM V2 DON (Director of Nursing) said that all residents are to get some form of activities every day in their room or outside of their room. The facility's Activity Program policy dated June 2018 showed that activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. The policy's Interpretation and Implementation showed: 1. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. 2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. 4. Activities are considered any endeavor, other than routine ADLs, in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive, or emotional health. 5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs.

Based on interview and record review the facility failed to ensure that a resident's signed POLST (Practitioner Order for Life-Sustaining Treatment) form and physician's order are consistent, to reflect the resident's treatment wishes in an event of a medical emergency, based on the facility's advance directives policy. This applies to 1 of 2 residents (R29) reviewed for advance directives in the sample of 16. The findings include: R29 was admitted to the facility on [DATE]. R29 had multiple diagnoses including Parkinsonism, generalized muscle weakness and stage 3 chronic kidney disease. R29's quarterly MDS (Minimum Data Set) dated [DATE] showed that the resident was cognitively intact. R29's active physician order summary report showed an order dated [DATE] for Full Code - CPR (Cardiopulmonary Resuscitation). R29's POLST form dated [DATE] showed that if R29 had a cardiac arrest and had no pulse, No CPR: Do Not Attempt Resuscitation (DNAR). The POLST form was signed by R29's legal representative and primary care physician. R29's POLST form was inside the resident's physical chart and was not scanned in the resident's electronic records. On [DATE] at 10:24 AM, V17 (Registered Nurse) reviewed R29's physical chart and stated that a signed POLST for No CPR was available. V17 reviewed R29's electronic physician's order report and stated that the order was Full Code. According to V17, he will ask the social service department for clarification because the POLST and the physician's order were conflicting. On [DATE] at 10:27 AM, V8 (Social Service Director) stated that the POLST form and the physician's order should reflect the same code status and/or advance directives to avoid confusion, because in an emergency the physician's order and the signed POLST will direct the care that should be given to a resident. On [DATE] at 12:27 PM, V2 (Director of Nursing) stated that a physician's order is part of the resident's plan of care. V2 stated that the code status order on a resident's physician's order and the signed POLST should always be consistent to prevent any concerns during provision of emergency procedure to a resident. According to V2, R29's order should have been changed from a Full Code to DNR (Do not Resuscitate) on [DATE] when the resident's POLST was signed by the legal representative. The facility's undated policy regarding advance directives showed 9. If resident has chosen any other advance directive from current OBRA (Omnibus Budget Reconciliation Act) definitions and guidelines, resident will have a valid POLST form or alternative state issued document placed in the physical chart 12. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.

Based on observation, interview and record review, the facility failed to administer oxygen to a resident as ordered by the physician. This applies to 1 of 1 resident (R42) reviewed for oxygen in a sample of 16. The findings include: Face sheet, dated April 23, 2024, shows R42's diagnoses include respiratory failure with hypercapnia, congestive heart failure, bradycardia, atrial fibrillation, obstructive sleep apnea, and anxiety disorder. Physician order, initiated July 17, 2023 and discontinued April 22, 2024 at 2:13 PM, shows R42 had a physician's order for continuous oxygen to be administered at 5 liters per minute via nasal cannula. Care plan, initiated April 22, 2024, shows R42 had orders for oxygen therapy related to congestive heart failure and his care plan interventions included providing oxygen as ordered. On April 22, 2024 at 11:38 AM, R42 was resting in his bed with his nasal cannula placed in his nose. R42's oxygen concentrator was turned on and R42's oxygen was set to deliver 3.5 liters per minute. At 1:33 PM, R42's oxygen remained set to deliver 3.5 liters per minute of oxygen. At 1:52 PM, V9 (CNA/Certified Nursing Assistant) examined R42's oxygen concentrator setting and stated the oxygen was set to deliver 3.5 liters per minute of oxygen. At 1:55 PM, V15 (Infection Control Nurse) and V16 (Licensed Practical Nurse) both examined R42's oxygen concentrator and stated R42's oxygen was set to deliver 3.5 liters per minute of oxygen. Facility policy Oxygen Administration, revised October 2023, shows, Verify that there is a physician's order for the procedure. Review the physician's order of facility protocol for oxygen administration 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute 10. Adjust the oxygen delivery device so that is comfortable for the resident and the proper flow of oxygen is being administered

Based on observation, interview and record review, the facility failed to ensure that a narcotic medication was not borrowed from one resident and given to another resident. This applies to 1 of 5 residents (R306) reviewed for medication administration in the sample of 16. The findings include: R306 is an [AGE] year old female admitted to the facility on [DATE] with medical diagnoses that include syncope and collapse, history of falling, pain in right shoulder, and presence of cardiac pacemaker. R306 has a physician order dated April 21, 2024 for hydrocodone/acetaminophen 5/325 milligrams (mg) - give 1 tablet every 4 hours as needed for moderate pain. R48 also has a physician order dated April 14, 2024 for hydrocodone/acetaminophen 5/325 mg - give 1 tablet by mouth every 8 hours as needed for pain. On April 22, 2024 at 11:13 AM while observing 3rd floor split cart and narcotic reconciliation, V12 (Registered Nurse) stated that the narcotic count would be off because he gave one of R48's hydrocodone/acetaminophen 5/325 mg tablets to R306. V12 stated that R306 has an order for hydrocodone/acetaminophen 5/325 mg but did not have a prescription for Hydrocodone 5/325 yet. V12 stated they are waiting for R306's doctor to send a prescription for hydrocodone/acetaminophen 5/325 mg. R48's controlled drug receipt record for hydrocodone/acetaminophen 5/325 mg showed that R48 had 17 tablets remaining. However, the actual count in the medication blister card was 16 tablets remaining. V12 stated that it is the facility's policy not to share one resident's narcotic medication with another resident. V12 also stated that he was not able to pull the hydrocodone/acetaminophen 5/325 mg tablet for R306 from the backup medication supply machine because there was no prescription available to be processed by the pharmacy at that time. Review of R306's medication administration record shows that hydrocodone-acetaminophen 5/325 mg was given to R306 on April 22, 2024 at 9:22 AM On April 23, 2024 at 10:41 AM, V12 stated R306's hydrocodone-acetaminophen 5/325 mg came that day. V12 stated he was able to get a prescription from the doctor yesterday afternoon via fax. V12 stated he then faxed the prescription to the pharmacy. On April 24, 2024 at 11:05 AM, V13 (Pharmacist) stated that an order is not an actual prescription when dealing with narcotics. V13 stated that they received an order for R306's Hydrocodone/acetaminophen 5/325 mg via fax on April 22, 2024 at 10:32 am. V13 state that the prescription came later in the day at 2:08 PM. V13 stated the facility would not be able to pull hydrocodone/acetaminophen 5/325 mg from the backup medication supply machine without a prescription. V13 stated that the nurse should not share narcotic medications with other residents. V13 stated that if the doctor has not signed the prescription and approved a narcotic medication then the facility should not administer the medication. On April 24, 2024 at 1:33 PM, V2 (Director of Nursing) stated there must be a prescription for a narcotic to be administered. V2 stated it is their policy not to take from one resident's medication and give it to another resident. V2 stated without a prescription for a narcotic medication, the physician is not giving his permission to administer the medication. V2 stated it is their policy not to give a narcotic medication until the pharmacy receives a valid prescription and agrees to its distribution. The facility's administering medications policy showed in-part, under Policy interpretation and implementation: 10. The individual administering the medication checks the label to verify the right resident, right medication, right dose, right time, right route, and right documentation of administration when giving the medication.

Based on observation, interview, and record review, the facility failed to identify and monitor behaviors and provide diagnosis targeted for a prescribed antipsychotic medication. This applies to 1 of 5 residents (R15) reviewed for unnecessary medications in the sample of 16. The findings include: On April 22, 2024 at 10:57am, R15 was in a wheelchair in the resident room. R15 was dressed, groomed, and calm. R15 answered questions with slight nods only. R15's affect was flat. According to the facility Face Sheet, R15 has diagnoses at admit, March 17, 2024, with diagnoses including pneumonia; urinary tract infection; weakness; shortness of breath; acute respiratory failure with hypoxia; unsteadiness on feet; dysphagia, oropharyngeal phase; unspecified atrial fibrillation; thoracic aortal aneurysm; hyperlipidemia; unspecified dementia, unspecified severity with other behavioral disturbance; anxiety disorder unspecified; other recurrent depressive disorders; anemia unspecified; presence of other vascular implants and grafts; essential (primary) hypertension; constipation unspecified. The physician order sheet (POS) shows an order for Quetiapine Fumarate (an anti-psychotic medication) 50 milligrams by mouth at bedtime for anxiety. The order is dated March 17, 2024. The diagnosis list includes no psychotic illness that would necessitate the use of an antipsychotic medication. The PASRR (Preadmission Screening and Record Review) for R15, dated March 15, 2024, shows PASRR Level 1 Determination: No Level 2 required - No SMI (severe mental illness). There is no record of monitoring R15's behavior in the facility record. A Progress Note dated April 1, 2024 at 3:50 pm, from the psychiatric Nurse Practitioner (V7) shows R15 has a history of screaming and resisting care and notes these behaviors are not occurring at the time of the examination and refers to no other diagnostic criteria for the use of an antipsychotic medication. On April 24, 2024 at 12:25 pm, V19 (Spouse to R15) stated R15 was not taking quetiapine or Seroquel (the brand name for quetiapine fumarate) at home before being hospitalized immediately prior to admission to the facility on [DATE]. The facility provided their policy titled Psychotropic Medication Use. The policy includes: 1. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. 7. Psychotropic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current and subsequent editions): a. Schizophrenia; b. Schizoaffective disorder; c. Schizophreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g. Medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g. high dose steroids); h. Tourette's Disorder; i. Huntington Disease; j. Hiccups; k. Nausea and vomiting associated with cancer or chemotherapy. 8. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or other; AND: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity; or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency. 11. Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self-care c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness or crying alone that is not related to depression or other psychiatric disorders; i. Fidgeting; j. Nervousness; or k. Uncooperativeness.

Based on observation, interview, and record review, the facility failed to properly label/date, seal/store, and remove expired food items and maintain a hazard free kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: Facility Resident Census and Condition of Residents (Form CMS--Centers for Medicare and Medicaid Services--672) dated [DATE] documents that the total census was 53 residents. On [DATE] at 11:41AM, V1 (Administrator) said all 53 residents eat from the facility kitchen. On [DATE] starting at 10:11AM, the facility kitchen was toured in the presence of V13 (Assistant Director of Dining Services/Dietician) and V12 (Executive Chef). On [DATE] at 10:24AM in kitchen refrigerator #3 the following food items were found: 1. A fully thawed half ham, dated [DATE]. 2. An unlabeled/undated/uncovered tray of raw catfish. The catfish was placed below a tray of raw salmon and visible condensation was seen dripping from the salmon tray onto the catfish. At 10:24AM, V12 (Executive Chef) said the catfish should be covered because there is a risk of cross contamination when left uncovered. 3. A tray of 17 filets labeled chicken bacon wrap dated ,d+[DATE]. At 10:30AM, V12 (Executive Chef) said the filets were thawed and served yesterday and the leftovers should have been thrown in the garbage yesterday. 4. A large deep silver bin labeled chicken teriyaki dated ,d+[DATE]. At 10:30AM, V12 (Executive Chef) said ,d+[DATE] is the date the food was frozen and they should have written a defrost date. 5. A small deep silver bin with unlabeled/undated cinnamon rolls. 6. A small deep silver bin labeled feta cheese and dated [DATE]. At 10:35AM, V12 (Executive Chef) said the feta cheese is expired; it should have been thrown away after 14 days. On [DATE] at 10:36AM in kitchen refrigerator #4, four large trays of defrosting chicken thighs were found uncovered and unlabeled/undated. At 10:36AM, V12 (Executive Chef) said the trays of chicken should be covered. On [DATE] at 10:41AM and [DATE] at 11:40AM in Freezer #5, water was observed dripping from the ceiling at freezer entrance and a layer of bumpy, chunky, and thick ice was observed on the floor. On [DATE] at 10:41AM, V12 (Executive Chef) said to be careful when walking into the freezer. On [DATE] at 10:52AM, V13 (Dietician) said all foods should be labeled and dated for food safety. V13 said thawed/defrosted food should be labeled with defrost date to ensure food is discarded by the correct date for food safety. V13 said all foods in the refrigerator should be sealed/covered to prevent contamination and risk of foodborne illness to the residents due to bacteria growth. V13 said the ice on the floor of the freezer is a fall hazard for kitchen staff. The facility's policy titled, Food Storage Policy revised [DATE] states, .4. Food and non-food supplies are to be clearly labeled. 5. Prepared food items will be used, frozen, or discarded within 7 days of preparation . 7. All food items will be stored in air tight packaging 11. All food stored in coolers shall be stored .not subject to .contamination by condensation . The facility's policy titled, Labeling, Dating, and Storage of Received and Prepared Foods Policy revised [DATE] states, .4. Any food items prepared in house will be labeled with food name and date of preparation. Prepared foods will be sealed air tight and placed in appropriate food storage areas. 5. All food storage areas will be monitored regularly to discard any outdated food items from inventory stock. The facility's undated policy titled, Maintenance Service states, Policy Interpretation and Implementation 2 b. maintaining the building in good repair and free from hazards .d. maintaining the heat/cooling system, refrigerator, . in good working order .

Based on observation, interview and record review, the facility failed to have visitors follow its Personal Protective Equipment (PPE) policy by having visitors visiting COVID-positive resident without having, mask, gown, gloves, and goggles. The facility also failed to perform hand hygiene with glove use during blood sugar checks and after intravenous medication administration and failed to contain oxygen and CPAP (Continuous Positive Airway Pressure) or BIPAP (Bilevel Positive Airway Pressure) mask and tubing to prevent contamination. This applies to six out of 20 (R21, R104, R203, R303, R304, R305) residents reviewed for infection control in the sample of 20. The findings include: 1. On 7/13/23 at 9:32 AM, R104 (COVID positive) observed with a PPE box at the door side. R104 has a visitor/daughter at the bedside without having a mask, gloves, gown, and goggles. V6 (Licensed Practical Nurse/LPN) was observed standing in the hallway talking to R104's visitor at the bedside. On 7/13/23 at 9:35 AM, V6 instructed the visitor to wear PPE when V6 noticed the presence of the surveyor. On 07/13/23 at 09:53 AM, V6 stated, R104 was admitted last night and had tested COVID positive in the Hospital. Everybody should wear a mask and gown to go to [R104's] room. On 7/13/23 at 10:32 AM, V16 (Infection Preventionist) stated, Everyone, including staff and visitors, should wear PPE. The nurses should educate the family to wear gowns, masks, gloves, and goggles for isolation resident rooms. The family should be educated on PPE use with COVID residents. The facility presented PPE Policy Statement (Revised October 2018) documenting: 7. Visitors and residents asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge. 46380 2. On 7/11/2023, at 3:20 PM, V8 (RN-Registered Nurse) administered an IV (Intravenous) antibiotic to R203. R203 had an implanted port on his right chest. After the medication was hung and all used supplies were discarded, V8 (RN) took off her gloves without performing any hand hygiene and left R203's room. V8 opened her computer and documented. R203's Admission Records showed he was admitted on [DATE] with a diagnosis of sepsis. 3. On 7/11/2023, at 11:43 AM, V6 (Licensed Practical Nurse/LPN) put on gloves without performing any hand hygiene and checked R304's blood sugar level. Afterwards, V6 removed his gloves and did not perform any hand hygiene. V6 (LPN) then went to the medication cart and documented. R304's Admission Record showed diagnosis of diabetes mellitus, type II. R304's POS (Physician Order Sheet) shows order for blood sugar checks before meals and at bedtime. 4. On 7/11/2023, at 11:53 AM, V6 (LPN) put on gloves without performing any hand hygiene and obtained a blood sample from R21. After the procedure, V6 discarded all the used supplies and removed his gloves and did not perform hand hygiene. V6 (LPN) then put on new gloves and prepared R21's insulin and injected R21's insulin into her abdomen. 5. On 7/11/2023, at 11:16 AM, R303's CPAP mask and tubing were lying on the nightstand unprotected. R303's oxygen tubing was draped around the oxygen concentrator machine with part of the tubing touching the floor. 6. On 7/11/2023, at 10:47 AM, R305's BIPAP mask and tubing were seen draped on top of the machine unprotected. R305's oxygen tubing and mask were seen draped around the oxygen concentrator with part of the tubing touching the floor. On 7/13/2023, at 9:44 AM, V2 (DON-Director of Nursing) said if oxygen masks and tubing and CPAP/BIPAP masks and tubing were not in use, they should be contained in a bag to prevent contamination and for infection control purposes. V2 said hand hygiene should be done before putting on gloves and after taking off gloves. V2 said hand hygiene is important especially when taking care of an implanted port and administering IV (intravenous) antibiotic medication because the resident already has an ongoing infection. Facility's undated Handwashing/ Hand Hygiene Policy stated the following: .2. All personnel shall follow the handwashing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use and alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; d. Before performing any non-surgical invasive device (e.g., catheters, IV access sites); i: after contact with resident's intact skin; m: After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Facility's undated Policy on Administering Medications by IV stated that hand antisepsis should be performed after medication administration. Facility's undated Policy on Storage of Drugs and Biologicals stated 9. O2 tubing, CPAP/BIPAP and masks should be washed and placed in a bag (dated) bedside after every use. If any of these devices are in room however not being used, should be placed in a bag, and sealed. 44387

Based on observation, interview, and record review, the facility failed to implement fall care plan interventions to prevent further falls. This applies to 1 of 6 residents (R42) reviewed for fall in a sample 20. The findings include: R42 is a [AGE] year-old female with severe cognitive impairment per Minimum Data Set, dated dated dated [DATE]. The facility presented fall risk assessment for R42 dated 6/11/23, documenting that R42 is at risk for falls. On 7/13/23 at 9:39 AM, R42 was observed in her wheelchair in the TV room talking to her husband. On 7/13/23 at 9:45 AM per the surveyor's request, V5 (Certified Nursing Assistant/CNA) escorted R42 back to the resident's room to see if any non-slip material was in place with the wheelchair and R42 was sitting in the wheelchair without having the material in place. On 7/13/23 at 9:50 AM, V5 stated, The night shift staff get her up. There should have been the [anti-slip material] on her wheelchair to prevent slipping. Record review on fall log/fall care plan review document that R42 had fallen on 2/23/23, 3/25/23, 3/25/23, 4/16/23, 5/2/23, and 5/20/23. R42's fall care plan documented anti-slip material was placed in a wheelchair to help prevent the resident from sliding. The facility presented Fall - Clinical Protocol (revised March 2018) document: 4. If the individual continues to fall, the staff and physician will re-evaluate the situation, reconsider possible reasons for the resident's falling, and reconsider the current interventions.

Based on observation, interview, and record review, the facility failed to ensure an IV (intravenous) dressing was changed. This applies to 1 of 2 residents (R203) reviewed for IV use and maintenance. Findings include: On 7/11/23 at 10:47 AM, R203 was in bed in his room. R203 said he was admitted to the facility because he needs IV antibiotics for infection. R203 said he is on two different antibiotics and will be here at the facility for four weeks. R203 had an implanted port/central venous catheter access site on his right upper chest for the antibiotic infusions. The date on the dressing of the central line that showed when the dressing was last changed was 7/3/23 (eight days earlier). R203's current Physician Order Sheet (POS) shows the following orders: access Port-A-Cath change Huber needle and dressing weekly, Meropenem-Sodium Chloride Intravenous solution reconstituted 1 gram (GM)/50 milliliters (ML) three times a day for infection until 8/4/23 and Sulfamethoxazole-Trimethoprim Intravenous solution 400-80 milligrams (MG)/5 ml three times a day for infections until 8/4/23. R203's face sheet dated 7/13/23 showed that R203 had diagnoses of intracranial abscess and granuloma, small cell B-cell lymphoma, sepsis and viral infection. On 7/11/23 at 3:10 PM, V8 (Registered Nurse-RN) said the catheter dressing is done weekly by the third shift nurses and as needed. V8 stated if the nurse is unable to change it, they should endorse it to the oncoming nurse. V8 confirmed that the date on dressing was 7/3/23 and that it should have been changed on 7/10/23 by the night shift nurse. On 7/13/23 at 9:45 AM, V2 (Director of Nursing-DON) said catheter dressing changes is done weekly by the third shift nurses, if they are busy, they should inform the morning shift nurses and it needs to be changed for infection control reasons. The facility's IV (Intravenous) Dressing Changes policy (undated) states that the purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Change the dressing if it becomes damp, loosened or visibly soiled and at least every 5-7 days.

Based on observation, interview and record review, the facility failed to assess for pain and address pain during wound dressing changes. This applies to 1of 1 resident (R253) reviewed for pain management in sample of 20. The findings include: R253's skin impairment care plan (revised 6/30/23) shows that R253 has an actual impairment to skin integrity to his legs, left and right upper arms, left ankle, left 4th toe, left bunion, right lateral big toe, scrotum, groin (related to edema with multiple dry blood blisters), chronic venous stasis ulcers, moisture-associated skin damage/rash, and skin tears, and R253 has diagnoses of multiple wounds, bruises, and skin tears. R253's pressure ulcer care plan (revised 6/30/23) showed he also has pressure injuries to his right and left buttocks and on his left heel. Interventions on R253's pressure ulcer care plan include to treat pain as per orders prior to treatment/turning to ensure [R253's] comfort and he prefers to be positioned with [head of bed] elevated for comfort. On 7/12/23 at 2:12 PM, V9 (Wound Care Nurse/Licensed Practical Nurse-LPN) completed wound dressing changes on R253. V9 was assisted by V11 (CNA-Certified Nurse Assistant Supervisor/Scheduler), and V10 (Wound Care Doctor) was at the bedside to assess and measure R253's wounds. V9 informed R253 of the dressing changes and gathered supplies. V9 and V11 removed both of R253's pressure-relieving boots and the pillows from under R253's knees. V9 then removed old dressing on R253's right upper arm. When V9 removed it, R253 flinched and said, Ow. V9 proceeded to remove old dressings on R253's left forearm and left upper arm, and R253 grimaced and said, ow that hurts- I want to sit up. V9 informed R253 that he will get up after the dressing change and that he needed to turn on his side and V11 assisted V9 with turning R253 to his right side. As they were turning R253, he grimaced again and said, Ow. V9 removed the old dressing on R253's buttocks and R253 said, Ouch. V9 apologized and V11 said, Take a deep breath. R253 grimaced and said again that he wanted to sit up and V11 said, Hang in there. V10 measured the wounds on R253's left forearm and left upper arm and V9 cleansed R253's skin tears on the left forearm and left upper arm with normal saline and applied skin prep. R253 said, Ouch and said he wanted the head of his bed elevated, V9 put the head of his bed up and did not ask R253 about his pain. V9 applied skin prep, the treatment, and covered the wound on R253's buttocks while R253 kept saying ow, ow, and ouch. V10 informed R253 to hold on and that he could get up when the dressing change was completed. V9 moved to the wound on his left toes; V9 removed dressing, R253 said Ouch, that hurts. V9 cleansed the wound on R253's left third and fourth toe and applied skin prep and dressings. During the treatment application, R253 said, Don't do that, whatever you are doing, it hurts. V9 said she was almost done. V9 and V11 repositioned R253 after the dressing changes. The observation of the dressing changes was from 2:12 PM to 3:00 PM. On 7/12/23 at 3:01 PM, V9 said R253 gets Acetaminophen 500 mg every 12 hours, and he received the last dose in the morning and was not sure if R253 receives any narcotic medication. R253's current Physician Order Sheet (POS) shows that R253 has the following orders: Acetaminophen 500 milligram (MG) by mouth every 12 hours for pain management. R253's July 2023 Medication Administration Record (MAR) showed that R253 received Acetaminophen 500 mg on 7/12/23 at 8:00 AM, six hours earlier. R253's pain care plan (revised 6/30/23) showed interventions of encourage/educate resident of methods to notify staff of pain and effectiveness of interventions, and review orders to identify pain relief medications or treatments, notify practitioner if ineffective. On 7/13/23 at 9:50 AM, V2 (Director of Nursing-DON) said that if the resident is in visible pain or distress, the nurse should have checked the last time the resident got medication and if it was effective and see why the resident was still in pain. The facility's policy Pain Management Clinical Protocol (undated) stated that the nursing staff will identify any situations or interventions where an increase in the resident's pain maybe anticipated, for example, wound care, ambulation, or repositioning. Staff will provide the elements of a comforting environment and appropriate physical and complementary interventions.

Based on observation, interview, and record review, the facility failed to identify and supervise a resident with a swallowing difficulty (R4); failed to provide adequate supervision for a resident with repeated falls (R142); failed to utilize a mechanical lift during transfers (R13); and failed to implement fall interventions to reduce the risk of falling (R250) for 4 of 5 residents (R4, R142, R13, R250) reviewed for safety and supervision in the sample of 15. The findings include: 1. On 9/27/22 at 10:06 AM, R4 was eating in her room by herself. R4 was gagging. R4 stated, She had a hard-boiled egg and it's stuck. R4 started gagging again and produced a copious amount of mucous surrounding a quarter-sized chunk of egg yolk. R4 stated, I have a hiatal hernia and this happens 3-4 times a month. It's so painful and sometimes I feel like I'm choking to death. I know it looks bad to you, but I'm used to it. I've been dealing with this for years. R4 was using hand towels from the bathroom to spit up the mucous and chunks of hard-boiled egg. There were 18 towels wadded up on the floor next to R4's bed. R4 was on continuous oxygen via nasal cannula. R4's breakfast tray was sitting on the overbed table, in front of her. R4's tray had soggy cereal, a slice of toast, apple juice and a carton of milk remaining. To the right of R4's tray was a medication cup with 8-9 pills (including a translucent capsule - noted to be Vit D). R4 stated, This happens all the time, it takes about an hour or so for me to calm down and get it all up. I can feel it right there (pointing to her midsternal area. At 10:13 AM, R4 started gagging again, but was unable to catch her breath. R4 had copious amounts of mucous hanging from her mouth with smaller chunks of egg whites. The surveyor ran to the hall to get staff assistance for R4. The first staff encountered was from the therapy department, she stayed with the resident while this surveyor found a nurse. R4 continued to have gagging episodes until 10:40 AM, producing more chunks of hard-boiled egg and copious amounts of oral secretions. At 10:29 AM, V4 (Licensed Practical Nurse - LPN) asked R4 to try to take a drink of water. R4 replied, No honey, I don't need that. My chest is still hurting. V4 said he has been R4's regular nurse since June and he's never seen her do this. R4 replied, Well, that's because most of the time I don't use the call light because I'm over it before someone comes. They (the staff) are too busy here. V4 left the room with R4's morning medications. At 10:36 AM, R4 continued to have episodes of gagging and producing small chunks of egg with oral secretions. On 9/28/22 at 10:08 AM, R4 was in her room alone with her breakfast tray in front of her. R4's call light was on. There was no facility staff in the room. R4 stated, I'm just finishing up my breakfast and wanted to let the nurse know that I'm ready for my medications. They are running behind today. R4 had remnants of scrambled eggs and toast on her plate. At 10:21 AM, V7 (Speech Language Pathologist) entered R4's room and introduced herself. V7 said she was from speech and swallowing therapy and wanted to evaluate R4's swallowing. V7 stated, I saw your light was on, did you need something? R4 replied, I think they are bringing my medications. This really isn't as big as a deal as everyone is making it. I have a hiatal hernia. I have for years. Sometimes things get stuck and that is what everyone is all excited about. It happens four times a month. V7 had a look of surprise and replied, Oh, that's not good. If food is getting stuck, it can go down into your lungs and cause pneumonia. The doctor ordered a swallowing evaluation and I think it is very important for you to have this done. Resident was hesitant and stated, I don't want to discuss it right now. V7 said she would come back at lunch. R4's Face Sheet dated 9/27/22 showed she had diagnoses to include: stage 3 [CONDITION(S)], heart failure, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], gastro-[CONDITION(S)] reflux disease (GERD), [CONDITION(S)], [CONDITION(S)], chronic pain syndrome, long-term use of anticoagulants, and [CONDITION(S)] [CONDITION(S)] of the right lower leg (including the hip). R4's facility assessment dated [DATE] showed she was cognitively intact and required supervision for eating. R4's Nutritional assessment dated [DATE] showed R1 was on a mechanical soft diet. R4's Care Plan did not contain any information regarding R4 having swallowing difficulty. R4's Speech Therapy Evaluation dated 9/28/22 (after the choking episode), Patient . reportedly was coughing with intake yesterday in the room. Her MD ordered ST (Speech Therapy) evaluation for dysphagia . Without therapy patient is at risk for choking and aspiration. The patient reports that this is normal for her and happens several times a month. She does not see it as a reason for concern and is resistive to the idea that it is problematic . The patient has not had prior speech therapy for the same condition in the past year. Precautions: Sit upright for all oral intake. Small bites and sips. Follow reflux precautions . Patient is alert and able to follow directions, however, shows a decreased awareness of the need for skilled intervention . R4's Speech Therapy Clarification Order dated 9/28/22 showed, .Treatment diagnosis: .Dysphagia, oropharyngeal phase . On 9/29/22 at 9:30 AM, V2 (Unit Manager/Licensed Practical Nurse - LPN) said he was very familiar with R4 and the residents on her hall. V2 said he was not aware that R4 had a hiatal hernia and was not aware of R4 having swallowing difficulty before the episode on 9/27/22. V2 said he was aware that R4 had refused any surgeries. V2 said if a resident has swallowing concerns, then they shouldn't eat alone in their room. It's a safety concern. Any resident with swallowing difficulty should be evaluated by Speech Therapy. I'm not aware of R4 having a Speech Evaluation before. I know she had refused Physical Therapy in the past. 2. On 9/29/22 at 11:33 AM, R142's visitor was assisting her from the wheelchair to her low bed. There were no staff in R142's room. There were thick fall mats on each side of R142's bed. The facility's Fall Log for the past six months showed R142 had fallen 12 times from 7/30/22 to 9/27/22. The falls occurred on 9/23, 9/14, 9/6, 8/30 (2 falls - laceration above left eye brow, left eye swollen. Sent 911 to local emergency room ), 8/27, 8/23, 8/20, 8/19, 8/8, 8/6, 7/30/22). R142's Face Sheet dated 9/29/22 showed diagnoses to include, but not limited to: [CONDITION(S)] Disease, repeated falls, generalized weakness, diabetes, anxiety, difficulty walking, and deformities of right foot. R142's facility assessment dated [DATE] showed R142 had moderate cognitive impairment; required extensive assistance of 2 staff members for bed mobility, transfers, and toilet use; required extensive assistance of 1 staff member for walking in room/corridor, locomotion on/off unit, and personal hygiene; and was not steady, only able to stabilize with staff assistance. R142's Neuropsychology Evaluation dated 6/16/22 showed, .She is diagnosed with [CONDITION(S)] disease, which contributes to her increased falls and fall risk . Diagnosis/Medical History: Repeated falls (admitting diagnosis), with primary diagnosis upon admission of [CONDITION(S)] disease including difficulty walking, limits in activity due to disability, need for assistance for personal care, cognitive communication deficit, dysphasia, diabetes, protein-calorie malnutrition, [CONDITION(S)] . Recommendations: .6. R142 remains at risk of falls . R142's Care Plan imitated 8/8/22 showed, R142 scoots/transfers herself onto the floor mats from low bed position at bedtime and will crawl around/scoot on bottom in room . Interventions: Anticipate and meet the resident's needs . R142's Care Plan imitated 8/10/22 showed, The resident has impaired cognitive function/dementia or impaired thought processes related to impaired decision making . Interventions: Cue, reorient, and supervise as needed . R142's Care Plan initiated 7/31/22 showed, R142 is at risk for falls related to deconditioning, [CONDITION(S)] medication use, diagnoses of [CONDITION(S)], diabetes . hypothyroid, depression, [CONDITION(S)], and anxiety . Family to have caregiver for R142 8:00 PM to 8:00 AM - family discontinued 8/7/22. R142 is impulsive and declines use of the call light . Interventions: Anticipate and meet the resident's needs . R142's Care Plan imitated 7/30/22 showed, R142 has had an actual fall with poor balance and poor cognition/comprehension . Interventions: Offer resident to go to bathroom before meals, at bedtime, and during the night. R142's Care Plan imitated 8/11/22 showed, R142 has bruises to BUE (bilateral upper extremities) related to fragile skin and diagnoses . 8/30/22 - R142 has actual impairment of skin integrity of the left eyebrow related to laceration. Diagnoses: Fall, [CONDITION(S)] . R142's Fall Risk Evaluation dated 9/14/22 showed she was At Risk for falls. R142's Post Fall Evaluation dated 9/14/22 showed, .Fall in resident room . reaching for something on the floor . sustained a laceration on left eyebrow . At about 4:40 PM, reported by CNA that resident is lying on the floor, immediately went to her room and noted resident lying on the floor in a prone position with her right side of the face resting on the floor; moderate amount of sanguineous drainage noted on the floor relatively close to her right cheek . wheelchair was unlocked . Laceration to left eye brow measuring 4 cm x 0.2 cm x 0.4 cm with bloody drainage . resident remained in the facility . R142's Incident Report dated 8/30/22 showed, At around 10:30 AM, this writer received a call from unit manager, V2, to go to resident's room. Entered resident's room and observed resident laying on her left side on the floor, in front of her wheelchair and next to her cabinet. Observed a puddle under resident's head. Turned resident slightly to look and injury (noted), laceration noted about left eyebrow approximately 4 cm. Left eye bruised and slightly swollen . Only pain was to head . 911 called . R142's emergency room Records dated 8/30/22 showed R142 had a fall due to losing her balance. R142 sustained a 2-inch laceration above left eye, an orbital fracture, and a broken nose. On 9/29/22 at 9:56 AM, V2 (Unit Manager/LPN) said R142 was admitted from an assisted living facility. R142 has [CONDITION(S)] and is here for long-term care. She has a very shuffled gait. She's not really able to walk, but she still tries. We found out very early that she has some different personal requests. She was telling the staff at night that she used to sleep on the floor. So, she would crawl onto the floor and sleep there. She requests to go the bathroom, but if the call light is not answered immediately, she's going without help. The staff should be rounding frequently on R142. R142 has had a couple of true falls, but most are from her getting on the floor and scooting around the room. V1 (Administrator) said R142 is alert and oriented, but has moments of forgetfulness. She knows her diagnosis but wants to do it on her own and is having trouble dealing with the loss of independence. She told us, Being on the floor was a comfort to her. V2 and myself met with her when we realized there was an issue and that's what she told us. The facility's Fall - Clinical Protocol (revised 3/18) showed, Assessment and Recognition: 1. The physician will help identify individuals with a history of falls and risk factors for falling . Treatment/Management: 1. Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . Monitoring and Follow-Up: 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall . 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented . 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. 5. As needed, and an after appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes. 3. R13's face sheet printed 9/29/22 showed diagnoses including but not limited to dementia, polyneuropathy, right side paralysis following [CONDITION(S)] disease, right foot drop, and repeated falls. R13's facility assessment dated [DATE] showed no severe cognitive impairment. The same assessment shows R13 requires extensive assistance of two plus persons for transfers and toilet use. R13's care plan showed a focus area initiated on 11/10/21 related to ADL (activities of daily living) self-performance deficit due to confusion, impaired balance, limited mobility, and right foot drop. Interventions include TOILET USE: The resident is max (maximum) assist x 1 with sit-to-stand. TRANSFER: The resident is max x 1 assist with sit to stand. Both interventions were revision dated 9/13/22. On 9/27/22 at 11:08 AM, V13 (CNA-Certified Nurse Aide) was observed transferring R13 from the edge of the bed into the wheelchair. V13 held onto the resident's arm while she stood up and guided her to the wheelchair. R13 was unsteady and shaky during the transfer. V13 pushed the wheelchair to the bathroom and said R13 can wash herself at the sink. This is how I get her out of bed and ready every day. On 9/29/22 at 10:45 AM, R13 was lying in bed and said on good days she stands and pivots with an aide to transfer. R13 said bad days are the only time she uses a sit-to-stand. R13 said the aides only use the lift if I feel weak. I just tell them how I feel, and they don't use it if I say I am having a good day. On 9/29/22 at 10:50 AM, V14 (CNA-Certified Nurse Aide)) said R13 needs the sit-to-stand lift anytime she is transferred. She has weak legs and bad knees. We are supposed to use it every time. We (CNAs) know how to transfer a resident based on the paper document posted inside the closet doors. We also get verbal updates from the floor nurse or other CNAs. V14 said she had not had any reports of R13 needed any less than a sit to stand for transfers. R13's closet door care need document was reviewed with V14. The document was dated 11/10/21 and showed 1 assist/ The document was blank under the lift-type section. V14 stated, That is outdated. She is not a one assist. She needs the sit-to-stand lift too. On 9/29/22 at 10:57 AM, V2 (Unit Manager/Licensed Practical Nurse-LPN) said R13's closet document is incorrect. She is a sit-to-stand lift transfer. She needs the support especially in the mornings and at night when she is tired. She has a problem with her knees buckling and has fell in the past. She has the potential for more falls and injury if she is not transferred correctly. V2 said he was in the process of transitioning her closet documentation to reflect the correct information. On 9/29/22 at 11:07 AM, V14 (CNA) transferred R13 from the wheelchair to the toilet. V14 did not use a sit-to-stand lift. V14 said she confirmed the transfer method with V17 (CNA-Certified Nursing Aide) and was told R13 only uses the lift at night. V14 said she does not need it for transfers in the morning. On 9/29/22 at 11:13 AM, V15 (Licensed Practical Nurse/LPN) said aides use the information posted inside resident closets to know how to transfer a resident. They can look there or come ask a nurse if they are unsure how to move a resident safely. The facility Safe Lifting and Movement of Residents policy revision dated 7/2017 states: 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. 4. The Post Fall Evaluation for R250 dated 9/23/22 at 8:00 AM, showed he fell in the bathroom and no injury occurred. The Incident Notes dated 9/23/22 at 3:00 PM for R250 showed, Around 2:45 PM, the therapist informed writer that resident is having pain on left wrist; as per assessment, swelling is present on the left wrist, and the resident is complaining of pain and restricted movement. Left message with the doctor Manager on duty made aware. R250's Nurse's Notes showed, On 9/24/22 at 1:04 PM, R250 was up in the dining earlier, alert, responsive upon name call. Left wrist remains swollen and (+) redness with ROM (range of motion) at this time. Observed with discomfort upon touch. Follow up X-ray done and will be done today. On 9/24/22 at 8:17 PM, Notified the doctor the resident's Xray result to the left wrist showing concern for mildly displaced fracture along the distal radial metaphysis. On-call Nurse Practitioner ordered resident to be sent out to the emergency room for evaluation and treatment. On 9/25/22 at 6:58, resident returned from the hospital at 5:50 AM via ambulance. Splint to left arm due to fracture of the left wrist. Resident to follow up with orthopedic doctor. No new orders. Per ER (emergency room ) verbal nurse report, resident had an unwitnessed fall while in ER. The Post-Fall Evaluation dated 9/25/22 at 9:52 AM for R250 showed he had a fall at the facility at 7:30 AM that was not witnessed. The fall was in front of the nursing station. R250 was ambulating when the fall occurred. The reason for the fall was documented as poor safety concern due to confusion. Resident was not using cane/walker as instructed. History of falls at home, at the facility and at the hospital. On 9/28/22 at 1:16 PM, V12 (Certified Nursing Aide/CNA) stated, I was here that day (9/23/22), but I don't recall R250 falling. I didn't witness R250's fall or go in to help with it. I was not aware of him falling. I believe I was his CNA that day. R250 is confused and tries to get up on his own. R250 has been trying to do that since he came into the facility. V12 stated staff know who is at risk for falls because there is a sign at the door and visuals like yellow socks and padding on the floor. V12 also stated that there are reddish-brown leaf signs that are placed on a resident's door if they are at risk for falls. On 9/28/22 at 1:24 PM, there wasn't a leaf sign on R250's door or next to it showing he is at risk for falls. R250 did not have any mats in his room. There was a sign on the wall written in English that stated, Call don't fall. Please use your call light for assistance. R250 is a Spanish-speaking resident. On 9/28/22 at 1:44 PM, V6 (Licensed Practical Nurse-LPN) stated if anyone is a fall risk we would put a leaf outside the door to inform staff that the resident is a fall risk so they are monitored closely. The leaf is outside of the resident's door. R250 should have a leaf outside of his door. Residents at risk for falls have the bed in low position and mats in room on floor next to the bed. If the resident is not in bed then the mats are folded up to the side when they are up. The Incident Note dated 9/28/22 for R250 showed he had a fall at 3:12 PM. The nurse heard a thud coming from the TV room and R250 was on the floor cradling his head. R250 was sent to the hospital. The Nurse's Note dated 9/28/22 for R250 stated he was admitted to the hospital for falls and [CONDITION(S)]. R250's Care Plan dated 9/22/22 showed he is at risk for falls. The interventions included: meet anticipate and meet resident needs, make sure call light is within reach, educate resident and family on safety reminders, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility, ensure resident is wearing appropriate footwear, physical therapy to treat as ordered as needed. R250's Care plan was revised on 9/28/22 showed he has had an actual fall on 9/23/22, 9/25/22 and 9/28/22. Prior to the new revision of R250's care plan on 9/28/22 the care plan had an intervention listed to follow the facility fall protocol. On 9/29/22 at 10:29 AM, V2 (LPN/Unit Manager) stated, I did some of R250's interventions for his care plan. He is very impulsive. I think social services reached out to R250's family to see if they could come and sit with him more because he is impulsive but they couldn't because they work. V2 stated the falling leaf was part of their fall program. It was in place so staff would know who was at risk for falling. V2 stated they don't always put up a leaf for people now. The Fall Risk Screening Tool used for R250, dated 9/20/22 showed a score of 11, at risk for falling. On 9/29/22 the Fall Program policy was requested and not received. The facility had a Fall Risk Assessment Policy (3/2018) that stated there were related documents, Falls and Fall Risk, Managing which were not received. The facility had Falls -Clinical Protocol (3/2018) that showed, Based on preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. The Facility Assessment Tool dated 9/19/22 showed common diagnoses that are treated at the facility include impaired cognition. Services and care they offer based on the residents' needs include mobility and fall/fall with injury prevention, management of medical conditions and care of someone with cognitive impairment. Staff training/education and competencies providing person centered care, cultural competency and activities of daily living. There wasn't any staff training/education and competencies listed related to falls or a fall program. The Admission Record for R250 printed 9/29/22 showed medical diagnoses including weakness, heart failure, dementia, hypertension, [CONDITION(S)], type 2 diabetes, [CONDITION(S)] heart disease, and [CONDITION(S)].

Based on observation, interview, and record review, the facility failed to ensure resident dignity was maintained during personal care for two of two residents (R13, R4) reviewed for dignity in the sample of 15. The findings include: 1. On 9/27/22 at 11:08 AM, R13 was seated on the edge of her bed, which was next to the window. The room lights were on, and the window blinds were open. V13 (CNA-Certified Nurse Aide) stated she had just completed changing R13's incontinence brief and was in the process of getting her dressed for the day. V13 removed the resident's gown and R13 was completely naked from the waist up. V13 helped the resident put on a bra and shirt. R13's room window was visible to other resident windows on the east and north units. On 9/29/22 at 10:57 AM, V2 (Unit Manager/Licensed Practical Nurse-LPN) stated aides should be closing window blinds during care. The goal is to expose the least amount of body parts possible. Personnel care should be provided in a private and dignified manner. No one wants to be seen exposed. It is a resident right for dignity during all care. The facility Resident Rights policy revision dated 12/2016 states: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity;. 2. On 9/27/22 at 10:29 AM, R4 was in bed with her breakfast tray in front of her. R4 was coughing and gagging after eating a hard-boiled egg. V4 (Licensed Practical Nurse - LPN) asked R4 why she hadn't turned on her call light. R4 replied, Most of the time I don't use my call light. When I call, no one answers. They (facility staff) are too busy here. Last night I didn't get changed from 2:00 PM to 10:00 PM. It doesn't feel good to sit in a wet diaper. The kids (CNAs) were so busy that they didn't get around to changing me. When the 10 PM kids (CNAs) came in, I asked them to clean me up and change me. They were not happy that the other kids hadn't cleaned me up. I told them it wasn't my fault. The kids are mostly good, but they are just too busy. R4's Face Sheet dated 9/27/22 showed she had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's facility assessment dated [DATE] showed she was cognitively intact; did not exhibit rejection of care behaviors; required extensive assistance of two staff members for bed mobility, toilet use, and personal hygiene; was always incontinent of urine; and frequently incontinent of bowel. R4's Care Plan initiated on 8/3/21 showed, R4 is at risk for self-care deficit for dressing as evidenced by resident is unable to fasten clothing due to arthritic pain. This document also showed, R4 has limited physical mobility related to contractures, neurological deficits, and weakness .; R4 is on diuretic therapy related to hypertension and CHF (Congestive Heart Failure) .; and R4 has functional bladder incontinence related to impaired mobility . Cleanse peri-area with each incontinence episode . R4's Personal Hygiene Task for the last 14 days had no entries on 9/26/22 (when R4 said she wasn't changed). R4's Bladder Elimination Task and Bowel Elimination Task for the last 14 days showed an entry at 3:37 AM and 11:43 PM. On 9/29/22 at 9:30 AM, V2 (Unit Manager/Licensed Practical Nurse - LPN) said he was very familiar with R4. V2 said R4 is very particular about her care and has CNA preferences. R4 is incontinent. She'll tell you that she doesn't know anymore. Every time she turns on her call light, she will ask for the bedpan. Most of the time, she had already been incontinent when I went in. She usually calls to be changed. She knows when she's wet, but she doesn't know when she has the urge. The CNAs should round about every 2 hours. I'm not sure why she wouldn't be changed from 2:00 - 10:00 PM. She has a fairly normal routine (9 AM, 4 PM, and 8 PM). That's usually when she calls for incontinence or to try the bedpan. The Residents' Rights for People in Long-Term Care Facilities (revised 3/17) showed, You have the right to safety and good care. Your facility must provide services to keep you physical and mental health, and sense of satisfaction . You have a right to privacy .

Based on observation, interview and record review the facility failed to monitor a splint to R250's left arm, ensure it remained intact, and provide interventions to decrease the swelling to the residents left hand for 1 of 1 residents (R250) reviewed for a change in condition in the sample of 15. The findings include: The Nurse's Notes for R250 showed on 9/23/22 the nurse was notified by therapy that R250 was having pain to his left wrist and there was swelling present. On 9/24/22 an X-ray was done at the facility that showed, concern for mildly displaced fracture along the distal radial metaphysis. On 9/25/22 R250 was sent back to the facility from the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Hospital Discharge Instructions dated 9/25/22 at 12:26 AM showed, Broken wrist. Keep your arm elevated to reduce pain and swelling. When sitting or lying down keep your arm above the level of your heart. You can do this by placing your arm on a pillow that rests on your chest or on a pillow at your side. R250's Nurse's Notes on 9/26/22 and 9/27/22 showed staff were aware that he touches the elastic bandage holding the splint in place on his left arm. The Nurse's Note for R250 showed that on 9/26/22 at 4:47 PM his left hand was swollen; no intervention was documented. The Physician's Progress Note for R250 dated 9/27/22 at 9:24 AM showed, R250 complained of left wrist pain and staff noted swelling a few days ago. The X-ray of the left wrist on 9/23/22 showed concern for a mildly displaced fracture along the distal radial metaphysis; R250 was transferred to the emergency department for evaluation. R250 returned to the facility on [DATE] in the morning with a splint to the left wrist/forearm with a recommendation to follow up with ortho. The Nurse's Skilled Evaluation for R250 dated 9/27/22 at 10:53 PM did not show any documentation of swelling to his left hand. On 9/28/22 at 09:52 AM, R250 was sitting in a wheelchair with his left arm laying in his lap. R250 had a posterior mold splint with an elastic bandage wrapped around it on his left wrist. The elastic bandage was no longer around his left hand and was hanging loosely around the splint. The splint to his left wrist was loose and did not appear to provide support for his wrist. R250's left hand and fingers were swollen three times the size of his right hand. R250's left arm was not in a sling or elevated on a pillow to help with the swelling to his left hand. R250 complained of pain to his left hand. At 09:56 AM, V10 (Registered Nurse/RN) was notified by the surveyor of the condition of the splint to R250's fractured left wrist and swelling to his hand. V10 stated R250's splint needed to be re-wrapped. At 9:57 AM, V10 took R250 to his room and removed the elastic bandage from his posterior mold splint. The splint fell on the floor and R250's left wrist was not supported. V10 picked the splint up from the floor, placed it on his left wrist and applied the elastic bandage around his hand and wrist over the top of the splint. V10 stated R250 has a hairline fracture to his left wrist so there was no sling applied. V10 stated she would get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V10 stated keeping his left arm elevated would help with the swelling to his left hand and wrist area. R250 stated pain when pointing to his left hand. V16 (Certified Nursing Assistant/CNA) was asked to come in and translate for the Spanish speaking resident and stated he was having pain to his left hand. On 9/29/22 at 10:29 AM, V2 (Licensed Practical Nurse-LPN/Unit Manager) stated, Staff should be checking the splint at least every shift. If there is a lot of swelling then they should call the doctor and request orders. V2 stated R250's left wrist splint and elastic bandage should be in place and secure. V2 stated, He didn't know if R250 fidgets with the splint or undid it. V2 stated if he does fidget with it then the splint should be checked more frequently. V2 stated if the splint is not on like it should be then it should be corrected immediately. If there is swelling then the nurse can elevate it on a pillow to decrease the swelling. V2 stated the nurse doesn't need and order to elevate his left arm. R250's Care Plan dated 9/27/22 showed, R250 has an alteration in musculoskeletal status related to a fracture of the left wrist. The interventions included Monitor/document/report as needed signs and symptoms or complications related to arthritis: joint pain, joint stiffness - usually worse on wakening; swelling . The intervention in place was for arthritis and not related to a fracture. There were no interventions in place to show the type of splint, monitoring of the splint related to the resident picking at the splint or for swelling of the splinted extremity. On 9/29/22 the facility's policy regarding splints was requested and no policy was received. The Facility Assessment Tool dated 9/19/22 showed common diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Services and care they offer based on the residents' needs include management of medical conditions and care of someone with cognitive impairment. Staff training/education and competencies providing person centered care, identification of resident changes in condition, including how to identify medical issues appropriately and how to determine if symptoms represent problems in need of intervention. The Admission Record for R250 printed 9/29/22 showed medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident by not having a proper fitting wheelchair cushion and leg rest for a wheelchair for 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling out of the wheelchair, sustaining a cervical fracture (neck fracture) needing surgical repair. The findings include: R1's electronic medical records shows R1 has [DIAGNOSES REDACTED]. R1's fall risk assessment dated [DATE] shows R1 was high risk for falls. The facility's fall incident report dated 6/25/2020 for R1 shows, After shower the CNA (Certified Nursing Assistant) was pushing resident out of the bathroom. Resident slid forward and hit her head on the floor. Resident assisted to her back, first aid administered to control the bleeding. 911 called to take resident to a (local hospital). The same incident report shows R1 was admitted due to fractures of 2nd cervical spine. (neck fracture) The local hospital CT scan report of the cervical spine for R1 dated 6/25 2020 shows, Impression: [MEDICATION NAME] of the odontoid process of C2. A Neurosurgeon consultation was done on 6/26/2020 for R1 due to R1's [MEDICAL CONDITION] of the odontoid process of C2. A surgical report dated 7/7/2020 for R1 shows R1 had underwent surgery for [REDACTED]. (surgical repair of the neck fractures) A progress note dated 7/13/2020 shows R1 was now back to the facility. The same progress note shows R1 had an eight centimeter surgical incision with 12 staples at the back of her neck-s/p C1 C2 cervical fusion. On 9/13/2020 at 9:02 AM, R1 was in bed with eyes closed. At 12:00 PM, R1 was in a reclined chair wearing a neck collar. A visible elongated surgical scar was visible at the back of R1's neck approximately 3 inches in length. R1 said she fell but cannot remember when. On 9/12/2020 at 3:00 PM, V3 (R1's Power of Attorney for Healthcare) said that on 6/25/2020, his mom (R1) fell out of her wheelchair, bumped her head, and broke her neck while being pushed in her wheelchair by a staff. V3 said his mom had to undergo surgery to fuse these broken bones in her neck that was caused by the fall. V3 said his mom was in the hospital for more than 10 days. V3 said his mom is now back to the facility. V3 said he was told by the facility that his mom slid out of her wheelchair because of her wheelchair cushion. On 9/13/2020 at 11:15 AM, V2 (Director of Nursing) said the facility investigated R1's fall that resulted in R1 to have neck fracture and having surgery after the fall. V2 said the fall investigation shows that R1's fall was due to a cushion that was not appropriate for her wheelchair and R1 not having a leg rest when she was being wheeled out from the shower room. V2 said that was also the statement of the nurse that was on duty when the incident happened with regards to R1's cause of fall. On 9/13/2020 at 9:30 AM, V4 (License Practical Nurse) said she was the nurse working on 6/25/2020 when R1 fell out of her wheelchair. V4 said V7 (Certified Nursing Assistant-CNA) came and got her to let her know R1 was on the floor. V4 said when she entered R1's room, R1 was on the floor face down by the shower room doorway in the room. V4 said there was blood coming from R1's forehead. V4 said R1's wheelchair was behind R1. V4 said she asked V7 what happened. V4 said V7 said R1 slid out of her wheelchair. V4 said she noticed R1's wheelchair cushion was 2 inches larger than R1's wheelchair. V4 said she cannot recall if R1 had her wheelchair leg rest on. V4 said the large cushion caused R1 to slide out of her wheelchair. On 9/13/2020 at 12:30 PM, V7 (Certified Nursing Assistant-CNA) said he was R1's CNA on 6/25/2020 when R1 fell . V7 said he gave R1 a shower in R1's shower room in her room. V7 said he then transferred R1 to her wheelchair. V7 said he noticed R1's cushion was larger than R1's chair and the cushion was extended forward. V7 said he did not apply R1's wheelchair leg rest. V7 said he also did not check if R1's foot was off the floor before pushing R1. V7 said as he pushed the wheelchair, R1 slid forward out from the wheelchair and fell face down. V7 said he noticed R1 was bleeding. V7 said he went to get the nurse immediately. On 9/13/2020 at 11:00 AM, V8 (Therapist) said it is important for residents to have appropriate cushions and leg rests while in their wheelchair for safety. V8 said the wheelchair cushion should not be too small and not oversized compared to the wheelchair base. V8 said wheelchair leg rests help in proper positioning when a resident is in the wheelchair. Inappropriate cushions and not using leg rests can create a fall risk or am actual fall like what happened to R1. V8 said R1 was on therapy after coming back from the hospital. V8 said R1 used to be able to feed herself and needs limited assistance with Activities of daily living. (ADLs). V8 said now R1 is total care with all her ADL's. On 9/13/2020 at 9:45 AM, V5 said she is R1's regular CNA. V5 said prior to the fall, R1 was able to feed herself and wheel herself around. V5 said after the surgery, R1 is now total care on everything. On 9/13/2020 at 12:45 PM, V6 (R1's physician) said residents safety is very important while they are in their wheelchairs. V6 said, the number one cause of death in elderly is a fall with injury. On 9/14/2020 at 9:13 AM, V2 said nursing and therapy assessed residents for proper wheelchair cushion and use of leg rest for safety. V2 said R1 has no assessment for the cushion and leg rest use (seating devices of her wheelchair) prior to the fall. R1's careplan dated 7/13/2020 shows s/p fall with C2 fracture, s/p C1-C2 cervical fusion. With intervention to include dycem (non skid) beneath and top of the cushion. R1's careplan did not address use of legrest.

Based on observation, interview and record review, the facility failed to follow their pressure sore prevention policy and procedures by preventing the development of a facility-acquired pressure sore and the worsening of another pressure sore for one (R26) of four residents in a sample of 16 residents. This failure resulted in R26 acquiring an avoidable unstageable pressure sore to the right trochantor (right hip) and a worsening unstageable wound becoming a stage 3 pressure sore to the right malleolus (ankle bone). Findings include: On 4/16/18 at 10:10 AM to 12:17 PM, R26 was observed sitting in a wheelchair in the common area with no staff repositioning R26 in her chair to off load pressure from her buttocks area. On 4/17/18, R26 was observed in the dining area sitting in her wheelchair at 12:10 PM to 2:00 PM for lunch and again was not repositioned or off-loaded in her wheelchair. On 4/18/18 at 9:38 AM wound observation conducted by two surveyors with V3 ( Wound Care nurse/Assistant Director of Nursing), V6 (C.N.A.-Certified Nursing Aide) and V7 (C.N.A.) showed R26 in bed fully clothed under a blanket, bed sheets and her mattress set on stand-by mode. V6 and V7 proceeded to remove R26's clothing and revealed her to be also wearing an incontinence brief under her clothes. R26 was lying atop a draw sheet that was folded over several times creating multiple layers under her buttocks. Under these multiple layers was a tightly fitted bed sheet that wrapped around the air mattress. V3 proceeded to change the dressing and revealed a small hole (pressure sore) to R26's right upper hip area. Asked to describe the pressure sore, V3 stated, The wound is at the right trochanter and it's considered unstageable because you can't visualize the wound bed because it's deep. It measures 1.6 centimeters (length) by 0.5 centimeters (width) by 1.0 centimeter (depth). It is also tunneling (a narrow opening or passageway underneath skin that can extend in any direction through soft tissue and results in dead space) measuring 2.4 centimeters. V3 proceeded to do wound dressing changes to the right malleolus (right ankle) and described the wound as 80% fibrotic and 20 % pink measuring 1.0 centimeters length by 1.1 centimeters width by 0.2 centimeters deep. Asked when she acquired this wound, V3 stated, She had this wound since 9/26/17 and it started as unstageable but now it's a stage 3 wound. Asked why R26's wound has taken over 7 months to heal, V3 stated, Well it got better at one point and recently its gotten worse, but she's also seen by the wound doctor. After the conclusion of the wound dressing changes, R26 was again placed back in her incontinence briefs, fully clothed and lay back in bed atop numerous layers of sheets and covered with a blanket. The air mattress remained on standby mode and was not placed on alternating pressure per doctor's orders to assist in off-loading of the wounds. R26's Physician order [REDACTED]. Facility wound surveillance report provided by V3 (Wound nurse/Assistant Director of Nursing) on 4/16/18 shows R26 with two pressure related wounds. One of the wounds is a facility-acquired wound identified on 2/20/18. This wound is described as Unstageable Right hip. The second wound is documented as a hospital acquired (admitted with 9/24/17) Unstageable Right malleolus wound, Stage 3 . Wound physician initial assessment dated [DATE] shows the facility-acquired wound as Wound location: Right Trochanter; pain level 3; type: pressure; stage: non-stageable; wound size: 1.0 centimeters (length) x 1.5 centimeters (width) x 0.7 centimeters (depth). Physician wound assessment dated [DATE] states in part, Assessment: Right ankle DTI (deep tissue injury); Right trochanter-new 2/28/18. Plan: offload; use heel protectors; low air loss overlay for bed. MDS (minimum data set) dated 1/2/18 shows R26 with a BIMS (Brief Interview of Mental Status) score of 2 for severe cognitive impairment; Section J for Health Conditions shows no weight loss; Section M for Skin Conditions shows R26 at risk for pressure ulcers; skin and ulcer treatments with pressure reducing device for chair and bed, pressure ulcer care, application of ointments/medications, however does not list R26 with any turning/repositioning program to coincide with R26's physician endorsed care plan. R26's Braden Scale for Predicting Pressure Sore Risk dated 4/18/18 show the facility considered R26 for eight consecutive months being At risk for pressure ulcer development for the period of assessments from 8/13/17 through 3/23/18. R26's Care plan dated 3/6/18 documents in part, Impaired skin integrity. admitted with unstageable/DTI (Deep Tissue Injury) Right Malleolus unstageable; Right hip stage 2 (facility-acquired 2/22/18) now Right hip unstageable; Risk for impaired skin integrity related to Primary medical history for dementia, anxiety, depression, and [MEDICAL CONDITION]. Alert to self unable make request known to staff, staff to anticipate needs; (R26) requires assist with ADL (activities of daily living) functions receives from nursing staff. She is often resistant to care and untrusting/paranoid with staff; Incontinent of Bowel and Bladder. Care Plan Goal: (R26) will have measurable wound healing and improvement of wound beds and have no further impaired skin integrity through next review. Care Plan Approach: Staff will assist with turning and positioning as needed (start date: 3/6/18) Night turning schedule every two hours. Keep off of right side (start 3/6/18); Pressure reducing mattress to bed. Low air loss mattress (start date: 2/26/18); Pressure reducing cushion in wheelchair (start date 2/7/18); Right lateral positioned on wheelchair (start 4/2/18). 4/18/18 telephone interview conducted by two surveyors at 2:40 PM with V5 (Wound care physician) states, I was brought on to see (R26) because she had a wound on her sacral area. I believe she got it at the facility I'm told and another is on her malleolus (ankle bone). That one I was told came from the hospital but we've been treating for quite a while. V5 was reminded of the date of 9/24/17, in which she replied, That sounds about right. Asked if this was an unavoidable wound, V5 struggled to answer and stated, well she's malnourished. Asked if she had any [DIAGNOSES REDACTED]. We're really providing comfort measures for her.Reminded that (R26) was not on hospice care, V5 stated, Well she should be but the family can't afford it. Asked again whether the wound could have been prevented, V5 stated, Perhaps but she's malnourished like I said and it's difficult to prevent her wounds with her condition. Asked how other wounds R26 had were healed, V5 stated, Well that was before she declined. Asked about her expectations of the facility to prevent pressure sores, V5 stated, Well they should be following their protocols, (R26) should be on an air mattress and they should check the mattress for bottoming out, etc. the mattress is very important and needs to be checked for proper inflation. The standby setting is not the correct setting, it should be on alternating pressure; they should be turning and repositioning the patient but the bed is more important than the positioning. The type of bed they are on is more important and watching incontinence. Beds they are on, barrier cream, turning every two hours is important but if that's the only strategy, that isn't enough. Asked about the impact of linens and over padding of the air mattress to manage heat dissipation, V5 stated, I don't get involved with that. The facility should follow their protocols on how to make their beds on those type of mattresses. They should know this. Policy and procedure dated (MONTH) 2013 titled Support Surface Guidelines states, The purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. General guidelines: Redistributing support surfaces are to promote comfort for all bed or chair bound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. Elements of support surfaces that are critical to pressure ulcer prevention and general safety include pressure redistribution, moisture control, shear reduction, heat dissipation/ temperature control, friction control, infection control. Interventions: Any individual at risk for development of pressure ulcers should be placed on a redistribution support surface when lying in bed. For residents that recline and depend on staff for repositioning, change positions at least q 2 hours. Reposition residents who are in chair at least q 2 hours. Avoid placing resident on the greater trochanter for more than momentary placement.