Every finding on record at Holton Manor

Based on observation, interview, and record review. the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (R16) of 2 residents reviewed for accidents.* R16 was not provided with the prescribed therapeutic diet and choked on food. R16 was sent to the hospital with a diagnosis of aspiration pneumonia (lung infection caused by inhaling a foreign material such as food). R16 was to be supervised intermittently while eating. R16 was observed not being intermittently supervised while eating and was left alone in the dining room for 20 minutes with no facility staff during noon meal on 5/4/2026 and 13 minutes at breakfast meal on 5/5/2026.Findings include:The facility policy titled, Therapeutic Diet Orders with no initiated, reviewed, or revised date documents: Policy: The facility provides all residents with foods in appropriate form and/or appropriate nutritive content as prescribed by a physician, and/ or assessed by the interdisciplinary team (IDT) to support the resident's treatment/ plan of care, in accordance with his/ her goals and preferences.Policy Explanation and Compliance Guidelines: 2. Therapeutic diet, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment.3. Therapeutic diets are provided only when ordered by the attending physician or a registered/ licensed dietician who has been delegated to write orders to the extent allowed by state law. Should the attending physician delegate the prescribing therapeutic diets, he or she will supervise the dietitian and remain responsible for the resident's care.4. The reason for a therapeutic diet is to be documented in the medical record and/ or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures.5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form.The facility policy titled, Foreign Body Airway Obstruction Management (Choking) with no initiated, reviewed, or revised date documents: Policy: It is the policy of this facility to ensure that residents will be effectively managed if a foreign body airway obstruction (FBAO) occurs. Policy Explanation: Foreign bodies can cause mild or severe airway obstruction and can affect anyone. Residents with impaired swallowing, neurological disorders or dental issues are at increased risk for foreign body airway obstruction.Compliance Guidelines:2. Residents should be assessed to determine if they are at higher risk for foreign body obstruction/ choking episodes and care planned accordingly. Consult the speech pathologist as needed.7. The facility will ensure that residents who have impaired swallowing issues are on an altered diet and receiving the appropriate diet.10. Document the event and response to the interventions implemented.R16 was admitted to the facility on [DATE] with diagnoses that include spastic hemiplegia affecting the right dominant side, dysphagia, traumatic brain injury (TBI), unspecified psychosis, vascular dementia with agitation and behavioral disturbance, and persistent affective mood disorder. R16's Quarterly Minimum Data Set (MDS) dated [DATE] indicated R16 was assessed to have moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 9. The MDs documents that R16 was assessed as needing supervision with eating.R16's Nutritional Status Care Area Assessment (CAA) dated 9/10/2025 documents: (R16) at facility for long term placement with a history of dysphagia. Diet is Dysphagia 3 (soft, moist foods that require minimal chewing), soft to chew, mechanical soft foods with nectar thick liquids. (R16) can feed self but needs supervision. (R16) uses adaptive equipment with meals to assist with feeding self. R16's at risk for aspiration due to dysphagia with poor positioning care plan dated as started on 11/10/2020 documents: R16 frequently chooses not to follow speech therapist (ST) recommendations such as educated to take small bites and R16 will put large bites into mouth on purpose. R16 becomes agitated with eating with small spoons and demands to have a fork for independence. R16 can become agitated at meals if R16 feels as if staff is looming over him and with education given. R16 has the following interventions initiated: - Diet as ordered per medical doctor (MD).- Monitor for signs/ symptoms of aspiration pneumonia.- Monitor need for changing diet consistency to increase ease of eating.- Observe resident closely for signs of difficulty swallowing and/or aspiration.- Obtain dietary consultation, flow recommendations.- Offer available substitutes if resident has problems with the food being served.- Provide assistance with meals such as set-up help, cueing, supervision.- Speech therapy consult, follow recommendations.- Thicken all liquids before serving.- Use aspiration precautions.R16's alteration in nutritional status care plan dated as started on 11/5/2020 documents: R16 requires Dysphagia 3 diet easy to chew, and mechanical soft foods with nectar thick liquids per MD orders. R16 has history of aspiration pneumonia. Dysphagia- oropharyngeal phase, TBI, and dementia. R16 at times will become agitated with small utensils and throw them on the floor. R16 will demand to use regular sized utensils at times.R16 has the following interventions initiated: - Dietician consult as needed (start: 1/24/2022)- Monitor for any chewing/ swallowing problems and report to nursing.- Set up and assist all meals as needed.- (R16) requires set up all meals, eat slowly, encourage to stay upright for 30 minutes after eating. (Start: 3/4/2022)- Dysphagia 3- Easy chew with nectar liquids. (Start date: 11/5/2020, edited 7/7/2022)- Intermittent supervision with eating. Encourage to eat slowly. Assist with setting up tray, encourage small bites alternating solids and liquids frequently. Encourage use of small spoon, may have a regular fork with foam grip. (Start: 7/8/2022, edited: 6/10/2025)On 5/4/2026, at 11:40 AM, Surveyor interviewed Family Member-N who stated R16 had a choking episode at supper a couple months ago and had to be sent to the hospital. Family Member-N stated R16 has a tendency to eat very fast and will choke on food so R16 has to be supervised frequently and told to slow down while eating.R16's progress note dated 3/1/2026, at 5:28 PM, written by Licensed Practical Nurse (LPN)-O documented: R16 was eating in dining room and started to throw up a lot of phlegm. LPN-O noted food on the floor R16 coughed up. R16 continues to cough up phlegm and at this time is able to say a few words. R16's coloring in face is improving. Vital signs: blood pressure- 116/80, oxygenation- 91% room air, pulse-98, respirations- 17, temperature- 98.4 degrees Fahrenheit. Orders received to send R16 to emergency room for further evaluation.R16's hospital after visit discharge note dated 3/1/26 documents: Diagnosis- Aspiration PNA (pneumonia).R16's progress note dated 3/1/2026, at 9:05 PM, written by LPN-O documented: R16 returned back to facility with diagnosis of aspiration pneumonia. Orders received for doxycycline (antibiotic) 100mg- 1 tab twice a day for 5 days. R16's at risk for aspiration care plan was revised with the following interventions:- ST (speech therapy) guidelines: supervision with eating. Encourage (R16) to eat slowly, assist with tray set up, use [sic] table close to trunk, encourage small bites alternating solids and liquids frequently. Encourage use of small spoon, uses sip cup and remind to clear throat and to stop to breath. (start: 3/4/2026)- Speech to evaluate.- DIET: mechanical soft with nectar liquids (start: 4/17/2026)- R16's legal guardian/ power of attorney (POA) desires to bring foods from home. POA has been educated on recommended diet and risk/benefit. R16's POA understands but preference is to bring upgraded foods and diet deviation form signed. Family must supervise closely if they give R16 regular foods. Staff will continue with diet as recommended/ ordered. R16's nutritional status care plan was revised with the following interventions:- Remind to go slow, stop, breath, clear throat 3 times throughout the meal. Place utensils near left side. Keep table close to trunk, supervise (Start: 3/4/2026)- Provide adaptive equipment with all meals to aid with independence. Inner lip plate, mat, covered cups, small spoon. (start: 4/17/2026)- Provide small spoon at meals to assure [sic] (R16) takes small bites. Give education if refusing to use small spoon and covered cups.- (R16's) POA prefers to bring in foods from home with visits. Diet deviation form signed and educated on risk/ benefit. (start 4/20/2026)Surveyor reviewed R16's certified nursing aide (CNA) care card and noted the following intervention started on 3/4/2026:-Problem category- Nutritional status- remind to go slow, stop, breath, clear throat three times throughout the mean. Place utensils near left side. Keep table close to trunk, supervise.Surveyor noted no interventions were in place on the CNA care card prior to 3/4/2026 and was unable to locate a therapeutic diet order on the care card to notify CNA's what R16's diet is supposed to be.On 5/4/2026, at 12:30 PM, Surveyor observed R16 sitting in the dining room at R16's table waiting for lunch to be served. On 5/4/2026, at 12:43 PM R16 received a meal tray and was noted to be moving R16's food around with a fork.On 5/4/2026, at 1:00 PM Surveyor overheard a CNA state R16 will probably not eat because R16 had a late lunch. Surveyor noted nursing staff leave dining room and noted R16 was left in the dining room with no supervision from facility staff. R16 was noted to start eating R16's lunch. R16 was noted to have a neck tilt to the left side and upper body was tilted and slumped over R16 left side. On 5/4/2026, at 1:27 PM Surveyor noted facility staff come into the dining room and asked if R16 was finished with lunch and cleaned up R16's dining spot. Surveyor noted that R16 was not being supervised while eating on 5/4/2026 from 1:00 PM to 1:27 PM.On 5/5/2026, at 9:19 AM, Surveyor observed R16 brought to dining area for breakfast. Surveyor observed 1 CNA in the dining room assisting another resident to eat and the CNA's back was facing R16. R16 started to eat breakfast. Surveyor noted the CNA did not turn to look at R16 while R16 was eating.On 5/5/2026, at 9:32 AM, another CNA came into the dining room and sat at the table next to R16 to assist another resident with breakfast. Surveyor noted that R16 did not get supervision with breakfast meal for 13 minutes or from 9:19 AM to 9:23 AM. On 5/5/2026, at 2:18 PM, Surveyor interviewed ST-P who stated R16's diet is International Dysphagia Diet Standardization Initiative (IDDSI) level 6 (soft and bite sized- moist, tender, and soft foods that do not require a knife to cut). ST-P stated R16 needs supervision during meals due to R16 having frequent episodes of coughing while eating because R16 tends to put a lot of food in R16's mouth at once. R16 will not eat if someone is sitting close to R16 or tells R16 how to eat, but staff should be close by R16 and within eyesight of R16. Staff should be facing R16 because of how R16 leans to the left side and staff should not have their back to R16 when supervising R16 to eat. ST-P stated R16 must always be supervised while eating due to recent episodes of R16 unable to clear the food out of his mouth and having to be sent to hospital for evaluation. On 5/5/2026, at 3:22 PM, Surveyor interviewed LPN-O who stated LPN-O was called to the dining room on 3/1/2026, due to R16 choking and coughing a lot. LPN-O stated by the time LPN-O got to the dining room, R16 had cleared what was causing R16 to cough. LPN-O saw floor on the floor and R16 was coughing up a lot of phlegm. LPN-O stated at that time R16's face was red and breathing easier. LPN-O received an order to send R16 to hospital for further evaluation and R16 came back later that night with an order for antibiotics due to aspiration pneumonia. LPN-O stated R16 should be supervised or have eyes on R16 while eating. LPN-O stated was passing medications at the time and was not in the dining area during R16's incident on 3/1/2026. On 5/6/2026, at 12:09 PM, Surveyor interviewed CNA-S who stated the meal that night was a taco dish. CNA-S was assisting another resident with eating and a family member of another resident alerted CNA-S that something was wrong with R16. CNA-S went to R16 and noted R16 to be a little purple in the face and was coughing/ vomiting food out. CNA-S noted there were shreds of lettuce and R16 was not supposed to get lettuce. CNA-S called LPN-O and R16 was assessed and sent to the hospital. CNA-S stated R16 received the supper meal tray, and no one checked the tray before R16 started to eat from it. CNA-S stated when a resident is supervised during meal, the resident has to be checked on to make sure the resident is eating ok and does not need any assistance. CNA-S stated R16 does not like to be watched when eating but still have to check to make sure R16 is ok.On 5/6/2026, at 12:23 PM, Surveyor interviewed Cook/ CNA-R who was working as a CNA on 3/1/2026. Cook/CNA-R was assisting another resident with eating in the dining area and heard CNA-S ask for help. Cook/CNA-R stated R16 received shredded lettuce and was not supposed to due to the therapeutic diet R16 is on. Cook/CNA-R stated the meal slips are color coded according to what diet the resident is to get. R16 has a yellow slip and documents the diet R16 is to have which is mechanical soft and documents foods R16 is not to get. Cook/CNA-R believes the cook that night on 3/1/2026 just did not look at R16's slip and feels that is why R16 received the wrong diet, and no one caught it. Cook/CNA-R stated R16 is not very complainant with R16's diet and R16's family brings R16 regular foods, but staff needs to supervise R16 to make sure eating ok and not putting too much into R16's mouth.On 5/6/2026, at 12:41 PM, Surveyor interviewed dietary supervisor-T who recalled being notified R16 was provided with the wrong therapeutic diet on 3/1/2026 and received shredded lettuce, had an episode of choking or coughing the food up and was sent out to the hospital for further evaluation. Dietary supervisor-T spoke with the cook on duty during evening meal and the cook stated not sure what happened, just made a mistake and probably did not read the ticket close enough. Dietary supervisor-T stated meal tickets are color coded according to what diet a resident should get and listed on the tickets what the resident cannot have. R16 should not have received shredded lettuce. On 5/6/2026, at 1:30 PM, Surveyor was provided with an infection tracker document for R16 for the antibiotic R16 was prescribes for diagnoses of aspiration pneumonia from 3/1/2026. Surveyor asked NHA-A if there was an investigation or root cause completed for R16's choking incident on 3/1/2026. NHA-A stated there was not because R16's issue is not new and interventions are implemented for R16.Surveyor notified NHA-A that R16 was provided with the wrong diet on 3/1/2026 and received shredded lettuce and that it was what R16 choked on. NHA-A stated NHA-A was not aware of R16 receiving the wrong diet and receiving shredded lettuce. Surveyor shared concerns with NHA-A of Surveyors observations on 5/4/2026 R16 was not supervised during noon meal for 20 minutes and not supervised for breakfast meal on 5/5/2025 for 13 minutes. NHA-A replied staff should check on periodically and does not need to be watched all the time. Surveyor informed NHA-A per ST-P staff should be in eyesight of and facing R16 and not be left alone when eating food. NHA-A stated that it was not relayed to NHA-A and will clarify R16's interventions and revise the care plan. Surveyor informed NHA-A that R16 was not supervised per R16's care plan during breakfast and noon meals, R16 was provided with a wrong diet on 3/1/2026 resulting in R16 having to go to the emergency room for evaluation and was diagnosed with aspiration pneumonia and required an antibiotic. NHA-A understood Surveyors' concerns and would be looking into the concerns.No additional information was provided at the time of write up.

Based on observation, interview, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 2 (R37, R7) of 4 residents reviewed for pressure injuries.*R37 admitted to the facility with a stage IV pressure injury that had an abscess of bursa for wound management. R37 proceeded to develop two new pressure injuries while at the facility.*R7 did not have a comprehensive assessment of their right buttock pressure injury from 4/2/2026, when discovered, until 4/14/2026.Findings include:The facility Policy titled Pressure Injury Prevention and Management copyright 2026, documents: Policy: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries.Policy Explanation and Compliance Guidelines:2. The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.3. Assessment of Pressure Injury [NAME]. Licensed nurses will conduct a pressure injury risk assessment. on all residents upon admission/re-admission, weekly x (times) four weeks, then quarterly or whenever the condition changes significantly.c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented.d. Assessments of pressure injuries will be performed by a licensed nurse, and documented in the resident progress notes. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS.4. Interventions for Prevention and to Promote Healinga. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions.b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics).c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to:i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.);ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination;iii. Provide appropriate, pressure-redistributing, support surfaces;iv. Provide non-irritating surfaces; ande. The goals and preferences of the resident and/or authorized representative will be included in the plan of care.f. Interventions will be documented in the care plan and communicated to all relevant staff.1.) R37 was admitted to the facility on [DATE] with pertinent diagnoses that include abscess of bursa on right hip (a serious, rare condition where the fluid-filled sac becomes infected, causing intense pain, swelling, redness, and fever), cutaneous abscess of right hip (a painful, pus-filled lump under the skin, typically caused by a bacterial infection entering through a small cut or follicle), paraplegia (a form of paralysis affecting the lower half of the body, including both legs and sometimes the abdomen), and acquired absence of left leg below knee (refers to the surgical or traumatic amputation of the left leg below the knee joint).R37's Quarterly Minimum Data Set (MDS) with an assessment reference date of 2/25/2026, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R37 is cognitively intact. R37 was coded to understand others and makes self understood. The MDS documents that R37 was assessed to have no behaviors exhibited during the look back period, which includes rejection of care. R37 has a catheter for elimination of bladder and is incontinent of bowel. The MDS documents that R37 was assessed as at risk of developing pressure injuries.R37's Braden Scale for Predicting Pressure Score Risk evaluation completed 11/20/2025, after R37 admitted to the facility documented that R37 was assessed as at risk with a score of 15. Surveyor noted R37 admitted with a stage IV pressure injury. R37's care plan, with start date of 11/18/2025, documents: R37 is at risk for skin breakdown, pressure injury, skin tears R/T (related to) impaired mobility, thin fragile skin, Abscess of bursa, right hip, Paraplegia, Peripheral vascular disease, Morbid (severe) obesity, moisture to folds, bowel incontinence, suprapubic catheter. R37 prefers to direct R37's own cares. R37's goal is documented as risk for skin breakdown will be minimized as evidenced by less than 1 pressure ulcers by next review with staff monitoring, education, encouragement, and approaches with a target date of 05/25/2026 .Pertinent Approach(s) include:-R37 prefers to determine how long R37 is in bed and how long R37 is in their electric WC, Start Date 03/04/2026-Ensure alternating air mattress is in place and functioning Every Shift, Start Date 11/20/2025-Foam Heel boot right foot when in bed due to paraplegia Every Shift, Start Date 11/20/2025-Roho cushion in wc (wheelchair) at all times, Start Date 11/18/2025-Chart episodes or refusals to reposition under OTHER tab, Start Date 11/18/2025-Assist to turn and reposition in bed frequently. Start Date 11/18/2025-Assist to make small frequent position changes while in chair. Start Date 11/18/2025-Educate on the risks vs (versus) benefits of staying in bed vs getting up for offloading and position changes to prevent breakdown if indicated. Start Date 11/18/2025-Avoid shearing resident's skin during positioning, transferring, and turning. Start Date 11/18/2025-Keep clean and dry as possible. Minimize skin exposure to moisture. Start Date 11/18/2025-Assess resident for presence of risk factors. Treat, reduce, eliminate risk factors to extent possible. Start Date 11/18/2025.R37's care plan, with start date of 11/18/2025, documents: R37 has wounds to right hip/buttock, left anterior upper thigh, back of left thigh upon admission. R37's goal was for R37 will show S/S (signs/symptoms) of stabilizing, healing, and risks for further breakdown will be reduced with staff monitoring, education, and approaches by next review has a target date of 05/25/2026.Pertinent Approach(s) include:-Wound care to right hip/buttock: **Wound VAC on HOLD* Cleanse wound with wound cleanser, pat dry, gently pack with VASHE soaked kerlix (ensure to wring out so gauze is only damp, apply alginate, cover super absorbent pad and secure with paper tape daily and PRN (as needed), Start Date 04/21/2026-Alternating air mattress is in place, Start Date 11/20/2025-Use off loading boot to relieve pressure on the heel. Start Date 11/18/2025-Provide incontinence care after each incontinent episode. Start Date 11/18/2025-Use Pressure relieving cushion for pressure reduction when resident is in chair. Start Date 11/18/2025-Instruct resident to reposition self frequently when resident is in bed. Start Date 11/18/2025-Turn and reposition frequently Q (per) shift. Start Date 11/18/2025-Keep resident off area as much as possible. Start Date 11/18/2025-Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin weekly by wound nurse. Start Date 11/18/2025-Conduct a systematic skin inspection weekly. Report any signs of any further skin breakdown (sore, tender, red, or broken areas). Start Date 11/18/2025-Keep linens clean, dry, and wrinkle free. Start Date 11/18/2025-Keep clean and dry as possible. Minimize skin exposure to moisture. Start Date 11/18/2025R37's physician order, dated 11/25/2025, documents monitor skin peri (around) wound vac for skin breakdown and s/s of infection Q shift. report changes to wound NP (Nurse Practitioner), Every Shift. R37's progress note, written by Registered Nurse (RN)-M, dated 11/18/2025, documents: Skin assessment - resident has several bruises, redness to several areas and scarring. Right front - bruising to right antecubital space, top of RFA (right forearm), top of right shoulder which is faint. PICC RUE (right upper extremity). Redness to under right axilla, under abdominal fold/crease, under right groin, scar (divet) by right knee. Right bottom of foot discolored area. Left front - Left axilla redness, left elbow 2 bruised areas, left inner forearm has 2 little red spots or bumps, left upper knee with scar, left inner thigh wound 2 cm x 1cm, left puncture wound with discoloration below thigh wound, left below knee amputation scar. Back - top of right shoulder scar past sx (surgery), right back leg oval shaped raised area, red skin very dry, 2 blister like areas left buttock and slit area covered by tegaderm.Surveyor noted only one measurement for R37's left inner thigh wound was included and no assessment information, including measurements or a wound bed description, was documented including the stage iv pressure injury resident admitted with.R37's progress note, written by previous Assistant Director of Nursing (ADON)-K, dated 11/19/2025, documents: Skin assessment: pink scar tissue noted to right shin -states this was from a scrape from her w/c (wheelchair)- now resolved, large callous noted to bottom of right heel, left anterior thigh: 0.5cm x 0.5cm x 0.5cm depth, 100% dry smooth pink tissue, pt (patient) states this is from a previous surgery, back of left inner thigh: 1cm x 0.5cm (50% scar tissue/50% pink tissue) scant amount of serous drainage noted, 1cm x 1cm blister below this area noted, skin prep applied and foam dressing to pink/scarred area -per patient, redness noted to bilat (bilateral) axilla and groin/[NAME] - per pt uses miconazole cream to these areas - areas cleansed with soap and water and cream applied, mepilex removed from coccyx, no redness or open areas to coccyx, bruise/greenish noted to right shoulder and outer aspect of right elbow, right buttock: x2 scabs both 1cm x 1cm, Right hip wound: 5cm x 8cm x 12cm at deepest point, slough visible at base, 80% granulated, large amount of serosanguinous drainage noted, slight malodor - resolved after cleaning wound, packed with Vashe soaked gauze and covered with ABDs and tape per patient, orders obtained for all of the above per Physician Assistant (PA)-J will add to wound rounds.R37's note from previous ADON-K to PA-J, dated 11/19/2025, documents: They were packing the large area on right hip Vashe moistened gauze roll and covering with ABDs (abdominal pads) and medipore tape. And for left ant (anterior) thigh: hydrogel and gauze with tape, back of left thigh. with blister below/skin prep applied f/b (followed by) foam border PA-J responded to message what was etiology of the hip wound? Those sound good to continue.R37's progress note, written by previous ADON-K, dated 11/25/2025, documents: Writer completed wound rounds with PA-J, left upper anterior thigh assessed: 3.5cm x 0.5cm, pt states this is from a previous surgery- dry pink tissue noted - cont. (continue) with hydrogel to this area, back of left thigh: 1.7cm x 1,6cm x<0.1cm and dry pink tissue/scar tissue - may cleanse with Vashe and apply foam dressing per pt preference, Right hip ulcer: 3.5cm x 11.3cm x 10.5cm at deepest point, edges irregular, peri wound is irritated from tape - skin prep applied, NOR for wound vac with black foam to be changed 3x/(times per) week and PRN, pt in agreement with this tx (treatment), Vac applied, pt tol (tolerated) well, no s/s of infection noted, pt has air mattress, education provided on being cautious with transfers etc, shifting weight to left side instead of right side where the wound is, okay to use beezy board with therapy per PA-J therapy team updated.R37's progress note, written by previous ADON-K, dated 1/6/2026, documents: Writer completed wound rounds with PA-J, wound to right hip/buttock assessed: 2.5cm x 8.4cm x 7.9cm, wound bed= 100% granulated tissue, no bone/facia etc. palpable, wound (previous bridged area from wound vac site): 2cm x 2.9cm x 0.2cm and is 100% granular with central ecchymottic tissue - NOR (new order received) for xeroform to this area, new linear DTI(deep tissue injury)/ecchymotic tissue above large ulcer and proximal to the previous area of skin break down above old vac site: 1.9cm x 1.7cm, pt states she does not know how this happened, appears to be from pressure, electric w/c has metal pieces with padding that this could likely be from, Additional new OA (open area), very superficial likely from tape: 1.5cm x 1.2cm- clean pink non-granular tissue base - NOR for xeroform and foam dressing to this area. education provided to pt on importance of repositioning and not sitting up in her w/c for extended amounts of time, pt states she often sits in chair from when she gets up until 10pm, Dressing change (Vashe) for large hip ulcer changed to once/day per patient request as she states BID (twice daily) is not sustainable, education provided, unable to place wound vac as planned d/t (due to) surrounding tissue/skin breakdown, pt has air mattress, pressure relief cushion and takes protein shakes.R37's progress note written on 02/03/2026, at 10:17 AM, documents: Wound improving, air mattress and pressure reduction interventions in place. Refusing protein supplements but resident buys own high protein food items and is very aware of interventions to assist with wound healing. Wound is improving, no s/s of infection noted. No pain noted, tolerating wound vac without issues.On 11/25/2025, R37 was seen by PA-J for initial evaluation after admitting to facility. R37's progress note documents: Evaluation of right hip postoperative wound as well as left medial thigh wound. R37 is seen today for wound care initial evaluation. Patient is a T9 paraplegic with a complex past medical history, most recently hospitalized due to right hip cutaneous abscess related to a pressure wound infection. She states that recently she had developed a pressure wound related to her hospital bed which became secondarily infected. She was hospitalized on [DATE] underwent surgical debridement resulting in a large postoperative wound. She has been discharged on IV antibiotics including vancomycin and meropenem. There was discussion about initiation of a wound VAC however this was not started prior to her discharge. In addition she has a left medial thigh wound as well as a left anterior lateral thigh healing wound. She denies any fevers or chills. She has a right arm PICC line in place. She denies any other complaints at this point in time.Interventions in place are documented as: Heel offloading with heel offloading boots or pillows as tolerated by patient. Turn and reposition every 2-3 hours with assistance as needed. Dietary collaboration, PT/OT (physical therapy/occupational therapy) collaboration.Wound #1Type: Full-thickness surgical wound; Site: Right lateral hip; Dimensions: 3.5 x 11.3 x 10.5 cm; Wound bed: Appears red and pink tissue with muscle and fascia noted to the wound bed deep, no bone exposed, no obvious slough or necrotic tissue apparent; Drainage: Moderate sanguinous; Periwound: Moist but intact; Status: Present on arrival, improved.Plan: Given depth, location, and size with the amount of drainage she is having she is a candidate for negative pressure wound therapy. Apparently this had been discussed prior to her even leaving the hospital but was not initiated. Patient has had wound vacs in the past for a left thigh wound as well. She is agreeable with starting today. Wound VAC was applied, see below. This will be changed 3 days/week with pressure set at 125 mmHg.Wounds #2 and #3 were assessed as partial thickness abrasions that were present on arrival.Surveyor noted R37 was seen 12/2/2025 by PA-J with assessments and treatments. Surveyor noted that at the time, the abrasions are deemed healed and R37's stage IV pressure injury was assessed weekly and treated appropriately by PA-J.On 12/9/2025, R37 was seen by PA-J and the progress note documents: R37 seen today for wound care follow-up. Events noted, VAC has been able to stay in place over the weekend with good suction. Continues to have issues with incontinence to the perineum area and the backside and has been trying to have the draw sheet and Chux changed out regularly. Denies any fevers or chills.A new wound is added to the evaluation. Type: partial-thickness pressure related unstageablel Site: right lateral hip/thigh; Dimension: 2.2 x 2.0 x UTD (unable to determine) cm; Wound bed: 50% slough 50% pink tissue; Drainage: small serosanguineous; Periwound: macerated edges with poorly defined edges; Status: stablePlan: Continue Medihoney with foam border. This is related to maceration from incontinence as well as pressure related from the bridging from the VAC device. Attention is being made to avoid these areas with continuation of the VAC device for the surgical wound.On 12/16/2025, R37 is seen by PA-J and the partial thickness pressure related unstageable remains to the right lateral hip/thigh. The new dimensions are 1.8 x 1.7 x UTD cm with same characteristics from 12/9/2025. The status is stable and the treatment remains the same.On 12/23/2025, R37 was seen by PA-J and wound type is changed to partial-thickness pressure related now able to classify as stage III post debridement to the right lateral hip/thigh. The assessment documents: Dimension: 2.4 x 2.9 x 0.2 cm post debridement; Wound bed: prior to debridement 100% slough which was necrotic appearing, post debridement 90% pink tissue, 10% scattered ecchymotic tissue; Drainage: small serosanguineous; Periwound: macerated edges with poorly defined edges be defined post debridement; Status: stalled.Plan: Site was debrided today. Post debridement, adjust to silver alginate with foam border changing 3 times weekly and as needed.On 12/30/2025, R37 is seen by PA-J and the wound type remains partial-thickness pressure related now able to classify as stage III to the right lateral hip/thigh. The assessment documents: Dimension: 3.7 x 2.7 x 0.2 cm post debridement; Wound bed: 60% granular with 40% slough post aggressive scrubbing of the wound; Drainage: small serosanguineous; Periwound: macerated edges with well defined edges; Status: improved; Plan: will adjust to hydrafera blue followed by foam border changing 3x per week and as needed. Continue offloading the site.On 1/6/2026, R37 was seen by PA-J the partial-thickness pressure related now able to classify as stage III to the right lateral hip/thigh remains. The assessment documents: Dimension: 2.0 x 2.9 x 0.2 cm; Wound bed: 100% granular with central area approximately half centimeter area of ecchymotic changes similar to prior; Drainage: small serosanguineous; Periwound: macerated edges with well defined edges; Status: stable; Plan: will adjust to Xeroform gauze followed by foam border changing 3x per week and as needed. Continue offloading the site.A new DTI (deep tissue injury) superior to the pressure wound was added to the 1/6/2026 assessment. The assessment documents: Dimension: linear DTI measuring 1.9 x 1.7 ; Wound bed: 100% ecchymotic linear; Drainage: none; Periwound: dry and fragile; Status: new; Plan: skin-prep to the site and will be covered by foam border given the location related to the adjacent pressure wound continue offloading.On 1/13/2026, R37 is seen by PA-J the partial-thickness pressure related now able to classify as stage III to the right lateral hip/thigh remains. The assessment documents: Dimension: 2.4 x 2.5 x 0.2 cm; Wound bed: 100% granular with no further ecchymotic changes; Drainage: small serosanguineous; Periwound: no further maceration of the edges; Status: stable; Plan: will apply collagen powder to the wound bed followed by foam border changing 3x per week and as needed. Continue offloading the site.The DTI superior to the pressure wound is assessed as: Dimension: linear DTI measuring 2.6 x 2.5 cm; Wound bed: 100% slough; Drainage: small serosanguineous; Periwound: poorly defined edges, mild maceration; Status: stable; Plan: will adjust to Xeroform gauze followed by foam border. Will change 3 times per week as needed.On 01/20/2026, at 02:40 PM, R37's progress note documents: Writer completed wound assessment on pt. DTI to right buttock is 100% resolved. wound superior to vac site while pt side laying position: 2.5cm x 3cm with Ecchymotic center 0.5cm x 0.25cm - cont. (continue) with collagen to this area.On 1/27/26, R37 is seen by PA-J the partial-thickness pressure related now able to classify as stage III to the right lateral hip/thigh remains. The assessment documents: Dimension: 2.0 x 3.1 x 0.2 cm; Wound bed: 100% granular; Drainage: small to moderate serosanguineous; Periwound: no maceration of the edges; Status: stable; Plan: will apply collagen powder to the wound bed followed by foam border changing 3x per week and as needed. Continue offloading the site.The DTI superior to the pressure wound is assessed as: Dimension: closed; Wound bed: 100% epithelialized; Status: resolved; Plan: will leave the area open to air but obviously continue to protect as this is being closed with the VAC apron.On 2/3/26, R37 is seen by PA-J the pressure wound to the right lateral hip remains. The assessment documents: Dimension: 1.9 x 2.1 x 0.1 cm; Wound bed: 100% granular; Drainage: moderate, described as sanguineous; Periwound: no maceration, dry and intact; Status: improved; Plan: collagen matrix to the wound bed with calcium alginate overlying, foam border dressing, change three times per week.On 2/10/26, R37 is seen by PA-J the pressure wound stage III superior medial to hip wound remains. The assessment documents: Dimension: 1.5 x 1.5 x 0.1 cm; Wound bed: 100% granular; Drainage: moderate serous drainage; Periwound: no maceration or erythema; Status: improved; Plan: will continue with collagen to the wound bed with calcium alginate overlying for drainage control followed by foam border changing three days per week.On 2/17/26, R37 is seen by PA-J the pressure (stage III) to the right lateral hip remains. The assessment documents: Dimension: 1.0 x 1.8 x 0.2 cm; Wound bed: 100% granular; Drainage: scant serosanguinous; Periwound: no maceration or erythema; Status: improved; Plan: collagen with calcium alginate and foam border; dressing changes three days per week.On 2/24/26, R37 is seen by PA-J the pressure ulcer, stage III medial to stage IV surgical wound remains. The assessment documents: Dimension: 1.0 x 1.9 x 0.1 cm; Wound bed: 100% granular; Drainage: scant, serosanguinous; Periwound: no erythema; Status: stable; Plan: collagen with foam border, dressing change three days per week.On 3/3/26, R37 is seen by PA-J the pressure (stage III) lateral to stage IV surgical wound remains. The assessment documents: Dimension: 0.6 x 1.6 x 0.1 cm; Wound bed: 50% epithelialized, 50% granular; Drainage: scant sanguinous; Periwound: no erythema, no maceration; Status: improved; Plan: collagen; foam border; dressing change 3 times per week.On 3/10/26, R37 is seen by PA-J the pressure ulcer (stage III) lateral hip right remains. The assessment documents: Dimension: 0.4 x 0.8 x <0.1 cm; Wound bed: 75% epithelialized, 25% granular; Drainage: none; Periwound: dry intact; Status: improved; Plan: collagen with foam border dressing; change 3 days per week.On 3/17/26, R37 is seen by PA-J the stage III pressure wound medial to stage IV hip wound is deemed healed. The assessment documents: Dimension: closed; Wound bed: 100% epithelialized; Drainage: none; Periwound: intact; Status: resolved; Plan: discontinue active wound dressing; monitor for skin integrity.Surveyor noted R37 continues to be seen by PA-J for the stage IV surgical wound and no additional wounds were present.On 05/05/2026, at 12:44 PM, Surveyor interviewed PA-J regarding R37's wound care. PA-J stated that the previous ADON-K assessed the stage IV surgical wound upon R37 admitting and reached out to PA-J for orders on treatment. PA-J started R37 on the wound VAC after the initial evaluation. Surveyor asked how the two new wounds started and was told the first was from the wound VAC bridging. The second was from R37's power wheelchair, PA-J showed Surveyor a hard edge next to the seat cushion in the wheelchair. PA-J stated that R37 is actively trying to get a consult for the initial stage IV wound to be closed up surgically, R37 is on a waiting list. On 05/06/2026, at 11:38 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A and asked if facility knew R37 was at risk for pressure injuries as R37 admitted with one, what was being done to prevent more pressure injuries while R37 resided in the facility. NHA-A stated will look at everything for R37 and get back to Surveyor. On 05/06/2026, at 2:00 PM, Surveyor followed up with NHA-A and was told Licensed Practical Nurse (LPN)-L was printing information now. Surveyor stated would review what was given, however the concern is what was done to prevent two new pressure injuries from starting.On 05/06/2026, at 2:39 PM, LPN-L told Surveyor R37 has an air mattress and takes a multivitamin. R37 was provided a bigger roho cushion for R37's wheelchair.Surveyor noted these interventions were on R37's care plan, yet two new pressure injuries developed. Surveyor noted R37 was admitted for care of the stage IV pressure injury, the risk of additional skin breakdown was known. R37's physician order, dated 11/25/2025, documents monitor skin peri (around) wound vac for skin breakdown and s/s of infection Q shift. report changes to wound NP (Nurse Practitioner), Every Shift. Surveyor noted the first wound started due to the bridging of the wound vac. Surveyor received additional information on 5/14/2026, Surveyor reviewed the information, which included the same Wound Care Assessments done weekly by Wound PA-J and facility wound care documentation by previous ADON-K. No new details were provided to prove the pressure injury development was unavoidable. Both pressure injuries developed in the facility. One was due to the wound vac bridging and there was an order in place to monitor skin peri (around) wound vac for skin breakdown. The other was suspected from R37's wheel chair rubbing and a new cushion was deemed necessary after the wound developed. Proper monitoring by the facility could have had the potential to prevent these new pressure injuries from developing. No additional information was provided. 2.) R7 was admitted to the facility on [DATE] with pertinent diagnoses that include systolic and diastolic heart failure with respiratory failure (both types of heart failure, sometimes occurring together, cause substantial lung dysfunction, decreased oxygenation, and increased mortality risk. Both can cause acute respiratory failure by creating high pulmonary pressures that lead to pulmonary edema and congestion.), dysphagia (difficulty swallowing), and gastrostomy (a surgically created opening in the abdomen that connects to the stomach, often for the purpose of feeding or administering medication).R7's 5 day Minimum Data Set (MDS) with an assessment reference date of 4/25/2026, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R7 is cognitively intact. R7 was coded to understand others and make self understood. The MDS documents that R7 was assessed to have no behaviors exhibited during the look back period, which includes rejection of care. The MDS documents that R37 is at risk of developing pressure injuries.R7's Braden Scale for Predicting Pressure Score Risk evaluation completed 3/18/2026 after R7 admitted to the facility documented that R7 was assessed as moderate risk with a score of 14.R7's care plan, with start date of 4/02/2026, documents: R7 is at risk for skin breakdown, pressure injury, skin tears r/t (related to) impaired mobility, thin fragile skin, recent CABG, foley, bed bound, g-tube, necrotic tissue in mouth d/t (due to) intubation. R7 prefers to spend most of her time in bed and needs encouragement to get up for position change. Folds and groin have redness. R7's goal is R7's risk for skin breakdown will be minimized as evidenced by less than 1 pressure ulcers by next review with staff monitoring, education, encouragement, and approaches and has a target date of 7/21/2026.Pertinent Approach(s) include:-Make sure bilateral heels are clean and intact, apply skin prep twice a day. Start date 4/7/2026.-Avoid shearing resident's skin during positioning, transferring, and turning. Start date 4/2/2026.-Chart episodes or refusals to reposition under OTHER tab, Start Date 4/2/2026-Educate on the risks vs (Versus) benefits of staying in bed vs getting up for offloading and position changes to prevent breakdown if indicated. Start Date 4/2/2026-Encourage & assist to make small frequent position changes while in chair. Start Date: 4/2/2026-Encourage & assist to turn and reposition in bed frequently. Start Date 4/2/2026-Float heels to reduce the risk of pressure and friction, Start Date 4/2/2026R7's care plan, with start date of 4/15/2026, documents: Problem: R7 has a pressure ulcer to R (right) buttock. R7's goal is R7 will show no S/S (signs/symptoms) of infection to wound and risks for further breakdown will be reduced with staff monitoring, education, and approaches by next review and has a target date of 05/29/2026 .Pertinent Approach(s) include:-Use off loading boots or pillows to relieve pressure on the heels. Document refusals, Start Date 04/21/2026-Alternating air mattress in place for pressure relief and off loading, Start Date 04/21/2026-Use Pressure relieving cushion for pressure reduction when resident is in chair. Start Date 04/21/2026-Turn and reposition frequently Q shift. Start Date 04/21/2026-Pressure sore to R buttock: Cleanse with normal saline, pat dry, apply Triad paste BID (Twice A Day), Start Date 04/21/2026-Keep resident off area as much as possible. Start Date 04/21/2026-Keep linens clean, dry, and wrinkle free. Start Date 04/21/2026-Instruct resident to reposition self frequently when resident is in bed. Start Date 04/21/2026R7's physician order documents: Ensure alternating air mattress is in place and functioning properly for pressure relief and off loading, every shift.R7's 4/2/2026 physician order documents: Assist with repositioning and floating heels in bed frequently. HOB > 30 degrees at all times.R7's 4/2/2026 physician order documents: Heel boots on at all times while in bed d/t (due to) DTI (deep tissue injury), risk for skin breakdown.Surveyor noted R7 admitted to the facility on [DATE], R7 readmitted to the hospital from [DATE] to 4/2/2026. On 3/29/2026 while in the hospital there was a skin assessment that documented no skin issues for R7.R7's progress note dated 04/02/2026, written at 07:20 PM, documents: Skin assessment.Resident has 2 deep tissue injury's noted - 1 to each heel. Left heel 0.4x 0.4 - right heel 0.5 x 0.2 - no drainage, dark tissue, DTI (deep tissue injury). Education done with daughter and resident on importance of using heel boots, states understanding. Stage II pressure ulcer noted to left buttock, 3cm x 3cm x 0.1 - 100% pink wound bed, non granulation, no drainage noted. No pain or s/s (signs/symptoms) of infection noted. New order for TRIAD paste BID until resolved. Message left to request air mattress d/t (due to) current pressure ulcers and high risk for skin breakdown.Surveyor noted Nursing Home Administrator (NHA)-A verified the air mattress was delivered 4/3/2026 for R7. Surveyor noted the stage II pressure ulcer was on the right buttock

Based on interview and record review, the facility did not ensure a staff person designated as the Infection Preventionist (IP) completed specialized training in infection prevention and control. This practice had the potential to affect all 53 residents residing in the facility.The Interim Director of Nursing (IDON)-B was the facility's designated IP. IDON-B did not complete specialized infection prevention and control training. The facility also failed to designate an alternate qualified resource to oversee or the infection prevention and control program (IPCP) responsibilities of the facility. Findings include:The facility policy titled Infection Preventionist with no initiated, reviewed, or revised date documents: Policy: The facility will employ one or more qualified individuals with responsibility for implementing the facility's infection prevention and control program. Policy Explanation and Compliance Guidelines:1. The facility will designate a qualified individual as IP whose primary role is to coordinate and be actively accountable for the facility's IPCP to include the antibiotic stewardship program.2. The facility will ensure the IP is qualified by education, training, experience or certification.4. The IP will have the knowledge to perform the role and remain current with infection prevention and control (IPC) issues and be aware of national organizations' guidelines, as well as those from national/state/local public health authorities.10. The IP must receive specialized IPC training beyond initial professional training or education. Specialized training should include the following topics:a. IPCP overviewb. IP rolec. Infection surveillanced. Outbreaks .h. Water managementi. Linen management .n. Antibiotic stewardship .11. responsibilities of the IP include .:a. Develop and implement ongoing (IPCP) to prevent, recognize, and control the onset and spread of infections in order to provide a safe, sanitary, and comfortable environment.b. Establish facility wide systems for the prevention, identification, reporting, investigation and control of infections and communicable diseases of residents, staff, and visitors.c. Develop and implement written policies and procedures in accordance with current standards of practice and recognized guidelines for infection prevention and control.d. Oversight of and ensuring the requirements are met for the facility's antibiotic stewardship program.e. Oversight if resident care activities .f. Review and/or revise the facility's (IPCP), its standards, policies, and procedures annually and as needed for changes to the facility assessment to ensure they are effective and in accordance with current standards of practice for preventing and controlling infections.g. Review/ revise and approve infection preventions and control training topics and content and ensure facility staff are training on IPCP.12. The IP will participate on and is part of the quality assessment and assurance committee (QAA) and will report regularly on the IPCP activities.On 5/5/2026, at 10:17 AM, Surveyor interviewed IDON-B about the IP role. IDON-B stated IDON-B was hired on 4/1/2026 to be the assistant DON but the previous DON no longer is employed with the facility since 4/24/2026 and IDON-B took over for DON until a permanent replacement is found. IDON-B's certification as an infection preventionist is currently being completed. Surveyor asked if she had previously served as an IP or had similar experience. IDON-B informed Surveyor that IDON-B had not previously worked in the IP role or had any similar experience. Surveyor asked if there was a resource or staff overseeing the IPCP program while IDON-B is getting certification. IDON-B stated IDON-B was not sure who IDON-B would go to if there were questions or concerns and would look into it.Surveyor noted that IDON-B was working in the IP role at the facility but did not obtain specialized IPC training beyond initial professional training or education prior to assuming the role.On 5/5/2026, at 3:01 PM Surveyor asked Nursing Home Administrator (NHA)-A what plan was put in place for the facility's IP and IPCP when the previous DON left the facility. NHA-A stated the previous DON was the IP and oversaw the IPCP and was working with IDON-B. NHA-A stated NHA-A would have to ask corporate if there is anyone to oversee the facility's IPCP with IDON-B. NHA-A stated there was an employee in the facility that has their certification, but that employee is not currently overseeing the IPCP or assisting IDON-B and was not in the IPCP role. The Facility Assessment's dated as reviewed on 2/28/2026 did not identify the role for the Infection Preventionist (IP) position and the IP role was not included in the facility's staffing hours listed in the Facility Assessment. Surveyor noted that the facility assessment did not list the amount of time required to fulfill the IP role, did not determine the resources the facility needs for its IPCP, and ensure that those resources were provided for the IP to be effective.On 5/6/2026, at 1:20 PM, NHA-A stated there is a resource at the corporate level with IP certification, however that resource would not be in the facility overseeing the IPCP with IDON-B. Surveyor shared concern the facility does not have a designated and qualified IP for the IPCP. On 5/8/26, NHA-A provided the state agency via email a statement that documented: Infection preventionist is not qualified because she is enrolled in but not completed with certification course. For qualifications, the federal regulation states: The facility must designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility's IPCP. The IP must: (1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; (2) Be qualified by education, training, experience or certification; (3) Work at least part-time at the facility; and (4) Have completed specialized training in infection prevention and control. IP participation on quality assessment and assurance committee. The individual designated as the IP, or at least one of the individuals, if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis. The person designated as our IP is a RN and has taken a few IP related courses, as shown in attachment, prior to assuming the role. She is enrolled in the certification course but not completed it yet. We do have an RN who is certified in IP to assist as needed which was shared with surveyors. Both work on-site, full time, and one does attend QA. Surveyor noted that when interviewed, NHA-A stated there was another RN on staff that help the IP certification, however the RN does not serve as the IP for the facility. Surveyor noted that when interviewed, NHA-A was asked if any other staff member or corporate staff could serve as the IP to assist IDON-B as IDON-B obtained her IP certification. NHA-A stated that at the time, the facility did not have other staff member or corporate staff that could serve as the IP while IDON-B obtained her certification. On 5/19/26 at 2:00 PM, Surveyor spoke with NHA-A regarding IDON-B's experience and certifications. NHA-A informed Surveyor that NHA-A believed IDON-B had sufficient courses taken to serve as the facility's IP and stated that a corporate staff member whom was certified could serve as the facility's IP only if required. Surveyor requested from NHA-A and experience or courses completed by IDON-B that documented her experience to serve as the facility's IP. On 5/19/26 at 2:20 PM, NHA-A emailed Surveyor a copy of courses completed by IDON-B. The courses included: Antibiotic Stewardship- completed 3/29/26Bloodborne Pathogens- completed 3/28/26Hand Hygiene- completed 3/28/26Infection Prevention and Control for All Staff- completed 3/29/26Personal Protective Equipment (PPE)- completed 3/29/26Surveyor noted that the courses documented as completed did not include any specialized IPC training beyond initial professional training or education prior to IDON-B assuming the infection preventionist role. The courses provided did not include courses in: Infection prevention and control program overview, the infection preventionist's role, Infection surveillance, outbreaks, Principles of standard precautions (e.g., content on hand hygiene, personal protective equipment, injection safety, respiratory hygiene and cough etiquette, environmental cleaning and disinfection, and reprocessing reusable resident care equipment), Principles of transmission-based precautions, Resident care activities (e.g., use and care of indwelling urinary and central venous catheters, wound management, and point-of-care blood testing), Water management, Linen management, Preventing respiratory infections (e.g., influenza, pneumonia), Tuberculosis prevention, Occupational health considerations (e.g., employee vaccinations, exposure control plan, and work exclusions), Quality assurance and performance improvement, Antibiotic stewardship, and care transitions. No additional information was provided.

Based on observation, interview, and record review, the facility did not maintain an effective infection prevention and control program or sanitary environment to help prevent the development and transmission of communicable diseases and infections potentially affecting 53 of 53 residents and 1 (R23) of 2 residents reviewed with indwelling urinary catheters. *The facility did not have a system for identifying potential infections utilizing a line list of symptomatic residents and did not report monthly infections with the calculations of rates of infection. Respiratory outbreaks did not have a summary to show an investigation of the source of transmission and the control of the infection. The facility did not use the data collected on infections to apply corrective action. *Linens were not handled in a sanitary manner to prevent the spread of infection. *The facility did not review policies and procedures on an annual basis, and the facility pneumococcal vaccine policy did not have the current immunizations documented. *R23's indwelling urinary catheter bag was observed on 5/4/2026 and 5/6/2026 to be on the floor with no barrier. Findings include: The facility policy and procedure titled Infection Control Policy, undated, documents: Policy Guidelines: Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. 3. All residents will be assessed by licensed personal [sic] on a continuous basis for early detection, intervention and treatment of any infection or possible infection. Such determination is based on several factors. This includes, but is not limited to: A. Date of Event: The date of event is defined as the date when the first clinical evidence (signs/symptoms) appeared or the date the specimen used to make or confirm the diagnosis was collected, whichever comes first. The infection control nurse complies [sic] monthly infection control information in the Infection Control Log. Including, but not limited to: A. Resident name B. Room number and unit in facility C. Date of onset D. Site E. Infection type F. Culture collected G. Organism if applicable H. Antibiotic prescribed I. Definition of infection met J. Nosocomial K. Date resolved L. Isolation is [sic] applicable Infection control logs will be complied [sic] monthly and reviewed at least quarterly with the Medical Director and Quality Assurance Committee to identify trends, patterns, and will implement corrective actions. The infection control nurse will monitor the 24-hour board daily and review the line list as needed. In the absence of the infection control nurse the DON or floor RN will review the 24-hour board and update the list. Each infection type will be recorded individually as a percent and monthly to identify rate of infections in those areas. 1.) On 5/5/2026, Surveyor reviewed the facility Infection Prevention and Control Program. The facility provided line lists and monthly infection data from December 2024 through May 2026. Surveyor noted from December 2024 through December 2025, a monthly Infection Summary was handwritten providing the number of each type of infection per unit and staff with a corrective action taken or a preventive measure taken. From January 2026 through April 2026, no Infection Summary was included. The monthly Infection Summaries did not have rates of infection calculated. Surveyor identified a COVID-19 outbreak in December 2024/January 2025, a COVID-19 outbreak in April 2025, a COVID-19 outbreak in August 2025, and an Influenza A outbreak in December 2025/January 2026. These outbreaks were identified by Surveyor by looking at the line lists provided. No outbreak summaries were provided and there was not a separate line list for the individual outbreaks. 2.) The facility policy and procedure titled Laundry dated 2025 documents: 1. Aligning with principles of standard precautions, staff should consider all previously worn clothing and used linens as potentially contaminated. 2. The facility's laundry area will provide hand washing facilities and products as well as PPE. (personal protective equipment) On 5/5/2026 at 11:30 AM, Surveyor observed the laundry room, including the dirty room for incoming dirty laundry. Laundry Aide (LA)-D was in the laundry room and escorted Surveyor through the laundry process. LA-D stated dirty linens and resident personal laundry are taken from resident rooms and put in hampers in a closet on each unit. LA-D stated either laundry staff or Certified Nursing Assistants (CNAs) bring the dirty laundry to the dirty area of the laundry and separate the items into the appropriate bins for laundering. Surveyor observed the dirty area of the laundry and did not see any gowns for staff members to wear while sorting the laundry. Surveyor asked LA-D if LA-D sorts any of the dirty linens or dirty personal resident laundry. LA-D stated yes. Surveyor asked LA-D what protective equipment LA-D wore when sorting dirty laundry. LA-D stated LA-D wears gloves when sorting clothing. Surveyor asked LA-D if LA-D ever wears a gown when sorting dirty laundry. LA-D stated no, well maybe if the laundry is wet or excessively soiled. Surveyor asked LA-D if LA-D wears a gown when placing dirty laundry into the washer. LA-D stated no. Surveyor asked LA-D if any of the CNAs wore gowns when sorting the laundry. LA-D stated the CNAs could wear a gown if they wanted to, but that was up to them. Surveyor observed LA-D to be in the clean area of the laundry holding a freshly laundered blanket. LA-D was holding the blanket so the blanket was up against LA-D's clothing. In an interview on 5/6/2026 at 8:49 AM, Surveyor asked CNA-G how dirty laundry was handled. CNA-G stated the dirty linen goes into a hamper in the soiled linen closet and then the laundry personnel come and get the dirty linens and take it to the laundry room. Surveyor asked CNA-G if CNA-G ever has to take dirty laundry to the laundry room and sort any clothes. CNA-G stated at the end of the day when the laundry staff are gone, the CNAs will take the soiled linen bags and sort them in the sorting area of the laundry. Surveyor asked CNA-G if CNA-G wore any PPE when sorting the laundry. CNA-G stated just gloves. Surveyor asked CNA-G if CNA-G ever wore a gown when sorting dirty laundry. CNA-G stated no, unless the linens are wet or something. 3.) The facility policy and procedure titled Policy and Procedure for Pneumococcal Vaccine, undated, documents the pneumococcal vaccines Prevnar 13 and Pneumovax 23 administration schedule. The policy does not address the most current pneumococcal vaccines and is outdated. No date of implementation or review was on the policy. The facility Infection Control Policy was undated, did not have a date of implementation, and did not have a review or updated date. On 5/6/2026 at 10:05 AM, Surveyor met with Interim Director of Nursing (IDON)-B who was the facility Infection Preventionist (IP). IDON-B had been employed at the facility since 4/1/2026 and had no recent background working in nursing homes. IDON-B stated NHA-A had been helping IDON-B go over all the IP duties and expectations and still has a lot to learn. Surveyor reviewed with IDON-B the line lists and monthly Infection Summary sheets that had been provided. Surveyor shared the concern the monthly rates of infection had not been calculated to show tracking and trending was done to focus educational opportunities for staff. Surveyor shared the respiratory outbreaks Surveyor had noted from the line lists did not have separate line lists or any outbreak summaries to show how the outbreak occurred or who was affected by the outbreak. Surveyor shared the concern the line lists only included those residents that had been prescribed an antibiotic and did not include symptom surveillance. Surveyor shared the concern the pneumococcal vaccination policy was not dated and did not contain current immunizations. Surveyor asked IDON-B if policies were reviewed annually. IDON-B stated they should be but had not been in the facility long enough to know if that had been happening. IDON-B stated the pneumococcal vaccination policy was definitely outdated and provided Surveyor with an algorithm for all current pneumococcal vaccines that IDON-B uses for all newly admitted residents to make sure they are up to date on their immunizations. Surveyor shared the concern the two policies, Infection Control Policy and Policy and Procedure for Pneumococcal Vaccine were not dated when they were implemented or reviewed. Surveyor shared with IDON-B the observation of the laundry sorting room where no gowns were available for staff to put on when sorting dirty laundry and the conversation with LA-D about not wearing gowns when sorting dirty laundry and the observation of LA-D holding a clean blanket up against LA-D's clothing. IDON-B and Surveyor informed Nursing Home Administrator (NHA)-A of the above findings. No additional information was provided. 4.) The facility policy titled Catheter Care with no initiated, reviewed, or revised date documents: Policy: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 20. Document care and report any concerns noted to the nurse on duty. R23 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following stroke affecting the right dominant side, aphasia, chronic kidney disease stage 3, obstructive and reflex uropathy, major depressive disorder, benign prostatic hyperplasia with lower urinary tract symptoms, . and gross hematuria. R23's admission Minimum Data Set (MDS) dated [DATE] indicated R23 has intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The MDS documents that R23 was admitted with an indwelling foley catheter and was assessed to need assistance with 1 staff member for activities of daily living (ADL's). R23's Indwelling urinary catheter related to obstructive and reflux uropathy care plan was initiated on 4/16/2026 documents the following interventions:- Assess drainage. Record amount, type, color, odor. Observe for leakage and keep closed system as much as possible to reduce risk of infection.- Assist with tubing management to reduce risk of tripping.- Enhanced barrier precautions.- Foley Catheter 22 French (F, size of tubing), 10cc balloon)- Monitor for signs/symptoms of urinary tract infection (UTI) such as pain, burning with urination, new frequency or urgency, fecer, change in urine character, altered mental status. Report abnormal findings to medical doctor (MD). Follow Mcgreers. R23's refusal care plan related to refusing showers, foley cares, and ADLs at times. R23 can become combative with cares was initiated on 4/20/2026 and documents the following interventions:- Allow (R23) to choose options.- Assess (R23's) noncompliance (e.g. expectations, cognitive status, motivation, lack of understanding). - Encourage (R23) to express concerns about showering. Clarify misunderstandings.- Give (R23) choices when possible.- Reiterate the purpose and advantages of showering for (R23) such as minimizing risk of breakdown and good hygiene.- Respect (R23's) right to refuse showers and re-approach at a later time. On 5/4/2026, at 9:46 AM, Surveyor observed R23 lying in bed watching TV. Surveyor observed R23's foley catheter bag hanging on the right side of R23's bed and the bottom half of the catheter was lying on the floor without a protective barrier. R23 stated has had the catheter for about a year since R23's stroke and was not able to urinate without the catheter. R23 stated facility staff take care of R23's catheter, but that R23 does not know what to do or how to care for the catheter and stated R23 does not touch the catheter at all. On 5/6/2026, at 8:07 AM, Surveyor observed R23 lying on the bed sideways with R23's back against the wall. Surveyor observed R23's catheter bag lying directly on the ground underneath where R23 was sitting on the bed, without a protective barrier. R23 was not aware how the catheter got under the bed on the floor. R23 was not sure when the catheter was last checked on or emptied. On 5/6/2026, at 8:23 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q who stated R23 tends to be fidgety and mess with the catheter bag. Surveyor asked if any interventions have been implemented to prevent R23 from messing with the catheter bag or prevent the catheter bag from ending up on the ground. CNA-Q stated she was not sure and stated that CNA-Q checks on R23 every couple hours to make sure R23 is okay and if R23's catheter bag has to be emptied. CNA-Q checked on R23 earlier in the morning and R23's catheter bag was hanging on the right side of the bed. On 5/6/2026, at 8:30 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who stated catheter bags should be kept off the floor and/or have a protective barrier to prevent the risk of possible infection. Surveyor shared observations of R23's catheter bag on the floor without a protective barrier. LPN-L stated R23 can be very restless and mess with the catheter bag. Surveyor asked if that was the case what is the process to prevent R23 from messing with the catheter bag. LPN-L stated revisions would be made to R23's care plan and assess why and when R23 tends to mess with R23's catheter bag and see if interventions can be implemented to prevent R23 from messing with the catheter bag and prevent the catheter bag ending up on the floor. Surveyor shared was not able to see revisions to the care plan implemented to indicate to staff R23 plays with the catheter bag or gets restless. LPN-L stated would look into the concerns. On 5/6/2026, at 8:54 AM, Surveyor shared observations of R23's catheter bag lying on the ground without a protective barrier on 5/4/2026 and 5/6/2026 with Nursing Home Administrator (NHA)-A. Surveyor shared concerns staff indicated R23 was restless at times and messed with R23's catheter bag, but no care plan revisions were implemented to indicate R23's behavior with being restless or messing with R23's catheter bag to prevent R23 from messing with the catheter bag and ending up on the ground without a protective barrier. No additional information was provided.

Based on observation, record review and interview, the facility did not ensure 1 (R10) of 1 sampled residents who are unable to carry out activities of daily living (ADL) receives the necessary services to maintain good grooming and personal hygiene. * R10 requires total staff assistance with ADLs, and was observed to have significant discharge matter coming from both eyes. Facility staff did not clean R10's eyes to ensure R10 maintained good personal hygiene. Findings include:1.) R10 was admitted to the facility on [DATE] and has diagnoses that include spastic quadriplegic cerebral palsy, epilepsy, hydrocephalus, mild cognitive impairment, dysphagia, aphasia, anxiety disorder, major depressive disorder and bipolar disorder. R10's Quarterly Minimum Data Set (MDS) dated [DATE] indicated R10 has a severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3. The MDS documents that R10 was assessed as being dependent on staff for activities of daily living (ADLs). R10's upper and lower limbs are contracted and R10 is unable to use R10's hands or feet.R10's care plan documents that R10 is dependent on staff for ADLs such as grooming, bathing and personal hygiene. On 4/24/2026, at 12:43 PM, in the progress notes nursing documented: (R10's) right eye lid noted to be slightly red with slight clear, crusting drainage. (R10) denies pain, itching, blurriness and sclera is clear. Nurse Practitioner (NP) saw (R10), order to wash both eyes with small amount of baby shampoo on a washcloth twice a day for 7 days.On 4/26/2026, at 5:40 PM, in the progress notes nursing documented (R10's) right eye continues to drain along with the left eye. A sty is forming on the right eye lid. (R10's) upper lid is red and slightly red on the lower lid. Orders received for artificial tears four times a day and warm compressed to right eye three times a day.R10 has the following physician orders:1. Erythromycin Ointment 5mg/gram (0.5%)- Apply small amount to both eyes four timed a day for 10 days for viral conjunctivitis (Start: 5/2/2026 - 5/12/2026)2. Warm compress to right eye three times a day until cleared (Start: 4/26/2026)On 5/5/2026, at 8:09 AM, Surveyor observed R10 lying in bed. R10 observed R10's right eye to have light yellow stringy drainage covering R10's right eye. Surveyor observed a sty to R10's right upper, inner eye lid. Surveyor asked if anyone washed R10's eyes or put a warm compress on R10's eyes; R10 replied no. Surveyor asked if R10 received ointment in both eyes yet and R10 replied no.On 5/5/2026, at 11:16 AM, Surveyor showed Interim Director of Nursing (IDON)-B R10's right and left eye with drainage over the whole right eye and a bit on the left eye. Surveyor shared with IDON-B R10 stated no one has cleaned R10's eyes, applied warm compress, or administered R10's erythromycin per R10 yet. IDON-B stated they would follow up with staff. On 5/6/2026, at 9:18 AM, Surveyor shared observations with Nursing Home Administrator (NHA)- A of R10's right and left eyes having drainage on 5/5/2026 and R10 stated did not get eyes cleaned, warm compress applied or administered erythromycin ointment per physician orders. NHA-A was made aware by IDON-B of Surveyors concern and noted R10's erythromycin ointment was administered per physician order, however R10's eyes should have been cleaned up to ensure R10's personal hygiene. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure residents with a gastrostomy tube received the appropriate treatment to prevent complications of enteral feeding for 1 (R7) of 1 resident with a gastrostomy tube.R7's gastrostomy tube was not checked for placement prior to the attempt to administer medication which had the potential of causing water and medication to enter the abdominal cavity rather than the stomach.Findings include:The facility policy and procedure titled Verifying Placement of Feeding Tube from dated 2025 documents: 1. Before beginning a feeding, flushing the tube, or administering a medication via the feeding tube, proper placement and functioning will be verified. 4. Procedure for verifying placement of feeding tubes: . c. Verify tube placement: i. For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube. Notify supervisor and/or physician of abnormal findings, OR ii. Measure length of tube from insertion site to tip upon new admission to facility or with a new/change in the tube and record the length. Check and record the length of the tube prior to feeding as per facility policy. Notify supervisor and/or practitioner if abnormal finding. iv. If unable to confirm placement, notify supervisor and/or physician. Consider alternative verification methods such as x-ray. Do not proceed with feeding, flush, or medication administration until tube placement is verified. v. If performed in the facility, measure the pH of the gastric secretions: 1) Draw back on syringe to slowly obtain 5-10 mL of aspirate, and empty into a clean medicine cup. 2) Dip the pH strip into the aspirate in the medicine cup. 3) Compare the color of the strip with color on chart as per manufacturer's instructions. (Note: Gastric fluid usually has a pH of 5 or less). d. If performing the pH measurement, flush feeding tube with 30 mL of water after residual measurements to maintain tube patency.R7 was admitted to the facility on [DATE] after hospitalization for a coronary artery bypass graft (CABG) surgery with traumatic intubation resulting in necrotic tissue in the mouth. R7 had placement of a percutaneous endoscopic gastrostomy (PEG) tube for R7 to receive all nutritional needs.R7's Tube Feeding Care Plan initiated 4/2/2026 has interventions:-Check gastric residuals if clinical assessment reveals R7 is not tolerating enteral feedings, the marked position of the tube has changed, the appearance and pH of aspirate suggests the tube is misplaced, or as ordered-Check placement and patency of feeding tube before each feeding or medication administration.-Check placement and patency of feeding tube every shift and before med pass.On 5/6/2026 at 1:05 PM, Surveyor observed Licensed Practical Nurse (LPN)-F prepare a medication to administer to R7. LPN-F donned a gown and gloves after hand hygiene was completed. LPN-F placed a stethoscope to R7's abdomen and listened to all four quadrants of R7's abdomen. Surveyor observed a gauze drain sponge around the base of the PEG tube obstructing the view of the entry of the PEG tube into the abdomen or of how the PEG tube was affixed to R7's abdomen. LPN-F did not remove the drain sponge at any time during the procedure. LPN-F connected an empty syringe barrel to R7's PEG tube, opened the valve and clamp, and placed approximately 30 mL of water into the barrel of the syringe. LPN-F did not check the PEG tube under the drain sponge to assess the entry point of the PEG tube, measure the length of the PEG tube from the abdomen to the end of the PEG tube, or attempt to aspirate stomach contents to verify placement of the PEG tube. The water LPN-F placed in the syringe barrel did not go into R7's PEG tube due to obstruction in the tube. LPN-F contacted LPN-E to assist with trying to unclog R7's PEG tube. They were unsuccessful at that time.Surveyor did not observe any physical markings on R7's PEG tube. In an interview on 5/6/2026 at 9:05 AM, Surveyor asked LPN-E how LPN-E checks for PEG tube placement before giving a medication or feeding. LPN-E stated LPN-E was not sure and would have to look it up. LPN-E went to the computer and looked online for how to check PEG tube placement. LPN-E stated you would pull back on the syringe to see if there are stomach contents.In an interview on 5/6/2026 at 1:05 PM, Surveyor asked interim Director of Nursing (IDON)-B what the facility protocol was for checking placement of a PEG tube prior to administering medication or tube feeding. IDON-B attempted to pull up the facility policy on the computer. Surveyor shared with IDON-B that Surveyor had the policy already and wanted to know IDON-B's expectation of staff when performing that task. IDON-B stated IDON-B did not know what the protocol was for checking placement; it is something that is new to IDON-B. Surveyor shared with IDON-B the concern placement of R7's PEG tube was not completed prior to attempting to administer medication by either observation of the tube base markings or aspiration of stomach contents.On 5/6/2026 at 3:23 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Nurse Clinical Officer (NCO)-I that R7's PEG tube placement was not checked prior to attempting to administer medication per R7's plan of care. NCO-I stated their policy is to go by the markings on the tube and the length of the tube. Surveyor shared the concern there was nothing in R7's medical record that documented the measurement of R7's PEG tube for staff to know the appropriate length or if there was a change in the length of the tube. Surveyor also informed NCO-I that Surveyor did not observe any physical markings on R7's PEG tube for staff to use a reference point for placement. On 5/12/26, the facility provided additional information that included the facility's policy on verifying placement of a feeding tube with the steps they follow along with R7's physician order which states in the special instructions how to verify placement of R7's PEG tube. The policy that was provided, titled Verifying Placement of Feeding Tube documents: For gastrostomy tubes, check that the enteral retention device is properly approximated to the abdominal wall by gently tugging on the tube and taking note of the marking on the tube. Notify supervisor and/or physician of abnormal findings, ORMeasure length of tube from insertion site to tip upon new admission to facility or with a new/change in the tube and record the length. Check and record the length of the tube prior to feeding as per facility policy. Notify supervisor and/or practitioner if abnormal finding.The physician's order for R7 that was provided documents: Special Instructions- First check that g-tube is properly approximated to abdominal wall by gently tugging or taking note of the marking on the tube. You may measure it as well. Surveyor noted that with the additional information, the facility did not provide documentation that explained why LPN-F was observed aspirating for stomach contents to check R7's tube placement or how facility staff would measure R'7s feeding tube if the tube had no visible markings on it when Surveyor observed it. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure 2 (R10 and R23) of 8 sampled residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion.* R10 was observed not having rolled up washcloths in both hands to prevent further decrease in range of motion and was not wearing shoes when up in R10's wheelchair per care plan.* R23 was observed not wearing R23's right ankle foot orthotic (AFO) to prevent further decrease in range of motion.Findings include:The facility policy titled Use of Assistive Devices with no initiated, reviewed or revised date documents: Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function, dignity, and quality of life. Policy Explanation and Compliance Guidelines: 2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care.3. The facility will provide assistive devices, as indicated, for residents who need them. Nursing, dietary, social services, and therapy departments will work together to ensure availability of devices, such as for ordering and/or replacement.6. Direct care staff will be trained on the use of the devices as needed to carry out their roles and responsibilities regarding the device. Training will also include when to refer to other departments for . or problems with the device.7. A nurse with responsibility for the resident will monitor the consistent use of the device and safety in the use of the device. Refusals of use, or problems with the device, will be documented in the medical record. Modifications to the plan of care will be made as needed.1.) R10 was admitted to the facility on [DATE] and has diagnoses that include spastic quadriplegic cerebral palsy, epilepsy, hydrocephalus, mild cognitive impairment, dysphagia, aphasia, anxiety disorder, major depressive disorder. and bipolar disorder.R10's quarterly Minimum Data Set (MDS) dated [DATE] indicated R10 has a severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3. The MDS documents that R10 was assessed as being dependent on 1-2 staff for activities of daily living (ADLs) and that R10's upper and lower limbs are contracted with R10 unable to use R10's hands or feet.R10's Restorative: Active and Passive range of motion (ROM) to maintain current range of motion to upper and lower extremities due to being admitted with contractures . care plan was initiated on 7/28/2025 with the following interventions: -Perform active ROM to bilateral upper and lower extremities with dressing two times a day, 7 days a week. use palm protectors on in the AM and of at night. (edited 10/23/2025)R10's ADLs functional status/ rehabilitation potential- R10 has self-care deficit and needs total assistance with all ADL's related to immobility, cognitive deficit, epilepsy, aphasia, contractures, tremors, spastic quadriparesis, and spasmodic torticollis care plan was initiated on 7/28/2026 with the following interventions: -Shoes on feet when up in wheelchair. (created: 1/7/2026)R10's Certified Nursing Aide (CNA) care card has the following CNA approaches/ (tasks) documented: - Use palm protectors on in the AM, of at night. (start: 7/28/2025)- Shoes on feet when up in wheelchair. (start: 1/6/2026)- Rolled wash cloths in both palms. [NAME] (put on) with AM cares after hands washed and dried and off with PM cares- wash/dry and lotion hands prior to bed. Change daily. (start: 3/8/2026)Surveyor noted R10 had a care plan to have both palm guards to both hands and rolled up washcloths in both palms to be put on in the morning and taken off at night.On 5/4/2026, at 12:26 PM, Surveyor observed R10 in the bedroom sitting in the wheelchair. R10 did not have shoes on both feet per R10's plan of care. On 5/5/2026, at 8:09 AM, Surveyor observed R10 in the bedroom sitting in the wheelchair. R10 did not have shoes on both feet and R10's right foot was crossed over R10's left foot. R10 did not have palm guards or rolled up washcloths in R10's right or left hands per R10's plan of care.Surveyor observed 3 pictures on R10's wall above R10's bed. The pictures demonstrated how R10 should be positioned in R10's wheelchair. Surveyor observed R10 wearing palm guards in the right and left hands. Surveyor could not locate a date for which the pictures were taken or hung up.On 5/5/2026, at 11:16 AM, Surveyor observed R10 lying in bed. R10 did not have palm guards or wash clothes in R10's right or left hands, per R10's plan of care. On 5/5/2026, at 2:17 PM, Surveyor interviewed Physical Therapy Assistant (PTA)-U and Certified Occupational Therapy Assistant (COTA)-V. PTA-U stated R10 had palm guards at first, then R10's power of attorney (POA) wanted rolled up washcloths instead of the palm guards. PTA-U stated R10 should wear shoes on right and left feet to prevent foot drop from occurring in R10's feet.Surveyor asked how changes to the care plan would get relayed to nursing staff. PTA-U stated the care plan would be revised either by the nursing staff or during morning stand-up and by therapy verbally telling nursing staff changes and then nursing staff would relay it during shift report. Surveyor asked if R10's care plan should have been revised when R10's POA requested R10 to have washcloths instead of palm guards. PTA-U stated the care plan should reflect what the resident currently should have in place.On 5/6/2026, at 8:23 AM, CNA-Q who stated R10 should have rolled up washcloths in both hands and was not sure if R10 ever had palm guards that CNA-Q could recall. CNA-Q stated R10 doesn't refuse cares or treatments, and if a resident refuses care or treatments CNAs are to notify the nurse, and the nurse would take care of it. CNA-Q was not sure if a note was written or if anyone got contacted regarding R10's refusal of cares or treatments. CNA-Q stated nursing staff notify CNAs of any changes, sometimes changes will be on the care cards, but mostly passed along verbally any changes. CNA-Q stated R10 should have shoes on both feet when up in the wheelchair. On 5/6/2026, at 8:54 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the observations of R10 not having rolled washcloths in both hands and shoes not on both feet per R10's care plan. Surveyor shared concern R10's care plan and CNA care card did not reflect what R10 currently should have in place to prevent contractures from worsening and R10's care plan document R10 should wear right and left hand palm guards and rolled up washcloths. NHA-A acknowledged concerns. No additional information was provided.2.) R23 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following stroke affecting the right dominant side, aphasia, . and major depressive disorder.R23's admission Minimum Data Set (MDS) dated [DATE] indicated R23 has intact cognition with a Brief Interview for Mental Status (BIMS) score of 15. The MDS documents that R23 was assessed as requiring maximal assistance with 1-2 staff for activities of daily living (ADLs). R23 was noted to have impairments to the right upper and right lower extremity due to history of having a stroke. R23's ADLs functional status/ rehabilitation potential- limited in ability to transfer self-related to impaired mobility requiring 2 persons assist, gait belt, and AFO (ankle foot orthodic) to right foot when transferring due to weakness and deconditioning post hospitalization care plan was initiated on 4/16/2026 with the following interventions: - Instruct in use of assistive devices.- Monitor skin under AFO for signs/symptoms of breakdown.Surveyor noted R23's use of an AFO is not documented on how often or when R23's AFO should be put on.R23's physician order documents: AFO to right foot due to foot drop, monitor skin for breakdown every shift: Day shift, Second shift, and Third shift. (Start: 4/17/2026)On 5/4/2026, at 9:49 AM, Surveyor observed R23 lying in bed watching TV. Surveyor observed R23's right foot to be turned inward. R23 stated R23 is not really able to move the right side of R23's body. Surveyor observed a black AFO foot brace with Velcro straps on R23's recliner chair at the end of R23's bed. Surveyor asked if R23 was supposed to have the brace on. R23 stated that R23 was unsure if the AFO is supposed to have it on and the brace just sits on the chair.On 5/4/2026, at 3:56 PM, Surveyor observed R23 lying in bed watching TV and R23's black foot AFO brace was on R23's reclining chair and R23 was not wearing it per R23's plan of care. On 5/5/2026, at 8:05 AM, Surveyor observed R23 lying in bed. Surveyor noted R23's right AFO brace sitting on R23's recliner. R23 stated R23 has not had the brace on at all that R23 can remember. Surveyor noted that R23 was not wearing the AFO per R23's plan of care. On 5/5/2026, at 10:31 AM, Surveyor observed R23 lying in bed sleeping and R23's right AFO brace was sitting on R23's recliner chair. Surveyor noted that R23 was not wearing the AFO per R23's plan of care. On 5/5/2026, at 2:06 PM, Surveyor observed R23 sitting up on the side of the bed, anti-slip socks were on both feet and R23's right AFO was sitting on R23's recliner chair. Surveyor noted that R23 was not wearing the AFO per R23's plan of care. On 5/5/2026, at 2:17 PM, Surveyor interviewed Physical Therapy Assistant (PTA)-U who stated R23 is to wear the right AFO brace at all times when in bed and when out of bed due to R23 having Right foot drop and the AFO was used to prevent further decline. Surveyor informed PTA -U that Surveyor has not observed R23 with Right AFO on R23's right foot on 5/4/2026 and 5/5/2026. PTA-U stated the therapy department does not monitor R23's right AFO and orthopedic doctor would monitor R23's right AFO.PTA-U stated R23 came form either the hospital or another facility with the Right AFO and PTA-U stated therapy continued the orders of R23 wearing the right AFO at all times, but ultimately R23 would have to see orthopedic doctor for further direction on when exactly R23 should wear the right AFO. PTA-U was not sure if R23 has been seen by an orthopedic doctor since being admitted to the facility.On 5/5/2026, at 3:00 PM, PTA-U shared information with Surveyor regarding having heard R23's right AFO is broken and that is why R23 is not wearing the right AFO. Surveyor asked to see documentation, however PTA-U stated it was all verbally passed along. PTA-U would look into if R23 has an orthopedic appointment for an AFO replacement and will get back to Surveyor. On 5/6/2026, at 8:07 AM, Surveyor observed R23 sitting on the side of the bed eating breakfast. Surveyor observed R23 to be wearing R23's right AFO. Surveyor asked if staff put R23's right AFO this morning. R23 could not recall when he got the AFO put on. Surveyor asked R23 if the AFO was comfortable or fit properly and if R23 heard anything about the AFO being broken. R23 stated the AFO felt fine and is not aware of the AFO being broken. R23 did not recall going to an orthopedic appointment since being admitted to the facility.On 5/6/2026, at 8:23 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q who stated R23 should wear the right AFO at all times is what she was told. CNA-Q has not heard anything about R23's right AFO being broken. CNA-Q stated R23 will refuse to wear the right AFO at times but usually will wear it part of the day most of the time. CNA-Q stated when R23 refuses the AFO nursing is made aware and will reapproach R23 later and ask if R23 wants the AFO on. On 5/6/2026, at 8:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who stated from what LPN-L understood, R23 is to wear the right AFO during transfers to help with stability. LPN-L was not aware of R23's right AFO being broken and not being able to use it. Surveyor shared concern regarding R23's care plan does not indicate exactly when and how often R23 should wear R23's right AFO and per physician order R23's AFO is to be worn at all times. Surveyor shared concern R23 was observed not wearing R23's right AFO on 5/4/2026 or 5/5/2026 and has not seen an orthopedic doctor regarding R23's AFO follow up. LPN-L stated LPN-L would look into concerns.On 5/6/2026, at 8:54 AM, Surveyor informed Nursing Home Administrator (NHA)-A that facility staff was not aware of when or how often R23 was to wear R23's right AFO and there was confusion on whether R23's right AFO was broken or not. NHA-A stated when R23 was admitted to the facility NHA-A recalled R23's family stating something about the AFO being broken and was trying to get R23's previous facility to pay for it, however NHA-A does not know what happened or if anything was done about R23's right AFO.Surveyor shared observations of R23 not wearing the right AFO on 5/4/2026, and 5/5/2026 per R23's physician's order and plan of care. Surveyor shared concern R23's care plan does not indicate when or how often or if R23 refuses to wear R23's right AFO. Surveyor also shared therapy department shared they do not monitor R23's AFO and R23 would have to see an orthopedic doctor for R23's maintenance of the right AFO and Surveyor did not find any evidence R23 is being evaluated and treated by an orthopedic doctor for R23's right AFO. NHA- understood the concerns and would look into what is happening with the use of R23's right AFO. No additional information was provided.

Based on observation, record review and interview, the facility did not ensure 1 (R5 and R10) of 1 sampled residents received the necessary care and services to ensure that a resident's abilities in activities of daily living (ADLs) do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable, including receiving ADL assistance to maintain grooming. * R5 requires staff assistance with ADLs and was not shaven for a couple days.Findings include:1.) R5's Quarterly Minimum Data Set (MDS) assessment completed 2/2/26 documents that R5 was assessed to have a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS documents that R5 was assessed to require partial to moderate staff assistance for and personal hygiene. R5's Certified Nursing Assistant (CNA) Plan of Care documents: Start date of 9/9/2024- Provide 1 assist with dressing/grooming.R5's Comprehensive Care Plan ADL's Function, started 9/6/2024, documents: R5 is at risk for self-care deficit and needs assistance with ADL's related to impaired mobility, Congestive Heart Failure exacerbation, oxygen at bedtime, hard of hearing, confusion, and situation confusion with delusions at times. The Goal Date is 5/4/26, needs will be met without distress by staff monitoring, education, encouragement, staff approaches daily. And Intervention, dated 9/6/24, is to Provide 1 staff assist for dressing/grooming.On 5/04/2026 at 9:43 AM, Surveyor observed, and interviewed, R5 in their room. R5 was sitting in their lounge chair watching TV. R5 had noticeable facial hair and did not know why they were not shaved. R5 stated they have a razor and is unsure why they were not shaved. On 5/05/2026, at 9:12 AM, Surveyor observed, and interviewed, R5 in their room. R5 had facial hair and did not get shaved. R5 did not know why they did not get shaved.On 5/05/2026, at 9:27 AM, Surveyor interviewed CNA-H. CNA-H stated they did not offer, or ask, to shave R5. CNA-H stated CNA-H did not shave R5 because R5 did not ask. On 5/05/2026, at 9:27 AM, Surveyor interviewed CNA Supervisor-C. CNA Supervisor-C would expect staff to ask residents if they want to be shaved.On 5/6/26, at 10:45 AM, Surveyor informed Nursing Home Administrator (NHA) -A that R5 was not shaved and that staff did not ask R5 if he wanted to be shaved. No additional information was provided as to why the facility did not ensure that R5 received the necessary care and services to ensure that R5's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable, including receiving ADL assistance to maintain grooming.

Based on interview and record review, the facility did not submit for the completion of a level 2 Preadmission Screening (PASARR) for 1 (R10) of 2 sampled residents with a mental disorder and intellectual disability to see if an individual requires such level of services or whether the individual requires specialized services. * R10 did not have a completed Level 2 PASARR screen for developmental disability or to see if R10 required specialized services. Findings include:The facility policy titled Resident Assessment- Coordination with PASSARR Program with no initiated, reviewed or revised date documents: Policy: This facility coordinates with the preadmission screening and resident review (PASSARR) program under Medicaid to ensure individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: ii. Positive Level 1 Screen- necessitates a PASSARR Level 2 evaluation prior to admission.b. PASSARR Level 2- A comprehensive evaluation by the appropriate state- designated authority . that determines whether the individual had Mental disorder, intellectual disability, or related conditions, determines the appropriate setting for the individual, and recommends any specialized services and/ or rehabilitative services the individual needs.3. A record of the pre-screening shall be maintained in the resident's medical record.6. The admissions nurse shall be responsible for keeping track of each resident's PASARR screening status and referring to the appropriate authority.7. Recommendations, such as any specialized services, from PASSARR level 2 determination and/ or PASSAR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. R10 was admitted to the facility on [DATE] with diagnoses that include spastic quadriplegic cerebral palsy, epilepsy, hydrocephalus with history of a ventriculoperitoneal shunt (drains excess cerebrospinal fluid from the brain), bipolar disorder, major depressive disorder and anxiety disorder.R10's admission Minimum Data Set (MDS) dated [DATE] indicated R10 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 3. On 5/4/2026, Surveyor reviewed R10's medical record was able to located R10's PASSAR level 1, which documented that R10 required a level 2 PASSAR screening. Surveyor was unable to locate R10's PASSAR level 2. Surveyor requested from the facility R10's PASSAR level 2.On 5/6/2026, at 1:32 PM, Nursing Home Administrator (NHA)-A informed Surveyor that NHA-A was not able to locate R10's PASSAR level 2. NHA-A stated the previous admissions staff kept everything in a folder; however, no one could locate that folder. NHA-A reached out to get a copy of what was submitted. Surveyor shared the concern that R10's PASSAR level 2 was not available for Surveyor to review or to verify that a PASSAR Level 2 screening was completed. NHA-A understood the concern and would notify Surveyor if the facility was able to locate R10's PASSAR level 2 screen. On 5/8/2026, at 1:11 PM, Surveyor received an email from NHA-A with an attachment documenting R10's PASSARR level 2 was completed. On 5/11/2026, at 9:20 AM, Surveyor reviewed the document but could not locate a date the PASSAR level 2 was completed. Surveyor emailed NHA-A confirming the receipt of R10's PASSAR level 2 screen and asked if NHA-A could provide a date the PASSAR level 2 was submitted for R10, as Surveyor was attempting to verify if R10's PASSAR level 2 screen was completed in a timely manner after R10's PASSAR Level 1 screen was completed.On 5/12/2026, at 8:19 AM, Surveyor received an email from NHA-A that documented NHA-A was not able to determine the date R10's PASSAR level 2 was submitted.On 5/14/2026, at 12:47 PM, Surveyor emailed NHA-A asking if NHA-A could provide a date the PASSAR level 2 was submitted for R10, as Surveyor was attempting to verify if R10's PASSAR level 2 screen was completed in a timely manner after R10's PASSAR Level 1 screen was completed.No response was received.No additional information was provided.

Based on interview and record review the facility did not ensure posted nurse staffing data included the total actual hours worked by registered nurses (RN), licensed practical nurses (LPN's), and certified nurse aides (CNAs) each shift. * The facility did not document the number and actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift.This deficient practice has the potential to affect all 53 residents residing in the facility.Findings include:On 5/4/2026, at 3:58 PM, Surveyor observed the nurse staff posting located to the right of the main entrance door. Surveyor noted the postings documented the total RN hours, total LPN hours, total medication tech (MT) hours and total CNA hours for the whole day. Surveyor noted the nursing staff hours were not broken up to indicate what licensed and unlicensed staff worked each shift.Surveyor requested to review nurse postings for last 30 days (4/1/2026 - 5/4/2026). Surveyor noted nurse posting from the last 30 days did not indicate what licensed and unlicensed staff worked each shift.On 5/6/2026, at 1:20 PM, Surveyor informed Nursing Home Administrator (NHA)-A the nurse staff postings did not include what licensed and unlicensed staff worked each shift. NHA-A stated the facility only ever documented the hours per day for nurse postings and not each shift. Surveyor informed NHA-A that the nurse postings should document the hours for licensed and unlicensed nursing directly responsible for resident care per shift. No additional information was provided.

Based on review of the facility policy and interview, the facility failed to ensure that seven of the 34 Skilled Nursing Facility (SNF) Certified Nurse Aides (CNA) 6, CNA9, CNA11, CNA13, CNA25, CNA29, and CNA33 reviewed for Continuing Education Requirements of 12 hours every 12-month period. Failure to ensure all CNAs receive the required ongoing education has the potential to decrease the quality of care for residents residing at the facility. Findings include: Review of the facility's policy titled, Continuing Educating Certified Nurse Aides, dated August 2022, indicated All nurse aide personnel participate in 12 hours continuing education per employee employment year. It further indicated Annual continuing education credits are no less than 12 hours per employee employment year. Review of the Continuing Education Records provided by the Administrator indicated seven CNAs were overdue for completing the 12-hour requirement as of 03/19/25. 1. Review of CNA6's Continuing Education Record indicated CNA6 had a date of hire (DOH) of 03/01/23. Based on the facility policy and date of hire, CNA6 should have completed her 12 hours by 03/01/25. 2. Review of CNA9's Continuing Education Record indicated CNA9 had a DOH of 03/13/24. Based on the facility policy and date of hire, CNA9 should have completed her 12 hours by 03/13/25. 3. Review of CNA11's Continuing Education Record indicated CNA11 had a DOH of 02/17/21. Based on the facility policy and date of hire, CNA11 should have completed his 12 hours by 02/17/25. 4. Review of CNA13's Continuing Education Record indicated CNA13 had a DOH of 03/07/22. Based on the facility policy and date of hire, CNA13 should have completed her 12 hours by 03/07/25. 5. Review of CNA25's Continuing Education Record indicated CNA25 had a DOH of 03/01/23. Based on the facility policy and date of hire CNA25 should have completed her 12 hours by 03/01/25. 6. Review of CNA29's Continuing Education Record indicated CNA29 had a DOH of 03/04/21. Based on the facility policy and date of hire, CNA29 should have completed her 12 hours by 03/04/25. 7. Review of CNA33's Continuing Education Record indicated CNA33 had a DOH of 03/27/24. Based on the facility policy and date of hire, CNA33 should have completed her 12 hours by 03/27/25. During an interview on 03/19/25 at 3:40 PM, the Administrator stated she was aware that some of the CNAs had not met the 12 hours every 12-month period, determined by their employee year, date of hire, for continuing education according to the facility policy and regulation.

Based on record review, interview and policy review, the facility failed to ensure that an Agency Certified Nurse Aide (Agency CNA) possessed the information and skill set necessary to recognize an important change in condition for one of four sample residents (Resident (R) 1) when R1 experienced chest pain during the night and the Agency CNA did not report it to the nurse on duty. Failure to report a residents change in condition has the potential to cause harm to residents. Findings include: Review of the facility's policy titled, Acute Condition Changes-Clinical Protocol, revised in March 2018, indicated .Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. The policy indicated .The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). Review of the Resident Face Sheet located in R1's electronic medical record (EMR) under the Demographics tab indicated R1 was admitted to the facility on [DATE], with diagnoses which included traumatic arthropathy, left knee-patellar instability, atherosclerotic heart disease of native coronary artery without angina pectoris, and atherosclerosis of coronary artery bypass graft(s) without angina pectoris-history of coronary artery bypass graft (CABG) four times. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/24 and located in R1's EMR under the MDS 3.0 tab indicated R1 had a Brief Interview for Mental Status (BIMS) score of five out of 15 which revealed R1 was severely cognitively impaired. Review of a statement provided by the facility and written by Skilled Nursing Facility (SNF) Certified Nurse Aide (CNA) 10 indicated that on the morning of 11/27/24 she was scheduled as the day aide on R1's nursing care unit. The statement indicated CNA10 received a report from the Agency CNA that had worked the night shift on that unit. The statement indicated that the Agency CNA told her that R1 had been up all night with chest pain and CNA10 asked if the Agency CNA had reported this to the nurse on duty that night, Licensed Practical Nurse (LPN) 3, and the Agency CNA replied that she had not reported it. The statement indicated that CNA10 reported it right away to the nurse coming on duty. During an interview on 03/20/25 at 10:53 AM, CNA10 stated she was the CNA on that unit for the day on 11/27/24, and when getting report from the Agency CNA, she mentioned that R1 had been up all night with chest pain. CNA10 stated she asked the Agency CNA if she had reported it to the nurse that had been on duty, and she said no. CNA10 stated she reported it to LPN3 right away. Review of the statement provided by the facility, from LPN3 indicated that between 7:15 and 7:20 AM on 11/27/24, she was told that R1 had experienced chest pain all night. The statement indicated that LPN3 questioned R1 about chest pain and R1 was able to tell LPN3 that she was short of breath and had pain in the middle of the chest (by pointing to the location). The statement indicated the physician, and the family member were notified and R1 was sent to the hospital. Review of a Progress Note, dated 11/27/24 at 7:48 AM, located in R1's EMR under the Resident Progress Notes indicated that R1 told LPN3 that she was having shortness of breath and chest pain overnight, the chest pain was located in the middle of the chest, radiating to the shoulders and the arms felt more weak than usual. The Progress Note indicated R1 denied having nausea, headache, dizziness, jaw pain or back pain. The Progress Note indicated R1's temperature was 97.3 degrees Fahrenheit with an oxygen concentration of 92% on room air, a blood pressure of 94/56, with a pulse of 91 beats per minute. The Progress Note indicated that the Physician was notified and R1 was sent to the hospital via ambulance. During an interview on 03/19/25 at 1:30 PM, the Family Member (FM) said R1 told a CNA that she was having chest pain and asked for help. The Family Member said this was not documented and said, they do not get it. The Family Member said that she was not saying the outcome would have been different, because R1 had been through a lot medically. During an interview on 03/20/25 at 11:45, the Medical Director said he was R1's physician. The Medical Director said the Agency Aide did not inform the Nurse on duty on the night shift but as soon as the day nurse was made aware of the information and assessed R1, he was notified. He said R1 had multiple co-morbidities and was terribly ill and frail, in general, for a long time. The Medical Director said the incident did not cause harm to R1 and said he did not feel that the outcome would have been different if he had been notified earlier. The Medical Director said that as soon as they discovered it, they acted, called us, and sent her out. Review of the Orientation Packet provided by the facility, that was received by the Agency CNA indicated the packet did not include the [Facility Name] Physician Notification Practice Guidelines from AMDA [American Medical Directors Association] which included guidelines relative to when staff should report things to a Nurse on duty and what to look for. Review of the [Facility Name] Physician Notification Practice Guidelines from AMDA indicated .Chest pain that is new onset, or recurrent, which is not relieved in 20 minutes by previously ordered Nitroglycerin pills x three doses, accompanied by a change in vital signs, diaphoresis, nausea, vomiting or shortness of breath should be reported immediately . During an interview on 03/20/25 at 9:00 AM, the Administrator said the facility used an Orientation Packet for facility staff as well as all Agency personnel that worked in the facility. The Administrator said that the Agency CNA that provided care on R1's nursing care unit on 11/27/24 received the packet and her signature, dated 09/17/24, was found on the document when it was reviewed. The Administrator said that the Agency CNA involved in this incident was no longer allowed to work at the facility. The Administrator also said that LPN3 was no longer employed at the facility. The Administrator said the packet had been revised to include information related to what needed to be reported and when. She said the revised packet has been provided to all Nursing Agencies that had their staff working at the facility.

Based on observation, interview, and record review the Facility did not provide 2 (R3 & R2) of 2 Residents who smoked and 2 (R1 & R4) of 3 Residents reviewed for falls the supervision and assistance to prevent accidents. * Staff smelled cigarette smoke in R3's room on multiple occasions. The Facility did not complete a smoke assessment or revise R3's smoking care plan to prevent further occurrences of smoking in R3's room. * The Facility identified R2 as being the only current Resident residing in the Facility who smokes. The Facility did not complete a smoking risk assessment and did not develop a smoking care plan. * R1 was observed being left alone in the bathroom. Interview with DON-B reveals R1 should not have been left alone in the bathroom. The Facility did not determine the root cause of R1's fall on 1/4/24. * R4 was observed alone in her room. An intervention on R4's fall care plan is R4 is to be in supervised areas when up. R4 was observed with a chair alarm and then without the chair alarm during survey. The facility did not thoroughly investigate and determine the root cause of R4's falls on 9/7/23, 9/20/23, 11/7/23, 11/9/23, & 12/15/23. Findings include: The Smoking Policy not dated under procedure documents the following: * Resident and/or Resident Representative will be informed at time of admission that [Facility's Name] is a smoke free facility, which includes surrounding campus. A copy of the facility smoking policy will be provided. * Upon resident request for use of an electronic cigarette or tobacco cigarette, nursing will conduct an Elopement assessment & a Smoking Risk assessment. These assessments will determine resident's ability to safety smoke supervised or unsupervised off facility premises. Assessments will then be performed quarterly and with significant change. * If resident is deemed unsafe per nursing assessments for independently smoking off premises, direct supervision will be provided by facility staff or resident representatives. A smoking apron will be provided by facility if indicated per nursing assessment. * Nursing will educate resident on risk associated with smoking and offer resident information on smoking cessation. * If resident or resident representative should choose to smoke/allow smoking despite nursing education and offers of cessation, resident and/or resident representative will sign a facility smoking agreement. * Under no circumstance may smoking materials be stored in resident's room. All smoking materials (i.e. cigarettes, lighters, e-cigarettes, and cartridges) will be locked in medication room of unit resident is living in. * Resident and/or Resident representative will be responsible for providing smoking materials. * Facility will ensure that there is a clear path to the designated smoking area (side walk next to facility grounds). 1. R3 was admitted to the facility on [DATE] and discharged on [DATE]. R3's diagnoses includes alcohol dependence, insomnia, anxiety disorder, nicotine dependence, severe protein-calorie malnutrition, and hypotension. R3's face sheet for smoking status documents Current every day smoker. The smoking care plan with a start date & edit date of 1/19/24 documents the following approaches: * Assess resident for safety while smoking. Start date & edit date of 1/19/24. * Resident will not smoke with oxygen on. Start date & edit date of 1/19/24. * [R3's first name] educated facility is a non smoking campus and smoking in room is strictly prohibited. Educated on the risks vs benefits. Cigarette and lighter were taken to be stored in the nursing office. Resident can smoke outside off the property. She is aware of the rules, and asking for cigs (cigarettes) and lighter when needed. Start date & edit date of 1/19/24. * Safe smoking observation quarterly. Start date & edit date 1/19/24. The nurses note dated 1/19/24 at 2:33 p.m. includes documentation of Resident was admitted from [Hospital Name]. She is admitting with Bronchitis, cough, weakness, some leg swelling and some therapy. She is A&Ox3 (alert and orientated times three) and is able to make her needs and wants known This nurses note was written by RN (Registered Nurse)-Q. The nurses note dated 1/21/24 at 7:03 p.m. documents Resident was smoking in her room so this writer took her cigarettes and placed them in the med (medication) room. This nurses note was written by RN-E. The nurses note dated 1/22/24 at 11:58 a.m. documents Writer spoke with resident regarding smoking in her room, she said she only took four puffs. Writer stated we are a smoke free facility. Resident stated she is trying to quit and is chewing the gum. Resident stated she feels like a prisoner because she cannot go outside. Writer told resident she is allowed to go outside in the courtyard area due to safety concerns with weather and ice she cannot go out the front door by herself. Maintenance cleared a path for resident to go outside and meditate per resident request. This note was written by DON (Director of Nursing)-B. The nurses note dated 1/22/24 at 1:29 p.m. documents Resident admitted for short term rehab d/t (due to) generalized weakness, pleural effusion, bronchitis. Resident also has DX (diagnosis) of chronic pancreatitis, hypotension, hyperbilirubinemia, chronic complex fluid collection in pancreatic head. Resident alert and orientated x 3, able to make needs known. Resident expressed being upset this AM (morning) regarding not being able to go out and smoke. Writer discussed nicotine patch with resident vs gum - states she wants to stick with the gum and understands she can not go outside to smoke. Cigarettes locked in med room. Labs drawn this AM, copy for NP (nurse practitioner) in binder. Colostomy patent, functioning properly. Resident states at home she manages own ostomy and does not have any questions regarding this. Intakes have been adequate, no issues chewing or swallowing noted. Transfers with 1 assist and wheeled walker. Resident has +2 pitting edema to BLE (bilateral lower extremities). Education done with resident about elevating legs, states understanding. Encouraged to lay down after meals. Added daily weight starting tomorrow. No SOB (shortness of breath) noted, remains on RA (room air), O2 (oxygen) sat 95% on RA. No coughing noted. BS (bowel sounds) active. Incontinent of urine at times. Cont (continue) to work with PT (physical therapy) and OT (occupational therapy) towards goal to return home. This nurses note was written by RN-F. The nurses note dated 1/22/24 at 5:10 p.m. documents Called to resident room by CNA (Certified Nursing Assistant) d/t (due to) smell of cigarettes' smoke, strong odor noted upon entering room. Resident admitted to taking 2 puffs, CNA and writer searched room and lighter and cigarettes put in med room, resident stated she knows better but just can't help it. Offered nicotine gum, resident agreeable, given at this time. Writer also explained risks of smoking in building and why is not allowed, states understanding. This nurses note was written by RN-F. The nurses note dated 1/23/24 at 4:17 a.m. documents Per CNAs, they had smelled cigarette smoke coming from resident's room. This writer found resident not in her room as her door was open. Resident out in lounge area eating. Had discussion regarding smoking is not allowed in her room or in the building. Resident did not admit to smoking in her room at this time. This nurses note was written by RN-G. The nurses note dated 1/23/24 at 8:55 a.m. documents Resident admitted to [Facility's Name] for short term rehab d/t generalized weakness, pleural effusion, bronchitis. Resident is A&Ox3, and able to make needs known. Education provided to resident on smoking within facility, and that we are a smoke free facility. Resident stated understanding of education. Has nicotine gum PRN (as needed). Does not want a nicotine patch at this time. Colostomy patent, functioning properly. Has managed her own prior to stay at [Facility's Name]. Incont. (incontinent) of bladder. LSC (lung sounds clear) bilat, heart rate is good. Denies SOB and chest pain at this time. Intakes have been adequate, no issues chewing or swallowing noted. Diet: regular diet, thin liquids. Transfers with 1 assist and wheeled walker. +2 pitting edema to BLE. Education provided on importance of elevating BLE to reduce edema. Resident is a daily weight. Resident cont (continue) to work with therapy to reach goals of returning home. This nurses note was written by RN-C. The admission SNF (skilled nursing facility) initial visit dated 1/23/24 under social history includes documentation of Patient is a current smoker never used vapes not currently using alcohol and uses cannabinoids. The nurses note dated 1/24/24 at 12:47 p.m. documents CNAs brought several cigarettes to writer, some half smoked and let writer know there was a smell of cigarettes' smoke in resident's room. Strong odor noted upon entering room. Resident told writer she did not light any and does not even have a lighter to do so. Room was searched and all cigarettes were removed and brought to office. Writer educated resident on risk of smoking in building and why is not allowed, states understanding and thanked staff for helping quit the bad habit. This note was written by NHA (Nursing Home Administrator)-A. The 5 day MDS (minimum data set) with an assessment reference date of 1/26/24 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R3 was discharged home on 1/28/24. During R3's record review Surveyor was unable to locate a smoking assessment for R3. On 1/31/24 at 10:15 a.m. Surveyor asked CNA (Certified Nursing Assistant)-I if R3 smoked. CNA-I replied yes. CNA-I informed Surveyor R3 smoked a few times in her room and they had to take the cigarettes away. CNA-I informed Surveyor R3 would blatantly lie about smoking. Surveyor asked how many times R3 was caught smoking in her room. CNA-I replied probably at least three times. CNA-I informed Surveyor one time they did take R3's cigarettes away and R3 had been hiding them in a Kleenex box. Surveyor inquired if R3 used oxygen as Surveyor observed an oxygen sign on the doorframe where R3 resided. CNA-I informed Surveyor that was for a previous resident. On 1/31/24 at 2:29 p.m. Surveyor asked CNA-P if R3 smoked in her room. CNA-P informed Surveyor she didn't see R3 smoke but could smell it. CNA-P stated R3's roommate complained to people about R3 smoking. Surveyor asked if R3 could have her own cigarettes. CNA-P informed Surveyor she thinks R3 ordered them from door dash. Surveyor asked CNA-P when R3 smoked in her room what would happen to R3. CNA-P informed Surveyor she wasn't sure, the nurses were told but it never stopped. On 1/31/24 at 2:31 p.m. Surveyor asked CNA-J if R3 smoked in her room. CNA-J explained she never saw R3 smoking but could smell the smoke. CNA-J informed Surveyor her partner told the nurse, DON (Director of Nursing)-B was told and she would talk to her. Surveyor asked CNA-J if R3 used oxygen while at the Facility. CNA-J replied no. Surveyor asked CNA-J if R3 could go outside the Facility to smoke. CNA-J informed Surveyor R3 could go out with family but they were not allowed to go with R3. On 1/31/24 at 3:04 p.m. Surveyor asked NHA-A if smoking assessments are completed. NHA-A informed Surveyor if we do one they are under the observation tab. NHA-A informed Surveyor they don't do assessments because they are smoke free and can't smoke on their property. Surveyor asked about a smoking assessment for R3. NHA-A informed Surveyor they had a smoking assessment for a previous stay explaining they made an agreement with R3 she could go on the sidewalk and smoke Surveyor noted R3 was previously at the Facility from 10/2/23 to 10/8/23. NHA-A informed Surveyor this stay she didn't want to go and do that and was trying to quit. NHA-A informed Surveyor they gave R3 an option of a nicotine patch. NHA-A informed Surveyor they did catch her trying to smoke & confiscated her cigarettes & lights. NHA-A informed Surveyor she knows there is a smoking assessment for R3's previous stay but not this one. On 1/31/24 at 3:18 p.m. Surveyor asked RN (Registered Nurse)-K about R3's smoking. RN-K informed Surveyor she didn't have R3 as she starts at the next room, [room number] but could smell the smoke. RN-K explained the nurses would go in and tell R3 not to smoke. RN-K informed Surveyor R3 was encouraged to go outside to smoke and saw R3 smoking right outside the front door. On 2/1/24 at 9:43 a.m. Surveyor asked LPN (Licensed Practical Nurse)-L who would complete a Resident's smoking assessment. LPN-L informed Surveyor the admitting nurse would if they are aware the Resident smokes. LPN-L explained it's not a normal part of their admission process. On 2/1/24 at 10:05 a.m. Surveyor asked LPN-M who is responsible for completing a Resident's smoking assessment. LPN-M informed Surveyor she assumes it would be the admitting nurse. LPN-M explained it doesn't happen very often that they have a Resident who smokes or if they smoke they don't smoke here. LPN-M informed Surveyor she has never admitted a Resident who smokes. Surveyor asked LPN-M if a Resident didn't have a smoking assessment and was caught smoking would an assessment be done. LPN-M replied absolutely. On 2/1/24 at 11:37 a.m. Surveyor asked LPN/CM (Licensed Practical Nurse/Clinical Manager)-N if she is responsible for Resident's care plans. LPN/CM-N replied yes. Surveyor asked LPN/CM-N to explain the Facility's process. LPN/CM-N explained if she is here when a Resident is admitted she usually puts in a baseline care plan and if she's not at the Facility the admitting nurse will put a baseline care plan in within the first 48 hours. LPN/CM-N explained she will go back check the care plan and update as needed. LPN/CM-N informed Surveyor the comprehensive care plan has to be done 7 days from the CAA (care area assessment) but usually has the care plans done sooner. LPN/CM-N explained the care plans would then be reviewed quarterly, annually and as needed. Surveyor asked about Resident's smoking care plan. LPN/CM-N informed Surveyor if she knows the Resident is a known smoker then will add a smoking care plan. LPN/CM-N informed Surveyor she knew R3 from her last stay and knew she had a history of smoking so she did a smoking care plan. LPN/CM-N informed Surveyor she knew R3 had a history of smoking in her room from her last admission so she kept the same approaches from R3's prior admission. Surveyor asked LPN/CM-N why R3's smoking care plan wasn't revised after staff smelled cigarette smoke multiple times in her room. LPN/CM-N informed Surveyor she wasn't aware of R3 smoking until she was basically gone. LPN/CM-N informed Surveyor she never saw or smelled the cigarette smoke. LPN/CM-N informed Surveyor if she had known she would have updated the care plan. LPN/CM-N informed Surveyor the nurse on the floor can update care plans but they have had some agency nurses and she wasn't sure if they know how to update care plans. LPN/CM-N informed Surveyor she tries her best to keep on top but doesn't always know everything. Surveyor inquired who would complete a Resident's smoking assessment. LPN/CM-N replied the nurse and explained they are pretty good at keeping this a smoke free facility. LPN/CM-N indicated they have never had a problem and this is new to them. On 2/1/24 at 1:38 p.m. Surveyor met with DON-B to discuss R3's smoking. Surveyor inquired why a smoking assessment was never completed. DON-B informed Surveyor they never actually saw R3 smoke only smelled the cigarette smoke. DON-B explained they didn't see her so they didn't do an assessment. DON-B informed Surveyor they took R3's cigarettes from her room but R3 would call an Uber and go out. DON-B informed Surveyor they would ask R3 if she was smoking in her room and she would deny smoking every time. Surveyor informed DON-B a smoking assessment should have been completed. Surveyor informed DON-B Surveyor had noted a smoking care plan with approaches all dated 1/19/24 but R3's care plan was not revised. DON-B replied sorry, should have done that. On 2/1/24 at 2:08 p.m. Surveyor asked SSD (Social Service Director)-O if she had any contact with R3. SSD-O replied just to do her discharge with her. Surveyor asked SSD-O if she spoke to R3 about smoking in her room. SSD-O replied no. 2. On 1/31/24 at 8:01 a.m. Surveyor asked NHA (Nursing Home Administrator)-A for a list of Residents who smoke. On 1/31/24 at 9:17 a.m. Surveyor was provided with a list of Residents who smoke. Surveyor noted there was only one Resident, R2, on the list. R2 was admitted to the facility on [DATE]. Diagnoses includes bilateral osteoarthritis of knee, alcoholic cirrhosis of liver with ascites, diabetes mellitus, anxiety disorder and depression. R2's face sheet for smoking status documents Current some day smoker. The admission MDS (minimum data set) with an assessment reference date of 1/17/24 has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. On 1/31/24 Surveyor reviewed R2's care plans and noted the following care plans: * Contact isolation. Start date & edit date 1/10/24. * Requires oxygen therapy. Start date & edit date 1/10/24. * At risk for alteration in nutrition. Start date & edit date 1/10/24. * Wishes to be a full code. Start date & edit date 1/10/24. * Dressing & grooming. Start date & edit date 1/10/24. * Limited in ability to transfer self. Start date & edit date 1/10/24. * At risk for constipation. Start date & edit date 1/10/24. * At risk for pain. Start date & edit date 1/10/24. * At risk for skin breakdown, pressure injury, skin tears. Start date & edit date 1/10/24. * At risk for incontinence. Start date & edit date 1/10/24. * At risk for falls. Start date 1/10/24 & edit date 1/17/24. * Potential risk for self care deficit or needs assistance with ADLs (activities daily living). Start date & edit date 1/10/24. * At risk for psycho-social well being. Start date & edit date 1/10/24. * To be discharged from facility. Start date & edit date 1/10/24. Surveyor did not note a smoking care plan for R2. On 1/31/24 at 1:13 p.m. Surveyor observed R2 awake in bed. Surveyor asked R2 if she smokes. R2 replied I do. R2 informed Surveyor right now she doesn't have any cigarettes so she's not smoking. R2 indicated if a family member comes they can take her out. On 1/31/24 at 1:20 p.m. Surveyor asked RN (Registered Nurse)-R where Surveyor would be able to locate smoking assessments. RN-R informed Surveyor she wasn't sure. Surveyor informed RN-R Surveyor had asked the Facility for a list of Residents who smoke and was provided with R2's name. RN-R informed Surveyor R2 is the only one that smokes. Surveyor asked what happens if a Resident smokes in their room. RN-R informed Surveyor they would have to talk to the Resident that it's not appropriate, would have to give their cigarettes to us. On 1/31/24 at 3:04 p.m. Surveyor asked NHA-A if smoking assessments are completed. NHA-A informed Surveyor if we do one they are under the observation tab. Surveyor inquired if there is a smoking assessment for R2 who is identified as smoking on the list provided to Surveyor. NHA-A informed Surveyor she didn't believe they did one. NHA-A informed Surveyor R2 attempted to smoke in the courtyard and NHA-A told R2 to put out the cigarette. NHA-A informed Surveyor she told R2 they are smoke free and R2 has not made any other attempts to smoke. NHA-A informed Surveyor they don't do assessments because they are smoke free and can't smoke on their property. On 2/1/24 at 9:43 a.m. Surveyor asked LPN (Licensed Practical Nurse)-L who would complete a Resident's smoking assessment. LPN-L informed Surveyor the admitting nurse would if they are aware the Resident smokes. LPN-L explained it's not a normal part of their admission process. On 2/1/24 at 10:05 a.m. Surveyor asked LPN-M who is responsible for completing a Resident's smoking assessment. LPN-M informed Surveyor she assumes it would be the admitting nurse. LPN-M explained it doesn't happen very often that they have a Resident who smokes or if they smoke they don't smoke here. LPN-M informed Surveyor she has never admitted a Resident who smokes. Surveyor asked LPN-M if a Resident didn't have a smoking assessment and was caught smoking would an assessment be done. LPN-M replied absolutely. On 2/1/24 at 11:37 a.m. Surveyor asked LPN/CM (Licensed Practical Nurse/Clinical Manager)-N if she is responsible for Resident's care plans. LPN/CM-N replied yes. Surveyor asked LPN/CM-N to explain the Facility's process. LPN/CM-N explained if she is here when a Resident is admitted she usually puts in a baseline care plan and if she's not at the Facility the admitting nurse will put a baseline care plan in within the first 48 hours. LPN/CM-N explained she will go back check the care plan and update as needed. LPN/CM-N informed Surveyor the comprehensive care plan has to be done 7 days from the CAA (care area assessment) but usually has the care plans done sooner. LPN/CM-N explained the care plans would then be reviewed quarterly, annually and as needed. Surveyor asked about Resident's smoking care plan. LPN/CM-N informed Surveyor if she knows the Resident is a known smoker then will add a smoking care plan. Surveyor asked LPN/CM-N why there wasn't a smoking care plan for R2. LPN/CM-N informed Surveyor she wasn't aware R2 was currently smoking. Surveyor informed LPN/CM-N R2's face sheet indicates she smokes and NHA-A informed Surveyor she caught R2 smoking in the court yard and told her to put out the cigarette. LPN/CM-N informed Surveyor she has never seen R2 smoke. Surveyor inquired who would complete a Resident's smoking assessment. LPN/CM-N replied the nurse and explained they are pretty good at keeping this a smoke free facility. LPN/CM-N indicated they have never had a problem and this is new to them. On 2/1/24 at 1:48 p.m. Surveyor asked DON (Director of Nursing)-B why a smoking assessment was not completed for R2. DON-B informed Surveyor she didn't know R2 was smoking and didn't know she was a smoker. Surveyor informed DON-B that NHA-A had informed Surveyor R2 attempted to smoke in the courtyard and she told R2 to put out the cigarette. Surveyor informed DON-B a smoking assessment was not completed for R2 and a smoking care plan was not developed. The Falls Clinical Protocol from 2001 Med Pass Inc. (Revised March 2018) under cause identification documents; 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, of if a fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. a. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. b. Many categories of medications and especially combinations of mediations in several of those categories, increase the risk of falling. 3. The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified or it is determined that the cause cannot be found or is not correctable. Falls: 3. R1 was admitted to the facility on [DATE]. Diagnoses includes fracture of right femur s/p ORIF (status post open reduction internal fixation), hypertension, diabetes mellitus, and dementia. The at risk for falling care plan with a start date of 12/19/23 & edited on 1/25/24 documents the following approaches: * Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair if indicated. Start date 12/19/23 & edit date 12/21/23. * Assure the floor is free of glare, liquids, foreign objects, and clutter. Start date 12/19/23 & edit date 12/21/23. * Educate resident on safety measures and approaches. Start date 12/19/23 & edit date 12/21/23. * Encourage resident to assume a standing position slowly. Start date 12/19/23 & edit date 12/21/23. * Give resident verbal reminders not to ambulate/transfer without assistance. Start date 12/19/23 & edit date 12/21/23. * Keep call light in reach at all times. Start date 12/19/23 & edit date 12/21/23. * Keep personal items and frequently used items within reach. Start date 12/19/23 & edit 12/21/23. * Leave night light on in room as desired. Start date 12/19/23 & edit date 12/21/23. * Low-high risk: Falling star. Start date 12/19/23 & edit date 12/21/23. * Obtain PT/OT (physical therapy/occupational therapy) consult for strength training, toning, positioning, transfer training, gait training, mobility devices. Start date 12/19/23 & edit date 12/21/23. * Orient resident to environment, room, and call light upon admission and as needed. Start date 12/19/23 & edit date 12/21/23. * Orient resident when there has been new furniture placement or other changes in environment. Start date 12/19/23 & edit date 12/21/23. * Provide proper, well-maintained footwear. Start date 12/19/23 & edit date 12/21/23. * Provide resident an environment free of clutter. Start date 12/19/23 & edit date 12/21/23. * Resident is cognitively and physically unsafe to be left alone on toilet for privacy with call light in reach and reminders not to self transfer until cleared by therapy. Start date 12/19/23 & edit date 12/21/23. * Review fall prevention information and contract with resident. Post signed contract in resident room within 24-72 hours of admission. Start date 12/19/23 & edit date 12/21/23. * Pad alarm implemented, placed on at all times to chair & bed. Start date 12/30/23 & created 1/2/24. * Sent to ER (emergency room ) for eval (evaluation) and admitted . Resident had been toileted 1 hour prior, resting in recliner with call light in reach, gripper socks on feet, and pad alarm on and functioning. Start bladder diary, recently started new seroquel for dementia with behaviors, restlessness, impulsiveness, agitation. To be in supervised areas when out of bed. Start date & create date 1/4/24. * Keep recliner remote in side pocket. Start date 1/22/24 & created 1/25/24. * Dycem to recliner to reduce the risk of sliding down. Start date 1/22/24 & created 1/24/24. The John Hopkins fall risk assessment dated [DATE] has a score of 13 which indicates moderate fall risk. The admission MDS (minimum data set) with an assessment reference date of 12/24/23 has a BIMS (brief interview mental status) score of 7 which indicates severe cognitive impairment. R1 is assessed as having no behavior including refusal of care. R1 is assessed as requiring substantial/maximal assistance for toileting/hygiene, mobility roll left to right, sit to lying, chair/bed to chair, and toilet transfer. R1 is occasionally incontinent of urine & bowel. Yes is answered for the question did resident have falls anytime in last month prior to admission. Yes is answered for question does resident have any fractures related to fall in last 6 months prior to admission/entry or reentry. The fall CAA (care area assessment) dated 1/1/24 under analysis of findings documents Resident has triggered for this CAA r/t (related to) her fall at home prior to admission. She is also at risk for fall per the antidepressant she is on. She is working with PT/OT to improve her strengthening and independence. She has had no falls while at the facility. She is at moderate risk for falls per the fall observation. Facility protocols are in place. Staff to ensure that all her needs are met with all encounters. The nurses note dated 1/4/24 at 5:50 a.m. documents Writer heard resident's chair/bed alarm while getting out from other's resident's room. Writer rushed thru resident's room and observed resident in front of reclining chair with head down/right side on the floor, with both knees in fetal position gripper socks on. Resident able to lift her head up herself. Asked resident what happened; states she was trying to go to the bathroom. Noted a quarter size bump, raised to right side of head/upper temple states discomfort kind a crying saying I hit my head Resident able to do active ROM (range of motion) to upper and lower extremities, WNL (within normal limits) per resident usual no deformity or shortening noted. BP (blood pressure) 159/8, T (temperature) 97.5 P (pulse) 98 R (respirations) 18 O2 (oxygen) 93% RA (room air. Bilateral hand grasps firm/strong and equal. Left side PERRLA (public equal round reactive light accommodation), right side not able to assess d/t (due to) treatment. Speech is clear answering questions appropriately. Transferred with 2 assist back to reclining chair per her choice without difficulty. Resident got toileted an hour prior of the fall. Resident's pan cake call light to her left side by her table where she wants it was in reach pad alarm was functioning. This nurses note was written by LPN (Licensed Practical Nurse)-S. The nurses note dated 1/4/24 at 6:30 a.m. documents Updated provider via hucu. Received order from [Name], APNP (advanced practice nurse prescriber) to send to ER (emergency room ) for evaluation d/t (due to) resident is taking eliquis. Called POA (power of attorney) son [Name] and updated in regards of residents fall; ok to what ever providers recommendation. Informed son that resident will be sent out to ER at [Hospital initials] for evaluation and voiced understanding. Requesting to keep him updated as resident has an appt (appointment) with ortho today and suppose to meet resident up to her appointment. This was passed on to AM (morning) nurse & will update son. Ambulance were called/[name]. Called ER nurse at [hospital initials] gave report in regards of resident to [name] RN (registered nurse). Ambulance came and left at 0615 (6:15 a.m.). DON (Director of Nursing) [Name] aware of fall. This nurses note was written by LPN-S. Surveyor reviewed R1's fall investigation and noted the Facility conducted a thorough investigation but did not determine the root cause of R1's fall on 1/4/24 to help prevent future falls. On 1/31/24 at 8:52 a.m. Surveyor observed R1 sitting in a personal type recliner in R1's room with her eyes closed. R1's legs were extended and was wearing yellow gripper socks. The call light pad is on the over bed table to the left of R1 and there is an alarm cord noted on the left arm going down to the seat of the chair. On 1/31/24 at 10:19 a.m. Surveyor observed R1 continues to be sitting in the personal type recliner with her legs down. The blue blanket is on the floor by R1's feet and R1 is rubbing her forehead. On 1/31/24 at 10:37 a.m. Surveyor observed CNA (Certified Nursing Assistant)-H leaving R1's room, the room door is almost closed and CNA-H pushed the round light device on the door frame. Surveyor asked CNA-H what the device was that she just pushed to turn the lights on. CNA-H replied so we know she is in the bathroom. On 1/31/24 at 10:43 a.m. Surveyor observed CNA-H leave the unit. On 1/31/24 at 10:49 a.m. Surveyor observed R1 sitting on the toilet in the bathroom with her pants down to her knees. On 1/31/24 at 10:49 a.m. Surveyor observed CNA-H back on the unit. On 1/31/24 at 10:51 a.m. Surveyor observed CNA-H enter R1's room and into the bathroom. CNA-H assisted R1 to stand, lowered R1's pants & assisted R1 to sit on the toilet. CNA-H indicated R1 must have at one point pulled up her pants and sat on toilet as R1 had her pants down when she (CNA-H) left her. CNA-H stated she was glad R1 didn't fall. CNA-H placed an incontinence product on R1 and asked R1 if she wiped good. R1 replied I [TRUNCATED]

Based on interview and record review, the facility did not ensure 1 (R1) of 4 residents reviewed for quality of care. R1 was admitted to the facility on [DATE] after a total left knee arthroplasty. After a revision arthroplasty and arthrotomy repair, R1 was readmitted to the facility on [DATE]. On 8/14/23 R1 had signs and symptoms of infection and the Orthopedic Surgeon (Ortho MD-F) requested to see R1 as soon as possible on 8/14/23 or 8/15/23 but the facility had no transportation. The facility said the in-house Nurse Practitioner (NP-G) would see R1 and update Ortho MD-F's office. There was no update from the NP or facility and there was no appointment scheduled to see Ortho MD-F until 10/24/23 when the knee was already grossly infected. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that included Encounter for Aftercare - Left Knee Arthroplasty, Coronary Artery Disease, Diabetes Mellitus 2, and Edema. Surveyor reviewed R1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/13/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. Surveyor reviewed the Hospital Discharge Summary with a discharge date of [DATE]. Documented was, On [6/28/23] [R1] had a fall at home when she tripped on a loose deck board at her home. She was found to have a moderately displaced, mildly angulated, comminuted fracture of the distal left femur . R1 had a total left knee arthroplasty and was admitted to the facility on [DATE] for rehab. On 7/20/23, R1 was readmitted to the hospital and underwent a left knee revision arthroplasty and arthrotomy repair. R1 was readmitted to the facility on [DATE]. Documented in Progress Notes on 8/14/23 at 10:08 AM by Assistant Director of Nursing (ADON)-D was, Writer assessed resident's L (left) shin/knee incision site. All steri strips intact, but a large amount of discharge is noted. Discharge is clear, no odor noted. Leg noted to have warmth, redness, and is tender to the touch. [MD-E] updated. Documented at 12:04 PM was, Writer reassessed resident's incision site due to increased serosanguineous discharge. Redness, warmth, and tender to touch. [MD-E] updated and also assessed resident in person. New orders for doxycycline 100 mg [twice daily] X 10 days. Resident being treated with [antibiotics (abx)] due to risk vs benefit. Call placed out to [Ortho MD-F's] office to update on current condition; awaiting call back. Resident also on an alarm reduction X 72 hours . Documented at 4:10 PM was, Resident presenting with +2 pitting edema to LLE (left lower extremity). Condition has worsened since this AM. Noted to have increased redness, warmth, and tender to touch. Increased drainage and incision site is now noted to be weeping. [Nurse Practitioner (NP)-G] updated. Stated to continue abx (antibiotic) orders and as long as she is hemodynamically stable she does not need to get sent out at this time. Surveyor noted the doxycycline antibiotic was started without cultures or clear indication if it would be effective for the possible infection. Documented in Progress Notes on 8/14/23 at 5:20 PM by Licensed Practical Nurse (LPN)-H was, Called [Ortho MD-F] to get resident seen asap [due to (d/t)] condition of [LLE (left lower extremity)]. 8/15 9 AM available, but facility and local facilities and [outside transport company] have no transport open. Notified [Ortho Registered Nurse (RN)-I] that [NP-G] will be in to access (sic) tomorrow, they stated to have Nurse call to update after [NP-G] accesses (sic) resident. Will cont to monitor for the time being, update w/any changes. Documented at 5:23 PM was, Blood glucose level: 498 this evening, Updated [NP-G], new orders to give 15 units . Documented at 5:46 PM was, Update from [Scheduler-J], [sister SNF facility] can help transfer resident Thursday or Friday Morning, if still needing a transport then. Surveyor noted there was no documentation that an Ortho appointment was scheduled for 8/15/23, or Thursday 8/17/23, or Friday 8/18/23. Documented in Progress Notes on 8/15/23 at 9:57 AM by LPN-J was, [NP-G] saw resident this AM. Assessed left knee incision. Received order for [labs] weekly x 3 weeks, increase Lasix to 40 mg daily. [NP-G] called out to [Ortho MD-F] for peer to peer. Surveyor noted there was no documentation of peer to peer conversation between NP-G and Ortho MD-F in R1's medical record. Surveyor reviewed visit note by NP-G with an assessment date of 8/15/23. Documented was: Chief Complaint [left (L)] knee pain . Subjective Since admission to rehab patient has continued to have external rotation of her left lower extremity since prior to her most recent surgical revision. Was started on doxycycline 8/14 due to surgical site infection . Physical Examination . Musculoskeletal-EXTERNAL ROTATION OF [L] KNEE, [L] KNEE EDEMA, LIMITED ROM, [L] KNEE INCISION WITH SEROSANGUINEOUS DRAINAGE, CIRCUMFERENTIAL ERYTHEMA RECEDING FROM DEMARCATION LINE, WARMTH AND TENDERNESS PRESENT . Assessment and Plan . Cellulitis, Surgical site infection -Continue doxycycline x 10 days, increase Lasix secondary to increased edema. Repeat CBC, BMP weekly x 3 weeks -Follow up with ortho . Documented in Progress Notes on 8/15/23 at 1:11 PM by RN-L was, [lab] results sent to [NP-G] via [phone app], new orders to repeat labs in 1 week. Documented on 8/16/23 at 7:10 AM by RN-L was, Writer notified [NP-G] that resident has increased redness to her Left knee spreading out of the outline and increased sanguineous drainage. +2 edema noted. New orders from [NP-G] is to keep changing dressing as needed for saturation. Continue with ABX and plan of care. Resident has no complaints of pain. Remains afebrile. No odor noted to incision site. There was no documentation that Ortho MD-F was updated on the lab results or the increased signs of infection. Documented on 8/17/23 at 1:48 PM by LPN-M was, resident being monitored d/t starting doxycycline and LLE weeping. tolerating antibiotic. [dressing] to LLE changed this morning during AM cares, old dressing had moderate serosanguineous drainage, distal incision weeping as soon as old dressing removed. non tender per resident, no foul odor noted. will cont. to monitor. Documented on 8/18/23 at 4:12 PM by LPN-N was, Resident is being monitored d/t administration of Doxycycline for redness/inflammation of left lower leg incision site. Tolerating it well; no adverse effect; afebrile. Old dressing was off; had a small amount of serosanguineous drainage; no foul odor; noted drainage from upper part of surgical site; steri strips intact; surgical site is reddened. Surrounding area is reddish/pink, slight warm, but non-tender; swelling noted; firm/+1 pitting. Cleansed the area with wound cleanser; pat dry and applied [dressing] and secured with tape. Has +4 pitting edema. Surveyor noted there is no indication a physician was updated with the noted increase to 4+ pitting edema. Documented on 8/19/23 at 2:27 PM by RN-L was, Resident admitted for short term rehab following recent revision of left knee arthroplasty. Resident alert and orientated x 2, with some periods of forgetfulness. Resident continues on ABX for Left knee. Resident has no complaints of pain at this time. Left knee continues to be red with small amount of drainage, but improving. No odor to incision site. Resident is compliant with laying down in bed between meals. Resident refused Ice machine today. Dressing to knee [clean/dry/intact (C/D/I)]. Resident remains afebrile . Documented on 8/20/23 at 5:12 PM by RN-L was, Resident admitted for short term rehab following recent revision of left knee arthroplasty. Resident alert and orientated x 2, with some periods of forgetfulness. Resident continues on ABX for Left knee. Resident has no complaints of pain at this time. No odor to incision site. Left knee continues to be warm, red and swollen, + 2 edema to the knee. + 4 to left foot and lower leg . Documented on 8/21/23 at 10:51 AM by RN-L was, Resident continues to be monitored for ABX for Left knee. Left knee continues to be swollen +2, red, warm, and moderate amount of drainage noted. Resident remains afebrile. No pain at this time. + 4 edema noted to left foot and lower leg. Resident encouraged to elevate her legs throughout the day . Documented on 8/22/23 at 3:39 AM by ADON-D was, Resident continues to be monitored for ABX for left knee. L knee remains swollen, red, warm. Moderate amount of drainage noted. Denies pain at time of assessment. +4 pitting edema noted to L foot/lower leg. Resident encouraged and educated by writer to elevate her legs throughout the day . Surveyor reviewed visit note by NP-G with an assessment date of 8/22/23. Documented was: .Assessment and Plan . Cellulitis, Surgical site infection -Overall has been improving slowly, redness and drainage continues to improve. Edema has improved to baseline prior to infection. -Continue doxycycline and will extend duration due to slow healing process. Already on several supplements including Arginaid, multivitamin, vitamin C, vitamin D, calcium. -Follow up with ortho . Surveyor noted that there was no documentation of any follow up with the Ortho MD and no appointment made for follow up with Ortho MD-F since requested on 8/14/23. Documented on 8/23/23 at 8:32 PM by ADON-D was, Residents LLE is weeping, changed bandage. Redness noted all around incision site. +1-2 edema noted. [Power of Attorney POA)-Q] insists she get accessed by [Ortho MD-F], writer called and left message w/receptionist, she stated if we don't hear a response by 10 am 08/24 then call [Ortho MD-F] again. Resident and [POA-Q] stated they did not want [NP-G] to assess, they only want her [Ortho MD-F], stated they want her seen by him ASAP (as soon as possible) . Documented on 8/24/23 at 9:32 AM by Scheduler-J was, Received a [voicemail (VM)] from [LPN-H] regarding her call into [Ortho MD-F's] office & need for [R1] to be seen asap. Also received a VM this morning from [Ortho RN-I] for an appt at 12:30 pm today. Writer received a call from [POA-Q] - stating that [R1] now has an appt today at 12:30 pm & transport is needed - writer arranged [facility] to transport & driver . Surveyor reviewed visit note by Ortho MD-F with an assessment date of 8/24/23. Documented was: History of Present Illness: [R1] is a . who we did a left hinged total arthroplasty for a comminuted distal femur fracture. She then had a fall with instability of the patella then revised her. She began having some question of some drainage in the incision last week. We instructed the care facility to bring her on the day of evaluation. They said they could not, but the Nurse practitioner would be evaluating her later that day or the next day and would let us know. We called multiple times and did not hear anything back. There was no response from the nurse practitioner who evaluated the knee. She came in today because of concern from the daughter and increasing drainage, knee today is grossly infected. There continues to be serous drainage, a foul smell. She is not having systemic symptoms. We discussed the seriousness of what is going on. We will aspirate the knee to send it for cell count, culture, 16S evaluation. We will have her see infectious disease. This is not if - of implant where we can do a full revision 2-stage. She would not do well. We would have to do rest of the articulating portions of the implant, thoroughly irrigate it and debride it, do IV antibiotics followed by chronic suppression. We will plan on doing this next Tuesday, once we have results from the [aspiration]. Given the fact that she is minimally ambulating now with all these surgeries, it is likely she will not ambulate again, but we want to give her a good stable base for transfers. If there are any issues, problems, questions, or concerns between now and surgery on Tuesday, they will let us know. Documented on 8/24/23 at 2:49 PM by LPN-O was, resident returned from Ortho MD-F], resident will need to go to [Infectious Disease (ID MD)-P] Monday 8/28/23 10 am, will require surgery 8/29/23, at [hospital] arrival time 1245, copy of notes given to scheduler dressing to be change daily and [as needed]. R1 was admitted to the hospital on 8/28/23 for Infection Associated with Internal Left Knee Prosthesis, subsequent encounter and discharged back to the facility on [DATE]. Hospital Discharge Summary documented: Principal Problem: 1. Infection of left knee, Wound infection after surgery: Patient is postoperative day 8 from irrigation and debridement and revision of left total knee arthroplasty performed by [Ortho MD-F]. She is doing well after surgery, having good pain control and eating fairly well. She was seen by infectious disease, [ID MD-P] on 8/28/23 and will continue to follow as an outpatient. - 8/24 preoperative cultures from the joint fluid that are growing Enterobacter cloacae, Cornybacterium striatum, and Streptococcus parasanguinis. - 8/29 joint fluid cultures collected during surgery are growing Enterobacter cloacae and Candida albicans. - 8/28 blood cultures are negative at >48 hours. - 8/31 and 9/6 plan was discussed with [Physician's Assistant] infectious disease (with [ID MD-P]). She is to continue Vancomycin (pharmacy to dose, trough goal 15-20) to target the Cornybacterium on prior joint aspiration, ertapenem 1g every 24 hours to target the Enterobacter cloacae and Streptococcus parasanguinis on prior joint aspiration and oral fluconazole 400 mg every 24 hours for the candida albicans. - She has a port in her R (right) chest that is accessed for infusions. Duration of therapy will be determined by infectious disease. She will eventually transition to lifetime oral suppressive therapy. - She will return to [facility] for subacute rehabilitation today. She is to have an immobilizer to her LLE when out of bed. It can be off while in bed due to pressure sore risk. Left Leg will be externally rotated due to intentional ER of the distal femoral component to prevent lateral patellar dislocation. She has been up with 2 assist and pivot to chair. The safest transfer for staff is to use a mechanical lift. A [wound vac] has been applied prior to discharge today. This will be managed by the orthopedic clinic . On 10/4/23 at 10:10 AM and 12:30 PM, Surveyor interviewed NP-G. Surveyor asked about R1 and her increased signs and symptoms of infection. NP-G stated MD-E saw R1 on 8/14/23 and started the antibiotics. NP-G stated she saw R1 on 8/15/23, ordered labs and spoke to a nurse in Ortho MD-F's office and spoke about the drainage. Surveyor asked if she ever spoke to Ortho MD-F. NP-G stated no. Surveyor asked if she ever called the Ortho office after that about a follow-up appointment. NP-G stated the facility would do that. Surveyor asked why she did not have her follow up appointment until 8/24/23. NP-G stated she did not know. NP-G stated all she knows is when she saw her on 8/22/23 it was improving. On 10/4/23 at 11:05 AM, Surveyor interviewed Ortho RN-I. Surveyor asked about R1 and the delay in treatment for her infection. Ortho RN-I stated on 8/14/23 she received a call from LPN-H about the increased drainage, swelling, and redness to the left knee. Ortho RN-I stated she told LPN-H she could get R1 an appointment on 8/14/23. Ortho RN-I stated she could not make that appointment due to no transportation. Ortho RN-I offered a 9:00 AM appointment on 8/15/23 as well. Ortho RN-I stated LPN-H stated they could not provide transportation for that appointment either but stated NP-G would see R1 in the morning. Ortho RN-I stated to LPN-H to have NP-G call the office after the assessment with her findings. Ortho RN-I stated NP-G called the office and left a message at 9:57 AM on 8/15/23. Ortho RN-I stated she returned the call to NP-G's cell phone and left a message at 10:12 AM. Ortho RN-I stated at 11:16 AM POA-Q called her concerned about R1's increased drainage, increased redness, and swelling to the incision, and a blood sugar in the 400's on 8/14/23 PM. Ortho RN-I told POA-Q she was trying to get her an appointment but the facility had no transportation. Ortho RN-I then called the facility at 11:17 AM and left a message for the nurse to call her back. Ortho RN-I stated she never received a call back from the facility or NP-G. Ortho RN-I stated when she arrived at work on 8/24/23 she had a voicemail from POA-Q about the urgency to see R1. Ortho RN-I called POA-Q and stated she made an appointment for that day at 12:30 PM for R1 and she will call the facility and tell them they need to find a way to get R1 there. Ortho-RN stated as soon as she hung up the phone LPN-H called her about making an appointment. Ortho RN-I stated she told LPN-H she needed to be seen at 12:30 PM that day. On 10/4/23 at 1:10 PM, Surveyor interviewed Scheduler-J. Surveyor asked why there was no transportation on 8/14/23 and 8/15/23 for R1? Scheduler stated the facility van was broken and getting fixed. Surveyor asked what is done if she cannot use the facility van for transport? Scheduler-J stated she calls 2 different contract companies and reaches out to 2 different sister facilities. Scheduler-J stated no one could transport on that short notice. Scheduler-J stated one of the sister facilities said they were available on Thursday or Friday of that week but she did not hear back from the nurse so she did not schedule anything. Surveyor asked what if it is an emergency transport and there are no options? Scheduler-J stated they will call an ambulance or call 911. On 10/4/23 at 1:59 PM, Surveyor interviewed Director of Nursing (DON)-B and on 10/4/23 at 2:36 PM, Surveyor interviewed DON-B and Licensed Practical Nurse (LPN)-K. Surveyor asked who would be responsible for updating Ortho about R1's left leg swelling, redness, and signs of infection? DON-B stated the nurse on the floor. Surveyor asked what happened with R1 and her left leg and Ortho appointments? LPN-K stated on 8/14/23 MD-E saw R1 and started her on antibiotics and NP-G saw R1 on 8/15/23 and spoke to Ortho MD-F. Surveyor noted MD-E documented follow up with Ortho ASAP and NP-G documented follow up with Ortho. Surveyor asked why the appointment still was not made? LPN-K stated she thought the conversation NP-G had with Ortho MD-F was sufficient since they did not hear anything else about it. Surveyor asked if they knew that NP-G never spoke to MD-E? DON-B and LPN-K stated no. Surveyor asked why a follow-up appointment was never made? LPN-K stated she assumed that NP-G spoke with Ortho MD-F and it was not needed. Surveyor asked if anyone followed up with NP-G and asked if she spoke with Ortho MD-F? DON-B stated no. LPN-K stated R1 had a follow-up appointment on 8/24/23. Surveyor noted that appointment was only made because POA-Q insisted. DON-B stated she was not aware of that. DON-B stated the follow up appointment should have been made and someone at the facility should have followed up with Ortho.

Based on interview & record review, the Facility did not ensure that 1 resident (R2) of 1 allegation an incident of physical abuse were thoroughly investigated, and the results of the investigation reported to the State Agency. R2 alleged that staff were rough when giving her a bed bath on 9/19/23. The investigation was not thoroughly investigated as no other staff were interviewed and other residents were not interviewed to see if they had similar concerns. Findings include: R2 was admitted to the facility on [DATE] with diagnoses that included Fibromyalgia and Depression, R2's Initial Minimum Data Set (MDS) dated [DATE] indicated R2 was assessed to have a Brief Interview for Mental Status score of 15 which indicated fully intact cognitive function. On 10/3/23 a grievance for R2 dated 9/20/23 reported by R2's family member was reviewed and indicated concerns that Certified Nursing Assistants (CNA) were being rough during a bed bath. R2 could not explain how the CNA's were rough with her. R2 indicated she was treated like an animal. The CNA's were interviewed and indicated R2 was scared to roll in bed and siderails were added after the grievance. No other staff or residents were interviewed as part of the investigation. On 10/3/23 at 10:00 AM R2 was interviewed and indicated that CNAs were previously rough with her while giving her care. R2 indicated it only happened once and the facility fixed the problem. R2 indicated she didn't want to be treated like that again. R2 did not remember who the CNA's were and could not elaborate on the incident. Positioning bars were observed on R2's bed. On 10/3/23 at 1:30 PM Former Nursing Home Administrator-C (who completed the investigation) was interviewed and indicated she did not report R2's allegation of rough treatment to the state because she ruled it out within 2 hours. Former Nursing Home Administrator-A indicated she did not interview any additional staff or other residents and should have. On 10/3/23 the facilities policy titled Reporting and Investigating Allegations of Caregiver Misconduct dated 11/2022 was reviewed and read: The administrator shall interview all employees who have had contact with the resident or individuals who may have been working at that time when the allegation was said to have occurred. The minimum timeframe shall include the 24 hours prior to the alleged abuse. The administrator or designee shall interview a sample of residents and staff regarding any concerns they may have which might indicate the extent of potential abuse. Interviews shall be documented. The only interviews as part of the investigation involving R2 on 9/19/23 were the 2 CNA's involved, R2 and R2's family member. On 10/3/23 at 3:00 PM Nursing Home Administrator (NHA-A) and Director of Nursing (DON)-B were informed of the above findings. Additional information was requested if available. No additional information was provided.

Based on interview & policy review, the Facility did not ensure 1 (R2) 1 allegations of abuse were reported to the Administrator and State Survey Agency. R2 alleged that staff were rough when giving her a bed bath on 9/19/23. The allegation was not reported to the state survey agency immediately and no longer than 2 hours from the allegation. Findings include: R2 was admitted to the facility on [DATE] with diagnoses that included Fibromyalgia and Depression, R2's Initial Minimum Data Set (MDS) dated [DATE] indicated R2 was assessed to have a Brief Interview for Mental Status score of 15 which indicated fully intact cognitive function. On 10/3/23 a grievance for R2 dated 9/20/23 reported by R2's family member was reviewed and indicated concerns that Certified Nursing Assistants (CNA) were being rough during a bed bath. R2 could not explain how the CNA's were rough with her. R2 indicated she was treated like an animal. The CNA's were interviewed and indicated R2 was scared to roll in bed and siderails were added after the grievance. No other staff or residents were interviewed as part of the investigation. On 10/3/23 at 10:00 AM R2 was interviewed and indicated that CNAs were previously rough with her while giving her care. R2 indicated it only happened once and the facility fixed the problem. R2 indicated she didn't want to be treated like that again. R2 did not remember who the CNA's were and could not elaborate on the incident. Positioning bars were observed on R2's bed. On 10/3/23 at 1:30 PM Former Nursing Home Administrator-C (who completed the investigation) was interviewed and indicated she did not report R2's allegation of rough treatment to the state because she ruled it out within 2 hours. Former Nursing Home Administrator-A indicated she did not interview any additional staff or other residents and should have. On 10/3/23 the facility's policy titled Reporting and Investigating Allegations of Caregiver Misconduct dated 11/2022 was reviewed and read: All alleged violations involving resident abuse are reported immediately to the Division of Quality Assurance. Department of Health Services requires the reporting of allegations of abuse immediately, but within 2 hours of the allegation. The allegation by R2 was not reported to the state agency. On 10/3/23 at 3:00 PM Nursing Home Administrator (NHA-A) and Director of Nursing (DON)-B were informed of the above findings. Additional information was requested if available. No additional information was provided.

Based on interview and record review the facility did not ensure residents have the right to voice grievances to the facility and receive a resolution to their grievance for 1 (R1) of 4 residents reviewed for grievances. R1's family voiced multiple concerns to the facility that were not documented, fully investigated and had no resolution. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that included Encounter for Aftercare - Left Knee Arthroplasty, Coronary Artery Disease, Diabetes Mellitus 2 and Edema. At the time of survey on 10/4/23 R1 was still a resident at the facility. Surveyor reviewed R1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/13/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired. R1 had an activated Power of Attorney (POA)-Q. On 10/3/23 Surveyor entered R1's room and Power of Attorney (POA)-Q was seated besides her. Surveyor asked if she had any concerns with the facility and R1's care. POA-Q stated yes and explained concerns such as her immobilizer causing blisters, the immobilizer being put on wrong, a delay in being seen by ortho in August and a delay in receiving antibiotics just to name a few. Surveyor asked if she had expressed these concerns to the facility. POA-Q stated yes. Surveyor reviewed facility's Grievance Log for July 2023 through October 2023. There were no grievances for R1. On 10/4/23 at 12:20 PM Surveyor interviewed Registered Nurse (RN)-R. Surveyor asked if R1 ever expressed any concerns to her. RN-R stated she has concerns, we just talk it over and address it. RN-R stated she does not think there is anything that has not been addressed. Surveyor asked if she reports these concerns to anyone or documents them. RN-R stated they discuss in morning meeting and sometimes she will discuss with Nursing Home Administrator (NHA)-A or Director of Nursing (DON)-B but they are both in morning meeting as well. RN-R stated she is also sure that NHA-A and DON-B have had some sort of meetings with R1 and POA-Q but she is not sure what they are about. On 10/4/23 at 12:20 PM Surveyor interviewed NHA-A. Surveyor asked if POA-A ever had any concerns or Grievances. NHA-A stated in July of 2023 she interviewed POA-A for a Quality Assurance project. NHA-A stated she wanted to get to the root of her issues. NHA-A stated POA-A stated she does not feel the facility is compassionate and were not educating her on discharging R1 and the possibility of private pay at the facility. NHA-A stated they had educated her and given her forms to fill out but they were never returned. NHA-A stated she also gave her outside referrals such as the ADRC (Aging and Disability Resource Center) for help with financial's. Surveyor asked if any of this was documented on a Grievance Form. NHA-A stated no. Surveyor stated that since July there are no Grievances from POA-Q and if she has so many concerns why are there no Grievances with investigations and resolutions. NHA-A stated that Former NHA-C would have been in charge at that time but even with her interview there should have been. NHA-A stated POA-Q has called and spoke to her about R1's pain management and her concerns. NHA-A stated that should have been in a Grievance as well.

Based on interview and record review, the facility did not provide adequate supervision to 1 of 2 (R27) residents reviewed for falls. R27 had multiple falls and the facility did not assess R27's need for supervision and develop a plan to provide supervision to R27 to reduce his risk of falls. Findings include: The facility's Fall Policy and Procedure dated 10/5/17 was reviewed. In the event of a fall the nurse will: -Review risk factor for fall (i.e. medical condition, pain, gait disturbance, medications, environmental factors, etc) -Revise plan of care as indicated to provide and implement an interventions(s) to reduce risk of likelihood of another fall IDT (Inter-Disciplinary Team) to review fall report to determine if further intervention can be added to POC (Plan of Care) and track for potential patterns in residents with repetitive falls R27 is [AGE] years old and was admitted to the facility with [DIAGNOSES REDACTED]. His admission Minimum Data Set (MDS), dated [DATE], noted that R27 was at risk for falls. The Falls Care Area Assessment (CAA) was completed on 9-25-20 and noted the following. Resident had recent fall resulting right side [MEDICAL CONDITION]. He was attempting to get up from his chair without assist and fell . Resident is working with Physical and Occupational therapy to improve his strength and function. He does have pain in his right hip occasionally, but is resolved with pain relief medication/non pharm (non-pharmaceutical) interventions. Resident participates with therapy. he is up in wheelchair daily, ambulates with walker, continues to stand unassisted and self transfer at times. Resident is alert, with impaired cognition, and poor safety awareness does not use call light to summon staff. Resident is taking opioids and antipsychotics effecting this area. Per Fall Risk Evaluation, resident is at risk for falls. precautions in place, staff to monitor with rounding, walker to be close to residents person, and proper foot wear to be worn. The facility developed a falls care plan for R27 upon his admission to the facility on [DATE]. The facility updated the care plan each time R27 had a fall; however, R27 continued to fall. R27 had 24 falls from 9/22/20 - 2/17/21. 17 of those falls resulted in no injury to R27. 7 of those falls resulted in minor injury to R27 that included skin tears or bumps. 20 of those falls occurred in R27's room where he was unsupervised; with the exception of his wife being in the room on one of those occasions. On 2/24/21 at 11:05 am, Nursing Home Administrator (NHA) - A, Director of Nursing (DON) - B, and Assistant Director of Nursing (ADON) - C were interviewed regarding R27's multiple falls and supervision. When the facility reviewed 2 of R27's falls, the Inter-Disciplinary Team (IDT) indicated that increased rounding should be provided by staff. 1 of the falls reviewed by the IDT indicated that R27 should be encouraged to remain in a supervised area when he was up in his wheelchair. When asked what increased rounding meant, DON - B said that it meant checking on R27 more frequently than every 2 hours which was standard rounding for residents at the facility. NHA - A said it could be hourly or more frequently, depending on R27's mood. NHA - A said that the facility had attempted to provide 1:1 supervision for R27, but was not successful. R27 was in the middle stage of Dementia and was confused, but acutely aware of his losses. In recognizing these losses, R27 was constantly agitated. When the facility attempted to provide 1:1 supervision, for R27 he would become verbally agitated. The agitation only decreased as staff decreased their proximity to R27. Facility staff attempted to provide 1:1 supervision from a distance. At times this worked, but often R27 retreated to his room and refused to leave the door open so that staff could supervise him from a distance. The facility attempted to provide activities of interest to R27. R27 was a shop teacher and the facility provided him with activities related to this. R27's wife also said that he had enjoyed classical music. When these activities were offered, R27 told staff that they were insulting his intelligence. R27's wife came to visit; but R27 would become agitated with her when he could not verbalize what he wanted to communicate. R27's wife would then leave. She said she was at a loss as to what might bring comfort to R27. Although the facility had attempted to provide increased supervision for R27, it appeared that the facility had not assessed R27's need for supervision and develope a specific plan that staff could implement to supervise R27 in an attempt to reduce his falls. R27's current falls care plan with a goal date of 3/13/21 was reviewed. The care plan contained the following interventions related to rounding and supervision. The 10/29/20 intervention indicated Frequent rounds to be completed on resident . The 12/12/20 intervention noted: Staff to complete frequent checks on (R27) while he is in room and encourage him to allow the door to remain open. The care plan did not define what frequent rounding/checks meant and how staff were to complete frequent checks and encourage R27 to leave his door open when these interventions increased R27's agitation.

Based on interview and record review, the facility did not ensure 1 (R1) of 3 residents reviewed for wounds ensured prevention of avoidable pressure injuries. On 12/31/19, R1 developed an unstageable deep tissue injury (DTI) while at the facility. The DTI was not reported to the MD and a treatment ([MEDICATION NAME]) was not put in place until 1/7/20 (7 days later). The care plan was not updated to reflect care of the DTI and reassessments were not documented in a timely manner. Wound Management assessments conducted on 1/6/20, 1/9/20, and 1/14/20 were not created and documented into R1's medical record until 1/17/20, the date of R1's discharge from the facility. R1 discharged home from the facility and had to have continued home care for the dressing changes and pain management. Findings included: On 9/3/2020 a complaint was called into the State Agency alleging R1 was admitted following a fall at home resulting in a fractured left femur and left hip. R1 had surgical repair. R1 was unable to move his left leg independently. Staff did not assure R1's left heel was lifted while R1 was in bed. R1 developed a pressure injury on his left heel. The pressure injury is healed, however R1 continues to have difficulty walking due to continued pain in his left heel. Surveyor reviewed facility's Pressure Injury Risk Assessment policy with a date of March 2020. Documented was, Purpose: The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injuries (PIs) . Steps in the Procedure 1. Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. 2. If necessary, allow the resident to take rest periods during the assessment. 3. Conduct a structured pressure injury risk assessment using a facility-approved tool. 4. Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for resident privacy. b. Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in the skin. 5. Develop the resident-centered care plan and interventions based on risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate . Reporting 1. Notify the supervisor if the resident refuses the procedure. 2. Report other information in accordance with facility policy and professional standards of practice. 3. Notify attending MD if new skin alteration noted . Surveyor reviewed facility's Pressure Injuries Overview policy with a date of March 2020. Documented was, Avoidable/Unavoidable Avoidable means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: Evaluation of the resident's clinical condition and risk factors; Definition or implementation of interventions that are consistent with resident needs, residents goals and professional standards of practice; Monitoring or evaluation of the impact of the interventions; or Revision of the interventions as appropriate. R1 was admitted to the facility on [DATE]. R1's [DIAGNOSES REDACTED]. R1 was discharged [DATE] and did not return to the facility. Surveyor reviewed R1's 12/11/19 admission skin assessment documented under Progress Notes. Documented was Skin assessment: no open areas noted. 2cm bruise to inner right wrist along with a 0.5cm bruise. Reddened knuckle to right middle finger. Black colored thumb nail. 1.5cm to left upper hand. 5x5cm and 4x3cm scars to left anterior ankle. Incision along left hip and extends to posterior buttocks, 38 staples in total. Dressing reinforced to incision. Some shadowing noted to superior end of dressing at buttocks region. Small red clustered areas noted to inner left thigh. No (complaint of) itching or discomfort. No other wound documentation, measurements or assessments were documented. No other facility-approved assessment tool documentation was found. Surveyor reviewed R1's Baseline Care Plan with a start date of 12/11/19. Documented under Skin Concerns was (Left) femur (fracture) 38 staples, dressing intact. All other assessment and intervention areas were blank including skin break risk, skin integrity goal, and skin break interventions. Surveyor reviewed R1's Certified Nursing Assistant Kardex with a start date of 12/11/19. Documented under Other was Encourage to turn/reposition often, elevate left leg, encourage to elevate heels. Surveyor reviewed R1's admission MDS (Minimum Data Set) with an assessment reference date of 12/18/19. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact. Documented under Functional Status for Bed Mobility and Transfer Status was 3/3 which indicated Extensive Assistance - resident involved in activity, staff provide weight-bearing support; Two plus persons physical assist. Documented under Skin Conditions was Risk of Pressure Ulcer/Injuries was Is this resident at risk of developing pressure ulcers/injuries? 1. Yes. Documented under Unhealed Pressure Ulcers/Injuries was Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. Surveyor reviewed R1's Care Area Assessment (CAA) for 16. Pressure Ulcer/Injury with an assessment reference date of 12/18/19. Documented under Analysis of Findings was Resident triggered CAA (related to) extensive assist with bed mobility and frequent incontinence. Resident admitted (status [REDACTED].) Resident is working with PT/OT and making progress with less assist required at times. Resident has a (history) of urinary incontinence, but is provided good incontinence care. Resident was admitted with surgical wound to left hip. No other (open areas) or redness noted. Skin remains clear. Surveyor reviewed R1's Braden Scale for Prediction of Pressure Sore Risk with an assessment date of 12/18/19. Braden score was 15.0 which indicates At Risk for pressure ulcers/injuries. Surveyor reviewed Event Report for R1 with a date of 12/31/19 completed by Registered Nurse (RN)-D. Report documents Pressure Ulcer - To left heel: 2.5cm x 5.9 Character of wound bed: Other - DTI, heel soft, purple/blue. Documented under Notification Guidelines: Notify MD/NP/PA immediately by phone or beeper for any of the following: New Pressure Sore/Stasis Ulcer development . Notifications: Physician notified: Yes. Date/Time: 01/07/2020 06:42 AM. Notification of MD was 7 days after initial assessment. This assessment was created on 1/6/20. Surveyor reviewed R1's Wound Management assessments completed by Wound RN-C. Documented with an assessment date of 12/31/19 was left heel wound 2.5 X 5.9cm, unstageable DTI, tissue type: closed/resurfaced, new order for [MEDICATION NAME]. This assessment was created on 1/17/20. Surveyor reviewed R1's Comprehensive Care Plan with a problem start date of 12/31/19. Documented was (R1) is at risk for skin breakdown (related to left [MEDICAL CONDITION],) limited mobility, and moisture. Documented under Approaches was Blue boots on at all times when in bed- resident refuses boots at times, educated about risks of not relieving pressure to heels. No revisions or updates were made to care plan to reflect wound treatment or prevention of worsening wounds during R1's time at facility. There was no care plan relating to refusal or denial of boots or cares for R1. Surveyor reviewed R1's Progress Notes for 12/31/19 through 1/6/20. There is no documentation of MD or NP contacted, order for [MEDICATION NAME] received or treatment administered. Surveyor reviewed R1's MD orders and Treatment Administration Record (TAR) for 12/31/19 through 1/6/20. There is no documentation of order for [MEDICATION NAME] received or treatment administered. Surveyor reviewed Nurse Practitioner (NP) visit note from 1/3/20. Documented under Objective was Skin: rash to buttocks resolved. No documentation of heel DTI wound or skin breakdown noted. Surveyor reviewed R1's Wound Management assessments completed by Wound RN-C. Documented with an assessment date of 1/6/20 was left heel wound 2.5 X 5.9cm, unstageable DTI, tissue type: closed/resurfaced, blister remains intact, dark purple in color. This assessment was created on 1/17/20. On 12/31/19 Event Report, it documented that MD was updated on 1/7/20. Surveyor reviewed 1/7/20 MD visit note. Documented under Objective was Heel has a black blister about (2cm by 2cm) with soft. No documentation of MD assessing heel was found prior to 1/7/20. Surveyor reviewed January 2020 TAR for R1. Documented with a start date of 1/7/20 was [MEDICATION NAME] left heel (every) shift, elevate heel; educate on healing process. No order prior to 1/7/20 was documented. Surveyor reviewed MD orders to confirm start date of treatment as 1/7/20. No order prior to 1/7/20 was documented. Surveyor reviewed R1's Wound Management assessments completed by Wound RN-C. Documented with an assessment date of 1/9/20 was left heel wound 2.5 X 5.9cm, unstageable DTI, tissue type: closed/resurfaced, seen by (NP.) wound care certified - remains intact and stable. This assessment was created on 1/17/20. Surveyor reviewed R1's Progress Notes. Documented on 1/10/20 was Resident left heel, deep tissue injury broke open and was bleeding. Area cleansed, skin prep peri wound and [MEDICATION NAME] applied with gauze around foot to keep dressing on. Small area dripping blood which had stopped by the time heel was covered with dressing. Feet elevated on off-loading wedge with heels off surfaces at this time. Surveyor reviewed January 2020 TAR for R1. Documented with a start date of 1/14/20 was [MEDICATION NAME] to left heel, cover with foam to protect and off load heel at all times. Surveyor reviewed R1's Wound Management assessments completed by Wound RN-C. Documented with an assessment date of 1/14/20 was left heel wound 2.5 X 5.9cm, unstageable DTI, tissue type: necrotic tissue, blister opened somewhat, remains stable, seen by (NP,) continue with [MEDICATION NAME]/foam - skin still coving blister. Several interventions in place. This assessment was created on 1/17/20. Surveyor reviewed R1's Progress Notes. Documented on 1/17/20 was residents left blood blister to left heel opened, measuring 2.8 cm x 5.8 cm, resident denied pain to area, beefy red, granulation tissue, called (Primary Care Physician (PCP)-E) and explained (open area,) he would like to see resident on Monday, explained to (wife) that she is to call his office on Monday for resident to follow up with MD, states understanding. (PCP-E) gave orders to cleanse area and apply [MEDICATION NAME].) R1 was discharged to the community on 1/17/20. On 9/9/20 at 10:51 AM, Surveyor interviewed R1 via phone. Surveyor asked if a nurse, NP or MD assessed his wound on his heel on a regular basis. R1 stated yes and no. He stated a nurse looked at it, days later an NP, I do not remember a doctor looking at it. Surveyor asked if there was a treatment or bandage put on it after the nurse looked at it the first time. R1 stated no, it was days later. Surveyor asked if the staff elevated his heels in blue boots. R1 stated they used pillows. Surveyor asked if he ever refused the blue boots or pillows for elevation. R1 stated no, they put the pillows under his legs at night. He was unsure about the blue boots. Surveyor asked what happened after he left the facility. R1 stated he was inconvenienced because a nurse came to the house and changed the bandage a lot. I had a lot of pain and trouble walking on that heel. On 9/9/20 at 10:34 AM, Surveyor interviewed Wound RN-C. Surveyor asked who was in charge of wound care. Wound RN-C stated the nurses on the floor complete the treatment and she measures weekly. Surveyor asked what the process is when a new wound is identified. Wound RN-C stated the floor RN would create an event in the chart, contact the MD and update them, and also update the Wound RN. Surveyor asked when this process should start. Wound RN-C stated right away after the wound is brought to the RN's attention. Surveyor asked when did she assess R1's heel wound. Wound RN-C stated she was not sure but according to charting it was 12/31/19. Surveyor asked who updated the MD and received treatment orders. Wound RN-C was unsure. Surveyor asked why all of the wound assessments were completed on 1/17/20; the day the patient was discharged . Wound RN-C stated she documents on her own paper and then puts the wound assessments in the computer when she has time. Wound RN-C stated sometimes . have a few weeks to put in at once. Surveyor asked if this was the policy for wound documentation. Wound RN-C stated she was unsure. Surveyor asked if the care plan should be updated with a new wound. Wound RN-C stated Acting (Director of Nursing) DON-B who also does MDS, updates the care plans. On 9/9/20 at 11:25 AM and 1:39 PM, Surveyor interviewed RN-D. Surveyor asked about the event sheet filled out for R1 on 12/31/19. RN-D stated she was made aware that he had a wound, assessed it and updated Wound RN-C who assessed it either that day or the next. Surveyor asked if the MD or NP was updated and a treatment order was received. RN-D stated yes, but she wasn't sure when. Surveyor noted the event report was created on 1/6/20 and MD notification was documented as 1/7/20. RN-D stated she was sure she updated the NP but not sure when. RN-D stated documentation of date and time were trying to be found. No further documentation was provided. Surveyor asked what the policy was on updating the MD and receiving treatment orders. RN-D stated the shift the wound is found on. Surveyor asked what the policy is for completing wound documentation and event report. RN-D stated there is not a written policy but it is expected within 24 to 48 hours. On 9/9/20 at 11:41 AM and 2:14 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked about R1's MDS and CAA. Surveyor asked where she (DON-B) would get the information for a triggering a CAA such as wounds. DON-B stated Braden scores, wound notes and Progress notes. She would also speak with the nurses. Surveyor asked if preventing pressure injuries should be on the care plan for R1 since his CAA triggered for potential risk for pressure injuries. DON-B stated yes. Surveyor asked how the staff know what interventions the resident has in place to prevent skin breakdown if the Comprehensive Care Plan did not address interventions prior to 12/31/20. DON-B stated a baseline care plan is in place and would be created in the first 24 to 48 hours. Surveyor noted no skin breakdown prevention measures on the baseline care plan, other than what was written on a separate CNA Kardex. DON-B stated the base line care plan should have interventions in place, it should not be blank. DON-B stated R1 did have blue boots in place for heel protection. Surveyor noted the blue boots were not put on the care plan until 12/31/19, the day the wound was found. DON-B stated they should have been added earlier. Surveyor asked if a care plan is added or updated if a new DTI would be identified. DON-B stated yes. Surveyor noted in the care plan that nothing was added after the heel wound was identified. DON-B stated she did not see one but the facility practice would be to update the skin care plan. Surveyor asked what the policy was on updating the MD and receiving treatment orders for a wound. DON-B stated an RN assesses it, an update is made to MD and to Wound RN-C. Surveyor asked what the timeframe was for updating an MD and receiving a treatment order. DON-B stated the nurse would be expected to do it on their shift but if no response to call the MD within 24 hours. Surveyor asked when an MD would assess a new wound. DON-B stated that an MD or NP is in the building 2 times weekly, so within a week. Surveyor asked why R1's new wound was not updated to an MD, treatment ordered and was not assessed for 7 days by an MD. DON-B was unsure. Surveyor asked for any addition documentation that would indicate the MD was updated, treatment ordered and completed and assessed timely. No additional documentation was provided. On 9/9/20 at 1:19 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor noted that wound documentation for R1 was not completed until 1/17/20 when R1 was discharged . Surveyor asked where weekly documentation of wound measurements should be done. NHA-A stated as long as the wound nurse has documentation, it is OK. Surveyor asked how the nurses and other staff would know how R1's wound changed/grew in size/progressed. NHA-A stated she does not know. Surveyor asked for any additional documentation that would indicated the MD was updated, treatment ordered and completed and assessed timely for R1. No additional documentation was provided.

Based on interview and record review, the facility did not implement an effective discharge plan for 2 of 2 residents (R1 and R8) who were discharged from the facility. Prior to being discharged to their homes, R1 and R8 voiced concerns that they were not ready for discharge from the facility. R1 and R8 had informed the facility that they were unsure they had the necessary support services to allow them to live in their homes independently. The facility did not address R1's and R8's concerns and discharged them from the facility. Findings include: 1.) On 6/28/19 the state agency received a complaint from R1's daughter that said R1 was not able to live on her own, was unable to care for herself, and the facility had not made arrangements for a safe discharge. FIRST DISCHARGE R1 was admitted to the facility on [DATE] for short term rehab, after having a Left Knee Replacement. According to the progress notes, R1 was alert and oriented to person, place, and time. She was able to independently make decisions. According to the 5/7/19 Progress Note, Director of Rehab (DOR) - D noticed that R1 was struggling to rise from her dining room chair. DOR - D approached R1 and asked R1 if she felt confident with her decision to go home. DOR - D documented that R1 is adamant that she will go home and 'I will be fine.' DOR - D informed R1 that it appeared that R1 could benefit from further therapy prior to returning home. R1 stated that she was not changing her mind and she was going home following her appointment on 5/8. R1 discharged to her home from the facility on 5/8/19. R1 lived alone. READMISSION TO FACILITY On 5/13/19, R1 called the facility and stated that she went home too early and wanted to be readmitted to the facility. R1 was re-admitted to the facility on [DATE]. Her 5/20/19 Minimum Data Set (MDS) provided the following information. R1 was cognitively intact. She required extensive assistance from one staff for transfers, walking, dressing, toileting, and hygiene. R1 expected to be discharged to the community and active discharge planning was in place. R1's care plan, with an admission date of [DATE], was reviewed. The care plan had short term goal dates of 6/28/19 and long term goal dates of 7/25/19. The care plan did not contain a discharge goal for R1. The progress notes were reviewed and from 5/13 - 5/29/19 and there was no documentation related to R1's discharge plans. On 5/30/19 the progress note simply stated: She will discharge home prior to her MRI tomorrow 5/31/19 It was unclear why the discharge was being initiated. There was no documentation that R1 had requested to be discharged from the facility. On 9/19/19, DOR - D and Social Services Designee (SSD) - [NAME] were interviewed and asked who had initiated the discharge for R1. DOR - D said that R1 wanted to go home, but her daughter did not want her to go home. DOR - D and SSD - [NAME] said that R1 would be going home to live alone and that her daughter would not be able to assist her with self care tasks. DOR - D said that R1 had met her rehab goals related to her Left Knee Replacement; but also said that R1 was having issues neurologically. SSD - [NAME] could not explain why R1 had no discharge care plan. When asked about discharge planning, SSD - [NAME] said that a care conference had been held and referred to the following note, dated 5/22/19. Care conference held today to discuss discharge plans. Resident agrees that she is continuing to make progress in therapy and her knee is doing well. Encouraged her to do more for herself. She feels that she has other physical things wrong with her and she should stay longer for rehab. Educated resident on how she was sent to rehab for a specific [DIAGNOSES REDACTED]. They could not do therapy on other things she may feel be (are) wrong with her. She will continue to do therapy and a tentative discharge date is set for 6/3/19. After reviewing the note, the surveyor questioned if R1 was ready and wanting to discharge from the facility. DOR - D and SSD - [NAME] referred to a progress noted written on 6/3/19 at the time of R1's discharge. The note indicated that R1's medications and discharge care plan were reviewed with her. It also indicated that R1 was Very happy to be going home, no questions or concerns at time of discharge. The surveyor indicated that at the time of discharge; R1 might have resigned herself to the fact that she needed to leave. The surveyor asked DOR - D and SSD - [NAME] to provide information that indicated the facility had addressed R1's concerns expressed on 5/21/19 about discharging home and that the facility had determined that R1 was safe to discharge home where she would live alone. A home visit had not been conducted prior to R1's discharge and it was unclear why this had not been done. SSD - [NAME] said that R1 was returning home with home health services. DOR - D said that R1 would receive physical therapy and occupational therapy 2 times weekly and that nursing would visit 1 time each week or as needed. DOR - D and SSD - [NAME] were unable to provide documentation, indicating that R1 wanted to go home and that the facility had encouraged R1 to stay at the facility. The surveyor noted that during R1's first discharge, it was clearly documented that the facility was unsure that R1 was ready to discharge and the facility had addressed this with R1. DOR - D and SSD - [NAME] were unable to explain why they had not documented R1's insistence on being discharged from the facility on this second occasion and that the facility had encouraged her to stay. The following documentation was reviewed. It indicated that R1 needed the assistance of one staff person to perform her ADL's (self care tasks) and that R1 did not have anyone living with her who might be able to assist her with this. A 5/31/19 occupational therapy note documented: Discussion with pt (patient) on family support; pt (patient) insists daughter will not help with any self care tasks. The 6/2/19 OT (Occupational Therapy) Discharge Summary documented the following recommendations: Assistance with ADLs .In-home aide or family support . It should be noted that R1 did sign her 6/3/19 Discharge Plan of Care. However, the plan documented that R1 required Assist of 1 for Dressing, Grooming, Transfer, and Ambulation/Mobility. On 9/23/19 at 9:50 PM, RN - F was interviewed. RN - F confirmed that she had completed the discharge paper work with R1 on 6/3/19. RN - F asked how R1 was discharging home with no caregiver support and that RN - F had documented that R1 needed the assistance of 1 staff for her self care tasks. RN - F said that she was unsure. RN - F thought that that R1 asked for help; but R1 did not really need it. On 9/23/19 at 8:40 am, R1's daughter was interviewed. The daughter said that the first time R1 was admitted to the facility, R1 initiated her own discharge. The second time that R1 was admitted to the facility, the facility initiated her discharge on 6/3/19 and that R1 had not been provided with adequate discharge services to live on her own. The daughter said that she was first notified on 5/30/19 that R1 was being discharged . The daughter said on 5/30/19, DOR - D told the daughter that R1 was being discharged on [DATE]; prior to her MRI appointment. The daughter indicated that a home visit had not been completed nor had the facility determined that R1 was safe to discharge to her home where she lived alone. The daughter said that after having been discharged home on[DATE], R1 was admitted to the hospital with [REDACTED]. R1 stayed at the hospital for 4 days. The daughter was asked why R1 had signed the paperwork indicating that R1's Medicare Benefits would end on 5/30/19. The daughter said that R1 had called her after signing the paperwork and was upset. R1 said that DOR - D had told R1 that R1 had to sign the paperwork. The daughter reported that R1 signed the discharge plan of care because R1 and her daughter thought they had no other choice. On 9/23/19 at 9:30 am, R1 was called. R1 was living in another skilled care facility. R1 said that she felt forced to sign the paperwork by the facility and that she felt like she had been forced to leave the facility. The facility did not ensure that upon discharge that R8 was transferring to a safe environment and that R8 was comfortable and prepared physically and emotionally for the discharge. The facility did not speak to any R8's support or family members to ensure they were willing and able to assist R8 with her needs. The facility did not ensure that upon discharge that R8 was able to safely enter and maneuver in and out of her home. 2.)Resident (R8) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R8 discharged home on[DATE]. R8's minimum data set (MDS) assessment, dated 8/01/19, showed R8 was cognitively intact. R8's functional assessment showed R8 needed limited assistance of one staff for transfers and R8 does not ambulate. R8's range of motion is limited on one side of her lower extremities. R8's MDS assessment, dated 8/20/19, showed R8 remained unable to ambulate, but was independent in transfers. R8's Medical Record/Progress Notes were reviewed that showed in part on: *On 7/29/19, at 2:19pm, R8 is tearful today having issues with her significant other and thinking about past experiences. R8 is requesting to see the psych Nurse Practitioner. *On 8/05/19, at 3:56pm, R8 states that she would be better off dead. SSD-E asked how often she is feeling like this and she states recently she is having personal issues with her significant other and past. R8 then states that she doesn't have a plan and would never hurt herself that it is just a figure of words and how she expresses her sadness. * On 8/26/19, at 3:44pm, by Social Services Designee (SSD-E), Notification of transfer given to R8. She states she cannot go home she has nobody to help her. She will have home health services, and I suggested a friend, her mother, her children, her boyfriend etc and R8 states none of them will help. R8 then states she has a step to get in the house and she cannot put weight on her foot yet, I suggested she can go up and down that step on her bottom and she said absolutely not, then she states she cannot get around in her trailer as her scooter battery is dead and it takes 90 day to get a new scooter. I suggested a wheelchair, and she states it won't work in the trailer. SSD-E continued to help her problem solve and R8 had excuses for why everything suggested could not work. SSD-E expressed to her that if she would not have declined therapy she could have worked on strengthening and problem solving for discharge. R8 then said don't worry about me ill figure it out and dismissed both myself and Admissions Licensed [MEDICATION NAME] Nurse (LPN-C). *On 8/27/19, at 12:18pm, The Registered Nurse (RN) documents, R8 was admitted to short term rehab due to right foot ulcer, osteo[DIAGNOSES REDACTED], diabetes and IV therapy. R8 is alert and oriented and able to make needs and wants known . Dressing to right foot ulcer was changed per orders with a moderate amount of drainage noted. R8 continues to refuse to be educated on changing the dressing, states she has to lay down at times when packing in between the toes because she can't handle it. R8 is able to remove old dressing and set up supplies used for treatments. R8 transfers independently between surfaces, but continues to be Non-weight bearing to her right lower extremity . PICC line dressing to Right upper extremity is clean dry and intact. R8's PICC is patent and flushing. R8 remains on contact isolation. R8 went out for MRI this morning. *On 8/27/19, at 6:06pm, The facility LPN documented in part: R8 returned from her doctor appointment with Infectious disease and her MRI appointment. R8 came back with After visit summary and Script for [MEDICATION NAME] (An antibiotic) 100mg to be taken two times a day orally . Instructions to Discontinue IV antibiotics today and transition to oral [MEDICATION NAME] for another 4 weeks and to follow up with MRI results when done. R8 will need aggressive wound care to hopefully heal and salvage foot. R8 has orders from the Doctor to discontinue the PICC line prior to discharge. R8 is very emotional and refusing to let staff remove PICC line in house according to her she will try to make an appointment for day surgery to remove PICC line. The Doctor stated he tried to approach her and take out PICC line while in office today and resident refused. LPN-C was called and updated her on R8's orders. The after visit summary, wound treatemtn orders, and new order for oral antibiotic will be faxed to home health nurse who will be taking over her care after discharge tomorrow * On 8/27/19, at 10:05pm, The facility LPN documents in part: R8 refuses to help with the dressing change due to statements that she cannot see the wound properly and can not handle the pain of bending over to pack the toe ulcer. *On 8/28/19, at 1:22pm, Assistant Director of Nursing (ADON) documented in part: ADON and multiple other nurses attempted to remove R8's PICC line today and R8 refused each time approached. R8 stated that we need to call the physician to make an appointment for her to be under anesthesia to remove PICC line. ADON educated that this is a simple procedure and can be done in facility. R8 continued to refuse to have PICC line removed. R8 was educated on the risks of leaving the PICC line in and that the order was not placed to remove the PICC line under anesthesia and resident still refused. R8 was encouraged to go to the ER directly after discharge to have PICC line removed. Waiver filled out by resident stating that the facility is not responsible for the PICC line or any infection/injury that occurs due to the PICC line after discharge. R8 signed the waiver. *On 8/28/19, at 3:46pm, R8 discharged from the facility. On 9/24/19, at 2:08pm, Surveyor interviewed Resident (R8), over the telephone, who stated The facility told me I had to leave so I went home. They said I was done with my intravenous (IV) antibiotics and I could do everything else at home. I was sent to the facility for wound care and IV antibiotics through my peripherally inserted central catheter (PICC) line. After I left the facility I went to the emergency room (ER) to have my PICC line removed. My last week to a week and a half in the facility, I feel as if I was pushed to get out of there. On 8/28/19, my son in-law picked me up and brought me home. They had to carry me into my house due to I could not get up the steps outside my house. On 9/24/19, at 3:01pm, Surveyor interviewed Social Service Designee (SSD-E) who noted that R8 was at the facility for wound care and IV antibiotics. Once R8 finished her IV antibiotics she could go home and finish her wound care there. Surveyor asked SSD-E if R8 was comfortable and safe going home on 8/28/19. SSD-E stated that R8 had a boyfriend at home, but there relationship was an on and off again relationship. R8 also had her Son that could help her. Surveyor questioned if the facility ever spoke to R8's boyfriend and Son to see if they were willing, able or capable of assisting R8 when she was discharged home. SSD-E stated No we did not speak to either of them. Surveyor questioned if any of R8's family was a part of discharge planning or attended the care plan meeting. SSD-E stated R8 did not want anyone to attend the care plan meeting and no other person was spoken to about R8's discharge. SSD-E stated R8 would change her story so much but she was going home and her sons would check on her and her boyfriend was there too. Why would they not help R8? Surveyor questioned if R8's boyfriend was still living with her if they have an on and off again relationship. SSD-E stated R8 was basically doing everything on her own here at the facility; she was doing everything she needed. Surveyor reviewed SSD-E's progress note written in R8's medical record on 8/26/19, at 3:44pm. SSD-E documented that R8 stated she cannot go home she has nobody to help her and R8 stated she has a step to get in at her house and she cannot put weight on her foot yet. SSD-E suggested she can go up and down that step on her bottom and R8 said absolutely not, then R8 stated she cannot get around in her trailer as her scooter battery is dead and it takes 90 day to get a new scooter. SSD-E suggested a wheelchair, and R8 states it won't work in the trailer. SSD-E continued to help R8 problem solve and she had excuses for why everything suggested could not work. SSD-E expressed to R8 that if she would not have declined therapy she could have worked on strengthening and problem solving for discharge. Surveyor questioned if after this meeting with R8, if SSD-E determined R8 was still safe to go home on her own and was safe to get in and out of her house and if it was safe for R8 to sit on her bottom to scoot up and down the stairs. SSD-E notes that other than nursing observing and how R8 functioned on her own I think she was safe. Surveyor questioned if therapy or the facility nurses performed any safety assessments to ensure that when R8 was discharge from the facility to her home that she would be safe. SSD-E replied I don't think so, R8 refused therapy and there were no safety assessments done by the nurses. On 9/24/19, at 3:37pm, Surveyor interviewed LPN-C who states she assists with the resident admit and discharges at the facility. Surveyor asked if she was with SSD-E on 8/26/19 discussing R8's coming discharge and if the facility identified it was safe for R8 to go home on 8/28/19 and if R8 was comfortable with going home on 8/28/19 with her functional capabilities. LPN-C replied, R8 was at the facility for IV antibiotics and wound care. R8 did not want to do any therapy while she was here in the facility. I know R8 had a son and a boyfriend at home. Surveyor asked LPN-C if anyone ever spoke to R8's family or boyfriend before she discharged home. LPN-C stated no one did speak to them. I told R8 two days before she was scheduled to discharge that R8 had declined therapy. We did nothing to see if R8 was safe at home, according to R8 she had a boyfriend that was on and off. I felt R8 would be safe when she left here. Surveyor questioned if the facility was aware what style of house did R8 live in and if there were any steps or barriers to her getting in and out of her house safely. LPN-C notes I think R8 had a mobile home. Usually therapy would come in and see if a resident is safe to go home and if they have stairs at home. LPN-C stated R8 is [AGE] years old, just a few years older than I am and I thought she would need to step up a bit. If a resident tells me that they do not need therapy then I don't know what to tell you. In R8's case it would have been best to do a home safety assessment, like it was suggested. Surveyor asked if LPN-C ever spoke to R8's family or boyfriend. LPN-C replied I did not speak to any of them. Surveyor questioned if any other options were discussed with R8 if she felt she was not able to go home safely on 8/28/19. LPN-C notes I know I mentioned about her staying as a private pay resident but I did not document it. R8 did have insurance but we did not look into if the insurance would help cover any of a longer stay.