Every finding on record at Lindengrove Menomonee Falls

Based on observation, interview, and record review the facility did not ensure 4 out of 7 residents (R2, R43, R1, R39) who were at risk for falling received the appropriate interventions to prevent further falls from occurring. The facility did conduct a thorough investigation of R2's falls on 5/11/26, 5/23/26, 6/2/26 and 6/4/26. The facility did not update the plan of care with additional interventions that could prevent R2 from future falls and injuries. R43 experienced a fall on 5/21/26 and 6/7/26. The facility did not thoroughly investigate and update R43's plan of care with interventions that could prevent R43 from future falls and injuries. The facility did not conduct a thorough investigation after R1 had a fall on 7/13/26. R39's falls care plan documented a call don't fall sign implemented 12/8/25 which was not observed to be in place. R39 had a fall on 3/31/26 and the interdisciplinary team (IDT) determined an appropriate intervention was to apply Dycem to the wheelchair, which was an intervention in R39's care plan effective 1/17/26. This is evidenced by: Policy review: Falls, last review date 4/9/26, which documents Prevention measures are put in place to reduce the occurrence off falls and risk of injury from falls. 1. Procedure: Fall Risk.a. Licensed nurse will complete an electronic Fall Assessment upon admission.b. A licensed nurse will complete a Fall Assessment quarterly, or with change in condition.c. A licensed nurse will determine the individual's risk for falls and individualized care needs. If the individual is at risk for falls, then create a falls care plan. 2. Procedure of Fall event and Implementation of Intervention:a. Licensed nurse completes electronic documentation of the Fall Incident Report.b. The care plan will be updated with an identified intervention.c. Registered Nurse (RN) reviews and completes the fall assessment and interventions.d. Fall follow-up assessment completed as indicated. 3. Administrative Review:a. The Interdisciplinary Team (IDT) will review Fall Incident report and utilize root cause analysis to make further recommendations.b. Director of Nursing (or designee) and Executive Director to review and sign Fall Incident Report.c. Quality Assurance and Process Improvement Committee reviews facility fall incidents and trends. 1.) R2 was admitted to the facility on [DATE] with diagnosis that include traumatic brain compression, vascular dementia, adult failure to thrive and repeated falls. On 4/13/26, the facility conducted an admission fall risk assessment for R2 which documented a score of 15, indicating R2 is at risk for falls. Surveyor conducted a review of R2's individual plan of care which documents: R2 is high risk for falls r/t (related to) history of falls, confusion, recent wander. Date Initiated: 04/13/2026. Interventions included: Risk of falls/falls with injury will be minimized. Date Initiated: 04/13/2026 5/11/2026: dycem to wheelchair. Date Initiated: 05/12/2026 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests forAssistance. Date Initiated: 04/13/2026 Call don't fall sign. Date Initiated: 04/16/2026 Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 04/13/2026 Ensure that the resident is wearing appropriate footwear non-skid socks when ambulating, transferring or mobilizing in w/c (wheelchair). Date Initiated: 05/12/2026 Follow facility fall protocol. Date Initiated: 04/13/2026. R2 has an ADL (activities of daily living) self-care performance deficit due to activity intolerance, hip fracture, skull fracture cognitive impairment, terminal. Date intitated 4/13/26. Interventions included:*Transfer: R2 is able to ambulate in the room, to/from the bathroom with 2 wheeled walker and the assist of 1. *Encourage R2 to use bell to call for assistance. Date initiated: 4/20/26. The plan of care identifies R2 has urge bladder incontinence due to activity intolerance and confusion. Interventions did not include any type of toileting plan or assistance level needed. R2's significant change MDS (minimum data set), dated 6/17/26 documents R2 has a BIMS (brief interview for mental status) score of 6, indicating severe cognitive impairment. R2 has had 1 fall since admission and no injuries as a result of the fall. Nursing note dated 5/11/2026 at 10:53 PM; R2 found on the floor sitting on her buttock on the floor. R2 called 911 for assistance. Writer entered the room with the fire dept. (department) and resident reported I'm sorry, I couldn't reach my call light from here so I had to call them R2 denies hitting head, dept picked up R2 and put her into bed. R2 demonstrated range of motion without difficulty or pain, completed skin check, no areas of concern, or skin tears, no edema, clubbing or hematomas noted. Started neuro (neurological), checks updated Nurse Practitioner, Manger on Duty, hospital and family. Will continue to monitor. Surveyor conducted a review of the facility's falls investigation for the fall that occurred on 5/11/26 at 10:00 PM which documented R2 was sitting on floor sitting on her buttocks. R2 called 911 because she couldn't reach call light. R2 moves around self propels in room and couldn't find the call light. The root cause was identified as R2 sliding from wheelchair while mobilizing with wheelchair in room. New intervention: Dycem applied to wheelchair to reduce sliding risk and promote safe positioning. Surveyor noted the investigation did not include any staff statements regarding the last time R2 had received cares or if falls interventions were in place at the time of the fall. Surveyor noted on 5/11/26, Dycem to wheelchair for safety was added to the Certified Nursing Assistant Kardex and the falls plan of care. Nursing note dated 5/23/2026 at 12:27 PM, documents R2 sustained UWF (unwitnessed fall). After receiving call for help from CNA (Certified Nursing Assistant), Writer found R2 lying on the floor on her back. There was a small pool of blood next to her and a noted laceration to the left eye. Writer asked if R2 was in pain anywhere , R2 stated just my head. Writer then asked her what she was trying to do, she said go to the bathroom. We assisted R2 back to bed and left to call the ambulance and update family/Supervisor/Physician. Surveyor conducted a review of the facility's falls investigation for the fall that occurred on 5/23/26 at 7:30 AM. CNA called to room for help, when Nurse walked into the room, Nurse witnessed R2 laying on her back on the floor next to her wheelchair. There was a small pool of blood where her head was and blood coming from a laceration on her eyebrow. R2 stated she was trying to go to the bathroom. Injury-laceration to face. Transferred to hospital. R2 tried to self-transfer, did not lock the wheelchair. IDT team met. R2 observed lying on her back on the floor next to her wheelchair, Blood was noted beneath the residents (sic) head with active bleeding from a laceration to eyebrow. Res (Resident) has been attempting to self-transfer at the time of the fall, Emergency services were activated, Root Cause-unassisted self-transfer. Surveyor noted the fall investigation did not indicate the last time R2 was toileted although it's documented that R2 was last seen by the Nurse at 6:30 AM on 5/23/26. R2 was incontinent of bowel and bladder at the time of the fall. No additional interventions were added to the care plan. Nursing note dated 6/2/2026 at 09:59 AM, documents R2 notified writer that she fell last night and got herself back to bed, however she is unsure if she notified the overnight RN. R2 reporting right forearm pain, very mild redness to the elbow, however full range of motion present without pain to the elbow. R2 is alert and orientated times 2. Pupils are equal and reactive, strength equal in the extremities. No signs of trauma. Vital signs stable and Nurse Practitioner- H notified. Is understanding and stated she will see R2 today. On 7/22/26, Surveyor requested to review the falls investigation for R2's fall on the evening of 6/1/26. Clinical Consultant- C confirmed the facility did not conduct a falls investigation, update the plan of care or obtain any staff statements for this unwitnessed fall. Nursing note dated 6/4/2026 at 06:26 AM, documents CNA called and informed writer R2 was found on the floor at the front of the nursing station. R2 was observed, lying down on the floor facing couch at front of nursing station with her back on her wheelchair. R2 stated she was looking for her family and when she did not see them R2 tried to transfer self to the couch and slid to the floor. Upon assessment, no bruise or injuries noted. Range of motion within normal limits. Neuro-checks started and were negative. Vital signs: BP. (blood pressure) 127/58, P. (pulse),69, T. (temperature),97.4, R. (respirations) 20. R2was assisted up from floor to wheelchair and is laying down in bed. Nurse Practitioner- H updated via text message. Surveyor conducted a review of the facility's falls investigation dated 6/4/26 and noted the following: CNA called and informed writer R2 was found on the floor at the front of the nursing station. R2 observed lying down on the floor facing the couch at front of nursing station with her back on her wheelchair. R2 stated she was looking for her family when she did not see them, she tried to transfer self to the couch and slid to the floor. No injuries noted. No statements found. IDT met regarding fall on 6/4/26. R2 was found lying on floor in front of the nursing station, facing the couch with her wheelchair positioned behind her. R2 reports that she attempted to transfer herself from the wheelchair to the couch, sliding to the floor. Root cause identified as R2 attempting an unassisted transfer while searching for family. Intervention: dycem placed under wheelchair cushion. Surveyor noted the intervention of Dycem to wheelchair added to R2's care plan already on 5/11/26. The investigation does not indicate the last time someone saw R2 or if the Dycem was in the wheelchair per the Kardex/Care Plan. The investigation did not indicate what type of footwear R2 was wearing at the time of the fall. No additional interventions were added to the plan of care to assist in the prevention of further falls. On 7/22/26, Surveyor interviewed Clinical Consultant- C regarding the fall's investigations for 5/11/26, 5/23/26, 6/1/26 and 6/4/26. Clinical Consultant stated everything the facility had on R2's falls had been provided to Surveyor. Clinical Consultant- C was made aware the plan of care had not been updated with further interventions to prevent R2 from further falls. Clinical Consultant- C again stated what was provided is all the facility had. On 7/22/26 at 3:00 PM, Surveyor interviewed Director of Nursing (DON)-B about R2's falls, DON- B stated she would need to follow-up and would get back to Surveyor with additional information. As of the time of exit on 7/23/26, the facility was unable to provide additional evidence that they had thoroughly investigated R2's falls in an attempt to update the plan of care with further interventions to keep R2 safe from further falls. 2.) R43 was originally admitted to the facility on [DATE] with diagnosis that included Dementia, Anxiety, malnutrition and chronic pain.R43 was admitted to hospice care on 2/16/26 with diagnosis of moderate calorie malnutrition. The facility completed an Admission falls assessment on 2/18/26. R43 has a score of 11, indicating at risk for falls. Surveyor conducted a review of R43's significant change MDS (Minimum Data Set), dated 2/22/26. The MDS documents R43 has a BIMS (brief interview for mental status) score of 6, indicating severe cognitive impairment. R43 is assessed to need substantial/maximal assistance for most activities of daily living. R43 is frequently incontinent of bowel and bladder. R43 has had 1 fall since admission and there was no injury. Surveyor reviewed R43's individual plan of care and noted the following: R43 is at risk for falls r/t (related to) Confusion, weakness, Gait/balance problems and history of falls, foot pain, dementia, fall 2/22/26. Date Initiated: 06/24/2024. Revision on: 02/23/2026.Interventions included: Risk of falls/falls with injury will be minimized. Date Initiated: 06/24/2024. 4/5/25-fall-staff to offer toileting q (every) 2 to 3 hours and as needed. Date Initiated: 04/05/2025 6/7/26: Reacher at bedside. Date Initiated: 06/08/2026. Be sure R43's call light is within reach and encourage R43 to use it for assistance as needed. Date Initiated: 06/24/2024. fall-5/25/25-staff to ensure resident not attempting to feed others when dining room. Date Initiated: 05/25/2025. Follow facility fall protocol. Date Initiated: 12/12/2025. Toilet resident after dinner Date Initiated: 02/22/2026. Nurses note dated 5/21/2026 at 11:51 PM, documents R43 had a fall at approximately 10:40 PM. R43 states she thought it was morning at the time of the fall. Vital signs stable. Neuro (neurological) checks initiated and ongoing. No visible injuries noted upon assessment. Director of Nursing notified. Physician notified. Hospice notified. Surveyor conducted a review of the facility's falls investigation dated 5/21/26. The investigation documents a staff statement was obtained on 5/27/26 (name unknown). Statement is that while in the hallway with another nurse, R43 was heard yelling. Upon entering the room, R43 was observed sitting upright on the floor with a pillow positioned under her knees/legs. R43 stated she thought it was morning and was attempting to get ready. Vital signs were obtained, and no injuries were noted upon assessment. R43 denied hitting her head. Surveyor noted there was no additional information regarding the last time R43 had been cared for and what fall prevention interventions were in place at the time of the fall. Surveyor requested to review this falls investigation on 7/21/26. The investigation had a note added on 7/21/26 written by Director of Nursing (DON)- B stating R43 experienced a fall at approximately 10:40 PM. R43 believed it was morning at the time of the fall. Suggesting impaired orientation to time. Root cause: impaired orientation regarding time of day. Interventions: maintain a low-stimulation environment overnight by turning off room lights at bedtime while ensuring adequate night lighting for safe mobility and keep call light in reach. Surveyor noted these interventions were not added to the plan of care and R43 was assessed to require substantial/maximal assistance from staff for mobility. Nursing note dated 6/7/2026 at 2:25 PM, documents Writer called to room. R43 on floor sitting on her butt, next to recliner with w/c (wheelchair) behind her, R43 was just placed in w/c by CNA (Certified Nursing Assistant). Call light in place, R43 had an unwitnessed fall from w/c to floor. R43 stated she was trying to reach for something. R43 was found alert with confusion per normal baseline, ROM (Range of Motion) WNL (Within Normal Limits), neuro (neurological) check negative, denies any additional pain other than the raised bump on the left side of her forehead about 5cm (centimeters) x (by) 4cm, ice applied, VSS (Vital Signs Stable), R43 transferred from floor to bed with 2 assist, Hospice on call notified, Hospice will come to SNF (Skilled Nursing Facility) to visit R43, message left for Dr. (Doctor) to update on fall. Power of Attorney updated on fall. On 6/7/2026 at 2:45PM, the facility completed a Skin Evaluation and documented the following: Skin warm & dry, skin color WNL, mucous membranes moist, turgor normal. R43 has current skin issues. Skin Issue: Bruising. Skin issue location: left forehead Length: 5cm Width: 5cm Tissue: Painful. Note / Notification / Education: Skin note: bumped head on floor. Provider Contacted: Time Notified: 246p (2:46 PM) Notification Details: message left. Person Contacted: Power of Attorney. Time Notified: 246pm (2:46 PM) Notification Details: n/a (not applicable). Resident / Responsible Party aware of diagnosis and plan of care: Yes. Resident education provided R/T (related to) new diagnosis: Yes. Resident education provided R/T new order: Yes. Education provided in preparation for discharge: Yes. Other Education Notes: n/a. On 7/21/26, Director of Nursing (DON)-B provided hospice communication regarding R43's fall on 6/7/26. DON- B stated the hospice RN arrived on 6/7/26 at 3:36 PM (approximately 2 hours after fall). The following was noted: Client Coordination Note Report dated 6/7/26; PM staff (facility staff) reports that R43 had a fall while she was sitting in her wheelchair. They (facility) report that R43 fell forward and hit her head. Fall unwitnessed. R43 obtained bump and bruise to left forehead and temple. No skin tear or wounds obtained. Vital signs stable. Per medication profile, R43 is taking Eliquis (anticoagulant/ blood thinner). R43 is sleeping on arrival and doesn't wake up to answer questions. Staff (facility) report R43 had Ativan. Surveyor reviewed June 2026 Medication Administration Record and noted Lorazepam 0.5 milligram tablet by mouth every 2 hours as needed for anxiety was administered on 6/7/26 at 9:00 AM, and 12:00 PM/noon. Fall Mat in place. Bed in low position. Remote within reach. Writer offered to obtain a Broda chair. They declined at this time. R43 has wheelchair in that (sic) is used to pedal around floor. Writer attempted to contact Power of Attorney, no answer and voicemail left to call with update, Fax sent to Nurse Practitioner . Fall education provided. They (facility staff) know to call with questions or concerns. R43 will be made in medical examiner case in relation to hitting her head. Surveyor verified Neuro checks were completed on 6/7/26 per facility's policy. R43 appeared to be at baseline. Surveyor conducted review of the following days nursing notes and there was no documentation regarding a change in mentation or pain from fall on 6/7/26. Hospice Progress note dated 6/8/26, documents RN (hospice) contacted Nurse Practitioner to updated on R43's fall. No new orders. RN to confirm with R43's Activated Power of Attorney if he/she is ok to discontinue Eliquis and let Nurse Practitioner know. Surveyor conducted a review of the facility's falls investigation dated 6/7/26. The post fall huddle form documents the fall occurred at 1:50 PM on 6/7/26. R43 was said to be reaching for her purse. R43 was documented to be seen 5 to 10 minutes prior to fall to be toileted. R43 had gripper socks on. R43 was not incontinent of bowel or bladder at the time of the fall. Was care plan being followed- yes. Was call light on- yes. Staff statements were obtained. Certified Nursing Assistant stated that they heard yelling and instantly went over and saw R43 on the floor trying to grab purse. Staff intervention was to put R43 back to bed and gave ice pack. It was documented as an intervention suggestion that the nurse told the Certified Nursing Assistant to put R43 back to bed and the nurse checked her vitals and gave R43 an ice bag. On 6/8/26 the Interdisciplinary Team met regarding R43's fall on 6/7/26, documented was R43 attempted to reach for her purse, which was out of reach at the bedside and slid from the bed to the floor while trying to retrieve it. The incident and contributing factors were reviewed by the team. Interventions: R43 reminded to use the Reacher to retrieve items that are out of reach and to use the call light for assistance rather than overreaching. Reacher remains at the bedside, and staff will ensure R43's purse and other frequently used personal items are kept within easy reach during routine care to reduce the risk of future falls. Surveyor noted R43's plan of care was updated on 6/7/26 for R43 to have a reacher at bedside. On 07/20/2026 at 12:11 PM, Surveyor observed R43 to be sleeping in bed. R43 was positioned with pillows and there was a fall mat to the left side of the bed. R43 did not have a reacher at her bedside. R43's care plan does not have the use of a fall mat as an intervention to prevent falls. On 07/21/2026 at 8:44 AM, Surveyor observed R43 asleep in bed that was low to the ground. There was a fall mat on floor. R43 did not have a reacher at bedside. R43's plan of care does not document the use of a low bed or mat on the floor as an intervention to prevent falls. On 07/22/2026 at 1:10 PM, Surveyor observed R43 seated in the wheelchair in her room. R43's lunch tray was served. Surveyor observed R43's reacher to be on the table and out of reach of R43. R43's purse was also on the other side of the room on top of a storage container, out of reach of R43. On 7/22/26 at 3:00 PM, Surveyor interviewed Nursing Home Administrator- A and DON-B regarding R43's falls and the plan of care. Surveyor shared the observations made of R43 in her room when the reacher was not available, her purse was not within reach and there were interventions being used that were not a part of the plan of care. DON- B stated she would look into this. On 7/23/2026 at 1:05 PM, Surveyor conducted an interview with Hospice RN- G regarding R43's fall on 6/7/26. Hospice RN -G stated generally they (hospice provider) can't send a patient out to the hospital without family's approval as it will change the payor source and take the individual off of hospice. Hospice RN- G reviewed note from Hospice RN who assessed R43 on 6/7/26. Surveyor asked why R43 wasn't sent out for further evaluation being R43 was receiving a blood thinner and had a bump to the forehead. Hospice RN- G stated she can't answer directly for this situation as she was not the nurse who conducted the in-person assessment of R43. As of the time of exit on 7/23/26, the facility was unable to provide additional information as to why R43's plan of care was not updated with interventions to assist in keeping R43 safe from falls. 3) R1 was admitted to the facility on [DATE], with diagnoses including generalized anxiety disorder, unspecified dementia, and major depressive disorder. R1's Annual Minimum Data Set (MDS) assessment dated [DATE] documented R1 had a Brief Interview of Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. R1 had an activated healthcare power of attorney (POA). R1's MDS documented 2 or more falls since admission with no injury. R1's Care Area Assessment (CAA) for falls dated 6/30/26 documented fall score of 21 indicates fall risk, fall history, gets up without assistance of call light, continue assistance to safely transition surfaces, encourage and remind to call for assist, proceed to care plan. R1's care plan for focus area at risk for falls initiated 6/25/26 documented the following interventions: -6/26/26- switch wheelchairs, resident to use broda chair -6/27/26- scoop mattress, bed in lowest position and mat on floor -6/29/26- change toileting plan and resident to be in broda chair while awake -anticipate and meet the resident's needs -follow facility fall protocol -review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team) as to causes. R1's fall investigation dated 7/13/26 written by licensed practical nurse (LPN)-N documented R1 had an unwitnessed fall in room, certified nursing assistant (CNA) found on knees on the floor mat in front of the bed, no injuries noted and vital signs stable. The notes section of the investigation documented IDT met regarding resident's fall . root cause identified as the resident attempting to self-transfer without assistance . intervention: resident reminded to use the call light for assistance with all transfers. Call don't fall sign placed. Surveyor notes R1's fall investigation did not include a statement from the CNA who discovered R1 had fallen on 7/13/26 or include a complete evaluation and analysis of R1's fall to identify the last time R1 was checked on by staff, offered toileting, or if care plan interventions were in place and effective at the time of the fall. On 7/22/26 at 1:13 PM, Surveyor observed R1's room and did not observe a call don't fall sign anywhere in R1's room. Surveyor notes the intervention for a call don't fall sign was not added to R1's fall care plan. On 7/22/26 at 8:30 AM, Surveyor asked Director of Nursing (DON)-B if the facility had any additional investigation or information regarding R1's fall on 7/13/26. DON-B stated a fall packet is usually completed with staff statements and more details regarding the last time a resident was last checked on or changed, and they would look for one for R1's fall on 7/13/26. On 7/22/26 at 2:04 PM, DON-B and Clinical Nurse Consultant (CNC)-C stated they were unable to locate any additional investigation or information regarding R1's fall on 7/13/26. Surveyor shared concern with DON-B and CNC-C that a thorough investigation was not completed for R1's fall on 7/13/26, and DON-B and CNC-C replied they were not sure why a complete investigation was not completed for that fall. 4.) R39 was admitted to the facility on [DATE] with diagnoses including depression, orthostatic hypotension, Type 2 Diabetes Mellitus, muscle weakness, other abnormalities of gait and mobility, repeated falls, and unspecified dementia. R39's admission Minimum Data Set (MDS) assessment dated [DATE] documented R39 had a fall in the last month and R39 required maximal assistance for transfers in and out of the wheelchair. R39's Care Area Assessment (CAA) for falls dated 11/17/25 documented a fall score of 13, indicating at risk for falls, proceed to care plan, at risk due to dementia and in new environment. R39's care plan for focus area at risk for falls initiated 11/10/25 documented the following interventions: -be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Resident needs prompt response to all requests for assistance -call don't fall sign placed in room (12/8/25) -dycem placed under wheelchair cushion (1/17/26) -educate resident/family/caregivers about safety reminders and what to do if a fall occurs -ensure resident is wearing appropriate footwear non-skid socks when transferring or mobilizing in wheelchair (12/10/25) -follow facility fall protocol (12/10/25) -resident encouraged to stay at the nurse's station/with staff for closer supervision (1/21/26) -resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach (12/10/25) On 7/21/26 at 7:52 AM, Surveyor observed R39's room and did not observe a call don't fall sign anywhere in the room. On 7/22/26 at 7:54 AM, Surveyor observed R39's room and did not observe a call don't fall sign anywhere in the room. On 7/21/26 at 10:10 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-O, who stated R39 is a fall risk and gets antsy in bed and in the wheelchair. CNA-O stated staff checks on R39 often and keep R39 in common areas during the day to prevent falls. CNA-O stated R39 does not really use the call light. CNA-O was not aware if R39 should have a call don't fall sign in their room. On 7/22/26 at 11:34 AM, Surveyor reviewed R39's fall investigations dated 1/17/26 and 3/31/26. R39's fall investigation dated 1/17/26 documented a root cause of sliding out of the wheelchair, and the IDT (Interdisciplinary Team) identified a new intervention of placing dycem under R39's wheelchair cushion to prevent further sliding would be appropriate. R39's fall investigation dated 3/31/26 documented a root cause of sliding out of the wheelchair due to poor positioning and stability, and the IDT determined a new intervention of dycem applied to R39's wheelchair to prevent sliding and promote stability. Surveyor notes the intervention of adding dycem to R39's wheelchair was added to R39's falls care plan on 1/17/26 and should have been in place at the time of R39's fall on 3/31/26. On 7/22/26 at 1:55 PM, Surveyor interviewed Director of Nursing (DON)-B, who stated R39's fall care plan interventions include a call don't fall sign in room, dycem to the wheelchair, proper footwear with non-skid socks, encourage to stay at nurse's station for supervision, and call light within reach. DON-B stated the call don't fall sign was implemented 12/8/25 and the dycem to the wheelchair was implemented 1/17/26. Surveyor shared concern with DON-B and Clinical Nurse Consultant (CNC)-C of observations of a call don't fall sign not being in place in R39's room and that R39's fall investigation on 3/31/26 documented a new intervention of dycem to the wheelchair, which was implemented on 1/17/26. CNC-C stated they would follow up with Surveyor regarding additional clarification of the dycem, but no additional information was provided.

Based on interview and record review, the facility did not ensure injuries of an unknown source were reported immediately, but not later than 24 hours after the event, to the State Agency for 3 of 3 residents (R1, R44, R43) reviewed for injuries of unknown origin from a sample of 12 residents. R1 was found by a family member with bruising and swelling the left ankle. The facility did not report the injury of unknown origin to the State Agency. R44 had an injury of unknown origin reported to staff by a family member on 7/6/26, which was not reported to the Nursing Home Administrator (NHA) until 7/11/26. R43 was found with bruising to the forehead. The facility did not report the injury of unknown origin to the State Agency. Findings include: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with approval date 8/28/17 and review date 2/11/26 documents: . Reporting and response . it is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility and to other officials (including to the State Survey Agency .) in accordance with State law through established procedures. 1) R1 was admitted to the facility on [DATE] with diagnoses including anemia, and unspecified dementia. R1 had an activated power of attorney (POA) for healthcare decisions. On 7/20/26 at 1:18 PM, Surveyor spoke with R1's POA via phone call who stated R1 has had quite a few falls since being at the facility and the facility stated there were no injuries, however, when they came to visit R1 on 7/14/26, they noticed R1's foot was swollen and bruised. R1's nursing progress note dated 7/13/26 documented an unwitnessed fall at 6:45 AM, R1 was found on the floor mat in front of the bed on knees, no injuries noted. Surveyor reviewed R1's electronic health record (EHR) and located an x-ray report dated 7/14/26 which documented the following: left foot x-ray, no acute findings . left ankle x-ray, no acute findings, soft tissue swelling noted around the ankle. Surveyor did not locate any nursing progress notes regarding bruising or swelling of R1's left foot or ankle on 7/14/26. R1's skin only evaluation dated 7/14/26 documented skin color within normal limits (WNL), no current skin issues. R1's skin monitoring: comprehensive shower review document dated 7/14/26 documented no new skin issues noted. Surveyor notes both the skin only evaluation and skin monitoring document were completed and signed by Licensed Practical Nurse (LPN)-F. On 7/22/26 at 8:30 AM, Surveyor interviewed LPN-F who stated when they assessed R1's skin on 7/14/26, they did not see any bruising or swelling, and R1 has never had any bruising or swelling on the left ankle. LPN-F did not recall R1 ever getting an x-ray on the left foot or ankle on 7/14/26. On 7/21/26 at 10:18 AM, Surveyor interviewed Hospice Registered Nurse (RN)-G who stated they saw R1 on 7/14/26 when R1's POA was at the facility and noted R1's left foot was swollen and blue. Hospice RN-G stated R1 did have a fall the day prior, but they were not sure if the swelling was from the fall or not. Hospice RN-G stated R1's Nurse Practitioner (NP) and Medical Doctor (MD) were both at the facility that day and looked at R1's foot and R1's MD ordered an x-ray. On 7/21/26 at 11:09 AM, Surveyor interviewed NP-H who confirmed they saw R1 on 7/14/26 after it was brought to their attention by Hospice RN-G that R1 had swelling and bruising on the left foot and ankle region and R1's MD ordered an x-ray that day, which came back negative for any fractures. NP-H stated there was not any notification from the facility regarding R1's bruising or swelling, and NP-H was only made aware of the swelling and bruising from Hospice RN-G. On 7/22/26 at 2:04 PM, Surveyor shared concern with Director of Nursing (DON)-B and Clinical Nurse Consultant (CNC)-C that R1 was found with bruising and swelling of the left ankle on 7/14/26, which was not reported to the State Agency as an injury of unknown origin. DON-B and CNC-C stated they would look into it and get back to Surveyor. On 7/23/26, Surveyor was provided with a document titled Client Coordination Note Report written by Hospice RN-G, with print date 7/22/26 at 3:25 PM. The report documented visit completed, R1's POA noted left foot swollen with trace edema. MD rounded on R1 and ordered an in-house x-ray. On 7/23/26 at 12:21 PM, Surveyor shared concern with NHA-A that R1 had a fall on 7/13/26 which the facility documented did not result in any injuries, and R1's skin assessments dated 7/14/26 documented no skin abnormalities, however, R1's hospice RN, NP, and MD were made aware of bruising and swelling to R1's left ankle on 7/14/26, which was not reported to the State Agency as an injury of unknown origin. NHA-A stated they believe the bruising and swelling were a result of R1's fall the day prior, but the facility did not document on the injury appropriately. NHA-A stated the facility should have documented better to determine if R1's bruising and swelling were from the fall or from an unknown event. 3) R43 was admitted to the facility on [DATE] with diagnosis that included Dementia and Anxiety. R43's quarterly MDS (Minimum Data Set), dated 5/22/26, documentsR43 has a BIMS (brief interview for mental status) score of 6 indicating severe cognitive impairment. R43 is also assessed to have 1 fall since admission without injury and no noted behavior concerns. Nursing note dated 6/11/26 at 5:34 AM, Skin Evaluation: Skin warm & dry skin color WNL (within normal limits), mucous membranes moist, turgor normal. [R43] has current skin issues. Skin Issue: Bruising. Skin issue location: left eye / forehead Length: 2cm (centimeters) x (by) 2cm Tissue: Painful. Note / Notification / Education: Skin note: RN(Registered Nurse)- [I] entered R43's room to do assessment, while doing vital signs , RN- [I] noticed [R43] in bed awake, [R43] had no O2(oxygen) in place , RN- [I] placed O2 on [R43] at 3L (liters) N/C (nasal cannula) , POX (pulse oximetry) - 91% , resp (respirations)- 20 , no SOB (shortness of breath) - bilateral lungs clear , RN-[I] changed [R43's] brief with skin cares, provided fluids, during assessment RN-[I] noted a large bruise / discoloration of yellow / blueish / green to left facial area and forehead with 2cm x 2cm hematoma - no O/A (open area) visible , [R43] can't recall if she fell today. On Jun 09, 2026 – [R43] did not have any facial bruising or discoloration during NOC (night shift) shift between 2200pm (10:00 PM) - 06am (6:00 AM). Nurse Practitioner- [H] made aware via text message, on call Supervisor made aware via text message, Hospice made aware at 4:00 AM left message, VSS (vital signs stable), neuro. (neurological) check x2 - wnl, PRN (as needed) meds (medication)effective for comfort, bed placed in low position with soft touch call light. On 7/22/26 at 12:15 PM, Surveyor interviewed Director of Nursing- B regarding R43's left facial and forehead bruising and hematoma. DON- B stated she was not in the facility at this time and would need to check into concern further. Surveyor reviewed the nursing note from 6/11/26 regarding the findings and noted facility staff member reported on 6/9/26, during NOC shift the bruising was not present. Surveyor asked DON- B if this injury should have been reported as an injury of unknown source. DON- B replied yes it should have been reported. On 7/22/26 at 12:45 PM, Surveyor interviewed RN Nurse Supervisor-D regarding R43's bruising that was discovered by RN- I on 6/11/26. RN Supervisor-D provided Surveyor with documentation regarding R43's fall on 6/7/26. The incident description documents R43 had an unwitnessed fall from the wheelchair to the floor. R43 denied pain other than the raised bump on the left side of her forehead about 5 centimeters by 4 centimeters. Ice was applied. Documented injuries reported for this fall was a bruise to the top of the scalp. Surveyor reviewed the comparison between the injuries noted from the fall on 6/7/26 and the injuries noted by staff on 6/11/26. Surveyor noted staff worked 6/9/26 and documented the injuries were not present. RN Supervisor- D stated she recalls talking about the fall 6/7/26 but did not have any additional information as to why a further investigation was not completed and reported to the State Survey Agency. 07/23/2026 9:24 AM Surveyor left a voicemail message for RN-I to return call to discuss R43's bruises that were discovered on 6/11/26. RN- I is no longer employed by the facility and did not return Surveyors phone call. As of the time of exit on 7/23/26, the facility was unable to provide additional information as to why R43's bruising to the left eye and forehead was not reported to the State Survey Agency. 2) R44 was admitted to the facility on [DATE] with diagnoses to include stroke, metabolic encephalopathy, abnormalities to gait and mobility and dementia. R44's Comprehensive Minimum Data Set (MDS), dated [DATE], documented R44 has a Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment. R44 was assessed to be at risk for falls. R44 is dependent on staff for assistance with mobility. R44's Nurse's Note, dated 7/11/2026 at 13:13 (1:13 PM), documented, Writer made aware of resident noted bruising to top of right hand fourth digit knuckle area and random area of discoloration to right forearm and an area on left forearm along with small skin shear to left knee. Writer assisted with rom (range of motion) to digits of affected hand and resident did not grimace, wince or flinch in pain or discomfort. R44 did not respond when asked if they were in pain. Rom per baseline to left knee without difficulty DON (Director of Nursing), ADON (Assistant Director of Nursing), NP (Nurse Practitioner) updated, received order for 2 view x-ray of wrist and hand. Ice pack applied for comfort. Writer updated POA (Power of Attorney) and notified them of new order for x-ray. POA (Power of Attorney) grateful for f/u (follow up) care. DON, ADON, NP and Administrator notified. Will continue with plan of care and keep family updated. The facility's Investigation Summary, dated 7/17/26, documented, in part .Assistant Director of Nursing (ADON)-D was contacted by Licensed Practical Nurse (LPN)-J on 7/11/26 and was informed that bruises and swelling were observed on resident. Resident was unable to describe the cause of the bruising and was unable to identify a staff member that was working with R44 when any incident may have occurred. Administrator was notified and investigation of an injury of unknown origin was initiated. Police were also notified.Several staff statements were completed. One of the staff statements, an aide stated Certified Nursing Assistant (CNA)-M stated the family informed them of bruises on 7/6/26. The CNA-M stated that they informed LPN-L, of the bruises on 7/6/26. During an interview with LPN-L they stated no one made them aware of the bruising or swelling. Resident was assessed by nursing on 7/11/26 and was sent to the hospital to be further evaluated. Police report will be forwarded upon completion.Through multiple interviews with staff and residents, the facility was unable to determine a cause of the injuries. It appears that the bruises may have been observed on 7/6/26, but it remains unclear if the nurse was notified of the bruises at that time. As a result, the facility is unable to substantiate abuse. Counselling was provided to the aide and nurse to ensure that notification and documentation of any injury of unknown origin need to be completed timely and that the DON an Administrator need to be notified immediately. Surveyor notes the facility's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report was submitted on 7/11/26 when the injury of unknown origin was initially identified by staff on 7/6/26. Once the injury of unknown origin was identified on 7/11/26 by a different staff member, it was reported to Nursing Home Administrator (NHA)-A. Surveyor noted the report was submitted 6 days late and should have been reported on 7/6/26 when the injury was initially identified. On 7/23/26 at 2:05 PM, Surveyor spoke with NHA-A and Director of Nursing (DON)-B and asked what the expectation for staff is to report an injury of unknown origin and NHA-A stated, immediately upon knowledge to NHA-A and/or DON-B. Surveyor let NHA-A and DON-B know that since staff knew of the bruising on 7/6/26 and it was not discovered by another staff member and reported on their discovery on 7/11/26 that this was a concern. NHA-A acknowledged this was a concern and NHA-A stated that this is why they educated staff on reporting any injuries of unknown origin immediately.

Based on interview and record review, the facility did not ensure an alleged violation of mistreatment, including injuries of unknown source, was thoroughly investigated for 2 of 3 (R1, R43) residents reviewed for injuries of unknown origin from a sample of 12 residents. R1 was found by a family member with bruising and swelling of the left ankle. The facility did not investigate the injury of unknown origin. R43 was found with bruising to the forehead. The facility did not investigate the injury of unknown origin or report an investigation. Findings include: The facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property with approval date 8/28/17 and review date 2/11/26 documents: . Investigation of injuries of unknown origin or suspicious injuries: must be immediately investigated to rule out abuse: . injuries include, but are not limited to, bruising of the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises, and/or bruising in an area not typically vulnerable to trauma. if an incident or allegation is considered reportable, the Executive Director or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within five (5) working days. Report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State law, including immediate or 24 hour reporting to the State Survey Agency, law enforcement and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. 1) R1 was admitted to the facility on [DATE] with diagnoses including generalized anxiety disorder, major depressive disorder, anemia, and unspecified dementia. R1 had an activated power of attorney (POA) for healthcare decisions. On 7/20/26 at 1:18 PM, Surveyor spoke with R1's POA via phone call who stated R1 has had quite a few falls since being at the facility and the facility stated there were no injuries, however, when they came to visit R1 on 7/14/26, they noticed R1's foot was swollen and bruised. R1's nursing progress note dated 7/13/26 documented an unwitnessed fall at 6:45 AM, R1 was found on the floor mat in front of the bed on knees, no injuries noted. Surveyor reviewed R1's electronic health record (EHR) and located an x-ray report dated 7/14/26 which documented the following: left foot x-ray, no acute findings . left ankle x-ray, no acute findings, soft tissue swelling noted around the ankle. Surveyor was unable to locate any nursing progress notes documenting bruising and swelling of R1's left foot or ankle on 7/14/26. R1's skin only evaluation dated 7/14/26 documented skin color within normal limits (WNL), no current skin issues. R1's skin monitoring: comprehensive shower review document dated 7/14/26 documented no new skin issues noted. Surveyor notes both the skin only evaluation and skin monitoring document were completed and signed by Licensed Practical Nurse (LPN)-F. On 7/22/26 at 8:30 AM, Surveyor interviewed LPN-F who stated when they assessed R1's skin on 7/14/26, they did not see any bruising or swelling, and R1 has never had any bruising or swelling on the left ankle. LPN-F did not recall R1 ever getting an x-ray on the left foot or ankle on 7/14/26. On 7/21/26 at 3:01 PM, Surveyor requested any investigation the facility completed for R1's left foot and ankle bruising and swelling on 7/14/26 from Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Clinical Nurse Consultant (CNC)-C. No additional information was provided to Surveyor at that time. On 7/22/26 at 2:04 PM, DON-B informed Surveyor that no investigation was found for R1's left ankle bruising and swelling on 7/14/26. On 7/23/26 at 12:21 PM, Surveyor interviewed NHA-A, who stated NHA-A is made aware of any potential injuries of unknown origin from the DON or assistant DON, who are told of any concerns by floor nurses and floor staff. NHA-A stated the facility would quickly determine if there were a reasonable cause for a resident's injury, and if the facility cannot determine a reasonable cause, they would investigate the injury as an unknown source. Surveyor shared concern with NHA-A that R1 developed bruising and swelling to the left ankle and foot on 7/14/26, but the facility did not investigate the injury. NHA-A stated they believed R1's bruising was a result of a fall the day prior, but the facility did not have any documentation that R1 had injuries or skin abnormalities on 7/13/26 or 7/14/26, so no investigation was completed. 2) R43 was admitted to the facility on [DATE] with diagnosis that included Dementia and Anxiety. The most recent quarterly MDS (Minimum Data Set), dated 5/22/26, documents R43 has a BIMS (brief interview for mental status) score of 6, indicating severe cognitive impairment. R43 is also assessed to have 1 fall since admission without injury and no noted behaviors. Nursing note dated 6/11/26 at 5:34 AM, Skin Evaluation: Skin warm & dry skin color WNL (within normal limits), mucous membranes moist, turgor normal. [R43] has current skin issues. Skin Issue: Bruising. Skin issue location: left eye / forehead Length: 2cm (centimeters) x (by) 2cm Tissue: Painful. Note / Notification / Education: Skin note: RN(Registered Nurse)- [I] entered R43's room to do assessment, while doing vital signs , RN- [I] noticed [R43] in bed awake, [R43] had no O2(oxygen) in place , RN- [I] placed O2 on [R43] at 3L (liters) N/C (nasal cannula) , POX (pulse oximetry) - 91% , resp (respirations)- 20 , no SOB (shortness of breath) - bilateral lungs clear , RN-[I] changed [R43's] brief with skin cares, provided fluids, during assessment RN-[I] noted a large bruise / discoloration of yellow / blueish / green to left facial area and forehead with 2cm x 2cm hematoma - no O/A (open area) visible , [R43] can't recall if she fell today. On Jun 09, 2026 – [R43] did not have any facial bruising or discoloration during NOC (night shift) shift between 2200pm (10:00 PM) - 06am (6:00 AM). Nurse Practitioner- [H] made aware via text message, on call Supervisor made aware via text message, Hospice made aware at 4:00 AM left message, VSS (vital signs stable), neuro. (neurological) check x2 - wnl, PRN (as needed) meds (medication) effective for comfort, bed placed in low position with soft touch call light. On 7/22/26 at 12:15 PM, Surveyor interviewed Director of Nursing- B regarding R43's left facial and forehead bruising and hematoma. Surveyor asked if an investigation had been conducted and DON- B stated she was not in the facility at this time and would need to check into concern further. Surveyor asked DON- B if this injury should have been investigated as an injury as an injury of unknown source. DON- B replied yes, it should have been further investigated. On 7/22/26 at 12:45 PM, Surveyor interviewed RN Nurse Supervisor-D regarding R43's bruising that was discovered by RN- I on 6/11/26. RN Supervisor-D provided Surveyor with documentation regarding R43's fall on 6/7/26. The incident description documents R43 had an unwitnessed fall from the wheelchair to the floor. R43 denied pain other than the raised bump on the left side of her forehead about 5 centimeters by 4 centimeters. Ice was applied. Documented injuries reported for this fall was a bruise to the top of the scalp. Surveyor reviewed the comparison between the injuries noted from the fall on 6/7/26 and the injuries noted by staff on 6/11/26. Surveyor noted staff worked 6/9/26 and the injuries were not present. RN Supervisor- D stated she recalls talking about the fall 6/7/26 but did not have any additional information as to why a further investigation was not completed. 07/23/2026 9:24 AM Surveyor left a voicemail message for RN-I to return call to discuss R43's bruises that were discovered on 6/11/26. RN- I is no longer employed by the facility and did not return Surveyors phone call. As of the time of exit on 7/23/26, the facility was unable to provide additional information as to why R43's bruising to the left eye and forehead was not further investigated as an injury of unknown source.

Based on interview and record review the facility did not ensure 3 (R56, R4 and R1) of 3 residents received necessary care and treatment. On 5/28/26 R56 had physician orders from a nephrology consult for daily weights and applying Sequential Compression Device (SCD) for edema. The facility did not obtain daily weights and SCD to monitor. On 12/30/25 R4 sustained an unwitnessed fall. The fall investigation documents neuro (neurological) checks to be conducted. The facility had no evidence neuro checks were completed. On 7/13/26 R1 sustained an unwitnessed fall. The fall investigation documents neuro (neurological) checks to be conducted. The facility had no evidence neuro checks were completed. Findings include: 1.) R56 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure, congestive heart failure, type 2 diabetes and chronic kidney disease stage 4. The admission minimum data set (MDS) dated [DATE] documents R56 is cognitively intact. On 5/28/26 R 56's nephrology consultation form documents the following orders: discontinue (d/c) Lasix, start bumex 2 milligram (mg) twice a day (BID), daily weights, if not losing weight to call nephrology and if possible, apply SCD (Sequential Compression Device) for edema. Surveyor reviewed R56's medication administration record (MAR) and treatment administration record (TAR). The MAR documents Lasix was d/c and bumex was ordered. There is no documentation of daily weights or SCD being ordered. On 5/30/26 R56 was discharged home with home health services. The discharge summary does not document if SCD was ordered for R56 for home use. On 7/23/26 at 9:35 a.m. Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked who is responsible for following through on the nephrology consult orders. DON-B stated the nurse that receives that consult is responsible. Surveyor explained the order for daily weights were not completed. Surveyor also explained SCD were not ordered. DON stated the facility does not order SCD. Surveyor asked if the nephrology office were made aware of SCD not ordered and if there were other devices or ways to help with R56 edema. Surveyor also asked if SCD were ordered as part of the discharge home orders. DON-B stated she was not sure and would look into it. On 7/23/26 at 11:02 a.m. DON-B explained the facility did not order SCD and did not follow up with nephrology because the order said if possible. DON-B stated R56 was sent home with home physical and occupation therapy, and they could assess R56's need for SCD and whether insurance would cover it. Surveyor notes here is no documentation the need for SCD for edema was communicated to the home health agency. 2.) R4 was admitted to the facility on [DATE] with diagnoses of vascular dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The quarterly minimum data set (MDS) dated [DATE] documents severe cognitive impairments and needs moderate assistance for bed mobility and dependent on staff for transfers. On 12/30/25 R4 had an unwitnessed fall. The fall investigation documents R4 was self-transferring from the wheelchair to the toilet. R4 was observed on his buttocks on the floor in the bathroom. The fall investigation documents, because R4 had an unwitnessed fall neuro (neurological) checks were started. On 7/22/26 at 9:30 a.m., Surveyor spoke with Director of Nursing (DON)-B and Clinical Nurse Consultant (CNC)-C. Surveyor asked to see the neuro checks that were completed for R4 related to the 12/30/25 fall. On 7/22/26 at 12:00 p.m., CNC-C and DON-B explained they are unable to locate any further information related to R4's fall and neuro checks. 3.) R1 was admitted to the facility on [DATE], with diagnoses including generalized anxiety disorder, unspecified dementia, and major depressive disorder. R1's Annual MDS assessment dated [DATE] documented R1 had a Brief Interview of Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. R1 had an activated healthcare power of attorney (POA). R1's MDS documented 2 or more falls since admission with no injury. R1's Care Area Assessment (CAA) for falls dated 6/30/26 documented a fall score of 21 indicates fall risk, fall history, gets up without assistance of call light, continue assistance to safely transition surfaces, encourage and remind to call for assist, proceed to care plan. R1's nursing progress note dated 7/13/26 documented an unwitnessed fall at 6:45 AM, found on knees on the floor mat in front of bed, no injuries noted, vital signs stable. On 7/22/26, Surveyor requested R1's fall investigation with evidence of neurochecks completed by the facility on 7/13/26 from Director of Nursing (DON)-B. On 7/22/26 at 2:04 PM, DON-B and Clinical Nurse Consultant (CNC)-C informed Surveyor they could not find an investigation for R1's fall on 7/13/26 with evidence that neurochecks were completed. CNC-C stated neurochecks should have been completed since it was an unwitnessed fall.

Based on interview and record review, the facility did not ensure 1 (R39) of 1 resident was free of significant medication errors from a sample of 12 residents.R39 received a different resident's medications on 6/10/26. R39 was prescribed Valbenazine Tosylate for Tardive Dyskinesia without a documented diagnosis of Tardive Dyskinesia or other documented indication to receive Valbenazine Tosylate. R39 was administered 32 doses of Valbenazine Tosylate 60 milligrams (mg) between the dates of 6/16/26 and 7/21/26.Findings include:The facility policy titled Pharmacy Services for Nursing Facilities dated 5/2018 documents: .Administration . if a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and/or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. the person who prepares the dose for administration is the person who administers the dose . residents are identified before medication is administered using two methods of identification. Methods of identification include: checking photograph attached to medical record, calling resident by name, having the resident verify his/her last name, if necessary, verifying resident identification with other facility personnel.R39 was admitted to the facility on [DATE] with diagnoses including depression, hypertension, generalized anxiety disorder, hypothyroidism, orthostatic hypotension, Type 2 Diabetes Mellitus, and unspecified dementia.R39's Quarterly Minimum Data Set (MDS) dated [DATE] documented R39 had a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. R39 had an activated power of attorney (POA) for healthcare decisions.Surveyor reviewed R39's electronic health record (EHR) and located a nursing progress note dated 6/10/26 at 22:42 (10:42 pm) written by Registered Nurse (RN)-E that documented at 1800 (6:00 pm) resident was mistakenly given meds (medications) meant for another resident. R39 was noted to spit meds out onto clothing and meds were accounted for except for one of the APAP (acetaminophen). Nurse Practitioner (NP) was called and notified. Orders received for blood pressures every 2 hours from 1800 (6:00PM) to midnight and then once more between 4:00 am and 5:00 am, as there was a blood pressure med with the meds spit out.On 7/22/26, Surveyor interviewed RN-E, who confirmed RN-E administered a different resident's medications to R39 on 6/10/26. RN-E stated R39 spit the medications out right away, but some of them were melted from being in R39's mouth. Surveyor asked RN-E if the facility followed up with RN-E regarding the medication error to obtain a statement or provide any education, and RN-E replied no. RN-E stated R39 was monitored after the event and there were not any adverse outcomes.On 7/21/26 at 3:01 PM, Surveyor asked Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Clinical Nurse Consultant (CNC)-C if there was any further information or investigation regarding R39 being administered a different resident's medications on 6/10/26. DON-B stated they would look into the matter, but no additional information was provided.On 7/21/26, Surveyor reviewed R39's current physician's orders and located an order for Valbenazine Tosylate Oral Capsule 60 mg, give 1 capsule by mouth in the morning for Tardive Dyskinesia with a start date of 6/16/26 and noted the order was still active. Surveyor reviewed R39's diagnoses and did not locate a medical diagnosis of Tardive Dyskinesia.R39's Medication Administration Record (MAR) for June 2026 and July 2026 documented R39 was administered Valbenazine Tosylate Oral Capsule 60 mg once a day on the following dates: 6/16/26, 6/17/26, 6/18/26, 6/19/26, 6/20/26, 6/21/26, 6/22/26, 6/23/26, 6/24/26, 6/25/26, 6/26/26, 6/27/26, 6/28/26, 6/29/26, 6/30/26, 7/2/26, 7/3/26, 7/7/26, 7/8/26, 7/9/26, 7/10/26, 7/11/26, 7/12/26, 7/13/26, 7/14/26, 7/15/26, 7/16/26, 7/17/26, 7/18/26, 7/19/26, 7/20/26, 7/21/26, totaling 32 doses administered.R39's Psychoactive Medication and Behavior Committee note dated 6/10/26 documented medications of Memantine HCl Tablet 5 mg for dementia and Sertraline HCl Tablet 25 mg for depression. The note did not document any adverse side effects, any monitoring for adverse side effects, or any interdisciplinary team (IDT) recommendations to include updating care plan, risk/benefit, and gradual dose reduction (GDR) request.R39's Abnormal Involuntary Movement Scale (AIMS) Evaluation dated 6/15/26 documented a score of 1, with muscles of facial expression: e.g. movements of forehead, eyebrows, periorbital area, cheeks, including frowning, blinking, smiling, grimacing scored as 1. minimal. The evaluation documented the higher the score (0-28), the greater the impact of observed movements on resident.On 7/21/26 at 1:59 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-D, who stated the monthly behavior committee meetings consist of ADON-D, the pharmacist, the psychiatrist, and one of the social workers at the facility. Surveyor asked ADON-D why R39 was started on Valbenazine Tosylate on 6/16/26, and ADON-D stated it may have been discussed at the behavior committee meeting on 6/10/26, but ADON-D had just started at the facility around that time and could not recall specifically if it was discussed or not. ADON-D confirmed the order was put into the system by ADON-D, but they could not state why the order was started.On 7/21/26 at 2:18 PM, Surveyor interviewed Life Coach (LC)-P, who confirmed they attend the behavioral committee meetings on a monthly basis including R39's meeting on 6/10/26. LC-P reviewed their notes from R39's meeting on 6/10/26 and did not locate any documentation regarding Valbenazine Tosylate or R39 having Tardive Dyskinesia. LC-P stated they would reach out to the pharmacist and psychiatrist and get back to Surveyor.On 7/21/26 at 2:57 PM, LC-P stated the pharmacist and psychiatrist spoke with LC-P on the phone and could not locate any documentation on why R39 was started on Valbenazine Tosylate. LC-P provided Surveyor with an email printout dated 7/21/26 at 2:49 PM, which documented the pharmacist had no notes from the meeting regarding R39 being on Valbenazine.On 7/22/26 at 2:02 PM, Surveyor shared concern with DON-B and CNC-C that R39 received a different resident's medications on 6/10/26, and R39 was administered Valbenazine Tosylate 6/16/26-7/21/26 without evidence of an indication of use. CNC-C stated no one really knows why R39 was started on Valbenazine. CNC-C stated a lot of verbal orders are discussed at the monthly behavioral meetings and they think the medication may have been intended for a different resident. CNC-C stated the medication was discontinued on 7/21/26 and the facility is still investigating what happened. Surveyor was provided with a medication error document dated 7/21/26 at 14:00 (2:00 pm) written by ADON-D, which documented medication reviewed and noted resident was started on Valbenazine due to medication transcription error, medication had been ordered for another resident.

Based on interviews, document review, and facility policy review, the facility failed to ensure the timely resolution of grievances raised during monthly Resident Council meetings and failed to document a rationale when grievances were not resolved for repeated concerns with staff attentiveness and call light response times, and housekeeping services for four of seven months of resident council minutes reviewed. This failure placed residents at risk for unmet and delayed care needs, decreased satisfaction with a clean and comfortable living environment, and reduced confidence in the grievance resolution process. Findings include:Review of the facility's policy titled, Grievance last reviewed 03/03/26 revealed, Purpose: Individual, guardian, and/or individual representative will be informed of the process to file a grievance or complaint and the facility's process to make prompt efforts to resolve grievances.Procedure: The facility fosters an environment of direct communication, prompt resolution, and continuous process improvement.Quality Assurance designee will assign a manager to complete the Quality Assurance Grievance investigation.The assigned manager will investigate the grievance and respond to the individual, guardian, and/or individual representative within five (5) working days, unless further investigation is needed.Review of the facility's Resident Council meeting minutes, provided by the facility, dated December 2025 through March 2026, revealed reoccurring grievances with the services provided by the housekeeping department and staff call light response times.Call Light Response:12/16/25 Old Business revealed residents had concerns with staff being on their phones, texting and talking.12/16/25 New Business revealed residents still had concerns with staff using their phones to text and talk at work. It was documented that nursing management was made aware.01/20/26 Old Business restated that residents had concerns with staff using their phones during work.01/20/26 New Business documented that residents reported staff on the third shift were always on their phones and would not answer call lights or do rounds. It was noted that because residents could not specify days and times, they were reminded that if it happened again, the resident should remember date and situation so that investigations with the social worker could be done. Residents again stated concerns with staff using their phone during work. Residents stated that call lights were not answered timely, and that staff often answered the call light and asked what was needed, turned off the light, and did not return. Again, residents were reminded to share specific time/shift/aide so they could reeducate and talk with the staff, and nurse management was made aware.02/17/26 Old Business restated resident concern about staff on the third shift using their phones during work, not answering call lights or doing rounds.02/17/26 New Business documented that residents again had a concern that staff respond to call lights, turn them off saying they would return, but not returning. Residents stated this happened on all shifts. Residents again stated a concern with staff on third shift using their phones during work. It was reported that managers intended to come to the facility on the third shift to address the concerns, and that staff would all be educated at the next all-staff meeting.03/17/26 Old Business documented that residents had concerns with staff responding to call lights, turning them off stating they would return, but not returning. This was noted to occur on all shifts. It was also restated that residents had concerns with staff on the third shift using their phones during work.03/17/26 New Business reported residents had a concern with staff still using their phones while working.The facility failed to document resolution to the residents' concerns regarding staff using their phones while working, or staff response to call lights. The facility documented that management was made aware for multiple months without follow-up or additional information being provided to Resident Council that any additional steps had been taken. Staff placed additional responsibility on residents with concerns about call light response times and staff turning off lights, requesting they remember and document the situations prior to any indication that the facility would investigate the concern. The repeat nature of the residents' allegations of staff not properly responding indicated that no resolution was successfully attempted. Housekeeping Services:12/16/25 Old Business revealed that residents had reported that their rooms were not being cleaned daily, and that the tables on the second-floor dining room were not being cleaned.12/16/25 New Business documented that residents stated that their rooms were not being cleaned daily, and that the toilets were not being cleaned. It was documented that a TELS (facility management system) order was in place for maintenance. Additional new business documented that staff would now be responsible for cleaning off dining room tables.01/20/26 Old Business revealed resident rooms were not being cleaned daily, and toilets were not being cleaned. It was documented that maintenance was aware.01/20/26 New Business revealed residents stated that their bathrooms were still not being cleaned, especially the toilets. It was again stated that a TELS order was placed for maintenance and that Facility Service Manager (FSM) and Executive Director were aware. Residents were asked if the dining room on the second floor was being cleaned. Residents stated that it was dirty. It was documented that the FSM was made aware and would address it.02/17/26 Old Business documented that residents had expressed concerns that their bathrooms were not being cleaned. It was noted that residents were reminded that their rooms were cleaned, but if any bathrooms needed attention, residents should notify staff. It was also reported that residents were concerned with the second-floor dining room not being cleaned. It was recorded that in the previous meeting minutes the FSM was made aware and would address it.02/17/26 New Business did not document any concerns.03/17/26 Old Business did not document any concerns.03/17/26 New Business revealed residents stated that they noticed the floors in the dining room were not being cleaned after meals, and that their trash was not being removed. Documentation stated that the maintenance team would be notified. Residents were reminded that they could always bring concerns about room cleanliness to the staff.The repeated concerns by residents during Resident Council indicated that a resolution had not been followed up on or documented. The documentation that the FSM would put orders into TELS did not translate into housekeeping services being provided or maintained to meet the needs of the residents.During an interview on 04/15/26 at 12:30 PM, the Director of Nursing (DON) stated that if staff had to receive one-on-one education or on-the-spot training for an area of correction the staff member would usually be called into the office, where they would speak with them. The DON stated that they did not always document when retraining or reeducation was needed.During an interview on 04/15/26 at 3:44 PM, the Life Enrichment Director (LED) stated she scribed the minutes at the monthly Resident Council meetings. The LED said that they always recap the old business first, the previous concerns, by reviewing the different departments. She said that if residents have complaints, she will take the notes and meet with the DON, Executive Director, Maintenance and Admissions in a standing meeting after the Resident Council meeting. The LED said that after that the meeting notes and minutes will be shared with the department heads. She said she would keep in touch with the department heads before the next Resident Council meeting. During the next meeting, if the residents still bring up the Old Business as current concerns that were not fixed. The DON would be invited to talk to the residents. The LED said that with housekeeping concerns the FSM has started to put the concerns into the TELS system. The LED confirmed residents state that housekeeping services were not being kept up, so FSM communicates with the housekeeping staff to do the work. The LED confirmed that call lights have continued to come up, that the facility had been working on staffing and call lights for a few months, and was working on resolutions.During a concurrent interview with the Executive Director and DON on 04/15/26 at 9:01 PM, the Executive Director stated that when there were repeated grievances or allegations it was important to complete a root cause analysis to determine the commonalities, to find the root cause. It was important to see what kind of systemic change could take place. The DON confirmed that it was important to also document when staff have had reeducation to correct a prior problem or action. They both agreed it was important to close the loop, the repeat nature of the concern.

Based on observation and staff interview, the facility failed to maintain a safe and homelike environment, including to ensure housekeeping services were conducted as necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, the facility failed to ensure floors were swept and cleaned of dirt and trash in common areas including dining rooms, on two of three units (B and D) hallways and resident rooms during three of three survey days. Specifically, this deficient practice had the potential to affect the residents quality of life in their rooms and common areas.Findings include:During an observation on 04/13/26 at 4:27 PM, the second-floor D unit dining room had papers and straws on dining room tables. The floor in this room had food debris, trash, and dirt scattered across the room and under dining room tables. During an observation on 04/14/26 at 11:00 AM through 11:24 AM, the second-floor D unit dining room floor had large black scuff marks throughout the room; straw wrappers, large accumulation of food and dirt debris under numerous resident dining room tables; used plastic cups and napkins were left on one dining room table, numerous napkins were left on the floor under another table, and a used cup and opened supplement drink were left on another table. Resident rooms 222, 224, 226, 231, and 232 had dirt, debris, and trash on the floor. During an observation on 04/14/26 at 11:29 AM, the first-floor B unit dining room revealed paper placemats and silverware placed on dining room tables for lunch services. The dining room floor was observed with extensive food and dirt debris throughout the room, including below dining room tables. Dark scuff marks were observed on the floors. There was dark residue built up around the floor perimeter under the small hydration refrigerators. During an observation on 04/14/26 at 4:26 PM, the second-floor D unit dining room revealed paper placemats and silverware placed on the dining room tables for dinner. Underneath multiple tables were food debris and trash; the same items identified during an earlier observation.During an observation on 04/14/26 from 4:13 PM through 4:25 PM on D unit, resident rooms 222, 223, 224, 226, 231, 232, 234, 237, and 243 had dirt and trash on the floor. Soiled napkins were on the hallway floor outside room [ROOM NUMBER]. Dirt was observed throughout the hallway floor.During an observation on 04/15/26 at 10:58 AM, the first-floor B unit dining room had paper placemats and silverware placed for lunch. The floors had significant dirt and debris under residents' dining tables.During an observation of resident rooms on 04/15/26 from 11:00 AM through 11:10 AM on Unit B, resident rooms [ROOM NUMBERS] had food and trash on the floor. The B unit hallway floor had significant dirt and debris.During a concurrent interview on 04/14/26 at 9:28 PM, Licensed Practical Nurse (LPN) 1 and Certified Nursing Assistant (CNA) 1 stated that there were only two housekeepers at the facility, and that housekeeping services were not being completed as they should be. LPN1 and CNA1 said that the upstairs dining room would only get cleaned if the CNAs swept itDuring an interview on 04/15/26 at 12:40 PM, housekeeper (HSKP) 1 stated that they worked in all areas of the facility. HSKP1 said that they often worked alone and that HSKP2 did not work today. They would start upstairs and spot clean and then go down to the first-floor units and do the best they could. HSKP1 confirmed their shift ended at 2:30 PM and HSKP2's shift would end at 4:00 PM.During an interview on 04/15/26 at 2:35 PM, the Facility Service Manager (FSM) stated that there used to be three housekeepers at the facility, but now there were just two. FSM confirmed that he had not given specific locations for the housekeepers to clean, just that they should share the units and collaborate. FSM said that the two housekeepers were responsible for cleaning all common areas and residents' rooms. FSM confirmed that he did not use a checklist or assignment log. During an interview on 04/15/26 at 3:44 PM, the Life Enrichment Director confirmed that residents had mentioned that housekeeping services had not been completed properly during multiple Resident Council meetings.During an interview and facility tour on 04/15/26 at 5:10 PM, the Executive Director confirmed that he had been rounding the facility and had seen some of these housekeeping concerns. The Executive Director stated that he was not aware that the FSM did not have a checklist or direct assignment established for the housekeeping staff and said that it would be hard for housekeeping staff to know what their responsibilities would be like without additional information. The Executive Director revealed that there was no current policy regarding housekeeping services.

Based on observations, interviews, and document review, the facility failed to ensure that the planned menus were followed as approved, scheduled, and posted. As a result, a pattern of 53 residents who received food prepared by the facility were not provided with the portion size as indicated on the planned menu. These failures placed facility residents at risk for weight loss, malnutrition, and dissatisfaction with their meals.Findings include:1. During an observation on 04/14/26 at 4:46 PM, the approved menus for the lunch meal revealed the following portion sizes: #8 scoop (4oz.) for mashed potatoes, apple crisp, mechanical chicken, ground chicken, carrots, and the chef choice vegetables; gravy at 2 oz.; and chicken cordon bleu, one each for regular.Review of the Portion Control Char, posted in the kitchen and in the first-floor satellite kitchen indicated that the #8 scoop (4 oz.) is identified as a gray color, #12 scoop (2 2/3 oz.) is identified as a green color, and the #16 (2 oz.) is identified by its blue color.During an observation of lunch service on 04/14/26 at 11:39 AM through 12:40 PM, the steam table in the first-floor satellite kitchen steam table contained: mashed potatoes, gravy, chicken cordon bleu, chef choice vegetables, carrots, apple crisp, mechanical and ground chicken.During lunch service on 04/14/26, Dietary Aide (DA) 1 was observed serving the meal with the following incorrect portion sizes: chicken cordon bleu mechanical and ground, carrots, and mashed potatoes were served with the #12 green scoop; the chef choice vegetables were served with the #16 blue spoodle (cross between a serving spoon and a ladle). Each item was underserved according to the menu.2. During an observation on 04/14/26 at 4:46 PM, the approved menu for the dinner meal indicated the following portion sizes: #8 scoop (4oz.) for creamy coleslaw, one grilled cheese sandwich and chocolate crispy bar, and 6 oz. of tomato soup.During an observation of dinner service on 04/14/26 at 4:48 PM, the steam table in the first-floor satellite kitchen was prepared for dinner with the following foods: tomato soup, creamy coleslaw, grilled cheese sandwiches, and chocolate crispy bar.During dinner service on 04/14/26 at 4:48 PM to 4:54PM, DA2 was observed serving the meal with the incorrect portion size for the tomato soup. DA2 used a 4 oz. soup ladle. DA2 confirmed that a 4 oz. soup ladle was used instead of the 6 oz soup ladle. DA2 stated that they used the recipes to determine what size scoop or ladle to use during mealtimes.During an interview on 04/15/26 at 4:13 PM, the Registered Dietitian (RD) stated most residents were on a regular diet. They said that they signed off on the extensions each week, and that the portion sizes were documented there. The RD confirmed that the kitchen used the universal equipment for portion standards. The RD said that they wanted the kitchen staff to follow the portion sizes that they had approved.During an interview on 04/15/26 at 5:10 PM, the Executive Director stated that the facility could not find a policy on following approved menus. He stated that menus would be followed by the Dietary department.During an interview on 04/15/26 at 6:04 PM, the Dietary Manager said that education and training was done every three or four months to ensure the dietary staff had training on the steam table, and which scoops to use. The DM confirmed that the DA had informed him that they had used the 4 oz. soup ladle for the previous dinner and not the appropriate 6 oz ladle. The DM said that the lunch meal on 04/14/26 portions were underserved.During an interview on 04/15/26 at 6:22 PM, the Director of Nursing (DON) stated that it was the expectation that the Dietary department would serve meals to the residents according to the approved menus.

Based on record review, interview, and policy review, the facility failed to report an allegation of abuse for one (Resident (R) 9) of one abuse allegation reviewed in the sample of 12 residents to the State Agency (SA) immediately, but no later than 2 hours after the incident. This failure had the possibility to negatively impact residents currently residing at the facility. Findings include:Review of the facility's policy titled, Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program revised 02/11/26 indicated, . G. Reporting and Response: It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse.are reported immediately, but not later than 2 hours after the allegation is made.to the Executive Director of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.Review of R9's admission Record in the electronic medical record (EMR) under the Census tab revealed R9 was admitted to the facility on [DATE] with the diagnosis of anxiety disorder and metabolic encephalopathy. Review of R9's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/11/25 located in the EMR under the MDS tab with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicated R9 was cognitively intact. The MDS did not indicate that R9 had a pressure ulcer.Review of the facility provided, Report of Grievance dated 01/12/26 indicated, . [R9] reports that Certified Nursing Assistant (CNA) [meaning CNA1] took picture of her buttocks wound on 01/05/26 or 01/06/26.Investigation Findings: CNA1 showed R9 a Goggle image of similar but worse buttock wound to R9 on 01/05/26 to demonstrate how wearing briefs at night could worsen R9's wound. CNA1 stated to R9 that her wound looks better and denies taking photo of R9. Resolution Description: Staff educated on keeping phones outside of R9's room, and pictures of residents should not be taken. Review of facility provided Grievance Log dated 01/26 verified that this grievance was not sent into the SA. Review of facility provided Facility Report Investigations (FRI) reports from 12/01/25-present revealed no evidence of this grievance being reported to the SA. During interview on 04/14/26 at 5:25 PM, CNA1 stated that she recalls R9 having a wound on her buttocks/coccyx area and speaking to R9 (did not recall the date) about doing what staff asked her to do regarding her wound. CNA1 said that one intervention was that R9 had been asked not to wear her briefs to bed at night and she had been noncompliant with this. CNA1 said she thought she was helpful by showing R9 a Google image of what her buttocks could look like. However, CNA1 denied taking a photo of R9's bottom. During interview on 04/14/26 at 5:51 PM with Social Services (SS) 1 and SS2, both confirmed what was written on the grievance form and both confirmed that the interdisciplinary (IDT) determined this was not abuse, so there was no need to report to the SA within two hours. Interview on 04/14/26 at 6:00 PM, the Director of Nursing (DON) could not state what was to be reported to the SA within two hours. Attempted interview with Administrator on 04/14/26 at 6:10 PM; however, he refused to answer any questions. Interview on 04/15/26 at 11:50 AM, the Admissions/Former Administrator confirmed that this grievance was not seen as an allegation of abuse because the facility staff talked with CNA1 who claimed she was just talking with R9 and that she did not take a photo of R9's buttocks on her phone. When asked what is reported to the SA, she stated if the resident said a staff member hit them, did not care for them or did anything derogatory to them. She then stated whatever the definition of abuse is. She stated that grievances/incidents are reported depending on how they are investigated. Each individual situation is different.

Based on interview, record review, and policy review, the facility failed to thoroughly investigate an allegation of abuse for one (Resident (R) 9) of one resident reviewed for abuse in the sample of 12 residents. This failure had the potential to negatively impact all residents currently residing at the facility. Findings include: Review of the facility's policy titled, Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program revised 02/11/26 indicated, .E. Investigation: ABUSE POLICY REQUIREMENTS:It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's Quality Assurance and Performance Improvement (QAPI) Incident Report and Investigation process. PROCEDURE:The investigation is the process used to try to determine what happened. The designated facility personnel will begin the investigation immediately.A. Investigation of Abuse: When an incident or suspected incident of abuse is reported, the Executive or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include.i. who was involved; ii. residents' statements.iv. Involved staff and witness statements of events.F. Protection.It is the policy of this facility that the resident (s) will be protected from the alleged offender (s).Review of R9's admission Record in the electronic medical record (EMR) under the Census tab revealed R9 was admitted to the facility on [DATE] with diagnoses of anxiety disorder and metabolic encephalopathy. Review of R9's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/11/25 located in the EMR under the MDS tab with a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R9 was cognitively intact. The MDS indicated that R9 had no psychosis, no behavioral symptoms, and no behavior of resisting care and/or medications. The MDS did not indicate R9 had a pressure ulcer.Review of facility provided, Report of Grievance dated 01/12/26 indicated, . R9 reports that CNA1 took picture of her buttocks wound on 01/05/26 or 01/06/26.Investigation Findings: CNA1 showed R9 a Goggle image of similar but worse buttock wound to R9 on 01/05/26 to demonstrate how wearing briefs at night could worsen R9's wound. CNA1 denies taking photo of R9. The facility's Social Services (SS) 1 and SS2 did not provide any evidence that this grievance was investigated. The facility's Admission/Former Administrator did not provide any evidence that there was any staff education about keeping phones outside of residents rooms and that pictures of residents are not to be taken. Interview on 04/14/26 at 5:25 PM, CNA1 denied taking a picture of R9's bottom. CNA1 stated that she showed R9 a Goggle picture of a wound that appeared to be worse than R9's wound indicating to R9 what could happen if she remained non-complaint with the intervention of not wearing briefs at night. During interview on 04/14/26 at 5:51 PM with SS1 and SS2, both confirmed that during the investigation of this grievance, CNA1 and multiple staff were interviewed, including CNA1; however, confirmed there was no documentation. Both confirmed that no residents were interviewed. Administrator attempted to be interviewed on 04/14/26 at 6:10 PM but refused to answer any questions by the survey team regarding this grievance. Interview on 04/15/26 at 11:50 AM, the Admissions/Former Administrator confirmed that after this incident staff were re-educated about not having phones in residents' rooms. However, when asked for documented evidence, the facility did not provide evidence of an investigation.

Based on the comprehensive assessment of a resident, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries and do not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 2 (R2 and R4) residents reviewed for pressure injuries. R2 admitted to the facility without pressure injuries and was identified to be at risk for pressure injuries. Care plan interventions to prevent pressure injuries were not implemented. R2 developed a facility acquired unstageable pressure injury and the care plan was not revised. Treatments were not completed as ordered and the wound became infected requiring debridement, antibiotic treatment, and a wound vacuum. The facility's failure to provide interventions and treatment for the prevention of pressure injuries for R2 created a finding of immediate jeopardy that began on 8/25/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 11/5/25 at 12:15 PM. The immediate jeopardy was removed on 11/6/25 when the facility completed an IJ removal plan. The deficient practice continues at a scope and severity of a D (potential for harm/isolated) based on the following example of additional noncompliance not at the level of immediate jeopardy: R4 was identified to be at risk for pressure injuries. Care plan intervention for offloading heels was observed not implemented while on survey. Findings include: The facility Policy and Procedure titled Pressure Injury Prevention and Managing Skin Integrity review date 5/8/25 documents: I. Prevention measures are put in place to reduce the occurrence of pressure injuries. 1. Risk Assessment a. Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. b. Re-evaluation. Braden Scale will be completed upon change of condition and quarterly. c. Based on the individual's Braden Scale Score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan a. Identify interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary (IDT) regarding the presence of breakdown and the intervention plan. b. Care Plan i. In developing a plan of care, the following will be considered: Individual pressure injury history, cognitive changes or impairment of the individual, current state of skin integrity and personal hygiene practices of the individual that impact skin health, any cultural practices that impact the health or integrity of the skin, risk for pressure ulcer development (Braden Scale). 4. Weekly Wound Rounds iii. Update the Care Plan with any new interventions as applicable. 1.) R2 admitted to the facility on [DATE] with diagnoses that included right femur fracture, atrial fibrillation, chronic kidney disease stage 4, type 2 diabetes mellitus, depression, gout, and hypothyroidism. R2's admission Minimum Data Set (MDS) dated [DATE] documented: Functional Limitation in Range of Motion lower extremity (hip, knee, ankle, foot) – impairment on one side. Mobility – the ability to roll from lying on back to left and right side and return to lying on back on the bed – partial/moderate assistance. R2's documented Brief Interview for Mental Status (BIMS) score of 15 indicates R2 is cognitively intact. R2's admission assessment dated [DATE] documented: Skin integrity - right thigh (rear) surgical incision, scattered bruising. Skin color normal, warm, turgor normal. Surveyor noted there were no other skin issues, wounds, or pressure injuries documented. The admission assessment also documented: Incontinent bowel and bladder greater than 1 year. Day/NOC (night) large amount. R2's Braden Scale for Predicting Pressure Ulcer Risk dated 8/8/25 documented a score of 18, indicating that R2 is at risk for the development of pressure injuries. Surveyor questioned the accuracy of R2's Braden assessment as R2 was marked as walks occasionally when in fact R2 was non-ambulatory upon admission. R2 was also marked for friction shear as potential problem/minimal assist, when in fact R2 required moderate assist with bed mobility. Interviews with staff and therapy confirmed the above and Director of Nursing (DON)-B agreed some areas in R2's Braden assessment may have been marked incorrectly. Surveyor also noted that R2 did not have a Braden assessment completed weekly for 4 weeks per the facility's pressure injury policy listed above. Although R2 was identified to be at risk for pressure injuries and needed assist with bed mobility, Surveyor noted that no care plan interventions were implemented to prevent pressure injuries to include offloading or how often she was to be turned and repositioned. In addition, R2 was incontinent of bowel and bladder and there were no care plan interventions related to toileting or how often she was to be checked and/or changed. R2's care plan documented: The resident has potential/actual impairment to skin integrity of the r/t (related to) fragile skin incontinence – initiated 8/6/25. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin – initiated 8/14/25. The resident has functional bladder incontinence r/t Activity Intolerance, Impaired Mobility initiated 8/6/25. Interventions: Barrier cream as ordered. Clean peri-area with each incontinence episode. Monitor skin for signs of skin breakdown related to incontinence. The resident has limited physical mobility r/t right femoral fracture – initiated 8/6/25. Intervention: The resident is weight bearing as tolerated for transfers only, then toe touch weight bearing with LLE (left lower extremity) when using Sara Steady. The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t Activity Intolerance - initiated 8/8/25. The resident requires left and right mobility bars to turn and reposition in bed as necessary – initiated 8/8/25. Turn and reposition every 2-3 hours, if resident allows. Offload sacral area with pillow, due to pressure ulcer – initiated 8/25/25. The resident is able to transfer and ambulate in room with 1 assist and a 2ww (wheeled walker) – initiated 9/2/25. The resident has actual impairment to skin integrity of the r/t fragile skin incontinence - revision on 8/15/25. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. The resident has actual impairment to skin integrity of the r/t fragile skin incontinence Sacrum unstageable PI (pressure injury) 8/15/25. Revision on 8/27/25. (Surveyor noted there were no new care plan interventions in this section. Offloading, turning, and repositioning were added to the ADL care plan on 8/25/25). On 11/3/25 at 1:55 PM, Surveyor spoke with Certified Nursing Assistant (CNA)-I who reported she took care of R2 from day one. CNA-I reported R2 needed assist to turn in bed, and she had to physically roll her so she could hold onto the grab bar. She remembered R2 complained of pain to her coccyx and her coccyx was really red and maybe had a tiny sore. CNA-I advised Surveyor she told the nurse but could not remember when or which nurse she told. On 8/15/25, Facility Progress notes (entered by DON-B) documented: Resident c/o (complained of) coccyx pain. On assessment noted to have Stage 2 PI (Pressure Injury) 2 cm (centimeters) x 0.2 cm x 0.1cm. Wound bed with white tissue. No drainage or odor. Covering NP (Nurse Practitioner) updated. Surveyor interviewed DON-B and asked her to describe what the wound looked like. DON-B said she was not a wound expert, but remembered the wound was small and had like white tissue, kind of stringy like. Surveyor asked DON-B if she knew what slough looks like, DON-B replied no. DON-B reported she described the wound to the doctor, and she ordered Medi honey with border foam daily. R2's pressure injury was followed by the facility Wound Advance Practice Nurse Practitioner (APNP)-R. On 8/18/25, Wound APNP-R's wound notes documented: Unstageable pressure injury to the sacrum full-thickness wound measuring 1.5 cm (centimeter) x 1.0 cm by UTD (unable to determine). The base is 100% slough covered with a moderate amount of serosanguineous drainage. Peri wound intact. No signs or symptoms of infection. Plan: Medi honey on bordered foam change daily. Continue pressure redistribution with alternating pressure mattress. Maintain strict turning and repositioning schedule every 2-3 hours. Recommend alternating pressure mattress and offloading boots. Pressure relieving cushion for sitting. Ensure heels are properly offloaded at all times using heel offloading boots. Apply barrier cream to intact skin at risk for breakdown. Assess all pressure points during each care session. Monitor for signs of infection including (erythema, warmth, purulence, drainage or odor) Surveyor noted that although R2 was identified to have a facility acquired unstageable pressure injury, the care plan was not revised to include new interventions or a schedule for offloading, turning and repositioning, toileting, or checking/changing for incontinence. None of Wound APNP-R's recommended interventions were added to R2's care plan. Surveyor did confirm an APM (alternating pressure mattress) was delivered for R2 on 8/20/25. Surveyor reviewed a grievance filed by R2 on 8/25/25. The resident complained that on 8/23/25, she was not changed at all on NOC (night) shift from 10 PM - 6 AM. Staff statement the next morning documented R2's bed was completely soaked, the brief was falling apart and she had to do a complete bed change. The CNA assigned to R2 that night was terminated. The termination notice documented: Complete and thorough investigation substantiates a lack of quality resident care. Resident was not changed/checked on entire NOC shift. Resolution description: Care plan updated to check and change and reposition resident every 2-3 hours. Surveyor noted this care plan intervention was implemented on the ADL care plan as the grievance resolution. On 8/25/25, Wound APNP-R's wound notes documented: Patient is sitting up in her wheelchair, she states that her wound is causing a great deal of discomfort. She reports that it limits her mobility. Unstageable pressure injury to the sacrum, full-thickness wound measuring 2.4 cm x 1.6 cm x 2.0 cm. Tunnel at 12:00 about 2.7 cm, the base is 100% slough covered with a moderate amount of malodorous purulent drainage. Peri wound with erythema and warmth. Status: Evolving-debrided. Plan: Dakin's moist Kerlix cover with border gauze change twice daily. Wound infection. Erythema, pain, odor, purulence. Plan: Culture could not be taken due to necrotic tissue within the wound. Begin Flagyl 500 mg (milligrams) 3 times daily and Doxycycline 100 mg twice daily both x 14 days. Anatomic location of debridement: Coccyx. Necrotic tissue. Type of tissue removed: Subcutaneous tissue. Selective debridement fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm. Percent of wound bed debrided 100%. On 11/4/25 at 8:00 AM, Surveyor spoke with Wound APNP-R and asked if she was aware that on 8/23/25, R2 was not changed or checked on the entire night shift (8 hours) and in the morning her bed was completely soaked, and the brief was falling apart. Wound APNP-R reported she was not sure if she was specifically made aware but recalled discussion to add to the care plan that R2 be checked and changed at 2 or 3 AM. (Surveyor noted this was not added to R2's care plan). Surveyor asked Wound APNP-R, if R2 was lying in bed, incontinent, and not changed or repositioned for a period of 8 hours, did she think this contributed to the pressure injury decline and infection that was identified 2 days later. Wound APNP-R reported she could not say specifically that the 8/23 occurrence led to the decline and infection of the wound. Wound APNP-R stated, Could it have? Maybe - but wounds get infected even if good incontinence care is provided. On 9/2/25, Wound APNP-R's wound notes documented: Patient is in bed laying on her right side. She states the pain to her wound is improved greatly stating last week she had a hard time sitting but not this week. Unstageable pressure injury to the sacrum full-thickness wound measuring 2.5 cm x 1.6 cm x 2.0 cm. Undermining 11-2:00~1.4 cm. The base is 100% granular with a moderate amount of serous drainage. Peri wound intact. No s/s (signs or symptoms) of infection. Status: improved. Plan: order wound vac and place with black foam. Change 3x/wk (week) and prn (as needed) until wound vac arrives gently pack calcium alginate and cover with border gauze, change daily. Wound infection resolved. On 9/8/25, Wound APNP-R's wound notes documented: Patient is just returned from therapy she transfers to her bed for evaluation. She states her buttocks feels a lot better - states she has no pain to her buttocks. Stage 3 pressure injury to the sacrum full-thickness wound measuring 2.5 cm x 1.6 cm x 1.5 cm. undermining 10-1:00~1.9 cm. The base is 100% granular with a moderate amount of serous drainage. Peri wound intact. No s/s of infection. Status: Improved. Plan: Wound vac change 3x/wk. On 9/15/25, Wound APNP-R's wound notes documented: Patient is just finished working with therapy she lays down in bed on her right side. She denies pain to her wound. She would like to get rid of the wound VAC as soon as possible. Family are looking to take patient home later this week. Stage 3 pressure injury to the sacrum full-thickness wound measuring 2.5 cm x 1.3 cm x 1.1 cm. Undermining 11-1:00~0.9 cm. The base is 100% granular with a moderate amount of serous drainage. Peri wound intact. No s/s of infection. Status: Improved. Plan: Wound vac change 3x/wk. When patient discharges home please discontinue wound VAC and begin Hydrofera Blue to ready followed by bordered foam 3 times a week. Surveyor noted the order to discontinue the wound vac prior to discharge and begin Hydrofera Blue was not transcribed, and therefore not completed. R2's progress notes on 9/20/25 at 1:05 PM documented: Resident discharged to home. Discharge paperwork discussed no concerns noted. Requested wound vac be removed before going home. Remove per request with education in regard to importance of wound vac. Wound cleaned dried with dressing intact. Surveyor noted facility staff removed the wound vac prior to discharge on ly after R2's request and there is no documentation of what type of dressing was placed on the wound prior to discharge. Surveyor review of R2's August 2025 TAR (Treatment Administration Record) documented: Pack wound with Dakin's-soaked gauze, then cover with bordered gauze dressing two times a day for wound care - ordered 8/25/25. Surveyor noted the treatment was not signed out as having been completed on 8/26 AM, 8/27 PM, 8/29 PM, 8/31 PM, and 9/1 PM. On 8/28 PM it was entered as 9 (other/see progress notes). Surveyor located no documentation in R2's progress notes as to why the treatment was not completed as ordered. On 11/4/25 at 9:00 AM, Surveyor spoke with Registered Nurse (RN) Supervisor-O. She reported she spoke with R2's family often. Surveyor asked if R2's family reported any concerns. RN Supervisor-O stated, Yes, her family reported concerns with the treatment not being done BID (twice daily) and Dakins not used. Surveyor noted on 8/30/25, R2's treatment order on the TAR was rewritten to include instructions dressing date and time written on bandage two times a day for wound care. RN Supervisor-O advised Surveyor the order was rewritten to include date/time on the dressing because of R2's family reporting the treatment was not being done BID. RN Supervisor-O informed Surveyor that when she looked into it, she found out that the nurses did not know where to find the Dakins solution. Surveyor asked how long the nurses were not able to find the Dakins and were not using it. RN Supervisor-O stated, About a week. Surveyor asked what the nurses were using for the treatment if they were not using the (ordered) Dakins solution. RN Supervisor-O stated, I don't know, probably normal saline. Surveyor located no documentation the Physician was notified Dakins solution was not being used as ordered. On 11/4/25 at 10:52 AM, Surveyor advised Nursing Home Administrator (NHA)-A of concerns: R2 admitted to the facility without pressure injuries and was identified to be at risk. No care plan interventions were implemented to prevent pressure injuries, to include offloading, turning and repositioning, toileting and/or checking/changing for incontinence. R2 developed a facility acquired unstageable pressure injury which declined and became infected 2 days after the resident was found to have not been not checked or changed for a period of 8 hours. After the pressure injury was identified, Wound APNP-R's recommended interventions were not implemented, and the care plan was not revised with any new interventions until after the pressure injury declined and became infected. In addition, R2's treatment was not consistently completed as ordered. No additional information was provided. On 11/4/25 at 3:00 PM, during the daily exit meeting with NHA-A, DON-B, and Sister Facility NHA-C, Surveyor advised of the above concerns. On 11/5/25 at 8:35 AM, NHA-A was advised Surveyors would be having a call to discuss R2's pressure injury concern. On 11/5/25 at 12:15 PM, NHA-A, DON-B and Sister Facility NHA-C were advised of the immediate jeopardy. The facility's failure to provide interventions and treatment for the prevention of pressure injuries for R2 created a reasonable likelihood for serious harm, thus leading to a finding of immediate jeopardy that began on 8/25/25. Surveyor notified NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the immediate jeopardy on 11/5/25 at 12:15 PM. The immediate jeopardy was removed on 11/6/25 when the facility completed an IJ removal plan, however, the deficient practice continues at a scope and severity level of D (potential for harm/isolated) based on the example for R4 and as the facility continues to implement the following action plan: - All other residents in the facility are at risk for developing a pressure ulcer, especially those bed ridden or a Braden higher than I0. - A facility-wide skin sweep audit was completed for all in house residents on November 5th and 6th 2025 to identify anyone with existing or potential pressure injuries. - Residents Braden assessments were completed for all in house residents on November 5ht and 6th 2025. - Pressure ulcer prevention interventions were verified for all at-risk residents, including care plan updates if needed. If a new intervention was needed, it was implemented. - Reviewed the Illuminus policy to ensure compliance with CMS and Wisconsin DBS guidance. Policy is appropriate. - Re-educated all nursing staff on: - Wound Nurse, via nurse consultant, on proper process for staging wounds and the required weekly documentation of each wound and a entered intervention. - Pressure injury prevention and skin Integrity. This includes accurate and timely documentation of skin assessments and treatments. - Importance of repositioning, offloading, and movement. - Facility will audit up to 4 residents with wounds a week. Focus on proper staging and documentation. - DON and/or designee with be responsible for these audits. All results will be repo1ied to QAPI committee for future action or adjustment. - Our practice is to follow National Pressure Ulcer Advisory Panel Standards along with the Critical Element Pathway (CEP-for pressure injuries). - Our WCC nurse is credentialed by the wound care educational institute. (WCEI) No additional information was provided. 2.) R4 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (complete and partial loss of movement on right side of the body after ischemic stroke – decreased blood flow to the brain causing lasting physical and mental deficits), Aphasia (inability to understand or speak), Dysphagia (difficulty swallowing), weakness, and need For Assistance with Personal Care. R4's Quarterly Minimum Data Set (MDS) completed 9/12/25 documented that R4 has severe cognitive impairment with a Brief Interview Mental Status score (BIMS) score of 3. The MDS also documents: R4 has unclear speech and is sometimes understood; R4 has impairment on one side upper and lower; R4 eats independently, requires partial to moderate assist for hygiene, showering, dressing, toileting, and bed mobility; R4 requires set up to supervision assist for all transfers. R4's Kardex as on 11/3/25, which instructs Certified Nursing Assistants (CNA) in the care for R4, documented: - Skin Integrity o Resident will at times decline cares; offer to come back, reapproach, different staff, to provide care as allowed. Document declines and reapproach prn (as needed). o Pressure redistributing w/c (wheelchair) cushion o Pressure relieving mattress encourage heel off loading (declines heel boots) air flow mattress with heel pressure reduction. R4's comprehensive care plan for R4 documented: - The resident has potential impairment to skin integrity r/t (related to) fragile skin, assisted to reposition, incontinence, immobility and hx of skin altercation. Scar tissue present to right buttock from prior healed area. Date initiated 6/9/25, revised 8/19/25. o Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated 6/9/25. o Resident will at times decline cares; offer to come back, reapproach, different staff, to provide care as allowed. Document declines and reapproaches prn. Date Initiated 11/3/25. o Pressure redistributing w/c (wheelchair) cushion. Date initiated 6/9/25 o Pressure relieving mattress encourage heel off loading as allows (declines heel boots) air flow mattress with heel pressure reduction. Date initiated 6/9/25, revised on 8/19/25. o The resident needs pressure relieving mattress to protect the skin while IN BED. Initiated on 10/8/25, revised on 11/3/25. R4's Braden scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 12, indicating that R4 is at high risk for the development of pressure injuries. R4's Braden scale for Predicting Pressure Sore Risk assessment dated [DATE] documents a score of 14, indicating that R4 is at high risk for the development of pressure injuries. This assessment was added as a late entry at 1:13 PM on 11/3/ 25 By Director of Nursing (DON)-B. On 11/3/25, at 9:49 AM, Surveyor spoke with R4 who is able to communicate with head nods and left-handed gestures. R4 nodded yes to staying in bed the majority of times and nodded no to getting out of bed generally. R4 nodded no to getting out of bed for activities. R4 nodded yes to being able to scoot and reposition self while in bed. When asked if staff helps R4 reposition, R4 shakes his hand side to side and squints eyes. Surveyor asked R4 if R4 refuses the care from staff, R4 nodded yes and grunts. Surveyor asked R4 if R4 likes to be left alone and do things in the room, R4 nodded yes. Surveyor gave R4 the opportunity to write if R4 had anything additional to add. R4 nodded no. Surveyor observed R4's heels were not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/3/25, at 10:38 AM, Surveyor observed R4 in Bed. R4's heels were not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/3/25, at 11:33 AM, Surveyor observed R4 in Bed. R4's heels were not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/3/25, at 12:24 PM, Surveyor observed R4 in Bed. R4's heels were not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/3/25, at 1:26 PM, Surveyor observed R4 in Bed. R4's heels were not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/3/25, at 1:36 PM, Surveyor interviewed Certified Nursing Assistant (CNA) -E who stated they have worked at this facility for 3 years and the hallway R4 is on is where they normally work. CNA-E stated R4 needs help with everything except eating. CNA-E stated R4 can adjust self in bed. CNA-E states R4 refuses repositioning and other cares like getting washed up and changing clothes. CNA-E stated CNAs are to tell the nurse of the refusal and then the nurse is supposed to chart the refusal because CNAs cannot make notes in the electronic medical record (EMR). On 11/3/25, at 3:17 PM, Surveyor interviewed CNA-L who has worked at the facility since December 2024 and floats around to all units, but has provided care for R4 frequently. CNA-L states R4 stays in bed mostly and refuses repositioning and will remove pillows, but can adjust self in bed. CNA-L stated when residents refuse CNAs are to inform the nurse so the nurse can document the refusal and help reapproach. CNA-L informed surveyor CNA-L reports the refusals to the nurses but does not think the refusals get documented. Surveyor noted that there are no documented refusals for pillows under R4's feet or that R4 refused repositioning. Surveyor also noted that R4 does not have a care plan in place for when R4 refuses cares until 11/3/25, when the survey started. On 11/4/25, at 7:35 AM, Surveyor observed R4 sleeping in bed on R4's back, R4's heels not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/4/25, at 8:52 AM, Surveyor observed R4 laying on R4's back and R4's heels are not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/4/25, at 9:56 AM, Surveyor observed R4 in bed and R4's heels are not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/4/25, at 10:58 AM, Surveyor observed R4 in bed and R4's heels not offloaded to prevent the development of pressure injuries and pressed against the footboard. On 11/4/25, at 11:02 AM, Surveyor interviewed CNA-E who stated the Kardex is used to indicate what cares each resident are ordered to receive. CNA-E stated they view the Kardex 'all the time'. When asked when the last time CNA-E viewed R4's Kardex CNA-E stated 'it's been awhile' and that R4 has been the same since R4 came here so there isn't a need to look at the Kardex and the interdisciplinary team is very good at updating the staff verbally and passing new information off in report. On 11/4/25, at 11:18 AM, Surveyor overheard a conversation between Licensed Practical Nurse/Nurse Supervisor (LPN/NS)-G and CNA-E. CNA-E walked up to LPN/NS-G and asked if LPN/NS-G removed the pillows from under R4. LPN/NS-G stated LPN/NS-G did not remove the pillows and only removed the straws. CNA-E stated all morning when CNA-E goes into the room, the pillows from under R4 are removed. LPN/NS-G told CNA-E to tell the nurse so that the nurse can document R4's refusal to be repositioned and have pillows placed. On 11/4/25, at 12:40 PM, Surveyor observed R4 in bed eating lunch, R4's heels are not offloaded to prevent the development of pressure injuries. On 11/4/25, at 12:44 PM, Surveyor interviewed DON-B on expectations on the CNAs rounding on the units and expectations on refusing. DON-B expects CNAs to do rounding as soon as the CNAs walk in, to loom into the rooms and observe the residents and the room and both should be 'presentable'. DON-B defined presentable as in room not dirty, garbage taken out, residents comfortable and clean, check to see if the residents need anything and call light in reach. DON-B stated when residents refuse cares that the CNAs should notify the nurse, and the nurse is expected to document and reapproach and document the outcome. On 11/4/25, at 1:39 PM, Surveyor observed R4 in bed and R4's heels are not offloaded to prevent the development of pressure injuries. On 11/4/25, at 3:03 PM, Surveyor shared R4 has been observed with heels not offloaded as documented on R4's Kardex and care plan with Nursing home administrator (NHA) -A, DON -B, and Sister Facility NHA-C. No additional information was provided as to why R4 has not had R4's heels offloaded to prevent the development of pressure injuries. On 11/4/25, at 3:40 PM, Surveyor noted R4 in bed and R4's heels were not offloaded to prevent the development of pressure injuries. On 11/5/25, at 8:21 AM, Surveyor reviewed R4's progress notes and did not see any refusal documentation from 11/4/25 for refusing repositioning and pillows. On 11/5/25, at 8:42 AM, Surveyor observed R4 in bed and R4's heels were not offloaded to prevent the development of pressure injuries. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent an accident from occurring for 3 of 3 Residents (R1, R3, and R4) reviewed for accidents. *R3 had 10 unwitnessed falls, 3 were not thoroughly investigated for a root cause. On 7/19/25, R3 had an unwitnessed fall in which R3 sustained a left hip fracture. *R1's fall on 10/16/25 was not thoroughly investigated for a root cause. R1's fall interventions of brushing teeth after lunch, toileting schedule, call light in reach, and transferring using a gait belt were observed not to be implemented. *R4's call light was observed to not be within reach and received straws which R4 should not have due to an aspiration risk during the survey process. Findings Include: The facility's undated Falls policy and procedure documents: Policy: Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls. Procedure: 1.Fall Risk: a. Licensed nurse will complete an electronic Fall Assessment upon admission. b. A licensed nurse will complete a Fall Assessment quarterly, or with change in condition. c. A licensed nurse will determine the individuals' risk for falls and individualized care needs. If the individual is at risk for falls, then create a falls care plan. 3.Administrative Review a. The Interdisciplinary Team (IDT) will review fall incident report and utilize root cause analysis to make further recommendations. 1.) R3 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side (complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Atherosclerotic Heart Disease of the Native Coronary Artery (plaque buildup narrows the arteries that supply blood to the heart), Chronic Kidney Disease (progressive damage and loss of function in the kidneys), Chronic Obstructive Pulmonary Disease (lung disease that block airflow and make it difficult to breathe), Epilepsy (disorder in which nerve cell activity in brain is disturbed causing seizures) Anemia (lack of blood), Dysphagia (difficulty swallowing foods) and Depression (mood disorder that causes persistent feelings of sadness and loss of interest). R3's 5-day Minimum Data Set (MDS) completed 8/25/25 documents R3's Brief Interview for Mental Status (BIMS) score to be 11, indicating R3 is moderately cognitively impaired. R3's MDS documents: R3 has no mood or behavior issues; R3 is setup for eating; R3 requires partial/moderate assistance for lower dressing, mobility, and transfers; R3 requires supervision for upper dressing; R3 is frequently incontinent of bladder and always continent of bowel. R3's Fall Care Area Assessment (CAA) dated 8/6/25 does not document any pertinent information. R3's fall assessment dated [DATE] documents a score of 10, indicating that R3 is at high risk for falls. R3's fall assessment dated [DATE] documents a score of 11, indicating that R3 is at high risk for falls. R3's fall assessment dated [DATE] documents a score of 18, indicating that R3 is at high risk for falls. R3's fall assessment dated [DATE] documents a score of 13, indicating that R3 is at high risk for falls. R3's fall assessment dated [DATE] documents a score of 17, indicating that R3 is at high risk for falls. R3's fall assessment dated [DATE] documents a score of 15, indicating that R3 is at high risk for falls. R3's Kardex as of 11/3/25 documents: Fall 9/1/25 Non-slip socks on while in bed if R3 allows Fall 8/12/25 Ensure room temperature is adjusted to R3's preference Fall 7/19/25 Staff to check on R3 every 30 minutes while in room Fall 7/17/25 Remind spouse to let staff know if R3 is ambulating unassisted while she is visiting with R3 Fall 7/12/25 Staff to offer to close R3's blinds as desired at HS Fall 6/30/24 Urinal at bedside Fall 6/24/25 R3 to be in common area when in wheelchair if permitted Fall 6/19/25 Call don't fall sign Fall mat at bedside while R3 in bed PT/OT evaluate and treat as ordered or as needed R3 needs a safe environment Transfer Status: assist of 1 with 2 wheeled walker Toilet Use: R3 is 1 assist with 2 wheeled walker or bathroom grab bar for toileting Be sure R3's call light is within reach and encourage R3 to use it for assistance as needed. R3 needs prompt response to all requests for assistance. Ensure that R3 is wearing appropriate footwear, non-skid when ambulating, transferring, or mobilizing in wheelchair. R3's comprehensive care plan documents R3 is high risk for falls due to deconditioning, gait/balance problems. Initiated 6/19/25 Revised 8/6/25 Be sure R3's call light is within reach and encourage R3 to use it for assistance as needed. R3 needs prompt response to all requests for assistance. 6/19/25 Ensure that R3 is wearing appropriate footwear, non-skid when ambulating, transferring, or mobilizing in wheelchair. 6/20/25 R3 needs a safe environment 6/20/25 Fall 9/1/25 Non-slip socks on while in bed if R3 allows 10/22/25 Fall 8/12/25 Ensure room temperature is adjusted to R3's preference 8/19/25 Fall 7/19/25 Staff to check on R3 every 30 minutes while in room [ROOM NUMBER]/21/25 Fall 7/17/25 Remind spouse to let staff know if R3 is ambulating unassisted while she is visiting with R3 7/27/25 Fall 7/12/25 Staff to offer to close R3's blinds as desired at HS 7/17/25 Fall 6/30/24 Urinal at bedside 6/30/25 Fall 6/24/25 R3 to be in common area when in wheelchair if permitted 6/24/25 Fall 6/19/25 Call don't fall sign 6/20/25 Surveyor noted that on 3/21/25 R3's Fall Assessment documented R3 is high risk for falls but a care plan was not implemented until 6/19/25 with the first fall. A continence evaluation completed 10/18/25 does not document a specific bowel/bladder program implemented for R3. Surveyor reviewed the facility investigations of R4's 10 falls: 6/19/25- R3 had an unwitnessed fall at 9:45 PM in the bathroom and R3 stated R3 was trying to use the bathroom. The investigation documents 1 person got R3 up off the floor of the bathroom. 6/24/25- R3 had an unwitnessed fall at 4:15 PM. R3 stated R3 was trying to go to the bathroom and lost balance. 6/30/25- R3 had an unwitnessed fall at 2:35 PM. R3 was found sitting on the floor of the bathroom. R3 stated R3 was trying to get on the toilet. R3's emergency contact was not updated. Neurological checks were not completed. 7/4/25-R3 had an unwitnessed fall at 9:45 AM. R3 was observed on the floor of the bathroom. R3 stated R3 was attempting to toilet self. The facility did not obtain any staff statements. The intervention of a bedside commode was initiated, however, R3 refused the bedside commode, and no new intervention was implemented. 7/12/25-R3 had an unwitnessed fall at 8:00 PM. R3 fell trying to close the blinds. R3's emergency contact was not updated, neurological checks were not completed, and the facility did not obtain statements from staff. 7/17/25- R3 had an unwitnessed fall 5:00 PM. R3 was trying to get to the bathroom. 7/19/25- R3 had an unwitnessed fall at 1:45 PM. R3 was trying to get to the bathroom. A facility reported incident was completed and submitted to the State Survey Agency. The summary of the fall stated that R3 was found in R3's room on the floor with blood coming from R3's head. The summary stated R3 was continent of bowel and bladder at the time of the occurrence. R3 was last seen in bed between 1:15 and 1:30 PM. When last observed, R3 had R3's call light within reach. R3's call light was activated when staff entered the room. The sign was up to call for help and R3's walker was at bedside. The summary documents R3 had a hematoma sized 2x1 inch on the left side of R3's head. R3 complained of hip pain. Neuro-checks were initiated. Physician gave order to send R3 out to the hospital for further evaluation. The summary documents that the room was clean and with no clutter and R3 had socks (does not document if non-skid) on at the time. The facility assessment documented left trochanter (hip) fracture. R3's family arrived to the facility and confirmed that the hospital had informed family R3 had broke R3's hip. Based on documentation in the summary of R3's fall the following interventions were in place: -call light within reach -the call don't fall sign was posted The intervention from 6/30/25 to have a urinal at bedside is not documented as being in place at the time of the fall on 7/19/25 Surveyor had observations during the survey process of the urinal not in place. The summary does not indicate if non-skid footwear initiated on 6/20/25 was in place at the time of the fall. Surveyor noted that the commode listed in the fall summary was not in place and removed on 7/7/25 because R3 refused the commode, but no other intervention was put into place when R3 refused. Surveyor noted R3 had five previous unwitnessed falls due to R3 attempting to ambulate to the bathroom prior to the 7/19/25 unwitnessed fall. Surveyor noted the hospital Discharge summary dated [DATE], documented R3 suffered a subcapital left femoral neck fracture-closed. Surveyor noted R3 was re-admitted from the hospital on 7/28/25 after sustaining a left hip fracture due to attempting to ambulate to the bathroom. Five days later, on 8/2/25, R3 had another unwitnessed fall attempting to ambulate to the bathroom. Upon return, the intervention initiated on 7/21/25 as a result of the fracture was to check on R3 every 30 minutes. The fall incident report completed on 8/2/25 does not document 30 minute checks being completed. 8/12/25- R3 had an unwitnessed fall at 2:00 PM. R3 was cold and trying to get a blanket. 9/1/25- R3 had an unwitnessed fall at 2:55 PM. R3 slid out of recliner and R3 stated R3 was trying to get to the bathroom. Surveyor noted the facility did not obtain staff statements for the 7/4/25 and 7/12/25 unwitnessed falls. Surveyor noted all of R3's falls except for two were the result of R3 attempting to ambulate to get to the bathroom. The facility did not complete a thorough investigation of the falls to establish a root cause analysis. The facility did not complete a bowel and bladder assessment to establish a toileting pattern, and the facility did not establish a pattern based on the times of the falls. Not establishing a root cause analysis of R3's falls resulted in R3 falling and resulting in a left hip fracture. On 11/3/25, at 10:27 AM, Surveyor observed R3 sitting in R3's recliner with call light within reach. R3 is aware that R3 is to get assistance when needing to get to the bathroom. On 11/4/25, at 7:25 AM, Surveyor observed R3 in bed, call light is within reach, and there is a mat next to the bed on the left side. The bed is pushed against the wall. Overbed table is next to the bed. Surveyor noted there is no urinal next to the bed as documented on R3's Kardex and care plan. On 11/4/25, at 9:10 AM, Surveyor observed R3 in bed eating breakfast and head of bed is elevated. There is no mat next to the bed and no urinal at bedside as documented on R3's Kardex and care plan. R3 stated that R3 had to get changed in the middle of the night. R3 confirmed R3 had no urinal last night and would use the urinal if the urinal was within reach. Surveyor observed no urinal in R3's room or bathroom. On 11/4/25, at 9:36 AM, Certified Nursing Assistant (CNA)-M confirmed R3's mat is down on the floor next to bed and CNA-M located the mat leaning up against the wall by the wardrobe. CNA-M confirmed the mat is supposed to be on the floor next to the bed when R3 is in bed. On 11/4/25, at 12:55 PM, Surveyor observed R3 in bed eating lunch. R3 states R3 got up later in the morning and then returned to bed. Surveyor observed the mat not down on the floor next to R3's bed and no urinal within reach of R3. On 11/4/25, at 1:16 PM, Surveyor interviewed Registered Nurse Supervisor (RN)-O in regard to R3's falls. RN-O has been new to the supervisor role since September. RN-O explained RN-O is supposed to be a part of a resident's fall investigation, but since RN-O is new to the role, RN-O is still learning the process. RN-O stated the expectation is that the CNAs do rounds at the beginning of their shift and make sure fall interventions are in place. RN-O has not been a part of establishing a root cause analysis for R3's 10 falls. RN-O stated that R3 can be impulsive and wants to be independent. RN-O stated the facility does not do a bowel/bladder patterning to in order to avoid falls. On 11/4/25, at 3:03 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Sister Facility (NHA)-C that R3 has had 10 falls with one resulting in a left hip fracture. Surveyor shared the serious concern that R3's fall investigations were not thoroughly investigated including not establishing a root cause analysis. Surveyor shared that all falls, but two, were because R3 was attempting to ambulate to the bathroom. Surveyor shared that the facility did not establish a bowel/bladder pattern along with time of day of the falls. Surveyor also shared that the mat and urinal at bedside interventions were observed during the survey process to not be in place. No additional information was provided. 2.) R1 was admitted with diagnoses that include chronic respiratory failure with hypoxia (long term condition where the lungs cannot supply enough oxygen to the blood resulting in low blood oxygen levels), dementia (loss of cognitive function that interferes with a person's daily life & activities), atrial fibrillation (irregular and rapid heartbeat), and anxiety disorder (group of mental health conditions characterized by excessive & persistent worry, fear, and nervousness that an interfere with daily life). R1's at risk for falls care plan initiated 6/24/24 & revised 6/25/25 documents the following interventions: *Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated & revised on 6/24/24. *Ensure that the resident is wearing appropriate footwear (shoes/socks with non-skid soles) when ambulating, transferring or mobilizing in w/c (wheelchair). Initiated & revised 6/24/24. *PT/OT (physical therapy/occupational therapy) evaluate and trat as ordered or PRN (as needed) Initiated & revised 6/24/24. *The resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal items within reach). Initiated & revised 6/24/24. *Fall 12-20-24-dycem to w/c (wheelchair) initiated 12/20/24. *4/5/25-fall-staff to assist resident with brushing teeth after lunch if permitted. Initiated 4/7/25. *4/5/25-fall-staff to offer toileting q (every) 2 to 3 hours and prn. Initiated 4/5/25. *5/25/25-fall-staff to ensure resident not attempting to feed others when dining room. Initiated 5/25/25. *Fall-5/31/25-staff to ensure bed is made to resident's preference. Initiated 5/31/25. *10/16/25: Reacher at bedside to help with sorting dirty clothes from the laundry hamper if needed. Initiated 10/27/25. R1's fall CAA (care area assessment) dated 6/25/25 documents under the analysis of findings section: At risk for fall – dementia -arthritic pain assisted to safely transition surfaces meds (medication) taken have risk potential. For care plan considerations under describe impact of this problem/need on the resident and your rationale for care plan decision documents At risk for fall – new environment dementia – foot pain. Assisted to safely transition surfaces. Continue to care plan – Falls place at risk for serious injury and potential of hospital return. R1's quarterly MDS (minimum data set) with an assessment reference date of 9/19/25 documents a BIMS (brief interview mental status) score of 6 which indicates severe cognitive impairment. R1 is assessed as having no behavior including refusal of care. R1 is assessed as being independent for eating, partial/moderate assistance for toileting hygiene, chair/bed to chair transfer, & toilet transfer and substantial/maximal assistance for roll left and right. R1 is assessed as being frequently incontinent of urine and occasionally. R1 is assessed as not having any falls since prior assessment period. R1's nurses note dated 10/16/25, at 11:03 a.m., written by Licensed Practical Nurse (LPN)-N documents: Writer heard loud screaming from resident's room, someone from PT (physical therapy) stated res. (resident) is on the floor as writer proceeded to resident's room. Writer observed res. On the floor on right side. Resident last observed eating at 1000 (10:00 a.m.) with O2 (oxygen) on. Writer observed res. Without O2 reapplied. Writer made NP (Nurse Practitioner) aware NP came and observed res. On the floor and assessed res. Writer called [Name] res contact person. Staff assisted writer sic (resident) off floor after assessment. Ice pack applied to left side of head, res. With large purplish hematoma, also has purplish bruise area on left hand with skin tear, writer cleaned area and proximated skin and applied steri strips and dry dressing. Neuro check negative, rom (range of motion) wnl (within normal limits) to upper and lower extremities although complaint of pain to coccyx area. R1's nurses note dated 10/16/25, at 14:38 (2:38 p.m.), written by LPN-N documents: NP sending resident out to hospital d/t (due to) previous fall. Resident with hematoma to left side of forehead, also developing a black eye to left eye. Writer called [Name] ambulance, waiting for ambulance to arrive. Writer to update res. Family [Name]. R1's nurses note dated 10/16/25, at 21:54 (9:54 p.m.), written by LPN-N documents: Resident returned from the hospital, test negative, resident in bed resting, offered no c/o (complaint of) pain/discomfort. R1's nurses note dated 10/17/25, at 15:18 (3:18 p.m.), written by LPN-N documents: F/u (follow up) fall: B/P (blood pressure) 112/63, T (temperature) 98.2, P (pulse) 78, R (respirations) 20, spO2 (peripheral oxygen saturation) 92%. Resident is alert and oriented, neuro check negative, rom wnl to both upper and lower extremities, res (resident) cont, (continue) with hematoma to left forehead and left hand. Resident denies pain/discomfort. Resident with dark purple bruises through out face, writer fed res. for breakfast this morning, but refused lunch, will cont. to monitor. On 11/3/25, at 3:07 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Nurse Clinical Consultant (NCC)-X Surveyor asked for the facility's investigation for R1's fall on 10/16/25. On 11/4/25, Surveyor reviewed the facility's investigation for R1's fall on 10/16/25. The information provided to Surveyor is an incident report completed by LPN-N, fall risk evaluation dated 10/19/25, fall questions/statement completed by CNA-I and neurochecks. Surveyor noted R1's incident report dated 10/16/25 under incident description for nursing description is the same documentation as LPN-N's nurses note dated 10/16/25 at 11:03 a.m. Under resident description documents Resident sated she was trying to sort out clothes. Under notes dated 10/16/25 documents Resident was found lying on the right side without oxygen in place, last seen eating at 1000 (10:00 a.m.) with oxygen on. NP was notified, assessed the resident, and informed [Name] contact person. Staff assisted resident off the floor after assessment. Ice pack applied to left side of head for large hematoma; left hand noted with bruising and skin tear? Area cleansed, approximated, and dressed with stei-strips and dry dressing. Neuro check negative, ROM (range of motion) within normal limits, resident reported pain to coccyx. Skin intact. Root cause identified as self-transfer trying to sort out clothing; reacher provided to assist with retrieving clothing. CNA-I's fall questions/statement dated 10/16/25 for time of fall 10:30 a.m. documents for question when was the resident last seen document 1000 (10:00 a.m.). For question what was the resident doing prior to fall documents in bed. For the question what was the resident wearing on their feet at the time of the fall documents nothing. For the question were previous fall interventions in place at the time of the current fall documents yes. Surveyor noted R1's fall interventions were not in place as there is a fall intervention for R1 to wear appropriate footwear (shoes/socks with non-skid soles) when ambulating, transferring or mobilizing in w/c. Surveyor noted there were no other staff statements obtained including LPN-N and Physical Therapy Assistant (PTA)-Y. On 11/5/25, at 9:10 a.m., Surveyor asked PTA-Y if he could explain to Surveyor what occurred on the morning of 10/16/25 when R1 was found on the floor. PTA-Y explained he was ambulating another resident in the hallway, as they were ambulating past R1's room he looked in and saw R1 sitting comfortably in the wheelchair as R1's door was wide open. PTA-Y explained he had the resident he was ambulating rest at the end of the hallway and then started ambulating back down the hall. When they were walking back, he heard a resident calling out help me help but he didn't recognize the voice, and the voice didn't sound like R1. PTA-Y informed Surveyor when they got to R1's door he looked in and saw R1 laying on the floor. PTA-Y informed Surveyor he had the resident he was ambulating with sit in their wheelchair and told this resident to rest. PTA-Y informed Surveyor he went into R1's room, R1 was still yelling out, asked R1 if she was having pain but R1 didn't answer him. PTA-Y informed Surveyor he pulled both nurse call lights. PTA-Y asked R1 if she was comfortable which R1 replied yes and left R1's room to look for a nurse. PTA-Y informed Surveyor the nurse was in the hallway, believes it was LPN-N and informed the nurse R1 was on the floor. PTA-Y informed Surveyor R1's wheelchair was behind her, and it seemed to him R1 tried to get up. On 11/5/25, at 9:29 a.m., Surveyor informed DON-B R1's fall on 10/16/25 was not thoroughly investigated and prior fall interventions were not in place. Surveyor informed DON-B there is only one staff statement from CNA-I. DON-B informed Surveyor they usually staff the unit with one CNA & one nurse. Surveyor informed DON-B there is not a statement LPN-N as to when she last saw R1, what was R1 doing etc. and there is no statement or interview with physical therapy. DON-B informed Surveyor she was not aware physical therapy was on the unit. Surveyor informed DON-B Surveyor spoke with PTA-Y as LPN-N's nurses note on 10/16/25 documents PT was on the unit. Surveyor informed DON-B PTA-Y was the first staff to find R1. Surveyor also informed DON-B R1's fall interventions were not in place as CNA-I's fall statements documents R1 didn't have anything on her feet and according to the plan of care R1 should wear shoes or gripper socks. R1's Visual/Bedside Kardex Report, which is the Certified Nursing Assistant care plan, as of 11/3/25 under the safety section documents *10/16/25: Reacher at bedside to help with sorting dirty clothes from the laundry hamper if needed. *4/5/25-fall-staff to assist resident with brushing teeth after lunch if permitted. *4/5/25-fall-staff to offer toileting q (every) 2 to 3 hours and prn. *Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. *Ensure that the resident is wearing appropriate footwear (shoes/socks with non-skid soles) when ambulating, transferring or mobilizing in w/c. *PT/OT evaluate and treat as ordered or PRN. *The resident needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, handrails on walls, personal. Surveyor noted there is no further documentation after the word personal. Under section toileting includes*TOILETING SCHEDULE: Assist with toileting every 2-3 hours and as needed. Under section Safety documents: *fall-12-20-24 dycem to w/c. *fall-5/25/25-staff to ensure resident not attempting to feed others when dining room. *fall-5/31/25-staff to ensure bed is made to resident's preference. *Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB (shortness of breath), loss of appetite, sudden changes in mental status, significant or changes in v/s (vital signs). Under the section Transfer documents *Transfer Status: assist of 2 with gait belt and 2ww (wheeled walker). *TRANSFER: The resident requires partial assistance by 1 staff and gait belt to move between surfaces as necessary. On 11/3/25, at 9:18 a.m., Surveyor observed R1 sitting in a wheelchair in R1's room with oxygen via nasal cannula. On 11/3/25, at 10:00 a.m., Surveyor observed Certified Nursing Assistant (CNA)-I stating to R1 I'm going to fill up tank and then will bring you out. I'll be back. CNA-I then left R1's room with the small portable oxygen tank. On 11/3/25, at 10:07 a.m. Surveyor observed CNA-I enter R1's room with the small oxygen tank and then Licensed Practical Nurse (LPN)-N entered R1's room. R1's nasal cannula oxygen tubing was connected to the small tank, R1 was wheeled out of her room and wheeled to the two chairs outside the nurses station to listen to music. On 11/3/25, at 10:18 a.m., Life Enrichment Director (LED)-Z asked R1 if she wants to come upstairs. R1 stated I hope I'm not making a mistake, LED-Z asked R1 about her glasses, wheeled R1 to her room to look for R1's glasses and then LED-Z wheeled R1 back down the hall, to the elevator and up to the 2nd floor for an exercise activity. On 11/3/25, at 11:04 a.m. Surveyor observed R1 sitting in a wheelchair in the sunroom on the 2nd floor participating in an exercise activity. On 11/3/25, at 11:30 a.m., Surveyor observed R1 sitting in a wheelchair by the two chair across from the nurse's station. Surveyor observed R1 continued to be sitting in a wheelchair by the two chair across from the nurse's station until at 12:01 p.m. when Certified Nursing Assistant (CNA)-I asked R1 if she was ready to eat. CNA-I then wheeled R1 to the dining room stating to R1 will get you some coffee and ice to cool it down. On 11/3/25, at 12:33 p.m., Surveyor observed R1 continues to be sitting in a wheelchair at a table in the dining room. Surveyor observed R1 has not been served lunch but has a cup of coffee and a glass of juice. On 11/3/25, at 12:55 p.m., Surveyor observed R1 continues to be sitting in a wheelchair at a table in the dining room with her lunch plate in front of R1. On 11/3/25, at 1:11 p.m., Surveyor observed R1 propelling herself in the wheelchair out of the dining room, down the hall, to the area where the two chairs with the CD player is. Surveyor observed R1 continued to sit in a wheelchair in the area by the two chairs with the CD player. R1 continued to sit in her wheelchair by the two chairs opposite the nurse's station. On 11/3/25, at 1:58 p.m. Surveyor asked CNA-I about when R1 is toileted. CNA-I informed Surveyor she thinks she asked R1 when she brought R1 her oxygen. Surveyor informed CNA-I she brought R1's oxygen around 10:00 a.m. CNA-I informed Surveyor when she got R1 up she took R1 to the bathroom. Surveyor asked CNA-I if she toileted R1 after she got R1 up. CNA-I replied no I didn't take her to the bathroom. Surveyor asked CNA-I how often R1 should be toileted. CNA-I replied suppose to take her every two hours. Surveyor asked CNA-I if she will toilet R1 before she leaves. On 11/3/25, at 2:02 p.m., Surveyor observed CNA-I wheel R1 to her room and into the bathroom. CNA-I placed a gait belt around R1, told R1 to wait a minute and placed gloves on stating to R1 you usually tell us. CNA-I moved R1's wheelchair closer to the grab bar on the wall. CNA-I assisted R1 to stand by holding on to the back of R1's pants. Surveyor noted although the gait belt was on R1, CNA-I did not use the gait belt to lift R1 off the chair. CNA-I lowered R1's product & pants and assisted R1 with sitting on the toilet. CNA-I removed her gloves, informed R1 she would step out to give her privacy, washed her hands, informed R1 to let her know when she is ready. R1 stating I'm done. Surveyor noted R1 urinated in the toilet. CNA-I placed gloves on, removed the incontinence product and place a new product on R1. CNA-I assisted R1 to stand by using the gait belt, wiped R1's peri area with toilet paper, and pulled up R1's incontinence product & pants. CNA-I used the gait belt to assist R1 with sitting in the wheelchair. CNA-I told R1 she was going to have her wash her hands, CNA-I removed her gloves & washed her hands, wheeled R1 to the sink and R1 washed her hands. CNA-I asked R1 if she wanted to come back out and listen to Elvis. CNA-I wheeled R1 out of the bathroom, removed the gait belt from R1, washed her hands, and wheeled R1 out of the room. On 11/3/25, at 2:13 p.m., Surveyor asked CNA-I when R1 brushes her teeth. CNA-I replied in the morning. If she refuses nothing can be done. CNA-I then stated after lunch. Surveyor informed CNA-I she did not offer to brush R1's teeth or have R1 brush her teeth. Surveyor noted R1's fall interventions were not implemented as R1 was not toileted every two to three hours, CNA-I did not offer to brush or have R1 brush her teeth and did not use the gait belt when transferring R1 onto the toilet. On 11/4/25, at 7:06 a.m., Surveyor observed R1 sitting in a wheelchair in her room with an over bed table in front of R1 and a reacher on the over bed table. Surveyor observed R1's call light is not in reach and is hanging on the headboard of R1's bed. On 11/4/25, at 7:36 a.m., Surveyor observed R1 continues to be sitting in a wheelchair in R1's room. R1 has her head down and appears to be sleeping. Surveyor observed R1's call light continues not to be in reach and is hanging on the headboard of R1's bed. On 11/4/25, at 8:36 a.m., Surveyor observed R1's continues to be sitting in a wheelchair in R1's room. Surveyor observed R1's call light continues to be hanging on the headboard of R1's bed and is not in reach. On 11/4/25, at 8:48 a.m., Surveyor observed Licensed Practical Nurse (LPN)-N deliver R1's breakfast tray to R1 who is sitting in a wheelchair in R1's room. Surveyor observed after LPN-N left R1's room, the call light continues to be hanging on the headboard of R1's bed and is not in reach. On 11/4/25, at 9:26 a.m., Surveyor observed R1 sitting in a wheelchair in R1's roo

Based on record review and staff interviews, the facility did not ensure that allegations of neglect, abuse, and/or misappropriation involving 7 residents (R6, R7, R8, R9,R10, R2 and R1) were reported immediately to the State Survey Agency. *On 8/18/25, R6 initiated a formal grievance to include an allegation of neglect that R6 had not been changed for over 2 hours. On 10/2/25, R6 initiated a formal grievance to include an allegation of neglect of having to wait to be changed until the next shift. The allegation of neglect was not reported to the State Survey Agency. *On 8/12/25, R7's representative initiated a formal grievance to include an allegation of neglect that R7 had to wait a long time to get R7's call light answered. The allegation of neglect was not reported to the State Survey Agency. *On 8/4/25, R8 initiated a formal grievance to include an allegation of neglect of having to wait a long time for call light to be answered multiple times. The allegation of neglect was not reported to the State Survey Agency. *On 9/12/25, R9's representative initiated a formal grievance to include an allegation of neglect that R9 had a bowel movement and was not cleaned up until 11:30 AM. The allegation of neglect was not reported to the State Survey Agency. *On 10/23/25, R10's representative initiated a formal grievance to include an allegation of neglect that R10's call light had been answered but the CNA informed R10 the CNA could not help R10 at that time and R10 had to wait a long time to get assistance. The allegation of neglect was not reported to the State Survey Agency. *On 8/12/25, a formal grievance was initiated to include an allegation of misappropriation involving R1. The allegation of misappropriation was not reported to the State Survey Agency. *On 8/25/25, R2 initiated a formal grievance to include an allegation of neglect that R2 was not changed all night resulting in R2 being soaked in urine so much that R2's brief was disintegrating. The allegation of neglect was not reported to the State Survey Agency. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program reviewed 11/8/23 documents: C. Prevention Abuse Policy Requirements: It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The facility will provide feedback regarding complaints and concerns. The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. D. Identification Abuse Policy Requirements: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated. Procedure: All staff will receive education about how to identify signs and symptoms of abuse. Residents will be monitored for possible signs of abuse. G. Reporting and Response Abuse Policy Requirements: It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility and to other officials(including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Procedure: Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Executive Director. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law. b. The executive Director, will involve key leadership personnel as necessary to assist with reporting, investigation and follow up. External Reporting: Each covered resident shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any resident who is a resident of or is receiving care from, the facility, and each covered resident shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegations: If an incident or allegation is considered reportable, the Executive Director or designee will make an initial(immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within 5 working days. When making a report, Misconduct Incident Reporting system will be used. Report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State law, including immediate or 24 hour reporting to the State Survey Agency, law enforcement and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The Executive Director or designee will inform the resident or resident's representative of the report of an incident and that an investigation is being completed. 1) R6 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Unspecified Diastolic Congestive Heart Failure(left ventricle stiffens and can't fill properly between heartbeats), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Morbid Obesity(too much body fat), and Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities). R6's Quarterly Minimum Data Set(MDS) completed 8/21/25 documents a R6's Brief Interview for Mental Status(BIMS) score of 13, indicating R6 is cognitively intact. R6's MDS documents: R6 has no mood or behavior issues; R6 has range of motion impairment of both upper and lower extremities on both sides; R6 requires substantial/maximum assistance for eating; R6 is dependent for upper and lower dressing, mobility, and transfers. R6 is always incontinent of bowel and bladder. On 8/18/25, R6 initiated a formal grievance to include an allegation of neglect that R6 had not been changed for over 2 hours. Staff had informed R6 that we are understaff. The box is checked yes that the individual/representative identify the event as abuse, neglect, or misappropriation. On 10/2/25, R6 initiated a formal grievance to include an allegation of neglect of having to wait to be changed until the next shift. R6 reported that it took 4 hours for R6's phone call to be answered. R6 had to use cell phone because R6's call light was not within reach. This was on the NOC shift. R6 needed to be changed. R6 was not changed until after first shift came in. R6 also reported that first shift refused to get R6 up. Surveyor noted that this allegation of potential neglect was not reported to the State Agency. 2) R7 was admitted to the facility on [DATE] with diagnoses of Encephalopathy(group of conditions that cause brain dysfunction), Essential Hypertension(chronic condition of persistently high blood pressure), and Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe). R7's admission Minimum Data Set (MDS) completed 8/15/25 documents R7's Brief Interview for Mental Status(BIMS) score of 12, indicating R7 is moderately cognitively impaired. R7's MDS documents: R7 has no mood or behavior issues; R7 has no range of motion impairment; R7 required set up for eating; R7 required partial/moderate assistance for showers; R7 required partial/moderate assistance for upper dressing and substantial/maximum assistance for lower dressing; R7 was independent for mobility and required partial/moderate assistance for transfers; R7 was frequently incontinent of bladder and always continent of bowel. On 8/12/25, R7's representative initiated a formal grievance to include an allegation of neglect that R7 had to wait a long time to get R7's call light answered. The call light response time was 30-40 minutes. Surveyor noted that this allegation was not reported to the State Agency. 3) R8 was admitted to the facility on [DATE] with diagnoses of Displaced Fracture of Body of Scapula, Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Anemia(lack of blood), Atrial Fibrillation(irregular, often rapid heart rate commonly causes poor blood flow), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), and Gout(inflammatory arthritis that causes pain and swelling in joints). R8's admission Minimum Data Set (MDS) completed 8/15/25 documents R8's cognitive status was not assessed. R8's MDS documents: R8 has no mood or behavior issues; R8 has range of motion impairment on both sides of upper extremity; R8 required set up for eating; R8 required substantial/maximum assistance for upper and lower dressing; R8 required substantial/maximum for mobility and transfers; R8 was frequently incontinent of bowel and always occasionally incontinent of bladder. On 8/4/25, R8 initiated a formal grievance to include an allegation of neglect of having to wait a long time for call light to be answered multiple times. R8 had to wait 35 minutes during day shift and another 30 minutes on the same day. Surveyor noted that this allegation was not reported to the State Agency. 4) R9 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease(disorder of the central nervous system that affects movement, often including tremors), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Depression(mood disorder that causes persistent feelings of sadness and loss of interest), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R9's admission Minimum Data Set (MDS) completed 9/12/25 documents R9 demonstrates modified independence for daily decision making. The MDS documents: R9 has episodes of disorganized thinking and altered level of consciousness; R9's MDS documents R9 has no mood or behavior issues; R9 has no range of motion impairment; R9 required partial/moderate for eating; R9 was dependent for showers; R9 required substantial/maximum assistance for upper dressing and dependent assistance for lower dressing; R9 was substantial/maximum assistance for mobility and dependent assistance for transfers; R9 was frequently incontinent of bladder and bowel. On 9/12/25, R9's representative initiated a formal grievance to include an allegation of neglect that R9 had a bowel movement and was not cleaned up until 11:30 AM. The CNA reported it was busy in the morning and was not able to get R9 up until later in the morning. Surveyor noted that this allegation of potential neglect was not reported to the State Agency. 5) R10 was admitted to the facility on [DATE] with diagnoses of Gout(inflammatory arthritis that causes pain and swelling in joints), Hypothyroidism(underactive thyroid), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Anemia(lack of blood), Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Chronic Myeloproliferate Disease(group of blood cancers) and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R10's admission Minimum Data Set(MDS) completed 10/28/25 documents R10's Brief Interview for Mental Status(BIMS) score of 15, indicating R10 is cognitively intact. R10's MDS documents: R10 has no mood or behavior issues; R10 has no range of motion impairment; R10 is independent for eating. R10 requires partial/moderate assistance for showers; R10 required supervision assistance for upper dressing and partial/moderate assistance for lower dressing; R10 required partial/moderate assistance for mobility and transfers; R10 was occasional incontinent of bladder and always continent of bowel. On 10/23/25, R10's representative initiated a formal grievance to include an allegation of neglect that R10's call light had been answered but the CNA informed R10 the CNA could not help R10 at that time and R10 had to wait a long time to get assistance. It was determined that a CNA had clocked out for the shift early, and the next shift did not provide assistance until much later in the shift. On 11/4/25, at 10:17 AM, Surveyor interviewed Life Coach (LC)-AA. LC-AA informed Surveyor that LC-AA is part of the investigation process and part of the resolution when there is a grievance documented. LC-AA interviews other residents if there is a facility reported incident. LC-AA informed Surveyor that LC-AA would initiate a facility reported incident if a resident used the term neglect or abuse or if LC-AA determined off of a risk assessment. Surveyor reviewed the five grievances with LC-AA. Surveyor shared the concern with LC-AA that the five grievances were reflective of allegations of neglect. LC-AA understands the concern. LC-AA stated that LC-AA is still getting comfortable with the role and is not always clear about what is abuse and/or neglect. LC-AA informed Surveyor that LC-AA would go to administration for help. On 11/4/25, at 3:03 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Sister Facility NHA (SFNH)-C that R6, R7, R8, R9, and R10's grievances had allegations of neglect that were no reported to the State Survey Agency. No additional information has been provided by the facility as to why R6, R7, R8, R9, and R10's allegations of neglect were not reported to the State Survey Agency. 6.) Surveyor reviewed a grievance filed by R2 on 8/25/25. The resident reported on 8/23/25, she was not changed at all on NOC (night) shift from 10 PM - 6 AM. Staff statement the next morning reported the residents' bed was completely soaked, the brief was falling apart and she had to do a complete bed change. The CNA assigned to R2 that night was terminated. The termination notice documented: Complete and thorough investigation substantiates a lack of quality resident care. Resident was not changed/checked on entire NOC shift. On 11/3/25 at 1:00 PM, Surveyor spoke with Director of Nursing (DON)-B and reviewed the grievance. Surveyor asked if the allegation of neglect contained in the grievance was reported to the state agency. DON-B stated, I don't know, I'll have to ask. No additional information was provided. On 11/4/25 at 1:30 PM, Surveyor spoke with Prior Life Coach-J and reviewed the grievance allegation. Prior Life Coach-J stated, Yes, I remember. I would have given that to the DON because it has an allegation of neglect. Surveyor confirmed, so you feel this was a neglect situation. Prior Life Coach-J stated, Yes, I gave it to the DON because she would have to report it. No additional information was provided. On 11/4/25 at 3:00 PM, during the daily exit meeting, the facility was advised of concern R2's grievance contained an allegation of neglect that should have been reported to the State agency. No additional information was provided. 7.) On 11/3/25, at 3:07 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Nurse Clinical Consultant (NCC)-X Surveyor asked for the grievance dated 8/12/25 involving R1. On 11/4/25, at 11:00 a.m., Surveyor reviewed the grievance dated 8/12/25 investigated by Prior Life Coach (PLC)-J. Surveyor noted the individual affected documents [R1's name]. Under describe concern using factual terms documents Writer was call to resident room (anonymous resident) because she was concerned resident from across hall (R1) was giving kitchen staff money. Writer ensured resident (anonymous resident) it will be addressed. On 11/4/25, at 12:30 p.m., Surveyor asked NHA-A if the grievance involving R1 dated 8/12/25 was reported to the State agency for an allegation of misappropriation. NHA-A informed Surveyor as long as she has worked at the facility R1 has made statements about having to pay. NHA-A informed Surveyor it was not reported. Surveyor informed NHA-A the grievance was made by another resident, and the allegation of misappropriation should have been reported to the State agency.

Based on record review and staff interviews, the facility did not ensure that allegations of neglect, abuse, and/or misappropriation involving 7 residents (R6, R7, R8, R9, R10, R2 and R1) were not thoroughly investigated. *On 8/18/25, R6 initiated a formal grievance to include an allegation of neglect that R6 had not been changed for over 2 hours. On 10/2/25, R6 initiated a formal grievance to include an allegation of neglect of having to wait to be changed until the next shift. The allegation of neglect was not thoroughly investigated. *On 8/12/25, R7's representative initiated a formal grievance to include an allegation of neglect that R7 had to wait a long time to get R7's call light answered. The allegation of neglect was not thoroughly investigated. *On 8/4/25, R8 initiated a formal grievance to include an allegation of neglect of having to wait a long time for call light to be answered multiple times. The allegation of neglect was not thoroughly investigated. *On 9/12/25, R9's representative initiated a formal grievance to include an allegation of neglect that R9 had a bowel movement and was not cleaned up until 11:30 AM. The allegation of neglect was not thoroughly investigated. *On 10/23/25, R10's representative initiated a formal grievance to include an allegation of neglect that R10's call light had been answered but the CNA informed R10 the CNA could not help R10 at that time and R10 had to wait a long time to get assistance. The allegation of neglect was not thoroughly investigated. *On 8/12/25, a formal grievance was initiated to include an allegation of misappropriation involving R1. The allegation of misappropriation was not thoroughly investigated. *On 8/25/25, R2 initiated a formal grievance to include an allegation of neglect that R2 was not changed all night resulting in R2 being soaked in urine so much that R2's brief was disintegrating. The allegation of neglect was not thoroughly investigated. Findings include: The facility's Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program reviewed 11/8/23 documents: C. Prevention Abuse Policy Requirements: It is the policy of this facility to prevent abuse by providing residents, families and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The facility will provide feedback regarding complaints and concerns. The facility leadership will assess the needs of the residents in the facility to be able to identify concerns in order to prevent potential abuse. D. Identification Abuse Policy Requirements: It is the policy of this facility that all staff monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may constitute abuse will be investigated. Procedure: All staff will receive education about how to identify signs and symptoms of abuse. Residents will be monitored for possible signs of abuse. G. Reporting and Response Abuse Policy Requirements: It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility and to other officials(including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. Procedure: Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Executive Director. **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law. b. The executive Director, will involve key leadership personnel as necessary to assist with reporting, investigation and follow up. External Reporting: Each covered resident shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located, any reasonable suspicion of a crime against any resident who is a resident of or is receiving care from, the facility, and each covered resident shall report immediately, but not more than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. Initial reporting of allegations: If an incident or allegation is considered reportable, the Executive Director or designee will make an initial(immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to the State Agency within 5 working days. When making a report, Misconduct Incident Reporting system will be used. Report the results of all investigations to the Executive Director or his or her designated representative and to other officials in accordance with State law, including immediate or 24 hour reporting to the State Survey Agency, law enforcement and the follow up report to the State Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. The Executive Director or designee will inform the resident or resident's representative of the report of an incident and that an investigation is being completed. 1) R6 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Unspecified Diastolic Congestive Heart Failure(left ventricle stiffens and can't fill properly between heartbeats), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Morbid Obesity(too much body fat), and Major Depressive Disorder(persistent feelings's of sadness, hopelessness, and a loss of interest or pleasure in activities). R6's Quarterly Minimum Data Set(MDS) completed 8/21/25 documents R6's Brief Interview for Mental Status(BIMS) score of 13, indicating R6 is cognitively intact. R6's MDS documents: R6 has no mood or behavior issues; R6 has range of motion impairment of both upper and lower extremities on both sides; R6 requires substantial/maximum assistance for eating; R6 is dependent for upper and lower dressing, mobility, and transfers; R6 is always incontinent of bowel and bladder. On 8/18/25, R6 initiated a formal grievance to include an allegation of neglect that R6 had not been changed for over 2 hours. Staff had informed R6 that we are understaff. The box is checked yes that the individual/representative identify the event as abuse, neglect, or misappropriation. The allegation of neglect was not thoroughly investigated. The facility did not obtain staff statements and did not interview other residents to determine if there was a pattern of neglect. On 10/2/25, R6 initiated a formal grievance to include an allegation of neglect of having to wait to be changed until the next shift. R6 reported that it took 4 hours for R6's phone call to be answered. R6 had to use cell phone because R6's call light was not within reach. This was on the NOC shift. R6 needed to be changed. R6 was not changed until after first shift came in. R6 also reported that first shift refused to get R6 up. The allegation of neglect was not thoroughly investigated. The facility did not obtain staff statements and did not interview other residents to determine if there was a pattern of neglect. 2) R7 was admitted to the facility on [DATE] with diagnoses of Encephalopathy(group of conditions that cause brain dysfunction), Essential Hypertension(chronic condition of persistently high blood pressure), and Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe). R7's admission Minimum Data Set(MDS) completed 8/15/25 documents R7's Brief Interview for Mental Status(BIMS) score of 12, indicating R7 is moderately cognitively impaired. R7's MDS documents: R7 has no mood or behavior issues; R7 has no range of motion impairment; R7 required set up for eating; R7 required partial/moderate assistance for showers; R7 required partial/moderate assistance for upper dressing and substantial/maximum assistance for lower dressing; R7 was independent for mobility and required partial/moderate assistance for transfers; R7 was frequently incontinent of bladder and always continent of bowel. On 8/12/25, R7's representative initiated a formal grievance to include an allegation of neglect that R7 had to wait a long time to get R7's call light answered. The call light response time was 30-40 minutes. The allegation of neglect was not thoroughly investigated. The facility did not obtain staff statements and did not interview other residents to determine if there was a pattern of neglect. 3) R8 was admitted to the facility on [DATE] with diagnoses of Displaced Fracture of Body of Scapula, Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Anemia(lack of blood), Atrial Fibrillation(irregular, often rapid heart rate commonly causes poor blood flow), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), and Gout(inflammatory arthritis that causes pain and swelling in joints). R8's admission Minimum Data Set(MDS) completed 8/15/25 documents R8's cognitive status was not assessed. R8's MDS documents: R8 has no mood or behavior issues; R8 has range of motion impairment on both sides of upper extremity; R8 required set up for eating; R8 required substantial/maximum assistance for upper and lower dressing; R8 required substantial/maximum for mobility and transfers; R8 was frequently incontinent of bowel and always occasionally incontinent of bladder. On 8/4/25, R8 initiated a formal grievance to include an allegation of neglect of having to wait a long time for call light to be answered multiple times. R8 had to wait 35 minutes during day shift and another 30 minutes on the same day. The allegation of neglect was not thoroughly investigated. The facility did not obtain staff statements and did not interview other residents to determine if there was a pattern of neglect. 4) R9 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease(disorder of the central nervous system that affects movement, often including tremors), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Depression(mood disorder that causes persistent feelings of sadness and loss of interest), Anxiety Disorder(mental health disorder characterized by feelings of worry, fear that interfere with daily activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R9's admission Minimum Data Set(MDS) completed 9/12/25 documents R9 demonstrates modified independence for daily decision making. R9 has episodes of disorganized thinking and altered level of consciousness. R9's MDS documents: R9 has no mood or behavior issues; R9 has no range of motion impairment; R9 required partial/moderate for eating; R9 was dependent for showers; R9 required substantial/maximum assistance for upper dressing and dependent assistance for lower dressing; R9 was substantial/maximum assistance for mobility and dependent assistance for transfers; R9 was frequently incontinent of bladder and bowel. On 9/12/25, R9's representative initiated a formal grievance to include an allegation of neglect that R9 had a bowel movement and was not cleaned up until 11:30 AM. The CNA reported it was busy in the morning and was not able to get R9 up until later in the morning. The allegation of neglect was not thoroughly investigated. The facility did not obtain staff statements and did not interview other residents to determine if there was a pattern of neglect. 5) R10 was admitted to the facility on [DATE] with diagnoses of Gout(inflammatory arthritis that causes pain and swelling in joints), Hypothyroidism(underactive thyroid), Gastro-Esophageal Reflux Disease(stomach contents leak backward from stomach into the esophagus(food pipe), Anemia(lack of blood), Peripheral Vascular Disease(circulatory condition in which narrowed blood vessels reduce blood flow to limbs), Chronic Myeloproliferate Disease(group of blood cancers) and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R10's admission Minimum Data Set(MDS) completed 10/28/25 documents R10's Brief Interview for Mental Status(BIMS) score of 15, indicating R10 is cognitively intact. R10's MDS documents: R10 has no mood or behavior issues; R10 has no range of motion impairment; R10 is independent for eating; R10 requires partial/moderate assistance for showers; R10 required supervision assistance for upper dressing and partial/moderate assistance for lower dressing; R10 required partial/moderate assistance for mobility and transfers; R10 was occasional incontinent of bladder and always continent of bowel. On 10/23/25, R10's representative initiated a formal grievance to include an allegation of neglect that R10's call light had been answered but the CNA informed R10 the CNA could not help R10 at that time and R10 had to wait a long time to get assistance. It was determined that a CNA had clocked out for the shift early, and the next shift did not provide assistance until much later in the shift. The allegation of neglect was not thoroughly investigated. The facility did not obtain staff statements and did not interview other residents to determine if there was a pattern of neglect. On 11/4/25, at 10:17 AM, Surveyor interviewed Life Coach (LC)-AA. LC-AA informed Surveyor that LC-AA is part of the investigation process and part of the resolution when there is a grievance documented. LC-AA interviews other residents if there is a facility reported incident. LC-AA informed Surveyor that LC-AA would initiate a facility reported incident if a resident used the term neglect or abuse or if LC-AA determined off of a risk assessment. Surveyor reviewed the five grievances with LC-AA. Surveyor shared the concern with LC-AA that the five grievances were reflective of allegations of neglect. LC-AA understands the concern. LC-AA stated that LC-AA is still getting comfortable with the role and is not always clear about what is abuse and/or neglect. LC-AA informed Surveyor that LC-AA would go to administration for help. On 11/4/25, at 3:03 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Sister Facility NHA (SFNH)-C that R6, R7, R8, R9, and R10's grievances had allegations of neglect that were not thoroughly investigated. The facility did not obtain staff statements and did not interview other residents to determine if there was a pattern of neglect. No additional information was provided by the facility as to why R6, R7, R8, R9, and R10's allegations of neglect were not thoroughly investigated to determine the circumstances of the allegations of neglect. 6.) Surveyor reviewed a grievance filed by R2 on 8/25/25. The resident reported on 8/23/25, she was not changed at all on NOC (night) shift from 10 PM - 6 AM. Staff statement the next morning reported the residents' bed was completely soaked, the brief was falling apart and she had to do a complete bed change. The CNA assigned to R2 that night was terminated. The termination notice documented: Complete and thorough investigation substantiates a lack of quality resident care. Resident was not changed/checked on entire NOC shift. On 11/3/25 at 12:30 PM Surveyor spoke with Director of Nursing (DON)-B and reviewed the grievance. Surveyor asked why the grievance indicated it was resolved on the same date it was filed by R2 (8/25/25). DON-B reported she did not know and would look for more information. Surveyor asked if any other residents assigned to the CNA involved in the allegation of neglect to determine if other residents were affected. DON-B reported she did not know and would look for more information. On 11/4/25 at 1:30 PM, Surveyor spoke with Prior Life Coach-J and reviewed the grievance allegation. Prior Life Coach-J stated, Yes, I remember. I would have given that to the DON because it has an allegation of neglect. Surveyor confirmed, so you feel this was a neglect situation. Prior Life Coach-J advised Surveyor she did not investigate the grievance allegation; she gave it to the DON. Surveyor advised Prior Life Coach-J that the grievance contains her signature as the assigned investigating individual, and the grievance officer reviewing resolution. No explanation was provided as to why she signed the form. Surveyor asked if she interviewed any other residents assigned to the CNA. Prior Life Coach-J stated, No, I didn't do the investigation. I know the CNA was terminated because of this. On 11/4/25 at 3:00 PM, during the daily exit meeting, the facility was advised of concern R2's grievance contained an allegation of neglect that was not thoroughly investigated. No other residents were interviewed to determine if any other residents were affected. No additional information was provided. 7.) On 11/3/25, at 3:07 p.m., during the end of the day meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Nurse Clinical Consultant (NCC)-X Surveyor asked for the grievance dated 8/12/25 involving R1. On 11/4/25, at 11:00 a.m., Surveyor reviewed the grievance dated 8/12/25 investigated by Prior Life Coach (PLC)-J. Surveyor noted the individual affected documents [R1's name]. Under describe concern using factual terms documents Writer was call to resident room (anonymous resident) because she was concerned resident from across hall (R1) was giving kitchen staff money. Writer ensured resident (anonymous resident) it will be addressed. Investigation Findings documents Resident believes that the oz (ounce) listed on menu are dollar amounts when staff delivers food, she believes she has to pay the bill. Resolution description documents Kitchen staff declines taking any money when offered as they are aware of policy and would not jeopardize their job. Date of resolution documents 8/12/25. On 11/4/25, at 12:19 p.m., Surveyor asked NHA-A if there is any investigation regarding the grievance involving R1 dated 8/12/25. On 11/4/25, at 12:30 p.m., NHA-A informed Surveyor she does not have any staff statements or resident's statements, she looked through the whole book and does not have an investigation. NHA-A informed Surveyor the name of Prior Life Coach (PLC)-J did the investigation, she doesn't work for the facility but works for the corporation. NHA-A informed Surveyor she can provide Surveyor with the phone number if Surveyor would like to speak with PLC-J. Surveyor informed NHA-A Surveyor would be happy to speak with anyone NHA-A would like Surveyor to. On 11/4/25, at 1:17 p.m., Surveyor spoke with PLC-J on the telephone. PLC-J explained a resident, who wanted to be anonymous, called her into the room and was concerned R1 was giving kitchen staff money. PLC-J explained she wrote the grievance, watched breakfast & lunch being served on the unit and saw no money was being exchanged. PLC-J informed Surveyor she spoke to the kitchen staff. Surveyor asked PLC-J who she spoke with. PLC-J replied I don't know, kind of all together in a group or in passing. PLC-J informed Surveyor the kitchen staff know they can't accept funds from residents. Surveyor asked PLC-J if she spoke to other residents to see if they had any concerns regarding having to give money to staff for their meals. PLC-J informed Surveyor she doesn't believe there were other residents in the area, and she just spoke with the two residents, anonymous resident & R1. The facility did not conduct a thorough investigation for an allegation of misappropriation as there is no evidence which dietary staff were interviewed and PLC-J only interviewed anonymous resident & R1 and did not interview other residents.

Based on interview and record review, the facility did not ensure 5 of 5 direct care staff chosen at random received Quality Assurance and Performance Improvement (QAPI) training with the potential to affect all 43 residents in the facility.Certified nursing assistant (CNA)-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not receive QAPI training as a new hire.Findings include:On 11/11/2025, Surveyor requested from nursing home administrator (NHA)-A the documentation of training for CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG. NHA-A stated the facility used Relias, an online computer-based training program, for staff education.Surveyor reviewed the provided training transcripts for CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG. CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not have documentation of receiving QAPI training.Surveyor reviewed the Facility Assessment, last review/ approval date of 3/27/2025, which documents, Staff Education, Training, and Competencies: Each job description identifies the required education and credentials for the job. Staff education and credentials are verified prior to hiring. Each staff member has knowledge competency in the following:- Resident Rights- Abuse, Neglect, Misappropriation- Fire Basics- HIPPA Compliance- Lockout-Tagout Basics- Infection Control- Corporate Compliance and Ethics- IT Policies- Personnel Handbook- Trauma Informed Care- Dementia Management and Behavioral Health .Competencies are verified upon orientation, at least annually and as needed. The facility provides education and training in various ways. The staff training and education program is designed to ensure knowledge competency for all staff. Education is provided through the on-line learning system Relias . The training program is reviewed and revised each time the Facility Assessment is reviewed and /or revised.Surveyor noted QAPI training was not included in the topics in the training plan.On 11/11/2025, at 1:07pm, Surveyor interviewed nursing home administrator (NHA)-A and asked how it is ensured that staff have completed all required trainings. NHA-A stated corporate employee-HH will email NHA-A staff that have education to be completed. Surveyor shared concern CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not have documentation of receiving QAPI training. NHA-A shared a phone number for corporate employee-HH as NHA-A does not have knowledge of the Relias education staff has to complete.On 11/11/2025, at 1:15pm, Surveyor interviewed corporate employee-HH via phone who stated was unable to talk at the time due to driving to an appointment. Corporate employee-HH requested an email be sent by Surveyor with specific questions and requests to corporate employee-HH and corporate employee-II.On 11/11/2025, at 1:25pm, Surveyor sent an email to corporate employee-HH and corporate employee-II requesting QAPI education completed by CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG.On 11/11/2025, at 1:16pm, Surveyor shared concern with nurse clinical consultant (NCC)-X CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not have QAPI training documented and waiting on reply back from corporate employee-HH or corporate employee-II. NCC-X stated staff was working on locating requesting documents.On 11/11/2025, at 2:21pm, Surveyor received an email from corporate employee documenting, . Every year a team sits down to review the training plan for the following year. Last year it was identified that we have a gap in QAPI training for our staff. We proactively assigned this to our staff for the 2025 calendar year. I will say that [Facility name] incorporates the input of our front line staff and asks that they actively participate in QAPI related initiatives. The QAPI training module is assigned to all staff in quarter (Q)4 of 2025.On 11/11/2025, at 2:30pm, Surveyor shared concern with NHA-A and NCC-X CNA-CC, CNA-DD, CNA-EE, CNA-FF, and CNA-GG did not receive QAPI training upon hire. NHA-A and NCC-X did not have further concerns or questions.

Based on interview and record review, the facility did not ensure 1 (R3) of 1 resident's representative was notified when there was a need to alter medical treatment.*R3's emergency contact/representative was not notified when R3 had a fall on 6/30/25 and 7/12/25.Findings include:The facility's undated Change of Condition and Provider Notification policy and procedure documents:I. Policy: Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care.II. Procedure:1.Change of Conditiona. Change of Condition is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death.3.Notificationb. As applicable, individual representative, managed care organization and hospice will be notified.R3 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side(complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Epilepsy(disorder in which nerve cell activity in brain is disturbed causing seizures) Anemia(lack of blood), Dysphagia(difficulty swallowing foods) and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R3's 5-day Minimum Data Set(MDS) completed 8/25/25 documents R3's Brief Interview for Mental Status score to be 11, indicating R3 demonstrates moderately impaired skills for daily decision making.On 11/3/25, at 10:27 AM, Surveyor interviewed R3 and assessed R3 to be alert and oriented to person, place, and time.On 6/30/25, R3 had an unwitnessed fall in the bathroom. Surveyor reviewed R3's electronic medical record(EMR) and the facility's unwitnessed fall investigation.Surveyor noted there is no documentation that R3's wife or emergency contact were contacted and informed of R3's fall and R3's potential change in condition. On 7/12/25, R3 had an unwitnessed fall in the room attempting to close the blinds. Surveyor reviewed R3's electronic medical record(EMR) and the facility's unwitnessed fall investigation.Surveyor noted there is no documentation that R3's wife or emergency contact was contacted and informed of R3's fall and R3's potential change in condition. On 11/3/25, at 1:15 PM, Surveyor interviewed R3 who stated that R3's wife should be notified of all things at the facility.On 11/4/25, at 8:22 AM, Director of Nursing (DON)-B informed Surveyor that R3's wife did not need to be informed of R3's 6/30/25 and 7/12/25 falls because R3 was R3's own person at the time. Surveyor shared that R3's falls was a change of condition and the emergency contact should have been notified of the change of condition. Surveyor shared there is no documentation that R3 stated R3 did not want R3's emergency contact updated on any change of condition.On 11/4/25, at 3:03 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON-B) and Sister Facility Nursing Home Administrator (SFNHA)-C that R3's emergency contact was not contacted when R3 fell on 6/30/25 and 7/12/25.No further information was provided by the facility as to why R3's emergency contact/representative was not contacted when R3 fell on 6/30/25 and 7/12/25 which per the facility's policy and procedure, R3's emergency contact/representative should have been contacted.

Based on observation, interview, and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R4) of 1 resident reviewed for ADL's (Activities of Daily Living).*R4 was to have maintained short fingernails per documented skin intervention. R4 fingernails were observed during the survey process to have extremely long fingernails on all fingers of both hands.Findings Include:The facility's undated policy titled STANDARD ADL (activities of daily living) PROTOCOL documents:- ADLS: Dressing, grooming, eating, toileting, bathing, personal hygiene (oral care, face, hands), mobility, transfers- Problem: Individual requires assistance with Activities of Daily Living (ADLs)- Goal: Individual will preform ADL's at highest functional level with or without staff assist.- CNA (Certified Nursing Assistant):o Trim finger and toenails on bath/shower day and as needed unless diabetico Offer handwashing/sanitizing before meals.R4 was admitted on [DATE] with diagnoses of Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side (complete and partial loss of movement on right side of the body after ischemic stroke - decreased blood flow to the brain causing lasting physical and mental deficits), Aphasia (inability to understand or speak), Dysphagia (difficulty swallowing), weakness, and need For Assistance with Personal Care.R4's Quarterly Minimum Data Set (MDS) completed 9/12/25 documented R4 has severe cognitive impairment with a Brief Interview Mental Status (BIMS) score of 3. The MDS documents: R4 has unclear speech and is sometimes understood; R4 has impairment on one side upper and lower; R4 eats independently, requires partial to moderate assistance for hygiene, showering, dressing, toileting, and bed mobility; R4 requires set up to supervision assistance for all transfers.R4's comprehensive care plan for R4 documented: The resident has potential impairment to skin integrity r/t (related to) fragile skin, assisted to reposition, incontinence, immobility and history of skin altercation. Scar tissue present to right buttock from prior healed area. Date initiated 6/9/25, revised 8/19/25.o Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Date Initiated 6/9/25. R4's activities of daily living (ADL) self care performance deficit related to Activity intolerance, fatigue, impaired balance-stroke related to hemiplegia care plan initiated 6/9/25 and revised on 6/17/25 documents:o BATHING/SHOWERING: check nail length and trim and clean on bath days and as necessary. Report any changes to the nurse. Initiated on 6/9/25.o Praise all efforts at self care. Resident refuses cares at times. Date initiated 6/9/25, revised on 10/14/25R4's Kardex as of 11/3/25, which instructs Certified Nursing Assistants (CNA) in the care for R4, documented:- Skin Integrity: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short.On 11/4/25, at 7:35 AM, Surveyor observed R4 sleeping in bed and observed R4's nails to be extremely long and dirty with debris. On 11/4/25, at 3:03 PM, Surveyor shared concerns with Nursing Home Administrator (NHA) -A, Director of Nursing (DON) -B, and Sister Facility NHA-C.The facility did not provide any additional information at this time as to why ADLs were not provided to R4 as R4's fingernails are extremely long and dirty.On 11/4/25, at 3:40 PM, Surveyor observed R4 in bed with extremely long and dirty fingernails. On 11/5/25, at 8:42 AM, Surveyor observed R4 in bed with extremely long and dirty fingernails.No additional information was provided.

Based on interview and record review the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 3 (R1, R2, & R3) of 4 residents. *R1 receives an anticoagulant twice a day. On 10/16/25 R1 sustained an unwitnessed fall hitting her head. R1 sustained a large purplish hematoma on the left side of the R1's forehead and a skin tear on the left hand. While R1 was laying on the floor, Licensed Practical Nurse (LPN)-N obtained vital signs and Nurse Practitioner (NP)-K assessed R1's range of motion. NP-K informed Surveyor after assessing R1's range of motion she left R1's room as multiple staff were coming into the room. NP-K informed Surveyor she planned on returning to R1's room. NP-K did not complete a comprehensive assessment and did not return until sometime after lunch. When NP-K returned sometime after 2:00 p.m., there was bruising on the left side of R1's face. NP-K ordered R1 to be transferred to the hospital. Surveyor also noted there was not a RN (Registered Nurse) assessment completed R1's fall. Surveyor noted R1's neurological check is incomplete as staff did not complete one of the 30-minute checks. According to the ambulance report, a call was received at 2:41 p.m. When the ambulance crew arrived at the unit, the nurse led them to R1's room informing the ambulance crew that R1 had a fall but that she needed to pass medication and would be around the corner. Concierge-BB contacted Licensed Practical Nurse/Nurse Supervisor (LPN/NS)-G to request she speak with the ambulance crew as LPN-N was passing medication. LPN/NS-G was unable to give the ambulance crew a report until she spoke with LPN-N as LPN/NS-G was supervising and was not working the floor. *The facility did not follow R2's physician order dated 9/15/25 to obtain a stool sample to check for C-Diff (Clostridioides difficile). *Neuro (neurological) checks were not completed for R3's unwitnessed falls on 6/30/25 & 7/12/25. Findings include: The facility's policy titled, Change of Condition and Provider Notification and last reviewed 5/8/25 under Policy documents Upon individual change of condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. Under Procedure for 2. Assessment documents a.) Licensed nurse is involved in the assessment process and contribute to the collection of the data base, the planning of interventions and evaluation of individual's response to condition change. b.) a licensed nurse is to complete the initial assessment, and follow-up evaluation as indicated by the complexity and stability of the individual's condition. c.) Change of Condition Assessment shall be reviewed by Registered Nurse. 1.) R1 was admitted to the facility with diagnoses that include chronic respiratory failure with hypoxia (long term condition where the lungs cannot supply enough oxygen to the blood resulting in low blood oxygen levels), dementia (loss of cognitive function that interferes with a person's daily life & activities), atrial fibrillation (irregular and rapid heartbeat), and anxiety disorder (group of mental health conditions characterized by excessive & persistent worry, fear, and nervousness that an interfere with daily life). R1's physician orders include an order dated 4/7/25 Eliquis oral tablet 2.5 mg (milligrams) (Apixaban). Give 2.5 mg by mouth two times a day for anticoagulant. R1's nurses note dated 10/16/25, at 11:03 a.m., written by Licensed Practical Nurse (LPN)-N documents: Writer heard loud screaming from resident's room, someone from PT (physical therapy) stated res. (resident) is on the floor as writer proceeded to resident's room. Writer observed res. On the floor on right side. Resident last observed eating at 1000 (10:00 a.m.) with O2 (oxygen) on. Writer observed res. Without O2 reapplied. Writer made NP (Nurse Practitioner) aware NP came and observed res. On the floor and assessed res. Writer called [Name] res contact person. Staff assisted writer sic (resident) off floor after assessment. Ice pack applied to left side of head, res. With large purplish hematoma, also has purplish bruise area on left hand with skin tear, writer cleaned area and proximate skin and applied steri strips and dry dressing. Neuro check negative, rom (range of motion) wnl (within normal limits) to upper and lower extremities although complaint of pain to coccyx area. R1's nurses note dated 10/16/25, at 14:38 (2:38 p.m.), written by LPN-N documents: NP sending resident out to hospital d/t (due to) previous fall. Resident with hematoma to left side of forehead, also developing a black eye to left eye. Writer called [Name] ambulance, waiting for ambulance to arrive. Writer to update res. Family [Name]. R1's nurses note dated 10/16/25, at 21:54 (9:54 p.m.), written by LPN-N documents: Resident returned from the hospital, test negative, resident in bed resting, offered no c/o (complaint of) pain/discomfort. On 11/3/25, at 11:34 a.m., Surveyor asked LPN-N about R1's bruising on R1's face. LPN-N informed Surveyor she was told that's why Surveyors are here. LPN-N then informed Surveyor she heard yelling; name of Physical Therapy Assistant (PTA)-Y was coming up from the end of the hall where he was treating another resident and said R1 fell. LPN-N stated she was on her way because a resident was yelling. LPN-N informed Surveyor R1 was on the floor in her room. Surveyor asked what time the fall was. LPN-N informed Surveyor she wrote the note at 11:30 a.m. so probably about 11:00 a.m. Surveyor later identified the fall as being at 10:30 a.m. LPN-N informed Surveyor she called the name of Nurse Practitioner (NP)-K. Surveyor asked LPN-N when she called for NP-K. LPN-N replied right away. LPN-N informed Surveyor she and staff got R1 off the floor. Surveyor asked LPN-N when did RN-K come to R1's room. LPN-N replied right away. On 11/3/25, at 12:25 p.m. Surveyor interviewed NP-K regarding R1's fall on 10/16/25. NP-K informed Surveyor they called her right after R1 fell. Surveyor asked NP-K if she remembers what time they called her. NP-K informed Surveyor she can tell Surveyor it was in the morning because she was in another room down the hall but would be guessing about the time. NP-K informed Surveyor she left the room she was in and went to R1's room. Surveyor asked if R1 was on the floor or in bed. NP-K informed Surveyor R1 was still on the floor and the nurse was getting vital signs. R1 was complaining of she thinks hip or knee pain. NP-K stated I was assessing ROM (range of motion) and then I left the room. NP-K explained multiple people came in to get R1 off the floor. Surveyor asked NP-K before she left R1's room did she give any instructions to the nurse. NP-K replied we talked about dressing her hand. NP-K stated my plan was to come back when she was not on the floor anymore. Surveyor asked NP-K if she returned to R1's room. NP-K replied yes, after lunch. NP-K informed Surveyor R1 had left side bruising, knot on forehead and no other complaints of pain. NP-K informed Surveyor she then gave the order to send R1 out. Surveyor asked NP-K why she decided to send R1 to the hospital. NP-K informed Surveyor R1 had a hematoma on forehead, bruising and on Eliquis. Surveyor informed NP-K she had said she came back to R1's room after lunch and asked NP-K if she remembers what time this was. NP-K stated 2:00 p.m. I'm guessing. Surveyor asked NP-K why she didn't send R1 out in the morning when R1 was on the floor when R1 had an unwitnessed fall, hit her head and was on Eliquis. NP-K replied I'm not sure why I didn't send her out. Surveyor asked NP-K if R1 should have been sent to the hospital right away. NP-K replied probably. On 11/3/25, at 12:42 p.m. Surveyor asked LPN-N if she remembers what time NP-K told her to send R1 to the hospital. LPN-N replied no, and I don't want to give you some bogus answer. Surveyor asked LPN-N if she was here when the ambulance crew arrived. LPN-N replied yes. Surveyor asked if she remembers what time the ambulance crew arrived. LPN-N replied no and explained she remembers calling them and them coming. Surveyor asked LPN-N if she spoke with the ambulance crew. LPN-N replies yes and explained she told them she has some papers to give them, but the secretary (Concierge-BB) is going to print them out. LPN-N informed Surveyor the ambulance crew asked her what happened, and she told them R1 fell and has a hematoma on her head. LPN-N informed Surveyor she was passing medication and told the ambulance crew if they needed her, she was around the corner. On 11/3/25, at 3:26 p.m., Surveyor asked Concierge-BB if she was involved with R1's fall on 10/16/25. Concierge-BB informed Surveyor she printed some paperwork as they were having problems with the printer on the unit. Surveyor asked Concierge-BB what she printed out. Concierge-BB informed Surveyor the face sheet, MAR (medication administration record), medication list, and transfer summary. Surveyor asked Concierge-BB if she had any contact with the ambulance crew. Concierge-BB informed Surveyor when she brought the paperwork into the room, there was a tall man and a shorter female with a bad attitude. Concierge-BB informed Surveyor she was barking at her questions, after questions. Concierge-BB informed Surveyor she told them she's sorry but she's not a nurse and went to get the nurse. Concierge-BB informed Surveyor the name of Licensed Practical Nurse/Nurse Supervisor (LPN/NS)-G was in the hallway. Surveyor asked if LPN/NS-G went in R1's room. Concierge-BB replied I believe so. Surveyor asked Concierge-BB if she spoke with LPN-N. Concierge-BB replied I didn't she was with another resident. Concierge-BB informed Surveyor she believes LPN/NS-G went to get LPN-N. On 11/3/25, at 3:30 p.m., Surveyor asked LPN/NS-G if she was involved with R1's transfer to the hospital. LPN/NS-G explained Concierge-BB came and got her and asked her to report to the ambulance staff. Concierge-BB told her LPN-N was passing meds. LPN/NS-G informed Surveyor she went in R1's room and the ambulance staff said they wanted report. LPN/NS-G informed Surveyor she told them R1 had a fall and was found in front of the bathroom door. LPN/NS-G informed Surveyor the female ambulance staff was really upset, they had asked for report from the nurse and the nurse was busy passing medication. LPN/NS-G informed Surveyor she gave them report but had to ask LPN-N first because she was the supervisor. Surveyor asked LPN/NS-G what the expectation for the nurse is when the ambulance crew arrive. LPN/NS-G informed Surveyor they always ask for report, need to let them know why we called, vital signs, injuries, stuff like that. Surveyor asked LPN/NS-G if LPN-N should have stopped passing medication and been with the ambulance crew. LPN/NS-G replied she was the nurse so I don't know who else would have been able to do it not the aides. On 11/3/25, at 3:43 p.m., Surveyor asked Registered Nurse/Nurse Supervisor (RN/NS)-O regarding R1's fall on 10/16/25. RN/NS-O informed Surveyor she doesn't know the exact time of the fall and LPN-N called reported she had fallen, had goose egg to her head and they discussed neuro checks, LPN-N to fill out fall risk assessment, and that's all she knows. Surveyor asked if she assessed R1. RN/NS-O replied I just looked at her, they were taking vital signs. Surveyor asked who was taking vital signs. RN/NS-O replied name of LPN-N. Surveyor asked if NP-K was there. RN/NS-O replied not while I was in there, I don't recall them telling me if she was in there previous or after. Surveyor asked RN/NS-O when she was there was R1 still on the floor or in bed. RN/NS-O replied she was already back in bed. On 11/4/25, at 9:51 a.m., Surveyor spoke with Anonymous EMT (emergency medical technician)-P on the telephone. Anonymous EMT-P informed Surveyor they were called for a fall, when they arrived, they were led to the resident's room by a nurse who barely gave them any information as she had to pass medication. Anonymous EMT-P informed Surveyor they did an assessment, the entire side of R1's face was black & blue, really swollen so was R1's hand. Anonymous EMT-P informed Surveyor believes it was the left hand and left side of the face. Anonymous EMT-P informed Surveyor they tried to talk to three different people to find out what time the fall was and if R1 was on blood thinner. Anonymous EMT-P informed Surveyor they received information from another resident who told them R1 had fallen in the morning. Anonymous EMT-P informed Surveyor they weren't getting any information, so they did vital signs, and transferred R1 onto the cot. Anonymous EMT-P informed Surveyor as they were rolling out, they finally were able to speak with a nurse. Anonymous EMT-P informed Surveyor they were told the fall happened at 10:30 a.m. & they were called at 2:00 p.m. Anonymous EMT-P stated Resident is [AGE] years old, on blood thinners, hit her head, one of the biggest emergencies, very dangerous can lead to brain bleed and death. Anonymous EMT-P informed Surveyor they got her to the hospital soon after. On 11/4/25, at 1:04 p.m., Surveyor asked RN/NS-O if she was aware NP-K assessed R1's range of motion after the fall but did not come back until told after lunch to complete the assessment. RN/NS-O informed Surveyor she wasn't aware NP-K didn't come right back and assumed NP-K did. Surveyor informed RN/NS-O Surveyor did not locate a RN assessment. RN/NS-O stated its hindsight but I should of told [Name of LPN-N] to send R1 out. Surveyor reviewed the ambulance report and noted the call was received on 10/16/25 at 14:41 (2:41 p.m.) and the ambulance crew arrived at the patient at 14:58 (2:58 p.m.). On 11/5/25, at 8:32 a.m., Surveyor asked LPN-N after resident falls when are neuro checks completed. LPN-N provided Surveyor with a blank neurological flow sheet stating she can't remember so she uses the paper. Surveyor noted vitals signs and neuro checks are completed at the time of event, q (every) 30 minutes x (times) 2, q 1 hour x 4, q shift x shift. Surveyor asked LPN-N about R1's neuro checks on 10/16/25 as Surveyor noted a 30-minute neuro check was not completed. LPN-N informed Surveyor they were doing the neuro checks wrong as they were including the time of event as one of the 30-minute neuro checks. LPN-N stated now I know how to do it. No additional information was provided. 2.) R2's Treatment Administration Record (TAR) documented the following physician order: Obtain stool sample to test for C diff (Clostridium Difficile) every shift - 9/15/25. Discontinue order once obtained. Surveyor located no evidence the facility followed up on the above physician order, no stool sample was obtained and sent to lab, and there was no documentation anywhere in R2's medical record regarding the order except for the TAR. On 11/3/25 at 3:30 PM, Surveyor spoke with the infection control nurse Registered Nurse (RN) Supervisor-O. RN Supervisor-O reported she was not aware and was not notified of the order to check for C diff. Surveyor and RN Supervisor-O reviewed R2's medical record and 24 hours boards. There was no documentation the facility followed up on the order to obtain a stool sample to check for C Diff. On 11/4/25 at 10:52 AM, Nursing Home Administrator (NHA)-A was advised of concern the facility did not follow through on the physicians order to check R2's stool for C Diff. No additional information was provided. 3.) The facility's undated Neurological Observation policy and procedure documents: A. Policy: Licensed nurse will monitor and record an individual's neurological status as indicated. B. Procedure: Neurological observation is to be done per the following Neurological Check Schedule, unless otherwise specified by a physician order. 1.At time of event 2.Q 30 minute x2 3. Q 1 hour x4 4. Q shift x3. R3 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side(complete paralysis on one side of body and partial/incomplete weakness on one side following stroke), Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), Chronic Kidney Disease(progressive damage and loss of function in the kidneys), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Epilepsy(disorder in which nerve cell activity in brain is disturbed causing seizures) Anemia(lack of blood), Dysphagia(difficulty swallowing foods) and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R3's 5-day Minimum Data Set(MDS) completed 8/25/25 documents R3's Brief Interview for Mental Status score to be 11, indicating R3 is moderately cognitively impaired. On 6/30/25, R3 had an unwitnessed fall in the bathroom. Surveyor reviewed R3's electronic medical record(EMR) and the facility's unwitnessed fall investigation. There is no documentation that neurological checks were completed on R3. On 7/12/25, R3 had an unwitnessed fall in the room attempting to close the blinds. Surveyor reviewed R3's electronic medical record(EMR) and the facility's unwitnessed fall investigation. There is no documentation that neurological checks were completed on R3. On 11/4/25, at 8:22 AM, Director of Nursing (DON)-B confirmed to Surveyor that there are no documented neurological checks for both R3's falls on 6/12/25 and 7/12/25. On 11/4/25, at 1:16 PM, Registered Nurse/Supervisor (RN)-O stated that neurological checks should be started and completed for any unwitnessed fall because you don't know if they hit their head. On 11/4/25, at 3:04 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, DON-B, and Sister Facility NHA (SFNHA)-C that neurological checks had not been started and completed for R3's unwitnessed falls on 6/30/25 and 7/12/25. No additional information has been provided by the facility as to why neurological checks were not started and completed for R3's unwitnessed falls on 6/30/25 and 7/12/25.

Based on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R1) of 2 residents receiving oxygen therapy.R1did not receive oxygen via nasal cannula per physician orders. On 10/16/25, the ambulance crew observed R1's oxygen tubing was disconnected at the connector and R1's oxygen level was 80%. The facility's intervention to prevent this from occurring in the future was to not use extension tubing. On 11/4/25, R1's oxygen tubing was observed to have extension tubing.Findings include:The facility's policy titled, Safe Use of Oxygen and last reviewed 11/8/23 under policy documents Entity will provide individuals who are in need of oxygen safe storage, use, and transportation in regulated health care settings.The facility's, Standard Respiratory Protocol not dated under the sections Registered Nurse (RN), Certified Nursing Assistant (CNA) & (Med Tech) MAA all include Apply oxygen as ordered.R1's diagnoses include chronic respiratory failure with hypoxia (long term condition where the lungs cannot supply enough oxygen to the blood resulting in low blood oxygen levels), COPD (chronic obstructive pulmonary disease) (group of lunch diseases that cause ongoing breathing problems) and dependence on supplemental oxygen.R1's quarterly MDS (minimum data set) with an assessment reference date of 9/19/25 has a BIMS (brief interview mental status) score of 6 which indicates severe cognitive impairment. Oxygen is checked yes for while a resident.R1's physician orders dated 6/24/24 documents Oxygen at 2 liters per NC (nasal cannula) to keep O2 (oxygen) sats (saturation) > (greater) or = (equal to) 95% every shift for hypoxia. Wean off when possible.Resident has SOB (shortness of breath)/Emphysema/COPD care plan initiated 6/24/24 & revised 3/26/25 documents the following interventions:*Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Initiated & revised 6/24/24.*Monitor for difficulty breathing (dyspnea) on exertion. Remind resident not to push beyond endurance. Initiated & revised 6/24/24.*Monitor for s/sx (signs/symptoms) of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest cyanosis, somnolence. Initiated & revised 6/24/24.*Monitor/document/report PRN (as needed) any s/sx of respiratory infection: fever, chills, increase in sputum (document the amount, color, and consistency), chest pain, increased difficulty breathing (dyspnea), increased coughing and wheezing. Initiated & revised 6/24/24.*O2 (oxygen) per MD (medical doctor) orders. Initiated 3/26/25.*OT (occupational therapy) consult for energy conservation recommendations. Initiated & revised 6/24/24.Resident has oxygen therapy care plan initiated 9/30/24 & revised 12/24/24 documents: Intervention of Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, increased heart rate (tachycardia), restlessness, diaphoresis (sweating), headaches, lethargy, confusion, atelectasis (partial or complete collapse of the lung tissue), hemoptysis (coughing up blood), cough, pleuritic pain (sharp stabbing pain in the chest), accessory muscle usage, skin color. Initiated 9/30/24.R1's incident report dated 10/16/25 for incident description under nursing description documents patient's oxygen tubing was detached at the connector, patient oxygen level 80%. Under resident description documents Resident unable to give description. Under immediate action taken documents Changed oxygen tubing to 1 long single tubing, instead of 2 tubes connected together to make it longer. Under notes dated 10/17/25 documents IDT (interdisciplinary team) met and discussed the resident incident involving hypoxia. The resident's oxygen was found disconnected between two nasal cannula (NC) tubes while the resident was lying in bed, with an O (oxygen) saturation of 80%. The resident is confused at baseline with no change in mentation noted and remains alert and oriented to self, place, and situation. Root Cause: Resident likely tossed in bed, pulling and disconnecting the oxygen tubing. The oxygen concentrator remained connected, so no alarm was triggered. Interventions: NC will now be connected directly to the oxygen concentrator without the use of extension tubing to prevent recurrence. Surveyor noted neither R1's oxygen therapy or SOB/Emphysema/COPD care plans were revised to include this intervention.On 11/3/25, at 9:18 a.m., Surveyor observed R1 sitting in a wheelchair in R1's room with oxygen via nasal cannula. Surveyor observed the oxygen concentrator is set at 3.5 liters. Surveyor noted R1's physician orders are for 2 liters.On 11/3/25, at 10:00 a.m., Surveyor observed Certified Nursing Assistant (CNA)-I stating to R1 I'm going to fill up tank and then will bring you out. I'll be back. CNA-I then left R1's room with the small portable oxygen tank. On 11/3/25, at 10:07 a.m., Surveyor observed CNA-I enter R1's room with the small oxygen tank and then Licensed Practical Nurse (LPN)-N entered R1's room. R1's nasal cannula oxygen tubing was connected to the small tank and R1 was wheeled out of her room. R1's small oxygen tank was set at 2 liters and observations of R1 until 3:50 p.m. revealed R1 continued to receive oxygen via the small tank.On 11/4/25, at 7:06 a.m., Surveyor observed R1 sitting in wheelchair in R1's room receiving oxygen via nasal cannula. Surveyor observed R1's oxygen concentrator is set at 3.5 liters, and the oxygen tubing is not one continuous tubing but two oxygen tubing connected together. Surveyor observed the tubing is green in color and clear.On 11/4/25, at 7:36 a.m., Surveyor observed R1 continues to be sitting in a wheelchair in R1's room. R1 is receiving oxygen via nasal cannula and the oxygen concentrator continues to be set at 3.5 liters. The oxygen tubing is not one continuous tubing but two oxygen tubes connected.On 11/4/25, at 8:04 a.m., Surveyor observed R1 continues to be sitting in a wheelchair in R1's room receiving oxygen via nasal cannula. R1's oxygen concentrator is set at 3.5 liters and there continues to be two oxygen tubes connected.On 11/4/25, at 8:36 a.m., Surveyor observed R1 appears to be sleeping in a wheelchair in R1's room. R1's oxygen concentrator is set at 3.5 liters and there continues to be two oxygen tubes connected.On 11/4/25, at 8:48 a.m., Surveyor observed Licensed Practical Nurse (LPN)-N deliver R1's breakfast tray to R1 who is sitting in a wheelchair in R1's room. R1's oxygen concentrator continues to be set at 3.5 liters and R1's oxygen tubing continues to have two tubing connected. Surveyor observed LPN-N did not adjust R1's oxygen concentrator to 2 liters.On 11/4/25, at 9:26 a.m., Surveyor observed R1 eating breakfast in R1's room. Surveyor observed the oxygen concentrator is still set at 3.5 liters and there continues to be two oxygen tubing connected.On 11/4/25, at 9:35 a.m., Surveyor asked LPN-N what R1's oxygen is supposed to be set at. LPN-N replied 2 to 3 liters. Surveyor informed LPN-N R1's physician orders are for 2 liters. LPN-N then accompanied Surveyor to R1's room where Surveyor showed LPN-N R1's oxygen concentrator is set at 3.5 liters. LPN-N then lowered R1's oxygen concentrator to 2 liters.On 11/4/25, at 1:00 p.m., Surveyor asked Registered Nurse/Nurse Supervisor (RN/NS)-O about R1's oxygen being disconnected and R1 was hypoxic on 10/16/25. RN/NS-O informed Surveyor she was informed after the fact R1's oxygen was not connected. RN/NS-O informed Surveyor when she was in R1's room she did not notice it. Surveyor asked RN/NS-O how she became aware. RN/NS-O informed Surveyor she doesn't remember who came and told her that the ambulance found the oxygen disconnected at the connectors. Surveyor asked RN/NS-O what was implemented so this would not happen again. RN/NS-O informed Surveyor instead of a connector they want one continuous tube from the nasal cannula to the concentrator.On 11/4/25, at 1:08 p.m., Surveyor asked RN/NS-O to accompany Surveyor to R1's room. Upon arrival to R1's room, Surveyor showed RN/NS-O R1's oxygen tubing with two oxygen tubes connecting. Surveyor informed RN/NS-O the intervention of one continuous tube was not added to R1's care plan.No additional information was provided.

Based on interview and record review the facility did not provide routine and emergency drugs and biologicals to its residents (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (R2) of 4 residents reviewed.R2's Mirtazapine was not given as ordered.Findings include:R2 admitted to the facility on [DATE] with diagnoses that included right femur fracture, atrial fibrillation, chronic kidney disease stage 4, type 2 diabetes mellitus, hypothyroidism and depression. R2's Brief Interview for Mental Status score was 15, indicating no cognitive impairment.The facility policy titled Medication administration - general guidelines dated May 2018 documents:Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.11) If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted, or medication removed from the night box/emergency kit.R2's Medication Administration Record (MAR) documented an order for Mirtazapine 15 mg (milligrams) give 1.5 tablet by mouth at bedtime for depression - start date 8/6/25.On 9/9, 9/10 and 9/13/25 the medication was documented as 9 (other/see progress notes). There was no documentation in the progress notes as to why the medication was not given.Surveyor review of the facility Omni inventory of available medications indicated Mirtazapine 15 mg tablet available in contingency.On 11/4/25 at 8:20 AM, Surveyor spoke with Pharmacy-S regarding R2's Mirtazapine. Pharmacy-S reported they received the script on 8/6/25 and sent 45 tablets (a month supply) to get through 9/3/25. She reported they received another script on 9/15/25 and sent another 45 tablets, and 38 tablets were returned when the resident discharged . Pharmacy-S reported she was not sure what the facility did from 9/4-9/15/25, as she is unable to view the contingency removal, but Pharmacy Manager-T would be available this afternoon.On 11/4/25 at 3:45 PM, Surveyor spoke with Pharmacy Manager-T. He confirmed a 30-day supply of Mirtazapine was sent for R2 on 8/6/25 which was enough to get through 9/3/25 and another 30-day supply was sent on 9/15/25. Pharmacy Manager-T reported the medication does not require a prescription, the facility only needs to remove the reorder label and fax the pharmacy for refill. Pharmacy Manager-T reviewed the Omnicel contingency for any medications removed for R2. Pharmacy Manager-T advised Surveyor no doses of Mirtazapine were removed for R2 from 9/5/25 to 9/15/25. R2's MAR indicated at least 3 doses of Mirtazapine were not given (9/9, 9/10 and 9/13/25). Although the MAR had check marks indicating the medication was given for the other dates between 9/5 and 9/14/25, Pharmacy confirmed no Mirtazapine was sent to the facility and the medication was not removed from contingency. On 11/4/25 at 10:52 AM, Nursing Home Administrator (NHA)-A was advised of concern regarding R2's Mirtazapine not given as ordered. No additional information was provided.

Based on observation, record review, and interview, the facility did not ensure 2 (R147 & R350) of 3 residents reviewed with pressure injuries received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new pressure injuries from developing. * R147 developed skin concerns of MASD (moisture-associated skin damage) noted at the facility on 10/28/24. There were no care plan revisions implemented and no comprehensive assessments completed. On 11/04/24, while at the hospital, R147 was found to have an infected sacral wound requiring debridement. After debridement, the wound was classified as a stage 4 pressure injury (PI.) Upon return to the facility on [DATE], the facility failed to comprehensively assess R147's pressure injuries, did not assess the appropriateness of the type of wheelchair cushion and mattress being used, and did not implement interventions to promote healing of PIs. The facility's failure to comprehensively assess and implement an individualized plan of care for R147's pressure injuries created a finding of immediate jeopardy that began on 10/28/24. Surveyor notified the Nursing Home Administrator (NHA)-A, Director of Nurses (DON)-B, and Regional Nurse Consultant (RNC)-N of the immediate jeopardy finding on 2/17/25 at 4:20 PM. The immediate jeopardy was removed on 2/20/25. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan and as evidenced by: * R350 was assessed for being at risk for pressure injury. Preventative interventions were not observed being implemented. Findings include: The facility's policy and procedure Pressure Injury Prevention and Managing Skin Integrity dated 12/5/24 documents that preventative measures are put in place to reduce the occurrence of pressure injuries. The procedures include: 2. Identifying Interventions and Care Plan: (a.i.) The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. (a.i.1.) This will be in collaboration with the Interdisciplinary Team regarding the presence of breakdown and the intervention plan. (a.i.3.) The identification of risk factors present or acquired that compromise skin integrity will be considered. (2.b.i.) The Care Plan development will consider: (a.i.2.) Cognitive changes or impairment of the individual. (a.b.3.) Current state of skin integrity and personal hygiene practices of the individual that impact skin health. 3. Skin Checks: (3.a.) Skin check will be done upon admission, readmission or as clinically indicated. 4. Weekly Wound Rounds: (4.a.) Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. (4.b.iii.) Update the Care Plan with any new interventions as applicable. 1.) R147 was readmitted to the facility from the hospital on 3/8/2024, with diagnoses including diabetes, congestive heart failure, and peripheral vascular disease. care plan related to a closed right ankle fracture initiated on 2/6/24 documents under the Goal section: The resident to remain free from skin breakdown due to incontinence and brief use. The initiated date is 2/6/24, and goal date of 3/11/25, and includes these interventions: - 2/6/24 barrier cream as ordered. - 2/6/24 monitor skin for signs of skin breakdown related to incontinence. - 2/15/24 clean peri-area with each incontinence episode. R147's Alternation in Nutrition due to Inadequate Intake care plan dated as initiated on 3/15/24 documents under the Goal section: Weight to stabilize 190 +- 10# (pounds), wound show signs and symptoms of healing, tolerate diet intake of greater than 75%, labs within MD (Medical Doctor) range, and resident will accept supplements: - 3/15/24 provide regular diet, additional protein via prosource twice a day and 6 ounces mighty shake twice a day, meals in dining room, treatment to wounds, confer with wound team, monitor intake, labs, weight, weigh per policy, staff assist/encourage at meals. R147's Quarterly Minimum Data Set (MDS) assessment completed on 9/13/24 documents that R147 had 1 unstageable pressure injury at the time of the assessment and is at risk for the development of pressure injuries. R147 is frequently incontinent of bowel and bladder and requires staff assist with activities of daily living. R147's skin assessment completed by Wound Nurse Practitioner (WNP)-O on 10/28/24 documents: Chief complaint is wound to the right heel, skin tear to left wrist/hand, wounds to R (right) posterior thigh and L (left) buttock. Subjective assessment the Patient is seen resting in bed. Staff report he has new areas of breakdown to buttocks. He denies pain, fevers or chills. He is eating and sleeping well. Medications electronic health record (EHR) reviewed. Diagnoses that could affect wound healing are type 2 diabetes, afib (atrial fibrillation), heart failure (HF), hyperlipidemia, hypertension, (peripheral vascular disease) PVD, hypothyroidism, on Warfarin. Interventions in place are 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, physical therapy and occupational therapy (PT/OT) collaboration; Physical Examination: +Right posterior heel (stage 3 pressure ulcer) Full thickness wound measuring 4.5 x 2.5 x 0.1 centimeter (cm). 100% granular tissue. Moderate amount of serous drainage noted, no odor. Peri wound without redness or warmth to indicate infection. Wound status: improving. The Plan: Cleanse with normal saline NS or wound cleanser then apply Hydrofera Blue to the base of the wound, cover with ABD (abdominal) pad and secure with kerlix. Change daily and prn (as needed). Continue offloading with Prevalon Boot. +Right thigh moisture associated skin damage (MASD) Full thickness wound measuring 1.5 x 1.5 x 0.1 cm. 100% granular tissue. Scant serosanguineous drainage. Peri-wound is dry, intact. No sign/symptoms (s/sx) infection. Status is a new area. The Plan is happy butt cream three times a day (TID) and as needed (PRN). +Left buttock (MASD) Full thickness wound measuring 0.5 x 0.8 x 0.1 cm. 100% granular tissue. Scant serosanguineous drainage. Peri-wound is moist, fragile, intact. No s/sx infection. Status is a new area. The Plan is happy butt cream TID and PRN. The Wound Assessment Summary is a pressure ulcer of right heel, stage 3 (not new). The new skin impairment areas are irritant contact dermatitis due friction or contact with other specified body fluids. Reviewed medical records. Discussed plan of care with nurse. Protein supplementation per dietary. Continue aggressive offloading, Prevalon boot to be worn at all times (cannot be used with transfers). Discussed results of X-ray and arterial studies with wife previously. At this time she will think about possible referral to vascular as patient with severe peripheral artery disease (PAD) which will compromise healing. Magnetic resonance imagining (MRI) is also recommended as the X-ray cannot exclude osteo - wife would like to hold off on the MRI at this time and think about getting an MRI in the future. Wound care re-evaluation in 1 week. Surveyor noted that there were new skin impairment areas for R147 that were a result of moisture association that were identified in R147's 10/28/24 assessment. Surveyor noted that there is no documentation of any revisions in the plan of care to promote healing. There were no changes to R147's plan of care for skin impairment and bladder incontinence care despite the new skin impairment areas that were identified in the above assessment. On 2/13/25, at 12:26 PM, Surveyor interviewed WNP-O via telephone. WNP-O assessed R147 on 10/28/24 and did not see any open skin areas. WNP-O stated the skin areas on 10/28/24 were from moisture. WNP-O stated they ordered zinc paste for the moisture areas. WNP-O would expect diligent incontinence care. WNP-O does not personally document in R147's plan of care. WNP-O informed Surveyor that WNP-O was not notified of any open areas prior to 11/4/24. WNP-O informed Surveyor that WNP-O relies on the facility to determine types of wheelchair and air mattresses that residents use for off-loading and pressure relief. Surveyor reviewed WNP-O's wound assessment plans. Surveyor informed WNP-O that there were no documented changes with R147's skin assessment on 10/28/24 and 12/2/24. WNP-O stated there was nothing to change in the plan of care. WNP-O stated R147 can be resistant to positioning and doesn't tolerate turning. WNP-O stated WNP-O goes to various facilities and that WNP-O leaves it up to the facility to determine what type of pressure relief intervention devices are used. Surveyor noted that WNP-O's assessments document just an air mattress (not specifics), continue aggressive off-loading, protein supplement per dietary, and Prevalon boots. WNP-O stated that WNP-O relies on the facility to develop an individualized plan of care. On 2/13/25, at 8:12 AM, Surveyor interviewed Director of Nurses (DON)-B. DON-B stated facility staff observed R147's skin on 10/28/24 with the Wound Nurse. DON-B stated there was not an open area that was observed. DON-B stated facility staff were not aware of an open area before 11/4/24. DON-B stated they would attempt to locate for skin sheets for R147. DON-B provided Surveyor with a Skin Sheet dated 10/15/24. Surveyor noted that there were no Skin Sheet or Skin Evaluations completed between 10/28/24-11/4/24. Despite R147 developing pressure injuries, Surveyor noted that there was no documentation of any changes to R147's dietary plan, no changes to R147's incontinent care/product use, and no changes in R147's turning and repositioning timeframes. R147 went to a scheduled imaging appointment on 11/4/24. At the start of R147's appointment, R147 had a change in condition and was sent directly to the emergency room (ER). While in the ER, a comprehensive assessment was completed. The assessment documented there was a pressure injury on the sacrum of R147 that was odorous, with tan drainage, and appeared infected. R147's hospital records included photographs and pre-debridement measurements of the sacral wound that were 6 cm (centimeters) by 6 cm and staged as a stage 4 pressure injury. The post-debridement assessment documents measurements of 6 cm x 8 cm x 2 cm in the deepest dimension. The assessment documents: Coccygeal ulcer with purulent drainage status post (s/p) debridement - 11/4 superficial coccyx wound culture with multiple organisms isolated and 4+ Bacteroides fragilis group. Acute care surgery consulted for coccyx wound with malodor and necrotic tissue on exam and patient ultimately underwent excisional debridement of sacral decubitus ulcer on 11/5/24; operative note reports tissue from wound bed was excised until healthy bleeding was noted at the wound base; no specimens were collected intraoperatively for culture. 11/14 computed tomography (CT) imaging showed appropriately 3.7 x 3 x 6 cm sacral decubitus ulcer/wound without fluid collection. Inpatient wound care team is following, see photos in chart of wounds. Continue local wound cares regularly. Surveyor noted that from 10/28/24 to 11/4/24 there is no facility documentation related to the sacrum pressure injury discovered on R147 on 11/4/24 in the ER. R147 remained in the hospital for multiple medical reasons and was readmitted to the facility on [DATE]. R147's Admit/Readmit Screener completed on 11/25/24 documents under the Skin section: - Unstageable pressure injury to the right heel measuring 2 cm x 3 cm x .1 cm. - Stage 4 pressure injury to the sacrum measuring 5 cm x 5 cm x 1 cm. Surveyor noted that the Admit/Readmit screener completed on 11/25/24 did not include any characteristics, along with percentages, describing the two wound bed or periwound areas. Surveyor noted that there is no documentation of any revisions that were completed to R147's plan of care. Surveyor noted that R147's pressure injuries were not comprehensively assessed when R147 was readmitted to the facility, as the above Admit/Readmit screener did not include wound bed characteristics, along with percentages or a description of the periwound areas on R147. On 2/13/25, at 7:29 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-R. LPN-R stated that R147 is a PM bath and that the CNAs fill out a bath sheet and the nurse does a skin evaluation at this time and that bath sheets are scanned into the EHR. LPN-R informed Surveyor that LPN-R saw R147 before they left the faciity on [DATE]. LPN-R stated R147 had a small open area on the sacrum, and it was red. LPN-R stated that the facility was putting zinc on the area and LPN-R described the area to look like a straw opening. LPN-R could not recall the wheelchair that was used for transporting R147 before he left. During this interview, R147's spouse was wheeling R147 into the dining room and informed Surveyor that the wheelchair that R147 was currently in was the wheelchair used to transport R147. Surveyor noted that the wheelchair R147 was sitting in had a wheelchair cushion in place. Surveyor was unable to locate any documentation that R147's pressure injuries were assessed until 12/2/24, or 7 days after R147 was readmitted to the facility, one week after R147 was readmitted to the facility from the hospital on 12/2/24. R147's comprehensive wound assessment dated [DATE] and completed by WNP-O documents: Return from leave assessment, has wound to right heel and sacrum. Subjective assessment: patient is seen resting in bed, recently returned from prolonged hospitalization . During hospitalization , sacral ulcer was debrided on 11/5. Was treated with intravenous (IV) antibiotics for concern for wound infection during hospitalization . R147 is seen resting in bed today. R147 complains of pain with exam. Staff report no fevers, chills or other concerns today. The current Medications in the EHR were reviewed. The diagnoses that could affect wound healing include type 2 diabetes, afib (atrial fibrillation), HF, hyperlipidemia, hypertension, PVD, hypothyroidism, on Warfarin. Interventions in place are 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 collaboration. Physical Examination: +Right posterior heel (unstageable pressure ulcer) Full thickness wound measuring 4.5 x 3.5 x 0.1 cm. 80% slough, 20% granular tissue. Moderate amount of serosanguineous drainage noted, no odor. Peri wound without redness or warmth to indicate infection. This was present on readmission. Plan: Cleanse with NS or wound cleanser then apply saline moistened Hydrofera Blue to the base of the wound, cover with ABD pad and secure with kerlix. Change daily and prn. Continue offloading with Prevalon Boot. +Sacrum (stage 4 pressure injury) Full thickness wound measuring 4 x 3.5 x 3.6 cm. 100% granular tissue. Moderate serosanguineous drainage. Peri-wound is moist, fragile, intact. No s/sx infection. This was present on readmission. Plan: Gently pack with saline moistened hydrofera blue. Cover with bordered foam. Change daily and PRN The Summary Assessment is an unstageable pressure injury on the right heel, stage 4 pressure injury on the sacrum, and moderate protein-calorie malnutrition. Reviewed medical records. Discussed plan of care with nurse. Protein supplementation per dietary. Continue aggressive offloading, Prevalon boot to be worn at all times (cannot be used with transfers). Wound care reevaluation in 1 week. Patient with multiple comorbidities and multiple risk factors for developing and worsening of pressure injuries. Interventions consistent with individual needs, goals and standards of care have been implemented. Revisions to interventions were made as appropriate. Wound is considered unavoidable, and patient is at risk for further worsening or development of additional areas. Surveyor noted that there were no revisions to R147's plan of care that individualized pressure relieving interventions to promote healing. Surveyor was unable to locate any documentation of an assessment that described what an appropriate wheelchair cushion for R147 was to be used due to R147's pressure injury development. Surveyor was unable to locate any documentation of an assessment as to what type of air mattress was appropriate for R147 due to R147's pressure injury development. Despite R147 developing pressure injuries, Surveyor noted that there was no documentation of any changes to R147's dietary plan, no changes to R147's incontinent care/product use, and no changes in R147's turning and repositioning timeframes. R147's Significant Change in Status completed on 12/2/24 documents 1 unstageable pressure injury and 1 stage 4 pressure injury present from R147's readmission to the facility. The MDS documents that R147 is frequently incontinent of bowel and bladder and requires staff assist with activities of daily living. R147's Care Area Assessment for Pressure Injuries documents continue with plan of care-ambitious goal to heal wounds. Immediate goal to keep risk in balance and provide interventions to reduce risk. Surveyor noted that there were no revisions to the plan of care for nutrition with the new onset(s) of R147's skin impairments. R147's current wound assessment completed by WNP-O on 2/10/25 documents: +Right posterior heel (stage 3 pressure ulcer) Full thickness wound measuring 1.1 x 1.3 x 0.1 cm. 100% granular tissue. Moderate amount of serosanguineous drainage noted, no odor. Peri wound without redness or warmth to indicate infection. The wound status has improved. There is no change in the plan of care. +Sacrum (stage 4 pressure injury) Full thickness wound measuring 3.5 x 2.8 x 2.5 cm. Undermining 9-2, 2 cm @ 12 o'clock. 100% granular tissue. Moderate serosanguineous drainage. Peri-wound is moist, fragile, intact. No s/sx infection. The wound status has declined. There is no change in the plan of care. On 2/10/25 at 9:52 AM, Surveyor observed R147 lying in bed. R147 was on their back with the bed in a semi-Fowler_position (head of bed elevated 30-45 degrees.) R147 was on a low air loss mattress set at 10-minute cycles. The bed coverings were over R147's feet. Per the facility pressure injury list that was provided to Surveyor, along with the roster matrix, R147 was reported to have a stage 3 and stage 4 pressure injury. 10 On 2/13/25 at 8:20 AM, Surveyor interviewed R147's Power of Attorney for Healthcare (POAHC)-S. POAHC-S stated R147 had a very small area on their bottom at the facility. POAHC-S stated staff used zinc on it. POAHC-S stated the facility should have treated R147's open area before it got bigger. POAHC-S stated R147 used their current wheelchair for transport and that there is not another wheelchair used by R147. Surveyor observed R147 in his wheelchair in the dining room and Surveyor observed the wheelchair to have a cushion in place. On 2/13/25, at 9:56 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-Q. CNA-Q informed Surveyor that CNA-Q recalls that R147 had a small open area on the buttocks. CNA-Q stated that R147 is a check and change for incontinence. CNA-Q stated R147 can use the urinal at times and ask for a bed pan. CNA-Q could not recall any changes in the air mattress or wheelchair cushion of R147. On 2/11/25, at 10:30 AM, Surveyor interviewed Registered Nurse (RN)-I who completes resident weekly wound assessments with WNP-O. RN-I stated RN-I was on maternity leave from 9/12/24 to 12/10/24. RN-I became the facility's wound nurse when she returned on 12/10/24. RN-I informed Surveyor that with new admissions and readmissions, staff complete the screener information, and that a physical skin check is completed by the admission nurse or floor nurse. RN-I stated that nursing staff will get the discharge orders for any skin concerns and that at the end of the week, RN-I reviews the documentation for wound concerns. RN-I stated that residents with wounds are added to the weekly wound rounds that are completed on Monday with WNP-O. RN-I stated WNP-O documents in the progress notes and that they take a picture of the wounds and generate it into the Point Click Care Skin Evaluation (part of the EHR). RN-I stated that WNP-O documents the initial wound assessment and that RN-I finishes it up. RN-I informed Surveyor that the admission/floor nurse only measures the wounds and makes sure that a treatment is in place. RN-I stated that the admission/floor nurses also put in the initial care plan for any new or readmitted resident. RN-I stated that when a new open skin area on a resident develops, RN-I would update the care plan for that resident. RN-I stated that the facility has weekly meetings to review the plan of care of residents and that all nursing staff can go into the system to update the plan of care for a resident. On 2/11/25, at 2:20 PM, Surveyor observed R147 receive wound care by Assistant Director of Nurses (ADON)-G and Nurse Extern NE-P. R147 was in bed and R147's room had a strong unpleasant odor. The ADON-G is not familiar with the development of R147's pressure injuries. The Nurse Extern (NE)-P assisted in the positioning of R147 in bed. R147 had pressure relief heel boots on, and the air mattress was set to low air loss at 10-minute cycles. Surveyor observed the pressure injury treatment to the right heel was completed as ordered and correlated with wound assessment. The sacrum wound dressing was saturated with urine and drainage. The dressing date was smeared due to the extent of saturation. There was an unpleasant odor. R147 had an incontinence brief on in bed. ADON-G completed the wound treatment as ordered to the sacrum. ADON-G and NE-P provided incontinence care and changed R147's brief. ADON-G stated they had not seen R147's pressure injuries prior to completing the wound treatments. ADON-G is also the Unit Manager for R147. ADON-G stated that residents have weekly skin checks with baths and that skin evaluations are completed and scanned into the EHR. On 2/13/25, at 1:39 PM, Surveyor interviewed Registered Dietitian (RD)-DD. RD-DD stated they have started, and stopped, nutritional supplements for R147 due to weight changes. RD-DD stated the company had a brand change in their protein supplements. RD-DD informed Surveyor that RD-DD has assessed R147's protein needs and feels they are being met. RD-DD stated RD-DD did not change anything when R147 returned from the hospital on 11/25/24 with a stage 4 pressure injury. RD-DD stated R147 did not receive any additional vitamin supplements. RD-DD stated there has been no discussion about vitamins and minerals for wounds for R147. RD-DD informed Surveyor that R147 is already on a multivitamin. Surveyor noted that there were no changes in R147's nutritional management care plan despite R147 developing pressure injuries. WHEELCHAIR CUSHION INTERVENTION On 2/13/25, at 11:18 AM, Facility Service Manager (FSM)-L provided Surveyor the manufacturer recommendations for the wheelchair cushion that is in R147's wheelchair. The wheelchair cushion used by R147 is an Express Comfort Foam Flat. The product information documents it is for comfort and support. The product information does not document use for a stage 4 pressure injury. On 2/17/25, at 8:01 AM, Surveyor interviewed ADON-G about R147's wheelchair cushion. The ADON-G stated the wheelchair cushion is probably from physical therapy. On 2/17/25, at 9:06 AM, Surveyor interviewed Rehab Director (RD)-T. RD-T stated the wheelchair cushions don't necessarily come from therapy. RD-T informed Surveyor that there is a closet where anyone can take one to use. RD-T stated they will look for an assessment for the wheelchair cushion used in R147's wheelchair. On 2/17/25, at 9:45 AM, RD-T informed Surveyor that therapy does not have an assessment on the wheelchair cushion currently used by R147. On 2/17/25 at 10:02 AM, Surveyor interviewed WN-I. WN-I stated they do not coordinate, or place, the wheelchair cushions used by residents. Surveyor was unable to locate any assessment that described what an appropriate wheelchair cushion for R147 was to be used due to R147's pressure injury development. AIR MATTRESS INTERVENTION On 2/17/25, at 8:01 AM, Surveyor interviewed ADON-G. ADON-G stated the air mattress is programmed by the delivery company. ADON-G stated that the facility does not program the air mattress. On 2/17/25 at 8:24 AM, ADON-G shared with Surveyor that the air mattresses in the facility are programmed by the delivery company. On 2/17/25, at 9:04 AM, ADON-G stated R147's current air mattress was delivered on 8/16/24. The ADON-G provided Surveyor the company invoice of the air mattress delivery. On 2/17/25, at 9:14 AM, Surveyor called the air mattress Contractor-U regarding R147's air mattress. Contractor-U informed Surveyor that upon delivery, they just input the weight of the resident. Contractor-U stated the air mattress delivery staff do not program the minute cycles or anything else. Contractor-U stated the default weight is 150 pounds if there was no weight provided. On 2/17/25 at 10:02 AM, Surveyor interviewed WN-I. WN-I stated they are not involved in setting up air mattresses for residents. WN-I stated that floor staff are supposed to make sure that air mattresses are on and functioning correctly. R147 documented weights in the EHR are: - 8/25/2024: 233.0 Lbs. - 12/1/2024: 189.5 Lbs. - 1/15/2025: 219.4 Lbs. - 2/5/2025: 200.2 Lbs. Surveyor noted that R147's weights have fluctuated. Despite the weight changes in R147, Surveyor was unable to locate any documentation that R147's air mattress was adjusted to accommodate R147's weight changes. Despite R147 developing pressure injuries, Surveyor noted that there was no documentation of any changes to R147's dietary plan, no changes to R147's incontinent care/product use, and no changes in R147's turning and repositioning timeframes. Surveyor was unable to locate any assessment of what type of air mattress was appropriate for R147 due to R147's pressure injury development. Surveyor noted that there were no revisions to R147's plan of care on 10/28/24 when R147 had increased skin moisture. Surveyor was unable to locate any documentation prior to 11/4/24 that R147's stage 4 pressure injury was assessed and treated by the facility. Surveyor was unable to locate a comprehensive pressure injury assessment upon R147's return to the facility on [DATE]. Surveyor noted that a comprehensive pressure wound assessment was completed 7 days after R147 was readmitted to the facility. Surveyor noted that R147's nutritional management did not change despite R147 being readmitted to the facility with a newly acquired stage 4 pressure injury. Surveyor noted there is no documentation of R147's refusing preventative turning and or repositioning. Surveyor was unable to locate any documentation of revisions to R147's turning/positioning timeframes with R147's onset of pressure injury and increased skin moisture. The facility's failure to comprehensively assess and implement an individualized plan of care for R147's pressure injuries led to serious harm for R147, thus leading to a finding of immediate jeopardy that began on 11/4/24. Surveyor notified the Nursing Home Administrator (NHA)-A, Director of Nurses (DON)-B and Regional Nurse Consultant (RNC)-N of the immediate jeopardy finding on 2/17/25 at 4:20 PM. The immediate jeopardy was removed on 2/20/25, when the facility completed the following interventions: - Resident continues to reside in facility and has resolving pressure injury to right heel and stable stage four PI to sacrum - goals of care are currently being met. - Skin sweep completed 2/17/25 to ensure all skin altercations have been identified, documented and have appropriate treatments and interventions in place. - Care plan sweep completed by 2/19/25 to ensure all interventions are individualized (guided by skin sweep results). - All staff educated on standard skin protocol before next shift to work. This includes skin integrity monitoring and change expectations for nurses, aides, dietary and therapy. - All licensed nurses educated on standard skin protocol, and comprehensive wound documentation expectations - including upon admit and recognition of a new skin altercation the licensed nurse will: alert provider and obtain any needed treatment orders, document comprehensive skin observation, interventions to be placed and documented as appropriate for resident, update DON or designee, update POA if applicable; and complete Risk Management for any new skin altercation - before next shift to work, competency quiz to validate understanding. - All nurse managers educated on PI (pressure injury) CEP and comprehensive wound system- this will include daily in stand-up clinical leader to review progress notes, RM, 24 hours boards to ensure all new skin altercations addressed appropriately including assessment and implementation of support surface, along with update to RD and wound team, to ensure compliance of F686. Education provided on 2/18/2025. - Facility skin sweep done by midnight 2/17/25. - All skin care plans updated and individualized per skin sweep observations completed by 2/20/25 which included support surface assessments and updates. - Weekly comprehensive wound rounds to continue with RN and NP. - Skin care plans will be reviewed weekly with clinical IDT focus meeting to ensure support surface interventions, and weekly wound rounds to validate appropriate support surfaces in place. - Standard Skin Protocol reviewed and updated 2/17/25. - Skin policy and procedure reviewed. - Updated and reviewed citation with Medical Director. - DON or designee will audit five residents weekly for comprehensive skin system compliance. Results to QAPI (Quality Assurance and Performance Improvement). The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following: 49435 2.) R350 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, Dementia, Pressure ulcer of right buttock, and Pressure ulcer of left heel. R350's admission Minimum Data Set assessment was in the process of being completed. R350's Brief Interview for Mental Status (BIMS) assessment dated [DATE], documents a score of 4, indicating that R350 is severely cognitively impaired. R350's Admission Section GG assessment dated [DATE], documents R350 requires substantial/maximum assist for bed mobility and R350 is dependent for transfers. R350's Braden Scale Assessment used for predicting pressure ulcer risk dated 2/6/25, documents that R350 is at risk for pressure injuries. R350 has an activated Power of Attorney (POA). R350's hospital Wound/Skin Nurse Specialist Consult note dated 2/3/25 documents, in part: [R350] has a full thickness, stage 3 pressure injury to right buttock that measures 8 x 8 x 0.1 centimeters (cm) and a stage 1 pressure injury to R350's left heel that measures 2.5 x 2.5 cm. R350's Hospital Discharge (D/C) summary dated 2/6/25 documents, in part: . discharge diagnoses: Pressure ulcers . You need to follow wound care instructions . Wound Care treatment to [Right] buttock: 1. Cleanse wound with Puracyn Plus, saturate gauze and soak 5 minutes. 2. Pat dry with gauze. 3. Apply 3M Cavilon barrier to peri-wound skin. 4. Apply [NAME] Tul A over wound. 5. Cover with Sacral Mepilex. [Registered nurse (RN)] to assess wound and change dressing three times a week. [NAME] dressings with date applied. Wound Care treatment to heels: 1. Cleanse wound with Puracyn

Based on interview and record review, the facility did not ensure 1 (R297) of 13 residents received treatment and care in accordance with professional standards of practice, the comprehensive person centered care plan and the residents choice. * R297 was admitted to the facility on [DATE] with an order to the left shin which continued until 8/1/24. There is only one skin assessment of this area dated 5/25/24. On 7/22/24 Advanced Practice Nurse Prescriber-FFF progress note documents two dressings on R297 left lower extremity. There are no skin assessments of R297's left lower extremity as to why dressings were applied. On 7/28/24, R297's left forearm was identified as being bruised and red with an indentation from R297's watch being too tight. On 8/1/24 R297's left forearm skin integrity changed from redness to scabbing. There is no skin assessment when R297's skin integrity changed. On 8/13/24 R297's experienced a change of condition which was not comprehensively assessed. Documentation of R297's meal intake for lunch was 0 to 25% which was the first time in the previous two weeks R297 ate only 0 to 25%. Licensed Practical Nurse (LPN)-H indicated when she came on duty R297 was in bed covered with a lot of covers which was unusual for R297 as he was usually rolling around. On 8/13/24 at 3:03 p.m., Nursing Student-CCC created an order for a UA (urinalysis). There is no assessment, including a RN assessment, no vitals signs for R297 prior to this order being created as to why this order was obtained. Approximately three hours later vital signs were obtained for R297 which revealed a temperature of 102.8 F with AMS (altered mental status). Even though R297 had an order for acetaminophen 650 mg (milligrams) every four hours for fever, this medication was not administered to R297 prior to being transported to the hospital. On 8/13/24 at 6:00 p.m., an ambulance company arrived and transported R297 to the hospital. R297 was admitted to the hospital for sepsis, UTI (urinary tract infection). Findings include: The facility's policy titled, Change of Condition and Provider Notification and last reviewed on 8/10/23 under Procedure documents 1. Change of Condition a) Change of Condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation that, without intervention, may result in complications or death. 2. Assessment a) Licensed nurse is involved in the assessment process and contribute to the collection of the data base, the planning of interventions and evaluation of individual's response to condition change. b) A licensed nurse is to complete the initial assessment, and follow-up evaluation as indicated by the complexity and stability of the individual's condition. c) Change of Condition Assessment shall be reviewed by Registered Nurse. 1.) R297 was admitted to the facility on [DATE] with diagnoses that include depression, benign prostatic hyperplasia, urinary retention, diabetes mellitus, peripheral vascular disease, congestive heart failure, anxiety, and Alzheimer's Disease. R297's POA (power of attorney) was activated on 4/1/22. R297's admission MDS (minimum data set) with an assessment reference date of 5/31/24 has a BIMS (brief interview mental status) score of 7 which indicates severe cognitive impairment. R297 is assessed as requiring set up for eating, supervision or touch assistance for toileting hygiene, independent for roll left & right, and partial/moderate assistance for chair/bed to chair transfer & toilet transfer. R297 has an indwelling catheter and is always continent for bowel. R297 is assessed as not having any pressure injuries, other ulcers, wounds and skin problems. Application of non surgical dressings (with or without topical medications) other than to feet is checked yes R297's impairment to skin integrity care plan initiated 5/24/24 & revised 5/25/24 documents under the intervention section: Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated 5/24/24 & revised 5/25/25. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to physician. Initiated 05/24/2024 & revised 5/25/24. R297's nurses note dated 5/24/24 at 22:46 (10:46 p.m.) written by Director of Nursing (DON)-B documents: New admit. resident alert and oriented able to make his needs known to staff. skin warm and dry. abd. (abdomen) soft and non tender with + (positive) BS (bowel sounds) x (times) 4 quads. (quadrants) LCTA. (lungs clear to auscultation) no cough or sob (shortness of breath). no s/s (signs/symptoms) of hypo/hyperglycemia. assist with adls (activities daily living) and transfers. no c/o (complaint of) pain or discomfort. R297's admit/readmit note dated 5/25/24 at 01:07 (1:07 a.m.) written by Registered Nurse (RN)- BBB documents Skin: Skin Color: Normal. Skin Temperature: Warm R297's physician orders dated 5/25/24 documents cleanse left shin with n/s (normal saline) foam border drsg (dressing) every evening shift every Mon (Monday), Wed (Wednesday), Fri (Friday) for wound care. R297's admit/readmit screener dated 5/25/24 under the skin integrity section documents under site 42) left lower leg (front), type documents abrasion and length 0.2, width 0.3, and depth 0.1. There is no further assessment of the left lower leg front and the treatment to R297's left shin continued until 8/1/24. APNP (Advanced Practice Nurse Prescriber)-FFF's note dated 7/22/24 under history of present illness documents [R297's name] 82 Y (year) male is seen in follow up day for increased LLE (lower leg edema). [R297's first name] is seen today in his room. His wife is at the bedside. She is concerned that he has some increased LLE (left lower extremity) edea sic (edema). He does have an order for prn (as needed) Bumex. She is also concerned that he is scratching at his legs. He has multiple scratch marks on his LLE. Some are bleeding. There are two dressings covering areas that were bleeding. His wife is concerned that he will develop open sores/infections from scratching as that has happened in the past. Under exam for skin documents scratch marks on BLE (bilateral lower extremities), some areas of bleeding on LLE (left lower extremity). Under medical decision making documents BLE statis dermatitis Start clotrimazole cream daily x (times) 14 days then Eucerin daily. Surveyor noted there is no assessment R297's left lower extremity when the two dressings were applied which is identified in APNP-FFF's note dated 7/22/24 nor is there any documentation as to when these dressings were applied. Surveyor noted there are no skin assessments of R297's left lower extremities, other than the admission/readmission screen on 5/25/24, while R297 resided in the facility. R297's nurses note dated 7/28/24 at 21:08 (9:08 p.m.) written by Nursing Student-CCC documents Resident left arm is bruised and red with indication of his watch being too tight on wrist. it appears to be red no edema but look irritated and raw resident stated that he is not in pain. Surveyor was unable to locate a Registered Nurse (RN) assessment of this area when it was identified. R297's nurses note dated 7/29/24 at 05:27 (5:27 a.m.) written by Licensed Practical Nurse (LPN)-H documents Bruise on resident left arm still remains with a purplish color. Resident has no complaints of pain or discomfort. R297's wound care initial evaluation dated 7/29/24 by Wound Nurse Practitioner-O under physical examination documents Left wrist No open wounds noted- area with bruising consistent with shape of a watch. Leave area open to air, avoid wearing watch until bruising resolves. Monitor closely for breakdown. Under assessment documents Traumatic ecchymosis of left wrist. R297's nurses note dated 7/29/24 at 13:03 (1:03 p.m.) written by Director of Nursing (DON)-B documents resident seen by wound GNP for area to LT (left) wrist. no noted pressure injuries to LTV. wrist, area with redness from indentation from wrist watch, wrist to be monitored for changes, watch removed and taken home by wife. R297's nurses note dated 7/31/24 at 00:14 (12:14 a.m.) written by Nursing-DDD documents we continue to monitor for redness to (AL) arm. Redness still remains. Resident denies any pain or discomfort. No bleeding or drainage noted. resident denies area itches. Will continue to monitor. R297's nurses note dated 8/1/24 at 03:17 (3:17 a.m.) written by LPN-EEE documents generalized scabbing of LTV. forearm. no c/o (complaint of) pain when asked. no s/s (signs/symptoms) of infection. T (temperature)96.9. There is no assessment of R297's left arm when R297's skin integrity changed from redness to scabbing. R297's nurses note dated 8/1/24 at 21:09 (9:09 p.m.) written by Nursing Student-CCC documents AL (left) forearm scabbing no s/s of infection or drainage. No c/o of pain or discomfort. R297's nurses note dated 8/4/24 at 00:23 (12:23 a.m.) written by Nursing-DDD documents resident left arm is scabbing. no complaints of any pain or discomfort. no itching noted. will continue to monitor. R297's nurses note dated 8/11/24 at 05:08 (5:08 a.m.) written by LPN-H documents Resident was scratching his left lower legs and reopen scabs that were already there. Leg was clean with NS (normal saline) and bf/b (foam border) was applied to area. Surveyor noted there is no assessment of this area and that there are no nursing notes dated 8/12/24. On 8/13/24 there is an order for USA - urinalysis one time only for UT (urinary tract infection). This order was created by Nursing Student-CCC on 8/13/24 at 15:03 (3:03 p.m.). There is no assessment for R297 as to why this urinalysis was ordered nor are their any vital signs prior to this order being created. Surveyor noted under the weights/vital tab on 8/13/24 at 17:52 (5:52 p.m.) R297's temperature was 102.8 F oral, blood pressure 145/70, pulse 55 bpm (beats per minute), and oxygen sats were 91% on room air. R297's respiratory rate was not obtained. The ambulance report documents: received 8/13/024 18:00:44 (6:00 p.m. & 44 seconds), dispatched 8/13/2024 18:00:57 (6:00 p.m. & 57 seconds) at patient 8/13/24 18:18:45 (6:18 p.m. and 45 seconds), transport 8/13/24 18:38:12 (6:38 p.m. and 12 seconds) and at destination 8/13/24 18:41:49 (6:41 p.m. and 49 seconds). The narrative documents [Ambulance company & Number] dispatched with lights and sirens to the listed nursing facility for an 82 y/o (year old) male with an altered mental status. Dispatch notes state not acting himself. Crew donned proper PPE (personal protective equipment) prior to patient contact. When arriving on scene we find our patient lying in bed with his wife at this side. His wife states the patient has been sleeping all day, has a fever, is weak and is hurting from the neck down. She states he has a history of a CVA (cerebral vascular accident) x2 (March 3rd and March 8th). She denies any falls or other trauma. Upon patient contact he presents as alert, A & O (alert and orientated) x 3 which is his baseline due to dementia, pale skin color and unlabored respirations. Patient also feels warm to the touch. Patient states he feels weak today and generally unwell. He states he is having lower back pain as well. He explained to EMS crew that he attempted to stand today to get out of bed and was unable to do so. He states he has a headache and that his vision went out for a few moments this morning. Stroke scale is performed and found to be positive at this time in patient only having a headache. No vision disturbances, facial droop, slurred speech, unsteady gait or unilateral weakness are noted at this time. At this time he is transferred onto EMS cot via draw sheet method and placed in positron of comfort. Baseline set of vitals are obtained and patient is found to be slightly tachycardic and hypoxic. Patient denies any shortness of break at this time. He is placed on 4L (liters) continuous oxygen via nasal cannula, secured x5 with safety straps and loaded in the ambulance. Once in the ambulance an oral temperature is obtained and found to be 102.9. Blood glucose is obtained and noted to be 81. 12-Lead EKG is perform and found to read sinus tachycardia. EKG is transmitted to receiving emergency department. SPO2 is noted to have increased with oxygen therapy. Additional vital signs are obtained and found to remain similar to initial set; with SPO2 having increased. Patient care report is called into receiving emergency department with an ETA (estimated time arrival) of 3 minutes. At this time transport began. R297's nursing note dated 8/13/24 at 21:49 (9:49 p.m.) written by LPN-H documents: Resident was sent out to hospital per POA (Power of Attorney) requested. MD (Medical Doctor) was informed of patients transfer. patient and an fever of 102.8 with altered mental status. Writer called [hospital initials] ER (emergency room ) to get an update and patient was admitted to hospital for an UTI (urinary tract) and high fever. R297's physician orders included Acetaminophen Tablet 325 mg (milligram) Give 2 tablet by mouth every 4 hours as needed for elevated temperature; pain. Surveyor noted R297 did not receive this medication when his temperature on 8/13/24 at 17:52 (5:52 p.m.) was 102.8 degree Fahrenheit. Surveyor reviewed R297's amount eaten from 7/30/24 to date of discharge on 8/13/24. Surveyor noted until 8/13/24 R297 ate 76-100% of his meals with the exception of breakfast on 8/6/24 & 8/9/24 and dinner on 8/12/24 when R297 ate 51-75% of his meals. On 8/13/24 two meals are documented as 0-25%. The eINTERACT Change in Condition Evaluation - V 5.1 dated 8/13/24 under status documents errors. The eINTERACT Transfer Form V5 dated 8/13/24 under status documents in progress. The hospital ED (emergency department) care time line dated 8/13/24 documents at 18:45:58 (6:45 p.m and 58 seconds) Arrival Complaint form [Facility's name] with AMS (altered mental status); fever of 102.8 not treated. The ED triage notes dated 8/13/24 at 18:49:25 (6:49 p.m. and 25 seconds) documents Patient arrives from [Facility Name] with complaint of fever and generalized weakness that started yesterday. Vitals at 18:50 (6:50 p.m.) documents 102.2 F (39 C) 108 24 167/78 86 % 81.6 kg (180 lb). The ED provider note dated 8/13/24 at 2051 (8:51 p.m.) documents History Chief Complaint Patient presents with Fever. HPI (history present illness) [AGE] year-old gentleman with past medical history of dementia presents emergency department today with a chief complaint of altered mental status Symptoms started earlier today in the facility reports he has been less active than usual. His wife came to visit him and noticed that he was warm to the touch. Has had prior UTIs as well as pneumonia. On arrival the patient is febrile and unable to provide any additional history and denies any pain or radiation of pain. Additional history limited to secondary to dementia. 2101 (9:01 p.m.) admitted for sepsis, UTI. The ED Notes Nursing Admission Handoff Report at 22:06:10 (10:06 p.m. and 10 seconds) documents Admitting diagnosis: Urinary tract infection with hematuria, site unspecified. The hospital infectious diseases consult dated 8/14/24 under Assessment/Medical Decision Making documents 82 Y male Alzheimer's dementia, COPD, T2DM who presented on 8/13/2024 with high fevers and confusion beyond baseline in addition to hypoxemic respiratory failure. Blood cultures obtained on arrival resulted as MRSA within 12 hours of collection. ID consulted for further evaluation. Exam significant for severe midline low back pain. I am concerned this is a result from MRSA bacteremia. Will order MRI T/L (thoracic/lumbar) spine with contrast to evaluate for osteodiscitis/epidural abscess which may require surgical evaluation. Will order TTE (transthoracic echocardiogram). Will order CT (computed tomography) chest without contrast due to concern for MRSA seeding lungs. Can stop ceftriaxone and azithromycin and continue vancomycin for now. Will follow repeat blood cultures. ID will follow. #Community-onset MRSA bacteremia #New onset back pain #Acute hypoxemic respiratory failure #T2DM #Bilateral LE wounds. The hospital physician death summary note dated 8/20/24 documents Death Summary [R297's name] was pronounced dead at 1908 (7:08 p.m.) on 8/20/24 Primary cause of death: MRSA (methicillin resistant staphylococcus aureus) Bacteremia. Secondary Cause of death: Sepsis secondary to cystitis. Tetiary cause of death: acute hypoxemic respiratory failure. On 2/14/25, at 1:27 p.m., Surveyor interviewed Advanced Practice Nurse Prescriber (APNP)-FFF regarding R297 on the telephone. Surveyor asked APNP-FFF if she was aware of R297 scratching his legs. APNP-FFF replied I think so and explained R297 had been at the facility one or two times prior for subacute and had this kind of behavior before. Surveyor informed APNP-FFF her 7/22/24 note documents two dressings covering areas that were bleeding and inquired if she ordered these dressings. APNP-FFF informed Surveyor she's honestly not sure. Surveyor informed APNP-FFF R297 had a change of condition on 8/13/24 and asked APNP-FFF if she assessed R297 on this date. APNP-FFF informed Surveyor she was not in the building but remembers a phone call or text about an elevated temperature. Surveyor asked APNP-FFF if she remembers what time the facility contacted her. APNP-FFF replied want to say late afternoon or evening. Surveyor asked if she gave any instructions to the nurse. APNP-FFF informed Surveyor she remembers asking her to obtain a UA and honestly doesn't recall if there was any blood work associated with the UA. Surveyor asked if she was notified R297 was being transferred to the hospital. APNP-FFF replied yes. Surveyor asked on 8/13/24 APNP-FFF if she wrote a note on the day R297 was discharged . APNP-FFF replied I wouldn't of written a note because I didn't do a visit. On 2/17/25, at 9:56 a.m., Surveyor interviewed Licensed Practical Nurse (LPN)-WW, who worked the day shift on 8/12/24 & 8/13/24, regarding R297 on the telephone. Surveyor asked LPN-WW if she remembers being informed of R297 not feeling well or having a fever prior to R297 being transferred to the hospital. LPN-WW replied I can't recall explaining it was so long ago. LPN-WW informed Surveyor R297 was usually okay, didn't have many issues. Surveyor asked LPN-WW if he had any skin impairments on his legs. LPN-WW informed Surveyor R297 had scratches and thought he had cream some time and a bandage with dressing. Surveyor asked LPN-WW if she ever did a treatment for R297. LPN-WW replied of course I did and informed Surveyor she thought it was just allevyn, didn't think he had any kerlix wrap. LPN-WW informed Surveyor it's been awhile and so many people come and go. On 2/17/25, at 10:18 a.m. Surveyor interviewed LPN-H, who worked the evening shift on 8/12/24 & 8/13/24, regarding R297. LPN-H informed Surveyor she sent R297 out on her shift. LPN-H explained R297 had a 100 and something fever and spoke to the NP who decided to send R297 out. LPN-H informed Surveyor she probably came to the facility around 1:30 p.m. and around 2:00 p.m. she saw R297 was in bed with a lot of covers over him he was not himself. LPN-H explained R297 was usually up talking, rolling around, and his wife said he wasn't feel good. LPN-H informed Surveyor she was informed R297 didn't eat breakfast or lunch today. Surveyor asked LPN-H when she took R297's vitals. LPN-H replied she has no clue as the med tech took vitals first as R297 is on Midodrine that was scheduled at 3:00 p.m. LPN-H informed Surveyor when she took R297's temperature it was high, she talked it over with the wife and reached out to the NP who was agreeable to send R297 out. Surveyor asked LPN-H if she assessed R297's respiratory rate or listened to his lung sounds. LPN-H replied no I didn't I went off temperature &altered mental status. He wasn't being himself that's what I reported to the NP I was going to send him. Surveyor asked LPN-H if she called 911 or [Name of] ambulance. LPN-H informed Surveyor she thinks she sent R297 out by [Name] ambulance company. LPN-H informed Surveyor R297 had an elevated temperature and altered mental status, it wasn't like a seizure or heart attack. LPN-H informed Surveyor the ambulance came pretty quickly. Surveyor asked LPN-H how long she thought it took the ambulance to arrive at the facility. LPN-H replied maybe 20 minutes. Surveyor asked LPN-H if she contacted a Registered Nurse. LPN-H replied no. Surveyor asked LPN-H if any of the Certified Nursing Assistants (CNA) reported anything to her about R297. LPN-H replied no and stated she didn't think a CNA went in R297's room. Surveyor informed LPN-H Surveyor noted an order for a UA and asked if she received this order from the NP. LPN-H informed Surveyor she didn't create so Nursing Student-CCC probably got the order. LPN-H informed Surveyor she doesn't remember that order. On 2/17/25, at 12:59 p.m., Surveyor interviewed Nursing Student-CCC on the telephone regarding R297. Nursing Student-CCC worked the evening shift on 8/13/24. Surveyor asked Nursing Student-CCC if she received anything in report regarding R297. Nursing Student-CCC informed Surveyor she didn't get report and was guessing the past couple of days he was ill. Nursing Student-CCC informed Surveyor R297 wasn't himself that's why she sent him out. Surveyor asked Nursing Student-CCC if she took R297's vital signs. Nursing Student-CCC informed Surveyor she took vital signs when starting med pass and again when R297 was sent out. Nursing Student-CCC informed Surveyor his temperature was really high that's what made her send R297 out. Surveyor asked Nursing Student-CCC if she called APNP-FFF. Nursing Student-CCC replied yes. Nursing Student-CCC informed Surveyor she was actually working under another nurse and there were two of them. Surveyor asked Nursing Student-CCC if the nurse was LPN-H. Nursing Student-CCC replied yes and said she (LPN-H) was kind of doing everything as she just graduated & was fresh out of school. Nursing Student-CCC informed Surveyor she was working under LPN-H and remembers bits and pieces. Surveyor informed Nursing Student-CCC Surveyor noted she created an order for a UA. Nursing Student-CCC informed Surveyor R297 wasn't himself, he wasn't urinating or anything. Surveyor asked if she spoke to APNP-FFF or did she text her. Nursing Student-CCC informed Surveyor she believes LPN-H called her. Surveyor asked Nursing Student-CCC if she spoke to any RN about R297's change of condition. Nursing Student-CCC informed Surveyor she's pretty sure LPN-H communicated with the DON and didn't think there was an RN in the building. Surveyor asked Nursing Student-CCC if any of the CNAs reported anything to her about R297. Nursing Student-CCC replied no not that I recall. Surveyor asked Nursing Student-CCC how she was aware R297 was not urinating. Nursing Student-CCC informed Surveyor she can't recall and doesn't know if LPN-H told her but she remembers something in that nature and thinks R297 told her he wasn't able to go. LPN-H informed Surveyor this is the first time she has sent a patient out. On 2/17/25, at 1:50 p.m., Surveyor interviewed Director of Nursing (DON)-B and asked what the expectation is if a resident has a change of condition and the nurse on the floor is a LPN. DON-B explained they would make their observations and update the MD (medical doctor) to get further orders. Surveyor asked if there would be a RN assessment. DON-B replied there is, they let management know and we will take a look at the resident as well. Surveyor asked DON-B if she remembers R297. DON-B replied slightly. DON-B informed Surveyor what she remembers R297 was a pleasant man, not many complaints, he was diabetic and there wasn't a lot of issues that she was informed of. DON-B informed Surveyor she knows he scratched himself a lot and he had cream ordered for that. Surveyor asked if there was anything ordered other than cream. DON-B replied no. Surveyor asked DON-B if a dressing was applied, would there be an assessment. DON-B replied there should be. Surveyor informed DON-B of APNP-FFF's note on 7/22/24 which documents two dressings. DON-B reviewed R297's record and then informed Surveyor there is no assessment. Surveyor asked DON-B if she was involved with R297's transfer to the hospital on 8/13/24. DON-B replied no. Surveyor asked DON-B if she was contacted regarding R297's change of condition on 8/13/24. DON-B informed Surveyor they would of contacted the on call and doesn't recall being called. Surveyor asked who was the on call RN. DON-B informed Surveyor she doesn't know. Surveyor asked DON-B to look up who was on call the evening of 8/13/24 and get back to Surveyor. DON-B did not provide Surveyor with the name of the on call RN. No additional information was provided.

Based on observation, record review and interview, the facility did not ensure that residents received adequate supervision and assistance to prevent accidents. The facility did not thoroughly assess falls and accidents for causative factors. The facility did not ensure fall interventions were implemented. This was observed with 6 (R12, R23, R36, R39, R346 and R347) of 6 residents reviewed for accidents. * R12's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions * R23's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions * R36 was observed not to have their call light not in reach per his falls plan of care. * R39's falls were not thoroughly assessed for causative factors. There was not observations of fall preventative interventions * R346 and R347's falls were not thoroughly assessed for causative factors. Findings include: The facility's policy and procedure Falls dated 12/5/24. The policy documents that preventative measures are put in place to reduce the occurrence of falls and risk of injury from falls. The procedures include: - Licensed nurse completes electronic documentation of the Fall Incident Report. - The care plan will be updated with an identified intervention. - Registered Nurse reviews and completes the fall assessment and interventions. - Fall follow-up assessments completed as indicated. - The (Interdisciplinary Team) IDT will review Fall Incident report and utilize root cause analysis to make further recommendations. On 2/11/25, at 3:55 p.m., Surveyor interviewed Director of Nursing (DON)-B regarding the facility's fall process. DON-B informed Surveyor when ever there is a fall the staff check out the resident, ask the resident what happened, what they were trying to do and get statements from the aides as to when the resident was last toileted, what were they doing, were they in bed, and what was going on before the fall. Staff calls the POA (power of attorney), NP (Nurse Practitioner), herself, and the case worker. The resident is placed on the 24 hour board and neuro checks should be charted on. Residents are monitored for three days and if there is any injury they let the NP know and get orders to send them out. Surveyor inquired if anyone reviews the falls. DON-B informed Surveyor the IDT (interdisciplinary team) reviews fall in the morning meeting explaining they read the notes, try to determine what happened. If there is not a clear picture they will ask the resident and follow up with the nurses. DON-B informed Surveyor the nurses are suppose to put in an immediate intervention and they follow up. Surveyor asked if anyone reviews to see if prior interventions were in place. DON-B explained they have a weekly meeting where they go over everything including risk, wounds, injuries. Surveyor asked if anyone follows up with the CNAs. DON-B informed Surveyor they try to follow up and the CNAs shouldn't write they don't know but sometimes its difficult to get a hold of them. 1.) R12's diagnoses includes vascular dementia and is receiving hospice care. R12's significant change MDS (minimum data set) with an assessment reference date of 11/27/24 has a BIMS (brief interview mental status) score of 1 which indicates severe cognitive impairment. R12 is assessed as being dependent for toileting hygiene, roll left & right, chair/bed to chair transfer and toilet transfer. R12 is assessed as being always incontinent of urine and bowel. R12 is assessed as not having any falls since prior assessment. R12's Falls CAA (care area assessment) dated 11/29/24 under analysis of findings for nature of problem documents At risk for fall progressive weakness-recent admit to hospice services-assisted to safely transition surfaces. Daily meds (medication) add to risk potential. Under care plan considerations documents Continue with care plan. Continue to assist to safely transition and reposition. Goal to maintain safety without fall. Falls place at risk for injury. R12's fall risk evaluation dated 8/19/24 has a score of 15. Under instructions documents Assess the resident status below. If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. R12's fall risk evaluation dated 9/12/24 has a score of 15 which indicates high risk. R12's at risk for falls care plan initiated & revised on 7/12/24 documents the following interventions: PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed). Initiated 11/5/23. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated 7/12/24 & revised 8/19/24. Ensure that the resident is wearing appropriate footwear (Shoes/socks with nonskid soles) when ambulating, transferring or mobilizing in w/c (wheelchair). Initiated 7/12/24 & revised 8/19/24. The resident needs a safe environment with a working and reachable call light, personal items within reach. Initiated 7/24/24 & revised 8/19/24. Bed in lowest position with floor mat when in bed. Initiated 8/19/24. Staff to assist resident to bed after breakfast if allows. Initiated 8/19/24. Staff to check and change q (every) 2 to 3 hours and prn if allows. Initiated 8/19/24. Body pillow when in bed. Initiated 9/12/24. Transfer bar to assist with bed mobility. Initiated 9/26/24 & revised 12/9/24. Air mattress with bolsters. Initiated 12/11/24 & revised 12/13/24. Air mattress - check function q (every) shift and prn (as needed). Initiated 12/11/24. R12's nurses note dated 9/12/24 at 21:27 (9:27 p.m.) written by Licensed Practical Nurse (LPN)-J documents Nurse went to give resident medication at about 6.30 PM and found resident on the floor by bed. Resident fell on the floor mat and was laying on her left side. Evaluation of all limbs functioning and moving well. Resident had a neuro check and vitals done and will be ongoing. Resident had a bm (bowel movement) and was cleaned up by CNA's and was placed in Hoyer to be put back into bed. No injury noted at the time of the assessment. Surveyor reviewed the facility's fall investigation provided by Director of Nursing (DON)-B for R12's fall on 9/12/24. Surveyor noted the facility investigation does not include whether prior interventions were in place at the time of R12's fall. R12's fall risk evaluation dated 9/26/24 has a score of 13 which indicates high risk. R12's nurses note dated 9/26/24 at 11:36 a.m. written by LPN-HH documents Resident had an unwitnessed fall and was found by med tech at 0635 (6:35 a.m.). Resident was face down on ground. Tech alerted nurse and nurse went to residents room. Nurse assessed resident. Resident c/o (complained of) head and left shoulder pain. Neuro checks started, vitals taken. DON (Director of Nursing), ADON (Assistant Director of Nursing), and NP (Nurse Practitioner), POA (Power of Attorney) notified. NP assessed resident as well. Resident alert as morning progresses and denies any pain in head or shoulder. Pupils reactive, normal ROM (range of motion) as resident had before fall. ADON talked to residents POA about transfer bars. No signs of injuries or bleeding. Surveyor reviewed facility's fall investigation provided by DON-B for R12's fall on 9/26/24. Surveyor noted the facility did not conduct a thorough investigation of R12's fall as there are no staff statements or evidence staff was spoken to as to when was R12 last seen, toileted, what was R12 doing, etc. There is no information as to whether prior interventions such as the body pillow were in place at the time of R12's fall. R12's fall risk evaluation dated 12/11/24 has a score of 13 which indicates high risk. R12's nurses note dated 12/11/24 at 10:45 a.m. written by LPN-WW documents Writer was called into the room around 6:45 this morning to find resident lying on the floor by her bed on her right side. Resident was alert/orient and responsive. Resident was assessed and assisted with Hoyer lift back into bed. Resident has small bump to right side of head. Resident denies any pain or discomfort @ (at) this time. VSS (vital signs stable). ROM (range of motion) per usual. Hospice was called and Nurse [Name] came out to assess pt. as well. NOR (new order received) to D/C (discontinue) neuro check and one time order for dilaudid. Husband was called and updated as well as DON and administrator. Will continue to monitor this shift. Surveyor reviewed facility's fall investigation provided by DON-B for R12's fall on 12/11/24. Surveyor noted the facility did not conduct a thorough investigation of R12's fall as the two day shift staff statements indicates they didn't know when R12 was last toileted or repositioned as this fall occurred shortly after the day shift started. There are no statements or indications the night shift staff was interviewed as to who last saw R12, when was R12 toileted or repositioned. CNA (Certified Nursing Assistant)/Med Tech-KK's statement includes documentation of matt not in place on floor, bed not in lowest position. There is no indication as to whether the prior intervention of the body pillow was in place at the time of R12's fall. On 2/11/25, at 7:17 a.m., Surveyor observed R12 in bed on the right side with the bed in the lowest position and a mat on the floor along the left side of R12's bed. Surveyor observed there isn't a body pillow on the left side. The right side of R12's bed is against the wall. On 2/11/25, at 7:36 a.m. Surveyor observed Certified Nursing Assistant (CNA)-K in R12's room and is wearing gloves. CNA-K placed the wash basin on the over bed table, removed the floor mat, and informed R12 she was going to get her up, dressed, and go down for breakfast. CNA-K raised the height of bed and positioned R12 on her back. CNA-K unfastened the incontinence product which Surveyor observed contained urine. CNA-K informed R12 she was going to wash her peri area and washed R12's inner thighs and frontal perineal area. CNA-K positioned R12 on the right side, and removed the soiled incontinence product and informed R12 she was going to put the brief under her. As CNA-K was attempting to place the incontinence product under R12, R12's knee kept hitting the wall on the right side. CNA-K removed her gloves and left R12's room. Prior to leaving R12's room, CNA-K did not lower R12's bed and did not place the body pillow or mat on the floor. CNA-K reentered R12's room with a sheet, placed gloves on, folded the sheet and placed the sheet under R12 & straightened out the incontinence product by positioning R12 from side to side. CNA-K pulled up the incontinence product between R12's thighs and fastened the product. CNA-K placed pants on R12, removed R12's shirt and placed a Hoyer sling under R12. CNA-K washed R12's upper body, placed a sweater on R12, and stated to R12 she was going to lower her down while she goes to get help. CNA-K lowered the bed down, removed her gloves and left R12's room at 7:51 a.m. CNA-K did not place the body pillow on R12's bed or the mat on the floor prior to leaving R12's room. At 7:53 a.m. CNA-K and CNA-LL entered R12's room, placed gloves on, and transferred R12 from the bed into the broda chair using a Hoyer lift. On 2/11/25, at 7:25 a.m., Surveyor asked CNA-K if they use the body pillow. CNA-K replied yes at night. Surveyor informed CNA-K Surveyor did not observe the body pillow on R12's bed this morning. On 2/11/25, at 8:37 a.m., Surveyor observed R12 sitting in a broda chair along side a table in the dining room. Surveyor observed there is a pillow between R12's knees and a pink U shaped pillow around R12's neck. On 2/11/25, at 8:55 a.m., Surveyor observed R12 continues to be along side the table in the dining room. R12 has a spoon in her hand and is eating oatmeal. On 2/11/25, at 9:31 a.m., Surveyor observed CNA-K wheel R12 into her room and left R12's room immediately. On 2/11/25, at 9:51 a.m. Surveyor observed R12 sitting in a broda chair, which is slightly reclined back in her room holding onto a pillow with the pink u shaped pillow on R12's lap. On 2/11/25, at 10:27 a.m., Surveyor observed R12 continues to be sitting in the broda chair in her room and has thrown the two pillows on the floor. On 2/11/25, at 10:43 a.m., Surveyor asked CNA-K if R12 lays down during the day. CNA-K informed Surveyor after lunch she goes back to bed. Surveyor asked CNA-K if R12 lays down after breakfast. CNA-K replied just lunch. Surveyor noted there is a fall intervention to lay down R12 after breakfast. On 2/11/25, at 11:09 a.m. Surveyor asked Registered Nurse/Wound Nurse (RN/WN)-I if a resident has fall interventions like a body pillow should they be in place. RN/WN-I replied they should have a body pillow. Surveyor asked if the intervention is a fall mat should the mat be next to the bed. RN/WN-I replied yes because you don't know what will happen, a fall can happen that quick. Surveyor informed RN/WN-I of the observations of R12's fall interventions not in place. On 2/11/25, at 11:24 a.m., Surveyor observed R12's call light was activated. Surveyor entered R12's room and observed R12 sitting in the broda chair holding onto the call light. Surveyor asked R12 if she put her call light on. R12 put the call light up to her hear stating hello, hello. On 2/11.25, at 2:44 p.m., Surveyor observed R12 awake in bed on her left side. Surveyor observed R12's bed is in the low position with the body pillow along the left side but the mat is not the floor next to R12's bed. Surveyor observed the floor mat is propped up against the recliner in the corner. On 2/11/25, at 3:36 p.m., Surveyor observed R12 continues to be in bed awake on her left side. Surveyor observed the body pillow continues to be propped up against the recliner and is not on R12's bed according to R12's plan of care. On 2/13/25, at 2:18 p.m., Surveyor informed DON-B of Surveyor's concerns of fall interventions observed not in place for R12 and facility's investigation for R12's falls on 9/12/24, 9/26/24, & 12/11/24 were not thoroughly investigated to prevent further falls. 2.) R23's diagnoses includes congestive heart failure, depression, diabetes mellitus, glaucoma, macular degeneration, and atrial fibrillation. R23 receives hospice care. R23's admission MDS (minimum data set) with an assessment reference date of 11/8/24 has a BIMS (brief interview mental status) score of 1 which indicates severe cognitive impairment. R23 is assessed as requiring partial/moderate assistance for toileting hygiene, roll left & right and toilet transfers. R23 is assessed as requiring substantial/maximal assistance for chair/bed to chair transfer. R23 has an indwelling catheter and is frequently incontinent of bowel. R23 is assessed as not having any falls prior to admission or since admission. R23's fall CAA (care area assessment) dated 11/11/24 under analysis of findings for nature of the problem/condition documents Hx (history) syncope due to orthostatic hypotension adm (admission) fall score=10 indicates risk. Decreased vision/vision Dx (diagnosis). At fall risk-assisted to safely transition surfaces. Under care plan considerations documents Proceed to care plan. Maintain safety throughout her stay. Falling places at risk for injury/Fx (fracture). R23's fall risk evaluation dated 11/1/24 has a score of 10. Under instructions documents Assess the resident status below. If the total score is 10 or greater, the resident should be considered HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. R23's high risk for falls care plan initiated & revised on 11/1/24 documents the following interventions: Anticipate and meet the resident's needs. Initiated 11/1/24. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Initiated 11/1/24 & revised 12/9/24. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Initiated 11/1/24. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Initiated 11/1/24 & revised 11/5/24. Ensure that the resident is wearing appropriate footwear non skid socks when ambulating, transferring or mobilizing in w/c (wheelchair). Initiated & revised 11/1/24. Follow facility fall protocol. Initiated 11/1/24. PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed). Initiated 11/1/24. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. Initiated 11/1/24. The resident needs a safe environment with: SPECIFY even floors from spills and/or clutter, adequate, glare-free light, a working and reachable call light, the bed in low position at night, personal items within reach. Initiated 11/1/24. Staff to ensure pillows are arranged on cough sic (couch) as resident allows. Initiated 11/17/24. Call don't fall sign. Initiated 12/10/24. Bedside commode. Initiated 12/13/24. Mattress with bolsters. Initiated 12/13/24. Body pillow when in bed if allows. Initiated 12/14/24. Recliner chair with lever replaced with recliner chair with remote for easier use. Initiated 1/22/25. Recliner chair replaced with chair that does not recline. Initiated 1/23/25. Resident to sit in Broda chair when out of bed when resident allows. Initiated 1/23/25 & revised on 1/24/25. R23's ADL (activities daily living) self-care performance deficit care plan initiated 11/1/24 includes an intervention of Transfer with assist of 1 with gait belt and walker. Initiated & revised 11/1/24. R23's nurses note dated 11/17/24, at 13:41 (1:41 p.m.), written by Licensed Practical Nurse (LPN)-H documents Resident had an UWF (unwitnessed fall) this morning. Upon checking resident was continent of B/B (bowel/bladder) with proper footwear on. Resident denies having any pain. No injuries were found after head/toe observation. Resident was fixing something on her couch when she lost her balance and fell on the floor. She crawled to her recliner chair to push her call light for help. She was then helped off the floor and helped into her recliner chair and was reeducated on calling for help before getting up. Resident son was informed of the fall when he came in to visit this morning, hospice notified and NP (Nurse Practitioner). Surveyor reviewed R23's fall investigation emailed by Director of Nursing (DON)-B on 2/12/25. Surveyor noted there are no statements or interviews with staff as to who last saw R23, what was R23 doing etc. There is no information as to whether previous interventions were in place. On 2/13/25, at 2:20 p.m., Surveyor interviewed DON-B regarding R23's fall on 11/17/24 and inquired if there are any staff statements/interviews. DON-B informed Surveyor she doesn't think she has any. R23's nurses note dated 12/13/24, at 10:17 a.m., written by LPN-HH documents Resident had a witnessed fall while getting up to go take a shower with CNA (Certified Nursing Assistant). Resident got dizzy, fell backward and hit her head on a wood side table. Residents head was bleeding and nurse stopped the bleeding with applied pressure. Resident said her head did not hurt when asked. Nurse called emergency contact and left a message for him to call back. [Name] hospice was notified. Neuro checks started. Surveyor reviewed the facility's fall investigation emailed by DON-B on 2/12/25. The root cause documents resident was being assisted to bathroom by CNA with wheeled walker, got dizzy and lost balance causing her to be lowered to the floor. On 2/13/25, at 2:21 p.m., Surveyor interviewed DON-B regarding R23's fall on 12/13/24. Surveyor asked if R23 was lowered to the floor how did she sustain a hematoma to the back of R23's head and was the CNA using a gait belt according to R23's plan of care. DON-B informed Surveyor she can't say if the gait belt was being used and lowered to the floor was probably a typo. Surveyor asked DON-B to get back to Surveyor with any further information regarding R23's 12/13/24 fall. DON-B did not provide Surveyor with any further information. R23's nurses note dated 12/14/24, at 05:49 (5:49 a.m.), written by Nurse Extern-XX documents Resident had a unwitnessed fall. Resident was trying to get out of bed. Gash noted from previous fall, no bleeding observed. Hospice nurse, POA, NP notified. resident did say she has no pain. Surveyor noted this fall occurred on 12/13/24 at 6:37 p.m. Surveyor reviewed the facility's fall investigation emailed by DON-B on 2/12/25. Surveyor noted there are no statements or interviews with staff as to who last saw R23, what was R23 doing etc. There is no information as to whether previous interventions were in place. On 2/13/25, at 2:24 p.m., Surveyor interviewed DON-B regarding R23's fall on 12/13/24 which was documented on 12/14/24. DON-B informed Surveyor there are not any staff statements. R23's nurses note dated 12/14/24, at 20:27 (8:27 p.m.) written by Nurse Extern-P documents UWF (unwitnessed fall) Resident was lying on the floor in front of bed on her back, assessed resident, resident said she has no pain, took vitals, resident said she is feeling ok. contacted NP, tried to contact son [Name] no answer tried contacting ADON (Assistant Director of Nursing) no answer. Surveyor reviewed the facility's investigation emailed by DON-B on 2/12/25. Surveyor noted the facility did not have a thorough investigation there are no staff statements/interviews as to who last saw R23, was R23 incontinent, what was R23 doing prior and whether prior interventions were in place. On 2/13/25, at 2:25 p.m., Surveyor interviewed DON-B regarding R23's fall on 12/14/24. Surveyor informed DON-B there are no staff statements/interviews as to who last saw R23, what was she doing and were prior interventions in place. Surveyor asked DON-B if the body pillow is a current intervention. DON-B informed Surveyor it's on her care plan so it's a fall intervention. Surveyor informed DON-B Surveyor has not observed R23's body pillow. R23's nurses note dated 1/21/25, at 21:20 (9:20 p.m.) written by LPN-H documents Resident was found on her floor in front of her wheelchair face down upon observation she has and large knot above her right eye, Ice was applied to the right eye. Resident had on proper footwear and was continent upon fall. Resident was asked if she would like to go to hospital and she refused, resident isn't on any blood thinners. Family, Hospice, NP and DON were informed. Neuro checks started. Family came up to facility to check on resident will let me know if they would like for her to be sent out to hospital. Surveyor reviewed the facility's investigation emailed by DON-B on 2/12/25. Surveyor noted CNA-YY's statement for time of incident 8:50 p.m. for the question when was the last time you saw the resident and what were they doing documents I saw her at 8:00 PM. She was sitting in recliner watching TV. For the question was the call light on a the time of the fall and was it within reach documents No I was in room at time. Surveyor noted this information is conflicting. On 2/13/25, at 2:26 p.m., Surveyor interviewed DON-B regarding the facility's fall investigation regarding R23's fall on 1/21/25 at 8:50 p.m. Surveyor informed DON-B CNA-YY's statement documents she last saw R23 at 8:00 p.m. but documents the call light was not on because she was in the room at the time. DON-B informed Surveyor she doesn't think she understood the questions. Surveyor asked DON-B if she asked CNA-YY if she was in R23's room when 23 fell . DON-B replied I didn't ask her. R23's Certified Nursing Assistant (CNA) kardex as of 2/11/25 under the transfer section documents Transfer with assist of 1 with gait belt and walker. On 2/10/25, at 1:49 p.m., Surveyor observed R23 sitting in a wheelchair in her room. There is a burgundy colored mat on the floor on the right side of R23's bed. On 2/10/25, at 3:41 p.m., Surveyor observed R23 sitting in a wheelchair facing the bed. Surveyor observed R23's call light is resting on the floor next to R23's bed by the floor mat. On 2/11/25, at 7:14 a.m., Surveyor observed R23 in bed on her back. R23's bed is in the low position, there is a mat on the floor on the right side and the call light is attached to the sheet on the right side hanging down. Surveyor did not observe the body pillow on R23's bed. On 2/11/25, at 8:09 a.m., Surveyor observed R23 continues to be in bed on her back. Surveyor observed there is still not a body pillow on R23's bed. On 2/11/25, at 10:36 a.m., CNA-K entered R23's room and placed gloves on. CNA-K informed Surveyor she will put on her socks after she is finished brushing her teeth. Surveyor observed R23 is sitting on the edge of the bed brushing her teeth. At 10:37 a.m. CNA-K placed tubi grips on R23's bilateral lower extremities and then placed gripper socks on. CNA-K asked R23 if she wants to lay down or sit up. R23 informed CNA-K she wants to sit in the wheelchair. CNA-K moved R23's wheelchair closer to the bed, placed the urinary collection bag under R23's wheelchair, held under R23's left arm & back and assisted R23 with standing, R23 took a couple steps to turn and sit in the wheelchair. CNA-K did not use a gait belt according to R23's plan of care. On 2/11/25, at 11:39 a.m., Surveyor asked CNA-K if she ever uses a gait belt when transferring R23. CNA-K replied no, just walker, used to be in care plan but hospice took it out. On 2/11/25, at 2:42 p.m., Surveyor observed R23 sleeping in bed on her back. Surveyor observed the bed is not at the lowest position, there is no floor mat on the right side and the body pillow is not on R23's bed. On 2/11/25, at 3:38 p.m., Surveyor observed R23 continues to be sleeping in bed on her back. Surveyor observed the bed is not at the lowest position, there is not a body pillow on R23's bed and there is not a floor mat on the right side of the bed. On 2/13/25, at 7:27 a.m., Surveyor observed R23 in bed on her back. Surveyor observed the bed is at the lowest position, there is a blue mat floor mat on the right side but there is no body pillow observed. On 2/13/25, at 7:36 a.m., Surveyor asked CNA/Med Tech-KK when R23 is in bed should there be a floor mat on the right side of R23's bed. CNA/Med Tech-KK replied yes. On 2/13/25, at 2:18 p.m., Surveyor asked DON-B if R23 should be transferred with a gait belt. DON-B replied if that is what the care plan says, yes. Surveyor informed DON-B of the observation of R23 being transferred without a gait belt and Surveyor had observed gait belt hanging on the back of R23's door. Surveyor also informed DON-B of other fall interventions, mat on floor and body pillow not being in place. No additional information was provided. 21855 Based on [NAME], [NAME], [NAME], [NAME] and [NAME] 7 of 7 reviewed for falls. [NAME] schroederus sustained a fall leading to hospitalization where resident required stiches [NAME] did not have through investigation related to picture frame falling off the wall and call light not within reach [NAME] and [NAME] fall investigation not through and interventions not in place [NAME] and Odelle not throughly investigated falls Resident #15 Accidents 02/10/25 10:21 AM bruise on right eye. Was reaching from bed and fell . Call light 1/23/2025 07:23 Nurse's Note Note Text: writer called to resident room due to unwitnessed fall. resident found in lying position to right side. upon assessment writer noticed bleeding to to right eye. Resident states he was in sitting position on bed when he attempted to help himself and fell . call light was in reach but not on. resident alert making needs known answering questions appropriately. Call out to NP and family ok to send resident to ER to eval and treat. Plan Of Care: The resident is High risk for falls r/t Deconditioning, Gait/balance problems, Incontinence Date Initiated: 01/20/2025 Revision on: 01/20/2025 Risk of falls/falls with injury will be minimized Date Initiated: 01/20/2025 Target Date: 04/20/2025 CANCELLED: Anticipate and meet The resident's needs. Date Initiated: 01/20/2025 Revision on: 01/21/2025 Cancelled Date: 01/21/2025 CNA LPN RN 01/21/2025 Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Date Initiated: 01/20/2025 Revision on: 01/20/2025 CNA LPN RN Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Date Initiated: 01/20/2025 LPN RN Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility Date Initiated: 01/20/2025 Revision on: 01/20/2025 LPN CNA RN Ensure that The resident is wearing appropriate footwear non-skid socks when ambulating, transferring or mobilizing in w/c. Date Initiated: 01/20/2025 Revision on: 01/20/2025 CNA LPN RN fall-1/23/25-bed in lowest position with mat on floor when in bed Date Initiated: 01/23/2025 CNA LPN RN fall-1/23/25-call don't fall sign in room Date Initiated: 01/23/2025 CNA LPN RN fall-1/23/25-staff to offer toileting q 2 to 3 hours and prn Date Initiated: 01/23/2025 CNA LPN RN PT/OT evaluate and treat as ordered or PRN. Date Initiated: 01/20/2025 02/11/25 08:13 AM In room . Dressed in wheelchair watching TV. Has splint and 1/2 table. 02/11/25 09:29 AM reviewed fall investigation by DON La. Just has follow-up interventions. Does not include events prior to the fall itself. Root cause is Resident trying to self transfer with interventions to place a fall sign and offer toileting every 2-3 hours and prn. There is not documentation of possible causative factors leading up to the fall. There is not documentation to support the interventions implemented. Plan of care revised. Admission MDS 1/27/25 has bims 14/15. No fall history. Had 1 fall after admission. Freq incontient of B/B not toileting plan. 1/23/25 ED visit has laceration with stitches 1/23/2025 14:44 Nurse's Note Note Text: resident back from ER visit due to unwitnessed fall. alert and oriented making needs known. states some pain to site. Dissolvable stitches in place to dissolve in 7 days. follow up with MD in regards. VSS resting in bed 02/13/25 08:07 AM DON this is the only information is the. I spoke to the resident. Nurse and CNA. He was trying to get up to use the toilet. Don't know when he was last toileted. No additional information at this time. 02/13/25 09:37 AM has white sign with black lettering on wall of TV. the sign states Sop. call don't fall. In room with wheelchair watching TV. Has call light in reach. Has another sign by the side if their bed. Resident can read it and understands what it means. 1/20/25 Fall Risk Assessment completed is at risk 13 42037 4.) R39 was admitted to the facility on [DATE] with diagnoses of Dementia, End Stage Renal Disease and Dependence on Renal Dialysis. R39's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/17/25 indicates that R39 requires maximal assistance with transfers and mobility. Surveyor reviewed R39's medical record, including physician's orders, fall risk evaluation forms and comprehensive care plans. R3 [TRUNCATED]

Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries from developing for 5 (R137, R40, R41, R27, and R18) of 8 residents reviewed for pressure injuries. *R137 was admitted to the facility on [DATE] after sustaining a right femur fracture following a fall at home. R137 had a Braden score of 11 indicating high risk for development of pressure injuries. R137 developed a skin tear and a reddened area on 10/25/23 and 10/30/23 respectively. The facility did not have a Care Plan to address bed mobility, repositioning, or incontinence until 11/8/2023, when R137 developed an unstageable pressure injury to the coccyx. There was not a comprehensive assessment of the pressure injury nor was the dietitian alerted to address dietary needs. On 11/06/23, the nurse practitioner (NP) ordered an antibiotic for a wound infection and indicated the resident should be seen by the wound nurse practitioner. R137 was not seen by the wound nurse practitioner. Seven days later, R137 was hospitalized and found to have necrotizing fasciitis. The facility's failures to implement preventive interventions for a resident at risk of developing pressure injuries, to determine the etiology of skin tears to the coccyx, to comprehensively assess a pressure injury, to involve the Wound NP, and to notify the dietician of the development of a pressure injury created a finding of immediate jeopardy that began on 10/25/2023. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Clinical Nurse Consultant (CNC)-F of the immediate jeopardy on 1/8/2024 at 3:00 PM. The immediate jeopardy was removed on 1/12/24, however, the deficient practice continues at a scope/severity of G (actual harm/isolated) as evidenced by the following examples. R40 and R41 are being cited at severity level 3. * R40 developed an unstageable pressure injury to the coccyx on 6/11/2023 that was not comprehensively assessed until 6/14/2023. R40 did not have a comprehensive care plan that addressed pressure injury preventative measures. * R41 developed a Deep Tissue Injury (DTI) to the right heel and a DTI to the left heel on 10/12/2023 that were not comprehensively assessed until 10/16/2023. R41 did not have a comprehensive care plan that addressed preventative measures. * R27 developed a Deep Tissue Injury (DTI) to the left heel which was discovered on 12/16/2023. There was no RN (Registered Nurse) assessment until 12/18/2023 (two days later.) R27's care plan was not updated to reflect the use of heel boots until 12/18/23. The facility did not get treatment orders for the DTI until 12/18/23 when at that time, the physician and R27's representative were notified of the DTI. * R18 developed a Stage 2 pressure injury to the left buttock on 12/7/2023 that was not comprehensively assessed. Findings include: The facility policy and procedure entitled Pressure Injury Prevention and Managing Skin Integrity dated 8/10/2023 states: I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedure: 1. Risk Assessment a. Upon Admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. b. Re-evaluation: Braden Scale will be completed upon change of condition and quarterly. c. Based on the individual's Braden Scale Score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team (IDT) regarding the presence of breakdown and the intervention plan. 2. When indicated, a referral to additional resources (ie. Wound Care Specialist, Registered Dietician, Physical Therapist, Occupational Therapist) may occur. 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan i. In developing a plan of care, the following will be considered: 1. Individual Pressure Injury History 2. Cognitive changes or impairment of the individual 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health 4. Any cultural practices that impact the health or integrity of the skin 5. Risk for pressure ulcer development (Braden Scale) 3. Skin Checks a. Skin check will be done upon admission, readmission or as clinically indicated. b. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the Skin Check in the medical record. 4. Weekly Wound Rounds a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concerns(s) will be added to weekly wound rounds. b. Registered Nurse (RN) or designee will: i. Conduct weekly skin evaluation. ii. Update the (PCP) with any decline in wound appearance, or as necessary iii. Update the Care Plan with any new interventions as applicable iv. Update Individual Representative as indicated 5. Administrative Review a. Interdisciplinary Team (IDT) reviews Pressure Ulcer/Abnormal Skin Findings through Quality Assurance Committee. 1. R137 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur, anemia, Type 2 Diabetes Mellitus, congestive heart failure, osteoarthritis, spinal stenosis, and osteoporosis. R137 had a fall at home, sustained the fracture to the right femur, and was admitted to the facility for Physical and Occupational Therapy. On 10/24/2023 at 4:57 PM in the progress notes, nursing charted R137 was admitted to the facility with a left hip fracture (Surveyor noted R137's right hip was fractured.) The Elopement Evaluation form on 10/24/2023 documented R137 was not an elopement risk because R137 was immobile. The Braden Scale score on 10/24/2023 was 11 indicating R137 was at high risk for skin breakdown. The Admit/Readmit Screener form on 10/24/2023 documented R137 had a pressure area to the sacrum that was red and blancheable and a rash under the left and right breast. On 10/24/2023 at 11:41 PM in the progress notes, nursing charted R137 was a new admission that day after a fall resulting in a right femur fracture. Nursing charted R137 was incontinent of bowel and bladder. The Baseline Care Plan initiated on 10/24/2023 was a tool for gathering information but did not implement any interventions. Bed mobility, toileting, and transfers were not assessed per the Baseline Care Plan. The Skin section of the Baseline Care Plan documented R137 had blancheable area to the coccyx and a rash under both breasts. Surveyor noted R137 did not have a Care Plan implemented to address Activities of Daily Living (ADLs) regarding the amount of assistance needed for bed mobility, incontinence care, or the prevention of pressure injuries such as developing a turning and repositioning program. R137 had limited mobility due to the healing right femur fracture. On 10/25/2023 at 10:18 AM in the progress notes, nursing charted R137 had a skin tear to the coccyx. Nursing charted the site was cleaned and Mepilex was applied per Nurse Practitioner (NP) verbal orders. Surveyor noted the treatment order was not entered into R137's Medication Administration Record (MAR) or Treatment Administration Record (TAR) and no etiology of how the skin tear developed was documented. No Care Plan preventative measures were initiated to prevent further skin breakdown. On 10/29/23, R137's ADL Care Plan was initiated with the following interventions: -Discuss with R137/family/POA (Power of Attorney) care any concerns related to loss of independence, decline in function. -Encourage R137 to discuss feelings about self-care deficit as needed. -Encourage R137 to participate to the fullest extent possible with each interaction. -Encourage R137 to use bell to call for assistance. -Monitor/document/report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. -Praise all efforts at self-care. -PT/OT evaluation and treatment as per physician orders. Surveyor noted R137's ADL Care Plan did not address the level of assistance needed for bed mobility, incontinence care, transfers, a turning and repositioning program or any other activity of daily living. On 10/30/2023 at 9:45 AM in the progress notes, nursing charted R137 had redness on the buttocks and a small skin tear. The documentation did not elaborate on the location of the skin tear and give the etiology of how the skin tear developed. No Care Plan interventions or preventative measures such as a turning and repositioning program were initiated to prevent further breakdown. On 10/30/2023 at 1:48 PM in the progress notes, Social Services charted a care conference was held for R137 and a medication list and care plan were given to R137 and family for review. Social Services charted R137 was non-weight bearing on leg and was working on standing and transfers. R137 did well with a slide board transfer and the plan was for R137 to discharge to home or an assisted living facility. R137's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R137 had a severe cognitive deficit with a Brief Interview for Mental Status (BIMS) score of 6 and the facility assessed R137 as needing moderate assist for rolling in bed, was dependent for toileting, was always incontinent of bowel and bladder. The MDS indicates R137 was admitted with no unhealed pressure injuries and was at risk for a pressure injury with a pressure reducing device in the chair only. Surveyor noted the MDS was not checked for a turning/repositioning program. The MDS indicates R137 was checked for having a surgical wound. The Pressure Injury Care Area Assessment (CAA) stated R137 was at risk for impaired skin with incontinence exposing skin to moisture and waste. R137's admission Braden score was 11 placing R137 at high risk and proceed to plan of care to assist R137 with repositioning needs and peri hygiene. The CAA stated open wound or skin places R137 at risk for infection. Surveyor noted R137's skin tear was not indicated on the MDS assessment, and no care plan was developed to assist R137 with positioning or peri hygiene at that time. On 11/6/2023 at 10:36 AM in the progress notes, nursing charted R137 did not have any new skin concerns. Surveyor noted no further documentation was found on the skin tear to the buttocks/coccyx. On 11/7/23, R137's Impairment to Skin Integrity related to fragile skin Care Plan was initiated with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Keep skin clean and dry; use lotion on dry skin. Surveyor noted R137's Impairment to Skin Integrity care plan did not include a turning and repositioning program. On 11/8/2023 at 1:10 PM in the progress notes, Social Services charted a care conference was held for R137 and R137 had been working on slide board transfers but due to redness on bottom, they put the slide board transfers on hold. On 11/8/2023 at 4:13 PM in the progress notes, Director of Nursing (DON)-B charted R137 had an unstageable pressure injury to the sacrum that measured 3 cm x 3 cm with slough, eschar, and a slight odor. Surveyor noted no depth was measured and the wound bed did not have percentages of tissue type documented to accurately describe the wound bed; this pressure injury did not have a comprehensive assessment. DON-B notified NP-J and the physician of the new pressure injury. An order was obtained to cleanse the wound with Puracyn, apply Medihoney, and cover the wound with Allevyn daily. Surveyor noted the Dietician was not notified of the new pressure injury. No supplements were ordered to address the increased protein need. On 11/8/23 R137's Pressure Ulcer to sacrum Care Plan was initiated with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing; measure length, width, and depth where possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Bed rest; up with therapy only. -Educate R137/family/caregivers as to causes of skin breakdown, including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -If R137 refuses treatment, confer with R137, IDT (Interdisciplinary Team), and family to determine why and try alternative methods to gain compliance; document alternative methods. -Inform R137/family/caregivers of any new area of skin breakdown. -Monitor dressing to ensure it is intact and adhering; report loose dressing to treatment nurse. -Monitor nutritional status; serve diet as ordered. -Monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size (length x width x depth), stage. -Obtain and monitor lab/diagnostic work as ordered; report results to physician and follow up as indicated. -Staff to assist with routine toileting and skin care for incontinence. -Treat pain as per orders prior to treatment/turning to ensure R137's comfort. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. On 11/9/2023 at 10:46 AM in the progress notes, nursing charted wound care was completed to the pressure injury which was yellow odorous eschar with pain to the touch. The DON and NP-J were aware and R137 was repositioned as needed. On 11/9/2023 at 11:29 AM in the progress notes, nursing charted R137 complained of chills and body aches; R137 was warm to the touch with a temperature of 102.4. Nursing charted NP-J was notified of the fever, Tylenol was given, and the rechecked temperature was 100.8. On 11/9/2023, R137 was evaluated by NP-J. NP-J documented R137 complained of occasional right hip pain and pain secondary to a wound on the sacrum which was being treated with daily local wound care. NP-J documented the Unstageable sacral wound had necrotic edges and the peri wound area was erythematous. NP-J documented the treatment plan for the Unstageable sacral wound was to start doxycycline (antibiotic) 100 mg twice daily for seven days for wound infection, continue daily local wound care with Medihoney, and resident will be followed by the facility Wound NP. Surveyor noted with record review the Wound NP did not evaluate or treat R137. On 11/9/23, R137's Pressure Ulcer to sacrum Care Plan was revised with the following interventions: -Avoid positioning R137 on back. -Staff to assist with turning and repositioning every 2-3 hours. -R137 requires air mattress; check function every shift and as needed. On 11/10/2023 at 9:17 PM in the progress notes, nursing charted oxycodone 5 mg was administered for pain to the sacral/coccyx area from sitting and repositioning and rest were ineffective. Surveyor noted R137 was to be on bedrest, yet pain was caused from sitting. On 11/11/2023 at 9:17 PM in the progress notes, nursing charted R137 had poor appetite and oral fluids were offered and accepted. Nursing charted incontinence rounds and wound care were completed; R137 had an air mattress and was repositioned frequently. R137 was currently resting in bed and in no distress with call bell and oral fluids in reach. Surveyor noted there was no dietician reassessment of R137's nutritional needs after R137 developed an unstageable pressure injury and was charted as having a poor appetite. On 11/13/2023 at 12:48 PM in the progress notes, nursing charted oxycodone 5 mg was administered for pain prevention prior to wound care. On 11/14/2023, R137 was evaluated by the physician. The physician documented R137 had an Unstageable sacral pressure ulcer with eschar and was tolerating doxycycline. The physician documented daily wound care was in progress with Medihoney and pressure relief and position changes were the treatment plan. On 11/16/2023, R137 was evaluated by NP-J at the request of R137's family for depressed mood and decreased appetite. On assessment, R137 was lying in bed and participated minimally in the conversation. The family reported R137 was more depressed that week, was lying in bed a lot, and sleeping more during the day. Family reported R137 was not eating unless the family fed R137, and the family requested a medication for depression. NP-J documented the Unstageable pressure injury to the coccyx had improved since the previous exam (on 11/9/2023). NP-J documented the treatment plan for the Unstageable sacral wound was to continue daily local wound care with Medihoney and will be followed by the facility Wound NP. Surveyor noted with record review the Wound NP did not evaluate or treat R137 and no weekly comprehensive assessment of the pressure injury to include measurements of the area (width, length, depth, type of tissue and exudate) was completed. On 11/16/2023 at 3:29 PM in the progress notes, DON-B charted R137 was assessed by NP-J with a new order received for Mirtazapine 7.5 mg every evening for depression/appetite. On 11/16/2023 at 3:51 PM in the progress notes, DON-B charted R137's family member was at bedside and stated R137 had increased confusion. DON-B charted DON-B attempted to ask R137 questions, but DON-B was unable to understand R137's answers. Per the family member, this was a change for R137. DON-B charted NP-J was made aware and new orders for labs were obtained. On 11/16/2023 at 10:47 PM in the progress notes, nursing charted R137's vital signs at 9:55 PM were as follows: blood pressure 95/48, pulse 101, temperature 99.7, respirations 30, oxygen saturation 91% on room air, and blood sugar 507. Nursing charted R137 was crying and whimpering at that time and was confused and disoriented. The NP was notified of the findings and an order was given to send R137 to the emergency room for further evaluation. Surveyor noted R137's blood sugar readings from 11/2/2023-11/16/2023 ranged from 115 to 507 with an average reading of 282 and only three of the 29 blood sugar readings were less than 200. On 11/17/2023 at 5:49 AM in the progress notes, nursing charted R137 was admitted to the intensive care unit for possible necrotizing fasciitis. R137 did not return to the facility and passed away on 11/19/2023. In an interview on 1/4/2024 at 8:54 AM, NP-J stated NP-J remembered seeing R137's sacral wound at least twice and was aware the physician saw R137's wound once, maybe twice. NP-J stated NP-J first saw R137's sacral wound on 11/9/2023. Surveyor asked NP-J if NP-J took any measurements of the wound. NP-J stated facility nursing staff was responsible for measuring the wound. NP-J recalled ordering an antibiotic for the wound on 11/9/2023 because the wound was foul smelling, and the peri wound was reddened and inflamed. NP-J stated the physician comes to the facility on Tuesdays and NP-J had the physician look at the wound on 11/14/2023 for a follow up visit. NP-J stated NP-J saw R137 on 11/16/2023 because the family said R137 was depressed and not eating. NP-J stated that was the initial reason NP-J saw R137 that day and since NP-J was there, NP-J checked on everything else including the pressure injury. NP-J stated the pressure injury looked better at that time compared to the previous week when NP-J had ordered the antibiotic. NP-J stated the skin around the wound and the wound itself had improved with the antibiotic and Medihoney. NP-J stated there was no visual presentation of anything brewing underneath the wound. NP-J stated NP-J would not have guessed necrotizing fasciitis was present and was shocked when that was reported to NP-J from the hospital. In an interview on 1/4/2024 at 9:34 AM, Surveyor asked MDS Registered Nurse (RN)-C what the process was for a resident that develops a pressure injury while a resident at the facility. MDS RN-C stated the floor nurse does the initial assessment and notifies the Assistant DON (ADON) or the DON of the new area; the DON or ADON will do a complete assessment and document the new areas in either the progress notes or in the assessment tab of the computer charting system. Surveyor asked MDS RN-C how the Wound NP was notified of a resident that needed an assessment and where that assessment would be documented. MDS RN-C stated the Wound NP is notified by either the DON or ADON and will put their own note into the computer charting system. Surveyor noted R137 did not have an initial comprehensive assessment on 11/8/2023 of the new pressure injury, was not comprehensively assessed weekly, and was not seen by the Wound NP. On 1/4/2024 at 10:16 AM, Surveyor shared with Clinical Nurse Consultant (CNC)-F the following concerns regarding R137: -R137's baseline care plan did not have any interventions to address R137's bed mobility with the right hip fracture. -R137 had a Braden score of 11 on admission placing R137 at high risk for a pressure injury and no preventive interventions were implemented. -R137 had a skin tear to the coccyx on 10/25/2023 and 10/30/2023 that were not assessed for etiology of the wounds to prevent future skin breakdown. -The skin tear on 10/25/2023 had a treatment applied that was not documented in the MAR/TAR. -When the ADL care plan was initiated on 10/29/2023, bed mobility and repositioning were not addressed. -On 11/8/2023 a pressure injury to the sacrum was discovered and the wound measurements did not include a depth or a complete description of the wound bed. -The dietician was not notified of the new pressure injury. -An air mattress and repositioning were not implemented on the care plan until after the development of a pressure injury. -On 11/9/2023 the pressure injury required antibiotics for an infection. -On 11/9/2023, NP-J requested the Wound NP be involved in R137's care; no documentation was found by the Wound NP of any assessment of R137's pressure injury. -R137 required opioids for pain control due to the pressure injury. -The pressure injury was not assessed weekly, and no documentation was found of the pressure injury being comprehensively assessed. -R137 was sent to the hospital on 11/16/2023 due to unstable vital signs and was admitted with necrotizing fasciitis. Surveyor shared with CNC-F no documentation was found for a comprehensive assessment or a weekly assessment of the pressure injury. CNC-F stated CNC-F had looked for that documentation the day before and did not see any but would look again. On 1/4/2024 at 10:54 AM, CNC-F stated CNC-F was not able to find any comprehensive skin assessments for R137 other than the admission assessment when R137 did not have any skin concerns for pressure injuries. CNC-F stated the DON at that time (November 2023) simply walked out on the job and they did not know if the DON had a wound log at that time; if the DON did have a wound log, they were not able to find it. CNC-F stated the Wound NP was not involved with R137 like NP-J wanted. In an interview on 1/4/2024 at 11:20 AM, Surveyor asked Licensed Practical Nurse (LPN)-E what the facility protocol was for a resident with a new pressure injury. LPN-E stated the staff nurse that discovers the wound gets the measurements and does the Skin Only Evaluation in the computer charting system. LPN-E stated the previous DON wanted to be notified of any new skin concerns, but there have been multiple DON changes, so it was changing all the time. LPN-E stated the current DON wants the nurse on the floor to get a measurement of the wound and let the NP and DON know about it so the DON will look at the area right away and the Wound NP can look at it on Mondays when the Wound NP assesses all wounds except the surgical wounds. In an interview on 1/4/2024 at 1:18 PM, Surveyor asked Registered Dietician (RD)-K how they are notified of residents with pressure injuries. RD-K stated the facility has wound meetings every week, but with the change in management, those meetings were changing all the time. RD-K stated they are starting to get into a routine with wound rounds on Mondays followed by a wound and nutrition risk meeting right after that on Mondays. RD-K stated that started in the last month. RD-K stated they have a new DON, so things have changed with meeting times and days. RD-K stated RD-K gets a list or report on Mondays of all the residents with skin issues; in the past RD-K had to hound them to get that information. Surveyor asked RD-K if RD-K was aware of R137 having a pressure injury. RD-K stated RD-K was not aware of R137 having a pressure injury. RD-K stated RD-K did the initial nutrition assessment upon admission and R137 was eating well so did not order supplements at that time. RD-K stated RD-K reviewed their notes to see if RD-K was ever told of R137's pressure injury and RD-K did not have any notes so was not aware of the pressure injury. In a phone interview on 1/4/2024 at 1:18 PM, Surveyor asked DON-B if DON-B recalled R137, a resident in the facility 10/24/2023-11/16/2023. DON-B denied having any knowledge of R137 because DON-B had just started working at the facility on 11/6/2023. Surveyor shared with DON-B that DON-B had documented in R137's record on 11/8/2023 of a new pressure injury to the sacrum. DON-B did not recall any information regarding R137 and DON-B did not have R137's medical record available for review at that time. Surveyor asked DON-B what documentation would be expected for a resident that sustained a skin tear. DON-B stated the skin tear should be documented in the progress notes and should include a treatment if that was ordered and the notification of the skin tear to the physician and the family. Surveyor asked DON-B if a treatment was ordered, where would that treatment be documented. DON-B stated the treatment would be on the TAR. Surveyor noted the treatment to the skin tear on 10/25/2023 was not entered onto the TAR. Surveyor asked DON-B where a comprehensive assessment would be documented of a new pressure injury. DON-B stated pressure injuries are documented in the Wound Skin Only assessment in the computer charting system. Surveyor asked DON-B how the Wound NP is notified of a resident that has a new pressure injury. DON-B stated either the nurse on the floor or NP-J lets the Wound NP know of a new area. DON-B stated wounds are assessed by the Wound NP weekly and the treatments are done as prescribed. Surveyor asked DON-B who does wound assessments if the Wound NP was not involved with the resident. DON-B stated the in-house NP and the nurse on the floor would look at the wound and document in the Skin Only form in the computer charting system and then DON-B or the nurse manager should document on the wound. Surveyor asked DON-B how the RD is notified of skin issues. DON-B stated the RD is aware of the residents with skin issues at the weekly meeting. Surveyor attempted to interview other staff that cared for R137, but all staff that documented on R137 were no longer employed at the facility. On 1/4/2023 at 1:42 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and CNC-F R137's timeline while at the facility and the concerns no preventive measures were implemented on admission to address R137's immobility and incontinence, development of skin tears with no etiology to prevent future skin breakdown, missing comprehensive assessments of the sacral Unstageable pressure injury, and no Wound NP or RD involvement in R137's care after the development of the pressure injury. R137 was placed on antibiotics for an infected pressure injury and was hospitalized with necrotizing fasciitis. NHA-A and CNC-F agreed no comprehensive assessments were completed, the Wound NP was not involved in R137's care, and RD-K was not informed of R137's pressure injury. No further information was provided at that time. The failure to implement preventive interventions for a resident at risk of developing pressure injuries, determine the etiology of skin tears to the coccyx, comprehensively assess the pressure injury, involve the Wound NP, and notify the dietician of the development of a pressure injury led to serious harm for R137 which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 1/12/24 when they completed the following: A facility skin sweep was completed on 1/8/24. All facility residents who are at risk for the development of pressure injuries had their care plans reviewed and updated as needed. All in facility residents with current skin alterations had their care plans reviewed, had an RN comprehensive skin evaluation, and ensured interventions and treatments are place. The facility including the Medical Director reviewed their Pressure Injury Prevention and Managing Skin Integrity Policy and completed a root cause analysis on 1/8/24. All nurses were educated on the facility's skin prevention policy and procedure. All nurses were educated on pressure relieving interventions for residents identified to be at risk for the development of pressure injuries. All nursing staff were educated on notification process of skin changes to be communicated to resident provider and to clinical leadership who then coordinates with the wound NP, dietitian, and provider as needed. Daily at stand up, DON or designee will review progress notes, risk management and 24 hour boards for any resident alterations of skin integrity. All training was completed by staff before their next working shift. Any nurses who did not complete the competency are not scheduled until the training is completed. Competencies and education were conducted by nursing management and/or a nurse who has passed the competency education and has been designated to give an education. The Interdisciplinary Team (IDT) conduct weekly wound meetings to review the status to include: pressure injury Policy and Procedure compliance with findings report to the Quality Assurance Performance Improvement committee (QAPI). The DON or designee will audit 5 new admission medical records to ensure that the skin policy and procedure is followed weekly X 4, then monthly X 3 with findings reported to QAPI. The deficient practice continues at a scope/severity of G (actual harm/isolated) based on the following examples: 20025 2. R40 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, bipolar, depression, and spinal stenosis and osteoarthritis. R40 was discharged from the facility on 7/28/23. R40 had a Braden Score completed on 3/14/23 which indicated a score of 20, which is not at risk for pressure injuries. R40 had no other Braden Score completed. The admission MDS (Minimum Data Set) dated 3/30/23 indicates R40 needed extensive assistance with bed mobility, transfers, dressing, and hygiene. It also indicates R40 is occasionally incontinent of urine. It also indicates R40 is at risk for pressure injuries, and has no unhealed Pressure injuries. The MDS indicates R40 only has a pressure r [TRUNCATED]

Based on observation, interviews, and record review, the facility did not ensure that residents with an indwelling catheter received the appropriate care and services for 2 of 2 Residents (R181, R4) reviewed for catheters. R181's urinary foley output was not measured consistently and according to the facility policy resulting in a subsequent hospitalization for a change in condition with urinary retention and urosepsis. R4's urinary Foley output was not measured consistently and according to the facility policy, and the Foley bag was not covered for privacy. Findings include: The facility policy, Use of Catheters, dated 8/87, revised 4/15, indicated Drainage Bags: Should always be covered when out of the room or up in a chair. Should be emptied at least one time per shift. 1. R181 was admitted to the facility on [DATE] and discharged to the hospital on 2/16/21 and admitted for urosepsis (urinary infection that travels to the bloodstream and can affect multiple body organ systems). R181 did not return to the facility. R181's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R181's admission progress note on 1/23/21 indicated R181 had an indwelling Foley catheter with urine flowing dark red with both physician and urologist aware. R181's progress note dated 2/9/21 indicated the Foley catheter was pulled during therapy, the head of the penis was swollen with trauma to the inside of foreskin. The NP (Nurse Practitioner) was notified with ice & elevation ordered, Urologist called, R181 was sent to the ER (emergency room ) where R181 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R181's RN progress note dated 2/11/21 indicated a section of the penile shaft had opened and the catheter was visible through the opening, a scant amount of bleeding from foreskin ulceration, and swelling was present. Surveyor noted R181's 2/11/21 progress note indicated the RN nursing supervisor was informed of the opening. There was no follow up to this note from either the RN, NP, or any reference to this in the hospital record. According to DON -B, the RN Supervisor did not conduct an assessment of this area because RN Supervisor thought it was the same issue referenced in the 2/9/21 trauma to the penis. NP indicated to Surveyor she was not made aware of the penile opening. R181's progress note on 2/16/21 indicated a change in condition with R181 being diaphoretic (sweaty), having difficulty answering questions, abnormal Vital Signs 78/62 84-92% oxygenation, pale, with feet blue. R181 was transferred to the ER where R181 was admitted with urosepsis. Surveyor reviewed R181's facility record of urinary output measurements. Multiple dates were noted that R181's urinary output was only measured one time in a 24 period. There was no urinary output documentation noted for several dates including 2/6/21, 2/9/21, 2/13/21, 2/15/21, and 2/16/21. Surveyor reviewed R181's urinary Foley output documentation with DON-B, with missing dates and missing shifts; and DON-B stated her expectation was that urinary output was measured and documented every shift. R181's Hospital Records, dated 2/16/21 indicated very malodorous frank purulence (pus) from R181's Foley catheter that was occluded, removed and new Foley placed with about 2 Liters (2000 ml) of frankly purulent urine output. R181's work-up was suggestive of urosepsis. Surveyor noted R181's urinary Foley output was not measured consistently and according to the facility policy with a subsequent hospitalization for a change in condition with urinary retention and urosepsis. 2. R4 was admitted to the facility on [DATE], transferred to the hospital on 4/22/21, and readmitted on [DATE]. R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/2/21, at 9:25 AM, Surveyor observed R4 without a privacy bag covering his Foley bag which was draining urine. On 6/3/21, at 11:10 AM, Surveyor interviewed DON-B (Director of Nursing) who stated the facility did not have privacy bags for Foleys as the staff searched and did not find one to put a privacy bag for R4. DON-B stated we did not think we had one but the consultant stated the privacy bags had been ordered. DON-B stated all the residents got Foley privacy bags today as we brought them up from central supply. Surveyor interviewed DON-B regarding how often the staff are to empty the Foley bag and measure the urine. DON-B stated the bags needs to emptied and measured every shift and the shifts are 8 hours long. Surveyor reviewed R4's facility record of urinary output measurements. Multiple dates were noted that R4's urinary output was only measured one time in a 24 period. There was no urinary output documentation noted for several dates including 5/7/21, 5/8/21, 5/9/21, 5/10/21, 5/12/21,5/21/21, and 5/26/21. Surveyor reviewed R4's urinary Foley output documentation with DON-B, with missing dates and missing shifts; and DON'-B stated her expectation was that output was measured and documented every shift. Surveyor noted R4's urinary Foley output was not measured consistently and according to the facility policy, and the Foley bag was not covered for privacy. On 6/7/21, at 2:00 PM, Survey team conducted the facility exit and no further information was provided.