Every finding on record at Lindengrove Mukwonago

Based on observation, record review, and interview, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety in 2 of 3 kitchens. *Food Services Manager-U was observed in the main kitchen preparing and handling food without wearing a hair restraint to cover facial hair. *The blender blade was observed not to be thoroughly cleaned and sanitized in the main kitchen between preparation of two puree foods. *Food debris was observed over several days on the main kitchen floor and underneath kitchen equipment in the main kitchen. *A jug of salsa with an open date labeled 6/4/25 was observed with other ready-to-serve condiments in a refrigerator in the main kitchen and was not discarded timely manner. *The refrigerator in a satellite kitchen serving residents was observed to be at 67 degrees Fahrenheit with food and drink items inside of the refrigerator. This deficient practice has the potential to affect all 36 residents who receive food from the main kitchen. Findings include:On 12/8/25 at 8:50 AM, Surveyor conducted an initial tour of the facility's main kitchen with Food Services Manager (FSM)-U. FSM-U stated food for the nursing facility is prepared and stored in the main kitchen then transported to two satellite kitchens classified as rehab kitchen and west kitchen for serving to nursing facility residents. FSM-U stated the facility follows Wisconsin Food Code for safe food practices. The Wisconsin Food Code documents: .food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens.equipment . and utensils shall be clean to sight and touch.facilities shall be cleaned as often as necessary to keep them clean.time/temperature control for safety food shall be maintained . at 41 degrees Fahrenheit or less.1. Hair RestraintsOn 12/8/25 at 8:50 AM, during the initial kitchen tour, Surveyor observed FSM-U walk around the main kitchen while not wearing a hair restraint for exposed facial hair. On 12/8/25 at 11:21 AM, Surveyor observed FSM-U preparing and handling food near the stove in the main kitchen while not wearing a hair restraint for exposed facial hair. On 12/9/25 at 2:03 PM, Surveyor informed FSM-U that Surveyor had several observations of FSM-U not wearing a hair restraint over exposed facial hair. FSM-U stated FSM-U was under the impression no restraint was needed if the facial hair was less than an inch in length. No additional information as to why food was not prepared, distributed, and served in accordance with professional standards for food service safety. 2. Food PreparationOn 12/8/25 at 11:21 AM, Surveyor observed Cook-V prepare puree recipes for cooked pork and cooked squash. After completing the pureed squash, Cook-V stated Cook-V rinsed the blender blade in soap and water. Surveyor observed several bits of squash still present on the blender blade before Cook-V began using the same blender blade to prepare the cooked pork puree. On 12/9/25 at 2:03 PM, Surveyor interviewed FSM-U regarding the expectation for cleaning the blender blade in between preparation of two pureed foods. FSM-U stated the blender blade should be run through the dishwashing machine between preparation of two foods. Surveyor shared concern with FSM-U that Surveyor observed bits of squash still present on the blender blade prior to pork puree being prepared and that Cook-V stated the blender blade was rinsed in soap and water. No additional information as to why food was not prepared, distributed, and served in accordance with professional standards for food service safety.3. Food StorageOn 12/8/25 at 8:50 AM, during the initial kitchen tour, Surveyor observed food debris all over the main kitchen floor and underneath the stove and steamer. On 12/8/25 at 9:00 AM, Surveyor observed an opened jug of salsa in a walk-in cooler in the main kitchen with the opened date documented as 6/4/25 on a label. The jug of salsa was stored with other ready-to-serve condiments. On 12/9/25 at 10:45 AM, Surveyor observed food debris all over the main kitchen floor and underneath the stove and steamer. Surveyor observed the jug of salsa still present in the walk-in cooler in the main kitchen.Surveyor notes the FoodKeeper application by the United States Department of Agriculture Food Safety and Inspection Service, version 9.0.0, build 68, documents for freshness and quality, salsa should be consumed within 1 month if refrigerated after opening.On 12/9/25 at 11:36 AM, Surveyor observed the thermometer on the outside and the inside of the refrigerator in the rehab satellite kitchen read 67 degrees Fahrenheit. Surveyor observed there was no alarm or other alert system indicating the temperature was above the standard temperature of 41 degrees Fahrenheit. Surveyor observed the following contents inside the refrigerator: milk, coffee creamer cups, pudding, Jello, pre-prepared grapes and cut up cantaloupe. Surveyor observed the pudding cups, Jello cups, and coffee creamer cups inside of the refrigerator were not cold to the touch. On 12/9/25 at 11:40 AM, Cook-W arrived at the rehab kitchen and was unaware the refrigerator temperature was 67 degrees Fahrenheit. Surveyor shared concern with Cook-W that the refrigerator temperature was 67 degrees Fahrenheit. Cook-W stated Cook-W checked the temperature in the morning of 12/9/25 and it was documented as 36 degrees Fahrenheit and Cook-W did not know how long the refrigerator was not at the proper temperature. On 12/9/25 at 2:03 PM, Surveyor interviewed FSM-U regarding how long condiments should be stored in the refrigerator or walk-in cooler. FSM-U stated condiments are stored in the cooler and portioned out as needed, and they are typically stored up to 3 months but are usually used before then. Surveyor shared concern with FSM-U that a jug of salsa with opened date 6/4/25 was observed in the walk-in cooler in the main kitchen over several days. FSM-U stated the salsa would be discarded. Surveyor shared concern with FSM-U regarding the rehab kitchen refrigerator being at 67 degrees Fahrenheit, and FSM-U confirmed all contents that were inside of the refrigerator were discarded and maintenance was contacted to work on the refrigerator. Surveyor shared concern with FSM-U that food debris was observed over several days on the main kitchen floor and underneath the stove and steamer. FSM-U stated the daily cleaning list would be revisited and updated as needed. On 12/9/25 at 3:03 PM, Surveyor shared the above concerns with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B.No additional information as to why food was not prepared, distributed, and served in accordance with professional standards for food service safety.

Based on interview and record review the facility did not ensure 4 (R1, R2, R50, & R3) of 4 residents reviewed for hospitalizations were notified of the reason for transfer/discharge and bed hold policy in writing to the resident & their representative. The facility's notice of transfer and bed hold form does not include the Ombudsman's email address. *R1 was admitted to the hospital on [DATE]. R1 and R1's POA did not receive in writing the reason for transfer/discharge and bed hold policy. The Ombudsman was not notified of R1 discharge to the hospital on 9/4/25. *R2 was discharged to the hospital on [DATE] & 10/30/25. R2 and R2's representative did not receive in writing the reason for transfer/discharge and bed hold policy. *R50 was discharged to the hospital on [DATE]. R2 and R2's representative did not receive in writing the reason for transfer/discharge and bed hold policy. *R3 was discharged to the hospital on 5/15/25. R3 and R3's representative did not receive in writing the reason for transfer/discharge and bed hold policy. Findings include: The facility's policy dated as last reviewed 5/2/25 and titled, Individual Transfer and Discharge documents under the Policy section: Ensure the discharge planning process addresses each resident's discharge goals and needs. Under the Procedure section it documents: A. Acceptable conditions for transfer or discharge from the facility includes 4. For medical reasons as ordered by a physician. The facility's policy dated as last reviewed 5/2/25 and titled, Individual Bed Hold documents under the Policy section: The individual, guardian, and/or individual representative will be informed upon admission and/or hospital/therapeutic leave of their bed hold options at the facility. Under Procedure B. Upon transfer to hospital and/or therapeutic leave documents 1. Individual will be informed and receive a copy of the bed hold procedure and letter. 1.) R1's diagnoses includes end stage renal disease (kidneys permanently have lost almost all their ability to function), chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), chronic obstructive pulmonary disease (group of lung disease that block airflow and make it difficult to breath), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), atrial fibrillation (irregular and rapid heartbeat), dementia (loss of cognitive function that interferes with a person's daily life and activities), and anxiety (emotional response involving feelings of worry, dread, and tension often accompanied by physical symptoms like a racing heart or sweating). R1's power of attorney for healthcare was activated on 12/24/23. R1's significant change MDS (minimum data set) with an assessment reference date of 9/18/25 documents a BIMS (brief interview mental status) score of 6, which indicates that R1 has severe cognitive impairment. R1's nurses note dated 9/4/25, at 23:24 (11:24 p.m.), documents: After left shoulder x-ray report confirmed by [Physician's name], new order to send to ER (emergency room) for evaluation of left hip and complete series. POA [Name] notified, request to send to [Hospital initials], [Name] ambulance notified, resident left facility at 16:00 (4:00 p.m.). Daughter notified facility of admit for possible surgery tomorrow. DON (Director of Nursing) and NP (Nurse Practitioner) [Name] notified. R1 was hospitalized from [DATE] to 9/11/25. Surveyor noted a notice of transfer and bed hold for R1 dated 9/4/25. This form included the Ombudsman's phone number and address but did not include their email address. Surveyor noted that R1's bed hold documents under verbal authorization given in person section it indicates: 2. Resident Representative. Surveyor noted that there is no evidence R1 and R1's POA were provided the notice of transfer and bed hold policy in writing. On 12/9/25, at 3:28 p.m., Surveyor interviewed Social Worker-N. Surveyor asked SW-N if she is involved with the bed hold policy when a resident is transferred/discharged to the hospital. SW-N explained that usually when a resident is on their way out the door to the hospital, its nursing who provides transfer/discharge documentation. SW-N informed Surveyor if the resident has been out over midnight, then either herself or admissions will call the family to see what they want. SW-N informed Surveyor the nurse sending the resident to the hospital does the notice of transfer and bed hold form and prints it off. SW-N informed Surveyor they will send the notice of discharge and bed hold form in the mail, the family can come in and get the form and if the resident is their own person they will send one with the resident to the hospital. A Surveyor asked if the Ombudsman is notified. SW-N replied yes, via email. On 12/9/25, at 3:50 p.m., Surveyor asked Registered Nurse (RN)-K what the process is if a resident needs to be transferred to the hospital. RN-K informed Surveyor she would contact the MD (Medical Doctor), update the POA (power of attorney) if required. Surveyor asked RN-K if she completes the notice of transfer and bed hold form. RN-K informed Surveyor RN-K does, usually makes a copy and sends this with the resident. Surveyor asked RN-K if the resident has a power of attorney does she send the form to the resident's POA. RN-K informed Surveyor she doesn't know if she is able to do that. RN-K informed Surveyor it would be verbal and doesn't know if they have any means of receiving it. On 12/10/25, at 8:11 a.m., Surveyor asked RN-J what the process is if a resident needs to be transferred to the hospital. RN-J explained she would assess the patient, ask the patient if they are their own person if she can send them to the hospital, let the doctor and NP (Nurse Practitioner) know. RN-J informed Surveyor if the patient has a POA she will call the POA to ask if it's okay to send to the hospital. Surveyor asked RN-J what paperwork she has to do. RN-J informed Surveyor a medication list, MAR/TAR (medication administration record/treatment administration record), a change in condition form is filled out in the computer, face sheet, code status, sometimes a H & P (history and physical) and any recent labs. Surveyor asked RN-J if she completes the notice of transfer and bed hold form. RN-J replied yes and if they have a POA we have to ask them what they prefer and sometimes the admission staff will help if they know the family. RN-J informed Surveyor she makes a copy of this form and places it with the other paperwork and sends it with the patient if the family hasn't decided whether to hold the bed. Surveyor asked RN-J if this form is sent to the resident's POA to provide this form in writing. RN-J if someone has their email sometimes admissions will help, or they will come in and sign it or give us a verbal saying to hold the bed. On 12/10/25, at 9:02 a.m., a Surveyor interviewed Admissions-O regarding the transfer notice & bed hold policy. Admissions-O informed the Surveyor nursing would complete the notices when a resident goes out to the hospital. Admissions-O stated that Admissions-O usually don't get involved but occasionally if a family has questions or if the social worker calls me and the family has questions about the bed rate or options. On 12/10/25, at 11:37 a.m., Surveyor reviewed the September 2025 discharge list which was emailed to the Ombudsman. Surveyor was unable to locate R1's name on this list. On 12/10/25, at 11:54 a.m., Surveyor showed SW-N the September 2025 discharge list and asked if this was the list sent to the Ombudsman. SW-N replied [Name of Ombudsman] yes. Surveyor asked why R1 who was admitted to the hospital on [DATE] wasn't on the list. SW-N informed Surveyor because she lives here. On 12/9/25, at 3:08 p.m., Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B there is no evidence R1's notice of transfer and bed hold form was provided to R1 and R1's POA when R1 was transferred/discharged to the hospital on 9/4/25. No additional information was provided. 2). R2 was admitted to the facility on [DATE] with diagnoses including displaced bimalleolar fracture of right lower leg (ankle fracture), chronic diastolic (congestive) heart failure, chronic kidney disease stage 3, and depression. R2 was hospitalized on [DATE] until 10/20/25 for revision surgery to the right ankle. Surveyor reviewed R2's electronic health record (EHR) and could not locate a notice of transfer or bed hold notice that was provided to R2 or R2's representative on 10/17/25. Surveyor noted that at the time of transfer, R2 was R2's own person. R2 was hospitalized on [DATE] until 11/3/25 for abnormal vitals and difficulty breathing. Surveyor reviewed R2's EHR and located an electronic version of a notice of transfer and bed hold dated 10/30/25 with verbal consent documented, but no evidence that this information was conveyed in writing to R2 at the time of transfer. Surveyor noted at the time of transfer, R2 was R2's own person. On 12/9/25 at 3:29 PM, Surveyor interviewed Social Worker (SW)-N regarding the process of providing written notice of transfer and bed hold when a resident is transferred to the hospital. SW-N stated the nurse on duty would be responsible for getting the notice of transfer and bed hold to the resident or their representative when a resident is sent to the hospital. SW-N stated the nurse on duty would print the notice and give it to the resident, or if the resident had an activated power of attorney (POA), the notice would be sent in the mail. Surveyor requested evidence that written notice of transfer and bed hold was provided to R2 on 10/17/25 and 10/30/25. On 12/10/25 at 8:43 AM, SW-N informed Surveyor that no bed hold notice or notice of transfer was provided to R2 on 10/17/25, as it was a planned surgery, and the resident was able to return to the facility following the surgery. SW-N stated the electronic notice of transfer and bed hold is in R2's EHR on 10/30/25. Surveyor shared concern with SW-N that the form dated 10/30/25 only documents verbal notification to R2 regarding the bed hold and transfer, and there is no evidence this information was provided to R2 in writing. SW-N did not provide any additional information. On 12/10/25 at 2:18 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the process of providing written notice of transfer and bed hold when a resident is transferred to the hospital. DON-B stated the nurse on duty would start the notice and send the paperwork to the hospital with the resident. DON-B stated if the resident has an activated POA, the facility contacts the POA to let them know of the bed hold rate and confirm if the POA agrees to hold the bed. Surveyor asked DON-B if a notice of transfer and bed hold is provided for a planned hospital stay. DON-B stated a notice of transfer and bed hold would not be issued in this instance. Surveyor shared concern with DON-B that there is no evidence R2 was provided a written notice of transfer or bed hold upon being hospitalized on [DATE], and only verbal notification was provided to R2 upon being hospitalized on [DATE]. No additional information was provided. 3.) R50 was admitted to the facility on [DATE] with diagnoses including encephalopathy (a disturbance of brain function), severe protein-calorie malnutrition, and vascular dementia (dementia caused by reduced blood flow to the brain) with behavioral disturbance. R50 had an activated power of attorney (POA). R50 was hospitalized on [DATE] due to poor intake. Surveyor reviewed R50's electronic health record (EHR) and did not locate a notice of transfer or bed hold notice on 10/14/25. On 12/9/25 at 3:29 PM, Surveyor interviewed Social Worker (SW)-N regarding the process of providing written notice of transfer and bed hold when a resident is transferred to the hospital. SW-N stated the nurse on duty would be responsible for getting the notice of transfer and bed hold to the resident or their representative when a resident is sent to the hospital. SW-N stated the nurse on duty would print the notice and give it to the resident, or if the resident had an activated power of attorney (POA), the notice would be sent in the mail. Surveyor requested evidence that written notice of transfer and bed hold was provided to R50's representative on 10/14/25. On 12/10/25 at 8:43 AM, SW-N informed Surveyor that no written bed hold notice or notice of transfer was located for R50 on 10/14/25. On 12/10/25 at 2:18 PM, Surveyor interviewed Director of Nursing (DON)-B regarding the process of providing written notice of transfer and bed hold when a resident is transferred to the hospital. DON-B stated the nurse on duty would start the notice and send the paperwork to the hospital with the resident. DON-B stated if the resident has an activated POA, the facility contacts the POA to let them know of the bed hold rate and confirm if the POA agrees to hold the bed. Surveyor shared concern with DON-B that there is no evidence R50's POA was provided a written notice of transfer or bed hold upon being hospitalized on [DATE]. No additional information was provided. 4.) R3 was admitted to the facility on [DATE] with diagnoses of History of Urinary Tract Infections, Retention of Urine, and Presence of Urogenital Implants (medical devices or injectable materials used to restore urinary or sexual function). R3's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10, indicating that R3 had moderate cognitive impairment and decision making. The MDS documents that: R3 requires set up assistance to eat and perform oral hygiene; R3 is completely dependent with all cares: toileting, showering, dressing, all other hygiene, changing positions (sit to lay, roll left and right in bed, and sit to stand.); R3 is incontinent of bowel and has a urinary catheter. R3's POAHC (Power of Attorney of Health Care) was activated on 2/24/25. On 5/15/25, at 6:18 PM, a nursing note written by RN-S documented: Patient still lethargic and sleepy. Blood sugar prior to dinner 391 and temperature 101.8. Prn tylenol given and staff attempted to feed patient. Patient ate one bite of dinner and fell back asleep. Updated POA (power of attorney) on patient's status and request to [NAME] hospital. POA in agreement and stated to seen patient to Hospital for evaluation. MD-Q updated and gave order to go to ER. On 5/15/25, at 11:07 PM, a nursing note written by RN-S documented: Ambulance called and report given to RN (registered nurse) at ER (emergency room). DON (Director of Nursing)-B notified. Patient left facility at 2000. Interact transfer form and all paperwork given to EMT's (emergency medical technicians). Surveyor could not located a bed hold and transfer notice in R3's medical record for when R3 was transferred to the hospital on 5/15/25. On 12/9/25, at 3:28 PM, Surveyor interviewed Social Worker (SW)-N who stated that nursing is responsible for sending the behold notice with the patient to the hospital. SW-N stated that she was unaware of where bed hold electronic assessment and hard copies of bed hold goes as it is the nursing department's job to issue the documents. SW-N stated the facility does not send out written bed hold notices to patients who have Medicaid as those patients will have Medicaid automatically pay for the bed hold for 15 days. SW-N stated a written copy of the bed hold notice was not completed or given to R3. On 12/9/25, at 3:49 PM, Surveyor interviewed RN-K who stated nurses send a written copy of the bed hold notice with the patient to the hospital and will get verbal confirmation from the resident or the resident's representative if they would like a bed hold. On 12/10/25, at 9:02 AM, a surveyor interviewed Admissions-O who stated Nursing would complete the bed hold notices when a resident goes out to the hospital, Admissions-O doesn't get involved unless the family has questions. On 12/10/25, at 2:17 PM Surveyor shared the concern of R3 and R3's representative not receiving a written bed hold notice with DON-B and Regional Nurse Consultant (RNC)- Q. No additional information was provided.

Based on interview, observation, and record review, the facility did not ensure 1 (R40) of 2 residents received adequate supervision and assistance devices to prevent accidents.* R40's fall on 11/16/25 was not thoroughly investigated and a root cause was not determined to help prevent further falls. On 12/9/25 & 12/10/25, Dycem was not observed on R40's wheelchair per R40's falls plan of care.Findings include:The facility's policy titled, Falls and last reviewed 5/8/25 documents under the policy section: Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls.R40's diagnoses include dementia (loss of cognitive function that interferes with a person's daily life and activities), hypertension (high blood pressure), and anxiety (emotional response involving feelings of worry, dread, and tension often accompanied by physical symptoms like a racing heart or sweating).R40's annual MDS (minimum data set) with an assessment reference date of 8/27/25 has a BIMS (brief interview mental status) score of 7 which indicates severe cognitive impairment. The MDS documents that: R40 is assessed as being dependent for rolling left and right & toileting hygiene and requiring substantial/maximal assistance for bed/bed to chair transfer and toilet transfer. R40 is frequently incontinent of urine and occasionally incontinent of bowel. R40 has fallen since prior assessment with one fall no injury.R40's fall CAA (care area assessment) dated 9/3/25 documents under the care plan consideration section: CAA triggered for falls due to risk factors resulting from balance problems: Not steady, needs assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer; Resident receives physician ordered anti-depressant medications, Refer to MAR (medication administration record). Resident has fall history. Resident has had one fall without injury during this assessment period, refer to DQI documentation. Nursing staff assists resident with ADLs (activities daily living) as needed according to facility policy. Resident is at risk for fall related injury. No referrals at this time, will proceed to care plan with goal to have no fall related injuries.R40's resident is moderate risk for falls care plan initiated 12/21/23 & revised 8/27/25 documents the following interventions:*Anticipate and meet the resident's needs. Initiated 8/23/24.*Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Initiated & revised 8/23/24.*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 8/23/24.*PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed). Initiated 8/23/24.*Provide reminders for resident to call for assist with transfers from w/c. Lock w/c brakes for resident. Initiated 8/27/24.*Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Initiated 3/21/25.*Ensure that the resident is wearing appropriate footwear\describe correct client footwear i.e. brown leather shoes, tartan bedroom slippers, black non-skid socks) when ambulating, transferring or mobilizing in w/c (wheelchair). Initiated 3/21/25 & revised 3/28/25.*The resident needs activities that minimize the potential for falls while providing diversion and distraction. Initiated 3/21/25 and revised 3/28/25.*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, the bed in low position at night; personal items within reach). Initiated 3/21/25 and revised 3/28/25.*Reminder signs placed in bathroom for resident to call for assist with toilet transfers. Initiated 3/28/25.*Offer recliner after dinner. Initiated 9/10/25.*The resident needs to be evaluated for and supplied\adaptive equipment or devices as needed). And as needed for continued appropriateness and to ensure least restrictive device or restraint. Initiated and revised 9/10/25*Dysem on w/c cushion. Initiated 11/17/25.R40's Visual/Bedside Kardex Report as of 12/10/25 under the resident care section includes Dysem on w/c cushion.R40's fall risk evaluation dated 8/27/25 has a score of 17 which indicates at risk. R40's fall risk evaluation has a score of 13 which indicates at risk.R40's nurses note dated 11/16/25, at 2012 (8:12 p.m.), and written by Licensed Practical Nurse (LPN)-E documents Resident found on floor in-between bed and window leaning up against wheelchair. Call light within reach proper footwear worn. Resident stated: I was trying to sit up and I slipped. No noted injury VSS (vital signs stable) denies pain. Writer CNA (Certified Nursing Assistant) RN (Registered Nurse) assisted resident off floor into wheelchair. [Name] RN nurse supervisor aware updated stated will call POA (Power of Attorney) [Name] to update. [Physician's name] updated.On 12/8/25, at 9:44 a.m., Surveyor observed R40 sitting in a wheelchair in her room. Surveyor observed there is a cushion in R40's wheelchair and R40 is wearing gripper socks on her feet. Surveyor asked R40 how she was doing. R40 stated trying to get warm. Surveyor observed a blanket on R40's recliner chair and asked R40 about the blanket. R40 stated that's for my baby. Surveyor observed a small stuffed dog wrapped in the blanket. On 12/8/25, at 12:55 p.m., Surveyor observed R40 propelling herself in the wheelchair by moving her feet out of the lounge area by the dining room.On 12/8/25, at 3:38 p.m., Surveyor observed R40 propelling herself in the wheelchair by moving her feet out of her room. R40 stated she wants a gown. R40 then stated to Surveyor you want a warm one? I'll look at her boxes another time. On 12/9/25, at 7:17 a.m., Surveyor observed R40 sleeping in bed on her back. Surveyor observed R40's bed is in the low position and the call light is within reach. Surveyor checked R40's wheelchair for Dycem. Surveyor did not observe Dycem on top or under the cushion in R40's wheelchair.On 12/9/25, at 8:07 a.m., Surveyor observed R40 propelling herself in the wheelchair by moving her feet. R40 is wearing gripper socks on her feet. R40 asked Surveyor if she should go down for dinner.On 12/9/25, at 9:48 a.m., Surveyor observed R40 sitting in a wheelchair in her room wearing gripper socks on her feet. R40 informed Surveyor she's waiting for her brother to call.On 12/9/25, at 10:57 a.m., Surveyor observed R40 sitting in a wheelchair facing R40's bed wrapping up items in napkins. Surveyor asked R40 what she was doing. R40 informed Surveyor she's wrapping up two tablespoons, started talking nonsensical, and then stated to Surveyor I haven't' seen my boyfriend since spring.On 12/9/25, at 1:02 p.m., Surveyor observed R40 sitting in the wheelchair in the dining room eating lunch.On 12/10/25, at 8:08 a.m., Surveyor observed R40 sitting in a wheelchair at the dining room table with her head down and appears to be sleeping.On 12/10/25, at 12:38 p.m., Surveyor reviewed the facility's investigation for R40's fall on 11/16/25 which consisted of a three-page incident report dated 11/16/25 20:15 (8:15 p.m.) and neurological flow sheet. The incident report dated 11/16/25 under the incident description section for nursing description documents Resident found on floor in-between bed and window leaning up against wheelchair. Call light within reach proper footwear worn. For resident description documents Resident stated: I was trying to sit up and I slipped. Under notes documents 11/17/25 IDT (interdisciplinary team) met to assess fall; resident slid from w/c. Dysem placed on seat of W/C. Surveyor noted the facility did not conduct a thorough investigation as the facility investigation does not include any staff statements or evidence staff were interviewed, there is no root cause, and there is no evidence prior interventions were in place to prevent this fall from occurring.On 12/10/25, at 1:10 p.m., Surveyor observed R40 sitting in a wheelchair in the area where the medication carts are along the wall outside the dining area.On 12/10/25, at 1:27 p.m., Surveyor asked Certified Nursing Assistant (CNA)-L what she does for R40. CNA-L informed Surveyor she gets her cleaned up, sometimes it takes two staff depending on R40, toilets R40, gets her to the dining room, and R40 goes back on her own to her room to watch TV. CNA-L informed Surveyor R40 needs reminders, we toilet, get R40 ready for bedtime and ready for during the day. Surveyor asked CNA-L how often R40 is toileted. CNA-L replied three times a shift, get up, before and after lunch. Surveyor informed CNA-L Surveyor knows R40 has a cushion in the wheelchair and inquired if she has Dycem. CNA-L replied I think she has a cushion and nothing underneath it. Surveyor asked CNA-L when she would be toileting R40. CNA-L informed Surveyor she will take her now. At 1:30 p.m. Surveyor observed CNA-L inform R40 she's going to take her to her room and to the bathroom. At 1:31 p.m. CNA-L wheeled R40 into her room asking R40 if she wants to try going onto the toilet. R40 asked CNA-L what's that? CNA-L asked do you have to go potty. At 1:33 p.m. CNA-L placed gloves on, removed the foot pedal, and locked the brakes on R40's wheelchair. CNA-L placed a gait belt around R40, asked R40 if she was ready stating going to get on the toilet, ready one, two, three, and stood R40 up. R40 slowly turned with CNA-L's encouragement, CNA-L stated to R40 wait I need to pull down your drawers but R40 sat on the toilet. CNA-L stated to R40 before you go need to stand up, you're on the toilet. CNA-L stood R40 up, pulled down pants & product and R40 sat on the toilet. At 1:37 p.m. CNA-L asked Surveyor if Surveyor wants to look under the cushion and lifted up R40's cushion. Surveyor did not observe dycem on top or under R40's wheelchair cushion per the plan of care.On 12/10/25, at 1:45 p.m., Surveyor informed Director of Nursing (DON)-B the facility did not conduct a thorough investigation as the facility investigation does not include any staff statements or evidence staff were interviewed, there is no root cause, and there is no evidence prior interventions were in place to prevent this fall from occurring. DON-B informed Surveyor she's sure there are staff statements and will look for the staff statements. Surveyor informed DON-B of Surveyor's observations of R40 not having Dycem either on top or under R40's wheelchair cushion. DON-B informed Surveyor she placed the Dycem in R40's wheelchair herself. Surveyor informed DON-B Surveyor did not observe the Dycem and when Surveyor asked CNA-L about the Dycem Surveyor was informed there is a cushion but nothing under.On 12/10/25, at 2:12 p.m., DON-B provided Surveyor with two staff statements. Surveyor reviewed the statements provided. Although the facility obtained staff statements the facility did not conduct a thorough investigation as there is no evidence prior interventions were in place and the facility did not determine a root cause.No additional information was provided as to why R40 did not have Dycem under his wheelchair cushion per R40's plan of care or why the facility did not conduct a thorough investigation as there is no evidence prior interventions were in place and the facility did not determine a root cause for R40's fall on 11/16/25.

Based on observation, interview, and record review, the facility did not ensure 1 (R1) of 1 resident was clinically appropriate to self-administer medications.R1 was observed with a white pill on R1's breakfast tray and approximately four pills in a medication cup on R1's breakfast tray located on the over bed table next to R1. R1 does not have a self-administration assessment. Findings include:The facility's policy dated May 2018 and titled, Self-Administration of Medications documents under the Policy section: In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Under Procedures documents A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process.R1's diagnoses includes end stage renal disease (kidneys permanently have lost almost all their ability to function), chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), chronic obstructive pulmonary disease (group of lung disease that block airflow and make it difficult to breath), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), atrial fibrillation (irregular and rapid heartbeat), dementia (loss of cognitive function that interferes with a person's daily life and activities), and anxiety (emotional response involving feelings of worry, dread, and tension often accompanied by physical symptoms like a racing heart or sweating).R1's significant change MDS (minimum data set) with an assessment reference date of 9/18/25 documents a BIMS (brief interview mental status) score of 6, which indicates severe cognitive impairment.On 12/8/25, at 9:24 a.m., Surveyor observed R1 sitting on the edge of the bed with R1's left leg extended and resting on top of the wheelchair cushion. To the right of R1 is an overbed table with R1's breakfast tray. Surveyor observed laying directly on the breakfast tray is a large white tablet and a medication cup containing approximately 4 tablets. Surveyor asked R1 about the medication on the breakfast tray. R1 stated she (the nursing staff) just left them; I take the big one first.R1's nurses note dated 4/12/25, at 17:05 (5:05 p.m.) and written by Licensed Practical Nurse (LPN)-I documents: Found several meds (medication) in room from this afternoon that resident did not take.R1's physician orders does not include an order for R1 to self-administer medication.Under the assessment section of R1's medical record there is an Assessment for Resident Self-Administration of Medications dated 4/20/25 that is documented as in progress. Surveyor reviewed this assessment and noted this assessment was not started and the entire assessment is blank. Surveyor was unable to locate any other self-administration of medication assessment in R1's medical record.On 12/9/25, at 11:12 a.m., Surveyor asked Registered Nurse (RN)-M where Surveyor would be able to find a self-administration assessment. RN-M informed Surveyor this is something the nurse practitioner may have to do. RN-M informed Surveyor she has asked the nurse practitioner in the past if it's okay for R1 to self administer medication. RN-M informed Surveyor she doesn't think there is one, referring to a resident's self-administration of medication assessment. LPN-H, who was also in the vicinity, informed Surveyor she thinks there is a medication administration assessment for R1. On 12/9/25, at 11:14 a.m., Surveyor asked RN-M if R1 can self-administer her medication. RN-M replied R1 does not.On 12/9/25, at 11:27 a.m., Surveyor asked Director of Nursing (DON)-B if self-administration of medications assessments are completed on residents who request to administer their own medication. DON-B replied we do for specific indications. Surveyor asked DON-B what she means by specific indications. DON-B explained if there is a new admission who wants to take their own medication, they would do an assessment, but assessments aren't done for every single patient. Surveyor asked DON-B if R1 can self-administer her own medication. DON-B replied no. DON-B informed Surveyor once in a while R1 asks the nurse to leave the bigger white pill and that R1 will take a few bites of her food and take the medication. DON-B informed Surveyor the nurse will go back to make sure she has taken the medication. Surveyor informed DON-B of Surveyor's observation of a large white tablet on R1'breakfast tray along with a medication cup containing four pills. Surveyor informed DON-B there is not a self-administration assessment for R1 to self-administer her own medication.After Surveyor spoke with DON-B, Surveyor noted an order with an order date of 12/9/25 that documents: Do not leave residents medication at the bedside, continue to reproach resident until she is willing to take medications. Every shift for consistent med management.No additional information was provided.

Based on interview and record review the facility did not ensure 1 (R1) of 1 resident have consistent pre & post dialysis communication and are monitored for complications for residents whom receive dialysis treatments. Findings include:The facility's policy dated as last reviewed 8/7/25 and titled, Dialysis documents under the Policy section: The care for a individual receiving dialysis will be coordinated and communicated between the Skilled Nursing Facility (SNF) and the relevant dialysis staff. Under the Procedure section it documents: A. An individual Care Plan will be developed/revised in the SNF in collaboration with information provided by the relevant dialysis facility. Individual record will reflect up to, and including: 1. Identified of individualized risk factors and potential complications related to dialysis; 2. Choices or preferences including advanced directives if any; 3. Medical status including status of comorbid conditions, frequency of vital signs, weights, and monitoring of fluids as ordered:.B. Individual record will reflect the coordination and collaboration with the relevant dialysis facility including exchange of pertinent information before, during, and post dialysis including emergency protocol contaction sic (contact) information.R1's diagnoses includes end stage renal disease (kidneys permanently have lost almost all their ability to function), dependence on renal dialysis, dementia (loss of cognitive function that interferes with a person's daily life and activities), and anxiety (emotional response involving feelings of worry, dread, and tension often accompanied by physical symptoms like a racing heart or sweating).R1's significant change MDS (minimum data set) with an assessment reference date of 9/18/25 has a BIMS (brief interview mental status) score of 6 which indicates severe cognitive impairment.R1's resident needs dialysis hemodialysis r/t (related to) renal failure care plan initiated 12/21/23 and revised 11/23/25 documents the following interventions:*Do not draw blood or take B/P (blood pressure) in arm with graft. Initiated 12/21/23.*Encourage resident to go to the scheduled dialysis appointments. Resident receives dialysis M-W-F (Monday-Wednesday-Friday), chair time 1200 (12:00 p.m.). Initiated & revised 12/21/23.*Monitor dry skin and apply lotion as needed. Initiated 12/21/23.*Monitor labs and report to doctor as needed. Initiated 12/21/23.*Monitor/document/ report PRN (as needed) for s/sx (signs/symptoms) of renal insufficiency: changes in level of consciousness, changes in skin tugor, oral mucosa, changes in heart and lung sounds. Initiated 12/21/23.*Monitor/document/report PRN new/worsening peripheral edema. Initiated 12/21/23.Surveyor noted R1's dialysis care plan does not include an intervention to monitor R1's access site for complications such as bleeding.R1's physician orders include an order with an order date of 9/11/25 of Resident has dialysis M-W-F (Monday-Wednesday-Friday), make sure dialysis binder is sent with resident. In the morning every Mon, Wed, Fri.Surveyor reviewed R1's November 2025 & December 2025 TAR (treatment administration record) and noted on each dialysis day R1's physician order to make sure dialysis binder is sent with resident is checked & initialed as being completed.R1's physician orders date of 9/12/25 document: Send a bag lunch with resident on dialysis days, chart refusals if resident declines to take the lunch with her. In the morning every Mon, Wed, Fri send bag lunch to dialysis, M-W-Fri, chart refusals.On 12/8/25, at 9:24 a.m., Surveyor observed R1 sitting on the edge of the bed with R1's left leg extended and resting on top of the wheelchair cushion. Surveyor asked R1 if she has any plans for today. R1 informed Surveyor she has dialysis.On 12/8/25, at 10:04 a.m., Surveyor observed R1 being wheeled out of her room by a Certified Nursing Assistant (CNA). R1is wearing a coat & an blanket is covering R1's lap & legs.On 12/8/25, at 3:45 p.m., Surveyor observed R1 sitting in a wheelchair with her coat on outside the nursing office by the counter.On 12/9/25, at 9:53 a.m., Surveyor asked Registered Nurse (RN)-M where Surveyor would be able to locate R1's dialysis binder. RN-M informed Surveyor she's not sure and then went to ask Licensed Practical Nurse (LPN)-H. On 12/9/25, at 9:54 a.m., RN-M stated to Surveyor I'll check her room as I don't see it in here, referring to the nursing office. Surveyor observed LPN-H checking the cabinets where the counter is.On 12/9/25, at 9:55 a.m., LPN-H informed Surveyor she not finding R1's binder and saw it a couple weeks ago.On 12/9/25, at 9:56 a.m., RN-M provided Surveyor with R1's dialysis binder informing Surveyor the binder was in R1's room.On 12/9/25, at 9:57 a.m., Surveyor reviewed the white dialysis binder provided by RN-M. Surveyor noted the outside of the binder is labeled 2024 [R1's name] Dialysis Communication Binder. Surveyor noted there are multiple blank dialysis/nursing facility communication forms in the binder. The top portion has instructions which indicates the nursing facility completes the top portion of the form prior to resident's dialysis treatment and sends with resident for each treatment. The top portion includes name of facility, facility address, facility telephone number, weight, vital signs, labs, etc. The bottom portion is completed by the dialysis unit at the end of treatment. A copy is for the dialysis record and the original is sent back to the nursing facility. Surveyor noted there are no forms for 2025. There are two sheets for 2024. For one sheet the top portion was not completed by the nursing facility and the bottom portion of the form was completed by the dialysis center with a date of 11/13/24. The second sheet has only the facility name, address, and phone number completed on the top portion of the form and the bottom section was completed by the dialysis center with a date of 1/17/24.On 12/9/25, at 10:10 a.m., Surveyor asked RN-M where R1's dialysis communication sheets for 2025 would be as R1's dialysis binder only has two sheets from 2024. RN-M informed Surveyor she didn't know. Surveyor asked RN-M if there is a nursing manager for the unit. RN-M informed Surveyor the first name of Director of Nursing (DON)-B.On 12/9/25, at 10:13 a.m. Surveyor asked RN-M how they communicate with the dialysis center for R1. LPN-H, who was with RN-M, stated sometimes the dialysis center gives us a call. If we need to give an update, we call the dialysis center like when R1 was hospitalized . RN-M informed Surveyor they also call for any medication changes. LPN-H informed Surveyor they don't call the dialysis center every Monday, Wednesday, and Friday. Surveyor asked where Surveyor would be able to locate monitoring for complications with R1's fistula. LPN-H replied probably progress notes. RN-M stated there isn't a specific place so probably nurses notes.During R1's record review, Surveyor did not note monitoring for complications of R1's fistula in the nurse's notes.On 12/9/25, at 10:16 a.m., Surveyor asked DON-B how the facility communicates with the dialysis center for R1. DON-B informed Surveyor R1 has a binder that goes back and forth with R1 and by phone call. The dietitian communicates with the dialysis center for weights. Surveyor asked DON-B what's in the binder. DON-B replied pretty much charting by exception explaining there is a place where the nurses can write vitals and labs. DON-B informed Surveyor this is only completed if there is something out of the ordinary, they (the dialysis center) need to know about. Surveyor asked DON-B where Surveyor would be able to locate monitoring for complications of R1's fistula such as bleeding. DON-B informed Surveyor it would be in R1's TAR. Surveyor asked DON-B if she could look at R1's TAR to see if the monitoring is documented. DON-B reviewed R1's TAR and stated to Surveyor it's not in the TAR. DON-B informed Surveyor she doesn't have an answer right this minute and she's trying to see if it fell off when R1 went to the hospital. DON-B informed Surveyor she will put it in right now. Surveyor informed DON-B R1's dialysis binder Surveyor was provided with only had two communication sheets from 2024. Surveyor informed DON-B Surveyor is unable to locate communication between the facility and the dialysis center for R1. There is no monitoring of R1's fistula for complications such as bleeding in R1's MAR/TAR (medication administration record/treatment administration record) or any where else in R1's medical record. R1's care plan does not address complications of R1's fistula. After Surveyor spoke with DON-B, Surveyor noted an order with an order date of 12/9/25 of Monitor dialysis site for s/sx (signs/symptoms) of infection or bleeding daily left arm every shift for bruit and thrill. R1's dialysis care plan was also revised to include an intervention to Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage initiated 12/9/25.On 12/10/25, at 9:45 a.m., DON-B informed Surveyor the binder Surveyor asked about is not how they communicate with the dialysis center. DON-B informed Surveyor they email them, they call, we call, that is the most preferred method. DON-B informed Surveyor their dietitian meets with dialysis once a month. DON-B informed Surveyor the binder has the risk to get lost and a phone call is the best outcome when they need to talk about R1. DON-B informed Surveyor she did print some communication the facility did with the dialysis center and provided these to Surveyor. Surveyor reviewed the information provided by DON-B and noted a nurses notes dated 10/20/25, 9/23/25, & 9/12/25. Nutrition/Dietary notes written by the dietitian with communication to the dialysis center dated 11/11/25, 10/14/25, 9/25/25, 9/22/25, 8/26/25, 7/14/25, 7/10/25, 7/8/25, 4/22/25, 6/7/24, 3/25/23, and 3/16/23. There is a nutritional note from the dialysis center dated 11/10/25 & a home medication reconciliation from the dialysis center dated 11/17/25.Surveyor informed DON-B prior to providing Surveyor with this information Surveyor did note multiple notes from the dietitian. Surveyor informed DON-B there is a physician order regarding a binder and the communication sheets inside this binder if completed provide assessment prior to and after treatment. Surveyor informed DON-B the facility was not monitoring for complications for R1's fistula.No additional information was provided.

Based on interview and record review, the facility did not ensure 1 (R2) of 16 residents reviewed for advanced directives had wishes clearly documented in the medical record.R2 did not have a current physician's order clarifying code status and R2's electronic medical record did not specify code status. Findings include:The facility policy titled Code Status with initial approval date of 2/8/17 and review date 5/8/25 documents: Policy: facilities will discover, maintain, and execute a (sic) individual's code status by following the documented wishes of each individual. if an individual wishes to be a Do-Not-Resuscitate (DNR), the individual's wishes will be maintained: provider signed DNR order, within the medical record, on a State DNR form, by wearing a facility approved DNR bracelet. if a (sic) individual does not wish to maintain their DNR bracelet, the Risk Agreement will be reviewed with the individual and/or individual representative. This choice will be documented in the care plan. staff will identify a (sic) individual's code status by: identification of a DNR bracelet on the individual, documentation within the medical record. the individual's medical record will be the primary reference in case of an emergency to verify code status. R2 was admitted to the facility on [DATE] with diagnoses including displaced bimalleolar fracture of right lower leg (ankle fracture), chronic diastolic (congestive) heart failure, chronic kidney disease stage 3, and depression. R2 had an activated power of attorney (POA). Surveyor reviewed R2's electronic medical record (EMR) and located a signed State DNR form by R2's POA dated 11/8/25 in the documents section. Surveyor noted the top portion of R2's EMR did not indicate code status as Surveyor had noted in other residents' EMR. Surveyor noted under the order tab in R2's EMR, R2's physician orders did not include a current order for DNR. On 12/9/25 at 3:25 PM, Surveyor interviewed Registered Nurse (RN)-S regarding how a resident's code status is determined in the event of an emergency. RN-S stated the resident should have a bracelet on their wrist, otherwise the code status should be written in their medical record under their name and there should be a physician order confirming the resident's code status. Surveyor reviewed R2's medical record with RN-S, and RN-S confirmed R2's medical record does not list R2's code status under R2's name, and there is no physician order confirming R2's code status. On 12/9/25 at 3:41 PM, Surveyor interviewed Social Worker (SW)-N regarding resident code status. SW-N stated upon admission, nursing staff asks a resident their preferred code status, a facility and state form is filled out and scanned into the resident's EMR, and a physician order is obtained. Surveyor shared concern with SW-N that R2's medical record did not specify R2's code status and no physician order was located stating R2 is DNR status. SW-N stated SW-N would look into this concern. On 12/9/25 at 3:47 PM, Surveyor shared concern with Director of Nursing (DON)-B that R2's medical record did not specify R2's code status and no physician order was located stating R2 is DNR status. DON-B reviewed R2's medical record and confirmed R2's code status is not specified underneath R2's name and there is no current physician order stating R2 is DNR status. DON-B located a discontinued physician order in R2's EMR documenting DNR status and confirmed this order was discontinued on 11/27/25. DON-B stated DON-B was not sure why this order was discontinued and would put in a new order. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure residents with a pressure injury, or those at risk for pressure injuries, received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 2 (R8, R21) of 4 residents reviewed for pressure injuries from a sample of 12. *R8 developed a pressure injury to the right inner ankle on 1/31/25, which progressed to a stage 3 pressure injury and became infected on 11/19/25 resulting in R8 having pain at the wound and requiring 2 antibiotics to treat the infection. R8 was assessed to be a high risk for developing pressure injuries. R8's care plan was not revised with alternative interventions when R8's right inner ankle wound progressed to an unstageable pressure injury. R8's ankle pressure injury was not always accurately assessed to identify the correct staging. *R21 developed a pressure wound to the right gluteus on 11/27/25, which was not comprehensively assessed by a Registered Nurse (RN) until 12/7/25, and R21's care plan was not revised to include interventions relating to the new pressure wound. Findings include: The facility's policy and procedure titled, Pressure Injury Prevention and Managing Skin Integrity with initial approval date 2/8/17 and reviewed date 5/8/25 documents . I. Policy: prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedure:1. Risk Assessmenta. 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 [NAME]. Identify interventionsi. 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 .b. Care Plani. In developing a plan of care, the following will be considered:1. Individual pressure injury history .5. risk for pressure ulcer development (Braden Scale)3. Skin Checksa. 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 Roundsa. 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. b. Registered Nurse (RN) or designee will:i. Conduct weekly skin evaluation.ii. Update the (PCP) (Primary Care Physician) with any decline in wound appearance, or as necessaryiii. Update the Care Plan with any new interventions as applicableiv. Update Individual Representative as indicated . The National Pressure Injury Advisory Panel (NPIAP) document titled, NPIAP Staging for Lightly Pigmented Skin dated 2/14/2020 defines a pressure injury as localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The document defines the following stages:Stage 2: partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough (yellowish/tan stringy or moist tissue) and eschar (hard, dead scab or crust of tissue) are not present. Stage 3: full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location . if slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Unstageable Pressure Injury: full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. 1) R8 was admitted to the facility on [DATE] with diagnoses including other specified disorders of brain, unspecified dementia, anemia (a blood condition with lack of healthy red blood cells to carry oxygen to body tissues), hypertensive heart disease with heart failure (long-term high blood pressure leading to heart weakness), other chronic pain, nonrheumatic aortic (valve) stenosis (narrowing of the heart's main exit valve leading to the heart working harder to push blood through the body), adult failure to thrive, and unspecified diastolic (congestive) he R8's admission skin assessment dated [DATE] documents bruising at the right and left antecubital (elbow) region, redness at the coccyx (tailbone), and a scab at the front left lower leg. R8's admission Minimal Data Set (MDS) dated [DATE] documents no current pressure ulcers and R8 is at risk for pressure ulcers. R8 has been enrolled in hospice services since 7/4/24. R8's potential for impairment to skin integrity care plan with an initiated date of 6/30/2024 documents the following interventions initiated 6/30/24:-Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin.-Follow facility protocols for treatment of injury. -Identify/document potential causative factors and eliminate/resolve where possible. -Keep skin clean and dry. Use lotion on dry skin.-Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Surveyor notes there are no pressure injury prevention interventions addressing turning, repositioning, or offloading R8's heels. The pressure injury Care Area Assessment (CAA) dated 7/11/24 documents CAA triggered for potential pressure ulcer due to need for extensive assistance with bed mobility, refer to ADL documentation. Further complicated by incontinent of urine and bowel. [R8] does not currently have a pressure ulcer or history of pressure ulcers, refer to admission assessment and weekly skin assessment documentation. [R8] is at risk for skin breakdown. R8's Braden Scale assessment dated [DATE] documents a score of 12.0 indicating high risk for pressure injury developmentR8's Braden Scale assessment dated [DATE] documents a score of 12.0 indicating high risk for pressure injury development. The physician order dated 7/5/24 documents Magic Cup in the evening for weight support, please provide Thrive. The physician order dated 9/22/24 documents Ensure Clear three times a day for supplement. A skin note dated 7/19/24 documents no reported skin issues, air mattress for skin protection. Surveyor notes there was no physician order for use of an air mattress and R8's care plan was not revised to include this intervention. The physician order dated 10/9/24 documents apply heel boots to right heel for protection. Chart refusals every shift. This order documents a discontinue date 1/5/25. Surveyor notes the physician ordered right heel boot was not added to the care plan at this time. R8's Treatment Administration Record (TAR) for December 2024 documents R8 refused to wear heel boot to the right heel 6 times between the dates of 12/1/24-12/31/24. R8's TAR for January 2025 documents R8 refused to wear heel boots the right heel 1 time between the dates of 1/1/25 and 1/5/25. The physician order dated 1/5/2025 documents apply heel boots for protection. Chart refusals. Surveyor notes this order does not specify when the heel boots should be applied such as in bed and when up in broda chair, or duration the heel boots should be applied. R8's TAR for January 2025 documents R8 refused to wear heel boots 6 times between the dates of 1/5/25-1/31/25. R8's quarterly MDS dated [DATE] documents R8 does not have a pressure ulcer/injury and is at risk for pressure ulcers. The MDS documents R8 does not have any range of motion impairments in the upper or lower extremities, and R8 is dependent for activities of daily living, bed mobility, and transfers. The MDS documents R8 has a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. A nursing progress note dated 1/11/25 documents [R8] is alert and oriented x1-2, able to make occasional needs known. Appetite fair and accepts protein supplements. On scheduled Tylenol, lidocaine patch, and fentanyl patch for pain. Requests PRN (as needed) morphine occasionally for additional pain. Heel boots and skin prep orders for protection, has air mattress for protection. R8's care plan for risk for malnutrition related to low Body Mass Index (BMI) for population, variable/low intake, unintended weight changes was revised 1/17/25 to include a new goal for [R8] to maintain adequate nutritional status as evidenced by maintaining weight within usual baseline weight of 110 pounds, no signs/symptoms of malnutrition, and consuming at least 50% of meals daily. A nursing progress note dated 1/31/25 documents: noted to have red intact fluid filled blister to right inner foot. Pain with assessment. Skin prep applied. Heel boots on in bed. Had gripper socks on when in Broda (a specific type of wheelchair); the wound is described as length 0.9 centimeters (cm), width 1.2 cm, tissue: painful and mushy. A new treatment order with start date of 1/31/25 documents apply skin prep every evening to intact blister to right inner foot. R8's TAR documents this treatment was administered on 2/1/25, 2/2/25, 2/3/25, 2/4/25, 2/5/25, 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/10/25, 2/12/25, and 2/13/25 until the order was discontinued on 2/14/25. Surveyor notes R8's care plan was not revised to include interventions of turning, repositioning or offloading R8's heels to promote healing. R8's weekly wound assessment dated [DATE] documents a blister to R8's right inner ankle measuring 15 millimeters (mm) (1.5 cm) long x 15 mm (1.5 cm) wide and is described as 100% scab. Surveyor notes there is no change to R8's right inner ankle treatment or changes to the care plan to promote healing when the area was assessed to be 100% scabbed. A new treatment order with start date 2/15/25 documents apply skin prep every evening to right inner foot scabbed blister. R8's TAR documents this treatment was administered on 2/15, 2/16, and 2/17 until the order was discontinued on 2/18/25. Surveyor notes this is the same treatment ordered on 1/31/25 when the right ankle blister was identified. A nurses note dated 2/15/25 documents [R8's] appetite varies but generally adequate, accepts supplements. Pain is controlled with lido (lidocaine), Fentanyl, scheduled Tylenol. At times takes PRN MSO4 (morphine) and/or Ativan. R8's weekly wound assessment dated [DATE] documents a blister to R8's right inner ankle measuring 15 mm (1.5 cm) long x 10 mm (1.0 cm) wide and is described as 100% scab. R8's potential for impairment to skin integrity care plan with an initiated date of 6/30/2024 and revised date of 2/19/25 documents the following interventions were added 2/19/25:-air mattress on bed-Broda chair for comfort, elevate BLE (bilateral lower extremities)-prevlon (sic) boots on feet when in bed Surveyor notes heel boots were ordered on 1/5/25 and the air mattress was documented as being in place on 1/11/25 with R8's care plan revision occurring on 2/19/25. R8's TAR for February 2025 documents R8 refused to wear heel boots 13 times between the dates of 2/1/25-2/28/25. Surveyor notes an additional order was added to R8's TAR with a start date of 2/18/25 documenting heel boots to be worn in bed and in Broda every shift for protection of pressure areas. R8's TAR documents 1 refusal between the dates of 2/1/25-2/28/25. No refusals were documented under this treatment in the months of March or April and this treatment order was discontinued on 4/3/25. A new treatment order with start date of 2/21/25 documents apply skin prep every evening shift every 3 days to right inner mid-foot scabbed blister, monitor for s/sx (signs/symptoms) of infection. R8's TAR documents this treatment was administered as ordered with no refusals between the dates of 2/21/25-3/25/25 when the order was discontinued. R8's weekly wound assessment dated [DATE] documents the wound to R8's right inner foot is a stage 2 pressure injury, 100% scab, and measures 10 mm long x 8 mm in size wide. Surveyor notes this is the first instance the wound is classified as a stage 2 pressure injury instead of a blister. On 12/10/25 at 12:48 PM, Surveyor interviewed Wound RN (Registered Nurse)-C regarding why R8's wound was classified as a stage 2 pressure injury on 2/23/25. Wound RN-C replied it was classified as a stage 2 pressure injury since it was more significant than a stage 1 Wound RN-C did not state why the wound would not be considered unstageable as the area was assessed with 100% scab Wound RN-C confirmed R8's wound was considered a pressure injury due to its location over a bony prominence. Surveyor asked Wound RN-C what interventions are typically implemented for a resident at risk for developing a pressure injury. Wound RN-C replied heel boots would typically be utilized for a resident at risk of pressure injury even if there are no current open areas and risk would be determined by a resident assessment and Braden Scale score. Surveyor shared concern with Wound RN-C that R8's care plan did not have the intervention for heel boots until 2/19/25, after the initial blister developed on R8's right inner foot. Wound RN-C was not sure why those interventions were not in the care plan when the boots had been ordered prior to this date. A nursing note dated 3/1/25 documents [R8] refused bath today, skin checked over, no new skin issues identified. Pain is controlled with lido, Fentanyl, scheduled Tylenol. At times takes PRN MSO4 (morphine) and/or Ativan. Air mattress for skin protection, heel boots in bed. R8's weekly wound assessment dated [DATE] documents a stage 2 pressure injury to R8's right inner ankle measuring 5 mm (0.5 cm) long x 8 mm (1.5 cm) wide and is described as 100% scab. R8's weekly wound assessment dated [DATE] documents a stage 2 pressure injury to R8's right inner ankle measuring 5 mm (0.5 cm) long x 8 mm (1.5 cm) wide and is described as 100% scab.R8's weekly wound assessment dated [DATE] documents the wound to R8's right inner foot is a stage 2 pressure injury, has granulation tissue and scant serosanguinous (pinkish, watery fluid) drainage, and measures 10 mm long x 10 mm wide in size. Surveyor notes the percentage of granulation tissue was not specified in this assessment and the pressure injury has doubled in size. In an interview on 12/10/25 at 12:48 PM, Wound RN-C confirmed R8's wound first opened on 3/25/25 resulting in drainage and a new treatment was started. A physician order dated 3/25/25 documents apply Medihoney Wound & Burn Dressing External Paste to right medial (inner) foot topically in the evening every 3 days for pressure area, cover with foam dressing, monitor for s/x (signs/symptoms) of infection. R8's TAR documents this treatment was administered as ordered between the dates of 3/25/25-8/12/25 and no refusals of this treatment were documented during this timeframe. R8's TAR for March 2025 documents R8 refused to wear heel boots 11 times between the dates of 3/1/25-3/31/25. R8's care plan was updated 3/28/25 to include care area: [R8] has a behavior problem, often refuses to wear heel boots related to comfort or being too hot. The following interventions initiated 3/28/25: -if reasonable, discuss the resident's behavior. Explain/reinforce why heel boots are needed for wound healing and skin protection as appropriate. Surveyor notes R8 has a diagnosis of dementia and a BIMS score of 00 indicating R8 is severely cognitively impaired. R8's weekly wound assessment dated [DATE] documents a stage 2 pressure injury to R8's right inner ankle measuring 8 mm (0.8 cm) long x 10 mm (1.0 cm) wide and is described as small intact scab. R8's weekly wound assessment dated [DATE] documents a stage 2 pressure injury to R8's right inner ankle measuring 4 mm (0.4 cm) long x 5 mm (0.5 cm) wide and is described as 100% scab but lists granulation tissue is present. Surveyor notes the percentage of granulation tissue is not specified in this assessment. R8's weekly wound assessment dated [DATE] documents a stage 2 pressure injury to R8's right inner ankle measuring 4 mm (0.4 cm) long x 5 mm (0.5 cm) wide and is described as 100% scab but lists granulation tissue is present. Surveyor notes the percentage of granulation tissue is not specified in this assessment. R8's weekly wound assessment dated [DATE] documents the wound to R8's right inner foot as a stage 3 pressure injury, noted to be worsening with 80% slough present, scant serosanguinous drainage, and measures 6 mm (0.6 cm) long x 6 mm (0.6 cm) wide. Surveyor notes this is the first instance the wound is classified as a stage 3 pressure injury. In an interview on 12/10/25 at 12:48 PM, Wound RN-C stated Wound RN-C is not sure why the wound worsened to a stage 3 and confirmed R8 did not typically refuse any treatments. Surveyor notes no care plan revisions or new interventions were added after the progression of R8's wound to a stage 3 pressure injury. R8's TAR for April 2025 documents R8 refused to wear heel boots 12 times between the dates of 4/1/25-4/30/25. A physician order dated 5/3/25 documents check placement of right medial foot dressing each shift. Change dressing if missing or soiled with a discontinued date 6/13/25. An updated order dated 6/13/25 documents monitor right medial foot dressing each shift for intactness, monitor for s/sx (signs/symptoms) of infection. R8's TAR documents this task administered as ordered with no documented instances of the dressing not being intact or any signs or symptoms of infection. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 50% slough, granulation tissue present but no percentage specified, with scant serosanguinous drainage, measuring 6 mm (0.6 cm) long x 6 mm (0.6 cm) wide. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with slough in center of wound but no percentage specified, granulation tissue present but no percentage specified, measuring 5 mm (0.5 cm) long x 5 mm (0.5 cm) wide. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 40% slough, granulation tissue present but no percentage specified, with scant serosanguinous drainage, measuring 6 mm (0.6 cm) long x 6 mm (0.6 cm) wide. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 40% slough, scant serosanguinous drainage, measuring 5 mm (0.5 cm) long x 5 mm (0.5 cm) wide. R8's TAR for May 2025 documents R8 refused to wear heel boots 5 times between the dates of 5/1/25-5/31/25. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 100% slough, small serous drainage, measuring 8 mm (0.8 cm) long x 8 mm (0.8 cm) wide. The wound was noted with bright red periwound and to be tender to the touch. A medical professional note dated 6/2/25 documents no calf tenderness, no edema (swelling), right medial ankle wound with slough at base, mild periwound erythema, no odor or purulent drainage. Continue topical treatment and monitor. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 90% slough, scant serous drainage, measuring 8 mm (0.8 cm) long x 8 mm (0.8 cm) wide. No signs/symptoms of infection documented. R8's TAR for June 2025 documents R8 refused to wear heel boots 2 times between the dates of 6/1/25-6/13/25. A new physician order dated 6/13/25 documents heel protector boots BLE (bilateral lower extremities) when in bed. Chart refusals, if refuses float heels on pillows. R8's TAR for June 2025 documents R8 refused to wear heel boots 1 time between the dates of 6/13/25-6/30/25. Surveyor notes the order now offers an alternative to float the heels on a pillow if R8 refuses the heel protector boots. Surveyor notes R8's care plan is not revised to include this intervention. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 90% slough, small serous drainage, measuring 6 mm (0.6 cm) long x 6 mm (0.6 cm) wide. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with epithelial tissue, granulation tissue, and slough but no percentages specified of each tissue type, measuring 5 mm (0.5 cm) long x 3 mm (0.3 cm) wide. R8's risk for malnutrition care plan was revised on 7/13/25 to include focus area pressure area to right ankle, healing potentially impacted by decline in condition and variable poor PO (by mouth) intake. The following intervention was initiated on 7/15/25:-provide and serve supplements as ordered: 240 ml (milliliters) Boost Breeze TID (three times per day) and Thrive Gelato (or Magic Cup) QD (daily). A nutrition/dietary note dated 7/14/25 documents stage 3 pressure are to right inner ankle showing improvement per 7/7/25 weekly skin report, area measures 0.5 cm x 04 cm, treatment in place. Continues to receive Ensure Clear TID (three times per day) and Magic Cup one time per day for added calories and protein. Healing and weight impacted by end of life/hospice care and primary goal of comfort. R8's TAR for July 2025 documents R8 refused to wear heel boots 4 times between the dates of 7/1/25-7/31/25. There is no documentation to support if R8 agreed to float her heels when she refused to wear the heel boots. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 80% slough, scant serosanguinous drainage, measuring 4 mm (0.4 cm) long x 3 mm (0.3 cm) wide. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle with 80% slough, scant serous drainage, measuring 5 mm (0.5 cm) long x 4 mm (0.4 cm) wide. A new treatment order with a start date of 8/15/25 documents apply Medihoney Wound and Burn Dressing External Paste to right medial foot topically in the evening every 3 days for pressure area, cover with foam dressing, monitor for s/x (signs/symptoms) of infection. R8's TAR documents this treatment was administered as ordered through 9/22/25 with no documented refusals of this treatment in this timeframe. R8's weekly wound assessment dated [DATE] documents R8's right inner foot as a stage 2 pressure injury with 80% slough present, scant serous (clear) drainage, and measures 5 mm (0.5 cm) long x 3 mm (0.3 cm) wide. Surveyor notes the facility back staged R8's right ankle pressure injury to a stage 2. In an interview on 12/10/25 at 12:54 PM, Wound RN-C confirmed a wound with slough present should be staged at a stage 3 and confirmed R8's wound assessment dated [DATE] did not have the accurate staging. A new physician order with start date of 8/20/25 documents maintain enhanced barrier precautions for wound. R8's weekly wound assessment dated [DATE] documents a stable stage 3 pressure injury to R8's right inner ankle measuring 1.3 cm long x 1.1 cm wide. Surveyor notes no percentage of tissue present specified. R8's TAR for August 2025 documents R8 refused to wear heel boots 2 times between the dates of 8/1/25-8/31/25. There is no documentation to support if R8 agreed to float her heels when she refused to wear the heel boots. R8's weekly wound assessment dated [DATE] documents a stable stage 3 pressure injury to R8's right inner ankle measuring 1.4 cm long x 1.2 cm wide. Surveyor notes no percentage of tissue present specified. A medical professional note dated 9/2/25 documents nursing staff noted redness around right ankle wound. Pt (patient) complaining of pain to the area with dressing changes, other pain is under control. Skin: right medial ankle wound with slough, periwound with erythema, tender to palpation. Continue topical treatment, start Keflex 500 mg (milligrams) PO (by mouth) BID (twice daily) for 7 days for wound infection. Surveyor notes R8's right ankle wound is now infected. A nursing note dated 9/4/25 documents resident continues oral antibiotic for right ankle wound. Erythema to wound with dressing C/D/I (clean/dry/intact). [R8] tolerating oral antibiotic well without adverse effects. Denies acute pain at rest and remains afebrile. R8's weekly wound assessment dated [DATE] documents an improved stage 3 pressure injury to R8's right inner ankle measuring 0.6 cm long x 0.6 cm wide. Surveyor notes no percentage of tissue present specified. A nutrition note dated 9/10/25 documents per 9/8/25 skin report, pressure are to right inner ankle is showing improvement, area measures 0.6 cm x 0.6 cm, antibiotic recently started. No recommendations at this time as skin integrity is improving with current plan. A nursing note dated 9/13/25 at 15:43 (3:43 PM) documents [R8] is alert and oriented to self, heel boots worn, wound to right inner foot with dressing intact. Currently on antibiotic for wound, no adverse effects. Complains of pain to wound and telling writer not to touch. Takes scheduled Tylenol, Fentanyl patch, and daily lido patch to neck. Appetite is fair, accepts supplements. A nursing note dated 9/13/25 at 20:41 (8:41 PM) documents antibiotic for foot wound has been completed. Dressing is C/D/I. R8's weekly wound assessment dated [DATE] documents an improved stage 3 pressure injury to R8's right inner ankle measuring 0.9 cm long x 0.9 cm wide. Surveyor notes no percentage of tissue present specified. R8's weekly wound assessment dated [DATE] documents an improved stage 3 pressure injury to R8's right inner ankle measuring 0.7 cm long x 0.9 cm wide. Surveyor notes no percentage of tissue present specified. A new treatment order with a start date of 9/22/25 documents apply Hydrocol External Pad to right inner ankle topically in the morning every 5 days for pressure area, cover with foam dressing, and monitor for s/sx (signs/symptoms) of infection. The Medication Administration Record (MAR) documents this treatment was administered as ordered with no documented refusals of this treatment, and no signs or symptoms of infection were documented. A new treatment order with a start date of 9/26/25 documents apply Hydrocol External Pad to right inner ankle topically every 5 days at bedtime for pressure area, cover with foam dressing, and monitor for s/sx (signs/symptoms) of infection. R8's TAR documents this treatment was administered as ordered with no documented refusals of this treatment in this timeframe. R8's TAR for September 2025 documents R8 refused to wear heel boots 4 times between the dates of 9/1/25-9/30/25. There is no documentation to support if R8 agreed to float her heels when she refused to wear the heel boots. R8's weekly wound assessment dated [DATE] documents a stable stage 3 pressure injury to R8's right inner ankle measuring 0.8 cm long x 0.8 cm wide. Surveyor notes no percentage of tissue present specified. R8's weekly wound assessment dated [DATE] documents a stable stage 3 pressure injury to R8's right inner ankle measuring 0.6 cm long x 0.7 cm wide. Surveyor notes no percentage of tissue present specified. R8's weekly wound assessment dated [DATE] documents a stable stage 3 pressure injury to R8's right inner ankle measuring 0.9 cm long x 0.9 cm wide. Surveyor notes no percentage of tissue present specified. R8's weekly wound assessment dated [DATE] documents a stable stage 3 pressure injury to R8's right inner ankle measuring 0.9 cm long x 0.7 cm wide. Surveyor notes no percentage of tissue present specified. R8's weekly wound assessment dated [DATE] documents a stable stage 3 pressure injury to R8's right inner ankle measuring 0.8 cm long x 0.8 cm wide x 0.1 cm deep. Surveyor notes no percentage of tissue present specified. Surveyor notes this is the first time R8's right inner ankle is described as having depth present. R8's weekly wound tool provided after the survey exit dated 10/27/25 documents and unchanged stage 3 pressure injury to the right inner ankle that measures 8 mm x 8 mm x 01 mm, with epithelial tissue and 80% slough tissue present, scant serous drainage, with no odor. No changes to the treatment plan was documented, R8's Medication Administration Record (MAR) for October 2025 documents R8 was administered PRN morphine 0.5 milliliters (ml) by mouth on 10/4/25, 10/7/25, 10/15/25, and 10/20/25. R8's MAR documents R8 was administered PRN morphine 1 ml by mouth on 10/4/25, 10/8/25, and 10/12/25. R8's weekly wound assessment dated [DATE] documents a stage 3 pressure injury to R8's right inner ankle measuring 1.0 cm long x 0.7 cm wide x 0.1 cm deep. Surveyor notes no percentage of tissue present specified. In an interview on 12/10/25 at 12:50 PM, Wound RN-C stated Wound RN-C was not sure why the weekly wound assessments were not available in R8's EMR because Wound RN-C remembered completing the electronic forms weekly and has a system to check off her paper weekly assessment when the electronic record is updated. Wound RN-C stated the electronic wound assessment would have been updated to include tissue descriptions, but Wound RN-C's paper wound assessments only document the measurements and stages of the wound. Wound RN-C stated the facility's IT (information technology) department was looking into why the electronic wound assessments were missing from R8's EMR. R8's weekly wound tool provided after the survey exit dated 11/5/25 documents a worsening stage 3 pressure injury to the right inner ankle with 80% slough, scant serous drainage, measuring 10 mm X 7 mm x 1, red blanchable peri wound and wound progress is stable and no change to the treatment. R8's weekly wound assessment dated [DATE] documents R8's right inner ankle wound is a unchanged stage 3 pressure injury with 100% slough, scant serous drainage, and measures 8 mm (0.8 cm) long x 8 mm (0.8 cm) wide x 1 mm (0.1 cm) deep. No signs or symptoms infection or inflammation were documented. A nursing progress note dated 11/15/25 documents resident received bed bath due to increased pain, combative. Dressings C/D/I (clean/

Based on observation, interview and record review, the facility did not ensure that 2 of 2 (R54, R1) received respiratory treatment in accordance with standards of practice. *R54's Continuous Positive Air Pressure (CPAP) device did not have physician's orders in place regarding proper settings or maintenance of their CPAP device. *R1 did not receive oxygen therapy in accordance with their physician's orders. Findings include: The facility's policy and procedure titled Standard Respiratory Protocol with no listed date documents: Problem: Impaired or potential impairment of gas exchange r/t (related to) chronic respiratory disease.Apply oxygen, CPAP as ordered. 1.) R54 was admitted to the facility 12/5/2025 with diagnoses including Obstructive Sleep Apnea (a sleep disorder which causes one to stop breathing for periods of time), Bladder cancer and Diabetes Mellitus. On 12/8/2025 at 10:04 AM, Surveyor observed R54 to have a CPAP machine at their bedside. Surveyor asked R54 if they receive assistance with their CPAP machine at hours of sleep. R54 responded that the nurses take care of that for them. On 12/9/2025 at 1:25 PM, Surveyor interviewed Licensed Practical Nurse (LPN)- T. Surveyor asked LPN-T what procedures would be followed for a resident who admits to the facility with a CPAP machine. LPN-T responded that the CPAP orders and settings should be put into the electronic medical record so nursing staff would know how the CPAP machine should be set up. Surveyor asked LPN-T if there should be orders in place for the cleaning and maintenance of a CPAP machine. LPN-T responded that there should be orders for each CPAP to be cleaned routinely. On 12/9/2025, Surveyor reviewed R54's electronic medical record. R54's Minimum Data Set (MDS) admission Assessment and Comprehensive Care plans had not yet been completed. Surveyor noted a physician's order documenting the following: CPAP, assist with placement and function QHS (at bedtime). Surveyor could not identify any physician's orders regarding cleaning or maintenance of R54's CPAP machine. On 12/09/2025 at 3:10 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding missing physician's orders regarding the proper settings and cleaning and maintenance of R54's CPAP machine. No additional information was provided. 2.) R1's diagnoses includes chronic respiratory failure with hypoxia (low levels of oxygen in body tissues), chronic obstructive pulmonary disease (group of lung disease that block airflow and make it difficult to breath), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), dementia (loss of cognitive function that interferes with a person's daily life and activities), and anxiety (emotional response involving feelings of worry, dread, and tension often accompanied by physical symptoms like a racing heart or sweating). R1's oxygen therapy care plan initiated 12/28/23 & revised 11/23/25 documents the following interventions: *Encourage or assist with ambulation as indicated. Initiated 12/28/23. *Give medications as ordered by physician. Monitor/document side effects and effectiveness. Initiated 12/28/23. *Monitor for s/sx (signs/symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, increased heart rate (Tachycardia), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Initiated 12/28/23. *OXYGEN SETTINGS: O2 (oxygen) via nasal prongs @ (at) 2L (liters) continuous. Humidified. Initiated & revised 12/28/23. *Resident has her own portable concentrator. Initiated 12/28/23. R1's significant change MDS (minimum data set) with an assessment reference date of 9/18/25 has a BIMS (brief interview mental status) score of 6 which indicates severe cognitive impairment. The MDS documents: Yes, is marked for oxygen while a resident for R1. R1's physician orders include an order with an order date of 9/19/25 of O2 (specify liter) per NC (nasal cannula) prn to keep sats (saturations) > (greater) 88% every shift. R1's physician orders include an order with an order date of 9/19/25 of check pulse ox monthly (every 4 weeks) on Sunday evening. Surveyor reviewed R1's TAR (treatment administration record) & under the weight/vital tab and noted R1's pulse ox was not checked according to physician orders on 10/19 & 10/26. R1's physician orders include an order dated 10/17/25 which documents: Change humidifier air canister every night shift every Friday. On 12/8/25, at 9:24 a.m., Surveyor observed R1 sitting on the edge of the bed with R1's left leg extended and resting on the cushion in R1's wheelchair. R1 is receiving oxygen via nasal cannula. Surveyor observed R1's oxygen is set at 2.5 liters and there is not a humidifier bottle. On 12/9/25, at 7:13 a.m., Surveyor observed R1 sitting on the edge of the bed drinking coffee. R1 has oxygen via nasal cannula which is set at 2.5 liters. Surveyor did not observe a humidifier bottle on the concentrator. On 12/9/25, at 8:10 a.m., Surveyor observed R1 sleeping on the left side with her knees bent. R1's head of the bed is elevated high and is receiving oxygen at 2.5 liters via nasal cannula. Surveyor did not observe a humidifier bottle on the concentrator. On 12/9/25, at 9:50 a.m., Surveyor observed R1 sleeping on the left side. R1 is receiving oxygen via nasal cannula at 2.5 liters. Surveyor observed there is not a humidifier bottle on the oxygen concentrator. On 12/9/25, at 10:55 a.m., Surveyor observed R1 awake in bed with the head of the bed up high. R1's nasal cannula is on the bridge of R1's nose. Surveyor observed R1's concentrator is set at 2.5 liters and there is not a humidifier bottle. On 12/9/25, at 12:56 p.m., Surveyor observed R1 sitting on the edge of the bed. R1 is receiving oxygen via nasal cannula at 2.5 liters. Surveyor observed there is not a humidifier bottle on the oxygen concentrator. On 12/9/25, at 11:14 a.m., Surveyor asked Registered Nurse (RN)-M if R1 should have a humidifier bottle on R1's oxygen. RN-M replied I don't think so but let me look, maybe she does. RN-M then checked R1's orders and stated to Surveyor there is an order to change it so I would say yes. On 12/9/25, at 11:16 a.m., RN-M accompanied Surveyor to R1's room to check R1's oxygen concentrator. RN-M stated it's not there, referring to the humidifier bottle, and then showed Surveyor the humidifier bottle which is located on a piece of furniture in R1's bathroom. Surveyor asked RN-M how many liters should R1's oxygen be set at. RN-M replied I think 2. Surveyor asked RN-M what is R1's oxygen set at. RN-M replied 2.5. On 12/9/25, at 11:20 a.m., Surveyor asked Director of Nursing (DON)-B if a resident's physician orders document the liters of oxygen a resident is to receive. DON-B asked Surveyor like a specific liter flow and informed Surveyor it's a range whatever the physician says it should be. DON-B stated facility staff would have to check oxygen saturation and titrate oxygen administration. Surveyor informed DON-B R1's physician order documents specify liter and R1's care plan documents 2 liters. DON-B informed Surveyor R1 is pretty independent with her oxygen. Surveyor informed DON-B Surveyor has noted R1's oxygen set at 2.5 liters. Surveyor asked DON-B how often is R1's oxygen saturation is checked. DON-B informed Surveyor that R1 does not have routine monitoring like every four hours. Surveyor informed DON-B Surveyor has not observed a humidifier bottle on R1's oxygen concentrator according to R1's physician orders. On 12/10/25, at 8:18 a.m., Surveyor observed R1 sitting on the edge of the bed eating breakfast. Surveyor observed R1 is receiving oxygen at 2.5 liters via nasal cannula. Surveyor did not observe a humidifier bottle on the oxygen concentrator. On 12/10/25, at 8:22 a.m., DON-B informed Surveyor the night nurse said R1 refused the humidifier bottle. Surveyor informed DON-B Surveyor did not note any documentation in R1's medical record regarding R1 refusing the humidifier bottle and there isn't a care plan regarding refusals. DON-B informed Surveyor she's going to care plan the refusal. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure that 2 (R54, R3) of 2 received urinary catheter care in accordance with standards of practice. *R54's foley catheter bag was observed directly on the floor without a protective barrier. R54's foley catheter order did not specify the proper size of catheter or the proper balloon inflation size. *R3's foley catheter order did not specify the proper size of catheter or the proper balloon inflation size. Findings include: 1.) R54 was admitted to the facility 12/5/2025 with diagnoses including Bladder Cancer, Obstructive Sleep Apnea (a sleep disorder which causes one to stop breathing for periods of time) and Diabetes Mellitus. On 12/8/2025 at 9:45 AM, Surveyor observed R54 in a reclining chair in their room. Surveyor observed R54's foley catheter bag on the floor without a protective cover or barrier. On 12/08/2025 at 11:54 AM, Surveyor observed R54 in a reclining chair in their room. Surveyor observed R54's foley catheter bag on the floor without a protective cover or barrier. On 12/08/2025 at 1:05 PM, Surveyor observed R54 in a reclining chair in their room. Surveyor observed R54's foley catheter bag on the floor without a protective cover or barrier. On 12/9/2025 at 1:25 PM, Surveyor conducted interview with Licensed Practical Nurse (LPN)- T. Surveyor asked LPN-T if a resident with a foley catheter bag should have some sort of protective cover over it. LPN-T responded that foley catheter bags should always be covered and kept off the floor. On 12/9/2025, Surveyor reviewed R54's electronic medical record. R54's Minimum Data Set (MDS) admission Assessment and Comprehensive Care plans had not yet been completed. Surveyor noted a physician's order documenting the following: Catheter Care- every shift, provide catheter care. Surveyor did not observe any physician order for R54's foley catheter specifying the proper size of the catheter or the proper balloon inflation size. On 12/09/2025 at 3:10 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B regarding observations of R54's foley catheter without a cover or protective barrier on 12/8/2025. Surveyor shared concern that they did not observe any physician order for R54's foley catheter specifying the proper size of the catheter or the proper balloon inflation size. No additional information was provided at this time. 2.) R3 was admitted to the facility on [DATE] with diagnoses of History of Urinary Tract Infections, Retention of Urine, and Presence of Urogenital Implants (medical devices or injectable materials used to restore urinary or sexual function). R3's Quarterly Minimum Data Set (MDS) dated [DATE] documented R3 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated R3 had moderate cognitive impairment and decision making. R3 requires set up assistance to eat and perform oral hygiene. R3 is completely dependent with all cares: toileting, showering, dressing, all other hygiene, changing positions (sit to lay, roll left and right in bed, and sit to stand.) R3 is incontinent of bowel and has a urinary catheter. R3's Annual MDS on 6/13/25 CAA (Care Area Assessment) Triggered Urinary incontinence and indwelling catheter due to R3 being dependent on toilet hygiene, toilet transfer and patient having an indwelling catheter. The CAA also documents CAA triggered due to resident has indwelling Foley catheter. Requires extensive assist of one person for toileting. Is that a risk for skin rashes, skin breakdown, falls, isolation, urinary infection. No referrals at this time. Will proceed to care plan. R3's Physician orders document: Catheter – care every shift provide catheter care start 5/22/25; May irrigate foley catheter with 60ML of normal saline as needed PRN for occlusion start date 9/22/25; Monitor catheter output every shift start date 5/22/25; Change drainage bag every night shift every two weeks on Friday date bag when changing start date 10/17/25. R3's Comprehensive care plan documented: The resident has indwelling catheter: pressure ulcer coccyx neurogenic bladder. Date initiated 9/12/25. Under the intervention section it documents: Monitor for signs and symptoms of discomfort on urination and frequency. Date initiated 5/22/25; Monitor and document for pain and discomfort due to catheter. Date initiated 5/22/25.; Monitor and record and report to MD for signs and symptoms of UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, changing behavior, changing eating patterns. Date initiated 5/22/25. Surveyor noted R3 does not have an order stating what size foley or how much to inflate the foley balloon in R3's orders or care plan. On 12/9/25, at 11:35 AM, Surveyor interviewed RN-M who stated when inserting a new foley catheter, RN-M would look at R3's physician orders to know what size catheter to use and how much fluid to inflate the foley catheter balloon to. RN-M went to review R3's orders and was not able to locate an order for balloon amount and foley size. RN-M stated I don't know what to tell you, it's (the balloon amount and foley size) usually in the MAR (medication administration record). RN-M also checked R3's paper charting and was unable to locate the information. On 12/9/25 at 12:01 PM, Surveyor interviewed LPN-T who stated when inserting a new foley catheter, LPN-T would look at R3's physician orders to know what size catheter to use and how much fluid to inflate the foley catheter balloon to. LPN-T stated if there is not an order then it would be based on policy what size catheter to use and how much to fill the catheter balloon. LPN-T does not know what they policy states for what size foley and balloon amount on the facility's policy. Surveyor noted that foley size and balloon amount is not listed in the facility's policy for urinary catheters. On 12/9/25 at 12:08 PM, Surveyor interviewed LPN-H who stated when inserting a new foley catheter, LPN-H would look at R3's physician orders to know what size catheter to use and how much fluid to inflate the foley catheter balloon to. LPN-H stated that to their knowledge there is not a policy that indicates what foley size or balloon amount to use if there is no order. LPN-H stated that the facility does not just make things up, the facility goes off of the physician orders. On 12/10/25, at 8:55 AM Surveyor noted R3 had a new physician order that documented: - Indwelling Foley catheter_changed on 12/3/25 with 16F5CC balloon. Start date 12/9/25 5:47 PM. - Foley catheter change PRN for signs and symptoms of not functioning. Start date 12/9/25 5:47 PM. These orders were placed by DON-B on 12/9/25. On 12/10/25 at 10:48 AM, Surveyor interviewed RN-J who stated when inserting a new foley catheter, RN-J would look at R3's physician orders to know what size catheter to use and how much fluid to inflate the foley catheter balloon to. RN-J stated the facility will mirror whatever the hospital's orders are for the foley size and balloon amount. If a new order is needed, RN-J stated RN-J would call MD-Q or NP-D to place a new order for the foley size and balloon amount. On 12/10/25 at 2:17 PM, Surveyor interviewed DON-B who stated when inserting a new foley catheter, DON-B expects nurses to look at the patient's foley that is currently inserted to know what size catheter to use and how much fluid to inflate the foley catheter balloon to. Surveyor informed DON-B that the nurses interviewed stated they would look for the physician orders to verify correct foley size and balloon amount. DON-B and Regional Nurse Consultant (RNC)- P both stated they have never seen an order that stated foley catheter size and balloon amount and DON-B and RNC-P personally have always looked at the foley that is currently inserted in the patient for that information. On 12/10/25, at 2:17 PM Surveyor shared the concern of R3 not have foley catheter size and balloon inflation amount in an order for the nurses to reference when placing a new foley catheter with DON-B and RNC-P. No additional information was provided.

Based on interview and record review, the facility did not ensure that 1 (R1) of 1 residents with an injury of unknown origin was reported to the State Survey Agency withing the required reporting timeframe. R1's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a bruise of unknown origin was submitted to the State Survey Agency on [DATE]. Nursing Home Administrator (NHA)-A stated in an interview that the Misconduct Incident Report was submitted to the State Survey Agency on [DATE], which is past the 5-business day required timeframe. Findings include: The facility policy with a last reviewed date of [DATE], titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property documents, in part: It is the policy of the facility that each individual will be free from Abuse . The Nursing Home Administrator or designee will report abuse to the state agency per State and Federal Guidelines . 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. When making a report, Misconduct Incident Reporting (MIR) 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 . R1 was admitted to the facility on [DATE]. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents R1 is severely cognitively impaired. R1's progress note dated [DATE] at 1:23 PM documents: New bruise noted on left forearm. [R1] states [R1] bumped it on the machine. Resident does not remember when this happened. Bruise measures 7.5 x 6 [centimeters]. No pain with palpation. Skin is intact. Vitals stable. On [DATE] at 10:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C, who was the CNA who first saw R1's bruise. CNA-C stated that CNA-C went into R1's room to help R1. R1 pointed at R1's wrist and told CNA-C to look at R1's wrist. CNA-C stated that CNA-C asked R1 how the bruise happened. R1 did not tell CNA-C how it happened but stated that it occurred last night. Surveyor asked if R1 mentioned that the bruise occurred while using the sit-to stand transfer device or if R1 mentioned bumping into the transfer device. CNA-C stated no. CNA-C stated that there was no transfer that CNA-C helped with that R1 hit R1's wrist on the transfer device. CNA-C stated that R1 does self-propel while R1 is in R1's wheelchair. CNA-C stated that R1 can be seen rolling in R1's room and moving belongings around. CNA-C thought that R1 might have bumped into something in R1's room and that could have been the cause of the bruise. Surveyor asked what CNA-C did after finding the bruise. CNA-C stated that CNA-C told the nurse. On [DATE] at 10:50 AM, Surveyor interviewed Registered Nurse (RN)-D, who was one of the nurses who assessed R1's bruise after it was found. RN-D stated that the bruise was brought to RN-D's attention by another nurse. RN-D stated that RN-D went to R1's room two times to see if R1 could tell RN-D how and when the bruise occurred. RN-D stated that R1 indicated that R1 bumped R1's left arm on the machine and pointed to the sit to stand transfer device. RN-D stated that the bruise was assessed and measured, R1's Power of Attorney and MD were notified, and administration was notified. Surveyor asked if R1 mentioned any names in association with how the bruise occurred. RN-D stated no. Surveyor reviewed the staff schedules and noted that CNA-C and CNA-E were some of the staff working on [DATE] the evening before R1's bruise was found. On [DATE] at 1:24 PM, Surveyor interviewed CNA-E. CNA-E stated that CNA-E has helped with transferring R1 in the past. Surveyor asked if there was ever a time that R1 was injured or bumped R1's arm during a transfer. CNA-E stated no. Surveyor asked if CNA-E recalled seeing or hearing about a bruise on R1's arm. CNA-E stated no but if CNA-E had seen the bruise, CNA-E would have alerted a nurse right away. Surveyor reviewed the facilities self report regarding R1's bruise. The self-report contained a summary of findings, an interview with R1, interviews with all other residents on R1's unit and 2 staff interviews. Surveyor did not locate a completed Misconduct Incident Report form documenting the submission of the investigative findings to the State Agency. On [DATE] at 12:53 PM, Surveyor interviewed NHA-A about the self-report on R1's bruise. NHA-A stated that NHA-A was made aware of the bruise on [DATE]. NHA-A indicated that NHA-A talked to R1. NHA-A asked R1 if any staff were involved when R1 received the bruise. R1 stated no. NHA-A asked R1 how the bruise happened, R1 pointed at R1's dresser drawer and then pointed to the sit to stand transfer device. NHA-A stated that R1 pointed more at the drawer. NHA-A stated that after the interview with R1, it was noted that a drawer in R1's dresser was not opening correctly, and maintenance had to come and fix R1's dresser drawer. NHA-A stated that resident interviews were completed, and NHA-A talked to staff. NHA-A stated that there have been no other injuries of unknown origin on the unit. NHA-A concluded that no abuse occurred and no one intentionally hurt R1. Surveyor asked about the report to the State Agency. NHA-A stated that the account that NHA-A uses to report an incident like this had expired. NHA-A stated that NHA-A created a new account. NHA-A tried multiple times to put in the new credentials to enter the report, but NHA-A was not successful. NHA-A sent an email to the Office of Caregiver Quality on [DATE] alerting the Agency of the bruise and the investigation. NHA-A stated that NHA-A submitted the final investigation (the five day) on [DATE] with all the attachments. Surveyor asked for evidence that the 5-day report was submitted. NHA-A state that it was submitted on the 22nd. NHA-A stated that the system accepted the report but there is nothing to give to Surveyor to provide evidence of the submission. NHA-A stated that NHA-A knew that the 5-day report was late but still wanted to make sure that the report was submitted. On [DATE] at 2:08 PM, NHA-A and Director of Nursing (DON)-B were notified of the concern that the final investigation findings of R1's injury of unknown origin were not submitted to State Agency within 5 working days of the incident.

Based on interviews and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 (R1) of 1 residents reviewed. Facility staff found a bruise on R1's left forearm on 4/13/25. Certified Nursing Assistant (CNA)-C informed Surveyor that R1 told CNA-C that the bruise happened the night before. R1 told Registered Nurse (RN)-D that R1 bumped R1's arm on the sit-to-stand transfer device. The facility investigation into R1's bruise included 2 staff interviews from CNA-C and RN-D. The facility did not interview or get statements from other staff members that had worked with R1 in the previous shifts before the bruise was found. Findings include: The facility policy with a last reviewed date of 11/8/2023, titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property documents, in part: It is the policy of the facility that each individual will be free from Abuse . It is the policy of this facility that reports of abuse are promptly and thoroughly investigated . The investigation is the process used to try to determine what happened . Investigation of injuries of unknown origin or suspicious injuries: must be immediately investigated to rule out abuse . R1 was admitted to the facility on [DATE]. R1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents R1 is severely cognitively impaired. R1's progress note dated 4/13/25 at 1:23 PM documents: New bruise noted on left forearm. [R1] states [R1} bumped it on the machine. Resident does not remember when this happened. Bruise measures 7.5 x 6 [centimeters]. No pain with palpation. Skin is intact. Vitals stable. On 5/14/25 at 10:40 AM, Surveyor interviewed R1. Surveyor asked about R1's bruise that R1 had about a month ago. R1 did not recall the bruise. Surveyor asked if R1 felt safe at the facility. R1 stated yes. Surveyor asked if R1 was in pain. R1 stated No. Surveyor asked if R1 had any concerns with facility staff. R1 stated No. On 5/14/25 at 10:55 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-C, who was the CNA who first saw R1's bruise. CNA-C stated that CNA-C went into R1's room to help R1. R1 pointed at R1's wrist and told CNA-C to look at R1's wrist. CNA-C stated that CNA-C asked R1 how the bruise happened. R1 did not tell CNA-C how it happened but stated that it occurred last night. Surveyor asked if R1 mentioned that the bruise occurred while using the sit-to stand transfer device or if R1 mentioned bumping into the transfer device. CNA-C stated no. CNA-C stated that there was no transfer that CNA-C helped with that R1 hit R1's wrist/arm on the transfer device. CNA-C stated that R1 does self-propel R1's wheelchair. CNA-C stated that R1 can be seen rolling in R1's room and moving belongings around. CNA-C thought that R1 might have bumped into something in R1's room and that could have been the cause of the bruise. Surveyor asked what CNA-C did after finding the bruise. CNA-C stated that CNA-C told the nurse. Surveyor noted that R1 told CNA-C that the bruise occurred the night before the bruise was found. On 5/14/25 at 10:50 AM, Surveyor interviewed Registered Nurse (RN)-D, who was one of the nurses who assessed R1's bruise after it was found. RN-D stated that the bruise was brought to RN-D's attention by another nurse. RN-D stated that RN-D went to R1's room two times to see if R1 could tell RN-D how and when the bruise occurred. RN-D stated that R1 indicated that R1 bumped R1's left arm on the machine and pointed to the sit to stand transfer device. RN-D stated that the bruise was assessed and measured, R1's Power of Attorney and MD were notified, and administration was notified. Surveyor asked if R1 mentioned any names in association with how the bruise occurred. RN-D stated no. Surveyor noted that R1 told RN-D that the bruise happened by bumping R1's arm on the sit-to-stand transfer device. Surveyor reviewed the facilities Self report regarding R1's bruise. The self-report contained a summary of findings, an interview with R1, interviews with all other residents on R1's unit and 2 staff interviews (CNA-C and RN-D). Surveyor noted that the facility did not review the staff schedules from the previous shifts to interview staff that were working prior to the development of the bruise. Surveyor noted that staff on previous shifts were not asked if there was a transfer that R1 hit R1's arm on the transfer device, were not asked if any bruising or other skin alteration was noted in the previous shifts and were not asked if they witnessed anything that would've caused R1 to bruise. Surveyor reviewed the staff schedules and noted that CNA-C and CNA-E were some of the staff working on 4/12/24 the evening before R1's bruise was found. On 5/14/25 at 1:24 PM, Surveyor interviewed CNA-E. CNA-E stated that CNA-E has helped with transferring R1 in the past. Surveyor asked if there was ever a time that R1 was injured or bumped R1's arm during a transfer. CNA-E stated no. Surveyor asked if CNA-E recalled seeing or hearing about a bruise on R1's arm. CNA-E stated no but if CNA-E had seen the bruise, CNA-E would have alerted a nurse right away. Surveyor attempted to interview other staff working the shifts prior to R1's development of the bruise but was unsuccessful. Surveyor noted that the local police department completed an investigation into R1's bruise. Surveyor reviewed the police report with an incident date of 4/13/25. Surveyor noted that after investigation, the case was closed and there were no charges filed in relation to R1's bruise. On 5/14/25 at 12:53 PM, Surveyor interviewed NHA-A about the self-report on R1's bruise. NHA-A stated that NHA-A was made aware of the bruise on 4/14/25. NHA-A indicated that NHA-A talked to R1. NHA-A asked R1 if any staff were involved when R1 received the bruise. R1 stated no. NHA-A asked R1 how the bruise happened, R1 pointed at R1's dresser drawer and then pointed to the sit to stand transfer device. NHA-A stated that R1 pointed more at the drawer. NHA-A stated that after the interview with R1, it was noted that a drawer in R1's dresser was not opening correctly, and maintenance had to come and fix R1's dresser drawer. NHA-A stated that resident interviews were completed, and NHA-A talked to staff. NHA-A stated that there have been no other injuries of unknown origin on the unit. NHA-A concluded that no abuse occurred and no one intentionally hurt R1. Surveyor asked if there are any additional staff statements or interviews that were completed. NHA-A stated that NHA-A would get the staff statements for Surveyor. NHA-A returned to Surveyor with CNA-C and RN-D's statements. On 5/14/25 at 2:08 PM, Surveyor informed NHA-A and Director of Nursing (DON)-B of the concern that a thorough investigation into R1's bruise was not completed. The facility did not interview staff who worked with R1 in the shifts prior to R1's development of the bruise. No additional information was provided.

Based on interview and record review the facility did not provide the opportunity for 1 (R1) of 4 residents reviewed to participate in the development and implementation of their person-centered plan of care. *R1's Activated Healthcare Power of Attorney (HCPOA) was not formally invited by the facility to participate in R1's Quarterly care conferences Findings Include: 1.) R1 was admitted to the facility on [DATE] with diagnoses of Dementia with anxiety, Mood disturbance and Edema. R1's Quarterly Minimum Data Set (MDS) dated [DATE] documents R1's Brief Interview for Mental Status (BIMS) score to be a 00, indicating R1 is severely cognitively impaired and unable to conduct daily decision making. R1 has an activated HCPOA. On 3/19/25 at 10:15 AM, Surveyor reviewed the grievance log and noted there were multiple grievance from regarding R1. Surveyor requested copies of grievances. On 3/19/25 at 10:47 AM, Surveyor interviewed R1's activated HCPOA over the phone in regards to care conferences. R1's activated HCPOA stated that the facility had requested multiple care conference both in person and over the phone. R1's activated HCPOA informed Surveyor that R1's HCPOA has not been invited by facility to participate with quarterly care conferences. On 3/20/25, Surveyor noted grievance concern forms regarding R1's HCPOA not being routinely invited or made aware of quarterly care conferences. Surveyor reviewed R1's HCPOA participation in care conferences and noted the following: 11/26/24-There is no documentation that R1's HCPOA was invited and/or participated. 2/26/25-There is no documentation that R1's HCPOA was invited and/or participated. On 3/20/25 at 11:10 AM, Surveyor interviewed Life Coach-E. Surveyor asked Life Coach-E if residents who have an activated HCPOA should be invited to quarterly care conferences. Life Coach-E responded that the expectation would be to include activated HCPOA and residents for quarterly care conferences. On 3/20/25 at 1:15 PM, Surveyor shared the concern with Administrator (NHA-A) and Director of Nursing (DON-B) the concern that R1's activated HCPOA has not been invited to care conferences and has not been given the opportunity to be a part of R1's care planning process. No additional information was provided.

Based on record review and staff interview, the facility did not ensure all allegations involving potential neglect were thoroughly investigated for 1 of 1 self-reports reviewed. * A Facility Misconduct Incident self-report submitted to the State Agency on 3/18/25 documents allegations that R4 was neglected by Certified Nursing Assistant (CNA)-F. The facility did not conduct a thorough investigation into this allegation of neglect when the facility's investigation did not include all interviews from other Residents in order to determine a possible pattern of neglect. Findings Include: Surveyor noted the facility had properly completed the following related to R4's allegation of neglect: -Submitted the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report within the required reporting time to the State Agency. -Submitted the Misconduct Incident Report within the required reporting time to the State Agency. Upon review of this self-report, Surveyor was unable to identify documentation of interviews with other residents in order to establish if there was a pattern of neglect from CNA-F. The self-report did not establish if all residents on the South unit who had the potential to have contact with CNA-F were interviewed by staff. On 3/20/25 at 11:10 AM, Surveyor conducted interview with Life Coach-E. Life Coach-E had been responsible for conducting an investigation related to R4's allegations of neglect by CNA-F. Surveyor asked Life Coach-E if there was a reason that they only attempted interviewing 12 of 16 residents on the South unit pertaining to R4's allegation of neglect by CNA-F. Life Coach-E responded that they were unaware that they should have attempted to conduct interviews with all residents on the South unit as they thought they only needed to review a sample of residents on the unit. Surveyor noted that attempting to interview all residents whom had the potential to work with CNA-F would ensure that a thorough investigation into potential neglect was conducted. On 3/20/25 at 1:15 PM, Surveyor conducted interview with NHA (Nursing Home Administrator)-A. Surveyor shared concern the facility had not completed interviews or obtained statements from all residents who may have had knowledge of allegations of CNA-F having a pattern of neglectful behavior towards residents on the South Unit. The facility was unable to provide additional information to Surveyor at this time.

Based on observation, record review, and interview, the facility did not develop and implement a comprehensive person-centered care plan for 2 (R2 and R3) of 4 residents to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment. * R2 and R3 frequently refused care and treatment and no care plan for refusal of care was developed. Findings include: The facilities policy titled Comprehensive Person-Centered Care Plan dated 8/10/23 documents: Within 21 consecutive days after admission, a comprehensive assessment will be completed, and a written care plan will be developed based on the individuals history, preferences and assessments from appropriate disciplines and the physician's evaluation and orders. 1.) R2 was admitted to the facility on [DATE] with diagnoses that included Myocardial Infarction and Pressure Injury of the sacrum. R2 discharged from the facility on 10/16/24 On 3/19/25, R2's progress notes were reviewed from 9/19/24 to 9/21/24 and notes were written for each shift indicating R2 refused to have his hospital acquired coccyx pressure injury evaluated. On 9/21/24, R2 allowed the assessment, and it was assessed to be a Deep Tissue Injury measuring 11 centimeters (cm) X 9 cm. Several notes also indicated R2 refused repositioning and was educated on the risks and benefits of refusal. On 9/24/24 an agreement was reached with R2 that he would reposition at least every 4 hours to which he agreed. On 3/19/25 at 1:11 PM, Registered Nurse (RN)-D who is the facilities wound nurse, was interviewed and indicated that R2 would frequently refuse care and treatment for his pressure injury. RN-D stated that R2 also refused care and treatment on previous admissions to the facility. On 3/20/25, R2's care plan was reviewed and did not include any care plans for refusal of care for his stay at the facility 9/19/24 to 10/16/24. On 3/20/25 at 11:30 AM, Director of Nurses (DON)-B was interviewed and indicated that a refusal of care care-plan should have been in place for R2 and was not. On 3/20/25 at 2:30 PM, the above findings were shared with Nursing Home Administrator (NHA)-A and DON-B. Additional information was requested if available and none was provided as to why R2 did not have a refusal of care care-plan developed. 2.) R3 was admitted to the facility on [DATE] with diagnoses that included Dementia and Chronic Pain. On 3/20/25, R3's current Physicians orders were reviewed and read: 2/28/24 heel boots to be worn in bed and in broad (type of wheelchair). On 3/20/25 at 9:45 AM, R3 was observed to be in the common area in the broad chair without heel boots on. The heel boots were observed in the chair in R3's room. On 3/20/25, R3's pressure injury assessment dated [DATE] was reviewed and documented a stage 2 pressure injury measuring 5 millimeters (mm) x 8 mm to her right ankle. On 3/20/25 at 10:00 AM, Certified Nursing Assistant (CNA)-C was interviewed and indicated that R3 refused her heel boots that morning and refuses them and kicks them off often. On 3/20/25, R3's Treatment Administration Record was reviewed and documented at least 12 refusals to wear heal boots from 1/1/25-3/20/25. On 3/20/25, R3's care plan was reviewed and did not include any care plans for refusal of care. On 3/20/25 at 11:30 AM, Director of Nurses (DON)-B was interviewed and indicated that a refusal of care care-plan should have been in place for R3 and was not. On 3/20/25 at 2:30 PM, the above findings were shared with Nursing Home Administrator-A and DON-B. Additional information was requested if available and none was provided as to why R3 did not have a refusal of care care-plan developed.

Based on observation, interview, and record review, the Facility did not ensure food was prepared and served in a sanitary manner. This practice had the potential to affect 3 of 3 kitchens serving food and 39 of 39 residents residing in the facility. * Vents over the sink and near the dishwasher in the main preparation kitchen were contaminated with dark brown spots on the surface. * Food in the 2 refrigerators in the main preparation kitchen was stored without an open on date and liquid egg cartons were not sealed. * The Rehab/West Unit did not have an approved dish washing machine. There were 2 kitchen staff utilizing this dish washing machine. * The Main/Long Term Care Unit kitchen was observed with staff not utilizing preventative infection control practices. Findings include: 1.) On 12/2/24, at 8:39 AM, Surveyor observed the main preparation kitchen and saw that the air vent by the dish machine and the air vent above the sinks had dark brown spots around the intake area. Surveyor interviewed Dietary Manager-F and asked about the vents and was told they believe the vents are cleaned monthly. On 12/2/24, at 9:35 AM, Surveyor interviewed Director of Environmental Services-C regarding the cleaning of the vents and was told they are done every six months per protocol. On 12/2/24, at 9:40 AM, Surveyor interviewed Facility Services Manager-D regarding the cleaning of the vents and was told it should be done every 6 months, but they are behind schedule, the cleaning has not been done since 4/11/24. The manager is waiting for a quote to schedule the next cleaning. When Programmed Cleaning comes into the Facility, they do the grease traps and vents in the whole building. Surveyor notes that over seven and a half months have passed since the last cleaning of the vents. On 12/2/24, at 11:24 AM, Surveyor told Nursing Home Administrator-A of the concern with the vents in the main kitchen being dirty and not serviced per the 6 month standard operating procedure Surveyor was advised of. No further information was provided. 2.) The Facility Policy and Procedure titled, Food Acceptance with no dates, states in part: Procedure . 4. Perishable foods will be properly covered, labeled and dated and promptly stored in the refrigerator or freezer as appropriate. On 12/2/24, at 8:39 AM, Surveyor observed the main kitchen refrigerators. Several items were observed to not be dated or not be covered leaving them open to contamination. -Sliced American cheese, no date on saran wrap -Liquid whole eggs, carton open -White meat in a stainless dish, no date on saran wrap -Sliced ham, no date on saran wrap -Shredded cheddar cheese, no date on the bag -1/2 of an apple, no date on the saran wrap -1/2 of a tomato, no date on the saran wrap -Bag of lettuce, opened with no date on the bag On 12/2/24, at 8:39 AM, Surveyor interviewed Dietary Manager-F about the food with no dates and the open carton as Dietary Manager-F was grabbing the items off the refrigerator shelves. The Surveyor was told that yes, the items should be dated and sealed and that is why they are being removed now to be put in the garbage. On 12/2/24, at 10:21 AM Surveyor requested the food dating policy from Dietary Manager-F due to the concern of items not dated and open in refrigerator. On 12/2/24, at 11:24 AM, Surveyor told Nursing Home Administrator-A of the concern with the open and undated food in the refrigerator in the main kitchen. No further information was provided. 21855 The facility's High Temp Dish machine Guidelines, undated document: Always wash your hands and use clean gloves before handling clean dishes. REHAB/WEST UNIT KITCHEN 3.) On 12/2/24, at 9:20 AM, Surveyor observed, and interviewed, Dietary Staff (DS)-I. DS-I was cleaning up after the breakfast meal. Surveyor observed plates, and mugs, laying upright on a towel. There were dirty pans in the adjacent room off the kitchen. The adjacent room had a commercial dish washer and a garbage disposal sink. Surveyor observed dirty pans in the sink area. DS-I stated the commercial dish machine has not worked for awhile. The DS-I stated they use the residential size dish machine. DS-I stated they wash all the dishes on the unit. On 12/2/24, at 11:15 AM, Surveyor observed, and interviewed, DS-G. DS-G stated the commercial dish machine has not worked for awhile. Surveyor observed DS-G load some dirty dishes into the residential dish machine. DS-G stated they wash all the dishes in the residential dish machine and if they are still wet, they dry them off with a towel. DS-G stated they use the Cascade tablets on the counter. DS-G did not have any sanitization or temperature logs. DS-G stated they use the Cascade tablets. On 12/2/24, at 11:24 AM, Surveyor shared the kitchen concerns with Nursing Home Administrator (NHA)-A. NHA-A stated they will follow up with the contracted kitchen manager. On 12/2/24, at 11:44 AM, Surveyor interviewed Dietary Manager (DM)-F. The DM-F stated there is not operational dish machine on the West/Rehab Unit. The staff are not supposed to use the residential dish machine. The staff are supposed to wash their dishes in the Long Term Care kitchen or main kitchen. LONG TERM CARE KITCHEN/MAIN UNIT The facility's policy and procedure for Hair Restraints, undated documents: All staff entering a kitchen will wear a hairnet/hair restraint, ensuring that all hair is completely covered by the hairnet. The facility's policy and procedure Dishware and Glassware, undated document: Glass and China and silverware once washed and sanitized need to AIR DRY prior to being stacked. 4.) On 12/2/24, at 9:31 AM, Surveyor observed and interviewed, DS-H load used dishware into racks. DS-H did not utilize gloves and pre-washed all the dishware. After the dishware was finished in the dish machine the trays of clean dishes were lined up for air drying. DS-H then handled the clean dishware with their bare hands without utilizing hand hygiene. DS-H handled used dishware without hand hygiene in between handling clean dishware. Surveyor observed this with 8 racks of clean dishware. DS-H stated they rinse off their hands in the used pre-wash sink water. DS-H stated the process is to wash their hands, however feels putting their hands in the pre-wash water is sufficient. On 12/2/24, at 9:37 AM. Surveyor observed Certified Nursing Assistant (CNA)-E in the kitchen. CNA-E was using the toaster and had no hair restraint. CNA-E stated they thought they only needed a hair restraint with resident food. Stating the toast they were making was for themselves. CNA-E did go obtain a hairnet after being queried by Surveyor. Surveyor observed, there is a sign with bolded print on the kitchen entry door stating: NOTICE hairnet required beyond this point. On 12/2/24, at 9:40 AM, Surveyor shared the kitchen concerns with NHA-A. NHA-A stated they would look into it; there should be hand hygiene and hairnets. On 12/2/24, at 10:21 AM, Surveyor interviewed DM-F. DM-F stated staff should be washing their hands between dirty and clean dishware. DM-F stated they educated staff about hand hygiene last week. DM-F stated that it is a known fact to wear hairnets in the kitchen.

Based on interview and record review the facility did not ensure 1(R24) of 5 residents had physician orders transcribed correctly. R24 had a physician order dated 2/5/24 for clonazepam 0.5 mg twice daily as needed for anxiety X 14 days. On 7/23/24, R24 continued to have this order and was receiving this medication despite the original order indicating it was only for 14 days. Findings include: 1.) R24 was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease), sleep apnea and panic disorder. R24's physician orders dated 2/5/24 document: clonazepam 0.5 mg twice daily as needed for anxiety X (for) 14 days. The MAR (medication administration record) indicates R24 continues to receive clonazepam 0.5 mg as needed. On 7/23/24 at 1:11 p.m., Surveyor interviewed DON-B regarding R24 physician order for clonazepam. Surveyor asked DON-B why is R24 still receiving clonazepam when the order was written for 14 days. DON-B stated she will look into it. On 7/23/24 at 2:40 p.m., DON-B explained to Surveyor the clonazepam order for R24 was extended for another 6 months. DON-B provided Surveyor with a pharmacy recommendation signed by the NP (nurse practitioner) on 3/8/24, to extend the order for 6 months for continued intermittent anxiety. Surveyor explained to DON-B this new order was not transcribed to the physician orders and on the MAR. DON-B agreed this was not done. No additional information was provided as to why the facility did not ensure R24's clonazepam medication order had physician orders transcribed correctly.

Based on observation, interview and record review, the facility did not ensure the resident's record reflected the accurate resuscitation code status election for 1 (R13) of 12 residents reviewed for code status. *R13's Emergency Care Do Not Resuscitate Order (DNR) form was signed by R13 and R13's Physician on 7/3/2024. R13's physician orders from 7/3/2024-7/22/2024 documents R13 is a full code. R13's code status in the Electronic Health Record (EHR) did not match R13's wishes for the first 19 days of R13's stay in the facility. Findings include: 1.) R13 was admitted to the facility on [DATE] with diagnosis that includes Hip fracture after a fall, Chronic heart failure, and Type 2 Diabetes. R13's Admission Minimum Data Set Assessment, dated 7/10/2024, documents R13 is cognitively intact. R13's Emergency Care DNR form was signed by R13 and R13 Physician on 7/3/2024. R13's Physician order with a start date of 7/3/2024, documents: FULL code, every shift monitor bracelet placement. R13's Treatment Administration Record (TAR) for July 2024 documents that R13 is wearing a Full Code bracelet from 7/3/2024-7/22/2024. Surveyor noted that R13's DNR election was not transcribed into R13's EHR when R13 signed the Emergency Care DNR form on 7/3/2024. On 7/22/2024 at 2:26 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-E. Surveyor asked how staff know a resident's code status. CNA-E stated code status is listed on a resident's bracelet. On 7/22/2024 at 2:38 PM, Surveyor observed R13 wearing a facility bracelet. The bracelet did not convey R13's DNR status and was not observed on R13's bracelet. On 7/22/2024 at 2:28 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F and LPN-G. Surveyor asked how staff know a resident's code status. LPN-F stated code status is documented in the Medication Administration Record (MAR). LPN-F indicated a signed copy of the Emergency Care DNR form would be in a paper chart at the nurse's station. Surveyor asked, what is R13's current code status? LPN-F stated, [R13] is a full code. LPN-G, who was showing Surveyor the file cabinet drawer with the resident's charts, located R13's paper chart. LPN-G stated that R13 has a signed DNR form on file in the paper chart. LPN-G stated that R13 and the physician signed the DNR form on 7/3/2024. LPN-F looked in R13's EHR and noted that R13's code status was listed as a Full code. LPN-F indicated the EHR, and the DNR form in R13's paper chart do not match. LPN-F stated LPN-F would correct the EHR. Surveyor asked what the process is for documenting code status on admission. LPN-G stated if a resident wishes to be a DNR, the resident signs the Emergency Care DNR form. The form is faxed to the physician to be signed. Once signed, the form is sent to medical records to be scanned into the EHR. A copy of the form is placed in the paper chart at the nurse's station. Surveyor noted that the signed Emergency Care DNR form was not scanned into R13's EHR. R13's July 2024 MAR (Medication Administration Record) documents: DNR, Full Code (discontinued as of 7/22/2024 2:30 PM). R13's Physician order with a start date of 7/22/2024 documents: DNR, every shift monitor bracelet placement. On 7/23/2024 at 9:30 AM, Surveyor observed R13 wearing a facility bracelet. R13's DNR status was observed on R13's bracelet. On 7/23/2024 at 11:33 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what the process is for obtaining code status and entering code status into the EHR. DON-B indicated admission orders go to health information services department and that department will enter the admission orders. A staff nurse will then verify and activate the orders. All the orders are then sent to the physician for the physician to sign. Regarding code status, DON-B stated if the hospital records indicate a resident is FULL code, a facility nurse will still verify code status with the resident or resident representative on admission. The admission nurse will change the code status order as necessary so that it matches the resident's wishes. Surveyor informed DON-B, R13's code status in EHR did not match R13's signed DNR form. DON-B stated that DON-B was made aware by nursing staff on 7/22/2024. DON-B indicated DON-B did not know why there was a discrepancy with R13's code status. DON-B stated that R13's signed DNR form should have been in R13's EHR. DON-B stated it could have been a computer issue. DON-B stated that because of the discrepancy, DON-B completed a sweep of the building to verify code status for all residents. DON-B stated no other issues were found. On 7/23/2024 at 3:12 PM, at the daily exit meeting, Nursing Home Administrator (NHA)-A and DON-B were made aware that R13's code status in EHR, did not match R13's wishes for the first 19 days of R13's stay in the facility. No other information was provided as to why the facility did not ensure the resident's record reflected the accurate resuscitation code status election.

Based on record review and interview the facility did not acquire a current contract /agreement in writing for outside dialysis services for 1(R19) of 1 residents receiving hemodialysis. Findings include: On 7/23/24 at 10:00 AM, Director of Nursing (DON)-B was asked for the dialysis contract/agreement for the company that R19 uses for renal dialysis. DON-B indicated at that time one could not be found but the provider was going to send an updated contract. On 7/24/24 at 10:15 AM, Nursing Home Administrator (NHA)-A was interviewed and indicated the facility had no contract/agreement with R19's dialysis company and one should be in place. R19's current physician orders were reviewed and documented that R19 receives dialysis 3 times a week and a communication binder is to be sent back and forth with every visit. On 7/24/24 at 10:15 AM, Surveyor informed NHA-A of the above findings. Additional information was requested if available and none was provided as to why the facility had no dialysis contract/agreement in place for R19's dialysis provider.

Based on observation, interview, and record review the facility did not ensure that food was prepared to conserve nutritive value and flavor. This has the potential to effect 1 (R11) of 1 residents on pureed diet. R11 informed Surveyor that R11's food lacked flavor. The Dining Room Manager (DM-D) did not follow a recipe for preparing texture and modified consistency diet for pureed food. Findings include: The facility policy titled, Dining-Preparation with a revision date of 5/23/2006 documents, in part: Foods shall be prepared by methods that conserve nutritive value, flavor and appearance and shall be served at the proper temperature . Foods shall be ground or pureed to meet individual needs . 1.) R11 was admitted to the facility on [DATE] with diagnoses that include Chronic heart failure, Protein-calorie malnutrition, and Colon Cancer. R11's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R11 is cognitively intact. On 7/23/2024 at 1:45 PM Surveyor interviewed R11 about the taste of R11's food. R11 stated, I don't recognize the taste at all. It doesn't taste like anything. On 7/23/2024 at 11:15 AM, Surveyor observed DM-D preparing pureed food. DM-D stated the facility has one resident on a pureed diet. DM-D put one baked chicken breast in the blender. DM-D took an unmeasured amount of hot water into the blender. DM-D blended the mixture. Surveyor asked how DM-D knows if the food is the correct texture. DM-D stated she knows because of DM-D's experience and practice. DM-D stated the pureed food should not have chunks. DM-D pointed at a container of thickening powder and stated that DM-D also has thickener to reach the correct consistency. Surveyor noted DM-D did not use thickener while preparing the pureed food. DM-D indicated that the chicken was at the correct consistency. DM-D poured the pureed food into a container, covered the container, and put the food in a warmer. Surveyor noted the mixture poured into the container was not a pudding like consistency. Surveyor asked if DM-D used a recipe to prepare pureed food. DM-D stated, No. Surveyor asked how much water DM-D put into the blender. DM-D stated DM-D did not measure the water but goes off experience to know how much to put in the blender. DM-D indicated that if DM-D was pureeing 4 ounces of meat, DM-D would use 2 ounces of water. On 7/23/2024 at 11:38 AM, Surveyor interviewed Food Service Director (FSD)-C. Surveyor asked if recipes should be used for pureed food. FSD-C stated that FSD-C does have recipes, but FSD-C needed to print the recipes. FSD-C stated that FSD-C dropped the ball on that. On 7/23/2024 at 12:29 PM, Surveyor interviewed Dietician D-H. Surveyor asked if a recipe should be used for a resident on a pureed diet. D-H stated a recipe should be used. D-H indicated that Kitchen staff and Dieticians have access to a computer program that has recipes created for each of the dishes served. Surveyor asked if there is a recipe for a baked chicken breast. D-H stated yes and provided the recipe for Surveyor. Surveyor reviewed recipe titled, Puree Baked Chicken Breast. Listed under ingredients: Baked chicken breast, prepared servings-1 serving (1 each). Chicken Broth, Hot- 1 [fluid ounce]. Thickener- 3/4 [teaspoon]. Listed under Method . 1. Measure the number of pureed portions required from the regular recipe. 2. Add to food processor and process to fine consistency. 3. Combine hot broth and thickener. Gradually add to meat while processing. All liquid may not be required. 4. Scrape down sides of processor and process for 30 seconds . Notes: May add commercial thickener if needed to obtain smooth pudding like consistency. Surveyor noted DM-D used water instead of chicken broth and therefore did not conserve nutritive value. DM-D did not add thickener and the pureed food did not appear to be a smooth pudding like consistency. On 7/23/2024 at 3:12 PM, at the daily exit meeting, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern DM-D did not use a recipe to prepare pureed food, DM-D used water instead of chicken broth and R11 indicated that R11's food is tasteless. No further information was provided as to why the facility did not ensure that food was prepared to conserve nutritive value and flavor.

Based on record review, staff interviews, and policy review, the facility failed to report allegations of abuse and neglect to the State agency immediately and failed to report the results of the investigation within five working days of the incident. This involved three (Resident (R) 1 R2, and R3) of three allegations of abuse/neglect investigation reports reviewed. Findings include: 1. Record review of R1's electronic medical record (EMR) revealed the resident was admitted o the facility on 05/08/23 and discharged from the facility on 05/20/23. Review of R1 discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/20/23 located in the MDS tab of the electronic medical record (EMR) identified the resident as having a Brief Interview for Mental Status score (BIMS) score of 11 indicating she was moderately cognitively impaired and she required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. An un-timed and undated written statement written by the Director of Nursing (DON) stated on 05/10/23 she spoke with the resident and the family regarding the resident's complaint of the staff being rough and the staff moving her call light out of reach. The statement did not contain any times. The resident did not know the aide's name but was able to describe her. The resident stated the aide got her dressed and was moving her from the bed to the wheelchair. The DON ask the resident if she thought the aide was being rough, mean or trying to hurt her on purpose and she stated the aide wasn't trying to hurt her on purpose but after she was placed in the wheelchair the aide came in and took her call light away and threw it on the bed. According to the statement the residents call button was located on the resident's bed within reach of the resident. The DON wrote she left the room and talked to Certified Nurse Aide (CNA) 4. She wrote CNA4 stated, she got the resident up, dressed her and put her in her wheelchair. She stated she did not think she was being rough with the resident. When asked about the call light, CNA4 stated the call light was in the resident's lap and the resident kept dosing off and activating the call light so she put the call light on the mattress but within reach of the resident. The DON told CNA4 to not provide care for R1 and CNA4 expressed sorrow and was sorry R1 was upset. Per the statement, the DON returned to the room and explained why CNA4 moved her call light and was told CNA4 would not be caring for her anymore. Review of the staffing schedule for 05/10/23 revealed CNA4 worked the day shift from 6:00 AM to 2:00 PM on the date the alleged incident was reported. Review of a document titled, Summary of Findings/Self-Report, dated 05/24/23. written by the Administrator, revealed on 05/17/23 R1's son contacted her with a concern that his mother had reported that CNA4 had relocated her call light; showered her roughly; and had oxygen tubing moved roughly. The statement was silent to what date the son was alleging this happened. The report stated the DON had met with the resident and daughters previously and it was reported by the resident that the staff was moving too fast during care and the call light was placed on the bed within site and reach of the resident. According to the document the son stated the resident probably had injuries and as result a body check was completed and no bruises, marks, scratches, or pain in range of motion were found. The report stated CNA4 was removed from assignment during the investigation. Review of a statement written by the Social Worker (SW), dated 05/18/23, revealed she interviewed the resident on 05/18/23. During the interview R1 told her the aide grabbed her cheeks and twisted as hard as she could. The resident stated her son told her the aide's name (CNA4) and the SW asked the resident when the last time the aide assisted her and she stated today. After checking the schedule, she told the resident CNA4 was not working to which the resident stated, I don't know, they all look alike. Review of a document titled, Department of Health Services Division of Quality Assurance Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report with a submission date of 05/19/23 at 12:24 PM, revealed the Administrator documented the incident was discovered on 05/17/23 and was reported to the State Agency on 05/19/24 at 12:24 PM by the Administrator. According to the statement written by the DON the resident initially made the allegation on 05/10/23, therefore it was not reported to the State Agency within 24 hours. During an interview on 10/25/23 at 10:53 AM, the Administrator stated the incident was not reported to the State Agency on 05/10/23 when R1 initially made the allegations because she and the DON decided it was all just a misunderstanding. She verified it was not reported until 05/19/24 two days after the son called her (05/17/23) and stated his mother informed him of the allegation. Review of a document titled, Department of Health Services Division of Quality Assurance Misconduct Incident Report The instructions in the report stated the facility was to submit the completed form, any available documentation, and the results of the investigation within five working days. Review of the report revealed it was submitted on 05/24/23 at 3:58 PM. Review of the calendar revealed it was five working days after 05/17/23 and 10 working days after 05/10/23, the date the initial allegation was made. 2. Review of R15's EMR revealed she was admitted to the facility on [DATE] and was discharged on [DATE]. Review of her admission MDS assessment and with ARD of 08/09/23 revealed she had a BIMS score of 15, indicating she was cognitively intact. She required extensive assistance with bed mobility, transfers, toilet use and personal hygiene. Review of a document titled, Interview, dated 08/10/23 and signed by the Physical Therapist, revealed on 08/10/23 R15 reported to her that a night shift CNA took her call button and water away because she called too many times. She wrote that she reported it to the SW immediately. Review of a written statement from the SW, dated 08/10/23, revealed she spoke to the resident and the resident told her the aide took her call light and water away and told her she was on the call light too much and going to the bathroom too much, so she was putting her on a two hour time out. Review of a document titled, Summary of Findings - Self Report, dated 08/17/23, revealed on 08/11/23 the resident's son relayed to staff that the resident told him that a CNA had removed water from the resident. The resident stated that she had spilled water on herself while she was in bed. The report stated the staff member did not replace the water and moved the call light from her reach. The resident described the aide, and the aide was identified as CNA 7. According to the statement CNA7 was removed from the schedule and was not allowed to return to the facility. The aide was from a staffing agency and the staffing agency was informed not to send CNA7 back to the facility. The Administrator contacted the police department who came to the facility and reviewed the details of the incident. R15 declined talking to the police stating, I want to move on, everyone has been good to me especially the night nurses, other girls who help me and the therapist and as long as that one person is gone, I am good. According to the report the facility could not definitely prove intentional abuse or neglect by this person. However, felt that further scheduling of this aide was not in the best interest of the facility. Review of a document titled, (facility name) Written Statement, dated 08/11/23 (no time) and written by the Administrator, revealed the resident stated she put her call light on when she spilled water. She stated a CNA removed her water glass and placed her call light cord out of her reach. She did not know the CNA's name but was able to describe the CNA and the Administrator determined it was CNA7. According to the report the incident happened on the night shift and both aides and the nurse on duty at the time of the alleged incident were interviewed. CNA7 denied the incident however she was the only person on duty who met the description and CNA1 and RN5 each stated they did not witness the alleged incident. Review of a document titled, Department of Health Services Division of Quality Assurance Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report revealed the facility initially reported the incident to the State Agency on 08/11/23 at 1:26 PM, the day after the allegation was reported to the facility. 3. Review of R2's EMR revealed she was admitted to the facility on [DATE] and discharged on [DATE]. According to the admission MDS with an ARD of 09/27/23 the resident had a BIMS score of 15 and required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. Review of an undated written statement from the Occupational Therapist (OT) revealed the resident complained to her of not sleeping well because she is on her back, and it was difficult to breathe. When the OT advised her to put the head of her bed up to breathe better, she stated the CNA would not let her. She stated she ask for the remote to raise the head of the bed and the aide said, what do you need that for? and did not give it to her. According to a document titled, (facility name) Written Statement written by the SW and dated 09/22/23, she wrote the OT made her aware of the resident stated the aide on night shift (09/21/23 to 09/22/23) refused to raise the head of her bed and refused to give her the bed remote to do it herself. She wrote she went to talk to the resident and the resident told her she had no recollection of any issues and stated all the aides had taken good care of her and she felt safe at the facility and had no complaints. Interview with the OT on 10/25/23 at 12:02 PM, she verified her statement did not contain a date or time. She stated in it was on 09/22/23 just before lunch. She stated the resident could not tell who the aide was or provide a description of the aide. She stated she immediately told the SW because the DON was on the phone. A review of the documentation collected during the investigation of the complaint revealed all the staff who worked that shift were interviewed. Review of resident interviews revealed three residents were interviewed on 09/27/23, five days after the allegation was reported. Review of documents titled Department of Health Services Division of Quality Assurance Misconduct Incident Report and Summary of Findings Self-Report revealed the first time this was reported to the State Agency was on 09/29/23 at 5:52 PM five days after the resident told the OT that the aide refused to give her the bed controls. Review of a policy titled, Comprehensive Abuse, Neglect, Mistreatment, and misappropriation of resident property program with a review date of 12/01/2022 was reviewed. The policy stated the following: The Executive Director or Designee will report abuse to the State Agency per State and Federal requirements. A summary of the investigation will be submitted to the State Agency within five working days of the initial report. It is the policy of the 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 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 or do not result in serious bodily injury, the executive director of the facility and other officials (including the State Survey Agency and adult protective services where stat law provides for jurisdiction in long-term care facilities).

Based on record review and staff interview, the facility did not ensure that 1 (Resident 1) of 2 sampled residents received care consistent with professional standards to prevent pressure injuries from developing. Resident (R) 1 was admitted to the facility without a pressure injury. R1 was assessed to have been at risk for pressure injury development. Interventions on the care plan to float heels to reduce pressure were not included in the Certified Nursing Assistant (CNA) Kardex. According to staff interviewed, directions to elevate R1's legs and free float R1s heels were not initiated upon admission and were implemented later but could not recall when. On 9/11/21, R1 was observed to have a broken blister on the left heel. On 9/12/21, heel protection boots were implemented after the discovery of the blister. The facility did not conduct a comprehensive assessments of this area until 9/13/20, at which time the broken blister was described as a deep tissue injury measuring 8.0 X 10.0 with a wound bed covered by eschar. There was no indication once the blister opened and the wound bed was covered with eschar the facility reclassified the ulcer into the appropriate stage. Findings include: According to the undated Facesheet, R1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility completed an Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/20. The MDS indicated R1 had moderate cognitive impairment, required extensive 1 staff assist for mobility in bed, was at risk for developing pressure injuries, but did not have any pressure injuries. The facility completed a Pressure Injury Care Area Assessment (CAA) completed on 09/09/20. The assessment indicated R1 was a new admission from the hospital with a history of Rhabdomyolosis, metabolic [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and [CONDITION(S)]. R1 utilized a pressure redistribution mattress and cushion. R1 was receiving assistance with repositioning. R1 was needing assist with Activities of Daily Living (ADLs) and transfers. R1 is attending therapy and able to make needs known. Will review goals and plan of care. The facility did develop a plan of care for Potential for Alteration in Skin Integrity, dated 08/28/20. The following interventions were listed: * Float heels to reduce pressure on heels and pressure points. Turn/reposition. * Notify Medical Doctor (MD) of any declining changes. * Check skin for redness, skin tears, swelling or pressure areas. Report any signs of skin breakdown. * Do not massage skin over pressure areas. * Perform nutritional screening. Adjust diet/supplements as needed . * Assess, document and report signs of systemic or localized infection . The Certified Nursing Assistants (CNAs) Kardex (the tool the CNAs utilize) dated 08/28/20, does not direct CNA staff to float heels to reduce pressure. According to the Wounds/Skin Check document, dated 08/28/20, R1 did not have any skin breakdown on either heels. The Wounds/Skin Check document, dated 09/11/20, indicated R1 had a left heel blister that was broken and Allevyn (a type of dressing) was applied. There was no further comprehensive assessment documented such as color, pain, periwound, drainage, skin temperature . The Clinical Notes Report dated 09/11/20 at 14:23 indicated, writer was called to room this AM. A broken blister noted to the left heel that measured 5.0 X 6.0 centimeters (CM) was noted. Area was leaking and fluid noted on the bed. Writer washed the left heel and placed an Allevyn dressing. No pain noted. Vital signs stable and [CONDITION(S)] noted to the bilateral lower extremities. The Clinical Notes Report dated 09/12/20 at 10:21 indicated, dressing intact. Sits with heel out and resting on the floor. Encouraged to keep feet up but doesn't feel comfortable with being reclined. Heel boots given but can't use when up due to fall risk. R1 gets up on his own. Encouraged to keep off floor. The Clinical Notes Report dated 09/13/20 at 13:48 indicated, resident being monitored for blister to left heel Resident provided new recliner to assist with elevation of feet and to keep heels off the floor Bilateral lower [CONDITION(S)] remains at plus 2 non pitting. Left heel draining serosanguious drainage, no odor and no signs/symptoms of infection .No complaints of pain to the heel. The Wound Assessment record dated 09/13/20 indicated R1 acquired a deep tissue injury (DTI) related to pressure at the facility. The DTI now measured 8.0 cm X 10.0 cm and the wound bed was covered by eschar (dead tissue) with the wound edges being macerated (soft, white, wet skin that occurs when skin is in contact with moisture for too long). The Assessment documents the DTI has moderate serosanguineous (discharge of both blood and blood serum) drainage, no odor and the surrounding tissue was pink/red. The Assessment documents that R1 has an 8 X 10 cm eschar area on the left heel. Had moderate amount of serosanguious drainage present. No odor. Is painful per resident. Encouraged to keep heels elevated in recliner. Was sitting with feet resting on said area. Heel boots initiated. Will get specialty mattress. According to the National Pressure Injury Advisory Panel (NPIAP), Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .Evolution may include a thin blister over a dark bed wound. The wound may further evolve and become covered by thin eschar .if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates full thickness pressure injury (Unstagable, Stage 3 or Stage 4) . There was no indication once the blister opened and the wound bed was described as covered with eschar the facility reclassified the ulcer into the appropriate stage. The facility added to the CNA Kardex on 09/13/20 to apply heel lift boots when R1 was in bed. The Kardex also indicated to have R1 not wear any shoes. The September 2020 Treatment Record first directed nursing staff to please make sure that resident is in recliner with heels floated or in bed with heels floated. May be up in wheelchair for meals and therapies only. Do not allow resident to self propel in wheelchair with feet until left heel blister has healed. On 03/16/20 at 10:45 AM, Surveyor interviewed CNAs A & B. CNAs A & B both indicated R1 was alert and had some cognitive confusion. CNAs A & B stated R1 wore gripper socks due to lower leg [CONDITION(S)]. CNAs A & B stated R1 was very anxious and needed direction. CNAs A & B indicated the direction to elevate the legs and free float R1's heels were not initiated upon R1's admission to the facility, and was implemented later but could not recall when. CNAs A & B indicated heel boots were used but not until after an area on the heel was discovered. CNAs A & B indicated R1 was weak and would be unable to lift his legs while laying in bed, but would move his legs independently so the heels would have been dragged across the mattress. On 03/16/20 at 11:00 AM, Surveyor interviewed Registered Nurse (RN) C. RN C verified she had documented the initial wound assessment on 09/11/20 when the blister was discovered. RN C reviewed the assessment and verified there was not a full assessment documented. RN C indicated the heel protection boots were implemented on 09/12/20 after the discovery of the blister. RN C stated R1 was independent with bed mobility and would move the legs independently in bed. RN C indicated she believed the blister developed because R1 would rub the heels across the mattress. On 03/16/20 at 2:20 PM, Surveyor interviewed Director of Nursing (DON) D. DON D stated R1 kept his heel protectors on once the facility educated R1 on the importance of keeping pressure off the heel. DON D indicated R1 wore tubigrips (a tubular elastic bandage designed to provide tissue support and compression) and would self propel the wheelchair (w/c) with his heels. Surveyor asked if the facility implemented interventions when aware of how R1 self propelled the w/c. DON D indicated the facility can't stop R1 from self propelling. Surveyor asked if R1 was educated regarding pressure injury prevention prior to the development, since it appeared once R1 was educated after the development, R1 was able to utilize the heel boots. DON D stated the facility implemented heel boots when in bed after the development of the pressure injury to the heel. When asked why the heel boots were not implemented when indicated R1 was at risk for pressure injury development, DON D indicated the facility could not apply heel boots to protect R1's heels because R1 would get out of bed independently to use the bathroom and that would be a fall risk. When asked by Surveyor if any education or other interventions were attempted, DON D indicated she would check to see if there was any more information that could be located. No further information regarding pressure ulcer prevention was given to Surveyor.

Based on observation, interview, and record review the facility did not provide the necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 10 residents (Resident 3) with a full code status and 2 of 61 with advanced directive bracelets (Residents 5 and 10). Resident 3 desired to receive Cardiopulmonary Resuscitation (CPR) in the event of a cardiac or [MEDICAL CONDITION] arrest. Resident 3 presented with rapid respirations, dyspnea and shortness of breath (SOB) from Resident 3's base line. The Licensed Practical Nurse (LPN) failed to notify the Registered Nurse (RN) on duty to assess and monitor Resident 3. When Resident 3 was found pulseless and non-breathing (PNB) the facility failed to immediately initiate CPR and call 911 for Resident 3. The responding LPN did not recognize the need to initiate CPR for Resident 3 but notified the facility RN that Resident 3 may have expired. The responding RN did not initiate CPR, yet she placed a call to Emergency Medical Services (EMS)/ 911 to respond for a possible PNB. The failure to provide the necessary care including immediately initiating CPR created a finding of immediate jeopardy. The immediate jeopardy began on [DATE]. The Nursing Home Administrator (NHA) was notified of the immediate jeopardy on [DATE] at 4:33 PM. The facility removed the jeopardy on [DATE], however the deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its removal plan and as evidenced by the following: The facility identifies a resident's CPR preference by placing either a Do not Resuscitate (DNR) or Full Code bracelet on the resident's wrist. Resident 5 and Resident 10 were found to have both a DNR and a full code bracelet on the same wrist. This is evidenced by the following: The Centers of Medicare and Medicaid Services Survey and Certification Memo ,[DATE] revised 1.23.15 states in part: Initiation of CPR -Prior to the arrival of emergency medical services (EMS), nursing homes must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. The American Heart Association (AHA) publishes guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). These guidelines reflect global resuscitation science and treatment recommendations from the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with Treatment Recommendations. According to the AHA, reversal of clinical death is among the goals of ECC since brain damage begins four to six minutes following [MEDICAL CONDITION] if CPR is not administered during that time. In the guidelines, AHA has established evidenced-based decision-making guidelines for initiating CPR when [MEDICAL CONDITION] occurs in or out of the hospital. AHA urges all potential rescuers to initiate CPR unless: 1) a valid DNR order is in place; 2) obvious signs of clinical death (e.g., rigor mortis, dependent lividity, decapitation, transection, or decomposition) are present; or 3) initiating CPR could cause injury or peril to the rescuer. (Note: Rigor mortis is caused by chemical changes in the muscles after death, causing the limbs of the corpse to stiffen. Rigor mortis can occur as soon as thirty minutes after death. Dependent lividity/livor mortis is a settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin. Livor mortis starts in ,[DATE] minutes. Then color becomes purplish red in next ,[DATE] hours.) The facility's CPR - Cardio-Pulmonary Resuscitation policy dated ,[DATE] states in part: Policy: (Facility Name) shall support the beliefs of residents to decide their specific course of care and treatment including the right to be resuscitated in the event of a cardio-pulmonary arrest. Purpose: To establish a protocol whereby a person who experiences sudden unexpected cardiac or respiratory arrest/failure, is resuscitated by personnel certified in CPR. Guidelines: 2. the admitting nurse is responsible to ensure the completion of the CPR Preference form and file it in the medical record. 4. If the resident's preference is CPR, the unit secretary will affix a Red/Pink Heart-shaped sticker to the spine of the resident's medical record. 6. Only residents who have elected to receive CPR will wear a Red/Pink Heart on their identification band (ID). 13. The resident's chart should always be checked immediately regarding the resident's code status. The nurse/therapist should not just rely on the absence or presence of a Red/Pink Heart ID band. Procedure: 1. If a resident is discovered without vital signs (they are warm to touch, their skin is not blue, their limbs are as flexible as prior to the arrest and there is no pooling of blood evident) then the resident CPR preference is followed: A. Person finding resident with cardiac and/or respiratory arrest shall summon help. C. Check patients' medical record for code status. In the event the resident is unresponsive with absence of vital signs summon help. D. Notify the nurse and/or nurse supervisor. 2. If the resident has indicated that he/she wants CPR, a designated staff person will activate the EMS. A. Yell for help B. Dial 911 immediately. 3. Initiate CPR 7. CPR will not be initiated if one or more of the following is present because any and/or all of these criteria could indicate that resuscitation would be ineffective. A. Rigor mortis. B. Pooling of blood in the body parts closet to the floor. (Depending on the position of the resident this could be the feet, the buttocks or the side the resident is lying on). This would indicate a significant time elapsing in circulation of blood. C. Upon discovery, a nurse must assess for the above. If any of these symptoms are present, CPR will not be initiated. Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's physician orders [REDACTED]. Resident 3 was [AGE] years old and his own decision maker. Resident 3's signed telephone order dated [DATE] states in part: Full Code. Resident 3's signed CPR Preference form dated [DATE] states in part: I want CPR attempts. In the event my heart and breathing should suddenly stop, I elect to have (facility name) employees initiate CPR. Nursing notes dated [DATE] at 11:11 PM state in part: Bi-pap on at night. [MEDICAL CONDITION] noted to all extremities; scattered bruising throughout entire body. Resident 3's vital signs dated [DATE] at 8:20 PM include: Pulse: 93, Respirations: 18, Temperature 97.0 and Blood Pressure: ,[DATE]. Nursing notes dated [DATE] at 12:45 AM state in part: rapid respirations, dyspnea, and shortness of breath or trouble breathing when lying flat. Breath sounds diminished, clear bilaterally. Head of bed elevated, oxygen on per physician orders. Multiple bruises and skin tears remain. Refused bi-pap on night shift; removed it 3 times stating I don't want to wear it. Oxygen on at 4 liter per nasal cannula; pulse oximetry (test used to measure the oxygen level of the blood). 91%. Head of bed elevated for shortness of breath. Resident 3's vital signs dated [DATE] at 12:45 AM include: Pulse: 60, Respirations: 28, Temperature 97.2 and Blood Pressure: ,[DATE]. Note Resident 3's respirations had increased from 18, baseline admission rate just 4 hours earlier, to 28. LPN D did not report this change to the registered nurse supervisor, RN-E, for further evaluation and assessment of the resident's condition. (Note: The American Medical Directors Association (AMDA) Acute Change of Condition in Long-Term Care algorithm indicates an immediate notification of the physician is warranted when respirations are greater than 28.) On [DATE] at 2:22 PM, Surveyor reviewed this note with LPN D. Surveyor asked LPN D if Resident 3 was working hard to breathe, using accessory muscle, struggling to breathe. LPN D stated I do not remember the respiratory rate but I know it was more than 20 or 24. Resident 3 was not working hard, the respirations were just rapid. Surveyor asked LPN D if she was concerned with his increased respirations. LPN D stated she was not concerned. Nursing notes dated [DATE] at 05:15 AM state in part: notified RN supervisor, RN E, regarding concern that Resident 3 may have expired. Resident 3 was last checked by LPN D at 4:00 AM. At that time Resident 3 was sleeping and appeared comfortable, oxygen on at 4 liters nasal cannula. 911 was called and arrived at 5:30 AM and confirmed that Resident 3 had expired. On [DATE] at 2:22 PM Surveyor interviewed LPN D regarding the facility's CPR policy. LPN D stated if a resident is a full code and is found PNB the staff must first call the supervisor to assess the resident. Once the supervisor assesses the resident then the staff should start CPR and call the ambulance. LPN D stated CPR does not have to be performed, however, if the resident is obviously deceased . Surveyor asked LPN D what she meant by obviously deceased . LPN D stated if the resident is cold and looks like they have been deceased for a while. Surveyor asked LPN D if she had worked with Resident 3 the day Resident 3 expired. LPN D stated she was on duty and was the nurse that found Resident 3. LPN D stated she was doing her rounds and walked by Resident 3's room and found Resident 3 slumped to the side, and Resident 3 appeared dead, skin was yellow in color. LPN D stated she checked Resident 3's radial pulse and there was no pulse. LPN D then checked Resident 3's apical pulse and found no pulse. LPN D stated she then called RN E, the RN Supervisor. Surveyor asked LPN D if Resident 3 was a full code. LPN D stated, Yes. Surveyor asked LPN D why she did not initiate CPR and LPN D stated the RN has to assess the resident before CPR is started. Surveyor asked LPN D if she called 911. LPN D stated, No, RN E called 911 after she assessed Resident 3. Surveyor asked LPN D if RN E knew Resident 3 was a full code. LPN D stated she told RN E Resident 3 was a full code. LPN D stated RN E assessed Resident 3 and stated Resident 3 was deceased and she stated not to start CPR. Nursing note by RN E dated [DATE] at 5:15 AM states in part: received call from LPN D that she thinks Resident 3 is dead and asked if writer, RN E, could assess. LPN D informed this RN, that LPN D checked in on Resident 3 at approximately 4:00 AM. Arrived to room and noted Resident 3 was unresponsive, slumped leaning to the right side of his bed, cold to touch, very cyanotic, pale white, PNB. 911 was notified, arrived within minutes to assess and confirmed that resident was deceased . The contemporaneous nursing note written by RN E does not indicate that rigor mortis was present or that lividity was present. Nursing note dated [DATE] at 7:38 AM states in part: LPN D notified this RN, RN E, at approximately 5:20 AM to come assess resident. 911 was notified at approximately 5:23 AM and arrived approximately 5:29 AM. On [DATE] at 3:03 PM Surveyor interviewed RN E regarding the facility's policy on CPR. RN E stated if a resident is a full code CPR should be initiated, 911 should be called and the supervisor should be notified in that order. Surveyor asked RN E if she worked with Resident 3 the night he expired. RN E stated she received a call from LPN D stating she thought Resident 3 had expired and asked me to come over to the unit to confirm. LPN D told me, RN E, that Resident 3 was a full code. RN E stated LPN D did not initiate CPR but she should have. RN E stated when I assessed Resident 3, according to RN E this was just seconds later, and Resident 3 was obviously dead, cyanotic and cold to touch. Surveyor asked RN E if cyanosis and cold to the touch were reasons not to initiate CPR. RN E stated, Yes. RN E stated she called 911 and EMS arrived on the scene moments later, hooked resident up to a cardiac monitor and confirmed Resident 3 was deceased . Surveyor asked RN E why she called 911 if she thought Resident 3 was obviously deceased . RN E stated it's facility policy. Surveyor asked RN E if she called 911 on all deceased Residents at the facility and she stated no but Resident 3 was a full code. Surveyor asked RN E if CPR was initiated by EMS or facility staff. RN E stated, No. RN E stated LPN D should have initiated CPR, called 911 then called the supervisor. RN E stated I told all of this to RN Nurse Manger (RNM) G. Surveyor asked RN E if she has received education regarding the facility CPR policy since the incident. RN E stated the facility had an in-service packet including the policy by the 24-hour report board. RN E stated staff were to read over the policy and sign that it was completed. A Prehospital Care Report from (Fire Department Name) Fire Department (EMS) dated [DATE] states in part: Response time: dispatch notified at 5:27 AM at scene 5:29 AM. Provider Impression: Primary Impression: [MEDICAL CONDITION]. Call type: Light and Sirens; 911 Response Narrative: (Fire Department Name) called for a male patient that is possibly PNB. Arrived at (Facility Name) to find a [AGE] year old patient lying slumped over in bed; the staff stated that they last saw the patient about an hour and a half ago. The patient was admitted to the rehab facility last night after a long stay at (Hospital Name). The patient has a long cardiac history; patient PNB, cold centrally. The patient was leaning to right side almost off the bed. [MEDICAL CONDITION] Data: [MEDICAL CONDITION] not witnessed. Initial Cardiac Rhythm: Asystole Resuscitation not attempted considered futile. (Asystole is a state of no cardiac electrical activity, hence no contractions of the myocardium and no cardiac output or blood flow. Asystole is one of the conditions that may be used for a medical practitioner to certify clinical or legal death.) On [DATE] at 9:35 AM Surveyor interviewed EMS Lieutenant H regarding what criteria the EMS uses to not initiate CPR. EMS Lieutenant H stated EMS will not initiate CPR for nursing home residents if the person has had an unknown down time or asystole as attempt is considered futile. A fax sent to Resident 3's physician dated [DATE] at 5:43 AM states in part: Resident 3 coded and EMS was notified. He has expired. On [DATE] at 2:10 PM Surveyor spoke with RNM G regarding Resident 3. RNM G stated when she did not see Resident 3 until approximately 6:20 AM and Resident 3 had been deceased for 1 to 1 ½ hours. RNM G stated Resident 3 had a lot of bruising to his arms from the hospital and terrible skin. RNM G stated when I saw Resident 3 I felt Resident 3 demonstrated lividity, almost frozen like had been dead for a little bit, but this was at least 1 to 1 ½ hours later. On [DATE] at 2:55 PM Surveyor interviewed Director of Nursing (DON) B regarding Resident 3. Surveyor asked DON B if a resident is a full code and has a respiratory or [MEDICAL CONDITION] how should the staff respond. DON B stated the staff should call for help, check the resident's chart for code status, initiate CPR immediately and call 911. Surveyor asked if she had spoken with either of the nurses regarding Resident 3 and why the nurses did not initiate CPR. DON B stated she spoke with LPN D and LPN D did not think Resident 3 was breathing so she called RN E. According to DON B, LPN D stated she had checked in on Resident 3 one hour before she found him PNB. DON B stated she asked LPN D why she did not start CPR and she stated no one told her to start CPR. Surveyor asked DON B if LPN D could initiate CPR without an RN assessment. DON B stated yes they should start CPR immediately. DON B stated she spoke with RN E. RN E stated she assessed Resident 3 and Resident 3 was cyanotic and cold. DON B stated cyanosis and cold is a reason not to initiate CPR. DON B stated based on what RN E had stated and documented she would not have expected CPR to be initiated. Surveyor asked DON B if the facility has completed mock code drills. DON B stated the facility has not completed mock code drills but DON B stated that would be a good thing to do. Surveyor asked DON B how the staff identifies a resident's CPR preference. DON B stated the staff would need to check the chart for CPR preference. Of note, DON B has worked at the facility for 6 months. On [DATE] at 4:33 PM Surveyor met with NHA A, DON B and RNM G. NHA A stated RNM G wrote a note about the incident with Resident 3. RNM G stated that she did not write a report. What LPN D and RN E told me sounded like he was deceased . Surveyor asked NHA A why RN E called 911. NHA A stated we even questioned why they called 911 when Resident 3 was obviously deceased . We did not get an answer for that. NHA A stated we provided an in-service on CPR. On [DATE] at 9:35 AM Surveyor was asked to meet with Nursing Home Administrator (NHA) A and RN F. NHA A stated we brought in RN E and LPN D and re-interviewed them and we would like them to speak with you. RN E entered the room and stated she had additional information she would like to share. RN E stated when she entered Resident 3's room Resident 3 was leaning to the right there was pooling in Resident 3's extremities. I could see the pooling I did not have to move Resident 3. Resident 3 was cold to the touch and I called EMS from the room. RN E stated Resident 3 was very cold, pale, pasty it was very obvious Resident 3 was deceased and laying there for some time. Surveyor asked RN E why she called 911 RN E stated it is facility policy to call 911 if a resident has a full code status. Surveyor asked RN E if a RN has to call 911. RN E stated anyone can call 911. RN E stated someone should call 911 immediately. RN E stated the policy states to initiate CPR; call 911 and call the RN supervisor. NHA A stated LPN D stated Resident 3 was slumped over, yellow /gray in color and cold and she called RN E right away. RN E thought he was dead. RN E stated LPN D told me that Resident 3 was a full code. I am not sure why LPN D did not call 911 immediately. NHA A stated if the resident is deceased we would not start CPR. NHA A stated I understand there are educational opportunities for CPR but Resident 3 was a compromised gentleman. RN E stated it was discussed that I stated Resident 3 was pale and cyanotic I did not use those words. Surveyor stated to RN E in our interview on [DATE] you described Resident 3 as being cyanotic and cold and these were reasons not to initiate CPR. Surveyor stated to RN E your nursing notes dated [DATE] at 5:15 AM state cyanotic and pale white. RN E stated I would have been wrong; cyanosis and pale are [MEDICAL CONDITION]. LPN D found Resident 3 to be PNB. LPN D did not initiate CPR for Resident 3 and did not immediately call 911. LPN D contacted RN E. RN E did not initiate CPR. The failure to immediately begin CPR created a finding of immediate jeopardy. The facility removed the immediate jeopardy on [DATE] when they began education with staff on the facility's CPR policy, starting CPR and notification of 911. Nursing staff were educated on change of condition when to assess and when to notify the physician regarding changes of condition. A facility sweep was completed to identify all full code residents and verify appropriate full code bracelet and ensure that signed consent in the chart matches the bracelet resident is wearing. Re-education is being provided to nurses on removing all unauthorized bracelets upon admission or when code status changes. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as evidenced by the following: Example 2. On [DATE] at 3:22 PM DON B stated to Surveyor that residents wear either a State DNR bracelet or a white bracelet with a heart on it for full code. Resident 5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of ,[DATE] indicates a Brief Interview of Mental Status (BIMS) score of 15 indicating Resident 5 is cognitively intact. On [DATE] at 5:00 PM Surveyor noted Resident 5 with State of Wisconsin DNR bracelet on her left arm and a clear bracelet with a red heart indicating Resident 5 is a full code. Surveyor asked Resident 5 what the State of Wisconsin DNR bracelet was Resident 5 stated a DNR bracelet. Surveyor asked Resident 5 what the red heart bracelet was Resident 5 stated I don't know something to do with my heart. Surveyor asked Resident 5 if her heart or breathing were to stop would she want CPR Resident 5 replied no I am a DNR. On [DATE] at 5:12 PM Surveyor interviewed LPN J regarding Resident 5's code status. LPN J stated residents wear a bracelet. Surveyor took LPN J to Resident 5's room and showed her Resident 5's two bracelets on the left arm one indicating DNR and one indicating full code. LPN J stated that's confusing, I'm not sure why she has two bracelets on unless she just changed to a DNR and someone did not take a bracelet off. Let's go ask RNM I. On [DATE] at 5:15 PM Surveyor interviewed RNM I regarding Resident 5's code status. RNM I stated Resident 5 is a DNR, she just changed her preference on [DATE] at Resident 5's quarterly staff meeting. I thought the full code bracelet was off; it should have been taken off [DATE]. Resident 5's CPR Preference form dated [DATE] states DNR. The facility failed to ensure residents have the appropriate CPR preference identification bracelet on. Consequently, residents could have had a delay in the initiation of CPR due to residents being identified with 2 bracelets indicating both DNR and CPR. Example 3 Resident 10 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident 10 had a Minimum Data Set completed on [DATE], Resident 10's BIMS (Brief Interview for Mental Status) was identified as a 13 indicating Resident 10 is Cognitively Intact. Resident 10's medical record indicates that he is of his own person and that on [DATE] his preference on code status was indicated as full code that if his heart stops beating that resuscitation measures should be taken. On [DATE] at 3:25 PM Surveyor observed a bracelet on Resident 10's right arm that is purple with the letters DNR printed on it in large black print. Under the bracelet a white bracelet is observed with a red heart on it. On [DATE] at 4:27 PM Director of Nursing (DON) B approached Surveyor and stated that Resident 10 should not have had the purple DNR bracelet on. She had told the unit to remove the purple DNR bracelet. DON B noted that Resident 10 now has considered that he may want to switch his code status to a DNR. DON B notified the social worker to go and discuss with Resident 10 his preference on Code Status. Surveyor asked DON B where Resident 10 received the purple DNR bracelet. DON B replied that Resident 10 received the bracelet about three weeks ago when he was in the hospital. On [DATE] at 3:30 PM Surveyor interviewed Registered Nurse (RN) N on how do you know the resident's wishes if he is to be listed as a Full Code or a Do Not Resuscitate (DNR). RN N stated that they would look on the dry erase board and the resident chart in the charting room. Surveyor asked what Resident 10's code status is. RN N identified from the medical chart and the dry erase board that Resident 10 is identified as a full code. Surveyor asked why Resident 10 has a purple bracelet identifying him as a DNR on his wrist. RN N stated that she would have to go look at his bracelet. RN N identified that Resident 10 had a purple DNR bracelet on and she wanted to ask the nurse manager. Surveyor asked RN N if she has conducted Mock Drills on Full Codes here at the facility. RN N stated that she has just started at the facility last May and they have not done one yet since she has been here, but if they did she would check the dry erase board and the chart. Surveyor asked RN N if she has done any trainings or in-services on Full Codes here at the facility. RN N stated I think so, but I am not sure. Surveyor asked RN N is there any time when assessing a resident that is listed as wanting to be a full code that you would not start CPR? RN N replied when they are cold I guess, but I will get the policy to double check. On [DATE] at 3:55 PM, Surveyor interviewed RN M on if she has ever participated in drills at the facility on how to perform a full code. RN M replied no that she has not participated in any drills. Surveyor asked RN M if there is a policy on when to initiate Cardiopulmonary Resuscitation (CPR) if someone is found pulseless and not breathing. RN M stated that they would run and check the chart or dry erase board in the chart room and that the resident should also have a white wrist band with a heart on it on their wrist. Surveyor asked RN M what criteria would be used when to not initiate CPR at this facility. RN M replied that if the resident is cold. We would probably start CPR but call the doctor to ask if we should do CPR, but still would probably start CPR. Surveyor asked RN M if she has participated in any in-services at the facility related to CPR and Full Codes. RN M stated no they have not done any regular in-services. Surveyor asked RN M how you would know if someone wants to be a full code. RN M replied that you would look in the chart room at the dry erase board, the resident's chart, and look for the white wrist band with the heart on it. RN M notes that they do offer CPR training to everybody both Certified Nursing Assistants and Nurses, but it is not mandatory. On [DATE] at 2:00 PM, Surveyor interviewed LPN R regarding any inservices or training she has had in the past week. LPN R indicated she has not had any training or inservices. LPN R was starting to work the evening shift. On [DATE] at 2:15 PM, Surveyor interviewed LPN S regarding any inservices or training she has had in the past week. LPN S indicated she has not had any training or inservices. LPN S was starting to work the evening shift. On [DATE] at 3:20PM, Surveyor interviewed LPN T regarding code status. LPN T indicated she had not had any inservicing/education regarding CPR/code status. LPN T stated Not since I got here mid-January related to having mock drills for code status. LPN T indicated residents would have a heart on their chart, a pink or red heart on their name band and would check the spine of a resident's chart as a quick glance. On [DATE] at 3:30PM, Surveyor interviewed RN U regarding code status. RN U indicated she did not remember any inservices/education recently related to code status and no mock drills recently. RN U indicated she would initiate CPR unless it was apparent beyond anything they can do. RN U stated such as apparent lividity, rigor, body temperature, like if cooling or clammy. [DATE] at 3:55PM, Surveyor interviewed RN Q regarding code status. RN Q indicated she would know a resident is a full code by looking in the chart, checking wristband with heart sticker, heart on spine of resident chart. RN Q indicated she has not had any in-services/education at facility related to code status. RN Q also indicated she has not participated in mock drills. Surveyor asked RN E how she would identify a resident's preference for CPR. RN E stated there is a sticker on the binding of the residents chart. RN E stated I think they have a bracelet as well I think it's yellow if the resident is a Do Not Resuscitate (DNR). Surveyor asked RN E what if the resident is a full code. RN E stated I don't know.

Based on record review and interviews the facility failed to ensure a resident who enters the facility without pressure injuries, does not develop pressure injuries unless the individuals clinical condition demonstrates that they were unavoidable and a resident having pressure injuries, received necessary treatment and services to promote healing, prevent infection and prevent new pressure injuries from developing for 2 of 15 Residents sampled (Residents 7 and 15). Resident 7 was admitted to the facility without a pressure Injury (PI) (previously known as a pressure ulcer) and was identified to be at risk for PI development. Interventions were not put into place to prevent Resident 7 from developing a PI or prevent the worsening of the PI. Resident 7 developed an avoidable, unstageable PI to the Right Buttocks/coccyx while in the facility. Resident 15 was admitted to the facility without pressure injuries. Resident 15 was assessed by the facility to be at risk for the development of pressure injuries. Resident 15 developed an avoidable Stage II Pressure injury which progressed to a Stage III pressure injury. The facility did not implement adequate measures to prevent pressure injuries from worsening after the development of Resident 15's pressure injury to his coccyx area. This is evidenced by: The National Pressure Ulcer Advisory Panel (<http://www.npuap.org/>) NPUAP defines Pressure Injury on 04/23/2016 as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue. NPUAP goes on to define on 04/23/2016 the following: Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in dark pigmented skin. Present of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial thickness skin loss with exposed dermis Partial thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence-associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-Thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-Thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Facility policy title Wound prevention, Management and Documentation in part, dated August 2014, Policy: (Facility name) is committed to wound prevention and management while meeting state and federal regulations. It is the facility policy to identify residents at risk for impaired skin integrity. Residents who have wounds will receive the necessary treatment and services to promote healing, prevent infection and prevent further skin breakdown. Procedure: 1. Braden assessment is completed on all residents upon admission, readmission, then quarterly, annually and whenever there is a change in condition. 2. Residents are assessed to identify the resident's potential risk for developing skin breakdown and to determine interventions to modify, stabilize or decrease risk factors. a. All residents at risk for developing skin breakdown have an appropriate care plan in place identifying preventative measures. Pressure Ulcer Prevention and Standard of Practice Interventions: 1. Mobility/Activity Deficit: a. For bed bound individuals: Reposition at least every 2 hours. Use Pillows or foam wedges to keep bony prominences from Direct contact. b. For chair bound individuals: Reposition at least every hour. Use pressure reducing devices for seating surfaces. Consider a therapy screen for postural alignment, distribution of weight, and pressure relief when positioning individuals in chairs or wheel chairs. Education: Education will be provided to all nursing staff on wound care protocols and management and prevention of pressure ulcers. Facility bed manufacturer form dated 2013, Joerns PrevaMatt series Therapeutic support surfaces (mattress). Per Maintenance Personnel W the facility uses the PrevaMatt Elite on the resident beds. PrevaMatt Elite; recommended for prevention and treatment of [REDACTED]. Two ply construction incorporates cross-cut two inches of viscoelastic foam [MEDICATION NAME] to envelope the body and redistribute pressure. Facility bed manufacturer form dated 2014, Joerns PrevaMatt series Therapeutic support surfaces (mattress), Per Maintenance Personnel W the facility uses the Alleviate mattress Tempur option Clinical indications: Prevention to stage III. Tempur option is suitable for treatment of [REDACTED]. On 6/29/16 at 2:42 PM Surveyor interviewed Maintenance personnel W regarding the facility mattress. Maintenance Personnel W stated the facility has order from 10 - 20 Alleviate mattresses in the past 18 months. He continued to state he does not keep a record of Resident on the New alleviate beds. Maintenance Personnel W stated when a Mattress goes bad we replace it with a new mattress. Maintenance Personnel W stated he does not place the mattress on the resident condition or if there is a pressure injury present. He also stated he has placed them around the facility not according to unit but whenever a mattress needs replacing he puts the new Alleviate in the place. Maintenance Personnel W stated he does not know how many he has actually replaced if it closer to 10 or 20 it was an estimated number. On 6/29/16 Surveyor interviewed Director of Nursing (DON) B regarding the type of mattresses used on beds. DON B stated she does not know what mattress is used on what resident. DON B stated she does not know if Resident 15 or Resident 7 was on which mattress, she does not look at the mattress when someone is at risk prior to getting an air mattress. DON B stated she would expect an air mattress on all resident with a stage III pressure injury or higher. Example 1 Resident 7 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Resident 7's Minimum Data Set (MDS) assessment, dated 12/30/2015, indicated that Resident 7 was at risk for developing pressure injuries; she did not have one or more unhealed pressure injuries at stage 1 or higher, and that Resident 7 has Moisture Associated Skin Damage (MASD). It has indicated that Resident 7 required extensive 1 person physical assist for bed mobility, and transfers, and that Resident 7 was totally dependent on staff for toilet use. Resident 7's Resident CNA (Certified Nursing Assistant) Care Card, dated 12-9-15 states in part: Transfers (To & from Bed - To & from chair) Reposition: assist every 1-2 hrs. (Hours) and prn (as needed) Bed Mobility: Assist of 2. Under Preventative skin interventions, the following is marked Float heels and Heel boots in bed no other interventions are marked. Resident 7's Resident CNA (Certified Nursing Assistant) Care Card, dated 1-12-16, with reviewed dates of 2/10/16, 2/16/16, 2/26/16 states in part: Transfers (To & from bed - to & from Chair) Reposition: assist every 2 hrs. Side to side in bed (hand written in with no date) Bed mobility assist of 1 and pillow between legs (hand written in with no date). Under section titled Preventative Skin Interventions the following is marked/indicated: wound: peri area , B (bilat/both) feet, RBTX (Right Buttock), R (right) groin, R thigh, no shoes, turn schedule Q 2 (every 2 hours) (and) PRN (as needed), Float heels, elevate extremities when up, other: vascular boots -keep feet elevated at all times (2/16/16), Protective treatment: peri area, protective dressing: RBTX, R foot, Positioning pillows: pillow between legs in bed side to side, WCC: air (1/12/16), specialty mattress: air (1/12/16). Resident 7's Resident CNA Care Card, not dated, with reviewed dates of 3/22/16 and 5/16/16, states in part: Transfers (To & from bed - to & from Chair) Reposition: assist every 2 hrs. Bed Mobility: Assist of 1. Under section titled Preventative Skin Interventions the following is marked/indicated: Wound: B feet, R groin, BTX Coccyx no shoes Encourage to lay down every 2 hours, position side to side float heels wedge pillow for floating, elevate extremities BLE (bilateral lower extremities) when in w/c (wheel chair) when possible, other: Vascular boots BLE at all times protective treatment: skin prep barrier cream peri, protective dressing: B feet, BTX, R groin positioning pillows, WCC air cushion, specialty mattress: air. Resident 7's Admission Care Plan/Medicare Guidelines under section alteration in skin integrity dated 12/4/2015, indicates reposition per turn schedule prn, float heels prn -in bed & recline and Vascular boot on in bed Resident 7's Admission Care Plan/Medicare Guidelines form dated 12/24/2015, states in part: Alteration in skin integrity . E/B (evidenced by): OA (open area) Buttock .Goal: .2. Improved skin integrity e/b: (no) OA. The following interventions were marked on the form: confer with wound care nurse prn , provide treatment as ordered .barrier cream .reposition per turn schedule, measure wound weekly, float heels, mattress: pressure reducing, multivitamin. Resident 7's Admission Care Plan/Medicare Guidelines form dated 1/9/2016, states in part: Alteration in skin integrity .E/B: OA R (right) buttock .Goal: 1. Open area will heal (without) infection 2. Improved skin integrity e/b: (no) OA's 3. No s/s (signs and symptoms) infection the following are marked under Goals: confer with wound care nurse prn, complete skin assessment, provide treatment as ordered repositions per turn schedule, measure wound weekly, float heels, mattress: pressure reducing, multivitamin. Resident 7's Admission Care Plan/Medicare Guidelines under section alteration in skin integrity dated 1/30/2016 states in part: E/B: OA to buttock- pressure ulcer the following are marked/indicated under Goal: 1. Open area will heal 2. Improved skin integrity 3. No s/s infection, confer with wound care nurse, complete skin assessment, see preventive choices, provide treatment as ordered: see Tx (treatment) book/ .per WCC RN (wound care certified Registered Nurse) recommendations MD (medical doctor) orders, 2/16/16 - confer c (with) wound clinic, reposition per turn schedule q (every) 2° (hrs.) side to side in bed, measure wound weekly, refer to RD (Registered Dietician), supplement: multivitamin, Juven BID (twice daily), provide special positioning device: air mattress, air cushion chair 2/16/16 at all times vascular boots, float heels, notify MD of any declining changes, mattress: air mattress, multivitamin, Resident 7's Care Plan, dated 3/22/2016 states in part: Actual Impaired Skin Integrity under approach the care plan states in part: apply lotion daily to residents skin, assess impaired skin area, color, odor, amount of drainage and surrounding skin at least weekly and record on weekly wound sheet, avoid pressure to affected area, complete Braden assessment per protocol, Consult wound care specialist as needed, encourage and educate resident to shift weight, Encourage resident to consume at least 75% of diet, monitor and record amount consumed, keep skin dry and moisturized, monitor for pain every shift, monitor for pain prior to treatment, medicate for pain prior to treatment, monitor for signs and symptoms of infection of impaired skin, monitor wound healing weekly and PRN, perform skin checks on bath and shower days, provide assistance as needed with turning and repositioning, .provide nutritional supplements as ordered, provide pressure reduction mattress-air mattress and cushion, provide resident with education regarding skin care, provide wound care as ordered by MD, air mattress to reduce pressure, educate resident on importance of laying down every two hours and positioning side to side to reduce pressure, .encourage resident to lay down every 2 hours, float heels in bed using wedge support, position side to side in bed to reduce pressure, wear vascular boots to bilateral LE at all times except for cares, review with hospice plan of care 12/4/2015 9:27:52PM Skin condition/wound progression note states in part: New (1st recording) for site-352. Present on the coccyx is redness. The following findings were document. General Comments: buttock cleft and peri area reddened. (Please note no measurement or staging of redness) 12/7/2015 9:42:21PM Progress note states in part: All skin intact. Barrier cream applied to buttock and peri area. 12/10/2015 12:15:00AM progress note states in part: slept in recliner 12/11/2015 3:30:00AM Progress note states in part: Resident is sleeping in her recliner over night 12/11/2015 11:42:32PM Progress note states in part: Braden score=16, low risk for skin breakdown, elevated to moderate risk r/t vascular insufficiency and occlusion on right ankle .Resident has DM type II. Barrier cream applied to redness to buttock and groin. No open areas noted at this time. 12/13/2015 1:39:51AM Progress note states in part: Resident sleeps in the recliner with her legs elevated per her preference. 12/14/2015 12:00:00PM Skin condition/wound progression note states in part: Skin and wound update to site-352. Present on the coccyx is a Redness .General comments: Redness continues due to MASD (Moisture associated skin damage) related to loose stools. Taking scheduled [MEDICATION NAME]. Barrier cream used. (Please note no measurement or staging of redness) 12/15/2015 9:43:04PM Progress note states in part: Reddened area to coccyx area appears macerated and with slough. Area cleansed and dried well. New cushion provided to w/c; gel with cut out to coccyx area. 12/16/2015 11:02:33AM Skin condition/wound progression note states in part: Skin and Wound Update to site-352. Present on the coccyx is a Redness .General comments: Excoriation along buttocks from MASD. Area to left of coccyx measures 1.5cm x 1.0cm (centimeter) is covered with white/yellowish slough. Skin is moist. Order for Santyl to slough and cover with [MEDICATION NAME] dressing daily and prn. Continue with barrier cream to buttocks excoriation, but assess if strong product needed. Updated RD also. 12/16/2015 2:57:46PM Progress note states in part: (physician name) was updated to the area to the coccyx. See new orders to wash area with normal saline, pat dry, apply santyl to the wound. Followed by the [MEDICATION NAME] dressing daily and prn. Resident was updated to the new orders. Treatment done and started this pm. 12/17/2015 5:29:18PM progress note states in part: Dressing replaced to coccyx over MASD with slough. Resident 7's Facility Discharge Summary states in part: admitted : 12/4/15 discharge date : 12/21/15, section labeled Skin Integrity states Decubitus: area to coccyx (with) Treatment: Santyl (and) [MEDICATION NAME] dressing daily (changed) 12/21/15 AM. Teaching states in part, Wound comments: Santyl + [MEDICATION NAME] to open coccyx area daily . 12/21/2015 9:00:00AM Progress note states in part: Resident discharging to (hospital name) for surgery today. Hospital Discharge summary dated 12/21/2015 states in part: You were admitted on : December 21, 2015 .You were discharged on : December 24, 2015 .Medication list Start taking these medications dimethicone 1% cream topically every 4 (four) hours as needed (Stage 2 Pressure Ulcer). 12/22/15 (Hospital name) Wound note by RN (Registered Nurse) Z states in part: She (Resident 7) has chemical erosion mostly on her right buttock. She has multiple small round open areas noted. They appear clean with pink base. 12/24/15 1:04PM (Hospital name) Discharge summary, electronically signed by MD on 12/24/15 at 1:39PM states in part: Pt (patient) was noted to have several excoriated ulcers on her buttocks .Discharge instructions: .4. Buttocks ulcerations: bid (twice a day) and with any stooling dust the buttocks with stoma powder and then apply skin protectant cream to open and red skin. 12/24/2015 4:34 PM progress note states in part: resident scores at low risk for skin breakdown using the Braden scale but elevated to high risk at this time secondarty (secondary) to open areas on the periarea . 12/24/2015 8:55:14PM, Skin condition/wound progression note states in part: Present on the Coccyx is Redness .General comments: Resident readmitted from hospital. Open area to buttocks from MASD still present. Treatment in place, skin tissue temperature is consistent with surrounding tissue, margins are irregular, General appearance of affected area is reddened . (Please note no measurement) 12/28/2015 3:58:38PM, Skin condition/wound progression note states in part: Present on the coccyx is redness .General Comments: There are three areas to the coccyx, and one is 3cm by 2cm, the second is 1 cm by 1 cm, and the third is 1 cm by 1 cm, and the treatment is in place. 01/04/2016 11:00:00AM Progress note states in part: Resident was discharged to (Hospital name) for surgery today, of the right femoral popliteal bypass. Resident 7's Facility Discharge Summary states in part: admitted : 12/24/15 discharge date : 1/4/16 section labeled Skin Integrity states in part: Decubitus: coccyx area Treatment: Cleanse buttock BID apply after BM Dust (with) stoma powder F/B (followed by) barrier cream 01/08/16 Hospital Wound note by RN Z states in part: The pressure ulcer is now one ulcer. There is about 1/3% soft eschar and rest is pink and clean .The ulcer in (is) only on the right side so she is leaning that way when she is up. Resident 7 discharged from hospital on [DATE] back to facility. 1/9/2016 9:50:50PM, Skin condition/wound progression note states in part: New (2nd recording) for site -352. Present on coccyx is a necrotic area .General Comments: This abnormality was recorded using the general observation program during a body check (please note no measurement or staging). 1/9/2016 10:06:36PM Progress note states in part: necrotic area to her R (right) bottom with open areas surrounding. (Please note no measurement or staging of area). 1/10/2016 5:13:35AM Progress note states in part: Necrotic area with surrounding blanchable redness noted to right buttock. No drainage noted. 1/11/2016 3:00:00PM, Skin condition/wound progression note states in part: New( 2nd recording) for site-352. Present on the Coccyx is a necrotic area . General comments: readmitted to facility on 1/9/16. Two areas remain to buttocks, two areas are now connected to make one site from previous admission. Will heal this site in computer to open under appropriate coding of stage 3 pressure ulcer .Entered on: 01/13/2016 1/11/2016 3:30:00PM, Skin condition/wound progression note states in part: New (3rd recording) for Site-352. Present on the Coccyx is a Pressure Ulcer (Pressure Injury). Staging Stage 3, Length in cm = 1.3, Width in cm = 2.1, no odor is apparent, drainage consistency is thin, scant drainage is present, color is tan. This wound was present on admission, wound base is visible, Pink wound base = 50% Yellow wound base = 10 %, other color in wound base = 40%, Granulation tissue type = 50 %, Slough tissue type = 60%, no foreign bodies present, surrounding tissue is reddened, skin tissue temperature is consistent with surrounding tissue, margins are irregular .General Comments: Resident admitted with pressure ulcer to upper right buttocks, 50% of wound size is covered with slough. Of that area 25% is yellow slough which surrounds 75% surface area of smooth gray slough. Other half of wound has a pink wound base and no slough present. Depth of pin area is 0.1 cm. Upon DON (Director of Nursing) wound care RN pressure area staged at 3. New treatment ordered for Santyl to slough, [MEDICATION NAME] applied to redness around site. [MEDICATION NAME] to protect wound daily. Air Mattress and air wheelchair cushion initiated Entered on: 01/13/2016 1/12/2016 4:00:00PM, Skin condition/wound progression note states in part: site-352 Present on the Coccyx is a pressure ulcer .General Comments: (Physician name) was aware upon admission .Entered on 01/13/2016 01/13/2016 P-2500 mattress 42 inch and P-2500 control unit delivery invoice signed and dated on 01/13/2016. The manufacturer operating instructions states in part: The P/2500 is a portable low air loss mattress replacement designed to economically provide therapeutic benefit to patients suffering from, or at risk of, developing pressure ulcers (pressure injuries). 01/13/2016 3:54:10PM Progress note states in part: see new orders to dc (discontinue) treatment to the buttocks, and was pressure ulcer to the right buttock with normal saline (ns), pat dry, and apply santyl to slough, apply [MEDICATION NAME] cream around the wound and cover with [MEDICATION NAME] daily and apply [MEDICATION NAME] cream to redness bid. 1/18/2016 1:30:00PM, Skin condition/wound progression note states in part: Skin and Wound Update to Site-352. Present on the Coccyx is a Pressure Ulcer .Staging Stage 3, Length in cm= 1.5, Width in cm= 3.4, no odor is apparent, drainage consistency is thin, scant drainage is present, color is red-tinged .General Comments: Woundbase improved color. Last week gray slough, now this week yellow. New blood blister present along side of wound. Continues on anticoagulant therapy. Surface area 75% blood blister, 25% yellow slough. Using Santyl to wound and cover dressing. Air mattress and air wheelchair cushion in place. Wound base is visible, Red wound base = 75%, yellow wound base =25%, Slough tissue type = 25%, [MEDICATION NAME] tissue type = 75%, no foreign bodies present, surrounding tissue is reddened, skin tissue temperature is consistent with surrounding tissue .Entered On:01/19/2016 Resident 7 was sent to the emergency roiagnom on [DATE], was admitted due to a fever, and increased drainage from her right groin incision. Resident 7's Facility Discharge Summary states in part: admitted : 1/9/16 discharge date : 1/26/16 section labeled Skin Integrity states in part: Decubitus: coccyx Treatment: wash pressure area R buttock with NS, pat dry, apply Santyl to slough apply [MEDICATION NAME] 1/0.05% cream around wound and cover with [MEDICATION NAME] dressing Teaching, states in part, Wound comments: wash buttock daily, apply [MEDICATION NAME] 1/0.05% topically to redness BID. 01/24/16 06:05AM Emergency Department note states in part: HPI (History of present illness) presents now with fever and increased drainage/redness at her post op sites .she has known stasis ulcers to her right buttocks Medical History Wound disruption 1-21-16 right buttocks-Santyl dressing change daily Rectal: Deferred; right buttock with 4-5cm necrotic appearing ulcer (Unstageable) 01/24/16 06:55AM Hospital Wound note states in part: [MEDICATION NAME] dressing removed per MD to assess right buttock wound. 5-6cm area of necrosis and purulent areas; no drainage. New [MEDICATION NAME] dressing applied. 01/24/16 11:05AM Hospital General Surgery Admission H&P (History & physical) states in part: Pressure sores to heels and buttock. Stage 2 01/25/16 Hospital Wound note by RN Z states in part: Plan is to d/c (discharge) back to NH (nursing home) The ulcer on the right sacral area is not stageable. Will try the [MEDICATION NAME] absorbent to soften the wound bed .skin red and moist but so far not further breakdown. 01/27/16 Hospital Wound note by RN Z states in part: The sacral ulcer on the right side is softening. 01/29/16 12:51 PM Hospital Wound note by RN Z states in part: The right sacral/buttock ulcer is slowly autolyticaly debreiding ([MEDICATION NAME]). The [MEDICATION NAME] or the [MEDICATION NAME] absorbent will clean up the necrotic tissue .limit her (Resident 7) sitting time to 1 hour or less at a time. 01/30/16 10:24AM Hospital Physician Discharge Summary states in part: admitted : 1/24/2016 discharge date : 1/30/2016 Discharge Diagnoses: [REDACTED].Right buttock ulcer- we changed to either a duoderm ([MEDICATION NAME]) or a [MEDICATION NAME] absorbent. They have been [MEDICATION NAME] 48 hours so maybe change MWF (Monday Wednesday Friday) or every 48 hours. I would use skin prep to the skin to secure the dressing . 1/30/2016 1:30:00PM Progress note states in part: Resident arrived from (Hospital name) 1/30/2016 8:57:53PM Skin condition/wound progression note states in part: Skin and Wound update to Site-352. Present on the Coccyx is a Pressure Ulcer. General Comments: wound to right buttock measures 4cm x 3cm. Treatment in place. Necrotic tissue visible to irregular wound bed. 2/1/2016 3:58:43PM Skin condition/wound progression note states in part: Present on the Coccyx is a Pressure Ulcer .Unable to accurately stage - Slough and/or Eschar Covered. Length in cm = 4, Width in cm = 3.5, Skin is not blanchable, no odor is apparent, drainage consistency is thin, scant drainage is present, color is red-tinged, PA, NP or MD was notified of the present status of this site General Comments: The Right Coccyx wound measurement 4 x 3.5cm with undetermined depth related to soft black tissue covering the wound with scant bloodtinged drainage. On left side of coccyx area has 0.5 x 0.7 cm open area with 100% thin yellow tissue covering the open area with very scant drainage. 02/01/2016 16:01 (4:01PM) Progress note states in part: dc duoderm to the coccyx area, and wash to coccyx areas with normal saline pat dry and apply Santyl to the wound bed, and follow with [MEDICATION NAME] dressing daily. 2/8/2016 7:00:00AM Skin condition/wound progression note states in part: Present on the Coccyx is a Pressure Ulcer .unable to accurately stage - Slough and/or Eschar Covered, Length in cm= 3.0, Width in cm = 2.7, Skin is not blanchable, no odor is apparent, drainage consistency is thin, minimal drainage is present, color is red-tinged .Entered on: 02/11/2016 2/15/2016 1:15:53PM, Skin condition/wound progression note states in part: Present on the Coccyx is a Pressure Ulcer .unable to accurately stage - Slough and/or Eschar Covered, Length in cm = 3.2, Width in cm=2.5, Skin is not blanchable, drainage consistency is thin, minimal drainage is present, color is tan General Comments: Artea (area) covered with thick grayish tissue 90% of wound and edges 10% yellowish tissue. Minimal tan drainage noted. Left side buttock has small open area .2 x .3cm with yellow tissue. Will continue current intervention. Will update MD of wound status. No signs or symptoms of infection. No odor noted. 2/22/2016 3:27:22PM Skin condition/wound progression note states in part: Present on Coccyx is a Pressure Ulcer. Unable to accurately stage -Slough and/or Eschar Covered, Length in cm = 4.5, Width in cm = 3.0, no odor is apparent, drainage consistency is thin, minimal drainage is present, color is tan .Wound base is visible, Yellow wound base = 100%, Slough tissue type = 100% surrounding tissue is reddened, skin tissue temperature is consistent with surrounding tissue General Comments: Right Buttocks measures 4.5cm x 3.0cm and left buttocks pressure ulcer measures 1.0cm x 1.0cm. Both covered with yellow slough. Air mattress and air wheelchair cushion remains in place . 2/29/2016 3:11:03PM Skin condition/wound progression note states in part: Present on Coccyx is a Pressure Ulcer. Unable to accurately stage -Slough and/or Eschar Covered, Length in cm = 3.5, Width in cm = 2.2, Skin is not blanchable, no odor is apparent, drainage consistency is thin, minimal drainage is present, color is tan, color is red-tinged .Wound base is not visible Granulation tissue type = 20%, Eschar tissue type = 40%, Slough tissue type = 40% . 2/29/2016 3:18:39PM Skin condition/wound progression note states in part: Present on Coccyx is a Pressure Ulcer .Staging Stage 2, Length in cm = 0.5, Width in cm = 1.2, Depth in cm = 0, Skin is blanchable, no odor is apparent, no drainage is apparent .Wound base is visible, . Granulation tissue type = 100%, General Comments: This area was previously covered with yellow tissue and currently clean and healing . 03/04/16 Hospital Physician Wound note states in part: 1. Pressure ulcer of ischium, right, Unstageable .being seen today for .pressure ulcer on the right buttocks/ischium. Skin: .(Nonstageable pressure ulcer right ischium/buttock measures 3.5 x 4 x 2 cm with undermining at 7:00-10:00 to 1.3cm. 100% adherent necrotic yellow slough in the wound bed. Positive odor. No purulent drainage .Assessment & Plan: 1) Right buttock, nonstageable pressure ulcer. Culture obtained. 1/4 strength Dakin's moistened wet to dry dressing BID for mechanical debridement and topical disinfection of wound bed. 3/7/2016 11:59:25AM Skin condition/wound progression note states in part: Present on Coccyx is a Pressure Ulcer. Unable to accurately stage -Slough and/or Eschar Covered, Length in cm = 4.5, Width in cm = 2.5, Skin is not blanchable, a faint odor is apparent, drainage consistency is thin, moderate drainage present, color is red-tinged . General comments: Resident on new treatment per wound clinic nurse recommendation. Noted undermining at 7 o'clock - 1 o'clock ( 7 to 1 o'clock) at 1.9cm. Encouraged resident to lay down in between meals and put resident on right side position in bed. Educated resident (Resident 7) on the importance of not staying up more than 2 hours at a time due to worsening of her right buttock ulcer . (Physician name) updated. Left side of coccyx open area is closed. Please note Resident 7 now has undermining, the PI is on the Right buttock, and staff is instructing to place Resident 7 on her right side that already has compromised tissue, there is now a moderate amount of red-tinged drainage.) 3/15/2016 4:45:53PM Skin condition/wound progression note states in part: Present on Coccyx is a Pressure Ulcer . Staging Stage 4, Length in cm= 4, Width in cm= 3.5, Depth in cm=2, Ski

Based on record reviews and interviews, the facility did not ensure that the care plan information was accurate so that staff could provide appropriate supervision to prevent accidents during transfers for 1 of 4 Residents (Resident #2) who were at risk for falls. *Resident #2 was assessed as requiring extensive assistance of 2 staff related to bed mobility due to his behaviors but his care card indicated that he required assistance of 1. As a result, on 6/26/15 at 7:00 a.m., a Certified Nursing Assistant (CNA) began preparation for a Hoyer transfer alone and Resident #2 sustained a fall with a fracture. Findings Include: On 12/16/15, Surveyor # began investigating a facility Self Report related to Resident #2. The self-report indicated that Resident #2 fell from his bed during the process of being transferred in a Hoyer lift. The resident sustained [REDACTED]. According to Resident #2's closed medical record, Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Significant Change and Quarterly Minimum Data Set assessments ((MDS) dated [DATE] and 6/21/15 indicated Resident #2 had symptoms of altered moods and increased behavior concerns that included wandering. The MDS assessments also indicated that Resident #2 required extensive assistance of 2 for bed mobility and was totally dependent on 2 staff persons for transfers. Progress note dated 1/8/15 indicates that Resident #2 is resistive to cares and is often physically aggressive with staff, with a history of rolling out of the bed. Progress note dated 1/11/15 indicates that Resident #2 hit a CNA while 2 staff was attempting to transfer him to bed. Progress note dated 1/19/15 indicates that Resident #2 was very restless and attempting to get out of bed. Due to these behaviors the facility implemented interventions of frequent checks, low bed position, mats on floor, bed against the wall, and gripper socks. Progress note dated 2/7/15 indicates Resident #2 punched a CNA in the eye while she and another CNA were turning the Resident to prepare him for a Hoyer transfer. Progress note dated 2/8/15 indicates that the Resident began to swing at the CNA while she and another CNA tried to place the sling under the Resident to prepare him for a Hoyer transfer back to bed. According to progress note dated 2/9/15 Resident #2 had 156 incidents in 19 days in a 3 month look back from the dates of 11/2/14-2/1/15. Progress note dated 2/14/15 indicates Resident #2 was found on the floor by CNA with body pillow in place. Progress note dated 6/5/15 indicates that Resident #2 was found on the floor, on mat, with a skin tear to right shin. Progress note 6/9/15 indicates Resident #2 was found on floor on right side, off of mat, with bed in low position. On 6/26/15 an incident report indicates that CNA-F reported that she had placed Resident #2 in the Hoyer sling and elevated his bed while she was in the process of moving the Hoyer lift toward the bed. She stated that at this time she witnessed him fall while attempting to reach for the lift. The self -report also indicates that the other 2 CNA's on duty were with other Residents but she had planned to call for assistance after she had gotten Resident #2 ready for the transfer. The self-report indicates the X-ray for Resident #2's left leg was positive for a displaced distal femur (thigh bone) fracture and a decision was made for Resident to be transferred to the emergency room for further evaluation. The emergency room MD and Resident #2's Power of Attorney agreed that no-surgical intervention would be the best course of care as Resident had been in hospice care since March 2015. Resident was fitted with a special knee brace that accommodated his leg contractures, and was returned to the facility at 7:00 p.m. on 6/26/15. Surveyor # reviewed the CNA care card for Resident #2 which indicated that he was an assist of 1 for bed mobility, to include transfer preparation. However, Resident #2's MDS assessments indicated that he needed extensive assistance of 2 for bed mobility. Surveyor # also reviewed progress notes which indicated that Resident #2 had been previously assisted by 2 staff persons for Hoyer transfers and preparation due to his resistive behaviors and history of falls from bed. On 12/17/15 at 12:01 p.m., Surveyor # interviewed CNA-C who indicated that staff use the CNA care cards as their guide to providing care for Residents. She indicated that if a Resident is care planned as an assist of 1 for bed mobility, it is ok for staff to start the preparation of the transfer and call in a second staff person to complete the transfer. CNA-C indicated that if a Resident is coded as assist of 2 for bed mobility then they need to have the assistance of 2 staff for the actual transfer and preparation of the transfer. At 12:17 p.m., Surveyor # interviewed CNA-D who indicated that there is an area on the CNA care card that indicates bed mobility status. CNA-D stated that if the Resident is coded as a 2 person assist this means that the Resident needs assistance while turning in bed, and this would include any preparation for a Hoyer transfer. CNA-D indicated that the CNA staff do not review the MDS assessments so they rely on the care plan to direct them regarding the Residents care needs. At 12:52 p.m., Surveyor # interviewed RN Manager-E who indicated that Resident #2 would wander around, strike out at staff, and was resistive to cares. RN Manager-E indicated that often times the Resident was combative. She indicated that he was changed to the Hoyer lift at the beginning of the year due to pain but he did not like the machine so it would take staff several attempts to get him in and out of bed. When asked if he was an assist of 1 or 2 for bed mobility RN Manager- E indicated that he required the assistance of 2 staff due to his behaviors. Surveyor showed RN Manager-E the CNA care plan which indicated that Resident #2 required the assistance of 1 staff for bed mobility. RN Manager-E indicated that she is in charge of the MDS assessments and updating the Care plans and she was not sure why his care plan didn't reflect the information that was on his most recent MDS assessment. RN Manager-E confirmed that the care plan was incorrect and stated that she would audit all of her Residents with falls to make sure everyone has the correct information. At 1:13 p.m., Surveyor # called CNA-F for interview but was unable to reach her at this time. The facility did not ensure that the CNA care card contained the accurate information to assist in preventing Resident #2 from sustaining a fall. Resident #2 has a history of combative, resistive behaviors during cares and transfers due to his dementia, and had sustained previous falls from bed. Due to his behaviors, Resident #2 should have been prepared for Hoyer transfer with 2 staff persons and the bed in low position until the transfer was to be completed. The CNA began preparation of a Hoyer transfer for Resident #2 alone due to following the care card that indicated assist of 1 when it should have been reviewed by management to ensure that the information correlated with the MDS assessment. As a result of this error Resident #2 sustained a fall with femur fracture. The Resident was on hospice care due to terminal cancer and passed away 2 days after this fall. The facility Administrative staff was notified of these findings upon exit on 12/17/15.