Every finding on record at Lindengrove New Berlin

Based on observation, interview, and record review, the facility failed to ensure that residents with a pressure injury or 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 4 (R94, R8, R77, and R1) of 7 sampled residents reviewed for pressure injuries out of a total survey sample of 18 residents. * R94 admitted to the facility with a stage 2 sacrum pressure injury (PI) and was at risk for development of PIs. The facility failed to complete comprehensive assessments, implement physician's orders, address incontinence as a contributing factor to development of new PIs, and did not implement proactive pressure relieving interventions. R94 developed 6 facility-acquired PIs, some of which deteriorated requiring hospitalization with IV (intravenous) antibiotics due to necrosis of muscle. The facility's failure to provide care to prevent the development of pressure injuries and promote healing of R94's pressure injuries created a finding of Immediate Jeopardy (IJ) that began on 4/9/26. Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Consultant-C, and Assistant Nursing Home Administer (ANHA)-UU were notified of the Immediate Jeopardy on 7/14/26 at 1:29 p.m. The immediate jeopardy was removed on 7/16/26. The deficient practice continues at a scope and severity of G (Actual harm/isolated) for examples involving R8 and R77. *R8 sustained a hip fracture after a fall on 3/2/2026 requiring surgical repair. Upon readmission to the facility, R8 was assessed to be at moderate risk for developing a pressure injury. The facility did not implement interventions to address R8's decreased mobility of their left leg. R8 developed a Deep Tissue Injury (DTI) to their left heel that evolved into an Unstageable pressure injury. *R77 was noted to have pressure injuries once an immovable splint was removed. The facility did not implement interventions to heal and prevent decline of the areas. R77 developed an unstageable pressure injury The following example regarding R1 is an example at the scope and severity of potential for harm. *R1 returned to the facility from the hospital on 4/30/26 with a stage 3 pressure injury. R1 did not have a treatment in place until 5/4/26. Findings include: The facility's policy titled, Pressure Injury Prevention and Managing Skin Integrity, and last reviewed 4/9/26 documents under policy: Prevention measures are put in place to reduce the occurrence of pressure injuries. Under procedure for 2. Identify Interventions and Care plan documents a. Identify Interventions. i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team (IDT) regarding the presence of breakdown and the intervention plan. 2. When indicated, a referral to additional resources (i.e. Wound Care Specialist, Registered Dietitian, Physical Therapist, Occupational Therapist) may occur. 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan i. In developing a plan of care the following will be considered: 1. Individual Pressure Injury History; 2. Cognitive changes or impairment of the individual; 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health; 4. Any cultural practices that impact the health or integrity of the skin; 5. Risk for pressure ulcer development. Under 4. Weekly Wound Rounds documents a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individuals 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 necessary. iii. Update the Care Plan with any new interventions as applicable. iv. Update Individual Representative as indicated. 1.) R94 was admitted to the facility on [DATE]. R94 had diagnoses that included dementia, fibromyalgia, and bilateral primary osteoarthritis of hip. R94 was discharged from the facility on 4/27/26. R94's power of attorney for healthcare was activated in October 2024. R94's Braden assessment score dated 11/17/25 was 17 which indicated mild risk for pressure injuries. R94's admit screen dated 11/17/25 documented for skin integrity site 53 on the facility form) sacrum, type was pressure, stage II (2). Surveyor noted this is not a comprehensive assessment as there are no measurements or a description of the wound bed. The recommended treatment at the time of admission was cleanse sacrum with soap & water, pat dry, followed by zinc barrier cream every shift & PRN (as needed). This was not implemented by the facility until 11/21/25, 4 days later. On 7/13/26 at 8:17 a.m., Surveyor interviewed Nurse Supervisor (NS)-L, who is the wound nurse at the facility. Surveyor asked NS-L who assesses the pressure injury when a resident is admitted with a pressure injury. NS-L replied that the nurse on the unit usually assesses it. Surveyor asked if the nurse on the unit is supposed to do a comprehensive assessment. NS-L informed Surveyor they do the skin assessment on our admitting screen; they don't do a real thorough one. Surveyor asked NS-L who would do the comprehensive assessment. NS-L informed Surveyor sometimes the assessment is completed later, when they do wound rounds. Surveyor asked NS-L how she is notified there is a resident with a pressure injury. NS-L informed Surveyor sometimes nurses send her an email, tell her, or Director of Nursing (DON)-B will tell her. Surveyor asked NS-L how a treatment is ordered. NS-L informed Surveyor a lot of time residents come with a treatment already ordered or the nurse goes with what was on the pressure injury at admission. Surveyor informed NS-L R94's stage 2 sacrum pressure injury wasn't comprehensively assessed, and a treatment didn't start until four days later. Surveyor asked NS-L if R94's sacrum pressure injury should have been comprehensively assessed and if a treatment should have been ordered upon admission. NS-L replied yes. R94's potential for impairment to skin integrity care plan initiated 11/18/25 documented interventions of: *Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated 11/18/2025. *Encourage good nutrition and hydration in order to promote healthier skin. Initiated 11/18/2025. *Keep skin clean and dry. Use lotion on dry skin. Initiated: 11/18/2025. *Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated 11/18/2025. R94's ADL (activities of daily living) self-care performance deficit care plan initiated 11/18/25 documented an intervention for toilet use: check and change every 2-3 hours initiated 11/21/25. This intervention was not revised while R94 resided at the facility. R94's admission minimum data set (MDS) with an assessment reference date of 11/21/25 had a brief interview mental status (BIMS) score of 11 which indicated moderate cognitive impairment. R94 was assessed as not having any behaviors including refusal of care. R94 was assessed as dependent for toileting hygiene, partial/moderate assistance for roll left and right, chair/bed to chair transfer, and toilet transfer. R94 had an indwelling urinary catheter and was always incontinent of bowel. R94 was at risk for pressure injury development and was assessed as having one Stage 2 pressure injury that was present upon admission. R94's pressure injury CAA (care area assessment) dated 11/28/25 did not have a complete analysis of findings for nature of problem/condition. The care plan considerations/description of problem/need and rationale documented that the resident had a stage 2 pressure injury to sacrum present on admission and had potential for pressure ulcer development r/t (related to) weakness, decreased mobility, cognitive impairment, and need for assistance with transfers. Staff encourage frequent repositioning and assist as needed. Monitor nutrition and hydration status. Nutrition requesting supplement to promote wound healing. Treatments per TAR (treatment administration record). Please refer to established care plan for further information. R94's late entry nurses note dated 11/24/25 at 10:28 a.m. and created on 11/25/25 at 1329 (1:29 p.m.) documented: No O/A (open area) to sacrum noted. May use Zinc barrier cream to prevent skin breakdown. R94's Foley catheter was discontinued on 11/28/25. The facility did not complete a voiding pattern or urinary assessment after R94's Foley catheter was discontinued. (Cross-reference F690). R94's Braden assessment dated [DATE] scored a 16 which indicated mild risk for pressure injuries. R94's nurses note dated 12/3/25 at 2130 (9:30 p.m.) documented: writer called into room during patient cares for new open areas to left and right buttock. MASD (Moisture Associated Skin Damage) areas noted: left buttock 3.0 x (times) 1.0 x 0.1 and right buttock 2.5 x 0.5 x 0.1. Happy butt cream applied. On 7/13/26 at 8:22 a.m., Surveyor asked NS-L when there is a change in a resident's skin integrity, such as MASD, would a resident's care plan be revised following an assessment? NS-L replied not necessarily. Surveyor noted R94's potential for skin integrity care plan was not revised until 12/8/25, 5 days after the noted open areas. On 12/8/25, Wound Physician Assistant (PA)-E and NS-L assessed R94's left gluteus and coccyx pressure injuries. R94's skin issue assessment dated [DATE] completed by NS-L documented: left gluteus, pressure ulcer, Stage 2, length was 3.84 cm (centimeters), width 1.82, depth is 0.1. Slough was 50% and other wound bed information was 50% red (slough/red mixture). R94's coccyx pressure injury was documented as a stage 2, length was 2.83, width 2.39, depth is 0.1. Slough was 50% and other wound bed information was 50% red (slough/red mixture). On 12/8/25, Wound PA-E documented the same measurements and stage as NS-L, but Wound PA-E assessed R94's left buttock wound bed as 100% mixed due to slough and red tissue that was nongranular. Wound PA-E assessed R94's coccyx wound bed as mixed slough with red nongranular tissue. The treatment for R94's pressure injuries was Hapi (sic) butt cream three times a day and as needed. The assessment documented interventions as heels offloading with heel offloading boots or pillows as tolerated by patient, turn and reposition every 2-3 hours with assistance as needed. Dietary collaboration, PT/OT (physical therapy/occupational therapy). It was noted the intervention for heel boots was never added to R94's potential for skin integrity care plan, use of pillows was not added until 3/24/26 (after R94 developed a right heel DTI) and repositioning every 2 to 3 hours was not added to R94's potential skin impairment care plan until 4/9/26. Surveyor noted R94's left gluteus and coccyx pressure injuries are incorrectly staged because stage 2 pressure injuries do not have slough. On 7/13/26 at 8:23 a.m., Surveyor asked NS-L if a Stage 2 pressure injury has slough in the wound bed. NS-L replied, yeah, it could. Surveyor asked NS-L what standard of practice the facility uses to stage pressure injuries. NS-L replied, Guess I'm really not sure how to answer that question. On 7/13/26 at 10:28 a.m., Consultant-C provided Surveyor with a pressure injury staging guide from the National Pressure Ulcer Advisory Panel. Surveyor noted the definition for a stage 2: Pressure Injury: Partial-thickness skin loss indicated 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. On 7/13/26 at 10:40 a.m., Surveyor spoke with Wound PA-E on the telephone. Surveyor asked Wound PA-E if there was slough in R94's wound bed, how were the pressure injuries staged as stage 2 wounds. Wound PA-E explained R94 was always wet with urinary incontinence and when R94 was rolled over R94 would leak out urine even during the assessment. Wound PA-E informed Surveyor R94's left gluteus was wet, moist, superficial, white, macerated tissue within the wound, it was partial thickness and that's why he staged the left gluteus as stage 2. Wound PA-E informed Surveyor the white tissue was still viable, non-slough and could technically turn to slough. Wound PA-E informed Surveyor he didn't describe the tissue type correctly. Wound PA-E informed Surveyor R94's coccyx should have been a stage 3. On 7/13/26 at 11:19 a.m., Wound PA-E called Surveyor back. Wound PA-E explained he spoke with a doctor who had been his preceptor regarding R94's left gluteus pressure injury. Wound PA-E informed Surveyor instead of documenting slough he should have been documenting white fibrinous tissue. On 12/8/25, R94's potential for impairment to skin integrity care plan was revised with the following interventions: *Apply wound tx (treatment) as ordered and monitor for effectiveness. Initiated 12/08/2025. *The resident needs pressure relieving/reducing air mattress to protect the skin while in bed. Monitor functioning q (every) shift & PRN (as needed). Initiated: 12/08/2025. *Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Initiated: 12/08/2025. On 1/5/26, Wound PA-E and NS-L assessed R94's coccyx pressure injury. R94's skin issue assessment dated [DATE] completed by NS-L documented: stage 2 coccyx, pressure ulcer, length was 1.9, width 0.83, depth is 0.1. Wound bed was documented as pink and/or red. On 1/5/26, Wound PA-E documented continued to have urinary incontinence affecting the coccyx wound and had noted whenever (R94) turned was when they became incontinent and felt the urine moisture had contaminated the wound site. (R94) had been getting barrier cream to the site regularly. Denied any fever or chills. No other complaints at this time. Wound PA-E assessed R94's coccyx pressure injury with the same stage and measurements as NS-L and Wound PA-E's wound bed was assessed as 100% red/pink nongranular tissue. Wound PA-E continued the coccyx treatment of Hapi (sic) butt cream three times a day and as needed. On 1/12/26, Wound PA-E and NS-L assessed R94's coccyx pressure injury. Wound PA-E documented [R94's first name] was evaluated in room today, laying (sic) in bed. Overall feeling well. Continued to have issues with urinary incontinence with turning in bed. Denied any pain at the coccyx site or to the buttocks. Wound PA-E documented site is closed, and wound bed is 100% epithelialized. Under plan was documented will utilize Hapi (sic) butt cream 3 times daily and as needed as a prevention as (R94) remains incontinent and at risk for reopening the site. As of 1/12/26, R94's pressure injuries were healed. R94's nutrition note dated 2/2/26 at 12:33 p.m. documented: Nurse notified writer that patient doesn't want to drink the House supplement anymore. Writer ok with this as patient has had a ~9# (approximate 9 pound) weight gain in about 2 months since admit, BMI (body mass index) 28 is in optimal range for an older adult, all of her wounds are healed, and she has good meal intakes. Supplement discontinued. POC (plan of care) updated. R94's nurses note dated 2/11/26 at 9:45 a.m. documented: Resident alert with increased weakness this morning. Continued to complain of pain to head, neck, and shoulders. Received scheduled cyclobenzaprine and PRN Butalbital for pain management. Resident had been refusing to get out of bed this week d/t (due to) having pain. Resident assisted with repositioning in bed as tolerated. Writer spoke with resident this AM (morning). Education provided in regard to importance getting out of bed and changing position to help prevent skin breakdown. Resident agreeable to try and get out of bed for at least one meal today. Will Follow up. Will continue to monitor Q (every) shift and PRN. R94's nurses note dated 2/11/26 at 2151 (9:51 p.m.) documented: Resident remained with complaints of pain to the neck and back. X-rays obtained Results sent via HUCU (patient communication program) waiting on a response. X-rays of spine is (sic) negative as well as the Xray of the shoulder. Tylenol was given this afternoon for the pain. R94's Braden assessment dated [DATE] scored 14 which indicates moderate risk for pressure injury development. R94's nurses note dated 2/18/26 at 10:13 a.m. documented: Resident c/o (complained of) not able to move her arms, legs and not being able to sit up in w/c (wheelchair). Resident was sent to the hospital and returned late evening; CT of head and spine and labs were all negative. R94's skin issue assessment dated [DATE] completed by NS-L documented stage 2 pressure injury to sacrum. Wound was acquired in house. Length was 2.68 cm, width 0.78, and depth is 0.1. Wound bed was documented as pink or red. Also, on 2/19/26, NS-L documented unstageable pressure injury to buttocks presented as a DTI. Wound acquired in house. Length was 2.07, width 0.17, depth is 0. Wound bed is documented as intact, dark purple. Included in the documentation was to turn every 2 hours and not to have foreign objects or layers of blankets or towels under resident. Surveyor noted that repositioning was not added to the potential skin integrity care plan until 4/9/26. On 2/19/26, R94's potential for impairment to skin integrity care plan was updated with an intervention of: Only sheet and thin draw sheet to be placed under resident while in bed. Do not place multiple layers of blankets and towels under resident. Initiated 2/19/26. On 7/13/26 at 8:27 a.m., Surveyor asked NS-L what foreign objects NS-L was referring to on 2/19/26. NS-L informed Surveyor R94 would have a lot of personal items in the bed. Surveyor asked if any were under R94. NS-L replied that they really didn't remember. Surveyor asked about the multiple linens and towels under R94 and asked if staff would place these. NS-L replied yes. Surveyor asked NS-L if she asked staff why they did that. NS-L informed Surveyor that was due to R94's heavy wetting. R94's nurses note dated 2/20/26 at 1507 (3:07 p.m.) documented: Resident was found to have new wound on sacrum in room by CNA (Certified Nursing Assistant) while doing cares and alerted RN (Registered Nurse) unit manager. RN assessed resident and noted stage 2 pressure to sacrum and DTI to left buttocks. Resident denied pain. Vitals stable. [Name] APNP (advanced practice nurse prescriber) notified. Resident's POA notified. Pertinent diagnoses included chronic pain syndrome, dementia, depression, weakness and HX (history): TIA (transient ischemic attack). IDT (interdisciplinary team) discussed new wounds, determined root cause to be air mattress not used to full therapeutic benefit r/t foreign objects and multiple linens in bed with resident. Resident and staff educated on proper use of air mattress to ensure it functions for pressure relief and skin protection. Care plan updated to only have sheet and thin draw sheet placed under resident while in bed. R94's quarterly MDS with an assessment reference date of 2/21/26 indicated R94 had a BIMS score of 11 which indicated moderate cognitive impairment. R94 was assessed as having verbal behavior 1 to 3 days and other behavior 1 to 3 days. R94 was not assessed as refusing cares. R94 was assessed as requiring substantial/maximal assist to roll left and right. R94 was dependent upon staff for toileting hygiene, chair/bed to chair transfer and toilet transfer. R94 was always incontinent of urine and bowel. R94 was at risk for pressure injury development and was assessed as having one stage 2 pressure injury and one unstageable DTI. On 2/23/26, Wound PA-E and NS-L assessed R94's sacrum and left buttock pressure injuries. R94's skin issue assessment dated [DATE] completed by NS-L documented a stage 2 pressure injury to sacrum. Wound was acquired in house. Length was 0.88, width was 0.44, and depth 0.1. Wound bed was documented as other. Other is defined as mild maceration. On 2/26/26, it was documented by NS-L (R94) had unstageable pressure injuries to the buttocks that presented as deep tissue injuries. Wound(s) acquired in house. Length was 1.05, width 0.5, depth 0. The wound bed is documented as other. Other is defined as:100% ecchymotic (large bruise), mild erythema (redness), partially blanching. On 2/26/26, Wound PA-E documented (R94) was using an air mattress and had experienced incontinence, which had contributed to skin breakdown. Wound PA-E assessed R94's sacrum pressure injury with the same stage and measurements as NS-L documented. The wound bed was documented as 100% red, non-granular, partial thickness. Plan was documented as continue barrier cream or happy butt paste three times daily and continue offloading of the site. Wound PA-E assessed R94's left buttock as linear with the same stage and measurements. Wound bed was 100% ecchymotic. Documented for plan was Apply zinc barrier cream or happy butt paste three times daily and continue offloading of the site. Even though Wound PA-E documented R94 had experienced incontinence that contributed to skin breakdown, the facility did not address R94's incontinence and did not revise R94's plan of care. A nutritional note dated 2/24/26 at 1510 (3:10 p.m.) documented: Patient now has a Stage 2 on her sacrum and new DTI on her L buttock. Recently on 2/2/26 her high-calorie, high-protein nutrition supplement was discontinued d/t refusal. Resident eats in dining room and has good PO (by mouth) intakes. Discussed re-starting nutrition supplements to promote wound healing. Patient agreeable to liquid protein supplement 30ml (milliliter) QD (every day) (60ml, 15g PRO). Order updated. Gave update on current weight: 147# (2/21). Weight stable x3 months. BMI 27.8 is within optimal range for older adult. POC updated. On 3/2/26, the skin issue assessment by NS-L and Wound PA-E documented R94's sacrum and left buttock wounds are healed. R94's Braden assessment dated [DATE] has a score of 15 which indicated mild risk for pressure injury development. R94's nurses notes dated 3/24/26 at 11:30 a.m. documented: writer in room with resident and noted DTI to right heel. 100% dark eschar, no drainage, measures 3.38 cm x (times) 4.79 x UTD (unable to determine). Skin prep applied. Denies pain. Resident has offloading boots but refuses to wear them. Risk/benefits discussed, and resident continues to strongly refuse. Resident willing to use pillows to offload. On 7/13/26 at 8:31 a.m., Surveyor discussed with NS-L there were no noted care plan interventions addressing offloading R94's heels until after R94 developed the deep tissue injury. NS-L informed Surveyor R94 refused boots so they used pillows. Surveyor again discussed with NS-L Surveyor didn't see this intervention until after the pressure injury developed. NS-L replied, Guess that's our standard. Surveyor also discussed with NS-L that there wasn't a care plan that addressed if R94 was refusing care nor were there documented discussions with R94 or their POA regarding risks/benefits if care was being refused. NS-L informed Surveyor they had care plan meetings. Surveyor asked NS-L to look into any documentation regarding discussed risks/benefits for R94. Surveyor was not provided with any risk/benefits information. On 3/24/26, R94's potential for impairment to skin integrity care plan was revised with the following interventions: * Encourage resident not to wear shoe to right foot. Initiated 03/24/2026. *Off load bilateral heels with pillows while in bed. Make sure heels are not touching. Initiated 03/24/2026. R94's potential for skin integrity care plan did not include an intervention of heel boots and there were no interventions implemented prior to the development of R94's right heel pressure injury to offload R94's heels. R94's skin issue assessment dated [DATE] completed by NS-L documented R94 had an unstageable DTI on their right heel. Wound was acquired in house. Length was 1.31, width was 1.6 and depth is 0. The wound bed was documented as other. Other was defined as 80% ecchymotic, 20% reabsorbed. Treatment was skin prep twice daily. R94's Braden assessment dated [DATE] scored 14 which indicated moderate risk. R94's skin issue assessment dated [DATE] completed by NS-L documented R94 had an unstageable DTI on their right heel that was acquired in house. Length was 1.64, width 2.22, and depth is 0. Documented on the assessment was off load heels with pillows. Resident refuses boots and refuses to lay on her side. Surveyor noted there was no refusal of cares care plan and Surveyor was unable to locate the risks and benefits of offloading/repositioning were discussed and documented. R94's nurses note dated 4/6/26 documented an open area to the sacrum was found this shift, approximately 6 mm (millimeter) by 12 mm. Left buttock wound noted, approximately 3 cm (centimeters) by 1 cm, superficial open area with surrounding erythema/ecchymosis, crusted blood present. The skin is mildly swollen and discolored. Resident reports no discomfort or pain from open areas. POA notified, (Wound PA-E) informed and unit manager was notified. Thera honey and a foam border was applied. Plan of care continued and will monitor for any further changes of condition. R94's change of condition documentation dated 4/6/26 completed by Licensed Practical Nurse (LPN)-X was checked for skin wound or ulcer. The summarized observation, evaluation and recommendation documented open area to sacrum and wound to left gluteal fold. Thera honey and foam border were applied. The skin status evaluation documented a skin assessment was relevant to the change in condition and was reported. The skin changes described an abrasion and wound at site 53)-sacrum as an open area (wound) and site 54)-gluteal fold described as an abrasion. On 7/13/26 at 8:35 a.m., Surveyor discussed comprehensive assessments and the timing of those assessments with NS-L. NS-L informed Surveyor it depended on the day an assessment may be needed as they round on Mondays. Surveyor asked NS-L what occurs if, for example, a resident developed a pressure injury on a Thursday, when would an assessment occur. NS-L informed Surveyor the floor nurse would do an assessment, notify the NP or on call and get a treatment. Surveyor asked NS-L what happens if the floor nurse is an LPN. NS-L replied they can still assess and measure and give the information to the NP. R94's late entry note dated 4/7/26, created on 4/17/26 by NS-L documented: Resident was noted to have 2 new wounds on her bottom in room (sic) by CNA (Certified Nursing Assistant) and alerted nurse. Areas cleansed and dressings applied. Resident last seen at that time receiving cares in bed. Call light within reach but not on. Resident wearing gripper socks. RN assessed resident and 2 unstageable pressure wounds noted. Resident denied pain. [Name] NP notified. Resident's POA notified. Pertinent diagnoses included weakness, chronic pain syndrome, dementia, depression, intervertebral disc degeneration, lumber region, and history of TIA. IDT discussed wounds, determined root cause to be pressure. After investigation it was noted that resident received new wheelchair and there was no cushion. Care plan updated to have cushion in wheelchair. R94's potential for impairment to skin integrity care plan was revised with the intervention of Cushion to w/c with Posi grip under w/c cushion. Initiated 4/7/26. On 7/13/26 at 1:22 p.m. DON-B provided Surveyor with a green sticky note which documented high back (wheelchair) 3/12/26. This was the date R94 received a new wheelchair that was high backed. Surveyor noted R94 did not have a cushion in their wheelchair from 3/12/26 to 4/7/26. R94's skin issue assessment dated [DATE] by NS-L, 3 days after R94 was identified with new pressure injuries, documented for skin issue #001 right heel unstageable DTI. Surveyor noted there are no measurements or descriptions of wound bed and no indication the right heel pressure injury is resolved. Skin issue #002 documented left gluteus, unstageable due to slough and/or eschar. Length was 4.52 cm, width 2.54, and depth 0. Slough was documented as 100%. The assessment documented drainage was difficult to determine due to incontinence. Skin issue #003 documented Sacrum, unstageable due to slough and/or eschar. Length was 0.74, width 0.59 and depth was 0. Slough was 100%. The assessment documented drainage for this wound was difficult to determine due to incontinence. Surveyor noted the facility still had not addressed R94's incontinence at that time. On 4/9/26, R94's potential for impairment to skin integrity care plan was revised with an intervention to assist to turn and reposition q (every) 2-3 hours. Initiated 4/9/26. Surveyor noted there was no prior intervention regarding repositioning prior to 4/9/26. On 7/13/26 at 8:41 a.m., Surveyor discussed the plan for turning and repositioning R94. Surveyor discussed with NS-L that Surveyor did not note any intervention regarding turning and repositioning prior to 4/9/26 despite R94's risk for and history of pressure injuries. NS-L informed Surveyor she thought R94 refused. R94's nurses note dated 4/9/26 documented (R94) was turned and repositioned every 2 hours (R94) refused turning to left on last turning & repositioning. R94's nurses note dated 4/9/26 documented Resident was re-educated on the risks and benefits of removing the sling while seated in the wheelchair, for prevention of worsening or new pressure wounds. Resident verbalized understanding and agreed to have the sling removed while in the wheelchair. Resident also stated she is agreeable to repositioning while in bed; however, she declined repositioning onto her left side due to discomfort in her left shoulder. On 4/13/26, Wound PA-E and NS-L assessed R94's right heel, left gluteus, and sacrum pressure injuries. R94's skin issue assessment dated [DATE] completed by NS-L documented the right heel is resolved. Skin issue #002 left gluteus, progress stable previously deteriorating, wound characteristics plateaued. Unstageable pressure ulcer/injury due to slough and/or eschar. Length was 5.48, width 1.72, & depth 0. Slough was 100%. Skin issue #003 sacrum documented progress stable, previously deteriorating wound characteristics, plateaued, stage 3. Length was 0.84, width 0.7, depth 0.1. Granulation was 50% and other wound bed was pink or red. On 4/13/26, Wound PA-E documented: Since last seen, she developed two new open areas at the sacral area and the left lower buttock/gluteal fold. They had ongoing issues over the weekend, with the main issue being urinary incontinence leading to tissue breakdown and extensive moisture. They denied fever or chills. They reported no issues with dressing falling off. Per discussion with nursing staff, the sacral site appeared improved. They denied other concerns at this time. Wound PA-E documented for sacrum, stage 3 the same measurements as NS-L and wound bed was documented as 50% granular, 50% pink non-granular

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R95) of 1 resident reviewed for feeding assistance and 5 (R50, R18, R77, R1, and R3) of 9 residents reviewed for falls. * R95 was assessed to be dependent on staff for eating, requiring a mechanical soft diet, needing assistance with feeding, and needing to take small bites while eating. Speech Therapist (ST)-K informed Surveyor that facility staff should be within 2 feet and at the same table while R95 is eating. On 6/13/26, R95 was in the dining room. Certified Nursing Assistant (CNA)-PP left the dining room to deliver room trays. R95's was served a tuna sandwich which was placed in front of R95 without staff supervision. Staff observed R95 to be choking and began administering the Heimlich maneuver and R95 expelled a large piece of bread. On 6/15/26, R95 was diagnosed with aspiration pneumonia and expired on 6/17/26. R95's immediate cause of death was Aspiration pneumonia. The facility's failure to provide adequate supervision and assistance to prevent R95 from choking created a finding of immediate jeopardy that began on 6/13/26. Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Consultant-C of the finding of immediate jeopardy on 7/14/2026 at 1:27 PM. The immediate jeopardy was removed on 7/15/26 when the facility implemented a removal plan. The deficient practice continues at a scope/severity of G (actual harm/isolated) for the following example involving R50: * R50 sustained a fall at the facility on 2/4/26 that resulted in a left femur fracture and required hemiarthroplasty on 2/6/26. R50 sustained an additional fall at the facility on 2/17/26 that was not investigated. R50's falls care plan was not updated to include fall interventions of a fall mat or use of a bolster in bed. The following examples are cited as a potential for more than minimum harm: * R18's falls care plan included interventions of anti-rollback brakes on wheelchair and monitor gripper socks, which were not observed in place 7/7/26-7/13/26. * R77's fall was not thoroughly investigated to determine a root cause analysis of the fall. * R1 had a history of repeated falls and alcohol abuse. R1 had four falls in which alcohol intoxication was the cause. The facility did not address R1's alcoholism as a root cause of the falls. * R3 did not have any previous fall interventions in place when R3 fell on 2/25/2026. Findings include: The International Dysphagia Diet Standardization Initiative (IDDSI) consumer handout titled, IDDSI Consumer Handouts General info, dated January 2019 documents, in part: IDDSI has created these handouts in consultation with clinicians and patients. The food levels also include examples of foods for each level, and food textures to avoid. Level 6- Soft and Bite-sized: Soft, tender, and moist, but with no thin liquid leaking/dripping from the food. Ability to bite off a piece of food is NOT required. Ability to chew bite-sized pieces so that they are safe to swallow IS required. Bite-sized pieces no bigger than 1.5 [centimeters (cm)] x 1.5 cm is size. Soft & Bite-sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. The pieces are 'bite-sized' to reduce choking risk. Examples of level 6 Soft and Bite-Sized food for adults: . NO regular dry bread due to high choking risk. The facility's policy, with an approved date 6/5/26 and titled, Mechanical Soft Diet documents, in part: The mechanical soft diet is for individuals who have difficulty chewing and/or swallowing regular texture foods. The speech language pathologist (SLP) evaluates and determines when a mechanical soft diet is appropriate for an individual. The regular menu is followed, and foods are altered to the highest consistency the individual can tolerate. Exceptions to this list will be made on an individual patient basis, ONLY with the written approval of the SLP. Foods allowed: Easy to chew bread (no hard crusts). R95 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following stroke, Dysphagia, and Vascular dementia. R95's admission Minimum Data Set (MDS) assessment dated [DATE], documents that R95 was assessed to be moderately cognitively impaired. The MDS documents that R95 was assessed as being dependent on staff for eating, that R95 does lose liquids and solids from the mouth when eating or drinking and that R95 holds food in mouth/cheeks or has residual food in mouth after meals. R95 is on a mechanically altered diet. R95's Nutrition Care Area Assessment (CAA) dated 1/20/26, documents in part: Puree diet, nectar thick liquids [secondary to] dysphagia from strokes. Difficulty swallowing with need for texture modified diet. R95's Swallowing care plan intervention initiated on 1/15/26 documents: Resident to eat only with supervision. R95's Nutrition care plan intervention initiated on 1/15/26 documents: Swallow guidelines- small bites, small single sips, upright and alert for all [by mouth intake], check for [left] side pocketing, encourage an additional swallow or use liquid wash, upright in chair for meals. R95's Activity of Daily Living (ADL) care plan intervention initiated on 1/21/26 documents: Feed resident for meals. R95's MD order with a start date of 1/14/26 documents: General/regular diet, Pureed texture, Nectar/Mildly thick consistency. Double portions. R95's Care conference note dated 2/9/26 documents, in part: . [R95] is still on a puree diet with nectar thick liquids but is working with speech therapy. Eats in the dining room. Per [power of attorney (POA)], [R95] is able to feed [themselves] a bit, but still may need help. Assist with feeding is indicated on his meal slip. R95's Hospital Discharge summary dated [DATE] documents, in part: Discharge diagnosis- Acute blood loss anemia. GI bleed. Aspiration Pneumonia. treated with [antibiotic]. R95's Hospital Speech-Language pathology screen dated 4/24/26 documents in part: Patient's baseline diet per recommendation after video fluoroscopic swallow study done on 1/14/26 is IDDSI Level 6- Soft & Bite-sized diet. Recommend diet advancement per medical team once medically approved to advance . Surveyor noted the hospital diagnosed R95 with aspiration pneumonia. The hospital SLP (Speech Language Pathologist) documented that R95 should follow the IDDSI level 6 diet recommendations for food. R95 returned to the facility on 4/28/26. R95's facility nutrition note dated 5/5/26 documents in part: . Previously on puree thick diet with nectar thick liquids. OK to upgrade to Mechanical soft diet per hospital SLP recommendation 4/24/26. Called POA and discussed. [POA] verified hospital was serving Mechanical soft diet and [POA] is happy about diet upgrade. R95's MD order with a start date of 5/5/26 documents in part: General/regular diet, Mechanical soft texture. R95's Hospital Discharge summary dated [DATE] documents in part: Hospital course: Acute gastrointestinal bleeding with Arteriovenous malformation of jejunum. Opacity of lung on imaging study. Persistent right-sided opacities, they do look better than last month. would cover with a course of oral [antibiotic] for now. General diet IDDSI level 6. Per SLP, aspiration precautions. Surveyor noted the hospital documented continued concerns with R95's lung opacities and recommended that R95 follow the IDDSI level 6 diet recommendations for food. R95's facility's speech therapy note dated 5/28/26 and written by ST-K documents: [Patient (Pt)] seen for swallowing evaluation to ensure and monitor for swallow and health safety. Oral cavity revealed missing dentition. [Cranial Nerve] exam revealed lingual/labial weakness/incoordination. Pt [with] left facial asymmetry. [By mouth] trials included nectar thick, puree, and [mechanical] soft. [With] mechanical soft: effective but prolonged mastication, [minimal] oral residue, cleared [with] liquid wash and multiple swallows. Pt [with] [signs/symptoms] of [aspiration] during trials. Will continue to monitor and evaluate for safest diet to reduce risk of [aspiration pneumonia]. R95's speech therapy note dated 6/8/26 and written by ST-K documents: Pt demonstrated effective mastication. Pt [with] [minimal to moderate] oral residue in left oral cavity. Pt required visual cueing to utilize liquid wash. Pt [with] increase rate of speed [with] trials. Pt required [moderate] verbal cueing to reduce rate of speed to support swallow/mastication safety. [Signs/symptoms] of [aspiration] x 1. Surveyor noted ST-K documented that R95 required visual cueing to utilize liquid wash after chewing food and verbal cueing to slow down the rate of speed while eating. R95's ST-K speech therapy note dated 6/10/26 documents: Pt (patient) required assistance [with] tray set up and feeding. Pt required [moderate] verbal cueing to reduce rate of speed [with] trials and clear oral cavity prior to additional trials. Surveyor noted ST-K documented that R95 required assistance with feeding and required verbal cueing to slow down the rate of speed in eating. R95's speech therapy note dated 6/11/26 and written by ST-K documents: Pt continues to require [moderate] verbal cueing to utilize small bites, clearing oral cavity prior to additional trials, and clearing [left] oral cavity of residue. Pt continues to demonstrate impulsivity [with] rate of speed of trials. Pt required [moderate] verbal cueing to reduce rate of speed, utilize single bites. Pt [with] [minimal-moderate] oral residue in [left] cavity. Surveyor noted ST-K documented that R95 required verbal cueing to utilize small bites and slow down the rate of speed in eating. Surveyor reviewed R95's CNA task documentation for eating. Surveyor noted that from June 1st through June 13th, facility CNAs documented 25 out of 30 times that R95 was dependent on staff for eating. Dependent is defined as Helper does ALL of the effort, and the resident does none of the effort to complete the activity. R95's meal ticket instructions as of 6/13/26, documented: Mechanical Soft. Assist with feeding. Small bites, small single sips, upright and alert for all [by mouth intake]. Check for [left] side pocketing, encourage an additional swallow or use liquid wash, upright in chair for meals. On 7/9/26 at 10:07 AM, Surveyor interviewed ST-K. ST-K stated that R95 was on a mechanical soft diet and needed cueing while eating. ST-K stated that R95 would try to feed himself and could with some trouble but stated that R95 needed assistance with meals. Surveyor asked what assistance was needed. ST-K stated actual feeding. Surveyor asked what is the expectation of CNA staff assisting R95 with feeding. ST-K stated that facility staff would need to be at the table within two feet of R95 while R95 was eating. On 7/13/26 at 11:55 AM, Surveyor interviewed DON-B. Surveyor asked what the expectation is for CNA staff that would be assisting R95 with eating. DON-B indicated that as long as someone was in the dining room monitoring R95, that would be sufficient. DON-B stated that R95 could feed himself but needed supervision. Surveyor noted the discrepancy between the expectation of ST-K and DON-B. ST-K expected staff to sit at table and be within two feet of R95 when R95 was eating. DON-B expected staff to be in the dining room monitoring R95. The facility menu for mechanical soft diet for dinner on 6/13/26 included: Tuna salad sandwich, cheese puffs, diced green beans, pudding cup, and milk. On 7/9/26 at 10:07 AM, Surveyor interviewed ST-K. Surveyor asked if R95 could eat a tuna sandwich. ST-K stated it would need to be on soft bread and cut into bite-sized pieces or at least into quarters. On 7/15/26 at 7:45 AM, Surveyor asked ST-K about the IDDSI level 6 diet versus the facility mechanical soft diet. ST-K stated they were aware that some foods not allowed on IDDSI are included in the facility mechanical soft diet. ST-K confirmed bread is not part of the IDDSI level 6 diet. Surveyor asked if ST-K had assessed R95's ability to chew bread. ST-K indicated they did not recall but stated the facility serves bread on a regular basis and R95 had it on meal trays prior to dinner on 6/13/26. ST-K stated it was safe for R95 to have bread as long as there was supervision and cueing from facility staff. On 7/13/26 at 2:07 PM, Surveyor interviewed Dietician-H. Dietician-H is familiar with the IDDSI level 6 diet. Dietician-H indicated they had implemented the IDDSI standard of practice in other workplaces, but that Dietician-H is following company guidelines at this facility. Dietician-H stated they had sent emails to management to implement IDDSI but at the current time, the facility does not follow the IDDSI standard of practice. Dietician-H stated that the facility has a crosswalk that will identify what altered diet texture order will be implemented at the facility. For R95, a IDDSI level 6 is comparable to the facility mechanical soft diet and that is why R95 was placed on that diet while in the facility. Dietician-H stated they acknowledged that they are not the same, but Dietician-H is following their company's direction and R95 was being evaluated by ST-K regularly. The facility Crosswalk document mentioned by Dietician-H is titled [Name of Company] Comparable Diets. The document has two columns. One column is titled, Admitting Diet Order. The other column is titled, [Name of Company] Comparable Diet. The [Name of Company] comparable diet column documents, in part: Mechanical Soft. In the Mechanical Soft Row is listed: Dysphagia Minced, National Dysphagia Diet 2 and 3, Dysphagia Mechanically Altered. Semi-solid, Dysphagia Soft/low, Soft, Dysphagia Advanced. IDDSI Level 7 Easy to Chew, IDDSI Level 6 Soft & Bite Sized, IDDSI Level 5 Minced and Moist. Surveyor noted that IDDSI Level 6 is included in the facility's list as comparable to a Mechanical Soft Diet. R95's progress note dated 6/13/26 at 5:40 PM, documents: While assisting with feeding CNA noticed resident choking and called nurse. Heimlich was at [5:30 PM]. Resident went unresponsive, lowered to the floor, CPR was started and 911 was called. On 7/13/26 at 2:07 PM, Director of Nursing (DON)-B provided Surveyor with statements from the staff members involved when R95 choked. DON-B informed Surveyor that DON-B got these statements over the phone and included conversations with CNA-PP, CNA-HH, and Licensed Practical Nurse (LPN)-Z. CNA-PP's statement dated 6/15/26 documents, in part: I was sitting in the dining room with [R95.] waiting for trays. Room trays were ready, so I left the dining room to pass them. When I left, [R95] did not have his food yet. I returned to the dining room approx. 5-6 min later and saw [R95] choking. I yelled for help. Nurses came in and started the Heimlich, then lowered [R95] to the floor and continued thrusts. [CNA-HH] was in the dining room the whole time. Surveyor noted in CNA-PP's statement, CNA-PP stated they were sitting with R95 but left R95 to pass room trays. Surveyor noted that R95's tray of food was delivered to R95 when CNA-PP was not sitting with R95. On 7/15/26 at 3:43 PM, CNA-PP returned Surveyor's phone call and stated they were familiar with R95. CNA-PP stated R95 required supervision for eating and that R95 was a resident that needed to be fed. CNA-PP indicated R95 needed someone sitting with him at the table while eating. CNA-PP stated they were not assigned to assist R95 with eating during the dinner meal on 6/13/26. CNA-PP had 2 other residents that they were going to help feed. CNA-PP was not sitting at R95's table when CNA-PP saw that room trays were ready. CNA-PP stated they had three room trays to pass on their hallway, and they left the dining room to do that. CNA-PP came back to the residents that they were going to help feed. CNA-PP stated all the residents in the dining room had their food trays, but CNA-PP did not know who delivered R95's tray. CNA-PP turned and saw R95. CNA-PP stated R95 looked deceased and was gray in color. That is when CNA-HH walked into the dining room. CNA-HH did the Heimlich and started compressions. While R95 was on the ground, CNA-PP saw food in R95's mouth and pulled it out. Surveyor asked how much food was pulled out of R95's mouth. CNA-PP stated, it was very big, like a whole bun. Surveyor asked if staff was in the dining room when CNA-PP returned from passing trays. CNA-PP stated no, there was no one in dining room. CNA-PP said, CNA-HH walked in when I noticed R95 looked bad and then called for help. Surveyor noted CNA-PP pulled a very big piece of food out of R95's mouth. Surveyor noted the discrepancy between what DON-B documented as CNA-PP's statement and what CNA-PP told Surveyor. Surveyor noted in the interview that CNA-PP informed Surveyor that CNA-PP was not sitting with R95 and was not assigned to help feed R95. In contrast, DON-B's written statement of CNA-PP's account stated that CNA-PP was sitting with R95. CNA-PP informed Surveyor that CNA-HH was not in the dining room when CNA-PP returned from passing trays. In contrast, DON-B's written statement of CNA-PP's account documents that CNA-HH was in the dining room the whole time. On 7/15/26 at 7:45 AM, Surveyor interviewed ST-K and asked if facility staff should have placed a food tray in front of R95 without staff at the table. ST-K stated no. ST-K stated R95 is very impulsive and required cueing to slow down their eating. ST-K stated when ST-K would assess R95, ST-K would put the tray in front of him, set it up and then assist feeding R95. ST-K would be at the table during R95's entire assessment. On 7/9/26 at 11:26 AM, Surveyor interviewed Dietician-H who stated R95 was on a mechanical soft diet starting in May. R95 got feeding assistance and needed supervision. Dietician-H stated R95 could do a little by themself, but you could not put a tray in front of R95 and leave. Surveyor asked if R95 could have a tuna sandwich. Dietician-H stated R95 could have a sandwich with soft bread if it was cut into small pieces or at least cut into four sections. Dietician-H stated if R95 was served a sandwich with a whole piece of bread, whoever was supervising R95 would be there to stop R95 from putting it all in R95's mouth. On 7/13/26 at 2:07 PM, Surveyor interviewed DON-B and asked if CNA-PP should have left R95's table. DON-B stated that as long as CNA-PP and CNA-HH worked it out, CNA-PP could help deliver trays. DON-B indicated that as long as one CNA is in the dining room at all times, it is ok. Surveyor noted the discrepancy between ST-K and Dietician-H's expectations compared to DON-B. ST-K and Dietician-H stated staff could not place a tray in front of R95 and leave it there. DON-B stated as long as the CNAs work it out, a CNA just needed to be in the dining room. CNA-HH's statement dated 6/15/26 documents: I was in the dining room pouring drinks at the time. [CNA-PP] came in and started yelling that [R95] was choking. Nurses came [into] the dining room. [LPN-Z] started the Heimlich then we lowered [R95] to the floor. I started thrusts. AED was hooked up to [R95] and no shock was advised. [Emergency medical services (EMS)] arrived. On 7/8/26 at 11:13, 7/9/26 at 8:53 AM, and 7/13/26 at 10:09 AM, Surveyor attempted to speak to CNA-HH over the phone, leaving multiple messages but did not receive a return call. On 7/13/26 at 2:07 PM, Surveyor interviewed DON-B and asked who delivered the food tray to R95 while CNA-PP was delivering room trays. DON-B stated they believe it was CNA-HH. Surveyor noted that in CNA-HH's statement, CNA-HH indicated that they were pouring drinks and were not sitting with R95 after R95's food tray was delivered. CNA-HH did not state in the statement that CNA-HH saw R95 putting food into R95's mouth and did not say that they saw R95 choking. LPN-Z's statement dated 6/15/26 documents: [CNA-PP] was assisting in the dining room. [CNA-PP] yelled from the dining room that [R95] was choking. I attempted the Heimlich, but it was not successful. I instructed staff to assist me to lower [R95] to the floor. Once on the floor, more thrusts. [CNA-PP] pulled a wad of food from [R95's] mouth. EMS arrived and took [R95] to the hospital. Surveyor noted a wad of food was pulled from R95's mouth. On 7/9/26 at 9:26 AM, Surveyor interviewed LPN-Z. LPN-Z stated they were at their medication cart and heard a CNA yelling that R95 was choking. LPN-Z stated when LPN-Z got to the dining room, CNA-HH was behind R95 doing the Heimlich maneuver. CNA-PP was also in the dining room. When LPN-Z entered the dining room, that is when R95 became unresponsive and was lowered to the floor. CNA-HH continued to do thrusts on the ground. CNA-PP reached in R95's mouth and retrieved food. LPN-Z stated it was bread and stated R95 is allowed to have bread on a mechanical soft diet. Surveyor asked what size of bread came out. LPN-Z stated, It was a nice size. LPN-Z stated it appeared that R95 tried to eat the whole slice of bread and not just a piece of it. LPN-Z stated Nurse Extern (NE)-DD came to the dining room with the code cart and AED. 911 was called and EMS came to the facility and took R95 to the hospital. Surveyor asked if LPN-Z documented any of what happened in the medical record. LPN-Z stated no. Surveyor noted discrepancies in LPN-Z's statement documented by DON-B and the interview with Surveyor. LPN-Z told DON-B that LPN-Z completed the Heimlich maneuver and thrusts. LPN-Z told Surveyor that CNA-HH did the Heimlich maneuver and thrusts. Surveyor noted that LPN-Z observed CNA-PP take out what appeared to be a whole slice of bread and not just a piece of it. R95's EMS response dated 6/13/26 at 5:24 PM, documents in part: Pt (patient) contact made finding pt in the dining room lying supine with staff present. Obstruction was confirmed cleared from the airway. Crew observed a big piece of bread by the pt head. Surveyor noted EMS staff documented that a big piece of bread was at R95's head when they arrived. Surveyor noted CNA-PP, LPN-Z, and EMS staff stated or documented that R95 had a big piece of bread pulled from his mouth. Surveyor noted facility staff did not follow meal ticket instructions in directing R95 to take small bites. Check for [left] side pocketing, encourage an additional swallow or use liquid wash. Surveyor noted a big piece of bread is not a small bite. R95 went to the Emergency Department (ED) on 6/13/26. R95's Hospital emergency provider note dated 6/13/26 documents in part: [R95] presents to the [ED] with a chief complaint of chest pain and shortness of breath. Apparently [R95] was choking on a sandwich at [the] facility and the staff ended up doing CPR on the patient for a few minutes and now the patient is complaining of some chest pain and shortness of breath. Chest X-ray 1 view completed. No acute cardiopulmonary findings. [R95] was stable for discharge. [R95] was instructed. to return to the emergency department if worse or any other concerns. R95 returned to the facility on 6/13/26. R95's 24-hour board dated 6/14/26 documents: Productive cough noted. Choking. Bruise upper mid chest. Noc shift: productive cough noted. Provider said to monitor. AM shift: Coughing noted. Slight [complaints of] chest discomfort. PM shift: Complaint of pain. Bruising chest fading away. R95's change of condition note dated 6/15/26 at 1:44 AM, documents, in part: Pulse Oximetry 68%. Resident observed with audible rattling/crackling respirations. SPO[2] (oxygen saturation) 68%. Resident sent to the hospital for further evaluation and treatment. R95's ED records dated 6/15/26 documents in part: ED workup today concerning for aspiration pneumonia versus pneumonitis in the setting of choking episode. Chest x-ray showed bilateral opacities. Patient required hospital admission for further evaluation and treatment. R95's Hospital Discharge summary dated [DATE] documents in part: [R95] was admitted to the hospital on . 6/15/26 for treatment of. aspiration pneumonia and acute respiratory failure when [R95] presented with hypoxia and shortness of breath. Clinical condition worsened during the early morning hours on 6/17/26 at which point patient started complaining of more shortness of breath and mild chest discomfort. On the morning of 6/17, after family assessed the patient, they decided that they would not like to pursue further investigation and wanted additional discussion with palliative care team about switching goals of care towards comfort plan of care. [R95] was admitted to hospice in hospital service. Medical problems: Aspiration pneumonia. On 7/7/26 at 1:46 PM, Surveyor interviewed R95's Family Member-TT. Family Member-TT stated R95 died on 6/17/26. Family Member-TT read Surveyor R95's Death Certificate which documented: [State] Certificate of Vital Record. Date completed: 6/19/26. date of death [DATE]. Immediate cause: Aspiration pneumonia. On 7/13/26 at 3:57 PM, Surveyor informed DON-B, Nursing Home Administrator (NHA)-A, and Consultant-C that R95 was assessed to need assistance with eating and was dependent on staff for eating. On 6/13/26, CNA-PP left the dining room to deliver room trays. CNA-PP returned from passing trays and alerted staff that R95 was choking. The Heimlich maneuver was completed and R95 was lowered to the floor. CNA-PP, LPN-Z, and EMS staff confirmed that a large piece of bread was pulled from R95's mouth. R95 was supposed to have bite-sized food and according to ST-K, have a staff member within two feet of R95 supervising R95 while assisting him to eat. R95 was not adequately supervised after given food at the table. R95 was later diagnosed with aspiration pneumonia. The failure to provide adequate assistance and supervision to R95 while R95 was eating created a reasonable likelihood for serious harm, thus leading to a finding of Immediate Jeopardy. The immediate jeopardy began on 6/13/26 when R95 choked on a piece of bread. NHA-A, DON-B, and Consultant-C were notified of the immediate jeopardy on 7/14/2026 at 1:27 PM. The immediate jeopardy was removed on 7/15/26 when the facility implemented the following removal plan, however, it continues at a scope/severity level of G (actual harm/isolated) for the example involving R50: The resident-specific event was immediately investigated and reviewed by facility leadership. A comprehensive review of all residents was completed to identify those who: Require supervised dining. Require feeding assistance or are dependent for eating. Have dysphagia or aspiration precautions. The ED, DON, RD, and SLP reviewed and reassessed residents requiring modified diets, feeding assistance, supervision during meals, dysphagia management, and aspiration precautions to ensure diet orders, supervision needs, and plans of care accurately reflected each resident's current condition. Dietary orders were reviewed for accuracy and compared to physician orders, Kardexes, meal tickets, and care plans. Individual resident specific food consistency exceptions and special preparation needs were documented in the care plan, Kardex, and meal ticket system. Staff assignments were immediately adjusted to ensure 2 staff members will be in the dining room for all meals. The facility determined the staffing plan based on the current resident census and the number of residents requiring supervision or feeding assistance. This staffing model allows approximately one designated staff member for every four residents requiring supervision or feeding assistance. If the number of residents requiring supervision or assistance increases, additional designated staff will be assigned. Residents continue to dine with their peers and are not required to move to designated supervised tables. Effective immediately, staff were instructed that any resident requiring supervised dining or feeding assistance must remain within arm's reach/at the same table of the assigned staff member while actively eating or drinking. Staff may not supervise these residents from across the dining room or while completing unrelated tasks. Licensed nurses verified meal assignments prior to each meal to ensure adequate staff coverage for residents requiring supervision. Prior to each meal, the licensed nurse reviews the written meal assignment schedule to verify which residents require supervision or feeding assistance and confirms designated staff assignments are adequate to safely meet resident needs. All licensed nurses, certified nursing assistants, dietary staff, and other staff providing meal assistance received immediate education regarding: Identification of residents requiring supervised dining. Expectations for remaining within arm's reach. Verification of diet order/texture being served via reading diet ticket. Identification of correct food consistencies using the facility diet guide. Verification that the food served matches the resident's meal ticket and physician diet order. Recognition of individualized food preparation requirements and the process for reporting discrepancies before meals are served. The facility implemented a Supervised Dining Protocol outlining staff responsibilities, supervision expectations, emergency response procedures, and documentation requirements. The SLP is responsible for assessing swallowing function and determining diet texture, liquid consistency, feeding assistance, and supervision needs. Nursing may immediately implement increased supervision or downgrade diets when clinically indicated while awaiting SLP assessment. When CNAs, nurses, dietary staff, or other caregivers identify a change in a resident's eating ability, the nurse notifies the SLP and RD for reassessment. Following reassessment, the SLP communicates recommendations to the interdisciplinary team. The licensed nurse implements physician orders and ensures the RD updates the meal planning system, meal tickets, Kardex, and care plan. Nursing communicates all changes through the 24-hour report and shift to shift communication. Meal observations were initiated by facility leadership to verify compliance with supervised dining expectations and provide immediate coaching when indicated. The dietary department utilizes a standardized diet preparation spreadsheet identifying preparation requirements for each diet consistency. A kitchen whiteboard identifies the current number of residents on each diet consistency to ensure accurate meal preparation. When the SLP identifies a resident-specific food preparation requirement (i.e., quartered sandwiches, bite-sized foods, etc.), the Registered Dietitian immediately updates the kitchen spreadsheet, meal planning system, meal ticket, Kardex, and care plan. Daily log created for verification of two staff members in dining room for all meals, nurses to sign for each meal. Observe meal service 3x/week four weeks, then decrease the frequency based on sustained compliance. Audit staff assignments to ensure 2 staff assigned to dining room for all meals. Immediately address and re-educate staff when noncompliance is identified. Review audit findings through the facility Quality Assurance and Performance Improvement (QAPI) process and implement additiona

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 (Wisconsin Food Code).*Dining Server (DS)-KK was observed in the main kitchen handling clean dishes without wearing a hair restraint that fully restrained hair*Assistant Director of Dining (ADOD)-MM was observed on the second floor serving kitchen without wearing a hair restraint that fully restrained hair or a beard restraint.*Certified Nursing Assistant (CNA)-V was observed handling a peeled ready to eat banana on a resident's plate for the resident to eat with bare hands.*DS-JJ, DS-KK and DS-LL were observed placing ready-to-eat bread products on resident plates with the same single-use gloves that were used to handle utensils and meal tickets.* Surveyor observed a foul odor and several flies near the hot temperature dishwasher in the main kitchen near dishes were air dried.This deficient practice has the potential to affect all 73 residents who receive food from the main kitchen.Findings include:On 7/7/26 at 8:24 AM, Surveyor interviewed Food Services Director (FSD)-NN who confirmed the facility follows the Wisconsin Food Code.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; . food employees may not contact exposed, ready-to-eat food with their bare hands;single-use gloves shall be used for only one task such as working with ready-to-eat food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.1. Hair RestraintsOn 7/8/26 at 11:18 AM, Surveyor observed DS-KK preparing lunch service by handling clean dishes and handling food in the steamer in the main kitchen while not wearing a hair restraint that fully restrained hair.On 7/9/26 at 12:24 PM, Surveyor observed ADOD-MM preparing and handling food and plates on the second floor serving kitchen while not wearing a hair restraint that fully restrained hair or a hair restraint that covered exposed facial hair.On 7/13/26 at 1:50 PM, Surveyor observed DS-KK handle clean dishes in the main kitchen, that serves food to all residents, while not wearing a hair restraint that fully restrained DS-KK's hair.In an interview on 7/13/26 at 1:55 PM, FSD-NN stated hair and beard restraints should be worn by staff during all service and production in the main kitchen or service kitchens. Surveyor informed FSD-NN that DS-KK and ADOD-MM were observed without hair or facial hair fully restrained in the main kitchen and second floor serving kitchen on the above dates.2. Food ServiceOn 7/7/26 at 12:23 PM, Surveyor observed the lunch meal served to residents in the second-floor dining room. Surveyor observed CNA-V peel a banana with her bare hands and then place the peeled banana on R29's plate for R29 to eat.On 7/7/26 at 12:34 PM, Surveyor observed R29 eat the banana.In an interview on 7/8/26 at 11:21 AM, FSD-NN stated staff should wear gloves when handeling a peeled banana, and a banana should never be handled with bare hands.On 7/9/26 at 12:15 PM, Surveyor observed DS-KK touch scoops and meal tickets with single-use gloves, then grab a ready-to-eat dinner roll with the same gloves and place it onto resident plates for a resident to eat.Surveyor noted that DS-KK did not remove their gloves and wash their hands and did not don new gloves prior to handling ready to eat food that was served for a resident to eat.On 7/9/26 at 12:26 PM, Surveyor observed DS-JJ touch a cup of applesauce and meal trays with single-use gloves, then grab a piece of ready to eat bread and place it on resident's plate for the residents to eat. Surveyor also observed DS-LL touch scoops and meal tickets with single-use gloves, then grab a dinner roll and hamburger bun and place the dinner roll and hamburger bun onto resident plates for a resident to eat.Surveyor noted that DS-JJ and DS-LL did not remove their gloves and wash their hands and did not don new gloves prior to handling ready-to-eat food that was served for a resident to eat.In an interview on 7/9/26 at 12:31 PM, FSD-NN stated ready to eat dinner rolls, bread, and buns should be placed on resident plates using tongs. Surveyor informed FSD-NN of observations of DS-KK, DS-JJ, and DS-LL placing ready-to-eat bread products onto resident plates using single-use gloves that previously handled utensils, meal tickets, applesauce, and meal trays without changing gloves, washing hands or use the of tongs. On 7/13/26 at 2:12 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the above findings.3. Kitchen CleanlinessThe facility policy titled, Staff training overview with no date, documents: All staff involved in food service are adequately trained to perform assigned duties and are required to participate in regularly scheduled inservice training sessions. Upon completion of initial training, each employee will be trained in all food service areas. The food service manager is responsible for orientation and training of new staff. Train staff on the following: . the importance of maintaining a high degree of cleanliness . food protection, care and cleaning of dishes and equipment.Surveyor observed a foul odor and several flies near the hot temperature dishwasher in the main kitchen.On 7/13/26 at 1:50 PM, Surveyor observed a foul odor near the hot temperature dishwasher in the main kitchen. Surveyor observed several flies in the area near the dishwasher, as well as in the area next to the dishwasher where clean dishes used by residents were air dried.On 7/13/26 at 1:55 PM, Surveyor shared concern with Food Service Director (FSD)-NN of the observation of a foul odor and several flies near the dishwasher in the main kitchen. FSD-NN stated they would look into it.On 7/13/26 at 2:12 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A of the observation of a foul odor and several flies in the dishwashing area in the main kitchen.On 7/14/26 at 8:05 AM, Surveyor interviewed facility services tech (FST)-GG who stated a pest control company comes to the facility once a month to address any pests in the kitchen. FST-GG stated the last time the pest control company was here, they mentioned the fruit flies in the kitchen had gotten a lot better.On 7/14/26 at 8:36 AM, Surveyor reviewed the pest control service report dated 6/26/26 which documented they spoke with kitchen staff and showed two areas in the kitchen that need thorough cleaning to eliminate fruit flies. Surveyor reviewed the pest control service report dated 7/10/26 which documented fifteen night-flying insects were counted in the main kitchen/dish rack location.

Based on interview and record review, the facility did not ensure professional standards of practice were followed for 1 (R95) of 16 Residents that receive an altered textured diet and choked. This deficient practice also has the potential to affect the 16 residents who currently receive altered texture diets.The facility does not follow current standards of practice for altered texture diets by not following IDDSI (International Dysphagia Diet Standardization Initiative).R95's Hospital Speech Language Therapist (SLP) recommended that R95 follow the International Dysphagia Diet Standardization Initiative (IDDSI) level 6 Soft & Bite sized diet, which does not include slices of bread. The facility does not follow the IDDSI standard of practice. Facility staff placed R95 on a mechanical soft diet, which did include soft bread. In an interview, the facility Speech Therapist (ST)-K, did not recall if they assessed R95's ability to eat bread. The facility did not provide documentation that ST-K assessed R95's ability to eat bread. R95 was given a tuna sandwich. R95 choked and a large piece of bread was removed from R95's mouth. R95 was diagnosed with Aspiration Pneumonia (a lung infection that happens when you breathe food, liquid, vomit, or saliva down the wrong pipe into your lungs instead of swallowing it down your stomach).Findings include:The IDDSI Framework (the Standard) website (The IDDSI Standard - Standards - IDDSI; https://www.iddsi.org/standards/framework) documented, in part: The IDDSI framework consists of a continuum of 8 levels (0 - 7), where drinks are measured from Levels 0 - 4, while foods are measured from Levels 3 - 7. The IDDSI Framework provides a common terminology to describe food textures and drink thickness. IDDSI Testing Methods are intended to confirm the flow or textural characteristics of a particular product at the time of testing. Testing should be done on foods and drinks under the intended serving conditions (especially temperature). The clinician has the responsibility to make recommendations for foods or drinks for a particular patient based on their comprehensive clinical assessment.The IDDSI Consumer Handouts General info dated January 2019 documents, in part: IDDSI has created these handouts in consultation with clinicians and patients. The food levels also include examples of foods for each level, and food textures to avoid. The definition of a Level 6- Soft and Bite-sized documented: Soft, tender and moist, but with no thin liquid leaking/dripping from the food. Ability to bite off a piece of food is NOT required. Ability to chew bite-sized pieces so that they are safe to swallow IS required. Bite-sized pieces no bigger than 1.5 [centimeters (cm)] x 1.5 cm is size. Soft & Bite-sized food may be used if you are not able to bite off pieces of food safely but are able to chew bite-sized pieces down into little pieces that are safe to swallow. The pieces are 'bite-sized' to reduce choking risk. Examples of level 6 Soft and Bite-Sized food for adults: . NO regular dry bread due to high choking risk. Soft & Bite-Size, Level 6 and Minced & Moist, Level 5 do not include regular dry bread, sandwiches, or toast of any kind, even if they are cut-up to the appropriate size indicated for each diet level. Use pre-gelled 'soaked' breads that are very moist and gelled through the entire product. When modifying the texture of a bread product or using a commercial product for bread menu items, be sure to validate the product before serving. Use the IDDSI Testing Methods for the IDDSI level you are serving. https://www.iddsi.org/images/AroundTheWorld/UnitedStates/faq/USIRGFAQExceptionsBreadsMixedConsistencyJan2025.pdfPer the National foundation of Swallowing Disorders, IDDSI is a global initiative that provides a standardized framework for diet modification for individuals with swallowing difficulties. IDDSI was launched in 2015 as a response to the confusion and inconsistencies surrounding food and drink modifications used for dysphagia management. Different countries and healthcare facilities had their own systems, which made it difficult for patients to understand and for caregivers and healthcare providers to communicate effectively. By creating a universal set of definitions and descriptors, IDDSI aims to ensure that individuals with dysphagia receive safe and appropriate diets regardless of where they are located. (https://swallowingdisorderfoundation.com/iddsi-nfosd)On 7/14/26, facility staff provided Surveyor with the total number of residents on an altered texture diet. The list documents 14 residents on a mechanical soft diet and 2 residents on a pureed diet.Surveyor noted a total of 16 residents who receive an altered texture diet through the facility kitchen.R95 was admitted to the facility on [DATE] with diagnosis that include: Hemiplegia and Hemiparesis following stroke and Dysphagia (difficult swallowing).R95's admission minimum data set (MDS) assessment dated [DATE], documented R95 was moderately cognitively impaired. R95 was dependent on staff for eating. R95 did lose liquids and solids from the mouth when eating or drinking. R95 held food in mouth/cheeks or had residual food in mouth after meals. R9 was on a mechanically altered diet.R95's Nutrition Care Area Assessment (CAA) dated 1/20/26, documented, in part: Puree diet, nectar thick liquids [secondary to] dysphagia from strokes. Difficulty swallowing with need for texture modified diet.R95's Nutrition care plan intervention initiated on 1/15/26 documented: Swallow guidelines- small bites, small single sips, upright and alert for all [by mouth intake], check for [left] side pocketing, encourage an additional swallow or use liquid wash, upright in chair for meals.R95's MD order with a start date of 1/14/26 documented: General/regular diet, Pureed texture, Nectar/Mildly thick consistency. Double portions.R95 experienced a change of condition and was hospitalized from [DATE] through 4/28/26.R95's Hospital Discharge summary dated [DATE] documented, in part: Discharge diagnosis- . Aspiration Pneumonia. treated with [antibiotic].R95's Hospital Speech-Language Pathology (SLP) screen dated 4/24/26 documented, in part: Patient's baseline diet per recommendation after video fluoroscopic swallow study done on 1/14/26, is IDDSI Level 6- Soft & Bite-sized diet, thin liquids. Recommend diet advancement per medical team once medically approved to advanced.Surveyor noted that the hospital SLP documented that R95 should follow the IDDSI level 6 diet recommendations for food. Surveyor also noted that an IDDSI level 6 diet was the recommended diet following the 1/14/26 video swallow study. At that time R95 was ordered a pureed diet in the facility. Surveyor noted this is a diet downgrade from IDDSI Level 6 (Soft & Bite-Sized) to IDDSI Level 4 (Pureed) means moving from tender, small pieces of food that need chewing down to a completely smooth, lump-free texture that requires no chewing at all. The reference to diet advancement was regarding an upgrade in level beyond level 6 in the future with medical team approval. There was no recommendation to go above or less than a level 6 diet.R95 returned to the facility on 4/28/26.R95's facility nutrition note dated 5/5/26 documented, in part: . Previously on puree thick diet with nectar thick liquids. OK to upgrade to Mechanical soft diet per hospital SLP recommendation 4/24/26. Surveyor noted the hospital recommendation made no reference to a mechanical soft diet and only referenced an IDDSI Level 6 diet with thin liquids. Called POA and discussed. [POA] verified hospital was serving Mechanical soft diet and [POA] is happy about diet upgrade.Surveyor noted the recommended diet was not clarified with the hospital SLP to understand potential differences in an IDDSI level 6 diet vs. general mechanical soft defined by the facility. There was no clarification with the Hospital SLP if R95 was offered a mechanical soft diet instead of an IDDSI level 6 diet and if there were any individualized restrictions or exceptions for R95; such as receiving bread.R95's MD order with a start date of 5/5/26 documented, in part: General/regular diet, Mechanical soft texture, thin liquids. Surveyor noted this is not IDDSI language and the hospital recommended IDDSI level 6.R95 experienced a change of condition and was hospitalized again from 5/19/26 through 5/26/26.R95's Hospital Discharge summary dated [DATE] documented, in part: . Hospital course: . Opacity of lung on imaging study. Persistent right-sided opacities they do look better than last month. would cover with a course of oral [antibiotic] for now. General diet IDDSI level 6. Per SLP, aspiration precautions.Surveyor noted the hospital documented continued concern with R95's lung opacities related to aspiration pneumonia and again recommended that R95 follow the IDDSI level 6 diet recommendations for food and R95 needed aspiration precautions.R95's Speech Therapist (ST)-K note dated 5/28/26, documented, in part: . [Patient (Pt)] seen for swallowing evaluation to ensure and monitor for swallow and health safety. Oral cavity revealed missing dentition. [Cranial Nerve] exam revealed lingual/labial weakness/incoordination. Pt [with] left facial asymmetry. [By mouth] trials included nectar thick, puree, and [mechanical] soft. [With] mechanical soft: effective but prolonged mastication, [minimal] oral residue, cleared [with] liquid wash and multiple swallows. Pt [with] [signs/symptoms] of [aspiration] during trials. Will continue to monitor and evaluate for safest diet to reduce risk of [aspiration pneumonia].Surveyor reviewed further notes documented by ST-K. Surveyor did not find documentation that R95's ability to eat bread was assessed by ST-K.R95's meal ticket instructions as of 6/13/26, documented: Mechanical Soft. Assist with feeding. Small bites, small single sips, upright and alert for all [by mouth intake]. Check for [left] side pocketing, encourage an additional swallow or use liquid wash, upright in chair for meals.On 7/9/26 at 10:07 AM, Surveyor interviewed ST-K. ST-K stated that R95 was on a mechanical soft diet and needed cueing while eating.The facility menu for mechanical soft diet for dinner on 6/13/26 included: Tuna salad sandwich, cheese puffs, diced green beans, pudding cup and milk.Surveyor noted that R95's dinner on 6/13/26 included full pieces of bread, which is not part of the IDDSI level 6 diet that was recommended by hospital SLP on 4/24/26.On 7/9/26 at 10:07 AM, Surveyor interviewed ST-K Surveyor asked if R95 could eat a tuna sandwich. ST-K stated that it would need to be on soft bread and cut into bite-sized pieces or at least into quarters. In a follow-up interview on 7/15/26 at 7:45 AM, Surveyor asked about the IDDSI level 6 diet verses the facility mechanical soft diet. ST-K stated that they were aware that some foods not allowed on IDDSI are included in the facility mechanical soft diet. ST-K confirmed that bread is not part of the IDDSI level 6 diet. Surveyor asked if ST-K assessed R95's ability to chew bread. ST-K indicated that they did not recall but stated that the facility serves bread on a regular basis and R95 had it on meal trays prior to dinner on 6/13/26. ST-K stated that it was safe for R95 to have bread as long as there was supervision and cueing from facility staff.On 7/13/26 at 2:07 PM, Surveyor interviewed Dietician-H. Dietician-H stated they are familiar with the IDDSI level 6 diet. Dietician-H indicated that they had implemented the IDDSI standard of practice in other workplaces but is following company guidelines at this facility. Dietician-H stated that they had sent emails to their bosses in order to implement IDDSI but at the current time, the facility does not follow the IDDSI standard of practice. Dietician-H stated that the facility has a crosswalk that will identify what altered diet texture order will be implemented at the facility. For R95, an IDDSI level 6 is comparable to the facility mechanical soft diet and that is why R95 was placed on that diet while in the facility. Dietician-H stated that they acknowledge that they are not the same, but Dietician-H is following their company's direction and R95 was being evaluated by ST-K regularly.The facility Crosswalk document mentioned by Dietician-H is titled [Name of Company] Comparable Diets. The document has 2 columns. One column is titled, Admitting Diet Order. The other column is titled, [Name of Company] Comparable Diet. The [Name of Company] comparable diet column documented, in part: Mechanical Soft. In the Mechanical Soft Row is listed: Dysphagia Minced, National Dysphagia Diet 2 and 3, Dysphagia Mechanically Altered. Semi-solid, Dysphagia Soft/low, Soft, Dysphagia Advanced. IDDSI Level 7 Easy to Chew, IDDSI Level 6 Soft & Bite Sized, IDDSI Level 5 Minced and Moist.Surveyor noted that IDDSI Level 6 is included in the facility's list as comparable to a Mechanical Soft diet.Surveyor noted that both Dietitian-H and ST-K are familiar with IDDSI but indicated that the facility does not follow the IDDSI standard of practice.R95's progress note dated 6/13/26 at 5:40 PM, documents: While assisting with feeding CNA notice resident choking and called nurse. Heimlich was at [5:30 PM]. Resident went unresponsive, lowered to the floor, CPR was started and 911 was called.On 7/15/26 at 3:43 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-PP, who was the facility staff who found R95 choking. CNA-HH did the Heimlich and started compressions. While R95 was on the ground, CNA-PP saw food in R95's mouth and pulled it out. Surveyor asked how much food was pulled out of R95's mouth. CNA-PP stated it was very big, like a whole bun.Surveyor noted CNA-PP pulled a very big piece of food/bread out of R95's mouth.On 7/9/26 at 9:26 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-Z, who responded to the dining room after R95 was choking. LPN-Z stated that CNA-PP reached in R95's mouth and got the food. LPN-Z stated that it was bread and stated that R95 is allowed to have bread on a mechanical soft diet. Surveyor asked what size of bread came out. LPN-Z stated, it was a nice size. LPN-Z stated that it appeared that R95 tried to eat the whole slice of bread and not just a piece of it.Surveyor noted that LPN-Z observed CNA-PP take out what appeared to be a whole slice of bread and not just a piece of it.R95's EMS response dated 6/13/26 at 5:24 PM, documents, in part: Pt contact made finding pt in the dining room lying supine with staff present. Obstruction was confirmed cleared from the airway. Crew observed a big piece of bread by the pt head.Surveyor noted EMS staff documented that a big piece of bread was at R95's head when they arrived.Surveyor noted that CNA-PP, LPN-Z and EMS staff stated or documented that R95 had a big piece of bread pulled from R95's mouth.R95 was sent to the hospital and returned to the facility on 6/13/26.R95's change of condition note dated 6/15/26 (two days after R95's choking incident) at 1:44 AM, documented, in part: . Pulse Oximetry 68%. Resident observed with audible rattling/crackling respirations. SPO[2] 68%. Resident sent to the hospital for further evaluation and treatment.R95's Hospital Discharge summary dated [DATE] documents, in part: . [R95] was admitted to the hospital on . 6/15/26 for treatment of. aspiration pneumonia and acute respiratory failure when [R95] presented with hypoxia and shortness of breath. Clinical condition worsened during the early morning hours on 6/17/26 at which point patient started complaining of more shortness of breath and mild chest discomfort. On the morning of 6/17, after family assessed the patient, they decided that they would not like to pursue further investigation and wanted additional discussion with palliative care team about switching goals of care towards comfort plan of care. [R95] was admitted to hospice in hospital service. Medical problems: Aspiration pneumonia.On 7/7/26 at 1:46 PM, Surveyor interviewed R95's Family Member-TT. Family Member-TT stated that R95 died on 6/17/26. Family member read Surveyor R95's Death Certificate which documented: [State] Certificate of Vital Record. Date completed: 6/19/26. date of death [DATE]. Immediate cause: Aspiration pneumonia.Surveyor noted IDDSI level 6 does not allow regular dry bread because of high choking risk. The facility did not provide documentation that R95's ability to eat bread was assessed and ST-K stated in an interview that they could not recall if they assessed R95's ability to eat bread. R95 choked and a big piece of bread was pulled from R95's mouth. R95 was diagnosed with aspiration pneumonia, and it was also determined to be the immediate cause of death.On 7/13/26 at 1:43 PM, Surveyor interviewed Food Service Director (FSD)-NN. FSD-NN stated that they had been in this role since March of this year. Surveyor asked if the facility follows the IDDSI standard of practice. FSD-NN stated that they are familiar with IDDSI but stated that the facility does not currently follow IDDSI. FSD-NN stated that the company does want staff to go through the training and implement IDDSI as soon as possible. FSD-NN stated that since the Survey team has been conducting the Survey, talks about IDDSI have been completed but there were not talks with FSD-NN before that time.On 7/13/26 at 2:07 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked if the facility follows the IDDSI standard of practice. DON-B indicated that at the beginning of June, the altered texture diets, including the mechanical soft diet, were reviewed and revised. This revision was signed off by multiple people including the dietician, ST-K and the Medical Director. DON-B stated that they are familiar with IDDSI- to a point. DON-B stated that the facility contracts with [Name of food company]. All direction, in relation to that, would come from that food company. DON-B stated that they have started communications about implementing IDDSI.The revised altered texture diet plan mentioned above is included at the beginning of this citation.On 7/13/26 at 3:57 PM, Surveyor informed DON-B and Nursing Home Administrator (NHA)-A of the above concerns. DON-B and NHA-A indicated that the facility had conversations and reviewed the altered diet plans with the Interdisciplinary team. The most appropriate diet for IDDSI level 6 is a mechanical soft diet. NHA-A confirmed that the facility does not currently follow the IDDSI standard of practice.Cross reference F689.

Based on interview and record review, the facility did not ensure the transfer notice contained the appeal rights with the information on the State agencies including the name, mailing address, email address, and telephone number, did not provide the notice of transfer to the resident or resident representative in writing, or did not ensure the State Long Term Care Ombudsman was notified of the transfer for 5 (R8, R70, R50, R18, and R47) of 6 sampled residents reviewed for hospitalizations. *R8 was transferred to the hospital on [DATE] and 3/2/2026; only the ombudsman contact information is documented on the bed hold/transfer form. *R70 was transferred to the hospital on 4/17/2026 and 5/29/2026; only the ombudsman contact information is documented on the bed hold/transfer form. *R50 was transferred to the hospital on 2/4/2026 and 3/4/2026; only the ombudsman contact information is documented on the bed hold/transfer form. *R18 was transferred to the hospital on 6/13/2026; only the ombudsman contact information is documented on the bed hold/transfer form. The facility did not notify the State Long Term Care Ombudsman of R18's transfer to the hospital. *R47 was transferred to the hospital on 6/25/2026; only the ombudsman contact information is documented on the bed hold/transfer form. Findings include: The facility policy and procedure titled Individual Transfer and Discharge dated 4/9/1990 last reviewed 3/3/2026 documents: II. Procedure: . B. Notice: 1. The individual, the individual's physician, guardian, relative or other individual representative will receive a written notice including the reasons for the transfer at least 30 days in advance of an involuntary removal unless the continued presence of the individual endangers the health, safety, or welfare of the individual or other individuals. 2. The notice shall contain the name, address and telephone number of the board on aging and long-term care. 3. The appropriate Ombudsman will be notified of all facility initiated discharges, including hospitalizations. The facility Bed Hold Confirmation Upon Transfer from the Skilled Nursing Facility form documents the resident's name, physician, date and time of transfer, and where the resident is transferring to as well as the daily rate of the bed hold if Medicare Part A, insurance, or private pay is the payor source and the explanation of the automatic 15-day bed hold for residents on medical assistance such as Medicaid, Title 19, or Family Care. The state ombudsman information is documented with address, email address, and telephone number. A place for the resident or representative's signature with date and time and staff signature with date and time are on the bottom of the form. No other required State Agency information is documented on the form. The form has a duplicate copy attached. In an interview with Nurse Supervisor (NS)-BB on 7/13/2026 at 9:50 AM, Surveyor asked NS-BB what the facility process was when a resident is sent to the hospital. NS-BB stated an e-interact transfer form goes with the resident to the hospital along with their face sheet, medication list, medication administration record, code status paperwork, and Power of Attorney (POA) paperwork. Surveyor asked if there is a bed hold form. NS-BB stated the facility keeps one copy of the bed hold form and the other page is sent with the resident to the hospital. Surveyor asked NS-BB how the POA is notified of the transfer regarding the hold and transfer notice and do they get a copy of the form. NS-BB stated the nurse would get the verbal okay from the POA to send the resident to the hospital and they let them know the reason for the hospitalization, but they do not send the bed hold or transfer notice to the POA. In an interview with Social Worker (SW)-AA on 7/13/2026 at 11:13 AM, Surveyor asked SW-AA what the facility process was for bed hold and transfer notices. SW-AA stated when the resident is sent out, the nurse will fill out the bed hold/transfer notice and contact the family and POA, if activated. The nurses would get a verbal consent for the bed hold and a carbon copy is given to the resident and then a copy is scanned into the resident's record. SW-AA stated they can send the bed hold/transfer notice in the mail, but SW-AA does not send the written copy to the POA automatically but could if they request it. Surveyor shared the concern with SW-AA the form only contained the ombudsman information and not the required State Agency information. In an interview with Nursing Home Administrator (NHA)-A on 7/13/2026 at 12:33 PM, Surveyor asked NHA-A what the process was for filling out the bed hold/transfer notice when a resident was hospitalized . NHA-A stated they have a carbon copy that is kept by the facility after the nurse or nurse manage working fills out the bed hold form. A copy gets sent with the resident to the hospital. Surveyor asked NHA-A about a resident with an activated POA. NHA-A stated if the POA is at the facility, they give it to them in person. If they are not present, they go over the bed hold with the POA verbally and if they want a copy they send it to them, but most of the time the POA does not want a copy. Surveyor shared the concern with NHA-A that the State Agency information was not included on the forms as required. In an interview with NS-S on 7/13/2026 at 2:04 PM, Surveyor asked NS-S what the process for a bed hold and transfer was. NS-S stated the bed hold is used to hold the bed based off the resident's insurance. It gives them the option if they want the bed held and what the rate is. They then decide if they are going to make that payment or not. The form is then scanned into the resident's chart, and it is also sent with them to the hospital in their packet. Surveyor asked NS-S if the form is given to the resident or the POA. NS-S stated if they ask for it, they will give it to them. In an interview with Director of Nursing (DON)-B on 7/14/2026 at 9:44 AM, Surveyor asked DON-B what the facility process was for completing a bed hold and transfer notice when a resident is sent to the hospital. DON-B stated the nurse sending the resident out will do the bed hold with the resident or the POA. A carbon copy goes with the resident to the hospital. Surveyor asked DON-B if the appeal rights were on the form. DON-B stated yes, the ombudsman information was on the form. Surveyor asked DON-B if the POA would get a copy of the form. DON-B stated yes, if they are at the facility at the time they will give it to them otherwise they will get a verbal consent for the bed hold. Surveyor shared with DON-B the concern that the State Agency information was not included on the forms as required. 1.) On 12/31/2025 at 7:30 AM in the progress notes, nursing documented R8 was having difficulty breathing and was congested. R8 was sent to the hospital. The bed hold/transfer notice form in R8's medical record did not include the State Agency information. There was no documentation the notice was sent to R8's POA. On 3/2/2026 at 11:01 PM in the progress notes, nursing documented R8 had fallen out of bed and was sent to the hospital for a left hip fracture. The bed hold/transfer notice form in R8's medical record did not include the State Agency information. There was no documentation the notice was sent to R8's POA. 2.) On 4/17/2026, R70 was transferred to the hospital for a cholecystectomy. The bed hold/transfer notice form in R70's medical record did not include the State Agency information. On 5/29/2026, R70 was transferred to the hospital and admitted for septic shock, acute metabolic encephalopathy, hyperkalemia, and acute hypoxemic respiratory failure. The bed hold/transfer notice form in R70's medical record did not include the State Agency information. 3.) On 2/4/26, R50 was transferred to the hospital for leg pain after a fall. R50 returned to the facility on 2/12/26. The bed hold/transfer notice form in R50's medical record did not include the State Agency contact information. On 3/4/26, R50 was transferred to the hospital for a possible infection. R50 returned to the facility on 3/11/26. The bed hold/transfer notice form in R50's medical record did not include the State Agency contact information. 4.) On 6/13/26, R18 was transferred to the hospital for abdominal pain and a sore throat. R18 returned to the facility on 6/19/26. The bed hold/transfer notice form in R18's medical record did not include the State Agency contact information. On 7/9/26 at 8:57 AM, Surveyor reviewed the facility's monthly notifications to the State Long Term Care Ombudsman for resident transfers and discharges. R18's hospitalization on 6/13/26 was not listed on the June 2026 notifications. On 7/13/26 at 12:33 PM, Surveyor shared concern with NHA-A that R18's hospitalization on 6/13/26 was not on the June 2026 monthly notification to the ombudsman. NHA-A was not sure why R18's hospitalization was not on the list. In an interview on 7/14/26 at 9:44 AM with DON-B, DON-B checked the report of monthly hospitalizations and was not able to locate R18's hospitalization on 6/13/26 on the report. DON-B was not sure why R18's hospitalization was not pulling through onto the report, and stated the facility uses this report to generate the monthly ombudsman notifications. DON-B stated they would have to look into why the information was not carried over. 5.) R47's progress note dated 6/25/2026, at 1:55 PM, documented R47 was admitted to the hospital with hyponatremia and altered mental state. R47's medical record documented R47 authorized via phone not wanting a bed hold. The Bed Hold Confirmation Upon Transfer Form from the Skilled Nursing Facility document has ombudsman contact information, however, lacks other pertinent State of Wisconsin contact information for appeal.

Based on interview and record review, the facility did not ensure staff received annual ethics training for 2 of 4 Certified Nursing Assistants (CNA) reviewed. The facility did not provide all Certified Nursing Assistant staff with the required annual ethics training.This deficient practice has the potential to affect all 74 residents in the facility who receive care from the two CNAs.Findings include:Surveyor reviewed four randomly selected CNAs employed over one year to verify they received the required training. Surveyor noted that two staff reviewed were not current with their ethics training.CNA-V, date of hire 12/4/2018, did not receive ethics training in the last 12 months.On 07/20/2026, at 1:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and was told that CNA-V last took the ethics training in 2023 and is scheduled again in 2027.CNA-CCC, date of hire 2/27/2018, did not receive ethics training in the last 12 months.On 07/20/2026, at 1:45 PM, Surveyor interviewed NHA-A who stated that CNA-CCC last received ethics training in 2022 and the system has CNA-CCC scheduled later in 2026.On 07/20/2026, at 1:57 PM, NHA-A informed Surveyor that ethics training is scheduled every four years and it should be every year. NHA-A will change system so that it is required annually.

Based on observation, interview, and record review, the facility did not ensure that medications used in the facility were labeled in accordance with currently accepted professional principles and expired medications were removed from 1 of 4 medication carts.*A bottle of Vitamin B-12 500 mcg (micrograms) expired on 4/26.*R41's deep sea nasal spray 0.65% expired March 2026.*R8's albuterol sulfate inhalation aerosol 90 mcg expired 6-30-26.*R94's Systane ultra 0.4-3% eye drops were opened, used and not dated. R94's eye drops remained in the medication cart even though R94 was discharged from the facility on 4/27/26.Findings include:The facility's policy titled, Consultant Pharmacist Services Provider Requirements, with an effective date of May 2018 for F. Specific activities that the consultant pharmacist performs includes, but is not limited to: documents 4.) Checking the medication storage areas [at least monthly], and the medication carts [at least quarterly], for proper storage and labeling of medications, cleanliness, and removal of expired medications.1.) On 7/9/26, at 10:31 a.m., surveyor observed in the 3rd compartment from the right in the top drawer of the right hall Unit B medication cart a stock bottle of Vitamin B-12 500 mcg (micrograms) with an expiration date of 4/26.On 7/9/26, at 10:34 a.m., surveyor asked Registered Nurse (RN)-PP who checks the medication carts for expired medication. RN-PP informed surveyor Nurse Supervisor (NS)-S does and they also check. Surveyor showed RN-PP the expired bottle of Vitamin B-12.2.) On 7/9/26, at 10:44 a.m., surveyor observed on the left side of the top drawer, back compartment in Unit A, left hall medication cart a deep-sea nasal spray 0.65% for R41 with the expiration date of Mar (March)/2026.3.) On 7/9/26, at 10:45 a.m. surveyor observed on the left side of the top drawer, in the third compartment in Unit A, left hall medication cart albuterol sulfate inhalation aerosol 90 mcg (micrograms) for R8 with the expiration date of 6-30-2026.4.) On 7/9/26, at 10:48 a.m., surveyor observed on the left side of the top drawer, in the second compartment in Unit A, left hall medication cart a bottle of Systane ultra 0.4-3% eye drops, that is open, used, and not dated when opened. On 7/9/26, at 10:58 a.m., surveyor asked Licensed Practical Nurse (LPN)-QQ who checks the medication carts for expired medication. LPN-QQ informed surveyor they are all responsible and there isn't a specific schedule for checking the medication carts. LPN-QQ informed surveyor sometimes pharmacy will check them. Surveyor showed LPN-QQ the expired medication and R94's eye drops which were not dated when opened. Surveyor informed LPN-QQ R94 discharged on 4/27/26.On 7/13/26, at 3:22 p.m. surveyor asked Director of Nursing (DON)-B who is responsible for checking medication carts for expired medication. DON-B informed surveyor medications are removed from the cart when expired. The medications carts are check by the nurse managers, herself and they have a consultant nurse from the pharmacy that audits the medication carts. Surveyor informed DON-B of the expired medications and R94's eye drops not dated when opened.

Based on interview and record review the facility did not ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection and restore continence to the extent possible for 1 (R94) of 2 sampled residents reviewed for bowel and bladder.R94 was admitted to the facility on [DATE] with an indwelling foley catheter. The facility discontinued R94's foley catheter on 11/28/25. The facility did not complete a comprehensive bladder assessment or develop a urinary care plan after R94's foley catheter was discontinued.Findings include:The facility's policy titled, Bowel and Bladder Management and last reviewed 4/9/26 under policy documents Prevention measures are put in place to promote bowel and bladder health. Under Procedure A. Assessment documents Staff will assess newly admitted individuals for past or present bowel and bladder patterns which may include medication review, medical diagnoses, and/or diet. The facility's policy does not address assessment after an indwelling urinary catheter is removed or there is a change in urinary incontinence.R94 was admitted to the facility on [DATE] with a foley catheter.R94's continence evaluation dated 11/20/25 documented R95 had an indwelling catheter. The documented reason for the appliance was acute urinary retention and/or bladder outlet obstruction.R94's admission minimum data set (MDS) with an assessment reference date of 11/21/25 has a brief interview mental status (BIMS) score of 11 which indicated moderate cognitive impairment. R94 was assessed as being dependent for toileting hygiene and toilet transfer was substantial/maximal assistance. R94 was checked for an indwelling catheter.R94's urinary incontinence and indwelling catheter CAA (care area assessment) dated 11/28/25 did not include an analysis of findings for nature of problem/condition. The documented care plan considerations, description of the impact of this problem/need on the resident and rational for care plan indicated: the resident has an indwelling catheter r/t (related to) urinary retention. Staff provide catheter care per policy. Resident on enhanced barrier precautions. Monitor output. Monitor for s/sx (signs/symptoms) of CAUTI (catheter associated urinary tract infection). Please refer to established care plan for further information. On 11/28/25 R94's foley catheter was discontinued. Following R94's foley being removed the facility did a post void residual every shift for three days. Surveyor was unable to locate a voiding pattern and comprehensive assessment including type of urinary incontinence after R94's foley catheter was discontinued.Surveyor was unable to locate a urinary incontinence care plan.R94's continence evaluation dated 2/19/26 under urinary continence evaluation section for the question does the resident have a history of urinary incontinence, yes is answered. For the question does the resident have a history of UTI (urinary tract infection) yes is answered. For the urinary continence frequently incontinent is answered. For perception of need to void, present is answered. Surveyor noted 8. Other voiding symptoms/problems, 10. Post-voiding perception, 11. If resident has persistent incontinence despite efforts to control contributing factors, which type of incontinence applies to this resident and 12. Based on the type of incontinence the resident is experiencing, indicate the appropriate type of intervention for this resident have not been completed.R94's quarterly MDS with an assessment reference date of 2/21/26 assessed R94 had a BIMS score of 11 which indicated moderate cognitive impairment. R94 was assessed as being dependent for toileting hygiene and toilet transfer. R94 was assessed as always being incontinent of urine.On 4/20/26 an R94 had an indwelling foley catheter inserted.R94's continence evaluation dated 4/22/26 documented R94 had an indwelling catheter to assist in healing of open sacral or perineal wounds with incontinence. (Cross-reference F686).On 7/14/26, at 8:11 a.m., surveyor asked Nurse Supervisor (NS)-L after a resident's indwelling urinary catheter is removed is a voiding pattern and urinary assessment completed. NS-L replied yes, we do a post void scan every shift for 3 days and the aides' chart if incontinent or continent. Surveyor informed NS-L surveyor noted a urinary evaluation on 11/20/25 when R94 had an indwelling catheter, on 2/19/26 there was a quarterly urinary evaluation and on 4/20/26 there was a urinary evaluation when a foley catheter was inserted. Surveyor asked if a urinary evaluation should have been done after R94's foley catheter was discontinued (11/28/25). NS-L informed surveyor she would have to check on this.On 7/14/26, at 9:22 a.m., surveyor asked NS-L if she had any information regarding a urinary assessment (evaluation) being completed after R94's foley was discontinued. NS-L informed surveyor she wasn't sure, so she asked [name of] Director of Nursing (DON)-B and DON-B hasn't gotten back to her. Surveyor informed NS-L surveyor would speak with DON-B.On 7/14/26, at 9:58 a.m., surveyor asked DON-B after a resident's foley catheter is discontinued, is there any voiding pattern and assessment done. DON-B informed surveyor they usually look at Certified Nursing Assistant (CNA) charting if continent or incontinent and then update the care plan. Surveyor informed DON-B after R94's foley catheter was discontinued on 11/28/25 surveyor could not locate any voiding pattern and a comprehensive assessment. Surveyor also informed DON-B surveyor did not note a urinary incontinence care plan.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (R47) residents out of 18 residents reviewed for infection prevention and control.* R47's nasal canula was observed laying on the floor in R47's room. Staff picked up and put same nasal canula back into R47's nose.Findings include:1.) R47 was admitted to the facility on [DATE] and with diagnoses that include encephalopathy, chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), and dependence on supplemental oxygen.R47's Minimum Data Set (MDS) assessment, dated 7/6/26, indicated that R47 is able to be understood by others and understands others. The MDS documents a that R47 was assessed to have a Brief Interview for Mental Status (BIMS) score of 15, indicating that R47 is cognitively intact. The MDS documents that R47 was documented as receiving continuous oxygen therapyR47's Care Plan, initiated on 6/15/2026, states The resident has Emphysema/COPD and interventions included: Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. Date Initiated: 06/15/2026; Monitor for s/sx (signs/symptoms) of acute respiratory insufficiency: Anxiety, Confusion, Restlessness, SOB (shortness of breath) at rest, Cyanosis, Somnolence. Date Initiated: 06/15/2026; OXYGEN SETTINGS: O2 (oxygen) via NC (nasal canula) at 2L (liters). Monitor placement of ear padding on tubing. Date Initiated: 06/15/2026R47's physician order dated 6/30/2026, documents O2 2L per NC-continuously to keep sats >88% for COPD.R47's physician order dated 6/30/2026, documents Change oxygen tubing PRN (as needed), when visibly soiled, malfunctioning and/or after a respiratory infection.On 07/07/2026, at 9:12 AM, Surveyor interviewed R47 as part of the screening process. Surveyor observed R47's oxygen tubing along with R47's nasal canula laying on the floor next to the bed. Surveyor left R47's room in an attempt to find staff to replace R47's oxygen.On 07/07/2026, at 9:16 AM, Surveyor and Registered Nurse (RN)-T entered R47's room. A Certified Nursing Assistant (CNA) was exiting the room as Surveyor and RN-T entered. Surveyor asked R47 if the CNA had put the nasal canula back that was sitting directly on the floor into R47's nose. R47 stated they had. R47 complained that there was now water dripping into R47's nasals from the canula. RN-T stated they would replace the tubing and nasal canula to alleviate the problem.The American Health Care Associated (AHCA) website states that the best practice when a resident's oxygen nares (nasal cannula prongs) drop on the floor is to immediately replace them with a new, clean cannula to prevent potential bacterial infections and respiratory illnesses.The oliveoxygen.com website states water droplets gathering at the nasal prongs can enter the nose, causing choking, coughing, or respiratory discomfort.On 07/09/2026, at 1:05 PM, Surveyor interviewed Nurse Supervisor-S regarding the expectation if tubing and nasal canula are on the floor. Nurse Supervisor-S stated staff should grab a new canula. Surveyor informed Nurse Supervisor-S of the above findings.

Based on interview and record review the facility did not ensure 2 (R93 & R9) of 18 residents reviewed for grievances had their grievances investigated and resolved. *R93's family complained of long call light response times. There is no evidence that the facility investigated and resolved this grievance. *The facility documented a grievance for R9 dated 4/7/26, however, the facility did not address the root cause of the grievance. Findings include: The facility's policy titled, Grievance and last reviewed 3/3/26 under policy documents Individual, guardian, and/or individual representative will be informed of the process to file a grievance or complaint and the facility's process to make prompt efforts to resolve grievances. Under procedure documents The facility fosters an environment of direct communication, prompt resolution and continuous process improvement. Grievances may be brought to any staff member at the time orally, in writing, or made anonymously. Grievances will be forwarded to the designated Grievance Officer and investigated through the QAPI (quality assurance performance improvement) Committee. B. Formal Grievance #3 documents The assigned manager will investigate the grievance and respond to the individual, guardian, and/or individual representative within five (5) working days, unless further investigation is needed. 1.) R93 was admitted to the facility on [DATE] and discharged on 10/13/25. On 7/13/26, at 11:38 a.m., surveyor asked Director of Social Work (DSW)-R during R93's stay at the facility did R93 or R93's family voice any concerns. DSW-R informed surveyor she was aware of call light issues, and she shared this concern with Nursing Home Administrator (NHA)-A. Surveyor asked DSW-R who would review the call light response times. DSW-R informed surveyor that would be Director of Nursing (DON)-B and NHA-A explaining they are the ones who have access to the call light times. DSW-R informed surveyor when [name of] R93's family was informing her of their concerns she was writing them down. DSW-R stated I tried to grievance everything. DSW-R informed surveyor R93's grievance would be in their grievance binder. DSW-R stated I know call lights were a big one and NHA-A was going to look into the call lights. On 7/13/26, surveyor reviewed R93's call light log for the period R93 resided in the facility (10/3-10/13/25). Surveyor noted the following call light response times that were over 10 minutes: 10/4/25 at 4:58 a.m. the call light was on for 12 minutes 50 seconds. 10/4/25 at 9:31 a.m. the call light was on for 16 minutes 35 seconds. 10/5/25 at 6:41 a.m. the call light was on for 30 minutes 53 seconds. 10/7/25 at 6:46 a.m. the call light was on for 11 minutes 47 seconds. 10/9/25 at 3:24 a.m. the call light was on for 11 minutes 47 seconds. 10/10/25 at 2:55 a.m. the call light was on for 15 minutes 3 seconds. 10/11/25 at 5:04 a.m. the call light was on for 15 minutes 14 seconds. 10/12/25 at 6:26 a.m. the call light was on for 21 minutes 3 seconds. 10/13/25 at 6:55 a.m. the call light was on for 13 minutes 20 seconds. Surveyor reviewed the facility's 2025 grievance binders and noted a grievance dated 10/6/25 regarding no phone cord, a grievance dated 10/7/25 regarding therapy, a grievance dated 10/7/25 regarding how staff are to transfer R93, a grievance dated 10/7/25 regarding wipes & incontinence products, and a grievance dated 10/7/25 regarding a tray table removed from R93's room. Surveyor was unable to locate a grievance regarding call light response times. On 7/14/26 at 7:54 a.m. surveyor asked NHA-A if he was aware of any call light concerns with R93. NHA-A informed surveyor that this doesn't ring a bell. NHA-A explained if the concerns turn into a self-report the investigation into call lights would be in there and if it was a grievance, it would be in there. NHA-A stated to surveyor I'm sure you have reviewed the grievances. Surveyor informed NHA-A surveyor did not see a grievance regarding R93's call lights. Surveyor asked NHA-A what an acceptable time for staff is to answer a resident's call light. NHA-A informed surveyor they want it answered as soon as possible, but usually 15 to 20 minutes. Surveyor then discussed R93's call light response times while R93 resided at the facility. Surveyor asked NHA-A if the family has a concern regarding call lights, is this something that is investigated. NHA-A replied yes, explaining if they have a concern then a concern form is filled out. Surveyor asked if the concern form is the grievance form. NHA-A replied yes. On 7/14/26, at 8:24 a.m., surveyor asked DSW-R if she would have written a grievance regarding R93's call light response times. DSW-R replied that one I know I did because it came up multiple times. Surveyor asked DSW-R if the grievance would be in the 2025 grievance binder. DSW-R replied yes, we write it up and when resolved goes in the binder. Surveyor informed DSW-R surveyor was unable to locate the call light grievance for R93. Surveyor informed DSW-R surveyor would return the 2025 grievance binder to her and asked DSW-R if she could see if she was able to locate the grievance. On 7/14/26, at 9:30 a.m., surveyor asked DSW-R if she was able to locate R93's grievance. DSW-R informed surveyor she couldn't find one, maybe she was mistaken and didn't write a grievance. On 7/14/26, at 9:52 a.m., surveyor asked Director of Nursing (DON)-B if any concerns were brought to her attention regarding R93's call light response times. DON-B informed surveyor she would have to refer to the grievance log as she doesn't recall. Surveyor informed DON-B surveyor was unable to locate a grievance for R93. There is no evidence the facility investigated and resolved R93's family's grievance regarding call light response times. 2.) The facility Receipt of Grievance form dated 4/7/26, documented: [R9's Name] family filed a grievance on 4/7/26, with Social Worker (SW)-AA. The documented concern was: Care conference Power of Attorney (POA) stated that resident doesn't get help to use the restroom. Investigation findings: Resident call light log pulled. Call lights answered not within expected timeframe. Call light does note some days with no entries. Resolution description documented included: resident reminded to use call light so staff can help assist with Activities of Daily Living (ADLs). The facility receipt of grievance form included an attachment titled Resident Incident Details Report with Incident Date Range 04/01/2026-04/07/2026 referencing R9 and R9's room number. This attachment documented call light details from April 2026 for R9. , Start Time 04/01/26 6:45:43 pm Duration 00:02:00Start Time 04/02/26 5:12:48 am Duration 00:01:20 Start Time 04/02/2026 8:48:37 am Duration 00:21:07 Start Time 04/02/2026 1:32:42 pm Duration 00:05:04 Start Time 04/02/2026 8:54:17 pm Duration 00:01:13 Start Time 04/03/2026 1:25:53 am Duration 00:01:04 Start Time 04/03/2026 5:14:07 am Duration 00:01:34 Start Time 04/03/2026 9:45:57 am Duration 00:06:00 Start Time 04/03/2026 6:26:27 pm Duration 00:07:45 Start Time 04/03/2026 6:37:47 pm Duration 00:02:41 Start Time 04/04/2026 4:07:11 am Duration 00:21:45 Start Time 04/04/2026 5:32:24 am Duration 00:03:49 Start Time 04/04/2026 7:50:09 am Duration 00:03:41 Start Time 04/04/2026 8:09:46 am Duration 00:30:16 Start Time 04/04/2026 4:22:18 pm Duration 00:00:54 Start Time 04/04/2026 5:40:27 pm Duration 00:00:28 Start Time 04/05/2026 5:13:43 am Duration 00:00:47 Start Time 04/05/2026 8:04:10 am Duration 00:06:47 Start Time 04/05/2026 10:31:50 am Duration 00:25:02 Start Time 04/05/2026 1:22:50 pm Duration 00:13:57 Start Time 04/05/2026 1:42:32 pm Duration 00:00:36 Start Time 04/05/2026 7:19:23 pm Duration 00:17:49 Start Time 04/05/2026 7:53:58 pm Duration 00:01:10 Start Time 04/05/2026 8:15:23 pm Duration 00:00:35 Start Time 04/05/2026 9:51:15 pm Duration 00:01:16 Start Time 04/06/2026 1:30:58 am Duration 00:01:29 Start Time 04/06/2026 5:17:37 am Duration 00:01:34 Start Time 04/06/2026 5:20:29 am Duration 00:00:56 Start Time 04/06/2026 5:35:03 am Duration 00:02:18 Start Time 04/06/2026 11:31:43 am Duration 00:05:35 Start Time 04/06/2026 12:00:53 pm Duration 00:44:13 Start Time 04/06/2026 4:18:39 pm Duration 00:01:30 Start Time 04/06/2026 4:31:46 pm Duration 00:14:44 Start Time 04/06/2026 5:11:45 pm Duration 00:01:27 Start Time 04/06/2026 5:25:54 pm Duration 00:07:18 Start Time 04/06/2026 6:53:49 pm Duration 00:32:32 Start Time 04/07/2026 2:59:35 am Duration 00:01:43 Start Time 04/07/2026 3:07:59 am Duration 00:01:47 Start Time 04/07/2026 5:47:29 am Duration 00:01:13 Start Time 04/07/2026 6:26:12 am Duration 00:02:32 Start Time 04/07/2026 9:21:06 am Duration 00:05:27 Start Time 04/07/2026 11:32:13 am Duration 00:02:01 Start Time 04/07/2026 6:43:02 pm Duration 00:03:10 Start Time 04/07/2026 9:17:16 pm Duration 00:01:05 Surveyor notes R9 used the call light 1 time on 4/1/26, 4 times on 4/2/26, 5 times on 4/3/26, 6 times on 4/4/26, 9 times on 4/5/26, 11 times on 4/6/26 and 8 times on 4/7/26. Surveyor noted review of the facility's Receipt of Grievance document did not include an investigation into the actual concern of not getting help to use the bathroom; the root concern of the grievance. On 7/14/26, at 9:29 AM, Surveyor interviewed SW-AA who stated she is the grievance officer. SW-AA shared they determine the resolution of the grievance; which is then reviewed in weekly meetings with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. SW-AA stated grievances and the resolution of every grievance is discussed at the weekly meeting. Surveyor reviewed R9's grievance filed by R9's family, dated 4/7/26, with SW-AA and asked how the facility determined the documented resolution to remind resident to use the call light addressed the alleged concern of using the bathroom. SW-AA stated the grievance was reviewed at the weekly meeting, SW-AA spoke with R9, and the facility pulled the call light log and noted some days R9 did not use the call light. Surveyor reviewed the call light log and wait times with SW-AA. SW-AA stated they noted longer wait times and educated staff about longer response times. Surveyor asked if there was documentation of education performed for call light wait times and SW-AA stated DON-B typically brings up call light response times in staff meetings and SW-AA stated she was 95% sure call light response times were brought up as a general reminder in the staff meeting. SW-AA stated R9's family member didn't think R9 was getting help which is why they pulled the call log and noted days that R9 did not use the call light. SW-AA stated family was under the impression R9 was waiting 45-60 minutes, but we were in the room in 5 minutes or so. SW-AA stated we were responding. Surveyor asked SW-AA what an acceptable call light time is, and SW-AA stated we try for a 10-20 minute range. Surveyor noted with SW-AA that the resolution to encourage (R9) to use call light did not specifically address the grievance concern that R9 was not getting help to use the restroom.

Based on observation, interview and record review, the facility did not ensure the accurate and safe administration of medication for 1 (R37) of 1 residents reviewed for self-administration of medication.Surveyor observed a large bottle of antacid medication on R37's bedside table multiple times throughout the Survey. R37 was not assessed for the ability to self-administer medications. R37 did not have an MD order to self-administer medications. R37 did not have a care plan to self-administer medications.Findings include: The facility policy with an effective date of May 2018 and titled, Self-Administration of Medications, documents, in part: 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. 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. The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan.R37 was admitted on [DATE] with diagnosis that include weakness and encounter for palliative care.R37's Quarterly Minimum Data Set assessment dated [DATE], documents, in part: R37 is moderately cognitively impaired.On 7/7/26 at 10:12 AM, Surveyor observed R37 in bed. On R37's bedside table, Surveyor observed a large bottle of ultra strength antacid medication. Surveyor asked R37 what the bottle on the bedside table was. R37 stated that it is TUMS. R37 stated that they can take it whenever R37 needs it. Surveyor asked if R37 has any other medication supply in their room. R37 indicated that they only can take TUMS from their room, all of the other medications come from facility staff.On 7/8/26 at 7:33 AM, 7/9/26 at 1:31 PM and 7/13/26 at 7:35 AM, Surveyor observed R37 in bed. On R37's bedside table, Surveyor observed a large bottle of ultra strength antacid medication.Surveyor reviewed R37's medical record and did not find an active MD order for self-administration of medication. Surveyor did not find documentation of a completed assessment that R37 can self-administer medications. Surveyor did not find a care plan documenting that R37 can self-administer medications.On 7/9/26 at 1:32 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-QQ, who was working on R37's unit. Surveyor asked what needs to be done for a resident to self-administer medications. LPN-QQ stated that they have to be assessed, and they or the family have to sign a consent that they are able to self-administer medications. Surveyor asked if anyone on the unit is able to self-administer medications. LPN-QQ stated that no one on this unit self-administers medications, that they are aware of.On 7/13/26 at 7:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-Y about the bottle of antacids on R37's bedside table. CNA-Y stated that R37 has that bottle on the bedside table all the time. CNA-Y stated that when they see the bottle on the table, they will put them in R37's drawer because they do not want R37 popping them whenever R37 wants. CNA-Y asked Surveyor if the bottle was on the bedside table. Surveyor stated yes.On 7/13/26 at 9:27 AM, Surveyor interviewed Nurse Supervisor (NS)-L. Surveyor asked what facility staff have to do if a resident wants to self-administer medications. NS-L stated that they have to have an MD order, and an assessment has to be completed. NS-L stated that self-administering medications would be part of the resident's care plan. Surveyor asked if R37 had an order, assessment or care plan. NS-L stated that R37 does not have that. Surveyor asked if NS-L was aware that R37 had a large bottle of antacids on their bedside table. NS-L stated that they were not aware of that. NS-L stated that they assume that family brought it in and did not tell facility staff.On 7/13/26 at 9:52 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what is expected before a resident can self-administer medications. DON-B stated that an assessment has to be completed, and an MD order needs to be obtained. DON-B indicated that it would also be a part of the resident's care plan. Surveyor informed DON-B of the concern that Surveyor observed a large bottle of antacid on R37's bedside table multiple times during the Survey. R37 told Surveyor that they can take it whenever they need it. R37 does not have an assessment, MD order or care plan for self-administration of medications. DON-B understood.On 7/13/26 at 3:07 PM, Surveyor informed Nursing Home Administrator (NHA)-A of the above concerns.

Based on interview and record review the facility did not ensure 1 (R93) of 2 allegations were thoroughly investigated.On 10/7/25 R93's family alleged neglect. The facility did not thoroughly investigate this allegation as R93 was not interviewed.Findings include:The facility's policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property last reviewed 2/11/26 under Procedure F. documents The facility will follow the attached Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program to comply with the seven-step approach to abuse and neglect detection and prevention. The Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program last reviewed 2/11/26 under E. Investigation for abuse policy requirements documents It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's QAPI (quality assurance performance improvement) incident report and investigation process. Under procedure a. Investigation of abuse documents When an incident or suspected incident of abuse is reported, the Executive or designee will investigate the incident with the assistance of appropriate personnel. The investigation will include: i. Who was involved; ii. Residents' statements a. For non-verbal residents, cognitively impaired residents or residents who refuse to be interviewed, attempt to interview resident first. If unable, observe the resident, complete an evaluation of resident behavior, affect and response to interaction, and document findings.R93's progress note dated 10/3/25, at 12:46 p.m., documented Patient arrived to facility via amb (ambulance) from [hospital initials] after hospitalization d/t (due to) elective CABG (coronary artery bypass graft) and aortic valve repair f/b (followed by) an aortic valve leak. Patient A&Ox4 (alert and orientated times four), forgetful at times, able to make needs known, one assist with transfers, occasionally incontinent of bladder, continent of bowel. R93's 5 day Medicare MDS (minimum data set) with an assessment reference date of 10/9/25 has a BIMS (brief interview mental status) score of 12 which indicates moderate cognitive impairment.On 7/9/26 surveyor reviewed the facility's reported incident regarding allegation of neglect involving R93 which was submitted on 10/7/25 to the state agency. Surveyor noted the facility's summary under background and event documented On Tuesday, October 7, 2025, NHA (Nursing Home Administrator-A) spoke with family member this morning who had stayed over with resident [R93's first name] in his room. Statement made We can't stay here because of the awful, neglectful care he has received since he moved into the building 4 days ago, [DATE]th, for rehab. We are leaving asap (as soon as possible). No other information provided. Full investigation underway. SW (social worker) will speak to POA (power of attorney) for more information as facility is just hearing about this concern. This has been reported to DHS (Department Health Services) as an allegation of neglect. If a staff member is named, they will be suspended.Surveyor noted multiple staff, licensed nurses & certified nursing assistants, on all three shifts and three residents were interviewed. Surveyor was unable to locate in the facility's investigation R93 was interviewed regarding the family's allegation of neglect.On 7/9/26, at 4:10 p.m., surveyor asked NHA-A if R93's facility reported incident provided to surveyor is the complete investigation. NHA-A informed surveyor he thinks it is but will look and get back to surveyor.On 7/13/26, at 11:59 a.m., surveyor asked NHA-A if there was any other information regarding R93's facility reported incident. NHA-A informed surveyor if there is something else there would be a soft file. Surveyor inquired if there is a soft file. NHA-A indicated there wasn't a soft file. Surveyor asked NHA-A if he conducted the investigation for R93's neglect allegation. NHA-A informed surveyor he and [name of] Assistant Nursing Home Administrator (ANHA)-UU would have done it and would have been in charge of doing the investigation. Surveyor asked NHA-A why R93 wasn't interviewed. NHA-A informed surveyor R93 wasn't the one who made the complaint, the family was the one who made the allegation. NHA-A informed surveyor that if a resident makes a complaint they usually talk to them to get more information. Surveyor informed NHA-A R93 should have been interviewed as part of the facility's investigation.

Based on interview and record review, the facility did not ensure COVID-19 immunization education was provided when vaccinations were refused for 3 (R1, R50, and R53) of 5 sampled residents reviewed for immunizations.*R1 had documentation no education of the COVID-19 vaccine that was provided when R1 refused the vaccine.*R50 had documentation no education of the COVID-19 vaccine that was provided when R1 refused the vaccine.*R53 had documentation no education of the COVID-19 vaccine that was provided when R1 refused the vaccine.Findings include:The facility policy and procedure titled Individual Immunizations dated as last reviewed 5/13/2026 documents: 2. Education a. Vaccination Information Sheet (VIS) will be provided and reviewed with individual including benefits, risks, and potential side effects associated with vaccination.1.) R1 was offered the COVID-19 vaccination on 11/20/2025 and R1 declined vaccination. Nurse Supervisor-BB documented that no education was provided regarding the immunization.2.) R50 was offered the COVID-19 vaccination on 2/3/2026 and R50 declined vaccination. Nurse Supervisor-BB documented that no education was provided regarding the immunization.3.) R53 was offered the COVID-19 vaccination on 11/20/2025 and R53 declined vaccination. Nurse Supervisor-BB documented that no education was provided regarding the immunization.On 7/13/2026 at 3:06 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B that R1, R50, and R53 were not given education when offered they were offered COVID-19 vaccinations and refused.On 7/14/2026 at 8:55 AM, NHA-A stated the facility did not give the risks and benefits education to the three residents when they declined the immunization. NHA-A stated it was simply clicking a box in the medical record and the box that no education was provided was not checked. No other documentation was provided that the residents received education on the COVID-19 immunization.

Based on interview and record review, the facility did not ensure the pneumococcal immunization education was provided after refusal for 3 (R1, R50, and R53) of 5 sampled residents reviewed for immunizations.*R1 had documentation no education of the pneumococcal vaccine was provided when R1 refused the vaccine.*R50 had documentation no education of the pneumococcal vaccine was provided when R1 refused the vaccine.*R53 had documentation no education of the pneumococcal vaccine was provided when R1 refused the vaccine.Findings include:The facility policy and procedure titled Individual Immunizations dated 11/1/2017 last reviewed 5/13/2026 documents: 2. Education a. Vaccination Information Sheet (VIS) will be provided and reviewed with individual including benefits, risks, and potential side effects associated with vaccination.1.) R1 was offered the Prevnar 20 vaccination on 1/10/2025 and declined the vaccination. Director of Nursing-B documented no education was provided regarding the immunization.2.) R50 was offered the Prevnar 20 vaccination on 2/3/2026 and declined the vaccination. Nurse Supervisor-BB documented no education was provided regarding the immunization.3.) R53 was offered the PPSV23 vaccination on 12/18/2024 and declined the vaccination. Nursing documented no education was provided regarding the immunization.On 7/13/2026 at 3:06 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R1, R50, and R53 were not given education after they declined the pneumococcal vaccination.On 7/14/2026 at 8:55 AM, NHA-A stated the facility did not give the risks and benefits of the vaccinations to the three residents after they declined immunization. NHA-A stated it was simply clicking a box in the medical record and the box that no education was provided was checked. No other documentation was provided that documented the three residents received education on the immunizations they declined.

Based on interview and record review, the facility did not complete a significant change in status Minimum Data Set (MDS) assessment for 1 (R54) of 3 residents reviewed for hospice.R54 enrolled in hospice services on 3/19/26. The facility did not complete a Significant Change MDS until 5/15/26.Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual version 1.19.1 dated 10/2024 documents:A Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program . the Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election.Surveyor reviewed R54's electronic health record (EHR) and located a hospice admission document with R54's admission on to hospice services documented as 3/19/26.Surveyor located a quarterly MDS dated [DATE] and a SCSA MDS dated [DATE] in R54's EHR.On 7/8/26 at 1:43 PM, Surveyor interviewed MDS nurse-I who confirmed they started working at the facility on 5/1/26, and they complete all MDS assessments for the residents in the facility. MDS nurse-I stated they are made aware of any residents enrolled in hospice services from the nurse practitioner or the social worker. MDS nurse-I stated when they started at the facility, they were given a list of residents on hospice and R54 was not on that list according to the MDS assessments. MDS nurse-I stated R54 was due for an annual MDS in May 2026 and stated they probably realized at that time that R54's admission on to hospice services was not reflected on the MDS yet, so they completed a SCSA.On 7/13/26 at 12:33 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A that R54 admitted on to hospice services on 3/19/26 but did not have a significant change MDS completed until 5/15/26. NHA-A stated the facility had an interim MDS person prior to MDS nurse-I starting, but now MDS nurse-I is more on top of things.

Based on observation, interview and record review the facility failed to ensure residents maintained acceptable parameters of nutrition status and hydration status for 2 (R62 and R47) of 6 sampled residents reviewed for nutrition. *R62 was admitted to the facility on [DATE] on a general diet, weighing 220.0 lbs. R62's diet was downgraded to mechanical soft with thin liquids on 10/16/25, due to trouble eating after R62's dentures were lost by facility staff and not replaced. R62 sustained weight loss. *R47 returned from the hospital on 6/30/2026 with recommendations for a fluid restriction. R47 was seen by the Nurse Practitioner on 7/1/2026, and a fluid restriction was recommended but not initiated. Findings include: 1.) On 7/14/26, at 2:14 PM, Surveyor requested a policy for nutrition/weight loss, one was not provided during the survey. R62 was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease (CKD), Major Depressive Disorder (MDD) and anxiety. R62's Comprehensive Minimum Data Set (MDS) dated [DATE], documented R62 has no dental concerns and no altered diet. R62 required set up by staff for eating and had no weight loss or weight gain. R62's Brief Interview for Mental Status (BIMS) score was 15, indicating R62 was cognitively intact. Surveyor reviewed R62's Comprehensive Care Plan with an initiation date of 8/29/25, which documented the following: (R62) has an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) weakness. Interventions included: (R62) requires set-up assistance by 1 staff to eat. (R62) has oral/dental health problems r/t full dentures. Interventions included: Full dentures (FYI). Date Initiated: 08/29/2025. Monitor/document/report as needed (PRN) any (s/sx) (signs/symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate), abscess, debris in mouth, lips cracked or bleeding, teeth missing, loose, broken, eroded, decayed, tongue (black, coated, inflamed, white, smooth), ulcers in mouth, lesions. Date Initiated: 08/29/2025 (R62) has nutritional problem or potential nutritional problem. Date Initiated 9/5/2025. Interventions include: Monitor and record weight as ordered. Notify MD (physician)/responsible party of significant weight changes. Date Initiated: 09/05/2025. Offer available substitutes if (R62) has problems with food being served. Date Initiated 09/05/2025. Provide, serve regular diet as ordered. Monitor intake and record (q) (every) meal. Date Initiated 09/05/2025. (RD) (Registered Dietician) to evaluate and make diet change recommendations (as needed) (PRN). Date Initiated 09/05/2025. On 7/7/26, at 9:34 AM, Surveyor interviewed R62 who was lying in bed. R62's breakfast tray was observed on R62's bedside table across the bed, in reach of R62. Surveyor said to R62, they have not touched their breakfast food. R62 replied they didn't have dentures and couldn't eat the breakfast sandwich. Surveyor observed R62's dinner tray from the previous night was sitting on the windowsill. Surveyor noted there was visible minced foods on the plate that were not touched and an open pudding container. R62 told Surveyor they do not like minced foods and they want to eat normal food again. On 7/8/26, at 1:31 PM, Surveyor interviewed R62 who was in bed with their lunch tray in reach on bedside table. Surveyor asked R62 how lunch was. R62 responded they don't like minced foods. R62 said they would like to eat a steak or ribs . R62 stated they are getting minced food because they have no teeth. R62 stated the facility lost their dentures and has not replaced them. R62 said without dentures they are not able to chew their food properly so the facility game them minced food. Surveyor observed R62 appeared to have loose fitting dentures on their bottom gums but no top dentures. R62 stated they cannot afford new dentures and needed to see a dentist. R62 stated the facility has not assisted with seeing a dentist or replacing dentures. On 7/9/26, at 10:29 AM, Surveyor interviewed R62 who was lying in bed with their breakfast tray on the bedside table within reach. Surveyor noted < (less than) 25% of breakfast was eaten. Surveyor asked R62 why they have not eaten their breakfast. R62 stated they don't like the minced food. R62 shared with Surveyor the facility lost their upper dentures and showed Surveyor their lower dentures that appeared very loose in F62's mouth. R62 stated she was previously on a regular diet and now they grind up my food and I don't like it. Surveyor asked R62 if they would eat more if their food wasn't ground up, and R62 replied, yes. On 7/9/26, at 10:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-N. CNA-N stated R62 will decline food at times and also takes a long time to eat their meals. CNA-N stated R62 was the only one with their breakfast tray on that unit at that time because staff allow R62 time to eat. CNA-N stated that R62 previously had dentures but not sure if R62 had replacement dentures. On 7/9/26, at 10:39 AM, Surveyor interviewed Registered Nurse (RN)-P about dentures and dentists. RN-P stated the facility doesn't have a dentist and residents have to schedule their own dentist appointments. RN-P stated she could call on the resident's behalf to schedule with their personal dentist and arrange transportation if the resident requests them to. RN-P stated R62 does not choke on food and is on a mechanical soft diet with thin liquids. Surveyor asked why R62 was on a mechanical soft diet and RN-P stated she doesn't typically work this unit. Surveyor reviewed R62's orders dated 8/25/25 which documented a general/regular diet, regular texture and regular/thin consistency. Surveyor noted on 8/25/25 R62's weight was 220.0 lbs. Surveyor reviewed a Nutrition/Dietary Note dated 9/5/25, by Dietician-H, which documented R62 had a good appetite eating > (greater than) 75% of meals on average, on a regular diet and having full dentures. R62's current body weight (CBW) at that time was 220 lbs., with usual body weight (UBW) of 230 lbs. Surveyor reviewed progress notes from Dietician-H, dated 10/16/25, which documented nursing staff downgraded R62's diet to mechanical soft due to reports of trouble eating after dentures were lost. Surveyor reviewed R62's orders which documented a diet change dated 10/26/25: General/Regular diet. Mechanical soft texture, regular/thin consistency. Surveyor noted the following care plan changes dated 10/16/25: (R62) has morbid obesity with Body Mass Index (BMI) >40. At risk for chewing/swallowing issues r/t missing dentures (AEB) (as evidence by) need for mechanical soft diet. Interventions include: Provide, serve mechanical soft diet as ordered. Monitor intake and record (q) every meal. Surveyor noted R62's weight on 10/21/25 was documented as 214.8 lbs. Surveyor reviewed a Nutrition/Dietary Note, dated 12/4/25, by Dietician-H, that documented R62 was on a mechanical soft diet (d/t) (due to) missing dentures. Eating 75% of meals on average. Showing weight loss of 9 lbs. in the past 3 months. No significant weight changes. Weight loss can be viewed as desirable d/t obesity. Surveyor noted the following care plan changes dated 12/4/25: (R62) has morbid obesity with BMI 40. At risk for chewing/swallowing issues r/t missing dentures (AEB) need for mechanical soft diet. R62's Quarterly MDS dated [DATE], documented (R62) has no broken or loosely fitting dentures. (R62) is on a mechanically altered diet with no weight loss or weight gain. Surveyor reviewed progress notes from Dietician-H, dated 12/18/25, that documented: Provided updates to (SW) (Social Work) for care conference today. (R62's) weight remains stable (~210-215#[pounds]). (R62) receives a daily liquid protein supplement d/t high risk for skin breakdown. being bedbound, having a previous (hx) (history) of (PIs) (pressure injuries), and being morbidly obese. Meal intakes vary 25-100%, but family brings in food at times. (R62) currently has (name of restaurant) lunch in (their) room. No other concerns or updates. Surveyor note that R62's meal intakes declined to 25-100%. Progress notes from Dietician-H, dated 1/12/26, documented: Significant weight loss (11.5#/5.4%) in the past month. (R62's) BMI of 38 remains obese. (R62's) meal intakes have been decreased recently, likely r/t illness. Only eating about 25% of meals on a mechanical soft diet. Recommend a high-protein/high-calorie nutrition supplement (TID) (three times a day) until appetite improves. House Juice Supplement (TID) will provide 250kcal, 9g PRO per serving and will also help provide extra fluids. (POC) (plan of care) updated. Notified (NP) (Nurse Practitioner) and (POA) (Power of Attorney) of weight loss. Surveyor noted there is no documented discussion with R62 about their weight loss. Surveyor noted the following care plan changes dated 1/12/26: (R62) has morbid obesity with BMI 40. At risk for malnutrition r/t chewing/swallowing issues d/t missing dentures (AEB) need for mechanical soft diet, poor (PO) (oral) intake (2/2) (secondary to) influenza (+) [DATE]. Progress note dated 3/4/26 by Physician-AAA documented: (R62) has had ongoing issues with variable oral intake ranging from 25 to 50%, continues on protein supplements and mechanical soft diet, and is being monitored closely for weight loss. On 3/5/26 Dietician-H documented (R62) is bed-bound. Receives ProStat 30ml QD (daily) (100kcal, 15g PRO) for high risk for skin breakdown (has history of PIs as well) but refuses it often. Charted to accept at <50%. Mechanical soft diet d/t missing dentures. PO intake down from 75% of meals on average last quarter to 50% this quarter. (R62) positive for the flu in (Mid-January), which was when (R62's) meal intakes started to decrease. Was only eating about 25% of meals at the time, and writer added a high-protein/high-calorie nutrition supplement TID. Receiving House Juice Supplement 8oz (250kcal, 9g PRO) TID, but acceptance is only about 50%. Has had significant weight losses 5.2% x1 month, 10.4% x3 months, and 12.9% x6 months. SW to schedule care conference so (GOC) (Goals of care) can be discussed. On 3/5/26 Dietician-H documented: Followed up with (R62) today about (their) weight loss, supplement and medication refusal, and overall goals of care. (R62) refused the ProSource and Boost that writer brought in and said (they're) not going to drink them anymore. Explained to (R62) that these supplements are being offered because (R62) is at high risk for skin breakdown, (R62) isn't eating very much, and has a history of PIs. (R62) doesn't remember having PIs. (R62) has dementia. Informed (R62) that (they) had a significant weight loss and that (R62's) currently 189#. (R62) says (R62's) aware and (R62's) happy about this. Told (R62), writer is glad (R62) is happy and agrees weight loss can be viewed as a good thing, but that if it happens too fast, it can lead to skin breakdown (2/2 [secondary to] malnutrition) and muscle loss. Reminded (R62) (they) can mitigate muscle loss by exercising (their) body and getting adequate protein. (R62) says (R62) wants to do physical therapy and that (R62) wants to walk again. (R62) has been bed-bound by choice since admit. Says (they) (isn't) interested in sitting up in (WC [wheelchair]) during day but is interested in walking. Informed Unit Nurse Manager of this. (R62) does say (R62's) agreeable to milk with all meals for extra calories and protein instead of doing supplements. Juice supplement (Boost) and ProSource d/c'd per request. (R62) was drinking milk with (their) meal when writer was present. (R62) says (R62's) making more of an attempt to take (their) medications instead of refusing them. Nurse endorses this. (R62) notes that (R62) thinks (their) antidepressants could potentially be more effective, but (R62) is also nervous about medication changes d/t potential side effects. Passed this along to SW and Unit Nurse manager. POC updated. Surveyor noted the following care plan changes dated 3/5/26: (R62) has morbid obesity with BMI >35. Simultaneously at risk for malnutrition r/t chewing/swallowing issues d/t missing dentures (AEB) need for mechanical soft diet, poor (PO) (oral) intake 50% of meals, refusing supplements. On 3/13/26 Dietician-H documented Attended a care conference with (POA) and (IDT) (Interdisciplinary Team). Provided (POA) with updates: that (R62) was refusing both ProSource and Boost, and they were discontinued. Discussed with (POA) that these supplements (are/were) being offered because (R62) is at high risk for skin breakdown, (R62) isn't eating very much, and has a history of PIs. Talked with (POA) about (R62's) significant weight loss, and that (R62's) currently (190#). (R62) was happy about (R62's) weight loss but discussed that rapid weight loss can lead to skin breakdown and muscle loss, amongst other health issues. Informed (POA) that (R62) is at least agreeable to milk with all meals for extra calories and protein instead of doing supplements. (POA) strongly feels that dentures will help (R62) eat more, as (R62) doesn't care much for the mechanical soft food. SW plans on having Health Drive come and see (R62) regarding the dentures. Continue current POC. R62's Quarterly MDS dated [DATE], documented (R62) has no broken or loosely fitting dentures. (R62) is on a mechanically altered diet. (R62) has weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. Surveyor reviewed progress notes from Medical Director (MD)-AAA, dated 5/20/26, which documents: (R62) has had ongoing issues with variable oral intake and has been noted to occasionally refuse medications. Weight loss continues to trend down, which is desirable. Surveyor reviewed progress notes from Dietician-H, dated 6/4/26, that documented: (R62) is bed-bound. High risk for skin breakdown. Has history of pressure injuries. Was receiving ProSource for skin integrity, but (d/c'd) (discontinued) d/t refusal. Mechanical soft diet d/t missing dentures. (PO) (oral) intake (cont.) to be about 50% average. (R62) positive for the flu in Mid-January 2026, which was when (R62's) meal intakes started to decrease. Was only eating about 25% of meals at the time, and writer added a high-protein/high-calorie nutrition supplement TID. Supplement has also been d/c'd d/t refusal. Has had significant weight losses 10.4% over the past 6 months. Weight has stabilized around 185# over the past month. BMI 34.9 remains obese. (R62) still noted to refuse medications at times. Receives milk with all meals per (R62's) preference for extra calories and protein. Also receives oatmeal at all meals with brown sugar per (R62's) request. Weekly weights for monitoring. Surveyor noted the following care plan changes dated 6/4/26: (R62) has morbid obesity with BMI 35. Simultaneously at risk for malnutrition r/t chewing/swallowing issues d/t missing dentures (AEB) need for mechanical soft diet, poor (PO) (oral) intake 50% of meals, refusing supplements. R62's Quarterly MDS dated [DATE], documented (R62) has no broken or loosely fitting dentures. R62 has weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. On 7/9/26, at 11:01 AM, Surveyor interviewed Dietician-H who stated she typically works at the facility 4 days a week and has communication through email and verbally with nursing staff, speech therapy and the facility provider. Dietician-H stated the hospital discharge summary, or a referral for speech therapy will be placed to evaluate the resident to determine diet and texture for meals. Speech therapy will downgrade a diet when there is dentition concerns, chewing concerns, swallowing issues or if a resident is taking a long time to eat. Dietician-H stated she creates and updates nutrition care plans. If a resident is noted to have weight loss, it is discussed in the IDT meeting. If weight loss is verified with a reweigh, Dietician-H stated she digs in more and notifies the POA and provider. Dietician-H stated she meets with residents and asks about their teeth. Dietician-H stated she does not complete the dental sections for MDS or care plan. Dietician-H stated R62 has dementia and stays in bed continuously per R62's choice. R62 had a large weight loss, and a care conference was completed R62 has since stabilized around 180 lbs and did not like the nutritional supplements that were ordered. Surveyor asked Dietician-H why R62 had a significant weight loss and Dietician-H responded stating R62 has muscle loss due to lying in bed all day and that's R62's right, and R62 is depressed. R62 has poor dentation and POA is working on getting dentures, and the mechanical soft diet doesn't help because it is not appetizing. R62's POA stated normal food would help R62 to eat. Along with the weight loss, R62 was refusing medications. On 10/16/25 nursing staff downgraded R62's diet to mechanical soft and reported R62 having trouble eating due to lost dentures. Dietician-H then stated, if we lose someone's stuff, we replace it for them. Dietician-H stated social work plans on having Health Drive Dentistry come in to assess R62. Dietician-H stated R62's goal for weight is around 180 lbs. and R62 is technically still overweight. Gradual weight loss wouldn't be the end of the world but the big drop in March was scary, and I called a care conference. We had to try different things with R62, and hospice was being discussed in the IDT meetings but never talked about with R62. Dietician-H stated R62 has since stabilized and is doing better. On 7/13/26, at 3:56 PM, Surveyor discussed with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Consultant-C of concerns with R62 being admitted on [DATE], weighing 220 lbs, receiving a general diet. R62's diet was downgraded to a mechanical soft diet on 10/16/25, due to lost dentures. R62's Electronic Medical Record (EMR) documented R62 had a significant weight loss of 5.2% x1 month, 10.4% x3 months, and 12.9% x6 months, decreased meal intakes and verbalization from R62 and R62's POA of not liking mechanical soft diet with no replacement of R62's dentures. Surveyor noted R62 with decreased meal intake and R62 verbalizing they do not like mechanical soft foods and would increase food intake if put back on a general diet on 7/7/26, at 9:34 AM, 7/8/26, at 1:31 PM and 7/9/26, at 10:29 AM. NHA-A, DON-B and Consultant-C acknowledged these concerns. On 7/14/26, at 7:56 AM, Surveyor spoke with Speech Therapist (ST)-K who stated she has never worked with or saw R62. ST-K stated when it comes to dentures, nursing staff can downgrade resident's diets when it comes to dentures, unless they had other issues like residue, signs of aspiration or positioning concerns. ST-K states sometimes nursing staff will run it by me briefly and ST-K will remind them they can downgrade diets. 2.) The facility policy, entitled Hydration in Resident Room, not dated, stated: Procedures. 2. Residents on fluid restrictions and thickened liquids will be provided fluids per MD (medial doctor) orders. R47 admitted to the facility on [DATE] and had diagnoses that included encephalopathy, diastolic heart failure, hypo-osmolality and hyponatremia. R47's Medicare 5 day Minimum Data Set (MDS) assessment, dated 7/6/26, indicated that R47 is able to be understood by others and understands others. The MDS documents a Brief Interview for Mental Status (BIMS) score of 15, indicating that R47 is cognitively intact. R47 was documented as receiving a diuretic. R47's Care Plan, initiated on 6/15/2026, and revised on 07/09/2026, stated has dehydration or potential fluid deficit r/t (related to) Diuretic use, 2000ml (milliliter) fluid restriction. Interventions included:2000ml fluid restriction: 600ml from nursing: 200ml q (per) shift. 1400ml from dietary: 480ml breakfast, 360ml lunch, 360ml dinner, 200ml HS (bedtime) snack. Date Initiated: 07/09/2026 R47's Care Plan, initiated on 6/15/2026, stated the resident is on diuretic therapy r/t CHF (congestive heart failure). Administer DIURETIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Date Initiated: 06/15/2026. Monitor/document/report PRN (as needed) adverse reactions to DIURETIC therapy: dizziness, postural hypotension, fatigue, and an increased risk for falls. Date Initiated: 06/15/2026. R47's hospital Discharge summary, dated [DATE], documented chronic hyponatremia . Continue 2L (liter) volume restriction. On 7/1/2026, at 08:00AM, Nurse Practitioner (NP)-G documented in R47's progress note tighten fluid restriction to 1.5L/day for hyponatremia management. R47's Nutritional Assessment dated 7/4/2026, documented for Nutritional/Dehydration Risk Factor, check all that apply, R47 is marked for diuretics and laxatives. R47 is not marked for fluid restriction. On 7/7/2026, at 10:00AM, NP-G documented in R47's progress note continue fluid restriction to 1.5L/day for hyponatremia management. On 07/08/2026, at 9:27 AM, Surveyor interviewed Registered Nurse (RN)-P who was working with R47 that day. Surveyor asked if R47 had a fluid restriction order. RN-P stated there was no fluid restriction order. R47's physician order dated 7/9/2026, documented 2000cc (cubic centimeter) fluid restriction daily every shift for hyponatremia 600ml from nursing: 200ml q shift. 1400ml from dietary: 480ml breakfast, 360ml lunch, 360ml dinner, 200ml HS snack. On 07/09/2026, at 11:01 AM, Surveyor interviewed Dietician-H about who sets up a fluid restriction for a resident. Dietician-H stated nursing enters the order, Dietician-H does the breakdown of how many ml per meal. The medical provider orders the fluid restriction. Surveyor asked how they monitor the fluid restriction and was told nursing monitors by the Certified Nursing Assistant reporting to nurse how much a resident drinks per shift. The nurse records the ml in the electronic medical record. Surveyor asked about R47 being on a fluid restriction. Dietician-H stated NP-G did not communicate that to Dietician-H. Dietician-H wouldn't enter a fluid restriction, if NP-G wanted a fluid restriction started NP-G would tell a nurse to enter the order. On 07/09/2026, at 1:08 PM, Surveyor interviewed Nurse Supervisor-S regarding R47 having a fluid restriction. Nurse Supervisor-S stated that R47 is not on a fluid restriction. Surveyor asked how staff receive NP-G's orders. Nurse Supervisor-S stated that NP-G usually verbally tells staff or enters the order themselves. On 07/09/2026, at 2:44 PM, Nurse Supervisor-S followed up with Surveyor that a 2000CC fluid restriction was added by the dietician today and clarified with NP-G. On 07/13/2026, at 11:46 AM, Surveyor interviewed NP-G related to starting a resident on fluid restrictions. NP-G stated sometimes a resident comes back from the hospital with fluid restriction orders or NP-G will base the need on labs or a resident's diagnosis. Surveyor asked how an order is processed for a fluid restriction order. NP-G stated it is written on a lab sheet or put in by the provider. Most of the time NP-G will give an order to nursing staff to enter. Surveyor asked why on 7/9/2026 was an order added for a 2000cc fluid restriction for R74 when previous recommendations by NP-G were for a 1500CC fluid restriction. NP-G stated they looked at R47's labs, R47 had more labs coming in today. Based on the labs NP-G felt R47 should be on fluid restriction of 2000cc.

Based upon observation, interview and record review, the facility did not ensure residents received medically related social services to address individual resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 1 (R1) residents reviewed.*R1 had a history of alcohol abuse, the facility did not comprehensively assess and implement a person-centered care plan with interventions.Findings Included:The facility does not have a policy regarding alcohol or substance use or residents who consume alcohol or substances.The facility's assessment, last revised 1/18/2026, documented the facility assessment is required to identify and analyze the facilities resident population and identify the personal, physical plant, environmental, and emergency response resources needed to competently care for the residents during day-to-day operations and emergencies.The facility assessment does not document substance abuse in its matrix population, resident characteristics population, or in other pertinent facts regarding residents. In the facility assessment section under admission capabilities there are three sections with different resident needs, able to meet resident needs, review to meet needs, and unable to meet needs. Alcohol use is not addressed; there is an illicit drug user class in the unable to meet needs section.R1 was admitted to the facility on [DATE]with diagnoses that included alcohol abuse.R1's Quarterly Minimum Data Set (MDS), completed on 12/11/2024, documented that R1 was assessed as having a Brief Interview for Mental Status (BIMS) score of 13, indicating that R1 was cognitively intact. The MDS documented R1 was assessed to not have physical, verbal, or other behavioral symptoms towards others.On 8/29/2024, R1's hospital discharge summary documents alcohol abuse as part of R1's diagnoses.Surveyor noted R1's initial admission was 8/10/2023 and the facility was familiar with R1's alcohol abuse.R1's substance abuse care plan, implemented on 12/4/2025, documented R1 is being followed by psychology and psychiatry, R1 lacks healthy coping skills and R1's current coping skills can be manipulative and consist of gas lighting at times. Interventions included: Staff to notify R1's physician immediately if withdrawal symptoms occur initiated on 12/4/2025; Observe R1 for signs of alcohol withdrawal (tremors, agitation, nausea, diaphoresis) initiated on 12/4/2025; R1 not to be served alcohol by the facility initiated on 12/4/2025.R1's care plan of misplacing items and accusatory behavior, implemented on 1/14/2025 and last revised 9/10/2025, documented R1's preference to not have their items touched unless approached by staff. Interventions include: If R1 does not want staff to clean their room, social services will meet with them and review risks and benefits. Initiated on 1/14/2025; Social services will meet with R1 and develop goals for cleanliness and safe keeping of personal items. Initiated on 1/14/2025; Staff to knock on door and explain purpose of visit to R1. Initiated on 1/14/2025.R1's behavior care plan, implemented on 8/22/2025 and last revised 1/8/2026, documented R1 displayed manipulative behaviors, such as control through deceit guilt tripling, attention seeking, or splitting (playing people against each other). R1 is followed by psychology and psychiatry. The following interventions were initiated on 8/22/2025: Address splitting behaviors by maintaining open communication between staff and presenting a united and consistent approach; Document all behaviors and interventions consistently; Encourage R1 to express feelings and validate the feeling but not the behavior; R1 will demonstrate the ability to express directly in 80% of observed interactions; R1 will exhibit decreased manipulative behavior; Provide positive reinforcement when R1 uses appropriate communication; Set firm consistent boundaries, do not engage in power struggle; Use clear and non-emotional language when responding to manipulative behavior.R1's care plan for accusatory statements that are not clear in nature, likely due to ineffective coping and periods of impairment, implemented on 9/18/2025, documented the following interventions: Encourage R1 expression of feelings and validate them, initiated 12/10/2025; Monitor for signs of behavioral escalation or distress and intervene early to maintain R1's safety. initiated 12/10/2025; Provide a calm, supportive environment to reduce stress. initiated 12/10/2025; Use active listening, reflecting, and clarifying statements to ensure understanding. initiated 12/10/2025.R1's repetitive movement care plan for perseverating on smoking, yelling and or screaming, abusive language, and threatening behavior. Implemented on 8/19/2025 and revised on 12/12/2025 documented: Administer medications as ordered. Initiated 8/19/2025; Anticipate and meet R1's needs. Initiated 8/19/2025; Provide R1 opportunity for positive interaction by stopping and talking to R1. Initiated 8/19/2025; Explain all procedures to R1 before starting and allow R1 time to adjust to changes. Initiated 08/19/2025, last revised 10/24/2025; Discuss R1's behavior and explain why the behavior is inappropriate or unacceptable. Initiated 08/19/2025, last revised on 10/24/2025; Intervene to protect the rights and safety of others. Approach our one in a calm manner, divert attention, remove R1 from the situation and take R1 to an alternate location. Initiated 08/19/2025, last revised on 10/24/2025; Monitor behavior episodes and attempt to determine underlying causes. Document behavior and potential causes. Initiated on 8/19/2020 5:00, last revised on 10/24/2025.R1's Resistive to care plan, implemented on 11/17/2025 and last revised 1272026, documented R1 refuses the removal of meal trays from their room. R1 is verbally aggressive and threats of physical aggression. This is related to the belief that care is not needed, that R1 knows best, mistrust of others, paranoia, and alcohol abuse. R1 is followed by psychology and psychiatry. The following interventions included: Allow R1 to make decisions about treatment regimen to provide sense of control. Initiated on 11/17/2025; Encourage R1 to participate during care activities. Initiated 11/17/2025; Give clear explanation of all care activities prior to. Initiated on 11/17/2025; Contact the unit manager if R1 refuses to have meal trays or spoiled food removed from their room. Initiated on 1/27/2026; If R1 resists activities of daily living, reassure R1 and return and try again. Initiated on 11/17/2025; Praise R1 when behavior is appropriate. Initiated 11/17/2025; Provide R1 opportunities for choice during care provision. Initiated on 11/17/2025.Surveyor noted the facility's care plan for R1's alcoholism is to notify the provider, but there are not any additional interventions for R1's alcohol consumption.Surveyor noted the facility acknowledges R1's various behaviors towards staff are linked to R1's mistrust, ineffective coping, not wanting staff to go into their room and remove items, and allowing R1 to make their own decisions for their own care. Surveyor noted this was not expanded on by the facility. A list of trusted staff was not documented or included in R1's plan of care.Surveyor reviewed R1's physician orders that documented: No alcoholic beverages with a start date of 12/5/2025; behavior monitoring for yelling, screaming, threatening behavior, and abusive language with a start date of 3/30/2026; smoking monitoring with a start date of 12/9/2024; refusal of care monitoring with a start date of 12/29/2024; and a medication refusal monitoring with a start date of 12/9/2024.Surveyor noted there is not an order to monitor R1 for alcohol use or intoxication.A trauma informed care assessment was attempted in 2024 and documented as refused by R1. Surveyor unable to find additional documentation that another trauma informed care assessment was reattempted for R1.Social ServicesOn 3/5/2025, a social worker note documented they spoke to R1 and acknowledged R1 is struggling with the loss of their family member. R1 stated they drink to escape the loss of their facility member. R1 was informed there has been a psychologist referral placed. R1 informed the social worker of their provider preference.On 7/13/2026, at 11:42 AM, Surveyor interviewed Social Worker (SW)-AA regarding their involvement with R1. SW-AA stated R1was at the facility before SW-AA started at the facility. SS-AA stated they know R1 drinks alcohol excessively. SS-AA stated they were aware that R1's family member passed and psychological services were set up for R1. R1 saw a preferred provider. R1 does not like women and prefers male providers. Surveyor asked SW-AA if there is a list of people that R1 prefers to talk to. SW-AA stated there is not a list per say, but SW-AA and R1's psychologist are preferred. Surveyor asked SW-AA if a trauma informed assessment was completed or any assessment through social services. SW-AA stated they were not sure and would have to check and referred Surveyor to speak to DSW-R. Surveyor asked what services have been provided to R1. SW-AA stated they were unsure as DSW-R mostly handles R1 as R1 is a difficulty case. SW-AA stated they know R1 sees psychological services. Surveyor asked SW-AA what services the facility has regarding alcohol and substance abuse. SW-AA referred Surveyor to DSW-R.Surveyor asked SW-AA how the social worker should address residents who refuse assessments. SW-AA stated it should be reattempted at least two times and that the social worker should know in times of distress or event changes that the resident may decline to talk and share their situation. SW-AA stated that the assessments should be reattempted sometime after the traumatic event, maybe even a few months after. SW-AA stated preferred staff members can also do the assessments, as the questions from assessments are written and can be read.On 7/23/2026, at 3:24 PM, Surveyor interviewed DSW-R regarding social services provided to R1. DSW-R stated R1 has behaviors and is manipulative and thatR1 will lie about interactions between staff. DSW-R stated that R1 drinks alcohol and does not see their drinking as a problem. DSW-R stated the facility was aware that R1 had drinking issues but not to the current extent. DSW-R stated R1 thinks the facility can't tell R1 what to do and refuses medical services.Surveyor asked what social services were provided to R1 while at the facility. DSW-R stated R1 sees a psychiatrist and psychologist. Outside alcohol and other drug abuse (AODA) programs were offered previously before R1's admission in late 2024 but not reattempted as R1 refused in the past. DSW-R stated they are not sure of what R1's plan is or last treatment options offered and Surveyor would need to follow up with SW-AA for more information regarding R1's services, as SW-AA is R1's primary social worker. DSW-R stated they only assist SW-AA with certain situations when asked. Surveyor asked DSW-R regarding a trauma informed assessment with R1. DSW-R stated one was attempted but not reattempted because of R1's behaviors. DSW-R denied SW-AA or other staff attempting to get a trauma informed assessment from R1. DSW-R stated questions are attempted at care conferences and DSW-R denied the attempts being documented.DSW-R stated all of R1's information was pulled from R1's hospital discharge and R1 will not confide in them and share information. DSW stated R1 has classic characteristics of trauma and one of R1's biggest trigger is not being able to be in control. Surveyor asked what services were provided after R1's family member died. DSW-R stated R1 was sent to see psychological services. DSW-R stated the facility attempted to find alternative placements for R1, as a less restrictive environment may be better for R1.Surveyor noted from interviews with DSW-R and SW-AA, both were unfamiliar with any current treatment plan for alcoholism for R1's or what social services were being provided, as both referenced each other when additional information was requested. Nursing ServicesMultiple nurses note from March 2025 to April 2026 document R1 smelling of alcohol. R1 had 4 falls relating to intoxication. There are multiple nurse's notes that document removal of alcohol from R1's room.On 5/6/2026, risks and benefits meeting occurred withR1. R1 acknowledged the risks of alcohol use and that the facility cannot provide them with alcohol.An undated terms of living at the facility documented: R1 can drink alcohol within reason and not to the point of inebriation.On 7/8/2026, at 2:16 PM, Surveyor interviewed Certified Nursing Assistant (CNA) - SS regarding R1's daily cares. CNA-SS stated R1 does many things themselves. R1 will let the staff know if they need anything by putting the call light on. CNA-SS stated R1 prefers some staff over others. Surveyor asked CNA-SS what information they know of R1's alcoholism. CNA-SS stated R1 has had falls from being intoxicated. CNA-SS stated R1 has had a problem from alcohol for a long time, even before coming to the facility. CNA-SS stated R1's family has told staff about R1's alcohol issues. CNA-SS stated about a year ago R1's family member passed away which caused an increase in R1's drinking and falls. CNA-SS stated they have cared and interacted with R1 when R1 was intoxicated. CNA-SS stated the CNAs are to inform the nurse if they suspect R1 is intoxicated. CNA-SS did not state any additional interventions staff are to do for R1 regarding alcoholism or intoxication.On 7/14/2026, at 9:22 AM, Surveyor interviewed Nurse Supervisor (NS)-BB regarding R1's drinking. NS-BB stated R1does not have an order for alcohol and if R1 leaves alcohol sitting out visible it is removed by staff. NS-BB stated R1 is closed off and difficult to get information from. Surveyor asked what interventions have been provided to R1 regarding alcoholism. NS-BB stated a risks and benefits regarding alcohol were explained to R1. Surveyor asked if a risks and benefits was completed before. NS-BB stated the only risks and benefits for alcohol was done on 5/6/2026 and that R1 signed a document with the previous administrator to limit R1's alcohol intake.NS-BB stated that R1 is spoken to with two staff members due to R1's behaviors. However, R1 feels ganged up on when two or more staff approach R1, so one staff member will be outside the door within ear shot as a witness. Medical Director (MD)-AAA has R1 flagged for no narcotics due to alcohol abuse. Surveyor asked NS-BB if R1 has any preferred staff to conversate with as part of R1's plan of care. NS-BB stated R1 has productive conversations with their psychologist.Surveyor noted R1's care plan does not include a list of R1's preferred staff. Surveyor noted the document NS-BB will attempt to limit R1's alcohol intake with the Terms of Living at The Facility document. Surveyor noted that the document did not specifically state as to what R1's limit was, just to drink within reason.On 7/14/2026, at 9:53, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding R1's alcoholism. NHA-A stated has a history of drinking and stated that R1 has a right to drink, although R1 does not have a physician's order to drink. NHA-A stated R1 has had falls due to intoxication. Surveyor asked NHA-A what interventions they are aware of that have been implemented to help R1 and their alcoholism. NHA-A stated they keep a soft file of sorts that has R1's risks and benefits for alcohol and the Terms of living at the facility document. NHA-A stated the terms document was an agreement R1 had with the previous Administrator. NHA-A stated R1 is followed by psychology and psychiatry services for roughly a year. NHA-A stated alternative placement was offered for R1 as the facility felt a less restrictive environment would benefit R1. Surveyor asked NHA-A when the terms documentation was completed. NHA-A stated it was sometime in September of 2025.Surveyor noted according to a note on 4/10/2025, alternative placement was not done for an intervention for R1 due to R1's not meeting their insurance criteria for a nursing home. Surveyor noted the Terms of Living at The Facility document stated R1 is to drink within reason.Surveyor noted that despite this, the facility did not attempt to complete a trauma informed assessment and did not implement any interventions for the treatment of R1's alcohol consumption.On 7/14/2026, at 10:49 AM, Surveyor interviewed Medical Director (MD)-AAA regarding their knowledge of R1's alcohol use. MD-AAA stated they are not very familiar with R1 but knows R1 sneaks alcohol into the facility. MD-AAA stated they are not aware of any specific interventions in place but knows the facility has an intervention for R1 to make sure R1 is not keeping alcohol is their room to prevent R1 from drinking alcohol.Surveyor noted removing alcohol from R1's room is not on R1's care plan.Psychological ServicesOn 3/10/2025, a psychiatry note documented facility staff requested evaluation as R1 was found drinking alcohol. R1 declined support groups and alcoholics anonymous (AA) in the past.R1 is seen bimonthly by a psychologist from early 2025 to current with the focus being cognitive behavioral therapy and gaining trust with R1.On 4/4/2025, a psychologist note documented R1's insurance is pushing R1 to less restrictive environment.On 4/21/2025, a psychologist note documented they would recommend R1 to see group therapy or AA, but R1 declined these in the past.On 7/21/2025, another psychiatrist was asked to evaluate R1. The psychiatrist's' note documented facility staff requested R1 be seen due to oppositional behavior and irritability. Saff are concerned about intermittent irritable behavior that is not redirectable. R1 stated they were unhappy at the facility due to feeling like a prisoner. R1 declined medical intervention at this visit.On 8/24/2025, , a psychologist note documented R1 is not happy about current placement but realizes this facility may be as good as any other facility.On 9/24/2025, , a psychologist note documented R1 has trouble sleeping and the phycologist suspects an emotional withdrawal from alcohol.On 10/23/2025, , a psychologist note documented alcohol consumption was brought up. R1 was initially was defensive and angry. R1 calmed down once R1 realized the psychologist was not judging them.On 11/28/2025, , a psychologist note documented R1 was angry and upset that staff had taken alcohol out of their room. R1 stated it violated their rights. It was explained to R1 that it's facility policy that residents do not drink alcohol.On 12/24/2025, a psychologist note documented difficulty getting R1 to focus on themselves and there was not discussed as R1 likes to avoid those conversations.On 1/28/2026, , a psychologist note documented R1 talking about going to a facility with less restrictions. R1 is referring to the facility not allowing R1 to drink. R1 gets upset when talking about drinking and stated I can do what I want.On 2/23/2026, a psychologist note documented R1 feels they have a good connection with a social worker. R1 continues to struggle with trust issues.On 3/10/2026, a psychologist note documented R1 signed a document limiting to 2 alcoholic beverages a day. R1 complains but accepts it. R1 presented with coping strategies of trying to avoid problems and ignore much of what goes on to just get along. R1 feels the staff have attitudes.On 4/7/2026, a psychologist note documented R1 continues to have conflicts at the facility and is not happy. R1 does not anticipate that it would be better anywhere else.On 5/8/2026, a psychologist note documented R1 is down and is critical of the entire facility staff. R1 resents attempts to control R1's behavior. The psychologist continues to have a good relationship with R1 and R1 does not see the psychologist as on of them.On 7/1/2026, a psychologist note documented R1 refused any issues with the facility about alcohol and did not comment on if R1 is drinking.R1 continues to see the psychologist.Surveyor noted that the psychologist focused on building a relationship with R1 and cognitive behavioral therapy. The psychologist addressed R1's alcoholism in October of 2025, after seeing R1 since early 2025. The psychologist noted R1 does not like to discuss their drinking and avoid those conversations.Surveyor noted that despite seeing the psychologist, no intervention to manage R1's alcohol use has been put in place for R1.On 7/14/2026, at 11:15 AM, Surveyor interviewed DON-B regarding their knowledge of R1's alcohol use. DON-B stated R1 drinks, has a right to drink, and the facility does not provide R1 alcohol. DON-B stated alcohol is removed from R1's room as the alcohol needs to be locked as it is a safety risk for other residents. DON-B added that the alcohol must be left out in the open for the facility to remove it. DON-B stated the alcohol is labeled and placed into the cabinet in their office and will be given back when R1 discharges the facility. Surveyor asked DON-B if alternative storage was offered, or if the facility offered to store the alcohol safely and give it to R1 to monitor R1's alcohol intake. DON-B stated the facility could not give R1 back the alcohol as it would be serving R1 alcohol and the facility cannot do that as R1 does not have an order for alcohol.On 7/14/2026, at 11:25, NHA-A walked in and joined the interview with DON-B. Surveyor asked DON-B if there is a policy for alcohol use and searches, as it has been referenced in multiple interviews with Surveyor. DON-B stated they were sure there was a policy but could not locate one. NHA-A stated there is not a policy and facility staff are confusing policy with procedure. NHA-A stated there is no written procedure, just verbal directions from DON-B or NHA-A. DON-B stated the procedure for removing alcohol is if the CNA finds it to notify the nurse, during business hours the nurse supervisor, DON-B, or NHA-A. After business hours, the nurse is to remove the alcohol from the area and lock it in the med room and send a text to DON-B or NHA-A. DON-B stated nurses are not to document in the resident's EHR when this is done as its not medically related and does not go into the resident's chart. DON-B denies any form of documentation of removal of R1's alcohol or an inventory to assure how much or what is to be returned to R1. DON-B stated alcohol is typically removed from R1's room when R1 is not at the facility, and R1 is informed of its removal upon R1's return. DON-B stated R1 cannot have alcohol in their room as it is a safety hazard to other residents that may wander into R1's room and either drink or take it.On 7/14/2026, at 11:25, NHA-A walked in and joined the interview with DON-B. DON-B continued that nurses are not to document in the resident's EHR when alcohol is removed from R1's room as this is done as its not medically related and does not go into the resident's chart. DON-B stated R1 cannot have alcohol in their room as it is a safety hazard to other residents that may wander into R1's room and either drink or take it. Surveyor asked DON-B and NHA-A if any other interventions were put in place or social services offered to treat and manage R1's alcohol use. DON-B and NHA-A both stated R1 was referred to psychology early 2025, a terms of living at the facility document that was undated but completed sometime in September 2025, and a risks and benefits was done 5/6/2026.Surveyor informed DON-B and NHA-A that R1 did not receive a comprehensive trauma informed assessment and person-centered care plan related to the treatment and management of R1's chronic alcohol use. Surveyor informed NHA-A and DON-B that there was no documentation that R1 was provided with medically related social services to treat and manager R1's alcohol consumption.

Based on observation, interview and record review, the facility did not ensure follow up dental care for 1 (R62) of 1 resident reviewed for dental care.R9's diet was downgraded to a mechanical soft diet on 10/16/25, due to lost dentures. As of 7/14/26, R9 has not seen a dentist to replace dentures lost by the facility and remainsed on a mechanical soft diet due to reports of trouble eating.Findings include:On 7/14/26, at 2:14 PM, Surveyor requested policy for dental or denture care. Director of Nursing (DON)-B stated the facility does not have a dental or denture care policy.R62 was admitted to the facility on [DATE]. R62's Comprehensive Minimum Data Set (MDS) dated [DATE], documents (R62) has no dental concerns and no altered diet. (R62's) Brief Interview for Mental Status (BIMS) score was 15, indicating (R62) is cognitively intact.R62's Quarterly MDS dated [DATE], documented a mechanically altered diet and no broken or loosely fitting dentures.R62's Quarterly MDS dated [DATE], documented no broken or loosely fitting dentures and no altered diet.R62's care plan initiated 8/29/25, revised on 6/4/26, documented (R62) has oral/dental health problems: full dentures. Interventions initiated on 8/29/25 documented, full dentures and monitor/document/report as needed any signs/symptoms of oral/dental problems needing attention: teeth missing, loose, broken, eroded, decayed.R62's care plan initiated 9/5/25, revised 6/4/26, documented (R62) has morbid obesity with Body Mass Index (BMI) 35. Simultaneously at risk for malnutrition related to (r/t) chewing/swallowing issues d/t missing dentures (AEB) (as evidenced by) need for mechanical soft diet, poor (PO) (oral) intake 50% of meals, refusing supplements. Interventions initiated on 9/5/25 documents to offer available substitutes if (R62) has problems with food being served.On 7/7/26, at 9:34 AM, Surveyor interviewed R62 who was lying in bed with their breakfast tray on the bedside table in reach of R62. Surveyor stated to R62 they noted they have not touched their breakfast food. R62 replied they didn't have dentures and can't eat the breakfast sandwich provided. Surveyor noted R62's dinner tray from the previous night sitting on the windowsill that had visible minced foods on the plate. Surveyor noticed the food was not touched and there was an open pudding container. R62 stated they do not like minced foods and wants normal foods again.On 7/8/26, at 1:31 PM, Surveyor interviewed R62 who was in bed with their lunch tray in reach. Surveyor asked R62 how lunch was and R62 responded they don't like minced foods and would just like to eat a steak or ribs. R62 stated they are getting minced food because they have no teeth. R62 stated the facility lost their dentures and they get their food minced due to being unable to chew food properly. R62 appeared to have lower dentures in their mouth that were loose when talking and no visible dentures to the top gums. R62 stated they cannot afford new dentures and needed to see a dentist. R62 stated the facility has not assisted with seeing a dentist or replacing the lost dentures and a family member was now looking into getting R62 new dentures.Surveyor reviewed progress notes from Dietician-H dated 10/16/25, which document nursing staff downgraded R62's diet to mechanical soft due to reports of trouble eating after dentures were lost.On 7/9/26, at 10:29 AM, Surveyor interviewed R62. Surveyor asked R62 if they had regular food, would they eat more, and R62 enthusiastically replied, yes. R62 stated dentures cost a lot and now that money will have to come out of my own pocket.On 7/9/26, at 10:34 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-N who stated R62 had dentures but not sure if R62 has replacement dentures.On 7/9/26, at 10:39 AM, Surveyor interviewed Registered Nurse (RN)-P who stated the facility doesn't have a dentist and residents have to schedule their own dentist appointments. RN-P stated she would call on the resident's behalf to schedule with their personal dentist and arrange transportation if the resident requests them to. RN-P stated R62 does not choke on food and is on a mechanical soft diet with thin liquids. Surveyor asked why R62 was on a mechanical soft diet and RN-P stated she doesn't typically work this unit.On 7/9/26, at 1:04 PM, Surveyor interviewed Social Worker (SW)-AA who stated the facility uses Health Drive for dental services. Health Drive will notify the facility they are coming approximately 1-2 weeks prior to arrival or Social Services will reach out to Health Drive when it's been a while. SW-AA stated she has a running list on her computer of residents wanting to be seen for dental services and that Dental Services occurs about every 3-4 months or she can call with emergent visits. SW-AA stated Health Drive does provide denture services. SW-AA stated R62 is not signed up for Health Drive and reviewed her personal running list on her computer and could not identify R62 on her personal list. SW-AA stated she is not aware of R62 having denture concerns but then stated she could check further into the chart.On 7/13/26, at 2:07 PM, SW-AA asked to speak with Surveyor and stated she was notified of R62 missing their dentures on 3/13/26 during a care conference, and family was going to get dentures. SW-AA stated she also enrolled R62 into Health Drive dental services on 12/18/25 for podiatry services and figured she should also enroll R62 with dental services at the same time. SW-AA stated R62 was seen on 12/29/25 and per the dentist's visit, R62 was unavailable. Surveyor requested documentation of the 12/29/25 dental visit. SW-AA then stated she talked with Health Drive who did an IT update and disenrolled R62 accidentally and SW-AA found this out on 7/10/26 after the Survey team brought it to her attention. SW-AA stated Health Drive sends her a roster of residents that are going to be seen, and SW-AA will make sure residents who requested dental services are on the list provided by Health Drive. Surveyor asked SW-AA who is responsible for following up on dentures that are lost by the facility and SW-AA stated I don't know if anyone is ultimately responsible for dentures and follow up. Surveyor notified SW-AA of concerns with the facility losing R62's dentures with no follow up or replacement by the facility.On 7/13/26, at 3:56 PM Surveyor notified Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B and Consultant-C of concerns with the facility losing R62's dentures and not replacing R62's dentures.On 7/14/26, at 10:31 AM, DON-B stated the facility should have followed up sooner on R62's dentures and the dentures fell through the cracks and not followed up on.

Based on observation, interview, and record review, the facility did not ensure 2 (R1 & R3) of 3 residents received adequate supervision and assistance devices to prevent accidents.*R1 was admitted to the facility on [DATE] with a history of falls. R1 fell on 8/11/25 while attempting to self transfer. The facility did not thoroughly investigate this fall and was aware of R1's multiple attempts to self transfer but did not address R1's self transferring behaviors. On 8/19/25 R1 fell, was transferred to the hospital and diagnosed with a pelvic fracture. R1 returned to the facility on 8/28/25. On 8/31/25 R1 fell. The facility did not thoroughly investigate this fall.*R3's falls on 6/26/25, 7/7/25, 7/13/25, 7/29/25, 8/2/25, 8/20/25, & 8/26/25 were not thoroughly investigated. On 9/4/25 R3 received the incorrect diet for lunch., putting R3 at risk for choking. On 9/8/25 during morning cares, R3 bed was not lowered according to R3's falls plan of care when CNA-L went into the bathroom and/or left R3's room.Findings include:The facility's policy titled, Falls and last reviewed 5/8/25 documents under Policy Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls. Under Procedure documents .2. Procedure of Fall Event and Implementation of Intervention: a. Licensed nurse completes electronic documentation of the Fall Incident Report. b. The care plan will be updated with an identified intervention. c. Registered Nurse reviews and completes the fall assessment and interventions. d. Fall follow-up assessments completed as indicated. 3. Administrative Review: a. The Interdisciplinary Team (IDT) will review Fall Incident report and utilize root cause analysis to make further recommendations. b. Director of Nursing (or designee) and Executive Director to review and sign Fall Incident Report. c. Quality Assurance and Process Improvement Committee reviews facility fall incidents and trends.On 9/4/25, at 12:01 p.m., Surveyor asked Registered Nurse (RN)-G to explain the process when a resident has a fall. RN-G informed Surveyor that after a fall, an RN will assess the resident from head to toe, obtains vital signs, contact the provider and POA if the resident has one have one. RN-G indicated an incident report, pain assessment, progress note, and fall assessment are completed. RN-G informed Surveyor usually the unit manager will let them know what new fall intervention was initiated. RN-G informed Surveyor if the fall was witnessed she will get witness statements and give these to the manager. If the fall is unwitnessed she will usually ask the CNAs questions such as who last saw the resident, if their bed was in a low position. RN-G informed Surveyor that the statements are then given to the unit manager.On 9/4/25, at 2:12 p.m., Surveyor asked Licensed Practical Nurse/Unit Manager (LPN/UM)-I to explain the process when a resident falls. LPN/UM-I informed Surveyor when a resident falls staff will let her know and if she is at the facility she will put in a new fall intervention. If she is not at the facility when she will comes back she will put in an intervention. LN/UM-I explained all assessment have been completed, she will do an investigation, the IDT (interdisciplinary team) will do a root cause and an intervention. Surveyor asked if LPN/UM-I if during the investigation she gets staff statements or are staff interviewed. LPN/UM-I informed Surveyor the nurse usually gets statements and puts them under her door. Surveyor asked what happens with staff statements. LPN/UM-I informed Surveyor they would be with the packet that is given to DON-B. Surveyor asked LPN/UM-I what she provides to DON-B. LPN/UM-I informed Surveyor the the investigation summary which includes what happened, diagnoses, IDT met discussed incident with root cause and care plan intervention. All assessments are printed out which include risk management, nurses note, fall risk assessment, pain assessment, and e-interact change of condition which is like an SBAR, and copy of the care plan with interventions. LPN/UM-I informed Surveyor she will put a new Kardex in the resident's room with the new intervention. Surveyor asked LPN/UM-I if DON-B would have staff statements. LPN/UM-I replied yes if there were statements given to me.1.) R1 was originally admitted to the facility on [DATE] with diagnoses which includes cardiogenic shock (inadequate blood flow to the body's organs due to dysfunction of the heart), diabetes mellitus (high blood sugar), atrial fibrillation (irregular and rapid heart beat), atrial fibrillation (irregular and rapid heartbeat), chronic kidney disease (kidneys are damaged and cannot filter blood and waste effectively), and heart failure (chronic condition in which the heart doesn't pump blood as well as it should). R1's hospital Discharge summary dated [DATE] for reason for hospitalization is falls.R1's fall risk evaluation dated 7/25/25 has a score of 4. A total score of 10 or greater is high risk for falls.R1's at risk for falls care plan initiated 7/25/25 & revised 8/31/25 documents the following interventions: Anticipate and meet the resident's needs, initiated 7/25/25. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 7/25/25. Follow facility fall protocol, initiated 7/25/25. PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed), initiated 7/25/25. Ensure that the resident is wearing appropriate footwear when ambulating, transferring or mobilizing in w/c (wheelchair), initiated 8/11/25 & revised 8/13/25. Call before you fall sign placed in bathroom, initiated 8/19/25. Offer resident assistance with using the toilet with every interaction, initiated 8/31/25. R1's admission MDS (minimum data set) with an assessment reference date of 8/1/25 has a BIMS (brief interview mental status) score of 12 which indicates moderate cognitive impairment. R1 is assessed as being dependent for toileting hygiene, supervision or touching assistance for rolling left and right & chair/bed to chair transfer and partial/moderate assistance for toilet transfer. R1 is frequently in continent of urine and always continent of bowel. R1 has fallen in the last month prior to admission and has not had any falls since admission.R1's functional abilities (self care and mobility) CAA (care area assessment) dated 8/4/25 under analysis of findings for nature of the problem/condition is blank. Under care plan conditions for describe impact of this problem/need on the resident and your rational for care plan decision documents CAA triggered due to resident requires extensive assist of 1 people for bed mobility, toileting and transfer. Extensive assist of 1 for dressing and personal hygiene. Dependent on staff for locomotion. Ambulating short distance with walker and CGA (contact guard assistance). Resident recently admitted from hospital where he had been for cariogenic shock. Lived with son prior to hospitalization. Currently resident has had a decline in mood related to situation. Isolates self in room. Goal is to return home. Resident has decondition. Is at risk for further decline in ADL's (activities daily living), falls, contractures, further isolation, complications of immobility: further pressure ulcers, muscle atrophy, incontinence and contractures. Referred to and is receiving PT/OT (physical therapy/occupational therapy) 5x/week (five times per week). Referred to MD (medical doctor) for evaluation of mood/depression and pain med (medication) management. Will proceed to care plan to prevent/minimize risks; work with resident to return to prior level of independent functioning.R1's falls CAA dated 8/4/25 under analysis of findings for nature of the problem/condition is blank. Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision documents CAA triggered for falls due to risk factors resulting from Balance problems: Not steady, only able to stabilize with human assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer; Resident admitted to facility with fall history. Resident has had no falls 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. Resident receives physician ordered Physical and Occupational Therapy services. No referrals at this time, will proceed to care plan with goal to have no fall related injuries.R1's nurses note dated 8/11/25, at 17:35 (5:35 p.m.) written by Licensed Practical Nurse/Unit Manager (LPN/UM)-I documents: Writer entered resident's room to take his blood sugar and found him sitting on his bottom on the floor between the head of the bed and night stand. Resident had both legs straight out in front of him, one gripper sock on his left foot and his right foot was bare. Resident's wheelchair was across from him about 3 feet away from where he was sitting at the foot of the bed facing him, parallel to the bed, the wheels were not locked. Writer had last seen resident about 10 minutes prior, he was on the toilet, resident asked writer to come back and take his blood sugar. Writer had reminded resident to use the call light to ask for help to get off the toilet when he was done. Writer checked with CNA (Certified Nursing Assistant) and resident had not called for help to get on or off the toilet. Resident joked that he decided to just sit on the floor for a little bit. Resident then stated he was attempting to get into bed he stated he stood up and went to pivot into the bed when his knees gave out causing him to fall landing on his bottom. Resident assessed for injury, none noted, resident denied pain or discomfort, skin check done no injuries noted, neuro checks started, were negative, vitals WNL (within normal limits); BS (blood sugar) 93. Resident assisted up off the floor and into bed by the writer and CNA. POA (power of attorney) [Name] updated, [Name] NP (Nurse Practitioner) updated, writer is on call manager so no notification to on call manager made. Resident placed on 24 hour board for monitoring, Risk Management started.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 8/11/25 prepared by RN/UM-H. The summary of alleged incident documents Writer entered resident's room to take his blood sugar and found him sitting on his bottom on the floor between the head of the bed and night stand. Resident had both legs straight out in front of him, one gripper sock on his left foot and his right foot was bare. Resident's wheelchair was across from him about 3 feet away from where he was sitting at the foot of the bed facing him, parallel to the bed, the wheels were not locked. Writer had last seen resident about 10 minutes prior, he was on the toilet, resident asked writer to come back and take his blood sugar. Resident joked that he decided to just sit on the floor for a little bit. Resident then stated he was attempting to get into bed he stated he stood up and went to pivot into the bed when his knees gave out causing him to fall landing on his bottom. Writer had reminded resident to use the call light to ask for help to get off the toilet when he was done. Writer checked with CNA and resident had not called for help to get on or off the toilet. Resident assessed for injury, none noted, resident denied pain or discomfort, skin check done no injuries noted, neuro checks started, were negative, vitals WNL; BS 93. Resident assisted up off the floor and into bed by the writer and CNA with hoyer lift. POA [Name] updated; [Name] NP updated. POA, [Name] made aware. Pertinent diagnoses included weakness, AFIB (atrial fibrillation), DM2 (diabetes mellitus two), Metabolic encephalopathy and unsteadiness on feet. IDT (interdisciplinary team) discussed fall, determined root cause to be resident not having proper footwear on. Care plan updated to have proper footwear on at all times. Also included in the fall investigation is an incident report dated 8/11/25, pain tool dated 8/11/25, fall risk evaluation dated 8/11/25, and SBAR (situation, background, appearance, review and notify) dated 8/11/25, neurological flow sheet started on 8/11/25 at 1710 (5:10 p.m.) a written statement dated 8/11/25 under statement documents was on ground sitted sic (sitting) up when walked in. The employee name is blank and this statement is not signed. The nurses note dated 8/11/25 at 17:35 (5:35 p.m.) and R1's at risk for falls care plan initiated 7/25/25 & revised 7/28/25.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate what prior interventions were in place at the time of R1's fall and whether these interventions continue to be effective. Additionally, the facility did not address R1 self transferring and none of R1's care plans address R1 self transferring.R1's fall risk evaluation dated 8/11/25 has a score of 9. A total score of 10 or greater is high risk for falls.R1's nurses note dated 8/19/25, at 11:04 a.m., documents Resident found on floor on his buttock in front of the toilet. Resident tried to self transfer to the toilet. Vitals 79/52, 121, 97.6%, 98.9, 16. Resident able to move all extremities and denies any new pain. Resident was sent to [Name] Hospital due to several low b/p (blood pressure), increased confusion and weakness.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 8/19/25 prepared by RN/UM-H. The summary of alleged incident documents Resident found on floor on his buttock in front of the toilet. Resident tried to self transfer to the toilet. Vitals 79/52 121, 976% sic (97%), 98.9, 16. Resident hypotensive. Resident able to move all extremities and denies any new pain. Neuro check performed. Resident assisted back into bed via hoyer lift. [Name] NP notified. Resident's POA, [Name] notified. Resident to be sent to [hospital initials] per NP for further evaluation. Pertinent diagnoses include weakness, AFib, DM2, Metabolic encephalopathy and unsteadiness on feet. IDT discussed fall, determined root cause to be resident not calling for assistance. Care plan updated to have call before you fall sign placed in bathroom. Also included in the facility's fall investigation is an incident report dated 8/19/25, fall risk evaluation dated 8/19/25, SBAR communication form dated 8/19/25, pain tool dated 8/19/25, neurological flow sheet starting on 8/19/25 at 0800 (8:00 a.m.), R1's progress notes 8/19/25 at 10:07 a.m. through 8/21/25 at 14:23 (2:23 p.m.), and R1's at risk for falls care plan initiated 7/25/25 & revised 7/28/25. The facility reported R1's fall on 8/19/25 with a fracture to the State agency. Included in the facility's investigation included staff interviews for the following questions: Resident was admitted to the hospital with a pelvic fracture. What can you tell us about this? What is the care routine like for [R1's first name]? Does [R1's first name] use his call light to make needs known? Is there anything else you would like to share with us regarding [R1's first name]? Surveyor noted 8 of 10 staff statements indicate R1's self transfers.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate who last observed R1, what was R1 doing, when was R1 last toileted, were prior interventions in place at the time of R1's fall and whether these interventions continue to be effective. In addition the facility did not address R1 self transferring and none of R1's care plans address R1 self transferring. R1's fall risk evaluation dated 8/19/25 has a score of 16. A total score of 10 or greater is high risk for falls.R1's nurses note dated 8/20/25, at 8:46 a.m., written by Registered Nurse/Unit Manager (RN/UM)-H documents Contacted [hospital initials] and spoke to [Name] RN. Dx (diagnosis): Pelvic facture. R1 was readmitted to the facility on [DATE].R1's hospital discharge summary for date of discharge 8/28/25 for Reason for hospitalization documents Unwitnessed fall. Under Discharge diagnoses includes documentation of L (left) ischiopubic ramus facture 2/2 (secondary to) fall and LC 1 injury to left hemipelvis 2/2 fall.R1's nurses note dated 8/31/25, at 01:13 (1:13 a.m.) written by LPN-F documents At 0025 (12:25 a.m.) writer and CNA heard the room door of [room number] close loudly. CNA went to check immediately and found resident laying on his back in the bathroom doorway. Resident had pulled his brief off prior to going to bathroom and urine was noted on the floor in center of room. Resident has used w/c to navigate to the bathroom door. W/C was outside the bathroom, facing into his room. Resident was barefoot. RN was called to assess resident. ROM (range of motion) WNL (within normal limits). Neuro check negative. No bumps or bruises noted. Resident alert. Forgetful. Did not put call light on. Urinal was in reach of bed as call light was also in reach on bed. Vitals taken at 0025 150/90 98.0 - 101 - 18 94%. Resident was hoyered into bed with 3 assist. Reminded to call for assistance or use urinal or to get up. Will continue neuro checks as facility protocol.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 8/31/25 prepared by Director of Nursing (DON)-B. The summary of alleged incident documents A door was heard slamming in resident's room. CNA went to room and found resident on the floor, laying on his back in the doorway of his bathroom. Resident stated he slipped and fell. Resident had removed his brief, and urine was on the floor. Call light was not in use. RN assessed resident. ROM (range of motion) WNL (within normal limits). Neuro check negative. Vitals stable. Resident assisted off the floor via hoyer lift. [Name] PA (physician assistant) updated via HUCU. Resident's POA [name] updated. Diagnoses include cerebral infarction, DM2, metabolic encephalopathy, fracture of L (left) pubis, syncope, falls, anemia, and CKD (chronic kidney disease). IDT discussed fall. Root cause determined resident self-transferring to bathroom without calling for assistance, related to cognitive deficits. New intervention to offer toileting with every interaction. Also included in the facility's fall investigation is an incident report dated 8/31/25, fall risk evaluation dated 8/31/25, e-interact change in condition evaluation dated 8/31/25, pain tool dated 8/31/25, R1's progress notes dated 8/31/25 at 01:13 (1:13 a.m.) and 01:18 (1:18 a.m.) and R1's at risk for falls care plan initiated 7/25/25 & revised 8/31/25.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate who last observed R1, what was R1 doing, when was R1 last toileted, and were prior interventions in place at the time of R1's fall and whether these interventions continue to be effective. There are no staff statements or evidence staff was interviewed regarding R1's fall. In addition the facility did not address R1 self transferring and none of R1's care plans address R1 self transferring. R1's fall risk evaluation dated 8/31/25 has a score of 11. A total score of 10 or greater is high risk for falls.On 9/3/25, at 3:32 p.m., Surveyor observed R1 sitting on the edge of the bed. Surveyor observed R1 is not wearing gripper socks and has bare feet. Surveyor observed Certified Nursing Assistant (CNA)-J enter R1's room and ask R1 about a shower. Surveyor observed CNA-J did not offer toileting to R1 according to R1's plan of care. On 9/3/25, at 3:35 p.m., Surveyor asked CNA-J about R1's toileting and if they ask R1 if he needs to use the bathroom. CNA-J replied no and explained R1 will call staff. CNA-J informed Surveyor R1 has an urinal at his bed so will only call when he has to have a BM (bowel movement).On 9/4/25, at 8:19 a.m., Surveyor observed R1's Visual/Bedside Kardex report as of 8/22/25 located inside R1's closet. Surveyor noted this kardex does not include the fall intervention to offer resident assistance with using the toilet with every interaction which was initiated on 8/31/25.On 9/4/25, at 12:08 p.m., Surveyor asked CNA-E when she goes in R1's room does she have to offer to toilet R1 or does he ask. CNA-E informed Surveyor this is the first day working with R1. CNA-E informed Surveyor R1 is incontinent but will say when he wants to be on the toilet.On 9/4/25, at 2:19 p.m., Surveyor met with LPN/UM-I to discuss R1's falls. LPN/UM-I informed Surveyor R1's first two falls occurred while R1 resided on the rehab unit. Surveyor inquired who Surveyor should speak with. LPN/UM-I replied name of RN/UM-H. Surveyor asked LPN/UM-I if she investigated R1's fall on 8/31/25. LPN/UM-I informed Surveyor name of DON-B investigated this fall.On 9/4/25, at 3:20 p.m., Surveyor interviewed RN/UM-H. RN/UM-H explained when a resident falls the nurse on the unit will check for injury, neuro checks are done, notify the provider, notify the family if there is a POA or if the resident is their own person will ask if they want the family contacted. The resident is transferred to bed with a hoyer. There is on going monitoring, vital signs, pain assessment and the care plan is updated with the latest intervention. Surveyor asked RN/UM-H if there is a fall investigation. RN/UM-H replied I do that. RN/UM-H explained she asked staff what happened, what was the resident doing, did they call for help. RN/UM-H informed Surveyor they try to figure out what happened and add an intervention. Surveyor asked RN/UM-H if their investigation includes staff statements. RN/UM-H replied we do, a lot of falls have statements. RN/UM-H informed Surveyor night shift is pretty good as she's not here. Surveyor asked RN/UM-H what happens to the staff statements. RN/UM-H informed Surveyor they are added to the incident report. Surveyor asked RN/UM-H what happens with her fall investigation. RN/UM-H informed Surveyor she gives the information to DON-B and DON-B and Nursing Home Administrator (NHA)-A review it. Surveyor asked RN/UM-H regarding R1's fall on 8/11/25. RN/UM-H informed Surveyor R1 was getting up frequently without calling staff. RN/UM-H informed Surveyor it looks like R1 didn't have the proper footwear on at the time R1 was attempting to get into bed. Surveyor informed RN/UM-H the investigation does not include who last saw R1 what was R1 doing and if prior interventions were in place. Surveyor informed RN/UM-H staff was aware R1 had self transferred onto the toilet but there is no evidence R1's self transferring was addressed. Surveyor inquired regarding R1's fall on 8/19/25. RN/UM-H informed Surveyor they were concerned with R1's mobility and stated we just knew something was wrong. Surveyor asked RN/UM-H after R1 was transferred to the hospital asked if there were any staff statements or was staff interviewed. RN/UM-H replied I don't believe for that one. Surveyor informed RN/UM-H Surveyor has the same concerns as R1's fall on 8/11/25. Surveyor informed RN/UM-H there is no evidence staff was spoken to as to what was R1 doing prior to the fall, when was R1 last observed, when was R1 last toileted so R1 wouldn't attempt to self transfer. Surveyor informed RN/UM-H the facility still had not addressed R1's self transferring.On 9/8/25, at 9:54 a.m., Surveyor met with DON-B. Surveyor inquired about staff statements. DON-B informed Surveyor they do not obtain staff statements. Surveyor asked DON-B if there is ever a time they would get staff statements or interview staff regarding a resident's fall. DON-B informed Surveyor if there is an unknown or vague documentation they would get staff statements. DON-B informed Surveyor for R1's fall with fracture on 8/19/25 they obtained staff statements. Surveyor informed DON-B the fall investigation she completed for R1's fall on 8/31/25 does not address who last saw R1, what was R1 doing, when was R1 last toileted, were prior intervention in place and were these interventions effective. Surveyor informed DON-B the facility did not address R1's self transferring and R1's care plans do not address self transferring. DON-B informed Surveyor she has never addressed self transferring in a care plan. Surveyor asked DON-B if there is anything Surveyor should review. DON-B replied nope.No additional information was provided. 2.) R3 was admitted to the facility on [DATE] with diagnoses which include hemiplegia (paralysis on one side of the body) and hemiparesis (weakness one one side) following cerebral infarction (type of stroke) affecting right dominate side, diabetes mellitus (high blood sugar), chronic kidney disease (kidneys are damaged and cannot filter blood and waste effectively), , aphasia (language disorder that affects a persons ability to communicate), and dysphagia (difficulty swallowing). R3's power of attorney for healthcare was activated on 5/6/25.R3's hospital Discharge summary dated [DATE] under admission diagnoses documents fall.R3's at risk for falls care plan initiated 6/12/25 and revised 8/26/25 documents the following interventions: Anticipate and meet the resident's needs, initiated 6/12/25. 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 6/12/25. Follow facility fall protocol, initiated 6/12/25. PT/OT (physical therapy/occupational therapy) evaluate and treat as ordered or PRN (as needed), initiated 6/12/25. Soft touch call light in place, initiated 6/26/25. Offer resident to eat meals by the nurses station per her preference, initiated 7/7/25 & revised 8/18/25. Offer the resident assistance to go to bed after dinner, initiated 7/14/25. Encourage resident to participate in activities and spend time in common areas while up in her wheelchair, initiated 8/2/25. Bed in lowest position while resident is in it, initiated 8/4/25. Encourage resident to rest in bed or take a nap after lunch, initiated 8/21/25. Dycem in wheelchair, initiated 8/26/25.R3's admission MDS (minimum data set) with an assessment reference date of 6/18/25 has a BIMS (brief interview mental status) score of 0 which indicates severe cognitive impairment. R3 is assessed as being dependent for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R3 is assessed as requiring substantial/maximal assistance for rolling left and right. R3 is frequently incontinent of urine and always incontinent of bowel. R3 fell one month prior to admission and has not fallen since admission. R3's Fall CAA dated 6/23/25 under analysis of finding for nature of the problem/condition is blank. Under care plan considerations for describe impact of this problem/need on the resident and your rationale for care plan decision documents CAA triggered for falls due to risk factors resulting from Balance problems: Not steady, only able to stabilize with human assistance for moving from seated to standing position, moving on and off toilet and surface-to-surface transfer; [R3's first name] has had a CVA (cerebrovascular accident) with right side flaccid. Resident admitted to facility with fall history. Resident has had no falls 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, Resident receives physician ordered physical and occupational therapy services. No referrals at this time, will proceed to care plan with goal to have no fall related injuries.R3's fall risk evaluation dated 6/11/25 & 6/30/25 has a score of 9. A total score of 10 or greater, the resident should be considered high risk.R3's nurses note date 6/26/25 at 7:49 a.m. created on 7/1/25 at 9:50 a.m. written by Registered Nurse/Unit Manager (RN/UM)-H documents: Patient found laying on floor next to bed by CNA (Certified Nursing Assistant) and called writer to room. Resident stated I crawled out of bed to go to the bathroom. Patient assessed, no injury noted, VSS (vital signs stable), no c/o (complaint of) pain/discomfort, patient transferred back into bed with hoyer lift. Neuro checks performed. [Name] NP (Nurse Practitioner) notified. Resident's POA (power of attorney) [Name] notified.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 6/26/25 prepared by RN/UM-H. The summary of alleged incident documents Patient found laying on floor next to bed by CNA and called writer to room. Resident stated I crawled out of bed to go to the bathroom. Patient assessed, no injury noted, VSS, no c/o pain/discomfort, patient transferred back into bed with hoyer lift. Neuro checks performed. [Name] NP notified. Resident's POA, [Name] notified. Pertinent diagnoses include weakness, DM, unsteadiness on feet, repeated falls and history of CVA. IDT (interdisciplinary team) discussed fall, determined root cause to be resident not calling for assistance. Care plan updated to have soft touch call light in place. Also included in the facility's fall investigation is an incident report dated 6/26/25, SBAR (situation, background, appearance, review and notify) dated 6/26/25, pain tool dated 6/26/25, fall risk evaluation dated 6/26/25, neurological flow sheet starting on 6/26/25 at 0715 (7:15 a.m.), R3's progress notes dated 6/26/25 at 07:15 (7:15 a.m.), 07:49 (7:49 a.m.) & 7:26 p.m., and R3's at risk for falls care plan initiated & revised 6/12/25.Surveyor noted the facility did not conduct a thorough investigation as the facility did not investigate who last observed R3, what was R3 doing, how was R3 positioned in bed, when was R3 last toileted, and were prior interventions in place at the time of R3's fall and whether these interventions continue to be effective.R3's nurses note dated 7/7/25 at 18:30 (6:30 p.m.) created on 8/21/25 by Licensed Practical Nurse/Unit Manager (LPN/UM)-I documents Resident had an unwitnessed fall in the dining room after dinner, discovered by housekeeping. She sustained a minor forehead laceration and bruising near the right eye but denied hitting her head. No other injuries noted; vitals and neuro checks were WNL (within normal limits). EMS (emergency medical services) transported resident to [Name] Hospital. POA (power of attorney), on call NP, and Unit Manager notified. Care plan updated for meals with nurses station per resident preference.Surveyor reviewed the facility's fall investigation which included an investigative report for date of incident of 7/7/25 prepared by LPN/UM-I The summary of alleged incident documents Resident experienced an unwitnessed fall in the dining room following dinner. She was discovered on the floor by housekeeping staff. On assessment, resident had a minor laceration to the right forehead and mild bruising with minimal bleeding noted at the corner of her right eye. Resident reported, I was trying to pick up my hearing aide and I was sliding, then I fell. She denied striking her head. Further assessment revealed no additional injuries to the head or body. Vital signs were obtained and neurological checks were initiated, all within normal limits. EMS was contacted and the resident was transferred to [Name] Hospital for further evaluation. The POA, on-call NP, and Unit Manager were notified. Pertinent diagnoses include: Hemiplegia and Hemiparesis following cerebral infarction affecting right dominate side, muscle weakness (generalized); polyarthritis, unspecified; repeated falls; spondylosis without myelopathy, lumbar region; strain of unspecified muscle; fascia and tendon at shoulder and upper arm level, right arm; type 2 diabetes mellitus; unspecified fall; unsteadiness on feet; vitamin D deficiency. The IDT reviewed the incident and determined that the fall occurred when the resident attempted to reach down to retrieve her hearing aid, causing her to slip from her wheelchair. The care plan was updated with: meals near nurses' station per resident preference. Also included in the facility's fall investigation is an in[TRUNCATED]

Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, the facility did not report 1 of 2 allegations reviewed for neglect/mistreatment to the State Survey Agency during the required timeframe.R2's daughter sent an email to the Nursing Home Administrator regarding a concern of mistreatment and neglect towards R1. This was delayed in being reported to the state agency.Findings include:The Facility Policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last reviewed 11/8/23, documents (in part): G. Reporting and ResponseAbuse Policy Requirements:It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Executive Director of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility.R2 was admitted to the facility on [DATE] with pertinent diagnoses that include hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side (a serious neurological condition characterized by paralysis (hemiplegia) or weakness (hemiparesis) on the left side of the body, with the left hemisphere of the brain being dominant), polyneuropathy (the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged. This condition often causes weakness, numbness and pain, usually in the hands and feet), morbid obesity (a condition in which you have a body mass index (BMI) higher than 35. BMI is used to estimate body fat and can help determine if you are at a healthy body weight for your size), and chronic pain syndrome (a condition characterized by persistent pain that lasts for more than three months).R2's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/8/25, documents a Brief Interview for Mental Status (BIMS) score of 13, indicating R2 is cognitively intact . The MDS documents that R2 was assessed to have no behaviors exhibited during the look back period. R2's Patient Health Questionnaire (PHQ-9) score was 00, indicating no depressive symptoms. R2 is coded as making self understood and understands others. Per the MDS, R2 has an impairment on one side for both the upper and lower extremities. The MDS indicates R2 is frequently incontinent of bladder and always incontinent of bowel.On 9/4/25, at 8:52am, Surveyor interviewed R2 about an aide ever stating they were going to take a picture of R2's bowel movement. R2 stated that the Nursing Home Administrator (NHA)-A had talked to R2 about the incident for about 20 minutes, but NHA-A never asked the name of the aide who stated they would take a picture of R2's bowel movement. On 9/4/25, at 10:45am, Surveyor interviewed complainant who stated that on 8/31/25, R2 called and stated an aide had wanted to take a picture of R2's bowel movement. The complainant then emailed NHA-A immediately to alert of the situation. The aide was identified to Surveyor. The email that was sent to NHA-A was forwarded to Surveyor with the time stamp of Sent: Sunday, August 31, 2025 7:41pm.On 9/4/25, at 12:03pm, Surveyor interviewed Nurse Supervisor-O who stated when R1 or their daughter have a concern NHA-A talks to staff about it.On 9/8/25, at 8:08am, Surveyor interviewed NHA-A and was told a self-report was filed with the state agency. It is being actively investigated, and the investigation is due tomorrow. A copy of the Division of Quality Assurance form F-62617 was provided.Surveyor noted that the email notification indicated being sent on 8/31/25, at 7:41pm. The self report form F-62617, documented the date that the incident was discovered as 9/2/25. Surveyor noted that NHA-A had previously being informed of the incident on August 31, 2025 via email, but the facility did not report the incident then to the state agency. On 9/8/25, at 9:34am, Surveyor followed up with NHA-A regarding the process when an allegation comes in over a weekend or Holiday. NHA-A stated a normal allegation would be reported to the nurse who then notifies the nurse manager. The nurse manager then reports concerns to the NHA-A. Surveyor asked if an email was sent on 8/31/25, why the delay in reporting until 9/2/25. NHA-A responded that they did not receive the email until Tuesday due to the holiday and that is when they responded and filed the self report. Surveyor asked if anyone else scans emails for time sensitive emails and was told no one else does. If it had been a time sensitive issue NHA-A stated they should have called a manager on duty. Surveyor noted during interview with NHA-A it was shared that R2 and the Complainant have a preference for direct communication with NHA-A. NHA-A informed Surveyor that an assistant NHA has been hired and that NHA-A tried to have this person be the contact, but that did not work out, so NHA-A has remained the primary contact for R2. NHA-A even puts it on the calendar to attend the quarterly care conferences to keep up communication with R2. On 9/8/25, at 10:50am, Surveyor informed NHA-A of the concern that there needs to be a process in place for allegations that come in over the weekend or holiday to be addressed timely and reported within the designated time frames. pNo additional information was provided as to why R2's allegation of mistreatment and neglect was delayed in being reported to the State Agency.

Based on interviews and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 2 (R1 and R2) residents reviewed for accidents. R1 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. CNA's transferred the resident with 2-person pivot. R1 sustained a leg fracture.R2 was care planned to transfer with a sit to stand mechanical lift and assist of 2 staff. The CNA transferred the resident alone. R2 sustained a fall from the sit to stand resulting in a head laceration requiring staples.Findings include:R1 admitted to the facility on [DATE] and entered onto Hospice [DATE]. Diagnoses included Atrial Fibrillation, Heart Failure, Peripheral Vascular Disease, Dementia, anxiety, Osteoporosis and Pulmonary Hypertension. R1 passed away at the facility on [DATE].R1's Care Plan documented: The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) activity intolerance, limited mobility - initiated [DATE]. Interventions include: Transfer: The resident requires Mechanical Lift sit to stand with 2 staff assist for transfers, May use Hoyer lift as needed when resident not tolerating the sit to stand lift - initiated [DATE] revised [DATE]. The facility does not have a policy and procedure specific to mechanical lifts. Surveyor was provided the facility policy and procedure with the subject Safe Individual Handling Program which documents (in part) A. Transfer assessment1. Individuals will be assessed according to ability per transfer and movement objective criteria. Nursing will perform this assessment in collaboration with therapy as applicable.2. Once the assessment is completed, the appropriate transfer status will be determined.B. Care Plan1. Individual-specific transfer status will be addressed on the Care Plan to include specific equipment type if applicable.2. All staff to transfer according to the Care Plan unless it is determined by the Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Certified Nursing Assistant (CNA) at the time that the transfer is not a safe transfer for either the individual or the staff member. On [DATE] at 9:42 PM, R1's progress notes included an Einteract change in condition (CIC) form completed by Licensed Practical Nurse (LPN)-G which documented: New or Worsening Pain. Nursing observations, evaluation, and recommendations are: When resident being transferred to bed. She stated that she was having pain in her left ankle from the transfer. Residents' bilateral ankles and feet are swollen 4+ pitting edema. No redness or bruising noted to the left ankle. On [DATE] at 12:06 AM, LPN-H documented: C/O (complained of) increased pain to left ankle / foot. Left ankle, foot appears swollen red pain to touch. Resident requested to go to the hospital. PRN (as needed) Morphine administered resident appears anxious update PRN Lorazepam administered. (Hospice) called at midnight requesting X-ray to left ankle left arm. Awaiting call back. On [DATE] at 12:19 AM, Hospice nurse out to evaluate resident.On [DATE] at 2:52 AM, Hospice Registered Nurse (RN)-I documented: Received a call stating that (LPN-H) called to report that pt (patient) is calling out in pain. States that pt said that she was pivot transferred into bed and her ankle hurts. Call placed to (LPN-H) who states per pt was pivot transferred to bed and is complaining of L (left) ankle pain and pt want to go to the hospital. (LPN-H) is requesting an X-ray. Writer will visit and assess pain. Arrived to pt room, pt moaning. Writer, I talked with pt and asked pt where her pain was and she stated, all over. Pt has L shoulder pain which is chronic. Upon assessment pt LLE (left lower extremity) swollenness 4+ pitting edema Knee to foot. L ankle pain when touched. L calf to ankle red hot to touch. Pt with 4+ pitting edema LLE. RLE (right lower extremity) 2+ pitting edema. Slight redness noted to inner side of calf near ankle. Pictures sent to (Physician). Orders received for Cephalexin 500 mg (milligrams) BID (twice daily) x 7 days. Pt was given morphine 10 mg x 2 and lorazepam 0.5 mg x1. Pt comfortable and sleeping at end of visit.On [DATE] at 10:59 AM, Surveyor spoke with Hospice Nurse-I who reported she spoke to the Physician and sent pictures. Hospice Nurse-I stated, It appeared to look like cellulitis, so he ordered an antibiotic. Surveyor confirmed with Hospice Nurse-I that she was aware the resident was pivot transferred into bed and complained of pain after. Surveyor asked if she notified the Physician. Hospice RN-I stated she did not recall if she notified the Physician that R1 was transferred incorrectly by pivot instead of the sit to stand and was complaining of pain after. Surveyor located no evidence the Physician was notified. On [DATE] at 7:51 AM, progress notes document: Resident has c/o pain to the left leg and foot, rating it 10/10. Slightly relived by MSO4 (Morphine). Resident screaming upon staff gently moving her leg. Writer placed a call to (Hospice) and received orders for a X-ray. On [DATE] at 8:46, Biotech here to do X-rays. On [DATE] at 9:40 AM, RN Hospice here to see this resident. Resident continues to c/o pain, stating that it is not cellulitis pain it is something different and more painful. MSO4 given at 9:05 AM and resident currently resting. RN is alerting family.On [DATE] at 10:31 AM, X-ray reveal acute distal tibia fracture. Ortho evaluation recommended. RN will contact (family) to see if she would like this resident to be hospitalized . Resident currently sleeping and appears comfortable. The Radiology Results Report dated [DATE] documents (in part) Clinical information: Pain in foot and leg. Was transfer by standing and not stood in 3-4 years. Test procedure: Left tibia and Fibula, Two views. Findings/Discussion: Acute spiral nondisplaced distal tibial fracture is identified. R1 was transferred to the hospital and returned the same day. R1 declined surgical intervention and returned with a splint on left lower extremity. On [DATE] at 10:50 AM, Surveyor spoke with Family Member-M who reported the prior Thursday ([DATE]) R1 was having wheelchair races with her roommate and by Sunday ([DATE]) she was in crisis pain because I was told she was transferred using a pivot instead of the stand-up lift.Surveyor review of progress notes prior to the incident were uneventful, no adverse events were documented. R1's meal consumption from 5/27-[DATE] documented R1 consumed 75-100% of all meals. On [DATE] (the day after the incident/when the fracture was identified) R1 had significant decline. She refused meals on [DATE], ate 0-25% x 2, and 25-50% x 1 on [DATE], refused all meals on 6/3 and 6/4, and passed away on [DATE]. Surveyor reviewed the Facility Self Report investigation. The investigation summary documents Resident care plan was reviewed, and all assigned interventions were in place. The facility cannot reasonably conclude how the fracture happened. Possible sources are old age of 98, resident transfer, self-propelling and repositioning. Surveyor noted the investigation was not thorough. The investigation included no information regarding staff using pivot transfer versus the stand-up lift as care planned. LPN-G's statement obtained by Nursing Home Administrator (NHA)-A documented: I worked PM 5/31. Don't remember any issues during the shift although Surveyor noted LPN-G completed the CIC form on [DATE] after the incident. CNA-F's statement obtained by Nursing Home Administrator (NHA)-A documented: We transferred her together on PM's. Nothing else to share. We are new and normally work upstairs so we don't know the resident as well as the regular staff.On [DATE] Surveyor spoke with NHA-A and asked if he was aware that staff did not follow the care plan and transferred R1 using a pivot, versus the stand-up lift resulting in R1's leg fracture. NHA-A stated, I don't know if it was ever actually determined to be the case. Surveyor asked NHA-A when he interviewed the CNA's involved, did he ask them how the resident was transferred. NHA-A stated, I don't recall that I specifically asked that question. Surveyor advised NHA-A of progress notes documenting R1 was transferred via pivot, complained of pain immediately after and X-ray results confirmed a spiral fracture of her tibia. Surveyor asked if he investigated the fact that staff did not follow the care plan and R1 was improperly transferred. NHA-A stated, Again, I don't recall specifically asking that question.On [DATE] at 12:25 PM, Surveyor spoke with Hospice RN-J. Hospice RN-J reported she was aware R1 was transferred with pivot versus the stand-up lift. Hospice RN-J stated, Staff at the facility were talking about it and I heard them. Hospice RN-J was unable to provide names of staff but heard many staff talking about how they broke her leg because they transferred her with pivot instead of the EZ stand. Surveyor asked if she felt the fracture contributed to R1's decline. Hospice RN-J stated, Absolutely. She was doing really well before, eating, wheeling around, very happy. Literally, the next day she declined, was confused, not eating, and died a few days later. On [DATE] at 3:40 PM, Surveyor spoke with CNA-F (staff member involved in incident) who reported she went in to see if R1 was ready for bed. CNA-F stated, I did look at her care card and I know it said 2-person transfer, but I don't recall if it specifically said stand up lift. CNA-F reported R1 was not ready for bed, so she answered other call lights. When I went back, I remember asking her (R1) how she transferred, she said with 2 people - so we put a gait belt on her and pivoted her to bed. CNA-F reported R1's leg buckled and when we got her into bed R1 said I can't do that again. CNA-F stated R1 was complaining of leg pain, so she got the nurse. On [DATE] at 11:00 AM Surveyor spoke with LPN-G (the nurse working [DATE] PM shift at the time of the incident). LPN-G confirmed the CNA reported R1 had pain after transferring her into bed. LPN-G stated, The aides (they were new) said R1 started to complain of pain after they put her to bed with a 2-person transfer, because that's what R1 told them. LPN-G said she told the CNA's R1 was a stand-up lift and confirmed with the CNA's that they transferred her with 2 people. LPN-G reported CNA-F said yes, we pivoted her. LPN-G reported she completed the einteract CIC form and notified Hospice and the on-call supervisor, RN-D. Surveyor asked LPN-G if she notified RN-D that R1 was transferred incorrectly using a pivot and was complaining of pain. LPN-G stated Yes. Surveyor asked about her statement obtained by NHA-A on 6/2 that documented, I worked PM 5/31. Don't remember any issues during the shift. LPN-G informed Surveyor she did not provide any statements to NHA-A or anyone else and that no-one talked to her about the incident after it happened. On [DATE] at 11:27 AM, Surveyor spoke with RN-D who confirmed she did receive a call on [DATE] that R1 was complaining of pain after being transferred to bed and she told the nurse to call Hospice. RN-D reported she did not recall if the nurse told her R1 was transferred with pivot and not the stand-up lift as care planned. Surveyor reviewed the staff sign in sheet titled Safe resident transfers dated [DATE] which was included in the facility investigation packet. Surveyor noted only 13 of 72 CNA's names on the sign in sheet as having received the training. On [DATE] at 10:17 AM, Surveyor spoke with Deputy Medical Examiner (ME)-L. Deputy MD-L stated, I got a call from the hospice nurse, and she told me about her death and the spiral fracture that occurred after she was improperly transferred and went quickly downhill after that. Surveyor asked what does the death certificate list as cause of death: Complications of spiral fracture of left tibia. Manner of death: Accident. Injury Description: Staff-assisted pivot transfer into bed. On [DATE] at approximately 3:00 PM, the facility was notified of concern that R1's care plan was not followed. R1's care plan indicated she was to transfer with stand-up lift and 2 staff assist. On [DATE], PM CNAs assisted R1 to bed using a 2-person pivot transfer. R1's leg buckled, and she immediately complained of pain. X-ray results were positive for a spiral tibia fracture. The facility investigation was not thorough, as there was no information or documentation related to the improper transfer and not following the care plan. R1 significantly declined following the incident and passed away 4 days later. The facility provided no additional information. 2) R2 was admitted to the facility on [DATE] with diagnoses that include, Alzheimer's disease, dementia, arthritis, spinal stenosis, osteoporosis, muscle weakness, paraplegia and anxiety disorder. R2's annual Minimum Data Set (MDS) assessment, dated [DATE], documents R2 has a Brief Interview of Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. A Patient Health Questionnaire (PHQ-9) score of 0, indicating no depressive symptoms, and no indicators of psychosis including no hallucinations or delusions. R2 is assessed to require substantial/maximal assistance for transfers from chair to bed. R2's Care Area Assessment (CAA) documents, R2 is triggered for falls due to use of antidepressants. Risk factors: incontinence, paraplegia, visual, hearing, cognition, and anxiety. R2's Care Plan, date initiated [DATE], documents, Focus: R2 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness, pain, dementia. Interventions include, R2 requires sit to stand lift with 2 staff assistance for transfers; date revised [DATE]. R2's CNA (Certified Nursing Assistant) Kardex dated [DATE], documents, Transfer: requires sit to stand lift with 2 staff assistance for transfers. R2's Progress Note, dated [DATE] at 19:13 (7:13 PM), documents, Note Text: The CNA reported to the floor nurse that the resident fell while using the sit to stand lift, striking the back of her head and briefly losing consciousness. Due to active bleeding, 911 was called, and the resident was transferred to [Hospital]. The POA (Power of Attorney], on-call manager, DON (Director of Nursing) and [On call Physician Group] were all notified. R2's Progress Note, dated [DATE] at 21:17 (9:17 PM), documents, NP (Nurse Practitioner) notified, pt (patient) sent to hospital post fall. Patient POA (Power of Attorney) notified of pt post fall. R2's Hospital emergency room summary, dated [DATE], documents, .Scalp: 2 cm (centimeter) laceration to the back of R2's head, bleeding was controlled prior to arrival. Significant amount of dried blood. Face: Abrasion to left temple, no bleeding. Left Upper Extremity: Multiple ecchymosis around the elbow.CT head: No acute findings or interval change intracranially. New small right posterolateral scalp, laceration/hematoma without skull fracture.Diagnosis: Laceration. Imaging of head and neck were negative for trauma. Laceration was repaired with 2 staples. R2's Physician orders, start date, [DATE], Laceration care to the right side of the skull, gently wash with NS (Normal Saline) to keep clean, end date [DATE]. R2's Physician orders, start date, [DATE], Monitor for S/S (Signs and Symptoms) of concussion: HA (headache) and the severity, change in mentation or behavioral changes. Chart in progress notes, end date, [DATE]. R2's Physician orders, start date, [DATE], may use ice pack to right back of head for pain relief, end date [DATE]. R2's Progress Note, dated [DATE] at 00:17 ( 12:17 AM) documents, Resident returned at approx (approximately) midnight. She had 2 staples placed to the laceration on the back of her head. AMS (Altered Mental Status) is at her baseline. Resident denies pain. Surveyor reviewed the facility's Alleged Nursing Home Resident Mistreatment, Neglect and Abuse Report, dated [DATE] and completed by Nursing Home Administrator (NHA)-A, which documents . Allegation Type: Injury of unknown source: Injury was not observed and is suspicious because of extent or location. Brief Summary: Resident is not her own person. Resident had a fall over the weekend and went to the hospital with a laceration to her head. Resident has now admitted back to the facility with 2 staples in her head as a treatment for the laceration. Full investigation underway. Self-reporting as a fall with major injury. The facility Misconduct Incident Report, dated [DATE], included a summary completed by NHA-A, which documents, .Certified Nursing Assistant (CNA)-R noted that during resident transfer, around 7:30 PM, resident slipped out of the sling and she fell to the ground. CNA-R then grabbed RN-S and CNA-E. R2 was transferred to the ER (Emergency Room) and returned to the facility with two stitches/staples. Aide was following care plan and process, no issues. This was an accident. Surveyor notes, care plan was not followed as the care plan documents, R2 requires sit to stand lift with 2 staff assistance for transfers and only 1 CNA was assisting R2 when she slid from the sit to stand mechanical lift. The facility Investigation Report dated [DATE], and completed by Licensed Practical Nurse (LPN) Supervisor-N, documents Summary of Alleged Incident: R2 witnessed fall on [DATE]. The resident's CNA (Certified Nursing Assistant) reported to the floor nurse that the resident experienced a fall while using the sit-to-stand lift during a transfer from a sitting to standing position. During the fall, the resident struck the back of her head on the ground and briefly lost consciousness but quickly regained awareness. Due to visible bleeding from the occipital area, staff made the decision not to move the resident and immediately called 9-1-1. The resident was unable to recall the incident. EMS (Emergency Medical Services) responded promptly, and the resident was transferred to [Hospital] for evaluation. The resident's family, on-call manager, Director of Nursing, and [on call physician group] were all notified and updated accordingly. Following her return from the Emergency Room, the resident was noted to have received two staples to the back of her head. She was placed on a 24-hour observation board with neuro (neurological) checks initiated per protocol. Pertinent diagnoses include age-related Osteoporosis; Alzheimer's Disease; Dementia in Other Diseases; Paraplegia, Spinal Stenosis. The IDT (Interdisciplinary Team) reviewed the fall and determined that the root cause was the resident losing her balance during a transfer, likely due to her underlying diagnosis. The care plan was updated with PT/OT (Physical Therapy/Occupational Therapy) to evaluate and treat for transfers. CNA-R completed a Written Statement dated [DATE], which documents, I went into R2's room to put her into bed around 7 PM 06/06. I put her on the sit to stand and was about to put her into bed but she slipped out of the sling. She hit the floor, I tried to call her name but I got no response. I went get a nurse and she called 911. I was not aware that I needed a second person with a sit to stand. On [DATE], Surveyor interviewed R2, who stated she just cannot remember what happened when she fell. R2 stated she feels safe at the facility, and no one has ever hurt her. On [DATE] at 11:12 AM, Surveyor interviewed DON-B, who stated, R2 was a sit to stand lift with assist of 2 prior to fall on [DATE]. DON-B stated, R2's fall occurred because her legs gave out and she slid out of the sling and out of lift. R2 was getting ready for bed with CNA-R. DON-B stated, Therapy reassessed R2 after the fall and determined R2 did not have the strength for a sit to stand lift and now uses a Hoyer lift. On [DATE] at 2:12 PM, Surveyor interviewed DON-B who when asked about how the CNA's know what sling size to use for each resident who uses a sit to stand and DON-B stated, there are charts on each unit by the linen carts that goes by weight of resident. Surveyor asked if sling sizes are on the Kardex for the CNA's and DON-B stated, no we have not put the sling sizes on the Kardex. Surveyor asked DON-B if the sling size is charted anywhere for the CNA's and DON-B stated, no. Surveyor asked DON-B what the expectation of a CNA before a resident is transferred and DON-B stated, Typically, there is a sling in each resident's room that uses a sit to stand lift. The slings are not labeled per resident, but each resident should have their own sling. DON-B stated, if there is not a sling in the resident's room, the CNA will check the weight chart for the appropriate size. Surveyor asked DON-B if there has been any training post fall on [DATE] regarding how to determine sling size, how to attach sling to sit to stand lift and resident safely and DON- B stated, no. On [DATE] at 2:22 PM, Surveyor interviewed CNA-E, who also works as the Scheduler and Transfer Mobility Coach. Surveyor asked CNA-E what she recalls from the evening of R2's fall on [DATE]. CNA-E stated that CNA-R was running past her office in a panic and CNA-E asked CNA-R what was going on. CNA-R told CNA-E, R2 fell, and she needed to find a nurse. CNA-E located both RN-S and RN-U and everyone went to R2's room. CNA-E stated, R2 was lying on the floor, face up. 911 was called and together, the RN-U and RN- S did a complete assessment. RN-S asked R2 what happened, and R2 could not recall. RN-S asked CNA-R what happened, and CNA-R, stated R2 slipped out of sit to stand lift and CNA-R was transferring R2 by herself. CNA-E stated, that with the sit to stand being used for R2, it can be an assist of 1. CNA-E stated, R2's Kardex indicates a sit to stand lift but CNA-E did not know if Kardex stated assist of 1 or 2. CNA-E stated she provided CNA-R with an additional 8 hours of orientation, training on mechanical lifts, and lift observations with CNA-R post R2's fall on [DATE]. On [DATE] at 2:35 PM, Surveyor interviewed CNA-R. Surveyor asked CNA-R what she recalls from the evening of R2's fall on [DATE]. CNA-R stated, R2 was being transferred in the sit to stand lift. CNA-R had sling around R2's waist and it was buckled in front. R2 had on non-skid socks on her feet. CNA-R stated, when R2 was in the standing position, R2 became weak and slipped out of the sling. R2's arms went up and the sling went over her head, and she slipped out. CNA-R stated she tried to catch R2 but it happened fast and R2 fell to the floor and hit her head. CNA-R stated she was alone when she did the transfer for R2. CNA-R stated she was aware the Kardex documented R2 required a sit to stand lift and did not remember if the transfer needed a 1 or 2 staff assist or what sling size was needed. On [DATE] at 2:45 PM, Surveyor interviewed CNA-T, who stated, she will generally find sling size on care plan, if not found on care plan, CNA-T goes to Kardex. Surveyor asked CNA-T if she could show an example of a sling size on a Kardex and CNA-T could not find any evidence of sling size on a Kardex. CNA-T stated, there are not slings in each resident's room for a sit to stand lift, only for Hoyer lifts. The slings are in the hallway by the linen carts. Surveyor asked CNA-T if she knew how to determine sling size and CNA-T stated, if she already does not know, she would then ask the nurse. On [DATE] at 9:12 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A, who stated on [DATE], the facility purchased all new sit to stand lifts. NHA-A stated, the manufacturer guidelines say that the new sit to stand lifts can either be an assist of 1 or 2 staff. NHA-A stated, on [DATE], following R1's fall, training occurred for staff that all sit to stand, and Hoyer lifts should be an assist of 2 staff. NHA-A stated, when R2's fall occurred on [DATE], the facility did an audit of each resident using a sit to stand lift to see each resident's care plan is an assist of 1 or 2 staff and if it matches what the CNA is doing. NHA-A stated, facility then determined if it still met the needs of each resident. Surveyor notes, NHA-A did not provide an audit for the completion of each resident using sit to stand and if it matches care plan after request to review all audits. The only audit provided, documents the review of 2 incident reports related to falls and if the care plan was followed. On [DATE], at 10:35 AM, Surveyor interviewed CNA-E (also Scheduler and Transfer Mobility Coach). Surveyor asked CNA-E what how she knows what sling size to use for each resident and CNA-E stated, there should be a sling in the room for each resident, if not, slings are found on each unit. Surveyor asked CNA-E how she know how much to tighten sling belt and CNA-E stated, adjust the sling belt so that the resident would not slip, the belt would hold up. Surveyor asked how CNA-E would determine if a sling would slip off and CNA-E stated, the sling would not be tight enough. CNA-E stated, it is her assumption this is what happened with the fall with R2 on [DATE]. On [DATE], Surveyor interviewed DON-B who stated R2's legs gave out and this is why she slipped out. If a resident lets go of on sit to stand lift, the arms can slouch right through sling. DON-B stated even if the belt is tightened to a resident's body, the resident can still easily slip out when arms are above head when falling. Surveyor notes, CNA-R was unavailable for interview for questioning on use of sling. On [DATE], at 11:20 AM, Surveyor interviewed NHA-A and asked how the facility determined the method of R2's transfer was done correctly on [DATE]. NHA-A stated, it is safe to say that we assumed it was just the care plan not being followed. Surveyor asked, did you investigate why R2 slipped out of the sit to stand, for example, was the correct sling size used or did the CNA know how to properly hook up and adjust the sling, or if there were two CNA's assisting? NHA-A stated, he did not investigate any of these potential factors. Surveyor notified NHA-A of concern regarding an incomplete investigation to determine the root cause of R2's fall. NHA-A acknowledges there were several other factors to investigate. Surveyor notified NHA-A of concerns regarding R2's care plan not being followed which documents assist of 2 and only 1 staff assisted with the sit to stand transfer. That transfer resulted in R2 slipping from the sit to stand, hitting their head and requiring 2 staples in the ER.

Based on interview and record review, the facility did not ensure that residents remain free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (R12) reviewed for accidents. R12 sustained a significant injury to her leg which required surgical intervention. The facility did not complete a thorough investigation as to how the injury occurred. Findings include: R12 admitted to the facility on [DATE] and has diagnoses that include Chronic Kidney Disease, Anemia, Atherosclerotic Heart Disease, PVD (Peripheral Vascular Disease), Hypothyroidism, Vascular Dementia with anxiety, Osteoarthritis and Neuromuscular Dysfunction of bladder. R12's BIMS (Brief Interview For Mental Status) Evaluation dated [DATE] documents a score of 4, indicating severe cognitive impairment. R12's Admission MDS (Minimum Data Set) dated [DATE] documents: Self-Care Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement - Dependent. Mobility: Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed - Dependent. Sit to lying: The ability to move from sitting on side of bed to lying flat on the bed - Dependent. Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support - Dependent. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed - Dependent. Toilet transfer: The ability to get on and off a toilet or commode - Dependent. R12's care plan documents: The resident has potential for impairment to skin integrity r/t (related to) weakness, incontinence, prediabetes, fragile skin, PVD. Actual skin impairment of hematoma that burst to left shin. Resident went out to hospital and received surgical intervention for hematoma - dated [DATE]. Interventions include: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface - initiated [DATE]. Resident to wear tubi grips to BLE (Bilateral Lower Extremities) for protection - initiated [DATE]. The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t weakness, dementia date initiated [DATE]. Interventions include: Bed mobility: Dependent, assist of 1. Toileting: Dependent, assist of 1. Transfer: Sit to stand lift and assist of 2. Dressing/personal hygiene: Dependent, assist of 1. Resident to wear slippers or gripper socks, not shoes. Encourage the resident to use bell to call for assistance. The resident is at risk for falls r/t weakness, dementia, vision impairment, potential medication side effects, incontinence. Interventions: Resident not to be put in room alone when in w/c (wheelchair) dated [DATE]. The resident has impaired cognitive function/dementia or impaired thought processes r/t Dementia initiated [DATE]. Interventions: Anticipate and meet needs. 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. Call before you fall sign placed in room to remind resident to use call light - initiated [DATE]. Posey grip placed under w/c (wheelchair) cushion to prevent slipping - initiated [DATE]. R12's Fall Risk Evaluation dated [DATE] documents a score of 12 - At Risk for falls. R12 sustained 2 prior falls: R12's medical record documents on [DATE], at 2:45 PM: Resident found on bathroom floor by CNA (Certified Nursing Assistant). Resident assessed by nurse. Neuro checks negative ROM (range of motion) WNL (within normal limits). No injuries noted. On [DATE], at 3:25 PM, R12's medical record documents: Called to room by CNA. Upon entering room, resident was observed sitting upright on her buttocks in front of her w/c (wheelchair) on the floor. Daughter of room [room number] was present in room visiting with her mother at time of incident per her statement to this writer. Visitor stated resident was sitting in her w/c in her room and was leaning forward in her w/c. Resident was attempting to self transfer herself into her recliner chair across from her w/c. Resident slid out of her w/c onto the floor landing on her buttocks. Resident did not hit her head. No injury noted. ROM WNL. Denies pain/discomfort. Posey grip placed on top of and underneath w/c cushion to help prevent slipping. On [DATE], at 11:19 AM, Surveyor observed R12 sitting in the common area with her son. R12 was well groomed, wearing socks and slippers and foot pedals were observed on the wheelchair. Surveyor spoke with R12's son who reported R12 bumped her left leg with therapy, adding It was an accident, I don't blame anyone for what happened. She was in the hospital for weeks for the wound on her leg, it took a long time to heal, I think it's pretty much healed now. Surveyor reviewed R12's progress notes entered by LPN (Licensed Practical Nurse)-J which documented: On [DATE], at 1:50 PM, Nurse's Note Text: Called to room by CNA (Certified Nursing Assistant). CNA reported to writer that resident hit her left shin on the sit to stand lift prior to transfer. Some bruising present. Ice applied. Skin is intact. No bleeding noted. On [DATE], at 2:30 PM, Nurse's Note Text: APNP (Advanced Practice Nurse Practitioner) in the building. Notified of resident left shin injury from sit to stand lift prior to transfer. APNP assessed resident. No new orders at this time. Monitor and administer PRN (as needed) Tylenol and Biofreeze as ordered. Call placed (son) POA-HC (Power of Attorney for Health Care). Notified of resident injury to left shin. On [DATE], at 3:55 PM, Nurse's Note Text: F/U (follow up) Left lower shin hematoma: Writer called to room by CNA. Hematoma had ruptured. Blood gushing. Large gash present to left lower shin. Left leg wrapped with towel and pressure applied. 911 emergency services called. On [DATE] APNP note: [R12's], . female with a history of multiple chronic conditions, was seen today in her usual social situation for a routine SNF (Skilled Nursing Facility) follow-up. She was found sitting up in her wheelchair, appearing comfortable without complaints of pain. She states she is doing well and reports her appetite as okay. She denies experiencing cough, shortness of breath, nausea, vomiting, diarrhea, or constipation. However, towards the end of the shift, nursing staff reported that the patient had an injury during a sit-to-stand transfer, resulting in a hematoma on the medial aspect of her left leg, causing significant pain. An ice pack was applied, and Tylenol was administered for pain relief. The nursing staff was instructed to hold Plavix for two days and to notify the patient's family. Subsequently, the hematoma ruptured, and the patient was sent out via 911 for further evaluation and treatment. The Hospital Discharge Summary dated: [DATE] documented: admitted with left leg wound with traumatic laceration with bleeding and large hematoma. S/P (status post) excisional debridement of the left leg wound necrotic skin, subcutaneous fat and fascia 8 cm (centimeters) x 10 cm on [DATE]. Started on wound vac [DATE]. Acute blood loss anemia due to left leg hematoma on top of chronic anemia. She received 2 units PRBC (packed red blood cells) on this admission. The facility Skin & Wound Evaluation dated [DATE] documented the wound healed. Surveyor asked for the facility investigation involving the injury to R12's leg. Surveyor was provided the Facility Investigation Report dated [DATE] which documented: Summary of alleged incident: Injury of known cause [DATE], 1:50 PM. CNA alerted nurse that resident had hit her left shin on sit to stand lift and developed a bruise that then became a hematoma. RN (Registered Nurse) assessed resident and noted bruise at that time. Later developed to a hematoma to left shin. Resident c/o (complained of) pain. PRN Tylenol given and ice pack applied. APNP in house and aware. Resident's POA notified. Pertinent diagnoses include Peripheral Vascular Disease and Vascular Dementia with anxiety. IDT (Interdisciplinary Team) discussed. Determined root cause to be resident moved leg and bumped on sit to stand machine. Care plan updated to have resident wear tubi grips to BLE (bilateral lower extremities) for protection. Nursing description: CNA notified writer and floor nurse that resident had hit her left shin on the sit to stand lift prior to transfer and that there was a bruise. Bruise was originally noted to left shin. Ten minutes later a large hematoma was present to LLE (left lower extremity). Resident also stated that her leg bumped the sit to stand lift. CNA-O's statement on [DATE] documented only: Hit shin bone left on sit to stand. Nurse was notified. On [DATE], at 3:30 PM, during the daily exit meeting with the facility, Surveyor asked if the investigation report provided was the entire investigation completed. DON (Director of Nursing)-B stated, Yes, what I gave you is everything, the whole investigation. Surveyor noted the investigation was not thorough to determine how the accident happened. CNA-O's statement did not include details or information of how R12 hit her shin bone on the sit to stand. On [DATE], at 10:08 AM, Surveyor interviewed CNA-O and asked her to walk through what happened regarding R12's leg injury. CNA-O stated, We were getting her up (Surveyor asked who she meant by we) me and the other aide. She (R12) was sitting on the side of the bed and we got her hooked up to the stand up lift. She said she had to go to the bathroom, so we took her. Surveyor clarified; so (R12) had no injury at this time before you took her to the bathroom. CNA-O stated, No. Surveyor asked CNA-O if she could see R12's legs. CNA-O stated, Yes. She had her pants on at her ankles, but when she said she had to go to the bathroom, we took her. We didn't pull them up because she had to go to the bathroom. Surveyor asked if the leg leg strap was in place on the sit to stand. CNA-O stated, Yes. When we got her onto the toilet, the other aide left and she was on the toilet while I stayed in the room, making her bed, and stuff. Surveyor clarified; so (R12) was alone on the toilet. CNA-O stated, Yes. When I went back into the bathroom I saw that she had kicked her leg out to the left and she must've bumped it on the lift frame and it was bleeding, so I got the nurse. Surveyor asked how R12 bumped her leg on the lift frame if the leg strap was on. CNA-O stated, We had the leg strap on when we took her to the bathroom, but then I unhooked it when she was on the toilet because she likes to move her legs around when she's sitting on the toilet. Surveyor confirmed; so everything else was still hooked up while she was alone on the toilet, but you undid the leg strap. CNA-O stated. Yes. Surveyor asked CNA-O if she received any education after the incident. CNA-O stated, We were told that she (referring to R12) shouldn't be left alone when on the toilet and stand up lift anymore and that we need to watch her legs closely. Surveyor asked CNA-O if R12 was wearing tubigrips. CNA-O stated, No, those were for her swelling, but she doesn't have swelling anymore, so she hasn't worn the tubi grips for some time. Surveyor informed CNA-O R12's care plan indicates the tubi grips are to be worn for protection because of the incident. CNA-O stated, I don't know about that, but if they want them put on again, I have no problem cutting her some more. On [DATE], at 10:34 AM, Surveyor asked Nursing Home Administrator (NHA)-A for the facility policy and procedure for the use of the stand up lift. NHA-A stated, I know we don't have a policy specific to the stand up lift, because I remember a complaint awhile back and they (referring to Surveyors) asked for it and we don't have one. Surveyor asked what is the expectation for staff regarding use of the stand up lift. NHA-A stated, Two people to transfer with stand up lift, that's my official statement. On [DATE], at 12:14 PM, Surveyor observed R12 sitting in her wheelchair in the dining room waiting for lunch to be served. R12 was wearing socks and slippers, no tubi grips. On [DATE], at 12:48 PM, Surveyor interviewed LPN (Licensed Practical Nurse)-J about the accident and injury involving R12. LPN-J reported she remembers the incident. LPN-J stated, The CNA came and told me the resident bumped her leg on the sit to stand. I think it was toward the end of the day, near change of shift, so I didn't look at it right away, but did go down shortly after. She was in her wheelchair in her room and she had a large bruise with swelling, so I elevated her leg and gave some ice for comfort. I remember her son was here in the room and he said this happened before and it burst open. He no sooner left, and like 15 minutes after he left the CNA told me it ruptured. So I immediately wrapped it, applied pressure and stayed in the room with her. 911 was called and she was sent out. Surveyor asked if, when the CNA first told her the resident bumped her leg on the stand up lift, did she give any other information of how it happened? LPN-J stated, No, I think it was when they were transferring her to the toilet, but I'm not sure. Surveyor asked, if leg straps are supposed to be used when transferring residents with a stand up lift, how did she think R12 bumped her leg? LPN-J reported she did not know. Surveyor asked LPN-J if she asked the CNA for details or inquired how it happened. LPN-J stated, No, I think it was close to shift change, she just told me she bumped it and then left I think. Surveyor noted CNA-O's interview of the incident and LPN-J's interview of the incident differ in significant details. CNA-O reported when she returned to the bathroom after leaving R12 alone on the toilet and removing the leg strap, she saw R12 had kicked her leg out to the left and she must've bumped it on the lift frame and it was bleeding. LPN-J reported the CNA reported the bruise, ice was applied and it later (approximately 2 hours per progress notes) burst open with bleeding. Surveyor notes LPN-J did not report any bleeding until the bruise burst open and CNA-O identified bleeding noted upon returning to the bathroom after R12 was left alone. R12's CNA care card dated [DATE] (on the door of R12's closet) includes no documentation regarding safety of the sit to stand/not to be left alone on the toilet, ensuring leg straps are in place or watching her legs closely when using the sit to stand or during transfers. R12's care plan included no interventions to prevent further incidents other than implementing tubi grips to protect her skin. On [DATE], at 3:10 PM, Surveyor asked CNA-M to walk me through how to perform a stand up lift transfer. CNA-M showed Surveyor the stand up lift used for R12. CNA-M demonstrated and stated, We hook them up with the straps, put the leg straps on and then raise them up. Surveyor noted blue padded knee area for legs to rest against during transfer. Surveyor noted there are no metal bars or metal areas on either side of the stand up lift. Surveyor asked CNA-M if he knew how R12 would have bumped her shin on stand up lift. CNA-M stated, I don't know how that would be possible, there's no metal bars to bump the leg on. She must have bumped it on something else. She does try to self transfer, which is why we try to keep her out in the open where we can see her. On [DATE], at 3:42 PM, Surveyor met with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor asked if a facility self report was completed regarding R12's leg injury. NHA-A stated, No. I believe what probably happened was the aide told the nurse what happened, that she bumped her leg on the lift and the nurse went with it. Surveyor notified NHA-A of the concern R12 sustained a significant injury to her leg, which required a hospital stay, surgical intervention and a wound vac and there was not a thorough investigation as to how the injury occurred. For example was the transfer completed correctly, was the leg strap in place, how/what did she bump her leg on (as Surveyor located no area on lift which correlates with CNA's interview). The CNA statement documents only that the resident hit her shin bone on the sit to stand but does not indicate how this occurred. In addition, R12 is at risk for falls, had 2 prior falls and was left alone on the toilet with the leg straps not attached. DON-B stated, I'm sure the nurse manager did more of an investigation, I can get a statement from her. Surveyor clarified; I was told this is the entirety of the investigation. DON-B reported she can see if the nurse manager did anything else and get a statement. Surveyor notified NHA-A and DON-B of the interview with CNA-O and how the injury occurred is different than progress note documentation . Surveyor read CNA-O's interview and progress note documentation and LPN-J's interview. Surveyor notified NHA-A and DON-B of concern it is not clear how the injury actually occurred and due to the extent of the injury a thorough investigation would expect to be completed. Surveyor notified NHA-A and DON-B the only intervention documented was to implement tubi grips to protect the skin, but no interventions were implemented to prevent further incident with the sit to stand, transfers or toileting assistance/supervision. Surveyor notified NHA-A and DON-B R12 was not observed wearing tubi grips during the time of survey. Surveyor asked if an assessment was completed upon R12's re-admission to determine if R12 is safe/appropriate for stand up lift use. NHA-A reported he did not know. Surveyor asked if education or audits were completed to ensure proper/safe transfer using the stand up lift. NHA-A stated, Probably not. I think what happed was the aide told the nurse the resident bumped her leg, so it was a known injury and there wasn't much to investigate. On [DATE], at 9:13 AM, DON-B reported she spoke to CNA-O and provided Surveyor a revised statement by CNA-O which documented: Addendum: Myself and another aide (no longer works here) sat (resident) up on side of bed and got her up with the sit to stand and put her on the toilet. We undid the leg straps once she was seated on the toilet. When we came back, she had shifted her legs off the lift and a bruise was noted to her left shin. (R12) said she bumped her leg on the lift. I notified the nurse of the bruise. Surveyor asked what did CNA-O report R12 bumped her leg on. DON-B stated, The blue knee rest padding, and I was reading her H&P (History and Physical) and the same thing happened the previous year, she bumped her leg on her wheelchair and needed surgical intervention for a hematoma, so she does have very fragile skin. Surveyor notified DON-B of the concern the addendum statement by CNA-O is different than the statement CNA-O provided to Surveyor earlier. Surveyor notified DON-B the concern remains that R12 sustained a significant injury and there was not a thorough investigation as to how the injury occurred and interventions were not put in place that address the root cause of the injury and to prevent future injury. Surveyor read R12's H&P which documented exactly 1 year previous, on [DATE] RLE (Right Lower Extremity) hematoma from trauma/wheelchair transfer. EMS (Emergency Medical Services) was called and she required CPR (Cardiopulmonary Resuscitation). She required surgical evacuation of the hematoma on [DATE]. Laceration was complicated by paper thin skin limiting ability for suture closure. On [DATE], at 9:30 AM, Surveyor spoke with Clinical Nurse Consultant-G. Surveyor was informed the facility does not have a policy and procedure for the stand up lift. Surveyor asked for evidence of education or training with the CNA's. Surveyor was provided evidence of the skills fair on [DATE] in which CNA's demonstrated competence. Surveyor reviewed the manufacturer recommendations for the stand up lift, no additional information was obtained. Surveyor notified Clinical Nurse Consultant-G of concerns R12 sustained a significant injury to her leg, requiring surgical intervention. There was not a thorough investigation as to how the injury happened. R12 is at risk for falls, sustained 2 prior falls and was left alone on the toilet with the leg strap not fastened. Clinical Nurse Consultant-G stated, I'm sorry, I don't know this person at all. I understand your concerns, with the severity of the injury there should have been more digging into what happened. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice, to prevent the development and to promote healing of pressure injuries for 4 (R3, R20, R15, and R16) of 4 residents reviewed for pressure injuries. * R3 was admitted to the facility on [DATE] with a deep tissue injury (DTI) to the left heel, an open area to the left buttock, and an open area to the right buttock. R3 had a care plan and interventions put in place for the DTI on the left heel but no care plan was put in place for the pressure injury to R3's left and right buttock. R3's left and right buttocks pressure injuries were not comprehensively assessed again after R3's admission to the facility. On 12/7/2022, R3 developed a new stage 2 pressure injury to left buttock. R3's left buttock wound was not care planned. On 12/21/2022, R3 developed a DTI to the right heel, stage 2 pressure injury to the left 4th toe, open area to the right foot 3rd toe, an open area on the right 4th toe, and excoriation to R3's right inner thigh. R3's new areas of concern were not addressed in R3's care plan. R3 did not have a comprehensive assessment for the left 4th toe or right 3rd toe pressure injuries after 2/14/2023. On 1/7/2023, R3 was noted to have a foul odor from R3's left heel DTI. There is no evidence the MD (Medical Doctor)/NP (Nurse Practitioner) were notified or made aware of the foul odor of R3's left heel or that it was assessed by nursing. On 1/26/2023, R3 was sent to the hospital to get a magnetic resonance imaging (MRI) scan and culture of R3's left heel due to tunneling being observed under the eschar cap of R3's left heel. R3's left heel was debrided on 1/27/2023 while in the hospital. On 3/13/2023, a Certified Nursing Assistant (CNA) charted in the progress notes R3 is being monitored for an area of concern to R3's sacrum that was noticed on 3/10/2023. There was no comprehensive assessment for R3's area to the sacrum/coccyx area on 3/10/2023 until 3/14/2023 and no other comprehensive assessments after 3/14/2023. R3's care plan was not revised for R3's new area of concern to R3's sacrum. On 3/14/2023, R3 was found to have a new area of concern to R3's right 4th toe when at the wound clinic. During treatment to R3's right 4th toe on PM shift, nursing charted that bone was visible on R3's right 4th toe. There is no evidence the wound clinic or R3's MD were updated on bone being visible on R3's right 4th toe until 3/16/2023. On 3/16/23 in the progress notes, the nurse practitioner charted the right 4th toe appears to have slough and not visible bone. The Nurse Practitioner also charted R3 has a wound to coccyx. On 3/20/2023, nursing charted that R3's right 4th toes had an odor and was necrotic. On 3/21/2023, nursing charted R3's left buttock pressure injury was unstable. There are no comprehensive assessments regarding a left buttock pressure injury for R3. R3 was sent to the emergency room due to elevated white blood cells. R3 was admitted to the hospital with diagnosis of soft tissue infection and IV (Intravenous) antibiotics were started. On 3/25/2023 in the progress notes, nursing charted R3 was still in hospital. R3 was not a candidate for surgical removal of the right 4th toe and was waiting to be assessed for hospice care. On 4/1/2023 R3 passed away. * R20 - Surveyor noted from 3/27/23-4/1/23, the only treatment being completed for R20's unstageable pressure injury was to apply zinc oxide eternal ointment 20% apply to buttock three times a day. From 3/27/23-4/1/23, there was also no dressing ordered to cover R20's pressure injury. Surveyor noted there was no weekly assessments completed for R20's pressure injury for the week of April 3, 2023. On 4/12/23 R20 developed a wound infection that was treated with antibiotics. On 5/17/23, the dressing on R20's coccyx wound was observed not attached at the bottom, was not dated and appeared soiled/wet. Surveyor observed LPN conduct wound care and then place a bordered foam dressing over the wound however the dressing was not big enough and the dressing's adhesive border was placed on the macerated area to the wound. NP-L was not aware of R20's macerated area and would have had staff apply zinc ointment on the macerated area with staff using a larger dressing to ensure the surrounding reddened macerated skin was under the foam part of the dressing and not the adhesive part. * R15 developed excoriation on 12/15/2022 that had conflicting documentation as to where the excoriation was: coccyx or right buttock. The wound healed on 1/10/2023. On 2/10/2023, R15 developed excoriation to the right and left buttocks with measurements of both areas. On 2/14/2023 on the Weekly Skin Report log, R15 developed excoriation to the sacrum; no documentation of any wound to the right or left buttock was found after the initial assessment even though a treatment was being provided to the right and left buttocks. On 3/28/2023, the sacral wound was documented as a Stage 3 pressure injury. On 4/12/2023 the sacral wound healed and R15 developed pressure injuries to the right lateral ankle, the left foot bunion, and the left heel. None of the pressure injuries were staged, no treatment was obtained, and no documentation was found indicating the physician or Power of Attorney (POA) were notified. A treatment to the right lateral ankle was obtained on 4/27/2023, fifteen days after the wound was identified. On 5/16/2023, R15 had documentation of having pressure injuries to the right lateral ankle and the left bunion. Observation of R15's feet with Director of Nursing (DON)-B on 5/17/2023 showed R15 to have pressure injuries to the right outer ankle, the left heel, and the left bunion. No current Skin Integrity Care Plan was in place. Documentation of R15's wounds were in a log that was not accessible to the staff caring for R15. The facility was not aware of the pressure injury to the left heel until brought to their attention by Surveyor. * On 1/4/23, R16 had an order for skin prep to the right heel and dark area at the sole of the foot near the right great toe. On 1/17/23, a wound assessment documented R16 had a Deep Tissue Injury to a boggy right heal with a dark area at the sole of the foot right great toe. The area was seen by the Nurse Practitioner on 1/4/23 with new orders. The area was measured and noted with eschar. The measurements did not denote if the area was to the right heel or the sole of the foot near the right great toe. The wound assessment documented the pressure injury as a Deep Tissue Injury but had the description of eschar. A pressure injury with eschar would be considered Unstageable. Documentation of the wound was inaccurately staged. On 1/16/23, nursing charted R16 having a Stage 2 pressure injury to the left hip. The 2/7/23 wound assessment identified the pressure injury to the left hip as having eschar. The facility inaccurately staged the left hip as a Stage 2 pressure injury. A pressure injury with eschar would not be a Stage 2 pressure injury. The 2/14/23 wound assessment of the left hip pressure injury was a Stage 2 with slough with present. This was inaccurately Staged as a Stage 2 pressure injury does not have slough present. R16 developed an Unstageable pressure injury to the left lateral heel on 1/31/2023. The wound assessment did not indicate the percentage of eschar noted in the pressure injury. There was no further charting found in R16's medical record regarding R16's left hip, right foot, and left heel after 2/16/23. Director of Nursing (DON)-B provided Surveyor with a Weekly Skin Report log used by DON-B to track wounds from January 2023 to the time of the survey. This Weekly Skin log is not part of R16's medical record nor is it visible to other staff members caring for R16. The Weekly Skin log continues to reflect inaccurate staging of the pressure injuries. There was no comprehensive assessment of the left lateral heel and the sole of the right foot below the great toe from 3/28 to 4/12/2023. On 4/19/2023, R16 developed a pressure injury to the right heel with a scab present. The wound was inaccurately staged as a Deep Tissue Injury. No documentation was found that the physician or POA were notified, and no treatment was obtained. Observations of R16 during survey showed R16 to have feet in direct contact with surfaces. On 5/16/2023, R16 had documentation of having pressure injuries to the left lateral heel and the right heel. Observation of R16's feet with Director of Nursing (DON)-B on 5/17/2023 showed R16 to have a Deep Tissue Injury to the left lateral foot, a Stage 3 pressure injury to the left lateral heel, a Stage 1 pressure injury to the ball of the left foot by the big toe, a Stage 2 pressure injury to the right heel, and a Stage 1 pressure injury to the right lateral foot. Dressings were noted on the left foot with no order for a dressing and the left lateral heel Stage 3 pressure injury had slough with no treatment. The facility was not aware of the pressure injuries to the left lateral foot, the ball of the left foot, and the right lateral foot until brought to their attention by Surveyor. No current Skin Integrity Care Plan was in place The failure of the facility to have systems in place to provide for the overall management in the prevention, care, and treatment of pressure injuries in accordance with current standards of practice, to include the identification of pressure injuries, pressure injury assessments, accuracy of assessments, physician notification, developing and implementing preventative care planned interventions, and updates to the care plans, follow through on obtaining treatment for pressure injuries and providing treatment as ordered created a condition of an Immediate Jeopardy for 4 of 4 residents reviewed for the care and treatment of pressure injuries which began on 12/21/2022. On 5/17/23 at 4:53 p.m. Administrator-A, DON (Director of Nursing)-B, Corporate-C, and Corporate-D were notified of the immediate jeopardy. The immediate jeopardy was removed on 5/23/23. The deficient practice continues at a scope/severity of E (potential for harm/pattern) as the facility continues to implement and monitor the effectiveness of their removal plan. Findings include: The facility policy entitled, Pressure Injury Prevention and Managing Skin Integrity with a facility review date of 6/24/2022 states: I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedures: 1. Risk Assessment a. Upon Admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. c. based on the individual's Braden scale score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan: a. identify interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team (IDT) regarding the presence of breakdown and the intervention plan. 2. Identification of risk factors present or acquired that compromise skin integrity will be considered. B. Care Plan i. In developing a plan of care, the following will be considered: 1. Individual pressure injury history. Current state of skin integrity and personal hygiene practices of the individual that impact skin health. 5. Risk for pressure ulcer development (Braden Scale). 1. Skin Checks: a. Skin Check Frequency i. Upon admission or readmission. 1. Skin check will be done upon admission and then done every shift for 72 hours after admission ii. Weekly 1. 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. 1. 4. Weekly Wound Rounds: a. Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. B. Wound Care Certified (WCC) nurse or designee will: i. conduct weekly skin evaluation, ii. Update the primary care physician (PCP) with any decline in wound appearance, or as necessary. iii. Update the care plan with any new interventions. c. The staff nurse will follow through with the skin care interventions implemented for prevention and treatment of skin breakdown. The facility policy entitled, Change of Condition and Provider Notification, with a facility review date of 7/22/2022, states: Policy: I. Upon individual change in condition, proper assessment and provider notification will occur to provide timely delivery of clinical care. II. Procedure: 1. Change of Condition a. change of condition (COC) is a deviation from an individual's baseline in physical, cognitive, behavioral, or functional status. Clinically important means a deviation, that without intervention, may result in complications or death. 2. Assessment . b. a licensed nurse is to complete the initial assessment process and follow up evaluation as indicated by complexity and stability of the individual's condition. d. Change of condition assessment shall be reviewed by Registered Nurse. 3. Notification a. Primary care provider (PCP) will be contacted for notification and obtain further orders from provider as necessary. 1. If PCP cannot be reached, on-call provider will be contacted. 2. If PCP and/or on call provider are not able to be contacted, the Medical Director will be contacted for notification. 4. Documentation a. individual with a change of condition will be monitored as appropriate. b. Licensed nurse shall complete the change in condition assessment in the individual's electronic medical record. 5. Care Plan a. Care Plan and interventions will be updated as indicated. 1. R3 was admitted to the facility on [DATE] with diagnoses that included: muscle wasting and atrophy, Alzheimer's disease, Dementia, chronic congestive heart failure, cancer of the kidneys (not getting treatment), and history of septic shock with urinary tract infection. R3's quarterly minimum data set (MDS) dated [DATE] indicated R3 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. The MDS assessed R3 as needing extensive assist with bed mobility, dressing, hygiene, and total dependence for transferring, toileting, and bathing. R3 had impairment to the lower extremities on R3's left side. R3 was frequently incontinent of bowel and bladder and wore an adult brief. R3 passed away on 4/1/2023 and was not observed during survey. On admission, 10/10/2022, R3 was noted to have; A deep tissue injury to R3's left heel that measured 3.0cm (centimeter) X 3.5cm, An open area to R3's left buttock that measured 0.3cm X 0.3cm X 0.1cm, and An open area to R3's right buttock that measured 0.5cm X 0.5cm X 0.1cm. (length X width X depth). Surveyor noted there are no further measurements for the open areas on R3's right and left buttocks after the admission measurements on 10/10/2022. R3's left heel DTI was comprehensively assessed weekly. R3's care plan addressing Alteration in skin integrity related to left heel unstageable pressure with eschar cap was initiated on 10/10/2022 with the following interventions: - Provide supplements as ordered. - Confer with wound nurse as needed. - Provide treatment as ordered. - Use specialty mattress. - Float heel to reduce pressure on heels and pressure points. - Measure wound weekly. - Refer to Dietician. - Multivitamin as ordered. - Notify medical doctor (MD) of any declining changes. - Assess, document, and report signs of systemic or localized infection such as changing in energy level, changes in vital signs, erythema, indurations. Discharge, foul odor, from or around the wound. - Monitor labs as ordered. - Assess R3 for any symptom of confusion, changes in mental status, delirium, or confusion as these may indicate process. - Pressure reducing device for bed. - Pressure reducing device for chair. R3's care plan addressing Potential for alteration in skin integrity was initiated on 10/10/2022 with the following interventions: - Provide hygiene after toileting. - Float heel to reduce pressure on heels and pressure points. Turn/reposition. - 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 indicated to reduce the risk of skin breakdown. - Assess, document, and report signs of systemic or localized infection such as change in energy level or changed in vital signs. R3's October 2022 medication administration record/ treatment administration record (MAR/TAR) had the following orders in place: - One time daily starting 10/11/2022: Apply skin prep to left heel DTI daily 'till healed. - Two times daily starting 10/10/2022: apply Z-GUARD topically to buttocks twice a day and as needed. - Pro-Stat sugar free 15 gram-100kcal/30mL oral liquid (30mL) one time a day starting 10/19/2022: for wound healing - Ensure Plus 0.05 gram-1.5 kcal/mL (240mL) two times daily starting 10/20/2022: for wound healing On 10/11/2022 in the wound notes, nursing charted L (left) heel, eschar, unstageable, edges lifting. On 10/14/2022 in the progress notes, nursing charted the IDT team met regarding R3's wounds and plan was for nursing to continue to monitor pressure on R3's heel and excoriated bottom. On 12/7/2022 in the progress notes, nursing charted R3 had a stage 2 pressure injury to the left buttock that measured 2.0cm X 4.0cm X 0.1cm, granulation, new area observed to left buttock as stage 2, 4 areas were measured as 1 area, no drainage or sign of infection. MD notified and new orders obtained. Surveyor noted no new orders were put onto MAR/TAR for R3's new stage 2 to the left buttocks. On 12/20/2022 in the weekly measurements for R3's left heel, nursing charted measurements to be 5.5cm X 5.0cm, unstageable, 100% eschar cap, unstable. MD notified and new orders were obtained for R3's left heel. On 12/21/2022 in progress notes nursing charted six new areas of concern for R3: 1. Right lateral heel DTI measuring 2.3cm X 2.5cm, unstageable, eschar, edges lifting. 2. Excoriation to right inner superior thigh 3. Excoriation to right inner inferior thigh 4. Left foot, 4th toe medial side stage 2 measuring 0.8cm X 0.5cm X 1.0cm, granulation, macerated wound edges 5. Right foot, 3rd toe lateral side open area measuring 0.8cm X 0.5cm, granulation, macerated, intact. 6. R foot 4th toe, medial side (open are between toes) measuring 0.8cm X 0.4cm, macerated edges - new orders obtained for bilateral feet and R3 added to podiatry list for onychomycosis (fungal infection of toenails). R3's Care plan was not revised to include R3's six new areas of pressure injuries/concern. R3's December 2022 MAR had the following orders in place: - Santyl one time daily for 14 days starting 12/21/2022: Cleanse DTI to left lateral heel with normal saline, apply nickel thick Santyl, cover with dressing daily for 14 days (12/22/22- 1/4/2023) - Skin prep one time daily for 14 days starting 12/21/2022: clean DTI to right heel with normal saline, apply skin prep every day for 14 days (12/22/292- 1/4/2023) - Pro-Stat sugar free 15 gram-100kcal/30mL oral liquid (30mL) two times a day starting: for wound healing (increased from 1 time a day) - Normal saline wash to bilateral feet, pat dry, place gauze between toes daily for 14 days starting 12/21/2022. - Zinc oxide 20% topical ointment - apply thin layer to buttocks and inner thigh excoriations three times daily ordered date 12/21/2022. - Hospice to evaluate and treat - ordered 12/9/2022 On 1/7/2023 at 2:29 PM in the progress notes nursing charted dressing to R3's left heel dressing was changed, foul odor noted. Surveyor noted there was no documentation that the MD was notified regarding the odor to R3's left heel. On 5/17/2023 at 9:40 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-EE who stated LPN-EE wrote a note regarding the foul odor to R3's left heel on the doctor's board so R3 could be seen next time the doctor was in. LPN-EE stated LPN-EE only changed R3's dressing to the left heel because the dressing was soiled and wet. LPN-EE stated LPN-EE usually did not work that unit and was not sure if R3 was followed up on regarding the odor to R3's left heel odor. There is no charting indicating R3's left heel was addressed by nursing or that the MD was notified or saw the doctor board to assess the odor to R3's left heel. On 1/17/2023 in the wound notes, nursing charted left heel measured 4.0cm X 5.0cm, 100% dark eschar, moveable. On 1/24/2023 in the wound notes, nursing charted the left heel measured 4.0cm X 4.5cm, edges macerated, scant serous drainage, part of the eschar cap fell off - deep tunneling noted but unable to be measured. Eschar cap is unable to be removed. On 1/25/2023, an X-ray was ordered for R3's left heel. On 1/26/2023 per the nurse practitioner note, R3 was sent to the emergency room to get a MRI (Magnetic resonance imaging) and culture of R3's left heel. R3 was admitted to the hospital. On 1/30/2023, R3 was admitted back to the facility. Hospital discharge summary documented that R3 was evaluated by podiatry specialty who performed debridement of the left heel ulcer on 1/27/2023 that included removal of eschar, necrotic fat, facial tissue, and devitalized (removal of bad tissue that prevents healing) tissues. Per team recommendation continue treatment with Santyl to the left heel while chronic small right heel was treated with betadine. R3's left heel DTI measured 5.0cm X 7.0cm X 3.0cm. R3 also was noted to have an open area to the right buttock measuring 1.0cm X 1.0cm X 1.0cm and listed as excoriation. R3's January 2023 MAR had the following orders in place: - Cleanse between toes, left foot 4th toe, right foot 3rd and 4th toe with normal saline, pat dry, followed by telfa between all toes. Daily and as needed, NO socks to feet. Order date: 1/10/2023, discontinued date: 1/19/2023 - Dakins wash followed by Santyl nickel thick, followed by dry gauze dressing and kerlix wrap daily and as needed. Encourage resident to wear boots to bilateral feet. Order date: 1/10/2023, discontinued date 1/18/2023. (Surveyor noted that this order did not state location treatment should be done.) - Cleanse between toes, left foot 4th toe, right foot 3rd and 4th toe with normal saline, followed by telfa between all toes every day and as needed. - Santyl 250 unit/gram: wash open area to left heel with normal saline, apply thin layer Santyl throughout wound, and cover with Allevyn every other day for 10 days. Ordered: 1/31/2023 On 2/1/2023, a referral for wound care was ordered for R3. On 2/7/2023, R3 saw podiatry and the wound clinic for R3's right heel, left heel, and right 4th toe pressure injuries. There was no evidence that R3's left 4th toe stage 2 pressure injury or right 3rd toe open area were assessed by the wound clinic podiatrist. After 2/14/2023, there are no more comprehensive assessments for R3's left 4th toe, medial side, stage 2 pressure injury, or R3's right foot 3rd toe lateral side. There is no documentation that the podiatrist was monitoring the open wounds. On 2/21/2023 R3's right heel and right 4th toe pressure injuries healed. R3's February 2023 MAR had the following orders in place: - Right heel: cleanse with mild soap and water, pat dry. Apply a tegaderm foam to heel. Change weekly. Ordered: 2/13/2023 - Left heel: cleanse with mild soap and water, pat dry. Apply Santyl, nickel thick to wound bed. Cover with saline wet to dry gauze, gauze, kerlix, change daily. Right 4th toe web- cleanse with mild soap and water, pat dry. Apply betadine to area, place gauze between 3/4 toes. Change daily. Ordered: 2/7/2023, discontinued: 2/21/2023 - Left heel: cleanse with normal saline, pat dry. Apply Santyl, nickel thick to wound bed. Cover with saline wet to dry gauze, gauze, kerlix. Change daily, place gauze between 3/4 toes. Change daily. Ordered 2/21/2023 On 3/13/2023 at 6:09 AM in the progress notes, there is charting done by a Certified Nursing Assistant (CNA) [R3] on 24 hour board monitoring area of concern to sacrum. Wound care team to assess sacrum per day shift nurse. On 3/14/2023 on a weekly skin check sheet for R3, an area is documented on R3's coccyx that measured 3.0cm X 2.0cm, pressure, 50% granulation. There was a note by the measurements noting the pressure wound was new on 3/10/2023. There is no comprehensive assessment done on R3's coccyx pressure injury that was first observed on 3/10/2023 per R3's weekly skin check sheet on 3/14/2023. There are no more comprehensive assessments for R3's coccyx area. On 3/14/2023 in the podiatrist wound visit notes, it is documented that R3 has a new area to R3's right 4th toes that measured 0.7cm X 0.7cm X 0.2cm. Orders to apply betadine to the open area and gauze. On 3/14/2023 at 10:20 PM in the progress notes, nursing charted R3 had a lot of pain to the right side of toes. Appeared that bone was visible, information passed to nursing to have MD/wound care updated. On 3/16/2023 at 5:30 AM in progress notes, Nurse Practitioner (NP)-FF charted R3's open area appears to have slough not bone, without drainage. Additionally, has wound to coccyx. R3's right toe was not assessed until 2 days after the concern of having bone exposed to R3's right foot was first noted. On 5/15/2023 at 1:20pm, Surveyor interviewed NP-FF who states NP-FF did not follow R3's pressure injuries. NP-FF stated R3 went to a wound clinic however Surveyor replied that R3 did not start going to the wound clinic until 2/3/2023. NP-FF stated NP-FF would look at a wound if nursing asked but would just look at nursing and wound clinic notes for measurements and information. On 3/20/2023 at 11:52 PM in the progress notes, nursing charted R3's right 4th toe necrotic with a foul odor. On 3/21/2023 at 2:30 AM in the progress notes, NP-FF charted noted concerns to R3's right 4th toe, digit necrotic. R3 was seen by podiatry on 3/14/2023 with orders in place. Facility staff to follow up with podiatry. Labs ordered. On 3/21/2023 in the progress notes, nursing charted R3 had a left buttock wound that measured 5.0cm X 7.0cm, unstable, 75% granulation, 25% epithelial, and that R3 was having loose stools. There is no documentation to show that R3's left buttock wound was followed up on or if MD/wound care was notified. On 3/21/2023 at 12:37 PM in the progress notes, nursing charted R3's lab results back and R3's white blood cell count was elevated. NP-FF updated and order to send to ER. On 3/21/2023, R3 was admitted to the hospital with a soft tissue infection and started on antibiotic therapy. R3's March 2023 MAR had the following orders in place: -betadine swab sticks 10%, apply between 3rd and 4th toes topically at bedtime for toes infection. Cleanse toes with normal saline, pat dry, apply betadine in between 3rd and 4th toes. Put dry gauze in between toes and secure with kerlix. Start: 3/1/2023 Surveyor noted the order does not specify if right or left toes. -Collagenase ointment 250 unit/gram: apply to left heel topically at bedtime for DTI left heel, Cleanse left heel with normal saline, pat dry, and apply nickel size Santyl to wound bed. Cover with normal saline wet gauze followed by dry gauze and secure with kerlix until healed. Start: 3/1/2023 On R3's March MAR - the above two treatments are signed out by nursing staff that it was done only 6 days in March on: 3/8, 3/10, 3/12, 3/14, 3/18, 3/20. Treatment was to be done daily. On 3/25/2023 in the progress notes, nursing charted a call placed to the hospital to check on R3's status - R3 was not a surgical candidate to get right 4th toe removed. R3 waiting on Hospice placement. On 4/1/2023, R3 passed away. R3 had not returned to the facility. On 5/16/2023 at 8:15 AM, Surveyor interviewed LPN-AA who stated R3 was usually at the wound clinic when the wound team would do wound rounds. Surveyor responded that R3 did not start seeing wound clinic until February 2023 and would go monthly. LPN-AA replied LPN-AA recalled that R3 was having diarrhea and R3's buttocks were excoriated, the toe was necrotic and R3 was sent to the hospital. LPN-AA could not recall much else regarding care for R3's wound treatment. LPN-AA was part of the wound team at the facility and is not wound care certified. On 5/16/2023 at 1:26 PM, Surveyor interviewed Registered Nurse (RN)-K who stated RN-K recalled R3 having diarrhea and R3's buttocks had excoriation. Does not recall if R3 had open areas to buttocks also. RN-K stated R3 saw the wound clinic for R3's open areas but did not recall when R3 started at the wound clinic. RN-K would notify R3's MD/NP about R3's pressure injuries regarding progression or new areas, but the MD/NP would not assess the areas unless nursing asked them to. On 5/17/2023 at 8:48 AM, Surveyor interviewed LPN-GG who stated R3's daily wound treatments were switched to PM shift because AM shift was unable to do them when R3's treatments should have been done. LPN-GG stated PM shift had more time to do the treatments. LPN-GG stated R3 was compliant with cares/treatments and never refused cares/treatment. Surveyor asked LPN-GG what the empty boxes on the MAR meant. LPN-GG replied that if there is an empty box on the MAR/TAR it would signify that that medication/treatment was not given or done. On 5/17/2023 at 11:15 AM, Surveyor interviewed RN-K who stated RN-K was part of the wound care team at the facility and was not wound care certified. RN-K was not sure if any of the nurses on the wound care team were certified. Surveyor asked RN-K how staff used the terms excoriation and open area, if it meant the same thing or different? RN-K replied sometimes staff would use it interchangeably. Surveyor asked RN-K if excoriation should be measured routinely and be on the weekly skin assessments? RN-K replied excoriation should be measured on rounds weekly to make sure it is getting better. RN-K did not recall if R3 was being monitored for excoriation or if R3 had pressure injuries to the buttocks. RN-K did not recall what areas the wound care clinic was monitoring for R3 or if R3 ever had visible bone by R3's toes. On 5/17/2023 at 11:52 AM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B was out on medical leave for several months (January-March) and DON-B is wound care certified. Surveyor asked DON-B if excoriation is monitored/measured during weekly wound team rounds? DON-B stated excoriation would not be measured weekly, just keep an eye on it. It could present as an open area, appropriate treatment would be house barrier cream or Z-guard, do not need doctors order for that. Surveyor asked DON-B when residents care plans should be revised? DON-B stated residents care plans should be revised when new concerns present and should be looked at often to make sure it has the most up to date information on them for staff to follow. Surveyor asked DON-B about R3's care plan and if each area of concern that R3 has on R3's feet and buttocks should have been care planned? DON-B responded that each of R3's areas of concern should have been care planned separately and revised appropriately. Surveyor asked DON-B what process was in place while DON-B was on medical leave? DON-B stated that no one was put in charge of the wound team. DON-B stated that DON-B knew it was bad while DON-B was gone but not that bad. DON-B stated Oak Medical started in the facility about 3 weeks ago to he [TRUNCATED]

Based on interview and record review, the facility did not ensure that each resident received needed supervision to prevent accidents for 4 (R4, R6, R11, & R9) of 5 residents reviewed for accidents. On 4/12/23, Certified Nursing Assistant (CNA)-Q was attempting to transfer R4 from the bed into bath chair using a sit to stand lift. CNA-Q transferred R4 by herself, not with assistance of 2, and did not secure R4 in the sit to stand lift properly. The RST (Resident Summary Template) care card dated 2/10/23 was not accurate as the transfer status documented Assist of 2+ with a gait belt when R4's transfer status was a Hoyer lift with an assist of 2 staff. R4 fell from the sit to stand hitting his head. RN-K assessed R4 on the floor, R4 was then transferred into bed using a Hoyer lift. Shortly after being placed in bed R4's breathing changed and was described by LPN (Licensed Practical Nurse)-P as being quicker and weird. R4 became unresponsive and 911 was called. R4 arrived at the emergency department unresponsive, with apnea & pulselessness and was declared dead upon arrival. The facility's failure to ensure R4 was transferred according to the plan of care and to ensure the accuracy of R4's care plan created a finding of immediate jeopardy that began on 4/12/23. On 5/17/23 at 4:53 p.m., Administrator-A, DON (Director of Nursing)-B, Corporate-C and Corporate-D were notified of the immediate jeopardy. The immediate jeopardy was removed on 5/19/23. However, the deficient practice continues at a scope/severity of E (potential for harm/pattern) for R6, R11, & R9 as the facility continues to implement and monitor its action plan and as evidenced by: * R6 was observed without a body pillow on the left side of the bed and without a fall mat on the floor on the left side of R6's bed. R6's at risk for fall care plan and the CNA (Certified Nursing Assistant) Kardex was not updated to reflect these interventions. * R11's falls on 9/19/22 & 10/24/22 were not thoroughly investigated. * R9's current care card indicates R9 requires extensive assist of 1 with a front wheeled walker. R9's care card located in the closet door indicates R9 is to be transferred with a gait belt. R9's physicians orders instructs for the use of bilateral transfer bars. On 5/16/23, R9 was observed being transferred without the use of a gait belt. R9 was not transferred using a front wheeled walker. R9 was not transferred using bilateral transfer bars. Findings include: The Safe Individual Handling Program policy and procedure with the latest review date of 6/24/22 documents under policy: The organization will adopt the Safe Individual Handling Program as outlined below. Under Procedure section B Care Plan documents: 1. Individual-specific transfer status will be addressed on the Care Plan to include specific equipment type if applicable. 2. All staff to transfer according to the Care Plan unless it is determined by the Registered Nurse (RN)/Licensed Practical Nurse (LPN)/Certified Nursing Assistant (CNA) at the time that the transfer is not a safe transfer for either the individual or the staff member. See Appendix B. The individual will be transferred by the safest means until reassessment by nursing or therapy. A registered nurse will be contacted for further review. The Falls policy and procedure with the latest review date of 6/24/22 documents under policy Prevention measures are put in place to reduce the occurrence of falls and risk of injury from falls. Under Procedure for 1. Fall risk documents: a. Licensed nurse will complete an electronic Fall Assessment upon admission. b. A licensed nurse will review electronic Fall Assessment quarterly, or with change in condition. c. A licensed nurse will determine the individuals' risk for falls and individualized care needs. If the individual is at risk for falls, then create a falls care plan. d. A individual falls care plan will be created as indicated. 1. R4 was originally admitted to the facility on [DATE] with hospitalization s from 3/16/23 to 3/27/23 and 4/2/23 to 4/6/23. On 4/6/23, R4's code status changed to DNR (do not resuscitate.) R4 fell on [DATE], and became unresponsive shortly after the fall. R4 was sent to the hospital unresponsive, with apnea and pulselessness. R4 was declared dead upon arrival to ED (Emergency Department). R4 was reviewed as a closed record. No observations could be conducted of R4. R4's diagnoses includes sepsis, aspiration pneumonia, acute kidney failure, hemiplegia & hemipareses following cerebral infarction affecting left non dominate side, Atrial Fibrillation, chronic systolic congestive heart failure, and presence of cardiac pacemaker. The at risk for falls care plan located in the facility's previous computer system with an effective & created date of 1/26/23 (date of admission) has the following interventions: * Encourage [R4's first name] to self propel w/c (wheelchair) on unit. Effective & created date of 1/26/23. * Individualized fall prevention measures on RST (Resident Summary Template) Care Card. Effective & created date of 1/26/23. * Footwear will fit properly and have non-skid soles. Effective & created date of 1/26/23. * Keep areas free of obstructions to reduce the risk of falls or injury. Effective & created date of 1/26/23. * Place call bell/light within easy reach. Effective & created date of 1/26/23. * Provide reminders to use ambulation and transfer assist devices as needed Effective & created date of 1/26/23. * Remind [R4's first name] to call for assistance. Effective & created date of 1/26/23. * Respond promptly to calls for assist to the toilet. Effective & created date of 1/26/23. * Complete Fall Risk Assessment per policy. Effective & created 1/26/23. The self care deficit care plan with an effective & created date of 1/26/23 includes an intervention also with an effective & created date of 1/26/23 & documents, See RST (Resident Summary Template) Care Card for transfer status. The admission MDS (Minimum Data Set) with an assessment reference date of 2/3/23 documents R4 has a BIMS (Brief Interview Mental Status) score of 13 which indicates resident is cognitively intact. R4 is assessed as not having any behaviors. R4 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use and does not ambulate. R4's urinary continence was not assessed and R4 is frequently incontinent of bowel. R4 has fallen the month prior to assessment and is assessed as not having any falls since admission. The fall CAA (care area assessment) is triggered but not completed. The RST (Resident Summary Template) (CNA (Certified Nursing Assistant) Care Card) with an updated date of 2/10/23 under the transfer section documents Transfers: Assist of 2+ (plus) (with gait belt). Under the safety precautions section documents, Safety Precautions: Call Before You Fall Sign Gripper Socks. On 5/16/23 at 12:36 p.m. DON (Director of Nursing)-B informed Surveyor this is the care card the CNA would have been using when R4 fell on [DATE]. Under the electronic record task tab for transfer status dated 3/30/23 it documents assist of 2 with Hoyer lift. The current electronic record, PCC (pointclickcare) only has care plans for limited physical mobility r/t (related to) disease process initiated 3/27/23 & revised 4/13/23, at risk for dehydration initiated 3/31/23 & revised 4/13/23, and at risk for unintended weight loss initiated 3/31/23 & revised 4/13/23. The fall risk evaluation dated 3/27/23 has a score of 14 which indicates at risk. The nurses note dated 4/7/23 at 2:29 a.m. documents: Resident is on follow up readmission from [Name] Hospital with diagnoses of heart failure with reduced ejection fraction, cardiomyopathy, aspiration pneumonia, AKI (acute kidney injury) and decondition. Resident is alert and oriented x (times) 3. Is able to make needs known to staff. Uses call light appropriately. Came with [hospital name] .: medications discontinued: Acidophilus, Aspirin, Atorvastatin, Losartan and Metoprolol, mostly due to resident's low blood pressure. Resident c/o (complained of) not feeling well and being able to breathe. Resident has O2 (oxygen) inhalation @ (at) 2L/min. (two liters per minute) with O2 saturation of 88%. Increased O2 to 4L/min to maintain O2 saturation of 92%. Resident is very weak, observed at times having abdominal breathing, which goes back to regular breathing after a while. Abdomen slight obese with + (positive) bowel sounds x 4 quadrants of the abdomen. Resident came back to facility a DNR (Do Not Resuscitate). Due to heart failure. Resident stated that he understood what is going on but if he can't breathe, he gets anxious and is afraid. Resident is to be evaluated by hospice. BP (blood pressure) 110/56, T (temperature) 97.1, P (pulse) 58, R (respirations) 18, O2 sat 88% @ 2L/min. Increased to 4L/min. to maintain O2 sat. (saturation) of above 92%. Checked and changed. Turned and repositioned, kept comfortable in bed. The nurses note dated 4/10/23 at 11:48 p.m. documents: Pt. remains alert and oriented. Able to make needs known. Responds to verbal and tactile stimuli. VS (vital signs) 101/56, P 53 T 97.2 SPO2 93% via nasal cannula at 5LPM (liters per minute). No c/o pain or discomfort noted at this time. Pt remains with right sided weakness. Stage 1 noted to sacrum/coccyx area. Pt consumed less than 25% of PM (evening) meal this shift. Pt would only accept ice cream cups and Ensure at this time. Family in to visit. Fluids encouraged. Needs anticipated by staff. Will continue to monitor. The nurses note dated 4/11/23 at 20:05 (8:05 p.m.) documents: Pt (patient) wife [name] and daughter [name] in to visit [R4's first name] this evening. They both stated concerns and complaint r/t (related to) pt not receiving shower since before his return back from the hospital. Family has demanded shower to be completed in the morning tomorrow. They have stated they do not want [R4's first name] to be bathed in bed, he must be showered. Reported to oncoming RN (Registered Nurse). Will continue to monitor. The incident note dated 4/12/23 at 13:22 (1:22 p.m.) documents: Resident had fall from sit to stand lift while being transferred from bed to bath chair. For bath per family's request. Resident sustained a skin tear to his right upper arm and to left side of head. When asked what happened resident stated I do not know. When asked if he knew where he was he said yes but did not say where. When asked if he was in pain he said no. Full body lift was used to left [sic] (lift) resident from floor with assist of 3 and placed in bed. Resident incontinent of bowel. After being placed in bed about 10 minutes after fall resident became unresponsive. 911 called by floor nurse at about 9:30am. Resident taken to [name of] hospital. [Name] NP (nurse practitioner) notified. Spoke with wife [name] and let her know what happened. Resident has passed. Also spoke with medical examiner and gave information on fall. Medical examiner believed that resident collapsed. States that the time was to quick from fall to unresponsiveness, that she believes that death was not from subdermal hematoma but resident had an incident. The incident note dated 4/12/23 at 17:48 (5:48 p.m.) documents: Writer was called to room [number] by assigned CNA. CNA reported resident fall in room [number] to writer. Unit Manager informed of incident immediately. Upon arrival, Resident was observed lying on his left side with towel under his head. Noted to have skin tear to his right upper arm and left side of head. Resident asked what happened, he stated he did not know. Was asked if he knew where he was, replied yes. When asked where he was, resident did not reply. Was asked if having pain, resident replied no. Resident assisted off the floor with mechanical Hoyer lift and 3 assist from floor into his bed. Resident was incontinent of stool. After resident placed in bed, he took a few big breaths. HOB (head of bed) elevated. Resident sneezed multiple times and become unresponsive. 911 called. DON informed of incident. Surveyor reviewed the incident audit report for incident date 4/12/23. Attached to the incident audit report is a statement from CNA-Q. CNA-Q's handwritten statement dated 4/12/23 under statement documents: @ (at) 9:20 am I went into [R4's first name] room to get him ready for an [sic] bath. I got the sit to stand for him. I put him on the sit to stand. I put the second holes on to make sure he was more secured then I stapped [sic] (strapped) him with the strap on 5 but one, he said not so tight which I didn't do so tight. Judging that he has skin tears. I didn't put the feet on (the straps by the feet) as I moved him to go into the shower/bath chair he let go and fell on to the floor. It happened so fast. [R4's first name] isn't strong enough for that. I immediately grab nurse [LPN (Licensed Practical Nurse)-P's first name] then put a towel on head. [R4's first name] isn't strong enough for him to stand by himself. Assisted with Hoyer lift with nurses to get [R4's first name] from floor onto the bed. Put strap around waist. Surveyor noted CNA-Q transferred R4 by herself, not with an assistance of 2 and did not place the straps on R4 correctly. The hospital record dated 4/12/23 at 0935 (9:35 a.m.) documents for chief complaint unresponsive and secondary complaint cardiac arrest. Under history of present illness documents Presented to the ER (emergency room ) unresponsive, pulseless and apneic. Report given via EMS (emergency medical services) at bedside. They reported getting a call from nursing home today of the patient reportedly fell and hit his head. Patient was initially responsive after fall and was transferred to this bed. While EMS was en route patient became unresponsive and his breathing slowed. On EMS arrival patient was unresponsive and had agonal breathing. No pulses were palpated and patient was found to be in PEA (pulseless electrical activity). He had signed DNR paperwork and EMS did not perform any interventions. They spoke with their med control and were told to bring patient to the ED (emergency department) despite his unresponsiveness, apnea and pulselessness. Patient was declared dead upon arrival to ED. His family has not been notified of the events of today. The certificate of death with date of death [DATE] and time of death documents 10:21. Under 41. Part I The conditions listed are the diseases, injury's or complication that caused death. Conditions leading to the immediate cause are listed sequentially and the underlying cause is listed last documents for Immediate Cause: (a) documents Intracerebral hemorrhage. Due to or as a consequence of: (b) documents Hypoxic respiratory failure. On 5/15/23 at 4:19 p.m., Surveyor spoke with R4's family member on the telephone. R4's family member informed Surveyor R4 would not have been able to hold onto the handles of the lift as he was too weak. R4's family member informed Surveyor they were told he let go of the handles and fell . The family member informed Surveyor doesn't want this to happen to anyone else. On 5/16/23 at 7:45 a.m., Surveyor spoke with RN (Registered Nurse) Supervisor-S regarding R4. RN Supervisor-S explained R4 came to the facility for rehab to get better but of course didn't get better as R4 had heart failure. Surveyor asked RN Supervisor-S if she was there when R4 fell on [DATE]. RN Supervisor-S replied no, and indicated she came in at night. Surveyor asked RN Supervisor-S if she remembered how R4 was transferred. RN Supervisor-S informed Surveyor she couldn't recall. RN Supervisor-S informed Surveyor the family requested R4 receive a bath as staff had been giving him a bed bath and on her shift R4 didn't get up. RN Supervisor-S informed Surveyor she believes the fall was with an agency aide. On 5/16/23 at 9:49 a.m., Surveyor spoke with Rehab Manager/PT (physical therapy)-R to inquire if R4 attended therapy and what R4's transfer status was. Rehab Manager/PT-R informed Surveyor R4 was to be seen for therapy 3/31/23 to 4/3/23 and that they saw R4 due to recent hospitalization . Rehab Manager/PT-R informed Surveyor the goal was for R4 to be transferred using a sit to stand lift. Rehab Manager/PT-R explained when R4 came back from the hospital he was a Hoyer lift and they were going to work on using a sit to stand lift. Surveyor asked Rehab Manager/PT-R if R4 was able to use the sit to stand lift? Rehab Manager/PT-R stated, looks like he was a Hoyer lift as he refused to do the sit to stand evaluation. Rehab Manager/PT-R informed Surveyor they only saw R4 on 3/31/23, R4 refused to do anything and then R4 went to the hospital. R4 came back on 4/6/23 but they did not see him as he came back on hospice. Surveyor asked Rehab Manager/PT-R if therapy made any recommendations on how R4 should be transferred when R4 returned from the hospital on 4/6/23. Rehab Manager/PT-R replied not by our therapy and wasn't sure if there was any recommendation from the hospital. Surveyor asked Rehab Manager/PT-R as far as therapy was concerned R4 was a Hoyer lift for transfers. Rehab Manager/PT-R replied correct. Rehab Manager/PT-R stated they only saw R4 on 3/31/23 which was a Friday and R4 went to the hospital on Monday. On 5/16/23 at 10:05 a.m., Surveyor asked DON-B if CNA-Q works at the facility. DON-B replied no, she is agency and doesn't work at the facility any more. On 5/16/23 at 12:36 p.m., Surveyor spoke to DON-B regarding R4's transfer status. DON-B informed Surveyor the last she knows R4 was an assist of 2. Surveyor informed DON-B the care card DON-B provided Surveyor with dated 2/10/23 documents R4 was an assist of 2 with a gait belt. Surveyor informed DON-B under the tasks (in the electronic record) and according to therapy, R4 was Hoyer lift with an assist of 2. Surveyor asked DON-B if it's possible the care card in R4's room was not updated? DON-B replied yes and indicated if therapy changed then they should have changed the care card. Surveyor informed DON-B the care card still states an assist of 2. DON-B informed Surveyor it didn't appear CNA-Q had 2 with the transfer. DON-B informed Surveyor she told the company CNA-Q needed to be disciplined and doesn't want her back. DON-B informed Surveyor even with the sit to stand CNA-Q was using there should have been 2 staff. DON-B informed Surveyor CNA-Q didn't follow what their protocol was. Surveyor inquired who develops the RST (Resident Summary Template) care card. DON-B informed Surveyor all different departments. Surveyor inquired if anyone checks to see if this care card is current. DON-B replied periodically, yes. Surveyor asked who is responsible to ensure the care cards are up to date? DON-B informed Surveyor it could be the manager, supervisor, she may ask a CNA to check, the nurses, not a single person. On 5/16/23 at 1:17 p.m., Surveyor spoke to RN (Registered Nurse)-K on the telephone regarding the day R4 fell . RN-K explained she was in the stand up meeting when the floor nurse came to the meeting and told her R4 fell . RN-K explained she went down to the room with her and completed an assessment in the room. RN-K informed Surveyor R4 was on the floor on his left side and there was an abrasion to the left side of his head and possibly on the right arm. RN-K indicated she asked R4 what happened but R4 didn't remember. R4 was able to move his arms & legs. They got a Hoyer and placed R4 in bed and that's when R4 took large gasps of air. RN-K indicated she raised the head of the bed, R4 sneezed a couple times and became unresponsive. RN-K informed Surveyor she asked the floor nurse to call 911. RN-K informed Surveyor she ran to get a stethoscope, came back with the DON, she couldn't hear anything and asked the DON to listen. Surveyor asked RN-K if she did any neuro checks. RN-K informed Surveyor she had R4 squeeze her hand. Surveyor asked RN-K what was the time period from when they placed R4 into bed until 911 was called. RN-K informed Surveyor she's not good at this but thinks it was about 10 minutes. On 5/17/23 at 8:14 a.m., Surveyor asked DON-B if there is anything else she did other than calling the agency and informing them they need to discipline CNA-Q and she doesn't want CNA-Q back? DON-B replied she got a statement from CNA-Q. Surveyor asked DON-B after R4's fall did she provide staff with any education? DON-B replied, I may have I can check. On 5/17/23 at 8:27 a.m., Surveyor spoke with LPN (Licensed Practical Nurse)-P. LPN-P wrote the incident note dated 4/12/23 at 5:48 p.m. LPN-P explained she was passing medication when the CNA came to her and told her R4 had fallen on the ground in his room. LPN-P informed Surveyor she thinks the CNA was using a sit to stand lift. LPN-P explained she went in R4's room, R4 was on the floor, and she made sure R4 was safe. LPN-P informed Surveyor she then went to get RN (Registered Nurse)-K who was in morning report. LPN-P informed Surveyor RN-K came out of report, went to R4's room and did an assessment. Surveyor inquired what type of assessment RN-K did. LPN-P explained RN-K basically did a head to toe assessment, checked to see if R4 could move his extremities, had R4 squeeze her hand, and asked him questions. LPN-P informed Surveyor R4 was clear in his responses, confused, which was his baseline. LPN-P informed Surveyor R4 did have an abrasion at the back of his head which was cleaned. LPN-P informed Surveyor they then proceeded to remove R4 off the floor with a Hoyer and explained when there is a fall they use a Hoyer to get the resident up. LPN-P informed Surveyor they got R4 into bed and then R4 started breathing quickly & weird. Surveyor inquired after they got R4 in bed how long was it that his breathing changed. LPN-P informed Surveyor within 3 minutes and she knows it was less than 5 minutes and then R4 became unresponsive. LPN-P informed Surveyor RN-K instructed her to call 911, she met 911 at the door and they were at the facility within 10 minutes. Surveyor asked LPN-P if the CNAs receive report in the morning. LPN-P informed Surveyor she provides the CNAs with the highlights and what needs to be done. LPN-P explained if she knows that it is a CNA's first time on her unit she will take out the Kardex and point things out to them. Surveyor inquired if she went over the Kardex with CNA-Q the morning of R4's fall. LPN-P informed Surveyor CNA-Q had been here a couple times so she wasn't new. Surveyor asked if R4 had any unresponsive episodes in the past? LPN-P replied no and explained she knows R4 had cardiac issues. Surveyor inquired who updates the care cards the CNA use. LPN-P informed Surveyor usually the unit manager but anyone can. LPN-P informed Surveyor she will update the care card but will ask the RN first as she thinks it is out of her scope of practice just to update the care card. On 5/17/23 at 8:59 a.m., Surveyor asked DON-B if she went to R4's room after R4 fell ? DON-B replied no. Surveyor asked DON-B if she had to give RN-K any instructions? DON-B informed Surveyor they knew what they were doing and they were sending him out. Surveyor asked DON-B if she assessed R4 before he went out? DON-B replied no, RN-K was down there, she didn't need to. On 5/17/23 at 9:49 a.m., Surveyor asked DON-B if she was able to find any education provided to staff after R4's fall? DON-B replied no would be the answer. Surveyor asked if anyone did a house wide sweep of the care cards in resident's closets to ensure they were accurate? DON-B informed Surveyor she can't remember if they did it right before she left in January. DON-B indicated this was on the docket for next week after the surveyors had been talking about the care cards. The immediate jeopardy was removed on 5/19/23 when the facility completed the following: * All residents' transfer status was reviewed for accuracy. * All residents' transfer status are care planned on CNA care cards. * Education material on transfer status provided for staff to review beginning 5/18/23. * Safe handling policy was reviewed and education to staff including agency was initiated on 5/18/23. * Competency check offs initiated using the manufacturers instructions provided for staff during the shift they worked. These competency check offs were Quality Assurance transfer and safe lift. Evaluation tools for both the full body and sit to stand devices we use on residents identified. * Trained CNAs, Restorative aides, and DON provided training to all nursing staff and competencies completed. * Audits will be completed to ensure competency and safe transfers to residents weekly. * The audit will be completed by DON and designees. * All residents' transfer status was reviewed by therapy staff. * DON/designees and therapy will be systematically looking at and reviewing care cards for accuracy. * Staff and agency staff will be orientated to location of care cards and transfer status during shift report daily. * DON/designee will review audits for QAPI presentation. * Care plan audits and care card audit for accuracy will be included in weekly audits. * Weekly audits initiated and results presented to QAPI. The deficient practice continues at a scope/severity of E potential for harm/pattern based on the following examples: 2. R6's diagnoses includes anxiety disorder, Parkinson Disease, and dementia. The at risk for falls care plan created 9/29/22 has the following interventions: * Encourage [R6's first name] to self propel w/c (wheelchair) on unit. Created 9/29/22. * Individualized fall prevention measures on RST (resident summary template) Care Card. Created 9/29/22. * Footwear will fit properly and have non-skid soles. Created 9/29/22. * Keep areas free of obstructions to reduce the risk of falls or injury. Created 9/29/22. * Place call bell/light within easy reach. Created 9/29/22. * Provide reminders to use ambulation and transfer assist devices as needed. Created 9/29/22. * Remind [R6's first name] to call for assistance. * Respond promptly to calls for assist to the toilet. Created 9/29/22. * Complete Fall Risk Assessment per policy. Created 9/29/22. The quarterly MDS (Minimum Data Set) with an assessment reference date of 4/13/23 has a BIMS (Brief Interview Mental Status) score of 8 which indicates moderately impaired. R6 is assessed as requiring extensive assistance with one person physical assist for bed mobility & extensive assistance with two plus person physical assist for transfer. R6 is assessed as not having any falls since prior assessment period. The CNA (Certified Nursing Assistant) Kardex as of 4/27/23 located in side R6's closet has the following sections: Transfer, Bed Mobility, Dressing, Eating/Nutrition, Activities, Resident Care/Skin, Mobility/Ambulation, Toileting, Person Hygiene/Oral Care, Resident Care, and Bathing. Under Resident Care documents; *A&Ox1 (alert and orientated times one). *Encourage the resident to use bell to call for assistance. *BEDFAST: The resident is bedfast all or most of the time. *Monitor/document/report PRN (as needed) for changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. *Special instructions: *The resident is WEIGHT-BEARING. Surveyor noted the CNA care card has not been updated to include the floor mat or body pillow. The Fall risk assessment dated [DATE] has a score of 10 which indicates at risk for falls. The nurses note dated 5/3/23 documents Resident is adjusting well. Hospice brought new w/c (wheelchair) and floor mat. Resident denies pain or discomfort at this time. No other issues or concerns noted. Will continue to monitor. On 5/15/23 at 9:40 a.m. Surveyor observed R6 in bed on her back with the head of the bed elevated eating breakfast. The right side of R6's bed is against the wall and there is a body pillow along the left side of the bed. Surveyor observed there is a gray floor mat folded at the head of R6's bed and is not on the floor by the left side of R6's bed. On 5/15/23 at 11:37 a.m. Surveyor observed R6 sitting in a broda chair with the back of R6's broda chair reclined slightly located by the window. R6's legs are extended with R6's feet resting on the foot portion of the broda chair. R6's eyes are closed and R6 appears to be sleeping. On 5/15/23 at 12:46 p.m. Surveyor observed R6 sitting in a broda chair in the dining room eating lunch. On 5/15/23 at 1:53 p.m. Surveyor observed R6 sitting in a broda chair in the dining room. There is a visitor sitting to the right of R6. On 5/16/23 at 6:59 a.m. Surveyor observed R6 in bed on her right side. The right side of R6's bed is against the wall, there is a body pillow along the left side of R6's bed and a gray mat on the floor on the left side of R6's bed. On 5/16/23 at 7:55 a.m. Surveyor observed R6 dressed for the day sitting in a broda chair at a table in the dining room. On 5/16/23 at 10:06 a.m. Surveyor observed R6 sitting in a broda chair by the left side of R6's bed with the call pad in reach. On 5/16/23 at 1:03 p.m. Surveyor asked CNA (Certified Nursing Assistant)-J if R6 is going to lay down. CNA-J informed Surveyor R6 is still eating and she had refused to lay down. On 5/17/23 at 7:02 a.m. Surveyor observed R6 in bed on her right side. R6's right side of the bed is against the wall. There is no body pillow along the left side of the bed and Surveyor observed the body pillow is in the chair. The gray floor mat is folded and is located at the foot of the bed. The gray mat is not on the floor on the left side of the bed. Surveyor observed R6's bed is up and is not at the lowest position. On 5/17/23 at 7:39 a.m. Surveyor observed R6 continues to be in bed on her right side. Surveyor observed there is still no body pillow on the left side of R6's bed and there is no mat on the floor. On 5/17/23 at 8:17 a.m. Surveyor observed R6 continues to be in bed on her right side. Surveyor observed there is still no body pillow on the left side of R6's bed and there is not a mat on the floor. On 5/17/23 at 8:50 a.m. Surveyor observed CNA-F wheeling R6 out of her room in a broda chair into the dining room and place R6 at a table. On 5/17/23 at 8:56 a.m. Surveyor asked CNA-F if he has cared for R6 before today. CNA-F replied once or twice. Surveyor asked CNA-F if he had been in R6's room prior to getting R6 up today. CNA-F replied no. Surveyor asked CNA-F if there should be a body pillow along R6's left side of the bed and a floor mat on the left side of the bed. CNA-F replied yes and then stated when he walked in R6's room it wasn't there. On 5/17/23 at 2:30 p.m. Surveyor informed DON (Director of Nursing)-B of the observations of R6 not having the body pillow on the left side of the bed and mat not on the floor. Surveyor also informed DON-B R6's at risk for falls care plan and CNA care card not updated with the body pillow & floor mat. 3. R11 was originally admitted to the facility on [DATE] and discharged [DATE]. R11 was reviewed as a closed record and therefore observations could not be conducted of R11. R11's diagnoses includes congestive heart failure, hypertension, diabetes mellitus, Alzheimer's Disease and dementia. The at risk for falls care plan effective 11/22/21 & revised 12/3/21 has the following interventions: * Encourage [R11's first name] *to self propel w/c (wheelchair) on unit. Effective 11/22/21. * Individualized fall prevention measures on RST (Resident Summary Template) Care Card. Effective 11/22/21. * Footwear will fit properly and have non-skid soles. Effective 11/22/21. * Keep areas free of obstructions to reduce the risk of falls or injury. Effective 11/22/21. * Place call bell/light within easy reach. Effective 11/22/21. * Provide reminders to use ambulation and transfer assist devices as needed. Effective 11/2 [TRUNCATED]

Based on interview and record review, the facility did not ensure residents were free of a significant medication error for 1 (R86) of 1 resident reviewed for medication errors. R86 did not receive omeprazole as ordered for four weeks resulting in a hospitalization for a [CONDITION(S)]. Findings include: The facility policy and procedure entitled Transcribing physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A. At the implementation stage, three conditions must be met before a nurse may legally follow through on any medication or treatment order: 1. The medication or treatment order must be valid. 2. The physician and nurse obtaining the order must be licensed. 3. The nurse must know the purpose, actions, effects, major side effects and appropriate dose for all medication orders. B. A valid order is one that leaves no room for doubt as to the directive, treatment or medication prescribed. Medications ordered must have a dose and route, and dosing intervals. All orders must include the prescribers name and signature of the licensed nurse accepting the order. The drug must be appropriate for the resident; therefore, a reason or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . C. A Licensed Nurse will initially enter all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If available, a second Licensed Nurse (RN/LPN) will complete a verification to assess the order for its preciseness, accuracy and appropriateness; this nurse will activate the order and print any medication and treatment orders for pharmacy. D. Licensed Nurses are to monitor the EMR system for any New Orders that require activation. F. All orders must be entered and worded in such a way that is correct, complete, and clearly understandable. An appropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If not, clarification must be sought from the MD who gave/wrote order or the nurse who accepted and entered the order. R86 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . hospitalization prior to admission included a surgical hernia repair and a transurethral resection of the prostate (TURP). The admission Minimum Data Set (MDS) assessment, dated 5/27/2022, indicated R86 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and needed extensive assistance with activities of daily living. On 5/20/2022, on the Hospital Discharge Summary, the Physician Assistant documented R86's hospital course as R86 having a right inguinal hernia repair and a TURP with continuous bladder irrigation for 24 hours. The following medications were ordered on discharge: omeprazole 20 mg Delayed Release (E.C.) daily, aspirin 81 mg chewable table daily, and re-start [MEDICATION(S)] ([MEDICATION(S)]) in 5 days. (No dose for the [MEDICATION(S)] was documented at that time.) Per WebMD, https://www.webmd.com/drugs/2/drug-3766-2250/omeprazole-oral/omeprazole-delayed-release-tablet-oral/details, Omeprazole is used to treat certain stomach and esophagus problems (such as acid reflux, ulcers). It works by decreasing the amount of acid your stomach makes. It relieves symptoms such as heartburn, difficulty swallowing, and cough. This medication helps heal acid damage to the stomach and esophagus, helps prevent ulcers, and may help prevent cancer of the esophagus. Omeprazole belongs to a class of drugs known as proton pump inhibitors (PPIs). Surveyor reviewed the facility orders for R86. On 5/20/2022, R86 had the following orders in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -aspirin 81 mg chewable tablet daily. -omeprazole 20 mg tablet delayed release daily for one day. (The order should not have read for one day.) On 5/26/2022, [MEDICATION(S)] 75 mg daily was started as ordered. Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/1/2022 on the Medication Regimen Review, the pharmacist noted the omeprazole was discontinued. On 6/1/2022 on the Skilled Nursing Facility History and Physical report, the physician documented R86 was seen in the wheelchair resting comfortably. The physician documented R86 had issues with [CONDITION(S)] secondary to bleeding and continued on [MEDICATION(S)] and aspirin; iron tablets would be started given the high risk of iron deficiency [CONDITION(S)] secondary to acute blood loss. The physical examination was unremarkable. The following labs were on the report: -5/23/2022: Hemoglobin 10.1g/dL, Hematocrit 30.7% -5/27/2022: Hemoglobin 9.1 g/dL, Hematocrit 28% -5/31/2022: Hemoglobin 8.7 g/dL, Hematocrit 27.3% The physician documented in the Assessment and Plan section for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R86 was not taking omeprazole at that time.) The physician documented to follow up with urinary symptoms, abdominal concerns, blood pressures, volume overload, progress with therapies, and routine laboratory monitoring. On 6/2/2022, at 8:42 PM, nursing charted R86 was straight catheterized due to urinary retention and 400 ml of dark cloudy yellow urine was drained. No blood was noted in the urine. On 6/2/2022, at 11:21 PM, nursing charted R86 requested a suppository and abdomen was firm in all four quadrants with hypoactive bowel sounds. A rectal check was completed and positive for firm but not hard stool plugging the rectum. The physician was contacted to request an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/3/2022, at 4:45 AM in the progress notes, nursing charted R86 was unable to urinate and was straight catheterized with clear, apricot colored urine returned. On 6/3/2022, at 9:22 AM in the progress notes, nursing charted R86 had a large bowel movement with no difficulty to pass. On 6/3/2022, at 9:53 AM in the progress notes, nursing charted a foley catheter was placed due to urinary retention. The urine was amber/straw colored. On 6/3/2022, at 9:19 PM, in the progress notes, nursing charted indwelling catheter was draining blood-colored urine. R86 asked for [MEDICATION(S)] or prune juice even though R86 had a bowel movement that day. R86's abdomen was soft, non-tender, and non-distended. The urine culture came back positive, and an antibiotic was started for five days. Vital signs were stable and afebrile. On 6/4/2022, at 1:46 PM, in the progress notes, nursing charted R86 had hematuria due to the resection of the prostate. On 6/5/2022, at 5:55 PM, in the progress notes, nursing charted the indwelling catheter was patent draining yellow urine at times and at other times the urine turns back to bloody red hematuria with blood shreds. Vital signs were stable. On 6/6/2022, at 1:24 AM, in the progress notes, nursing charted the indwelling catheter was patent and intermittently draining straw-colored yellow, amber, and blood colored urine with mucous shreds. Vital signs were stable. On 6/7/2022, at 4:32 AM, in the progress notes, nursing charted the indwelling catheter was patent and draining clear yellow urine; no hematuria was noted. On 6/7/2022, at 10:37 AM, in the progress notes, nursing charted R86 had a soft, flat abdomen with active bowel sounds. The indwelling catheter was draining clear yellow urine. On 6/8/2022, on the Skilled Nursing Facility Progress Note, the Nurse Practitioner (NP) documented R86 had labs completed on 6/6/2022 with a decrease in hemoglobin. No rectal bleeding had been noted and orders were for a close follow up of hemoglobin. On 6/6/2022, the Hemoglobin was 7.7 g/dL and the Hematocrit was 24.2%. The NP documented in the Assessment and Plan section for the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R86 was not taking omeprazole at that time.) The NP documented to follow up with urinary symptoms, blood pressures, volume overload, progress with therapies, and routine laboratory monitoring. On 6/8/2022, at 12:39 PM, in the progress notes, nursing charted R86 requested to have nightly scotch as that is the normal routine for R86 at home. An order was obtained for R86 to have 1-2 ounces of scotch nightly. On 6/9/2022, at 11:03 AM, in the progress notes, nursing charted R86 was alert and oriented with forgetfulness at times with anxiety related to bowel movements. R86 frequently wants something for bowel management even if R86 had a bowel movement. Nursing had been doing frequent education regarding bowel management and going over medication list and as needed medications with R86. R86 was informed bowel movements are tracked for all residents daily. R86's abdomen was flat and soft with active bowel sounds. The indwelling catheter was draining clear yellow urine. On 6/11/2022, at 9:38 AM, in the progress notes, nursing charted R86's abdomen was soft and non-tender with active bowel sounds in all four quadrants. R86 denied nausea, vomiting, and diarrhea. R86 reported having a complete clean out of the bowels yesterday after having Milk of Magnesia, fiberstat and a suppository. The indwelling catheter was patent draining dark urine. On 6/12/2022, at 1:00 PM, in the progress notes, nursing charted R86's abdomen was soft and non-tender with active bowel sounds in all four quadrants. The indwelling catheter was patent draining dark urine. On 6/13/2022, on the Skilled Nursing Facility Progress Note, the NP documented R86 was doing well that morning and nursing reported R86 had no pain and tolerating acetaminophen for pain. R86's urinary catheter was draining golden yellow urine without hematuria (blood in the urine). R86 reported an excellent appetite stating 100% of the breakfast was eaten. Labs were reviewed and hemoglobin was 6.7, previously at 8.9 on 6/9/2022. No active signs of bleeding were noted, and orders were placed for follow up lab in the morning to trend. The NP documented R86 may require further evaluation if hemoglobin remains low or drops further. R86 had no fevers, upper respiratory symptoms, shortness of breath, cough, nausea, abdominal pain, urinary concerns, diarrhea, or constipation. The following labs were on the report: -6/9/2022: Hemoglobin 8.9 g/dL, Hematocrit 27.6% -6/13/2022: Hemoglobin 6.7 g/dL, Hematocrit 20.9% On 6/13/2022, at 5:36 PM, in the progress notes, nursing charted R86's indwelling catheter was draining straw-colored urine that was clouded with sediment. R86 had an order per R86's request to have a serving of scotch liquor every day at 2:00 PM. R86 complained this afternoon of gas pains/stomach discomfort. Scheduled [MEDICATION(S)] was given before dinner. On 6/14/2022, at 8:56 AM, in the progress notes, nursing charted R86 complained of nausea with dry heaves. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/14/2022, at 9:00 AM, in the progress notes, nursing charted R86's abdomen was soft and flat with hypoactive bowel sounds. R86 had an extremely large bowel movement that morning that was not difficult to pass. The indwelling catheter was draining clear straw/yellow colored urine. On 6/14/2022, on the Skilled Nursing Facility Progress Note, the NP documented R86 was seen on that date due to [CONDITION(S)]. Labs that morning confirmed a decrease in hemoglobin at 6.1 and had noted fatigue that morning in addition to worsening weakness. R86 did not have shortness of breath or audible cough. R86 reported poor appetite this morning. The urinary catheter had golden yellow urine without hematuria or sediment. Nursing staff reported R86 had a large dark bowel movement this morning. Vital signs were reviewed with a noted low blood pressure at 90 systolic. R86 reported mild abdominal discomfort. Orders were placed to have R86 evaluated in the emergency department due to [CONDITION(S)]. The following labs were on the report: -6/13/2022: Hemoglobin 6.7 g/dL, Hematocrit 20.9% -6/14/2022: Hemoglobin 6.1 g/dL, Hematocrit 18.3% The Assessment and Plan section of the Note stated Hemoglobin at 8.9 on 6/9/2022 and now confirmed at 6.1 on 6/14/2022 with dark stool led to R86 being sent to the emergency room for further evaluation. On 6/14/2022, at 11:01 AM, in the progress notes, nursing charted an order was received to send R86 out to the hospital due to the repeat lab draw this morning of the hemoglobin and hematocrit. On 6/15/2022, at 9:19 AM, in the progress notes, nursing charted R86 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R86 did not return to the facility. R86 was discharged from the hospital to a different facility for skilled nursing services. Surveyor reviewed the facility grievance log. A grievance was filed by R86's family member on 6/17/2022 regarding a medication error. Surveyor requested to see the follow up of the grievance. On the Incident Report-Medication Error form dated 6/17/2022, the error occurred on 5/22/2022 with a discovery date of 6/17/2022. The error that was discovered was a transcription error. The details of the incident section of the form stated the incident was brought to the attention of the facility that R86 was not receiving omeprazole. Through investigation it was noted that the medication was placed in the computer but only for one day. R86 only received one dose of omeprazole. The summary stated the policy was reviewed with both individuals about medication transcription as it was noted that the order was put in wrong and verified wrong. Employee statements were obtained during the investigation. The statement by Licensed Practical Nurse (LPN) that entered the orders into the EMR stated that was the first time entering orders into the EMR since hire date of 4/8/2022 and the LPN stated there were multiple admissions with frequent interruptions while entering the medication orders. The LPN stated they will now take initiative when more that one admission is coming in on the day shift and will slow down and do what is to be done with all tasks. The statement by Registered Nurse Unit Manager (RNUM)-D that activated the medication orders stated the medication was ordered to start the next day but did not note that the medication was written for one dose only. RNUM-D stated they were going to quickly and will now slow down and check to see if an amount in days was scheduled. On 8/9/2022, at 3:04 PM, Surveyor met with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and RNUM-D. Surveyor shared the concern R86 did not receive omeprazole for four weeks on admission that resulted in hospitalization for a [CONDITION(S)]. No further information was provided at that time.

Based on interview and record review, the facility did not promptly consult with the resident's physician when 1 of 1 residents (R2) had a significant change in medical condition. Additionally, after the significant change the facility administered a medication that had the potential to further cause harm. On 2/27/19, R2, who is receiving anticoagulant therapy to prevent blood clots, had frank bleeding from the open areas on his buttock and from his gastric tube ([DEVICE]) stoma. The Medical Doctor (MD) was not consulted and the nurse administered an evening dose of his anticoagulant ([MEDICATION NAME]) after the frank bleeding was observed. Findings Include: The facility policy entitled, Change in Condition, dated 07/2016, states: A change of condition (C[NAME]) is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional capacity. Clinically important means a deviation that without intervention may result in complications or death. Change in Condition File Cares: are a decision support tool for the licensed nursing staff and medical providers to help with determining whether to report specific symptoms, signs and lab results immediately vs. non-immediately. (Located on medication carts and nurses station). Surveyor reviewed the Change of Condition binder at the Nurses Station that showed: When to report to MD/NP/PA (Medical Doctor/Nurse Practitioner/Physician Assistant), Interact version 4/0, dated 2014. Shows Immediate notification - Any symptom, sign or apparent discomfort that is: acute or sudden in onset and a marked change in related to usual symptoms and signs, or unrelieved by measure already prescribed. Under Symptom or Signs/Wounds - Immediate notification of any wound that will not stop bleeding, or that exposes subcutaneous tissue. R2 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. Gastrostomy ([DEVICE]) status. R2's care plan does not address the anticoagulant therapy identifying any problems, goals, approaches, or interventions. R2's Certified Nursing Aide (CNA) Care Card, updated 2/28/19, printed on 3/04/19, does not indicate monitoring R2 for bleeding. Under the section titled Additional Comments: R2 wears a binder to prevent R2 from picking at PEG Tube. Dated 8/22/18, please keep abdominal binder in place for [DEVICE] protection. Insure PEG clamp is not on resident skin but on preventative dressing on abdomen. R2's Medication Administration Record [REDACTED]. Give [MEDICATION NAME] 2.5mg along with 1mg to = 3.5mg total every HS. On 2/26/19 at 12:36 PM, Family Member (FM-PP) stated that R2's bottom has been bleeding and developing sores. On 2/27/19 at 11:30 AM, Surveyor observed CNA-P and CNA-R assist R2 transfer from his wheelchair to the toilet using a mechanical lift (Sit to stand). R2 was raised to the standing position and CNA-P lowered R2's pants and removed his brief. CNA-R stated that R2 has blood in the toilet and flushed the toilet before the nurse could view the blood and amount. Licensed Practical Nurse (LPN-G) applied prescribed ointment noting that R2 is bleeding from his buttock. Surveyor observed that R2 has blood dripping onto the floor. R2 was assisted in to the bedroom with the mechanical lift where the CNA placed a towel on the floor to catch the blood that is dripping from R2's buttock. LPN-G noted that R2's buttock is excoriated and bloody. R2's disposable brief was reapplied and he was brought to the dining room for lunch. Surveyor requested to observe R2 again after lunch with the Director of Nursing (DON-B) who is the facility wound nurse. On 2/27/19 at 1:17 PM, Surveyor observed R2 assisted to bed using the mechanical lift. CNA-P positioned R2 on his bed when Surveyor observed frank bleeding coming from R2's abdomen below his abdominal binder that covers his gastric tube ([DEVICE]). FM-PP appeared upset stating that I have never seen this before, noting the frank blood on R2's abdomen. R2 was positioned on his back in bed with his head elevated. DON-B and Registered Nurse Manager (RN-N) removed R2's shirt. Surveyor observed blood coming through both layers of R2's abdomen binder. R2's abdominal binder was open exposing R2's [DEVICE] site and the 4X4 split drain sponge. The sponge was saturated with frank blood. DON-B removed the sponge and cleaned his abdomen. Surveyor observed that no open areas were found on R2's abdomen that caused the frank bleeding. R2's pants and brief were removed to examine his buttock. R2's buttocks has multiple excoriated areas with three circular wounds with defined edges along the left ischial and another wound at the base of his scrotum. All the open areas noted appeared to be weeping blood. FM-PP continued to note that she has never seen this before and it was noted that R2 is on blood thinners which may cause him to bleed more. DON-B noted that the open areas on R2's buttock are considered Moisture Associated Skin Damage (MASD). On 2/28/19 at 10:07 AM, Surveyor observed CNA-L and CNA-O transfer R2 from his wheelchair to the toilet using the mechanical lift. R2 was assisted to the standing position and his pants were lowered. Surveyor observed that R2 continues to have frank bright red blood dripping from his buttock onto the floor. LPN-G entered the bathroom to apply R2's ointments to his buttock. LPN-G noted that his buttock looks the same as it always has. Surveyor interviewed CNA-L and CNA-O. CNA-L noted that R2's skin looks worse than ever with this bleeding. On 2/28/19 at 10:44 AM, Surveyor interviewed RN-N who noted that the lab called to report a critical lab for R2's International Normalized Ratio (INR - a test in the laboratory that can evaluate the time required for clotting of the blood) is at 5.53 (A normal INR is 0.8 to 1.1 for people not taking blood thinners and 2.0 to 3.0 for people taking [MEDICATION NAME] and other blood-thinning drugs, according to MedlinePlus) a critical lab value, we are calling to get an order for [REDACTED]. RN-N noted that she did not feel it was needed at the time since she was working late on 2/27/19 and was watching him. On 2/28/19 at 3:10 PM, Surveyor interviewed Medical Doctor (MD-U) who stated that he did not receive any call from the facility on 2/27/19, but they may have called his Nurse Practitioner (NP-V). Surveyor informed MD-U that R2 has an order for [REDACTED]. The [DEVICE] could have been irritated but I would have held the dose of [MEDICATION NAME] for that evening of 2/27/19. On 2/28/19 at 3:16 PM, Surveyor interviewed NP-V who noted that she did not receive a call from the facility related to R2 bleeding from the [DEVICE] stoma and buttock. NP-V noted that she was notified this morning about the bleeding and the critical INR. If someone is on [MEDICATION NAME] I would have told them to hold the [MEDICATION NAME] and order a CBC and INR right away. I would be concerned about the administration of another dose of [MEDICATION NAME] if bleeding is noted. I would have held the dose and called the doctor. This elevated INR is unusual for R2. On 3/04/19 at 10:30 AM, Surveyor interviewed RN-N who noted that on 2/28/19 at 10:45 AM she received orders to discontinue the [MEDICATION NAME] and to give one dose of Vitamin K and to recheck R2's INR. On 3/01/19 R2's INR was at 3.14 and new orders were received to restart the [MEDICATION NAME]. RN-N stated, I did not notify the MD on 2/27/19 when R2 had the frank blood noted on his abdomen and buttock. I checked his [DEVICE] placement and I did not feel that I needed to notify the MD at that time. (R2's) buttock is bleeding like that on and off. On 3/04/19 at 10:49 AM, Surveyor observed R2's buttock with DON-B and RN-N while he was in bed. R2's buttock appeared less reddened and the excoriation open areas have decreased in size. Surveyor observed that only a small amount of bleeding was noted to R2's buttock. On 3/04/19 at 11:23 AM, Surveyor interviewed LPN-G who noted that she observes R2 every shift when his ointment is applied. R2's buttock has bled occasionally but never like it was last week. Last week every time we wiped his buttock it started to bleed again. The blood was dripping onto the floor. On 3/05/19 at 10:24 AM, Surveyor interviewed DON-B related to if the bleeding that was observed on 2/27/19 for R2 was considered a change of condition from his baseline. DON-B noted that she did not know and that she would have to look into it more. DON-B stated, I was aware of the blood observed from the abdomen but not the blood that was observed dripping from R2's buttock. On 2/27/19 R2's abdomen did have blood soaked gauze that went into the layers of his abdominal binder. RN-N had worked late on 2/27/19 and was watching R2. I thought it was nothing more than a [DEVICE] tug that caused a lot of the bleeding. Surveyor questioned if the facility should have contacted the MD or NP on 2/27/19 when it was observed that R2 had bled from his [DEVICE] and buttock. DON-B stated she did not think the MD or NP should have been notified. Surveyor questioned if R2 was noted to have frank blood from multiple open areas if he should have received his evening dose of [MEDICATION NAME]. DON-B replied that if R2 was actively bleeding after she wiped down the abdomen than she would have looked into it a little further. That is why we needed to look at if it was trauma then it could have bled quicker even under the skin. R2 had no change in mentation and even though the blood had soaked the sponge and abdomen binder there was strings of clots. Surveyor questioned if R2's Care Plan addressed his use of anticoagulants. DON-B noted that R2 did not have a care plan related to his use of anticoagulants that would watch for what medication he was on and to watch for things like increased bruising. DON-B indicated, It upsets me that he did not have a care plan for anticoagulant . I need to work with staff on care plans and the details that belong in the care plan. (Cross Reference F684 and F757)

Based on observation, record review and interview, the facility did not ensure that 3 (R312, R14 & R22) of 4 sampled residents with pressure injuries, received consistent measures to prevent the development of pressure ulcers. * R312 did not have appropriate staging, monitoring, assessment or a plan of care for a stage III facility acquired pressure injury. * R14 did not have a appropriate staging, monitoring, assessment or a plan of care for a stage III facility acquired pressure injury. * R22 did not have a appropriate staging, monitoring, assessment or a plan of care for a stage II facility acquired pressure injury. Example 1 and example 2 rise to the scope and severity level of G (Isolated/Harm). Findings Include: 1. Surveyor reviewed R312's medical record from 1/3/18 to 1/10/18. R312 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R312's Admission MDS (Minimum Data Set) dated 12/20/17, documents a BIMS (Brief Interview for Mental Status) score of 13, indicating that R312 is cognitively intact. Section G (Functional Status) documents that R312 requires extensive assistance and a two person physical assist for her bed mobility needs. Section G also documents that R312 has total dependence and requires a two person physical assist for her transfer needs. Section G0400 (Functional Range of Motion) documents that R312 has impairment to one side of her lower extremities. Section M (Skin Conditions) documents that R312 is at risk for the development of pressure ulcers and had no pressure injuries on admission to the facility. Although R312's Admission MDS dated [DATE] documents that R312 had no pressure injuries on admission to the facility, R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17 documents, Wound background: Pt (patient) continues with deep tissue injury to coccyx. R312's Admission physician progress notes [REDACTED]. fluctuance or induration. R312's Pressure Ulcer CAA (Care Area Assessment) dated 12/28/17, documents under the Care Plan Considerations section, Resident is at risk for pressure area r/t (related to) deconditioning. Resident has MASD (Moisture Associated Skin Damage) to buttock area from deconditioning and incontinence. Resident has a [MEDICATION NAME] dressing to this area to help with healing. Resident is repositioned with staff assistance. Resident is on a pressure relief mattress and pressure relief w/c (wheelchair) cushion when in chair. Surveyor noted that R312's Pressure Ulcer CAA dated 12/28/17 does not address or document the deep tissue injury documented in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. R312's Braden Scale for Predicting Pressure Sore Risk dated 12/19/17 documents a score of 16, indicating that R312 is at risk for skin breakdown. Surveyor noted that R312's Braden Scale for Predicting Pressure Sore Risk dated 12/19/17 did not address or document the deep tissue injury documented in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. R312's Skin Integrity care plan dated 12/20/17 does not document or address any skin issues regarding R312's alleged MASD area and or deep tissue injury documented in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. R312's Admission Wounds/Skin Check dated 12/19/17 documents a shearing area to R312's Coccyx 4.2 centimeters in length and 2.5 cm in width. Surveyor noted that R312's Admission Wounds/ Skin check sheet dated 12/19/17 did not address or document the deep tissue injury documented in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. Surveyor also noted that R312's Admission Wounds/Skin check sheet dated 12/19/17 was completed by an LPN (Licensed Practical Nurse) and there was no documentation that an RN (Registered Nurse) had verified or completed an assessment on R312's skin upon admission on 12/19/17. R312's Weekly Wound Observation Report dated 12/19/17 documents, Type of Wound: Shearing/ MASD; Date first observed: Admission 12/19/17; Location of Wound: Right Upper Buttock; Length: 4.2 cm (centimeters); Width: 2.5 cm; Undermining: None; Edges of Wound: Healthy; Wound Bed: Pink; Exudate Type: None Surveyor noted that R312's Weekly Wound Observation Report dated 12/19/17 did not address or document the deep tissue injury documented in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. Surveyor noted that R312's Skin Integrity care plan dated 12/20/17 does not document or address any skin issues regarding R312's coccyx ulcer as documented in R312's deep tissue injury documented in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. R312's December 2017 and January 2018 TAR (Treatment Administration Record) documents the following treatment order, Wound: Two Times Daily starting 12/19/17; Notes: DTI (Deep Tissue Injury) on Coccyx area-Wash the area with soap and water and apply orange calaznie cream to the open area. Surveyor noted that the above treatment from 12/19/17 to 1/7/18. Surveyor noted that the DTI described in R312's December 2017 TAR did not have an assessment performed by an RN, monitoring or a care plan upon R312's admission. Surveyor noted that the DTI described in R312's December 2017 and January 2018 TAR did not have weekly monitoring or documented assessments performed by an RN or Physician from 12/19/17 to 12/21/17 and from 12/22/17 to 1/2/18. R312's Nursing Note dated 12/31/17 documents, Pt (patient) on report for a pressure area to her coccyx. Surveyor could not locate any documentation that documented that an RN assessment or any type of assessment of R312's described coccyx pressure area was completed on 12/31/17. R312's Weekly Wound Observation Report dated 1/2/18 documents, Type of Wound: Shearing/ MASD; Date first observed: Admission 12/19/17; Location of Wound: Right Upper Buttock. Length: 1.5 cm Width: 2.5 cm; Undermining: None; Edges of Wound: Healthy; Surrounding Skin: Maceration; Exudate Type: None; Comments: Wound bed: Pink. Add TAO (Triple Antibiotic Ointment) to promote healing. Surveyor noted that R312's Weekly Wound Observation Report dated 1/2/18 does not document or stage R312's pressure injury and does not document a change in R312's Skin Condition from MASD to a pressure injury. R312's Weekly Wound Observation Report dated 1/9/18 documents, Type of Wound: Shearing/ MASD; Date first observed: Admission 12/19/17; Location of Wound: Right Upper Buttock. Length: 1.5 cm Width: 2.5 cm; Progress: Deteriorated; Comments: Wound bed with 70% pink granulation tissue, 30 % slough; Surrounding Skin: Maceration; Edges of Wound: Healthy. Surveyor noted that R312's Weekly Wound Observation Report dated 1/9/18 does not stage R312's pressure injury as described in R312's Weekly Wound Observation Report comments. Surveyor could not locate in R312's medical record, a plan of care for R312's pressure injury as described in R312's Admission physician progress notes [REDACTED]. On 01/09/18 at 8:59 a.m., Surveyor interviewed R312 and R312's family member. Surveyor asked R312 if her pressure injury to her coccyx was improving. R312 and R312's family member informed Surveyor that they did not know if R312's pressure injury to her coccyx was improving as the facility had not formally assessed R312's coccyx pressure injury until this morning (1/9/18). R312 and R312's family member at this time declined for Surveyor to observe a treatment or cares of R312's coccyx pressure injury. On 1/9/18 at 10:42 a.m., Surveyor informed RN (Registered Nurse) Care Manager-M of the above findings. Surveyor asked RN Care Manager-M why R312 did not have a plan of care for R312's pressure injury as described in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17 or for R312's MASD as described in R312's Pressure Ulcer CAA dated 12/28/17. RN Care Manager-M informed Surveyor that the R312's Skin Integrity plan of care was not updated to reflect R312's pressure MASD as described in R312's Pressure Ulcer CAA dated 12/28/17. RN Care Manager-M informed Surveyor that R312 did not have a pressure injury upon admission as described in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. Surveyor asked why R312's Admission physician progress notes [REDACTED]. assessment. RN Care Manager-M informed Surveyor that she had no further information why R312's Admission physician progress notes [REDACTED]. RN Care Manager-M informed Surveyor that R312's Skin Integrity plan of care should be updated and that its on a list of things for RN Care Manager-M to do. Surveyor asked RN Care Manager-M if R312 currently had a pressure injury and if he did, what stage was it currently assessed as, as R312's Weekly Observation Reports do not document any staging to R312's pressure injury. RN Care Manager- M informed Surveyor that R312 currently has a Stage III pressure injury as documented in R312's Weekly Wound Observation Report dated 1/9/18. Surveyor asked RN Care Manager-M when R312's pressure injury first developed as Surveyor noted that R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17 and R312's Admission physician progress notes [REDACTED]. RN Care Manger-M informed Surveyor that R312 had MASD upon admission and no open areas upon admission to the best of her knowledge. RN Care Manger-M informed Surveyor that R312 developed a facility acquired stage II pressure on 12/31/17 as documented in R312's nursing notes. Surveyor asked RN Care Manager-M why R312's coccyx pressure injury was not assessed until 1/2/18 and not on 12/31/17 when it was first documented in R312's Nursing Notes dated 12/31/17. RN Care Manger-M informed Surveyor that she was not working on 12/31/17 and did not assess R312's coccyx pressure injury until 1/2/18. Surveyor asked RN Care Manager-M if other RN were available from 12/31/17 to 1/2/18 to assess R312's coccyx pressure injury. RN Care Manager-M informed Surveyor that other RNs were available and that an assessment of R312's coccyx pressure injury should have been done on 12/31/17. Surveyor asked RN Care Manager-M if there was any evidence of an RN assessment being completed for R312's Unstageable pressure injury upon admission, as described in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. RN Care Manager-M informed Surveyor that she had no evidence that an RN assessed R312's Unstageable pressure injury upon admission, as described in R312's Hospital Rehabilitation Discharge Instructions dated 12/19/17. RN Care Manager-M confirmed to Surveyor that the first time an RN assessed R312's pressure injury to her coccyx was on 1/2/18, when she (RN Care Manager-M) performed an assessment of R312's coccyx pressure injury. RN Care Manager-M again confirmed to Surveyor that R312 had a facility acquired Stage III pressure injury to her coccyx. On 1/9/18 at 1:15 p.m., Surveyor asked RN Care Manager-M why R312's Weekly Wound Notes for 1/2/18 and 1/9/18 did not include any staging of R312's coccyx pressure injury. RN Care Manager-M informed Surveyor that there is no area on R312's Weekly Wound Notes where she could document a stage for R312's coccyx pressure injury and again confirmed that as of 1/9/18, R312's facility acquired coccyx pressure injury had progressed from a stage II pressure injury to a stage III pressure injury. RN Care Manager-M informed Surveyor that R312's coccyx pressure injury should be staged and that she would change R312's Weekly Wound Notes worksheet so that facility staff should stage R312's pressure injury. Surveyor asked RN Care Manager- M why R312 did not have a plan of care for R312's pressure injury as described in R312's Weekly Wound Observation Report dated 1/2/18 and 1/9/18. RN Care Manager-M informed Surveyor that R312's Skin Integrity plan of care should be updated and that its on a list of things for RN Care Manager-M to do. The facility's policy dated as revised on August 2014 and titled Wound Care Prevention, Management and Documentation documents under the Procedure section, 2. Residents are assessed to identify the residents' potential risk for developing skin breakdown and to determine interventions to modify, stabilize or decrease risk factors; (d) All residents have a weekly skin inspection done by the unit nurse with their bath.; 3. Changes in skin condition or skin breakdown are reported to the physician. Under the Pressure Ulcer Prevention and Standard of Practice Interventions section it documents, 2. Skin Care and Early Treatment, Inspect skin at least once a day for high risk individuals and weekly with resident's bath. On 1/ 9/18 at 3:06 p.m., during the daily exit conference, Surveyor informed Administrator-A and Interim DON (Director of Nursing)-B of the above findings. No further information was provided as to why the facility did not develop and implement a comprehensive person centered Pressure Injury plan of care for R312 when R312 developed a Pressure Injury. 2. R14 admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. R14's annual MDS (Minimum Data Set) dated 10/9/17 documents: Risk of Pressure Ulcers. Other Problems - Moisture Associated Skin Damage (MASD). Bed mobility extensive 2 person assist. Brief Interview for Mental Status (BIMS) 15 indicated cognitively intact. Monthly Optum note dated 12/12/17 documents: Member has no complications from urinary incontinence as evidenced by intact skin. R14's most recent Braden risk score dated 8/23/17 documents score of 16 which is at risk. 01/04/18 09:05 AM Surveyor observed LPN-V complete treatment to R14's left gluteal wound. LPN-V applied skin prep to the surrounding skin, Santyl to center of the wound bed and covered the area with a [MEDICATION NAME] dressing. Surveyor noted the left gluteal wound to be approximately the size of quarter. The center of the wound bed has yellow slough present, surrounded by granulation tissue. Surveyor review of R14's medical record noted the following: On 12/22/17 clinical notes document: Monitoring left gluteal. Issue of left gluteal skin condition added to 24 hour report. CNA (Certified Nursing Assistant) reported skin condition on resident. Writer observed left gluteal red area with yellow/brown area in center. Area measured 2 cm (centimeter) x 1 cm. Area cleansed, skin prep applied. On 12/24/17 clinical notes document: The left gluteal area is reddened with a yellow area with a brown center is noted. No drainage or odor is noted. On 12/25/17 clinical notes document: Left gluteal open area red with yellow center. On 12/27/17 clinical notes document: Resident is on the 24 hour report sheet due to a MASD (Moisture Associated Skin Damage)/Irritation on the left gluteal area noted on 12/22/17. New order received 12/26/17 for [MEDICATION NAME] cream application every shift x 14 days. No wound assessment or measurements were documented. On 12/30/17 clinical notes document: Resident is on the 24 hour report sheet due to a MASD/Irritation on the left gluteal area noted on 12/22/17. New order received - apply [MEDICATION NAME] dressing and change every 3 days. No wound assessment or measurements were documented. On 12/31/17 clinical notes document: Deterioration of MASD left gluteal. Left gluteal open area treatment every 3 days with [MEDICATION NAME]. No wound assessment or measurements were documented. On 1/1/18 clinical notes document: The left gluteal area is now an open area per pm shift report. A [MEDICATION NAME] dressing is currently clean, dry and intact. No drainage or odor is noted. Skin prep is applied around the area. [MEDICATION NAME] cream is applied to the area around the [MEDICATION NAME] dressing. No wound assessment or measurements were documented. On 1/3/18 clinical notes document: Impaired skin integrity and decreased mobility. MASD/Irritation on the left gluteal area since 12/22/17. On 1/3/18 treatment changed to Santyl application. No wound assessment or measurements were documented. Weekly skin check sheet dated 12/14/17 and 12/21/17 showed no documentation of skin breakdown left glutueal. Weekly skin check sheet dated 12/28/17 documents: Left gluteal [MEDICATION NAME] ointment applied to MASD to left butt/gluteal area. Weekly skin check sheet dated 1/4/18 documents: Left gluteal area open area - dressing changed as ordered. Surveyor reviewed R14's left gluteal wound sheet signed by an LPN (Licensed Practical Nurse) dated 1/2/18. Measurements: 2 cm length x 1.5 cm width. Undermining none. Scant amount serous exudate, no odor. Wound bed yellow slough 80%, pink 20%. Edges of wound pink, surrounding skin healthy. Progress marked as new. Change treatment 1/3/18 Santyl with [MEDICATION NAME]. Pain - yes/tender. Comments: Reposition every 2 hours, specialty mattress, Equagel cushion in wheelchair, Arginade and Prosource. Patient had [MEDICATION NAME] ointment, then [MEDICATION NAME] treatment then 1/2/18 call to Nurse Practitioner for order for Santyl with [MEDICATION NAME]. Surveyor noted there was no staging of the pressure injury documented on the wound sheet. Wound sheet dated 1/2/18 was the only one provided to surveyor for R14's left gluteal pressure injury. 01/09/18 11:48 AM Surveyor interviewed RN (Registered Nurse) Care Manager/IC-M who reported she is the wound nurse. RN Care Manager/IC-M stated they were aware of R14's left gluteal fold on 12/22/17 and were considering it MASD. On 12/26/17 [MEDICATION NAME] was put in place for 2 weeks. RN Care Manager/IC-M stated on 1/2/18 the left gluteal fold turned into a pressure ulcer and the treatment was changed to Santyl, prior to 1/4/18 it was considered to be MASD. Surveyor reviewed the wound sheet with RN Care Manager/IC-M and confirmed there is not a stage of the wound listed on the sheet, only a description of the wound. RN Care Manager/IC-M confirmed there is no documentation of wound assessments or measurements of the left gluteal area until it was considered a pressure ulcer on 1/2/18. 01/09/18 01:48 PM Surveyor reviewed progress notes dated 12/22/17 with RN Care Manager/IC-M. Documentation stated: Writer observed left gluteal red area with yellow/brown area in center. Area measured 2cm x 1cm. Surveyor asked if the measurements of the yellow/brown area in center would be consistent with MASD. RN Care Manager/IC-M reported the RN who documented it is the supervisor, she would expect her to know the difference between MASD and pressure, so she trusts her assessment. Stated Maybe there was something yellow or brown on her skin that could be wiped off. RN Care Manager/IC-M confirmed R14's left gluteal pressure injury is stage 3. Surveyor noted there was no RN assessment of R14's left gluteal area since it was discovered on 12/22/17, and no measurements documented until 1/2/18. Facility Wound Care Prevention, Management and Documentation policy dated August 2014 documents: Purpose to provide an interdisciplinary program for assessing a resident's risk for skin breakdown and implement a comprehensive care plan to maintain or improve skin integrity which may include treatment for [REDACTED]. R14's current Care Plan was not updated with interventions for R14's left gluteal stage 3 pressure injury (cross reference F656) 3. R22 was admitted to the facility on [DATE], and has [DIAGNOSES REDACTED]. The facility policy, entitled Wound Care Prevention, Management and Documentation, dated August 2014 states: . Residents are assessed to identify the residents' potential risk for developing skin breakdown and to determine interventions to modify, stabilize or decrease risk factors. All residents at risk for developing skin breakdown have an appropriate care plan in place identifying preventative measures. R22's Change of Condition MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/13/17, indicates a BIMS (Brief Interview of Mental Status) assessment score of 5. Indicating that R22 is severely cognitively impaired. R22 currently does not have any pressure injuries but was at risk for development of such. R22 is frequently incontinent of urine and always incontinent of bowel. R22 requires extensive assist of two staff members for bed mobility and toilet use. R22's care plan dated 2/22/16-present does not address the history of skin impairment, the risk of development of a new pressure injury, interventions to prevent pressure injuries or the new pressure injury documented on 1/5/18. (Cross reference F656) R22's Baden Scale for Predicting Pressure Sore Risk assessment dated [DATE], documents a score of 15. Indicating that R22 is at high risk for the development of a pressure area. The assessment also indicates that staff should proceed with a plan of care. R22's Baden Scale for Predicting Pressure Sore Risk assessment dated [DATE], documents a score of 15. Indicating that R22 is at high risk for the development of a pressure area. The assessment also indicates that staff should proceed with a plan of care. R22's Weekly Skin Check assessment dated [DATE], documents an open area to the right buttocks measuring 0.5 cm (centimeters) by 0.5 cm. The wound base is light red with surrounding skin in tact. Barrier cream applied and R22 was repositioned off that area. A second open area to the right buttocks measuring 1.5 cm by 0.5 cm. was also documented. The wound base is light red with surrounding skin in tact. Barrier cream is applied and R22 is repositioned off that area. On 01/10/18 at 07:45 AM Surveyor interviewed RN (Registered Nurse) Manager-O about R22's high risk for pressure injuries, documentation of care plan to prevent new pressure injuries and treatment of [REDACTED]. RN Manager-O stated that she was not aware that R22 had a pressure injury. R22's name did not appear on RN Manager-O's list of residents with pressure injuries. RN Manager-O is not aware of the size or staging of the pressure injury. RN Manager-O stated that she would expect to see a care plan for any resident that is found to be at risk for pressure injuries or that has developed a new pressure injury. RN Manager-O confirmed that R22 does not have a care plan in place for being at risk for the development of pressure injuries or a care plan for the treatment of [REDACTED]. RN Manager-O indicated that the care plan creation is the responsibility of the MDS (Minimum Data Set) nurses. MDS nurses are alerted to the need to create or update care plans at the daily morning meetings with the Interdisciplinary Team. RN Manager-O states that since they have not been having daily morning meetings the MDS nurses most likely are not aware of R22's new pressure injury and did not create a care plan. On 1/10/18 at 8:34 AM Surveyor interviewed Clinical Reimbursement Director-AA and MDS Specialist-GG, who stated they were not aware that R22 had a pressure injury. Clinical Reimbursement Director-AA and MDS Specialist-GG informed surveyor that they would expect to see a care plan for any resident that is found to be at risk for pressure injuries or if a new pressure injury is documented. On 1/10/18 at 9:35 AM Surveyor informed Interim DON (Director of Nursing)-B of the above concern. Interim DON -B informed Surveyor that she would have RN Nurse Manager-O assess the pressure injury and document staging of area today. On 1/10/18 at 09:44 AM A member of the survey team observed the wound of R22 with RN Manager-O. Surveyor observation of the wound is documented as: Stage two pressure injury to the right coccyx area - measures 1.6 cm x 0.6 cm. The wound bed has pink granulation tissue. Progress note dated 1/10/18 at 12:55 PM documents, R22 is on report for new open area to the right side of coccyx/buttocks. Open area is staged as a stage two pressure injury r/t (related to) incontinence and decreased mobility as evidenced by open area. The plan: order air mattress, continue glucerna 4oz (ounces) TID (three times a day), daily magic cup, turn Q2 (every 2 hours), rest after meals as resident will tolerate, treatment of [REDACTED]. The facility did not care plan preventative measures to be taken by staff after assessing R22 to be at high risk for the development of pressure injuries. The facility did not create a care plan for the treatment of [REDACTED]. R22's pressure injury was not staged nor further interventions put into place to promote the healing of a new pressure injury until the Surveyor brought the concern to the facilities attention on 1/10/18. On 1/10/18 at 3:00 PM Administrator-A and Interim DON-B were informed of the above concern. No further information was provided.