Every finding on record at Meadowbrook at Appleton

Based on staff interview and policy review, the facility did not ensure a qualified person was designated to serve as the Dietary Manager. This practice had the potential to affect kitchen sanitation and quality of care related to food and nutrition for all 35 residents residing in the facility. The former Dietary Manager left employement with the facility in October. The Administrator was acting as the Dietary Manager. The Administrator was not certified in food service management.Findings include: The facility's Dietitian policy, revised February 2021, indicates: .7. If a Dietitian is not employed full time (35 or more hours per week) a Director of Food Service Management will be designated. This individual will: a. Be a certified Dietary Manager; or b. Be a certified Food Service Manager; or c. Be nationally certified in food service management and safety; or d. Have an associates (or higher) level degree in food service management or hospitality (must be from an accredited institution and include courses in food service or restaurant management); e. Meet any state requirements for Food Service or Dietary Managers; and f. Receive frequently scheduled consultations from a qualified Dietitian or qualified Nutrition Professional. During an interview on 10/20/25 at 10:00 AM, the Administrator indicated the Dietary Managter left at the beginning of October and the Administrator was filling in. The Administrator verified she did not have a food service certification. During an interview on 10/20/25 at 3:16 PM, the Registered Dietician stated she did not work full time at the facility but approved the menus and was responsible for the spreadsheets. During an interview on 10/22/25 at 1:45 PM, the Administrator provided the facility's Dietitian policy which indicated the Dietary Manager needs to be certified.

Based on staff interview and record review, the facility did not notify a representative when an antipsychotic medication was increased for 1 resident (R) (R1) of 3 sampled residents.R1 was prescribed an atypical antipsychotic medication. R1's representative was not notified when the dose of the medication was increased.Findings include: The facility's undated Notify of Changes policy indicates: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .3. Circumstances that require a need to alter treatment. This may include: a. New treatment; b. Discontinuation of current treatment due to: .iii. Exacerbation of a chronic condition. R1's admission Record revealed a facility admission date of 8/18/25. A psychiatric practitioner note, dated 8/21/25, indicated R1 was admitted with hallucinations and the dose of R1's atypical antipsychotic medication was increased. R1's progress notes and assessments did not reveal R1's represenative was notified of the dose increase. During an interview on 10/22/25 at 3:30 PM, the Administrator stated they could not find notice of the medication increase which should have been completed.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 46 residents residing in the facility.The facility did not monitor and document food cooling temperatures.Staff did not test the Quaternary sanitizing solution (used to sanitize food preparation surfaces) per manufacturer's instructions. In addition, the facility did not monitor the Quaternary sanitizing solution for proper water temperature and parts per million (PPM). Findings include:Food Cooling:The 2022 Food and Drug Administration (FDA) Food Code documents at 3501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57 Celsius (C) (135 Fahrenheit) (F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less. (B) Time/temperature control for safety food shall be cooled within 4 hours to 5 C (41 F) or less.The 2022 FDA Food Code documents at section 3501.15 Cooling Methods: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under S 3501.14 by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment; (4) Stirring the food in a container placed in an ice water bath; (5) Using containers that facilitate heat transfer; (6) Adding ice as an ingredient; or (7) Other effective methods.During an initial kitchen tour that began at 8:17 AM on 7/21/25, Surveyor observed the following cooked items/leftovers in the reach- in cooler:~ A steam table container labeled Cheesy eggs and ham dated 7/21/25~ A steam table container labeled Puree sausage dated 7/20/25~ A steam table container labeled Puree eggs dated 7/20/25~ A container labeled Oatmeal dated 7/20/25~ A steam table container labeled Burgers/Hot dogs dated 7/19/25Surveyor did not observe a food cooling log for the pre-cooked and cooled foods. On 7/22/25 at 12:10 PM, Surveyor interviewed Dietary Manager (DM)-D who indicated the food cooling log was in a binder. DM-D went to retrieve the documentation and indicated there were no cooling logs for the foods in the reach-in cooler. DM-D indicated the cheesy and pureed eggs were no longer in the cooler and were consumed by residents that morning. DM-D indicated staff should cool foods properly and document per policy and regulation. DM-D also confirmed the foods observed in the cooler were not documented as properly cooled using a food safety cooling method.Quaternary Sanitizer:During an initial kitchen tour that began at 8:17 AM on 7/21/25, Surveyor noted the three-compartment sink contained a sanitizer bucket. Surveyor observed a sanitizer log next to the three-compartment sink and noted the log did not contain documented PPM but contained white or multi-colored Hydrion Quaternary sanitizer strips. Tthe log contained a column for the water temperature but did not contain documentation of water temperatures.Surveyor observed a poster above the three-compartment sink that indicated the following: QUAT Hydrion 65-75 degree water temperature with PPM at 150-400. On 7/22/25 at 12:10 PM, Surveyor interviewed DM-D who indicated the three-compartment sink is used to fill buckets for sanitizing kitchen prep areas. DM-D confirmed staff taped Hydrion Quaternary sanitizer test strips to the log and verified staff do not document PPM of the sanitizing solution. DM-D confirmed the test strips change colors and when adhered to the log no longer display the same color. DM-D confirmed the strips do not accurately record the PPM. DM-D also confirmed the log contains a column to document the water temperature of the sanitizing solution and verified staff do not test the water temperature of the sanitizing buckets prior to testing the PPM as required.

Based on observation and staff and resident interview, the facility did not ensure food was served at a safe and appetizing temperature for 5 residents (R) (R5, R6, R8, R12, and R30) of 16 sampled residents.During interviews on 7/21/25 and 7/22/25, R5, R6, R8, R12 and R30 indicated their food was not appetizing and was served at a temperature they did not prefer. A test tray obtained during meal service on 7/22/25 indicated the food was not served at a palatable temperature.Findings include:1.On 7/21/25, Surveyor reviewed R5's medical record. R5 had diagnoses including chronic deep vein thromboses (DVTs) of bilateral lower extremities, chronic obstructive pulmonary disease (COPD), neuropathy, edema, and anxiety. R5's Minimum Data Set (MDS) assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. R5 was R5's own decision maker.On 7/21/2025 at 1:16 PM, Surveyor interviewed R5 who indicated food is delivered cold at every meal. R5 indicated R5 does not ask staff to reheat the food because staff are too busy during meals.On 7/22/25 at 9:26 AM, Surveyor interviewed R5 who indicated breakfast was served cold. R5 indicated R5 did not ask staff to reheat the meal because staff are too busy to reheat food to a temperature that is palatable for R5. 2. On 7/21/25, Surveyor reviewed R6's medical record. R6 had diagnoses including dementia, end stage renal disease (dialysis), COPD, and depression. R6's MDS assessment, dated 6/3/25, had a BIMS score of 10 out of 15 which indicated R6 had moderate cognitive impairment. R6 had an activated decision maker for healthcare decisions.On 7/21/25 at 9:16 AM, Surveyor interviewed R6 who indicated food is delivered cold all the time. R6 also indicated R6 uses butter but the butter does not melt and stays solid. 3. On 7/21/25, Surveyor reviewed R8's medical record. R8 had diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3, anxiety, and depression. R8's MDS assessment, dated 5/5/25, had a BIMS score of 15 out of 15 which indicated R8 had intact cognition. R8 was R8's own decision maker.On 7/21/25 at 11:08 AM, Surveyor interviewed R8 who indicated the food is not really great and stated R8 chooses to eat in R8's room. R8 indicated R8's room trays contain cold and lukewarm food which is not appetizing. R8 indicated even when the food is lukewarm it is not at a good temperature. R8 indicated R8 receives a meal tray timely because R8 is one of the first ones served. R8 indicated despite receiving room trays on time, the food is not served at an appetizing temperature. On 7/21/25 at 12:11 PM, Surveyor observed R8 receive a lunch tray. Surveyor interviewed R8 who indicated the vegetables were cold and the burger was warm. R8 indicated R8 was not going to eat cold vegetables. On 7/22/25 at 7:45 AM, Surveyor interviewed R8 who indicated yesterday's dinner was warm but not hot or appetizing. R8 stated if the meal is not at a desired temperature, R8 does not ask staff to reheat the meal because staff are too busy. R8 stated R8 will just not eat the cold items.4. On 7/21/25 Surveyor reviewed R12's medical record. R12 had diagnoses including type 2 diabetes mellitus, cellulitis, and pressure injury stage 4. R12's MDS assessment, dated 5/16/25, had a BIMS score of 15 out of 15 which indicated R12 had intact cognition. R12 was R12's own decision maker.On 7/21/25, at 11:44 AM, Surveyor interviewed R12 who indicated the food is not always hot and does not taste good at times due to the temperature. 5. On 7/21/25, Surveyor reviewed R30's medical record. R30 had diagnoses including osteomyelitis, dysphagia, post traumatic stress disorder (PTSD), and sprain of ligaments of cervical spine. R30's MDS assessment, dated 6/3/25, had a BIMS score of 14 out of 15 which indicated R30 had intact cognition. R30 was R30's own decision maker.On 7/21/25, at 11:15 AM, Surveyor interviewed R30 who indicated food for all meals arrives cold. R30 confirmed R30 receives meal trays and eats in R30's room.During a continuous observation that began at 10:25 AM on 7/22/25, Surveyor observed lunch service at the kitchen steam table. Surveyor noted the first room tray cart was full and one room tray was on top of the cart. Surveyor continued to observe lunch service and noted room trays for a second meal cart were placed in the cart. Surveyor requested a test tray as the last tray was served. Surveyor noted the tray cart was full and R8's tray was transported on top of the cart. The test tray was placed next to R8's tray on top of the cart. The cart left the kitchen to begin delivery to residents at 11:51 AM and Surveyor and Dietary Manager (DM)-D followed the cart to the unit. At 12:03 PM (halfway through the delivery of meal trays), DM-D removed the test tray from the top of the cart and temped the food. Surveyor observed DM-D obtain the following temperatures of food served to residents for lunch:~ The roast beef was 124 degrees Fahrenheit (F); The peas were 127 degrees F; The mashed potatoes were 123 degrees F.DM-D indicated kitchen staff received complaints from residents regarding food temperatures. DM-D indicated the facility has two meal service carts and had a third cart at one time. DM-D did not know if the plate warmer worked correctly or if the warmer was plugged in during meal service.On 7/22/25 at 12:07 PM, DM-D and Surveyor went to the kitchen and noted the plate warmer was not plugged in. When staff plugged in the plate warmer, Surveyor noted the light did not ignite. DM-D indicated the plate warmer was fixed a while ago and might need to be replaced. DM-D indicated the steam table was recently replaced due to resident complaints about cold food and indicated there were recent food temperature concerns from residents.

Based on observation and staff and resident interview, the facility did not provide a safe, clean, comfortable, and home-like environment for 1 resident (R) (R31) of 16 sampled residents.The facility did not ensure food debris, spills, dirt, and used medical supplies were removed from R31's floor or that R31's garbage was emptied in a timely manner. Findings include:On 7/21/25, Surveyor reviewed R31's medical record. R31 had diagnoses including pressure ulcer of sacral region stage 2, paraplegia, infection and inflammatory reaction due to indwelling urethral catheter, and pressure ulcer of right buttock stage 3. R31's Minimum Data Set (MDS) assessment, dated 6/26/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 was R31's own decision maker.On 7/21/25 at 9:15 AM, Surveyor observed R31 in bed. R31 expressed concerns with room cleanliness, specifically that the floor is dirty and the garbage is overflowing. R31 also indicated housekeeping was an issue. Surveyor observed clothing, linens, and various items stacked on R31's heating and cooling register. Surveyor noted R31's garbage was almost full and contained used personal protective equipment (PPE) and food. Surveyor also observed dirt, dust, food debris, a cotton swab used to clean wounds, and a lancet top on R31's floor. R31 indicated there is one housekeeper that does a good job but indicated no one had been in to clean R31's room or take out the garbage in a few days. R31 also indicated housekeeping does not clean on a regular basis. R31 stated R31 cannot physically do the tasks and relies on housekeeping to do them. On 7/21/25 at 1:09 PM, Surveyor observed R31 in bed and noted R31's floor was still dirty, the garbage was overflowing, and clothing, linens, and other items were still stacked on R31's heating and cooling register. Surveyor also noted the cotton swab and lancet top were still on the floor. R31 indicated no one cleaned R31's room or removed the garbage. R31 also indicated staff changed R31's socks earlier that morning and threw them on the floor next to the hamper. On 7/22/25 at 7:54 AM, Surveyor noted R31's room was in the same condition as the previous day. Surveyor observed an orange peel, a cotton swab, two lancet tops, dirt, and black debris on the floor and an overflowing garbage can that contained used PPE. R31 indicated no one cleaned R31's room, removed clothing and linens from the heating and cooling register, or took out the garbage. R31 indicated the housekeeper that does a good job would hopefully be in that day and clean R31's room. On 7/22/25 at 1:26 PM, Surveyor noted R31's room was still in the same condition as previously observed at 7:54 AM. Surveyor observed an orange peel, two lancet tops, dirt, and debris on R31's floor and an overflowing garbage can. Surveyor noted the cotton swab that was previously on the floor was in the garbage. R31 indicated R31 asked staff and was told someone would clean R31's room that day. On 7/22/25 at 1:28 PM, Surveyor interviewed Housekeeper (HSK)-F who indicated laundry and housekeeping staff do both jobs. HSK-F indicated one staff who usually works in laundry is on leave and HSK-F and another housekeeping staff were doing all of the housekeeping. HSK-F indicated there are usually two housekeepers per wing but currently there is only one per wing which is not enough. HSK-F indicated Maintenance Director (MD)-E is the laundry and housekeeping supervisor and is responsible for ensuring housekeeping and laundry tasks are completed per residents' requests and preferences. On 7/22/25 at 1:50 PM, Surveyor interviewed MD-E in R31's room. MD-E confirmed R31's floor contained dirt, debris, and black-colored stains and R31's garbage was overflowing. MD-E confirmed there were lancet tops on the floor and stacked laundry and linens on the the heating and cooling register. MD-E indicated resident rooms should be cleaned daily which includes removing the garbage and cleaning the floor. MD-E indicated one staff is on leave and the facility is attempting to hire. MD-E indicated one housekeeper comes in at 11:00 AM and only does floors. MD-E confirmed R31's room was not cleaned on 7/21/25 or 7/22/25.

Based on observation, staff and resident interview, and record review, the facility did not ensure they completed regular pest control which affected 1 resident (R) (R30) of 17 sampled residents.R30 indicated there were fruit flies in R30's room and R30 had a bug bite on the right hand. The facility did not ensure they completed regular pest control.Findings include:On 7/21/25, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including deep vein thrombosis/pulmonary embolism secondary to factor V Leiden mutation on Xarelto, chronic diastolic congestive heart failure, chronic obstructive pulmonary disease (COPD), and morbid obesity. R30's Minimum Data Set (MDS) assessment, dated 6/9/25, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R30 had intact cognition. A progress note, dated 7/21/25 at 9:24 AM, indicated the writer updated the Nurse Practitioner (NP) that R30 had a new bug bite on the right hand and had a previous bug bite that became infected. The area was slightly swollen, red, and itchy. The NP ordered hydrocortisone cream 1% three times daily (TID) as needed (PRN).On 7/22/25 at 11:15 AM, Surveyor interviewed R30 who indicated R30 did not get up much. R30 showed Surveyor R30's right hand and indicated R30 had a bug bite. R30 stated something bit R30 and it hurt so bad that R30 woke up and the bite swelled up right away. R30 indicated staff put cream on the bite and it looked better. R30 indicated R30 had been in the hospital due to a right hand infection and did not want to get another infection. R30 indicated the previous infection resulted from R30 wrapping a hospital band around R30's thumb. R30 thought a spider bit R30's hand. Surveyor checked R30's room for spiders and noted several fruit flies in the room. R30 indicated fruit flies are everywhere in the building. On 7/22/25 at 12:25 PM, Surveyor interviewed Maintenance Director (MD)-E who indicated the facility has routine pest care mostly for rodents and outside things. When Surveyor requested to see 6 months of pest control documentation, MD-E indicated MD-E does not keep records of when Company (CP)-K comes to the facility but thought CP-K had been there in May. MD-E indicated CP-K comes monthly to check traps, but MD-E did not have documentation. MD-E indicated CP-K changed hands multiple times and sometimes states they do not have an account for the facility. MD-E provided Surveyor with CP-K's number and indicated the facility had discussed using a different pest control companyOn 7/22/25 at 12:32, Surveyor contacted CP-K and spoke to Customer Service Agent (CSA)-L who indicated CP-K was last at the facility on 2/28/25. CSA-L indicated the facility contacted CP-K on 2/24/25 and CP-K provided services on 2/28/25. CSA-L indicated there was no active service for the facility and no one from CP-K checked traps or sprayed monthly.On 7/22/25 at 2:51 PM, Nursing Home Administrator (NHA)-A provided Surveyor with an invoice that indicated CP-K was last at the facility in February of 2025. NHA-A indicated CP-K told the facility there was an outstanding invoice so CP-K would not come to the facility to provide pest control. NHA-A confirmed the facility does not have a current contract for pest control and has not had pest control since February.

Based on observation, staff interview, and record review, the facility did not ensure transmission-based precautions (TBP) were implemented for 1 resident (R) (R52) of 2 residents with a diagnosis of a transmittable infection.R52 had diagnoses of sepsis and pneumonia and was placed on droplet precautions. Staff did not don the appropriate personal protective equipment (PPE) when entering R52's room on 7/21/25 and 7/22/25. Findings include:The facility's Isolation Precautions policy, revised 3/2020, indicates: To establish transmission-based precautions for residents who are suspected or confirmed to have communicable diseases/infections that can be transmitted to others. Transmission- based precautions will be used when transmission cannot be reasonably prevented by standard precautions alone .Droplet precautions .prior to entering the isolation room, the following steps are required: Perform hand-hygiene and apply gloves and mask prior to entering the room, while providing direct resident care, remove gloves and wash hands after coming in contact with infectious material. Remove gloves and perform hand hygiene before leaving the room.On 7/21/25, Surveyor reviewed R52's medical record. R52 was admitted to the facility on [DATE] and had diagnoses including sepsis, pneumonia, and urinary tract infection (UTI) all due to E-coli, stage 1 pressure injury, chronic obstructive pulmonary disease (COPD), and paranoid schizophrenia. R52's admission Minimum Data Set (MDS) assessment, dated 7/16/25, had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R52 had moderately impaired cognition. R52 had an activated decision maker for healthcare decisions. A care plan, dated 7/16/25, indicated R52 had pneumonia and contained the following interventions: Educate R52/family on precaution policies; Follow the facility's policy for implementation of any precautions related to active infection; Staff to follow standard precautions and transmission precautions when appropriate. On 7/21/25 at 9:15 AM, Surveyor observed R52 in R52's room and noted the door contained a sign that indicated R52 was on droplet precautions. Surveyor also observed a PPE cart outside R52's room. On 7/21/25 at 9:18 AM, Surveyor observed Certified Nursing Assistant (CNA)-G enter R52's room with an oxygen tank and close R52's door. CNA-G did not don PPE prior to entering the room. Surveyor also observed CNA-G in R52's room without a mask when CNA-G opened the door. Surveyor interviewed CNA-G who indicated unless CNA-G was doing cares, CNA-G did not need to wear a mask or PPE. CNA-G indicated CNA-G entered R52's room to give R52 oxygen and was not required to wear PPE because CNA-G was not in contact with bodily fluids. On 7/21/25 at 9:28 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed R52 was on droplet precautions and antibiotics for a UTI, pneumonia, and sepsis. DON-B indicated R52 would be removed from droplet precautions when R52's antibiotics were completed. On 7/22/25 at 7:42 AM, Surveyor observed housekeeping staff change R52's bed linens without wearing gloves or a mask. R52 was in the room at the time. On 7/23/25 at 9:24 AM, Surveyor interviewed DON-B who confirmed staff who enter R52's room should adhere to the facility's policy and procedure for TBP and verified staff should wear a mask when entering the room of a resident on droplet precautions. DON-B verified Surveyor's observations of staff in R52's room without proper PPE was not in accordance with the facility's policy and procedure.

Based on observation, staff and resident interview, and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R5) of 2 sampled residents.R5 had an order for a Fentanyl patch for pain to be changed every three days. During observations on 7/21/25 and 7/22/25, R5's Fentanyl patch was dated 7/17/25. R5 stated R5 felt achy and had difficulty sleeping. Findings include:The facility's Pain Management policy, revised 10/2024, states the facility will develop and implement a care plan for pain management. The goal of the pain management system is to effectively and consistently identify and treat pain .Staff should be proactive to address the resident's pain to aid in achieving relief. Evaluation of pain, implementation of interventions, and communicating with the care team regarding pain management strategies are important components of a successful pain management system .Nursing staff are to administer pain medications as ordered and observe for effectiveness. From 7/21/25 to 7/23/25, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had diagnoses including chronic deep vein thromboses (DVTs) (blood clots) of both legs, neuropathy, depression, anxiety, and chronic pain. R5's most recent Minimum Data Set (MDS) assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R5 had intact cognition. The MDS assessment also indicated R5 experienced pain almost constantly which frequently interfered with day-to-day activities and therapies. R5's comprehensive care plan, revised 5/29/25, indicated R5 experienced chronic pain related to bilateral DVTs of the lower extremities. The care plan contained interventions for repositioning, distraction, heat, and pain medications. On 7/21/25 at 1:24 PM, Surveyor interviewed R5 regarding pain management. R5 indicated R5 had a Fentanyl patch that was changed every three days. Surveyor noted the patch was dated 7/17/25. Per R5's physician order, the patch should have been changed on 7/20/25. R5 stated R5's pain was currently an 8 out of 10 and mostly in R5's legs due to the blood clots. On 7/22/25 at 7:59 AM, Surveyor observed R5's Fentanyl patch and noted it was still dated 7/17/25. R5 stated R5 had a tough time sleeping last night and was achy. R5 stated staff did not offer non-pharmacological interventions for pain but doubted they would be effective. R5's most recent comprehensive pain assessment, dated 7/10/25, stated R5 experienced pain almost constantly which affected R5's sleep and activities. On 7/22/25 at 8:51 AM, Surveyor entered R5's room with Director of Nursing (DON)-B who verified R5's Fentanyl patch was dated 7/17/25. DON-B verified R5's patch should have been changed on 7/20/25 but indicated the facility did not re-order the Fentanyl patch prior to using the last one on 7/17/25. On 7/22/25, Surveyor reviewed R5's Medication Administration Record (MAR) for 7/13/25 through 7/22/25 and noted R5's pain was typically between 5 and 7 out of 10. R5 took as needed (PRN) oxycodone every 6 hours during that time period. On 7/22/25, Surveyor reviewed a fax sent to R5's physician on 7/21/25 requesting a refill for R5's Fentanyl patch. On 7/23/25 at 8:01 AM, Surveyor noted R5's Fentanyl patch was dated 7/22/25. R5 indicated R5 felt much better and rated R5's pain at a 5 out of 10. On 7/23/25, Surveyor reviewed R5's MAR which indicated R5's Fentanyl patch was applied on 7/22/25 at 5:02 PM and R5's pain was rated at a 5 out of 10.

Based on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R35 and R4) of 2 sampled residents who were fed via enteral feeding (a way of sending nutrition right to the stomach or small intestine via tube) received care and services to avoid complications.On 7/21/25, Registered Nurse (RN)-C did not check for placement or residual prior to administering medication and enteral feeding to R35 .On 7/21/25 Licensed Practical Nurse (LPN)-H did not check placement or residual prior to administering medication to R4. Findings include: The facility's Enteral Feeding and Medication Administration Policy, dated March 2020, indicates: .Registered Nurse (RN)/Licensed Practical Nurse (LPN) will administer nutrition and medication through nasogastric, gastrostomy, or jejunostomy tube upon order of physician to provide nutrition and hydration for residents with compromised nutritional status or inability to consume oral intake .3. Check for proper placement prior to each feeding/medication administration (or every 4 hours for critically ill residents) by aspirating gastric contents or by auscultation while injecting 10 milliliter (ml) of air into tube. Notify physician if it appears tube has been displaced. 1. On 7/21/25, Surveyor reviewed R35's medical record. R35 was admitted to facility on 5/24/23 and had diagnoses including Parkinsonism, cerebral infarction, systemic inflammatory response, muscle wasting, atrophy, and neurocognitive disorder. R35's Minimum Data Set (MDS) assessment, dated 3/28/25, indicated R35 was dependent on staff for transfers, hygiene, dressing, feeding, and bathing. R35's tube feeding care plan, dated 8/30/23, contained an intervention to check for tube placement and gastric contents/residual volume per facility protocol and orders. On 7/21/25 at 11:54 AM, Surveyor observed RN-C administer an acidophilus capsule and Jevity 1.5 calorie 240 ml via percutaneous endoscopic gastrostomy (PEG) tube for R35. RN-C sanitized hands, donned a gown and gloves, opened R35's PEG tube port, and flushed the tube with 60 ml of water. RN-C then administered acidophilus with 30 ml water and flushed the tube with 60 ml of water. RN-C then administered 240 ml of Jevity 1.5 calorie and flushed with 60 ml of water. On 7/21/25 at 11:58 AM, Surveyor interviewed RN-C who indicated R35 did not have orders to check placement or residual. RN-C indicated RN-C often checks placement and residual if a resident is new and in rehab, however, R35 has had a PEG tube for a long time. On 7/23/25 at 11:32 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated it is a standard of practice to check placement and nurses should check for placement when administering medication or feeding via PEG tube. DON-B indicated one of the nurses approached DON-B yesterday and indicated they did not check placement when administering a medication via PEG tube. DON-B indicated DON-B educated all nurses on the facility's policy and put orders in the Medication Administration Record (MAR) for all residents with PEG tubes. 2. On 7/21/25, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had diagnoses including dysphagia with cerebral vascular accident, obesity, and type 2 diabetes. R4's MDS assessment, dated 6/2/25, had a BIMS score of 15 out of 15 which indicated R4 had intact cognition. The MDS assessment also indicated R4 received enteral feeding via gastronomy tube. A care plan, dated 5/9/25, indicated R4 required tube feeding post stroke related to tracheostomy, dysphagia, and swallowing issues. The care plan contained interventions to check for tube placement and gastric contents/residual volume per facility protocol. On 7/21/25 at 11:21 AM, Surveyor observed LPN-H administer R4 medication via gastrostomy tube. LPN-H washed hands, applied a gown and gloves, and crushed R4’s medication. LPN-H then added 90 cubic centimeters (ccs) of water and aspirated the medication into a syringe. LPN-H opened R4’s G-tube and administered the medications. Surveyor noted LPN-H did not check placement of the tube prior to administering the medication. Surveyor verified with LPN-H that tube placement should have checked prior to administering medication and that R4's MAR contained an order to check tube placement.

Based on observation, staff interview, and record review, the facility did not provide the appropriate care and services for 2 residents (R) (R31 and R25) of 3 sampled residents with an indwelling catheter.R31 recently recovered from a urinary tract infection (UTI). On 7/21/25, R31's uncovered catheter bag was observed on the floor.R25 had a history of UTIs. On 7/22/25, R25's catheter bag was observed on the floor.Findings include: The facility's Catheter Care Policy, revised July 2025, indicates: …9. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine . The Centers for Disease Control and Prevention (CDC) Guideline For Prevention of Catheter-Associated Urinary Tract Infection 2009 https://www.cdc.gov/infection-control/hcp/cauti/index.html, indicates: .III. Proper Techniques for Urinary Catheter Maintenance .B. Maintain unobstructed urine flow .2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor . 1. On 7/21/25, Surveyor reviewed R31's medical record. R31 had diagnoses including pressure ulcer of sacral region stage 2, paraplegia, infection and inflammatory reaction due to indwelling urethral catheter, neurogenic bladder, and pressure ulcer of right buttock stage 4. R31’s Minimum Data Set (MDS) assessment, dated 6/26/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R31 had intact cognition. R31 was R31's own decision maker. R31’s medical record indicated R31 was transferred to the emergency room (ER) on 6/22/25 due to cognitive change, weakness, and cloudy urine and diagnosed with a UTI. R31 received intravenous (IV) antibiotics in the ER, was prescribed oral antibiotics, and returned to the facility. On 7/21/25 at 9:15 AM, Surveyor observed R31 in bed and noted R31’s uncovered catheter bag was hung from the side of the bed and in contact with the floor. R31 indicated R31 recently had a UTI, was upset the catheter bag was on the floor, and stated, “That bag should not be on the floor like that.” R31 indicated the catheter bag is usually placed in a blue (dignity) bag. R31 indicated the dignity bag and keeping the catheter bag off the floor help with infection prevention. R31 indicated R31’s floor had not been cleaned in a few days and was dirty. On 7/21/25 at 9:22 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-G in R31's room. CNA-G indicated R31's catheter bag should not be on the floor. Surveyor observed CNA-G rehang the bag on the side of the bed and ensure it was off the floor. CNA-G did not place the bag inside a dignity bag. On 7/23/25 at 8:08 AM, Surveyor observed R31 in bed with the door open and noted R31’s catheter bag was hung facing the open door and hallway and was not in a dignity bag. On 7/23/25 at 9:13 AM, Surveyor observed R31 in bed with the door open and noted R31’s catheter bag was hung facing the door and hallway was not in a dignity bag. R31 indicated R31 was upset that the bag was hung on the side of the bed that faced the door and hallway and indicated R31 did not like bag hung on that side. R31 also indicated the catheter bag should be covered with a dignity bag. R31 indicated R31 would ask staff to move the bag and cover it with a dignity bag. On 7/23/25 at 9:24 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated residents with catheters should have a dignity bag and stated R31 had a dignity bag if R31 left the room. DON-B acknowledged a dignity bag should be used if a resident’s catheter bag is visible from the hallway and verified catheter bags should be hung below the bladder and should not be on the floor for infection prevention purposes. 2. On 7/21/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including sequalae following cerebrovascular disease, UTI, dysphagia, hemiplegia, and hemiparesis. R25's MDS assessment, dated 5/15/25, had a BIMS score of 0 out of 15 which indicated R25 had severe cognitive impairment. R25 had an activated Power of Attorney for Healthcare (POAHC). On 7/22/25 at 10:51 AM, Surveyor observed R25 and noted R25's catheter bag was hung from the side of R25's bed. R25's bed was in the lowest position and the catheter bag was on the floor. On 7/22/25 at 10:52 AM, Surveyor interviewed CNA-I who verified R25's catheter bag was on the floor. CNA-I indicated when CNA-I put R25's bed in the lowest position, CNA-I did not notice that R25's catheter bag was on the floor. CNA-I verified catheter bags should not be on the floor. On 7/22/25 at 1:24 PM, Surveyor interviewed DON-B who stated staff should adjust catheter bags so they do not touch the floor.

Based on observation, staff interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 1 resident (R) (R25) of 4 sampled residents.R25 fell on 5/2/25. An intervention was added to R25's care plan to ensure R25's bed was in the lowest position. The intervention was not consistently followed. Findings include:The facility's Fall Management Policy, revised October 2024, indicates: .9. The Interdisciplinary Team designee will discuss recommended significant changes to the care plan to minimize repeat falls with the resident and/or resident's representative. The care plan will be reviewed and/or revised as indicated .Kardexes (abbreviated care plans used by nursing staff) are updated as appropriate .On 7/21/25, Surveyor reviewed R25's medical record. R25 was admitted to the facility on [DATE] and had diagnoses including sequalae following cerebrovascular disease, dysphagia, hemiplegia, and hemiparesis. R25's Minimum Data Set (MDS) assessment, dated 5/15/25, had a Brief Interview for Mental Status (BIMS) score of 0 out of 15 which indicated R25 had severe cognitive impairment. R25 had an activated Power of Attorney for Healthcare (POAHC).A facility investigation indicated staff discovered R25 on the floor between R25's bed and window on 5/2/25 at 4:00 PM. R25 had a laceration on the top of the head and could not recall what R25 was attempting to do. The investigation indicated the fall occurred because R25 was exhibiting terminal restlessness. An intervention was added to have R25's bed in the lowest position. A care plan, initiated on 5/2/25, contained an intervention to ensure R25's bed was in the lowest position.On 7/22/25 at 7:44 AM, Surveyor observed R25 in bed and noted R25's bed was in the highest position.On 7/22/25 at 7:53 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-H who indicated R25 was not a fall risk and independently held the bed remote and adjusted the height of the bed. After reviewing R25's care plan, LPN-H verified R25's bed should be in the lowest position. LPN-H adjusted the height of R31's bed and removed the handheld control from R25. On 7/22/25 at 1:26 PM, Surveyor interviewed Director of Nursing (DON)-B who verified staff should follow a resident's care plan. On 7/22/25 at 2:23 PM, Surveyor observed R25 in bed and noted R25's bed was in a medium height position. On 7/22/25 at 2:23 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-I who verified R25's bed was not in the lowest position but should be. CNA-I then lowered R25's bed.

Based on staff interview and record review, the facility did not develop a comprehensive bowel and bladder care plan for 1 resident (R) (R7) of 16 sampled residents.R7 was admitted to the facility in August of 2024. Documentation indicated R7 was occasionally incontinent of bladder, typically during the night. R7's comprehensive care plan, updated on 5/16/25, did not include problems, goals, or interventions related to incontinence. Findings include: On 7/21/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including schizophrenia, dysphagia (difficulty swallowing), depression, and diabetes. R7's most recent Minimum Data Set (MDS) assessment, dated 5/16/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderate cognitive impairment. The MDS assessment also indicated R7 was occasionally incontinent of bladder and did not have a toileting program. R7 was R7's own decision maker. On 7/21/25, Surveyor reviewed R7's Certified Nursing Assistant (CNA) charting related to urinary incontinence over the last 30 days and noted R7 was incontinent on 4 out of 73 occurrences, all during the night shift. On 7/21/25 at 1:12 PM, Surveyor interviewed CNA-J who stated R7 was continent at all times and independent with toileting. CNA-J was not aware R7 was occasionally incontinent during the night shift. On 7/21/25 at 1:22 PM, Surveyor interviewed Director of Nursing (DON)-B who verified R7's comprehensive care plan did not include problems, goals, or interventions related to urinary incontinence. DON-B stated toileting/incontinence status should be included in a resident's comprehensive care plan.

Based on staff and resident interview and record review, the facility did not ensure 1 resident (R) (R28) of 17 sampled residents was offered the opportunity to create or obtain Power of Attorney for Healthcare (POAHC) paperwork.R28 was admitted to the facility on [DATE]. The facility did not obtain R28's POAHC document or offer R28 the chance to fill out a new document prior to 7/21/25. Findings include:The facility's Advanced Directive policy and procedure, dated October 2020, indicates: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law .Purpose: To help ensure a resident's right to formulate an advanced directive .2. The facility will inquire at the time of admission whether the resident has previously executed an advance directive. 3. If a resident has executed an advance directive, the facility must obtain a copy from the resident or the legal representative which is stored in the resident's medical record. Nursing notifies the physician of the resident's or the legal representative's wishes, obtains orders as appropriate, and enters the information in the electronic health record.On 7/21/25, Surveyor reviewed R28's medical record. R28 was admitted to the facility on [DATE]. R28's medical record did not contain POAHC documentation or a POAHC refusal document. On 7/21/25 at 10:15 AM, Surveyor interviewed R28 who stated R28's POAHC document was at home in a safe and R28's family had access to the document.On 7/21/25 at 1:50 PM, Surveyor interviewed Social Services Director (SSD)-M who stated R28 informed SSD-M that a copy of an advanced directive was in R28's safe at home and R28's family had access to the document. Surveyor reviewed a documented conversation with R28's family member that occurred on 5/12/25 and contained a request for a copy of the document. R28's medical record did not contain any further documented attempts to contact the family member to obtain R28's POAHC document. On 7/23/25 at 1:14 PM, Surveyor interviewed Director of Nursing (DON)-B who stated staff are expected to either obtain a copy of a resident's POAHC document or offer to create a new one.

Based on staff and resident interview and record review, the facility did not ensure 3 residents (R) (R5, R7, and R6) of 16 sampled residents were given the right to participate in care planning.R5 was admitted to the facility in December of 2024. R5's medical record did not contain documentation of any care conferences.R7 was admitted to the facility in August of 2024. R7's medical record did not contain documentation of any care conferences.R6 was admitted to the facility in November of 2024. R6's medical record did not contain documentation of any care conferences.Findings include: The facility's Care Plan Conference policy, revised 2/2021, states the Interdisciplinary Team, in conjunction with the resident and/or the resident representative, will develop the plan of care based on the comprehensive assessment. The care plan conference is held to identify resident needs and establish obtainable goals .The facility must encourage residents and/or their representatives to participate in care planning including their attendance at the care planning conference. The facility must make efforts to schedule care planning meetings at the best time of day for residents and representatives .Document the care planning conference in the progress notes. Be sure to include at least the following information: summary of the meeting; list of attendees; and if the resident and/or their representative do not participate in the meeting, document the reason why 1.On 7/21/25, Surveyor reviewed R5's medical record. R5 was admitted to facility on 12/20/24. R5's medical record did not contain documentation of any care conferences. On 7/21/25 at 9:54 AM, Surveyor interviewed R5 who stated the facility does not communicate with R5 regarding discharge planning or R5's plan of care. R5 stated R5 has not had a care conference since R5 was admitted to the facility. On 7/23/25 at 11:28 AM, Surveyor interviewed Social Services Director (SSD)-M who stated R5 had a care conference upon admission, however, SSD-M was unable to find documentation of any care conferences. SSD-M indicated care conferences should be completed quarterly. 2. On 7/21/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE]. R7's medical record did not contain documentation of any care conferences. On 7/21/25 at 10:13 AM, Surveyor interviewed R7 who stated R7 had not had a care conference since R7 was admitted to the facility. On 7/23/25 at 11:28 AM, Surveyor interviewed SSD-M who stated R7 had a care conference upon admission, however, SSD-M was unable to find documentation of any care conferences. SSD-M indicated care conferences should be completed quarterly. 3. On 7/21/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE]. R6's medical record did not contain documentation of any care conferences. On 7/21/25 at 9:54 AM, Surveyor interviewed R6 who stated the facility does not communicate with R6 or R6’s Power of Attorney (POA). R6 indicated questions are asked about R6's treatment plan and discharge but no answers are received. R6 was not aware of any care conferences for R6. On 7/23/25 at 11:31 AM, Surveyor interviewed SSD-M who stated R6 had two care conferences, however, SSD-M was unable to find documentation of any care conferences. SSD-M indicated care conferences should be completed quarterly. On 7/23/25 at 1:17 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated care conferences should be completed on a quarterly basis.

Based on staff and resident interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R13) of 2 sampled residents. R13 was admitted to the facility on [DATE] with a stage 4 pressure injury on the right hip and a wound vac (a device used to promote healing in wounds that are slow to close that includes a sealed dressing and a vacuum pump which helps remove fluid and bacteria, reduce swelling, and encourage new tissue growth). On 6/18/25, Wound Nurse Practitioner (WNP)-P indicated R13's wound vac dressing had been applied incorrectly which caused the skin around the wound to deteriorate and the wound to increase in size. Findings include: The facility's Pressure Ulcer Prevention and Treatment policy, revised August 2024, indicates the facility must ensure residents with pressure ulcers receive necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from forming. Treatments and interventions will be used based on current standards of practice and provider's orders. From 6/24/25 to 6/25/25, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had diagnoses including stage 4 pressure injury, cellulitis, and paraplegia (paralysis of the lower half of the body). R13's most recent Minimum Data Set (MDS) assessment, dated 5/22/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 had intact cognition. R13 required the assistance of 1 to 2 staff for repositioning in bed. On 6/24/25, Surveyor reviewed a grievance, dated 6/18/25, that indicated R13 reported that R13's wound vac dressing was not being done correctly. The facility's investigation indicated Registered Nurse (RN)-K had completed R13's last dressing change on 6/16/25. Director of Nursing (DON)-B told R13 that RN-K and other nursing staff would be educated on proper placement of the wound vac dressing. R13's June 2025 Treatment Administration Record (TAR) indicated RN-K completed R13's right hip wound vac dressing change on 6/13/25 and 6/16/25. The order stated to remove the old vac dressing, apply skin prep to the peri-wound (skin surrounding the wound), window wound with vac drape, apply black sponge to wound bed and bridge to anterior upper thigh, apply top drape, and reconnect wound vac at 125 millimeters of mercury (mmHG) pressure. The order began on 5/30/25, was held on 6/18/25, and resumed on 6/26/25. Surveyor also noted R13 received intravenous (IV) ceftriaxone (an antibiotic) daily for a wound infection beginning on 5/20/25. R13's right hip weekly wound assessments indicated the following: ~ 5/28/25 - 4.6 centimeters (cm) x 8.9 cm x 2.2 cm, stage 4, heavy purulent (pus-filled) drainage ~ 6/4/25 - 6.3 cm x 9.2 cm x 2.5 cm, stage 4, heavy serosanguinous (blood-tinged) drainage ~ 6/11/25 - 6.7 cm x 9.5 cm x 1.8 cm, stage 4, moderate serosanguinous drainage; improving ~ 6/18/25 - 8.5 cm x 10 cm x 2.5 cm, stage 4, heavy serosanguinous drainage; worsening A wound note, dated 6/18/25 at 9:45 AM and written by WNP-P, indicated upon removal of the wound vac it was discovered that a drape was not placed to protect the skin during the last wound vac change which resulted in a secondary wound, skin erosion, and irritation. On 6/25/25 at 9:40 AM, Surveyor interviewed WNP-P who verified WNP-P observed R13's wound on 6/18/25 and noted the wound vac dressing was applied incorrectly when RN-K did not apply the base drape layer around the wound. WNP-P stated the purpose of the drape is to protect the skin around the wound from the drainage that is being pulled out of the wound via the vacuum as well as to help create an air-tight seal to ensure the vacuum is functioning to the best of its ability. WNP-P stated the skin around the wound was irritated and the wound was larger and had worsened from the previous week. WNP-P stated the wound vac could not be put back on and R13 needed a wet-to-dry dressing for a week so the skin around the wound could heal. WNP-P verified the incorrect application of the wound vac dressing contributed to the worsening of R13's pressure injury. WNP-P stated staff have WNP-P's phone number and are encouraged to call if there are any concerns with wounds or wound vacs. On 6/25/25 at 9:55 AM, Surveyor interviewed R13 who stated staff had issues with R13's wound vac in the past and verified R13 received IV antibiotics since admission for a right hip wound infection. R13 stated R13 spoke to RN-K the previous day (RN-K worked the AM shift on 6/24/25) and RN-K told R13 that RN-K had not received any recent education regarding wound vacs. R13 stated DON-B told R13 that the facility would be training all nursing staff on wound vacs and R13 now felt that DON-B was not sincere in addressing R13's concerns. R13 stated R13 felt the wound vac issues were delaying R13's discharge home which caused R13 to feel depressed. On 6/25/25 at 10:05 AM, the facility provided Surveyor with a correction plan related to the incorrect application of R13's wound vac dressing. The facility indicated the root cause was that the wound vac dressing was not completed accurately which caused skin irritation and was due to lack of education for the nurse who applied the dressing. The facility's plan stated all nursing staff would be educated on wound vac dressings by 6/24/25. Surveyor reviewed the signed education sheets and noted all nursing staff who worked the 6/24/25 PM shift, 6/24/25-6/25/25 night (NOC) shift, and the 6/25/25 AM shift had signed the staff education sheet. All other nursing staff were provided verbal education via telephone which did not include a demonstration of how to properly complete the wound vac dressing change. Surveyor also observed a 1:1 In-Service Record education form provided to RN-K, dated 6/18/25, regarding wound vacs. The education sheet was signed by DON-B and RN-K but did not contain signature dates. Surveyor noted R1 and R21 (who discharged on 6/23/25) also had active wound vac orders during that time. On 6/25/25 at 10:13 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-M who stated LPN-M was provided wound vac education on the evening of 6/24/25. On 6/25/25 at 10:15 AM, Surveyor interviewed RN-L who stated RN-L was provided wound vac education on the morning of 6/25/25 and did not receive education related to the incident prior to 6/25/25. On 6/25/25 at 10:21 AM, Surveyor interviewed RN-K who stated RN-K was not aware RN-K had completed R13's dressing incorrectly until R13 mentioned it on 6/24/25. RN-K verified RN-K was not provided education or follow-up until approximately 5:00 PM on 6/24/25 and did not sign the 1:1 In-Service Record form until approximately 5:30 PM on 6/24/25. On 6/25/25 at 11:13 AM, Surveyor interviewed DON-B who initially stated RN-K signed the 1:1 In-Service Form on 6/18/25 then indicated education was started on 6/18/25 but the form was not signed until 6/24/25. DON-B verified it was possible that some staff may have signed the staff education sheet on the evening of 6/24/25 or the morning of 6/25/25. DON-B stated the facility was planning a lunch and learn on 6/26/25 that would include a demonstration of the wound vac with the facility's wound care RN.

Based on observation, staff and resident interview, and record review, the facility did not ensure 4 residents (R) (R7, R12, R15, and R17) of 19 sampled residents were provided safe administration of drugs and biologicals. On 6/24/25, Surveyor observed an albuterol inhaler and a vial of DuoNeb solution on R7's bedside table. Surveyor also observed a nebulizer on the nightstand that contained a full chamber of solution. R7 did not have a physician's order or self-administration of medication assessment that indicated R7 could self-administer medication. On 6/24/25, Surveyor observed a 1 ounce bottle of Afrin nasal spray on R12's nightstand. R12 did not have a physician's order for Afrin nasal spray or a self-administration of medication assessment that indicated R12 could self-administer medication or store medication at the bedside. On 6/24/25, Surveyor observed an albuterol inhaler on R15's bedside table. R15 did not have a physician's order or a self-administration of medication assessment indicated R15 could self-administer medication or store medication at the bedside. On 6/24/25, Surveyor observed 2 tubes of [NAME] Pain Relief, a 3 ounce bottle of miconazole 2% powder, a 16 ounce bottle of Dakin's solution, and a 1 ounce bottle of Adapt stoma powder on R17's nightstand. R17 did not have a physician's order or a self-administration of medication assessment that indicated R17 could self-administer medication or store medication at the bedside. Findings include: The facility's Self-Administration of Medication policy, revised May 2020, indicates: .3. The nurse will interview the resident to determine the resident's ability to identify, prepare, and self-administer medications. 4. Based on Interdisciplinary Team (IDT) review, a decision is made as to whether or not the resident is a candidate for self-administration. This will be recorded on the Medication Self-Administration Assessment .5. The nurse will obtain a physician's order for each resident self-administering medication. 1. From 6/24/25 to 6/25/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including respiratory failure, anxiety disorder, rhabdomyolysis, repeated falls, and weakness. R7's Minimum Data Set (MDS) assessment, dated 5/2/25, had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R7 had moderately impaired cognition. On 6/24/25 at 10:52 AM, Surveyor observed an albuterol inhaler and a vial of DuoNeb solution on R7's bedside table. Surveyor also observed a nebulizer on the nightstand that contained a full chamber of solution. R7 indicated R7 was unsure what medications R7 was prescribed. R7 confirmed R7 self-administered the inhaler for shortness of breath and indicated the DuoNeb vial was left for R7 to use in the nebulizer machine when R7 needed it. R7's medical record contained a self-administration of medication assessment, dated 4/26/25, that indicated R7 was not approved to self-administer medication. R7 had a physician's order to keep the albuterol inhaler at the bedside (dated 6/6/25). On 6/25/25 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed staff should have completed a new self-administration of medication assessment for R7 that indicated R7 could store the albuterol inhaler at the bedside in conjunction with the physician's order. DON-B also indicated staff should not leave medication for R7 to self-administer without a self-administration assessment and order. 2. From 6/24/25 to 6/25/25, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including pneumonia, wedge compression fracture of 5th lumbar vertebra, hypothyroidism, atrial fibrillation, and abnormalities of gait and mobility. R12's MDS assessment, dated 5/5/25, had a BIMS score of 11 out of 15 which indicated R12 had moderately impaired cognition. On 6/24/25 at 11:00 AM, Surveyor observed a 1 ounce bottle of Afrin nasal spray on R12's nightstand. R12's medical record did not contain a physician's order for Afrin nasal spray or a physician's order or self-administration of medication assessment that indicated R12 could self-administer the nasal spray or keep the nasal spray at the bedside. On 6/25/25 at 11:50 AM, Surveyor interviewed DON-B who confirmed R12 did not have a physician's order for the use of Afrin nasal spray or a physician's order or self-administration of medication assessment that indicated R12 could self-administer the nasal spray. 3. From 6/24/25 to 6/25/25, Surveyor reviewed R15's medical record. R15 was admitted to the facility on [DATE] and had diagnoses including lymphedema, reduced mobility, weakness, and trigeminal neuralgia. R15's MDS assessment, dated 5/13/25, had a BIMS score of 12 out of 15 which indicated R15 had moderate cognitive impairment. On 6/24/25 at 11:04 AM, Surveyor observed an albuterol inhaler on R15's bedside table. R15's medical record did not contain a physician's order or self-administration of medication assessment that indicated R15 could self-administer the inhaler or store the inhaler at the bedside. On 6/25/25 at 11:50 AM, Surveyor interviewed DON-B who confirmed the albuterol inhaler should not have been at R15's bedside in accordance with a self-administration of medication assessment that indicated R15 was not able to self-administer medication or store medication at the bedside. 4. From 6/24/25 to 6/25/25, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including traumatic spinal cord dysfunction, pressure ulcer-sacral region stage 2, muscle wasting and atrophy-multiple sites, metabolic encephalopathy, mononeuropathy of unspecified lower limb, weakness, and effusion of right hip. R17's MDS assessment, dated 5/1/25, had a BIMS score of 13 out of 15 which indicated R17 had intact cognition. On 6/24/25 at 11:34 AM, Surveyor observed 2 tubes of [NAME] pain relief, a 3 ounce bottle of miconazole 2% powder, a 16 ounce bottle of Dakin's solution, and a 1 ounce bottle of Adapt stoma powder on R17's nightstand. R17's medical record did not contain a physician's order or a self-administration of medication assessment that indicated R17 could self-administer the medications or store the medications at the bedside. On 6/25/25 at 11:50 AM, Surveyor interviewed DON-B who confirmed R17 did not have a physician's order or self-administration of medication assessment that indicated R17 could self-administer the medications or keep the medications at the bedside.

2. The 2022 Federal Food and Drug (FDA) Food Code documents at 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: .(B) With tight-fitting lids or doors if kept outside the food establishment . On 6/24/25 at 7:33 AM, Surveyor conducted an environmental tour of the facility and noted a garbage dumpster in the rear parking lot was open on top and in the back. On 6/24/25 at 2:38 PM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. On 6/25/25 at 8:25 AM, Surveyor observed multiple pieces of discarded furniture near the dumpster in the rear parking lot and noted the top of the dumpster was still open. Surveyor observed Dietary Aide (DA)-D throw boxes in the recycling dumpster and walk back into the building without closing the lid of the dumpster that contained garbage. Based on observation, staff interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment for residents, staff, and the public. This practice had the potential to affect more than 4 of the 44 residents residing in the facility. The facility's front entrance contained broken concrete outside the main entrance and lifted floor tile in the walkway between the main entrance front doors. On 6/24/25, a commercial dumpster that contained garbage was left open in the parking lot. Findings include: 1. On 6/24/25, Surveyor entered the facility and noted the cement in front of the main entrance was uneven, cracked, and heaving. When Surveyor entered the first door of the main entrance, Surveyor also noted the floor tile was lifted and cracked. On 6/24/25 at 3:56 PM, Surveyor again observed the flooring in the entrance way and noted it was lifted in the middle of the entrance way. On 6/25/25 at 12:58 PM, Surveyor measured the cracks at the front entrance. When facing the front door, the cement on the the left side of the entrance contained a crack that measured approximately 2.5 inches from the top piece of concrete to the next piece of concrete. The concrete also had an approximate 2.75 inch gap from the ground to top of the highest piece. The distance between the two pieces of concrete measured approximately 1.5 inches. At approximately the middle of the front entrance, Surveyor measured an approximate 5.5 inch gap/rise in the concrete from the ground. Several pieces of the concrete were cracked, missing, or flaking. To the right of the front entrance, Surveyor also measured an approximate 1 inch gap. On 6/25/25 at 1:00 PM, Surveyor measured an area on the left past the patio/sitting area outside the main entrance that contained a drop of approximately 4.5 inches on the right side of the raised concrete ramp going down to the sidewalk on the side of the building. On 6/25/25 at 1:05 PM, Surveyor and Maintenance-R toured the outside entrance and observed the concrete at the front entrance and the area in between the doors where the floor tile was lifted and cracked. Maintenance-R indicated repairs to concrete or flooring are completed by Maintenance-R as needed. Maintenance-R confirmed Maintenance-R completes smaller projects and indicated larger jobs need to be quoted and approved by management. Maintenance-R indicated the front concrete entrance way should be repaired along with the floor tiles in between the doors in the entrance way. Maintenance-R stated the facility has talked about replacing both but nothing was planned so far. On 6/25 at 1:12 PM, Surveyor and Director of Nursing (DON)-B toured the outside entrance and observed the concrete approach to the front door and the area in between the doors where the floor tile was lifted. DON-B indicated the facility had not had complaints or issues concerning the concrete or floor tile, however, the facility would look at it.

Based on observation, staff and resident interview, and record review, the facility did not ensure staff provided activities of daily living (ADLs) in accordance with preferences for 1 resident (R) (R13) of 19 sampled residents. R13 was dependent on staff for oral care, pericare, and personal hygiene and filed a grievance on 5/26/25 regarding the provision of timely care. The grievance indicated the issue was resolved, however, staff continued to not provide care in a timely manner or at R13's preferred time of day. Findings include: The facility's Routine Resident Care policy, revised May 2020, indicates: Residents receive the necessary assistance to maintain good grooming and personal/oral hygiene .3. Daily personal hygiene minimally includes assisting or encouraging residents with washing their faces and hands, combing their hair each morning, and brushing their teeth and/or providing denture care .Incontinence care is provided timely according to each resident's needs .9. Residents' call lights are answered timely and residents' requests are addressed . From 6/24/25 to 6/25/25, Surveyor reviewed R13's medical record. R13 had diagnoses including pressure ulcer of right ankle unstageable, unspecified injury at T7-T10 level of thoracic spinal cord, paraplegia, pressure ulcer of right buttock stage 4, colostomy, and urostomy. R13's Minimum Data Set (MDS) assessment, dated 5/29/25, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R13 had intact cognition. A care plan, dated 5/19/25, indicated R13 had paraplegia related to a spinal cord injury and required assistance with ADLs and locomotion. On 6/24/25, Surveyor reviewed the facility's grievance file and noted a grievance filed by R13 on 5/26/25 regarding timely care. The grievance indicated R13 voiced concerns that R13 did not receive consistent morning cares. The grievance indicated the concern was resolved on 5/30/25, staff were educated, and R13 was updated and in agreement with staff follow-up. A summary of the investigation indicated Director of Nursing (DON)-B spoke with R13 and Certified Nursing Assistants (CNAs) scheduled on the days R13 reported concerns. The CNAs were educated on R13's daily care routine during a staff meeting. The summary of findings indicated there was miscommunication between the CNAs when one assumed another had completed cares. The grievance indicated R13 was aware staff were being educated and stated DON-B would follow-up with R13 on a regular basis. On 6/25/25 at 9:55 AM, Surveyor interviewed R13 who indicated R13 was washed up maybe fifty percent of the time and often did not receive assistance with cares until between 12:00 and 1:00 PM. R13 indicated most of the time PM shift staff provided ADLs for R13. R13 indicated R13 frequently asks for cares to be completed during the AM shift but staff say R13 has to wait and staff will come back, but never do. R13 indicated R13's grievance was not resolved because staff continue to not provide assistance with ADLs in the morning per R13's preference. R13's medical record to included documentation of oral cares and bathing/bed baths. Surveyor noted R13 received assistance with ADLs 26% of the time on the AM shift from 5/27/25 to 6/25/25 despite the fact R13 indicated R13 preferred to receive assistance with cares during the morning hours. On 6/25/25 at 12:02 PM, Surveyor interviewed DON-B who indicated DON-B followed-up with R13 and R13 indicated things were getting better. DON-B stated DON-B continues to follow-up with R13 who had not indicated that R13 still had concerns. On 6/25/25 at 12:10 PM, Surveyor interviewed R13 who indicated R13 had not seen DON-B since last week. R13 indicated the most recent times R13 spoke to DON-B were about wound care and not ADLs. R13 recalled that when the grievance was submitted, DON-B indicated staff education would occur. R13 indicated during the interview with Surveyor that R13 had not received oral care yet. R13 also indicated the only reason R13's Chux pad was changed that day was because R13 had wound care. R13 stated R13 had a colostomy and ostomy but still needed pericare, oral care, and a Chux pad change since R13 had wounds that seep and drain and had occasional drainage from the colostomy and ostomy. R13 stated R13 was made to just sit in that with a wet Chux. R13 indicated R13 was able to do oral care independently but needed assistance with set-up. R13 also stated R13 was not washed up in a timely manner and indicated R13 was paralyzed and unable to do certain things independently. R13 indicated R13 used the call light and repeatedly asked staff to provide cares which were not provided most of the time until the PM shift. R13 indicated R13 wakes up at 9:00 AM and informed staff and administrative staff several times that R13 prefers to be assisted with ADLs at approximately 10:00 AM which rarely happens.

Based on staff interview and record review, the facility did not ensure a allegation of misappropriation was thoroughly investigated for 1 resident (R) (R3) of 1 sampled resident. On 5/16/25, R3 reported to the facility that R3 was a missing a blue jacket worth $75. The facility did not provide staff education on misappropriation of resident property or documenting residents' personal property upon admission despite the fact education was listed as an immediate and ongoing intervention in the facility's investigation. Findings include: The facility's Missing Resident Belongings policy, dated 3/2021, indicates: Synergy Senior Care seeks to ensure residents' belongings are protected from loss/theft. Every effort to ensure that missing items are located will be made .1. Missing belongings will be reported to all departments by residents, families, and nursing staff. 2. Staff should promptly fill out a concern form to identify missing item(s). The form should include follow-up and conclusion to be communicated to the resident or responsible party. 3. Social Services will assist the resident/family in searching the resident's room for the item .Nursing and housekeeping staff need to watch out for glasses. Nursing staff should check every pocket before sending items to laundry. Nursing and dietary staff should check napkins on plates. Housekeeping staff should check room trash for items which may have fallen into the waste basket. Laundry staff should check clothing tags to make sure laundry gets back into the correct closet. 4. Social Services will search for the item(s) in an appropriate area if any. 5. Social Services will notify administration, housekeeping, nursing, and other departments as appropriate of any missing item(s). An ongoing list will be kept in the Social Services area. 6. If there is an allegation or accusation of deliberate misappropriation (theft), the facility will immediately initiate an investigation in accordance with the facility abuse prevention policy (investigation, reporting, police report as required, etc.) On 6/25/25, Surveyor reviewed a facility-reported incident (FRI) that indicated R3 called the facility on 5/16/25 after R3 was discharged and indicated R3 was missing a blue jacket worth $75. The facility initiated an investigation on 5/16/25, notified the police, and filed a report with the State Agency (SA) after a search for the missing jacket was unsuccessful. Staff and resident interviews were completed for the allegation of misappropriation with no concerns noted. Staff interviews indicated staff had not seen R3 wear a blue jacket. The investigation indicated the facility could not substantiate misappropriation but would reimburse R3 for the jacket if R3 provided proof of the cost. The investigation indicated a personal inventory form was not completed upon R3's admission, therefore, the facility could not determine if R3's blue jacket was present upon admission. The investigation indicated the facility would educate staff on ensuring an inventory form is completed upon admission to ensure accuracy of personal items brought to the facility. On 6/25/25 at 1:00 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified the facility did not have proof of staff education regarding the allegation of misappropriation.

Based on staff interview and record review, the facility did not ensure Informed Consent for Medication forms were signed or verbal consent was obtained prior to administering psychotropic medication for 1 resident (R) (R6) of 1 sampled resident. R6 was administered psychotropic medication without written or verbal consent from R6's Power of Attorney for Healthcare (POAHC). Findings include: The facility's Psychotropic Management policy, revised July 2020, indicates: .1. Upon receipt of new orders for psychotropic medication, the licensed nurse will implement the following: .B. Complete the appropriate psychotropic medication consent form; Consents for psychoactive medications must be obtained by the physician if state regulation requires it. C. Education of the resident and/or the resident representative is conducted to communicate the risks and benefits of the medication. Per the facility's Psychotropic Management System flow chart step 3 .Nurse/physician completes informed consent and education with the resident or representative. From 6/24/25 to 6/25/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, degeneration of nervous system due to alcohol, alcohol dependence with other alcohol-induced disorders, personal history of transient ischemic attack (TIA) and cerebral infarction (stroke), and anxiety disorder. R6's Minimum Data Set (MDS) assessment, dated 2/25/25, had a Brief Interview for Mental Status (BIMS) score of 4 out of 15 which indicated R6 had severely impaired cognition. R6 had an activated POAHC. R6's Medication Administration Record (MAR) indicated R6 was prescribed the following medications which require informed consent: Seroquel (started on 2/19/25); melatonin (started on 2/19/25); BuSpar (started on 2/19/25); citalopram (started on 3/1/25); and lorazepam (started on 2/28/25). Surveyor reviewed R6's Informed Consent for Medication forms and noted R6 had consents for Seroquel, melatonin, citalopram, and BuSpar which were signed on 2/21/25, however, the medications were started on 2/19/25. The consent forms did not indicate verbal consent was obtained prior to the start of the medications. R6's citalopram consent was signed on 3/7/25, however, the medication was started on 3/1/25. The consent form did not indicate verbal consent was obtained prior to the start of the medication. Surveyor verified R6 did not have an Informed Consent for Medication form for lorazepam when copies of R6's Informed Consent for Medication forms were provided to Surveyor. On 6/24/25 at 11:50 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed informed consent and Informed Consent for Medication forms should have been obtained prior to starting the medications.

Based on staff interview and record review, the facility did not ensure food was prepared and served in a form designed to meet individual needs for 1 resident (R) (R1) of 4 residents who had an order for a mechanically-altered diet. R1 was admitted to the facility on [DATE] following a hospitalization . R1's hospital discharge orders indicated R1 should receive a pureed diet, however, staff transcribed R1's diet order as mechanical soft with nectar-thickened liquids. On 3/13/24, R1 received the wrong meal tray and was served food that was not in accordance with R1's diet order. R1 aspirated, required hospitalization , and passed away on 3/23/24 from respiratory failure secondary to aspiration pneumonia. The facility's failure to prepare and serve food in a form to meet a resident's needs created a finding of Immediate Jeopardy that began on 3/13/24. The State Agency (SA) notified Nursing Home Administrator (NHA)-A of the Immediate Jeopardy on 4/2/24 at 3:34 PM. The Immediate Jeopardy was removed and corrected on 3/17/24. Findings include: As of October 2021, the Academy of Nutrition and Dietetics announced International Dysphagia Diet Standardization Initiative (IDDSI) is the only professionally recognized standard of care for texture modified diets in the Nutrition Care Manual of the Academy of Nutrition & Dietetics for the United States. The IDDSI framework identifies five levels for foods: 7. Regular, easy to chew; 6. Soft and bite-sized (most similar to mechanical soft); 5. Minced and moist; 4. Pureed; and 3. Liquidized. The facility's Consistency of Modified Foods policy, revised January 2021, indicates: Pureed foods are pudding-like or have a consistency similar to mashed potatoes with a homogenous consistency, without coarse textures . The facility's Physician Orders policy, revised March 2020, indicates: When receiving a written/faxed order .After noting an order, the receiving licensed nurse enters the order into the electronic medical record (EMR) and ensures it is active in the electronic administration record as appropriate. On 4/2/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including dementia, Down syndrome, anxiety, and dysphagia (difficulty swallowing). R1's Minimum Data Set (MDS) assessment, dated 3/14/24, contained a Brief Interview for Mental Status (BIMS) score of 99 which indicated R1 was cognitively impaired. R1's guardianship was active upon admission. On 4/2/24, Surveyor reviewed an investigation, dated 3/17/24. The investigation indicated R1 was given a regular diet instead of a pureed diet on 3/13/24 and had an episode of coughing and emesis (vomiting). R1 was hospitalized the following morning and diagnosed with aspiration pneumonia. The investigation indicated an incorrect diet was entered in R1's medical record upon admission. Surveyor noted R1's hospital discharge paperwork, dated 3/10/24, stated Dysphagia I Pureed diet, however, R1's medical record contained a diet order, dated 3/10/24, that stated Regular diet, mechanical soft texture, nectar thickened liquid consistency. R1's baseline care plan indicated R1 had a regular, mechanical soft diet with nectar-thickened liquids and ate in the dining room. A nursing progress note, dated 3/13/24, indicated: (Licensed Practical Nurse (LPN)-E) was informed by (Certified Nursing Assistant (CNA)-G) that (R1) was given the wrong tray in the dining room. (R1) coughed and vomited. (LPN-E) called the Nurse Practitioner (NP) who gave an order for a stat (immediate) chest X-ray one time only for suspected aspiration. On 4/2/24 at 9:40 AM, Surveyor interviewed NP-F who verified an on-call NP ordered an X-ray on 3/14/24 and instructed staff to send R1 to the hospital. NP-F reviewed R1's hospital record and stated R1 received intravenous (IV) antibiotics for aspiration pneumonia. NP-F confirmed R1 passed away at the hospital on 3/23/24 due to respiratory failure secondary to aspiration pneumonia. On 4/2/24 at 10:14 AM, Surveyor interviewed LPN-E who verified LPN-E took verbal report via telephone for R1's admission. LPN-E stated LPN-E was made aware of R1's pureed diet order and completed a dietary communication form that indicated R1 should receive a pureed diet. LPN-E stated on LPN-E's next shift on 3/13/24, CNA-G told LPN-E that R1 was coughing and spitting out R1's dinner. LPN-E immediately assessed R1 and notified the on-call NP. On 4/2/24 at 10:19 AM, Surveyor interviewed Dietary Manager (DM)-H who verified R1's dietary slip stated mechanical soft. DM-H stated R1 was served a bean and meat burrito, not cut up because the tortilla was soft enough, along with refried beans and banana crumble with no topping. On 4/2/24 at 11:10 AM, Surveyor interviewed Registered Nurse (RN)-D who verified RN-D entered a mechanical soft diet order in R1's medical record. RN-D could not recall where RN-D got the order and was unsure if a second check was completed for R1's admission orders. RN-D could not recall if RN-D placed R1's admission orders on the nursing station desk or in the basket designated for orders needing a second check. On 4/2/24 at 12:42 PM, Surveyor interviewed Chief Nursing Officer (CNO)-C who verified the facility was unable to confirm if a second check was completed for R1's admission orders, but confirmed all orders should be verified by a second licensed nurse. On 4/2/24, Surveyor reviewed a written and signed statement from Cook (CK)-I that indicated CK-I provided R1 with a dinner tray on 3/13/24. CK-I stated R1's dietary card stated mechanical soft and R1 was served a mechanical soft tray. On 4/2/24, Surveyor reviewed a written and signed statement from CNA-G, dated 3/17/24, that stated R1 was seen spitting up R1's food and coughing. CNA-G immediately notified LPN-E. CNA-G indicated R1 had not received a pureed diet since R1 was admitted to the facility. The failure to prepare and serve a diet which met R1's needs led to serious harm for R1 which created a finding of Immediate Jeopardy. The facility removed and corrected the jeopardy on 3/17/24 when it completed the following: 1. Reviewed residents' diet orders for accuracy. 2. Educated all nursing, dietary, and CNA staff. 3. Initiated daily audits to ensure diet accuracy.

Based on observation, interview and record review, the facility did not ensure necessary care and services were provided to promote healing and/or prevent pressure injuries from worsening/developing for 2 Residents (R) (R195 and R3) of 6 sampled residents reviewed for pressure injuries. R195 admitted to facility with several pressure injuries. Facility did not consistently administer physician ordered treatments and failed to maintain specialty mattress at correct setting to reduce pressure which caused R195's sacral (lower back near buttocks) pressure injury to worsen. R3 developed a Stage IV pressure injury in June of 2020. The facility did not consistently implement proper positioning and maintain specialty air mattress at the correct settings to reduce the risk of worsening R3's pressure injury. Findings include: 1. On 4/11/22, Surveyor reviewed R195's medical record. R195 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R195's Minimum Data Set (MDS) assessment dated [DATE] stated R195's Brief Interview for Mental Status (BIMS) score was 01 out of 15 which indicated R195 had severe cognitive impairment. R195's medical record contained a Michigan Guardianship dated 10/19/21 which indicated R195's Guardian/Spouse was responsible to R195's medical decisions. On 4/12/22 at 10:37 AM, Surveyor interviewed R195's Guardian (G)-C via telephone. G-C stated, I am just concerned about [R195's] bed sores . [R195] got bed sores in hospital. Also concerned about [R195's] sugars being high, that's not good to heal bed sores. G-C additionally stated, I really want [R195] back in Michigan . the hospital said Michigan nursing homes wouldn't take [R195] because of bed sores . On 4/12/22, Surveyor reviewed R195's medical record. R195's care plan stated, The resident has numerous pressure injuries unstageable (full thickness tissue loss in which the actual depth of the wound is completely obscured by slough (yellow devitalized tissue that can be stringy or thick and contributes to delayed wound healing) and/or eschar (dead or devitalized tissue) in the wound bed) to left lateral foot,Stage 1 (superficial reddening of the skin that when pressed does not turn white) to left lateral foot, Stage 1 to left lateral Pinky Toe, unstageable to left 4th (fourth) toe, Stage 1 to left great toe, Stage 1 to anterior (front) left great toe and Stage 3 (full-thickness loss of skin, in which fat tissue is visible) to Sacrum r/t (related to) decreased mobility with interventions to include, . Administer treatments as ordered and monitor for effectiveness .pressure reduction bed . R195's medical record contained the following information: ~Skin Observation Tool dated 3/27/22: . pressure wound to coccyx (sacral area), peri-wound deep red. ~PUSH Tool (Pressure Ulcer Scale for Healing - a tool used to monitor pressure injuries over time) dated 3/30/22 for sacral area indicated measurements of 1.5cm length, 1.5cm width and 0.0cm depth. Tool indicated sacral wound was considered Stage 3 with 100% non-granulating (clean but not healing) tissue in wound bed. Tool further stated, Continue current treatment provided by hospitalist upon discharge (from hospital). ~PUSH Tool dated 4/6/22 for Sacral area indicated measurements of 2.0cm length, 1.2cm width and 0.1cm depth. Tool indicated sacral wound bed contained 100% slough and stated, Wound has improved in size, however wound bed 100% slough. New treatment ordered to help remove slough. ~Nursing Progress Note dated 4/8/22 which stated, New wound care orders per [named] NP (nurse practitioner) . POA (Power of Attorney/Guardian) made aware of new orders and agreeable. On 4/13/22 at 9:16 AM, Surveyor observed Licensed Practical Nurse (LPN)-D, who indicated LPN-D was the facility's wound nurse, administer treatment to and measure R195's sacral wound. Surveyor observed R195's sacral wound with slough in wound bed. LPN-D stated, The (wound) edges are more indistinct than they were (compared to previous week). LPN-D indicated R195's sacral wound measured 2.9cm (centimeters) in length, 2.3cm in width and 0.1cm in depth. LPN-D indicated R195's wound bed contained 80% slough and 20% non-granulation tissue. On 4/13/22, Surveyor reviewed R195's medical record which contained Treatment Administration Records (TARs). R195's March and April 2022 TARs contained the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ~ Bilateral buttocks/coccyx - Apply [MEDICATION(S)] (brand of skin treatment) advanced skin or equivalent allow to dry. Do not apply any creams, powders, or ointments on top of [MEDICATION(S)]. Cut piece of hyddrofera blue (type of wound treatment) foam to size of wound and apply directly to wound with writing face out. Cover with sacral [MEDICATION(S)] (type of wound dressing) one time a day every 2 day(s) with start date of 3/27/22 and discontinuation date of 4/11/22. There were no nurse initials for the scheduled dates of 4/4/22, 4/6/22 and 4/8/22. ~ Cleanse wound to sacrum with NS (normal saline, a type of wound cleanser), skin prep periwound (treatment to skin around wound to promote adherence of dressing), apply santyl (type of treatment used to break down/remove dead tissue) to wound bed and cover with bordered gauze one time a day for wound care with start date of 4/8/22 and discontinuation date of 4/13/22. There were no nurse initials for the scheduled date of 4/8/22. On 4/14/22 at 11:55 AM, Surveyor interviewed LPN-D who stated, It's hard for me to say why it's (sacral wound is) worsening. Shouldn't be nutritional because of tube feeding (R195 received all nutrition via tube directly into stomach) and shouldn't be mobility because [R195]'s repositioned so frequently. I talked to NP yesterday, [NP] changed dressing and frequency thinking maybe wound is too wet. When questioned about the type of mattress R195 was on, LPN-D stated, I know it's an air mattress of some sort but not typical with pockets of air. On 4/14/22 at 12:00 PM, Surveyor along with LPN-D, observed R195's mattress. The control box of mattress was running with Comfort Adjust set to 1 and Mode set to Therapy. LPN-D indicated LPN-D was unsure what settings meant. LPN-D verified R195's TARs contained missing nurse initials on be above listed dates. When questioned what missing initials signified, LPN-D stated, Typically it's (the treatment is) not completed or they (nurses) forgot to sign it out (to indicate completed treatment). On 4/18/22 at 9:28 AM, Surveyor reviewed facility provided manufacturer User-Support Manual (USM) for R195's mattress with LPN-D. The USM stated, The Therapy light is illuminated when in Therapy mode. This mode should be used along with the Comfort Adjust keys to increase or decrease the general firmness of the . mattress . Control unit includes a BMI (body mass index) Comfort Adjust Guide to provide caregiver guidance on selecting patient comfort adjust setting . Page 12 of the USM contained a chart with key to assist caregivers in choosing correct setting. LPN-D stated R195's BMI was 20.9 based on R195's height of 71 inches and weight obtained yesterday was 149.8 pounds. LPN-D indicated LPN-D was unaware of mattress's BMI setting feature. LPN-D verified USM chart indicated Comfort Adjust setting should be at 2 instead of 1 based on R195's BMI. LPN-D confirmed that missing dressing changes and incorrect settings on mattress could affect wound healing. On 4/18/22, Surveyor reviewed R195's medical record which indicated R195 weighed 151.0 pounds on 3/29/22, 150.3 pounds on 4/3/22 and 149.8 pounds on 4/17/22. On 4/18/22 at 9:37 AM, Surveyor interviewed Director of Nursing (DON)-B. When questioned what missing initials meant on TARs, DON-B stated, To me that would mean it (treatment) was not done. DON-B verified missed dressing changes and improper mattress setting could play a part in lack of wound healing for R195. 2. R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's most recent MDS assessment, dated 1/11/22, reveals severely impaired cognition, impairment in range of motion to all extremities, and requiring total staff assistance for repositioning. R3's most recent comprehensive care plan, revised 1/11/22, indicates pressure-reducing interventions such as assist to reposition about every 1-2 hours and prn (as needed) .pressure relieving air mattress. On 4/18/22 the Surveyor reviewed R3's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] - 4/15/22 Air mattress settings to resident's comfort level without the resident having direct pressure with mattress base. Check air mattress and pump function every shift - 4/1/22 Reposition from side to side every hour. DO NOT have him lay on his back. R3's electronic health record also contained the following progress notes: - 4/1/2022 Note Text: Placed wound vac on resident after his return from the wound clinic. Wound care done as per new orders. Did inform CNAs that resident has to be repositioned every 1 hour, per wound clinic, and he is not supposed to be on his back. Resident tolerated the procedure well. - 4/1/2022 Note Text: Note Text: IDT Weekly At-Risk Review Meeting held with Social Service Director, IP/wound nurse, Dietary Manager, Administrator, and DON. Sacral wound declined. POA and wound clinic made aware. Wound clinic did not provide new orders as it's anticipated that wound will not ever fully heal and anticipated to fluctuate in size. Main going with wound care is to prevent infection and discomfort. POA did not have any concerns following update on wound status. The Surveyor had the following observations of R3's mattress settings and positioning in bed: 4/11/22 6:55 PM on back in bed. 4/13/22 2:37 PM in bed on back, air mattress set static/normal. 4/14/22 9:19 AM in bed on back 4/18/22 11:27 AM in bed on back, air mattress set static/normal, max weight of +400 lbs. On 4/18/22 at 12:24 P.M., the Surveyor interviewed Licensed Practical Nurse (LPN) - D, who is the wound care nurse. LPN-D verified that R3 was not supposed to be positioned on his back but rather side to side and that R3's air mattress should be alternating and set to the proper weight amount based on R3's current weight (158.3 lbs as of 4/12/22).

Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to maintain the highest practical physical well-being in accordance with professional standards of practice related to wound management for 2 Residents (R) (R1 and R4) of 3 sampled residents, resulting in R1 requiring further surgical intervention and potential additional amputation. R1 was readmitted to the facility on [DATE] with a right below-the-knee amputation (BKA) along with orders for daily dressing changes and Rigid Removable Device (RRD) (protective covering for amputation wounds) to be in place 23 hrs./day. R1's surgical wound was not assessed upon admission on 4/9/21. R1's treatment orders were not initiated until 4/13/21 (4 days after admission). R1's medical record reflected multiple missed dressing changes as well as R1's RRD not being in place on multiple dates. R1's Nurse Practitioner (NP) and R1's surgeon were not updated on R1's delayed/missing treatments. R1's wound dehisced (opened up) on 4/23/21 and was assessed to have tunneling, necrotic (dead) tissue, and purulent drainage (thick, milky discharge, often indicating an infection). R1 was scheduled for additional debridement/potential above-the-knee amputation (AKA) on 5/5/21. Facility failure to properly assess, monitor, and treat R1's surgical wound created a finding of Immediate Jeopardy (IJ) that began on 4/9/21. Surveyor notified Nursing Home Administrator (NHA) of the IJ on 5/4/21 at 3:00 PM. The IJ was removed on 5/4/21. However, the deficient practice continues at a scope/severity of D (potential for more than miminal harm/isolated) as the facility continues to implement its action plan and as evidenced by the following example: Staff did not follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings Include: 1. The facility policy, entitled Dressings, Dry/Clean dated September 2020, states: review the resident's current orders. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the dressing was changed 3. The name and title (or initials) of the individual changing the dressing 4. The type of dressing used and wound care given. R1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's most recent Minimum Data Set (MDS) assessment, dated 4/16/21, indicated R1's cognition is impaired and that R1 required extensive staff assistance with bathing, transferring, and repositioning. R1's most recent skin care plan, revised 4/14/21, indicated RRD to be worn 23 hours per day, only to be removed for bathing. R1's re-admission skin assessment, completed 4/9/21, did not include any assessment or interventions for R1's surgical wound. R1's surgical discharge orders from the hospital, dated 4/9/21 state: Change dressing over incision daily: Use xeroform or [MEDICATION(S)] (petroleum-based) gauze over incision line with kerlix (bandage roll) and keep RRD in place. Pt (patient) should wear RRD 23 hrs./day only removing for bathing. Keep incision clean and dry. R1's medical record shows R1's surgical discharge orders were not transcribed into R1's treatment orders until 4/13/21. On 5/3/21 at 4:41 P.M., the Surveyor interviewed Director of Nursing (DON)-B, who verified that the facility discovered R1's surgical order transcription error on 4/12/21. R1's medical record contained no indication that the daily dressing changes and RRD monitoring were completed from 4/10-4/12. R1's TAR further shows that R1 did not receive daily ordered dressing changes on the following dates: 4/17, 4/18, 4/19, 4/20, 4/25, and 4/28. R1's RDD was not signed out in the TAR on the following dates/times: 4/23 (AM), 4/23 (NOC), 4/27 (PM), 4/29 (NOC), 4/30 (AM), and 5/2 (PM). On 5/3/21 at 4:41 P.M., the Surveyor interviewed Director of Nursing (DON)-B who stated that R1's surgeon and nurse practitioner were not notified of missed dressing changes. On 5/3/21 at 9:15 A.M., the Surveyor interviewed former staff RN-G, who verified that RN-G signed out R1's treatment for 4/14 and 4/15 in R1's TAR but was unable to complete the dressing change due to staffing shortfalls and care for other residents. RN-G also stated that RN-G informed the Nursing Home Administrator (NHA)-A that dressing changes were not being completed. R1's weekly skin assessment, dated 4/16/21, stated: 19 staples and 11 stitches intact to surgical incision. Area is tender to touch but no active drainage. Moderate amount of serosanguineous (blood-tinged) drainage to old dressing noted (dressing was from hospital stay). Incision is 20 cm long .NP (nurse practitioner) present with changing of dressing. On 5/3/21 at 9:28 A.M., the Surveyor interviewed former staff RN-H, who stated that RN-H completed R1's wound assessment on 4/16/21 along with Nurse Practitioner (NP)-E. RN-H observed that R1 still had on the original wound dressing from the hospital during the 4/16/21 assessment. RN-H also stated that RN-H told NHA-A about dressing changes not being completed as ordered. On 5/3/21 at 12:20 P.M., the Surveyor interviewed NP-E. NP-E verified that RN-H and NP-E discovered the old hospital dressing still in place on R1 during rounds with RN-H on 4/16/21 and NP-E stated NP-E was not updated by the facility of missed dressing changes. R1's dressing was not changed on 4/17, 4/18, 4/19 and 4/20/21 during the next week (4/17 - 4/23/21). A progress note from R1's Infectious Disease office visit on 4/23/21 stated: When removing the RRD and dressing, there was purulent (thick and milky) drainage. It appears wound has dehisced and has some areas of ischemia (impaired circulation leading to tissue death). It (wound) is not healing well. Currently,[R1] is taking oral [MEDICATION(S)] (broad spectrum antibiotic). I will add [MEDICATION(S)] (penicillin-type antibiotic) for gram +/- and some anaerobic coverage (from organisms that do not require oxygen for growth) .I do believe further surgical intervention is needed. A progress note from RN-H, dated 4/23/21 at 5:38 P.M., stated: 12 staples and 7 sutures were removed from the dehisced tissue. Upon further inspection, the area is open more than the previous noted statement. Upon reviewing ID (Infectious Disease) notes, they are aware of the dehiscence and ID to converse with [R1's surgeon] on treatment plan. Area was dressed as per the order received. 9 staples remain and 4 sutures remain . A progress note from R1's surgical follow-up appointment on 4/27/21 stated: RBKA grossly (largely) dehisced wound .has deep tunneling section of necrosis (tissue death) about 3cm deep. Sharp debridement (medical removal of dead tissue) was performed and santyl (ointment to promote wound healing) placed on slough (dead) tissue .Will work on getting pt. scheduled for formal OR (operating room) debridement vs AKA (above the knee amputation) of that right leg. R1's weekly skin assessment, dated 4/27/21, stated: R(ight)BKA incision dehiscence .moderate amount of serosang(uineous) drainage. On 5/3/21 at 10:47 A.M., the Surveyor observed R1 lying in bed without R1's RRD in place. At 1:35 P.M., R1's RRD was still sitting on the bedside table. Registered Nurse (RN)-D verified that R1's RRD should be in place and R1's right leg should be elevated. RN-D placed R1's call light on for assistance in securing R1's RRD in place. At 1:54 P.M., R1's RRD was applied properly and right leg was elevated off the bed. On 5/3/21 at 4:50 P.M., the Surveyor interviewed Physician's Assistant (PA)-F. PA-F assisted with R1's surgery and verified being unaware that R1's dressing changes were not being completed as ordered. PA-F also stated that daily dressing changes allow people to lay eyes on the wound and that could lead to potential sooner and more mild interventions than surgical debridement or amputation. PA-F further stated that if R1 had drainage on a dressing for a prolonged period of time, that could lead to impaired healing and skin breakdown. On 5/5/21 at 2:18 P.M., the Surveyor interviewed R1's Power of Attorney (POA), who verified that R1 was scheduled for a surgical debridement and likely above the knee amputation on 5/5/21 (note: the 5/5/21 procedure was further delayed due to R1 being provided breakfast at the facility prior to to scheduled procedure. See F580 for additional information.) R1's POA also stated that the surgeon noted R1 would likely need at least 2 inches of bone removed. Above the Knee Amputations notes, An above-knee amputation is associated with enormous morbidity; unlike a below-knee amputation, fitting a prosthesis for an above-knee stump is difficult. In fact, most patients cannot adapt to an above knee prosthesis and eventually succumb to a wheelchair to get around. This leads to other complications like pressure sores, inability to perform daily living activities and depression. When possible, clinicians need to avoid an above knee amputation because of the high morbidity . https://www.ncbi.nlm.nih.gov/books/NBK 0/ The failure to properly assess, monitor, and treat R1's surgical wound created a finding of IJ. The facility removed the jeopardy on 5/4/21, when it completed the following: All active licensed nursing staff educated on skin management, including assessment of wounds, wound documentation, and wound treatments. Date initiated: May 4, 2021 with 100 percent of active licensed nurses working in facility completed on May 4, 2021, no licensed staff will be allowed to work until they have received education. All active licensed nursing staff educated on facility policy and procedure for wound measurement, including how to conduct a wound assessment (Date Initiated: May 4, 2021), documentation required for wound assessment (Date initiated: May 4, 2021), and wound dressing application (Date Initiated: May 4, 2021). Nurses will complete a competency for wound assessment, applying wound dressing, and wound documentation (dressing changes & assessments) according to standards of practice. Date initiated: May 4, 2021 with 100 percent of active licensed nurses working in facility completed on May 4, 2021, no licensed staff will be allowed to work until they have received education. All active licensed nursing staff educated on physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] PointClickCare upon admission to facility, after appointments and as needed basis. Date initiated: May 4, 2021 with 100 percent of active licensed nurses working in facility completed on May 4, 2021, no licensed staff will be allowed to work until they have received education. All active licensed nursing staff educated on wound dressing change expectations according to standard of practice and physician orders. Date initiated: May 4, 2021 with 100 percent of active licensed nurses working in facility completed on May 4, 2021, no licensed staff will be allowed to work until they have received education. All active licensed nursing staff educated on resident care plans that include approaches for wound treatment and skin management. Licensed nursing staff will be educated on following resident care plan and care plan development for skin management. Date initiated: May 4, 2021 with 100 percent of active licensed nurses working in facility completed on May 4, 2021, no licensed staff will be allowed to work until they have received education. All training noted above to be completed prior to each licensed nurse next working shift. Any nurses who do not complete the competency will not be scheduled until completed. Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to give an education. On May 4, 2021, facility reviewed policy and procedure on Dressings Clean/Dry, Medication & Treatment Orders, and Wound Measurement in coordination with medical director, including wound identification, wound assessment, wound treatment, and wound documentation to ensure policy meets current standards of practice. Policy was deemed to be up to date with current practices for wound and skin care management. On May 4, 2021, all residents in facility received a head-to-toe skin assessment by RN. All wounds were measured and treatments were reviewed for appropriateness and accuracy. On May 4, 2021, facility procured services with a wound MD to conduct weekly wound rounds with facility wound nurse for residents with wounds that are not followed externally by a wound clinic. DON and Nursing Supervisors will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x 3 months for residents that receive wound dressing treatments to ensure treatments are applied according to physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] documented accordingly. Results of the audits will be reviewed at the QAPI meeting for further recommendations. Nursing Management or Administrator will conduct audits daily x 2 weeks, weekly x 8 weeks, and monthly x 3 months for wound documentation completion. Results of the audits will be reviewed at the QAPI meeting for further recommendations. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) based on the following example: 2. R4 was admitted on [DATE] with a surgical wound to R4's lower extremity. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If having drainage apply strip of [MEDICATION(S)] non-adherent gauze (gauze coated with [MEDICATION(S)] [MEDICATION(S)] that does not adhere to the wound) along incision site then wrap BKA (below knee amputation) site with kerlix gauze to keep clean and dry. On 5/5/21 at 11:07 AM, Surveyor observed LPN (Licensed Practical Nurse)-C perform a dressing change to R4's surgical wound. LPN-C cleansed and assessed R4's wound. LPN-C asked R4 if the gauze felt like it was sticking to R4's wound. R4 stated, No. LPN-C applied Kerlix (gauze used to cover wounds) over the surgical wound. On 5/5/21 at 11:25 AM, Surveyor interviewed LPN-C. LPN-C verified R4's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN-C stated R4's wound had not been currently draining during the dressing change and that R4 wants the Kerlix on because the wound will drain. LPN-C stated LPN-C did not apply the [MEDICATION(S)]-non-adherent gauze over R4's incision site due to R4 having steri-strips (sterile pieces of medical tape used to close wounds and help the edges grow back together) in place over the incision. LPN-C stated adding the [MEDICATION(S)] non-adherent gauze over steri-strips could cause the steri-strips to fall off. LPN-C stated LPN-C did not want to cause harm to R4's surgical site. On 5/5/21 at 11:29 AM, Surveyor interviewed wound certified RN-D. RN-D stated the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/5/21 at 12:40 PM, Surveyor interviewed RN-C. RN-C stated RN-C did not follow the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . RN-C stated RN-C would contact the physicians office via fax for order clarification that RN-C felt was not appropriate for a resident. RN-C stated RN-C would continue to provide the treatment RN-C felt was best for the resident while waiting for a reply from the physician's office.

Based on observation, staff interview and record review, the facility did not ensure 1 (R (Resident) 1) of 4 sampled residents reviewed for falls had an environment as free from accident hazards as possible and was provided adequate supervision and/or devices to prevent falls and injuries. R1 was admitted to the facility following hospitalization for multiple traumas from a suspected fall. The facility did not develop a comprehensive, individualized care plan based on the resident's history of falls to prevent further falls and fall related injuries. On 12/29/16, R1 fell and sustained a fractured skull and 2 millimeter (mm) thickness subdermal hematoma. R1 continued to fall at the facility, including three falls that occurred in the 18.5 inch space between the resident's bed and heat register. R1 has sustained additional fall related injuries. Findings include: On 1/13/17, Surveyor reviewed R1's medical record, including the facility's self-report/investigation of R1's fall that occurred on 12/29/16, that resulted in a skull fracture and subdermal hematoma. The following documentation was noted regarding R1: ~ hospital discharge summary dated 11/28/16- discharged from hospital to nursing facility following a 21 day hospitalization for the treatment of [REDACTED]. ~ initial fall prevention care plan dated 11/28/16- contained only one intervention before the resident's fall on 12/29/16: evaluate medications if patient demonstrates changes in mental status, ADL (activities of daily living) function, appetite, neurological status, etc. ~ hospital discharge record dated 12/29/16- [DIAGNOSES REDACTED]. R1's fall incident reports and nursing notes document the following details regarding the resident's falls: ~ 12/29/16 at 12:44 a.m.- unwitnessed fall in resident room in front of bathroom. Injuries: (documented by hospital admission report dated 12/29/16) small acute left-sided subdural hematoma, additional asymmetric thickening of the right tentorium, left parietal scalp soft tissue swelling. Care plan updated with one intervention - 1:1 observation for falls. ~ 1/1/17 at 3:04 a.m.- unwitnessed fall in resident room next to dresser. Injuries: none noted. Care plan updated with one intervention - gripper socks to be worn as patient allows. ~ 1/1/17 at 9:45 p.m.- unwitnessed fall in resident room rolled out of bed between bed and heater. Injuries: none noted. Care plan updated with primary intervention of scoop/perimeter mattress. ~ 1/2/17 additional interventions added to care plan: * Encourage to transfer and change positions slowly. * Have commonly used articles within easy reach. * Provide assist to transfer and ambulate as needed. * Reinforce need to call for assistance. ~ 1/4/17 at 1:15 p.m.- witnessed fall in resident room. R1 stood up, felt dizzy, fell on buttocks, then fell backwards. Injury: hit head on wall. No updates to care plan noted at this time. ~ 1/5/17 at 9:00 a.m.- witnessed fall in resident room. R1 rummaged in trash can, stood up, then fell forward sustaining injuries: hitting face on floor between wall and register. Bilateral cheeks pink. Care plan updated with 1 additional intervention: activity department to provide busy basket to stave off boredom. ~ 1/5/17 at 3:00 p.m.- unwitnessed fall in resident room. R1 fell between register and bed. 1:1 staff was at R1's room doorway with back to R1. Injuries: left wrist bruised, red and swollen, small skin tear noted. X-ray revealed non-healing fracture to left wrist which R1 was admitted with. No updates to care plan noted at this time. ~ 1/6/17- witnessed offsite fall during doctor visit with guardian. R1 was bending over in wheelchair and tipped out. Injuries: none noted. Physician assessment at this time revealed R1's history of alcohol abuse damaged R1's cerebellum (part of brain) and spinal cord. Continued falls and decline are expected. No updates to care plan noted at this time. ~ 1/11/17 at 2:30 p.m.- witnessed fall in resident room. R1 rolled out of bed reaching for a pair of socks. 1:1 staff was at foot of bed at this time. Injuries: hit left side of head against register; left eye swelling; bleeding from mouth; left arm pain; bruise to left lower back. Care plan updated with 1 intervention: bed at knee height position. Additional interventions were added to R1's care plan on this day of survey, 1/13/17: helmet for protection as patient allows. Padding to heat register. On 1/13/17 at 11:23 a.m., Surveyor observed R1 in the resident's room. R1 was the only resident assigned to this resident room. R1 was lying in bed at the time of this observation and the 1:1 staff member was seated in a chair approximately 4 to 5 feet away (measured at 3:50 p.m. by facility staff to be 4 feet) from R1's bed. R1's bed was approximately 18 inches from the heat register (measured at 3:50 p.m., by facility staff to be 18.5 inches). The heat register was noted to be metal and protruded from the wall approximately 6 to 9 inches. The room was illuminated by the television with some natural daylight entering through the window. R1's face had a fading, yellow bruise visible under the resident's right eye (eye closest to the window's light). A helmet was located on a chair next to R1's bed. The surveyor attempted to interview R1 at that time, but R1 was unable to maintain a conversation, verifing had fallen at the facility. On 1/13/17 at 11:26 a.m., Surveyor interviewed Licensed Practical Nurse (LPN)-C who indicated R1 has exhibited increased confusion over the duration of R1's stay at the facility. LPN-C indicated an example of R1's increased confusion included the resident would take medication with prompting, currently R1's medications have to be crushed due to R1 attempting to put pills in the straws. When asked, LPN-C indicated R1's room has not been re-arranged since R1 moved to this private room on 12/7/16. On 1/13/17 at 11:31 a.m., Surveyor interviewed Registered Nurse (RN)-D regarding R1's room arrangement. RN-D verified R1's room had not been re-arranged since R1 moved to this private room on 12/7/16. On 1/13/17 at 1:57 p.m., Surveyor interviewed Director of Nursing (DON)-B regarding R1's falls and what injury prevention interventions had been put in place. The surveyor and DON-B reviewed R1's falls that occurred on 1/1/17, 2 falls on 1/5/17 and 1 fall on 1/11/17, noting the resident landed next to and/or impacting the heat register. DON-B indicated the facility began discussing padding corners of furniture on 1/12/17, in response to R1's fall on 1/11/17 with injury. DON-B further indicated R1's room arrangement had been discussed, but discarded the idea as an option due to the possibility of R1 having increased combative behaviors and/or agitation. On 1/13/17 at 3:47 p.m., during an interview with Surveyor , DON-B verified not discussing the possibility of room rearrangement for R1's safety with R1 and/or R1's court ordered guardian. In addition, DON-B indicated the 1:1 staff for R1 was related to R1's resident-to-resident altercation that occurred on 12/29/16, not to prevent falls. DON-B stated the 1:1 staff are to keep R1 in visual range, but not necessarily within arm's reach. On 1/13/17 at 3:50 p.m., Surveyor and NHA-A received permission from R1 to entered R1's room to obtain measurements. R1's bed was measured by NHA-A to be 18.5 inches from the heat registered, which protruded from the wall beneath the room's window. The surveyor now noted the resident's heat register was padded on the corners and along the angled edges. NHA-A measured the distance between R1's bed and the 1:1 staff chair to be 4 feet. The 1:1 staff member was sitting 4 feet from R1, who was lying in bed. On 1/13/17 at 3:57 p.m., Surveyor interviewed Dietary Aide (DA)-E, who verified being R1's 1:1 staff member at this time and works in dietary and not cross-trained as a Certified Nursing Assistant. DA-E indicated had received a briefing before beginning the 1:1 duties for R1. DA-E stated had recently moved the 1:1 staff member's chair closer to R1, as the resident had sat up in bed. On 1/13/17 at 3:58 p.m., Surveyor interviewed NHA-A regarding R1. NHA-A indicated the 1:1 staff person is primarily to prevent resident-to-resident altercations and 1:1 staff are aware to redirect and call for assistance as needed. NHA-A stated the 1:1 staff monitors for falls to increase response time if R1 falls. NHA-A indicated R1's room was located near a nursing station to assist in monitoring and 1:1 monitoring is for when R1 is outside room and inside R1's room when allowable. NHA-A indicated the 1:1 staff may provide companionship, but is not expected to be within arms reach of R1 due to staff safety concerns because of R1's combative behavior history. NHA-A indicated the facility does not use fall mats for R1 or any other resident because it's a trip hazard. NHA-A verified R1 had not been referred to therapy since R1 began falling.

Based on record review and staff interview, the facility did not immediately notify the physician when a resident developed a change in mentation after a fall for 1 (resident #1) of 10 sampled residents. Resident #1 sustained a fall on [DATE], and developed a change in mentation on [DATE], 4 ,[DATE] hours after the fall had occurred. The facility did not immediately consult with the physician The physician came to the facility on a routine visit approximately 10 hours after resident #1 had fallen. The physician assessed resident #1 and sent resident #1 to the hospital for an evaluation. Resident #1 was diagnosed with [REDACTED]. Resident #1 expired at the hospital. Facility failure to ensure immediate consultation with the physician of the resident's mentation change after the resident fell and suffered a head injury created a finding of immediate jeopardy that began on [DATE]. Nursing Home Administrator (NHA) was notified of immediate jeopardy on [DATE] at 2:00 p.m. The immediate jeopardy was removed, and the deficient practice corrected on [DATE], prior to the start of the survey and was therefore Past Noncompliance. Findings include: On [DATE], surveyor # reviewed resident #1's medical record. According to the face sheet with a print date of [DATE], resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of [DATE] documented resident #1 was admitted to the facility on [DATE], had moderately impaired cognitive skills for daily decision making, but remained his own decision maker. The MDS indicated resident #1 had clear speech and the ability to understand conversation. Resident #1 required staff assistance for transfer and ambulation. The MDS assessment indicated there was a discharge plan for the resident to return to the community. Resident #1 was receiving [MEDICATION NAME] for [MEDICAL CONDITION] and the facility completed an INR (international ratio) on [DATE] which was 3.98 (recommended value for resident receiving [MEDICATION NAME] for [MEDICAL CONDITION] is 2.0 - 3.0). The physician was notified and orders were received to decrease the dose of [MEDICATION NAME] and recheck the INR on [DATE]. The Progress Notes dated [DATE] at 23:35 (11:35 p.m.) indicated resident #1 was found lying on the floor on top of his walker in front of the sink. Resident #1's call light was not on when he was found. When asked what the resident was trying to do, resident stated, I went boom. Resident was able to roll over to back and sit up with two person assist. The resident was noted to have a large hematoma to the left side of his forehead with a scrape. Resident also had scrapes to the left hand. Left hand/wrist swollen and bruising. Resident had equal hand grasps. Does have discomfort at scrape site but denies pain when hand is moved. Resident states hand was already swollen. Call placed to on call MD (Medical Doctor). MD updated of fall and new orders received to do hand and wrist X-ray in early AM Neuro (neurological) checks started and within normal limits. The nurse in charge of resident #1's care at the time of the fall initiated Neuro checks. The checks were to be completed every 30 minutes for four checks, then every hour for four checks, then every eight hours for nine checks . The Neuro checks started at 2315 (11:15 p.m.) and indicated resident #1 was alert, not lethargic (sleepy), was oriented to person, place and situation, communication was present and the resident's speech was not slurred. The Neuro checks remained the same until 0345 (3:45 a.m.) on [DATE]. At that time, the flow sheet indicated resident #1 was alert to self only and was lethargic. The flow sheet also indicated resident #1 was not oriented to place or situation and that speech had become slurred at times and would not speak. The assessment completed again at 0445 (4:45 a.m.) also indicated resident #1's condition had remained the same as the 0345 assessment. The next assessment documented as day but without a time indicated resident #1 was alert to self, was lethargic and semi comatose. The Neuro assessment also indicated resident #1 remained oriented to person only but again not to place or situation. The Neuro check now indicated resident #1 had no motor movement in the right upper and lower limb and was not communicating. The Progress Note dated [DATE] at 09:31 (9:31 a.m.) indicated the resident was assessed at 0630 (6:30 a.m.) and Neuro checks and vital signs were within normal limits at that time. Resident only responds to name and physical stimulation by opening right eye. Patient has remained nonverbal this morning. Pupils are equal and reacting to light. Left eye swollen shut with extensive bruising on the left forehead and eye lid. MD (Medical Doctor) updated and in building to assess resident. Resident sent out to hospital for evaluation. The Progress Note dated [DATE] documented at 21:32 (9:32 p.m.) indicated a call was placed to the hospital to inquire about the resident and was told the resident was admitted to ICU (intensive care unit) for brain hemorrhaging. The hospital H&P (History and Physical) dated [DATE] indicated the assessment as status [REDACTED]. Please note the patient has been on [MEDICATION NAME] and the plan is to reverse this with FFP (fresh frozen plasma) and vitamin K as quickly as possible. I have discussed this case with the family and reviewed imaging studies with the family. Overall prognosis is extremely poor due to the patient's poor neurologic status in regards to motor and ambulation. This area involves the language area. It is likely he will have irreversible language deficits of a severe nature because of this. It is also likely due to his dementia that this will progress significantly and will likely have worsening motor function after this injury as well as mental function. The family wishes to make DNR (do not resuscitate) at the present time. We continue supportive care overnight. It is likely that they will discontinue care and proceed with comfort measures if there is not a miraculous improvement overnight. The Laboratory Summary Report completed at the hospital dated [DATE] indicated resident #1's INR was 3.41. The hospital Consultation Report dated [DATE] indicated the assessment as 1) Severe [MEDICATION NAME] hemorrhage secondary to trauma 2) Complex [MEDICAL CONDITION] requiring anticoagulation, especially for the mechanical aortic valve 3) Dementia 4) Acute [MEDICAL CONDITION] secondary to reduced level of consciousness and compromised airway protection . Plan: Ventilator support will be continued pending decisions between the family and physician regarding next steps and management of this severe neurologic injury. Extubation and comfort care will probably be the most appropriate management. On [DATE] at 10:25 a.m., surveyor # interviewed RN (Registered Nurse)-A regarding care that was provided to resident #1 after the fall. RN-A verified she was the day shift nurse on [DATE] and indicated she received report from the night nurse. RN-A stated she heard in report that resident #1 fell and struck his head and had a bump on his head. RN-A indicated the night nurse said resident had just fallen asleep as the resident was up all night. RN-A stated, after report of fall, she had the night nurse come with her to the resident's room to assess the resident. RN-A stated the resident had a golf ball size hematoma to the left forehead and the left eye was swollen shut. RN-A indicated that she had to take both hands to open the eye to assess the pupil. RN-A stated the resident was lethargic and would not verbally respond. RN-A indicated the night nurse kept saying to her that the resident just fell asleep at 5:00 a.m. RN-A stated she was concerned because the resident was not verbal but the nurse did consider the resident had just fallen asleep. RN-A indicated she had the CNAs (Certified Nursing Assistants) keep checking on him. RN-A stated she thought the resident's INR was elevated also. RN-A indicated the physician (MD) comes to the facility on Sundays so when the MD arrived at the facility RN-A updated the MD on the status of the resident. RN-A stated the MD came out of the resident's room and indicated to send the resident to the hospital. RN-A indicated the night nurse stated the resident was seated by the nurses station until 5:00 a.m., and that was when staff placed the resident in the recliner in his room. RN-A indicated the resident's right eye still tracked but the left eye was completely swollen shut and the resident was non verbal. RN-A stated if the resident would have slept for a couple of hours and was still nonverbal she would have sent the resident to the hospital, but since he was only sleeping for less than an hour, then she had given the benefit of the doubt that he was tired. Surveyor # and RN-A reviewed the neurological flow sheet. RN-A indicated if she would have been working when the resident's speech became slurred and then wasn't talking that would have been a change in condition and she would have sent the resident to the hospital right away. On [DATE] at 1:00 p.m., surveyor # conducted a telephone interview with physician (MD-B) regarding the care that was provided to resident #1. MD-B stated he routinely comes to the facility on Sundays and that he arrived at the facility at approximately 9:20 a.m., MD-B stated he was updated on the resident's condition and went to the room to assess the resident. MD-B stated there was a large hematoma above the left eye and there was left eye swelling. MD-B stated the resident was not verbally responding. MD-B indicated he went and told the nurse to transfer the resident to the hospital. MD-B stated the nurse should have called the physician when the resident presented with a change in condition with slurred speech and then non verbal. MD-B indicated there could have possibly have been a different outcome to the resident if the resident received treatment earlier at the hospital but this resident was not a surgical candidate so I don't think the outcome would have been different. On [DATE] at 8:50 a.m., surveyor # conducted a telephone interview with LPN (Licensed Practical Nurse)-C regarding resident #1's condition on the night shift after the fall on [DATE]. LPN-C stated when the resident did fall she had assessed the resident and initiated Neuro checks. LPN-C indicated the resident was placed at the nurses station for observation. LPN-C stated at the 3:45 a.m., she did write on the Neuro flowsheet the resident had slurred speech but it was more like drunk speech. LPN-C verified the speech was a change but the resident was up all night and she thought the resident was just tired. LPN-C indicated later in the shift the resident did not verbally respond. LPN-C stated at the end of shift during shift report she had went with RN-A to the resident's room to assist with the assessment of the resident. LPN-C stated the resident was just placed back in the recliner at 5:00 am and because he was tired the resident did not verbally respond but the resident did open the right eye (could not open the left eye due to swelling). On [DATE] at 12:30 p.m., surveyor # interviewed CNA-D regarding resident #1's condition on the night shift of [DATE]. CNA-D stated resident #1's condition did change during the course of the night shift. CNA-D indicated initially the resident was joking around and between 3:00 a.m., and 3:30 a.m., she had noticed the resident was more lethargic and his voice was soft and mumbled. CNA-D stated a few hours later the resident did not verbally respond, but did open his right eye when spoken to. CNA-D stated staff had transferred resident #1 to the recliner around 5:00 a.m., (was at nurses station prior) and the resident did not verbalize at that time. CNA-D indicated she didn't know if the resident was just tired. The hospital discharge summary with a corrected date of [DATE] indicated resident #1 expired at the hospital on [DATE] as a result of nontraumatic [MEDICATION NAME] hemorrhage as the cause of death. The facility failure to immediately consult with the physician regarding resident #1's mentation change after the resident fell and suffered a head injury created a finding of immediate jeopardy at began on [DATE]. The jeopardy was removed and the deficient practice corrected by [DATE], when the facility provided education to staff on [DATE] and [DATE], that directed staff after a resident falls if there is a head injury or the fall was unwitnessed staff were to initiate neurological checks. If there is evidence that a head injury occurred continue neurological checks and send to the hospital if any changes noted in any areas. The education continued to direct staff that if there was a head injury and the resident is on [MEDICATION NAME] to send the resident to the emergency room due to risk for bleeding.

Based on observations, record review and staff interviews, the facility did not provide necessary treatment and services to prevent pressure ulcers from developing or provide treatments to promote healing for 1 (resident #2) of 3 residents with pressure ulcers, from the total sample of 15 residents. Resident #2 was admitted to the facility with a stage IV pressure ulcer. The following concerns were identified: PRESSURE REDISTRIBUTION SURFACE: When transferred out of the bed, an obvious hollow or concavity was noted in the center of resident #2's air mattress, the location of the resident's stage IV pressure ulcer. Staff did not recognize this as a potential problem. When the locking mechanism was activated on the air pump, some staff were unable to de-activate the lock to allow the mattress to be adjusted and/or re-inflated. Staff were unaware of what type of mattress was recommended for resident #2 according to the facility's IDT's (Inter-Disciplinary Team) decision. Staff were not aware of how and when to make adjustments to the alternating air pressure mattress, for resident comfort and/or to provide pressure relief. CARE PLAN INTERVENTIONS The written plan of care for resident #2 indicated staff should utilize a draw sheet or maxi slide to prevent shearing. An observation was made whereby staff did not utilize a maxi slide or draw sheet. The resident's heels were dragged across the mattress. Additionally, the plan of care indicated a cushion or pillow was to be placed between the resident's knees to prevent pressure when the resident sat in a chair, observations were made whereby the cushion was not placed and the resident's knees were in direct contact with one another. CARE PLAN REVISION When resident #2 developed an additional pressure ulcer on the heel, no additions or modifications to the written plan of care were noted. ASSESSMENT/DOCUMENTATION a. Facility policy indicated wound assessments would be conducted every week. It was noted the resident's stage IV pressure ulcer was not assessed from 9/23/15 until 10/14/15. b. Resident #2 developed an open area on the right heel. Staff did not stage the ulcer. c. The heel ulcer was not assessed from 10/3/15 to 10/20/15. d. When wound care was observed, the RN (Registered Nurse) verbally indicated the ulcer was healed, however the nurse educator and the DON (Director of Nursing), who were present at the time, verified the draining wound was a stage II pressure ulcer. INFECTION CONTROL/WOUND CARE: During an observation of wound care, breaches in handwashing were observed. Wound care and dressing change for resident #2's heel ulcer was ordered to be performed daily. The dressing change was not completed on 10/19/15. The failure of the facility to provide appropriate treatment to heal resident #2's stage 4 pressure ulcer and its failure to provide interventions to prevent the development of a stage 2 heel ulcer for this diabetic resident created a finding of Immediate Jeopardy, beginning 9/30/15, The NHA (Nursing Home Administrator) was formally notified on 10/20/15 that the immediate Jeopardy situation existed. The Immediate Jeopardy was removed on 10/21/15, however the deficient practice continues at a scope and severity of E (potential for more than minimal harm/pattern) as evidenced by the following examples: The facility did not operationalize its policy regarding bed systems and support surfaces; a. related to utilizing a comprehensive assessment to make a decision on the best option for a pressure relieving mattress, b. by providing ongoing monitoring for the effectiveness of the mattress, and c\. by providing education to staff regarding the use and function of any type of air pressure mattress. This practice had the potential to affect 30 additional residents (residents #3, #4, #5, #10, #11, #12, #16, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, and #41) who utilized specialty mattresses, from the total census of 72. Findings include: According to the Mayo Clinic's Website, updated 12/13/14, Complications of pressure ulcers include: Sepsis.[MEDICAL CONDITION] occurs when bacteria enter the bloodstream through broken skin and spread throughout the body. It's a rapidly progressing, life threatening condition that can cause organ failure. [MEDICAL CONDITION]. [MEDICAL CONDITION] is an infection of the skin and connected soft tissues. It can cause severe pain, redness and swelling. People with nerve damage often do not feel pain with this condition. [MEDICAL CONDITION] can lead to life threatening complications. Bone and joint infections. An infection from a pressure sore can burrow into joints and bones. Joint infections (septic arthritis) can damage cartilage and tissue. Bone infections (osteo[DIAGNOSES REDACTED]) may reduce the function of joints and limbs. Such infections can lead to life-threatening complications. Cancer. Another complication is the development of a type of squamous cell [MEDICAL CONDITION] that develops in chronic, nonhealing wounds (Marjolin ulcer). This type [MEDICAL CONDITION] is aggressive and usually requires surgery. According to online website, Medscape, copywritten 2015, 15% (of diabetics) develop a foot ulcer, and 12-24% of individuals with a foot ulcer require amputation. Indeed, diabetes is the leading cause of nontraumatic lower extremity amputations in the United States. (Diabetics account for 3% of the US population and for over half of all nontraumatic lower leg amputations.) Similarly, the American Academy of Family Physician noted on 3/15/1998, The risk of lower extremity amputation is 15 to 46 times higher in diabetics than in persons who do not have diabetes mellitus .The vast majority of diabetic foot complications resulting in amputation begin with the formation of skin ulcers. The NPUAP (National Pressure Ulcer Advisory Panel) Quick Reference Guide, published 2014, indicated the following: General Recommendations for Mattress and Bed Support Surfaces: 1. Select a support surface that meets the individual's needs. Consider the individual's need for pressure re-distribution based on the following factors: level of immobility and inactivity; need for microclimate control and shear reduction; size and weight of the individual's risk for development of new pressure ulcers; and number and severity and location of existing pressure ulcers .3. Examine the appropriateness and functionality of the support surface on every encounter with the individual. 4. Identify and prevent potential complications of support surface use. (Proper selection and operation of support surfaces is the key to preventing complications) . 5. Verify that the support surface is being used within its functional life span .Mattress and bed support Surfaces for Pressure Ulcer Prevention .2. Use an active support surface for individuals at higher risk of pressure ulcer development .Mattresses and Bed Support Surfaces for Individuals with Existing Pressure Ulcers; 1. Wherever possible, do not position an individual on an existing pressure ulcer. 2. Consider replacing the mattress with a support surface that provides more effective pressure redistribution, shear reduction .if (the person) has a pressure ulcer on two or more turning surfaces .fails to heal or demonstrates ulcer deterioration bottoms out on the existing support surface .4. Consider a using a high specification foam mattress or non powered pressure redistribution support surface for individuals with stage I and II pressure ulcers. 5. Select a support surface that provides enhanced pressure re-distribution .for Stage III and IV pressure ulcers . The 2015 facility policy entitled Bed Systems and Support Surface Guidelines indicated,The interdisciplinary team, physician and family work together to make a decision on the best option for a support surface based on a comprehensive evaluation that includes risk versus benefit, ongoing monitoring and re-evaluation of the efficacy and need .When a bed system is selected to meet an individual patient needs, each component of the system requires proper installation, inspection and maintenance on an ongoing basis . EXAMPLE: On 10/19/15, surveyor # reviewed the medical record of resident #2. The undated facesheet contained within the medical record indicated resident #2 was admitted with [DIAGNOSES REDACTED]. Resident #2's most recent quarterly MDS (Minimum Data Set) assessment dated [DATE], documented the resident was severely cognitively impaired, scoring 4 of 15 on the BIMS (Brief Interview for Mental Status). In addition, the MDS documented resident #2 was dependent upon staff for extensive assistance with bed mobility and total assistance with transfers. Resident #2 was admitted on [DATE], and the resident's written plan of care which was initiated 5/31/15, included the use of a Pressure re-distributing device on bed and wheelchair. Resident #2's Pressure Ulcer CAA (Care Area Assessment) worksheet dated 5/28/15, described the impact of this problem on the resident and the facility's rationale for care plan decision .[DIAGNOSES REDACTED].(resident #2) was admitted to this facility with a stage IV pressure ulcer to left ischial tuberosity and uses a wound vac for treatment continues with use of a cushion in wheelchair and a pressure relieving mattress. Current Braden is 13. Proceed to care plan. PRESSURE REDISTRIBUTION SURFACE: On 10/20/15 at 7:52 a.m., surveyor # observed resident #2's morning cares and transfer provided by CNA (Certified Nursing Assistant)-H and CNA-G. Using a Hoyer lift, the CNAs transferred the resident from the bed to the motorized wheelchair. An obvious concavity (depression) was observed in the bed mattress where the resident's lower back, buttocks and upper thighs had rested. The bed mattress was attached to a pump that hung from the foot board of the bed. The lights illuminated on the pump indicated Alternating and 5 minutes. Surveyor # touched the hollow of the mattress, comparing it to the more inflated head and foot ends of the bed mattress and noted a significant difference in the inflation. In that central, concave section of the mattress, air could not be palpated, but the foam cushion below was felt. Above and below the indented portion of the air mattress, a lip on the mattress could be felt. During the care observation and subsequent assessment of the mattress, from 7:52 a.m. until 8:30 a.m., the surveyor did not detect any audible air flow sounds to indicate the bed mattress was inflating, deflating or pumping air to the mattress. On 10/20/15 at 8:20 a.m., surveyor # interviewed DON (Director of Nursing)-D and asked him to assess the bed mattress. DON-D verified the center of the mattress was depressed and was unable to adjust the air flow on the pump, stating It must be locked. I don't know how to unlock it. At that time, DON-D called CSC (Central Supply Clerk)-Z to unlock the pump. At 8:30 a.m., CSC-Z indicated to surveyor # that the air mattress was pretty low and that this was the first time CSC-Z was aware the mattress could not be adjusted. Surveyor # interviewed DON-D regarding how staff would assess the mattress and know when it needed an adjustment of air flow. DON-D stated it was based on resident comfort. On 10/20/15 at 8:31 a.m., surveyor # interviewed LPN (Licensed Practical Nurse)-E, who regularly cared for resident #2. LPN-E indicated not knowing how to adjust the air mattress. LPN-E also stated the CNAs are responsible for the air mattress adjustment and managing their pump. LPN-E indicated she has never assessed resident #2's bed air mattress and the resident has never complained about being uncomfortable. On 10/20/15 at 8:36 a.m., surveyor # interviewed CNA-AA regarding bed air mattresses. CNA-AA indicated if the bed air mattress was flat, he would report it to the nurse. CNA-AA confirmed he was unaware resident #2's bed air mattress had a flattened area. On 10/20/15 at 8:40 a.m., surveyor # interviewed CNA-BB regarding bed air mattresses. CNA-BB stated she was unaware how to adjust air mattresses, was never trained but would like to learn. CNA-BB further indicated if a bed air mattress was flat, she would notify the nurse. On 10/20/15 at 9:15 a.m., surveyor # interviewed CNA-G regarding bed air mattresses. CNA-G stated she noted resident #2's bed air mattress was low on Sunday (two days earlier). CNA-G indicated she thought maintenance had been called regarding resident #2's deflated air mattress and commented she did not know how to unlock or adjust the pump. On 10/20/15 at 9:20 a.m., surveyor # interviewed CNA-H regarding resident #2's bed air mattress. CNA-H stated he was unaware that resident #2's mattress was concave or hollowed in the center. I didn't notice. CNA-H commented he would call someone if the air mattress needed adjustment, but not sure who. On 10/20/15 at 9:21 a.m., surveyor # interviewed CNA-CC regarding resident #2's bed air mattress. CNA-CC indicated not knowing how to adjust the resident's air mattress and was unaware that the air mattress was concave in the center. CNA-CC indicated if there was a problem with the air mattress she would notify CSC-Z. On 10/20/15 at 9:23 a.m., surveyor # interviewed RN (Registered Nurse)-V regarding bed air mattresses. RN-V indicated he was an agency staff working as needed. When asked a question regarding air mattress settings, RN-V stated the resident's plan of care and physician's orders [REDACTED]. RN-V demonstrated how to adjust the air mattress and unlock the controls. On 10/20/15 at 9:30 a.m., surveyor # interviewed ESS (Environmental Services Supervisor)-DD regarding resident #2's bed air mattress. ESS-DD indicated he was on-call this last Sunday and was not notified resident #2's mattress was flat or locked. ESS-DD expressed familiarity with adjusting and unlocking the bed air mattress pump controls. On 10/21/15 at 9:10 a.m., surveyor # interviewed LPN-EE who regarding bed air mattresses. LPN-EE stated she did not know what settings to program an air mattress and that there was no direction on resident #2's TAR (Treatment Administration Record) how the bed air mattress should be programmed. LPN-EE further indicated she had not had any training regarding bed air mattresses. On 10/21/15 at 9:35 a.m., surveyor # interviewed LPN-FF regarding bed air mattresses. LPN-FF indicated she did not have any training regarding how to adjust an air mattress pump and if the air mattress didn't work, maintenance should be called. On 10/20/15 at 7:15 p.m., surveyor # was approached by RNSE (Registered Nurse Staff Educator)-K who stated the mattress used by resident #2 was a dual purpose support surface that had the capability to be used with or without the alternating air pressure pump and provided the surveyor with a manufacturer's specification sheet. The sheet identified the mattress used by resident #2 as a Joerns P.R.O. Matt Plus. The specification sheet documented In the non-powered mode, the (mattress) design allows the provision of optimal interface pressures through controlled air cell inflation for at risk patients in the prevention and treatment of [REDACTED]. For stage III and IV treatment, care staff should be able to re-position the patient off of the pressure wound in at least 2 positions. RNSE-K stated Resident #2 did not need the alternating air option, the mattress still had the foam which provided pressure relief. We rely on staff to reposition the resident every 2 hours. The surveyor then asked why the facility would elect to use the static (foam) option instead of the alternating air pressure, RNSE-K stated I can't answer that, it was a team decision in May. RNSE-K confirmed the team's rationale, assessment and decision which type of mattress to use for resident #2 (static foam option or alternating air) had not been documented. On 10/21/15 at 8:05 a.m., surveyor # interviewed MT (Manufacturer's Technician)-GG via telephone. MT-GG stated The P.R.O. Matt Plus is really focused on stage I and stage II pressure ulcers and those at risk .whether or not to use the foam option or alternating air option is a matter of preference. However, the more air flow, the more pressure relief is provided. On 10/21/15 at 2:00 p.m., surveyor # interviewed the NCD (National Clinical Director) of Joerns, the manufacturer of the P.R.O. Matt Plus, who was WCC (Wound Care Certified). NCD (National Clinical Director)-HH was provided with a description of resident #2's mattress concave appearance, NCD-HH confirmed if the mattress was flattened or hollowed in the center and did not in re-inflate within 5 minutes, the pump could have been malfunctioning. Additionally, NCD-HH stated the choice for which option to use (static foam or alternating air) would be dependent upon staff's assessment and that effectiveness of the mattress should be assessed frequently. NCD-HH indicated resident #2's mattress is comprised of cells, that when in the alternating air mode, should inflate and deflate by the action of the electric pump. On 10/21/15 at 3:00 p.m., the facility presented a list, which was then visually verified by surveyor # , of all the residents in the facility that utilize any type of air mattress. The list included the following 31 residents: #2, #3, #4, #5, #10, #11, #12, #16, #18, #19, #20, #21, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, and #41. INFECTION CONTROL/WOUND CARE According to the facility's Dressing Change policy dated 12/2009, dressing changes are to be performed in accordance with physician orders. Staff are directed to perform non sterile dressing changes by performing hand hygiene, applying gloves, removing the soiled dressing, disposing of the dressing, assessing the wound, removing gloves, and then performing hand hygiene prior to completing the wound treatment per physician orders. On 10/20/15 at 11:20 a.m., surveyor # observed RN-F complete resident #2's wound care. After washing hands and applying clean gloves, RN-F removed a dressing from resident #2's right heel. The soiled dressing had a moderate amount of brown and yellow drainage noted. While wearing the same soiled gloves, RN-F removed the cap from the container of wound cleanser (normal saline), applied saline to clean gauze and cleanse the wound. While wearing the same soiled gloves, RN-F picked up the new dressing package and started to open the package. RN-F stopped and set the package down, removed the soiled gloves, sanitized hands, applied clean gloves and picked up the same dressing package and proceeded to finish opening the dressing. Once the package was opened, RN-F applied the new dressing. RN-F removed her gloves and without sanitizing hands, rummaged through a nearby drawer looking for tape. RN-F dated and initialed the tape, applying the tape to secure the resident's heel dressing. RN-F then returned the container of saline that had been touched with soiled gloves, to the resident's drawer and then performed hand hygiene. On 10/20/15 at 11:20 a.m., during the above observation of RN-F completing resident #2's right heel dressing change, DON-D washed hands at the sink in the room of resident #2. A soiled paper towel fell on the floor and DON-D picked the paper towel up from the floor and without performing hand hygiene, applied gloves and assisted with resident #2's wound care by holding the resident's leg. Resident #2's TAR (Treatment Administration Record) dated 10/1/15, documented the physician's orders [REDACTED]. Change [MEDICATION NAME] (name brand) dressing daily and PRN (as needed) every evening shift for blister to right heel. The TAR dated 10/1/15 did not include documentation that resident #2's right heel dressing change had been completed on 10/19/15, as ordered by the physician. CARE PLAN INTERVENTIONS Resident #2's written CNA care card (Kardex) with a printed date of 10/19/15, included the following directives for the treatment and prevention of pressure ulcers: Heel Protectors, reposition every hour, use draw sheet in bed to aide in re-positioning. Resident #2's written plan of care for alteration in skin integrity initiated on 5/31/15 and revised 7/8/15, included the following: .use soft pillow/knee separator between knees when up in wheelchair. On 10/19/15 at 1:14 p.m., surveyor # observed RN-F and LPN-E complete resident #2's wound care. The resident's bed did not have a draw sheet or maxi-slide as staff turned and repositioned the resident. On 10/20/15 at 7:52 a.m., surveyor # observed personal cares provided to resident #2 by CNA-G and CNA-H. The resident's bed did not have a draw sheet or maxi slide. CNA-G and CNA-H were observed to drag resident #2's heels across the sheets of the mattress as they turned and dressed resident #2. On 10/20/15 at 8:00 a.m., surveyor # observed resident #2 sitting in a motorized wheelchair without a pillow between the resident's knees. Resident #2's legs were bent at a 90 degree angle, with both knees touching each other and leaning towards the right of the chair. On 10/20/15 at 9:09 a.m., surveyor # interviewed DON-D regarding resident #2's turning and repositioning schedule. DON-D stated staff do not document re-positioning every two hours They know its the standard, it's in the Kardex. On 10/21/15 at 9:00 a.m., surveyor # interviewed CNA-I regarding resident #2. CNA-I indicated the resident should be transferred with the use of a maxi slide and staff should place a pillow between the resident's knees when up in the chair. On 10/20/15 at 7:15 p.m., surveyor # interviewed RNSE-K regarding resident #2. RNSE-K indicated the resident's care plan included a 2 hour turning schedule and stated We rely on staff to reposition residents. When asked if the staff reposition resident #2 hourly as per the written plan of care, RNSE-K stated No, not hourly. CARE PLAN REVISION Resident #2's medical record included a fax to the resident's physician dated 9/15/15 that indicated Blister noted to resident's heel during HS (Hour of Sleep/bedtime) cares. Blister has broken, open area measures 2.8 cm (centimeters) x (by) 2.0 cm. x 0.1 cm. New pressure reducing boots obtained and applied . Resident #2's written plan of care had not been revised after the development of a new stage II pressure ulcer, as no additions to the skin integrity plan of care was noted after 7/28/15. A change in the resident's turning schedule and a re-evaluation of the resident's mattress was not initiated at that time. On 10/20/15 at 10:15 a.m., surveyor # spoke to DON-D regarding resident #2. DON-D verified revisions to resident #2's plan of care were not evident after the new stage II pressure ulcer had developed. ASSESSMENT AND DOCUMENTATION Resident #2's electronic nurses note's describing wound measurements of the resident's left ischial stage IV pressure ulcer were documented as follows: ~ 5/20/15- 2 cm x 1.5 cm x 1.7 cm ~ 5/27/15- 2.4 cm x 2 cm x 1.8 cm ~ 6/3/15- 2.6 cm x 1.8 cm x 1.6 cm ~ 6/10/15- 2.4 cm x 1.8 cm x 2 cm ~ 6/17/15- 2.0 cm x 1.4 cm x 1.4 cm ~ 6/26/15- 2.5 cm x 2.2 cm x 1.4 cm ~ 7/1/15- 2.5 cm x 2.0 cm x 1.2 cm ~ 7/8/15- 2.5 cm x 2.0 cm x 1.3 cm ~ 7/17/15- 1.7 cm x 1.5 cm x 1.3 cm ~ 7/22/15- 2.0 cm x 1.5 cm x 1.5 cm ~ 7/29/15- 2.0 cm x 1.5 cm x 1.5 cm ~ 8/5/15- 2.0 cm x 1.5 cm x 1.5 cm ~ 8/12/15- 1.5 cm x 1.2 cm x 1 cm ~ 8/19/15- 2.0 cm x 1.5 cm x 1.3 cm ~ 8/26/15- 1.0 cm x 1.0 cm x 1.0 cm ~ 9/2/15- 2.0 cm x 1.0 cm x 1.0 cm ~ 9/9/15- 1.5 cm x 2.0 cm x 1.0 cm ~ 9/16/15- 2.0 cm x 1.0 cm x 1.0 cm ~ 9/23/15- 2.3 cm x 1.0 cm x 1.0 cm ~ 9/30/15- no documentation ~ 10/7/15- no documentation ~ 10/14/15- 2.0 cm x 3.0 cm x 2.0 cm After not having been assessed for three weeks, width of the pressure ulcer had tripled and depth had doubled. Length remained the same. Resident #2's nurse's notes dated 9/15/15, document Blister to resident's heel measured, results transcribed on skin alteration sheet. Blister has broken, open are measures 2.8 cm x 2.0 cm x 0.1 cm .moderate drainage noted .will continue to monitor and encourage frequent repositioning. After 9/15/15, the next nurse's note that included documentation of resident #2's wound assessment was noted on 10/3/15. The nurse's note dated 10/3/15 documented .broken blister to left heel dry with no drainage noted . This entry did not include wound measurements, staging or a description of the open are noted on the left heel. On 10/20/15 at 10:15 am., surveyor # interviewed RN-F regarding resident #2's left stage II heel wound. RN-F stated It wasn't pressure because it wasn't on the bottom of the heel, it was off to the side. On 10/20/15 at 10:25 a.m., surveyor # interviewed DON-D and RNSE-K regarding documentation and assessment of resident #2's heel wound dated 9/15/15 and missing wound assessments for the resident's stage IV and the stage II ulcers. DON-D and RNSE-K verified the nurse's notes as written above dated 9/15/15, did not identify a stage II pressure ulcer. DON-D and RNSE-K indicated, based on the wound description it should have been documented as a stage II. DON-D explained the facility's wound nurse had ended employment at the .end of September. DON-D indicated he was unfamiliar with the former wound nurse's system, which residents the wound nurse followed and commented no other staff took over. We started 10/14/15, with wound rounds, until then there was no documentation or assessments. DON-D indicated resident #2's right heel ulcer was resolved and resident #2's medical record did not include additional wound documentation for the dates missing. On 10/20/15 at 11:20 a.m., surveyor # , DON-D, RNSE-K and RN-F observed resident #2's heel. RN-F removed the soiled dressing and noted a moderate amount of tan/brown drainage on the undated dressing. As RN-F left the room to obtain supplies, RNSE-K and DON-D confirmed the pressure ulcer was not resolved and was noted to be a stage II. At that time, RNSE-K instructed RN-F to measure the wound. RN-F commented the heel wound was not open and she would not call the heel wound a stage II. RN-F asked DON-D and RNSE-K for guidance how and where to measure the open wound. On 10/21/15 at 2:30 p.m., surveyor # was approached by CNC (Clinical Nurse Consultant)-L, who stated It's clear there is a documentation issue. There is a plan in place and we started educating staff. The facility removed the immediate jeopardy when they completed the following on 10/20/15: Resident #2: ~ A skin assessment completed by a RN. Completed and documented the assessment and measurements of ischial and heel wounds. No new areas of skin impairment. ~ Braden scale and PUSH tool completed. ~ Care plan reviewed and revised- new Air mattress given, no obvious defects were noted upon review of the mattress. ~ MD to updated with assessment and measurement results. Residents with the potential to be affected: ~ All residents on an air mattress assessed for proper inflation and functioning. No additional concerns with functioning found. ~ Skin sweep to be conducted on all residents, if any concerns noted, MD (Medical Doctor) to be notified with treatment orders and plan of care to be revised. ~ All residents with pressure ulcers to have documentation of wound assessment. System revisions: ~ 1:1 education given to ADON (Asisstant Director of Nursing) and DCD on the Skin Practice Guide/Skin policy and procedure to include PUSH tool documentation. ~ Education given to all licensed staff on Skin Practice Guide, prior to start of next shift. ~ Education given to all nursing staff on the set up and functioning of the air mattress, prior to start of next shift. Ongoing Monitoring: ~ ADNS and DCD to complete weekly wound rounds on all residents with pressure ulcers and document the assessment and PUSH tool completed. NHA to validate completion. ~ DCD to enroll and complete Wound Certification class. ~ ADNS/DCD or designee will conduct random audits 5x/week for mattress functioning. ~ Information from mattress functioning audits will be forwarded to the QAA (Quality Assessment and Assurance) committee for further review and recommendation.

Based on observations, staff interviews and record review, the facility did not ensure that a resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and did not ensure a resident having pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing in 4 (residents #4, #3, #6, and #8) in 10 sampled residents reviewed for pressure ulcer risk. The facility assessed resident #4 to be at high risk for pressure ulcer development. The resident had sustained fractures to the right hip and femur on two occasions, most recently in March of 2014 with resultant lateral (outer side) pronation (the foot facing downward) of the right foot. The facility was aware that the intervention to use pillows to free float the resident's heels were not been effective due to the resident removing the pillows. Additionally, the facility was aware the resident's improper seating in the wheel chair which required the resident to reposition self when sliding down in the chair by planting the lateral side of the right foot to boost self. The facility did not implement appropriate pressure ulcer preventative measures until after the development of 2 SDTI's (Suspected Deep Tissue Injury) to the lateral right malleolus and lateral boney prominence of the right foot. In this citation, resident #4 is considered at actual harm isolated (G level); residents #3, #6 and #8 are considered less than actual harm, isolated (D level). The facility had assessed resident #3 to be at high risk for the development of pressure ulcers. The resident had a physician's orders [REDACTED]. That intervention had not been consistently implemented. Additionally, the resident utilized chronic oxygen delivered via a nasal cannula. The facility did not develop a plan of care to include padding of the oxygen tubing at the ears. The resident was noted to have red, blanchable dents at the tops and behind the ears due to pressure from the oxygen tubing. Resident #6 was assessed as being at moderate risk for pressure ulcer development and the facility utilized pillows to free float the heels. Although staff were aware resident #6 kicked the pillows out from underneath his lower extremities, the facility did not initiate alternative interventions to offload pressure of resident #6's heels. Subsequently resident #6 developed a reddened area on the inner aspect of the left heel on Saturday 09/20/14. The physician was updated and indicated the area must be from pressure and orders were given to apply pressure relieving boots. The facility did not store the Prevalon boots (the specific kind of boot that were utilized) in the facility, but kept in a storage unit on the facility property outside of the facility. Staff were unable to provide resident #6 with the Prevalon boots until Monday 09/22/14, 2 days after the physician order, due to staff not having a key to the storage unit. Resident #8 was assessed at risk for developing pressure ulcers. The facility did not implement effective interventions to protect the bony prominences of the resident's heels. Findings include: The Quick Reference Guide entitled "Pressure Ulcer Prevention", published by the European and National Pressure Ulcer Advisory Panel in 2009, indicated that a SDTI (Suspected Deep Tissue Injury)-depth unknown is classified as purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become coved by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in resident condition. Develop and implement a prevention plan when individuals have been identified as being at risk of developing pressure ulcers. Risk factors identified in a risk assessment should lead to an individualized plan of care to minimize the impact of those variables. Select a seated posture that is acceptable for the individual and minimizes the pressures and shear exerted on the skin and soft tissues. The reduction of pressure and shear at the heel is an important point of interest in clinical practice. Because the heel is covered with a small subcutaneous tissue volume, mechanical loads are transmitted directly angular to the bone. Given the small surface area of the heel, it is challenging to try to redistribute load from the heels through the use of pressure redistributing devices. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure-a state sometime called "floating heels." Support surfaces usually fail to increase the total contact area of the heel bone, which would spread the load and reduce pressure. To reduce the pressure at the heels to 0 mmHg (millimeters of mercury), elevate the heels from the mattress. Heel protection devices should elevate the heel completely (offload them). The publication entitled "Medical Device Related Pressure Ulcers: The Hidden Epidemic Across the Lifespan" published by the National Pressure Ulcer Advisory Panel in 2013 indicated medical device related pressure ulcers are defined as localized injury to the skin or underlying tissue as a result of sustained pressure from a device (e.g., nasal cannula tubing). Tissue injury typically mimics the device shape and tend to progress rapidly as they often occur over areas without adipose (fat) tissue. Medical device related pressure ulcers occur due to failure to check tubing, lack of awareness of need to remove, reposition and provide basic care to skin under devices, lack of best practice guidelines and lack of standardized practice. Cushion and protect the skin with dressings in high risk areas. Confirm that devices are not placed directly under an individual who is bedridden or immobile. 70% of medical device related pressure ulcers develop on the head, neck and face. 1. Resident #4's admission face sheet dated 3/5/14 indicated the resident had [DIAGNOSES REDACTED]. Resident #4's pressure ulcer CAA (Care Area Assessment) dated 3/24/14 indicated, "Due to impaired mobility, cognitive deficit, bowel and bladder incontinence and variable intakes with weight loss, resident remains at increased risk for pressure ulcer development." An associated Braden Scale assessment used for the prediction of pressure ulcer risk indicated the resident was at high risk for the development of pressure related ulcers. Resident #4's admission skin integrity care plan, dated 3/14/14, included interventions of a standard pressure reducing mattress on bed and chair, use pillow and positioning devices as needed and encourage to reposition. Resident #4's MDS (minimum data set) assessment, dated 6/18/14, indicated the resident scored a 5 of 15 on the cognitive screen (the higher the score, the more cognizant); had multiple verbally abusive behaviors; required extensive assistance to perform bed mobility and transfers; was non ambulatory, had an unplanned weight loss, was frequently incontinent of bowel and bladder and was at risk for pressure ulcers and had no present skin integrity issues. Resident #4's medical record indicated on 7/23/14, the resident developed an open area to the coccyx which developed into a stage II pressure ulcer by 9/9/14. The area was still present at the time of survey. Review of resident #4's nursing documentation in the medical record indicated that on 8/22/14, the resident had presented with, "Suspected DTI noted to right lateral ankle. Area measures 0.8 cm (centimeters) by 1.0 cm and unable to determine depth with the wound base 100% deep purple discoloration. Peri-wound skin intact, free from [DIAGNOSES REDACTED], maceration or [MEDICAL CONDITION]. No exudate noted from the wound bed. Patient complained of mild discomfort with assessment and palpation of the area. Suspected DTI noted to lateral right mid foot. Area measures 2.0 cm by 2.0 cm and unable to determine depth. The wound was 100% deep purple discoloration. Peri-wound skin intact, free from [DIAGNOSES REDACTED], maceration or [MEDICAL CONDITION] and no exudate noted from the wound bed. Prevalon boots were obtained for the patient to be worn at all times." On 8/22/14, a care plan was developed for the 2 SDTI's noted as above for resident #4. On 9/9/14, an alternating air mattress replaced the standard pressure reducing mattress and on 9/18/14, the Prevalon boots were replaced with Heel Medix boots as patient allows and to free float heels as able. On 8/25/14, the resident was re-evaluated by therapy for evaluation and treatment of [REDACTED]. chair cushion. On 9/23/14 at 8:45 a.m., surveyor # interviewed RN (Registered Nurse)-H regarding resident #4. RN-H functions as the facility's certified wound nurse. RN-H stated, "(Resident #4) developed a coccyx slit which then progressed to a stage II a week or two ago. (Resident #4) had a [MEDICAL CONDITION] hip and tends to pronate his right foot out and would sustain friction and shear to the outer right foot often. (Resident #4) was resistant to repositioning. Staff would free float his heels as allowed on pillows. We started him using Prevalon boots. He now has a SDTI on his right lateral ankle and foot. (Resident #4) was very behavioral before, but is now better with changes in his medication regimen." On 9/23/14 at 1:10 p.m., surveyor # interviewed CNA (Certified Nursing Assistant)-E and CNA-G regarding resident #4. Both staff verified prior to resident #4 developing 2 SDTI's to the right foot and ankle, the resident was to have heels floated on pillows and did not have bilateral boots in his plan of care. CNA-G stated, "(Resident #4) pushed the pillows away from his feet and behind his back. We would find him lying on his back with his right outside foot on the mattress and he would slide his foot against the mattress. That's how we found him a majority of the time on our rounds every two hours. They didn't try anything else unfortunately until the sore developed. (Resident #4) did fracture his right femur and often was noted to have his right foot lying to the outside. Had no boots, and was using a standard mattress on his bed at the time." CNA-E stated, "At night, (resident #4) would allow repositioning." On 9/23/14 at 1:25 p.m., surveyor # interviewed RN-H regarding resident #4. RN-H stated, "(Resident #4) had a standard pressure reducing mattress on his bed prior to the development of the 2 SDTI's. We switched him to an alternating air mattress after the wounds were discovered. (Resident #4) would sit way forward on the wheelchair at the edge of his seat with his legs out and would reposition himself, sometimes after removing his shoes by planting his lateral right foot on the ground and pushing backwards." On 9/23/14 at approximately 2:30 p.m., surveyor # interviewed RN-H regarding resident #4. RN-H verified to the surveyor that the resident's orthopedic surgeon had not been updated on the resident's actions regarding repositioning self in wheel chair utilizing the outer aspect of the right foot and stated, "I would update ortho when he was self transferring and was not to be weight bearing on the right leg. The SDTI on his right foot and ankle were noted on 8/22/14 due to drop foot from the fracture and keeping his foot and ankle rotated outward and rubbing it against surfaces. (Resident #4) often would kick his shoes off in the wheel chair and was only wearing socks. (Resident #4) had boggy heels on admission. We suspended the heels as he allowed with pillows but he wasn't always cooperative, is better with the med changes we made. I was focusing on his heels since they were boggy. We initiated the Prevalon boots, but noticed that his foot would still rotate in the boots, so that's why the boots were changed (to Heel Medix boots). (Resident #4) has always had the external rotation of the right foot since admission. We were lotioning his feet and off loading heels with pillows and looking at nutritional aspects. If he took the pillows out, staff would re approach. They would notice that the pillows were not in position and would constantly explain and re approach." On 9/24/14 at 8:20 a.m., surveyor # interviewed RTM (Regional Therapy Manager)-L regarding resident #4. RTM-L stated, "Initially on admission we attempted to evaluate and treat (resident #4) but he was not cooperative due to behaviors. (Resident #4) was reevaluated by Occupational Therapy on 8/25/14. We noticed at that time that his sitting posture and balance was an issue. We trialed a new wheel chair with a high back and wedge cushion. I talked to therapy staff and on initial evaluation in March of 2014, he was very resistive and seating and positioning in the chair was not an issue. He looked good in his position in the wheel chair. When we picked him up again in August of 2014, we worked on transfer status because his medications had been changed and his behavior had improved. We thought he needed to have his positioning in the chair adjusted which was not requested by nursing." On 9/24/14 at 9:35 a.m., surveyor # interviewed PTA (Physical Therapy Assistant)-M regarding resident #4. PTA-M stated, "(Resident #4) was noted to be sliding way down in his wheel chair when we evaluated him on 8/25/14 and we revamped his seating. At the time, he had a cushion with a cut out or maybe it was a slope at the coccyx. With revising his wheel chair, we could get him not to slide down." On 9/24/14 at 4:00 p.m., surveyor # interviewed CNA-F regarding resident #4. CNA-F stated, "I work a lot with (resident #4). (Resident #4)had no boots on his feet prior to the pressure ulcers developing on his right foot and ankle. He kicked the pillows out from under his feet. On rounds, we would have to put the pillows back in place at least 50% of the time. (Resident #4) would also take the pillow out from behind his back. (Resident #4) does lay with his right foot externally rotated and does rub the foot on the bed." 2. Resident #3's re-admission face sheet dated 5/2/14 indicated the resident had [DIAGNOSES REDACTED]. At the time of survey, the resident was receiving Hospice services. Review of the resident's medical record indicated a physician's orders [REDACTED]. The resident had been hosptalized on [DATE] for exacerbation of [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. The CNA care card for resident #3 dated 9/23/14, did not include that staff were to free float the resident's heels. A plan of care in the resident's medical records for "At risk for alteration in skin integrity" dated 1/21/13 and revised on 9/6/14 included interventions to encourage to reposition as needed, and to use pillows/positioning devices as needed. There was no intervention listed on the TAR or plan of care relating to skin integrity addressing the resident's use of oxygen therapy and to address the nasal cannula tubing that required padding at the ears to prevent pressure ulcers. Resident #3's most recent MDS assessment dated [DATE], indicated the resident had scored a 4 of 15 on the cognition screen; required extensive assistance from staff to perform bed mobility and transfers; was non ambulatory; had an unplanned weight loss (was 60 inches tall and weighed 90 pounds. Had been 115 pounds on the prior assessment dated [DATE]); was at risk for the development of pressure ulcers and was usually incontinent of bowel and bladder. The resident's most recent Braden Scale assessment used for the prediction of pressure ulcers dated 8/18/14, indicated the resident was assessed to be at high risk for the development of pressure ulcers. On 9/23/14 at 8:45 a.m., surveyor # observed resident #3 lying in bed on her back sleeping, with gripper socks on her feet. A flat pillow was under the resident's calves. Both heels were in full contact with the mattress and were not free floating. It was also noted that the resident was lying with her left ear positioned on a pillow. The resident's oxygen therapy was delivered via a nasal cannula. No padding was noted around the oxygen tubing at the tops of the resident's ears. On 9/23/14 during periodic observations by surveyor # from 10:35 a.m. until 11:40 a.m., resident #3 was noted in the same position, asleep with both heels in full contact with mattress and no padding on the oxygen tubing at the ears. On 9/23/14 at 12:55 a.m. and 2:15 p.m., surveyor # observed resident asleep in bed positioned on her left side with the left ear positioned on a pillow. The resident had soft soled non skid booties on both feet. Two pillows were positioned under the resident's calves and the right medial heel and right medial malleolus were in full contact with the bed and the left lateral heel and left later malleolus were in full contact with the medial side of the right foot. The resident's oxygen tubing was not padded at the ears. On 9/23/14 at 2:50 p.m., surveyor # observed resident #3 lying in bed and was noted to be bare footed and lying on her left side in bed with the oxygen tubing and nasal cannula lying on the bed. The resident was awake and restless in bed. The surveyor asked CNA-BB to observe resident #3. CNA-BB verified resident #3's heels were not free floating per her plan of care. The surveyor observed the resident's heels at this time. Both heels were dusky pink/light purple in color and blanchable without skin integrity issues. CNA-BB stated, "(Resident #3) does move around in bed when awake and the pillows are not adequate to free float her heels." CNA-BB replaced the resident's oxygen at that time. On 9/23/14 at 6:45 a.m., surveyor # observed resident #3 seated in a wheel chair with oxygen therapy delivered via a nasal cannula. The oxygen tubing was not padded at the ears. On 9/24/14 at 10:10 a.m., surveyor # interviewed RN-CC regarding resident #3. RN-CC verified resident #3 had blanchable redness at the tops of the ears bilaterally below where oxygen tubing had been placed and stated, "Padding needs to be placed there." On 9/24/14 at 10:30 a.m., surveyor # interviewed RN-H regarding resident #3. RN-H functions as the facility's certified wound nurse. RN-H verified to the surveyor that the facility follows the NPUAP (National Pressure Ulcer Advisory Panel) standard of practice relating to prevention of pressure ulcers and stated, "I was unaware of the NPUAP article regarding medical device related pressure ulcer prevention. We do skin checks and don't automatically pad oxygen tubing in those resident's who are assessed to be at high risk and use chronic oxygen. I agree that pressure ulcers can occur rapidly on the tops of the ears and skull due to decreased adipose tissue at that site. The licensed staff do skin checks weekly and the CNA staff also do them weekly to equal skin checks twice weekly." 3. On 09/23/14, surveyor # reviewed resident #6's medical record. Resident #6's care plan titled "At risk for alteration in skin integrity related to: impaired mobility, variable intakes, bowel incontinence episodes" was initiated 08/01/14. The care plan directed staff to use pillows/positioning devices as needed. The facility completed a Braden Scale (a tool used to assist with identifying residents who would be at risk for pressure ulcer development), dated 08/13/14. The Braden scale identified resident #6 to be at moderate risk for pressure ulcer development. The Braden scale indicated that resident #6 had very limited ability to change and control body position and that friction/shear was a problem. A progress note, dated 09/20/14 at 11:31 a.m., indicated "Patient has a fifty-cent piece size reddened, soft area on the medial aspect of his left heel. MD (Medical Doctor) notified via phone and ordered boot protectors to bil. (bilateral) heels and [MEDICATION NAME] spray to left heel BID (twice daily) and PRN (as needed) until healed. On 09/23/14 at 2:55 p.m., surveyor # interviewed CNA-B regarding resident #6. CNA-B stated prior to the development of the reddened area on the heel, the heels were free floated over a pillow. CNA-B indicated resident #6 would push the pillow out frequently. CNA-B stated resident #6 was able to move his legs, but could only move in a way that the heels would shear across the bed. CNA-B indicated that resident #6 could not lift his legs above the surface of the bed to move them. CNA-B stated the nurses were aware that resident #6 would push the pillows out, and staff were directed to replace resident #6's heels over the pillows. CNA-B indicated at times, resident #6 would state he did not like the pillows but when asked why he didn't like the pillows, resident #6 would not elaborate. CNA-B stated resident #6 needed encouragement, but would not refuse. CNA-B verified the facility had not initiated any alternatives to free float heels until after resident #6 developed the reddened area, when the pressure relieving boots were implemented. On 09/23/14 at 3:20 p.m., surveyor # interviewed RN-C regarding resident #6's reddened area to the left heel. RN-C verified she was the RN which documented the initial finding of the area. RN-C stated she was really sure of how the reddened area developed but believed it was from pressure. RN-C indicated she was informed by a CNA and she went and assessed the area. RN-C stated the area on the left medial heel was about fifty cent piece in size, was deep red in color and was blanchable. RN-C stated she called the MD and the MD stated it was probably from pressure and ordered a specific boots. RN-C stated the facility didn't have the boots in the supply room, so staff elevated the extremities with extra pillows. RN-C indicated she wasn't aware that resident #6 pushed out the pillows that were previously used to offload pressure from resident #6's heels. RN-C stated resident #6 did not receive the specific boots until Monday 09/22/14, as the boots were stored in a storage unit out of the facility and were not available to staff. RN-C stated resident #6 spends most of his day in bed per his choice, and is only up for meals. RN-C indicated she wasn't aware if any staff identifies the causal factors when a reddened area is observed. RN-C stated she wasn't aware if the facility employed a nurse that was wound certified. On 09/23/14 at 3:25 p.m., surveyor # and RN-C observed resident #6's reddened area to the left inner heel. The reddened area was approximately a 50 cent piece in size and was medium pink in color. RN-C pressed on the reddened area which was observed to be blanchable. RN-C stated the skin is still soft but had improved since 09/20/14. On 09/24/14 at 11:20 a.m., surveyor # interviewed ADON (Assistant Director of Nursing)-A regarding resident #6. ADON-A verified resident #6 spends most of his day in bed and the heels were offloaded on pillows prior to the development of the reddened area on the left medial heel. ADON-A stated she wasn't aware that resident #6 kicked out his pillows so his heels were not offloaded, but wasn't surprised to hear that. ADON-C indicated resident #6 was at risk for pressure ulcer development and the physician ordered the Prevalon boots after the reddened area developed. ADON-A stated she does the assessment to determine the causal factor for the development, and the assessment was still in progress. ADON-A indicated the nurses do not complete causal factor assessments. ADON-A stated the documentation regarding the assessment of the reddened area should be documented in centimeters and not as a 50 cent piece size. ADON-A indicated she thought the reddened area possible was related to pressure due to it is red, blanchable, boggy and over a bony prominence, but that would only be speculation. ADON-A stated the facility does have a certified wound nurse and she was notified yesterday of the reddened area. Surveyor # updated ADON-A that a care plan for actual skin integrity concerns was not noted in the medical record. ADON-A verified she had completed a care plan for the reddened area on 09/23/14, as the nurses usually didn't develop care plans, but can. Surveyor # questioned ADON-A regarding the Prevalon boots being offsite and were not available for placement on Saturday 09/20/14 when ordered by the physician. ADON-A stated the Prevalon boots were kept in a storage unit outside the facility and the keys were not available to the nurses. ADON-A indicated on Monday 09/22/14, when she learned of the MD order, the boots were retrieved from the storage unit. ADON-C verified there wasn't any interventions to offload pressure to resident #6's heels except the use of pillows, until after the reddened area developed on 09/20/14. 4. Resident #8's face sheet dated 9/19/14, indicated the resident had multiple [DIAGNOSES REDACTED]. Resident #8 was assessed to be at risk for developing pressure ulcers. On 9/18/14 the facility implemented an "At risk for alteration in skin integrity" plan of care for resident #8. The plan of care included multiple interventions including "Float heels as able." On 9/23/14 at 11:20 a.m., surveyor # observed resident #8 supine in bed with both heels in full contact with the mattress and the head of bed elevated. On 9/23/14 at 11:35 a.m., surveyor # observed CNA-G and CNA-E care for resident #8. The CNAs verified the resident's heels had been in full contact with the mattress upon entering the room. The CNAs verified the resident had limited movement to the lower extremities, and pillows had been used to try to float the resident's heels, but it was uncomfortable for the resident so they stopped using them. The resident's feet were wrapped with ACE wrap and the feet were noted to be [MEDICAL CONDITION], which was normal for this resident. On 9/24/14 from 10:50 a.m. through 11:35 a.m., surveyor # observed resident #8 supine in bed with both heels indirect contact with the mattress. Resident #8 verified staff had tried to float his heels with pillows, but it was uncomfortable, and they have not tried anything else since. Resident #8 verified movement to the right lower leg was very limited.