Every finding on record at Milwaukee Catholic Home

Based on interview and record review, the facility did not ensure that 2 of 3 residents (R1 and R5) reviewed for falls received adequate supervision and assistive devices to prevent accidents.* R1 had a fall on 7/7/26, R1 was found by the van driver on the floor of the transport vehicle. The facility did not adequately evaluate and analyze the circumstances of R1's fall on 7/7/26 to identify the factors contributing to the falls and determine whether additional interventions were necessary to reduce the risk of future falls or accidents. Additionally, R1's fall interventions were observed not to be in place.* R5 was found in the bathroom in the fetal position on the floor on 8/17/26. The facility did not adequately evaluate and analyze the circumstances of R5's fall to identify the factors contributing to the fall and determine whether additional interventions were necessary to reduce the risk of future falls or accidents.Findings Include:The facility policy, entitled Incident/Accident Reports, revised 2/25, documents:Policy: Incident/Accident Report forms will be completed for each event that occurs. An injury of unknown origin must be thoroughly investigated whether it is an incident or an accident.Procedure For Incident or Accident: .2. An Incident/Accident process electronic medical record (EMR) related to the type of incident will be completed by the nurse.7. The Fall Huddle Report accompanies the Incident/Accident Report for falls and is discussed as soon as possible with all staff on the unit at the time of the fall. 8. All Incident/Accident Reports are reviewed and interventions discussed by the interdisciplinary team (IDT) at the falls meeting held after morning report.1) R1 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease, vascular dementia, anxiety disorder, and delirium due to known physiological condition.R1's Quarterly Minimum Data Set (MDS) assessment, dated 7/13/26, documented R1's Brief Interview for Mental Status (BIMS) score of 3, indicating R1 demonstrated severely impaired skills for daily decision making. The MDS documents: R1 was assessed to have lower extremity range of motion impairment to one side; R1 was occasionally incontinent of urine and frequently incontinent of bowel; R1 required partial/moderate assistance for upper body dressing and mobility. R1 required substantial/maximum assistance for lower body dressing and was dependent for transfers.On 4/7/26, R1's fall risk assessment documented a score of 18, indicating a high risk for falls.On 4/13/26, R1's fall risk assessment documented a score of 18, indicating a high risk for falls.On 5/5/26, R1's fall risk assessment documented a score of 18, indicating a high risk for falls.On 5/27/26, R1's fall risk assessment documented a score of 17, indicating a high risk for falls.On 7/7/26, R1's fall risk assessment documented a score of 21, indicating a high risk for falls.R1's comprehensive care plan dated 12/27/23 documented that R1 was at risk for falls due to impaired mobility, left above-the-knee amputation, cognitive deficits, and impaired safety awareness as evidenced by resident (R1) attempting to ambulate without assistance. Interventions included:- When resident is in bed, bed should be in lowest position. Effective: 12/27/23- Hoyer lift 2 assists for all transfers. Effective: 1/5/24- Fall mat. Effective: 1/5/24- Toilet resident around 7:00 PM. Effective: 2/12/24- Place a sign above the resident's bed that reads, Please call; don't fall. Effective: 2/28/24- Check on the resident between 3:00 and 4:00 AM every morning. Effective: 9/20/24- Gripper socks at night. Effective: 11/1/24- Dycem above and below the wheelchair. Effective: 4/10/25- Staff should never leave the resident unattended during transfers or repositioning, especially when the resident requires mobility assistance or uses a mechanical lift (such as mechanical sling). Curved mattress applied 5/29/26. Effective: 5/28/26R1's certified nursing assistant (CNA) care card located in R1's closet instructed CNAs regarding safety interventions for R1, which documented: Fall risk-Ensure bed is close to wall after transfers; Ensure bed wheels are locked; Ensure wheelchair foot pedals are in place and in use during transportation; Staff to declutter resident's (R1) area every shift; When the resident (R1) is in bed, bed should be in the lowest position; Place resident (R1) in her (R1) wheelchair while up so that she (R1) can propel herself (R1) around the room/unit. Remove foot pedals; Place a sign above the resident's (R1) bed that reads, Please call; don't fall; Gripper socks at night; Dycem above and below the wheelchair.On 7/7/26, R1's medical record documented that Registered Nurse (RN)-M was called to assess R1. Resident had slid out of the wheelchair in the transportation van. Per wheelchair van driver, resident was complaining of pain in her back. Resident started shifting her weight. She had a sling under her as she was a Hoyer (mechanical) lift resident. Resident then slid out of the wheelchair with her butt on the ground and her back against the wheelchair. Driver stated she did not hit her head. No redness noted to back. Left lower extremity (LLE) was amputated. Resident denied any pain to right lower extremity (RLE) and was able to move. Resident was assisted out of the wheelchair van and back into the wheelchair for transport back to the unit. Unit nurse and CNAs assisted resident back to the unit.On 7/7/26, Registered Nurse Unit Manager RNUM-D documented: The resident had an unwitnessed wheelchair/van fall with a third-party account. Per the van driver, after resident arrived back at the facility and the seat belt was removed, resident became very restless due to lower back pain and slid from the wheelchair onto the van floor. The driver reports that the resident landed on her buttocks and denies seeing a head strike. Resident was assisted back to the chair and transported into the facility.R1's fall incident report dated 7/7/26 documented that the van driver removed the seat belt and R1 became restless due to lower back pain and slid from the wheelchair to the van floor. The van driver stated R1 landed on R1's buttocks. No evidence of injury was noted after assessment.On 7/8/26, R1 had severe pain with repositioning.R1's care plan was updated on 7/8/26 with the fall prevention intervention to ensure wheelchair foot pedals are in place and in use during transportation.On 7/16/26, R1 had an x-ray of the back, and no fractures were identified.On 8/24/26, at 12:50 PM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-E, who stated that they understood the van driver took the seat belt off and R1 fell out of the wheelchair while the van was parked out front of the facility. RNUM-E did not recall if the van driver stated whether R1 hit R1's head. RNUM-E stated the facility ordered a seatbelt for the wheelchair but never used the seatbelt and instead R1 was transferred to hemodialysis by ambulance.On 8/24/26, at 1:39 PM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-D, who stated they understood that the van driver did not strap R1 in correctly. RNUM-D stated the van was parked at the time that R1 slipped out of the wheelchair.On 8/25/26, at 7:13 AM, Surveyor observed R1 in bed sleeping. The bed was in the lowest position with a mat on the floor. Surveyor observed R1's wheelchair. Surveyor observed there was blue Dycem on top of the cushion but there was no Dycem under the cushion.Surveyor noted that R1's Dycem intervention below the cushion was not in place per R1's falls plan of care.On 8/25/26, at 7:46 AM, Surveyor interviewed Director of Nursing (DON)-B. DON-B confirmed the van driver would not provide a statement as to what happened with R1 on 7/7/26. DON-B spoke to the van company supervisor, who stated R1 fell out of the wheelchair due to R1's sling. DON-B stated the van company supervisor would not confirm if the lap strap and shoulder harness were on R1 while in the van. DON-B could not confirm if the van driver was driving at the time R1 fell out of the wheelchair. DON-B also stated that the transportation requirement was to have a shoulder harness and lap strap for transport. DON-B could not confirm that both these items had been on R1 at the time of transport on 7/7/26. DON-B informed Surveyor that the story did not make sense.On 8/25/26, at 8:44 AM, Surveyor interviewed Receptionist (REC)-I. REC-I was not certain if R1's incident happened in the van when it was parked or while it was driving at the time of R1's incident. REC-I stated the van driver came into the facility without R1 and had informed REC-I that R1 had slipped out of the wheelchair and that the driver was not a nurse and did not want to hurt R1. REC-I called upstairs, and staff came down to help R1.On 8/25/26, at 10:35 AM, DON-B informed Surveyor that DON-B was not sure who went to help R1 in the van.On 8/25/26, at 10:51 AM, Surveyor interviewed RNUM-D regarding R1's incident on 7/7/26. RNUM-D stated they went out to the van and observed R1 on the ground of the van. RNUM-D stated the van driver had informed RNUM-D that R1 had become anxious and was having back pain. The van driver undid the straps while parked, and R1 fell out of the wheelchair. R1 went down on her knee and buttock, and the van driver had informed RNUM-D that R1 had not hit her head.On 8/25/26, at 11:58 AM, Surveyor observed R1 in R1's Broda chair. Surveyor interviewed CNA-F, who confirmed there was Dycem on top of the cushion but none on the bottom. CNA-F explained the cushion is moved from the wheelchair to the Broda chair.Surveyor noted there was no Dycem under R1's cushion as identified in R1's falls care plan interventions.Surveyor also noted the facility did not obtain staff statements related to R1's fall on 7/7/26 and therefore did not establish the circumstances contributing to the fall or determine whether additional fall-prevention interventions were necessary.On 8/25/26, at 12:40 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern of R1's 7/7/26 fall in the van not being thoroughly investigate and that R1's care plan intervention requiring Dycem to be placed on and below R1's cushion was not observed to be in place per R1's falls plan of care.DON-B stated, we expected a recommendation concerning falls. We know we have work to do concerning falls.2) R5 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's disease with late onset, depression, and insomnia.R5's Significant Change Minimum Data Set (MDS) assessment, dated 8/18/26, documented R5 demonstrated short- and long-term memory impairment and demonstrated severely impaired skills for daily decision making. The MDS documents that R5 was assessed as: R5 demonstrated inattention and disorganized thinking; R5 had no range of motion impairments; R5 was frequently incontinent of urine and always incontinent of bowel; R5 required partial/moderate assistance for upper body dressing; R5 required substantial/maximum assistance for lower body dressing and was dependent for transfers; R5 was independent with mobility and required supervision for transfers.On 8/18/26, R5's Falls Risk Assessment documented a score of 15. A score of 10 or higher indicates that R5 was at high risk for falls.R5's comprehensive care plan documented that R5 was at risk for falls due to physical and cognitive decline, effective 3/23/26.Active Interventions included:Encourage activities between meals. Effective 3/23/26Footwear will fit properly and have non-skid soles. Effective 3/23/26Keep areas free of obstructions to reduce the risk of falls or injury. Effective 3/23/26Soft touch call light within reach. Effective 3/23/26Provide reminders to use ambulation and transfer assist devices. Effective 3/23/26Monitor/Anticipate/Intervene for factors causing prior falls. Effective 3/23/26Engage R5 in activities that improve strength, balance, and posture. Effective 3/23/26Involve family and/or R5 in decision making process to prevent falls. Effective 3/23/26Wheelchair for distance. Effective 8/18/26Standby assist for all ambulation. Effective 8/18/26R5's certified nursing assistant (CNA) care card located in R5's closet instructed CNAs for safety interventions for R5: Fall risk; Low bed; Soft touch call light; Encourage activities between meals; Standby assist for all ambulation; Transfers. 1 person weight bearing help (move/support/hold); Toileting. 1 person weight bearing help (move/support/hold); Thinks she (R5) is self-directed. Offer toileting upon arising, before or after meals, at HS, every 3-4 hours on nights, and as needed (PRN).On 8/17/26, Registered Nurse Supervisor (RNS)-H documented: Writer called to resident's room. Resident found lying in a fetal position on her right side on the bathroom floor. Resident was incontinent. Resident able to sit up. Resident able to stand with assistance. Resident assisted onto the toilet due to incontinence. Resident's ROM WNL. No c/o pain or distress noted. Resident stated she is not in pain.On 8/17/26, Registered Nurse Supervisor (RNS)-H documented: Resident has noted confusion at baseline and wanders throughout the unit for her normal day to day. Resident (R5) began to guard her (R5) right hip after using the bathroom. STAT X-Ray of the right hip ordered.R5's fall incident report documented that on 8/17/26 at 9:59 PM, R5 was found in the fetal position on the bathroom floor. R5 had a bowel movement (BM) while lying on the floor of the bathroom.Surveyor noted the fall huddle report dated 8/17/26 did not document R5's location prior to the time of the fall and did not document when R5 was last checked.Surveyor noted that the facility did not obtain facility staff statements as part of the fall investigation to determine when R5 was last seen or what interventions were in place to prevent R5's fall on 8/17/26.On 8/18/26, R5's x-ray results documented no fracture.On 8/25/26, at 9:12 AM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-C. RNUM-C stated R5 would be one of the last residents to go to bed and would have been assisted to bed around 8:00 PM or 9:00 PM. RNUM-C stated R5 was in bed. Surveyor stated that the fall incident report stated R5 had shoes on at the time of the fall. RNUM-C stated, maybe they were slippers. Surveyor asked RNUM-C how RNUM-C knew that R5 was in bed prior to the fall. RNUM-C stated, I assumed R5 was in bed, and agreed with Surveyor that it was not documented in R5's fall incident report.RNUM-C was unable to confirm who was assigned to R5 at the time of the fall and stated there had been a call in and the assignments were not clear. RNUM-C confirmed that R5 was on a toileting program and staff needed to get a hold of the toileting program because R5 had behaviors in the bathroom.On 8/25/26, at 10:35 AM, Surveyor interviewed Director of Nursing (DON)-B regarding R5's 8/17/26 fall incident report. Surveyor discussed the details of R5's fall incident report dated 8/17/26. Surveyor shared the concern of R5's fall incident report not being thoroughly investigated. DON-B agreed R5's fall incident report was not thoroughly investigated to determine the circumstances contributing to the fall and establish whether additional interventions were necessary.On 8/25/26, at 11:25 AM, Surveyor interviewed Registered Nurse Supervisor (RNS)-H via telephone. RNS-H informed Surveyor that R5 had been found in a ball on the bathroom floor. RNS-H had asked whom the CNA assigned to R5, when R5 was last checked and believed it had been an hour prior to the fall and confirmed RNS-H did not obtain a statement from that CNA. Surveyor asked RNS-H if staff knew how long R5 had been on the bathroom floor. RNS-H stated staff did not know how long R5 had been on the bathroom floor. RNS-H stated RNS-H started the fall incident report but, because it was at the end of the shift, left the fall incident report to be finished by the oncoming nurse. DON-B was present for the interview of RNS-H and informed Surveyor that the nurse should have finished the fall incident report and the team huddle.On 8/25/26, at 12:40 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R5's 8/17/26 fall had not been thoroughly investigated to determine the circumstances contributing to the fall and establish whether additional interventions were necessary. DON-B stated, we expected a recommendation concerning falls. We know we have work to do concerning falls.

Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 1 (R4) of 6 sampled residents reviewed for transfers.*R4 was assessed and care planned to transfer with a sit to stand mechanical lift (EZ stand) and assist of 2 staff. Surveyor observed Certified Nursing Assistant (CNA)-C transfer R4 with the sit to stand mechanical lift without the assistance of another staff member.Findings include:The facility policy titled, Transfer of a resident with the Sit to Stand dated 10/2025 documents: Policy: The safe transfer of a resident who is able to bear weight can be done with the Sit to Stand and the assist of one or two staff per plan of care (POC). Procedure: .4. Place sling under the arms of the resident with the padding next to resident. Be sure sling fits snugly. Adjust accordingly. R4 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis- Lumbar region, Type 2 Diabetes Mellitus with Diabetic Foot Ulcer and Neuropathy, Weakness, history of falls, and . Sciatica on the right side.R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R4 was assessed as having moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. The MDS assessed R4 as needing maximal assistance for transfers and total assistance with toileting hygiene. The MDS documents that R4 is frequently incontinent of bladder and occasionally incontinent of bowel and that R4 transferred using a sit to stand mechanical lift.R4's risk for falls and history of falls care plan initiated on 11/14/2022 documents the following interventions:- Provide reassurance during transfers and ensure leg-strap is in place (Effective: 3/19/2026).- EZ Stand (sit to stand mechanical device) with 2 assist for all transfers (Effective: 5/16/2026).R4's alteration in comfort related to spinal stenosis, neuropathy, scoliosis, . care plan was initiated on 11/14/2022 with the following interventions: -EZ Stand with one assistSurveyor noted R4 has 2 different transfer statuses with the EZ stand that are currently active, with one care plan documenting a transfer status of an assist of 2 staff and the other with an assist of 1 staff.R4's resident summary (CNA care card) has the following interventions: - Transfer/ Positioning: EZ-Stand with assist of 2 for all transfers. Provide Reassurance during transfers and ensure leg-strap is in place.- Transfers: 2+ person weight bearing help (move/support/hold), EZ- Stand with 2 assist for all transfers.- Toileting: 2+ person weight bearing help (move/support/hold). On 5/19/2026, at 9:52 AM, Surveyor observed CNA-C in R4's bedroom getting ready to transfer R4 to the toilet from R4's electric wheelchair. Surveyor observed CNA-C transfer R4 from R4's electric wheelchair to the bathroom toilet using a sit to stand mechanical device and assist of 1 staff member. Surveyor noted the chest strap around R4 was loose and above R4's chest area. R4 had a grimacing facial expression during the transfer. CNA-C walked out of R4's bedroom to grab more washcloths and towels. Surveyor asked R4 if R4 was in pain from the transfer. R4 stated the transfer was uncomfortable and felt like R4 was hanging from the strap and R4 pulled at the strap around R4's chest area. On 5/19/2026, at 9:56 AM, CNA-C came back to R4's room and raised the sit to stand mechanical device up so CNA-C could provide peri cares to R4. CNA-C finished providing cares to R4 and applied a clean protective brief and pulled up R4's pants. On 5/19/2026, at 10:00 AM, CNA-D came into R4's room and assisted CNA-C with transferring R4 from the bathroom to R4's electric wheelchair.On 5/20/2026, at 9:07 AM, Surveyor interviewed CNA-C. Surveyor asked CNA-C to clarify R4's transfer status. CNA-C stated R4 was a transfer using an EZ Stand with 2 staff. Surveyor asked CNA-C why CNA-C transferred R4 alone on 5/19/2026. CNA-C stated R4 is not CNA-C's normal patient and when CNA-C answered R4's call light on 5/19/2026, CNA-C was helping CNA-D and stated that CNA-C decided to assist CNA-D and take R4 to the toilet. CNA-C stated R4 wanted to use the toilet right away, so CNA-C just transferred R4 alone. CNA-C stated R4 was initially a transfer with 1 staff member, but a few weeks ago R4 changed to needing 2 staff members with transfers. Surveyor asked CNA-C how staff are made aware of changes to a resident's care plan. CNA-C stated the resident summary is updated and nursing tells staff regarding the changes.On 5/20/2026, at 9:44 AM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-E. Surveyor asked RNUM-E to clarify R4's transfer status. RNUM-E stated R4 was changed to assist of 2 with an EZ Stand because it was no longer safe for R4 to be transferred with 1 staff member. Surveyor showed RNUM-E R4's care plan and the conflicting transfer statuses in 2 different sections of R4's care plan. RNUM-E confirmed R4 should be an EZ-Stand with assist of 2.RNUM-E was not sure why R4's transfer status was different in 2 separate sections of R4's care plan. RNUM-E stated staff should follow a residents care plan, resident summary or the CNA care card, and nursing staff and the managers with verbally update staff as well of any changes to resident's plan of care. Surveyor shared observation of CNA-C transferring R4 from R4's electric wheelchair to the bathroom alone. RNUM-E stated R4 can be impatient at times, but staff still need to follow R4's plan of care. Surveyor shared observation of strap not positioned correctly on R4's chest area and R4 stated it felt like R4 was hanging. RNUM-E confirmed the chest strap should sit below the resident chest snugly so avoid residents from slipping out of it. On 5/20/2026, at 10:04 AM, Surveyor shared observations with Director of Nursing (DON)-B of CNA-C transferring R4 from R4's electric wheelchair to the bathroom alone and the chest strap around R4 was loose. Surveyor shared R4's care plan had conflicting transfer statuses for R4. DON-B stated if staff see that, staff must report the discrepancy and follow the status with the most assistance until further clarification is received. DON-B was not sure why R4 had a transfer status in the pain section of the care plan.No additional information was provided.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R4) of 1 sampled residents observed for incontinence cares. *Staff was observed not wearing appropriate personal protective equipment (PPE) while providing personal to R4. R4 was on Enhanced Barrier Precautions (EBP).Findings include:The facility policy titled Enhanced Barrier Precautions dated 4/2025 documents: Policy: Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to significant morbidity and mortality for residents and increased cost for the health care system. This policy will target gown and glove use during high contact resident care activities and is designated to reduce transmission of MDRO's. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDRO's that employs targeted gown and glove use during high contact resident care activities.Procedure: 1. Upon identification of . or at risk resident, a sign indicating EBP will be placed on the door and a cart with supplies outside of room.4. Put on (DON) PPE. Gown and gloves will be utilized for all high contact activities which include: .c. Transferringd. Providing hygiene .f. Changing brief or assisting with toileting.R4 was admitted to the facility on [DATE]with diagnoses that include Type 2 Diabetes Mellitus with diabetic foot ulcer and Chronic Osteomyelitis, and history of Urinary Tract Infections. R4's Quarterly Minimum Data Set (MDS) dated [DATE] documented that R4 was assessed as having moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12. The MDS assessed R4 as needing maximal assistance with 1-2 staff members for activities of daily living (ADL's) and assessed R4 as being frequently incontinent of bladder and occasionally incontinent of bowel. The MDS documents that R4 was receiving hospice services and on was on EBPs.On 5/19/2026, at 9:52 AM, Surveyor observed an EBP sign hanging on R4's doorway and a bin with 3 drawers that had PPE (gowns, gloves) in the drawers. Surveyor observed Certified Nursing Assistant (CNA)-C take R4 to the bathroom to use the toilet. CNA-C did not put on appropriate PPE and wore only gloves on both hands while providing incontinence cares for R4. Surveyor observed CNA-C remove a soiled protective brief and put it in the garbage. Surveyor then observed CNA-C take off CNA-C's gloves and walk out of the room. Surveyor did not observe CNA-C wash CNA-C's hands in R4's bedroom before exiting R4's bedroom.On 5/19/2026, at 9:56 AM, CNA-C re-entered R4's room with gloves on and no gown. Surveyor observed CNA-C provide perineal cares for R4. On 5/19/2026, 10:04 AM, CNA-D walked into R4's bedroom wearing only gloves and no gown and assisted CNA-C transferring R4 back into R4's electric wheelchair. Surveyor asked when staff have to wear PPE if someone is on EBP. CNA-C stated R4 is no longer on precautions. CNA-C stated R4 was on precautions but had recently cleared. Surveyor showed CNA-C R4's EBP sign on R4's bedroom door. CNA-C and CNA-D stated R4 is not on any precautions, and the nurse has to take the sign down.Surveyor noted the EBP sign posted on R4's door documented: EBP: EVERYONE MUST: clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contact Resident Care Activities:- Dressing- Bathing/ Showering- Transferring- Changing Linens- Providing Hygiene- Changing briefs or assisting with toileting- Device care use: .- Wound Care: any skin opening requiring a dressing.R4's impaired skin related to immobility, diabetes mellitus, history of skin breakdown and diabetic ulcers on the right foot . care plan was initiated on 11/15/2022 and revised on 5/20/2025 with the following intervention:-Contact Isolation (effective 5/20/2025 - current)R4's resident summary/CNA care card has the following interventions documented:- EBPs .- Contact IsolationOn 5/19/2026, at 12:38 PM and 2:07 PM, Surveyor observed the EBP sign on R4's door and bin with available PPE by R4's doorway.On 5/20/2026, at 9:07 AM, Surveyor observed the EBP sign on R4's door and a bin with available PPE by R4's doorway. Surveyor asked CNA-C if R4 was supposed to be on any transmission based precautions (ex: contact isolation) or EBP because R4 still had the RBP sign outside R4's doorway. CNA-C stated R4 is not on any precautions and does not wear any PPE when provided cares for R4. CNA-C stated the nurse has not taken down R4's sign or taken away the PPE yet.On 5/20/2026, at 9:23 AM, Surveyor interviewed Registered Nurse/ Infection Preventionist (RN/IP)-F, Director of Nursing (DON)-B was also present for the interview. RN/IP-F stated R4 was on contact isolation due to R4's wounds and history of having Multidrug-Resistant Organism (MDRO) infections, but currently R4 is on EBP and will always be on EBP due to R4's comorbidities (medical conditions).Surveyor asked RN/IP-F if staff should don PPE when toileting and providing peri cares for R4. RN/IP-F stated staff should don PPE when toileting and providing peri cares for R4. Surveyor shared observations with DON-B and RN/IP-F of CNA-C and CNA-D not wearing appropriate PPE when providing incontinent cares and transferring R4. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure food was stored in a safe manner. This practice has the potential to affect all 22 residents located on the 2nd floor rehab unit. *The resident food refrigerators located in the medication (med) rooms have a desired temperature documented on the temperature log of 36 to 45 degrees Fahrenheit (F). The facility food storage policy documents that food refrigerators should be between 35 and 41 degrees. Surveyor observed the food refrigerator located in the 2nd floor Rehabilitation (Rehab) unit med room multiple times during survey. Surveyor observed the food refrigerator temp to be between 44 and 46 degrees on observations. The facility did not always document a temperature on the temperature log located in the 2nd floor Rehab med room. Findings include: The facility policy dated 7/24 titled, Storage of Medications documents, in part: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Medications requiring refrigeration or temperatures between 2 [degrees Celsius (C)] (36 [degrees F] and 8 [degrees C] (46 [degrees F]) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medication requiring storage in a cool place are refrigerated unless otherwise directed on the label. The facility policy dated 2/24 titled, Food and Nutrition documents, in part: . Food safety requirements: the facility must- . Store, prepare, distribute and serve food in accordance with professional standards for food service safety. Refrigerator temperature to be between 35 and 41 degrees . Surveyor observed a total of 3 out of the 5 medication rooms in the facility. The facility has 2 refrigerators within each medication room observed. One refrigerator is for medication storage and one refrigerator is for resident food items. Surveyor reviewed the temperature log used by the facility to document each refrigerator temperature two times a day. Surveyor noted that both medication and food refrigerator temperature checks are logged on the same form. Documented at the bottom of the temperature log is the following: Temperatures must be checked [two times a day] of both food and medication refrigerators. They must register between 36-45 degrees F on thermometer in refrigerator where food and meds/vaccines are kept. Surveyor noted that the temperature range located on the temperature log is 36 to 45 degrees F. The facility storage of medication policy documents the range for medication refrigerator should be 36 to 46 degrees F. Surveyor noted that there is not a separate temperature range that staff should follow for the food refrigerator temperature. The facility food and nutrition policy documents that a food refrigerator temperature should be between 35 and 41 degrees. On 5/28/25 at 12:18 PM Surveyor observed the food refrigerator located in the 2nd floor Rehab med room. Surveyor opened the refrigerator door and noted a thermometer gauge in the refrigerator. The thermometer read 44 degrees F. On 5/29/25 at 10:20 AM Surveyor observed the food refrigerator located in the 2nd floor Rehab med room. Surveyor opened the refrigerator door and noted a thermometer gauge in the refrigerator. The thermometer read 46 degrees F. On 5/29/25 at 12:31 PM Surveyor observed the food refrigerator located in the 2nd floor Rehab med room. Surveyor opened the refrigerator door and noted a thermometer gauge in the refrigerator. The thermometer read 46 degrees F. Surveyor noted that within the food refrigerator was: Glucerna and ensure (meal replacement/dietary supplement shake), applesauce, pudding, and juices. Surveyor reviewed the MAY 2025 Medication/Vaccination and Food Refrigerator Temperature Log posted on the door of the medication refrigerator located in the 2nd floor Rehab med room. Surveyor noted the following dates and times that the food refrigerator was above 41 degrees F, which is the facility policy: May 10: 44 degrees F. May 11: 46 degrees F. May 12: 44 degrees F. Surveyor noted that no temperature was logged for the food refrigerator on May 13th. May 14: 45 degrees F. May 15: 45 degrees F. May 16: 45 degrees F. Surveyor noted that no temperature was logged for the food refrigerator on May 17th. May 18: 43 degrees F. May 19: 44 degrees F. May 20: 45 degrees F. May 21: 45 degrees F. Surveyor noted that no temperature was logged for the food refrigerator on May 22nd. May 23: 42 degrees F. May 24: 42 degrees F. May 25: 42 degrees F. May 28: 46 degrees F. May 29 45 degrees F. On 5/29/25 at 12:16 PM Surveyor interviewed Registered Nurse (RN)-C. Surveyor asked who is responsible to check and log the temperatures for the refrigerators in the med room. RN-C stated that nurses are supposed to log the temperature 2 times a day. Surveyor asked what temperature the food refrigerator should be at. RN-C stated that RN-C believed it is supposed to read from 38 to 43 degrees. Surveyor asked what staff should do if the refrigerator temperature is off. RN-C stated that RN-C would put a work order in the TELS system, which would notify maintenance that the refrigerator needs repair. Surveyor asked what is typically in the food refrigerator located in the med room. RN-C stated that there are typically supplements, pudding, applesauce, and other resident food items. On 5/29/25 at 1:43 PM Surveyor interviewed Culinary Services Manager (CSM)-D. Surveyor asked what a food refrigerator temperature should be. CSM-D stated that a refrigerator should be between 34 and 42 degrees F. On 5/29/25 at 2:02 PM Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor asked what the temperatures of the refrigerators in the medication rooms should be. NHA-A gave Surveyor a medication storage policy and stated the refrigerators should be between 36 to 46 degrees F. Surveyor asked if that is the same temperature range for the food refrigerator located in the medication rooms. NHA-A stated NHA-A can find out but NHA-A believed it would be 42 degrees F or below. On 5/29/25 at 3:00 PM NHA-A gave Surveyor the food and nutrition policy which documents food refrigerators should be between 35- and 41-degrees F. Surveyor informed NHA-A and Director of Nursing (DON)-B of the concern that Surveyor observed the food refrigerator located in the 2nd floor Rehab med room multiple times over the last 2 days and noted that the temperatures were above 41 degrees. The temperature log documents that the food refrigerator temperatures have been reading higher than 41 degrees since May 10th. The temperature log was not always filled out. The temperature log does not differentiate what the temperature range is for a food refrigerator and the medication refrigerator. DON-B indicated that they are actively fixing this concern. On 6/02/25 at 8:38 AM Surveyor interviewed NHA-A. Surveyor asked to speak to the maintenance director. NHA-A stated that the Maintenance director is not working today or tomorrow. Surveyor asked NHA-A if a TELS request was placed for a refrigerator anytime during the month of May. NHA-A stated that NHA-A would look into that and get back to Surveyor. On 6/02/25 at 8:58 AM NHA-A stated that NHA-A looked, and NHA-A could not find a work order for a refrigerator to be fixed anytime during the month of May. 06/02/25 10:01 AM Surveyor observed the two med rooms located on the 3rd floor of the facility. Surveyor noted a new temperature log form on both the medication and the food refrigerator. Surveyor noted that the temperature log on the food refrigerator documents that the refrigerator temperature should between 35 to 41 degrees F.

Based Observation and interview, the facility did not ensure the tube feeding pole for 1 (R39) of 1 Residents reviewed for cleanliness of tube feeding equipment, had equipment that was clean and operating in a sanitary manner. Multiple observations were made of R39's tube feeding pole having dried tube feeding splatter and adhered debris to the screen, base of pole and cord. Findings include: On 05/29/2025, at 08:30 AM, R39 asked for the tube feeding to be disconnected. Surveyor observed Licensed Practical Nurse (LPN)-G disconnect R39's tubing, removed the tubing from under R39's bottom while on the commode and then hang the tubing on R39's tube feeding pole. Surveyor noted that R39's tube feeding pole was also covered in crust and unknown matter at the base of the pole and the black power cord had debris built up on it. On 06/02/2025, at 08:41 AM, Surveyor noted that R39's tube feeding pole was still filthy with crusty unknown matter consistent with tube feeding, on the screen, black power cord, and base of pole. On 06/02/2025, at 08:41 AM, Surveyor noted R39's tube feeding pole still had crusty unknown matter, consistent with tube feeding, on the screen, base and black power cord. On 06/02/2025, at 09:27 AM, Surveyor interviewed LPN-E on who is responsible for cleaning the tube feeding poles. LPN-E indicated she was not sure who is primarily responsible but may be third shift or cleaning crew. On 06/02/2025, at 10:06 AM, Surveyor interviewed DON-B regarding the observations of R39's tube feeding pole being unclean. DON-B indicated that housekeeping is responsible for cleaning the tube feeding poles, but the nurse could wipe down and clean after themselves. On 06/03/2025, at 08:16 AM, Surveyor observed R39's tube feeding machine still has unknown splatter on the screen, crust on the black power cord and at the base of the pole. On 06/03/2025, at 08:30 AM, Surveyor interviewed Housekeeping-J. Housekeeping-J indicated that nursing is to clean the tube feeding poles. Housekeeping will clean the tube feeding poles once a resident is discharged out of the room. On 06/03/2025, at 08:32 AM, Surveyor interviewed LPN-E. LPN-E indicated that LPN-E will clean the tube feeding poles at the end of the shift, and each shift should be wiping them down at the end of each shift. On 06/03/2025, at 08:34 AM, Surveyor notified DON-B of observations of R39's unclean tube feeding pole. DON-B indicated that the housekeeping director was notified yesterday to clean the tube feeding machine, and they may just need to get a new one. DON-B will go check R39's machine. On 06/03/2025, at 08:42 AM, Surveyor notified NHA-A notified of above concerns. At time of exit, DON-B indicated that the unknown matter on the screen of R39's tube feeding machine was new and indicated that DON-B would expect staff to clean up after themselves. No further information was provided at time of write up.

Based on observation and interview the facility did not maintain infection prevention and control designed to reduce the transmission of disease and infection for 1 (R39) of 1 resident reviewed for bowel and bladder cares. *On 05/29/2025, Surveyor observed R39 with R39's tubing for their feeding tube under R39 while having a bowel movement, while on R39's bedside commode. Surveyor observed Licensed Practical Nurse (LPN)-G disconnect R39's tubing from R39's feeding tube port, remove the tubing from under R39, hang the tubing back on R39's tube feeding pole, then reconnect R39's tubing to R39's feeding tube port once R39 had returned to R39's chair. On 05/29/2025, Surveyor observed CNA-F clean R39 after a bowel movement, then handed R39 a washcloth with unchanged, dirty gloves, to clean R39's peri area. On 06/03/2025, Surveyor observed CNA-I bring a clear garbage bag of washcloths from the bathroom into R39's room. CNA-I pulled a washcloth from the garbage bag and began wiping R39's buttocks. CNA-I then dropped the clear garbage bag on the floor causing the washcloths to fall onto the floor. CNA-I then picked up a washcloth from the floor and handed the washcloth to R39 so R39 could clean R39's peri area. Findings include: R39 was admitted to the facility on [DATE] with pertinent diagnoses which include, hemiplegia (paralysis of one side of the body) affecting left side and Gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). R39's Annual Minimum Data Set (MDS), dated [DATE], documents R39 is able to understand and be understood, has a Brief Interview for Mental Status score of 15, indicating R39 is cognitively intact. R39 does not exhibit behaviors or rejection of care, has impairment in upper extremity on one side, requires partial/moderate assistance with toileting hygiene and toileting transfers, is frequently incontinent of bowel and bladder. On 05/29/2025, at 08:20 AM, Surveyor observed Certified Nursing Assistant (CNA)-F assist R39 with transferring from R39's reclining chair to R39's bed side commode. Surveyor observed R39 sit directly on R39's tubing for their feeding tube while R39 used the commode. On 05/29/2025, at 08:34 AM, Surveyor observed CNA-F provide cleaning to R39's rectal area after R39 completed a bowel movement. R39 asked CNA-F for a washcloth for R39 to clean R39's peri area with. CNA-F then handed R39 a washcloth using CNA-F's dirty gloves. CNA-F then grabbed R39's cream and applied the cream to R39's buttock with dirty, unchanged gloves. On 05/29/2025, at 10:07 AM, Surveyor checked with R39. Surveyor noted R39's tube feeding was connected to R39 and running. R39 indicated that staff reconnected R39's tube feeding and did not change the tubing prior to reconnecting to R39. On 05/29/2025, at 10:11 AM, Surveyor interviewed Clinical Consultant Director RN-H regarding what Clinical Consultant Director RN-H would expect to be done if a resident sat on their tubing for their feeding tube while using the toilet. Clinical Consultant Director RN-H indicated to Surveyor that she would expect the tubing to be changed and would refer to the policy and procedure because not completely sure if anything else. Surveyor informed Clinical Consultant Director RN-H of the concern regarding R39. Clinical Consultant Director RN-H informed Surveyor that R39's tubing will be changed right away. On 05/29/2025, at 03:01 PM, Surveyor informed the Facility of the above concerns regarding R39. On 05/29/2025, at 12:41 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B informed Surveyor that all staff was educated on how tubing should be disconnected prior to a resident transferring, unless if it's an emergency. On 06/03/2025, at 08:18 AM, Surveyor observed R39 on R39's bedside commode. CNA-I brought a clear, plastic garbage bag with washcloths from R39's bathroom into R39's room. CNA-I then took a washcloth from the clear, plastic garbage bag and wiped R39's rectal area. During this, CNA-I dropped the bag and the remaining washcloths in the bag fell on floor. R39 requested a washcloth for R39's peri area. CNA-I picked up a washcloth from ground and gave it to R39 to use. Surveyor asked CNA-I if washcloths were clean, CNA-I stated, yes.

Based on observation, record review and interview, the facility did not ensure food was stored and prepared safely, in 1 (kitchen on 2nd floor) of 2 kitchens. This deficient practice has the potential to affect residents residing on 2 East who receive their meals from the second-floor kitchenette. *Cook-C used gloved hand to touch ready to eat food after touching multiple surfaces. Findings: The facility policy, entitled Food Safety Requirements - Use, Storage, Procurement, dated 1/2018, states: It is the policy of this Milwaukee Catholic Home to provide safe and sanitary storage, handling, and consumption of all foods including those brought to residents by family and other visitors. Factors implicated in foodborne illnesses: Poor personal hygiene - personal health and hygiene are significant factors in preventing foodborne illness .Proper hand washing techniques and exclusion of infectious workers from handling food are critical for prevention of foodborne illness. On 02/08/24 at 07:49 AM, Surveyor along with Director of Dining Services-E observed Cook-C in the second-floor kitchenette prepare and serve food to residents on 2 East. Cook-C was observed to wash hands and don gloves. She then approached the steam table and began sorting through meal tickets, placing them on the shelf ticket holder. Cook-C then grabbed a plate with same gloved hand and scooped hashbrowns, grabbed a sausage patty with gloved hand, chopped it with knife to bit size pieces and then grabbed French toast with gloved hand. Cook-C then grabbed the meal ticket and placed it under the plate and then placed the plate on the plate warmer shelf. Cook-C then grabbed French toast with gloved hand, scooped scrambled eggs, grabbed bacon with gloved hand and then grabbed the meal ticket and placed it under the plate and then placed the plate on the plate warmer shelf. Cook-C grabbed French toast with gloved hand and scooped scrambled eggs, grabbed the meal ticket and placed it under the plate and placed the plate on the plate warmer shelf. This pattern continued for two more plates where Cook-C picked up French toast and a pancake with gloved hand and then wiped gloved hands down the front of apron. Cook-C then grabbed another bunch of meal tickets and began to sort through them with the same gloved hands. At 08:00 AM, Cook-C opened the refrigerator door with gloved hands to get out yogurt and began to scoop yogurt into cups. Cook-C then used gloved hands to grab mixed fruit from a container to add to the top of the yogurt cups. Cook-C did this multiple times to fill 5 yogurt parfaits. Cook-C then returned to the steam table to continue to make resident food. Cook-C grabbed a pancake with gloved hand, scooped scrambled eggs and grabbed bacon with gloved hand. She proceeded to do this for two more plates of food. Cook-C then opened a bread bag and removed 4 slices of bread with gloved hand and put in toaster. Cook-C then went to prep table and used gloved hand to pick up a handful of diced tomatoes and placed them into a cup and used gloved hand to pick up diced mushrooms and placed then into a cup. The Cook then placed the tomatoes and mushroom on the grill and proceeded to crack three eggs. It was at this point Cook-C then stopped and removed the gloves, washed hands and donned new gloves. On 02/08/24, at 08:13 AM, Surveyor spoke with Director of Dining Services-E and asked what the expectation was for plating pancakes, French toast, bacon and sausage. Director of Dining Services-E stated that a barrier should be used at all times. She stated that she too, observed Cook-C picking up prepared food with a gloved hand and verified that tongs should have been used. Director of Dining Services-E stated that she would provide immediate corrective education and provide Surveyor with a policy.

Based on observation, interview and record review the facility did not revise resident care plans for 2 (R84 and R25) of 20 resident care plans reviewed. *R84 developed a facility acquired stage 3 pressure injury to the right buttock. R84's care plan was not revised to include interventions for the stage 3 pressure injury. *R25 developed a facility acquired stage 2 pressure injury to the left heel. R25's care plan was not revised to include interventions for the stage 2 pressure injury. Findings include: The facility's policy entitled, Comprehensive Care Plan, revised date 9/2023, states: Each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs. #6. The resident's care plan will be reviewed after each assessment, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. #7. The resident's care plan will include services provided or arranged by the facility. 1. R84 was admitted to the facility on [DATE] for aftercare following a fall with fracture. R84 also has diagnoses that include, parkinsonism, type 2 diabetes, chronic kidney disease and anemia. R84's Quarterly MDS (Minimum Data Set) assessment, dated 1/10/24, indicates that R84 is at risk for development of pressure injuries. BIMS (Brief Interview of Mental Status) score of 15 indicates R84 is cognitively intact. A BRADEN score taken on 11/15/23 documents a score of 17 indicating R84 is at risk for pressure injuries. On 02/08/24, at 09:39 AM, during the screening process R84 was observed sitting up in a chair in their room. R84 stated that they had been in the facility for several months recovering from a fall. R84 stated that they did have an open sore on their buttock and sees the wound doctor. Surveyor reviewed R84's progress notes. On 1/31/24 a wound note was documented. It documents, Dr.-K saw resident 1/30/24 for right buttock wound. New order received. Surveyor reviewed R84's physician orders documented as Cleanse open area to right upper butt with soap and water f/b (followed by) xeroform and cover with mepilex daily, start 1/30/24. And Cleanse wound on right buttock with wound cleanser. Xeroform gauze f/b foam border dressing once daily. start 1/31/24. Surveyor reviewed R84's initial wound note dated 1/30/24 which documents, initial wound evaluation, stage 3 to the right buttock measuring 1cm x 1.5cm x 0.1 cm with moderate serous and 100% granulation tissue. Surveyor reviewed R84's care plan and was unable to locate a care plan for a pressure injury to buttock. On 02/12/24, at 01:05 PM, Surveyor spoke with RN Manager-D who informed Surveyor that floor nurses as well as nurse managers are responsible for updating care plans for residents. She started that typically RN Managers are responsible for ensuring that care plans are audited and that interventions are appropriate. Surveyor asked if a facility acquired stage 3 pressure injury should be included in a care plan. RN Manager-D stated, absolutely, it is a change in skin condition. Surveyor informed RN Manger that they were unable to locate a care plan for R84 and the stage 3 pressure injury to buttock. RN Manager-D stated they would look into it. On 02/12/24, at 02:10 PM, at the end of day meeting with Nursing Home Administrator ([NAME])-A and Director of Nursing-B (DON), Surveyor shared a concern regarding R84 and the lack of a care plan for the facility acquired stage 3 pressure injury to buttock. DON-B stated that it would be best practice to include that pressure injury within the plan of care. Surveyor requested a care plan policy and procedure. No further information was provided as to why R84's care plan was not revised after the development of a facility stage 3 pressure injury. 21855 2. R25 was admitted to the facility on [DATE] with diagnoses that include hemiplegia unspecified affecting right dominant side, type 2 diabetes mellitus, pressure ulcer of left heel - unstageable, pressure ulcer of left and right buttock - stage 2, cognitive communication deficit, and muscle weakness. The Quarterly MDS (Minimum Data Set) dated 1/3/2024 indicates R25 has a BIMS (Brief Interview for Mental Status) of 15, indicating cognitively intact for daily decision making. R25 is dependent on a caregiver for eating, oral hygiene, toileting, bathing, and upper/lower body dressing. R25 does not have an activated Power of Attorney. On 02/07/24 at 10:36 AM Surveyor reviewed R25's skin assessment dated [DATE] which revealed that an open area to the left heel was discovered as a new skin problem. A description of the skin problem states: resident had bed bath this shift o/a left heel was noted area was cleaned f/b xeroform dressing and mepilex wound doctor to f/u tomorrow. On 02/07/2024 R25's care plan for impaired skin integrity related to incontinence, impaired mobility was reviewed dated 8/21/2021 with most recent interventions added 1/3/2024 to include: - Pressure reduction sitting/wheelchair surface applied 8/20/21 -Complete risk assessment for R25 as per protocol -Heel boots to both feet when in bed. Occ refuses -Wound consult PRN On 02/08/24 at 01:22 PM Surveyor spoke with DON (Director of Nursing)-B who stated they were just notified today that R25 has a pressure injury on left heel. On 02/08/24 at 01:50 PM Surveyor spoke with RN (Registered Nurse) Case Manager-F who stated facility was made aware at noon today of the pressure injury. LPN (Licensed Practical Nurse)-G found it and did not notify manager or supervisor, as per facility protocol, so assessment could be done. Per RN Case Manager-F, R25 had a pressure injury there a couple years ago but does not like boots or to offload heels, likes to lay on back. Also, RN Case Manager-F stated that R25's weight was stable because gets a supplement. Surveyor noted no new interventions were added to the care plan after discovery of the pressure injury to left heel on 1/29/2024, until 2/8/2024. At this time a problem of potential for inadequate energy/protein intake r/t self feeding deficit aeb (as evidenced by) max assist 1:1 feeding for all meals and chronic poor skin integrity was added. With interventions effective 2/8/2024 to include: - Monitor skin integrity -Allow adequate time to eat; provide cues; encouragement, and assistance -Assess/record/report to MD s/x of malnutrition, factors interfering with nutrition, significant width loss -Encourage food/fluid intake during food related activities -Provide diet/texture/supplement as ordered -Record and monitor meal/fluid/supplement intake -Obtain and monitor weights as ordered -Report any swallowing problems to RN, MD, ST and/or RD. Will intervene and TX prn On 02/08/24 at 03:05 PM during the end of day meeting the lack of revision of care plan concerns were shared with NHA (Nursing Home Facilitator) -A and DON-B. No additional information was provided.

Based on record review and interview, the Facility did not ensure the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist, and that irregularities identified by the pharmacist were reviewed, and action taken to address the identified concerns. This was observed with 1(R14) of 5 residents reviewed for medication regimen review. * R14 did not have monthly Pharmacy Medical Record Reviews completed and recommendations reviewed by the attending physician or Medical Director. Findings include: The Facility policy titled Medication Regimen Review (MRR) last approved 8/17/2023 documents (in part): Procedure 1. The Consultant Pharmacist will conduct MRRs if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record . 7. The pharmacist will address copies of residents' MRRs to the Director of Nursing and the attending physician and to the Medical Director. Facility staff should ensure that the attending physician, Medical Director, and Director of Nursing are provided with copies of the MRRs 8. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR 8.1 For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept or act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 8.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. R14 was admitted to the facility on [DATE] with diagnoses which include other specified anxiety disorders, chronic kidney disease with heart failure and stage five chronic kidney/end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with diabetic neuropathy, glaucoma, failure to thrive, and atrial fibrillation. The Quarterly MDS (Minimum Data Set) dated 1/10/2024 indicates R14 has a BIMS (Brief Interview for Mental Status) of 15, indicating cognitively intact. R14 needs partial to moderate assistance with bathing, dressing upper body and transfers. R14 needs substantial to maximum assistance dressing lower body and putting on/taking off footwear. R14 uses a manual wheelchair for locomotion. On 02/12/24 at 12:38 PM Surveyor reviewed R14's electronic medical record. The monthly drug regiment pharmacist consultant review/reports (or MRR) were not in the medical record. The Facility did not receive a monthly pharmacist medication review report from the admitted [DATE] till date of survey, when issue was brought to the Facility's attention by Surveyor requesting the information. On 02/12/24 at 02:21 PM Surveyor spoke with DON (Director of Nursing)-B who stated that the consultation reports for November and December were not done for R14. The pharmacist consultant changed, the previous retired, and R14 was somehow missed. The new pharmacy consultant was able to send the Facility a combined November and December drug regimen review as well as a January 2024 review today (2/12/2024). The November 1, 2023, through December 31, 2023, pharmacist consultation report was provided to the Surveyor on 02/12/24 at 02:21 PM which included the recommendation to discontinue PRN Lorazepam or specify a finite duration of medical need (e.g., stop date) and specify an indication for use (anxiety). The facility would have identified the concern with the Lorazepam prior to Surveyor bringing this to the facility's attention had they received the November through December pharmacist consultation report. Per DON-B, once received (on 2/12/24), the physician for R14 reviewed the pharmacist's recommendations and gave verbal orders with follow through on the recommendations. The physician's orders were provided 02/12/24 at 02:57 PM for the five resulting medication recommendations and were dated 2/12/2024. In regards to a PRN Lorazepam order, on 2/12/2024 the physician ordered change to QD (once a day), PRN X60 days. Per DON-B to ensure this does not happen again the Facility will go through census and make sure everyone gets included monthly for correction. On 2/13/2024 at the facility exit meeting these concerns were shared with NHA (Nursing Home Facilitator) -A and DON-B. No additional information was provided.

Based on interview and record review the facility did not ensure 2 (R82 and R14) of 3 resident were free from PRN (as needed) psychotropic medications. * On 12/28/23 R82 was prescribed Lorazepam (anti-anxiety medication) 1 mg every two hours PRN without a stop date. * On 10/17/23 R14 was prescribed Lorazepam 0.5 mg twice daily PRN without a stop date. Findings include: Surveyor reviewed the facility's Policy and Procedure, Psychotropic Medications dated 11/2022, noting the following as applicable: PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN anti-psychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication. The goal is to monitor the resident's outcome, quality of life and functional capacity, while using psychotropic medications only when needed to treat a specific condition that is diagnosed and documented. In addition, providing an interdisciplinary collaborative process to implement a resident-centered plan of gradual dose reductions, non-pharmacological interventions, monitoring and action with PRN orders for psychotropic medications, will assist the care team to identify that their use is limited and necessary. Psychotropic drugs include but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. PRN orders for psychotropic drugs are limited to 14 days. The resident will be monitored for the behavior, non-pharmacological interventions and outcome, and use of the psychotropic drug to report to physician. If the physician believes that the PRN order should be extended beyond the 14 days, the physician must document rationale in the medical record. If the PRN is an antipsychotic medication, the medication will be limited to 14 days and not renewed unless the physician evaluates the resident for appropriateness of the medication and documents in the medical record. 1. R82 was admitted to the facility on [DATE] with diagnosis of palliative care, Alzheimer's disease, and depression. Surveyor reviewed R82's physician orders and noted on 12/28/23 Lorazepam 1 mg every two hours PRN for anxiety/terminal restlessness was prescribed with no stop date. On 2/12/24 at 2:13 pm, during the daily exit meeting with Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A, Surveyor explained the concern with R82 having an order for Lorazepam (a psychotropic medication) 1 mg every two hours PRN with no stop date. DON-B indicated someone must have missed the end date when ordering Lorazepam. Surveyor requested additional information if available. On 2/12/24 at 2:53 pm, RN Manager-H notified Surveyor she forgot to put the end date on the order for the Lorazepam 1 mg every two hours PRN and has corrected the order to include an end date. 2. R14 was admitted to the facility on [DATE] with diagnoses which include other specified anxiety disorders, chronic kidney disease with heart failure and stage five chronic kidney/end stage renal disease, dependence on renal dialysis, type two diabetes mellitus with diabetic neuropathy, glaucoma, failure to thrive, and atrial fibrillation. The Quarterly MDS (Minimum Data Set) dated 1/10/2024 assesses R14 as having a BIMS (Brief Interview for Mental Status) of 15, indicating cognitively intact. R14 needs partial to moderate assistance with bathing, dressing upper body and transfers. R14 needs substantial to maximum assistance dressing lower body and putting on/taking off footwear. R14 uses a manual wheelchair for locomotion. Surveyor reviewed R14's physician orders and noted on 10/17/2023 Lorazepam 0.5 mg tablet as needed two times daily was prescribed. The order does not have a stop date for the medication. Surveyor noted according to the State Operations Manual, the need to limit the timeframe for PRN psychotropic medications, which are not antipsychotic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner. The Facility did not receive a monthly pharmacist consultation report from admitted (10/4/23) till date of survey, when brought to the Facility's attention, which would have identified a concern with the Lorazepam. The November 1, 2023, through December 31, 2023, pharmacist consultation report was provided to the Surveyor on 02/12/24 at 02:21 PM with the recommendation to discontinue PRN Lorazepam or specify a finite duration of medical need (e.g., stop date) and specify an indication for use (anxiety). The physician response was provided 02/12/24 at 02:57 PM and was dated 2/12/2024 indicating change to QD, PRN x 60 days. (Cross reference F756) Surveyor reviewed the October MAR (Medication Administration Record) and during the 14 days from order date PRN Lorazepam was given 6 times. In November per the MAR (after the 14 day recommendation) PRN Lorazepam was given 14 times. Administration continues monthly until 2/12/2023 when the order was fixed. On 02/12/24 at 02:21 PM Surveyor spoke with DON (Director of Nursing)-B who stated that the consultation reports for November and December were not done for R14. The pharmacist consultant changed, previous retired, and R14 was somehow missed. The new consultant was able to send but the Facility did not get November or December till today (2/12/2024). Per DON-B to ensure this does not happen again the Facility will go through census and make sure everyone gets included monthly for correction. On 2/13/2024 at the facility exit meeting these concerns were shared with NHA (Nursing Home Facilitator) -A and DON-B. No additional information was provided.

Based on observation, interview, and record review the facility did not ensure a resident received routine dental services for 1 (R1) of 1 resident reviewed for dental services. The facility did not arrange routine dental services for R1. Findings include: The facility policy entitled Dental Services revised on 1/2024 states: The facility will assist residents in obtaining routine and 24-hour emergency dental care. PROCEDURE: 1.The facility- a.Will provide or obtain from an outside resource, the following dental services to meet the needs of each resident: i. routine dental services (to extent covered under the State plan) . b.Will, if necessary or if requested, assist the resident- i. In making appointments; and ii. By arranging for transportation to and from the dental services locations. R1 was admitted to the facility on [DATE] and has diagnoses that include dysphagia- oropharyngeal phase (difficulty swallowing), dementia, anxiety disorder, altered mental status, anorexia (lack or loss of appetite for food), and cognitive communication deficit. R1's quarterly minimum data set (MDS) dated [DATE] indicated R1 had intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R1 needing set up assistance with eating and oral hygiene, had upper and lower dentures, and indicated no concerns with R1's oral dental status. On 2/7/2024 at 9:38 AM Surveyor observed R1 sitting in R1's recliner chair without dentures in R1's mouth. Surveyor asked R1 if R1 had any concerns with R1's dentures. R1 stated there were no concerns but did not wear the dentures all the time by choice. Surveyor asked R1 if the dentures fit properly in R1's mouth. R1 stated that they did but R1 has not seen a dentist since being admitted to the facility. Surveyor asked R1 if R1 would like to see a dentist. R1 replied that R1 has no concerns but would be nice to see a dentist. Surveyor reviewed R1's medical record and was unable to locate a dental consultation for R1. On 2/13/2024 at 9:43 AM Surveyor interviewed Director of Nursing (DON)-B who stated a Dentist would come to the facility to do routine dental exams on the residents but has stopped going to the facility since COVID-19 in 2020. DON-B stated the facility is trying to find another dentist who will go to the facility for residents' routine oral exams. Surveyor asked DON-B if any resident has seen a dentist since 2020. DON-B stated that if a resident requests to go out to see the dentist or is having an issue that needs attention, then an appointment is made. DON-B stated Social Services (SS)-I assists in making appointments if needed or requested. On 2/13/2024 at 11:33 AM Surveyor interviewed SS-I who stated if a resident wants to see a dentist, the family will make arrangements for the appointment. Surveyor asked SS-I what happens if the family is not aware of the need for a routine dental appointment. SS-I stated that it is reviewed at quarterly reviews and care conferences. Surveyor asked SS-I if a routine dental exam for R1 has ever been brought up or suggested at R1's quarterly review or care conference. SS-I stated SS-I does not recall if it has ever been brought up or discussed with R1's family. SS-I stated SS-I is not aware of R1 having any issues or concerns with her dental care. On 2/13/2024 DON-B and Nursing Home Administrator (NHA)-A were made aware of Surveyors concerns that R1 was not provided with routine dental services. No further information was provided at this time.

Based on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1 of 9 (R25) residents reviewed for pressure injuries. * R25 did not have a comprehensive assessment with measurements or treatment put in place when a new stage two pressure ulcer of left heel was discovered on 1/29/2024 and was missing weekly assessments and measurements for 10 days until 2/8/2024. R25 was observed to not have heels supported off the bed or heel boots on during this time. Finding include: The facility policy titled Pressure Injury Documentation Sheets with a revision date of 11/2022 documents in part: Policy: It is the policy of facility to have documentation for all pressure related injuries. These sheets will enable staff to evaluate progress on a weekly/PRN basis. Procedure: 1.Wound measurements will be done weekly by the Certified Wound Nurse or designee. Documentation will be noted on the Wound Assessment form in EMR . 3. Progress of any pressure related injuries will be re-evaluated by the Certified Wound Nurse or designee weekly and/or PRN. Physician and resident's representative will be updated as indicated. Documentation of MD notification will be recorded on the Skin Intervention Team Summary. 4. Information regarding presence of pressure related injuries will be transferred to the care plan. Follow protocol for staging. 5. The Unavoidable Pressure Injury Tool is completed with newly acquired pressure injuries. R25 was admitted to the facility on [DATE] with diagnoses that include hemiplegia unspecified affecting right dominant side, type 2 diabetes mellitus, pressure ulcer of left heel - unstageable, pressure ulcer of left and right buttock - stage 2, cognitive communication deficit, and muscle weakness. R25 does not have an activated Power of Attorney. The Quarterly MDS (Minimum Data Set) dated 1/3/2024 indicates R25 has a BIMS (Brief Interview for Mental Status) of 15, indicating cognitively intact for daily decision making. R25 is dependent on a caregiver for eating, oral hygiene, toileting, bathing, and upper/lower body dressing. R25 transfers with a hoyer lift. R25 had a Braden Scale for Predicting Pressure Sore Risk evaluation done on 1/3/2024 and scored a 12, putting R25 at high risk of developing a pressure injury. The evaluation was repeated on 2/8/2024 and R25 scored a 12 again. R25 has a potential for impaired skin integrity care plan in place effective 8/21/2021. Appropriate interventions implemented include (in part): -Air mattress pressure reduction support surface in bed, effective 8/20/2021. -Pressure reduction sitting/wheelchair surface, effective 8/20/2021. -Reposition R25 every 2 hours when in bed and with rounds and as needed - as will allow, prefers to lay on back, effective 8/21/2021 -Assist R25 with repositioning every 2 hours in bed, with rounds and as needed. Utilize pillow/support devices if needed to protect bony prominences as he will allow, prefers to lay on his back, effective 9/20/2022. -Encourage R25 to wear heel boots to both feet when in bed, often refuses, effective 11/3/2021. Surveyor noted no care plan interventions added between 1/29/2024 and 2/8/2024. Through record review Surveyor noted the MAR (Medication Administration Record) for February 2024, R25 has an order for Ensure Plus three times daily starting 2/2/2024 for nutrition and skin integrity. Per the Treatment record for February 2024 there are no interventions in place for or to prevent heel pressure injuries. In the Physician Orders for February 2024 there is an order to apply heel boots to both heels dated 8/20/2021. On 02/07/24 at 9:30 AM Surveyor observed R25 who had no heel boot on either foot, socks were on feet, resting on bed, R25 was on his back in high fowlers position. On 02/08/24 at 09:25 AM Surveyor observed R25 resting on back in high fowlers position in the bed with bare feet directly on bed. Surveyor noted in both observations heels were not supported off the bed or heel boots in place per care plan and Physician Orders. On 02/07/24 at 10:36 AM Surveyor reviewed R25's skin assessment on the electronic medical record dated 1/29/2024, completed by LPN (Licensed Practical Nurse)-G, which revealed that an open area to the left heel was discovered as a new skin problem. A description of the skin problem states: resident had bed bath this shift o/a left heel was noted area was cleaned f/b xeroform dressing and mepilex wound doctor to f/u tomorrow. On 2/8/2024 at 11:41am Surveyor requested R25's wound documentation for January and February and was provided R25'skin integrity reports and the Wound Evaluation and Management Summary for January, no documents for February. Surveyor noted no previous finding of current left heel pressure injury open area until 1/29/2024. After the 1/29/2024 initial assessment, there was no comprehensive assessment or measurements completed until 10 days later on 2/8/2024. On 2/8/2024 the Initial Wound Assessment provided shows a stage two pressure injury to the left heel, facility acquired. The length was 0.20 and width 0.20 with no depth. Zero percent slough and 99% granulation with a pink color. This was completed by RN (Registered Nurse) Manager-F on 2/8/2024 at 1:11pm. On 02/08/24 at 01:22 PM Surveyor spoke with DON (Director of Nursing)-B who stated they were just notified today that R25 has a pressure injury on left heel. On 02/08/24 at 01:33 PM Surveyor spoke with LPN-G who stated forgetting to report the pressure injury but was doing the treatments. LPN-G stated having a verbal order from nursing manager for heel treatment of xeroform and mepilex. Per LPN-G R25 missed wound doctor on Tuesday due to going out for lunch. LPN-G states found out Tuesday this week but forgot to put the order in the computer. Did treatment last 2 days. LPN-G states the protocol would be for Nurse Manager to put order in computer. LPN-G told Surveyor the doctor and POA were not notified on the day found. On 02/08/24 at 01:33 PM Surveyor observed R25's right heel which had no wound and the stage two pressure injury to R25's left heel after the heel boot and dressing were removed. LPN-G cleaned skin around area, then completed the treatment of xeroform and mepilex to left heel, dated the dressing, and put heel boot back on. On 02/08/24 at 01:50 PM Surveyor spoke with RN Manager-F who stated facility was made aware at noon today of the pressure injury. LPN-G found it and did not notify manager or supervisor, as per facility protocol, so assessment could be done. RN Manager-F notified the doctor, and a verbal order was received. RN Manager-F started the wound assessment and unavoidable pressure injury paperwork. Per RN Manager-F, R25 had a pressure injury there a couple years ago but does not like boots or to offload heels, likes to lay on back. Surveyor noted R25 had a stage two pressure injury that was discovered on 1/29/2024 which was not comprehensively assessed until 2/8/2024. At this time orders were placed for treatment protocol. There was a 10-day lapse before the pressure injury was assessed and treatment orders obtained. Surveyor noted observations on 2/7/2024 and 2/8/2024 where resident's heels were directly on bed, no heel boots on or feet supported off bed. On 02/08/24 at 03:05 PM during the end of day meeting these pressure injury concerns were shared with NHA (Nursing Home Facilitator)-A and DON-B. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that 2 (R14 and R46) of 3 residents reviewed received dialysis services consistent with professional standards of practice. * R14 was admitted to the facility needing dialysis and did not have physician orders for hemodialysis and frequency of the dialysis. There was no communication between the facility and the dialysis facility with each visit. * R46 did not have a physician's order documenting the frequency of dialysis treatments or the location of the dialysis center in the community. There was no communication between the facility and the dialysis center with each visit. Findings include: The facility policy entitled Dialysis Services revised on 1/2024 states: [Facility name] will work collaboratively with the resident's dialysis center to ensure a unified coordination of services. Procedure: . 4. Facility will send a consult sheet along with resident to appointments for communication purposes. 5. Facility will collaborate with dialysis facility regarding resident's weights, labs, medications, vital signs, fluid status and other necessary measures. 6. Any changes in the resident's condition will be communicated to the resident's physician, dialysis center, and the resident's representative. 1. R46 was admitted to the facility on [DATE] and has diagnoses that include end stage renal disease, dependence on renal dialysis, anemia in chronic kidney disease, chronic kidney disease stage 5, and dementia. R46's admission minimum data set (MDS) dated [DATE] indicated R46 had moderately impaired cognition with a brief interview for mental status (BIMS) score of 9. Dialysis is checked while a resident. R46's care plan documents, Need for enhanced barrier precaution during direct cares related to subclavian hemodialysis catheter initiated 12/20/2023 and revised on 1/11/2024 with the following interventions: - Monitor weights. - Keep dressing clean, dry, and intact. Dressing changes will be done by dialysis nurse when out to dialysis. - Monitor for signs and symptoms of infection around subclavian hemodialysis catheter. - Monitor labs ordered by Medical Doctor (MD). R46's Resident Summary that the certified nursing assistants use for guidance on providing cares for resident's documents: - Dialysis Monday, Wednesday, Friday (M, W, F) - Do not take to dining room for lunch on dialysis days - Feed (R46) [residents name] early in the nurse's station or send bag lunch to dialysis. Surveyor reviewed R46's physician orders: -FYI Hemodialysis: Dialysis double lumen ports. Do not touch Hemodialysis ports to the right side of her chest. If dressing is not intact call the supervisor. (Order date 12/15/2023) Surveyor could not locate dialysis communication in R46's electronic medical record or a physician order for R46's dialysis documenting the frequency of dialysis treatments, or location of the dialysis center. Surveyor asked Nursing Home Administrator (NHA)-A if there were dialysis binders on the units. NHA-A stated the facility does not have binders, but packets are sent with residents for dialysis. NHA-A stated it is hard to get the packets back and the dialysis centers do not fill out the communications sheets. NHA-A stated it has been an ongoing battle to get the sheets filled out. Surveyor received patient summary reports from [dialysis facility] that were faxed to the facility on [DATE] at 3:04:43 PM. Surveyor noted that the patient summary report was not provided or obtained at the end of each dialysis treatment and the report did not provide before and after assessments to the facility on the day of treatment. On 2/13/2024 at 8:48 AM Surveyor shared concerns with Director of Nursing (DON)-B that Surveyor could not locate a physician order or communication notes for R46 dialysis. DON-B stated if there is not an order in the medical chart then DON-B would have to get that from R46's physician. DON-B stated that it is hard to get communication from the dialysis center. DON-B stated requesting the communication forms from dialysis is not something the facility has been asking the dialysis center for but understands there still has to be communication between the facility and the dialysis center. No further information was provided at this time. 21855 2. R14 was admitted to the facility on [DATE] with diagnoses of peripheral vascular disease, chronic kidney disease with heart failure and stage five chronic kidney/end stage renal disease, dependence on renal dialysis, other specified anxiety disorders, type two diabetes mellitus with diabetic neuropathy, glaucoma, failure to thrive, and atrial fibrillation. The Quarterly MDS (Minimum Data Set) dated 1/10/2024 indicates R14 has a BIMS (Brief Interview for Mental Status) of 15, indicating cognitively intact. R14 needs partial to moderate assistance with bathing, dressing upper body and transfers. R14 needs substantial to maximum assistance dressing lower body and putting on/taking off footwear. R14 uses a manual wheelchair for locomotion. R14 receives dialysis services at [name] Dialysis Center three times a week. Through record review Surveyor determined there weren't any physician orders regarding R14's hemodialysis and frequency/days of such. A discharge summary from hospital to facility dated 10/4/2023 has discharge instructions that include continue outpatient dialysis as per Tue/Th/Sat schedule and follow up with Dr. [name] for your ERSD (End Stage Renal Disease), no physician orders were obtained. On 02/13/2024 at 08:51 AM Surveyor spoke with DON (Director of Nursing)-B who stated if not in the computer they do not have orders for days of dialysis. On 02/13/2024 at 08:51 AM Surveyor spoke with DON-B who indicated the Facility was working on finding communication for dialysis. DON-B stated it was hard to get them (dialysis) to fill out the form, so hard to get communication. DON-B stated it has become an ongoing battle, but if there is a change, they (dialysis) will call nurses on floor to update. On 02/13/24 at 09:10 AM the Facility provided four consultation forms completed by [name] Dialysis Center dated 1/2/2024, 1/25/2024, 2/8/2024 and 2/10/2024. Surveyor noted no other pre or post assessment documentation for other appointments was provided. On 02/13/24 at 09:50 AM the Facility provided treatment details reports from [name] Dialysis Center for February, which were faxed on 2/13/2024 to the facility, not provided at end of each appointment. Surveyor noted this does not provide before and after assessments to the facility on the day of treatment. The Facility was unable to provide Surveyor with a dialysis order. In addition, the Facility was unable to provide Surveyor with evidence of ongoing communication and collaboration between the Facility and the dialysis center regarding dialysis care and services for R14. On 2/13/2024 at the facility exit meeting these concerns were shared with NHA (Nursing Home Facilitator) -A and DON-B. No additional information was provided.

Based on interview and record review the Facility did not notify a Resident's representative and attending physician when there was a change of condition involving 1 (R25) of 20 residents reviewed for notification of a representative. * R25 developed a stage 2 pressure injury to the left heel. There was no documentation R25's representative or attending physician were updated when the change of condition occurred. Findings include: Facility policy entitled, Pressure Injury Protocol, last revised 2/2023 states: Stage 2 Pressure Injury . L. Keep physician and resident's representative advised of current treatment plan. Surveyor noted according to the State Operations Manual, S483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- . (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). R25 was admitted to the facility on [DATE] with diagnoses that include hemiplegia unspecified affecting right dominant side, type 2 diabetes mellitus, pressure ulcer of left heel - unstageable, pressure ulcer of left and right buttock - stage 2, cognitive communication deficit, and muscle weakness. R25 has a responsible party listed as his representative to contact. The Quarterly MDS (Minimum Data Set) dated 1/3/2024 indicates R25 has a BIMS (Brief Interview for Mental Status) of 15, indicating cognitively intact for daily decision making. R25 is dependent on a caregiver for eating, oral hygiene, toileting, bathing, and upper/lower body dressing. On 02/07/24 at 10:36 AM during record review of the electronic medical record Surveyor noted there was no documentation R25's resident representative and attending physician were updated regarding the development of a stage 2 pressure injury to the left heel, discovered on 1/29/2024. On 02/08/24 at 01:22 PM Surveyor spoke with DON (Director of Nursing)-B who stated they were just notified today that R25 has a pressure injury on heel. No documentation that the resident representative or attending physician were notified could be provided. On 02/08/24 at 01:33 PM Surveyor spoke with LPN (Licensed Practical Nurse)-G who confirmed the doctor and representative were not notified then (1/29/2024) when pressure injury to left heal was discovered by LPN-G. On 02/08/24 at 03:05 PM during the end of day meeting these concerns were shared with NHA (Nursing Home Facilitator) -A and DON-B. No additional information was provided.

Based on observation, interview, and record review, the facility did not follow proper sanitation in accordance with professional standards for food service safety to ensure dishes and utensils were properly sanitized by the facility's dishwashing machine. This had the potential to affect all 100 Residents who receive nutrition orally from food prepared in the kitchen. This is evidenced by: The facility is using the Champion brand pro series Standard Rack Conveyor Dishwasher. Surveyor conducted a review of the operation, cleaning, and maintenance manual on 10/24/22. The following was noted for Sequence of Operation: ( includes) 3.) The incoming wash temperature displays in the Wash *F ( Fahrenheit) box. The final rinse temperature displays in the Rinse * F box during the final rinse, the final rinse temperature display is blank at all times. 4.) READY: the status bar indicated Ready when the machine is full of water. WAIT FOR THE WASH TEMPERATURE to read 160 degrees before inserting a dish rack into the machine. 5.) Slide a dish rack into the machine until the wash pump(s) start. The conveyor will catch the rack and move it through the machine. The minimum wash temperature displayed must be 160 degrees when the rack is in the wash zone. The final rinse temperature displayed when the dish rack is in the final rinse zone must be 180 degrees. The dishwasher runs for 90 seconds for one rack, inserting additional racks continues the automatic operation until the last rack exits the machine. On 10/19/22 at 09:24 AM, Surveyor conducted a tour of the facility's kitchen with VP Culinary Services- C. At this time, Surveyor made an observation of dietary staff washing the dishes from the breakfast meal. Surveyor made observations of Dietary Staff- D load a plastic tray full of glassware and insert into the dishwasher (Champion Brand). At this time it was observed that the digital read out of the wash temperature indicated it was at 154 degrees. Observations were made of 4 trays full of glassware and utensils and plates that had already gone through the dish machine and were waiting to be dried and put away. Surveyor asked Dietary Aide- D what was the wash temperature suppose to be for this dishwasher. Dietary Aide answered 160 degrees. Surveyor asked Dietary Aide if he was aware that the machine is stating the wash temperature is only at 154 degrees. Dietary Aide stated that the wash temperature was at 160 degrees when he started this morning. Surveyor asked how many trays of dishes have gone through this morning and Dietary Aide- D stated that he has sent through many trays already. Surveyor then asked Dietary Aide- D how he knows that the dish machine is working appropriately if the temperature is not reaching 160 degrees for the wash on the digital readout. Dietary Aide- D stated that the water is very hot and he put his arm in the machine earlier and it felt really hot. Dietary Aide- D stated that he will also use the temperature test strips. Surveyor asked Dietary Aide- D to stop putting dishes through the machine and to do a test strip and a test tray to make sure the wash temperature was correct. Dietary Aide- D was unsure how to utilize the test strip, placing the test strip directly onto the tray and saturating the strip so the results were unable to be read. Dietary Aide - D did this 3 times before Surveyor asked him to clarify the instructions on the test strip container. VP of Culinary Services - C then stated that the rinse is over 180 degrees so it does not matter that the wash temperature is not hot enough. Surveyor stated its a 2 part system and the wash and rinse need to be of correct temperature, per the operation manual. Surveyor requested a new test strip. Test strip put through per directions under glass in the fork prongs. Test strip did not indicate the water was reaching 160 degrees. Surveyor told staff to stop doing the dishes and contact dish machine manufacturer to ensure the dish machine is appropriately working. Surveyor reviewed the dishwasher temperature log for October, 2022. Each entry indicated that the wash temperature was 160 degrees. On 10/19/22 1:40 p.m., interview with Administrator- A who stated that a company was here to evaluate the dishwasher. The unit burned up stated that contactor had burned up and the part will be shipped over night and will be repairing the machine in the morning. The facility will continue to use plastic utensils etc. for dinner services. On 10/19/22 observations were made of the facility staff using disposable utensils and plates for meal service due to the dish machine not working properly. On 10/24/22, Administrator- A reported to Surveyor that the dish machine was not working as it should have been due to contactor that had malfunctioned. This piece was replaced and the dish machine is now working per the manufacture recommendations for use. On 10/24/22 at 11:10 a.m., Surveyor observed the dish machine in use and the wash temperature was at 160 degrees and maintained this temperature through the entire cycle. The rinse temperature was noted to be 190 degrees.

Based on observation, interview, and record review the facility did not complete a quarterly comprehensive assessment for repositioning/assist bars for 1 (R24) of 1 residents observed with repositioning/assist bars. *R24 was observed with repositioning/assist bars on their bed. The facility did not complete a quarterly assessment for the use of repositioning /assist bars for R24. Findings Include: The facility policy, entitled Bed Assistive Device, dated 7/2021, documents (in part .): Policy: Bed assistive devices will be assessed on an individual basis. Bed assistive devices will only be applied if manufactured for the specific bed. .Procedure: 1. If a resident or responsible party requests a bed assistive device, physical therapy will assess, and the RN (registered nurse) manager will document the resident's cognitive and functional ability for use. 2. If an assessment shows the resident's ability is appropriate, the bed assistive device will be attached to the bed. 3. An assessment will be done quarterly, with a change of condition, and annually to determine if use of the bed assistive device continues to be appropriate. R24 was admitted to the facility on [DATE] with diagnoses of hypertension, dysphagia, dementia, and anemia. R24's Annual MDS (Minimum Data Set) assessment dated , 8/5/22, documents a BIMS (Brief Interview for Mental Status) score of 14, indicating R24 is cognitively intact for daily decision making. Section G (Functional Status) documents R24 requires extensive assistance of two-person physical assist with bed mobility and personal hygiene. R24's care plan documents, Turning/positioning in bed (bed mobility) - R24 requires extensive assistance. RT (related to) Hx (history) knee surgery, hx of back surgery, deconditioning and weakness. Uses Assistive bed device to assist with repositioning. R24 determines R24's repositioning. R24 prefers to lie on R24's back. Under the interventions section documents, R24 uses bilateral grab bars in bed. On 10/19/22 at 09:33 AM, Surveyor observed R24 in bed. Surveyor observed two grab bars on both sides of R24's bed. R24 reported to Surveyor that they use the bars to help turn in bed. On 10/20/22 at 10:19 AM, Surveyor observed R24 in bed. Surveyor observed two grab bars on both sides of R24's bed. Surveyor's review of R24's medical record indicated that R24 was assessed for the use of bilateral grab bars 11/2021. This assessment included the risks and benefits of grab/assist bars, including the risk of entrapment and was signed by R24. Surveyor noted there were no quarterly assessment completed after R24's assessment completed on 11/2021 which would include an ongoing assessment to assure that the grab/assist bars are used to meet R24 needs and to assess the risks and benefits including the risk of entrapment. On 10/24/22 at 12:35 PM, Surveyor interviewed Director of Nursing (DON)-B. DON-B reported assessments for grab/assist bars are completed annually by therapy and are to be done quarterly by the Registered Nurse (RN) Unit Managers. On 10/24/22 at 12:49 PM, Surveyor interviewed RN-E. RN-E reported that assessments of grab bars are to be completed quarterly for residents. RN-E reported an initial assessment is completed by therapy and nursing and once it is determined that the resident would need grab bars, the Nursing Home Administrator is the one to come and place those on the resident's bed. RN-E reported grab bars are not in the physician's orders, however, grab bars would be reflected in the resident's care plan. On 10/24/22 at 12:55 PM, Surveyor shared above concerns regarding no ongoing quarterly assessments for R24's assist/grab bars on their bed with DON-B. No additional information was provided.

Based on observation, interview, and record review, the facility did not ensure that a resident who developed a pressure injury while at the facility received necessary treatment and services, consistent with professional standards of practice, to promote healing for 1 of 5 (R79) residents reviewed for pressure injuries. *R79 developed an unstageable pressure injury to their left heel while at the facility. Weekly wound assessment of the pressure injury documented a decline in the pressure injury and the physician and wound clinic were not informed of the decline in the pressure injury. Weekly wound assessments were not completed timely for R79's pressure injury on the left heel. There were 12 days between the 7/21/22 and 8/02/22 assessments of R79's pressure injury. Findings Include: The Facility Policy and Procedure, entitled Pressure Injury Protocol, dated 1/2021, documents (in part) . Policy Residents will be assessed for risk factors which may lead to the development of pressure injuries. Preventative measures will be initiated to prevent pressure injury formation, however, certain conditions may make the development of pressure injuries unavoidable. Residents with pressure injuries will receive appropriate treatments and services to promote healing, prevent infection and prevent new injuries from developing. The Facility Policy and Procedure, entitled Pressure Injury Documentation Sheets, dated 5/2021, documents (in part) . Policy It is the policy of the facility to have documentation for all pressure related injuries. These sheets will enable staff to evaluate progress on a weekly/PRN (as needed) basis. Procedure 1. Wound measurements will be done weekly by the Certified Wound Nurse or designee. Documentation will be noted on the Wound Assessment Form in EMR (Electronic Medical Record). 2. The Pressure Ulcer Scale for Healing (PUSH) is done on all residents with pressure injuries. 3. Progress of any pressure related injuries will be re-evaluated be the Certified Wound Nurse or designee weekly and/or PRN. Physician and resident's representative will be updated as indicated . Findings Include: R79 was admitted to the facility on [DATE] with diagnoses of Type II diabetes, muscle weakness, localized edema, hypertension, and hypothyroidism. R79's care plan initiated 7/1/2016, documents an impairment of skin integrity related to PVD (peripheral vascular disease), PAD (peripheral arterial disease), neuropathy, and daily urinary incontinence. History of vascular ulcer left great toe and history of vascular ulcers left heel. Vascular wound left great toe. Recurring blisters left foot. Bruises easily. Does not like to nap/elevate lower extremities. No sensation in left foot. 6/22 pressure area on left heel. R79's current care plan interventions document to assist with repositioning every two hours and as needed when in bed, R79 is being seen by the wound clinic, monitor labs, weights, and intake, provide hygiene after toileting to prevent skin breakdown, treatment as ordered by physician and wound physician, left heel boot on at all times, provide protein supplements as ordered, and vascular consult as needed. R79's Pressure Ulcer/Injury/ CAA (care area assessment), dated 1/8/2022, documents, R79 is alert and oriented and able to make needs known and plan own day. Requires increased assist with transfers and mobility. Will call for assist. Is able to assist with position change in bed and weight shift in wheelchair. Does have history of PVD and foot ulcers related to that. Boot to be worn at all times. Foot Ulcers have episodic opening and healing with treatment. S/P (Status Post) vascular surgery to increase blood flow to foot with continued ulcer issues. Anti-pressure mattress to bed and cushion in wheelchair. Is resistive to offloading. Skin is intact at present time. R79's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 13, indicating that R79 is cognitively intact for daily decision-making skills. Section E (Behavior) documents that R79 does not exhibit rejection of care behaviors. Section G (Functional Status) documents that R79 requires extensive assist with one-person physical assist for bed mobility, toilet use, and personal hygiene. Section M (Skin Conditions) documents R79 is at risk for developing pressure injuries and that R79 has unhealed pressure injuries. On 10/19/22 at 10:11 AM, Surveyor observed R79 in a wheelchair. Surveyor observed a blue heel boot on R79's left foot. R79 reported to Surveyor they have wounds on their foot from diabetes. Surveyor reviewed R79's medical record and noted R79 has a long history of wounds on R79's lower extremities and was being seen at a wound clinic. R79's wound clinic consultation form, dated 6/8/2022, documented R79 has a new deep tissue injury (DTI) to R79's left heel. Allevyn 3 times per week. Left heel DTI measuring 2 cm (centimeters) x 2 cm. R79's physician's orders documented every three days starting 6/11/2022 to apply Allevyn heel dressing to R79's left heel. R79's weekly wound assessment completed by the facility, dated 6/13/22, documented R79's left heel pressure injury as acquired on 6/8/2022. Measurements documented length of 2.0 cm by width of 2.0 cm. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Areas noted at last appointment wound healing clinic 6/8/2022. Area is intact and slightly discolored. Assessment documented the wound edges as intact, no drainage, and no odor. Wound bed description was 0% slough, 0% granulation, 0% eschar. R79's unavoidable pressure injury tool documented R79 refuses aspects of care and treatment, and that non-compliance has been discussed with resident and/or family. R79's unavoidable pressure injury tool explains R79 refuses to elevate leg when they are up during the day and that R79 refuses surgery and has chronic wounds on lower extremities. R79 stated, I was born with two feet, and I will die with two feet . R79's weekly wound assessment completed by the facility, dated 6/21/22, documented R79's pressure injury as length of 2.0 cm by width of 2.0 cm. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Area is intact and slightly discolored. Assessment documented the wound edges as intact, no drainage, and no odor. Wound bed description was 0% slough, 0% granulation, 0% eschar. R79's wound clinic consultation form, dated 6/29/2022, documented to continue Allevyn foam border dressing to high-risk heel. R79's weekly wound assessment completed by the facility, dated 6/30/22, documented R79's pressure injury as length of 2.0 cm by width of 2.0 cm. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Area is intact and slightly discolored. Assessment documented the wound edges as intact, no drainage, and no odor. Wound bed description was 0% slough, 0% granulation, 0% eschar. R79's weekly wound assessment completed by the facility, dated 7/11/22, documented R79's pressure injury as length of 2.5 cm by width of 3.5 cm. Assessment documented the wound as 100% brown slough. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Area is larger and now covered with brownish slough. Assessment documented the wound edges as intact, serosanguineous drainage, and no odor. Surveyor reviewed R79's medical record and was unable to locate documentation that the physician or the wound clinic was updated regarding the above change in R79's pressure injury on their heel until R79 was assessed by the wound clinic on 7/20/2022. Surveyor also noted the treatment for R79's pressure injury was not changed until R79 was assessed by the wound clinic on 7/20/2022. R79's wound clinic consultation form, dated 7/20/2022, documented that R79's pressure injury to their left heel had a notable decline and was now an unstageable pressure injury. Treatment for R79's pressure injury on their left heel was changed to Iodosorb and to cover with a dressing, and kerlix, continue heel pad and offloading boot, and to elevate and float heels. R79's weekly wound assessment completed by the facility, dated 7/21/22, documented R79's pressure injury as length of 3.2 cm by width of 3.6 cm. Assessment documented the wound as 100% brown slough. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Area is larger and now covered with brownish slough. Assessment documented the wound edges as intact, serosanguineous drainage, and no odor. R79's weekly wound assessment completed by the facility, dated 8/02/22, documented R79's pressure injury as length of 3.0 cm by width of 6.0 cm. Assessment documented the wound as 90% black eschar. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Area is larger and now covered with black eschar. Assessment documented the wound edges as intact, serosanguineous drainage, and no odor. Surveyor noted 12 days between the 7/21/22 and 8/02/22 assessments of R79's pressure injury to their left heel. No assessment was completed during the week of 7/24/22. Surveyor reviewed R79's medical record and was unable to locate documentation that the physician or the wound clinic were updated regarding the above change noted on 8/2/22 in R79's pressure injury on their heel. R79's weekly wound assessment completed by the facility, dated 8/8/22, documented R79's pressure injury as length of 4.5 cm by width of 7.0 cm. Assessment documented the wound as 100% black eschar. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Area is larger and now covered with black eschar. Assessment documented the wound edges as intact, serosanguineous drainage, and no odor. R79's wound clinic consultation form, dated 8/17/2022, documented R79's left heel pressure injury declined and instructions for treatment documented to use more iodosorb to R79's pressure injury and continue current treatment. R79's weekly wound assessment completed by the facility, dated 8/22/22, documented R79's pressure injury as length of 4.5 cm by width of 7.5 cm. Assessment documented the wound as 100% black eschar. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Edges now slightly reddened. R79 was reminded to elevate lower extremities. Assessment documents R79 offers many reasons why he can't and replies, Maybe someday. Assessment documented the wound edges as red/warm, serosanguineous drainage, and no odor. R79's wound clinic consultation form, dated 9/9/2022, 9/23/22, and 10/7/2022, documented R79's pressure injury to their left heel was now healing and stable. R79's wound clinic consultation form, dated 10/7/2022, documented R79's pressure injury on their left heal was debrided. R79's weekly wound assessment completed by the facility, dated 9/13/22, 9/21/22, 9/28/22, and 10/5/22 all document R79's leg as edematous. Wound notes document that R79 is reminded to elevate their lower extremities and that R79 continues to refuse. R79's weekly wound assessment completed by the facility, dated 10/10/22, documented R79's pressure injury as length of 7.0 cm by width of 9.0 cm. Assessment documented the wound as 25% slough and 75% black eschar. Assessment documented R79's pressure injury as unstageable and a suspected DTI. Assessment notes document, Wound debrided by wound clinic on 10/7/22. Increased amount of drainage noted. Gabapentin added at HS (bedtime) for comfort. Assessment documented the wound edges as macerated, serosanguineous drainage, and no odor. On 10/20/22 at 10:14 AM, Surveyor interviewed R79. R79 was sitting in their wheelchair. Surveyor observed a blue heel boot on R79's left foot. Surveyor observed both of R79's feet to be on the floor. R79 reported to Surveyor that staff at the facility do ask R79 to lay down during the day and to elevate R79's feet while in the wheelchair. R79 reported they (R79) do not want to put their foot up and that they want to stay in their wheelchair just how they are now. R79 reported they know their wounds might not get better by doing this. Surveyor observed R79 to have an air mattress on their bed. On 10/20/22 at 10:23 AM, Surveyor interviewed Licensed Practical Nurse (LPN) F. LPN F reported that if they discovered a new pressure injury or were informed of one, they would notify the supervisor and the supervisor would be the one to do an assessment. On 10/20/22 at 11:01 AM, Surveyor interviewed Registered Nurse (RN) Manager G. RN Manager G reported to Surveyor that when they are notified that a resident has a new pressure injury, they would go and assess the wound and get measurements. RN Manager G reported a treatment would be ordered right away and the wound care nurse and doctor would get involved if appropriate. RN Manager G reported to Surveyor that they do assessments of all pressure injuries on a weekly basis. Surveyor asked if a resident with a pressure injury goes out to a wound clinic for treatment of a pressure injury, what would their process be. RN Manager G reported they would do their own comprehensive assessments of the pressure injury. On 10/20/22 at 03:05 PM, Surveyor shared concerns related to R79's pressure injury to their left heel with Nursing Home Administrator (NHA) A and Director of Nursing (DON) B. Surveyor shared the concern regarding R79's weekly assessment showing a decline in the wound and the physician and wound clinic not being updated. Surveyor also shared the concern related to the timing of assessments and the long period of time in between assessments. On 10/24/22 at 09:46 AM, Surveyor interviewed RN Manager H and DON B. RN Manager H reported that the process when a new pressure injury is identified would be getting measurements and completing an assessment. RN Manager H reported the physician would be notified as well as the dietician. RN Manager H reported the care plan would be updated as needed. RN Manager H reported assessment of a resident's pressure injury going forward from an initial assessment is that a wound physician comes in weekly and looks at a majority of residents with pressure injuries. RN Manager H reported if there are changes in the wounds or treatments, the family is notified of those changes. RN Manager H reported the team meets weekly to discuss new areas. RN Manager H reported if the resident goes to the wound clinic, measurements are still recorded weekly, but it would depend on how often the resident goes to the wound clinic. RN Manager H reported weeks that the resident would be seen at the wound clinic, the facility would not complete their own assessment as the wound clinic would already be completing the assessment of the pressure injury. Surveyor asked RN Manager H why the physician or wound clinic wasn't notified on 7/11/2022 when R79's pressure injury was assessed to have declined and assessment documented the wound to be 100% slough. RN Manager H reported that the resident goes to the wound clinic regularly and they knew the resident was going to the wound clinic soon so it would be assessed at that time. DON B reported that R79 goes to the wound clinic on a regular basis. DON B reported the decline was expected by the facility and the wound clinic. R79 was not appropriate for debridement. DON B reported R79 does their own thing and refuses to elevate their foot and lay down as instructed by the wound clinic. Surveyor asked RN Manager H why there were 12 days between the facility's weekly wound assessments on 7/21 and 8/2 and why the physician was not notified when it was assessed to have increased in size and documented a change in the wound bed description. DON B reported RN Manager H was not able to be working at the facility during the time between assessments. DON B reported if RN Manager H is not in the facility, DON B would be doing weekly wound assessments. DON B reported that during this time, DON B was out of the facility as well, so R79's weekly assessment was missed during that time. Surveyor asked RN Manager H and DON B if the risks and benefits were explained to R79 regarding their refusal with not laying down during the day and not elevating their foot. RN Manager H and DON B both reported that risks and benefits were explained to R79 on multiple occasions. DON B reported that surgery has been discussed with R79 multiple times and R79 refuses. DON B reported the wound clinic also discussed amputation with R79 and R79 declined. At the time of exit, no additional information was provided by the facility.

Based on record review and interview, the facility did not always ensure that 2 (R38 and R81) out of 3 residents reviewed, who received psychotropic medications received behavior monitoring based on their targeted behaviors. * R38 was administered scheduled Seroquel and Ativan with no specific reason for use identified or consistent behavior monitoring completed. * R81 was administered scheduled Zoloft with with no specific reason for use identified or consistent behavior monitoring completed. R81 did not have a care plan developed for use of Zoloft or management of her depression. Findings include: On 10/24/22 the facility policy titled Psychotropic Medications dated 11/20 was reviewed and read: The indication for any psychotropic medication will be thoroughly documented in the clinical record to include identification of the behavioral symptoms being treated. Identified target behaviors will be monitored each shift. 1. R38 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease. On 10/24/22, R38's current Physicians orders were reviewed and read: Seroquel (Quetiapine) 25 milligrams(MG) once a day diagnosis exempt with a start date of 8/26/22. Ativan (Lorazepam) 0.5 mg once a day for anxiety and sleep with a start date of 9/15/22 On 10/24/22 at 9:43 AM Director of Nurses (DON)-B was interviewed and indicated that R38's behavior for use of the Seroquel (antipsychotic) and Ativan (antianxiety) should be identified and monitored and it didn't appear that it was put into the system. On 10/24/22 R38's current care plan for receiving antipsycotic drugs on a regular basis restless behaviors at night was reviewed and did not indicate any specific behaviors of restlessness and included the intervention Record behaviors on Behavior Tracking Form. Monitor pattern of behavior (time of day, precipitating factors, specific staff or situations). On 10/24/22 R38's medical record was reviewed and no specific targeted behaviors for his Seroquel or Ativan usage could be found and no behavior monitoring each shift was found. On 10/24/22 at 2:00 PM the Administrator-A and DON -B were informed of the above findings. Additional information was requested if available. None was provided. 2. R81 was admitted to the facility on [DATE] with diagnoses that included Depression On 10/24/22 R81's current Physicians orders were reviewed and read: Zoloft (Sertraline) 25 MG once a day for depression with a start date of 9/28/22. On 10/24/22 at 9:43 AM Director of Nurses (DON)-B was interviewed and indicated that R81's behavior for use of the Zoloft (antidepressant) should be identified and monitored and it didn't appear that it was put into the system. On 10/24/22 R81's medical record was reviewed and no specific targeted behaviors for her Zoloft usage could be found and no behavior monitoring each shift was found. On 10/24/22 R81's current care plan and nothing was found in the care plan to address R81's depression or use of Zoloft. On 10/24/22 at 2:00 PM the Administrator and DON were informed of the above findings. Additional information was requested if available. None was provided.

Based on interview and record review the facility did not ensure 1 (R2) of 2 residents reviewed for grievances received resolution to their concern. R2's family made multiple complaints to the facility that were not documented, filed or followed up on by the facility or grievance officer. Findings include: Surveyor reviewed facility's Grievance Policy with an effective date of 10/2021. Documented under Policy was It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances including those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay that differs from general feedback from residents or their resident representative. They have the right to and the facility must make prompt efforts to resolve grievances the resident may have . G. Response Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role or authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official . H. Resolution 1. The facility will strive for a prompt resolution outcome for all grievances or complaints rendered. A reasonable time frame will be agreed upon with all parties involved. 2. The Grievance Official will complete a written response (Grievance Response) to the resident or resident representative which includes: i. Date of grievance/concern ii. Summary of grievance iii. Investigation steps iv. Findings v. Resolution outcome and actions taken and date decision was issued I. The Grievance Official will maintain a log of all grievances for a period of 3 years including i. Date of the Grievance ii. Tracking number or identification iii. Type of Grievance iv. Location/Department v. Person assigned to investigate vi. Date response letter sent vii. Comments/Actions . R2 was admitted to the facility 7/28/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2 was discharged from the facility on 8/8/21. On 11/2/21 at 2:06 PM Surveyor interviewed R2's Family Member-G. Surveyor asked if Family Member-G had spoken to anyone at the facility about concerns he had. Family Member-G stated yes, he had spoken to the Nurse Manager (Registered Nurse (RN)-E) on the unit a few times, talked about concerns in care conferences with the Social Worker (SW)-F and spoke with the Nursing Home Administrator (NHA)-A. Family Member-G stated I filed grievances but no one followed up on them. Family Member-G stated these grievances included R2 receiving medications late, waiting for assistance to be transferred off the toilet, R2 unable to stand at walker and Therapy notes stating she could, R2's documentation stating she had a caregiver at home but she did not, and unsafe discharge from the facility. Surveyor reviewed the Grievance Log for the facility from 2021. There are no documented grievances regarding R2. On 11/3/21 at 8:57 AM Surveyor interviewed SW-F. Surveyor asked if Family Member-G ever brought any concerns to her attention. SW-F stated he had lots of concerns and had a care conference on 8/5/21 because he was concerned about her discharge home being unsafe. SW-F stated we did not discharge her until 8/8/21 instead of 8/7/21 so they could get their caregiver in place for assistance. Surveyor asked if she ever filed a grievance about R2. SW-F stated no, she mainly handles missing items. SW-F stated the grievances are usually followed up on by the head of the identified department and NHA-A fills out the grievance forms. On 11/3/21 at 9:33 AM Surveyor interviewed RN-E. Surveyor asked RN-E if Family Member-G had brought any concerns to her attention during R2's stay at the facility. RN-E stated everyday it was something. RN-E stated he complained about everything from the food to R2 not being transferred off the toilet soon enough. Surveyor asked how these concerns were followed up on. RN-E stated we talk about it in morning meeting. Surveyor asked if RN-E ever filled out a grievance form for Family Member-G. RN-E stated I have never filled one out. Surveyor asked who is in charge of grievance forms. RN-E stated SW-F and NHA-A. On 11/3/21 at 9:10 AM Surveyor interviewed NHA-A. Surveyor asked if R2 or Family Member-G had concerns. NHA-A indicated they had an issue with the discharge but it didn't rise to the level of a grievance. Surveyor asked what constitutes being a grievance. NHA-A stated it needs to be a significant issue including an unresolvable issue from a family member or missing items. Surveyor noted the multiple concerns from Family Member-G. NHA-A asked if every little concern is considered a grievance. NHA-A stated he remembers Family Member-G had some of concern that needed to be addressed. NHA-A stated he will need to take a look closer at the grievance process at the facility.

Based on observation, interview and record review the Facility did not ensure that 1 (R4) of 3 residents at risk for development of pressure injury received care and services to prevent the development of pressure injuries. * R4 was assessed to be at risk for development of pressure injuries and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . R4 was observed to not have on the care planned pressure reduction boot on the right heel. Findings include: R4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/2/21 at 9:20 AM R4 was observed in bed with no pressure relief boot on her right foot. The boot was observed in R4's Broda chair. On 11/2/21 at 11:30 AM R4 was observed in her Broda chair with shoes on. The pressure reduction boot was in her closet. On 11/2/21 at 2:00 PM R4 was observed in her room in the Broda chair without her pressure reduction boot on. Licensed Practical Nurse (LPN) -D was asked to come in R4's room and indicated R4 should have her pressure reduction boot on. LPN-D then removed R4's sock and R4's right heel was observed to be intact. LPN-D then applied R4's pressure relief boot to R4's right heel. On 11/2/21 R4's pressure injury documentation for her right heel pressure injury was reviewed. The records indicated R4 developed an unstageable pressure injury to her right heel on 6/2/21 and the pressure injury was fully healed on 7/19/21. On 11/2/21 R4's care plan for impairment of skin integrity on 6/2/21 the intervention of blue boot right heel at all times. The above findings were shared with the Administrator and Director of Nurses on 11/2/21 at 3:00 PM. Additional information was requested if available. None was provided.

Based on observation, interview and record review the facility did not ensure 2 (R26 and 24) of 8 residents received the necessary services to prevent falls. On 3/8/19 R26 was being transferred from bed to her wheelchair using a mechanical lift and only one CNA (certified nursing assistant) was assisting. The care plan and facility policy indicated transferring a resident using a mechanical lift, two staff are needed for the transfer. R26 slipped out of the sling, fell on to the floor and sustained a right femoral neck fracture. R24 has a history of falls and interventions for falls were not consistently completed and the care plan was not updated. Findings include: 1) The facility's policy and procedure for Transfer of a Resident with the Hoyer lift dated 3/2013 indicates The safe transfer of a resident with the hoyer lift is done with the assist of two. It also indicates: 5) With a CNA on either side of the bed, position the sling so it's lower edge is even with the resident's coccyx by rolling resident side to side 9) The first CNA stays at the base of the lift and raises the resident to a sitting position, and continues to lift the resident until the resident is clear of the bed. 10) The second CNA at the head of the bed provides support for the resident's head and maneuvers the resident over the chair or toilet. R26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set) dated 2/22/19 indicates R26 is alert and oriented and able to make her needs known. It also indicates R26 is dependent for transfers with two staff assist, dependent with dressing with one staff assist, needs extensive assistance with bed mobility and hygiene with one staff assist. The care plan created 2/28/18 indicates R26 is transfer with assist of 2 staff and hoyer lift. The nurses note dated 3/8/19 at 2:30 p.m. indicates Nurse was called to resident's (R26) room because resident had a fall. Staff notified nurse that during transfer from resident's bed to wheelchair resident slipped out of the Hoyer. Staff and resident's daughter were present at the time of the witnessed fall. Nurse went to assess resident and resident complained of pain rated a 9 in lower back. (physician) updated at 14:40 (2:40 p.m.) about fall and complaints of pain and okay to send to hospital. Resident agreed to be transfer to hospital. Resident's daughter states, She was rushing staff to transfer into chair. Nurse was able to get a set of vitals 177/80-60-20-98.0 temp and 94% O2 (oxygen) RA (room air). RN (registered nurse) Manager notified and Resident was sent to hospital at 15:00 (3:00 p.m.) via ambulance stretcher, resident's daughter accompanied. Surveyor reviewed the facility's investigation into R26 fall. The investigation dated 3/11/19 indicates on 3/8/19 employee was going to transfer res (R26) out of bed with hoyer lift (mechanical lift). Employee asked another CNA to help her. While waiting for other CNA, Res daughter said I'll help you get her up. The hoyer was already attached. The daughter was in a hurry to get to happy hour. They did not wait for the other aide. Emp (employee) felt rushed and pressured to get the transfer done and proceed to transfer res with daughter. Res fell out of sling while in air to floor. The conclusion to the investigation indicates employee should have waited for other CNA for assistance The hospital discharge summary report dated 3/16/19 indicated R26 sustained fall resulting in right femoral neck fracture with mild displacement. On 8/12/19 at 11:17 a.m. Surveyor interviewed NHA (nursing home administrator) A regarding R26 fall which sustained in a fracture. Surveyor asked beside the competency for the hoyer lift for the CNA involved was there any training for other staff. NHA indicated the CNA was the only staff retrained. Surveyor asked if prior to R26's fall, was it ok to have a staff person and family member do a mechanical lift transfer, NHA A stated the policy states two person assist he didn't mean two persons off the street could do a transfer. 2) The facility's Incident/Accident Reports policy and procedure, revised 5/2017, states .7. The Fall Huddle Report accompanies the Incident/Accident Report and is discussed as soon as possible with all staff on the unit at the time of the incident/accident. 8. The Fall Prevention Strategies list is available at every Nurse's station to assist staff during their Huddle meeting. 9. All Incident/Accident Reports are reviewed and interventions discussed by the Interdisciplinary Team at the falls meeting held after morning report. R24 has [DIAGNOSES REDACTED]. R24's Annual Minimum Data Set assessment, with an assessment reference date of 5/24/19, documents R24's cognitive skills for daily decision making as severely impaired, and required extensive assistance of on person's physical assist for transfers and walking in the room and corridor. R24's fall care area analysis, documented as completed 5/29/19, documents (R24) is at risk for falls due to episodes of unsteadiness, sensory impairments and dementia. He requires an assistive device. Fall history related to cognitive impairments, including poor safety awareness. He often attempts ambulation with out an assistive device. Is not always accepting of assist and or redirection. Proceed to care plan as fall risk. On 08/12/19 at 01:42 PM the surveyor interviewed RN Manager-G. The surveyor asked RN Manager-G what the process is when a resident falls. RN Manager-G stated fill out an assessment, notify MD and family, fill out an internal incident report that the nurse that answered the call to the fall look at, complete a fall risk analysis and scored, and do a fall huddle right away with staff working on the unit to look at fall in depth. RN Manager-G stated when the managers comes on she will look at all the information and depending on what the fall is, sometimes will initiate a change in the care plan, initiate something that was working, or change something that was not working or not in place. RN Manager-G stated falls are also talked about in morning meeting. On 4/3/19 at 11:58 am progress notes document At 1130 am writer was called to resident's room. Resident was laying on the floor next to recliner chair . The fall huddle report documents Resident was trying to walk around his room without assistance to fix his blinds. Resident was unable to recall why he was trying to fix his blinds. The Fall Team Report documents the root cause of the fall as confusion. Poor balance. The Team Recommendations is documented as Offer 1:1 Support as resident will allow. The surveyor reviewed R34's plan of care and noted his care plan related to cognition/behavior related to Poor long and short term memory, needs cues and reminders and has difficulty with word finding at times. (R24) becomes combative during cares at time included the intervention for 1:1 as needed created 6/1/18. The surveyor reviewed R24's plan of care related to At Risk for Falls R/T (related to) DEMENTIA, [MEDICATION NAME] DEGENERATION AMB (ambulation): UNSTEADY GAIT, CONFUSION (becomes more agitated with staff assisting him). CONTINUES TO CLOSE DOOR TO ROOM AND [NAME]C (occasionally) BL[NAME]KS BATHROOM DOOR. [MEDICAL CONDITION] MED (medication) USAGE. (R24) TENDS TO 'STOOP' AND PICK THINGS OFF THE FLOOR. Able to sit on floor and get self-up without assist. did not include an intervention related to providing 1:1 support as resident will allow. On 4/27/19 at 4:37 PM progress notes document Pt (patient) taking self to BR (bathroom after dinner, without a device, fell in bathroom landing on his back slightly to his right side. The Fall Team Report documents Determine Root Cause of Fall: confusion. Poor Balance. The report under Team Recommendations is blank. The date of the review on the report is 4/23/19 (prior to the fall). The surveyor reviewed R24's care plan and noted no new interventions on 4/27/19 related to R24's fall. On 08/12/19 at 01:42 PM the surveyor interviewed RN Manager-G. The surveyor shared related to the fall on 4/27/19 not being able to find a fall team recommendation. RN Manager-G reviewed the form and stated you're right. Progress notes on 5/18/19 at 9:48 PM document Called to room by CNA at 2030 (8:30 pm) saying resident had fall. Upon arrival noted resident lying on left side on floor by bed with head on wall . The Fall Team Report documents Determine Root Cause of Fall: lost balance. The report documents under Team Recommendations continue current plan of care. Resident is impulsive, and unaware of safety precautions. He becomes very irritated when questioned. He will test his limitations without regard to safety. The surveyor reviewed R24's plan of care and noted no updates related to the 5/18/19 fall. Progress notes on 6/22/19 at 10:35 AM document Found lying on R (right) side by bed/ W/c (wheelchair overturned alongside him at 1010 (10:10 am) Patient unable to state reason for fall. Unable to find words to explain r/t (related to) declining Neurological disorder .Patient had allowed for bath this AM but become agitated after breakfast and insisted on staying in room in w/c (wheelchair) . The Fall Team Report documents Determine Root Cause of Fall: Paranoid delusions secondary to Frontal lobe dementia. The Team Recommendations are documented as enc (encourage) resident to allow staff to keep door open. Behavior varies. At times he is more willing to allow staff to assist. Other times he barricades door and refuses staff assist. The surveyor reviewed R24's plan of care and noted the intervention ENCOURAGE RESIDENT TO KEEP DOOR OPEN AT ALL TIMES was documented as being created and in place since 1/8/19. Progress notes on 7/28/19 at 7:17 PM document Writer was called to resident's room at 1820 (6:20 pm). Resident was in room with his wife .when (wife), who witnessed fall stated that she was sweeping the floor in his room when he suddenly decided to roll off his wheelchair, onto the floor, and curled up in a fetal position . The Fall Team Report documents Determine Root Cause of Fall: Poor posture in chair. The team recommendations are documents as provide reminders to sit up in chair as resident will accept. The surveyor reviewed R24's plan of care and noted this intervention was not documented on R24's care plan. On 08/12/19 at 02:09 PM the surveyor interviewed RN (registered nurse) Manager-G. The surveyor informed RN Manager-G of being unable to find the recommendation intervention on R24's care plan. RN Manager-G reviewed R24's care plan and confirmed the intervention was not on the care. R24's at risk for falls care plan, printed by the facility on 8/8/19 at 9:19 AM includes a current intervention to KEEP WALKER NEXT TO RESIDENT AT ALL TIMES WHEN IN ROOM initiated 11/5/18. On 08/06/19 at 02:21 PM the surveyor observed R24 in his room in his recliner with his feet over the side of the recliner. The surveyor noted R24 was not sitting up in his chair. The surveyor observed R24's walker was not near him. On 08/07/19 at 09:57 AM, 10:09 AM, and 11:27 AM the surveyor observed R24 in his room , in his wheelchair, alone. The surveyor observed R24's walker was not near him. On 08/07/19 at 01:16 PM the surveyor observed R24 in his room in his recliner. The surveyor observed R24's walker was not near him. On 08/07/19 at 03:21 PM the surveyor observed R24 in his room in his recliner with no staff present. The surveyor observed R24 was reaching down to the floor to pick up what appeared to be possible food that fallen on to the floor. The surveyor observed R24's walker was not near him. On 08/07/19 at 04:02 PM the surveyor observed R24 in his room in recliner. The surveyor observed R24's walker was not near him. On 08/12/19 at 01:42 PM the surveyor interviewed RN Manager-G. The surveyor asked RN Manager-G if R24 still used his walker. RN Manager-G informed the surveyor R24 is still capable of walking, he may or may not use his walker, may use his can. The surveyor informed RN Manager-G of the observations of R24 in his room without his walker near him. RN Manager-G stated she may have changed that last Thursday (8/8/19) afternoon or Friday (8/9/19) morning. The surveyor informed RN Manager-G the observations made were prior to 8/8/19.

Based on observation, record reviews and interviews, the facility did not make care plan revisions to proactively address the prevention of new pressure injuries, follow physician orders, consistently implement treatments, or reposition residents as needed to promote healing, prevent infection and prevent new pressure injuries (PI) from developing for 3 of 6 sampled residents (R2, R4 and R5) with recent or present pressure injuries, out of a total of 22 sampled residents. *R2 has developed 15 facility-acquired PI on 11 different locations on her body since 5/25/16. The multiple PI range from Stage 2, Stage 3, Stage 4, and unstageable. The facility failed to recognize factors which may have led to the development of these pressure injuries and assess the measures instituted to prevent their formation. The facility failed to develop and implement a repositioning schedule and to develop a plan of care to keep R2 off the affected areas. The facility failed to implement physician orders [REDACTED]. The facility failed to ensure treatments ordered by the wound care clinic were followed as ordered, as the wound care clinic notes that upon arrival to the wound care clinic R2 had no dressing in place over a Stage 3 and Stage 4 pressure injuries where a tendon is visible on the right ankle and again R2 arrived at wound care clinic again with no dressing in place on 2 Stage II pressure injuries after wound care clinic recommended dressing to be used on her last visit. The facility failed to change R2's position every two hours keeping her off of her affected areas, and to be up for meals only as R2 was observed on 3/14/17, sitting up in her Broda chair for 4.5 hours without any observed change in position. *R4 developed a facility acquired pressure injury of the coccyx on 2/9/17. The pressure injury was initially determined to be a Stage 2 pressure injury measuring 0.1cm x 0.5cm x 0.3cm. By 2/28/17, R4's pressure injury had deteriorated and was determined to be a Stage 4 pressure injury with malodorous drainage and visible bone. The pressure injury measured 4.5cm x 2.0cm x 0.8cm. On 3/14/17, Surveyor observed R4 sitting up in her Broda chair from 8:25am until 10:45am. On 3/14/17, Surveyor observed R4 sitting up in her Broda chair from 8:00am until 1:50pm. Additionally, Certified Nursing Assistant (CNA)-F informed Surveyor that R4 had been up in her Broda chair prior to CNA-F beginning her work day at 6:30am. R4's care plan did not include interventions related to the need for offloading the pressure injury area, nor address how staff may address refusals for offloading the coccyx pressure injury. The facility's failure to develop and implement aggressive offloading plans of care for R2 and R4, and ensure treatments were completed as ordered, resulted in a finding of immediate jeopardy, which began on 3/14/17. Administrator-A and Director of Nursing (DON)-B were notified of this finding on 3/16/17 at 11:15am. The immediate jeopardy was removed on 3/17/17. The deficient practice continues at a scope and severity level of D (potential for harm that is not immediate jeopardy/isolated), as evidenced by observations of R5 who recently had resolved pressure injury, was to be positioned from side to side only while in bed. Surveyor had multiple observations of R5 lying flat on his back in bed while in bed. Findings include: *According to the National Pressure Ulcer Advisory Panel's (NPUAP) Prevention and treatment of [REDACTED]. In section, Prevention and Treatment, Additional Recommendations for Individuals with Existing Pressure Ulcers, #1 states: Do not position individual directly on a pressure ulcer. In section, Repositioning of the Individual with Existing Pressure Ulcer in a Chair, approaches include: Consider periods of bedrest to promote ischial and sacral ulcer healing, If sitting in a chair is necessary for individuals with pressure ulcers on the sacrum/coccyx or ischia, limit sitting to three times a day in periods of 60 minutes or less, and Modify sitting time schedules and re-evaluate the seating surface and the individuals posture if ulcer worsens or fails to improve. (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Ulcer Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park; Australia; 2014.) The facility policy titled, Standard of Practice, undated, states in part: Mobility and Transfers: *Assess/record/report to the Medical Doctor symptoms of immobility, complications, contractures, fall related injury, skin breakdown, thrombus formation, and/or mobility status changes. *Reposition those residents unable to do so themselves, at least every two hours. *Document any decline in function including measures taken to prevent decline. The facility policy titled, Pressure Injury Protocol, dated 9/2016, states in part: Policy: Factors which may lead to the development of pressure injuries will be assessed and measure instituted to prevent their formation, unless the resident's medical condition makes development unavoidable. Residents with pressure injuries will receive appropriate treatments and services to promote healing prevent infection and prevent new injuries from developing. Procedure: -Stage II Pressure Injury: Partial thickness skin loss with exposed dermis. * Be aware of contributing factors such as change I condition, weight loss, loss of mobility and incontinence. * Provide pressure reducing devices as indicated. * Establish a repositioning schedule if needed * Encourage mobility * Apply barrier cream if indicated * Update dietitian * Initiate care plan * Update Certified Nursing Assistant (CNA) care card as needed * Nurse will initiate weekly skin assessment form * Notify physician and resident's representative * Initiate treatment as ordered by physician * Assess efficacy of treatment every other week at a meeting of the skin team which consists of the Director of Nursing (DON), nurse managers and dietitian. -For stage 3, stage 4, unstageable, or deep tissue pressure injuries, follow the steps listed below: * Be aware of contributing factors such as change I condition, weight loss, loss of mobility and incontinence. * Provide pressure reducing devices as indicated * Consider alternate pressure reduction surface * Establish a repositioning schedule. Keep resident off affected area unless contraindicated * Encourage mobility * Apply barrier cream if indicated * Update dietitian * Initiate care plan * Update CNA care card * Nurse will initiate weekly skin assessment form * Notify physician and resident's representative * Initiate treatment as ordered by physician * Assess efficacy of treatment every other week at a meeting of the skin team which consists of the DON, nurse managers, and dietitian. * Keep physician and resident's representative advised of current treatment plan. * Monitor need for or initiate MDS Change of Condition 1. R2 was admitted to the facility on [DATE], and has the [DIAGNOSES REDACTED]. R2's Minimum Data Set (MDS) assessment, dated 01/15/2016, indicated that R2 is at risk for pressure injuries, but R2 does not have any pressure injuries at that time. R2's MDS assessment, dated 12/20/16, indicated that R2's mental status is severely impaired. R2 is at risk for pressure injuries and currently has a Stage 3 and Stage 4 pressure injury. The MDS identifies that the pressure injury treatments utilized at the time are: pressure reducing devices to the bed and wheelchair, nutrition and hydration interventions, and pressure injury care. The MDS does not identify that R2 is on a turning or repositioning program, but on the MDS completed on 9/20/16 R2 was identified as having a turning and repositioning program. R2's Current Care Plan initiated on 3/29/16 states: * Problem: Alteration in skin integrity related to immobility, contractures, and incontinence. Pressure injury on coccyx remains. Had surgery for [REDACTED]. - Goal: Pressure area will decrease in size 1 centimeter (cm) per week X90 days, with a goal date of 3/21/17. Interventions: * Keep air mattress at half firmness * Turn every two hours at night, Monitor skin during cares, and change position when in Broda chair. * Skin on legs is dry and fragile. [MEDICATION NAME] as ordered and Foam boots at all times. * Treatment to pressure area per wound clinic recommendations and Medical Doctor (MD) approval. * Foam boots at all times. Roho cushion in broda chair. * Nap after lunch. If refuses, allow to stay up. * 8 ounces (oz) Plus 2 (protein Supplement) with meals. The revisions to the care plan are as indicated: *Problem: Alteration in skin integrity related to immobility, contractures, and incontinence. Small circular area on right lateral foot has healed. Pressure injury on coccyx remains. Had surgery for [REDACTED]. Last changed 1/26/2017. (Remains the same as 1/25/17, 12/20/16, 9/21/16, 914/16, and 6/15/16.) - Goal: Pressure areas with decrease in size 1cm per week X 90 days. Last changed 1/26/2017. (Remains the same as 1/25/17, 12/20/16, 9/21/16, 914/16, and 6/15/16.) No revisions were made to the interventions to address the repeated pressure injuries. Treatments changed in response to the development of new areas, but there were no revisions that proactively addressed the prevention of new pressure injuries. 1. R2's wound assessment, completed 5/25/16, showed R2 has a new, Stage 2 pressure injury (PI), to the left gluteal cleft, which was acquired in the facility. The wound measurements were noted as 2.8 X 1.5 centimeters (cm). Wound care provided notes: [MEDICATION NAME] tape. R2's wound assessment, completed 6/02/16, showed the wound measurements as 1.0 x 0.5 cm. 2. R2's wound assessment, completed 6/02/16, showed R2 has a healing unstageable PI to the right lateral foot, which was acquired in the facility on 3/09/16. The wound measurements were noted as 0.5 x 0.2 cm. Wound care provided notes: [MEDICATION NAME] followed by Dry Sterile Dressing (DSD) daily. 3. R2's wound assessment, completed 6/02/16, showed R2 has a PI to the right ankle that is unstageable which was acquired in the facility. The wound measurements are 1.0 x 1.0. Wound care provided notes: [MEDICATION NAME] followed by Dry Sterile Dressing (DSD) daily. 4. R2's wound assessment, completed 6/02/16, showed R2 has a PI to the right heel that is unstageable which was acquired at the facility. The wound measurements are 1.0 x 0.5 cm. Wound care provided notes: Santyl followed by DSD. 5. R2's wound assessment, completed 6/02/16, showed R2 has PI (granulation tissue) to the right gluteal fold which was acquired in the facility. The wound measurements are 1.0 x 0.5 cm. Wound care provided notes: skin prep applied followed by duoderm. 6. R2's wound assessment, completed 6/16/16, showed R2 has an unstageable PI to the right posterior heel, which was acquired at the facility. The wound measurements are 2 x 1.5 cm. Wound notes state: small black area on right heel, adjacent area that was open is healed, wears foam boots at all times and has air mattress. Wound care provided notes: Left open to air. 7. R2's wound assessment, completed 6/23/16, showed R2 has a new acquired Stage 3 PI to the right ankle, which was acquired at the facility. The wound measurements are 1.0 x 1.6 x 0.2 cm. Wound notes state: Seen at wound care clinic on 6/22/16 and x-rays were taken. R2 has a [DIAGNOSES REDACTED]. Wound care provided notes: wash, santyl, ABD gauze, [MEDICATION NAME] tape. 8. R2's wound assessment, completed 6/23/16, showed R2 has a new acquired PI to the 4th toe on the left foot. The wound measurements are 0.3 x 0.4 x 0.4. Wound notes state: found open area 4th toe web space when seen at wound care clinic on 6/22. R2 was provided with different protective boots. Wound care provided states: Dry sterile dressing (DSD) between toes. 9. R2's wound assessment, completed 6/23/16, showed R2 has a new acquired Stage 2 PI to the right hip on 6/22/16. The wound measurements are 0.8 x 0.4 x 0.2. Wound care provided states: wash, santyl, ABD, [MEDICATION NAME]. R2's was treated at the Wound Care Clinic on 6/24/16. The wound assessment notes R2 had 6 PI's treated. The Wound Healing Center completed x-rays to the left hip and right ankle. [DIAGNOSES REDACTED] was suspected of these sites. They note to continue dressing recommendations from 6/22/16 and for R2 to wear prevalon boots when sitting or lying supine and to follow-up in ortho and infectious disease clinic in July. R2 was treated at the Wound Care Clinic on 7/06/16. The wound assessment notes R2 had 6 different PI's measured and treated. The plan noted was to dress right hip, right ankle, and right mid foot ulcers with santyl, thin gauze and to change them daily. Dress the left fore foot ulcer with xeroform gauze and gauze and to change the dressings daily. Keep pressure off ulcers, change position, every two hours and as needed. Wear offloading boots when sitting/supine. - Addendum sent from wound care notes per impression and plan, in part: 1. Left forefoot ulcer between the fourth and fifth toes. No dressings were applied when she showed up today, dressed this with Xeroform gauze and then gauze and to change the dressing daily. (Emphasis added.) 2. R2 has a stage 2 PI on the right hip, right lateral ankle and right lateral midfoot .Her right lateral heel ulcer appears to have healed. 3. R2 has been evaluated by the wound care infectious disease physician, who did not feel R2 had osteo[DIAGNOSES REDACTED] in the right hip or the right fibula. R2 should have her offloading boots worn when she is sitting in a supine position, R2's position should be changed every 2 hours and as needed. R2 was seen at wound care clinic, on 7/27/16. The report notes that R2 was seen for multiple pressure injuries. The right ankle pressure injury is worse. The plan is to dress the right hip and coccyx with a [MEDICATION NAME] border lite dressing. The right ankle and right midfoot pressure injuries should be treated with santyl and gauze every day. R2 should change position every 2 hours and as needed. R2 should wear the offloading boots when sitting or lying supine. R2's wound assessment, completed 7/28/16, showed the PI on R2's ankle looks worse from last seen. Eschar is present now and wound clinic measured 1.4 x 1.5 x 0.2 cm on 7/27. R2's wound assessment, completed 7/28/16, showed R2's right hip is reddened over the hip prosthesis. The prosthesis is easily felt. R2 is at risk for breakdown related to location of prosthesis. They plan to keep off right hip as much as possible. 10. R2's wound assessment, completed 7/28/16, showed R2 has a Stage 2 PI over the coccyx that was facility acquired. The wound notes state: Stage 2 over coccyx was covered with meflex by wound clinic but was too moist. The treatment was changed to thin duoderm by wound clinic nurse which was used in the past to keep area dry and protected. The wound care provided is noted as: cleanse, thin duoderm, and change every 3 days and as needed. The wound care assessment states this is not a new wound, but this is the first note in the record of a PI to the coccyx. R2's Wound Care Clinic notes, completed 8/12/16, state the left foot ulcer between the 4th and 5th toes has healed and no dressing is needed. The right hip injury has healed and to protect it with duoderm. Change the dressing every 3 days and as needed for 6 more days, then discontinue. The coccyx has a Stage 2 injury that should be dressed with a duoderm and to change it every three days and as needed. R2 should wear the offloading boots when sitting and when lying supine. R2 should change her position every 2 hours and as needed. Keep pressure off the pressure injuries as much as possible. No obvious [MEDICAL CONDITION] associated with the ulcers is noted today. 11. R2's Wound Care Clinic progress notes, dated 9/02/16, states in-part: R2 has a Stage 2 PI to the left coccyx and left posterior superior thigh. Duoderm can be applied and changed every 3 days. Right ischium has healed. R2 has a right midfoot Stage 3 PI laterally and a Stage 4 on the right lateral ankle. They are unchanged in size compared to last visit, but the tendon is visible on the ankle. The physician noted in capital letters; there was NO DRESSINGS in place here today. (Emphasis added.) I again ordered dressings - Xeroform gauze, then gauze and then Kerlix wrap, this should be changed daily. R2 needs to wear offloading boots when sitting or supine and her position changed every 2 hours and as needed. Pressure should be kept off of the ulcers as much as possible. R2's ABI's are normal bilaterally. The right Toe Brachial Index (TBI) is in mild ischemia, the left is in moderate ischemia. With mild arterial insufficiency on the right, I don't think seeing a vascular specialist is warranted at this time. R2's Wound Care Clinic progress note, dated 9/16/16, states in part: Stage 2 on left coccyx has healed. Stage 2 PI's on right and left posterior superior thigh - Duoderm can be applied and changed every 3 days and as needed. Right midfoot Stage 3 PI laterally-now partial thickness and smaller. Stage 4 PI on the right lateral ankle - measures smaller although tendon still seen and has odor, but no [MEDICAL CONDITION] seen. R2 needs to wear offloading boots when sitting or supine and have her position changed every 2 hours and as needed. Pressure should be kept off the ulcers as much as possible. Venous ultrasound on 9/02/16 showed: abnormal study. There is no evidence of [MEDICAL CONDITION] on the right. On the left there is evidence of [MEDICAL CONDITION] partially occluding the superficial femoral vein. This is most likely a chronic clot. R2's Wound Care Clinic progress note, dated 9/30/16, states in part: History of present illness: R2 has multiple PI on the right and left posterior superior thigh - Duoderm changed every 3 days and as needed. No dressings are in place on these areas today, but she has duoderms on buttock bilaterally- there is a new ulcer on left buttock. The Impression and Plan is as follows: Stage 2 PI on right and left posterior superior thighs have healed. New Stage 2 PI on left buttock - apply duoderm and change every 3 days and as needed. Right midfoot Stage 3 PI laterally is healed. Stage 4 PI on right ankle-measures similar in length and width. R2 needs to wear offloading boots when sitting or supine and have her position changed every 2 hours and as needed. Pressure should be kept off the ulcers as much as possible. R2's wound assessment, completed on 10/20/16, showed R2 has a facility acquired PI to the right foot. The measurements noted are 0.5 x 0.5 cm with granulation tissue and a PUSH score of 2. The wound notes state: treatment does not cause pain. Pain is from raising contracted leg. R2 receives 8 oz of Plus 2 at each meal. The wound care provided is: cleanse, xeroform, [MEDICATION NAME]. R2's wound assessment, completed on 11/16/16, and showed R2 has a facility acquired PI to the right heel. The measurements noted are 3.0 x 2.5 cm. The wound notes state: new open area despite foam boots, air mattress, 8 oz of Plus 2 at meals. [MEDICATION NAME] has been put on both feet related to very dry skin. 12. R2's wound assessment, completed on 11/16/16, notes that R2 has a new facility acquired, unstageable PI to the right ischial tuberosity. The measurements noted are 1.4 x 2.0 x 2.0 and the tissue is noted as necrotic with a PUSH score of 7. The wound notes state: New unstageable pressure area over right ischial tuberosity developed since last week. Suspect from odor and green drainage that organism is pseudomonas. R2 had pain with the assessment and dressing change. The writer will as for pain medication and antibiotics per wound nurse. The wound care provided is noted as: cleanse, skin prep, santyl, gauze, [MEDICATION NAME], change two times a day and R2 should be up for meals only. (Emphasis added.) R2's wound care clinic progress note, dated 11/21/16, notes in part: History or present illness that R2 is up for meals only and repositioned every 2 hours, has an air mattress and roho cushion when up in chair per facility notes. She does wear offloading boots. The plan identified is: Stage 2 PI on left buttock has healed, Stage 3 PI on right ischium (new), Stage 4 PI on right lateral ankle is smaller than last visit, Stage 3 PI on the right heel (New), R2 needs to wear off loading boots when siting or supine and have her position changed every 2 hours and as needed. Pressure should be kept off the ulcers as much as possible. R2's wound assessment, completed on 11/30/16, notes that R2's facility acquired PI on the right ankle is unstageable with measurements of 2.0 x 1.3 cm and a PUSH score of 2. The wound notes state: The PI is flat with good granulation. The surrounding tissue is darker in HUE, almost looks like bruising. The wound care provided states: cleanse, xeroform, skin prep and mefis. R2's wound assessment, completed on 12/27/16, notes that the facility acquired PI over R2's coccyx is clean. It has granulation tissue evident at the base of the wound. There is significant tunneling which is hard to measure. The wound is packed with about 6 inches of CA Alginate. All the areas on R2's feet are closed. Skin prep to heel to maintain integrity. R2 continues to wear foam boots, air mattress, turn schedule, and Roho cushion. R2's wound care clinic progress note, dated 1/02/17, states in part: Stage 3 PI on right ischium is smaller in length and larger in width than last visit. Stage 4 PI on right lateral ankle has healed. R2 needs to wear offloading boots when sitting or supine and have her position changed every two hours and as needed. Pressure should be kept off the ulcer as much as possible. R2's wound assessment, completed on 1/18/17, states that the PI on the right ischial tuberosity measures at 1.5 x 1.3 x 0.6 cm. The wound notes state: Wound assessed today. Tunneling noted from 11 to 1 o'clock with the deepest part measuring 1.4 inches in length. The wound bed is pink and moist. No odor was noted on the wound assessment. The wound care provided states: Cleansed with wound cleanser and packed with calcium alginate. Cover with ABD pad as secondary dressing. The teaching provided is noted as: Staff repositioning resident every two hours. R2's wound care clinic progress notes, dated 2/10/17, state in part: Stage 3 PI on right ischium is similar in size since last visit. R2 needs to wear offloading boots when sitting or supine and have her position changed every 2 hours and as needed. The aide states this is being done. Pressure should be kept off the ulcer as much as possible. The aide indicates that R2 is up for meals, otherwise in bed. R2's Wound Care Clinic progress notes, dated 2/24/17, states in part: History of present illness: R2 has a Stage 3 PI on the right ischium. A nurse at the wound care clinic spoke to a facility nurse who stated the PI is larger and that R2 is turned regularly, but not eating well. The impression and plan notes in part: the Stage 3 PI on the right ischium measures differently in size compared with the last visit. It is larger in some dimensions and smaller in other. R2 needs to wear offloading boots when sitting or supine and have her position changed every 2 hours and as needed. R2's Wound Care Clinic progress note, dated 3/10/17, states in part: The impression and plan notes in part: Stage 3 PI on the right ischium measures longer and deeper than the last visit. R2 needs to wear offloading boots when sitting or supine and have her position changed every 2 hours and as needed. Pressure should be kept off the ulcer as much as possible. On 3/14/17, at 08:07am, Surveyor observed R2 seated upright in her Broda chair in the dining room eating breakfast. R2 completed 100% of her meal and extra fluids were accepted. Foam boots were in place. At 09:00am, R2 was assisted via the Broda chair directly into the activity room. R2 was seated along the wall by the TV. At 10:10am, R2 remained in the activity room in the Broda chair seated upright. No change of position was offered or attempted. At 11:00am Surveyor returned to the Activity room where R2 remained in the same location and position, seated upright in the Broda chair. No observed attempts made to reposition or to check if R2 remained clean and dry. At 11:35am, Surveyor observed R2 being assisted in the Broda chair back into the dining room. No change of position made in the Broda chair. At 12:25pm, Surveyor observed R2 seated upright in her Broda chair with no change in position. R2 was now sleeping in her Broda chair at the dining room table. At 12:30pm, Surveyor observed R2 assisted from the dining room by Certified Nursing Assistant (CNA) J back to R2's bedroom. With the assistance of two staff R2 was transferred from the Broda chair back into her bed. R2's pants were removed and red creased lines along with square imprints from the Roho cushion were noted along R2's legs/thigh areas. A strong odor was noted of urine and stool. A disposable brief was removed that appeared saturated and a small amount of black colored stool was present. Surveyor interviewed CNA J about R2's regular routine. CNA J states that R2 does not lie down after breakfast and that R2 likes to go to the activities. CNA J notes that they do routine changes off of R2's pressure points a couple times each day. CNA J stated that after breakfast she changed R2's position in the activity room. Surveyor did not observe any change in position for R2 on 3/14/17 from 08:07 am to 10:10 am. At 11:00 am. Resident was observed in the same place and position in the Broda chair as to when Surveyor observed R2 at 10:10 am. Surveyor continued to observe R2 from 11:00 am through 12:30 pm, with no repositioning. On 3/14/17, R2 was not repositioned from 8:07 am until 12:30 pm when R2 was transferred from the Broda chair back into her bed, a total of 4.5 hours. On 3/14/17 at 12:45, Surveyor interviewed Registered Nurse (RN) H, who stated the intervention used for R2's risk of skin breakdown is to turn and change R2 more often. They do not let R2 (stay) up too long or down too long. They try to keep R2 clean and dry and off the PI for too long. R2 does not use the toilet anymore. RN H stated that it is a lot for R2 to use the bathroom. Surveyor questioned RN H about R2 being up in the Broda chair for 4.5 hours and how long she should be left in her chair with PI on her bottom. RN H replied, it is hard to say what is too long. Surveyor asked RN H about the physician order [REDACTED]. RN H replied that R2 was feeling isolated and was vocal at times. RN H stated that she was unaware that the 11/16/16 physician order [REDACTED]. On 3/14/17 at 1:25pm, Surveyor interviewed RN S, who stated that he is wound care certified and has been working with R2 and her PI areas. RN S stated that he expects that the staff reposition R2 every hour and to lay down every afternoon. When R2 is in bed she should be repositioned every 2 hours. Surveyor questioned RN S about the 11/16/16 physician order [REDACTED]. RN S replied that he knows that the physician's orders [REDACTED]. RN S reviewed the medical record for R2 and identified that the order is in the medical record and that the facility missed it. The order to be up for meals only has been in the medical record every month since November 2016. Surveyor discussed with RN S about R2 being up in her Broda chair from 08:00am this morning and not assisted back to bed until 12:30pm. RN S stated that it was probably too long for R2 to be up in the Broda chair. On 3/14/17 at 2:30pm, Surveyor interviewed Registered Nurse/Nurse Manager (RN/NM) K, Director Of Nursing (DON) B, and Registered Nurse, Vice President of Clinical Information (VP/CI) C. Surveyor asked for information related to the physician order [REDACTED]. RN/NM K stated that MD W's physician's orders [REDACTED]. RN/NM K stated that R2 was lying down after meals but was uncooperative. R2's Husband Family Member (FM) G did not want R2 to be in bed, and it was FM G that asks for R2 to be up as possible and as tolerated. On 3/15/17 at 9:01am, Surveyor interviewed R2's Family Member (FM) G. FM G stated that he is R2's husband and healthcare power of attorney. FN G states that he visits R2 often. He notes that R2 is sitting in that chair all the time. Surveyor questioned if he remembers seeing R2 out of the Broda chair in mornings? FM G replied, I don't think so. Surveyor asked if FM G has any concerns for R2. FM G stated that he is concerned R2 is sitting too long and now has sores. She has got them on her tail bone. She can't move around and she just sits there. Surveyor questioned what his preference is for R2 to attend social activities or to go to bed? FN G replied that it would be alright if R2 was lying down intermittently. FM G stated that after each meal they push R2 in that activity room and that's it. FM G is not even sure that R2 is able to participate in the activities anymore. Surveyor questioned FM G on what his concern and goal would be for R2 to be up and active, participating in the activities or to work on getting her off her butt and out of the chair off the sores (PI)? FM G stated that he is very concerned with the sores and would rather see those sores healed up. It is more important than the activities. On 3/15/17 at 10:10am, Surveyor interviewed RN/NM K, DON B, and VP/CI C about R2's PI and wound care interventions: *DON B stated after R2 developed the Stage 2 on her left buttock on 5/25/16, dietary added a protein supplement called Plus 2 at each meal. The facility also added a Roho cushion in October of 2015, a pressure reduction mattress/low air loss mattress in March of 2016. The MD was notified and the treatment/dressings were changed. A care plan was initiated on 3/29/16 but no new interventions were noted except the dressing changes. It was noted that on 6/15/16 the PI on the left buttock was healed. *DON B stated that related to the Care Plan she would consider the new interventions as the changes in the treatment orders. DON B would expect the treatment orders to be noted on the Treatment Administration Record (TAR) and the nurses would have to sign them out. Those interventions would be monitored on the TAR. *DON B stated that on 6/22/16 wound care clinic took x-rays and diagnosed R2 with [DIAGNOSES REDACTED]. Surveyor notes on 8/04/16, R2 was administered antibiotic for a right foot infection. DON B identified that this was related to the osteo[DIAGNOSES REDACTED] and the intervention would be the antibiotics. On the care plan the [DIAGNOSES REDACTED]. *RN/NM K stated the facility follows the current standards of practice (SOP) related to proper turning and repositioning. RN/NM K would expect the staff to follow the current SOP, but they have not been added turning and repositioning to the care plan at this time. *Surveyor notes on 11/16/16 an unstageable PI was noted on R2's right ischial tuberosity and no changes were made to the care plan. New orders were received from MD W for R2 to be up for meals only. This never made it to the care pla

Based upon interview and record review, the facility did not ensure that 2 (Residents #2 and #1) of 2 sampled Residents reviewed received adequate supervision and assistance devices to prevent accidents. ~ Resident #2 was identified by the facility to be at risk for falls. On 7/15/14 Resident #2 fell . The care planned interventions at the time of the fall included for Resident #2 to use her walker and use a call light to ask for assistance, neither of which was utilized at the time of the fall. The fall report indicates that Resident #2 is independent in her transfers and independently can get herself to the bathroom. This is not consistent with the Resident's assessments. Following this fall no changes were made to the Resident's care plan, even though staff was now on notice that Resident #2 would not always use her call light or her walker. On 10/3/14 Resident #2 fell and fractured her hip when attempting to toilet herself. During this fall Resident #2 again did not use the care planned interventions of using a walker and remembering to use her call light. Resident #2 returned to the facility from the hospital and now utilizes a Broda chair to sit in. ~ Resident #1 was admitted to the facility for respite care and was identified to be at risk for falls upon admission. At the time of admission, a care plan was not developed to address Resident #1's risk for falling. A care plan was developed 4 days after admission and then did not specifically address individualized approaches to prevent Resident #1 from falling; including the level of supervision when in common areas of the facility. On 10/6/14 the Resident fell when seated in her wheelchair in the activity room, as staff came and went from the room, and sustained a hip fracture. Findings include: 1.) On 10/13/14 surveyor # began record review for Resident number #2. Resident #2 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #2's 4/29/14 quarterly Minimum Data Set (MDS) indicates that Resident #2 is at risk for falls and requires one person physical assist for transfers and walking. For locomotion on the unit the MDS indicates that she requires extensive assistance. The MDS also indicates that Resident #2's balance is unsteady and that she is only able to stabilize with staff assistance and that she utilizes a wheelchair for assistive devices. Surveyor # began review of the fall that Resident #2 had on 7/15/14 and noted that the care plan was not immediately updated after this fall. Surveyor # noted that the fall huddle report dated 7/15/14 indicates that during this fall Resident #2 did not use her walker nor did she use a call light prior to attempting to walk to the facility sun room. The report indicates that the use of the walker and asking for help with the call light are interventions that were in place at the time of the fall and the recommended intervention post fall is to call for help before trying to ambulate. The care plan approaches only address the resident's attempts to "crawl to the bathroom", and other interventions related to toileting. The facility fall investigation document also states that the resident's fall was witnessed by the writer of the document and 2 other staff persons, however there were no statements from any staff related to this incident. It is unclear of the resident's level of supervision at the time of this fall. Review of the fall huddle report dated 7/15/14 indicates that Resident #2 gets up to use the bathroom at night often and that she is independent. Surveyor # noted that the indication that Resident #2 is independent in her transferring is not consistent with facility assessments, including the MDS. Review of Resident #2's quarterly MDS dated [DATE] indicates that Resident #2 is at risk for falls and that she requires the physical assistance of 1 staff person for transfers, walking in room and the corridor and moving about the facility unit. Resident #2 also requires the assistance of 1 staff person for toilet use. The MDS indicates that Resident #2 continues to have balance issues and can steady herself. Resident #2's care plan dated 7/29/14 for falls indicates as a goal that Resident #2 will remain free of injury x (times) 90 days with a goal date of 10/14. Approaches include: Monitor/anticipate/intervene for factors causing prior falls: specify family states she often crawls to the bathroom. Maintain safe environment, bed in low position, soft touch call light on bed to alert staff when she tries to rise, clutter free pathways, curved mattress. Fall leaf magnet, toileting schedule PRN (as needed) and offer assist daily early am 5-6:00. Encourage res (resident) involvement in active sports, exercise and strength and balance programs. Encourage participation in activities as is less likely to focus on bladder. Will try to rise to find bathroom or will scoot in chair to find a bathroom. Surveyor # noted that despite the indication on this care plan that Resident #2 has a tendency to focus on her bladder and will want to use the bathroom often and will try to seek it out, the care plan did not establish a set toileting schedule but rather indicates an as needed toileting care plan with an early in the day start range that can begin between 5-6:00 am. Surveyor # noted that the care plan does not clearly identify when the facility identified the potential for falling to be a problem for Resident #2 as the care plan does not include a date that this concern was identified. Despite knowledge that Resident #2 would not always use her call light or walker, as evidenced by her fall on 7/15/14, these approaches remained on the care plan. On 10/3/14 at 22:45 (10:45pm) Resident #2 was heard crying out from her room and was found sitting on the floor at the foot of her bed with her walker 2 feet from her bed, according to the facility resident accident/incident report dated 10/3/14. The Resident indicated that her left hip hurt and that she was unable to move her left leg. The fall huddle report indicates that she was trying to go to the bathroom and that she was last checked at 22:30 (10:30 pm) and last toileted at 20:00 (10:00 pm). The huddle report indicates that the Resident did not use her walker and that she did not use the call light to ask for help. The report indicates that the Resident is independent in her transfers which, is inconsistent with her assessments. The huddle report is blank where it asks if the care plan was updated post fall and states "gets up on own to use toilet. Able to get to toilet on own many times/day. Will need therapy after hospitalization ." Following this fall Resident #2 was sent to the hospital and was diagnosed with [REDACTED].#2 returned to the facility on [DATE]. Review of Resident #2's care plan dated 10/9/14 indicates as a goal that Resident #2 will remain free of injury x (times) 90 days with a goal date of 1/15. Approaches include: Monitor/anticipate/intervene for factors causing prior falls: specify family states she often crawls to the bathroom. Maintain safe environment, bed in low position, soft touch call light on bed to alert staff when she tries to rise, clutter free pathways, curved mattress. Fall leaf magnet, toileting schedule PRN (as needed) and offer assist daily early am 5-6:00. Encourage participation in activities as is less likely to focus on bladder. Will try to rise to find bathroom or will scoot in chair to find a bathroom. Hand written is more comfortable in Broda chair - fewer requests to use bathroom. Surveyor # noted that the falls care plan for Resident #2, post a fall with a fracture, still does not clearly identify individualized approaches to help prevent Resident #2 from falling again. The care plan contains the same approaches that were in place prior to her October 4th fall which were unsuccessful in preventing her from falling on both 7/15/14 and 10/3/14. On 10/13/14 at approximately 1:45pm Surveyor # interviewed Director of Nursing (DON)-B regarding Resident #2's falls and the care plans to prevent falls. Surveyor # asked DON-B why there is not a date on the care plans that clearly indicates when the facility identified falls to be an area of concern for Resident #2. DON-B indicated that she is not sure why there is no start date indicated related to when the Resident's fall risk was identified and she is not sure if the start date for the approaches are accurate because they have a lot of problems with the AOD charting system. She also stated that it is the expectation that the care plan should be updated immediately after any significant changes related to the resident. When asking about the Resident's falls, DON-B indicated that for the July fall Resident just got up from her wheelchair, in the hallway and began attempting to walk without assistance and this is what caused the fall. DON-B stated that several other staff were present at the time of this fall but she did not have any written statements from them. In regards to the 2nd fall she stated that the Resident fell attempting to toilet herself and her care plan was updated the next day on this incident. DON-B indicated that all of the information regarding these falls should be on the falls reports. 2.) Resident #1 was admitted to the facility for short term respite stay. Per clinical record review, Resident #1 has Alzheimer's Dementia, generalized weakness and Osteoporosis. The resident was also identified to be alert with short and long term memory problems. The "Nursing Admission Data Base" dated 09/22/14 (day of admission) identified that Resident #1 has weakness in her right and left legs and requires assistance with her mobility. The "Fall Risk Evaluation" also dated 09/22/14 identified that Resident #1 was at risk for falls based on the eight clinical condition parameters of mental status, history of falls, ambulation, vision, gait and balance, blood pressure, medications and predisposing diseases. Per the assessment tool a "total score of 10 or above represents HIGH RISK." Resident #1 scored 12 for this assessment therefore identifying her at high risk for falls. A review of the care plan with a "start date" of 09/26/14 (4 days after admission) identified Resident #1 as having "Fall potential with potential for injury related to dementia as evidence by unsteady gait, needed assist with transfers." The goal identified states, "will remain free of injury as evidenced by free of falls or accidents times 90 days, goal date of 12/25/14." The interventions documented as follows, "monitor/anticipate/intervene for factors causing prior falls," "maintain safe environment-bed in low position, call light within reach, clutter free pathways," "complete falls risk assessment on initial admission and quarterly per facility policy," "ensure adaptive appliances/devices are accessible to resident and in good working order, wheelchair for long distances," "provide activities that minimize potential for falls while meeting other needs," "recreation C.O.T.A to provide ambulation/ROM/walking program," "assist with transfers as needed," "make sure resident is alert and prepared for the transfer." The last intervention states "to be in recliner chair in activity room" with a start date of 10/06/14. On 10/06/14 per clinical record and per facility investigation, Resident #1 who was seated in her wheelchair in the lounge/dayroom after an activity, stood up without assistance and fell on to her left side also striking her head on the wall. Per the clinical record, the resident "complained of pain to her left hip and right inner thigh, unable to give ROM (range of motion) to left lower extremities without resident yelling out in pain." The resident was transferred to the hospital after notification to the physician and the resident's son. Evaluation and admission to the hospital concluded that the resident had sustained a fractured left hip. The resident was hospitalized and received surgery for [REDACTED]. Per interview with the DON on 10/13/14 at 11:00 a.m., surveyor requested evidence of the initial care plan that was established on admission after assessing at the time of admission that Resident #1 was at risk for falls. Per the DON the care plan that Surveyor was currently viewing was the only care plan. When questioned as to the last intervention that states that the resident is to be in the recliner chair in activity room, the DON stated that the resident was to be placed in the recliner only to keep her feet elevated at the request of the resident's spouse. Surveyor then requested what interventions were put into place to prevent falls as the identified care plan does not address individualized interventions or approaches including supervision of the Resident. There was no evidence of a initial care plan for Resident #1 and no evidence that the care plan started 09/26/14 addressed the supervision and safety of the resident. Per interview with RN-C (registered nurse) on 10/13/14 at 11:30 a.m., RN-C stated that she was not on duty when the resident was admitted and was not able to answer questions regarding the resident's care plan. RN-C did state that Resident #1 "was total cares, fed by staff, two staff required to pivot her on/off the toilet." The failure of the facility to ensure that Resident #1 had individualized interventions that included supervision based on the admission fall assessment that had identified her at risk for falls, created harm to the resident who sustained a fall with injury. These findings were shared with the NHA and DON on 10/13/14.