Every finding on record at Pavilion at Glacier Valley

Based on observation, interview, and record review, the facility did not ensure adequate supervision and staff education were provided for 1 resident (R) (R1) of 10 sampled residents following two incidents of familial abuse. On [DATE], staff heard Family Member (FM)-G yell at R1 and observed them slap R1 on the arm. On [DATE], staff entered R1's room and observed FM-H with a hand in R1's groin. FM-H was arrested and a no contact order was issued. Information was not posted or available at the nursing station on R1's unit to alert staff that FM-H was not allowed in the building and could not visit R1. In addition, R1's care plan was not updated to alert staff of the abuse and no contact order and the incidents were not documented in R1's medical record. Findings include: The facility's undated Abuse Prevention, Identification & Reporting policy indicates: Residents have the right to be free from: Abuse .Types of Physical Abuse: .slapping .Possible indicators: Bruising .Verbal Abuse: Includes spoken .or gestured communication that is degrading, threatening, or offensive .All staff are mandatory reporters. Immediately report: Suspected or witnessed abuse .Inappropriate staff, visitor, or family behavior The facility will: .Implement immediate interventions to protect residents .Documentation should always be: Objective; Timely; Factual .Document: Exact observations; .Notifications made; Interventions initiated; Witnesses and relevant details . R1 was admitted to the facility on [DATE] following a hospitalization for a left hip fracture and had diagnoses including cognitive communication deficit, cerebrovascular accident (CVA) (otherwise known as stroke), insomnia, and depression. R1's Minimum Data Set (MDS) assessment, dated [DATE], stated R1 had a Brief Interview for Mental Status (BIMS) score of 5 out of 10, indicating severely impaired cognition. R1 required moderate to substantial assistance with activities of daily living (ADLs) and had an activated Power of Attorney for Healthcare (POAHC) as of [DATE]. A facility-reported incident (FRI) submitted to the State Agency (SA) on [DATE] indicated Assistant Director of Nursing (ADON)-M heard tense, raised voices coming from R1's room on [DATE] at 12:35 PM and approached the open doorway. ADON-M heard FM-G yell something at R1, and observed FM-G slap R1 on top of the right hand and forcefully grab R1's right upper and lower arm. ADON-M instructed FM-G to stop and separated the two. When ADON-M stated FM-G's behavior was inappropriate, FM-G indicated R1 was their mother and they could do what they wanted. FM-G stated they lightly held R1's upper arm and denied they slapped or roughly handled R1. The police were notified. Supervised visitation was implemented for FM-G pending completion of the facility's investigation. The investigation indicated R1 appeared confused during the incident but felt safe in the facility, denied any abuse, and did not appear to be upset. An initial assessment did not reveal any injuries or bruising; however, an assessment completed at 1:50 PM identified bruising on R1's right upper arm, left arm, and left thumb. A FRI submitted to the SA on [DATE] indicated Speech Therapist (ST)-O entered R1's room on [DATE] at approximately 3:00 PM and observed FM-H lying on R1's bed. R1 was seated in a wheelchair adjacent to the bed. FM-H's hand was in R1's groin area. FM-H appeared startled, removed their hand, and began discussing discharge plans. ST-O removed R1 from the room. The police and Adult Protective Services (APS) were notified. APS reported a no contact order was initiated. FM-H was not allowed to contact or visit R1 and was prohibited from entering the facility. The investigation included a review of R1's behavioral patterns since admission. Staff reported R1 was usually calm, cooperative, sociable, and easily redirectable when family were not present. Family visits frequently resulted in increased confusion, emotional distress, verbal agitation, and repeated requests for R1's deceased spouse. R1 frequently misidentified FM-H as their spouse and became distressed when family attempted to orient R1 to reality. The investigation indicated the facility was committed to maintaining R1's safety and dignity while cooperating with any ongoing investigations. A care plan, initiated [DATE], indicated R1 had a diagnosis of post-traumatic stress disorder (PTSD)/trauma and was at risk for periods of anxiety, fearfulness, irritability, poor sleep, destructive behavior, nightmares, and flashbacks. (Of note: R1's diagnoses list did not contain a diagnosis of PTSD/trauma.) A goal indicated R1 would have a reduction in unwanted mood or behaviors stemming from the effects of PTSD. The care plan contained the following interventions: Encourage R1 to verbalize feelings and fears; Establish a trusting relationship with R1 and identify PTSD symptoms .; Identify known and/or potential triggers and develop an action plan if traumatic feelings are triggered; Assure R1 of their safety as needed; Avoid unnecessary touching. (Of note: The care plan did not mention familial abuse, supervised visits, or that FM-H was prohibited from contacting R1 or visiting the facility.) R1's medical record did not contain mention of the incidents on [DATE] and [DATE]. On [DATE] at 9:05 AM and 11:29 AM, Surveyor interviewed Registered Nurse (RN)-I who was working on R1's unit. When asked about family visitation for R1, RN-I indicated R1 and FM-G usually visit in the dining room and staff prefer to have them visit in common areas. RN-I was not sure if R1 and FM-G required supervision during visits or if they could visit in R1's room with the door closed. RN-I indicated there used to be a posting at the nursing station that indicated FM-H could not visit but it must have been removed. When asked how staff are aware of the family abuse allegations and know that FM-H can't contact or visit R1, RN-I stated the information is passed on in report. RN-I verified the facility uses agency staff. RN-I stated family was visiting with R1 in the dining room at that time. When asked if R1 was visiting with FM-G, RN-I wasn't sure and stated FM-G had a twin and it was difficult to tell them apart. (Of note: Surveyor did not observe a posting or any visible information related to FM-H at the nursing station on R1's unit.) On [DATE] at 11:27 AM, Surveyor interviewed RN-L who was working at the nursing station on R1's unit. RN-L stated they were training and weren't aware of any restricted visitation for R1. On [DATE] at 11:40 AM, Surveyor interviewed Receptionist (RCP)-E who stated there is a staff member at the front desk from 8:00 AM-7:00 PM on weekdays and 8:00 AM-4:00 PM on weekends. RCP-E showed Surveyor a posting at the desk that contained FM-H's name and picture and stated FM-H is not allowed in the building and cannot go past the lobby. The posting instructed staff to ask FM-H to leave immediately and to call the police and Nursing Home Administrator (NHA)-A if FM-H refused. RCP-E was not sure if the information was posted anywhere else in the facility. (Of note: Surveyor entered the facility at approximately 8:00 AM that morning and waited for staff at the reception desk for approximately 1 minute before walking down the hall to Assistant Director of Nursing (ADON)-M's office which was near the nursing station for the 400-600 units.) On [DATE] at 11:45 AM, Surveyor observed the nursing station on the 400-600 units which did not contain a posting or visible information related to FM-H. On [DATE] at 11:45 AM, Surveyor interviewed Housekeeper (HSK)-P who was cleaning the unit across the dining room from R1's unit. HSK-P was not aware of anyone who could not visit the facility and did not receive related education. (Of note: The facility provided an education sheet signed by HSK-P on [DATE] (which was before the incident with FM-H) that indicated HSK-P received education on abuse prevention and identification.) On [DATE] at 11:52 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who recently started on R1's unit and was orienting with staff. CNA-K was not aware of any restricted visitation for R1. On [DATE] at 11:57 AM, Surveyor interviewed ADON-M who stated the front desk is staffed from 8:00 AM-6:00 PM seven days per week. ADON-M stated FM-H was registered in the facility's electronic visitor sign-in system which would alert designated staff if FM-H attempted to sign in. Surveyor informed ADON-M there wasn't a posting or information at the nursing stations to indicate FM-H cannot visit. When asked how staff know FM-H cannot not visit if FM-H enters the facility when staff are away from the reception desk, ADON-M stated multiple stafff would recognize FM-H. ADON-M verified R1's care plan did not indicate why R1 had PTSD/trauma and did not indicate R1 had been abused by family and there was a no contact order in place for FM-H. The care plan also did not contain information related to monitoring family visits or encouraging visits in common areas. ADON-M indicated supervised visits for FM-G were discontinued but was not sure when they were discontinued. On [DATE] at 12:08 PM, Surveyor interviewed NHA-A and Director of Nursing (DON)-B via phone. DON-B indicated Social Services Director (SSD)-N initiated a trauma care plan for R1. NHA-A indicated they discussed posting information related to FM-H at the nursing station on R1's unit so staff were aware if FM-H attempted to enter the unit, however, they didn't want R1 or their family to get upset if they saw the posting. NHA-A indicated FM-H hadn't attempted to visit since the incident and was still detained. Regarding supervised or monitored visits for FM-G, NHA-A indicated they ended shortly after the facility's investigation of the incident on [DATE]. NHA-A stated R1's family members didn't trust the facility and would rather meet in a common area. NHA-A verified the abuse incidents weren't documented in R1's medical record or on R1's care plan so staff, especially newly hired staff and agency staff, were aware. On [DATE] at 12:30 PM, Surveyor interviewed SSD-N who verified R1's PTSD/trauma care plan did not indicate why R1 had PTSDS or trauma and did not provide an accurate representation of R1 or their family dynamics. On [DATE] at 1:05 PM, ADON-M approached Surveyor and indicated SSD-N posted information related to FM-H at the nursing station on R1's unit and updated R1's care plan. In addition, a progress note was added to R1's medical record regarding the incident on [DATE] and indicated FM-H was prohibited from contacting R1.

Based on observation, interview, and record review, the facility did not post required direct care staffing levels in a timely or accurate manner. This practice had the potential to affect all 67 residents residing in the facility.The 6/11/26 daily direct care staff was not posted in a timely manner. In addition, daily direct care staff postings did not list the hours worked per shift or correct shift times. Findings include:The facility's Posting of Licensed and Unlicensed Direct Care Staff policy, revised 11/1/17, indicates: The Director of Nursing (DON) or designee shall post the direct care staffing on a daily basis .1. Direct care staffing for licensed and unlicensed staff is posted on a daily basis. 2. Data requirements for posting include the following information: .C. The total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1) Registered Nurses (RNs); 2) Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs); 3) Certified Nurse Aides (CNAs); .A. The facility must post the nurse staffing data specified in the above section on a daily basis at the beginning of each shift .On 6/11/26 at 8:42 AM, Surveyor observed the direct care staff posting at the reception desk which was dated 6/10/26. Receptionist (RCP)-E was at the desk but did not know when the staffing information for 6/11/26 would be posted. RCP-E confirmed Staff Coordinator (SC)-C posts the daily schedule and works from 8:00 AM-3:00 PM. Surveyor noted the 6/10/26 posting listed the AM shift as 6:00 AM-2:30 PM, the PM shift as 2:00 PM-10:30 PM, and night (NOC) shift as 10:00 PM-6:30 AM. Direct care staff titles were listed as RN, LPN, Certified Medication Tech (CMT), and CNA with a handwritten number behind each title that indicated how many staff were working for each of the 3 shifts. The column titled actual hours worked for each discipline was not completed.On 6/11/26 at 9:11 AM, Surveyor observed the 6/11/26 direct care staff posting at the reception desk. The posting included the census and number of staff working per shift per discipline, however, the actual hours worked column was not completed. Shift times were the same as the 6/10/26 posting. On 6/11/26 at 9:30 AM, Surveyor compared the posting to the nursing department schedule. The numbers on the posting matched the names on the schedule, however, the schedule indicated one of the AM shift CNAs was scheduled until 10:00 AM versus the full shift. The direct care staff posting did not reflect the actual hours worked by nursing staff, including whole and partial shifts.On 6/11/26 at 9:45 AM, Surveyor interviewed SC-C who was responsible for the nursing department schedule and completed the direct care staffing posts. SC-C indicated the hours staff work is based on the census. SC-C stated the facility uses a patient per day (PPD) calculation which may reduce the hours worked in a shift. SC-C provided examples of having a CNA work from 6:00 AM-10:00 AM, 2:00 PM-6:00 PM, or 6:00 PM-10:00 PM. SC-C indicated staff hours are cut when the census is lower and added when the census is higher. When Surveyor indicated the posting did not indicate the actual hours, SC-C was not aware the posting should include actual hours worked. SC-C indicated they do not complete the actual hours worked until the day is over, therefore, it is not reflected on the daily posting for residents or visitors to see. On 6/11/26 at 1:31 PM, Surveyor reviewed direct care staffing posts with Human Resources Representative (HRR)-D from the last 12 months which contained the actual hours worked. HRR-D indicated the actual hours worked are entered after the posting is taken down and used as a tool for tracking purposes. HRR-D stated staff education will be completed to ensure actual hours are listed on the posting for residents and family to see in real time. On 6/11/26 at 2:00 PM, Surveyor observed AM shift nursing staff on the long-term care unit and expected to see PM staff starting at 2:00 PM. Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated the PM shift starts at 2:30 PM. Between 2:12 PM and 2:25 PM, Surveyor observed PM shift staff enter the unit to begin their shift. On 6/12/26 at 3:21 PM, Nursing Home Administrator (NHA)-A indicated the current shift times are as follows: CNAs: AM shift: 6:00 AM-2:30 PM; PM shift: 2:15 PM-10:45 PM; NOC shift: 10:30 PM-7:00 AM; Nurses: AM shift: 6:00 AM-2:30 PM; PM shift: 2:00 PM-10:30 PM; NOC shift: 10:00 PM-6:30 AM. Surveyor noted the PM and NOC shift times for CNAs were different than the times listed on the direct care staffing post which indicated the PM shift was from 2:00 PM-10:30 PM and the NOC shift was from 10:00 PM-6:30 AM.

Based on observation, staff interview, and record review, the facility did not ensure menus and serving sizes were followed. This practice had the potential to affect all 67 residents residing in the facility. On 2/17/26, the lunch menu indicated the vegetable was seasoned broccoli. Residents were served wax beans instead and were not notified of the menu change.On 2/17/26, the lunch menu included a fresh baked roll and cheesecake. Residents with pureed diets did not receive a roll and received applesauce instead of cheesecake. On 2/17/26, residents with consistent carbohydrate diets were served a dinner roll for lunch but were not supposed to receive a dinner roll.On 2/17/26, lunch portion sizes were not followed in accordance with the menu.Findings include:The facility's Menus policy, revised 10/15/25, indicates: The current menu is posted in the facility so it is available to residents and staff. Make appropriate substitutions when items on the menu are not available. Record these substitutions and keep the records on file with the menus. Substitutions offer similar nutritive value to the food being replaced and are approved by the facility's dietitian. The facility's Therapeutic Diets policy, revised 10/15/25, indicates: .6. Portion sizes are evident for each item on the extended menu .8. Prepare and serve all therapeutic and mechanically-altered diets as planned. 9. Check all trays for accuracy before they are served to residents. 1. On 2/17/26 at 11:28 AM, Surveyor observed [NAME] (CK)-K serve lunch. A lunch menu posted in the dining room indicated: Red beans, rice, and sausage; Fresh baked roll; Seasoned broccoli; and Cheesecake. Surveyor noted wax beans were served instead of broccoli. Surveyor interviewed CK-K regarding the change in vegetable. CK-K was not sure why there was a change and stated when CK-K came in that morning, the meal was being prepared. CK-K did not think residents were notified of the menu change. On 2/17/26 at 12:20 PM, Surveyor interviewed Registered Dietitian (RD)-J who confirmed residents should be notified if there are substitutions or changes to the menu.2. From 2/15/26 to 2/17/26, Surveyor reviewed R31's medical record. R31 was admitted to the facility on [DATE] and had a diet order that indicated: House, 3 honey/moderately thick 3, pureed, large protein portions.From 2/15/26 to 2/17/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had a diet order that indicated: House, pureed, large protein portions, Kennedy cup.On 2/17/26 at 11:28 AM, Surveyor observed CK-K serve lunch meal in the dining room and prepare plates for R31 and R10. Surveyor noted R31 and R10 did not receive a dinner roll. When asked why R31 and R10 did not receive a dinner roll, CK-K asked Dietary Aid (DA)-H if there were any pureed dinner rolls.On 2/17/26 at 12:04 PM, DA-H stated DA-H did not puree dinner rolls for residents on pureed diets. When asked if residents on pureed diets received pureed cheesecake, DA-H stated residents on pureed diets were getting applesauce instead. DA-H stated DA-H did not puree cheesecake because DA-H was not sure if the crust would puree. On 2/17/26 at 12:10 PM, RD-J entered the kitchen and informed DA-H that the top of the cheesecake could have been pureed for residents on pureed diets who should receive the same items that residents on regular diets receive. 3. From 2/15/26 to 2/17/26, Surveyor reviewed R44's medical record. R44 was admitted to the facility on [DATE] and had a diet order that indicated: Consistent carbohydrate.From 2/15/26 to 2/17/26, Surveyor reviewed R36's medical record. R36 was admitted to the facility on [DATE] and had a diet order that indicated: Consistent carbohydrate, mechanical soft, chopped meats, extra gravy, Kennedy cup.R49 was admitted to the facility on [DATE]. R49 had a diet order that indicated: Consistent carbohydrate.On 2/17/26 at 11:28 AM, Surveyor observed CK-K serve lunch. The extended menu indicated residents on consistent carbohydrate diets should not receive a dinner roll. Surveyor observed dinner rolls on R44, R36, and R49's trays.On 2/17/26 at 12:20 PM, Surveyor interviewed RD-J who confirmed residents with consistent carbohydrate diets should not receive dinner rolls.4. The extended menu for the 2/17/26 lunch meal indicated the following portion sizes: 8 ounces (oz) of red beans, rice, and sausage.On 2/17/26 at 11:28 AM, Surveyor observed CK-K serve lunch in the dining room and use a 6 oz scoop for regular red beans, rice, and sausage and a 4 oz scoop for pureed and mechanical red beans, rice, and sausage. Surveyor observed CK-K provide one scoop of red beans, rice, and sausage for all of the meals which meant residents with regular diets received 6 oz instead of 8 oz of red beans, rice, and sausage. Residents with pureed and mechanical diets received 4 oz instead of 8 oz of red beans, rice, and sausage.On 2/17/26 at 12:20 PM, Surveyor interviewed CK-K. When asked how CK-K determined scoop sizes, CK-K stated the scoops were laid out for CK-K when CK-K arrived at 10:00 AM. RD-J was present during the interview and indicated CK-K should check to make sure the scoop sizes are correct for the portions.

Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 67 residents residing in the facility. Temperature logs for meal service were not consistently completed. Hand hygiene was not completed appropriately during the lunch meal on 2/17/26.Staff did not consistently test the internal temperatue of the dishwasher. Serving utensils and bowls were not stored properly to prevent contamination.Staff did not consistently document the parts per million (PPM) of the sanitizing solution in sanitizing buckets.Findings include:On 2/15/26 at 9:15 AM, Surveyor completed an initial kitchen tour with [NAME] (CK)-G who was not sure which food code the facility follows. Nursing Home Administration (NHA)-A later informed Surveyor that the facility follows the Federal Food and Drug Administration (FDA) Food Code.Temperature Logs:The 2022 FDA Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that: I) Employees are properly maintaining the temperatures of time/temperature controlled foods for safety during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures. During the initial kitchen tour on 2/15/26, Surveyor requested to review cooking and holding temperature logs which CK-G provided. Surveyor noted the following: ~ On 2/1/26, dinner temperatures were not documented.~ On 2/12/26, 2/13/26, and 2/14/26, breakfast, lunch, and dinner temperatures were not documented.~ On 2/15/26, breakfast temperatures was completed, however, the log did not contain breakfast temperatures. CK-G stated CK-G had not completed the log.Hand Hygiene:The facility's Nutrition Policies and Procedures: Hand Hygiene/Hand Washing policy indicates: Wash hands: After contact with soiled or contaminated articles, such as dirty dishes. The 2022 FDA Food Code documents at 3-301.11 Preventing Contamination from Hands: Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. On 2/17/26 at 11:28 AM, Surveyor observed CK-K serve lunch meal in the main kitchen. The menu contained dinner rolls. CK-K had gloves on and was taking serving temperatures when Surveyor walked into the kitchen. Throughout meal service, Surveyor observed CK-K touch scoop handles, make a grilled cheese sandwich, touch CK-K's clothing, and continue, with the same gloved hand, to put dinner rolls on plates. On 2/17/26 at 12:07 PM, Surveyor interviewed Registered Dietitian (RD)-J who confirmed CK-K should use tongs or a utensil to put dinner rolls on plates. Dishwashing Temperatures: The 2022 FDA Food Code documents at 4-302.13 Temperature Measuring Devices, Manual and Mechanical Warewashing:(B) In hot water mechanical warewashing operations, an irreversible registering temperature indicator shall be provided and be readily accessible for measuring the utensil surface temperature.A dishwashing log posted near the dishwashing area indicated the rinse temperature should reach 180 degrees Fahrenheit (F).On 2/17/26 at 1:13 PM, Surveyor observed Dietary Aid (DA)-H and DA-I wash dishes in a mechanical hot water sanitizing dishwasher. Surveyor observed 4 loads of dishes go through the machine and noted the rinse temperature reached 172 degrees F. When Surveyor asked DA-H and DA-I to run a temperature test strip through the dishwasher to test the surface temperature, DA-H and DA-I were not sure where the test strips were stored. Surveyor observed the dishwashing log and noted an internal test strip was last run through the dishwasher on 2/6/26. CK-K looked behind the dishwashing log and found a test strip for the sanitizing buckets. DA-H, DA-I, and CK-K could not find internal dishwashing temperature strips and did not know how often the internal surface temperature should be tested. When Surveyor exited the dishwashing area, Nursing Home Administrator (NHA)-A was in the dining room. Surveyor informed NHA-A that the dishwasher was not reaching the appropriate rinse temperature. NHA-A also attempted to find a test strip but could not find one. NHA-A was not sure what the facility's policy stated regarding how often internal surface temperatures should be tested. On 2/17/26 at 1:24 PM, NHA-A approached Surveyor and stated the test strips were found. NHA-A stated staff ran a test strip through the dishwasher which indicated an appropriate surface temperature. NHA-A also stated the facility asked a company to look at the dishwasher. Storage:The 2022 FDA Food Code documents at 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: (B) Clean equipment and utensils shall be stored (2) Covered or inverted. During an initial kitchen tour on 2/15/26, Surveyor observed a stack of mixing bowls stored upright. CK-G verified the bowls should be stored upside down on the shelf. During an initial kitchen tour on 2/15/26, Surveyor observed uncovered plastic containers of various serving utensils on a bottom shelf next to the deep fryer. The shelf above the utensils contained a toaster oven. CK-G confirmed the utensils should be covered but stated the bins were so full that the covers did not close. CK-G verified crumbs from the toaster oven and splatter from the deep fryer could contaminate the utensils. CK-G stated CK-G tries to ensure crumbs from the toaster do not fall into the bins of serving utensils when CK-G makes toast. Sanitizing Solution:The 2022 FDA Food Code documents at 2-103.11 Person in Charge: The person in charge shall ensure that: (L) employees are properly sanitizing cleaned multi-use equipment and utensils before they are reused, through routine monitoring of solution temperature and exposure time for hot water sanitizing, and chemical concentration, pH, temperature, and exposure time for chemical sanitizing.On 2/17/26 at 1:13 PM, Surveyor asked CK-K how often the sanitizing buckets are tested. CK-K indicated the AM cook tests the sanitizing solution in the morning and before lunch. CK-K indicated the facility did not have a log to document PPM of the sanitizing solution. On 2/17/26 at 1:24 PM, Surveyor asked CK-K to test PPM of the sanitizing solution in the sanitizing bucket. CK-K was unsure how many PPM the test strip should indicate. Another staff stated there was a poster above the sink that indicated the correct PPM. NHA-A was present when CK-K confirmed the facility did not have a log to doucument PPM of the sanitizing solution. NHA-A was not sure if the facility had a policy or procedure for testing PPM of the sanitizing solution.

Based on staff and resident representative interview and record review, the facility did not ensure a Power of Attorney for Healthcare (POAHC) was notified of a change in condition for 1 resident (R) (69) of 18 sampled residents.R1's primary POAHC was not notified of two new skin abrasions that were discovered on 1/22/26.Findings include: From 2/16/26 to 2/17/26, Surveyor reviewed R69's medical record. R69 had diagnoses including unspecified focal traumatic brain injury with loss of consciousness greater than 24 hours with return to pre-existing conscious level, mild neurocognitive disorder due to known physiological condition with behavioral disturbance, diffuse traumatic brain injury without loss of consciousness, subsequent encounter, delusional disorders, and contracture of muscle. R69's Minimum Data Set (MDS) assessment, dated 1/15/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R69 had intact cognition. R69 had an activated POAHC.R69's POAHC document indicated POAHC-M was R69's chosen healthcare agent. The document indicated if POAHC-M was unable or unwilling to make healthcare decisions for R69, POAHC-N would make healthcare decisions for R69. The document indicated POAHC-M is considered unable to make healthcare decisions if POAHC-M is too ill to act for R69, is unavailable either temporarily or permanently, or is dead. POAHC-M is also considered unavailable to make healthcare decisions for R69 if POAHC-M cannot be reached by telephone within a reasonable period of time given the healthcare decision that must be made, or if POAHC-M has stated in writing that POAHC-M is unavailable to make healthcare decisions for R69 for a period of time. If POAHC-M is able or available to make healthcare decisions for R69, POAHC-M will again be R69's primary healthcare agent. POAHC-M may authorize R69's alternative healthcare agent to act in POAHC-M's place for a period of time or regarding particular issues related to R69's healthcare.A facesheet in R69's medical record indicates: If (POAHC-M) does not answer when called, (POAHC-N) should be called right away. Healthcare Power of Attorney (HCPOA) is activated by (R69) by choice. Call (POAHC-M) whenever R1 is refusing.Surveyor reviewed an email from POAHC-M to the facility, dated 1/16/26, that stated POAHC-M could not attend R69's care conference on 1/22/26. The email stated POAHC-M sent the care conference invite to POAHC-N. A progress note, dated 1/22/26, indicated R69 had two new skin alterations. R69 had a chronic open area on the left ear due to phone usage/poor neck strength which caused R69 to lean toward the left side. The area measured 0.5 centimers (cm) (length) x 1 cm (width). R69 also had an abrasion on the left side of the head from R69's bilevel-positive airway pressure (BiPAP) machine straps. A new mask and straps were provided. The abrasion measured 0.4 cm x 2.8 cm. R69 was encouraged to use the phone on speaker mode and to apply bordered foam/gauze for protection before applying BiPAP equipment at bedtime. A progress note indicated POAHC-N was present for R69's care conference (on 1/22/26) and skin integrity was discussed. R69's skin assessments indicated the following: Left Head:~ On 1/22/26, the abrasion measured 2.8 cm x 0.4 cm and was red with scant drainage.~ On 1/27/26, the abrasion measured 0.4 cm x 0.5 cm and had a dry, red scab.~ On 2/4/26, the area was resolved.Left Ear:~ On 1/22/26, the area measured 0.5 cm x 1 cm and had a dry scab.~ On 1/27/26, the area measured 0.3 cm x 0.3 cm and had a dry scab.~ On 2/4/26, the area was resolved.On 2/16/26, Surveyor interviewed POAHC-M who stated the facility did not notify POAHC-M of two sores discovered on R69's head on 1/22/26. POAHC-M stated POAHC-N informed POAHC-M of the sores. On 2/16/26 at 2:20 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-L who was the facility's wound care nurse. LPN-L measured R69's wounds weekly and completed wound care as often as every other day. LPN-L was informed of R69's left ear scab and head abrasion during a care conference on 1/22/26. LPN-L measured the head abrasion and left ear scab and discussed the areas with POAHC-N in person on 1/22/26.On 2/17/26 at 12:00 PM, Surveyor interviewed Nusing Home Administrator (NHA)-A who indicated staff correspond with POAHC-M via email. NHA-A stated Social Services is designated to respond to POAHC-M so multiple staff are not responding to correspondence. NHA-A indicated POAHC-N visits R69 more frequently than POAHC-M and attended R69's care conference on 1/22/26 when the left head and ear abrasions were discovered. NHA-A stated POAHC-M was out of the country and informed the facility via email that POAHC-N would attend the care conference. NHA-A stated POAHC-N interacts with staff and staff discuss R69's cares and concerns with POAHC-N if POAHC-N is in the facility. NHA-A verified POAHC-N is R69's alternate POAHC and stated POAHC-N takes pictures of R69's skin weekly.On 2/18/26 at 11:21 AM, Surveyor interviewed POAHC-N who stated POAHC-M told POAHC-N the date and time of R69's care conference. POAHC-N stated POAHC-M asked POAHC-N to attend the care conference because POAHC-M would be unavailable for five days. POAHC-N informed POAHC-M on 1/23/26 or 1/24/26 of R69's skin integrity and discussed the sores on R69's head. POAHC-N stated POAHC-M and POAHC-N work together to ensure R69 receives appropriate care. POAHC-N verified that POAHC-N visits weekly and assesses R69's skin during the visits.

Based on staff interview and record review, the facility did not ensure a comprehensive resident-centered care plan was implemented for 1 resident (R) (R11) of 1 sampled resident.R11 had a diagnosis of dementia. R11's care plan did not contain goals or interventions for dementia care.Findings include: The facility's Care Plan Process, Person-Centered Care, revised 5/5/23, indicates: The facility will develop and implement .comprehensive care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .3. Following Resident Assessment Instrument (RAI) Guidelines, develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.From 2/15/26 to 2/17/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had a diagnosis of dementia. R11's Minimum Data Set (MDS) assessment, dated 12/29/25, had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated R11 had moderate cognitive impairment. The MDS assessment indicated R11 had a diagnosis of dementia. R11 had an activated Power of Attorney for Healthcare (POAHC).Surveyor reviewed R11's care plan and noted the care plan did not contain dementia goals or interventions.On 2/17/26 at 12:01 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-D who confirmed R11 had a diagnosis of dementia but did not have a dementia care plan. LPN-D indicated Director of Nursing (DON)-B and Assistant Director of Nursing (ADON)-C were responsible for developing care plans.On 2/17/26 at 1:32 PM, Surveyor interviewed ADON-C who confirmed R11 had a diagnosis of dementia but did not have a dementia care plan. ADON-C stated Social Worker (SW)-E is responsibe for developing behavior care plans and nurses are responsible for other aspects such as transfer status. SW-E entered ADON-C's office during the interview. Surveyor interviewed SW-E who confirmed Social Services is responsible for behavior-related care plan development. SW-E indicated R11 should have a dementia care plan.On 2/17/26 at 2:10 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated R11 should have a care plan for dementia which is a substantial diagnosis and has the potential to advance.

Based on observation, staff and resident interview, and record review, the facility did not ensure care and treatment was provided in accordance with professional standards of practice for 2 residents (R39 and R55) of 17 sampled residents. R39 was hospitalized for low blood sugar from 1/25/26 to 1/29/26. R39's physician orders did not include parameters for notification of high or low blood sugars. R39 continued to have high blood sugars after the hospitalization. The facility did not notify R39's physician or develop a diabetes care plan. R55 was hospitalized from [DATE] to 1/9/26 for significant weight gain, worsening lower extremity edema, and failed outpatient diuretic escalation. Hospital discharge paperwork indicated R55 should have a consistent carbohydrate/no added salt diet with a fluid restriction. A follow-up cardiology appointment indicated R55 should maintain a fluid restriction. A fluid restriction was not implemented for R55.Findings include: The facility's Physician and Other Communication/Change in Condition policy, revised 5/5/23, indicates: Complete assessment of the resident, which may include but is not limited to: .E. Blood Glucose .3. Notify the physician of the change in medical condition. The facility's Physician Orders policy, revised 5/5/23, indicates: 1. The qualified licensed nurse completes an admission medication regimen review from the transfer record from an acute care hospital .A call is placed to the physician to confirm the orders and request any additional orders as needed .3. Upon admission, the facility has physician orders for the resident's immediate care to include but not limited to: A. Dietary orders. 1. From 2/15/26 to 2/17/26, Surveyor reviewed R39's medical record. R39 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes, congestive heart failure (CHF), and left below-the-knee amputation. R39's Minimum Data Set (MDS) assessment, dated 2/6/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R39 had intact cognition.R39's plan of care did not indicate R39 had diabetes. R39 had a generic care plan related to various medications; however, the care plan did not indicate which medications R39 was currently taking.On 2/15/26 at 12:25 PM, Surveyor interviewed R39 who stated R39 was diabetic and had been having issues with blood sugars. R39 stated R39 had not had a problem with blood sugars prior to residing at the facility and was recently hospitalized related to blood sugars.R39 had the following physician order:~ Humulin 70/30 Kwik pen 100 units/milliliter (ml) - 60 units at breakfast and 55 units at supper (dated 1/19/26). The order did not contain parameters for physician notification related to high or low blood sugars. On 1/25/29, R39 was hospitalized due to hypoglycemia. During the hospitalization, Humulin was discontinued. R39 was prescribed 50 milligrams (mg) of Januvia daily with a recommendation to follow-up with Endocrinology. R39 had an order to check blood sugars twice daily and as needed. Surveyor reviewed R39's blood sugars and noted the following:~ On 2/5/26 at 7:04 PM, R39 had a blood sugar of 458 with no documented physician notification.~ On 2/13/26 at 7:34 PM, R39 had a blood sugar of 386 with no documented physician notification.~ On 2/14/26, R39 had a blood sugar of 291. R39's physician was notified. On 2/16/26 at 1:47 and 2:29 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who confirmed R39 should have a diabetic care plan. ADON-C reviewed R39's care plan and indicated the care plan should indicate which medications R39 is taking. ADON-C indicated if there are no blood sugar parameters in place, the facility follows physician notification for a blood sugar under 70 over 350. ADON-C verified the physician was not notified of R39's high blood sugars on 2/5/26 and 2/13/26. ADON-C spoke to the Nurse Practitioner (NP) who indicated they don't generally do parameters for residents who are not on insulin. Surveyor informed ADON-C that R39 was prescribed Humulin insulin prior to R39's hospitalization for low blood sugars. Surveyor noted Humulin was discontinued after R39's hospitalization on 1/29/26 and R39 was started on Januvia. R39 continued to have occasional high blood sugars after starting Januvia and staff continued to check R39's blood sugar. ADON-C indicated R39 should have had physician notification parameters in place which were later added.2. From 2/15/26 to 2/17/26, Surveyor reviewed R55's medical record. R55 was admitted to the facility on [DATE] and had diagnoses including acute on chronic renal failure, severe bilateral lower extremity edema, type 2 diabetes, and CHF. R55's MDS assessment, dated 11/14/25, had a BIMS score of 14 out of 15 which indicated R55 had intact cognition.R55 was hospitalized from [DATE] to 1/9/26 due to significant weight gain, worsening lower extremity edema, and failed outpatient diuretic escalation. R55's medical record did not contain a hospital discharge summary. Surveyor requested the discharge summary. A hospital Discharge summary dated [DATE], indicated R55 had diuresed over 60 pounds while in the hospital. During the hospitalization, R55's recommended diet as of 12/31/25 was consistent carbohydrate with a fluid restriction of 2000 ml. The discharge summary indicated Nephrology was consulted and recommended intravenous (IV) diuresis with continuous bumetanide infusion, fluid restriction, and daily monitoring of urine output and weights. R55's nutrition was managed with a consistent carbohydrate diet, fluid restriction, and protein supplementation to support wound healing with good appetite and intake documented. A hospital nutrition assessment, dated 1/5/26, indicated R55 should receive a consistent carbohydrate diet with a 2 liter fluid restriction. An after visit summary from a follow-up appointment with Cardiology on 1/16/26 indicated: Please continue taking your medications as prescribed. Please weigh yourself daily and record the weights. Please avoid dietary salt as much as possible and keep your consumption to 2 grams or less total per day. To help prevent retaining fluid, please drink less than 2 liters per day of any type of fluids. This includes water, milk, tea, juice, coffee, soda (diet or regular) and any other fluids that you might drink. R55's medical record contained an order (prior to and post-hospitalization) for a consistent carbohydrate diet with no added salt. R55's weights were monitored daily. R55's medical record did not indicate R55 was on a fluid restriction.On 2/17/26 at 10:47 AM, Surveyor interviewed Registered Dietitian (RD)-J who stated RD-J reviews hospital returns but does not review after visit summaries from return or specialty appointments. RD-J stated if changes come from those appointments, staff enter the diet change and RD-J makes a note. RD-J indicated if a hospital discharge summary was not scanned into R55's medical record, RD-J might not have seen it. RD-J stated RD-J would then refer to the diet order entered into the system upon R55's return from the hospital. RD-J indicated the diet order entered into R55's medical record after R55 returned from the hospital did not change and RD-J completed a post hospitalization note that did not address a fluid restriction. RD-J stated RD-J would err on the side of no fluid restriction in the nursing home setting due to the risk of dehydration but would defer to what the physician wanted. On 2/17/26 at 12:25 PM, Surveyor interviewed ADON-C who indicated the fluid restriction order was not listed with the medications in R55's discharge summary. ADON-C provided a form that was scanned into R55's medical record from the 1/16/26 Cardiology appointment. ADON-C indicated the facility uses a facility form so physicians can write changes on the form. The form titled Medical Consultation Form indicated: Continue current management. ADON-C indicated staff generally refer to the facility form for any changes and was not sure if anyone saw R55's after visit summary. A progress note, dated 2/17/26 at 1:33 PM, indicated the writer called R55's Cardiology office to clarify if R55 should be on a fluid restriction and was waiting for a return call.On 2/17/26 at 4:30 PM, Surveyor asked to be informed when the physician responded about the fluid restriction.On 2/23/26 at 2:50 PM, Director of Nursing (DON)-B provided Surveyor with information that indicated the facility called Cardiology and received updated orders for a 1.8 liter fluid restriction which R55 had maintained. DON-B also provided R55's intakes. Despite the fact the fluid restriction was not noted in R55's medical record, R55's intakes indicated R55 was within the restriction limit with the exception of a holiday party.

Based on observation, staff interview, and record review, the facility did not ensure food preferences were followed for 2 residents (R) (R16 and R58) of 14 sampled residents. R16's meal ticket indicated R16 disliked sausage. R16 was served sausage for lunch on 2/17/26.R58's meal ticket indicated R58 should receive a half cup of super potatoes for lunch. R58 did not receive a half cup of super potatoes for lunch on 2/17/26.Findings include:The facility's Food Preferences: Diet History policy, revised 10/15/25, indicates: .G. The Certified Dietary Manager (CDM) refers to the preferences list when making the tray ticket and when collecting data.The facility's Therapeutic Diets policy, revised 10/15/25, indicates: .9. Check all trays for accuracy before they are served to residents.From 2/15/26 to 2/17/26, Surveyor reviewed R16's medical record. R16 was admitted to the facility on [DATE]. R16's Minimum Data Set (MDS) assessment, dated 1/21/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R16 had intact cognition. The MDS assessment also indicated R16 was at risk for malnutrition (Section I). From 2/15/26 to 2/17/26, Surveyor reviewed R58's medical record. R58 was admitted to the facility on [DATE]. R58's MDS assessment, dated 2/17/26, had a BIMS score of 11 out of 15 which indicated R58 had moderate cognitive impairment. The MDS assessment also indicated R58 was at risk for malnutrition (Section I). On 2/17/26 at 11:28 AM, Surveyor observed [NAME] (CK)-K serve lunch in the main kitchen. The main entree was red beans, rice, and sausage. During meal service, Surveyor observed the following:~ R16's meal ticket indicated R16 disliked sausage. Surveyor observed CK-K put the main entree (which contained sausage) on R16's plate. CK-K plated the remainder of R16's meal and passed the plate to Dietary Aid (DA)-I to serve. Surveyor stopped DA-I and asked whether R16 should receive the main entree. CK-K stated CK-K missed it on the meal ticket and made R16 a grilled cheese sandwich.~ R58's meal ticket indicated R58 should receive a half cup of super potatoes. Surveyor observed CK-K put red beans, rice, sausage, a dinner roll, and wax beans on R58's plate and hand the plate to DA-I to serve. When asked if R58 should get super potatoes, CK-K stated yes and indicated CK-K missed it on the meal ticket. R58 was given a half cup of super potatoes.On 2/16/26 at 4:45 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified food preferences were not followed. NHA-A stated the facility was working on food and dining preferences with residents. In a subsequent interview on 2/17/26 after lunch, NHA-A confirmed residents should receive preferences that are noted on their meal tickets and staff should check tickets and plates for accuracy before meals are served.

Based on observation, staff and resident interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R39) of 4 sampled residents.R39 was on contact precautions due to loose stools. Staff brought R39 to the dining room to eat breakfast and seated R39 at a table with other residents.Findings include:The facility's Transmission Based/Standard Precautions and Enhanced Barrier Precautions policy, revised 5/15/23, indicates: Contact Precautions: .O. Protocols: Resident Placement: .b. When a resident is experiencing wound drainage, fecal incontinence, or diarrhea .that can't be contained and there is an increased potential for extensive environmental contamination and risk of transmission of a pathogen. This should be implemented prior to identifying the specific organism. F. The resident should remain in their room for the duration of transmission-based precautions unless for medically necessary care. From 2/15/26 to 2/17/26, Suveyor reviewed R39's medical record. R39 was admitted to the facility on [DATE] and had diagnoses including C-difficile, heart failure, and type 2 diabetes. R39's Minimum Data Set (MDS) assessment, dated 2/6/26, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R39 had intact cognition.On 2/15/26 at 12:25 PM, Surveyor interviewed R39 who was in bed and stated R39 was not feeling well. R39 indicated R39 had diarrhea all morning and was not sure why. Surveyor did not observe a precautions signs on R39's door at that time. R39 stated R39 did not have an appetite which was why R39 did not go to the dining room for lunch.A progress note, dated 2/15/26 at 3:27 PM, indicated R39 had multiple loose bowel movements and a poor appetite. The note indicated R39's stools were watery and did not look like C-difficile. Fluids were encouraged and the provider was updated.A progress note, dated 2/15/26 at 3:42 PM, indicated orders were received for Imodium and to check R39's stool for C-difficile and norovirus.A progress note, dated 2/15/26 at 8:35 PM, indicated R39 started on contact isolation due to loose stools. R39's loose stools were not enough for a sample. A stool sample needed to be collected.On 2/16/26 at 6:46 AM, Surveyor observed a contact precautions sign posted on R39's door. R39 was not in the room. On 2/16/26 at 6:58 AM, Surveyor observed R39 in the dining room waiting for breakfast at a table with other residents. The residents were filling out meal tickets for the following week. On 2/16/25 at 12:49 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who cared for R39 on the AM shift. CNA-F stated CNA-F was not informed in morning report that R39 was ill and should not be in the dining room. CNA-F indicated CNA-F must have missed the contact precautions sign on R39's door.A progress note, dated 2/16/26 at 3:10 PM, indicated the writer spoke to the CNA who worked on R39's unit during the AM shift. The CNA reported that R39 had five loose stools. A stool specimen was collected at approximately 11:00 AM. R39 continued on contact precautions while the results were pending and until symptoms resolved. A progress note, dated 2/16/26 at 11:00 PM, indicated R39 had loose watery stools and was on contact precautions and strict isolation. R39 tested positive for C-diff. The provider was updated. On 2/16/26 at 4:45 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who confirmed R39 should have eaten breakfast in R39's room since R39 was on contact precautions due to loose stools.

Based on staff interview and record review, the facility did not ensure Hospice services during end of life care were coordinated for 1 resident (R1) of 2 sampled residents.On the 9/6/25 AM shift, Hospice Registered Nurse (HRN)-C informed Certified Nursing Assistant (CNA)-E that R1 was actively passing and should not be gotten out of bed. The information was not communicated to PM or night shift staff. R1 was gotten out of bed in accordance with R1's routine by night shift staff who were unaware that R1 was actively passing. Findings include:The facility's Hospice Care policy, dated 5/5/23, indicates: Procedures: .4. To provide continuity of care, the Hospice, nursing home, and resident/representative must collaborate in the development of a coordinated care plan which includes but is not limited to, the following: Interventions that address, as appropriate, the identification of timely, pertinent non-pharmacologic and pharmacologic interventions to manage pain and other symptoms of discomfort .8. The facility and Hospice provider will have ongoing collaborative communication. Facility staff must immediately contact and communicate with Hospice staff and the resident's family and/or legal representative any significant changes in the resident's status, clinical complications, or emergent situations. These situations may include but are not limited to changes in condition or a sudden unexpected decline in conditin .The facility's Hospice contract for Hospice Company (HC)-F, dated 4/22/19, indicates: Coordination of Services: Hospice and facility will immediately inform the other of any change in the condition of the Hospice patient including, but not limited to, i. A significant change in the Hospice patient's physical, mental, social, or emotional status; ii. Clinical complications appear that suggest a need to alter the plan of care .On 10/8/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including unspecified dementia, wedge compression fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing, and pain. A Minimum Data Set (MDS) assessment completed 8/28/25 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15 which indicated R1 had moderate cognitive impairment. R1 had an activated Power of Attorney for Healthcare (POAHC). R1 started Hospice services with HC-F upon admission to the facility. R1 passed away at the facility on 9/7/25. A Hospice note, dated 9/6/25 at 8:55 AM and written by HRN-C, indicated HRN-C met R1 and R1's family in the common area. R1 was in a wheelchair drinking coffee. R1's family indicated R1 was more responsive that morning and they wanted to get R1 out of bed for a while. R1 struggled to stay awake during the visit and was unable to hold R1's head up or hold a coffee cup without assistance. Mottling was noted on R1's arms, knees and lower legs and R1's extremities were cool. When asked if R1 wanted to lay down, R1 mumbled yes. R1's pain was at a level 0 out of 10 at rest; however, R1's pain increased to a level 5 out of 10 with the Hoyer transfer to bed as evidenced by R1 moaning, grimacing, and guarding R1's stomach. All routine medications were discontinued. Comfort meds only were to be given. On 10/8/25 at 12:40 PM, Surveyor interviewed HRN-C via phone. HRN-C saw R1 on the morning of 9/6/25 for an end of life daily visit. R1's family had R1 up when HRN-C arrived. HRN-C indicated to staff in the room (who HRN-C thought was Licensed Practical Nurse (LPN)-D but was actually CNA-E who was also a Medication Technician) that if R1 had a rally moment, it would be appropriate to get R1 up but otherwise R1 should remain in bed. R1 was responsive during HRN-C's visit. HRN-C indicated LPN-D (who was actually CNA-E) was in the room for a period of time. Stopping medications and feeding and focusing on comfort was discussed. R1 appeared comfortable at the beginning of the assessment but expressed pain when laid flat. An assessment indicated the pain was due to urinary issues. HRN-C had not ordered any scheduled medications for R1 at that point. R1 had orders for as needed (PRN) comfort pain medications.On 10/8/25, Surveyor attempted to contact LPN-D and CNA-E with no return phone calls.On 10/8/25 at 2:22 PM, Surveyor interviewed CNA-G who worked the 9/6/25 PM shift. CNA-G indicated CNAs do a 1:1 shift report; however, CNA-G could not find CNA-E for shift report that afternoon and was not told that R1 was actively passing and should remain in bed. CNA-G did not get R1 out of bed during CNA-G's shift. CNA-G indicated R1's family visited most of the shift and it didn't look like R1 should get out of bed. CNA-G informed night shift CNA-H that R1 didn't eat anything and had 50 cubic centimeters (ccs) of output in R1's catheter. On 10/8/25, Surveyor attempted to contact CNA-H with no return phone call. On 10/8/25 at 12:30 PM, Surveyor interviewed LPN-I who worked the night shift from 9/6/25 into 9/7/25. LPN-I indicated neither LPN-I or CNA-H were informed that R1 was actively passing. LPN-I indicated R1 slept all night and appeared comfortable. LPN-I and CNA-H got R1 up in the morning per usual as R1 was usually gotten up on the night shift. LPN-I stated R1 was R1's usual self during the transfer. On 10/8/25, the facility provided Surveyor with a grievance filed by R1's family that indicated R1 was up in the morning on 9/7/25 and in pain when they arrived. The facility's investigation indicated HRN-C asked CNA-E not to get R1 out of bed on the 9/6/25 AM shift but R1 was gotten out of bed on the 9/6/25 PM shift. The investigation indicated verbal education was done with staff; however, the education was not signed or documented.On 10/8/25 at 1:35 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B spoke with HC-F to ensure they informed their staff to communicate with the nurse on the shift instead of the CNA. DON-B indicated the facility's investigation determined CNA-G was told that R1 should not be gotten out of bed. Surveyor informed DON-B that if was actually AM shift CNA-E who was informed that R1 should not be gotten out of bed and when CNA-G could not find CNA-E for shift report, the information was not relayed to CNA-G or communicated to night shift staff. DON-B confirmed staff should complete shift-to-shift reports. DON-B indicated verbal education was only completed with CNA-G (who worked the PM shift) despite the fact the Hospice note and interview with HRN-C indicated the Hospice visit occurred on the AM shift.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R6 and R7) of 10 sampled residents. Staff did not ensure enhanced barrier precautions (EBP) were followed during high-contact cares for R6 and R7.Findings include:The facility's Infection Prevention and Control Policies and Procedures, revised 5/15/23, indicates: 1. Enhanced barrier precautions (EBP) expand the use of personal protective equipment (PPE) (gown and gloves) during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDROs) to staffs' hands and clothing. A. EBP will be implemented for all residents with the following: .2. Wounds and/or indwelling medical devices (central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. B. EBP will be implemented during the following high-contact resident care activities: .3. Transferring; 4. Providing hygiene; .6. Changing briefs or assisting with toileting.1.On 8/8/25, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including dementia, displaced fracture to shaft of left clavicle, wedge compression fracture of third lumbar vertebra, retention of urine, pain, weakness, and anxiety. On 8/8/25, Surveyor reviewed R6's August 2025 Treatment Record Administration (TAR) which indicated R6 was placed on EBP for chronic wounds on 6/27/25.On 8/8/25 at 9:39 AM, Surveyor observed Certified Nursing Assistant (CNA)-C assist R6 to the bathroom. Surveyor observed an EBP sign posted outside R6's room but did not observe a PPE cart near R6's room. CNA-C entered R6's room, donned gloves, put a gait belt around R6, and transferred R6 to the toilet. After CNA-C assisted R6 onto the toilet, CNA-C stepped outside the bathroom and Surveyor asked if R6 was on EBP. CNA-C indicated R6 was not on EBP. When Surveyor showed CNA-C the EBP sign outside R6's room, CNA-C stated there was no need for PPE and indicated there were no gowns in or near R6's room to put on. CNA-C indicated the sign meant extra precautions were needed.2. On 8/8/25, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including traumatic subdural hemorrhage, urinary tract infection, local infection of the skin, neuromuscular dysfunction of bladder, pressure induced deep tissue damage of left heel, methicillin-resistant Staphylococcus aureus (MRSA) infection, and type 2 diabetes mellitus.On 8/8/25, Surveyor reviewed R7's August 2025 TAR which indicated R7 was placed on EBP for wounds, MDRO/MRSA to wound, and a Foley catheter on 2/5/25.On 8/8/25 at 10:16 AM, Surveyor observed CNA-E and Licensed Practical Nurse (LPN)-D in R7's room without PPE. Surveyor noted CNA-E and LPN-D were about to transfer R7 into bed. R7 had an indwelling catheter. Surveyor noted a sign outside R7's room that indicated R7 was on EBP and PPE should be worn during high-contact cares. After the transfer was completed, Surveyor interviewed CNA-E and LPN-D. When asked if R7 was on EBP, LPN-D was not sure. When asked if PPE should be worn while transferring a resident on EBP, LPN-D indicated R7 was on EBP due to scabs on R7's feet. When asked if PPE was needed because R7 had an indwelling catheter, LPN-D stated a gown was not needed. Surveyor did not observe any gowns in or near R7's room. On 8/8/25 at 12:27 PM, Surveyor interviewed Director of Nursing (DON)-B who confirmed PPE, including a gown and gloves, should be worn during high-contact cares for residents on EBP. DON-B verified transferring and toileting are considered high-contact cares and indicated residents on EBP should have bins near their rooms with PPE.

Based on staff interview and record review, the facility did not designate a person to serve as the food and nutrition services director who was a certified dietary manager, had a national certification for food service management and safety from a national accrediting body, or had an associates or higher level degree in food service management or hospitality. This had the potential to affect all 72 residents residing in the facility. Dietary Manager (DM)-N did not have an approved dietary manager or food service manager certification course or other related education. Findings include: During an initial kitchen tour on 11/10/24 at 10:33 AM, Surveyor interviewed DM-N who indicated DM-N had been at the facility for a short time and did not have a dietary manager certification. DM-N indicated DM-N had a ServSafe certification, but was not yet enrolled in an approved course. DM-N also indicated the facility used a part-time Dietitian. On 11/12/24 at 1:41 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed DM-N did not have an approved certification course for dietary or food service management. NHA-A indicated DM-N was new and the facility's dietitian had sent NHA-A a couple of options for courses. NHA-A indicated the facility was in the process of reviewing the courses for DM-N and other kitchen staff. NHA-A verified NHA-A had not yet enrolled DM-N in a certified dietary manager course.

Based on observation, staff and resident interview, and record review, the facility did not ensure sufficient staffing was provided to meet the needs of 5 residents (R) (R30, R11, R17, R50, and R26) of 25 sampled residents with the potential to affect additional residents. The facility had low staffing on 4/14/24, 5/11/24, 5/12/24, and 6/23/24. On 11/10/24, R30 activated R30's call light for assistance with toileting on multiple occasions. Staff turned off R30's call light without providing assistance. On 11/10/24, R11 activated R11's call light for assistance to bed. Certified Nursing Assistant (CNA)-Y turned off R11's call light and left the room without assisting R11. On 11/10/24, R17 activated R17's call light for assistance to bed. CNA-Z turned off R17's call light and left the room without assisting R17. On 11/10/24, R50 activated R50's call light for an evening snack. Licensed Practical Nurse (LPN)-F turned off R50's call light and left the room without providing a snack. R26 did not consistently receive scheduled showers. Findings include: The facility's Staffing Policy, dated 5/5/23, indicates: The facility will implement strategies to mitigate staffing shortages during times of illness, pandemic, or additional situations that may lead to decreased numbers of available staff. The facility will adjust staffing needs to include day, evening, and night shifts based on changes in the resident population .1. The facility will collaborate with Human Resources and regional personal to implement staffing strategies to mitigate staffing shortages in any department. 2. The facility will attempt to ascertain reasons or root causes for staff unavailability for work and address as practicable and able. Low Staffing: The facility calculates the number of CNAs and Registered Nurses (RNs) by the following formula: 3.08 times the census = total hours to schedule per day divided by 8 = number of staff to schedule per shift On 11/12/24, Surveyor reviewed the facility's staffing schedules from 4/1/24 to 6/30/24. Surveyor identified 4 weekend days in April, May, and June where the facility was low on staff. On 4/14/24, the facility had a census of 78 and required 240 staffing hours for the day. The facility had 199.8 hours scheduled and was down 4 CNAs due to call-ins and/or no-shows. On 5/11/24, the facility had a census of 73 and required 224 staffing hours for the day. The facility had 186.4 hours scheduled and was down 4 CNAs due to call-ins and/or no-shows. On 5/12/24, the facility had a census of 72 and required 221 staffing hours for the day. The facility had 201.8 hours scheduled and was down 3 CNAs due to call-ins and/or no-shows. On 6/23/24, the facility had a census of 77 and required 237 staffing hours for the day. The facility had 192.5 hours scheduled and was down 2 CNAs due to call-ins and/or no-shows. On 11/12/24 at 3:08 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility had low staffing on the above mentioned days and couldn't get coverage. NHA-A indicated the facility tries to call agency, other staff, or have nurse managers cover, but they couldn't find anyone on those days. Call Lights: On 11/10/24 (Sunday) at 2:46 PM, Surveyor observed a CNA enter R30's room, turn off the call light, and exit the room. On 11/10/24 at 3:36 PM, Surveyor interviewed R30 who indicated R30 activated the call light to use the bathroom, but a CNA turned off the call light and left to get another staff and a lift. R30 indicated it was the fourth call R30 had made since 12:00 PM; the first and second calls were on the AM shift and the third and fourth calls were on the PM shift. R30 did not know the CNAs' names. R30 indicated R30 was incontinent of a small amount of urine due to the wait and felt like a second-class citizen. On 11/10/24 at 3:40 PM, Surveyor observed Medication Technician (MT)-T enter R30's room, ask about R30's concern, and turn off R30's call light to address another resident's fall. On 11/10/24 at 6:40 PM, Surveyor observed R11 enter the hallway from R11's room in a wheelchair. R11 was visibly upset and stated, For cripes sake, he turned my light out and said he needs to find a lift, but the lift is sitting right there. Surveyor observed a mechanical lift in the hallway near R11's room. R11 indicated a male CNA entered R11's room, turned off R11's call light, went to help a resident across the hall, and did not return. R11 indicated the lift needed to transfer R11 had been in the same spot for 15 minutes, however, that was the excuse given why R11 was not assisted. R11 stated, I am not dumb. R11's roommate (R57) then exited the room and stated to CNA-Y, You guys need to realize when they (residents) turn their lights on it is because they need someone to help them, and you should not turn it (call light) off. R11 indicated staff frequently turn call lights off and don't provide timely care on the weekends. On 11/10/24 at 6:47 PM, Surveyor interviewed CNA-Y who confirmed CNA-Y turned off R11's call light without assisting R11. CNA-Y indicated CNA-Y needed a second staff to assist with the transfer and a second staff was not available. On 11/10/24 at 7:20 PM, Surveyor observed R17 in a recliner and noted R17's call light was activated. Surveyor interviewed R17 who stated R17 wanted to go to bed. R17 said R17's call light had been on for an hour now. On 11/10/24 at 7:21 PM, Surveyor observed CNA-Z turn off R17's call light and exit the room. Surveyor also observed CNA-Z turn off a call light across the hall and exit the room. Surveyor interviewed CNA-Z who confirmed CNA-Z turned off R17's call light without providing assistance because CNA-Z needed to get a lift. Surveyor observed CNA-Z go to the 500 wing and start to move a lift in the hallway. When Surveyor turned to leave, CNA-Z stopped moving the lift and went to do something else. On 11/10/24 at 7:31 PM, Surveyor observed R17 still sitting in the recliner. R17's head was down and R17 appeared to be asleep. R17 had not been assisted to bed yet. On 11/11/24 at 11:39 AM, Surveyor interviewed NHA-A who was not aware of the incidents and indicated NHA-A would start an investigation. Showers: On 11/10/24 at 12:44 PM, Surveyor interviewed R26 who indicated R26 was supposed to receive two showers per week but did not consistently receive them. Surveyor reviewed R26's shower documentation for the past three months which was in the form of weekly skin checks and shower sheets that were not consistently completed and didn't always indicate if R26 had a shower or a bed bath. Documentation indicated showers were given or refused by R26 on 10 of 26 opportunities since 8/1/24. On 11/12/24 at 3:32 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated showers were a problem for awhile and the facility was working to restructure them. DON-B indicated the facility was going trial a shower aide the following week. Staff Interviews: On 11/11/24 at 10:34 AM, Surveyor interviewed CNA-DD who indicated staffing was a concern at times and CNA-DD sometimes had to care for a wing of 13 residents. CNA-DD indicated when the census is low on the rehab unit, there is no CNA on the night (NOC) shift. CNA-DD indicated CNA-DD has found that residents were not changed during the night. On 11/11/24 at 10:41 AM, Surveyor interviewed RN-E who indicated the facility had enough staff to care for residents unless there was a call in. RN-E indicated call light response times become longer when many residents make requests at the same time. On 11/11/24 at 10:49 AM, Surveyor interviewed Med Tech (MT)-G who indicated there were not enough staff to care for residents and indicated the facility did not find replacements for call ins. MT-G indicated there was turnover at the facility because CNAs quit when they felt they could not give good care. On 11/11/24 at 10:53 AM, Surveyor interviewed CNA-AA who indicated it is hard to find a replacement if someone calls in. CNA-AA indicated residents frequently complain about call light response times especially on the PM and NOC shifts.

Based on observation, staff interview, and record review, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One of five medication carts was observed unlocked and unattended in a resident hallway. One of two medication storage rooms contained expired medication and medical supplies. A prescription label on a medication card was not labeled according to the provider's order for 1 resident (R) (R33) observed during medication administration. This practice had the potential to affect more than 4 of the 72 residents residing in the facility. On [DATE], a medication cart on the 600 wing was unlocked and unattended. In addition, a cup that contained medication was on top of the cart and a computer screen that contained residents' personal information was open. The medication storage room on the long-term care unit contained expired medication and medical supplies. A medication card for R33 was not labeled according to the physician's order. Findings include: The facility's Medication Storage Policy, dated [DATE], indicates: Proper medication storage is a standard of practice. The pharmacy fills medications using a specially packaged administration system designed to assist facilities in reducing medication errors .Expired and/or discontinued medication should be stored separately from other medication and disposed of in a timely manner .Medication carts and cabinets should be locked when unattended .It is the qualified staff member's responsibility to maintain the possession of the keys and security of the medication cart. The medication cart always needs to be securely locked when it is out of the qualified staff member's visual sight. 1. On [DATE] at 3:24 PM, Surveyor noted a medication cart on the 600 wing was unlocked and unattended. In addition, a cup that contained medication was on the top of the cart and a computer screen that contained resident's information was open. Licensed Practical Nurse (LPN)-F returned to the cart at 3:28 PM. On [DATE] at 3:28 PM, Surveyor interviewed LPN-F who indicated it was not LPN-F's usual practice to leave the medication cart unlocked and unattended. LPN-F also indicated it was not LPN-F's usual practice to leave medication unattended on the cart and residents' information exposed. LPN-F indicated LPN-F was called away for a fall on another wing. LPN-F indicated LPN-F was an agency nurse and should not have to deal with all of this. On [DATE] at 3:10 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated staff should lock medication carts and medication when unattended and should turn off or shut down computer screens when unattended. 2. On [DATE] at 2:14 PM, Surveyor observed the medication storage room on the long-term care unit with Registered Nurse (RN)-E and noted the following items: ~ Acetaminophen suppositories with an expiration date of ,d+[DATE] ~ Asper creme lidocaine with an expiration date of ,d+[DATE] ~ Oyster shell calcium 250 milligrams (mg) with an expiration date of ,d+[DATE] ~ A Drug buster drug disposal system (3 containers) with expiration dates of ,d+[DATE] ~ Twenty nine 18-gauge syringes with expiration dates of ,d+[DATE] ~ Forty five pic line caps with expiration dates of ,d+[DATE] ~ One female luer lock cap with an expiration date of ,d+[DATE] ~ Multiple heparin lock flushes with expiration dates of ,d+[DATE] and ,d+[DATE] (75% of floor stock) On [DATE] at 2:30 PM, Surveyor interviewed RN-E who was not aware who was responsible for maintaining medications and supplies in the medication storage rooms. On [DATE] at 3:10 PM, Surveyor interviewed DON-B who indicated DON-B expects staff to dispose of expired medication and supplies. DON-B indicated pharmacy staff check the medication carts and storage rooms monthly and completed an annual quality review on ,d+[DATE]. 45943 3. On [DATE] at 8:10 AM, Surveyor observed RN-H administer two bumetanide (Bumex) 2 mg tablets to R33. The pharmacy medication label stated bumetanide 2 mg (1 tab once a day to give with 1 mg to equal 3 mg total). On [DATE] at 8:15 AM, Surveyor asked RN-H about the discrepancy. RN-H verified the label was incorrect and indicated there was a new order for Bumex 4 mg daily in R33's Medication Administration Record (MAR). Surveyor verified R33's current order was for Bumex 4 mg daily.

Based on observation, staff and resident interview, and record review, the facility did not ensure 6 residents (R) (R11, R17, R50, R12, R30, and R26) of 25 sampled residents who required the assistance of staff for activities of daily living (ADLs) were provided care in a timely and consistent manner. On 11/10/24, R11 activated R11's call light for assistance to bed. Certified Nursing Assistant (CNA)-Y turned off the call light and left the room without assisting R11. On 11/10/24, R17 activated R17's call light for assistance to bed. CNA-Z turned off the call light and left the room without assisting R17. On 11/10/24, R50 activated R50's call light for an evening snack. Licensed Practical Nurse (LPN)-F turned off the call light without providing a snack. R12 stated call light response times were lengthy and R12 was not given a bedpan or a bed change when requested. R30 was not given a bedpan or provided assistance to the toilet in a timely manner. R26 did not receive scheduled showers on a consistent basis. Findings include: The facility's Staff Education Policies/Procedures Competency: Showers, with a revision date of 7/1/13, contained sign-offs for the following areas: 1. Encourages participation where appropriate .12. Document appropriately. The facility did not provide a shower/bathing policy. 1. From 11/10/24 to 11/12/24, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure (CHF), cervical spondylosis (painful condition of the spine due to degeneration), chronic obstructive pulmonary disease (COPD), stage 4 chronic kidney disease, and venous insufficiency. R11's Minimum Data Set (MDS) assessment, dated 10/10/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R11 was not cognitively impaired. The MDS indicated R11 required substantial/maximal assistance of staff for transfers. On 11/10/24 at 6:40 PM, Surveyor observed R11 enter the hallway from R11's room via wheelchair. R11 was visibly upset and stated, For cripes sake, he turned my light off and said he needs to find a lift, but the lift is sitting right there. Surveyor noted a mechanical lift in the hallway near R11's room. R11 explained to Surveyor that a male CNA had entered R11's room, turned off the call light which R11 had activated for assistance, and then went to help a resident across the hall and did not return. R11 indicated the lift R11 needed to transfer had been sitting in the same spot for 15 minutes but that was the excuse why R11 was not assisted. R11 stated, I am not dumb. R11's roommate (R57) then exited the room and stated to CNA-Y, You guys need to realize when they (residents) turn their lights on it is because they need someone to help them and you should not turn it (call light) off. R11 indicated call lights are frequently turned off and cares are not provided timely on the weekends. On 11/10/24 at 6:47 PM, Surveyor interviewed CNA-Y who confirmed CNA-Y turned off R11's call light even though CNA-Y did not provide R11 assistance. CNA-Y indicated CNA-Y needed another staff to assist with R11's transfer and another staff was not available. 2. From 11/10/24 to 11/12/24, Surveyor reviewed R17's medical record. R17 was admitted to the facility on [DATE] and had diagnoses including COPD, pressure injury, muscle weakness, insomnia, and obstructive sleep apnea. R17 received Hospice services. R17's MDS assessment, dated 10/28/24, had a BIMS score of 14 out of 15 which indicated R17 was not cognitively impaired. The MDS indicated R17 was dependent on staff for transfers. On 11/10/24 at 7:20 PM, Surveyor noted R17's call light was activated. Surveyor interviewed R17 who was sitting in a recliner and indicated R17 wanted to go to bed. R17 indicated the call light had been on for an hour now. On 11/10/24 at 7:21 PM, Surveyor observed CNA-Z turn off R17's call light and exit the room. Surveyor also observed CNA-Z turn off a call light across the hall and exit the room. Surveyor interviewed CNA-Z who confirmed CNA-Z turned off R17's call light without providing assistance and indicated CNA-Z needed to get a lift. Surveyor observed CNA-Z go to the 500 wing and start to move a lift in the hallway. As Surveyor walked in the opposite direction, CNA-Z stopped moving the lift and went to do something else. On 11/10/24 at 7:31 PM, Surveyor observed R17 still sitting in the recliner. R17's head was down and R17 appeared asleep. R17 had not been assisted to bed yet. 3. From 11/10/24 to 11/12/24, Surveyor reviewed R50's medical record. R50 was admitted to the facility on [DATE] and had diagnoses including major depressive disorder and generalized anxiety disorder. R50's MDS assessment, dated 10/15/24, had a BIMS score of 12 out of 15 which indicated R50 had moderate cognitive impairment. On 11/10/24 at 7:23 PM, Surveyor observed LPN-F turn off R50's call light without providing assistance. Surveyor interviewed LPN-F who indicated R50 wanted a snack but LPN-F was an agency staff and did not know where the snacks were located. On 11/12/24 at 3:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who confirmed NHA-A expects staff to complete residents' requests before turning off their call lights. 43361 4. From 11/10/24 to 11/12/24, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including obesity, overactive bladder, chronic kidney disease (CKD), and chronic peripheral venous insufficiency. R12's MDS assessment, dated 8/23/24, had a BIMS score of 15 out of 15 which indicated R12 was not cognitively impaired. On 11/10/24 at 12:17 PM, Surveyor interviewed R12 about care at the facility. R12 stated call light response times ranged from ten minutes to one hour. R12 indicated R12 asked for a bedpan which an unnamed CNA would not provide. R12 stated R12 thought the refusal was cruel and inhuman treatment. R12 also indicated R12 asked staff to hold down a bed pan while R12 turned to get off the bed pan. R12 said the CNAs didn't do it which caused the bed pan to spill. R12 indicated sometimes staff didn't change R12's bedding and R12 had to lay on wet bedding for a half hour until night shift staff arrived. On 11/11/24 at 11:39 AM, Surveyor interviewed NHA-A who was not aware of the incidents and indicated NHA-A would start an investigation. 5. From 11/10/24 to 11/12/24, Surveyor reviewed R30's medical record. R30 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, chronic pain syndrome, diabetes type 2 with diabetic polyneuropathy, obesity, and anxiety. R30's MDS assessment, 8/21/24, had a BIMS score of 14 out of 15 which indicated R30 was not cognitively impaired. On 11/10/24 at 11:46 AM, Surveyor interviewed R30 regarding care at the facility. R30 stated an unnamed CNA on the PM shift refused to give R30 a bedpan which caused R30 to be incontinent of urine. R30 refused to name the CNA due to fear of retribution. On 11/10/24 at 2:46 PM, Surveyor observed a CNA enter R30's room and turn off the call light. The CNA did not toilet R30. On 11/10/24 at 3:36 PM, Surveyor interviewed R30 who indicated R30 needed assistance to the bathroom, but the CNA turned off the call light and left to get another staff and a lift. R30 indicated it was the fourth call R30 had made since 12:00 PM; the first and second calls were on the AM shift and the third and fourth calls were on the PM shift. R30 did not know the CNAs' names. R30 indicated R30 was incontinent of a small amount of urine due to the wait. R30 stated R30 felt like a second-class citizen. On 11/10/24 at 3:40 PM, Surveyor observed Medication Technician (MT)-T enter R30's room, ask about R30's concern, and turn off R30's call light to address another resident's fall. On 11/11/24 at 11:39 AM, Surveyor interviewed NHA-A who was not aware of the incident and indicated NHA-A would start an investigation. 6. From 11/10/24 to 11/12/24, Surveyor reviewed R26's medical record. R26 was admitted to the facility on [DATE] and had diagnoses including muscle weakness, difficulty in walking, unsteadiness on feet, and pain. R26's MDS assessment, dated 11/8/24, had a BIMS score of 14 out of 15 which indicated R26 was not cognitively impaired. The MDS assessment indicated R26 was dependent on staff for showering/bathing. On 11/10/24 at 12:44 PM, Surveyor interviewed R26 who indicated R26 was supposed to receive two showers per week but did not consistently receive them. On 11/11/24, Surveyor requested R26's shower documentation for the past three months. Surveyor received R26's shower documentation which was in the form of weekly skin checks (some did not state that R26 had a shower) and shower sheets that were not consistently completed and didn't always indicate if R26 had a shower or a bed bath. Surveyor also reviewed R26's medical record which contained inconsistent bathing documentation. R26's progress notes sometimes indicated whether R26 received a shower or bed bath or refused. Documentation indicated showers were given or refused on 10 of 26 opportunities since 8/1/24. The other missed documentation showed the following: ~ A weekly skin assessment on 8/1/24 did not note if a shower was given. ~ R26 received a bed bath on 8/15/24 but staff did not document if R26 refused a shower. ~ A progress note, dated 8/23/24, indicated R26's Power of Attorney for Healthcare (POAHC) was updated on R26's new schedule for twice weekly showers on Wednesdays and Saturdays. ~ Documentation indicated R26 received a partial bed bath on 8/24/24 but did not indicate if R26 refused a shower. ~ Documentation indicated R26 received a bed bath on 9/4/24 but did not indicate if R26 refused a shower. ~ A weekly skin assessment on 9/11/24 did not indicate if R26 had a shower. ~ A shower sheet, dated 9/21/24, was checked bath/shower; however the area that indicated if R26 received a bed bath or shower was not filled out. ~ A shower sheet, dated 9/28/24, was signed by the nurse but was not filled out. ~ A weekly skin assessment, dated 10/5/24, was completed but did not indicate if R26 had a shower. ~ A shower sheet, dated 10/9/24, was signed by the nurse but was not filled out. ~ There was no documentation on 10/16/24 or 10/19/24. ~ A bed bath was documented on 10/23/24 but did not indicate if R26 refused a shower. ~ There was no documentation on 10/26/24, 10/30/24, 11/2/24, or 11/6/24. On 11/11/24 at 4:04 PM, Surveyor interviewed CNA-O who showed Surveyor the shower schedule. Surveyor noted R26 was on the schedule on Wednesday and Saturday. CNA-O indicated shower sheets should be filled out and showers should be documented in residents' medical records. On 11/12/24 at 3:32 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated showers were a problem for awhile but the facility had been working to restructure them. DON-B indicated DON-B expects CNA staff to complete shower sheets and nurses to complete weekly skin observations in residents' medical records. DON-B indicated audits were being done to ensure weekly skin observations were being completed. DON-B confirmed shower sheets should be filled out completely and refusals should be documented. DON-B indicated the facility was going trial a shower aid the following week.

Based on observation, staff and resident interview, and record review, the facility did not ensure a call light was within reach for 1 resident (R) (R1) of 25 sampled residents. R1 was dependent on staff for mobility and other cares. During an observation on 11/10/24, R1's call light was not within reach. Findings include: From 11/10/24 to 11/12/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including traumatic brain injury (TBI), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, pain, and dysphagia (difficulty swallowing). R1's Minimum Data Set (MDS) assessment, dated 10/18/24, had a Brief Interview for Mental Status (BIMs) score of 15 out of 15 which indicated R1 was not cognitively impaired. The MDS indicated R1 was dependent on staff for mobility and transfers. R1 had alteration in vision due to a TBI. R1 was legally blind and relied on staff to help with items R1 needed. R1's plan of care indicated staff should to explain to R1 where R1 could feel for the call light when clipped near R1, explain where R1's fluid cup was, and keep and explain where R1's phone was so R1 could access the phone on R1's own. A behavior symptoms care plan contained an intervention, dated 12/28/17, to familiarize R1 with new staff and familiarize new staff with R1 and R1's routine. On 11/10/24 at 6:51 PM, Surveyor entered R1's room and was told by R1's roommate (R54) that R1 needed R1's phone. Surveyor observed R1 in a Broda chair at the foot of R1's bed. Surveyor noted R1's phone was on the night stand which was next to the head of the bed. R1's call light pad was also on the nightstand. R1 confirmed R1 could not reach the phone or the call light. Surveyor had to step over a garbage can to get to the night stand which was approximately three feet from R1's Broda chair. R1 indicated staff usually clipped the call light to R1's pants and stated, He (staff) didn't give it (call light) to me. Surveyor noted a male agency Certified Nursing Assistant (CNA) (CNA-Y) was assigned to R1's wing with a female CNA (CNA-CC). Upon Surveyor's request, CNA-CC provided R1 with the phone and call light. On 11/10/24 at 6:57 PM, Surveyor interviewed CNA-CC who confirmed R1 could not reach the call light on R1's own. On 11/10/24 at 8:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated CNA-Y was an agency staff and believed it was CNA-Y's first time working in the facility. NHA-A confirmed call lights should be within reach of residents.

Based on staff interview and record review, the facility did not ensure a grievance was thoroughly investigated and resolution was provided for 1 resident (R) (R7) of 25 sampled residents. R7 told staff that R7 was missing items from laundry. Staff did not follow the facility's grievance process or follow-up with R7. Findings include: The facility's Missing Items policy, with a review date of 6/9/23, indicates: .5. When personal items are missing, the resident/responsible party is responsible to inform staff immediately and will complete a complaint/grievance form. From 11/10/24 to 11/12/24, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and muscle weakness (generalized). R7's Minimum Data Set (MDS) assessment, dated 9/11/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R7 was not cognitively impaired. On 11/10/24 at 12:05 PM, Surveyor interviewed R7 who indicated R7 was missing a purple cat T-shirt and a blanket with polka dots. R7 indicated the items were meaningful to R7 because the cat T-shirt reminded R7 of R7's cats whom R7 missed and the blanket was given to R7 by a friend. R7 indicated R7 told staff about the missing items a couple of weeks ago. R7 indicated staff wrote a note and indicated they would give it to the laundry supervisor, however, R7 had not heard anything yet. On 11/11/24 at 12:55 PM, Surveyor interviewed Laundry Supervisor (LS)-X who indicated LS-X was new to the facility and still learning. LS-X indicated that since LS-X had started, LS-X had not seen any grievances for missing clothing. LS-X was not aware that R7 was missing anything and had not received a note regarding R7's missing items. LS-X showed Surveyor a cart that contained missing items and said residents and families can search through the items if they are missing anything. On 11/11/24 at 1:04 PM, Surveyor interviewed Laundry Aid (LA)-W who delivered laundry in the facility. LA-W indicated LA-W had not heard that R7 was missing clothing but thought LA-W saw a blanket with polka dots. LA-W and Surveyor checked the lost and found but did not find the blanket. LA-W pointed to a yellow sticky note pinned to the bulletin board in the laundry room and indicated if residents are missing items, staff write a note and put it on the bulletin board. LA-W indicated LA-W had not seen a grievance form and had not filled out a grievance form for missing laundry. On 11/11/24 at 1:58 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who was not aware R7 was missing items from laundry. NHA-A indicated R7 had a lot of belongings and still had belongings at a previous facility. NHA-A indicated if NHA-A had been aware of R7's missing items, NHA-A would have first checked R7's inventory to see if the items were logged on the inventory sheet. NHA-A then would have searched laundry. NHA-A confirmed a grievance form should be filled out for missing laundry items. NHA-A indicated Social Worker (SW)-V was the facility's Grievance Officer. On 11/11/24 at 2:22 PM, Surveyor interviewed SW-V who was not aware that R7 was missing any items. SW-V indicated that not all of R7's belongings came with R7 from a previous facility. SW-V checked R7's inventory log which did not contain the specified items. SW-V indicated there was not much on R7's inventory log, however, R7 ordered items online and a few inventory sheets contained R7's online orders. SW-V indicated if SW-V had been aware of R7's missing items, SW-V would have done a room search (with R7's permission), searched laundry, determined if the missing items required a self-report or a grievance form, and would have called R7's family members to see if they took the items home. SW-V indicated all grievances go through SW-V so they can be distributed to the correct departments for follow-up. Surveyor informed SW-V that laundry staff indicated they do not see grievances, do not fill out grievance forms when they hear about missing items, and that Certified Nursing Assistants (CNAs) write notes and put them in the laundry area if a resident is missing an item. SW-V indicated missing items should be turned into grievances so SW-V can track them and provide follow-up. On 11/12/24 at 11:25 AM, Surveyor interviewed Med Tech (MT)-T who indicated R7 told MT-T about a week and a half ago that R7 was missing a T-shirt and a polka dot blanket. MT-T indicated MT-T wrote a note and gave it to the supervisor on duty. On 11/12/24 at 3:32 PM, Surveyor interviewed NHA-A and informed NHA-A that staff knew about R7's missing items but the information was not received by laundry staff. NHA-A confirmed a grievance should have been completed for R7's missing items.

Based on observation, staff, resident and family interview, and record review, the facility did not ensure 3 residents (R) (R67, R17 and R1) of 5 sampled residents reviewed for pressure injuries received the necessary care and services to promote healing and/or prevent pressure injuries from developing. R67 had a pressure injury on the right heel. R67 did not have interventions in place that were recommended by the wound care provider. In addition, R67's care plan did not contain the wound care provider's recommendations. R17 developed a pressure injury from oxygen tubing that was not padded. R1 had a self determination care plan that indicated R1 chose to have a urinal propped against R1's scrotal area. R1's care plan did not contain an intervention to monitor for or prevent potential skin injury to R1's scrotal area. Findings include: The facility's Wound care Policies and Procedures, with a revision date of 6/1/15, indicates: Evaluation is the formal process in which wound characteristics, underlying conditions and contributory medical history are identified/quantified. Evaluation should result in treatment approaches including elimination or compensation for causative factors and a prognosis for healing. 3. Evaluation results are communicated to the members of the care team through documentation, care plan meetings, and care planning. The National Pressure Injury Advisory Panel released the 2nd version (6/23) of the Standardized Pressure Injury Prevention Protocol Checklist (SPIPP-Adult) 2.0 which directs the care provider to: Assess risk factors for pressure injury to guide risk-based prevention: .Use a structured assessment approach (e.g. Braden or other validated risk tool) on admission; Reassess risk every shift and with significant change in condition; Patient/family informed of pressure injury risk and prevention plan; Assess skin/tissue for signs of skin damage and pressure injury; Assess skin (comprehensive, visual, palpation) upon admission and every shift for erythema, discoloration, edema, and temperature; Assess skin under medical devices every shift; Inspect heels every shift. 1. From 11/11/24 to 11/12/24, Surveyor reviewed R67's medical record. R67 was admitted to the facility on [DATE] and had diagnoses including dementia and a stage 2 pressure injury to the right heel. R67's Minimum Data Set (MDS) assessment, dated 8/4/24, indicated R67 was severely cognitively impaired. On 11/10/24 at 11:44 AM, Surveyor observed R67 sleeping in a wheelchair in R67's room with shoes on. Surveyor noted heel boots on R67's bed. R67's medical record indicated: ~ A care plan, initiated on 9/18/24, indicated R67 had a pressure injury on the right posterior ankle related to immobility, pain, diabetes mellitus type 2, anemia, and muscle weakness. The care plan contained an intervention (initiated on 9/18/24) to use pressure relieving boots to relieve pressure on the heels. ~ A wound note, dated 11/5/24, indicated R67 was seen by the wound care team and wound Nurse Practitioner (NP). R67 had a right posterior ankle wound. The wound bed was yellow with no drainage. The note indicated the wound could be left open to air with no shoe on the right foot. An order for Betadine 3 times per week was initiated. ~ A wound note, dated 11/12/24, indicated to protect R67's heels with 2-3 pillows/offloading boots. The note indicated the wound could be left open to air with no shoe on the right foot. On 11/11/24 at 12:01 PM, Surveyor observed R67 in the dining room in a Broda chair with shoes on. R67 was not wearing heel boots. On 11/11/24 at 4:02 PM, Surveyor observed R67 in the lobby with shoes on. R67 was not wearing heel boots. On 11/12/24 at 11:35 AM, Surveyor interviewed Medication Technician (MT)-T who indicated R67 usually wore shoes during the day and wore heel boots when R67 was in bed. On 11/12/24 at 12:32 PM, Surveyor interviewed Registered Nurse (RN)-U who did wound rounds with the wound care provider. Surveyor informed RN-U of Surveyor's observations of a shoe on R67's right foot and no heel boots. Surveyor also informed RN-U that R67's care plan did not indicate that R67 should not wear a shoe on the right foot. RN-U confirmed wound care provider interventions should be added to care plans and communicated to staff. RN-U confirmed R67 should not have been wearing a shoe on the right foot and should have had heel boots on. 45943 2. From 11/10/24 to 11/12/24, Surveyor reviewed R17's medical record. R17 received Hospice services and had diagnoses including chronic obstructive pulmonay disease (COPD), congestive heart failure (CHF), chronic kidney disease (CKD) stage 3, and recurrent and persistent hematuria (blood in the urine). A Braden scale assessment, dated 11/10/24, had a score of 14 which indicated R17 was at moderate risk for pressure injury development. R17 had a physician's order for 1-6 liters per minute (LPM) of oxygen per nasal cannula. On 11/10/24 at 10:38 AM, Surveyor observed R17 receiving oxygen at 2 liters per nasal cannula via a concentrator. Surveyor observed redness and irritation behind R17's left ear under the unpadded oxygen tubing. Surveyor interviewed R17 who indicated staff had looked at R17's ear but did nothing about it. Surveyor reviewed R17's skin assessments through 11/6/24 and noted the skin assessments did not contain documentation of redness or irritation behind R17's ear. A skin assessment, dated 11/10/24, documented a new reddened area behind the top of R17's left ear due to pressure from R17's oxygen tubing. Surveyor noted R17's care plan, dated 4/4/23, did not contain an intervention to inspect behind R17's ears due to the oxygen tubing. On 11/12/24 at 10:43 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated if a resident is on oxygen staff should check placement of the oxygen tubing and assess skin integrity every shift. DON-B indicated staff should also ensure the oxygen tubing does not have kinks and provides appropriate airflow. DON-B indicated if there is irritation behind a resident's ear, staff should initiate some kind of protection such as foam ear protectors. 42423 3. From 11/10/24 to 11/12/24, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury (TBI), non-pressure chronic ulcer of skin of other sites limited to breakdown of skin, pain, and dysphagia (difficulty swallowing). R1's MDS assessment, dated 10/18/24, had a Brief Interview for Mental Status (BIMs) score of 15 out of 15 which indicated R1 was not cognitively impaired. The MDS also indicated R1 was dependent on staff for mobility and transfers. On 11/11/24 at 9:40 AM, Surveyor interviewed R1's Power of Attorney (POA-J) who indicated R1's Family Member (FM-K) visualized R1's skin (including R1's scrotal area) over the weekend and noted an area below the penis that looked reddened and ring-like. (According to the facility's visitor login, FM-K visited R1 on 11/9/24 from 11:48 AM to 1:41 PM.) POA-J also indicated a nurse told POA-J that a urinal was being left underneath R1's perineal area so R1 did not get wet (from urine). R1 was present at the time of the conversation and stated staff remove the urinal after R1 urinates, empty the urinal, and then put it back. POA-J indicated FM-K spoke with Registered Nurse (RN)-E and told RN-E to stop placing the urinal between R1's legs because it was causing a sore to the penile area. On 11/11/24 at 11:45 AM, Surveyor interviewed POA-J and DON-B. DON-B indicated placing the urinal between R1's legs was care planned as a request from R1. DON-B indicated staff completed skin checks regularly for R1. DON-B indicated DON-B was unaware of a reddened area on R1's penis and would check R1's medical record. On 11/11/24 at 1:30 PM, DON-B provided Surveyor with R1's self-determination care plan that indicated: Problem: R1 prefers to have urinal placed/propped between legs whenever uses urinal and at bedtime. Approach: Education provided in regards to skin integrity as R1 wishes to have the urinal placed/propped between legs at night. Long Term Target Date: 10/1/24, Skin integrity will remain intact. An evaluation note on the care plan indicated: 2/21/23, Seen by wound care NP (Nurse Practitioner)-L. NP-L was concerned about high risk of developing pressure injury to the scrotum/penis due to preference of urinal placement. R1 understood and stated R1 knows the risks of developing a pressure injury. R1 prefers to keep urinal placed between R1's leg while in bed. Last reviewed/revised: 7/8/24 by Assistant Director of Nursing (ADON)-M. On 11/12/24 at 10:13 AM, DON-B informed Surveyor that ADON-M assessed R1's skin on 11/11/24 after DON-B was notified of R1's perineal area and noted no reddened areas or sores to R1's scrotum. DON-B indicated R1 had a treatment order for buttock areas on the wound log (initiated on 11/7/24). On 11/12/24 at 12:52 PM, Surveyor interviewed RN-E who indicated RN-E worked regularly on R1's unit but was not aware of a sorer on R1's penis. RN-E indicated RN-E worked the 11/3/24 night shift into the morning of 11/4/24. As recent as that shift, RN-E indicated R1 demanded the urinal be placed between R1's legs. RN-E indicated R1's regularly-scheduled Certified Nursing Assistants (CNAs) placed the urinal between R1's legs per R1's request. RN-E indicated if staff do not place the urinal between R1's legs or if there is a new staff who is not aware of R1's request, R1 calls out repeatedly, activates R1's call light, and/or calls the nursing station by phone and demands the urinal be placed between R1's legs. RN-E indicated R1 wants the urinal there. RN-E indicated R1's regular CNAs know to check every two hours and empty the urinal. RN-E indicated FM-K told staff on 11/9/24 to stop putting the urinal between R1's legs. RN-E verified R1 did not request that staff stop placing the urinal between R1's legs. RN-E indicated R1 abides by R1's family's wishes for awhile and then goes back to what R1 wants. A skin check, dated 10/19/24, indicated R1's skin was checked by a CNA during a bath/shower and was also checked by Licensed Practical Nurse (LPN)-R. The skin check contained a body diagram with two small circles drawn on the front of the body below the stomach/top of groin. The comments section contained a hand-written note that indicated R1 had small red areas to the groin. A skin check, dated 10/22/24 with CNA and nurse signatures/initials, indicated R1 had no skin areas noted. An undated skin check form which was placed between the 10/22/24 skin check and the 11/3/24 skin check and signed by LPN-R contained a hand-written note in the comment section that indicated R1 had red areas on the groin. The body diagram contained the same marked areas as the 10/19/24 skin check. A Skin Focused Observation note, dated 10/27/24, indicated R1 had no new areas of concern, no open areas, and R1's buttocks were not red. A Skin Focused Observation note, dated 10/29/24, indicated R1 had no new skin issues. A Skin Focused Observation note, dated 11/1/24, indicated R1 had no new skin areas and a previous red area on the groin. Skin checks, dated 11/3/24 and 11/5/24, were signed by a nurse and a CNA and noted no marks on the diagram or comments related to skin areas. A Skin Focused Observation note, dated 11/5/24, contained no documentation related to the groin. In addition to the previously mentioned self-determination care plan, Surveyor reviewed an untitled care plan with a problem start date of 11/10/22 that indicated: R1 is at risk for skin breakdown related to a Braden score of 16, generalized weakness and need for staff to assist with repositioning, frequent incontinence, morbid obesity, high risk for shearing, contracture and tightening of joints, desire to hang on to items such as cell phone when in bed, rosacea, history of choric/recurring MASD (moisture-associated skin damage) under skin folds and between gluteal crease, redness of buttocks, lymphedema .R1 demands that a urinal be propped between legs when in bed with a pillow against it which pushes the urinal even tighter against R1's skin. If staff do not do this, R1 will keep calling the facility or yelling out for help until it is done. The care plan had a long term goal target date of 10/1/24 which was: R1 will have interventions to prevent skin breakdown. The care plan contained the following interventions: Assess R1's skin daily during bathing, especially over bony prominence; Licensed nurse to do a weekly skin check. The care plan did not contain an intervention to monitor for skin issues related to the urinal placement between R1's legs with the pillow against it which pushed the urinal tighter against R1's skin. On 11/12/24 at 2:02 PM, Surveyor interviewed LPN-D who indicated LPN-D gave R1 a shower that day. LPN-D indicated LPN-D did not observe any skin issues or reddened areas on R1's scrotum. LPN-D indicated R1 had small raised bumps on R1's lower abdomen approximately two weeks ago which were getting better. LPN-D indicated two scratched areas were observed on R1's coccyx on 11/7/24. LPN-D indicated LPN-D called POA-J with no answer, called FM-K with no answer, and called POA-J a second time and left a voicemail regarding the skin areas. LPN-D did not receive a return call. On 11/12/24 at 2:17 PM, Surveyor received R1's permission to view the area of concern. LPN-D and CNA-BB pulled R1's incontinence brief down and Surveyor observed two dark pink rings/creases on R1's scrotum. R1's skin was intact with no open areas. LPN-D indicated R1 used the bedpan, was incontinent at times, and wore a brief. LPN-D indicated LPN-D was not aware that R1 used a urinal. On 11/12/24 at 2:24 PM, Surveyor interviewed CNA-BB who indicated R1 requests staff prop a urinal on a towel and then notifies staff when R1 is finished urinating. When Surveyor asked about propping the urinal versus holding the urinal, CNA-BB indicated R1 prefers to have the urinal propped. CNA-BB indicated R1 asks staff to keep the urinal between R1's legs and usually calls staff shortly after. On 11/12/24 at 2:25 PM, Surveyor interviewed DON-B regarding the red marks on R1's scrotal area. DON-B indicated DON-B first heard about the red marks on 11/11/24 during the interview with POA-J and Surveyor. DON-B had ADON-M assess R1's skin which ADON-M indicated contained no open areas on the scrotum. DON-B also indicated R1's regular AM shift CNA (CNA-S) did not notice any red marks on 11/11/24. DON-B indicated R1 was reassessed after lunch on 11/12/24 and staff noted a u-shaped mark on R1's scrotal area. DON-B indicated RN-U obtained an order for zinc. DON-B indicated CNA-S told DON-B that R1 was placed on the urinal last night and CNA-S removed the urinal this morning. On 11/12/24 at 2:37 PM, Surveyor interviewed ADON-M who indicated ADON-M viewed R1's skin that morning and noted two bright red creases which, upon reassessment after lunch, appeared diminished and pink (versus red). ADON-M noted the potential causes for the marks which included incontinence while sitting in R1's Broda chair and use of the urinal. ADON-B confirmed staff rest the urinal between R1's legs per R1's request. ADON-M was unsure if R1 made the request that day. ADON-M confirmed regular staff place the urinal between R1's legs and new staff learn to do it when R1 demands they place the urinal there. ADON-M indicated R1's medical record confirmed the risks were explained to R1 and indicated an order for zinc was requested. On 11/12/24 at 2:45 PM, Surveyor interviewed DON-B who confirmed R1's care plan did not include prevention and/or monitoring of the skin for damage due to R1's request of the urinal placement.

Based on staff and resident interview and record review, the facility did not ensure the appropriate care and services were provided to increase and/or prevent further decrease in range of motion for 3 residents (R) (R14, R6, and R7) of 3 sampled residents. R14 did not receive restorative therapy per therapy discharge recommendations. Staff did not correctly enter the recommendations in R14's medical record, therefore, R14's Minimum Data Set (MDS) assessment was not coded correctly. R6 did not consistently receive restorative therapy. R7 did not consistently receive range of motion (ROM) per R7's orders and care plan. Findings include: On 11/11/24, Surveyor requested the facility's policy for restorative services. The facility provided a training that was titled Restorative Nursing Program Quick Start from Fundamental Clinical and Operational Services, LLC 2024 which contained educational slides for the restorative nursing program (RNP). The training indicated: .Care planning: specific detail approaches, and periodic evaluation. Daily documentation 1. From 11/10/24 to 11/12/24, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and muscle weakness (generalized). R14's MDS assessment, dated 9/11/24, had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R14 was not cognitively impaired. The MDS assessment indicated R14 did not have a restorative program but had limited ROM. On 11/10/24 at 12:05 PM, Surveyor interviewed R14 and noted an exercise sheet on R14's wall. When Surveyor asked if staff did exercises with R14, R14 said no and wondered if R14 should be doing them on R14's own. On 11/11/24 at 12:35 PM, Surveyor interviewed Occupational Therapist Registered (OTR)-Q who indicated R14 had a restorative program from 7/22/24 that was posted in R14's room. OTR-Q indicated R14 should be doing the exercises with staff. OTR-Q indicated when a resident is discharged from therapy, therapy provides a sheet with information with what should be done. OTR-Q indicated OTR-Q also trains staff and posts exercises in residents' rooms. OTR-Q provided Surveyor with R14's therapy communication form, dated 7/22/24, that indicated: 1. Range of motion program daily prior to donning right resting hand splint-see attached. 2. R14 to wear right resting hand splint at night, for 8 hours daily, or per R14's tolerance. 3. R14 may wear left wrist splint up to 4 hours during AM or PM as requested for left wrist pain. Surveyor noted the restorative program was not in R14's care plan. Surveyor also noted there was no documentation on R14's restorative program in R14's medical record. On 11/11/24 at 2:52 PM, Surveyor interviewed Minimum Data Set Coordinator (MDSC)-I who indicated MDSC-I was responsible for restorative therapy. MDSC-I indicated another nurse put in the the order for R14's restorative care when it was sent from therapy, however, the staff entered the order under R14's physician orders and did not attach it to R14's Medication Administration Record (MAR) or Treatment Administration Record (TAR). MDSC-I indicated the staff also did not add the order to R14's care plan or to the Certified Nursing Assistant (CNA) tasks in R14's medical record. MDSC-I confirmed those steps should have been taken so staff knew R14 had a restorative program that they should complete and document. Because staff did not document or complete restorative therapy for R14, MDSC-I indicated MDSC-I did not code R14's MDS correctly to indicate that R14 had a restorative program. 2. From 11/10/24 to 11/12/24, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including multiple sclerosis, muscle weakness, and abnormal posture. R6's MDS assessment, dated 8/21/24, had a BIMS score of 15 out of 15 which indicated R6 was not cognitively impaired. A care plan, dated 6/19/23, indicated R6 received passive range of motion (PROM) and active range of motion (AROM) and required splint brace assistance once per day. On 11/10/24 at 11:46 AM, Surveyor interviewed R6 and noted R6 was leaning in R6's chair and somewhat contracted. When asked if staff assisted R6 with exercises, R6 indicated sometimes they did. On 11/11/24 at 12:35 PM, Surveyor interviewed OTR-Q who confirmed R6 had a maintenance program for restorative therapy. OTR-Q provided Surveyor with a therapy communication form, dated 6/28/23, that indicated: PROM to left and right shoulder flexion. Elbow flexion/extension. Wrist flexion/extension and digit and thumb extension 11 reps. Bilateral lower extremity range of motion for ankle dorsiflexion, hip abduction, and knee extension 10 reps daily. OTR-Q also indicated splint assistance should be provided. Surveyor reviewed documentation on R6's restorative programming from 8/1/24 through 11/11/24 and noted the following: R6's Splint/Brace Assistance Restorative Program: In August 2024, there was no charting on 17 out of 31 days. In September 2024, there was no charting on 18 out of 30 days. In October 2024, there was no charting on 18 out of 31 days. In November 2024, there was no charting on 5 out of 10 days. R6's Active Range of Motion Restorative Program: In August 2024, there was no charting on 17 out of 31 days. In September 2024, there was no charting on 16 out of 30 days. In October 2024, there was no charting on 16 out of 31 days. In November 2024, there was no charting on 5 out of 10 days. R6's Passive Range of Motion Restorative Program: In August 2024, there was no charting on 7 out of 31 days. In September 2024, there was no charting on 3 out of 30 days. In October 2024, there was no charting on 13 out of 31 days In November 2024, there was no charting on 4 out of 10 days. On 11/11/24 at 12:35 PM, Surveyor interviewed MDSC-I who confirmed staff should consistently document on restorative programs, including refusals. MDSC-I indicated MDSC-I used the information to code residents' MDS assessments accurately. 32768 3. From 11/10/24 to 11/12/24, Surveyor reviewed R7's medical record. R7 was admitted to facility on 6/30/15 and had diagnoses including multiple sclerosis, anxiety disorder, muscle weakness, abnormal posture, osteoporosis, and contracture of muscle and joint. R7's MDS assessment, dated 10/16/24, indicated R7 required substantial maximal assistance with bathing and upper dressing and was dependent on staff for toileting, lower dressing, and transfers. R7 had functional limitation with range of motion and impairment to the upper and lower extremities. A BIMS score indicated R7 was not cognitively impaired. A care plan, dated 10/16/23, indicated: Passive range of motion to bilateral lower extremities 4 to 7 days a week. dorsiflexion bilateral feet 2 times a day, toe passive range of motion 2 times a day, hip passive range of motion 2 times a day, lower trunk rotation, knee rocks 2 times a day, hip abduction/adduction 2 times a day. On 11/10/24 at 1:31 PM, Surveyor interviewed R7 who indicated staff were not doing R7's ROM anymore. R7 indicated ROM was supposed to be done in the morning and afternoon. R7 indicated there was only one CNA who assisted R7 with ROM. On 11/12/24, Surveyor reviewed R7's medical record for lower extremity ROM documentation from 8/1/24 to 11/11/24. The documentation was inconsistent and noted the following: On 8/1, 8/3, 8/4, 8/5, 8/6, 9/2. 9/10, 10/8, 10/13, 10/22, 10/27, 11/6, and 11/10, R7 missed both sessions. On 8/2, 8/9, 8/13, 8/16, 8/20, 8/27, 8/30, 8/31, 9/1, 9/4, 9/5, 9/8, 9/9, 9/14, 9/17, 9/22, 9/24, 10/7, 10/9, 10/11, 10/12, 10/14, 10/15, 10/18, 10/19, 10/20, 10/26, 10/28, 11/3, and 11/8, R7 missed 1 session On 11/12/24 at 12:22 PM, Surveyor interviewed MDSC-I who indicated if a resident's point of care history indicates ROM was not performed then ROM was not completed for that shift or day.

Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent a urinary tract infection (UTI) for 1 resident (R) (R17) of 4 residents reviewed for catheter care. On 11/10/24, R17's uncovered catheter drainage bag was observed on the floor. Findings include: The facility's Catheter-Urinary Catheter, Cleaning and Maintenance Policy and Procedure taken from the Lippincott Nursing Procedures 9th edition (Copyright 2023 with complete revision: May 5, 2023) indicates: Don't place the drainage bag on the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infection (CAUTI). From 11/10/24 to 11/12/24, Surveyor reviewed R17's medical record. R17 received Hospice services and had diagnoses including chronic kidney disease (CKD) stage 3 and recurrent and persistent hematuria (blood in the urine). R17 had a physician order for an indwelling Foley catheter for acute urine retention (dated 10/18/24) and an order for a privacy bag in place every shift (dated 10/18/24). On 11/10/24 at 10:28 AM, Surveyor observed R17 in a recliner with catheter tubing that ran down R17's right pant leg and drained light clear yellow urine into an uncovered collection bag that was laying on the floor. On 11/10/24 at 10:53 AM, Surveyor interviewed Infection Preventionist (IP)-C who verified R17's uncovered catheter bag was on the floor. IP-C indicated the catheter bag should not touch the floor and should be covered for infection control and privacy. On 11/11/24 at 8:45 AM, Surveyor interviewed Registered Nurse (RN)-H who verified R17's uncovered catheter bag was secured to R17's bed frame. On 11/12/24 at 10:40 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed catheter drainage bags should be covered and not in contact with the floor.

Based on observation, interview, and record review, the Facility did not ensure Residents (R) that were assessed to be at risk for the development of pressure injuries or residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 (R373, R64, R223, R67) of 6 Residents reviewed for pressure injuries. * R373 was assessed to be at high risk for the development of pressure injures. R373's care plan did not include person centered interventions to prevent the development of pressure injures based on R373's risk assessment. R373 developed a facility acquired stage lll pressure ulcer to the left buttock on 10/04/2022 and there were no wound care treatment orders implemented until 10/11/2022. * R64 was admitted to the facility on [DATE] with a community acquired deep tissue injury to the right heel, which was not comprehensively assessed, nor was there a treatment ordered until 9/13/2022. * R223 was admitted on [DATE] and noted to have an open area on buttock crease with zinc applied. On 10/1/22, there was no comprehensive assessment of the open area on the buttock crease other than measurements. There was no staging of the pressure injury, no description of the wound bed, whether there was drainage, and no description of the periwound. Three days later on 10/4/22 a wound assessment documents gluteal crease pressure injury is Unstageable - Slough and/or Eschar. Measurements in centimeters are for length 1.93, width 0.81, and depth 0.2. 75% slough with a new treatment order to cleanse with 1/4 dakins followed by skin prep followed by santyl, followed by bordered gauze daily. On 10/6/22 the wound assessment is documented as - coccyx: Unstageable pressure wound measures 1.0 x 0.5 x 0.2 cm. R223 was on a mattress appropriate for a for a stage I (1) or II (2) pressure wound until 10/06/22 even though R223 was noted to have an unstageable PI on 10/4/22. On 10/6/22, the facility implemented the use of an air mattress. On 10/6/22, the air mattress was not on while R223 was in bed at 2:07 pm, 3:06 pm, and at 3:17 pm. The air mattress was turned on at 3:50 pm. The facility had no information on R223's wheelchair cushion as to whether the cushion was appropriate for an unstageable PI. R223's care plan did not address the offloading of R223's heels. R223 was observed on 10/5, 10/6, and 10/10/22 to have their heels directly on the mattress and not floated. R223 was observed to have his feet/balls of his feet pressing against the foot board. * R67 was admitted on [DATE] with diagnoses that included a left tibia fracture with an immobilizer in place. On 9/29/22, R67 developed an area to the left thigh and an area to the left lower extremity related to the immobilizer. A nursing order was written on 9/29/22 to inspect skin under brace to left leg every shift. This had not been an order upon admission on 6/2/22 even though R67 had been wearing the immobilizer brace since admission. R67's wound to the left lateral thigh, caused by the brace, was not comprehensively assessed. There was no evidence that the physician was notified and that an order for treatment was obtained. Further review of the plan of care showed that it was not updated to list interventions to prevent further skin breakdown. As of the time of exit on 10/11/22, the facility had not comprehensively assessed the open area to R67's left lower leg that was first observed on 9/29/22. The facility did not obtain a treatment order for the area, nor did they update the plan of care with interventions to prevent further skin breakdown. Example 1 involving R373 rises to a scope and severity level of G (harm/isolated). Findings include: The facility policy titled, Wound Care Policies and Procedure, with the subject, Pressure Ulcers and an email revision date of 03/23/2017 states: . 1. Evaluate the pressure ulcer initially for location; stage (see specific policy), size (in cm's (centimeter)), sinus tracts, undermining, exudate (type, odors), necrotic tissue, and the presence and or absence of granulation tissue and epithelialization. .Suspected Deep Tissue Injury: Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue .the wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. .Stage lll: Full thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present . 1.) R373 was admitted to the facility on [DATE] with diagnoses that include, nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing, abnormal posture, muscle weakness, and depression. R373's Admission MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 9/27/2022, documents R373 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R373 is cognitively intact for daily decision making; a PHQ-9 (Patient Health Questionnaire) score of 16, indicating moderately severe depressive symptoms; requires extensive assist of 2 plus staff for bed mobility, is totally dependent on 2 plus staff for dressing, toilet use, and personal hygiene, and totally dependent on one staff person for eating, frequently incontinent of bowel and bladder; and is at risk for pressure ulcers, but did not have any pressure injuries documented upon admission. R373's CAAs (Care Area Assessment) related to skin breakdown documents, at risk for pressure injuries as evidenced by needing extensive assistance for bed mobility and incontinent of bowel and bladder. Staff will apply barrier cream to buttocks and peri area with cares to prevent skin breakdown. Goal is to be free from skin breakdown. Care plan will address to avoid complications and minimize risk and improve skin integrity. Staff will continue to assess skin condition with ADL (Activities of Daily Living) cares daily and report any abnormalities. Staff will continue to encourage and assist turning and repositioning regularly. R373's Braden scale assessment dated [DATE], documents a score of 12, indicating R373 is at high risk for the development of pressure ulcers. R373's care plan documents, Alteration in skin integrity related to bruises and scab on left elbow, initiated on 9/20/2022; interventions include: Assess/Monitor/Document and communicate with nurse signs and symptoms of itching, skin bleeding, blisters, broken/cracked skin . Assist with change of position every 2-3 hours . Check and change upon rising, before and after meals, at hour of sleep and with night shift rounds . Provide peri cares followed by moisture barriers as needed The above interventions were initiated on 09/20/2022. The care plan did not include person centered preventative interventions based on an assessment such as a pressure reducing mattress or speciality wheelchair cushion. Surveyor did not locate any other pressure ulcer care plan interventions until 10/4/2022 when R373 was seen by the wound care Nurse Practitioner (NP) and a wound to the left buttock was identified and assessed. The left buttock wound was assessed as a Stage III, measuring 1.43 cm (centimeters) by 1.76 cm with 100% granulation tissue. A treatment of zinc was ordered by the wound NP. On 10/4/22, R373's care plan was updated to include the following: Alteration in skin integrity related to abrasion to left buttock due to shearing. The interventions include all of the same interventions as the 9/20/22 alteration in skin integrity care plan with a newly added intervention of: treatment as per MD (Medical Doctor) order. Surveyor notes there were no new preventative interventions put in to place to address the assessed cause of the pressure injury as related to shearing. On 10/5/22, at 9:33 AM, Surveyor observed R373 lying in bed on back with pillows underneath bilateral arms. Heel riser boots were observed in place to bilateral lower extremities. R373 was lying on an air mattress. R373 told Surveyor, I have a decubitis ulcer on my rear end. It is small, maybe the size of a dime or quarter. R373 told Surveyor the ulcer was acquired at the facility. R373 stated she thought the staff cleaned the area good and put some type of cream on the area. Surveyor reviewed R373's medical record. On 10/4/22, at 13:24 (1:24 pm), LPN (Licensed Practical Nurse) M documented in R373's medical record, Resident seen by wound care team and wound care NP (Nurse Practitioner) for assessment of left buttock. Wound bed granulated with edges attached. Scant amount of serous drainage with no odor. Peri wound erythematous. New order to apply zinc TID (three times a day). On 10/4/2022, at 13:23PM (1:23 pm), LPN M documents R373's wound measurements: Length - head to toe direction (centimeters) 1.43 Width - side to side direction (centimeters) 1.76 Stage: Stage III Tissue Type: Granulation Tissue Percent of wound covered by granulation tissue: 100% Wound edges/margins: Edge attached to base Skin surrounding wound: Assess within 4 cm of wound edge Erythema (redness)/blanchable Comments: New patient - left buttock Stage 3 New Rx (Prescription) : zinc paste TID Surveyor reviewed R373's current physician's orders and could not find an order for zinc paste ordered by the wound NP on 10/4/22. On 10/6/22, at 9:21 AM, R373 gave permission for Surveyor to observe morning cares with two CNAs (certified nursing assistants), CNA N and CNA G. On 10/6/22, at 9:26 AM, R373 was turned onto left side and CNA N wiped R373's buttocks with wipes. Surveyor noted a small, quarter sized open area to left buttock. The wound appeared superficial with no signs or symptoms of infection. At this time, Surveyor could see a thick white cream surrounding the wound, but no cream on the wound. The two CNAs continued cleaning R373's peri-area and at 9:28 AM, CNA N applied zinc paste to coat the wound. On 10/10/2022, at 13:35 (1:35 pm) Surveyor asked RN (Registered Nurse) H what the current treatment for R373's pressure wound consists of. RN H stated she was not certain what the current treatment was. During R373's medical record review, Surveyor noted CNA W documented on 9/21/22, 9/26/22, and 9/28/22 that R373 has redness to buttock. Surveyor could not locate any other documentation relating to R373 having redness to the buttocks, prior to the 10/4/22 wound documentation. On 10/11/22, at 2:04 PM, Surveyor interviewed LPN M who stated R373's wound was being treated with Zinc cream and there should have been an order under the treatments section of the EMR (Electronic Medical Record). Surveyor informed LPN M that Surveyor was unable to locate an order for the zinc paste in R373's medical record. LPN M also told Surveyor that R373 had been seen by the wound team, and a new treatment was in place. At this time LPN M did not have access to the Internet and was going to review R373's medical records and report back to Surveyor. On 10/11/22, at 2:36 PM, LPN M informed Surveyor there was no order for zinc paste for R373. Surveyor asked when LPN M was made aware of the wound and LPN M replied either on 10/4/22 or the day before. Surveyor expressed concerns there were no wound care orders on the EMAR (Electronic Medication Administration record) or ETAR (Electronic Treatment Administration Record) from 10/4/22, date the left buttock wound was identified, until 10/11/22 when Surveyor brought the concern to the facility's attention. LPN M informed Surveyor the wound is getting better and there is a treatment order in now. On 10/11/22, at 2:40 PM, Surveyor interviewed CNA W who stated R373 had redness to the buttocks since admission. Per CNA W, the redness was localized to the buttocks area and where the wound is currently located. CNA W thought the nurses were aware of the redness and a zinc paste was being used. On 10/11/22, at 2:42 PM, Surveyor asked RN H if R373 had skin issues on buttocks prior to the wound. RN H told Surveyor yes it has always been red since admission, but RN H was unsure of the measurements. RN H stated she thought staff was putting zinc paste on it. Surveyor reviewed R373's medical record and noted a new physician's order dated 10/11/22 which documented, R (right) buttocks wound treatment: cleanse with 1/2 strength Dakins f/b (followed by) skin prep to periwound and bordered gauze daily. Surveyor notes the new physician's order for treatment to the buttocks was ordered for the right buttock when the pressure injury was located on the left buttock. Surveyor also notes a new wound assessment, dated 10/11/22, documenting wound healing status as improving with measurements of 0.87 cm x 1.01 cm. The wound is documented as a stage lll with light drainage and 100% granulation tissue. On 10/11/22, Surveyor informed Nursing Home Administrator A, Director of Nursing B and Assistant Director of Nursing C of the concern there is no documentation of interventions put into place to prevent pressure injuries when R373 was assessed to be at high risk for the development of pressure injuries such as a pressure relieving mattress or wheelchair cushion. R373 developed a Stage III pressure injury to the left buttocks on 10/4/22 and R373's care plan was not updated to include new preventative interventions other than the order for zinc paste. The zinc paste was not added to R373's treatment administration record and was not documented as being completed 3 times per day as ordered on 10/4/22. The first treatment order that was documented as being completed was on 10/11/22 after Surveyor brought the concern to the facility's attention. 2.) R64 was admitted to the facility on [DATE] with diagnoses that include, end stage renal disease, on dialysis; unsteadiness on feet, long term use of anticoagulants, and type two diabetes mellitus with diabetic neuropathy. R64's admission MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 9/14/2022, documents R64 has a BIMS (Brief Interview for Mental Status) score of 15, indicating R64 is cognitively intact for daily decision making; is at risk for pressure ulcers and has one stage three pressure ulcer that was present upon admission. R64's care plan titled, At risk for skin breakdown related to dialysis three days per week with prolonged sitting during this time, weakness, actual skin breakdown noted upon admission, shearing, incontinence of bladder, pain, obesity, HERD (end stage renal disease), lower extremity cellulitis and DM (diabetes mellitus), has a start date of 09/07/2022 and has interventions that include: Assess resident skin daily during bathing; Bilateral tubigrips; Diabetic foot checks daily; Use low air loss mattress for pressure reduction when resident is in bed. Surveyor notes all of the interventions for R64's skin breakdown care plan were initiated on 09/07/2022. Surveyor reviewed R64's medical record and notes documentation from [name of hospital] upon discharge, dated 9/07/2022 which documents, Community acquired: deep tissue pressure injury to right heel. On 9/8/22, at 1:15 AM, R 64's medical record documents: Skin check done. Resident right hand 2nd fingernail has come off. Dry skin noted to cuticle area. Blister that has popped is now dark skin which includes entire pad of finger. Dry flaky skin extends around entire area from pad of finger up around to nail bed. Right hand 3rd fingernail has come off and is slightly red around cuticle. Left anterior shin has 2.5 cm (centimeter) x (by) 1.5 cm superficial wound. Fresh bleeding noted. Resident also has a 2 cm x 3.5 cm bright to right antecubital space, a 6 x 6 cm bruise to right mid inner forearm from IVs (Intravenous therapy). Has a 9 cm x 4 cm faint black bruise to right back of hand. Has a 1 cm x 2.5 cm red area from cardiac monitors to left back rib area, Has bruises to abdomen from injections. Resident right foot 2nd toe missing r/t (related to) hx (history) of amputation. Has 1 cm blister behind right inner knee, Has a 5 cm x 7 cm faint bruise to right knee lateral. Has a 7.5 cm x 1.5 cm old blister area which is dark red in color under left anterior knee. Has a 4 cm x 3 cm scab to left 4th toe. 5th pinky toe amputated and well healed. Surveyor notes the 9/8/22 skin check does not document the presence of the right heel deep tissue pressure injury that was documented on R64's hospital discharge paperwork on 9/7/22. R64's admission physician orders, dated 9/07/2022 included: Diabetic foot checks every noc (night shift). Special Instructions: Check skin breakdown on feet every night. Surveyor was unable to locate documentation of a right heel, deep tissue injury documented during diabetic foot checks every night. On 9/13/2022, at 12:29 PM, LPN (Licensed Practical Nurse)-M documents in a progress note: Resident seen by wound care team and wound care NP (Nurse Practitioner) for assessment of left shin and right heel .Right heel wound bed with granulation and eschar. Edges attached. New order to cleanse with NS (Normal Saline). Apply iodosorb f/b (followed by) bordered gauze 3x (times)/week. On 9/13/2022, LPN-M documents in wound management progress notes: Date/Time Observed: 9/13/2022, at 13:57 PM (1:57 PM), New patient- right posterior heel Stage 3 . Length - head to toe direction (centimeters) 1.1 Width - side to side direction (centimeters) 1.32 . Tissue Type: Granulation Tissue Percent of wound covered by granulation tissue: 75% Percent of wound covered by eschar tissue: 25% . Present on admission/re-entry: Yes . R64 has an active physician's order with a start date of 9/13/2022 which documents, Right posterior heel treatment: Cleanse with NS f/b iodosorb f/b bordered gauze 3x/week and PRN(as needed) for soiling/saturation. Once A Day on Tue (Tuesday), Thu (Thursday), Sat (Saturday). Surveyor was unable to locate physician's orders or wound documentation related to the right heel deep tissue injury prior to 9/13/2022. On 10/11/22, at 1:40 PM, Surveyor interviewed LPN-M, who stated she works with the facility wound NP once a week and she documents the wound findings in the resident's charts. For an admission, LPN-M stated the admitting nurse should measure the wound, note what color the wound is, describe the wound bed and document the findings in a progress note and under the wound management tab in the resident's electronic chart. LPN-M stated, if a resident is admitted with a wound, the admitting nurse would use the wound care orders from the hospital until the resident is seen during wound rounds which happens on Tuesdays. LPN-M informed Surveyor the admitting nurse would do the wound assessment even if it is not always an RN (Registered Nurse). LPN-M stated, the ADON (Assistant Director of Nursing) and the DON (Director of Nursing) do not get involved with wound assessments, but sometimes the facility NP will assess a wound and prescribe a treatment, if needed. LPN-M informed Surveyor R64's right heel wound was not documented in the admission skin check, but R64 did admit with that wound. Surveyor expressed concerns regarding no wound assessment for R64's right heel deep tissue injury from admission on 9/7/2022 until 9/13/2022. Surveyor asked LPN-M if any treatments were ordered for R64's right heel prior to 9/13/2022. LPN-M did not have access to the Internet at that time and told Surveyor she would check R64's medical records and get back to surveyor. On 10/11/22, at 2:04 PM, LPN-M informed Surveyor there were no treatment orders for R64's right heel deep tissue injury prior to 9/13/2022, but the wound is getting better. On 10/11/2022, at 7:16 am, Surveyor observed R64's right heel wound. RN-V removed R64's sock and Surveyor observed there was no dressing covering the right heel deep tissue injury. R64 stated the dressing must have come off but could not remember when. Wound care was preformed by RN-V per professional standards of practice. Surveyor noted the wound appeared superficial, did not have drainage and had no signs or symptoms of infections. R64 did not have signs of pain during the wound care, and R64 stated, I feel nothing on that foot. Surveyor reviewed R64's wound assessments which documented the right heel deep tissue injury had decreased in size from 1.1 cm x 1.32 cm on 9/13/2022 to 0.94 cm x 1.14 cm on 10/11/2022. However, Surveyor cannot ascertain if the wound worsened or progressed from admission on 9/7/22 until the first assessment of the area on 9/13/22 because there is no documentation of the right heel deep tissue injury until 9/13/2022. 3. R223 was admitted to the facility on [DATE] with diagnoses which includes dementia, anxiety, hypertension and benign neoplasm of meninges. The nurses note dated 10/1/22 documents Res (Resident) admitted to room [number] at 1400 (2:00 p.m.) via [name of] Ambulance. Res oriented to room, call light, TV remote, meal times, shower day, and staff. Res is A&O x (times) 2-3 (alert and orientated times two to three), occasional forgetfulness. Makes needs known. Understands and able to use call light. Denies dizziness. Speech clear, slow to respond. admitted to facility for strengthening following hospitalization r/t (related to) bilateral PE (pulmonary embolism), also has hx (history of) of BPH (benign prostatic hyperplasia), dementia, HTN (hypertension), heart failure, hyperlipidemia, meningoma with frontal craniotomy. LCTA (lungs clear to ausciltation)/diminished in the bases. Denies SOB (shortness of breath), but appears SOB when talking. POX (pulse oximetry) 97% 2L (liters). No coughing noted. HOB (head of bed) elevated. Covid test negative. Abdomen soft/nontender. BS (bowel sounds) active x 4. Appetite good. Able to feed self general diet. Oral mucosa pink and moist. Skin turgor WNL (within normal limits). Fluids encouraged. No s/sx (signs/symptoms) of dehydration. Continent of B&B (bowel and bladder). No c/o (complaint of) pain. 1 assist with walker for transfers. Skin assessment: bruises: 1.5 x 1.5 cm (centimeter) RAC (right antecubital), greenish, LAC (left antecubital) 0.5 x 0.5cm reddish, 5 x 5cm top of left hand greenish. 16 cm incision to forehead, sutures intact, no drainage noted. Open area to buttocks crease 2 cm x 0.5 cm, zinc applied. Res to participate in PT/OT (physical therapy/occupational) for strengthening. Wife here at this time. Pleasant with cares. The admission observation dated 10/1/22 under the skin section documents Skin temperature: Warm, Skin moisture: Dry, Skin color: Normal color, Petechiae present? No, Skin turgor: Normal, Alterations in skin? No, and Comments: see skin progress note and skin observation. The Focused Observation dated 10/1/22 under observation details for skin documents Skin temperature: Warm, Skin moisture: Dry, Skin color: Normal color, Petechiae present? No, Skin turgor: Normal, and Alterations in skin? Yes. Under Ulcer documents Location: coccyx, Length - head to toe direction (centimeters): 2, Width - hip to hip direction (centimeters): 0.5, Can depth be measured? No, and Proceed with wound care observation? No. Surveyor noted R223's coccyx pressure injury was not comprehensively assessed on 10/1/22 as the nurses note and focused observation only includes measurements and does not include the Stage of the pressure injury, description of the wound bed, whether there is drainage, and description of the periwound. The MD (medical doctor) order dated 10/1/22 documents Apply zinc barrier cream to buttocks TID (three times a day) and PRN (as needed). The Braden assessment dated [DATE] has a score of 18 which indicates at risk. The baseline care plan dated 10/3/22 under approach for skin integrity is checked for at risk & pressure ulcers. Complete skin checks is checked. The wound assessment dated [DATE] documents for R223's gluteal crease pressure injury for the Stage is Unstageable - Slough and/or Eschar. Measurements in centimeters are for length 1.93, width, 0.81 and depth 0.2. Exudate amount is light and exudate color and consistency is documented as serous (clear, amber, thin, and watery). The tissue type is documented as slough. The percent of wound covered by granulation tissue is documented as 25 and the percent of wound covered by slough tissue is 75. Under comments documents New patient - unstageable pressure ulcer to gluteal crease New Rx (prescription)- skin prep, Santyl then bordered gauze, change daily. Surveyor noted this comprehensive assessment is 3 days after R223 was admitted to the Facility. The nurses note dated 10/4/22 documents Resident seen by wound care team and wound care NP (nurse practitioner) for assessment of gluteal fold. Wound bed with granulation and slough, edges attached to base. Scant amount of serous drainage, no odor present. Periwound C/D/I (clean/dry/intact). New order to cleanse with 1/4 dakins f/b (followed by) SP (skin prep), f/b santyl, f/b bordered gauze daily. The physician order dated 10/4/22 documents Gluteal crease treatment: Cleanse with 1/4 strength dakins. Apply skin prep to periwound. Apply santyl to wound bed f/b (followed by) bordered gauze daily. Change PRN (as needed) for soiling/saturation. The pressure ulcer care plan with a start date of 10/5/22 has the following approaches all dated 10/5/22: * Assess pain (every) 4 hours and medicate prn (as needed) for dressing changes and wound rounds. * Avoid positioning directly on the trochanter. * Cleanse skin at the time of soiling. Avoid hot water, use mild cleansing agents. Use moisturizers on dry skin. Apply to skin while still damp from bathing. * CNA's (Certified Nursing Assistant) to inspect skin daily during bathing, especially over bony prominences LN (Licensed Nurse) to do skin check weekly. * Encourage foods high in protein and calories. * Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage. Use barrier cream for skin protection. * Refer for nutritional assessment. * Reposition Q 2-3 hours. * Screen by OT/PT for rehab potential. * Use pressure relieving mattress support surface for bed. * Use turn sheets for positioning. * Wound care as ordered. See treatment record. * Wound team to evaluate wound(s), treatments and weekly healing. Surveyor noted there are no interventions regarding offloading R223's heels. On 10/5/22 at 12:02 p.m. Surveyor observed R223 sitting in a wheelchair in his room with a lunch tray on the over bed table in front of R223. Surveyor observed R223 has a cushion in his wheelchair. On 10/5/22 at 12:53 p.m. Surveyor observed R223 in bed on his back with the head of the bed elevated. R223's heels are on the mattress and R223's left foot is pressed against the foot board. On 10/5/22 at 1:31 p.m. Surveyor observed R223 continues to be in bed on his back. R223's heels continue not to be offloaded and R223's left foot continues to be pressing against the foot board. On 10/5/22 at 3:26 p.m. Surveyor observed R223 bed on his back with the head of the bed elevated watching TV. Surveyor observed R223 is wearing yellow gripper socks, R223's heels are resting directly on the mattress and the ball of R223's feet are pressing against the foot board. The nurses note dated 10/6/22 documents Wound assessment - coccyx: Unstageable pressure wound measures 1.0 x 0.5 x 0.2 cm, white center surrounded by granulation tissue, edges intact. No drainage or odor. Treatment applied per orders, skin prep to periwound f/b new bordered gauze dressing. Pillow to support R (right) hip placed for pressure relief to area, res lying toward L (left) side at 30 degrees. Heels firm with normal colored tissue. Pillow added to float heels. Spouse was present during treatment, stated notable improvement. On 10/6/22 at 7:31 a.m. Surveyor observed R223 in bed on his back with the head of the bed elevated. R223 is wearing glasses and oxygen via nasal cannula. Surveyor observed R223 heels are not being offloaded and the balls of R223's feet are pressing against the foot board. Surveyor asked R223 if staff have washed him up this morning. R223 replied not yet. Surveyor inquired about the treatment. R223 informed Surveyor it was already done. On 10/6/22 at 7:52 a.m. Surveyor observed R223 continues to be in bed on his back. R223's heels are not being offloaded. On 10/6/22 from 8:25 a.m. to 9:00 a.m. Surveyor observed morning cares for R223 with CNA (Certified Nursing Assistant)-G. During this observation at 8:20 a.m. Surveyor checked the cushion in R223's wheelchair which is black with gray. Surveyor did not note a brand name on the cushion. At 8:27 a.m. Surveyor observed R223 has direct supply panacea original mattress which is blue & gray on bed. On 10/6/22 at 9:47 a.m. Surveyor observed R223 in bed on his back with the head of the bed elevated. Surveyor observed R223's heels are not being offloaded. On 10/6/22 at 11:12 a.m. Surveyor observed R223 sitting in a wheelchair in the salon getting his hair cut. At 11:13 a.m. Surveyor observed CS (Central Supply)-S wheeling R223 out of the salon. Surveyor observed R223 has a cushion in the wheelchair. As CS-S was wheeling R223 by therapy, a therapist came out and asked R223 if he was up for therapy. Surveyor then observed R223 sitting in his wheelchair in the therapy department. On 10/6/22 at 11:20 a.m. Surveyor asked RN (Registered Nurse)-H asked if there is an admission nurse who would admit Residents. RN-H informed Surveyor there is someone that does the medications but she or who ever is working when a Resident arrives would do the admission. Surveyor inquired what happens when a Resident is admitted with a pressure injury. RN-H informed Surveyor that they usually look to see if there is a treatment and follow that same treatment. Surveyor asked RN-H if she stages the pressure injury. RN-H replied I don't. Surveyor asked RN-H if she measures the pressure injury. RN-H replied we measure it. Surveyor asked RN-H about the wound bed. RN-H informed Surveyor she describes it as best as she can on her wound note. Surveyor asked RN-H if she document the percentages of the wound bed. RN-H replied no. Surveyor asked RN-H after the initial note is completed who would assess the pressure injury next. RN-H informed Surveyor it would depend on what shift the treatment is on. RN-H explained there is a wound team on Tuesdays and that the wound NP (nurse practitioner) comes in with LPN (Licensed Practical Nurse)-M. Surveyor asked if the wound team consists of just the wound NP and LPN-M. RN-H replied usually just the two of them. Surveyor asked RN-H when R223 was admitted was there slough in the wound bed. RN-H informed Surveyor she doesn't recall and she's not good at describing the wound bed but told LPN-M right away. On 10/6/22 at 2:07 p.m. Surveyor observed R223 in bed on his back with the head of the bed elevated attempting to place batteries in his hearing aides. Surveyor observed R223's heels are on the mattress and both feet are against the foot board. Surveyor observed there is now an air mattress box at the foot board which is off. On 10/6/22 at 2:13 p.m. Surveyor asked RN-H if R223 received a new mattress today. RN-H replied I don't recall. On 10/6/22 at 3:06 p.m. Surveyor observed R223 in bed on his back with the head of the bed elevated high. R223's heels are not being offloaded and the balls of his feet are pressing against the foot board. Surveyor noted R223's air mattress continues to be off. Surveyor noted the air mattress box manufacture is joerns convertible controller. Surveyor asked R223 if he was comfortable. R223 stated Well I haven't moved. Once I get comfortable [TRUNCATED]

Based on interview and record review the facility did not ensure 1 (R2) of 2 residents with pressure injuries received the necessary treatment to promote healing. R2 was admitted to the facility on [DATE] with some redness to the buttocks and chronic loose stools. On 1/25/21 R2 developed an unstageable pressure injury to the right buttock. On 1/25/21 Wound Physician C changed the treatment order and the new treatment order was not implemented by nursing staff until 2/8/21. No significant changes or healing was noted from 1/25/21-2/8/21. Findings include: R2 was admitted to the facility on [DATE] with a history of cerebral infarction with [CONDITION(S)] on right side, GI bleed, [CONDITION(S)] and neuromuscular dysfunction of bladder. The admission note dated 1/9/21 indicate R2 had slight redness noted to buttocks. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS (minimum data set) dated 1/14/21 indicate R2 had mild cognitive impairment, needed extensive assistance of two staff for bed mobility, dependent for transfers, and extensive assistance with one staff for hygiene and dressing. It also indicates R2 is at risk for pressure injuries and had no unhealed pressure injury. The care plan dated 1/22/21 indicates R2 is at risk for continued skin breakdown which is unavoidable r/t (related to) Braden score of 10, weakness, chronic bowel incontinence of diarrhea, PVD (peripheral vascular disease), CVA (cerebral vascular accident) with [CONDITION(S)], foley tubing, poor appetite with poor appeal of solid consistency, MASD (moisture associated skin dermatitis) noted on admission. Resident slides down in bed causing continued breakdown. The interventions dated 1/22/21 indicate Avoid positioning her directly on the trocanter. Cleanse skin at the time of soiling. Avoid hot water, use mild cleansing agents. Keep bony prominences from direct contact with one another with pillows or pads. Keep clean and dry as possible. Minimize skin exposure to moisture. Refer for nutritional assessment. Use moisture on dry skin. Apply while skin is still damp from bathing. Multiple nurses notes indicate R2 was experiencing incontinent loose stool. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Try to seal it or cover with tape to prevent soiling. Twice a day. There is not a nursing assessment of the excoriated area on the buttocks. The nurses notes dated 1/23/21 indicate R2 was placed on an air mattress. On 1/25/21 Wound physician C documented assessment indicate R2 had an unstageable pressure injury to the right buttock. The assessment indicates the pressure injury is unstageable measuring 5.98 cm (centimeter) by 4.45 cm by 0.1 cm. It indicates there is eschar in the wound bed. Wound Physician C ordered a new treatment, Cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep, apply Santyl to wound bed, cover wound with ABD, secure dressing with medi/[MEDICATION(S)], change daily, change PRN (as needed) for soiling and/or saturation. This order is not observed in the TAR (treatment administration record) and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The care plan was updated on 1/29/21 which indicates Turn and reposition Q 2-3 hours. Ensure that (R2) has RUE (right upper extremity) elevated with pillows to avoid subluxation to shoulder. Also make sure patient LEs (lower extremity) are elevated in bed to avoid patient sliding down in bed. The Wound Physician C assessment dated [DATE] indicates R2's unstageable pressure injury measures 4.34 cm by 3.51 cm by 0.1 cm with eschar in the wound bed. Treatment continued to be the same. The Wound Physician C assessment dated [DATE] indicates R2's unstageable pressure injury measures 4.89 cm by 3.74 cm by 0.1 cm there is still eschar in the wound bed. Treatment continued to be the same. The 1/25/21 treatment order was actually implemented on 2/8/21. The care plan was updated on 2/11/21 Follow with (Wound Physician C) for wound assessment and orders. Surveyor noted the care plan was not updated when the air mattress was applied or any pressure relief cushion for the wheelchair. The Wound Physician C assessment dated [DATE] indicates R2's unstageable pressure injury measures 4.54 cm by 4.38 cm by 1.20 cm. The assessment indicates early/partial granulation noted in the wound bed. On 3/31/21 at 12:35 p.m. Surveyor interviewed LPN (licensed practical nurse) Nurse manager D. LPN Nurse Manager D stated upon admission R2 had [MEDICATION(S)] ordered for the redness to the buttocks. LPN Nurse Manager D stated R2 had incontinent loose stool and on 1/22/21 excoriation to the buttock was noted and [MEDICATION(S)] with covered dressing was implemented. Surveyor indicates there isn't a nursing assessment of the excoriated buttocks. LPN Nurse Manager stated R2 buttock was excoriated but no open areas were noted. LPN Nurse Manager D stated on 1/25/21 is when R2 was discovered with the right buttock unstageable pressure injury. LPN Nurse Manager D stated the pressure injury happened fast. LPN Nurse Manager D stated R2 had a roho cushion (not sure when it was implemented) and the air mattress was applied on 1/23/21. Surveyor asked why the Wound Physician C treatment order dated 1/25/21 was not implemented until 2/8/21. LPN Nurse Manager D stated the nurse manager at that time, no longer works at the facility, forgot to transcribe the order. LPN Manager D stated Wound Physician C debrided the wound bed on 2/8/21 and ordered bed rest for R2. On 3/31/21 at 1: 26 p.m. Surveyor interviewed DON (Director of Nursing) B. DON B stated the nurse manager that was responsible for transcribing Wound Physician C order no longer works at the facility. DON B stated that LPN Nurse Manager D found out about the treatment error. DON B stated LPN Nurse Manager D was put in charge of logging all of Wound Physician C visits with treatment changes, the facility was meeting weekly to discuss at risk residents including residents with pressure injuries and now Wound Physician C visits are discussed in these meeting and the facility's Regional nurse requires all weekly wound assessments to be scanned to her and discussion with the nursing team is being conducted. Surveyor asked DON B if education was done with any other nursing staff beside the previous nurse manager, DON B stated no education was conducted with other nursing staff. On 3/31/21 at 2:50 p.m. Surveyor met with NHA A to discuss concerns with R2. Surveyor explained to NHA A the concern R2's unstageable pressure injury treatment was not implemented for two weeks and R2 wound did not show any signs of healing during that time. Surveyor also explained the care plan was not updated with interventions, such as when the air mattress was applied. NHA A stated she understood the concern. Surveyor asked NHA A if the facility has a policy regarding transcribing and implementing physician orders. NHA A stated she would look into it. On 3/31/21 at 3:28 p.m. NHA A stated the facility did not have a specific policy regarding transcribing and implementing physician orders. NHA A stated they are now educating all nurses to treat Wound physician C visits as a consult visit and the facility's consultation form will be filled out with each resident Wound physician C visits so all nurses are aware of any new orders. On 4/1/21 Surveyor received an email from DON B. DON B indicated R2's body failed her and was not responding to treatment despite the interventions that were in place. DON B also indicated R2 did not have motivation to off load, seek additional consults to determine the cause of her GI issues which were contributing to her skin breakdown and overall decline. She also did not wish to get up and did not eat well. R2's medical record does not reflect R2's lack of motivation to offload. R2's care plan does not reflect R2's lack of motivation to offload. On 4/1/21 at 2:25 p.m. Surveyor interviewed Wound Physician C. Wound Physician C stated he was made aware, on 2/8/21, that the treatment ordered on 1/25/21 did not get transcribed and implemented until 2/8/21. Wound Physician C stated the wound looked better on 2/8/21 than it did when he first saw it on 1/25/21. Wound Physician C stated he ordered Santyl so that it would help breakdown the necrotic area so that he can easily debride it. Wound Physician C stated he debrided it anyway on 2/8/21. Wound Physician C stated there wasn't any signs or symptoms of infection.

Based on interview and record review, the facility did not ensure that residents receive care, consistent with professional standards of practice, to prevent pressure injuries from developing for 1 (R1) of 1 residents reviewed for pressure injuries. R1 resided at the facility and was determined to be at risk for pressure injuries (PI) and developed unstageable pressure injuries on both of her heels. The facility did not implement appropriate interventions to prevent the pressure injuries from developing. Findings include: R1 admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. R1's Minimum Data Set (MDS) with an annual reference date of 11/1/19 section G0110 - Activities of Daily Living documented: Bed mobility - how a resident moves to and from lying position, turns side to side and positions body while in bed as extensive two person physical assist. Section G0400 - Functional Limitation in Range of Motion documented impairment of one lower extremity. Section M0150 - Risk of Pressure Ulcers/Injuries documented R1 to be at risk of developing pressure injuries. Section M0210 documented R1 had no pressure injuries upon admission. R1's Braden dated 10/26/19 documented a score of 16 indicating R1 to be at risk for pressure injuries. R1's Weekly Skin Note dated 10/26/19 was checked for left hip surgical incision. Special equipment: Overlay mattress, wheelchair cushion, splinting/positioning devices, pressure relief mattress and pressure reduction mattress - none of which were checked as having been implemented. No pressure injuries were documented. R1's Care Plan dated 10/25/19 Approach: Skin Integrity documented - at risk. Surgical wounds. Turn and reposition. Complete skin checks. R1's Care Plan problem start date 11/1/19 Created 1/7/20 documented: R1 is at risk for pressure ulcer due to friction and shear. Approach: Skin assessment and inspection every shift with close attention to heels. Chartable task in POC (point of care): Unchecked. Include on profile: Unchecked. Approach: Minimum of 2 people plus draw sheet to lift resident while in bed. Approach: Check incontinence pads frequently (every 2-3 hours) and change as needed. Moisturize dry unbroken skin. Use moisture barrier ointments (protective skin barriers). Surveyor noted there were no interventions indicated on R1's Care Plan to include offloading of her heels to prevent pressure injury. In addition, there was no indication of when or how often R1 was to be turned and repositioned and no indication of when or how often skin checks were to be completed. R1's Progress note dated 10/26/19 documented in part: Resident has heel dressings on both feet for protection. These were placed at the hospital. Resident and daughter insisted that both be removed. No skin issues noted on heels. Placed feet on pillow to offload heels. Surveyor noted no further documentation in R1's progress notes in regard to offloading of her heels. R1's October and November 2019 TAR (Treatment Administration Record) indicated no inspection or offloading of R1's heels documented prior to the development of the unstageable pressure injuries. R1's Progress note dated 11/9/19 documented in part: Writer was alerted by Physical Therapy that resident had a 14 x 7 cm (centimeter) fluid filled blister on bottom of heel left. As writer was assessing left heel, checked right heel and noticed 2 x 2 cm fluid filled blister. Writer applied skin prep and [MEDICATION NAME] dressing to prevent blisters from popping. Updated emergency contact and notified MD (Medical Doctor). Interventions: Apply skin prep to both heels every shift and apply [MEDICATION NAME] daily. Resident will be encouraged to elevate feet to avoid pressure. R1's Physician wound care notes documented: 11/12/19 Left heel - 5.39 x 5.96 cm. Pressure ulcer unstageable. Early/partial granulation. Cleanse with ½ strength Dakins solution, protect periwound with skin prep, cover wound with foam, change Tuesday, Thursday, Saturday and as needed (PRN). Right heel - 2.70 x 1.81 cm. Pressure ulcer, suspected DTI (Deep Tissue Injury). Purple. 11/26/19 Left heel - 4.44 x 5.11 cm. Eschar. Apply [MEDICATION NAME] from base of toes to below knee, change daily and PRN soiling and/or saturation. Right heel - 2.68 x 2.68 cm. Purple. 12/3/19 Left heel - 3.50 x 4.33 cm. Eschar. Right heel - 2.94 x 2.91 cm. Eschar. 12/10/19 Left heel - 3.63 x 4.70 cm. Eschar. Right heel - 2.54 x 2.58 cm. Eschar. 12/24/19 Left heel - 3.85 x 4.45 cm. Early/partial granulation. Excisional debridement completed. Protect periwound with skin prep, apply Iodosorb to wound bed, cover with ABD (abdominal) dressing, secure with Kerlix, change daily and PRN soiling and/or saturation. Right heel - 2.98 x 3.12 cm. Eschar. 12/31/19 Left heel - 3.93 x 3.49 cm. Early/partial granulation. Right heel - 3.10 x 3.28 cm. Eschar. (Resident was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]). 1/21/20 Left heel - 4.31 x 4.70 cm. Early/partial granulation. Eschar unstable, debrided at this visit. Cleanse wound with saline, protect periwound with skin prep, apply [MEDICATION NAME] to wound bed, cover wound with ABD dressing with Kerlix, change Tuesday, Thursday, Saturday and PRN. Right heel - 3.62 x 3.33 cm. Eschar. On 3/5/20 at 11:10 AM Surveyor spoke with Physical Therapy Assistant (PTA)-D who reported she was the one who found the blister. PTA-D stated she was seeing R1 in bed that day, she needed a lot of range of motion. When I touched her heels, she said ouch so I took off her gripper socks. PTA-D was unable to recall if R1's heels were floated, but did not think she was wearing boots. On 3/6/19 at 8:00 AM Surveyor spoke with Certified Nursing Assistant (CNA)-E who reported she did not think R1 had boots on until after the blisters were found. Surveyor asked CNA-E how she would know how to care for a resident per their Care Plan. CNA-E proceeded to the Kiosk and logged into a current residents' profile. CNA-E stated: This is where it would list if they are supposed to wear boots or float heels and stuff like that. Everyone should look here before they care for a patient. I know she had boots on, but I'm pretty sure it was after the blisters. I don't remember her ever wearing shoes, I know she didn't wear them after the blisters for sure. Surveyor asked if R1 had foot pedals and if R1 wore anything on her feet when up in the wheelchair. CNA-E reported R1 did have foot pedals, wore gripper socks and her feet rested on the foot pedals. On 3/6/19 Surveyor spoke with Unit Manager (UM)-C regarding R1's Care Plan. UM-C reported the baseline care plan is a template, it does not include floating heels or boots. Surveyor asked what interventions were implemented after R1 was identified to be at risk for pressure injuries. UM-C reviewed R1's Care Plan and could not find any interventions indicating offloading of heels was implemented. UM-C stated: Maybe we didn't put boots on her because of fall risk, I don't know. Surveyor asked what were the expectations for residents admitted with [MEDICAL CONDITION] and determined to be at risk for pressure injury? UM-C stated: Offload heels, get boots, get an air mattress if determined she needed one. Surveyor asked what interventions were implemented, to which UM-C replied: I'm not sure if she had boots. Surveyor located no evidence the facility offloaded R1's heels to prevent pressure injury. UM-C was unable to provide explanation of how the pressure injury developed. Surveyor asked UM-C to clarify what unchecked indicated on the Care Plan. UM-C reported if it was marked checked it would appear in the residents' profile in the Kiosk for the CNAs (Certified Nursing Assistant)'s to follow on the care card. Unchecked indicated it would not appear on the CNA care card. UM-C could not give explanation of why the approaches were not checked to appear on R1's CNA care card. Surveyor asked UM-C why the care plan she created on 1/7/20 listed a problem date of 11/1/19. UM-C reported she did not know and was unable to provide an explanation. Surveyor review of R1's Care Plan indicated the facility did not implement appropriate interventions to prevent pressure injuries from developing. This deficient practice resulted in R1 developing unstageable pressure injuries on both of her heels, one of which required surgical debridement. On 3/6/20 at 3:00 PM Surveyor met with Nursing Home Administrator-A and Director of Nursing-B and advised them of the above concerns. No additional information was provided.

Based on observation, interview and record review, the facility did not ensure residents received care and services consistent with professional standards of practice to prevent pressure injury development for 2 of 5 (R35 and R72) residents reviewed to be at risk for pressure injuries. R35's heels were not floated per the plan of care. R72 had no initial assessment or measurement of pressure injuries and her heels were not floated per the plan of care. Findings include: The facility Pressure Ulcer policy and procedure dated (YEAR) documents: 1. Evaluate the pressure ulcer initially for location; stage, size (in centimeters), sinus tracts, undermining, tunneling, exudate (type, odors), necrotic tissue and the presence and or absence of granulation tissue and [MEDICATION NAME]. 2. Determine and record the date of onset for each pressure ulcer identified as stage II or greater. 1.) R72 was admitted to the facility on [DATE] following hospitalization for a left [MEDICAL CONDITION]. She was hospitalized and readmitted to the facility on [DATE] with same [DIAGNOSES REDACTED]. R72's Braden dated 5/26/19 documented a score of 13 indicating moderate risk - if other major risk factors are present advance to next level of risk. The residents care plan Problem Start Date 5/9/2019 documents: R72 is at risk for pressure ulcers related to left [MEDICAL CONDITION], decrease mobility, muscle weakness. Approaches include: Avoid shearing resident's skin during positioning, transferring, and turning. Encourage resident to reposition every 2-3 hours with assist of 1-2. Report any signs of skin breakdown (sore, tender, red, or broken areas). Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry and wrinkle free. Maintain the head of the bed at the lowest degree of elevation possible. Provide incontinence care after each episode. Avoid friction to skin. Use moisture barrier product to perineal area. R72's Admission/Readmission Nursing Data Collection Tool dated 5/26/19 documents: 7H. Musculoskeletal - Bed mobility self performance: Total dependence, two plus persons 7I. Skin Condition - Stage 2 pressure ulcers - not assessed. Stage 3 pressure ulcers - 0. Unstageable pressure ulcers with suspected deep tissue injury in evolution - not assessed. R72's Skin Risk Analysis and Interventions form dated 5/26/19 documents: - Pressure ulcers present. There was no documentation of an assessment, including location and measurements on the form. - Use pillows or devices that totally relieve pressure on the heels if patient/resident is completely immobile Use pressure relieving device for seating surfaces R72's Weekly Skin Note dated 5/26/19 documents: 1) small OA (open area) with redness to R (right) buttocks. There was no documentation of an assessment or measurements of the wound. 6) soft pink L (left) heel Surveyor reviewed R72's progress notes which documented: 5/26/2019 15:25 Admission skin check: L heel pink and soft . OA with redness to R buttocks. There was no assessment or measurements of the wound documented. 5/27/2019 13:06 .Pressure injury to coccyx area stage 2. Dressing changed per order. There was no assessment of the wound or measurements documented. 5/28/2019 09:58 Extensive 2 assist required with total dependence to roll in bed. 5/29/2019 16:44 SKIN: Resident readmitted [DATE] with noted unstageable PI (pressure injury) to R gluteal cleft. Current measure: 3.5 x 2.7 unblanchable deep red colored tissue with an island in the center that measures 1.3 x 1.5; island wound base is not visible; 100% yellow slough. Current treatment: [MEDICATION NAME] F/B (followed by) foam. Surveyor noted the 5/29/19 charting of wound characteristics and measurements was completed 3 days after R72 admitted to the facility. There was no documentation of an assessment of the wound or measurements of the wound prior to 5/29/19. 5/30/2019 23:00 (Recorded as Late Entry on 05/31/2019 02:32) While repositioning and floating heels, noticed a bluish-purple pressure area on res. (residents) inner aspect of her left heel. Skin is intact. Denies pain. Immediate intervention to place second pillow under heels/res. tends to move feet off of pillow. Heel cleansed. Will update MD (medical doctor) with request for skin prep to left heel and protective boots. Surveyor noted there was no assessment or measurements documented. 5/31/2019 16:22 SKIN: Resident with new unstageable PI to L heel. Current measure: 1.6 x 1.8 base is not visible. 100% soft eschar capped .offloading boots as tolerated when in bed. The care plan Problem Start Date 5/31/19 documents: R72 has an unstageable pressure injury to her left heel and an unstageable pressure injury to her right buttocks. Appropriate approaches were implemented on the care plan including: Air mattress for pressure control. Heel lift boots to both feet as tolerated when in bed. On 6/10/19 at 11:00 AM Surveyor observed R72 lying in bed on her back wearing a soft blue protective boot on her left foot. There was no pillow under her right leg and her right heel was resting directly on the mattress. On 6/11/19 at 6:45 AM Surveyor observed R72 lying in bed on her back. She was wearing a soft blue protective boot on her left foot. There was no pillow under her right leg and her right heel was resting directly on the mattress. On 6/12/19 at 1:59 PM Surveyor observed R72 lying in bed on her back wearing a soft blue protective boot on her left foot. Surveyor observed a flat pillow under her right leg, but her right heel was resting directly on mattress. Surveyor noted the current care plan intervention heel lift boots to both feet as tolerated when in bed was not being followed. On 6/11/19 at 3:22 PM Director of Nursing (DON)-B met to discuss concern with pressure injury. Surveyor advised DON-B of admission skin assessment which documented small OA with redness to R buttocks with no assessment or measurements documented. Surveyor advised of concern regarding documentation 3 days later (5/29/19) of unblanchable and 100% slough which would indicate a possible unstageable pressure injury. (Surveyor and DON-B read the documentation together). Surveyor asked if the initial assessment of a wound should include documentation of a description of the wound, staging, and measurements? DON-B stated: Of course they (referring to the nurses) should do that. They have been in-serviced to do that right away. I don't know why they didn't. DON-B added: It was a holiday weekend, so RN-G didn't see it until that Wednesday during wound rounds. DON-B provided Surveyor with incident investigation dated 5/30/19 which documented: Type of incident/accident: Blood blister. Secondary injury: Blood blister left heel. List patient [DIAGNOSES REDACTED]. Describe exactly what happened: While repositioning resident with CNA (Certified Nursing Assistant) noted a blood blister 1.5 cm (centimeters) x 1.5 cm on the inner aspect of residents left heel. Skin is intact. Area cleansed and skin prep applied. Second pillow placed under heels for better off loading. Findings and analysis: New PI to left heel. Follow up/steps taken to prevent reoccurrence: Air mattress, heel lift boot. IDT (Interdisciplinary Team) review: New treatment in place: [MEDICATION NAME] daily, air mattress in place for pressure control, weekly skin checks - wound team. Facility Acquired PU (Pressure Ulcer) investigation tool: Determination of root cause for PU development, both resident and system level: Heel resting on bed. Action plan for resident and system improvements: Heel lift boots as tolerated in bed. R72's (MONTH) 2019 Treatment Administration Record (TAR) documented: - 5/26/19 Float heels when in bed every shift - 5/31/19 Apply skin prep to right heel daily for skin protection once a day - 5/31/19 Heel lift boots to both feet as tolerated when in bed three times a day DX (diagnosis): Pressure ulcer of left heel, unstageable. On 6/12/19 at 7:27 AM Surveyor observed wound care performed by RN-G, assisted by RN-H and RN-I. Surveyor was informed wound rounds are completed weekly every Wednesday with all 3 staff members present. Current wound observation L heel: 75% black eschar cap, outer perimeter pink granulation. Measurements: 1.4 x 1.0 cm. Surveyor asked RN-G how she though the wound occurred? RN-G stated: After her injury she wasn't moving as much, I think it happened from rubbing her foot on the bed. Wound observation of R buttocks (which RN-G confirmed is same wound as charted R coccyx/gluteal): Measurements: 0.7 x 0.5 cm, 100% slough, 0.1 depth, pink surrounding skin. On 6/12/19 at 2:58 PM Surveyor and DON-B reviewed R72's TAR. Surveyor asked DON-B about the heel pressure injury development. DON-B stated: She does move around a lot in bed. Surveyor advised of documentation extensive 2 assist required with total dependence to roll in bed, and care plan intervention for heel lift boots to both feet as tolerated when in bed - with current observations not in place. DON-B stated he will talk to RN-G about the boots. On 6/13/19 at 7:43 AM Surveyor spoke with RN-J and reviewed her admission progress note together. Surveyor asked why there were no measurements or description of the buttocks wound. RN-J stated: That would be on the weekly skin sheet. Surveyor advised RN-J there were no measurements or description of the wound on the sheet, it documented only: Small OA with redness to R buttock. RN-J stated: I thought I would have put that other stuff on the sheet. Surveyor asked RN-J if she could describe what the wound looked like that first day when R72 admitted ? RN-J stated: It was small, like maybe 1 cm, superficial with pink tissue. On 6/13/19 at 10:27 AM Surveyor spoke with RN-G who stated: We don't have the nurses stage the wound because we want the wound team to do it. We want to make sure first of all, that it is a pressure injury, and second of all, that it is staged correctly. On 6/13/19 at approximately 11:00 AM, Surveyor advised DON-B of the above concerns regarding R72's pressure injury. No additional information was provided. 2.) R35 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. R35's Quarterly MDS (Minimum Data Set) dated 4/16/19 documents short and long term memory problems for R35. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R35's cognitive skills for daily decision making are severely impaired. Section G (Functional Status) documents that R35 has total dependence on staff and requires a two person physical assist for her transfer and bed mobility needs. Section M (Skin Conditions) documents that R35 is at risk for the development of pressure injuries and that at the time of the assessment had no open pressure injuries. R35's Pressure Ulcers/Injuries CAA (Care Area Assessment) dated 6/27/18 documents under the Analysis of Findings section, Document the description of the problem, causes and contributing factors, and risk factors related to the care area: limited mobility, cognition, incontinence. Under the Care Plan Considerations section it documents, Care plan will be updated and reviewed. R35's Braden Scale For Prediction of Pressure Sore Risk assessment dated [DATE] documents a score of 9, indicating that R35 is at very high risk for the development of pressure injuries. R35's Pressure Ulcers/Injuries care plan with a start date of 4/1/16 documents under the Approach section, Elevate heels off matters with pillows when in bed. On 6/10/19 at 11:22 a.m., Surveyor observed R35 in bed with her heels resting directly on the mattress and not offloaded to relieve pressure as documented in R35's plan of care. On 6/11/19 at 8:20 a.m., Surveyor observed R35 supine in bed with her heels resting directly on the mattress and not offloaded to relieve pressure as documented in R35's plan of care. On 6/13/19 at 7:41 a.m., Surveyor observed R35 in bed with her heels resting directly on the mattress and not offloaded to relieve pressure as documented in R35's plan of care. On 6/13/19 at 10:44 a.m., Surveyor informed LPN (Licensed Practical Nurse) Unit Manager-C of the above findings. Surveyor asked LPN Unit Manager-C if R35 should have her heels offloaded to relieve pressure as documented in R35's plan of care. LPN Unit Manager-C informed Surveyor that while R35 is contracted, R35 should have her heels offloaded with boots or pillows to relieve pressure as documented in R35's plan of care. No additional information was provided as to why R35 did not have pressure relieving interventions in place to prevent the formation of pressure injuries.

Based on interview and record review, the facility did not provide basic life support, including CPR (Cardiopulmonary Resuscitation) for 1 (R34) of 1 residents reviewed, in accordance with the resident's directives. On [DATE] upon admission to the facility R34 designated that she was not executing an advanced directive at that time and signed acknowledgement that this would mean that should R34 become pulseless and unresponsive, cardiopulmonary resuscitation (CPR) would be provided to R34. On [DATE] R34 was found by nursing staff to be pulseless and not breathing. Nursing staff did not initiate CPR despite R34 acknowledging in her directives that by not designating a code status CPR would be provided per signed directive and facility policy. The Facility's failure to ensure that R34 received basic life support, including CPR, in accordance with R34's directives and wishes created a finding of Immediate Jeopardy beginning on [DATE]. Administrator-A and DON (Director of Nursing)-B were informed of the Immediate Jeopardy finding on [DATE] at 11:31 a.m. On [DATE] the facility recognized the deficient practice by the facility nursing staff and took steps to correct the deficient practice and ensure compliance at the time of the recertification survey. Based upon this determination, the immediate jeopardy was removed and corrected on [DATE]. Findings include: The facility's Nursing Policies and Procedures dated as revised on [DATE] and titled Cardiopulmonary Resuscitation, Emergency Code Blue documents under the Policy section, 3. The facility ensure provision of basic life support and CPR, including: (A) Staff are directed to initiate CPR when cardiac or respiratory arrest occurs for residents who do not show obvious clinical signs of irreversible death and (1. )Who have requested CPR in their advance directives, or (2.) Who have not formulated an advance directive, or (3.) Who do not have a valid DNR order. The facility's Nursing Policies and Procedures dated as revised on [DATE] and titled Do Not Resuscitate (DNR) documents under the Policy section, Facility staff will follow the resident's advance directives in accordance with applicable law and regulation as well as the applicable Facility Policies and Procedures. Each resident's medical record will be flagged in a standardized manner to identify the residents code status as DNR or FULL CODE. Absent any appropriate DNR Order/identifier, facility staff will respond to medical emergencies with CPR measures and FULL CODE will be instituted. 1. Surveyor reviewed R34's medical record from [DATE] to [DATE]. R34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R34's 5 Day Schedule Assessment MDS (Minimum Data Set) dated [DATE] does not document a BIMS (Brief Interview for Mental Status) score, but it does document that R34 has no short or long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R34 is independent with daily decision making and that R34's decisions are consistent and reasonable. A review of R34's medical record documents R34 was her own person and did not have an activated POA (power of attorney) or guardian in place. Upon admission on [DATE], in the facility's admission agreement, R34 initialed under the document titled Authorizations, Consents and Acknowledgements under the Advance Directive Acknowledgement section the following acknowledgement: I acknowledge that I have received, read and have had read to me, and understand Facility's Policy and State Requirements for Advance Directives and have elected to NOT execute any advance directive at this time, including DNR (do not resuscitate) Identification. I understand that facility staff will respond to medical emergencies with CPR measures and full code will be instituted. The above section is initialed and the document is signed by R34 on [DATE]. Along with R34's signature of acknowledgement, Admission Director-M also signed on [DATE] as a witness to R34's advance directive choices. A written statement signed by Admission Director-M provided to Surveyor documents, New admit R34 came to the facility on (MONTH) 25, (YEAR), where at 5:45 pm writer (Admission Director-M) signed admission paperwork with resident, no POA (power of attorney) or guardian noted. Resident was sitting up in w/c (wheelchair), answered questions appropriately. On consent page 4, resident initialed to be full code. R34's EHR (electronic health record) documents that R34 was a full code and the facility face sheet used to determine R34's code status also documents R34 is a full code. R34's admission nursing note dated [DATE] documents, Res (resident) arrived at facility at 1350 (1:50 p.m.) via ambulance. Transferred to bed with assist of 3. She (R34) is a full code, is 79 y.o. (years old), and appears her age. The facility's initial self report to the State Agency submitted on [DATE] documents that R34 was a full code and did not receive basic life support, including CPR, according to R34's advance directive wishes. The facility's 5 day self report to the State Agency submitted on [DATE] documents that R34 was a full code and did not receive basic life support, including CPR according to R34's advance directive wishes. The 5 day self report documents under the Investigation Summary section, Initial Report: On (MONTH) 27, (YEAR) (Director of Nurses) DON-(B) was notified that (R34) was found in her room approximately 4:15 AM unresponsive, no vitals present, non-breathing, body was cold. Immediate investigation initiated and it was learned that the responding nurse, RN (Registered Nurse)-(J) did not follow the facility's CPR policy and process. RN-(J) failed to check the code status of (R34), which was full code, CPR wasn't initiated. Administrator-(A) was notified of event .(R34's) son was notified of by RN-(J) (of (R34's) death) and gave instruction to call the funeral home. (R34's) primary doctor in the facility was notified of the event and pronounced time of death (for R34) at 4:30 AM. Under the Investigation section it documents, RN-(J) in her statement, At approximately 4:15 AM, staff call me STAT (immediately) to go see, assess the resident (R34). When I came in to the room, assess (R34), no vital signs anymore, non-breathing and body was cold I think she's been gone for a while when I saw her. It was about 4:20 AM when I called and updated the DON (DON-B) and was instructed to call and updated MD, also to get time of pronouncement and release of body order. Then DON (DON-B) called back approximately 20 minutes after, and asked if I had checked resident (R34) code status after knowing resident was unresponsive, and I said not at that time, then when I checked residents (R34) file, I learned she was a Full code. At this time I already talked and updated (R34's) the son of the event. Follow up statement from RN-J: At start of shift, I normally checked the board, who to chart an all. I recall I assessed the resident (R34) at around 11 PM but I did my charting around 1:05 PM for (R34). DON-(B) asked RN-(J) about rounding, and replied, I know, I missed rounding on her in between. DON-(B) asked RN-(J) why she didn't start CPR and/or follow CPR protocol and process, for any unresponsive resident that is full code that Nursing staff should initiate it immediately, RN-J replied, I didn't know that, I didn't know I have to do CPR (on R34). Especially because I though she was gone for a while at that point as her body was cold. CNA-N stated, Yes, I did work that shift, I had (R34) in my assignment. At start of shift, I did cares at around 11:00 PM, then I saw her (R34) again at 11:30 PM, resting, sleeping, I'm sure she was breathing at that time. Then my next rounding to her room was about 4:15 AM, when I noticed she was unresponsive and not breathing anymore, so I called the nurse RN-(J) to the room stat (immediately). The light in my assigned hallway was like light from a Christmas tree that night, lights were just going on. That's why I (CNA-N) wasn't able to see the resident between 11:30 PM and 4:15 AM. CNA-(L), in her statement, I was working on different hallway, hall 200. CNA-(N) called me to the room and told me, 'she does not look right, think she passed away.' I left the room after she called the nurse. It was a very busy night for us that night. RN-K, who was the incoming shift nurse, also stated, I found out about the death from nurse to nurse report. RN-(J) nurse, told me, 'she was fine at 11 PM, then at 430 AM she was dead. Why would I start CPR if she was already cold.' This is what the RN-(J) told me. R34's nursing note dated [DATE] and completed by RN-J documents, Resident vitals taken earlier in shift around 2300 on [DATE]. Resident was checked by CNA (Certified Nursing Assistant) around the same time. CNA called writer stat to room. Resident not breathing and no heartbeat. Call made to MD (Medical Doctor) pronounced death around 4:30 AM. Call made to son .to inform regarding mother's passing. Son declined to come in and wanted us to call funeral home. Call made to funeral home in Hartford. Will be here in approx (approximately). 45 minutes. A written statement from RN-J confirms the above statements included in the facility's self report to the Stage Agency dated [DATE], Surveyor was unable to interview RN-J to confirm RN-J's statement as RN-J was no longer employed at the facility. On [DATE] at 3:12 p.m., Surveyor interviewed RN-K regarding R34's death on [DATE]. Surveyor asked RN-K if the statement included in the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. RN-K informed Surveyor that the statement included in the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. On [DATE] at 1:32 p.m., Surveyor interviewed CNA-L regarding R34's death on [DATE]. Surveyor asked CNA-L if the statement included in the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. CNA-L informed Surveyor that the statement included in the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. On [DATE] at 4:09 p.m., Surveyor interviewed CNA-N regarding R34's death on [DATE]. Surveyor asked CNA-N if the statement included in the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. CNA-N informed Surveyor that the statement included in the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. On [DATE] at 08:50 a.m., Surveyor interviewed DON-B regarding R34's death on [DATE]. Surveyor asked DON-B if the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. DON-B informed Surveyor that the facility's submitted self report investigation to the State Agency on [DATE] and above information was accurate. Surveyor asked DON-B if it was the facility's policy to provide CPR to residents when there is no DNR in place. DON-B informed Surveyor that it is the facility's policy to provide CPR to residents when there is no DNR in place and that CPR should be provided by staff for full code residents. DON-B informed Surveyor that the facility does not have the authority not to start CPR regardless of resident condition (rigor mortis, cold) and that EMS (emergency medical services)should be contacted to continue CPR and that in obvious case of death EMS should pronounce the resident dead not the facility. Surveyor asked DON-B why he did not direct RN-J to check the R34's code status and begin CPR on R34 when first contacted by RN-J. DON-B informed Surveyor that the way the RN-J explained the situation, it seemed like R34 was already dead for a long time, that's why he (DON-B) directed RN-J to notify the physician and alert R34's family of R34's death. DON-B informed Surveyor that as he (DON-B) was getting ready, as it was approximately 4 AM, DON-B called RN-J and asked if EMS had arrived or been called. DON-B informed Surveyor that when he called RN-J back, he was informed by RN-J that CPR was not provided to R34. Surveyor asked DON-B if the facility should have provided R34 with basic life support, including CPR, in accordance with the R34's directives and wishes. DON-B informed Surveyor that the facility should have provided R34 with basic life support, including CPR, in accordance with the R34's directives and wishes. No further information was provided why the facility did not provide R34 with basic life support, including CPR, in accordance with the R34's advance directives and wishes. The facility's failure to ensure R34 received CPR following her designation on [DATE] to be full code created a situation of immediate jeopardy on [DATE] when R34 was found pulseless and not breathing and CPR was not provided to R34 by nursing staff. The facility recognized the deficient practice and took the following corrective steps to ensure that deficient practice did not occur again: On [DATE], the facility identified the deficient practice and put in a plan of correction in place that provided training to regarding CPR administration. The facility developed a Performance Improvement Plan in which no direct care staff (nursing and CNAs) were allowed to work a shift until they received mandatory training that outlined the facility's CPR policy and the steps needed to be taken when a resident is found to be pulseless and non-breathing. All full time staff being the mandatory training on the morning of [DATE] and all full time staff completed the training by [DATE]. Part time and as needed staff were all trained within two weeks of [DATE], but all staff was not allowed to work until they completed the mandatory training on CPR administration. During the survey, no deficient practice was identified regarding CPR administration to full code residents. Through record review, staff interview and observations, it was revealed that staff had received the mandatory training on CPR administration and were knowledgeable about the steps needed to be taken when a resident is found to be pulseless and non-breathing effective [DATE].

Based on observation, interview and record review, facility staff did not provide supervision and assistive devices needed to maintain a safe environment for 7 (Resident #3, #4, #5, #8, #13, #7, & #2) of 8 Residents reviewed who sustained falls. *Resident #3 had 7 falls since 9/15/16. Staff did not investigate the circumstances surrounding the falls to try to determine the root cause of the falls. Staff reported new interventions that were supposed to already be in place. Investigations did not always identify if the care plan interventions had been followed. Resident #3 sustained a laceration to her forehead on the 5th fall that required 6 sutures to close. A nurse had seen Resident #3 - who is confused and who had fallen 10 days earlier - 30 minutes prior to the fall. Resident #3 was calling out to go to bed, trying to get her night clothes on, was restless and anxious, but staff did not assist her and Resident #3 ended up falling and needing sutures. Resident #3 fell again the next morning and again needed to be sent out and skin adhesive was applied to her head to close another laceration. * Resident #4 had a Fall Risk Assessment completed on admission that indicated he was not at risk for falls. However, the assessment omitted several items that should have been identified as risks for Resident #4. Including those items would have identified Resident #4 as being at high risk for falls. Resident #4 fell 5 days and 7 days after admission. On the second fall, he was trying to get to the bathroom. The care plan was updated to toilet Resident #4 based on his needs and pattern, but no toileting pattern or diary was ever completed. * Resident #5's family member reported Resident #5 was transferred without a gait belt. Staff provided education to staff members, but the investigation, which they self-reported, did not include any other information, such as where was Resident #5 transferred to/from, when, why, did the CNA (Certified Nursing Assistant) have updated transfer status information, if not -why not? Did the CNA have a gait belt? Was the CNA assigned to the Resident or helping out in response to a call light? Such detail is needed to know what went wrong and what needs to be fixed. Depending on what the particular issues were, interventions need to be formulated accordingly to address the issue. * During this survey review period Resident #8 has sustained 2 different falls. The first fall resulted in Resident #8 requiring 7 sutures and the second fall resulted in an occipital hematoma. With both falls, the facility did not thoroughly analyze the circumstances surrounding the falls to complete a root cause analysis to prevent further falls. Resident #8's continence status was a factor with both falls. The facility did not review Resident #8's continence status and pattern of voiding to develop a care plan to reduce this risk factor in relation to Resident #8's falls. The facility did not analyze why previously care planned safety interventions such as alarms did not prevent the fall and instead continued to use safety interventions that may not be effective for reducing Resident #8's risk fir falls. * Resident #13 was admitted to the facility with a seizure disorder and with a history of falls prior to admission. Resident #13's first fall after admission occurred when Resident #13 was attempting to clean himself up in the bathroom. Resident #13 fell with such force he sustained a laceration behind his ear and had neurological checks post fall that were positive for findings, Resident #13's speech made no sense and his eye reflex was sluggish. Resident #13 wound up having a seizure and required hospitalization for 2 days. The facility failed to care plan Resident #13's specific needs and the level of assistance Resident #13 required for personal hygiene to ensure his needs were met. The facility did not evaluate the circumstances surrounding this fall to ensure care plan interventions were effective to prevent future falls. Prior to this fall Resident #13 did not have a care plan related to his seizure disorder. Resident #13 sustained a second fall where he had to be lowered to the ground after he went into seizure activity when being awakened by staff. The facility did not analyze the circumstances surrounding the fall to determine if interventions were needed to prevent future falls or possible injuries should this occur again. * Resident #7 was admitted to the facility in May of 2015 for rehabilitation. During Resident #7's stay in the facility Resident #7 sustained 12 falls many resulting in some form of injury. During this survey review period Resident #7 experienced two falls; one fall occurred after staff had documented Resident #7 had been increasingly restless prior to the fall and nursing staff had administered Ativan to Resident #7 which had been ineffective. The facility failed to increase supervision to Resident #7 beyond the previously established 15 minute checks which had not previously prevented falls for Resident #7. Resident #7 required 9 sutures to his eye after this fall. Resident #7 sustained an additional fall with similar circumstances to the previous fall where Resident #7 had attempted to pick up his shoes. There is no indication this fall was unavoidable as the facility had not completed a root analysis, overall, of Resident #7's 12 falls while a resident. * Resident #2 is at risk for falls. Resident #2 has sustained 3 falls - 1 from her wheelchair and 2 from her bed. With each fall, the facility failed to comprehensively analyze the details surrounding each fall to determine a root cause for Resident #2's falls. Resident #2 demonstrated increased restlessness prior to some of her falls however there is no indication increased supervision occurred to help prevent the fall. Additionally, Resident #2's continence status is a factor with each fall; however, the facility has not completed a comprehensive assessment of Resident #2's continence status and voiding patterns to help reduce this risk factor as it related to Resident #2's risk for falls. During this survey multiple concerns have been identified related to staffing, care planning, incontinence care and assessment which all have played a significant role in creating an environment where the facility has not ensured the safety and well-being of each resident at risk for falls. (Cross-reference F353, F279, F315, and F272.) Systemically, the facility's failure to collect and analyze all available information and to thoroughly examine each fall to identify the root cause; so as to implement targeted interventions that addressed the root cause along with the facility's failure to implement their policies and procedures (which indicate staff will assess residents fall risk and develop appropriate care plans to include creative, functional strategies to prevent falls or injury) created a situation of immediate jeopardy that started on 2/13/16. The facility's administration was notified of the determination of immediate jeopardy on 5/17/16 at 3:50 pm. At this time, the facility administration was asked who in the facility would they consider to be at risk for falls? The facility Corporate Director of Clinical Services-D indicated that they would have to consider all residents at risk for falls at this time because they do not know who is at risk. The facility removed the immediate jeopardy on 5/23/16 after they initiated their action plan related to assessing and care planning to prevent falls for all of the facility residents. Following the removal of the immediate jeopardy, the scope and severity (s/s) of the deficient practice continues at an E (potential for harm/pattern.) Findings include: 1.) Surveyor # reviewed Resident #3's medical record 5/5/16-5/19/16. Resident #3 has resided at the facility since November 2014, and has major [DIAGNOSES REDACTED]. On the first day of the survey, 5/5/16, Surveyor # observed Resident #3 in a Broda chair in the dining room, being fed by CNA (Certified Nursing Assistant)-P. Resident #3 continually ran her fingers, hands through her hair, or kept her hands on top of or on the sides of her head. A cord (looks like a phone cord) was wrapped around a bar on the back of Resident #3's Broda chair. It appeared to be a cord that should be plugged into an alarm box, but no box was present. Surveyor # asked CNA-P if that cord should be attached to an alarm box for Resident #3. CNA-P stated she is from an outside agency and does not know if the cord is supposed to be attached to anything. A few minutes later, Surveyor # observed CNA-Q take over feeding Resident #3. Surveyor # asked CNA-Q if the cord should be attached to an alarm. CNA-Q stated it was her first day and she did not know. Neither CNA made any attempt to find out if Resident #3 should have an alarm attached. The CNAs do not carry anything with them informing them of a Resident's care needs. They access that information either at a binder at the nurses' station or at the kiosks in the hallway. Surveyor # then asked CNA-T, who was also at the dining room table, about Resident #3's alarm. CNA-T also stated she was from an outside agency and did not know Resident #3. Surveyor # then asked CNA-R, who stated she wasn't sure what the status of the alarm was because she heard someone say they were thinking of discontinuing the alarm because Resident #3 has declined physically recently. On 5/5/16 at 2:20 p.m., Surveyor # observed Resident #3 in a low bed, with an alarm cord visible, but not attached to an alarm box. Surveyor # went to find staff to clarify if Resident #3 is supposed to have an alarm or not. At 2:35 p.m., Surveyor # asked CNA-R to verify if Resident #3 should have an alarm on while in bed. CNA-R was called into a Resident's room to hand him his urinal. CNA-R accompanied Surveyor # to Resident #3's room. At that time, second shift CNA-S entered Resident #3's room with an alarm box. CNA-S attached the alarm to the bed alarm cord, and said the alarm had not been discontinued yet, though they are talking about doing so. On 5/9/16, Surveyor # observed a physician's orders [REDACTED].#3's bed and chair alarms. Resident #3 has always been assessed as being at risk for falls, (scoring 10 or higher on the Fall Risk (Acuity) Assessment, including assessments dated 9/26/15, 11/25/15, 12/16/15, 2/3/16, 2/13/16, 2/14/16 and 3/17/6 (all dates of Resident #3's falls). Resident #3 was noted to be at risk for falls due to Mental Status- disoriented x (times) 3, diminished safety awareness; Balance and Gait- requires use of assistive devices; is ambulatory and incontinent; receives antidepressants, anti-hypertensive, and laxative medications; medication changes; history of falls; Perceptual limitations (impaired hearing, impaired vision, dizziness/vertigo); and Psychiatric or Cognitive conditions (delirium, decline in cognitive skills, manic depression, Alzheimer's disease or other dementia). Resident #3's Significant Change in Status MDS (Minimum Data Set) Assessment, with an assessment reference date of 10/20/15 indicates Resident #3 did not have any falls since the previous assessment (MDS) (Quarterly MDS 8/4/15), but staff should have answered Resident #3 had one fall with no injury because Resident #3 fell on [DATE]- she was found on the floor next to her bed at 2:15 a.m. This MDS notes Resident #3 required extensive assistance of two or more staff for bed mobility, and transfers; she was not steady and only able to stabilize with human assistance when moving from a seated position to standing, when getting on and off the toilet, and during surface to surface transfers (bed to wheelchair). Resident #3 was noted to have moderate cognitive impairment for daily decision-making. Resident #3's Quarterly MDS, with an assessment reference date of 1/13/16 indicates Resident #3 had one fall since the previous assessment with no injury and one fall with minor injury. Resident #3's Quarterly MDS with an assessment reference date of 3/21/16 indicates Resident #3 had one fall with no injury and two or more falls with minor injury. Resident #3's Significant Change in Status Assessment MDS with an assessment reference date of 4/15/16 indicates Resident #3 had no falls since the previous MDS assessment (3/21/16). The Falls CAA (Care Area Assessment) completed with this assessment states Resident #3 is at risk for falls due to weakness, impaired physical mobility and previous fall with fracture. She is also at risk for injury due to behaviors that involve pulling her hair out. She does this all day and it interferes with eating. She always has her hands up to her head and will not feed herself. Surveyor # reviewed Resident #3's care plan for falls, initiated 11/21/14 and most recently revised 5/6/16. The Problem states Resident #3 Has the potential for injury related to recent fall with hip and knee contusion, recent history of hip replacement (Nov. 2014). 9/26/15 fell OOB (out of bed), fell transferring self from toilet to w/c (wheel chair); 11/25/15 Fall with abrasion to left elbow and back; 12/6/15 fell out of wheel chair onto buttocks, no injury noted; 2/3/16 fell out of wheel chair, no injury; 2/13/16 Fall with laceration to forehead; 2/14/16 Fall with laceration; 3/17/16 fall, no injury noted. The Goal is Resident #3 will remain safe in her environment for 90 days; goal target date 7/23/16. Approaches and their start dates include: 11/21/14- Place call light within easy reach; Ensure proper footwear prior to transfers/ambulation; Assist with strengthening to enable safe transfers and ambulation; Assess/document changes in mental status. 2/8/15- Dycem placed on wheel chair to help prevent slipping from chair; assess changes in medical status, i.e. infections, etc. causing mental status changes. 9/28/15- Transfer: 1 assist with walker; PT (physical therapy) evaluation and treatment. 11/25/15- Bed alarm-check placement and function Q (every) shift. 2/4/16- PT evaluation and treatment post fall. 2/14/16- Chair alarm added post fall on 2/14/16- check placement and function Q (every) shift. 2/15/16- Review of psych medications post fall from 2/13/16. 3/18/16- Notify staff when visitors leave so resident can be more closely monitored. 5/6/16- Alarms on bed and chair d/c'd (discontinued) 5/6/16 d/t (due to) general decline and not self-transferring. Surveyor # reviewed Resident #3's falls beginning 9/26/15: *9/26/15 The Patient/Resident Incident/Accident Investigation Worksheet states Resident #3 was found at 2:15 a.m. lying next to bed on right side, awake, head slightly under glider chair. Resident states she was getting up to eat dinner. Blankets under Resident's body and behind her right arm, leg and bilateral knees- pink, blanchable . Follow-up steps taken to prevent reoccurrence and person(s) responsible: -close observation; gripper socks on, PT eval and treat. No injuries noted. Resident has been using call light appropriately. Medical Considerations: increased confusion. Incontinent of bladder, Resident did not report the need to be toileted. Has impaired vision, cognitive impairment, low level of physical activity. Had no socks on her feet. The RN (Registered Nurse) statement indicates Resident #3 had bare feet; the CNA's statement left blank the question 11. What was the Resident's footwear? The CNA stated she had last checked and changed Resident #3 at 12:30 a.m. (Surveyor note: as noted above in the Care Plan, since 11/21/14 staff were to ensure proper footwear for Resident #3. While it does not state gripper socks are to be worn, that would be the most logical proper footwear while Resident #3 was in bed. Staff did not add a separate Approach that Resident #3 should wear gripper socks in bed- assuming the proper footwear includes gripper socks when in bed.) *11/25/15 The Patient/Resident Incident/Accident Investigation Worksheet states Resident #3 was found supine on the bathroom floor at 4:30 a.m. Resident stated I just had a bowel movement and was getting back into my chair. Resident #3 sustained a small pink abrasion to left elbow and mid-back, 32 cm. (centimeter) long scratch to lower back to left buttock. Neuro (neurologic) check negative . Bed alarm added . Resident has no issue from fall. Calls for help when needed .Incontinent of bladder, did not report the need to be toileted . (Surveyor note: staff again document Calls for help when needed when this is the second fall in two months where Resident #3 did not call for help when needed. In fact, the report asks Did Resident require supervision? - 1 assist. Did Resident call for help? - No. Was call bell within reach? - yes. This is also the second fall where Resident #3 is incontinent of bladder and did not report the need to be toileted, but staff do not re-evaluate her toileting care plan. Staff statements indicate Resident #3's care plan calls for Resident #3 to be checked and changed every two hours at night; Resident #3 was incontinent of bowel and bladder at 1:00 a.m., and dry at 3:10 a.m., and she was wearing gripper socks. The report indicates Resident #3's Zoloft (antidepressant) was increased that week, but makes no mention of increasing supervision in relation to the medication change. *12/6/15 The Patient/Resident Incident/Accident Investigation Worksheet states Resident (#3) was found sitting on her buttocks against her wheel chair in her room at 12:00 p.m. Resident #3 stated she fell asleep and slipped out of her chair. No injury noted. Follow up/ steps taken to prevent reoccurrence and person(s) responsible: Explain safety awareness to resident. Check Dycem in chair. The statements from the nurse and CNA make no mention of Dycem- whether or not it was in Resident #3's wheel chair. Back on 2/8/15, ten months earlier, staff added Dycem placed on wheel chair to help prevent slipping from chair to Resident #3's care plan. Since the Follow up/ steps taken to prevent reoccurrence is to check Dycem in W/C, it appears there was no Dycem in Resident #3's wheel chair. None of the documentation indicates if staff were aware Resident #3 needed Dycem in her wheel chair, and what education was provided to staff to ensure it was not missed again. The nurse's statement says Resident #3 was wearing tennis shoes on her feet. The CNA's statement says What was the Resident's footwear? Slippers- shoes don't fit. None of the documentation indicates those who reviewed the investigation followed up on this discrepancy. *2/3/16 The Patient/Resident Incident/Accident Investigation Worksheet states Resident #3 was found on her back in her room at 2:10 p.m. Resident #3 had vomited and was previously sitting in her wheel chair. The call light was within reach, but Resident #3 did not use the call light. She had been started on Tamiflu prophylactically that week. The nurse documented Resident #3 was wearing shoes; the CNA wrote Resident #3 was wearing grippy slippers. Neither statement mentions the presence or absence of Dycem in the wheel chair which may have prevented Resident #3 from falling out of her wheel chair. The Approach after Resident #3's 12/6/15 fall was staff are to check for the Dycem in her wheel chair. No documentation was noted indicating staff followed up regarding the Dycem, or to clarify what Resident #3 was wearing on her feet. Staff note Resident #3 had been pulling on her hair due to nerves. (Though this behavior is mentioned often in Nurses' notes staff do not develop a care plan for this behavior- cross reference F279.) Resident #3 was sent to the ER; a CT scan of her head was negative. *2/13/16 The Patient/Resident Incident/Accident Investigation Worksheet indicates at 1900 (7:00 p.m.) Resident #3 was found lying on her right side on the floor near the doorway with active bleeding coming from her right forehead, a 3 cm. laceration was noted. Resident #3 was sent to the ER and received 6 sutures. Resident #3's Zoloft had been increased 2/12/16. Resident #3 was noted to be agitated at the time of the fall, and an increase in her behavior of hair pulling was observed over the previous 90 days. Resident #3 had been sitting in her wheel chair. Follow up/ steps taken to prevent reoccurrence and person(s) responsible: psych to review medications. The Investigation Worksheet states: Activity at the time of the fall or what was Resident attempting to do? - Get ready for bed .Was call bell within reach? - No. Staff did not indicate on this worksheet if Resident #3 was incontinent, but indicated she had not reported to staff she needed to be toileted. A CNA statement says Resident #3 was incontinent of urine, and she had been toileted before supper, about 5:10 p.m. What was Resident's footwear- No. What is the Resident's usual bed time- 7:30 -8:00 p.m. Ask the Resident what she was trying to do at the time of the fall- trying to get in bed. This CNA was assisting another Resident at the time of the fall. She last saw Resident #3 at supper. A statement by the RN on duty states she saw Resident #3 thirty minutes before Resident #3 was found on the floor. The statement asks: What was the Resident doing when you observed them? - The RN answered: calling to be put to bed. Were they displaying any behaviors? - restless, anxious. Where were the nurse and CNA at the time of the fall and what were they doing? - At nurses' station (does not say what they were doing). What was the Resident doing? - undressing. What was the Resident's footwear? - Socks. Was resident agitated prior to the fall? - Yes. What interventions were taken at that time? -left blank. Ask the Resident what they were trying to do at the time of the fall- get ready for bed. (Surveyor Note: The RN's statement does not indicate what she did when she observed Resident #3- agitated, calling to be put to bed, trying to undress; a Resident who had fallen 10 days prior, and 4 falls within the previous five months.) A second CNA's statement says she was in another Resident's room at the time of the fall, but when the Resident was found, she had socks on. This fall was self-reported to the Office of Caregiver Quality (OCQ). The Summary states Working chair alarm in place. Resident's usual bedtime is 7:30-8:00 p.m. Resident stated she was trying to get ready for bed . Intervention to prevent future falls- psych to review medications. (Surveyor Note: No documentation discussed reviewing Resident #3's bowel and bladder care plan- this was at least the third fall where Resident #3 was incontinent (Cross reference F272 and F315); why her call light was not within reach; what-if anything- the RN did when she saw Resident #3 thirty minutes earlier calling out to go to bed, restless, agitated, trying to undress; was there Dycem in Resident #3's wheel chair; and if anyone tried to clarify what Resident #3 had on her feet- two staff wrote socks; one said no when asked what was the Resident's footwear. Ensure proper footwear was added to Resident #3's care plan in November 2014. Also, documentation in Resident #3's chart indicates a chair alarm was not ordered or applied until 2/15/16, so it is unknown why the summary submitted to OCQ states working chair alarm in place.) *2/14/16 Facility self-report to OCQ states Resident #3 was found at 10:00 a.m. lying on her back on the floor in her room, bleeding from the left side of her head. Resident (#3) stated she was trying to get up. Resident was last toileted at 9:15-9:30 a.m. by CNA. Resident was sent out and the laceration on her head was closed with skin adhesive. The Patient/Resident Incident /Accident Investigation Worksheet states Resident #3 was attempting to get out of her chair, she did not call for help, her call bell was within reach, her Zoloft was increased on 2/12/16, she was restless at the time of the fall. Resident #3 was noted to be incontinent of urine at the time of the fall, but she did not report the need to be toileted. Chair alarm added after fall on 2/14/16. A CNA statement says Was the Resident incontinent- No- or continent- No- at the time of the fall, which conflicts with itself. Resident #3 can't be both continent and incontinent of urine at the time of the fall, but no one clarified what that meant. Resident #3 was last toileted at 9:30 a.m. Resident #3 was wearing gripper slippers, per this CNA. The CNA also states Resident #3 was moody, was agitated, heard resident yell Help, ran to room, found Resident on the floor. There is no statement from the nurse caring for Resident #3 that day. There is no mention whether or not there was Dycem in Resident #3's wheel chair, or why she was in her room alone when she had just fallen and required sutures approximately 12 hours before. There is no evidence staff increased supervision of Resident #3 despite her fall 2/3/16, 2/13/16, and increase in antidepressant medication 2/12/16, and restless, agitated behaviors. *3/17/16 The Patient/Resident Incident/Accident Investigation Worksheet states Resident #3 was found face down in her room at 5:00 p.m., chair alarm sounding. Developed bruise to right forehead. Resident #3 was trying to get a pillow; has had increased confusion. Resident #3 did not call for help and her call bell was within reach. Follow up/ steps taken to prevent reoccurrence and person(s) responsible: Explain the need to use the call light; notify staff when visitors leave so resident can be in a public area. The LPN (Licensed Practical Nurse)'s statement says he last saw Resident #3 self-propelling her wheel chair (does not indicate what time). The LPN documented Resident #3 was wearing tennis shoes. There is no mention of Dycem in Resident #3's wheel chair. There are four CNA statement forms included in the investigation. One CNA indicated she had not seen Resident #3 that shift, two other CNAs, with their names written down as being on-duty, left the interview forms totally blank. The last one was completed by a CNA who stated she toileted Resident #3 at 4:30 p.m., and she was wearing slippers. The CNA wrote I was on break. Resident was happy to use the rest room after her company left. I went on break, came back and heard about the fall. Surveyor # did not observe any documentation or indication that despite Resident #3 having six previous falls within the previous six months, including two lacerations requiring trips to the ER and sutures and skin adhesive, that staff were to ask or encourage Resident #3 to remain in a supervised area when up in her wheel chair. There is no evidence staff ascertained whether or not Dycem was in her wheel chair, or clarified what footwear she was wearing- again, and why there are continued discrepancies on this issue. Are some staff just guessing at what she was wearing rather than noting what footwear she had on at the time. Lastly, why would staff add the Approach Notify staff when visitors leave so staff can place in a public area when the CNA's statement makes clear she knew Resident #3's visitors had left- Resident #3 said how happy she was to use the restroom now that they were gone. On 5/12/16, Surveyor # shared the above observations and concerns at the daily exit meeting. Surveyor # noted several of Resident #3's falls involved Resident #3 being incontinent or trying to get to the bathroom, yet her care plan remained very generic- toilet upon rising, before and after meals, at HS (hour of sleep), and per request, check and change for bowel and bladder incontinence during night rounds, apply a protective skin barrier to skin after bladder incontinence- the same as almost every resident in the facility (cross reference F315). Surveyor # noted several of the investigations had conflicting information but no evidence was seen indicating staff tried to reconcile or clarify the conflicting statements. Several falls were from Resident #3's wheel chair but the investigations do not indicate if the Dycem was in place. No further information was observed regarding the 2/13/16 fall when the nurse saw Resident #3 thirty minutes earlier, restless, anxious, calling out to go to bed, trying to get undressed- then she fell , sustaining a laceration to her forehead requiring six sutures. Why did the nurse not assist Resident #3 or get a CNA to assist her? Was there sufficient staff on duty? They cannot get to the root cause of the fall without analyzing these issues. Surveyor # noted none of the staff in the dining room at lunch on 5/5/16 knew if Resident #3 should have an alarm attached to the cord hanging off the cord on the back of her wheel chair, or made any attempt to find out if Resident #3 should have an alarm. Resident #3 was in bed at least a half hour without an alarm until the second shift CNA brought an alarm box in and attached it to the cord coming from Resident #3's bed alarm. The alarms were not discontinued until the next day, 5/6/16. On 5/16/16, RN Manager-E informed Surveyor # she had no additional information regarding what Resident #3 had on her feet on the dates noted. She does not know if socks meant regular socks or gripper socks, or when one staff wrote tennis shoes and another wrote Slippers- shoes don't fit- which was accurate. If any follow up was done, it was not documented. The only information available is what Surveyor # already reviewed regarding Resident #3's falls. 2.) Surveyor # reviewed Resident #4's medical record 5/5/16-5/18/16. Resident #4 was admitted to the facility 4/6/16 with major [DIAGNOSES REDACTED]. Surveyor # reviewed a Fall Risk (Acuity) Observation (assessment) completed for Resident #4 on 4/7/16. Resident #4 was noted to score 7, not at risk for falls. A score of 10 or higher represents a high risk for falls, according to the form. Staff noted Resident #4 was: Disoriented X 3 (person, place, time), diminished safety awareness; balance problem while standing and walking, requires use of assistive devices; impaired mobility/continent (assist with toileting). However, staff indicated Resident #4 used none of the listed types of medication when in fact, he was receiving an antihypertensive (atenolol and losartan), diuretic (furosemide), antihistamine (famotidine- antacid/histamine-2 receptor antagonist), and an antidepressant (Venlafaxine) (all categories/ types listed). In addition, staff could have selected other as Resident #4 was also receiving temozolomide to treat brain cancer and levetiracetam- an anticonvulsant, in addition to those types listed, according to Resident #4's admission orders [REDACTED] If staff had identified the actual medications taken by Resident #4 in the previous seven days as the assessment asks, that would have added 4 points to the seven point total, equaling 11 points and then identifying Resident #4 as high risk for falls. (A score of 10 or higher is high risk.) The form indicates if one or two of the medication-types were taken, score two points, if three or more of the medication types were taken - score 4 points. Also, the Observation/assessment asks if the Resident has any of the following conditions and staff again marked none of the above when they could have identified conditions present for Resident #4. Resident #4 was noted to have atrial fibrillation, but staff indicated no cardiovascular issues or dysrhythmias. Resident #4

Based on observations, interviews, and record review the facility did not ensure that the ability to walk did not diminish for 1 (Resident #12) of 1 Residents who had a decline in his ability to ambulate. Findings include: Resident #12's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of 3/10/16, has a Brief Interview for Mental Status score of 15, indicating that Resident #12 is cognitively intact. Resident #12 was admitted to the facility on [DATE] to receive rehabilitation services including physical therapy. Resident #12's Physical Therapist Progress and Discharge Summary note dated 9/9/15 documents that Pt (patient) has improved in all areas of functional mobility though needing encouragement to perform at his max. Staff is comfortable with his level of assist and provides help only as needed. Resident #12's Discharge Plans & Instructions are that Pt (patient) will be referred to walk-to-dine to keep activity level up. Resident #12's current ADL (activities of daily living) Functional/ Rehabilitation Care Plan includes the approach with a start date of 9/11/15 to Ambulate resident to/from meals with 1 assistance using wheeled walker (w/c to follow). Will need rest break half way to/from Dining Room. Record minutes in POC (point of care). Resident #12's MDS Assessment with an assessment reference date of 12/15/15 indicates Resident #12 needed limited assistance from staff to walk in corridor. Surveyor observation, the resident and family member's statements, the CNA's statement, and facility documentation all indicate that staff was not assisting Resident #12 with ambulation as indicated in the Functional/Rehabilitation Care Plan. On 5/10/16 at 11:52 a.m. Surveyor # observed Resident #12 self propel himself in his wheelchair from his bedroom to the dining room. Resident #12 reached the dining room at 12:01 p.m. Surveyor # noted that Resident #12 was not offered or encouraged to ambulate to the dining room. Surveyor # observed Resident #12 eat lunch. At 12:47 p.m. Resident #12 self-propelled himself in his wheelchair out of the dining room. Surveyor # observed Resident #12 self-propel himself in his wheelchair down the hallway, and arrive back to his bedroom at 12:56 p.m. Surveyor # noted that no staff offered or encouraged Resident #12 to ambulate to or from the Dining room for lunch. Facility documentation indicates Resident #12 was walked for 10 minutes on the first shift on 5/10/16 and no minutes on the second shift. On 5/11/16 at 8:11 a.m. Surveyor # observed Resident #12 in the dining room. Surveyor # observed Resident #12 eat breakfast. At 9:01 a.m. Surveyor # observed Resident #12 self-propel himself in his wheelchair out of the dining room, to the activity board, and then down the hall to this bedroom. Surveyor # noted that Resident #12 was not offered or encouraged to ambulate from the dining room after breakfast. On 5/11/16 at 11:15 a.m. Surveyor # spoke with Resident #12 and Family Member-EEE. Resident #12 told Family Member-EEE Guess what?!?! I got walked today! Resident #12 informed Surveyor # that he was assisted to ambulate before breakfast this morning. Resident #12 informed Surveyor # that this was the first time he had been walked in a long time, 2 months or so. Resident #12 informed Surveyor # that he never has been walked three times a day, and never both to and from meals. Resident #12 confirmed that he was not offered to ambulate after breakfast today. Family Member-EEE informed Surveyor # that Resident #12 was supposed to have been walked since therapy ended, and that has not happened. Family Member-EEE stated that Resident #12 has lost his strength from just sitting in the chair all of the time. Facility documentation for 5/11/16 indicates Resident #12 was walked for 5 minutes (10:35 AM) and 15 minutes (11:00 AM). Surveyor # spoke with Anonymous Staff Member-KK who informed Surveyor # that staff does not have time to walk Residents as it is hard enough to meet the Residents' basic needs, and unfortunately walking Residents becomes low on the list of things. Review of Resident #12's Number of minutes for walking? Point of Care record documents that: On 1/11/16, 1/20/16, 2/10/16, 2/12/16, 2/16/16, 2/19/16, 2/22/16, 2/24/16, 2/25/16 , 3/9/16, 3/15/16, 3/25/16, 4/1/16, 4/2/16, 4/8/16, 4/10/16, 4/13/16, 4/19/16, 4/22/16, 4/27/16, 4/28/16, 4/30/16, 5/2/16, 5/3/16, 5/4/16, 5/9/16, 5/11/16 there was no documentation of minutes walked on 2nd shift. Surveyor # noted that per Resident #12's plan of care he should be assisted to walk to and from dinner, which is during 2nd shift. On 1/18/16, 1/21/16, 2/2/16, 2/9/16, 2/13/16, 3/19/16, 4/18/16, 4/20/16, 4/21/16, 4/24/16, 5/5/16, 5/10/16 on 2nd shift Resident #12's minutes of walking was documented as Not Performed with no documented reason why it was not performed. From 1/11/16 - 5/11/16, there is either no documentation or documentation of Not Performed on 39 of 122 days for second shift (32% of the time). On 2/15/16, 2/24/16, 3/15/16, 3/25/16, 3/29/16, 4/8/16, 4/25/16, 4/30/16, 5/9/16 for 1st shift documentation there was no documentation of minutes walked. Surveyor # noted that per Resident #12's plan of care he should be assisted to walk to and from breakfast and lunch which is on 1st shift. On 2/12/16, 4/22/16, 4/28/16, 5/6/16 on 1st shift Resident #12's minutes of walking was documented as Not Performed with no documented reason why it was not performed. From 2/15/16 - 5/11/16, there is either no documentation or documentation of Not Performed on 13 of 87 days for first shift (15% of the time). Resident #12's most recent MDS Assessment, with an assessment reference data of 3/10/16, documents that Resident #12 needs extensive assistance from staff to walk in the corridor. This is a decline from the MDS Assessment with an assessment reference date of 12/15/15. On 5/31/16 at 3:45 p.m. Surveyor # interviewed MDS RN-O who stated that she gets the information for the MDS Assessment from the Certified Nursing Assistants' charting. Surveyor # asked MDS RN-O if she had told anyone about Resident #12's decline in walk in corridor. MDS RN-O stated that she had not, that she knew Resident #12 was on a restorative program, sometimes does not participate, and his level of assistance fluctuates. On 5/17/16 at 8:32 a.m. Surveyor # interviewed Director of Nursing (DON)- B. Surveyor # showed DON-B Resident #12's ambulation care plan. DON-B confirmed that Resident #12 should be offered ambulation both to and from breakfast, lunch, and dinner. DON-B stated that staff should be documenting if Resident #12 refuses or other reasoning if this does not occur. Surveyor # informed DON-B of the above observations, interview with staff, and that Resident #12 had a decline in his ambulation. On 5/27/16 Surveyor # received a Physical Therapy Plan of Care (Evaluation Only) document dated 5/24/16. The evaluation documents under functional deficits for Gait, Level Surfaces that Resident #12's prior level was stand by assistance (close enough to reach patient if assist needed) and current level is contact guard assist (contact with patient due to unsteadiness). Under Reason for Referral is documented PT (patient) assessment indicates no significant change from baseline functional level. Restorative program is appropriate and will be reinforced with staff. Under Therapy Necessity documents No current indication for PT (physical therapy). Restorative follow-up of routine ambulation along with continued ab lib w/c (wheelchair) propulsion and participation in facility activities is appropriate to prevent loss of function.

Based on observations, record reviews and interviews the facility did not ensure that 2 (Residents #10 and #7) of 4 sampled residents reviewed for urinary catheter care and usage received appropriate treatment and services related to the use of urinary catheters, and the facility did not ensure that 8 (Residents #2, #3, #4, #5, #8, #12, #15 and #16) of 10 sampled residents with urinary incontinence received appropriate treatment and services to restore as much normal bladder function as possible. *Resident #10, who required the use of a urinary catheter for a [DIAGNOSES REDACTED]. Resident #10 presented with hematuria on 3/21 and 3/23/16. The urinary catheter, which was scheduled to be changed on 3/27/16, was not replaced. There was no documentation as to why the urinary catheter was not replaced. On 3/31/16, Resident #10 complained of abdominal pain and his abdomen was distended. When the afternoon shift nurse assessed Resident #10, he presented with increased abdominal pain. Resident #10 was sent to the hospital where a bladder scan revealed 980cc of urine in the bladder. Resident #10's penis and scrotum were reddened and there was purulent drainage from the urethra. The catheter was discolored, with no active drainage from the catheter. The Emergency Department (ED) nurse was unable to remove the catheter and a urologist was summoned to the ED. The urologist removed the urinary catheter. When the new catheter was inserted 1,200 cc of urine was drained from Resident #10's bladder. The admission [DIAGNOSES REDACTED]. The failure to change the urinary catheter when ordered contributed to the eventual blockage of the catheter, [MEDICAL CONDITION] with increased abdominal pain and urinary tract infection. The failure of facility nursing staff to change Resident #10's catheter is being cited at severity level 3 (actual harm). The remaining examples are being cited at severity level 2 (potential for more than minimal harm). *On 5/11/16, Resident #10 was observed ambulating with Therapist-X. Resident #10's urinary drainage bag was attached to the frame of the wheelchair. While ambulating, the catheter tubing was pulled taut. *Resident #7's urinary catheter was being irrigated by nursing staff with no physician's order for irrigation. *Residents #2, #3, #4, #5, #8, #12, #15 and #16 have urinary incontinence. No comprehensive bladder assessments, including the completion of a bladder diary were completed. The lack of a comprehensive assessment prevents the facility from providing appropriate treatment and services to restore as much bladder function as possible. Findings include: 1.) Surveyor # reviewed Resident #10's record on 5/17-5/18/16 as part of a complaint investigation. Resident #10 has an indwelling Foley catheter related to a [DIAGNOSES REDACTED]. A urology consult on 1/26/16 states Resident #10 has [MEDICAL CONDITION] with a failed voiding trial today. Recommendations were to continue Foley with every month changes at the facility. A physician's order in the computerized medical record, shows an order dated 2/27/16, for Foley catheter to straight drainage size 16F/10cc balloon. Change PRN (as necessary) for leaking, blockage or displacement. Special instructions: Change monthly per urologist-Once a day on the 27th of the month. The Treatment Administration Records (TARs) from 2/27/16 through 3/31/16, reveals Resident #10's Foley catheter was changed on 2/27/16 but was not changed on 3/27/16. The March 2016 TAR indicated Licensed Practical Nurse (LPN)-AA initialed the TAR and indicated the treatment (Catheter change) was not administered. A review of the nurses' note documentation on 3/27/16 reveals no documentation as to why the catheter was not changed. LPN-AA is no longer employed by the facility. Nursing progress notes from 3/3/16 through 3/31/16, were reviewed. On 3/21/16 at 9:48pm, nursing documents that the CNA reported that when the urine drained there was blood in it. Registered Nurse (RN)-BB assessed the urine and wrote hematuria (blood in urine) noted with no clots. Resident #10 had no complaints of pain and vital signs were within normal limits. RN-BB wrapped Resident #10's penis in gauze due to blood around catheter insertion site. On 3/22/16 at 5:56am, documentation indicated the hematuria had cleared. There was no further hematuria noted until 3/23/16 at 9:42pm, when nursing documents, Slight hematuria noted in urine with leg bag. On 3/24 and 3/26/16 nursing documents no hematuria. On 3/31/16 at 2:19pm, LPN-Y documents, Res. c/o (complains of) abdominal pain. VS (vital signs) 99.2-91-22-162/90-97%RA (room air). Some distention noted to abdomen. Bowel sounds active all four quadrants. 350cc output noted with Foley cath. Updated MD. New order for KUB (abdominal x-ray), CBC (complete blood count) and CMP (complete metabolic panel) STAT (immediately). POA did not wish to send to hospital at this time. On 3/31/16 at 3:39pm, LPN-Z documents, At start of shift report was given as to residents increase in pain and discomfort to his abdominal region, KUB on STAT order. Writer felt that with such a sudden onset of increasingly more pain to his abdominal region another call to MD was necessary. Spoke with Dr. ----- to update on increase pain and discomfort, new order to send to ER (emergency room ) for eval (evaluation) and treat (treatment) VS at time of transfer 99.8-94-20-176/82-96%RA, Foley intact at time of transfer, meatus extremely red and irritated . A review of Resident #10's hospital record reveals: The [MEDICAL CONDITION] physical examination in the ED revealed the penis is [DIAGNOSES REDACTED]tous (reddened, inflamed) as is the scrotum. There is some active purulent drainage from the urethra. Foley catheter is in place. The catheter itself is discolored. There is not any active drainage from the catheter. Upon arrival Resident #10 had a septic workup initiated because of a low grade temperature. His lactic acid came back minimally elevated and his white blood cell count is 18 which meant he met criteria for [MEDICAL CONDITION]. He was not in septic shock. Initially the nursing staff attempted to change the Foley catheter but they were unable to remove the catheter without meeting significant resistance. The urologist came to the ED, removed the old catheter and replaced it with a new Coude (type of catheter). [DIAGNOSES REDACTED]. ED nursing documentation indicated Resident #10 had a bladder scan completed that showed more than 980ml in the bladder. The purpose of a urinary catheter is to keep urine drained from the bladder, making bladder scan results of more than 980ml an abnormal finding. The hospital admission history and physical indicated Resident #10 has [MEDICAL CONDITION] by criteria likely due to UTI (Urinary Tract Infection) and scrotal infection. The urology consult from the hospital record reveals Resident #10 was seen by the urologist while in the ED. The urologist documents, Nurses tried to change Foley in ER but could not remove it after deflating the balloon. Also noted a lot of penile [DIAGNOSES REDACTED], discharge, excoriation and Foley irritation. Documentation of the [MEDICAL CONDITION] examination indicated: Meatus shows breakdown from Foley, and some purulent drainage. Scrotum is moderately [DIAGNOSES REDACTED]tous, without swelling or excoriation. Foley was extracted with tension. Encrustation of tip is noted. Foley replaced. Coude placed easily. Pyuria (puss in urine) noted, and approximately 1200cc urine drained. Resident #10 remained hospitalized until 4/6/16. Final [DIAGNOSES REDACTED]. On 5/18/16 at 12:05pm, Surveyor # informed Director of Nursing (DON)-B of the concerns related to Resident #10's catheter not being changed and subsequent hospitalization [MEDICAL CONDITION] related to a UTI. No additional information was provided. 2.) Surveyor # reviewed Resident #10's record on 5/17-5/18/16. Resident #10 was hospitalized on ,[DATE]-[DATE] and 5/1-5/6/16 with [MEDICAL CONDITION] related to urinary tract infections/indwelling Foley catheter. A Urology consult dated 4/26/16, noted meatal breakdown from the Foley, probable tape allergy. Recommendations were to use Foley strap to keep Foley secure, keep tension off of Foley. On 5/11/16 at 12:05pm, Surveyor # observed Therapist-X ambulating Resident #10. Resident #10 was holding onto a wheeled walker, while Therapist-X was holding the gait belt around Resident #10's waist with one hand and using his other hand to pull Resident #10's wheelchair behind him. Surveyor # observed the Foley catheter tubing coming down Resident #10's right leg leading to the drainage bag which was attached to the frame of the wheelchair. The Foley tubing was pulled taut then relaxed during the observation. On 5/17/16 at 9:40am, Surveyor # observed 2 catheter leg bags in Resident #10's bathroom. On 5/17/16 at 10:36am, Resident #10 was observed in the dining room area. Surveyor # observed catheter tubing coming out of the right pant leg, leading to the drainage bag placed in a privacy pouch attached to the frame of Resident #10's wheelchair. On 5/17/16 at 1:00pm, Surveyor # asked Certified Nursing Assistant (CNA)-CC when Resident #10 wears the catheter leg bag. CNA-CC stated she was familiar with Resident #10's care needs, but was not assigned to him today. Resident #10 was assigned to an agency CNA. CNA-CC stated Resident #10 usually uses the catheter leg bag when up and the large drainage bag when in bed. 3.) Surveyor # reviewed Resident #15's medical record on 05/17-05/18/16. Review of Resident #15's admission Minimum Data Set (MDS), dated [DATE], reveals Resident #15 is frequently incontinent of bladder. Further review of the record revealed no evidence the facility had completed a comprehensive assessment of Resident #15's bladder function including a bladder diary to determine whether Resident #15 had a pattern of times of urinary incontinence. On 05/18/16 at 9:45a.m., Surveyor # asked Nurse Manager Registered Nurse (RN)-E for a comprehensive assessment of Resident #15's bladder function. On 05/18/16, at 10:58a.m., RN-E indicated the facility had not completed a comprehensive assessment of Resident #15's bladder function. 4.) Surveyor # reviewed Resident #16's medical record on 05/17-05/18/16. Resident #16's admission Minimum Data Set ((MDS) dated [DATE] reveals Resident #16 is frequently incontinent of bladder. Further review of the record revealed no evidence the facility had completed a comprehensive assessment of Resident #16's bladder function including a bladder diary to determine whether Resident #16 had a pattern of times of urinary incontinence. On 05/18/16 at 9:45a.m., Surveyor # asked Nurse Manager Registered Nurse (RN)-E for a comprehensive assessment of Resident #16's bladder function. On 05/18/16, at 10:58a.m., RN-E indicated the facility had not completed a comprehensive assessment of Resident #16's bladder function. 5.) Surveyor # reviewed Resident #3's medical record 5/5/16-5/18/16. Resident #3 was admitted to the facility in 2014. In April, 2016, staff determined a Significant Change in Status Assessment (SCSA) MDS (Minimum Data Set) should be completed. Surveyor # reviewed the SCSA MDS with an Assessment Reference Date of 4/15/16. To complete a SCSA, staff need to comprehensively assess a Resident's bladder status. Resident #3 was noted to be always incontinent of bladder on the 4/15/16 SCSA. Resident #3 had previously been frequently (but not always) incontinent of bladder on her Quarterly MDS dated [DATE]. No evidence was observed indicating staff had further assessed Resident #3's decline in bladder continence, nor was there evidence indicating staff attempted to ascertain any pattern to Resident #3's bladder incontinence, which could help staff know when to assist Resident #3 to the toilet to improve continence. Surveyor # reviewed Resident #3's Care Plan which states: Urinary Incontinence: Problem Start Date: 2/8/15. Problem: Resident is frequently incontinent of bladder due to limited mobility, incontinence and dementia. Goal: Long Term Goal Target Date: 7/23/16. Resident will remain odor free and no occurrence of skin break down will occur over next 90 days. Approach: The following have Start Date of 2/8/15: Assess for causes of incontinence; Determine urinary incontinence type-Mix of stress and urgency; Encourage fluid intake within dietary limits; Labs as ordered; Monitor for signs/symptoms (s/s) of infection, report to MD; Monitor for s/s skin breakdown-report to MD and responsible party; Provide incontinence products as needed; Toilet upon rising, before and after meals and HS (hour of sleep) and per request, check and change for B&B (bowel and bladder) incontinence during night rounds, apply a protective skin barrier to skin after bladder incontinence. On 5/4/15 staff added Prefers to be check and change during the night. This care plan is not based on an individual assessment. The Surveyor # interviewed, DON (Director of Nursing)-B, RN Manger-E, and MDS RN-O, asking if they conducted any further assessment to try to improve Resident #3's bladder continence and to identify contributing factors of her decline in continence that may be reversible. All three stated staff complete the Bladder Observation in the EHR (Electronic Health Record), which does not include any type of diary or patterning of a resident's bladder habits. DON-B stated they stopped completing bladder patterning about a year ago when they moved to the EHR. RN MGR-E stated she looks back 7 days in the CNA (Certified Nursing Assistant) electronic charting to ascertain whether or not a Resident is continent or not, or how often incontinent. Surveyor # reviewed some of Resident #3's CNA bladder documentation and noted there are often gaps or 4, 6, 8, 10 and 12 hours between CNA's documenting Resident #3's toileting status (if she was continent, incontinent, if she had a bowel movement, etc.) With such large gaps in time they cannot determine if Resident #3 may have been continent if she was toileted at one hour after lunch, for example, but the documentation was for hours later showing incontinence. Surveyor # reviewed the TENA Bladder Observation in the EHR completed 4/20/16 which indicates Resident #3 is incontinent of bladder, has impaired mobility, dependent on two persons for transfer, severe cognitive impairment, has wet clothes or pads, nighttime bed wetting, [MEDICAL CONDITION], polypharmacy, urinary tract infection within the last 30 days, impaired ambulation, decreased manual dexterity, Alzheimer's dementia, has had falls, takes antidepressants and bet-adrenergic agonists, no physical exam was performed, no post void residual was performed, Resident #3 has stress incontinence without sensation of urine loss, urge incontinence-bed wetting, functional incontinence due to mobility/manual dexterity impairments and medications. Resident #3 is not appropriate for toileting or retraining program, rationale- impaired cognition. Progress Note: Resident is alert but disoriented x 3 (person, place and time); staff anticipate needs. Does not use call light and transfers with a Hoyer. She is always incontinent of bowel and bladder. Not appropriate for a toilet program due to impaired cognition. Surveyor # requested the facility's Policies and Procedures regarding bladder incontinence management. Surveyor # was provided with Restorative Nursing Policies and Procedures- Management of Urinary Incontinence, revised 12/1/2014. This Policy directs staff to complete a form CP1699, but staff no longer use that form but instead use the TENA Bladder Observation in their EHR. This policy does direct staff to complete a 3-day Bladder Voiding Diary (form CP1703) while simultaneously (recommended) beginning an Intake and Output MP 5429 record to measure the amounts of fluids being consumed .If a Resident is unable to maintain a diary due to cognition and/or motivation, utilize a modified diary, whereby Nursing Assistants document: a.) Continence status each hour during waking hours; and b.) Results of toileting every two hours, during waking hours . This Policy contains a Flow Sheet titled Types of Incontinence. It first asks Is Resident Continent? If no, evaluated for UTI (urinary tract infection). If No UTI, conduct a 3-Day Voiding Diary . Separate policies for Prompted Voiding, Habit Training/Scheduled Toileting, and Routine Toileting for Bladder Incontinence (ADL-Activities of Daily Living-Based Schedule) all start out by stating 1. Evaluate the patient/resident's voiding pattern. DON-B provided Surveyor # with the Face Sheet from the #23 Nursing Policies and Procedures manual, distributed 9/1/2011 and most recently revised 7/22/15 that the above policy came from. The previous NHA (Nursing Home Administrator), current medical director and DON-B signed on 9/16/15 that the contents of the manual have been reviewed and have been accepted as practice guidelines in the health care center. DON-B acknowledged that they do not follow the policies for bladder management as directed in the manual because they have moved on to the EHR, which has its own bladder assessment tool. The forms noted in the policy are no longer used. Resident #3's SCSA with ARD (Assessment Reference Date) of 4/15/16 indicates she needs total assistance of two or more staff for Toilet Use. Without a detailed assessment of Resident #3's bladder habits and patterns, and evaluation of whether or not Resident #3 receives the assistance she needs when she needs it, an individualized care plan cannot be developed, which is needed for staff to try to reverse or minimize Resident #3's bladder incontinence. Resident #3's Care Plan for urinary incontinence is very generic, not individualized because staff have not conducted a voiding diary or pattern. Resident #3's most recent MDS (SCSA 4/15/16) indicates she is totally incontinent of bladder after previously being only frequently incontinent of bladder just one month earlier (Quarterly MDS 3/21/16) yet no comprehensive look at factors that may have contributed to the decline were evaluated. Other Residents have mentioned in Resident Council that they have to wait a long time for staff to assist them with toileting needs. (Cross reference F166.) There is no indication such concerns were looked at regarding Resident #3's decline in urinary continence. This information was shared at the daily exit meeting on 5/12/16. No further information was provided. 6.) Resident #4 was admitted to the facility 4/6/16 following hospitalization for multiple issues, including urinary tract infection, acute [MEDICAL CONDITION], constipation, lack of bowel control, possible [MEDICAL CONDITION] colon and bladder .Reason for admission: rectal pain, constipation. Staff did not conduct a comprehensive assessment of Resident #4's bowel and bladder incontinence, nor did they develop an individualized care plan. (For further details please see F272, F279.) Surveyor # reviewed Resident #4's Care Plan for Urinary Incontinence. It states Resident is incontinent of bladder and bowel related to UTI (urinary tract infection), diuretics, cognitive impairment, and neurogenesis of bowel and bladder. Short Term Goal Target date: 7/23/16. Goal: Resident will remain clean, dry and odor free and no occurrence of skin break down will occur over the next 90 days. Approach: Assess for causes of incontinence: Determine incontinence type- (functional was noted); encourage fluid intake within dietary limits; labs as ordered; monitor for incontinence every 2 hours and prn (as needed), change promptly and apply a protective skin barrier to skin; monitor for signs/symptoms (s/s) of infection and report to MD; monitor for s/s of skin breakdown .; Place resident on toileting program if appropriate. Resident #4's Care Plan for Falls includes an Approach of Provide individualized toileting interventions based on needs/patterns. Check and change upon rising, before and after meals and at bedtime. Always incontinent of bowel and bladder. Resident #4's Care Plan for At risk for Pressure Ulcers includes an Approach of Check and change upon rising, before and after meals, at HS (hour of sleep) and with night rounds. On Toileting Plan- see Flow. Toilet per request. Surveyor # did not observe a Toileting Plan other than the generic toilet upon rising, before and after meals . and ask for information regarding Resident #4's Toileting Plan. DSS (Director of Social Services)-C reported that staff checked and do not see a specific toileting plan for Resident #4. On 5/16/16, Surveyor # interviewed CNA-XX, who frequently assists Resident #4. CNA-XX stated Resident #4 is continent at times- he is not always incontinent of bowel or bladder. CNA-XX stated that at times when Resident #4 puts his call light on to use the toilet, when they get to him to assist him he is at times already wet but he then also voids or has a BM in the toilet. Surveyor # asked if there were a delay in getting to Resident #4, if that could contribute to his incontinence, as some residents have voiced in Resident Council. CNA-XX stated they get to everyone as quickly as they can. Surveyor # observed in Resident #4's record a Discharge Summary dated 4/6/16 (the day Resident #4 was admitted to the facility). Resident #4's Discharge [DIAGNOSES REDACTED]. History of Present Illness: The patient presented to the emergency room with rectal pain and inability to have bowel movements and a bladder infection with Proteus. He had presented to the ER two days earlier with hematuria (blood in urine) Was also having rectal pain and not being able to pass bowel movements . Hospital Course: The Patient was admitted . He was given a variety of laxatives including magnesium [MEDICATION NAME] and [MEDICATION NAME]. He ultimately was given [MEDICATION NAME]. He was given [MEDICATION NAME] and senna. The patient did eventually started having bowel movements, but they were soft and mushy bowel movements that he had no control over. He could not precipitate a bowel movement, the stool pretty much just runs out of him .Exam did reveal that he had virtually no sphincter tone. He was not able to squeeze his rectum closed at all. He was not able to expel bowel movement that was in his rectum, so he does have continued rectal incontinence. He also developed [MEDICAL CONDITION] and had a post void residual of 750 ml (milliliters). A Foley catheter was placed .Because of the possibility of [MEDICAL CONDITION] colon and [MEDICAL CONDITION] bladder, a CT scan of his lumbosacral spine was done which did not show any cauda [MEDICATION NAME] syndrome. I doubt the patient will get any rectal function back, and I think he is going to be incontinent of stool. We will need to keep his stool soft. We will need to give him some bowel stimulants and may need to give him intermittent [MEDICATION NAME] . A consult from a Urologist dated 4/5/16, the day before Resident #4 was discharged from the hospital and admitted to the facility states: Assessment and Plan: .male with UTI, [MEDICAL CONDITION]. -Unclear etiology of UTI as this appeared to begin prior to retention episode. However, severe constipation could have contributed to both. -Continue culture sensitive antibiotic, continue [MEDICATION NAME]. -Foley catheter for at least 5 days. Surveyor # shared the above information with DON-B, MDS-O and RN-E, noting Resident #4 has significant recent issue of bowel and bladder complications that have not been comprehensively assessed, therefore they did not develop a care plan that was individualized, with measurable resident goals, that included pertinent information about Resident #4's detail bowel and bladder conditions that recently required hospitalization . At the daily exit meeting on 5/16/16, Surveyor # noted Resident #4''s care plan is not individualized for his particular bowel and bladder concerns; the Falls Care Plan includes an intervention of Providing individualized toileting based on needs/ patterns but no patterning was ever done and staff then used the generic timing schedule, even though Resident #4 may need more frequent toileting based on his pattern and [DIAGNOSES REDACTED]. Staff that assist Resident #4 state he is not always incontinent, but the care plan developed does not promote Resident #4's bowel continence. No further information was provided. 7.) Resident #5 was admitted to the facility 12/11/15 following surgical repair of a broken femur. Resident #5's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 12/18/15 showed Resident #5 was continent of bowel and bladder. MDS RN (Registered Nurse)-O informed Surveyor # that coding was in error- Resident #5 had a urinary catheter in during the assessment reference period, and was frequently incontinent of bowel. (Cross reference F278.) Resident #5's 12/25/15 14-day MDS indicates she is occasionally incontinent of bladder and frequently incontinent of bowel. Subsequent MDS's (2/1/16 -5 day; 2/16/16 - 5 day; and 3/8/16 -Quarterly) show Resident #5 to be frequently incontinent of bowel and bladder. Resident #5's Nursing Care Plan does not have a specific care plan Problem pertaining to bowel and bladder incontinence. However, Resident #5's CNA (Certified Nursing Assistant) Flowsheet includes an entry dated 12/11/15 stating: Check and change upon arising, before and after meals, and at bedtime and during night shift rounds. On 2/9/16 staff added Frequently incontinent of B&B (bowel and bladder). On 2/17/16, staff added Frequently incontinent of urine, occasionally incontinent of bowel. While this gives direction to the CNAs, it is not a sufficient care plan to address Resident #5's bowel and bladder incontinence. The plan is not based on an individualized assessment- no evaluation of Resident #5's bowel and bladder habits was conducted, nor does it contain measurable goals for Resident #5. There is no evaluation that if staff toileted Resident #5 more often- could she be more continent of B&B? Surveyor # reviewed CNA toileting documentation that often contains long gaps- 4,12 hours in the documentation, so it is not useful in determining Resident #5's toileting patterns and habits, which is needed to then develop an individualized care plan. On 5/10/16 at 10:52 a.m. Surveyor # observed CNA-U assist Resident #5 to the toilet after breakfast (Resident #5 had finished breakfast about 9:00 a.m., almost two hours earlier.) Resident #5 had dribbled a little urine when she stood up from her wheel chair, but was not otherwise incontinent. Resident #5 voided in the toilet. CNA-U stated they cannot always get to Resident #5 before she is incontinent. Surveyor # interviewed MDS RN-O asking if staff tried toileting Resident #5 on a more frequent schedule to improve her frequent incontinence, seeing how she successfully voided on the toilet on 5/10/16. MDS RN stated they just have the data from the CNA documentation, which does have large gaps of time between entries, at times. Surveyor # noted without trying to more closely assess her voiding pattern and toilet Resident #5 more often if warranted, staff may be missing an opportunity to improve Resident #5's continence. This information was shared at the daily exit meeting on 5/12/16. No further information was provided. 8.) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/16/15 Admission Minimum Data Set signed as complete on 11/24/15 indicates Resident #2 experiences severe dementia and Resident #2 is not experiencing [MEDICAL CONDITION]. The Resident mood interview indicates Resident #2 felt down, depressed or hopeless on several days of the assessment reference period along with feeling tired or having little energy nearly every day. The total summary score for symptom frequency was 04. Review of the MDS also indicates Resident #2 is not exhibiting any behaviors including no refusals of care. The assessment for Activities of Daily Living (ADL's) indicates Resident #2 requires extensive assistance of 1 staff for personal hygiene and physical help by one staff for part of bathing. Resident #2 is continent of bowel and frequently incontinent of bladder. Resident #2's 11/16/15 Admission MDS indicates Resident #2 is frequently incontinent of bladder and continent of bowel, and Resident #2 is on a bladder toileting program. The CAA for Urinary Incontinence an Indwelling Catheter indicates (Resident #2) is frequently incontinent of bladder and continent of bowel. She is placed on a toileting program after completion of a bowel and bladder assessment. The CAA indicates to proceed to care plan to ensure elimination needs are met on a daily basis. Resident #2's progress notes dated 11/16/15 at 16:09 (4:09 pm) indicates Resident (#2) is alert but disoriented; able to make needs known; uses call light; and transfers with 1 assist. Resident is always continent of bowel and is frequently both continent and incontinent of bladder - mainly at night. Will initiate toilet program. CP (care plan) updated. Surveyor # noted Resident #2's plan of care is not based upon an individualized assessment as the facility has not determined clearly what Resident #2's continence status is stating she is both frequently incontinent and continent of bladder. A TENA Bladder Observation form with an observation date and completion date of 11/16/15 indicates: Resident (#2) is currently incontinent with risk factors including impaired mobility and severe cognitive impairment. Signs and symptoms of urinary incontinence include: urine leakage on way to bathroom, clothes or incontinence pad is wet, and nocturnal enuresis (bedwetting). Potential reversible causes of incontinence include [MEDICAL CONDITION] and polypharmacy, impaired mobility/ambulation, decreased manual dexterity, and decreased vision. Contributing [DIAGNOSES REDACTED]. Contributing medications include antidepressants/antipsychotics, beta-adrenergic agonists and diuretics. The TENA forma indicates no physical exam was performed nor was a urinalysis or a post void residual (PVR). Incontinence Symptom Profile indicates stress incontinence: incontinence without sensation of urine loss and urge urinary incontinence: urine loss on way to toilet room and enuresis. Functional urinary incontinence: mobility/manual dexterity impairments and medication. The summary and program placement decision indicates Resident #2 most likely experiences urge incontinence with a treatment program of scheduled toileting/habit training. The Notes state: Resident is alert but disoriented; able to make needs known; uses call light; and transfers with 1 assist. Resident is always continent of bowel and is frequently both continent and incontinent of bladder - mainly at NOC (night). Will initiate toilet program. CP updated. Surveyor # noted upon review of this assessment that there is no indication a pattern of elimination was assessed to help determine the true type of incontinence Resident #2 has and to help establish a toileting schedule based upon individual voiding patterns. Resident #2's quarterly MDS dated [DATE] indicates Resident #2 is frequently incontinent of bladder and continent of bowel. Resident #2 continues on a toilet trainin

Based upon observation, interview and record review, the facility did not ensure that 3 of 4 Residents, (Residents #3, #5, and #1), reviewed for pressure ulcers did not develop a pressure ulcer unless it was unavoidable and the pressure ulcer received appropriate cares and treatment once it had developed. ~Resident #3 was admitted to the facility on [DATE] with facility assessment and documentation indicating Resident #3's skin as intact. On 8/17/13 Resident #3 was hospitalized with ED (Emergency Department) skin assessment documentation indicating Resident #3 enters the hospital with "an area on his coccyx measuring 3 cm, which is open." "Yellow drainage noted and this was cultured." "Right heel has a darkened area, but the skin is intact." On 8/19/13, further evaluation by the hospital's wound clinic assesses the coccyx wound as a Stage 2 pressure ulcer and a black, purple area on the right heel, as a suspected deep tissue injury. On 8/26/13, during initial tour of the facility, Resident #3's, pressure ulcers were identified by the facility as non-facility acquired, indicating pressure ulcers were developed during the recent hospitalized from [DATE], with return to facility on 8/23/13. On 8/27/13, the facility indicated that Resident #3's pressure ulcers were identified as facility-acquired based on an investigation, which the facility had begun on 8/23/13, following Resident #3's return to the facility. ~ Resident #5 has a Stage 4 pressure ulcer on his coccyx. During the survey Resident #5 was observed to be positioned on top of a "soaker pad" placed on top of an air mattress decreasing the pressure relieving properties of the mattress. Additionally, Resident #5 was observed seated on a lift sling on top of a pressure relieving Roho cushion in his wheelchair thereby decreasing the pressure relieving property of the cushion. Resident #5 did not receive the correct treatment to his pressure ulcer on 8/26/13. ~ Resident #1 was observed positioned on a thick "soaker pad" on top of an air mattress decreasing the pressure relieving properties of the air mattress. Findings include: 1.) Surveyor # reviewed Resident 3's medical record on 8/26/13-8/29/13. Resident #3 has [DIAGNOSES REDACTED]. Resident #3 was recently hosptalized on [DATE]-8/23/13 with pneumonia and a urinary tract infection. On 8/26/13, at 9:30 AM, during the initial tour of facility of Unit 3, with DON-B, Surveyor # asked whether Resident #3 has a pressure ulcer as indicated on the Roster/Sample Matrix and if so, was the pressure ulcer acquired while at the facility. DON-B, confirmed Resident #3 did have pressure ulcers on his coccyx and heel though they were not-facility acquired but rather acquired during recent hospitalization for aspiration pneumonia and UTI from 8/17/13 through 8/23/13. Resident #3's admission MDS (Minimum Data Set) of 3/18/13, indicates a BIMS (Brief Interview for Mental Status) of 11 indicating cognitive impairment. Resident #3's Quarterly MDS dated [DATE] indicates a BIMs score of 11 and more a more recent MDS data collection tool showed a BIMs score of 9 indicating moderate impairment. No behavioral or symptoms of depression identified. Pressure reducing measures for chair and bed with application of ointments/medications are identified on the MDS. Extensive assistance of 2 staff is needed for bed mobility, transfers, toilet use and personal hygiene. The resident is frequently incontinent of bowel and bladder A Foley catheter remains in place since hospitalization of 8/17/13. Braden assessments completed on 3/11/13 and 3/18/13 showed a score of 17 indicating Resident #3 is at mild risk for the development of pressure ulcers. Braden assessments dated 3/24/13, 4/11/13 and 6/15/13 indicate a risk score of 15 indicating mild risk for pressure ulcers. On 8/23/13 following readmission from the hospital, a Braden assessment was completed with a risk score of 13 indicating moderate risk for the development of pressure ulcers. Surveyor # requested to review Braden Assessments for May and July and none were provided by the facility. The CNA (Certified Nursing Assistant) care card for August reflects transfer with 2 assist with Hoyer, check and change upon arising, before and after meals, at HS (bedtime) and NOC (night) rounds with 3 day toileting assessment to continue through 8/30/13, Restorative ROM, BLE (bilateral lower extremity) Tubi-grips on AM and off at HS, honey-thickened liquids - small amounts at a time. On 8/26/13 revisions were made to Resident #3's CNA care card including to keep Resident #3's HOB (head of bed) elevated to 30 degrees at all times while in bed and to wear bilateral EZ boots when in bed. On 8/22/13, passive ROM (range of motion) to upper and lower extremities was initiated on care plan to be completed 2 times daily by CNA (Certified Nursing Assistant). On 8/23/13, the "Nursing Data Collection Tool" under Physical Exam/[MEDICAL CONDITION] is checked as "always continent." On 8/23/13, air mattress to bed added to care plan. On 8/26/13, at 10:45 AM, Surveyor # introduced herself to Resident #3 and observed him sitting in his wheelchair in his room with the television on. Surveyor # noted that the cushion in Resident #3's wheelchair was not visible at this time, as Resident #3 was observed sitting on a hoyer sling that extended under Resident #3's buttocks and up his back. Surveyor # observed that Resident #3 had tennis shoes on both feet, which were positioned on wheelchair footrests. Surveyor # spoke with Resident #3 who only answered with yes and no responses. Surveyor # asked if he liked his current room/home and Resident #3 answered no. Surveyor # asked if he was excited about moving to the new building and Resident #3 answered no. Surveyor # asked Resident #3 if he was going to be lying down later and he answered yes. Surveyor # observed that there was an air mattress on Resident #3's bed. On 8/26/13 at approximately 11:15 AM, Surveyor # observed that Resident #3 continued to be seated in his wheelchair on a sling with tennis shoes on his feet. Resident #3's mother came in to visit and Surveyor # introduced self. On 8/26/13 Surveyor # continued to make observations of Resident #3 sitting in the same seated position in his wheelchair in his room although his head was now down towards his chest as if asleep this was observed at 11:30 AM, 11:45 AM and at 12:00 PM. At 12:15 PM Resident #3 was observed to be sitting in the same location and position in his wheelchair though he was now awake. At approximately 12:20 PM Surveyor # observed that Resident #3 was wheeled to line up at the elevator to go to the dining room for lunch. Surveyor # noted that Resident #3 continued to be seated on a lift sling with tennis shoes on his feet. Lunch was served at approximately 12:45 PM. On 8/26/13 at approximately 1:50 PM Surveyor # observed CNA-L ask Resident #3 if he would like to lay down. CNA-L pushed the Hoyer lift into Resident #3's room with the assistance of CNA-M. The Hoyer sling has remained in place under the resident since earlier observation of resident at 10:45 AM. CNAs L and M both washed their hands and gloved and the sling was hooked to the hoyer lift, catheter bag placed in Resident #3's lap, the privacy curtain was pulled and the resident was lifted and moved into bed in a back lying position. Surveyor # observed that a thick, soaker pad was visible on Resident #3's bed that Resident #3 was positioned on. The resident's catheter bag was hooked to the left side of the bed. CNAs L and M removed the resident's shoes and pants. Lower extremity Tubi-grips were observed to be in place. Resident #3 was turned to his left side, with the use of the soaker pad. The incontinence product was checked by CNA-L. A small to moderate bowel movement was noted and CNA-L cleansed buttock area with cleansing wipes and removed soiled coccyx and gluteal dressings, cleansing area with a clean wipe after removal. CNA-L removed the incontinence product from under the resident with the help of CNA-M replacing with a clean product. Both CNA's washed hands and re-gloved. CNA's L and M left resident in a left side-lying position, using the soaker pad to lift Resident #3 higher in the bed, placing a pillow behind his back, a blanket between resident's legs and covering the resident with a bed blanket, asking if he was comfortable. Surveyor # observed no off-loading of Resident #3's heels, nor were EZ boots applied. CNA-L called Licensed Practical Nurse (LPN)-N on facility paging device to inform that resident had soiled the wound dressing and would need to be replaced. LPN-N responded via paging device that she would be in to change the dressing. On 8/26/13 at approximately 2:10 pm LPN-N knocked on Resident #3's door and brought the treatment cart into the resident's room. LPN-N washed hands, unlocked the treatment cart and gathered the supplies needed for the dressing change. LPN-N rewashed hands and gloved and removed dry incontinence product. LPN-N washed the area with NS (normal saline), and placed dated [MEDICATION NAME] border dressing on Resident #3's coccyx. LPN-N rewashed hands and re-gloved, washed gluteal area with NS, and placed dated [MEDICATION NAME] dressing on gluteal wound. Surveyor # requested to view Resident #3's heels. Surveyor # observed Resident #3's right heel to be spongy with purple discoloration. Sure-prep was applied by LPN-N. LPN-N then off-loaded Resident #3's heels placing a pillow under the resident's calves. EZ boots were not applied although Resident #3's care plan indicates EZ boots to be placed on both feet when resident in bed. On 8/26/13 at approximately 3:00 PM, DON-B shared with Surveyor # that she was in the process of investigating the possible skin breakdown for Resident #3 prior to hospitalization . DON-B indicated that she had initiated the investigation on 8/23/13 after resident's readmission to the facility from the hospital. DON-B indicated she was still in the process of interviewing staff involved and would share information when received but the pressure ulcers for Resident #3 are facility acquired. Review of the 8/17/13 ED (Emergency Department) skin assessment documentation indicates that Resident #3 entered the hospital with "an area on his coccyx measuring 3 cm., which is open." "Yellow drainage noted and this was cultured." "Right heel has a darkened area, but the skin is intact." Review of the Aurora Hospital Wound Clinic documentation from 8/19/13 by Surveyor # indicates evaluation of a Stage II posterior coccyx pressure ulcer measuring 5.7cm (length) x 6.0cm (width) x 0.1cm depth. Granulated wound bed with peri-wound [DIAGNOSES REDACTED] and well defined wound edge with small serous wound exudate. Treatment includes cleansing with soap and water with application of Calazine zinc barrier and [MEDICATION NAME] powder. Evaluation of the right heel reveals a suspected deep tissue injury which measures 2.4cm (length) x 3.3cm (width) which is black; purple in color with skin intact, cleanse with soap and water with recommendation to elevate heels. The wound culture on the drainage from Resident #3's coccyx pressure ulcer came back as positive for yeast, moderate gram positive cocci, few gram negative rods, beta lactamase positive E. coli, moderate coag-negative Staphylococcus and few [MEDICAL CONDITION][MEDICATION NAME]. Review of the "Wound Treatment & Progress Record" by Surveyor # reveals wound measurements were completed on 8/23/13 upon readmission to facility by RN-Q. Under treatment section of form, documentation indicates "OA (opper area) to coccyx, 8.1 x 6.2, Stage II, red granulated, blanchable surrounding;" "OA to R (right) gluteal fold 1.0 x 1.2 skin blanchable, granular wound bed." The right heel measured "4.0 x 5.0 cm", "red, boggy, unblanchable" "skin intact stage-unstageable." The NPUAP (National Pressure Ulcer Association) "stages for pressure ulcers" on the same form was not completed. On 8/26/13 Resident #3's care plan was revised to include: Roho cushion to wheelchair, foam boots to bilateral lower extremities while in bed, monitor for bruises, scabs, treatments to open areas and to right shin as ordered per MD, Sure-prep to right and left heel, catheter care, antibiotic use, coccygeal culture positive for yeast, moderate gram positive cocci, few gram negative rods, beta lactamase positive E. coli, moderate coag-negative Staphylococcus and few [MEDICAL CONDITION][MEDICATION NAME], glucose checks and injection site rotation and elevation of HOB (head of bed) at least 30 degrees per MD order. The Treatment Record for August and post-readmission indicates nurse to complete weekly skin check with shower. Daily skin checks are completed and recorded by CNAs. Foley catheter change PRN (as needed) for blockage, leakage or displacement, obtain U/A with C & S (urinalysis with culture and sensitivity) as needed. Braden scale weekly x3 after initial completed, weigh daily x3 days, [MEDICATION NAME] protective paste applied topically to buttocks twice daily. On 8/23/13, dressing order changed to NS (normal saline) wash followed by [MEDICATION NAME] border dressing to right gluteal fold and coccyx to be changed every 3rd day or PRN until healed. [MEDICATION NAME] dressing to right shin, changed every third day and skin prep to right heel TID (3x a day). On 8/27/13 the order was changed to "d/c (discontinue) [MEDICATION NAME] to coccyx et (and) gluteal fold. Start [MEDICATION NAME] to buttock et (and) gluteal fold TID until healed." On 8/27/13 at approximately 7:45 AM, Resident #3 was observed by Surveyor # sitting in his wheelchair on a hoyer sling outside of his room waiting to be pushed to the elevator to go down to breakfast. Surveyor # observed that Resident #3's shoes are on and positioned on his wheelchair foot rests. Surveyor # observed EZ boots lying on top of the resident's bed and that the soaker pad previously observed on Resident #3's bed had been removed from bed. At 8:15 AM Resident #3 was taken to breakfast. On 8/27/13 at 2:10 PM Resident #3 was observed by Surveyor # to be in line outside of the dining room waiting for the elevator to take up to unit. Surveyor # noted that the hoyer sling remains positioned under resident on top of the cushion in his wheelchair. Surveyor # noted that Resident #3 has his shoes on and they are resting on wheelchair footrests. On 8/27/13 at approximately 3:45 pm Surveyor # shared with the facility administration concerns regarding observations of Resident #3 being seated in his wheelchair for extended lengths of time without repositioning while seated on a sling for a hoyer lift. Additionally, concern was expressed regarding observations of Resident #3 wearing tennis shoes despite having a deep tissue injury on his heel and an observation of care staff not floating Resident #3's heels after providing cares. On 8/28/13 Surveyor # was provided a copy of Resident #3's revised care plan that was changed to include bilateral EZ boots at all times as well as mesh Hoyer slings only. On 8/28/13 at 10:50 AM, DON-B was interviewed by Surveyor # regarding a change in pressure ulcer treatment from the use of [MEDICATION NAME] dressing to [MEDICATION NAME] to the buttock area and gluteal fold TID (three times daily) until healed that started on 8/27/13. DON-B indicated MD-S had ordered [MEDICATION NAME] dressing in a discharge note that differed from the hospital wound clinic orders. DON-B telephoned wound clinic MD who ordered a change to [MEDICATION NAME] paste with follow up in wound clinic in one week. Appointment made per DON-B. On 8/28/13 DON-B provided Surveyor # with information regarding the placement of the lift slings on Resident #3's Roho cushion The information is from a question and answer section of the product's website the document indicates: Can I place an incontinence pad, towel, drawl sheet or hoyer lift sling over top a ROHO cushion and/or a ROHO mattress? Unfortunately, anything that you place over a ROHO cushion or mattress, actually any cushion or mattress, can interfere with the effectiveness. A ROHO cushion/mattress works by increasing the contact area of the individual when they immerse (sink) into the product thus redistributing the force so there is limited peek pressures at one specific landmark. When anything is placed between an individual and the cushion/mattress, surface tension is increased and thus they have a more difficult time immersing (sinking) into the cushion/mattress effectively. However, since each and every individual needs to be treated individually and a plan of care needs to be considered based upon that individual's specific circumstances, we also realize that other needs like incontinence, safety during transfers etc. need to be considered. A licensed healthcare professional should weigh the risks of placing a pad, towel or Hoyer lift sling, thus reducing the effectiveness of the cushion/mattress, versus the risk of not placing these items. If an incontinence pad or drawl sheet is required while the individual is sitting on the cushion or lying on the mattress, it is our recommendation that the least amount of layers are used and these pads/sheets are put overtop the cushion/mattress in a fashion where they are very loose and NOT tight. If the removal of a Hoyer lift sling from underneath a patient, who was transferred onto the cushion, is going to cause increased shear and friction, which may be detrimental to an individuals skin, a licensed healthcare professional should weigh the risks of keeping the client on the cushion WITH the sling in place, versus removing the sling. Surveyor # noted while this information allows for consideration of a sling if shearing is of concern, there is no specific assessments completed by the facility to demonstrate that Resident #3 is at a specifically higher risk of shearing with the removal of the sling versus losing the pressure relieving benefits of the Roho cushion. On 8/28/13 DON-B also provided Surveyor # with a print out regarding Invacare Patient Sling Reference Guide - Full Body Sling. This document indicates: ...Choose from solid polyester fabric or bathing mesh, with or without commide opening. The mesh slings may be used for bathing or when the sling will be left under the resident. The sold polyester slings should not be left under the resident for extended periods because the padding retains body heat. Residents may be seated on "pressure reduction" cishions. However, the efficacy of those cushions is diminished when solid padded slings are left under the resident. Surveyor # noted that during all of the observations of Resident #3 being seated in his wheelchair seated on a sling, the sling was a blue, sold sling and not a mesh sling. On 8/29/13 at 8:00 AM, DON-B offered additional information regarding the skin investigation into Resident #3's pressure ulcers, which she started on 8/23/13. Caregiver II-R documented that an open area was noted on Resident #3's buttocks on 8/17/13 on the "CNA Daily Skin Inspection Record", nothing was documented regarding the Resident's heels, and Caregiver II-R notified LPN-T of skin findings. LPN-T, cleansed the area and applied PRN [MEDICATION NAME] paste, documented on the TAR (Treatment Administration Record). There was no documentation related to skin issue found in the nursing notes. Caregiver II-R submitted nurse's notes documentation dated 8/29/13 in reference to care given to Resident #3 on 8/17/13, indicating "reddened raised area on buttocks," and "throughout the day with cares there was no change. There was nothing on his heels." On 8/29/13 at 11:50 AM, RN-Q, measured Resident #3's pressure ulcers including the right gluteal with 2 areas separated by "thin layer of [MEDICATION NAME] tissue," the upper right wound measuring at "0.5 x 0.6 red, granular, blanchable, 0 (zero) drainage" and the right lower measuring at "1.5 x 2.5 - red, granular, blanchable, 0 drainage and 0 depth" and the coccyx involving "3 separate areas now." The right upper measuring "3.0 x 1.9, red, granular tissue, right lower 1.9 x 2.5 red granular scant amount of drainage, left 3.0 x 2.6 red granular tissue, 0 odor, 0 tunneling, 0 undermining, shallow depth." Reference "Wound Treatment & Progress Record" of 8/29/13. The right heel now measuring "3.5 width x 3.7 length, 0 depth, dry brown, skin intact, unstageable - tissue damage beneath area mushy, normal blanchable surrounding." Reference "Wound Treatment & Progress Record" of 8/29/13. On 8/17/13 Resident #3 was admitted to the hospital with [REDACTED]. The wound culture on the drainage from Resident #3's coccyx pressure ulcer came back as positive for yeast, moderate gram positive cocci, few gram negative rods, beta lactamase positive E. coli, moderate coag-negative Staphylococcus and few [MEDICAL CONDITION][MEDICATION NAME]. On 8/17/13 prior to admission to the hospital Caregiver II-informed LPN-T of an open area on Resident #3's coccyx. LPN-T applied a treatment to Resident #3 however did not have a RN assess Resident #3's wounds nor was a physician notified about the newly developed area. Upon return to the facility on [DATE] DON-B became aware of Resident #3's pressure ulcers that developed while he was at the facility prior to hospitalization . Despite awareness that Resident #3 developed multiple stage 2 pressure ulcers and a deep tissue injury Resident #3 was observed during the survey to not receive repositioning for extended periods of time. Additionally, Resident #3 was observed on multiple occasions with a lift sling positioned under him, with no specific assessment, which reduced the pressure relieving abilities of the resident's Roho cushion identified as a prevention intervention. Additionally, Resident #3 was observed to be wearing tennis shoes and to not have his heels floated following cares despite having a deep tissue injury to his heels. Following exit from the facility no additional information was provided by the facility to review regarding Resident #3's pressure ulcer care. Surveyor # 2.) At the start of the survey, it was identified that Resident #5 had a stage 4 pressure ulcer to his coccyx. Surveyor # reviewed Resident #5's medical record and observed documentation indicating on 7/22/13, Resident #5 had a superficial abrasion noted to his coccyx. Resident #5 was sent to the hospital on [DATE] following an unresponsive episode. Upon readmission to the facility 8/16/13, Resident #5 had a Stage 4 pressure ulcer to his coccyx measuring 9.8 cm. (centimeters) x 6.0 cm. x 2.0 cm. Resident #5's care plan dated 8/17/13 states: Pressure Ulcer- has Stage 4 pressure ulcer to his coccyx. He has potential for further breakdown or additional areas secondary to decreased mobility, poor nutrition, [MEDICATION NAME] therapy, history of choosing not to change positions, incontinent of bowel. Family desires palliative wound care- no surgical interventions at this time. Care plan interventions include: limit time up in chair to two hours or less; Prevalon boots when in bed; Sure Prep to heels- preventative; treatment to coccyx per MD order, follow up with wound doctor per orders, notify if decline in wound status; air mattress and Roho cushion; no brief in bed; Resident chooses not to change positions over night-educate/re-approach prn (as needed); assess/monitor/document and communicate with nurse signs and symptoms of IE: itching, skin bleeding, blisters, broken, cracked skin, dry, hot, scaly red, thickened skin; assist with change of position per house protocol- every 2-3 hours when in bed or up in chair, with rounds, meals, toileting, and night rounds; [MEDICATION NAME] cream to buttocks/scrotum twice a day as needed-preventative, Gold Bond to affected areas as needed; house barrier cream to affected areas as needed; check and change upon rising, before and after meals, at HS (hour of sleep) and with night rounds, pericare after incontinent episodes; monitor for increased [MEDICAL CONDITION] lower extremities, encourage resident to elevate both legs; monitor skin daily and on bath days and record; monitor skin under right leg brace when worn; and [MEDICATION NAME] on in a.m. off at HS. On 8/26/13 at 11:55 a.m., Surveyor # observed CNAs (Certified Nursing Assistants)- L and M transfer Resident #5 from his wheel chair to his bed per his request. Surveyor # had observed Resident #5 up in his chair since 10:30 a.m., with a Hoyer sling underneath him, but on top of the Roho pressure redistribution cushion in his wheel chair. Additional layers of linens, slings, or clothing reduces the effectiveness of the pressure redistribution device. Surveyor # observed a thick, plaid "soaker" pad on Resident #5's bed before staff transferred him to bed. CNA- L and CNA-M transferred Resident #5 to bed and laid Resident #5 on top of the soaker pad, again lessening the effectiveness of the pressure redistribution air mattress. Once transferred to bed, CNA-L and CNA-M lowered Resident #5's slacks and opened his brief. They noted he had been incontinent of stool, which soiled Resident #5's dressing to his coccyx. CNA-M called for the nurse to change the dressing. CNA-L left the room. Resident #5 had new treatment orders as of 8/23/13 stating: "Irrigate wound with quarter strength Dakin's Solution. Clean peri-wound with [MEDICATION NAME] 4%. Rinse with normal saline wound wash. Pack loosely with Hydrofoil Blue (moisten with normal saline and ring) into undermined ulcer. Cover with calcium alginate. Apply [MEDICATION NAME] paste peri-wound to protect skin. Cover all with ABD pad. Change daily- entire dressing. Change ABD pad prn with soiling /drainage." On 8/26/13 at 12:09 p.m., LPN (Licensed Practical Nurse)-N came to Resident #5's room, bringing the treatment cart into the room with her (cross reference F441). LPN-N put on gloves, removed and discarded the soiled dressing and her gloves, washed her hand, donned new gloves, and moistened gauze with the Dakin's Solution. LPN-N then packed the Dakin's moistened gauze into Resident #5's pressure ulcer and informed Surveyor # that she checked with RN (Registered Nurse)-Q who stated LPN-N should leave the Dakin's packing in for 10 minutes. Surveyor # asked why they would do that if the physician's orders [REDACTED]. LPN-N stated that is how they use Dakin's in their facility. At 12:12 p.m., LPN-N and CNA-M then left the room, stating they would be back in 10 minutes to complete the treatment. LPN-N left the treatment cart in Resident #5's room. LPN-N proceeded to administer mid-day medications to residents, and did not return to Resident #5's room. At 1:00 p.m., RN-Q entered Resident #5's room to complete the treatment. RN-Q stated she just learned LPN-N was unable to get back to finish the treatment, so she will finish it. Surveyor # asked why they packed the wound with Dakin's moistened gauze instead of irrigating the wound as the order states. RN-Q stated the previous order was to pack the wound for 10 minutes, and while she knew the order changed on 8/23/13, she did not know the order now read "irrigate". RN-Q stated LPN-N just asked her how long to leave the packing in, so she assumed the order still directed nurses to pack the wound. RN-Q proceeded to remove the gauze moistened with Dakin's Solution, discarded the gauze and her gloves, washed her hands and donned new gloves. RN-Q then rinsed the wound with normal saline, packed the wound with the Hydrofoil Blue after moistening it with normal saline, covered it with calcium alginate, applied [MEDICATION NAME] to peri-wound and covered it all with by an ABD pad. Surveyor # asked RN-Q why she did not clean the peri-wound with [MEDICATION NAME] 4% solution as the orders state, prior to the normal saline rinse. RN-Q looked at the treatment orders and stated she was not aware of the [MEDICATION NAME] order. RN-Q removed the ABD pad, wiped off the [MEDICATION NAME] ointment, removed the Hydrofoil Blue packing, and re-did the treatment, including the cleansing of the peri-wound with the [MEDICATION NAME]. After removing the packing, RN-Q stated after thinking about it, she could have left the packing in place since the cleansing with [MEDICATION NAME] is to the peri-wound. RN-Q completed the treatment, removed her gloves, washed her hands, and removed the treatment cart from Resident #5's room. Resident #5 remained lying on top of the soaker pad that was on top of the air mattress at least until 4:20 p.m., the last observation by Surveyor # on 8/26/13. On 8/27/13 at 7:50 a.m., Surveyor # observed Resident #5 sitting up in his wheel chair in his room. Resident #5 was sitting on top of the Hoyer sling used to transfer Resident #5 from his bed to his wheel chair. The sling was on top of the Roho cushion. On 8/27/13 at 8:38 a.m., Surveyor # observed staff take Resident #5 downstairs to breakfast in his wheel chair. The sling remained on top of the Roho cushion. At 9:50 a.m., Surveyor # observed Resident #5 in therapy, sitting in his wheel chair with the sling between him and the Roho cushion. At 10:40 a.m., and 2:20 p.m. Surveyor # observed Resident #5 in bed, lying on top of the soaker pad placed on top of the air mattress. Surveyor # shared the above observations with NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B at the daily exit meeting on 8/27/13. On 8/28/13, at 7:55 a.m., 8:20 a.m., and 9:28 a.m. Surveyor # observed Resident #5 in his wheel chair sitting on top of the Hoyer sling. DON-B provided Surveyor # with a Daily Skilled Nurse's Note dated 8/28/13 at 1:00 p.m. stating: Wound clinic consulted regarding use of mesh Hoyer slings with Roho cushions in wheel chair. RN in agreement and MD in agreement with keeping mesh sling under resident rather than removing it as this would increase friction and sheer. Will continue with current interventions. Surveyor # reviewed the facility's "Wound Care Policies and Procedures" revised 12/2011 which state: Policy: A dressing change will follow specific manufacturer's guidelines and general infection control principles. Procedures: ...9. Follow manufacturer's guidelines (available on the wound care product's package insert) and physician's orders [REDACTED]. Surveyor # asked if they had tried different slings that may be easier to remove once a resident is seated in the wheel chair and easier to reinsert when they were going to transfer Resident #5 back to bed, or if they observed staff transferring Resident #5 to make sure they were transferring him correctly, to lessen any friction or shearing. DON-B stated they felt it was better for Resident #5 to leave the sling under him in the wheel chair on top of the Roho cushion, but they did remove the soaker pad from the bed. DON-B had no further information regarding why Resident #5's treatment was not done as ordered (LPN-N packed wound with gauze moistened with Dakin's for 45 minutes instead of irrigated with Dakin's solution, and RN-Q did not cleanse peri-wound with [MEDICATION NAME] until Surveyor # asked about it. 3.) Surveyor # reviewed Resident #1's medical record on 8/26/13 to 8/28/13. Resident #1 has a pressure ulcer on her left heel and is at risk for developing further pressure ulcers. Resident #1 has a Midline Supra air mattress on her bed. On 8/26/13 at 11:05 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-F place Resident #1 on a bed pan. After CNA-F removed the covers from Resident #1, Surveyor # observed there was a thick soaker pad on the air mattress. On 8/26/13 at 1:48 p.m. Surveyor # observed CNA-F place Resident #1 on a bed pan. Surveyor # observed that Resident #1 continues to have a thick soaker pad on the air mattress under her buttocks. On 8/27/13 at 9:35 a.m. Surveyor # observed AD (Activities Director)-C and CNA-H reposition Resident #1 in bed. Surveyor # observed that Resident #1 has a thick soaker pad on the air mattress under her bu

Based on record review, observations and interviews, the facility did not provide the necessary supervision to 1 (Resident #3) of 1 sampled residents with swallowing deficits. The facility also did not ensure that safety interventions were in place/or carried out for 3 (Resident's #1, #8, and #5) of 6 residents reviewed at risk for falls. ~ Resident #3 has a [DIAGNOSES REDACTED]. On 3/19/13, swallowing recommendations indicated Resident #3 receives a regular diet, honey consistency for liquids, body position should be upright in wheelchair with special instructions to take small amounts (less than one teaspoon), alternate solids and liquids and to remain upright for 30-60 minutes following any eating or drinking and no straw use. A Nutritional Review dated 6/18/13 indicates that Resident #3 requires extensive assistance from staff to eat. Trial of pureed food, no added salt diet and honey thickened liquids. The Speech Therapy SLP Evaluation & Plan of Treatment form for the period of 6/14/13 through 8/12/13 indicates: Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for further decline in function and aspiration. Nurse's notes dated 8/15/13 at 23:30 (11:30 pm), indicate Resident #3 found "coughing" and "observation of cranberry juice and cup lying on bed", "possible aspiration," "Res (resident) does not recall what happened." On 8/17/13 Resident #3 was hospitalized with aspiration pneumonia. Resident #3 returned to the facility on [DATE]. Hospital discharge records indicate that Resident #3 requires close supervision for meals due to continued risk of aspiration pneumonia. The facility did not provide close supervision during meals observed on 8/26/13, and did not update Resident #3's care plan to reflect the need for close supervision with meals. ~ Resident #1 is assessed as being at risk for falls. During the survey, Resident #1 was observed to be in bed with a mat propped up against the bed instead of being placed on the floor as care planned. ~ Resident's #8 and #5 were observed to be in bed with the beds left in the high position despite being at risk or falls. Findings include: 1.) Surveyor # reviewed Resident #3's record on 8/26-8/29/13. Resident #3 has [DIAGNOSES REDACTED]. Resident #3's admission MDS (Minimum Data Set) of 3/18/13 indicates a BIMS (Brief Interview for Mental Status) of 11 indicating cognitive impairment and that Resident #3 requires limited assistance of 1 staff for eating. The Care Area Assessment (CAAs) indicates that Resident #3 requires assistance for all activities of daily living (ADL's) related to his progressive [DIAGNOSES REDACTED].#3 has a BMI under 24.9 and is receiving a therapeutic diet and that Resident #3 has poor nutrition. Resident #3's quarterly MDS dated [DATE], indicates a BIMS (Brief Interview for Mental Status) of 11 indicating cognitive impairment. The MDS indicates that Resident #3 is independent with eating requiring set up assistance only. The MDS also indicates that Resident #3 coughs or chokes during meals or when receiving medications. A nutritional Review for Resident #3 dated 6/18/13 indicates that Resident #3 requires extensive assistance from staff to eat. Trial of pureed food, no added salt diet and honey thickened liquids. Surveyor noted that this is not consistent with Resident #3's quarterly MDS dated [DATE] and signed as complete on 6/20/13. On 3/19/13, swallowing recommendations were made by Speech Therapist-U, indicating that Resident #3 receives a regular diet, honey consistency for liquids, body position should be upright in wheelchair with special instructions to take small amounts (less than one teaspoon), alternate solids and liquids and to remain upright for 30-60 minutes following any eating or drinking and no straw use. Facility Care Plan with start date of 3/22/13, for Resident #3 includes nutritional status which indicates that Resident #3 receives a no added salt diet with honey thickened liquids. On 6/20/13 a pureed diet was added to the care plan. The care plan for approach indicates to provide appropriate level of assistance at meals, depending on changing needs. Also, the August Certified Nursing Assistant (CNA) Care Plan indicates, "honey thickened fluids small amounts at a time. Occasional checks during meals." The Speech Therapy SLP Evaluation & Plan of Treatment form for the period of 6/14/13 through 8/12/13 indicates: Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for further decline in function and aspiration. Review of Resident #3's treatment administration record (TARs) for August indicates that Resident #3 is to receive honey thickened fluids small amounts at a time. Nurses' notes dated 8/15/13 at 23:30 (11:30 pm), indicate Resident #3 found "coughing" and "observation of cranberry juice and cup lying on bed", "possible aspiration," "Res (resident) does not recall what happened." Nurse's notes dated 8/16/13 at 01:00 am indicate: ...temperature 100.6, no coughing/SOB (shortness of breath). Some improvement to lungs with continued rhonchi. Skin warm/dry. Denies discomfort. PRN (as needed) Tylenol given PO (by mouth) for elevated temp. Tolerated honey thick liquids well. HOB (head of bed) at 70 degrees. Will continue to monitor. Nurse's notes dated 8/16/13 at 5:00 am indicate: temperature 101..Tylenol 650 mg PRN given PO for elevated temp. Drank 60 cc honey thick liquids without difficulty ....skin very warm/moist. Denies discomfort. MD aware of recent COD (change of condition). UA pending - urine fowl smelling, concentrated with pyuria. Encourage fluids. Nurse's notes dated 8/16/13 at 9:35 am indicates: Resident up in wheelchair per usual activity. Rhonchi noted to lungs. Occasional non-productive cough noted. Appetite poor. Drank 1200 cc of nectar thick liquids. Assisted into bed after breakfast. HOB at 30 degrees. Will monitor. Surveyor # noted that this entry indicates the wrong fluid consistency for Resident #3 documenting presentation of nectar thickened liquids rather than the ordered honey thickened liquids. Nurse's notes dated 8/16/13 at 20:00 (8:00 pm) indicate Resident started on antibiotic for aspiration pneumonia ....lungs crackly, will continue to monitor. Nurse's notes dated 8/17/163 at 10:25 am indicate: ...Resident had poor appetite, up in wheelchair for breakfast. Laid down in bed with HOB up... Nurse's note dated 8/17/13 at 13:15 (1:15 pm) indicates: Res ate poor for lunch leaning in w/c (wheelchair), 1 assist with feeding. Res assisted back into bed after lunch. Elevated temp 100.7 noted. PRN 650 mg Tylenol given. Denies pain, no SOB ...Audible congestion noted ...able to clear throat. HOB up 30 degrees, will continue to monitor. Nurse's notes dated 8/17/13 at 16:15 (4:15 pm) indicates: ...lungs with rhonchi, no SOB, increased congestion noted. Skin warm and moist. Res alert and answers questions. PRN albuterol nebulizer treatment given, no change, HOB up, denies pain, will continue to monitor. Nurse's note dated 8/17/13 at 18:30 (6:30 pm) indicates: Tylenol 650 mg given for increased temp. Cool moist washcloth applied to forehead, res ate 50% of supper. Nurse's notes dated 8/17/13 at 20:15 (8:15 pm) indicates: Rep rate 38. PRN albuterol nebulizer treatment given. No changes. POX (pulse ox) 90%. Writer attempted to start 02. Res with some SOB. Res pulled 02 tubing out of nose. Attempts x3. Call out to POA to update on current condition. Rec'd order earlier today "may send to ER for Eval and TX (treatment) if condition worsens." POA in agreement to send Res to ER ... The hospital admission summary dated 8/18/13, indicates that the facility had identified that liquid had been found next to Resident #3's bed on 8/16/13, and "they think that he drank the liquid while lying down and he started to cough and probably aspirated into his lungs." Started on oral Augmentin at that time. Surveyor # noted that there is documentation in Resident #3's medical record to indicate if facility staff investigatedto determine if the liquid that Resident #3 aspirated on was the correct consisitency or not. Surveyor # also noted that having liquids bedside that Resident #3 could drink while in bed is not consisitent with the swallowing precautions that have previously been established for Resident #3 that indicate that he should be upright in wheelchair, honey thickened liquids with small amounts at a time and assessments that indicate that Resident #3 requires extensive assistance. A Video Swallow evaluation of Resident #3 was completed 8/22/13, while hospitalized . The Swallow Study indicates oropharyngeal dysphagia for puree solids and thickened liquids. Nectar liquids were silently aspirated below the cords due to swallow delay and reduced pharyngeal propulsion. Puree and honey thick were not aspirated during the study but resident will continue to be an aspiration risk due to weakness and reduced pharyngeal closure and when MS is declining. The Hospital SLP (Speech/Language) Acute Treatment Plan of Care Note dated 8/22/13: Objective for Feeding Guidelines indicates: Constant supervision; feeds self; Sit up for 30 minutes after meal; Small bites/sips. Review of the Speech Therapy SLP Evaluation & Plan of Treatment form with a certification period of 8/24/13 through 10/22/13 indicates for Supervision for Oral Intake: Close Supervision, and identified on the same form are Risk Factors: Due to documented physical impairments and associated functional deficits, the patient is at risk for further decline in function, aspiration and pneumonia. On 8/26/13 at approximately 11:15 am Surveyor # observed Resident #3 to be seated in his wheelchair in his room with a glass of thickened red juice in front of him on his bedside table. Resident #3 was observed to pick up the juice and take multiple drinks of the juice. No staff was present in the room at this time and immediately following this a family member came into Resident #3's room. On 8/26/13 at approximately 12:45 pm lunch was provided to Resident #3 consisting of a pureed pork chop, mashed potatoes, pudding and thickened milk and juice. Resident #3 was observed, by Surveyor # to pick up his fork and take 2 small forkfuls of food on the tip of the fork, one right after the other. Surveyor # noted that given the height of Resident #3's wheelchair and the table that it was an extended reach for Resident #3 to access his plate. Surveyor # also noted that there was no staff present at Resident #3's table, just one additional resident seated at the table and all staff in the dining room was seated at other tables assisting other residents. At approximately 12:50 pm Dietary Aide-W came out of the kitchen and walked past Resident #3's table and asked if Resident #3 was hungry. Dietary Aide-W did not stay with Resident #3 to assist or supervise with eating. At approximately 12:55 pm Resident #3 was observed to drink his juice, taking multiple sips at one time. Surveyor # noted that Resident #3 did proceed to cough multiple times after drinking his juice. Surveyor # observed that no staff were supervising Resident #3 or encouraging him to take small sips. Following this, Resident #3 was observed to take small forkfuls of mashed potatoes and pudding; still with no direct staff supervision or assistance. Following this, Resident #3 sat in his wheelchair and did not eat anything more. At approximately 1:15 pm RN-E approached Resident #3 and asked Resident #3 if he wanted anything else to eat. Resident #3 indicated no and took a drink of his juice as RN-E walked away. RN-E came back and removed Resident #3's meal slip and Resident #3 was assisted to line up to get on the elevator. On 8/26/13 at approximately 2:15 pm, Surveyor # asked Certified Nursing Assistant (CNA)-L whether Resident #3 requires assistance at mealtimes. CNA-L responded that she assists Resident #3 when needed, and he is "going downhill, needs encouragement." On 8/26/13 at approximately 4:10 pm, Surveyor # observed Resident #3 lying in bed on left side facing the opposite direction of the over the bed table on which a snack had been placed. Surveyor # observed that the call light was not in reach. Surveyor # asked Resident #3 if he would eat his snack if assisted. He responded he would. Surveyor # notified DON-B of the Surveyor's observation and Resident #3's need for help. DON-B was then observed going into Resident #3's room. On 8/27/13 at approximately 8:15 am, Surveyor # observed Resident #3 being pushed up to the dining table. Honey thickened juice and milk were observed on the table in front of him. At approximately 8:25 am, a staff member assisted Resident #3 with meal set-up, and Speech Therapist-U was sitting next to Resident #3, encouraging the resident to eat. Resident #3 was feeding himself oatmeal. Speech Therapist-U left table at 8:30 am and Resident #3 stopped eating. Speech Therapist-U returned to table at 8:35 am to assist with the set-up of another resident at the table, encouraging Resident #3 to eat at the same time. Resident #3 was observed to be coughing with eating. At 8:45 am, Resident #3 attempted to self- feed pudding and dropped the pudding on the floor. Speech Therapist-U went to get another pudding and started feeding spoonfuls of pudding to Resident #3, with direction to swallow hard. No coughing noted with swallowing. On 8/27/13 at approximately 9:00 am, Surveyor # interviewed Speech Therapist-U regarding Resident #3. Speech Therapist-U indicated that Resident #3 has had multiple video swallows in the past, most recently during hospitalization , and that Speech Therapist-U had attended the hospital video swallow on 8/22/13. Speech Therapist -U also indicated Resident #3 has had a decline in cognition and is now easily distracted during meals. Speech Therapist-U indicates she would like to increase oral intakes and has discussed this with DON-B. Speech Therapist-U, would like to discuss a feeding tube with resident and facility care team to maintain nutrition needs and hydration with some food by mouth to maintain quality of life. On 8/27/13 at approximately 9:40 am Surveyor # interviewed DON-B who indicated that a conference is planned with MD, Nurse Practitioner, and Speech Therapy along with resident and family members to discuss the resident's wishes regarding advanced directives. On 8/27/13 at approximately 3:15 pm Surveyor # interviewed RN-E regarding the observations of Resident #3 in the dining room at lunch time on 8/26/13. RN-E confirmed that she was assisting in the dining room on 8/26/13 at breakfast and lunchtime. Surveyor # asked RN-E if she was familiar with Resident #3 and his eating needs. RN-E indicated to Surveyor # that she does not take care of him on the floor, but "knows he doesn't eat much." On 8/28/13, at approximately 8:05 am, Surveyor # interviewed Dietitian-V regarding Resident #3. Dietitian-V indicated this was her first day in this week and she has not worked with Resident #3 since before he left for the hospital and was unaware the resident was back. Dietician-V indicated she had just entered building and would review resident's chart and follow up with resident today. On 8/28/13 Surveyor # shared her concerns with facility administration regarding Resident #3 not receiving supervision and assistance during the survey despite Resident #3's recent hospitalization for aspiration pneumonia. Surveyor # 2.) Surveyor # reviewed Resident #1's medical record on 8/26/13 to 8/28/13. The fall risk evaluation dated 7/13/13 has a total score of "22". A score of ten or higher indicates the Resident is at risk for falls. The falls plan of care has an approach dated 3/4/13 of "Bed alarm and chair alarm for safety; mat next to L (left) side of bed." On 8/26/13 at 10:30 a.m. Surveyor # observed Resident #1 asleep in bed on her back. Surveyor # observed Resident #1's bed was up and not in the lowest position. Surveyor # observed there was a mat on the left side of the bed. On 8/26/13 at 1:40 p.m. Surveyor # observed Resident #1 asleep in bed. Surveyor # observed Resident #1's bed was up and not in the lowest position. On 8/27/13 at 8:51 a.m. Surveyor # observed Resident #1 asleep in bed. Surveyor # observed the floor mat is propped up against the bed and is not on the floor. On 8/27/13 at 9:19 a.m. Surveyor # observed Resident #1 asleep in bed. Surveyor # observed the floor mat continues to be propped up against the bed and is not on the floor. On 8/27/13 at 9:33 a.m. Surveyor # observed AD (Activities Director)-C leave Resident #1's room with a clothing protector in her hand. Surveyor # observed the mat is now on the floor next to Resident #1's bed on the left side. On 8/27/13 at 3:25 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above. 3.) Surveyor # reviewed Resident #8's medical record on 8/28/13. The fall risk evaluation dated 8/20/13 has a total score of "18". A score of ten or higher indicates the Resident is at risk for falls. On 8/28/13 at 9:59 a.m. Surveyor # observed Resident #8 asleep in bed. Surveyor # observed Resident #8's bed was up high. On 8/28/13 at 10:01 a.m. Surveyor # spoke to CNA (Certified Nursing Assistant)-H regarding the height of Resident #8's bed. CNA-H informed Surveyor # that Resident #8 doesn't usually move in bed and that CNA-H is used to having the bed up to her waist level. CNA-H then asked Surveyor # "Do you want me to put the bed down?" Surveyor # informed CNA-H for Resident #8's safety, the bed should be at the lowest position. CNA-H then lowered the bed down. 4.) On 8/26/13 at 11:55 p.m. Surveyor # observed CNAs (Certified Nursing Assistants)-L and M transfer Resident #5 from his wheel chair to bed, per his request. The CNAs raised Resident #5's bed up to the highest position for the transfer. The CNAs discovered Resident #5 had been incontinent of stool, and CNA-M called LPN (Licensed Practical Nurse)-N to Resident #5's room to re-apply his pressure ulcer dressing since it was soiled. CNA-L left the room. On 8/26/13 at 12:09 p.m., LPN-N came to Resident #5's room at the request of CNA-M, bringing the treatment cart into the room with her (cross reference F441). LPN-N put on gloves, removed and discarded the soiled dressing and her gloves, washed her hand, donned new gloves, and moistened gauze with the Dakin's Solution. LPN-N then packed the Dakin's moistened gauze into Resident #5's pressure ulcer and informed Surveyor # that she checked with RN (Registered Nurse)-Q who stated LPN-N should leave the Dakin's packing in for 10 minutes. Surveyor # asked why they would do that if the physician's orders [REDACTED]. LPN-N stated that is how they use Dakin's in their facility. At 12:12 p.m., LPN-N and CNA-M then left the room, stating they would be back in 10 minutes to complete the treatment. Neither LPN-N nor CNA-M lowered Resident #5's bed. Surveyor # remained in Resident #5's room until 12:18 p.m., and no staff returned to lower Resident #5's bed. Surveyor # then requested LPN-N, who was down the hall a ways, come back and lower Resident #5's bed for safety. LPN-N came and lowered Resident #5's bed.

Based on record review and interviews, facility staff did not further assess and investigate 1 of 8 Resident's (Resident #5) avoidable decline in bowel continence to identify possible reversible or modifiable causes for the increased incontinence in an effort to regain as much bowel continence as possible. Additionally, 1 (Resident #5) of 2 Residents did not have a protective dressing on. * The annual MDS (Minimum Data Set) completed on 1/10/12 shows Resident #5 is continent of bowel and the significant change MDS completed on 3/14/12 identified Resident #5 as frequently incontinent of bowel. The Facility was unable to locate patterning and did not complete an assessment of Resident #5's bowel incontinence. * Resident #5 did not have a protective dressing over the excoriated area on his upper buttock for approximately five hours. Findings include: According to the National Digestive Diseases Information Clearinghouse (NDDIC), Fecal incontinence (FI) is the inability to hold a bowel movement until reaching the bathroom. FI is not always a part of aging, but it is more common in older adults, especially women. In addition one of the causes of FI is constipation. Over time, constipation can stretch and weaken sphincter muscles therefore reducing the rectum ' s ability to hold stool. The NDDIC website on FI identified treatment to include one or more of the following: eating, diet, and nutrition; medication, pelvic floor exercises, bowel training, surgery, and electrical stimulation. Because FI can cause embarrassment, fear, and loneliness, taking steps to deal with it is important. Treatment can dramatically improve quality of life and help people with FI feel better about themselves. (<http://digestive,niddk,nih.gov/ddiseases/pubs/fecalincontinence>) 1. Surveyor # reviewed Resident #5's medical record on 5/21/12 & 5/22/12. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 has an activated power of attorney. The annual (Minimum Data Set) completed on 1/10/12 for Resident #5 has a summary score of "11" (moderately impaired), is continent of bowel, and requires extensive assistance with two person physical assist for toilet use. The urinary incontinence and indwelling catheter CAA (Care Area Assessment) dated 1/10/12 does not address Resident #5's bowels. The nursing data collection tool dated 3/2/12 under bowel continence is checked for "occasionally incontinent." The weekly summary for bowel continence and patterns is checked for "frequently incontinent" on 3/7/12, 3/14/12, 3/21/12, 3/28/12, 4/4/12,4/11/12,4/18/12, and 4/25/12. The weekly summary for bowel continence and patterns is checked for "always incontinent" on 5/9/12 & 5/16/12. The significant change MDS completed on 3/14/12 has a summary score of "6" (0-7 severe impairment), is frequently incontinent of bowel, and requires extensive assistance with two person physical assist for toilet use. The urinary incontinence and indwelling catheter CAA dated 3/14/12 documents under analysis of findings, "Resident incontinent of B & B (bowel and bladder) with some control, utilizes briefs, on diuretics, needs assist with transfers & toileting, memory deficits, weakness." The Resident profile utilized by the CNA's (Certified Nursing Assistants), last updated 4/9/12 documents, "incontinent of Bowel and Bladder, needs assist with pericare." On 5/22/12 at 3:45 p.m., Surveyor # informed RN (Registered Nurse)-E that Surveyor # was unable to locate a bowel assessment in Resident #5's medical record and asked if a bowel assessment was done when Resident #5 declined from continent to frequently incontinent in March 2012. RN-E informed Surveyor # that she would look into this and get back to Surveyor # . The nurses note dated 5/22/12 documents, "Spoke with res. (resident) re. (regarding): B & B (bowel and bladder) incontinence. Pt. (patient) stated it bothered him, "to a point." He stated he has "very short notice, when referring to whether or not he could anticipate the need to void/BM. Asked him if he'd be willing to give a toilet plan a try explained how it would work - pt. stated, "let's try it." Pt. does not, however, want to be woken during the NOC (night) hrs. (hours) stated, "let's try it when I'm awake." At this point plan is to set up toilet plan during his awake hours." On 5/23/12 at 7:54 a.m., while observing LPN (Licensed Practical Nurse)-M administer Resident #5 his medication, Resident #5 informed LPN-M that he had to go to the bathroom. Resident #5 asked LPN-M if she could walk him to the bathroom. LPN-M asked Resident #5 if he could wait until after he received his medication and then LPN-M would have someone come in. Resident #5 agreed. On 5/23/12 at 9:05 a.m., RN-E informed Surveyor # that she knows a bowel and bladder patterning was done on 3/9/12 as it is signed out as being done in the MAR (Medication Administration Record) but she is unable to find the patterning. RN-E informed Surveyor # that she spoke with Resident #5 and that he told her it bothered him a little bit about being incontinent and they are going to start a toileting plan with Resident #5. Surveyor # asked what the procedure is for completing a bowel patterning and assessment. RN-E informed Surveyor # that the normal procedure is they place the three day bowel and bladder on the CNA clip board and they write on it for those three days. When the three days are complete it is supposed to go to RN-E. Surveyor # asked RN-E if she remembers doing a bowel assessment for Resident #5 in March. RN-E replied, "no." RN-E then explained she has a system. RN-E informed Surveyor # that she has a notebook which she writes down the Resident's name and when they did an assessment for the Resident. RN-E informed Surveyor # that the last time a bowel and bladder assessment was completed for Resident #5 was in January. RN-E informed Surveyor # they were going to start a new three day patterning for Resident #5 and then a bowel assessment would be completed. On 5/23/12 at 9:22 a.m., Surveyor # spoke with CNA-L to inquire if she provided continence cares for Resident #5. CNA-L informed Surveyor # around 8:50 a.m. she placed Resident #5 on the bed pan and he had a large BM (bowel movement). On 5/23/12 at 3:05 p.m., during the daily exit conference the Administrator and Director of Nursing were informed of Resident #5 not being assessed when he experienced a decline in his bowel continence making it an avoidable decline. On 5/24/12 at 11:57 a.m., during a meeting with the Administrator and Director of Nursing, Surveyor # asked if there was any additional information regarding a bowel assessment for Resident #5. Surveyor # was informed there wasn't any more information. 2. The significant change MDS (Minimum Data Set) completed 3/14/12 documents that Resident #5 is frequently incontinent of bowel & bladder and does not have a pressure ulcer. The nurses note dated 3/19/12 documents, "Upper (B) (bilateral) buttocks reddened/excoriated. Pt. (patient) has been incontinent of B & B (bowel and bladder). MD updated. NO (new order) received for Exuderm. POA (power of attorney) aware. Spoke with resident regarding side to side positioning." The physician telephone order dated 3/19/12 documents, "Exuderm to upper buttocks change Q (every) 5 days & prn (as needed) - excoriation, D/C (discontinue) zinc oxide to butt." On 5/22/12 from 8:05 a.m. to 1:06 p.m. Surveyor # made continuous observations of Resident #5. During this time period, Resident #5 was not toileted and/or checked & changed for approximately 5 hours. Cross Reference F315 for exact times. On 5/22/12 at 1:04 p.m., Surveyor # observed CNA-C in Resident #5's room. CNA-C washed her hands and placed gloves on. CNA-C asked Resident #5 if he needed to use the bed pan. Resident #5 shook his head no. CNA-C hooked the sling to the Hoyer lift. At 1:06 p.m., CNA-K entered Resident #5's room. CNA-K placed gloves on and Resident #5 was raised off the wheelchair and transferred over to the bed. After being lowered onto the bed, the sling was unhooked from the Hoyer lift, and CNA-K removed Resident #5's shoes. Resident #5 was positioned from side to side to lower his pants. CNA-K unfastened the incontinence product. Surveyor # observed Resident #5 was wearing an incontinence product with a liner inside the product. Surveyor # observed the liner was saturated with urine. CNA-C informed Surveyor # that Resident #5 is doubled because he is a heavy wetter due to the tube feeding. CNA-C washed Resident #5's frontal perineal area. Resident #5 was then positioned on his right side. Surveyor # observed Resident #5 did not have on the protective dressing. Surveyor # observed the area on the upper buttocks was excoriated but not open. Surveyor # asked CNA-C if there was a dressing in Resident #5 product. CNA-C removed the product from the garbage can next to the bed, checked the product, and informed Surveyor # there was not a dressing. CNA-C informed Surveyor # that she would tell the nurse that Resident's #5 dressing is off. Surveyor # noted that during the five hours that Resident #5 was not toileted and/or checked & changed, Resident #5 did not have a dressing over the excoriated area. On 5/22/12 at 1:25 p.m. Surveyor # informed RN-E that Resident #5 did not have on the protective dressing. On 5/23/12 at 3:05 p.m. during the daily exit conference the Administrator and Director of Nursing were informed of the above.