Every finding on record at Serenity Spring Senior Living at Scandia Village

Based on observation, interview, and record review, the facility did not ensure appropriate supervision and preventative measures were in place to address wandering and related concerns for 1 resident (R) (R6) of 10 sampled residents.R6 displayed intrusive behavior, including wandering into other residents' rooms and touching other residents, and exit seeking. The facility did not ensure safety measures were consistently implemented and residents' care plans were updated to prevent reoccurrence.Findings include:The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised January 2026, indicates: The program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not limited to .b. other residents .7. Implement measures to address factors that may lead to abusive situations.The facility's Wandering and Elopements policy, revised January 2026, indicates: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment .1. If identified as a risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.On 8/17/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had diagnoses including dementia with other behavioral disturbance and insomnia. An admission Minimum Data Set (MDS) assessment, dated 8/10/26, indicated R6 had severe cognitive impairment, episodes of physical behavior toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually), and other behavioral symptoms toward others (e.g., physical symptoms such as hitting or scratching, self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated the behaviors significantly interfered with R6's care, participation in activities or social interactions, significantly intruded on the privacy and activities of others, and disrupted the care/living environment. The MDS assessment also indicated R6 had episodes of wandering which placed them at significant risk of getting to a potentially dangerous place (e.g., stairs, outside of the facility) and significantly intruded on the privacy and activities of others. On 8/17/26 at 12:36 PM, Surveyor interviewed Registered Nurse (RN)-H who said R6 tended to gravitate to them and other male staff. RN-H stated R6 is not consciously aware of personal boundaries, gets in others' personal space, and touches or grabs at other people. RN-H was not aware of negative interactions between R6 and other residents. RN-H confirmed R6 wanders into other residents' rooms, and touches residents' arms or belongings, but stated it is not done in a malicious manner. RN-H verified R6 has a WanderGuard (WG) but stated it only alarms if R6 tries to exit the facility, not when they wander into others residents' rooms. RN-H stated the WG should be tested every shift to ensure it is operating correctly and staff should document the test in R6's Treatment Administration Record (TAR). RN-H stated R6 is also 1:1 with staff due to wandering, however, RN-H did not think 1:1 supervision was consistently completed. RN-H stated 1:1 supervision is only initiated when staffing allows. RN-H confirmed there are times when R6 is not on 1:1 supervision because there are not enough staff. RN-H stated safety interventions are communicated shift-to-shift and should be on a resident's care plan.On 8/17/26 at 12:50 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated R6 tries to exit the building which is why they are on 1:1 supervision. LPN-I verified R6 touches other residents but not in a combative way. LPN-I confirmed they were in the dining room when R6 tried to touch R5 and their belongings. LPN-I intervened and no physical contact occurred. LPN-I confirmed R5 did not like R6 in their personal space and stated many residents get concerned when R6 enters their rooms or personal space. LPN-I stated R6's combativeness has only occurred with staff and occurs when staff attemp to provide care or redirect them. LPN-I stated R6 hit them in the lip when they tried to redirect them from leaving the building. An alarm sounded and staff responded appropriately. LPN-I stated providing 1:1 supervision is easier on the AM shift when there are more staff. LPN-I stated R6 sits in the office with administration or walks with the nurse during medication pass if there are not enough staff. LPN-I stated 1:1 supervision is often not available and safety interventions are communicated shift-to-shift. LPN-I was unsure if the interventions are listed anywhere for staff.On 8/17/26 at 1:23 PM, Surveyor interview Certified Nursing Assistant (CNA)-J who stated R6 likes to grab at or touch other residents and try to adjust their clothing. CNA-J stated R6 also wanders into other residents' rooms, touches their belongings, and becomes agitated when staff try to redirect them. CNA-J indicated R6 should always have 1;1 supervision, but stated it is not always possible due to staffing. CNA-J could not provide specific concerns regarding other residents and their interactions with R6.On 8/17/26 at 2:02 PM, Surveyor observed R6 touching RN-H's arms and shirt with both hands and leaning over the medication cart into their personal space at the nurses' station during shift change when nurses were counting medication and giving report. R6 was moving independently without the use of a mobility device. R6's movements were quick, direct, and intrusive. CNA-J was at the nurses' station and encouraged R6 to sit with them. R6 appeared restless and fixated on RN-H and would not sit down. RN-H attempted to reassure R6 by holding their hand as they attempted to count medication and give report. R6 then walked toward their family member in the hallway who held R6's hand and walked with them. When the family member attempted to leave, R6 would not let go of their hand. When the family member attempted to walk away, R6 continued to grab their hand and walk with them. Staff intervened in order to allow the family member to leave and provided 1:1 supervision for R6 after they left.On 8/17/26 at 2:10 PM, Surveyor was interviewing R9 in their room when R6 entered the room. R6's 1:1 staff remained in the doorway. R6 grabbed and moved R9's walker and touched their arm. R6's 1:1 staff intervened and escorted them out of the room. R9 did not appear distressed but stated the interaction was odd and they didn't know why it occurred. (Surveyor noted R6's 1:1 staff remained in the doorway, did not prevent R6 from entering the room, and did not intervene until R6 touched R9.) On 8/17/26 at 2:29 PM, Surveyor interviewed Social Services Designee (SSD)-K who was aware of R6's wandering and intrusive behavior. SSD-K confirmed safety interventions should be listed on R6's care plan. SSD-K indicated R6 had a WG since admission and started 1:1 supervision approximately 3 days after admission. SSD-K stated R6 should always be on 1:1 supervision during the AM and PM shifts, but was unsure about the night (NOC) shift. SSD-K stated Director of Nursing (DON)-B and Unit Manager (UM)-E update care plans.On 8/17/26 at 2:56 PM, Surveyor interviewed UM-E who was aware of R6's behaviors. UM-E stated all nursing staff are responsible for updating care plans. UM-E stated R6 is not on 1:1 supervision at all times but could not state when or how often they should be on 1:1 supervision. UM-E stated R6's WG is monitored every shift and documeted in the TAR.A progress note on 8/15/26 at 3:08 PM stated R6 was observed following a resident into the attached assisted living facility. Staff were unsuccessful redirecting R6 and followed them into the assisted living facility. R6 approached the resident who was seated in a chair watching a movie on their phone. R6 became fixated on the resident and began touching their walker and drinking from their cup. The resident became upset and stated they would call the police if R6 did not leave them alone. R6 became increasingly agitated and combative with staff during attempts at redirection. Staff eventually redirected R6 back to their room.A behavior care plan, dated 8/11/26, indicated R6 had attention seeking behaviors. The care plan contained an intervention (dated 8/11/26) to provide 1:1 attention, especially during increased attention seeking behaviors. The care plan did not specify the attention-seeking behaviors or when/how often 1:1 attention should be implemented. (Surveyor noted R6 did not have a care plan for specific intrusive behaviors, including wandering and, exit seeking, or WG placement.)Surveyor reviewed R6's TAR for 8/3/26 through 8/16/26 which did not include orders for monitoring, placement, or operation of R6's WG.On 8/17/26 at 3:23 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated 1:1 supervision for R6 is provided as needed and based on their mood and behavior. NHA-A stated the facility does not offer or provide 1:1 supervision at all times. NHA-A confirmed R6's WG should be monitored and documented every shift. NHA-A indicated safety interventions should be included in a resident's care plan or Kardex (an abbreviated care plan used by nursing staff) and communicated shift-to-shift. NHA-A verified R6's care plan did not include specifics on behaviors or safety interventions and verified R6's TAR did not indicate to monitor their WG.On 8/17/26 at 4:13 PM, Surveyor interviewed NHA-A and Regional Director of Clinical Services (RDCS)-L. RDCS-L stated the facility does not allow for continuous 1:1 supervison which was only implemented for R6 as needed. Surveyor informed NHA-A and RDCS-L that R6 entered R9's room and touched their belongings and arm while on 1:1 supervision and staff did not stop them. When Surveyor asked when staff who provide 1:1 supervision should intervene, RDCS-L stated staff cannot stop all residents from entering other residents' rooms and 1:1 attention is more so used to help R6 with anxiety. RDCS-L stated R6 walks the hallways but does not wander or exit seek. When Surveyor informed NHA-A and RDCS-L that staff stated R6 wanders into other residents' rooms and exit seeks, RDCS-L reiterated that residents will wander into others' rooms and staff cannot always prevent it. NHA-A and RDCS-L agreed R6 may be at risk of harm from others due to intrusive behaviors. NHA-A and RDCS-L did not provide information on how the facility is ensuring preventative measures are taken to keep R6 and other residents safe.

Based on interview and record review, the facility did not ensure physician orders were in place at the time of admission for 1 resident (R) (R6) of 10 sampled residents.R6 was admitted to the facility on [DATE]. The facility did not obtain admission orders from R6's physician prior to admitting them to the facility.Findings include:The facility's Admissions Policies, dated January 2026, indicates: .The objective of the policy is to .e. Assure appropriate medical and financial records are provided to the facility prior to or upon the resident's admission.On 8/17/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] from an assisted living facility.R6's admission record indicated they were evaluated by an Advanced Practice Nurse Prescriber (APNP) on 7/8/26. The evaluation was electronically signed. The APNP's handwritten signature was added to the evaluation on 7/31/26; however, the facility did not provide evidence or documentation to indicate the APNP saw and evaluated R6 again on 7/31/26. R6's admission record did not include a physician order to admit them to the facility. In addition, the facility did not provide documentation to indicate an examination by a physician was completed prior to or since R6 was admitted to the facility. On 8/17/26 at 4:13 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Regional Director of Clinical Services (RDCS)-L who were not aware R6's admission orders were not completed by a physician. NHA-A and RDCS-L were also not aware R6 was not evaluated by a physician prior to or since admission.

Based on interview and record review, the facility did not ensure 1 resident (R1) of 13 sampled residents was free of significant medication errors. R1 did not receive medications as ordered when the facility did not obtain updated orders after their wound care appointment. Findings include: The facility's Administering Medications policy, revised October 2023, indicates: Medications are administered in a safe and timely manner and as prescribed .4. Medications are administered in accordance with the prescriber order, including any required time frame . On 8/17/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including methicillin-resistant Staphylococcus aureus (MRSA) and an open-to-the-bone toe wound. A Minimum Data Set (MDS) assessment, dated 5/11/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 8/17/26, Surveyor reviewed R1's medical record. An after visit summary from a wound care visit on 7/17/26 indicated: ~ Culture results MRSA, resistant to current antibiotic doxycycline ~ Start clindamycin 300 milligrams (mg) three times daily (TID) for 7 days, take with probiotic R1's Medication Administration Record (MAR) indicated they did not start clindamycin until the 7/20/26 PM shift. R1 missed 9 doses of clindamycin between when it was ordered on 7/17/26 and when it was first administered on 7/20/26. On 8/17/26 at 12:27 PM, Surveyor interviewed Wound Clinic Registered Nurse (WCRN)-G who indicated R1 was seen on 7/17/26 and their culture results for MRSA were resistant to doxycycline. R1's antibiotic was changed to clindamycin.WCRN-G indicated the clinic called the facility, notified Registered Nurse (RN)-H, and ordered the antibiotic through the facility's pharmacy. When R1 returned to the wound clinic on 7/20/26, they had not started clindamycin. The wound clinic provided R1 with a bottle of clindamycin to take back to the facility to ensure the appropriate antibiotic was administered. On 8/17/26 at 1:11 PM, Surveyor interviewed RN-H who indicated R1 did not have any documented medical orders until 7/20/26. RN-H indicated it was not usual practice for the hospital wound clinic to send medication with a resident. On 8/17/26 at 2:50 PM, Surveyor interviewed Unit Manager (UM)-E who was not aware of the delay in antibiotic administration for R1. UM-E indicated the facility uses an E-Fax system for providers' orders and was not sure how the oversight occurred. UM-E verified it was not usual practice for a resident to receive medication from the wound clinic.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R1) of 4 sampled residents. Staff did not wear gowns while providing personal care for R1 who was on enhanced barrier precautions (EBP) for a wound with methicillin-resistant Staphylococcus aureus (MRSA). Findings include: The facility's Enhanced Barrier Precautions policy, dated 1/2026, indicates: .1. Enhanced barrier precautions (EBP) are used as an infection control intervention to reduce the spread of multidrug-resistant organisms (MDROs) to residents. 2. EBP employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply .3. EBP is indicated for residents with wounds .4. Examples of high-contact resident care activities requiring the use of a gown and gloves for EBP include: .e. changing briefs or assisting with toileting . On 8/17/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had a diagnosis of MRSA and an open-to-the-bone toe wound. A Minimum Data Set (MDS) assessment, dated 5/11/26, stated R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. On 8/17/26, Surveyor reviewed R1's medical record. R1 was on EBP for an open-to-the-bone toe wound with MRSA. On 8/17/26 at 11:12 AM, Surveyor observed Certified Nursing Assistant (CNA)-C toilet R1 without wearing a gown. On 8/17/26 at 11:20 AM, Surveyor interviewed CNA-C who indicated Licensed Practical Nurse (LPN)-D told them personal protective equipment (PPE) for EBP should only be worn during wound care. On 8/17/26 at 11:38 AM, Surveyor interviewed LPN-D who verified they instructed CNA-C that a gown was only needed when providing wound care for residents on EBP. LPN-D reviewed the facility's EBP sign and confirmed a gown and gloves should be worn during toileting. On 8/17/26 at 2:50 PM, Surveyor interviewed Unit Manager (UM)-E who indicated staff should wear a gown and gloves for high-contact care activities, including toileting, when caring for residents on EBP.

Based on observation, interview, and record review, the facility did not ensure physician recommendations were followed for 1 resident (R) (R5) of 1 sampled resident from a total sample of 5 residents.R5 did not receive physician recommended shoes to aid in wound healing. In addition, staff did not monitor R5 for factitious disorder/picking behaviors to prevent further foot trauma.Findings include:The facility's Prevention of Pressure Injuries policy, revised June 2023, indicates: .Do not rub or otherwise cause friction on skin that is at risk for pressure injuries.The facility's Pressure Ulcers/Skin Breakdown policy, revised January 2026, indicates: .The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as .macerated or friable skin .The physician will help identify medical interventions related to wound management .The physician will guide the care plan as appropriate .Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident or a substitute decision-maker.Per the National Library of Medicine, last updated June 17, 2026, Venous Leg Ulcer authored by [NAME]-[NAME], [NAME] Jaar, and [NAME] Kimyaghalam indicates arterial ulcers, caused by tissue ischemia, normally appear as deep, dry wounds affecting the toes, foot dorsum, and the anterior aspect of the leg, with abnormal distal pulses, ABPI, and cold extremities. https://www.ncbi.nlm.nih.gov/books/NBK567802/R5 had a diagnosis of Parkinson's disease. A Minimum Data Set (MDS) assessment, dated 4/14/26, indicated R5 was at risk for pressure injuries but did not have any skin injury/concerns. The assessment also indicated R5 had moderately impaired cognition. A facility-provided resident matrix indicated R5 had a pressure injury.R5's medical record contained the following weekly wound assessments of the right hallux (bunion):~ An assessment on 5/18/26 described the area as a pressure injury (not staged) that measured 0.9 centimeters (cm) (length) x 0.9 cm (width) x 0.1 cm (depth). The physician was notified. Treatment was initiated, including an antibiotic. The assessment indicated R5's shoes appeared to be rubbing and they agreed to wear gripper socks until the area was healed. ~ An assessment on 5/26/26 described the wound as a pressure injury (not staged) that measured 0.7 cm x 0.8 cm with no depth and scant serosanguinous drainage. ~ An assessment on 6/2/26 described the wound as a pressure injury (not staged) that measured 0.7 cm x 0.9 cm with no depth and no drainage. The area was firm with no redness. The assessment indicated R5 no longer wore shoes that fit too tightly and mostly wore grippy socks. ~ An assessment on 6/9/26 described the wound as a pressure injury (not staged) that measured 0.7 cm x 0.8 cm with no depth and no drainage. ~ An assessment on 6/19/26 indicated the wound was arterial and measured 1.2 cm x 1 cm x 0.1 cm, with low serous drainage and autolysis. The wound size was expected to increase. Compression wraps were in place. ~ An assessment on 6/23/26 indicated the wound was arterial and measured 0.5 cm x 0.7 cm x 0.1 cm with low clear drainage. Compression wraps were in place. ~ An assessment on 6/30/26 indicated the wound was arterial and measured 0.5 cm x 0.8 cm x 0.1 cm with low clear drainage. Compression wraps were in place. ~ An assessment on 7/7/26 indicated the wound was arterial and measured 0.7 cm x 0.7 cm x 0.1 cm with low clear drainage and epibole (sign that healing has stalled or become impaired). Redness extended approximately 2 cm beyond the wound edge and was painful to the touch. Compression wraps were in place. The assessment indicated staff would contact the wound clinic regarding the pain and redness. ~ An assessment on 7/13/26 indicated the wound was arterial and measured 0.6 cm x 0.7 cm x 0.1 cm with moderate clear drainage. A second assessment on the same day indicated the wound was trauma and measured 0.6 cm x 0.7 cm x 0.1 cm with moderate clear drainageA wound center note on 7/13/26 indicated the etiology of R5's ulcers were uncertain. The note indicated some of wounds may be due to factitious disorder/picking behavior or from traumatic injuries as a result of R5 self-propelling a wheelchair. The lesions on the toes and foot were on pressure points/prominent bony surfaces suggesting friction from footwear that may be too tight. The note indicated R5 should not be allowed to wear shoes until the wounds completely healed. Shoes worn after the wounds healed should be properly sized with a wide toebox. Given the suspicion regarding factitious disorder/picking behavior, R5 should be monitored.An undated skin integrity care plan printed on 7/16/26 indicated R5 had actual impairment to skin integrity related to a history of pressure ulcers and had the potential for further pressure ulcer development related to immobility and incontinence. R5 should be encouraged to wear grippy socks but preferred tennis shoes and grippy socks. R5 should avoid scratching by keeping hands and body parts from excessive moisture and fingernails short. The care plan also indicated R5 was at high risk for skin injury and staff should use extra caution during transfers and bed mobility to prevent striking R5's arms, legs, and hands against sharp or hard surfaces. An undated activity of daily living (ADL) care plan printed on 7/16/26 indicated R5 required physical assistance with transfers. The care plan did not indicate R5 had factitious disorder/picking behavior or that R5 injured or had the potential to injure themself by self-propelling a wheelchair. The care plan did not contain monitoring interventions for factitious disorder/picking behavior.On 7/16/26 at approximately 11:30 AM, Surveyor interviewed R5 who was wearing shoes and socks. R5 stated the shoes could have caused their bunion and indicated the right shoe was tighter than the left shoe. Surveyor observed a bunion bulging from the side of R5's right shoe.On 7/16/26 at 2:52 PM, Surveyor interviewed wound clinic Advanced Practice Nurse Practitioner (APNP)-E who stated the wound clinic was not calling R5's wound a pressure injury because it was clear that while the injury was on a bony prominence, the injury was caused from shoes or the bed rubbing on the area. APNP-E stated R5 should definitely not be wearing shoes.On 7/16/26 at 3:10 PM, Surveyor and Wound Nurse Consultant (WNC)-D observed R5 in their room. WNC-D confirmed R5 was wearing shoes. WNC-D removed the shoes, put socks on R5, and stated, We do not want to have pressure at the end of those toes. Surveyor pointed out an area on the top of R5's foot where the edge of the shoe had been and where the skin was peeled back.On 7/16/26 at 4:04 PM, Surveyor interviewed WNC-D who stated R5's right bunion was an arterial wound, not a pressure injury. WNC-D stated the bunion could have resulted from light friction or being bumped, but the etiology was unknown. WNC-D stated R5's shoes seemed okay but removed them because the wound clinic suggested they not wear shoes. When Surveyor asked about the wound clinic's recommendation that R5 have shoes that were properly sized with a large toebox, WNC-D did not know if R5's shoes were properly fitted and did not know how to measure them for a large toebox. WNC-D contacted the wound clinic for instructions on how to ensure R5 had shoes that were properly fitted.On 7/16/26 at 4:06 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-F who stated R5 had a different pair of shoes that R5 stated rubbed on their toes. LPN-F thought R5's Power of Attorney had gotten them a new pair of shoes.On 7/16/26 at 4:40 PM, Surveyor interviewed R5's Emergency Contact (EC)-G who stated they had not gotten R5 new shoes. EC-G was uncertain how R5's bunion developed and stated if R5 needed new shoes, the facility could request them and EC-G would get them.

Based on observation, staff, resident, represenatative interview, and record review, the facility did not ensure the resident enviornment was as free of accident hazards as possible for 2 residents (R) (R10 and R15) of 3 sampled residents. In addition, the facility did not ensure 2 residents (R6 and R18) of 2 sampled residents had behavioral interventions and were adequately supervised. R10 had a fall with injury on 4/24/26. The facility did not update R10's care plan post-fall. R15 had a fall with injury on 6/2/26. The facility did not complete post-fall assessments, provide prompt or appropriate medical care, implement falls interventions, or notify the required parties. R6 and R18 were known to wander into other residents' rooms uninvited. R6 and R18's care plans did not contain interventions to address wandering or appropriate levels of supervision. Findings include: The facility's Care Planning-Interdisciplinary Team policy, revised January 2026, indicates: The Interdisciplinary Team (IDT) is responsible for the development of resident care plans .Comprehensive, person-centered care plans are based on resident assessments and developed by the IDT. The IDT includes but is not limited to: the resident's attending physician; a registered nurse with responsibility for the resident; a nursing assistant with responsibility for the resident; a member of the food and nutrition services staff; to the extent practicable, the resident and/or the resident's representative; and other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident. The resident, the resident's family, and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan . The facility's Goals and Objectives, Care Plans policy, revised January 2026, indicates: Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .Care plans will be modified accordingly. Care plan goals and objectives are .resident oriented; behaviorally stated and measurable; and contain timetables to meet the resident's needs .Goals and objectives are reviewed and/or revised: when there has been a significant change in the resident's condition; when the desired outcome has not been achieved; when the resident has been readmitted to the facility from a hospital/ rehabilitation stay; and at least quarterly. The facility's Assessing Falls and Their Causes policy, revised January 2026, indicates: The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .Review the resident's care plan to assess any special needs of the resident .Residents must be assessed upon admission and regularly afterward for potential risk of falls. Relevant risk factors must be addressed promptly .After a fall: If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. Obtain and record vital signs as soon as it is safe to do so .Notify the resident's attending physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, notify the practitioner immediately by phone. When a fall does not result in significant injury or a condition change, notify the practitioner routinely (e.g., by fax or by phone the next office day). Observe for delayed complications of a fall for approximately 48 hours after an observed or suspected fall and document findings in the medical record. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function .Complete an incident report for resident falls no later than 24 hours after the fall .Within 24 hours of a fall, begin to try to identify possible or likely causes of the incident .and/or whether there is a pattern of falls for this resident .When a resident falls, the following information should be recorded in the resident's medical record: The condition in which the resident was found; assessment data, including vital signs and any obvious injuries; interventions, first aid, or treatment administered .Completion of a falls risk assessment. Appropriate interventions taken to prevent future falls . 1. R10 had diagnoses including Alzheimer's disease, dementia, and repeated falls. R10's Minimum Data Set (MDS) assessment, dated 3/22/26, stated R10 had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition. R10 had an activated Power of Attorney (POA). A care plan, revised 3/27/26, indicated R10 was at high risk for falls related to immobility, history of falls, dizziness, and giddiness. The last intervention added to the care plan indicated the blinds should be closed when dark outside and open when light outside (dated 11/4/25). A progress note, dated 4/24/26, indicated staff found R10 found face down on the floor of the bathroom with a bedside toilet seat caught in R10's brief and pajamas. R10 was bleeding from a gash on the left side of the forehead. R10's left eye was swollen and bruised and R10 had skin tears to both elbows. The bed alarm did not sound but was in place and working properly. Immediate interventions were to encourage R10 to use the call light for assistance and ensure the bed alarm was functioning properly. (Of note: There were no fall interventions added after R10's care plan follwing the fall.) A fall report, dated 4/24/26, contained the same information as the progress note above and also indicated an assessment was completed, 911 was called, and R10 was sent to the Emergency Department (ED). Injuries reported post incident - none identified. Predisposing environmental factors - none identified. Predisposing physiological factors identified were confusion, gait imbalance, impaired memory, and incontinence. Predisposing situation factors were identified as a walker. Other information indicated R10's wheelchair was in front of the bed and walker was in front of the sink in the bathroom. A Hospital After Visit Summary, dated 4/24/26, indicated R10 had a laceration on the left forehead, skin tears on the forearm and upper left arm, a hemorrhage on the inside of the eye, and a contusion on the face. On 6/1/26 at 12:09 PM, Surveyor observed R10 in the dining room with a bandage on the left side of their forehead. On 6/1/26 at 12:38 PM, Surveyor interviewed Power of Attorney (POA)-R who expressed concern that a bed alarm did not sound when R10 got out of bed and fell. POA-R indicated R10 might have gotten up to use the bathroom and required assistance with ambulation. POA-R indicated R10's facial injuries were extensive and R10 was heavily bruised. POA-R did not know what the facility was doing to prevent future falls or injury. POA-R indicated staff tested R10's bed alarm and stated it was functioning properly. On 6/3/26 at 10:34 AM, Surveyor interviewed Director of Nursing (DON)-B who indicated falls are reviewed by the IDT and interventions are reviewed and revised in a residents's care plan following a fall. DON-B confirmed a fall intervention was not added to R10's care plan following the fall on 4/24/26. 2. R15 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, difficulty walking, and delirium due to known physiological condition. R15's MDS assessment, dated 4/23/26, stated R15 had a BIMS score of 6 out of 15, indicating severely impaired cognition. R15 had an activated POA. A care plan, dated 7/22/25, indicated R15 was at high risk for falls related to delirium and forgetfulness and right-sided weakness from cerebral infarction (stroke). The care plan contained interventions to follow the facility's fall protocol, review information on past falls and attempt to determine cause of falls, record possible root causes, and alter or remove potential causes if possible. The care plan indicated R15 had chair and bed alarms and staff should ensure they were in place and working correctly. On 6/2/26 at approximately 7:45 AM, Surveyor observed Certified Nursing Assistant (CNA)-Q push R15 in a wheelchair down the hallway. CNA-Q informed Registered Nurse (RN)-V that R15 required RN-V's attention. Surveyor observed RN-V provide wound care for R15's left arm and elbow. Surveyor interviewed R15 who stated, I slipped. After completing wound care, RN-V left R15 without further assessment to continue with medication pass. On 6/2/26 at 1:11 PM, Surveyor interviewed POA-S who expressed concern related to follow-up for R15's fall on the morning of 6/2/26. POA-S arrived at the facility at 10:40 AM and observed R15 at the nurses' station with a bandage on the left forearm. When POA-S asked what occurred, RN-V stated R15 must have bumped it. POA-S indicated RN-V just brushed it off. POA-S stated RN-T completed wound care for R15's left forearm and assessed R15. RN-T observed rug burn on R15's left knee and applied a bandage. POA-S indicated R15 could not accurately report what occurred due to cognitive deficit. POA-S attended an activity with R15 during which an activity aide told POA-S that R15 fell before breakfast. POA-S asked Regional Registered Nurse (RRN)-U about the fall. RRN-U indicated R15 fell near the front entrance of the facility and had likely gotten up and continued to walk to the dining area for breakfast. CNA-Q found R15 and informed RN-V that R15 needed assistance. There was blood on R15's arm and knee and a trail of blood from the dining area to the front entrance. POA-S was frustrated that the fall was not addressed properly and R15 did not receive adequate care following the fall. POA-S indicated R15's forearm and knee were not addressed until POA-S arrived hours later and noted the injuries. POA-S was also frustrated that RN-V did not tell POA-S the truth right away. On 6/3/26, Surveyor reviewed R15's medical record which did not contain a fall report, assessment, investigation, or neurological assessments for the unwitnessed fall that occurred on 6/2/26. Surveyor noted two progress notes, dated 6/2/26 and written by RN-T, that indicated R15's wounds were assessed and dressed and a progress note that indicated POA-S would speak with DON-B regarding the injuries. On 6/3/26 at 10:34 AM, Surveyor interviewed DON-B who indicated administration discussed the fall and concluded RN-V did not look into the fall or handle the fall correctly per policy. DON-B verified there was not a fall investigation, appropriate wound care, or notification. DON-B indicated a grievance was filed immediately for POA-S regarding notification of fall with injuries. On 6/3/26 at 1:31 PM, Surveyor interviewed CNA-Q who discovered R15 in the dining room with blood on the left arm and observed a trail of blood from R15 to the hallway. CNA-Q indicated R15 stated they had fallen. CNA-Q assisted R15 to their bedroom and informed RN-V that R15 had fallen and needed assistance. CNA-Q also informed Licensed Practical Nurse (LPN)-M and Social Services Director (SSD)-C of the incident. CNA-Q indicated LPN-M and SSD-C stated they believed that was where the blood by the front door came from. CNA-Q indicated R15 would have been able to get off the floor independently and stated if staff had noticed R15 on the floor, they would have provided assistance immediately. On 6/3/26 at 1:45 PM, Surveyor interviewed Regional Director of Clinical Services (RDCS)-W verified staff did not follow the facility's fall protocol for R10 and R15. 3. On 6/1/26 at 10:47 AM, Surveyor interviewed R38 who expressed concern that R6 frequently entered R38's room uninvited. R38 stated R6 entered their room at 12:30 AM that morning (6/1/26), turned on the light while R38 was sleeping, and stated the room belonged to R6. R38 indicated R6 entered their room approximately five times last week, including once in the middle of the night, and stated it was R6's daughter's room and R6 needed to get her up. R38 indicated R6 threated to call the police on R38 last week and in another incident indicated they needed to use R38's bathroom. R38 tried to redirect R6 to their room next door to use their own bathroom. R38 stated R6 used R38's bathroom instead and urinated all over the toilet and floor. R38 indicated their sleep is disrupted at night and they are in a private room and should have privacy. R38 stated staff remove R6 from the room, however, the incidents continue to occur and R38's privacy and personal space is not respected. (Of note: R38's MDS assessment, dated 5/14/26, indicated R38 had intact cognition.) R6's medicdal record indicated R6 had diagnoses including dementia, insomnia, and unspecified mood disorder. R6's MDS assessment, dated 5/20/26, stated R6 had a BIMS score of 14 out of 15, indicating intact cognition. A care plan, revised 2/3/25, indicated R6 had behavior problems, refused assistance, and did not use a call light appropriately due to dementia and poor safety awareness. The care plan indicated R6 liked to wander the facility freely and had a WanderGuard on the left ankle (initiated 2/19/25). The care plan contained an intervention to monitor behavior episodes and attempt to determine underlying cause .consider location, time of day, persons involved, and situations and document behavior and potential causes. A progress note, dated 5/17/26, indicated R6 had visual hallucinations, periods of anger and harm to others with a walker, and many attempts to exit the building. Surveyor did not observe any progress notes that indicated R6 wandered into others' rooms and required redirection or that the IDT discussed behavioral interventions and/or care plan updates/interventions for behavioral concerns and wandering. During a Resident Council meeting at 1:00 PM on 6/2/26, R7 expressed concern that R6 entered their room uninvited. R7 indicated it happened at least three times and they changed rooms due to the disturbances. (Of note: R7's MDS assessment, dated 5/6/26, indicated R7 had moderately impaired cognition.) On 6/2/26 at 1:21 PM, Surveyor interviewed CNA-Q who stated R6 pulls clothing out of their closet during the day and requires assistance with putting the clothing back in. CNA-Q indicated R6's behavioral concerns have increased during the evening and night hours, including entering other residents' rooms uninvited. CNA-Q indicated R18 enters other residents' rooms all the time and there really isn't much we can do. CNA-Q indicated when R6 enters other residents' rooms, staff redirect R6. CNA-Q was not aware of any other interventions to prevent the behavior. (See additional interview under example 4.) 4. On 6/2/26, Surveyor reviewed the facility's grievance file and noted R33 submitted a grievance on 4/1/26 that indicated R33 was asleep in a dark room and awoke to find (R18) standing in the room with what appeared to be a candy wrapper in their hand. R33 yelled for (R18) to get out of room. (R18) began to leave and then came back. R33 activated the call light for assistance and again told (R18) to leave. (R18) left the room prior to staff arriving. The grievance form indicated R18 entered another resident's room the day prior (3/31/26). The resolution indicated staff would continue to redirect R18 from entering others' rooms and the facility would look into stop signs to prevent residents from entering other residents' rooms. The date completed was 4/25/26. R18's medical record indicated R18 had diagnoses including frontotemporal neurocognitive disorder (umbrella term for a group of progressive brain diseases that damage the frontal and temporal lobes, affecting personality, behavior, language, and sometimes movement) and panic attacks. R18's MDS assessment, dated 5/7/26, stated R18 had a BIMS score of 2 out of 15, indicating severely impaired cognition. A care plan, revised 11/26/25, indicated R18 was an elopement/wander risk and had a history of putting themself in other residents' rooms/beds when wandering (dated 9/21/25). The care plan contained an intervention to identify pattern of wandering and intervene as appropriate (dated 8/1/25). On 6/2/26 at 10:10 AM, Surveyor interviewed R33 who indicated they submitted a formal grievance due to R18 entering their room. R33 recalled the incident and stated it scared me. R33 stated the incident occurred in the early morning while it was still dark and R33 awoke to find R18 standing over them and staring at them with a candy wrapper in hand. R33 shouted twice at R18 to get out of the room, however, R18 left and came back. R33 used the call light the second time when R18 didn't leave but stated R18 eventually left before staff arrived. R33 indicated R18 frequently enters others' rooms uninvited. R33 stated staff are aware and redirect R18, however, nothing is done to prevent it. R33 stated R18 is calm and quiet during the day, roams the halls, and does not enter others' rooms until late afternoon or later. R33 indicated R18 chases people around. R33 thought R18 follwed R33 in common areas of the facility after the incident which frightened R33 to the point that R33 does not like to come out of R33's room at all due to feeling watched and pursued by R18. R33 indicated staff told them R18 has a mind of a child and is harmless. R33 stated the incidents have made them more secluded and they do not feel safe to freely move about the facility. R33 indicated there aren't stop signs on doors or other deterrents to keep others from entering rooms aside from staff redirection. R33 indicated the incident felt like an invasion of my privacy. R33 stated the incidents are not handled appropriately and R33 was told R18 had a right to move freely in the facility and outside of R18's room. R33 stated they have a right to feel safe in their home which they feel is not being considered. R33 stated the facility should do something before something bad happens to someone. (Of note: R33's MDS assessment, dated 3/19/26, indicated R33 had moderately impaired cognition.) During a Resident Council meeting at 1:00 PM on 6/2/26, R23 stated R18 is constantly in and out of my room. R23 state it is scary and indicated residents who wander were previously on a secured unit and did not have access to other units without assistance. (Of note: R23's MDS assessment, dated 5/28/26, indicated R23 had intact cognition.) On 6/3/26 at 10:05 AM, Surveyor conducted an abbreviated tour of the facility and did not observe stop signs on residents' doors or in hallways. On 6/3/26 at 10:34 AM, Surveyor interviewed DON-B who was not aware R6 and R18 frequently entered other residents' rooms which was a concern for other residents. DON-B indicated concerns are addressed in IDT meetings and interventions are discussed and implemented. DON-B reviewed R6 and R18's care plans and confirmed they did not contain updated interventions for supervision or to assist in the prevention of entering other residents' rooms. DON-B indicated the grievance form filled out by R33 would need follow-up by the IDT. DON-B indicated if the incident occurred, the resolution should be in R33's care plan and R18's behavior should be monitored through behavioral tracking which was not occurring for R6 or R18. DON-B stated DON-B would investigate further to find updated care plan interventions and IDT notes. (Of note: Surveyor did not receive updated care plan interventions or IDT notes for R6 or R18.)

Based on staff interview and record review, the facility did not ensure vaccines were offered for 2 residents (R) (R2 and R7) of 5 sampled residents.R2 was not offered the influenza vaccine in accordance with the facility's policy.R7 was not offered the PCV20 vaccine in accordance with the facility's policy.Findings include: The facility's Influenza Vaccine policy, revised January 2026, indicates: All residents .who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza .between October 1st and March 31st each year, the influenza vaccine shall be offered to residents. The facility's Pneumococcal Vaccine policy, revised Janauary 2026, indicates: All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections .upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series and when indicated, are offered the vaccine series within 30 days of admission to the facility unless medically contraindicated. 1 . R2 was admitted to the facility on [DATE] and had diagnoses including dementia, hand fracture, and anxiety. R2's Minimum Data Set (MDS) assessment, dated 4/16/26, stated R2 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. R2 was their own healthcare decision maker. On 6/3/26, Surveyor reviewed R2's immunization records and noted R2 signed consent to receive the pneumococcal vaccine on 4/15/25. Surveyor reviewed R2's immunizations in the facility's electronic health record as well as the Wisconsin Immunization Registry (WIR) and did not see any pneumonia vaccinations provided. (See interview under example 2.) 2. R7 was admitted to the facility on [DATE] and had diagnoses including femur fracture, diabetes, and pressure injuries. R7's MDS assessment, dated 3/24/26, stated R7 had a BIMS score of 15 out of 15, indicating intact cognition. R7 was their own healthcare decision maker. On 6/3/26, Surveyor reviewed R7's immunization records and noted R7 signed consent to receive the influenza vaccine on 12/17/25. Surveyor reviewed R7's immunizations in the facility's electronic health record as well as the WIR and did not see any influenza vaccinations provided during the 2025-2026 influenza season. On 6/3/26 at 10:04 AM, Surveyor interviewed Director of Nursing (DON)-B who could not provide documentation/evidence that R2 received a pneumococcal vaccine or R7 received an influenza vaccine in accordance with the facility's policy.

Based on staff interview and record review, the facility did not ensure a comprehensive care plan was developed and implemented for 1 resident (R) (R7) of 14 sampled residents. R7 had orders for oxygen use and Hospice care. R7's care plan did not contain goals or interventions to address R7's dependence on oxygen and potential for airway disturbance or need for Hospice care. Findings include: The facility's Individual Care Plans-Baseline policy, dated 1/2026, indicates: .The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident, including but not limited to, the following: .b. Physician orders . R7 was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), acute and chronic heart failure, and pressure ulcers. R7's Minimum Data Set (MDS) assessment, dated 5/18/26, stated R7 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R7 had an activated Power of Attorney for Healthcare (POAHC). R7's medical records contained the following orders: ~ Change oxygen (O2) tubing and nasal cannula every night shift, every Thursday (dated 5/28/26)~ 2 liters/minute (LPM) oxygen via nasal cannula to maintain O2 saturation level greater than 90% as needed for hypoxia (dated 4/24/26)~ Admit to Hospice care (dated 5/8/26) On 6/1/26 at 10:13 AM, Surveyor observed R7 in bed using oxygen at 2 LPM via nasal cannula. R7 indicated they used oxygen at all times. On 6/2/26, Surveyor reviewed R7's care plan which didn't contain goals or interventions to address R7's dependence on oxygen and potential for airway disturbance or R7's need for Hospice care. On 6/3/26 at 11:48 AM and 1:38 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated R7's care plan should include interventions for oxygen use and Hospice care. DON-B stated the facility was aware care plans needed to be updated and would work to complete the updates.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R7 and R23) of 3 sampled residents were offered the opportunity to create or obtain Power of Attorney for Healthcare (POAHC) paperwork. R7 was admitted to the facility on [DATE]. The facility did not obtain R7's POAHC document or offer R7 the chance to fill out a new document prior to 6/1/26. R23 was admitted to the facility on [DATE]. The facility did not obtain R23's POAHC document or offer R23 the chance to fill out a new document prior to 6/1/26. Findings include: The facility's Advanced Directive policy and procedure, dated January 2026, indicates: .1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .8. If the resident indicates that he or she has not established advance directives, facility staff will offer assistance in establishing advance directives . 1. R7 was admitted to the facility on [DATE]. R7's medical record did not contain a POAHC document with witness signatures or a POAHC refusal document. (See interview under example 2.) 2. R23 was admitted to the facility on [DATE]. R23's medical record did not contain a POAHC document or a POAHC refusal document. On 6/2/26 at 3:34 PM and 6/3/26 at 12:47 PM, Surveyor interviewed Social Services Director (SSD)-C who indicated if a POAHC document does not contain witness signatures, the document is not valid. SSD-C verified R7's POAHC document was not valid and indicated SSD-C would work with R7 to complete a new document. SSD-C indicated the facility did not have a POAHC document on file for R23. SSD-C indicated advance directives are discussed at the time of admission and if a resident wants to fill one out, assistance is provided. SSD-C indicated they do not provide follow-up to verify completion. On 6/3/26 at 10:53 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff should obtain a copy of a resident's POAHC document or offer the resident the opportunity to create a new POAHC document upon admission.

Based on staff and resident interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when they did not ensure an allegation of misappropriation was reported to the State Agency (SA) or local police for 1 resident (R) (R14) of 1 sampled resident. R14's wallet went missing after 4/15/26. The facility did not report the allegation of misappropriation to the SA or local police. Findings include: The facility's Abuse, Neglect, Exploitation, and Misappropriation Policy, revised April 2021, indicates: Residents have the right to be free from .misappropriation of resident property .the facility will implement policies and protocols to prevent and identify .theft, exploitation, or misappropriation of resident property .identify and investigate all possible incidents of .misappropriation of resident property .investigate and report any allegations within the timeframes required by federal requirements. R14 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, insomnia, and history of stroke. R14's Minimum Data Set (MDS) assessment, dated 4/14/26, stated R14 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. On 6/3/26 at 9:38 AM, Surveyor asked Certified Nursing Assistant (CNA)-D if any residents were missing a wallet. CNA-D indicated R14's wallet was missing a few weeks ago. CNA-D was not sure if the wallet was found. On 6/3/26 at 9:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who heard R14 was missing a wallet with money. LPN-E stated R14 misplaced things but staff always found them. LPN-E was not sure if R14's wallet was found. On 6/3/26 at 10:07 AM, Surveyor interviewed Staffing Coordinator (SC)-F who indicated R14's wallet was reported missing to Social Services Director (SSD)-C a few weeks ago by a CNA or housekeeper. SC-F regularly worked the floor and stated R14 misplaced things, however, staff always found the items in R14's room. When SC-F was told by SSD-C that R14's wallet was missing, SC-F went to R14's room to search for the wallet. On 6/3/26 at 10:27 AM, Surveyor interviewed SSD-C who indicated a staff member reported that R14's wallet was missing. SSD-C asked R14 to describe the wallet and if there was any money in it. SSD-C stated R14 indicated there was between $100 and $900 in the wallet. SSD-C asked if R14 wanted to file a grievance but R14 declined. SSD-C indicated the allegation of misappropriation was not reported to the SA or the local police. On 6/3/26 at 10:36 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who became aware of the missing wallet a couple weeks ago. NHA-A confirmed R14 often misplaced items. NHA-A indicated R14's missing wallet was not reported to the SA or local police because R14 did not allege theft, only that the wallet was missing. On 6/3/26 at 1:19 PM, Surveyor interviewed R14 regarding the missing wallet. R14 verified the wallet was missing and contained $900 which was now gone. R14 believed the money was stolen. On 6/3/26 at 1:22 PM, Surveyor interviewed Personal Care Worker (PCW)-G who visited R14 every week to assist with errands and appointments. PCW-G stated they brought R14 to the bank on 4/15/26 to withdraw $1000. PCW-G indicated R14 liked to stash things but always put items in the same few spots. On 6/3/26 at 1:25 PM, PCW-G located R14's wallet in a dresser drawer. Surveyor observed a receipt in the wallet from a local bank for a withdrawal of $1000. Surveyor did not observe any money in the wallet or in the dresser drawer. R14 verified it was R14's wallet and the money was missing.

Based on staff and resident interview and record review, the facility did not ensure an allegation of misappropriation was thoroughly investigated for 1 resident (R) (R14) of 1 sampled resident. R14's wallet went missing after 4/15/26. The facility did not thoroughly investigate the allegation of misappropriation or report the findings to the State Agency (SA). Findings include: The facility's Abuse, Neglect, Exploitation, and Misappropriation Policy, revised April 2021, indicates: Residents have the right to be free from .misappropriation of resident property .the facility will implement policies and protocols to prevent and identify .theft, exploitation, or misappropriation of resident property .identify and investigate all possible incidents of .misappropriation of resident property .investigate and report any allegations within the timeframes required by federal requirements. R14 was admitted to the facility on [DATE] and had diagnoses including Parkinson's disease, insomnia, and history of stroke. R14's Minimum Data Set (MDS) assessment, dated 4/14/26, stated R14 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderately impaired cognition. On 6/3/26 at 9:38 AM, Surveyor asked Certified Nursing Assistant (CNA)-D if any residents were missing a wallet. CNA-D indicated CNA-D heard R14 was missing a wallet a few weeks ago. CNA-D was not sure if the wallet was found. On 6/3/26 at 9:45 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who confirmed they heard R14 was missing a wallet with money. LPN-E stated R14 sometimes misplaced things but staff always find them. LPN-E was not sure if R14's wallet was found. On 6/3/26 at 10:07 AM, Surveyor interviewed Staffing Coordinator (SC)-F who indicated R14's wallet was reported missing to Social Services Director (SSD)-C a few weeks ago by a CNA or housekeeper. SC-F regularly worked with R14 and stated R14 misplaced things often, however, the items were always found in R14's room. When SC-F was told by SSD-C that R14's wallet was missing, SC-F went to R14's room to search for the wallet. On 6/3/26 at 10:27 AM, Surveyor interviewed SSD-C who indicated a staff member reported that R14's wallet was missing. SSD-C asked R14 to describe the wallet and if there was any money in it. SSD-C stated R14 indicated the wallet contained between $100 and $900. SSD-C asked if R14 wanted to file a grievance, however, R14 declined. SSD-C did not have documentation to show evidence of an investigation. On 6/3/26 at 10:36 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated they became aware of R14's missing wallet a couple weeks ago and was aware that R14 often misplaced items. NHA-A indicated any documentation/investigation was SSD-C's responsibility. On 6/3/26 at 1:19 PM, Surveyor interviewed R14 who verified the wallet was missing and contained $900 which was now gone. R14 believed the money was stolen. On 6/3/26 at 1:22 PM, Surveyor interviewed Personal Care Worker (PCW)-G who visited R14 every week to assist with errands and appointments. PCW-G stated they brought R14 to the bank on 4/15/26 to withdraw $1000. PCW-G indicated R14 liked to stash things but always put things in the same few spots. On 6/3/26 at 1:25 PM, PCW-G found R14's wallet in a dresser drawer. Surveyor observed a receipt in the wallet from a local bank for a withdrawal of $1000. Surveyor did not observe any money in the wallet or dresser drawer. R14 verified the wallet was R14's and the money was missing.

Based on staff interview and record review, the facility did not ensure proper discharge procedures and/or a written transfer or bed hold notice was provided to 3 residents (R) (R43, R8, and R41) of 3 sampled residents. R43 discharged from the facility on 4/10/25. R43's medical record did not contain a recapitulation of stay, confirmation of discharge against medical advice (AMA), indicate discharge orders were received from R43's primary care physician, or indicate education and further services were offered prior to discharge.R8 was transferred to the hospital on 2/23/26 and 4/29/26. R8's medical record did not contain written transfer or bed hold notices.R41 was transferred to the hospital on 4/5/26. R41's medical record did not contain a written transfer or bed hold notice. Findings include: The facility's policy Bed-Holds and Return policy, revised January 2026, indicates: .All residents/representatives are provided with written information regarding facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice. Notice 1: Well in advance of any transfer (e.g., in the admission packet); and Notice 2: At the time of transfer (or, if the transfer was an emergency, within 24 hours) .Multiple attempts to provide the resident representative with notice 2 should be documented in cases where staff are unable to reach and notify the representative timely. Written bed-hold notices provided to residents/representatives explain in detail: The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the facility; the reserve bed payment policy as indicated by the state plan (for Medicaid residents); the facility policy regarding bed-hold periods; the facility per-diem rate required to hold a bed (for non-Medicaid residents), or to hold a bed beyond the state bed-hold period (for Medicaid residents); and the facility's return policy, the requirement that residents be permitted to return to the facility following hospitalization or therapeutic leave applies to all residents regardless of payer source . The facility's Discharge Summary policy, revised January 2026, indicates: The discharge summary includes a recapitulation of the resident's stay and a final summary of the resident's status at the time of the discharge .Every resident is evaluated for his/her discharge needs and has an individualized post-discharge plan. The post-discharge plan is developed by the care planning/Interdisciplinary Team (IDT) with the assistance of the resident and his/her family and includes: where the individual plans to reside; arrangements that have been made for follow-up care and services; a description of the resident's stated discharge goals; the degree of caregiver/support person availability, capacity, and capability to perform required care; how the IDT will support the resident or representative in the transition to post-discharge care; what factors may make the resident vulnerable to preventable readmission; and how those factors will be addressed . 1. R43 was admitted to the facility on [DATE] for rehabilitation and had diagnoses including sepsis, gross hematuria, and congestive heart failure. R43's Minimum Data Set (MDS) assessment, dated 4/21/26, stated R43 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R43 was their own decision maker. R43's medical record indicated R43 discharged from the facility on 4/10/25. A progress note, dated 4/10/26, indicated R43 left the facility AMA at 5:30PM with their belongings. R43's medical record did not contain a recapitulation of stay, services offered prior to discharge, confirmation if R43 was discharged AMA, if discharge orders were received from primary care physician (PCP)-O, or if education was offered prior to discharge. On 6/3/26 at 10:01 AM, Surveyor interviewed Hospital Social Worker (HSW)-N who indicated PCP-O sent orders for R43 to be seen at the emergency room (ER) on 4/9/26 because R43 had shortness of breath and an oxygen saturation level of 87%, however, R43 did not go to the ER. HSW-N indicated there was concern when R43 did not go to the ER and PCP-O's office contacted the facility for follow-up. HSW-N indicated R43's medical record at the physician's office indicated the facility informed PCP-O's office on 4/17/26 that R43 left the facility, however, the facility did not know what day R43 left and thought R43 left AMA. HSW-N indicated R43's medical record at the physician's office did not contain an order from PCP-O to discharge R43 from the facility. Surveyor requested R43's medical record from PCP-O's office. On 6/3/26 at 11:46 AM, Surveyor interviewed Social Services Director (SSD)-C who indicated R43 was admitted to the facility on [DATE] from the hospital for rehabilitation. SSD-C was not working the day R43 left and recalled being told the discharge was a really weird situation and R43 indicated they were leaving the facility, R43 indicated to nursing staff that R43 did not need to be at the facility. Licensed Practical Nurse (LPN)-M obtained discharge orders from PCP-O. A discharge progress note was entered which indicated R43 left AMA. SSD-C indicated if a resident leaves AMA, the facility has the resident sign AMA paperwork. SSD-C confirmed R43's medical record did not contain signed AMA paperwork or signed discharge orders. On 6/3/26 at 11:59 AM, Surveyor interviewed LPN-M who called PCP-O's office and received a telephone order to discharge R43 from the facility on 4/10/26 otherwise R43 was going to leave the facility AMA. LPN-M indicated R43 was homesick and was visiting with family at the facility when R43 stated R43 no longer needed to be at the facility and requested family take them home. LPN-M showed Surveyor an order in R43's medical record, dated 4/10/26 and entered 4/13/26, from PCP-O to discharge R43 from the facility. LPN-M was not sure why the order was dated 4/10/26 but was entered on 4/13/26. LPN-M verified the order was a phone order and there was not a signed discharge order in R43's medical record. On 6/3/26 at 1:30 PM, Surveyor reviewed R43's medical record from Hospital (HSP)-Y and noted the following: ~ A summary note, dated 4/9/26, indicated PCP-O's office received a call from the facility at 11:10 AM that R43 was short of breath and had a low oxygen (O2) saturation level of 87%. PCP-O gave an order for R43 to be seen in the ER. The order was hand-delivered to Former Director of Nursing (FDON)-P. ~ Phone log documentation from PCP-O's office indicated PCP-O called the facility on 4/17/26 to follow-up on why R43 did not go to the ER. PCP-O's office phone log indicated the facility stated R43 left AMA but were unsure when R43 left. PCP-O's office called R43 at home. R43 stated they left the faciity on 4/9/26. On 6/3/26 at 3:26 PM, Surveyor interviewed FDON-P who indicated R43 experienced shortness of breath and a low O2 saturation level on 4/9/26 and refused to be seen in the ER. FDON-P indicated R43 was visiting with family the next day and indicated R43 was leaving the facility and did not need to be there for care. FDON-P indicated LPN-M received a phone order from PCP-O to discharge R43. FDON-P indicated R43 indicated they were going to leave AMA prior to LPN-M receiving phone order. FDON-P indicated a phone order was received for discharge and PCP-O was updated at that time. FDON-P was unsure what documentation or discharge processes were conducted following the phone order for discharge. 2. R8 had diagnoses including gastrointestinal bleeding and cellulitis. R8's MDS assessment, dated 5/28/26, stated R8 had a BIMS score of 15 out of 15, indicating intact cognition. R8 was their own decision maker. R8's medical record indicated R8 was transferred to the hospital on 2/23/26 for concerns of abnormal vital signs post-fall and possible gastrointestinal bleeding. R8 was also transferred to the hospital on 4/29/26 for chest pain. R8's medical record did not contain a written transfer or bed-hold notice for either transfer. On 6/3/26, Surveyor requested a copy of R8's written transfer and bed-hold notices for 2/23/26 and 4/29/26 from Nursing Home Administrator (NHA)-A. On 6/3/26 at 9:54 AM, NHA-A confirmed R8 was not provided a written transfer or bed-hold notice for the hospital transfers on 2/23/26 and 4/29/26. 3. R41 was admitted to the facility on [DATE] and had diagnoses including heart disease, atrial fibrillation, panic disorder, and post-traumatic stress disorder (PTSD). R41's MDS assessment, dated 1/25/26, stated R41 had a BIMS score of 15 out of 15, indicating intact cognition. R41 was their own decision maker. R41's medical record indicated R41 was transferred to the hospital on 4/5/26. A progress note, dated 4/7/26, indicated R41 was admitted to the hospital. R41's medical record did not contain a written transfer or bed-hold notice for the hospital transfer. On 6/3/26 at 1:32 PM, Surveyor interviewed NHA-A who indicated NHA-A could not provide written transfer or bed hold notices for R43, R8, or R41. NHA-A recognized there was a process concern with transfers/discharges and stated NHA-A would educate staff on the proper procedure.

Based on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 2 residents (R) (R21 and R15) of 7 sampled residents. R21 was on contact precautions which required staff to don a gown and gloves prior to room entry. Registered Nurse (RN)-L did not don a gown and gloves prior to entering R21's room to provide medication. RN-L did not complete hand hygiene in accordance with the facility's policy during wound care for R15. Findings include: The facility's Handwashing/Hand Hygiene policy, indicates: .This facility considers hand hygiene the primary means to prevent the spread of infections .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap .and water for the following situations: .Before and after direct contact with residents; Before preparing or handling medications; Before performing any non-surgical invasive procedures; .Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; After handling used dressings, contaminated equipment, etc.; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves; Before and after entering isolation precaution settings .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: Before aseptic procedures; When anticipating contact with blood or body fluids; and When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions . The facility's Isolation-Initiating Transmission-Based Precautions policy indicates: Transmission-Based Precautions (TBP) are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents .When TBP is implemented, the Infection Preventionist (or designee): a. Clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used; .Determines the appropriate notification on the room entrance door and on the front of the resident's chart so personnel and visitors are aware of the need for and type of precautions: 1. Signage informs the staff of the type of precautions, instructions for use of PPE, and/or instructions to see a nurse before entering the room .Ensures protective equipment is maintained outside the resident's room so anyone entering the room can apply the appropriate equipment .Ensures protective equipment and supplies needed to maintain precautions during care are in the resident's room; . R21 was admitted to the facility on [DATE] and had diagnoses including type 2 diabetes mellitus and C-difficile (highly contagious bacterium that causes diarrhea and colitis). According to a Centers for Disease Control and Prevention (CDC) Contact Precautions sign posted at the entrance to R21's room: Everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. On 6/2/26 at 7:39 AM, Surveyor observed RN-L prepare R21's medications and noted a contact precautions sign at the entrance to R21's room. Next to R21's room was a personal protective equipment (PPE) cart that contained gowns, gloves, and masks. RN-L entered R21's room without donning a gown or gloves. After entering R21's room, RN-L handed a medicine cup with pills to R21. RN-L elevated the head of the bed and handed R21 a cup of water. R21 took the medication and handed the water cup back to RN-L who threw it in the garbage. RN-L exited the room, walked across the hall into R15's room, and washed hands with soap and water. R15 was in the room waiting for RN-L to tend to a bleeding wound on R15's left elbow. R15 was admitted to the facility on [DATE] and had diagnoses including hemiplegia and hemiparesis following a stroke. R15's medical record contained an order for contact precautions due to C-difficile (dated 6/1/26 at 12:56 PM and entered by Infection Preventionist (IP)-M). On 6/2/26 at 7:54 AM, Surveyor observed RN-L exit R15's room and don a gown and gloves from a PPE cart. RN-L washed R15's arm with soap and water. R15's arm contained blood from the elbow to the hand and was actively bleeding. RN-L removed their gown and gloves and exited the room without completing hand hygiene. RN-L opened two doors to get to a storage room with medical supplies. RN-L took a package of steri-strips, again exited through the two doors, and removed a pair of bandage scissors from a cloth bag. RN-L entered R15's room without completing hand hygiene, donned a gown and gloves, and opened the steri-strips. RN-L then removed the gown and gloves and exited the room without completing hand hygiene. RN-L retured to the supply room, retrieved a package of gauze, and returned to R15's room without completing hand hygiene. R15 donned a gown and gloves and used gauze and wound cleanser to clean R15's arm. While attempting to put steri-strips on the wound, RN-L dropped a set of steri-strips on the floor. RN-L picked the steri-strips off the floor with a gloved hand and put the steri-strips on a table. Without changing gloves and completing hand hygiene, RN-L picked up another set of steri-strips and applied three steri-strips over the wound. RN-L then dated and initialed an adhesive bandage placed over the wound. RN-L disposed of all garbage and washed hands with soap and water. On 6/2/26 at 8:14 AM, Surveyor interviewed RN-L who did not know RN-L should wear a gown and gloves when entering the room of a resident on contact precautions if only administering medication. RN-L acknowledged the missed hand hygiene opportunities during R15's wound care. On 6/2/26 at 11:30 AM, Surveyor interviewed IP-M who verified staff should don a gown and gloves prior to entering the room of a resident on contact precautions, even when the intent is to pass medication. IP-M also stated staff should complete hand hygiene and change gloves after soiled tasks and prior to clean tasks. IP-M stated after Surveyor's observation of wound care with RN-L, R15's wound care was redone by the consulting wound nurse.

Based on staff interview and record review, the facility did not ensure the provision of pharmacy services to meet the needs of 1 resident (R) (R6) of 5 sampled residents.A urinalysis and culture was ordered for R6 for a possible urinary tract infection. The facility did not promptly follow-up on the results or an antibiotic order which caused a delay in R6's treatment.Findings include: The facility's Guidelines for Notifying Physicians of Clinical Problems policy, revised January 2026, indicates: These guidelines are intended to help ensure .medical care problems are communicated to medical staff in a timely, efficient and effective manner and .all significant changes in resident status are assessed and documented in the medical record .The charge nurse or supervisor should contact the attending physician if a clinical situation appears to require immediate discussion and management . R6 had diagnoses including dementia, unspecified mood disorder, displaced fracture of the right femur due to a fall without routine healing, and insomnia. R6's Minimum Data Set (MDS) assessment, dated 5/20/26, stated R6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. A behavioral note, dated 5/25/26, indicated the physician was notified and requested a urinalysis and culture and lab work to assess for possible underlying infection or metabolic/electrolyte abnormalities contributing to a change in condition due to an acute increase in R6's behaviors and altered mentation. (Of note: R6's medical record did not contain urinalysis and culture results, lab results, or a progress note indicating any new orders.) On 6/3/26, Surveyor reviewed the facility's infection surveillance line list for May 2026 and noted R6 was not listed as having signs or symptoms of an infection, labs orders/results, or any antibiotics prescribed. On 6/3/26 at 10:43 AM, Surveyor interviewed Director of Nursing (DON)-B who confirmed the behavioral note indicated lab orders were received. DON-B verified R6's medical record did not contain the lab results or any new orders. DON-B stated DON-B would obtain the lab results and any new orders. On 6/3/26 at 11:29 AM, DON-B provided R6's urinalysis and culture results to Surveyor. The results indicated a urinalysis on 5/28/26 was abnormal with white blood cells, blood, leukocytes, and mucus and was positive for nitrites. R6's physician reviewed the results and added an order on 5/29/26 (Friday) to culture the sample and treat with cefpodoxime (an antibiotic medication) 200 milligrams (mg) by mouth twice daily for seven days. The order was sent to the pharmacy. DON-B indicated the results and orders were emailed to the facility but floor nurses do not have access to emails. DON-B confirmed administration (who had access to the email containing the results) did not follow-up with the orders on 6/1/26 (Monday). DON-B indicated the facility requested floor nurses have access to faxes to prevent further delays in treatment of residents with lab or medication orders. DON-B also confirmed R6 was not added to the infection surveillance line list for monitoring.

Based on staff interview and record review, the facility did not maintain acceptable parameters of nutritional status, including usual body weight range for 1 resident (R) (R39) of 1 sampled resident. R39 experienced a weight gain of greater than 5 pounds (lbs) in one week. The facility did not update the dietitian or R39's physician as ordered. Findings include: The facility's Weight Assessment and Intervention policy, dated 2026, indicates: Resident weights are monitored for undesirable or unintended weight .gain .Any weight change of 5 pounds (lbs) (or at the discretion of the dietitian) or more since the last weight assessment is retaken the next day .undesirable weight change is evaluated by the treatment team .and will include the resident's target weight range, caloric, protein, and other nutrient needs, relationship between current medical condition/clinical situation, recent fluctuations in weight, and to what extent weight stabilization can be anticipated. R39 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, depression, hypertension, and vitamin D deficiency. R39's Minimum Data Set (MDS) assessment, dated 4/7/26, stated R39 had a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. R39 had an activated Power of Attorney for Healthcare (POAHC). R39's comprehensive care plan, dated 4/7/26, indicated R39 had a potential nutritional problem related to dementia and confusion. The care plan contained a goal to maintain adequate nutrition as evidenced by weight stability. The care plan contained an intervention for staff to obtain weights per protocol and notify the physician/dietitian of significant weight changes (loss or gain) per protocol/physician order. On 6/3/26, Surveyor reviewed R39's physician orders. R39's medical record contained an order, dated 5/14/26, to complete weekly weights and notify the physician of weight gain of more than 5 lbs in one week. On 6/3/26, Surveyor reviewed R39's weekly weights and noted the following: ~ On 5/14/26, R39 weighed 167.9 lbs (mechanical lift)~ On 5/21/26, R39 weighed 176.4 lbs (mechanical lift) (which was an 8.5 lb weight gain)~ On 5/28/26, R39 weighed 181.8 lbs (mechanical lift) (which was a 5.4 lb weight gain) R39's medical record did not indicate the physician or dietitian was notified of the weight gains. On 6/3/26 at 2:48 PM, Surveyor interviewed Director of Nursing (DON)-B who could not provide documentation that R39's physician or the dietitian were notified of R39's weight gains.

Based on staff interview and record review, the facility did not ensure 2 residents (R) (R23 and R3) of 4 sampled residents received the necessary care and services to promote healing and/or prevent pressure injuries from worsening.R23 was seen in the wound clinic on 5/28/26 for right dorsal foot, left fifth dorsal toe, and right hallux bunion wounds. New treatments were ordered. The facility was not aware of the updated orders which resulted in a missed dressing change for R23's right dorsal foot on 5/31/26. R3 had a stage 4 pressure injury on the left heel and an order for a dressing change every other day. R3's Treatment Administration Record (TAR) indicated the dressing change was not completed on 5/20/26.Findings include:The facility's Wound Care policy, revised January 2026, indicates: The purpose of the policy is to provide guidelines for the care of wounds to promote healing .Documentation: The following information should be recorded in the resident's medical record: .2. The date and time wound care was given .1. R23 was admitted to the facility on [DATE] and had diagnoses including pressure ulcers to calf and foot, malignant neoplasm of sigmoid colon, and protein calorie malnutrition. R23's Minimum Data Set (MDS) assessment, dated 3/17/26, stated R23 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. R23's medical record contained the following wound care orders:~ Ensure wound dressings are clean, dry, and intact. Every shift for wound care (dated 4/28/26)~ Wound Care: (Right) Dorsal Foot: Remove dressing down to the Mepilex Transfer, but DO NOT remove the white Mepilex Transfer foam as R23 has Grafix underneath. Reapply the outer dressing including part of an ABD pad held in place with a few turns of Kerlix. Change just the outer portion of the dressing on Tuesday, Thursday, and Sunday once daily every Tuesday, Thursday, Sunday for wound care (dated 5/21/26)~ Wound Care: Left Hallux Bunion: Cleanse with saline, pat dry. Paint with Betadine and keep covered with protective Band-Aids changed every 2 days. Every day shift every other day for wound care (dated 5/21/26)~ Wound Care: Left Hallux Bunion: Cleanse with saline, pat dry. Paint with Betadine and keep covered with protective Band-Aids changed every 2 days. Every 24 hours as needed for wound care (dated 5/21/26 On 6/2/26 at 10:28 AM, Surveyor observed Registered Nurse (RN)-X provide wound care for R23's left hallux bunion wound with observation/instruction from RN-T. During wound care, R23 indicated to RN-X that at R23's last appointment at the wound clinic on 5/28/26, the provider changed the orders for the right dorsal foot. RN-T indicated the facility would call the provider for updated orders. On 6/2/26, Surveyor reviewed orders written by the wound clinic following R23's appointment on 5/28/26 which indicated the following:~ (R23) to wear heel raiser/heel protector boot to right foot at all times, except showering. Check skin surrounding area twice daily. Two times a day for wound care. (Of note: The order was dated 5/28/26 and transcribed 6/2/26.)~ Wound Care: Right Dorsal Foot: Remove dressing and cleanse with Vashe or normal saline. May perform a dry gauze rub to remove any superficial slough/bioburden. Cover the open area with UrgoClean AG then cover with an ABD pad held in place with a few turns of Kerlix. R23 may continue to use foam heel pads placed beneath the Tubigrip as before. Change 3 times per week (once in the wound clinic on Thursdays). One time a day every Tuesday and Sunday. (Of note: The order was dated 5/28/26 and transcribed 6/2/26.)~ (R23) to plan for surgery on 6/19/26. Podiatry will call 2 days prior with the time of surgery. (Of note: The order was dated 5/28/26 and transcribed 6/2/26.) On 6/2/26, Surveyor reviewed R23's Medication Administration Record (MAR)/TAR and noted a missed dressing change for the right dorsal foot on 5/31/26.On 6/3/26 at 11:33 AM, Surveyor interviewed Director of Nursing (DON)-B who verified the updated orders were not obtained after R23's wound clinic appointment on 5/28/26 which resulted in a missed treatment on 5/31/26. 2. R3 was admitted to the facility on [DATE] and had a diagnosis of pressure ulcer to left heel. R3's MDS assessment, dated 3/27/26, stated R3 had a BIMS score of 15 out of 15, indicating intact cognition. R3's medical record contained the following order: ~ Left Heel: Remove dressing. Cleanse with Vashe (may substitute saline if Vashe is not available). May perform a dry gauze rub to remove any superficial slough. May apply emollient cream (dated 5/13/26) On 6/3/26, Surveyor reviewed R3's TAR and noted wound care was not completed on 5/20/26. On 6/3/26 at 1:17 PM, Surveyor interviewed DON-B who verified R3's wound treatment was not documented as completed on 5/20/26. DON-B indicated staff should complete wound treatments and document completion.

Based on observation, staff and resident interview, and record review, the facility did not ensure physican orders were followed and appropriate wound care and treatment was provided for 1 resident (R) (R35) of 4 sampled residents.R35 was seen in the wound clinic on 5/8/26 for non-pressure right anterior and posterior leg wounds. New treatments were ordered. The facility did not update R35's orders until 5/14/26. R35 was seen in the wound clinic again on 5/22/26. The physician ordered a wound vac and transitioned R35 from non weight-bearing to weight-bearing status. The facility did not order the wound vac, update R35's weight-bearing status, or update R35's care plan and Kardex (an abbreviated care plan used by nursing staff). Findings include:On 6/2/26, 6/3/26, and 6/16/26, Surveyor requested the facility's policy for obtaining, transcribing, and/or following physician orders. A policy was not provided. R35 was admitted to the facility on [DATE] and had diagnoses including dementia, displaced unspecified condyle fracture of lower end of right femur, initial encounter for closed fracture, contusion of right lower leg, and laceration of right lower leg. R35's Minimum Data Set (MDS) assessment, dated 5/4/26, stated R35's Brief Interview for Mental Status (BIMS) score was 7 out of 15, indicating severely impaired cognition.A care plan, initiated on 4/29/26, indicated R35 had self-care deficits related to recent trauma to the right leg. The care plan contained an intervention, dated 4/29/26, to transfer with the assistance of 1 staff and a walker and indicated R35 was non weight-bearing on the right leg. R35's medical record contained the following wound care orders:~ Anterior right calf: Wash with Vashe, apply 1-2 layers of Aquacel AG to wound bed, apply ABD pad, wrap leg with Kerlix, and apply size E Tubigrips once daily on odd days (ordered 5/1/26; discontinued 5/13/26)~ Posterior right calf: Wash with Vashe, remove sloughing skin gently with normal saline soaked gauze, apply oil emulsion over blistered area, and an ABD pad. Wrap with Kerlix and apply Tubigrips to bilateral legs every other day on odd days (ordered 5/1/26; discontinued 5/13/26)Surveyor reviewed wound clinic orders following R35's appointment on 5/8/26 and noted the following:~ Wound care orders: TO BE DONE AT WOUND CLINIC ONLY! Remove dressing, cleanse the right anterior and posterior calf with Vashe and pat dry. Cover the eschared area ulcerations of right posterior/lateral calf with oil emulsion gauze, and an ABD pad. Cover the right anterior calf ulcer with 1-2 layers of Aquacel AG, 2 layers of Drawtex, and an ABD pad. Place the right leg in a dual layer of 3M light compression wrap from toes to knee. Seen weekly in wound clinic (ordered 5/14/26; discontinued 5/20/26)~ Right anterior calf wound and other minor wounds: Cleanse with Dakins or Vashe solution. May perform a dry gauze rub to remove any superficial slough. Cover open areas with oil emulsion gauze/adaptic and ABD pads. Wrap leg with a layer of Kerlix that extends from the base of the toes to just below the bend of the knee to ensure Coban does not touch the skin. The outer Coban wrap should be placed from the base of the toes to the bend of the knee at 50% overlap and 50% stretch. Once daily (ordered 5/20/26)~ Right posterior calf wound: Remove dressings, clean with Dakins or Vashe. May perform dry gauze rub to remove superficial slough. Fill the entire wound, including undermining anteriorly and distally with Dakins or Vashe dampened Kerlix and cover with dry gauze. Cover with ABD pad and wrap with generous amount of Kerlix from base of toes to just below the bend of the knee. Wrap with Coban which should not touch the skin. Place Coban from base of toes to bend of knee with 50% stretch and 50% overlap. Once daily. May change more than once daily if loose or excessive drainage noted (ordered 5/22/26)A progress note, dated 5/11/26 at 12:01 PM, indicated staff found paperwork from the wound clinic on a table in R35's room. The paperwork indicated dressings were only to be changed at the wound clinic. R35's right leg dressing was changed on 5/9/26. Staff notified the wound clinic on 5/11/26. A wound clinic appointment was scheduled for 5/12/26 at 10:30 AM.Surveyor reviewed wound clinic orders following R35's 5/22/26 appointment and noted the following:~ Negative pressure therapy is ordered to accelerate granulation tissue formation which cannot be achieved by other topical wound treatments. The skilled nursing facility is going to attempt to source a negative pressure wound therapy system to begin utilizing it as soon as possible.Surveyor verified with wound clinic staff that the orders were faxed to the facility on 5/22/26. (Of note: R35's medical record did not contain an order for a wound vac.)A wound clinic note, dated 5/22/26, indicated orthopedics recommended weaning R35's immobilizer and allowing R35 to bear weight. On 6/3/26 at 11:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who indicated R35 walked independently in their room. LPN-E was unsure if R35 was weight-bearing or non-weight-bearing status. LPN-E indicated a physical therapy document in R35's closet indicated R35 was weight-bearing, however, R35's care plan stated R35 was non weight-bearing on the right leg. LPN-E verified R35's medical record did not contain an order for weight-bearing status. LPN-E stated LPN-E needed to confirm R35's status with Unit Manager/LPN-M.At 6/3/26 at 11:33 AM, Surveyor observed R35 walking independently in their room. A therapy communication document in R35's closet, dated 5/27/26, indicated: Independent in room. Walking to/from meals only. The document was signed by Physical Therapist (PT)-Z. Surveyor interviewed R35 who indicated R35 walked independently and was not in pain. Surveyor observed a shadow of drainage on the outside of the sock that coverd R35's right lower leg dressing.On 6/3/26 at 1:11 PM, Surveyor interviewed LPN-M who verified R35 did not have an order for weight-bearing status. LPN-M indicated R35's Hospital After Visit Summary, dated 4/27/26, indicated R35 was non weight-bearing on the right leg. LPN-M verified R35's care plan indicated R35 was non weight-bearing on the right leg and R35's Kardex indicated R35 required the assistance of one staff with a gait belt and walker and was non weight-bearing on the right leg.At 6/3/26 at 2:10 PM, Surveyor interviewed PT-Z who received documentation from R35'snclinic visit on 5/22/26 transitioning R1 to weight-bearing status. PT-Z posted an update in R35's room on a therapy communication document and placed the updated documentation in DON-B's mailbox.On 6/3/26 at 2:13 PM, Surveyor interviewed Director of Nursing (DON)-B who started employment at the facility on 5/28/26 and did not observe updated documents or orders regarding R35's weight-bearing status.On 6/3/26 at 1:11 PM, Surveyor interviewed LPN-M who indicated the facility received an order from the wound clinic on 5/22/26 regarding the need for wound vac for R35. LPN-M indicated the facility had not received the wound vac as of 6/3/26. LPN-M did not know who was responsible for ordering the wound vac.On 6/3/26 at 2:00 PM, Surveyor interviewed LPN-E who received a call on the 5/22/26 PM shift from Hospital Registered Nurse (RN)-BB who told LPN-E that R35 was seen in the wound clinic and the physician ordered a wound vac. RN-BB advised LPN-E the facility needed to obtain a wound vac. LPN-E was not familiar with the process of ordering a wound vac and indicated management was gone for the day. LPN-E put a note under DON-B and LPN-M's door regarding the need for a wound vac. On 6/3/26 at 1:40 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated Housekeeper (HSK)-AA ordered all medical and wound supplies.On 6/3/26 at 2:05 PM, Surveyor interviewed HSK-AA who indicated nursing staff did not inquire about ordering a wound vac for R35. HSK-AA did not know which supplier to contact to obtain a wound vac and had not previously ordered a wound vac.On 6/3/26 at 3:21 PM, Surveyor observed LPN-EE complete R35's right anterior and posterior leg dressing change and noted R35 did not have a wound vac.On 6/4/26 at 9:16 AM, Surveyor interviewed Hospital Quality Director (QD)-GG who indicated the facility reported to wound clinic staff that they were not receiving orders. QD-GG indicated orders from the clinic are sent to the facility via fax. QD-GG indicated Hospital (HSP)-Y's IT department investigated the issue and verified faxes were being transmitted successfully on the clinic side. QD-GG indicated the clinic has not had issues with faxes being received at other clinics or providers. On 6/4/26 at 9:20 AM, Surveyor interviewed Hospital Director (DIR)-CC who verified RN-BB spoke to LPN-E on 5/22/26 at 3:40 PM regarding R35's wound clinic appointment on 5/22/26 and the order for a wound vac. RN-BB advised the facility to order the wound vac and stated the clinic does not order wound vacs for residents in skilled nursing facilities. DIR-CC verified RN-BB faxed the wound vac order to the facility on 5/22/26 and stated R35 was seen in the wound clinic on 5/29/26 without a wound vac. DIR-CC indicated RN-DD spoke to LPN-E on 5/29/26 regarding the need for a wound vac. LPN-E told RN-DD the facility would get a wound vac for R35. On 6/4/26 at 10:07 AM, Surveyor interviewed Medical Doctor (MD)-FF who verified MD-FF ordered a wound vac for R35's right leg on 5/22/26 due to dead space after debridement. MD-FF saw R35 in the clinic on 5/29/26 and stated R35 did not have a wound vac. MD-FF asked clinic staff to contact the facility to ensure the wound vac was ordered on 5/29/26. MD-FF stated MD-FF will see R35 in the clinic on 6/5/26 and expects R35 to have a wound vac. MD-FF expressed concern that the facility did not follow MD-FF's order. MD-FF stated MD-FF sees R35 every Friday and R35's right leg is frequently not dressed according to MD-FF's order. MD-FF indicated facility staff have reported problems with the facility's fax machine not working. MD-FF stated clinic staff have been calling the facility to ensure they obtain wound clinic orders in a timely manner. MD-FF indicated when facility staff do not follow orders, it delays resident care. On 6/4/26 at 1:07 PM, Surveyor discussed the facility's process of receiving orders with NHA-A who indicated the facility had difficulty receiving faxed orders for 2 weeks in May. NHA-A indicated staff were not present on the weekend to take orders and weekend staff did not have access. NHA-A indicated a new process is in place.(Of note: Surveyor requested R35's care plan and Kardex on 6/3/26 from NHA-A and LPN-M. Surveyor received the care plan and Kardex on 6/3/26 at 3:04 PM with revisions dated 6/3/26.)

Based on staff and resident interview and record review, the facility did not have a process to ensure mail was delivered on Saturdays. This practice had the potential to affect all 37 residents (R) residing in the facility. The facility did not have a process to deliver mail on weekends. Mail delivered to the facility on Saturdays was not provided to residents until the following Monday. Findings include: The facility's Mail and Electronic Communication policy indicates: .4. Mail and packages will be delivered to the resident within twenty-four hours of delivery on premises or to the facility's post office box (including Saturday deliveries). The facility's admission Agreement indicates: .Your mail will be delivered to your room within 24 hours of receipt at the center. On 6/2/26 at 1:03 PM, Surveyors conducted a Resident Council meeting. R7, R1 , R23 , R24, R36, and R38 were in attendance. R7 stated residents do not receive mail on Saturdays. When Surveyor asked the other residents if they receive mail on Saturdays, all residents indicated they receive mail Monday through Friday but not on Saturday. (Of note: R7's medical record contained a Minimum Date Set (MDS) assessment, dated 5/6/26, that stated R7 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition.) On 6/2/26 at 1:54 PM, Surveyor interviewed Recreation Director (RD)-I who stated activity staff do not deliver mail. RD-I stated maintenance staff deliver mail Monday through Friday. RD-I was unsure if mail is delivered on Saturdays. On 6/3/26 at 11:13 AM, Surveyor interviewed Maintenance staff (MS)-J who stated Transportation Driver (TD)-K delivers mail in-between transports Monday through Friday, however, TD-K does not work on the weekend.

Based on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R12) of 4 sampled residents received the necessary pressure injury care and treatment to promote healing and prevent pressure injuries from worsening.R12 had a stage 2 sacral pressure upon admission that measured 6.2 centimeters (cm) (length) x 4.1 cm (width) x 0.2 (depth) cm. A wound clinic note included in R12's admission paperwork stated offloading was of the utmost importance and R12 should be repositioned side-to-side every two hours. If the sacral wound progressed, R12 should be started on an alternating air mattress as soon as possible. R12's sacral wound was documented as worsening on 1/21/26 and 1/28/26 and measured 9.1 cm x 7.9 cm x 0.1 cm with a reddened peri-wound and pain. As of 2/10/26, R12 did not have an alternating air mattress. In addition, R12 was admitted to the facility with a deep tissue injury (DTI) on the left heel that measured 1.8 cm x 1.3 cm. A wound clinic note stated to keep the site covered with a protective border dressing and use heel boots at all times to float R12's heels off the mattress. An assessment on 2/4/26 indicated the left heel DTI measured 2.5 cm x 3 cm. On 2/9/26 and 2/10/26, R12 was observed without heel boots in bed with both heels in contact with the mattress and the footboard. On 2/10/26, R12's protective dressing was dated 2/4/26 (6 days prior) but was supposed to be changed daily.The facility's Wound Care policy, revised June 2017, indicates: The purpose of the policy is to provide guidelines for the care of wounds to promote healing and to review the resident's care plan to assess for any special needs .The following information should be recorded in the resident's medical record: date and time wound care was given and if the resident refused the treatment. From 2/9/26 to 2/10/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had diagnoses including congestive heart failure, anxiety, and type 2 diabetes. R12's most recent Minimum Data Set (MDS) assessment, dated 1/17/26, had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R12 had intact cognition. The MDS assessment also indicated R12 had impaired mobility of both lower extremities and needed moderate assistance with rolling from side-to-side. R12's comprehensive care plan, revised 2/6/26, indicated R12 had current pressure injuries. The care plan contained interventions to reposition R12 at least every 2 hours and to float heels/heel boots on at all times.Surveyor reviewed R12's admission paperwork, including wound care notes. A visit note, dated 1/8/26, indicated R12 had a stage 3 sacral decubitus ulcer and offloading was of the utmost importance. The note indicated R12 should not lay directly on the sacrum and should be turned side-to-side every 2 hours. If R12's sacral ulcer progressed, R12 should be started on a group 1 alternating pressure pump mattress as soon as possible. Instructions for the left heel indicated to use offloading boots at all times and stated R12 would benefit from keeping R12's calves elevated on pillows while in bed to float heels off the mattress.Surveyor reviewed R12's coccyx wound assessments which indicated the following (Of note: The wound clinic identified the wound as a sacral wound and the facility identified the wound as a coccyx wound):~ On 1/14/26, R12 had a stage 2 pressure wound on the coccyx that measured 6.2 cm x 4.1 cm x 0.2 cm with 100% granulation tissue, a reddened peri-wound, and pain.~ On 1/21/26, R12 had a stage 2 pressure wound on the coccyx that measured 8.9 cm x 8.1 cm x 0.1 cm with 100% granulation tissue, a reddened peri-wound, and pain. Wound Registered Nurse (WRN)-C noted the wound had worsened.~ On 1/28/26, R12 had a stage 3 pressure wound on the coccyx that measured 9.1 cm x 7.9 cm x 0.1 cm with 100% granulation tissue, a reddened peri-wound, and pain. WRN-C noted the wound had worsened.~ On 2/4/26, R12 had a stage 3 pressure wound on the coccyx that measured 8.9 cm x 6.5 cm x 0.1 cm with 50% granulation tissue, 40% slough (stringy yellow/white non-healing tissue), 10% eschar (black/brown dead tissue), and pain. WRN-C noted the wound had worsened. R12's medical record did not indicate an alternating air mattress was ordered as recommended by the wound clinic (on 1/8/26) when R12's coccyx wound worsened on 1/21/26, 1/28/26, and 2/4/26.Surveyor reviewed R12's left heel wound assessments which indicated the following:~ On 1/14/26, R12 had a deep tissue injury (DTI) on the left heel that measured 1.8 cm x 1.3 cm.~ On 1/21/26, R12 had a DTI on the left heel that measured 2.8 cm x 3.0 cm. The wound was larger in size and darker in color with pain. The note indicated R12 should wear heel boots at all times/heels floated in bed. WRN-C noted the wound had worsened.~ On 1/28/26, R12 had a DTI on the left heel that measured 1.8 cm x 2.5 cm with pain. WRN-C noted the wound was stable.~ On 2/4/26, R12 had a DTI on the left heel that measured 2.5 cm x 3 cm and was larger with a hardening center piece and pain. WRN-C noted the wound was stable.R12 had the following wound care orders:~ Stage 3 right - Remove old dressing, cleanse with wound wash, cover surrounding skin with skin prep, cover open areas with single layer Aquacel AG, cut to fit contours, secure with 4 x 4 foam border dressing in a diamond fashion; Change daily and as needed until resolved (dated 2/4/26)~ Stage 3 left - Remove old dressing, cleanse with wound wash, cover surrounding skin with skin prep, cover open areas with Medi-honey, secure with 4 x 4 foam border dressing in a diamond fashion; Change daily and as needed until resolved (dated 2/4/26)~ Left heel - Wound cleanser, blot dry, Betadine, cover with foam border; Change daily and as needed until resolved (dated 1/21/26)R12's January and February 2026 Treatment Administration Records (TARs) indicated R12's coccyx wound treatment was not completed on the following dates:~ 1/23/26, 1/24/26, 1/25/26, 1/26/26, 1/29/26, 1/31/26, 2/1/26, 2/2/26, and 2/3/26~ (Left) 2/6/26~ (Right) 2/7/26 and 2/8/26R12's January and February 2026 TARs indicated R12's left heel wound treatment was not completed on the following dates:~ 1/23/26, 1/24/26, 1/25/26, 1/26/26, 1/29/26, 1/31/26, 2/1/26, 2/2/26, 2/3/26, 2/7/26, and 2/8/26R12's January 2026 TAR indicated R12 was not repositioned every 2 hours and staff did not ensure R12's heels were free floating during 18 of 252 opportunities.R12's February 2026 TAR indicated R12 was not repositioned every 2 hours and staff did not ensure R12's heels were free floating during 10 of 116 opportunities.On 2/9/26 at 10:21 AM and 2:17 PM and on 2/10/26 at 9:41 AM, Surveyor observed R12 in bed on a regular pressure relieving mattress. R12 was not wearing heel boots (which were in the room) and both heels were in contact with the mattress and footboard. The dressing on R12's left heel was dated 2/4/26.On 2/10/26 at 9:43 AM, Surveyor interviewed R12 regarding repositioning, heel boots, and dressing changes. R12 stated R12 was usually receptive to wound care and heel boots and stated, If they offer, I don't say no.On 2/10/26 at 2:03 PM, Surveyor interviewed RN-D regarding R12's left heel dressing. RN-D stated RN-D changed R12's sacral dressing that day but did not change R12's heel dressing because it was not assigned on RN-D's (AM) shift. RN-D stated R12 refused cares at times which was documented in the TAR. RN-D did not recall if R12 refused to wear heel boots or reposition that day.On 2/10/26 at 3:12 PM, Surveyor observed R12 with WRN-C. WRN-C verified R12's heel dressing was dated 2/4/26 and was supposed to be changed daily. WRN-C also verified R12's heels should be floated off the mattress with heel boots or pillows. When WRN-C asked if it was okay to put heel boots on, R12 was agreeable. WRN-C indicated if a resident refuses treatment/repositioning, staff should document the refusal in the TAR and notify WRN-C or Director of Nursing (DON)-B. On 2/10/26 at 3:28 PM, Surveyor interviewed WRN-C regarding R12's wound clinic note from 1/8/26. WRN-C stated WRN-C did not review the note prior to survey and if WRN-C had reviewed the note upon admission, WRN-C would have called the wound clinic to clarify what progresses meant. WRN-C stated the facility does not currently have any alternating air mattresses but has the ability to order them if needed. WRN-C stated R12's family was considering Hospice care and a room change which caused a delay in providing R12 with an alternating air mattress. WRN-C verified an alternating air mattress was discussed during R12's care conference on 2/4/26. WRN-C was not sure if the mattress was ordered and was waiting for R12's family to decide if R12 would enroll in Hospice care.On 2/10/26 at 4:22 PM, Surveyor interviewed DON-B regarding the alternating air mattress that was discussed on 2/4/26. DON-B stated it typically took a few days to receive an alternating air mattress once ordered. DON-B stated R12 was signing on to Hospice care with a first visit on 2/12/26 and an alternating air mattress would be ordered through the Hospice agency.

Based on observation, staff and resident interview, and record review, the facility did not ensure residents with orders for a consistent carbohydrate (CCHO) diet received their prescribed diet. This practice had the potential to affect 12 residents (R) (R1, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14) of 12 sampled residents. R1's hospital discharge orders indicated R1 should have a low carb diet (60 grams of carbohydrates per meal). The order in R1's medical record indicated R1 should have 90 grams of carbohydrates per meal.R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, and R14 had orders for a CCHO diet and did not receive what was on the CCHO diet lunch menu on 2/10/26.Findings include:The facility's undated Controlled Carbohydrates policy indicates: .Carbohydrates balanced consistently at each meal providing a range of 70-80 grams of carbohydrates. These diets can be used for the diabetic resident with glucose control concerns following regular and low-concentrated sweets are not omitted but planned into the total carbohydrate allowance for the meal.1.On 2/9/26, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R1's most recent Minimum Data Set (MDS) assessment, dated 1/20/26, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderate cognitive impairment. R1's hospital discharge orders, dated 1/14/26, indicated R1 should have a carb-controlled diet with 60 grams of carbohydrates per meal. A follow-up section on the discharge orders indicated: Follow up, next physician nursing home rounds: Instructions: Monitor chronic medical problems, diabetes on high dose of insulin, running high. R1's medical record contained an order (dated 1/14/26) for a CCHO, no added salt (NAS) 90 gram carbohydrate diet. On 2/10/26 at 12:30 PM, Surveyor interviewed Dietary Manager (DM)-E who was not aware that R1's diet order specified 90 grams of carbohydrates. DM-E was not sure how many grams of carbohydrates were provided on a CCHO diet on the facility's menu and indicated Registered Dietitian (RD)-F would review that. DM-E did recall that R1 had a preference for no juice or sweet desserts and that R1 liked cottage cheese and yogurt. On 2/10/26 at 1:00 PM, Surveyor interviewed RD-F who stated a carb-controlled diet is usually 55-70 grams of carbs per meal. RD-F stated if R1 was admitted with more carbohydrates identified in the order per meal, the facility should provide additional carbohydrates to follow the order. RD-F indicated an order for a specific number of carbohydrates per meal should be given to the Dining Director so the facility can provide the right amount of carbs and address the changes on the meal ticket. RD-F was not sure how many carbs per meal the facility's menu provided. RD-F indicated the Dining Director sends RD-F the menus for the menu cycle and RD-F reviews them. 2. On 2/9/26, Surveyor reviewed R6's medical record. R6 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. During a previous admission to the facility, R6's MDS assessment, dated 1/6/26, had a BIMS score of 15 out of 15 which indicated R6 had intact cognition. R6 had an order for a CCHO diet.On 2/10/26 at 10:50 AM, Surveyor interviewed R6 who indicated R6 prefers to follow a CCHO diet but does not always receive a CCHO diet. R6 stated R6 is served a lot of potatoes and bread and would prefer to not get so many carbohydrates. On 2/9/26, Surveyor reviewed R14's medical record. R14 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R14's MDS assessment, dated 2/10/26, had a BIMS score of 15 out of 15 which indicated R14 had intact cognition. R14 had an order for a CCHO diet. On 2/10/26 at 11:25 AM, Surveyor interviewed R14 who indicated R14 prefers to follow a CCHO diet but does not always receive a CCHO diet. R14 indicated R14 chooses to either eat smaller portions of what is provided or not eat what R14 feels does not fit a CCHO diet. On 2/9/26, Surveyor reviewed R4's medical record. R4 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R4's MDS assessment, dated 12/26/25, had a BIMS score of 0 out of 15 which indicated R4 had severe cognitive impairment. R4 had an order for a CCHO diet. On 2/9/26, Surveyor reviewed R5's medical record. R5 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R5's MDS assessment, dated 11/15/25, had a BIMS score of 8 out of 15 which indicated R5 had moderate cognitive impairment. R5 had an order for a CCHO diet. On 2/9/26, Surveyor reviewed R7's medical record. R7 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R7's MDS assessment, dated 12/13/25, had a BIMS score of 15 out of 15 which indicated R7 had intact cognition. R7 had an order for a CCHO diet. On 2/9/26, Surveyor reviewed R8's medical record. R8 was admitted to the facility on [DATE] and had a diagnosis of stroke. R8's MDS assessment, dated 12/16/25, had a BIMS score of 4 out of 15 which indicated R8 had severe cognitive impairment. R8 had an order for a CCHO no added salt (NAS) diet. On 2/9/26, Surveyor reviewed R9's medical record. R9 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R9's MDS assessment, dated 12/22/25, had a BIMS score of 4 out of 15 which indicated R9 had severely impaired cognition. R9 had an order for a CCHO diet. On 2/9/26, Surveyor reviewed R10's medical record. R10 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R10's MDS assessment, dated 12/18/25, had a BIMS score of 3 out of 15 which indicated R10 had severe cognitive impairment. R10 had an order for a CCHO diet. On 2/9/26, Surveyor reviewed R11's medical record. R11 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R11's MDS assessment, dated 1/27/26, had a BIMS score of 15 out of 15 which indicated R11 had intact cognition. R11 had an order for a CCHO diet. On 2/9/26, Surveyor reviewed R12's medical record. R12 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R12's MDS assessment, dated 1/17/26, had a BIMS score of 14 out of 15 which indicated R12 had intact cognition. R12 had an order for a CCHO NAS diet. On 2/9/26, Surveyor reviewed R13's medical record. R13 was admitted to the facility on [DATE] and had a diagnosis of type 2 diabetes. R13's MDS assessment, dated 11/13/25, had a BIMS score of 15 out of 15 which indicated R14 had intact cognition. R13 had an order for a CCHO NAS diet. On 2/10/26 at 11:51 AM, Surveyor observed lunch service from the kitchen. Surveyor reviewed the lunch menu which indicated residents on a CCHO diet should receive: 3 ounces (oz) of baked ham; 4 oz of scalloped potatoes; 4 oz of buttered green beans; 1 dinner roll; and a half slice of Boston cream pie. When Surveyor entered the kitchen area, the dining room trays were pre-set and included a meal ticket, drinks, dessert, and silverware. Surveyor observed slice of pie on each tray which were all approximately the same size. On 2/10/26 at 12:10 PM, Surveyor interviewed DM-E regarding the observation that residents on a CCHO diet did not receive a half piece of pie on their tray and all pie slices appeared to be the same size. DM-E stated DM-E noticed that also and verified residents on a CCHO diet should receive a half piece of pie.

Based on staff and resident interview, and record review, the facility did not ensure 1 Resident (R) (R1) of 3 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent future falls. R1 was at risk for falls and fell out of bed on 3/21/23 while having a bad dream. The facility did not implement additional interventions to prevent R1 from falling out of bed again while having a bad dream. On 4/7/23, R1 fell out of bed and fractured R1's right upper arm. Findings include: The facility's Fall Prevention & Follow-Up Reporting policy, reviewed/revised on 11/2/22, contained the following information: Each resident will be assessed for fall risk and, if identified as high risk for falls or fall precautions, the resident's care plan will be flagged with risk for falls and a risk for falls assessment will be reviewed quarterly. A fall is when a resident is found on the floor or is seen falling. A fall report will be completed on the computer and documented for 72 hours in progress notes. All 72 hour fall reports will be reviewed by the Director of Nursing (DON) or Social Services Designee within 72 hours of the incident. The Interdisciplinary Team (IDT) will review and discuss preventatives at weekly mini-managers meetings. A committee will review resident falls every month to determine what new, preventive measure(s) should be put in place. 1. On 4/26/23, Surveyor reviewed R1's medical record. R1 was admitted to the facility with diagnoses to include history of falls with fracture, diabetes mellitus, anxiety, depression, and dementia. R1's Annual Minimum Data Set (MDS) assessment, dated 3/28/23, indicated R1's cognition was 13 out of 15 (the higher the score, the more cognizant), R1 required set up assistance for transfers and ambulation and had one fall with injury. On 4/26/23, Surveyor reviewed R1's plan of care. R1's plan of care, initiated on 7/23/19 and revised on 4/12/23, indicated R1 had a fall on 4/7/23 with a right arm fracture and was at risk for falls related to gait/balance problems, history of falls resulting in left humeral fracture and backache. An intervention, initiated and revised on 4/22/21, indicated a concave mattress was placed on R1's bed. An intervention, dated 3/21/23, stated educate/instruct R1 and family on safe use of assistive devices. Additional interventions, dated 3/22/23, stated to contact physical therapy (PT) for consult for strength and mobility and X-ray to lumbar spine and right hip per physician order. R1's plan of care, dated 3/21/23, indicated R1 had a sleep disturbance related to nightmares/troubled dreams as evidenced by R1 having dreams about R1's ex-spouse and the emotional disturbance the dreams caused R1. Interventions, initiated and revised on 3/21/23, included to allow R1 time to respond due to slower processing of cognition skills and adjust R1's environment to promote sleep per R1's preference. R1's plan of care, initiated on 7/31/19 and revised on 3/21/23, indicated R1 had impaired cognitive function/dementia or impaired thought processes related to a diagnosis of dementia as evidenced by short-term memory deficits, confusion, poor safety awareness (rolling out of bed), and struggles with orientation to time. All interventions were initiated on 7/31/19. On 4/26/23 at 12:36 PM, Surveyor interviewed Anonymous Family Member (AFM)-D who verified R1 fell out of bed on 3/21/23 after having a bad dream. AFM-D stated no new interventions, including a fall mat, lowering the bed, or replacing the grab bars with partial side rails were attempted. AM-D stated a lipped mattress with an opening was on R1's bed for a long time prior to R1's 3/21/23 fall out of bed. AFM-D verified R1 fell out of bed again on 4/7/23 and fractured R1's right upper arm. AFM-D stated R1 will no longer sleep in bed because R1 is more comfortable sleeping in the recliner due to the fracture and is fearful of sleeping in bed. AFM-E was in the room during the interview with AFM-D and stated the facility did not put any interventions in place after R1's first fall on 3/21/23. AFM-E stated AFM-E asked numerous times why a fall mat wasn't placed on the floor, why the bed wasn't lowered, and why side rails weren't placed on the bed prior to R1 falling out of bed a second time on 4/7/23. On 4/26/23 at 12:44 PM, Surveyor interviewed R1 and AFM-E. R1 stated R1 won't sleep in bed because R1 is afraid of falling without a new intervention in place to prevent R1 from falling out of bed. AFM-E verified R1 was afraid of falling again since an intervention to prevent falls was not put in place after AFM-E told the facility's administration an intervention was needed. R1 then stated R1 would love to get back in bed. On 4/26/23 at 2:22 PM, Surveyor interviewed AFM-F who stated AFM-F was at the facility when AFM-E requested a new intervention be put in place to attempt to prevent R1 from falling out of bed. AFM-F stated the facility did not implement any new interventions, including a fall mat, lowering the bed, or putting different rails on the bed. AFM-F stated the facility indicated paperwork was being completed for a new intervention, but a new intervention was not initiated. On 4/27/23, Surveyor reviewed R1's fall report, dated 3/21/23 at 12:30 AM. The fall report indicated R1 was heard crying in R1's room and was found lying prone on the floor next to R1's bed. R1 was unable to recall what happened other than R1 thought R1 was laying in bed (not standing or walking) and having a bad dream about R1's ex-spouse. There were no injuries noted at the time and R1 was assisted to sit on the edge of the bed. R1's family member, physician and Interim Director of Nursing (IDON)-B were notified. R1 was oriented to person, place, time, and situation. The fall report indicated the IDT met to review the incident and R1's care plan was updated as needed. A root cause analysis was completed and indicated former trauma contributed to the fall. The report indicated R1 saw telepsych, Social Services (SS) would meet with R1 on a 1:1 basis as needed and staff would continue to monitor R1. On 4/27/23, Surveyor reviewed R1's progress note, dated 4/7/23 at 9:10 AM and written by Registered Nurse (RN)-G. The progress note indicated the hospital called to advise the facility R1 needed transport back to the facility and had sustained a bad break to the upper right arm. On 4/27/23, Surveyor reviewed R1's fall report, dated 4/7/23 at 1:10 AM. The fall report indicated R1 was on the floor next to R1's bed and crying in pain. R1 stated R1 fell out of bed, complained of shoulder pain and was unable to move R1's right shoulder. R1 was sent to the Emergency Department (ED) for evaluation. R1 was oriented to person and place. The IDT met to review the incident and a root cause analysis was completed. The report indicated this was a pattern with R1 and may be due to night tremors or other related psych diagnoses. The report stated R1's bed was as low as it could be and indicated staff would follow up and update R1's care plan as needed. On 4/27/23 at 12:48 PM, Surveyor interviewed RN-G who stated R1 was independent in R1's room and reported to staff that R1 was having nightmares. RN-G stated cueing and encouragement were provided. RN-G indicated one of R1's family members stated the family was going to file a lawsuit against the facility after the second fall on 4/7/23. RN-G advised R1's family member that people fall, (R1) is independent and (facility staff) can't be in (R1's room) all the time. On 4/27/23 at 1:12 PM, Surveyor interviewed IDON-B who stated R1 had a regular mattress prior to the first fall on 3/21/23 which was changed to a scoop mattress after the fall. IDON-B verified R1's plan of care indicated R1 had a concave mattress since 4/22/21, not a regular mattress. IDON-B stated Former Director of Maintenance (FDOM)-K got the scoop mattress for R1 and placed the mattress on R1's bed. IDON-B confirmed the facility did not place a mat on the floor because R1 was able to get out of bed independently prior to the second fall and could trip over the mat. In addition, IDON-B verified R1's bed could be lowered to the ground, but stated the facility did not lower the bed to the ground because R1 would get up and go to the bathroom independently. IDON-B confirmed R1 was able to raise and lower the bed per self. On 4/27/23 at 2:09 PM, Surveyor interviewed R1 and AFM-D regarding R1's mattress. R1 and AFM-D stated the lipped mattress with an opening was not changed after R1 fell out of bed on 3/21/23 and the same mattress was on R1's bed for awhile. On 4/27/23 at 2:12 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-L regarding R1's mattress. CNA-L looked at R1's lipped mattress with an opening and stated R1 had the same mattress for a long time and well before the new year. On 4/27/23 at 3:17 PM, Surveyor interviewed IDON-B who stated interventions put in place after R1's fall on 3/21/23 included a mattress change and to monitor R1. IDON-B verified IDON-B did not document the mattress change. IDON-B confirmed R1's family members requested side rails for the bed. IDON-B didn't complete an assessment for side rails because IDON-B thought side rails were a restraint. On 5/4/23 at 8:40 AM, Surveyor interviewed CNA-H via telephone. CNA-H confirmed the same lipped mattress was on R1's bed prior to the fall on 3/21/23, after the fall on 3/21/23 and after the fall on 4/7/23. CNA-H verified R1's mattress had a lip with an opening before and after the falls. CNA-H stated R1's mattress was not changed after the first or second fall. On 5/4/23 at 9:02 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated LPN-I was not quite sure honestly if mattress was changed after R1 fell on [DATE]. On 5/4/23 at 11:08 AM, Surveyor interviewed IDON-B via telephone regarding the difference between a concave and scoop mattress. IDON-B stated the concave mattress has a continuous curve and the scoop mattress has a middle that sinks in and has an opening. IDON-B stated R1's mattress was changed from concave to scoop after R1 fell out of bed on 3/21/23 and additional monitoring was completed. IDON-B stated the monitoring consisted of staff visiting R1 more often during the day and night. IDON-B verified the monitoring was not documented and stated staff just checked on R1. On 5/4/23 at 12:29 PM, Surveyor interviewed FDOM-K who did not recall putting a mattress on R1's bed and stated there were four or five other maintenance staff working at the facility. FDOM-K stated if a nurse told maintenance a mattress was needed, maintenance would get the mattress. FDOM-K stated FDOM-K did not know the difference between a concave and scoop mattress because the facility only had one standard bolster (raised curve or lip on sides) mattress available and that mattress had an opening. On 5/4/23 at 1:28 PM, Surveyor interviewed RN-J who confirmed R1 had the same mattress with a lip on the edge prior to the fall on 3/21/23 and after the fall on 3/21/23 until RN-J no longer worked at the facility.

Based on observation, record review and staff interview, the facility failed to ensure that three residents (R) (R13, R11 and R23), received the necessary services to prevent wandering and ensure personal safety. The facility implemented a resident elopement warning system (Wanderguard - a sensor, attached to the resident's body via a band, designed to alarm when the resident exits through the door,) device on R13's body to prevent elopement from the facility. On 8/6/22, a staff member saw R13 outside through the window. Staff working at that time indicated the Wanderguard system was not alarming as intended when a resident wearing the Wanderguard device exited the door. The facility implemented a Wanderguard device on R11's body to prevent elopement from the facility. On 9/8/22, R11 was found outside by a staff member in the staff parking lot. Staff working at that time indicated the Wanderguard was not alarming as intended. The facility implemented a Wanderguard device on R23's body. On 10/12/22, R23 was observed outside the facility by a staff member. Staff working at that time indicated the Wanderguard was not alarming as intended. The failure to ensure the facility's resident Wanderguard system was functioning properly created a finding of Immediate Jeopardy that began on 8/6/22. Regional Field Operations Director (RFOD) notified the Director of Nursing (DON)-B of the immediate jeopardy 10/19/22 at 12:00 PM. The immediate jeopardy was removed on 10/20/22. However, the deficient practice continues at a scope and severity of E as the facility continues to implement its action plan. Additionally, based on observation, record review and staff interview, the facility did not ensure two residents, R11 and R16, who had a history of falls, had fall-prevention interventions implemented to reduce repeat falls. R11 fell at the facility on 9/30, 9/26, 9/20, 9/17, 8/14, 7/22, 6/20, 6/1 and 5/13/22. Immediate or subsequent fall interventions were not implemented following R11's falls to prevent further falls/injury. R16 used a personal tab alarm at all times as a fall prevention measure to alert staff when R16 attempted to exit the bed. R16 was observed in bed without the personal tab alarm in place. Findings include: Elopement Facility policy titled Elopement, with a revision date of 1/12/22, indicated the following: * Purpose: To assess and identify residents at risk for elopement. To clearly define the mechanisms and procedures for monitoring residents at risk for elopement. To provide a system of documentation for the prevention of, and in the event of, elopement. To minimize risk for elopement through individualized interventions. * Definition: Elopement: When a resident who needs supervision leave the premises or a safe area without authorization and/or any necessary supervision to do so. * Policy: The location will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents at risk for elopement. These include identifying environmental hazards and resident risk; evaluation/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. All residents will be assessed for risk of elopement through the pre-admission and/or admission process as needed. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented and all follow-up required by state and federal regulations will occur. *During the Stay: Elopement drills are recommended to be completed on a routine basis. When elopement drills are conducted, all employees will participate . Conduct the Preventing Elopement Focus Audit to review your facility's elopement prevention and response protocols to determine whether any gaps exist. * Elopement Search: The documentation should include the following information: A. Weather conditions at the time of elopement: raining, snowing, evening, daylight, temperature, etc. Facility policy titled Means of Egress Requirements, Elopement Alarm System, with a revision date of 2/15/22, indicated: Test receivers for functionality at all doors where installed. It is recommended that these devices be tested weekly. 1. R13 was admitted to the facility on [DATE]. R13's diagnoses included dementia, depression, adjustment disorder, anxiety and history of transient ischemic attack (TIA) (a brief stroke-like attack). Minimum Data Set (MDS) assessment, dated 8/29/22, indicated R13 required no physical assistance of staff for ambulation. R13 utilized a walker as an assistive device for ambulation. R13's cognitive score recorded on 6/6/22 and 8/29/22 was 3/15 (indicating severe cognitive impairment). R13's Elopement Assessments dated 9/16/21, 12/16/21, 3/16/22, 6/2/22 and 8/23/22 each indicated R13 was at-risk for elopement. R13's care plan indicated: The resident has potential for elopement r/t (related to) dementia, restlessness, agitation e/b (evidenced by) wandering, exit seeking. (Initiated 9/16/21. Revised: 8/8/22.) Goal: Resident will not leave facility unattended. (Date Initiated 9/28/18. Revised: 6/21/22) Interventions: Personal Alarm: Wanderguard used to alert staff to resident's movement and to assist staff in monitoring movement. (Initiated: 9/28/18. Revised: 9/16/21). Discontinued interventions for R13 related to elopement risk: 30 minutes checks initiated 8/8/22, discontinued 8/29/22. R13 resided on the facility's memory care unit (Birchwood) which contained two exit doors secured with alarms and alarmed doors leading to the main nursing home hallway. Each of the doorways in Birchwood alarmed if any individual opened the door. One of the two exit doors had the Wanderguard system which would sound a second alarm for any resident who utilized the Wanderguard system. The doors leading to the main nursing home hallway alarmed if opened without providing an access code before use. Surveyor reviewed R13's Electronic Health Record (EHR) which included a progress note by Licensed Practical Nurse (LPN)-P, dated 8/6/22 at 5:56 PM, which documented: CNA (Certified Nursing Assistant) notified writer that res (resident) was found outside. Res was walking outside on the sidewalk. CNA is not sure how resident escaped. Res at baseline confusion. Res was redirected into the facility easily. Wanderguard rechecked. Ordered CNAs to watch resident more closely. Progress note of 8/9/22 indicated: Resident alert. Resident has been actively exit seeking and frequently wants to leave to go look for (R13's) car. Resident is on 30 minute checks related to exit seeking. Able to make needs known. Ambulates with walker but needs frequent reminders to utilize walker 2. R11 was admitted to the facility on [DATE] and discharged on [DATE]. R11's diagnoses included chronic kidney disease - Stage 3, anxiety, hallucinations, congestive heart failure, chronic arthritis, recent left wrist fracture and hip contusion post fall, hearing deficit and memory deficits. MDS assessments dated 7/26/22 and 10/2/22 indicated R11 required extensive assistance of staff for locomotion on the unit/in the corridors. R11 utilized a wheelchair for mobility. R11's cognitive score recorded on 7/26 and 10/2/22 was 12/15 (indicating moderate impairment). R11's Elopement assessment dated [DATE] indicated R11 was at-risk for elopement. On 7/20/22, R11's Elopement Assessment indicated R11 was not at-risk for elopement. The care plan for R11 indicated: The resident has potential for elopement r/t (related to) cognitive impairment and recent history of elopement. (Initiated 5/17/22.) Goal: Resident will not leave the facility. Interventions: Wanderguard to wrist used to alert staff to resident's movements. (Date initiated: 5/17/22. Revised: 5/21/22) R11 resided in the main portion of the facility (not the memory care unit), which contained nine exit doors equipped with a Wanderguard system designed to sound when a resident wearing a Wanderguard device was near the door as it opened or attempted to exit the alarmed door. Progress note for R11 dated 9/8/22 at 1:31 PM, documented by Registered Nurse (RN)-H indicated: Staff found resident out in the parking lot of (named facility), (R11) had propelled w/c (wheelchair) outside. Wanderguard was on (R11's) right wrist but did not alarm when (R11) went out the exit door. CNA and writer accompanied resident back into the facility, resident was sitting upright in w/c alert/with confusion. Progress note dated 9/8/22 at 4:26 PM documented by Activities Staff (AS)-V indicated, Resident had attended Devotions at 11:00. As each resident was being wheeled to dining room, this writer returned to the Chapel hallway to find resident pushing outside door leading to courtyard sitting midway over threshold. R11 said (R11) wanted to go outside. Writer pulled (R11) back in and told (R11) that we were not going outside at this time and that it was time for lunch. Resident was guided toward dining room as (R11) refused to be pushed with a very loud NO! After returning from wheeling another resident to the dining room, this writer found (R11) had returned to door getting ready to push it again. (R11) was again guided to the hall to find (R11's) way to the dining room as (R11) adamantly did not want to be pushed. 3. R23 was admitted to the facility on [DATE]. R23's diagnoses included Alzheimer's disease, dementia, anxiety, delusional disorders, depression and heart failure. MDS assessment, dated 8/30/22, indicated R23 required no physical assistance from staff for ambulation. R23 ambulated without an assistive device. R23's cognitive score recorded on 8/29/22 was 3/15 (indicating severe cognitive impairment). R23's elopement assessments, dated 3/10/22, 6/2/22 and 8/25/22, indicated R23 was at-risk for elopement. EHR indicated R23 initially resided in the main portion of the facility. On 10/13/22, R23 was moved to Birchwood. EHR indicated R23 would spend some time on the regular unit afterwards due to not adjusting to the move to Birchwood. Care plan for R23 indicated: The resident has potential for elopement r/t progression of dementia, exhibits wandering behavior, history of elopement. (Date initiated: 3/10/22. Revised 3/10/22.) Goal: Resident will not leave facility unattended. Interventions: Personal Alarm: Wanderguard used to alert staff to resident's movement and to assist staff in monitoring movement. (Date Initiated 3/21/22) Check Wanderguard functionality every shift to ensure Wanderguard is in working order. (Date Initiated 3/10/22) A progress note for R23, dated 10/12/22 at 7:35 AM, documented by RN-H indicated: Staff entering facility found resident (R23) sitting on the porch at the end of 500 wing. (R23's) Wanderguard was on (R23's) wrist. RN and writer entered outside to find (R23) ambulating toward the parking lot. Resident stated I'm just going to meet (family). Writer reassuring that (family) will meet (R23) inside at (R23's) room. Resident pushing at writer, RN and writer able to ambulate with (R23) into the facility. Alarm sounded as resident entered through the door. Vitals WNL (within normal limits), will continue to monitor. Progress note dated 10/13/22 at 6:48 AM documented by RN-H indicated: Resident ambulated down the 100 hallway, past housekeeping and exited 100 wing doors, as writer was coming around the corner, observed resident ambulating through the double doors and exited outside. Assist of two nurses, escorted resident back into the building, resident was compliant and escorted (R23) down to Birchwood. Teaching done with staff to supervise at all times d/t recent elopement, increased confusion/paranoid, Wanderguard on (R23's) wrist. On 10/18/22 at 3:00 PM, Surveyor interviewed LPN-G who stated, following an elopement, the nurse would obtain a set of vital signs, call the family and Social Services staff, then conduct a risk management assessment. This would be followed by a fax to the doctor. LPN-G offered that this (an elopement) recently happened with R23. LPN-G explained that Volunteer Coordinator (VC)-F found R23 outside on the porch. LPN-G indicated that at the time of elopement, the door alarms were not sounding despite R23 having a Wanderguard device. LPN-G indicated that the alarm did sound when R23 was brought back into the facility. LPN-G stated, Maintenance looked at it (door alarm) and said nothing was wrong with it (door alarm). LPN-G clarified the door looked at by maintenance was the 500 wing door. LPN-G stated, The same thing happened with R11. LPN-G further indicated that R23 was seen by LPN-G to be going out the 100 wing doors after being found outside the 500 wing door. LPN-G indicated the 100 wing doors did alarm, R23 made it outside then too, but staff responded. LPN-G stated, It's just the 500 wing door that doesn't seem to work. LPN-G confirmed the facility did not conduct elopement drills, LPN-G stated, It wouldn't be a bad idea. LPN-G indicated that R23 was moved to Birchwood after exiting the 100 wing doors So there are eyes on (R23). LPN-G confirmed it being Hard to keep an eye on R23 on the main unit. Out here (main unit) we (nursing department) are not fully staffed enough to keep an eye on everyone. LPN-G further indicated, even if we do 15 minutes checks (on residents at-risk for elopement), they could walk out of the room after we check on them. Somebody is always in the back on Birchwood, and we can trust those alarms to go off in Birchwood. LPN-G indicated LPN-G thought R11 exited the 500 wing door also. LPN-G indicated, at the time, R11 was found outside, there were no alarms sounding in the facility. LPN-G indicated residents' Wanderguard devices are checked on PM shift each day to ensure the devices are functioning properly. LPN-G confirmed these tests were done at the nurse station with a testing device, not at an exit door. Wanderguard device checks were not documented in the EHR for R11 on 9/19, 9/20, 9/21 and 9/30/22. On 10/18/22 at 3:45 PM, Surveyor interviewed RN-H who verified being at the nurses station on 9/8/22 when a housekeeper indicated R11 was out in the employee parking lot. RN-H confirmed no alarms were sounding from exit doors at that time. RN-H and another staff member went out to the parking lot and found R11 had walked down a sidewalk and deep into the parking lot. RN-H demonstrated where R11 was found. The sidewalk leading to the employee parking lot wrapped around the outside of the facility which Surveyor estimated to be over 100 feet. Surveyor observed a woods adjacent to the parking lot with a large decline, appearing to be an empty retention pond. The hole was approximately 15-20 feet deep and 45 to 60 feet wide. RN-H confirmed the end of the driveway ends with a downhill slope and dipped back up. RN-H also clarified the exit door alarm did sound when they brought R11 back in the door but was not sounding prior to that. RN-H contacted R11's family about the event and when family asked how R11 got out, RN-H responded, (R11) just wheeled out. RN-H expressed to Surveyor Sad thing is - (Nurses) are now helping the aides (CNAs). Pointing to the call light indicator panel at the nurses station We (nursing) can see these (lights for each room) but we cannot see down the halls. RN-H identified three other residents at risk for elopement stating, We cannot see through the walls. As a rule of thumb, we watch when residents go down 500 wing. Regarding R11, RN-H stated, Thank God (R11) did not get to the decline out of the parking lot .we would have never found (R11). RN-H further verified they were lucky because staff are usually not coming .housekeeper went out on a lunch break. Later, Maintenance checked the doors after the event and they felt really bad. RN-H also verified that R11 would not know or be able to remember the door code that disengages the alarm system. RN-H stated, (R23) went through there a couple days ago, same door. RN-H indicated the door alarm(s) were not alarming at the time R23 was found outside either. RN-H confirmed R23 was found by Volunteer Coordinator (VC)-F outside the facility near the 500 wing door. VC-F came in and said 'Oh my God, (R23) is out in front' and so we ran and went and got (R23). RN-H confirmed no alarms were sounding from the exit doors at the time. RN-H indicated Maintenance department checked the doors and nursing staff checked the resident devices at the nurse station. RN-H confirmed that no one interviewed RN-H following the elopement event. On 10/18/22 at 3:46 PM, Surveyor interviewed Social Services Coordinator (SS)-E who indicated an investigation was routinely begun after an elopement event; the Maintenance department checked the doors, nursing checked the resident's Wanderguard device and examined the resident. SS-E indicated that during the next clinical meeting, We discuss what happened and ask, can we figure out how they got out? Can we confirm which door they got out? And that the head of maintenance double checks the Wanderguard system computer to see if the elopement registered. SS-E then stated, Sometimes, unfortunately, it (Wanderguard) does (alarm) and sometimes it doesn't. With the resident, we try to interview as to what happened, sometimes they have no memory of leaving .best we could figure is the resident went out the end of 500 wing and however long it took - there is no timeline - it was difficult to establish other than long enough to get out the door, around the sidewalk and headed towards the employee parking lot .we would all be guessing because no one witnessed the elopement. SS-E believed R11 never got to the parking lot, only the sidewalk. SS-E confirmed not having staff interviews or any other sort of documentation for elopements. SS-E confirmed not having interviews of staff working during elopement timeframes to determine when and where the residents were last seen. SS-E indicated another resident eloped from that door (500 wing exit). SS-E stated, There is a problem with that door, it is very hit or miss if it goes off. On 10/18/22 at 5:50 PM, Surveyor interviewed Maintenance Supervisor (MS)-X. MS-X indicated being aware of one resident who went outside .out the 500 wing exit door. MS-X indicated that the company who installed the Wanderguard system ran into a little block of the signal (from the resident's device). MS-X indicated the receiver had to be moved to pick up a signal. MS-X also confirmed a second resident was found outside. MS-X indicated the 500 wing exit door was double-alarmed at the time of that next elopement with a tabs alarm (a device that has an alarm box with a string connecting from the box to a magnetic tab which alarms once the string pulls from the box). MS-X indicated resident was provided a new Wanderguard device which was tested and worked. MS-X confirmed having no documentation related to an investigation into the potential door alarm malfunction. On 10/18/22 at 6:05 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who stated, I cannot say without having concrete evidence that (R23) went out the said door (500 wing door). For all we know, (R23) could have followed someone out a door, or manipulated something or watched someone use the code. All we know is (R23) ended up outside in the 500 wing patio. It is certainly an option (R23) exited the 500 wing door. When asked what was done following R23's elopement, NHA-A indicated, We checked R23's Wanderguard at the nurse station with the device nursing uses to check resident Wanderguard devices. We know the Wanderguard alarmed when R23 returned through a door. NHA-A did not know which door R23 was returned into the facility. NHA-A confirmed Maintenance Department would check the exit doors which had Wanderguard sensors with the maintenance testing device. NHA-A indicated having made a request to have R23's Wanderguard device changed out of precaution as well. Surveyor questioned NHA-A about the tabs alarm mentioned by MS-X. NHA-A stated, They (maintenance staff) put a pull tab on the door as a means to alarm as the system was not alarming. On 10/18/22 at 6:21 PM, Surveyor and NHA-A observed the 500 wing exit door. Surveyor immediately observed the pull tab alarm was unattached; therefore it would not alarm if the door was opened. NHA-A took the end of the string, stuck it back onto the glass and stated, It must have come off. On 10/18/22 at 6:27 PM, Surveyor requested facility test a Wanderguard device through the 500 wing door to see if the door would alarm. Surveyor opened the 500 wing door with NHA-A near the door holding the Wanderguard device. Neither of the two alarms sounded. Surveyor then pointed out to NHA-A the tabs alarm and pull device/string were unattached and could not alarm if the door was opened. NHA-A stated, They weren't thinking when they did that. NHA-A confirmed the way the tabs alarm was set up, it would not alarm if a resident were to open/attempt to exit the door. The 500 wing door closed and Surveyor again opened it and NHA-A walked through the door while holding the Wanderguard device; the Wanderguard system again did not alarm. NHA-A stated, Maybe this (Wanderguard sensor) is a dud. NHA-A then retrieved R9's Wanderguard bracelet which, when tested through the door, also did not alarm. Several more attempts were made to activate and de-activate the door alarms with various bracelets and sensor placements, all of which verified inconsistent functioning. Maintenance Mechanic (MM)-L demonstrated an incorrect placement of the tabs alarm which again failed and verified via interview the malfunctioning door alarm was recognized 4 - 6 weeks prior. On 10/18/22 at 7:20 PM, Surveyor asked NHA-A and DON-B how many residents in the facility were at-risk for elopement and how staff would be aware which residents were at-risk for elopement. NHA-A and DON-B looked briefly around the nurse station for a list, and NHA-A indicated there was not one at the nurse's station. On 10/18/22 at 7:21 PM, Surveyor interviewed LPN-S who confirmed being a new employee and confirmed not being aware of which residents in the facility were at-risk for elopement. LPN-S looked through some papers and confirmed not having a list or knowing where to find a list of residents who were at-risk of elopement. On 10/18/22 at 7:55 PM, DON-B provided a list of residents, five total, who were at risk for elopement. DON-B retrieved the list from DON-B's computer. On 10/18/22 at 8:00 PM, NHA-A stated, We found another door that is not working, R23 could have gone out this door. MM-L indicated having not checked all exit doors yet. MM-L stated, Some are more temperamental than others. MM-L stated, MM-M will work on it (testing door alarms) tomorrow. Surveyor asked MM-L what would be done tonight, NHA verified tab alarm would be used. On 10/19/22 at 7:45 AM, Surveyor interviewed MS-X who indicated Maintenance mechanics were in the process of checking all alarmed exit doors. MS-X provided Surveyor with preventative maintenance logs which included a task titled Doors, locks, gates and alarms. The task was signed out weekly as completed. The tasks were not specific as to which doors were tested . MS-X explained each alarmed door is checked on a weekly basis. MS-X was not able to provide Surveyor with the date the doors were tested . When asked about an investigation into the elopement, MS-X indicated, only intervention put into place included a tabs alarm on the door after R11 was found outside. MS-X said for R23, R23 was given a new bracelet (where the Wanderguard device is attached to). MS-X indicated, maybe (R23) followed a staff out, but that would be making a guesstimate. Regarding the tab alarm being disconnected on 10/18/22, MS-X indicated, People go through that door and disconnect it (the tabs alarm) and likely do not reconnect. On 10/19/22 at 8:08 AM, Surveyor observed MM-M testing exit door alarms. MM-M confirmed utilizing the maintenance department's testing device to do so (not a device already assigned to a resident). MM-M tested nine doors which MM-M said were alarmed with a Wanderguard. Surveyor observed each door to alarm when maintenance tested them, including 500 Wing Exit Door. On 10/19/22 at 9:05 AM, Surveyor contacted the vendor who installed the Wanderguard. Customer Service Representative (CR)-T indicated the last service call made to the vendor by the facility was on 7/15/22. CR-T confirmed there were no tickets initiated by the facility or for the facility after 7/15/22. On 10/19/22 at 9:40 AM, Surveyor re-interviewed MS-X regarding contacting the Wanderguard vendor following the elopements in which alarms did not sound. MS-X stated, We did not call them (vendor). We moved the sensor ourselves. On 10/19/22 at 11:36 AM, Surveyor reviewed a computer-based door alarm report with MS-X. For 10/18/22, the report did not show an exit taking place with R9's device at 6:37 PM (which coincides with the door not alarming when NHA-A exited the 500 wing door with R9's device). At 6:38 PM, the report showed the alarm activated (which coincides with NHA-A's subsequent attempt to exit with R9's device after entering numbers into the keypad). MS-X confirmed the report only included one exit for R9's device for the evening of 10/18. Regarding maintenance tests following elopements and on a weekly basis, MS-X indicated these tests would likely not show up as maintenance does not use a device which is assigned to a resident name. MS-X reviewed the log for R23's elopement date of 10/12/22 and confirmed there was only one alarm noted (at main entry), which was at 7:32 AM. Surveyor indicated to MS-X that R23's EHR indicated the alarm sounded upon returning R23 to the facility. MS-X confirmed there was not an indication on the report for both an exit and an entry; only indication that the alarm activated once. For 9/8/22, the report indicated R11's sensor activated at 3:40 PM and at 3:46 PM (main entry). MS-X confirmed there to be no entry for R11's sensor around the time R11 was discovered outside earlier that date (approximately 1:30 PM). On 10/19/22 at 12:35 PM, Surveyor interviewed RN-H who stated, No one is supposed to use the 500 wing exit door, but to be honest, smokers (staff) sometimes do. Surveyor observed a piece of wood next to the door which RN-H confirmed is likely used to prop the door open. RN-H explained that even if a resident tried to follow a staff out the door, the door should alarm as the door can only be deactivated with the keypad. RN-H stated, (R11) went out that door (500 wing door), no doubt in my mind. RN-H further indicated, if (R11) would have exited another door, those alarms were more sensitive. RN-H indicated the 500 wing is newer and RN-H said, I think there is a spot somewhere in here (as RN-H stands by the 500 wing exit door) that does not receive the signal (Wanderguard device's). RN-H confirmed the tabs alarm now on the door and stated, When we (nursing staff) are all the way down the hall, we won't hear the tabs alarm. On 10/19/22 at 12:55 PM, Surveyor interviewed DON-B regarding investigations related to the three resident elopements. DON-B indicated these would be documented in the EHR under risk management. Surveyor reviewed EHR risk management report for R11's 9/8 elopement which was reviewed by DON-B on 9/21/222. Action Taken indicated: Writer (RN-H) - Resident was sitting upright in w/c (wheelchair), alert/pleasantly confused, speech is clear, unable to lift feet, CNA and writer escorted into facility. Wanderguard on right wrist, no injuries. Writer checked Wanderguard and noted it is working. Will get (R11) a new Wanderguard for safety. Risk management documentation for R13 indicated, 8/6/22: CNA notified writer (LPN-P) that resident was found outside. Resident was walking outside on the sidewalk. CNA is not sure how resident eloped. Resident is at baseline confusion. Action Taken: Resident was redirected into the facility. Wanderguard checked. Ordered CNAs to watch resident more closely. On 10/19/22 at 2:23 PM, Surveyor interviewed Environmental Services staff (ES)-W who indicated having found R11 in the employee parking lot. ES-W indicated, I tried to bring (R11) in and (R11) put (R11's) feet down, so I locked R11's wheelchair brakes and went inside to get the nurses. ES-W confirmed, when ES-W entered the facility to get help and when leaving the facility prior to finding R11, there were no alarms sounding. On 10/19/22 at 3:15 PM, Surveyor interviewed DON-B regarding R13. DON-B confirmed the elopement occurred on a Saturday. When DON-B returned to the facility on Monday, DON-B believed DON-B had maintenance check the doors for alarming on Birchwood unit. DON-B recalled one door's alarm to be quieter than DON-B wanted it to be so DON-B had maintenance staff turn the volume up. DON-B confirmed that, at the time staff found R13 outside, doors were not alarming at all. When asked what steps were taken to prevent elopements from recurring, DON-B stated, We met with the the Interdisciplinary Team, reviewed the care plan and we would have charted to monitor the resident closely in Point of Care charting (EHR CNA instructions). DON-B was unaware R13 was found outside. DON-B confirmed R13's care plan intervention of 30 minutes checks started on 8/8/22 and was discontinued on 8/29/22. Surveyor reviewed R13's EHR. R13's Treatment Administration Record (TAR) initiated on 8/8/22 at 3 PM read, Monitor resident q 30 (every 30) minutes due to elopement risk for two weeks. On 10/20/22 at 7:45 AM, Surveyor interviewed Volunteer Coordinator (VC)-F. VC-F confirmed being the staff who found R23 outside on 10/12/22. VC-F indicated, I was coming from the employee parking lot about 7:30 AM and saw (R23) outside. I was carrying a bunch of stuff so I went to the nurse station where I notified (RN-H). VC-F confirmed there were no door alarms sounding in the building at the time VC-F entered the facility. VC-F indicated the weather to be cooler, around 40-something that morning. VC-F confirmed R23 did not have a jacket on at the time nor interviewed about the elopement. VC-F confirmed R23 walked independently and was unaware of R13's elopement. On 10/20/22 at 8:09 AM, Surveyor interviewed NHA-A and DON-B regarding root cause analysis or investigative documents related to the elopements and/or the failure of the resident Wanderguard. NHA-A stated, I vaguely recall the elopement for (R13). With regards to the doors not alarming for the three residents who eloped, NHA-A confirmed the trial done on 10/18 in which R9's device did not alarm when exiting the 500 Wing door and stated, It is almost like there is something with the system, maybe it needs to be reset or something. NHA-A confirmed the facility did not conduct elopement drills. On 10/20/22 at 8:15 AM, Surveyor interviewed Social Services Coordinator (SS)-E regarding R13's elopement and elopement procedures. SS-E indicated, we have something at the nurse's station who should be called, certainly for an elopement, someone should call the DON or Social Service person on-call. SS-E looked for the policy which was not provided to Surveyor. On 10/20/22 at 8:40 AM, Surveyor interviewed CNA-Q who indicated not knowing how R13 eloped. CNA-Q said, We (CNAs) are left back here (Birchwood) alone, I could be toileting someone and someone else can fall. We have the radio but we call and often no one will answer. CNA-Q indicated R13 ambulated independently. During this interview, CNA-R approached and added, We never did figure out what door R13 got out. CNA-R then showed Surveyor an exit door which led to a courtyard. The door had an alarm that sounded if staff do not enter a code prior to opening the door. Surveyor observed the door to lead to a path in a courtyard, the courtyard gate was open as well. CNA-R stepped outside to close and secure the courtyard exit gate, at which time an alarm sounded at the door. CNA-R entered a code and the a [TRUNCATED]

Based on observation, record review, and staff interview, the facility did not ensure each resident received necessary treatment to prevent pressure injuries from developing for 1 Resident (R) (R9) of 5 sampled residents reviewed for pressure injuries. R9 developed an unstageable pressure injury to the right ankle on 8/1/22. When R9 developed a scab to the pressure injury, facility staff did not properly assess R9's pressure injury until 10/18/22 after the pressure injury developed a scab and after A & D ointment was placed on the wound to soften the scab. The wound developed to a stage 3 pressure injury. R9's plan of care was not updated to include R9's unstageable pressure injury and R9 did not have a treatment plan in place. Findings include: The facility policy entitled Pressure Ulcer/Wound Care Resource Packet - Rehab/Skilled with a revised date of 5/26/22, indicated promotion of healing, pain management and prevention of complications is extremely important, as well as accurate assessment and documentation. Wound RN (Registered Nurse) Assessment is required at least every seven days and as needed when skin integrity is impaired or open area is present. Resources for the policy included NPIAP (National Pressure Injury Advisory Panel) and staff are to use and follow their recommendations. 1. On 10/18/22, the Surveyor reviewed R9's medical record. R9 was admitted to the facility with diagnoses to include cerebral infarction (stroke), rheumatoid arthritis and depression. R9's medical record also indicated R9 developed a red area on the outside of R9's right ankle bone at the facility on 8/1/22. R9's admission MDS (Minimum Data Set) assessment, dated 7/22/22, indicated R9's cognition was 12 out of 15 (the higher the score, the more cognizant). R9's MDS also indicated R9 was at risk for the development of pressure injuries, R9 did not have a pressure injury and R9 had pressure relieving devices for bed and chair. R9's plan of care, dated 7/18/22, indicated R9 had potential for pressure injury development related to impaired mobility and Braden score of 16. R9's interventions included to turn/reposition every two (2) hours and to notify the nurse immediately of any areas of skin breakdown including redness. R9's Braden Scale was completed on 10/12/22. R9's score was 19, which indicated, R9 was not at risk for the development of a pressure injuries. R9 was chairfast. Another Braden scale was completed on 10/19/22 after the Surveyor made the facility aware R9 had a pressure injury to the right ankle. The Braden scale completed on 10/19/22 indicated R9 was at mild risk for the development of pressure injuries with a score of 18. R9 was chairfast and mobility was slightly limited. R9's progress note, dated 7/18/22, indicated R9 was admitted to the facility on [DATE] with no open areas noted. R9's progress note, dated 8/1/22, indicated R9 had a red area on outside of R9's right ankle bone. Area not hot, but sensitive to touch. Sleeps on right side. Will wear heel lift boots to prevent skin breakdown. R9's MAR (medication administration record) and TAR (treatment administration record) were reviewed for September 2022 and October 2022 with no wound care noted. On 10/19/22 at 6:28 PM, the Surveyor interviewed DON (Director of Nursing)-B and IP/RN (Infection Preventionist/Registered Nurse)-J regarding the border gauze dressing on R9's right ankle which was not dated or initialed. DON-B and IP/RN-J stated they were not made aware of any pressure injuries or wounds to R9's right ankle. On 10/19/22 at 6:38 PM, the Surveyor interviewed LPN (Licensed Practical Nurse)-S regarding R9's right outer ankle. LPN-S removed R9's sock while R9 winced in pain. LPN-S confirmed R9 had a 4x4 border gauze dressing on the right ankle which was not dated nor initialed. LPN-S indicated LPN-S did not have knowledge of R9 having a wound on the right ankle. LPN-S confirmed R9's wound was not documented on R9's MAR or TAR. LPN-S measured the wound on the right outer ankle to be 0.5 cm (centimeter) x 0.5 cm x 0.2 depth and indicated the wound was white in the center and red on the periphery of the wound. LPN-S cleansed the wound with normal saline and placed a dry dressing on the wound until orders are received from the physician. LPN-S stated LPN-S would ask the nurse in the morning to follow up on the wound. On 10/19/22 at 6:45 PM, the Surveyor interviewed CNA (Certified Nursing Assistant)-Z, DON-B and IP/RN regarding the dressing on R9's right ankle. CNA-Z stated the dressing is from R9 scratching self. DON-B and IP/RN confirmed R9 did not have a TAR, did not have any wound orders, neither of them were notified of a pressure injury or wound to the right ankle, and the physician was not notified regarding the wound. On 10/20/22 at 9:47 AM, DON-B was taking off R9's sock to observe R9's wound on the right ankle. DON-B stated DON-B heard (R9's) ankle was red. R9 was wincing in pain and pulling leg slightly back when DON-B was removing R9's sock to be able to remove the bandage off R9's right ankle. DON-B stopped taking the bandage off due to pain and stated will administer pain medication prior to removing the bandage. On 10/20/22 at 12:29 PM, the Surveyor observed RN-H remove the dressing from R9's ankle. When removing the dressing, a thin layer of skin with a small amount of red drainage was on the dressing. RN-H stated there was slough in the wound. R9 stated the area was tender and requested to stay in bed because the wound hurt. On 10/20/22, RN-H sent a fax to R9's physician. The fax indicated R9 had an old scabbed area on right ankle that measure 0.6 cm x 0.4 cm x 0 cm. Reddened area. R9 complained of pain. Can we have an order to apply Hydrogel foam dressing? Change daily until healed. On 10/20/22 at 12:50 PM, the Surveyor interviewed DON-B regarding R9's pressure injury on the right ankle. DON-B stated DON-B was not aware R9 had a pressure injury to the right ankle until the Surveyor advised DON-B of the pressure injury to the right ankle. DON-B was not able to locate documentation which would indicate R9's wound was measured, if the physician was notified or if the pressure injury was staged and described to determine if slough. Per RN-H, It was a lack of communication and documentation that RN-H put A&D ointment on R9's right ankle pressure injury to remove the scab. Was not aware R9 had an open area prior to that. The next shift was not informed of the pressure injury, staff were not informed at shift change and there was not an RN assessment completed on the pressure injury. Per DON-B, R9's pressure injury is a stage 3 pressure injury as there is slough. Will request a honey dressing. Additionally, DON-B verified R9's plan of care did not include a pressure injury. On 10/20/22 at 1:38 PM, the Surveyor and WCCRN (Wound Care Certified Registered Nurse)-CC observed R9's pressure injury to the right ankle. WCCRN-CC stated, don't know what is under the slough. Could be a tunnel. Because there is slough in the wound bed, needs to be stage 3. Definitely pressure because on bony prominence. WCCRN-CC measured the pressure on R9's right ankle. The pressure injury on the right ankle measured 1 cm x 1.1 cm. WCCRN-CC then stated, a pressure injury can develop quickly if R9 did not get out of bed or was not repositioned. Medi-honey would be the best treatment. Foam dressing would be best to stay on for 3 to 5 days because each time the dressing is removed, the wound bed stops healing. A&D ointment should not be placed on a scab as the goal for the scab is to remain intact to protect the integrity and not introduce potential infection.

Based on staff and family interviews and record review, the facility did not immediately consult with the physician of 1 Resident (R) (R2) of 4 sampled residents when there was a significant change in the resident's physical, mental, or psychosocial status (a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); and when there was a need to alter treatment significantly (a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment.) R2 was prescribed three diuretic medications (medications that increase the excretion of water from the body) due to profuse lower extremity [MEDICAL CONDITION] (swelling caused by excess fluid.) The most recently added diuretic medication was prescribed on [DATE]. On [DATE], R2 began to decline in condition and nutritional status. Laboratory findings indicated worsening BUN(Blood Urea Nitrogen), low GFR (Glomerular Filtration Rate indicative of worsening of [MEDICAL CONDITION] stage III) and increased creatinine levels. On [DATE], R2 began to complain of daily increased weakness and fatigue and oral intake of food and fluids began to decline. On [DATE], R2 complained of abdominal pain and nausea. Laboratory findings completed on [DATE] to include [MEDICATION NAME] level (R2 was on the steroid medication [MEDICATION NAME]) due to notable moon face and back [MEDICAL CONDITION], a sedimentation rate (used to confirm [MEDICAL CONDITION] processes) and uric acid (high levels indicate gout flare up) levels were drawn and noted to be within normal limits. R2 continued to complain of symptoms. The facility did not notify the physician related to R2's change in condition. R2 saw the primary care provider on [DATE] and laboratory work was ordered. On [DATE], R2 was admitted to the hospital with [REDACTED]. R2 expired on [DATE]. Findings include: Review of R2's closed medical record indicated [DIAGNOSES REDACTED].(Urinary Tract Infections) with urosepsis, [MEDICAL CONDITION], and gout. R2 was own decision maker. R2's MAR (Medication Administration Record) indicated R2 was prescribed the diuretic medication [MEDICATION NAME] 40 mg (milligrams) daily on [DATE]: the diuretic medication [MEDICATION NAME] 2.5 mg daily on [DATE] which was held from [DATE]-[DATE]; and the diuretic medication [MEDICATION NAME] 25 mg daily on [DATE], all with [DIAGNOSES REDACTED]. Further review of the MAR indicated [REDACTED]. On [DATE] R2's laboratory findings included a BUN of 26 (normal ,[DATE]); a Creatinine of 1.0 (normal 0XXX,[DATE].0); a potassium of 3.4 (normal 3XXX,[DATE].1); and a GFR of 53.4 (Normal ,[DATE]). R2's medication Potassium 20 meq (miliequivalents) was increased to twice daily for 5 days then resumed at daily after that. On [DATE], R2 was noted to have significant lower extremity [MEDICAL CONDITION]. R2's primary care provider was notified and a new diuretic [MEDICATION NAME] 25 mg daily and hold [MEDICATION NAME] from [DATE]-[DATE] then resume, was initiated into R2's medication regime. A Basic Metabolic Panel dated [DATE] indicated a BUN of 59; creatinine of 1.4 and GFR of 36.2. On [DATE], R2 was seen for nursing home rounds by the primary care physician. Review of MD (Medical Doctor)-E's dictated note indicated, Recent adjustment of diuretic have been helpful (R2) is down 10 pounds. Legs are less swollen and can get shoes on again. Creatinine is 1.3. Oral Cavity is moist. Will check basic metabolic panel. Review of the Basic Metabolic panel dated [DATE], indicated that R2's BUN was now 42; Creatinine was 1.3; and GFR was 39.4. On [DATE], a Basic Metabolic Panel for R2 indicated a BUN of 65; a Creatinine of 1.9; and a GFR of 25.4. The primary care physician noted the laboratory levels and ordered a repeat Basic Metabolic Panel in three weeks. Review of R2's medical record indicated the following: On [DATE], the staff documented R2 refused one meal. Oral intake of fluids for the day during meals was 720 ml (milliliters.) R2's weight was listed as 198.8 pounds. Vital signs were not documented for that day. On [DATE], staff documented R2 refused two meals. Oral intake of fluids for the day during meals was 240 ml. Vital signs were normal with no orthostatic vitals obtained. It was noted that R2 was not able to stand but orthostatic vitals can be revised to include monitoring the blood pressure and pulse while lying, then rechecking after one minute in a seated position. a nursing entry indicated, Received a phone call from (R2's) daughter concerned about (R2) stating just got off the phone with (R2) and (R2) stated was so weak could barely walk. Daughter commented that something needs to be done, even thought the lab work is normal there is something wrong with (R2). Informed daughter (R2) had spoken with writer earlier and had commented that (R2) was feeling tired. Daughter commented that something needs to be done, maybe even needing to be in the hospital since (R2) was so weak. Informed daughter that writer was going into room and would be checking on (R2). Also informed daughter that writer would check vitals. Daughter made a comment in regards to the [MEDICAL CONDITION] and if that could be back and causing problems. Again informed that writer would be checking vitals and look at (R2). Upon entering room, (R2) was sitting on edge of recliner, transferring self to wheel chair. Speaking soft but voice audile. Skin warm and dry to touch. Did speak with (R2) that daughter had called concerned about resident. (R2) commented that was tired. Questioned what the doctor had said the other day about when told was tired. Informed the doctor acknowledged being informed of being tired. (R2) transferred to toilet by writer. Stood without difficulty. (R2) did comment that there must be something wrong as was tired. Questioned if (R2) could have polyfibrosis. (R2) became weepy when speaking with writer. Vital taken, reassurance given. On [DATE], R2 refused one meal. Oral intake of fluids for the day during meals was 720 ml. Vital signs were within normal limits with no orthostatic vitals obtained. A nursing entry indicated, Sat up on edge of bed this a.m. to take med's. Did comment that was stiff but that usually goes away after moves around. Took meds without difficulty. Did get dressed and sat up in wheel chair. Spent shift in room. Was sleeping when writer approached with noon med's. (R2) did comment that was so tired today. Was going to have soup and tea for lunch. Skin warm and dry to touch. Takes fluids well. No tenting noted to skin. Afebrile. On [DATE], the staff recorded only two meals; one with response not required. Oral intake of fluids for the day during meals was 240 ml. No blood pressure was documented for that day. No nursing documentation was noted on [DATE] in R2's medical record. On [DATE], R2 ate well and took in 600 ml of fluid during meals. No blood pressure was documented for that day. Pulse was listed as 95 and irregular. A nursing entry indicated, Canceled appointment with physician today. (R2) not feeling well enough to attend the appointment. On [DATE], R2 ate well and took in 240 ml fluids with meals. Blood pressure was high at ,[DATE]. A nursing entry indicated, Sent fax to (MD-E) requesting order for OT (Occupational Therapy) eval due to poor positioning in wheel chair and requested order for [MEDICATION NAME] level. (R2) is moon-faced and complaining of muscle weakness and tiredness. On [DATE], R2 ate only ,[DATE] % of one meal, refused one meal, and had an oral intake of fluids for the day during meals of 600 ml. Vital signs were within normal limits with no orthostatic vitals obtained. Weight was listed as 198 pounds. No further nursing documentation was completed for R2 on [DATE] except that sedimentation rate, [MEDICATION NAME] level and uric acid level was drawn. On [DATE], R2 refused two meals and had an oral intake of fluids for the day during meals of 600 ml. The only vital signs listed were a normal pulse and temperature. A nursing entry indicated that (R2) was having increased pain in hips then denying pain medications because wasn't having pain in hips but could not be specific to pain site then (R2) commented wasn't having any pain at all. (R2) did comment that was having some abdominal pain. Did also have a bowel movement. Declined to eat breakfast or lunch. Complained of feeling nauseated. Was sipping on soda. Declined any offer of food except soda crackers. Skin warm and dry to touch. No tenting noted. Does receive 3 diuretics. On [DATE], R2 ate well and had an oral intake of fluid for the day during meals of 720 ml. The only vital sign listed was a normal pulse. A nursing entry indicted, (R2's) daughter concerned regarding (R2) being weak and tired. When writer would ask (R2) what was wrong, (R2) would begin crying stating, 'I'm just so tired.' Did not mention anything about pain or weakness. (R2's) daughter questioning about what was being done about (R2's) weakness. Writer informed daughter that labs were drawn on [DATE] and had not gotten the results back yet. Spoke about (R2) being evaluated at the ER or Urgent Care. (R2's) daughter agreeable to continue to monitor resident at facility and for (R2) to see primary care physician on Monday ([DATE]). Will leave note for facility scheduler. Will continue to monitor. It was noted that R2 did not see the primary care provider until [DATE]. On [DATE], R2 refused one meal and ate only ,[DATE]% of another meal. The oral intake of fluids during meals was listed as 600 ml. Pulse was 78 and irregular. No nursing documentation was completed on [DATE]. On [DATE], through [DATE], R2 ate and drank well (except for one meal on [DATE] where intake was ,[DATE]%.) A nursing entry indicated, Daughter worried about how tired (R2) was. Follow up appointment made with doctor for [DATE]. An additional nursing entry for [DATE] indicated, Resident has appointment to see (MD-E) on [DATE] for mood/depression. On [DATE], per request of R2's daughter, the Dietician evaluated R2. The documented notes indicated, Spoke with (R2), states appetite is 'terrible.' Willing to have 4 ounce vanilla shake at lunch today. In the last week, intake down to 49% average. Will continue to monitor. Per chart [DATE] 198 pounds, [DATE] 211 pounds. This is a significant weight loss of 13 pounds, down 6% in last month. Per nursing decreased fluid. [MEDICATION NAME] 25 mg started on [DATE] for [MEDICAL CONDITION] and receiving [MEDICATION NAME] 40 mg. Significant wt (weight) loss combination of decreased intake and decreased fluid. Staff have been encouraging resident at meals/snacks. On [DATE], R2 ate ,[DATE]% of two meals and had an oral intake of fluids during meals of 680 ml. R2's weight was listed as 197.2 pounds with a pulse rate of 86 and irregular. It was noted that the meal intake charting for fluids, documented by the CNAs often listed. Response not required for 11 of the meals from [DATE]-[DATE]. At no time between [DATE] and [DATE] did the facility consult with R2's primary provider regarding continual fatigue, lethargy, abdominal pain, nausea or decrease in appetite. The Surveyor reviewed R2's medical record and only noted one fax sent to R2's primary care physician about R2 being tired which was dated [DATE]. At that time, the physician ordered a [MEDICATION NAME] level, uric acid level and sedimentation rate. All laboratory values returned within normal limits. On [DATE] at 12:20 p.m., the Surveyor interviewed DON (Director of Nursing)-B. DON-B verified to the Surveyor that there were no additional faxes sent to R2's physician in spite of continued decline in R2's condition. On [DATE], R2 was evaluated out of the facility by MD-E. Dictated notes from that evaluation were not located in R2's medical record and the Surveyor had to request that consult. The facility's Clinical Referral notes sent along for the consult indicated problem to be evaluated as, Depression screening/decrease in number of medications given daily (per the resident's request.) There was no indication on the referral to make MD-E aware of R2's recent symptoms and decrease in food and fluid intake. The consult dictated by MD-E indicated, (R2) comes in with daughter today for failure to thrive over the past 2 weeks. The patient has had a slow decline. has spent time 'spaced out.' (R2) has a harder time remembering things. (R2) has been more fatigued. Appetite has been reduced. This has been a slow but steady decline. The patient offers really nothing in the way of useable history. I did a review of systems with the resident and could not really identify anything other than some bladder irregularity potentially urinary tract infection and potentially some signs of dehydration. Oral cavity is somewhat dry. Assessment: Failure to thrive. [MEDICAL CONDITION]. Plan: Will get chest X-Ray, A1C, CBC, Basic Metabolic Panel, TSH, urinalysis. (R2's) (blood sugar) done at the nursing home earlier this month was 275. (R2) has a history of diabetes but only when on high steroids, (R2) is only on 5 mg of [MEDICATION NAME] now. It could be that (R2) is dehydrated from high sugar and increase in [MEDICATION NAME] use. Since [MEDICAL CONDITION] is better controlled using compression stocking will discontinue the [MEDICATION NAME]. Will decrease Mirabegron which could cause come confusion. Reduce [MEDICATION NAME] to twice daily from three times daily. Reduce [MEDICATION NAME] from 37.5 to 25 mcg daily. Will await further work up. It is possible they will have to send resident to the ER for fluids if it looks like (R2) is clinically dehydrated. There are suspicions of that on exam today. On [DATE], R2's laboratory results were obtained and R2's physician ordered R2 to be sent to the hospital to be treated for [REDACTED]. On [DATE], R2 was evaluated at the hospital. The emergency room documentation indicated that R2's BUN was now high at 87; Creatinine was high at 2.03; low GRF at 23.56 and high BUN/Creatinine ratio was 42.9 (normal 3XXX,[DATE]). [NAME] blood cell count was high at 14,000 (normal ,[DATE]). The evaluation indicated that R2 had a low blood pressure of ,[DATE] and had dry mucous membranes. The evaluation indicated, Onset gradually over the last 3 weeks or so. Debilitated fatigue sensation and increased somnolence. Precipitated by unknown however the patient has significant comorbidities and multiple medications which could impact mental status as admission for urosepsis in recent years. Daughter states that the patient is not one to take by mouth fluids in the first place and suspects by mouth intake has been less than normal in recent weeks. Positive associated decreased mouth intake of fluids and decreased urine output. Patient presents to the the department after outpatient visit yesterday and blood work reviewed today showing significant deviation from baseline indices notably the BUN and Creatinine which are elevated consistent with dehydration. The patient has significant risk for infection notably UTI give comorbidities and medications. Diagnostic work up consistent with urosepsis and dehydration contributing to mental status change and debilitation. R2 was admitted to the hospital. The hospital history and physical dated [DATE] indicated, (R2) reports feeling very weak and exhausted. Reports some dizziness. Has had a greatly decreased appetite starting about 3 weeks ago as well. Currently feels a little nauseous and has no appetite. Daughter reports increased confusion and slowing of cognition from baseline. Blood pressure ,[DATE]. Has increased frequency of urine. Lethargic and slow to respond, difficult to gather a history, oriented to time, person, and place. Assessment: [MEDICAL CONDITION]. UTI. IV(Intravenous [MEDICATION NAME] (antibiotic). Acute on chronic kidney injury. [MEDICAL CONDITION] stage III. Start IV at 75 ml/hour with careful monitoring as to not fluid overload patient. Hold [MEDICATION NAME] because of kidney injury and fatigue. R2 remained confused and debilitated during hospital stay despite laboratory findings improving. R2 was placed on Hospice services and expired on [DATE]. It was noted that on [DATE], R2 had an ADPOAHC (Activated Durable Power of Attorney for Health Care initiated. On [DATE] at 12:00 p.m., the Surveyor interviewed MD (Medical Doctor)-E via the telephone. MD-E was R2's primary care provider. MD-E stated, I evaluated (R2) at the nursing home on [DATE]. The main concerns were back pain and lower extremity [MEDICAL CONDITION]. The [MEDICAL CONDITION] was better and the weight was down. I wanted (R2) to loose weight related to the [MEDICAL CONDITION]. Between the time I evaluated (R2) on [DATE] and [DATE], there was a significant change. (R2) was very confused and out of it. I was concerned that (R2) was dehydrated, so I ordered lab work. I don't have access to faxes that the facility sent me. We don't keep those records in the office. Whatever faxes that are in (R2's) chart at the nursing home is what staff was relaying to me. The lab work from [DATE] showed a high white blood cell count, a low sodium, a high creatinine and BUN and there was a questionable UTI, but I wasn't sure at the time since the urine culture was pending. I don't know what happened at the hospital. I know on (R2's) death certificate, cause of death was listed as [MEDICAL CONDITION], but I don't think this was the case. (R2's) white blood cell was not high enough to indicate that. If the facility thought or the family had relayed concerns to the nurses about (R2's) health status, (R2) should have been sent to the ER (emergency room ). I'm not sure how quickly (R2) went down hill. On [DATE] at 2:10 p.m. the Surveyor again interviewed MD-E via the telephone. MD-E stated, If staff would have told me that (R2) wasn't doing well, I would have evaluated (R2) at the clinic or had (R2) sent to the ER earlier. On [DATE] at 4:45 p.m., the Surveyor interviewed FM (Family Member)-D. FM-D stated, (R2) was own decision maker until hospitalized . On [DATE], I was made activated power of attorney for health care for (R2). I was sick from [DATE]-[DATE] so I didn't see (R2) until [DATE]. I noticed (R2's) lips were cracked with black scab like streaks on them. (R2) always complained of dry lips and mouth, but I've never seen (R2's) lips look like that. They appeared that way all the way up to hospitalization (on [DATE]). I am the one that asked for the Dietician to look into getting a shake or something for (R2). (R2) wasn't eating and isn't much of a water drinker. When I was visiting, (R2) drank very little with my encouragement. They refilled the water jug in the room every day, but most of the water from the day before was still in the jug and was dumped before refilling. When I was there, I never saw any staff encourage or offer (R2) fluids. I thought (R2) should go to the hospital on [DATE], but staff felt it wasn't necessary because it wasn't emergent. I didn't push for hospitalization because I trusted the staff and felt they were the professionals and knew what they were doing. Staff told me they would have the doctor see (R2) the following Monday ([DATE]) but (R2) didn't see the doctor until [DATE]. (R2) was very weak and tired. (R2's) other family member had commented on the same thing when talking to (R2) on the phone that (R2) was so weak and tired could hardly talk. (R2) was so weak that when I did offer water, (R2) could hardly hold a glass. While at the hospital, the oncologist evaluated (R2) and told us that [MEDICAL CONDITION] had not reoccurred. (R2) was not eating at the hospital and refused tube feeding, so the decision was made to initiate Hospice services. On [DATE] at 10:00 a.m., the Surveyor interviewed CC (Care Coordinator)-F. CC-F stated, When residents go to a doctors visit outside of the facility, they use the form, Clinical Reference and wire in the concerns they want addressed with that visit. On [DATE] at 10:10 a.m., the Surveyor interviewed RN (Registered Nurse)-[NAME] RN-G stated, I knew (R2) was on three diuretics and intake of fluids was decreased. (R2) was sad. We were encouraging to drink more but only wanted to take sips. We didn't force (R2). (R2) decided to stay in room and didn't come out for meals. (R2) just didn't want to eat or drink. Staff relayed this to me and I also observed this. (R2) just had the 'blahs.' (R2) got extra water with med's, at least when I gave the med's. Approximately three 4 ounce glasses of water and took med's three times daily. Any hydration assessment would be in the progress notes. (R2) would occasionally accept soup. (R2) seemed more depressed to me. Hydration assessments are initiated only when needed. . On [DATE] at 11:00 a.m., the Surveyor again interviewed DON-B. DON-B stated, Staff were not concerned about (R2) because the doctor was monitoring labs. Refer to the citation text at F692 for additional information regarding R2.

Based on record review and staff and family interviews, the facility did not ensure that 1 Resident (R) (R2) of 4 sampled residents was offered sufficient fluid intake to maintain proper hydration and health based on a resident's comprehensive assessment. R2 was prescribed three diuretics (medications that increase the excretion of water from the body) medications due to profuse lower extremity [MEDICAL CONDITION]. The most recently added diuretic medication had been prescribed on [DATE]. On [DATE], R2 began to decline in nutritional status. Laboratory findings indicated worsening BUN (Blood Urea Nitrogen), low GFR (Glomerular Filtration Rate indicative of worsening of [MEDICAL CONDITION] stage III) and increased creatinine levels. On [DATE] R2 began to complain of daily increased weakness and fatigue and oral intake of food and fluids began to decline. On [DATE], R2 complained of abdominal pain and nausea. Laboratory findings completed on [DATE] to include [MEDICATION NAME] level (was on the steroid medication [MEDICATION NAME]) due to notable moon face and back [MEDICAL CONDITION], a sedimentation rate (used to confirm [MEDICAL CONDITION] processes) and uric acid (high levels indicate gout flareup) levels were drawn and noted to be within normal limits. R2 continued to complain of symptoms. The facility did not follow the standards of practice regarding hydration and abdominal assessments on R2, and did not qualitatively monitored intake of fluids. R2 saw the primary care provider on [DATE] and laboratory work was ordered. On [DATE], R2 was admitted to the hospital with [REDACTED]. Additionally, the facility did not review and revise R2's nutritional/hydration plan of care in spite of worsening laboratory findings and resident decline and did not follow the plan of care that was already in place. R2 expired on [DATE]. Findings include: According to relias.com, dehydration simply means that someone doesn't have enough fluids in their body. Water plans a key role in many bodily function, and when those functions are disrupted, simple dehydration can spiral into serious problems. Risk factors for dehydration include infections which can decrease the person's motivation to drink, certain medications (diuretics) increase fluid loss through urination. Signs of dehydration can include dry mouth, tongue or skin; feeling of low energy, tiredness or lethargy, change in mood, and confusion and disorientation. Prolonged lack of fluids can allow bacteria and waste to accumulate in the urinary tract and kidneys. This can contribute to UTI's. UTI's can result in kidney damage or failure if not treated promptly. According to the guide entitled, Dehydration and Fluid Imbalance, published by the American Medical Directors Association, the criteria for clinical [DIAGNOSES REDACTED]. (2) At least two physiological or functional signs or symptoms suggesting dehydration (e.g., dizziness, dry mucous membranes, functional decline). (3) A BUN(Blood Urea Nitrogen)/creatinine ratio of over 25.1 OR orthostatsis (described as a drop in systolic blood pressure over 20 on a change of position) OR a pulse of over 100 beats/minute OR a pulse change of ,[DATE] beats/minute above baseline with a change in position. The facility's hydration policy, dated (MONTH) of (YEAR), indicated to recognize, evaluate and address the needs of every resident including but not limited to the resident at risk or already experiencing impaired nutrition and hydration. Develop care plan to address impaired nutrition and hydration that reflects the resident's personal goals and preferences. Review periodically for effectiveness. Notify the physician as appropriate in evaluating and managing causes of the resident's nutritional risks and impaired nutritional status. Monitor to determine whether the resident is consuming adequate food and fluid for needs. Fluid includes beverages, foods that are liquid at room temperature and fluid in foods. Monitor weight and intake of foods and fluids. Nutritional status includes both nutrition and hydration status. The facility utilizes the Care Path Dehydration model, dated (MONTH) of (YEAR), which indicated if a change is noted in a resident at risk for dehydration, to include decreased oral intake over 48 hours, and diuretic use, take vital signs to include orthostatic [MEDICAL CONDITION] if possible based on clinical condition. If vital signs within normal limits, nursing is to further evaluate mental status, abdomen and skin. evaluate symptoms and signs for immediate notification to include not eating or drinking at all, nausea, or acute metal changes. If negative, consider contacting physician for further orders. If tests are negative, monitor vital signs (including orthostatic), fluid intake/urine output every ,[DATE] hours for ,[DATE] hours. If on diuretic, consider holding. Offer frequent fluids. Monitor response to ensure vital signs criteria met and if worsening condition and/or immediate notification criteria met. Review of R2's closed medical record indicated R2 had [DIAGNOSES REDACTED].(Urinary Tract Infections) with urosepsis, [MEDICAL CONDITION], and gout. R2 was deemed to be own decision maker. R2's MAR (Medication Administration Record) indicated R2 had been prescribed the diuretic medication [MEDICATION NAME] 40 mg (milligrams) daily on [DATE]: the diuretic medication [MEDICATION NAME] 2.5 mg daily on [DATE] which was held from [DATE]-[DATE]; and the diuretic medication [MEDICATION NAME] 25 mg daily on [DATE] all with [DIAGNOSES REDACTED]. Further review of the MAR indicated [REDACTED]. On [DATE] R2's laboratory findings included a BUN of 26 (normal ,[DATE]); a Creatinine of 1.0 (normal 0XXX,[DATE].0); a potassium of 3.4 (normal 3XXX,[DATE].1); and a GFR of 53.4 (Normal ,[DATE]). The resident's medication potassium 20 meq (miliequivalents) was increased to twice daily for 5 days the resumed at daily after that. On [DATE], R2 was noted to have significant lower extremity [MEDICAL CONDITION]. R2's primary care provider was notified and a new diuretic, [MEDICATION NAME] 25 mg daily and hold [MEDICATION NAME] from [DATE]-[DATE] then resume was initiated into R2's medication regime. A Basic Metabolic Panel dated [DATE] indicated a BUN of 59; creatinine of 1.4 and GFR of 36.2. On [DATE], R2 was seen for nursing home rounds by the primary care physician. Review of MD (Medical Doctor)-E's dictated note indicated, Recent adjustment of diuretic have been helpful (R2) is down 10 pounds. Legs are less swollen and can get shoes on again. Creatinine is 1.3. Oral Cavity is moist. Will check basic metabolic panel. Review of the Basic Metabolic panel dated [DATE] indicated that R2's BUN was now 42; creatinine was 1.3; and GFR was 39.4. On [DATE], a Basic Metabolic Panel for R2 indicated a BUN of 65; a creatinine of 1.9; and a GFR of 25.4. The primary care physician noted the laboratory levels and ordered a repeat Basic Metabolic Panel in 3 weeks. Review of R2's medical record indicated the following: On [DATE], the staff documented R2 refused one meal. Oral intake of fluids for the day during meals was 720 ml (milliliters). R2's weight was listed as 198.8 pounds. Vital signs were not documented for that day. On [DATE], the staff documented R2 refused two meals. Oral intake of fluids for the day during meals was 240 ml. Vital signs were normal with no orthostatic vitals obtained. It was noted R2 was not able to stand but orthostatic vitals can be revised to include monitoring the blood pressure and pulse while lying, then rechecking after one minute in a seated position. a nursing entry indicated, Received a phone call from (R2's) daughter concerned about (R2) stating just got off the phone with (R2) and (R2) stated was so weak could barely walk. Daughter commented that something needs to be done, even thought the lab work is normal there is something wrong with (R2). Informed daughter (R2) had spoken with writer earlier and (R2) had commented that was feeling tired. Daughter commented that something needs to be done, maybe even needing to be in the hospital since (R2) was so weak. Informed daughter that writer was going into room and would be checking (R2.) Also informed daughter that writer would check vitals. Daughter made a comment in regards to the [MEDICAL CONDITION] and if that could be back and causing problems. Again informed that writer would be checking vitals and look at (R2.) Upon entering room, (R2) was sitting on edge of recliner, transferring self to wheel chair. Speaking soft but voice audile. Skin warm and dry to touch. Did speak with (R2) that daughter had called concerned about (R2). (R2) commented that was tired. Questioned what the doctor had said the other day about when told was tired. Informed the doctor acknowledged being informed of being tired. (R2) transferred to toilet by writer. Stood without difficulty. (R2) did comment that there must be something wrong as was tired. Questioned if (R2) could have polyfibrosis. (R2) became weepy when speaking with writer. Vital taken, reassurance given. There was no documented compete physical assessment of R2's hydration status completed with no orthostatic vitals obtained in lieu of R2's decreased intake; being on three diuretic medications; and complaining of being tired. On [DATE], (R2) refused one meal. Oral intake of fluids for the day during meals was 720 ml. Vital signs were within normal limits with no orthostatic vitals obtained. A nursing entry indicated, (R2) Sat up on edge of bed this a.m. to take med's. Did comment that was stiff but that usually goes away after moves around. Took med's without difficulty. Did get dressed and sat up in wheel chair. Spent shift in room. Was sleeping when writer approached with noon med's. (R2) did comment that was so tired today. Was going to have soup and tea for lunch. Skin warm and dry to touch. Takes fluids well. No tenting noted to skin. Afebrile. No complete hydration assessment was completed with no orthostatic vitals obtained in lieu of the resident's decreased intake; being on three diuretic medications; and complaining of being tired. On [DATE], the staff had recorded only two meals for R2; one with response not required. Oral intake of fluids for the day during meals was 240 ml. No blood pressure had been documented for that day. No nursing documentation was noted on [DATE] in R2's medical record. On [DATE], R2 ate well and took in 600 ml during meals. No blood pressure was documented for that day. Pulse was listed as 95 and irregular. A nursing entry indicated, Canceled appointment with physician today. (R2) not feeling well enough to attend the appointment. No complete hydration assessment was completed with no orthostatic vitals obtained in spite of R2's decreased intake, being on three diuretic medications, and complaining of being tired. On [DATE], R2 ate well and took in 240 ml with meals. Blood pressure was high at ,[DATE]. A nursing entry indicated, Sent fax to (MD-E) requesting order for OT (Occupational Therapy) eval due to poor positioning in wheel chair and requested order for [MEDICATION NAME] level. (R2) is moon-faced and complaining of muscle weakness and tiredness. On [DATE], R2 ate only ,[DATE] % of one meal, had refused one meal, and had an oral intake of fluids for the day during meals of 600 ml. Vital signs were within normal limits with no orthostatic vitals obtained. Weight was listed as 198 pounds. No further nursing documentation was completed for R2 on [DATE] except that sedimentation rate, [MEDICATION NAME] level and uric acid level was drawn. On [DATE], R2 refused two meals and had an oral intake of fluids for the day during meals of 600 ml. The only vital signs listed were a normal pulse and temperature. A nursing entry indicated R2 was having increased pain in hips then denying pain medications because wasn't having pain in hips but could not be specific to pain site then (R2) commented wasn't having any pain at all. (R2) did comment that was having some abdominal pain. Did also have a bowel movement. Declined to eat breakfast or lunch. Complained of feeling nauseated. Was sipping on soda. Declined any offer of food except soda crackers. Skin warm and dry to touch. No tenting noted. Does receive 3 diuretics. No complete hydration assessment or abdominal assessment was completed with no orthostatic vitals obtained in lieu of R2's decreased intake; being on three diuretic medications; and complaining of having abdominal pain and nausea. On [DATE], R2 ate well and had an oral intake of fluid for the day during meals of 720 ml. The only vital sign listed was a normal pulse. A nursing entry indicted, (R2's) daughter concerned regarding resident being weak and tired. When writer would ask (R2) what was wrong, (R2) would begin crying stating, 'I'm just so tired.' Did not mention anything about pain or weakness. (R2's) daughter questioning about what was being done about (R2's) weakness. Writer informed daughter that labs were drawn on [DATE] and had not gotten the results back yet. Spoke about (R2) being evaluated at the ER or Urgent Care. (R2's) daughter agreeable to continue to monitor (R2) at facility and for (R2) to see primary care physician on Monday ([DATE].) Will leave note for facility scheduler. Will continue to monitor. It was noted that R2 did not see the primary care provider until [DATE]. On [DATE], R2 refused one meal and ate only ,[DATE]% of another meal. The oral intake of fluids during meals was listed as 600 ml. Pulse was 78 and irregular. No nursing documentation was completed on [DATE]. On [DATE], through [DATE], R2 ate and drank well (except for one meal on [DATE] where intake was ,[DATE]%). A nursing entry indicated, Daughter worried about how tired (R2) was. Follow up appointment made with doctor for [DATE]. An additional nursing entry for [DATE] indicated, Assessed (R2's) buttocks, redness on both upper right/left buttocks, little open areas on both buttocks, appears to be more shearing than pressure. (R2) was emotional stating, 'I can't stand that long' writer cuing (R2) to allow staff to complete dressing to buttocks. (R2) has appointment to see (MD-E) on [DATE] for mood/depression. On [DATE], per request of R2's daughter, the facility dietician evaluated R2. The documented notes indicated, Spoke with (R2), states appetite is, 'terrible.' Willing to have 4 ounce vanilla shake at lunch today. In the last week, intake down to 49% average. Will continue to monitor. Per chart [DATE] 198 pounds, [DATE] 211 pounds. This is a significant weight loss of 13 pounds, down 6% in last month. Per nursing decreased fluid. [MEDICATION NAME] 25 mg started on [DATE] for [MEDICAL CONDITION] and receiving [MEDICATION NAME] 40 mg. Significant wt (weight) loss combination of decreased intake and decreased fluid. Staff have been encouraging (R2) at meals/snacks. On [DATE], R2 ate ,[DATE]% of two meals and had an oral intake of fluids during meals of 680 ml. R2's weight was listed as 197.2 pounds with a pulse rate of 86 and irregular. It was noted that the meal intake charting for fluids, documented by the CNAs often listed, Response not required for 11 of the meals from [DATE]-[DATE]. At no time did the facility initiate quantitative oral intake of fluids per 24 hours for (R2) and R2's plan of care, with the exception of addition of a 4 ounce shake daily, had not been revised in lieu of symptoms R2 had presented with and decreased oral intake of foods and fluids at meals. Review of R2's most recent plan of care dated [DATE] indicated R2 was on diuretic therapy related to [MEDICAL CONDITION]. The goal of the plan included R2 will be free of adverse side affects of diuretic therapy. Interventions included to monitor resident condition based on clinical practice guidelines or clinical standards of practice related to use of [MEDICATION NAME]. The corresponding CNA (Certified Nursing Assistant) care kardex indicated under the category of eating/nutrition/hydration that the resident was able to feed self independently. Provide resident with a calm, quiet setting at meal times with adequate eating time. Provide 4 ounce shake at lunch daily. Monitor resident condition based on clinical practice guidelines or clinical standards of practice related to use of [MEDICATION NAME]. The care plan was not updated when R2's medication regime included more than one diuretic medication; when R2 had a decrease in food/fluid intake; or when R2 began having symptoms of weakness, fatigue, abdominal pain and nausea. The facility's procedure entitled Residents at risk for Dehydration/Fluid Maintenance revised on (MONTH) of (YEAR) indicated a purpose listed as to provide additional measures for ensuring adequate hydration for residents determined to be at dehydration risk. The plan of care will include approaches to encourage the resident to achieve and/or maintain hydration status if the resident has symptoms which can lead to dehydration such as the following: Nausea which impacts food/fluid intake; cardiovascular agents; when diuretic medication is changed, nursing employees will have a system in place to monitor hydration needs; [MEDICAL CONDITION], limited fluid intake. Employees will write the problem/goal for dehydration/fluid maintenance on the care plan. If the plan of care identifies specific amounts of fluid at meals/snacks, the fluid intake needs to be documented so that progress or lack of progress to the goal can be charted by nursing employees. On [DATE], R2 was evaluated out of the facility by MD-E. Dictated notes from that evaluation were not located in R2's medical record and the Surveyor had to request that consult. The facility's Clinical Referral notes sent along for the consult indicated problem to be evaluated as, depression screening/decrease in number of medications given daily (per the resident's request). There was no indication on the referral to make MD-E aware of R2's recent symptoms and decrease in food and fluid intake. The consult dictated by MD-E indicated, (R2)comes in with daughter today for failure to thrive over the past 2 weeks. The patient has had a slow decline. has spent time spaced out. (R2) has a harder time remembering things. (R2) has been more fatigued. Appetite has been reduced. This has been a slow but steady decline. The patient offers really nothing in the way of useable history. I did a review of systems with (R2) and could not really identify anything other than some bladder irregularity potentially urinary tract infection and potentially some signs of dehydration. oral cavity is somewhat dry. Assessment: Failure to thrive. [MEDICAL CONDITION]. Plan: Will get chest X-Ray, A1C, CBC, Basic Metabolic Panel, TSH, urinalysis. (R2's) sugar done at the nursing home earlier this month was 275. (R2) has a history of diabetes but only when on high steroids, resident is only on 5 mg of [MEDICATION NAME] now. It could be that (R2) is dehydrated from high sugar and increase in [MEDICATION NAME] use. Since [MEDICAL CONDITION] is better controlled using compression stocking will discontinue the [MEDICATION NAME]. Will decreased Mirabegron which could cause come confusion. Reduce [MEDICATION NAME] to twice daily from three times daily. Reduce [MEDICATION NAME] from 37.5 to 25 mcg daily. Will await further work up. It is possible they will have to send resident to the ER for fluids if it looks like (R2) is clinically dehydrated. There are suspicions of that on exam today. On [DATE], R2's laboratory results were obtained and R2's physician ordered R2 to be sent to the hospital to be treated for [REDACTED]. On [DATE], R2 was evaluated at the hospital. The emergency room documentation indicated that the resident's BUN was now high at 87; creatinine was high at 2.03; low GRF at 23.56 and high BUN/Creatinine ratio was 42.9 (normal 3XXX,[DATE]). [NAME] blood cell count was high at 14,000 (normal ,[DATE]). The evaluation indicated that the resident had a low blood pressure of ,[DATE] and had dry mucous membranes. The evaluation indicated, Onset gradually over the last 3 weeks or so. Debilitated fatigue sensation and increased somnolence. Precipitated by unknown however the patient has significant comorbidities and multiple medications which could impact mental status as admission for urosepsis in recent years. Daughter states that the patient is not one to take by mouth fluids in the first place and suspects by mouth intake has been less than normal in recent weeks. Positive associated decreased mouth intake of fluids and decreased urine output. Patient presents to the the department after outpatient visit yesterday and blood work reviewed today showing significant deviation from baseline indices notably the BUN and Creatinine which are elevated consistent with dehydration. The patient has significant risk for infection notably UTI give comorbidities and medications. Diagnostic work up consistent with urosepsis and dehydration contributing to mental status change and debilitation. The resident was admitted to the hospital. The hospital history and physical dated [DATE] indicated, (R2) reports feeling very weak and exhausted. Reports some dizziness. Has had a greatly decreased appetite starting about 3 weeks ago as well. Currently feels a little nauseous and has no appetite. Daughter reports increased confusion and slowing of cognition from baseline. Blood pressure ,[DATE]. Has increased frequency of urine. Lethargic and slow to respond, difficult to gather a history, oriented to time, person, and place. Assessment: [MEDICAL CONDITION]. UTI. IV(Intravenous [MEDICATION NAME] (antibiotic). Acute on chronic kidney injury. [MEDICAL CONDITION] stage III. Start IV at 75 ml/hour with careful monitoring as to not fluid overload patient. Hold [MEDICATION NAME] because of kidney injury and fatigue. R2 remained confused and debilitated during hospital stay despite laboratory findings improving. R2 was placed on Hospice services and expired on [DATE]. It was noted that on [DATE], R2 had an ADPOAHC (Activated Durable Power of Attorney for Health Care initiated. On [DATE] at 11:30 a.m., the Surveyor interviewed RD (Registered Dietician)-C via the telephone. RD-C stated, I did only look at (R2's) meal percentages (during eval on [DATE]). I didn't really look at hydration status. (R2) would get fluids from foods eaten, beverages offered during meals, and water available in room. (R2) feeds self. I should have reviewed the nurses notes. If I would have, I would have been able to know more about what was going on with (r2). I know I encouraged staff to make sure were offering (R2) fluids. At 56 inches and 197 pounds, the daily fluid needs of (R2) would have been 1670 ml/day. I'm not sure how much fluids (r2) was taking in. I'm sure I asked (R2) if (R2) was drinking, but didn't document that. I did not have access to review laboratory result at my assessment, but I can't really remember. If a dehydration assessment by the nurses had been abnormal, meaning dry mucous membranes, low output, sunken eyes, I would have reevaluated (R2) the next week. I am aware that (R2) has [MEDICAL CONDITION]. When the Surveyor asked RD-C if was aware of what vital signs would be indicative of dehydration (i.e., orthostatic vitals) RD-C verified to the Surveyor was not sure what orthostatic [MEDICAL CONDITION] was. On [DATE] at 12:00 p.m., the Surveyor interviewed MD (Medical Doctor)-E via the telephone. MD-E was R2's primary care provider. MD-E stated, I evaluated (R2) at the nursing home on [DATE]. The main concerns were back pain and lower extremity [MEDICAL CONDITION]. The [MEDICAL CONDITION] was better and the weight was down. I wanted (R2) to loose weight related to the [MEDICAL CONDITION]. Between the time I evaluated (R2) on [DATE] and [DATE], there was a significant change. (R2) was very confused and 'out of it.' I was concerned that (R2) was dehydrated, so I ordered lab work. I don't have access to faxes that the facility sent me. We don't keep those records in the office. Whatever faxes that are in (R2's) chart at the nursing home is what staff was relaying to me. The lab work from [DATE] showed a high white blood cell count, a low sodium, a high creatinine and BUN and there was a questionable UTI, but I wasn't sure at the time since the urine culture was pending. I don't know what happened at the hospital. I know on (R2's) death certificate, cause of death was listed as [MEDICAL CONDITION], but I don't think this was the case. (R2's) white blood cell was not high enough to indicate that. If the facility thought or the family had relayed concerns to the nurses, about (R2's) health status, (R2) should have been sent to the ER (emergency room ). I'm not sure how quickly (R2) went down hill. On [DATE] at approximately 12:45 p.m., the Surveyor interviewed DON (Director of Nursing)-B. DON-B stated, Nurses would do hydration assessments and document those assessments in the resident's record if it was noted that oral intake of fluids was declining. Hydration assessments would include urine intake, oral intake, looking at labs, orthostatic vitals, although (R2) was unable to stand long enough, skin tenting, sunken eyes, listening to heart and lungs. On [DATE] at 2:10 p.m. the Surveyor again interviewed MD-E via the telephone. MD-E stated, If staff would have told me that (R2) wasn't doing well, I would have evaluated (R2) at the clinic or had the resident sent to the ER earlier. On [DATE] at 4:45 p.m., the Surveyor interviewed FM (Family Member)-D. FM-D stated, (R2) was own decision maker until hospitalized . On [DATE], I was made activated power of attorney for health care for (R2). I was sick from [DATE]-[DATE] so I didn't see (R2) until [DATE]. I noticed (R2's) lips were cracked with black scab like streaks on them. (R2) always complained of dry lips and mouth, but I've never seen (R2's) lips look like that. They appeared that way all the way up to hospitalization (on [DATE]). I am the one that asked for the dietician to look into getting a shake or something for (R2). (R2) wasn't eating and isn't much of a water drinker. When I was visiting, (R2) drank very little with my encouragement. They refilled the water jug in the room every day, but most of the water from the day before was still in the jug and was dumped before refilling. When I was there, I never saw any staff encourage or offer (R2) fluids. I thought (R2) should go to the hospital on [DATE], but staff felt it wasn't necessary because it wasn't emergent. I didn't push for hospitalization because I trusted the staff and felt they were the professionals and knew what they were doing. Staff told me they would have the doctor see (R2) the following Monday ([DATE]) but (R2) didn't see the doctor until [DATE]. (R2) was very weak and tired. (R2's) other family member had commented on the same thing when talking to (R2) on the phone that (R2) was so weak and tired could hardly talk. (R2) was so weak that when I did offer water, (R2) could hardly hold a glass. While at the hospital, the oncologist evaluated (R2) and told us that [MEDICAL CONDITION] had not reoccurred. (R2) was not eating at the hospital and refused tube feeding, so the decision was made to initiate Hospice services. On [DATE] at 9:25 a.m., RD-C approached the Surveyor and stated, I didn't know that (R2) was on three diuretics. I don't know medication trade names versus generic names. What I mean in my dictated note (from [DATE]) was the fluid was down meaning the [MEDICAL CONDITION] in the lower extremities had decreased. Residents with [MEDICAL CONDITION] with decreased intake and taking diuretics are at high risk for dehydration. Nursing asked me to see (R2) because of decreased oral intake of foods. When I spoke to (R2) (on [DATE]), (R2) was focused on back pain and looked as always had. I didn't know quantitatively how much fluid (R2) was taking in. I looked only at the meal time fluid intake which was averaging 675 ml/day. I was concerned about how to get more calories into (R2.) I should have documented that I educated staff on need to increase fluids for (R2), and should have had staff follow up with me to see if the plan was working. On [DATE] at 10:00 a.m., the Surveyor interviewed CC (Care Coordinator)-F. CC-F stated, When residents go to a doctors visit outside of the facility, they use the form Clinical Reference and wire in the concerns they want addressed with that visit. On [DATE] at 10:10 a.m., the Surveyor interviewed RN (Registered Nurse)-[NAME] RN-G stated, I knew (R2) was on three diuretics and intake of fluids was decreased. (R2) was sad. We were encouraging to drink more but only wanted to take sips. We didn't force (R2). (R2) decided to stay in room and didn't come out for meals. (R2) just didn't want to eat or drink. Staff relayed this to me and I also observed this. (R2) was not on any scheduled hydration assessments. We can do orthostatic vitals, but only lying and sitting for (R2). (R2) can't stand long enough to do vital standing. For hydration assessments, we look at labs, skin tenting, but (R2) was a large woman and tenting may not be the best indicator. We would look at mouth and lips which were not dry. (R2) just had the 'blahs.' (R2) got extra water with med's, at least when I gave the med's. Approximately three 4 ounce glasses of water and took med's three times daily. Any hydration assessment would be in the progress notes. (R2) would occasionally accept soup. (R2) seemed more depressed to me. Hydration assessments are initiated only when needed. We did not document how much water (R2) was taking in with med's, etc. Only monitored intake of fluids with meals. On [DATE] at 11:00 a.m., the Surveyor again interviewed DON-B. DON-B stated, Staff were not concerned about (R2) because the doctor was monitoring labs. Staff were not quantitatively documenting intake of fluids for (R2). (R2's) plan of care was not changed when diuretics were increased and when (R2) had a change in condition with symptoms, or when noted was not eating and drinking as usual. On [DATE] at 11:30 a.m., the Surveyor again interviewed CC-F. CC-F stated, (R2) saw the doctor on [DATE]. The comment by the doctor was the intent of the weight loss was positive because the [MEDICAL CONDITION] was decreasing. We were checking labs and monitoring that. Hydration assessments by staff would include looking at lab values, checking mucous membranes, skin tenting, fever, monitoring intake and out put qualitatively. We like to get input from the doctor about if we should get and start hydration assessments. Formal hydration assessments for (R2) would have been helpful. I recognized that (R2) was declining over entire stay here. Labs were indicative of the fact that there were concerns. We did do [MEDICATION NAME] and sedimentation labs on (R2). We could have done better with our basic assessments of the resident. When (R2) complained of abdominal pain and nausea, the only note in the record was that had a bowel movement recently. Looking a little further would have been helpful to include determining where the abdominal pain was and if it was over the bladder. This is an opportunity to remind us to do do better in the future.

Based on observation, record review and staff interview, the facility did not ensure that one (resident #1) of 1 resident who receives enteral nutrition per a GT (Gastrostomy tube) received treatment and services to prevent aspiration pneumonia. Resident #1 has received enteral feeding per GT since 11/2014, and has a history of recurrent hospitalization s relating to aspiration pneumonia. Resident #1's most recent re-admission from the hospital was 8/25/15. An observation of resident #1's HOB (Head of Bed) was positioned at 15 degrees while the resident was lying in bed with the GT feeding infusing was made, despite physician's orders [REDACTED]. Additionally, the CNA (Certified Nursing Assistant) who positioned and cared for resident #1 was not aware of the order or policy. Findings include: The American Society for [MEDICATION NAME] and Enteral Nutrition (2009) provided enteral nutrition practice recommendations, Elevate the backrest (HOB) to a minimum of 30 degrees, preferably 45 degrees, for all patients receiving enteral nutrition, unless a medical contraindication exists .then use the reverse trendelenberg (bed) position. The facility's policy and procedure, dated 9/2012, entitled Tube Feeding: Gastrostomy or Jejunostomy indicated the following: Raise HOB 30 to 45 degrees during feeding and keep elevated 30 - 60 minutes after feeding to prevent regurgitation or aspiration . An additional facility policy dated 9/2012 entitled Tube Feeding: General Information indicated: Elevate HOB 30 to 45 degrees at all times during feeding and for at least 30 - 40 minutes after feeding is stopped. The written plan of care for resident #1 initiated on 11/5/14 and updated 6/15/15 indicated The resident requires tube feeding related to left mandible fracture and inability to effectively swallow following [MEDICAL CONDITION] as evidenced by PEG tube placed .Resident will remain free of side effects of complications related to tube feeding .HOB: elevate HOB 30 degrees at all times due to continuous tube feeding. When repositioning .have the nurses stop the tube feeding 5 minutes prior to completing care .Minimize the amount of time the HOB is flat . On 8/20/15, an anonymous complaint was received regarding resident #1. The complainant reported observations of the resident's HOB lower than 30 degrees despite physician's orders [REDACTED]. On 8/27/15 at 8:45 a.m., surveyor # interviewed FM (Family Member)-E who verified observations of resident #1's HOB at 12 to 15 degrees. When asked how FM-E measured the degree of bed angle, FM-E stated there was a dial on the side of the bed with a notch that showed the position. On 8/27/15 at 9:15 a.m., surveyor # observed resident #1 lying in bed, the HOB was angled at 15 degrees. An enteral feeding pump was noted at the bedside infusing [MEDICATION NAME] liquid nutrition at 70 ml (milliliters) per hour. CNA-A entered the room to provide morning cares and verified to surveyor # the HOB was angled at 15 degrees. CNA-A indicated there was a diagram printed on the side of the bed to guide staff to determine the appropriate angle of the bed. CNA-A further indicated she was unaware of the ordered angle of the HOB for resident #1. CNA-A stated the resident had been positioned at this angle since 6:30 a.m. or 7:00 a.m. that morning and had not been moved since then. CNA-B then entered the resident's room and confirmed to surveyor # the HOB was positioned at 15 degrees, but that it should be 30 to 45 degrees. CNA-B raised the HOB at that time. On 8/27/15, surveyor # reviewed the medical record of resident #1. A hospital admission note for resident #1 dated 8/10/15 documented the resident was admitted with a past medical history significant for dysphagia, PEG (Percutaneous Endoscopic Gastrostomy) tube feeding, history of recurrent aspiration pneumonia and recurrent urinary tract infection .Assessment and plan: (resident #1) is presenting with 1. Metabolic [MEDICAL CONDITION] .2. Aspiration pneumonia . A physician consult report dated 8/23/15, documented (Resident #1) was admitted [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staph Aureus) UTI (Urinary Tract Infection) and bacteremia. There was evidence of left lower lobe aspiration pneumonitis. A hospital discharge note dated 8/25/15 documented (Resident #1) has copious oral secretions that are difficult for (the resident) to manage. (Resident #1) is very dysphagic and has been treated for [REDACTED].Please follow strict aspiration precautions given high risk aspiration. On 8/27/15 at 9:30 a.m., surveyor # interviewed RN (Registered Nurse)-D regarding resident #1. RN-D indicated the HOB for resident #1 should be at a minimum, 30 to 45 degrees because the resident can't clear the airway and because of a high risk for aspiration. RN-D stated the resident could be positioned straight up to help with the clearing the oral secretions. On 8/27/15 at 11:00 a.m., surveyor # interviewed RN-B who served as a care manager for the facility. RN-B confirmed resident #1 had multiple hospitalization s related to aspiration pneumonia. RN-B indicated the facility policy as well as resident #1's the care plan and physician's orders [REDACTED].#1 greater than 30 degrees.

Based on observations, record review, staff and family interviews, the facility did not ensure that 5 (resident #1, #6, #2, #10 and #8) of 9 sampled residents reviewed for pressure ulcer risk who entered the facility without pressure ulcers did not receive pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident who was at risk for the development of pressure-related ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. In this citation, residents #1 and #6 are considered at actual harm, isolated (G level); residents #2, #10 and #8 are considered less than actual harm, isolated (D level). Resident #1 was at risk for the development of pressure-related ulcers. The facility was aware that the resident was unable to wear shoes due to an abrasion and only wore gripper socks on their feet. The facility was aware that resident #1 rested his socked heels on the metal foot rest of the chair while seated. No changes in the resident's plan of care were initiated until the resident presented with a deep tissue injury to the left posterior heel and a stage III (3) pressure ulcer to the right heel. Pressure ulcer prevention interventions had not been implemented until after the pressure ulcers had occurred. Resident #6 had a history of [REDACTED]. As a result, the resident developed a pressure area above the right ear and a stage III pressure ulcer behind the left ear. Staff indicated, after the second pressure ulcer developed behind resident #6's left ear, the glasses were removed and the resident no longer wears glasses. Resident #2 was assessed to be at risk for the development of pressure ulcers. The resident refused to wear shoes or socks and preferred to be bare footed. The resident's bilateral heels rested on the metal on the back of the Broda chair foot rest. As a result, the resident had a red blanchable indentation on the left heel and a red, boggy blanchable area on the right heel that did not subside after 20 minutes after sustaining the pressure load. Resident #10 was at risk for pressure ulcers. The facility did not implement pressure reducing/relieving interventions and nutritional interventions until after the discovery of a Stage II (2) pressure ulcer on the resident's coccyx. Resident #8 was at risk for pressure ulcers. The facility did not ensure that the resident's heels were free floated during several observations. The resident's care plan dated 6/5/14, included the intervention to free float the heels while in bed. Findings include: The Quick Reference Guide entitled "Pressure Ulcer Prevention", published by the European and National Pressure Ulcer Advisory Panel in 2009, indicated that a stage III pressure ulcer is defined as full thickness tissues loss. Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by the individual's condition. Reassessment should also be undertaken if there is any change in resident condition. Develop and implement a prevention plan when individuals have been identified as being at risk of developing pressure ulcers. Risk factors identified in a risk assessment should lead to an individualized plan of care to minimize the impact of those variables. Select a seated posture that is acceptable for the individual and minimizes the pressures and shear exerted on the skin and soft tissues. The reduction of pressure and shear at the heel is an important point of interest in clinical practice. Because the heel is covered with a small subcutaneous tissue volume, mechanical loads are transmitted directly angular to the bone. Given the small surface area of the heel, it is challenging to try to redistribute load from the heels through the use of pressure redistributing devices. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure-a state sometime called "floating heels." Support surfaces usually fail to increase the total contact area of the heel bone, which would spread the load and reduce pressure. To reduce the pressure at the heels to 0 mmHg (millimeters of mercury), elevate the heels from the mattress. Heel protection devices should elevate the heel completely (offload them). The publication entitled "Medical Device Related Pressure Ulcers: The Hidden Epidemic Across the Lifespan" published by the National Pressure Ulcer Advisory Panel in 2013 indicated medical device related pressure ulcers are defined as localized injury to the skin or underlying tissue as a result of sustained pressure from a device (e.g., nasal cannula tubing). Tissue injury typically mimics the device shape and tend to progress rapidly as they often occur over areas without adipose (fat) tissue. Medical device related pressure ulcers occur due to failure to check tubing, lack of awareness of need to remove, reposition and provide basic care to skin under devices, lack of best practice guidelines and lack of standardized practice. Cushion and protect the skin with dressings in high risk areas. Confirm that devices are not placed directly under an individual who is bedridden or immobile. 70% of medical device related pressure ulcers develop on the head, neck and face. 1. Resident #1's admission face sheet dated 8/12/13 indicated the resident had [DIAGNOSES REDACTED]. Resident #1's most recent MDS (minimum data set) assessment dated [DATE] indicated the resident was non ambulatory, required extensive assistance from staff to transfer and perform bed mobility, had range of motion deficits in one lower extremity and was at risk for the development of pressure related ulcers. A document noted in resident #1's medical record dated 4/24/14 indicated the resident had presented with an abrasion to the Achilles area of the right heel due to ill fitting shoes. A plan of care intervention to use gripper socks and no shoes was implemented and reported to all staff via a weekly newsletter dated 4/25/14 which indicated," Resident (#1) has scab on back of heel. Gripper socks at all times. No shoes." Resident #1's plan of care included the potential for pressure ulcer development related to immobility and incontinence dated 6/9/14. This plan of care included a goal that the resident would have intact skin, free of redness, blisters or discoloration. Interventions included to assist the resident to turn and reposition at least every 2 hours, suspend heels in bed and notify nurse immediately of any new areas of skin breakdown. A nursing entry in the resident's medical record dated 6/10/14 indicated, "Writer summoned to resident room to assess bilateral posterior heels. Right posterior heel noted to have what appears to be a Stage IV pressure ulcer 1.2 x 2.2 x 0.4. Left posterior heels noted to have an area of deep tissue injury 0.7 x 1.3. Per staff report, resident often will rest the back of his heels on the metal edge of his wheel chair foot rest. Care plan changed to have heels boots on at all times and to check positioning to resident's legs when up in wheel chair every 2 hours so that they re not resting on edge of foot rest. Will also request that maintenance pad resident foot rest or switch wheel chair. MD (Medical Doctor) notified of pressure sites via fax with request for referral to wound clinic due to unsure whether right posterior heel wound bed has exposed tendon versus bone and the potential for osteo[DIAGNOSES REDACTED] if exposed bone. Request for daily dressing change of [MEDICATION NAME] until evaluated at wound clinic. Daily Prostat supplement also included in fax." Resident #1's plan of care was revised on 6/10/14 to include the above interventions. On 7/15/14 at 1:15 p.m., surveyor # interviewed DON (Director of Nursing)-B regarding resident #1's evaluation at the wound clinic on 6/17/14. DON-B verified that the wound clinic had diagnosed resident #1 with a stage III pressure ulcer on the right heel. DON-B further verified that the resident's plan of care interventions to prevent pressure ulcers had not been revised until after the resident presented with a deep tissue injury on the left heel and a stage III pressure ulcer on the right heel. On 7/15/14 at 12:30 a.m., surveyor # interviewed CNA (Certified Nursing Assistant)-M regarding resident #1. CNA-M stated, "(Resident #1) was having issues with new shoes a while ago that his wife brought in. His old shoes didn't fit well either. We changed him to gripper socks. He was originally using a Geri chair which was switched to a Broda chair with longer foot rests. He is very tall and stiff and had a habit of resting his heels on the ends of the foot rests and we were constantly having to put his feet correctly on the foot rests. They didn't have us put boots on his feet until after he got the pressure ulcers. We now are supposed to be checking his foot placement. It would have saved his heels if the boots had been put on right away." On 7/16/14 at 9:00 a.m., surveyor # observed bilateral heel wound care for resident #1 performed by RN (Registered Nurse)-L. It was noted by the surveyor that a small scab was present on the dressing when it was removed from the left posterior heel and a small amount of sero sanguineous drainage was noted on the dressing removed from the right posterior heel. The right posterior heel contained a linear pressure ulcer. RN-L stated, "His feet were resting on the metal part of the old chair foot rest and he got pressure ulcers. The chair was changed out and his foot rests were also changed. You can see the shape of the pressure ulcers were identical to the metal ends of his old chair." On 7/16/14 at 9:30 a.m., surveyor # interviewed resident #1's ADPOAHC (Activated Durable Power of Attorney for Health Care), FM (Family Member)-V via the telephone. FM-V verified that the facility staff had relayed that resident #1's bilateral heel pressure ulcers were a result of the resident resting his socked heels on the metal part of the chair foot rests. The facility was aware that resident #1 rested his socked heels on the metal foot rest of the chair while seated. No changes in the resident's plan of care were initiated until the resident presented with a deep tissue injury to the left posterior heel and a stage III pressure ulcer to the right heel. 3. Resident #6's current electronic Medical [DIAGNOSES REDACTED]. The most recent quarterly MDS assessment, dated 6/30/14, indicated resident #6 has an unhealed stage III pressure ulcer and require extensive assistance with dressing and other personal cares. Resident #6's plan of care dated 4/9/14 stated the resident is dependent on staff for activities and cognitive stimulation due to advanced dementia as evidenced by short and long term memory loss, short attention span, and requires the need for cueing. This plan of care states resident #6 likes crossword puzzles and staff are to provide resident with crosswords puzzles as an individual activity. On 7/16/14 at 7:40 a.m., surveyor # interviewed RN-L regarding resident #6's preferences. RN-L stated resident #6 had a nightly routine of working on crossword puzzles in bed and falling asleep during this activity wearing glasses. A 'Fax Communication to Physician' form, dated 12/28/13, indicated resident #6 had a 2 cm (centimeter) by 1/8 cm scabbed area above the right ear due to the bow of the glasses cutting into the skin. The plan was to apply gauze to the bow of the glasses to prevent the bow of the glasses from applying pressure to the area until the resident could be seen by the optometrist. The Clinical Referral form dated 1/28/14, indicated resident #6 was seen by the optometrist who recommended over the counter reading glasses. A progress note dated 5/29/14, indicated resident #6 had a stage III pressure ulcer behind the right ear due to pressure from the bow of the glasses. The progress note stated resident #6 had an indentation behind the right ear as well, however this area was not open. Resident #6 was to remain without glasses until the resident could be assessed by the optometrist on 6/3/14. A subsequent progress note dated 6/4/14 stated the optometrist recommended resident #6 remain without glasses at this time. The current electronic plan of care printed 7/16/14 directed staff to provide resident #6 with glasses daily. On 7/16/14 at 7:30 a.m., surveyor # interviewed CNA-J regarding resident #6's glasses use. CNA-J stated in December of 2013, resident #6 did not reside on the locked unit, therefore she was not aware that the resident had developed a pressure area above the right ear related to the use of glasses. CNA-J stated resident #6 has been living on the special care unit for a few months and the unit staff put resident #6's glasses on daily; every day in the morning with cares. CNA-J stated the resident wore the glasses throughout the day and that the glasses were worn at all times and not just for reading. CNA-J stated when resident #6 developed the pressure ulcer behind the left ear, the glasses were removed and have not been put on since. CNA-J stated she is waiting for direction from a supervisor as to what to do for resident #6 since the pressure ulcer is now healed. On 7/16/14 at 7:40 a.m., surveyor # interviewed RN-L regarding resident #6's glasses use. RN-L stated resident #6 was falling asleep with the glasses on which resulted in the pressure ulcer above the right ear. RN-L stated resident #6 received new glasses, however the resident continued to fall asleep with the glasses on, which resulted in the second pressure ulcer behind the left ear. After the second pressure ulcer developed the glasses were removed and the resident no longer wears glasses. 3. Resident #2's admission face sheet dated 3/31/11 indicated the resident had a progressive neuro-[MEDICAL CONDITION] disease ([DIAGNOSES REDACTED]) with resultant jerky movements, multiple joint contractures and arthritis. The resident had been receiving Hospice services since prior to admission to the facility. The resident's most recent MDS assessment dated [DATE] indicated the resident required extensive assistance from staff to perform bed mobility and transfers, was non ambulatory, had range of motion deficits in both upper and both lower extremities. Resident #2's most recent Braden Scale for the prediction of pressure ulcer risk indicated the resident had scored a 11, which placed the resident at high risk for pressure ulcer development. The Braden Scale Reference Tool, utilized in conjunction with the Braden Scale by the facility indicated that residents who were assessed to be at high risk for pressure ulcer development would have plan of care interventions to include frequent turning and repositioning with a planned schedule, supplement with small shifts in position, pressure reduction support surface, maximal remobilization, protect heels, manage moisture, manage nutrition and manage friction and shear. Resident #2's most current CNA Kardex dated 7/15/14 (a.m.), included skin integrity interventions to notify nurse immediately of any new areas of skin breakdown, provide low air loss mattress to bed, and to assist to turn and reposition in bed. On 7/15/14 at 12:00 p.m., surveyor # observed resident #2 seated in a Broda chair, bare footed with both heels in full contact with a bare metal bar of the foot rest. On 7/15/14 at 12:45 a.m., surveyor # observed resident #2 seated in a Broda chair, bare footed with both heels in full contact with a bare metal bar of the foot rest. CNA-S assisted the resident into bed with use of a Hoyer lift and it was noted by the surveyor that the foot rest of the resident Broda chair did not contain any padding. CNA-S and the surveyor inspected the resident's heels. There was an obvious linear dent on the left heel which was red and boggy and a red blanchable area on the right heel. CNA-S stated "It's from the metal rod on her chair foot rest isn't it?" CNA-S verified to the surveyor that the resident had no plan of care intervention to protect heels or pad the Broda chair foot rest while seated. At 12:50 p.m., RN-R entered resident #2's room and completed wound care. When wound care was completed at 1:05 p.m., RN-R and the surveyor inspected the resident's heels. RN-R verified that a dent was still notable on the resident's left heel and an area of blanchable redness was still notable on the resident's right heel, a full 20 minutes after offloading of pressure from the Broda chair foot rest had been initiated. On 7/15/14, resident #2's potential for skin impairment plan of care was revised to include interventions to pad assist bar, wheel chair arms, footrest of Broda chair or any other source of potential injury if possible and to monitor for position of feet correctly on footrest in chair every time repositioned. On 7/17/14 at 8:30 a.m., surveyor # observed resident #2 in the dining room seated in a Broda chair with the entire foot rest of the Broda chair padded and sheep skin under both feet. 4. Resident #10's medical record indicated the resident was at risk for pressure ulcer. According to the resident's current MDS assessment, dated 5/6/14, the resident's [DIAGNOSES REDACTED]. This MDS assessment indicated the resident's cognition was impaired and the resident required one staff assist to reposition in bed. Resident #10's plan of care dated 5/29/14 indicated the resident requires one staff assist for bathing, dressing and grooming, able to feed self and requires one staff assist to toilet and requires one staff for transfers. On 6/19/14, resident #10's nurse's notes document that the resident had a fever, low oxygen saturations and was coughing. The resident was started on [MEDICATION NAME] pak (antibiotic) and oxygen therapy. On 6/21/14, resident #10's nurse's notes document that the resident was weak, had an upper respiratory infection and was bed bound. On 7/2/14, resident #10's nurse's notes document that the resident had an open area on the coccyx, measuring 1.2 cm by 0.5 cm by less than 0.1 cm. On 7/3/14, resident #10's nurse's notes document that the resident's coccyx area was assessed to have a stage III pressure ulcer and the plan of care was initiated on 7/3/14. Pressure reducing/relieving interventions and nutritional interventions were put in place after the discovery of Stage II pressure ulcer. On 7/17/14 at 10:30 a.m., surveyor # interviewed DON-B regarding resident #10. DON-B indicated the resident did not have a risk for pressure ulcers prior to an upper respiratory infection, as the resident was up and fairly mobile. DON-B indicated the resident was not reassessed for pressure ulcers and the resident's plan of care was not revised related to skin and pressure ulcer prevention when the resident was bed bound, until resident #10 developed a pressure ulcer. 5. Resident #8's medical record indicated the resident was at risk for pressure ulcers. According to the resident's current MDS assessment dated [DATE], the resident's diagnosis's included [MEDICAL CONDITION], debility, rhambdmylosis (a condition in which damaged skeletal muscle tissue breaks down rapidly), weakness, [MEDICAL CONDITIONS] and pre diabetes. This MDS indicated the resident was alert and cognizant and required one staff assist to turn and reposition while in bed. Resident #8's plan of care dated 6/5/14 included the intervention to have the resident's heels free floating while in bed. On 7/15/14 at 9:15 a.m., surveyor # observed resident #8 in bed with both heels in full contact with mattress. On 7/15/14 at 3:15 p.m., surveyor # observed resident #8 in bed with both heels in full contact with mattress. On 7/16/14 at 6:55 a.m., surveyor # observed resident #8 in bed with the resident's right lateral heel and ankle and left heel in full contact with mattress. On 7/16/14 at 805 a.m., surveyor # observed resident #8 in bed with both heels in full contact with mattress. On 7/16/13 at 8:08 a.m., surveyor # interviewed RN-T regarding resident #8. RN-T stated resident #8's plan of care indicated the resident's heels should be free floating while in bed. Surveyor # and RN-T observed resident #8 in bed with both heels in full contact with mattress. RN-T observed resident #8's heels and indicated both heels were blanchable and felt boggy. RN-T stated that she would have a CNA bring resident #8 a heel floating wedge immediately to free float the resident's heels.

Based on observations, staff interview and record review, the facility did not ensure each resident received adequate supervision and assistive devices to prevent accidents and the resident environment remained as free of accident hazards as possible for 4 (residents #1, #5, #12, and #20) of 16 sample and supplemental sampled residents. Resident #1 fell in the shower room, experiencing extensive and serious injury to the right ear. Staff had not followed resident #1's plan of care or the facility's policy, which directed staff to use a gait belt during transfer. Resident #1 was unpredictable and self-directed. The facility's expectation was that staff would provide supervision of resident #1 when the resident was in the bathroom. Staff were observed on two occasions leaving resident #1 unattended in the bathroom. During one of those times, resident #1 self-transferred off the toilet. Resident #5 had a plan of care requiring two staff and a sit-to-stand mechanical lift for transfers. An observation was made of staff not following the written plan of care. Resident #12 had swallowing difficulty. The physician ordered honey thickened liquids. On two occasions resident #12 was observed to be served liquids that did not reach honey consistency. Resident #20 used an oxygen concentrator. An observation was made of resident #20 sitting under an electric hair dryer in the facility's beauty shop with the oxygen concentrator butting up against the electric hair dryer. Findings include: 1. On 2/28/11 surveyor # reviewed the medical record for resident #1. The 6/22/09 face sheet indicated resident #1 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. Additions to the [DIAGNOSES REDACTED]. The 11/23/10 MDS (Minimum Data Set) indicated resident #1 had moderate cognitive impairment (made poor decisions, cues/supervision required); behaviors of verbal abuse; required extensive staff assistance with transfer, dressing, ambulation and bathing; was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS indicated resident #1's balance was not steady when moving from a seated to a standing position and when moving on and off the toilet. The 1/6/11 fall assessment indicated resident #1 was a high risk for falls. The plan of care, updated on 12/2/10, indicated resident #1 was to shower and transfer with assistance of one staff and to have a tabs alarm to the wheel chair, bed and toilet. Progress notes indicated on 12/9/10 at 4:30 a.m. resident #1 was found on the floor next to the bed, and at 8:10 p.m. resident #1 was found on the floor in front of the wheel chair. The 1/31/11 progress note indicated resident #1 fell in the shower, resulting in a laceration to the head, contusions to the forehead, back, sacrum and eye. Resident #1 was sent to the emergency room . The 1/31/11 emergency room report indicated resident #1 had a through-and-through laceration of the entire pinna from the superior aspect all the way to the inferior aspect involving the cartilage. The laceration measured 6 cm (centimeter). Resident #1 also had a 2.5 cm laceration over the mastoid prominence, behind the right ear. After resident #1 was provided with anesthesia, eleven absorbable and sixteen closure sutures were placed. On 3/2/11 at 1:30 p.m. surveyor # interviewed DON (Director of Nursing)-D. DON-D indicated the facility had reviewed resident #1's 1/31/11 fall. The facility determined CNA (Certified Nursing Assistant)-V had not followed the facility policy nor the plan of care for resident #1. DON-D indicated the facility's policy for gait belt transfer meant a gait belt was to be used for all transfers, including transfers in the shower. On 3/2/11 at 2:20 p.m. surveyor # interviewed CNA-V regarding resident #1's fall on 1/31/11. CNA-V indicated on 1/31/11, after resident #1's shower was completed, she assisted the resident to a standing position, asked the resident to hold onto the grab bar, then turned to obtain the wheel chair. CNA-V indicated for unknown reasons, resident #1 let go of the grab bar and fell . CNA-V verified a gait belt had not been used for resident #1 and the facility policy had not been followed. 2. On 3/1/11 at 8:15 a.m. surveyor # observed CNA-O exit resident #1's room. CNA-O closed the room door and walked toward the nursing station (approximately forty feet away), around the corner and out of sight. From 8:15 a.m. to 8:22 a.m. surveyor # provided constant observation. Staff were not observed in the area. At 8:15 a.m. resident #1's bathroom alarm sounded, and CNA-O reappeared. CNA-O and surveyor # entered resident #1's room. At the same time, resident #1's clip alarm began to sound. The door to resident #1's bathroom had been closed. CNA-O opened the bathroom door and discovered resident #1 had transferred off the toilet and to a standing position. After assisting resident #1 into the wheel chair, CNA-O explained to the surveyor, "(Resident #1) stands pretty good, but we can't trust her. We put an alarm on her, and we don't go very far. You never know when she is going to stand up." CNA-O went on to indicate resident #1 liked privacy and many times insisted the bathroom door be closed. On 3/2/11 at 10:15 a.m. surveyor # observed CNA-V assist resident #1 into the bathroom and transfer onto the toilet. Then CNA-V left the bathroom, closed the bathroom door, left the resident's room and closed the room door, leaving resident #1 alone in the bathroom. CNA-V walked to the nurses' station and out of sight. On 3/2/11 at 2:20 p.m. surveyor # interviewed CNA-V regarding the above observation. CNA-V indicated, "I don't let (resident #1) out of my sight, because I know she can do unpredictable things. She is fast and stubborn. (Resident #1) wants to do things her way." On 3/2/11 at 1:30 p.m. surveyor # interviewed DON-D regarding the above observations. DON-D indicated the facility did not have a policy regarding leaving residents alone in the bathroom; however, staff were aware resident #1 was unpredictable. DON-D indicated the facility's expectation would be for staff to remain in the room when resident #1 was in the bathroom. 3. On 3/3/11 surveyor # reviewed the medical record for resident #12. The current MDS, dated [DATE], indicated resident #12 was admitted to the facility on [DATE], had severe cognitive impairment and was dependent on staff for cares. The 4/29/10 [DIAGNOSES REDACTED]. The nurses' note dated 8/5/10 indicated resident #12 had a large emesis with severe coughing following ingestion of ice cream. The note indicated crackles were heard when obtaining lung sounds. The nurses' note dated 2/3/11 indicated resident #12 had coughing/choking during a meal and required suctioning. The 2/11/11 physician diet order included honey-like liquids. On 3/3/11 at 10:20 a.m. surveyor # interviewed MDSC-E about resident #12's diet order. MDSC-E indicated on 1/5/08 resident #12 experienced a coughing/choking episode during the noon meal. A three-day trial of honey thickened liquids was successful, and on 1/10/08 resident #12's physician ordered honey thickened liquids. On 3/2/11 at 7:30 a.m., during medication pass observation, surveyor # observed LPN (Licensed Practical Nurse)-Q provide resident #12 miralax 17 grams. LPN-Q mixed the medication with tomato juice and provided it to resident #12. Thickener was not added to the juice. Resident #12 drank the juice. On 3/3/11 at 7:45 a.m. surveyor # observed resident #12 during the breakfast meal. Resident #12 was consuming four different liquids. The surveyor interviewed MDSC (Minimum Data Set Coordinator)-E about the consistency of the liquids resident #12 had been served. MDSC-E identified the liquids as coffee, tomato juice, mighty shake and protein drink. MDSC-E indicated the four liquids were not a honey consistency. On 3/3/11 at 8:00 a.m. surveyor # interviewed DON-D regarding the consistency of the four liquids. DON-D inspected each liquid and determined the protein drink had been thickened to honey consistency. DON-D indicated the coffee, tomato juice and mighty shake were not a honey consistency. DON-D indicated the facility's Food Service Director and Dietitian would be notified. 4. The facility's policy entitled "Transfer Lift Assessment for Residents" dated September 2009 indicated the following: "* (assessment) to be completed by an RN (Registered Nurse)... * new form to be completed if changes are identified... * residents who do not have moderate upper body strength or the ability to follow directions, require a total lift." On 2/28/11 surveyor # reviewed the medical record of resident #5. The face sheet dated 1/20/09 indicated resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] revealed resident #5 was dependent on staff for extensive assistance with transfers in bed and out of bed. A "Transfer Lift Assessment" dated 1/26/11 indicated resident #5 required two staff and a sit-to-stand mechanical lift for transfers. That assessment was completed by an RN. A "Falls Data Collection Tool" dated 9/15/10 revealed resident #5 was at "high risk" for falls. A "Physical Therapy Evaluation and Plan of Treatment" dated 1/20/11 documented, "(resident #5) no longer able to ambulate due to extension rigidity...has had significant decline in body awareness/posture and is holding self rigidly, often." The written plan of care for resident #5 dated 1/20/11, revealed, "Transfers: sit to stand lift with 2, or if legs unable to bend to stand on lift platform 2 CNAs need to do a full body lift." On 3/1/11 at 9:00 a.m. surveyor # observed transfer and toileting of resident #5. CNA-G applied a gait belt around the waist of resident #5, who was sitting in a Broda chair. Lifting under the arms of resident #5, the CNA lifted the resident out of the chair and transferred the resident to the toilet. Surveyor # noted the feet of resident #5 were extended. Only her toes touched the ground during the transfer. In the same manner, CNA-G transferred resident #5 from the toilet back to the Broda chair. On 3/1/11 at 10:00 a.m. surveyor # interviewed CNA-F regarding communication of changes to residents' plans of care. CNA-F confirmed CNA care cards could be found on the bathroom doors of each resident room and reviewed for pertinent data regarding resident cares. CNA-F also verified changes were communicated verbally through shift-to-shift report. The document entitled "Care Plan", which was found hanging on the bathroom door in the room of resident #5 was last updated on 11/29/07 and listed the following interventions: "* hand held assist with mobility... * transfer with assist of 1." On 3/2/11 at 8:10 a.m. surveyor # interviewed MDSC-E about the written plan of care for resident #5. MDSC-E confirmed RNs communicated changes to a resident's plan of care via the computer, which generated documentation for the medical record. MDSC-E indicated that printed plan of care should be the most current. MDSC-E also indicated the CNA care cards on the back of bathroom doors were no longer used and should have been removed. When asked, MDSC-E stated the current intervention for transferring resident #5 "...was difficult to answer because of a recent decline. The sit-to-stand lift was not working well. She (resident #5) used to be able to stand and pivot, now they cradle lift her." MDSC-E was unaware the plan of care directed staff to use a full lift if the sit-to-stand lift was not adequate. At the final exit with the facility on 3/3/11 at 3:00 p.m., surveyor # presented a copy of the "care plan" for resident #5, revised 11/07, which had been found on the bathroom door in the room of resident #5. DON-D indicated that plan of care was obsolete and should have been removed. Additionally, MDSC-E indicated CNAs were empowered to make decisions regarding when to use what type of transfer aid. 5. On 3/2/11 at 10:42 a.m. surveyor # observed resident #20 being wheeled into the beauty shop by staff. An oxygen concentrator was placed next to resident #20, the nasal cannula applied to resident #20 and the concentrator turned on. At 11:15 a.m., surveyor # observed resident #20 under an electric hair dryer, nasal cannula in place and the concentrator next to the resident's wheel chair, between the hair dryer and wall. The liter flow of the oxygen was at 2 liters. Surveyor # observed the hair dryer to have three settings; low, normal and high. The hair dryer knob was positioned to "normal." Surveyor # assessed the temperature of the air blowing from the hair dryer bonnet. The air was warm to touch. On 3/2/11 at 11:16 a.m. surveyor # interviewed HS (Hair Stylist)-I regarding use of oxygen while residents were under the hair dryer. HS-I confirmed the temperature of the air blown from the hair dryer was warm, and resident #20 routinely used oxygen in the beauty shop. HS-I indicated she was unaware of restrictions regarding oxygen use in the beauty shop and had not received education regarding such. On 3/2/11 at 11:20 a.m. surveyor # interviewed DON-D and DOM (Director of Maintenance)-J regarding oxygen safety. Neither staff was aware of safety risks of oxygen and electric hair dryers. Policy and procedures, as well as manufacturer's recommendations, were requested at that time. On 3/2/11 at 1:50 p.m. DON-D presented surveyor # with the facility's "Guidelines - Oxygen safety" last updated in January 2009, which indicated the following precaution: "Electrical appliances should not be used within five feet of oxygen source..." Additionally, the Operator's Manual for the Invacare "Perfecto2 Series" oxygen concentrator dated June 2008 indicated, "Keep the oxygen tubing, cord, and unit out from under items such as blankets, ...heated or hot surfaces, including space heaters...and similar electrical appliances." On 3/2/11 at 1:52 p.m. DON-D verified, based on the above policies and recommendations, the facility should not use oxygen in the beauty shop near electrical hair dryers.