Every finding on record at St. Anne's Salvatorian Campus

Based on observation, interview, and record review, the facility did not ensure residents at risk of pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries for 1 (R34) of 1 resident reviewed. *R34 was admitted to the facility 2/23/26 without any pressure injuries, and the facility assessed R34 to be at high risk for the development of pressure injuries. R34 developed two avoidable facility acquired, unstageable pressure injuries to the right and left legs on 3/22/26. The facility did not implement person centered interventions to prevent pressure injuries from developing, did not accurately assess the pressure injuries upon discovery, did not identify the root cause of the pressure injuries to allow the facility to identify person centered interventions to promote healing and prevent new pressure injuries from developing. Findings include:The facility's policy and procedure titled, Pressure Injury Prevention and Managing Skin Integrity with initial approval date 2/8/17 and reviewed date 5/8/25 documents . I. Policy: prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedure:Risk Assessment . Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. Re-evaluation: Braden Scale will be completed upon change of condition and quarterly. Based on the individual's Braden Scale score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record.Identify Interventions and Care Plan . Identify interventions . The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown . Identification of risk factors present or acquired that compromise skin integrity will be considered . Care Plan . In developing a plan of care, the following will be considered: . Individual pressure injury history . risk for pressure ulcer development (Braden Scale) . Skin Checks . Skin check will be done upon admission, readmission or as clinically indicated. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the Skin Check in the medical record. Weekly Wound Rounds . Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. Registered Nurse (RN) or designee will: Conduct weekly skin evaluation. Update the (PCP) (Primary Care Physician) with any decline in wound appearance, or as necessary . Update the Care Plan with any new interventions as applicable . Update Individual Representative as indicated.The National Pressure Injury Advisory Panel (NPIAP) document titled, NPIAP Staging for Lightly Pigmented Skin dated 2/14/2020 defines a pressure injury as localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The document defines the following stages:Stage 2: partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (hard, dead scab or crust of tissue) are not present. Stage 3: full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location . if slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.Unstageable Pressure Injury: full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. R34 was admitted to the facility on [DATE] with diagnoses including other sequelae (long-term effects) of cerebral infarction (stroke).R34's admission skin evaluation dated 2/23/26 documents bruising at the left and right antecubital (front of the elbow) regions and an abrasion to the left elbow. R34's significant change Minimal Data Set (MDS) dated [DATE] documents no current pressure injuries or skin conditions, and R34 is assessed to be at risk for developing pressure injuries. The MDS documents R34 has a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS documents R34 requires moderate assistance from staff for rolling in bed and R34 is dependent on staff for activities of daily living (ADLs), transfers in and out of bed, transfers in and out of a wheelchair, and is unable to walk. R34's Care Area Assessment (CAA) for pressure injuries dated 3/16/26 documents the CAA triggered for potential pressure ulcer due to need for assistance with bed mobility . further complicated by incontinent of urine and bowel, utilizes brief daily to manage. [R34] does not currently have a pressure ulcer or history of pressure ulcers . [R34] is at risk for skin breakdown . will proceed to plan of care with goal to maintain skin integrity. R34's Braden Scale assessment dated [DATE] documents a score of 11, indicating high risk for pressure injury development.R34's care plan documents [R34] has potential for impairment to skin integrity r/t (related to) decreased ambulation. Date initiated:3/2/26, revision on 3/2/26. Interventions include:- [R34] will maintain clean and intact skin by the review date.-The resident will maintain clean or develop clean and intact skin by the review date.-Follow facility protocols for treatment of injury. -[R34] needs pressure relieving/reducing cushion to protect the skin while up in chair. -The resident needs (Specify: pressure relieving/reducing mattress, pillow, sheepskin padding etc. (etcetera)) to protect the skin while up in chair. Surveyor notes the facility did not identify resident specific interventions to prevent pressure injuries from developing including what type of cushion R34 required while up in a chair. In an interview with R34 on 3/23/26 at 1:52 PM, R34 was unable to state what happened to R34's legs. Surveyor observed a wound dressing on both R34's right and left lower legs dated 3/23. R34's legs were observed to not be resting on the Broda chair and a roho cushion was in place. Surveyor reviewed R34's electronic health record (EHR) and located a nursing progress note written by Registered Nurse (RN)-K dated 3/22/26 at 1:59 PM, which documents two new open areas to [R34]'s knees: the right lateral (outer) knee showed no drainage, and the surrounding skin was pink and intact. The left lateral knee also had no drainage, with the surrounding skin being pink and intact. The areas were cleaned with wound cleaner, f/b (followed by) bordered foam dressing. The resident denies pain in the area. POA (Power of Attorney), DON (Director of Nursing) and ADON (Assistant Director of Nursing) and [name of hospice company] RN (Registered Nurse) were made aware of the above. R34's EHR documents a skin care form dated 3/22/26 which documents Skin color WNL (within normal limits). New skin issue. Location: Front right knee. Laterality. Tissue type: Open lesion. Progress: New wound. Wound acquired in-house. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: in-house nursing. Length (cm): 0.5, Width (cm) 2.5, Depth (cm) 0.1, Undermining: No. Tunnelling: No. Periwound: epithelization. Periwound: Rolled ddge (sic) (Epibole). Surrounding tissue: Fragile. Surrounding tissue: Intact. Induration: Induration (the localized hardening or firming of soft tissue surrounding a wound) < 2cm around the wound. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: 0%. Cleansing solution: None. Primary Dressing: foam. Secondary dressing: No secondary dressing applied. Modalities: None. Frequency of treatment: Clean wound with wound cleaner f/b bordered foam dressing 3x (times) week. New skin issue. Location: Front left knee. Laterality/orientation: Left. Laterality/orientation: Lateral. Issue (sic) type: Open Lesion. Progress: New wound. Wound acquired in-house. It is unknown how long the wound has been present. Signs and symptoms of infections: None. Painful: No. Staged by: In-house nursing. Length (cm):1, Width (cm): 1, Depth (cm) 0.1. Undermining: No. Tunnelling: No. Granulation: 0%. Slough: 0%. Exudate type: None. Odor after cleaning: None. Periwound: Rolled ddge (sic) (Epibole). Surrounding tissue: Intact. Surrounding tissue: Erythema. Induration: Induration (the localized hardening or firming of soft tissue surrounding a wound) < 2cm around the wound. Edema: No swelling or edema. Periwound temperature: Normal. Dressing appearance: Intact. Dressing saturation: 0%. Cleansing solution: None. Primary Dressing: foam. Secondary dressing: No secondary dressing applied. Modalities: None. Frequency of treatment: Clean wound with wound cleaner f/b bordered foam dressing 3x (times) week. On 3/25/26 at 2:33 PM, Surveyor interviewed RN-K via phone call. RN-K confirmed a certified nursing assistant (CNA) discovered R34's wounds on 3/22/26 and alerted RN-K. RN-K confirmed an assessment was completed 3/22/26 for R34's new wounds and RN-K confirmed the wounds were documented as open lesions. RN-K stated R34's wounds looked like maybe a blister had opened and RN-K was unsure of the etiology. Surveyor asked why RN-K categorized the wounds as open lesions and RN-K stated RN-K was not sure what to categorize the wounds as and did not think the wounds were due to pressure and RN-K didn't know if it was shearing or a blister. RN-K stated R34 does tend to cross R34's legs when sitting in the wheelchair, so maybe the wounds developed from shearing when R34 was crossing their legs. RN-K stated R34 usually wears socks and takes them off and moves around a lot. RN-K stated they (RN-K) have done a lot of wound care but did not necessarily receive education from the facility. RN-K stated there is an area on the form (facility skin care form) to document root cause. RN-K stated unknown should have been documented, wound bed newly granulating, 0% granulation since it was brand new, no slough or exudate was observed. Surveyor notes the facility did not implement care plan interventions to promote healing to address possible shearing when R34 crosses their legs. On 3/24/26 at 7:37 AM, Surveyor observed R34's wound care performed by RN-F. Surveyor asked RN-F how R34's wounds may have developed. RN-F stated R34 appears to have a curvature to the lower legs on both sides where the wounds developed, and the wounds are over a prominent area, so they could have developed due to the curvature of R34's legs. Surveyor notes the facility did not implement interventions to address R34's leg curvature as a possible cause of R34's pressure injuries. On 3/24/26 at 8:50 AM, Surveyor went with Director of Nursing-B and Wound Nurse Practitioner (Wound NP)-J to R34's room. DON-B and Wound NP-J stated 3/24/26 is the first date R34's wounds are being assessed by DON-B and Wound NP-J. Wound NP-J observed R34's wounds and stated the wounds are over a very prominent area on R34's lower legs so the wounds would be considered pressure injuries. Wound NP-J stated the right lower leg wound is a full thickness wound measuring 0.5 cm in length, 0.5 cm in width, and unable to determine (UTD) depth with 80% granular tissue and 20% slough with small serous drainage, no signs of infection. Wound NP-J stated the left lower leg wound is a full thickness wound measuring 1.0 cm in length, 2.0 cm in width, and UTD depth with 20% granular tissue and 80% slough with small serous drainage, no signs of infection. Wound NP-J stated both wounds are considered unstageable pressure injuries since slough is present in both wounds. Wound NP-J stated the wounds may have developed from R34's mattress from resting on the scoops on the edge of the mattress. Surveyor notes the scoops on the edge of the mattress are located only at the head and foot of the mattress. The Wound Care Initial Evaluation in R34's EHR dated 3/24/26 at 12:36 PM, written by Wound NP-J documents etiology of wounds is unclear, however [R34] needs full assistance with cares. Air mattress to be ordered, continue to reposition, avoid laying on either side for more than two hours at a time while in bed. On 3/24/26 at 12:52 PM, Surveyor observed R34 lying in bed on R34's left side with both lower legs off of the mattress and resting directly on an extra mattress next to R34's bed. Surveyor asked RN-F why there is an extra mattress next to R34 and RN-F stated the extra mattress is a fall intervention because R34 has had previous falls out of bed. RN-F stated R34 likes to lay in this position. Surveyor notes the facility did not implement pressure injury preventative interventions to address R34's preference to lay with his legs off the bed and resting directly on the extra mattress next to the bed. On 3/25/26 at 8:20 AM, Surveyor interviewed CNA-L and CNA-M who stated R34 does cross R34's legs a lot in the wheelchair and when lying in bed. CNA-L demonstrated to Surveyor how CNA-L observes R34 cross the legs and Surveyor notes the heel is demonstrated to be resting on the opposite leg in the same area of R34's wounds. CNA-L and CNA-M stated they have observed R34 cross R34's legs in this manner since R34 was admitted to the facility. R34's impairment to skin integrity care plan was revised 3/25/26 (3 days after the pressure injuries were identified) and documents the following interventions:-alternating pressure mattress (initiated 3/25/26)-avoid laying on either side for greater than 2 hours when in bed (initiated 3/24/26)-every 2 hours turn and reposition schedule on even hours when in bed (initiated 3/25/26)-monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration etcetera (initiated 3/24/26)-weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (initiated 3/24/26)Surveyor notes no interventions were added to reduce pressure to R34's legs while R34 is up in the wheelchair, to reduce pressure/shearing when R34 crosses R34's legs, to address the curvature of R34's legs, or 34's preference to lay with legs off the bed all of which facility staff have identified as a possible causes for the pressure injuries. On 3/25/26 at 2:46 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, DON-B, Assistant Director of Nursing (ADON)-C and Regional Nurse Consultant-D that R34 admitted to the facility on [DATE] without any pressure injuries and was assessed to be at high risk for the development of pressure injuries, and developed two unstageable pressure injuries to the right and left lower legs on 3/22/26. Surveyor shared additional concern R34's care plan was not revised to address the staff identified causes for the pressure injury development. On 3/26/26 at 8:00 AM, NHA-A provided Surveyor with a document titled New Wound for R34. Surveyor notes DON-B documented in the notes section dated 3/24/26 [R34] was seen on Tuesday with normal rounds, wound assessed and addressed by Wound NP. [R34] has had multiple falls with behaviors of crawling around which has been care planned . initial wound assessment was done by floor nurse who is uncertified in wound care. Floor nurse description of wound bed and measurements was not accurate. On 3/26/26 at 12:09 PM, NHA-A provided initial pictures of R34's wounds taken on 3/22/26 by RN-K to the survey team. Surveyor notes the pictures show slough tissue in both wounds upon discovery. On 3/26/26 at 8:25 AM, Surveyor interviewed DON-B regarding the pictures of R34's pressure injuries. DON-B confirmed the pictures indicate slough was present in R34's wounds when the wounds were first discovered, so the wounds should have been categorized as unstageable pressure injuries. Surveyor shared concern with DON-B that R34's wounds were not accurately staged or described as unstageable pressure injuries when they were discovered. DON-B expressed understanding. No additional information was provided.

Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This has the potential to affect all residents that reside at the facility. *Registered Nurse (RN)-F did not properly disinfect a glucometer that is shared between residents. This deficient practice has the potential to affect 5 residents that require blood sugar testing on the first floor. *The facility had a COVID-19 outbreak in February 2025 and did not provide evidence that the outbreak was reported to the local public health authority. This deficient practice had the potential to affect all residents residing in the facility during the February 2025 outbreak. Findings include: The facility policy titled Infection Prevention and Control Program with approval date 6/14/17 and review date 8/29/25 documents: the facility will report to the public health department according to the Centers for Disease Control (CDC) and state guidelines. The State of Wisconsin Memo BCD 2023-05 dated 9/29/2023 documents outbreaks of any communicable disease, including COVID-19, remain a category 1 reportable condition. The State of Wisconsin Chapter DHS (Department of Health Services) 145 Appendix A, titled Communicable Diseases and Other Notifiable Conditions documents category 1 conditions include: Outbreaks, confirmed or suspected: other acute illnesses. The disease shall be reported by telephone to the patient's local health officer or to the local health officer's designee upon identification of a case or suspected case. In addition to the immediate report, complete and fax, mail or electronically report an Acute and Communicable Diseases Case report to the address on the form, or enter the date into the Wisconsin electronic Disease Surveillance System, within 24 hours. On 3/24/26 at 11:34 PM, Assistant Director of Nursing (ADON)-C confirmed ADON-C is the Infection Preventionist (IP) at the facility and provided Surveyor with two infection control binders. ADON/IP-C stated one binder is for information about the IP program from January 2026 to current and the other binder is information about the IP program from January 2025 to December 2025. ADON/IP-C stated ADON/IP-C started the IP role in August 2025 and was not sure who the IP for the facility was prior to then. Surveyor noted documentation of a COVID-19 outbreak between the dates of 1/26/25 to 2/25/25 which affected 12 residents and 3 staff members. Surveyor was unable to locate evidence that the facility reported the outbreak to the local health officer. Surveyor did not note any other outbreaks documented in the facility between January 2025 to current. On 3/25/26 at 1:52 PM, ADON/IP-C stated the information available in the binder that was provided to Surveyor is all the information ADON/IP-C has regarding the COVID-19 outbreak and no additional information is available. On 3/25/26 at 2:46 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, ADON/IP-C and Regional Nurse Consultant-D that there is no evidence the facility reported the COVID-19 outbreak to the local health officer in February 2025. Regional Nurse Consultant-D confirmed no additional information was located and all information regarding the COVID-19 outbreak in February 2025 the facility has was provided in the binder. 2.) On 3/24/26 at 8:10 AM, Surveyor observed Registered Nurse (RN)-F prepare medications for R17. Surveyor observed a glucometer resting on a white wipe on the medication cart. RN-F picked up the glucometer and removed a wipe from a container with blue top labeled Sani hands instant hand sanitizing wipe. RN-F wiped the glucometer for 15 seconds and placed it on top of the wipe. Approximately 1 minute later, RN-F sanitized his hands, put on gloves and entered R17's room to obtain her blood sugar. After obtaining R17's blood sugar, RN-F walked back to the medication cart, removed his gloves and sanitized his hands. RN-F applied gloves, obtained a wipe from the same container and wiped the glucometer for 15 seconds before placing it on a clean glove on the medication cart. Upon completion of R17's medication pass, Surveyor asked if residents have their own glucometers or if they are shared between residents. RN-F stated, On this floor it is shared, upstairs they have their own each in a plastic bag with their name. Surveyor asked RN-F if he had any other blood sugars to do. RN-F stated, Yes, one more. Surveyor asked RN-F if any other residents' blood sugars have been done. RN-F stated, Yes, room [room number] and room [room number]. Surveyor verified those residents as R24 and R29. Surveyor asked how the glucometer is cleaned between residents. RN-F stated, I use this wipe (showed Surveyor the instant hand sanitizing wipe container) and wipe it down, some of these have instructions to keep it wet for a while, so that's why I wipe it down and leave it wet to air dry. On 3/24/26 at 8:25 AM, Surveyor asked RN-F if there were any other wipes in the medication cart to clean the glucometer. RN-F checked the drawers and stated, No, but after thinking about it, I realize now that I didn't use the right wipe, I think it's supposed to be the purple top. Surveyor advised RN-F of concern he cleaned the glucometer using a hand sanitizing wipe. RN-F reported he would obtain the proper wipe to clean the glucometer. On 3/24/26 at 8:30 AM, Surveyor asked Nursing Home Administrator (NHA)-A and Consultant-D what the expectation is for cleaning glucometers. NHA-A said, I think an alcohol wipe, I'm not sure. Consultant-D corrected her, stating No, we use the germicidal wipe. Surveyor observed a container with a purple top on the table labeled Super Sani Cloth germicidal disposable wipe. Consultant-D confirmed this is the wipe to be used. Surveyor asked for a copy of the facility policy and procedure for cleaning glucometers. On 3/24/26 at 8:45 AM, NHA-A advised Surveyor the facility does not have a policy and procedure on cleaning glucometers, We would follow the manufacturer recommendations on the container. I assume you're asking because (RN-F) used the wrong wipe, the one with the blue top. Surveyor advised NHA-A of concern the glucometer was cleaned with a hand sanitizing wipe. NHA-A stated, We spoke with him, did education and gave him the correct wipe with the purple top. Surveyor asked NHA-A for evidence of how many residents on the unit require blood sugar testing and if any residents have bloodborne pathogens. Surveyor was provided with a list of residents requiring blood sugar testing on the first floor to be: R10, R17, R21, R24 and R29. Surveyor verified none of the residents had bloodborne pathogens. The blue top Instant hand sanitizing wipes container label documents: Cleans and sanitizes hands. Kills 99.9% of many common bacteria. Safe to use before eating and drinking. Contains moisturizing aloe and vitamin E. Active ingredient: Ethyl alcohol 70% by volume - antiseptic. Use: To decrease bacteria on the skin. The purple top Super Sani-Cloth germicidal disposable wipe container label documents: Effective against: Bacteria, multi-drug-resistant bacteria, viruses, bloodborne pathogens, mycobacterium (TB), pathogenic fungi. Kills HIV-1(Human Immunodeficiency Virus), Hepatitis B and Hepatitis C on the environmental surface/object within 2 minutes. Contact time: Allow surface to remain wet for 2 minutes, let air dry. The Assure Prism glucometer manufacturer recommendations document: To minimize the risk of transmission of blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. After disinfection, users should remove gloves and wash hands before testing the next patient. Cleaning and disinfecting: The cleaning procedure is needed to clean dirt as well as blood and other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood-borne pathogens. The meter should be cleaned and disinfected after use on each patient. This blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfection procedures are followed. We have validated Super Sani-cloth germicidal disposable wipe for disinfecting the assure prism multi meter. It has been shown to be safe for use with the meter. On 3/34/26 at approximately 10:00 AM, NHA-A and Consultant D were advised of the above concern. No additional information was provided.

Based on record review and staff interview, the facility did not ensure the Infection Preventionist (IP) had specialized training in infection prevention and control. This has the potential to affect all 36 residents in the facility. *The Assistant Director of Nursing (ADON)-C began the IP role in August 2025 and did not provide evidence of completing specialized training in infection prevention and control prior to assuming the role of the IP. Findings include:The facility policy titled Infection Prevention and Control Program with review date 8/29/25 documents: the IP will maintain current knowledge in the filed of infectious disease and epidemiology through training provided through the Centers for Disease Control (CDC) in collaboration with Centers for Medicare and Medicaid (CMS). On 3/24/26 at 11:34 AM, Surveyor met with ADON/IP-C to discuss the facility's infection control program. During this meeting, Surveyor asked ADON/IP-C if ADON/IP-C has specialized training in infection prevention and control with evidence of a certificate. ADON/IP-C stated ADON/IP-C does not have any certification or specialized training and has not completed training through the CDC. ADON/IP-C stated ADON/IP-C took over the role of IP for the facility in August 2025. Surveyor shared concern with ADON/IP-C that ADON/IP-C has been the IP for the facility since August 2025 without completing specialized training. ADON/IP-C understood the concern. Surveyor reviewed the facility infection control program information provided by ADON/IP-C from January 2025 to March 2026 and did not note any documented outbreaks in the facility between August 2025 to March 2026 when ADON/IP-C served as the facility's IP.In an interview on 3/25/26 at 1:52 PM, ADON/IP-C informed Surveyor that the facility enrolled ADON/IP-C in the infection prevention and control program on 3/24/26, after it was brought to the facility's attention. During the interview, Surveyor asked ADON/IP-C if ADON/IP-C participates in the facility's water management program. ADON/IP-C stated ADON/IP-C has not participated in the water management program and was not aware of what the IP role in the facility's water management program would be. On 3/25/26 at 2:46 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and regional nurse consultant-D that ADON/IP-C did not have evidence of completing specialized training in infection prevention and control prior to assuming the role of IP in August 2025, and there is no evidence this training has been completed as of 3/25/26. Regional nurse consultant-D confirmed ADON/IP-C was enrolled in the CDC infection preventionist training course on 3/24/26 but ADON/IP-C has not yet completed the course. In an interview on 3/26/26 at 12:19 PM, regional nurse consultant-D stated regional nurse consultant-D does have the CDC certification for infection prevention and control and will continue monitoring and assisting ADON/IP-C with the infection control program until ADON/IP-C has completed the certification course. Surveyor requested regional nurse consultant-D's evidence of specialized training completion, but regional nurse consultant-D was unable to locate the certificate. On 3/26/26 at 5:26 PM, NHA-A sent additional information to Surveyor with a certificate for nurse consultant-O documenting completion of the CDC course Nursing Home Infection Preventionist Training Course dated 7/16/2024. NHA-A stated in the email that nurse consultant-O also assists the facility with the infection control program.

Based on interview and record review, the facility did not ensure 5 (R5, R6, R30, R37, and R1) of 8 resident's reviewed for hospitalization received the proper notice of transfer and bed-hold to include; date and reason for transfer, location of transfer, duration of bed hold, reserve bed hold payment, appeal rights, and name and address, and telephone number of the Office of the State Long-Term Care Ombudsman. *R5 transferred and admitted to the hospital on the following dates, 6/14/25, 7/2/25 and 12/4/25 while residing in the facility and evidence was not provided R5 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold. *R6 transferred and admitted to the hospital on the following dates, 11/21/25 and 2/19/26 while residing in the facility and evidence was not provided R6 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold. *R30 transferred and admitted to the hospital on the following dates, 1/31/26 and 2/24/26 while residing in the facility and evidence was not provided R30 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold. *R37 transferred and admitted to the hospital on the following dates, 12/3/25, 1/4/26 and 3/13/26 while residing in the facility and evidence was not provided R37 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold. *R1 transferred and admitted to the hospital on [DATE] while residing in the facility and evidence was not provided R1 or their representative were notified in writing of the reason for the transfer/discharge to the hospital and the facility policy for bed hold. Findings include: The facility policy, entitled Individual Bed Hold, dated 5/8/91 with most recent review dated 3/3/26, documents, in part . Policy: The individual, guardian, and/or individual representative will be informed upon admission and/or hospital/therapeutic leave of their bed hold options at the facility. Procedure: .B. Upon transfer to hospital and/or therapeutic leave. 1. Individual will be informed and receive a copy of the bed hold procedure and letter. 2. Options will be given for a decision to be made regarding bed hold status. 3. If individual is unable to make preference known, designee will contact guardian and/or individual representative to determine preference. 4. Response will be documented. 5. Life Coach, or designee, will contact the individual representative on the next working day to ensure that the representative understands the bed hold and return to facility information. 6. Life Coach, or designee will make periodic contact with the individual and/or representative during the individual's absence. C. Bed Hold Parameters. 1. For Private Pay Individuals: An individual's bed will be held and the individual will be billed the day (sic) rate for each day he or she is away from the entity. The individual and/or individual representative may request that he or she does not want the bed held. 2. For Medical Assistance Individuals and Managed Care Individuals: Medical Assistance and Managed Care will pay to hold the bed for 15 days. The individual, guardian, and/or individual representative may choose to pay privately on the 16th day after the leave to hold the bed. If the bed hold is not desired, the individual may be offered the next available bed at the entity for admission. 3. For Medicare and/or other Insured Individuals: An individual's bed will be held and the individual will be billed the day (sic) rate for each day he or she is away from the entity. Medicare does not cover the cost of a bed hold during hospitalization or therapeutic leave. The individual, guardian, and/or individual representative may request that he or she does not want the bed held. 1.) R5 was admitted to the facility on [DATE]. R5 has an activated Power of Attorney (POA) effective 6/14/25. R5's Nurses Note, dated 6/14/25 at 8:02 AM, documents, Resident assessed by writer @ (at) 0645 (6:45 AM) R/T (related to) decline in condition. Resident weak. Not changing position in bed. More confused than usual. Lethargic and not accepting fluids. Skin turgor poor with tenting. A (alert) & O (oriented) X (times) 1 only. T (temperature)-99.0 P (pulse)-78 R (respiration)-18. B.P. (blood pressure)130/70. STAT (immediately, instantly or without delay) labs and STAT urine not obtained 6-13-25 per writer conversation with PM (second shift) nurse. Writer called POA on above and states she wants her to be sent to the ER (emergency room). NP (Nurse Practitioner) called and updated states to send Resident out to [hospital name] ER per ambulance. Ambulance called to transport. All papers sent with [name of company] ambulance when transported @ 0715 (7:15 AM).[Hospital name] ER called and ER RN (Registered Nurse) updated on Resident transfer and condition. 2nd floor cell phone number provided to ER nurse to call with any questions. R5's Nurses Notes, dated 6/14/2025 at 12:11PM, documents, Resident admitted with DX (diagnosis) Hypokalemia (lower than normal level of potassium in the blood) and elevated WBC (white blood count). R5's Discharge/Transfer Note, dated 6/16/2025 at 8:48AM documents, Bed hold completed, the residents bed will be held according to the facility bed hold policy. R5's Nurses Note, dated 6/24/2025 at 5:29 PM, documents, Resident follow up readmit, slept through the night, no complaints of pain or discomfort, none reported. R5's Nurses Note, dated 7/2/2025 at 13:38 (1:38 PM) documents, Resident working with PT (Physical Therapy) when writer was called to her room as Resident was unresponsive. Resident unresponsive and sitting on the toilet. Eyes closed and body limp. 911 called by writer and Resident monitored continually until ALS (Advanced Life Support) in room. Writer was instructed not to move Resident and keep her NPO (nothing by mouth). Resident with shallow breathing and PT stated she was unresponsive about a minute. Resident became responsive when ALS arrived. Resident slow to respond @ first. Resident transported to [hospital name] ER per stretcher. POA called and updated on above. POA thanked writer for sending her to [hospital name] as Resident has a CVA/T.I.A. (stroke/transient ischemic attack) HX (history). R5's Nurses Note, dated 12/4/2025 at 06:22 AM, documents, Patient had coffee brown emesis x1 on shift, BP 174/106, RR 20, HR 85, and Spo2 96%. [Physician service] updated, voicemail left to POAs. Resident sent to ER to get eval and to treat. On 03/24/2026 at 12:11 PM Surveyor requested from Nurse Consultant-D, the Bed Hold and Transfer notices for R5's hospitalizations that occurred on 6/14/25, 7/2/25 and 12/4/25. On 03/24/2026 at 12:30 PM, Nursing Home Administrator (NHA)-A provided Surveyor a copy of R5's Bed Hold confirmation upon Transfer from the Skilled Nursing Facility for hospitalization on 6/14/25 and a copy of R5's Notice of Transfer and Bed Hold Form for hospitalization on 12/4/25. NHA-A confirmed there is no evidence of R5's bed hold or transfer notice for hospitalization on 7/2/25. R5's Bed Hold Confirmation upon Transfer from the Skilled Nursing Facility form, dated 6/14/25, documents, R5's name, physician, date of transfer, location of transfer, payor source as Medicaid, 15 day bed hold, appeal rights, and name and address with the telephone number of the Office of the State Long-Term Care Ombudsman but did not document R5's reason for transfer, reserve bed hold payment daily rate and does not have R5's signature or representative signature nor documentation if a verbal notification was provided. R5's Notice of Transfer and Bed Hold Form dated 12/03/25 documents R5's name, physician, date of transfer, location of transfer, reason for transfer, payor source as Medicare, reserve bed hold payment daily rate, appeal rights, and name and address with the telephone number of the Office of the State Long-Term Care Ombudsman but did not document R5's POA was informed of bed hold and transfer notice. Surveyor notes, R5's Notice of Transfer and Bed Hold Form dated 12/03/25, for actual hospitalization on 12/4/25, documents incorrect payor source of Medicare when it should be Medicaid and a 15-day bed hold was not indicated. On 03/24/2026 at 2:58 PM, Surveyor informed NHA-A, Director of Nursing (DON)-B, Assistant Director of Nursing (ADON)-C, and Nurse Consultant-D of missing or incomplete/inaccurate bed hold and transfer notices for the R5. NHA-A expressed understanding. 2.) R6 was admitted to the facility on [DATE]. R6 was appointed legal guardianship effective 12/6/24. R6's Progress Note, dated 11/21/2025 at 10:45 AM documents, Resident c/o (complained of) non-radiating stabbing chest pain (8/10). VS (Vital Signs) WNL (Within Normal Limits) SPO2 (oxygen level) 96% RA (room air). Resident request to go to ER (emergency room) for evaluation. 911 called. Aspirin 324mg (milligrams) administered order by 911. Resident maintained NPO (nothing by mouth). 1110 (11:10 AM) 911 on the unit. EKG (electrocardiogram) (teste that measures the heart's electrical activity) completed; negative. Chest pain continues at 8/10. Resident request ER evaluation. POA (Power of Attorney) called; agrees to send resident to [name of hospital] Hospital for evaluation and treatment. R6's Progress Note, dated 2/19/2026 at 21:08 (9:08 PM), documents, Resident presents with red-tinged projectile vomiting x (times) 2. 97.1 80 139/82 17 94% RA BS 398. [Physician service] notified; ordered to send to Hospital for evaluation and treatment. DON (Director of Nursing) and POA notified. 911 called. On 03/24/2026 at 8:34 AM, Surveyor requested from NHA-A, R6's bed hold and transfer notices for hospitalizations on 11/21/25 and 2/19/26. On 03/24/2026 at 10:38 AM, NHA-A stated the facility used to have a full time Admissions Coordinator and when this person vacated the position, job duties were split between two other staff members and somehow the bed hold and transfer notices fell between the cracks and the documents are no longer being completed. NHA-A confirmed there is no evidence of R6's bed hold and transfer notices for hospitalizations on 11/21/25 and 2/19/26. 3.) R30 was admitted to the facility on [DATE]. R30 makes his/her own health care decisions. R30's Nurses Note, dated 1/31/2026 at 10:42 AM, documents, Writer called in the room by CNA (Certified Nursing Assistant) who stated the resident was on the floor when she entered the room. When writer entered the room, the resident was lying on R30's right side with his face against the nightstand in R30's room walker was under R30, and the resident had bowel movement on the floor behind R30. Writer asked the resident how did R30 fall and R30 stated that R30 was trying to go to the bathroom. call light was not on gripper socks on. writer asked the resident did R30 hit head R30 stated I don't know writer completed a full assessment and the resident was able to move all extremities. The CNA helped hoyer him into the bed. during neuro check the resident became confused and asked where am I? who are you? spo2 (oxygen level) dropped to 75%. writer placed 2L (liters) of 02 (oxygen) on the resident and called Ambulance for transport to the hospital. BP 132/65 pulse 104 respirations 25 temp 97.8. POA, DON and on call NP all notified. R30's Nurses Note, dated 2/24/2026 at 9:47 AM, documents, Resident c/o (complained of) sob (shortness of breath) refused prn (as needed) breathing treatment. edema noted to upper and lower extremities NP (Nurse Practitioner) notified. R30's Nurses Note, dated 2/24/2026 at 10:28 AM, documents, Resident sent out to hospital via Bell ambulance NP updated. On 03/24/2026 at 8:34 AM, Surveyor requested from Nursing Home Administrator (NHA)-A, R30's bed hold and transfer notices for hospitalizations on 1/31/26 and 2/24/26. On 03/24/2026 at 10:38 AM, NHA-A provided R30's Notice of Transfer and Bed Hold Form for hospitalization on 1/31/26 and confirmed there is no evidence of bed hold and transfer notice for R30's 2/24/26 hospitalization. R30's Notice of Transfer and Bed Hold Form dated 1/31/26, documents name, physician, date of transfer, location of transfer, reason for transfer, payor source as Medicare, appeal rights, and name and address with the telephone number of the Office of the State Long-Term Care Ombudsman but did not document R30's reserve bed hold payment daily rate. On 03/24/2026 at 2:58 PM, Surveyor informed NHA-A, Director of Nursing (DON)-B, Assistant Director of Nursing (ADON)-C, and Nurse Consultant-D of missing or incomplete/inaccurate bed hold and transfer notices for the R30. NHA-A expressed understanding. 4.) R37 was admitted to the facility on [DATE]. R37 makes his/her own health care decisions. R37's Progress Note, dated 12/3/2025 at 8:30 AM, documents in part .Patient is seen today for vomiting and diarrhea. Nursing reported patient had vomiting and diarrhea overnight. Provider attempted to see patient – R37 was laying in bed, extremely pale, fatigued, and asleep. R37 appeared extremely comfortable. Provider stepped out to see another patient. When nurse went to take vitals, blood pressure was 80/50. Patient was sent to the emergency department for ongoing workup and fluids. R37's Nurses Note, dated 1/4/2026 at 10:37 AM, documents, Resident being sent out to [name of hospital]. reported trouble breathing. very loud wheezing/rhonchi, using accessory muscles. inhaler provided, PO2 (oxygen level) 88%. placed on O2, saturation increased to 92%. EMT (Emergency Medical Technician) provided breathing treatment. w/ (with) no improvement to wheeze or accessory muscle use. resident requested to go to [name of hospital]. writer requested prn (as needed) neb (nebulizer) (breathing treatment) treatment order. R37's Nurses Note, dated 3/13/2026 at 11:28 AM, documents, Resident with increased S.O.B. (shortness of breath) PO2 80 % on room air. O2 applied @ L per N/C.PO2 up to 92%. Audible wheezing noted. T-98.2 P-100 R-26 B.P.158/80. Resident wn (sic) person and Full Code Status. Resident alert and able to make needs known. Resident stated that she wants to go out to ER. [Name of physician service] updated by secure message. Ambulance called and transporting to [hospital] ER. On 03/24/2026 at 12:11 PM Surveyor requested from Nursing Home Administrator (NHA)-A, R37's bed hold and transfer notices for 12/3/25, 1/4/26 and 3/13/26 transfers. On 03/24/2026 at 12:30 PM, NHA-A confirmed there is no evidence of bed hold and transfer notices for R37's hospitalizations on 12/3/25, 1/4/26, and 3/13/26. On 03/24/2026 at 2:58 PM, Surveyor informed NHA-A, Director of Nursing (DON)-B, Assistant Director of Nursing (ADON)-C, and Nurse Consultant-D of missing or incomplete/inaccurate bed hold and transfer notices for the R5, R6, R30 and R37. NHA-A expressed understanding. 5.) R1 admitted to the facility on [DATE]. R1 was hospitalized for a change in condition on 10/6/25. R1's progress note dated 10/6/25 at 7:48 AM, documents nurses note: Called to Residents room by Med Tech stating that Residents PO2 (oxygen saturation) was 32%. Resident stated he was S.O.B. (short of breath). O2 applied per N/C (nasal cannula) at 2 liters. Resident A & O (alert and oriented) X 4. Stated he was just relaxing. T (temperature) 98.2 P (pulse) 116 R (respirations) 22 B.P. (blood pressure)152/85. PO2 98%.PO2 level fluctuating down to 92%. Expiratory wheezing noted using chest muscles with respirations. Medical provider updated. N.O.R. (new order received) Send to ER (emergency room) for Eval & TX (evaluation and treatment). Ambulance called to transport. Resident updated. Writer continually monitoring resident condition until ambulance here and transports. R1 was subsequently admitted to the hospital and readmitted to the facility on [DATE] with diagnoses acute mixed respiratory failure, CHF (congestive heart failure), fluid overload. Surveyor found no evidence transfer and bed hold notice was provided to R1 or his Power of Attorney. On 3/24/26 at 1:46 PM, Surveyor asked Nursing Home Administrator (NHA)-A and Consultant-D for evidence transfer and bed hold notice was provided. Surveyor was told No, neither was provided. No additional information was provided.

Based on interview and record review the facility did not ensure residents receiving psychotropic medications as needed (PRN) have an order limited to fourteen (14) days for 3 (R9, R6, and R34) of 7 residents reviewed for unnecessary medications: *R9 Clonazepam 0.5mg- 1 tablet every 12 hours as needed for increased agitation with no end date. *R6 has an order for Clonazepam 2mg- 1 tablet every 6 hours as needed for anxiety with no end date. *R34 Lorazepam 0.5 mg- 1 tablet every 3 hours as needed for anxiety with no end date. Findings include: The facility policy titled Standard Psychoactive Medication Protocol with no initiation or revision date documents: Problem: Individual is prescribed a psychotropic medication. Goal: Individual will have minimized side effects of psychotropic drug use. Nursing: . psychoactive team is to review for gradual dose reduction as indicated. All: offer non-pharmacologic approaches. 1.) R9 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, Dementia with anxiety and mood disturbance, major depressive disorder, and anxiety disorder. R9's quarterly minimum data set (MDS) dated [DATE] indicated R9 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5. Nursing assessed R9 and indicated R9 did not have behavior concerns. R9 has an activated power of attorney (POA) for healthcare decisions. R9 care plan documents uses Clonazepam (benzodiazepine medication acts as a central nervous system depressant calming overactive nerves in the brain) due to dementia and anxiety disorder, initiated on 3/9/2025 with the following interventions:- Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness EVERY SHIFT.- Monitor/ document/ report PRN any adverse reactions to ANTI-ANXIETY therapy: . and UNEXPECTED SIDE EFFECTS: . R9's physician order dated 1/6/2026 documents Clonazepam Oral Tablet 0.5mg- Give 1 tablet by mouth every twelve (12) hours as needed for increased agitation. Surveyor noted the PRN Clonazepam 0.5mg order date was beyond 14 days and still active. R9's medical record/ physician order did not include documentation from the attending physician or the prescribing practitioner justifying the need for R9 to receive Clonazepam 0.5mg PRN beyond the 14 day timeframe. Surveyor reviewed R9's 3/2026 medication administration record (MAR) and noted facility staff documented administering Clonazepam 0.5mg to R9 on:-3/3/2026, 3/6/2026, 3/9/2026, 3/11/2026, 3/12/2026, 3/14/2026, 3/16/2026, 3/20/2026, 3/22/2026, and 3/23/2026 in the morning and 3/9/2026 in the evening. On 3/26/2026, at 12:02 PM, Surveyor interviewed director of nursing (DON)-B who stated pharmacy will review residents' medications monthly and notify DON-B what medications need end dates or other recommendations. DON-B stated medications also get reviewed in the psychoactive medication and behavior committee meetings and medications get discussed at those times as well. Surveyor shared concern R9's PRN Clonazepam 0.5mg medication did not have an ordered 14 day stop date or an indication for requiring the medication longer. DON-B stated it must have been overlooked during the meetings and on medication reviews. No further information was provided at the time of this write up. 2.) R6 was admitted to the facility on [DATE] and has diagnoses that include paranoid schizophrenia, major depressive disorder, generalized anxiety disorder, and dementia. R6's Minimum Data Set (MDS) annual assessment dated [DATE] documents R6 has a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. The MDS indicates R6's use of antipsychotic and antianxiety medications. R6's Physician Orders, dated 1/30/26, documents, clonazePAM Oral Tablet 1 MG (milligram) (Clonazepam) Give 1 mg by mouth three times a day for Anxiety. Pharmacy Active 1/30/2026. R6's Physician Orders, dated 1/29/26, documents, ClonazePAM Tablet 2 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety. Pharmacy Active 1/29/2026 1/29/2026 (sic). R6's Medication Administration Record, documents R6 received PRN doses of ClonazePAM Tablet 2 MG on 3/5/26 and 3/21/26 Surveyor notes, R6's PRN Clonazepam 2 MG tablet order date is beyond 14 days since ordered on 1/29/26 and remains an active order. R6's medical record or physician order provides do not provide evidence the physician or the prescribing practitioner's justification for R6 to receive Clonazepam 2 MG beyond 14-day timeframe. On 3/26/2026, at 12:02 PM, Surveyor interviewed director of nursing (DON)-B who stated pharmacy will review residents' medications monthly and notify DON-B what medications need end dates or other recommendations. DON-B stated medications also get reviewed in the psychoactive medication and behavior committee meetings and medications get discussed at those times as well. Surveyor shared concern R6's PRN Clonazepam 2 MG medication did not have a 14 day stop date or an indication for requiring the medication longer. No further information was provided at the time of this write up. 3.) R34 was admitted to the facility on [DATE] with diagnoses including other sequelae (long-term effects) of cerebral infarction (stroke), and other chronic pain. R34's significant change Minimal Data Set (MDS) dated [DATE] documents R34 has a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and R34 did not have behavior concerns. The MDS documents R34 takes an antianxiety medication. R34 has an activated power of attorney (POA) for healthcare decisions. R34's Care Area Assessment (CAA) for psychotropic drug use dated 3/16/26 documents CAA triggered for psychotropic drug use due to antianxiety medication use due to recent enrollment onto hospice for end-of-life cares. R34's physician order dated 3/20/26 documents Lorazepam Oral Tablet 0.5 mg (milligrams)- give 1 tablet by mouth every 3 hours as needed (PRN) for anxiety, restlessness, dyspnea (difficulty breathing), nausea. Drugs.com documents Lorazepam belongs to a class of medications called benzodiazepines, which work by enhancing the activity of certain neurotransmitters in the brain. Surveyor notes the physician order for Lorazepam is still active with no stop date documented. Surveyor reviewed R34's electronic health record (EHR) and did not locate any documentation from R34's prescribing practitioner with a rationale R34 requires PRN Lorazepam beyond 14 days. Surveyor reviewed R34's 3/2026 medication administration record (MAR) and noted facility staff documented administering Lorazepam 0.5mg to R34 on 3/23/26 and 3/24/26. On 3/26/2026, at 12:02 PM, Surveyor interviewed director of nursing (DON)-B who stated pharmacy will review residents' medications monthly and notify DON-B what medications need end dates or other recommendations. DON-B stated medications also get reviewed in the psychoactive medication and behavior committee meetings and medications get discussed at those times as well. Surveyor shared concern R34's PRN Lorazepam 0.5mg medication did not have an ordered 14 day stop date or an indication for requiring the medication longer. DON-B stated it must have been overlooked during the meetings and on medication reviews. No further information was provided at the time of this write up.

Based on observation, interview, and record review ,the facility did not ensure the medical record reflected the advanced directive wishes for 1 (R40) of 3 residents reviewed.*R40 was readmitted on [DATE]. R40's Hospital Discharge summary dated [DATE] documents R40's code status was changed to DNR (do not resuscitate). On 4/29/26, R40 was observed wearing a purple DNI (do not intubate)/DNR bracelet on R40's right wrist. Despite this, R40's physician orders, code status by R40's picture in the electronic medical record and care plan continued to document full code until 4/29/26.Findings include:The facility's policy titled, Code Status and last reviewed 4/9/26 under Policy documents Facilities will discover, maintain, and execute a individual's code status by following the documented wishes of each individual. Under Procedure A. Discovery: 1. Upon admission, a designated staff member will discover any current code status directives that a individual may have in place. 2. The designated staff member will review the current code status for accuracy with the individual and/or individual representative. 3. If an individual does not have any code status directives in place, the staff member will provide materials to individual and/or individual representative. B. Maintenance: 2. Do-Not-Resuscitate a. If an induvial wishes to be a DNR, the individual's wishes will be maintained: i. Provider signed DNR order. ii. Within the medical record. iii. On a State DNR Form. iv. By wearing a facility approved DNR bracelet, until the state DNR bracelet is acquired.R40 was readmitted to the facility on [DATE]. R40 has an activated power of attorney and receives hospice services.R40's diagnoses includes dementia (loss of cognitive function that interferes with a person's daily life and activities), congestive heart failure (heart doesn't pump enough blood to meet the body's needs), neurocognitive disorder with Lewy bodies (progressive dementia that destroys brain cells, leading to cognitive decline, unpredictable fluctuating alertness, visual hallucinations, and motor issues), anxiety (emotional response involving feelings of worry, dread, and tension often accompanied by physical symptoms like a racing heart or sweating), and hypertensive heart disease with heart failure (prolonged high blood pressure that leads to the hearts inability to pump blood effectively.R40's physician orders dated 10/18/2023 documents Full Code.R40's physician orders dated 4/8/26 documents send to [Hospital Name] ER (emergency room) per POA (power of attorney) request, Full code status, continued decline in condition.R40's hospital discharge summary for date of discharge: [DATE] documents code status at discharge: DNI/DNR (do not intubate/do not resuscitate).R40's nurses note dated 4/27/26 at 14:30 (2:30 p.m.) written by Registered Nurse (RN)-H includes documentation of readmitted [R40's name] 84/F (female) 11/24/41 from [Hospital initials] DNI/DNR, Hospice.R40's progress note dated 4/28/26, at 11:13 a.m., written by Life Coach/Social Worker (LC/SW)-J documents [R40's first name] is a [AGE] year old female who readmitted to St. [NAME] on 4/27 following her stay at [hospital initials]. [R40's first name] readmits with a primary diagnosis of pressure ulcer of sacral region. [R40's first name] has a past medical history of, but not limited too; arthritis, hypertension, and hallucinations. Per hospital documents upon discharge, [R40's first name] was alert and oriented x4. [R40's first name] readmitted to her room on the long term care unit where it is expected she will remain to reside. Writer to meet with resident to conduct readmit assessments and schedule care conference. Writer will continue to follow and support resident while on campus.On 4/29/26, at 9:42 a.m., RN-F informed Surveyor the med tech is still doing med pass and then she will give R40 morphine and Ativan. RN-F explained R40 has Lewy body dementia. R40 is full code and the daughter is not ready to let mom go.On 4/29/26 from 10:30 a.m. to 11:00 a.m. Surveyor observed R40's sacrum pressure injury treatment with RN-F and Med Tech-E & Certified Nursing Assistant (CNA)-G. During this observation Surveyor observed R40 was wearing a purple DNI/DNR bracelet on R40's right wrist.On 4/29/26, at 11:15 a.m., Surveyor noted R40's electronic medical record by R40's picture documents Code status (Advanced Directive) full code. R40's physician orders still includes Full code.On 4/29/26, at 12:17 p.m., Surveyor reviewed R40's resolved care plans and noted [R40] code status is full code initiated 10/23/23 and revised & resolved 4/29/26. Intervention documents Social Worker will follow up with resident and family as needed or as requested by resident or family. Initiated 10/23/23 and revised & resolved 4/29/26.Surveyor reviewed R40's current care plans and noted the facility did not develop an advanced directive care plan for DNR after R40's full code care plan was resolved.Surveyor reviewed R40's progress notes from date of readmission until 4/29/26. Surveyor was unable to locate any progress notes regarding facility staff contacting R40's power of attorney to discuss the change of code status since returning from the hospital until 4/29/26 at 11:32 a.m. R40's progress note dated 4/29/26, at 11:32 a.m. written by Regional Nurse Consultant (RNC)-C documents Review acute care hospital records - full code status deactivated 4/14/26 and initiated DNR no resuscitation no intubation for resident. Verified by DON (Director of Nursing) with daughter/POA [first name] with writer as verbal witness. Code status changed to DNR in HER (electronic health record). Hospice cares to continue as ordered, end of life cares being provided.On 4/29/26, at 12:24 p.m. Surveyor asked RN-F when a resident is readmitted from the hospital who reviews the hospital records. RN-F informed Surveyor the floor nurse. Surveyor asked who checks to see if the resident code status has changed. RN-F replied the nurse, admitting nurse. Surveyor asked RN-F if social services have anything to do with code status. RN-F explained to Surveyor they used to years ago now pretty much it's nursing. Surveyor asked RN-F if she is aware R40's code status changed to DNR. RN-F replied no. Surveyor informed RN-F when Surveyor reviewed R40's medical record today her code status still documented full code. RN-F informed Surveyor she wasn't here when R40 was admitted . R40 came in on Tuesday and the nurse had two admissions. RN-F informed Surveyor she hasn't looked at her record. Surveyor showed RN-F code status which documents full code. RN-F informed Surveyor when a resident is readmitted , they don't have two nurses checking it only one person which is not ideal.On 4/29/26, at 12:39 p.m., Surveyor asked RNC-C what prompted her to review R40's code status and write the progress note today. RNC-C informed R40 is their only wound in house for the facility's verification visit and was reviewing her record. Surveyor asked RNC-C who reviews hospital records for code status. RNC-C informed Surveyor she didn't know. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were also in the office with RNC-C. NHA-A informed Surveyor they were aware R40's code status changed to DNR when she returned from the hospital, but they didn't have the state form, and their policy is until they have this form so they kept her as full code. DON-B informed Surveyor she has spoken to R40's POA trying to get the paperwork. Surveyor asked DON-B who reviews paperwork when a resident is readmitted . DON-B replied the floor nurses. Surveyor asked if this would also be for code status. DON-B replied yes, explaining they get the paperwork from the ambulance when they come back. Surveyor informed facility staff there is no documentation in R40's record regarding speaking with R40's POA and hospital documentation reveals the code status was changed to DNR which is not reflected in R40's medical record.On 4/29/26, at 1:03 p.m., Surveyor asked RNC-C, NHA-A, and DON-B who were in NHA-A's office when the facility changed R40's code status today to DNR did they have a signed DNR paper. NHA-A informed Surveyor admissions are trying to get it from Epic. Surveyor asked again if there was a signed DNR paper. RNC-C replied no explaining they have a difference of opinion regarding their policy.On 4/29/26, at 1:15 p.m., met with RNC-C, NHA-A, and DON-B. NHA-A informed Surveyor the social worker meets with the resident regarding advanced directives. Surveyor asked if a residents advance directives change who is responsible for the paper work. NHA-A informed Surveyor our social worker. On 4/29/26, at 1:30 p.m., Surveyor asked NHA-A who the name of the facility's social worker. NHA-A explained their social worker is on medical leave and [name of] LC/SW-J from their sister facility is covering.On 4/29/26, at 1:40 p.m., Surveyor telephoned LC/SW-J and left a message requesting a return call. LC/SW-J did not return Surveyor's telephone call.No additional information was provided.

Based on interview and record review, the facility failed to perform preadmission screening for individuals with a mental disorder for 1 (R17) of 1 resident reviewed for Pre-admission Screen and Resident Review (PASARR) Level II completion. *R17 had a positive Level I PASARR dated [DATE] and was identified to have a major mental disorder and, unspecified intellectual disabilities. The facility did not submit the positive Level 1 screen to the State mental health authority to complete a PASARR Level II evaluation after the initial 30-day hospital discharge exemption had expired. Findings Include:The facility policy titled admission Criteria/Requirements with an initial approval date [DATE] and reviewed date [DATE] documents: Residents diagnosed with serious mental illness or developmental disabilities will be screened prior to admission utilizing Preadmission Screen and Resident Review (PASARR). PASARR will contribute to individual's plan of care. PASARR Level 2 screen may be utilized to determine the facility's ability to manage the individual need. R17 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder (a mental health condition combining schizophrenia symptoms, such as hallucinations and delusions, and mood disorder episodes, such as depression or mania), unspecified dementia with other behavioral disturbance, anxiety disorder, and unspecified intellectual disabilities. On [DATE] at 12:01 PM, Surveyor reviewed R17's electronic health record (EHR) and located a PASARR Level I with effective date documented as [DATE]. Surveyor notes the PASARR Level I Screen Summary does not have the date the screen was completed documented. The Level I Screen Summary documents yes to the questions: Does the person have a major mental disorder, has the person displayed any symptoms that may suggest the presence of a major mental illness, and has this person received psychotropic medication(s) to treat symptoms or behaviors of a major mental disorder and documents R17 received Seroquel (an antipsychotic medication used to treat schizophrenia). The provider response to the screening result resident is suspected of having a serious mental illness is documented as agree. The Level I Screen Summary documents yes for hospital discharge exemption- 30 day maximum. Surveyor reviewed R17's EHR and noted R17 receives psychiatry services at the facility on a monthly basis. On [DATE] at 1:59 PM, Surveyor interviewed Director of Admissions-N via phone call. Director of Admissions-N stated Director of Admissions-N completes the PASARR Level I screen on admission and the social worker would assist with a Level II screen if indicated. Director of Admissions-N stated a Level II screen would be required if a resident has a mental illness such as depression or anxiety. Director of Admissions-N stated the Level II would be completed right away after the Level I unless there is a hospital discharge exemption. Director of Admissions-N stated if the resident is still at the facility after the 30-day maximum for a hospital discharge exemption, then the Level II would be completed. Director of Admissions-N confirmed R17 should have had a PASARR Level II completed since R17 was on Seroquel on admission and had a major mental illness. Director of Admissions-N confirmed no PASARR Level II is in R17's EHR, which it would be if it were completed. On [DATE] at 2:20 PM, Nursing Home Administrator (NHA)-A informed Surveyor the social worker for the facility was not available for interview due to being out on leave. On [DATE] at 3:03 PM, Surveyor shared concern with NHA-A, Director of Nursing (DON)-B, Assistant Director of Nursing (ADON)-C, and regional nurse consultant-D that no PASARR Level II screen was completed for R17 after the 30-day maximum exemption period expired and the PASARR Level I screen was positive for major mental illness and prescribed psychotropic mediation. On [DATE] at 10:26 AM, NHA-A provided Surveyor with documentation a new PASARR Level I screen was completed by Director of Admissions-N for R17 dated [DATE]. NHA-A also provided Surveyor with an email printout dated [DATE] at 10:25 AM, which documents Director of Admissions-N requested the PASARR Level II screen for R17. NHA-A stated the previous admissions coordinator left around [DATE] and the PASARR Level II screens have not been completed since then. No additional information was provided as to why a PASARR Level II screen was not completed for R17 after the 30-day maximum exemption period.

Based on interview and record review the facility did not ensure 1 (R9) of 12 resident's care plans reviewed were revised.R9's care plan was not revised after R9 was diagnosed with a right shoulder dislocation.Findings include:The facility policy titled Comprehensive Person Centered Care Plan last reviewed 5/8/2025 documents: I. Policy: The comprehensive person centered care plan will reflect the individual's needs and preferences to facilitate care. II. Procedure: . C. Care plan shall be reviewed and revised quarterly, upon change of condition, and/or as needed.*R9 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, and Dementia with anxiety. R9's quarterly minimum data set (MDS) dated [DATE] indicated R9 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 5. R9 has an activated power of attorney (POA) for healthcare decisions. R9's care plan documents chronic pain related to history of fractured left humerus, initiated on 2/27/2025 with the following interventions:- Administer medication per medical doctor (MD) order.- Anticipate (R9's) need for pain relief and respond immediately to any complaint of pain.On 3/2/2026, at 12:57 PM, in the progress notes registered nurse (RN)-G documented (R9) got x-ray to right arm and right shoulder due to (R9) guarding right arm at times.On 3/3/2023, at 7:36 AM, in the progress notes RN-G documented (R9's) x-ray results for right shoulder/right arm x-rays document an anterior subluxation was noted across the glenohumeral joint space (dislocation of the right shoulder). Order received to send R9 out for further evaluation and treatment.On 3/3/2023, at 12:55 PM, in the progress notes nursing documented . (R9's) shoulder was reduced back into place . (R9) will be returning to the facility with and order for a sling and follow up orthopedic appointment.Surveyor reviewed R9's medical record and noted the following physician order:-Sling to right arm and shoulder area. Monitor for placement every shift and document refusals every shift for post shoulder reduction. Start date: 3/4/2026.Surveyor noted R9's care plan was not revised to indicate R9's need for a right shoulder/arm sling or how often to keep R9's sling in place. Surveyor reviewed R9's certified nursing assistant (CNA) care card and noted no interventions documenting R9 had a sling in place to the right arm/shoulder.Surveyor reviewed R9's progress notes and noted nursing staff documenting R9's refusals to wear the right shoulder/arm sling. Surveyor noted there were no care plan revisions regarding R9 refusing the right shoulder/arm sling or interventions to be implemented in place of R9's right shoulder/arm sling.On 3/24/2026, at 10:33 AM, Surveyor observed R9 sitting in in a recliner without R9's right shoulder/arm sling. Surveyor asked R9 if R9's right arm hurt and if R9 wanted R9's right arm sling on. R9 shook R9's head back and forth indicating a 'No gesture. On 3/24/2025, at 10:34 AM, Surveyor interviewed RN-H who stated R9 refused to wear the right arm sling at times. RN-H stated R9 had the right arm sling on earlier in the morning when staff assisted with getting R9 dressed, but then later in the morning R9 removed the right arm sling and refused to put the right arm sling back on. Surveyor asked if the physician was aware or if there were other interventions implemented when R9 does not want to wear the right arm sling but still has protection for R9's right shoulder. RN-H stated they were not aware of other interventions other than monitoring and assessing pain. RN-H was not sure if R9's physician was aware R9's refuses to wear the right arm sling at times however it is documented in progress notes and the physicians read progress notes. Surveyor asked who would update care plans with revisions to reflect current care needs for residents. RN-H stated the interdisciplinary team (IDT) meets in the mornings and reviews the care plans.On 3/24/2026, at 3:12 PM, Surveyor interviewed licensed practical nurse (LPN)-I who stated LPN-I did not update care plans with revisions. LPN-I stated management updates care plans and makes revisions for residents. Surveyor asked how management knows when to update residents care plans to show the most up to date care needs for residents. LPN-I stated LPN-I believes management reviews resident progress notes to see what is happening with residents.On 3/25/2026, at 3:17 PM, Surveyor asked nursing home administrator (NHA)-A and director of nursing (DON)-B process for revising care plans. DON-B replied care plans can be revised by nursing staff when needed to have the most up to date interventions for resident needs. DON-B stated care plans are reviewed in morning meetings. Surveyor shared concern R9's care plan was not revised when R9 right should was found to be dislocated on 3/2/2026 and on 3/3/2026 when R9 returned from the hospital after having R9's right shoulder put back into place and had an order for a right arm sling. Surveyor shared concern nursing staff documented right arm sling refusals for R9 but no care plan revisions were made to indicate R9's refusals or if new interventions were to be implemented to prevent further injury to R9's right shoulder. No further information was provided to Surveyor at the time of this write up.

Based on interview and record review, the facility did not ensure each resident was offered the COVID-19 vaccine when available to the facility for 1 (R21) of 5 residents reviewed for immunizations. *R21 did not have evidence of being offered the COVD-19 vaccine upon admission to the facility on 1/9/26. Findings include:The facility policy titled Individual Immunizations with approval date 10/9/17 and review date 8/29/25 documents: . Prophylactic immunizations will be offered to individuals to promote the absence of Health Care Acquired Infections . upon admission, the organization will verify the individual's immunization status, update Primary Care Provider (PCP) as indicated, and administer immunizations as ordered. Individual will be offered immunizations based upon the Center for Disease Control (CDC) recommendations and guidelines . Immunization consent and or refusal shall be documented within the Electronic Medical Record (EMR). On 3/26/26 at 8:26 AM, regional nurse consultant-D provided Surveyor with the CDC vaccine and immunization guidelines the facility utilizes for resident vaccines. Surveyor notes for COVID-19, the CDC recommends adults over the age of 65 receive 2 or more doses of 2025-2026 vaccine. R21 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation (a sudden worsening of chronic respiratory symptoms such as shortness of breath), chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot adequately transfer oxygen in the blood), and acute bronchitis (temporary swelling in the airways and lungs), unspecified asthma (inflammation of the airways). R21 had an activated power of attorney (POA) for healthcare decisions effective 1/24/26. On 3/23/26, Surveyor reviewed R21's EMR and located a tab titled immunizations. Surveyor noted no documentation of R21's POA consent or refusal to the COVID-19 vaccine, and no documentation of the last time R21 received the COVID-19 vaccine. On 3/25/26 at 2:19 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. ADON-C confirmed ADON-C is the Infection Preventionist (IP) at the facility. ADON-C confirmed as the IP, ADON-C is responsible for resident vaccinations, which are reviewed and offered upon resident admission to the facility. ADON-C stated if a resident has an activated POA, ADON-C will call the POA to get verbal consent for the vaccines and then document that verbal consent was obtained from the POA in the immunizations section in the resident's EMR. Surveyor shared concern with ADON-C there is no evidence R21 was offered the COVID-19 vaccine upon admission to the facility 1/9/26 in the immunizations section in R21's EMR. ADON-C responded ADON-C would look into it. On 3/25/26 at 2:46 PM, Surveyor shared concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, ADON-C and Regional Nurse Consultant-D there is no evidence the COVID-19 vaccine was offered to R21 upon admission. On 3/26/26 at 9:56 AM, ADON-C informed Surveyor ADON-C realized R21 was not offered the COVID-19 vaccine upon admission, so ADON-C obtained consent from R21's POA on 3/26/26 to administer the COVID-19 vaccine, and ADON-C administered the vaccine to R21 on 3/26/26. ADON-C stated ADON-C must have forgot to offer R21 the COVID-19 vaccine upon admission. No additional information was provided.

Based on interviews and record review the facility did not ensure that residents' environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 (R2) residents reviewed for accidents. R2 sustained an avoidable fall from bed during cares. R2 was assessed as being dependent for bed mobility as assessed and documented on their significant change and most recent quarterly Minimum Data Set. An assessment code of 01 dependent indicates the need for two staff assistance. R2 was also assessed by therapy as being dependent on staff for bed mobility with the number of staff assistance needed not specified. R3's care plan dated 8/9/23 indicated R2 requires the assistance of 1 staff for bed mobility and was not reflective of current assessments or level of assist needed by R2. During the fall, 1 staff provided cares and assistance to R2 while in bed. The Certified Nursing Assistant (CNA) rolled R2 away from themselves and onto R2's side affected by hemiplegia. The CNA did not maintain control of R2 when the CNA reached for a towel and R2 fell from bed requiring hospitalization, sutures to repair a head laceration and questionable rib fracture.Findings include:R2 admitted to the facility on [DATE] and had diagnoses that include hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, syringomyelia (neurological disorder of the brainstem and spinal cord), anemia, chronic obstructive pulmonary disease, depression, anxiety disorder, hypertension and chronic respiratory failure.The facility policy and procedure titled Comprehensive Person-Centered Care Plan documents (in part) . I. Policy: The comprehensive person-centered care plan will reflect the individual's needs and preferences to facilitate care.II. Procedure:A. Within 48 hours after admission a baseline care plan will be completed and reviewed with individual and/or individual representative.B. Within 21 consecutive days after admission, and in correlation with the Minimum Data Set (MDS), a comprehensive assessment will be completed and a written are plan will be developed based on the individual's history, preferences, and assessments from appropriate disciplines and the physician's evaluation and orders.C. Care plan shall be reviewed and revised quarterly, upon change of condition, and/or as needed.R2's significant change MDS dated [DATE] section GG - Functional Abilities documents (in part) . Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed as Dependent - helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.R2's quarterly MDS submitted and accepted on 10/3/25 also identifies R2 was assessed as being dependent on staff for rolling left and right in bed.According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 dated October of 2025 for section GG0130: Self-Care and GG170 Mobility: Code 01, Dependent: (is assessed/coded) if the helper does ALL of the effort. Resident does none of the effort to complete the activity; or the assistance of two or more helpers is required to complete the activity. Code 01 Dependent: if two helpers are required for safe completion of an activity, even if the second helper provides supervision/stand-by assist only and does not end up needing to provide hands-on assistance. Code 01, dependent: if a resident requires the assistance of two helpers to complete an activity (one to provide support to the resident and a second to manage the necessary equipment to allow the activity to be completed.R2's care plan documents: (R2) has an ADL (activity of daily living) self-care performance deficit r/t (related to) hemiplegia - date initiated 8/9/23. Interventions include Bed mobility: Assist of 1. Uses 1/2 bed rails bilaterally for repositioning and bed mobility - initiated 8/9/23.R2's Side Rail Assessment and Risk Screen dated 5/2/25 documents: Which type would be beneficial (choices half side rail or bed bar). Bed bar was checked. Summary of evaluation: Enabler bars indicated.Review of R2's therapy documentation includes reference in therapy notes for dates 2/11/25 - 5/11/25 R2 is dependent in all bed mobility. Surveyor noted there is no documentation to specify R2 requires the assistance of only 1 staff for bed mobility and/or the determination of dependent would differ from the definition of dependent as defined by the RAI Manual.On 6/10/25 at 5:30 AM, R2 sustained a fall from bed. The facility investigation interview with the Certified Nursing Assistant (CNA) involved documents: She stated she was getting (R2) prepared for a shower but needed to do peri care as he was incontinent of stool first. She stated the height of the bed was up as she was doing cares. The bed was slightly angled per resident preference. She stated that he does have arm spasms from time to time and did have one while she had turned him onto his right side, however it did stop. At this time, she noted that she needed the towel and reached for the towel which was located on his w/c (wheelchair) which was next to her. While she did this, she noticed that he continued to roll and slid out of bed onto the floor. She was unable to stop him from rolling out of bed towards that other side. Immediately called for help and 911 was called. Surveyor noted documentation of the facility interview with the involved CNA indicates R2 was rolled away from the CNA during cares creating a safety risk.According to https://www.pioneernetwork.org/wp-content/uploads/2018/07/Restorative-Transfers.pdf: Dependent Roll - Set-up - Make sure that the resident has plenty of room on the side direction he/she wishes to roll. Pre-roll Positioning - The person assisting positions him/herself on the side of the bed toward which the resident is to roll. Cross the lower leg farthest away from you over the extremity closest to you. Cross the arm farthest away from you over the chest, supporting the arm as necessary. Place one hand on the back of the pelvis and one hand on the shoulder blade. Roll - Gently roll the resident toward you onto his/her side. Encourage the resident to turn his/her head in the direction of the roll. Position arms and legs with pillows as needed. Encourage the resident to assist in the following ways: Flexing the opposite hip and knee, placing the foot flat and aiding the roll by reaching forward with the pelvis. Turn the resident's head in the direction of the roll. If the roll is toward the affected side, have the resident place his/her unaffected arm in the direction of the roll. If the roll is toward the unaffected side, have the resident clasp his/her hands together (as in praying), and reach with both arms in the direction of the roll.Facility investigation Summary documents: After review and investigation of the findings of the fall, this facility determined that the care plan was not violated in reference to any interventions. This was (R2's) first fall in the facility since admission. The CNA was unable to stop him from rolling as stated it happened so fast. The locks on the bed were in proper working order.Surveyor was advised by Nursing Home Administrator (NHA)-A that a self-report was not submitted because it didn't meet the criteria, and the care plan was followed.The hospital Discharge summary dated [DATE] documented: Presented to ED (Emergency Department) after patient fell out of bed when he was being turned by a CNA. Landed face down. Post fall c/o (complained of) pain to face, right chest, right shoulder and left sided pain from left shoulder to left foot. Does have history chronic pain on multi-modal pain regimen. Pan-scan on arrival was notable for questionable right anterior 3rd rib fracture, correlation with physical exam is recommended, prominent left periorbital subcutaneous hematoma with small blood products extending along the lateral post septal left orbit, no acute intracranial findings. Sustained laceration above left eye which was repaired in ED with 6 absorbable sutures.On 1/7/26 at 10:38 AM, Surveyor spoke with Registered Nurse (RN)/MDS-D about R2's significant change MDS dated [DATE]. Surveyor noted R2 was coded as dependent for bed mobility and asked what that meant. RN/MDS-D stated, That staff do everything for them, the resident does not participate. If they're marked as dependent, they require 2-person assist. Per CMS guidelines, the definition of dependent is 2-person assist. RN/MDS-D added, If the care plan indicated he was 1 person assist, then the care plan is not updated or correct. RN/MDS-D reported she does her MDS entry strictly by nursing documentation and is not involved with the care plan.On 1/7/26 at 11:00 AM, Surveyor spoke with Director of Nursing (DON)-B. Surveyor asked about the side rail assessment completed on 5/2/25. DON-B reported she did not do the assessment, that it was completed by therapy and Physical Therapy Assistant (PTA)-F could walk Surveyor through the process. Surveyor advised DON-B that documentation in R2's annual MDS, assessments and documentation in the medical record indicates R2 was dependent for bed mobility. DON-B stated, He was limited, he could not turn or reposition himself, he was dependent for bed mobility. Surveyor shared the MDS nurse during interview stated dependent for bed mobility requires 2 assist and asked why R2's care plan documented 1 assist with bed mobility. DON-B stated, Because that's what therapy determined, that he was 1 assist for bed mobility. Surveyor advised therapy notes for dates 2/11/25 - 5/11/25 document R2 is dependent in all bed mobility and does not specify 1 assist. DON-B stated, He was very top heavy, and we think he just rolled out of the bed. Surveyor advised the fall investigation documented R2 was turned on his right side and he has left sided hemiparesis, so he wouldn't have been able to use the grab bar with his left hand. Surveyor asked DON-B did she think it was safe to turn R2 with 1 person assist. DON-B stated, That's what therapy determined. Surveyor advised all documentation indicated he was dependent for bed mobility and was providing care in bed with 1 person was safe. DON-B stated, I'm not really sure.On 1/7/26 at 11:30 AM, Surveyor spoke with Physical Therapy Assistant (PTA)-F. He reported he did not help R2 out of bed, but did exercises on his back. PTA-F stated, He could not roll himself at all. He was dependent for bed mobility which means he would require 2 assist.On 1/7/26 at 12:00 PM, Surveyor asked CNA-H about R2's bed mobility. CNA-H stated, He could not turn himself at all, we had to roll him over. I'd roll him onto his side, and he would just like stay there, it's hard to explain, but he would just stay there. CNA-H reported she would roll R2 by herself, but after he came back from the hospital following the fall he was always 2-person assist. On 1/7/26 at 1:10 PM, Surveyor spoke with Assistant Director of Nursing (ADON)-E. Surveyor reviewed education titled Ensuring resident safety while providing cares in bed which was provided to staff on 12/4/25 following a fall from bed involving a different resident. Surveyor asked if this education was in place prior. ADON-E stated, Yes, this is always the expectation. We just did re-education after that one resident fell. The education provided documents (in part) .To ensure resident safety and preventing falls from bed while using proper mechanics and positioning techniques when performing cares - such as perineal care, brief changes, skin checks and/or repositioning.1. Prepare the environment first. Before touching the resident, ensure the environment is safe: Lock the bed wheels - no exceptions. Ensure adequate lighting so you can see what you're doing. Keep the call light within reach if you momentarily step away. Gather all supplies first; avoid leaving the resident to retrieve items.3. Follow side rail policies correctly. If side rails are not allowed, stand firmly on the side the resident could roll toward.4. Maintain control of resident positioning. Hands-on safety is the #1 fall prevention method during cares in bed. Keep one hand on the resident while they are turned.7. Never leave resident unattended on a raised bed. If the bed is up at working height and you must step away - even for a second - lower the bed first. If you cannot lower the bed (e.g. in the middle of turning), call for help instead of leaving.9. Use proper body mechanics to maintain control. Stand close to the bed - don't lean over far. Work from one side at a time instead of stretching across the bed. If the resident is large or cannot assist, ask another caregiver for assistance.Quick safety checklist for cares in bed: Bed wheels locked. Supplies ready. One-hand contact during turning. Resident not left alone on raised bed. Bed lowered before leaving bedside.On 1/7/26 at 2:22 PM, Surveyor spoke with NHA-A and shared concern R2's nursing documentation, MDS assessments and interview with RN/MDS-D documents R2 was dependent for bed mobility which requires 2-person assist and R2's care plan documented 1 person assist. NHA-A reported the definition of dependent does not specify 2-person assist is required and reviewed definition with Surveyor. Surveyor shared concern not only related to care plan, concern that R2 was dependent for bed mobility and was rolled away from the CNA during cares onto his right side leaving his affected left (hemiplegia) side exposed. The CNA reached for a towel and did not maintain control of R2, which resulted in the fall from bed requiring hospitalization, sutures to repair a head laceration and questionable rib fracture.On 1/7/26 at 2:50 PM, Surveyor asked NHA-A what the difference between 1/2 side rail, bed bar and enabler bar is. Surveyor was advised the facility does not use side rails or 1/2 side rails, and enabler bar and bed bar are the same thing - it is small a horseshoe shaped grab bar. Surveyor advised NHA-A of the facility reported expectation and training to staff which indicates if side rails are not allowed, a staff person is to stand firmly on the side that the resident could roll toward. No additional information was provided at time of survey exit.

Based on record review and interview, the facility did not ensure 1 (R1) of 1 resident reviewed for adequate monitoring and indications for use with a medication was administered the medication in accordance with physician ordered parameters. R1 was transferred to the hospital on [DATE] following a fall and returned to the facility the same day. While in the emergency department R1 was diagnosed with atrial fibrillation (A Fib). On 11/27/25 Metoprolol Tartrate 25 mg (milligrams) once daily for heart failure and A Fib was ordered. This order was not implemented until 12/1/25. R1's Metoprolol Tartrate 25 mg orders included parameters to hold the medication for heart rate less than 60 or systolic blood pressure under 100. R1 received Metoprolol Tartrate 25 mg when this medication should have been held on 12/2/25, 12/9/25, 12/14/25, & 12/19/25.Findings include:R1's diagnoses include congestive heart failure) (heart doesn't pump enough blood to meet the body's needs, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side) following cerebral infarction (type of stroke) affecting left nondominant side, hypertension (high blood pressure), and Atrial Fibrillation (irregular and rapid heartbeat).R1's hospital ED (emergency department) notes dated 11/26/25 includes documentation of Given the fact that the patient was on hospice, we engaged in extensive shared decision making with the patient and her daughter on how to proceed with workup and final disposition. It was ultimately decided to not proceed with imaging as this would likely not change intervention given her hospice status which the patient wished to stay on. She was additionally noted to be in atrial fibrillation with RVR (rapid ventricular response) likely secondary to fluid overload. We discussed attempting treatment with oral metoprolol with the patient and her hospice team as well as the patient's daughter. We did attempt to rate control the patient with oral metoprolol in the ED. We additionally provided pain control, and she stated that her pain was adequately controlled throughout ED course. After discussion with hospice team, patient and her daughter we ultimately discharged the patient back to her nursing [NAME] to continue her hospice care.R1's nurses note dated 11/27/25, at 0426 (4:26 a.m.), written by Licensed Practical Nurse (LPN)-I documents Resident returned from hospital at 1600 (4:00 p.m.) following post fall in stable condition. Resident alert and oriented x (times) 3. Hospice visited at 1700 (5:00 p.m.). VSS (vital signs stable). No new injury noted. Needs met, call light within reach.R1's physician verbal order dated 11/27/25 documents Metoprolol Tartrate 25 mg (milligram) oral tablet; Take 1 tab(s) oral once daily for heart failure and fib (A Fib) (Atrial Fibrillation).R1's nurses note dated 11/27/25, at 09:49 (9:49 a.m.), written by Registered Nurse (RN)-J documents Resident is resting. Vs (vital signs) 101/65, hr (heart rate): 56, O2 (oxygen): 91% ra (room air), RR (respiratory rate): 16 using accessory muscles. C/o (complained of) lethargy. No c/o pain or discomfort will continue to monitor. Grandson present and concerned about breathing. [Name] hospice notified. New orders provided by MD (medical doctor) and faxed to pharmacy. PRN (as needed) O2 applied.R1's nurses note dated 11/28/25, at 12:06 p.m., written by Hospice RN-K documents Pt (patient) today sleeping in bed when I arrived. I was able to wake her up easily. She responded saying my name and asking if we are having our study today. I said we will do it next week and that I wasn't sure how she felt after this fall. Pt has short periods of labored breathing lasting about 20 seconds and then her respirations will be non-labored and regular. She denies any SOB (shortness of breath). Respirations range from 14-20 per minute. Pt is on 3 liters of oxygen, decreased it to 2 liters. Pt sating at 92-93%, BP (blood pressure) 84/66, HR (heart rate) 108. Writer faxed over new order for metoprolol 25 mg (milligrams) once daily to control her afibb (sic) since patient was in afibb (sic) with RVR (rapid ventricular response) in the emergency room on 11/26. Hospice RN will see patient tomorrow (Saturday) for this COC (change of condition) regarding her need for oxygen and afibb (sic).R1's nurses note dated 12/1/25, at 13:39 (1:39 p.m.), written by Hospice-K documents Pt today sitting in bed with lunch in front of her. Pt is not eating and reports she doesn't have an appetite. She drinks her chocolate milk though. Pt seems to be back to baseline, alert, oriented x (times) 2-3. Pt is able to answer questions appropriately but does not really keep the conversation going or ask me questions. She was happy to know I was ordering her a bigger bed after this fall. New order for metoprolol that I ordered last week was not in [Name of electronic charting system], so I refaxed it again and they are putting the order in. Pt will need to get a dose of her metoprolol today since she is still in afibb (sic) 115-130's. Pt is asymptomatic, denies SOB. Oxygen 95% on 1 liter of oxygen. Writer decreased her oxygen to 1 liter from 2 liters. BP 11/73-HR 111. Writer told facility nurse to give metoprolol dose today. Writer ordered a bariatric bed and mattress for patient safety reasons after her fall out of bed last week. Should be delivered within 24 hours.R1's nurses note dated, 12/1/25 at 13:13 (1:13 p.m.), written by RN-C documents N.O.R. (new order received) per [Name] RN [Name] hospice for Metoprolol Tartrate 25 mg q (every) AM (morning).Medical Doctor (MD)-L's progress note dated 12/8/25 under assessment and plan includes documentation of *I48.91 - Unspecified atrial fibrillation*: Patient was found to have atrial fibrillation with rapid ventricular response during emergency department visit on 11/26/2025 for fall from bed with head strike. Heart rate was 248 in ED and was treated with metoprolol tartrate 25 mg for rate control. Metoprolol tartrate 25 mg daily was ordered on 12/1/2025 for tachycardia. Heart rate has improved, ranging 56-92 over the past week (12/1/2025-12/7/2025). Patient remains on hospice care with focus on comfort measures. Metoprolol tartrate is being increased to 25 mg twice daily for improved rate control. Will monitor heart rate.Surveyor reviewed R1's November 2025 MAR (medication administration record) and noted Metoprolol 25 mg once daily is not included on this MAR.Surveyor reviewed R1's December 2025 MAR and noted the following:Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth in the morning related to Hypertensive Heart Disease with Heart Failure (I11.0) hold medication for heart rate less than 60 or systolic B.P. (blood pressure) under 100. Start date 12/2/25 and discontinued 12/8/25.Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day related to Hypertensive Heart Disease with Heart Failure (I11.0) hold medication for heart rate less than 60 or systolic B.P. (blood pressure) under 100. Start date 12/9/25.Physician orders were not followed for holding Metoprolol Tartrate 25 mg when R1's heart rate is less than 60 or systolic blood pressure is under 100 on 12/2/25 when R1's pulse was documented as 60. The morning dose on 12/9/25 when R1's pulse was 49, the morning dose on 12/14/25 when R1's systolic blood pressure was 98 & pulse was 50 and the morning dose on 12/19/25 when R1's systolic blood pressure was 79.On 1/7/26, at 11:05 a.m., Surveyor asked Director of Nursing (DON)-B who reviews paperwork from the hospital when a resident returns. DON-B informed Surveyor the floor nurse gets the paperwork and reviews this paperwork. Surveyor asked DON-B who Surveyor should speak with regarding R1 when R1 returned from the hospital on [DATE]. DON-B informed Surveyor she should speak with RN-C as RN-C is the main nurse and possible may have the answer.On 1/7/26, at 11:34 a.m., Surveyor asked RN-C who is responsible for reviewing a resident's hospital paperwork when they return from the hospital. RN-C informed Surveyor the nurse doing the admission. Surveyor asked how they are aware if hospice orders a medication. RN-C informed Surveyor hospice should let the nurse know if they don't there is a disconnect. Surveyor asked RN-C if she reviews hospice notes in a resident's medical record. RN-C informed Surveyor hospice is supposed to talk with the nurse, and she doesn't review hospice notes. Surveyor asked RN-C if there are parameters when to hold a medication should these parameters be followed. RN-C replied yes.On 1/7/26, at 12:20 p.m., Surveyor asked DON-B if hospice writes an order how is the nurse on the floor aware. DON-B informed Surveyor hospice typically sends the order over the fax. Surveyor asked DON-B when a medication is ordered by hospice who ensure the order is implemented. DON-B informed Surveyor hospice orders go upstairs so the nurse on the floor would get the order and put the order in the system. Surveyor asked DON-B if the physician orders parameters when to hold medication should the nurse follow the physician orders for holding the medication. DON-B replied yes. Surveyor informed DON-B there is a telephone order dated 11/27/25 for Metoprolol 25 mg once daily for R1. On 11/28/25 there is a hospice note for R1 which includes writer fax over new order for Metoprolol 25 mg daily and a hospice note dated 12/1/25 which indicated new order for Metoprolol 25 ordered last week was not in system. Surveyor informed DON-B R1 did not receive Metoprolol 25 mg according to physician orders. Surveyor also informed DON-B R1 should not have received Metoprolol 25 mg on 12/2/25, 12/9/25, 12/14/25, and 12/19/25 as R1's pulse and/or systolic heart rate was below the parameters for which the medication should be administered.

Based on record review, staff interviews, and policy review, the facility failed to report an allegation of abuse to local law enforcement for one of one resident (Resident (R) 1) reviewed for abuse of six residents in the sample. This failure had the potential to increase a resident's risk of abuse throughout the facility. Findings include: Review of the facility's policy titled, Comprehensive Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Program, revealed .Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to local law enforcement to be investigated. Facility staff will fully cooperate with the local law enforcement designee. A summary of the investigation will be submitted to the State agency within five working days of the initial report. Review of R1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/03/25 revealed R1 was admitted to the facility on [DATE] with diagnoses that included joint replacement surgery, presence of left artificial shoulder joint, anxiety disorder, and depression. R1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. R1 was discharged from the facility on 04/07/25. Review of Misconduct Incident Report, provided by the facility dated 05/06/25 revealed, At approximately 2:00 PM on 03/04/25 [R1] reported to the therapy director that she did not want [Physical Therapy Assistant (PTA) 1], the PTA seeing her anymore stating he made her feel uncomfortable. When asked why she said he patted her by the butt a while ago. Investigation begun immediately; [PTA1] was suspended pending investigation. Resident refused to have law enforcement notified. During an interview on 06/12/25 at 3:28 PM, the Occupational Therapist (OT) 1 stated she did not witness the event between R1 and PTA1. On 03/04/25, OT1 stated she was speaking with R1 when R1 stated she was not feeling comfortable with working with PTA1. OT1 stated R1 informed her that R1 found PTA1 creepy and that PTA1 had patted her bottom. OT1 stated she immediately informed the Social Worker (SW) 1 and the former Administrator 1. OT1 stated PTA1 did not recall touching R1 inappropriately or touching her in any way. OT1 stated R1 was unable to give details about when and how the incident occurred. During an interview on 06/12/25 at 3:37 PM, PTA1 stated he was unsure of the date R1 alleged that he touched her. PTA1 stated his recollection was two or three days before the accusation. PTA1 stated R1 was lying in bed, and PTA1 got her out of bed, using a walker, into the wheelchair. He stated R1 stood up from the wheelchair for a minute or two, then sat down in the wheelchair, then transferred back to the bed. PTA1 stated according to his notes on that day, R1 did not need any physical assist and no physical contact from him at all. During an interview on 06/13/25 at 4:09 PM the Director of Nursing (DON) stated it was the previous Administrator 1 conducted the investigation into R1's allegation. During an interview on 06/13/25 at 5:00 PM the Corporate Senior Executive Director stated if he had been the one in charge, he would have called the police whether the resident wanted to or not, because he was aware it was the law. During an interview on 06/13/25 at 5:13 PM, the SW stated she recalled R1's allegation that PTA1 patted her butt. The SW stated she immediately informed the former Administrator and the facility conducted an investigation. The SW stated she did not recall if the police were called.

Based on observations, record review, staff interviews, and facility policy review, the facility failed to follow appropriate infection control practices for hand hygiene for one of one residents (Resident (R) 2) observed during medication administration of six residents in the sample. The failure had the potential for the spread of pathogens in the facility. Findings include: Review of the facility's policy titled Infection Control Hand Hygiene, dated 12/05/24 revealed I. Policy: The organization will promote clean hands as the single most important factor in preventing the spread of pathogens, antibiotic resistance, and incidence of infections. II. Procedure: A. Specific Indications for Hand Hygiene 1. Immediately before touching a patient .3. Before moving from work on a soiled body site to a clean body site on the same patient. 4. After touching a patient or the patient's immediate environment. 5. After contact with blood, body fluids, or contaminated surfaces .1. Wear gloves when in contact with blood, body fluids, or potentially other infectious materials. Review of R2's annual Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 03/07/25 revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nonalcoholic steatohepatitis (NASH), acute respiratory failure, end stage renal disease, type two diabetes mellitus with diabetic chronic kidney disease, chronic diastolic (congestive) heart failure, other pancytopenia, cirrhosis of liver, epilepsy, without status epilepticus, and dementia. R2 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Review of the EMR Orders tab revealed an order, Enhanced Barrier Precautions (EBP) for Wounds. Everyone must clean their hands, before entering and when leaving the room. Providers and staff providing high touch-contact care activities must wear gloves and gowns dated 04/23/25. During observation on 06/13/25 at 12:42 PM, Medication Administration Technician (Med Tech) 1 returned to R2's room, did not perform hand hygiene before entering R2's room, and wore no gloves. Med Tech1 held the cup of the liquid medication to R2's mouth with bare hands in multiple sips. Med Tech1 obtained a tissue and dabbed R2's mouth as some of the medication dribbled out. When done with the medication administration, Med Tech1 discarded the tissues and medication cup in the trash and touched the trash can lid. Med Tech1 attempted to perform hand hygiene with the wall alcohol hand rub dispenser in R2's room, but it was empty. Med Tech1 walked out of R2's room and across the hallway into another resident's room to use the wall alcohol dispenser in that room. During an interview on 06/13/25 at 12:46 PM Med Tech1 acknowledged she did not wear gloves or perform hand hygiene to give an oral liquid medication that spilled out of the resident's mouth and dabbed the resident's mouth with tissue using her bare hands. During an interview on 06/13/25 at 12:50 PM, Registered Nurse (RN)2 stated it was her expectation that Med Tech1 should have performed hand hygiene before entering R2's room. Furthermore, R2 was on EBP. RN2 stated that Med Tech1 should have worn gloves to give the medication to R2 since it involved possible contact with R2's bodily fluids. During an interview on 06/13/25 at 4:09 PM, the Director of Nursing (DON) stated it was her expectation that Med Tech1 should have worn gloves when giving the resident a medication to drink out of a cup and should have performed hand hygiene before entering a resident's room.

Based on observations, record review, staff interviews, and review of facility policy, the facility failed to ensure that staff discarded dispensed liquid medications that were not immediately administered to residents for one of two residents (Resident (R) 2) during medication administration for six residents in the sample. This failure had the potential to expose the resident to contamination in the medication. Findings include: Review of facility's undated policy titled, Preparation and General Guidelines: Equipment and Supplies for Administering Medications revealed, the facility maintains equipment and supplies necessary for the preparation and administration of medications to residents . Review of R2's annual Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 03/07/25 revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nonalcoholic steatohepatitis (NASH), end stage renal disease, chronic kidney disease, cirrhosis of liver. R2 had a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated the resident was severely cognitively impaired. Review of physician's orders located under the orders tab of the EMR, revealed the following order: Lactulose Oral Solution 10 GM (milligram)/15ML (milliliter) (Lactulose). Give 45 ml orally four times a day for Constipation During an interview on 06/13/25 at 12:21 PM, Registered Nurse (RN) 2 stated that the 1:00 PM dose of Lactulose was signed out by the medication administration assistant (Med Tech) 1. During an interview on 06/13/25 at 12:23 PM, Med Tech1 stated she signed out the Lactulose at 12:00 PM and went to R2's room to give it. Med Tech1 stated R2 was asleep, so she did not give R2 the medication. During an observation on 06/13/25 at 12:40 PM, Med Tech1 walked to the nurse's station with a cup of liquid medication without her medication cart to R2's room. At 12:42 PM, Med Tech1 administered R2 the medication in a cup. During an interview on 06/13/25 at 12:46 PM, Med Tech1 stated when she first attempted to give the Lactulose, R2 was asleep, she returned the liquid medication to her medication cart. When asked if she returned an open cup of liquid uncovered to her cart, she stated she had two small medication cups with 30 mL and 14 mL each, and that she covered the smaller cups with a big cup and locked her cart. When asked if she had just administered the same medication that was pulled about 45 minutes ago that was stored in her cart in open cups, she stated, yes. During an interview on 06/13/25 at 12:50 PM, RN2 stated it was unacceptable for Med Tech1 to sign out a medication she had not yet given. It was also unacceptable that Med Tech1 returned the medication to the cart in open cups or at all. RN2 stated Med Tech1 should have discarded the medication, informed the nurse the medication was not given, and documented her actions. RN2 stated staff have been trained not to pre-sign medications that have not been given. During an interview on 06/13/25 at 4:09 PM, the Director of Nursing (DON) stated it was her expectation that Med Tech1 should have discarded the medication that was not given and documented it.

Based on interviews and record reviews, the facility did not ensure 1 of 3 residents reviewed (R27) was free of significant medication errors. * R27 was not administered his AM medication on 1/27/25 because he told Registered Nurse (RN)-K he received it. The Medication Administration Record (MAR) was not signed out as to R27's medication being given that day and RN-K did no further investigation to find out if R27 received his medication however documented refused on all his AM medication. R27's AM medication included blood pressure medication and on 1/27/25 at 5:30 PM his blood pressure went up to 217/211 and R27 was transferred to the hospital and admitted . This resulted in actual harm to R27. Findings include: R27 was admitted to the facility on [DATE] with diagnoses to include hemiplegia, anxiety, and hypertension. R27's quarterly Minimum Data Set, dated dated dated [DATE] was reviewed and indicated R27 had a Brief Interview for Mental Status score of 15 (cognitively intact). On 3/3/25, R27's January 2025 MAR was reviewed and documented by RN-K was: R27 refused his AM medication which included: Clopidogral Bisulfate (platelet inhibitor) 75 milligrams (MG), Duloxatine (Depression) 30 MG, Isosorbide Mononitrate (Hypertension) 30 MG, Lexapro (Anxiety) 10 MG, Lineclotide (constipation) 290 micrograms, Miralax (constipation) 17 grams, multivitamin 1 tab, Olmesartan Medoxomil (Hypertension) 30mg, Pantoprazole Sodium (acid reflux) 40 MG, Pregabalin (pain) 300 MG, Brimondine Tartrate 0.2% 1 drop both eyes, Dorzolamide 1 drop both eyes, Eliquis (pulmonary embolism) 5 MG, Hydroxine (anxiety) 25 MG, Oxymetazoline 0.05% (congestion), Ranolazine (Hypertension) 500 MG, Senna (constipation) 17.2 MG, Tizanadine (pain) 2 MG, and Endocet (pain) 10-325 MG. Surveyor notes the only refusal documented for the whole month of January 2025 was on 1/27/25 in the AM. On 3/3/25, R27's progress note dated 1/27/25, at 5:30 PM, written by RN-K was reviewed and documented: R27 alert and oriented times 4. He complains of slight chest tightness. Respirations unlabored, reports slight shortness of breath, no complaints of pain, afebrile. High blood pressure 217/211, Heart rate 76, respiratory rate 18. Ibratropium-Albuterol 0.5-2.5 MG and blood pressure medication given. R27 did not get full relief from the medications. Transferred to [name of hospital]. Resident had refused morning medications. Vitals were taken which were baseline in the morning. On 3/4/25, at 8:00 AM, Medication Technician (MT)-F was interviewed and indicated on 1/27/25 she was passing medication on R27's unit and RN-K instructed her not to give R27 his AM medication. On 3/4/25, RN-K refused to talk to Surveyor. On 3/4/25, RN-K's employee file was reviewed. Surveyor noted the concern with R27's medication administration on 1/27/25 was documented. On 3/3/25, at 1:30 PM, R27 was interviewed and indicated he has never refused his medication but could not recall the details of 1/27/25 and could only recall he did not get his medication. On 3/4/25, a grievance filed on behalf of R27 was reviewed and documented: during medication pass on 1/27/25 R27 indicated to nurse that he had taken medication earlier that morning. Medications were not signed out, however nurse advised MT not to give medications. Nurse and MT educated on medications that are not signed out should be considered not given, investigation should occur with any questions. On 3/4/25, at 2:00 PM, Director of Nurses-B was interviewed and indicated RN-K should have found out if R27 received his medication and she did not. On 3/4/25, R27's discharge summary from his hospitalization from [DATE] to 1/31/25 was reviewed which listed the chief concern on 1/27/25 as chest pressure. On the summary it was documented R27 had hypertension upon admission with a blood pressure reading of 157/77. R27 did not receive 3 medications for his hypertension as ordered on 1/27/25 in the AM. The above findings were shared with Nursing Home Administrator-A and Director of Nurses-B on 3/4/25. Additional information was requested if available. None was provided as to why R27 did not receive his AM medications on 1/27/25.

Based on observations, interviews, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 1of 2 residents (R5) reviewed for pressure injuries. R5, who was assessed to be at risk for pressure injuries, developed a stage 2 coccyx pressure injury on [DATE]. Facility staff did not complete a thorough assessment with measurements of the pressure injury until [DATE]. R5's care plan was not updated with new offloading interventions after the development of the coccyx pressure injury. On [DATE], R5 developed a Deep Tissue Injury (DTI) to R5's right heel. R5's care plan was not updated with new interventions after the development of the right heel deep tissue injury. The facility wound Nurse Practitioner (NP)-G completed weekly assessments of R5's two pressure injuries. On [DATE], NP-G was unable to complete the weekly assessment. The facility Wound Nurse, who is the Assistant Director of Nursing (ADON)-E, completed R5's wound assessment. ADON-E completed measurements but did not complete a thorough assessment that included a thorough description of the wound bed. On [DATE], R5's coccyx pressure injury declined to an unstageable pressure injury. R5's care plan was not updated with new interventions after the coccyx wound worsened. R5 was hospitalized from [DATE] through [DATE] with sepsis related to bilateral parotitis (inflammation and infection of both parotid glands [salivary glands located in front of the ears]). While hospitalized , R5's pressure injuries were both staged as unstageable. R5 was readmitted to the facility on [DATE] on hospice. Facility staff determined that hospice staff would be responsible for assessing and treating R5's pressure injuries. Communication between the facility and hospice staff was not clear. Hospice Nurse, Registered Nurse (RN)-J told Surveyor that RN-J was not aware that RN-J was the only staff member caring for R5's pressure injury. NP-G was no longer involved in R5's care. From [DATE] through [DATE], R5's coccyx pressure injury was not measured, and a thorough assessment was not documented by the facility staff or hospice staff. From [DATE] through [DATE], hospice staff measured R5's heel wound 3 out of the 6 weeks, but a thorough assessment of the pressure injury was not completed. On [DATE], R5 developed a wound to R5's right lateral leg. The facility staff or hospice did not complete an assessment of R5's wound with measurements or a description of the wound bed. RN-J measured the new wound for the first time on [DATE] and determined the wound was a laceration. Facility staff and Hospice staff did not determine the root cause of the new wound to R5's right lateral leg and did not update R5's care plan with new interventions. On [DATE], R5 died while in hospice at the facility. Findings include: The facility policy titled, Pressure injury prevention and managing skin integrity with a review date of [DATE], documents, in part: Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries . Risk Assessment: . Based on the individual's Braden Scale Score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record . Identify Interventions: The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown . Identification of risk factors present or acquired that compromise skin integrity will be considered. Weekly Wound Rounds: Upon identification of abnormal skin findings, a licensed nurse will complete a skin assessment. Individual with abnormal skin concern(s) will be added to weekly wound rounds. Registered Nurse (RN) or designee will: Conduct weekly skin evaluation. Update the [Primary Care Provider] with any decline in wound appearance, or as necessary. Update the Care plan with any new interventions as applicable . R5 was admitted to the facility on [DATE] with diagnosis that include Chronic Kidney disease, Type 2 Diabetes, Dementia, Stroke history, Encephalopathy and Adult Failure to Thrive. R5's Significant Change Minimum Data Set assessment dated [DATE] documents R5 has a moderate cognitive impairment. R5 is dependent for bed mobility, hygiene cares, and transfers. R5 has a catheter and is always incontinent of bowel. R5 is at risk for pressure injury development but does not have any unhealed pressure injuries. R5's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents a score of 15 making R5 at risk for developing a pressure injury. R5's potential for pressure ulcer development care plan, with an initiation date of [DATE], documents the following interventions: The resident will have intact skin, free of redness, blisters, or discoloration by/through review date. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. The resident requires pressure reducing mattress on bed and pressure reducing cushion in [wheelchair]. R5's potential impairment to skin integrity care plan, with an initiation date of [DATE], documents the following interventions: Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Keep skin clean and dry. Use lotion on dry skin. Use a draw sheet or lifting device to move resident. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. R5's progress note dated [DATE] documents, in part: Resident was recently hospitalized for [Altered Mental Status] and delirium. Resident was in hospital from ,d+[DATE] to ,d+[DATE]. [By mouth] intake has decreased. Intake was ~75% most meals, intake is now 38% on average. Writer notified [Registered Dietician] of decrease in intake .Resident receives diabetic house supplement [Every day]. Resident has house snack order in the evening for [Diabetes] and will often snack at other times. Resident might be enrolling in hospice after evaluation. No wounds. Surveyor noted R5's meal consumption was significantly decreased, hospice was being considered due to R5's health decline, and R5 did not have any wounds. R5's progress note dated [DATE] at 11:27 AM documents: This writer informed that resident had an open area to her coccyx. writer updated resident's daughters and house Nurse Practitioner. Resident will be put on wound rounds to be seen by wound NP on [DATE]. Surveyor reviewed R5's Electronic medical record and did not locate an assessment that included measurements or a thorough description of the coccyx wound bed. Surveyor noted that a comprehensive assessment of R5's coccyx pressure injury was not completed by facility staff on the day the coccyx pressure injury was found. R5's initial Wound Evaluation completed by NP-G dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer) Partial thickness wound with 100% smooth pink tissue at the base. Wound measuring 1 x 0.7 x 0.1 cm . Plan: Cleanse with [Normal Saline] or wound cleanser, then apply skin prep to the peri wound and cover with bordered foam. Change 3 [times]/week. Continue offloading measures. Surveyor reviewed R5's MD orders. Surveyor noted that the treatment for R5's coccyx wound was entered as a MD order on [DATE]. On [DATE], R5's potential impairment to skin integrity care plan focus was updated with stage 2 open area to coccyx. Surveyor noted the only offloading measures on R5's care plan was an air mattress and cushion in wheelchair. No additional offloading measures like turning and repositioning were implemented after the development of the coccyx pressure injury. On [DATE] 08:26 AM Surveyor interviewed Certified Nursing Assistant (CNA)-F. Surveyor asked what CNA-F would do if CNA-F identified a new wound on a resident. CNA-F stated that CNA-F would report it to the nurse. Surveyor asked if CNA-F was familiar with R5's wound care. CNA-F stated that CNA-F would reposition R5 every 2 hours. CNA-F stated that staff would float R5's heels when R5 was in bed. CNA-F stated aside from that, the nurses took care of the wound care. On [DATE] at 8:04 AM, Surveyor interviewed Registered Nurse (RN)-H. Surveyor asked if RN-H could explain what a nurse should do if a new wound is found on a resident. RN-H stated that RN-H would measure and assess the wound. RN-H stated that not all nurses would do this because they are not all comfortable, but RN-H stated that she would definitely measure and assess the wound. RN-H would call the MD, Risk management team and the Power of Attorney, if applicable. RN-H would put the resident on the 24-hour board and implement an intervention. RN-H stated that it depends on the wound, but would implement repositioning, floating heels, etc. depending on where the wound was found. RN-H stated after finding a wound, the resident would be included in the weekly wound rounds. Surveyor asked if RN-H was familiar with R5 and the development of R5's pressure injuries. RN-H stated that the facility had been speaking with R5's family and they were talking about hospice before the wounds developed. RN-H stated R5's family were not agreeable to hospice in June or July of this year. RN-H stated that staff were implementing repositioning and propping up R5's heels as interventions after R5's wound developed. On [DATE] at 10:41 AM, Surveyor interviewed ADON-E. Surveyor asked what the process is when a nurse finds a new wound on a resident. ADON-E indicated the nurse should measure the wound, cover the wound and report it to the MD, Power of Attorney, and the management team. ADON-E stated that the resident would be added to the weekly wound rounds and the NP would do a thorough assessment of the wound and recommend treatment. Surveyor asked what interventions were in place to prevent the development of a pressure injury for R5. ADON-E stated that R5 was on an air mattress, had a cushion on R5's chair and stated R5 was always using a blue floater pillow for floating R5's heels. Surveyor asked if those interventions should be listed on R5's care plan. ADON-E stated yes. On [DATE] at 8:18 AM, Surveyor interviewed Director of Nursing (DON)-B and Clinical Nurse Coordinator (CNC)-D. Surveyor asked what the process is when a nurse finds a new wound on a resident. DON-B stated the nurse should do an assessment, notify the doctor, power of attorney and wound care nurse (ADON-E). Surveyor asked what the initial assessment should include. DON-B indicated the wound should be measured and have a description of the wound bed including the surrounding skin, drainage, and odor. DON-B stated that an intervention should be placed to address the area of concerns. Surveyor noted that staff stated that turning and repositioning, as well as floating heels was possibly implemented but the interventions were not present on R5's care plan so that all staff caring for R5 were aware of plan. R5's MD order dated [DATE] documents: Reduced sugar House supplement between meals twice daily. R5's Wound Evaluation completed by NP-G dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer). Partial thickness wound with 100% smooth pink tissue at the base. Wound measuring 1.5 x 3.0 x 0.1 cm . Status: deterioration. Plan: Cleanse with [Normal Saline] or wound cleanser, then apply skin prep to the peri wound and cover with bordered foam. Increase frequency of changes to daily and [as needed]. Continue offloading measures. Surveyor reviewed R5's MD orders and noted that the frequency of dressing changes was updated to daily and [as needed]. On [DATE], R5's potential impairment to skin integrity care plan was updated with the following intervention: [Treatment] per MD order. Surveyor noted no additional offloading measures like turning and repositioning were entered on R5's care plan after the coccyx pressure injury deteriorated. R5's Wound Evaluation completed by NP-G, dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer). Partial thickness wound with 100% smooth pink tissue at the base. Wound measuring 0.2 x 0.8 x 0.1 cm . Continue offloading measures. Right lateral heel (DTI). Absorbing fluid filled blood blister measuring 5 x 7.5 x UTD cm . Status: New. Plan: Apply skin prep followed by ABD pad and secure with kerlix, change 3 [times]/week. Prevalon boot to be worn whenever in bed. Surveyor noted the coccyx wound improved and the treatment remained the same. Surveyor noted R5 developed a new pressure injury to R5's right lateral heel. Surveyor reviewed R5's MD orders and noted the treatment for R5's right lateral heel wound was entered as a MD order on [DATE]. On [DATE], R5's potential impairment to skin integrity care plan focus was updated with DTI to right lateral heel. Surveyor reviewed R5's Care plan and noted that no new interventions were placed after R5 developed the new pressure injury to R5's Right heel. Surveyor noted NP-G recommended a Prevalon boot to be worn whenever in bed and this intervention was not added to R5's care plan. On [DATE] at 10:41 AM Surveyor interviewed ADON-E. Surveyor asked about interventions for R5's heels. ADON-E stated that ADON-E believed that R5 had a Prevalon boot in place. Surveyor asked if that intervention should be listed on the care plan. ADON-E stated yes. Surveyor informed ADON-E that R5's care plan was not updated with an intervention after R5 developed the heel pressure injury and after NP-G recommended a Prevalon boot. ADON-E stated, I remember, it was there. On [DATE] at 8108 AM, Surveyor interviewed DON-B. Surveyor about R5's right heel pressure injury. Surveyor asked if interventions that the wound NP recommends should be added to R5's care plan. DON-B stated that repositioning and floating of heels should have been added to R5's care plan. DON-B indicated that after the heel injury developed, the Prevalon boot should have been added to R5's care plan as directed by NP-G. R5's Wound Evaluation completed by NP-G, dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer). Partial thickness wound with 100% smooth pink tissue at the base. Wound measuring 0.8 x 1.8 x 0.1 cm . Status: deteriorating . Continue offloading measures. Right lateral heel (DTI). Absorbing fluid filled blood blister measuring 5 x 5.5 x UTD cm . Prevalon boot to be worn whenever in bed. Avoid use of shoes. Surveyor noted R5's coccyx pressure injury deteriorated. Surveyor noted the treatment remained the same and no additional offloading interventions like turning or repositioning were added to R5's care plan. Surveyor noted R5's right lateral heel pressure injury improved. Surveyor noted NP-G added that R5 should avoid the use of shoes. Surveyor reviewed R5's care plan and noted that this intervention was not added to R5's care plan. R5 had wound evaluations completed on [DATE] and [DATE]. Surveyor noted both of R5's pressure injuries were documented as improving. R5's Wound Evaluation completed by NP-G, dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer). Partial thickness wound with 100% smooth pink tissue at the base. Wound measuring 1.0 x 0.3 x 0.1 cm . Status: deterioration . Continue offloading measures. Right lateral heel (DTI). Blood blister evolved to an eschar measuring 3.8 x 4.2 x UTD cm. Eschar is intact/adherent and without fluctuance . Plan: Apply betadine daily, leave [Open to air]. Prevalon boot to be worn whenever in bed. Avoid use of shoes. Surveyor noted R5's coccyx pressure injury deteriorated. Surveyor noted the treatment remained the same and no additional offloading interventions like turning or repositioning were added to R5's care plan. Surveyor noted R5's right lateral heel pressure injury improved. Surveyor noted Prevalon boots and that R5 should avoid use of shoes was documented again by NP-G. Surveyor noted that neither of these interventions were added to R5's care plan. R5's progress note dated [DATE] at 12:49 PM documents, in part: . wound NP was not in house today, but this writer did see resident's wound and did treatments. treatment in place in [electronic medical record], staff will continue to follow [plan of care]. On [DATE] at 10:41 AM, Surveyor interviewed ADON-E about wound rounds on [DATE]. ADON-E stated that it was over Labor Day weekend an ADON-E completed the assessments on R5. Surveyor informed ADON-E that Surveyor could not find any documentation in R5's medical record indicating the measurements and assessment of R5's pressure injuries. ADON-E stated that ADON-E has the assessment on paper in ADON-E's office. ADON-E returned to Surveyor with a one-page spreadsheet of all the wounds that ADON-E assessed on [DATE]. ADON-E's documentation of R5's pressure injuries dated [DATE] documents: Coccyx 1.5 x 1.8. Right heel 2.8 x 2. Surveyor noted ADON-E's documentation did not include a comprehensive assessment on R5's pressure injuries. Surveyor noted both the coccyx pressure injury and the right lateral heel pressure injury deteriorated. Surveyor noted the treatment remained the same to both areas and R5's care plan was not updated with new interventions. R5's Wound Evaluation completed by NP-G, dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer evolved to unstageable). Full thickness wound with 100% slough at the base. Wound measuring 2.5 x 1.5 x UTD cm . Status: deterioration. Plan: Cleanse with [Normal Saline] or wound cleanser, then apply skin prep to the peri wound medihoney to the base of the wound followed by Alginate and cover with bordered foam, change daily and [As needed]. Continue offloading measures. Right lateral heel (DTI). 100% eschar measuring 5 x 6 x UTD cm . Eschar is intact/adherent and without fluctuance . Prevalon boot to be worn whenever in bed or use of heels up cushion. Avoid use of shoes. Surveyor noted the coccyx pressure injury deteriorated and was staged as unstageable. Surveyor noted the treatment to the coccyx was changed and a new MD order for treatment was placed in R5's electronic medical record. Surveyor noted no additional offloading interventions like turning or repositioning were added to R5's care plan. Surveyor noted R5's right lateral heel pressure injury treatment remained the same. Surveyor noted that NP-G's documentation included Prevalon boot or the use of heels up cushion and that R5 should avoid the use of shoes. Surveyor noted that none of these interventions were added to R5's care plan. R5's Wound Evaluation completed by NP-G, dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer evolved to unstageable). Full thickness wound with 100% slough at the base. Wound measuring 2.5 x 2.0 x UTD cm . Status: deterioration. Continue offloading measures. Right lateral heel (DTI). 100% eschar measuring 5 x 6 x UTD cm. Eschar is intact/adherent with slight lifting at the margins, without fluctuance. Prevalon boot to be worn whenever in bed or use of heels up cushion. Avoid use of shoes. Surveyor noted that R5's Coccyx pressure injury deteriorated, and the treatment remained the same. Surveyor noted no additional offloading interventions like turning or repositioning were added to R5's care plan. Surveyor noted R5's right lateral heel pressure injury treatment remained the same. Surveyor noted that NP-G's documentation included Prevalon boot or the use of heels up cushion and that R5 should avoid the use of shoes. Surveyor noted that none of these interventions were added to R5's care plan. R5's Wound Evaluation completed by NP-G, dated [DATE] documents, in part: Coccyx (stage 2 pressure ulcer evolved to unstageable). Full thickness wound with 100% soft light brown necrotic tissue at the base. Wound measuring 7 x 4.0 x UTD cm . Continue offloading measures. Right lateral heel (DTI). 100% eschar measuring 4 x 6 x UTD cm. Eschar is intact/adherent with slight lifting at the margins, without fluctuance . Prevalon boot to be worn whenever in bed or use of heels up cushion. Avoid use of shoes. Surveyor noted R5's Coccyx pressure injury deteriorated from 2.5 x 2 to 7 x 4 in one week. The treatment remained the same and no additional offloading interventions like turning or repositioning were added to R5's care plan. Surveyor noted R5's right lateral heel pressure injury treatment remained the same. Surveyor noted that NP-G's documentation included Prevalon boot or the use of heels up cushion and that R5 should avoid the use of shoes. Surveyor noted that none of these interventions were added to R5's care plan. R5's progress note dated [DATE] at 12:02 PM documents, in part: [By mouth] intake has decreased to ~25%. At the time of last nutrition assessment 3 months ago, PO intake was 38% on average. R5's progress note dated [DATE] at 3:33 PM documents: Resident was transferred to [name of local hospital] today via ambulance accompanied by EMT due to lethargy, poor appetite, and critical labs. The ADON and family updated. R5 was admitted to the hospital from [DATE] through [DATE] with Severe sepsis in setting of bilateral parotitis. While hospitalized , R5 had an x-ray completed of R5's right lower extremity and Vascular Surgery visited R5. R5's X-ray results dated [DATE] documents a final result of: suspicious for osteomyelitis given overlying wound. R5's Vascular Surgery Consult dated [DATE] documents, in part: [R5] with functional decline and poor [by mouth] intake in the past 4 months who is bed/wheelchair bound at this point . The heel wound appears to be a pressure wound . The eschar is hard and well adhered to the heel. Given these findings of the heel wound, no surgical debridement is recommended . Suggestion of osteomyelitis on [x-ray]- it is highly unlikely that this is contributing to [R5's] [altered mental status] and overall deconditioning . Given the patient's age, multiple co-morbidities and her current altered status with sepsis that is being treated, no surgical intervention is recommended . Recommend heel off-loading shoe. Surveyor noted Vascular Surgery signed off on R5's care and noted that R5 should have a heel off-loading shoe. R5 was readmitted to the facility on [DATE] with hospice care. R5's progress note dated [DATE] 2:34 PM documents, Hospice will take over wound care for resident [related to] hospice services. On [DATE], R5's potential impairment to skin integrity care plan focus was updated with Hospice will do all wound care on admission to hospice. Surveyor noted that a heel off-loading shoe was not placed as an intervention as recommended by the Vascular Surgery MD. Surveyor reviewed R5's electronic medical record and did not locate any measurements or assessments of R5's wound from [DATE] until [DATE]. R5's progress note dated [DATE] 10:15 PM documents, in part: An open area noted to resident [right] lateral leg. No bleeding noted. Dressing applied. No s/s of infection noted. ADON and hospice updated. Message left for family to call facility for update. Surveyor reviewed R5's electronic medical record and did not locate any further documentation of the new right lateral leg wound including measurements and a comprehensive wound bed assessment. R5's care plan was not updated with this new wound and a new interventions was not place. Surveyor noted a wound treatment with a start date of [DATE] was put in place for the right lateral leg wound and staff were completing treatments for this new wound. On [DATE] at 10:41 AM Surveyor interviewed Assistant Director of Nursing (ADON)-E. Surveyor asked what the plan was for R5's wound care after R5 returned to the facility on [DATE]. ADON-E stated that the hospice nurse, RN-J, told ADON-E that RN-J would complete all R5's wound care needs. ADON-E stated that RN-J would do all the dressing changes and assessments. If needed, the facility staff would fill in the gaps when RN-J was not in the facility on the weekends. Surveyor asked ADON-E if hospice was completing the assessments of R5's wounds. ADON-E stated that no assessments or measurements were in the electronic health record, but ADON-E reached out to the hospice company on [DATE] to get the documentation of the assessments. ADON-E stated that hospice did not have the documentation and stated that they did not document on the wounds. On [DATE] at 12:27 PM, Surveyor interviewed RN-J, the hospice nurse, regarding R5's wound care. RN-J stated that RN-J remembered having a conversation about completing R5's wound care with the Director of Nursing (DON)-B. RN-J stated that RN-J remembers saying that RN-J would complete the wound care treatments and take care of any MD orders associated with R5's wound care. RN-J stated that RN-J was not aware that RN-J was the only staff member who would be getting measurements of the wounds or assessing the wounds. RN-J stated that in other facilities, RN-J will work with the Wound Doctor or Nurse Practitioner. RN-J stated that during the conversation, RN-J recommended that DON-B follow up about having the facility Wound Nurse Practitioner (NP)-G continue to follow R5's wounds. Surveyor asked about the wound that developed on [DATE]. RN-J stated that the wound was not a pressure injury, but it was a laceration. Surveyor asked if it was a laceration, how the laceration occurred. RN-J stated that it could have happened from a transfer or from a pillow. RN-J was not sure how the injury happened but stated again that it was a laceration/skin tear not a pressure injury. RN-J stated that RN-J did get measurements of the laceration when she did an assessment on [DATE], but that was the first-time measurements were completed. Surveyor asked if hospice or the facility determined the cause of the new wound. RN-J was not sure if a cause was identified. Surveyor asked if any measurements or assessments were completed on R5's pressure injuries/wounds from [DATE] through [DATE]. RN-J gave the following assessment information from RN-J's notes: [DATE]- Coccyx unstageable pressure injury was not measured or assessed. Right heel pressure injury was unstageable and measured 7 x 5.5 cm. Wound had eschar and was moist with red, pink, and black areas. Small amount of drainage. Right lateral leg laceration measured 7 x 1.5. Wound had a small amount bloody drainage and was moist with red and pink wound bed. [DATE]- Coccyx unstageable pressure injury was not measured. Facility RN was doing wound care, so RN-J looked at the wound and documented the coccyx wound to be moist with red, pink, and yellow areas. Small amount serosanguineous drainage. Right heel unstageable pressure injury measured 7.5 x 4.5 cm. Moist, black with no drainage. Right lateral leg laceration measured 8 x 3.5. Wound was pink and yellow with a small amount of tan drainage. [DATE]- Coccyx unstageable pressure injury was not measured or assessed. Right heel unstageable pressure injury measured 7.5 x 4.5 cm. Dry. Black. No drainage. Right lateral leg laceration measured 8 x 3.5 Clean. Wound was scabbed and edges were attached. No drainage was noted. Surveyor asked if there were any changes that were made to R5's MD orders regarding treatment of the pressure injuries. RN-J stated that R5 already had previous treatment orders in place before R5's hospitalization and those treatment orders continued the entire time RN-J cared for R5's wounds. RN-J stated that RN-J was more focused on R5's comfort. RN-J stated that R5 was not eating or drinking so the pressure injuries were not going to heal but RN-J wanted to make sure that R5 was comfortable. Surveyor asked what interventions were in place for R5's skin integrity. RN-J stated R5 had the following interventions on the hospice care plan: Air mattress. Incontinent care. Assess skin and pressure areas. SNF (skilled nursing facility) to perform wound care. Surveyor asked if RN-J's hospice care plan included any offloading measures for R5. RN-J stated that RN-J remembers R5 having a pillow offloading her coccyx area. RN-J stated that RN-J was not sure if R5 was turned every 2 hours because that would be the facility staff responsibility. Surveyor noted that the facility communication of the wound care plan was not communicated clearly to RN-J. Surveyor noted that none of the wound measurements given to Surveyor in the interview with RN-J were located anywhere within R5's electronic medical record. Surveyor noted that without facility and hospice staff knowing the status of R5's wound, staff would not be able to tell if the wounds were deteriorating or not. Surveyor noted that the new wound on R5's Right lateral leg was designated a laceration by RN-J. Surveyor noted that a treatment was put in place but there was not a root cause analysis completed for the [DATE] wound. Surveyor noted that the right lateral leg wound was not thoroughly assessed or measured until 5 days after its development and was not thoroughly assessed or measured weekly. R5's care plan was not updated with a new intervention after the development of this new wound. Surveyor noted that R5's Coccyx pressure injury was not assessed or measured after R5 was placed on hospice. Surveyor noted that R5's Right heel pressure injury was not assessed on admission to the facility. The right heel was not assessed or measure from [DATE] through [DATE]. The [DATE] assessment completed by RN-J did not include a thorough wound bed assessment including the percentage of eschar, slough, or granulation tissue present. The right heel was not assessed or measured from [DATE] through [DATE]. The [DATE] and the [DATE] assessment completed by RN-J did not include a thorough wound bed assessment including the percentage of eschar, slough, or granulation tissue present. On [DATE] at 9:12 AM, Surveyor interviewed NP-G. NP-G stated that NP-G initially saw R5 after R5 developed a coccyx/sacral pressure injury and cared for R5 until R5 went on hospice. NP-G stated that R5's overall condition was declining and R5 was refusing oral intake. Surveyor asked if NP-G knew what interventions were in place to prevent a pressure injury from developing. NP-G stated that R5 was on an air mattress and believed that R5 had other offloading interventions as well. NP-G stated that NP-G did not expect R5's wounds to heal. NP-G stated that wounds do not heal with poor nutrition. NP-G stated that the facility and R5's family had discussions about hospice care, but the family did not agree to that. NP-G stated that NP-G talked to R5's family about Arterial studies and more aggressive care after R5 developed the Right heel pressure injury, but the family was not agreeable to an aggressive plan. NP-G stated that the goal was limit the risk of infection and continue with treatments on the pressure injury areas. NP-G stated on [DATE] when R5 was transferred to the hospital, R5 had taken a fast downward spiral. NP-G stated R5 was not acting like herself. NP-G stated when R5 returned to the facility NP-G was no longer involved in R5's care. Surveyor asked if R5's wound care and assessments schedule would need to change since R5 was on hospice. NP-G stated that taking care of R5's wound would be no different if R5 was on hospice or not. NP-G stated that you still need to do assessments and change treatments as needed while a resident is on hospice. NP-G stated that at other facilities, NP-G continues to care for resident's wounds even when the resident is put on hospice. NP-G did not know why the decision was made for hospice to care for R5's pressure injuries. On [DATE] at 11:08 AM, Surveyor interviewed Nursing Home Administrator about R5's wounds after R5 was placed on hospice. NHA-A indicated that NHA-A did not like that R5's wound care assessments and measurements were missed. NHA-A stated that NHA-A was not happy with the hospice care team. NHA-A indicated that NHA-A had spoken to t[TRUNCATED]

Based on observation, interview, and record review, the facility did not ensure the safety of 3 of 4 residents (R25, R28, and R2) reviewed for accidents. *R25 sustained 5 unwitnessed falls including a fall with a left femur fracture at the facility on 10/13/24. R25 was observed on survey to not have adequate supervision in effort to prevent additional falls or accidents for R25. The facility did not complete root cause analysis for each fall to develop interventions to prevent future falls. *R28 did not receive adequate supervision or assessment by the facility regarding their ability to smoke independently. *R2 sustained a fall that was not thoroughly investigated by the facility. *Facility staff did not ensure medications were safely stored on 1 of 2 units reviewed for medication administration and storage. Findings include: 1.) R25 was admitted to the facility on [DATE] with diagnoses of dementia, psychotic disturbance, and mood disturbance. R25's 6/11/24 quarterly Minimum Data Set (MDS) documents R25 does not have any behaviors, including refusal of cares. R25 is assessed as requiring supervision for going from a sitting to standing position, and transfers. R25's Brief Interview for Cognitive Status (BIMs) indicates a score of 02 indicating severe cognitive impairment. R25's annual Minimum Data Set (MDS) dated [DATE] also documents R25 has no behaviors including refusal of cares. R25 is assessed as requiring supervision for going from a sitting to standing position, and transfers. The facility identified R25 to be at risk for falls with a fall risk assessment score of 15 on 6/27/24. A score of 10 or greater indicates high risk. R25's 10/13/24 and 10/15/24 fall risk assessments scored a risk score of 8 indicating R25's fall risk had actually decreased despite multiple falls and a fall with major injury. R25's 10/20/24 fall risk evaluation scores R25 at a 7 and the 10/28/24 evaluation scores R25 at a risk value of 15 again indicating high risk for falls. R25's Care plan initiated and revised on 5/8/23 has a focus area of: The resident has had an actual fall with major injury Poor Balance (sic), Unsteady (sic) gait, dementia. The goal initiated 5/8/23 and revised on 9/22/23, 9/23/23 and 10/21/24 is for the resident's right fractured wrist to resolve without complication by due date. An additional goal indicates initiated on 5/8/23 with revision on 10/31/24 to have (R25's) left hip fracture resolve without complications by the review date. The target date is 1/28/25. Interventions include: 5/8/23 - continue interventions on the at-risk plan. 6/28/24 - Fall: 6/27/24: give resident pull-ups instead of briefs 8/26/24 - fall intervention 8/24/24: offer assistance with getting up. 5/8/23 - Monitor/document/report PRN (as needed) x (times) 72h (72 hours) to MD (medical doctor) for s/sx (signs/symptoms): pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. 5/8/23 - Neuro-checks x 3 days 5/8/23 - Provide activities that promote exercise and strength building where possible. Provide 1:1 activities if bedbound. 5/8/23 - PT (physical therapy) consult for strength and mobility. 5/16/23 - Resident will be on a toileting schedule due to attempts to self-ambulate to restroom - RESOLVED 6/27/24. R25's plans of care reference for R25: Staff to assist with routine toileting and skincare for incontinence - initiated 5/8/23, revised 11/13/24 Staff to assist with turning and repositioning - initiated 5/8/23, revised 11/13/24 R25's care plan for incontinence references bowel incontinence with no reference to urine continence status: Check resident every two hours and assist with toileting as needed - initiated 5/15/23 Observe pattern of incontinence, and initiate toileting schedule if indicated - 5/15/23 Provide pericare after each incontinent episode - 5/15/23 R25's activities of daily living (ADLs) care plan documents for interventions: Toilet use: independent - initiated 5/8/23, revised on 6/21/24 Transfer: Independent - initiated 5/8/23, revised on 6/21/24 On 11/12/24, Surveyor requested the last three months of fall investigations for R25. R25 sustained falls on 8/24/24, 10/13/24, 10/20/24, 10/25/24 and 10/28/24. R25's fall investigation report dated 8/24/24 indicates this was an unwitnessed fall. Other information documents: self-transfers and ambulates without assistance, unaware of own safety needs. The report documents R25 requires assistance with ambulation. Predisposing physiological factors identified include confusion, impaired memory, none is checked, along with weakness/fainting. Notes document: Writer was called into Res. (resident) room by CNA (Certified Nursing Assistant) @ (at) 0845 as Res. Was sitting on the floor in front of her bed. Res. Stated she had tried to get into her W/C (wheelchair) and slid off the bed. Denies injury. Denies pain/discomfort. R.O.M. (range of motion) WNLS (within normal limits) VSS (vital signs stable) & documented in AOD. Assisted to standing position with gait belt and assist of 2 staff members then assisted into he (sic) W/C. Neuro checks thus far this shift have been negative. Res. Refuses help with cares, transfers, mobility and toileting. (Name of Nurse Practitioner [NP]) called and updated on above, NNO (no new orders). Intervention: offer assistance to (sic) with getting out of bed. Surveyor noted the fall investigation indicates R25 refuses assistance however, the identified intervention is to offer assistance. Surveyor also noted the fall data collection tool dated 8/14/24 indicates R25 did not use her call light prior to the fall. The intervention does not identify how staff are to supervise R25 to offer the assistance identified as an intervention. The unwitnessed fall report dated 10/13/24 includes for an incident description: 05:42 Resident had an unwitnessed fall during shift. Resident is alert and able to make needs known. No apparent injuries noted from fall, neuro checks negative, ROM WNL, VS (vital signs) stable. Call placed out to hospice, POA (power of attorney) and (name of medical group) updated. Text messages sent to both ADON (Assistant Director of Nursing) and DON (director of Nursing). Offers no c/o (complaints of) pain or discomfort. Writer (sic) was notified by CNA that resident was found sitting upright on the floor in room in front of bed. Mental status: oriented to person, oriented to situation. Injury type: No injuries observed post incident. Predisposing physical factors: none. Predisposing Physiological factors: checked is confusion, gait imbalance, impaired memory, weakness/fainted. Predisposing situational factors identified include other(describe). Other info (information) documents poor judgement. Statements taken indicate just the staff person creating the report. The section of the report to document vitals only documents a pulse of 78 and pain level of 0; other vitals have none entered. The report documents other weights and vitals current in this shift with no time specified. These vitals indicate R25's blood pressure was 150/92 and was flagged as a high blood pressure. Pulse was 100, blood sugar and height: non entered, O2 (oxygen sats (saturations): 98 on room air, 0 for pain level. Progress notes document: 10/13/24, 07:15: Nurse's Note: Note text: Resident had an unwitnessed fall during sift. Resident is alert and able to make needs known. No apparent injuries from fall, neuro checks negative, ROM WNL, VS stable. Call placed out to hospice, POA, and (name of medical provider) updated. Text messages sent to update both ADON and DON. Offers no c/o pain. 10/13/24, 16:36 (4:36 pm), note text: Resident is alert and oriented. She is not able to bear weight on her left foot following the fall. The right upper leg is swollen. She is reporting much pain in the leg. Morphine was administered for the pain. (Name of hospice group) triage nurse was notified. POA notified. They have decided that resident wait for a hospice nurse to assess her in 2 hrs. (hours) who will then decide if she needs mobile x ray. 10/13/24, 16:51 (4:51 pm) note text: Her blood pressure is also high. 10/13/24, 21:18 (9:18 pm) - hospice note - note text: Res found sitting at the side of her bed this morning at 0542. She has been demonstrating pain in her LLE (left lower extremity) per staff since then and has not been using her legs to self-propel her w/c. Upon arrival res is in the hallway with (family) She was given prn morphine for pain. She has no foot pedals because she propels with her feet. Her (name of POA) pulled the w/c backwards to her room as she was unable to keep her feet up. Res speech is difficult to understand which is normal per (POA family member). Writer discussed treatment options with them. They do not wish to send res to ER and have no intentions on pursuing aggressive treatment should there be a fracture, but they still want x-rays done. They are in agreement to have mobile Xray come to the facility tomorrow. Staff assisted res into bed for assessment. Res able to lift her buttocks off the bed to remove her pants. Stated pain was minimal until writer attempted to have her raise her foot up and bend her knee toward her waist. She had facial grimacing and guarding. Limited ROM to LLE. Difficult to determine rotation or shortening as she has difficulty keeping her legs flat. No abnormalities palpated but there is swelling in her upper thigh and left hip. RLE (right lower extremity) no discomfort or ROM limitations. Spoke with (name of). She will update the NOC (nights) RN (Registered Nurse) when she come in and they will monitor pain and use prn morphine as needed. SN (shift nurse) to call (name of family member) when x-ray results are available. 10/14/24, 06:39 - nurse's note - note text: F/U (follow up) UWF (unwitnessed fall) and right foot wound . neuro checks negative., slept through the night, no SOB (shortness of breath) or distress noted, minimal swelling noted to left hip, vss, denies pain or discomfort when asked. 10/14/24, 13:06 (1:06 pm) - nurse's note - note text: F/U UWF: Res assessed earlier in shift by writer: Alert and c/o pain to L (left) hip/leg area. Unable to move L leg. Writer called x-ray and inquired about if x-ray results for L-hip/femur leg were complete. X-ray stated not ordered. Writer ordered STAT x-ray to L-hip, L-femur, L-knee, LLE, & foot DX (diagnosis) f/u fall, pain & swelling to area. Res was medicated with 20 mg (milligrams) of MS (morphine sulfate). (Name of medical group) APNP (Advanced Practice Nurse Practitioner) (name of) here and aware. X-ray obtained and showed L-femur intertrochanteric FX (fracture). (Name of hospice group/name of staff) called and updated. (Name of staff) stated she will update hospice MD and POA and report possible orders to writer . R25 was non weight bearing post fracture. Surveyor noted the fall information for R25's 10/13/24 fall does not include a root cause analysis or details to show what R25 was doing prior to the fall. Surveyor noted the fall on 8/24/24 included many of the same identified predisposing physiological factors that contribute to R25 falling but were not assessed further or addressed to help prevent R25's 10/13/24 fall. The fall intervention dated 8/26/24 is for staff to offer assistance to R25 to get up from bed. The fall details do not indicate if this was offered to R25 or what staff were doing regarding supervision to be able to implement this intervention when R25 wanted to get up from bed. R25 fell on [DATE] with the unwitnessed fall report documenting a time of 15:30 (3:30 pm). Incident description documents: Resident was found by writer on the floor next to wheelchair lying on her back, resident was assessed, no noted injuries, alert and awake. A&O (alert & oriented) to self. 139/89, 100, 97.6, 16 RR (respirations), 94% and resident stated she has no pain. Resident stated she was trying to get in bed, no call light on, and resident was dry. Resident had on one gripper sock on left foot right foot open to air. DON updated at 3:40 pm. Hospice on call nurse called at 3:51 pm (name of) no new orders await call back on 1/21/24 for regular hospice nurse. POA (name of) called and updated at 3:35 pm. Immediate action taken assessed for pain/injuries, called hospice with updates, vitals checked. No injuries noted at time of incident. Mobility is identified as wheelchair bound. Mental status is oriented to person. No predisposing environmental factors identified. Predisposing physiological factors documented include confusion, gait imbalance, impaired memory, and weakness/fainting. Surveyor noted these are the same predisposing physiological factors identified on R25's last two previous falls. Predisposing situation factors documents: none along with improper footwear, ambulating without assist. Notes within the unwitnessed fall report include details as documented in the description. Added documentation includes Intervention: Assist resident with getting into bed. Surveyor noted R25 has a previous intervention to offer assistance with getting up from bed. Both interventions do not include what the level of supervision should be to ensure this intervention is implemented as R25 has not demonstrated use of the call light during previous falls and R25 has a known history of self-transferring. Surveyor noted this fall is 7 days post R25's last fall with a resulting hip fracture and non-weight bearing status. Review of R25's actual fall care plan does not include this identified intervention as being added to the plan of care. Review of the fall data collection tool dated 10/24/24 documents for the question what should we do to try to decrease the incident of another fall or at least prevent an injury? Educate is documented by staff. There is no indication R25 was educated about her risks related falling. Surveyor noted R25 has a BIMs of a 2 and staff document R25 is only oriented to herself. R25's Significant Change MDS (Minimum Data Set) assessment dated [DATE] indicated R25 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 2 and required extensive assistance with bed mobility and transfers. On 10/25/24 at 11:45 am R25 had another unwitnessed fall. The incident description documents: Res found by (name of housekeeper) lying on the floor of her bathroom. Res states she was trying to get on the toilet. Neuro check negative. VSS. Resident denied LOC (loss of consciousness). Denied pain/discomfort. Assisted from floor to w/c with assist of 2 and gait belt NWB (non-weight bearing) maintained to LLE. Res wearing slippers. Intervention was to wear non-skid socks. DON CM (case manager) updated on above. (Name of hospice) case manager (name of) called by writer and updated on above. (Name of CM) stated that she will update the family and MD on above. (Name of CM) stated that she will come to the facility for a res visit also stated she will order gripper socks for her. Residential (sic) stated she wanted to use the toilet. Immediate action taken documents: Resident unable to sit on toilet. Incontinent care was given. Non-skid slippers also. (sic) initiated. Resident also monitored in a supervised area. Mental status indicates R25 was oriented to person, situation and place at the time of the fall. No injuries observed post fall. Predisposing environmental factors checks other (describe) no description of the environmental factor is documented. Predisposing physiological factors documented is incontinent. Predisposing situation factors identified are improper footwear and other with other info documented as unable to self-transfer. A note dated 10/25/24 in the unwitnessed fall report documents details as above however it also documents Intervention: Assist resident with toileting/toileting schedule. Surveyor review of R25's care plan does not include the referenced interventions of non-skid footwear, monitor in a supervised area and assist with toileting were not added to R25's care plan. Surveyor noted the intervention to monitor n a supervised area is the first reference to supervision for R25 despite multiple falls. Surveyor also noted the intervention for R25 to be on a toileting program had been a previous intervention that was resolved on 6/27/24. The post fall data collection tool dated 10/25/24 documents R25 had a last wellness check at 9:45 am and was last toileted at 10:00 am. The fall occurred at 11:5 am. The answer to the question of what we should do to try to decrease the incident of another fall or at least prevent injury documents non-skid footwear. A 10/28/24 23:28 (11:28 pm) unwitnessed fall report documents for incident description: Resident found lying on the floor on her back in her room. She stated she was trying to get up and fell off of the chair. Resident stated she hit the top of her head on the floor. Swelling noted, but resident denies any pain. Assisted to bed by Hoyer lift. Hospice updated; hospice nurse visited the resident. She stated she should just be monitored . Immediate action taken documents: Assisted to bed by Hoyer lift. Hospice updated; hospice nurse visited the resident. She stated resident should just e monitored. R25's mental status at the time of the fall is oriented to person and place. No injuries noted post incident. No predisposing environmental factors are identified. Predisposing physiological factors include confusion, gait imbalance, impaired memory, none, weakness/fainting. Predisposing situation factors include ambulating without assist. A note dated 10/28/24 in the unwitnessed fall report documents details as above. The note includes an intervention: For no apparent reason acute injury, determine and address causative factors of the fall. Additional note dated 10/29/24: IDT (interdisciplinary team) review: bed in the lowest position. Continue current interventions. Continue Q (every) 2-hour checks for safety. Surveyor noted this was documented by Nursing Home Administrator (NHA)-A. Surveyor noted this is the first reference to R25 receiving supervision every 2 hours. Surveyor noted having R25's bed in the lowest position is not included as an intervention on R25's care plan. The post fall data collection tool dated 10/28/24 documents the time of the fall as being 22:00 (10:00 pm). For the question was there anything different about the resident prior to the fall (change in transfer status, ambulation status, cognitive status)? No is documented. However, checked is gait, cognitive, and decrease in transfer or ambulate from baseline. The data tool documents the last wellness check as being at 21:30 (9:30 pm). Last time the resident was toileted is blank. R25 was continent. Why do you think the resident fell ? Staff document she was trying to walk. The question what should we do to try to decrease the incident of another fall or at least prevent injury? Documented is Resident should be encouraged to call for help. Surveyor noted the call lights was not activated by R25 for this fall as it was also not activated in previous falls. Surveyor also noted R25 has an extreme cognitive impairment. A progress note dated 10/28/24 documents received a message from (initials of staff) that pt (patient) had a fall out of w/c in her room near doorway. Unwitnessed. At approximately 2000 (8:00 pm) and pt states she hit her head, arrived to pts room. Pt restless, had gown off. Stated she needed to go to the bathroom. Pt placed on bedpan. Pt has bump to frontal area of head. Area soft and squishy. Redness noted. No bruising at the time of assessment. No other injuries noted during assessment. Ice applied. Recommend medicating pt prior to cares and movement. Facial grimacing noted with turning. Pt did deny pain . Will order scoop mattress, fall mat and broad (sic) chair per facility request. Surveyor noted these interventions were not added to R25's care plan that was presented to Surveyor during the survey. On 11/13/24 at 8:20 AM, 8:30 AM, 8:45 AM, 8:55 AM, 9:05 AM, 9:15 AM and 9:35 AM Surveyor observed R25's room door to be closed. Upon knocking and entering R25's room No staff were noted to be present and R25 was found to be unsupervised in her room with her door closed. Surveyor noted previous referenced intervention to monitor R25 in a supervised area was not being implemented. Surveyor also noted all of R25's falls occurred in R25's room when not supervised. On 11/14/24 at 10:10 AM, Surveyor conducted an interview with DON (Director of Nursing)-B. Surveyor asked DON-B if R25 is at risk for falls. DON-B responded that they do recall R25 falling and sustaining a fracture before. Surveyor asked DON-B if a resident who is at risk for falls should be unsupervised in their room with the door closed. DON-B told Surveyor that it would depend what the resident's care plan says. Surveyor asked if a resident with a fall investigation intervention to redirect and to use their call light would be appropriate for a resident who has a fall risk assessment score of 15 and a BIMS score of 2, indicating a severe cognitive impairment in addition to fall risk. DON-B responded that they would need to look into this further and let Surveyor know if they find more information. No additional information was supplied by DON-B for the remainder of the Survey. On 11/14/24 at 11:20 AM, Surveyor conducted an interview with NHA (Nursing Home Administrator)-A. Surveyor shared concerns related to R25's unwitnessed fall on 10/13/24 which led to a left femur fracture and current observations of R25 not receiving adequate supervision by staff in an effort to safeguard R25 from additional falls or accidents or concerns related to inappropriate fall interventions such as redirecting R25 to utilize her call light with her fall risk score of 15 in addition to a severe cognitive impairment as evidenced by a BIMS score or 02. The facility did not supply any additional information to Surveyor at this time. 38146 2.) R2 admitted to the facility on [DATE] and has diagnoses that include Peripheral Vascular Disease, Diabetes Mellitus with Diabetic Neuropathy, Spastic Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side, Hypertension, Fibromyalgia, Osteoarthritis, Anxiety Disorder, Depression, Anemia, Abdominal Aortic Aneurysm, Cardiac Pacemaker, Cellulitis of lower limb, R2's Admission MDS (Minimum Data Set) dated 9/2/24 documents a BIMS (Brief Interview for Mental Status) score of 14, indicating no cognitive impairment. Section GG0170 documents Mobility: Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed - Dependent. Toilet transfer: The ability to get on and off a toilet or commode - Dependent. R2's Care plan Focus area documents: Risk for falls r/t (related to) Deconditioning, Gait/balance problems, Incontinence - date initiated 5/23/23. Anticipate and meet the resident's needs - date initiated 5/23/23. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance - date initiated 5/23/23. Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility - date initiated 5/23/23. Fall intervention 6/2/23: PT (Physical Therapy)/OT (Occupational Therapy) eval - date initiated 9/1/23. Fall intervention for 5/27/24: Maintenance to audit all shower chairs for safety - date initiated 5/28/24. 10/21/24 Intervention: Carefully inspect sling and properly place on resident before use of Hoyer lift - date initiated 11/1/24. On 11/11/24 at 11:12 AM, during initial interview with R2, she reported having had 2 falls. R2 reported 1 fall occurred when she was going to the shower, she fell through the shower chair onto the ground. R2 stated, The whole seat let loose and I fell on the ground. R2 reported she could not remember the date, that it was maybe 5 months ago. R2 reported the 2nd fall was from the sit to stand. R2 reported the machine made a strange noise when she first got into it, she could not explain what it was and didn't say anything. R2 reported she was taken to the bathroom and when she was finished, the CNA (Certified Nursing Assistant) raised her up slightly so I was standing up more to clean me. She didn't have the seat belt strap around me. The strap on one side came off and I fell landing on my bottom, I felt like my back was jarred. R2 reported no other injuries and did not want to go to the hospital because it takes 6 hours to be seen. Surveyor review of R2's medical record revealed a facility progress note dated 5/27/24 at 9:30 PM which documented: Late Entry: Resident is alert and oriented, able to make needs known. The resident was sitting in a shower chair, going to take a shower. The chair got broken. Resident lowered to the floor by the Aide. Was able to move all extremities. Assessment done; no injury noted. Surveyor review of R2's medical record revealed a facility progress note dated 10/21/24 at 4:23 PM which documented: Resident had a fall in the bathroom during morning shift today at 11 am. Witness and resident informed nurse that she was being assisted at the bathroom when she started to slide off the 'Sit to Stand' Transfer and was safely lowered to the floor. Upon assessment, resident was found lying on her back. No lacerations, indentations, swelling or bleeding observed. Resident denied hitting the head on the ground. Alert and oriented times four. Moves all extremities without complains of pain or discomfort. Reported slight pain at the lower back. Resident declined going to the hospital for checkup and notification to family. She was assisted back to her wheelchair and is comfortably seated on her wheelchair. Neuro checks negative. On 11/12/24 at 9:07 AM, Surveyor asked DON (Director of Nursing)-B for R2's fall investigations and was provided the following: Fall Data Collection Tool - date of fall 10/21. Where did the fall happen? Residents bathroom. Being toileted. Why do you think the resident fell ? Lowered to the floor. What should we do to try to decrease the incident of another fall or at least prevent an injury? Carefully inspect sling. CNA statement: On 10/21/24 (resident) was lowered to the floor in the bathroom of residents bed room. After being lowered to the floor the resident was checked over by nurse. Resident had no injuries or skin issues. Resident was asked if she wanted to get sent out to the hospital and she stated no. Surveyor noted the fall investigation did not include an interview or statement from R2. R2 reported to Surveyor the seat belt strap was not around her and the strap on one side came off and she fell landing on her bottom. The fall investigation question of why do you think the resident fell documented lowered to the floor but did not indicate why R2 was lowered to the floor. The fall investigation question of what should we do to try to decrease the incident of another fall or at least prevent an injury documented Carefully inspect sling indicated there was a problem with the sling that contributed to the fall. Surveyor noted R2's care plan was updated with: Carefully inspect sling and properly place on resident before use of Hoyer lift - date initiated 11/1/24. Fall data collection tool - date of fall 5/27/24. Time of fall 9:30 PM. Where did the fall happen? At the resident door. The resident was in the shower chair while the aid was pushing the chair. Why did the resident fall? Maybe the resident weight or the chair was already broken. What should we do to try to decrease the incident of another fall or at least prevent an injury? Buy new chairs or inspect the chairs before use. CNA statement: Shower chair collapsed while trying to roll it to the shower room. Supported resident from behind with my arms underneath hers. I lowered her sliding her body down easy to the floor while supporting her head. Resident did not hit her head. I made sure she had a pillow under her head until the nurse arrived. The nurse and I then transferred her after assessment to flat bed and shower chair to proceed with shower. Surveyor noted the fall investigation did not include an interview or statement from R2. R2 reported to Surveyor that the whole seat let loose and she fell on the ground. The CNA statement indicated she lowered R2's sliding body down easy to the floor. The investigation did not include a determination if the shower chair is safe to use as a transport for residents from their room to the shower room. Surveyor noted R2's care plan was updated with: Maintenance to audit all shower chairs for safety - date initiated 5/28/24. On 11/12/24 at 12:12 PM, Surveyor asked CNA-L to accompany to the shower room. Surveyor observed 3 shower chairs and 1 reclining shower chair - all have wheels. Surveyor asked about R2. CNA-L stated, I know she had a shower last week. Surveyor asked which residents use the shower chairs. CNA-L stated, Anyone who can sit upright can get a shower. Surveyor pointed out that all the shower chairs have wheels. CNA-L stated, Yes, we take the shower chair to their room, transfer them onto it and then we wheel them down to the shower room. On 11/12/24 at 12:23 PM, Surveyor reviewed R2's fall investigations with NHA (Nursing Home Administrator)-A. Surveyor advised the fall investigations were not thorough to determine a root cause analysis. The fall on 10/21/24 documented R2 was lowered to the floor, however it was not clear as to what happened and why R2 was lowered to the floor. R2 reported to Surveyor she did not have the seat belt strap around her, the strap on one side came off and she fell landing on her bottom. The fall investigation did not include a statement from R2. The intervention was to carefully inspect the sling, indicating there was a problem with the sling that contributed to the fall. There was no evidence all slings were inspected or education was provided to all staff regarding safe transfer from the stand up lift. The fall on 5/27/24 documented the shower chair collapsed while trying to roll it to the shower room and the resident was lowered easy to the floor. R2 Resident reported to surveyor the seat let loose and she fell to the floor landing on her buttocks. The fall investigation did not include a statement from R2. There was no evidence the chairs were inspected or determined they are safe to be used as transport for distance to shower room. On 11/12/24 at 1:11 PM, NHA-A provided risk management forms that documented: 5/27 sitting in shower chair going to take a shower. The chair got broken. Resident lowered to floor by the aide. Resident was unable to give description. Notes: Maintenance to audit all shower chairs for safety. Surveyor located no evidence all shower chairs were audited for safety. 10/21 Resident had fall around 11 am. Resident reports that she was being assisted to the bathroom when she started sliding from sit to stand transfer and was safely lowered to the floor by witness. Intervention: Carefully inspect sling and properly place on resident before use of Hoyer lift. Surveyor located no evidence all slings were inspected or staff were educated and audits completed with staff on safe transfers using the sit to stand. On 11/12/24 at 1:51 PM, Surveyor asked Facility Services Manager-I if he has done audits on all shower chairs within the last 6 months. Facility Services Manager-I stated, No. About a month ago I got a slip asking me to take a look at one that wasn't rolling properly. Surveyor asked if he was aware of any shower chairs that were broken or involved in a fall. Facility Services Manager-I stated, No. There was one that was broken awhile ago, the back wasn't reclining or staying up, we ended up throwing it out. Facility Services Manager reported he is not aware of any shower chair involved in a fall. Surveyor asked if he had any information regarding the manufacturer recommendations regarding the shower chair, if it can or should be used for transport. Facility Services Manager-I stated, I would say that it shouldn't, it's not a wheelc [TRUNCATED]

Based on observation, record review and interview, the facility did not implement infection control measures. This was observed with 2 (R41 and R38) of 2 residents with glucometer's. The facility did not conduct an infection control program to prevent, and track, potential infections. This had the potential to effect all 43 residents in the facility. * R41 and R38 received blood sugar through a unsanitized glucometer machine. * The facility did not transport linens under sanitary conditions. * The facility did not implement and document Legionella control measures. * The facility did not track staff who can utilize a N95 mask during an outbreak. * The facility did not calculate infections to determine trends for preventative interventions. * The facility did not document surveillance of infections to identify concerns. Findings include: The facility's policy and procedure Infection Control, dated 9/20/2023. The procedure under surveillance states: Properly store, handle, process, and transport linens to minimize contamination.; Perform surveillance and investigation to prevent, to the extent possible, the onset and the spread of infection.; Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. LAUNDRY 1.) On 11/13/24, at 9:21 AM, Surveyor observed Laundry Staff (LS)-S delivering clothes to residents on the 2nd floor. Surveyor observed there was no cover over the clothes rack in the hallway. The clothes were delivered by LS-S to rooms as the clothes rack was stationary in the hallway uncovered. Surveyor interviewed LS-S about clothing delivery. LS-S stated they have been working in Laundry for a year and has never seen a cover for the cart. On 11/13/24, at 9:49 AM, Surveyor interviewed Laundry Supervisor (LS)-T, along with observing the facility Laundry areas. LS-T did not have any covers for the clothing racks and was not aware of using them. WATER MANAGEMENT During review of the Facility Assessment, dated 7/31/24, Surveyors noted the facility assessment does not identify who makes up the Water Management Committee for the facility and how the facility addresses the possibility of Legionella. (Cross-reference F838). Surveyor reviewed the Facility's Water Management Plan. The facility identifies the following control measures to prevent Legionella: - ice machine cleaning every 3 months. - circulation pumps checked for functioning weekly. - water heaters monitor weekly. - unoccupied resident rooms - run faucet. Surveyor requested documentation to review how these control measures were being carried out. On 11/13/24, at 1:50 PM. Maintenance Director (MD)-I provided an invoice for cleaning the ice machine. Review of the provided ice machine invoice does not indicate what was completed during the cleaning. MD-I does not have documentation of water boiler temperatures. Surveyor reviewed the documentation for control measures from the facility plan with MD-I. MD-I only has the ice machine contractor service report. MD-I showed Surveyor a blank form for unoccupied resident room checks. MD-I was able to show documentation for the circulating pumps. However, the documentation is for oiling the circulation pumps every 2 months versus showing they are checked weekly for functioning. On 11/13/24, at 2:27 PM, MD-I provided Surveyor 1 form for running the faucet in an unoccupied resident room. The last entry was from 1/2/2024. MD-I did not have any additional documentation. There is no water heater temperature documentation. It was noted there is no documentation indicating the control measures per the facility water management plan, are being carried out as planned. On 11/13/24, at 2:40 PM, MD-I spoke with Surveyor. MD-I stated the Ice Machine company does the checklist attached to the invoice. However, the checklist is blank. The ice machine invoice just indicates preventative maintenance. There is no documentation of what was performed with the facility ice machines to prevent Legionella. OUTBREAK N95 MASK On 11/13/24, at 1:14 PM, Surveyor interviewed the (Infection Preventionist) IP-B and (Nurse Consultant) NC-C. IP-B has been in this role since August 2024. NC-C stated the Nurse Educator for the facilities comes in annually to do staff fit-testing. NC-C provided a binder with staff names and types of mask. There are no dates documented, nor does the list identify if these are current staff or not. NC-C stated they will look for more information regarding how they complete/maintain staff being fit tested in preparation of an outbreak. On 11/13/24, at 2:46 PM, NC-C spoke with Surveyor. NC-C was unable to provide a current list of staff that are N95 fit tested . NC-C could only locate a staff list from 2021. SURVEILLANCE/TRACKING/TRENDS On 11/13/24, at 1:14 PM, Surveyor interviewed, IP-B and NC-C, and reviewed the facility's Infection Control program. The surveillance tracking documentation does not have consistent data, nor current infections in the facility. The surveillance/tracking forms are not documented per infection to help identify trends in infections/infection activity in the facility. It was identified the facility utilizes McGeer's criteria for their definitions of infections. IP-B indicated they do utilize this criteria if a resident is admitted from the hospital on an antibiotic. IP-B shared they do not document when isolation is required, or the type of organism of the infection to identify training and preventative measures. IP-B shared the facility floor nurses will call IP-B with any newly ordered antibiotic or symptoms. IP-B also reviews the Electronic Record Monitoring daily as part of infection prevention and control. IP-B stated they also review the infection details monthly with Quality Assurance and Improvement Plan (QAPI) meetings. On 11/14/24, at 8:41 AM, IP-B spoke with spoke with Surveyor. IP-B queried the process to calculate baseline infection rates. IP-B showed Surveyor the formula to calculate baseline infection rates. Surveyor noted IP-B is calculating by the group of all infections in a month and that IP-B is not calculating infections individually and by census days to determine trends. The IP-B stated moving forward, they will calculate infection rates per infection and census days. 38146 Glucometer Sanitization On 11/12/24 at 7:36 AM, Surveyor observed RN (Registered Nurse)-O prepare to do blood sugar testing for R38. RN-O removed a glucometer, alcohol wipes, bottle of strips and a lancet from the left pocket of her scrub uniform. RN-O applied gloves, wiped R38's finger with an alcohol wipe, poked her finger and obtained a blood sample using the glucometer. RN-O wiped R38's finger with a tissue and discarded the lancet in the garbage can. RN-O walked back to the medication cart, placed the glucometer on top of the cart (without a barrier), removed her gloves, sanitized her hands and proceeded to prepare R38's medications. After administering R38's medications, RN-O walked back to the medication cart, picked up the glucometer and placed it in her left scrub pocket. Surveyor noted the glucometer was not cleaned after obtaining R38's blood sugar. Surveyor continued to observed RN-O during medication pass. On 11/12/24 at 8:07 AM, Surveyor observed RN-O prepare to do blood sugar testing for R41. RN-O removed the glucometer and supplies from her left scrub pocket, entered R41's room, sanitized her hands and applied gloves. RN-O wiped R41's finger with an alcohol wipe, poked his finger and obtained a blood sample using the glucometer. After obtaining R41's blood sugar, RN-O placed the glucometer in the left pocket of her scrubs, removed her gloves and sanitized her hands. On 11/12/24 at 8:18 AM, Surveyor asked RN-O if residents have their own glucometer's or if they are shared between residents. RN-O stated, They share, we have two. RN-O opened the drawer of the medication cart revealing an empty black pouch. RN-O stated, The other one must be on the treatment cart. Surveyor confirmed RN-O used the observed glucometer to test blood sugars for both R38 and R41. Surveyor asked what is used to clean the glucometer. RN-O stated, Either alcohol wipes or a sanitizing wipe, we have a container. RN-O looked on, and in the medication cart, but did not locate a container of sanitizing wipes. RN-O stated, It must be on the treatment cart. On 11/12/24 at 9:07 AM, Surveyor advised DON (Director of Nursing)-B of observation the shared glucometer used on the first floor was not cleaned between residents' use. Surveyor asked for a list of residents on the first floor that require blood sugar testing and the policy and procedure on glucometer cleaning. Surveyor reviewed diagnoses of residents that utilize the shared glucometer on the first floor. There were no residents (including R38 and R41) with communicable disease. On 11/12/24 at 11:04 AM, Clinical Development Coordinator-D advised Surveyor the facility does not have a policy and procedure on glucometer cleaning. Surveyor asked what is the expectation for cleaning of the glucometer. Clinical Development Coordinator-D reported the expectation is staff would use the Sani cloth wipes (with the purple top), adding Alcohol wipes are not effective for cleaning glucometer's. Education has been provided to all staff. No additional information was provided. 50700

Based on record review and interview, the facility did not conduct and document a facility-wide assessment. The assessment did not include the hours allocated for the (Infection Preventionist) IP, the Water Management Committee, infectious diseases, and staffing ratios. This had the potential to affect all 43 residents currently in the facility. Findings include: Surveyor reviewed the Facility assessment dated [DATE]. The staffing in the facility is not documented for shift ratios breakdown. This would assess the resident care levels and the staff needed to implement the care. Director of Nurses (DON)-B is also the facility IP and the time allocated to each role is not assessed. The facility's Water Management Committee is not documented in the assessment. The potential infection organisms such as Covid, influenza, Legionella, etc. are not assessed. CROSS REFERENCE F880 and F725. On 11/13/24 at 12:24 PM, Surveyor interviewed the Nursing Home Administrator (NHA)-A and reviewed the Facility Assessment. NHA-A stated, the DON role is combined with the IP role as one. The water management and infections are reviewed with QAPI. NHA-A stated, They are focusing on other things in the facility right now and not the Facility Assessment. On 11/14/24 at 08:02 AM, NHA-A provided Surveyor with a revised facility assessment dated [DATE]. The revised highlighted section included, The Director of Nursing currently serves as the Infection Preventionist above and beyond her role and DON. She dedicates time needed for (Infection Preventionist Control Program) IPCP as needed. We follow the Water management plan outlined in the Emergency Preparedness Plan for compliance. As a part of the IPCP we monitor for all types of potential infections including COVID, Influenza, respiratory syncytial virus (RSV), methicillin-resistant staphylococcus aureus (MRSA,) and Legionella to name a few.

4.) R3 was admitted to the facility on [DATE] with diagnosis that include Dementia, Type 2 Diabetes. Alcoholic cirrhosis of the liver, chronic kidney disease with heart failure, and Pulmonary edema. R3's progress note dated 3/3/2024 at 11:19 PM documents: swelling noted to abdomen, hips, legs, and feet. 5+ pitting edema noted. resident was asymptomatic and vital[s] within normal range. family requested for resident to be sent out to hospital. resident left to [Local hospital] at [7 PM] for further evaluation. R3 was admitted to the hospital from [DATE] through 3/6/24 with acute hepatic encephalopathy. Surveyor reviewed R3's medical record and was unable to locate evidence of a transfer notice provided to R3. On 11/13/24 at 10:38 AM, Surveyor asked Nursing Home Administrator (NHA)-A for evidence that a transfer notice was provided to R3. NHA-A stated that NHA-A would get the transfer notice. At 11/13/24 at 11:08 AM , NHA-A informed surveyor that NHA-A did not think the facility had a transfer notice for R3. NHA-A asked Surveyor if Surveyor was looking for a bed hold? Surveyor said no, Surveyor is looking for written notification of transfer when R3 was sent to the hospital. NHA-A stated, we will look for that. On 11/13/24 at 2:44 PM, Surveyor informed Director of Nursing (DON)-B, NHA-A, and Clinical Nurse Coordinator (CNC)-C of the concern that R3 was not provided a written transfer notice when R3 was sent to the hospital on 3/4/24. No further information was provided as to why R3 was not given a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. 5.) R5 was admitted to the facility on [DATE] with diagnosis that include Chronic Kidney disease, Type 2 Diabetes, Dementia, Stroke history, Encephalopathy and Adult Failure to Thrive. R5's progress note dated 9/24/2024 at 3:33 PM, documents: Resident was transferred to [Local] hospital today via ambulance accompanied by EMT due to lethargy, poor appetite, and critical labs. The [Assistant Director of Nursing] and family updated. R5 was admitted to the hospital from [DATE] through 10/2/24 with severe sepsis in setting of bilateral parotitis. Surveyor reviewed R5's medical record and was unable to locate evidence of a transfer notice provided to R5. On 11/13/24 at 10:38 AM, Surveyor asked Nursing Home Administrator (NHA)-A for evidence that a transfer notice was provided to R5. NHA-A stated that NHA-A would get the transfer notice. At 11/13/24 at 11:08 AM , NHA-A informed surveyor that NHA-A did not think the facility had a transfer notice for R5. NHA-A asked Surveyor if Surveyor was looking for a bed hold? Surveyor said no, Surveyor is looking for written notification of transfer when R5 was sent to the hospital. NHA-A stated, we will look for that. On 11/13/24 at 2:44 PM, Surveyor informed Director of Nursing (DON)-B, NHA-A, and Clinical Nurse Coordinator (CNC)-C of the concern that R5 was not provided a written transfer notice when R5 was sent to the hospital on 9/24/24. No further information was provided as to why R5 was not given a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. 6.) R28 was admitted to the facility on [DATE] with diagnosis that include Hemiplegia, Hemiparesis, Type 2 Diabetes, Chronic Kidney disease, disease with heart failure, Muscle weakness, and Depression. R28's progress note dated 6/7/2024 at 9:16 PM documents, in part: Resident is alert and oriented with confusion. Did not eat breakfast, lunch, or dinner. Writer tried to feed the resident, but she could not swallow. Resident became more restless, more slurred speech also noted . Writer updated the [Nurse practitioner (NP)] on call . The NP stated the resident is to be sent to hospital. The resident transferred to [Local] hospital at [9 PM]. The [Assistant Director of Nursing] updated, message left for resident's [Power of Attorney] to call facility for update. R28 was admitted to the hospital from [DATE] through 6/13/24 with Encephalopathy. Surveyor reviewed R28's medical record and was unable to locate evidence of a transfer notice provided to R28. On 11/13/24 at 10:38 AM, Surveyor asked Nursing Home Administrator (NHA)-A for evidence that a transfer notice was provided to R28. NHA-A stated that NHA-A would get the transfer notice. At 11/13/24 at 11:08 AM , NHA-A informed surveyor that NHA-A did not think the facility had a transfer notice for R28. NHA-A asked Surveyor if Surveyor was looking for a bed hold? Surveyor said no, Surveyor is looking for written notification of transfer when R28 was sent to the hospital. NHA-A stated, we will look for that. On 11/13/24 at 2:44 PM, Surveyor informed Director of Nursing (DON)-B, NHA-A, and Clinical Nurse Coordinator (CNC)-C of the concern that R28 was not provided a written transfer notice when R28 was sent to the hospital on 6/7/24. No further information was provided as to why R28 was not given a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. Based on interview and record review, the facility did not ensure 6 (R3, R5, R16, R22, R28, R38) of 6 residents reviewed that required hospitalizations were given written reason for transfer to the hospital and the facility did not send this notification to the Ombudsman. R3 was transferred to the hospital on 3/3/24 for a change in condition. R3 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R5 was transferred to the hospital on 9/24/24 for a change in condition. R5 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R16 was transferred to the hospital on 7/30/24 for a change in condition. R16 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R22 was transferred to the hospital on 7/30/24 for a change in condition R22 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R28 was transferred to the hospital on 6/7/24 for a change in condition. R28 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R38 was transferred to the hospital on [DATE] for a change in condition. R38 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. Findings include: 1.) R16's medical record indicates, R16 transferred to the hospital on 7/30/24 due to a change in condition. 2.) R38's medical record indicates, R38 transferred to the hospital on [DATE] due to a change in condition. On 11/12/24, at 1:19 PM, Surveyor interviewed Social Services- Q who indicates she is not responsible for written notification of transfer and notification to the Ombudsman. Social Services- Q states Referral Specialist- M is responsible for written notification of transfer and notification to the Ombudsman. On 11/12/24, at 1:22 PM, Surveyor interviewed Referral Specialist- M who stated she is only responsible for bed holds and does not take care of the written notification of transfer and notification to the Ombudsman. Surveyor asked Referral Specialist- M who is responsible for the written notification of transfer and the notification to the Ombudsman. Referral Specialist- M states the staff on the floor take care of the transfer notice form. On 11/12/24, at 3:33 PM, Surveyor asked Nursing Home Administrator (NHA)- A, who is responsible for the written notification of transfer forms and notification to the Ombudsman. NHA- A indicated Social Services- Q is responsible for the written notification of transfer forms and notification to the Ombudsman. Surveyor notified NHA- A, Social Services- Q states she is not responsible and Social Services- Q directed Surveyor to speak with Referral Specialist- M. Surveyor notified NHA- A that Referral Specialist- M states she is not responsible and directed Surveyor to floor staff who complete the written notification of transfer forms along with notification to the Ombudsman. NHA- A indicates Referral Specialist- M verifies the written notification of transfer forms however, NHA- A then stated ideally the facility would have nursing floor staff complete the written notification of transfer forms along with notification to the Ombudsman and management would verify completion of this task. Surveyor requested a copy of the facility's policy and procedure for the written notification of transfer forms and notification to the Ombudsman. Surveyor notified NHA- A of concerns with R16 and R38 not having written notification of transfer forms along with no notification to the Ombudsman. Survey requested additional information if available. None was received. 3.) R22 admitted to the facility on [DATE] and has diagnoses that include Diabetes Mellitus Type 2 with Chronic Kidney Disease, Atrial Fibrillation, Venous Insufficiency, Depression, Hypothyroidism, Urine Retention, Congestive Heart Failure, Peripheral Vascular Disease, Anemia, Acquired absence of left leg below knee and Atherosclerotic Heart Disease. R22 was hospitalized on [DATE]. Facility progress notes document: 7/30/24 at 9:05 AM: Called to Res (residents) room by CNA (Certified Nursing Assistant) stating that Res. had a large amount of blood on his diaper and around his penis. Catheter bag was full of [NAME] blood,100 cc (cubic centimeters). Blood in catheter tubing. No movement of blood in tubing. Resident A&O (alert and oriented) X 3. Denies pain/discomfort. Abdomen soft & non-distended. Incontinent of a large amount of SF (soft formed) stool. T (temperature) 98.6 p (pulse) 60 R (respirations) 16 B.P, (blood pressure) 90/40 checked X 2. Receives Eliquis 5 mg (milligrams). Call placed to NP (Nurse Practitioner) to update. Bell ambulance called to transport to (hospital) ER (emergency room) R/T (related to) bleeding in catheter and around penis, Foley not patent and low B.P. Attempted to call POA (Power of Attorney) and message left to call writer for update on above. Surveyor noted R22 was subsequently admitted to the hospital for acute on chronic hematuria and Leukocytosis from urinary obstruction. Surveyor located no evidence a transfer notice was provided to the resident or resident's representative. The facility advised Surveyor a transfer notice was not provided. On 11/13/24 at 3:00 PM, the facility was advised of concern a transfer notice was not provided to R22 or his representative related to his 7/20/24 hospitalization. No additional information was provided.

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (R20) was free from abuse. The facility did not ensure R20 was free from an alleged sexual abuse by a visitor. On 7/21/23, Certified Nursing Assistant (CNA-D), observed visitor (I) inappropriately touching R20 with his hand between R20's legs and on R20's vagina. CNA-D did not immediately report this allegation of abuse. Visitor (I) remained in the facility and was later observed in R20's room with the lights off and with his hand under the covers while R20 was in bed. CNA-D did not report the observations of alleged sexual abuse until 7/24/23, allowing visitor (I) to visit R20 one more time (on 7/23/23) before being reported. The facility did not protect R20 from further potential sexual abuse. The facility's failure to keep R20 free from sexual abuse created a finding of Immediate Jeopardy, which began on 7/21/23. On 8/9/23, at 3:42 PM, Nursing Home Administrator (NHA)-A, and Director of Nursing (DON)-B were informed of the Immediate Jeopardy. The immediate jeopardy was removed on 8/14/23. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor its action plan. Findings Include: Surveyor reviewed the facility's Policy and Procedure on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last revised 12/1/22. .Procedure A. Individuals will be protected from abuse, neglect, and harm while they are residing at the facility. B. No abuse or harm of any type will be tolerated. C. Individuals and staff will be monitored for protection. D. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. E. The facility will encourage and support all individuals, staff, families, visitors, volunteers, and individual representatives in reporting any suspected acts of abuse to the Administrator or designee. F. The Administrator or designee will report abuse to the state agency per State and Federal guidelines. G. The facility will follow the attached comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program to comply with the seven step approach to abuse and neglect detection and prevention. H. The abuse policy and comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program will be reviewed on at least an annual basis and will be integrated into the facility quality assurance and performance improvement program. Overview of Seven components -Screening -Training -Prevention -Identification -Investigation -Protection -Reporting and Response Training Components It is the policy of this facility to train employees, through orientation and on-going sessions on issues related to abuse and prohibition practices. Prevention It is the policy of this facility to prevent abuse by providing Residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without the fear of reprisal or retribution. The facility leadership will assess the needs of the Residents in the facility to be able to identify concerns in order to prevent potential abuse. Procedure: 1. Resident Assessment Every Resident is unique and may be subject to abuse based on a variety of circumstances, including physical Program, environment, the Resident's health, behavior, or cognitive level. b. Upon admission and periodically after that, each Resident will have a comprehensive assessment completed which identifies potential vulnerabilities such as cognitive, physical, psychosocial, environment and communication concerns. c. The interdisciplinary team(IDT) will identify the vulnerabilities and interventions on the Resident care program. 2. Supervision of Staff Staff will be supervised to identify inappropriate behaviors while caring for or in attendance with Residents. Identification It is the policy of this facility that all staff monitor Residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns, and trends that may constitute abuse will be investigated. Investigation It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's QAPI Incident Report and Investigation process. Additional Investigation Protocols -Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to law enforcement to be investigated. Protection It is the policy of this facility that the Resident(s) will be protected from the alleged offender. Procedure: Immediately upon receiving a report of alleged abuse, Administrator (NHA-A) and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable Resident are of utmost priority. Safety, security, and support of the Resident, roommate, if applicable and other Residents with the potential to be affected will be provided. i. The alleged perpetrator will immediately be removed and Resident protected. ii. If a family member or Resident representative is possibly contributing to the potential abuse and the Resident could be at risk, evaluate the situation and identify options to put into place for Resident protection. iv. Examine, assess and interview the Resident and other Residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. Notify Resident physician. v. Life Coach or designee should keep in frequent contact with the Resident and/or Resident representative. vii. Notification of law enforcement and/or State Agency viii. A medical, evidentiary, or sexual assault exam should be completed as possible, as appropriate . R20 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dysphagia, Adult Failure to Thrive, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, and Cognitive Communication Deficit. R20 has an activated Health Care Power of Attorney (HCPOA). R20's Admission Minimum Data Set (MDS) dated [DATE] documents R20's Brief Interview for Mental Stats (BIMS) score to be 11, indicating R20 demonstrates moderately impaired skills for daily decision making. R20 has no behaviors and R20's PHQ-9 score is 6, indicating R20 has minimal depression. R20's MDS also documents that R20 requires extensive assistance of one for bed mobility, transfers, dressing, and toileting. R20 requires supervision for eating. R20 has both upper and lower range of motion impairment on one side. R20 was admitted to the hospital from home due to falls. On 8/8/23 at 3:34 PM, Surveyor was able to obtain information on R20 from Hospital Social Worker (HSW-L). Prior to admission to the facility, R20 had been living with a family member who was R20's primary caregiver. A home health care agency was going into the home, however, staff would not go back because the family member was restricting visits, and R20 was left in the same clothes for several weeks in a row, not being bathed, and not receiving incontinence care. The appropriate agencies were notified of these concerns. On 8/9/23 at 9:15 AM, HSW-M was interviewed and communicated that there were allegations of physical abuse of R20 due to bruises; further, the activated HCPOA did not want R20 to return living in the home. R20's Case Manager (CM-N) on 8/8/23 at 12:31 PM, informed Surveyor that CM-N was informed that CM-N's initial intake documents that R20's family member was abusing R20 in the home. Surveyor reviewed R20's hospital paperwork dated 5/5/23 which indicates R20 appeared weak and frail looking. There is no documented social history obtained by the facility, and/or no background information. On 8/8/23 at 11:46 AM, Surveyor asked NHA-A if a social history should have been obtained on R20. NHA-A confirmed that would be the expectation that information should have been gathered at the time of admission. Surveyor notes there was a trauma assessment completed on admission for R20, but nothing was noted on the trauma assessment except R20 would be upset if family members were to die. The facility had no prior information about visitor (I), another relative of R20. R20 had no care plan implemented for mild depression at time of admission. R20 has impaired cognitive function/dementia or impaired thought process due to dementia care plan implemented on 5/8/23. Interventions initiated on 5/8/23 include ask yes or no questions in order to determine the Resident's needs and communicate with Resident/family/caregivers regarding R20's capabilities and needs. On 7/12/23, R20 was moved from the first floor rehabilitation unit to the long-term care unit on the 2nd floor. On 8/9/23 at 10:49 AM, CNA-WW informed Surveyor that the rehabilitation unit is quiet while the second floor can be more busy and chaotic at times. CNA-WW stated it can be hard to monitor visitors on the second floor. On 8/8/23 at 11:25 AM, Surveyor interviewed CNA-D in regard to the alleged allegation of sexual abuse and then spoke with CNA-D again on 8/8/23 at 2:18 PM. CNA-D reported the following; On 07/21/23, R20 was eating in the dining room as per R20's usual and R20's visitor (I) was sitting with R20 at the table. At some point, the visitor (I) informed staff that R20 needed to be toileted and offered to assist. CNA-D stated CNA-D thought that was unusual because R20 had not indicated to staff that R20 needed to be toileted as R20's usual routine was to alert staff. CNA-D became busy with transferring Residents out of the dining room and providing cares. At approximately 7:20 PM, CNA-D heard noise in R20's bathroom, entered the bathroom, and found R20 sitting on the toilet in a nightgown and observed the visitor's (I) hand between R20's legs and on R20's vagina. CNA-D's statement included that the visitor (I) had changed R20 out of R20's clothes. Surveyor asked CNA-D if the visitor (I) had a wipe or toilet paper in their hand and CNA-D said no. CNA-D felt visitor (I) was clearly inappropriately sexually touching R20 and told Surveyor that their hand was on R20's vagina. CNA-D asked the visitor (I) what they were doing and they said, I brought R20 to the bathroom. CNA-D informed the visitor (I) CNA-D would take care of R20 and asked the visitor (I) to leave the bathroom. CNA-D completed cares and then put R20 to bed. Another CNA entered the room with R20's roommate and the CNAs asked the visitor (I) to leave the room so they could put the roommate to bed. The visitor (I) remained in the hallway outside R20's door. At this point, CNA-D had not reported the alleged sexual abuse observed in the bathroom, the police were not contacted, and the visitor (I) remained in the facility. Although the facility may not have foreseen that the incident between R20 and Visitor (I) would occur, the facility now had knowledge that it needed to protect R20 from further potential abuse. This did not occur. The CNAs exited the room and the visitor (I) went back into the room. CNA-D returned about 5-6 minutes later and thought it was unusual that the lights were out in R20's room. CNA-D entered the room, turned the lights on, and saw the visitor's (I) hand under R20's covers. CNA-D stated visitor (I) jerked their hand from under the covers as if startled. CNA-D observed visitor (I) begin walking to the elevator. Visitor (I) then returned to the room to retrieve a bag and left the room. CNA-D is uncertain at what point visitor (I) left the facility. CNA-D stated that CNA-D informed the nurse of the allegation of abuse that evening prior to the end of her shift on 7/21/23. On 8/9/23 at 11:24 AM, Surveyor interviewed Licensed Practical Nurse (LPN-C) who denies ever being made aware of the allegation of abuse. LPN-C reiterated had LPN-C been made aware of the incidents, LPN-C would have immediately reported it to the NHA-A. Surveyor asked CNA-D how R20 appeared to be during these 2 separate observations. CNA-D stated happy and enjoying what was going on as if it had been going on for some long time. CNA-D said CNA-D did not share this with the facility at the time they interviewed CNA-D. On 8/7/23 at 11:35 AM, Surveyor reviewed the facility's visitor sign in log from R20's admission to present. Surveyor notes the visitor (I) started visiting R20 three days after admission to the facility. The visitor (I) regularly visited R20 approximately 2-3 times a week and always on the PM shift. On 7/21/23, on the day of the alleged sexual abuse, visitor (I) signed in at 5:35 PM and signed out at 9:53 PM. Documentation shows that visitor (I) again visited R20 on 7/23/23 signing in at 5:23 PM and leaving at 9:00 PM. On 8/8/23 at 10:05 AM, Surveyor interviewed R20's activated HCPOA-H over the phone. HCPOA-H indicated in the past, family shared with HCPOA-H that visitor (I) had mental health issues. HCPOA-H has requested visitor (I) not visit and stated the following: if the nurse said it happened, then it probably did. On 8/8/23 at 12:52 PM, Surveyor interviewed the Director of Nursing (DON-B). DON-B confirmed on 07/24/23, 3 days after the observations of alleged sexual abuse, CNA-D reported the incidents to DON-B. DON believes it was reported on 7/24/23 after 3:30 PM but before 4:00 PM. DON-B immediately completed a skin check and pain evaluation. There is no documentation that R20's attending physician was notified or documentation that a physician came to assess R20. DON-B informed Surveyor that DON-B checked for scratches and bruises during the evaluation but there is no documentation of this. DON-B then obtained a statement from R20 who said R20 didn't think anyone touched R20 sexually inappropriately. DON-B said it was communicated that R20 was being herself and had no changes after the incidents. On 7/24/23, 3 days after the observations, CNA-D reported the incidents to DON-B. HCPOA-H was notified, and the police department was called. At 11:00 PM that night, the police notified the facility they would not be coming until the next day. On 7/25/23, the police responded to the facility and indicated there was not enough evidence for a SANE evaluation (Sexual Assault Nurse Examiner) in part due to the delay in reporting. Surveyor asked NHA-A on 8/8/23 at 11:46 AM during an interview why R20 was not sent out to the ER when notified of the alleged sexual abuse (fondling) and NHA-A stated the family did not want R20 to go. There is no documentation indicating sending R20 to the ER was discussed with HCPOA-H. The case is currently pending with the District Attorney. Surveyor attempted to get the police report but has not received anything yet. Surveyor checked the Wisconsin sex offender registry, and the visitor (I) is not listed. Surveyor reviewed the facility's investigation and notes the facility obtained multiple staff statements; all indicating they had no observations of the visitor (I) acting inappropriately or any behaviors displayed that would have indicated issues. Surveyor notes CNA-E's statement, (the CNA who was with CNA-D in R20's room at one point), states that CNA-D reported to CNA-E that CNA-D had caught visitor (I) playing with R20. CNA-E assumed the visitor had been touching R20 inappropriately. CNA-E documented in CNA-E's statement that CNA-E had seen the visitor bending over R20 but did not actually see anything. On 8/8/23 at 10:25 AM, Surveyor attempted to interview CNA-E over the phone but did not receive a return phone call back. On 8/8/23 at 3:35 PM, Surveyor spoke to Maintenance Lead (ML-F) who confirmed the facility has cameras. ML-F stated the cameras had gotten knocked out with a storm on 6/14/23 and were repaired about two weeks later. However, no one knew the cameras were not actually recording until NHA-A requested to view the footage from 7/21/23. Surveyor notes there is a picture of visitor (I) at the receptionist desk and on the units with a note stating visitor (I) is not allowed to visit and if visitor (I) attempts, the police should be notified. The facility informed Surveyor the facility took immediate action (on 7/24/23) with CNA-D, however the schedule indicated CNA-D worked on 7/25/23. On 8/8/23 at 11:46 AM, Surveyor reviewed CNA-D's punch detail and notes CNA-D worked on 7/25/23 from 2:10 PM to 10:30 PM. On 8/8/23 at 2:31 PM, Surveyor asked NHA-A about CNA-D working when the facility indicated immediate action had been taken with CNA-D. NHA-A informed Surveyor that CNA-D was talking with the police the entire time. However, Surveyor reviewed the police log which indicates the police arrived on 7/25/23 at 1:40 PM and left at approximately 5:16 PM. On 8/9/23 at 9:44 AM, NHA-A stated NHA-A took action against CNA-D on 7/26/23 after learning that CNA-D had completed abuse education. Surveyor notes that on 7/6/23 and 7/10/23, all staff received education on the abuse policy and procedure prior to this allegation of sexual abuse which occurred on 7/21/23. On 7/25/23, re-education was provided, however, it was only provided to 18 employees, all CNAs, including CNA-D who according to NHA-A should not have been in the facility. Surveyor confirmed with Nursing Staff Coordinator (NSC-J) that there is no orientation on abuse for agency staff. On 8/9/23 at 11:24 AM, LPN-C, agency nurse, confirmed that LPN-C has not received an orientation to the facility policies and procedures, including on abuse. The facility has stopped using agency aides 2 weeks ago but still has agency nurses. On 8/8/23 at 3:05 PM, Surveyor toured the 2 time clock areas and did not find any posting instructing employees on reporting any suspicion of a crime. On 8/9/23 at 8:20 AM, ML-F brought Surveyor to a break room and ML-F showed Surveyor a poster hanging in the breakroom instructing employees to report any suspicion of a crime immediately. Surveyor asked ML-F if everybody uses this break room and ML-F said no, not everybody. ML-F does not know if there is one designated person to go and report a suspicion of a crime to. The facility's self-report submitted to the state survey agency, states the facility was unable to validate if the allegation of sexual abuse occurred. This decision is based on all interviews from staff showing no observations of inappropriate behavior from the visitor(I), with the exception of CNA-D and E's statements. On 8/8/23 at 12:44 PM, Surveyor spoke to Life Coach (LC-K) in regards to R20. LC-K stated that LC-K assessed R20's cognitive status as a result of the alleged sexual abuse, and R20 scored a 3 on R20's BIMS, indicating R20 is now severely impaired for daily decision making. Surveyor asked LC-K why the significant change in cognitive status, and LC-K stated everyone has a good day and a bad day. LC-K confirmed that getting background information is very important in caring for Residents. LC-K confirmed that LC-K did not complete any referrals or develop any interventions as a result of the alleged sexual abuse, a possible new trauma. LC-K confirmed that other than speaking with R20 for two days after the alleged sexual misconduct(fondling), LC-K has not monitored for any psychosocial outcome. The interdisciplinary team (IDT) did not implement a comprehensive care plan addressing R20's alleged incident, signs/symptoms of trauma with person centered interventions to best care for R20 after the allegation of sexual abuse. Surveyor notes that the facility did not refer R20 for any psychological intervention/follow-up after the alleged sexual abuse. The facility did not intervene and monitor R20 for any signs/symptoms of behavior, pain, psychosocial changes since the alleged sexual abuse. On 8/7/23 at 1:20 PM, Surveyor observed R20 who appeared to be thin and frail. R20 was able to tell Surveyor what R20 had for lunch and what day of the week it was. On 8/8/23 at 11:07 AM, Surveyor found R20 nestled in an armchair in a lounge and appeared to be sniffling and had a Kleenex in R20's hand. Surveyor asked R20 if R20 was sad and R20 indicated R20 was, as she missed family. R20 was able to indicate that R20 is aware that the alleged perpetrator has not been in to visit since 7/24/23. On 8/9/23 at 10:15 AM, Surveyor spoke with R20 who stated that R20 was sad when asked how R20 was feeling. R20 stated R20 was sad because R20 had a lot on R20's mind, but could not pinpoint one main thing. On 8/8/23 at 2:31 PM, Surveyor shared the serious concern with NHA-A and DON-B that the facility did not ensure R20 was free of alleged sexually abused, and the facility failed to protect R20 from any further allegations of sexual abuse. Surveyor shared that after the first initial observation of alleged sexual abuse, CNA-D did not report immediately the allegation, and then CNA-D observed a second alleged sexual abuse by visitor(I) with R20. Surveyor shared visitor (I) returned to the facility and visited R20 one more time before CNA-D reported the allegations of abuse to the NHA, thus leaving R20 vulnerable for further sexual abuse and possibly other Residents. Surveyor shared that the police investigation was hampered by the fact the sexual abuse was not reported until 3 days later. Surveyor shared that the physician was not notified, and no actual physical assessment of possible sexual trauma was completed. Surveyor shared that only 18 CNAs were re-trained on the abuse policy and procedure and not all staff. NHA-A stated, we have concerns too. No further information was provided by the facility at this time. On 8/9/23 at 9:44 AM, NHA-A and DON-B spoke with Surveyor about the serious concern involving R20 and the alleged incident of sexual abuse. Both NHA-A and DON-B stated that R20 did not show signs of trauma. NHA-A and DON-B informed Surveyor that both NHA-A and DON-B do not believe the alleged incident of sexual abuse occurred. Surveyor shared that no physical or psychosocial assessment had been completed following the alleged sexual abuse. Surveyor was informed, it happens (referring to follow up with R20). NHA-A stated, NHA-A is livid it was not reported immediately and the facility did their job to educate staff on abuse. Unwanted sexual contact would cause a reasonable person to have psychosocial harm that may take months or years to manifest in R20 and have long term effects. Literature indicates that the most prevalent psychosocial outcomes of abuse are depression, anxiety, and posttraumatic disorder. Other possible outcomes can be manifested physically like weight loss, pain, repeated falls, and/or unexplained behavior changes. According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. This makes it more difficult to provide these victims with necessary services because they are unable to express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders In Sexual Abuse of Older Nursing Home Residents: A Literature Review, the authors note the statement by the World Health Organization, Regardless of the type of abuse [psychological, physical, sexual, financial, and neglect], it will certainly result in unnecessary suffering, injury or pain, the loss or violation of human rights, and a decreased quality of life for the older person https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302365/ Although R20 did not immediately display reactions or behaviors, a reasonable person who has been sexually assaulted could feel Recurrent (i.e., more than isolated or fleeting) debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of a specific staff member.) A person who has been sexually assaulted could also experience Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation . The facility's failure to prevent R20 from being allegedly sexually abused by visitor I, the failure of not immediately reporting the allegation of sexual abuse and not protecting R20 from further alleged sexual abuse created a reasonable likelihood for serious harm, thus resulted in a finding of an immediate jeopardy which was removed on 8/14/23 when; - A Root Cause Analysis was completed on August 10, 2023. - A Quality Assurance Committee Meeting was completed on August 11, 202 - The interdisciplinary team was educated on social history assessments, Trauma assessments, and notification of physician on August 11, 2023 - R20 did not show any signs or voice any fear, anxiety or trauma response. R20's social history was completed and care plan updated on 8/14/23 based on the social history. - No other residents were found affected by delinquent practice. - All residents are at risk for potential abuse. - All other residents were audited and a social history was completed and care plans updated as needed as of 8/14/23. - Review of the policies titled: Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy. The reasonable suspicion of a crime reporting requirement was posted at both time clocks and remains posted in break room. - Staff education was provided by Executive Director and Director of Nurses starting on August 9, 2023 on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, Reasonable Suspicion of a Crime Mandatory and the requirement of reporting to law enforcement, administrator, and DQA. - A post quiz and signed acknowledgement of understanding of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, Reasonable Suspicion of a Crime and Mandatory requirement of reporting. - Director of Nursing and or designee will audit 5 resident record for 3 weeks and then after 5 times for 3 months the following new admission to validate that Social History were completed on new admissions and assessments reflected in care plan reporting any findings to the Quality Assurance Performance Improvement committee (QAPI). - Administrator and or designee will audit 5 staff members for 3 weeks and then 5 staff members for 3 months on their understating of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, and Reasonable Suspicion of a Crime Mandatory requirement of reporting, and will report findings to QAPI committee.

Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (R20) of 1 residents reviewed where an allegation of abuse was not reported as a suspicion of a crime to law enforcement, and where 2 (R20 and R30) of 3 residents reviewed for allegations of abuse was not reported immediately, but not later than 2 hours to the state agency, and steps were not immediately taken to prevent further potential abuse. On 7/21/23, Certified Nursing Assistant (CNA-D), observed a visitor (Visitor I) inappropriately touching R20, with his hand between R20's legs and on R20's vagina. CNA-D did not immediately report this allegation of sexual abuse as a suspicion of a crime to the Nursing Home Administrator (NHA-A) or designee. The failure of CNA-D to notify NHA-A of a suspicion of a crime resulted in the facility and CNA-D not immediately reporting this allegation of sexual abuse as a suspicion of a crime to law enforcement. The facility policy for suspicion of a crime is to immediately report to law enforcement to be investigated. The failure of CNA-D to immediately report this allegation of sexual abuse resulted in the facility not reporting this allegation of abuse to the state agency within 2 hours. The failure of CNA-D to immediately report this allegation of sexual abuse allowed Visitor I to remain in the facility and later on 7/21/23 he was observed in a darkened room with his hand under the covers while R20 was in bed. For the second time on 7/21/23, CNA-D did not report the observations of alleged sexual abuse immediately to the Administrator or designee. The facility and CNA-D did not immediately report to law enforcement as per facility policy this allegation of sexual abuse as a suspicion of a crime and the facility was not able to report to the state agency the allegation of sexual abuse within 2 hours. The failure to report this allegation of sexual abuse allowed Visitor I to be able to visit with R20 one more time (on 7/23/23) before CNA-D reported the allegation of sexual abuse to Director of Nursing (DON)-B on 7/24/23. The facility failed to protect R20 from further potential sexual abuse by not immediately reporting this allegation as a suspicion of a crime to law enforcement and to the state agency. On 7/24/23 the police were notified and indicated they would respond the following day. On 7/25/23 the police responded to the facility and indicated there was not enough evidence for a sexual assault nurse examiner partly due to the delay in reporting. Failure to report the allegation to the police did not allow for a full investigation into the allegation. The facility's failure to report this allegation of sexual abuse as a suspicion of a crime to law enforcement and to the State Agency within 2 hours resulted in the failure to protect R20 and other residents from further potential sexual abuse, which created a finding of Immediate Jeopardy, which began on 7/21/23. On 8/9/23, at 3:42 PM, NHA-A and DON-B were informed of the Immediate Jeopardy. The immediate jeopardy was removed on 8/12/23. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor its action plan and as evidence by: * R30 reported a Certified Nursing Assistant (CNA) was rough with R30 when assisting with putting a shirt on. R30 stated the CNA grabbed R30's arm to put it through the sleeve and when R30 told the CNA she was hurting R30, the CNA told R30 to Suck it up, I'm almost done getting your top on. I know it hurts but that's the way things are. R30 reported this allegation of abuse to the Therapy Department Program Manager - RR, who in turn reported this allegation of abuse to Director of Nursing (DON)-B. DON-B did not immediately report this allegation to the Administrator who was informed of the allegation a few days after it had been reported to the DON-B. In addition this allegation of abuse was not immediately reported to the state agency. Findings include: Surveyor reviewed the facility's Policy and Procedure on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last revised 12/1/22. .Procedure: (includes in part .) E. The facility will encourage and support all individuals, staff, families, visitors, volunteers, and individual representatives in reporting any suspected acts of abuse to the Administrator or designee. F. The Administrator or designee will report abuse to the state agency per State and Federal guidelines. G. The facility will follow the attached comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program to comply with the seven step approach to abuse and neglect detection and prevention. H. The abuse policy and comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program will be reviewed on at least an annual basis and will be integrated into the facility quality assurance and performance improvement program. Overview of Seven components -Screening -Training -Prevention -Identification -Investigation -Protection -Reporting and Response Investigation It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's QAPI (Quality Assurance Performance Improvement) Incident Report and Investigation process. Additional Investigation Protocols -Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to law enforcement to be investigated. Protection It is the policy of this facility that the Resident(s) will be protected from the alleged offender. Procedure: Immediately upon receiving a report of alleged abuse, Administrator (NHA-A) and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable Resident are of utmost priority. Safety, security, and support of the Resident, roommate, if applicable and other Residents with the potential to be affected will be provided. i. The alleged perpetrator will immediately be removed and Resident protected. ii. If a family member or Resident representative is possibly contributing to the potential abuse and the Resident could be at risk, evaluate the situation and identify options to put into place for Resident protection. iv. Examine, assess and interview the Resident and other Residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. Notify Resident physician. v. Life Coach or designee should keep in frequent contact with the Resident and/or Resident representative. vii. Notification of law enforcement and/or State Agency viii. A medical, evidentiary, or sexual assault exam should be completed as possible, as appropriate. Reporting and Response It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Resident property, are reported immediately, but no later than 2 hours after the allegation is made. Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator (NHA-A). **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law. External Reporting Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to law enforcement to be investigated. Employee rights will be posted (identify conspicuous location) . 1. R20 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dysphagia, Adult Failure to Thrive, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Cognitive Communication Deficit. R20 has an activated Health Care Power of Attorney (HCPOA). R20's Admission Minimum Data Set (MDS) dated [DATE] documents R20's Brief Interview for Mental Status score to be 11, indicating R20 demonstrates moderately impaired skills for daily decision making. R20 has no behaviors and R20's PHQ-9 score is 6, indicating R20 has minimal depression. R20's MDS also assesses R20 as requiring extensive assistance of one for bed mobility, transfers, dressing, and toileting. R20 requires supervision for eating. R20 has both upper and lower range of motion impairment on one side. R20 resided on the long-term care unit on the 2nd floor. On 8/9/23 at 10:49 AM, CNA-WW informed Surveyor that the rehabilitation unit is quiet and the second floor can be more busy and chaotic at times and CNA-WW stated it can be hard to monitor visitors up on the second floor. On 8/8/23 at 11:25 AM and again on 8/8/23 at 2:18 PM, Surveyor interviewed CNA-D regarding the allegation of sexual abuse. During Surveyor's interviews, CNA-D reported that on 7/21/23, R20 was eating in the dining room and Visitor I was sitting with R20 at the table. Visitor I informed staff that R20 needed to be toileted and he offered to assist. CNA-D was assisting other residents and at approximately 7:20 PM, she heard noise in R20's bathroom, entered the bathroom, and found R20 sitting on the toilet in a nightgown and observed Visitor I's hand between R20's legs and on R20's vagina. CNA-D's statement included that Visitor I had changed R20 out of R20's clothes. Surveyor asked CNA-D if Visitor I had a wipe or toilet paper in their hand and CNA-D said No. CNA-D felt Visitor I was clearly sexually inappropriately touching R20 and told Surveyor that their hand was on R20's vagina. CNA-D had Visitor I leave the bathroom and she completed toileting for R20, putting her to bed afterwards. Another CNA entered the room with R20's roommate and the CNAs asked Visitor I to leave the room so they could put the roommate to bed. Visitor I remained in the hallway outside R20's door. At this point, CNA-D had not reported the incident in the bathroom to anyone, the police were not contacted, and Visitor I remained in the facility. The CNAs exited the room and Visitor I went back into the room. CNA-D returned about 5-6 minutes later and thought it was unusual that the lights were out in R20's room. CNA-D entered the room, turned the lights on, and saw Visitor I's hand under R20's covers. CNA-D stated Visitor I jerked their hand from under the covers as if startled. CNA-D observed Visitor I begin walking to the elevator. Visitor I then returned to the room to retrieve a bag and left the room. CNA-D is uncertain at what point Visitor I left the facility. CNA-D stated that CNA-D informed a Licensed Practical Nurse (LPN-C) of the observations. On 8/9/23 at 11:24 AM, Surveyor interviewed LPN-C who denies ever being made aware of the allegations of sexual abuse. LPN-C reiterated had LPN-C been made aware of the allegations, LPN-C would have immediately reported it to the NHA-A. On 8/8/23 at 12:52 PM, Surveyor interviewed DON-B. DON-B confirmed that on 07/24/23, 3 days after the observations of alleged sexual abuse, CNA-D reported the allegations to DON-B. DON believes it was reported on 7/24/23 after 3:30 PM but before 4:00 PM. Surveyor notes the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 7/24/23 was submitted at 5:46 PM. The Misconduct Incident Report was submitted on 7/28/23 at 4:47 PM. On 7/24/23, 3 days after the observations, CNA-D reported the incidents to DON-B. HCPOA-H was notified, and the police department was called. At 11:00 PM that night, the police notified the facility they would not be coming until the next day. On 7/25/23, the police responded to the facility and indicated there was not enough evidence for a SANE evaluation (Sexual Assault Nurse Examiner) in part due to the delay in reporting. Surveyor asked NHA-A on 8/8/23 at 11:46 AM during an interview why R20 was not sent out to the emergency room (ER) when notified of the alleged sexual abuse. NHA-A stated the family did not want R20 to go. There is no documentation indicating a conversation about R20 going to the ER was discussed with HCPOA-H. The case has been referred to the District Attorney. On 8/8/23 at 3:05 PM, Surveyor toured the two-time clock areas and did not find any posting instructing employees on reporting any suspicion of a crime. On 8/9/23 at 8:20 AM, Maintenance Lead (ML)-F brought Surveyor to a break room and ML-F showed Surveyor a poster hanging in the break room instructing employees to report any suspicion of a crime immediately. Surveyor asked ML-F if everybody uses this break room and ML-F said No, not everybody. ML-F does not know if there is one designated person to go and report a suspicion of a crime to. The facility's reported self-report submitted to the state survey agency, states the facility was unable to validate if the allegation of sexual abuse occurred. This decision is based on that all interviews from staff showed no observations of inappropriate behavior from Visitor I with the exception of CNA-D. On 8/8/23 at 2:31 PM, Surveyor shared the serious concern with NHA-A and DON-B that the facility failed to protect R20 from any further potential incidents of sexual abuse by the lack of immediate reporting. Surveyor shared that after the first initial observation of alleged sexual abuse by CNA-D, CNA-D did not immediately report this allegation of sexual abuse to the Nursing Home Administrator or designee and did not report this allegation of abuse as a suspicion of a crime. Surveyor indicated the facility did not report this allegation of sexual abuse as a suspicion of a crime to law enforcement and did not report this allegation of sexual abuse to the state agency within 2 hours. CNA-D observed a second incident of alleged sexual abuse by Visitor I on 7/21/23 and again failed to immediately report this allegation of sexual abuse to the Nursing Home Administrator and/or designee and failed to report the sexual abuse as a reasonable suspicion of a crime to law enforcement. Surveyor shared Visitor I visited one more time before CNA-D reported the allegations, leaving R20 and possibly other residents vulnerable to further potential sexual abuse. Surveyor shared that the police investigation was hampered by the fact the allegation of sexual abuse was not reported until 3 days later. On 8/9/23 at 9:44 AM, NHA-A and DON-B spoke with Surveyor about the serious concern involving R20 and the alleged incident of sexual abuse. Both NHA-A and DON-B stated that R20 did not show signs of trauma. NHA-A and DON-B informed Surveyor that both NHA-A and DON-B do not believe the alleged incident of sexual abuse occurred. NHA-A stated, NHA-A is livid it was not reported immediately, and the facility did their job to educate staff on abuse. According to the National Institute on Aging (NIH), Elder Abuse, abuse can happen to anyone, no matter the person's age, sex, race, religion or ethnic background. Each year hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited. This mistreatment is called elder abuse. Abuse can happen anywhere, including in the older person's home, a family member's home, an assisted living facility or a nursing home. The mistreatment of older adults can be by family members, strangers, health care providers, caregivers, or friends .Abuse can happen to any older adult. Most victims of abuse are women, but some are men. Older adults without family or friends nearby and people with disabilities, memory problems, or dementia may be more vulnerable to abuse. Mistreatment most often affects those who depend on others for help with activities of everyday life- including bathing, dressing and taking medicine . Most importantly, if you suspect an older person is being abused, report what you see to an authority. Many adults are too ashamed to report mistreatment. Or they're afraid if they make a report, it will get back to the abuser and make the situation worse. Therefore, family and friends must step in to address problems . Some types of elder abuse may be criminal. You do not personally need to prove the abuse is occurring: professionals will investigate. Many local, state, and national social service agencies can help. These include: Adult Protective Services . The National Center on Elder Abuse . Long-term care ombudsman . http:// www.nia.nia.gov/health/elder-abuse, July 21, 2023 Although R20 did not immediately display reactions or behaviors as a result of this allegation of sexual abuse, it should be noted however, given R20's history of abuse, she may have been used to being abused and that this was a familiar pattern to which she was accustomed. Her reaction was markedly incongruent to what a reasonable person might experience. Using the reasonable person concept a reasonable person who has been sexually assaulted would want the involvement of law enforcement, would want the option to be evaluated by a sexual assault nurse examiner and would want the protection from the facility against any further sexual abuse. The facility's failure to protect R20 from further potential sexual abuse, the facility's failure to immediately report this allegation of sexual abuse as a suspicion of a crime to law enforcement as per facility policy, and to report to the state agency within 2 hours resulted in a finding of an immediate jeopardy. The immediate jeopardy was removed on 8/12/23 when: * A Root Cause Analysis was completed on August 10, 2023. * A Quality Assurance Committee Meeting was completed on August 11, 2023. * R20's social history was completed, and care plan updated based on the social history. All other residents were audited, and a social history was completed, and care plans updated as needed. No other residents were found affected by delinquent practice. * Staff education was provided by Executive Director and Director of nurses was started on August 9, 2023 on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, Reasonable Suspicion of a Crime Mandatory requirement of reporting to law enforcement, administrator, and to the Division of Quality Assurance (DQA). A post quiz and signed acknowledgement of understanding of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, and Reasonable Suspicion of a Crime Mandatory requirement of reporting. * The Interdisciplinary Team was education on social history assessments, Trauma assessments, notification of physician on August 11, 2023. * Review of the policies titled: Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy. * The reasonable suspicion of a crime reporting requirement was posted at both time clocks and remains posted in break room. * DON and or designee will audit 5 resident record for 3 weeks and then after 5 times for 3 months the following new admission to validate that Social History were completed on new admissions and assessments reflected in care plan reporting any findings to QAPI. * Administrator and or designee will audit 5 staff members for 3 weeks and then 5 staff members for 3 months on their understating of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program and Reasonable Suspicion of a Crime Mandatory requirement of reporting. * Findings from the audits will be reported to the Quality Assurance Performance Improvement committee. The deficient practice continues at a scope and severity level of D (potential for harm/isolated as evidenced by: 38253 2. R30 was admitted to the facility on [DATE] with diagnoses of right humerus fracture, compression fracture of the spine, diabetes, anxiety, depression, peripheral vascular disease, and anemia. R30's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R30 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R30 as needing extensive assistance with bed mobility, transfers, and toilet use, and limited assistance with dressing and hygiene. R30 did not have an activated Power of Attorney. On 8/14/2023 at 10:07 AM, Surveyor met R30 in R30's room. R30 had the right arm in a sling and R30 stated R30 had broken the arm when R30 fell at home. R30 stated about two weeks ago a Certified Nursing Assistant (CNA) was rough with R30 when helping put a shirt on. R30 stated the CNA grabbed R30's arm to put it through the sleeve and when R30 told the CNA she was hurting R30, the CNA told R30 to Suck it up, I'm almost done getting your top on. I know it hurts but that's the way things are. Surveyor asked R30 if R30 had told anyone when it had happened. R30 stated R30 told Therapy Department Program Manager (TDPM)-RR. Surveyor asked R30 if R30 knew the name of the CNA that hurt R30. R30 could not recall the CNA's name. Surveyor asked R30 if anyone came to talk to R30 after R30 reported the incident to TDPM-RR. R30 stated someone from administration came and talked to R30 after it was reported but could not remember what the staff member's name was. Surveyor asked if R30 saw the CNA after the incident was reported. R30 stated R30 was in the dining room later and the CNA stayed away from R30. R30 stated the incident happened about two weeks ago and had not seen the CNA since then. R30 felt the problem was resolved but stated the CNA that did that to R30 commands everybody so what this CNA says goes and other staff follow. R30 stated R30 felt safe before that happened but does not feel safe now because R30 is wondering which CNA will be next to hurt R30. R30 stated, You don't get over something like that right away. On 8/14/2023 at 3:01 PM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B all facility reported incidents that had occurred in the last month. No reports involving R30 were provided. In a phone interview on 8/15/2023 at 9:59 AM, Surveyor asked TDPM-RR if R30 had reported to TDPM-RR any problems with a CNA. TDPM-RR stated R30 had reported a couple of weeks ago to TDPM-RR and a physical therapy assistant that a CNA had been very rough with R30. TDPM-RR stated TDPM-RR reported the allegation to DON-B immediately and was later told DON-B and Nurse Supervisor-HH went to see R30 and did not know what the conversation was with them. TDPM-RR stated the facility had a Care Conference right after that and as far as TDPM-RR knew, the issue was resolved. In an interview on 8/15/2023 at 1:31 PM, Surveyor asked NHA-A if NHA-A was aware of R30's allegation of abuse. NHA-A stated NHA-A was not aware of the allegation until a few days after it was reported to DON-B. Surveyor asked NHA-A why the allegation of abuse was not reported to the State Agency. NHA-A stated DON-B said it was not reportable. In an interview on 8/15/2023 at 1:39 PM, Surveyor asked Life Coach (LC)-K what the facility process was for an allegation of abuse. LC-K stated the abuse is reported to NHA-A and NHA-A will let nursing know about the allegation. Nursing will do the investigation. Surveyor asked LC-K who files the reports with the State Agency? LC-K stated NHA-A does all the reportable incidents. LC-K stated staff should report the allegation as soon as possible and they must verbally tell administration what the situation is, they can't just leave a note, it must be verbally reported. In an interview on 8/16/2023 at 7:50 AM, Surveyor asked DON-B why DON-B did not feel the allegation of abuse by R30 was reportable. DON-B stated when DON-B was talking to R30 about the allegation, R30 did not know the CNA's name and could not describe the CNA. DON-B asked R30 if the CNA was just going too fast and rushing R30 as opposed to hurting R30 on purpose. DON-B stated R30 said R30 supposed it was from rushing so DON-B determined it was not abuse and was just a customer service issue. Surveyor noted DON-B asked leading questions when interviewing R30 about the allegation of abuse. On 8/16/2023 at 11:14 AM, NHA-A stated the allegation of abuse involving R30 was reported to the State Agency that morning. No further information was provided at that time.

Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 5 (R137, R31, R88, R21, & R87) of 5 Residents reviewed for pressure injuries. * On 1/24/2023, R137 developed a Stage 3 pressure injury to the coccyx and a Stage 3 pressure injury to the right ear A treatment was not started until 3 days later on 1/27/23. The pressure injury resolved on 2/7/23. On 1/31/2023 the Stage 3 pressure injury to the coccyx became Unstageable and no treatment was implemented at that time. The coccyx pressure injury became infected and was treated with antibiotics. A treatment for the coccyx pressure injury was not implemented until 14 days after discovery. An order was received for Santyl on 2/7/23. From 2/8/2023 to 2/28/2023, the treatment of Santyl was not administered as ordered. Staff instead treated the pressure injury with wound gel as the facility did not have Santyl. Neither Wound NP-O nor the physician were not notified of missing treatments or treatment alterations provided by staff. * On 3/24/2023 R31 was admitted to the facility with a pressure injury. The facility did not complete an assessment, including measurements or characteristics and no interventions were implemented on the baseline Care Plan. On 3/30/2023, 6 days after admission, a treatment order was obtained. On 4/4/2023, 11 days after admission, Wound NP-O did an initial assessment of the Stage 3 pressure injury and wrote orders for treatment. The treatment order was not transcribed onto the Treatment Administration Record (TAR), and the Stage 3 Pressure Injury Care Plan was not initiated. On 4/18/2023, R31's pressure injury became Unstageable. Wound NP-O ordered a new treatment. That treatment was not transcribed onto the TAR, and the recommendation of bed rest for one week was added to the TAR for three days but with documentation bed rest was not followed on those three days. On 4/25/2023, the ordered treatment was not transcribed onto the TAR. On 5/2/2023, R31's Unstageable pressure injury became infected requiring antibiotics, and the treatment was not signed out as being provided as ordered. From 5/9/2023 to 5/30/2023 Wound NP-O's weekly treatment order was not transcribed onto the TAR. On 5/30/2023 the treatment order was transcribed but facility staff did not sign out the treatments as being completed as ordered. * R88 was admitted to the facility on [DATE]. The admit/readmit screen dated 6/14/23 completed by an LPN (Licensed Practical Nurse) documents two - Stage 2 coccyx pressure injuries. There is no RN assessment and no treatment ordered until 6/20/23, six days later. The Wound Nurse Practitioner's (NP's) initial evaluation dated 6/20/23 documents a deep tissue injury to the sacrum with measurements of 11.5 cm (centimeters) x 10.5 cm x 0.1 cm. R88 was discharged to the hospital on 6/21/23 and readmitted on [DATE]. The Wound NP-O's note dated 6/27/23 documents an unstageable sacrum pressure injury with measurements of 10.0 cm x 10.0 cm x 0.1 cm and an unstageable pressure injury to the right shoulder. Although the facility began a baseline care plan, it was marked as in process and no interventions were included. Nurses notes on 6/30/23 and 7/4/23 documents the pressure injury has a foul odor and slough present. On 7/5/23 Wound NP-O assessed R88's sacrum pressure injury as Stage 4. There was a change in treatment which the Facility did not implement. On 7/12/23 the Wound NP ordered Cipro 500 mg (milligrams) twice daily for two weeks and Penicillin 500 mg twice daily for two weeks for wound infection. The facility also completed an actual skin integrity care plan on this date, which is nearly a month after R88 was first admitted with a pressure injury. On 7/25/23 R88 was identified with an unstageable left buttock pressure injury and a treatment was ordered. The treatment for R88's sacrum was changed on this date also. The facility did not pick up either order. R88 was discharged to the hospital on 7/26/23. The Facility's failure to provide care to prevent the development of pressure injuries and promote the healing of pressure injuries for R137, R88, & R31 including the failure to develop &/or update resident's pressure injury care plans and the failure to implement and carry out treatments in accordance with physician/nurse practitioner orders created a finding of Immediate Jeopardy (IJ) which began on 2/7/23. Surveyor notified NHA (Nursing Home Administrator)- A & DON (Director of Nursing)-B of the immediate jeopardy on 8/9/23 at 3:43 p.m. The immediate jeopardy was removed on 8/12/23. The deficient practice continues at a scope and severity of G (actual harm/isolated) related to the examples involving R21 & R87 and as the Facility continues to implement its action plan. * R21 was admitted to the facility on [DATE] without any pressure injuries. The Braden scale dated 12/2/22 documents moderate risk for pressure injury development. An at risk for pressure injury care plan was developed on 12/29/22. There were no interventions to offload R21's heels. The nurses note written by an LPN (Licensed Practical Nurse) on 1/13/23 documents a half dollar size blister on the left heel. There was no RN (Registered Nurse) assessment until 1/17/23, four days later, there were no revisions to R21's at risk for pressure injury care plan and an actual pressure injury care plan was not developed until 3/22/23. Surveyor was unable to locate an assessment for the week of 2/12/23 to 2/18/23. On 2/16/23 an LPN documented a lesion to R21's inner thigh fold. There was no RN assessment until 5 days later. On 2/21/23 NP-O's wound assessment documents R21's heel wound separated into 2 wounds. Unstageable left lateral heel, Stage 3 left posterior heel and an unstageable pressure injury to the right inner thigh. There was no revision in R21's at risk for pressure injury care plan and the actual pressure injury care plan was not developed until 3/22/23. * R87 was admitted to the facility on [DATE] without any pressure injuries. A Braden assessment completed on 6/16/22 & 7/3/22 identified R87 at risk for pressure injury development. On 7/4/22 a nurses note includes documentation of a dressing intact to the left heel blister. There is no documentation as to when this pressure injury developed although NP-O's wound note dated 7/5/22 documents the wound to left heel was discovered this past weekend. A pressure injury care plan was not developed until 10/10/22. R87 was hospitalized from 7/8/22 to 7/13/22. The admit/readmit screen completed by an LPN on 7/13/22 documents unstageable left heel pressure injury with measurements of 4 cm x 6 cm. There was no RN assessment until 5 days later. On 9/15/22 an LPN documents the left heel has yellowish/green foul smelling slough. There was no RN assessment until 5 days later and no physician notification. On 9/30/22 and 10/2/22 an LPN documents foul odor with the ADON (Assistant Director of Nursing) being notified. There was no RN assessment. On 10/4/22 R87 was identified with a DTI (deep tissue injury) to left Hallux (great toe). A pressure injury care plan was not developed until 10/10/22. Findings include: The facility's Pressure Injury Prevention and Managing Skin Integrity policy & procedure last reviewed 6/24/22 under policy documents Prevention measures are put in place to reduce the occurrence of pressure injuries. Under Procedures there are 5 sections. 1. Risk Assessment, 2. Identify Interventions and Care Plan, 3. Skin Checks, 4 Weekly Wound Rounds and 5. Administrative Review. Section 2 documents: a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent. further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team (IDT) regarding the presence of breakdown and the intervention plan. 2. When indicated a referral to additional resources (i.e Wound Care Specialist, Registered Dietician, Physical Therapist, Occupational Therapist) may occur. 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan i. In developing a plan of care, the following will be considered: 1. Individual Pressure Injury History 2. Cognitive changes or impairment of the individual 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health. 4. Any cultural practices that impact the health or integrity of the skin. 5. Risk for pressure ulcer development (Braden Scale). 1.) R137 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, protein-calorie malnutrition, depression, anxiety, anemia, and compression fracture of the spine. R137's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R137 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R137 as needing limited assistance with bed mobility, transfers, dressing, and hygiene. R137 did not have an activated Power of Attorney. R137 was discharged from the facility on 3/8/2023 and was not a resident of the facility at the time of the survey. On 1/12/2023 at 7:48 PM in the progress notes, nursing charted R137 did not have any skin impairments on admission. Surveyor noted no comprehensive admission assessment was documented when R137 was admitted to the facility and the Baseline Care Plan, started by nursing staff on 1/12/2023, was in progress and never completed or implemented while R137 was in the facility. On 1/13/2023, R137 had an order for Ensure 8 ounces daily as a nutritional supplement. On 1/16/2023, R137's Braden score was 21 indicating R137 was not at risk for developing a pressure injury. On 1/20/2023, R137 had an order for Health Shake 4 ounces daily as a nutritional supplement. On 1/21/2023, R137 had an order for ProSource 30 cc daily as a nutritional supplement. On 1/24/2023, R137 was seen by Wound Nurse Practitioner (NP)-O. Wound NP-O documented R137 had a Stage 3 pressure injury to the coccyx that measured 1.6 cm x 2.5 cm x 0.1 cm with 100% granulation. A treatment was ordered for bordered foam to be changed three times a week and a recommendation was made for an alternating pressure mattress. Wound NP-O also documented R137 had a Stage 3 pressure injury to the right ear that measured 0.5 cm x 0.5 cm x 0.1 cm with a dry yellow wound base with no drainage. A treatment was ordered for foam to the area and to check placement every shift. Wound NP-O documented the current interventions in place were a pressure relieving cushion for sitting, an up and down schedule of back to bed after lunch and up for dinner and elevate heels off the bed with pillows. Surveyor reviewed the Treatment Administration Record (TAR) and no treatment for the coccyx or right ear was documented as being implemented on 1/24/2023. R137's Pressure Injury Care Plan was initiated on 1/24/2023 with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Educate (R137)/family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. -Follow the facility policies/protocols for the prevention/treatment of skin breakdown. -Inform (R137)/family/caregivers of any new area of skin breakdown. -Monitor nutritional status; serve diet as ordered; monitor intake and record. -Staff to assist with routine toileting and skin care for incontinence. -Staff to assist with turning and repositioning. On 1/25/2023 at 1:06 PM in the progress notes, nursing charted barrier cream was applied to the buttocks for breakdown prevention. Surveyor noted the treatment ordered by Wound NP-O was not provided to the coccyx or ear. On 1/27/2023, the orders written by NP-O were first entered on the TAR. The orders included to lay down after lunch and get back up for dinner daily. R137 had an order for a treatment to the open area behind the right ear: soap and warm water wash, pat dry, apply foam, check placement every shift; if not present, reapply. On 1/31/2023, R137 was seen by Wound NP-O. Wound NP-O documented the pressure injury to the coccyx had declined. The now Unstageable pressure injury measured 3.5 cm x 3.5 cm x 0.1 cm with 100% slough to the wound base and was deep purple in color with moderate serous drainage. The treatment order was changed to Medihoney on bordered foam, changed three times a week. Wound NP-O again recommended an alternating pressure mattress and to be up no longer than two hours at a time. Surveyor noted Wound NP-O had recommended an alternating pressure mattress on 1/24/2023 that was not implemented. Wound NP-O documented R137's Stage 3 pressure injury to the right ear measured 0.4 cm x 0.4 cm x 0.1 cm with a pink base and no drainage. Wound NP-O continued with the original treatment to the area and since R137 was no longer on oxygen, Wound NP-O anticipated the right ear wound would heal in the next week or so. Surveyor noted NP-O's treatment change to the coccyx pressure injury was not entered onto the TAR on 1/31/2023. R137's Pressure Injury Care Plan was revised on 2/1/2023 to include the following intervention: -Air mattress to bed due to pressure injury. On 2/1/2023 at 7:50 PM in the progress notes for the daily Medicare charting, nursing charted the coccyx wound had slough noted and was cleansed and redressed with a foam dressing per order. At 8:08 PM in the progress notes, nursing charted R137 complained of discomfort to the coccyx and the affected area was cleansed with normal saline followed by Medihoney and a foam dressing. Surveyor noted R137 did not have any documented orders for a treatment to the coccyx on the TAR. On 2/2/2023 at 1:17 PM in the progress notes, nursing charted R137 had discomfort to the coccyx wound and a treatment was done with some visible slough and no redness or signs or symptoms of infection. At 7:21 PM in the progress notes for the daily Medicare charting, nursing charted R137's coccyx wound was cleansed with normal saline. Visible slough with no foul odor was noted. Skin prep to the peri wound was applied and Medihoney to the wound bed and covered with a foam dressing. Surveyor noted R137 did not have any documented orders for a treatment to the coccyx on the TAR. On 2/3/2023 at 3:05 PM in the progress notes, nursing charted the dressing to the coccyx wound was changed and intact with no signs or symptoms of infection. On 2/4/2023 at 1:44 PM in the progress notes, nursing charted a treatment was applied and the dressing was intact to the coccyx wound with no visible signs or symptoms of infection. At 10:44 PM in the progress notes for the daily Medicare charting, nursing charted the treatment was applied to the coccyx wound; the affected area was cleansed with wound cleanser, visible slough and no foul odor was noted, skin prep to the peri wound followed by Medihoney to the wound bed and a foam dressing was applied. At 11:54 PM in the progress notes, nursing charted the same information regarding the treatment to R137's coccyx wound that had been charted at 10:44 PM. Surveyor noted R137 did not have any documented orders for a treatment to the coccyx on the TAR. On 2/5/2023 at 7:08 PM in the progress notes, nursing charted R137's coccyx wound had visible slough and no foul odor. The affected area was cleansed with normal saline followed by Medihoney and foam dressing. At 10:14 PM in the progress notes for the daily Medicare charting, nursing charted the same information that had been charted at 7:08 PM. Surveyor noted Wound NP-O had ordered the dressing to be changed three times a week and per the progress notes, nursing had been changing the dressing daily if not more than once a day. With no order transcribed onto the TAR to be signed out when completed, Surveyor was unable to determine when or how often the treatment was being done, if the charting was that nurse's personal assessment, if they completed the treatment at the time of the charting, or if the information was being passed along from other nurses on previous shifts. On 2/7/2023, R137 was seen by Wound NP-O. Wound NP-O documented the coccyx wound was evolving and continued to be an Unstageable pressure injury that measured 3.9 cm x 3.2 cm x 0.1 cm with 100% slough with moderate serosanguineous drainage. The peri wound had erythema (reddening) and had slight warmth. The treatment order was changed to Santyl on bordered foam to be changed daily. Wound NP-O documented the coccyx wound was infected and ordered Doxycycline 100 mg twice daily for ten days. Wound NP-O documented the pressure injury to the right ear had resolved. Surveyor noted staff had not been following the treatment orders given by Wound NP-O from 1/24/2023 through 2/6/2023 and subsequently the Unstageable pressure injury became infected requiring antibiotics. On 2/7/2023 on the TAR, a treatment order for the coccyx was entered to wash wound with wound cleanser, pat dry followed by Santyl followed by a foam border dressing daily. This was the first treatment order on the TAR since the wound was discovered on 1/24/2023, 14 days later. On 2/8/23 the ProSource and Ensure supplements that R137 was receiving for malnutrition were discontinued and Health Shake, 4 ounces, three times a day was ordered. On 2/8/2023 at 12:48 PM in the progress notes, nursing charted R137's dressing was changed due to the bandage being soiled. On 2/8/2023, 2/9/2023, 2/10/2023, and 2/13/2023 on the TAR, Santyl was not available in the facility. No documentation was found that Wound NP-O or the physician were notified that the Santyl was unavailable. On 2/9/2023 at 8:41 PM, on 2/10/2023 at 7:13 PM, and on 2/13/2023 at 11:03 PM in the progress notes, nursing charted the coccyx wound was cleansed with wound cleanser followed by topical wound gel and covered with a foam dressing. No documentation was found indicating Wound NP-O or a physician were consulted with regarding wound gel being applied instead of the ordered Santyl. On 2/14/2023, R137 was seen by Wound NP-O. Wound NP-O documented the Unstageable pressure injury to the coccyx had improved and measured 3.5 cm x 2.5 cm x 0.1 cm with 100% slough with moderate serosanguineous drainage. Wound NP-O continued the treatment of Santyl on bordered foam daily. No documentation was found that Wound NP-O was aware the Santyl had not been applied and was unavailable or that wound gel had been used on the wound instead of the Santyl. R137's Pressure Injury Care Plan was revised on 2/14/2023 to include the following interventions: -Assess/record/monitor wound healing weekly by the wound team; measure length, width, and depth where possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Monitor the dressing every shirt to ensure it is intact and adhering; report loose dressing to treatment nurse. -(R137) needs assistance of one to turn/reposition at least every 2 hours, more often as needed or requested. -(R137) requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. -Treat pain as per orders prior to treatment/turning etc. to ensure (R137's) comfort. On 2/14/2023, 2/15/2023, 2/16/2023, 2/18/2023, and 2/19/2023 on the TAR, Santyl was not available in the facility. No documentation was found that Wound NP-O or the physician were notified that the Santyl was unavailable. On 2/14/2023 at 7:39 PM, on 2/15/2023 at 11:58 PM, on 2/16/2023 at 11:55 PM, on 2/18/2023 at 7:18 PM, and on 2/19/2023 at 10:45 PM in the progress notes, nursing charted the coccyx wound was cleansed with wound cleanser followed by topical wound gel and covered with a foam dressing. No documentation was found indicating Wound NP-O or a physician was consulted with regarding wound gel being applied instead of the ordered Santyl. On 2/19/2023 at 10:27 PM in the progress notes, nursing charted the order for Santyl was refaxed with wound measurements to the pharmacy. On 2/21/2023, R137 was seen by Wound NP-O. Wound NP-O documented the Unstageable pressure injury to the coccyx measured 3.5 cm x 2.8 cm x 0.2 cm with 100% slough with moderate serosanguineous drainage. No documentation was found that Wound NP-O was aware the Santyl had not been applied and was unavailable or that wound gel had been used on the wound instead of the Santyl. Wound NP-O changed the treatment order to Medihoney on border foam and change three times a week. Surveyor noted the treatment for Medihoney to the Unstageable coccyx pressure injury was not entered onto the TAR as ordered by Wound NP-O on 2/21/2023. The order for the daily application of Santyl to the wound continued as the treatment on the TAR. On 2/21/2023, 2/22/2023, and 2/23/2023 Santyl was not available in the facility. No documentation was found that Wound NP-O or the physician were notified that the Santyl was unavailable. Had staff contacted Wound NP-O about the inability to attain Santyl, the treatment order may have been corrected to include Medihoney. On 2/21/2023 at 11:49 PM, on 2/23/2023 at 12:01 AM, and on 2/23/2023 at 8:04 PM in the progress notes, nursing charted the coccyx wound was cleansed with wound cleanser followed by topical wound gel and covered with a foam dressing. No documentation was found indicating Wound NP-O or a physician was consulted with regarding wound gel being applied instead of the ordered treatment. The treatment of Santyl to the coccyx wound followed by a border foam dressing was signed out as being completed on 2/24/2023, 2/25/2023, 2/26/2023, and 2/27/2023. Surveyor noted Santyl was not the current treatment that Wound NP-O had ordered. On 2/28/2023, R137 was seen by Wound NP-O. Wound NP-O documented the Unstageable coccyx pressure injury measured 3.5 cm x 2.6 cm x 0.2 cm with 75% slough and 25% granulation with moderate serosanguineous drainage. Wound NP-O changed the treatment order to Santyl on bordered foam, nystatin powder and zinc ointment to the peri wound and change daily. No documentation was found that Wound NP-O was aware the Santyl had continued as the order and not changed to Medihoney as ordered on 2/21/2023 and wound gel had been used on the wound instead of the Santyl. On 3/1/2023 on the TAR, a treatment order for the coccyx was entered: wash wound with wound cleanser, pat dry followed by antifungal powder followed by zinc followed by Santyl followed by a foam border dressing daily. On 3/7/2023, R137 was seen by Wound NP-O. Wound NP-O documented the coccyx pressure injury was now a Stage 3 that measured 3.1 cm x 1.7 cm x 0.2 cm with 10% slough and 90% granulation. Wound NP-O changed the treatment to Medihoney on bordered foam and nystatin powder and zinc to the peri wound changed three times a week. On 3/8/2023, R137 was discharged from the facility as planned. In a phone interview on 8/8/2023 at 12:44 PM, Surveyor asked Wound NP-O how Wound NP-O became aware of R137's pressure injuries. Surveyor shared with Wound NP-O that no documentation was found of any skin impairments prior to Wound NP-O seeing R137 on 1/24/2023. Wound NP-O stated generally Wound NP-O is notified by the facility of new wounds when Wound NP-O comes to the facility on Tuesdays to do wound rounds. Wound NP-O did not know the details of how or when R137's pressure injuries were discovered. Surveyor asked Wound NP-O what the process was on wound round days regarding seeing residents and having treatment orders entered onto the TAR. Wound NP-O stated either the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would accompany Wound NP-O when assessing the residents. Wound NP-O stated Wound NP-O would verbally tell whoever was assisting the treatment order, whether it was to continue the current treatment or to change the treatment to something different. Wound NP-O stated whoever was assisting would then enter the new orders into the resident's medical record. Wound NP-O stated the facility was going through a transition with administrative staff at one point and that may have been when R137 was in the facility. Wound NP-O stated Wound NP-O would give all paperwork to the Nursing Home Administrator (NHA) or the interim DON after rounds. Surveyor asked Wound NP-O if Wound NP-O would be notified if a specific treatment could not be completed as ordered due to not having the necessary supplies or if a different treatment was done due to lack of supplies. Wound NP-O stated Wound NP-O would expect to be notified. Surveyor shared with Wound NP-O the initial order on 1/24/2023 for R137's right ear Stage 3 pressure injury was not started until 1/27/2023 and the initial order for the coccyx Stage 3 pressure injury was not started at all and when the treatment order was changed on 1/31/2023, that was not started either. Surveyor shared with Wound NP-O that R137 did not have a treatment to the coccyx until 2/8/2023, two weeks after the wound was discovered. Surveyor shared with Wound NP-O that the Santyl treatment was not completed as ordered due to not receiving the Santyl from the pharmacy and the nursing staff substituted wound gel for the Santyl. Surveyor asked Wound NP-O if Wound NP-O was aware of the substitution. Wound NP-O was unaware of the facility not having Santyl available and stated the wound gel would not have been a substitution that Wound NP-O would have ordered. Surveyor shared with Wound NP-O that when Medihoney was ordered on 2/21/2023, the order was never entered onto the TAR and the facility continued with the Santyl order and the wound gel substitute. Wound NP-O was not aware of any of Surveyor's concerns and had not been notified by the facility of any alterations in treatment or that treatments were not changed when new orders were provided. The DON and ADON that were in the facility at the time R137 was a resident were no longer employed at the facility and unavailable for interview. On 8/9/2023 at 12:46 PM, Surveyor met with Nursing Home Administrator (NHA)-A and DON-B to discuss the concerns with R137's pressure injuries including the missed treatments orders, incorrect treatments used, and failure to notify Wound NP-O or the physician of the inability to complete a treatment as ordered. NHA-A and DON-B did not have provide any further information at that time. 2.) R31 was admitted to the facility on [DATE] with diagnoses of dementia with psychotic disturbance, diabetes, sarcoidosis (a condition that causes small patches of swollen tissue to develop in the organs of the body which could affect the skin), osteoarthritis, and Bell's Palsy. R31's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R31 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and the facility assessed R31 as needing extensive assistance with bed mobility, transfers, and toilet use and limited assistance with all other activities of daily living. R31 had an activated Power of Attorney (POA). Hospital discharge paperwork was reviewed and R31 did not have any documentation of skin breakdown while at the hospital. No treatment orders were on the discharge summary. On 3/24/2023 at 2:02 PM in the progress notes, nursing charted R31 had an open area to the coccyx. No further description was documented. At 6:38 PM in the progress notes, nursing charted R31 had a Stage 3 pressure injury to the coccyx with serosanguineous drainage. Both entries were written by Licensed Practical Nurses (LPNs). No assessment of R31's skin was documented by a Registered Nurse (RN). On 3/24/2023, a Baseline Care Plan was completed and indicated R31 had a current skin integrity issue to the coccyx. No measurements or descriptors were documented, and no interventions were implemented from the Baseline Care Plan. On 3/24/2023, R31's Braden assessment had a score of 13 putting R31 at moderate risk for skin breakdown. No treatment order was obtained from a physician and there was no documentation a physician was consulted with regarding R31's pressure injury. On 3/25/2023 at 3:28 PM in the progress notes, nursing charted R31 had an open area to the coccyx and a treatment was in place. Surveyor noted nursing did not chart what treatment was in place to the coccyx and no physician treatment order had been obtained. On 3/26/2023, an order for ProSource twice daily was implemented. Additionally, on 3/29/2023, an order for Boost 8 ounces daily was implemented. On 3/30/2023, a treatment order to cleanse the coccyx with normal saline, apply Xeroform and then apply Allevyn and cover with a border dressing daily was implemented. On 4/4/2023, R31 was seen by Wound Nurse Practitioner (NP)-O. Wound NP-O documented this assessment was the initial encounter with R31 and current interventions in place were pressure relieving cushion for sitting, every two hours turns while in bed, and elevate heels off bed with pillows or boots. Surveyor noted R31 did not have a Care Plan in place on 4/4/2023. Wound NP-O documented R31 had a Stage 3 pressure injury to the coccyx that measured 2.0 cm x 1.0 cm with 100% granulation and a scant amount of serosanguineous drainage. The peri wound was intact and blanchable with no signs or symptoms of infection. Wound NP-O ordered a treatment of Medihoney and bordered foam daily. Surveyor noted the new treatment order was not placed on the Treatment Administration Record (TAR). The facility continued with the treatment that had been implemented on 3/30/2023. On 4/10/2023, R31 tested positive for COVID-19. On 4/11/2023, R31 was seen by Wound NP-O. Wound NP-O documented the coccyx Stage 3 pressure injury measured 2.0 cm x 1.0 cm x 0.2 cm with 10% granulation and 90% healed with scant amount of serosanguineous drainage. Wound NP-O continued the current treatment of Medihoney daily. There is no indication that Wound NP-O was made aware that the Medihoney order was not implemented on 4/4/2023. R31's Stage 3 Pressure Injury Care Plan was first initiated on 4/11/2023 with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing weekly by the wound team; measure length, width, and depth where possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Follow the facility policies/protocols for the prevention/treatment of skin breakdown. -Inform (R31)/family/caregivers of any new area of skin breakdown. -(R31) to have air mattress on bed to reduce pressure and pressure relieving cushion in wheelchair -Staff to assist with routine toileting and skin care for incontinence. -Staff to assist with turning and repositioning with all care and as needed. On 4/15/2023, Magic Cup 4 ounces daily was ordered as a supplement. On 4/17/2023, R31 was diagnosed with pneumonia in addition to COVID-19. Doxycycline 100 mg twice daily was ordered for seven days. On 4/18/2023, R31 was seen by Wound NP-O. Wound NP-O documented the coccyx pressure injury was now Unstageable measuring 2.0 cm x 2.0 cm x 0.4 cm with 100% yellow slough and moderate serosanguineous drainage. Wound NP-O continued the current treatment of Medihoney daily and recommended bed rest for one week and an alternating pressure mattress. There was no indication that Wound NP-O was aware that R31 was not [TRUNCATED]

Based on interview, and record review, the facility did not provide necessary treatment and services to promote healing for 2 (R13 & R16) of 2 residents reviewed for pressure injuries. * R13's developed a stage 2 pressure injury on 7/29/20. There are no measurements, wound description or revision of the care plan. There is no further documentation for the Stage 2 pressure injury until a late nurses note on 8/16/20 for 8/12/20. There is no description of wound bed and no revision in care plan. On 9/28/20 the nurses notes indicates R13 is being monitored for a coccyx wound. There is no assessment, no revisions in the care plan and no further documentation until 10/25/20. On 1/29/21 the nurses note documents a small open area. There is no assessment of this area and no RN (Registered Nurse) assessment until 2/1/21 when DON-B indicated contact [CONDITION(S)]. On 3/7/21 R13 is identified as having an Unstageable pressure injury. * R16's heels were not floated according to the plan of care. Findings include: The Wound Care (Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . To implement preventative measures. To provide appropriate treatment modalities for ulcers according to industry standards of care. Under procedures 5. treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A. Inspect the wound B. Measure the wound C. Document the site, size, depth, color, drainage, and order in the wound charting button in ECS. Also document if there is any pain associated with the wound and/or s/s (signs symptoms) infection. D. MD/NP (medical doctor/nurse practitioner) must be notified and treatment orders must be documented. (See Facility Wound Care Protocols. E. Dietitian is to be notified. F. Care plan must be updated. G. DON (Director of Nursing) must be notified. H. Update family/responsible party. I. Document on the 24 hour change of condition board. 1.) On 3/22/21 at 8:16 a.m during the entrance conference meeting with CEO (Chief Executive Officer)-H and Administrator-A Surveyor requested a list of Residents with skin impairments including pressure injuries. At 10:56 a.m. Surveyor reviewed the pressure injury list dated 3/17/21 listing R13. Surveyor noted R13 is the only resident on the pressure injury list. Surveyor noted under the section [NAME] (in house acquired) is checked. Stage documents Left buttock Stage 3, wound measurements documents 2.24 x 1.13. x 0.10 partial granulation, under treatment documents [MEDICATION(S)] TID (three times daily and PRN (as needed), Braden documents 14 and air mattress documents yes. R13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] CARE PLANS The care plan I have the potential for impaired skin integrity related to my impaired mobility and notruria dated 12/12/18 documents approaches of Nurses --- Assess skin status dated 12/12/18 and Nurse Aide---encourage and assist to reposition. Skin barrier as needed, Inspect skin with cares and report abnormalities upon finding. The care plan I have the Potential for impaired skin integrity related to my impaired mobility and incontinence dated 2/4/2021 does not have any new approaches. The care plan potential for further impaired skin integrity related to my impaired mobility, narcotic use and incontinence Currently I have a pressure ulcer on my left buttocks dated 3/12/2021 documents approaches Nurses---Assess skin status, Air Mattress, Speciality cushion in wheel chair. dated 3/21/2021, Nurse Aide---Encourage and assist to reposition, Skin barrier as needed, Inspect skin with cares and report abnormalities upon finding. dated 12/12/2018 and Dietary---Provide food supplement. dated 3/12/21. The second floor CNA (Certified Nursing Assistant) care card updated 3/19/21 for R13 under the skin care section documents OPEN AREA on Buttocks Nap in bed after lunch. Under the bowel and bladder section documents Continent of B & B (bowel and bladder) Offer toileting after lunch Will need to use the bathroom right after eating for a bowel movement Uses bedpan at night, limit time to 10 minutes to prevent injury on buttocks. NURSES NOTES/MDS (MINIMUM DATA SET) The nurses note dated 7/23/20 documents new or sudden onset/change in condition: deep tissue injury to left buttocks 3.0 cm (centimeter) x (times) 3.0 cm with redness noted to affected area BP (blood pressure) 112/71, p (pulse) 80, T (temperature) 97.8, R (respirations) 17 SPO2 (oxygen saturation) 97% resident issue may be contributed to being on the bed pan at NOC (night) too long. resident will sit not longer than 10 minutes on bed pan to prevent further deep tissue injury. affected area will have a foam gauze applied, no [MEDICATION(S)] at this time, [Physician-I] will assess as needed on 7/23/2020. The Braden assessment dated [DATE] has a score of 19 which indicates not at risk. The nurses note dated 7/29/20 documents new or sudden onset/change in condition: Has a new sheared stage 2 open area to right lateral coccyx aligns directly to edge of bedpan. Residents daughter POA (power of attorney)-[J] updated. Does not want bed pan discontinued as it is her mothers right and feels she has fallen when she did not use bed pan at NOC (night). [Physician-I] updated on wound. Will see Resident tomorrow. Surveyor noted there are no measurements, no wound description and no revision in R13's care plan. There is no further documentation until late entry on 8/16/20 for 8/12/20. The 8/16/20 late entry for 8/12/20 indicates left buttocks stage 2 foam dressing q (every) 3 days measurements 2.0 x 1.0 x 0 description: no [CONDITION(S)] no s/s infection family request foam border dressing. nursing to monitor moisture from foam border dressing and change to thin [MEDICATION(S)] as needed. Surveyor noted there is no description of the wound bed and there is no revision in R13's plan of care. The nurses note dated 8/14/20 documents Updated POA-[J] and [K] daughter coccyx wounds are healed. Will cont (continue) to use foam dressings for protections. The nurses note dated 9/21/20 documents Walking program in room with staff. Dressing to coccyx CDI (clean dry intact) Will cont to monitor. The nurses note dated 9/28/20 documents Resident is alert and orientated x 2-3. Pleasant and cooperative. Noted for some forgetfulness at times. Resident is on a walking program and is ambulating with staff in the room. Resident is also being monitored for a coccyx wound. Dressing is CDI, not removed to assess area. Will cont to monitor. Denies pain and discomfort at this time. Surveyor noted this is the first documentation since the coccyx healed on 8/14/20. There is not an assessment with measurements, stage, or description of wound bed and no revisions in R13's care plan. There is no further documentation until 10/25/20. The nurses note dated 10/25/20 documents ongoing change in condition: Coccyx site reddened but blanchable, coccyx cleansed with NS (normal saline) and covered with thin [MEDICATION(S)] dressing. Reminded staff to Q2 (every two) repo (reposition) with pillows between legs. The annual MDS with an assessment reference date of 1/12/21 has a BIMS (brief interview mental status) score of 8 which indicates moderately impaired. R13 is dependent with two plus staff physical assist for bed mobility & transfers, requires extensive assistance with two plus person physical assist for toilet use and does not ambulate. R13 is frequently incontinent of bowel and bladder, is at risk of pressure injury development and is coded as not having any pressure injuries. The nurses note dated 1/29/21 documents Resident with small o/a (open area) to coccyx, left side, measures 1 cm x 1 cm. Dressing applied. DON (Director of Nursing) aware. Resident denies pain or discomfort at this time. Writer discussed with daughter-[K] about resident laying down after lunch. Per daughter, she face times resident after lunch. Daughter asked could we put a foam dressing on and writer explained that that is the dressing that is on. This note was written by an LPN (Licensed Practical Nurse). Surveyor noted there is no further assessment with the stage or wound description, and there is no revision in R13's plan of care. The nurses note dated 1/31/21 documents Monitored for ABT (antibiotic) tooth infection and O/A (open area) left coccyx. No adverse noted from ABT, Temp 98.1, dressing to coccyx area clean, dry and intact. Repositioned from side to side Q (every) 2 hrs (hours). No s/s (sign/symptom) of pain or discomfort noted. Stable and slept well during night. The nurses note dated 1/31/21 documents Continues on antibiotic for tooth abscess. No c/o pain. Dressing changed to coccyx/right buttocks to thin [MEDICATION(S)] due to increased skin moisture with foam border dressing. Continue to monitor skin integrity. VSS (vital signs stable) Afebrile at 97.4. The nurses note dated 2/1/21 includes history of resolved ulcers For condition documents has contact [CONDITION(S)] with pinpoint oa's (open areas) at edges of old drsng (dressing) not on bony prominence appears to be from incontinence and soiling of foam drsng (dressing). Area cleansed larger foam drsng. applied denies pain/disc. (discomfort). The nurses note dated 2/3/21 documents F/U (follow up) coccyx open area, dressings noted CDI. Resident repositioned to sides and slept between cares. No apparent distress or c/o pain voiced thus far. Stable. The nurses note dated 2/4/21 documents VSS Afebrile. Continues on antibiotic for tooth abscess - no complaints of pain - tolerating food without difficulty. Thin [MEDICATION(S)] placed on coccyx and right medial buttock-wounds dry and closing. No surrounding [CONDITION(S)]. The Braden assessment dated [DATE] has a score of 16 at risk. The nurses note dated 2/6/21 documents Resident remained calm until after supper. [MEDICATION(S)] 0.25 mg (milligram) given. Coccyx drsg (dressing) applied after cleansing with NS (normal saline). Site dry, healing. The nurses note dated 2/8/21 documents Thin [MEDICATION(S)] placed on coccyx extending to medial right and left buttock. No noted open area. Left buttock with small scab formation. No [CONDITION(S)]. R13 was hospitalized from 2/23/21 to 2/25/21. The nurses note dated 2/25/21 includes documentation of dressing to buttocks changed per POC (plan of care). Surveyor was unable to locate an assessment of R13's skin when she was readmitted . The nurses noted dated 2/26/21 includes documentation Dressing to buttocks changed. The nurses note dated 3/1/21 includes documentation Area to coccyx healed, dressing intact to coccyx for protection. The nurses note dated 3/7/21 documents Resident with o/a to left buttock 5 cm x 3.4 cm and to right buttocks .4 x .4 cm. Area with some odor. Wound bed to left buttock with pinkness and yellow tone to wound bed and right buttock with pink wound bed. Updated DON. Received new order Cleanse with NS, apply Santyl to wound bed left buttock, f/b (followed by) skin prep and foam border dressing. Cleanse right buttock with NS f/b skin prep and foam boarder dressing. Resident was laid down after lunch and pillows used for positioning. Resident with no pain to coccyx. There are no revisions to R13's care plan The nurses note dated 3/8/21 includes documentation of left buttocks, unstageable tissue type slough measurements 4.5 x 3.0. The significant change MDS with an assessment reference date of 3/8/21 documents a BIMS score of 7 which indicates moderately impaired. R13 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use, does not ambulate and is frequently incontinent of bowel & bladder. R13 is at risk for pressure injuries and is coded as having 1 unstageable slough and/or eschar pressure injury. The nurses note dated 3/17/21 documents Weekly monitoring [Wound Doctor-Q] in assessed buttock wound reports area is not pressure but excoriation due to incontinence NOR (new order received) dc (discontinue) foam dressing apply [MEDICATION(S)] barrier cream q (every) shift and prn (as needed). residents daughter [POA-J] updated. The nurses note dated 3/22/21 indicates has full thickness of exposed (stage 3) Left buttocks granulation 2.24 x 1.13. Treatment changed to [MEDICATION(S)] TID (three times daily) and PRN (as needed). OBSERVATIONS AND INTERVIEWS On 3/22/21 at 10:30 a.m. Surveyor observed R13 sitting in a wheelchair in her room trying to match up her stockings. Surveyor observed R13 is sitting on a wheelchair cushion. On 3/22/21 at 11:41 a.m. Surveyor observed R13 sitting in a wheelchair in her room watching mass on TV. On 3/22/21 at 12:45 p.m. Surveyor observed R13 sitting in a wheelchair in the dining room eating lunch. Surveyor observed there is a cushion in R13's wheelchair. On 3/22/21 at 1:46 p.m. Surveyor observed R13 sitting in a wheelchair in her room Face-timing. On 3/23/21 at 7:24 a.m. Surveyor spoke with RN (Registered Nurse)-C and asked if she does treatments. RN-C replied yes. Surveyor asked RN-C if she has completed any Resident's treatments. RN-C replied no. Surveyor informed RN-C Surveyor would like to observe R13's treatment. RN-C informed Surveyor she can do the treatment now if R13 is getting up. At 7:28 a.m. Surveyor accompanied RN-C to R13's room. Surveyor observed CNA (Certified Nursing Assistant)-G is in R13's room. R13 was observed in bed with her pants down to her ankles and wearing an incontinence product. CNA-G indicated she had just washed R13 up. RN-C washed her hands and placed gloves on. CNA-G positioned R13 on her left side and RN-C showed Surveyor R13's pressure injury, explaining to Surveyor where the pressure injury started and showed how the pressure injury was on the left and right buttocks. RN-C informed Surveyor they are just putting [MEDICATION(S)] on the pressure injury and were placing a border foam dressing prior. RN-C applied the [MEDICATION(S)] on R13's pressure injury and informed CNA-G she will leave the [MEDICATION(S)] so when she changes R13 later she can put on the [MEDICATION(S)]. RN-C removed her gloves and washed her hands. CNA-G fastened the incontinence product and pulled up R13's pants by positioning her from side to side. On 3/23/21 at 11:48 a.m. Surveyor observed R13 sitting in a wheelchair in her room. On 3/24/21 at 7:41 a.m. Surveyor asked RN-C how R13 developed the pressure injury. RN-C informed Surveyor she didn't exactly know but it was probably from sitting in the chair. RN-C explained she had a little sore on the coccyx which they were placing an [MEDICATION(S)] and then border dressing. RN-C informed Surveyor she was off a few days came back and there was something on the right buttocks which she thought started as an abrasion. RN-C informed Surveyor therapy doubled checked the cushion as R13 spends a lot of time in the chair and thinks Therapy Director-F brought her a new cushion. RN-C informed Surveyor she spoke with Therapy Director-F last week or the week before. Surveyor asked RN-C if R13 is able to reposition herself in the wheelchair. RN-C informed Surveyor R13 can do a little but staff would have to reposition her in her wheelchair and they would have to reposition her at meal time. RN-C informed Surveyor the R13 is now eating in the dining room and eats better. On 3/24/21 at 7:46 a.m. Surveyor observed R13 in bed sleeping on her right side. Surveyor observed R13's heels are not being offloaded. On 3/24/21 at 10:16 a.m. Surveyor spoke with TD (Therapy Director)-F regarding R13's cushion. TD-F explained on 9/21/20 Administrator-A requested they do a wheelchair audit for Residents with a low Braden score. At this time R13 was sitting on a foam cushion and the cushion was changed to a low profile Roho cushion. On 3/24/21 at 12:45 p.m. Surveyor met with DON (Director of Nursing)-B to discuss R13's pressure injury. Surveyor informed DON-B R13's care plan dated 3/12/21, which Surveyor was provided with, has an approach dated 12/12/18 and inquired if there was a previous care plan. DON-B informed Surveyor there was a previous care plan. DON-B provided Surveyor with this care plan which is listed under the care plan section. DON-B informed Surveyor after she started at the Facility, which was June 30, 2020 they did a skin sweep, education to the CNA's regarding recognizing any redness or change in skin with incontinence, repositioning, check & change frequently and if a Resident is refusing to document. Also staff were using bath blankets which she had housekeeping remove. DON-B informed Surveyor one of the things they are doing is looking at Braden scores and implementing interventions based on the score. Surveyor inquired how often Resident's skin is assessed. DON-B informed Surveyor weekly on shower days. Surveyor informed DON-B Surveyor did not note weekly skin assessments for R13 and asked where this information would be documented. DON-B informed Surveyor it's in the to do list which DON-B informed Surveyor she doesn't know if Surveyors have access to. DON-B informed Surveyor R13's initial pressure injury was received from the bed pan which healed. The family refused to get rid of the bed pan so they continued with foam dressing because she broke down in the area frequently. DON-B informed Surveyor the daughter wanted her mother to use the bed pan instead of being toileted as she was afraid she would get up on her own and fall. Surveyor asked if there was any investigation as to how long R13 was on the bed pan. DON-B informed Surveyor she's not sure how long R13 was on the bed pan but they padded the bed pan and educated the night shift. DON-B inform Surveyor she's not sure if she was informed of R13's development of a Stage 2 pressure injury in August as if she was told she would have charted. Surveyor inquired when R13 was readmitted back from the hospital on 2/25/21 was her skin assessed as Surveyor had noted in the nurses note R13's dressing should be changed according to the plan of care. DON-B informed Surveyor they do an assessment upon admission. Surveyor informed DON-B Surveyor was unable to locate an assessment. Surveyor informed DON-B on 3/7/21 the nurses note indicates pressure injuries on the left and right buttocks and her note dated 3/8/21 only addressed the left buttocks. Surveyor inquired what happened with the right buttocks. DON-B informed Surveyor there was nothing there. Surveyor inquired how R13's pressure injury developed on 3/7/21. DON-B informed Surveyor she was monitoring R13 pretty closely and can see the area is related to incontinence stool under the foam pad and was definitely pressure from sitting or laying. Surveyor asked why wasn't the pressure injury identified until it was Unstageable and then became a Stage 3. DON-B informed Surveyor it was really weird, the wound bed was yellow whitish and firm when she saw it. Surveyor asked DON-B how Wound Doctor-Q classified R13's left buttocks as excoriation when there was slough in the wound bed. DON-B explained Wound Doctor-Q saw the area after the fact. DON-B informed Surveyor she explained to Wound Doctor-Q the area had slough and was a pressure injury. DON-B informed Surveyor after her discussion with Wound Doctor-Q he told her to stage the area as a Stage 3 pressure injury. DON-B informed Surveyor Wound Doctor-Q changed the treatment to [MEDICATION(S)]. Surveyor informed DON-B of the concerns of R13's development of stage 2 pressure injury on 7/29/20 with no measurements, wound description or revision of the care plan. There is no further documentation until a late note on 8/16/20 for 8/12/20. There is no description of wound bed and no revision in care plan. On 9/28/20 the nurses notes indicates R13 is being monitored for a coccyx wound. There is no assessment, no revisions in the care plan and no documentation until 10/25/20. On 1/29/21 the nurses note documents a small open area. There is no assessment of this area and no RN (Registered Nurse) assessment until 2/1/21 when she indicated contact [CONDITION(S)]. On 3/7/21 R13 is identified as having an Unstageable pressure injury. 2.) R16's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The at risk for ulcers care plan dated 9/25/20 documents approaches of Nurses---Assess skin status, Assess nutrition status dated 12/14/18 and Nurse Aide---Encourage and assist to reposition, Skin barrier as needed, Inspect skin with cares and report abnormalities upon finding, May use gripper socks/slippers. Float heels in bed. The significant change MDS (minimum data set) with an assessment reference date of 1/22/21 documents a BIMS (brief interview mental status score) of 00 which indicates severe impairment. R16 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers and does not ambulate. R16 is at risk for pressure injury development and is coded as not having any pressure injuries. The second floor CNA (Certified Nursing Assistant) care sheet updated 3/19/21 under the ADL's (activities daily living) section documents Assist of 1 with ADLS. Gripper sock/slippers to be worn for transfers and when he is up in chair. NO SHOES float heels in bed. Bilateral tubi grips on AM (morning) off at HS (hour sleep). Encourage to sleep in bed. Enabler bar to help in bed repositioning. On 3/22/21 at 10:08 a.m. Surveyor observed R16 in bed with his eyes closed and on his back with the head of the bed elevated. Surveyor observed R16's heels are resting directly on the mattress and are not being offloaded. On 3/23/21 at 7:20 a.m. Surveyor observed R16 laying flat on his back with his eyes closed. Surveyor observed R16's heels are resting directly on the mattress and are not being offloaded. On 3/23/21 at 8:26 a.m. Surveyor observed R16 awake in bed on his back holding a Styrofoam glass with water. Surveyor observed R16's heels are resting directly on the mattress and are not being offloaded. R16 informed Surveyor he wants a glass of water. Surveyor explained to R16, Surveyor wasn't able to give him water but would find staff. Surveyor informed SW (Social Worker)-E of R16's request. On 3/23/21 at 12:07 p.m. Surveyor observed R16 in bed on his back with the head of the bed elevated high. Surveyor observed R16's heels are resting directly on the mattress and are not being offloaded. On 3/24/21 at 7:40 a.m. Surveyor asked RN (Registered Nurse)-C how staff should float R16's heels when he is in bed. RN-C informed Surveyor with pillows and she has taught staff to put a pillow length-wise so his heels will float and also use a pillow in the chair. On 3/24/21 at 7:48 a.m. Surveyor observed R16 awake in bed on his back. R16 has bare feet and his heels are resting directly on the mattress. On 3/24/21 at 8:34 a.m. Surveyor observed R16 continues to be in bed. Surveyor observed R16's heels are not being offloaded. On 3/24/21 at 9:05 a.m. Surveyor informed RN-C of the observations of R16's heels resting directly on the mattress and not being offloaded. RN-C replied that's a problem. On 4/24/21 at 12:42 p.m. Surveyor informed DON (Director of Nursing)-B of the observations of R16's heels on the mattress and not being offloaded.

Based on interview and record review, the facility did not ensure that 3 of 4 residents reviewed for falls (R13, R6, and R12) received adequate supervision and assistive devices to prevent falls. Residents R13, R6, and R12 were at risk for falls. When completing a root cause analysis, the facility did not assess the effectiveness of previous fall interventions and modify the care plan based on the assessment. Example 1 regarding R13 is being cited at a scope and severity of a G (actual harm/isolated) related to R13 requiring sutures following a fall. Findings include: The facility's Falls Assessment/Prevention & Intervention/Catch a Falling Star Policy & Procedure was dated 1/15/18. The section titled, IDT [Interdisciplinary Team] review noted the following: Resident and interventions will be reviewed for effectiveness at the Weekly Fall Review Meeting and modifications will be made as necessary. Verify care plan and CNA care card were updated. 1.) R13 diagnoses includes hypertension and arthritis. The at risk for falls care plan initiated 12/1/18 documents approaches of Nurses--Encourage to ask for assistance, Instruct on safety, Check comfort dated 12/1/18. Nurse Aide---Call light in reach, Assist with ambulating, transferring, toileting, Anticipate needs dated 3/11/19. OT (Occupational Therapy) screen. Encourage to ask for assistance dated 2/5/19 Resident is being seen in therapy, interventions remain current 3/12/19. Reminder cues to resident to lock her wheel chair when scooting back dated 11/3/19. Provide a visual reminder in room (lock wheels) dated 11/5/19. Staff immediately educated on proper use of gait belt dated 6/5/20. Staff instructed to use gait belt with all transfers. Frequent checks dated 10/6/20. Medication review dated 11/24/20. Medical evaluation and Offer assist with getting clothes from closet dated 2/24/21. If leaning forward or to the left side encourage to lay down in bed dated 2/25/21. The second floor CNA (Certified Nursing Assistant) care sheet updated 3/19/21 for R13 under the ADL (Activities Daily Living) section includes Offer to get clothes from closet If leaning to the left or forward while sitting in w/c (wheelchair) lay down in bed. The nurses note dated 6/4/20 for incident type documents Unintentional Change in Position to a lower plane. Date of incident documents 06/04/2020. Time of Incident documents 16:15 (4:15 p.m. ). Notes documents resident was being walked for restorative therapy and slipped. The incident report dated 6/4/20 under describe exactly what you observed or head documents writer was informed resident legs gave out, buckled and lost balance and fell . Staff did not have gait belt applied to resident teaching done. The fall investigation form dated 6/4/20 for the question did the resident sustain an injury as a result of fall documents right elbow with 1.5 x 1.5 cm (centimeter) Under what happened? documents She had her walker while I had the wheelchair behind her and she fell forward after I told her to sit. The nurses note dated 10/1/20 late entry for 9/30/20 documents Upon writer coming onto the unit at 1400 (2:00 p.m.), I was called by a staff member to resident's room to witness resident lying on her left side on to the floor in a pool of blood, writer and a second nurse proceeded to assess resident and obtain vitals and information as to what happened, resident stated she was trying to pick up a fork off the floor and fell out her chair hitting the left side of her body. resident was found to have a 6cm (centimeter) skin tear to left forearm, skin tear to right knee, bruising to bilateral hands and top of left shoulder BP (blood pressure) 128/70, R (respirations) 18, P (pulse) 88 T (temperature) 98.2. resident was then placed back in her chair and her wounds were cleaned and dressed. Writer was called by staff at 1440 (2:40 p.m.) to witness resident had fallen onto the floor again resident stated she was trying to fold clothes and tipped out of her chair, with a laceration to the right side of her temple hitting her head a second time, writer notified administration and was told to send resident out to [name] ER (emergency room ) for evaluation. resident returned at 2115 (9:15 p.m.) with CT and labs with the exception of the UA (urinalysis) were all negative, UA pending per hospital and results would be provided. Resident right side of face is swollen, bruised with a visible hematoma, multiple bruising to upper extremities, and steri strips are intact to left forearm BP 93/55, SPO2 96% RA (room air), P 75, T98.7, R 16, resident placed on crane checks, ROM WNL (range of motion within normal limits). The incident report dated 9/30/20 at 1405 (2:05 p.m.) under describe exactly what happened indicates maintenance man yelled for nurse. Resident was laying on floor blood from skin tear seen. resident stated that she was trying to pick up a fork that was on the ground. The incident report dated 9/30/20 at 1440 (2:40 p.m.) indicates CNA got writer and stated they heard resident hit the floor. resident was found lying on floor resident stated she was trying to fold laundry when she fell . The fall investigation dated 9/30/20 for the question did the resident sustain an injury as a result of fall documents hematoma (R) forehead. assisted to bed sent to ER. Surveyor noted the Facility did not determine the root cause of R13's fall including investigating as to who last saw R13 and were previous interventions in place. The nurses note dated 10/6/20 documents follow up: fall on 9/30/2020 times 2 unwitnessed with multiple bruises/swelling to right side of face and 6 cm laceration to left forearm with steri strips intact, resident is now a easy stand due to inability to stand, resident ROM is decreased to lower extremities, resident received schedule Tylenol times 2 500mg (milligram) for facial discomfort. The nurses note dated 11/18/20 documents Up in w/c self propel. +1 LE (lower extremity) [CONDITION(S)] to RLE (right lower extremity)/ankle. VSS (vital signs stable) Afebrile. Surveyor noted this is the only nurses note dated 11/18/20. The incident report dated 11/18/20 under describe exactly what you observed or heard documents Resident yelling for help on floor on butt/side large hematoma forehead had been incontinent. Under were any immediate measures put into place to protect the resident and ensure safety? documents Got resident ready for bed [MEDICATION(S)] x 1 dose given not effective took considerable time to settle down and relax. Surveyor noted the Facility did not determine the root cause of R13's fall including investigating as to who last saw R13 and were previous interventions in place. The nurses note dated 11/20/20 documents Fall f/u (follow up) of 11/18/20 [NAME] checks WNL (within normal limits) VSS, Afebrile 97.9 Resident up in w/c self propelling with room reading papers, cards-keeping busy. Reduced swelling of forehead. Bruising of right eye and cheek present. Denies pain/discomfort at present. The annual MDS with an assessment reference date of 1/12/21 has a BIMS (brief interview mental status) score of 8 which indicates moderately impaired. R13 is dependent with two plus staff physical assist for bed mobility & transfers, requires extensive assistance with two plus person physical assist for toilet use and does not ambulate. R13 is frequently incontinent of bowel and bladder and is coded as not having any falls since prior assessment. The nurses note dated 2/23/21 documents 1615 (4:15 p.m.) Res (Resident) found by staff on the floor near bed and closet/dresser face down. Res states was reaching for clothing, lost balance in w/c and fell to floor. Laceration to LT (left) forehead and hematoma to LT eye. Neuros WNL (within normal limit). Res was sent to [name] hosp. (hospital). The incident report dated 2/23/21 under describe exactly what you observed or heard documents Found laying on floor face down next to closet w/c behind her. The falls investigation under what happened documents she was leaning forward and was reaching down to pick up clothes on floor and She always gets her bed clothes out every night. Under why think the fall happened documents She's always reaching into her closet and drawers there was a sock & sweater on the floor and I had just seen her and help her sit up because she was leaning forward. Surveyor noted the Facility did not determine the root cause of R13's fall including investigating as to who last saw R13 and were previous interventions in place. The nurses note dated 2/25/21 documents Pt (patient) re admitted from [name] Hosp w/Dxs (with diagnoses) [CONDITION(S)] (hypertension)/post fall. Alert and oriented w/(with) intermittent periods of confusion and forgetfulness norm per baseline. Very pleasant and [NAME] (cooperative) w/ appropriate affect. VSS AP (apical pulse) RRR (regular rate and rhythm). Lungs diminished clear; No SOB (shortness of breath), cough or adventitious sounds auscultated. Pox 95% on RA (room air). Skin pink warm and dry w/ adequate tugor. 3 sutures to forehead CDI (clean dry intact). Multi bruising/discoloration to L facial/orbital area noted . The nurses note dated 3/1/21 documents Re-admission. Resident slept well, awake for cares. Response time seems a bit slower than usual. Ecchymosis present to entire left periorbital area, but improving, starting to turn yellow with some yellow extending down left cheek. Sutures intact to upper mid forehead, no s/s (signs/symptoms) infection. VS (vital signs): BP 169/69, P74, R14, pulse oximeter 94% on room air. PRN Tylenol given at 0415 (4:15 a.m.) for c/o (complaint of) headache. The nurses note dated 3/8/21 documents Resident is alert and orientated with periods of confusion and forgetfulness. Bilateral buttocks dressing changed. Forehead sutures x (times) 3 removed. Area is clean and dry. No s/s of infection. The significant change MDS with an assessment reference date of 3/8/21 documents a BIMS score of 7 which indicates moderately impaired. R13 requires extensive assistance with two plus person physical assist for bed mobility, transfer, & toilet use, does not ambulate and is frequently incontinent of bowel & bladder. R13 is coded has having a fall one month and two to six months prior to admission. On 3/22/21 at 10:30 a.m. Surveyor observed R13 sitting in a wheelchair in her room trying to match up her stockings. Surveyor observed R13 is sitting on a wheelchair cushion. On 3/22/21 at 11:41 a.m. Surveyor observed R13 sitting in a wheelchair in her room watching mass on TV. On 3/22/21 at 12:45 p.m. Surveyor observed R13 sitting in a wheelchair in the dining room eating lunch. Surveyor observed there is a cushion in R13's wheelchair. On 3/22/21 at 1:46 p.m. Surveyor observed R13 sitting in a wheelchair in her room Face-timing. On 3/23/21 at 11:48 a.m. Surveyor observed R13 sitting in a wheelchair in her room. RN-C was exiting R13's room stating R13 had lost her snickers candy bar. On 3/24/21 at 7:46 a.m. Surveyor observed R13 in bed sleeping on her right side. On 3/24/21 at 2:24 p.m. Surveyor spoke with DON-B regarding R13's falls. Surveyor informed DON-B Surveyor the Facility did not determine the root cause of R13's fall including investigating as to who last saw R13 and were previous interventions in place. Surveyor inquired for R13's fall on 6/2/20 would the expectation have been when R13 was being ambulated, should staff have put a gait belt on. DON-B informed Surveyor when staff are hired the therapist trains them they have to use a gait belt unless the resident is hand held. Surveyor inquired about R13' two falls on 9/30/20 and what was done to keep her safe. DON-B informed Surveyor their intervention was to have therapy screen after the first fall. DON-B informed Surveyor she wants to say R13 has a reacher. Surveyor informed DON-B this is not on R13's care plan. DON-B indicated after R13's first fall on 9/30/20 the nurse was doing neurochecks and paper work for the first fall, then R13 fell again and she had to be sent out. Surveyor informed DON-B Surveyor did not note any increase in her supervision after the first fall. Surveyor discussed R13's fall on 11/18/20. DON-B informed Surveyor a medication review was done. Surveyor discussed R13's fall on 2/23/21 with DON-B. DON-B informed Surveyor the CNA had just seen R13 a few minutes prior as the nurse told the CNA to help R13 as she was leaning far forward. DON-B informed Surveyor she spoke with the CNA who informed her R13 was in her closet trying to get her night clothes out, the CNA repositioned R13 in her wheelchair and she must have dropped something on the floor. DON-B indicated when R13 was found she was face forward and her sweater was on the floor. DON-B informed Surveyor R13 went to the hospital had a medical evaluation due to bumping her head and required sutures. Surveyor informed DON-B R13 has sustained multiple falls due to her reaching for an item and Surveyor did not note where there is a plan in place to address this. DON-B informed Surveyor R13 is very anxious and nervous. R13 doesn't want to listen to staff and her family is right with her. DON-B informed Surveyor R13's family told DON-B R13 likes to go in her closet and get things out that's why they wanted a big room. DON-B informed Surveyor staff has stepped on her hearing aides twice and the facility had to pay for them when they were going into her room. DON-B informed Surveyor they are trying to find interventions but doesn't know how to change what R13 likes. R13 likes to look at her stuff and doesn't want help. 2.) R6's diagnoses includes Alzheimer's Disease, hypertension, and anxiety. The at risk for falls care plan initiated 5/30/18 documents interventions starting 2020 of Offer to stand at the railing when restless in chair dated 2/4/2020 When leaning forward in chair, offer to lay down in bed dated 3/10/20 Bolster pillow to be placed on both sides of the bed dated 3/17/20 Increase 1 on 1 visits due to behaviors related to Covid-19 isolation measures. Bed rearranged in room and staff educated on double checking that wheels to bed are not engaged when it is low dated 3/24/20 Wheelchair removed. Broda to be used at tall (all) times. dated 4/28/20 Offer to get up at 0630 (6:30 a.m.) if allows, body pillow at edge of bed to make feel more secure dated 8/31/20 Keep head of bed less than 35 degrees Motion Sensor dated 9/22/20 Lay down for nap after lunch and dinner dated 2/7/21. Pillow at edge of bed near wall dated 3/8/21 The second floor CNA (Certified Nursing Assistant) care sheet updated 3/19/21 under the ADL's (activities daily living) section documents 1 assist with ADLS, Gripper socks when in bed, Bolster pillows both sides when in bed Offer light blanket on hot days, Pillow @ (at) edge of bed, Pillow under legs in broda chair, Reposition frequently in broda chair for comfort, Increase supervision at night, If allow get up at 6:30 am, Keep HOB (head of be) less than 35 degrees, Lay down for nap after lunch and dinner. Pillow at edge of bed near wall. The nurses note dated 8/26/20 for incident type documents Unintentional change in position to a lower plane. Date of incident documents 8/26/20. Time of Incident documents 06:50 (6:50 a.m.). The incident report dated 8/26/20 documents for describe exactly what you observed or heard documents Found on the floor at the side of bed hanging off of bedside mat laying on (L) (left) arm. Resident denied hitting head, brief dry, bruising to (L) arm ROM WNL (range of motion within normal limits). The fall investigation form for did the resident sustain an injury as a result of the fall documents bruising to (L) arm/bed not functioning won't go down. Surveyor noted the Facility did not determine the root cause of R6's fall including investigating as to who last saw R6 and were previous interventions in place. The nurses note dated 9/18/20 for incident type documents Unintentional change in position to a lower plane. Date of incident documents 9/18/20. Time of Incident documents 18:40 (6:40 p.m.). The incident report dated 9/18/20 for describe exactly what you observed or heard documents Resident found laying on (L) (left) side on top of foam mat HOB (head of bed) was elevated 80-90 degrees, bolster and pillow under resident on mat. Surveyor noted the Facility did not determine the root cause of R6's fall including investigating as to who last saw R6 and were previous interventions in place. The nurses note dated 2/7/21 documents Resident had a fall from her Broda chair. No injury. Resident often swings legs over the side of the chair. Surveyor noted the Facility did not determine the root cause of R6's fall including investigating as to who last saw R6 and were previous interventions in place. The incident follow up note dated 3/6/21 documents At 0530 (5:30 a.m.) CNA (Certified Nursing Assistant) entered room and found resident laying on right side with knees bent on the floor between bed and wall. CNA had just been in room at approximately 0500 (5:00 a.m.) to change resident's brief (dry brief at time of fall). With bed being down all the way down, not able to lock position. Resident has some mild redness to mid back. No apparent head injury; however, since fall was not witnessed, neurological assessments initiated. [Physician-R], DON (Director of Nursing), Administrator, and family notified of fall. [Name] Hospice called and RN (Registered Nurse) was here to assess. The incident report dated 3/6/21 for describe exactly what you observed or heard documents At 0530 CNA entered room and found resident laying on (R) (right) side with knees bent on the floor between bed and wall. CNA had just been in room appox 0500 to change resident brief (dry brief at time of fall) Bed all the way (down arrow) not able to lock in position injury listed above. For recommended steps needs a bed that doesn't move or just a frame reoccurrence is likely d/t (due to) residents habit of swinging legs around and pushing against wall. Surveyor noted the Facility did not determine the root cause of R6's fall including investigating as to who last saw R6 and were previous interventions in place. The annual MDS (minimum data set) with an assessment reference date of 3/10/21 has a BIMS (brief interview mental status) score of 00 which indicates severely impaired. R6 requires extensive assistance with two plus person physical assist for bed mobility, is dependent with two plus person physical assist for transfers, requires extensive assistance with one person physical assist for toileting and does not ambulate. R6 is always incontinent of bowel and bladder and is coded as having one fall with no injury since prior assessment. On 3/22/21 at 1:49 p.m. Surveyor observed R6 in bed on her left side. Surveyor observed the left side of the bed is against the wall and the right side has a mattress on the floor. There is a pillow under the fitted sheet on the right side. Surveyor did not observe a pillow on the left side against the wall. On 3/23/21 at 7:44 a.m. Surveyor observed R6 in bed on her side dressed for the day. Surveyor observed the head of the bed is up high, greater than 35 degrees. Surveyor observed there is mattress on the floor next to the bed on the right side. Surveyor observed R6 placing both of her legs out of the bed on the side and then placing them back on the mattress. Resident is yelling out [NAME]. On 3/23/21 at 12:14 p.m. Surveyor observed R6 sitting in a broda chair in her room. On 3/24/21 at 7:51 a.m. Surveyor observed R6 in bed on her right side. Surveyor observed the bed is down low, the left side of the bed is against the wall and the right side there is a mattress on the floor. Surveyor observed there is a pillow on the mattress on the left side. On 3/24/21 at 8:36 a.m. Surveyor observed R6 sitting in a broda chair in her room with her legs hanging over the side of the broda chair. On 3/24/21 at 2:10 p.m. Surveyor spoke with DON-B regarding R6's falls. Surveyor informed DON-B Surveyor the Facility did not determine the root cause of R6's fall including investigating as to who last saw R6 and were previous interventions in place. DON-B informed Surveyor for R6's fall on 9/18/20 staff had assist R6 with fluids and doesn't know why staff left R6's bed that way. Surveyor inquired how R6's bed should have been. DON-B informed Surveyor the head of the bed should be less than 35 degrees because R6 likes to curl up into a ball and if the head of the bed is up she will tumble off. DON-B informed Surveyor for R6's fall on 2/7/21 she thinks R6 was restless and wanted to lay down. DON-B indicated CNA-T brought R6 into her room after dinner, did other things and didn't lay R6 down . CNA-T was in the mist of giving R6 a shower to another Resident when R6 fell . DON-B informed Surveyor for R6's fall on 3/6/21 DON-B stated to Surveyor, you probably have seen [R6] puts her legs off everything, this is kind of what she likes to do dangle her legs when in bed. DON-B informed Surveyor staff has been educated the bed needs to be low and the wheels locked. DON-B informed Surveyor there should also be a pillow on the edge of the bed so she knows where the edge is. 3.) R12 is [AGE] years old and has diagnoses of Alzheimer's, Anxiety, and [CONDITION(S)]. The 8/14/20 Significant Change Minimum Data Set noted that R12's cognition is severely impaired. R12 requires extensive assistance from one staff person for transfers. Her balance is unstable and she is only able to stabilize with staff assistance. The 7/28/20 Falls Care Area Assessment (CAA) was triggered due to R12's history of falls, her severely impaired vision and the use of antipsychotic, antianxiety, and antidepressant medications. It was determined that R12 continued to be at risk for falls and staff would continue to provide interventions to reduce R12's risk of falls. The facility initiated a care plan on 6/2/19 due to R12's risk for falls. The facility initiated interventions with each new fall and those interventions are detailed below. R12 had 11 falls between 9/26/20 and 3/15/21. R12 incurred only minor injuries that included skin tears and a bump to her forehead. 11 of those falls occurred in R12's room and only 2 of them were witnessed by staff. All of the falls occurred on either the PM of Night Shift. Seven of the 11 falls occurred when R12 was attempting to use the bedside commode in her room. The facility attempted to determined a root cause analysis by completing an Accident/Incident Report and a Falls Investigation Form, for each of R12's falls. However when completing these forms the facility did not review the interventions in place at the time of the fall and determine whether the fall interventions were working to prevent further falls. New interventions were initiated, but not always added to the care plan. Additionally, there is no evidence that the facility assessed R12's need for increased supervision when 9 of her 11 falls occurred in her room when no staff were present. FALLS R12's falls were reviewed with Director of Nursing (DON) - B on 3-24-21 at 9:05 am.) 9/26/20 9:00 PM R12 slid off of her bed when she attempted to transfer herself to her bedside commode. The falls investigation form indicated that the root cause was R12's wanting to use the commode and wanting help immediately. The IDT recommended that Occupational Therapy (OT) evaluate R12's room environment and R12's toileting plan was to be re-evaluated. The care plan was updated on 9/29/20 and noted the OT intervention. There was no update to the toileting plan. When interviewed, DON - B was unable to explain why the care plan did not include a toileting plan for R12. 10/29/20 12:30 AM R12 fell when she transferred herself from her bed in an attempt to get to the commode which was across the room. The fall was not witnessed and R12 incurred no injury. The fall investigation form indicated that R12's air mattress should be discontinued, as it caused R12 to slide out of bed. It was also recommended that R12's bowel and bladder pattern be reviewed. The care plan was updated on 11/6/20 and noted these interventions, to include toileting every 2-3 hours. The fall investigation form did not indicate that the effectiveness of the OT room assessment had been reviewed. The plan to assess R12's bowel and bladder pattern was not a new intervention and was to have been implemented with the prior fall as noted above. DON - B was unable to explain why R12's toileting plan had not been updated with her 9/26/20 fall. 11/16/20 6:30 AM R12 fell when she tried to sit on her walker because she thought it was her commode. This fall was witnessed by staff and R12 sustained a skin tear to her left arm. The fall investigation form indicated that R12 should have a low bed and that her commode should be near her walker at the head of the bed. These interventions were added to the care plan on 11/16/20. DON - B said that the rationale for the low bed was to prevent R12 from injuring herself during transfers. The placement of the commode near the head of the bed, was to allow R12 easy access to the commode. These 2 interventions appeared to work at cross purposes. If R12 exited her bed in the low position, it would be harder for her to safely stand up and access her walker and the commode. DON - B said that they wanted to encourage R12 to use the commode, as she had urinated on the room heater in the past. Again, the facility had not reviewed the prior intervention which including a toileting plan for R12 and whether or not this was working or needed to be updated. When interviewed, DON - B said that the investigation form noted that R12 had last been toileted at 6:00 AM and so R12's toilet plan was not reviewed. 11/17/20 4:30 PM R12 was found on the floor in the bathroom of her room. She said that she wanted to wash her hands. The fall was not witnessed and no injury occurred. R12 had eaten a snack and her hands were dirty. The fall investigation determined that R12's hands should be washed after eating. This intervention was added to the care plan on 12/1/20. The fall investigation did not review R12's need for increased supervision. R12 had 4 falls in less than 2 months. 3 of the 4 falls occurred in R12's room when she was not supervised by staff. 12/17/20 6:35 AM Staff witnessed R12 as she slid off of the commode in her room. Her brief was at her ankles. The fall investigation form did not review the prior interventions of the low bed and the placement of the commode at the head of the bed. The new intervention was to toilet R12 between 5:30 am and 6:00 am and to check R12 every 2 hours after that if she was awake. The fall investigation form did not review prior interventions. When R12 fell on [DATE], it noted that she had been toileted at 6:00 am and fell at 6:30 am attempting to use the commode. It did not make sense that toileting R12 between 5:30 am - 6:00 am and then checking her every 2 hours would prevent further falls when R12 attempted to toilet herself every 30 minutes on 11/16/20. DON - B was unable to provide additional information. The intervention was added to the care plan on 12/29/20. 12/18/20 5:55 AM Staff heard the resident calling for help via a monitor at the nurses' station. Staff found R12 on the floor in front of the commode with her brief pulled down. The fall was not witnessed and R12 sustained a skin tear to her left middle finger. The falls investigation form indicated that R12 should be toileted between 5:30 am and 6:00 am and this was added to the care plan on 12/29/20. This intervention was recommended when R12 fell on [DATE], but not reviewed and added to the care plan until 12/29/20. However, the fall investigation form did not review when R12 had last been toileted when she was found on the commode at 5:55 am and if her toileting plan needed to be adjusted. DON - B was asked about the monitor at the nurses' station and said that it had been implemented as a fall intervention on 11/17/20 so that staff could hear if R12 was attempting to move about in her room. This intervention had not been added to the care plan and there was no root cause analysis of the monitor as an intervention to prevent falls for R12. There was no evidence that the IDT had reviewed the effectiveness of the monitor when R12 fell on [DATE] and 12/18/20. R12 had 6 falls in less than 3 months. 5 of the 6 falls occurred when R12 was attempting to use the commode in her room and unsupervised. The IDT did not assess R12's need for increased supervision. 12/29/20 11:30 AM R12 fell when she was walking to her closet to get pants. The fall was not witnessed and R12 sustained no injury. The fall investigation report indicated that all of R12's pants were too small for her. R12 had removed the tight pants and was walking to the closet to get a different pair of pants. The fall investigation report indicated that larger pants would be obtained for R12. This intervention was not added to the care plan until 2/1/21. 1/24/21 3:30 PM R12 was found sitting on the floor in her room. Her commode was tipped over and there was urine on the floor. The fall was unwitnessed and R12 sustained bruising to her right forehead. The fall investigation form indicated that R12 was to be brought to the nurses' station after being toileted between 2:30 PM and 3:00 PM. This was added to the care plan on 1/26/20. The previous interventions including the monitor at the nurses' station and the location of the commode in R12's room had not been reviewed by the IDT to determine if they had been implemented and whether or not they were effective. 2/22/21 8:15 PM R12 fell when she attempted to transfer herself to bed. The fall was unwitnessed and she sustained a bruise to her left elbow. The fall investigation form did not assess the prior interventions of the low bed and the monitor at the nurses' station. The new intervention was to assist R12 to bed between 8:00 PM and 9:00 PM. 3/10/21 7:30 PM R12 was found sitting on the floor next to her bed. The commode was tipped over. R12 had been assisted to the toilet 30 minutes prior to this when she was assisted to bed. The fall was unwitnessed and R12 sustained no injury. The falls investigation form did not assess the prior interventions of the low bed and the monitor at the nurses' station. The new intervention was to move R12's commode to the foot of her bed. When interviewed, DON - B said the commode was moved to the foot of the bed from the head of the bed. When the commode was at the head of the bed, it was thought that R12 was using the commode to assist in rising from the bed. 3/15/21 9:45 PM R12 was found lying on the floor with a blanket beneath her head. The fall investigation did not address the prior interventions of the low bed and monitor. The new intervention was to schedule pain medication. On 3/17/21, the care plan noted that R12 was receiving scheduled Tylenol. DON - B said that R12's blood pressure was elevated at the time of the fall and this was discussed with R12's physician. It was thought that R12 might be experiencing pain related to her elevated blood pressure. R12's medication was reviewed as related to her pain. However, R12 was receiving an antipsychotic, antianxiety and antidepressant since at least December 2019. There was no evaluation of these medications and how they might contribute to R12's falls. Cross-reference F758.

Based on observation, interview, and record review the facility did not ensure 1 (R13) of 3 residents received necessary services to promote healing and prevent pressure injuries from worsening R13 was noted to have a new open area to their coccyx on 5/17/19. A complete RN assessment was not documented to the open area, R13's care plan was not updated, the treatment administration record does not contain documentation of a treatment to the area, and the facility's nurse who completes weekly assessments of pressure injuries was not notified. From 5/17/19-6/5/19 there was no documented complete RN assessment of the wound. On 6/5/19, R13 was observed by the surveyor to have two unstageable wounds to the coccyx sacrum area. Findings include: The facility's Wound Care policy and procedure, updated on 10/2, documents, Upon discovery of a pressure ulcer and other alterations in skin, the licensed staff must: A. Inspect the wound B. Measure the wound C. Document the site, size, depth, color, drainage, and odor in the skin folder in ECS (electronic charting system), Also document if there is any pain associated with the wound and/or s/s (signs/symptoms) of infection. D. MD/NP (Nurse Practitioner)must be notified and treatment orders must be documented. E. Dietician is to be notified F. Care Plan must be updated. G. Wound Care Nurse or Designee must be notified. H. Update Family/responsible party. I Document on the 24 hour change of condition board. R13 had [DIAGNOSES REDACTED]. R13's Significant Change Minimum Data Set (MDS) assessment with an assessment reference date of 3/29/19 documents R13 had a Brief Interview for Mental Status Score of 9 indicating R13 is moderately cognitively impaired, required extensive assistance of two plus persons physical assist for bed mobility, transfers, and toilet use. The assessment documents R13 is at risk for the development of pressure injuries. R13's Pressure Ulcer Care Area Analysis from the 3/29/19 Minimum Data Set Assessment documents R13 had impaired mobility and a recent decline in ADLs (activities of daily living.) The Care Area Analysis documents the description of problem as (R13) was admitted with factors that may increase her risk for pressure ulcers. Staff used a Braden Scale to help determine her current risk. At this time, she is considered to be at risk. Progress notes on 5/10/19 document R13's general skin condition as intact. Progress notes on 5/17/19, by LPN (licensed practical nurse)-H document, Hospice in and gave bath. Skin w/d (warm/dry) and pale. Has tiny reopened area to buttocks per RN hospice nurse. Told to apply barrier creame (sic). No [MEDICAL CONDITION]. Is slight of build. Hospice notes on 5/17/19 document, Skin intact (reported by HHA/Home Health Aide) pt (patient) has a very small opening on butt. Pt stays in her chair for 12 hrs (hours) a day. Applying barrier cream to this area. The surveyor reviewed R13's medical record and was unable to find documentation the physician was notified of the new skin impairment on 5/17/19. The surveyor reviewed R13's TAR (treatment administration record)and noted no documentation of barrier cream being applied to the open area in May. The surveyor reviewed R13's care plan and noted R13's care plan was not updated with the development of actual skin impairment on 5/17/19. The surveyor was unable to find documentation of an assessment that included, measurements, color, and a description of the wound bed. Hospice notes on 5/21/19 document New open area to coccyx reported by HHA, unable to visualize @ this visit. On 06/06/19 at 10:08 AM, the surveyor interviewed Hospice RN-K, DON (Director of Nursing)-B, and RN-D. Hospice RN-K informed the surveyor on 5/17/19 she was notified by an aide that R13 had an open area. Hospice RN-K stated it was a pin point area, that was more white, like no circulation into that area so we were using barrier cream. Hospice RN-K stated a couple of day later R13 was having diarrhea, was on senna, so we backed off on the senna. Hospice RN-K stated then an aide told her a couple of days later something was going on, that R13 had a linear type area that was described like a fissure. Hospice RN-K stated she was unable to see the area because R13 did not want to lay down. The surveyor asked if Hospice RN-K told the facility. Hospice RN-K stated no, she felt it was due to the diarrhea. Hospice RN-K stated she did not think it was a wound, was very superficial. Progress notes on 5/24/19, by LPN-J, document O/A noted to coccyx area, (2.5x3cm.) Tender to touch. Wound bed pink in color, no drainage or foul odor noted. Message left for (RN-D)(wound nurse)and (physician) update at time. [MEDICATION NAME] border (for protection) in place until wound team assesses. On 5/24/19 a new treatment was ordered to Apply [MEDICATION NAME] border to coccyx area AM every other day. On 5/28/19 a new treatment was ordered to Cleanse coccyx with normal saline apply skin prep to area surrounding wound and cover with foam dressing with border every other day PM. Progress notes on 5/31/19, by LPN-I document, Bed bath given, o/a (open area) to coccyx, foam dressing applied. On 06/05/19 at 02:47 PM the surveyor interviewed RN-D, who oversees pressure injuries at the facility. The surveyor asked what the process is when a new skin impairment is noted. RN-D stated nursing staff on the unit do an assessment, update the physician, if the cause is questionable I do an assessment to see if pressure or not. The surveyor asked how RN-D becomes notified. RN-D stated they leave me a message. The surveyor asked RN-D if she updates the care plan. RN-D stated yes, usually the nurses update it right away. The surveyor asked who continues to monitor wounds. RN-D stated if it is pressure she does every week. The surveyor asked what is expected for an assessment. RN-D stated location, measurement, push score, drainage, odor, an overall description of the wound for that week. The surveyor informed RN-D of the concern of R13 having a documented open area on her coccyx with no documented complete RN assessment of the area. RN-D stated it was her understanding R13 had macerated skin. The surveyor asked RN-D if the area was open. RN-D stated not to my understanding. On 06/05/19 02:52 PM the surveyor interviewed LPN-C. LPN-C informed the surveyor she had done R13's treatment to her coccyx over the weekend. The surveyor asked LPN-C to describe R13's wound. LPN-C stated the area is on the coccyx, is about a dime size first layer of tissue is gone and on the left side some slight discoloration, slightly red/slightly purple. LPN-C reported the wound bed was pinky white, with no bleeding, no drainage, and no slough. Progress notes on 6/5/19, by LPN-C, document a late entry for 6/2/19 stating open area-location(s): coccyx with affected area pink in color, no visible drainage or swelling, redness noted, area at 1cm x 1cm. area cleansed with normal saline f/b (followed by) skin prep to outer aspect of wound followed by foam dressing, resident repositioned on side. On 06/05/19 at 04:11 PM, the surveyor observed R13 in her room in her bed. R13 gave the surveyor permission to observe RN-D complete her treatment. The surveyor observed RN-D remove an old dressing. The surveyor observed 2 approximate dime sized pressure injuries on R13's sacrum/coccyx. The surveyor observed the pressure injury on the coccyx was dark red/ brown in color with yellowish white adherent slough around it, and a second area with 100% adherent yellow/white slough. At 04:19 PM, RN-D informed the surveyor it is pressure, and that she is very disappointed. RN-D stated both areas are unstageable with 100% slough. RN-D stated she will talk with hospice, but will probably recommend Santyl. On 6/5/19, after the observation with the surveyor, RN-D documented the area to the coccyx as unable to stage, 1x1.4 cm with 100% adherent slough, with yellow/dark brown wound tissue. RN-D documented the area proximal to the coccyx wound as unable to stage, 1.5 x 1 cm, with 100% adherent yellow slough. The surveyor noted from when the area was first noted on 5/17/19-6/5/19 there was no documented complete RN assessment of the wound. On 6/5/19 R13's care plan was updated related to the development of actual skin impairment. On 06/06/19 at 10:08 AM DON-B informed the surveyor LPN-C had left a message for RN-D, but RN-D's phone was not taking any new messages and that is where the breakdown occurred.

Based on observations, record reviews and interviews, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for 4 ( R3, R4, R1 and R5) of 5 sampled residents. *On 1/7/17, R3 fell out of a stand up lift during a transfer. According to the investigation, R3 raised her hands off the handles of the lift and lifted her arms, somehow falling out of the lift. Although there were 2 staff present during the transfer, one of the Certified Nursing Assistants (CNAs) had her back turned to R3 when the fall occurred. R3 sustained a large hematoma to the back of her head. There was no evidence that all staff were re-educated on proper application of the harness used in the stand up lift, and the need for 2 staff be involved, hands on, for a safe stand up transfer. * On 2/1/17, R4 was transferred to the toilet with a 1 person assist instead of a stand up lift as specified in the care plan. R4 was left on the toilet unsupervised, and fell to the floor without sustaining injury. The facility investigated the incident and action was taken with the CNA who transferred R4 and left R4 on the toilet unsupervised (CNA-G). The facility did not have evidence that all direct care staff were re-educated regarding the need to follow care plans in regard to transfer status. *On 4/20/17, R1 who according to the care plan required a full mechanical lift for transfers, was pivot transferred by Certified Nursing Assistants' (CNAs) H and I, sustaining a right ankle fracture. The facility investigated the incident and submitted the investigation to the state agency. The investigation revealed no mechanical lift had been used for the transfer. Although the facility put some corrective measures in place after this injury, the facility did not have evidence that all direct care staff were re-educated on the need to follow care plans in regard to transfer status. * On 6/22/17, the surveyor observed CNAs C and L complete a transfer for R5 utilizing a stand up lift. The harness was not snugly fastened around R5's chest. Although CNAs C & L initially widened the base of the lift when raising R5 from the wheelchair, the base was narrowed to get through a doorway into the bathroom. The base was not widened again when R5 was lowered to the toilet, or when raised from the toilet and taken back to the wheelchair. The base was widened to lower R5 into the wheelchair. The manufacturer recommends the base be widened for safety. Occupational Therapist (OT)-J, who trains new employees on the use of lifts in the facility, stated he trains staff to ensure the harness is snugly fastened before raising the lift. Example #3 pertaining to R1 rises to scope and severity level for G (actual harm/isolated). Findings include: The facility Mechanical Lift policy with an approval date of 8/2015, indicated: 1. Nursing and/or Physical Therapy to assess the resident need for a Mechanical lift or stand. 2. Indicate need for stand/lift on the residents care card. 3. Two staff persons are to perform the lifts and transfers with the device. 4. Staff to examine the slings and lifts before using them. Any defective equipment is to be removed immediately and reported to Maintenance or Nursing Supervisor. 5. Report any worn or faulty slings to the nurse on duty. Do not use worn/faulty slings. Remove them from the units. 6. Maintenance Director to inspect equipment and accessories monthly. 7. Maintenance Dept. to mark all removable parts (swivel bars, slings etc.). 8. Nursing to transfer Resident according to the operations manual. 1. The surveyor reviewed R3's medical record on 06/21-06/22/17. Review of the record revealed R3 had a fall from a sit-to stand (EZ) lift, occurring on 01/07/17. Electronic Nurses' Note documentation on 01/07/17, indicates, Resident in mechanical lift stand to transfer, slipped out of belt some how and fell to floor. 7 x 8 hematoma-posterior top of head. R3 was sent to the Emergency Department for further evaluation and had no other injuries other than the hematoma. The surveyor requested and received a Post Fall Assessment. The assessment dated [DATE], indicates R3's fall occurred at 7:00p.m. as Certified Nursing Assistants (CNA)s-E and G were transferring her to the bathroom. CNAs E & G informed the nurse completing the post fall nursing assessment that R3 let go of the device (EZ stand) and threw her arm over the top of it rather than holding on to the handles. Review of a QA (Quality Assurance) Tool included in the Post Fall Assessment indicated under the section Contributing Factors: 1. R3 may have let go of the stand and 2. Belt of EZ stand needed to be replaced The facility provided the surveyor with an inspection report (completed by a representative of the manufacturer of the lift) of the EZ stand used in the transfer of R3. The report dated 01/04/17, found no issues with the lift. The facility initiated an investigation and collected statements from the 2 Certified Nursing Assistants (CNAs)-E & G involved in R3's transfer and fall. Review of the statements revealed no information as to how R3 may have fell from the EZ stand lift. However, the statement obtained from CNA-E indicated that once R3 was in the EZ stand lift, she turned her back to R3 to pull down the covers on her bed and was not actively participating in the transfer. CNA-E's statement indicates she did not see R3 fall, rather heard the fall. During an interview with the Director of Nursing (DON)-B on 06/21/17 at 1:20p.m., DON-B indicated that her expectation for staff during a transfer with an EZ stand lift is that both staff members have hands on a resident from the initiation of the lift until the resident is seated on the toilet. A statement obtained from Registered Nurse (RN)-K dated 01/08/17, revealed RN-K had CNAs E &G re-enact R3's transfer using RN-K in place of R3 on the lift. Again, the facility could not determine the cause of R3's fall from the EZ stand lift. The surveyor spoke with Nursing Home Administrator (NHA)-A on 06/21/17, at 3:00p.m. NHA-A indicated re-education on the proper use of the EZ stand lift was provided to CNAs E & G but not other facility staff. On 06/21/17 at 1:52p.m., the surveyor spoke with CNA-D. CNA-D reported she has received no recent in-service training on the use of mechanical lifts and/or following the resident care plan when providing assistance with transfers. On 06/22/17 at 8:57a.m., the surveyor spoke with CNA-C. CNA-C reported she worked at the facility for approximately 1 year and has received no recent in-service training on the use of mechanical lifts and/or following the resident care plan when providing assistance with transfers. 2. A review of the personnel file for CNA-G (one of the CNAs involved when R3 fell out of the stand up lift), revealed references to a fall involving R-4 on 2/1/17. On 6/22/17, the surveyor reviewed R4's record and the investigation of the fall. According to the Post Fall Nursing Note, R4 fell /slid off the toilet to the floor in the shower room toilet. R4's care plan specified the use of an EZ stand (stand up lift), which according to the Post Fall Nursing Note was not utilized. Staff left R4 unattended in the bathroom prior to the fall. No injury was sustained. According to an annual MDS dated [DATE], R4 requires extensive assistance and 2 staff for transfers. A review of the facility investigation of the fall revealed CNA-G did not use a stand up lift as she initially stated was used. CNA-G told NHA-A that R4 did not need to use the stand up lift anymore. Additionally, CNA-G transferred R4 by herself. On 6/22/17 at 8:45am, NHA-A told the surveyor that it is facility protocol that any resident who uses a lift for transfers is not to be left unsupervised in the bathroom due to the risk of falls. NHA-A stated action was taken with CNA-G for not following the care plan by using the stand up lift and not following facility policy regarding supervision while toileting. On 6/22/17 at 1:50pm, DON-B told the surveyor that R4 should have been transferred with an EZ stand lift, and instead was transferred by one CNA, CNA-G. Initially, it was reported that 2 CNAs had participated in the transfer with no EZ stand lift, CNA-G and CNA-H. Upon re-interview, it was determined that CNA-G had acted independently. According to investigative notes written by NHA-A, CNA-H was counseled as she was a new employee. On 6/22/17 at 8:45am, NHA-A stated that the action taken with CNA-G and counseling of CNA-H were the documented responses to this fall. There was no evidence provided that direct care staff were re-educated regarding following the care plans in terms of resident specific transfer status. 3. Surveyor reviewed R1's record on 6/21-6/22/17. R1 had a Brief Interview for Mental Status (BIMS) completed on 4/21/17. This assessment indicated R1 was cognitively intact. A Quarterly Minimum Data Set (MDS) with a target date of 1/29/17, indicated R1 required total assistance and 2 staff with transfers. A Quarterly MDS, with a target date of 4/27/17, also indicated R1 required the total assistance and 2 staff with transfers. An undated copy of the CNA care sheet for R1, which was included with the facility self report investigation, indicated R1 utilized a mechanical lift with transfers. According to documentation in the nurses notes on 4/20/17 at 7:50pm, R1 was complaining mild right ankle/foot pain. Nursing documented on 4/20/17 at 8:55pm, that R1 stated It happened so fast, but did not specify what happened. R1 complained of foot and ankle pain. No swelling, redness, heat or bruising was noted. The facility self-report investigation revealed the following: Certified Social Worker (CSW)-M was asked to see R1 the morning of 4/21/17 regarding complaints of ankle pain. R1 told CSW-M that she hurt her foot yesterday getting into bed. R1 indicated she stumbled and had 2 helpers with her. R1 was pretty sure staff had not used the mechanical lift. Administrator-A and Director of Nursing-B were notified of the report of staff transferring R1 without the mechanical lift. An investigation was initiated. It was determined that CNAs H & I had transferred R1 in the afternoon of 4/20/17 without a mechanical lift. CNA-H's statement (undated) indicated she and CNA-I transferred R1 by a two person transfer after being incontinent. CNA-I had told CNA-H that it was ok to transfer R1 that way. After the transfer R1 complained of pain. The nurse was immediately informed of the complaint of pain. CNA-I's statement (undated) indicated that on 4/20/17, at 2:05pm, R1 had been incontinent of bowel and the CNAs did not have proper equipment in the room and it was no where to be found. CNA-I stated that earlier in the day CNA-I had assisted a student with a transfer using a sling that was too small. CNA-I indicated CNA-H and herself transferred R1 under arm into the bed. After she got into bed R1 started screaming her ankle. There was no evidence in the investigation that CNA-I followed the facility procedure regarding the need to report equipment problems with lifts to the nurse supervisor. Licensed Practical Nurse (LPN)-O's statement (dated 4/21/17) indicated that CNA-I was aware R1 needed to be transferred back to bed for incontinence care on 4/20/17 at 1:30pm. CNA-I told LPN-O that she had never put the sling back under R1 (sling is removed after resident in wheelchair). LPN-O instructed CNA-I on how to place the lift sling. At approximately 2:30pm, LPN-O was notified that R1 was complaining of foot pain. The right foot was slightly more puffy than the left foot. R1 stated she didn't know why she was hurting, and the CNAs denied bumping the foot during the transfer. On 4/21/17, R1 was moaning with pain. LPN-O noted the right foot was more swollen and painful. On 4/21/17, R1 told LPN-O that the 2 girls yesterday that put me back to bed didn't use a machine. LPN-O questioned CNA-H about the transfer and was told they didn't use the lift because of R1 having loose stools up her back and down her legs, so they did a pivot transfer with 2. LPN-O notified the Nurse Practitioner (NP)-P. A progress note written by NP-P on 4/21/17, indicated NP-P was requested to evaluate R1 due to pain in the right ankle. The right ankle was hyperextended, swollen and painful with attempts to passive range of motion. An x-ray was ordered. Results of the X-ray taken on 4/21/17, was a nondisplaced transverse fracture of the right distal tibia (fractured ankle). R1's ankle was immobilized until she could be seen by an orthopedic physician. On 6/21/17 at 10:00am, the surveyor spoke with DON-B regarding R1's transfer and subsequent fractured ankle. DON-B stated R1 told her that she hadn't stood for years, implying that the CNAs stood her for a pivot transfer. DON-B told the surveyor that she believed staff stood R1 and pivot transferred her causing the fracture. On 6/21/17 at 1:35pm, the surveyor spoke with DON-B regarding any staff re-education regarding following care plans in regard to transfers. DON-B stated some 1:1 re-education with staff (particularly CNA-H) was done, but DON-B stated she did not keep any record of the re-education provided. During the daily meeting with NHA-A on 6/21/17 at 3:00pm, the surveyor was informed that Occupational Therapist (OT)-J does all the staff training for transfers and lift usage. NHA-A stated OT-J has been doing on-going training of staff as needed. The surveyor spoke with OT-J on 6/21/17 at 10:00am. OT-J stated he does all new employee lift training and reviewed the check list used for the training with the surveyor. The check list includes instructions to use the CNA caresheet when caring for residents. OT-J stated he also is part of the team that reviews all residents after falls. When asked if he has done any staff retraining regarding using lifts and following the care plans, OT-J stated he may have done some staff training, but it would have been specific to a particular resident's transfer needs. OT-J stated he has not done any recent house wide training, but would be willing to do so if asked. On 6/21/17, NHA-A shared with the surveyor a copy of the P(NAME) (Plan of Correction) related to the incident of 4/20/17 with R1. The plan included, Policies were reviewed and staff were re-educated and 1:1 counseling provided by DON. An extensive audit of all care plans focusing on transfer status was completed and audits of all transfer techniques were initiated. On-going training regarding all obligations to resident (neglect, care plan, Quality of Care, Quality of Life and reporting obligations) will continue with all staff routinely and random audits will occur daily. During the exit with the facility on 6/22/17, NHA-A stated the facility has provided training to staff regarding following care plans and transfers. The surveyor asked NHA-A to provide evidence of the training and who has attended. On 6/26/17, NHA provided a sample (via electronic messaging) of individualized training for CNA-I. It showed CNA-I had attended CNA meetings on 1/16/17 and 2/23/17. The meetings covered handwashing protocol, dignity cares, general interaction with residents, bowel and bladder sheets, merit increases, round protocol, customer service, taking direction from nurse, draw sheets, and 2 hour rounds. The surveyor was not provided any evidence that the facility has retrained staff with an emphasis on transfers and following the care plan in regards to transfers. On 6/22/17 at 8:10am, the surveyor asked CNA-F, who stated she had been employed by the facility for 6 years, if there had been any in-services or training related to transfers and following the care plan. CNA-F stated there had not been any additional training offered or required. 4. On 6/22/17 at 9:15am, the surveyor observed CNAs C and L complete a stand up transfer for R5. A review of R5's record on 6/22/17 reveals: An annual MDS dated [DATE], indicated R5 requires extensive assistance with 2 staff for transfers. According to the CNA Caresheet, last updated 6/21/17, R5 transfers with a mechanical stand lift. At 9:15am R5 was taken to her room. The Medcare lift was brought to the room. The legs of the stand were opened to fit around the wheelchair. R5 was cued to place her feet on the foot platform. The harness was placed around R5's upper body, and the safety strap was clipped together but not tightened. There was a visible gap of approximately 4 inches between R5's clothing and the safety strap. R5 was cued place her hands on the handles. R5 was raised to a standing position. The harness shifted upwards slightly resting at R5's under arm area. The legs of the stand were closed to fit through the bathroom door. Once through the door the legs were left closed as R5 was placed over the toilet and lowered. Once on the toilet, the lift was not disconnected. At 9:25am, R5 was raised from the toilet. The legs of the lift remained in the closed position. CNAs L and C returned R5 to her wheelchair (in bedroom adjoining the bathroom). The legs were opened to fit around the wheelchair and R5 was lowered into the wheelchair. The lift harness was disconnected from lift and the safety belt was released to remove the harness. On 6/22/17 at 10:00am, the surveyor spoke with Occupational Therapist (OT)-J, who provides orientation and training on transfers and lifts. The surveyor asked how OT-J instructs staff to secure the safety strap on the harness for the stand up lift. OT-J states staff are told that the safety strap should be snug to prevent the harness from shifting upwards and causing pressure under the arms. The surveyor described what was observed with R5's transfer and OT-J stated it sounded like the safety strap was not snug enough. The surveyor then asked about opening the legs of the lift. OT-J stated that he instructs staff that the legs should be opened for stability. If the base needs to be closed to fit under a bed or through a door ways, the base should be opened as soon as possible. On 6/22/17 at 10:30am, the surveyor shared the transfer observation with DON-B. DON-B stated the base should be open when moving the lift, except when passing through a doorway. The surveyor asked for a copy of the manufacturer recommendations for the use of the stand up lift. The following information is from a copy of the Medcare Lift and Stands operators manual. Applying Harness: Position the top of the harness around the upper body of the resident, just below the shoulder blades and under the arms. Fasten safety strap around the patient to secure resident in harness. Positioning the Medcare Stand: Open the legs of the stand with the leg spreader bar and position in front of resident Resident Transfer and Repositioning Procedure: Transfer resident to commode, chair, toilet, wheelchair, bed etc. Lower resident by using handset control. When resident is seated, remove straps and remove sling and push stand away. The facility mechanical lift policy directs staff to follow the operations manual. During the observation of R5's transfer, CNAs L and C did not ensure the safety strap was securely fastened, did not keep the legs in the open position whenever possible and did not remove the harness and push the sling away after R5 was assisted to the toilet. When R3 fell out of the stand up lift during a transfer on 1/7/17, the facility did not use the fall as an opportunity to re-educate all staff on the proper use of the stand up lift. The observation of the transfer with R5 on 6/22/17, indicates staff are still not following operator recommendations for safe use of the stand up lift. When R4's care plan was not followed on 2/1/17, and staff transferred R4 without the standup lift and left R4 unattended on the toilet, which resulted in a fall, staff were not re-educated on following care plan recommendations for transfers. On 4/20/17, staff did not use a stand up lift to transfer R1 as recommended in the care plan, resulting in R1 sustaining a fractured ankle. After R1's improper transfer, the facility still has not conducted facility wide training as demonstrated by interviews with CNAs C, D, & F.