Every finding on record at The Estates at Rush City LLC

Based on observation, interview, and document review the facility failed to ensure dishes were properly dried and stored to prevent the growth of bacteria. In addition, the facility failed to ensure safe storage of resident personal food item occurred at the facility. These deficient practices had the potential to impact all residents who dined at the facility and or stored food in the designated resident fridge. Findings include:During an observation on 1/28/26 at 9:40 a.m., the dietary aide (DA-A) was washing dishes in the kitchen. DA-A removed plates from the washing rack, stacked the plates, and then put them in the plate cart. The plates had visible droplets of water on them. DA-A removed wet plate holders and lids from wash racks, stacked them, and then placed them on storage carts. Upon interview, DA-A confirmed the plates, lids and plate holders had been put away wet. DA-A explained the dishwasher had a drying agent that dried dishes fast, so they waited until things were mostly dry before they put them away. They had not been told it was not okay to stack and put things away if they were not all the way dry.During an interview on 1/28/26 at 10:09 a.m., the culinary director (CD) inspected the plate holders, lids, and plates and confirmed they were not dry. The CD stated all dishes should be completely dry before being stacked. The primary concern with putting dishes away wet was infection prevention. Trapped stale moisture or water sitting could lead to mold, mildew, or bacteria growth.During a resident fridge review on 1/28/26 at 11:43 a.m., the CD stated the mini fridge/freezer in the dining room was designated for resident storage of personal food items. The CD opened the fridge and then the freezer compartment. The CD found a large, folded icepack under frozen meals in the freezer. The CD removed the ice pack from the freezer, put it in the garbage, and stated only food should be stored in the fridge. There should never be therapeutic ice packs or non-food items stored in the fridge as it was unsanitary and created risk for cross contamination of food items. The icepack was approximately 8.5 by 14 inches long with the wording equate therapy combo hot or cold packs with illustrations of the ice pack applied to different body parts. During an interview on 1/29/26 at 1:50 p.m., the director of nursing (DON) stated their expectation was that only food would be stored in the resident fridge. For food safety, there should never be personal use packs or other non-food items stored in the fridge.On 1/29/26, a request for dishwashing and storage policies was made. The facility response indicated the facility did not have policies specific to dish washing and storage.The resident policy for personal food items did not address the storage of non-food items within the fridge.

Based on interview and document review, the facility failed to ensure accuracy of the minimum data set (MDS) for 3 of 4 residents (R1, R26, R34) reviewed for accuracy of assessments.Findings include:R1's quarterly minimum data set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of metabolic encephalopathy and palliative care. The functional assessment, section GG, was not completed.R1's care plan dated 1/27/26, identified R1 was non-ambulatory and needed assistance with all activities of daily living (ADL)s. R26's admission minimum data set (MDS) dated [DATE], identified intact cognition with diagnoses of disc displacement of the lumbar region, chronic pain, and congestive heart failure (CHF). The functional assessment, section GG, was not completed.R26's care plan dated 1/6/26, identified the need for assistance with bathing, dressing, personal hygiene, ambulation, and transfers.R34's quarterly minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of congestive heart failure and hypertension (HTN). M=no pressure ulcer/injury, risk for PU, no stage 1-4, no unstageable, no venous or arterial. Negative responses for other ulcers, wounds and skin problems, pressure relieving device for bed. R34's provider order dated 11/19/25 identified to provide wound care to the right posterior thigh lesion by cleansing with wound cleanser, pat dry, apply skin barrier to peri wound, dust collagen particles over the wound bed and cover with hydrocolloid dressing and change every three and as needed for saturated or missing dressing.R34's January treatment administration record (TAR) identified R34 had dressing changes performed on 1/3, and 1/6.During an interview on 1/29/26 at 11:44 a.m., registered nurse (RN)-A who identified as an MDS coordinator confirmed R34's MDS dated [DATE], section M didn't indicate dressing changes were performed and R34's TAR had wound care for a lesion on 1/3, and 1/6/26. For R 1 and R26, RN-A confirmed section GG was not done and stated they had a nurse manager who wasn't working out during that period.During an interview on 1/29/26 at 2:33 p.m., the director of nursing (DON) stated MDS accuracy was important because it needs to be accurate and correct and was part of their payment.

Based on observation, interview and record review, the facility failed to ensure proper personal protective equipment (PPE), hand cleaning and gloving practices were in place during the care of a resident on enhanced barrier precautions (EBP) for 1 of 1 resident (R1) reviewed for catheter care. In addition, the facility failed to provide hand hygiene or sanitation prior to meals. This had the ability to affect all residents who ate in the dining room.Findings include: R1: During a medication administration observation on 1/29/26 at 11:25 a.m., licensed practical nurse (LPN-B) was getting R20's medications ready for administration. LPN-B stepped to the wall hand sanitizer, sanitized their hands, and without gloves broke one of R20's pills in half. LPN-B administered an inhaler to R20 first and then proceeded to administer R20's pills with apple sauce. R20 stated they could not swallow one of the pills and asked LPN-B to break the pill in half. LPN-B picked up the pill, broke it in half and administered it to R20. LPN-B did not perform hand hygiene or apply gloves prior to handling the pill. During an interview on 1/29/26 at 11:31 a.m., LPN-B stated they had sanitized their hands before they broke the tablet in half at the medication cart, but gloves would have been better. LPN-B confirmed they had not sanitized their hands and/or applied gloves before they broke R20's pill in the room. For infection control, they should have sanitized their hands and put gloves on before they handled R20's pill. During an interview on 1/29/26 at 1:50 p.m., the DON stated for infection prevention reasons nurses should not directly handle resident pills. They expected nurses to properly sanitize their hands and apply gloves before they directly handled resident medications. The facility policy Preparation and General Guidelines Medication Administration dated 5/2022, section 6. Medication Splitting: instructed prior to handling tablets for splitting hands are to be sanitized and examination gloves are to be worn to prevent touching tablets during splitting. R1's quarterly minimum data set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of metabolic encephalopathy, palliative care, unstageable pressure ulcer (PU) left buttock, stage four PU to the right elbow, vascular dementia, restlessness, agitation, and delusional disorder. The MDS also identified R1 had an indwelling urinary catheter and wound care but didn't assess R1's functional status under section GG. R1's care plan dated 1/21/26, identified the need for assistance of two to assist with toileting hygiene, dressing, grooming, and bathing, to provide catheter care per policy, an assist of two with mechanical lift for transfers, and to provide assistance with bed mobility and repositioning. R1's provider orders dated 1/19/26, identified enhanced barrier precautions (EBP) be in place related to R1 having wounds and a catheter. During an observation and interview on 1/28/26 at 10:05 a.m., nursing assistant (NA)-D donned gloves and checked R1's incontinent brief and used a disposable wipe to clean the top layer of barrier cream off R1's groin and inner thigh area. NA-D turned from the bed and opened the bathroom door with the knob using her still-gloved hand. NA-D brought a trash can from the bathroom to the bedside, with the same gloves, and proceeded to wipe his front perineal area. NA-D then removed her dirty gloves, grabbed the bed controller and adjusted the bed height and attempted to roll R1 onto his right side. After NA-D was not successful with this, she stated she needed to go get help. At 10:14 a.m., NA-D stated she did know what the EBP sign on R1's door meant and realized she had forgotten to put it on the first time she went in and attempted to turn R1. At 10:30 a.m., licensed practical nurse (LPN)-A and NA-D donned gown and gloves on entering R1's room. NA-D used disposable wipes to clean up his rectal area, stated she had forgotten to grab a clean brief and proceeded to use her still-gloved hands to open two different drawers to find an incontinent brief. After completing care for R1, NA-D removed her dirty gloves, didn't perform hand hygiene, collected the trash, walked down the hall and opened the door to the dirty utility room to throw the trash, then cleaned her hands. During an interview on 1/28/26 at 1:54 p.m., NA-D stated she understood she should have worn PPE and taken her gloves off before she touched things, so she didn't spread infection. A policy, Enhanced Barrier Precautions dated 4/4/24, identified it was the practice of the facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). All staff receive training on enhanced barrier precautions on hire and at least annually and are expected to comply with all designated precautions. All staff receive training in high-risk activities and common organisms that require enhanced barrier precautions. Clear signage will be posted on the door or wall outside the resident room indicating the type of precautions. The policy defined high-risk contact as activities including dressing, bathing, transferring, providing hygiene, changing linens, changing or assisting with toileting, wound care and device care. A Handwashing Policy dated 2/2024, identified proper hand-washing techniques should be used to protect the spread of infection. The section, Hand Washing and Gloves, identified when conducting a procedure requiring the use of gloves, proper hand washing shall be completed before donning gloves and after removing gloves. Dining: During an observation of dining on 1/26/26 starting at 5:34 p.m., residents were seated in the dining room. Dietary staff and the culinary director (CD) delivered meals to the residents. A nursing assistant remained in the dining room. There was a wall mounted hand sanitizer by the kitchen door. No other portable hand sanitizing products were visible in the dining area. No observations of residents' hand sanitization occurred. During an observation of the breakfast meal on 1/27/26 starting at 8:33 a.m., staff present and/or delivering food to residents in the dining room did not offer residents hand sanitization before meal delivery. No portable hand sanitizing products were visible in the dining area. During a breakfast observation on 1/28/26 starting at 8:20 a.m., staff present and/or delivering food to residents in the dining room did not offer residents hand sanitization before meal delivery. No portable hand sanitizing products were visible in the dining area. During an observation of breakfast meal on 1/29/26 starting at 8:30 a.m., staff present and/or delivering food to residents in the dining room did not offer residents hand sanitization before meal delivery. No portable hand sanitizing products were visible in the dining area. During an observation on 1/29/26 at 12:22 p.m., NA-A entered R23's room with a meal tray and exited without offering R23 an opportunity to sanitize their hands before eating. NA-B entered R40's room with meal tray and did not offer R40 an opportunity to sanitize their hands before they began to eat. During an observation of the lunch meal on 1/29/26 starting at 12:24 p.m., NA-A remained in the dining room other staff intermittently present and/or delivering food to residents in the dining room did not offer residents hand sanitization before delivery and consumption of their meal. No portable hand sanitizing products were visible in the dining area. During an interview on 1/29/26 at 12:46 p.m., both R40 and R23 were present. R40 stated they had not been offered to sanitize their hands prior to meals today. Staff used to offer all the time, but they had stopped offering hand sanitization at mealtimes. R23 voiced agreement with R40. During an interview of a family member FM-A in the dining room on 1/29/26, FM-A stated they were often present at meals, and it had been quite a while since they had seen staff offer hand sanitization to residents before meals. During an interview on 1/29/26 at 12:49 p.m., NA-A stated they kept hand sanitizer in the dining area. NA-A looked for hand sanitizer on the dining tables and in cabinets in the dining room and did not find any. NA-A confirmed they had not offered any residents hand sanitization prior to meals on that day. During an interview on 1/29/26 at 1:57 p.m., the DON stated for infection control reasons, they would expect hand sanitization to be offered and happen for all residents before every meal. During an interview on 1/29/26 at 2:15 p.m., the CD stated it was culinary staff's responsibility to deliver food to the residents in the dining room. Nursing staff were always present to monitor residents for choking. Offering hand sanitization to residents was not something that culinary staff did, that was routinely done by the NA staff. The CD confirmed room delivery meal trays did not have individual hand sanitizing packets on them. The facility had containers of hand sanitizing wipes for resident use. During an interview on 1/29/26 at 2:51 p.m., NA-C stated staff offered residents wipes to clean their hands before meals. NA-C went to the dining room counter by the coffee dispenser and stated the wipes were usually on the counter. NA-C thought maybe the wipes had been relocated but did not find any after they searched dining room cabinets. NA-C went to storage room, returned with a container of hand sanitizing wipes and placed them on the dining room counter. The facility policy Handwashing dated 2/2024, directed hand washing techniques should be used to protect the spread of infection. Before eating food was included in list of when handwashing should be completed.

Based on interview and document review, the facility failed to ensure informed consent, as well as the risk, benefits, and alternatives to psychotropic medications were provided to 1 of 5 residents (R26) reviewed for unnecessary medications.Findings include:R26's admission minimum data set (MDS) dated [DATE], identified intact cognition with diagnoses of chronic pain, panic disorder, major depression and post-traumatic stress disorder (PTSD). Section N identified R26 took antidepressant medication. R26's care plan dated 1/6/26, identified a focus statement for potential for psychotropic drug adverse drug reactions (ADR)s related to daily use of a psychotropic medication with interventions to administer medication per order, monitor target behaviors and report signs of ADRs.R26's medication administration record (MAR) had an order dated 1/17/26, to give duloxetine (an antidepressant, considered a psychotropic medication) 30 milligrams (mg) in the morning related to panic disorder. The order was signed off as given from 1/17/26 through current.R26's electronic medical record (EMR) didn't contain evidence of informed consent for the psychotropic duloxetine which she started receiving on 1/17/26.During an interview on 1/29/26 at 2:33 p.m., the director of nursing (DON) stated they get consent for psychotropic medications, she would look for it. A policy, Psychotropic Medication Use Policy dated 05/2025 identified the following for consent: Provide the resident or resident representative with information on the medication indication dose, side effects, adverse consequences and goal of treatment. Obtain consent and document education, information regarding the medication indication and directions for use, side effects and potential adverse consequences, risks and benefits of the medication and resident choice.

Based on interview and document review, the facility failed to provide the resident or their representative a written bed hold notice for 1 of 3 residents (R36) reviewed for hospitalization. Findings include:R36's admission Minimum Data Set (MDS) dated [DATE], identified R36 had diagnoses with included metabolic encephalopathy (a change in how the brain works due to an underlying condition that can cause confusion), diabetes mellitus, long term use of anticoagulant, prosthetic heart valve, and depression. In addition, R36's MDS identified he was able to understand and be understood and was moderately cognitively intact.A progress note dated 12/3/25 at 10:54 a.m., identified R36 had had a fall with a closed head injury and was sent to the emergency department for evaluation.A progress note dated 12/3/25 at 9:25 p.m., identified facility staff had called the emergency department for and update and were told R36 had been admitted . The note further identified an attempt was made to call R36's family with no success.A further review of the notes gave no indication if R36 had signed a bed hold or if further attempts were made to contact R36's family.During an interview on 1/29/26 at 2:26 p.m., the administrator verified they would expect staff to have a resident sign the bed hold or get a verbal confirmation. The administrator verified attempts should be made to notify the family as well, stating the goal is to get the bed hold signed. He stated he would expect staff to follow the process.A request was made for a copy of the bed hold; the facility was unable to provide this information.A review of the Bed-Holds and Returns dated 5/2023, identified the following: When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer, and a notice of transfer must be provided to the resident and resident representative as soon as practicable before the transfer.

Based on observation, interview, and document review, the facility failed to ensure timely turning, repositioning and oral care for the comfort for a resident on end-of-life services for 1 of 2 (R1) residents and in addition, the facility failed to provide ordered interventions for a resident with constipation for 1 of 2 residents (R26) reviewed for quality of care.R1's quarterly minimum data set (MDS) dated [DATE], identified severe cognitive impairment and diagnoses of metabolic encephalopathy, palliative care, unstageable pressure ulcer (PU) left buttock, stage four PU to the right elbow, vascular dementia, restlessness, agitation, and delusional disorder. The MDS also reflected that R1 received hospice and end-of-life care. The functional assessment at section GG was not completed. R1's care plan dated 1/21/26, identified hospice care and coordination with Ecumen Hospice Services, to monitor pain, assess pain per protocol, treat with non-pharmacologic interventions and as-needed (PRN) pain medication and document effectiveness. R1 needed physical assistance of two for toileting hygiene, dressing, grooming, and bathing. To turn and reposition JR1 every two to three hours. The care plan lacked direction for R1's oral care during the active dying process.R1's provider orders dated 7/27/23, identified an order for pain monitoring every shift every day, on 12/15/25 for non-pharmacologic pain interventions, to administer PRN pain medication before wound care, and to give hydromorphone two milligrams (mg) every four hours for pain or dyspnea (difficult breathing) AND give two mg every one hour PRN pain or dyspnea.During a continuous observation on 1/28/26 from 7:17 a.m. until 10:30 a.m., R1 was not observed to be provided with oral care. R1 was observed to be breathing with his mouth open during this time. R1 was observed in his bed with eyes closed, lying mostly on his back with his upper torso rotated to his right. At 9:51 a.m., NA-B peeked into R1's room then went back to the nurse's station. At 9:55 a.m., NA-D entered the doorway to R1's room pulled the privacy curtain further shut so R1 wasn't visible from the hall, then NA-D left and went down the hall. At 10:05 a.m., NA-D entered R1's room and attempted to reposition him. NA-D explained he was actively dying. R1 appeared to have irregular shallow breaths and a smooth face. NA-D used a chuck pad to roll R1 onto his right side, R1 grimaced and opened his eyes. NA-D explained she needed to go get some help because he keeps slipping. At 10:22 a.m., LPN-A came over and talked with NA-D and stated she wanted to check if she should do the dressing change or if hospice would be doing it. An unidentified hospice nurse entered the building and talked with LPN-A and ultimately decided she would come back at 3 p.m. when the wound care provider was there. NA-D asked LPN-A if she should continue cleaning and turning R1. At 10:30 a.m., LPN-A and NA-D entered R1's room and worked together to turn R1 onto his right side to clean his rectal area. R1 had a facial grimace and LPN-A said to him, I know, I'm sorry. LPN-A stated it had been 45 minutes since he had pain medication, and suggested they not move him anymore until he had some more. LPN-A and NA-D worked together to cover him back up and R1 remained in the same position as when they started. Neither provided oral care.During an interview on 1/28/26 at 1:29 p.m., LPN-A stated R1 had a dry mouth so she performed oral care every time she went in there and would also expect it to be part of his morning cares. LPN-A stated she thought R1's care plan indicated two to three people because even before his decline he was a big guy and would kind of push against them when they repositioned him.During an interview on 1/28/26 at 1:54 p.m., NA-D stated she worked for the float pool, has worked here before, and knew how to care for the residents based on the group sheets. NA-D demonstrated the group sheet for R1 which identified he needed two people for bed mobility, NA-D stated she was wrong earlier when she thought she could do it alone.During an interview on 1/29/26 at 2:58 p.m., the director of nursing (DON) stated she would expect staff to attempt to offload after three hours, confirmed the care guide indicated an assist of two for repositioning, and stated the care guide was the primary source of information for the nursing assistants. The DON stated the risk of repositioning a resident without enough help would be the potential for injury to the resident and themselves. Furthermore, the DON stated her expectation would be for oral care to be done every time a someone went in his room because R1 was actively dying, and this would be her expectation for any dying resident. A policy related to end-of-life or comfort care was requested but not received.R26's admission minimum data set (MDS) dated [DATE], identified intact cognition and diagnoses of chronic pain and gastroparesis (a condition with delayed gastric emptying, where the stomach muscles don't function properly, leading to slow movement of food through the digestive tract). Section N identified R26 had opioid medication. The functional assessment at section GG was not completed. Always continent of bowels and constipation was present.R26's care plan dated 1/6/26, identified the potential for alteration in elimination related to need for staff assist with transfers and included interventions for an assist of one with toileting and to monitor BMs as the occur. R26's care plan lacked direction for constipation management.R26's medication administration record (MAR) identified an order dated 12/31/25, for sennosides (a laxative medication) tablet 8.6 milligrams (mg) every 12 hours PRN for constipation. There were no other activated orders related to bowel management.R26's electronic medical record (EMR), for the period of 12/31/25 to 1/21/26 identified the following:No bowel movement (BM) recorded 12/31/25 through 1/5/26. Sennosides were administered on 1/3 and1/4/26. A small BM was recorded on 1/6/26.BM recorded 1/10/26, Sennosides were administered on 1/13/26. BM recorded 1/15.No BM recorded 1/17 through 1/20/26. Sennosides were administered on 1/19/26. A small BM was recorded on 1/21/26.R26's EMR contained a nurse note entry on 1/19/26 at 4:21 p.m., resident shared she hadn't had a BM in three days, sennosides 8.6 mg 1 tab administered. At 7:30 p.m., a follow up note indicated the intervention was not effective. On 1/20/26 at 2:57 p.m., a note indicating sennosides 8.6 mg 1 tab administered per resident request for constipation. At 4:05 p.m., a follow-up note indicated the intervention was not effective. No other interventions or assessments for constipation were identified.During an interview on 1/26/26 at 3:44 p.m., R26 stated she had trouble with constipation and would sometimes go weeks without a BM. R26 wasn't sure what the facility was doing to help her.During an interview on 01/29/2026 2:33 p.m., the DON stated the facility followed the bowel protocol in the standing orders and would start interventions at three days or more of no BM. The DON stated ideally overnight shift ran a BM report and then handed off to day shift or do an intervention prior to the end of their shift. The DON stated she would expect the nurses to be going off the standing house protocol with the next intervention if the previous one wasn't effective after 24 hours.A policy regarding bowel management was requested but not received.A document, Standing Orders for Skilled Nursing Facilities revised 2025, identified the following for constipation (perform steps sequentially):Consider rectal check to determine if an impaction was present.Encourage 2000 milliliters (mL) daily unless contraindicated.Consult nutrition services for dietary recommendations.Give sennoside 8.6 mg two tablets by mouth daily PRN for up to three days, if no BM by day three, offer/give Bisacodyl suppository 10 mg rectally once daily PRN for up to two days.Reattempt sennosides or Bisacodyl if no results after 24 hours and notify provider.

Based on observation, interview, and record review the facility failed to ensure 1 of 2 residents (R9) had accessibility to their call light to call for help. Findings include.R9's comprehensive Minimum Data Set (MDS) dated [DATE], indicated R9 was significantly cognitively impaired with the diagnoses of dementia, dysphagia, cognitive communication deficit, and hypertension. MDS section GG. indicated R9 required moderate assistance with transfer from bed to chair and with toileting. R9's undated facility provided care plan included focus areas with interventions for: fall risk, mobility related to impulsivity, communication, and behavior. R9's care plan directed assist of 1 with toileting and pivot transfers.R9's care plan did not include call light placement or use in fall risk, impulsivity or behavior interventions. During observations on 1/27/26:-at 3:03 p.m. R9 was seated in their wheelchair beside the head of their bed facing the door. R9's call light was located hanging on the wall above the foot of R9's bed. R9's tv was located on a stand just beyond the foot of R9's bed. -at 3:48 p.m., call light is still hanging on the wall behind R9. During an interview on a1/27/26 at 3:57 p.m., nursing assistant (NA-G) stated the call light should always be placed within a resident's reach before they left a resident room. NA-G stated they had not been in R9's room yet, but R9's call light should always be within reach. During an interview on 1/27/26 at 4:03 p.m., NA-A stated R9 was one of their residents. As part of their routine, they rounded on R9, but if R9 needed something between rounds, R9 would call on the call light. During an interview on 1/27/26 at 4:06 p.m., registered nurse (RN-B) stated R9 used a soft touch call light. R9 also required frequent checking because R9 required transfer assistance but often took self to the bathroom. RN-B confirmed R9's call light was hanging on the wall out of R9's reach. RN-B stated they always made sure R9 had their call light when they left R9's room, but they were not sure R9 could use it. During an interview on 1/27/26 at 4:11 p.m., NA-G stated before they left resident rooms they always made sure a resident's call light was within reach. When they took care of R9 they always positioned R9's call light across the bed so R9 could reach it from their wheelchair. R9 didn't always use their call light, but sometimes R9 did. During an observation on 1/28/26 at 7:19 a.m., R9 was in bed, turned away from the wall with eyes closed and lights off. R9's soft touch call light hanging on the wall above the foot of R9's bed. During an interview on 1/28/26 at 7:52 a.m., NA-B confirmed R9's call light was hanging on the wall. NA-B did not enter R9's room to address the call light. During an observation on 1/28/26 at 7:54 a.m., R9 self-transferred self to wheelchair and self-propelled self into the hallway. NA-F asked R9 if they wanted to go back to their room to get ready, but R9 declined. NA-B and NA-F confirmed R9's call light was hanging on the wall. NA-F stated normally they put R9's call light on R9's bed. NA-F questioned if R9 put the call light on the wall themselves or if maybe the night staff had forgotten to put the call light back on the bed. During an observation on 1/28/26 at 8:37 a.m., R9's call light was laying across R9's bed. On 1/28/26 at 12:00 p.m., NA-F stated R9's call light was found hanging on the wall. R9 must have put it there. During an observation on 1/28/26 at 3:53 p.m., R9 was seated in their wheelchair. R9's call light was out of reach hanging on the wall behind the bed. During an observation on 1/29/26 at 8:04 a.m., R9 was in bed. R9's call light was out of reach hanging on wall at the foot of the bed. During an interview on 1/29/26 at 1:47 p.m., the director of nursing (DON) stated it was their expectation that a call light be placed within reach for all residents every time staff left a resident room. The facility Call Light Policy dated 5/16/23, instructed a nurse call must be provided for each resident and must be placed within reach of the resident.

Based on observation, interview and document review, the facility failed to ensure direct-care nursing staff were appropriately trained and competent on blood glucose checks and infection control policies of the facility for 2 of 2 resident (R2, R7) who had their glucose checked. The facility also failed to confirm agency staff (staff brought in on a temporary basis to assist in resident cares) received facility and resident specific orientation and training prior to working with the residents. Findings include: The facility Temporary Agency Staff Orientation Checklist (TASOC) undated, indicated agency staff would be oriented to facility policies and practices that included emergency preparedness, abuse policy, use of mechanical lifts, medication systems and infection control. On 12/4/24, at 12:53 p.m., licensed practical nurse (LPN)-A was observed leaving the dining room wearing gloves and carrying a small plastic container with a glucometer in the container. The glucometer had a used glucose strip in the machine. Registered nurse (RN)-A had stopped LPN-A and told her she could not wear gloves in the hallway. LPN-A removed her gloves and proceeded to R7's room carrying the plastic container with the glucometer and the used strip in the machine (LPN-A did not clean the glucometer) or remove the used strip. LPN-A entered R7's room and was then asked to step out. When LPN-A was in the hallway she stated she had planned to clean the glucometer once she was in the room and stated she thought there would be wipes in the room. LPN-A cleaned the shared glucometer with purple top wipes in R7's room. R7 stated she had already had her meal, LPN-A stated she could not find R7 before lunch. R7's glucometer reading was 224 milligrams (mg) per deciliter (dl). LPN-A then proceeded to R11's room, R11's meal was in his room, he stated he had finished eating. LPN-A cleaned the glucometer using the purple top wipes she had carried with her and obtained R11's blood sugar which was 244 mg/dl. LPN-A stated she had checked R2's blood sugar in the dining room. During an interview on 12/4/24 at 1:06p.m. LPN-A stated the facility had not given her any kind of orientation or training to the facility policy, procedures, or equipment prior to working with the residents and/or equipment. On 12/4/24 at 1:48 p.m., LPN-A's TASOC and schedule were reviewed. A blank TASOC with LPN-A's name was provided. LPN-A's working schedule indicated LPN-A's first shift at the facility as an agency nurse was on 11/30/24. On 12/4/24 at 1:50 p.m., registered nurse (RN)-B's TASOC and schedule were reviewed. RN-B's TASOC was completed and dated 12/4/24. RN-B's schedule indicated the first day worked as an agency nurse was 3/31/24. During and interview on 12/4/24 at 1:00p.m. RN-B stated she could not remember if the facility gave her any kind of orientation or training to the facility policy, procedures, or equipment prior to working with the residents and/or equipment. RN-B did confirm the facility had just finished the orientation packet prior to the interview. During an interview on 12/5/24 at 10:18 a.m., the director of nursing (DON) reviewed the dates and education of LPN-A and RN-B. The DON confirmed the education was not completed the day of their first shift, but days later. The DON stated the expectation was that staff working with the new agency staff member would perform the checklist with the new staff member before they started work with the residents and equipment. A facility policy for orientation of agency staff was requested but not provided.

Based on observation, interview and document review, the facility failed to ensure a shared glucometer was properly cleaned and disinfected between residents for 3 of 3 residents (R2, R7, R11) reviewed for blood glucose monitoring. Findings include: R2's Diagnosis Report dated 12/6/24, identified R2 had type 2 diabetes mellitus. R2's active orders as of 12/5/24, identified the following order: Blood Sugars before meals and at bedtime And: Novolog FlexPen 100 units per milliliter (ml) Solution pen-injector Inject as per sliding scale: 70 - 149 = 0 150 - 199 = 1 200 - 249 = 2 250 - 299 = 3 300 - 349 = 4 350 - 399 = 5 400 - 999 = 6 subcutaneously with meals R7's Diagnosis Report dated 12/6/24, identified R7 had type 2 diabetes mellitus. R7's active orders as of 12/5/24, identified R7 required Humalog insulin per sliding scale: 70 - 149 = 0 150- 199 = 1 200 - 249 = 2 250 - 299 = 3 300 - 349 = 4 350 - 399 = 5 400 - 999 = 6 subcutaneously before meals R11's Diagnosis Report dated 12/5/24, identified R11 had type 2 diabetes mellitus with diabetic chronic kidney disease. R11's active orders as of 12/5/24, identified blood sugars needed to be checked three times a day. And: Humalog Injection Solution (Insulin Lispro) Inject as per sliding scale: 70 - 149 = 0 Units 150 - 199 = 8 units 200 - 249= 10 units 250 - 299 = 12 units 300 - 349 = 14 units; 350 - 399 = 16 units 400+ = 18 units 400 or greater give 18 units subcutaneously before meals On 12/4/24, at 12:53 p.m., licensed practical nurse (LPN)-A was observed leaving the dining room wearing gloves and carrying a small plastic container with a glucometer (a device used to measure blood sugars) in the container. The glucometer had a used glucose strip in the machine. Registered nurse (RN)-A had stopped LPN-A and told her she could not wear gloves in the hallway. LPN-A removed her gloves and proceeded to R7's room carrying the plastic container with the glucometer and the used strip in the machine (LPN-A did not clean the glucometer) or remove the used strip. LPN-A entered R7's room and was then asked to step out. When LPN-A was in the hallway she stated she had planned to clean the glucometer once she was in the room and stated she thought there would be wipes in the room. LPN-A cleaned the shared glucometer with purple top wipes in R7's room using one wipe. LPN-A then proceeded to R11's room, R11 stated he had finished eating. LPN-A cleaned the glucometer using one wipe from the purple top wipes container that she had carried with her. She did not clean the glucometer after using the machine. On 12/4/24 at 1:03 p.m., LPN-A brought the plastic bin with the used glucometer and placed it on top of the medication cart. LPN-A did not clean or disinfect the glucometer machine prior to walking away from the cart. On 12/4/24, at 1:10 p.m., the director of nursing (DON) stated she did not have any training for LPN-A on glucometer use. The DON stated she would expect nursing staff to clean and disinfect a glucometer prior to placing the machine back in the container. The DON also stated each resident had their own glucometer and the glucometer LPN-A was using was only for emergencies. On 12/4/24 at 1:18 p.m., LPN-A stated she thought she had wiped the glucometer off before putting it back in the box. LPN-A stated she thought the glucometer should stay wet for about 20 seconds. The document titled Blood glucose monitoring no date, identified the following: Clean and disinfect the blood glucose meter with a disinfectant wipe, following the manufacturer's instructions wet/kill time. Contaminated blood glucose monitoring equipment increases the risk of infection by such blood borne pathogens as hepatitis B, hepatitis C, and human immunodeficiency virus . The Assure Prism user instruction manual dated 2/2020, page 38 identified the following: Cleaning and Disinfecting: The meter should be cleaned and disinfected after each use on each patient. The products listed were Clorox Healthcare bleach Germicidal Wipes -contact time 1 minute Dispatch Hospital Cleaner Disinfectant Towels with Bleach - contact time 1 minute CaviWipes1 - contact time 1 minute PDI Super Sani-Cloth Germicidal Disposable Wipe - contact time 2 minutes (purple top wipes) Cleaning: Wearing gloves using 1 towelette wipe the entire surface of the meter 3 times horizontally and 3 times vertically. Disinfecting: Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically. Allow the exteriors to remain wet for the corresponding contact time for each disinfectant.

Based on observation, interview and document review, the facility failed to ensure blood sugars were obtained as ordered for 3 of 3 residents (R2, R7, R11) reviewed for blood glucose monitoring. Findings include: R2's Diagnosis Report dated 12/6/24, identified R2 had type 2 diabetes mellitus. R2's active orders as of 12/5/24, identified the following order: Blood Sugars before meals and at bedtime And: Novolog FlexPen 100 units per milliliter (ml) Solution pen-injector Inject as per sliding scale: 70 - 149 = 0 150 - 199 = 1 200 - 249 = 2 250 - 299 = 3 300 - 349 = 4 350 - 399 = 5 400 - 999 = 6 subcutaneously with meals R7's Diagnosis Report dated 12/6/24, identified R7 had type 2 diabetes mellitus. R7's active orders as of 12/5/24, identified R7 required Humalog insulin per sliding scale: 70 - 149 = 0 150- 199 = 1 200 - 249 = 2 250 - 299 = 3 300 - 349 = 4 350 - 399 = 5 400 - 999 = 6 subcutaneously before meals R11's Diagnosis Report dated 12/5/24, identified R11 had type 2 diabetes mellitus with diabetic chronic kidney disease. R11's active orders as of 12/5/24, identified blood sugars needed to be checked three times a day. And: Humalog Injection Solution (Insulin Lispro) Inject as per sliding scale: 70 - 149 = 0 Units 150 - 199 = 8 units 200 - 249= 10 units 250 - 299 = 12 units 300 - 349 = 14 units; 350 - 399 = 16 units 400+ = 18 units 400 or greater give 18 units subcutaneously before meals On 12/4/24, at 12:53 p.m., licensed practical nurse (LPN)-A was observed leaving the dining room wearing gloves and carrying a small plastic container with a glucometer (device to measure blood sugars) in the container. The glucometer had a used glucose strip in the machine. Registered nurse (RN)-A had stopped LPN-A and told her she could not wear gloves in the hallway. LPN-A removed her gloves and proceeded to R7's room carrying the plastic container with the glucometer and the used strip in the machine (LPN-A did not clean the glucometer) or remove the used strip. LPN-A entered R7's room and was then asked to step out. When LPN-A was in the hallway she stated she had planned to clean the glucometer once she was in the room and stated she thought there would be wipes in the room. LPN-A cleaned the shared glucometer with purple top wipes in R7's room. R7 stated she had already had her meal, LPN-A stated she could not find R7 before lunch. R7's glucometer reading was 224 milligrams (mg) per deciliter (dl). LPN-A then proceeded to R11's room, R11's meal was in his room, he stated he had finished eating. LPN-A cleaned the glucometer using the purple top wipes she had carried with her and obtained R11's blood sugar which was 244 mg/dl. LPN-A stated she had checked R2's blood sugar in the dining room. On 12/4/24, at 1:10 p.m., the director of nursing (DON) stated she would expect blood sugars to be obtained prior to residents eating their meals. The DON stated she did not have any training for LPN-A on glucometer use. The blood glucose monitoring check list included verify practioner's order as the first step in blood glucose monitoring. The DON stated she would expect any nurse to be trained on obtaining blood sugars as part of their nursing school education. The DON stated she would expect nursing staff to clean a glucometer prior to placing the machine back in the container. The DON also stated each resident had their own glucometer and the glucometer LPN-A was using was only for emergencies.

Based on observation, interview and document review, the facility failed to ensure repositioning and checking and changing were offered for 1 of 3 residents (R12) reviewed for pressure ulcers. Findings include: R12's quarterly Minimum Data Set (MDS) dated [DATE], identified R12 had diagnoses which included fibromyalgia (a long-term condition that involves widespread body pain and tiredness), muscle weakness, hypothyroidism, unspecified mood disorder, restless leg syndrome, and acute pain. R12's MDS identified R12 was cognitively intact, required substantial to maximum assistance with activities of daily living, was always incontinent of bowel and bladder, and was at risk for pressure ulcers. R12's nursing assistant care guide undated, identified staff were to assist with toileting every two to three hours and as needed and to turn and reposition every two to three hours and as needed. R12's care plan dated 2/16/24, identified R12 had an alteration in skin integrity, interventions included to turn and reposition every two to three hours and as needed. In addition, R12 had an alteration in elimination related to urinary incontinence, requiring staff assitance with toileting. Interventions included assist of one with toileting every two to three hours and as resident called. R12 orders dated 11/27/24, identified When resident refusing cares i.e. washing up, changing, repositioning, dressing make a note. Reattempt, utilize other staff and update provider if continued refusals. Every shift A review of R12's progress notes from 11/27/24, through 12/3/24, identified the following: -11/27/24 10:45 a.m., Risk versus benefits form filled out for refusing cares such as showering, turning/repositioning, am/pm cares, incontinence changes, getting up. Resident was educated on potential risks for non-compliance such as risk for infection, impaired skin integrity and pain. Residentwas understanding at this time. -Several notes regarding topical ointments refused, no documented refusals of repositioning or checking and changing. During a continuous observation on 12/4/24 from 7:04 a.m., to 10:05 a.m., no offers were made by nursing staff to reposition, toilet, or check and change. During an interview on 12/4/24 at 9:55 a.m., nursing assistant (NA)-B stated she was responsible for R12's care. She stated she had not offered any cares and would only go in if R12 put her light on. NA-B stated she thought nights had checked on her before they left and R12 only liked certain people like NA-A. NA-B stated she did not have a plan for checking and changing R12. During an interview on 12/4/24 at 10:01 a.m., NA-A stated no one had approached him with a plan for R12's care. NA-A stated R12 would often refuse cares but stated someone should still be offering repositioning and checking and changing every couple of hours. On 12/4/24 at 10:05 a.m., NA-A checked on R12 and asked her if she needed to be changed. R12 replied she thought she was okay and said the night person had changed her around 2:00 a.m., NA-A asked if he could check, R12 said ok but wanted privacy. During an interview on 12/4/24 at 10:19 a.m., NA-A stated R12 was wet, not soaking and said he would check in with her again after lunch. NA-A stated R12 said nights had last changed her between 1:00 a.m. and 2:00 a.m During an interview on 12/5/24 at 9:03 a.m., the director of nursing (DON) stated she would expect staff to offer cares, repositioning, and checking and changing even if the resident had a history of refusals. The DON stated she would expect the NA to tell the nurse and to document the refusals. The Skin Assessment and Wound Management policy dated 3/2024, identified pressure wounds wound be reviewed and the care plan would be updated including interventions.

Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 5.56 % with 2 errors out of 36 opportunities for error involving 2 of 7 residents (R9, R5) who were observed during the medication passes. Findings include: R9: R9's quarterly Minimum Data Set (MDS) dated [DATE], identified R9 was cognitively intact and had diagnoses which included diabetes mellitus. R9's current order summary report dated 12/5/24, identified R9 had the following order: Lantus Solostar 100 unit per milliliter (ml) inject 10 units subcutaneously at bedtime On 12/2/24 at 6:21 p.m., licensed practical nurse (LPN)-B stated R9 liked to have his bedtime medications at 6:00 p.m LPN-B removed the glargine/lantus insulin from the drawer scrubbed the hub of the insulin pen with an alcohol wipe, dialed up 2 units of insulin, pushed the plunger expelling the insulin, dialed up 10 units of insulin and then put the needle onto the pen. LPN-B then entered R9's room to give the insulin. During an interview on 12/2/24 at 6:27 p.m., LPN-A verified she primed the pen prior to putting the needle on the insulin pen and stated that was how she always did it. R2: R2's annual MDS dated [DATE], identified R2 was moderately cognitively intact and and had diagnoses which included diabetes mellitus. R2's current order summary report dated 12/5/24, identified R2 had the following order: Insulin glargine 20 units subcutaneously in the morning. On 12/4/24 at 8:49 a.m., LPN-A dialed up 20 units of insulin with the cover on the insulin pen and no needle, then placed the pen into the box with the glucometer. LPN-A stated R5 had already refused twice so she was going to ask registered nurse (RN)-B to give the insulin. RN-B went with LPN-A to the dining room, LPN-A dialed the pen back to zero. RN-B cleaned the top of the pen with an alcohol wipe, placed the needle on the pen, dialed 20 units, then brought R5 to his room, he refused the injection initially and then allowed RN-B to give the insulin. During on interview on 12/4/24 at 12:12 p.m., LPN-A stated she checks the insulin order, finds the right pen, checks for the number of units, dials up the units. When prompted about priming the needle LPN-A stated, oh yes need to prime with one unit of insulin. During an interview on 12/4/24 at 12:16 p.m., the director of nursing stated it was her expectation nurses would cleanse the top of the insulin pen, place a needle, and then prime the needle with 2 units of insulin prior to dialing the insulin units. A policy on priming insulin pens was requested but not provided.

Based on interview and document review the facility failed to complete comprehensive fall analysis to determine accurate causal factors and implement appropriate care plan interventions to prevent or mitigate the risk of recurrent falls for 1 of 3 residents (R1) reviewed for falls. The facility's failures resulted in actual harm when R1 fell and sustained an acute nondisplaced fracture involving sacral (tailbone). Findings include: R1's Face Sheet, undated, identified R2 had diagnoses that included Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (stroke) and fracture of T7-T8 vertebra (thoracic area of back). R1's Admission data collection tool dated 8/23/24, identified R1 arrived at facility on 8/23/24 at 12:00 noon. R1 was not cognitively intact. R1 was assessed for pain with non-verbal sounds (e.g. Crying whining, gasping, moaning or groaning). Vocal complaints of pain (e.g. that hurts, ouch, stop), protective body movements (e.g. bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement). R1 was totally dependent on two or more staff for transfers. R1's orders dated 8/23/24 direct R1 to wear back brace (TLSO) during showers, no lifting greater than 10 lbs., wear brace for three months, when head of bed is greater than 30 degrees and this includes when resting in bed, sitting and walking. Avoid excessive, bending, twisting or turning. Monitoring for falls was added on 8/28/24. R1's care plan dated 8/23/24, identified a fall risk related with the intervention for staff to monitor and document on safety. Review information on past falls and attempt to determine cause of falls. Record possible root causes and after remove any potential cause if possible. Educate resident/family/caregivers/ interdisciplinary team as to causes. There was no interventions identified to reduce R1's risk of falls. R1's fall incident report dated 8/23/24 at 8:00 p.m., indicated R1 had an unwitnessed fall. R1 was found face down in between the bed and window with his back brace lying on the bed. R1 was pleasantly confused, orientated to person, and was not able to answer the nurse's questions. R1 moaned in pain when repositioned. Immediate action taken: resident transferred from floor to bed using a full body mechanical lift. Skin check completed no new injury noted, No changes from range of motion from the time of admit. Temperature 100.1 (normal 97-99 degrees Fahrenheit ), pulse 103 (normal 60-100), respirations 19 (normal 12-18), blood pressure 138/82 (normal 90/60 to 120/80 mmHg), oxygen at 92% (normal 95-100%) on room air. The on call provider was notified and new order to send R1 to the emergency room for further evaluation. Predisposing environmental factors included medical device (bed, wheelchair, cords etc.) Resident removal of safety devices. Predisposing physiological factors include change in behavior, confused, forgetful, unsteady gait, gait imbalance, and impaired memory. Predisposing situation factors include new admission and rolled out of bed. R1's progress note dated 8/24/24, identified R1 returned to the facility after the emergency room (ER) visit at 3:30 a.m. Document titled Incident Review and analysis dated 8/26/24, identified the R1's fall on 8/23/24 at 8:00 p.m. and indicated the interdisciplinary team (IDT) reviewed the fall. The review indicated staff noticed R1 had increased pain, R1 was not incontinent at the time of the incident, there were no cords R1 could have tripped on, and the call light was within reach when R1 was in bed. Contributing factors included: R1 was new admission, was confused, had an unsteady gait, forgetful, unable to realize limitations. The section for current intervention in place directed see care plan and the section Possible interventions and Other Interventions was left blank. Although R1's record identified potential causal factors, it was not evident further analysis was completed to identify interventions that addressed R1's contributing risk factors of R1's not recognizing own limitations, confusion, impaired memory, unsteady gait, and forgetful. R1's care plan dated 8/26/24 identified intervention added on 8/23/24 environmental changes to room: bed position change. During interview on 09/06/24 at 3:30 p.m., registered nurse RN-(B) reported to be the admitting nurse for R1 and aware of R1's fall history prior to admission. RN-B also the nurse who found R1 on the ground on 8/23/24 reported R1 was located face down between the bed and the window, his back brace was on the bed. R1 was incontinent of bowel movement (which was inconsistent with the 8/26/24 Incident Review report). RN-B reported R1's care plan was not followed as R1 did not have TLSO brace on at time of the fall. R1 went to hospital due to unwitnessed fall and pain, arrived back at the facility at 3:30 a.m. with no injuries. During interview on 9/4/24 at 11:28 a.m., nursing assistant (NA)-A reported R1 was a major fall risk when he was admitted and checked on him frequently because of that. NA-A would use a lot of pillows on both sides of him when he was in bed to prevent him from falling. R1 was supposed to have a concave mattress but did not. NA-A recalled on 8/24/24 between 6:00 and 6:45 a.m. she had been walking past R1's room and saw R1 off the edge of the bed with a hand on the ground and foot nearly touching the ground demonstrating the shape of a star fish with his back against the side of the bed. NA-A communicated to RN-A who entered the room, they boosted R1 back to bed. Not long after the near miss fall around 7:00 a.m. NA-A went to check on R1 and found him on the floor. R1 was incontinent. NA-A was unsure if R1 hit his head so she had RN-A assess R1 and NA-B assisted with putting four to five pillows on each side of R1. NA-A thought that was the best course of action to secure R1 in bed. After the fall R1 had been moaning a little during the day. NA-A indicated the intervention to use pillows was not part of the care plan until a few days later. During interview 9/5/24 at 1:54 p.m., RN-A stated he worked on 8/24/24. RN-A stated the first incident was a near fall where he was partially on the floor and then he was found on the floor a short time later. RN-A stated anything he did that day would be documented in the medical record. During interview on 9/5/24 at 2:30 p.m., nursing assistant (NA)-B worked the morning of 8/24/24. NA-B stated R1 had fallen because she assisted NA-A to transfer R1 off the floor and into bed. R1 was incontinent at the time of the fall. During on 9/5/24 at 1:45 p.m., NA-A and DON-A reviewed circumstances of a fall and NA-A confirmed this had happened on her shift of 8/24/24. DON-A reported the facility was unaware of the first incident as RN-A never reported the fall. R1's Mobility assessment dated [DATE] identified, R1 required substantial/maximal assistance for rolling left and right, substantial/maximal assistance for sitting to lying. R1 was dependent to wheel 50 feet with two turns in a manual wheelchair. R1's fall incident report dated 8/28/24 at 9:35 a.m., indicated R1 had an unwitnessed fall in his room at 9:30 am. R1's call light had been on when staff found R1 on the floor lying on his left side near his bed with his back brace on. R1 denied hitting his head and pain. R1's vital signs: blood pressure 103/93, pulse 113, respirations 18, and blood glucose 170 (normal 70-99 mg/dl). No injuries noted at the time of the incident, pain level was zero, and R1 was alert to person however confused. Predisposing physiological fall risk factors included: history of falls, not always able to realize limitations, narcotics, and anticoagulant (blood thinning medication). Predisposing situation factors was blank. The immediate intervention directed staff to use a body pillow while in bed. The physician, administrator, family were notified at 11:23 a.m.-11:28 p.m. R1's incident report dated 8/28/24 at 10:45 a.m., indicated R1 had an unwitnessed fall at 10:45 a.m. The report indicated R1 had appeared to roll out of bed and was found on the floor lying on his back with his back brace on. R1 reported he had not hit his head, denied pain, and no injuries were observed. R1 was confused and his urine appeared to be dark in color compared to baseline. The body pillow was in place and the care plan followed at the time of the fall. Predisposing physiological fall risk factors included: anticoagulant, not always able to realize limitations, and narcotics. The physician, administrator, family were notified at 11:35 a.m.-11:36 p.m. Immediate action identified was a physician order to send R1 to the hospital for altered mental status and multiple falls. Document titled Incident review and analysis dated 8/28/24, identified the aforementioned fall information with additional information that included the IDT reviewed the incident. Further included the contributing factors was documented as R1 had recent hospice consult, R1 BIMS of 0 (indicating severe cognitive impairment). R1's records did not include a comprehensive analysis for individualized fall interventions that addressed R1's contributing risk factors such as (but not limited to) R1's not recognizing own limitations, confusion, severe cognitive impairment, and narcotic pain medication. R1's care plan was updated on 8/28/24 with the intervention of Body pillow when resident is in bed to prevent falls. R1's hospital record dated 8/28/24, indicated R1 arrived via ambulance at 12:01 p.m. for urgent admission following two unwitnessed falls from his bed today (8/28/24). The note indicated the need for further evaluation because R7 had recent thoracic spine fracture (T7), was on a Plavix therapy (blood thinner), and had a potential head strike. R1 was alert, but unreliable historian, somewhat confused, and had back pain. R1's neurological exam was listless, low level of interactivity and R1 was only able to answer yes or no questions. CT (computed tomography) identified R1 had an acute nondisplaced fracture involving an anterior marginal endplate osteophytes at S1 with questionable extension into the vertebral body anterior. Further lab tests identified R1 had have worsening leukocytosis (high white blood cells), abnormal urine analysis (UA), COVID 19 positive, evidence of dehydration, and abnormal liver function tests (LFT's). Plan for transfer for further evaluation and treatment following imaging. During interview on 09/04/24 at 9:03 a.m., R1's medical power of attorney (POA) indicated upon admission they made the facility aware R1's fall history and were concerned with the level of supervision the facility had been providing. POA stated the facility had called them on 8/23/24 at 11:46 to report R1 had a fall out of bed. Then on 8/28/24 at 2:45 p.m. the facility had called to inform them R1 had two falls and was transferred to the hospital. POA stated R1 was hospitalized for an additonal fracture in his spine. During interview on 9/6/24 at 1:37, p.m. nurse manager (NM)-A indicated she had worked on 8/28/24 when R1 rolled out of bed twice. NM-A was not sure if R1 was crawling out of bed or if he had rolled out of bed and why R1 would be trying to get out of bed. NM-A explained she had implemented the intervention of the body pillow after the first fall with the goal of reducing the risk of R1 rolling out of bed, however NM-A did not complete an assessment to determine if the pillow would be effective and/or appropriate. During a subsequent interview on 9/4/24 at 2:27 p.m., Nurse manager NM-A explained after resident falls the nurse immediately completes an assessment for injuries then the nurse completes a checklist. Nurses are expected to document the fall, complete a causal analysis, and determine and immediate intervention to prevent recurrent falls. The IDT then meets to complete the comprehensive analysis and evaluate for any further fall interventions. The expectation was to immediately notify director of nursing (DON), physician, and family. On 9/5/24 at 10:50 a.m., a group interview was held with administrator, NM-A, DON-A, DON-B, regional manager (RM)-A (on phone) and regional director of operations (RD)-A (on phone). DON-A reviewed R1's falls and indicated the fall that occurred on 8/28/24 at 9:35 a.m. staff should have started neurological assessments. The fall was unwitnessed and was not known if R1 hit his head even though he reported he did not; he was not a reliable historian because he had severe cognitive impairment. R1's level of supervision was not increased to prevent or reduce his risk for falls. R1 was sent to the hospital following the second fall due to being worried about his safety, altered mental status, and signs of infection. First immediate intervention to prevent falls was environmental and moving the bed following the fall on 8/23/24 at 10:00 p.m., Second fall on 8/28/24 at 9:35 a.m. with a second immediate intervention was a body pillow and the third fall on 8/28/24 at 10:45 a.m. R1 was sent to the hospital and did not return. Facility staff were not aware of a 8/24/24 when R1 was found half out of bed, almost on the floor. Facility policy titled fall prevention and management dated 2/2024, identified nursing staff are to complete a fall risk evaluation to identify and document risk factors for falls upon admission, annually, with a significant change in condition, and as needed. Facility staff will identify interventions related to the residents specific risks and try various interventions, based on the nature or type of fall, until falling is reduced, stopped or until the reason for the continuation of falling is identified as unavoidable. Staff may also identify and implement relevant interventions to try to minimize serious consequences of falling. Staff will monitor and document each residents response to the intervention intended to reduce the risk of falling . When a fall occurs: when a resident has fallen, or is found on the floor, nursing staff will provide comfort, but not move the resident until evaluated for injury. The nursing staff will record vital signs (including orthostatic BP) when appropriate. If a bump on the head is suspected or confirmed complete neuro checks and update the provider timely. Nursing should utilize the neuro flow sheet per policy. I a resident is noted to be on a blood thinking medication and sustains a fall there is significant risk of bleeding. This should be reported to the provider in a timely manner. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid. If a fracture is suspected, do not move resident, but stay with resident and wait for instructions. From medical provider or emergency medical staff to arrive. Reporting to the state survey agency. All falls with serious injury that are determined to be a result of abuse, neglect, exploitation or misappropriation shall be reported to the state survey agency through the only reporting process immediately but not later than 2 hours after identifying the injury. For all other falls, follow the Abuse and Neglect Allegations decision tree. Avoidable accident -means that an accident occurred because the facility failed to evaluate/analyze the hazards and risks and eliminate them, if possible , or if not possible identify and implement measures to reduce the hazards/risks as much as possible and/or implement interventions including adequate supervision and assistive devices, consistent with a residents need, goals, care plan and current professional stands of practice in order to eliminate the risk, if possible, and if not, reduce the risk of an accident and/or monitor the effectiveness of the intervention and modify the care plan as necessary in accordance with current professional standards

Based on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in potential harm when 1 of 1 residents (R1)'s wound was not comprehensively monitored or cleaned. Findings include R1's Face Sheet, identified R2 had diagnoses that included Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (stroke) and fracture of T7-T8 vertebra. R1's Admission data collection dated 8/23/24, identified R1 arrived at facility on 8/23/24 at 12:00 p.m. R1 required total dependance for transfers from two or more staff. The skin assessment identified R1 had redness to mid upper vertebrae, redness to groin, and left buttock pressure ulcer, and both heels were red. The assessment indicated treatment(s) and monitoring had been set-up. R1's record did not include comprehensive assessments of the areas of impaired skin integrity that included further description, stage of ulcer(s), measurements, and any associated pain. R1's care plan dated 8/24/24, included R1 had alteration in skin integrity related to bruising on bilateral upper extremities, redness in groin and upper mid vertebrae, discoloration of front of right knee, pressure on left buttock. Staff were to monitor skin integrity daily during cares. Weekly skin inspection by nurse. Monitor for skin breakdown for signs/symptoms of infection. Report signs/symptoms to medical doctor or physician assistant, certified (PA-C). R1's physician orders dated 08/24/24, included the following: -Monitor scattered bruises on bilateral upper extremities for any signs of pain and infection until healed- every shift. -Monitor resident pressure sore on the left bottom for any signs of pain and infection until healed. -Monitor reddened bilateral heals until healed every shift. -Monitor redess to groin until healed. R1's treatment administration record (TAR) identified the aforementioned treatment orders. The documentation indicated the treatments were completed by check marked boxes with no other information aside from the staff intials who completed the documentation. R1's progress note dated 8/24/24 at 12:57 p.m., identified R1's skin was warm/dry, had surgical wound to back and did not have open wounds. Treatment to wound performed on shift as ordered. No further description was given. R1's progress note dated 8/24/24 8:54 p.m. identified Skin was warm/dry. Additionally note indicated No surgical wound noted. Turned and repositioned frequently. Offloading of affected area. Skin treatments performed as ordered. R1's progress note dated 8/24/24 1:56 p.m., identified Skin was cool and clammy.Additionally note indicated no surgical wound noted. No open wounds noted. Turned and repositioned frequently. Free from signs and symptoms of pain. R1's progress note dated 8/25/24 at 11:36 p.m. identified Skin is warm/dry. Additionally note indicated no surgical wound noted. No open wounds noted.Turned and repositioned frequently. Offloading of affected area. R1's progress note dated 8/26/24 12:36 p.m., identified Skin is warm/dry. Additionally note indicated No surgical wound noted. No open wounds noted. Turned and repositioned frequently. Offloading of affected area. Free from signs and symptoms of pain. Client Coordination note report from the hospice team dated 08/26/24 identified resident chose not to admit to hospice services. R1 does not ambulate or transfer and is bed bound. Skin was identified to have a coccyx wound. The note did not include a comprehensive assessment of the wound. R1's care plan dated 8/26/24 identified, R1 was on enhanced barrier precautions due to surgical incision, pressure sore on left bottom. Staff were to monitor skin integrity daily during cares Weekly skin inspection by nurse. Report signs symptoms to medical doctor (MD) or physician assistant. R1's progress note dated 8/27/24 4:01p.m. identified Skin is warm/dry. Additionally note indicated no surgical wound noted. No open wounds noted.Turned and repositioned frequently. Offloading of affected area. R1's Nurse practitioner note dated 8/27/24, identified R1 as a new patient. Skin inspection identified no rashes or ulcers. R1's progress note dated 8/28/24 at 12:28 p.m., Skin is warm/dry. No surgical wound noted. No open wounds noted. Turned and repositioned frequently. Free from signs and symptoms of pain. R1's Hospital note dated 08/29/24 at 2:14 a.m. identified while providing care to R1 writer noted a wound on his left buttocks. See chart for picture. The picture that was included identified a large unstageable oblong pressure ulcer that covered almost all of R1's left buttock. The ulcer base was approximately 95-98% black eschar, with yellowish slough surrounding the top 1/2 of the eschar, the entire wound periphery was red. Approximately 2-5% of the wound bed was red with one small fluid filled blister located within the wound periphery. The note further indicated R1 was taken to the medical surgical floor and given a shower. Barrier cream applied to his wound on his buttocks. Signed at 2:22 a.m. hospital note at 8:02 a.m. hospital registered nurse (RN)-D reported R1's family friend had called for an update and had reported the facility had informed them the wound was healing well. During a return call interview from 9/6/24 at 2:12 p.m., RN-D reported R1's left buttock wound was identified by the overnight RN from 8/28/29 to 8/29/29. RN-D indicated the facility had not informed the hospital of R1's buttock wound upon or after the transfer to the hospital. RN-D described the wound as a stage three pressure ulcer from the top of R1's buttocks down to the bottom. The eschar tissue is noted to be black with not a lot of drainage. Yellow crust on the outside on the outer edge. Scar tissue starting to form on the outside of the wound. There may have been a open area on the outer left side. Approximation of size was at least 15 centimeters (CM) by 8.0 or 9.0 cm. During interview on 9/4/24 at 9:03 a.m. family member (FM)-A reported concerns for R1's care while in the facility. FM-A was concerned of the wound located on R1's left buttock and would ask staff how the wound was healing; staff reported the wound was healing and doing really good. Once R1 arrived at the hospital on 8/28/29 hospital staff were concerned regarding the size and coloring of the wound. Hospital staff reported to the family R1's wound was not healing. During interview on 9/6/24 at 3:30 p.m., registered nurse (RN)-B stated he/she completed R1's admission and completed the skin assessment. R1 had a pressure ulcer upon admission on the left buttock that was approximately 5.0 cm by 5.0 cm with some black/purple eschar. RN-B recalled doing the skin assessment and notifying management per the facility's wound care policy. RN-B did not recall if R1 had orders from the hospital for wound cleaning and R1 did not call to clarify orders regarding wounds. During interview on 9/4/24 at 11:28 a.m., nursing assistant (NA)-A stated he/she was familiar with R1. On 8/24/24, NA-A recalled R1's bottom to be red but did not remember any ulcers and would consider the skin to be normal otherwise. NA-A stated R1 had ongoing diarrhea and used barrier cream to protect the skin. NA-A stated she would reposition/offload a couple of times a shift but R1 did not have a specific repositioning/off-loading schedule. During interview on 9/5/24 at 2:30 p.m., nursing assistant (NA)-B stated he/she assisted NA-A with changing R1 on 8/24/24 and did not recall any sores but R1's bottom was red because of diarrhea. They applied a lot of barrier cream During interview on 9/5/24 at 1:54 p.m., registered nurse (RN)-A stated no recollection of R1 having an unstageable wound on his left buttock and only recalled his bottom being red. During interview nurse manager (NM)-A 9/5/24 at 12:38 p.m., nurse manager (NM)-A indicated she participated in wound rounds which were completed weekly. Since R1 was only in the facility for five days so R1 was not seen by the wound nurse on wound rounds. NM-A reviewed R1's record and confirmed the admission record identified a left buttock pressure ulcer and there was not a comprehensive pressure ulcer assessment completed. NM-A indicated it was not possible to ascertain the size of the ulcer upon admission and not possible to identify if the ulcer had deteriorated or improved because there was not a description, or measurements recorded. NM-A indicated pressure ulcers were supposed to be comprehensively assessed upon identification and then weekly. Additionally, wounds should be routinely monitored for changes. During interview on 9/6/24 at 12:58 p.m. nurse practitioner (NP)-A reported R1 had a wound on his buttocks, however never visualized it. Typically, if there was a concern about a wound, a specialized wound nurse practitioner would do a full skin assessment. NP-A was not notified about any concerns regarding the wound. NP-A reported R1 was in the facility less than a week and R1 may have missed the wound care rounding. NP-A was unable to locate measurements of the left buttock wound upon admission, was not able to locate a monitoring order for R1's wound, there was no documentation of monitoring from 8/24/24 through 8/28/24 and did not locate any treatment orders. The goal for monitoring wounds was to identify if it was getting better or worse. NP-A indicated wounds when identified should be comprehensively assessed to include the stage and measurements to determine if the wound is worsening or improving. During interview on 9/5/24 at 3:20 p.m., director of nursing (DON)-B reviewed R1's record and confirmed the admission skin assessment identified pressure ulcer on R1's left buttock. DON-B stated based on the assessment there should have been treatments orders however, R1's records did not have any treatment orders for the left buttock wound. During interview on 9/6/24 at 1:15 p.m., director of nursing (DON)-A reported she had not ever visualized R1's buttock and had not ever met R. DON-A reported if there were any concerns DON-A would report to NM-A for R1 to be seen for wound rounds. DON-A indicated an unawareness R1 had a pressure ulcer on his left buttock. During interview with administrator on 9/6/24 at 2:05 p.m., administrator reported its the facilities responsibility to prevent or mitigate the risk of pressure sores and possible wounds. Skin assessment and wound management policy dated 3/2024 identified the purpose is prevention and identification to Provide guidelines for assessing and managing wounds. 1) a pressure ulcer risk assessment (Braden Scale) will be completed per monarchs assessment schedule/grid. 2) implement appropriate preventive skin measures. Examples include, but are not limited to, nutrition interventions, mobility and repositioning plan, pressure redistribution plan. 3) Skin evaluation and skin risk factors form was to be completed prior to the initial MDS, annually and upon significant change. 4) Staff were to provide routine skin inspections (with daily care). 5)Nurses to be notified if skin changes are identified. 6) A weekly skin inspection will be completed by licensed staff. Pressure wounds: New skin problems: when a pressure ulcer is identified, the following actions will be taken: 17. notify provider/treatment orders 18. notify resident representative 19. complete education with resident/resident representative including risk and benefits. 20. Initiate skin and wound evaluation 21. notify nurse manager/wound nurse 22. Referral to dietary 24. review and update care plan including interventions 25. update resident care lists 26. update care plan to identify risk for skin breakdown. Ongoing skin isses: -update provider and resident/representative as needed. - update care plan as needed.

Based on interview and record review, the facility failed to comprehensively assess, monitor for signs and symptoms of dehydration and implement timely interventions for 1 of 1 residents (R1) reviewed for hydration status. Findings include: R1's Face Sheet dated 8/23/24, identified R1 had diagnoses that included frontal lobe and executive function deficit following cerebral infarction, aphasia following cerebral infarction, fracture of T7-T8, type 2 diabetes mellitus and benign prostatic hyperplasia without lower urinary tract symptoms. R1's Admission data collection dated 8/23/24, identified R1's nutritional status identified weight loss/gain in the last month and mechanically altered diet. R1 used a foley catheter. R1's care plan dated 8/23/24, identified a focus of nutritional status with the goal to maintain adequate nutritional status. R1 was to have diet regular diet, mechanical soft texture, and nectar consistency. Care plan was updated on 8/26/24 as R1 required assist with feeding. R1's orders dated 8/23/24, identified R1 required staff to obtain output every shift. Staff are to monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting, diarrhea, muscle/joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose bleeds. R1's record did not include a comprehensive nutritional assessment that identified daily caloric and fluid needs and goals. R1's fluid intake and output logs were reviewed from 8/23/24 through 8/28/24. R1's record did not include an evaluation of 24-hour daily intake to ensure adequate hydration. R1's Fluid record log included the following documentation: o 8/24/24 at 9:49a.m. 120cc's (cubic centimeters), and at 1:22 p.m. 355cc's o 8/25/24 at 11:39a.m. 120 cc's, at 1:36 p.m. resident refused, at 8:19 p.m. 150 cc's o 8/26/24 at 10:37 a.m. resident refused, at 1:58 p.m. resident refused, at 8:59 p.m. 150 cc's o 8/27/24 at 12:00 noon 480 cc's, at 12:17 p.m. 480cc's, at 7:44 p.m. 240 cc's o 8/28/24 - Resident not available R1's output log included the following documentation: o 8/23/24 nocturnal shift (Noc) 650 cc's o 8/24/24 Day 850 cc's, Evening1,000 cc's, Noc 500 cc's o 8/25/24 Day 700 cc's, Evening 350 cc's, Noc 300 cc's o 8/26/24 Day 500 cc's, Evening 250 cc's, Noc 250 cc's o 8/27/24 Day 250 cc's, Evening 350 cc's, Noc 300 cc's o 8/28/24 hospitalized During interview on 9/6/24 at 10:18 a.m., registered Dietitian-(A) stated typically residents who are short term rehab, without specifically calculating, calculating it would say a rough estimate of 1,500 ml intake a day and food at least 50%. D-A explained based off chart review R1 had poor oral intake and could have benefited from a supplemental source of hydration. He would have been at risk for dehydration because he had Covid and had pressure ulcers. There was a tool to screen for malnutrition however R1 had not been at the facility so one was not completed, and a comprehensive assessment was not completed. The facility had not notified her of any concerns or was a part of his care. R1's record did not include and was not evident R1 was continuously assessed and monitored for signs and symptoms of dehydration for any necessary treatments or interventions even though R1 was at risk for dehydration. R1's progress note dated on 8/23/24 and 8/24/24, indicated R1 was alert and orientated only to himself. R1 had an indwelling urinary catheter (Foley) that was draining clear yellow urine. The note indicated R1 ate meals and drinks fluids by mouth, he had adequate food/fluid intakes this shift. Fluids were encouraged. R1's progress note dated on 8/25/24 at 1:56 p.m. R1 was disoriented to person place and time. Urine color as clear yellow. R1's progress note dated on 8/25/24 at 7:55 p.m., identified R1 was alert and oriented to person. 240 cc of fluid this shift, few bites of his meal. R1 was febrile with a temperature of 101.4 (normal ?). Tylenol was administered and effective. R1's progress note dated on 8/26/24 at 7:55 p.m., indicated R1 was alert and oriented and urine color was clear yellow. Adequate food/fluid intake this shift. Holding food in mouth/cheeks or residual food in mouth after meals. Encouraged fluid intake. R1 was more alert and offered few words but responding to yes/no questions. R1 had 240 cc of fluid for this shift, few bites of meals. R1's progress note dated on 8/26/24 at 1:18 a.m., identified. R1 had 120 cc nectar apple juice. At 10:17 a.m. no swallowing difficulties observed, encouraged increase fluid intake, and R1 displayed difficulty of movement in extremities. R1's progress note dated on 8/27/24 at 3:59 p.m. R1 ate 100% breakfast and 50% lunch with fluid intake. Clear amber urine and fluids were encouraged this shift. R1's history and physical by nurse practitioner dated 08/27/24, Identified since admission R1 was minimally responsive, will occasionally answer yes/no questions, R1 had not been out of bed and had poor intake by mouth. R1's progress note dated on at 8/28/24 12:28 p.m., Urine was amber color. Fluids encouraged this shift. Displays a decreased appetite this shift. Decreased fluid intake this shift. R1's progress note dated on 8/28/24 at 11:36 a.m., Order received to send R1 to hospital for altered mental status and multiple falls Resident urine appears to be dark in color compared to baseline. R1's current diet was nectar consistency (resident doesn't like the consistency currently working with speech therapy). R1's Emergency Medical Services (EMS) records identified being notified on 8/28/24, at 10:52 a.m. due to a fall and altered mental status. Facility staff reported to EMS R1 had an altered baseline, but on this day, it was worse and R1 was not using complete sentences like usual. Staff reported R1 was on thickened liquids and not receiving enough water and R1 was dehydrated. Fluid bolus administered and as a result did increase responsiveness. R1 was receiving 550 milliliters (ml) of normal saline. R1's blood pressure at 11:20 a.m. was 98/65 pulse was 113 regular, respirations at 30 with rapid effort. During a follow up return call from 09/06/24 at 1:27 p.m., emergency medical technician (EMT)- A reported to be present and part of the transport assist to the hospital. On arrival R1 was noted to be found sitting alone in a wheelchair in his room with his head down and his fluids were across the room on a table out of his reach. Upon physical observation R1 appeared extremely dehydrated and was difficult to arouse. R1 had thick build up on his lips, his tongue was dry/discolored, his mouth had a heavy layer of thickened matter on it and EMT-A was concerned R1 was dehydrated. EMT-A had asked the facility staff the last known time R1 had fluids and they were unable to answer. EMT-A explained oxygen and intravenous fluid (IV) fluids were immediately initiated and R1 started to perk up and engage more after he got some fluids. R1's emergency department visit note dated 8/28/24 at 3:18 p.m. indicated R1 arrived to the hospital at 12:01 p.m. R1 was ill appearing and mouth mucous membranes were dry. Abnormal urinalysis and evidence of dehydration. Sodium level was 150 compared to last taken on 8/23/24 when it was 138, creatine now 1.97 compared to 1.05 on 8/23/24. During interview on 9/4/24 at 11:28 a.m., nursing assistant (NA)- A indicated familiarity with R1. R1 was Covid positive and had to eat in his room, required staff assistance, and did not eat a lot. There were a lot of times when she delivered a food tray to his room and he would be sleeping so she would re-attempt. R1 would maybe eat 25% and drink a cup a day during NA-A'S shift for breakfast and lunch. NA-A recalled R1's urine was usually darker in color and R1 had loose stools and diarrhea frequently. During interview on 9/5/24 at 2:30 p.m., NA-B recalled R1 typically ate about 25% of his food and would help him drink his fluids. He would typically drink about 160 cc's of fluid for breakfast and would drink more than he ate. R1 frequently had diarrhea and his urine was darker in color. During interview on 9/5/24 at 12:26 p.m., NA-C worked the night shift and R1 was not ever hungry or thirsty. During interview on 9/6/24 at 9:41 a.m., registered nurse (RN)-C stated when residents were on thickened liquids they were at risk for dehydration. When a resident was at risk for dehydration the facility would implement a standing order to monitor for signs and symptoms for dehydration such as confusion, lethargy, tenting of skin or delayed rebound, and dry oral mucosa. The monitoring would be documented on the treatment administration record (TAR). RN-C reviewed R1's record and reported on 8/25/24 an order was put to monitor output however, there was not an order to monitor for dehydration and 24 hour-intake was not calculated. During interview on 9/5/24 at 1:54 p.m., RN-A worked with R1 multiple times. Staff would attempt to assist R1 with eating and drinking but he would not drink a lot. RN-A thought R1 was dehydrated. During interview on 9/5/24 at 12:38 p.m. nurse manager (NM)-A reported residents who were identified at risk of dehydration should see a dietician to lower risks of becoming dehydrated so the nutritionist can assess the fluid needs of the resident. NA-A was not aware if R1 had been seen by the dietician. During interview on 9/5/24 at 2:53 p.m., culinary director (CD)-A recalled R1 required a room tray due to isolation precautions and was on a mechanical soft nectar thick diet (fluids had been altered to a thicker consistency). CD-A recalled R1 was not really eating or drinking. He would be offered water, juice or milk with all of his meals and would eat and drink about half of what was served. CD-A was involved in general conversations with R1 not drinking enough, but figured R1 was not feeling well because of Covid. CD-A could not recall if R1 was in the facility long enough to meet the dietitian. During interview on 9/6/24 at 12:58 p.m., nurse practitioner (NP)-A reported R1 was at risk of dehydration and was notified by facility staff R1 was not drinking very much fluid. Staff were expected to manage the fluid intake by encouraging fluid consumption and document the results. NP-A would expect ideally a resident in that situation would have had a dietician consult. Policy titled hydration dated 09/2012, identified aging is one of the major factors for dehydration resulting from physiological changes in kidney functions, changes in thirst mechanism, ad chronic diseases impairing the elderly's functional abilities. Dehydration in the elderly has long been considered a significant health problem which can lead to increased morbidity and mortality and costly medical care. It is the policy to provide adequate hydration to each resident so that each one is able to achieve and maintain overall health status. The facility will provide adequate hydration by taking into consideration each residents underlying disease state, mental and physical limitations; unless the residents clinical condition indicates that a decline is unavoidable. 1. Upon admission the hospitality services director and/or dietitian will assess each resident for a minimum fluid needs. 2. Hydration status will be assessed upon admission by the nurse manager or other designated nurse and documented on the initial nursing assessment form. 3. A resident's actual fluid requirement will be jointly determined by the Hospitality service doctor and/or Dietitian and Nurse Manager and/or Director of Nursing, and documented on the Nutrition Assessment Form. 4. Actual fluid requirement will be determined using the following guideline: a. 30cc/kg of actual body weight for resident with a weight within 1WR. b. 100ml/kg for first 10 kg, 50 m/kg for next 10 kg, and 15 ml for remaining kt for underweight and over weight residents. 5. It is believed that a resident shall receive a minimum fluid requirement of 1500 cc/day to compensate for the expected weight loss through skin, lungs, kidneys, and bowel for unusual losses resulting from vomiting, diarrhea, hemorrhage or fever, unless otherwise noted by physician. 6. Additional fluid will be offered when the resident experiences and increased in fluid needs. 7. A resident is receiving approximately 1485 cc fluid from trays at meal times if all fluid is consumed. 8. Additional fluid will be provided between meals though the water pass program. 9. If a therapeutic diet eliminates coffee or limits milk to two cups per day, water or other fluid will be sent on the trays as a replacements. NOTE: for resident with impaired swallowing mechanisms or diabetes mellitus . Water or other appropriate beverages thickened to the appropriate consistency will be used. 10. Fluid intake will be monitored for three days for all newly admitted residents by the primary nurse. If the resident is consuming adequate amounts of fluid, then the fluid intake monitoring will be discontinued until a risk factor emerges. Note: intake and output (I/O) will be monitored only if ordered by physician. 11. The following are risk factors for dehydration. A resident health may or may not be placed in jeopardy based on the following risk factors: a. Inability to obtain water freely, due to any number of conditions such as a stroke, impaired movement, impaired cognition, impaired communication, or those physically or chemically restrained. b. Extra sweating, such as hot weather, high fever. c. GI volume loss such as vomiting and diarrhea d. Any change in the residents mental status or those residents with persistent cognitive deficits. e. Residents with severe kidney or hepatic failure. f. Residents taking diuretics or any medication that alters volume or electrolyte balance. g. Resident with impaired swallowing. h. Resident with impaired digestion, such as Crohn's disease. i. Resident with significant increase in respiratory rates for prolonged periods of time. j. Residents with wounds that have large volumes of drainage. k. Resident with determined at nutritional risk, l. Resident with meal intake less than 50%. Fluid intake will be monitored for the resident per nurse manager and/or hospitality service directors discretion. If it is determined their condition is compromised due to inadequate fluid intake, their individual fluid requirements will be documented in the care plan

Based on observation, interview and document review, the facility failed to comprehensively assess when a new fall risk was identified and failed to safely implement and maintain resident equipment for 1 of 3 residents (R1) who utilized an air mattress that was not maintained at the recommended pressure. Additionally, the facility failed to assess and immediately implement new interventions for 1 of 3 residents (R2) who had falls related to self-transfers. Findings include: R1: R1's significant change Minimum Data Set (MDS), dated [DATE], identified R1 was severely cognitively impaired and received total physical assist for most cares; however, extensive assist was provided for bed mobility. R1 was free of falls in the past quarter. Diagnoses included traumatic brain injury (TBI), sleep disorder, and muscle spasms. An Order Summary Report identified an order was entered on 6/5/23 for an air mattress to R1's bed. Staff were directed every shift to ensure proper function, inflation, and tie downs. A [comprehensive] Fall Review Evaluation form, locked 5/16/24, identified no history of falls in the past three months; however, R1 was at risk due to the following: medications administered, cognitive impairments, total bowel and bladder incontinence, wheelchair dependence with disorientation, and hands-on assistance to move from place to place. The Summary/Interventions section indicated R1 required dependence on a wheelchair for mobility as she was unable to walk. She was limited to only making slight changes to her extremities and required assistance with mobility. The evaluation lacked a fall analysis and information related to air mattress use, muscle spasms, chronic pain, or seizure activity, nor did it address any potential associated risks related to these. On 7/18/24, R1's weight was 145.8 pounds. R1's care plan identified an intervention for skin integrity that included a pressure redistribution mattress and for mobility she required two staff for bed mobility. The interventions were free of an assessed pressure setting identification or any additional mattress instructions. In addition, with a revision date of 3/17/22, R1 was a fall risk related to defined medication usage, impaired cognition and mobility, along with history of seizures. The goal was for her to be safe and free from falls. Interventions directed placement of foam side boards to her wheelchair for proper body alignment. Staff were directed to monitor and document on safety, review information on past falls and attempt to determine cause(s), record possible root causes of falls, and alter or remove any if possible. A Risk Management Found on Floor incident report, dated 7/20/24 at 10:40 p.m., indicated R1 was observed on the floor wrapped up in her bedding. She displayed intermitted confusion and she stated she tried to get up. R1 moaned and reported back, hip, and neck pain at a 10 when transferred to bed. She appeared still and refused to move when a skin assessment was attempted. An order was received for emergency department evaluation. Predisposing Environmental Factors identified Other and Bed Position. Predisposing Situation Factors identified Rolled out of bed. The form lacked intervention and/or any investigatory information. R1's progress notes identified the following: -7/21/24 at 0:18 a.m.: the ambulance arrived at 12:10 a.m. and R1 was transported at 12:35 a.m. A copy of the incident report was placed in the director of nursing (DON)'s box. -7/21/24 at 6:11 a.m.: hospital staff updated the facility R1 was assessed to have a C2 (cervical) fracture and was being transferred to another hospital. -From 7/21/24 through 7/24/24, the progress notes lacked identification a 7/21/24 fall analysis and/or any interventions to mitigate a reoccurrence. R1's hospital information identified the following: -7/22/24, a neurosurgical consultation note identified R1 was seen at an outside hospital where imaging revealed a C2 fracture with possible widening of the disc space. Fortunately, MRI [was] without disc injury, ligament injury or significant edema. There is a minimal fracture line at C2 - difficult to determine acuity. -An MRI cervical spine final report identified an oblique fracture at the anterior-inferior corner of the C2 vertebral body without significant displacement. There was no overlying prevertebral soft tissue swelling or evidence of ligamentous injury or malalignment. There was minimal T2 hyperintense signal along the fracture. Given the minimal associated marrow T2 hyperintensity, as well as the lack of prevertebral soft tissue swelling, this fracture is age indeterminate and could be hyperacute or subacute to chronic in nature. -R1's hospital documentation lacked evidence of suspected head/cranial injury. A progress note, dated 7/23/24 at 4:10 p.m., identified R1 returned to the facility at 1:30 p.m. An Incident Review and Analysis form, dated 7/23/24 at 2:49 p.m., identified R1's 7/20/24 fall where R1 reported she potentially laid too close to the edge of the air mattress and pressed her call light after she fell . Her mattress was assessed and functioned properly with the right weight. She was potentially too close to the edge of the bed, causing her to slip out. An intervention section directed to See Care Plan. Other interventions were identified as a foot cradle and a perimeter air mattress overlay. The form indicated that during the investigation, therapy reported R1 was unable to turn her body at all but was able to move her arms. She was not incontinent at the time of the fall and was checked on 40 minutes prior where she was left laying supine with no pillows used to offload her body and gripper socks on. R1's care plan history identified fall risk interventions were created on 7/23/24 (three days later) to include a foot cradle and a perimeter air mattress overlay. Resident group sheets were reviewed. R1 was identified as a fall risk, and she was to utilize nonskid footwear and to provide safety if a seizure occurred. Under bed mobility, staff were directed to ensure her air mattress functioned properly every shift. The group sheet lacked information related to R1's observed right sided leaning, perimeter overlay, bed cradle, mattress pump setting, bed height, and/or head elevation. An Order Listing Report, printed 7/25/24, identified all orders entered for R1 since 7/20/24. On 7/21/24, an order to send R1 to the ED for post-fall evaluation was entered. The orders lacked a fall batch order entry. When interviewed on 7/24/24, at 10:27 a.m., R1 lacked signs and/or symptoms of distress. Her forehead/face was free of bruising or signs of injury. A neck collar was in place while she laid on an inflated air mattress that housed a head and foot sectioned perimeter overlay. A foot cradle was in place without concerns. She was centered within the bed with her head slightly elevated (approximately 20-30 degrees). She was questioned on her observed neck collar use. She explained she fell from bed a couple of weeks ago when she attempted to get out of bed as it was morning. R1 confirmed this was her first fall and she was able to move in bed. However, R1 was unable to move her lower extremities when cued by the surveyor, but she brought her arms to her forehead when asked to do so. She denied any staff concerns or fears while staff rolled her in bed. R1 identified she rolled off the bed, yelled for help, and staff came right away. She acknowledged this was the first time she attempted to get out of bed herself. R1 identified she went to the hospital after the fall to get checked out and she denied any injuries were found. R1 denied concerns with her air mattress. On 7/24/24, at 10:46 a.m., immediately after R1's interview, her air mattress pump was examined. The pump identified it was a Custom Medical Solutions - Matrix ALAL Mattress System. The mattress pump identified the pump was on and lacked any lit warning identifications. The alternating cycle mode was set to every 15 minutes and the setting was set to 6. The Soft to Firm setting scale identified a setting of 6 was for a person who weighed an estimated 245 pounds. On 7/24/24, at 2:27 p.m., R1's family member (FM)-A was interviewed via telephone. He stated he visited with R1 most evenings; however, missed the evening of her fall. He was concerned on how someone who was immobile for almost 40 months could flop themselves out of bed. FM-A informed him she remembered being on the floor, but she did not remember any overall details. He explained there were instances about three to four months ago when she pushed herself in her wheelchair with her left leg, and so maybe she pushed on the wall with her left leg enough to slide out of bed. Sometimes she sits too straight and may have slid a little also. He adjusted her in bed at times due to this. FM-A identified R1's head was often elevated at a 45-degree angle. He stated R1 thought she could stand and walk. She is bullheaded. FM-A stated when R2's MRI/CT scan results came back, R1 had a C2 fracture; however, no one could figure out if this was new or old as there was no swelling of the ligaments and no indication it was an acute fracture. FM-A identified R1's air mattress was never to be static; it was always to be rotating. He often checks this as he had found this on static in the past. FM-A was unaware of what the other pump settings should be. During an interview on 7/24/24, at 3:40 p.m., TMA-B stated resident care plans identified their fall risk. She did not consider R1 a fall risk prior to the fall despite episodes where she witnessed R1 leaning while in bed. When this occurred, staff just helped reposition her. TMA-B explained R1 preferred to lay on her back, with her head elevated so she could watch TV, along with the bed frame as close to the floor as it went to ensure overall safety. She indicated this was the position she left R1 in around 7:00 p.m. the evening relevant to her fall. TMA-B was unaware of R1's mattress pump settings and explained the monitoring on the TAR indicated she was to check the bed and make sure it was on and inflated: maintenance or management adjusted the beds as she was not allowed to touch any of the settings. TMA-B was unaware of any new or updated interventions to mitigate R1's fall risk. She was unaware if R1 had bumpers on her bed even though she previously worked with R1 this day. R2: R2's Face Sheet identified R2 admitted on [DATE], from the hospital, after he sustained multiple fractures of his right sided ribs. Additional diagnoses present on admission were history of a fall, muscle weakness, unsteadiness on his feet, aphasia, fracture of right femur, malnutrition, and history of TBI. R2's Admission/Initial Data Collection form, dated 7/9/24, identified memory impairments, both short and long, assistance needed for mobility and toileting, ROM impairments on both upper and lower extremities right sides. In addition, R2 was frequently incontinent of bowel and bladder, had broken ribs and femur, and experienced falls in the past month and again in the past six months. R2's 48 Hour Care Plan, dated 7/10/24, identified he was at risk for falls. No etiologies were identified. The goal was for him to remain safe and free from falls. Staff were directed to follow therapy instructions for mobility and to monitor and document on safety, review information on past falls and attempt to determine cause(s), record possible root causes of falls, and alter or remove any if possible. Staff were then to educate resident, family, caregivers, and the IDT (interdisciplinary team) on any findings. Resident group sheets were reviewed. R2's was identified a fall risk. There was no additional information under the safety heading. Toileting directions were provided for every two to three hours. A Leisure Act. - Rehab. - Restorative section identified he was to be offered to get up around 4:00 a.m. and 6:00 a.m., toilet, provide a cup of coffee, turn the news on, and offer to lay back down when coffee was finished. The group sheet lacked information related to his self-transfers, the use of a night light, or ensuring a Reacher was near him. R2's medical record identified the following entries and identified information: -7/10/24 progress note at 2:56 p.m.: R1 required one-on-one supervision with staff due to his high fall risk. The note lacked any additional details. -7/10/24 progress note at 10:53 p.m.: R1 attempted self-transfers and was restless. -7/11/24 progress note at 9:34 p.m.: R1 was observed standing next to his wheelchair. -7/12/24 provider progress note: R2 was assessed. The note lacked information related to the self-transfers. The plan of care was to be continued and there were no concerns from R2 or staff at that time. -7/15/24 Task behavioral documentation at 5:59 a.m.: one self-transfer attempt. Despite reassurance being provided, the behavior was unchanged. -7/15/24 progress note at 10:25 a.m.: after a three-day bowel and bladder screen, R2 was incontinent of bowel and bladder and required assistance with toileting. A plan was initiated for him to be assisted with his toileting needs every two to three hours and as needed. -7/15/24 Task behavioral documentation at 1:59 p.m.: one self-transfer attempt. Despite reassurance being provided, the behavior was unchanged. -7/15/24 progress note at 2:33 p.m.: R2 liked to self-transfer and wandered. -7/15/24 progress note at 3:01 p.m.: R2 was found seated on the floor [at 6:00 a.m.]. No injuries were assessed. R2's only response was 'look at all of this' as he pointed at the room. -7/15/24, an occupational therapy (OT) progress note at 3:01 p.m., identified OT approached R2 and found him on the floor. The note did not identify at what time R2 was found. No injuries were observed. -7/15/24 order listing report identified fall batch orders to complete a post fall progress note every shift for 72 hours with directions to Make sure to include any [signs/symptoms (s/s)] of injury and effectiveness of new fall interventions. The second order identified interventions for medication review request and call light reminder sign. There orders were discontinued 7/16/24. A Risk Management Found on Floor incident report, dated 7/15/24 at 6:00 a.m., identified R2 was found seated on the floor. He was unable to identify what happened and he was injury free. He was returned to bed and checked on frequently afterwards. Immediate actions identified staff placed a sign in his room to call for assistance and he was frequently checked on throughout the day. Lighting concerns were identified, along with R2's confusion, history of falls, and not always able to realize his limitations in which R2 ambulated/transferred without assist. R2's medical provider was updated at 2:59 p.m., the DON at 3:00 p.m., and FM-B at 3:24 p.m. An admission [comprehensive] Fall Review Evaluation form, dated 7/15/24 at 9:50 a.m., identified R2's history of multiple falls in the past month and past six months with risk factors related to psychotropic medication, memory impairments, impaired mobility, occasionally incontinent of bowel and bladder, and exhibited agitated, or wandering, behaviors in the past seven days. Environmental factors provided an option for Lighting [as identified on the Risk Management 7/15/24 form]; however, this was blank. A summary identified R2 had potential risk for falls related to decreased mobility and listed medication and he was disoriented and required two staff for transfers. Fall interventions directed to see the care plan and staff would continue to monitor and update the plan of care as needed. The evaluation was free of information related to the 7/15/24, 6:00 a.m. fall. An Incident Review and Analysis form, dated 7/15/24 at 10:20 a.m. and signed as complete on 7/18/24, identified the information from R2's 7/15/24 Found on Floor incident report. The form analysis indicated R2 was brought to the activity room after the incident. Contributing factors included inability to always realize his limitations, history of falls, lacked remembrance to use the call light, expressive aphasia, and the lack of room light. The form directed one to the care plan for interventions and indicated RN-C spoke to FM-B and was informed R2 enjoyed picking things up from the ground, such as sticks in the yard. In addition, he liked things tidy. The call do not fall sign was removed as R2 was severely cognitively impaired and he was provided with a grabber/Reacher. An admission MDS driven Behavioral Symptoms CAA (Care Area Assessment), dated 7/16/24, identified R2 displayed three occurrences of self-transferring within a seven day look back period. The behaviors would be care planned to slow or minimize declines and risks. The CAA was free of information related to self-transfer mitigation. An admission MDS driven Falls CAA, dated 7/16/24, identified R2's fall history with injury and that he fell on ce since admission. R2 displayed balance problems during surface transitions and transfers in which staff ensured his footwear prevented slipping, his room was set up to accommodate his needs, and his personal items were within his reach. The fall risk would be care planned to avoid complications and minimize risks. The CAA was free of information related to R2 footwear or room accommodation specifics. In addition, the CAA lacked details related to his 7/15/24 fall, his self-transfers, or any overall comprehensively assessed fall risk details and determined resident specific fall interventions. R2's subsequent medical record identified the following entries and identified information: -7/16/24 provider note identified R2 had 2 falls last night and 1 this morning. R2 continued to be forgetful and impulsive with self-transfers. A fall matt next to his bed was recommended. -7/16/24 progress note at 6:52 a.m.: Fall Charting - vitals and neuros within R2's norm. No falls tonight on this shift. The note lacked effectiveness of interventions. -7/16/24 progress notes at 10:35 a.m.: R2 was seated on his bedroom floor [at 6:25 a.m.]. No injuries assessed. R2 unable to provide fall details. He was checked on frequently afterwards. -7/16/24 order listing report identified the fall batch orders were initiated with direction to monitor the effectiveness of a medication review request and call light reminder sign. A Risk Management Found on Floor incident report, dated 7/16/24 at 6:25 a.m., identified R2 was found seated on the floor without injury. He was unable to identify what happened. He was returned to bed and checked on frequently. An immediate intervention was a fall mat. Poor Lighting was identified, along with R2's incontinence, gait imbalance, and cognitive impairments. The medical provider was updated at 11:59 a.m., the DON at 12:01 p.m., and FM-B at 11:59 a.m. An Incident Review and Analysis form dated 7/16/24 at 4:08 p.m., and signed as completed on 7/18/24, identified the information from the 7/16/24 Found on Floor incident report. R2 was found incontinent, and the room was dark. He was cleaned up and new cloths donned. Current interventions directed one to the care plan. RN-C spoke with FM-B as the falls occurred at approximately the same time on two consecutive days. Based on FM-B's statements of R2's routines, interventions were implemented; however, the poor lighting concern and the fall matt from the incident report on 7/16/24 was not addressed. R2's subsequent medical record identified the following entries and identified information: -7/18/24 progress note at 5:44 a.m.: R2 remained a fall follow up. He continued to self-transfer. The note lacked effectiveness of interventions. -7/18/24 physical therapy (PT) progress note identified R2 continued to require two staff due to his fall risk and impulsive movements. -[7/19/24 progress notes lacked documentation R2 fell at 5:00 a.m.] -7/19/24 order listing report identified an order to cleanse above the right elbow skin tear, apply skin prep, and cover with non-adherent dressing. Change every three days. -7/19/24 order listing report identified fall batch orders to complete a post fall progress note every shift for 72 hours with monitoring the effectiveness of a fall mat and night light interventions. -7/19/24 provider note identified R2 was assessed for pain, fall, and blood pressure follow-up. He continued to have multiple falls, was impulsive, and had a fall matt in place. He was reminded to use the call light and was agreeable; however, he was forgetful. Blood pressure would continue to be monitored. A Risk Management Found on Floor incident report, dated 7/19/24 at 5:00 a.m., identified R2 was found on the floor in which he was not on the fall mat. He and his bed were wet with urine. He was without socks and his bed was in the lowest position. He was unable to identify what happened and sustained a right elbow skin tear. He was changed into a new brief and gown, and socks were placed. An immediate intervention was a a toileting plan. The form lacked specific toileting plan detailed adjustments to the 7/15/24 and 7/16/24 initiated toileting plans. Lighting, Noise, and Poor Lighting concerns were identified. The report lacked evidence FM-B was notified. An Incident Review and Analysis form dated 7/22/24 (three days after the fall), at 2:57 p.m., identified the information from the 7/19/24 Found on Floor incident report; however, did not identify R2 was found off the fall mat or there were lighting issues identified. Current interventions directed one to the care plan. Other intervention identified a toileting plan. The form lacked specific toileting plan detailed adjustments to the 7/15/24 and 7/16/24 initiated toileting plans. R2's fall risk care plan identified he was at risk related to history of falls with injuries. He was to remain safe and free of falls. The following information was identified: -On 7/18/24 [two days after a fall], a grabber or Reacher intervention was initiated. -On 7/18/24 [two days after a fall], a 4:00 a.m. to 6:00 a.m. plan to offer R2 the opportunity to get out of bed, use the bathroom, have a cup of coffee, place channel 9 news on, and after done offer him to lay down for a nap was entered on the care plan. -On 7/19/24, auto-lock brakes to the wheelchair were entered on the care plan. R2's chart lacked additional information on the brakes. R2's subsequent medical record identified the following entries and identified information: -7/19/24 progress note at 11:00 p.m.: R2 remained on fall follow up. Continued to attempt self-transfers but was easily redirectable. Confused per baseline. The note lacked effectiveness of interventions. -7/20/24 Task behavioral documentation at 1:59 p.m.: five attempts at self-transfers. Despite redirection the behavior was unchanged. -7/20/24 progress note at 3:06 a.m.: R2 was found seated on his bedroom floor [at 12:30 a.m.]. He was unable to state what happened. He was free of injury and toileted with his call light left within reach. Gripper socks were applied, and he was redirected to call for help instead of self-transferring. The incident report was placed in the DON's box. -7/20/24 order listing report lacked evidence fall batch orders were initiated related to R2's 7/20/24 fall. A Risk Management Found on Floor incident report, dated 7/20/24 at 12:30 a.m., identified R2 was found seated on the floor by the bathroom and was without injury. He was unable to identify what happened. R2 was toileted. Other and Poor Lighting were identified as concerns and he continued with previously identified risk factors. The report identified RN-C was notified at 3:04 a.m., but lacked evidence FM-B was notified, and/or the provider. An Incident Review and Analysis form, dated 7/20/24 at 1:51 p.m. and signed as completed on 7/23/24, identified the information from the 7/20/24 Found on Floor incident report. Contributing factors identified the room was dark when he was found. Current interventions directed one to the care plan. An implemented intervention was a night light to his room. R2's provider was updated; however, the Responsible Party incident review designation box was unchecked. R2's subsequent medical record identified the following entries and identified information: -7/20/24 progress note at 9:39 p.m.: R2 remained a fall follow up. He continued to demonstrate weakness and self-transfers. He was redirected successfully. The note lacked effectiveness of interventions. -7/21/24 Task behavioral documentation at 1:59 p.m.: one self-transfer attempt. Despite a change in location the behavior was unchanged. -7/22/24 PT progress note identified R2 was found self-transferring to the toilet upon therapy approach. The note lacked identification nursing was updated. -7/22/24 OT progress note identified R2 stood alone in the bathroom upon approach. The note lacked identification nursing was updated. -7/23/24 provider note identified R2 was assessed; however, the note lacked information related to his 7/20/24 fall, his continued fall risk, and self-transfers, or involved discussion related to fall interventions. -7/23/24 Task behavioral documentation at 1:59 p.m.: one self-transfer attempt. Despite redirection the behavior was unchanged. -From 7/10/24 to 7/24/24, neither OT or PT progress notes identify R2 fell on [DATE], 7/19/24, or 7/20/24 and/or any involvement with nursing staff related to fall analysis and intervention discussions. R2's fall risk care plan identified he was at risk related to history of falls with injuries. He was to remain safe and free of falls. The following information was identified: -On 7/22/24 [two days after a fall], toilet R2 every two to three hours was entered on the care plan. -On 7/23/24, [three days after a fall], night light to room was entered on the care plan. R2's July 2024 TAR was reviewed. This identified 19 shift opportunities which directed staff to monitor injury and the effectiveness of designated fall interventions associated with orders initiated on 7/15/24, 7/16/24, and 7/19/24. The TAR lacked directions related to R2's 7/20/24 fall. All 19 opportunities were signed off by staff as completed. In relation, progress notes from 7/15/24 through 7/24/24, identified six progress notes for fall follow-up. Out of these six, none evaluated the effectiveness of the fall interventions. During an initial tour on 7/24/24, at 10:18 a.m., R2 was not observed in his room. A red colored mat was on the floor. In addition, a soft-touched call light rested on the bed and the standard mattress was at an average bed height. Immediately after, TMA-A confirmed this was a fall mat. When interviewed on 7/24/24, at 1:35 p.m., R2's room was free of the previously noted red fall mat and there were two signs within his room to remind him to put his call light on for help before getting out of his wheelchair and a sign on the bathroom door to please use call light for assistance. The bed height was at a standard height. Communication was more drawn out due to his expressive aphasia; however, with communication techniques, the interview progressed. He was good and agreed it was July. When asked where he was, he responded I am not really sure. He confirmed falls since admission and these falls were from bed. When asked the reason for the falls, he stated, I know the reason .was trying to go to the bathroom. He denied injury from the falls. He was able to find his call light when cued and his Reacher when asked if he was able to use it. He acknowledged episodes where he had a hard time controlling his bladder and bowels and he felt staff toileted him to his liking. He denied concerns with his stay. During an interview on 7/24/24, at 1:51 p.m., trained medication aide (TMA)-A stated resident fall risk was identified on the group sheets and within their charting system. He lacked the group sheets on him at that time. TMA-A thought fall interventions were identified on the group sheets but was not 100 percent sure. He did not feel R1 was a fall risk, and her recent fall surprised him. He stated R1 preferred to be in bed, on her back, and was not up for long periods of time. TMA-A explained R1 was able to move herself a little bit when in bed and she preferred her head elevated. R1 was overall dependent on staff but she helped feed herself at times. TMA-A indicated R1 utilized an air mattress and denied any noted concerns with it. He denied the facility educated him on air mattress expectations and/or what the manufacturer guidelines for use were. TMA-A denied he adjusted the pump settings as It is there for a reason. He was unsure what R1's pump settings were expected to be set at. When he worked with her, he just checked to ensure the mattress was on and inflated. He was unable to identify when the perimeter overlay was placed. -TMA-A stated he continued to monitor R2 constantly, somewhere where he needs to be in sight as he tries to jump out of his wheelchair. He identified R2 was much better when he was in bed and less likely to self-transfer. Fall interventions utilized on R2 were the obvious ones such as gait belt, making sure he had a steady rail in the bathroom, etc. He did not feel R2 had any specialized fall risk interventions. However, he explained basically every two to three hours they toileted him and attempted to keep him involved in as many activities he could for distraction purposes. Despite this, R2 continued to self-transfer and required his interception. The self-transfers varied per shift and depended on what R2 was doing at those moments. He denied nurses and/or management spoke to him about his insight into R2 and his fall risk for potential assist with intervention development and/or adjustments. When interviewed on 7/24/24 at 2:58 p.m., registered nurse (RN)-A stated the nurse managers performed the fall risk assessments but explained all the residents were at risk for falls - some were just higher risk than others. After a resident fell , she was expected to enter an incident report into PointClickCare (PCC) which management then reviewed and who then developed intervention(s). RN-A explained if she were to initiate an intervention, this would be documented with her fall note. She expected all fall interventions to be entered in the care plan or on the group sheets. RN-A identified that on 7/20/24, she observed R1 on the floor wrapped up in her bedding. R1 informed RN-A that she attempted to get up. R1's call light was unplugged from the wall and her bed was high despite R1's need for a low bed. RN-A clarified R1's bed was expected to be at standard height but she was higher. She was unsure of R1's head elevation status as she was more concerned with getting R1 off the floor, but R1 preferred the head of her bed elevated about 30 to 45 degrees. The air mattress was inflated, and she did not feel she remembered any notable concerns. RN-A explained the NAs checked the air mattresses every shift to ensure they functioned properly and thus she did not personally check to ensure functionality: if staff did not approach her with any concerns, she initialed it off on the treatment administration record (TAR) that it was checked. R1's mattress setting(s) were unknown to her and she guessed the setting should be maybe around 350. RN-A denied knowledge of previous R1 falls but within the past few months she had assisted R1 to reposition as she was closer to the edge of the bed with her head elevated, in which R1 had a tendency of doing when her head was elevated. RN-A explained the intervention put into place after R1's fall was her transfer to the hospital. She did not investigate any potential causes of the fall, or her concern related to the bed height. During the same interview, RN-A identified R2 required a low bed, a soft-touched call light, a fall mat, frequent checks, and gripper socks due to his self-transfers. RN-A explained R2 just get up when he felt the need but did not understand his weakness. She often had to tell R2 to use his call light. RN-A explained one-night R2 fell despite there already being a fall mat in

Based on interview and document review, the facility failed to ensure mail was delivered to residents on Saturdays. This had the potential to affect all residents who receive mail to the facility. Findings include: On 10/25/23 at 10:09 a.m., during a resident council interview, the participating residents were unsure if mail was delivered on Saturdays. On 10/25/23 at 10:36 a.m., therapeutic recreation director (TRD)-A stated she delivered the mail Monday through Friday and did not know if the mail was delivered to residents on Saturdays. The mail generally came between 11:00 a.m. and 11:30 a.m., and was delivered to a mailbox on the edge of the property. When TRD-A arrived Monday at 8:00 a.m. she would check the mail box before going into the facility and there would generally be mail in the box from the weekend. On 10/25/23 at 10:49 a.m. registered nurse (RN)-D stated she was not sure if anyone picked up and delivered mail to residents on Saturdays. On 10/25/23 at 10:50 a.m., the director of nursing stated she was unsure how or if mail was delivered to residents on Saturdays and thought it probably sat in the mailbox until Monday when TRD-A picked it up. On 10/25/23 at 10:53 a.m., the administrator stated she was unsure if mail was delivered to residents on Saturdays. Mail delivery was a resident right and resident's should not have to wait to receive their mail delivered in the Saturday mail until Monday. The Resident Right policy dated 2016, identified one of the resident's rights was to receive mail. The undated, Resident Care Policy, identified Mail is available to the Center's residents each day that the mail is delivered to the center.

Based on observation, interview and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety by failing to maintain safe food storage temperatures. This practice had the potential to affect all residents consuming food at the facility. Findings include: During an observation on 10/24/23 at 11:10 a.m., dietary aid (DA)-A filled the top shelf of a cart with two gallons of milk, and some pitchers of juice, none of which were held on ice. DA-A filled glasses with beverages and placed them on resident trays stacked on a speed cart for delivery. During an observation on 10/24/23 at 11:20 a.m., DA-A brought the cart of beverages, not on ice, out to the dining room. During an observation on 10/24/23 at 12:08 p.m., the cart with juice and milk, not on ice, was still sitting in the dining room. During an interview on 10/24/23 at 12:10 p.m., the dietary manager (DM) poured a glass of milk from the one of containers on the cart and took the temperature for 15 to 20 seconds, and stated it was 55 degrees Fahrenheit. The DM stated he would not serve this, and discards the two gallons of milk, because there was a risk of bacterial growth from not being held below 41 degrees Fahrenheit. During an interview on 10/25/23 at 3:34 p.m., the administrator stated her expectation was that milk would be kept at proper temperatures because the risk would be spoiled milk that may cause illness. An undated document, Food Preparation and Service, identified the danger zone for food temperatures was between 41 to 135 degrees Fahrenheit. Potentially hazardous foods (PHF) were identified as meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained below 41 degrees Fahrenheit or above 135 degrees Fahrenheit.

Based on interview and document review, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 1 resident (R8) reviewed for MDS accuracy. Findings include: R8's quarterly MDS dated [DATE], identified R8 was cognitively intact and included diagnoses of right-sided hemiplegia (one-sided paralysis) and hemiparesis (one-sided weakness) following a stroke. R8 used anticoagulation (to prevent blood clotting) medication daily. R8's undated provider orders identified R8 was not prescribed anticoagulation medication during the look back period. During an interview on 10/25/23 at 2:50 p.m., registered nurse (RN)-B stated she was not sure what happened with R8's MDS from 8/15/23, because R8 was not on an anticoagulant medication. RN-B stated she would talk with the regional director and then modify the MDS. During an interview on 10/25/23 at 3:33 p.m., the administrator stated the expectation was MDS' were accurate so billing and care provided were appropriate. A policy regarding MDS accuracy was requested but not received.

Based on observation, interview, and document review the facility failed to ensure a comprehensive assessment was completed to identify causative factors and ensure appropriate interventions were implemented to promote healing for 1 of 1 residents (R21) who's heel wound was observed. Finding include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 was cognitively intact and at risk for developing pressure ulcers. No pressure or non-pressure foot wounds were documented. R21's undated, face sheet, included diagnoses of acute chronic congestive heart failure, edema, type 2 diabetes, and severe chronic kidney disease. The undated provider orders included the following orders: - 6/27/23, weekly skin inspection completed by a licensed nurse on bath day. - 8/25/23, float heels until healed okay to use Prevalon boot (cushioned boot worn to protect heels) as resident allows. - 8/25/23, apply skin prep to bilateral heals every shift for prevention. This order was updated on -10/26/23, to include monitor heels for any changes and update NP with concerns. R21's medical record lacked a comprehensive assessment related to the heel wound, to identify potential causative factors, measurements, classification of the wound and a plan and interventions. R21's undated care plan was requested, but not received. The following MHM Weekly Skin Inspection V-4 completed by licensed nursing staff lacked comprehensive assessment and documentation of R21's right heel wound: - 8/29/23, did not document on the heel. - 9/5/23, R21 had redness on abd [abdomen] and left breast, heel dressing prep applied. - 9/12/23, under left breast red, middle abd red, heel boot and skin prep applied to right heel. - 9/20/23, skin prep to heels done. Visible areas of skin were CDI [clean dry and intact]. - 9/29/23, bed bath, no redness skin fold, abdomen, or breast. Right heel looked the same. Skin prep applied to right heel. - 10/3/23, bed bath, skin is CDI [clean dry and intact], left foot edema, leg elevated. -10/17/23, redness skin breakdown lower abd fold. washed and powder applied. Right heel gets skin prep. The weekly skin inspections failed to identify size, description of the wound and whether it was healing. The nurse practitioner note dated 10/16/23, described R21's heel as an intact callous with no signs of drainage. R21's nursing progress notes identified the following: - 8/25/23, R21 had a 2-centimeter (cm) x 5 cm bluish black area on the right heel. Skin prep was applied, and the area was covered with a gauze dressing and a boot was placed that foot. - 8/25/23, the provider was notified R21 had a purple spot on their heel. The provider ordered float heels, and skin prep to both heels. -10/2/23, identified R21 had been seen by podiatry. Podiatry recommended floating R21's heels while in bed to prevent injuries. During an interview on 10/25/23 at 3:13 p.m., registered nurse (RN)-A confirmed R21 had a heel wound and identified the wound was being treated two times a day with skin prep. The last time they was the wound, the part with open areas started to grow new skin and there was an area over the purple part where skin started to flake off. All wounds and/or skin conditions should have a documented assessment on the weekly skin assessment until healed. The assessment was needed to determine if the wound is getting better or worse. During an interview on 10/26/23 at 9:18 a.m., R21 stated the regular nurses treated his heel wound a couple times a day, but a wound nurse had not looked at it. About two weeks ago a podiatrist looked at the wound and shaved some skin off it. On 10/26/23 at 9:50 a.m., LPN-A reviewed R23's medical record and could not find a wound classification for R21's wound. R21's wound was observed. The outer aspect of R21's heel had a purple hued area with a pink center which contained small scabs and sloughing skin. The wound was not measured but was approximately 3 centimeters (cm) x 4 cm. On 10/26/23 at 10:00 a.m., the director of nursing (DON) looked at R21's heel and indicated she was not wound certified but felt R21 did have a wound with skin break down. R21's medical record identified R21's wound was not assessed comprehensively assessed and not adequately described during weekly skin checks. The facility wound nurse stated R21's heel was bruised so it was not included in wound rounds. Bruises or other types of skin impairment should be included in the weekly skin inspection until they are resolved. When R21's skin started to break down, the facility process should have been implemented and the wound nurse should have been consulted for weekly rounding. The DON expected R21's heel wound to be assessed and documented on in the weekly skin check assessment until resolved. The facility Skin Assessment & Wound Management policy dated 2/10/23, identified routine skin inspections should be done with routine care, and weekly skin inspection should be completed by a licensed nurse. Staff were also directed to initiate a weekly wound evaluation for newly discovered pressure ulcers, significant non-pressure wounds, and/or altered skin integrity.

Based on observation, interview, and document review, the facility failed to accurately assess pressure ulcers, implement care plan interventions to prevent worsening of unavoidable pressure ulcers, and provide ongoing monitoring of pressure ulcers for 1 of 4 residents (R10) reviewed for pressure ulcers. In addition, the facility failed to comprehensively assess and provide ongoing monitoring of pressure ulcers to prevent the development and worsening of avoidable pressure ulcers for 1 of 4 residents (R7) reviewed for pressure ulcers. In addition, the facility failed to accurately assess, implement interventions, and provide ongoing monitoring to prevent the worsening of avoidable pressure ulcers for 1 of 4 residents (R17) reviewed for pressure ulcers. This resulted in actual harm for R7, R17, and R10. Findings include: Pressure Ulcer stages defined by the National Pressure Ulcer Advisory Panel (NPUAP): Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin 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 are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss 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; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss 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. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. R17's [DIAGNOSES REDACTED]. R17's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R17 had moderately impaired cognition, had no behaviors and rejected cares. R17 needed the extensive assistance of two staff with bed mobility and the extensive assistance of one staff with transfers, locomotion, dressing, toilet use and personal hygiene. R17 did not walk and used a wheelchair for mobility. R17 was at risk for pressure ulcers, had no unhealed pressure ulcers and did not have pressure ulcers on the prior assessment. R17 had pressure relieving devices on the bed and wheelchair. R17's care plan updated 11/1/17, indicated R17 was at risk for pressure ulcers due to the [DIAGNOSES REDACTED]. The care plan further indicated R17 had a history of [REDACTED]. The care plan interventions included hourly turning and repositioning, diabetic foot monitoring, a toileting plan, skin care after each incontinence episode and apply barrier cream, a weekly wound assessment and treatments as ordered. R17's care plan lacked indication of the right heel pressure ulcer. R17's nursing assistant (NA) care guide undated, directed staff to offer every hour repositioning off of buttocks. Use pillows when in bed. The guide did not address the heel pressure ulcer. On 1/4/18, R17 was continuously observed from 7:55 a.m. through 10:35 a.m. At 7:55 a.m. R17 was observed up in the wheelchair in the dining room at the table. R17 had a blue pressure relieving boot on the right foot. At 8:01 a.m. R17 received breakfast. At 8:40 a.m. R17 was taken out of the dining room by nursing assistant (NA)-B and requested to talk to the staff in the business office. At 8:43 a.m. R17 was brought to his room by NA-B. NA-B in was in R17's room for approximately 20 seconds. NA-B did not offer or change R17's position, offload (removing pressure to an area for a period of time), or toilet R17. At 8:53 a.m. NA-B was in R17's room and made the bed. NA-B did not offer or change R17's position, offload or toilet R17. At 8:54 a.m. registered nurse (RN)-A offered R17 an activity and R17 declined. At 9:01 a.m. NA-B and RN-A exited R17's room. NA-B and RN-A did not offer or offload, reposition or toilet R17. At 9:21 a.m. licensed practical nurse (LPN)-B checked R17's oxygen saturation level and did not offer or offload, reposition or toilet R17. At 10:11 a.m. the dietary staff brought R17 a snack of cheese and crackers. On 1/4/18, at 10:30 a.m. NA-A stated she had not moved or repositioned R17, and R17 was up in the wheelchair when she got to work at 6:00 a.m. NA-B stated she had not moved or repositioned R17 since she had arrived at work at 6:00 a.m. NA-B stated R17 often refused, but verified she had not offered to toilet, reposition, or offload R17. On 1/4/18, at 10:35 a.m. (after no offloading, reposition, or toileting for 2 hours and 40 minutes) R17's skin was observed with NA-B and RN-A. R17 complained of his foot being sore. R17's buttock skin was pink and blanchable. R17 had healed pressure ulcer areas on the right and left sides of the coccyx. The pressure ulcers were covered with superficial shiny skin. RN-A stated R17 had also been incontinent of urine. R17's brief was wet with urine. On 1/4/18, at 2:19 p.m. R17's right heel pressure ulcer was observed during the dressing change with RN-B. RN-B stated she looked at the resident's wounds weekly. RN-B removed the heel boot, R17's sock and the old dressing. R17's heel pressure ulcer measured 4 cm x 4 cm. RN-B described the pressure ulcer as granulation on the top and the rest was eschar. RN-B cleansed the pressure ulcer, applied skin prep to the surrounding skin, applied the [MEDICATION NAME] dressing, and wrapped the foot with a rolled gauze. RN-B stated the pressure relieving heel boot was to be on at all times and the pressure ulcer was unstageable due to the eschar. A progress note dated 12/16/17, indicated a NA informed the nurse that R17 had a sore on the heel of his right foot. The heel appeared to have had a blister on it that had already drained. The area measured 2.2 cm by 4.2 cm, with a darker area that was 1.2 cm by 2.2 cm. The area was cleaned with wound cleanser, [MEDICATION NAME] was applied then covered with [MEDICATION NAME] (a foam dressing). A pressure relieving boot was placed on the foot. The nurse practitioner (NP) was notified and directed to continue the treatment, change the [MEDICATION NAME] every three days, unless the bandage falls off or drainage leaked through. R17's Weekly Wound Evaluation dated 12/19/17, indicated R17 had a 3 cm by 4 cm Stage 2 pressure ulcer on the right heel. The pressure was cleaned with wound cleanser, skin prep was applied around the open area then covered with a [MEDICATION NAME] dressing (a dressing which draws fluid and dead tissue away from the wound and into the dressing). R17's Weekly Wound Evaluation dated 12/26/17, indicated R17 had a 2.5 cm by 4.5 cm unstageable pressure ulcer on the right heel, with a change in the wound bed with 100% eschar. R17's Weekly Wound Evaluation dated 1/2/18, indicated R17 had a 3 cm by 4 cm, Stage 4 pressure ulcer on the right heel. The pressure ulcer was identified on 12/19/17, and was 25% slough (defined as yellow devitalized tissue, that can be stringy or thick and adherent on the tissue bed) and 75% eschar (a slough or piece of dead tissue that is cast off from the surface of the skin). On 1/2/18, at 6:46 p.m. R17 was observed up in the wheelchair in his room. R17 had a dressing on the right heel and a blue pressure relieving boot on his foot that went to the knee. R17 did not have a sock on the foot. On 1/3/18, at 3:46 p.m. R17 was in his room, up in the wheelchair with the blue pressure relieving boot on the right foot. On 1/4/18 7:00 a.m. R17 was up in the wheelchair in the front lobby, with the blue pressure relieving boot on the right foot. On 1/4/18, at 10:54 a.m. the NA care sheet was reviewed with NA-A and RN-A. The group sheet directed to take R17 to the bathroom every hour and to reposition him every hour. On 1/4/18, at 2:00 p.m. LPN-A stated R17 usually got up in the wheelchair on the night shift, at approximately 4:30 a.m. On 1/4/18, at 2:48 p.m. RN-B stated R17 was at risk for pressure ulcers due to being diabetic and needing assistance with mobility. RN-B stated the pressure ulcer was caused from R17 crossing his legs. R17's right heel was the bottom foot with the right heel directly on the floor. R17 did not like to have foot pedals on the wheelchair. RN-B stated the pressure ulcer was avoidable because R17 should have been turned at least every two hours or more frequently due to the current pressure ulcer. Interventions also included a multivitamin, and to have the heel pressure relieving boot on at all times. On 1/5/18, at 11:01 a.m. the director of nursing (DON) was interviewed and verified R17's current pressure ulcer was not on the care plan, and should have been added to the care plan when the pressure ulcer was discovered. The DON verified there was not an assessment of R17's heels completed until after the pressure ulcer developed. The DON stated R17's risks for pressure ulcers included the need for assistance with mobility, incontinence, noncompliance and diabetes. The DON stated she did not know how R17 got the heel pressure ulcer. The DON thought maybe R17 crossed his feet. The DON stated R17 was always wearing shoes and R17's shoes now were not the original ones. The DON stated R17's guardian brought in new shoes for a better fit. The DON verified R17 was to be repositioned every one hour, and the intervention was put into place when R17 started having breakdown. The DON stated everything on the NA care sheets was reflected off the care plan. The DON would expect staff to reposition and or offload as directed by the care plan. On 1/5/18, at 11:52 a.m. NA-B stated on 1/4/18, she was unable to get everything done because there were a lot of call lights on. NA-B also stated the NA's charting takes a long time to complete, and the facility does not want to have over time so, Corners are cut. The facility's Tissue Tolerance Evaluation/Observation policy, dated 6/18/14, directed the tissue tolerance evaluation would be completed when in the chair or bed upon admission, when there was a change in condition that affected mobility, readmission, annually and the development of a pressure related area. Once the resident's turning and repositioning schedule was determined the NA would do a daily skin inspection and the licensed nurse would do a weekly skin inspection to ensure there were no adverse effects to the skin, ensuring the repositioning schedule was appropriate. If a resident refused skin care interventions or treatment a Risk and Benefit form would be completed and reviewed with the resident and/or responsible family member. Documentation would be completed in the medical record. This included updating the care plan and the NA care sheets. The facility's Assessment Schedule dated 5/17/17, directed a skin inspection, a wound evaluation for pressure ulcers, and a skin evaluation for other areas of concern would be completed weekly. R7 stated on 1/3/18, at 9:45 a.m. that he had a sore on his left heel, but did not know how it developed. R7 stated it had been hurting, and when the nurse took off his shoe, there was a big sore. R7 stated he wore a boot on his foot all the time. R7's Admission Record printed 1/5/18, indicated R7's [DIAGNOSES REDACTED]. R7's quarterly MDS dated [DATE], indicated R7 was not at risk for pressure ulcers, required extensive assist for bed mobility, and was frequently incontinent of bowel. The MDS also indicated R7 had no pressure ulcers, and had no pressure relief device in chair or bed. R7's progress notes dated 9/7/17, indicated R7 was lying in bed with a ring of fluid on the bed sheet near the left foot and a fluid filled blister on the left heel had opened. R7 wore Tenoshapes and had [MEDICATION NAME] (a skin ointment) applied to lower extremities. The blister was measured at 5 centimeters (cm) x 5 cm with copious amounts of drainage. The blister was dressed and NP was notified. R7's annual MDS dated [DATE], indicated R7 required extensive assistance for bed mobility and activities of daily living (ADLs), including toilet use and personal hygiene. The MDS indicated R7 was non-ambulatory, and was always incontinent of bladder, and frequently incontinent of bowel. R7's MDS further indicated R7 was at risk for pressure ulcers and had an unstageable pressure ulcer measuring 3.0 cm x 3.5 cm x 0 cm that had eschar (collection of dead tissue) on it, had a pressure reducing device for chair and bed, and received pressure ulcer care. R7's Care Area Assessment (CAA) for pressure ulcers dated 10/9/17, indicated R7 was at risk for pressure related breakdown, and incorrectly identified R7's skin was currently intact. R7's CAA indicated R7 had [MEDICAL CONDITION] of lower extremities and staff applied Tenso stockings (compression stockings) every morning and removed in the evening. R7's care plan dated 9/7/17, identified R7's risk for pressure ulcers and actual development of a blister to left lateral heel related to friction from sandals identified on 9/7/17. Interventions included Braden Scale (an assessment tool used to assist in determining an individual's risk for pressure ulcers) per facility policy, weekly skin inspections, foam heel protector until blister resolved, pressure reduction/relieving mattress, treatments as ordered, supplements as ordered (initiated 10/10/17, for increased nutrient needs related to pressure ulcer and need for healing), protective boot for left foot, and request family to provide proper fitting footwear. R7's nursing assistant (NA) group/care guide sheet identified fragile skin, blister to left heel, and directed staff to put on Tenoshapes (compression stockings), foam heel protector in place at all times until resolved, and to wear no footwear on left lower extremity. R7's group sheet further indicated R7 was independent with bed mobility and to assist with repositioning as needed. On 1/4/17, at 3:10 p.m. during observation of R7's pressure ulcer, RN-B stated the back of R7's sandal had rubbed and formed a blister, which opened, and then developed eschar. [MEDICATION NAME] was used and it had pulled off the eschar. RN-B stated she was not sure how the eschar developed. RN-B removed R7's dressing and measured R7's left heel pressure ulcer at 1.5 cm x 0.5 cm with 100% granulation. Wound edges had a thin line of slightly macerated skin. R7's pressure ulcer was oval shaped with regular edges. RN-B stated R7's pressure ulcer was avoidable, as his shoes were too tight for his feet, and nursing should have caught that. RN-B stated R7's pressure ulcer went from unstageable to Stage 4, but was now improving. A facility incident report dated 9/7/17, indicated R7 had a 5.0 cm x 5.0 cm blister on the left lateral heel. R7's incident report indicated R7's blister was fluid-filled, but draining on the bed sheet, so was open at that time. Contributing factors included limited mobility and tight-fitting sandals. Interventions to prevent re-occurrence included a treatment, weekly wound monitoring, offloading of lower extremity and foam heel boot. R7's family would be contacted to provide new footwear. R7's NP visit progress note dated 9/8/17, indicated R7 had a Stage 2 pressure ulcer of the left heel that had opened from a large blister on the left heel. The NP documented R7's pressure ulcer was draining copious amounts. R7 was unaware of the pressure ulcer. The NP further documented the pressure ulcer had developed where R7's skin rubbed on his sandal straps, and was a large blister filled with fluid measuring 2 inches in diameter, and was draining clear fluid. Orders included off load pressure, obtain wider shoes, dressings to left heel. R7's Order Review Report indicated an order for [REDACTED]. R7's physician visit progress note dated 9/13/17, indicated R7 had [MEDICAL CONDITION] of feet. R7's progress note lacked documentation regarding left heel pressure ulcer. R7's Weekly Wound Evaluation dated 9/19/17, indicated R7 had a left heel open blister, initially identified on 9/7/17, measuring 4.5 cm x 4.8 cm and was 100% slough with heavy tan drainage that had an odor and macerated edges. R7 had no pain associated with the pressure ulcer at that time. R7's Tissue Tolerance Evaluation (a tool to assist in determining the ability of the skin and it's supporting structures to endure the effects of pressure with out adverse effects) and Skin Risk Factors assessment dated [DATE], indicated R7 was at moderate risk for pressure ulcers. The Tissue Tolerance portion of the test was not completed. R7's physician orders [REDACTED]. R7's Order Review Report indicated R7's treatments for the blister on his left heel were initiated on 9/8/17, and were changed as the status of the pressure ulcer changed. R7's NP visit progress note dated 10/3/17, indicated R7's left heel unstageable pressure ulcer had increased odor. R10's treatment was changed from [MEDICATION NAME] Blue (antibacterial foam dressing) to [MEDICATION NAME] (debrides or remove dead, damaged tissue to aid in healing), and documentation indicated R7 may need sharp debridement if [MEDICATION NAME] did not debride the wound. R7's Weekly Wound Evaluation dated 10/7/17, indicated R7's left heel pressure ulcer was unstageable with 100% eschar, and measured 4 cm x 4 cm. R7's heel pressure ulcer had a moderate amount of tan drainage with an odor present and macerated edges. The plan at that time was to change the treatment to [MEDICATION NAME] to debride the pressure ulcer. R7's Weekly Wound Evaluation dated 10/10/17, indicated R7's left heel pressure ulcer measured 3 cm x 3.5 cm and was unstageable with 50% slough and 50% eschar, and scant yellow drainage with odor. Wound edges were intact with [DIAGNOSES REDACTED] (redness) and pain was associated with the pressure ulcer. R7's Weekly Wound Evaluation dated 10/18/17, indicated R7's left heel pressure ulcer measured 3.5 cm x 4.5 cm and was unstageable with 100% slough, and some blood around the edge of the wound at 11 o'clock. Wound edges were [MEDICAL CONDITION] and pink, and the pressure ulcer had a moderate amount of tan drainage with an odor. The pressure ulcer was to be cleaned with [MEDICATION NAME] (antimicrobial wound cleanser), apply Sure Prep (skin protectant) to wound edges, apply [MEDICATION NAME] dressing, and wrap with kerlix (gauze). R7 had pain with the pressure ulcer and was given [MEDICATION NAME] (narcotic pain medication) as necessary with the dressing change. The Wound Evaluation indicated the wound bed was improving. R7's NP visit progress notes dated 10/20/17, indicated R7's left heel pressure ulcer was unstageable, and was covered in eschar. The NP documented R7's lower extremities were red, but no swelling. R7's NP visit progress notes dated 10/24/17, indicated R7's left heel pressure ulcer was unstageable with one inch diameter eschar remaining over pressure ulcer. The NP noted the eschar had softened with the [MEDICATION NAME], and the wound had an odor. The NP indicated debridement may facilitate healing, and this would be scheduled. R7's Weekly Wound Evaluation dated 11/1/17, indicated R7's left heel pressure ulcer was Stage 3, measuring 2.3 cm x 3.5 cm x 0.3 cm with 75% granulation (healing tissue), and 25% slough, and a moderate amount of serosanguineous (yellow with a small amount of blood) drainage without odor. Wound edges were pink and rolled, no pain with the pressure ulcer, but controlled with [MEDICATION NAME] as necessary. Treatment changed from [MEDICATION NAME] dressing to [MEDICATION NAME] gel. No change in Weekly Wound Evaluation dated 11/7/17, MD contacted to discontinue [MEDICATION NAME] before wound treatment due to no pain. R7's progress notes dated 11/4/17, indicated R7 complained of pain of left heel pressure ulcer, and rated pain at a 6 out of 10. R7's NP visit progress note dated 11/14/17, documented R7's left heel was healing well with eschar debrided with [MEDICATION NAME], and granulation was filling. Narcotic pain medication was discontinued as it was no longer necessary prior to pressure ulcer treatment. Progress note noted order for protein powder that had been ordered for wound healing twice daily. R7's Weekly Wound Evaluation dated 11/22/17, indicated R7's left heel pressure ulcer measured 1.7 cm x 3.0 cm, was documented as a Stage 2, and was 100% granulation without any drainage. R7's wound edges were pink and rolled and R7 had no pain with the pressure ulcer, and was improved. R7's Weekly Wound Evaluation dated 12/5/17, indicated R7's left heel pressure ulcer dated 0.7 cm x 2.0 cm, was a Stage 2 with 100% granulation, and scant tan drainage without odor and pink, rolled edges. R7's Weekly Wound Evaluation dated 1/2/18, indicated R7's left heel pressure ulcer measured 1.0 cm x 1.5 cm, was documented as Stage 2 with 100% granulation, without drainage, and edges were pink and rolled. R7 did not have pain with the pressure ulcer. On 1/3/18, at 4:14 p.m. R7 was observed in his room doorway with the blue pressure relieving boot on his left foot. On 1/4/17, at 7:16 a.m. R7 was observed sitting in the dining room with the blue pressure relieving boot on his left foot. On 1/5/18, at 10:19 a.m. LPN-C stated R7 did not have persistent pain with the pressure ulcer now. LPN-C stated she was not sure if R7 had swollen feet when the pressure ulcer opened, but stated he did not really have [MEDICAL CONDITION] now. On 1/5/18, at 10:45 a.m. NA-D stated she did not remember R7 having a lot of swelling in his feet, but stated he used to wear sandals. NA-D stated R7 did not express having pain of his heel and did not resist repositioning. On 1/5/18, at 11:04 a.m. the DON stated risk assessments should be done upon admission, annually, and with any changes. The DON stated she did not know why there had been such a delay in assessing skin after the identification of pressure ulcers, but would expect the assessments to be done right away when a new pressure ulcer developed. The DON stated R7 did not have [MEDICAL CONDITION] present at the time he developed the pressure ulcer on his heel. The DON stated R7 propelled himself in his wheelchair, and his sandals did not fit properly. The DON stated R7 did not want the heel protector on at first, but did wear it. The DON stated she felt R7's heel worsened due to the constant pressure from propelling his wheelchair with his feet, and R7 would not stay off of it. The DON stated they do not do a specific analysis for root cause of pressure ulcers, though they do an incident report that looks at risks, interventions, and a summary of investigation. The DON stated R7 should have repositioning every 2 hours. On 1/5/18, at 11:36 a.m. RN-A stated R7 did not have a Braden scale done at the time of the MDS in July, so she put him as, Not at risk, on the MDS, and verified she did not make the determination of risk for pressure ulcers based on limitations in bed mobility and incontinence. RN-A verified R7 was at risk for skin breakdown. R10's Admission Record printed 1/4/18, indicated R10's [DIAGNOSES REDACTED]. R10's MDS dated ,[DATE], indicated R10 was at risk for pressure ulcers, had no pressure ulcers at that time. A Tissue Tolerance Observation (a tool to assist in determining the ability of the skin and it's supporting structures to endure the effects of pressure with out adverse effects) dated 6/23/17, indicated R10 tolerated sitting in one position for 2 hours. A Braden Scale assessment dated [DATE], identified R10 was at high risk for skin breakdown. R10's significant change MDS dated [DATE], indicated R10 had a severe cognitive deficit, and rejected care daily. The MDS also indicated R10 required extensive assistance of 2 staff for bed mobility and transfers, and required extensive assistance of one staff for toilet use and personal hygiene. R10's MDS further indicated R10 was always incontinent of bowel and bladder, was at risk for pressure ulcers, and currently had a Stage 3 pressure ulcer with slough that measured 1.0 centimeters (cm) x 1.0 cm x 0 cm, and had a pressure-reducing device for the chair and bed. R10's CAA for cognitive loss and dementia dated 10/13/17, indicated staff must anticipate R10's needs and discuss risk versus benefits related to R10's refusal of cares and treatments with the family, and to inform the physician if R10's behaviors interfered with activities of daily living (ADLs). R10's CAA for behaviors 10/18/17, indicated R10 had refused cares almost daily and yelled at staff at times during the assessment period, which was not unusual behavior for R10. R10's CAA for pressure ulcers dated 10/13/17, indicated R10 was at risk for pressure ulcers related to incontinence and required extensive assistance with ADLs. R10's pressure ulcer CAA indicated R10 had a pressure reducing cushion in the wheelchair and pressure reducing mattress on the bed, staff observed skin daily with cares, and weekly skin checks by a licensed nurse, with changes in skin integrity reported to the physician (MD) or nurse practitioner (NP). R10's care plan revised 8/21/17, indicated R10 had an open area to the coccyx (tail bone area) identified on 8/21/17. R10's interventions included a Braden Scale per facility policy, occupational therapy evaluation and treatment as indicated for wheelchair positioning (initiated 8/22/17), pressure reducing wheelchair cushion, and pressure reduction/relieving mattress. R10's interventions further directed skin assessments per facility policy, turning and repositioning to include offloading every 2 hours while in wheelchair and R10 was independent with repositioning in bed. R10's care plan revised 3/8/17, directed the use of an air mattress. R10's care plan further indicated R10 had increased nutrient needs due to wound healing and had an unintentional weight loss related to decline in oral intake. R10's care plan interventions dated 10/10/17, included a nutritional supplement as ordered by the physician, and interventions to attempt to increase R10's nutritional intake. R10's care plan dated 10/16/17, indicated R10 had been admitted to Hospice related to end stage disease. R10's NA group sheets/care guide for R10, directed staff to turn and reposition every 2 hours, and as necessary. The care guide lacked information on R10's pressure ulcer. R10's progress notes dated 8/11/17, indicated R10 had a Stage 2 pressure ulcer on the coccyx region, measuring size of a nickel, treated with an unspecified wound care and [MEDICATION NAME] (foam dressing suitable for pressure ulcers), and nursing would continue to treat and monitor. A NP visit note dated 8/18/17, noted R10 was sitting in a reclining wheel chair during the visit, however, the note lacked documentation of R10's pressure ulcer. R10's progress notes lacked further documentation regarding the pressure ulcer until 8/21/17, indicating a Stage 2 pressure ulcer had been found on R10's coccyx and measured 8 cm x 10 cm x less than 1 cm deep with scant clear drainage without odor. R10's progress note dated 8/21/17, indicated a [MEDICATION NAME] dressing was applied and wheelchair repositioning was initiated. A facility incident report dated 8/21/17, indicated R10's pressure ulcer was found by a NA during cares. The Stage 2 pressure ulcer was observed by registered nurse. The incident report identified causal factors as refusal of cares, dementia, agitation, and incontinence. Recommendations and interventions identified to prevent re-occurrence were occupational evaluation for wheelchair positioning, turn and reposition every two hours while up in wheelchair, and encourage R10 to understand the risk of refusal of repositioning. The summary of investigative findings on the incident report were: Orders in place/treatment. Monitor until resolved. The report lacked documentation of a comprehensive investigation. A Weekly Skin Inspection dated 8/23/17, noted a small pressure ulcer previously documented on R10's coccyx. R10's Weekly Wound Evaluation dated 9/7/17, indicated a new pressure ulcer on the coccyx, and documented it was identified on 9/7/17. The Weekly Skin Evaluation indicated the Stage 2 pressure ulcer measured 1.5 cm x 1 cm, was 75% granulation (new, healing tissue), 25% eschar (dark dead tissue), and had scant serosanguineous (yellowish with small amounts of blood) drainage without odor. The treatment was identified as [MEDICATION NAME] dressing changed every 3 days and as needed if saturate (TRUNCATED)

Based on observation, interview and document review, the facility failed to provide treatments and services to prevent pressure ulcers from developing or promote healing of existing pressure ulcers for 2 of 2 residents (R41 and R32) in the sample who had been reviewed for pressure ulcers. This resulted in actual harm for R41 who had a recurrence of a stage II pressure ulcer (Partial thickness tissue loss) on the right buttock. Findings include: R41 was not provided timely assistance with repositioning and developed a recurrent stage II pressure ulcer to the right buttocks. In addition, a pressure reducing device was not applied to the seat of the wheelchair as recommended in 12/11. R41's [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE], indicated R41 had no cognitive impairment and was able to communicate his needs. R41 was non-ambulatory, required extensive assistance of one to two staff for transfers and bed mobility and was incontinent of bowel and bladder. The MDS identified R41 as having pressure ulcers and was at risk for developing pressure ulcers. The pressure ulcer Care Area Assessment (CAA) dated 10/28/11, identified R41 was at risk for pressure ulcers due to needing extensive assistance with bed mobility, frequent incontinence and having more than two, stage II or higher, pressure ulcers. Other risk factors included diabetes, [MEDICAL CONDITION]/[MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. The assessment indicated that R41 was admitted with two stage II pressure ulcers one located on the coccyx and the other on the right buttock. The CAA indicated R41 was provided a pressure reduction mattress on the bed and a pressure reduction cushion in the wheel chair. The comprehensive summary note dated 11/04/11 indicated R41's skin was always red at pressure points when sitting for extended periods of time and needed hourly offload (removing pressure to an area that is sensitive to pressure induced skin damage especially at the bony prominences which includes the buttocks.) The "Braden Scale " a tool used to evaluate pressure ulcer risk dated 10/18/2011, indicated R41 was at moderate risk for developing pressure ulcers. The quarterly MDS dated [DATE], indicated no change in cognitive or functional abilities from the admission MDS. The MDS identified R41 had a stage III and stage IV pressure ulcers located on R41 ' s feet and a stage II pressure ulcer on the right buttock. The Comprehensive Summary quarterly review dated 2/6/12 indicated R41 had ongoing wound care to a coccyx pressure ulcer which had healed. The plan had hourly off-loading; however, it also indicated R41 was "non-compliant with this plan and prefers to sit in his electric wheelchair for hours at a time." R41's care plan under skin integrity dated 2/4/2012 indicated R41 had several risk factors for skin breakdown and had a current pressure ulcer. The interventions included: provide pressure reduction wheel chair cushion, alternating air mattress on bed, provide thorough skin care after incontinent episodes and apply barrier cream, assisted off-load/repositioning every hour. On 2/28/12, at 7:00 a.m., R41 was observed in the wheelchair in the front hall and there was no pressure reduction cushion located under the resident's buttocks. At 7:10 a.m. R41 was down the hall by the medication cart waiting for medications. At 7:28 a.m. R41 went into his room and received an insulin injection. At 7:30 a.m. R41 left the building through the front door per in his electric wheel chair. R41 was observed outside in the smoking area. At approximately 7:43 a.m. R41 came inside and took his wheel chair down the hall. R41 stopped at the medication cart and then went directly to the dining room for breakfast. At 7:55 a.m. R41 remained in the dining room eating and visiting with table mates. At approximately 8:07 a.m. R41 went to the therapy room and stated that he was getting the right hand wheelchair tray looked at. At 8:11 a.m. R41 went outside to smoke. During an interview while smoking R41 stated he had not been offered or had been provided repositioning from 7:00 when he was helped to his wheel chair. After the interview at 8:15 a.m. R41 went into the facility and asked registered nurse (RN)-A if she could use the standing lift to help him reposition. RN-A responded that he would have to wait until she had finished passing medications to the residents. Then R41 went to his room and asked the licensed practical nurse (LPN)-B at 8:17 a.m. if she could help him go to the bathroom. LPN-B replied that two other residents were ahead of him so it would be about 20 minutes before the standing lift was available to help him go to the bathroom. Following this dialog with LPN-B at 8:20 a.m., she stated that R41 required use of the standing lift every hour for repositioning and toileting. R41 went directly back into the therapy room where the occupational therapist (OT)-I provided range of motion to his right hand. R41 remained in the therapy room until approximately 8:45 a.m. when the nursing assistant (NA)-C came in to ask R41 about toileting/repositioning. R41 left the therapy room at 9:05 a.m. and looked for LPN-B to help him go to the bathroom. R41 was taken into the tub room at 9:15 a.m. and assisted to transfer to the toilet with the assist of LPN-B and NA-C. On observing R41`s skin there had been a stage II pressure ulcer located on the right buttocks. The assistant director of nursing measured the pressure ulcer on the right buttock to be 3.8 cm by 3.3 cm at that time. Occupational therapy (OT) notes dated 12/14/11 indicated the nurse practitioner requested a pressure reduction cushion for R41's electric wheelchair due to a pressure ulcer next to his tail bone. The OT note indicated that R41 stated there was a gel cushion in the cushion (pressure reduction) on his wheel chair. OT-A had been interviewed on 2/29/12, at 8:15 a.m., indicated she thought R41 had a gel cushion in the wheel chair. She indicated that she was unable to determine for sure if the cushion was a gel cushion. Observation of the electric wheel chair cushion on 2/29/12 indicated the cushion was made of urethane foam and had not been identified as a pressure reduction cushion. Review of the weekly Wound Evaluation Flow Sheets indicated the right buttocks pressure ulcer was present from 10/25/2011, to 11/29/11. The right buttock pressure ulcer re-opened from 12/18/11, to 1/19/12. From 2/2/12, until 2/6/12 the right buttock pressure ulcer again was open and measured 1.4 cm x 1 cm. On 2/6/12, the documentation indicated the ulcer had healed. There was no more documentation regarding the right buttock pressure ulcer status until it was observed to be open on 2/28/12 at 9:15 a.m. (during survey). The weekly Wound Evaluation Flow Sheets also indicated that R41 had a stage II pressure ulcer on the left heel which was 3 cm by 1.2 cm by 1 cm deep, measured on 2/20/12, being treated by off-loading boots. R41 had a stage IV pressure ulcer on the right lateral metatarsal that had been surgically repaired on 2/1/12 along with the removal of his small toe. Nursing progress notes on 2/2/12 at 9:39 a.m. indicated that R41 had a pressure ulcer on the right buttock, located in a previous pressure ulcer that healed on 2/6/12. The ADON, interviewed on 2/28/12, at 9:25 a.m., confirmed that the buttock pressure ulcer had been healed in January 2012, and now had reopened. The facility's skin integrity guideline policy revised January 2011 indicated that residents utilizing a wheel chair as a primary mode of transportation will have a pressure reducing cushion. It further indicated if there is a decline in skin integrity pressure redistribution surfaces will be reviewed for appropriateness. Residents will be observed by the NA daily for reddened/open areas, [MEDICAL CONDITION] of feet or sacrum. Changes will be reported to licensed nurse and documented. R32 did not receive services to promote the healing and prevent infection of pressure ulcers. R32 had multiple [DIAGNOSES REDACTED]. At 9:00 a.m. on 2/29/12 nursing assistant-F (NA-F) indicated that R32 needed more help with her mobility as her knees were "getting worse." Documentation revealed a quarterly nursing review dated 1/24/12 which identified a Braden skin risk of 22 identifying no skin issues. Tissue tolerances completed on 11/7/11 noted R32 to be independent with repositioning and off-loading. A wound evaluation flow sheet, initiated 2/22/12 identified a pressure ulcer on the right heel. On 2/23/12 the pressure ulcer was identified to be 1.5 cm in diameter and to be a DTI (Deep Tissue Injury). There was no drainage or pain identified. Prevention identified was leaving shoes off, and foam boots in bed. On 2/28/12 the wound is documented to be 1.3 cm in diameter with no drainage or pain, blanching tissue and soft edges. There was no staging identified for the 2/28/12 entry. On 2/22/12 documentation indicated the GNP (Geriatric Nurse Practitioner) was updated as she was here at the time and the GNP informed staff to use a pressure relief boot at night. The plan of care was documented as initiated on 2/26/12 after the pressure ulcer developed. On 2/26/12 at 10:40 a.m. R32 was observed wearing black dress shoes which slid on the tile floor. At 8:45 a.m. on 2/28/12 R32 was observed sitting in the recliner with her feet up on a stool with pressure directly on both heels. Although there was a decorative square pillow on the stool, R32 ' s heels were observed to rest directly on the hard surface of the stool. At 10:30 a.m. on 2/28/12 the pressure ulcer was observed with licensed practical nurse (LPN)-C. According to LPN-C, the pressure ulcer was being left open to air and R32 wore a boot in bed. LPN-C further indicated the pressure ulcer did hurt R32 "some." When R32 was asked about pain with the ulcer she stated, "That hurts some" when the wound was touched but when left alone "it doesn't hurt." The pressure ulcer was observed to remain intact with significant redness surrounding the blister. LPN-C confirmed the observation. At 9:00 a.m. on 2/29/12 nursing assistant (NA)-F identified the heel boot worn in bed by R32. NA-F confirmed the heel boot was only worn on the right heel and only worn when in bed. The heel boot observed with NA-F was a plaid, quilted heel boot which provided minimal pressure relief. At 10:40 a.m. on 2/29/12 The Director of Nursing (DON) stated she was unaware the heel boot currently being used was not a pressure relieving device. She further stated R32 ' s shoes had been put on the top shelf of the closet so they would not be used. The DON was surprised that the shoes were being used again. She further indicated the ADON was in charge of skin care and would know more about R32 skin needs. At 11:15 a.m. the ADON was interviewed regarding R32's pressure ulcer. The ADON stated, "She used to be a lot more mobile but she's not as much anymore. I'm thinking she's had a physical decline too in terms of doing things for herself. I told her she should have her heel protector on if she's got her feet up ... I need to include it to use on the recliner as well. She always wore those black dress shoes ... it was rubbing up and down on her foot. She probably shouldn't have been wearing them to begin with." The ADON was unaware the heel boot currently being utilized was not pressure relieving type. The ADON indicated she would work with therapy and obtain a pressure relieving boot, further indicating she would obtain boots for both feet.