Every finding on record at Wheaton Franciscan HC - Terrace at St Francis

Based on interview and record review the facility did not ensure 1 (R1) of 4 residents are treated with respect & dignity and recognizes each resident's individuality.At the end of November, the facility was changing resident's beds that were not changed five or six years ago. R1 was approached about changing her bed and said no. R1's bed was changed on 11/25/25. R1 complained to staff about the bed and being in pain. Surveyor did note an increase in her pain scale and use of prn (as needed) Norco 5/325 mg (pain medication) during the time R1 was provided with the new bed. After a few weeks, the facility agreed to change R1's bed back to an older bed and R1's bed was switched back to an older bed on 12/18/25. For the beds to be switched R1's belongings needed to be removed to the hallway. During this process several of R1's possessions were removed from the hallway and placed in the garbage chute room as staff had been trying to clean R1's room. After the bed was switched and R1's belongings were brought back in the room, R1 realized some of her belongings were missing and came out in the hallway visibly upset. R1's usual custom is not to leave her room. A housekeeper then went to the garbage chute room and returned the items.Findings include:The facility's policy titled, Residents Rights and last revised 7/2018 under policy statement documents It is the policy of [Corporate Name] to promote and protect the rights of residents residing in our ministry. Under policy interpretation and implementation includes documentation of 2. Residents are entitled to exercise their personal and legal rights and privileges to the fullest extent possible. 3. Our ministry will make every effort to assist the resident in exercising his/her rights and to assure that the resident is always treated with respect, kindness and dignity.R1's diagnoses include progressive multiple sclerosis (disease in which the immune system eats away the protective covering of nerves resulting in disruption in communication between the brain and body), hypertension (high blood pressure), and glaucoma (group of eye conditions that damage the optic nerve).R1's quarterly MDS (minimum data set) with an assessment reference date of 10/21/25 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact.R1's care plan documents, has impaired behavior related to hoarding items in her room, hx (history) of displacement twice due to hurricanes; refuses care at times, refuses medications, won't allow room to be more organized and clutter free;` care plan initiated 10/22/24 document approaches of:*Avoid the following identified triggers: removing items from room without resident participation including but not limited to items such as additional linen in bathroom and Styrofoam cups. Initiated 10/22/24.*Provide on going education, encouragement why routine care and medication is important; enlist her cooperation by offering alternative times to return. Initiated 5/20/25.*Refer to psych if appropriate and as she allows. Refuses Psychiatric intervention. Initiated 5/20/25.R1's progress note dated 12/1/25, at 16:39 (4:39 p.m.), and written by Chaplain-G documents Resident was lying on the bed when writer arrived. Resident continues to express her depression and concern for her quality of life. Resident stated that she would much rather live with/near her family and friends. Resident reviews her emotions regarding living her sic (here) and her hopes for living in New York with/near her sisters. Writer assisted resident in finding items in her room. Writer offered to assist resident in throwing out any food or garbage. Resident declined underscoring that she can't imagine these items filling the land fill. Writer was able to find many items and rearrange them in her room to allow better accessibility. Writer provided a ministry of active reflective listening and emotional support.R1's progress note dated 12/7/25, at 13:06 (1:06 p.m.), and written by Licensed Practical Nurse (LPN)-M documents Resident alert. Able to make needs known. Resident c/o (complained of) increased pain to right hip and lumbar area. Requesting x-ray. Resident denies falling or sudden movement that would cause pain in those areas. Updated [Physician Name] on request. New order received for x-ray right hip, lumbar area. 2 views. Order placed to [Name] Mobile Imaging.R1's progress note dated 12/9/25, at 15:57 (3:57 p.m.), and written by Registered Nurse/Unit Manager (RN/UM)-J documents Xray result reviewed and faxed to [Physician Name]. No new orders received at this time.R1's social service note dated 12/18/25, at 14:18 (2:18 p.m.), with event date of 12/17/25 and written by Interim Social Worker (ISW)-H documents SW spoke with the resident during angel rounds. States she is not happy with the new bed received and prefers the older model. Resident says the current bed is causing back pain and she would like the bed switched as soon as possible. SW told resident she would follow up with maintenance regarding the switch and would assist with the transition. SW received an email correspondence from the ombudsman stating that she had been contacted by the resident regarding the bed. SW informed the ombudsman that the transition was already in progress to occur 12/19 and SW will keep the ombudsman updated. ED (Executive Director) updated.R1's social service note dated 12/18/25, at 14:24 (2:24 pm.), and written by ISW-H documents SW met with the resident for bed change. The resident has requested to switch back from the new model to previous one. SW moved multiple of resident belongings off the bed, underneath and side of the bed into the hallway and on nightstand to clear a pathway for removal while resident sat in wheelchair and watched. Resident held both of her purses and glasses along with a couple of other items. Resident initially refused to have soiled bedding changed, SW was able to convince her to do so. Maintenance was called in and removed old bed, brought in older model already made up. Resident had SW remove all pillows and placed a throw blanket inside of the pillow slip. Stating it is easier for her to sleep on and better on her neck/back. SW assisted resident with placing personal items back underneath, on top and to side of the bed. Resident stated she would arrange everything to her liking. Stated thank goodness. SW sent correspondence to ombudsman and updated facility IDT (interdisciplinary team).R1's physician orders include assess pain and document every shift dated 8/3/22 and Norco 5/325 mg (milligrams) [Hydrocodone-acetaminophen] three times a day PRN for breakthrough pain dated 6/9/25.Surveyor reviewed R1's October 2025 MAR (medication administration record) and noted the daily pain assessments q (every) shift documents 0 for each day and each shift. R1 received Norco 5/325 mg prn one time on 10/16/25 at 2151 (9:51 p.m.) with a pain scale documented as 8.Surveyor reviewed R1's November 2025 MAR and noted the daily pain assessments q (every) shift documents 0 for each day and each shift. R1 did not received Norco 5/325 mg prn during November 2025.Surveyor reviewed R1's December 2025 MAR and noted the following daily pain assessments: During the night shift on 12/7/25 the pain scale is 10 and on 12/17/25 the pain scale is 8. Surveyor noted all other days for the night shift are 0. During the day shift on 12/31/25 the pain scale is 4. All other days during December for the day shift are documented as 0. During the evening shift 12/2/25 the pain scale is 2, 12/5/25 the pain scale is 3, 12/10/25 the pain scale is 9, 12/16/25 the pain scale is 7, 12/19/25 the pain scale is 7, 12/20/25 the pain scale is 6, 12/22/25 the pain scale is 8, 12/23/25 the pain scale is 4, 12/24/25 the pain scale is 5, 12/26/25 the pain scale is 9, 12/29/25 the pain scale is 8 and on 12/31/25 the pain scale is 6. During December 2025 R1 received Norco 5/325 mg prn on 12/3/25, 12/5/25, 12/8/25, 12/9/25, 12/10/25, 12/11/25, 12/12/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/22/25, 12/20/25, & 12/31/25. Surveyor noted an increase in R1 being administered Norco 5/325 mg prn during the period when R1 had the new bed & mattress she did not want and had an increase in her pain level. R1 received Norco 5/325 mg 11 times during this time.On 1/5/26, at 9:22 a.m., Surveyor observed R1 in bed on the left side with multiple items/bags on the bed. Surveyor observed there are boxes on the left side as Surveyor entered the room. There is an over bed table stacked with used Styrofoam cups and medication cups. Along the perimeter of the walls there are bags, various items and boxes stacked. Between R1's bed and personal type recliner there are multiple items, and the personal type of recliner is piled with linens and various other items. Surveyor asked R1 how she was doing. R1 stated to Surveyor her major complaint is the bed situation. R1 explained a few weeks ago maybe longer they insisted I have a new bed. I said no. R1 informed Surveyor a Corporate person said she had to get a new bed. The corporate person was with nurse Registered Nurse (RN)-E [first name] and informed Surveyor she's on duty now. R1 stated Chaplain-G came in to help me move items and they gave me a new bed. Surveyor asked R1 if staff said why she needed a new bed. R1 replied they said everyone was getting a new bed. R1 informed Surveyor she told head of maintenance this bed is killing me. Surveyor asked how long she had the new bed. R1 replied two weeks, every day, every shift I complained the bed was killing me, I could feel the bars in my back, couldn't stand up. R1 informed Surveyor she stupidly told the NP (nurse practitioner) from [company]. Surveyor asked R1 what she meant by stupidly. R1 informed Surveyor the NP sent PT (physical therapy) in to fix me not the bed. Surveyor asked R1 why the facility staff decided to change her bed back to the old bed. R1 replied I called the Ombudsman; she knows me so well and right then they were changing Administrators. R1 informed Surveyor when they changed her bed back Chaplain-G wasn't here so first name of Interim Social Worker (ISW)-H moved my things to put the old bed back in, that's when it happened. Surveyor asked what happened. R1 replied she, referring to ISW-H, stole my things. Surveyor asked what was stolen. R1 replied this bag, pointing to a flower bag on the bed and the other bag pointing to the bag with an Eiffel Tower located on the floor. R1 informed Surveyor she has the bag there so she can keep an eye on it and two small tote bags. Surveyor asked R1 how she got her bags back. R1 informed Surveyor she didn't get everything back as there is another bag with $75.00 of snacks, cookies, bar-b-que chips and other chips she didn't get back. Surveyor asked R1 about the other bags. R1 informed Surveyor housekeeping ran and said she was going to look for them. Surveyor asked who the housekeeper was. R1 informed Surveyor the first name of Housekeeping-F. R1 stated this bag, referring to the bag with the flowers on R1's bed, was in a black garbage bag. R1 explained the other two bags were not in the garbage bag and the housekeeper said the snacks were gone as she couldn't find them. R1 informed Surveyor this was on 12/18. R1 informed Surveyor she asked to speak to the Social Worker two times and the new Administrator, but they never came up to speak to her. On 1/5/26, at 9:48 a.m., Surveyor asked Registered Nurse (RN)-E when R1 received a new bed. RN-E informed Surveyor she doesn't remember exact time, but all the beds got switched, could be a month, it wasn't long. Surveyor asked RN-E if she knew why the beds were being changed. RN-E replied no, I'm just a floor nurse. RN-E informed Surveyor the mattresses were also changed. Surveyor asked RN-E if R1 complained about her new bed. RN-E informed Surveyor R1 told her so any times about the bed and one time she caught the Administrator and maintenance. RN-E informed Surveyor R1 is a hoarder and when they changed the bed, they needed to get R1's stuff away and R1 complained. RN-E informed Surveyor R1 got a new bed & mattress, and she didn't like it. R1 wanted the old ones back. RN-E informed Surveyor R1 told everyone, R1 called [Name of company] NP. RN-E informed Surveyor she didn't know the solution and reached out to the chain of command. Surveyor asked who the chain of command was. RN-E informed Surveyor the first name of RN/UM-J. RN-E informed Surveyor R1 is happy with the old mattress and bed.On 1/5/26, at 10:51 a.m., Surveyor interviewed Director of Facilities Management (DFM)-D regarding the new beds. DFM-D explained about five years ago they replaced 26 beds and just got 52 or 54 beds in. Surveyor asked DFM-D which residents received the new beds. DFM-D informed Surveyor it was by rooms and all the first floor. DFM-D informed Surveyor they replaced all the beds that were not replaced five years ago. Surveyor asked who swapped out the beds. DFM-D informed Surveyor of the name of the company and they had extra CNAs getting residents out of their beds. Surveyor asked what if a resident didn't want a new bed. DFM-D replied they had to be changed because they were older beds. Surveyor asked DFM-D if there were any residents who refused to have their beds changed. DFM-D replied there was, I can read your mind, there was a resident who didn't want their bed changed. Surveyor asked who the resident was. DFM-D replied the first name of R1. DFM-D explained they tried one day to change the bed, but she didn't want it so the following day they did change it out. DFM-D informed Surveyor R1 was not happy with him so he had the Chaplain speak with R1. DFM-D explained R1 was not happy with the new bed, mattress or grab poles. Surveyor asked DFM-D if R1 still has the new bed. DFM-D replied no and explained they put a bed in there like they replaced five or six years ago. Surveyor asked when the bed was replaced. DFM-D replied believe couple weeks ago. Surveyor asked why R1's bed was changed. DFM-D informed Surveyor she had asked for it. DFM-D informed Surveyor after they changed everything to the old bed & mattress everything was fine. Surveyor asked DFM-D if he could investigate when R1's bed was originally changed and when R1 received the old bed back. DFM-D later this same day left a yellow piece of paper for Surveyor which indicated R1 got the new bed 11/25/25 and changed bed, mattress, and side rails on 12/18/25.On 1/5/26, at 11:26 a.m., Surveyor interviewed Housekeeping-F regarding R1's belongings. Surveyor informed Housekeeping-F R1 had informed Surveyor when her bed was being changed back to the old bed, she had bags missing and R1 indicated she (Housekeeping-F) brought the bags back. Housekeeping-F informed Surveyor they had been trying to clean R1's room. Housekeeping-F informed Surveyor they were going to switch R1's bed so her and the social worker were going to get rid of some of R1's things. Housekeeping-F explained there is a garbage chute and she put R1's things in there. Housekeeping-F informed Surveyor she knows not to throw R1's things away. Housekeeping-F informed Surveyor R1 said her things were missing, R1 was out in the hallway and throwing a fit saying she wanted everything back from her room. Housekeeping-F stated I went right to the room, referring to the garbage chute room, and brought all her stuff back. Surveyor asked if R1 was missing anything after that. Housekeeping-F replied no I put everything in the room. I made sure they didn't get thrown down. Housekeeping-F explained there was an incident before when R1's bedding was changed and R1 was upset with the CNA, so she knows how R1 is. Surveyor asked Housekeeping-F who decided which bags to remove from R1's room. Housekeeping-F replied she did referring to Interim Social Worker (ISW)-H. Housekeeping-F informed Surveyor they have been trying to clean out R1's room and R1 says no. Housekeeping-F informed Surveyor R1 knows her stuff that's why she didn't throw her things down the chute. Surveyor asked Housekeeping-F if she was there when R1's bed was changed to the new bed. Housekeeping-F replied no and R1 kept complaining about the new bed.On 1/5/26, at 12:12 p.m. Surveyor asked Chaplain-G if she was there when R1 received a new bed. Chaplain-G replied I was and explained she was there because of R1's things and R1 trusts her. Chaplain-G informed Surveyor she moved her things out of the way, cleaned her floor, and changed the linen. Chaplain-G explained they changed out R1's bed and mattress. Chaplain-G informed Surveyor R1 did not want her bed changed but they were changing the beds in the facility. Chaplain-G informed Surveyor it is a better bed, could go in a sitting position. Surveyor stated to Chaplain-G R1 didn't want her bed to be change. Chaplain-G replied correct. Chaplain-G informed Surveyor she and Director of Nursing (DON)-B were there. Chaplain-G informed Surveyor R1 was not happy with her new bed. Surveyor asked Chaplain-G if R1 complained to her about the new bed. Chaplain-G informed Surveyor she is R1's guardian angel so she gets all R1's complaints. Chaplain-G informed Surveyor she's at the facility on Monday, Tuesday, and every other Friday. Chaplain-G informed Surveyor R1 told her she was not comfortable, and Chaplain-G asked R1 to give it a full week. Surveyor asked Chaplain-G if she was here when R1's bed was switched back to the old bed. Chaplain-G informed Surveyor she wasn't.On 1/5/26, at 1:46 p.m., Surveyor asked ISW-H if she was involved when resident's beds were switched out. ISW-H replied not so much that was maintenance. Surveyor asked ISW-H if R1 complained about the new bed. ISW-H informed Surveyor apparently R1 had been complaining for a couple weeks about the bed, complaining about back pain, and wanted her old bed back. ISW-H informed Surveyor one morning she stopped in R1's room and R1 was asking to get her old bed back. ISW-H informed Surveyor she talked to maintenance, arranged to get the new model out and the old bed and mattress back. ISW-H informed Surveyor R1 wanted to keep the assist bars which were on the new bed and was able to get these assist bars on the old bed. ISW-H informed Surveyor R1 watched them, they cleared a pathway to switch the bed. ISW-H informed Surveyor everything was placed in bags or left. ISW-H informed Surveyor they placed R1's things along the wall in the hallway. Surveyor asked ISW-H who helped her place R1's items in the hall. ISW-H informed Surveyor one of the housekeepers. Surveyor asked if anything was taken to the garbage chute room to be thrown away. ISW-H replied no. Surveyor asked ISW-H if she had any contact with the Ombudsman-I regarding R1. ISW-H informed Surveyor she had an email from Ombudsman-I that morning about R1 having pain. ISW-H informed Surveyor she did email her that everything was taken care of, and she did hear from R1 and everything was fine.On 1/5/26, at 2:14 p.m., Surveyor asked DON-B if she was involved with residents receiving new beds and asked if she spoke to any residents about having to get a new bed. DON-B replied no. DON-B informed Surveyor from what she understands it came down from corporate, they ordered the beds. Surveyor asked DON-B if she was aware R1 did not want to change her bed. DON-B replied yes. Surveyor asked DON-B how she became aware. DON-B informed Surveyor she went to R1's room with the Chaplain. R1 was concerned about the beds being taken to the land fill. DON-B informed Surveyor she didn't know where the beds were going. DON-B informed Surveyor corporate wanted all the beds to be changed as they had changed 25 beds before, they were buying better beds, better quality. Surveyor asked DON-B if anyone asked corporate if R1 could keep her old bed. DON-B replied I do not know.On 1/5/26, at 3:20 p.m. Surveyor asked Housekeeping-F if ISW-H told her to throw R1's belongings out. Housekeeper-F informed Surveyor she's not going to say she did, but she was there. Housekeeper-F explained R1's things were sitting in the hallway; she just grabbed them and took them to the back. Surveyor asked Housekeeping-F if she was referring to the garbage chute room. Housekeeping-F replied yes. Surveyor asked Housekeeping-F if she or ISW-H asked R1 if they could throw any of her belongings away. Housekeeping-F replied no. Surveyor asked Housekeeping-F if ISW-H knew she had taken R1's belongings to the garbage chute room. Housekeeping-F replied yes, I told ISW-H. Housekeeping-F informed Surveyor after she brought R1 back her belongings back to R1's room she told her boss.On 1/6/26, at 9:07 a.m., Surveyor asked R1 who she spoke to about not liking her bed and having pain. R1 informed she told the night nurse, [Name] he comes in sometimes and said he has nothing to do with the beds, name of Chaplain-G, and another nurse who R1 doesn't know her name but works for an agency. Surveyor asked R1 if she spoke to any CNAs. R1 replied no I don't see them. R1 informed Surveyor she spoke to the doctor and nurse practitioner. R1 informed Surveyor the corporate person said you're getting a new bed. R1 informed Surveyor she said no. R1 informed Surveyor she was told she has to. R1 informed Surveyor she hadn't seen her before or after. On 1/6/26, at 9:15 a.m., asked Director of Clinical Operations/Regional Nurse (DCO/RN)-C if there was anything additional, she wanted to inform Surveyor regarding the new beds. DCO/RN-C informed Surveyor she had spoken with others in corporate and the beds were outdated so the company wide they ordered new beds. The beds ordered were pretty awesome and the mattresses were two-sided mattresses with a soft or hard side. DCO/RN-C informed Surveyor the mattresses were 42 inches wide, and they can go into a Fowlers position. Surveyor asked DCO/RN-C if she was at the facility when the beds were changed. DCO/RN-C replied no and explained she was visiting when the beds were delivered but was not at the facility for the changeover. Surveyor asked DCO/RN-C if anyone from corporate came to speak with residents. DCO/RN-C replied yes it was sporadic when walking the halls. DCO/RN-C informed Surveyor being medical supplies, equipment they had to be replaced. Surveyor informed DCO/RN-C it's Surveyor's understanding there was nothing wrong with R1's bed, it wasn't broken. Surveyor asked DCO/RN-C what if a resident said no what would happen? DCO/RN-C replied personally I would find out the reason. Was it comfort, safety, fear. DCO/RN-C informed Surveyor if they were fearful, they would let them keep it. DCO/RN-C informed Surveyor if they didn't want the new bed, they would make it work. Surveyor informed DCO/RN-C of the concerns of R1's bed being changed when R1 said no, belongings being taken to the garbage chute room, and these items not being returned until R1 became aware of the missing items and was upset.On 1/9/26, at 4:19 p.m., Surveyor was emailed additional information from DCO/RN-C. This additional information included two notes written by ISW-H dated 12/18/25 which Surveyor has referenced in the citation, Compliment, Suggestion & Concern form dated 12/17/25 which Surveyor had reviewed during the investigation, and correspondence between Ombudsman-I & ISW-H dated 12/17/25 & 12/18/25. This additional information does not change the deficient practice.

Based on interview and record review the facility did not ensure a resident receives care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new injuries from developing for 1 of 1 (R2) residents reviewed for pressure injuries.R2 was assessed to be at risk for the development of pressure injuries and developed a facility acquired pressure injury that was not comprehensively assessed until 1 week later when seen by the wound physician, which then documented an unstageable pressure injury due to necrosis. The care plan did not identify person-centered interventions for the frequency of turning and repositioning, the frequency of checking and changing due to incontinence, and the care plan was not revised when a new pressure injury was identified and recommended treatment was not transcribed and completed as ordered. Two different wound treatments were ordered and are documented as being completed. The facility did not clarify with the wound physician what treatment should be completed. Findings include:R2 admitted to the facility on [DATE] and has diagnoses that include primary progressive Multiple Sclerosis (MS), chronic kidney disease, osteoporosis, severe protein-calorie malnutrition and cirrhosis of liver. R2 entered onto hospice care 9/25/23.The facility policy titled Pressure Injury Assessment/Treatment documents (in part) . The purpose of this procedure is to provide guidelines for a consistent method of identification and for the initial care of identified pressure injuries, alterations in skin integrity and the prevention of acquiring additional pressure injuries.Pressure injury treatment requires a comprehensive approach, including and not limited to:Eliminate or reduce the source of pressure using positioning techniques, preventative measures to reduce the risk of further tissue loss, interventions that increase the potential for healing.Stage 3 pressure injury: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.Unstageable: 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 in the wound bed.The following information should be recorded in the resident's medical record, treatment sheet or designated wound form:All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. R2's bowel and bladder evaluation dated 9/15/25 documents (in part) . Always incontinent of bowel and bladder. Treatment/management program: Provide scheduled incontinence care and comfort. R2's care plan documents: At risk for pressure ulcers and other skin related to but not limited to Braden and other skin related injuries. Has history of resolved pressure area on buttocks - dated 7/5/23. Interventions include:-Goal: Maintain skin integrity without new skin related injuries over the next review period - goal 2/17/26.-Enc (encourage) proper peri hygiene and the use of barrier cream after each incontinence episode and PRN (as needed) - dated 7/5/23-Observe skin for redness and breakdown during routine care - dated 7/5/23.-Low air loss mattress set to pulse weight setting 6. Check function and settings every shift - dated 7/5/23.-Encourage to float heels - dated 7/6/23.-Use pressure relieving gel pad cushion to Broda - dated 5/21/25.-Turn and reposition during rounding - dated 6/19/25.-Use lift sheet to reduce friction and sheer - dated 6/19/25. (R2) has altered elimination due to incontinence of bladder. Interventions include:-Goal- Skin will remain clean, dry and free of breakdown related to incontinence - goal 2/17/26.-Perineal cleansing and apply protective skin barrier after each incontinent episode - dated 7/7/23.-Provide adult incontinent products and monitor for incontinence - dated 7/7/23.-Assess and report signs of impaired skin integrity or breakdown - dated 7/7/23. R2's CNA (Certified Nursing Assistant) worksheet dated 1/5/26 documents (in part) . Toileting: I need total assistance with 1 person staff support. I am incontinent of bladder and incontinent of bowel. I use briefs. Surveyor notes R2's care plan does not identify person-centered interventions for the frequency of turning and repositioning, or the frequency of checking and changing due to incontinence Review of R2's medical record revealed a history of pressure injuries on her buttocks. R2's wound physician note dated 4/16/25 documented a coccyx stage 3 pressure injury present greater than 82 days. On 5/7/25 the wound physician signed off on the patient as the pressure injury had healed.R2's medical record revealed a pressure injury to the sacrum/coccyx was identified on 12/11/25. The skin assessment summary documented: Pressure injury full thickness wound 1.0 x 0.5 cm (centimeters). Surveyor notes there was no other documentation of a comprehensive assessment to include depth or description of the wound bed. Color was entered as inapplicable. Stage was entered as Further assessment required. Treatment: Clean with NS (normal saline) and apply zinc covered with foam dressing.On 12/11/25 at 6:04 PM, nursing progress notes documented: Hospice nurse assess sacrum/coccyx wound. NOR (new order received) for tx (treatment) changed. Cleanse with normal saline wash, pat dry, apply barrier cream to non-open areas, cover with Mepilex tx in place. Surveyor reviewed R2's Hospice binder and was unable to locate a comprehensive assessment of the pressure injury. Surveyor notes there was no documentation at all regarding the pressure injury.R2's December 2025 Treatment Administration Record (TAR) documented the Mepilex treatment order to be done every 3 days was signed out as completed through 12/30/25.On 12/18/25, R2 was seen by [NAME] wound physician. Focused wound exam: Unstageable (due to necrosis) sacrum full thickness. Wound size 7 cm x 10 cm. Depth is unmeasurable due to presence of nonviable tissue and necrosis. Open ulceration area of 14.00 cm2 (squared). Moderate serous exudate. 20% thick adherent devitalized necrotic tissue. Intact normal skin 80%. No signs of infection. Dressing treatment plan: Primary dressing - Alginate calcium apply once daily and as needed. Collagen powder apply once daily and as needed. Secondary dressing - gauze island with border apply once daily and as needed.Surveyor noted the pressure injury was identified on 12/11/25 and the wound physician documentation indicated it was unstageable and larger on 12/18/25. The facility did not revise R2's care plan, R2's care plan still documented at risk for pressure injuries with no new interventions implemented after the pressure injury was identified. There was no indication as to how often R2 was to be turned and repositioned. In addition, R2 was always incontinent of bowel and bladder and R2's care plan was not personalized as to how often she was to be checked and changed for incontinence.Surveyor noted R2's December TAR documented the wound physician order; however, the order was not transcribed correctly. Collagen powder was not transcribed on the order. The treatment was signed out as having been completed 12/19/25 through 12/31/25. Surveyor noted that both treatments - Mepilex change every 3 days, and the daily treatment were both signed off as having been completed. Surveyor notes the facility did not clarify with the wound physician what treatment should be discontinued and which treatment should be completed.An assessment and measurements of R2's pressure injury was not completed again until 12/29/25 and was not completed by a Registered Nurse (RN). Documentation entered by Licensed Practical Nurse (LPN)-K on 12/29/25 included the same measurements and wording of the wound description as documented by the [NAME] wound physician on 12/18/25, 7 cm x 10 cm.On 1/5/26 at 11:30 AM, Surveyor spoke with Certified Nursing Assistant (CNA)-L and asked how often she does rounds. CNA-L reported they do rounds every 2-3 hours.On 1/5/26 at 2:30 PM, Surveyor spoke with Director of Nursing (DON)-B who reported the wound doctor comes weekly on Thursday. Surveyor noted R2's pressure injury was assessed by the wound doctor on 12/18/25 and was not comprehensively assessed and measured again until 11 days later, on 12/29/25 and the documentation was entered by an LPN. Surveyor asked who is responsible for the weekly assessment and measurements of pressure injuries when the wound doctor is not here. DON-B reported it is the responsibility of the nurse working the floor. Surveyor asked how the nurses know they are supposed to assess and measure the wound in the absence of the wound doctor. DON-B stated, They are just told if the wound doctor won't be there. Surveyor confirmed there was nowhere to assign or sign out that the weekly assessment and measurements are to be completed in absence of the wound doctor. DON-B stated, It will be assessed and measured again on Thursday when the wound doctor comes in. Surveyor noted this would be 10 days after the last wound assessment and measurements. On 1/5/26 at 2:40 PM, Surveyor asked LPN-K to watch wound care. Surveyor asked to watch wound care and was advised that it wouldn't be done until later that evening. LPN-K stated, but it's twice a day, so you can watch tomorrow. Surveyor attempted to observe wound care several times but was unsuccessful. Surveyor asked to view the current (January 2026) TAR together to determine the current treatment order. LPN-K read the Mepilex order and stated. OK, it's every 3 days. Surveyor advised there were 2 different treatment orders and read the other order which documented the calcium alginate and border to be changed daily. Surveyor asked LPN-K which treatment she has been doing. LPN-K stated, I haven't been here since last week, but I have been doing the 3 times a week border dressing. I haven't been doing the calcium alginate because she (R2) complained that it burned so I haven't been using it. I left a message with her primary doctor. Surveyor asked if there was a reason she didn't contact the wound doctor. LPN-K stated, I didn't know she had a wound doctor. Surveyor asked if she was using any other treatment, beside the calcium alginate, such as a powder. LPN-K stated, No, she only has an order for calcium alginate, and she said it burns so I'm no using it anymore. Surveyor located no evidence in R2's medical record that the physician was notified of R2's complaint of treatment burning and that the treatment was not being completed as ordered.On 1/6/26 review of R2's skin/wound tracking report documented the following entered by LPN-K on 1/5/26, at 9:44 PM: Full thickness wound. Pressure injury. 1.0 x 1.0 cm. Tissue type: Granulation. Light exudate. Stage: Further assessment required. Treatment: Clean area with NS, pat dry, apply calcium alginate cover with gauze island w/border daily and PRN is soiled.On 1/6/26 at 10:45 AM, Surveyor spoke with RN-E about her documentation of R2's wound on 12/11/25. Surveyor advised the documentation didn't include a comprehensive assessment, description of the wound or staging. RN-E stated, We don't do that. If we find a new wound or there's a new admit with a wound, we just measure it, we don't stage it. Surveyor advised there was no documentation of an assessment, such as what the wound looked like, wound characteristics, exudate. RN-E stated, I don't think it had any of that. Surveyor asked why a comprehensive assessment of the wound wasn't documented. RN-E stated. We just measure, we don't stage wounds.On 1/6/26 at 10:51 AM, Surveyor spoke with RN/Unit manager-J. Surveyor asked if she remembered what R2's pressure injury looked like on 12/18/25 when seen by the wound doctor. RN/Unit manager-J stated, He measures as a cluster if there is more than one. There was a few, I can't remember how many, maybe 2 or 3, but he measures as a cluster not each separate. Surveyor advised physician recommended treatment included collagen powder, which was not added to the TAR. RN/Unit manager-J stated, I'm not sure how that got missed.On 1/6/25 at 2:30 PM, Nursing Home Administrator (NHA)-A was advised of concern: R2 has a history of stage 3 pressure injury on her buttocks. On 12/11/25 a facility acquired pressure injury was identified. R2's care plan was not revised with new interventions. The wound was not comprehensively assessed or staged until 1 week later by the wound physician which then documented the pressure injury as unstageable due to necrosis and was larger in size (decline). The physician recommended treatment was not transcribed or completed as ordered and there is no evidence the physician was notified. In addition, the pressure injury was not comprehensively assessed weekly by an RN. No additional information was provided at the time of survey exit.

Based on observation, record review and interview, the facility did not ensure a resident wound was comprehensively assessed weekly, along with interventions to promote healing. This was observed with 1 (R4) of 1 resident observed with a skin wound. R4 developed a skin wound requiring a treatment. This wound was not comprehensively assessed weekly to determine progression of healing.Findings include:The facility policy and procedure titled Skin Identification, Evaluation and Monitoring dated 11/2022 documents: The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity. Communities will implement preventative measures, and an individualized care plan will be formulated upon completion of findings.The Procedure; Weekly: the licensed nursing associate will document integumentary findings appearance of the wound including measurements treatment applied or initiated per healthcare provider order in the medical record. Document evaluation in the medical record. Update plan of care with each intervention.R4 was admitted to the facility on [DATE] for a traumatic brain injury and has a guardian.On 12/4/25 the Progress Note (PN) documents: R4 seen by wound care doctor today and was assessed to have a full thickness non-pressure wound to right upper scapula measuring 6 centimeters (cm) by 6 cm by 0.1 cm with light serous drainage. There is 10% necrotic tissue and no signs of infection. Dressing change done as ordered.The Wound Evaluation and Management Summary dated 12/4/25 by the wound care doctor documents: The treatment plan is a gauze island with border dressing daily and as needed. Follow-up: Evaluation by wound care provider weekly.The Wound Evaluation and Management Summary dated 12/11/25 by the wound care doctor documents: The right upper scapula wound measures 6 cm by 3 cm by 0.1 cm with light serous drainage. The area has 20% slough which was debrided at this time. The treatment plan is unchanged. The Recommendations: to reposition per facility protocol and off-load wound. The Follow-up: Evaluation by wound care provider weekly or sooner as needed, with further intervention as indicated based on response to current treatment plan.R4 Plan of Care (POC) was reviewed. There is no documentation identifying the non-pressure wound. Therefore, there are no documented interventions to promote healing.The Wound Evaluation and Management Summary dated 12/18/25 by the wound care doctor documents: The patient's visit has been rescheduled. Patient refused wound evaluation.Surveyor notes R4's medical record does not have a comprehensive assessment of their non-pressure wound since 12/11/25. Surveyor also notes there is not a POC for the non-pressure wound.On 1/5/26, at 2:15 PM, Surveyor interviewed the Director of Nurses (DON) -B. DON-B stated the wound care doctor comes very week on Thursday. They do wound rounds with the Registered Nurse Manager (RNM)-J. The Floor Nurse will do the assessment if they are not available. Surveyor shared there is no documentation of a comprehensive wound assessment since 12/11/25. The DON-B stated they will look into it.On 1/5/26, at 3:00 PM, at the facility exit meeting with Nursing Home Administrator (NHA) -A, DON-B and Regional Nurse Consultant (RNC) -C, Surveyor shared the concern R4 did not have a comprehensive wound assessment since 12/11/25 and no plan of care that identifies this wound with interventions to promote healing.On 1/5/26, at 3:28 PM, Surveyor observed R4's wound and treatment by Licensed Practical Nurse (LPN) -N. Surveyor notes R4 has 2 wound areas as stated in the 12/11/25 wound assessment.On 1/6/26, at 7:35 AM, Surveyor interviewed RN/Unit Manager-J. The RN/Unit Manager-J stated the floor nurse will also conduct the weekly assessment. RN/Unit Manager-J stated they will look into any documented wound assessments since 12/11/25.On 1/6/25, at 10:31 AM, Surveyor interviewed RN/Unit Manager-J. The RN/Unit Manager-J did not provide a comprehensive wound assessment after 12/11/25. The RN/Unit Manager-J stated the Minimum Data Set (MDS) Nurse does the plan of cares. The RN/Unit Manager-J did not know why the wound was not identified in R4 POC.The MDS Nurse was not available to interview. Surveyor notes there is no documentation R4's wound was identified in R4's care plan with interventions to promote healing.Surveyor also notes R4's medical record did not contain documentation of a comprehensive wound assessment from 12/11/25 through 1/6/25, and the wound was not identified on R4's care plan with person-centered interventions to promote healing and identify if interventions and/or treatments needed to be adjusted.

Based on observation, interview, and record review, the facility did not ensure 3 (R3, R1, and R6) of 5 Residents received adequate supervision and assistive devices to prevent accidents. *R3 sustained a left femur fracture when CNA-P transferred R3 alone when R3 was to be a two person transfer and the sit-to-stand lost power. During the survey, R3 was observed not have the leg brace on at all times per physician orders, a follow-up x-ray of the left femur was not obtained, and Certified Nursing Assistants (CNA-F and CNA-G) were observed not operating the mechanical lift correctly when transferring R3. *R1's floor mat was not down next to the bed per care plan during the survey process. *R6's fall interventions were not followed for toileting after meals. Findings include: The facility's policy titled Lifting Machine, Using a Portable last revised [DATE] documents: Purpose: The purpose of this procedure is to help lift residents using a manual lifting device. Preparation: A. Review the resident's care plan to assess for any special needs of the resident. B. Assemble the equipment and supplies as needed. General Guidelines .Two nursing associates are required to perform total lift transfers One nursing associate may be used per manufacturer recommendations for a sit to stand lift. Procedure for total lift transfer: .C. The sling should be placed from under the resident's shoulders to the back of the knees. Have the same amount of sling material on both sides of the resident so that the resident is centered in the sling. D. Place the lift frame facing the bed with legs under the side of bed. Lock wheels on the base of lift. E. Elevate the head of the bed so the resident is partially sitting up. F. Attach the sling to the lift. Pay close attention to ensure resident is not injured by lift cross bars. G. Ask the resident to cross their arms over their chest before operating the lift. I. Raise the resident up to a sitting position with the lift. While you operate the lift, your helper should help you guide the resident. J. Before moving the lift, ensure the legs of the lift are open to widest position. K. Unlock wheels. You may need to guide the resident's legs. N. Position the resident in the chair, leaving the sling under them. Procedure for Sit-to-stand B. Position sit-to-stand lift sling under resident's axilla and secure safety belt around waist. C. Position the lift facing the resident. D. Have lift base straddle chair opened to widest position. E. Instruct resident to hold on to cross bar. F. Secure resident's feet on lift platform. G. Ensure knees are against knee rests on lift. H. Before moving the lift, ensure legs of the lift are open to widest position. I. Crank(or raise) the resident up with the lift. Your helper guides the resident by holding the sling. 1.) R3 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart) Block, Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Iron Deficiency Anemia(blood does not have enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R3 was discharged to the hospital on [DATE] and returned from the hospital on [DATE] with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed [DATE] documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. The MDS documents: R3 is not demonstrating mood or behavior symptoms; R3 has range of motion impairment on one side of lower extremity; R3 requires supervision for eating; R3 is dependent for upper and lower dressing and for transfers; R3 requires substantial/maximum assistance for mobility; R3 is always incontinent of bowel and bladder; R3 is at risk for developing pressure ulcer/injuries; R3 is mobile via wheelchair. Surveyor noted there are documented changes with the level of assistance R3 required prior to the fracture of the left femur versus after the fracture. R3's Quarterly MDS completed [DATE] documents the following changes: -R3 has no range of motion impairment -R3 is set-up for meals -Upper dressing-partial/moderate assistance -Lower dressing-substantial/maximum assistance -R3 requires partial/moderate assistance for mobility -R3 is occasionally incontinent of bladder -R3 is always continent of bowel R3's Care Area assessment dated [DATE] documents R3 is at risk for falls with injury evidenced by history of falls-recent femur fracture, non-weight bearing, poor balance, pain, weakness, fatigue, medication and poor endurance. Working with physical therapy and occupational therapy to improve ambulation, safety awareness, and endurance. R3's current([DATE]) Certified Nursing Assistant(CNA) worksheet documents: -Turn and reposition after ALL CARES and during rounds. Offload both heels while R3 is in bed. Utilize heel suspension boots offloading device to ensure heels are elevated and free from pressure. Check placement. Inspect skin integrity-heels and beneath left leg brace daily-day shift. Use lift sheet with 2 staff to reduce friction and sheer. 1.Left leg brace on at all times-do not bend leg. Brace may be removed for cares, skin inspection, and while on shower cart. 2.Leg should not be bent 3.Use mechanical lift-medium sling, transfer with total assistance of 2 staff person support. MUST SUPPORT LEFT LEG AT ALL TIMES 4.Transfer from bed into high back wheelchair in R3's room 5.Foot and leg rest should be straight out. Once R3 is in wheelchair(while still supporting R3's leg, attach wheelchair footrest with leg rest-put pillow on top of leg rest and gently lower leg onto pillow. -R3 needs extensive assistance with bed mobility. 2 person maximum assist with bed mobility. Use lift pad to prevent shearing. Reposition-turn side to side with each encounter. Not only for pain relief, but for pressure relief. -NON WEIGHT BEARING BRACE ON AT ALL TIMES IN LOCKED POSITION -R3 should wear soft pants or pajama bottoms under brace -Make sure left leg is supported, aligned, and cushioned during turning and transfers R3's Certified Nursing Assistant(CNA) worksheet at the time([DATE]) of the incident causing a left femur fracture documents: -R3 needs total assistance of 2 staff person support with transfers using SIT TO STAND LIFT medium yellow sling with transfers.(lower knee plate to shin level, stand R3 up halfway only due to flexed knees) R3's current comprehensive care plan with interventions documents: R3 will have no major injuries from a fall [DATE] -Gripper socks at HS-nonskid footwear [DATE] -Position in middle of bed. Use bolsters to provide support for side laying and pressure ulcer prevention [DATE] Surveyor noted R3 was being transferred prior to the left femur fracture utilizing a sit-to-stand device and now after the left femur fracture is requiring a mechanical lift to safely transfer. On [DATE], Certified Nursing Assistant (CNA)-P was transferring R3 from the toilet alone using the sit-to-stand lift. The lift's battery died mid-transfer, resulting in R3's left leg giving out. CNA-P yelled for help. Licensed Practical Nurse (LPN)-E heard CNA-P yell for help and went running to R3's room. LPN-E assisted CNA-P to lower R3. LPN-E assessed R3 and noted R3's left leg was swollen and bruised on the top of R3's foot. An x-ray was ordered and completed. The result is that R3 suffered a non-displaced oblique fracture of the distal shaft of the left femur. R3 was sent to the hospital and admitted with a left femur fracture. R3's CNA worksheet instructing in the care of R3 at the time of the incident, R3 was to be transferred by 2 staff with the sit-to-stand. CNA-P was transferring R3 alone. R3 returned from the hospital on [DATE] with orders to wear left leg brace in locked position at all times every shift. Left leg brace for proper positioning, hinge alignment(center over knee joint, strap security-snug-but not too tight-use two finger test. May remove while on shower cart with a start date of [DATE]. R3's physician orders also document physical and occupational therapy to eval and treat R3. R3's physician orders also document on [DATE] an order to obtain an x-ray of R3's left femur on [DATE] and fax results to R3's orthopedic doctor. Surveyor reviewed R3's Treatment Administration Record(TAR) for October and noted that nursing staff were checking off since [DATE] to present for obtaining the x-ray. Surveyor reviewed R3's electronic medical record and noted there is no documentation that the facility obtained the x-ray of R3's left femur on [DATE] or anytime after. On [DATE], at 10:02 AM, Surveyor spoke with R3's family who informed Surveyor that when family spoke to administration at the time of the fall, administration admitted that the machine was low on power at the time and one CNA completed the transfer when it should have been two CNAs. Family also informed Surveyor that R3 has not been wearing R3's brace when times when visiting. On [DATE], at 1:55 PM, Surveyor observed R3 in bed. Surveyor observed R3's brace is not on. R3 informed Surveyor that CNA-F put R3 to bed. On [DATE], at 2:10 PM, CNA-F confirmed CNA-F put R3 to bed. On [DATE], at 3:22 PM, Surveyor interviewed Maintenance Director (MD)-C in regard to the battery of the sit-to-stand. MD-C explained that the sit-to-stand has an internal battery and the sit-to-stand needs to be plugged in all times when not in use. MD-C stated that all the batteries were replaced after the incident. MD-C also stated that MD-C inspected all sit-to-stands and mechanical lifts and no mechanical issues were noted. MD-C stated that the sit-to-stand needs to have 3 green lights to be fully charged when in use. On [DATE], at 3:59 PM, Surveyor observed R3 in bed and not wearing the brace. The brace was observed sitting on R3's wheelchair. On [DATE], at 8:00 AM, Surveyor observed R3 in bed. R3's brace is not on and the brace sitting on R3's wheelchair. R3 informed Surveyor I don't know what happened. They never put it on. Surveyor noted R3 is alert and oriented. On [DATE], at 8:47 AM, Surveyor interviewed Physical Therapy Assistant/Rehabilitation Director (PTA)-D who states R3's bed mobility has decreased. PTA-D confirmed R3 went from a sit-to-stand to a mechanical lift. PTA-D stated R3 is non weight bearing. PTA-D stated PTA-D trained the staff on how to operate the mechanical lift properly and to support the leg at all times during the transfer. PTA-D confirmed R3 should be wearing the brace at all times except for showers. On [DATE], at 9:45 AM, Surveyor observed R3's transfer with the mechanical lift. R3 gave permission for Surveyor to observe. Surveyor observed R3's brace is currently not on. CNA-F and CNA-G started by placing pants on R3. Surveyor observed R3 grimace in pain as CNA-F and CNA-G move R3's left leg to place the pants on R3. CNA-F and CNA-G were talking about R3's brace. R3 informed CNA-F and CNA-G that the brace was not put on last night. CNA-F asked R3 if R3 should be wearing the brace. R3 stated that nobody has told me anything. CNA-F asked if R3 wanted the brace on, but then CNA-G stated the brace should be put on. Surveyor observed the mechanical lift transfer of R3 from bed to wheelchair. Surveyor observed that CNA-F was operating the mechanical lift. CNA-F did not lock the mechanical lift as R3 was being raised off the bed. Surveyor noted that the head of the bed was not elevated and R3 was not asked to cross R3's arms across R3's chest. As CNA-F moved the mechanical lift, CNA-F did not extend the legs of the mechanical lift to the widest position. As R3 was in the air, Surveyor observed R3's left leg dangling in the air, and CNA-G did not support R3's left leg during the transfer. R3 was lowered into R3's wheelchair with the sling underneath. CNA-G boosted R3 up in the chair by grabbing R3's pants and pulling. Surveyor asked CNA-F and CNA-G if therapy had trained them on mechanical lift transfers. CNA-F stated only that there must be 2 staff to complete the transfer with a mechanical lift and to keep R3's brace on. Surveyor asked CNA-F why did CNA-F take R3's brace off yesterday when CNA-F put R3 to bed. CNA-F informed Surveyor that CNA-F does not recall. On [DATE], at 10:05 AM, Surveyor interviewed LPN-E in regard to the incident resulting in R3's left femur fracture. LPN-E heard CNA-P yelling for help. LPN-E hit the emergency button on the sit-to-stand to lower as soon as possible. LPN-E observed R3's left leg was inward on the sit-to-stand. LPN-E made all necessary notifications and called for an x-ray. LPN-E provided pain medication. LPN-E stated that as CNA-P raised the sit-to-stand, it stopped working and R3's weight became dead weight causing R3's legs to buckle and R3's left leg gave way. LPN-E confirmed that R3 is supposed to wearing the brace at all times. LPN-E stated that if R3 refuses the brace, staff should let the nurses know so nurses can document the refusals. On [DATE], at 11:53 PM, Registered Nurse (RN)-H confirmed that an x-ray has not been obtained on [DATE] or any day after. RN-H stated that the last x-rays were completed in August. Surveyor reviewed R3's TAR for October and noted that nursing staff have been documenting that they are checking for the placement of the brace, however, Surveyor has observations of the brace not being on R3. Surveyor reviewed the facility training provided on mechanical lifts and sit-to-stands after R3's incident and noted all staff have not received the training. On [DATE], Director of Nursing (DON)-B stated that the agencies received the facility orientation packet and staff sign off on it prior to working a shift. DON-B confirmed that no one completes a competency evaluation of agency staff. On [DATE], at 3:01 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B that R3 suffered a left femur fracture as a result of CNA-P operating the sit-to-stand by CNA-P's self and the sit-to-stand lost power. Surveyor also shared that the physician order for a follow-up x-ray on [DATE] and fax to R3's orthopedic doctor was not completed. Surveyor also shared that during the survey process, R3 has not been wearing the brace at all times. Surveyor shared that Surveyor observed CNA-F and CNA-G improperly operate the mechanical lift while transferring R3 from bed to wheelchair and left R3's left leg dangling with out support while in mid air. No additional information was provided as why R3 was not transferred by two staff using the sit-to stand, the improper use of the mechanical lift by CNA-F and CNA-G, why R3's brace was observed to not be on at all times and why an x-ray per physician order was not obtained. 2.) R1's diagnoses include multiple sclerosis, (disease in which the immune system eats away the protective covering of nerves resulting in disruption in communication between the brain & body) and spastic paraplegia (group of inherited neurological disorders characterized by progressive weakness, stiffness, and spasms in the legs). R1's significant change MDS (minimum data set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 7, which indicates severe cognitive impairment. R1 is assessed as being dependent. R1 is assessed as being dependent for toileting, roll left & right, and chair/bed to chair transfer. R1 has not had any falls since prior assessment period. The facility did not trigger the fall CAA (care area assessment). R1's at risk for falls care plan with a goal date of [DATE] documents the following approaches: *Keep room clutter free and provide adequate lighting. Start date [DATE]. *Keep call light within reach. Start date [DATE]. *Encourage to keep bed at the appropriate height-prefers bed against wall POA (power of attorney) agreeable, LOW bed. Start date [DATE]. *Keep frequently used items within reach. Start date [DATE]. *Fall mat at bedside. Start date [DATE]. *Call light with reach at all times-Soft touch call light, prefers placement near/close to chin. Start date [DATE]. *Encourage resident to use call light when needing assistance if Alexa device is not functioning. Start date [DATE]. R1's fall risk assessment dated [DATE] has a score of 24. A score of 16-35 is moderate risk of falls. R1's Certified Nursing Assistant (CNA) Worksheet for Monday [DATE] All Shifts under the appliance/safety/skin precaution section documents Fall mat at bed side. On [DATE], at 10:06 a.m., Surveyor observed R1 in bed on back with the head of the bed elevated. R1's bed is at the low position and the right side of the bed is against the wall. Surveyor observed there is not a floor mat on the left side of R1's bed. On [DATE], at 11:14 a.m., Surveyor observed R1 continues to be in bed on the back with the head of the bed elevated and the bed in the low position. Surveyor observed there is still not a floor mat on the left side of the bed. Surveyor observed the gray floor mat is folded between the garbage can and R1's wardrobe. On [DATE], at 1:12 p.m., Surveyor observed R1 in bed with a pillow under R1's upper left & right side, head of the bed is elevated, and the bed is in the low position. Surveyor observed there is not a mat on the left side of R1's bed. Surveyor observed the gray floor mat is folded between the garbage can and R1's wardrobe. On [DATE], at 3:30 p.m., Surveyor observed R1 is in bed towards left side with the head the bed elevated, and the bed in a low position. Surveyor observed there is still not a floor mat on the left side of R1's bed. Surveyor observed the gray floor mat is folded between the garbage can and R1's wardrobe. On [DATE], at 7:13 a.m., Surveyor observed R1 in bed towards left side with the head of the bed elevated. Surveyor observed the bed is not at a low position and there is not a floor mat on the left side of R1's bed. Surveyor observed the gray floor mat is still folded between the garbage can and R1's wardrobe. On [DATE], from 8:30 a.m. to 9:16 a.m. Surveyor observed R1's morning cares and treatment with CNA (Certified Nursing Assistant)-J, Licensed Practical Nurse (LPN)-E and CNA-G. Surveyor observed there was not a floor mat when staff entered for morning cares & treatment and upon completion staff did not place the floor mat on the left side of R1's bed. Surveyor observed the gray floor mat is still folded between the garbage can and R1's wardrobe. On [DATE], at 10:48 a.m., Surveyor observed R1 in bed on his back with the head of the bed elevated and R1's bed in a low position. Surveyor observed there is not a floor mat on the left side of R1's bed and the gray floor mat is still folded between the garbage can and R1's wardrobe. On [DATE], at 12:05 p.m., Surveyor observed CNA-J feeding R1 who is in bed. Surveyor observed there is not a floor mat on the left side and the gray floor mat is still folded between the garbage can and R1's wardrobe. On [DATE], at 1:10 p.m., Surveyor observed R1 in bed on his back with the head of the bed elevated, and the bed in a low position. Surveyor observed there is not a floor mat on the left side and the gray floor mat is still folded between the garbage can and R1's wardrobe. On [DATE], at 1:19 p.m., Surveyor asked CNA-J Surveyor noted on R1's CNA care plan R1 is suppose to have a floor mat at R1's bed side but Surveyor has not observed a floor mat. CNA-J informed Surveyor she has not picked it up or moved the floor mat. On [DATE], at 2:12 p.m. Surveyor informed Registered Nurse/Interim Unit Manager (RN/IUM)- M according to R1's fall care plan and CNA care plan R1 is to have a floor mat at bed side. Surveyor informed RN/IUM-M Surveyor has not observed the floor mat by R1's bed and has been folded up between the garbage can and wardrobe. On [DATE], at 3:05 p.m., during the end of the day meeting, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B Surveyor has not observed a floor mat on the left side of R1's bed according to R1's plan of care. On [DATE], at 7:34 a.m., Surveyor observed R1 in bed on the left side with the head of the bed elevated and bed down low. Surveyor observed there is not a mat on the floor next to R1's bed and the floor mat continues to be folded between the garbage can and wardrobe. 3.) R6's diagnoses include Dementia (loss of cognitive function that interferes with a person's daily life & activities) and hypertension (high blood pressure). R6's potential for falls care plan with a goal date of [DATE] documents the following approaches: *Keep pathways clear and provide adequate lighting. Start date [DATE]. *LOW bed-bed against the wall per preference. Start date [DATE]. *Keep personal items within reach. Start date [DATE]. *Gripper socks while in bed and gripper socks or shoes when up. Start date [DATE]. *Avoid allowing resident to sit up in WC (wheelchair) in room for prolonged periods of time, offer and encourage to lay down or engage in activity. Start date [DATE]. *Fall mat next to bed. Start date [DATE]. *TAKE RESIDENT TO TOILET AFTER MEALS -Fall prevention intervention. Start date [DATE]. R6's fall CAA (care area assessment) dated [DATE] under causes and contributing factors documents Resident is at risk for falls with injury evidenced by history of falls r/t (related to) unsteady gait, poor balance, pain, weakness, fatigue, medication and poor endurance. Working with PT (physical therapy) and OT (occupational therapy) to improve ambulation, safety awareness, and endurance. R6's quarterly MDS (minimum data set) with an assessment reference date [DATE] has a BIMS (brief interview mental status) score of 2 which indicates severe cognitive impairment. R6 is assessed as not having any behavior including refusal of cares. R6 is assessed as requiring supervision for eating, substantial/maximal assistance for toileting hygiene, chair/bed to chair transfer, and toilet transfer. R6 is assessed as being frequently incontinent of urine and bowel. R6 has not fallen since prior assessment. R6's nurses note dated [DATE], at 2205 (10:05 p.m.), documents Resident noted to be sitting on floor by CNA (Certified Nursing Assistant) at 1615 (4:15 p.m.) on [DATE]. Resident noted to be sitting upright on coccyx with back toward bed feet facing door in room. Called to room by CNA resident sitting upright next to bed back toward bed and feet facing door. Resident states she was trying to get in bed and fell. Resident is incontinent of urine at time of fall call light on bed within reach resident states she thought she could do it. Prior to fall resident was in w/c (wheelchair). No injury noted at time of fall. Resident denies pain at time of fall. Resident current level of consciousness is alert with no change from baseline. Resident is pleasant, cooperative with care with no change from baseline. Resident range of motion full to upper extremities, full to lower extremities o difference noted between sides of boy, with no change from baseline. Resident denies pain with range of motion. Resident assisted up to bed by 2 staff using gait belt. Safety measures in place at time of fall include low bed. Fall interventions in place include visibility area. Care plan reviewed with interventions updated as indicated. [Physician Name] updated [DATE] at 1800 (6:00 p.m.) NNO (no new orders). Family [Name] updated on fall [DATE] at 1900 (7:00 p.m.). R6's fall risk assessment dated [DATE] has a score of 5. A score of 0-15 is minimal risk for falls. R6's nurses note dated [DATE], at 12:25 p.m., documents Follow up to unwitnessed fall on [DATE]. New measures were implemented including mats placed on floor beside bed and toileting program. Nursing will continue to monitor each shift. R6's Certified Nursing Assistant (CNA) Worksheet for Monday [DATE] All Shifts under the section Appliances/Safety/Skin Precaution includes TAKE RESIDENT TO TOILET AFTER MEALS. On [DATE], at 12:00 p.m., Surveyor observed R6 sitting in a wheelchair at a table in the dining room eating lunch. On [DATE], at 12:16 p.m., Surveyor observed R6 state I'll see you later. R6 wheeled self away from the table, propelled self-down and the hall and into R6's room. Surveyor remained in the R6's hallway to observe when staff would toilet R6 after lunch On [DATE], at 12:26 p.m., Surveyor observed R6 sitting in a wheelchair in her room reading the New Testament. Surveyor asked R6 how she was doing. R6 replied my name is [stating her first name] and then started rubbing her right upper leg. Surveyor then went back in R6's hallway. On [DATE], at 12:51 p.m., Surveyor observed CNA-N wheel R7's, who is R6's roommate, broda chair into their room. R7 was stating she has to use the bathroom. Surveyor observed R6 is not in the room and the bathroom door is closed. CNA-N placed candy on the over bed table in front of R7. CNA-N informed Surveyor this is usual behavior for R7, referring to having to go to the bathroom, and CNA-N had checked R7 before. CNA-N asked R7 if she wanted something to drink and left the room. Surveyor noted CNA-N did not check the bathroom prior to leaving the room. At 12:56 p.m. CNA-N returned with a cup of coffee for R7. After giving R7 coffee, CNA-N opened the bathroom door. Surveyor observed R6 sitting on the toilet, the New Testament book is on the handrail and R6's wheelchair is next to the toilet. CNA-N placed gloves on, stated let me get a gait belt for her and left the bathroom. CNA-N returned with a gait belt and placed the gait belt around R6. CNA-N attempted to stand R6 asking R6 are you going to help me? R6 replied I don't know. CNA-N then left R6's bathroom. At 1:00 p.m. CNA-N and CNA-K entered R6's bathroom, placed gloves on, and an incontinence product was placed on R6. CNA-K informed R6 they were going to stand her up to clean her bottom, R6 was stood up, CNA-N wiped R6's with a disposable wipe and R6's product and brief were pulled up. R6 was then seated in the wheelchair. CNA-K removed her gloves & left R6's bathroom. CNA-N stated to R6 I don't want you to do any more self-transfers. Do not put yourself on toilet. CNA-N handed R6 the New Testament and wheeled R6 out of the bathroom into her room. CNA-N showed R6 the call light and told R6 to use it. CNA-N placed the gait belt in the bathroom, gathered garbage removed her gloves & cleansed her hands. CNA-N told R6 next time to let her know when she has to go to the bathroom, don't go herself and left R6's room with the garbage. Surveyor noted R6 was not toileted after lunch according to her fall plan of care and R6 transferred herself. On [DATE], at 1:08 p.m., the facility's chaplain wheeled R6 out of the room informing Surveyor she's going to take R6 to services. On [DATE], at 10:12 a.m., Surveyor asked Licensed Practical Nurse/Interim Unit Manager (LPN/IUM)-L if R6 has a fall intervention to take resident to toilet after meals what is the expectation. LPN/IUM-L stated right after meal. Surveyor asked LPN/IUM-L how would the CNA know this. LPN/IUM-L informed Surveyor the care card is updated with the fall intervention plan. Surveyor informed LPN/IUM-L of the observation of R6 not being taken to the toilet after lunch and R6 self-transferred herself onto the toilet. No additional information was provided.

Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 1 Resident.* Staff did not perform hand hygiene before, during, and after transferring R3 with the mechanical lift. Staff did not wipe down the mechanical lift after transferring R3.Findings include:The facility's Hand Hygiene last revised 6/25 documents:Policy Statement: This community considers hand hygiene the single most important practice to prevent infections and promote resident safety. Evidence based hand hygiene guidance is practiced to reduce the risk of transmission of pathogenic microorganisms to residents, associates, and visitors.Policy Interpretation and ImplementationA. Supplies necessary for adherence to hand hygiene are readily accessible in all areas where resident care is being delivered.E. Hand hygiene is practiced:1.Immediately before touching a resident4. After touching a resident or the resident's immediate environment6. Immediately after glove removalF. Hand hygiene is the final step after removing and disposing of personal protective equipment.G. The use of gloves does not replace hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.H. Single-use disposable gloves should be applied:3. When in contact with a resident, the equipment or the environment of a resident, who is on contact precautions.The facility's Lifting Machine, Using a Portable last revised 6/25 policy and procedure documents:Steps in the ProcedureA. Perform hand hygiene before beginning the procedureC. Perform hand hygiene when transfer is completed and the resident is in a safe and comfortable position.Procedure for total lift transfer:Q. Lift should be wiped down after use, with either a disinfectant or sanitizing wipe.R3 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart) Block, Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Iron Deficiency Anemia(blood does not have enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R3 was discharged to the hospital on 8/18/25 and returned from the hospital on 9/11/25 with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. The MDS documents: R3 is not demonstrating mood or behavior symptoms; R1 has range of motion impairment on one side of lower extremity; R3 requires supervision for eating. R3 is dependent for upper and lower dressing and for transfers; R3 requires substantial/maximum assistance for mobility; R3 is always incontinent of bowel and bladder; R3 is at risk for developing pressure ulcer/injuries and that R3 is mobile via wheelchair.On 10/28/25, at 9:45 AM, Surveyors observed Certified Nursing Assistant (CNA)-F and Certified Nursing Assistant (CNA)-G transfer R3 from bed to wheelchair utilizing a mechanical lift. R3 gave permission for Surveyor to observe.Surveyor notes that CNA-F brought a mechanical lift into R3's room and CNA-G also entered R3's room. Surveyor observed CNA-F and CNA-G place gloves on, but did not perform hand hygiene prior to placing the gloves on. Both CNA-F and CNA-G transferred R3 utilizing the mechanical lift. CNA-F took CNA-F's gloves off, did not perform hand hygiene prior to exiting R3's room. CNA-F entered R3's room carrying a towel, washcloth, and pad for the bed. Surveyor observed CNA-F not performing hand hygiene. CNA-F went into the bathroom and got the washcloth wet and handed the washcloth to R3 to wipe R3's face. CNA-F did not perform hand hygiene or place gloves on. Both CNA-F and CNA-G exited R3's room and did not perform hand hygiene. Team member Surveyor observed CNA-G take the mechanical lift and place in the equipment room. Surveyor observed CNA-G not wipe down the mechanical lift after use in transferring R3.On 10/28/25, at 3:01 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that CNA-F and CNA-G did not perform hand hygiene before, during, and after transferring R3 with the mechanical lift and did not wipe down the mechanical lift after use.No additional information has been provided by the facility as to why CNA-F and CNA-G did not perform hand hygiene or wipe down the mechanical lift with the transfer of R3.On 10/29/25, at 7:37 AM, Surveyor interviewed Registered Nurse (RN)-H who confirmed that RN-I is the facility Infection Preventionist. RN-H stated that staff were trained about two months ago on hand hygiene. RN-H stated the expectation is that staff perform hand hygiene prior to entering a resident room, perform resident activities, and perform hand hygiene prior to leaving the resident room.

Based on observation, interview, and record review the facility did not ensure 1 (R1) of 2 residents with indwelling urinary catheter received the appropriate care and services.R1 was observed without a stat lock on R1's catheter tubing per physician orders and CNA-J was observed not clean the end of spigot prior to placing the spigot back in the collection bag.Findings include:The facility's policy titled, Urinary Elimination Standard of Care Including Indwelling Urinary Catheter Insertion/Maintenance/Removal & Urinary Incontinence and Retention - Adult and last revised 5/23/22 under Indwelling Catheter Maintenance documents G. Maintain unobstructed urine flow by keeping the collection bag below the bladder, off the floor, unkinked and regularly empty collection bag with patient specific collection container. Avoid touching drainage spigot with collection container when emptying.R1's diagnoses include multiple sclerosis, (disease in which the immune system eats away the protective covering of nerves resulting in disruption in communication between the brain & body), spastic paraplegia (group of inherited neurological disorders characterized by progressive weakness, stiffness, and spasms in the legs), and neuromuscular dysfunction of bladder (condition where the nerves and muscles that control bladder function are impaired, leading to abnormal urinary symptoms).R1's altered elimination related to use of suprapubic catheter care plan with a goal date of 12/15/25 includes approaches of STATLOCK device - to secure catheter change. Start date 9/11/25. STATLOCK - Device to secure catheter. Change weekly and PRN (as needed) if STATLOCK id (is) not secure or underlying skin issues. Start date 9/11/25.R1's significant change MDS (minimum data set) with an assessment reference date of 10/7/25 has a BIMS (brief interview mental status) score of 7 which indicates severe cognitive impairment. R7 is assessed as being dependent for toileting and is checked for an indwelling catheter.R1's physician order dated 10/8/25 documents Stat lock device used to secure catheter Change weekly and PRN (as needed) if stat lock is not secure every week every week & PRN change stat lock device.On 10/27/25, at 10:06 a.m., Surveyor observed R1 in bed on his back with the head of the bed elevated. Surveyor observed R1's urinary collection bag is attached to R1's bed frame on the left side.On 10/28/25, at 8:30 a.m., Surveyor observed CNA-J place PPE (personal protective equipment) on. Surveyor asked CNA-J other than feeding R1 has she done any other cares for R1 this morning. CNA-J replied no just check catheter. At 8:33 a.m. Licensed Practical Nurse (LPN)-E entered R1's room wearing PPE. CNA-J lowered the head of R1's bed and placed a wash basin on R1's over bed table. CNA-J removed the pillow from under R1's head & removed R1's pressure relieving boots, and LPN-E removed a wedge from under R1's left shoulder. At 8:40 a.m. LPN-E removed the urinary collection bag from R1's bed frame and held onto the bag while CNA-J removed the spigot from the holder, placed the spigot into a graduate and emptied 400 cc (cubic centimeters) of yellow urine. CNA-J placed the spigot back in the holder, went into the bathroom, emptied the urine into the toilet and rinsed the graduate. Surveyor observed CNA-J did not cleanse the end of the spigot with an alcohol pad. LPN-E attached the urine collection bag back on R1's bed frame. CNA-J & LPN-E removed their gloves, cleansed their hands, and placed gloves on. Surveyor observed morning cares for R1 until 9:16 a.m. During this observation Surveyor did not observe a stat lock to hold R1's catheter tubing.On 10/28/25, at 10:33 a.m., Surveyor asked LPN-E if R1 should have a stat lock on for the catheter tubing. LPN-E replied yes. Surveyor informed LPN-E R1 does not have a stat lock on. LPN-E stated Oh my God I didn't even notice it. I'll put one on.On 10/28/25, at 11:00 a.m. Surveyor asked Director of Nursing (DON)-B procedure for emptying a urinary catheter bag. DON-B informed Surveyor staff should place gloves on, remove spigot, empty, clean tip and place back in holder, empty in commode, and rinse. Surveyor informed DON-B of the observation of R1's spigot not being cleaned with an alcohol pad.No additional information was provided.

Based on observation, interview and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 2 (R1 & R3) of 4 residents reviewed for pressure injuries. *R1 has multiple pressure injuries which developed prior to the facility's last recertification survey with an exit date of 8/20/25. R1 was hospitalized from [DATE] to 9/11/25. The assessment for R1's left buttocks does not have the correct stage. Registered Nurse/Interim Unit Manager (RN/IUM)-M assessed R1's left buttock as a Stage 2 with granulation tissue. A stage 2 does not have granulation tissue. R1 was hospitalized from [DATE] to 10/3/25. R1's right lateral foot pressure injury was not assessed until 10/9/25 by Wound Doctor-Q. On 10/7/25 LPN-O completed a skin evaluation form for R1's right buttock, thigh left posterior, buttock left lower and buttock midline. None of these areas were described as pressure injuries by LPN-O and there is no tissue description. There was not a RN assessment and Wound Doctor-Q did not assess these areas until 10/9/25. On 10/28/25 Licensed Practical Nurse (LPN)-E did not do the treatment for R1's right lateral foot. *R3 is at risk for pressure injury development. R3 was observed during the survey without R3's pressure relieving boots on nor were R3's heels offloaded. Findings include: The facility's policy titled, Procedure: Pressure Injury Assessment/Treatment and last revised 7/2024 under purpose documents The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries. Under the section Definitions and Descriptions for Stage 2 Pressure Injury documents Partial-thickness loss of skin with exposed dermis. The wound bed is 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. This policy/procedure does not address assessment of a resident's pressure injury upon admission/readmission and what the assessment should consist of. 1.) R1's diagnoses include multiple sclerosis, (disease in which the immune system eats away the protective covering of nerves resulting in disruption in communication between the brain & body) and spastic paraplegia (group of inherited neurological disorders characterized by progressive weakness, stiffness, and spasms in the legs). R1 was hospitalized from [DATE] to 9/11/25. R1's nurses note dated 9/11/25 at 14:46 (2:46 p.m.) written by Licensed Practical Nurse (LPN)-E documents Resident arrived at 1400 (2:00 p.m.) from [hospital initials] in stable condition. Vitals taken and stable. Resident has no c/o (complaint of) pain or discomfort. Resident RUA (right upper arm) picc (peripherally inserted central catheter) line that is patent. Resident is ordered ABT (antibiotic) for UTI (urinary tract infection). RN/IUM-M assessed R1's pressure injuries dated 9/12/25. The skin evaluation form for R1's left buttock under type is pressure injury, and under description documents Open areas with exposed dermis peri wound erythema new wound from hospital stay. Length is 3.0 cm, width 2.5 cm and depth 0.1 cm. Tissue type is granulation and stage is 2. Surveyor this assessment is inaccurate as a stage 2 pressure injury does not have granulation. Surveyor also noted the are no documented percentages of tissue type for the wound bed. R1 was hospitalized from [DATE] to 10/3/25. R1's nurses note dated 10/3/25 at 23:06 (11:06 p.m.) written by Licensed Practical Nurse (LPN-O documents 21:41 (9:41 p.m.): Patient arrived by stretch accompanied by two paramedics and his wife. Resident was transferred to bed x (times) 3 assist. Patient is alert and oriented x 4 [NAME] (pupils equal round reactive to light accommodation), mucous membranes pink and most. Original teeth, hearing adequate, vision adequate. Skin color normal good turgor, Lungs clear x 4 lobes, no cough, Oxygen is on room air, Heart sounds normal, Pulse regular 92, pedal pulse present bilateral feet, Bowel sounds active x4 quadrants, abdomen soft non-tender, Foley cath (catheter) 16 fr. (French), involuntary movement in all four extremities. Patient is incontinent BM (bowel movement). Frontal skin assessment performed. Wife requested not to move him for posterior skin check. States her husband has been through a lot today. Please check posterior tomorrow. RUA (right upper arm) PICC (peripherally inserted central catheter) line placement. Resident will start IV (intravenous) antifungal medication @ 10:00am. No c/o (complaint of) pain, respirations are even and unlabored and no s/s (signs/symptoms) of distress noted. Nurse Manager informed of arrival. R1's Braden assessment dated [DATE] has a score of 11. A score of 12 or less is high risk for pressure injury development. R1's skin evaluation form dated 10/3/25 completed by LPN-O for site documents Toe Right Great. Under description documents Outer area skin red dry abrasion on bilateral great toes. There are no measurements and stage is inapplicable. Surveyor noted prior to R1's hospitalization on 9/21/25 the right toe was assessed as an unstageable DTI (deep tissue injury). There is not a Registered Nurse (RN) assessment and Wound Doctor didn't assess R1's pressure injuries until 10/9/25. There was no assessment of R1's right lateral foot on 10/3/25 until Wound Doctor-Q assessed R1 on 10/9/25. Wound Doctor-Q's assessment dated [DATE] documents unstageable DTI (deep tissue injury) right lateral foot. Etiology is pressure. Wound size is 1.2 x 0.8 x not measurable cm. On 10/7/25 LPN-O completed a skin evaluation form for R1's right buttock, thigh left posterior, buttock left lower and buttock midline. The skin evaluation form by LPN-O for R1's right buttock under description documents red abraised abrasion. Measurements are length 4.0 cm (centimeter) and width 4.5 cm. There is no tissue type documented, and stage is inapplicable. The skin evaluation form by LPN-O for R1's left posterior thigh under description documents red irritated MASD (moisture associated skin damage). There is no tissue type documented, and stage is inapplicable. The skin evaluation form by LPN-O for R1's left lower buttock under description documents red abraised area. Length is 4.0 cm and width 2.0 cm. There is no tissue type documented, and stage is inapplicable. The skin evaluation form by LPN-O for buttock midline under description documents red abrased area with serosanguinous drainage. There is no tissue type documented, and stage is inapplicable. Prior to hospitalization on 9/21/25, these areas were assessed as pressure injuries by the wound doctor. These areas were not assessed by a RN and Wound Doctor-Q did not assess these areas until 10/9/25. Wound Doctor-Q's assessment dated [DATE] documents unstageable DTI (deep tissue injury) of the right buttocks. Etiology is pressure. Wound size is 5 x 6 x not measurable cm. Skin is intact with purple/maroon discoloration. Wound Doctor-Q's assessment dated [DATE] documents Stage 3 pressure wound of the left ischium. Wound size is 20 x 12 x 0.4 cm. Slough is 10%, Granulation tissue is 30% and skin is intact normal color 60%. Wound Doctor-Q's assessment dated [DATE] documents Unstageable DTI of the posterior, shares dressing with left ischium thigh. Etiology is pressure. Wound size is 11 x 12 x 0.2 cm. R1's significant change MDS (minimum data set) with an assessment reference date of 10/7/25 has a BIMS (brief interview mental status) score of 7 which indicates severe cognitive impairment. R1 is assessed as being dependent for eating, toileting, roll left & right, and chair/bed to chair transfer. Indwelling catheter is checked and R1 is always incontinent of bowel. R1 is at risk for pressure injury development and is assessed as having one Stage 2 pressure injury, one stage 3 pressure injury and four unstageable slough and/or eschar pressure injuries. R1's pressure injury CAA (care area assessment) dated 10/13/25 under care plan response documents proceed to plan of care. Under causes and contributing factors documents See above. Surveyor noted the only documentation for see above is proceed to plan of care. R1's physician order dated 10/10/25 documents Cleanse wound right lateral foot tx (treatment) topical every day apply betadine and leave open to air for DTI. On 10/28/25, at 8:29 a.m., Surveyor inquired about R1's treatments with LPN-E. LPN-E informed Surveyor the night nurse did the treatments for R1's buttocks but she will do the treatment for R1's toes. On 10/28/25, at 8:59 a.m., Surveyor observed LPN-E apply betadine to R1's toes according to physician order. During this observation Surveyor did not observe LPN-E complete the treatment for R1's right lateral foot. On 10/28/25 during R1's morning cares observation, at 9:01 a.m. Surveyor observed Certified Nursing Assistant (CNA)-J and CNA-G position R1 on the right side. Surveyor observed three foam dressings. CNA-J washed and dried R1's buttocks. A incontinence product & soaker pad was placed under R1, R1 was positioned to the other side to straighten out the incontinence product & soaker pad and remove the soiled linen. R1 was positioned on his back and the incontinence product was fastened. A pillow was placed under R1's head, R1's bed was lowered & move against the wall on the right side. CNA-G washed R1's face while CNA-J covered R1 with a blanket. CNA-J placed the pressure relieving boots back on R1 and asked R1 if he was okay. CNA-G removed her PPE, cleansed her hands and left R1's room. CNA-J emptied the wash basin and shut off the overhead light. CNA-J placed soiled items in a blue bag, told R1 she would see him for lunch, removed her PPE, cleansed her hands, and left R1's room with the soiled linen. Surveyor noted neither CNA-J or CNA-G applied any skin protectant cream on R1's buttocks around the foam dressings. On 10/28/25, at 1:56 p.m., Surveyor met with RN/IUM-M regarding R1's pressure injuries. RN/IUM-M informed R1 had the pressure injuries when she started in August. RN/IUM-M informed Surveyor they start to heal, R1 goes to the hospital and gets worse at the hospital. R1's wife thinks it's the other way around. Surveyor inquired about the pressure injury assessments after R1 returned to the facility on [DATE]. RN/IUM-M explained with the most recent admission on [DATE] R1 returned at 9:50 p.m. which was a Friday. R1's wife was in the room and didn't want them to turn R1 for the back side. RN/IUM-M informed Surveyor they assessed the toes and R1's groin was red. RN/IUM-M informed Surveyor they were suppose to follow up but they didn't do in on the weekend. Surveyor inquired when R1's pressure injuries were assessed. RN/IUM-M informed Surveyor on 10/7/25. Surveyor asked RN/IUM-M if staff should be applying a skin protectant on R1's buttocks. RN/IUM-M replied yes and there is an order. Surveyor asked what the order is. RN/IUM-M informed Surveyor they should put on A & D ointment. Surveyor informed RN/IUM-M during morning cares staff did not apply A & D or any other skin protectant on R1's buttocks. On 10/29/25, at 7:48 a.m., Surveyor asked LPN-E after Surveyor observed her yesterday with the treatment for R1's toes did she go back to R1 and do any other treatments. LPN-E replied no. Surveyor informed LPN-E Surveyor did not observe her complete the treatment for R1's right lateral foot. LPN-E informed Surveyor she didn't think there was anything there. LPN-E then looked in the computer. Surveyor asked LPN-E what the treatment for R1's right lateral foot. LPN-E replied to betadine. Surveyor asked if she did this treatment yesterday. LPN-E replied no. On 10/29/25, at 9:54 a.m., Surveyor asked RN/IUM-M what a skin assessment consists of. RN/IUM-M informed Surveyor it's a head-to-toe assessment. Surveyor asked what a pressure injury assessment consists of. RN/IUM-M informed Surveyor if a resident doesn't have any wounds then they indicate skin intact. If the skin is not intact, they go in there and document under the skin condition. RN/IUM-M inform Surveyor the skin condition is for each wound and has type of injury, size, if there is any drainage, if surrounding skin is intact or red. Surveyor asked if they describe the wound bed. RN/IUM-M replied yes. Surveyor asked what the wound bed assessment consists of. RN/IUM-M explained a general description like if the wound bed is red. Surveyor asked if there are percentages for the type of wound bed. RN/IUM-M informed the nurses do not necessarily do that. Surveyor asked RN/IUM-M if she does. RN/IUM-M replied I do it sometimes. Surveyor asked RN/IUM-M if a pressure injury had granulation tissue what stage would the pressure injury be. RN/IUM-M replied it depends, I would say healing stage 2 or 3. Surveyor informed RN/IUM-M a stage 2 pressure injury does not have granulation tissue. Surveyor informed RN/IUM-M on 10/28/25 Surveyor observed the treatment with LPN-E for R1's pressure injury on R1's feet as the night nurse had completed the treatment for R1's buttock. Surveyor informed RN/IUM-M LPN-E completed the treatment for R1's toes but did not do the treatment for R1's right lateral foot. No additional information was provided. 2.) R3 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart) Block, Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Iron Deficiency Anemia(blood does not have enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R3 was discharged to the hospital on 8/18/25 and returned from the hospital on 9/11/25 with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. The MDS documents: R3 is not demonstrating mood or behavior symptoms; R3 has range of motion impairment on one side of lower extremity; R3 requires supervision for eating; R3 is dependent for upper and lower dressing and for transfers; R3 requires substantial/maximum assistance for mobility; R3 is always incontinent of bowel and bladder; R3 is at risk for developing pressure ulcer/injuries and that R3 is mobile via wheelchair. R3's Pressure Ulcer/Injury Care Area Assessment(CAA) completed 9/16/25 documents R3 is at risk for pressure ulcers, and injury due to decreased mobility, wheelchair bound, incontinence and age-related factors. Pressure reducing devices in place, skin monitored with care and bathing. R3's Braden Skin Assessment completed 9/18/25 documents a score of 14. Sensory-no impairment Moisture-very moist Activity-chairfast Mobility-very limited Nutrition-adequate Friction and Shear-problem A score of 12 or less indicates a resident is high risk for developing a pressure injury. R3's Certified Nursing Assistant(CNA) worksheet dated 10/27/25 documents: -Turn and reposition after ALL CARES and during rounds. -Offload both heels while R3 is in bed. -Utilize heel suspension boots offloading device to ensure heels are elevated and free from pressure. Check placement. -Inspect skin integrity-heels and beneath left leg brace daily-day shift -Use lift sheet with 2 staff to reduce friction and sheer. -Use pressure reducing cushion in wheelchair. R3's comprehensive care plan documents R3 is at risk for pressure ulcers and other skin related to re-admission post left leg fracture, prolonged hospitalization, immobility, friction, leg brace, and need for total assist with incontinence and activities of daily living(ADLS). On 10/27/25, at 1:55 PM, Surveyor observed R3 in bed. R3's boots are on the floor next to R3's bed. R3's heels are not floated while in bed. On 10/27/25, at 3:59 PM, Surveyor again observed R3 in bed. R3's boots are on the floor next to R3's bed. R3's heels are not floated while in bed. On 10/28/25, at 8:00 AM, Surveyor observed R3 in bed. R3's boots remain on the floor next to R3's bed in the same location as the day before. R3's heels are not floated while in bed. On 10/28/25, at 9:45 AM, CNA-F and CNA-G verified that R3's heels are not floated. On 10/28/25, at 10:05 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-E in regard to R3. LPN-E verified R3 should be wearing heel boots while in bed. LPN-E stated that if R3 is refusing to wear the heel boots, the CNAs should be informing the nurse so the nurse can document the refusal. On 10/29/25, at 7:25 AM, Surveyor observed R3 in bed and R3's heel boots are not on or floated. Surveyor reviewed R3's Treatment Administration Record(TAR) for October. Offload both heels while resident is in bed, every shift with a start date of 9/15/25. Surveyor notes that nursing staff have been documenting R3's heels boots have been on 10/27, 10/28, and 10/29/25 on all 3 shifts even though Surveyor has had observations of R3's heels not floated and no heel boots are on. On 10/28/25, at 3:01 PM, Surveyor with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R3 is at risk for developing pressure ulcers and other skin conditions and Surveyor has observed R3 during the survey process not wearing R3's bilateral heel boots and R3's CNA worksheet instructs CNAs to place them on R3 when R3 is in bed. No additional information as to why R3 was not wearing R3's bilateral heel boots when in bed during the survey process.

Based on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (R1) of 6 Residents. R1's has a right upper extremity PICC (peripherally inserted central catheter). Upon R1's readmission to the facility on [DATE], the PICC line dressing order was incorrectly entered, and facility staff were only changing the transparent portion of the dressing weekly and not the entire dressing per current standards of care. Findings include:The facility's policy last revised 12/2017 and titled, Procedure: Midline Dressing Changes documents: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened, or soiled catheter-site dressings. Under General Guidelines section it documents: A. Change midline catheter dressings 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.R1's diagnoses include multiple sclerosis, (disease in which the immune system eats away the protective covering of nerves resulting in disruption in communication between the brain & body) and spastic paraplegia (group of inherited neurological disorders characterized by progressive weakness, stiffness, and spasms in the legs).R1 was readmitted to the facility on [DATE].R1's physician orders dated 10/3/25 documents: Change PICC line transparent dressing weekly [physician name] change intravenous every week for PICC line and dated 10/3/25 Change PICC line transparent dressing PRN (as needed) [physician name] change intravenous every week for PICC line.On 10/28/25, from 8:30 a.m. to 9:16 a.m. Surveyor observed R1's morning cares and treatment with CNA (Certified Nursing Assistant)-J, Licensed Practical Nurse (LPN)-E and CNA-G. During this observation, Surveyor observed R1 has a right upper extremity PICC line which has a gauze dressing, covered with transparent dressing and has a date of 9/29/25.On 10/28/25, at 10:22 a.m., Surveyor spoke to Licensed Practical Nurse (LPN)-E regarding R1's PICC line. Surveyor asked who changes R1's PICC line dressing. LPN-E informed Surveyor the RN does it weekly or sometimes they let us. LPN-E explained they keep R1's PICC line in because he gets a lot of infections. LPN-E informed Surveyor after Surveyor was asking about the PICC line she changed the transparent dressing.On 10/29/25, at 7:41 a.m., Surveyor asked LPN-E about R1's PICC line dressing. LPN-E informed Surveyor she said it's just the transparent cover not the entire dressing being changed. LPN-E informed Surveyor since the order was for transparent cover the pharmacy was only sending the transparent cover. LPN-E informed Surveyor after speaking with DON-B, LPN-E put an actual order in to change the complete IV dressing. LPN-E informed Surveyor the order should have been put in different as it should have been entire dressing not just the transparent part being changed. Surveyor asked LPN-E when R1 was readmitted on [DATE], did LPN-E put the order in for R1's PICC line dressing. LPN-E explained to Surveyor they do the assessments, and the supervisors put the orders in. LPN-E informed Surveyor she gives the AVS (after visit summary) to them and the supervisors put the orders in, she just does the assessments. LPN-E informed Surveyor all their orders go in by the higher ups. LPN-E stated what she was told by DON-B it should have been the entire dressing not just the transparent. Surveyor asked LPN-E if she remembers who entered R1's orders. LPN-E replied [first name of Registered Nurse/Interim Unit Manager (RN/IUM)-M.R1's physician order dated 10/28/25 documents Change RUA (right upper arm) PICC line dressing weekly [Physician name] 1 x (time) every week for PICC line maintenance.On 10/29/25, at 7:54 a.m., Surveyor interviewed RN/IUM-M regarding R1's PICC line dressing order when R1 was readmitted on [DATE]. RN/IUM-M informed Surveyor when R1 was readmitted it was a rough night as R1 came in at 9:50 p.m. Surveyor asked about the PICC line orders she entered. RN/IUM-M explained there is a library of orders, and the library only has change transparent dressing weekly. RN/IUM-M informed Surveyor she thinks they changed the order yesterday. Surveyor asked RN/IUM-M if the order should have been entered to change the entire dressing weekly not just the transparent portion. RN/IUM-M stated I just got it from the library, now you brought it to our attention we fixed it. Thank you.On 10/29/25, at 10:33 a.m., Surveyor asked DON-B if she knew why R1's PICC line dressing was incorrectly entered. DON-B informed Surveyor she thinks the person putting in the order was trying to be helpful, and the correct template wasn't chosen that's way the entire dressing wasn't changed.Surveyor noted R1's entire PICC line dressing was not changed weekly since R1 was admitted on [DATE]. No additional information was provided.

Based on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R1) of 6 residents reviewed for ADL's (Activity of Daily Living).On 10/28/25 R1 was not provided with or offered oral care, shaving, or brushing/combing R1's hair.Findings include:The facility's policy titled, Patient Personal Hygiene: Guidelines for Providing Care (CHG Bathing) last revised 1/11/24 under policy statement documents As a health ministry of the Catholic Church, and in accord with all applicable laws and regulations, it is the policy of Ascension St. [NAME] Indiana to provide guidance for providing personal hygiene to all inpatients. Personal Hygiene (including washing hair) is to be offered to all inpatients at least daily and documented as completed or refused in the patient's medical record. Under mouth care section for A. Adult Oral Care - non-intubated patient documents 1. Examine mouth for abnormalities/area of concern. If noted, notify RN (Registered Nurse). 2. Position patient in an appropriate manner. 3. At least twice per day, provide mouth care using hospital provided toothbrush/toothpaste or patient's own from home. Use oral swabs if oral tissues are tender, inflamed, or bleeding.R1's diagnoses include multiple sclerosis, (disease in which the immune system eats away the protective covering of nerves resulting in disruption in communication between the brain & body) and spastic paraplegia (group of inherited neurological disorders characterized by progressive weakness, stiffness, and spasms in the legs).R1's ADL (activity daily living) care plan with a goal date of 12/15/25 includes an approach with a start date 9/11/25 HYGIENE/ORAL CARE: I need total assistance with 1 person staff support. Assist & Enc (encourage) oral care BID (twice daily) and PRN (as needed) - use mouth rinse upon rising and @ (at) HS (hour sleep), Total A (assist) with grooming. Offer SHAVE every other day.R1's significant change MDS (minimum data set) with an assessment reference date of 10/7/25 has a BIMS (brief interview mental status) score of 7 which indicates severe cognitive impairment. R1 is assessed as being dependent for eating, oral hygiene, toileting, and personal hygiene: the ability to maintain personal hygiene including combing hair, shaving, applying makeup, washing/drying face & hands (excludes baths, showers & oral hygiene).R1's Certified Nursing Assistant (CNA) Worksheet for Monday 10/27/25 All Shifts under the Diet/Bathing/Dressing/Hygiene section includes documentation of HYGIENE/ORAL CARE: I need total assistance with 1 person staff support. Assist & Enc. (encourage) oral cares BID (twice daily) and PRN (as needed) - use mouth rinse upon rising and @ (at) HS (hour sleep). Total A (assistance) with Grooming. Offer SHAVE every other day.On 10/27/25, at 1:12 p.m., Surveyor observed R1 in bed on his back with the head of the bed elevated high. Surveyor observed R1 has not been shaved for which appears to be for a few days, R1's hair is disheveled and has the appearance of not being combed or brushed.On 10/27/25, at 1:15 p.m., Surveyor observed CNA-J enter R1's room with a covered plate. CNA-J removed the covering and started to feed R1 the sandwich which was cut into four pieces.On 10/27/25, at 3:30 p.m., Surveyor observed R1 in bed towards his left side. Surveyor observed R1 has not been shaved, and his hair is still not been combed or brushed.On 10/28/25, at 7:13 a.m., Surveyor observed R1 in bed on towards his left side. Surveyor observed R1 has not been shaved, and his hair is disheveled.On 10/28/25, at 7:52 a.m., Surveyor spoke with CNA-J to inquire when she would be doing morning cares for R1. CNA-J informed Surveyor she is going to feed R1 first.On 10/28/25, at 8:30 a.m., Surveyor observed CNA-J place PPE (personal protective equipment) on. Surveyor asked CNA-J other than feeding R1 has she done any other cares for R1 this morning. CNA-J replied no just check catheter. At 8:33 a.m. Licensed Practical Nurse (LPN)-E entered R1's room wearing PPE. CNA-J lowered the head of R1's bed and placed a wash basin on R1's over bed table. CNA-J removed the pillow from under R1's head & removed R1's pressure relieving boots, and LPN-E removed a wedge from under R1's left shoulder. LPN-E held onto R1's urinary collection bag while CNA-J drained the urine into a graduate. LPN-E & CNA-J removed their gloves and performed hand hygiene after emptying the collection bag. At 8:41 a.m. CNA-G entered R1's room wearing PPE. R1's bed was lowered and moved away from the bed for CNA-G to be on the right side of R1's bed. At 8:44 a.m. LPN-E removed her PPE, cleansed her hands, and left R1's room. CNA-J washed around R1's suprapubic site, frontal area, tubing of catheter, and R1's inner thighs. The sheet and soaker pad were rolled under R1. CNA-J removed R1's T-shirt and washed R1's upper body. At 8:53 a.m. LPN-E returned to R1's room. CNA-J and CNA-G placed a new T shirt on R1. LPN-E cleansed around R1's suprapubic site and completed the pressure injury treatment to R1's toes according to physician orders, removed her PPE, cleansed her hands and left R1's roomCNA-J & CNA-G rolled R1 onto his right side. CNA-J washed and dried R1's buttocks. A incontinence product & soaker pad was placed under R1, R1 was positioned to the other side to straighten out the incontinence product & soaker pad and remove the soiled linen. R1 was positioned on his back and the incontinence product was fastened. A pillow was placed under R1's head, R1's bed was lowered & move against the wall on the right side. CNA-G washed R1's face while CNA-J covered R1 with a blanket. CNA-J placed the pressure relieving boots back on R1 and asked R1 if he was okay. CNA-G removed her PPE, cleansed her hands and left R1's room. CNA-J emptied the wash basin and shut off the overhead light. CNA-J placed soiled items in a blue bag, told R1 she would see him for lunch, removed her PPE, cleansed her hands, and left R1's room with the soiled linen.Surveyor noted during this observation CNA-J did not perform or offer any oral care, to shave R1 or brush/comb R1's hair.On 10/28/25, at 10:48 a.m. Surveyor observed R1 in bed on his back. R1 has not been shaved, and his hair is still not been brushed or combed. Survey asked R1 if the CNA used mouthwash or toothbrush for oral cares this morning before breakfast. R1 replied no.On 10/28/25, at 1:19 p.m., Surveyor asked CNA-J when she does oral care for R1. CNA-J informed Surveyor probably every other day and explained R1 can't open his mouth wide. CNA-J informed Surveyor she doesn't think a toothbrush would be able to go in R1's mouth. Surveyor asked CNA-J if the facility has toothette oral swabs if she can't use a toothbrush. CNA-J informed Surveyor she doesn't know if they have these. Surveyor asked if she shaves R1. CNA-J informed Surveyor when R1's wife comes in she shaves him. Surveyor asked CNA-J about combing or brushing R1's hair. CNA-J informed Surveyor R1's wife brings in shampoo, thinks selsun blue. R1's wife brushes his hair after she washes it. Surveyor asked CNA-J if she brushes or combs R1's hair. CNA-J replied no.On 10/28/25, at 2:14 p.m., Surveyor asked Registered Nurse/Interim Unit Manager (RN/IUM)-M if staff shave residents. RN/IUM-M replied yes. Surveyor asked if they brush or comb residents' hair. RN/IUM-M replied yes. Surveyor asked if staff does oral care. RN/IUM-M replied yes. Surveyor informed RN/IUM-M R1 is dependent on staff for his ADL's and during morning care observations CNA-J did not offer or do oral care, shave or brush/comb R1's hair.No additional information was provided.

Based on record review and interviews, the facility did not ensure 1(R3) of 1 allegations of neglect were thoroughly investigated and submitted to the State Survey Agency.*On 8/27/25, Surveyor reviewed the grievance dated 8/27/25 which documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended.The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Survey Agency. The facility did not submit a Misconduct Incident Report to the State Survey Agency.Findings include:The facility's Abuse Prevention policy and procedure last revised 8/2025 documents:IdentificationA. The community will assist associates in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This would include identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. B. Associates or persons affiliated with the community who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report suspected abuse or incidents of abuse to the Nursing Home Administrator or designee.D. If there is concern related to possible abuse and/or neglect of the resident, a nurse will assess the individual and document findings.InvestigationA. The community will investigate and report any allegations of abuse within timeframes as required by federal, state, and local requirements.Reporting/ResponseA. The community will immediately, but not later than 2 hours after the allegation is made, if the event or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, to the Administrator and/or designee, State report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, to the Administrator and/or designee, State Agency, adult protective services and to all other required agencies within specified time frames.D. Implement interventions as a result of the investigation.The facility's Abuse Investigation and Reporting last revised 11/23 documents:Policy StatementAll reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown source(abuse) shall be promptly reported to local, state, and federal agencies(as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the facility Abuse Prevention policy.Policy Interpretation and ImplementationRole of the Administrator or designee:A. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator or designee will assign the investigation to an appropriate individual.B. The Administrator or designee will provide any supporting documents relative to the alleged incident to the person in charge of the investigation.E. The Administrator or designee will monitor that any further potential abuse, neglect exploitation or mistreatment is prevented while the investigation is in progress.Role of the Investigator:A. The individual conducting the investigation will, at a minimum:1.Review the completed documentation forms3.Review the person(s) reporting the incident4.Interview any witnesses to the incident5.Interview the resident7.Interview associates members(on all shifts) who have had contact with the resident during the period of the alleged incident.9.Interview other residents to whom the accused employee provides care or services.10.Review events leading up to the alleged incident.Reporting.A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies:1.The State licensing/certification agency responsible for surveying/licensing the communityB. Alleged violations involving abuse, neglect, exploitation or mistreatment(including injuries of unknown source and misappropriation of resident property) will be reported:1.Abuse or Serious Bodily Harm-Immediately but not later than 2 hours. If the alleged violation involves abuse or results in serious bodily injury.2. No Serious Bodily Injury-As soon as practical, but not later than 24 hours. If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury.E. The administrator or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five(5) working days of the occurrence of the incident. R3 was first admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart) Block, Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Iron Deficiency Anemia(blood does not have enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life).R3 was discharged to the hospital on 8/18/25 and returned from the hospital on 9/11/25 with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. R3 is not demonstrating mood or behavior symptoms.On 10/27/25, at 10:27 AM, Surveyor interviewed R3. Surveyor determined R3 is currently alert and oriented times three.On 10/27/25, at 12:16 PM, Surveyor reviewed the facility grievance log. R3 has two listed grievances for 8/8/25, and 9/8/25. Surveyor requested and received the written grievances for those dates from the facility.The grievance dated 8/8/25 documents:R3 states, I was extremely late to lunch today because Certified Nursing Assistant (CNA)-F and his phone got me up. R3 stated cares were put on pause so CNA-F could discuss care issues on the phone.Surveyor reviewed the grievance which documents that Certified Nursing Assistant (CNA)-F received a documented counseling session dated 8/27/25.The area of concern documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended.-3rd resident reported she was extremely late to lunch because CNA-F on CNA-F's phone instead of getting R3 cleaned up to go to breakfast.On 10/28/25, at 11:01 AM, Surveyor interviewed Social Worker (SW)-I. SW-I stated SW-I is not involved in the grievance process other than to just enter grievances on a grievance spreadsheet. SW-I is not involved in the investigation process of any allegations of neglect or abuse.On 10/28/25, at 11:10 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A. NHA-A confirmed there is no formal grievance process currently in the facility. Surveyor shared with NHA-A the concern that there are multiple residents including R3 that shared concerns of neglect that were not reported to the State Survey Agency and were not thoroughly investigated by the facility. NHA-A informed Surveyor that NHA-A would look for additional information in regard to the allegations of neglect. NHA-A understands the concern that residents' allegations of neglect were not thoroughly investigated and reported to the State Survey Agency.On 10/28/25, at 3:01 PM, Surveyor shared the concern to NHA-A and Director of Nursing (DON-B) that R3's and other residents' allegations of neglect were not thoroughly investigated, and the investigation findings was not submitted to the State Survey Agency.No additional information was provided as to why the facility did not thoroughly investigate and submit the findings of the allegations of neglect to the State Survey Agency.

Based on record review and interviews, the facility did not ensure 1 (R3) of 1 allegations of neglect were immediately reported to the Administrator and/or Grievance Officer and submitted to the State Survey Agency. *On 8/27/25, Surveyor reviewed the grievance dated 8/27/25 which documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended.The facility did not submit an Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report to the State Survey Agency.The facility did not submit a Misconduct Incident Report to the State Survey Agency.Findings include:The facility's Abuse Prevention policy and procedure last revised 8/2025 documents:IdentificationA. The community will assist associates in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property. This would include identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. B. Associates or persons affiliated with the community who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report suspected abuse or incidents of abuse to the Nursing Home Administrator or designee.Reporting/ResponseA. The community will immediately, but not later than 2 hours after the allegation is made, if the event or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, to the Administrator and/or designee, State report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, to the Administrator and/or designee, State Agency, adult protective services and to all other required agencies within specified time frames.D. Implement interventions as a result of the investigation.The facility's Abuse Investigation and Reporting last revised 11/23 documents:Policy StatementAll reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown source(abuse) shall be promptly reported to local, state, and federal agencies(as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the facility Abuse Prevention policy.Policy Interpretation and ImplementationRole of the Administrator or designee:A. If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator or designee will assign the investigation to an appropriate individual.Reporting.A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies:1.The State licensing/certification agency responsible for surveying/licensing the communityB. Alleged violations involving abuse, neglect, exploitation or mistreatment(including injuries of unknown source and misappropriation of resident property) will be reported:1.Abuse or Serious Bodily Harm-Immediately but not later than 2 hours. If the alleged violation involves abuse or results in serious bodily injury.2. No Serious Bodily Injury-As soon as practical, but not later than 24 hours. If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury.E. The administrator or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five(5) working days of the occurrence of the incident. R3 was first admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart) Block, Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Iron Deficiency Anemia(blood does not have enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life).R3 was discharged to the hospital on 8/18/25 and returned from the hospital on 9/11/25 with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. R3 is not demonstrating mood or behavior symptoms.On 10/27/25, at 10:27 AM, Surveyor interviewed R3. Surveyor determined R3 is currently alert and oriented times three.On 10/27/25, at 12:16 PM, Surveyor reviewed the facility grievance log. R3 has two listed grievances for 8/8/25, and 9/8/25. Surveyor requested and received the written grievances for those dates from the facility.8/8/25-The grievance documents:R3 states, I was extremely late to lunch today because Certified Nursing Assistant (CNA)-F and his phone got me up. R3 stated cares were put on pause so CNA-F could discuss care issues on the phone.Surveyor reviewed the grievance dated 8/27/25 which documents:-Showers have not been completed, with CNA-F documenting multiple refusals while other staff are able to accomplish the task.-One resident reported needing assistance in cleaning up food that had spilled from her bedside table; she stated that CNA-F refused to help her with the cleanup.-Another resident expressed wanting to get up and be ready for therapy, but CNA-F reportedly came, turned off light and left the room, leaving her unattended.-3rd resident reported she was extremely late to lunch because CNA-F on CNA-F's phone instead of getting R3 cleaned up to go to breakfast.On 10/28/25, at 11:01 AM, Surveyor interviewed Social Worker (SW)-I. SW-I stated SW-I is not involved in the grievance process other than to just enter grievances on a grievance spreadsheet. SW-I is not involved in the investigation process of any allegations of neglect or abuse.On 10/28/25, at 11:10 AM, Surveyor spoke with Nursing Home Administrator (NHA)-A. NHA-A confirmed there is no formal grievance process currently in the facility. Surveyor shared with NHA-A the concern that there are multiple residents including R3 that shared concerns of neglect that were not reported to the State Survey Agency and were not thoroughly investigated by the facility. NHA-A informed Surveyor that NHA-A would look for additional information in regard to the allegations of neglect. NHA-A understands the concern that residents' allegations of neglect were not reported to the State Survey Agency.On 10/28/25, at 3:01 PM, Surveyor shared the concern to NHA-A and Director of Nursing (DON-B) that R3's and other residents' allegations of neglect were not reported to the State Survey Agency.No additional information was provided as to why the facility did not report the allegations of neglect to the State Survey Agency.

Based on interview and record review, the facility did not ensure that all written grievance decisions included the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued for 2 of 2 (R2 and R3) residents reviewed for grievances. R2 and R3's grievances were not thoroughly investigated; no corrective action was taken, and a written decision was not issued. Findings include: 1.) R2 admitted to the facility on [DATE] and had diagnoses that include hypertension, congestive heart failure, atrial fibrillation, depression, chronic obstructive pulmonary disease, renal failure, chronic pain, urinary tract infection and sepsis. R2 discharged from the facility on 10/11/25. The facility policy titled Complaints and Grievances last approved 06/2025 documents (in part) . . It is the policy of Ascension Living to provide residents and family members/legal representatives the opportunity to voice complaints and grievances free from restraint, interference, coercion, discrimination or reprisal. Such complaints or grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, as well as any other concerns regarding the resident's stay or services provided. Complaints and grievances will be documented and managed in accordance to this policy and where available, recorded in the grievance reporting system. Complaint – Any simple service issue or concern received from residents or family members that are easily resolved by associates to the resident/family satisfaction. Grievance – Any moderately complex complaint or service issue received verbally or in writing from residents or resident representative regarding treatment or services provided that require management intervention and a written resolution letter. All written complaints received by residents or resident representatives through any means will be considered a grievance. Prompt Efforts to Resolve – Include facility acknowledgement of a complaint/grievance and actively working toward resolution of that complaint/grievance. Each community must designate a Grievance Official to oversee and ensure responses to complaints and grievances in accordance to policy. 1. The Grievance Official or designee, will be responsible for the complaint and grievance process through their conclusion to include: a. Review and provide an acknowledgement of receipt of grievances to complainant. b. Coordinating the investigation by the community to include but not limited to: i. Reviewing reports for any reportable issues ii. Interviewing complainant, staff and/or witnesses. iii. Reviewing the medical record (if applicable) iv. Coordinating with other departments when needed. d. Acknowledging the grievance as soon as possible, but at least within 5 working days from receipt e. Issuing a final written grievance decision to the resident and/or family members within a reasonable time frame but not to exceed 30 days. Surveyor reviewed the grievance log provided by the facility, noting a grievance for R2 dated 10/5/25. Surveyor asked for the grievance and was provided a form titled Compliments, Suggestions and Concerns. Surveyor asked if this was the grievance. Nursing Home Administrator (NHA)-A stated Yes and reported it was generated by the chaplain from a negative google review by the family. The grievance form documented: Todays date- 10/5. Date the compliment suggestion or concern is in reference to 10/4 and 10/5. Describe/explain with as much detail as possible: 1. Catheter wasn't emptied on 10/4 so resident overflowed onto the bed requiring full bedding change. CNA (Certified Nursing Assistant) 1st shift Sunday stated that she couldn't do it because you know I am busy. 2. Daughter emptied catheter at 4 PM on Sunday 10/5 because it was full and needed emptying. 3. Resident has not received a shower since arriving on Wednesday, no bed bath either. Would you like to be contacted about this matter? Yes. (R2's daughter provided name and phone number). Resolution of Grievance/Concern. The grievance/concern was not confirmed. Was the grievance/concern resolved – Yes, describe resolution. Include: 1) steps taken to investigate the grievance 2) a summary of pertinent findings or conclusions regarding the resident's concern(s) and 3) any corrective action taken by the facility as a result of the grievance. Handwritten notes by NHA-A document: I called (R2's daughter) at 8:15 AM on 10/15/25. I let her speak to the concerns addressed. I then apologized that her experience with us was less than favorable. She stated her mother would not be returning and wished us the best as we navigate the customer service opportunities at the facility. Identify the method(s) used to notify the resident and/or resident representative of the resolution: Written notification (required) AND Phone conversation or One-to-One discussion. Surveyor noted Phone conversation was the only area marked with an X. On 10/27/25 at 3:00 PM during daily exit meeting with the facility, Surveyor asked for additional information regarding the grievance. NHA reported he found the grievance under the door of the administrators' office on 10/13/25 and he called the daughter on 10/15/25. Surveyor asked what the process is for filing a grievance. NHA reported they should go in the lock box for the Social Worker. Surveyor asked NHA-A if there was any other information included with the grievance provided, such as an investigation. NHA-A stated, It happened before I started, with the other administrator, but let me look, there might be more. Surveyor asked if, when he became aware of the grievance, was an investigation or staff interviews completed. NHA reported he would look for additional information. NHA-A advised Surveyor the morning huddle notes indicate they were aware of the grievance on 10/7/25. Surveyor reviewed the community morning huddle meeting notes dated 10/7/25 which documented: Social Services Grievances: (R2) – nursing care issue. The note dated 10/9/25 documents: Social Services Grievances: 0 new. (R2) – working on. On 10/29/25, NHA-A was advised of the concern a grievance involving care concerns for R2 was filed on 10/5/25. The facility did not investigate the concerns or provide corrective action taken as a result of the grievance, and R2's daughter was not provided written decision of the conclusion of the grievance. No additional information was provided. 2.) R3 was admitted to the facility on [DATE] with diagnoses of Atherosclerotic Heart Disease of the Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart) Block, Paroxysmal Atrial Fibrillation(irregular heartbeats occur intermittently and spontaneously resolve within 7 days), Iron Deficiency Anemia(blood does not have enough healthy red blood cells to carry oxygen throughout body, Hypothyroidism(underactive thyroid), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R3 was discharged to the hospital on 8/18/25 and returned from the hospital on 9/11/25 with a diagnosis of Non-displaced Oblique Fracture of the Distal Shaft of Left Femur. R3's Significant Change Minimum Data Set(MDS) completed 9/16/25 documents R3's Brief Interview for Mental Status(BIMS) score to be 12, indicating R3 is moderately cognitively impaired. On 10/27/25, at 10:27 AM, Surveyor interviewed R3. Surveyor determined R3 was alert and oriented to person, place and time. On 10/27/25, at 12:16 PM, Surveyor reviewed the facility grievance log. R3 has two listed grievances for 8/8/25, and 9/8/25. Surveyor requested and received the written grievances for those dates from the facility. The grievance dated 8/8/25 documents: R3 states, I was extremely late to lunch today because Certified Nursing Assistant (CNA)-F and his phone got me up. R3 stated cares were put on pause so CNA-F could discuss care issues on the phone. The grievance document does not document a thorough investigation, corrective action taken, and required written notification was implemented and completed. There is no documentation that R3 was notified of a resolution. The grievance dated 9/8/25 documents: R3's daughter requested care conference to be scheduled to discuss August transfer that resulted in a fall and injury. Corrective action taken was to hold a care conference on 9/19/25. Daughter requested a care conference to take place every other week. Required written notification was not provided to the daughter. There is no Follow-Up signature and Administrator Review with date on the grievance form. A care conference documented progress note was not available in R3's electronic medical record. Upon request by Surveyor of the care conference on 9/19/25 documentation, the facility provided documentation. Surveyor notes the Social Worker (SW)-I documented the care conference note on 10/28/25 during the survey process. Surveyor notes that a conference has not taken place every other week to include R3, daughter, and the facility interdisciplinary team(IDT). On 9/15/25, R3's daughter submitted a written grievance in regard to an incident where the facility sit to stand battery lost power resulting in R3 suffering a left femur fracture. R3's daughter had concerns with R3's brace not being on, and soiled linens. The grievance document does not document a thorough investigation, corrective action taken, and required written notification was implemented and completed. There is no documentation that R3's daughter was notified of a resolution. :01 On 10/28/25, at 11:01 AM, Surveyor interviewed SW-I in regard to the facility's grievance process. SW-I explained SW-I is contracted and started in August. SW-I stated SW-I started in the middle of September creating a spreadsheet for the grievances and that is all SW-I's responsibility is with the grievance process. SW-I confirmed there has not been a care conference every other week involving R3 and R3's daughter. SW-I confirmed again that SW-I is not part of the grievance process at the facility. On 10/28/25, at 11:10 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A in regard to the grievance process at the facility. NHA-A informed Surveyor there is no grievance process currently at the facility. NHA-A stated SW-I should be in charge of the grievance process but SW-I is not. NHA-A explained that SW-I is contracted. On 10/28/25, at 3:01 PM, Surveyor shared with NHA-A and Director of Nursing (DON)-B there is a concern with the facility's grievance process. Surveyor shared a thorough investigation of the grievances was not completed, corrective action taken was not taken, and required written notification was not implemented and completed involving R3. No further information has been provided by the facility at this time in regard to why R3's three grievances were not thoroughly investigated and a written resolution with corrective action was not provided to R3 and R3's daughter.

Based on observation, interview and record review, the facility did not provide pharmaceutical services that assure proper dispensing of medications, did not ensure drug records are in order, or all controlled drugs are maintained and periodically reconciled.*The facility does not have a process for medications that should be returned to the pharmacy for possible reimbursement or otherwise destroyed; and keeping a log of those medications.*The facility did not ensure that controlled medication logs were accurate and reconciled.This deficient practice has to potential to affect 41 of 41 residents residing at the facility whom have the potential to and or receive pharmaceutical services. Findings:The Facility's policy, titled Discarding and Destroying Medications, dated 01/2024, documents . C. Unless otherwise prohibited under applicable federal or state laws, individual resident medications supplied in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that: 1. No medications covered under the Federal Comprehensive Drug Abuse Prevention and Control Act of 1976 are returned; 2. All such medications are identified as to lot or control number; and 3. The receiving Pharmacist and a Registered Nurse employed by the community sign a separate log that lists the resident's name; the name, strength, prescription number (if applicable) and amount of the medication returned; and the date the medication was returned. F. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: 1. Take the medication out of the original containers. 2. Mix medication, either liquid or solid with an undesirable substance. Undesirable substance includes sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. 3. Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses. 4. Document the disposal on the medication disposition record. 5. Include the signature(s) of at least two witnesses. On 08/19/2025, at 12:00 PM, Surveyor observed the medication room on the second floor. Surveyor noted numerous packages of resident medications in a small bin, filled to the rim on the counter, injectable medication and intravenous medication with resident names, some expired. Surveyor also noted a large garbage size bag, with a zip tie closure, full of medications.On 08/19/2025, at 3:35 PM, Surveyor interviewed DON-B regarding the medication in the medication room. DON-B informed Surveyor that DON-B would look into why there are expired medication sitting in the medication room on the second floor.On 08/19/2025, at 4:12 PM, Surveyor interviewed Pharmacist-H. Pharmacist-H informed Surveyor that Pharmacist-H comes to the facility about once per month and was last at the Facility approximately 1 week ago. Pharmacist-H preforms spot checks of the medication rooms, medication carts, check insulin pens, stock medication and inform the nurse on duty as well as DON-B of any findings. The facility would need to request a nurse if the facility wanted a complete audit of the medication rooms and medication carts. Pharmacist-H indicated that the facility does not return medications to the pharmacy and would need to contact the operations side of pharmacy for those services. Pharmacist-H informed Surveyor that the last spot check report on 08/12/2025 showed expired medications were found and were taken out of circulation.On 08/20/2025, at 8:17 AM, Surveyor observed Narcotic medication count on the third floor with RN-N. Surveyor noted R30's Lorazepam 0.5mg(milligrams) was documented as 22 remaining, but there was only 21 in the medication card. Surveyor noted R30's medication card was not being dispensed in numerical order, and number 9 was circled in pen. RN-N indicated the circled number means missing, that it either fell out into the lock box or something. RN-N indicated RN-N would look into it and inform the nurse manager and get back to Surveyor with additional information.Surveyor noted R27's morphine 20mg/ml (milliliters) is currently documented as 25ml remaining as of 7/31/25. The previous administration was on 7/28/25 with 27.25ml remaining. Surveyor noted R27's order indicates to give 0.5ml by mouth every one hour as needed for pain, which indicates 2.25ml are unaccounted for. RN-N informed Surveyor that on 7/31/25 RN-N documented received on the narcotic count log it is documented that RN-N noted 25 ml remaining and informed the nurse manager that the count was inaccurate. Surveyor noted R10's lorazepam 0.5mg had a circle in pen around number 9. RN-N indicated again circled means missing and reported to the unit manager and/or DON for follow up on 5/6/25. Surveyor noted, on 5/6/25 was documented as wasted but then crossed off.Surveyor noted R18's diazepam 2mg had a circle around number 8.On 08/20/2025, at 9:12 AM, Surveyor interviewed DON-B. DON-B informed Surveyor that DON-B started looking at the narcotic medication counts yesterday and noticed R27's morphine looks like it may have spilled, and DON-B may have me sign off on it but would have to check policy regarding spills. DON-B went through all the liquid morphine and began audits since the previous DON had no documentation that audits were done. On 08/20/2025, at 12:51 PM, Surveyor informed the facility of the concerns regarding medication disposal, inaccurate narcotic count logs and expired medications. DON-B informed Surveyor that DON-B went through the Narcotic medications, noted the inconsistencies, did assessments on residents and spoke to the pharmacy consultant. DON-B explained to Surveyor, the morphine counts are always off, per pharmacy- within 5ml, they do not consider the count to be off.Surveyor asked DON-B how the facility is ensuring accurate dispensing and account for liquid narcotic medications. DON-B indicated that they look for repetitive administering of as needed medications given by a nurse that is not given, patterns in how the medication is given, and the pharmacist will have to do a total audit anyway. DON-B informed Surveyor that reeducation and Inservice of staff on notifying DON-B immediately of any discrepancies and ensuring dispensing medication in correct order to avoid further issues. DON-B stated that as of now, the facility does not have a process for returning medications to pharmacy or documenting the destruction of non-narcotic medications. NHA-A and DON-B aware of concerns.On 08/20/2025, at 8:43 AM, RN-N informed Surveyor that the facility utilizes the drug buster in the dirty utility room and medications are never picked up by pharmacy. RN-N indicated that medications come in and the night shift will destroy and stock medications. RN-N was unsure of any form that is used for medication destruction, but 2 nurses are required for controlled medication destruction.On 08/20/2025, at 8:50 AM, Surveyor interviewed UM-O, who indicated that she has only been at the facility for 3 days. UM-O informed Surveyor that the drug buster is used for destruction of all medications. Non-narcotic medications do not need to record destruction but for narcotic medications, there is a page that is filled out by 2 nurses to witness and destroy the medications in the drug buster. UM-O indicated that pharmacy does not come pick up medications and medications should just be destroyed. Surveyor asked UM-O to come into the medication room with Surveyor. Surveyor noted the Facility's stock Insulin, Novolin 70/30, dated 6/27 with instructions to discard 42 days after opening. UM-O indicated the Insulin should not be used and should be discarded.On 08/20/2025, at 11:08 AM, Surveyor asked DON-B to come to the 2nd floor medication room with Surveyor. Surveyor showed DON-B all the medications laying around the medication room, and asked DON-B about the large garbage sized bag of medications, which now had been ripped open. DON-B informed Surveyor that pharmacy delivered medications and night shift will put them in the medication carts for the next day. DON-B was unsure what was going on with the small bin of medications and the expired intravenous medications. DON-B indicated he was still looking into it and will get back to Surveyor.On 08/21/2025, at 6:05 PM, Surveyor emailed NHA-A to ask for any destruction logs the Facility has. NHA-A responded that the Facility utilizes the drug buster to destroy medications, but there is no recording keeping of that.No additional information was provided as to why the facility did not provide pharmaceutical services that assure proper dispensing of medications, did not ensure drug records are in order, or all controlled drugs are maintained and periodically reconciled.

Based on interview and record review, the facility did not ensure that 1 of 5 Certified Nursing Assistant (CNA) reviewed received registry verification that the individual has met competency evaluation requirements. CNA-L's Wisconsin Nurse Aide Registry certification expired and CNA-L continued working in the facility. This deficient practice has the ability to affect 41 of 41 residents residing at the facility whom have the potential to and or received cares from CNA-L.Findings include:According to the Wisconsin Nurse's Aide Training and Registry, Nurse Aides must be listed on the Wisconsin Nurse Aide Registry in order to be employed in any federally eligible health care setting in Wisconsin. The registry ensures that that the individual has met competency evaluation requirements to work as a CNA. On [DATE], Surveyor reviewed CNA registry information for 5 randomly CNAs. CNA-L was listed on the registry. Surveyor noted that CNA-L's CNA certification expired on [DATE] and was not renewed. CNA-L had worked in the facility a total of 89 days since the expiration of their CNA certification according to documentation provided by the facility.On [DATE] at 11:25 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding CNA-L's expired CNA certification. NHA-A responded that they were unaware that CNA-L's certification had expired. Surveyor informed NHA-A that per facility documentation, CNA-L has worked a total of 89 days without an active CNA certification. No additional information was provided as to why the facility did not ensure that prior to CNA-L working, the facility ensure that it received registry verification that CNA-L had met competency evaluation requirements.

Based on record review and interview, the facility did not timely act upon recommendations based on a pharmacist medication regimen review report for 4 (R6, R5, R8 and R42) of 5 residents reviewed for unnecessary medications. Findings include: The facilities policy titled Pharmacy Services-Role of the Consultant Pharmacist dated 2/25 was reviewed and documented: The Director of Nurses (DON), or designee will ensure the recommendations are followed through on a timely basis, which does not exceed 30 days. Irregularities will be addressed as soon as possible, but not to exceed 24 hours. The attending physician will document in the resident's medical record that the irregularity was received and what action was taken to accommodate it. 1) R6 was admitted to the facility on [DATE] with diagnosis that included Depression and Schizophrenia. R6's Pharmacist's Medication Regimen Recommendations (MRR) documented: * 3/19/25: R6 is currently receiving clozapine, for which the following lab oratory monitoring is recommended: Complete Blood Count (CNC) with Absolute Neutrophil Count (ANC) during the first 6 months of clozapine treatment. If ANC remains above 1,500 monitoring may be downgraded to biweekly the next 6 months. If ANC remains, then monitoring may be downgraded to monthly and should continue indefinitely. Additionally, the following is recommended. Complete Metabolic Panel (CMP) and Thyroid Stimulating Hormone (TSH) at least annually. Blood pressure, pulse and weight checks regularly. Neurological function testing as warranted. The recommendation is not signed by R6's Physician. * 4/16/25, 5/14/25, 6/18/25 and 7/16/25 have the exact same recommendations. 4/16/25, 5/14/25, 6/18/25 were not signed by R6's physician and the 7/16/25 MRR was signed by R6's physician on 7/29/25. On 8/20/25, R6's physician orders were reviewed and indicated R26 had been receiving clozapine (an antipsychotic) since admission to now. The orders for the recommended labs from the MRR were not put into R6's orders until 7/29/25. On 8/20/25 at 10:20 AM, Director of Nursing(DON)-B was interviewed and indicated that R6's MRR's were not addressed until 7/29/25 and when the physician put the orders in. Labs for R6 had been completed sporadically until then but not always weekly as ordered. Vitals and Weights were checked regularly. On 8/20/25 at 1:00 PM, the above findings were shared with Nursing Home Administrator-A and DON-B. Additional information was requested if available. None was provided as to why R6's MRR's were not followed up on for 3/19/25, 4/16/25, 5/14/25, and 6/18/25. 2.) R5 was admitted to the facility on [DATE] and has diagnoses that include hemiplegia following cerebral infraction, major depressive disorder and dementia with behavioral disturbance. R5's Minimal Data Set (MDS) assessment, dated 3/26/25, documents R1 has a Brief Interview for Mental Status (BIMS) of 0, indicating severe cognitive impairment. R5's physician orders to treat dementia and depression include: Donepezil tab 10 mg (milligrams) - 1 tb (tablet) by mouth every PM for dementia ordered 3/22/25 and Venlafaxine 37.5 mg tab by mouth every PM for depression ordered 8/14/25 Surveyor reviewed R5's Medication Regime Review (MRR) completed by a pharmacist for April, May, June, and August of 2025. Surveyor was unable to locate any documentation that an MMR was completed for July 2025 for R5. The MMR recommendation forms for April, May, June, and August of 2025, documented the recommendations from pharmacy. These MMR recommendation forms did not have the facility physician signature, date of signature or response whether or not the physician agrees, disagrees or other. Surveyor reviewed R5' electronic health record (EHR) and could not locate any documentation that showed R5's MRR recommendations were followed. On 4/17/25, R5's MMR recommendation was a [NAME] discontinuation of divalproex. At this time, divalproex was not discontinued and there is no contraindication from the physician explaining why the physician did not order a trial discontinuation. On 5/15/25, R5's MRR recommendation was changing venlafaxine to immediate Release 37.5 BID if crushing is required. At this time, there was no change and there is no contraindication from the physician explaining why the physician did not make the change. The second MRR recommendation was to discontinue bisacodyl, consider vit (vitamin) c and vit B1 supplement remains necessary. The physician discontinued the bisacodyl, vitamin c and vitamin B1, but this was not documented on R5's MRR form. On 6/19/25, R5's MRR recommendation was changing venlafaxine to immediate Release 37.5 BID if crushing is required. At this time, there was no change and there is no contraindication from the physician explaining why the physician did not make the change. The second MRR recommendation was to discontinue divalproex order per psych recommendation. Divalproex sprinkle cap 125 mg by mouth every day for mood behavior was discontinued on 6/20/25, but not documented on R5's MRR form. On 8/20/25 at 12:16 PM, NHA-A informed Surveyor that NHA-A cannot locate a completed MRR for R5 for July 2025. On 8/11/25 recommended MRR recommendation was trial reduction of venlafaxine ER to 37.5 QAM.(once every morning). At this time, there was no change and there is no contraindication from the physician explaining why R5's physician did not make the change. 08/20/2025 10:46 AM Director of Nursing (DON)-B stated there is an issue with locating the signed MRR's, as medical records had some staffing changes. DON-B stated the MRR recommendations are being followed but stated if the physician disagrees with MRR recommendations, there is no documentation to be found. On 08/20/2025 at 1:07 PM, Surveyor interviewed DON-B and asked who is responsible for the pharmacy reviews being completed. DON-B stated that DON-B was responsible. DON-B stated, the process is DON-B received the MRR recommendations from the pharmacy and and divides up the recommendations for each physician, the physician signs and dates, and documents whether or not physician agrees or disagrees. the facility inputs orders as indicated. Medical records scans copies but there is an issue with scanning and consistency with staff. Now there is a consistent staff member and she is playing catch up. DON-B stated, the signed MRR's might be located in the future once medical records staff catches up. DON-B stated, in the future DON-B will house all the signed MRR recommendations in a binder so this issue of not being able to locate does not occur again. No additional information was provided. 3.) R8 was admitted to the facility on [DATE] with diagnoses that include vascular dementia, moderate, with psychotic disturbance. R8 Quarterly (Minimum Data Set) MDS assessment completed 7/18/25 documents that R8 uses antipsychotic and antidepressant medication. R8 had a (Medication Record Review) MRR conducted on 2/12/2025 by the facility's contracted pharmacy. The report recommends tapering the Lexapro dose or switch to a different antidepressant. R8 is currently on Lexapro 30 mg daily. This report does not have documentation of being reviewed by R8 physician to agree with the recommendations or disagree. R8 had a MRR conducted on 3/20/2025 by the facility's contracted pharmacy. The report recommends initiating Zyprexa 25mg at bedtime for delusional disorder and taper Lexapro to Vibryd, R8 is currently on Lexapro 20 mg daily. This report does not have documentation of being reviewed by R8 physician to agree with the recommendations or disagree. R8 had a MRR conducted on 4/17/2025 by the facility's contracted pharmacy. The report recommends initiating Zyprexa 25mg at bedtime for delusional disorder and taper Lexapro to Vibryd, R8 is currently on Lexapro 20 mg daily. This report does not have documentation of being reviewed by R8 physician to agree with the recommendations or disagree. R8 had a MRR conducted on 5/15/2025 by the facility's contracted pharmacy. The report recommends initiating Zyprexa 25mg at bedtime for delusional disorder and taper Lexapro to Vibryd, R8 is currently on Lexapro 20 mg daily. This report does not have documentation of being reviewed by R8 physician to agree with the recommendations or disagree. R8 had a MRR conducted on 8/11/2025 by the facility's contracted pharmacy. The report recommends conducting an (Abnormal Involuntary Movement Scale) AIMS/ (Dyskinesia Identification System Condensed User Scale) DISCUS semiannually and 4 weeks after dose changes. R8 is currently on an antipsychotic medication which requires monitoring. This report does not have documentation of being reviewed by R8 physician to agree with the recommendations or disagree. On 8/20/2025, at 10:38 AM, Surveyor interviewed the (Director of Nursing) DON -B and (Nursing Home Administrator) NHA -A regarding the MMR reports. Both stated that they were not able to locate the physician signed reports for R8's pharmacy recommendations. DON-B stated when we get the reports we will fax them to the physician. The physician will fax them back to me then the Nurse Managers will input the orders. DON-B stated that R8 has psychiatry consults monthly that review their psychotropic medications and adjust the dosing. No additional information was provided as to why the facility did not act timely upon recommendations based on R8's pharmacist medication regimen review reports. 4.) R42 was admitted to the facility 3/14/25 with diagnosis of vascular dementia (decline in mental abilities) and Paranoid Schizophrenia (a persistent brain disorder that can impact one's thoughts, emotions and behaviors. R42's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 3/25/25 documents a Brief Interview for Mental Status (BIMS) score of 4, indicating that R42's cognitive abilities are severely impaired. Surveyor reviewed R42's Electronic Health Record (EHR) including physician orders. Surveyor noted R42 receives Seroquel (an antipsychotic medication) 25 mg twice daily for Paranoid Schizophrenia and Citalopram (an antidepressant medication) 40 mg daily for Depression. R42 had a Monthly Medication Record Reviews (MRR) conducted on 3/19/25 and 5/14/25 by the facility's contracted pharmacy. MRR dated 3/19/25 recommends reducing the dosage of R48's Citalopram from 40 mg daily to 20 mg daily. MRR dated 5/14/25 recommends reducing the dosage of R48's Citalopram from 40 mg daily to 20 mg daily. All the MMR reports do not have documentation of being reviewed by R42's physician to agree with the recommendations or disagree regarding R48's Citalopram dosing. Surveyor can not identify any Monthly MRRs recommended for R42 since 5/14/25. On 8/20/2025 at 10:38 AM, Surveyors interviewed Director of Nursing (DON)-B and Nursing Home Administrator (NHA )-A regarding the Monthly MMR reports. They were not able to locate the physician signed reports for R42's pharmacy recommendations on 3/19/25 or 5/14/25. The DON-B stated when we get the reports we will fax them to the physician. The physician will fax them back to me then the Nurse Managers will input the orders .Sometimes the reports do not always come back . Surveyor shared concerns related to R42's physician not addressing the Pharmacy's recommendation to reduce R42's Citalopram medication and the facility's inability to supply Surveyor documentation that R42's Monthly MRRs were conducted for June 2025 and July 2025. The facility did not provide any additional information.

Based on interviews and record review, the facility did not complete neurological (neuro) checks in accordance with policy and procedure for 5 (R27, R5, R42, R8 and R11) of 5 residents reviewed for falls. *R27 had an unwitnessed fall on 08/10/2025, no neurological checks were completed. *R5 had 5 unwitnessed falls, 2 of the falls had incomplete neurological checks and 1 fall had no neuro checks documented. *R42 had had 4 falls, 2 of the falls had incomplete or missing neurological checks. *R8 had 1 unwitnessed fall with incomplete neurological checks. *R11 had 1 unwitnessed fall with no documented neurological checks completed. Findings include: 1.) On 08/18/2025, at 10:08 AM, Surveyor observed R27 with a large bruise to the right side of R27's forehead that extended down under R27's right eye. Surveyor Reviewed R27's Electronic Health Record (EHR) and noted a progress note dated 08/10/2025, indicating R27 had an unwitnessed fall on 08/10/2025 and a neurological assessment was completed. Surveyor requested R27's fall investigation for 08/10/2025 from the Facility. Surveyor reviewed the Facility provided document titled, Root Cause Analysis (RCA) Report for R27's. The RCA report documented R27 had an unwitnessed fall on 08/10/2025 at 5:15 PM, post incident monitoring documents R27 was monitored per post-fall protocol, including neurological checks. Surveyor noted R27's Neurological Checks were not included in the RCA report. Surveyor requested R27's neuro checks from the facility, along with the facility's policy for Neurological checks. On 08/18/2025, at 2:20 PM, Surveyor was informed by Quality Director-C that the Facility does not have an official policy regarding neurological checks. Quality Director-C indicated that if a resident has an unwitnessed fall or has a witnessed fall and hit their head, neurological checks are expected to be completed. On 08/20/2025, at 12:51 PM, Surveyor informed the facility of the concern regarding R27 not having neurological checks completed after an unwitnessed fall on 8/10/25. No additional information was provided, 2.) R5 was admitted to the facility on [DATE] and has a diagnoses that include hemiplegia following cerebral infraction, major depressive disorder, dementia with behavioral disturbance. R5's Minimal Data Set (MDS) assessment, dated 3/26/25, documents R1 has a Brief Interview for Mental Status (BIMS) of 0, indicating severe cognitive impairment. Per R5's electronic medical record, R5 had 3 unwitnessed falls where either there was incomplete or no neurological checks completed. R5 had an unwitnessed fall on 5/29/25 with incomplete neurological checks. R5 had an unwitnessed fall on 6/6/25 with incomplete neurological checks. R5 had an unwitnessed fall on 8/725 with no neurological checks. On 08/19/2025 at 9:01 AM, Surveyor interviewed Director of Quality-C regarding neurological checks post a resident fall. Director of Quality-C stated the process of completing neurological checks occurs when there is an unwitnessed fall (UWF) or witnessed fall when a resident hit head. Surveyor asked how often the neurological checks occur and Director of Quality-C stated he/she could not recite off the top of head but would get a neurological form and let Surveyor know. Director of Quality-C returned and reviewed with Surveyor the Neuro Assessment form that documents that neuro checks need to be completed following an unwitnessed fall or a resident hitting their head, every 15 minutes for 1 hour (4 times), every 30 minutes for 1 hour (2 times), every hour for 2 hours (2 times), every 2 hours for 8 hours (4 times), every 4 hours for 12 hours (3 times) and every shift for 48 hours (4 times). Director of Quality-C stated, if neurological checks are not if fall investigation packet, the facility does not have them. On 08/20/2025 at 1:07 PM, Surveyor interviewed Director of Nursing (DON)-B and asked who is responsible for neurological checks following a resident unwitnessed fall and/or hitting head. DON-B stated, the floor nurses are responsible for this. Surveyor notified NHA-A and DON-B of concerns regarding incomplete or no evidence of R5's neurological checks following unwitnessed falls on 5/29/25, 6/6/25 and 8/7/25. No additional documentation was provided. 3.) R42 was admitted to the facility 3/14/25 with diagnoses of Vascular Dementia (a decline in mental abilities) and Paranoid Schizophrenia (a persistent brain disorder that can impact one's thoughts, emotions and behaviors. R42's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 3/25/25 documents a Brief Interview for Mental Status (BIMS) score of 4, indicating that R42's cognitive abilities are severely impaired. R42 was assessed by the facility to be at risk for falls. Surveyor reviewed R42's Electronic Health Record (EHR). Surveyor noted that R42 sustained a total of three unwitnessed falls on 6/2/25, 7/17/25 and 8/5/25. Surveyor reviewed the facility's fall investigations including root cause analysis and staff statements for R42's unwitnessed falls on 6/2/25, 7/17/25 and 8/5/25. Surveyor noted Neurological Checks were completed for R42's unwitnessed falls that occurred on 6 /2/25 and 8/5/25. Surveyor reviewed a sample of a facility document titled Neuro Assessment flow sheet. Surveyor notes that the flow sheet instructs staff to document Neurological Check Assessments at the following intervals: Every 15 min (minutes) x 4 (Every 15 minutes for 1 hour), Every 30 min x 2 (1 hour), Every 1 hour x 2 (2 hours), Every 2 Hrs (Hours) x 4 (8 hours), Every 4 Hrs x 3 (12 hours), Every shift x 4 (48 hours). Surveyor noted the neurological checks for R42's unwitnessed fall was missing documented entries on 7/20/25 for the following time slots: 0300 and 0700. On 08/18/2025, at 2:20 PM, Surveyor interviewed Quality Director-C. Surveyor was informed by Quality Director-C that the facility does not have an official policy regarding neurological checks. Quality Director-C indicated that if a resident has an unwitnessed fall or has a witnessed fall and hit their head, neurological checks should be expected to be completed in their entirety. On 08/20/2025, at 12:55 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B and informed of them of the above concerns regarding missing neurological check entries related to R42's 7/17/25 unwitnessed fall. No additional information was provided by the facility. 4.) R8 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia (a decline in mental abilities), Anemia (a lack of oxygen rich red blood cells in one's body which may result in tiredness or weakness) and Depression. R8's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 4/19/25 documents a Brief Interview for Mental Status (BIMS) score of 9, indicating that R8's cognitive abilities are moderately impaired. R8 was assessed by the facility to be at risk for falls. Surveyor reviewed R42's Electronic Health Record (EHR). Surveyor noted that R8 sustained an unwitnessed fall on 8/3/25 in their room. Surveyor reviewed the facility's fall investigation including root cause analysis and staff statements for R8's unwitnessed fall on 8/3/25. Surveyor noted neurological checks were not completed for R8's unwitnessed falls that occurring on 8/3/25. Surveyor reviewed a sample of a facility document titled Neuro Assessment flow sheet. Surveyor notes that the flow sheet instructs staff to document Neurological Check Assessments at the following intervals: Every 15 min (minutes) x 4 (Every 15 minutes for 1 hour), Every 30 min x 2 (1 hour), Every 1 hour x 2 (2 hours), Every 2 Hrs (Hours) x 4 (8 hours), Every 4 Hrs x 3 (12 hours), Every shift x 4 (48 hours). Surveyor could not identify a completed Neuro Assessment flow sheet for R8's unwitnessed fall from 8/3/25. On 08/18/2025 at 2:20 PM, Surveyor interviewed Quality Director-C. Surveyor was informed by Quality Director-C that the facility does not have an official policy regarding neurological checks. Quality Director-C indicated that if a resident has an unwitnessed fall or has a witnessed fall and hit their head, neurological checks should be expected to be completed in their entirety. On 08/20/2025, at 12:55PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B and shared concerns related to R8 not having any documented neurological checks completed after R8's unwitnessed fall on 8/3/25. No additional information was provided. 5.) R11 was admitted to the facility on [DATE] with pertinent diagnoses that include Type II Diabetes, Schizoaffective Disorder, unsteadiness on feet and Hypertensive Heart Disorder with Heart Failure. R11's Quarterly Minimum Data Set (MDS) assessment, dated 3/28/2025 indicates that R11 is understood and understands, and that R11 has moderately impaired cognition. Surveyor reviewed R11's Fall Scene Investigation Form (RCA) dated 6/3/2025, which documented a fall that was not witnessed. The RCA packet contained statements from staff that documented that R11 was found in the bathroom, on the floor, and that R11 stated R11 rolled from her bed to the bathroom. Surveyor did not locate neurological checks within the RCA packet. Surveyor reviewed R11's Electronic Health Record (EHR) and could not locate any neurological checks for the fall on 6/3/2025. On 8/19/2025, at 8:59 AM, Surveyor interviewed Director of Quality (DOQ) -C, who indicated that if the neurological checks were not in the fall packet, then the neurological checks were not completed. DOQ-C stated that the neurological checks should be done for 3 days that it is hard for nurses to get these done because it is for 3 days. DOQ-C stated that if there is an unwitnessed fall or a fall with a head injury that neurological checks should be initiated. On 8/20/2025, at 4:33 PM, Surveyor informed NHA-A, of a concern that the fall investigation from 6/3/2025 had missing neurological checks. Surveyor also informed NHA-A, that surveyor interviewed DOQ-C, who indicated that if the neurological checks were not in the RCA fall packet, then they weren't completed. No additional information was provided.

Based on interview and record review the facility did not ensure 5 (R1, R2, R5, R33, and R44) of 5 residents reviewed for hospitalizations received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, and name and address (including mail and email) with the telephone number of the Office of the State Long-Term Care Ombudsman, were notified of the reason for transfer/discharge & bed hold policy in writing to the resident & their representative and the rate to reserve the residents bed, and there was no documentation that the ombudsman was being notified of hospitalizations. *R1 was transferred to the hospital on 3/20/2025, 5/20/2025, and 6/27/2025. A transfer notice and bed hold rate was not provided in writing to R1 and/ or R1's representative. There is not evidence that the ombudsman was notified of R1's hospitalizations. *R2 was transferred to the hospital on 5/12/2025 and 6/2/2025. A transfer notice and bed hold rate was not provided in writing to R2 and/or R2's representative. There is no evidence that the ombudsman was notified of R2's hospitalizations. *R5 was transferred to the hospital on 3/12/2025. A transfer notice and bed hold rate was not provided in writing to R5 and/ or R5's representative. There is no evidence that the ombudsman was notified of R5's hospitalization. *R33 was transferred to the hospital on 3/3/2025 and 5/5/2025. A transfer notice and bed hold rate was not provided in writing to R33 and/ or R33's representative. There is no evidence that the ombudsman was notified of R33's hospitalizations. *R44 was transferred to the hospital on 6/13/2025. A transfer notice and bed hold rate was not provided in writing to R44 and/ or R44's representative. There is no evidence that the ombudsman was notified of R44's hospitalization. Findings include: The facility policy titled Transfer and Discharge Notice last approved 6/2022 documents: Policy Statement- Our community shall provide a resident and/or the resident's representative with a thirty (30) day written notice of an impending transfer or discharge. B. Exceptions to the 30-day requirement apply when the transfer or discharge is effected . in these cases, the notice is provided as soon as practicable and the notice to the ombudsman is sent when practicable: .6. Immediate transfer or discharge is required by the resident's urgent medical needs.C. The community will notify resident and/or resident representative . as soon as practicable . the resident and/or resident representative:1. The reason for the transfer or discharge.2. The effective date of the transfer or discharge.3. The location to which the resident is being transferred or discharged .4. A statement of the resident's rights to appeal the transfer or discharge, including:a. The name, address, email, and telephone number of the entity which receives such requests.b. Information about how to obtain, complete and submit an appeal form.c. How to get assistance in completing the appeal process.5. The community bed hold policy.6. The name, address, e-mail and telephone number of the Office of the State Long-term Care Ombudsman.7. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental disabilities.8. The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities.9. The name, address, email, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.D, A copy of the notice will be sent to the Office of the State Long-Term Care Ombudsman. The facility policy titled Bed-Holds and Returns last approved on 1/2025 documents: Policy Statement: At the time of transfer for hospitalization ., nursing facility must provide to the residents or residents representative written notice which specified the duration for the bed-hold. Policy Interpretation and Implementation: .3. Prior to a transfer, written information will be given to the residents and the resident representatives that explain in detail:a. the duration of the bed-hold.b. The reserve bed payment policy as indicated by the state plan.c. The details of the transfer (per notice of the transfer). 1.) R1 was initially admitted to the facility on [DATE] with a recent readmission to the facility on 7/7/2025 and has diagnoses that include Multiple Sclerosis (disease that affects the central nervous system), quadriplegia (partial/total loss of all four limbs), . and neuromuscular dysfunction of the bladder. R1's quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R1 has a moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 10. Surveyor reviewed R1's medical record and noted R1 was transferred and admitted to the hospital and readmitted to the facility on :- 3/20/2025 – 3/26/2025- 5/20/2025 – 5/25/2025- 6/27/2025 – 7/7/2025 Surveyor reviewed R1's bed hold notices for 3/20/2025, 5/20/2025, and 6/27/2025 and noted that R1's bed hold notifications were not signed or dated by R1's APOA and noted that R1's APOA was made aware via phone call of the bed hold notice on 3/21/2025 (1 day after R1 was admitted to the hospital), 5/21/2025 (1 day after R1 was admitted to the hospital), and 6/30/2025 (3 days after R1 was admitted to the hospital). Surveyor was not able to locate transfer notices in R1's medical records for 3/20/2025, 5/20/2025, or 6/27/2025. On 8/20/25, at 9:01 am, Surveyor interviewed Social Worker (SW)-F, who stated the business office completes the bed hold notice. Surveyor asked who notifies the ombudsman of facility discharges or admission to the hospital. SW-F was not aware who at the facility notifies the ombudsman when a resident transfers to the hospital. On 8/20/25, at 9:03 am, Surveyor interviewed Business Office Manager (BOM)-G, who stated BOM-G is responsible for completing the bed hold notice. BOM-G calls the resident or the resident's representative the day after the resident goes out to the hospital to inform of the bed hold policy. BOM-G stated the private pay rate is verbally provided to the resident or resident representative. Surveyor made BOM-G aware that the pay rate listed on the provided bed hold agreements for R1 documents the pay rate is different from the verbal she provided Surveyor and that the signature on the bed hold agreement document was from an administrator that has not worked at the facility for several years. BOM-G stated that the bed hold notice should have been updated to reflect current information, but since BOM-G does not send it out or give a copy to the resident or representative of a resident, BOM-G has not updated the bed hold agreement. BOM-G stated if a resident has Medicaid insurance, the bed is automatically held for a 15-day period, and BOM-G would only call a resident or resident representative after the 15-day period has passed to confirm if the bed should be held beyond the 15 days. BOM-G stated BOM-G was not responsible for transfer notices and thought the floor nurse may complete those. BOM-G was not aware who at the facility notifies the ombudsman when a resident transfers to the hospital. On 8/20/25, at 10:06 am, Surveyor interviewed Licensed Practical nurse (LPN)-E, who stated the nurse will call the hospital 3 to 4 hours after a resident is sent to the hospital to determine if the resident will get admitted or return to the facility. LPN-E stated a transfer notice or bed hold agreement would only be completed if a resident is being admitted to the hospital. On 8/20/25, at 10:47 am, Surveyor interviewed Registered Nurse unit manager (RNUM)-D who stated the business office usually calls regarding the bed hold policy when a resident is transferred to the hospital. RNUM-D stated the floor nurse on duty should be completing a transfer and discharge notice when a resident goes to the hospital. RNM-D was not sure of this facility's process and was not able to say where a transfer notice or bed hold notice could be located. On 8/20/25, at 10:54 am, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the bed hold and transfer notice process. NHA-A stated as a resident is leaving, the resident or resident representative should be called regarding the bed hold. NHA-A stated if a resident has Medicaid insurance, the resident's bed would be automatically held, but the family or resident should still be notified. NHA-A was not aware of the process for providing a written transfer notice to a resident. NHA-A stated the social worker would be responsible for notifying the ombudsman monthly of any hospitalizations, but the previous social worker is no longer at the facility. NHA-A was unable to provide any evidence of ombudsman notification of R1's hospitalizations on 3/20/2025, 5/20/2025, and 6/27/2025. On 8/20/25, at 1:25 pm, Surveyor shared concerns with NHA-A and Director of Nursing (DON)-B that a transfer notice or bed hold notice with updated bed hold rate was not provided to R1 or R1's APOA when transferred to the hospital on 3/20/2025, 5/20/2025, and 6/27/2025. Surveyor also shared concern that there was no documentation provided that the ombudsman was notified of R1's hospitalizations on 3/20/2025, 5/20/2025, and 6/27/2025. No additional information was provided. 2.) R2 was admitted to the facility on [DATE], with most recent readmission to facility on 7/3/25, with the following diagnoses: hemiplegia following cerebral infarction (stroke) affecting left nondominant side, diabetes mellitus type 2 with diabetic chronic kidney disease, end stage renal disease (kidney failure), dependence on renal dialysis, and depression. R2's admission Minimal Data Set (MDS) assessment completed by the facility on 7/9/25 documents R2 has a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, R2 is dependent for activities of daily living and transfers, and R2 receives dialysis services. R2 is their own person. R2 was transferred and admitted to the hospital on [DATE] and 6/2/25, with readmission to the facility 5/27/25 and 7/3/25, respectively. Surveyor reviewed written copy of bed hold agreement for R2 provided by facility dated 5/12/25 and 6/2/25. Surveyor noted the bed hold agreement does not have R2's signature and does not indicate if R2 agreed or disagreed to hold R2's bed. Surveyor was not provided with a transfer notice for R2's hospitalizations on 5/12/25 or 6/2/25, and Surveyor did not locate the transfer notices in R2's electronic health record (EHR). On 8/20/25, at 9:01 am, Surveyor interviewed Social Worker (SW)-F, who stated the business office completes the bed hold notice. SW-F was not aware who at the facility notifies the ombudsman when a resident transfers to the hospital. On 8/20/25, at 9:03 am, Surveyor interviewed Business Office Manager (BOM)-G, who stated BOM-G is responsible for completing the bed hold notice. BOM-G stated BOM-G calls the resident or the resident's representative the day after the resident goes out to the hospital to inform of the bed hold policy. BOM-G stated the private pay rate is verbally provided to the resident or resident representative. Surveyor made BOM-G aware that the pay rate listed on the provided bed hold agreements for R2 documents is different than what she informed Surveyor, and BOM-G stated BOM-G will need to update that. BOM-G stated a written copy of the bed hold notice is not provided to the resident or the resident representative. BOM-G stated if a resident has Medicaid insurance, the bed is automatically held for a 15-day period, and BOM-G would only call a resident or resident representative after the 15-day period has passed to confirm if the bed should be held beyond the 15 days. BOM-G stated BOM-G was not responsible for transfer notices and thought the floor nurse may complete those. BOM-G was not aware who at the facility notifies the ombudsman when a resident transfers to the hospital. On 8/20/25, at 10:06 am, Surveyor interviewed Licensed Practical Nurse (LPN)-E, who stated the nurse will call the hospital 3 to 4 hours after a resident is sent to the hospital to determine if the resident will get admitted or return to the facility. LPN-E stated a transfer notice or bed hold agreement would only be completed if a resident is being admitted to the hospital. On 8/20/25, at 10:47 am, Surveyor interviewed Registered Nurse Manager (RNM)-D who stated the business office usually calls regarding the bed hold policy when a resident is transferred to the hospital. RNM-D stated the floor nurse on duty should be completing a transfer and discharge notice when a resident goes to the hospital. RNM-D could not locate any completed transfer notices for R2. On 8/20/25, at 10:54 am, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the bed hold and transfer notice process. NHA-A stated as a resident is leaving, the resident or resident representative should be called regarding the bed hold. NHA-A stated if a resident has Medicaid insurance, the resident's bed would be automatically held, but the family or resident should still be notified. NHA-A was not aware of the process for providing a written transfer notice to a resident. NHA-A stated the social worker would be responsible for notifying the ombudsman monthly of any hospitalizations, but the previous social worker is no longer at the facility. NHA-A was unable to provide any evidence of ombudsman notification of R2's hospitalizations on 5/12/25 or 6/2/25. On 8/20/25, at 1:25 pm, NHA-A was made aware of the concern that a transfer notice or bed hold notice with updated bed hold rate was not provided to R2 upon leaving the facility 5/12/25 or 6/2/25, and no evidence was provided that the ombudsman was notified of R2's hospitalizations on 5/12/25 or 6/2/25. NHA-A understood the concern. No additional information was provided. 3.) R5 was admitted to the facility on [DATE] and has a diagnoses that include hemiplegia following cerebral infraction, major depressive disorder, dementia with behavioral disturbance. R5's Minimal Data Set (MDS) assessment, dated 3/26/25, documents R1 has a Brief Interview for Mental Status (BIMS) of 0, indicating severe cognitive impairment. R5's Progress Note dated 3/14/25 at 22:33 (10:33 PM), documents in part: Writer observed right leg and notices swelling to from the hip down to the feet on the right side along with a bruise to the back of leg. Writer and DON (Director of Nursing) observed resident and leg.MD made aware.Resident sent to the hospital. Surveyor could not locate a bed-hold and transfer notice in electronic health record (EHR) for R5's hospitalization on 3/14/25 and Surveyor asked Nursing Home Administrator (NHA)-A if there were paper copies of the bed-hold and transfer notice. NHA-A provided Surveyor with a blank copy of R5's bed-hold agreement and form letter to residents regarding bed-hold. The blank copy of R5's bed-hold agreement documented R's name, when R5 was hospitalized and Family Care (payor). There was no documentation of bed hold preference nor signature of resident or resident representative. There was no documentation resident or resident representative received verbal notice. NHA-A did not provide a copy of R5's transfer notice. On 08/20/2025 at12:03 PM, Surveyor asked NHA-A who is responsible to notify the Ombudsman of transfer/discharge notices. NHA-A stated social workers are responsible for this process and each month they should send the residents name, date and reason for transfer/discharge to the Ombudsman. Surveyor asked for last 6 months of documentation and NHA-A stated the social worker is new and cannot locate any evidence of past transfer/discharge notices to Ombudsman. On 08/20/2025 at 1:15 PM, Surveyor notified NHA-A and Director of Nursing (DON)-B of concern regarding incomplete bed hold and no transfer notice for R5. Surveyor notified NHA-A and DON-B of concern regarding no evidence of facility notifying ombudsman of transfer/discharges. NHA-A and DON-B agreed facility the process needs attention. No additional information was provided. 4.) On 8/20/25, the Surveyor reviewed R33's medical record and it indicated R33 was transferred and admitted to the hospital on [DATE] and 5/5/25. R33's medical record did not include documentation that a transfer notice and bed hold information had been given to the resident and/or their representative for the hospitalization. On 8/20/25 at 10:00 AM Nursing Home Administrator (NHA)-A was interviewed and indicated no transfer notice or bed hold information could be found for R33's hospitalizations on 3/3/25 and 5/5/25. NHA-A indicated she could not find any evidence that R33's hospitalizations on 3/3/25 and 5/5/25 were reported to the ombudsman. On 8/20/25 at 1:00 PM, the above findings were shared with NHA-A and Director of Nursing-B. Additional information was requested if available. None was provided as to why a transfer and bed hold notice were not given to R33 and/or their representative for their hospitalizations, and the ombudsman not notified of R33's readmission to the facility on 3/3/25 and 5/5/25. 4.) R44 was admitted to the facility 5/19/25/25 with diagnoses that include stroke, hypertension (high blood pressure) and heart failure. R44's admission Minimal Data Set (MDS) Assessment with an Assessment Reference date (ARD) of 5/23/25 documents R44 is rarely to never understood due to cognitive impairment On 6/13/25, R44 was discharged to the hospital due to a change of condition. Surveyor reviewed R44's electronic health record (EHR). Surveyor could not locate a bed-hold or transfer notice for R44's hospitalization on 6/13/25. On 8/19/25 at 3:35 PM at the daily exit meeting, Surveyor asked Nursing Home Administrator (NHA)-A if there were paper copies of the bed-hold and transfer notice that were provided to R44's representative. On 8/20/25 at 8:15 AM, NHA-A provided Surveyor with a blank copy of R44's bed-hold agreement and form letter to residents regarding bed-hold. The blank copy of R's bed-hold agreement documented R44's name and when R44 was hospitalized . There was no signature of resident or resident representative on R44's bed-hold agreement. NHA-A was unable to provide a copy of R44's transfer notice. On 08/20/2025 at12:03 PM, Surveyor asked NHA-A who is responsible to notify the Ombudsman of transfer/discharge notices. NHA-A stated social workers are responsible for this process and each month they should send the residents name, date and reason for transfer/discharge to the Ombudsman. Surveyor requested the last six months of Ombudsman notifications. NHA-A responded that the facility's social worker is new and cannot locate any evidence of past resident transfers or discharges notices to the Ombudsman. On 8/20/2025 at 1:15 PM, Surveyor notified NHA-A and Director of Nursing (DON)-B of concerns regarding R44's incomplete bed- hold and lack of transfer notice for R44. Surveyor notified NHA-A and DON-B of concern regarding lack of evidence of facility notifying Ombudsman of resident transfers/discharges. No additional information was provided by the facility at this time.

Based on interview and record review, the facility did not ensure that 4 (R8, R5, R42 and R11) of 6 residents and/or their representative that were reviewed, were provided the risks and benefits for prescribed psychotropic medication. * R8 received an antidepressant and antipsychotic medication with no evidence that the risks and benefits were explained, reviewed or provided. * R5 received an antidepressant medication with no evidence of risks and benefits were explained, reviewed or provided. * R42 received an antidepressant and antipsychotic medication with no evidence of risks and benefits were explained, reviewed or provided. *R11 received an antipsychotic medication with no evidence of risks and benefits were explained, reviewed or provided. The facility's policy and procedure, Psychotropic Medication, dated 6/2025 documents under Section T, Consents for Psychotropic Medications: 1. If a resident is admitted on a psychotropic medication, nursing will obtain appropriate and necessary written consent. 2. A consent will be obtained by nursing prior to a new medication is initiated and each time it is increased. Findings include: 1.) R8 was admitted to the facility on [DATE] with a diagnoses that included vascular dementia, moderate, with psychotic disturbance. R8 has an activated Power Attorney for Health Care since 4/11/2023. R8 Quarterly (Minimum Data Set) MDS assessment completed on 7/18/25 documents the use of antipsychotic and antidepressant medication by R8. R8's Psychiatry Follow-up note dated 2/20/2025 documents that new medications including antipsychotic Abilify 12.5 (milligram) mg daily; antidepressant Zoloft were switched to Lexapro 5 mg daily and Trazadone 50 mg daily. R8 does not have documentation that the consent for risks and benefits of this antidepressant medications and antipsychotic medication were explained, reviewed or provided. R8's Psychiatry Follow-up noted dated 3/20/25 documents an increase to R8's Abilify to 10 mg daily, Trazadone 50 mg daily and Lexapro 20 mg daily. R8 does not have documentation of the consent for risks and benefits of dose changes in the antidepressant and antipsychotic medication were explained, reviewed or provided. On 08/20/2025, at 1:07 PM, Surveyor interviewed the (Director of Nursing) DON -B and asked who is responsible for obtaining medication consents explaining risks and benefits for psychotropic medications. DON-B informed Surveyor that floor nurses should be responsible for obtaining the consents and the floor nurses are not doing this and plans on following up. No additional information was provided as to risks and benefits for the antidepressant and antipsychotic medications that R8 was prescribed. 2.) R5 was admitted to the facility on [DATE] with diagnoses that included hemiplegia following cerebral infraction, major depressive disorder, dementia with behavioral disturbance. R5's Minimal Data Set (MDS) assessment, dated 3/26/25, documents a Brief Interview for Mental Status (BIMS) of 0, indicating that R1 has severe cognitive impairment. R5's Physician Order, dated 8/14/25, documents: Venlafaxine 37.5 mg tab (sic) by mouth every PM for depression. R5's Care Plan dated 3/21/25, documents: Psychotropic Drug Use, R5 has a potential for drug related complications associated with use of related to antidepressant use. R5 will remain free of drug related cognitive/behavioral impairment, gait disturbance, hypotension or movement disorder. Interventions, observe, document, report to MD (Medical Doctor) prn (as needed) s/sx (signs and symptoms) of drug related complications. Interventions include, Observe for target behaviors/symptoms and document per facility protocol date initiates 3/21/25. Observe for increase in depressive/behavior symptoms and document PRN interventions as appropriate. Date initiated 3/21/25. Surveyor was unable to locate any documentation in R5's medical records that R5 or R5's representative provided consent or were provided with the risks and benefits of the antidepressant medication that R5 was prescribed. On 8/20/25 at 12:27 PM, Nursing Home Administrator (NHA)-A informed Surveyor that there is no signed medication consent by R5 or by R5's representative regarding risks and benefits of Venlafaxine (psychotropic medication for depression). 08/20/2025 1:07 PM Surveyor interviewed Director of Nursing (DON)-B and asked who is responsible for obtaining medication consents explaining risks and benefits for psychotropic medications. DON-B informed Surveyor that the floor nurses should be responsible for this. Surveyor asked if DON-B if this occurring and DON-B stated, if he had to bet, the floor nurses are not having consents signed and plans on following up. Surveyor notified NHA-A and DON-B of concerns regarding that R5 or R5's representative provided consent or were provided with the risks and benefits of the antidepressant medication that R5 was prescribed. NHA-A and DON-B acknowledged the concern. No additional information was provided. 3.) R42 was admitted to the facility 3/14/25 with diagnosis of vascular dementia (decline in mental abilities) and Paranoid Schizophrenia (a persistent brain disorder that can impact one's thoughts, emotions and behaviors. R42 has an activated Power Attorney for Health Care. R42's admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 3/25/25 documents a Brief Interview for Mental Status (BIMS) score of 4, indicating that R42's cognitive abilities are severely impaired. R42's physician orders documents: Seroquel (an antipsychotic medication) 25 mg twice daily for Paranoid Schizophrenia and Citalopram (an antidepressant medication) 40 mg daily for Depression. Surveyor was unable to locate any documentation of consent for risks and benefits of both R42's antipsychotic or antidepressant medication in R42's electronic health record. On 08/20/2025 at 1:07 PM, Surveyor interviewed Director of Nursing (DON)-B and asked who is responsible for obtaining medication consents explaining risks and benefits for psychotropic medications. The DON-B responded that the floor nurses should be responsible for obtaining the consents and that floor nurses are not currently obtaining the consents. DON-B added that they plan to follow up on these concerns. No additional information was provided by the facility at this time. 4.) R11 was admitted to the facility on [DATE] with diagnoses that include Type II Diabetes, Schizoaffective Disorder, unsteadiness on feet, and Hypertensive Heart Disorder with Heart Failure. R11's Quarterly Minimum Data Set (MDS) assessment dated [DATE], documents that R11 is understood and understands, and R11 has moderately impaired with cognition. R11's physician orders with a black box warning (The most serious warning the Food and Drug Administration can issue for a medication. The warning is to alert the user of the major risks of taking the medication) documented, with a start date of 12/23/2024: Olanzapine 15 Milligrams (MG) by mouth at Hour of Sleep (HS) for Schizophrenia. The last documented date of R11 receiving the above-mentioned medication is on 8/19/2025. R11's Electronic Health Record (EHR) did not include informed consents for this medication, including the explanation of the risks and benefits of the medication, potential side effects or alternative treatments. On 8/19/2025, at 2:02 PM, Surveyor interviewed Nursing Home Administrator NHA-A, regarding the location of the signed consent form for R11's Medication Olanzapine. NHA-A indicated that R11 doesn't currently see a specialist for psychiatric services. NHA-A stated that R11's primary doctor takes care of her schizophrenia diagnosis. On 8/19/2025, at 2:07 PM, Surveyor was informed by NHA-A that informed consent for R11's medication Olanzapine was not able to be located. On 8/20/2025, at 4:33 PM, Surveyor informed NHA-A, of the concern that R11's consent form, explaining the risks and benefits, for Olanzapine was reviewed, explained or provided to R11 or R11's representative. No additional information was provided.

Based on observation and interview the facility did not ensure resident's right to personal privacy and confidentiality of his or her personal and medical records for 1(R9) of 41 residents reviewed.*On 08/19/2025, at 7:23 AM, R9's personally identifiable information (PII) or Personal Health Information (PHI) was observed to be thrown into the regular garbage during medication pass.Findings:The Facility's policy, titled Health Insurance Portability and Accountability Act (HIPPA) Privacy Program last revised 06/01/2023, documents in part, . [Name] Health Alliance is committed to protecting the privacy rights of our patients and residents ( individuals). In compliance with Health Insurance Portability and Accountability Act of 1996 ( HIPPA), the Health Information Technology for Economic and Clinical Health Act ( HITECH) and applicable federal and state laws and regulations (together, HIPPA Rules), this [Name] Procedure ( Procedure) sets forth the HIPPA Privacy Program policies, procedures, and standards (the Program) for [Name], and describes how [Name] implements, enforces, updates, and documents its compliance with the HIPPA Rules. This [Name] Procedure and supporting standards replaces and supersedes all HIPPA privacy policies within [Name]. 2. Enforcement: a. The Privacy Officer has general responsibility for implementation of the HIPPA Privacy Program. d. Workforce Member Responsibilities i. Accounting for Disclosures of PHI ii. De-Identification of PHI and Limited Data Sets iii. Privacy Training iv. Privacy Investigations and Breach Notification v. Mitigation of HIPPA Related Incidents vi. Sanctions for HIPPA- Privacy Violations vii. Safeguarding PHI . On 08/19/2025, at 7:23 AM, Surveyor observed Licensed Practical Nurse (LPN)-E prepare R9's medications. Surveyor noted the facility utilizes prepackaged medications that contains R9's personally identifiable information, as well as the name of the medication R9 receives, listed on the packaging. Surveyor observed LPN-E discard R9's package into the garbage located on the medication cart. Surveyor noted LPN-E did not attempt to protect R9's PII before discarding in the garbage. Surveyor asked LPN-E if discarding the medication packages, with resident PII, into the regular garbage was standard procedure. LPN-E indicated yes, LPN-E will typically throw the medication packages with resident PII into the medication cart garbage, but that there is also a shredder in the nurses' station, but that would require holding on to all the garbage till the end of med pass.On 08/19/2025, at 3:35 PM, Surveyor interviewed and informed Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A regarding disposal of R9's PII and PHI. DON-B indicated that PII and PHI should be disposed of in the shredder or the resident's name and PII should be marked off with black marker so the PII cannot be read.On 08/20/2025, at 12:51 PM, Surveyor informed NHA-A and DON-B of the concerns regarding R9's PII and PHI was thrown into the regular garbage. NHA-A indicated that education regarding proper disposal of PII and PHI would be conducted.No additional information was provided.

Based on interview and record review, the facility did not ensure that an alleged violation involving misappropriation was thoroughly investigated for 1 of 1 Facility Reported Incidents reviewed.*The facility could not provide documentation that weekly audits of narcotic medication counts were preformed, following a narcotic discrepancy identified on [DATE].Findings:Surveyor reviewed the Facility Reported Incident (FRI) submitted to the State Agency on [DATE] regarding a discrepancy in the appearance of R27's liquid Morphine (a controlled, narcotic medication), indicating the Morphine was lighter in color instead of the usual dark blue hue.The facility indicated the police were notified, the medication was removed from the medication cart, pain assessments were completed for residents, residents were interviewed as well as staff, weekly audits during medication counts for the next six weeks and medication audit found medication were properly stored.On [DATE], Surveyor requested the full investigation for the FRI from the Facility. The Facility provided Surveyor with the Facility's investigation.Surveyor reviewed the Facility provided document titled INVESTIGATION SUMMARY and noted the following documented, Conclusion: Based on the findings of this investigation, there is no substantiated evidence of misuse of the resident's medication. It is plausible that the change in color was due to extended circulation of the bottle and having low volume, especially considering it is PRN medication that is not administered frequently and filled [DATE] and a discard date of [DATE]. We will continue to work with the Milwaukee Police Department to find out if there were any changes in concentration. To enhance monitoring and ensure the integrity of all liquid medications, the facility will implement a weekly audit, overseen by DON or a designee, during medication counts for the next six weeks. This audit will include documentation of the color and consistency of all liquid solution medications. It is also important to note that all medications, including liquid solutions, were found to be properly stored, not expired and no residents were reported to have been adversely affected. On [DATE], at 12:40 PM, Surveyor requested the audits conducted by the Facility. NHA-A indicated she would look for the audits.On [DATE], at 2:07 PM, Surveyor was informed by Nursing Home Administrator (NHA)-A that NHA-A had to reach out to the previous Director of Nursing (DON) and indicated DON-B is working on obtaining the audits. On [DATE], at 11:41 AM, Surveyor spoke with Pharmacist Consultant-H via phone. Pharmacist Consultant-H indicated that generally, liquid morphine has a blue tint, but over time the color is expected to fade, especially if the product has been open for an extended amount of time and not used.On [DATE], at 3:13 PM, NHA-A informed Surveyor that the narcotic medication audits could not be located.On [DATE], at 3:25 PM, Surveyor informed the NHA-A and DON-B of the concern that the narcotic audits were not located and available for review to determine if a thorough investigation into potential misappropriation of resident's medication was completed. No additional information was provided that an alleged violation involving misappropriation was thoroughly investigated.

Based on interview and record review, the facility did not ensure 1 (R24) of 1 resident reviewed for a suprapubic catheter received appropriate treatment and services related to catheter care. * R24 has physician orders in place for catheter care and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed many dates care was not documented as provided. R24 has been treated for urinary tract infections (UTIs) four times in the last six months, in addition to the prophylactic antibiotic R24 has physician orders to receive twice daily to prevent UTIs. Findings include: The facility procedure titled Catheter Care, Urinary last approved 1/2024, states in part: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Complications A. Observe the resident for complications associated with urinary catheters . 2. Check the urine for unusual appearance . 5. Observe for other signs and symptoms of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately . Managing Obstruction . B. Catheter irrigation may be ordered to prevent obstruction in residents at risk for obstruction . Documentation The following information should be recorded in the resident's medical record: A. The date and time that catheter care was given. B. The name and title of the individual(s) giving catheter care . 1.) R24 was originally admitted to the facility on [DATE]. R24's pertinent diagnoses include multiple sclerosis, neuromuscular dysfunction of bladder, paraplegia, and personal history of urinary tract infections. R24's Significant Change Minimum Data Set (MDS), with an assessment reference date of 1/6/25, documents a Brief Interview for Mental Status (BIMS) score of 09, indicating that R24 has moderate cognitive impairment. The MDS documents that R24 was assessed to have no behaviors exhibited during the look back period. R24 is coded to have an indwelling catheter and is always incontinent of bowel. R24 has a health care Power of Attorney. R24's physician order dated 11/8/24 documents, acetic acid irr (irrigation) soln (solution) 0.25% - 60cc FYI (for your information) every day for irrigate suprapubic catheter to maintain patency . Surveyor noted that from 3/1/25 to 3/20/25 this order was not documented as completed on 3/5/25, 3/7/25, 3/9/25, 3/16/25, and 3/18/25. (5 missed treatments) R24's physician order dated 9/8/23 documents, suprapubic catheter . inserted for neurogenic bladder. Check function and patency Q (every) shift. Update MD (medical doctor) for any concerns . Surveyor noted from 3/1/25 to 3/20/25 this order was not documented as completed on 3/5/25, 3/7/25, 3/8/25, 3/9/25, and 3/14/25 for day shift. The order was not documented as completed on 3/4/25, 3/15/25, and 3/16/25 for evening shift, and on 3/3/25 for the night shift. (9 missed treatments) R24's physician order dated 1/29/21 documents, mx (monitor) for atypical s/s (signs/symptoms) of infection specific for resident-making nonsensical statements, confusion, eyes glossy and right eye becomes lazy. Complete VS (vital signs) and assessment, SBAR (situation, background, assessment, recommendation) and update Optum NP (Nurse Practitioner) immediately - every shift for chronic UTI . Surveyor noted from 3/1/25 to 3/20/25 this order was not documented as completed on 3/5/25, 3/7/25, 3/8/25, 3/9/25, and 3/14/25 for day shift. The order was not documented as completed on 3/4/25, 3/11/25, 3/15/25, and 3/16/25 for evening shift, and on 3/3/25 for the night shift. (10 missed treatments) R24's physician order dated 8/24/22 documents, suprapubic cath (catheter) site - NSW (normal saline wash) pat dry, apply thin layer of house stack Zguard cream FB (followed by) drain sponge and secure with tape daily - every day . Surveyor noted from 3/1/25 to 3/20/25 this order was not documented as completed on 3/5/25, 3/7/25, 3/8/25, 3/9/25, and 3/14/25. (5 missed treatments) R24's physician order dated 9/8/24 documents, suprapubic site-wash with soap and water, pat dry FB drain sponge change - topical every shift change every shift for cath dressing change . Surveyor noted from 3/1/25 to 3/20/25 this order was not documented as completed on 3/5/25, 3/7/25, 3/8/25, 3/9/25, 3/12/25, 3/14/25, 3/16/25, and 3/20/25 for day shift. The order was not documented as completed on 3/4/25, 3/9/25, and 3/11/25 for evening shift, and on 3/3/25 for the night shift. (12 missed treatments) R24's physician order dated 4/2/22 documents, hiprex tab (tablet) 1GM tabs (methenamine Hippurate) - 1 gram by mouth twice a day for UTI prophylaxis. Surveyor noted from 3/1/25 to 3/20/25 this order was not documented as administered for the 8:00 AM administration time on 3/5/25, 3/7/25, 3/9/25, 3/12/25, and 3/16/25. (5 missed administrations) For the 4:00 PM administration time his order was not documented as completed on 3/4/25 and was marked as medication refused on 3/16/25. (7 missed administrations) Surveyor noted that multiple times over a twenty day span, the medications and treatments for R24's urinary catheter and catheter care are not documented as completed leaving R24 at risk of infection. Surveyor noted that on 3/20/25, R24 was transferred to the hospital due to acute encephalopathy from a UTI (urinary tract infection). Surveyor noted R24 has been prescribed antibiotics 11/7/24, 12/8/24, 12/30/24 (medication changed on 1/4/25,) and 3/15/25 related to UTIs. R24's physician order dated 11/7/24 with stop date of 11/10/24 documents, Rocephin inj (injection) 1 GM - 1 gram intramuscular every day for prophylactic . R24's physician order dated 12/8/24 with a stop date of 12/15/24 documents, cipro tab (tablet) 500mg by mouth twice a day for proph (prophylactic) uti . R24's physician order dated 12/30/24 with a stop date of 1/4/25 documents, cefepime 1 gram solution for injection - 1 gram intravenous every 12 hours for UTI prophylactic . R24's physician order dated 1/4/25 with a stop date of 2/7/25 documents, cefpodoxime 200 mg tablet - 200 mg by mouth every 12 hours for bacteria in the urine . R24's physician order dated 3/15/25 with a stop date for medication of 3/20/25 documents, Rocephin inj 1 GM - 1 gram intramuscular every day . Surveyor noted that on 3/20/25, R24 was transferred to the hospital due to acute encephalopathy from a UTI. On 1/16/25, R24 was seen by an urologist for symptom of urinary retention with visit description of suprapubic catheter dysfunction, subsequent encounter; neurogenic bladder; urinary retention. The visit notes document, .continues with flushes and super pubic tubing changes at the facility . Reports one UTI causing mental status changes, R24's usual sign which was treated and improved back to baseline. I again recommend culture directed antibiotics when symptoms of UTI; they are aware of colonization/chronic bacteria. On 3/31/25 at 3:09 pm, Surveyor interviewed Director of Nursing (DON)-B regarding R24 and was told R24 has had frequent UTIs and that staff always notify the optum nurse and R24's wife when one is suspected. Surveyor asked about the treatments not documented as completed on the TAR and Hiprex doses not documented as administered on the MAR was told by DON-B: we all monitor R24, it doesn't matter what you do, you cannot prevent infection, for R24 it is easy to get infections. On 4/1/25 at 9:29am, Surveyor interviewed Certified Nursing Assistant (CNA)-G about care for R24's suprapubic catheter and was told that staff empty the catheter bag and clean around the insertion site. CNA-G puts a gown and gloves on. CNA-G stated that CNA-G takes multiple washcloths to clean around the site and dry the area and then puts a brief on to cover the area. Surveyor noted this does not correspond with either of the treatment orders for cleaning the site. On 4/1/25 at 2:49pm, Nursing Home Administrator (NHA)-A let Surveyor know that 1/16/25 was the only urology after visit summary available. Per NHA-A, the facility heard back from the urology office and R24 had not been seen before that since 2023. Surveyor noted the multiple antibiotic treatments for R24 and lack of urology involvement from the facility. On 4/1/25 at 3:45pm, Surveyor met with NHA-A and DON-B to discuss the concern of multiple treatments not being signed out in the TAR, missed Hiprex doses, and the multiple UTIs that R24 has experienced. No additional information was provided as to why the facility did not ensure R24 received appropriate treatment and services related to catheter care to prevent acute encephalopathy from a UTI.

Based on observation, interview, and record review, the facility did not ensure residents received care consistent with professional standards of practice to prevent development of pressure injuries or received care to promote healing and prevent new ulcers from developing for 4 (R4, R16, R13, and R9) of 4 residents reviewed with pressure injuries. *R4 did not have skin assessments completed timely when readmitted to the facility with the development of pressure injuries. Treatments were not initiated when ordered or completed as ordered, and weekly comprehensive assessments of the pressure injuries were not documented. Surveyor observed R4 with a pressure injury to the right buttock that the facility staff was not aware of. * R16 developed a Stage 2 pressure injury to the left buttock on 2/13/2025 that was not comprehensively assessed and a Stage 2 pressure injury to the right buttock developed on 2/26/2025. The treatment order was not implemented and was documented as an intervention on the Communication Care Plan. Treatments were not consistently signed out as being completed. The Stage 2 pressure injury resolved on 3/7/2025. Surveyor observed a pressure injury to the left heel and the right buttock that the facility staff was not aware of. The Registered Dietician had not been informed of the Stage 2 pressure injury to the right buttock that developed on 2/13/2025 or 2/26/2025. *R13 developed a Stage 3 pressure injury to the left buttock and an Unstageable pressure injury to the sacrum on 1/15/2025 and a treatment was not started until 1/20/2025. Treatments were not consistently signed out as being completed. The Registered Dietician had not been informed of the Stage 3 or Unstageable pressure injuries. The pressure injuries healed on 2/21/2025. *R9 was admitted on [DATE] with treatment orders for a Stage 2 pressure injury to the right thigh and a Stage 2 pressure injury to the left buttock. A skin assessment was not completed until 2/12/2025. On 2/12/2025, the facility documented R9 had a Stage 2 pressure injury to the sacrum that had no description of the wound base. The right thigh and left buttock did not have an assessment documented. R9 was seen by the wound physician on 2/12/2025 and a treatment was ordered for the Stage 2 sacrum pressure injury. The treatment was not initiated until 2/19/2025. Treatments were not consistently signed out as being completed. The wound resolved on 3/26/2025. Findings include: The facility policy and procedure titled Skin Identification, Evaluation and Monitoring dated 11/2022 documents: Licensed nursing associate will evaluate the skin integrity through a physical skin evaluation and use of the Braden Skin at Risk tool. Upon admission, weekly for three weeks, quarterly and when a significant change is identified. The nursing assistant will observe the resident's skin when assisting with activities of daily living and report changes to the nurse. Upon Admission: The Licensed Nursing Associate: A. Complete physical skin evaluation, document findings. If a skin condition is present on admission: 1. Initiate protective dressing 2. Notify healthcare provider with findings and for further treatment orders 3. Notification/Education of resident and resident representative of findings and physician orders 4. Document evaluation in the medical record. A. [sic] Complete Braden Skin at Risk on admission, then weekly for the next 3 weeks, following admission. B. Initiate preventative and/or treatment intervention, as indicated. C. Notify Dietitian of Pressure Injury identified. D. Document findings, notifications and interventions. Weekly: The Licensed Nursing Associate: A. Complete a General Skin Check to evaluate for changes in skin integrity. B. Document and medical record the finding of general skin check 1. If wound is present and previously identified: a. Document integumentary findings i. Appearance of the wound, including measurements ii. Treatment applied/initiated per health care provider order in the medical record. 2. If new wound is identified: a. Initiate protective dressing b. Notify healthcare provider of findings and for further treatment orders. 3. Notification/Education of resident and resident representative of finding and physician orders. 4. Document evaluation in the medical record. C. Update plan of care with each intervention. The Certified Nursing Assistant (CNA) should: A. Observe skin for changes when assisting with activities of daily living. B. Cleanse skin with bath/shower and after each incontinence episode C. Apply barrier cream, as indicated D. Report skin integrity changes to nurse. The Director of Nursing/Wound Champion or designee should: A. Review skin and wound documentation to identify opportunity, as indicated. B. Review medical record to identify need for diagnostic review for comorbidity relation. Communicate with physician, as indicated. C. Review newly identified skin integrity changes identified by CNA and/or Licensed Nursing Associate. D. The interdisciplinary team (IDT) will review for completion of documentation and assist with identification of further resident centered interventions as needed. E. Care plan updated as indicated. F. The report will be available for review by the interdisciplinary team (IDT). Skin Integrity Treatment Program The treatment program will focus on the following strategies: A. Eliminate or reduce 1. the source of pressure using positioning techniques 2. other sources of skin injury by evaluating the cause and providing interventions B. Pain Control C. Preventative measures to reduce the risk of further tissue loss D. Managing and reducing the risk of infections E. Interventions that increase the potential for healing F. Nutritional evaluation and intervention as indicated G. Managing systemic issues (edema, venous insufficiency, etc.). H. Debridement, when needed as ordered by the physician. 1.) R4 was admitted to the facility on [DATE] with diagnoses of anemia, coronary artery disease, peripheral vascular disease, obstructive uropathy requiring an indwelling urinary catheter, depression, and anxiety. R4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R4 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and did not have any skin integrity concerns. R4's Activities of Daily Living (ADL)/Rehab Potential Care Plan was initiated on 2/19/2024 with the intervention R4 needs extensive assistance with one person for bed mobility. R4's Pressure Ulcers/Skin Prevention Care Plan was initiated on 2/19/2024 with the following interventions in place as of 9/27/2024: -Braden Scale to be completed. -Observe skin for redness and breakdown during routine care. -Use pressure relieving devices, cushion on wheelchair and off of heels, as indicated. -Follow community skin care protocol. -Treatments, as indicated, see physician order sheet. -Pressure reducing mattress on bed. -Encourage to float left heel and right stump on pillows when able. -Provide treatment as ordered. -Keep skin clean and dry. -Wound physician assessed with recommendations: left heel treatment as preventative, moisture associated skin damage (MASD) to gluteal crease barrier cream, physician updated, continue treatment per recommendations. (added to Care Plan 2/26/2024) Surveyor reviewed R4's medical record. Surveyor noted no wound physician documentation was found. On 3/27/2025 at 2:50 PM, Surveyor requested from Nursing Home Administrator (NHA)-A all of R4's wound documentation. NHA-A stated NHA-A would have to obtain copies from the wound clinic. Surveyor noted and shared the concern with NHA-A that facility staff would not be able to see what the wound physician documented to determine if there is a change in the wound or to put ordered treatments in place. NHA-A agreed. NHA-A provided the wound physician documentation and Surveyor used that documentation to get a more clear picture of R4's wound status. On 2/20/2024, a treatment was initiated: Remedy dimethicone cream (house stock) to buttocks and peri area every shift and as needed. Surveyor noted the treatment was not consistently signed out as being administered. This order was in place at the time of survey. On 9/20/2024 at 12:55 PM in the progress notes, nursing documented R4 was admitted to the hospital with hypoglycemia and elevated lactic acid. On 9/27/2024, R4 was readmitted to the facility. The Admission Observation/Evaluation form was completed by a Licensed Practical Nurse who documented R4 did not have any skin concerns. On 9/28/2024 on the Skin Evaluation Form, Director of Nursing (DON)-B documented: -Left mid back Deep Tissue Injury (DTI) measured 1.4 cm x 0.7 cm x 0.1 cm with intact skin. Surveyor noted a DTI wound is not an open wound so no depth would be measured. -Right lower buttock pressure injury measured 1.5 cm x 2.3 cm with epithelial tissue. Surveyor noted the pressure injury was not staged, no depth was measured, and no percentage of epithelial tissue was documented. -Left outer heel Stage 3 pressure injury measured 1 cm x 0.9 cm x 0.1 cm. No tissue type was documented. On 9/28/2024 at 1:10 PM in the progress notes, DON-B documented the wound physician made wound rounds and R4 had new orders for the Stage 3 pressure injury to the left heel and the wound to the mid back. Treatments were initiated on 9/28/2024: -Mid back: clean with normal saline and cover with a foam dressing three times weekly. (discontinued 11/20/2024) -Right buttock: cleanse with normal saline and apply foam dressing daily. (discontinued 12/8/2024) -Left heel: cleanse with half Dakins solution and cover with foam dressing three times weekly. (discontinued 11/20/2024) R4's Quarterly MDS dated [DATE] documented R4 had a Stage 3 pressure injury that was present upon readmission, an Unstageable pressure injury that was present upon readmission, and a DTI that was present upon readmission. No documentation of wound assessments was found from 9/28/2024 to 12/8/2024. On 12/8/2024 on the Skin Evaluation Form, DON-B documented: -Right lower buttock pressure injury measured 1.5 cm x 2.3 cm with epithelial tissue. Surveyor noted the pressure injury was not staged, no depth was measured, and no percentage of epithelial tissue was documented. -Left outer heel Stage 3 pressure injury measured 1 cm x 0.9 cm x 0.1 cm. No tissue type was documented. Surveyor noted both pressure injuries had the same documentation as 9/28/2024. No documentation of wound assessments for the right lower buttock or the left outer heel was found after 12/8/2024. Surveyor noted the treatment to the left outer heel had been discontinued on 11/20/2024 and the treatment to the right buttock was discontinued on 12/8/2024 while both wounds continued to have measurements. R4's Annual MDS assessment dated [DATE] documented R4 did not have any pressure injuries. On 1/12/2025 at 12:15 PM in the progress notes, DON-B documented R4 was sent to the hospital after vomiting and having a low blood pressure. On 1/22/2025, R4 was readmitted to the facility. The Admission Observation/Evaluation form was not completed, and the skin section was blank. No skin assessment documentation was found. Review of the Treatment Administration Record (TAR) showed no treatments were in place for any wounds. On 2/14/2025 at 1:25 AM in the progress notes, nursing documented R4 was minimally responsive and sent to the hospital. On 2/27/2025, R4 was readmitted to the facility. The Admission Observation/Evaluation Form documented R4 did not have any skin concerns. No skin assessment documentation was found. On 3/7/2025 at 12:54 PM in the progress notes, DON-B documented the wound physician saw R4 and evaluated R4's admission wounds. Surveyor noted R4's medical record did not have any skin documentation on readmission indicating R4 had any wounds on admission. On 3/7/2025 on the Skin Evaluation Form, DON-B documented: -Right elbow Stage 2 pressure injury measured 0.5 cm x 0.5 cm with granulation tissue. The right elbow Stage 2 pressure injury was documented a second time that measured 0 cm x 0 cm. -Left heel pressure injury measured 1.0 cm x 0.8 cm x 0.2 cm with granulation tissue. This was documented twice. The left heel pressure injury was not staged. The wound physician assessed R4 on 3/7/2025 and documented: -Right elbow Stage 2 pressure injury measured 0.5 cm x 0.5 cm x not measurable due to presence of dried fibrinous exudate with open areas with exposed dermis. -Left heel Stage 3 pressure injury measured 1 cm x 0.8 cm x 0.2 cm with 100% granulation tissue. -Left buttock Stage 2 pressure injury measured 0.5 cm x 0.5 cm x 0.1 cm with open areas with exposed dermis. -Left upper back Stage 2 pressure injury measured 2 cm x 6.5 cm x 0.1 cm with open areas with exposed dermis. The wound physician ordered treatments to the pressure injuries. The treatments were not initiated until 3/10/2025, three days after the treatments were ordered. Surveyor noted no wounds were documented on readmission to the facility on [DATE] and R4 developed four pressure injuries with no treatment in place. The facility documented R4 had two pressure injuries on 3/7/2025 to the right elbow and the left heel while the wound physician assessed R4 to have four pressure injuries. R4's Significant Change MDS assessment dated [DATE] documented R4 did not have any pressure injuries. On 3/10/2025 on the Skin Evaluation Form, DON-B documented the pressure injuries were evaluated by the wound physician on 3/7/2025. DON-B entered the wound physician treatment orders into R4's TAR at that time, delaying treatment by three days. On 3/10/2025 at 1:19 PM in the progress notes, nursing documented R4 was hypoxic with oxygen saturations in the 70s and was sent to the hospital. On 3/24/2025, R4 was readmitted to the facility. The Admission Observation/Evaluation form was not completed, and the skin section was blank. On 3/24/2025 on the Skin Evaluation Form, DON-B documented Existing wounds noted no change(s). No other documentation was found to elaborate on the statement. On 3/25/2025 on the Skin Evaluation Form, DON-B documented: -Right elbow Stage 2 pressure injury measured 0.4 cm x 0.4 cm x 0.1 cm. No wound description was documented. -Left upper back Stage 2 pressure injury measured 0.6 cm x 0.7 cm x 0.1 cm with epithelial tissue. No percentage of tissue type was documented. -Left heel Stage 2 pressure injury measured 1 cm x 0.5 cm x 0.2 cm with granulation tissue. No percentage of tissue type was documented. -Right buttock MASD. No measurements or wound description was documented. The wound physician assessed R4 on 3/26/2025 and documented: -Right elbow Stage 2 pressure injury measured 0.4 cm x 0.4 cm x 0.1 with open areas with exposed dermis. -Left heel Stage 3 pressure injury measured 1 cm x 0.5 cm x 0.2 cm with 100% granulation tissue. -Left buttock Stage 2 pressure injury resolved. -Left upper back Stage 2 pressure injury measured 0.6 cm x 0.7 cm x 0.1 cm with open areas with exposed dermis. -Right buttock Stage 2 pressure injury measured 0.6 cm x 2 cm x 0.1 cm with open areas with exposed dermis. Surveyor noted the facility documented the left heel to be a Stage 2 and not a Stage 3, and the right buttock to be MASD and not a Stage 2 as the wound physician had assessed. On 3/26/2025, the wound physician changed the treatment to the right elbow and added a treatment order for the right buttock. The treatment to the right elbow was not initiated until 3/30/2025 and the treatment to the right buttock was not initiated at all. R4's Pressure Ulcers/Skin Prevention Care Plan was revised on 3/27/2025 with interventions: -Monitor labs as ordered and notify the physician of abnormal values. -Educate resident and/or family to the importance of frequent turning/shifting and repositioning. On 3/29/2025 on the Skin Evaluation Form, DON-B documented: -Left heel Stage 2 pressure injury measured 1 cm x 0.5 cm x 0.2 cm with granulation tissue. No percentage of tissue type was documented. -Right buttock MASD was documented three times, one assessment had no measurements, one assessment documented 0.5 cm x 2 cm x 0.2 cm with no description of the wound bed, and one assessment documented 0.6 cm x 2 cm x 0.1 cm and had resolved on 3/26/2025. No wound physician assessment was provided to compare and clarify what pressure injuries were present. On 4/1/2025 at 8:32 AM, Surveyor observed R4 lying in bed on a regular mattress. R4 was asleep and appeared to be emaciated. Tube feeding was running at 60cc/hour and the head of the bed was elevated slightly, less than 30 degrees. R4 was lying flat on the back with a heel boot to the left foot. R4 had an amputation of the right leg. No pillows were on the bed other than one pillow under R4's head. Surveyor asked LPN-E who does the treatments to R4's wounds. LPN-E stated LPN-E would have to check with DON-B to see when the wound team was coming because if the wound team was coming, they would do the treatments. If the wound team was not coming, LPN-E would do the treatment. In an interview on 4/1/2025 at 9:17 AM, Registered Dietician (RD)-C stated if a resident is admitted with a wound, RD-C would look at the admission skin assessment and the hospital record so RD-C would know right away if the resident had a wound. RD-C stated if an existing resident developed a new wound, RD-C would not be aware of the wound until RD-C completes the monthly review. RD-C stated the facility staff is not consistent in relaying wound information. Surveyor asked RD-C if RD-C is told directly if a resident develops a wound. RD-C stated RD-C is not notified directly by facility staff. RD-C stated when RD-C becomes aware of a wound, RD-C would do a nutritional assessment and would increase protein or order supplements. RD-C stated RD-C can put in an order for supplements directly without having to go through the physician. Surveyor asked RD-C if RD-C was aware of R4 having wounds. Surveyor shared with RD-C R4's pressure injuries. RD-C reviewed R4's medical record and stated the RD documented on 3/27/2025 R4 had a Stage 2 pressure injury to the upper back, but did not mention the right elbow pressure injury. RD-C stated the right buttock is listed as MASD and RD-C was not sure when the left heel pressure injury was found. Surveyor asked RD-C if any changes had been made to R4's tube feeding formula to account for wound healing. RD-C stated there have not been any changes to the tube feeding formula and was meeting the estimated needs for maintenance and healing. RD-C stated if the skin assessment is documented, RD-C will see it, but if it is not documented until after the nutritional assessment is completed, the RD does not catch the wound concerns. On 4/1/2025 at 10:45 AM, Surveyor observed R4 in the same position as at 8:32 AM, lying flat on the back with a heel boot to the left foot. The head of the bed was slightly elevated, but less than 30 degrees with tube feeding running. No pillows were on the bed other than one pillow under R4's head. A pillow with no pillowcase was observed to be on top of a shelving unit in the room. Surveyor asked Certified Nursing Assistant (CNA)-F how often R4 was repositioned in bed. CNA-F stated R4 gets checked and changed every two hours and repositioned then, too. CNA-F stated R4 does not take anything orally. CNA-F left without any opportunity for follow up questions. On 4/1/2025 at 1:49 PM, Surveyor observed R4 in the same position as at 8:32 AM and 10:45 AM, lying flat on the back with a heel boot to the left foot. The head of the bed was slightly elevated, but less than 30 degrees with tube feeding running. No pillows were on the bed other than one pillow under R4's head. On 4/1/2025 at 2:20 PM, Surveyor asked LPN-E what wounds R4 currently had. LPN-E stated R4 had a wound to the upper back, the right elbow and the left heel. LPN-E was looking at R4's TAR to gather supplies for wound care. Surveyor asked LPN-E if R4 had a wound to the right buttock. LPN-E stated according to the computer, no. Surveyor accompanied LPN-E and DON-B into R4's room to observe wound care. The dressing to R4's elbow was dated 3/24/2025, eight days ago. The Stage 2 pressure injury measured approximately 1 cm x 1 cm x 0.1 cm with 100% pink tissue. The left upper back wound was located on the upper back to the right of the spine. The dressing to R4's back wound was dated 3/24/2025, eight days ago. Surveyor asked DON-B if the wound that was being treated was considered the left upper back. DON-B stated DON-B tries to use the same terminology as the wound physician, so it is not always accurate, and the wound physician put mid upper back. Surveyor noted R4 had scarred circular areas to multiple places on the back. The back wound measured approximately 1 cm x 1 cm x 0.1 cm with 100% pink tissue. The left heel dressing was dated 3/25/2025, seven days ago. The Stage 3 pressure injury measured approximately 2 cm x 1 cm x 0.1 cm with dark tissue to the upper aspect and pink/white tissue to the rest of the wound. Surveyor requested to see R4's right and left buttock to verify if any wounds were present. No dressings were observed to the right or left buttock. Surveyor observed an open wound to the right buttock that measured approximately 1 cm x 2 cm x 0.2 cm with a dark red wound base. Surveyor asked DON-B if R4 was receiving a treatment to the right buttock. DON-B stated Remedy cream is applied with incontinence care. Surveyor asked DON-B if DON-B was aware of this wound. DON-B stated R4 did not have a wound there last week. DON-B stated the wound must be from friction and not pressure and must have just opened up. DON-B stated DON-B would contact the wound physician to let them know. Surveyor asked DON-B how R4 was being repositioned when no pillows were observed to be used that day. DON-B stated R4 had a wedge for positioning and thought maybe it was in R4's closet. DON-B looked and was not able to find the wedge. DON-B saw the pillow on top of the shelving unit and requested a pillowcase for the pillow. DON-B stated the CNAs would have to be questioned as to how they were repositioning without a pillow. On 4/1/2025 at 3:04 PM, Surveyor asked CNA-G if CNA-G helped R4 reposition that day. CNA-G stated CNA-F covered R4's hallway for the first shift while CNA-G worked on the other hallway for first shift and was working R4's hallway for second shift. Surveyor asked CNA-G if CNA-G assisted CNA-F to reposition R4 during the first shift. CNA-G stated yes. Surveyor asked CNA-G if pillows were used when repositioning R4. CNA-G stated no, they did not use any pillows to reposition R4. On 4/1/2025 at 3:06 PM, Surveyor asked LPN-E if LPN-E was aware of the open area to R4's right buttock. LPN-E stated nobody reported the open area to LPN-E. On 4/1/2025 at 3:35 PM, Surveyor shared with NHA-A and DON-B the concerns R4 did not have skin assessments completed timely when readmitted to the facility with the development of pressure injuries. Treatments were not initiated when ordered or completed as ordered, and weekly comprehensive assessments of the pressure injuries were not documented. Facility documentation did not match what the wound physician was documenting. Surveyor observed R4 with a pressure injury to the right buttock that the facility staff was not aware of and the concern R4 was not repositioned that day. Surveyor shared the concern the wound physician documentation was not in R4's medical record. DON-B stated DON-B would have to look into why there was a delay in starting treatments. 2.) R16 was admitted to the facility on [DATE] with diagnoses of diabetes, congestive heart failure, coronary artery disease, atrial fibrillation, and dysfunction of the bladder requiring an indwelling urinary catheter. R16's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R16 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and did not have any skin integrity concerns. R16's Pressure Ulcers/Skin Prevention Care Plan was initiated on 8/13/2024 with interventions: -Braden Scale to be completed. -Keep bed linens wrinkle free and do not use excess pads. -Observe skin for redness and breakdown during routine care. -Use pressure relieving devices, cushion on wheelchair and off of heels, as indicated. -Follow community skin care protocol. -Treatments, as indicated, see physician order sheet. -Pressure reducing mattress on bed. On 8/13/2024, a treatment order was initiated for skin prep to heels at bedtime daily. Surveyor noted the treatment was not consistently signed out as being administered as ordered. Surveyor reviewed R16's medical record. Surveyor noted no wound physician documentation was found. On 3/27/2025 at 2:50 PM, Surveyor requested from Nursing Home Administrator (NHA)-A all of R16's wound documentation. NHA-A stated NHA-A would have to obtain copies from the wound clinic. Surveyor noted and shared the concern with NHA-A that facility staff would not be able to see what the wound physician documented to determine if there is a change in the wound or to put ordered treatments in place. NHA-A agreed. NHA-A provided the wound physician documentation and Surveyor used that documentation to get a more clear picture of R16's wound status. On 2/13/2025 at 1:45 PM in the progress notes, nursing documented R16 received a shower, and a body check was performed. R4 had a 2 cm x 2 cm open area to the left buttock. The physician and Director of Nursing (DON)-B was notified. No new orders were obtained. On 2/13/2025 on the Skin Evaluation Form, DON-B documented R16 had a Stage 2 pressure injury to the left buttock that measured 2 cm x 2 cm x 0 cm. No description of the wound bed was documented. No further documentation of the left buttock Stage 2 pressure injury was found. On 2/21/2025, R4 was assessed by the wound physician. The wound physician did not document any wounds to R4's left buttock. On 2/26/2025 on the Skin Evaluation Form, DON-B documented R16's Stage 2 pressure injury to the right buttock measured 0.5 cm x 0.5 cm. No depth or description of the wound bed was documented. Surveyor noted DON-B documented the right buttock rather than the left buttock. Surveyor was unable to determine if the left buttock pressure injury had healed and a new pressure injury developed on the right buttock, or if the location of the original wound was not documented accurately. R16 was seen by the wound physician on the same date and documented R16 had a Stage 2 pressure injury to the right buttock that measured 0.5 cm x 0.5 cm x not measurable due to presence of dried fibrinous exudate with open areas with exposed dermis. The wound physician ordered skin prep daily. The Treatment Administration Record did not have the treatment order initiated. On 2/26/2025, the Communication Care Plan had the intervention: apply skin prep to stage 2 pressure ulcer. Surveyor noted the order was not initiated on the TAR and was not added to the Pressure Ulcers/Skin Prevention Care Plan. On 3/7/2025, R4's Stage 2 pressure injury to the right buttock had resolved. On 4/1/2025 at 8:39 AM, Surveyor observed R16 in their room. R16 had just finished breakfast and was sitting in a recliner chair with feet elevated resting on the seat of the wheeled walker. Surveyor asked R16 if R16 had any concerns regarding their skin. R16 stated they had a sore at the bottom of the spine that has had a sore for ages. R16 stated R16 puts some cream on the area that the nurses give R16. Surveyor asked R16 if any of the nurses look at the area to see if there is a wound. R16 stated they look once in a while. R16 stated the wound formed a scab. Surveyor asked R16 if R16 currently had a scab. R16 stated yes, but no one has looked at it. R16 stated the scab came off a while ago, but a new scab has formed because R16 can feel it. Surveyor asked R16 if R16 had any problems with the heels since R16 had their feet up on the hard cushion of the wheeled walker seat. R16 stated the left heel hurts. R16 removed R16's sock and Surveyor observed a nonblanchable red area that measured approximately 1 cm x 1 cm. R16 stated the heel was open at one time and puts Vaseline on the heel to protect it. In an interview on 4/1/2025 at 9:17 AM, Registered Dietician (RD)-C stated if a resident is admitted with a wound, RD-C would look at the admission skin assessment and the hospital record so RD-C would know right away if the resident had a wound. RD-C stated if an existing resident developed a new wound, RD-C would not be aware of the wound until RD-C completes the monthly review. RD-C stated the facility staff is not consistent in relaying wound information. Surveyor asked RD-C if RD-C is told directly if a resident develops a wound. RD-C stated RD-C is not notified directly by facility staff. RD-C stated when RD-C becomes aware of a wound, RD-C would do a nutritional assessment and would increase protein or order supplements. RD-C stated RD-C can put in an order for supplements directly without having to go through the physician. Surveyor asked RD-C when a nutritional assessment was last done for R16. RD-C stated a quarterly assessment was completed in January 2025. RD-C reviewed R16's medical record and stated a Stage 2 pressure injury to the right buttock was found on 2/26/2025 per the skin documentation. RD-C stated R16 needs to be assessed. Surveyor asked RD-C if RD-C was aware R16 had a pressure injury to the right buttock. RD-C stated no. Surveyor shared with RD-C the observation of the pressure injury to the left heel. RD-C stated RD-C would do a nutritional assessment. RD-C stated Ensure Enlive 4 ounces three times daily had been added to R16's orders in 11/2024 to address decreased appetite, but no other supplements had been ordered. On 4/1/2025 at 10:27 AM, Surveyor requested Registered Nurse (RN)-D go with Surveyor to look at R16's skin. Surveyor shared with RN-D the concern R16 was complaining of pain to the sacrum with a scab to the area and the observation of a pressure injury to the left heel. RN-D observed R16's left heel and agreed R16 had a pressure injury to the heel. R16 exposed the sacral area and a scab that measured approximately 1 cmx 1 cm was present with redness to the peri wound and excoriation to the inner crease. RN-D was not aware of either pressure area. On 4/1/2025 at 3:35 PM, Surveyor shared with NHA-A and DON-B the concerns R16 developed a Stage 2 pressure injury to the left buttock on 2/13/2025 that was not comprehensively assessed and a Stage 2 pressure injury to the right buttock developed on 2/26/2025. The treatment order was not implemented and was documented as an intervention on the Communication Care Plan. Treatments were not consistently signed out as being completed. The Stage 2 pressure injury resolved on 3/7/2025. Surveyor observed a pressure injury to the left heel and the right buttock that the facility staff was not aware of. The Registered Dietician had not been informed of the Stage 2 pressure injury to the right buttock that developed on 2/13/2025 or 2/26/2025. Surveyor shared the concern the wound physician documentation was not in R16's medical record. DON-B stated DON-B would have to look into why the treatment was not started. 3.) R13 was admitted to the facility on [DATE] with diagnoses of respiratory failure, atrial fibrillation, anemia, and diabetes. R13's Admission Minimum Data Set (MDS) assessment dated [DATE] documented R13 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 6 and had impairment to both arms and legs. The assessment documented R13 did not have any pressure injuries. On 12/31/2024, R13 had a treatment [TRUNCATED]

Based on observation, interview, and record review the facility did not ensure each resident (R) received adequate supervision and assistance devices to prevent accidents for 3 (R29, R25, and R13) of 4 residents. *R29 had an injury of unknown origin of bruising to left eye on 5/2/24. On 5/16/24, R29 had bruising to right eye and right foot. R29 sustained a laceration requiring 2 stitches between the right big toe and second toe and had an acute fracture in the proximal phalanx of the first digit. On 6/3/24, R29 sustained an acute impacted fracture at the distal femur. The facility stated the injuries were by different safety concerns that were not assessed or thoroughly investigated to prevent future injury. *R25 had a fall on 6/30/24 and the intervention of having a reacher accessible was put in place. *R13 was transferred by 1 staff instead of 2 by Hoyer lift and was lowered to the ground on 3/29/24. Findings Include: The facility's Accidents and Incidents-Investigating and Reporting for Residents dated 12/2016 and last revised 1/2020 documents: .Policy Statement Accidents or incidents involving Residents shall be investigated and reporting completed, per State and Federal requirements. Policy Interpretation and Implementation A. The nurse should promptly initiate and document investigation of the accident or incident. B. The following information shall be included in the investigation, as applicable. 1. The date and time the accident or incident took place. 2. The nature of the injury, if indicated. 3. The circumstances surrounding the accident or incident. 4. Where the accident or incident took place. 5. The name(s) of witnesses and their accounts of the accident or incident. 6. The Resident's account of the accident or incident. 7. The time the Resident's Health Care Provider was notified, as well as the time the Health Care Provider responded and his/her instructions. 8. The date/time the Resident representative was notified and by whom. 9. The condition of the Resident, including vital signs. 10. The disposition of the Resident. 11. Interventions initiated. 12. Follow-up information. 13. Other pertinent data as necessary or required. 14. The signature and title of the associate completing the report. D. Document the accident or incident in the Resident's clinical record, including health care provider and legal representative notification. E. The Health Care Administrator, Director of Nursing, or designee, shall initiate reporting per state and federal requirements and internal reporting. 1.) R29 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anemia, Unspecified Dementia, and Anxiety Disorder. R29 has an activated Health Care Power of Attorney (HCPOA) effective 9/16/2019. R29 has been receiving hospice service since 4/24/23. R29's Annual MDS dated [DATE] documents R29 has short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R29's MDS also documents that R29 is at risk for developing skin issues and has no current skin issues, osteoporosis is not documented as a current diagnosis, R29 is receiving scheduled pain medications, and that a pain interview can be completed but then it's documented that R29 is unable to answer any questions. R29's MDS documents R29 has range of motion impairment on both upper and lower extremities on both sides and that R29 is dependent for assistance with eating, hygiene, mobility, and transfers. R29's fall Care Area Assessment (CAA) dated 4/3/24 documents that R29 entered hospice on 4/24/23 and is either chair or bedfast due to dementia, anxiety, and anemia. Staff anticipates the resident's needs. Staff will continue to monitor and report any concerns. R29's comprehensive care plan has the following documented: 1. (R29) has potential for falls related to recent admission to community with the following interventions: -Keep pathways clear and provide adequate lighting 4/24/23 -Keep personal items within reach 4/24/23 -Orient to room and call light 4/24/23 -Low bed 4/24/23 -Encourage gripper socks when up 4/24/23 2. (R29) has potential for falls related to medication use, history of falls, decreased mobility and dexterity, poor safety awareness with the following interventions: -Provide proper non skid footwear 4/24/23 -Place fall mat beside the bed 4/24/23 -Place bed in lowest position while in bed 4/24/23 -Encourage to attend activities of choice 4/24/23 -Keep personal items within reach 4/24/23 -Keep room neat, orderly, and organized 4/24/23 -Proper peri care provided, R29 repositioned and replaced in bed 6/16/23 -Offer and assist to get up in Broda chair to common/supervised areas if observed awake during last night rounds 12/27/23 The following is documented in the hospice Skilled Nursing Visit Notes for R29: On 5/2/24, Hospice Registered Nurse (HRN)-S documented that HRN-S noted bruising to R29's left eye. The facility did not call hospice reporting any injuries or falls. HRN-S and hospice home health aide noticed bruising to R29's left eye and left breast as well prior to showering. HRN-S spoke with facility nurse and reported the bruising. Facility nurse stated she did not get that during report and was not told anything about bruising. HRN-S attempted to find Director of Nursing (DON)-B and facility social worker (SW)-O, however, neither present in their office. HRN-S found the facility Nursing Home Administrator (NHA)-A and reported the bruising. NHA-A asked HRN-S and HHA (Home Health Aide) for a statement. HRN-S wrote statement of finding the bruising prior to cares being provided by hospice. HRN-S updated activated HCPOA who stated that HCPOA noticed the bruising yesterday evening and thinks it could be from the Hoyer lift. HCPOA had several concerns about the facility that was shared and HRN-S told HCPOA to express the concerns to NHA-A and DON-B. Surveyor reviewed R29's facility nursing progress notes. There is no documentation located in R29's medical record and notes prior to 5/2/24 of R29 having bruising to the left eye. On 5/12/24, there is facility documentation that R29 is noted to have bruising to the right eyelid. On 5/15/24, there is facility documentation that DON-B was notified about a cut under the right great toe and dressing applied. Per DON-B, R29 is to be added to the facility wound MD list. On 5/16/24, HRN-S documents new bruising is noted to R29's right eyelid. Bruising is from unknown origin. R29's left eyelid remains bruised and appears purple in color suggestive of a newer bruise occurring again. DON-B completed an investigation and found R29 to be combative and capable of hitting self to create a bruise. HRN-S noted a large bruise to R29's right foot which was not reported to Hospice. R29's toes have dried blood on them as well. R29 screaming in pain when HRN-S touches foot. Shower completed. HRN-S cleansed R29's foot to assess where the bleeding was occurring. Licensed Practical Nurse (LPN)-M entered shower room and assessed R29's foot while 4 staff members held R29. Picture from LPN-M's phone of R29's foot revealed R29 had a deep laceration in between R29's right great toe and second toe. HRN-S found previous DON and new Unit Manager from the 3rd floor. HRN-S discussed new injuries and concerns related to R29. Previous DON reports hearing about a cut that an LPN wrapped yesterday. HRN-S showed previous DON the picture of the laceration and expressed that it potentially needed stitches. Director of Nursing (DON)-B entered room and HRN-S explained situation. DON-B and and new RN manager went to the 2nd floor to conduct an investigation. DON-B completed initial investigation and reports that the Broda chair has a cap missing which could have cut R29's foot. DON-B also reports R29 being combative and could have kicked or bumped into something. HRN-S updated NHA-A who states NHA-A is aware of an investigation already being conducted and that R29 is combative so perhaps R29's medications need to be adjusted. HCPOA decided to have R29 transferred to the emergency room for stitches and a foot x-ray. HRN-S documents in the hospice Interdisciplinary Group Meeting dated 7/3/24 that on 5/16/24, R29 was transferred to the emergency room and received 2 sutures and surgical glue to the laceration. Surveyor noted there is no indication the facility reviewed R29's Broda chair or made repairs, or investigated to determine how R29's foot sustained a laceration from the Broda chair to prevent future accidents. On 5/21/24, HRN-S attempted to assess R29's feet, but R29 became agitated and yelled when HRN-S attempted to do so. Updated DON-B and NHA-A regarding visit. DON-B and NHA-A tell HRN-S that they believe R29's chair caused the injury to R29's right toe. HRN-S placed a new order for another chair from the DME company. HRN-S asked DON-B if R29's behaviors have been unmanageable for the facility staff. DON-B denied R29's behaviors as being challenging and told HRN-S that no medication adjustments were necessary at this time. On 5/22/24, an x-ray is obtained by hospice of the right foot. The finding is an acute fracture in the proximal phalanx of the first digit. Surveyor notes there is no facility documentation addressing R29's right great toe fracture. The care plan for R29 documents: (R29) has a diagnosis of osteopenia with a history of fractures presented 5/22 and 6/3/24. -Broda chair will be used to support trunk weakness with pillows in use as needed 5/22/24 -Hoyer lift will be used for safe transfers with a 2 person assist 5/22/24 -Limbs and extremities will be clear of entanglement of slings, gait belts, clothing, blanket, sheet, or anything else that could endanger (R29) 5/22/24 -(R29) will have a facility staff accompany hospice staff for any and all visits 5/22/24 -Per MD orders as of 6/5/24 as discussed in the care conference, (R29) will be on permanent bedrest due to transitioning -Remove immobilizer every shift (qs) for skin assessment 5/22/24 On 5/23/24, HRN-S documented that facility SW-O, DON-B, and R29's family along with HRN-S discussed R29's injuries. Facility staff present stated that they believe the injuries were self inflected and occurring from R29's chair. New chair was delivered. Facility reports that caregivers have been using the Hoyer lift without 2 people. R29's care plan was discussed. R29 will always be a 2 person assist according to facility. On 5/30/24, HRN-S documents HCPOA called HRN-S on 5/28/24 regarding R29's knee possibly needing an x-ray. HCPOA reports R29's knee was swollen over that weekend and that R29 needed morphine. HRN-S notified DON-B who assessed R29 and told HRN-S that DON-B's assessment did not reveal any abnormalities. HRN-S attempted to assess R29's knees on 5/29/24, however, R29 was up in Broda chair resting comfortably and anytime HRN-S attempted to touch R29, R29 cried out. HRN-S assessed R29's knees during visit today. R29's right knee is notably swollen compared to R29's left knee. DON-B made aware and assessed the knee with HRN-S. DON-B reports that R29 often crosses R29's knees which could cause swelling or perhaps R29 has fluid on R29's knee. ROM was attempted by HRN-S, however, R29 is unable to lift R29's right leg off of the bed which is new. HRN-S attempted to move R29's lower extremity, but R29 yelled out in pain, crying, it hurts. HRN-S updated hospice physician. Orders received for X-rays of R29's femur and tibia/fibula. Complete bed rest until x-ray results are in. On 6/1/24, an x-ray of R29's right tibia and fibula was obtained. On 6/3/24, HRN-S documents upon arrival, R29 was lying in bed favoring R29's right side with eyes closed. R29 also said, ouch, it hurts when cares were not being provided, but would not tell HRN-S where it hurt. X-ray results were faxed to hospice today. R29's right distal femur is fractured. HRN-S notified hospice leadership and team members, facility leadership and caregivers, and R29's HCPOA. Hospice physician ordered scheduled morphine and non-weight bearing to right lower extremity and discontinued Tramadol. Per hospice physician, R29 can be up as tolerated via the Hoyer lift. HRN-S communicated these new orders with DON-B and NHA-A. HRN-S explained that R29 should be considered bedrest, but that R29 could get up as tolerated. HRN-S gave an example of R29 not having pain and R29 actively attempting to get out of bed. Those would be signs that R29 could tolerate getting transferred into R29's Broda chair. NHA-A asked if NHA-A should be getting up at all and HRN-S explained no unless R29 would have a significant improvement. Facility leadership will conduct another investigation from the unknown origin of the injury. On 6/3/24, the x-ray results document there is an acute impacted fracture at the distal femur. No evidence of osteomyelitis. According to https://www.britannica.com the documented definition of an impacted fracture is a .closed fracture that occurs when pressure is applied to both ends of a bone, causing the broken ends to jam together.An impacted fracture occurs when the broken ends of the bone are jammed together by the force of the injury. On the evening of 6/3/24, the facility sent R29 to the emergency room without notifying the activated HCPOA to obtain another x-ray. The x-ray report stated there is a mildly displaced fracture of the distal femoral diaphysis with mild, half shaft width of impaction. Mildly thickened mid femoral cortex, possibly stress reaction versus sequela of bony demineralization. It is documented in the hospice Interdisciplinary Group Meeting dated 7/3/24 that activated HCPOA is upset with R29 being sent to the ER by R29's self. Surveyor notes there is no facility documentation that the facility contacted the activated HCPOA to obtain permission to send R29 to the emergency room for a second x-ray. On 6/5/24, HRN-S documented a care conference was held this afternoon prior to visit. Family updated during care conference and during visit. The family has concerns related to the injuries that R29 sustained. The facility reports that they have investigated each injury and concern and believe the injuries to be pathological. On 6/20/24, HRN-S documents during repositioning, R29 complained of pain by stating, Ouch. Registered Nurse (RN)-L reports that the CNAs from the facility got R29 up via the Hoyer lift and transferred R29 to the Broda chair for breakfast. RN-L and DON-B transferred R29 back to bed to remain on complete bedrest. On 7/5/24, HRN-S documents R29 is visibly in pain as evidenced by facial grimacing and moaning. R29 is stating, it hurts while grabbing towards R29's right leg. Pain 8. R29 is also very agitated. HRN-S called for assistance from the facility to assist with incontinence cares and repositioning. On 7/16/24, at 10:43 AM, Surveyor interviewed HRN-S. HRN-S observed on 5/2/24 the bruising to R29's left eye and left breast and brought it to the facility's attention. HRN-S was informed by the facility that R29 did to self by holding R29's baby doll tight and caused bruising to chest and eye. HRN-S found bruising to the right eye and right foot on 5/16/24. HRN-S confirmed R29 was being hoyered at that time. HRN-S noticed blood and found a laceration between R29's right great toe and second toe and requested for R29 be sent to the emergency room . HRN-S stated it was not getting done, so hospice called the ambulance and R29 received 2 stitches and surgical glue. Facility stated it either happened when R29 was up for meals and may have accidentally hit it and the facility stated that R29's Broda chair was missing a cap on the left side. HRN-S stated the injury was on the right side and didn't understand. HRN-S has never observed R29 to be restless or thrashing around when up in the Broda chair. R29 ends up with confirmation of a right great toe fracture on 5/22/24. HRN-S stated there was no swelling present to R29's right knee between 5/23-5/28/24. On 6/3/24, R29 was found to have a right distal femur fracture. On 7/16/24, at 3:49 PM, Nursing Home Administrator (NHA)-A informed Surveyor that R29 has had no falls in the past 6 months. Surveyor noted the facility indicated R29's injuries were caused either by missing/damaged parts to R29's Broda chair, the facility notes staff were not transferring R29 with the correct amount of staff for safety, and implied R29 may have been sustaining injury/bruising from holding a hard doll too tight. None of the possible safety concerns were thoroughly assessed by the facility with a root cause analysis to prevent future safety concerns. On 7/17/24, at 8:55 AM, Surveyor reviewed a statement dated 6/5/24 written by R29's primary physician (MD)-U. MD-U documents R29 has a pathological right distal diaphyseal fracture of the right femur, most likely secondary to osteoporosis per history, non traumatic. Surveyor noted R29 does not have a diagnosis of osteoporosis and xray results reference osteopenia as being present (this is less severe than osteoporosis). On 7/18/24, at 9:32 AM, Surveyor interviewed DON-B in regards to R29. DON-B confirmed the bruising on the left eye but does not recall bruising on the right eye. On 7/18/24, at 9:47 AM, Surveyor interviewed DON-B again in regards to R29. DON-B explained the chair R29 was using was supposed to have a cover on the clamp, but did not and there were sharp edges. DON-B stated R29 moves around a lot and staff needed to make sure a pillow was in place when R29 was up in the chair. DON-B thinks R29's pillow probably fell out and R29 sustained a clean straight cut. DON-B stated both caps were off and the edges were sharp as a razor blade. DON-B stated DON-B sent R29 to the ER because DON-B was very concerned about the injury and needed to know what happened. DON-B stated DON-B could not obtain any answers from talking with staff. DON-B confirmed that DON-B was notified of the first x-ray that stated the injury was acute and wanted to get a second opinion. DON-B was informed that R29 has severe osteopenia and staff should be very careful with R29 and wouldn't be surprised if R29 has more fractures. DON-B stated the intervention was to keep R29 on bedrest. On 7/18/24, at 11:20 AM, Surveyor made observations with HRN-S of R29's chair. R29's Broda chair was located in R29's bathroom and had black plastic caps on either side. Surveyor and HRN-S made observations of 2 empty Broda chairs pushed at the end of the hallway. The 2 Broda chairs are identical to R29's new Broda chair. Both chairs have missing black caps on either side. Surveyor observed pointy, jagged metal on either side. The jagged metal on each side is very sharp and uneven to the touch. On 7/18/24, at 12:21 PM, Nursing Home Administrator (NHA)-A informed Surveyor there is no hospital record from R29's visit to theER on [DATE] because the computer system was down. On 7/18/24, at 10:27 AM, Surveyor interviewed R29's primary physician MD-U over the phone. MD-U stated that the conclusion was R29 has severe osteoporosis and can have spontaneous fractures due to R29's bones being brittle. On 7/18/24 at 3:42 PM, Surveyor shared with NHA-A the concern that R29 had an injury of unknown origin resulting in bruising to left and right eye, and the fracture of the right great toe and the right femur fracture. NHA-A stated the fractures are a result of R29's osteoporosis. Surveyor expressed the concern if the facility knew R29 was susceptible to fractures, what was the facility doing to prevent R29 from injury? At this time, NHA-A had no further information. On 7/22/24, at 1:23 PM, Surveyor interviewed NHA-A in regard to R29's injuries. Surveyor requested any additional information that NHA-A had on R29's injuries Surveyor notes the facility submitted a self report to the state agency dated 6/11/24 in regard to R29's femur fracture. Surveyor asked NHA-A about the documented statement in the self report summary stating, Furthermore, on 5/16, R29 had a Broda chair transfer incident in which R29's right foot got caught up in the foot rest. A signed grievance dated 5/23/24 by NHA-A documents that the bruising to R29's eyes were self inflicted by R29. The intervention for R29's fractures was the buddy system. Surveyor notes implementing the buddy system is not on R29's CNA worksheet or comprehensive care plan. NHA-A stated the right great toe fracture may be related to getting caught between the foot rest and side of Broda chair and the femur fracture is related to R29's diagnosis of osteoporosis. 2) R25 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis, Type 1 Diabetes Mellitus, Alcoholic Cirrhosis of Liver with Ascites, Legal Blindness, Acquired Absence of Right Leg Below Knee, Kidney Transplant, Pancreas Transplant, and Depression. R25's Admission MDS completed on 2/23/24 documents R25 has a Brief Interview for Mental Status (BIMS) score of 11, indicating R25 demonstrates moderately impaired skills for daily decision making. R25's MDS also documents that R25 has an indwelling catheter, is on a mechanically altered diet with a feeding tube, has range of motion impairment on 1 side of lower extremity, requires partial/moderate assistance for mobility, and substantial/maximum assistance for transfers. R25's Care Area Assessment (CAA) dated 2/23/24 documents R25 is at significant risk for falls related to fall assessments. R25 has had two fall assessments completed: 2/20/24-fall risk assessment completed on admission has a score of 39 indicating significant risk for falls 6/30/24-fall risk assessment completed after R25's fall has a score of 27 indicating moderate risk for falls. On 7/16/24, at 1:49 PM, Surveyor reviewed R25's unwitnessed fall investigation. R25 was trying to reach a Gatorade, forgot R25 had 1 leg, and fell in the process. R25 was helped off the floor and placed back in bed. A root cause analysis was completed and the intervention was to provide R25 with a reacher. Surveyor is unable to locate a registered nurse (RN) assessment to rule out any injuries of R25 prior to moving R25 off the floor and back into bed. R25's Certified Nursing Assistant (CNA) Worksheet as of 7/16/24 documents that R25 is a fall prevention program participant and reacher assist device is to be accessible as of 6/30/24. R25 has a potential for falls care plan established 2/19/24 with the following interventions: -Keep pathways clear and provide adequate lighting -Keep bed at the appropriate height -Keep personal items within reach -Transfer per intake information until seen by therapy, then follow therapy recommendations/plan of treatment -Orient to room -Encourage to wear gripper socks -Monitor orthostatic blood pressures as needed-added 2/20/24 -Provide comfort measures/pain management as needed-added 2/20/24 -Fall prevention program participant-added 2/20/24 -Reacher assist device accessible-provided by therapy department-added 7/2/24 On 7/15/24, at 2:24 PM, Surveyor observed R25 in bed eating lunch and Surveyor does not observe a reacher at R25's bedside, within reach. On 7/16/24, at 11:52 AM, Surveyor observed no reacher at R25's bedside and cannot find one anywhere in R25's room. R25 informed Surveyor that R25 does not know where the reacher is. On 7/17/24, at 7:12 AM, Surveyor observed no reacher at R25's bedside, within reach On 7/17/24, at 7:35 AM, Surveyor interviewed Director of Rehabilitation (DOR)-N. DOR-N recalls providing R25 with a reacher. On 7/17/24, at 8:09 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-K who believes CNA-K saw R25's reacher last week. CNA-K and Surveyor went into R25's room and CNA-K was able to locate R25's reacher which was in the corner of the room, behind a chair, on the floor, and not accessible to R25. On 7/17/24, at 3:53 PM, Surveyor shared with Nursing Home Administrator (NHA)-A the concern that there is no documented RN assessment for injury after R25's 6/30/24 unwitnessed fall, and the intervention of having a reacher accessible for R25 has not been observed for 3 days during the survey process. No further information was provided by the facility at this time. 20483 3.) R13 was admitted to the facility on [DATE] and discharged on [DATE]. Diagnoses include fracture of left ankle, diabetes mellitus, coronary artery disease, chronic kidney disease, osteomyelitis of left ankle, peripheral vascular disease, and cellulitis of the left leg. The hospital AVS (after visit summary) for 3/20/24 to 3/28 under other instructions for additional discharge instructions to patient documents: NWB (non weight bearing) to left LE (left extremity.) The potential for fall care plan documents the following approaches with a start date of 3/28/24 * Keep pathways clear and provide adequate lightening. * Keep bed at the appropriate height. * Keep personal items within reach. * Transfer per intake information until seen by therapy, then follow therapy recommendations/plan of treatment. * Orient to room and call light. The [R13's first name] has fall history documents the following approaches with a start date of 3/29/24: * Monitor Orthostatic BPs (blood pressure) as needed. * Provide proper non skid footwear. * Place fall mat beside the bed. * Therapy review transfer status. The nurses note dated 3/28/24, at 14:35 (2:35 p.m.), documents: Arrived at facility at 1340 (1:40 p.m.) via ambulance from [hospital's initials]. VSS (vital signs stable). hospitalized for L (left) ankle fx (fracture). Pins in place. PMH (primary medical history) COPD (chronic obstructive pulmonary disease), CAD (coronary artery disease), elevated lipids, DM (diabetes mellitus), uterine cancer stage 4 with mets, currently chemo is on hold. Transferred to bed with assist of 2. A & O (alert and orientated) times 3/4. Son present. This nurses note was written by RN (Registered Nurse)-FF. The [NAME] fall risk assessment dated [DATE] has a score of 14. A score of 0-15 is minimal risk for falls. The nurses note dated 3/29/24, at 18:43 (6:43 p.m.) documents resident had witnessed fall. CNA (Certified Nursing Assistant) was transferring resident from chair to bed. Resident had unsteady gait so CNA eased resident to the floor. Resident was sitting on the floor with back behind the chair. Resident alert and oriented x (times) 3. No c/o (complaint of) pain noted. No injury noted. Denies hitting her head. ROM (range of motion) WNL (within normal limits). Left leg dressing C/D/I (clean/dry/intact) with brace in place. B/P (blood pressure) 142/55, P (pulse) 65, R (respirations) 18, SPO2 95% ra (room air). T (temperature) 98.0. [Physician name] was here and assessed resident. This nurses note was written by LPN (Licensed Practical Nurse)-GG. Surveyor reviewed R13's fall investigation dated 3/29/24. Surveyor noted the fall occurrence interview-staff dated 3/29/24 for CNA (Certified Nursing Assistant)-HH for the question how did you find out this resident fell documents, I lowered her to the floor. For the question what was the resident doing at the time of the fall documents, Transferring into bed. This interview was conducted by RN-II, who is no longer employed at the facility. The investigation does not address why CNA-HH transferred R13 by herself when at the time R13 was a Hoyer transfer and was non weight bearing. The SBAR (situation, background, assessment, recommendation) dated 3/29/24 for the change in condition, symptoms, or signs observed and evaluated is/are: documents fall. Under resident evaluation for 2. Functional status evaluation is checked for falls. Under describe symptoms or signs documents CNA eased her to the floor. This SBAR was completed by LPN-GG. On 7/18/24, at 9:43 a.m., Surveyor asked RN/UM (Registered Nurse/Unit Manager)-AA if she remembers R13. RN/UM-AA informed Surveyor R13 was on her floor but she left the day before she got here. RN/UM-AA informed Surveyor she has heard her name but doesn't know anything about her. On 7/18/24 at 9:45 a.m. Surveyor asked CNA (Certified Nursing Assistant)-DD what she could tell Surveyor about R13. CNA-DD informed Surveyor when she first got here she was a Hoyer lift because of all the hardware on her foot, she worked with therapy and when R13 left she was a one assist. Surveyor asked CNA-DD when R13 was admitted to the facility was she total care. CNA-DD replied yes, total care. Surveyor asked CNA-DD if R13 had any falls while at the facility. CNA-DD informed Surveyor not that she was aware of. On 7/18/24, at 9:53 a.m., Surveyor spoke with PTA (physical therapy assistant)-EE and asked PTA-EE what he could tell Surveyor about R13. PTA-EE informed Surveyor R13 came in with a left external fixator, was non weight bearing for a while, she was weak, and very motivated to work with therapy. Surveyor asked PTA-EE when R13 was admitted what was her transfer status. PTA-EE replied Hoyer because of the external fixator. Surveyor asked if R13 was a Hoyer transfer during the entire stay. PTA-EE replied no did get weight bearing on that leg because the external fixator was taken out. Surveyor asked PTA-EE when R13's transfer status changed. PTA-EE informed Surveyor he didn't know. Surveyor asked PTA-EE if he could find out when R13 was no longer a Hoyer transfer and could bear weight. On 7/18/24, at 10:40 a.m., Surveyor asked DON (Director of Nursing)-B if she knew R13. DON-B informed Surveyor the day she came back, R13 went to the hospital and doesn't have any information regarding R13. On 7/18/24, at 11:00 a.m., Surveyor spoke with COTA/DOR (Certified Occupational Therapy Assistant/Director of Rehab)-N. COTA/DOR-N informed Surveyor R13 went back to the hospital on 4/17/24 to get the fixator removed and when she came back she was weight bearing as tolerated with a cam boot. COTA/DOR-N informed Surveyor she doesn't have a copy of the order but they all go into the system. Surveyor asked COTA/DOR-N if R13 was a Hoyer transfer on 3/29/24. COTA/DOR-N replied yes because she was non weight bearing with left foot and per the therapist at the end of her stay she was walking about 60 feet. On 7/18/24, at 12:22 p.m., Surveyor asked NHA (Nursing Home Administrator)-A who Surveyor could speak with regarding R13's fall on 3/29/24 as at the time of the fall R13 was non weight bearing with a Hoyer lift and the CNA transferred R13 by herself. NHA-A informed Surveyor the staff here now weren't here. NHA-A informed Surveyor he will get the number of 3 staff who were here and see if they will speak with Surveyor. On 7/18/24, at 4:06 p.m., during the end of the day meeting Surveyor informed NHA-A Surveyor has a concern the facility's investigation for R13's fall on 3/29/24 does not address the CNA transferring R13 by herself when R13 was a Hoyer lift. Surveyor informed NHA-A R13 was a Hoyer lift transfer until 4/17/24 when she went to the hospital to have the external fixator removed. On 7/22/24, at approximately 8:00 a.m., NHA-A provided Surveyor with LPN-GG's name and phone number. Surveyor was not provided with any other staff to contact. On 7/22/24, at 9:15 a.m., Surveyor spoke with LPN-GG on the telephone. Surveyor informed LPN-GG Surveyor wanted to speak with her about R13 who had a fall on 3/29/24. Surveyor asked LPN-GG if she remembers R13. LPN-GG informed Surveyor she doesn't remember R13 and then informed Surveyor she remembers one time on the 3rd floor there was a resident who was lowered to the floor. LPN-GG informed Surveyor she was by herself and called the manager. LPN-GG informed Surveyor she wasn't sure if she did the SBAR or the manager did. Surveyor read LPN-GG her nurses note dated 3/29/24 and asked if she was involved in the investigation. LPN-GG replied no. LPN-GG informed Surveyor the manager was going to take care of everything. Surveyor inf [TRUNCATED]

Based on the comprehensive assessment of a fesident, the facility did not ensure that fesidents receive care, consistent with professional standards of practice, to prevent pressure injuries and to ensure residents do not develop pressure injuries unless the individual's clinical condition demonstrates they were unavoidable; and residents with pressure injuries receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (R29, R5, and R11) of 4 residents reviewed for pressure injuries. *Facility was notified of R29's stage 1 pressure ulcer on the coccyx area on 6/19/24 by hospice. Hospice requested for R29 to be evaluated by the facility wound care doctor. The facility did not assess the area and did not coordinate for the facility wound care doctor to evaluate R29. During the survey process, R29's air mattress was set at 5 for 300 pounds. R29's Treatment Administration Record (TAR) has to check R29's air mattress for setting of 3 for 200 pounds and inflation every shift. On 7/3/24, R29 only weighed 105.3. R29 has had no care plan revisions with the development of the pressure areas. R29 currently has an unstageable pressure ulcer to the coccyx area. *R5 identified with unstageable pressure injury to the left buttock and no turning and repositioning per care plan during the survey process were observed, and treatments were not completed . *R11 had no care plan revision on 6/27/24 for deep tissue injury to the left heel. No treatment was put into place until 6/29/24. During the survey process no heel boots observed in place. No assessment on 7/15/24. Findings Include: The facility's policy Prevention of Pressure Injuries Protocol for Residents dated 12/2016 and last revised on 1/2018 documents: .Preparation A. Review the Resident's care plan to assess for any special needs B. Review current Braden Scale assessment tool General Guidelines A. Pressure injury are usually formed when a Resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation to that area and subsequent destruction of tissue. B. The most common site of a pressure injury is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. C. Pressure can also come from splints, cast, bandages, and wrinkles in the bed linen. If pressure injury are not treated when discovered, they quickly get larger, become very painful for the Resident and often times become infected. D. Pressure injury are often made worse by continual pressure, heat, moisture, irritating substances on the Resident's skin(feces, urine), decline in nutrition and hydration status, acute illness and/or decline in the Resident's physical and/or mental condition. E. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious skin condition for the Resident. F. The community should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed. J. Routinely assess and document the condition of the Resident's skin per community wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury to the supervisor. Interventions and Preventive Measures: SKIN E. Routinely assess and document the condition of the Resident's skin per Weekly Skin Integrity form for any signs and symptoms of irritation or breakdown. F. Report any signs of a developing pressure injury to the physician. G. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. Assessment A. Risk Assessment. A pressure injury risk assessment will be completed upon admission, and then weekly times 3 weeks, with each additional assessment; quarterly, annually and with significant changes. B. Skin Assessment. Skin will be assessed for the presence of developing pressure injuries on a weekly basis or more frequently if indicated. C. Monitoring: 1. Staff will perform routine skin assessments(with daily care). 2. Nurses are to be notified to inspect skin if skin changes are identified. 3. Nurses will conduct skin assessments at least weekly to identify changes. Identifying Residents at Risk A. Extrinsic risk factors for pressure include: 1. Pressure-Resident is not capable of moving without assistance 2. Shear-sliding movement of skin and subcutaneous tissue 3. Maceration-persistently wet 4. Friction-rubbing of one body against another or force that resists relative motion between 2 bodies in contact and/or material elements sliding against each other B. Intrinsic risk factors for pressure ulcers include: 1. Immobility 2. Altered mental status 3. Incontinence 4. Poor nutrition Steps in the Procedure A. Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the Resident's condition and willingness to participate D. Once inspection of skin is completed proceed to the Admission Assessment or Weekly Skin Integrity tool(depending on whether this is a new admission or an existing Resident) and complete documentation of findings. E. If new skin alteration is noted, initiate a new skin evaluation record related to the type of alteration in skin. F. Proceed to care planning and interventions individualized for the Resident and their particular risk factors Documentation The following information should be recorded in the Resident's medical record utilizing community forms: A. The type of assessment conducted(Admission Assessment, Weekly Skin Integrity tool) B. The date and time and type of skin care provided, if appropriate C. The name and title of the individual who conducted the assessment D. Any change in the Resident's condition, if identified E. The condition of the Resident's skin if identified. J. The signature and title of the person recording the data. K. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. L. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care if indicated. M. Documentation in medical record addressing family, guardian or Resident notification if new skin alteration noted with change of plan of care if indicated. 1.) R29 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Anemia, Unspecified Dementia and Anxiety Disorder. R29 has an activated Health Care Power of Attorney (HCPOA) effective 9/16/2019. R29 has been receiving hospice service since 4/24/23. R29's Annual MDS dated [DATE] documents R29 has short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R29's MDS also documents that R29 is at risk for developing skin issues and has no current skin issues, osteoporosis is not documented as a current diagnosis, R29 is receiving scheduled pain medications and that a pain interview can be completed but then is documented that R29 is unable to answer any questions. R29's MDS documents R29 has range of motion impairment on both upper and lower extremities on both sides and that R29 is dependent for assistance for eating, hygiene, mobility, and transfers. R29's Care Area Assessment (CAA) for pressure ulcer/injury dated 4/3/24 documents R29 is on hospice, oriented to self only, confusion, and remote memory conversations. R29 is incontinent and dependent. Staff anticipates R29's needs. Staff will continue to monitor and report any concerns. On 4/29/24, the most recent completed Braden skin assessment places R29 to not be at risk with a score of 15. R29's comprehensive care plan includes R29 is at risk for pressure ulcers and other skin related injuries including to but not limited to Braden scale, decreased mobility and dexterity, contractures, dermal fragility, poor intake, MASD (moisture associated skin damage), systemic lupus erythematous, incontinence with a start date of 4/24/23. The following interventions for R29 are documented: -Braden scale to be completed quarterly-4/24/23 -Include proper peri hygiene and the use of barrier cream after each incontinence episode and as needed-4/24/23 -Observe skin for redness and breakdown during routine care-4/24/23 -Use pressure relieving devices, cushion on wheelchair and offload of heels, and use pillows as indicated-4/24/23 -Follow community skin care protocol-4/24/23 -Treatments, as indicated, see physician order sheet-4/24/23 -Pressure reducing mattress on bed- 4/24/23 -Encourage to float heels in bed-4/24/23 -Specialized mattress on bed. Type: Pressure relief air mattress, check setting (3) and inflation Q (each) shift. Only one barrier between body and mattress-5/10/23 -Offer assistance to bed after lunch-9/27/23 2. R29 has a diagnosis of osteopenia with a history of fractures presented 5/22 and 6/3/24. -Per MD orders as of 6/5/24 as discussed in the care conference, R29 will be on permanent bedrest due to transitioning -Remove immobilizer every shift (qs) for skin assessment 5/22/24 Surveyor notes that R29's facility comprehensive care plan does not have any new interventions added when R29's new open areas were identified to the chest, left buttocks, and coccyx areas. On 7/15/24, Surveyors were provided with a facility skin/wound tracking report for the dates of 6/15/24-7/15/24 and R29 is not listed in the report. The facility provided Surveyor on 7/16/24, 1 skin evaluation form that was completed on 6/12/24 for an open area on the chest. The order reads for small foam dressing every three days or as needed. Surveyor notes there are no documented measurements on the skin evaluation form. The facility was not able to provide Surveyor with weekly skin checks on R29. On 7/16/24, Surveyor was provided R29's current physician orders which documents: -2/8/24-skin prep bilateral heels every shift -3/12/24-left heel: skin prep every AM-1 topical every day for prevention/skin integrity -6/12/24-apply foam dressing left chest area. Change every 3 days and as needed. 1 patch topical every 3 days for skin break down prevention. R29's Treatment Administration Record (TAR) document to check pressure relief mattress, check setting (3) and inflation every shift with a start date of 11/20/22. Surveyor reviewed R29's hospice visit notes which lists a care plan problem of skin integrity. The following is documented: 5/2/24-Hospice Registered Nurse (HRN)-S documents R29's buttocks is reddened, barrier cream applied. R29's groin is reddened so anti-fungal powder was applied. Bilateral heels are reddened. Scratch marks noted to R29's left upper thigh. R29 scratches self when incontinent. Scratches are in various healing stages, no open skin noted. 5/21/24-HRN-S documents R29 has the following risk factors for skin breakdown and healing -bony prominences -bowel incontinence -external factors of pressure -inability to change positions -increased susceptibility related to other existing disease process -poor nutrition -urine incontinence 5/23/24-HRN-S documents from care conference meeting that family is concerned R29 is sitting in the Broda chair too long throughout the day. New plan for scheduled wake up, nap, and bedtime routines for R29. Facility to add this to their established care plan. Surveyor notes this routine was not added to R29's Certified Nursing Assistant (CNA) worksheet or R29's comprehensive care plan. 6/3/24-HRN-S documents HRN-S performed peri care and applied barrier cream. R29's buttocks is reddened and blanchable. Education was provided to the CNAs at the facility regarding the importance of repositioning every 2 hours and applying barrier cream to prevent skin breakdown. HRN-S updated facility Registered Nurse (RN)-L. 6/5/24-HRN-S documents skin checks in and around the immobilizer should be performed every 8 hours to prevent skin breakdown. Director of Nursing (DON)-B was updated regarding visit. Written communication sheet handed directly to DON-B. Surveyor notes there is no documentation that the facility was monitoring for skin breakdown every 8 hours around the immobilizer despite a care plan intervention dated 5/22/24 to remove R29's immobilizer each shift for assessment/skin monitoring. 6/19/24-HRN-S documents facility caregivers assisted HRN-S with repositioning. A new stage 1 pressure ulcer is noted on R29's coccyx. HRN-S applied barrier cream. R29's right calf is also reddened from the immobilizer being in place. Facility received hospice written communication note from HRN-S documenting the new stage 1 pressure ulcer to the coccyx and the new reddened area from the immobilizer. 6/20/24-HRN-S assisted hospice home health aid with repositioning and cleansing her back and buttocks. A new state 1 pressure ulcer is noted to R29's left buttock and coccyx. HRN-S placed a foam border dressing. R29 has reddened areas of skin on her mid-spine, right calf, chest, and bilateral heels. Foam border dressings were placed on all areas of reddened skin to prevent further skin breakdown. Facility received hospice written communication note from HRN-S documenting that dressings to be changed if soiled or every 3-5 days. Foam border dressing to bilateral heels, coccyx, right calf and chin. Hospice Care Plan Documentation-Wound care to coccyx-wash with soap and water or wound cleanser. Apply skin prep to peri wound skin. Cover with foam border dressing. 2 times a week and as needed. Surveyor notes the facility does not have documentation that a physician order was obtained and added to R29's treatment orders. Surveyor reviewed the hospice Interdisciplinary Group Meeting dated 7/3/24 which HRN-S documents: 6/19/24-R29 cannot reposition self to prevent skin injuries. R29 does have a new stage 1 pressure injury on R29's chest. This is thought to be from R29's chin always resting on R29's chest. A foam border dressing is in place to prevent further breakdown. R29's buttocks and bilateral heels are reddened. Barrier cream and skin prep are in use to prevent further deterioration. 7/3/24-R29 has new stage 1 pressure ulcers to chest and coccyx. R29's chest wound is from chin continuously resting on chest. R29 is unable to hold head up on R29's own. R29's coccyx wound is related to being being bed bound and reduced repositioning. An alternating pressure mattress is in use in R29's room. 7/5/24-HRN-S documents HRN-S called for assistance from the facility to assist with incontinence cares and repositioned. R29 was incontinent of urine and bowel. R29's coccyx wound is deteriorating. The blanch-able reddened areas remain as before to R29's spine and right leg. R29's chest wound remains a stage 1. The skin on R29's chest is very thin and fragile. Facility staff updated. Facility received hospice written communication note from HRN-S documenting the status of the wound areas. On 7/9/24-HRN-S documents: Left Buttocks /Decubitus/Pressure Ulcer- Unstageable Onset: 7/9/24 Assessment: Wound Bed-Moist, Bed Color/Percentage-Red, Pink, Purple Wound Edges-Detached, Indistinct, Macerated Peri Wound Skin-Erythema, Scattered tearing Drainage Amount-Moderate Color-Sanguineous/bloody-yellow Odor-Foul Wound Status-declined Left Medial Buttocks Coccyx/Decubitus/Pressure Ulcer- Unstageable Onset: 6/19/24 Assessment: Wound Bed-Moist, Non-granulating Bed Color/Percentage-Red, Pink, Purple Wound Edges-Detached, Indistinct Peri Wound Skin-Erythema, Scattered tearing, Macerated Drainage Amount-Moderate Color-Sanguineous/bloody-yellow Odor-Foul Wound Status-declined Care Plan Documentation-Coccyx wound has increased in size and worsened in stage levels. Wound is currently unstageable. HRN-S documents on 7/9/24 that wound cares completed. R29's coccyx wound continues to have deterioration in size and staging. Foam border dressing placed. Other reddened areas are noted and covered during visit. HRN-S removed R29's heel boots as they were too tight and causing further skin breakdown. HRN-S updated facility nurse and DON-B regarding visit. Facility received hospice written communication note from HRN-S documenting coccyx wound is deteriorating. Stage 2. On 7/11/24-HRN-S documents: Left Buttocks /Decubitus/Pressure Ulcer- Unstageable Onset: 7/9/24 Assessment: Wound Bed-Moist, Bed Color/Percentage-Red, Beefy Red, Pink, Purple Wound Edges-Detached Peri Wound Skin-Erythema, Scattered tearing Drainage Amount-Small Color-Sanguineous/bloody-yellow Odor-Foul Wound Status-declined Left Medial Buttocks Coccyx/Decubitus/Pressure Ulcer- Unstageable Onset: 6/19/24 Assessment: Wound Bed-Moist, Slough Bed Color/Percentage-Red, Beefy Red, Pink, Purple Wound Edges-Detached, Indistinct Peri Wound Skin-Erythema, Scattered tearing, Excoriated Drainage Amount-Moderate Color-Sanguineous/bloody-yellow Odor-Foul Wound Status-declined Care Plan Documentation-Deterioration has occurred to coccyx wound. HRN-S documents on 7/11/24 that Licensed Practical Nurse (LPN)-M and DON-B were updated regarding visit. HRN-S asked for the facility wound care MD to see R29 on Monday for further wound recommendations and follow-up. DON-B and LPN-M verbalized understanding. Surveyor reviewed R29's nursing progress notes located in R29's medical record from May to present and there is no facility documentation referring to any skin areas of concern for R29. On 5/15/24 there is a nurse's progress note that documents to add R29 to wound MD list for cut under the right great toe per DON-B. The facility has no documentation that R29 was evaluated by the facility wound MD for the cut. On 7/15/24, at 10:37 AM, Surveyor observed R29's air mattress is set at 5 which indicates 300 pounds. On 7/15/24, at 2:12 PM, Surveyor observed R29's air mattress is set at 5. On 7/16/24, at 7:47 AM, Surveyor observed R29's mattress is set at 5. On 7/17/24, at 7:16 AM, Surveyor observed R29's air mattress remains set at 5. On 7/17/24, at 12:16 PM, Surveyor observed R29's air mattress remains set at 5. On 7/18/24, at 9:26 AM, Surveyor observed R29's air mattress is now set at 1 which is for 100 pounds. On 7/15/24, at 3:31 PM, Surveyor reviewed R29's most recent weight from 7/3/24 which is 105.3. Surveyor reviewed previous weights going back to 11/9/23 which was 117.20. The highest weight recorded for R29 was 120 pounds on 1/8/24. On 7/16/24, at 10:43 AM, Surveyor interviewed HRN-S in regards to R29's pressure wounds. HRN-S stated that R29 has had a stage 1 to the left buttock and coccyx since 6/19/24 and has reminded staff to reposition R29. On 7/9/24, HRN-S states HRN-S marked it as a stage 2 because the wound was decorating. HRN-S stated HRN-S is not wound care certified so HRN-S reviewed it with the hospice wound nurse who stated the wound was unstageable. HRN-S requested from DON-B on 7/11/24 for R29 to be seen by the facility wound care MD. HRN-S stated R29 was supposed to be seen 7/15/24. HRN-S asked Unit Manager (UM)-J why R29 was not evaluated by the facility wound care MD, and UM-J informed HRN-S because state is here. HRN-S saw wound today and it is getting worse. Hospice will be coming back to get measurements. HRN-S confirmed that HRN-S have communicated with the facility about the pressure areas. HRN-S is not aware of the facility getting measurements of the pressure areas. HRN-S has been dating the dressings and sometimes its the original date indicating to HRN-S the treatment has not been getting done. On 7/17/24, at 7:21 AM, Surveyor asked Registered Nurse (RN)-L about R29's pressure area on the coccyx. RN-L stated RN-L has been on vacation, returned to work this weekend and is not aware of any open area on R29's left buttocks and coccyx. RN-L is only aware of the area on the chest. On 7/17/24, at 7:22 AM, Surveyor interviewed UM-J in regards to R29's open area on the left buttocks and coccyx. UM-J confirmed that R29 has an open area to the coccyx and believes R29 receives a daily treatment to the area. On 7/17/24, at 11:42 AM, Surveyor was provided R29's July TAR which documents apply foam dressing to sacrum every 3 days and as needed if soiled effective 7/17/24. On 7/17/24, at 12:16 PM, Surveyors requested to observe R29's pressure areas, however, facility staff never came to get Surveyors. On 7/17/24, at 12:26 PM, Surveyor interviewed UM-J again in regards to R29's pressure areas. UM-J alleges that hospice never communicated the concerns of the open areas. UM-J informed Surveyor that UM-J went back through the notes and found the information and put order in for the foam dressing today. UM-J agreed there is no measurements/assessment of R29's pressure areas. UM-J stated that measurements are obtained on admission and if a new area is found, measurements and assessment is completed. Surveyor shared the concern with UM-J the concern of no assessment and measurements by the facility in regards to R29's pressure areas. UM-J acknowledged the concern. Surveyor discussed R29's air mattress setting. UM-J stated that the setting of an air mattress is based on a Resident's weight. UM-J stated, will need to look at setting order from hospice. On 7/17/24, at 3:56 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that the facility has no documented skin assessments for R29's pressure areas on the left buttock and coccyx and that the air mattress has not been set at the right setting during the survey process. No further information was provided by the facility at this time. On 7/18/05, at 9:05 AM, Surveyors observed R29's pressure areas and treatment performed by RN-L and UM-J. R29's coccyx is observed to have dime size area with slough, a pinkish red area slightly above, and the entire coccyx area red with MASD. RN-L applied thera honey gel on cotton applicator with silicone border dressing on entire area. On 7/18/24, at 9:11 AM, Surveyors asked to see R29's feet. UM-J removed boots from both feet which are very dry. The right heel has no areas noted. The left heel has outer brownish area. On 7/18/24, at 9:13 AM, Surveyors asked UM-J about the area on R29's left heel. UM-J stated they are not good with wounds and will have DON-B look at it. On 7/18/24 at 9:19 AM, Surveyors were informed by DON-B that DON-B did an assessment on 7/4/24 and R29 did not have any concerns with the left heel. DON-B stated Wound Physician (WMD)-W would be notified along with the primary and confirmed that daily and as needed skins checks should be done. On 7/18/24, at 9:32 AM, Surveyor interviewed DON-B. DON-B stated that UM-J informed DON-B that R29 needed to be seen by WMD-W but does not recall the exact date. DON-B does not know why WMD-W did not see R20 on 7/15/24. DON-B confirmed the air mattress setting is determined by weight. On 7/18/24, at 10:27 AM, Surveyor interviewed R29's primary physician (PP)-U via phone who stated PP-U was not notified by the facility that R29 had any pressure areas. On 7/18/24, at 10:37 AM, Surveyor interviewed HRN-S again. HRN-S informed Surveyor that medi honey is not ordered as the treatment to R29's open area. HRN-S confirmed that DON-B was told last week to place R20 on WMD-W list to be seen but was informed that R29 did not get seen because state was in the facility. HRN-S confirmed that on 6/20/24 both RN-L and DON-B were informed of R29's stage 1 pressure area on the left buttock and coccyx. On 7/18/24, at 11:19 AM, Surveyor spoke with WMD-W via phone. WMD-W confirmed that WMD-W was first notified on 7/17/24 in the morning that R29 needed to be evaluated by WMD-W. Surveyor asked WMD-D how important are air mattress settings to be correct. WMD-D stated It is very important to be correct. Do not want to be incorrect and have a Resident 'bottom out'. WMD-D confirmed the setting is based on a Resident's weight. On 7/18/24, at 4:06 PM, Surveyor again shared the concern with NHA-A that R29's heel, left buttock, and coccyx has not been assessed with measurements by the facility. Surveyor shared that hospice had requested on 7/11/24 for R29 to be seen by the WMD-W and that was not initiated by the facility and the treatment order for the coccyx was not entered until 7/17/24 after Surveyor expressed concern. Surveyor stated that R29's air mattress has not been set at the correct setting during the survey process and R29's primary physician was not updated when the new pressure areas were identified. Surveyor shared the concern that R29's pressure areas have deteriorated. 20483 2.) R5's diagnoses include multiple sclerosis, cirrhosis of the liver, unspecified protein calorie malnutrition, hypertension, anxiety disorder, and depression. [R5's first name] at risk for pressure ulcers and other skin related to but not limited to Braden and other skin related injuries documents the following approaches dated 7/5/23: * Braden scale to be completed. * Encourage proper peri hygiene and the use of barrier cream after each incontinent episode and PRN (as needed). * Observe skin for redness and breakdown during routine care. * Use pressure relieving devices, cushion on wheelchair and off of heels as indicated. * Follow community skin care protocol. * Treatments as indicated see physician order sheet. * Pressure reducing mattress on bed. * Encourage to float heels, W/C (wheelchair) with cushion is dated 7/6/23. Surveyor noted this care plan does not include approaches for repositioning R5. The physician orders dated 9/18/23 documents Hospice Eval (evaluation) and treat. The significant change MDS (minimum data set) with an assessment reference date of 9/29/23 has a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R5 is assessed as not having any behavior including not refusing cares. R5 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility & transfers, extensive assistance with one person physical assist for toilet use, is occasionally incontinent of urine and always incontinent of bowel. R5 is at risk for pressure injuries and is assessed as not having any pressure injury. R5 is checked for hospice care. The pressure injury CAA (care area assessment) dated 9/30/23 documents see Fall CAA. The Falls CAA dated 10/1/23 documents Resident sig (significant) change new admit to hospice. She is alert with dx (diagnosis) of MS (multiple sclerosis). See attachments tab-general/labs/orders/consults/PT (physical therapy)/OT (occupational therapy)/ST (speech therapy) tabs. See Dx tab. She is innocent sic (incontinent) of both b/b (bowel bladder) see point of care tab-daily. Does use w/c (wheelchair) for mobility. Does not walk at this time. Does take Morphine, oxycodone eliquis and Lasix see EMAR (electronic medication administration record). Has had PRN (as needed) Ativan over look back, See assessments/forms tab- assessments 923-9/29. Has a PHQ9 (patient depression questionnaire) score of 4 and BIMS 15 indicating intact cognition. Resident is alert and able to choose her daily activities. Does not have pressure ulcer, see skin tab. Does have pressure reducing mattress, remedy cream and w/c cushion in place see ETAR (electronic treatment administration record) see skin care plan. Has had no falls over look back. Will proceed to care plans. See ID (interdisciplinary) notes Braden immunizations care plan wts (weights) emar/etars. The nurses note dated 11/8/23, at 17:16 (5:16 p.m.) documents General skin check completed on resident. Resident has a new issue that were identified during the skin check. See site specific note for full details of the new issue(s) identified during the skin check. This nurses note was written by RN-MM. The Braden assessment dated [DATE] has score of 12. If a resident's score is 12 or less consider him/her high risk for pressure ulcer development. The [R5's first name] has impaired skin integrity related to pressure area to left ischium documents the following approaches: * Provide treatment with a start date of 11/8/23. * Provide pain management with dressing changes PRN with a start date of 11/8/23. * Keep skin clean and dry with a start date of 11/8/23. * Provide peri-care after each incontinence episode and apply skin protectant with a start date of 11/8/23. * Educate resident and/or family to the importance of frequent turning/shift and repositioning with a start date of 11/8/23. * Minimize force and friction applied to skin with a start date of 11/8/23. * Registered Dietician consult with a start date of 11/8/23. * Assist/teach to reposition self to reduce pressure (shifting own weight or turning) with a start date of 11/8/23. * Provide supplements to promote healing as ordered by physician with a start date of 11/8/23. * Specialized mattress on bed. Type: Pressure relief air mattress, check setting (2) and inflation Q (every) shift. Only one barrier between body and mattress, CHUX of sic (or) brief not both with a start date of 11/8/23. * MD (medical doctor) and hospice updated on skin sweep and status of wounds. Continue with current POC (plan of care). Hospice/MD and [R5's first name] in agreement with a start date of 1/19/24. * Wound rounds with [Wound MD-W's name] (wound MD) POC reviewed, physician orders updated. Hospice and POA (power of attorney) aware with a start date of 2/12/24. * Wound MD assessed with recommendations-MD updated, Tx (treatment) changed to daily and PRN. Resident/Hospice/Family updated on status/POC with a start date of 2/19/24. * Wound MD assessed, wound stable with recommendations to continue current Tx-MD updated, Resident/Hospice updated on status/POC with start dates 2/26/24, 3/4/24, 3/11/24, 3/18/24, 4/1/24, & 4/8/24. Surveyor noted the approach to reposition was not implemented until R5 was identified with an unstageable left upper buttocks pressure injury. R5's left upper buttocks pressure injury assessment dated [DATE] documents the stage as unstageable. The description is eschar & slough. Measurements are 2.4 cm (centimeters) x (times) 1.8 cm x utd (unable to determine. The tissue type is necrotic eschar. Drainage type is serosanguineous, odor is mild, color is green and exudate is light. There is no evidence on the assessment R5's physician was notified of the pressure injury. R5's left upper buttocks pressure injury weekly assessment dated [DATE] documents stage as unstageable. The description is left upper buttocks (ischium/bony prominence) eschar with slough noted to wound base. Measurements are 2.4 cm x 1.6 cm x utd, tissue type is necrotic eschar, MD/hospice updated. Surveyor noted weekly assessment from 11/21/23 to 12/12/23. R5's left upper buttocks pressure injury weekly assessment dated [DATE] documents stage as Stage 3. Description is left upper buttocks (ischium/bony prominence) wound bed red bloody. Measurements are 3.8 cm x 2.8 cm x utd. Drainage is bloody/sanguineous. Tissue type is granulation. R5's left upper buttocks pressure injury weekly assessment dated [DATE] documents stage as Stage 3. Description left upper buttock (ischium/bony prominence) 100% granulation to wound bed resolved. Measurements 3.8 cm x 3 cm x 3 cm. Tissue type is granulation. Drainage is bloody/sanguineous. Undermining throughout wound edges. Surveyor noted weekly assessments dated 12/26/23 to 1/2/24. R5's left up [TRUNCATED]

Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 (R13 & R25) of 12 residents. * R13 was admitted to the facility on [DATE]. R13's treatments for surgical pin sites didn't start until 3/31/24 and the left heel did not start until 3/30/24. The facility did not follow the treatment recommended by the hospital for the pin sites and the nurse who wrote the order is no longer at the facility. There are no assessments for the left heel after 4/5/24, the left upper thigh after 4/1/24, and there are no assessment for the left ankle pin site. R13 was transferred to the hospital on 5/14/24 after a wound appointment and was admitted with severe sepsis. * Neuro checks were not complete in accordance with facility policy following R25's 6/30/24 fall. Findings include: The facility's policy titled, Skin Identification, Evaluation and Monitoring last revised 11/2022 under Purpose documents: The purpose of this policy is to outline a method of identification, evaluation and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care plan will be formulated upon completion of findings. Under Procedure for Weekly: The Licensed Nursing Associate: A. Complete a General Skin Check to evaluate for changes in skin integrity. B. Document in medical record the findings of general skin check. 1. If wound is present and previous identified: a. Document integumentary findings i. Appearance of the wound, including measurements ii. Treatment applied/initiated per health care provider order in the medical record. 1.) R13 was admitted to the facility on [DATE] and discharged on [DATE]. The hospital discharge date d 3/28/24 under brief hospital course and important issues for outpatient follow up documents: came with ankle fracture, underwent fixation and needs follow up. For medication changes and reasoning documents Lovenox for DVT (deep vein thrombosis) prophylaxis antibiotics for left heel infection. Discharge follow up documents orthopedic surgery. The AVS (after visit summary) for 3/20/24 to 3/28/24 under other instructions for additional discharge instructions to patient documents NWB (non weight bearing) to left LE (lower extremity). Pin site cares with 1/2 NS (normal saline) and 1/2 hydrogen peroxide BID (twice daily). Elevate. Additional discharge instructions to patient documents NWB to LLE (left lower extremity). Elevate. Pin site care BID with 1/2 strength hydrogen peroxide and normal saline. Dressing changes daily to incision with nonstick gauze, 4 x (by) 4, and wrap. Surveyor reviewed R13's March 2024 TAR (treatment administration record) and noted the facility did not implement treatment to R13's left extremity until 3/31/24. The facility did not follow the hospital AVS recommendations/orders as facility treatment with a start date of 3/30/24 documents: LLE external fixator pin sites. Swab pin sites with betadine and allow to dry twice daily. R13's left heel wound treatment of cleanse with NS pat dry. Skin prep peri wound, apply Santyl nickel thick to base of wound bed. Cover with gauze dressing and wrap with kerlix was not implemented until 3/30/24, two days after admission. The nurses note dated 3/28/24, at 14:35 (2:35 p.m.) documents: Arrived at facility at 1340 (1:40 p.m.) via ambulance from [hospital initials]. VSS (vital signs stable). hospitalized for L (left) ankle fx (fracture). Pins in place. PMH (past medical history) COPD (chronic obstructive pulmonary disease), CAD (coronary artery disease), elevated lipids, DM (diabetes mellitus), uterine cancer stage 4 with mets, currently chemo on hold. Transferred to bed with assist of 2. A & O (alert and orientated) times 3/4. Son present. This nurses note was written by RN (Registered Nurse)-FF. The nurses note dated 3/29/24, at 18:43 (6:43 p.m.), includes documentation of .Left leg dressing C/D/I (clean/dry/intact) with brace in place . This nurses note was written by LPN (Licensed Practical Nurse)-GG. The care plan [R13's first name] has impaired skin integrity related to L (left) heel wound, and LLE (left lower extremity) surgical site present upon admission documents the following approaches: * Provide treatment as ordered. Start date 3/30/24. * Pressure reducing cushion to chair Describe: WC (wheelchair) cushion. Start date 3/30/24. * Keep skin clean and dry. Start date 3/30/24. The nursing note dated 3/30/24, at 04:13 (4:13 a.m.), Pt (patient) new admit to unit after hospitalization for left ankle fx. Pt is alert and oriented with some forgetfulness noted. Has external pins to left ankle. Pt. states she has no feeling to top of left foot and 4 toes. Pt has a noted missing left great toe. Pt. states it has been amputated some time ago. Pt. states bil. (bilateral) great toes have been amputated. Denies any pain or discomfort. No apparent injury sustained from lowering to floor on PM (evening) shift. Pt. resting quietly in bed at this time. left leg on pillow. This nurses note was written by Nursing-OO. The nurses note dated 3/31/24, at 21:52 (9:52 p.m.), documents Resident alert. Able to make needs known. Lungs clear. Denies sob (shortness of breath). No c/o (complaint of) pain noted. Left leg with pins and rods attached. Left heel wound dressing changed. Left surgical leg elevated. Requires assist of 2 with Hoyer transfers. This nurses note was written by LPN-Y. The admission MDS (minimum data set) with an assessment reference date of 4/2/24 has a BIMS (brief interview mental status) score of 14 which indicates R13 is cognitively intact. R13 is assessed as requiring substantial/maximal assistance for toileting hygiene, partial/moderate assistance for rolling left & right & toilet transfers. R13 is always continent of bowel and urine. R13 is checked for diabetic foot ulcer and surgical wound. The nurses note dated 4/6/24 at 21:33 (9:33 p.m.) documents Resident alert, pleasant and cooperative. Able to make needs known. Lungs clear. Denies sob (shortness of breath). Resident has pins and screw to lle (left lower extremity). No c/o pain noted. Area cleaned and wrapped. No apparent injuries noted r/t (related to) fall. This nurses note was written by LPN-Y. The nurses note dated 4/17/24, at 15:56 (3:56 p.m.), documents Resident out on surgical appointment at before 630 a.m. Writer got update from hospital resident will come tomorrow. This nurses note was written by RN-L. The nurses note dated 4/18/24, at 14:16 (2:16 p.m.), documents Patient transferred back at 1300 (1:00 p.m.) by [Name of] Ambulance. No complaints of pain, MD (Medical Doctor) updated. All vital signs stable. Admission tasks started. This nurses note was written by RN-PP. The care plan [R13's first name] has impaired skin integrity related to L (left) heel wound, and LLE (left lower extremity) surgical site present upon admission documents the following approaches: * Provide treatment as ordered. Start date 4/18/24. * Pressure reducing cushion to chair Describe: WC (wheelchair) cushion. Start date 4/18/24. * Keep skin clean and dry. Start date 4/18/24. * Specialized mattress on bed. Type: Pressure relief air mattress, check setting (2) and inflation Q (every) shift. Only one barrier between body and mattress, CHUX of sic (or) Brief Not Both. Start date 4/18/24. The nurses note dated 4/20/24 at 21:05 (9:05 p.m.) documents Resident alert. Able to make needs known. Lungs clear. Denies sob. Resident c/o pain to left surgical leg. Sutures intact. No warmth noted. Left heel wound improving. Dressing changed. Cam boot on. This nurses note was written by LPN-Y. The nurses note dated 5/7/24, at 14:10 (2:10 p.m.), documents Patient went out for a consult with [Name] of WI (Wisconsin) for her left foot. Sutures remain in the bottom of the foot and to the lower heel area. New order received to keep Left ankle open to air as much as possible. Cam Boot when ambulating and place a non-stick gauze and wrap to lower leg when she wears the Cam Boot. Wound care consult. Follow up with [Name] of WI in 1 week. Patient dressing redone to the heel as it was coming off. This nurses note was written by RN-JJ. The May 2024 TAR with a start date of 4/20/24 for Left Lateral Heel: Clean site with NS (normal saline), pat dry, cover with foam dressing q (every) 3 days and PRN (as needed) 1 Every 72 hours for change dressing every three days or if soiled as needed. Report any changes to MD. Surveyor noted this treatment is not initialed as being completed on 5/8/24, & 5/11/24. The nurses notes dated 5/14/24, PM (evening shift), documents Resident went out for an appointment for (L) foot wound, was referred to the hospital and got admitted at [Name of Hospital]. This nurses note was written by LPN-QQ. The hospital ED (emergency department) dated 5/14/24 includes documentation of Seen by wound care for wound check to LLE prior to arrival. Redness, drng (draining), open wound x (times) 1 week. Under updates documents 5/14/24 1308 (1:08 p.m.) Severe sepsis secondary to cellulitis post operative infection. Patient was given broad spectrum antibiotics WBC (white blood count) 13.12, Lactate 2.9. Xrays demonstrate periprosthetic fracture. Call placed to [Physician's name], ortho. SKIN ASSESSMENTS: Left Leg: Origin date: 3/29/24, charting date 3/29/24 category documents skin condition, description documents fracture of the left ankle. There are no measurements documented. On the body diagram there is a X on the left upper thigh. This assessment was completed by LPN (Licensed Practical Nurse)-QQ. Origin date: 3/29/24, charting date 4/1/24, category documents skin condition, description documents fracture of the left ankle. There are no measurements documented. On the body diagram there is a X on the left upper thigh. This assessment was completed by RN-II. Surveyor was unable to locate evidence of any further assessments for the left upper thigh. Surveyor was unable to locate any assessments of R13's left ankle pin site. Left Heel: Origin date: 3/29/24, charting date 3/29/24, category is skin condition, cause is trauma, measurements documents length is 5.0 cm (centimeters), width 3.0 cm, depth UTD (unable to determine). Wound edge is documented as irregular. Eschar is 50%, slough 50% and granulation is 0. This assessment was completed by RN-II. Origin date: 3/29/24, charting date 4/5/24, category is skin condition, cause is trauma, measurements documents length is 5.0 cm (centimeters), width 3.0 cm, depth UTD (unable to determine). Wound edge is documented as irregular. Eschar is 50%, slough 50% and granulation is 0. This assessment was completed by RN-II. Surveyor was unable to locate evidence of any further assessment after 4/5/24 for R13's left heel wound. On 7/18/24, at 9:43 a.m., Surveyor asked RN/UM (Registered Nurse/Unit Manager)-AA about R13. RN/UM-AA informed Surveyor R13 was on the floor but R13 left the day before she got here. RN/UM-AA informed Surveyor she has heard R13's name but doesn't know anything about her. On 7/18/24, at 9:45 a.m., Surveyor asked CNA (Certified Nursing Assistant)-DD if R13 wore a boot. CNA-DD replied yes she had to wear the boot. Surveyor asked when R13 would wear this boot. CNA-DD informed Surveyor anytime R13 was bearing weight on that foot. Surveyor asked CNA-DD if she remembers R13 having wounds. CNA-DD informed Surveyor R13 had a wound on the heel with that boot and was pretty sure it was the left heel. On 7/18/24, at 9:53 a.m., Surveyor asked PTA (Physical Therapy Assistant)-EE if R13 had any wounds on her foot. PTA-EE replied yes she did. Surveyor inquired if therapy did anything with R13's wounds. PTA-EE replied nursing generally does wound care. Surveyor asked PTA-EE if R13 ever voiced any concerns about her wounds. PTA-EE replied yes she did and there were days when we had to take it easier. PTA-EE informed Surveyor some days she didn't feel comfortable standing as her foot hurt. On 7/18/24, at 10:40 a.m., Surveyor asked DON (Director of Nursing)-B if she knew R13. DON-B informed Surveyor the day she came back to the facility, R13 went out to the hospital. DON-B informed Surveyor she doesn't have any information regarding R13. On 7/18/24, at 11:00 a.m. Surveyor asked COTA/DOR (Certified Occupational Therapy Assistant/Director of Rehab)-N if R13 had any wounds on her foot. COTA/DOR-N informed Surveyor she knew she had a surgical site. On 7/18/24, at 12:22 p.m., Surveyor asked NHA (Nursing Home Administrator)-A for all R13's wound assessments while she was at the facility from 3/28/24 to 5/14/24. On 7/22/24, at 8:35 a.m., NHA-A provided Surveyor with R13's wound assessments. Surveyor reviewed the wound assessments. Surveyor was not provided with any assessments for R13's left upper thigh after 4/1/24, was not provided with any assessments for R13's left ankle pin site, and was not provided with any assessments for R13's left heel after 4/5/24. R13 was discharged from the facility on 5/14/24. On 7/22/24, at 9:15 a.m., Surveyor spoke with LPN-GG on the telephone. Surveyor asked when a resident is admitted to the facility who reviews the discharge summary to ensure the hospital treatment is transcribed and started. LPN-GG informed Surveyor she's not a regular nurse at the facility and doesn't know. On 7/22/24, at 9:55 a.m., Surveyor asked DON-B when a resident is admitted to the facility who reviews the hospital records to ensure the hospital treatment is transcribed and started. DON-B informed Surveyor the nurses of course as well as the nursing manager and she also reviews it. Surveyor inquired if they follow the hospital treatment orders. DON-B explained they have to call the doctor and verify orders. They let them know the resident is a new admission, diagnoses and medication, and treatments. They will ask the doctor if they should continue the treatment or change it. The doctor will tell us to get a wound consult and the wound doctor may change the treatment unless the wound is surgical then he won't mess with that. Surveyor asked DON-B who Surveyor could speak with regarding R13. DON-B informed Surveyor she remembers when she came back on the 15th (May 15) R13 wasn't here. DON-B informed Surveyor name of LPN-Y was here and the majority of the nurses are agency. On 7/22/24, at 10:01 a.m., Surveyor spoke to LPN-Y regarding R13. LPN-Y informed Surveyor she remembers R13's ankle, left heel was broken up. Surveyor asked LPN-Y if she was involved with admitting R13. LPN-Y replied no. Surveyor asked when a resident is admitted who reviews the hospital information. LPN-Y informed Surveyor it would be the floor nurse and then go to the manager. Surveyor informed LPN-Y R13 was admitted on [DATE] but her treatment for her left heel didn't start until 3/30/24 and pin site until 3/31/24. LPN-Y replied can't answer that. Surveyor inquired about the treatment for R13's pin sites as the hospital ordered 1/2 normal saline and 1/2 hydrogen peroxide and the facility's order was betadine. LPN-Y informed Surveyor she sees the order but she doesn't change the order. LPN-Y informed Surveyor this order is definitely not from her. Surveyor asked LPN-Y if there was anyone Surveyor should speak with. LPN-Y informed Surveyor the nurse who wrote the order is no longer here. Surveyor asked LPN-Y if she was involved with R13's wound assessments. LPN-Y replied not so much with wound assessments and explained if she found something she would notify the nurse manager and DON at that time. Surveyor informed LPN-Y Surveyor has for the left heel only assessments dated 3/29/24 & 4/5/24 and left leg 3/29/24 & 4/1/24. LPN-Y informed Surveyor that's what I'm seeing. Surveyor asked LPN-Y if she is able to locate any assessment for R13's left ankle. LPN-Y replied no, I don't see any. On 7/22/24, at 10:23 a.m., Surveyor spoke with Physician-RR on the telephone. Surveyor asked Physician-RR if he recalls changing R13's treatment to the pin sites when R13 was admitted on [DATE]. Physician-RR replied you know what, I don't know, explaining the facility has went through a lot of changes. Physician-RR informed Surveyor he saw R13 on 3/28/24 & 4/18/24. Physician-RR informed Surveyor he has to actually copy the orders into his notes as he can't upload into [name of computer system]. Physician-RR informed Surveyor he just wrote the note per wound service and how they changed that he doesn't know. Physician-RR informed Surveyor when he receives a call for wounds with specific questions he tells the staff to call the wound service. On 7/22/24, at 1:10 p.m., Surveyor informed NHA-A R13 was admitted on [DATE] and treatments for the pin sites didn't start until 3/31/24 and left heel treatment did not start until 3/30/24. The facility did not follow the treatment recommended by the hospital for the pin sites and the nurse who wrote the order is no longer at the facility. There are no assessments for the left heel after 4/5/24, the left upper thigh after 4/1/24, and there are no assessments for the left ankle pin site. R13 was transferred to the hospital after a wound appointment and was admitted with severe sepsis. NHA-A informed Surveyor he had given Surveyor R13's left ankle assessments. Surveyor informed NHA-A Surveyor has not received any assessments for the left ankle. Surveyor informed NHA-A it's Surveyor's understanding R13 was not seen by Wound Doctor-W. NHA-A reviewed Wound Doctor-W's assessments and verified R13 was not seen by Wound Doctor-W. 38829 2.) R25 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis, Type 1 Diabetes Mellitus, Alcoholic Cirrhosis of Liver with Ascites. Legal Blindness, Acquired Absence of Right Leg Below Knee, Kidney Transplant, Pancreas Transplant, and Depression. R25's Admission MDS completed on 2/23/24 documents R25 has a Brief Interview for Mental Status(BIMS) score of 11, indicating R25 demonstrates moderately impaired skills for daily decision making. R25's MDS also documents that R25 has an indwelling catheter, is on a mechanically altered diet with a feeding tube, has range of motion impairment on 1 side of lower extremity, requires partial/moderate assistance for mobility and substantial/maximum assistance for transfers. The facility's Accidents and Incidents-Investigating and Reporting for Residents dated 12/2016 and last revised 1/2020 documents: .Policy Statement Accidents or incidents involving Residents shall be investigated and reporting completed, per State and Federal requirements. Policy Interpretation and Implementation C. If the Resident sustains a witnessed head trauma or an unwitnessed fall, the Resident should be observed for neurological abnormalities. Neurological checks are initiated and completed for 72 hours. If abnormal symptoms occur, the health care provider should be notified. On 7/16/24, at 1:49 PM, Surveyor reviewed R25's unwitnessed fall investigation. R25 was trying to reach for a Gatorade, forgot R25 had 1 leg, and fell in the process. R25 was helped off the floor and placed back in bed. Surveyor is unable to locate any neurological checks (neuro checks) completed for R25's 6/30/24 unwitnessed fall in R25's medical record. On 7/17/24, at 7:26 AM, Surveyor interviewed Unit Manager (UM)-J. UM-J confirmed that if a resident has an unwitnessed fall, that neuro checks should be completed. Surveyor shared that Surveyor is unable to locate the neuro checks for R25's unwitnessed fall on 6/30/24. UM-J stated UM-J will look for R25's neuro checks. On 7/17/24, at 3:51 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A that there are no documented neuro checks for R25's 6/30/24 unwitnessed fall. No further information was provided at this time by the facility. The facility has been unable to provide completed neuro checks for R25's 6/30/24 unwitnessed fall. On 7/22/24, at 9:07 AM, Surveyor interviewed Director of Nursing (DON)-B in regards to neuro checks. DON-B stated that neuro checks are documented on paper. DON-B stated the initial neuro check is completed right after the fall. DON-B then stated that neuro checks should be every 15 minutes times 4, every 30 minutes times 4, every hour times 4, and once a shift (3) for 3 days. DON-B confirmed that all neuro checks should be completed with all unwitnessed falls. Surveyor shared the concern with DON-B that neuro checks have not been located for R25's 6/30/24 unwitnessed fall. DON-B stated DON-B will need to look for R25's neuro checks. On 7/22/24, at 2:47 PM, Surveyor received from NHA-A neuro checks for R25. Surveyor notes the initial neurological check is completed. There are only 2 15-minute neuro checks completed, not 4. There are only 2 30-minute neuro checks completed, not 4. There are only 2 every hour assessments completed, not 4. Only 1 shift is completed with a date of 6/30/24. 2 shifts for 7/2/24 completed with 1 not signed and 2 shifts dated 7/3/24 that are not signed. Surveyor notes there are no documented neuro checks completed for 7/1/24. Surveyor shared with NHA-A that R25 not having neuro checks completed for R25's 6/30/24 fall remains a concern. NHA-A had no further information at this time. On 7/29/24, at 12:33 PM, Surveyor reviewed additional information provided by the facility after the survey process was completed. Surveyor noted the submitted forms reviewed do not identify a resident name or room number on the forms. Surveyor continues to have concerns that R25's neuro checks are not completed per procedure of the facility that was provided by the DON-B on 7/22/24.

Based on record review and interviews, the facility did not ensure staff followed a resident's plan of care for transfers for 1 (R5) of 3 residents reviewed for transfers. The facility staff did not report or investigate a resident's fall to determine causative factors and did not implement preventative measures for 1 (R2) of 3 residents reviewed with falls. * On 12/11/23, R5 was transferred with 1 staff instead of 2 staff as identified on R5's care plan, and with a Hoyer lift sling that was not the appropriate size, resulting in a fall from the Hoyer lift and death. R5's plan of care was not followed regarding sling size and the need for 2 staff assistance for transfers. The facility's failure to ensure staff followed the resident's plan of care resulted in a fall, injury, and death, and created a finding of immediate jeopardy that began on 12/11/23. Surveyor notified Nursing Home Administrator-A of the immediate jeopardy on 1/11/24 at 2:35 PM. The immediate jeopardy was removed on 12/12/23, however, the deficient practice continues at a scope/severity of D (potential for harm/isolated) as evidenced by the following example: * R2 had a fall on 12/11/23 that was not documented until 12/21/23, and not assessed for causative factors, and preventative measures were not implemented. Findings include: 1) R5 was reviewed by Surveyor related to a FRI (Facility Reported Incident). The FRI indicates on 12/11/23, at 6:20 AM, R5 fell out of a Hoyer lift onto the floor. R5 was transferred by 1 staff instead of 2 staff, and the Hoyer sling used was not the correct size. R5 was transferred by (Certified Nursing Assistant) CNA-F with a Hoyer lift at the end of her shift. CNA-F did not ask for help from other staff for the transfer despite being aware that R5 required 2 staff assistance with a Hoyer transfer. 911 was called and law enforcement was contacted after the paramedics arrived at the facility. R5 was pronounced dead at the scene of the fall. The FRI included staff statements and resolution to prevent further harm to other residents. This included education for staff and Hoyer equipment evaluation. Surveyor requested, through an open record request, the 911 report and police report for this event. Surveyor reviewed these reports. The staff witness statements and timeline correlate with the facility's FRI investigation. The police investigation ruled this an accidental death. R5's medical record was reviewed by Surveyor. R5's original admission to the facility was on 8/26/19 with a readmitted [DATE]. R5 had an activated Power of Attorney for Healthcare and primary diagnosis of stroke. R5 is a DNR (do not resuscitate) code status. R5's plan of care for ADLs (activities of daily living), dated 9/23/23, indicates for Transfer: I need total assistance with 1 person staff support; I use total lift assistive device; Total assist of 2 staff using Hoyer lift large control (green colored border) divided legs sling with transfers; no ambulation; wheelchair with mobility. On 1/11/24, at 7:25 AM, Surveyor spoke with (Registered Nurse) RN-C who was the Nurse Supervisor during this event. RN-C was called to the floor by (Licensed Practical Nurse) LPN-G. LPN-G had indicated that R5 had fallen. RN-C went to R5's room and observed R5 laying on her back across the Hoyer support legs. R5 had agonal breathing. They called 911 and then they lifted R5's upper neck/back area to remove the Hoyer support feet from underneath her. RN-C noted R5 was bleeding from the back of her head. R5 already had oxygen in the room, and staff applied it for breathing comfort. The paramedics arrived and instructed staff to exit R5's room. The Hoyer with sling was removed from the room. RN-C stated CNA-F did assist R5 appropriately the shift before with a Hoyer lift and that CNA-F had asked LPN-G to assist them when they were ready to transfer R5 from bed into the wheelchair. However, CNA-F did not come back to LPN-G to ask for assistance again with the Hoyer lift transfer. RN-C indicated they have never seen this happen before and did not know why CNA-F transferred R5 without assistance. On 1/11/24, at 9:10 AM, Surveyor spoke with CNA-D who was working on R5's unit during this event. CNA-D stated LPN-G indicated R5 was on the floor, and they needed help. CNA-D assisted with removing the Hoyer lift from under R5's body, then the paramedics arrived and asked everyone to leave R5's room. CNA-D was educated on proper use of Hoyer lifts and the need to use 2 staff and the proper sling, along with following the resident's plan of care. On 1/12/24, at 10:54 AM, Surveyor spoke with LPN-G. LPN-G indicated CNA-F was going to let them know when they needed their assistance with the Hoyer lift transfer for R5. CNA-F came to them and indicated R5 had fallen. LPN-G indicated the sling was still attached to the Hoyer. The sling was not the right size for R5. CNA-F did not indicate why they did not get help with the Hoyer lift transfer. RN-C called 911 and they assisted in getting the Hoyer out of the room. The paramedics arrived and they had everyone leave R5's room. Everyone had education about the correct sling size and the need to use 2 staff for a Hoyer transfer. The facility failure to ensure staff followed the resident's plan of care created a finding of immediate jeopardy which began on 12/11/23. The facility removed the jeopardy on 12/12/23 when it completed the following: * All Hoyer lifts and slings were evaluated for proper use. * A 30-day look back of falls in the facility for Hoyer transfer involvement. * All care plans and care guides reviewed for accurate sling and transfer status. * All staff trained on following the plan of care and appropriate Hoyer use. * Audits of Hoyer transfers for the next 3 months. 47094 2) R2 was admitted to the facility on [DATE] and has diagnoses that include left hip femoral neck fracture with hemiarthroplasty repair, weakness, type 2 diabetes mellitus, thrombocytopenia, gout, Cirrhosis of the liver- nonalcoholic steatohepatitis (NASH), esophageal varices, gastroesophageal reflux disease (GERD), obstructive uropathy, coronary artery disease, pulmonary hypertension, and anemia. R2's admission minimum data set (MDS) dated [DATE] indicated R2 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R2 needing assistance with set up for eating and drinking and needing maximal assistance of one staff member with personal hygiene, putting on and taking off footwear, showering, toileting, and mobility. R2 was assessed as needing 1 staff member to do pivot transfers from bed or chair to wheelchair with no ambulation, and weight bear as tolerated on left leg. R2 had an indwelling catheter and was occasionally incontinent of bowel. R2 was assessed to be a moderate risk for falls with a Fall Risk score of 34 that was assessed upon admission on 11/28/2023. R2's Activities of Daily Living (ADL) Functional/Rehab potential Care Plan was initiated on 11/28/2023, which documented [R2] needs assistance with daily ADL care. [R2] will have daily care needs met through next review period. Interventions include . - MOBILITY: [R2] needs extensive assistance with 1 person staff support. [R2] uses wheelchair assistive device. No Ambulation, wheelchair with mobility. - TRANSFER: [R2] needs extensive assistance with 1 person staff support. [R]2 uses pivot assistive device. Extensive assist with 1 person using two wheeled walker (stand and pivot for stability only) with transfers. Weight bear as tolerated to left lower extremity. Initiated 12/1/2023 - TOILETING: [R2] needs extensive assistance with 1 person staff support. Minimum to moderate assist of 1 person using two wheeled walker (stand and pivot for stability only) with toilet transfers. Maximum assist with clothing management and peri cares with toileting. Initiated 12/1/2023 R2's Falls Care Plan was initiated on 11/28/2023, which documented [R2] has potential for falls related to recent admission to community [R2] is at risk for falls related to change in environment. [R2] wants to remain free from injury related to falls over the next review period. Interventions include: - Keep pathways clear and provide adequate lighting. - Keep bed at the appropriate height. - Keep personal items within reach - Transfer per intake information until seen by therapy, then follow therapy recommendations/plan of treatment. - Orient to room and call light. - Encourage to wear gripper socks (initiated on 11/29/2023). [R2] has potential for falls related to history of falls, left femur fracture post left hemiarthroplasty . initiated 11/29/2023. Interventions include: - Place fall mat beside the bed. - Provide comfort measures/pain management as needed. - Fall prevention program participant. R2's CNA (Certified Nursing Assistant) care Kardex had the following care instructions noted for staff personal: Transfers: Minimum to Moderate assist of 1 staff person using two wheeled walker (stand and pivot for stability only) with transfers, weight bear as tolerated to left lower extremity, No ambulation, wheelchair with mobility. Toileting: . Minimum to Moderate assist of 1 staff person using two wheeled walker (stand and pivot for stability only) with toilet transfers, maximum assist with clothing management and peri cares with toileting . Fall Prevention: Encourage bed at appropriate height and call light within reach. Gripper socks or shoes on when up. Fall mat beside the bed at bedtime and when napping. On 12/21/2023, at 11:33 PM, documented as a late entry for 12/11/23, R2's nursing progress notes charted nursing notified by CNA she had to slide resident to the floor while transferring to the bed. Resident alert and oriented per usual. Denies any c/o (complaint of) pain or discomfort. Returned to bed. Surveyor noted R2 was not in the facility on 12/21/2023 but was in the hospital. and that the event date listed on the charting was 12/11/2023. Surveyor requested fall investigations for R2. Surveyor received a fall investigation for R2 for 12/11/2023. Surveyor reviewed the fall investigation for R2's fall on 12/11/2023. The Facility's Fall Occurrence Resident Interview & Root Cause Analysis form dated 12/11/23 documents, -Date: 12/11/23 but no time is documented -BIMS: left blank -Is the resident able to follow directions-yes -Do you remember falling-yes -Are you okay-yes -What were you doing? Resident Response: going back to bed -Where were you going? Resident Response:getting ready to go back to bed Nurse to answer what you see: -Resident fell near bed or near toilet? How far away: next to bed -Were they on their back, front, left/right side?: L (left) side -Position of the arms and legs? underneath stretched out -What was the surrounding area like? written in: got weak . -What was the residents appear? gripper socks -Did the resident have hearing aids? no -Did the resident have glasses? yes -What safety measures were put into place at the time of the incident? Please review care plan/care card and explain measures in place: this was left blank -Have there been any similar incidents? No, resident was slid to the floor during CNA transferring him from the chair to bed. -Additional comments, or resident/family information: resident had no injuries was able to hold on to w/c (wheel chair). Signed as completed by Licensed Practical Nurse (LPN)-W on 12/11/23, at 10:15 PM. -Did you observe the resident during your shift? no is crossed out but yes in not circled -Was the resident assigned to you at the time of the fall? yes -Prior to the incident-What time was the resident last checked or seen by you? 10:00 PM, gave meds (medications) he (R2) asked to go to bed so I (LPN-W) alerted the aide. -Prior to the incident-what was the resident doing at the time? sitting in recliner watching TV. -Prior to incident-what assistance did you provide to the resident? gave meds, safety rounds. -Time last toileted? 5 min (minutes) prior to the fall-slid out of wc (wheelchair) with aide. -Time resident last ate or drank? dinner and with meds. -Where items within reach? marked with a check mark- call light, water, urinal, phone, TV remote, glasses and personal items. -Was the resident agitated prior to the fall? No signs of agitation. -What interventions were taken at that time? This is left blank. Staff statement from CNA-S, who was assigned to care for R2 on 12/11/23. CNA-S's statement was undated and did not include the time and date of R2's fall occurred. CNA-S statement documents they were assigned to care for R2 and last checked on R2 10 minutes prior to the fall. The statement continues to document .[R2] was waiting for me to come back to change him and assist him to the bed. The assistance provided prior to the incident was to turn the light off, take food tray, and help call a family member. Last time toileted was before the start of CNA-S's shift. The last time the resident ate or drank was at dinner 5 or 4:00. Interventions taken at the time: CNA-S documented they slowly lowered [R2] to the ground after he couldn't stably sit in his wheelchair. CNA-S then proceeded to get the other CNA and nurse and we were able to get the hoyer and lift [R2] up back to the bed and CNA-S proceeded to change [R2]'s brief and adjust [R2] in bed with the RN's (registered nurse) help. Surveyor noted below concerns with the Facility's fall investigation for R2's fall on 12/11/2023: 1. Emails dated 12/21/23 were included in the fall investigation related to staff statements for R2's fall on 12/11/2023 indicating the investigation of fall being after R2 transferred to hospital on 12/17/2023 and did not return to the facility. 2. CNA-S, assigned to care for R2 at the time of the fall, statement does not indicate a time or date R2's fall occurred and did not include how CNA-S was attempting to transfer R2 at the time of the fall, i.e. with or without a gait belt, with or without the recommenced 2 wheeled walker. 3. CNA-S documents R2 was last assist to the bathroom prior to CNA-S starting their shift. This conflicts with the Interdisciplinary Team (IDT) fall committee review follow up that documents R2 was toileted 5 minutes prior to the fall. 4. IDT fall committee review follow up form does not indicate date and time of which the IDT met to discuss R2's fall that occurred 12/11/2023. The follow up also included information from R2's hospital admission on 12/17/2023 which would not pertain to R2's fall on 12/11/2023. There is also a noted on the bottom of the follow-up page that documents a phone conversation with R2's family member and Medical Doctor notification but did not indicate when these conversations took place. 5. A skin evaluation form was not completed for R2 until 12/21/2023 but was dated for 12/11/2023 and was left blank. Surveyor notes no information was provided regarding R2's skin evaluation after R2's fall on 12/11/2023. 6. R2's medical record does not document the incident of R2 being lowered to the ground until 12/21/23. R2 was transferred to the hospital on 12/17/23 due to a change of condition of R2 appearing jaundice, poor appetite, increased hip pain, +3 lower extremity edema and weeping, swollen body, swollen penis, Foley with cloudy urine with sediment. R2 was transferred to the hospital on 12/17/23 at the family's request and it wasn't until after R2 was transferred to the hospital that the facility documented the incident and investigated R2's fall On 1/11/2024, at 3:32 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-W who stated CNA-S came to get LPN-W because CNA-S had to lower R2 to the floor during a transfer. LPN-W stated LPN-W assessed R2 and did not have any concerns, so LPN-W, CNA-S, and another CNA lifted R2 off the floor using a Hoyer lift and put R2 back to bed. CNA-S then finished cares for R2. Surveyor asked LPN-W if LPN-W did a skin assessment or notify anyone regarding R2's guided fall to the floor on 12/11/2023. LPN-W replied that LPN-W recalled the fall was around the end of LPN-W's shift and stated, so I probably did not cross my T's and dot my I's, I was more concerned with making R2 comfortable, and getting ready to go home. LPN-W stated LPN-W recalled putting dressings over R2's right and left calves per R2's request. Surveyor asked LPN-W if there was an order to do that or if LPN-W notified the physician regarding R2's request. LPN-W stated LPN-W just wanted to make R2 comfortable and did not think of documenting R2's request. Surveyor asked if the blisters on R2's right and left legs were open. LPN-W could not recall but thought they were open, but not draining and R2 just wanted something over R2's right and left calves. Surveyor asked LPN-W if LPN-W had any other concerns regarding R2 at that time. LPN-W stated R2 was in R2's wheelchair most of the shift and family was there to visit. LPN-W did not recall any concerns regarding R2 on 12/11/2023 prior to fall. On 1/16/2023, at 9:52 AM, Surveyor interviewed Registered Nurse Unit Manager (RN UM)-J who stated expectations of staff for changes of condition for residents are to fill out a Situation, Background, Assessment and Recommendation (SBAR) form and notify the physician for further direction. RN UM-J was not sure why a SBAR form was not filled out for R2 regarding getting weak during transfers. Surveyor asked RN UM-J when the facility became aware R2 was assist to the ground on 12/11/2023. RN UM-J stated they were not sure about the date of notification, but looking at the paperwork RN UM-J stated it looked like management did not know about R2's guided fall on 12/11/2023 until 12/21/2023 but was not sure. On 1/16/202,3 at 11:12 AM, Surveyor interviewed CNA-S who stated CNA-S was transferring R2 to R2's bed from the wheelchair and R2 stated R2 needed to sit down. CNA-S stated R2 was unable to pivot back to wheelchair and R2 started to sit down, so CNA-S guided R2 onto the ground. Surveyor asked CNA-S if R2 was using any other devices to help with pivot transfer. CNA-S stated there were not other devices in R2's room and R2 grabbed onto the bed and wheelchair arms to assist with pivoting. Surveyor asked CNA-S if CNA-S used a gait belt to transfer R2. CNA-S stated the CNAs did not have access to gait belts and that only therapy had access to gait belts. CNA-S stated there were no issues with R2's transfers throughout the shift on 12/11/2023 that CNA-S could recall. CNA-S stated nursing was notified and assisted R2 off the floor using a Hoyer lift and put R2 into bed and finished cares for the night before CNA-S left to go home. Surveyor noted CNA-S did not transfer R2 using a two wheeled walker during pivot transfer as stated in R2's care plan and CNA care Kardex. On 1/16/2023, at 11:41 AM, Surveyor interviewed Medical Doctor (MD, primary physician)-K who stated MD-K saw R2 on 12/12/2023 and did not recall if MD-K was aware of R2's fall. MD-K stated MD-K did not have notes on R2. MD-K stated MD-K was not aware of any red flags at the visit on 12/12/2023. MD-K stated facility staff call when all residents have a fall. On 1/16/2024, at 3:00 PM, Surveyor informed Nursing Home Administrator (NHA)-A of Surveyors concerns regarding R2's fall investigation not occurring until 5 days after the fall and when R2 had already been transferred to the hospital on 12/17/23 due to a change in condition. No further information was provided at this time.

Based on interview, and record review the facility did not ensure residents received treatment and care based on a comprehensive assessment and in accordance with professional standards of practice for non-pressure injuries and a change in medical conditions for 1 (R2) of 13 residents reviewed. -R2 had a left hip surgical wound that was not assessed after admission on 11/28/2023, treatments were not routinely completed as ordered, and it became infected and required intravenous antibiotics on 12/17/2023. -R2 had conflicting treatments for a left hip surgical site. Nursing admission documentation states there is a non-removal dressing, but the admission orders document to clean surgical site with normal saline followed by a dry dressing, change daily and as needed. Staff did not clarify which order to follow. -R2 had left leg weakness and increased pain on 12/10/2023 requiring a transfer using a sit to stand. The facility did not investigate or do an assessment for R2's increased weakness and pain to R2's left leg. R2 was transferred to the hospital at their family's request and a slight displacement of the femoral shaft was noted and pain medication was scheduled vs. PRN (as needed). -The facility did not arrange for a follow up Orthopedic appointment as recommended after hospitalization [DATE]. -R2 did not have compression stockings or treatments done per order R2 was documented to have +3 lower extremity edema. -R2 developed right and left lower leg blisters on 12/6/2023. There are no assessments of the blisters after 12/6/2023. R2 was admitted to the hospital on 12/17/2023 with an infection to R2's top of right foot blister requiring intravenous antibiotics. -R2 did not have assessments done for R2's bruising after admission on 11/28/2023 or monitoring of bruising. Findings include: The facility policy Entitled Skin Identification, Evaluation, and Monitoring revised on 11/2022 states: The purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. Communities will implement preventative measures and an individualized care plan will be formulated upon completion of findings. Procedure: Licensed nursing associate will evaluate the skin integrity though a physical skin evaluation and use of the Braden Skin at Risk tool. Upon admission, weekly for three weeks, quarterly and when a significant change is identified. The nursing assistant will observe the resident's skin when assisting with activities of daily living and report changes to the nurse. Weekly: The Licensed Nursing Associate: A. Complete a general skin check to evaluate for changes in skin integrity. B. Document in medical record the finding of general skin check. -1. If wound is present and previously identified: a. Document integumentary findings: i. Appearance of the wound, including measurements. ii. Treatment applied/initiated per health care provider order in the medical record. -2. If new wound is identified: a. Initiate protective dressing. b. Notify health care provider of findings and for further treatment orders. -3. Notification/ Education of resident and resident representative of finding and physician orders. -4. Document evaluation in medical record. C. Update plan of care with each intervention. The Certified Nursing Assistant (CNA) should: A. Observe skin for changes when assisting and activities of daily living. B. Cleanse skin with bath/shower and after each incontinence episode. C. Apply barrier cream, as indicated. D. Report skin integrity changes to nurse. The Director of Nursing/ Wound Champion or Designee should: A. Review skin and wound documentation to identify opportunity, as indicated. B. review medical record to identify need for diagnostic review for comorbidity relation. Communicate with physician, as indicated. C. Review newly identified skin integrity changes identified by CNA and/or licensed nursing associate. D. The interdisciplinary team (IDT) will review for completion of documentation and assist with identification for further resident centered interventions as needed. E. Care plan updated as indicated. F. The report will be available for review by the IDT. Skin Integrity Treatment Program- the treatment program will focus on the following strategies: A. Eliminate or reduce. 1. The source of pressure using positioning technique. 2. Other sources of skin integrity by evaluating the cause and providing interventions. B. Pain Control. C. Preventative measures to reduce the risk of further tissue loss. D. Managing and reducing the risk of infections. E. Interventions that increase the potential for healing. F. Nutritional evaluation and intervention as indicated. G. Managing systemic issues (edema, venous insufficiency, etc.). The facility policy entitled Procedure: Wound Care/Dressing Change revised on 5/2023 states: The purpose of this procedure is to provide guidelines for dressing changes of wounds in a sterile and non-sterile technique to promote healing. Documentation- the following information should be recorded in the resident's medical record: A. The type of wound care given. B. The date and time the wound care was given. C. The position in which the resident was placed. D. The name and title of the individual performing the wound care. E. Any change in the resident's condition. F. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Complications related to the wound. G. How the resident tolerated the procedure. Any problems or complaints made by the resident related to the procedure. H. If the resident refused the treatment, the reason for refusal and the resident's response to the explanation of the risks of refusing the procedure, the benefits of accepting and available alternatives. I. Document physician and family notifications of refusal. J. The signature and title of the person recording the data. Reporting: A. Notify the supervisor if the resident refuses wound care. B. Report other information in accordance with facility policy and professional standards of practice. R2 was admitted to the facility on [DATE] and has diagnoses that include left hip femoral neck fracture with hemiarthroplasty repair, weakness, type 2 diabetes mellitus, thrombocytopenia, gout, Cirrhosis of the liver- nonalcoholic steatohepatitis (NASH), esophageal varices, gastroesophageal reflux disease (GERD), obstructive uropathy, coronary artery disease, pulmonary hypertension, and anemia. R2's admission minimum data set (MDS) dated [DATE] indicated R2 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R2 needing assistance with set up for eating and drinking and needing maximal assistance of one staff member with personal hygiene, putting on and taking off footwear, showering, toileting, and mobility. R2 was assessed as needing 1 staff member to assist with a pivot transfers from bed or chair to wheelchair with no ambulation, and weight bear as tolerated on left leg. R2 had an indwelling catheter and was occasionally incontinent of bowel; had a stage 1 pressure injury or scar over a bony prominence or a non-removable dressing or device; surgical wound, skin tears and moisture associated skin damage (MASD). Skin Concerns [R2's name] Pressure Ulcers/Skin Prevention Care plan was initiated on 11/28/2023, which documents: [R2] is at risk for pressure ulcers and other skin related to [sic] but not limited to Braden and other skin related injuries- [R2] will maintain skin integrity without new skin related injuries over the next review period. Interventions include: - Braden scale to be completed. - Encourage proper peri hygiene and the use of barrier cream after each incontinence episode and as needed. - Observe skin for redness and breakdown during routine care. - Use pressure relieving devices, cushion, and wheelchair and off of heels, as indicated. - Follow community skin care protocol. - Treatments, as indicated, see physician order sheet. - Pressure reducing mattress on bed. - Encourage to float heels, wheelchair with cushion. - Labs to be drawn, follow treatment prescribed by physician. (Initiated on 12/6/2023) -[R2] has impaired skin integrity related to left hip surgical incision, right elbow skin tear, moisture associated skin damage (MASD) to buttocks present upon admission- [R2] will be free from signs and symptoms of infection and will demonstrate optimal healing. initiated on 11/29/2023. Interventions include: - Provide treatment as ordered. - Provide pain management as ordered. - Keep skin clean and dry. - Provide-peri care after each incontinence episode and apply skin protectant. - Educate resident and/or family to importance of frequent turning/shifting and repositioning. - Minimized force and friction applied to skin. - Pressure relief air mattress, check setting (3) and inflation every shift. Only one barrier between body and mattress (CHUX or brief, not both). R2's physician ordered the following on 11/28/2023, upon admission: - Weekly skin check . (document results of skin check in skin and wound module)- every week on Tuesdays evening shift. - Compression stockings to bilateral lower extremities. On in the morning, off at bedtime every 12 hours for bilateral lower extremity edema. - May follow facility wound nurse in (sic) regarding wound care and treatment recommendations. - Left lower extremity Surgical incision: Cleanse with normal saline, followed by dry dressing. Change daily and as needed. Update physician of any wound dehiscence, drainage, redness, increased bleeding, warmth, etc. - Enoxaprin (Lovenox) 30MG/0.3ML subcutaneous syringe. At bedtime for deep vein thrombosis (clot) prophylactic. - Furosemide 40mg- 40mg by mouth every day for edema. (Order date: 12/13/2023, start 12/14/2023). - Monthly weights every month (start date: 1/2/2024) Surveyor reviewed R2's Treatment Administration Record (TAR) for November and December 2023 and noted concerns for the following orders and dates: 1. Left lower extremity surgical incision: cleanse with normal saline followed by dry dressing. Change daily. Order date: 11/28/2023 - Surveyor noted 11/29, 12/1, 12/7, 12/9, 12/11, 12/12, 12/14, 12/15 dates are missing initials as being completed. 2. Compression stockings to bilateral lower extremities every 12 hours (AM (morning) ON)- Order date: 11/28/2023, - Surveyor noted 11/28, 11/30, 12/4, 12/5, 12/6, 12/13 have initials with off signed out indicating the compression stockings were never put on. - Surveyor noted 11/29, 12/1, 12/7, 12/11, 12/12, 12/14, 12/15 dates are missing initials indicating the compression stockings were not put on or taken off. On 1/16/2024, at 9:52 AM, Surveyor interviewed Registered Nurse Unit Manager (RN UM)-J who stated empty boxes on the TAR indicate one should assume the task was not done. RN UM-J stated if a task is not done staff is supposed to still initial and then put a note as to why it the task was not done. RN UM-J was not sure why R2's compression stockings were not put on or why R2's left hip dressing was not completed several days in November and December. RN UM-J stated nursing is supposed to review all their charting and run a missed medication report at the end of their shift to see if anything was missed. RN UM-J stated no one came to her with concerns regarding R2's compressions stockings or if R2 was refusing them. Surveyor noted there is no documentation from nursing related to R2 refusing treatments or cares. On 11/28/2023, at 12:28 PM, in the progress notes nursing charted . Resident (R2) has left surgical incision with non-removable dressing intact. Bruises noted to left arm, left hand, left forearm, right hand, right arm, right forearm, left inner leg, pubic area, left side abdomen, lower back, . penis swollen Surveyor reviewed R2's skin evaluation forms completed upon admission, dated 11/28/23 which document: -Left arm bruise, blanchable redness; no description of the area and no measurements. -Right forearm bruise, no description of the area and no measurements. -Right arm bruise, no description of the area and no measurements. -Left hand bruise, no description of the area and no measurements. -Right hand bruise, no description of the area and no measurements. -Blanchable redness to both buttocks, Moisture Associated Skin Damage (MASD), no measurements. -Blanchable redness to gluteal cleft, gluteal crease R/T (related to) MASD, no measurements. -S/T (skin tear) to right elbow R/T fall at home, unable to approximate skin, present upon admission. Length: 2.0 cm (centimeters) by Width: 0.8 cm by Depth: 0.1 cm. -Left hip surgical incision related to left hemiarthroplasty. Approximated with clean, dry, and intact staples. F/U (follow-up) with orthopedic surgeon. 18.0 (length) X 1.0 (width). Surrounding skin: bruising. Surveyor noted not all the bruising documented in R2's admission note dated 11/28/23, at 15:30 (3:30 PM) were documented on the initial skin evaluation form. Surveyor noted there are no further assessments or measurements for R2's left hip surgical wound after R2's 11/28/2023 admission assessment. There are no further assessments of R2's bruising after R2's 11/28/2023 assessments. Surveyor also noted nursing documented R2 had a non-removable dressing to left hip incision upon admission, but a treatment was ordered to the left hip area from the admitting physician. Surveyor notes the facility did not clarify with the admitting physician or the orthopedic surgeon the appropriate order for R2's left hip surgical site. Surveyor also notes the facility did not arrange a follow up orthopedic appointment for R2 upon admission to the facility. R2 was admitted to the hospital on 12/17/24 where R2's left hip surgical incision was assessed to be infected. On 12/2/2023, at 8:51 PM, in the progress notes nursing charted . left hip incision clean, dry, intact. Bruises noted to incisional side and inner legs Surveyor noted nursing does not indicate if bruising to incisional side or inner thighs is new or worsening for R2 and did not indicate if a physician was notified of observed bruising. On 12/3/2023, at 10:06 PM, in the progress notes nursing charted . left hip incision clean, dry, and intact with non-removable dressing, +3 bilateral leg edema noted, tubi-grips on. Surveyor noted nursing stated non removable dressing intact, but treatments are still scheduled and being signed by nursing as being completed with no clarification from physician or orthopedic surgeon as to the appropriate treatment for the area. Nursing also stated R2 has +3 leg edema and nursing does not indicate if this is new for R2 or if a physician was contacted, and R2 is supposed to have compression stockings on bilateral lower legs per physician order and taken off at bedtime however nursing charted that R2 had tubi grips at bedtime. Surveyor noted the facility did not clarify if appropriate for R2 to have tubi-grips instead of the ordered compression stockings. On 12/5/2023, A weekly skin/body check sheet was completed for R2, and nursing documented no new wounds or areas of concern noted for R2. On 12/6/2023, at 5:33 PM in the progress notes nursing charted new areas of concern for R2. Surveyor reviewed R2's skin evaluation forms dated 12/6/2023 and noted the new areas of concerns for R2: 1.Right foot (dorsal-top of foot)-blister, open-5.0 cm X (by) 3.0 cm, yellow serous moderate drainage. 2.Right calf-blister, closed-1.5 cm X 1.5 cm 3.Left calf-blister, closed-2.0 cm X 2.0 cm New orders obtained for R2 from physician include: - Top of right foot- clean site with normal saline, pat dry, apply Vaseline gauze to site, wrap with kerlix, and secure with tape every night. (order/start date: 12/6/2023) - Bilateral calf- Apply skin prep every 12 hours. (order/start date: 12/6/2023) Surveyor noted R2's care plan was not revised to include the new blisters that were identified, and the treatments ordered. Surveyor notes there are no further skin evaluation assessments of R2's blisters after the initial assessment on 12/6/2023. Surveyor reviewed R2's Treatment Administration Record (TAR) for December 2023 and noted concerns for the following orders and dates: 1. No initials for staff completing treatment orders for R2's top of right foot blister for evening shift on: 12/7, 12/9, 12/11, 12/12, 12/14, 12/15, 12/16, 12/17. 2. No initials for staff completing the treatment order for R2's skin prep to bilateral calves at 8:00 AM on: 12/7, 12/11, 12/13, 12/14, 12/15. 3. No initials for staff completing the treatment order for R2's skin prep to bilateral calves for evening shift on: 12/7, 12/11, 12/12, 12/14, 12/15. Surveyor notes R2 was transferred to the hospital on 12/17/23 due to a change in condition and was assessed to have bruising all over the upper right torso and arms, multiple areas with open wound and purulent drainage, lower leg edema and need for IV (intravenous) Lasix and antiboitics, right leg wound infection, right foot wound infection, and left hip infection. Change of Condition/Transfer Status On 12/10/2023, at 11:25 AM, nursing charted in the progress notes . [R2] unable to transfer with certified nursing assistant (CNA) to bathroom using walker to transfer to toilet. Nursing charted two CNA's and nurse transferred [R2] using a sit to stand (mechanical lift) to toilet [R2] and then [R2] placed in bed. Nursing charted about half hour later nursing received call from [R2]'s family and stating [R2] was in a lot of pain and wanted to go to the hospital. Nursing charted [R2] complaining of pain in left hip area, left hip swollen with 3+ edema noted. [R2] sent to emergency room . Surveyor reviewed R2's 12/10/2023 emergency room provider notes that stated: . Presents from nursing home via ambulance for left hip pain and left lower leg swelling. Patient had a hip replacement after left femoral neck fracture following a fall 1 month ago.Patient reports he has not been able to ambulate due to pain and swelling which has worsened since his arrival at the subacute rehab. Patient reported the pain is a 10 prior to arrival and given fentanyl. Imaging X-ray left hip: Comparison: 11/13/23 and prior Findings: . A mildly displace greater trochanteric fracture fragment is again noted. There is also linear fracture fragments adjacent to the medial proximal femur. X-ray left hip Impression: -Left hip arthroplasty in near-anatomic alignment. The previously noted trochanteric fracture fragment is mildly displaced. There are also linear fragments along the medial proximal femur which are slightly displaced from the femoral shaft, not previously visualized. Consider orthopedic consultation. Medical Decision Making: - . Can not find any follow-up with orthopedic surgeon since [R2] was discharged from the hospital. [R2] advised that they need to call orthopedic surgeon tomorrow to schedule follow-up for further recommendations. Surveyor noted the facility did not investigate why R2 was not able to pivot transfer during toileting and had to use a sit to stand. The facility did not arrange a follow-up appointment with orthopedic surgery for R2 to assess the left hip surgical site or investigate the results of the left hip x-ray completed in the hospital. On 12/11/2023, documented as a late entry with a documentation date of 12/21/2023 at 23:33 (11:33 PM) Writer notified by CNA she had to slide resident to the floor while transferring him to the bed. Resident alert & (and) oriented per usual. Denies any c/o (complaint of) pain or discomfort. Returned to bed. Surveyor notes the documentation does not identify when the fall occurred. The CNA statement does not document the day or time of the fall. (Cross Reference F689) On 12/13/2023 at 2:25 PM in the progress notes nursing charted . R2 left side swollen, +3 bilateral leg edema noted Surveyor noted nursing did not indicate if this was new swelling or worsening or if physician was notified. On 12/16/2023, at 8:35 PM, in the progress notes nursing charted . abdomen distended, bruised, multiple old, bruised areas noted, penis swollen. Surveyor noted nursing did not indicate where the bruising was on R2 or investigate into how R2 got the bruising. Nursing did not indicate if physician was consulted with regarding R2's bruising, distended abdomen, and swollen penis. On 12/17/2023, at 10:26 PM, in the progress notes nursing charted [R2] appeared more tired with poor appetite. right foot blister dressing was changed and bilateral leg weeping. Surveyor noted there is no documentation R2's physician was consulted with and there were no assessments completed on the bilateral leg weeping regarding if there were new areas of concerns or if R2's blisters on the right and left calves worsened. On 12/17/2023, at 12:26 AM, documented on 12/18/2023 at 12:26:51 AM, in the progress notes nursing charted [R2] confused and appears jaundiced, appetite poor. [R2] has increased pain to left hip, +3 lower extremity edema, body swollen, penis swollen. [R2]'s family at bedside and requesting [R2] be transferred to the hospital. [R2] was sent to the hospital. On 12/18/2023, at 3:20 PM, in the progress notes nursing charted [R2] was admitted to the hospital with acute kidney injury and altered mental status. (Cross Reference F690) Surveyor reviewed the hospital progress note from R2's hospital admission on 12/17/2023. The notes state: -Acute metabolic encephalopathy -Hypotension -Failure to thrive, generalized weakness, left hip fracture. -Has bruising all over [R2]'s upper torso and arm, multiple areas with open wound and purulent drainage. -Concern for poor care at facility Left hip pain. -Has some drainage-sent for culture. Lower Leg Edema -Acute on Chronic diastolic congestive heart failure -Needs intravenous Lasix but due to hypotension (low blood pressure) will try cautious fluids until blood pressure improved then will need aggressive diuresis. Irregular Heart Rate. -Concern for Atrial Fibrillation -Acute Kidney Infection. Likely due to infection Evaluation: -appears edematous, bruising to body. -according to ER nurses, foley had sediment around it and was replaced. -fluid overload, elevated BNP (Brain Natriuretic Peptide) -oral membranes dry. -Rocephin IV given for 1 wound on right leg-purulent drainage. Wound cultures from left hip surgical incision and right top of foot blister grew MSSA (methicillin-susceptible staphylococcus aureus, bacteria commonly found on skin staph infection) Urine culture grew klebsiella oxytoca. Infectious Disease was consulted in the hospital, [R2] was started on intravenous antibiotics for infections. On 1/10/2024, at 12:57 PM, Surveyor interviewed registered nurse unit manager (RN UM)-J who stated RN UM-J recalled R2 having a lot of bruising to R2's body when admitted to the facility. Surveyor asked RN UM-J if bruising should be monitored for residents. RN UM-J stated bruising should be monitored for residents to monitor if bruising is improving or investigate reasoning if bruising is new. RN UM-J recalled assessing R2's blistering to R2's right and left lower extremities. RN UM-J is not sure why there are no other skin evaluations for R2's right and left lower leg blistering, left hip incision site, or bruising to R2's body. RN UM-J stated wound rounds are done weekly and R2's bruising, blistering, and left hip incision would have been looked at. RN UM-J did not recall R2 having issues with R2's left hip incision or blisters and did not recall staff expressing concerns regarding R2's left hip incision site, bruising, or right and left lower leg blisters. On 1/11/2024, at 10:00 AM, Surveyor interviewed licensed practical nurse (LPN)-I who stated LPN-I recalled R2 having a lot of bruising and swelling issues. LPN-I stated R2's bruising and swelling was from admission throughout R2's stay at the facility. Surveyor asked if LPN-I ever notified physician regarding R2's bruising and swelling and changes in swelling. LPN-I stated LPN-I could not recall if R2's physician was notified or not, but LPN-I usually charts physician notification if LPN-I notified the physician. LPN-I stated LPN-I did not remember having concerns regarding R2's left hip surgical site or blistering on lower legs. Surveyor asked LPN-I regarding LPN-I's charting about R2's +3 lower extremity edema, and swollen penis. LPN-I stated R2 was always swollen on R2's body, not sure if it was more at the time of charting or not. On 1/11/2024, at 11:45 AM, Surveyor interviewed Registered Nurse Unit Manager (RN UM)-J who stated when a resident gets admitted into the facility or comes back from an appointment any follow-ups the resident needs will get put into the computer and the scheduler will make the appointment and arrange for transportation if needed. Surveyor asked RN UM-J if R2's urology and orthopedic surgery follow-up appointments were followed through with per R2's discharge instructions from prior facility. RN UM-J stated RN UM-J did not see R2's paperwork and would have to check if the urology and orthopedic surgeon appointments ever got made for R2. On 1/11/2024 at 3:32 PM Surveyor interviewed LPN-W who stated LPN-W recalled R2's left hip incision looking good. LPN-W stated there was an area that had a little clear drainage. LPN-W stated LPN-W put a foam dressing over area. Surveyor asked LPN-W if the physician was notified regarding the area on R2's left hip incision. LPN-W stated LPN-W did not have any concerns with the are on the left hip incision. Surveyor asked LPN-W if LPN-W measured the area or made the unit manager aware of the area and that a foam dressing was applied to R2's left hip surgical site area. LPN-W stated LPN-W did not think to measure or anything because LPN-W did not have any concerns. LPN-W stated LPN-W did not look at the orders for R2, LPN-W just applied the dressing for R2's comfort. LPN-W also stated LPN-W did not have any concerns regarding R2's lower extremity blisters. On 1/16/2024, at 9:52 AM, Surveyor interviewed RN UM-J who stated RN UM-J could not see that R2's urology appointment was ever made to follow-up with R2's catheter and that an appointment was never made with the orthopedic surgeon either for R2. Surveyor asked RN UM-J what empty boxes mean on the TAR where nursing initials once the task is completed. RN UM-J stated that if a box is left empty then assume the task was not done. RN UM-J stated that if a task is not done staff is supposed to still initial and then put a note as to why it the task was not done. RN UM-J was not sure why R2's cares were not done on the several days in November and December. RN UM-J stated nursing is supposed to review all their charting and run a missed medication report at the end of their shift to see if anything was missed. RN UM-J stated no one came to her with concerns regarding R2. Surveyor asked RN UM-J about R2's left hip incision dressing and if it stays non removable dressing but there is a treatment ordered, what does the facility do. RN UM-J stated staff did not get a clarifying order regarding R2's dressing to the left hip area and that some staff was doing a treatment and other staff was not. RN UM-J stated there was not a flag at the time to get a clarifying order for R2's left hip dressing. Surveyor asked RN UM-J if there was an investigation into 12/10/2023 when R2 was unable to bear weight on R2's left leg and had to be transferred by a sit to stand. RN UM-J stated there was not an investigation because R2's did not have any concerns when working with therapy. Surveyor asked RN UM-J if therapy was aware of R2 needing to use a sit to stand on 12/10/2023. RN UM-J was not sure if therapy was aware that R2 needed to use a sit to stand on 12/10/2023. On 1/16/2024, at 10:00 AM, Surveyor interviewed facility Scheduler-V who stated Scheduler-V does not recall making an appointment for a urology or orthopedic follow-up for R2. Scheduler-V stated she also does not see she arranged transportation for R2 to any appointments. Surveyor asked Scheduler-V how Scheduler-V is notified of a need for an appointment. Scheduler-V stated she will get a note from nursing or from the resident's paperwork when the resident comes back from an appointment. On 1/16/2024, at 11:41 AM, Surveyor interviewed Medical Doctor (MD, primary physician)-K who stated MD-K saw R2 on 11/29/2023, 12/6/2023, and 12/12/2023 and noted R2 had lymphedema in the lower extremities. MD-K stated MD-K does not recall if the facility staff notified MD-K of R2's lower extremity edema, swollen penis, or distended abdomen. MD-K stated when MD-K assessed R2 on 12/12/2023 MD-K did not have any red-flags regarding R2. MD-K stated R2's albumin was slightly low and R2 was anemic which contributed to R2's lower leg edema but R2's kidney function was normal, so MD-K did not have concerns at that time. Surveyor asked MD-K if MD-K had any concerns regarding R2's left hip incision or lower leg blistering. MD-K could not recall if MD-K saw the blistering or left hip incision but wrote orders for the wound nurse to follow R2 for R2's left hip surgical incision and lower leg blistering. MD-K stated the facility did not contact MD-K regarding concerns of R2's wounds. On 1/16/2023, at 3:00 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A. No further information was given at this time.

Based on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries received care consistent with professional standards of practice to prevent pressure injuries from developing for 3 (R4, R7, and R10) of 5 residents reviewed for pressure injuries. *R4 developed a Deep Tissue Injury (DTI) to the right outer ankle and a DTI to the right heel on 10/25/2023. The right heel was documented as an Unstageable pressure injury with characteristics of a DTI. Antibiotics were ordered on 10/25/2023 due to the presentation of the right heel pressure injury with potential for osteomyelitis. The right ankle pressure injury was not comprehensively assessed weekly from 10/25/2023 through 11/21/2023. No revision was made to the Care Plan when the pressure injuries were discovered. The Registered Dietician was not informed of the pressure injuries. Antibiotics were ordered on 11/13/2023 due to the presentation of the right ankle pressure injury. R4 was hospitalized from 11/22/2023 through 11/27/2023. Hospital documentation showed R4 had an Unstageable pressure injury to the right heel with 100% eschar, an Unstageable pressure injury to the right lateral ankle with 100% eschar, and a DTI to the right lateral fifth metatarsal. R4's pressure injures were not assessed upon readmission. R4 also developed an unstageable pressure injury to the right inner buttock. R4's pressure injuries deteriorated on the foot with the hospital noting R4's boot was applying pressure to R4's foot wounds. The facility did not address this in a plan of care. R4 developed additional facility acquired wounds including one to their shin from the pressure relieving boot strap resting on the other leg. *R7 needed extensive assistance with bed mobility. R7 was under Hospice care and Hospice ordered an air mattress for R7 on 9/21/2023 that was never implemented by the facility until 11/8/2023 when R7 developed an Unstageable pressure injury. Per interview with Hospice, the air mattress was attempted to be delivered twice and the facility refused the delivery. Hospice and R7 reported R7 was not turned or repositioned on a regular basis prior to implementation of the air mattress on 11/8/2023. A treatment was ordered for the coccyx wound on 11/6/2023; no documentation was found indicating R7 had a wound on 11/6/2023. Per interview with Hospice, R7 had two open areas: the coccyx and the left upper buttock. An Unstageable pressure injury was discovered on 11/8/2023 to the left upper buttock with eschar and slough noted. The wound did not have any depth measurement or percentage of tissue type in the wound bed. The pressure injury had green drainage and a mild odor. Antibiotics were ordered for a wound infection. The Registered Dietician was not informed of the new pressure injury. Antibiotics were reordered on 11/14/2023 due to continuation of green drainage and mild odor to the wound. The pressure injury did not have a depth measurement until 12/26/2023 where the depth was documented as 3 cm with 100% granulation tissue to the wound bed. The pressure injury was not staged, and the undermining was not measured. On 1/9/2024, the pressure injury had a sinus tract that measured 0.3 cm with no change to treatment. During observation of wound care on 1/11/2024, the Registered Nurse Unit Manager (RN UM) took scissors out of the scrub pocket and cut calcium alginate to the size of the wound bed without disinfecting the scissors before use. Nursing staff placed R7's heels directly on the pillow under the legs instead of floating the heels. Surveyor questioned the placement of R7's feet and staff then floated R7's heels. Treatments were not signed out as being completed on the Treatment Administration Record (TAR). *R10 needed maximum assistance with bed mobility and did not have repositioning as an intervention in the Skin Prevention Care Plan. R10 developed an open area to the mid lower back that was discovered on 10/27/2023. No etiology of the wound was documented. On 10/30/2023, the location of the Stage 3 pressure injury is described as the upper right coccyx and measures 1 cm x 1 cm with no depth measurement with 50% slough and red pink. No depth of the pressure injury is measured at any time. Documentation in the Progress Notes states R10 had an open wound to the upper back and buttock. No further documentation was found to clarify if R10 had a second wound. The Registered Dietician was not informed of the new pressure injury. The wound declines, gradually increases in size with 100% slough. A Deep Tissue Injury (DTI) was discovered on 11/30/2023 to the right heel. The Registered Dietician was not informed of the new pressure injury. No revisions were made to the Care Plan. On 1/2/2024 the DTI has open areas that were not comprehensively assessed, and the staging of the wound was inaccurate. Surveyor observed R10 being repositioned in bed by facility staff. R10's heels were placed directly on the pillow under the legs and not floated. Treatments were not signed out as being completed on the Treatment Administration Record (TAR). Findings include: The facility policy and procedure entitled Skin Identification, Evaluation and Monitoring dated 11/2022 states: Weekly: The Licensed Nursing Associate: A. Complete a General Skin Check to evaluate for changes in skin integrity. B. Document in medical record the finding of general skin check 1. If wound is present and previously identified: a. Document integumentary findings i. Appearance of the wound, including measurements ii. Treatment applied/initiated per health care provider order in the medical record. 2. If new wound is identified: a. Initiate protective dressing b. Notify health care provider of findings and for further treatment orders 3. Notification/Education of resident and resident representative of finding and physician orders 4. Document evaluation in the medical record. C. Update plan of care with each intervention. The Director of Nursing/Wound Champion or Designee should: A. Review skin and wound documentation to identify opportunity as indicated. B. Review medical record to identify need for diagnostic review for comorbidity relation. Communicate with physician, as indicated. C. Review newly identified skin integrity changes identified by CNA and/or Licensed Nursing associate. D. The interdisciplinary team (IDT) will review for completion of documentation and assist with identification of further resident centered interventions as needed. E. Care plan updated as indicated F. The report will be available for review by the interdisciplinary team (IDT). The International Pressure Injury Advisory Panel has the following definitions for the Stages of Pressure Injuries: -Stage 1 Pressure Injury: Non-blanchable erythema of intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema 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 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. -Stage 3 Pressure Injury: 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 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 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 erythema 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 epidermal 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). 1.) R4 was admitted to the facility on [DATE] with diagnoses of cancer of the oropharynx resulting in getting the majority of nutrition through a gastrostomy (G-tube) with some oral intake, depression, dementia, Wernicke's encephalopathy, anxiety, and renal cancer. R4's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R4 was severely cognitively impaired and R4's Power of Attorney (POA) was activated. The MDS indicates R4 has one unstageable-deep tissue injury, is at risk for pressure injuries and has no venous wounds but does have an infection on the foot. R4 was admitted to the hospital 9/26/2023 for hyponatremia and was readmitted to the facility on [DATE]. R4's comprehensive Care Plan in place on 10/3/2023 included: Activities of daily living (ADL) Care Plan with the following interventions: -limited assistance of 1 for bed mobility, encourage to lay on back or left side, use pillows for positioning, encourage to float heels, res prefers to stay in bed, discourage res when noted in bed rubbing heels/feet back and forth. -incontinent of bowel and bladder, assist as needed. -extensive assistance with toileting Surveyor noted facility was aware R4 rubbed the heels/feet on the bed back and forth causing friction and no heel boots were implemented. PRESSURE ULCERS/SKIN PREVENTION Care Plan with the following interventions: -Braden Scale to be completed per policy and as needed. -Do not use excess pads. -Observe skin for redness and breakdown during routine care. -Use pressure relieving devices as indicated: wheelchair cushion, pressure relieving mattress. -Follow community skin care protocol. -Treatments as indicated, see physician order sheet. -Pressure reducing mattress on bed: 9/25/2018 pressure relief air mattress, check setting and function every shift and as needed, one barrier between body and mattress (either brief or chux pad, not both). -Encourage to float heels on pillows as allows - (R4) noted to frequently kick away. -When (R4) observed with knees to chest or sliding feet back and forth on bed causing friction, redirect R4 and encourage to float heels on pillow, offer to get up in wheelchair. -Offer and encourage to use heelz up cushion with pillow on top to assist with offloading, (R4) noted to pull knees to chest frequently and kick pillows away, check placement with every encounter. -Encourage to use pressure relieving boots on when up in wheelchair. -Encourage and assist with repositioning as indicated. -Encourage head of bed no more than 30 degrees. -Observe for verbal and non-verbal signs and symptoms of discomfort. -Encourage proper peri hygiene and the use of barrier cream after each incontinence episode and as needed. -Recurring self-inflicted scratch marks to left shoulder, lotion applied, refuses to allow staff to cut nails. Surveyor noted R4's Pressure Ulcers/Skin Prevention Care Plan did not include a turning and repositioning program and the heel boots were only to be used in the wheelchair and not when in bed where R4 was at risk of pressure from rubbing heels on bed. R4 had the following orders in place: -Multivitamin daily started 8/12/2020. -Jevity 1.2 cal 240 cc started 12/28/2021. -Skin prep to bilateral heels twice daily started 3/26/2020. -Low air loss mattress check function started 3/27/2020. On 10/20/2023 on the Shower Day Weekly Skin/Body Check/Weight/Hygiene Report, the Certified Nursing Assistant (CNA) marked R4 did not have any skin concerns. On 10/24/2023 on the Shower Day Weekly Skin/Body Check/Weight/Hygiene Report, the CNA wrote in the skin section of the form R4 had a rash all over. The form was signed by the CNA and the nurse. No other documentation was found on that day for skin concerns. On 10/24/2023, R4's Braden score was 14 indicating moderate risk for development of a pressure injury. On 10/25/2023 on the Skin Evaluation Form, Registered Nurse Unit Manager (RN UM)-J documented the right outer ankle had a Deep Tissue Injury (DTI) that measured 4 cm x 4 cm that was purple with redness to peri wound and extending above. No further documentation of area was found until 11/21/2023, 4 weeks later. On 10/25/2023 on the Skin Evaluation Form, RN UM-J documented the right heel had an Unstageable pressure injury that measured 6.6 cm x 5.2 cm x Unable to Determine (UTD). The site was dark purple and the was skin intact. Surveyor noted the pressure area should have been documented as a DTI due to the characteristics of the pressure injury. RN UM-J completed a Skin Evaluation Form on 10/31/2023 and 11/7/2023 for the right heel pressure injury. RN UM-J documented the wound with similar measurements and as being Unstageable but with characteristics of a DTI. On 10/25/2023, R4 was seen by the Nurse Practitioner (NP) who documented R4 had a new DTI to the right heel. R4 was in excruciating pain during examination of the right heel. The right posterior heel had various discolorations with purple and maroon with mild erythema that extended to the inner part of the foot/heel. R4 had pain with movement and palpation. The NP did not document any observation of the right ankle. The NP ordered antibiotics for possible cellulitis and ordered a STAT x-ray of the right calcaneus to rule out osteomyelitis. The NP documented to continue to monitor for worsening skin integrity, strict 2-hour turning, continue with Prevalon boots with elevation of bilateral lower extremities, and defer to wound care nurse recommendations. The contingency plan was to consult wound care as needed for new or worsening symptoms. Surveyor noted R4 was not seen by any wound physician, wound nurse, or wound clinic. Strict 2-hour turning was not added to the Care Plan. The treatment of Skin Prep to the heels continued as the treatment from 3/26/2020. Prevalon boots to bilateral lower extremities was added to the Medication Administration Record/Treatment Administration Record (MAR/TAR) on 10/25/2023. Cipro 500 mg every 12 hours for cellulitis started on 10/25/2023 and was discontinued on 10/26/2023. Doxycycline 100 mg twice daily was ordered 10/26/2023-11/9/2023 for cellulitis. Augmentin 500 mg twice daily was ordered 10/28/2023-11/8/2023 for foot wound. X-rays were ordered on 10/25/2023 of the right calcaneus/ankle to rule out osteomyelitis and an arterial (doppler) study was ordered. Results of the x-ray was no osteomyelitis was present. A Pressure Injury Investigation Form was completed by the facility on 10/25/2023 indicating the pressure injury was unavoidable. The form had the following information: Routine preventive care provided - use of pressure reducing surfaces, skin care, clean and dry bed linens, nutritional interventions to meet resident needs with tube feeding. (Surveyor noted Consistent turning and repositioning was not marked as being provided.) Primary risk factors 2 or more diagnoses present - Peripheral Arterial Disease (PAD), chronic bowel incontinence, failure to thrive, chronic urinary tract infection (UTI). (Surveyor noted bowel incontinence and UTI would not affect pressure injuries to the feet.) Treatments 2 or more present - head of bed elevated most of the day for J (jejunostomy) Tube. (Surveyor noted only one treatment was marked.) Signs of Malnutrition - sallow skin tone, cachexia (wasting syndrome), muscle wasting, reduced urinary output. Handwritten on the side of the form was doppler ordered, Severe PAD peripheral arterial disease), vascular consult need. Preventative Measures implemented - Encourage turning/repositioning, pressure reducing mattress, encourage floating heels, pressure relieving boots, peri care, barrier cream, encourage frequent turning, consult dietary, PEG tube feeding, water flushes, liquid at bedside. Summary was the pressure injury was unavoidable. Surveyor noted not all sections of the form had the required number of treatments to determine unavoidability and the interventions were to encourage R4 rather than ensure heels were floated. On 10/30/2023, the Doppler arterial study of right lower extremity was completed. The report stated R4 had a history of a pressure ulcer to the heel/necrotic right heel and the impression on the report stated R4 had moderate to severe Peripheral Vascular Disease without occlusion. On 10/31/2023 at 1:29 PM in the progress notes, nursing charted the physician and NP were aware of the doppler results and a new order was obtained for a vascular consult secondary to severe PAD. On 11/1/2023 at 8:24 PM in the progress notes, nursing charted R4's boots were off due to erythema noted to the right lateral malleolus (ankle). Skin Prep was applied, and heels were floated on two pillows. R4 had momentary discomfort with repositioning. On 11/3/2023, R4 received an order for Skin Prep to bilateral ankles every 12 hours. On 11/13/2023, R4 was seen by the NP who charted R4 had a new right ankle DTI with accompanying erythema surrounding the ankle and going up the lower leg. The NP charted the NP was unable to measure the two DTIs due to R4's extreme pain and discomfort during the examination. The NP charted antibiotics were started by the physician and labs were ordered. The plan was to continue to monitor for worsening skin integrity, strict 2-hour turns, continue Prevalon boots with elevation of bilateral lower extremities, and defer to wound care RN recommendations. For new or worsening symptoms, obtain STAT x-ray of right ankle to rule out osteomyelitis and consult with wound care as needed. Surveyor noted the right ankle DTI was present since 10/25/2023 and had not been assessed after the initial encounter. Surveyor noted R4 was not seen by any wound physician, wound nurse, or wound clinic. Strict 2-hour turning was not added to the Care Plan. R4 had the following orders from the NP: -Doxycycline 100 mg twice daily for skin structure infection, then changed on 11/14/2023 for prophylaxis through 11/21/2023. -Amoxicillin 500 mg every 12 hours for prophylaxis through 11/21/2023. Surveyor noted there were no orders for culture of the wound(s) to coincide with the antibiotics. On 11/14/2023, R4 received a treatment order for the right ankle: clean site with normal saline, pat dry, skin prep to peri wound, apply Silvadene to site, and cover with dry dressing daily. Surveyor noted there was no comprehensive assessment of the right ankle pressure injury showing the need for a treatment change; Silvadene is typically ordered for an open pressure injury with slough present to the wound bed (Stage 3 or 4.) On 11/14/2023 on the Skin Evaluation Form, Assistant Director of Nursing (ADON)-E documented R4's right heel pressure injury was a DTI measuring 6 cm x 5 cm with intact skin. On 11/21/2023 on the Skin Evaluation Form, RN UM-J charted DTI to the right outer ankle measured 4 cm x 3.8 cm that was purple with redness to peri wound and extending above. Surveyor noted this was the same description as 10/25/2023 yet the wound was receiving Silvadene as the treatment. On 11/21/2023 on the Skin Evaluation Form, RN UM-J charted the right heel DTI measured 6 cm x 5 cm, and the right heel DTI was intact. On 11/22/2023, R4 had an order on the MAR/TAR for Silvadene 1% topical cream for pressure ulcer twice daily with no location of where the Silvadene was to be applied. No wound description charted of the right heel or right outer ankle showed a pressure injury was open. R4 was admitted to the hospital on 11/22/2023 for seizure activity. HOSPITAL DOCUMENTATION On 11/24/2023 R4 had a wound consult which documented the following: Right heel pressure injury is dry stable eschar which wraps the posterior heel and extends to the plantar surface. Base is black with outer area of the wound a light maroon color indicating initial wound was a DTI. No peri wound erythema, induration, or increased warmth. Lateral right ankle dry brown, black eschar base with light maroon, no peri wound erythema, induration, or increased warmth. Fifth lateral metatarsal DTI, light maroon in color, no erythema. Foot cleansed, all areas skin prepped and left open to air. R4 made no indication of discomfort. Eyes closed during assessment, no response to verbal stimuli. Left heel intact, heel lift boot intact. Heel lift boot removed from right foot; right foot off loaded without boot due to lateral pressure from boot on wounds. Sequential Compression Devices intact, bony prominences padded. R4 is on a mattress overlay to relieve pressure. Per nurse buttock and peri area skin intact, barrier cream used. Current Braden score 10. Right heel ulcer, per record started 9/23/2023. -11/24/2023 right heel pressure ulcer Unstageable 100% eschar 10 cm x 5 cm x 0.1 cm, cleansed with warm water, foam border Ag. -11/24/2023 right lateral malleolus Unstageable 100% eschar 3 cm x 3.5 cm x 0.1 cm, cleansed with warm water, open to air. -11/24/2023 right lateral fifth metatarsal DTI maroon 1.8 cm x 1 cm x 0.1 cm, cleansed with warm water, open to air. Plan: Dressing change: skin prep, open to air, off load at all times, weekly follow up and as needed, no instructions to R4 as no response to verbal communication. R4 was readmitted to the facility on [DATE]. The order for Multivitamin daily was discontinued 11/27/2023 upon readmission. R4's Care Plan was reinstated with added interventions to wear Prevalon boots and continue to encourage resident to float heels. This was in the MAR/TAR previously. Surveyor noted R4's Pressure Ulcers/Skin Prevention Care Plan did not include a turning and repositioning program. Surveyor also noted the hospital evaluation of the wounds on R4's feet indicated a boot was applying pressure to R4's feet and was removed in the hospital. On 11/27/2023 on the Skin Evaluation Form, nursing charted the right outer ankle had a wound that measured 3.01 cm x 2.02 cm with no depth documented with necrotic tissue with eschar. No etiology or staging of the wound was given. On 11/27/2023 on the Skin Evaluation form, nursing charted the right heel had a wound that measured 2.8 cm x 3.1 cm with no depth documented with necrotic tissue and eschar and was Unstageable. No etiology of the wound was given. On 11/27/2023 on the Skin Evaluation form, nursing charted the left outer foot had a wound that measured 1 cm x 0.2 cm and was described as a linear dark red wound with clean borders and dry. No etiology or staging of the wound was given. Surveyor noted the hospital documentation of pressure injuries did not correlate with the facility assessment of the wounds with nothing noted to the right lateral foot as in the hospital and the measurements were very different for the right outer ankle and right heel. On 11/28/2023 on the Skin Evaluation Form, Assistant Director of Nursing (ADON)-E charted the right outer ankle pressure injury was Unstageable measuring 3 cm x 4 cm x UTD (unable to determine) with 50% eschar, 50% brown scab and present on admission. The physician and NP were updated, and a treatment was in place (Skin Prep to right ankle every shift.) On 11/28/2023 on the Skin Evaluation Form, ADON-E charted the right heel pressure injury was Unstageable measuring 6 cm x 10 cm x UTD with the right heel wound extending throughout entire heel with necrotic tissue. The wound was present upon admission, the physician and NP were updated, and a treatment was in place (Skin prep to right heel every shift). No depth of the wound was measured, and no percentage of tissue type was documented. On 11/28/2023 on the Skin Evaluation Form, ADON-E charted the left outer foot wound was a Stasis/Venous Ulcer measuring 1 cm x 1.5 cm x UTD. The wound was closed non-blanchable redness to the left outer foot with light pink patchy areas scattered to left foot that was present upon admission. The physician and NP were updated, and a treatment was in place (Skin Prep to left outer foot twice daily). Surveyor noted a Stasis/Venous ulcer would be an open area and the description of the wound is consistent with a DTI pressure injury. Surveyor noted the hospital documentation is of the right lateral fifth metatarsal and not the left outer foot. On 11/28/2023, R4 was seen by the NP who charted R4 had two chronic DTIs to the right heel and right ankle that remained unchanged. Surveyor noted R4's pressure injuries prior to hospitalization were DTIs and on readmission were Unstageable pressure injuries with eschar and necrotic tissue. RIGHT OUTER ANKLE - measured weekly as follows: -12/5/2023 Unstageable pressure injury measuring 3 cm x 4 cm x UTD with 50% eschar necrotic tissue and 50% brown scabbed area. -12/12/2023 Unstageable pressure injury measuring 3 cm x 4 cm x UTD with 50% eschar necrotic tissue and 50% brown scabbed area. -12/19/2023 Unstageable pressure injury measuring 3 cm x 3.8 cm x UTD with 50% eschar necrotic tissue and 50% brown scabbed area. -12/26/2023 Unstageable pressure injury measuring 3.5 cm x 4 cm x UTD with 50% eschar necrotic tissue and 50% brown scabbed area. -1/2/2024 Unstageable pressure injury measuring 4.2 cm x 4 cm x UTD with 50% eschar necrotic tissue and 50% brown scabbed area. Treatment was changed to cleanse with normal saline, skin prep to surrounding wound, betadine swab and foam dressing twice weekly on Tuesday and Friday. -1/9/2024 Unstageable pressure injury measuring 4 cm x 4 cm x UTD with 75% stringy slough with 25% eschar necrotic non-adherent tissue/scab to wound base. RIGHT HEEL - measured weekly as follows: -12/5/2023 Unstageable pressure injury measuring 6 cm x 9.6 cm x UTD with the right heel wound extending throughout entire heel with necrotic tissue. -12/12/2023 Unstageable pressure injury measuring 6 cm x 9.6 cm x UTD with the right heel wound extending throughout entire heel with necrotic tissue. -12/19/2023 Unstageable pressure injury measuring 6 cm x 9.6 cm x UTD with the right heel wound extending throughout entire heel with necrotic tissue. -12/26/2023 Unstageable pressure injury measuring 6 cm x 10.5 cm x UTD with the right heel wound extending throughout entire heel with necrotic tissue. -1/2/2024 Unstageable pressure injury measuring 6 cm x 10.5 cm x UTD with the right heel wound extending throughout entire heel with necrotic tissue. Treatment was changed to cleanse with normal saline, skin prep to surrounding wound, betadine swab and foam dressing twice weekly on Tuesday and Friday. 1/9/2024 Unstageable pressure injury measuring 6 cm x 7 cm x UTD with the right heel wound extending throughout entire heel with necrotic tissue. LEFT OUTER FOOT - measured weekly as follows: -12/5/2023 Stasis/Venous Ulcer measuring 1 cm x 1.3 cm x UTD with closed non-blanchable redness to the left outer foot with light pink patchy areas scattered to left foot that was present upon admission. -12/12/2023 Stasis/Venous Ulcer measuring 1 cm x 1.2 cm x UTD with closed non-blanchable redness to the left outer foot with light pink patchy areas scattered to left foot that was present upon admission. -12/19/2023 Stasis/Venous Ulcer measuring 1 cm x 1 cm x UTD with closed non-blanchable redness to the left outer foot with light pink patchy areas scattered to left foot that was present upon admission. -12/26/2023 Stasis/Venous Ulcer measuring 1 cm x 1 cm x UTD with closed non-blanchable redness to the left outer foot with light pink patchy areas scattered to left foot that was present upon admission. -1/2/2024 wound healed with blanching skin. Surveyor noted the wound description is the definition of a DTI with non-blanchable skin; a Stasis/Venous ulcer would be an open wound. R4 had an order for a hospice consult and hospice services started on 12/29/2023. On 12/28/2023 on the MAR/TAR, R4 had an order for the right inner buttock Stage 2 treatment: soap and water, zinc daily. No documentation was found of any pressure injury to the right buttock. The treatment order was discontinued on 1/9/2024. Surveyor reviewed the MAR/TAR for October 2023, November 2023, December 2023, and January 2024 and noted treatments to the right heel, right ankle, and left outer foot were not consistently signed out as being completed. On 1/10/2024 at 3:51 PM, Surveyor observed R4 sleeping in bed. R4 had pillows to the right side of the bed by the wall with knees drawn upwards. R4 had an air mattress in place. In an interview on 1/11/2024 at 9:58 AM, Certified Nursing Assistant (CNA)-N stated R4 needed total assistance with bed mobility and eating, but R4 refuses to eat. CNA-N stated food is offered to R4 at mealtimes, but R4 refuses any food offered. On 1/11/2024 at 10:12 AM, Surveyor observed R4's wound care by Licensed Practical Nurse (LPN)-M and RN UM-J. R4 had a heel boot on the left foot that was up around the calf and barely on the foot exposing the outer foot and heel and offering no protection from pressure. The left outer foot had a reddened area that measured approximately 1.5 cm x 1.5 cm. Surveyor noted per charting, the left outer foot wound had healed. The right outer ankle had a dressing in place dated 1/8 (Monday) and the dressing was scheduled to be changed on Tuesdays and Fridays which would have been 1/9/2024. The right outer ankle pressure injury measured approximately 3 cm x 3 cm x 0.5 cm with 100% slough including a long flap of tissue attached at the upper portion of the wound that RN UM-J was not sure how to treat. RN UM-J cleansed the area and applied betadine, then covered with a foam dressing. The peri wound was red and inflamed. The right heel had an eschar cap that measured approximately 5 cm x 3 cm with red and inflamed peri wound. R4's right foot and leg were observed with the following pressure areas of concern: -The right bunion had a dark discolored area that measured approximately 1.5 cm x 1.5 cm with a calloused center that measured approximately 1 cm x 1 cm. -The right shin had a large, scabbed or eschar area that measured approximately 3 cm x 1 cm with inflamed red skin surrounding the wound. Surveyor noted the wound appeared to be lined up with the top of the boot or the Velcro portion of the boot that would be highly abrasive to the skin. -The right inner ankle was dark red. Surveyor aske [TRUNCATED]

Based on interview and record review, the facility did not ensure residents who have indwelling catheters were assessed for removal as soon as possible unless clinical conditions demonstrate catheterization is necessary and received appropriate treatment and services to prevent urinary tract infections for 1 (R2) of 2 residents reviewed for incontinence. R2 was admitted to the facility with a Foley catheter. R2's admission paperwork to the facility recommended a urology follow up appointment for R2's Foley catheter. The facility did not arrange a follow up urology appointment and there was no attempt at a trial removal of R2's Foley catheter. On 12/17/2024, R2's family requested R2 be transferred to the hospital for further evaluation. R2 was diagnosed with a Catheter-Associated Urinary Tract Infection (CAUTI). Antibiotics were administered. R2 became mentally altered and developed acute kidney injury. Findings include: The facility policy entitled PROCEDURE: Catheter Care, Urinary approved on 1/2024 states: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Input/Output: -A. Observe the resident's urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to the physician or supervisor . Infection Control: - A. Use standard precautions when handling or manipulating the drainage system. - B. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. 1. Do not clean the periurethral area with antiseptics to prevent catheter-associated urinary tract infections (UTIs) while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate. 2. Be sure the catheter tubing and drainage bag are kept off the floor. 3. Empty the drainage bag regularly using separate, clean collection container for each resident. Avoid splashing and prevent contact of the drainage spigot with nonsterile container. 4. Empty the collection bag at least every eight hours . Complications: -A. Observe the resident for complications associated with urinary catheters . 2. Check the urine for unusual appearance (color, blood, etc.) . 4. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. 5. Observe for other signs and symptoms of (UTIs) or urinary retention. Report findings to the physician or supervisor immediately. Documentation: - A. The date and time that catheter care was given. - B. The name and title of the individual(s) giving catheter care. Reporting: - A. Notify the nurse of any issues related to catheter care, complaints made by resident related to the procedure, or if the resident refuses the procedure. - B. Report other information in accordance with community policy and professional standards of practice. R2 was admitted to the facility on [DATE] and has diagnoses that include left hip femoral neck fracture with hemiarthroplasty repair, weakness, type 2 diabetes mellitus, thrombocytopenia, gout, Cirrhosis of the liver-nonalcoholic steatohepatitis (NASH), esophageal varices, gastroesophageal reflux disease (GERD), obstructive uropathy, coronary artery disease, pulmonary hypertension, and anemia. R2's admission minimum data set (MDS) dated [DATE] indicated R2 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R2 as needing assistance with set up for eating and drinking and needing maximal assistance of one staff member with personal hygiene, putting on and taking off footwear, showering, toileting, and mobility. R2 was assessed as needing 1 staff member to do pivot transfers from bed or chair to wheelchair with no ambulation, and weight bear as tolerated on left leg. R2 had an indwelling catheter on admission and was occasionally incontinent of bowel. During R2's medical record review, Surveyor noted documentation on 11/14/2023 stating R2 had an indwelling catheter placed in the hospital due to urinary retention after R2's surgical procedure to repair a left femoral neck fracture following a fall in the community. R2's discharge summary from the inpatient rehab facility R2 was at prior to R2's admission to the facility on [DATE] documented R2 still has a Foley catheter and needed to be seen by urologist. Surveyor noted the facility did not schedule a follow up urology appointment for R2 to assess the continued need for the Foley catheter. Surveyor also noted the facility did not attempt a trial of removing the Foley catheter to assess if R2 could have normal bladder function restored or improved. R2's Incontinence/Catheter care plan was initiated on 12/5/2023, which documented: [R2] has altered elimination related to use of foley catheter. Diagnoses obstructive uropathy and urinary retention. [R2] will be free from signs and symptoms of UTI (Urinary Tract Infection) and/or complications from foley catheter. Interventions include: - Monitor for signs and symptoms of UTI (i.e., elevated temperature, lethargy, foul odor to uring [sic], complaints of pain on urination, etc.) as needed. - Indwelling catheter care per facility policy. - Maintain closed drainage system. - Change catheter as needed to assure patency. - Offer and encourage frequent fluids/juices to reduce infection potential. R2's Certified Nursing Assistant care Kardex had the following interventions in place: Toileting: Foley catheter cares every shift and as needed . R2's physician orders documented: - Change catheter bag as needed, use alcohol wipe and cap connector when not in use as needed. - Foley catheter cares every shift and as needed (check use of stat lock, replace if not observed intact) every shift. - Switch foley drainage bag to leg bag when up upon request or as needed (use alcohol wipe and cap connector when not in use) as needed. - Switch foley leg bag to large drainage bag at bedtime (use alcohol wipe and cap connector when not in use) as needed. - Replace leg bag and obtain new after each use as needed. - Change indwelling catheter and foley bag as needed. - Foley catheter 18FR (size of catheter tubing to be used), 10 cc (cubic centimeter) balloon inserted for obstructive uropathy. Check function and patency every shift. Update medical doctor (MD) for any concerns every shift. Surveyor reviewed R2's November 2023 and December 2023 treatment administration records (TARs). Surveyor noted R2's indwelling catheter orders/cares had blank spaces on the TAR for both November and December. 1. Foley catheter cares every shift were not signed as complete by staff per physician order for the following dates: - Day shift: 12/6, 12/7, 12/9, 12/11, 12/13, 12/14, 12/15. - Evening shift: 11/29, 12/1, 12/7, 12/11, 12/12, 12/14, 12/15. - Night shift: 12/3, 12/12, 12/14, 12/17. 2. Check foley catheter function and patency every shift was not signed as completed by staff per physician order for the following dates: - Day shift: 12/6, 12/7, 12/9, 12/11, 12/13, 12/14, 12/15. - Evening shift: 11/29, 12/1, 12/7, 12/11. 12/12, 12/14, 12/15. - Night shift: 12/3, 12/12, 12/14, 12/17. On 12/6/2023, at 3:30 PM, in in the progress notes nursing charted [R2] . has 18fr, 10cc foley catheter is patent with amber colored urine. Nursing encouraged R2 to drink fluids, R2's penis swollen. On 12/16/2023, at 8:35 PM, in the progress notes nursing charted [R2] . abdomen distended . penis swollen, foley patent draining. On 12/17/2023, at 10:26 PM, documented on 12/18/23, at 12:26:43 AM, in the progress notes nursing charted [R2] appears more tired, . foley patent with cloudy urine with sediments. On 12/17/2023, at 12:26 AM, documented on 12/18/23, at 12:26:51 AM, in the progress notes nursing charted [R2] confused, . penis swollen, . foley patent with sediment and cloudy urine. [R2]'s family requesting R2 be sent to [name of] hospital. (Cross Reference F580) On 12/18/2023, at 3:20 PM in the progress notes nursing charted [R2] was admitted to hospital with AKI (acute kidney injury .) Surveyor reviewed the progress note from R2's hospital admission 12/17/23, which documents: - Acute metabolic encephalopathy-likely multifactorial but found to have UTI. -CAUTI-On Rocephin . -Patient came with Foley and noted to have cloudy and crusty urine. Foley was exchanged and UA (Urine Analysis) obtained. ceftriaxone 1 g (gram) for possible right leg wound infection and UTI and admitted for further management. - Urine culture grew klebsiella oxytoca. ID (Infectious Disease) was consulted and doxycycline continued but ceftriaxone switched to cefepime. Cefepime was eventually switched to ciprofloxacin along with doxycycline. Patient initially did better with improved mental status. However, he started to become mentally altered again and developed acute kidney injury.Patient was enrolled in inpatient hospice care. On 1/11/2024, at 10:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated she could not recall notifying R2's physician regarding R2's swollen penis, distended abdomen, or concerns with R2's catheter. LPN-I stated LPN-I could not remember R2 having issues with R2's catheter until R2 was sent to the hospital on 12/17/2023. On 1/11/2024, at 11:45 AM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-J who stated when a resident gets admitted into the facility or comes back from an appointment any follow-ups the resident needs will get put into the computer and the scheduler will make the appointment and arrange for transportation if needed. Surveyor asked RNUM-J if R2's urology follow-up appointment was followed through with per R2's discharge instructions from inpatient rehab stay. RNUM-J stated RNUM-J did not see R2's paperwork and would have to check if the urology appointment ever got made for R2. On 1/16/2024, at 9:52 AM, Surveyor interviewed RNUM-J who stated RNUM-J could not see that R2's urology appointment was ever made for follow-up with R2's catheter. Surveyor asked RNUM-J what empty boxes mean on the TAR where nursing initials once the task is completed. RNUM-J stated if a box is left empty then assume the task was not done. RNUM-J stated if a task is not done staff are supposed to still initial and then put a note as to why the task was not done. RNUM-J was not sure why R2's catheter cares and checks were not done on the several days in November and December. RNUM-J stated nursing is supposed to review all their charting and run a missed medication report at the end of their shift to see if anything was missed. RNUM-J stated no one came to her with concerns regarding R2's catheter. On 1/16/2024, at 10:00 AM, Surveyor interviewed Scheduler-V who stated Scheduler-V does not recall making an appointment for a urology follow-up for R2. Scheduler-V stated she also does not see she arranged transportation for R2 to any appointments. Surveyor asked Scheduler-V how Scheduler-V is notified of a need for an appointment. Scheduler-V stated she will get a note from nursing or from the resident's paperwork when the resident comes back from an appointment. On 1/16/2024, at 11:41 AM, Surveyor interviewed Medical Doctor (MD, primary physician)-K who stated MD-K does not recall being notified by the facility of any concerns related to R2's catheter. MD-K stated MD-K does not recall any red flags from visits with R2 that would indicate R2 had any issues with R2's catheter. Surveyor asked MD-K if R2 ever had a follow-up with urology that MD-K was aware of. MD-K stated MD-K could not find any evidence R2 saw urology regarding R2's catheter. MD-K stated typically residents follow-up with urology if there are concerns with a resident's catheter or has diagnoses such as urine retention or benign prostatic hyperplasia. MD-K stated MD-K was not sure why R2 had an indwelling catheter placed, MD-K thought possibly for R2's left hip surgical site. Surveyor stated R2's catheter was placed in the hospital due to R2 having urinary retention. MD-K was not sure why R2 did not follow-up with urology for R2's indwelling catheter. On 1/16/2024, at 3:00 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A regarding R2 not having a urology follow-up for R2's catheter, the facility not attempting to do a trial removal of R2's urinary catheter, and R2 being hospitalized and diagnosed with Catheter Associated Urinary Tract Infection (CAUTI) and the need for antibiotics and R2's further decline in the hospital noted with inpatient hospice services implemented.

Based on interview, and record review the facility did not ensure a resident's primary provider was notified when there was a change of condition for 1 (R2) of 13 residents reviewed for notification of changes. R2's physician was not notified when facility staff assessed R2 as having upper body bruising, +3 edema to bilateral lower extremities with bilateral lower extremity weeping, swollen body, swollen penis, decline in oral intake, fatigued, cloudy urine with sediment, and jaundice in color. Facility staff did not get a clarifying conflicting orders regarding R2's left hip surgical site to determine if R2's non-removable dressing should stay in place or if R2 should receive a treatment as ordered. R2's family requested R2 be transferred to the hospital on 12/17/2023. R2 was diagnosed with infected wounds, and infected surgical cite, urinary tract infection all requiring IV antibotics and IV Lasix for aggressive diuresis. Findings include: The facility policy entitled Change in a Resident's Condition Status revised on 2/2022 states: Our community shall promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: A. The nurse will notify the residents Health Care Provider or physician on call when there has been a(an): 1. accident or incident involving the resident. 2. discovery of injuries of unknown source. 4. significant change in the residents physical/emotional/mental condition. 5. need to alter the resident's medical treatment significantly. 6. need to transfer the resident to a hospital/treatment center. 8. specific instruction to notify the health care provider of changes in the resident's condition. B. A significant change of condition is a major decline or improvement in the resident's status that: 1. Will not normally resolve itself without intervention by associate or by implementing standard disease-related clinical interventions. 2. Impacts more than one area of the resident's health status. 3. Requires interdisciplinary review and/or revision of the care plan. C. Prior to notifying the health care provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider including information prompted by the interact Situation, Background, Assessment, and Recommendation (SBAR) form. E. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status. H. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. R2 was admitted to the facility on [DATE] and has diagnoses that include left hip femoral neck fracture with hemiarthroplasty repair, weakness, type 2 diabetes mellitus, thrombocytopenia, gout, Cirrhosis of the liver- nonalcoholic steatohepatitis (NASH), esophageal varices, gastroesophageal reflux disease (GERD), obstructive uropathy, coronary artery disease, pulmonary hypertension, and anemia. R2's admission minimum data set (MDS) dated [DATE] indicated R67 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R2 needing assistance with set up for eating and drinking and needing maximal assistance of one staff member with personal hygiene, putting on and taking off footwear, showering, toileting, and mobility. R2 was assessed as needing 1 staff member to do pivot transfers from bed or chair to wheelchair with no ambulation, and weight bear as tolerated on left leg. R2 had an indwelling catheter and was occasionally incontinent of bowel. R2's Dehydration/Fluid Maintenance care plan was initiated on 12/5/2023 which documents: [R2] has a potential for fluid volume deficit related to medication use: [R2] will be free from signs and symptoms of dehydration and will be well hydrated as evidenced by physical conditions. - Assess for signs and symptoms of dehydration (dizziness/confusion/ poor skin turgor/ fever/ constipation) as needed. - Assess [R2]'s understanding of the reasons for maintaining adequate hydration and methods for reaching goal of fluid intake. - Keep fresh water, or beverage in reach. - Assess [R2]'s preferred fluids and provide. - Monitor weight as ordered - Assess skin turgor and mucus membranes for signs of dehydration as needed. - Monitor blood pressure and orthostatic changes. - Monitor for active fluid loss from wounds, diarrhea, bleeding, vomiting. - Hydration cart will make rounds and offer fluids of choice to resident per ordered diet. R2's Pressure Ulcers/Skin Prevention Care plan was initiated on 11/28/2023, which documents, [R2] is at risk for pressure ulcers and other skin related to but not limited to Braden and other skin related injuries-[R2] will maintain skin integrity without new skin related injuries over the next review period. Intervetntions include: - Braden scale to be completed. - Encourage proper peri hygiene and the use of barrier cream after each incontinence episode and as needed. - Observe skin for redness and breakdown during routine care. - Use pressure relieving devices, cushion, and wheelchair and off of heels, as indicated. - Follow community skin care protocol. - Treatments, as indicated, see physician order sheet. - Pressure reducing mattress on bed. - Encourage to float heels, wheelchair with cushion. - Labs to be drawn, follow treatment prescribed by physician. (Initiated on 12/6/2023) [R2] has impaired skin integrity related to left hip surgical incision, right elbow skin tear, moisture associated skin damage (MASD) to buttocks present upon admission. [R2] will be free from signs and symptoms of infection and will demonstrate optimal healing. (Initiated on 11/29/2023) - Provide treatment as ordered. - Provide pain management as ordered. - Keep skin clean and dry. - Provide- peri care after each incontinence episode and apply skin protectant. - Educate resident and/or family to importance of frequent turning/ shifting and repositioning. - Minimized force and friction applied to skin. - Pressure relief air mattress, check setting (3) and inflation every shift. Only one barrier between body and mattress (CHUX or brief, not both). R2's Blood Thinner Care Plan was initiated on 12/5/2023, which documents: [R2] is at risk for complications from blood thinning medications: Aspirin and Lovenox. [R2] will not develop complications from blood thinning medications and will not require outside medical intervention. Interventions include: - Vital signs per routine and as needed. - Monitor for presence of bone, abdominal, joint, or other pain. - Monitor for presence or absence of signs of hemorrhage under the skin, oral mucosa, and/or conjunctiva. - Monitor for presence or absence of active bleeding such as hematuria, petechiae, bruising, bloody stools, or nose bleeds. - Monitor color for evidence of cyanosis or pallor. - Administer medications and monitor labs per orders and inform physician of lab results and concerns. - Prevent falls which could potentially cause high risk of bleeding due to anticoagulant use. R2's Cardiovascular Care Plan was initiated on 12/5/2023, documents Hypertension:[R2] has elevated blood pressure,[R2]'s blood pressure will remain stable. Interventions include: - Administer medications per physician. - Monitor blood pressure per physician orders and notify physician of any changes. (Cardiovascular Disease: [R2] has potential for complications from hyperlipidemia (high cholesterol), coronary artery disease, pulmonary hypertension, and thrombocytopenia (low platelets that can result in bleeding problems)-[R2] will have no complications for cardiovascular disease and will not require outside medical intervention). - Provide medication and treatment per physician's orders. Monitor for side effects of medication and inform physician of concerns. - Monitor vital signs as ordered and as needed. Report abnormalities to physician. - Monitor oxygen saturation as needed and administer oxygen per orders. - Monitor for signs and symptoms of cardiovascular symptoms: hypertension, dysrhythmia, shortness of breath, chest pain, edema, dizziness, numbness, nausea, and heartburn. - Encourage nutritional intake, fluid intake per plan of care. - Reinforce energy conservation techniques. Encourage rest periods during activity. - Encourage to elevate head of bed as needed. - Monitor labs as ordered and report results to physician. R2's physician ordered the following on 11/28/2023: - Weekly skin check . (document results of skin check in skin and wound module)- every week on Tuesdays evening shift. - Monthly weights every month (start date: 1/2/2024) - Compression stockings to bilateral lower extremities. On in the morning, off at bedtime every 12 hours for bilateral lower extremity edema. - May follow facility wound nurse regarding wound care and treatment recommendations. - Left lower extremity Surgical incision: Cleanse with normal saline, followed by dry dressing. Change daily and as needed. Update physician of any wound dehiscence, drainage, redness, increased bleeding, warmth, etc. - Enoxaprin (Lovenox) 30MG/0.3ML subcutaneous syringe. At bedtime for deep vein thrombosis (clot) prophylactic. - Furosemide 40mg- 40mg by mouth every day for edema. (Order date: 12/13/2023, start 12/14/2023). On 11/29/2023, at 3:30 PM, in the progress notes nursing charted . R2 has left surgical incision with non-removable dressing intact. Bruises to left arm, left hand, left forearm, right hand, right arm, right forearm, left inner leg, pubic area, left side abdomen, and lower back, penis swollen . Surveyor noted nursing does not indicate if the physician was notified regarding R2 having a non-removable dressing to left hip surgical site and an order to do daily dressing changes to the same area. The facility did not obtain clarification on how to care for R2's left surgical hip area. Nursing also did not indicate if the physician was made aware of all the bruising noted to R2 upon admission or of R2's swollen penis for further direction. On 12/2/2023, at 8:51 PM, in the progress notes nursing charted . bruises noted to R2's incisional side and inner legs . Surveyor noted nursing does not indicate if this is new bruising to R2 or if R2's physician was notified of the bruising. Surveyor also notes R2 has orders to receive - Enoxaprin (Lovenox) 30MG/0.3ML subcutaneous syringe. At bedtime for deep vein thrombosis (clot) prophylactic. On 12/10/2023, at 11:25 AM, in the progress notes nursing charted . R2 had to transfer using a sit to stand due to R2 being unable to pivot transfer. about a half hour later R2's family requesting R2 to go to the hospital due to increased left hip pain and swelling . Surveyor noted Facility did not notify the physician of R2's decline in transfer ability and increased pain until R2's family requested R2 be sent to the hospital for further evaluation. R2 was hospitalized on [DATE] with a chief compliant of hip pain. R2 reported to hospital staff they had not been able to ambulate due to pain and swelling which had worsened since arrival to subacute. R2 reported pain at 10 prior to pain medication given at the hospital. Hip x-rays at the hospital revealed a greater trochanteric fracture fragment mildly displaced and linear fracture fragments along the medial proximal femur which are slightly displaced from the femoral shaft, not previously visualized. On 12/13/2023, at 2:25 PM, in the progress notes nursing charted . R2's left side swollen, +3 bilateral lower extremity edema noted . Surveyor noted that nursing does not indicate if R2's left side swelling, and +3 edema is new for R2 or if the physician was consulted with related to this change. On 12/16/2023, at 8:35 PM, in the progress notes nursing charted . R2's abdomen distended, bruised. Multiple old, bruised areas noted, penis swollen. Surveyor noted nursing does not document if R2's physician was notified of R2's abdominal distention, bruising, and swollen penis. On 12/17/2023, at 10:26 PM, documented on 12/18/23, at 12:26:51AM, in the progress notes nursing charted R2 appears more tired and has poor appetite . R2 has bilateral lower extremity weeping and R2's foley patent with cloudy urine and sediment. On 12/17/2023, at 10:38 PM, documented on 12/18/23 at 12:26:43 AM, in the progress notes nursing charted R2 was confused and appeared jaundiced in color. R2's appetite poor and has increased left hip pain . +3 lower extremity edema, body swollen, penis swollen, foley with sediment and cloudy urine. R2's family at bedside requesting R2 be sent to the hospital. Surveyor noted nursing did not document if R2's physician was notified of R2's decline or change in status prior to R2's family requesting R2 be sent to the hospital. Surveyor reviewed the hosptial records from R2's transfer to the hospital on 12/17/23. The notes document: -Acute metabolic encephalopathy -CAUTI (catheter-associated urinary tract infection) -Hypotension-likely related to infection but also has underlying congestive heart failure. -Failure to thrive, generalized weakness, Left hip fracture.Has bruising all over upper torso and arms, multiple areas with open wound and purulent drainage. Concern for poor care at facility. -Left hip pain. Has some drainage-sent for culture. Orthopedic surgery consulted. May need infectious disease involvement. -Lower Leg Edema. Acute on Chronic diastolic congestive heart failure -Needs intravenous Lasix but due to hypotension (low blood pressure) will try cautious fluids until blood pressure improved then will need aggressive diuresis. -Irregular Heart Rate. Concern for Atrial Fibrillation -Acute Kidney Infection. Likely due to infection. Continue IV fluids. Subjective: . Patient laying in bed. Cannot tell me if he fell at rehab or not when asked about his significant bruising to his chest. Edema in bilateral lower extremities. Unable to move left leg much. Medical decision making: . Does appear edematous. Also has bruising to his body. Urinalysis was ordered as patient has a Foley. patient's Foley had sediment around it and had to be replaced. Rocephin 1 g (gram) IV was also given due to 1 wound on right leg. Foul-smelling oozing discharge from left hip surgical site and culture collected. He also has purulent wound on right leg and culture was collected. Lasix 20 mg (milligrams) for bilateral lower extremity edema, . ceftriaxone 1g for possible right leg infection and UTI (Urinary Tract Infection). Ceftriaxone dose was increased to 2 g for possible cellulitis and CAUTI. Patient seen by wound care. Wound cultures from the right foot and left hip grew MSSA (Methicillin-Sensitive Staphylococcus Aureus) (Staph.) Urine culture grew Klebsiella Oxytoca. ID (Infectious Disease) was consulted and doxycycline continued but ceftriaxone switched to cefepime. On 1/11/2024, at 10:00 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-I who stated LPN-I recalled R2 having a lot of bruising and swelling issues. LPN-I stated R2's bruising and swelling was from admission throughout R2's stay at the facility. Surveyor asked if LPN-I ever notified physician regarding R2's bruising and swelling and changes in swelling. LPN-I stated LPN-I could not recall if R2's physician was notified or not, but LPN-I usually charts physician notification if LPN-I contacted the physician. LPN-I stated LPN-I did not remember having concerns regarding R2's left hip surgical site or blistering on lower legs. Surveyor asked LPN-I regarding LPN-I's charting about R2's +3 lower extremity edema, and swollen penis. LPN-I stated R2 was always swollen, not sure if it was more at the time of charting or not. On 1/11/2024, at 3:32 PM, Surveyor interviewed LPN-W who stated LPN-W recalled R2's left hip incision looking good. LPN-W stated there was an area that had a little space between staples. LPN-W stated LPN-W put a foam dressing over area. Surveyor asked LPN-W if the physician was notified regarding the area on R2's left hip incision. LPN-W stated LPN-W did not have any concerns with the area on the left hip incision. Surveyor asked LPN-W if LPN-W notified R2's physician of the area and that a foam dressing was applied to R2's left hip surgical site. LPN-W stated LPN-W did not notify R2's physician because LPN-W did not have any concerns. LPN-W stated LPN-W did not look at the orders for R2, LPN-W just applied the dressing for R2's comfort. LPN-W also stated LPN-W did not have any concerns regarding R2's lower extremity blisters. On 1/16/2024, at 9:52 AM, Surveyor interviewed Registered Nurse Unit Manager (RNUM)-J regarding R2's left hip incision dressing and if it has a non-removable dressing but there is a treatment ordered, what does the facility do. RNUM-J stated staff did not get a clarifying order regarding R2's dressing to the left hip area and that some staff were doing a treatment and other staff were not. RNUM-J stated there was not a flag at the time to get a clarifying order for R2's left hip dressing with the physician. Surveyor asked RNUM-J if R2's physician was notified when R2 was unable to bear weight on R2's left leg and had increased pain and had to be transferred by a sit to stand and R2's family had requested R2 be sent to the hosptial for evaluation. RNUM-J stated RNUM-J does not think the physician was notified prior to sending R2 out to the hospital to get R2's left hip checked out due to increased pain. On 1/16/2024, at 11:41 AM, Surveyor interviewed Medical Doctor (MD, primary physician)-K who stated MD-K saw R2 on 11/29/2023, 12/6/2023, and 12/12/2023 and noted R2 had lymphedema in the lower extremities. MD-K stated MD-K does not recall if the facility staff notified MD-K of R2's lower extremity edema, swollen penis, bruising, or distended abdomen. MD-K stated when MD-K assessed R2 on 12/12/2023 MD-K did not have any red-flags regarding R2. MD-K stated R2's albumin was slightly low and R2 was anemic which contributed to R2's lower leg edema but R2's kidney function was normal, so MD-K did not have concerns at that time. MD-K did not recall starting R2 on Furosemide 40mg every day on 12/13/2023. Surveyor asked MD-K if MD-K had any concerns regarding R2's left hip incision or lower leg blistering. MD-K could not recall if MD-K saw the blistering or left hip incision but wrote an order for the wound nurse to follow R2 for R2's left hip surgical incision and lower leg blistering. MD-K stated the facility did not contact MD-K regarding concerns of R2's wounds. Surveyor asked MD-K what MD-K's expectations were for obtain residents vital signs. MD-K stated expectations would be to obtain vital signs per facility protocol or orders to monitor the resident. MD-K could not recall if the facility ever notified MD-K of concerns related to R2's vital signs. On 1/16/2023 at 3:00 PM Surveyor shared concerns with nursing home administrator (NHA)-A. No further information was given at this time.

Based on observations, interviews, and record reviews the facility did not identify, evaluate, analyze, or implement interventions to reduce hazards and risks for 6 of 15 sampled (Residents #9, #14, #5, #7, #3) residents and 1 supplemental resident (Resident #19). *Resident #9 had a fall on 8/6/15 that resulted in fractured ribs and a pneumothorax. Resident #9 did not have gripper socks on per her plan of care at the time of the fall. Resident #9 was not offered gripper socks per her plan of care when observed to be assisted to take a nap on 3/6/16. Resident #9 did not have a dycem in her wheelchair on 3/7/16 per her plan of care. *Residents #19, #14, #5, #7, and #3's mattresses where shorter than the length of the bedframe with no device to prevent the mattress from sliding creating a potential for entrapment between the mattress and the head or foot board. *Resident #5 was observed being provided with food not part of her mechanical soft diet, and family members and companions who assisted Resident #5 to eat were not educated on Resident #5's swallowing precautions. Example 1 involving Resident #9 rises to severity level 3 (actual harm). Findings include: Surveyor: # 1. Resident #9 was originally admitted to the facility on [DATE]. Surveyor # 0 reviewed Resident #9's medical record. Resident #9 has [DIAGNOSES REDACTED]. Resident #9's Nurses Notes document on 8/6/15 at 11:42 p.m. Writer called to resident room by CNA resident noted lying on floor on her left side on the floor at foot of the bed blood noted around her head resident alert and oriented responds to verbal and tactile stimuli resident yelling out that fell trying to walk to the bathroom. Resident yelling at staff to get her up from the floor resident rolled unto bath blanket in recovery position golf sized hematoma noted to left side of her head attempts at placing ice pack to head resident removes and returns to yelling to get off the floor Stating staff has no compassion resident with no internal or external rotation of ext (extremities) no lengthening or shortening of ext noted resident able to flex and extend ext with display of discomfort. Supervisor notified NOR (new orders received) to send to ST Francis HOSP ER (hospital emergency room ) call placed to Bell Ambulance for transportation call placed to son (name) aware of above and transportation to hospital states he will go to hospital in AM. Resident #9's Nurses Notes document on 8/7/15 at 3:50 a.m. Spoke to St. Francis ER (emergency room ). Resident has been adm. (admitted ) with dx. (diagnosis) traumatic head injury and aspiration pneumonia. The Fall Assessment completed for the fall on 8/6/15 under ACTIVITY LEVEL AS IDENTIEFIED ON CARE PLAN has check marks indicating that Resident #9 was Up with assistance and Up with Assistive Device. The Fall Investigation completed for the fall on 8/6/15 includes: A section titled, Position Prior to Fall: which has a check mark indicating that Resident #9 was in bed. A section titled, Safety Measures In Place Prior to Fall which has check marks indicating Call light within reach and Bed in low position. A section titled Contributing Factors which includes a subsection titled, Cognitive Factors which has check marks that indicate cognitive factors of agitated, decline in cognitive skill, depress, forgetfulness, restless, compulsive/impulsive behavior, dementia, and poor judgment. Another subsection under Contributing Factors titled, Functional Factors. This section includes a choice of Inappropriate footwear/clothing (explain) Handwritten in the blank space provided after Inappropriate footwear/clothing (explain) is socks. A section titled MANAGER/SUPERVISOR DOCUMENTATION includes a subsection titled, Investigation Findings which documents Resident lying on floor in room, on left side at foot of bed. Blood noted around head. Resident alert + (and) oriented. Hematoma noted to left side of head. Ice applied. Resident able to Flex/extend ext. (extremities). Transferred to St. Francis ED (emergency department) for further eval (evaluation) and tx (treatment). Another subsection titled, Steps taken to prevent further falls does not include any check marks for interventions listed or include any handwritten interventions used. Another subsection titled, Follow-up/Intervention with Staff (include names): documents Send to ED for eval and tx. Will refer to PT (physical therapy) upon return to facility. Reminder to use call light. The IDT (interdisciplinary team) Fall Committee Review form documents Interventions previously in place: fall mat, toileting schedule, dycem grip pad to wheelchair, gripper socks @ (at) HS (hour of sleep). Interventions taken that directly address the root cause(s) of the fall: Refer to PT (physical therapy) upon return from hospital, sig (significant)(change) MDS (minimum data set assessment), Reminder to use call light. On 3/8/16 at 3:54 p.m. Surveyor # interviewed Registered Nurse (RN)-J. RN-J confirmed that she had completed the Fall Investigation Report for Resident #9 related to the fall on 8/6/15 and that for Inappropriate footwear/clothing (explain) she had written socks. Surveyor # asked RN-J why she had written socks as inappropriate footwear/clothing. RN-J informed Surveyor # that usually residents have gripper socks on in bed. RN-J stated that when Resident #9 fell (on 8/6/15) she did not have gripper socks on, she had on black socks. Resident #9's fall care plan includes the intervention Gripper socks on at HS (hour of sleep) and when napping with an initiation date of 5/13/2015. Resident #9's physician's orders [REDACTED]. Surveyor # reviewed Resident #9's Fall Assessment Form, Fall Investigation Form, Fall Occurrence Interviews with staff form, Fall Occurrence Interview with Resident form, IDT Fall Committee Review form, and IDT Fall Committee Review: FOLLOW UP form related to Resident #9's fall on 8/6/15. Surveyor # noted that these forms did not address that Resident #9 was not wearing gripper socks per her plan of care at the time of the fall. Resident #9 was admitted to the hospital following her fall on 8/6/15. Resident #9 was discharged from the hospital on [DATE] with discharge [DIAGNOSES REDACTED]. Fall with multiple right 3rd, 4th, 5th, 6th, 7th, 8th, rib fractures. 2. Secondly ( ) emphysema, very small pneumothorax 3. Possible aspiration pneumonia 4. Head Trauma. Progress notes on 8/11/2015 document that PRN Administration was :Ineffective. Call placed to (MD) for pain medication more effective. On 8/12/15 Resident #9 received an order for [REDACTED]. On 3/6/16 at 1:56 p.m. Surveyor # observed Certified Nursing Assistant (CNA)-R and CNA-S assist Resident #9 to lie down for a nap. Surveyor # observed CNA-R take Resident #9's shoes off her feet. Surveyor # noted that Resident #9 had black socks on. Surveyor # noted that CNA-R and CNA-S did not offer or attempt to assist Resident #9 to wear gripper socks while she was napping. Resident #9's fall care plan includes the intervention Gripper socks on at HS (hour of sleep) and when napping with an initiation date of 5/13/2015. Resident #9's physician's orders [REDACTED]. On 3/8/16 at 1:10 p.m. CNA-O, who frequently works with Resident #9, informed Surveyor # during an interview that Resident #9 does not refuse her gripper socks. On 3/8/16 at 1:20 p.m. Surveyor # interviewed CNA-R related to why she did not offer or attempt to assist Resident #9 to wear gripper socks when she assisted her to lay down for a nap. CNA-R informed Surveyor # that she did not offer Resident #9 gripper socks because she is alert and able to say what she wants. Resident #9's most recent Minimum Data Set assessment dated [DATE] indicates that Resident #9 has a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment. On 3/7/16 at starting at 9:38 a.m. Surveyor # observed CNA-O and CNA-T assist Resident #9 get up out of bed and ready for the morning. Surveyor # observed no dycem/grip pad on top of Resident #9's cushion on the seat in her wheelchair. At 10:09 a.m. Surveyor # asked CNA-T to lift up Resident #9's cushion on her wheelchair. Surveyor # noted no dycem/grip pad under Resident #9's cushion on her wheelchair. At 10:15 a.m. Surveyor # observed CNA-O and CNA-T transfer Resident #9 into the wheelchair with no dycem or grip pad in place. Surveyor # noted that Resident #9 was not offered a dycem to be in place. Resident #9's fall care plan includes the intervention Dycem/Grip pad to wheelchair to prevent sliding. Resident #9's physician's orders [REDACTED]. Check placement every shift. On 3/8/16 Surveyor # interviewed CNA-T. Surveyor # asked CNA-T why Resident #9 did not have a Dycem/Grip pad in her wheelchair on 3/7/16. CNA-T informed Surveyor # that she was not sure why Resident #9 did not have it in place on 3/7/16, but stated that Resident #9 did have a dycem in place today (3/8/16). On 3/9/16 at 11:43 a.m. Surveyor # shared the above with Director of Nursing-B. On 3/9/16 at 2:30 p.m. Surveyor # shared the above with Nursing Home Administrator-A and Director of Nursing-B. No further information was provided to Surveyor # . Surveyor # 2. Surveyor # reviewed Resident #8's medical record on 3/6/16-3/9/16. Resident #8 has a [DIAGNOSES REDACTED]. Resident #8's CNA (Certified Nursing Assistant) Resident Status Sheet, undated, but current as of 3/6/16 per RN (Registered Nurse)-V, states Positioning: W/C (wheelchair) cushion. Dycem/gripper pad in wheelchair to prevent sliding. A Fall Risk assessment dated [DATE] notes Resident #8 is at high risk for falls due to status [REDACTED]. Resident #8's Initial MDS (Minimum Data Set) dated 10/22/15 indicates Resident #8 had one fall with no injury since Admission 10/15/15. Resident #8 scored 14/15 on her Brief Mental Status Exam, meaning she is cognitively intact. Resident #8 is noted to have limitations on one side of both upper and lower extremities. Resident #8 requires extensive assistance of two people for transfers. Resident #8's Care Plan initiated 10/15/15 on admission states Potential for Falls/Injury: related to CVA (stroke) left side weakness, diabetes, hypertension, use of hypoglycemics and antihypertensives, NSAIDs (non-steroidal anti-inflammatory drugs), narcotics, psychotropics, laxatives and anticoagulants. Interventions include: Ensure Resident is wearing appropriate footwear (shoes, nonskid socks when ambulating or up in wheel chair). (Cross reference F282 regarding Resident #8 wearing diabetic socks- not protective footwear). On 10/20/15, staff added Resident #8 should use a reclining wheelchair and non-skid cover. The care plan notes Resident #8 had a witnessed fall with no injury on 10/20/15. Resident #8 also has a Care Plans for Self-Care Deficits and Impaired Physical Mobility dated 10/15/15 related to deconditioning, decreased strength, balance and gait problems, vision problems, pain, coordination issues, activity tolerance, and safety awareness. Surveyor # reviewed documentation from the fall on 10/20/15 which states Resident #8 slipped from her wheelchair to the floor. On 3/6/16 at 11:40 a.m. -12:00 p.m., and at 12:10 p.m., Surveyor # observed Resident #8 in her wheelchair in her room. Surveyor # could not see any Dycem, but it is not always visible. On 3/6/16 at 2:37 p.m., Surveyor # observed Resident #8 in bed resting. With Resident #8's permission, Surveyor # inspected Resident #8's wheelchair and cushion. No Dycem was visible on top of the cushion. Surveyor # lifted the cushion and noted no Dycem was underneath the cushion. Resident #8 said there was no Dycem in the chair while she was up. On 3/7/16 at 7:28 a.m., Surveyor # noted Resident #8 was out at an appointment. On 3/7/16 at 12:37 p.m., Surveyor # observed CNA-BB and RN (Registered Nurse)-V transfer Resident #8 from her wheelchair to her bed. Surveyor # observed no Dycem in Resident #8's chair, neither underneath nor on top of the cushion in Resident #8's wheel chair. On 3/8/16, Surveyor # shared the above observations at the daily exit meeting. No further information was provided. Surveyor: # 3. The U.S. Department of Health and Human Services' Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment guidance dated March 10, 2006 states, Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system discussed in this guidance are the head, neck, and chest. The guidance goes on to states that, To reduce the risk of head entrapment, opening in the bed system should now allow the widest part of a small head (head breadth measure across the face from ear to ear to be trapped. Country-specific anthropometric data show that a 1st percentile female head breadth may be as small as 95mm (3 ¾ inches). A dimension of 120 mm (4 ¾ inches) encompasses the 5th percentile female head breadth in all data sources used to develop these recommendations, and includes 1st percentile female head breadth as reported in some data sources. FDA (Food and Drug Administration) is therefore using a head breadth dimension of 120mm (4 ¾ inches) as the basis for is dimensional limit recommendations. The guidance identifies that the area between the head or foot board and the end of the mattress may .present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or footboard. 3.1 On 3/7/16 at 3:04 p.m. Surveyor # observed Resident #19's bed. Surveyor # observed a space greater than 6 inches between the edge of Resident #19's mattress and the footboard of her bed. Surveyor # checked the bed frame and noted there was no device on the bed frame that would stop the mattress from sliding either towards the head and/or foot board. 3.2 On 3/7/16 at 3:05 p.m., Surveyor # observed Resident #14's bed. Surveyor # observed a space greater than 6 inches between the edge of Resident #14's mattress and the footboard of her bed. Surveyor # checked the bed frame and noted there was no device on the bed frame that would stop the mattress from sliding either towards the head and/or footboard. On 3/7/16 at 3:24 p.m. during the daily exit conference Surveyor # informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the observations of Resident #19's and Resident #14's mattresses not fitting the bed frame appropriately. On 3/8/16 at 1:05 p.m. NHA-A informed Surveyor # that the facility had recently bought new mattresses not realizing that the bed frame was longer. NHA-A informed Surveyor # that the therapy department was working on putting an intervention in place to address the space between the mattress and the head/foot boards. Surveyor: # 3.3 Surveyor # reviewed Resident #7's medical record 3/6/16-3/9/16. Resident #7 was admitted to the facility in July, 2015. Resident #7 currently receives palliative care. On 3/6/16 at 2:46 p.m., Surveyor # observed an approximately 8 inch gap between the end of Resident #7's mattress and the footboard on the bed. Resident #7's head of bed was elevated approximately 45 degrees. On 3/7/16 at 7:25 a.m. and 9:17 a.m. Surveyor # observed an approximately 8 inch gap between the end of Resident #7's mattress and the footboard. Resident #7's head of bed was elevated approximately 90 degrees. At the daily exit meeting on 3/7/16, Surveyor # shared the above observations, noting a gap between the mattress and head or foot of the bed can create an entrapment risk. On 3/8/16, NHA (Nursing Home Administrator)-A informed Surveyor # that Resident #7's bed was provided by hospice and they will contact hospice for an appropriate size mattress. 3.4 Surveyor # reviewed Resident #3's medical record on 3/6/16 to 3/9/16. Resident #3 is on an every two hour turn/repositioning schedule, does not ambulate, and is transferred with an assist of two staff with a sit to stand lift. On 3/7/16 at 7:08 a.m. Surveyor # observed Resident #3 asleep in bed on his back with the head of the bed slightly elevated. Surveyor # observed there is a large gap between the end of the mattress and the head board of Resident #3's bed. On 3/7/16 at 7:59 a.m. Surveyor # observed Resident #3 continues to be asleep in bed on his back with the head of the bed slightly elevated. Surveyor # observed there is a large gap between the end of the mattress and the head board of Resident #3's bed. On 3/7/16 at 11:51 a.m. Surveyor # measured the space between the end of the mattress and the head board on Resident #3's bed. Surveyor # noted the space measures approximately 6 inches. Surveyor # checked the bed frame and noted there is no device on the bed frame that would stop the mattress from sliding either towards the head and/or foot board. On 3/7/16 at 3:26 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed Resident #3's mattress does not fit the bed frame appropriately. 3.5 Surveyor # reviewed Resident #5's medical record on 3/6/16 to 3/9/16. Resident #5 is dependent upon staff for all her ADL's (activities of daily living). On 3/7/16 at 7:11 a.m. Surveyor # observed Resident #5 awake in bed on her back. Surveyor # noted there is a large gap from the bottom of the mattress to the foot board of the bed. On 3/7/16 at 8:25 a.m. Surveyor # observed Resident #5 continues to be in bed on her back. Surveyor # noted there continues to be a large gap from the bottom of the mattress to the foot board of the bed. On 3/7/16 at 9:25 a.m. Surveyor # measured the space between the end of the mattress and the foot board on Resident #5's bed. Surveyor # noted the space measures approximately 8 inches. Surveyor # checked the bed frame and noted there is no device on the bed frame that would stop the mattress from sliding either towards the head and/or foot board. On 3/7/16 at 3:26 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed Resident #5's mattress does not fit the bed frame appropriately. 4. Surveyor # reviewed Resident #5's medical record on 3/6/16 to 3/9/16. The Speech /Language Pathology daily note dated 1/15/16 documents under skilled services provided, Swallow evaluation completed with meal assessment. Please refer to certification report. Under functional problems remaining documents oral dysphagia secondary to cognitive decline. Under describe caregiver education provided today documents educated pt's (patients) caregivers in swallow precautions established to insure pt. (patient) safety. The monthly physician's orders [REDACTED]. The CNA (Certified Nursing Assistant) care plans dated 3/3/16 under the section diet documents, Mechanical soft diet. Swallowing precautions - Must supervise, feed resident. Position upright at 90 degrees. Solids- small bites. Alternate solids with puree and liquid. Slow rate - Make sure Resident #5 clears her mouth before presenting another bite. After meals - oral care to remove pocketed food. On 3/6/16 at 12:44 p.m. Surveyor # observed Resident #5's POA (power of attorney) feeding Resident #5. Surveyor # observed that Resident #5 POA fed Resident #5 multiple spoonfuls of macaroni & cheese and mashed potatoes without giving Resident #5 a drink of her milk. Surveyor # also noted that the POA was not feeding Resident #5 at a slow rate as she would give a spoonful of macaroni & cheese and then immediately give a spoonful of mashed potatoes. At 1:03 p.m. Surveyor # observed Resident #5 had completed 100% of her lunch. On 3/7/16 at 9:17 a.m. Surveyor # observed CNA (Certified Nursing Assistant)-P wheel Resident #5 out of her room in the Broda chair and place Resident #5 at a table in the dining room. At 9:33 a.m. Surveyor # observed Companion-Q feeding Resident #5 her breakfast which consisted of sausage links that were cut up into approximately one inch pieces, french toast, and scrambled eggs. Surveyor # observed the sausage links were not of a mechanical soft texture. Surveyor # observed Companion-Q feed Resident #5 by giving Resident #5 multiple bites of the sausage link and french toast before offering milk or juice. At 9:53 a.m. Surveyor # observed Resident #5 ate 100% of her breakfast and beverages. On 3/7/16 at 12:10 p.m. Surveyor # asked Companion-Q if there are any special feeding instructions for Resident #5. Companion-Q replied no, just make sure doesn't pocket food. On 3/7/16 at 12:14 p.m. Surveyor # observed Resident #5 sitting in the Broda chair at a table in the dining room with a glass of milk & juice in front of her. Surveyor # noted that Companion-Q and Resident #5's POA (power of attorney) were sitting with Resident #5. At 12:16 FSA (Food Service Aide)-I gave Resident #5 a bowl of soup. At 12:40 p.m. FSA-I gave Resident #5 a hamburger on a bun with a piece of lettuce on the hamburger. Surveyor # noted that the hamburger was not of a mechanical soft texture. Surveyor # observed Companion-Q cut the hamburger with lettuce on a bun into pieces and start to feed Resident #5. On 3/8/16 at 7:13 a.m. Surveyor # asked FSA-H how she knows what diet a Resident is on and if they should receive puree or a mechanical soft consistency. FSA-H informed Surveyor # that they have a list that RD (Registered Dietitian)-K gives them and there is one for each floor with diets. Surveyor # informed FSA-H that Surveyor # observed there is sausage on the steam table for breakfast and asked if Residents who are on a mechanical soft diet would they receive the sausage. FSA-H informed Surveyor # that she wouldn't give the Residents the sausage but would give them applesauce. On 3/8/16 at 7:43 a.m. Surveyor # asked RD-K Residents who are on a mechanical soft consistency diet what would their meat look like. RD-K informed Surveyor # that it is either ground or shaved or if meatloaf was on the menu they would receive the meatloaf as it is served. Surveyor # informed RD-K of the observation of Resident #5 receiving sausage link cut into pieces of approximately one inch. RD-K informed Surveyor # that Resident #5 should not have received this. Surveyor # then informed RD-K that Resident #5 received a hamburger with a bun with a piece of lettuce on the hamburger. RD-K informed Surveyor # that Residents on a mechanical soft diet usually don't get raw fruits or vegetables and Resident #5 shouldn't have received this. On 3/8/16 at 12:55 p.m. Surveyor # spoke with ST (Speech Therapist)-M regarding Resident #5. ST-M informed Surveyor # that she wasn't the therapist that did the evaluation but would try to help Surveyor # . ST-M informed Surveyor # that Resident #5 was seen on 1/15/16 and was discharged on the same day and is on a mechanical soft diet with thin liquids. ST-M stated that education was provided to the caregivers on swallowing precautions. Surveyor # discussed the observations of Resident #5's POA and Companion-Q feeding Resident #5. ST-M informed Surveyor # that the way the swallowing precautions are written who ever is feeding Resident #5 should make sure after every bite they should have Resident #5 open her mouth and look in. Surveyor # asked if the caregivers education included Resident #5's POA or companion. ST-M informed Surveyor # that she didn't know and offered to telephone ST-N. At 1:06 p.m. ST-M spoke with ST-N on the telephone. After speaking with ST-N, ST-M informed Surveyor # that ST-N remembers educating the nursing staff but doesn't remember the POA. On 3/8/16 at 3:21 p.m. during the daily exit conference Administrator-A and DON (Director of Nursing)-B were informed of the above. Surveyor # asked for any education that was provided to Resident #5's POA or Companion-Q regarding the swallowing precautions. As of the date of the exit on 3/9/16 Surveyor # was not provided with any additional information.