Based on observation, interview, and record review, the facility failed to implement interventions to address range of motion (ROM) for one resident (#15) of one resident reviewed for limited range of motion. This deficient practice resulted in the potential for pain, discomfort, and worsening of contractures. Findings include: Resident #15 (R15) On 4/1/25 at 1:42 p.m., R15 was observed sleeping in her bed. R15 was noted to have a left hand contracture with fingers inside her palm, with no palm grip or splint observed. Review of R15's Electronic Medical Record (EMR) revealed admission to the facility on 2/23/19 with diagnosis including Lewy bodies, Parkinson's disease, dementia and muscle weakness. Review of R15's 2/20/25 Minimum Data Set (MDS) assessment revealed severely impaired cognition, and Section GG revealed R15 had ROM impairment on both upper extremities. Review of R15's 'progress note' dated 3/3/25, written by Registered Nurse (RN) B revealed the following: Resident with bilateral hand contractures. [R15] has palm grips to (B) (bilateral) hands at all times except for hygiene. OT (Occupational Therapy) evaluation, using our standing orders, initiated to possibly establish a ROM and splinting program . R15's 'care plan' had the following intervention, Palm grips to (B) hands at all times - remove to wash and dry hands. Approach Start Date: 2/21/25 . On 4/2/25 at 1:48 p.m., R15 was observed being assisted to the therapy gym by OT A. It was observed that while being assisted down the hallway, R15 did not have a palm grip or splint on her left hand, which visually appeared contracted. OT A began to perform ROM exercises to R15's left hand while in the therapy gym. OT A was interviewed and stated R15 has started therapy services again, with the intention of opening up R15's left hand more to attempt using a splint. On 4/3/25 at 10:20 a.m., RN B was interviewed regarding R15's contractures. RN B stated R15 was currently in therapy services, but during this time she was to have palm grips on both her right and left hands at all times. A request for an observation of R15 with RN B at this time revealed R15 sleeping in her bed. RN B confirmed R15 did not have a palm grip or splint on her left hand and was unable to locate the palm grip in her room. An interview was conducted with the Director of Nursing (DON) on 4/3/25 at 10:36 a.m. The DON confirmed R15 should be wearing bilateral palm grips.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide behavioral health care needs to maintain the highest practicable level of physical, mental and psychosocial well-being, for one Resident (#59) of 19 residents reviewed for behavioral care. This deficient practice had the potential to result in worsening signs and symptoms of depression, anxiety, and psychosocial decline. Findings include: Resident #59 (R59) On 4/1/25 at 10:52 a.m., R59 was interviewed and stated, I am blind, and I can't see. My favorite hobby is astronomy, and I would like to learn something new and talk to someone about it. I am bored . I have my tablet and it is the only thing that keeps me sane .I know if I had someone to talk to me I hurt less and don't think about my constant pain . no one comes to sit and visit with me and since you have been in here talking to me I have not had any pain . there is nothing to do but lay here . I am so glad that you came to see me, please don't leave because I don't have any pain since you are here visiting me. Review of R59's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 6/28/23 with active diagnoses that included anxiety, depression, diabetes mellitus, Diabetic retinopathy (diabetes that affects the eyes) and neuropathy (nerve damage that often affects the legs and feet). According to Section B of the MDS, R59 had severely impaired vision. R59 scored a 14 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. Review of Electronic Medical Record (EMR) Face Sheet revealed R59 was blind in left eye, had central blindness in right eye, and experienced chronic pain. On 4/2/25 at 2:44 p.m., during an interview, Certified Nurse Aide (CNA) C reported R59 leaves his room for doctor appointments but does not leave his room for anything else .{R59} used to get up for meals but hasn't for the past three months .{R59} likes to talk a lot but no one comes to visit him, I think he is bored .his vision was poor when he was first admitted , progressively got worse, and now he is completely blind. I would say he is depressed and lonely and just wants someone to talk to. On 4/3/25 at approximately 7:25 a.m., CNA D was interviewed and reported R59 was usually in his room all day .he is completely blind and needs some company .he is on his tablet but how long can someone do that, it would be so isolating sitting there in the dark all day by himself. On 4/3/25 at 7:35 a.m., Housekeeping Aide E was interviewed and stated I don't see anyone in his room that much .he is in his bed all the time. On 4/3/25 at 7:39 a.m., CNA F was interviewed and reported that R59 likes to talk with people, but no one ever comes to visit with him. I don't see anyone go in there during the day. CNA F stated, R59 used to come out of his room and now he won't. CNA F stated, R59 does not say he is depressed but it sure appears that way. On 4/3/25 at 8:28 a.m., Licensed Practical Nurse (LPN) G was interviewed and reported (R59) is very lonely, and I feel that he does better when there is someone to talk to, I think that would really help him. On 4/3/25 at 9:24 a.m., Social Worker (SW) H was interviewed and was asked about R59 reporting being lonely and depressed. SW H reported R59 is distracted from thinking about his pain when he has someone to talk to. When asked about behavioral care services being offered, SW H stated, I have not offered behavioral care support for him in the past quarter or so. During a follow-up interview at 10:36 a.m., Social Worker H acknowledged someone did ask for R59 to receive an outside consult from (Behavioral Care Provider), but I did not do it. On 4/3/25 at 11:56 a.m., the Director of Nursing (DON) was interviewed and acknowledged R59 did not receive an outside referral for behavioral care solutions and R59 needed behavioral support due to concerns of resident being lonely and bored. Review of facility policy titled Social Services date implemented 6/24/24 read in part, .the facility .will provide medically related social services to each resident, to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being .making referrals and obtaining services from outside entities .the facility should provide .or obtain needed services from outside entities during situations that include .expressions or indications of distress that affect the residents mental and psychosocial well being resulting from depression, chronic disease .difficulty coping with change or loss .and need for emotional support. Review of facility policy titled Behavioral Health Services date reviewed/revised 1/7/25 read in part, .It is the policy of this facility to ensure all resident receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise care plans after multiple falls for two Residents (#10 and #83) of 18 residents reviewed for care planning. Findings include: Resident #10 (R10) Review of R10's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 6/5/19, with active diagnoses including: dementia, anxiety disorder, depression, coronary artery disease, hypertension, and peripheral vascular disease. R10 scored 5 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of severe cognitive impairment. Review of facility fall reports revealed R10 had four falls in March. One fall on 3/8/24, two falls on 3/11/24, and one fall on 3/12/24. The care plan for R10 was not revised after each fall. Review of R10's fall prevention care plan revealed no updated interventions for any of the four falls R10 sustained in March. R10's care plan was initiated 6/5/19 and last care plan evaluation was on 3/12/24. During an interview on 3/26/24 at 4:14 p.m., ADON E stated, No revisions were made to (R10's) care plan after any of the falls. ADON E stated, Revisions should be made after each fall. Resident #83 (R83) Review of R83's MDS assessment, dated 1/15/24, revealed admission to the facility on [DATE], with active diagnoses including: Alzheimer's disease, anxiety disorder, and. R83 scored a 3 of 15 on the BIMS assessment, reflective of severe cognitive impairment. Review of facility fall reports revealed R83 had three falls in March. One on 3/5/24, one on 3/11/24, and one on 3/17/24. The care plan for R83 was not revised after each fall. Review of R83's fall prevention care plan revealed no updated interventions for any of the falls R83 sustained in March, and was noted last revised on 1/23/24. During an interview on 3/27/24 at 10:33 a.m., ADON E acknowledged no revisions were made to R83's care plan. Review of facility policy titled Fall Prevention Program last revised 9/30/23, read in part, .resident risk factors will be evaluated ., interventions in the care plan will be monitored ., and the care plan will be revised.

Based on record review, and interview the facility failed to document and/or complete post-fall assessments in accordance with professional standards of care and per facility protocol related to fall with head injury for one (Resident #22) of three residents reviewed for falls. Findings include: Resident #22 (R22) Review of facility provided matrix provided on 3/25/24 indicated R22 had a fall with major injury. Review of R22's face sheet revealed admission to the facility on 3/11/24 from an acute care hospital with muscle weakness, hemiplegia (paralysis of one side of the body) affecting right dominant side, and acute respiratory failure with hypoxia. Review of the 2/27/24 Minimum Data Set (MDS) assessment indicated R22 had a brief interview for mental status (BIMS) score of 14 out of 15 indicating intact cognition. A review of the care plan for R22 indicated she was at a risk for falls related to hemiplegia, with interventions including: (R22) is noted to have had some forgetfulness and impulsiveness at times. Remind (R22) to use (R22's) call light if needing assistance. Staff to provide reminders and cueing and check on (R22) frequently. Mattress on floor next to bed and bed in lowest position. Keep call light and personal items within reach. Encourage (R22) to be self-sufficient in tasks that are safe within physical parameters. A review of R22's medical record indicated she had a fall on 3/16/24. On 3/16/24 at 10:41 PM a nursing progress note for R22 stated in part, . called to resident's room by certified nursing assistant (CNA) at 9:30 PM. CNA stated she heard a loud thud come from resident's room, and she entered resident's room and observed (R22) lying on the floor on their right side. (R22) was lying on their right side with their right arm wedged back behind them. Pool of blood noted to be under resident's head. (R22) had previously been sitting in their wheelchair with their lap belt buckled. (R22) unbuckled (R22's) lap belt to reach for (R22's) phone that was on the floor. Range of motion (ROM) performed on all four extremities without difficulties. (R22) rolled slowly to their back. (R22) noted with deep laceration to the top/middle of their forehead. Pressure applied. Bleeding slowly subsided. Pressure bandage applied. (R22) was holding their right arm at the elbow. (R22) did state she had a pressure feeling in her right arm. Vitals within normal limits (WNL). On call provider called. Okay to send (R22) to hospital for evaluation and treatment. Husband notified and will be meeting (R22) at hospital. Emergency medical services (EMS) called and here to pick (R22) up at 10:05 PM. A review of R22's medical record indicated vital signs were taken prior to the fall incident at 2:35 PM on 3/16/24 with a blood pressure of 130/60, respirations of 16, and a pulse rate of 74. These are almost 7 hours before R22 sustained the fall. The nurse noted R22's vitals were within normal range at time of incident, however the next set of vitals charted for R22 were on 3/16/24 at 10:41 PM with a blood pressure of 142/88, respirations of 16, and a pulse rate of 88. It was discovered the 3/16/24 vital signs were charted as taken at 10:41 PM approxiamtely 36 minutes after the resident was taken by EMS to the hospital per the nursing progress note dated 3/16/24 at 10:41 PM. On 3/17/24 at 2:59 AM, a nursing progress note for R22 stated in part, .physician's assistant (PA) from (Acute Care Hospital) called to ask questions about resident fall. (R22) being admitted as she has two subdural hematomas and is going to be evaluated by neurosurgery in the morning . A review of the facility's Fall Prevention Program dated 11/6/23, stated that when a resident experiences a fall, the facility will assess the patient, complete a post-fall assessment, complete an incident report, document all assessments and actions. A review of the facility's Neuro(neurological) Checks policy from 9/25/23 stated in part, that a neurological assessment will be performed on any resident who has sustained a head injury. Perform frequent neurological assessments every 15 minutes for the first hour. On 3/27/24 at 7:58 AM, an interveiw was conducted with the ADON regarding the neuro checks paperwork post fall with head injury. When asked what the facility's expectations were for filling out the form provided in the neuro checks policy, the ADON stated she would have expected the assessment form was filled out completely. The ADON then pointed out the policy states staff must fill out at a minimum assessment of pulse, assessment of pupil size and reactivity, equality of hand grips and strength, blood pressure, and respirations. A review of the neuro checks paperwork for R22, performed by staff on 3/16/24 after the fall, did not have the blood pressure, grip strength, pupil size, respiration, or pulse filled out for three 15-minute check opportunities required per the facility's Neuro Checks policy, prior to R22 being sent to the hospital. On 03/27/24 at 10:57 AM, a follow-up interview was conducted with the ADON, who reviewed the medical record pertaining to the fall on 3/16/24 for R22. The ADON acknowledged neuro checks were not performed appropriately and the expected post fall head to toe assessment was also not charted.

Based on observation, interview, and record review, the facility failed to ensure enteric precautions (recommended personal protective equipment (PPE), isolation procedure, and hand hygiene method) were followed for one Resident (R55) of three residents reviewed for infection control practices. This deficient practice resulted in the potential for spread of Clostridium Difficile (C. diff: a bacterial infection of the colon with symptoms that can range from diarrhea to life-threatening) within the facility resident population. Findings include: During an observation on 3/25/24 at 1:55 p.m., Certified Nurse Aide (CNA Trainee) F donned an isolation gown, gloves, and a surgical mask to enter R55's enteric isolation room. R55 shared the room with Resident R47, who was not exhibiting any signs or symptoms of C. diff. Minutes later CNA Trainee F exited R55's room wearing the same isolation gown, gloves, and surgical mask worn into the resident's room. CNA Trainee F forcibly pulled and ripped the tie closure at the neck to remove the isolation gown while standing in the hallway with CNA G and this Surveyor. CNA Trainee F then removed the surgical mask and gloves she was wearing, disposing all PPE in the housekeeping cart positioned outside R55's room in the hallway. CNA Trainee F performed hand hygiene using alcohol-based hand rub following removal of all PPE. Signage observed outside R55's room door included: Contact Enteric Precautions, Visitors: Please speak with nurse prior to entering room. Clean hands with sanitizer prior to entering. Do not wear the same gown and gloves for the care of more than one person . Discard gloves and gown before room exit. Use dedicated or disposable equipment. Clean hands with soap and water upon leaving. Clean and disinfect reusable equipment before use on another person. During an interview on 3/25/24 at 2:00 p.m., when asked her work position in the facility, CNA Trainee F stated, I am a student (CNA Trainee). When asked how hand hygiene had been performed following room exit, CNA Trainee F stated, After taking the gloves off I sanitized with hand sanitizer. I did not wash with soap (and) water. CNA G, present at the time of the interview, spoke up and stated, We washed our hands before we came out of the room. When asked how CNA Trainee F could have washed their hands inside R55's room when she exited the room wearing all required PPE, including gloves, CNA Trainee F and CNA G remained silent. During an interview on 3/25/24 at 2:03 p.m., Education Director/Registered Nurse (RN) H was asked what PPE staff should be donning prior to entrance into R55's room. RN H stated, Gown, gloves . (and) surgical mask. The PPE should be doffed (removed) in the room (R55's isolation room). What we have been doing is taking the mask and eye protection off outside in the hall. Take the gown off in the room. With C. diff we have everything on our head when we come out. When asked what the concern would be with removal of the isolation gown worn by CNA Trainee F in a C. diff residents' room (R55's) out in the hallway, RN H stated, Concern is getting it (C.diff) airborne in the hallway . (and the potential spread to other facility residents and facility staff.) Review of the facility Management of C. Difficile Infection policy, Date Implemented 7/13/23, revealed the following, in part: .5. General principles related to contact precautions for C. difficile: a. All staff are to wear gloves and a gown upon entry into the resident's room and while providing care for the resident with C. difficile infection. b. Hand hygiene shall be performed by handwashing with soap and water in accordance with facility policy for hand hygiene . g. A private room with a dedicated toilet is preferred .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop appropriate Care Planning for two Residents (#37 and #46) of 19 residents reviewed for Care Plans. This deficient practice had the potential to cause limitations in care coordination and adverse outcomes. Findings include: Resident #37 Review of the Minimum Data Set (MDS) admission assessment, dated 09/08/22, revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including coronary artery disease, peripheral vascular disease, osteomyelitis (bone infection) of the right ankle and foot, obstructive uropathy, acquired below knee amputation, myocardial infarction (heart attack), and arthritis. The assessment revealed Resident #37 required two-person assistance for bed mobility, transfers, and toileting, and was non-ambulatory. Resident #37 was always continent of bowel and bladder and had no pressure injuries and was at risk for pressure injuries. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed Resident #37 was cognitively intact. Review of Resident #37's MDS assessment, dated 12/09/22, revealed Resident #37 had three Unstageable Deep Tissue Injuries (DTI's). The BIMS assessment showed a score of 15/15. Review of facility pressure ulcer log, titled Weekly Pressure Ulcer Report, dated 02/09/23, provided by Licensed Practical Nurse (LPN) R, revealed Resident #37 had a left heel, yellow/black, full thickness pressure ulcer (full thickness skin loss with tissue destruction, necrosis, or damage to muscle, bone, or supporting structures), with scant/seropurulent drainage (a mixture of blood and pus which typically is indicative of infection). The left heel ulcer was measured 7.5 cm (length) x 6 cm (width) x 0.2 (depth). A column marked D.T.I. was checked (Deep Tissue Injury). The date acquired was 09/12/22 (after admission), and the facility acquired column was checked Yes. During an interview on 02/15/23 at 5:04 p.m., Resident #37 was asked about the development of the left heel pressure ulcer. Resident #37 reported he had no pressure ulcer on his left heel upon admission to the facility. Resident #37 was asked if he was educated on offloading his left heel upon admission, given his high risk of developing pressure injuries. Resident #37 reported he was not educated to keep his left heel off the bed and had placed his left heel directly on the bed in the weeks after admission. Resident #37 stated, I didn't realize that [was a concern] at that time. Resident #37 clarified he did not have a positioning device to offload his left heel until after the left heel pressure ulcer developed and said the focus of his treatment was on his right leg, given a new below knee amputation (BKA), not his left leg. Resident #37 showed Surveyor a large foam positioning device which he currently used to offload his left heel on the bed, which he said he received after the pressure ulcer developed to his left heel. Review of Resident #37's admission skin assessment revealed no pressure injury or ulcer to the left heel. The assessment showed scarring of the left leg; the heel was not mentioned. During an interview on 02/15/23 at 5:36 p.m., the Rehabilitation Director and wound care nurse, Registered Nurse (RN) S, was asked about the cause and progression Resident #37's left heel pressure ulcer. RN S reported Resident #37 developed the left heel ulcer on 09/18/22. RN S reported since Resident #37 came in with a right leg amputation (BKA), they knew he had bad PVD [Peripheral Vascular Disease] and had provided a specialized air mattress and pressure relief pad over the mattress. RN S confirmed they had not educated Resident #37 to offload his left heel, as he could move his leg. When asked to clarify Resident #37's bed mobility status upon admission, RN S acknowledged Resident #37 required assistance for bed mobility. Review of Resident #37's nursing progress note dated 09/02/23 at 15:51 p.m. (3:51 p.m.), provided by RN S, revealed an admission skin assessment was completed. This showed small scars on LT [left] lower leg, with no mention of a left heel or skin concern, past or present. The note confirmed Resident #37 had a specialized air mattress and pressure relief surface on bed and wheelchair. There was no mention of education or any intervention to offload the left heel. Review of Resident #37's Care Plan, with history, provided and reviewed with RN S on 02/15/23, revealed there were no intervention to offload Resident #37's left heel upon admission. An intervention was not found until 01/04/2023, care planned by RN S, which showed, .Float lf [left] heel while in bed. RN S confirmed they did not see any care planning to offload Resident #37's heel until 01/04/23 in Resident #37's Care Plan. Further review of Resident #37's Care Plan with history showed, Resident is at high risk for pressure ulcers R/T [related to] decreased mobility and incontinence as evidenced by Braden [standardized] pressure ulcer assessment score less than 10 . Review of Resident #37's ADL (Activities of Daily Living) Care Plan intervention dated 09/01/22 revealed Resident #37 required extensive assist with bed mobility, with no mention of offloading the left heel. An updated intervention dated 10/03/22 revealed staff to encourage side lying when in bed to prevent pressure to left heal by RN S, after the development of the left heel pressure ulcer. During an interview on 02/16/23 at 8:33 p.m., LPN R (with RN S present) reported they were the primary wound care nurse who addressed Resident #37's wound care. LPN R clarified the left heel wound developed on 09/18/23. Surveyor noted Resident #37 reported he had not been educated to offload his heel prior to 09/18/23. Both were asked if Resident #37 should have had his left heel offloaded prior to developing the DTI on 09/18/23 and responded they had provided other pressure relieving interventions including the specialized air mattress and a pressure relief padded overlay on the mattress. Surveyor asked if the left heel pressure injury was avoidable. RN S clarified CNAs were taught to float a resident's heels in their training class, so this would be an expectation for care. Surveyor conveyed the wound appeared avoidable due to Resident #37's left heel not being offloaded until after the pressure ulcer developed. LPN R reported they understood the concern. RN S responded they would have expected Resident #37 to not develop a heel wound as they could move their left leg. During an interview on 02/16/23 at 10:06 a.m., Certified Occupational Therapy Assistant (COTA) Q and Physical Therapist (PT) T were asked if they provided education to Resident #37 to offload their heel while in bed. Both confirmed they had not provided this education, as they presumed this was done by nursing staff. PT T confirmed Resident #37 required moderate to maximal assistance with bed mobility upon admission. PT T acknowledged Resident #37 would have required some assistance for positioning his left leg upon and soon after admission. When asked about the cause of Resident #37's heel ulcer, PT T reported they believed it was caused by pressure to his heel when laying on his back in bed. During an interview on 02/17/23 at 08:37 a.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked about Resident #37's facility-acquired avoidable left heel pressure ulcer, and left heel offloading was not care planned for Resident #37's left lower extremity until three months after the wound developed. The DON and ADON had no comment regarding care planning, and the DON reported the wound occurred from peripheral vascular disease. Resident #46 Review of Resident #46's Minimum Data Set (MDS) assessment, dated 12/16/22, revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including stroke, arthritis, malnutrition, anxiety, depression, and vision impairment (from glaucoma). Resident #46 required two-person assistance for bed mobility, transfers, toileting, and dressing, one-person assistance with eating, and supervision with wheelchair locomotion. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 5/15, which indicated Resident #46 had severe cognitive impairment. The sensory assessment showed Resident #46 was usually understood and usually could understand, with highly impaired vision. The PHQ-9 assessment for depression revealed a score of 12/27, which showed Resident #46 had moderate depression. The behavioral assessment showed Resident #46 had physical and verbal behaviors directed towards others 1-3 days during the assessment period. The assessment showed no falls occurred during the look back period. During an interview on 02/14/23 at 3:12 p.m., Resident #46 was asked about a large bruise on the dorsum (top) surface of their left hand and forearm. Resident #46 denied abuse or rough treatment, and reported it occurred about a week ago, however she could not recall what happened. During an interview on 02/14/23 at 3:30 p.m., LPN V was asked about Resident #46's bruise to her left hand and forearm. LPN V confirmed Resident #46 demonstrated physical behaviors during cares, such as being combative and striking out. LPN V clarified Resident #46 may have bumped her left hand and arm during cares, as the bruising was partly on the outside of her left arm and hand. Review of Resident #46's nursing progress notes revealed Resident #46 demonstrated ongoing behaviors, including hollering, care refusals, swatting her hands at staff, refusing medications, and other physical and verbal behaviors during cares. Review of Resident #46's Care Plan, accessed 02/16/23, revealed no behavioral management problem, goal, or interventions when physical or verbal behaviors directed towards others occurred, including how to educate staff to manage behaviors when they occurred, care strategies, behavioral monitoring, non-pharmacological interventions, or psychosocial support, given Resident #46's ongoing behaviors noted in the EMR and reported by nursing staff. The Care Plan did not reveal any sensory interventions to accommodate for Resident #46's progressive vision loss and reported fearfulness and anxiety, to provide calming and help Resident #46 successfully engage in her environment. Review of Resident #46's Behavioral Health notes, titled Clinical Rounds: Behavior Note, or Behavior Analysis Report, provided by the Director of Nursing (DON), revealed behavioral incident notes which showed physical and/or verbal behaviors on 08/27/22, 08/25/22, 09/07/22, 10/17/22, 10/25/22, 01/01/23, and 01/03/23. These notes reflected medication changes but did not reflect strategies to address Resident #46's behaviors. Review of Resident #46's Behavioral Provider consults provided by the DON revealed the last outside provider visit had occurred on 10/14/22, with no additional referral or consult confirmed or provided by the DON upon request. This visit note made recommendations for non-pharmacological interventions to address Resident #46's behaviors, which were not reflected in the Care Plan. Review of Resident #46's most recent behavioral notes dated 01/01/23, and 01/03/23, revealed, Kicking others. Date: 01/01/23 .[Resident #46] was yelling, hitting, and kicking at CNA's [Certified Nurse Aide] and the CN [aide] this morning during cares. [Resident #46] did calm down after a while but was agitated and scratching a lot from the upsetting time during her morning wash up. Hitting self. Date: 01/03/23 .[Resident #46] was banging her head on her bed and trying [sic] kick when trying transfer back into bed because she had to wear shoes. [handwritten response] [Resident #46] does not like help and struggles to communicate and gets frustrated when staff [sic] does [sic] not understand. There were descriptions of Resident #46's behaviors, and notations about her struggles and frustration, however there were no interventions or recommendations noted to manage Resident #46's behaviors, or Care Plan revisions or updates after these occurrences. During an interview on 02/17/23 at 7:57 a.m., Resident #46 was greeted and asked how they were doing. Resident #46 reported she was doing terrible, and it was not a good day. Resident #46's head was down, and she appeared discouraged and unhappy. During an interview on 02/17/23 at 8:00 a.m., CNA P was asked about Resident #46's behavioral needs, and if they had been educated regarding how to manage Resident #46's behaviors during cares. CNA P reported they worked frequently with Resident #46 and had not received any instruction on how to manage Resident #46's behaviors. CNA P reported they had just finished morning cares with Resident #46, and she had yelled at them, as she had spilled water on herself. CNA P confirmed Resident #46 was sometimes combative with cares, and they worked to keep the same morning routine for her, which seemed to help, however noticed other aides did not keep the same routine. CNA P reported Resident #46 was most calm and cooperative during morning cares when she was able to be up in her wheelchair in the bathroom to get ready for the day. CNA P explained when other nursing staff got her ready partly in the bed and partly in the bathroom, Resident #46 became agitated. CNA P confirmed there was no Care Plan to their awareness designating Resident #46's care preferences, and they had figured out strategies on their own. During an interview on 02/17/23 at 8:16 a.m., the Assistant Director of Nursing (ADON), Registered Nurse (RN) C, and the DON were asked about Resident #46's lacking behavioral care problems, goals, and interventions for physical and verbal behaviors directed towards others in the Care Plan, given Resident #46's recent bruise to hand, and documentation of resistance to cares. Both were unable to provide any additional information to this regard by the end of the survey. The DON reported the Social Worker addressed behavioral management, and they were unavailable for interview the week of the survey as they were out of the country, and there was no other designated representative. Review of the policy, Resident Care Planning, rev [revised] 8/05, revealed, An assessment of a new resident shall be initiated by licensed personnel within 24 hours of admission to the facility, and the results of the assessment will be documented in the resident's clinical record. 2. The nursing care provided to each resident will be based on all of the following: a. Written assessment of the resident. B. Identification of health problems. C. A written plan of care with interventions. D. Implementation of the care plan. e. Evaluation of the results of the planned care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate pressure ulcer care and treatment to prevent two facility acquired pressure ulcers for two Residents (#37 and #52) of six residents reviewed for pressure ulcers. This deficient practice resulted in the development of a pressure injury for Resident #52, and the development and progression of a pressure ulcer for Resident #37, including infection and pain, and the potential for additional adverse outcomes. Findings include: Resident #37 Review of the Minimum Data Set (MDS) admission assessment, dated 09/08/22, revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including coronary artery disease, peripheral vascular disease, osteomyelitis (bone infection) of the right ankle and foot, obstructive uropathy (excess urine in the kidneys causing swelling), acquired below knee amputation, myocardial infarction (heart attack), and arthritis. The assessment revealed Resident #37 required two-person assistance for bed mobility, transfers, and toileting, and was non-ambulatory. Resident #37 was occasionally incontinent of bowel and bladder. Resident #37 had no pressure injuries and was designated as at risk for pressure injuries. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, which showed Resident #37 was cognitively intact. Review of Resident #37's MDS assessment, dated 12/09/22, revealed Resident #37 had three Unstageable Deep Tissue Injuries (DTI's). The BIMS assessment showed a score of 15/15. Review of facility pressure ulcer log, titled Weekly Pressure Ulcer Report, dated 02/09/23, provided by Licensed Practical Nurse (LPN) R, revealed Resident #37 had a left heel, yellow/black, full thickness pressure ulcer (full thickness skin loss with tissue destruction, necrosis, or damage to muscle, bone, or supporting structures), with scant/seropurulent drainage (a mixture of blood and pus which typically is indicative of infection). The left heel ulcer was measured 7.5 cm (length) x 6 cm (width) x 0.2 (depth). A column marked D.T.I. (Deep Tissue Injury) was checked. The date acquired was 09/12/22 (after admission), and the facility acquired column was checked Yes. During an observation on 02/15/23 at 5:00 p.m., Resident #37 was observed in their room seated in a tall manual wheelchair. He was wearing a prothesis on his right leg and a slipper on his left foot. During an interview on 02/15/23 at 5:04 p.m., Resident #37 was asked about the development of the left heel pressure ulcer. Resident #37 described he had a new Right Below Knee Amputation (BKA) from an infection and came to the facility for rehab. Resident #37 reported he had no pressure ulcer on his left heel upon admission to the facility and showed Surveyor how his left heel was covered by a foam dressing and recently with a protective cup to prevent pressure. Resident #37 reported he was no longer able to wear a shoe on his left foot since the development and progression of the left heel ulcer, however he did not feel the slipper was safe either, as it 'slipped' sometimes. Resident #37 reported he had no other device or orthotic for ambulation. Resident #37 stated he had been ambulating with physical therapy and staff in his room with a two-wheeled walker, however recently had increased pain in the left leg/heel with standing and walking due to the progression of the left heel pressure injury. Resident #37 added therapy had backed off somewhat as he was struggling to stand and walk due to pain. Resident #37 conveyed he was at the wound clinic this week, where they removed tissue from the left heel which was black and discolored. Resident #37 was asked if he was educated on offloading his left heel upon admission, given his high risk of developing pressure injuries. Resident #37 reported he was not educated to keep his left heel off the bed and had placed his left heel directly on the bed in the weeks after admission. Resident #37 stated, I didn't realize that [was a concern] at that time. Resident #37 clarified he did not have a positioning device to offload his left heel until after the left heel pressure ulcer developed and said the focus of his treatment was on his right leg, given the new BKA, not his left leg. Resident #37 showed Surveyor a large foam elevating positioning device which he currently used to offload his left heel on the bed, which he said he received after the pressure ulcer developed on his left heel. Resident #37 reported he had received a specialized air mattress for pressure relief a couple days after he was admitted (on 09/01/23). Resident #37 shared he recently saw a vascular surgeon to evaluate his left leg circulation and the potential to improve circulation for wound healing, and it was determined he was not a candidate for surgical intervention to address the circulatory blockages in his (left) leg. Review of Resident #37's admission skin assessment revealed no pressure injury or ulcer to the left heel. The assessment showed scarring of the left leg; the heel was not mentioned. During an interview on 02/15/23 at 5:36 p.m., the Rehabilitation Director and wound care nurse, Registered Nurse (RN) S, was asked about the cause and progression Resident #37's left heel pressure ulcer. RN S reported Resident #37 developed the left heel ulcer on 09/18/22 (date discrepancy from wound care log). RN S stated since Resident #37 came in with a right leg amputation (BKA), they knew he had bad PVD [Peripheral Vascular Disease] and had provided a specialized air mattress and pressure relief pad over the mattress. RN S confirmed they had not educated Resident #37 to offload his left heel, as he could move his leg. When asked to clarify Resident #37's bed mobility status upon admission, RN S acknowledged Resident #37 required assistance for bed mobility. Review of Resident #37's nursing progress note dated 09/02/22 at 15:51 p.m. (3:51 p.m.), provided by RN S, revealed an admission skin assessment was completed. This showed small scars on LT [left] lower leg, with no mention of a left heel or skin concern, past or present. The note confirmed Resident #37 had a specialized air mattress and pressure relief surface on bed and wheelchair. There was no mention of education or any intervention to offload the left heel. Review of Resident #37's Care Plan, with history, provided and reviewed with RN S on 02/15/23, revealed there were no intervention to offload Resident #37's left heel upon admission. An intervention was not found until 01/04/2023, care planned by RN S, which showed, .Float lf [left] heel while in bed. RN S confirmed they did not see any care planning to offload Resident #37's heel until 01/04/23 in Resident #37's Care Plan. An updated intervention on 01/06/23 added, .Float left heel while in bed with purple leg elevating foam with a [brand name] case [pressure relieving pad] covering it. Make sure heel is hanging over edge of foam, no pressure on heel PLEASE. The note was by RN S. Further review of Resident #37's Care Plan with history showed, Resident is at high risk for pressure ulcers R/T [related to] decreased mobility and incontinence as evidenced by Braden [standardized] pressure ulcer assessment score less than 10. Suspected Deep Tissue Injury [DTI] on (R) [right] knee .Deep tissue injury left great toe, left heel. Edited 10/27/22. This problem area showed Resident #37 had three DTI's on 10/27/22. An updated problem area dated 01/05/23 showed .Deep tissue injury on left heel . Review of Resident #37's ADL (Activities of Daily Living) Care Plan intervention dated 09/01/22 revealed Resident #37 required extensive assist with bed mobility, with no mention of offloading the left heel. An updated intervention dated 10/03/22 revealed staff to encourage side lying when in bed to prevent pressure to left heal by RN S, after the development of the left heel pressure ulcer. Review of Resident #37's physician orders, accessed 02/15/23, including history, reviewed with RN S, revealed there were no treatment or other orders to provide offloading to Resident #37 left heel, with RN S concur post review with Surveyor. Review of Resident #37's Treatment Administration History logs, provided by RN S, reviewed from 09/2022 through 02/15/23, showed no treatment orders to offload the left heel. The treatments showed the left heel wound was initially treated with [Brand name] (collagenase Clostridium) ointment histo. [an enzyme wound treatment which broke up and removed dead wound tissue], alginate [a highly absorbent wound dressing derived from seaweed], an appropriate secondary dressing, and to use skin prep [a skin treatment which protects skin from irritation, friction, and shear] to wound every day. New orders dated 2/14/23 post wound clinic visit showed treatment to left heel to cleanse wound with soap and water or normal saline or wound cleanser, and cover with [Brand name] [an antimicrobial large, rolled dressing], and [Brand name] [foam wound dressing] foam [to] [left] heel. Review of the Electronic Medical Record (EMR) including Wound Management Detail Reports revealed Resident #37's right knee and left great toe pressure wounds had closed on 11/02/22 and 01/05/23 respectively, however the left heel wound remained opened. Review of Resident #37's Wound Management Detail Reports, provided by RN S, dated 02/15/23 at 10:06 a.m., revealed Resident #37's heel wound progressed in size, and developed an infection during treatment. The wound was currently significantly larger in size since the development, with measurements and description as follows: [Resident #37]. Wound type: Other - suspected DTI. Wound location: left heel. Date/Time identified: 09/18/2022 14:07 [2:07 p.m.]. Present on admission/re-entry: No. This wound has not been healed or discontinued . 09/18/22: 1.5 cm [centimeters] x 2.3 cm, Skin intact. 09/27/22: 1.5 cm x 0.8 cm, Improving, skin intact, area shrinking. 10/06/22: 2.8 cm x 2.4 cm, Area reabsorbed. Scabbed with edges lifting. 10/14/22: 2.4 cm x 2.1 cm, Stable. Thick eschar [a collection of darkened dead tissue covering a wound]. No drainage or redness. No odor. 10/20/22: 5.0 cm x 4.0 cm, Declining. Area open. 11/02/22: 5.4 cm x 6.2 cm, Declining. 11/09/22: 5.3 cm x 4.2 cm, Improving. Chemically debriding [removing infected or dead tissue of a wound] area .Does have 0.1 cm depth. No redness or odor present. 11/23/22: 6.8 cm x 5.3 cm, Stable, Debriding area .25% slough [dead wound tissue with a yellow appearance] and 75% eschar. 11/30/22: 6.0 cm x 4.8 cm, Stable. Chemically debriding wound .50% eschar and 50% yellow slough. Decreased redness in peri-wound and no odor present. 12/08/22: 6.4 cm x 4.2 cm, Declining. Debriding wound. Has slight odor before cleaning. About 3 c.m. of redness around wound and edema noted in leg. Will obtain a culture in a.m. of wound drainage . 12/16/22: 6.0 cm x 6.0 cm, Stable. 0.2 cm depth [worsening depth]. Is currently on antibiotics for infection in heel .Slight odor remains prior to cleansing. 12/22/22: 6.3 cm x 4.8 cm, Stable. O.2 cm depth. Slight odor .Some redness noted in peri-wound [around wound]. 01/01/23: 6.6 cm x 5.2 cm, Improving. Depth is 0.2 cm. Wound bed is yellow and black. Debriding .Slight odor prior to cleansing .slightly red in peri-wound .Decreased pain .Continues on oral Vancomycin [an antibiotic]. 01/05/23: 6.2 cm x 5.4 cm, Improving .debriding wound. No redness or odor. 01/12/23: 7.0 cm x 5.4 cm, Improving. Continue to chemically debride area. 01/18/23: 7.5 cm x 4.9 cm, Stable . 01/26/23: 7.5 cm x 4.9 cm, Stable. 0.2 cm depth. Wound is 50% yellow and 50% black. Debriding . 02/01/23: 7.5 cm x 4.9 cm, Improving. Debriding area .and eschar is soft and mushy. No odor . 02/09/23: 7.5 cm x 6.0 cm, Stable. Has 0.2 cm depth and is chemically debrided . Review of LPN R's nursing progress note, dated 10/17/23, revealed they believed a rigid pressure relieving positioning boot (provided after the left heel pressure ulcer had developed) caused the pressure sore on the left heel to worsen, as the wound subsequently became larger with bloody drainage and black eschar. The boot was discontinued on 10/17/23, as Resident #37 would complain to them of his left leg hurting from the frames of the boot. Review of Resident #37's progress note dated 12/12/22 at 5:35 p.m. showed the Infectious disease physician was aware of resident having multiple bacteria in left heel wound and would follow up with them on 12/15/23. Review of Resident #37's progress note dated 12/15/22 at 4:01 p.m. showed new orders from the Infectious disease physician for (Brand name antibiotic) 125 mg to continue until 12/29/22 four times per day, then three times a day for three weeks. Review of Resident #37's wound clinic note, dated 02/13/23, revealed the left heel wound was to be cleansed, and [Brand name Antimicrobial large wound dressing] was recommended, [Brand name] heel cup to cushion, [Brand name elastic compression bandage] was recommended with heel cut out to relieve pressure, and an alternate protein supplement was added. X-ray of left foot was ordered. There was no wound description of type of wound, or any wound treatment completed, only wound orders. During an interview on 02/15/23 at 5:36 p.m., RN S was asked about Resident #37's wound care clinic visit on 02/15/23. RN S reported they debrided the left heel wound via sharp debridement [a surgical procedure using sharp instruments to cut away dead or infected tissue]. RN S acknowledged the wound size had significantly increased since it's discovery, and reported Resident #37 had compromised circulation which contributed. RN S clarified the infectious disease physician reported it was a non-healing wound during the last visit. RN S reported there was no current infection and acknowledged Resident #37 was on antibiotics when the wound became infected. RN S was asked why Resident #37's left heel was not offloaded on the bed prior to the wound occurring. RN S responded it was a standard of practice to float a resident's heels on the bed, and they believed Resident #37 could reposition their heel themselves and therefore did not educate resident or staff. During an observation on 02/16/23 at approximately 8:00 a.m., RN S and LPN R were observed providing wound care treatment to Resident #37's left heel. Resident #37 agreed to Surveyor observation and was in their bed with a left heel offloading support and was wearing a pressure relief soft foam boot foot protector. The dressing covering the wound was dated 02/15/23, and Resident #37 earlier confirmed his dressing was changed daily. Standards of practice for infection control and wound treatment were observed. Once the heel protective cup and bandage were removed, the wound was observed. LPN R reported the wound was a Stage IV pressure ulcer, measuring 7.5 cm x 5.3 cm x 0.3 depth, and reported it appeared open down to the bone or tendon. The large heel wound appeared open as it was debrided, with dark, red and yellow areas of coloration. LPN R reported the black wound covering (eschar) had been removed during the sharp debridement by the wound care clinic on 02/15/23. There was no odor, and no pus or signs of infection. There were no other wounds observed on Resident #37's left leg or foot. LPN R provided the wound treatment as specified in the physician orders. During an interview with on 02/16/23 at 8:33 p.m., LPN R (with RN S present) reported they were the primary wound care nurse who addressed Resident #37's wound care. LPN R confirmed the left heel wound developed on 09/18/23. Both reported they were unclear why the heel wound started. Surveyor noted Resident #37 reported he had not been educated to offload his heel prior to 09/18/23. LPN R reported Resident #37 had poor circulation in his leg, which may have increased his risk for developing a pressure sore. Both were asked if Resident #37 should have had his left heel offloaded prior to developing the DTI on 09/18/23 and responded they had provided pressure relieving interventions including the specialized air mattress and a pressure relief padded overlay on the mattress. Surveyor asked if the left heel pressure injury was avoidable. RN S reported they did everything they knew to do, as Resident #37 was at higher risk due to poor circulation. RN S clarified CNAs were taught to float a resident's heels in their training class, so this would be an expectation for care. Surveyor asked why Resident #37 was not referred to the wound clinic until 02/15/23, given the wound progression, infection, and the wound was recently classified as non-healing per RN S . RN S reported the infectious disease physician completely trusted LPN R to provide the wound care, as she was an excellent wound care nurse for many years. LPN R reviewed the wound care notes with Surveyor and agreed the wound had significantly worsened and became infected. LPN R noted the wound was originally classified as an unstageable DTI, however the wound appeared to be a Stage IV during observations in the past week, as the bone and/or tendon were visualized. Both were asked for any documentation of the left heel pressure ulcer was avoidable or unavoidable, as a limited wound description was noted on the wound treatment notes on 09/18/23 when it was discovered. Both reported they had not completed this type of documentation, or any further description of the wound cause when discovered, as this was not part of the wound care documentation process. Surveyor conveyed the wound appeared avoidable due to Resident #37's left heel not being offloaded until after the pressure ulcer developed, per standards of practice. LPN R reported they understood the concern, and Resident #37 could have been referred to the wound care clinic sooner, however, was being followed by an infectious disease physician. RN S responded they would have expected Resident #37 to not develop a heel wound as they could move their left leg upon admission, despite the admission Care Plan showing Resident #37 required extensive assistance for bed mobility. During further interview, LPN R clarified they believed a prior rigid pressure relief offloading boot may have contributed to the progression of Resident #37's heel pressure ulcer, as it was not padded at the heel, and had rigid components. RN S was asked if they could show Surveyor the boot Resident #37 was wearing, however they could not be certain which boot Resident #37 wore. RN S showed Surveyor some of the offloading boots in the facility; they were observed with lambswool padding, however, did have a rigid frame and a metal heel piece to offload the heel which was not padded. LPN R reported they had found the boot twisted on Resident #37's leg, with pressure areas observed on their left leg and foot, so the boot was discontinued, which their progress note confirmed. During an interview on 02/16/23 at 10:06 a.m., Certified Occupational Therapy Assistant (COTA) Q and Physical Therapist (PT) T were asked if they provided education to Resident #37 to offload their heel while in bed. Both confirmed they had not provided this education, as they presumed this was done by nursing staff. PT T confirmed Resident #37 required moderate to maximal assistance with bed mobility upon admission, and was maximal assistance to dependent with transfers, requiring the use of a lift. PT T acknowledged Resident #37 would have required some assistance for positioning his left leg upon and soon after admission. PT T and COTA Q reported Resident #37 was currently needing supervision (to independent) with bed mobility currently, required minimal assistance or contact guard assistance to transfer, and could walk 200' with contact guard assistance and a two-wheeled walker. When asked about the cause of Resident #37's heel ulcer, PT T reported they believed it was caused by pressure to his left heel when laying on his back in bed. PT T conveyed when asked they had not done skin inspections of Resident #37's left heel during treatment, as they understood this was the role of nursing staff. Review of Resident #37's physician notes confirmed referral to the infectious disease physician on 11/10/22, and referral to the wound care clinic on 2/08/23. Review of the infectious disease physician note, dated 12/29/22 , revealed, .I met [Resident #37] because of a new posterior left heel pressure [ulcer] 1 that possibly occurred from a [Brand name rigid pressure offloading] boot .open wound, heel - Onset: 11/23/22. The note further revealed when Resident #37 had been seen on 12/15/23, the wound had declined with increased odor, increased redness, and other signs of infection, and Resident #37 had been placed on oral Vancomycin. The note revealed an arterial Doppler [circulation test] was done which showed occlusion which may or not be amenable to .intervention . Review of the infectious disease physician note, dated 12/15/22, specifically revealed, Follow-up: Open wound, heal. Onset: 11/23/22 [Resident #37] had a large necrotic [premature tissue death] wound involving the posterior left heel that measures 6 centimeters from proximal to distal and 4.5 centimeters from right to left. The left lower extremity was swollen including the foot and ankle; there was [sic] possibly exposed Achilles tendon and the central wound was necrotic without foul odor or exposed bone .I agree that there is [sic] changes in the wound that could be consistent with infection. After reviewing the cultures .we are going to switch to Keflex [antibiotic] .in addition to the oral Vancomycin .Assessment/Plan: 1. Osteomyelitis left foot. 2. Open wound heel. Unspecified open wound left foot. Subsequent encounter. Additional wound visit records during the week of February 13th [2023] were requested and unavailable by the end of the survey. During an interview on 02/17/23 at 08:37 a.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked about Resident #37's facility-acquired avoidable left heel pressure ulcer, and the concerns with the development in the facility, lack of offloading upon admission and in the weeks after admission, the progression in size and severity, the development of infection, and the questionable potential of the pressure wound to heal, per resident and nursing staff interviews, as well as record review. The DON reported the pressure wound was unavoidable, given Resident #37's peripheral vascular disease, however, did not provide any documentation the pressure ulcer was unavoidable. The DON clarified the pressure ulcer would still be classified as a DTI, as a DTI was unstageable. The DON reported the left heel wound would not be classified as a full thickness wound or Stage 4 pressure ulcer, per the weekly wound care log dated 02/09/23, and interview with LPN R. The ADON had no comment. Resident #52 Review of Resident #52's MDS assessment, dated 11/30/22, revealed Resident #52 was admitted to the facility on [DATE], with diagnoses including kidney disease, dementia, joint dislocation, and thoracic kyphosis (excessive curvature of mid-spine). Resident #52 required extensive two-person assistance for bed mobility, transfers, and toileting, and supervision for wheelchair locomotion. The BIMS assessment revealed a score of 14/15, which indicated Resident #52 was cognitively intact. The assessment revealed Resident #52 was at risk for pressure ulcers and had no pressure ulcers. Review of facility pressure ulcer log, dated 02/09/23, titled Weekly Pressure Ulcer Report, provided by Registered Nurse (RN) S, revealed Resident #52 had a Stage II (shallow skin loss or blister) facility acquired pressure ulcer on her spine discovered on 01/11/23, which measured 1.2 cm x 1.0 x 0 cm, with scant bloody drainage. Review of the facility resident matrix revealed Resident #52's pressure ulcer was marked as U for Unstageable (a wound covered with slough or eschar which cannot be staged, or a deep tissue injury per the DON). There was a discrepancy between the facility matrix and the facility wound log. During an observation on 02/15/23 at approximately 4:45 p.m., Resident #52 was seated in their manual recliner wheelchair, and was observed to have thoracic kyphosis of the spine. There was a [Brand name] pressure relief pad covering the backrest of her wheelchair. During an interview on 02/15/23 at approximately 4:48 p.m., Resident #52 reported she had a wound which was sore and tender in the middle of her back, and confirmed she was receiving daily dressing changes. Resident #52 reported the wound was healing and was not infected. Resident #52 did not appear to be in pain, and had no concerns with wound treatment. Review of Resident #52's pressure ulcer Care Plan revealed a goal for pressure ulcer, start date 12/31/2018, revealing Resident #52 was at high risk for developing pressures R/T [related to] decrease in mobility, HX [history of] pressure sore mid spine .Deep tissue injury on mid spine The Care Plan revealed Resident #52 had a specialized air mattress, a pressure relief pad over mattress and on wheelchair, and an air cushion for their wheelchair, and was to avoid shearing and friction. Review of Resident #52's ADL Care Plan revealed she was encouraged to lay down in bed for one hour, two to three times per day on her side. There was no mention of non-compliance with positioning in the entire Care Plan. The Care Plan revealed Resident #52 required extensive assist of one staff for bed mobility, and two-person assistance with use of a mechanical lift for transfers. During an interview with RN S on 02/15/23 at 9:39 a.m., the weekly pressure ulcer wound care log dated 02/09/23, was reviewed with Surveyor. The log showed Resident #52 had a Stage 2 facility acquired pressure ulcer on her mid spine. RN S confirmed the pressure ulcer was facility acquired. During an observation on 02/15/23 at approximately 1:45 p.m., Resident #52 was observed sliding down in their wheelchair and observed in sacral sitting (abnormal pelvic posture). REsident #52 sliding against the wheelchair back has the likliehood of causing shearing and additional and/or worsening skin breakdown. During an interview on 02/16/23 at 11:10 a.m., COTA Q was asked about Resident #52's wheelchair positioning and observed sliding down in their wheelchair. COTA Q reported they would follow-up and understood the concern. During an interview on 02/16/23 at approximately 12:10 p.m., Resident #52 was asked if she slid down in her wheelchair. Resident #52 confirmed she slid down in her wheelchair once in a while, but she liked the wheelchair. She was observed upright during the interview. Review of Resident #52's Wound Management Detail Reports, accessed 02/15/23, provided by RN S, revealed Resident #52's wound had increased in size, and had developed slough over the wound bed. Measurements and description as follow: [Resident #52]. Wound type: Other -suspected DTI. Wound location: Mid-thoracic back. Date/Time identified: 01/11/23. Present on admission/re-entry: NO. This wound has not been healed or discontinued . The report showed the wound had originally healed on 11/23/22 and was classified at the time as a Stage 3 pressure ulcer. 01/11/23: 1.3 cm x 1 cm, Light [drainage], bloody .Unstageable - Deep Tissue .80 [% granulation (healing) tissue], stable. New deep tissue injury from bandage being rolled up, causing pressure. 01/18/23: 1.2 cm x 1.2 cm, Light [drainage], bloody .well defined wound edges, Erythema [redness] .Stable. 01/26/23: 1.0 cm x 0.8 cm, Light, serous - clear, amber, thin watery [drainage], Unstageable - Deep Tissue .Tissue type: Slough .Percent of wound covered by slough tissue: 10[%] .Improving. 02/01/23: 2.0 cm x 1.2 cm, Light [drainage] bloody .Unstageable - Deep Tissue .Tissue type: Slough .Percent of wound covered by slough tissue: 25% .Improving. There were no other wound management detail reports since 02/01/23, other than the weekly pressure ulcer log, which RN S confirmed. Review of a nursing progress note dated 01/11/23 by LPN R revealed, Residents bandage for protection on spine was rolled up causing a deep tissue injury. Will change company brand for cover dressing for prevention. Review of Resident #52's physician orders revealed, 01/30/2023: Open ended. Mid-back: cleanse area with AB [antibacterial] soap and water, cover wound bed with collagen powder [wound healing agent] and cover wound with dry dressing daily. Once a day; Dayshift. During an observation on 02/16/23 at 7:34 a.m., LPN R (with RN S present) provided wound care to Resident #52's thoracic spine pressure ulcer. LPN R described the wound as a dime-sized, circular shallow wound, with bloody drainage and minimal slough, covering approximately 25% of the wound. The remainder of the wound was red in appearance. Review of the EMR including nursing progress notes showed no evidence Resident #32 was non-compliant with turning, repositioning, or wound care recommendations. During an interview on 02/16/23 at 9:04 a.m., LPN R was asked to describe the wound and progression with RN S present. LPN R reported the wound today was 75% red and 25% yellow, with slough. Surveyor asked why the wound would be classified as a Stage 2 wound on the wound care log, given slough and former unstageable classification. LPN R reported when one could see the base of the wound bed, you could stage the wound. RN S confirmed the wound had closed and reopened prior and had last healed on 11/23/22. RN S reported they covered the wound with a protective foam dressing after it healed, and the dressing was found rolled up, and had caused a DTI. RN S reported the new wound care products were not as high quality as they usually received. Both reported the wound was red and open, not purple, and clarified it was not a DTI, but a Stage 2 wound, and this was a documentation error. Surveyor asked LPN R and RN S if the wound reopening was preventable and avoidable. LPN R stated, Yes .we went through a new wound care company and they gave us different bandages that didn't stay on as well. RN S reported the wound could have occurred from sweating, and not necessarily the bandage. It was unclear why the facility continued to use wound care products that did not adhere well or were secured in a different manner. Both confirmed there was no additional documentation which showed if the wound was classified as avoidable or unavoidable, per their documentation process. During an interview on 02/17/23 at 8:51 a.m., the DON reported Resident[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake # MI00132484 Based on interview and record review, the facility failed to ensure resident safety by implementing care, planned interventions, monitoring residents, and implementing safety intervention for residents at high risk for falls for two residents (Residents #38 and #333) out of five residents reviewed for accidents, hazards, and supervision, resulting in ongoing falls, and the potential for serious injury, and deterioration in health status. Findings include: Resident #333 Review of Resident #333's face sheet revealed Resident #333 was admitted to the facility on [DATE], with diagnoses including displaced fracture of base of neck of right femur, encounter for closed fracture with routine healing, weakness, encounter for other orthopedic aftercare, pain in left knee, and benign prostatic hyperplasia (enlarged prostate and excessive need to urinate worsens). The Minimal Data Set (MDS) assessment, dated 11/2/22, revealed Resident #333 required extensive two-person assistance for bed mobility, transferring, dressing, and toileting. Resident #333 also required a mobility device with a wheelchair. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 03/15, which indicated Resident #333 had severe cognitive impairment. Review of Resident #333's Progress Notes, dated 10/26/22, read in part, Res [Resident] arrived via EMS [Emergency Medical Services]. Transferred to bed via 3 person slide assist . Review of Resident #333's Fall Risk Assessment, dated 10/26/22 revealed a score of 16, which indicated Resident #333 had a high risk for falling. Review of Resident #333's Fall Risk Assessment, dated 11/8/22 revealed a score of 16, which indicated Resident #333 had a high risk for falling. Review of Resident #333's Care Plan, dated 10/26/22, read in part, Problem: ADL [Activities of daily living] Functional / Rehabilitation Potential. I need assistance from staff with Activities of Daily Living r/t [related to] (blank) which puts me at risk for falls, injury . Goal: I will be free from falls and injury daily through the next 90 days. Approach: Ensure proper non slip foot wear is in place and encourage resident to wear them at all times. Review of Resident #333's Event Report, dated 11/2/22 at 00:30 (12:30 AM), read in part, Res [resident] found on side next to bed .What was the residents footwear? Bare feet .What time was the resident last toileted - 2000 (8:00 PM) .Evaluation Notes: IDT [Interdisciplinary team] reviewed event. Continues in isolation on Covid Unit .Plan is to move him closer to nursing station once his isolation is done on11/6/22. Review of Resident #333's Progress Note, dated 10/26/22 at 00:54 (12:54 AM), read in part, Res was found on the floor next his bed on his right side. Trauma assessment found no bodily injury and did not hit his head .Assisted back into bed x3 assist via Maxi .Res now resting in bed. Will continue to monitor. Review of Resident #333's Event Report, dated 11/2/22 at 10:15 (AM), read in part, Res noted on floor next to bed. Stated hit his head. No injury noted. Neuros in initiated .What were you trying to do? Go to the bathroom .What was the residents footwear? Bare feet .What time was the resident last toileted - 11-7 (shift) .Evaluation Notes: IDT reviewed event. Continues in isolation on Covid Unit .Plan is to move him closer to nursing station once his isolation is done on11/6/22. Review of Resident #333's Progress Note, dated 11/2/22 at 10:42 (AM), read in part, Hospitality Aides alerted CNA (Certified Nurse Aide) that res was yelling for help. CNA observed res on floor next to bed. Res and floor was covered in urine. Res stated he hit his head. No bumps, redness or lacerations noted. Res did respond yes to pain but didn't respond to where. ROM per usual. Old bruises noted to res all over. Redness noted to inner (L) forearm. Res lifted to bed with two person via maxi lift. Res currently up in w/c .Daughter updated and would like res to have a pull tab alarm. Will monitor. Review of Resident #333's Event Report, dated 11/2/22 at 17:05 (5:05 PM), read in part, Res pull tab alarming and res on the floor .What time was the resident last toileted - day shift .Evaluation Notes: IDT reviewed event. Continues in isolation on Covid Unit. He does have a pull tab alarm. Plan is to move him closer to nursing station once his isolation is done on11/6/22. Review of Resident #333's Progress Note, dated 11/2/22 at 17:28 (5:28 PM), read in part, CNA went up to assist another res and heard pull tab alarm going off. Looked in on res and res was on the floor. CNA informed this nurse that res was on the floor. Res on back parallel to the bed on the floor. Res assessed for injury. No injury noted .With maxi lift and assist x3 res assisted into w/c . Review of Resident #333's Event Report, dated 11/16/22 at 22:42 (10:42 PM), read in part, Res observed on his left side on floor .What were you trying to do? Reach urinal on table .What was the residents footwear? Bare feet .What time was the resident last toileted - 9pm .Evaluation Notes: IDT reviewed event .Urinal holder on side rail to keep urinal close by. Alarm did not sound at desk .Staff have increased rounding on him to every one hour . Review of Resident #333's Progress Note, dated 11/16/22 at 23:16 (11:16 PM), read in part, Res alarm sounding, upon entering room res was noted on his left side on floor. No apparent injuries. Res states he was trying to reach for his urinal . Review of Resident #333's hourly rounding, dated 11/17/22 at 1400 (2:00 PM), revealed increased rounding did not start until seven hours after his fourth fall in the facility. On 2/16/23 at 1:23 PM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON described the falling star program to be for residents who have had three falls in a three-month period. The ADON was asked if Resident #333 should have been placed on the falling start program sooner than 12/7/22. The ADON confirmed that he should have been placed on the program after 11/2/22 and was not sure why this did not happen sooner. The ADON confirmed that Resident #333 should have been wearing nonslip socks and should have been checked on more frequently related to his cognition, assistance level, fall history, and incontinence needs. The ADON also confirmed she did not think Resident #333 could have been able to remove nonslip socks. The ADON was asked if Resident #333's care plan was updated after every fall and responded, I don't know if it was necessarily updated for every fall. No, there are no added interventions after the first two falls. Resident #38 A review of Resident #38's face sheet revealed an admission date of 8/30/22, with diagnoses including a fracture of the right femur (thigh bone), abnormal gait and mobility-balance disorder, osteoarthritis, dizziness, anxiety and depression. The MDS assessment dated [DATE], revealed Resident #38 required extensive one-person assistance for bed mobility, transferring, dressing, toileting, and personal hygiene. This MDS assessment revealed the resident had a fall with fracture prior to admission and had a fall with injury after admitting to the facility. The BIMS assessment for Resident #38 revealed a score of 07/15, which indicated severe cognitive impairment. On 2/14/23 at 1:11 PM, the resident was observed in her room. When asked if she had fallen at the facility, she replied she had fallen that day. She attributed the fall to many cords in my room. Resident #38 was observed to be wearing an oxygen canula which had tubing running across her room. A review of the electronic medical record and Event Reports revealed Resident #38 had the following recent falls: - 2/14/2023 at 11:58 AM Res hollering and staff went to check on resident. She was noted on her backside in her doorway one leg on each side of the door. Res assessed for injury and she denied hitting her head . Res was assisted off the floor via maxi-lift. - 2/11/23 at 2:10 AM Res found on floor next to her bed stating she was trying to call her daughter. Res denied Nursing pain or injury. Assisted back to bed. Trauma assessment found no injury. Resting in bed now . - 1/31/23 at 15:05 (3:05 PM) DESCRIPTION Slid out of bed onto her butt. No injuries. Was reaching for w/c (wheelchair) - 1/12/23 at 5:30 AM Res slid out of wheelchair onto floor . bare feet . Res found on the floor in her room next to her wheelchair. Res stated she was trying to use the bathroom but slid out of chair. Trauma assessment found no injury and res denied pain. Administered scheduled Tylenol. Res now resting in bed . - 12/31/22 at 1:00 AM Writer called to resident's room at approx (approximately) 0100. Resident was on the toilet and being assisted by CNA. CNA noticed small amount of blood coming from resident's L (left) ankle. Resident's ankle noted w/(with) small approx. 1/4 (inch) long skin tear. Skin tear cleansed w/soap and water and patted dry. Band-Aid applied. Bleeding subsided. Resident is unaware of how skin tear occurred . - 12/27/22 at 10:45 AM, documented at 14:08 (2:08 PM) Resident was yelling out and CNA (name) observed res. Sitting on her buttocks next to bed. Nursing Stated she had hit her head and neurological checks initiated. Small skin tear noted to be on left hand and denies pain to area and hematoma (bruising) on forehead and ice pack given for treatment . The Care Plan for Resident #38 was reviewed on 2/15/23 and included an ADL Functional problem listing diagnoses which puts (Resident #38) at risk for falls injury and skin issues. This problem had an Approach Start Date: 12/27/2022. The Long Term Goal Target Date: 3/20/23 was listed as I will be free from falls and injury daily though the next 90 days. The Approaches were last updated on 12/27/22 as SAFETY DEVICES: call light, FALLING STAR PROGRAM. Other interventions and approaches included: Ensure proper non slip foot wear is in place and encourage resident to wear them at all times. No updates to this care plan were found after 12/27/22. During an interview on 2/17/23 at 9:18 AM, the ADON (RN C) was asked about interventions to prevent falls for Resident #38. RN C reviewed the Care Plan and stated she did not see any interventions added to the care plan after the fall on 12/27/22 despite the additional five falls which occurred on 12/31/22, 1/12/23, 1/31/23, 2/11/23 and 2/14/23. A facility policy titled FALL DOCUMENTATION/INVESTIGATION which was undated but noted as filed as: Falls/p&p/rev12/15 read in part, . review care plan and update as needed . All falls will be discussed by the IDT (Interdisciplinary Team) at the morning QAPI (Quality Assurance Process Improvement) meeting, Mon-Fri, excluding holidays. At this meeting, further interventions will be discussed for implementation. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet the behavioral health care needs of one Resident (#46) of one resident reviewed for behavioral health care. This deficient practice resulted in Resident #46 demonstrating ongoing physical and verbal behaviors, with the potential for an adverse outcome, and psychosocial decline. Findings include: Review of Resident #46's Minimum Data Set (MDS) assessment, dated 12/16/22, revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including stroke, arthritis, malnutrition, anxiety, depression, and vision impairment (from glaucoma). Resident #46 required two-person assistance for bed mobility, transfers, toileting, and dressing, one-person assistance with eating, and supervision with wheelchair locomotion. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 5/15, which indicated Resident #46 had severe cognitive impairment. The sensory assessment showed Resident #46 was usually understood and usually could understand, with highly impaired vision. The PHQ-9 assessment for depression revealed a score of 12/27, which showed Resident #46 had moderate depression. The behavioral assessment showed Resident #46 had physical and verbal behaviors directed towards others 1-3 days during the assessment period. The assessment showed no falls occurred. During an observation on 02/14/23 at 3:05 p.m., Resident #46 was observed in her room, seated upright in her manual wheelchair. A large green and purple bruise was noted on the dorsum [top] of her left wrist, extending from the 4th metacarpal (knuckle bone on her ring finger), over the dorsal hand and wrist, and up the ulnar (outer) side of her left forearm, about 2 below the elbow, with a slightly raised area the size of a quarter on the dorsum of the hand. The bruise was reported to Licensed Practical Nurse (LPN) V, who reported the bruise to the Director of Nursing (DON). Resident #46 was looking down, wearing a large green coat with a hood, and appeared sad and downcast. During an interview on 02/14/23 at 3:12 p.m., Resident #46 was asked about the bruise. Resident #46 denied abuse or rough treatment, and reported it occurred about a week ago, however she could not recall what happened, and denied any falls. During an interview on 02/14/23 at 3:30 p.m., LPN V was asked about Resident #46's bruise to her left hand and forearm. LPN V confirmed Resident #46 demonstrated physical behaviors during cares, such as being combative and striking out. LPN V clarified Resident #46 may have bumped her left hand and arm during cares, as the bruising was partly on the outside of her left arm and hand, such as if she struck out, and there was no evidence of a blood draw. Review of Resident #46's Electronic Medical Record (EMR) on 02/14/23 with LPN V including skin assessments and nursing progress notes revealed no earlier documentation of Resident #46's bruise to her left hand and arm, discovered by Surveyor during initial tour. Review of Resident #46's nursing progress notes revealed Resident #46 demonstrated ongoing behaviors, including hollering, care refusals, swatting her hands at staff, refusing medications, and other physical and verbal behaviors during cares, including progress notes on 01/31/23, and a progress note on 02/05/23. Review of Resident #46's Behavioral Health notes, titled Clinical Rounds: Behavior Note, or Behavior Analysis Report, provided by the Director of Nursing (DON), revealed behavioral incident notes which showed physical and/or verbal behaviors on 08/27/22, 08/25/22, 09/07/22, 10/17/22, 10/25/22, 01/01/23, and 01/03/23. These notes reflected medication changes but did not reflect strategies to address Resident #46's behaviors. Review of Resident #46's Care Plan, accessed 02/16/23, revealed no behavioral management problem, goal, or interventions when physical or verbal behaviors directed towards others occurred, including how to educate staff to manage behaviors when they occurred, care strategies, behavioral monitoring, non-pharmacological interventions, or psychosocial support, given Resident #46's ongoing behaviors noted in the EMR and reported by nursing staff. The Care Plan did not reveal any sensory interventions to accommodate for Resident #46's progressive vision loss and reported fearfulness and anxiety, to provide calming and help Resident #46 successfully engage in her environment. Review of Resident #46's Behavioral Provider consults provided by the DON revealed the last outside provider visit had occurred on 10/14/22, with no additional referral or consult confirmed or provided by the DON upon request. This visit note made recommendations for non-pharmacological interventions to address Resident #46's behaviors, which were not reflected in Resident #46's Care Plan. Review of the Social Services (SS) notes including assessments, from 08/16/22 through 02/15/23, provided by the DON, showed SS Staff, Social Worker (SW) W, had noted Resident #46's behaviors (on the 12/19/22 and 10/17/22 assessments), however had not addressed how to manage the behaviors in their documentation, and did not show any SS supportive visits, education with staff, behavioral referrals, behavioral monitoring, or the provision of any psychosocial support by the Social Worker. There was no additional SS progress note since the 12/19/2022 assessment. It was noted on the assessments Resident #46 was frustrated due to her eyesight failing, needing additional feeding assistance, family visits stopping, depression with behaviors, communication impairment, being tired with poor sleep, having trouble concentrating, becomes scared due to poor vision, poor interest in activities, and hitting and yelling at caregivers. There was no coordination of Resident #46's behavioral care or behavior management documented in SW W's progress notes and assessments or found in the EMR progress notes. Review of Resident #46's most recent behavioral notes dated 01/01/23, and 01/03/23, provided by the DON, revealed, Kicking others. Date: 01/01/23 .[Resident #46] was yelling, hitting, and kicking at CNA's [Certified Nurse Aide] and the CN [aide] this morning during cares. [Resident #46] did calm down after a while but was agitated and scratching a lot from the upsetting time during her morning wash up. Hitting self. Date: 01/03/23 .[Resident #46] was banging her head on her bed and trying [sic] kick when trying transfer back into bed because she had to wear shoes. [handwritten response] [Resident #46] does not like help and struggles to communicate and gets frustrated when staff [sic] does [sic] not understand. There were descriptions of Resident #46's behaviors, and notations about her struggles and frustration, however there were no interventions or recommendations noted to manage Resident #46's behaviors, or Care Plan revisions or updates after these occurrences. During an interview on 02/17/23 at 7:57 a.m., Resident #46 was greeted and asked how they were doing. Resident #46 reported she was doing terrible, and it was not a good day. Resident #46's head was down, and she appeared discouraged and unhappy. During an interview on 02/17/23 at 8:00 a.m., Certified Nurse Aide [CNA] P was asked about Resident #46's behavioral needs, and if they had been educated regarding how to manage Resident #46's behaviors during cares (activities of daily living tasks). CNA P reported they worked frequently with Resident #46 and had not received any instruction on how to manage Resident #46's behaviors. CNA P reported they had just finished morning cares with Resident #46, and she had yelled at them, as she had spilled water on herself. CNA P confirmed Resident #46 was sometimes combative with cares, and they worked to keep the same morning routine for her, which seemed to help, however noticed other aides did not keep the same routine. CNA P reported Resident #46 was most calm and cooperative during morning cares when she was able to be up in her wheelchair in the bathroom to get ready for the day. CNA P explained when other nursing staff got her ready partly in the bed and partly in the bathroom, Resident #46 became agitated. CNA P confirmed there was no Care Plan to their awareness designating Resident #46's care preferences, and they had figured out strategies on their own. CNA P reported they were not doing any daily charting of Resident #46's behaviors when they were combative or agitated with cares. Further review of Resident #46's Care Plan revealed no specific interventions related to care styles and preferences during resident cares. During an interview on 02/17/23 at 8:16 a.m., the Assistant Director of Nursing (ADON), Registered Nurse (RN) C, and the DON were asked about Resident #46's lacking behavioral care problems, goals, and interventions for physical and verbal behaviors directed towards others, given Resident #46's recent bruise to hand, and documentation of resistance to cares. Both were unable to provide any additional information to this regard by the end of the survey. During an interview on 02/16/23 at approximately 5:45 p.m., and on 02/17/23 at approximately 8:30 a.m., the DON confirmed SW W remained unavailable during the survey to interview regarding Resident #46's behavioral concerns and behavioral management, as they were out of the country, despite Surveyor offering to be contacted off hours if needed during the survey. The DON was asked if there was another representative who could summarize the behavioral care and management of Resident #46, and reported there was no one, and they wished the SW W was available during the survey. The DON confirmed abuse was not substantiated related to Resident #46's bruise on her left hand and arm. Review of the policy, Behavioral Health Services, dated 01/04/23, revealed, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .Non-pharmacological intervention refers to approaches to care that do not involve medications, generally directed towards stabilizing and/or improving a resident's mental, physical, and psychosocial well-being .Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders, psychosocial adjustment difficulty, and trauma .The facility will ensure that necessary behavioral health care services are person-centered and reflect the residents' goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being .Use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated. 10. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the staff member and resident needs identified .e. Individualized non-pharmacological approaches to care .11. Facility staff will implement person-centered approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. Examples of individualized, non-pharmacological interventions to help meet behavioral health needs of all ages may include, but are not limited to: .Individualizing sleep and dining routines, adjusting the environment to be more individually preferred, consistent staffing to optimize familiarity .Assisting residents with access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem solving therapy; and providing support with skills related to verbal de-escalation, coping skills, and stress management. 12. The Social Services Director shall serve as the facility's contact person for questions regarding the behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists. Review of the policy, [Facility] Standard of Practice to Ensure that Staff will Adhere to Resident's Rights .Revised 08/07/2017, provided by the DON, revealed, ADL's (Activities of Daily Living] .All staff will review the styles and preferences with resident's cares prior to administration of cares .Staff will document behavior changes in behavior book/nurses notes and discuss at clinical rounds as needed. Psych: .Social Worker will visit with resident PRN [as needed] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure provision of adequate medically related social services for one Resident (#46) of one resident reviewed for behavioral care needs and social services. This deficient practice resulted in limited coordination of care for Resident #46 related to behavioral care needs, lack of interventions for physical and verbal behaviors towards others, and the potential for psychosocial decline. Findings include: Review of Resident #46's Minimum Data Set (MDS) assessment, dated 12/16/22, revealed Resident #46 was admitted to the facility on [DATE], with diagnoses including stroke, arthritis, malnutrition, anxiety, depression, and vision impairment (from glaucoma). Resident #46 required two-person assistance for bed mobility, transfers, toileting, and dressing, one-person assistance with eating, and supervision with wheelchair locomotion. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 5/15, which indicated Resident #46 had severe cognitive impairment. The sensory assessment showed Resident #46 was usually understood and usually could understand, with highly impaired vision. The PHQ-9 assessment for depression revealed a score of 12/27, which showed Resident #46 had moderate depression. The behavioral assessment showed Resident #46 had physical and verbal behaviors directed towards others 1-3 days during the assessment period. The assessment showed no falls occurred. Review of Resident #46's nursing progress notes revealed Resident #46 demonstrated ongoing behaviors, including hollering, care refusals, swatting her hands at staff, refusing medications, and other physical and verbal behaviors during cares. Review of Resident #46's Care Plan, accessed 02/16/23, revealed no behavioral management problem, goal, or interventions when physical or verbal behaviors directed towards others occurred, including how to educate staff to manage behaviors when they occurred, care strategies, behavioral monitoring, non-pharmacological interventions, or psychosocial support, given Resident #46's ongoing behaviors noted in the EMR and reported by nursing staff. Review of Resident #46's Behavioral Health notes, titled Clinical Rounds: Behavior Note, or Behavior Analysis Report, provided by the Director of Nursing (DON), revealed behavioral incident notes which showed physical and/or verbal behaviors on 08/27/22, 08/25/22, 09/07/22, 10/17/22, 10/25/22, 01/01/23, and 01/03/23. These notes reflected medication changes but did not reflect strategies to address Resident #46's behaviors. Review of Resident #46's Behavioral Provider consults provided by the DON revealed the last outside provider visit had occurred on 10/14/22, with no additional referral or consult confirmed or provided by the DON upon request. This visit note made recommendations for non-pharmacological interventions to address Resident #46's behaviors, which were not reflected in the Care Plan. Review of the Social Services (SS) notes including assessments, from 08/16/22 through 02/15/23, provided by the DON, showed SS Staff, Social Worker (SW) W, had noted Resident #46's behaviors (on the 12/19/22 and 10/17/22 assessments), however had not addressed how to manage the behaviors, and did not show any SS supportive visits, education with staff, behavioral referrals, behavioral monitoring, or the provision of any psychosocial support by the Social Worker. There was no additional SS progress note since the 12/19/2022 assessment. It was noted on the assessments Resident #46 was frustrated due to her eyesight failing, needing additional feeding assistance, family visits stopping, depression with behaviors, communication impairment, being tired with poor sleep, having trouble concentrating, becomes scared due to poor vision, poor interest in activities, and hitting and yelling at caregivers. There was no coordination of Resident #46's behavioral care or behavior management documented in SW W's progress notes and assessments or found in the EMR progress notes. Review of Resident #46's most recent behavioral notes dated 01/01/23, and 01/03/23, revealed, Kicking others. Date: 01/01/23 .[Resident #46] was yelling, hitting, and kicking at CNA's [Certified Nurse Aides] and the CN [aide] this morning during cares. [Resident #46] did calm down after a while but was agitated and scratching a lot from the upsetting time during her morning wash up. Hitting self. Date: 01/03/23 .[Resident #46] was banging her head on her bed and trying [sic] kick when trying transfer back into bed because she had to wear shoes. [handwritten response] [Resident #46] does not like help and struggles to communicate and gets frustrated when staff [sic] does [sic] not understand. There were descriptions of Resident #46's behaviors, and notations about her struggles and frustration, however there were no interventions or recommendations noted to manage Resident #46's behaviors, or Care Plan revisions or updates after these occurrences. During an interview on 02/17/23 at 7:57 a.m., Resident #46 was greeted and asked how she was doing. Resident #46 reported she was terrible, and it was not a good day. Resident #46's head was down, and she appeared discouraged and unhappy. During an interview on 02/17/23 at 8:00 a.m., CNA P was asked about Resident #46's behavioral needs, and if they had been educated regarding how to manage Resident #46's behaviors during cares. CNA P reported they worked frequently with Resident #46 and had not received any instruction on how to manage Resident #46's behaviors. CNA P confirmed there was no Care Plan to their awareness designating Resident #46's care preferences, and they had figured out strategies on their own. CNA P reported they were not doing any daily charting of Resident #46's behaviors when she was combative or agitated with cares. During an interview on 02/17/23 at 8:16 a.m., the Assistant Director of Nursing (ADON), Registered Nurse (RN) C, and the DON were asked about Resident #46's lacking behavioral care interventions for physical and verbal behaviors directed towards others, given Resident #46's documentation of resistance to cares. Both were unable to provide any additional information to this regard by the end of the survey, as they reported the Social Worker addressed these concerns. During an interview on 02/16/23 at approximately 5:45 p.m., and on 02/17/23 at approximately 8:30 a.m., the DON confirmed SW W was still unavailable to interview regarding Resident #46's behavioral concerns and behavioral management, as they were out of the country, despite Surveyor offering to be contacted off hours if needed during the survey. The DON was asked if there was another representative who could summarize the behavioral care and management of Resident #46, and reported there was no one, and they wished the SW W was available during the survey. Review of the policy, Behavioral Health Services, dated 01/04/23, revealed, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning .Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of .psychosocial adjustment difficulty .The facility will ensure that necessary behavioral health care services are person-centered and reflect the residents' goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety .Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being .Use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated. 10. All facility staff .shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Education shall be based on the role of the staff member and resident needs identified .11. Facility staff will implement person-centered approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions .Assisting residents with access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem-solving therapy; and providing support with skills related to verbal de-escalation, coping skills, and stress management. 12. The Social Services Director shall serve as the facility's contact person for questions regarding the behavioral services provided by the facility and outside sources such as physician, psychiatrists, or neurologists. Review of the document, Job Description for Social Worker, rev [revised] 5/19, provided by the DON, revealed, .Job Summary: The Licensed Social Worker, under the direct supervision of the Administrator, will maintain an orderly system of admission to the facility, provide continuing resident/family liaison, assist in developing and implementing resident care plans, and assures adherence to the Resident [NAME] of Rights. This position also provides continuing Social Work services to residents and family members, arranges referrals ., and will participate in interdisciplinary team approach to maximize facility care and well-being of the residents. Essential functions: 3 .Attends interdisciplinary care conferences on all residents. Identifies psych-social problems/needs, and monitors goal achievement specific to the individualized plan of care. 4. Deals with and seeks to resolve residence problems .and behavioral concerns .Meets with family members and residents reinforcing positive attitudes, counseling, and encouraging progress .16. Coordination of Behavior Care Services . Review of the policy, [Facility] Standard of Practice to Ensure that Staff will Adhere to Resident's Rights .Revised 08/07/2017, provided by the DON, revealed, .Psych: .Social Worker will visit with resident PRN [as needed] .

This citation pertains to Intake #MI00132484. Based on interview and record review, the facility failed to ensure medications were administered correctly for one Resident (#37) of 10 residents reviewed for unnecessary medications and medication administration during the survey. This deficient practice resulted in the Resident #37 consuming medications prescribed to another facility resident and the potential of medication interactions and adverse outcomes with ingestion of unprescribed medications to Resident #37. Findings include: During an interview on 2/16/23 at 10:33 a.m., Resident #37 confirmed he had taken (ingested) medication prepared and offered to him by Registered Nurse (RN) X. Resident #37 said the medication administration error occurred several months ago when there were two Residents with the same first name. Resident #37 stated, They had me confused with another patient, whose name was [same as Resident #37's name] . It was [RN X], and they insisted that I take that medication. I took the medication that one time, and that was all . Resident #37 said it almost happened with another nurse as well, but Resident #37 said he again insisted that was not his medication and would not take it. Review of Resident #37's Minimum Data Set (MDS) assessment, dated 12/9/22, revealed Resident #37 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. Resident #37 had clear speech and was able to understand others and make his needs clearly known to others. During review on 2/16/23 at 11:29 a.m., of a Medication Error Report, dated 10/27/22, showed the times of the errors as 1800 (6:00 p.m.) and 2030 (8:30 p.m.). The date of the report was 10/27/22, Details of the report included, in part: Physician Notified: NO, No Action Required DON (Director of Nursing)/Supervisor notified YES. Notification of Error occurred on 10/27/22 at 2100 (9:00 p.m.) to the DON .' [Resident #37] received [another Resident's] medications at 1800 and 2030. Incorrect meds (medications): coumadin, colace, metoprolol succinate, mirtazapine, senna, AREDS (eye vitamin), and simethicone. Outcome to Resident (#37): NONE - will monitor he received another residents PO (oral) medications in error. Type of Error: Wrong medication; Wrong Resident. Reason for Error(s): Failure to identify residents. Person making Error: [RN X] During an interview on 2/16/23 at 1:25 p.m., RN X confirmed he had prepared, administered, and insisted Resident #37 take the medications provided on 10/27/22. RN X stated, Yes I did have a medication error for [Resident #37]. RN X reviewed the October Medication Administration Records (MARs)for Resident #37 the other resident with the same first name and acknowledge he had documented the medications were administered to [another Resident with the same first name], not Resident #37, when RN X had insisted Resident #37 consume the medications. RN X acknowledged he did not check the MAR when Resident #37 said the medications were not his medications. RN X told Resident #37 he was sure they were his (Resident #37's) prescribed medications and he needed to take them. RN X said he should have checked the MAR and confirmed they were the correct medications for the correct resident. When asked if the physician and pharmacist should have been notified, RN X stated, I would definitely think (they) would have been notified . Had I known those people were not called within 24 hours I would have called the physician and the pharmacist. On 2/16/23 at 1:57 p.m., a Medication Error policy was requested from the DON. The DON said she would look for a policy but did not believe there was a policy specific to medication errors. On 2/17/23 at 8:20 a.m., the DON confirmed there was no Medication Error policy, and acknowledged RN X should have verified the correct resident before administration of medications to Resident #37. Review of the Medication Administration policy, revised 9/25/17, revealed the following, in part: POLICY: To provide a safe and efficient manner for administering medications to residents, the following procedure will be followed. Medications will be administered by licensed personnel only. PROCEDURE: A. Dispense medications following the Five rights: 1. Right Patient 2. Right Drug 3. Right Amount 4. Right Time 5. Right Route . I. The nurse first checks the medication to be given at that specific time in the EMAR (electronic medication administration record). Each medication to be given is taken from the resident cassettes; the residents name, medication name, dosage, time, and routes are double checked against the computer .The nurse with the cup of medication, identifies the resident by checking medication book photo and greeting the resident by name .

This citation pertains to Intake #MI00132428. Based on observation, interview, and record review, the facility failed to provide food that accommodated the preferences of one Resident (#8) of three residents reviewed for food preferences. This deficient practice resulted in food dissatisfaction, decreased food consumption and potential weight loss when food preferences were not provided as requested. Findings include: Observation on 2/16/23 at 12:32 p.m., of Resident #8's lunch meal tray, and meal tray card revealed Resident #8 was served Polish Sausage Coins, GF (gluten free) Mac and Cheese, and Winter Blend Vegetables. Resident #8's meal plate contained the Polish Sausage Coins and broccoli, with approximately half of the plate filled with sausage, and the other half with broccoli. During an interview at this same time, Resident #8 was asked about her enjoyment of the food. Resident #8's plate appeared untouched, with very little to nothing consumed from the sausage or the broccoli. Resident #8 said she did not like the sausage, and she does not like broccoli. When asked if she had notified the dietary department of her food preferences, Resident #8 stated, It just goes in one ear and out the other. I have told them, and told them, and told them and it's (broccoli) is still there. During an interview on 2/16/23 at 12:46 p.m., Certified Nurse Aide (CNA) U said Resident #8 was sending notes to the dietary department everyday about her food and dietary was giving her oatmeal every day, and a piece of chicken. CNA U said there was no excuse that the facility could not serve her some gluten free items. CNA U confirmed Resident #8 did not like broccoli and told the staff and dietary that over and over. CNA U said the facility had pizza, but Resident #8 didn't get pizza, she got oatmeal, even though there was a gluten free pizza in the freezer. They (dietary staff) just didn't want to get it and prepare it for her. During an interview on 2/16/23 at 2:13 p.m., when asked about Resident #8's food preferences related to broccoli, Dietary Manager (DM) N said that she was not sure if Resident #8, liked broccoli or not, and said she would have to look at the food tracker which identified resident food preferences. DM N said she would print that report of food preference for Resident #8. Review of Resident #8's Meal Tracker Resident Profile with DM N on 2/16/23 at approximately 2:30 p.m., revealed the Resident had 18 dislikes that included the following: broccoli, fish, gravy, onions, zucchini, broccoli, broccoli and cauliflower, winter blend vegetables, zucchini, zucchini bake, zucchini bread, broccoli and cauliflower salad, broccoli and cauliflower with dip, broccoli cheese soup, broccoli cheese soup/mug, broccoli cuts, mango, and Philly cheesesteak. DM N acknowledged and agreed that Resident #8 should not have been served broccoli, or the meal tray listing of winter blend vegetables based on her clearly identified dislike of broccoli and winter blend vegetables.

Based on interview and record review, the facility failed to provide evening snacks per policy for three confidential interviewable Residents (#C-5, #C-7, #C-8) of eleven residents reviewed. This deficient practice resulted in missed snacks, with the potential for nutritional and medical outcomes, and feelings of frustration. Findings include: During a group interview on 02/15/23 at 1:18 p.m., Confidential Group residents were asked about receiving an evening snack. Residents responded as follows: #C-5: Reported they had not been offered or received evening snacks. #C-7: Reported they had not been offered or received evening snacks. Resident #C-7 stated, I can't get an evening snack; they [staff] ignored me [when they requested]. #C-8: Reported they had not been offered or received evening snacks. Resident #C-8 stated, They [nursing staff] said the dietary department cut it out, and reported they went hungry in the evenings. During an interview on 02/15/23 at 03:49 p.m., the Assistant Director of Nursing (ADON), Registered Nurse C, was asked about the three confidential group residents not being offered or receiving evening snacks. RN C reported they understood the concern with residents being told they could not have an evening snack, as snacks were readily available in unit pantries. RN C stated the nursing staff were responsible for the provision of snacks, per resident request. During an interview on 02/16/23 at 1:57 p.m., the Dietary Manager, Staff M was asked about the provision of evening snacks to the residents. Staff M reported the nursing staff were responsible for the provision of snacks, per resident request. During a follow-up interview on 02/16/23 at 5:27 p.m., RN C reported they had followed up regarding resident snack concerns and confirmed some of the concerns had occurred in the past few months. RN C reported they had begun educating residents about the availability of evening snacks and were planning to educate the staff. Review of the policy titled, Nourishments, rev [revised] 7/11, provided by the Director of Nursing (DON), revealed, Policy: To assure all prepared nourishments are being given to residents and to provide nourishment for those who choose to snack at Hour of Sleep (HS). Procedure: .2 .Dietary will deliver Dietary Department prepared HS snacks to the kitchen .4. At HS, the CNAs (Certified Nurse Aides) will distribute the assigned nourishments to the proper residents, while at the same time, offer a snack of juice, fruit, etc. to those residents that don't have a prepared HS nourishment. 5. After distributing nourishments to residents, the CNA will document on the Supplement Acceptance Record the status of those residents who had prepared snacks . Review of the policy, [Facility] Standard of Practice to Ensure that Staff will Adhere to Resident's Rights .Revised 08/07/2017, provided by the DON, revealed, .Dietary .Staff will offer H.S. [evening/nighttime] snack and record acceptance .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes: #MI00132484 and #MI00132428 Based on interview and record review, the facility failed to answer call lights timely for five Residents (#37, #C-2, #C-4, #C-5, and #C-7) of 12 residents reviewed for dignity and resident rights. This deficient practice resulted in incontinence, and feelings of frustration and discouragement. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 12/09/22, revealed Resident #37 was admitted to the facility on [DATE], with diagnoses including coronary artery disease, peripheral vascular disease, obstructive uropathy, acquired below knee amputation, myocardial infarction (heart attack), and arthritis. The assessment revealed Resident #37 required two-person assistance for bed mobility, transfers, and toileting. Resident #37 was always continent of bowel and bladder and had three Unstageable Deep Tissue Injuries (DTI's). The Brief Interview for Mental Status (BIMS) assessment revealed a score of 15/15, indicating Resident #37 was cognitively intact. During an interview on 02/15/23 at 5:19 p.m., Resident #37 reported they frequently waited 15 to 30 minutes, and sometimes even longer for their call light to be answered. Resident #37 stated, When you have to go, that's a long time [to wait]. Resident #37 reported this included waiting on the toilet, after staff had transferred him there, which was frustrating to him. Review of Resident #37's call light timing logs, from 01/16/23 to 02/16/23, received from the Assistant Director of Nursing (ADON), Registered Nurse (RN) C, revealed 14 extended call light wait answering times beyond 20 minutes, on the following dates: 01/16/23, 01/19/23, 01/21/23 (twice), 01/22/23 (twice), 01/26/23, 02/04/23, 02/06/23 (twice), 02/09/23, 02/10/23, and 02/12/23 (twice). This included Resident #37 waiting 25:04 minutes on 02/12/23 at 14:19 (2:19 p.m.), waiting 30:24 minutes on 02/12/23 at 7:32 a.m., waiting 26:10 minutes on 02/10/23 at 17:51 p.m. (5:51 p.m.), and waiting 25:24 minutes on 02/04/23 at 21:15 (8:15 p.m.). During a group interview on 02/15/23 at approximately 1:30 p.m., confidential group residents were asked about call light response timeliness. Resident #C-7 reported she had waited 30 minutes recently and had incontinence episodes when she waited this long. Resident #C-7 reported it made her feel not important, and this upset her, and added the facility needed to hire more help. Resident #C-2 reported she had waited an hour and 15 minutes two days ago, and had an incontinence episode, which made her feel angry. Resident #C-4 reported she had waited 20 minutes for her call light to be answered before the group meeting. Resident #C-5 reported they frequently waited 15 to 20 minutes and had incontinence episodes. Resident #C-5 reported she felt frustrated and angry when she was left on the toilet this long. Review of call light logs for Residents #C-2, #C-4, #C-5, and #C-7 revealed extended call light wait times (beyond 20 minutes) during the time period 01/16/23 to 02/17/23. It was confirmed Resident #C-4 waited 19:05 minutes for their call light to be answered on 02/15/23 at 09:19 a.m , 39:48 minutes for their call light to be answered on 02/06/23 at 20:24 (8:24 p.m.), and 22:02 minutes for their call light to be answered on 02/09/23 at 12:09 p.m Resident #C-2 waited 20:51 minutes for their call light to be answered on 02/14/23 at 6:25 a.m., 26:14 minutes on 02/12/23 at 18:24 (6:24 p.m.), and 34:06 minutes on 02/12/23 at 08:31 a.m Resident #C-7 waited 38:44 minutes on 02/04/23 at 19:33 p.m. (7:33 p.m.), 27:58 minutes for their call light to be answered on 01/31/23, and 25:25 minutes for their call light to be answered on 01/31/23. Resident #C-5 waited 20:40 minutes for their call light to be answered on 01/28/23 and 47:22 minutes for their call light to be answered on 01/16/23 at 8:48 a.m During a phone interview on 02/16/23 at 4:18 p.m., Staff U was asked about staffing respective to call light timeliness. Staff U reported there were staff (CNA) shortages on the day shift and at mealtimes, and there were frequent call-ins (staff calling off work), with inadequate staff to cover their absence. Staff U reported all departments were struggling with staffing shortages and reported this had affected resident care. During an interview on 02/15/23 at 3:56 p.m., call light timeliness concerns were reviewed with RN C. RN C understood the concerns and reported they would follow-up. Review of the policy, Call Light and Alarm answering Policy and Procedure, undated, provided by the Director of Nursing (DON), To be carried out by every employee at the facility. Objective: To ensure resident call lights and alarms are being answered and needs addressed in a timely manner. Rationale: Not all needs require a CNA [Certified Nurse Aide] or Nurse .Policy: 1. Call lights are to be answered by every employee in the facility. All employees are to answer call lights when lit. Any staff member can carry out non-skilled care needs .If an alarm is sounding, all employees are responsible for responding to them promptly .

On 2/14/23 at 10:06 AM, the State Agency (SA) entered the facility to perform an annual survey. The facility was found to have three Residents in quarantine due to testing positive for Covid-19. On 2/15/23 at approximately 4:30 PM, the Director of Nursing and the Infection Preventionist (RN B) confirmed the County community transmission/positivity rates for Covid-19 had been high or substantial since October 2022. RN B stated, Precautions can be eased if the community/county is in the substantial for 2 weeks in a row- but that has not occurred. RN B Infection Prevention December 2022 Nosocomial Report and Summary revealed 20 employees tested positive for Covid-19 and there were 27 cases of Covid-19 infections in residents in that month. The Covid 19 Outbreak lasted 21 days in December. RN B compiled the January 2023 Nosocomial Report and Summary which revealed 3 employees tested positive for Covid-19 and 1 new Covid-19 infection was recorded in January. This citation pertains to intake # MI00132437. Based on observation, interview and record review, the facility failed to ensure monitoring of environmental cleaning processes resulting in inadequate concentration of disinfectant in solutions used for cleaning resident rooms, including those designated with Transmission Based Precaution (TBP) conditions. This deficient practice has the potential to result in the transmission of disease causing organisms and pathogens to all 82 residents in the facility. Findings include: On 2/15/23 at approximately 9:45 AM, observations were made with Housekeeping (HK) supervisor A related to the solutions used to disinfect resident rooms, including TBP designated (Also known as isolation rooms). Three housekeeper's supply rooms were located, with HK A, each having a chemical dispenser/mixer used by staff to clean resident rooms. These dispensers were used to fill buckets on the mobile cleaning carts, and the solution used to disinfect surfaces in residents' rooms. The disinfectant used for infection control and the elimination pathogens was identified by HK A, and confirmed by a review of the container, as a concentrated solution of peroxide. This concentrate was dispensed and mixed with water from an automatic mixing valve connected to the faucet of the mop sink in each housekeeping closet. A sample container was filled at each three mixing locations, then tested with test strips provided by HK A for the residual concentration of the peroxide. It was observed when tested, Hall A and Hall C's dispenser tested below the required 2250 ppm (parts per million) concentration for a proper disinfecting process. The buckets containing the cleaning solution on each of the housekeeping carts were then tested with the same source of test strips and found to be below the required 2250 ppm concentration. Observation of HK A conducting the test revealed a lack of knowledge regarding the testing. HK A demonstrated the testing by immersing the strip in the first solution for 10 seconds, then comparing the color changing end pad to the strip container color guide for the concentration result. When asked to read the strip container's instructions, HK A stated Oh. You only dip it for one second. I thought it was ten. HK A affirmed she was not aware of the proper testing procedure used to validate the concentration of the disinfectant from the mixing dispensers. An interview was conducted with HK A on 2/15/23 at 1:45 PM and was learned the facility's vendor for the chemical tested the solutions on a monthly basis, but the facility did not conduct any testing of the disinfectant concentration between the vendor's visits. Documentation of six months of vendor's visits was provided for review and dated back to 7/26/22, and were titled Regular Service Call. The dates provided included: 7/26/22; 9/27/22; 10/26/22; 12/19/22; and 1/25/23. None of the Regular Service Call reports included any specific measurement of the housekeeping chemical testing result, rather, stated under Dispensers was evaluated as Good. Policies and procedures for the proper daily cleaning and disinfecting of TBP rooms was requested from HK A on 2/15/23 at 8:32 AM. At 9:31 AM HK A was again requested to produce the policy for cleaning. HK A replied I have them here, I am just updating them. At 10:05 AM the policy Terminal Disinfection of Isolation Room, dated rev 7/2016, then with handwritten notes dated 2/22 and then 2/23 were provided for review. When asked if the Terminal cleaning was the same as the daily cleaning of TBP rooms, HK A initially answered Yes, but when further questioned, revealed that not all the terminal cleaning procedures were utilized on a daily basis. On 2/15/23 at 3:30 PM a policy titled Transmission-Based (Isolation) Precautions dated 1/5/23, copyright 2022 The Compliance Store, LLC was presented as the policy and procedure to be followed for daily cleaning of rooms. None of the policies and procedures specifically identified the disinfectant to be used to clean TBP rooms, did not identify the concentration of the disinfectant to be used to ensure proper elimination of pathogens during the cleaning process, nor did the policies identify a testing protocol to ensure the proper concentration of disinfectant was being dispensed to be used for pathogen elimination.

. Based on interview, and record review, the facility failed to ensure effective communication including notification to residents regarding positive cases of COVID-19 (a highly transmissible viral infection). This deficient practice resulted in the potential for residents to be unaware of the COVID-19 status within the facility. Findings include: During an interview on 2/16/23 at 10:43 AM, the Infection Preventionist Registered Nurse (RN) B stated, I am not aware the residents are told of Covid positive cases. The facility had a system to inform the Resident Representatives, but RN B was not aware of a procedure or policy to inform the residents. Cumulative updates were also done but did not go to residents. During an interview on 2/16/23 at 1:33 PM, Resident # 65 stated, My daughter gets messages and gets a robo call when there is Covid in the building. Resident #65 said she had asked a nurse aide one time about Covid-19 in the building after the residents were being tested. The nurse aide said she wasn't supposed to tell the residents. During an interview on 2/16/23 at 2:00 PM, Resident # 54 said she was not alerted of cases of Covid-19 in the building. Resident #54 stated, I have heard it (Covid-19) is in the building, but they do not let me know. During an interview on 2/16/23 at 2:08 PM, the Director of Nursing (DON) did not have a procedure for alerting residents of Covid-19 infection among residents or staff. The DON stated there were postings in the foyer, but not in the areas where residents resided. A facility policy titled COVID-19 and COVID-19 Vaccine Reporting was presented by RN B. This policy read in part: . 6. Residents, their representatives, and families are notified of the conditions inside the facility related to COVID-19: a. By 5:00pm the next calendar day following the occurrence of either: i. A single confirmed infection of COVID-19 ii. 3 or more residents or staff with new-onset of respiratory symptoms that occur within 72 hours of each other (i.e. outbreak) b. Cumulative updates will be provided weekly or by 5:00pm the next calendar day following the subsequent occurrence of either: i. Each time a confirmed infection of COVID-19 is identified ii. Whenever 3 or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other (i.e. outbreak). .