**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure that residents with pressure injuries received necessary treatment and services to promote healing and prevent new injuries from developing for 1 of 2 (R3) residents reviewed for pressure injuries. R3's pressure injuries were not comprehensively assessed and treatment was not implemented timely. This deficient practice resulted in R3's development of a stage 3 pressure injury. Findings include: The facility policy titled Skin Assessment implemented 3/1/19 documents (in part) . . It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management. 1. A full body, or head to toe skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: Document type of wound. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). The facility policy titled Wound Management which was not dated, documents (in part) . .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. 5. Treatment decisions will be based on: Etiology of the wound, characteristics of the wound (pressure injury stage, size and volume/characteristic of exudate) and location of the wound. 7. Treatments will be documented on the Treatment Administration Record. R3 admitted to the facility on [DATE] and has diagnoses that include severe hypoxic ischemic encephalopathy, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with hypoxia, anoxic brain damage, Cerebral Infarction, Heart Failure, Major Depressive Disorder, spondylosis lumbosacral region, Hidradenitis Suppurativa, and Epilepsy. R3's admission MDS (Minimum Data Set) dated 1/27/25 documents: Always incontinent of B&B (bowel and bladder) and dependent for toileting hygiene and bed mobility. The Care Area Assessment (CAA) documented: Is this resident at risk of developing pressure ulcers? Yes. Resident has one or more unhealed pressure ulcer(s) at stage 2 or higher, or one or more likely pressure ulcers that are unstageable at this time as indicated by: Number of stage 3 pressure ulcers = 1. Existing pressure ulcer/injury - assess location, size, state, presence and type of drainage, presence of odors, condition of surrounding skin. Extrinsic risk factors: Pressure, needs special mattress or seat cushion to reduce or relieve pressure. Maceration - Moisture Associated Skin Damage (MASD). Intrinsic risk factors: Altered mental status, cognitive loss, incontinence, poor nutrition. R3 has a care plan implemented for pressure injuries with appropriate interventions, but did not have an incontinence care plan implemented (Cross reference F690). R3's Clinical admission note dated 1/23/25 documents: New skin issue. Location: Left gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 4 x 1.5 x 0 cm (centimeters). Left gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 2.5 x 1 x 0 cm. Left gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 1 x 1 x 0 cm. Left gluteus open lesion, present on admission 0.7 x 0 cm. Right gluteus stage 2 pressure injury - partial thickness skin loss with exposed dermis, present on admission 3.5 x 1 x 0 cm. Coccyx - Moisture Associated Skin Damage (MASD) 7 x 1 cm. Surveyor review of R3's January 2025 Treatment Administration Record (TAR) revealed no treatment was implemented for R3's pressure injuries or MASD when identified on 1/23/25 until 5 days later, after R3 was seen by the wound physician. On 1/27/25 (4 days after admission to the facility), R3 was seen by (name of medical group) Wound Physicians. The initial wound evaluation and management summary documented: Patient presents with wounds on her coccyx, bilateral buttocks. Focus wound exam site 1: Stage 3 pressure wound coccyx full thickness 5.7 x 0.8 x 0.1 cm. Moderate serosanguineous exudate. 20% thick adherent devitalized necrotic tissue. 40% slough. 40% granulation tissue. Surgical excisional debridement procedure: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 2.74 cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a dept of 0.2 cm and healthy bleeding tissue was observed. Dressing treatment plan: Leptospermum honey with foam border apply once daily. Focus wound exam site 2: Non-pressure wound of the bilateral buttock, partial thickness. MASD 14.3 x 13 x 0.1 cm. Surface area 185.90 cm. Light serosanguineous exudate. Open areas with exposed dermis. Dressing treatment plan: House barrier cream apply Q (every) shift (3 times a day) and as needed for 30 days. Surveyor noted R3's clinical admission note dated 1/23/25 documented several stage 2 pressure injuries and MASD to her coccyx. No treatment was implemented. On 1/27/25, the wound physician identified a stage 3 pressure injury to her coccyx which required mechanical debridement. R3 was hospitalized for a change in condition on 1/30/25 and readmitted to the facility on [DATE]. R3's Clinical admission note (entered by a Licensed Practical Nurse that no longer works for the facility) dated 2/5/25 documents: Skin issues have not been evaluated. Surveyor noted the documentation and measurements of R3's open areas were the same as previously documented on R3's 1/23/25 Clinical admission note, including coccyx MASD 7 x 1 cm, even though R3 had a stage 3 pressure injury to her coccyx identified on 1/27/25. Surveyor review of R3's February 2025 TAR revealed no treatment was implemented for R3's pressure injuries upon readmission to the facility on 2/5/25. Only house barrier cream to sacrum/coccyx was implemented on 2/7/25, which is not an appropriate treatment for stage 3 pressure injury. On 2/10/25, (5 days after readmission to the facility), R3 was seen by (name of medical group) Wound Physicians. The wound evaluation and management summary documented: Patient has wounds on her coccyx, right buttock. Focus wound exam site 1: Stage 3 pressure wound coccyx full thickness. 5.6 x 7.4 x 0,1 cm. Moderate serosanguineous exudate. 20% thick adherent devitalized necrotic tissue. 40% slough. 40% granulation tissue. Wound progress exacerbated due to hospitalized . Surgical excisional debridement procedure: The wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, 15 blade was used to surgically excise 24.86 cm of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a dept of 0.2 cm and healthy bleeding tissue was observed. Dressing treatment plan: Leptospermum honey with foam border apply once daily. Focus wound exam site 2: Non-pressure wound of the left buttock partial thickness. MASD. Wound size 8 x 1 x 0.1 cm. Surface area 8.00 cm. Moderate serous exudate. Open areas with exposed dermis. Dressing treatment plan: Leptospermum honey with foam border apply once daily. Focus wound exam site 3: Non-pressure wound of the left buttock partial thickness. MASD. Wound size 7.5 x 4.5 x 0.1 cm. Surface area 33.75 cm. Moderate serosanguineous exudate. Open areas with exposed dermis. Dressing treatment plan: Leptospermum honey with foam border apply once daily. The wound physician notes on 2/10/25 documented R3's wound progress exacerbated due to hospitalization, however Surveyor noted R3's wounds were not comprehensively assessed and measured upon readmission to the facility on 2/5/25 and no treatment was implemented. R3's clinical admission note dated 2/5/25 documented R3's skin issues have not been evaluated and listed the same information and measurements as on the 1/23/25 clinical admission notes (including MASD to the coccyx even though she had a previously identified stage 3 pressure injury to her coccyx). On 2/7/25, house barrier cream was implemented and not the previously ordered treatment for the stage 3 pressure injury. On 2/10/25, when R3 was seen by the wound physician, the Stage 3 pressure injury to her coccyx had declined, was larger in size and required mechanical debridement. On 2/17/25, R3 was seen by (name of medical group) Wound Physician. The wound evaluation and management summary documented: Patient has wounds on her coccyx, right buttock, left buttock. Stage 3 pressure wound coccyx full thickness, non-pressure wound of left and right buttocks partial thickness. Surveyor noted there was no evidence of decline or increase in size of the wounds. The coccyx and right buttock wounds were debrided during this visit and appropriate treatment continued. On 2/24/25, (name of different medical group) physicians took over care of R3's wounds. Weekly assessments and appropriate treatments completed. As of 3/17/25, the coccyx stage 3 pressure injury measures 1.4 x 0.9 x 0.1 cm. Over 50% granulation with a scattered pattern of beefy red quality. Between 0-25% nonviable material of slough/fibrin. Bilateral buttocks red, blanchable, partial thickness skin breakdown to multiple small areas on bilateral buttocks. Improvement in overall surface area of wound openings and improvement to peri wound skin. On 3/17/25, Surveyor spoke with (different medical group name) Nurse Practitioner (NP)-F. NP-F reported R3 has a stage 3 pressure injury on her coccyx, which she was told was present on admission, and several partial thickness areas of MASD to bilateral buttocks. Surveyor asked what she thought was the cause of the MASD. NP-F stated, probably combination of wetness from incontinence and shearing. NP-F reported all areas are improving and she anticipates the coccyx to heal within the next couple of weeks. Surveyor asked if the facility implemented a check and change schedule related to incontinence. NP-F reported she did not know. Surveyor asked if R3's MASD is a result of wetness from incontinence, would she expect routine or more frequent checking/changing for incontinence. NP-F stated. Of course. I'm sure they have a protocol for weight shifting and skin care incontinence protocol. Surveyor asked if she has communicated the need for weight shifting and skin care/incontinence care. NP-F stated, I have, it would be in my notes. Surveyor confirmed NP-F's progress note dated 2/24/25 documents (in part) . HPI: The pressure ulcer is located on the coccyx and has been present for 5 weeks. The pressure ulcer was present on admission. According to the NPIAP (National Pressure Injury Advisory Panel) staging system, the pressure ulcer is classified as stage 3. Additional factors that contribute to non-healing include bed-bound status, bowel incontinence and bladder incontinence. Provider Comments document Prognosis: Guarded, dependent on offloading and moisture management. Discussed pressure relief and redistribution strategies. Patient is on an appropriate support surface for the patient to use when supine and should be on a weight shifting schedule and skin care/continence schedule per facility protocol. The balance of moisture is critical to wound healing. I have given caregivers instructions about managing skin moisture which include using a skin barrier and wicking agent. Patient wears an adult brief. Consider Foley catheter in future if urine management becomes a problem. R3 did not have an incontinence care plan implemented (Cross reference F690). On 3/18/25 at 9:00 AM, Surveyor met with Acting Director of Nursing (DON)-C to discuss concerns: R3 admitted to the facility with pressure injuries and MASD to her coccyx. Treatment was not implemented until 5 days later, after R3 was seen by the wound physician. At this time a stage 3 pressure injury was identified on her coccyx which required mechanical debridement of necrotic tissue and slough. R3 was readmitted following hospitalization on 2/5/25. The facility did not complete a comprehensive assessment and measurements of R3's wounds and no treatments were implemented until 2 days later, which included only barrier cream and not the previously ordered (appropriate) treatment for stage 3 pressure injury. 5 days later, the wound physician documented R3's coccyx stage 3 pressure injury declined/was larger in size and required mechanical debridement of necrotic tissue and slough. Acting DON-C reported she will review information and see if there is any additional information to provide. No additional information was provided prior to survey exit. On 3/19/25 at 12:30 PM, Nursing Home Administrator (NHA)-A, Acting DON-C, and DON-B were advised of the above concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 1 (R8) of 4 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal pressure injuries. R8 developed a facility acquired, unstageable pressure injury to their right great toe despite being at risk for the development of pressure injuries. R8's skin was not assessed upon admission and an individualized care plan was not developed based upon R8's risks and care needs. Assessments by the contracted wound care provider incorrectly identified the location of the wounds. Facility wound assessments were not comprehensive. Findings include: The facility's policy titled, Wound Management documents: . In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatment decisions will be based on: Etiology of the wound: Pressure injuries will be differentiated from non-pressure injuries, such as arterial, venous, diabetic, moisture or incontinence related skin damage. Surgical, Incidental, Atypical Characteristics of the wound: Pressure injury stage (or level of tissue destruction if not a pressure injury) Size - including shape, depth, and presence of tunneling and/or undermining. Volume and characteristics of exudate Presence of pain Presence of infection or need to address bacterial bioburden Condition of the tissue in the wound bed Condition of peri-wound skin Location of the wound Goals and preferences of the resident/representative Guidelines for dressing selection may be utilized in obtaining physician orders. The guidelines are to be used to assist in treatment decision making. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. The facility will follow specific physician orders for providing wound care. Treatments will be documented on the treatment administration record (TAR) The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: Lack of progression towards healing Changes in the characteristics of the wound. Changes in the residence goals and preferences, such as at end of life or in accordance with his/her rights. R8 was admitted to the facility on [DATE] and has diagnoses that include muscle wasting and atrophy, epilepsy, dysphagia, abnormalities in gait and mobility, dementia, adult failure to thrive, and peripheral vascular disease. R8's hospital discharge paperwork dated 11/27/24 documents R8 as having the following pressure injuries: Left great toe wound that is unstageable with eschar and necrotic tissue. Treatment orders include betadine on Monday, Wednesday, and Friday and to keep open to air. Right heel wound that is unstageable with eschar, skin intact, and necrotic. Treatment orders include paint with betadine, cover with gauze and secure with Kerlix dressing on Monday, Wednesday, and Friday. Surveyor notes the facility did not place treatment orders until 12/2/24. On 1/7/25, at 9:53 am, Surveyor interviewed Licensed Practical Nurse (LPN) - H who indicated nurses will typically get wound care orders from the hospital discharge paperwork with a newly admitted resident. LPN- H states they will call the hospital if they do not receive wound care orders and will also contact the facility provider for wound care orders. LPN- H states the facility nurse will contact the provider service (name of telehealth provider) for orders if it is after hours. LPN- H states every resident receives a comprehensive skin assessment by the facility nurse on the day of admission R8's facility admission medical records include a Clinical admission assessment dated [DATE], identifying R8 as having a right heel wound present on admission that is painful. Surveyor notes there are no measurements, staging, or properties for the right heel wound on admission. Surveyor also notes the left great toe wound is not identified or documented by the facility on the Clinical admission Assessment. Surveyor notes no comprehensive skin assessments being completed on admission on [DATE]. R8's admission Minimum Data Set (MDS) with an assessment reference date of 12/1/24 documents R8 is dependent with rolling left to right, chair and bed transfers, and shower/tub transfers. R8's MDS documents R8 as being at risk for pressure injuries and has one unstageable pressure injury and one Deep Tissue Injury (DTI). R8 was documented as having a Brief Interview for Mental Status (BIMS) score of 15 indicating R8 is cognitively intact. R8's care plan, dated 11/27/24, documents: A physical functioning deficit related to mobility impairment and self-care impairment (date initiated 11/29/24). Interventions include: (R8) requires a Hoyer lift with assistance of two for transfers (date initiated 11/29/24). (R8) requires total assistance for bed mobility (date initiated 11/29/24). (R8) has altered skin integrity with wounds to his left toe and right heel upon admission and wounds to his right toe. (R8) refuses to wear heel boots (date initiated 11/29/24). Interventions include: (R8) requires an air mattress (date initiated 11/29/24). Conduct weekly skin inspection (date initiated 11/29/24). (R8) will wear bilateral heel boots at all times. Staff will encourage (R8) to wear them (date initiated 12/19/24). Monitor for signs and symptoms of infection such as swelling, redness, warm discharge, odor, notify physician of significant findings (date initiated 11/29/24). Provide pressure reduction/relieving mattress (date initiated 11/29/24). Weekly wound evaluation (date initiated 11/29/24). Surveyor reviewed R8's Braden Scale's (a clinical tool used to assess a resident's risk for developing pressure injuries) which document the following: 11/27/24 R8 is high risk for developing pressure injuries. 12/4/24 R8 is at moderate risk for developing pressure injuries. 12/11/24 R8 is at high risk for developing pressure injuries. 12/25/24 R8 is at high risk for developing pressure injuries. 1/1/25 R8 is at moderate risk for developing pressure injuries. Surveyor noted R8's Braden Scales dated 12/4/24 and 1/1/25 document R8 is independent with rolling/moving in bed which is not reflected in R8's other assessments and impacted the overall score to assess R8's overall risk for developing pressure injuries with the Braden tool. Surveyor reviewed R8's medical record which documents a provider progress note dated 11/30/24, with wound care instructions to the right heel and left great toe. Surveyor notes orders were not present on R8's Medication Administration Record (MAR) or TAR until 12/2/24. On 12/2/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 6 cm x 3.8 cm x not measurable, with a surface area of 22.80 cm. 100% thick adherent black necrotic tissue (eschar) is present. Recommendations to apply betadine once daily and to off-load wound. *Unstageable right great toe DTI pressure injury that was noted on admission per staff. Measuring 1.3 cm x 1.8 cm x not measurable, with a surface area of 2.34 cm. Skin is intact with purple/maroon discoloration present. Recommendations to apply betadine once daily and off-load wound. Surveyor notes the hospital discharge documentation identified R8 as having unstageable pressure injuries on the right heel and left great toe at the time of discharge that were noted to have eschar present. There is no comprehensive assessment of the wounds by the facility to support the present upon admission statement. Additionally, it was not assessed upon admission that R8 had a pressure injury on their right great toe. Surveyor noted treatment orders were now initiated for R8 despite having recommended treatment orders since admission on [DATE]. On 12/9/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 6 cm x 3.2 cm x not measurable, with a surface area of 19.20 cm. 100% thick adherent black necrotic tissue (eschar) present. Wound progress has improved evidence by decreased surface area. Recommendations to apply betadine once daily and to off-load wound. *Unstageable right great toe DTI pressure injury that was noted on admission per staff. Measuring 1.3 cm x 1.8 cm, x not measurable, with a surface area of 2.34 cm. Skin is intact with purple/maroon discoloration and wound progress at goal. Recommendations to apply betadine once daily and to off-load wound. Surveyor notes the wound care progress note for R8 documents the DTI was identified as the right great toe instead of the left great toe in error. *A new unstageable DTI of the right first toe pressure injury measuring 1.2 cm x 1.6 cm x not measurable with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Recommendations to apply betadine once daily and off-load wound. Surveyor notes this is a new facility acquired pressure injury for R8. Review of R8's care plan indicates no revisions were made to the care plan to help prevent further decline or development of pressure injuries to R8's toes. On 12/16/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 5.9 cm x 3.2 cm x not measurable, with a surface area of 18.88 cm. 100% thick adherent black necrotic tissue (eschar) present. Wound progress has improved as evidence by decreased surface area. Recommendations to apply betadine once daily and to off-load wound. Unstageable DTI of the right first toe pressure injury measuring 1.1 cm x 1.6 cm x not measurable, with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Duration of wound > 11 days. Recommendations to apply betadine once daily and off-load wound. *Unstageable left great toe DTI pressure injury that was noted on admission per staff. Surveyor notes the wound care progress note for R8 documents the DTI now being corrected to be the left great toe that was noted in the hospital discharge documents at the time of discharge from the hospital. This area measures 2 cm x 1.8 cm, x not measurable, with a surface area of 3.60 cm. Skin is intact with purple/maroon discoloration and wound progress is not at goal. Recommendations to apply betadine once daily and to off-load wound. Surveyor notes this wound is not at goal and measurements are greater than the previous week. The first facility wound assessment was completed on 12/18/24 by Licensed Practical Nurse (LPN)- O which documents R8 having a right heel wound that was present on admission. Surveyor notes there are no measurements or detailed characteristics assessed regarding the right heel wound. Surveyor also noted the left great toe and right first toe pressure injuries are not identified on the 12/18/24 facility skin assessment. Surveyor noted the facility skin assessment being completed by LPN- O with no registered nurse (RN) assessment. Surveyor noted this is the first facility wound assessment initiated by facility nursing staff despite R8 being admitted to the facility on [DATE]. Additional review of R8's medical record indicates the same assessment forms were documented dated 12/22/24, 12/29/24, and 1/5/25 which documented the same details as the 12/18/24 assessment completed by LPN-O. Surveyor noted the facility assessment sheets Surveyor noted these assessments were not completed upon current standards of practice and did not include a comprehensive assessment by an RN. Surveyor reviewed R8's TAR and noted missed wound care treatments on 12/19/24 and 12/20/24. On 12/23/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 5.9 cm x 3.2 cm x 0.1 cm, with a surface area of 18.88 cm. 90% thick adherent black necrotic tissue (eschar) and 10% granulation tissue present. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable DTI of the right first toe pressure injury measuring 1.1 cm x 1.6 cm x not measurable, with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Duration of wound > (greater than) 18 days. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable left great toe DTI pressure injury that was noted on admission per staff. Measuring 2 cm x 1.8 cm, x not measurable, with a surface area of 3.60 cm. Skin is intact with purple/maroon discoloration and wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. On 12/30/24 R8 was seen and evaluated by a contracted wound care provider. The documentation of this visit indicates the following: *Unstageable right heel DTI pressure injury with necrosis that was present on admission per staff. Measuring 5.9 cm x 3.2 cm x 0.1 cm, with a surface area of 18.88 cm. 90% thick adherent black necrotic tissue (eschar) and 10% granulation tissue present. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable DTI of the right first toe pressure injury measuring 1.1 cm x 1.6 cm x not measurable, with a surface area of 1.76 cm. Skin is intact with purple/maroon discoloration. Duration of wound > 25 days. Wound progress is at goal. Recommendations to apply betadine once daily and to off-load wound. *Unstageable left great toe DTI pressure injury that was noted on admission per staff. Measuring 1.9 cm x 1.8 cm, x not measurable, with a surface area of 3.42 cm. Skin is intact with purple/maroon discoloration and wound progress is improved as evidenced by decreased surface area. Recommendations to apply betadine once daily and to off-load wound. On 1/7/25, at 8:32 am, Surveyor observed R8 laying on his back in bed with his head of the bed up approximately 45 degrees. R8 was sleeping and appeared to be comfortable with his heels resting directly on the bed and not off loaded. Surveyor observed R8's blankets to be resting directly on top of his toes and heel boots were observed on a shelf across the room. On 1/7/25, at 9:16 am, Surveyor interviewed R8 who stated he does not like wearing his heel boots due to pain. R8 indicates the heel boots cause him a lot of pain. R8 was noted to have his heels resting directly on his bed with his blankets directly on his toes. On 1/8/25, at 9:15 AM, Surveyor observed R8's wound care with LPN- D. Surveyor entered the room and R8 was observed lying in bed on his back with head of bed up approximately 45 degrees. R8's heels were observed to be floated with a pillow and blankets laying directly across R8's toes and feet. R8's right great toe revealed a dime size necrotic/black area on the tip of the toe, slightly medial, with no redness to the surrounding area and no odor. R8's left great toe revealed a nickel sized necrotic/black area on the tip of the toe with no redness to the surrounding area and no odor. R8's left heel displayed no redness and no signs or symptoms of pressure injury. R8's right heel revealed a large necrotic/black area on the back of the heel. The black area extended to the lateral side of the heel to the achilles area. Surveyor observed LPN- D applied betadine to R8's right heel, left great toe, and right great toe. On 1/8/25, at 9:46 am, Surveyor interviewed Director of Nursing (DON)- B and Assistant Director of Nursing (ADON)- C regarding concerns with R8's pressure injuries. Surveyor discussed R8 was admitted to the facility on [DATE], with no comprehensive skin assessment on admission, R8 did not have wound care treatment orders implemented until 12/2/24, and R8 developed a facility acquired DTI to his right first toe. Surveyor discussed R8's contracted wound care assessments documenting inaccurate pressure injury sites on 12/2/24 and 12/9/24. DON-B and ADON-C acknowledged the contracted wound care provider had inaccurately documented their assessment indicating the wrong toe/location on R8. Surveyor asked about R8's facility skin assessments not identifying R8's DTIs to his right great toe and left great toe, and all of R8's facility skin assessments being completed without an RN assessment. No additional information or clarification was provided at this time by DON-B or ADON-C. DON- B and ADON- C understood the concerns and had no additional information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for 1 (R6) of 3 residents. R6 did not have a CBC (complete blood count) & BMP (basic metabolic panel) during the week of 5/19/24 to 5/25/24 according to physician orders. CNAs (Certified Nursing Assistants) documented 14 episodes of loose, watery, diarrhea stools starting 5/25/24. On 5/28/24, Imodium 2 mg (milligram) was ordered every six hours as needed. Also on 5/28/24, NP (Nurse Practitioner) recommended Metamucil for R6. An order wasn't obtained until 5/30/24 two days later for psyllium husk powder (an ingredient in Metamucil.) The facility did not comprehensively assess R6's bowels and a stool sample was not obtained to rule out an infectious process. On 6/4/24, R6 was discharged from the facility to a family member. The family member transported R6 to the hospital where in the emergency room R6 was diagnosed with dehydration, C-Diff (Clostridioides difficile), and a Urinary Tract Infection (UTI). Findings include: R6 was admitted to the facility on [DATE] and discharged on 6/4/24. R6 did not have an activated healthcare power of attorney. R6's diagnoses includes urinary tract infection, severe protein calorie malnutrition, hypertension, and rheumatoid arthritis. The physician orders include an order dated 5/15/24 which documents CBC (complete blood count), CMP (comprehensive metabolic panel) x (times) 1, CBC, bmp (basic metabolic panel) weekly. Surveyor noted a CBC and CMP was collected on 5/17/24 and a CBC and BMP was collected on 5/30/24. Surveyor was unable to locate a CBC & BMP was collected during the week of 5/19/24 to 5/25/24. On 7/1/24, at 9:47 a.m., Surveyor asked LPN/UM (Licensed Practical Nurse/Unit Manager)-F when the lab comes into the facility. LPN/UM-F informed Surveyor Tuesday and Fridays but labs can be ordered any day of the week. Surveyor informed LPN/UM-F Surveyor was unable to locate a CBC & BMP during the week of 5/19/24 to 5/25/24 according to physician orders. LPN/UM-F informed Surveyor R6 refused one lab. Surveyor informed LPN/UM-F Surveyor did not note any documentation regarding refusal of a lab. LPN/UM-F informed Surveyor it may be on the lab form. Surveyor asked LPN/UM-F to provide this form to Surveyor. On 7/1/24, at 11:01 a.m., LPN/UM-F informed Surveyor labs for the week (5/19-5/25/24) there was an issue with drawing labs as the lab didn't have staff. The NP (nurse practitioner) was made aware and ended up drawing labs the next week. Surveyor asked LPN/UM-F when was the NP notified as Surveyor did not note any documentation regarding this. On 7/1/24, at 11:06 a.m., Surveyor called [name of ] lab and spoke with LR (lab representative)-O on the telephone. Surveyor inquired during the week of 5/19/24 to 5/25/24 if they didn't have staff available to draw a CBC & BMP at [name of] facility. LR-O informed Surveyor they have staff 24-7 and informed Surveyor she knows a couple times they had a break of service as they did not pay their bills. LR-O asked Surveyor for the name of the resident who did not have their lab work, which Surveyor provided. LR-O informed Surveyor they had a break of service as the facility was not paying their bills and services were stopped. The admission MDS (minimum data set) for R6 with an assessment reference date of 5/18/24 has a BIMS (Brief Interview for Mental Status) score of 12 which indicates moderate cognitive impairment. R6 is assessed as requiring partial/moderate assistance for toileting, hygiene, chair/bed to chair transfer, and toilet transfer. R6 is assessed as always continent for urine and bowel. The functional abilities (Self-Care and Mobility) CAA (care area assessment) dated 5/20/24 under analysis of findings for nature of problem/condition documents: Res (Resident) recent decline due to UTI (urinary tract infection) and dizziness. Daily antianxiety, ABT (antibiotic)-UTI. SOB (shortness of breath) when flat per MAR (medication administration record), moisturizer to extremities. Therapy ppoc (per plan of care). Skin and pain monitored. Pressure reducing devices in place. Assist w (with) ADLs (activities daily living). The physician functioning deficit care plan initiated 5/16/24 includes an intervention of, I require mod (moderate) assist x (times) 1 to complete toileting. Initiated 5/16/24. The alteration in elimination of bowel and bladder Constipation, History of UTIs initiated 5/20/24 documents the following interventions: * Monitor and report S&S (signs and symptoms) of UTI: changes in color, odor, or consistency of urine, dysuria, frequency, fever, pain. Initiated 5/20/24. * Monitor bowel status frequency. Initiated 5/20/24. * Provide easy access to clothing. Initiated 5/20/24. APNP (Advanced Practice Nurse Prescriber)-R's note dated 5/17/24 under review of systems includes documentation of Gastrointestinal: Positive for diarrhea (last couple days.) Negative for abdominal distention and abdominal pain. APNP-R's note dated 5/22/24 documents 5/22 follow up visit with patient today, family at bedside. She had a care conference today. Plan is for patient to go home after rehab, ALF (assisted living facility) has been recommended by therapy. She denies pain, cp (chest pain), sob (shortness of breath) or other concerns. States diarrhea has resolved. Family trying to fix and get battery in to her hearing aid. She is anxious to go home. Denies new concerns at this time. APNP-R's note dated 5/28/24 documents: 5/28 follow up visit with patient today, states over the weekend had some diarrhea. Today it was loose so she felt it was getting better. States she thought she received something this am (morning), but didn't know what it was. No antidiarrheal on med (medication) list. Will add prn (as needed) imodium if needed, later received msg (message) from nursing stool loose, not watery and mucous noted. Will add Metamucil as well. Continue to monitor BMs (bowel movements). Patient is eating and drinking fluids ok . Under review of symptoms documents: Gastrointestinal: Positive for diarrhea (vs soft stools). Negative for abdominal distention and abdominal pain. Under assessment and plan documents: For loose stool plan to add Metamucil 1 packet daily and imodium 2 mg (milligrams) 4 times daily as needed for diarrhea. The physician order dated 5/28/24 documents Imodium A-D oral capsule 2 mg (Loperamide HCI) Give 1 capsule by mouth every 6 hours as needed for diarrhea and dated 5/30/24 Psyllium Husk Powder (Psyllium Husk (Bulk)) Give 1 Tbsp (tablespoon) by mouth one time a day for Digestive Health. Surveyor noted there was a 2 day delay in ordering Psyllium Husk (Metamucil) for R6. The initial cardiac progress note dated 5/29/24 by NP (Nurse Practitioner)-S under history of present illness includes documentation of: Resident was examined resting in her room in her wheelchair today. She is extremely hard of hearing and anxious. She reports a 3 day history of diarrhea with no other symptoms. She denied the following cardiac symptoms including dizziness, visual disturbances, chest pain, chest pressure or tightness, palpitations, shortness of breath, PND (paroxysmal nocturnal dyspnea), lower extremity edema or syncope. There are no nursing concerns at this time. The nurses note dated 5/30/24, at 12:18, under gastrointestinal includes documentation of: Date of last BM (bowel movement): 5/30/24 Bowel movement appearance: WNL (within normal limits). Gastrointestinal Note: Resident started on Metamucil for digestive health. Bowel sounds x 4 quads with soft non-dist (distended) ABD (abdomen). Resident denies constipation or pain upon palpation. Stools noted to be very soft. This nurses note was written by LPN/UM (Licensed Practical Nurse/Unit Manager)-F. APNP-R's note dated 6/3/24 documents: 6/3 visit with patient today. Denies cp, sob, or new concerns. She states she believes she is still having diarrhea, she pulled down her brief to look and there was a mix of loose stool and some formed, (incontinent) she had new underwear in room but requested pull ups. Stool appeared dark brown, darker than previous seen, writer did an poc (bed side) occult blood test which was negative. She denies abdominal pain, nausea/vomiting. Per nursing she is declining nutritional supplements. She states she has not received her Metamucil or imodium, writer discussed with nursing to make sure she gets this today. The nurses note dated 6/4/24, at 13:46 (1:46 p.m.), documents Pt (patient) d/c (discharged ) from facility about 1345 (1:45 p.m.) via private transportation with daughter and son. VSS (vital signs stable). No SS (signs symptoms) distress. Denies SOB. All remaining meds were provided. Discharge med list and paperwork all explained to Pt and family by writer and [Name]; daughter verbalized understanding in her own words. Pt left the facility alert, orientated, and stable. This nurses note was written by LPN-U. The hospital ED (emergency department) note dated 6/4/24 documents [R6's first name] is a nontoxic-appearing [AGE] year-old female who presents with concerns for diarrhea and generalized weakness. Vitals were AFVSS (afebrile vital signs stable) throughout care. Differential was broad and included but was not limited to C. difficile, UTI, electrolyte abnormalities, AKI (acute kidney injury) and many other etiologies. C difficile was positive and her UA (urinalysis) appeared infectious. CBC was remarkable for a leukocytosis without anemia. CBC showed normal electrolytes and kidney function. She was treated with a liter bolus, oral vancomycin, and ceftriaxone for her dehydration, UTI, and C. difficile. We attempted to ambulate her and she was only able to take a few steps without assistance. The patient, her daughter, and I discussed admission for UTI and C. difficile treatment in additional to potential PT/OT (physical therapy/occupational therapy) and help with finding a safe discharge plan for her as they noted she would be going home by herself with no one to help care for her long term. They were amenable to this plan and she was admitted to the medicine service without incident. On 6/26/24, at 2:27 p.m., Surveyor showed CNA (Certified Nursing Assistant)-Q R6's picture and asked CNA-Q if she remembered R6. CNA-Q replied yes. Surveyor asked CNA-Q if she assisted R6 with using the bathroom. CNA-Q replied yes. Surveyor asked CNA-Q if R6 had diarrhea when she was at the facility. CNA-Q informed Surveyor she didn't remember and then stated they all have diarrhea. On 6/27/24, at 7:50 a.m., Surveyor received R6's bowel records and noted the following: 5/25/24 day shift continent, medium, loose/watery/diarrhea. 5/26/24 day shift incontinent, large, loose/watery diarrhea and night shift continent, medium, loose/watery/diarrhea. 5/27/24 evening shift continent, medium, loose/watery/diarrhea. 5/28/24 day shift continent, large, loose/watery/diarrhea. 5/29/24 evening shift incontinent, medium, loose/watery/diarrhea. 5/30/24 day shift incontinent, large, loose/watery/diarrhea. 5/31/24 day shift incontinent, large, loose/watery/diarrhea and evening shift incontinent large loose/watery/diarrhea. 6/1/24 day shift continent, large, loose/watery/diarrhea and evening shift incontinent medium loose/watery/diarrhea. 6/2/24 day shift incontinent medium, loose/watery/diarrhea and evening shift incontinent medium loose/watery/diarrhea. 6/3/24 day shift incontinent, medium, loose/watery/diarrhea. Surveyor noted the CNAs documented 14 episodes of loose/watery/diarrhea bowel movements. On 6/28/24, at 11:07 a.m., Surveyor asked PTA (Physical Therapy Assistant)-T if R6 complained about diarrhea while in therapy. PTA-T informed Surveyor she would complain of loose stool at times and for a period of time her participation decreased because of it. PTA-T explained they would modify her treatment if she wasn't feeling well but R6 would still receive therapy. Surveyor inquired if she received therapy in the therapy department or in her room. PTA-T informed Surveyor R6 would come to the therapy aside from the time when she was having loose stools. PTA-T informed Surveyor R6 knew when she had to use the bathroom and they would take her back to her room. PTA-T informed Surveyor he believes the loose stool started about a week prior to R6 being discharged . On 6/28/24, at 1:34 p.m., Surveyor asked LPN/UM-F if she remembers R6. LPN/UM-F replied a little bit. Surveyor asked if they tested R6's stool for any infectious process. LPN/UM-F informed Surveyor they did attempt to test but the stool was never loose enough to submit it. LPN/UM-F explained the lab wouldn't accept it as they tried to test another resident at one time and the lab refused to test the sample. Surveyor informed LPN/UM-F Surveyor was unable to locate an order for a stool specimen or any documentation regarding a stool specimen. Surveyor asked LPN/UM-F to look into this and get back with any information. On 6/28/24, at 2:52 p.m., Surveyor spoke to LPN-U on the telephone regarding R6. Surveyor asked LPN-U if R6 was having diarrhea while she was at the facility. LPN-U informed Surveyor R6 had been having diarrhea which was ongoing. LPN-U informed Surveyor R6 was on Metamucil but the daughter stated it wasn't going to work. Surveyor asked LPN-U on the day of discharge does she remember R6 having diarrhea. LPN-U informed Surveyor she doesn't remember R6 having loose stool on the day she was discharged . Surveyor asked LPN-U if R6 could go to the bathroom herself. LPN-U replied not sure. On 7/1/24, at 9:12 a.m., Surveyor showed CNA-P R6's picture and asked CNA-P if she remembers R6. CNA-P informed Surveyor she didn't like to be disturbed if she was sleeping. Surveyor inquired if she assisted R6 with cares. CNA-P informed Surveyor she would offer but she wanted to do them herself. Surveyor asked if R6 had diarrhea. CNA-P informed Surveyor she thinks she had diarrhea and would report this to the nurse. CNA-P informed Surveyor a lot of times R6 took herself to the toilet. Surveyor asked when R6 took herself to the toilet could she clean herself. CNA-P informed Surveyor she didn't think she was supposed to and offered to help. Surveyor asked CNA-P if she remembers who she reported R6's diarrhea to. CNA-P replied no I don't, think they are no longer here. On 7/1/24 at 9:47 a.m., Surveyor met with LPN/UM-F to follow up on the date when a stool specimen was attempted for R6. LPN/UM-F informed Surveyor they did discuss collecting R6's stool but the sample was soft, mushy and the lab would reject it unless the sample was watery. Surveyor again asked for the dates of when this was attempted. Surveyor asked LPN/UM-F who reviews the CNA charting of residents' bowel movements. LPN/UM-F informed Surveyor a report comes up if a resident hasn't had a bowel movement for three days. Surveyor inquired who would review the bowel records for loose/watery/diarrhea and inquired if there is an alert for loose/watery/diarrhea. LPN/UM-F didn't answer Surveyor and informed Surveyor she knows she showed APNP-R or the doctor a picture of R6's stools. On 7/1/24, at 10:28 a.m., Surveyor asked DON (Director of Nursing)-B for any bowel policy the facility has. On 7/1/24, at 11:01 a.m., LPN/UM-F provided Surveyor with the following bowel policy. The facility's policy titled, Incontinence and implemented 3/26/23 under Policy Explanation and Compliance Guidelines includes documentation of : 4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. LPN/UM-F then informed Surveyor she doesn't have a date as to when she showed the NP or MD a picture of R6's stools. On 7/1/24, at 11:24 a.m., Surveyor spoke to APNP-R about R6. APNP-R explained she is at the facility Monday to Friday and usually sees residents twice a week depending how stable they are and if they are stable then will see them once a week. Surveyor asked if there were any concerns with R6 having diarrhea. APNP-R informed Surveyor the only thing was the daughter would say R6 was having diarrhea but R6 did not complain of diarrhea to her. APNP-R informed Surveyor one time they said she had loose with some formed pieces, that's all she knows. Surveyor asked APNP-R if she reviews the bowel records which the CNAs chart. APNP-R informed Surveyor she doesn't look at this record unless there is a problem. Surveyor asked APNP-R if she recalls nursing informing her R6 was having loose stools/diarrhea. APNP-R informed Surveyor if they told her R6 was having diarrhea she would have ordered a specimen, it would have been a verbal order. Surveyor asked APNP-R if she was aware of the number of times loose, watery, diarrhea was being documented. APNP-R replied no and wasn't told it was diarrhea. Surveyor informed APNP-R of the 14 times it was documented R6 had loose, watery, diarrhea. APNP-R informed Surveyor when she saw R6's stools they were not watery. Surveyor asked APNP-R if she remembers when this was. APNP-R replied not off the top of my head. On 7/1/24, at 1:12 p.m., NHA (Nursing Home Administrator)-A and DON-B were informed of R6's CBC & BMP not being drawn during the week of 5/19/24 to 5/25/24 and R6 experiencing multiple episodes of what was documented by the CNAs as loose/watery/diarrhea without facility assessing R6's bowels and ordering a stool specimen to determine if there was an infectious process. DON-B informed Surveyor the provider ordered Metamucil on 5/30/24. Surveyor informed DON-B R6 continued to have loose/watery/diarrhea 7 times after the Metamucil.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the comprehensive assessment of a resident, the facility did not ensure that residents received care, consistent with professional standards of practice, to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure injuries received necessary treatment and services to promote healing, prevent infection, and prevent new injuries from developing for 2 of 4 (R4 and R5) residents reviewed for pressure injuries. R4 was dependent for bed mobility and identified to be at high risk for pressure injuries. Care plan interventions to include offloading, turning, and repositioning were not implemented. R4 developed a stage 3 pressure injury to her buttock and the care plan was not revised to include increased offloading, turning, and repositioning. Initial assessment and measurements were not completed and treatment for the pressure injury was not immediately implemented. In addition, R4 developed a Deep Tissue Injury (DTI) to her left heel. There was no documentation of a comprehensive assessment or measurements. R5 required maximal assistance for bed mobility and was identified to be at risk for pressure injuries. Care plan interventions to include offloading, turning, and repositioning were not implemented. R5 developed a DTI to his right heel. A comprehensive assessment and measurements of the pressure injury were not completed. Findings include: The facility policy titled Pressure Injury Prevention Guidelines (which is not dated) documents (in part) . .To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency of performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel flotation devices, cushions, mattresses). 7. Interventions will be documented in the care plan and communicated to all relevant staff. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changes in wound characteristics. c. Changes in the resident's goals and preferences, such as at end of life or in accordance with his/her rights. Repositioning: 1. Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition. 2. Routine repositioning schedule: Every two hours, using both side-lying and back positions. Reposition when in bed and out of bed. 5. Repositioning techniques: f. Ensure that heels are floated off the surface of the bed, using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon. Pressure Relieving Devices: 1. Support surfaces do not eliminate the need for turning and repositioning. 2. Pillows and wedges may be utilized to maintain proper positioning. 3. Apply heel suspension devices according to the manufacturer's instructions. a. For prevention, stage 1 or stage 2: Use pillows or heel suspension devices. If using heel protectors, will still need to utilize pillows for floatation. b. For stage 3, 4, unstageable or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury. Check the skin each shift and prn (as needed) for signs of redness or skin breakdown related to the boot. 1.) R4 admitted to the facility on [DATE]. Diagnoses include Respiratory Failure, Parkinson's Disease, Pulmonary Embolism, dysphagia, Alzheimer's Disease, orthostatic hypotension, and insomnia. R4 admitted to the facility with no pressure injuries. R4's Braden Score dated 3/26/24 documented a score of 12 indicating High Risk. R4's admission Minimum Data Set (MDS) dated [DATE] documents: Is this resident at risk of developing pressure ulcers/injuries? Yes. Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed: Dependent - helper does all of the effort. Resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity. R4's CAA (Care Area Assessment) worksheet documents: Pressure Ulcer/Injury Potential. Bed mobility is impaired, and she had episodes of incontinence. At risk for functional decline and skin breakdown. Goal is to improve her functional status and to not develop skin impairment. R4's Care Plan Focus initiated 3/27/24 documents: Physical functioning deficit related to mobility impairment, self-care impairment. Interventions: Bilateral bed canes for bed mobility. I require Hoyer lift with assist x 2 to complete transfers. I require max assist x 2 to complete bed mobility. Pressure ulcer actual or at risk due to assistance required in bed mobility, bowel incontinence, Braden Score 18 or < (less) - initiated 4/3/24. Interventions: Complete Braden Scale per living center policy. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. Provide thorough skin care after incontinent episodes and apply barrier cream. Prevalon boots to bilateral feet initiated 4/12/24. Resident has an actual pressure ulcer left lateral upper buttocks, left inferior heel. Resident refuses to wear Prevalon boots. R&B (risks and benefits) were discussed with resident - initiated 4/9/24. Interventions: Evaluate need for pain reliever prior to cleansing or dressing changes. Notify practitioner if symptoms worsen or do not resolve. Provide pressure reducing wheelchair cushion. Provide pressure reduction/relieving mattress. Treatments as ordered. Weekly wound assessment. Float heels initiated 5/6/24. R4's Physical Therapy Evaluation & Plan of Treatment start of care dated 3/27/24 documents: Bed Mobility roll left and right = Dependent. R4's admission Skin assessment dated [DATE] documents blancheable redness to left buttocks, no wounds. Surveyor noted although R4 was identified to be at high risk for pressure injuries and was dependent on staff for bed mobility, there were no care plan interventions to include offloading, turning, or repositioning implemented. Facility Progress Notes document: 4/8/24 at 4:27 AM Skin tear was observed by CNA (Certified Nursing Assistant) during patient care. Upon observation is appeared to be a pressure sore on her left gluteal. Family is aware and NP (Nurse Practitioner) notified via text. Surveyor noted there was not a comprehensive assessment or measurements of the pressure injury documented, and no new treatment was ordered or implemented. 4/9/24 at 3:55 AM Pt (patient) monitoring r/t (related to) skin tear to left buttocks. Frequent repositioning encouraged. Barrier cream applied. 4/9/24 6:32 PM Patient seen by Wound Care for left lateral upper buttocks and left inferior heel. Patient had no c/o (complaints of) pain or distress during treatment, will follow current treatment regimen in place and continue to see patient weekly for wound rounds. Surveyor noted this was the first mention of a left heel wound. There was no documentation of an assessment or measurements of the wound. The Wound Pros progress reports document: 4/9/24 [AGE] year-old female presents with a chronic non-healing pressure ulceration of the left lateral upper buttocks. The wound has been present for approximately less than 30 days and is for initial evaluation. Previous treatments include off-loading and Advanced wound care dressings. Surveyor noted R4 did not have previous treatment orders for advance wound care dressings and the care plan did not include off-loading. Left lateral upper buttocks new stage 3 pressure ulceration. Length/Width/Depth measurements 5.39 x 3.81 x 0.2 cm (centimeters). 80% granulation, 10% fibrous tissue, 10% necrotic tissue. Sanguineous bright red exudate. Sharp debridement. Left inferior heel new Deep Tissue Injury 3.5 x 1.5 x 0.01 cm. Wound size medium. Surveyor noted although the facility identified a DTI to the heel and Stage 3 pressure injury to R4's buttocks, and R4 was dependent for bed mobility, the care plan was not revised to include frequent offloading, turning, and repositioning. Appropriate treatment was ordered and implemented. The wounds were followed weekly with periodic sharp and mechanical debridement of the buttocks wound. On 5/11/14 at 6:43 PM Facility progress notes document: Writer informed by the aides that pt's tx (treatment) came off and wound looks worse. Upon assessment wound appears worse, strong odor present. Writer contacted MD (Medical Doctor), NOR (new order received) for CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel) which was drawn earlier today, awaiting results. Start pt on Augmentin 875 mg (milligrams) BID (twice daily) x 7 days. Pending evaluation by wound team and obtain wound culture. Surveyor noted a comprehensive assessment and measurements of R4's buttock wound was not completed when the decline was noted on 5/11/24. On 5/14/24 R5 was seen by The Wound Pros: Left inferior heel healed. Left lateral upper buttocks stage 3 deteriorating. 6.4 x 4.6 x 3.5 cm. Moderate serosanguineous light red/pink exudate. Mild odor. 100% necrotic tissue. Undermining 4.5 cm from 9 to 6 o'clock. Sharp debridement. Appropriate treatment was ordered and implemented. R4 was hospitalized from [DATE] through 5/22/24 for change in condition - decreased food/fluid intake, functional decline, Covid, and Failure to Thrive. Upon readmission to the facility on 5/22/24, R4 continued to be followed by wound care weekly. Periodic sharp and mechanical debridement was performed. No further infection noted. R4 signed on to Hospice care on 5/28/24 and discharged home with Hospice care on 6/5/24. On 6/27/24 at 12:15 PM, Surveyor spoke with Licensed Practical Nurse (LPN) Unit Manager (UM)-D and Wound Care Nurse (WCN)-L. Surveyor advised of the above concerns. LPN UM-D reported she was unable to locate any facility assessments or measurements of R4's heel wound. LPN UM-D stated, I know there were issues before I came, I've been trying going forward, but I can't fix what happened. Basically, this is why the other WCN isn't here anymore. On 6/27/24 at 3:00 PM during the daily exit meeting, the facility was advised of the concern R4 admitted to the facility with no pressure injuries, was identified to be at high risk and was dependent on staff for bed mobility. No care plan interventions to include offloading or turning and repositioning were implemented. R4 developed a left heel deep tissue injury that was not comprehensively assessed or measured and a stage 3 pressure injury to her buttock. After the stage 3 pressure injury was identified, the facility did not revise the care plan to include frequent turning and repositioning and treatment for the stage 3 pressure injury was not immediately ordered and implemented. 2.) R5 admitted to the facility on [DATE]. Diagnoses include Right Femur Fracture, Polymyalgia Rheumatica, Atherosclerotic Heart Disease, Pulmonary Hypertension and Chronic Kidney Disease stage 3. R5 admitted to the facility with no pressure injuries. R5's admission Minimum Data Set (MDS) dated [DATE] documents: Is this resident at risk of developing pressure ulcers/injuries? Yes. Functional Limitation in Range of Motion: Impairment on one side - lower extremity (hip, knee, ankle, foot). Roll left and right: The ability to roll from lying on back to left and right side and return to lying on back on the bed: Substantial/maximal assistance - helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort. R5's CAA worksheet documents: Pressure Ulcer/Injury Potential. Resident does not have any pressure ulcer impairments at this time. Care plan considerations: Minimize risks. Care plan to address and to minimize the risk for pressure ulcer impairments. R5's Care Plan Focus initiated 3/14/24 documents: Physical functioning deficit related to mobility impairment, self-care impairment. Interventions: Bilateral bed canes for bed mobility. Max assist x 1 to complete toileting. Max assist x 1 to complete bed mobility. Pressure Ulcer at risk due to decreased mobility initiated dated 3/19/24. Interventions: Complete Braden scale per living center policy. Conduct weekly skin inspection. At risk of Pressure Injuries due to assistance required in bed mobility initiated 3/20/24. Interventions: Conduct weekly skin inspection. Heel boots. R5's Physical Therapy Evaluation & Plan of Treatment start of care dated 3/14/24 documents: Bed Mobility roll left and right = Substantial/maximal assistance (The patient will require bed rails for bed mobility performance and the use of pillows or A frame to maintain proper hip alignment with rolling, side lying and bed mobility). There was no evidence in R5's electronic health record (EHR) an admission skin assessment or Braden was completed. R5's skilled evaluations (skin section) in the EHR included no documentation of pressure injuries through 3/27/24. R5's Treatment Administration Record (TAR) documented: Skin prep R (right) heel two times a day - ordered 3/19/24. Prevalon boot on while in bed every shift - ordered 3/19/24. Apply non-adherent dressing to right heel every day shift - ordered 3/28/24. Surveyor noted a Physician's order dated 3/28/24 for wound care to evaluate and treat right heel. Surveyor was unable to locate any documentation of R5's right heel wound in the medical record. There was no evidence a comprehensive assessment or measurements were completed. On 6/25/24 at 3:00 PM, Surveyor advised the facility R5 had treatment orders for a right heel wound, however there was no documentation of the heel wound in R5's medical record. Surveyor asked the facility for all documentation regarding R5's right heel wound. On 6/26/24 at 9:00 AM, Director of Nursing (DON)-B provided Surveyor two (2) Wound Pros progress reports, stating: That's all we have. 3/26/24 Wound Pros Progress notes document: [AGE] year-old male last seen on March 26, 2024, as a consult for a skin issue on the right medial heel that was present for less than 30 days. Location: Right medial heel Blister. Skin Health Status: At Risk. Size: Medium. Orders/recommendations: Off-loading. Recommend heel protectors. Surveyor noted there were no measurements documented. The picture on the form appeared to be a large dark blister. Wound Pros Visit Details 4/2/24: Wound Evaluation right medial heel. Status unchanged. Pressure ulceration. Stage: Deep Tissue Injury. 3.0 cm (centimeters) x 2.5 cm x 0.01 cm. Wound size: Small. Necrotic tissue. Surveyor noted the picture showed the darkened area appeared smaller in size. On 6/26/24 at 9:50 AM, DON-B advised Surveyor the facility did not have evidence a skin assessment or Braden was completed on R5 upon admission to the facility and the facility did not have a comprehensive assessment or measurements of R5's right heel pressure injury when it was identified. DON-B reported the previous wound care nurse no longer works for the facility and new systems have been put in place since. Surveyor confirmed with DON-B there was no documentation of R5's heel pressure injury from the time treatment was implemented on 3/19/24 until he was seen by The Wound Pros on 3/26/24. On 6/27/24 at 10:55 AM, Surveyor spoke with Licensed Practical Nurse (LPN) Unit Manager (UM)-D who reported she remembered R5 had a pressure injury on his heel. Surveyor asked what the expectation for a resident is who admits to the facility with a hip fracture and requires maximal assistance with bed mobility for offloading and turning and repositioning. LPN UM-D stated: Really anyone with that should automatically have their heels floated or pressure relieving boots put on, that's just a given because they can't move their leg or turn themselves. Surveyor reviewed R5's TAR noting an order for skin prep to the right heel implemented 3/19/24. Surveyor advised there is no documentation of an assessment or measurement of the pressure injury when it was identified. LPN UM-D reported whichever nurse finds any wound they should document an assessment and measure it, then get a treatment order. LPN UM-D stated: I'm not making any excuses, but we had a lot of agency at one point and they sometimes are just here for the paycheck it seems, they don't do as good of job as the regular staff. If I find any wound, I document what it looks like, measure it and call for treatment orders. On 6/27/24 at 3:00 PM during the daily exit meeting, the facility was advised of concern R5 admitted to the facility with no pressure injuries, was identified to be at risk, and required max assist with bed mobility. No care plan interventions to include offloading or turning and repositioning were implemented. R5 developed a right heel Deep Tissue Injury that was not comprehensively assessed or measured until at least 1 week after it was identified. No additional information was provided at this time. On 7/1/24 at 10:15 AM, Assistant Director of Nursing (ADON)-C provided Surveyor a pressure injury Performance Improvement Plan (PIP). ADON-C reported it was created for the overall pressure injury program in general. ADON-C reported on 4/11/24 she noticed things were not matching up, such as measurements and treatments. An audit was completed which identified problems with assessments and treatments not being done and the prior WCN information not matching documentation or what was seen. ADON-C reported she and DON-B created a PIP on the whole wound process from beginning to end. ADON-C reported it's a work in progress and they have not yet done education with staff on prevention and assessments. Surveyor review of the PIP start date 4/14/24 documented key area for improvement: Wound process not timely, initial measurements missing, weekly measurements not always completed, wound round not organized, treatments not always completed, wound nurse not doing treatments. Surveyor noted the PIP did not address concern regarding pressure injury prevention and implementing interventions to assist with prevention of pressure injuries. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6) R298 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction, Difficulty in Walking, and Cognitive Communication Deficit. Surveyor reviewed R298's MDS (Minimum Data Set) with an assessment date of 3/5/2023. Documented under Cognition was a BIMS (Brief Interview for Mental Status) score of 03 which indicated severe impairment. R298 had an activated Power of Attorney (POA.) Surveyor reviewed R298's Progress Notes. Documented on 3/7/2023, at 10:15 AM, was patient had a shower and skin assessment done. new bruised area with bump noted to right eyebrow area. all skin tears healing with no bandages on. patient was asked how she got a bump and bruise on her right eyebrow area and patient said she would have to think about it. Surveyor reviewed R298's Electronic Medical Record. Surveyor noted the bruise was an injury of unknown origin but was on her head which could possibly have other detrimental effects. There were no Neurological Checks documented. There were no assessments of the resident's cognition, skin, or other assessments noting any change in R298's mentation after the bruise was found. There was no physician notification documented relaying the bruise found. On 6/15/23, at 1:25, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor asked about the bruise to R298's head and any follow up completed. NHA-A stated the bruise was reported to Former Director of Nursing (DON)-HH. NHA-A stated DON-HH did interviews with staff on 3/7/23 to see if anyone noted the bruise prior to that date or if any falls or incidents happened prior to that date. NHA-A stated she thinks DON-HH assessed R298 at that time for other injuries. Surveyor asked if that was documented in R298's chart? NHA-A stated she will look. Surveyor asked if any other assessments were completed after the initial assessment. NHA-A stated not that she knew of but will also investigate that. Surveyor asked what the process was if a resident has a head injury? NHA-A stated we would do neuro checks but she was unsure if they were done or not. NHA-A stated she will investigate that. Surveyor noted there was no documentation of assessment, vital signs, neuro checks, physician notification, or monitoring of R298 after the bruise was identified on 3/7/23. No additional documentation was provided. Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for non-pressure injuries and neurological checks after a potential head injury for 4 (R247, R146, R97, and R38) of 6 residents reviewed for non-pressure injuries and 2 (R38 and R298) of 4 residents reviewed for neurological checks after potential head injury. *R247 was admitted with excoriation to the right and left buttocks with discharge orders from the hospital for a treatment to the area and to not have an incontinence brief on. Surveyor observed staff peel an incontinence brief from R247's right and left buttock causing R247 to cry out in pain and causing excessive bleeding from open wounds. The wounds were not comprehensively assessed until eleven days after admission. Documentation was conflicting as to where R247 had wounds and a surgical wound to the right hip with a wound vac was not comprehensively assessed for eleven days. R247 was on anticoagulant medication and no documentation was found that the physician was notified of the excessive bleeding with the wound treatment. *R146 sustained a skin tear to the right leg after a fall that was not assessed and a treatment was not provided as ordered. *R97 was admitted on [DATE] with diabetic foot ulcers to the right and left feet per the hospital discharge summary with treatments ordered to each foot. The right foot ulcer was not comprehensively assessed until 6/13/2023 and the left foot ulcer was not assessed at all through the time of the survey. *R38 had non-pressure injuries that were not comprehensively assessed weekly. *R38 had incomplete neurological checks after a fall with a potential head injury. *R298 did not have neurological checks after the discovery of an injury of unknown origin to the head. R247 is being cited at a severity level 3 (Actual harm that is not immediate jeopardy). R146, R97, R38, and R298 are cited at severity level 2 (No actual harm with potential for more than minimal harm). Findings include: The facility policy and procedure entitled Wound Management dated 10/28/2021 states: . 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: A. Feces has seeped underneath the dressing. B. The dressing has dislodged. C. The dressing is soiled otherwise, or is wet. 4. Dressings will be applied in accordance with manufacturer recommendations. 5. Treatment decisions will be based on: A. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesions, pyoderma, calciphylaxis). B. The characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including shape, depth, and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. C. Location of the wound. D. Goals and preferences of the resident/representative. 6. Guidelines for dressing selection may be utilized and obtaining physician orders (see attached). a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above). c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1) R247 was admitted to the facility on [DATE] with diagnoses of osteomyelitis to the right femur, Parkinson's disease, rheumatoid arthritis, diabetes, paraplegia, peripheral vascular disease, depression, heart failure, and gastroparesis. R247 had not been in the facility long enough to have a Minimum Data Set (MDS) assessment completed at the time of survey. The nursing assessment on 6/2/2023, at 8:00 PM, in the progress notes charted R247 needed total assistance with bed mobility, transferring, eating, toilet use, and hygiene. R247 had a suprapubic urinary catheter in place. R247 did not have an activated Power of Attorney. On the After Visit Summary - Transition hospital paperwork dated 6/2/2023, the Problem List included a pressure ulcer, a deep tissue injury (DTI,) a tear of the skin of the right buttock, and an open wound. Wound documentation was included in the paperwork for a right hip surgical wound and right anterior proximal thigh with a negative pressure wound vac in place and a Stage 2 pressure injury to the right buttock with a treatment of antifungal powder doing the crusting technique. The discharge treatment instructions for the buttock DTI and sheering wound was a crusting technique with antifungal powder and no sting times three layers and if unavailable, use remedy antifungal cream; do not use Depends. On 6/2/2023, at 8:05 PM, in the progress notes, Licensed Practical Nurse/Unit Manager (LPN/UM)-E charted R247's admission assessment. LPN/UM-E charted R247 had a pressure injury to the right hip with a wound vac in place, moisture associated skin damage (MASD) to the buttocks with entire buttock with open wounds and excoriation, open lesions of the right toes, open lesions of the left toes, and bilateral feet with scabbed areas. No measurements or descriptions of the wounds with tissue type, exudate, or odor were documented. On 6/2/2023, R247's treatment order for the buttocks was to apply Happy Butt Cream every shift. Surveyor reviewed R247's admission orders and noted the hospital discharge orders for the antifungal powder, no sting barrier, and not using Depends was not put in place. R247's Pressure Ulcer Care Plan was initiated on 6/2/2023 with the following interventions: -Complete Braden scale per facility policy. -Conduct weekly skin inspection. -Evaluate the need for pain reliever prior to cleansing or dressing changes. -Heel boots. -Monitor vital signs as needed. -Notify practitioner if symptoms worsen or do not resolve. -Provide pressure reduction/relieving mattress. -Provide thorough skin care after incontinent episodes and apply barrier cream. -Skin assessment to be completed per facility policy. -Treatments as ordered. -Weekly wound assessment. R247 was admitted to the facility with orders for warfarin 2.5 mg (milligrams) Tuesday, Wednesday, Thursday, Saturday, and Sunday and 5 mg Monday and Friday, aspirin 81 mg daily, venlafaxine 27.5 mg twice daily, and ceftriaxone 2 Gm intravenously daily. (Venlafaxine and Ceftriaxone may increase the effects of warfarin and cause bleeding more easily.) R247's INR (International normalisation ratio) was being monitored every Tuesday and Friday per physician orders. R247's At Risk for Complications related to Anticoagulant Care Plan was initiated on 6/2/2023 with the interventions: -Apply prolonged pressure to venipuncture sites. -Monitor dietary intake of foods high in Vitamin K (green leafy vegetables) -Monitor medication regime for medications which increase effects (NSAID (Non Steroidal Anti-Inflammatory Drug) such as aspirin, antidepressants, antibiotics, fish oil, etc.). -Observe for adverse reaction: fever, skin lesions, anorexia, nausea, vomiting, cramps, diarrhea, hemorrhage, hemoptysis. -Observe for signs/symptoms of bleeding such as tarry stools, blood in urine, bruising, petechiae. -Obtain and monitor lab/diagnostic work as ordered and report results to the physician and follow up as indicated. -Utilization of soft bristle toothbrush and inspect oral cavity for ulcerations or bleeding gums. On 6/6/2023, at 9:24 PM, in the progress notes, Director of Nursing (DON)-B charted R247 would not allow DON-B to look at buttock or use the wound app to take measurements. DON-B charted DON-B would attempt to assess R247 the next day. On 6/7/2023, at 11:41 AM, in the progress notes, LPN-G charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. On 6/7/2023, at 9:21 PM, in the progress notes, DON-B charted R247's wound vac to the right lateral thigh was no longer working and orders were obtained to remove the wound vac. DON-B charted new orders, cleanse with normal saline followed by a gauze island dressing, was completed. DON-B charted the wound looked clean, dry, and intact. Surveyor noted no measurements or description of the wound tissue was documented. DON-B charted R247 again refused to have DON-B look at the wounds on the buttocks and R247 was aggravated by DON-B asking to assess the buttocks. On 6/8/2023, at 9:29 PM, in the progress notes, DON-B charted R247 refused to have DON-B assess the buttock wound and R247 was informed of risks of not having the wound assessed. On 6/9/2023, at 11:43 AM, in the progress notes, LPN-G charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. Surveyor noted the wound vac had been discontinued on 6/7/2023 due to the vac no longer working and the progress note referred to the wound clinic appointment that had taken place the day before. On 6/9/2023, at 9:31 PM, in the progress notes, DON-B charted DON-B attempted to assess R247's buttock and R247 refused to be turned to have buttock assessed. DON-B charted R247 was aggravated by DON-B's attempts to assess the buttocks. On 6/10/2023, at 11:08 AM, on 6/11/2023 at 10:58 AM, and on 6/13/2023 at 10:55 AM in the progress notes, LPN-G charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. Surveyor noted the wound vac had been discontinued on 6/7/2023 due to the vac no longer working. On 6/12/2023, at 4:34 PM, in the progress notes, LPN-O charted R247 had a pressure injury to the right hip with wound vac in place until the wound clinic appointment on 6/8/2023 per surgeon, MASD to the buttocks with entire buttock with open wounds and excoriation, an open lesion to the right toes, and an open lesion to the left toes. Surveyor noted the skilled evaluation note in the progress notes for R247's skin on 6/7/2023, 6/9/2023, 6/10/2023, 6/11/2023, 6/12/2023, and 6/13/2023 had the same areas of concern with the same descriptors of the wounds with no variation in the charting even when the wound vac had been discontinued and new treatment orders for the right hip had been implemented. This charting matched the initial admission assessment completed on 6/2/2023. On 6/13/2023, at 10:45 AM, Surveyor accompanied Regional Director of Wound Management (RDWM)-J and Nurse Manager-I into R247's room to observe the wound treatment and assessments of R247's wounds. RDWM-J stated RDWM-J had not seen R247's wounds before and commented that it appeared R247 had a treatment to the right lateral thigh and buttocks. Surveyor asked RDWM-J who assesses the skin of a new resident and who does the weekly wound rounds in the facility. RDWM-J stated RDWM-J was the wound nurse for seven facilities and therefore could not be in each building weekly, so Director of Nursing (DON)-B does the initial wound assessment when the resident is first admitted and the weekly wound rounds of all the residents with wounds. Certified Nursing Assistant (CNA)-H was asked to assist in positioning R247. R247 was lying in bed on an air mattress with bilateral heel boots on. R247 was turned onto the left side. R247 had a border dressing to the right hip/trochanter with a small amount of serous drainage when removed. The right hip incision was well approximated at the proximal and distal ends and measured approximately 10 cm in length. The center of the incision had a slight gap that measured approximately 0.2 cm. Surveyor was unable to see the wound bed. RDWM-J cleaned the incision with normal saline and applied a border foam dressing. R247 denied any pain to the right hip. R247 stated the pain was in my cheeks, referencing the buttocks. R247 had an incontinence brief in place. RDWM-J attempted to remove the brief, but the wounds were stuck to the brief and R247 yelled out in pain. RDWM-J continued to pull at the brief peeling it from the buttocks and once removed, rivulets of blood flowed from the open buttocks wounds. The right buttock had an open area that measured approximately 0.5 cm x 1.5 cm with active bleeding and a pink wound base. Nurse Manager-I was able to stop the bleeding of the right buttock wound by applying pressure with a wet washcloth. The left buttock had five open areas with four of the open areas in vertical orientation on the medial aspect of the left buttock and a single open area to the left of the four open areas. The four linear wounds each measured approximately 1 cm x 1 cm and the lateral wound measured approximately 3 cm x 1 cm. The wound bases were not visible due to the amount of blood present in the wounds. Nurse Manager-I placed pressure to the left buttock wounds with a wet washcloth and the washcloth was immediately saturated with blood. The skin to R247's right and left buttocks was discolored and macerated. RDWM-J applied Happy Butt Cream to the right and left buttocks. The cream was white in color before being applied to the buttocks and turned pink while being applied due to the extent of active bleeding from the left buttock wounds. A clean incontinence brief was placed on R247 by rolling R247 back and forth. Blood smeared onto the sides of the brief during the process of putting the brief on. R247 cried out in pain, held their breath, and inhaled quickly throughout the process of assessing and treating the buttocks wounds. Nurse Manager-I asked R247 to rate the pain to the buttocks. R247 stated the pain was a five-and-a-half that comes and goes. Nurse Manager-I told R247 that Nurse Manager-I would ask the nurse to bring in some pain medication to R247. R247 replied, Thank you. RDWM-J instructed R247 to stay off of the butt, turn side to side, and eat a good diet to promote wound healing. In an interview on 6/13/2023, at 11:42 AM, Surveyor asked CNA-H if CNA-H had ever seen R247's buttocks and if the amount of blood seen during the wound treatment that day was typical for R247. CNA-H stated R247 had always had that much bleeding. Surveyor asked CNA-H if the nurse was aware of the bleeding. CNA-H stated CNA-H thought so because they would let the nurse know about the need to apply the Happy Butt Cream and the nurse would come in to do that and see R247's buttocks. CNA-H stated sometimes the nurse would give the Happy Butt Cream to the CNA to apply so then they would not see it. Surveyor asked CNA-H if R247's wounds were getting better or worse since the last time CNA-H saw the wounds. CNA-H stated it was hard to say because the wounds were hard to see because of all the bleeding. Due to the amount of bleeding noted during the wound observation, Surveyor reviewed R247's H/H (Hemoglobin and Hematocrit) lab work. (13.7-17.5/40-51 is considered low.) 5/27/2023 (hospital lab) - 10.5/35.1 5/31/2023 (hospital lab) - 10.5/35.3 6/6/2023 - 9.8/33 6/13/23 - 9.2/31 On 6/13/2023 on the Skin and Wound Evaluation form, RDWM-J charted the right lateral thigh surgical wound measured 5.5 cm x 0.8 cm x 0.1 cm with 100% granulation with moderate serosanguineous drainage. On 6/13/2023 on the Skin and Wound Evaluation form, RDWM-J charted the right gluteus MASD measured 5.6 cm x 2.8 cm x 0.1 cm with 100% granulation with moderate serosanguineous drainage. The surrounding tissue was macerated. On 6/13/2023 on the Skin and Wound Evaluation form, RDWM-J charted the left gluteus MASD measured 7.0 cm x 4.8 cm x 0.1 cm with 100% granulation with moderate serosanguineous drainage. The surrounding tissue was blanching. Surveyor noted the assessments of the right and left gluteus did not correlate with the observations made during wound care on that date. In an interview on 6/13/2023, at 1:47 PM, DON-B stated when a new resident is admitted , the nurse on the floor is expected to measure the wounds and then DON-B would come in and measure the wound the following day. DON-B stated a treatment for any wounds that are noted on admission and do not have treatment orders from the hospital are told to the physician to get a wound treatment in place depending on what they find. R247's Care Plan was updated on 6/13/2023 to address refusals by R247 and on 6/14/2023 to incorporate no incontinence product to be used. In an interview on 6/14/2023, at 1:10 PM, LPN-G stated LPN-G charted on R247 every day shift that LPN-G worked. Surveyor asked LPN-G how the charting system was set up for daily charting, such as were sections of the charting pre-filled from previous shifts or were preset charting options selected each time charting was completed. LPN-G stated there were no pre-filled sections on the charting; the nurse had to click on the appropriate information in the charting system. Surveyor asked LPN-G if R247's buttock had been observed by LPN-G the day before, on 6/13/2023. LPN-G stated no, LPN-G had not seen R247's buttocks in a long time. Surveyor noted LPN-G had charted on R247 on 6/7/2023, 6/9/2023, 6/10/2023, 6/11/2023, and 6/13/2023. LPN-G could not recall when LPN-G last saw R247's buttocks. Surveyor noted LPN-G had charted information in R247's medical record without verifying that information. LPN-G stated LPN-G heard the previous day that R247's buttock was really red and they were getting a new treatment with nystatin to add to the Happy Butt cream. Surveyor asked LPN-G if R247's buttocks were bleeding the last time LPN-G observed R247's buttocks. LPN-G stated it was macerated and excoriated, but nothing was bloody, and the skin looked like it was peeling. Surveyor asked LPN-G if any CNAs had reported to LPN-G that R247 was bleeding from the buttock. LPN-G stated no. Surveyor asked LPN-G if the admitting nurse reviews the discharge summary from the hospital when a new resident comes in. LPN-G stated that would depend on what time the resident gets to the facility. LPN-G stated the After Visit Summary is looked at for the medications and the Unit Managers go through the charts the next day to make sure the orders are all in the charting system. In an interview on 6/14/2023, at 1:46 PM, Surveyor asked LPN/UM-E what LPN/UM-E could recall when R247 was admitted to the facility on [DATE]. LPN/UM-E stated R247 had a wound vac on the hip and that was to be left in place until R247 was seen by the wound clinic. LPN/UM-E reviewed the charting in the computer charting system and stated R247's bottom had open excoriation and got orders for Happy Butt Cream. LPN/UM-E stated the buttocks had bloody drainage. Surveyor asked LPN/UM-E if LPN/UM-E had seen the wound treatment discharge orders from the hospital for R247? LPN/UM-E stated there was an order for a cream that the facility did not have so they got an order from the physician for the Happy Butt Cream which was an equivalent. LPN/UM-E stated on admission, R247's buttocks wounds were pretty extreme with blood, so much so that LPN/UM-E did not know how to describe the wounds. Surveyor shared with LPN/UM-E the concern R247 was on warfarin, along with aspirin and an antibiotic that would increase the possibility of bleeding, and R247 had very active bleeding during wound care with an order from the hospital not to put incontinence briefs on. LPN/UM-E stated they were not aware of that order. In an interview on 6/15/2023, at 7:47 AM, Surveyor asked CNA-Q if CNA-Q had attended to R247 that morning? CNA-Q stated CNA-Q changed the bed linen, did all cares on the upper and lower body, and R247 requested to not have any clothes on when CNA-Q was done so that was how CNA-Q left R247. Surveyor asked CNA-Q if R247 had an incontinence brief on? CNA-Q stated yes, and CNA-Q changed the brief. Surveyor asked CNA-Q what CNA-Q observed when changing the brief? CNA-Q stated R247's buttocks had areas that were excoriated. CNA-Q stated there were no dressings to the open areas, so CNA-Q put a cream on which was basic skin protection. CNA-Q showed Surveyor the cream that had been applied. The cream was Periguard ointment. CNA-Q stated CNA-Q dabbed the area to get it clean and R247 complained of pain while CNA-Q was doing that. CNA-Q stated there was no active bleeding from the wounds. CNA-Q reiterated there were about three open areas with no dressing, so CNA-Q put the cream on. In an interview on 6/15/2023, at 8:05 AM, LPN-G stated LPN-G did the treatment yesterday and there was a little bit of blood but not like it was on 6/13/2023. LPN-G stated LPN-G would be doing the treatment again that day after lunch. On 6/15/2023, at 1:53 PM, Surveyor observed LPN-G with R247. R247 had an incontinence brief underneath the buttocks that was not fastened in the front. R247 was rolled to the side and R247 asked, Did it stop bleeding? pointing to R247's bottom. R247 stated they said it was really bleeding last night. R247 stated R247 had not gotten much sleep at night because of the pain to the bottom. R247 grimaced in pain when being turned and moved. R247's right hip dressing was removed. Serosanguineous drainage dripped down the leg from the open area in the incision. The wound was cleansed with normal saline and a border foam dressing was placed. Cream was visible on R247's buttocks and peri area. LPN-G cleaned off the cream with wipes and R247 had vocalizations of pain when the area was touched and held their breath for the majority of the process. The right buttock open area had improved since the observation on 6/13/2023 with no active bleeding noted and the left buttock, originally having five open areas, had changed to three open areas with four wounds merging to form two wounds. The left buttock wounds had minimal bleeding noted. R247's wife was in the room and stated when R247 was at home, there was a pad on the buttocks wounds so no stool would go on it and R247's wife would clean the area and put on a clean pad. R247's wife stated R247 had an appointment with the wound clinic on 6/22/2023. Surveyor asked R247 about R247's pain to the buttocks. R247 stated R247 could not sleep at night because of the pain. R247 stated R247 could take pain medications but the relief only lasts so long and the cream helps with the pain but only for a little while. In an interview on 6/19/2023, at 10:52 AM, Surveyor asked DON-B if R247 had any wounds to the toes of the right and left feet as documented repeatedly in the progress notes? DON-B adamantly stated R247 did not have any wounds to the feet or toes. DON-B stated R247's feet were contracted, but there were no wounds on them. DON-B stated DON-B could not figure out why that was continually charted. Surveyor discussed with DON-B the concern there was a lot of bleeding with wound care on 6/13/2023 and no documentation was found that the physician was notified of the extent of bleeding since R247 was on warfarin. DON-B agreed with the lack of documentation and could not determine if the physician had been told of the bleeding. Surveyor shared with DON-B the concern R247's wounds were not comprehensively assessed until 6/13/2023, eleven days after admission. DON-B stated R247 would not allow DON-B to assess R247's backside and that was documented. Surveyor shared with DON-B R247 had incontinence cares completed with bowel movements and had cares completed twice daily when R247's backside would have been exposed. DON-B agreed those would have been opportunities to see R247's skin. Surveyor shared with DON-B the concern the assessment documentation completed by RDWM-J on 6/13/2023 did not reflect the observations made at the same time by Surveyor regarding the amount of bleeding, RDWM-J documented moderate serosanguineous drainage when there was copious amounts of active bleeding, or in the description of the wounds to the left buttock, only charting the multiple wounds as one wound. 2) The facility's policy and procedure for Skin Integrity-Skin Tears, dated 3/1/19 was reviewed by Surveyor. The policy indicates a systematic approach for the prevention and management of skin tears. This includes assessment, care planning, monitoring, and modification of interventions as appropriate. Surveyor reviewed R146's medical record which documents: Note on 11/1/22, at 5:23 AM, states R146 had an unwitnessed fall on 11/1/22, at 4:35 AM. R146 obtained a skin tear on the right lower leg. There is no documentation of an assessment or treatment of the skin tear in the medical record. On 11/1/23, at 5:16 AM, the Progress Note indicates R146 is confused and hallucinating. R146 obtained a minor skin tear to the right lower leg and right great toe. Due to R146's change in behavior with the fall they are sent out to the hospital. Surveyor notes R146's medical record does not have a documented assessment of the skin tear and abrasion R146 obtained from the fall. R146's hospital notes from 11/1/22 visit were reviewed by Surveyor. The hospital ER (emergency room) assessment notes a skin tear on the right lower leg that does not require stitches. There is also an abrasion on the small right toe. The Hospital Summary for 11/1/22 indicates to keep skin tear clean, wash daily, and cover with a band aid. R146's Treatment Administration Record for 11/22 was reviewed, along with the physician plan of care. There is no treatment order documented for the right lower leg skin tear or the right small toe abrasion. On 06/14/23, at 9:07 AM, Surveyor spoke with DON-B (Director of Nurses). R146's medical record was reviewed during this interview. DON-B agreed there was no skin assessment nor treatment documented for the right lower leg and right small toe. There was no further information provided. On 6/14/23, at 9:31 AM, Surveyor spoke with LPN/UM-E (Licensed Practical Nurse) who is also the Unit Manager. R146's medical record was reviewed during this interview. There was no skin assessment nor treatment documented for the right lower leg and right small toe. On 6/14/23, at 2:50 PM, at the Facility Exit Meeting, Surveyor shared the concerns of no skin assessments and treatments documented for F146's right lower leg skin tear and right small toe abrasion. 3) R97 was admitted to the facility on [DATE]. Diagnoses includes end stage renal disease, diabetes mellitus with foot ulcer, heart failure, hypertension, and dependence on renal dialysis. The hospital Discharge summary dated [DATE] under principle diagnosis includes Bilateral diabetic foot ulcers without infection. The Clinical admission assessment dated [DATE] is checked for diabetic foot ulcer(s). The physician orders dated 6/3/23 documents, Left dorsal foot: Wash with soap/water, pat dry. Apply Iodosorb f/b (followed by) secondary dry dressing. Change daily and prn (as needed.) Every evening shift for wound care. Review of R97's June TAR (treatment administration record) reveals the treatment is not initialed as being completed on 6/6/23, 6/8/23, 6/9/23, 6/11/23, 6/12/23, & 6/13/23. The physician order dated 6/3/23 documents Right hallux (big toe): Wash with soap and water, pat dry. Apply Iodosorb f/b dry dressing. Change 3x's (three times)/week on AM (day shift) M-W-F (Monday-Wednesday-Friday) and prn (as needed) every evening shift every Mon, Wed, Fri for wound care. Review of R97's June TAR (treatment administration record) reveals the treatment is not initialed as being completed on 6/9/23 & 6/12/23. The Skin Only Evaluation dated 6/3/23 documents, Skin: Skin Issue: #001: New. Issue type: Erythema and warmth. Location: Chest - generalized. Painful: Yes - episodic pain. Erythema present on surrounding skin. Skin Issue: #002: New. Issue type: Other skin issue. Location: Right lower leg. Other skin issue description: Scattered dry wounds. Wound odor: No. Tunneling: No. Painful: No. Skin Issue: #003: New. Issue type: Other skin issue. Location: Right foot. Other skin issue description: mix of granular tissue and dry blood. Wound odor: No. Tunneling: No. Painful: No. Skin Issue: #004: New. Issue type: Other skin issue. Location: Left lower leg. Other skin issue description: Scattered dry wounds. Wound odor: No. Tunneling: No. Undermining: No. Painful: No. Skin Issue: #005: New. Issue type: Other skin issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6.) R15 was admitted to the facility on [DATE] with diagnoses of dementia, diabetes mellitus and weakness. R15 was admitted to the facility with an unstageable pressure injury to the right heel. On 6/13/23, at 1:31 PM, R15 was observed in bed. R15's heels were lying directly on their mattress. No pressure relieving boots were in place and heels were not offloaded. On 6/13/23, at 3:35 PM, R15 was observed in bed. R15's heels were lying directly on their mattress. No pressure relieving boots were in place and heels were not offloaded. On 6/13/23, at 1:55 PM, Surveyor conducted interview with CNA-H. Surveyor asked if a resident has pressure injuries on their feet what kind of interventions should be in place. CNA-H told Surveyor sometimes residents will wear heel boots or have their heals floated if they have sores on their feet. On 6/14/23, at 7:33 AM R15 was observed up in their wheelchair in unit common area. R15's heels were observed directly on wheelchair's footrests. No pressure relieving boots were in place. On 6/13/23, Surveyor reviewed R15's skin integrity comprehensive care plan. Pressure ulcer at risk due to: decreased mobility L (left) Heel ulcer present on admit Care plan interventions initiated on 5/29/23 include: Complete Braden Scale per Living Center Policy Date, Conduct weekly skin inspection, Evaluate need for pain reliever prior to cleansing or dressing changes, Provide pressure reducing wheelchair cushion. Surveyor noted additional interventions initiated on 6/14/23 including: Float heels, Heel boots on while in bed and in wheelchair, Turning/repositioning every 2-3 hours. Surveyor noted care plan revisions were initiated by Regional Director of Wound Management-J. On 6/14/23, at 2:55 PM, Surveyor conducted interview with Regional Director of Wound Management-J. Surveyor asked Regional Director of Wound Management-J if residents with pressure injuries on their feet should have their feet directly on surfaces such as foot rests or their bed mattress. Regional Director of Wound Management-J told Surveyor that their heels should be floated or they should have pressure relieving boots in place. Surveyor asked Regional Director of Wound Management-J why R15's comprehensive skin integrity care plan did not have interventions in place for their right heel pressure injury until today, 6/14/23. Regional Director of Wound Management-J did not provide any additional information to Surveyor at this time. On 6/15/23, at 3:33 PM, Surveyor conducted interview with Director of Nursing (DON)-B related to R15's pressure injury. Surveyor asked DON-B if residents with pressure injuries should have their heels floated or have pressure relieving boots in place. DON-B replied Yes that is correct. Surveyor reviewed R15's pressure injury assessments from 5/27/23-6/13/23. Surveyor noted from 6/3/23 to 6/13/23, the facility did not assess the status of R15's right heel pressure injury. On 6/19/23, at 10:55 AM, Surveyor conducted interview with NHA-A and DON-B. Surveyor shared concerns related to observations of R15's pressure injury interventions not being in place on 6/13/23 & 6/14/23. Surveyor also shared concerns of the facility's missing pressure injury assessment from 6/3/23 through 6/13/23. The facility did not have any additional information to share at this time. 5.) R245 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, chronic respiratory failure, morbid obesity, and depression. R245 had not been in the facility long enough to have a Minimum Data Set (MDS) assessment completed at the time of survey. R245's Braden score was 16 placing R245 at risk for pressure injuries. On 6/5/2023, at 4:52 PM, on the Skin Only Evaluation in the progress notes, nursing charted R245 had a pressure injury to the coccyx that measured 1.3 cm (centimeter) x (by) 1 cm with no depth documented. The pressure injury was not staged and did not have any description of the wound bed. On 6/6/2023 an order for a treatment to the coccyx pressure injury was initiated from the hospital discharge summary: clean with soap and water, pat dry, apply Calmoseptine or equivalent to wound bed twice daily and as needed if soiled or saturated. This treatment order was discontinued on 6/11/2023. R245's Pressure Ulcer Care Plan was initiated on 6/6/2023 with the following interventions: -Complete Braden Scale per facility policy. -Conduct weekly skin inspection. -Monitor vital signs as needed. -Provide thorough skin care after incontinent episodes and apply barrier cream. -skin assessment to be completed per facility policy. On 6/7/2023 on the Skin and Wound Evaluation form, Director of Nursing (DON)-B completed an assessment of R245's coccyx pressure injury. DON-B charted the Stage 2 pressure injury measured 1.2 cm x 0.6 cm with depth not applicable with 100% granulation and moderate serous drainage. R245's Pressure Ulcer Care Plan was revised on 6/8/2023 to include the following interventions: -Air mattress placed on bed. -Heel boots. -Provide pressure reducing wheelchair cushion. -Turn and reposition every 2-3 hours. On 6/8/2023 the treatment order was changed to clean with normal saline, pat dry, apply xeroform and cover with a foam dressing daily. Surveyor reviewed the Treatment Administration Record (TAR) and noted R245 had two treatments at the same time to the coccyx from 6/8/2023 until 6/11/2023 when the original order for Calmoseptine was discontinued. Surveyor was unable to determine if R245 was getting both treatments from 6/8/2023 through 6/11/2023. On 6/13/2023, at 9:16 AM, Surveyor met with Nursing Home Administrator (NHA)-A and requested to see R245's wound care when staff were going to be completing the treatment or on wound rounds. NHA-A stated wound rounds were being completed that day by Regional Director of Wound Management (RDWM)-J and would let RDWM-J know of Surveyor's request. On 6/13/2023, at 10:45 AM, Surveyor met with RDWM-J to observe wound care to R245. RDWM-J stated DON-B does the initial wound assessment when a resident is first admitted and also does the weekly wound rounds when RDWM-J is not available. RDWM-J stated RDWM-J had not observed or completed R245's wound care since R245 had been admitted . R245 was not in the room at the time as R245 was attending a therapy session. Surveyor arranged with RDWM-J to observe the treatment when R245 was back on the unit. On 6/13/2023, on the Skin and Wound Evaluation form, RDWM-J charted R245's Stage 2 pressure injury to the coccyx measured 1.0 cm x 0.5 cm x 0.1 cm with 100% granulation and moderate serosanguinous drainage. R245 was sent out to the hospital on 6/14/2023 for respiratory distress. Surveyor was unable to observe R245's pressure injury. On 6/19/2023, at 10:46 AM, Surveyor met with DON-B and shared the concern R245 had a Stage 2 pressure injury that was not comprehensively assessed until 6/7/2023, two days after admission and care plan interventions were not initiated until 6/8/2023 to address the pressure injury that R245 was admitted with. DON-B agreed the wound should have been assessed on admission and stated the facility was trying to find a wound nurse to manage the wounds in the facility since DON-B was currently responsible for doing the wound rounds and assessing new residents. No further information was provided at that time. Based on observations, interviews and record review the facility did not ensure that residents received care consistent with professional standards of practice to prevent pressure injuries and did not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 6 of 7 (R197, R21, R199, R22, R245, R15) residents reviewed for pressure injuries. R197 admitted to the facility without pressure injuries and was identified to be at risk. No preventative care plan (CP) interventions to offload heels were implemented. The resident developed a Suspected Deep Tissue Injury (SDTI) to the right heel, which R197 described as hurts so bad. There was a delay in treatment and Surveyor had observations care plan interventions not in place while on survey. R21's pressure injury incurred a delay in treatment and observations on survey of care plan interventions not in place. R199's pressure injury incurred a delay in assessment and treatment. R22's pressure injury was missing comprehensive assessments, incurred a delay in treatment and documented conflicting staging of the pressure injury. R245's pressure injury was not comprehensively assessed upon admission. R15's pressure injury did not have weekly comprehensive assessments and observations on survey of care plan interventions not in place. R197 is being cited at severity level 3 (actual harm). Findings include: The facility Policy and Procedure titled Pressure Injury Prevention implemented 3/1/19 documented (in part) . Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present. Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care. 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify physician to obtain orders. 5. Prevention devices will be utilized in accordance with manufacturer recommendations (e.g., heel floatation devices, cushions, mattresses). 6. Guidelines for prevention may be utilized in obtaining physician orders. a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. When physician orders are present, the facility will follow the specific physician orders. 7. Interventions will be documented in the care plan and communicated to all relevant staff. 8. Compliance with interventions will be documented in the medical record. a. For at-risk residents: Treatment or medication administration records. B. For residents who have a pressure injury present: Treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure injury. b. Lack of progression towards healing or changed in wound characteristics. c. Changes in the resident's goals and preferences, such as end-of-life or in accordance with his/her rights. The facility policy titled Wound Management dated 10/28/21 documents (in part) . Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 4. Dressings will be applied in accordance with manufacturer recommendations. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound. c. Changes in the resident's goals and preferences, such as end-of-life or in accordance with his/her rights. 1.) R197 admitted to the facility on [DATE] and has diagnoses that include displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture, spondylosis without myelopathy or radiculopathy, cervical region and mild protein-calorie malnutrition. R197's Braden Scale for Predicting Pressure Sore Risk dated 5/26/23, documents a score of 15 indicating R197 is at risk for pressure injuries. R197's Braden score dated 6/3/23 documented a score of 14 - moderate risk for pressure injuries. R197's Clinical admission skin assessment dated [DATE] documented: Skin baseline: Skin warm and dry, skin color WNL (within normal limits), turgor normal met. Surveyor noted there were no skin areas of concern marked on the picture of the body on the form. R197's skin only evaluations dated 5/26/23 and 5/31/22 had no documentation of pressure injuries. R197's admission MDS (Minimum Data Set) dated 5/29/23 documents: Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture - as extensive assistance 2 plus person physical assist. Transfer - how resident moves between surfaces including to or from bed, chair, wheelchair, standing position (excludes to/from bath/toilet) - as extensive assistance 2 plus person physical assist. Functional Limitation in Range of Motion: Upper extremity (shoulder, elbow, wrist, hand) impairment on 1 side, Lower extremity (hip, knee, ankle, foot) - impairment on 1 side. R197's Care Plan Focus area dated 5/29/23 documents: I have a physical functioning deficit related to: Mobility impairment, Self care impairment. Interventions include: - Bed mobility assistance of ( ) (Nothing entered) - Call bell within reach - I require mod (moderate) assist x 2 to complete transfers - I require total assist to complete personal hygiene Care plan Focus area dated 5/29/23 documents: Pressure ulcer actual or at risk due to: Right hip fracture s/p (status post) ORIF (Open Reduction Internal Fixation). Interventions include: - Complete Braden Scale per Living Center Policy - Conduct weekly skin inspection - Nutritional and Hydration support - Provide pressure reducing wheelchair cushion - Provide thorough skin care after incontinent episodes and apply barrier cream - Air mattress date Initiated: 6/9/23 - Heel boots date Initiated: 6/9/23 Care plan Focus area dated 6/8/23 documents: Pressure ulcer actual: DTI (Deep Tissue Injury) right heel. Interventions include: - Evaluate need for pain reliever prior to cleansing or dressing changes - Float heels - Provide pressure reducing wheelchair cushion - Provide pressure reduction/relieving mattress - Treatments as ordered - Turning and repositioning every 2-3 hours - Weekly wound assessment Surveyor noted R197 was identified to be at risk for pressure injuries and require extensive physical assistance of 2 persons for bed mobility, however, the care plan did not include interventions of turning and repositioning or offloading of heels until after the SDTI (Suspected Deep Tissue Injury) developed on the right heel. Review of R197's medical record revealed an E-interact form dated 6/3/23 which documented: Pressure ulcer/injury - New onset Grade 2 or higher pressure ulcer/injury. Right heel slightly purple in the center, reddened around the area is blanchable, no open skin noted. [She] has stage one to right heel 3 cm (centimeters) x 3 cm with purple in the center .8 x .3 skin prep to heel BID (twice daily). R197's Point Click Care wound evaluation dated 6/7/23 documented: Pressure - DTI right heel in house acquired. 1.9 x 2.2 cm. Wound bed: Purple tissue. Treatment: skin prep. Additional care: cushion, mattress with pump, other,specify: float heels. R197's June, 2022 Medication Administration Record (MAR) documented: Skin Prep wipes miscellaneous (ostomy supplies) Apply to Rt (right) heel topically one time a day for DTI - order date 6/9/23. Surveyor noted a 1 week delay in treatment of R197's right heel DTI. R197's right heel DTI was identified on 6/3/23 and no treatment was ordered until 6/9/23 and treatment was not started until 6/10/23. In addition, R197's care plan was not revised to include turning and repositioning every 2-3 hours and offload heels until 6/8/23, 5 days after the DTI was identified even though R197 was identified to be at risk for the development of pressure injuries upon admission to the facility on 5/26/23. On 6/12/23, at 10:21 AM, Surveyor observed R197 lying in bed on her back. Surveyor noted an air mattress on the bed and R197 was wearing Prevalon boots on both feet. On 6/12/23, at 1:12 PM, Surveyor observed R197 lying in bed with the head of bed elevated and a meal tray on the tray table in front of her. Surveyor observed R197's heels were not offloaded, her heels were resting directly on the mattress and the Prevalon boots were on the dresser in the corner. Surveyor asked R197 if she is able to lift her right leg off the bed. R197 attempted to lift her leg off the bed, but was unable, stating: I just can't do anything anymore. R197 informed Surveyor she needed to be up higher to eat. Surveyor encouraged her to put the call light on, which she did. Within 30 seconds, the facility Social Worker (unknown name) entered the room to answer the light. R197 asked for chicken soup or broth. The Social Worker left the room, but did not turn the call light off. On 6/12/23, at 1:17 PM, Certified Nursing Assistant (CNA)-DD entered R197's room to answer the call light. Surveyor heard another staff member say someone is getting her some chicken soup. R197 informed CNA-DD she did not want anything else on her tray and CNA-DD removed the tray from her room. Surveyor noted although R197's heels remained resting directly on the mattress and the Prevalon boots were on the dresser, R197 was not repositioned to offload their heels. On 6/12/23, at 1:19 PM, The Social Worker returned to R197's room with soup/broth. The Social Worker advised another staff member R197 needed a spoon, as their tray had been removed. On 6/12/23, at 1:20 PM, CNA-DD brought R197 a plastic spoon and left the room. Surveyor observed R197 struggling to eat the soup stating: I can't reach it and I can't even keep the soup on this spoon. Surveyor asked CNA-DD (in hall) to accompany to R197's room. R197's told CNA-DD she needed to be up higher and couldn't reach her soup. CNA-DD left the room to find assistance. On 6/12/23, at 1:23 PM, Surveyor observed CNA-DD and another staff member enter R197's room. After the staff members left R197's room, Surveyor noted R197 to be positioned more upright to eat, however, Surveyor noted R197's heels remained resting directly on the mattress and the Prevalon boots were in the corner. On 6/12/23, at 1:28 PM, Surveyor observed R197 taking sips of the chicken broth. R197 remained positioned upright with the head of bed elevated. Surveyor noted R197's heels remained resting directly on the mattress and the Prevalon boots remained on the dresser. On 6/13/23, at 7:58 AM, Surveyor spoke with R197 and asked how they were feeling today. R197 stated: OK, but my right heel hurts so bad, I can't understand why. Surveyor observed R197 to be wearing Prevalon boots on both feet. On 6/13/23, at 11:44 AM, Surveyor observed R197 lying in bed on her back with her head on a pillow. Surveyor observed the Prevalon boots on the dresser. Surveyor observed R197 to be wearing socks and a pillow under R197's calves, however the pillow was flat and both of her heels were resting directly on the mattress. On 6/13/23, at 1:54 PM, Surveyor advised Director of Nursing (DON)-B of concern R197's DTI was identified on 6/3/23, but no treatment was implemented until 6/10/23. DON-B reported she would look and gather all information to review. No additional information was provided. On 6/13/23, at 2:35 PM, Surveyor observed R197's wound care with Nurse Manager-I and Regional Director of Wound Management-J. Nurse Manager-I removed R197's blanket revealing the flat pillow under R197's calves and heels resting directly on the mattress. Surveyor asked Nurse Manager-I if R197 should have their heels offloaded. Nurse Manager-I stated: Yes, she should be wearing her boots, I don't know why they're not on, they're right there (pointing at Prevalon boots on the dresser). Nurse Manager-I removed R197's right sock revealing a dark purple DTI to the right medial heel with redness surrounding the peri wound. Regional Director of Wound Management-J utilized her phone to obtain a picture and measurements of the pressure injury which measured 1.7 x 1.9 cm. Observation of R197's left heal revealed no signs or symptoms of pressure injury. On 6/14/23, at 10:26 AM, Surveyor observed R197 sitting up in her wheelchair, dressed, wearing regular socks. R197's heels were not offloaded, both feet were resting directly on the foot pedals. Surveyor observed the Prevalon boots on the dresser in R197's room. On 6/14/23, at 1:19 PM, Surveyor spoke with DON-B. Surveyor advised DON-B of the following concerns: R197 admitted to the facility with no pressure injuries, and was identified to be at risk. She was dependent for bed mobility and unable to lift her right leg off the bed. There were no care plan interventions for turning/repositioning or offloading of heels to prevent pressure until after the DTI developed. The DTI was identified on 6/3/23, however no treatment was implemented until 6/10/23. The initial assessment on 6/3/23 documented the area as stage 1 although listed as purple in center. Reddened surrounding skin documented as blanchable, but no mention of blanching of the purple area. Surveyor asked how she would expect the area to be staged. DON-B stated: It should have been documented as a SDTI. Surveyor advised DON-B of observations on survey: R197 not wearing Prevalon boots, heels not offloaded/lying directly on the mattress and resting directly on foot pedals. DON-B reported she understands the concerns and has already done education with nursing staff. 2.) R21 admitted to the facility on [DATE] with Hospice services and has diagnoses that include acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure and morbid obesity. R21's Braden Scale for Predicting Pressure Sore Risk dated 4/28/23 documented a score of 16 - at risk. R21's admission Minimum Data Set (MDS) dated [DATE] documents bed mobility and transfer as limited 1 person assist. Functional limitation in ROM (range of motion) - no impairment. R21's Care plan Focus area dated 4/30/23 documents: Pressure ulcer actual due to: Pressure Ulcer Present on coccyx. Interventions include: - Float heels - Notify practitioner if symptoms worsen or do not resolve - Provide pressure reducing wheelchair cushion - Complete Braden Scale per Living Center Policy - Provide thorough skin care after incontinent episodes and apply barrier cream - Weekly Wound assessment R21's medical record indicated R21 was admitted to the facility with a stage 2 pressure injury to the coccyx. Progress notes document: 4/28/23, Resident arrived to facility @1140 (11:40 AM) via ambulance, resident is officially [Name of hospice provider] Hospice Care. She is A/O (alert and oriented) x 1/2 forgetful, denies pain at this time. Observed pressure ulcer injury to coccyx wound bed is pink and moist, linear in shape, has minimal serous drainage noted. 100% granulation and measurement is 2.0 x 1.5 x 0.1. R21's April 2022 Treatment Administration Record (TAR) documented wound care orders dated 4/30/23: Coccyx wound: Cleanse with NS (normal saline) F/B (followed by) medi honey F/B gauze island daily and prn (as needed) soiling as needed for wound care. Surveyor noted R21 admitted on [DATE] with a stage 2 pressure injury, however treatment orders were not obtained until 4/30/23. In addition, the treatment was entered on the TAR as PRN and not scheduled for a specific time or shift, thus the treatment was not signed out as having been completed on 4/30/23. R21's May 2022 TAR documented the coccyx treatment: Cleanse with NS F/B medi honey F/B gauze island daily and prn soiling in the evening for wound care scheduled for 8:00 PM. Surveyor noted several missing signatures indicating the treatment was either not completed or not documented. On 5/22/23 the treatment was changed to barrier cream every shift for wound care. Measurements on 5/25/23 were 1.0 x 0.6 no depth. On 6/4/23 measurements were 1.0 x 0.6 no depth. (The wound has decreased in size.) On 6/12/23, at 10:48 AM, Surveyor observed R21 sitting on a pillow in her wheelchair and not a pressure reducing cushion as indicated on her care plan. On 6/12/23, at 2:29 PM, Surveyor observed R21 sitting on a pillow in her wheelchair and not a pressure reducing cushion as indicated on her care plan. On 6/14/23, at 9:50 AM, Surveyor observed R21 sitting on a blue cushion in a wheelchair. Surveyor asked about the cushion. R21 stated: They just gave that to me. I had one awhile ago, but I don't know what happened to it, so I was using the pillow to sit on. On 6/14/23, at 1:19 PM, Surveyor advised Director of Nursing (DON)-B of concerns regarding R21 pressure injury: Resident admitted with stage 2 pressure injury to the coccyx on 4/28/23. No treatment was ordered until 2 days later on 4/30/23 and treatment was not implemented on the TAR until 5/1/23. Observations on survey of care plan interventions/pressure reducing cushion not on wheelchair, observed resident sitting on pillow. DON-B reported she understands the concerns and has already done education with nursing staff. 3.) R199 admitted to the facility on [DATE] receiving Hospice services and has diagnoses that include encephalopathy, secondary malignant neoplasm of brain, generalized idiopathic epilepsy and personal history of other diseases of the digestive system. R199's Braden Scale for Predicting Pressure Sore Risk dated 6/5/23 documented a score of 21 - not at risk, although R199 admitted to the facility with a stage 2 pressure injury. R199's Braden Scale for Predicting Pressure Sore risk dated 6/12/23 documented a score of 10 - high risk. R199's Care Plan Focus area dated 6/8/23 documents: Pressure ulcer at risk due to: Decreased mobility. Stage 2 to coccyx upon admit. Interventions include: - Float heels - Provide pressure reducing wheelchair cushion - Provide pressure reduction/relieving mattress - Turning and repositioning schedule per assessment R199's medical record indicated R199 was admitted with a stage 2 pressure injury to the coccyx. R199's Clinical admission form dated 6/5/23 documented: Location - coccyx. Skin issue - Pressure ulcer/injury. Surveyor noted there was no description, staging, or measurements of the wound. R199's Point Click Care/Electronic Medical Record wound evaluation dated 6/7/23 documented: Stage 2 Pressure Injury coccyx present on admission. 3.7 x 1.9 cm (centimeters), 100% granulation. On 6/12/23, at 10:33 AM, Surveyor observed R199 lying in bed on their back, asleep. An air mattress was on the bed and their heels were offloaded on a pillow. On 6/13/23, at 8:59 AM, Surveyor observed R199 lying in bed on his back, asleep. Care plan interventions of air mattress and offloading heels were in place. R199's June 2022 Treatment Administration Record (TAR) documented wound care orders dated 6/8/23: Coccyx wound: Cleanse with NS (normal saline) F/B (followed by) medi honey F/B foam border every day shift for wound care, which was not signed out as completed - D/C (discontinue) date of 6/9/23. Coccyx wound: Cleanse with NS F/B medi honey F/B foam border every evening shift for wound care - order date 6/9/23. Surveyor noted R199 admitted on [DATE] with a stage 2 pressure injury, however treatment orders were not obtained until 6/8/23 and not implemented on the TAR until 6/9/23. On 6/13/23, at 1:47 PM, Surveyor advised DON-B of concerns regarding R199's pressure injury: R199 admitted to the facility on [DATE] with a pressure injury. There was no assessment, staging or measurements of the wound upon admission. Treatment for the pressure injury was not ordered until 6/8/23 and not implemented until 6/9/23. R199's admission Braden score indicated a score of 21- not at risk, although R199 admitted to the facility with a pressure injury. DON-B stated: Yeah, that's not right. DON-B looked at the TAR and stated: I see that, maybe they were just using barrier cream until a treatment was ordered. DON-B reported an LPN (Licensed Practical Nurse) identified the pressure injury on 6/5/23, but did not stage or measure the wound. I came in a couple of days later on the 7th and did my assessment and measurements and ordered a new treatment, but I see that it didn't get started until the 9th. DON-B reported she understands the concerns and has already done education with nursing staff. 4.) R22 was admitted to the facility on [DATE]. Diagnoses includes diabetes mellitus, hypertension, heart failure, atrial fibrillation, chronic kidney disease, and depression. R22 was discharged on 6/13/23. The hospital Discharge summary dated [DATE] under primary discharge diagnoses includes Stage 4 pressure ulcer on coccyx, POA (present on admission). The Braden assessment dated [DATE] has a score of 21 which indicates not at risk for the development of pressure injuries. The clinical admission dated 5/23/23 includes documentation of Skin: Skin warm & dry, skin color WNL (within normal limit) and turgor is normal. Skin Issue: #001: New. Issue type: Pressure ulcer/ injury. Location: Coccyx (Back of body above buttocks). Skin Issue: #002: New. Issue type: Other skin issue. Location: Left shin. Other skin issue description: healed venous ulcer. Wound odor: No. Painful: No. Skin Issue: #003: New. Issue type: Pressure ulcer/ injury. Location: Right heel. Painful: No. Skin Issue: #004: New. Issue type: Bruising. Location: Left anterior elbow. Painful: No. Skin note: drsg (dressing) intact and dry to Rt (right) heel and coccyx, healed venous ulcer The physician's order with an order date of 5/24/23 documents, Coccyx wound: Cleanse with normal saline f/b (followed by) Acticoat f/b dry dressing 3x (times) a week and prn every day shift every Mon (Monday), Wed (Wednesday), and Fri (Friday) for wound care. Surveyor noted R22 was admitted on [DATE] and the treatment for R22's coccyx did not start until 5/26/23, 3 days later. Review of R22's May 2023 TAR (treatment administration record) reveals the treatment is not initialed as being completed on 5/29. Review of R22's June 2023 TAR reveals on 6/9 code 7 is documented. 7 is other/see nurses notes. The EMAR (electronic medication administration note) dated 6/7/23 documents, Patient not in her room. The physician's orders with

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) R6 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left-Dominant Side, Sleep Apnea, Insomnia, Other Idiopathic Scoliosis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Other Obsessive-Compulsive Disorder, Unspecified Attention-Deficit Hyperactivity Disorder, and Other Psychoactive Substance Abuse. R6 is currently their own responsible party. R6's 5 day Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status(BIMS) score to be a 14, indicating R6 is cognitively intact for daily decision making. R6's MDS also documents R6 requires extensive assistance of 2 staff for bed mobility and transfers. R6 requires extensive assistance of 1 staff for dressing and toileting and has range of motion (ROM) impairment on 1 side for both upper and lower extremities. R6 has 2 Fall Risk Evaluations completed with the following scores. A score of 10 or higher indicates a Resident is high risk for falls. 4/19/23-Fall Risk Evaluation with a score of 5 5/23/23-Fall Risk Evaluation with a score of 3 Surveyor notes R6 has not had any documented falls since admission. Surveyor reviewed R6's comprehensive care plan and notes the following related to R6's risk for falls: -At risk for falls related to CVA (Cerebrovascular Accident)-initiated 4/22/23 with the intervention of bed in low position -At risk for falls related to: use of medication, stroke-initiated 5/24/23 with the intervention of bed in low position On 6/4/23, R6's medical record documents by the nurse practitioner treating R6 has high risk for falls if not receiving adequate therapy and pain control. On 6/12/23, at 11:11 AM, Surveyor observed R6 to be in bed, head of bed elevated and bed is in not in a low position. On 6/13/23, at 7:19 AM, Surveyor notes R6's Kardex Bedside Report as of 6/13/23 documents R6's bed is to be in the low position. At this time, Surveyor observed R6 in bed, and R6's bed is not in the low position. On 6/14/23, at 7:11 AM, Surveyor observed R6 in bed, head of bed is elevated and R6's bed is not in the low position. On 6/14/23, at 9:48 AM, Surveyor observed R6 to be in bed, head of bed is elevated and R6's bed is not in the low position. On 6/14/23, at 9:53 AM, Surveyor interviewed Certified Nursing Assistant(CNA-Q). Surveyor asked CNA-Q if R6's bed should be in the low position and CNA-Q informed Surveyor that she does not believe so. Surveyor had CNA-Q observe R6's bed at this time, and CNA-Q confirmed R6's bed was not in the low position. On 6/14/23, at 10:45 AM, Surveyor interviewed Licensed Practical Nurse(LPN)-I who is the unit manager on R6's unit. LPN-I confirmed R6's care card documents R6's bed should be in the low position. LPN-I confirmed R6 is a risk for falls, therefore R6's bed should be in the low position. LPN-I is not aware of R6 refusing to have the bed in the low position. LPN-I stated if the low bed is added to the care plan it should be followed. LPN-I agreed if the bed is not in low position, it's not following the care plan and care card and puts R6 at risk for an accident. LPN-I will check on R6's low bed status. On 6/14/23, at 3:03 PM, Surveyor shared with Administrator (NHA)-A and Director of Nursing (DON)-B the concern R6's care plan and Kardex document the fall prevention intervention of having R6's bed in the low position and Surveyor's observations of R6's bed no being in the low position 3 days. 3) R246 was admitted to the facility on [DATE] with diagnoses of compression fracture of the fourth lumbar vertebra, morbid obesity, anxiety, and Alzheimer's disease. R246 had not been in the facility long enough to have a Minimum Data Set (MDS) assessment completed at the time of survey. R246's At Risk for Falls Care Plan was initiated on 6/3/2023 with the following interventions: -Assess for pain. -Assess that the wheelchair is of the appropriate size; assess need for footrests; assess for need to have wheelchair locked/unlocked for safety. -Elevated toilet seat. -Encourage fluids. -Encourage rest periods of feeling fatigued. -Footwear to prevent slipping. -Gait belt with transfers. On 6/5/2023, at 4:12 AM, on the Post Fall Evaluation in the progress notes, nursing charted R246 had an unwitnessed fall on 6/4/2023 at 10:45 PM in R246's room when R246 was attempting to go to the bathroom. R246 had bare feet and was not using a cane or walker as instructed. R246 did not have oxygen on as ordered and the call light had not been activated. An incident report was initiated indicating R246 was found on the floor soaking wet and R246 stated R246 was coming back from the bathroom and fell. R246 was educated on using the call light and no self-transferring. On 6/5/2023, at 12:53 PM, on the Post Fall Evaluation in the progress notes, Licensed Practical Nurse (LPN)-F charted R246 had an unwitnessed fall on 6/5/2023 at 10:44 PM. In an interview with LPN-F on 6/14/2023 at 1:19 PM, LPN-F clarified the fall had occurred at 10:44 AM and not 10:45 PM as documented. R246 was attempting to go to the bathroom unassisted. R246 had bare feet and was not using a cane or walker as instructed. R246 did not have oxygen on as ordered and the call light had not been activated. An incident report was initiated by LPN-F indicating R246 was found sitting on the buttocks on the floor next to the bed and R246 stated R246 was trying to get up to go to the bathroom and slipped and fell. R246's At Risk for Falls Care Plan was revised on 6/5/2023 with the following interventions: -Offer toileting upon wakening, after meals, and before bed. -Offer activities of residents liking. On 6/7/2023, at 11:59 AM, on the Post Fall Evaluation in the progress notes, LPN-F charted R246 had an unwitnessed fall in the bathroom on 6/7/2023 at 11:00 AM when R246 self-transferred and tripped and fell. R246 was wearing shoes at the time of the fall. R246 was not using a cane or walker as instructed and did not have oxygen on as ordered. The call light had not been activated. An incident report was initiated by LPN-F indicating R246 was found sitting on the buttocks on the bathroom floor and R246 stated R246 got up to use the bathroom and tripped and fell. R246 was confused at baseline and did not use call light appropriately for needs per staff. R246's At Risk for Falls Care Plan was revised on 6/8/2023 with the intervention to have gripper socks at all times. Surveyor noted this intervention did not address the cause of the fall on 6/7/2023 as R246 was wearing shoes at the time of the fall. Surveyor reviewed R246's medical record. No interdisciplinary team (IDT) notes were found for R246's falls on 6/4/2023, 6/5/2023, or 6/7/2023 showing R246's At Risk for Falls Care Plan was reviewed for appropriate interventions and a root cause analysis was completed to determine what interventions should be initiated to prevent future falls. On 6/12/2023, at 11:13 AM, Surveyor observed R246 in R246's room. R246 was lying in bed with a gown on, which R246 stated was by choice. R246's bed was in a low position and the wheelchair was close to the bed. R246 stated R246 had to go to the bathroom. Surveyor asked R246 if R246 could push the call light for help. R246 located the call light and pushed the button. A Certified Nursing Assistant (CNA) came into the room and asked R246 if R246 needed anything. R246 could not recall that R246 had wanted to go to the bathroom. When the CNA asked R246 if R246 needed to use the bathroom, R246 was not sure. The CNA asked R246 if R246 wanted to use a bed pan. R246 said yes. When the bed pan was provided, R246 refused to use it and stated R246 wanted to go into the bathroom. The CNA assisted R246 to the bathroom. In an interview on 6/14/2023, at 1:19 PM, Surveyor asked LPN-F what the facility process was when a resident had a fall. LPN-F stated whoever finds a resident on the floor leaves them there and gets the nurse to do an evaluation. LPN-F stated the nurse would get vital signs, do neurological checks, check range of motion, and inspect the skin for bleeding or injury. LPN-F stated neurological checks are completed at the time the resident is found and then every 15 minutes for an hour, every 30 minutes for an hour, every hour for four hours, and then the resident is put on the 24-hour board to be monitored every shift. Surveyor asked LPN-F about R246's falls that LPN-F was involved with on 6/5/2023 and 6/7/2023. LPN-F stated R246 has Alzheimer's dementia and has had multiple conversations with the family to get ideas of what to do to keep R246 safe. LPN-F stated after the fall, LPN-F would bring R246 out to the nurses' station while doing all the vital signs and neurological checks to keep an eye on R246 and even then, R246 would walk away. Surveyor asked LPN-F who updates the Fall Care Plan after a resident has a fall. LPN-F stated as the nurse on the floor, they would look at the circumstances of the fall and decide what to do for the resident. LPN-F stated with R246 a very low bed and a fall mat would not be good interventions because R246 gets up and walks and you do not want to have a tripping hazard. LPN-F stated LPN-F tried to implement a lower bed, but R246 is not always compliant. LPN-F stated sometimes R246 does not like to wear shoes, so the gripper socks were an alternate choice for R246. Surveyor asked LPN-F if there is an IDT that meets to review falls. LPN-F stated falls are talked about every morning during the morning report and every Thursday there is an IDT for falls. In an interview on 6/14/2023, at 1:30 PM, Surveyor asked LPN Unit Manager (UM)-E if there is an IDT that reviews falls and how often the IDT meets. LPN UM-E stated the IDT meets every week to review falls. LPN UM-E stated they look at the reason for the fall: if the resident needed to use the bathroom, if the resident has confusion, or what the resident was wearing or not wearing. With that information they determine an intervention that is appropriate. Surveyor reviewed with LPN UM-E R246's falls. LPN UM-E stated after R246 fell on 6/4/2023 the intervention was added to offer toileting after meals and before bed. LPN UM-E stated after the fall on 6/5/2023 the intervention was added to have gripper socks on because R246 had bare feet. Surveyor shared with LPN UM-E the intervention of having gripper socks on was not added to the Falls Care Plan until 6/8/2023, after R246 fell on 6/7/2023 while wearing shoes. LPN UM-E could not recall any other information about the fall reviews and stated there was a binder that they use for IDT meetings and more information might be in there. LPN UM-E did not provide any additional information regarding the IDT meetings for R246's falls. On 6/19/2023, at 10:27 AM, Surveyor reviewed with Director of Nursing (DON)-B R246's falls on 6/4/2023, 6/5/2023, and 6/7/2023. DON-B stated toileting was added to R246's Falls Care Plan to address the fall on 6/4/2023. DON-B stated gripper socks were added to R246's Falls Care Plan to address the fall on 6/5/2023. Surveyor shared the concern that intervention was not added until 6/8/2023. DON-B agreed that intervention should have been added to the Falls Care Plan right after the fall on 6/5/2023 and not three days later. Surveyor asked DON-B if the IDT documents their meetings or discussions in the resident's medical record. DON-B stated usually they have IDT notes put into the progress notes after their weekly meetings. DON-B stated the IDT met on 6/8/2023, which was after R246 had the three falls, and notes should have been entered into R246's medical record. DON-B reviewed the computer and stated R246's falls must have somehow gotten missed. DON-B stated wounds, weights, and falls are reviewed weekly looking at the interventions in place and then a progress note is written. DON-B stated if the resident is a frequent faller, a medication review is completed as well by notifying the pharmacist to assist with that. DON-B reviewed the emails sent to the pharmacist and did not see R246 as being one of the residents included in the email to be reviewed. DON-B stated DON-B was not sure why R246's falls were not reviewed and agreed there was not any documentation to show R246's falls were thoroughly investigated. No further information was provided at that time. Based on observation, interview, and record review the Facility did not ensure 4 (R96, R38, R246, & R6) of 8 Residents reviewed for accidents received care and services to prevent accidents. * R96 transferred herself onto the toilet. CNA (Certified Nursing Assistant)-X entered the bathroom and did not place a gait belt on R96 according to R96's plan of care. CNA-X assisted R96 off the toilet, R96 washed her hands, R96 then reached for the walker and fell. R96 sustained a femur fracture. R96 was moved by CNA-X & CNA-KK prior to RN-AA assessing R96. * The Facility did not determine a root cause following R38's fall on 5/21/23, did not investigate or determine root cause of R38's fall on 5/27/23 and did not implement any interventions on R38's at risk for falls care plan. On 6/19/23, R38 was observed attempting to get out of bed. R38's call light was on the floor by the footboard of the bed & not within R38's reach. * R246 had 3 falls. There was no IDT (interdisciplinary team) review and the fall prevention interventions were not appropriate for the root cause of the falls. * R6's falls care plan has an intervention for a low bed. R6 was observed not in a low bed. R96 is being cited at severity level 3 (actual harm). Findings include: The Falls Management process policy dated 9/21/20 documents, . 1. In the event a resident has fallen and/or is found on the ground, a complete head-to-toe assessment must be performed prior to moving the resident unless life-threatening safety concerns are present (fire, highway etc.). Remain with the resident while calling for assistance, if at all possible. 11. The nurse will complete an event documentation report, fall risk assessment, pain assessment, and obtain witness statements. 12. The nurse will determine the most appropriate intervention, implement, and update care plan. The Use of Gait Belt Policy, not dated, documents, . It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. Under Policy Explanation and Compliance Guidelines documents . 3. It will be the responsibility of each employee to ensure they have it available for use at all times when at work. 1) R96 was admitted to the facility on [DATE] and discharged on 5/10/23. The Clinical admission assessment dated [DATE] includes documentation of, Able to move all extremities. Upper extremity ROM (range of motion): No impairment. Lower extremity ROM: No impairment. Gait is unsteady. Balance is poor. The fall risk assessment dated [DATE] has a score of 11, which indicates at risk for falls. The at risk for falls care plan initiated 4/19/23 has an intervention of Gait belt with transfers, initiated & revised 4/19/23. The I have a physical functioning deficit related to mobility impairment, self care impairment care plan initiated 4/20/23 includes interventions of: * Gait belt with transfers, initiated & revised 4/19/23. * I require 2 ww (two wheeled walker), initiated & revised 4/20/23. * I require max (maximum) assist to complete toileting, initiated & revised 4/20/23. * I required mod (moderate) assist to complete transfers, initiated & revised 4/20/23. The admission MDS (minimum data set) with an assessment reference date of 4/21/23 has a BIMS (brief interview mental status) score of 00 which indicates severe impairment. R96 is assessed as requiring limited assistance with one person for bed mobility, transfer, & toilet use and does not ambulate. R96 is assessed as being occasionally incontinent of urine and continent of bowel. R96 has not had any falls prior to admission and has not fallen since assessment. The fall CAA (care area assessment) dated 5/3/23 under of analysis of findings documents [AGE] year old [gender] recently admitted after a hospital stay for UTI (urinary tract infection) and general weakness. Other dx (diagnoses) include but are not limited to dementia, arthritis, A fib (atrial fibrillation), CAD (coronary artery disease), CHF (congestive heart failure), and osteoporosis. [R96's first name] triggered the falls CAA because she has impaired mobility and poor balance. [R96's first name] is at risk for functional decline, falls, and related injury. Plan is for [R96's first name] to participate in MD (medical doctor) ordered therapy and to monitor fall risk. Goal is for [R96's first name] to improve her functional status and to not fall. Care plan in place The nurses note dated 5/10/23 documents, Resident sent out 911 due to witnessed fall and c/o (complaint of) pain to left hip and leg. [Physician's name] made aware as well as son. The EMAR (electronic medication administration record) note dated 5/10/23 documents, Resident sent to hospital at 1530, (3:30 p.m.) later admitted . The post fall evaluation dated 5/10/23, at 19:22 (7:22 p.m.) documents, Fall Details: Date / Time of Fall: 05/10/2023, 3:15 PM Fall was witnessed. Who witnessed fall: [CNA (Certified Nursing Assistant)-X's name] Fall occurred in the bathroom. Resident was reaching for item(s) at time of the fall. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: Resident was c/o pain in her left leg and hip. Did fall result in an ER (emergency room) visit/hospitalization: Yes. ER Visit/Hospitalization Details: 911 called. ER called to inform us of admit due to fracture of left femur. Provider: [Physician's name]. Time notified: 05/10/2023. Notified of: fall. Fall Details Note: resident fell in bathroom reaching for walker after washing her hands with CNA in attendance. Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: Yes. Footwear at time of fall: Shoes. Resident was using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Bedside call light on when Resident was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Medication Changes: Recent change to Resident's medications: No. Vitals: T (temperature) 97.8 - 5/10/2023 19:26 (7:26 p.m.) Route: Forehead (non-contact) BP (blood pressure) 173/120 - 5/10/2023 19:26 (7:26 p.m.) Position: Sitting r (right)/arm. P (pulse) 125 - 5/10/2023 19:26 (7:26 p.m.) Pulse Type: Regular Character: Normal. R (respirations) 18 - 5/10/2023 19:26 (7:26 p.m.) W (weight) 164.4 lb (pounds) - 5/9/2023 14:40 (2:40 p.m.) Scale: Wheelchair Pain: Indicators of pain: Vocal complaints of pain. Pain Issue: #001: New. Location: Left thigh - generalized. Pain score: 5. Sharp. Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Physical Findings: Change in diagnosis status: No. Recent diagnosis of stroke, TIA (transient ischaemic attack) or arrhythmia: No. Decrease in fluid intake: No. Change in blood glucose levels: No. Change in blood pressure: No. Change in mental status: No. Change in behaviors: No. Change in mobility status: No. Recent weight loss: No. Sensory impairment: No. Resident does not have orthostatic BP changes. Surveyor reviewed the Facility's investigation and noted the Facility self reported this incident according to regulations and the Facility obtained statements from CNA-X, RN (Registered Nurse)-AA and CNA-KK. CNA-X's handwritten statement dated 5/10/23 documents, [CNA-X's name] I was a witness to a resident fall [R96's name]. She was in the bathroom I transferred her from the toilet to the sink. She wanted to wash her hands reaching for her walker and lost her balance and felt [sic] (fell) to the floor. Between the toilet and the wall in a sitting position. CNA-KK's handwritten statement dated 5/10/23 documents, At about 1515 (3:15 p.m.) I was walking past [room number], when my co-worker [CNA-X's first name] called my name. [CNA-X's first name] was hold up [room number] [R96's first name] in the doorway of the bathroom with [R96's first name] leaning on the door jamb and holding her walker. [R96's first name] wheelchair was outside the door (bathroom) and [CNA-X's first name] and I attempted to pivot [R96's first name] so she could get in her wheelchair, but her legs buckled and [CNA-X's first name] and I lowered [R96's first name] to the floor. RN-AA's statement in an email to Prior DON (Director of Nursing)-HH dated 5/11/23 documents, [CNA-KK's first name] came and got me to tell me [room number] was on the floor. When I came in the room the resident was sitting in the bathroom doorway with her butt in the bathroom and her feet on the doorway. I was told she fell in the bathroom and it was witness by [CNA-X's name]. I asked her and the resident if she hit her head. The resident said no and [CNA-X's first name] said she may have hit her head on the wall. I assessed her head and asked the resident what happened. She did not remember. I was told by [CNA-X's first name] that she was on the toilet. She stood up to wash her hands and lost her balance reaching for her walker. She fell between the wall and toilet. I asked how she got over by the door and was not given an answer. [CNA-KK's first name] proceeded to raise her right leg and then her left leg when she let out a scream in pain. I went and told [first name] she fell, text [Physician's name] and called 911. I also called her son. On 6/15/23, at 3:51 p.m., Surveyor asked RN-AA if she could tell Surveyor what she remembers about R96's fall on 5/10/23. RN-AA informed Surveyor she was at the nurses station when CNA-KK came and got her indicating they needed her help with a patient who had fallen. RN-AA informed Surveyor she went to R96's room and R96 had her feet up against the door frame. RN-AA indicated she asked the aide what happened and was told she (CNA-X) stood R96 off the toilet, R96 went to wash her hands then reached for her walker and fell. RN-AA informed Surveyor CNA-KK said R96 was not complaining of anything so lets get her up. A gait belt was placed on R96. RN-AA informed Surveyor she couldn't remember if she or CNA-KK placed the gait belt on. RN-AA informed Surveyor they went to put R96's left leg up and R96 hollered. RN-AA informed Surveyor she told CNA-KK not to move R96 and 911 was called. RN-AA informed Surveyor she called the doctor and R96's son. Surveyor asked RN-AA if she asked how R96 got over to the doorway. RN-AA informed Surveyor she never got a clear answer, doesn't want to accuse people of anything but she's not stupid. Surveyor inquired if CNA-KK was working. RN-AA informed Surveyor CNA-KK is on vacation. On 6/15/23, at 4:02 p.m., Surveyor asked CNA-X to tell Surveyor what she remembers about R96's fall on 5/10/23. CNA-X informed Surveyor she remembers she was walking down the hall and RN-AA asked her to go to the room because she didn't want R96 walking around. CNA-X informed Surveyor she went to the room and R96 was sitting on the toilet and she went to get her walker. CNA-X indicated R96 got up off the toilet & stated she wanted to wash her hands. CNA-X informed Surveyor she was standing a little behind her when R96 turn away and that's when she slipped and fell. Surveyor asked where R96 fell. CNA-X informed Surveyor she fell between the toilet and wall. Surveyor asked after R96 fell what did she do. CNA-X indicated she stuck her head out of the doorway and called for help. Surveyor asked if anyone came to help her. CNA-X replied yes [CNA-KK's first name]. CNA-X indicated after CNA-KK came in she doesn't know if they tried to get R96 up and that's when R96 complained of hip pain. Surveyor asked CNA-X how to explain how they tried to get R96 up. CNA-X informed Surveyor they asked R96 if anything hurt then stated I don't know it's been a minute, we couldn't get her all the way, when she complained of pain they laid her there and got the nurses. Surveyor asked CNA-X when R96 was on the toilet did she put a gait belt around R96. CNA-X replied no I didn't see a gait belt. On 6/19/23, at 7:20 a.m., Surveyor asked DON (Director of Nursing)-B if a Resident's care plan documents a gait belt to be used with transfers and a CNA observed a Resident who had placed themselves on the toilet, should the CNA place a gait belt on that Resident prior to getting the Resident off the toilet. DON-B informed Surveyor should always put a gait belt on unless independent. Surveyor informed DON-B the Resident is not independent. DON-B replied yes there should be a gait belt. On 6/19/23, at 7:53 a.m., Surveyor asked Administrator-A how the Facility found out R96 sustained a fracture femur. Administrator-A informed Surveyor from the hospital. Surveyor asked Administrator-A if she investigated R96's fall on 5/10/23. Administrator-A replied I believe I did, looked at the investigation and stated yes I did. Surveyor asked during the investigation did you find out if a gait belt was used. Administrator-A replied no this one self transferred to the bathroom, the aide went in to assist her, the resident had already been on the toilet. Surveyor asked Administrator-A if she asked CNA-X why she didn't put a gait belt on R96. Administrator-A informed Surveyor the resident was trying to get up. Surveyor informed Administrator-A of the concern R96's fall prevention interventions were not in place at the time of the witnessed fall and staff attempted to move R96 prior to the RN assessment after the fall. 2) R38 was admitted to the facility on [DATE]. The Clinical admission assessment dated [DATE] includes documentation of Safety Note: patient is high fall risk. The fall risk assessment dated [DATE] has a score of 19 which indicates high risk for falls. R38's at risk for falls care plan, initiated 5/21/23, does not have any interventions documented. R38's physical functioning deficit care plan, initiated 5/22/23, includes an intervention also dated 5/22/23 of Call bell within reach. The nurses note dated 5/21/22, documents Pt (patient) had a fall and was found at 5:15 this morning Sunday May 21st. He has a new skin tears to his left arm. I called and left a message for his daughter [name]. [First name of DON (Director of Nursing)-B] is aware. The incident report dated 5/21/23, 05:00 (5:00 a.m.), under the section incident description for nursing description documents, resident heard calling out for help when staff entered room and observed resident out of bed and holding on to a chair in the room by the window blood observed in bed and to LUE (left upper extremity), skin tear noted, first aide provided neuro checks initiated, VS (vital signs) checked skin and neuro assessments completed. Under resident description documents, dementia. Under immediate action taken for description documents, first aide to injury vs (vital signs) taken, neuro/skin assessment. Under injuries observed at time of incident for injury type documents, skin tear and injury location is left antecubital. The incident report dated 5/21/23, at 16:45 (4:45 p.m.), under the section incident description for nursing description, documents, Writer observed resident in his room sitting on bathroom floor. Under resident description documents, dementia. Under immediate action taken for description documents, VSS (vital signs stable), skin assessment: skin tear noted to posterior of rue (right upper extremity) area clean and dried, currently on neuro checks. Under injuries observed at time of incident documents, for injury type skin tear and for injury location right elbow. The post fall evaluation dated 5/22/23, at 05:56 (5:56 a.m.), (for fall on 5/21/23 at 4:45 p.m.) documents, Fall Details: Fall was not witnessed. Fall occurred in the Resident's room. Activity at the time of fall: unwitnessed. The reason for the fall was not evident. Did an injury occur as a result of the fall: Yes. Injury details: s/t (skin tear) anterior RUE (right upper extremity) Did fall result in an ER (emergency room) visit/hospitalization: No. Provider: [Physician's name] Time notified: 05/21/2023 Notified of: fall/injury. Contributing Factors: Recent change in environment: No. Was fluid spilled on floor: No. Clutter present on the floor: No. Floor mat was on floor: No. Poor lighting in the area: No. Bed was at an improper height: No. Other furniture involved: No. Wheelchair was not involved in fall. Wearing glasses at the time of the fall: Yes. Footwear at time of fall: Non-skid shoes/socks. Resident was not using cane/walker as instructed. Resident was not wearing oxygen as prescribed at time of fall. Resident was using incontinence supplies at the time of the fall. Incontinent at time of fall: No. Bedside call light on when Resident was found: No. Bathroom call light on when Resident was found: No. Personal alarm sounding when Resident found: No. Other Residents were not involved in fall. Medication Changes: Recent change to Resident's medications: No. Vitals: W (weight) 181.0 lb - 5/21/2023 10:45 Scale: Wheelchair Pain: Indicators of pain: None. Skin: Skin warm & dry, skin color WNL (within normal limits) and turgor is normal. Skin note: skin tear to RUE Skin Issue: #001: Needs Review. Issue type: Skin tear. Location: Left forearm. Skin Issue: #002: Needs Review. Issue type: Pressure ulcer/ injury. Location: Left buttock. Wound odor: No. Tunneling: No. Undermining: No. Pressure ulcer staging: Stage 2 Pressure ulcer / injury - partial thickness skin loss with exposed dermis. Physical Findings: Change in diagnosis status: No. Recent diagnosis of stroke, TIA (transcient ischaemic attack) or arrhythmia: No. Decrease in fluid intake: No. Change in blood glucose levels: No. The EMAR (electronic medication administration record) note dated 5/22/23 documents, Resident placed in view of staff and q (every) 15 min (minute) checks provided, is high risk for fall. Skin tear to RUE both clean and dry. Neuro checks wnl, incontinent cares provided by two staff. Resident restless and uncooperative with staff regarding laying down, was up wandering around unit most of shift. Fluids/snacks offered frequently, VSS (vital signs stable). No limitations noted during ROM (range of motion), no other injuries noted. AM (morning) shift to f/u (follow up) with MD (medical doctor). The admission MDS (minimum data set) with an assessment reference date of 5/22/23 has a BIMS (brief interview mental status) score of 14 which indicates cognitively intact. R38 is assessed as requiring extensive assistance with two plus person physical assist for bed mobility & transfer, extensive assistance with one person physical assist to ambulate in the room, does not ambulate in corridor, and extensive assistance with one person physical assist for toilet use. R38 is assessed as being occasionally incontinent of urine and frequently incontinent of bowel. R38 has fallen one month prior to admission, fallen 2 to 6 months prior to admission and since admission has fallen two or more times with no injury and two or more times with injury not major. The nurses note dated 5/26/23 documents 24 hour board monitoring: room change for increased supervision r/t (related to) fall risk. Adjusting to new room/environment well. No attempts made to self transfer. Stood with assist of two and gait belt, pivot transferred into w/c (wheelchair). Dined in main dining room for meals. Appetite good. Alert with confusion. Toileted every 2-3 hours for check and change. Continues to follow plan of care. Participated[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not: identify and seek ways to support resident's individual needs through the assessment and care planning process, make referrals and obtain needed services from outside entities, and provide and arrange for needed mental and psychosocial services related to difficulty coping with change in condition and loss of meaningful life, and need for emotional support for 1 of 1 Residents (R6) reviewed for medically related social services. R6 was not provided medical related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. *R6's electronic medical record (EMR) documents that R6 had suicidal ideation on [DATE], and was given a 30 day discharge notice on [DATE], 1 day after having suicidal ideation. There is no documentation that at any point, R6 was being monitored for any psychosocial symptoms, care plan interventions were not followed through with, and R6's mental health issues were not being addressed through medications, psychological services, non pharmacological interventions, or support from the Interdisciplinary Team (IDT.) Findings include: Surveyor reviewed the facility's Behavioral Health Services policy and procedure implemented [DATE], which states in part: .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. Policy Explanation and Compliance Guidelines: 1. Behavioral health encompasses a Resident's whole emotional ad 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 or post-traumatic stress disorders . 4. Behavioral health care and services shall be provided in an environment that is conducive to mental and psychosocial well-being. 5. Conditions that are frequently seen in nursing home Residents and may require facility to provide specialized services and supports based upon Resident's individuals needs, include, but are not limited to: a. Depression b. Anxiety c. Schizophrenia d. Bipolar 6. The facility uses the comprehensive assessment process for identifying and assessing a Resident's mental and psychosocial status and providing person-centered care. This process includes, but is not limited to: a. PASRR (Preadmission Screening and Resident Review) screening b. Obtaining history from medical records, the Resident, and as appropriate the Resident's family and friends, regarding mental, psychosocial, and emotional health c. MDS (Minimum Data Set) and care area assessment d. Ongoing monitoring of mood and behavior e. Care plan development and implementation f. Evaluation 7. The Resident, and as appropriate the Resident's family, are included in the comprehensive assessment process along with the interdisciplinary (IDT) and outside sources, as indicated. The care plan shall: a. Have interventions that are person-centered, evidence-based, culturally competent, trauma informed, and in accordance with professional standards of practice. b. Provided for meaningful activities which promote engagement and positive, meaningful relationships. The facility will ensure that activities are provided to meet the needs of these Residents. c. Reflect the Resident's goals for care. d. Account for the Resident's experiences and preferences. e. Maximize the Resident's dignity, autonomy, privacy, socialization, independence, and safety. f. Use pharmacological interventions only when non-pharmacological interventions are ineffective or when clinically indicated. g. Address any other individualized needs the Resident may have related to the mental disorder. h. Be reviewed and revised as needed, such as when interventions are not effective or when the Resident experiences a change in condition. 8. If a behavioral contract is used, it will only be used with Residents who have the capacity to understand it. A contract will only be used as a method of encouraging the Resident to follow their plan of care, and not as a system of reward and punishment . 10. Facility staff will implement person-centered care 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 not limited to: a. Ensuring adequate hydration and nutrition b. Exercise c. Pain relief d. Individualizing sleep and dining routines f. Adjusting the environment to be more individually preferred or homelike g. Consistent staffing h. Supporting the Resident through meaningful activities that match his/her individual abilities, interests and needs i. Assisting the Resident outdoors in the sunshine and fresh air k. Assisting the Resident to participate in activities that support their spiritual needs l. Assisting with the opportunity for meditation and associated physical activity m. Focusing the Resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities, offering verbal reassurance, especially in terms of keeping the Resident safe; acknowledging that the Resident's experience is real to him/her o. Assisting Resident with substance abuse disorders to access counseling p. Assisting Residents with access to therapies, such as psychotherapy, behavior modification, cognitive behavioral therapy, and problem solving q. Providing support with skills related to verbal de-escalation, coping skills, and stress management. The facility assessment last updated on [DATE] document the facility may accept Residents with anxiety, depression, schizophrenia, and post-traumatic stress disorder. The facility assessment also documents that the Director of Nursing (DON-B) would assess the referral and determine if the facility is able to meet the Resident's needs listed above and the staff would be educated in necessary clinical needs of the Resident. Currently, the facility assessment documents there are no Residents with behavioral health needs and active or current substance use disorders. Lastly, the facility assessment states the facility can manage the medical conditions related to the Resident's mental health: anxiety, depression, trauma, dementia, and other mental health disorders. R6 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left-Dominant Side, Sleep Apnea, Insomnia, Other Idiopathic Scoliosis, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Other Obsessive-Compulsive Disorder, Unspecified Attention-Deficit Hyperactivity Disorder, and Other Psychoactive Substance Abuse. R6 is currently R6's own person. R6's admission MDS dated [DATE] documents R6 has a BIMS (Brief Interview of Mental Status) score of 15 of 15 (cognitively intact) and requires limited assistance of 1 for bed mobility, dressing, toileting, and hygiene and limited assistance of 2 person plus assistance for transfers. R6 has no range of motion impairment and no behavior symptoms. R6 has a PHQ-9 score of 9 indicating mild depression. R6's 5-day Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score to be a 14, indicating R6 is cognitively intact for daily decision making. R6's MDS also documents that R6 requires extensive assistance with 2 for bed mobility and transfers. R6 requires extensive assistance of 1 for dressing and toileting and has range of motion impairment on 1 side for both upper and lower extremities. R6's MDS reflects a patient health questionnaire (PHQ-9) score of 9 indicating mild depression. There are no behavior symptoms documented. Surveyor notes that the most current MDS dated [DATE] documents that R6 is now requiring more assistance with activities of daily living (ADLs) than one month earlier. Surveyor notes R6's PASRR (Preadmission Screening and Resident Review) Level 1 dated [DATE] does not accurately document R6's status on admission on [DATE]. The PASRR also does not document that R6 is receiving Cymbalta and Fluvoxamine Maleate for depression. On [DATE], R6 was evaluated by psychiatric services and was diagnosed with Schizoaffective Disorder, Bipolar Type due to R6 having delusions and hallucinations. R6's PASRR Level 1 was not updated to accurately reflect R6's mental health status at time of admission on [DATE]; failure to identify mental health signs and symptoms impacted the facility's ability to formulate a person-centered approach to improve R6's quality of life. On [DATE] at 1:42 PM, Doctor (DR-MM) shared with Surveyor that R6 has multi-level pain issues and has recommended to the facility to get R6 to focus on hobbies and take the focus off of R6's pain. DR-MM stated, There is is a lot of psychosocial outcome that is related to the focus on R6's pain. R6 has no control over anything. R6 is focused on pain because it is the only thing R6 can try and be in control of. I would be in the same position if I was dealing with what R6 is. As noted later, in an interview on [DATE] at 10:49 AM, R6 stated her pain was not controlled, which led her to asking her son to bring in pain medication from home. R6's electronic medical record (EMR) has the following documentation: [DATE] 8:18 PM General Note Note Text: Patient arrived to facility via van service in wheelchair patient is alert, denies any pain or discomfort at this time patient wheelchair switched out for highback wheelchair. Patient and son has concerns in regards to social services and cares and plan of care writer left message for social services. patient requires no male caregivers or therapist upon per patient upon arrival. patient educated on call light system and is in bed resting comfortable. On [DATE] at 1:32 PM, Surveyor spoke to Social Worker (SW)-T about R6 not having male caregivers. SW-T states SW-T was not aware of this request. Surveyor notes no male caregivers is not on the care plan or R6's care card, and there is no other documentation that this was addressed. Surveyor reviewed R6's current physician orders. R6 is on the following medications: Melatonin 10 MG-Give 1 tablet at bedtime for sleep Alprazolam .25 MG-Give 1 tablet every 8 hours as needed for anxiety Cymbalata-60 MG-Give 1 capsule 1 time a day for depression Fluvoxamine Maleate-1 tablet 3 times a day for depression It also states for the anti-anxiety use to observe closely for significant side effects: sedation, abnormal thoughts, behavior confusion, agitation every shift. Surveyor reviewed R6's entire EMR and notes that it is documented that R6 consistently and frequently asked for the Alprazolam for anxiety. Surveyor reviewed R6's Medication Administration Records and Treatment Administration Records since admission and notes there is no documentation that R6 is being monitored for signs and symptoms of anxiety and depression. The facility is not monitoring R6's sleep pattern on a nightly basis and Surveyor notes 2 sleep studies (4/19 - [DATE] and 5/23 - [DATE]) were not completed fully. The following was documented in R6's EMR progress notes: [DATE] 21:43 (9:43 PM) General Note Note Text: patient day 5 new admit patient has vape pin in narc drawer and a second vape pin purple in color was retrieved and given administrator. staff reported she has another vape red in color, writer did go and speak to patient and patient stated she doesn't have another vape. patient called writer in room later in shift complaining of lightheadness and dizzy, writer did take vitals and blood pressure was 142/74 afebrile and hr 80 writer will let unit manager know patient will benefit from patch and MD should be updated in am. [DATE] 6:52 PM General Note Note Text: writer called to room patient not responding to staff as per usual. writer walked in to room and asked resident is she ok, resident stated take off socks please no socks was on patient, patient response speech is minimal slurred and patient is lethargic arousable for only a few seconds at a time. patient is not on any PRN (as needed) narcs at this time. MD gave order to send patient to ER to be evaluated and treated. Patient was in bed with vape pen in hand patient continued to sleep thru writer overall assessment. patient was verbal when asked about what hospital to go to. Patient will be transported to St. Luke's Hospital via Bell ambulance, writer called daughter and son and left message on voice mail to call facility for detailed updated in regards to patient. Surveyor notes that R6 returns from the hospital and no smoking cessation was offered. No smoking cessation was offered and implemented on R6's admission. On [DATE] at 1:21 PM, DON-B confirmed that no smoking cessation was offered to R6. Surveyor has concerns that R6's vape was taken, and no alternatives were offered to R6 along with smoking cessation which could potentially cause a higher level of anxiety. [DATE] 22:39 (10:39 PM) General Note Note Text: Writer was alerted by aide that the resident was found to have prescription opioids at her bedside. CNA brought a few pills to writer that she found. Writer and 2 CNAs went into resident's room and found a total of 18 oxycodones in tin container. Res appears sleepy and hard to arouse. VSS stable at this time. DON updated and suggests to have res sent out for evaluation. MD updated. 911 called and police arrived with paramedics. Res refuses to go to the hospital. Police and EMTs are not able to take resident and she is now more alert and vitals are still normal. Daughter was called and did not get an answer. DON and ADON aware of non transfer to hospital. On [DATE], R6 was evaluated by psychiatric services. It is recommended to consider switching from alprazolam to lorazepam .5 MG 2 times a day, longer acting buspiroren 5 MG twice a day. Schizoaffective Disorder, Bipolar type was added with the plan to consider depakote sprinkles 125 MG 2 times a day or seroquel 12.5 MG daily if hallucinations/delusions persist. Drug rehabilitation/social worker to help with family counseling/grief therapy and outpatient psychiatry/psychotherapy upon discharge as well. [DATE] 8:55 AM General Note Note Text: writer took a call from patient's daughter. Daughter reports that patient called her at least 4 time early this morning talking about suicide. writer went in and spoke to patient. writer asked patient if she is currently thinking of hurting herself. patient replied no but reports she was sad last night. writer looking into precautions for patient. Surveyor noted Suicidal ideation was not addressed on R6's care plan. On [DATE] at 1:32 PM, SW-T confirmed SW-T was not aware of R6 having suicidal thoughts. Surveyor was unable to interview the nurse who documented that R6 was having suicidal ideation due to no longer working at the facility. [DATE] 7:12 AM General Note Note Text: Resident continues to utilize call light system through out the night, resident continues to state she wants to get up and go outside to smoke and needs constant reminders this is a no smoking facility, resident is very agitated and angry on this writers shift, will continue to redirect and monitor. [DATE] 3:31 PM General Note Note Text: Writer, resident's assigned SW, BOM (business office manager), and Administrator met with resident in her room to review 30 Day Notice of IVD (Involuntary discharge notice). Writer and aforementioned team members spoke with resident about reasoning behind 30 Day IVD - Safety d/t use of non-prescription drugs in room and vaping/smoking in room - and resident verbalized understanding. Writer educated resident on appeal process and provided resident with information on how to appeal and timelines. Resident verbalized understanding and signed 30 Day IVD. Resident provided with original copies of documents alongside stamped and preaddressed envelope to Division of Hearings & Appeals. Physician and Ombudsman notified and received faxed copies of 30 day IVD. Discharge planning to commence to suitable transfer location. On [DATE] the facility developed care plans addressing substance abuse (which included an intervention to establish a verbal or written behavioral contract) and frequent complaints related to mood (which included an intervention to evaluate underlying factors leading to complaints). On [DATE], R6 was seen by psychiatry services for follow-up. R6 is complaining of anxiety, difficult sleeping, panic attacks regularly. States grieving loss of husband and mother. States pain is not controlled. States misses husband, passed away 5 years ago. It is recommended to consider switching from alprazolam to lorazepam .5 MG 2 times a day, longer acting buspiroren 5 MG twice a day. Consider increasing Cymbalta to 90 MG daily. Schizoaffective Disorder, Bipolar type was added with the plan to consider depakote sprinkles 125 MG 2 times a day or seroquel 12.5 MG daily if hallucinations/delusions persist. On [DATE] at 1:32 PM, Surveyor attempted to contact psychiatric services but did not receive a return call. [DATE] 2:48 AM General Note Note Text: patient awake most of the night. patient c/o anxiety. Tylenol given for HA. deep breathing done for anxiety. patient snacking on cookies. On [DATE] at 1:21 PM, Surveyor interviewed DON-B. DON-B states there is no behavior meeting to review medications. DON-B is not sure how psychiatric services communicates medication changes and agrees that recommendations of medication changes (4/30 & [DATE]) for R6 were never followed through with. On [DATE] at 2:17 PM, DON-B communicated the following in regard to R6: I am just seeing the pysch recommendations now. I had no idea. I do not know how psych communicates changes that need to be made. I don't know what the old DON-B was doing with recommendations prior to [DATE]. Surveyor reviewed R6's physician progress notes and there is no documentation of the physicians addressing R6's anxiety, depression, and substance abuse signs and symptoms. Surveyor reviewed R6's current comprehensive care plan, which indicates in part: 1. I would like to continue participating in the recreational activities I currently enjoy. Initiated [DATE] . Invite me to my favorite activities, and to try new things that I might be interested in. I enjoy bingo, board games, and crafts. R6's Resident Preferences Evaluation dated [DATE] at time of admission documents, it is very important for R6 to keep up on the news, listen to music, be around animals, do things with groups of people, to do favorite activities, and to get fresh air. On [DATE] at 11:11 AM, Surveyor observed R6 in bed, flat affect, answered questions appropriately. R6 stated R6 wanted to be up for lunch because R6 likes to be in the dining room with other residents and does not like to eat in bed. On [DATE] at 11:14 AM, R6 informed Surveyor that activities never come to R6's room. R6 would like to get R6's hair and nails done to feel better. R6 states not getting out of the room makes R6 sad, causes anxiety, wants to be involved with activities, and it would make a difference for R6. On [DATE] at 12:44 PM, Surveyor observed R6 up and in wheelchair, flat affect, and stated that R6 was able to get up and eat lunch in the dining room. On [DATE] at 9:13 AM, Surveyor observed R6 in bed eating breakfast in bed. R6 again stated that R6 wants to be up every day so R6 can eat meals in the dining room. On [DATE] at 10:49 AM, Surveyor observed R6 in bed with flat affect, and resident became tearful at times during the interview with Surveyor. R6 explained that R6 is very worried about the 30 day discharge notice and nothing has been communicated about the process with R6. R6 stated the 30 day is hanging over R6's head. R6 explained that R6 was not aware that vaping is included in the policy of being a smoke-free facility. R6 stated it was not explained to R6 that R6 could not vape. R6 stated the facility took all her vapes away and have offered no alternative or smoking cessation. R6 stated R6's pain was not being managed despite repeatedly asking for assistance, so R6 had R6's son bring in R6's purse which R6 knowingly knew there was pain medication in the purse. R6 stated R6 needed to manage R6's own pain. R6 has asked for 'talk therapy,' but no one has gotten back to R6. I feel my depression is getting worse. I have lot of stuff going on in my head. I felt so bad about the vaping and medication issue. R6 has not had a behavior contract and no referrals for mental health assistance or substance abuse. R6 stated, I asked for smoking cessation after they took everything away, never gave me anything. My anxiety is very high. Staff do not come around to ask or offer anything at bedside for anxiety. It would help. I cry every night because of all this stress. Especially with the 30 day notice. That's why I don't sleep. My husband committed suicide in 2018 on 4th of July, anniversary is coming up. My mom died in 2019 and then I had my stroke. It's been very painful for me and to deal with. Sometimes I have feelings of suicide, but I never have a plan. SW-T is aware but I have only seen SW-T 1 or 2 times, but has not been back in a month and has offered no support to me. Activities would help but is never offered. I want to be around people to take my mind off of everything. I really want to feel better, but I am so sad and miserable with everything. I really hope they do not retaliate against me for the vaping and the medication issue. On [DATE] at 1:32 PM, SW-T confirmed SW-T has done nothing for R6 other than to work on discharge plans due to the 30 day discharge notice given to R6. Surveyor notes there is no social service documentation from the day of R6's admission to the facility on [DATE] until today ([DATE]). Surveyor also acknowledges there is no documentation that R6 had any other behavior issues involving vaping and medications after the 1 enty documented on both issues. On [DATE] at 1:52 PM, Surveyor spoke with R6 who was up in a chair, watching TV. Surveyor interviewed R6 who was extremely happy to have gotten R6's nails and hair done and was very proud to show Surveyor R6's nails. R6 was smiling and engaging in conversation. On [DATE] at 9:41 AM, R6 reported to Surveyor that R6 got out of bed on Saturday but did not get out of bed on Sunday because of the pain. On [DATE] at 10:34 AM, Surveyor interviewed Administrator (NHA-A) who stated that NHA-A did not review R6's referral information as that is done by team members from corporate. NHA-A is unsure what standard of practice as far as the Trauma Assessment is being utilized by the facility. NHA-A is unaware that R6 had requested no male caregiver or had suicidal ideations. NHA-A is unaware that R6 has polysubstance abuse. Surveyor shared the concern that smoking cessation was not offered to R6 after staff took R6's vape away. Surveyor shared that mental health services and interventions have not been implemented to address R6's anxiety and depression. Surveyor shared that there has been no monitoring of R6's signs and symptoms with documentation including delusions/hallucinations and suicidal ideation. Surveyor shared that a structured activity program has not been implemented to reduce R6's pain, depression, and anxiety. Surveyor shared that R6 has been seen 2 times by psychological services for medication management with no follow-up and has not received 1:1 counseling and referrals for R6's polysubstance abuse. Surveyor shared the concern that R6's coping mechanisms were taken away with no interventions put into place. NHA-A understands the concern that R6 was not provided medically related social services to maintain the highest practicable physical, mental, and psychosocial well-being. No further information was provided by the facility at this time. On [DATE] at 1:55 PM, NHA-A shared with Surveyor that NHA-A has spoken to R6 about the 30 day discharge notice and has since rescinded the 30 day discharge notice because R6 has not had any further behavior issues at the facility.