**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents received adequate assistance devices to prevent accidents for 1 (R13) of 3 residents reviewed for accidents. *R13's At Risk for Falls Care Plan had the intervention of bilateral fall mats on the floor. Observations were made of R13 having one fall mat on the floor and not two fall mats. Findings include: 1.) R13 was admitted to the facility on [DATE] with diagnoses of osteoarthritis, malnutrition, anxiety, chronic kidney disease, and Alzheimer's disease. R13's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R13 was severely cognitively impaired per staff assessment. R13 has been receiving hospice services since admission on [DATE] with a diagnosis of senile degeneration of the brain. R13 has an activated Power of Attorney. R13's Risk for Falls Care Plan was initiated on 1/28/2022 with the following interventions: -Anticipate and meet R13's needs. -Bed to be in lowest position and bilateral floor mats. -Educate R13/family/caregivers about safety reminders and what to do if a fall occurs. -Neuro checks per policy. -Vital signs per policy. No revisions were made to the Risk for Falls Care Plan since its initiation on 1/28/2022. R13 did not have any falls documented. On 7/13/2024 on the Fall Risk Evaluation form, nursing documented R13 was a moderate risk for falls with a score of 10. On 9/24/2024, at 10:57 AM, Surveyor observed R13 sitting in a Broda chair in the common area of the unit by the nurses' station. R13 appeared well groomed. Surveyor observed one fall mat in R13's room between the bed and the window. No second fall mat was observed on the floor or folded out of the way. On 9/24/2024, at 12:24 PM, Surveyor observed R13 lying in bed on the left side. The bed was in a low position. A fall mat was observed on the floor between the bed and the window. No fall mat was observed on the side of the bed between the bed and the door. In an interview on 9/25/2024, at 8:02 AM, Surveyor asked Licensed Practical Nurse (LPN)-G if R13 was supposed to have one or two floor mats. LPN-G looked in the computer charting system to find out. LPN-G stated LPN-G was not very familiar with the electronic charting system, so it took a little time to find information. LPN-G stated the Care Plan says R13 should have bilateral fall mats. Surveyor shared with LPN-G the observation of R13 having only one floor mat in the room. LPN-G stated LPN-G would get another fall mat placed in R13's room. On 9/25/2024, at 10:04 AM, Surveyor shared with Director of Nursing (DON)-B the observation of R13 having one fall mat on the floor when the At Risk for Falls Care Plan indicated there should be two fall mats. DON-B stated LPN-G had shared that information with DON-B earlier. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility did not ensure that Residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R10) of 3 Residents reviewed for pressure injuries. R10 had a history of pressure injuries. R10 was admitted with a Stage 3 pressure injury on the right & left buttocks, an unstageable pressure injury on the right heel and a stage 3 pressure injury on the left heel. R10's right buttocks was identified as being healed on 5/28/24, the left buttocks pressure injury was healed on 6/11/24, the right heel was healed on 7/30/24, & the left heel was healed on 8/6/24. On 7/15/24, R10 developed three Stage 3 pressure injuries on the coccyx, left & right buttock. The Facility did not revise R10's care plan after development of these pressure injuries, R10's care plan does not include interventions of how often R10 should be repositioned and when incontinence cares should be provided for R10 who was identified as being a heavy wetter. Findings include: The facility's policy titled, Prevention of Pressure Ulcers and revised 1/16/24 under General Guidelines documents: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decreased of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. 3. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linen. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 4. Pressure ulcers are often made worse by continued pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 5. Once a pressure ulcer develops, it an be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. R10 was admitted to the facility on [DATE] with diagnoses which include major depressive disorder, diabetes mellitus, morbid obesity and altered mental status. R10 was admitted with a Stage 3 pressure injury on the right & left buttocks, an unstageable pressure injury on the right heel and a stage 3 pressure injury on the left heel. R10's right buttocks was identified as being healed on 5/28/24, the left buttocks pressure injury was healed on 6/11/24, the right heel was healed on 7/30/24, & the left heel was healed on 8/6/24. The potential/actual impairment to skin integrity care plan initiated 5/20/24 & revised 8/6/24 documents the following interventions: * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Initiated & revised on 5/20/24. * Conduct weekly body audit. Initiated 5/20/24. * Follow facility protocols for treatment of injury. Initiated and revised on 5/20/24. * Identify/document potential causative factors and eliminate/resolve where possible. Initiated & revised on 5/20/24. * Keep skin clean and dry. Use lotion on dry skin. Do not apply on ANY WOUND. Initiated and revised on 5/20/24. * Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (medical doctor). Initiated & revised on 5/20/24. * The resident needs pressure relieving/reducing mattress, pillows, sheepskin padding etc to protect the skin while up in chair. Initiated and revised on 5/21/24. * Therapy as ordered by MD. Initiated 5/20/24. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Initiated & revised on 5/20/24. The CNA (Certified Nursing Assistant) [NAME] as of 8/13/24 under the skin section documents * Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. * Keep skin clean and dry. Use lotion on dry skin. Do not apply on any wound. * Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. * Wash feet daily with mild soap and water. Dry thoroughly. May use a light dusting powder or lotion. Do not apply lotion or powder between the toes. Under the Resident Care section documents: * All staff to converse with resident while providing care. * Explain all procedures to the resident before starting and throughout cares. * Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. * TRANSFER: Requires Hoyer A (assist) x (times) 2 for all transfers to/from bed and w/c (wheelchair). Surveyor noted the CNA [NAME] does not document how often R10 should be repositioned and when to provide incontinence cares. The admission MDS (minimum data set) with an assessment reference date of 5/27/24 has a BIMS (brief interview mental status score of 15 which indicates R10 is cognitively intact. R10 is assessed as not refusing cares. R10 is assessed as requiring substantial/maximal assistance for rolling left & right and is assessed as being dependent for toileting hygiene, chair/bed to chair transfer, & toilet transfer. R10 is always incontinent of bowel and bladder. R10 is assessed as being at risk for pressure injury development and has three Stage 3 pressure injuries which were present upon admission. The pressure injury CAA (care area assessment) dated 6/2/24 for nature of problem has not been completed & is blank. For existing pressure injury documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). For extrinsic risk factors documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). For intrinsic risk factors documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). For medications that increase risk for pressure ulcer/injuries development documents (Click here to add supporting documentation. Provide the basis/reason for items by clicking, including the location & date & source (if applicable), of that information). Diagnosis & conditions that present complications or increase risk for pressure ulcer/injury is checked for diabetes, chronic or end stage renal, liver or heart disease, malnutrition, depression and pain. Treatments and other factors that cause complications or increase risk has newly admitted or readmitted checked. Resident and/or family representative and care plan considerations has not been completed and is blank. The Braden assessment dated [DATE] has a score of 17 which indicates low risk for pressure injury development. The nurses note dated 7/7/24, at 21:50 (9:50 p.m.), documents Resident monitored for low SPO2, increased pulse and low BS (blood sugar), BS 144 and O2 (oxygen) 95, Resident denies any pain, resident has had loose stools throughout the day x (times) 6, given PRN (as needed) loperamide. There is excoriation bilateral to buttocks, writer covered with bordered bandage. Resident states pain of 3/10 to buttocks area. Will continue to monitor. This nurses note was written by Nursing-R. Surveyor noted there is no notification to R10's physician regarding the excoriation and bordered bandage applied. The nurses note dated 7/9/24, at 04:05 (4:05 a.m.), includes documentation of Changed sacrum drsg (dressing) This nurses note was written by LPN-S. Surveyor noted there is not an order for a sacrum dressing nor any assessment for the sacrum. The nurses note dated 7/15/24, at 05:51 (5:51 a.m.), documents Resident resting throughout the night no s/s (signs/symptoms) of pain or discomfort noted Right and Left buttock open area noted resident provided peri care barrier cream applied. This nurses note was written by RN-T. Surveyor noted there is no notification to R10's physician regarding the open areas. The nurses note dated 7/15/24, at 12:31, documents Writer followed up r/t (related to) open areas to BIL (bilateral) buttocks. Writer assessed buttocks and cluster wound is noted to coccyx. 3 open areas observed with purple discoloration surrounding them. Documented as cluster DTI (deep tissue injury). Res (Resident) is already seen weekly by wound MD for BIL heel wounds, new wounds added to Wound MD roster. This nurses note was written by Wound Nurse/LPN-K. Surveyor noted there is no RN assessment of R10's pressure injuries. The nurses note dated 7/15/24, at 12:36, documents F/U (follow up) to add wound measurements. Wound measures 6.5 cm x 4.5 cm x 0.1 cm. This nurses note was written by Wound Nurse/LPN-K. The nurses note dated 7/16/24, at 15:43 (3:43 p.m.), documents Res seen by Wound MD this day and BIL heel wounds noted with improvement. Yesterday after reports of new wounds writer assessed res and measured 3 wounds to coccyx area as 1 cluster wound. MD has separated these wounds to be measured and treated separately d/t location of sites. New wounds to left and right buttock as well as coccyx are stage 3's. Writer phoned res RP(Responsible Party) [Name] but she is out of the office today. Writer left message for [Name] to return call for a wound update. Sharps debridement done at bedside per MD and res tolerated well. New tx (treatment) orders received and initiated for buttocks wounds. POC (plan of care) updated to reflect the above. This nurses note was written by Wound Nurse/LPN-K. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32.) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 3.7, width 1.8, and depth 0.1. Stage is Stage III (3). Summary documents res noted with new wound to left buttock on 7/15. Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 23.) Coccyx. Type is Pressure. Length 1.6, width 1.1, and depth 0.1 Stage is Stage III (3). Under Summary documents res noted with new wound to coccyx on 7/15. wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31.) Right Buttocks. Type is Pressure. Length 0.9, width 1.3, and depth 0.1. Stage is Stage III (3). Summary documents Res noted with new wound to right buttocks on 7/15. wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Surveyor noted there were no revisions to R10's skin integrity care plan after R10 developed the three stage 3 pressure injuries. None of R10's care plans include interventions on how often R10 should be repositioned or when continence cares should be provided. The nurses note dated 7/18/24, at 23:29 (11:29 p.m.), documents Resident alert and responsive able to voice needs, treatment maintained to buttocks, resident repositioned as needed tolerated well bilat (bilateral) heels elevated in bed, This nurses note was written by Nursing-U. On 7/22/24 an intervention to the ADL (activities daily living) self care performance deficit care plan was added which documents Resident is resistive to cares, turning, and repositioning. This intervention was added 7 days after R10 developed 3 stage 3 pressure injuries. There is not a refusal of cares care plan. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 2.9, width 1.7, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 40% granulation and 60% slough. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. Date of onset is 7/15/24. Wound site documents 23) Coccyx. Type is Pressure. Length 1.6, width 1.1, and depth 0.1 Stage is Stage III (3). Under Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31) Right Buttocks. Type is Pressure. Length 0.9, width 0.8, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 2.0, width 1.5, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. Date of onset is 7/15/24. Wound site documents 23) Coccyx. Type is Pressure. Length 1.6, width 1.0, and depth 0.1 Stage is Stage III (3). Under Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31) Right Buttocks. Type is Pressure. Length 0.8, width 0.8, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. The weekly wound assessment dated [DATE] documents for date of onset 7/15/24. Wound site is 32) Left Buttocks. Type is Pressure. Length in cm (centimeters) is 3.5, width 0.8, and depth 0.1. Stage is Stage III (3). Summary documents Wound bed with 40% slough, 10% granulation, and 50% skin. Light serosanguineous drainage. Wound edges well defined. No evidence of infection observed. Date of onset is 7/15/24. Wound site documents 23) Coccyx. Type is Pressure. Length 1.1, width 0.8, and depth 0.1 Stage is Stage III (3). Under Summary documents Wound bed with 100% granulation. Light serosanguineous drainage. Wound edges well defined. Date of onset is 7/15/24. Wound site documents 31) Right Buttocks. Under summary documents wound is now healed. On 8/12/24, at 10:50 a.m., Surveyor observed R10 in bed on her back with her eyes closed, as oxygen via nasal cannula, and the head of the bed elevated. R10 is on an air mattress and is wearing blue pressure relieving boots. Surveyor noted the air mattress was provided on 5/21/24. On 8/12/24, at 12:21 p.m., Surveyor observed R10 continues to be in bed on her back with the head of the bed elevated. On 8/12/24, at 1:55 p.m., Surveyor observed R10 continues to be in bed on her back. Surveyor asked R10 what staff does for her. R10 replied they take care of what ever I need. Surveyor asked R10 if staff repositions her from side to side. R10 replied Usually I stay on my back. Surveyor asked R10 if staff asked her if she wanted to be repositioned on her side today. R10 replied no. Surveyor asked R10 if she has any pressure ulcers. R10 replied on my left heel. Surveyor asked R10 if she has anything on her bottom. R10 replied yes, two sores. Surveyor asked R10 has she developed the sores. R10 replied I don't know. On 8/13/24, at 8:19 a.m., Surveyor observed R10 in bed on her back with the head of the bed up high. R10 is on an air mattress and is wearing pressure relieving boots. On 8/13/24, at 9:41 a.m., Surveyor observed CNA-G & CNA-H enter R10's room. Surveyor asked CNA-G & CNA-H what they were going to do. CNA-G informed Surveyor they were going to change R10. Surveyor observed CNA-G & CNA-H were wear gloves. CNA-G lowered R10's head of the bed and raised the bed up. R10's blanket was removed and staff unfastened the incontinence product. Surveyor observed there is BM (bowel movement) up R10's frontal perineal area. CNA-G informed R10 she was going to clean her and washed R10's frontal perineal area to remove the BM. CNA-G informed R10 she was going to turn R10 towards the window. CNA-G pulled on the soaker pad to move R10 towards the left side of the mattress and CNA-G & CNA-H positioned R10 on the right side. CNA-G removed the dressing from R10's coccyx/left buttocks. Surveyor observed there is a Stage 3 pressure injury on R10's coccyx and left buttocks. CNA-G washed R10's rectal area & buttocks to remove the BM, applied barrier cream on R10's buttocks and an incontinence product was placed under R10 & fastened. CNA-G informed R10 the wound doctor would be here to change her patch. Surveyor asked CNA-G & CNA-H if Surveyor could look at R10's feet. CNA-G removed R10's blue pressure relieving boots. Surveyor did not observe any pressure injuries on R10's feet. CNA-G placed the pressure relieving boots back on R10 and R10 was positioned on the left side. On 8/13/24, at 9:54 a.m., Surveyor asked CNA-G how R10 developed the pressure injuries. CNA-G replied I'm not really sure. On 8/13/24, at 9:56 a.m., Surveyor asked CNA-H if she knew how R10 developed the pressure injuries. CNA-H informed Surveyor she usually works on the first floor or the other hallway explaining she gets moved around. Surveyor asked CNA-H if she did provided any cares to R10 prior to Surveyor's observation. CNA-H informed Surveyor she gave her ice water and changed her. CNA-H informed Surveyor R10 gets up after lunch depending on how she is. Surveyor asked CNA-H what time did she take care of R10. CNA-H informed Surveyor around 7:30 a.m. Surveyor asked CNA-H how often R10 should be repositioned CNA-H informed Surveyor probably every hour or so. On 8/13/24, at 9:59 a.m., Surveyor asked CNA-G how often R10 is repositioned. CNA-G replied every two hours. On 8/13/24, at 10:29 a.m., Surveyor asked Wound Nurse/LPN (Licensed Practical Nurse)-K how R10 developed the three Stage 3 pressure injuries on 7/15/24. Wound Nurse/LPN-K informed Surveyor it started as maceration, she's a heavy wetter, and has a history of wounds in the same area. Surveyor asked who revises skin impairment care plans. Wound Nurse/LPN-K replied typically me when we have wounds or is resolved. On 8/13/24, at 10:31 a.m., Surveyor observed wound rounds for R10 with Wound Nurse/LPN-K & Wound MD-Q. Wound MD-Q assessed R10's pressure injuries stating both are smaller today. Wound MD-Q assessed R10's coccyx Stage 3 pressure injury as having measurements of 0.7 cm (centimeters) x (times) 0.3 cm x 0.1. The wound bed 50% granulation and 50% slough. The left buttocks measurements are 0.5 cm x 0.3 cm x 0.1 cm. The wound bed is 100% granulation. After Wound MD-Q assessed R10's pressure injuries, Wound Nurse/LPN-K completed the treatment according to physician's orders. There were no concerns identified during this observation. On 8/13/24, at 10:49 a.m., Surveyor asked Wound MD-Q how R10 developed the Stage 3 pressure injuries on the left & right buttocks and coccyx on 7/15/24. Wound MD-Q informed Surveyor R10 is overweight and sometimes refuses positioning. Wound MD-Q informed Surveyor sitting in the same position you develop a pressure injury right away. Wound MD-Q stated now that R10 has the wounds she is listening more, before that not so much. On 8/13/24, at 10:51 a.m., Surveyor asked RN/UM (Registered Nurse/Unit Manager)-D how R10 developed the three Stage 3 pressure injuries on 7/15/24. RN/UM-D replied I don't know if I'm the right person. RN/UM-D informed Surveyor R10 was admitted with wounds. RN/UM-D informed Surveyor sometimes R10 can be non compliant with repositioning and doesn't always want to get out of bed which is their right to choose. Surveyor then read R10's nurses note dated 7/7/24 which includes there is excoriation bilateral to buttocks, writer covered with bordered bandage. Surveyor informed RN/UM-D Surveyor did not note where R10's physician was notified or any order for the excoriation. RN/UM-D informed Surveyor this may be an agency nurse. Surveyor then read R10's nurses note dated 7/9/24 which includes changed sacrum dressing. RN/UM-D informed Surveyor she didn't know anything and this was a third shift nurse. Surveyor read R10's note dated 7/15/24 which included noted right and left buttock open area noted resident provided peri care barrier cream applied. Surveyor informed RN/UM-D there is no physician notification and no assessment of the open areas. RN/UM-D informed Surveyor this nurse is no longer employed. Surveyor asked RN/UM-D who revises the care plans as Surveyor noted R10's care plan was not revised after development of the three pressure injuries. RN/UM-D replied our DON (Director of Nursing) or wound nurse does. On 8/13/24, at 11:41 a.m., Surveyor asked DON (Director of Nursing)-B and ADON (Assistant Director of Nursing)-N who revises care plans. DON-B replied we do that as a team. Surveyor asked when care plans are revised. DON-B informed Surveyor on admission, readmission, any changes that occur such as fall or new open area. Surveyor informed DON-B & ADON-N R10 developed 3 stage 3 pressure injuries on 7/15/24. There were no revisions after development of the pressure injuries to R10's care plan. Surveyor informed DON-B & ADON-N on 7/7/24 there is a nurses note regarding excoriation with a dressing being applied. Surveyor noted there was no physician notification or order for treatment. On 7/9/24 there is a nurses note which documented the sacrum dressing was changed. There is no order for a dressing or assessment of this area. On 7/15/24 there is a nurses note regarding left & right buttock open area with barrier cream being applied. The RN didn't assess this area and there is no notification to the physician. Surveyor informed DON-B and ADON-N R10's care plans do not have any interventions as to how often R10 should be repositioned and Surveyor was informed R10 is a heavy wetter but there are no interventions as to how often R10 should be checked and changed. Surveyor asked DON-B and ADON-N to provide any additional information Surveyor may have not reviewed. On 8/13/24, at 12:31 p.m., NHA (Nursing Home Administrator)-A, DON-B and ADON-N were informed of the above. No additional information was provided to Surveyor regarding the development of R10's three Stage 3 pressure injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure each resident receives adequate supervision or assistance devices to prevent accidents for 1 (R8) of 3 residents reviewed for accidents. *R8 was re-admitted to the facility on [DATE] and had a significant change in R8's cognition and activities of daily living (ADL's) performance and enrolled onto Hospice services. R8 care plan and certified nursing (CNA) care [NAME] was not revised to indicate R8's decline. R8 had a fall on 5/18/2024 that resulted in a dislocated finger with avulsion and 3 sutures for a laceration. Findings include: The facility policy, entitled Change in a Resident's Condition or Status, revised on 5/10/2024, documents: . 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 5. The Nurse Supervisor/Charge Nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The facility policy, entitled Care Plan Revisions, implemented on 6/14/2024, documents: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change, 2. Procedure for reviewing and revising the care plan when a resident experiences a status change: a. The Interdisciplinary Team (IDT) will discuss the resident condition and collaborate on intervention options. b. The care plan will be updated with the new or modified interventions. c. Staff involved in the care of the resident will report resident response to new or modified interventions. d. Care plans will be modified as needed by the minimum data set (MDS) Coordinator or other designated staff member. R8 was initially admitted to the facility on [DATE] and R8 was readmitted to the facility on [DATE] and has diagnoses that include Chronic Obstructive Pulmonary Disease (COPD), Acute on Chronic Respiratory Failure with Hypercapnia and Hypoxia, Major Depressive Disorder, Anxiety Disorder, Metabolic Encephalopathy, history of alcohol abuse, muscle weakness, adult failure to thrive, and was dependent on supplemental oxygen. R8's quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated R8 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 and the facility assessed R8 to require minimal assist of 1 staff member for oral hygiene, toileting hygiene, repositioning and transferring and modified independent with set up with eating, bathing, upper and lower body dressing, and personal hygiene. R8 was able to propel self in a manual wheelchair with R8s lower legs for long distance and ambulate independently with a wheeled walker in R8's bedroom. R8 was occasionally incontinent of urine and frequently incontinent of bowel and wore adult briefs for protection. R8 was assessed on 5/17/2024 to be a moderate risk for falls with a fall risk score of 10.0. R8 was admitted on to Hospice care on 5/17/2024 for terminal COPD. R8's ADL (Activities of Daily Living) self-care care plan . care plan initiated on 1/21/2021 and last reviewed on 12/14/2023 had the following interventions in place: . - Locomotion: (R8) has a w/c (wheelchair) and is able to propel self and can ambulate independently in his room. (initiated: 5/5/2021, revision: 2/4/2022) - Bed Mobility: Independent (initiated: 1/21/2021, revision: 5/24/2023) - Toilet use: Independent, he is continent of bowel and bladder (initiated: 1/21/2021, revision: 5/24/2023) - Transfer: patient able to transfer in room to/from bed, w/c and toilet at MI (modified independent with use of grab bars for support. Able to ambulate in hallway with four wheeled walker and staff, requires supervision. When up ambulating with four wheeled walker, patient should have supervision for O2 (oxygen) tubing management and safety. (initiated:1/21/2024, revision: 5/2/2024) - Encourage resident to use bell to call for assistance (Initiated 5/5/2021) - Monitor/document/report PRN (as needed) any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function (initiated 5/5/20210) R8's risk for falls care plan . initiated on 1/27/2021 and last reviewed on 12/14/2023 had the following interventions in place: . - Be sure (R8's) call light is within reach and encourage (R8) to use it for assistance as needed. (initiated 1/27/2021, revision: 5/5/2021) - Ensure (R8) is wearing appropriate footwear when ambulating or mobilizing in w/c. (initiated 5/5/2021, revision: 11/3/2021) - Provide a reacher (initiated 2/26/2024) On 5/6/2024, R8 was admitted to the hospital with symptoms of shaking, tremors and elevated temperature. R8 underwent testing in the hospital, and it was documented that a lesion was found on R8's liver. R8's history indicated possible primary lung malignancy with metastasis to the liver. R8's power of attorney (POA) was activated and determined no further testing to be done due to R8's frailty and malignancy diagnosis. R8 and R8's POA decided to admit R8 into Hospice services. On 5/17/2024, at 18:30 (6:30 PM), in the progress notes nursing charted R8 arrival back to facility with Primary dx (diagnosis) documented as possible metastatic lung cancer versus chronic aspiration, Severe COPD On 5/17/2024, at 18:42 (6:42 PM), in the progress notes Assistant Director of Nursing (ADON)-N documented Nurse Practitioner (NP) aware of (R8) readmit to the facility and clarified medication orders with the NP. On 5/17/2023, at 21:37 (9:37 PM), in the progress notes nursing documented (R8) assessed by [Hospice company] and admitted to hospice care with diagnosis of terminal COPD. New orders noted for comfort medications. On 8/13/2024, Surveyor reviewed R8's hospital occupational therapy (OT) notes dated 5/17/2024 at 2:55 PM that documented: Cognitive Status: - (R8) confused and flat affect, oriented to person, disoriented to time, situation, and place. - overall status: impaired Sitting Balance: -Minimal assist required due to posterior lean when performing UE/LE (upper extremity/ lower extremity) exercise. Bed Mobility: - Repositioning in bed: 2 person, total assist-dependent (boost towards HOB (head of bed)) - Minimal assist for BLE (bilateral lower extremity) advancement and scooting towards end of bed. (R8) tolerated sitting up two minutes before returning back to lying. Assessment: - No functional improvements. - ADL's requiring support at discharge: transfers, dressing, grooming, bathing, toileting, and ambulation. - Staff assists. - Current self-care score-12 (score key indicates score of 9-12 requires maximal assist) - (R8) seen for occupational therapy session. (R8) wanting to sit at end of bed for session. (R8) confused with poor tolerance, quickly returning back to supine in bed. Plan for hospice at facility, poor activity tolerance, and limited progress made with therapy- will discharge 5/17/2024. End of Session: - (R8) in bed. - Safety measures: alarm system in place/re-engaged, lines intact and call light within reach. - Handoff therapist to nurse. Surveyor noted recommendations from OT regarding R8's ADL activity required maximal assist with all ADL's and R8 was documented to be more confused and have a flat affect. Surveyor also noted R8 required an alarm system when in the hospital. Surveyor noted there were no revisions made to R8's ADL or fall care plan with the recommendations from the hospital occupational therapist assessment of R8 on 5/17/2024. On 8/13/2024, Surveyor reviewed R8's CNA [NAME] dated 5/17/2024 with the following care recommendations for R8: ADL: - Bed Mobility: Supervision, one person physical assist - Transfer: Independent, no setup or physical help from staff - Walk in room: Independent, setup help only - Walk in corridor: Independent, no setup or physical help from staff - Locomotion on unit: Independent, no setup or physical assist from staff - Locomotion off unit: Independent, no setup or physical help from staff - Dressing: Independent, setup help only - Eating: Supervision, setup help only - Toilet use: Supervision, one person physical assist - Personal hygiene, Supervision, one person physical assist - Bathing: Total dependence, One person physical assist. Not Steady during Transitions/ Walking for: - Moving from seated to standing - Walking - Turning around - Moving on and off toilet - Surface to surface transfers Surveyor noted the CNA [NAME] was not revised to indicate the recommendations for R8 from the hospital regarding R8's ADL needs with the noted change in condition. On 5/18/2023, at 06:47 (6:47 AM), in the progress notes nursing documented (R8) alert and responsive. No s/s (signs/ symptoms) of pain or discomfort noted. Repositioning Q (every) 2 (two) hours and PRN (as needed) Surveyor noted the above intervention: Repositing every 2 hours and PRN was not added to R8's care plan or CNA [NAME]. On 5/18/2024, at 22:21 (10:21 PM), in the progress notes Registered Nurse (RN)-L documented resident found on floor by staff. Unable to explain what made (R8) fall down. On assessment (R8) was lying on right side, had injury, right 4th finger was bleeding without stopping, pressure applied. Right elbow and right shoulder also had some bleeding. (R8) was transferred to [Hospital Name] for further evaluation On 5/19/2024, at 01:22 (1:22 AM), in the progress notes nursing documented R8 will be returning back to facility with diagnoses of dislocated finger. On 5/19/2024, at 06:30 (6:30 AM), in the progress notes nursing documented (R8) returned from emergency room . splint on right hand, fourth digit Surveyor reviewed R8's emergency room report that documented on physical exam: -Right wrist swelling (and ecchymosis (bruising) of ring finger), deformity (ring finger), laceration (pulp of ring finger), tenderness and bony tenderness present. Procedure: -Right ring finger, length: 2 cm, 3 sutures to area, tolerated well without complications. X-ray of right hand and right fingers: Impression: - Dislocation of the fourth phalanx (finger) with avulsion (when an injury causes a ligament or tendon to break off a small piece of bone that is attached to it). - Overlying soft tissue defect consistent with known laceration of the fourth digit. - Right fourth phalanx put into splint. Surveyor reviewed the fall investigation for R8's fall on 5/18/2024. RN-L documented R8 was incontinent at the time of fall and the resident stated, I was trying to go pee. The IDT (Interdisciplinary Team) reviewed the fall and documented R8 had a recent decline in health and now on Hospice services. R8 has lung cancer with metastasis. BIMS score of 9 with moderate impairment. R8 does not always call for assistance, R8 was independent prior to recent hospitalization, due to change in medical condition new intervention implemented is toileting every 2-3 hours as R8 will allow. On 8/13/2024, at 10:37 AM, Surveyor interviewed RN- L who stated RN-L is an agency nurse and moves around a lot and could not recall anything specific about R8 or a fall on 5/18/2024. Surveyor asked RN-L how RN-L would find information for a resident that RN-L was not familiar with to know what cares the resident needed. RN-L stated it would depend on what the facility policy is, but typically information would be gathered with shift change reporting from the previous nurse. RN-L also stated RN-L reviews the 24 hour board and will look at the care plan and what interventions are documented. Surveyor asked RN-L if RN-L recalls reviewing R8's care plan or revising the care plan after R8's fall on 5/18/2024. RN-L stated RN-L could not recall any detail regarding R8 or a fall on 5/18/2024. On 8/13/2024, at 11:27 AM, Surveyor interviewed Director of Nursing (DON)- B and ADON- N. Surveyor asked what staff is responsible for revising care plans. DON-B stated DON-B and ADON-N will do the initial care plan with appropriate interventions when able and any revisions to care plans are done as a team at weekly at risk meetings and as needed by other nursing staff. DON-B stated new admission, readmissions and changes of conditions are discussed with the IDT at weekly at risk meetings. DON-B stated any nursing staff is able to initiate a care plan and communicate it to management, put concerns on the 24 hour board, and make a note in progress notes. Surveyor asked what the process was when residents are readmitted to the facility and have a significant change to their previous plan of care. ADON- N stated the admitting nurse would update the care plan and manager. ADON- N stated the admitting nurse also fills out a readmit screener form and the form touches on the residents ADL function and if there are changes noted on the screener than from previous assessments of the resident then the care plan is updated and also should be noted on the 24 hour board and documented in the progress notes. Surveyor asked ADON- N if ADON- N recalled the readmission for R8 on 5/17/2024 and the changes documented from the hospital for R8. ADON- N stated ADON- N could not recall specific details about R8's readmission on [DATE] or if she reviewed any of the admission paperwork. Surveyor informed ADON- N that ADON- N documented in the progress notes about contacting R8's NP regarding clarification orders for R8. ADON-N stated ADON- N did not recall the specifics or if ADON-N assisted with anything else from R8's readmission on [DATE]. Surveyor reviewed R8's re-admission screener form that was documented by RN-L on 5/17/2024, at 18:55 (6:55 PM). RN-L documented the following assessments for R8: BIMS-9, moderately impaired cognition ADLs - Eating, 5-set up or clean up assistance - Oral hygiene, 5- set up or clean up assistance - Toileting hygiene, 3- partial/moderate assistance - Sit to lying, 3- partial/moderate assistance - Lying to sitting on side of bed, 3-partial/moderate assistance - Sit to stand, 88- not attempted due to medical condition or safety concerns - Chair/bed to chair transfer, 88- not attempted due to medical condition or safety concerns - Toilet transfer, 88- not attempted due to medical condition or safety concerns - Walking, 88- not attempted due to medical condition or safety concerns Bladder: - Continent-No - How often is resident wet-once or more per shift - Resident is wet during-day and nighttime Bowel: - Continent-yes Mobility: -locomotion on unit (self-performance)-2, limited assistance Surveyor noted R8's assessed decline in ADL performance, toileting needs, mobility, and cognition did not get revised on R8's care plan or CNA [NAME]. Surveyor reviewed the 24 hour boards from 5/17/2024 and 5/18/2024. The 24 hour board had the following documentation on 5/17/2024: PM shift: -(R8) alert and oriented X3 (person, place, time), no respiratory distress noted, Assist of 1 with all cares and transfers, incontinent at times. NOC (night) shift: -(R8) no respiratory distress noted at this time, O2/ NC (nasal cannula) as ordered, scheduled breathing treatments, repositioning. The 24 hour board had the following documentation on 5/18/2024: AM shift: -No Issues PM shift: -(R8) fell with injury, out to hospital. On 8/13/2024, at 12:30 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A, DON-B and ADON-N that R8's care plan and CNA [NAME] were not revised to indicate R8's change in condition regarding R8's decline in cognition, ADL needs when R8 was readmitted from the hospital on 5/17/2024 and R8 experienced a fall on 5/18/2024 that resulted in a right hand, 4th ring finger fracture with avulsion and required 3 sutures for a laceration. On 8/13/2024, at 1:24 PM, Surveyor interviewed RN unit Manager (RNUM)-D who stated R8 was independent with ADLs and then declined rather quickly once R8 was readmitting to the hospital after the new cancer diagnosis and was put on hospice. Surveyor asked RNUM- D how staff are made aware of significant changes or care concerns for residents. RNUM- D stated the concerns are reviewed in the morning stand up meetings with the IDT M-F, care plans are initiated and/or revised, education is provided to nursing, concerns are put on the 24 hour board and passed on in shift to shift reporting, and documenting in progress notes. Surveyor asked what happens if concerns should arise after hours or on a weekend. RNUM-D stated managers are always on call if nursing needs guidance, but care plans should still be updated, concerns put on 24 hour board, and documented in progress notes then the IDT reviews the next business day to make sure all the concerns were addressed and updated where needed. On 8/13/2024, at 1:33 PM, Surveyor interviewed CNA-M who stated CNA-M noted R8 to be more confused and antsy after returning from the hospital on 5/17/2024. CNA-M stated R8 was independent with most ADLs but when he came back from the hospital and put on Hospice R8 needed more redirection and assistance. CNA-M stated CNA-M was in R8's room frequently redirecting R8 and putting R8's oxygen tubing back on because R8 kept taking it off. CNA-M stated CNA-M last checked on R8 and noted R8 to be dry and sitting in R8's wheelchair watching TV. CNA-M stated CNA-M went to collect supper trays and another CNA notified CNA-M that R8 had fallen. Surveyor asked CNA-M how CNA-M was made aware of R8's new care concerns or where CNA-M would look to see what needs R8 required. CNA-M stated in shift report CNA-M was told R8 required more assistance and redirection. CNA-M stated CNA-M also looks at the resident's care [NAME] for direction of any care concerns or interventions a resident might have. Surveyor asked CNA-M if CNA-M communicated to the nurse that R8 was antsy and confused. CNA-M could not recall if CNA-M communicated that or not. CNA-M stated CNA-M and RN-L checked in on R8 frequently due to needing more assistance and redirection. No further information was provided to Surveyor at this time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R17 was admitted to the facility on [DATE] with diagnoses of osteoarthritis of the right hip, malnutrition, anxiety, Alzheimer's, depression, and pemphigoid (an autoimmune disease that causes blisters to form on the arms, legs, and abdomen). R17's annual Minimum Data Set (MDS) assessment dated [DATE] indicated R17 was severely cognitively impaired per staff assessment and the facility assessed R17 as needing extensive assistance with bed mobility and dressing and total assistance with transfers, toilet use, hygiene, and bathing. R17 had an activated Power of Attorney (POA) and was on hospice services. R17's ADL (Activities of Daily Living) Care Plan was initiated on 2/5/2022 with the intervention for bed mobility: one staff assist to turn and reposition in bed every two to three hours as necessary. R17's Skin Integrity Care Plan was initiated on 2/15/2022 when R17 developed a Deep Tissue Pressure Injury to the left heel and had the following interventions: -Educate R17 and family of causative factors and measures to prevent skin injury. -Encourage good nutrition and hydration in order to promote healthier skin. -Follow facility protocols for treatment of injury. -Identify potential causative factors and eliminate/resolve when possible. -Keep skin clean and dry; use lotion on dry skin; do not apply at site of injury. -Monitor/document location, size and treatment of skin injury; report abnormalities, failure to heal, sign or symptoms of infection, maceration, etc. to the physician. -No bleached linens. -Provide pressure relieving/reducing mattress, Prevalon boots, pillow between thighs for pressure relief. -Treatment and supplements per physician order. R17's Skin Integrity Care Plan was resolved on 1/4/2023. R17's Actual Impairment to Skin Integrity Care Plan was initiated on 1/4/2023 due to bullous pemphigoid and unstageable pressure injuries to the sacrum and the left buttock with the interventions: -Avoid scratching and keep hands and body parts from excessive moisture; keep fingernails short. -Follow facility protocols for treatment or injury. -Geri sleeves to bilateral arms to provide comfort and protect skin. -Identify/document potential causative factors and eliminate/resolve where possible. -Monitor/document location, size, and treatment of skin injury; report abnormalities, failure to heal, signs or symptoms of infection, maceration, etc. to the physician. -Staff to assist in turning and repositioning; (R17) will refuse to lay on side frequently. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R17's Pressure Injury Care Plan was initiated on 4/8/2023 with the interventions: -Apply barrier cream during periods of incontinence/toileting and as needed per physician orders to help prevent skin breakdown. -Assess, record, and monitor wound healing daily; measure length, width, and depth were possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Avoid positioning R17 on the sacrum. -R17 has specialty air mattress; use one disposable pad over lift sheet (no cloth pads); check to be sure pump/mattress is functioning correctly with care; manufacturer guidelines available in resident room. -R17 needs moisturizer applied frequently to skin; do not massage over bony prominence's and use mild cleansers for peri care and washing. -R17 requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. -R17 requires a pressure relieving reducing device on the bed and chair. -Complete every shift foot checks. -Follow facility policies and protocols for the prevention and treatment of skin breakdown. -Monitor R17's dressing daily to ensure it is intact and adhering; report loose dressing to treatment nurse. -Monitor, document, and report to wound physician or wound nurse as needed changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size, and stage. -Offload heels from mattress and wheelchair (Broda chair) pedals. -Reposition R17 side to side every 3 to 4 hours while in bed to minimize pressure to sacrum or coccyx -Wheelchair cushion. R17 was comprehensively assessed weekly by the wound physician and facility staff for pressure injuries that developed 7/18/2022 and open areas due to pemphigoid blisters that ruptured. On 5/5/2023 on the Weekly Wound assessment tool, nursing charted R17 had an Unstageable pressure injury to the sacrum that measured 3.8 cm x 1.5 cm x 0.5 cm with 76-100% granulation tissue. R17 had this pressure injury since 7/18/2022. Surveyor noted with the percentage of granulation tissue present, the wound was a Stage 3 pressure injury and not Unstageable as documented. No other pressure areas were present. On 5/8/2023 at 1:31 PM, Surveyor observed R17 sitting in a Broda chair in the resident room. Surveyor observed a bolstered alternating pressure air mattress on the bed. A Hoyer lift sling was observed to be underneath R17 in the chair and a cushion was in place under R17. A sign stating to please turn R17 side to side every two hours when in bed was noted to be on the wall at the head of the bed. R17 had the left leg crossed over the right leg with no pillow in between the legs and R17 had fluffy socks on with the feet resting on the foot pedals and on the calf rests of the Broda chair. Surveyor noted heel boots were on the top of the dresser. R17 had non-sensical talk and was unable to answer any questions. On 5/9/2023 at 11:16 AM, Surveyor observed R17 sitting in a Broda chair in the dining area across from the nurses' station. R17 had heel boots on. On 5/9/2023 at 1:54 PM, Surveyor observed R17 receiving wound care by Licensed Practical Nurse (LPN)-F and assisted by LPN-K who was in training. LPN-F provided wound care to the Unstageable pressure injury and when the treatment was completed, LPN-F and LPN-K positioned R17 on their back. LPN-F asked LPN-K to raise the head of the bed up slightly. Surveyor noted the positioning of R17 put direct pressure on the sacral pressure injury. LPN-F stated the wound nurse no longer worked at the facility as of a week ago so now the floor nurses have to do all the treatments. LPN-F stated they had been a nurse for only four months with this facility being the only place they had worked and they were learning as they go about how to do treatments and how to look at wounds. On 5/10/2023 at 1:15 PM, Surveyor met with Nursing Home Administrator (NHA)-A and shared the concerns with the observations of R17 having the feet directly on the Broda chair foot pedals and calf rests and how LPN-F positioned R17 after doing the wound care treatment to the sacral pressure injury. Surveyor shared with NHA-A that R17's intervention of having a pillow between the legs was removed on 1/4/23 when the skin integrity care plan was noted to be resolved. Surveyor shared with NHA-A multiple observations that were made throughout the survey of R17 having the left leg crossed over the right leg. Surveyor shared with NHA-A that R17 had a history of a wound to the right upper thigh where the left leg crossed over and would benefit from having protection to that area. (Documentation of the right upper thigh wound was originally documented as being from pressure but was then determined to be from pemphigus as a ruptured blister.) Surveyor asked NHA-A if NHA-A knew why the Skin Integrity Care Plan with those preventive interventions was resolved and why the current Pressure Injury Care Plan did not incorporate the heel boots or pillow between the legs. NHA-A did not know why the Skin Integrity Care Plan was discontinued. No further information was provided at that time. Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 (R16, R4, & R17) of 4 Residents reviewed for pressure injuries. * On 4/17/23, R16 developed an SDTI (suspected deep tissue injury) on the right medial heel. On 5/8 and 5/9/23, R16 was observed with the left thigh on top of the SDTI (right heel) and neither the left or right heel were offloaded. R16 was not wearing a Prevalon boot on the right foot. R16 did not have bilateral heel floaters while in bed as per physician's order dated 11/24/21. After R16 developed the SDTI on 4/17/23, the pressure injury care plan was not revised. During the weeks of 4/23/23 to 4/29/23 there was no RN assessment of R16's pressure injury. There were two different treatments for R16's right heel which were: 11/17/22 right medial heel cleanse with saline protect periwound with skin prep cover with foam change every Monday, Wednesday and Friday and 4/18/23 right heel cleanse with soap & water, pat dry, skin prep area followed by foam border on right heel daily and prn for preventative protection. Example 1 rises to a scope and severity level of G harm/isolated. * R4 was observed with non blanchable skin on the coccyx during continence cares. Barrier cream was not applied as R4 did not have any barrier cream. * R17 was observed having the feet directly on the Broda chair foot pedals and calf rests. The intervention of having a pillow between the legs was removed and the multiple observations that were made throughout the survey of R17 having the left leg crossed over the right leg where R17 has a wound to the right upper thigh. After R17's sacral pressure injury treatment was completed the head of the bed was elevated and R17 was positioned on the back. Findings include: The Prevention of Pressure Ulcer policy and procedure from 2001 Med-Pass Inc., (Revised October 2010) under general preventative measures documents: 2. For a person in bed: a. Change position at least every two hours or more frequently if needed. b. Determine if resident needs a special mattress. c. If a special mattress is needed use one that contains foam, air, gel or water as indicated; d. Raise the head of the bed as little and for as short a time as possible, and only as necessary for meals, treatments and medical necessity. 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of the interventions; and to modify the interventions as appropriate. 1. R16's diagnoses include encephalopathy, hemiplegia and hemiparesis after cerebral vascular accident affecting right dominate side, chronic respiratory failure, contracture of right knee, anxiety disorder, and depressive disorder. The potential for pressure injury/ulcer development initiated 6/18/19 & revised 11/7/22 has the following interventions: * 1/15/22 weekly skin checks per policy. Initiated 1/18/22. * Administer treatments as ordered and monitor for effectiveness. Initiated 6/19/19. * Avoid positioning [R16's first name] on R (right) medial foot. Initiated 6/18/19 & revised 11/26/19. * Continue to encourage and educate [R16's first name] on the importance of floating her heels when in bed and to use prevalon boot to right foot. Initiated 8/21/20 & revised 8/6/22. * Daily foot checks by licensed staff. Initiated 8/27/19. * Education provided to [R16's first name] and family r/t (related to) appropriate positioning and skin protection. Initiated 5/31/22 & revised 8/6/22. * Ensure bedside table moved away from bed with all cares and repositioning. Initiated 3/25/22. * Inspect skin daily with cares-nursing assistant to report any concerns or changes to the nurse. Initiated 8/27/19. * Medacure APM mattress. Initiated 11/25/20. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 6/18/19. * Obtain and monitor lab/diagnostic work as ordered. Report results to MD (medical doctor) and follow up as indicated. Initiated 6/18/22. * Sheepskin palm guard on am (morning) off hs (hour sleep). Initiated 3/18/22. * Treatment as ordered to fungal rash R (right) hand. Initiated 3/18/22. * Turn and reposition every 2-3 hours while in bed and while up in chair, document refusals. Initiated 8/27/19 & revised 2/26/20. * Vitamin and protein supplements. Initiated 2/15/22. * W/C (wheelchair) cushion. Initiated 8/27/19 & revised 8/2/22. * Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, wound MD to follow. Initiated 6/18/19 & revised 12/14/21. The Braden assessment dated [DATE] has a score of 12 which indicates high risk. Surveyor was unable to locate another Braden assessment after 6/7/22. The CNA (Certified Nursing Assistant) Kardex as of 5/9/23 under the section monitors documents w/c (wheelchair) cushion. The other sections on this CNA Kardex are toileting, personal hygiene/oral care, eating/nutrition, dressing/splint care, and bathing. None of these sections address pressure relieving interventions including floating heels or repositioning. The quarterly MDS (minimum data set) with an assessment reference date of 3/5/23 documents a BIMS (brief interview mental status) score of 12 which indicates resident is moderately impaired. R16 is coded as not having any behavior including refusal of cares. R16 requires extensive assistance with two plus person physical assist for bed mobility & toilet use, is dependent with two plus person physical assist for transfer, and does not ambulate. R16 is always incontinent of urine and bowel. R16 is at risk for pressure injuries and is coded as not having any pressure injuries. Surveyor reviewed R16's physician orders and noted the orders include the following: * Bilateral heel floaters while in bed every shift with an order date of 11/24/21. * Right medial heel Cleanse with saline protect periwound with skin prep cover with foam change every Monday, Wednesday, Friday for treatment with an order date of 11/7/22. * Alternating air pressure mattress for prevention and wound tx. (treatment) every shift monitor for functioning with an order date 1/19/23. * Right heel Cleanse with soap & water, pat dry, skin prep area f/b (followed by) foam border dressing on right heel daily and prn for prevenative protection. Every day shift for wound care and as needed for preventative management (protection) every day shift for preventative care with an order date of 4/18/23. The late entry nurses note dated 4/17/23 & created on 4/18/23 documents: Writer notified that resident has an open area to the right heel. Right heel then washed with soap and water, dry skin removed. Observed small DTI (deep tissue injury). Assessment-Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration no epidermal separation revealing a dark wound bed (2.0 cm (centimeter) x (times) 0.9 cm). NP (nurse practitioner) notified & POA (power of attorney) [name] husband notified at 1333(1:33 p.m.) via phone call. TX (treatment) order placed. This nurses note was written by Former Wound Nurse/LPN (Licensed Practical Nurse)-M. The late entry nurses note dated 4/17/23 & created on 4/18/23 documents: Writer assessed new wound to right outer heel. Skin flaky, scaly skin. Area cleansed with normal saline and pat dry. Area is deep red not open measures 2cm x 1 cm. No s/s (signs/symptoms) pain with wash or measurement. Foam border placed on wound and change every 3 days and as needed. This nurses note was written by RN (Registered Nurse) Supervisor-H. The nurses note dated 4/19/23 documents: Resident had tears running down her cheek, when asked if she was having pain she put her thumb up which means yes. Resident pointing down to her foot, but can not verbalize where the pain exactly is. NP (Nurse Practitioner) [name] updated and new order for PRN (as needed) Tramadol ordered. If staff asked if she was having pain she can put her thumb up for yes or put her thumb down for no. Will continue to monitor pain and prn pain medication effectiveness. The weekly wound assessment dated [DATE] for date of onset 4/17/23 documents for wound site 49) right heel, type is pressure, and stage is Suspected Deep Tissue Injury. Measurements are length 2.0 and width 0.9. Treatment is wash with soap and water, pat dry, skin prep, f/b (followed by) foam border placed on wound and changed every 3 days and as needed. The summary section is blank. This assessment was completed Former Wound Nurse/LPN-M. There was no revision in R16's pressure injury care plan after R16 developed the suspected deep tissue injury. The weekly wound assessment dated [DATE] for date of onset 4/17/23 documents for wound site 49) right heel, type is pressure, and stage is Suspected Deep Tissue Injury. Measurements are length 2.0 and width 0.9. Treatment is wash with soap and water, pat dry, skin prep, f/b (followed by) foam border placed on wound and changed every 3 days and PRN. Preventative. The summary section documents Margin detail attached edges Wound bed assessment epithelialized Drain description none Periwound C/D/I (clean/dry/intact) This assessment was completed Former Wound Nurse/LPN-M. Surveyor noted there is no RN assessment. The weekly wound assessment dated [DATE] for date of onset 4/17/23 documents for wound site 49) right heel, type is pressure, and stage is Suspected Deep Tissue Injury. Measurements are length 1.0, width 1.0 and depth 0. Treatment is wash with soap and water, pat dry, skin prep, f/b (followed by) foam border placed on wound and changed every 3 days and PRN. Preventative. The summary section documents Margin detail attached edges Wound bed assessment epithelialized Drain description none Periwound C/D/I (clean/dry/intact) wound bed is 100% skin will monitor and may heal next assessment. On 5/8/23 at 10:25 a.m., Surveyor observed R16 in bed on her back, with the head of the bed elevated. R16 has an air mattress and R16's heels do not appear to being offloaded. Surveyor asked R16 if she was wearing pressure relieving boots? R16 gave Surveyor thumbs down. R16 communicates by thumbs up indicates yes & thumbs down is no. Surveyor asked R16 if she was wearing socks? R16 gave Surveyor thumbs up. Surveyor asked R16 if she has a pillow under her legs? R16 gave Surveyor thumbs down. On 5/8/23 at 11:31 a.m., Surveyor asked LPN (Licensed Practical Nurse)-F if she is responsible for completing resident's pressure injury treatments? LPN-F informed Surveyor she was. Surveyor inquired if any treatments have been done this morning? LPN-F informed Surveyor she hasn't done any residents' treatments yet and she usually waits until the end of her shift. Surveyor informed LPN-F Surveyor would like to observe R16's pressure injury treatment. On 5/8/23 at 12:39 p.m., Surveyor asked CNA (Certified Nursing Assistant)-D to accompany Surveyor to R16's room as Surveyor would like to look at R16's feet. CNA-D placed PPE (personal protective equipment) on and entered R16's room with Surveyor. Surveyor asked R16 permission to look at her feet with CNA-D. R16 gave Surveyor thumbs up. CNA-D removed R16's bedding. Surveyor observed there is a pillow under R16's left leg with her left heel resting directly on the pillow. R16's right knee is contracted and R16's right medial heel is resting under R16's left thigh and directly on the mattress. R16 is wearing yellow gripper socks on both feet and not wearing a prevalon boot on her right foot as per care plan dated 8/21/20 and 8/6/23. On 5/8/23 at 1:53 p.m., Surveyor observed the treatment for R16's SDTI with LPN (Licensed Practical Nurse)-F. LPN-F washed her hands, placed an isolation gown on, and informed R16 she was going to do her treatment. LPN-F gathered R16's treatment supplies, moved the over bed table from the right side of R16's bed to the left, and placed the treatment supplies directly on the over bed table. Surveyor observed R16 is in the same position as Surveyor's previous observation. R16's left heel is resting directly on the pillow and R16's right medial heel is under the left thigh. LPN-F placed gloves on, removed the bedding off R16, removed the dressing from R16's right medial heel, squirted normal saline on four by four gauze, and removed her gloves. LPN-F placed new gloves, dated the dressing, cleansed the SDTI with the normal saline, applied skin prep around the SDTI, and placed a border gauze dressing over the SDTI. LPN-F removed her gloves, washed her hands, and then removed her gown. On 5/8/23 at 2:02 p.m., Surveyor asked LPN-F how R16 developed the SDTI on her right medial heel? LPN-F replied, I honestly don't know. On 5/8/23 at 3:04 p.m., during the end of the day meeting with Administrator-A and DON (Director of Nursing)-B, Surveyor asked if the wound doctor assesses all residents with pressure injuries? Administrator-A replied yes, unless they are on hospice or refuse. On 5/8/23 at 3:10 p.m., Surveyor informed Administrator-A Surveyor isn't able to locate any wound doctor notes and asked for a copy of the wound doctor notes for R16's right heel. On 5/8/23 at 3:27 p.m., Surveyor observed R16 in bed in the same position as R16 was after LPN-F completed her treatment with R16's left heel resting directly on the pillow and her right heel positioned under the left thigh and directly on the mattress and without wearing a prevalon boot. Surveyor asked R16 if she ever gets out of bed? R16 shook her head no. On 5/9/23 at 7:21 a.m., Surveyor observed R16 in bed on her back with the head of the bed elevated. R16's left heel does not appear to be offloaded. On 5/9/23 at 9:22 a.m., Surveyor observed on R16's wall a blue sign which states: Also please make [R16's first name] keep the pillow under her leg so her heel is not resting against her leg. On 5/9/23 from 9:20 a.m. to 10:00 a.m., Surveyor observed morning cares including incontinence cares for R16 with CNA-D and CNA-N. During this observation at 9:27 a.m., the bedding was removed off R16. Surveyor observed there is a pillow under R16's left leg with R16's left heel resting directly on the pillow. R16's left heel is not being offloaded. R16's right medial heel is under R16's left thigh and directly on the mattress. Upon completion of R16's cares, a pillow was placed under R16's left lower leg. Surveyor observed R16's left heel is resting directly on the pillow and is not being offloaded. On 5/9/23 at 10:05 a.m., Surveyor asked CNA-D if R16 only wears gripper socks on her feet? CNA-D replied yes, she doesn't like her feet to be open to air. On 5/9/23 at 10:15 a.m., Administrator-A informed Surveyor the wound doctor's last note for R16's heel is dated 11/7/22. On 5/9/23 at 11:34 a.m., Surveyor asked LPN-F what staff was doing to promote healing of R16's right medial pressure injury & prevent further pressure injuries? LPN-F informed Surveyor they reposition R16 the best they can due to the position of R16's legs, they are taking care of the current wound and she receives prostat. Surveyor informed LPN-F of the observations of R16's left heel not being offloaded and the right heel under R16's left thigh and not offloaded. LPN-F informed Surveyor sometimes her leg is on top of the right heel. Surveyor informed LPN-F Surveyor is confused regarding R16's right heel treatment. Surveyor informed LPN-F there are currently two treatments for R16's right heel, one cleansing with soap & water and the other with saline followed by skin prep and covered with foam dressing. LPN-F informed Surveyor the CNAs are responsible for soap & water. Surveyor informed LPN-F they wouldn't apply skin prep & a dressing. LPN-F replied, now I'm confused. LPN-F informed Surveyor the wound nurse would be responsible for the treatments but they don't currently have a wound nurse. LPN-F informed Surveyor someone should have discontinued one of the orders and doesn't know why it wasn't discontinued. Surveyor informed LPN-F Surveyor noted a physician's order for bilateral heel floaters in bed and asked if these are currently being used? LPN-F replied, I don't believe so. On 5/9/23 at 1:43 p.m., Surveyor observed R16 in bed on her back with the head of the bed elevated. R16's right heel is resting directly on a pillow and is not being offloaded. On 5/9/23 at 3:20 p.m., Administrator-A and DON (Director of Nursing)-B were informed of the above. On 5/9/23 at 3:53 p.m., Surveyor met with RN/Supervisor-H regarding R16. Surveyor read RN/Supervisor-H R16's note dated 4/17/23 which she wrote. Surveyor asked how she became aware of R16's SDTI? RN/Supervisor-H informed Surveyor one of the CNAs told her. RN/Supervisor-H informed Surveyor at this time she was acting DON. RN/Supervisor-H informed Surveyor she notified the doctor, spoke with the family, and left a note under the wound nurse's door. Surveyor asked RN/Supervisor-H if Former Wound Nurse/LPN-M reviewed R16's pressure injury measurements and the information she collected with her? RN/Supervisor-H replied no, she didn't go over this with her. Surveyor inquired who revises the pressure injury care plans. RN/Supervisor-H replied the wound nurse. On 5/10/23 at 12:38 p.m., Surveyor asked Administrator-A if there is any additional information regarding R16's pressure injury or is there anyone else Surveyor should speak with? Administrator-A replied no. 2. R4's diagnoses includes diffuse traumatic brain injury, stroke with hemiplegia to dominate right side, hypertension, mixed receptive-expressive language disorder, aphasia, and vascular dementia. The at risk for falls care plan initiated 2/20/20 & revised 1/30/23 includes the intervention of * Check and change after meals. Initiated 12/1/22 & revised 1/30/23. The potential for pressure injury/ulcer care plan initiated 4/27/20 & revised 1/30/23 has the following interventions: * 9/2/21 encourage resident to sit with hands on the table not under to avoid skin tears. Initiated 9/3/21 & revised 11/30/21. * Administer treatments as ordered and monitor for effectiveness prn (as needed) per MD (medical doctor) orders. Initiated 5/13/20 & revised 9/1/20. * Assist with repositioning every 2-3 hours when in bed or w/c (wheelchair). Initiated 4/27/20. * Educate [R4's first name]/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Initiated & revised 4/27/20. * Follow facility policies/protocols for the prevention/treatment of skin breakdown. Initiated & revised 4/27/20. * Inform the resident/family/caregivers of any new area of skin breakdown. Initiated 4/27/20. * Monitor nutritional status. Serve diet as ordered, monitor intake and record. Initiated 4/27/20. * Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X (times) width X depth), stage. Initiated 4/27/20. * Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Initiated 4/27/20. The quarterly MDS (minimum data set) with an assessment reference date of 2/22/23 documents R4 has short & long term memory problems and is severely impaired for cognitive skills for daily decision making. R4 requires extensive assistance with two plus person physical assist for bed mobility, & transfer, does not ambulate and requires extensive assistance with one person physical assist for toilet use. R4 is coded as being always incontinent of urine & frequently incontinent of bowel. R4 is at risk for pressure injury development and is coded as not having any pressure injuries. On 5/8/23 at 10:23 a.m. Surveyor observed R4 in bed on his back with the head of the bed up high. On 5/8/23 at 11:26 a.m. Surveyor observed R4 continues to be in bed on his back with his eyes closed. On 5/8/23 at 11:34 a.m. Surveyor observed CNA (Certified Nursing Assistant)-D place a gown & gloves on. Surveyor inquired what she was going to do. CNA-D informed Surveyor she was going to change and reposition R4. At 11:36 a.m. CNA-D informed R4 she was going to get him cleaned up for the day. At 11:39 a.m. CNA-D removed her PPE (personal protective equipment) stating she need to get R4 a brief as there is none in the room and left R4's room. At 11:41 a.m. CNA-D cleansed her hands, placed a gown on and entered R4's room. At 11:43 a.m. CNA-D informed R4 I'm back going to get you cleaned up. CNA-D placed water in a basin, cleansed her hands and placed gloves on. CNA-D informed Surveyor they don't have any face towels & she needs to use what they have. CNA-D then placed the end of a bath towel in the water basin. CNA-D raised the height of the bed and lowered R4's head of the bed down. CNA-D informed R4 she was going to do his face & top half. CNA-D then proceeded to wash R4's face and ears. CNA-D informed R4 she was going to uncross his legs and roll him towards the curtain. CNA-D then rolled R4 onto his left side. Surveyor observed the back of R4's incontinence product is saturated with urine. CNA-D then rolled R4 onto his right side to finish removing his shirt. At 11:52 a.m. Surveyor asked CNA-D if this was the first time today she has provided cares to R4. CNA-D replied yes. CNA-D explained when she got here she was the only CNA here along with [name of] Med Tech-E and a nurse. CNA-D informed Surveyor later another CNA came. CNA-D informed Surveyor she wanted to do R4 before lunch. CNA-D explained she started with the back half and was told there would only be two of them (CNA's) today. CNA-D washed R4' upper half. Surveyor observed the front portion of R4's incontinence product is saturated with urine. CNA-D placed deodorant and a shirt on R4. At 12:02 p.m. CNA-D informed R4 she was going to clean his lower area. CNA-D then informed R4 she needs to cover him back up, covered R4 with the bedspread, lowered the bed down and informed R4 she needed to get more towels and will be right back. CNA-D removed her PPE, went down the hallway, and washed her hands. At 12:05 p.m. CNA-D placed PPE on and entered R4's room with towels. CNA-D informed R4 she was back to finish him up. CNA-D raised the bed up, uncovered R4, folded the urine saturated product between R4's legs and washed R4's frontal area. At 12:10 p.m. CNA-D removed her gloves, cleansed her hands, placed gloves on and told R4 she was going to do the back area and was going to roll him towards the curtain. R4 was placed on his left side. CNA-D folded the saturated product under R4, washed R4's buttocks and rectal area to remove stool. After washing R4, CNA-D stated I don't have any cream, you need some cream. Surveyor observed there are no open areas but R4's coccyx area is pinkish-red in color. Surveyor informed CNA-D Surveyor can't touch Residents and asked CNA-D if she could press her finger where R4's skin is pinkish red. CNA-D pressed her finger approximately three times where R4's skin was pinkish red. Surveyor observed R4's skin stayed pinkish red. CNA-D informed Surveyor it's red and he needs some cream. CNA-D went to the left side of R4's bed informed R4 she was going to pull him towards her and roll him the other way. After rolling R4 onto his right side, CNA-D placed a clean draw sheet & product under R4. CNA-D fastened the left side of the product, positioned R4 on his other side to fasten product and straighten out the linen. CNA-D removed R4's gripper socks, Surveyor checked R4's heels and did not observe any open areas on R4's feet. CNA-D placed new gripper socks on R4, removed her gloves, cleansed her hands, and placed new gloves on. CNA-D informed Surveyor she needs to get help to boost R4 up, covered R4 with bed spread, lowered bed down, placed call light in reach, removed PPE and washed her hands. Surveyor noted during[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility did not ensure 2 of 6 Residents (R) reviewed for quality of care received treatment and care in accordance with standards of practice (R80 and R81.) The facility did not provide for the care and treatment of a non-pressure wound for 1 of 1 (R80) sampled residents with non-pressure wounds and did not conduct adequate neurological checks for 1 of 3 (R81) residents reviewed for falls. * R80 was admitted to the facility on [DATE]. On 5/17/22 R80's Braden Scale documented R80 was high risk for developing wounds. On 5/23/22, the wound care doctor documented an open area to the left buttock and requested a dermatology consult to rule out eczema versus psoriasis. The dermatology consult was not followed up on by the facility. There is no documentation that skin evaluations and assessments including description, measurements, and characteristics were completed on R80's open areas. On 7/17/22, the nurse practitioner documented that R80 has an unstageable area to coccyx approximately 1cm x 1cm. On 8/28/22, a weekly skin evaluation documents there are multiple open areas to right and left back, hip, and buttocks. The documentation does not contain measurements, description, or characteristics. On 9/8/22, in R80's electronic medical record, it is documented that R80 has multiple areas that are now open and tissue is red in color. There is no documentation that the facility assessed R80's open areas further to include measurements, description, and characteristics. The wound doctor is aware and will see R80. The wound care doctor was in the facility on 9/13/22 and 9/20/22 and did not assess R80's open areas. *R81 had unwitnessed falls while at the facility and the facility did not perform completed neurological assessments of the resident post fall. R81 had an unwitnessed fall on 8/10/22. It was determined that R81 hit R81's head on the floor. R81 was sent to the emergency room and determined to have no injury as a result of the fall. Surveyor notes that neuro checks were not completed per facility policy and procedure. R81 had another unwitnessed fall on 9/10/22 and neuro checks were not completed per policy and procedure. Findings Include: Surveyor reviewed the facility's undated skin assessment policy and procedure and notes the following applicable: Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, 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: a. Include date and time of the assessment, your name, and position title. b. Document observations(e.g. skin conditions, how the Resident tolerated the procedure, etc.) c. Document type of wound d. Describe wound(measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if Resident refused assessment and why. f. Document other information as indicated or appropriate. 1. R80 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Morbid Obesity, Type 2 Diabetes Mellitus, Bilateral Primary Osteoarthritis of Hip, Other Specified Peripheral Vascular Diseases, Unspecified Dementia, Anxiety Disorder, and Major Depressive Disorder. R80 has an activated health care power of attorney (HCPOA). Surveyor reviewed R80's hospital paperwork and notes on 5/12/22 it is documented that R80 has scattered shallow open areas, scratch marks, and eschars from picking and scratching. Recommend pressure injury prevention measures. R80 needs aggressive off-loading with low air loss mattress or equivalent, frequent turning/repositioning at least every 2 hours. Surveyor notes R80's Braden Scale dated 5/17/22 indicates R80 is at high risk for developing pressure areas. On 5/23/22, the wound care doctor assessed R80's left buttock and documents the open area to be 2.04 cm x 2.11 cm x .10 cm. Total area 3.24cm. Wound bed Assessment-Early/Partial granulation, moderate serous drain amount. The wound care doctor requested a dermatology consult to determine the etiology: eczema versus psoriasis. Surveyor noted no dermatology consult per the 5/23/22 wound MD's request in R80's medical record. On 7/19/22, R80's nurse practitioner assessed R80. It is documented that R80's skin at this time had healing multiple scabbed wounds, scratch marks to upper extremities. Open unstageable area to coccyx approximately 1cm x 1cm, right lower extremity open area, bandage is in place, clean and dry. Surveyor noted there was no comprehensive assessment/description of the above referenced healing multiple scabbed wounds. Surveyor spoke to R80's nurse practitioner (NP F) on 9/23/22 at 2:05 pm, in regard to NP F's note dated 7/19/22. NP F stated that if NP F documented there are open areas, then they are there . I wouldn't have written it otherwise. NP F stated NP F did not do a physical head to toe assessment but wrote the note based on information provided by the floor nurse at the time. R80's record continues: R80's Quarterly Minimum Data Set (MDS) dated [DATE] documents R80's BIMS (Brief Interview for Mental Status) score to be an 8, indicating R80 demonstrates moderately impaired skills for daily decision making. R80's MDS also documents that R80 requires extensive assistance for bed mobility and hygiene. R80 requires total assistance for transfers and toileting. On 8/28/22 a weekly skin evaluation was completed for R80. The evaluation documents that R80 has multiple open areas red in color no drainage to right and left iliac crest and multiple areas red in color no drainage to the right and left buttock. Clobetasol Propionate Cream 0.05% applied to arms/legs/chest/back/buttocks. Surveyor noted there was no comprehensive assessment of the above referenced multiple open areas such as how many, size, etc. On 8/30/22, Surveyor notes that Allegra allergy oral tablet 60 mg 2 times a day for dermatitis/allergic reaction for 2 weeks was ordered. Surveyor noted R80 was ordered a medication for dermatitis/allergic reaction on 8/30/22 however the facility did not follow up with a dermatologist consult as requested by the physician on 5/23/22. On 9/24/22, the facility provided documentation of a progress note written by R80's physician and electronically signed on 9/23/22 at 11:46 PM. R80 was seen by R80's physician on 8/30/22 which documents that R80 is an elderly frail female with recurrent rash and dermatitis, multiple scratch marks and scab wounds at various stages of healing, also has increased itching and possibility of underlying chronic urticaria. Has been referred to dermatology and wound care team. Surveyor noted there was no comprehensive assessment of the scab wounds during R80's 8/30/22 physician visit and no follow up to the dermatology clinic or to the wound care team. On 9/7/22, R80's electronic medical record (EMR) contains documentation that R80 has been scratching excoriated areas to right buttock, which are large, and needs the wound physician to assess. R80's fingernails have been cut and filed. Writer was advised to place Tricimalone cream on areas and dressing to prevent further scratching. 9/8/22 at 6:34 AM, R80 is being monitored due to open areas on right buttock. 9/8/22 at 8:52 AM, R80 has areas to back, bilateral arms, and hips. R80 has an ongoing issue with itching to areas and a scheduled cream with an as needed cream. Areas are now open, and tissue is red in color. Wound physician is aware and will see R80 next week. Surveyor spoke to ADON D on 9/23/22 at 3:18 pm who confirmed that ADON D did not measure R80's open areas on 9/8/22 when assessing R80. Nursing Home Administrator (NHA A) confirmed during a conversation with Surveyor on 9/23/22 at 3:10 pm, that the wound care doctor was in the facility on 9/13/22 and 9/20/22 and did not assess R80. Surveyor noted there was still no comprehensive assessment of these wounds, no dermatology follow-up and R80 was not seen by the wound care team. On 9/23/22, Surveyor received a copy of R80's comprehensive care plan with revisions and notes the following: There is a focused problem indicating R80 has a mood problem due to anxiety, feeling depressed, having little energy, poor appetite, and feeling restless. Initiated 5/31/22 Revised 8/30/22 R80 has the potential for pressure injury/ulcer development due to impaired mobility, incontinence. 5/16/22 Readmit with stage II pressure left buttock (deemed open skin rather than pressure ulcer with new treatment order 5/23/22) 9/8/22 Excoriated areas to entire back, bilateral shoulders, bilateral buttocks, bilateral arms. Initiated 6/18/20, revised 9/8/22. Interventions: 5/23/22 dermatology consult 9/20/20 bilateral prevalon boots when in bed 8/31/21 Reposition at least every 2-3 hours when in bed or wheelchair 2/14/22 Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. 2/14/22 Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate Provide unbleached linens-initiated 4/28/21, revised 2/28/22 R80 requires an air mattress for pressure relieve-initiated 2/14/22, revised 2/28/22 9/8/22 R80 observed scratching lower extremities, keep nails trimmed. Surveyor noted according to R80's care plan initiated on 2/14/22 and revised on 2/28/22, R80 requires the use of an air mattress. A Surveyor from the Survey team requested to see R80's skin on 9/23/22 at 2:35 PM. Surveyor noted R80's bed does not have a pressure relieving air mattress in place. R80 is wearing pressure relieving heel boots to bilateral feet at this time. Surveyor noted R80's care planned identified the need for unbleached linens. Surveyor spoke to Laundry Supervisor (LS G) on 9/23/22 at 4:20 pm, who stated all the sheets and towel are washed together in bleach. LS G is unaware of any residents needing their towels and sheets washed in an unbleached condition. Surveyor interviewed Laundry Aide (LA H) on 9/24/22 at 7:13 am, who has worked at the facility for 16 years. LA H stated there are 2 residents, 1 of which is R80, who require their sheets, gown, towels to be washed in an unbleached condition. LA H stated there is spot in the laundry room with a note marked for these 2 residents, 1 of which is R80, require this special precaution. Further, these 2 Residents, 1 of which is R80, have special drawers marked indicating that these drawers contain unbleached items. Surveyor took a tour with LA H of the laundry room who confirmed that R80 was not posted as needing unbleached linen. Surveyor then conducted a tour with LA H of R80's drawers in R80's room. Surveyor notes at this time, R80's drawers are completely empty except for 1 washcloth. LA H stated that LA H needed to get R80 added to the list down in the laundry room for requiring unbleached linen and would need to get R80's drawers filled with unbleached linen. R80's medical record continues: On 9/10/22 R80 continues to have open areas, treatment completed, continues to monitor for new open areas. On 9/21/22, a weekly summary documents R80 is not currently receiving treatment for skin problems. Surveyor reviewed R80's bedside [NAME] report as of 9/23/22 which documents R80 was observed scratching R80's lower extremities by nursing. Staff to encourage R80 to avoid scratching. Keep nails trimmed short. Prevlon boots at all times. R80 requires air mattress for pressure relief. Provide unbleached linens. On 9/24/22, Surveyor was provided an updated comprehensive care plan for R80 and notes the following added for the focused problem for having the potential for pressure injury/ulcer development due to impaired mobility, incontinence. 9/23/22 Shallow open areas noted to bilateral back, bilateral buttocks, and bilateral hips. Revised 9/24/22 Interventions added: 9/23/22 Dermatology consult requested 9/23/22 Administer medications as ordered. Monitor/document for side effects and effectiveness 9/23/22 Follow facility policies/protocols for the prevention/treatment of skin breakdown. 9/24/22 Inform R80/family/caregivers of any new area of skin breakdown. 9/24/22 Obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow-up as indicated. Surveyor notes that since re-admission to the facility on 5/16/22, subsequent assessment by wound physician on 5/23/22, the facility was only able to provide 1 weekly skin evaluation for R80. Further, the facility was unable to provide any documentation a weekly skin assessment was completed on the open areas which include measurements, description, color, drainage, pain, etc. for R80's open areas. On 9/23/22, the facility completed a Braden on R80 which documents that R80 is high risk for developing pressure areas. The facility also completed a weekly skin evaluation dated 9/23/22, which documents that R80 has shallow various sized open areas noted with distinct edges, red wound base, and scant amount of serosanginous drainage which appear to itch and be slightly painful to touch on the right and left buttock and right and left lower back. It is noted that neither document any measurements. On 9/23/22, R80's EMR contains documentation that there is no drainage or signs/symptoms of infection noted to multiple areas on buttock, back, legs, and arms. Mattress changed. Surveyor noted R80's mattress was changed back to an air mattress. On 9/23/22 at 10:56 AM, Surveyor interviewed Assistant Director of Nursing (ADON D) who confirmed ADON D has been the Registered Nurse (RN) monitoring and assessing the wounds in the facility. ADON D states that ADON D is wound care certified. ADON D informed Surveyor that ADON D spoke to the wound care physician about R80's open areas but that the wound care doctor would not assess because the doctor still maintained that R80 needed to be assessed by a dermatologist. ADON D confirmed at this time that R80 should be receiving unbleached sheets and towels and washcloths. On 9/23/22 at 11:40 AM, Surveyor interviewed ADON D again. ADON D confirmed there is not a lot of documentation regarding R80's open areas. ADON D confirmed that the expectation is that there should have been a documented assessment and weekly skin evaluations pertaining to R80's skin condition. ADON D stated that some staff are doing weekly skin evaluations in the Resident's EMR and some are doing the paper skin evaluations. ADON D stated that the nurse should be taking the CNA skin check and assessing the Resident on the weekly shower days and signing off on it. On 9/23/22 at 12:02 PM, ADON D confirmed that as of 9/23/22, a dermatologist consult originally ordered on 5/23/22 was not completed. On 9/23/22 at 2:35 PM, a Surveyor from the Survey team requested to see R80's skin. ADON D told Surveyor that R80 has a scattered rash that comes and goes on their body. ADON D showed Surveyor R80's back and buttocks. Surveyor noted a total of 6 open areas resembling ruptured blisters on R80's left buttock and 2 open areas on their left lower back resembling ruptured blisters. On R80's right buttock and right lower back there are 10 open areas resembling ruptured blisters. Surveyor notes R80's bed does not have a pressure relieving air mattress in place. R80 is wearing pressure relieving heel boots to bilateral feet at this time. Surveyors reviewed R80's medical record. Surveyors could not identify any weekly skin assessments referencing R80's current open areas to the bilateral buttocks and back. Surveyor spoke to ADON D on 9/23/22 at 3:18 pm, who stated she is not sure who took R80 off the wound board, because typically R80 should have remained on the board. ADON D was informed that R80 was itching more and recommended unbleached sheets. ADON D confirmed that there is no formal diagnosis for R80's skin condition at this time. ADON D confirmed that a Braden evaluation should be done on change of condition, re-admission, and every 3 months. ADON D stated that R80 should and needs to have had an air mattress and if that was an intervention for a fall (to remove the air mattress), they should have come up with another intervention. ADON D confirmed that skin checks should be completed weekly and documented in each Resident's EMR. On 9/23/22 at 3:30 PM, a Surveyor from the survey team conducted an interview with ADON D. ADON D is the facility's wound nurse and was hired by the facility on 9/1/22. ADON D told Surveyor that they assist the facility's wound MD with weekly wound rounds. Surveyor asked if residents at risk for pressure injury or those with current pressure injuries should have a pressure relieving air mattress on their bed. ADON D responded that any resident at risk or with current pressure injuries should have a pressure relieving air mattress on their bed. Surveyor asked ADON D how they would characterize the open areas to R80's bilateral buttocks and back. ADON D told Surveyor that these areas appear as if they were blisters at one time and have now popped open. ADON D told Surveyor that they would characterize these areas as stage 2 pressure injuries. Surveyor asked ADON D if they had been conducting weekly wound assessments to R80's open areas. ADON D told Surveyor that they were not aware that R80 had multiple open areas to R80's skin and that they believed that R80 just had a rash to their back and buttocks that was being treated with medicated topical treatments. ADON D told Surveyor that the facility had not conducted weekly wound assessments for R80's open areas and have not measured the areas. On 9/23/22 at 3:56 PM, Nursing Home Administrator (NHA A) stated that the expectation is for skin evaluations to be done weekly. NHA A stated that the facility would expect an evaluation to contain a description of all areas with measurements. On 9/23/22 at 4:30 PM, a Surveyor from the Survey team conducted an interview with DON B. Surveyor asked DON B if a resident has open areas or pressure injuries if the areas should be measured and comprehensively assessed on a weekly basis. DON B responded Yes. R80's medical record continues: On 9/24/22 at 5:02 AM, R80's EMR documents that the nurse practitioner was updated on R80's skin condition. R80 currently has an order for Clobetasol Propionate Cream 0.05% to be applied. This order was continued, and dermatologist was called to schedule an appointment. On 9/24/22 at 7:45 AM, a Surveyor from the Survey team asked DON B if they had observed R80's current skin condition. DON B told Surveyor that she had seen R80's skin condition. Surveyor asked DON B what DON B's assessment of R80's open areas was? DON B told Surveyor that the areas appear to be blisters that are no longer intact and that they would say that the areas appear to be multiple stage 2 pressure injuries. On 9/24/22, the wound care physician came to the facility and assessed R80. Documentation does not include any measurements and states no wound detected with attached edges, early/partial granulation, small serous drainage. On 9/24/22, Surveyor notes that the facility added a diagnosis to R80 of dermatitis, unspecified without a dermatology consult. Surveyor reviewed R80's Treatment Administration Record (TARS) from May 2022-September 2022 and notes that R80's Treatment Administration Record (TARS) indicate that a body check was to be completed every evening shift on Mondays. The facility was unable to provide documentation that this was completed. On 9/24/22 at 9:20 AM, Surveyors interviewed Wound Care Doctor (WCD E) who confirmed that WCD E assessed R80 today (9/24/22). Per WCD E's 9/24/22 assessment and documentation of R80, WCD E documented no wound detected. WCD E described R80's area as attached edges, early/partial granulation, small serous drainage with normal odor. Depth is 0.10. Surveyor asked WCD E if they had expected R80 to have had their dermatology consult that he had ordered 5/23/22 to have been completed by now. WCD E stated that it is a concern that the facility never had R80 seen by a dermatologist as WCD E ordered on 5/23/22. WCD E told Surveyors that the ball had been dropped and that R80's dermatology consult had not been followed up on in a timely fashion. WCD E also confirmed that the facility should have been assessing R80's open areas/blisters on a weekly basis including description, measurements, and characteristics of R80's open areas. WCD E confirmed that WCD E was not notified about R80's open areas until 9/7/22. WCD E told Surveyors he did not believe R80's open areas to be pressure injuries but a skin condition which was why he had previously given the facility an order for a dermatology consult for R80. WCD E told Surveyors that he was planning on conducting a biopsy of R80's skin condition on 9/26/22 for further evaluation. On 9/24/22 at 11:57 AM, Surveyor shared with NHA A and DON B the concern that R80 did not get a dermatology consult completed as ordered on 5/23/22, weekly skin evaluations were not completed, and open area skin assessments were not completed including measurements, description, and characteristics for R80. After Surveyors exited from the facility on 9/24/22, NHA A provided Surveyors and Regional Field Operation Supervisors with the following additional information: Received from NHA A on 9/27/22, the results of a Dermatology appointment dated 9/26/22 by Advanced Practice Nurse Practitioner (APNP) J. The results indicate in part; The following areas were examined with significant findings as noted scalp/hair, head/face .scalp with excoriated lesions frontal parietal regions, upper and lower back scars and excoriated .Picker nodules .trim nails short to limit trauma of skin when pt scratches propopic 0.1 oint (ment) BID back and scalp, possibly ruptured/unroofed blisters 3.5 pinch R hip R/O (rule out) bullous pemphigoid .Aquaphor/Telfa for now right hip and right ant (anterior) tubia . Received from NHA A 10/4/22 the results of a 10/3/22 Skin Biopsy report (from MD I) which states in part Conclusion: This pattern is most commonly observed in bullous pemphigoid. It can, however, occur in other, less common conditions, including epidermolysis bullosa [NAME], anti-epiligrin cicatricial phemphigoid, and p200 pemphigoic . Miscroscopc Description: This lesion apparently was relatively old when sampled, because it reveals a shallow, reepithelizlising ulcer which extends across most of the specimen's width. At the edge of the ulcer is a narrow focus of dermoepidermal detachment. Many eosinophils are present within the ecleft and underlying dermis. These findings are consistent with pemphigoid but not entirely specific. Pathologic Diagnosis skin, right hip, punch biopsy-consistent with pemphigoid. Regional Field Operations Supervisor noted, according to Mayo Clinic Bullous pemphigoid https://www.mayoclinic.org Bullouspemphigoid-symptoms and causes-Mayo clinic Overview Bullous pehphigoid is a rare skin condition that causes large, fluid-filled blisters. They develop on areas of skin that often flex-such as the lower abdomen, upper thighs or armpits. Bullous pemphigoid is most common in older adults. Bullous pemphigoid occurs when your immune system attacks a thin layer of tissue below your outer layer of skin. The reason for this abnormal immune response is unknown, although it sometimes can be triggered by taking certain medications. Bullous pemphigoid often goes away on its own in a few months, but may take as many as five years to resolve. Treatment usually helps heal the blisters and ease any itching. It may include corticoseroid medications, such as prednisone, and other drugs that suppress the immune system. Bullous pehphigoid can be life-threatening, especially for older people who are already in poor health. Symptoms The signs and symptoms of bullous pemphigoid may include: Itching skin, weeks or months before blisters form Large blisters that don't easy rupture when touched, often along creases or folds in the skin Skin around the blisters that is normal, reddish or darker than normal Eczema or a hive-like rash Small blisters or sores in the mouth or other mucous membranes. When to see a doctor See your doctor if you develop: Unexplained blistering Blisters on your eyes Signs of infection . 2. Neurological Checks: Surveyor reviewed the Neurological Assessment policy and procedure revised October 2010 and notes the following: The purpose of this procedure is to provide guidelines for a neurological assessment: 1) when following an unwitnessed fall; 2) subsequent to a fall with a suspected head injury; or 3) when indicated by Resident condition. Neurological assessments are indicated: a. Following an unwitnessed fall b. Following a fall or other accident/injury involving head trauma; or when indicated by Resident's condition c. Any change in vital signs or/neurological status in a previously stable Resident should be reported to the physician immediately. Surveyor notes the facility protocol is for neuro-checks to completed every 15 minutes x 4, 30 minutes x 4, 1 hour x 4, 4 hours x 4, 8 hours x 6. R81 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Hypothyroidism, Peripheral Vascular Disease, and Vascular Dementia. R81 has an activated HCPOA. R81's Quarterly MDS (Minimum Data Set) dated 7/23/22 documents that R81 has both short and long term memory impairment and demonstrates severely impaired skills for daily decision making. R81's MDS also documents that R81 requires supervision for bed mobility and transfers, limited assistance for toileting, and extensive assistance for hygiene. R81's fall risk evaluations dated 4/19/22, 8/10/22, and 9/10/22 all indicate that R81 is at moderate risk for falls. R81's bedside [NAME] as of 9/24/22 instructs staff to anticipate and meet R81's needs. The [NAME] also documents to distract R81 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: Surveyor notes this is blank on the [NAME]. Surveyor reviewed R81's comprehensive care plan and notes that on 2/1/22, a focused problem indicating R81 is at risk for falls due to dementia, fall history, gait/balance problems, vision problems, and unaware of safety needs was established. This focused problem was last revised on 9/12/22. Surveyor notes an intervention of neuro-checks per policy was initiated 2/2/22. Surveyor reviewed R81's fall report dated 8/10/22. R81 had an unwitnessed fall and was found in the middle of the floor. It was determined that R81 hit R81's head on the floor. R81 was sent to the emergency room and determined to have no injury as a result of the fall. Surveyor notes the physician and activated HCPOA were notified. Surveyor notes that neurochecks were not completed for the 8/10/22 fall per facility policy and procedure. R81 had another fall on 9/10/22 which was unwitnessed with no determined injury. R81 was found in another Resident's room, lying on the floor on her back. Surveyor notes the physician and activated HCPOA were notified. Surveyor notes that neurochecks were not completed per facility policy and procedure. Surveyor notes that R81 did not have neuro-checks completed per facility policy and procedure for each of their falls. On 9/24/22 at 9:12 AM, NHA A confirmed that the facility was unable to locate any neuro-checks completed for R81's falls. On 9/24/22 at 11:57 AM, Surveyor shared the concern that neuro-checks had not been completed for R81's unwitnessed falls per facility policy and procedure. No further information was provided by the facility at this time. Surveyor notes that on 9/23/22 and 9/24/22, facility nurses received an in-service training conducted by NHA A and discussed neuro-checks, open areas being reported, and follow-up appointments need to be completed/scheduled. On 10/4/22, the facility provided additional information in regards to R81's neuro-checks. The facility provided a LTC Neuro Assessment form with a date of 9/10/22 in regards to R81's unwitnessed fall. The LTC Neuro Assessment form has documented that R81 went to the hospital emergency room and returned on 9/10/22 at 1730 (5:30pm). Surveyor notes that per R81's EMR, the following is documented in regards to R81's 9/10/22 fall: 9/10/22 at 2:27 PM it is documented that R81 was found in another Resident's room on the floor on R81's back. R81 stated R81's head, back, and right arm was hurting. Nurse practitioner was updated and advised to monitor R81 and allow to eat and drink. At 2:30 PM, R81 stated R81 had no pain. R81 is sleepy and resting in bed. 9/10/22 at 10:13 PM, it is documented that R81 was sleeping as was upset by being woken up to obtain vitals. Surveyor notes that R81's EMR does not contain documentation that R81 was sent to the emergency room on 9/10/22 and as indicated on the 9/10/22 LTC Neuro Assessment form submitted on 10/4/22; but rather R81 remained in the facility and was monitored per nurse practitioner instructions. R81's 9/10/22 neuro checks that were listed on the LTC Neuro Assessment form submitted on 10/4/22 indicates upon R81's return from ER at 1730 (5:30 pm). The LTC Neuro Assessment form completed indicates the following dates and times when the neuro checks were completed: 9/10/22 1730, 1830, 9/11/22 0230, 1030, 1830, 9/12/22 0230 and 1030. Surveyor noted the neuro checks were not performed according to the instructions on the LTC Neuro Assessment form. Surveyor also notes, that neuro-checks for R81's fall on 8/10/22 have not been provided by the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review the facility did not ensure that they provided the necessary care and treatment to 2 of 2 (R10 and R47) residents reviewed with pressure ulcers to promote the healing and prevent new ulcers from developing. R10 was noted to have an open blister to the right heel that went without a comprehensive assessment until the area became worse. R10 was also observed to have an area to the left heel that went without an assessment and was observed to have a treatment in place without a physician order. R47 developed an intact blood filled blister to the right heel. The facility did not comprehensively assess the area to ensure that the proper treatment and interventions were in place to assist in healing the area. This is evidenced by: Review of the Facility's policy and procedure, Pressure Ulcer Treatment, last revised October 2010, documents: Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Definitions and Descriptions (includes) Stage #2 Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and / or eschar(tan, brown or black) in the wound bed. Documentation: The following information should be recorded in the resident's medical record: 1. The type of treatment and resident response 2. The date and time the wound care was given. 3. The name and title of the individual performing the care. 4. Any change in the resident's condition. 5. All assessment data (i.e , color, size, pain, drainage, etc.) when inspecting the wound. 6. Resident tolerance of the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. Resident refusal of the treatment and reason(s) why. 9. The signature and title of the person recording the data. 1.) R10 was originally admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, Dementia, Hypertension, Alzheimer's Disease, muscle weakness and major Depressive Disorder. Surveyor conducted a review of the significant change MDS (Minimum Data Set), dated 4/18/22. R10 was assessed to have severely impaired cognitive skills for daily decision making. Extensive or total dependence on staff is needed for ADL's (activities of daily living) . R10 did not walk in corridor or walk in room. R10's locomotion on unit required total dependence and 1-person physical assist. No locomotion off unit occurred. R10 does not use a walker or cane. R10 is said to use a wheelchair. Yes- Resident (R10) has a pressure ulcer. Yes - R10 is at risk for developing pressure ulcers/ injuries. Yes- has 1 or more unhealed pressure ulcer. 1- Unstageable area with slough and/ or eschar. Nursing note dated 3/29/2022, at 10:54 p.m. states; This writer was called to resident's room (R10) re: blood on resident's right sock. When sock was removed noted an open area on right heel 5.5 cm in diameter. Wound base pink in color with flap of loose skin over wound. Area was washed with soap and water with dry dressing applied. Prevalon boots applied to both feet. R10 unable to state how wound was obtained due to confusion. Left message for Power of Attorney, NP (Nurse Practitioner)- C, DON (Director of Nursing) -B, and Wound RN- J. ( Note written by LPN- L) IDT (Interdisciplinary Team) note dated 3/31/22, states the Interdisciplinary Team reviewed open blister to right heel. Area noted clean dry intact 100% skin with skin flap noted. Treatment orders and Prevalon boots in place. Blister consistent with shoe rubbing back of foot. Plan of care was updated for R10 not to wear shoes until area resolved. A review of R10's individual plan of care which documented the following: R10 is at risk for pressure injury due to impaired mobility, bowel/bladder incontinence, at risk Braden score, Diabetes and peripheral vascular disease. On 3/30/22 open blister to posterior R heel - SDTI (Suspected deep tissue injury) 4/12/22 - Unstageable pressure ulcer- 4/18/22 The plan of care was initiated: 11/02/2021 and last revised on 5/3/2022. Interventions included the following: R10's remaining skin will be intact, free of redness, blisters or discoloration through review date; R10's Pressure injury/ulcer will show signs of healing and remain free from infection by/through review date; Follow facility policies/protocols for the prevention/treatment of skin breakdown; Monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length X width X depth), stage; No shoe to right foot (open area). (Date Initiated: 04/01/2022); No shoes until posterior right heel blister resolved (Date Initiated: 03/30/2022); Prevalon Boots to both feet at all times. May remove for bathing. (Date Initiated: 04/12/2022) treatment per order. Nursing note dated 4/12/2022, at 11:21 a.m.; Writer noted during wound care to right heel is rounded with slight foul odor, with moderate sero-sang drainage noted with wound bed is 85% eschar. Prevalon boots intact. Wound RN (Registered Nurse)- J and DON (Director of Nursing)- B is here to assess. Skin/Wound note dated 4/12/2022, at 12:19 p.m. ; WCC (Wound Care Certified) RN -J called to room to assess open blister to R heel, area has worsened and formed SDTI (Suspected Deep Tissue Injury) at this time. R10 in bed, Prevalon boots in place per order, all skin protection orders in place. SDTI measures 5 x 3 cm (centimeters), dark purple at center, open blistering at edges with moderate serous drainage. NP-C updated and new treatment orders, MTV (multivitamin) and prostat orders obtained. Daughter called with updated, in agreement with TX (treatment) plan. Weekly Non- Pressure Wound Tracking, dated 4/12/22, documents that R10 had a right heel pressure area that is 5 cm in length by 3 cm in width. Suspected deep tissue injury. Onset date 3/30/22. Treatment ordered: normal saline, Iodosorb, foam border three times a week and as needed. Open blister to R heel noted 3/30/22 consistent with rubbing of shoe has worsened and formed SDTI at this time. R10 in bed, Prevalon boots in place per order, all skin protection orders in place. SDTI measures 5 x 3 cm, dark purple at center, open blistering at edges with moderate serous drainage no noted signs/symptoms infection. Edge defined and intact, surrounding skin warm/ dry/intact. R10 complain of pain during cleansing, pain ceases after. Further review of R10's medical record showed that the open blister (stage #2 pressure ulcer according to facility policy) had not been comprehensively assessed since the first date it was observed on 3/29/22. A treatment was obtained to wash open blister posterior right heel with soap and water, apply triple antibiotic ointment followed by border form. Change every other day and as needed for soilage or dislodgement. Weekly Wound Assessment, dated 4/18/22, right heel, pressure, onset 3/30/22 measures 2.84 cm by 2.49 cm, by 0.1. Unstageable. Nursing note dated 4/20/2022 at 10:42 a.m.; R10 seen by wound MD for right heel wound. Measurements: length 2.84 cm width 2.49 cm depth 0.10 cm margin detail attached edges wound bed assessment granulation 1-25% slough 51-75% drain amount moderate serous odor normal periwound edematous treatment: cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep, apply iodoflex to wound bed, cover wound with bordered gauze change daily and PRN. Doppler study results pending. Weekly Wound Assessment dated 4/25/22. Right heel pressure, Unstageable measures 1.9 cm by 2.1 cm by 0.1. Unstageable pressure ulcer to right heel improved, notes 80 % well adhered eschar, 20 % pink moist granulation with noted moderate serous drainage. No noted odor, redness or signs of infection. Treatment orders changed this visit per Wound MD. Weekly Wound Assessment dated 5/2/22; right heel pressure area, unstageable. Measures 1.9 cm by 1.5 cm by 0.1. Unstageable pressure ulcer to right heel improved, noted to be 50% well adhered yellow slough, 50% pink moist granulation with noted moderate serous drainage. No noted odor. No s/s pain. Weekly Skin Assessment dated 5/9/22; Date of onset: 3/30/22 right heel - pressure area, measures 1.9 x 1.7 x 0.1 unstageable. Summary: Unstageable pressure ulcer to R heel debrided this assessment per Wound MD. Wound presents post debridement 60% well adhered yellow slough, 40% pink granulation. Moderate serous drainage noted pre debridement, no odor or s/s infection noted. Wound edges defined and intact, surrounding skin warm dry intact. No s/s pain or discomfort noted treatment: Cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep. Apply Santyl to wound bed and cover with border gauze daily and PRN Facility conducted a Braden scale skin assessment on 5/10/22 stating R10 is at low risk for pressure ulcer development. On 5/11/22, at 2:25 p.m., Surveyor interviewed Wound RN- J regarding R10's open blister to the right heel that was initially identified on 3/29/22. RN- J stated that she was pretty sure risk management met and decided the original blister was from R10's from shoe. RN- J stated it was an intact blister at one time. Surveyor asked why there was not a comprehensive assessment, conducted by a Registered Nurse, of the area to the right heel until 4/12/22. RN- J stated that she did not assess the area until it became worse, she does not assess blisters and was not considering it as a pressure ulcer. RN- J stated that area in which the blister was kept changing. It was first like on the Achilles area of the right foot and moved down to heel. I thought it to be 1 area. RN- J stated that she believes the wound MD is still calling the right heel an unstageable SDTI. (Noted to be called pressure ulcer in MD assessment) RN- J stated again that the area was a clear fluid filled blister at 1 time. RN- J stated that they did obtain treatment initially for skin prep. RN- J stated that there should have been an assessment by one of the floor nurses at the time it was discovered. RN- J stated that R10 had the Prevalon boots in place when the blister was discovered. RN- J stated that somehow the area to R10's right heel got worse. Surveyor asked RN- J how she determined that R10 had a SDTI. RN- J responded based on what it looked like, I determined it to be a Deep Tissue Injury. On 05/11/22, 2:54 PM, RN- J provided Surveyor with the facility risk management IDT review of the open blister to right heel dated 3/31/22, which documented, area noted clean dry intact 100% skin with skin flap noted. Treatment orders and Prevalon boots in place. Blister consistent with shoe rubbing back of foot. POC updated for resident not to wear shoes until area resolved. RN - J stated she did not do a weekly comprehensive assessment of area until it became a Deep Tissue Injury. Verified area was open on 3/29/22. Surveyor asked RN- J why she did not assess area, RN stated well it was really only like a flap, like a deflated balloon. For a period of time, I was only following pressure ulcers. The Wound MD that I consult with has trained me that the trauma can't be staged and doesn't need assessing. Did not consider the flap to be a pressure ulcer. Surveyor verified facility policy with RN-J that a Stage #2 may also present as an intact or open/ruptured serum-filled blister. RN- J is agreeable per facility policy this meets the definition. On 05/12/22, at 8:35 AM , Surveyor made observations of Wound RN-J administering the treatment to R10's right heel. The following was observed: RN-J washed hands and applied gloves. Removed dressing to the R heel - small amount serous drainage on old dressing. RN-J wash hands and re-gloved; cleansed area with normal saline and gauze. RN-J had the cup up with gauze in it on table with barrier present; squirted pink bullets of normal saline onto gauze which was used to cleanse wound. Wound base appeared moist superficial area. No slough, necrosis or drainage noted. The area observed to be slightly larger than a 25 cent piece. No s/sx infection noted. No redness to surrounding skin. RN-J then washed her hands and re-gloved; skin prep applied to the surrounding skin; then applied Santyl with wood stick to wound bed; covered with clean dressing; replaced protective boot. Surveyor then asked to look at R10's L heel. Wound RN- J removed protective boot and sock. Surveyor observed dressing on L heel. RN- J stated: Oh! I wasn't aware she (R10) had something on that heel. Surveyor noted the dressing to be dated 4/28. Upon removal of dressing Surveyor noted large amount of yellow substance on dressing. Surveyor asked what the yellow substance was. Wound RN- J I don't think it's Iodosorb - it looks like maybe Iodine. Wound RN- J removed a piece of dried yellow matter, approximate size of a quarter, from the center of the old dressing and stated: This is some dried skin. Wound RN- J looked at heel and stated: I don't think anything is there, it just looks really dirty. I'm going to clean it up. Wound RN- J thoroughly cleansed heel with NS (Normal Saline) and gauze. Surveyor observed evidence of a previous (healed) blister; intact pink skin measuring 3 cm x 3 cm with surrounding peeling skin around edges. Wound RN- J palpated skin - reported it felt firm. stated: It's not open, I don't think there was a blister. Surveyor pointed out 3 x 3 cm area of healthy pink skin with surrounding peeling skin, and the evidence of the piece of skin in the old dressing. Wound RN- J stated: Maybe there was a blister there at one time, there's nothing there now. Wound RN- J applied skin prep to L heel. On 5/12/22, at 10:15 a.m., Surveyor interviewed Wound Care RN- J which stated R10's area started on the right Achilles from shoe rubbing. Surveyor asked if this would be considered pressure. Wound RN- J stated no, her shoes were too big for her. The Wound MD thought that the SDTI was actually a new area and told me I made a mistake. Wound RN- J- stated I thought the area had just moved down from Achilles to heel, it was the same area. Wound RN-J stated that on 4/12/22 she was made aware that R10 had an area to the right heel that was purple. I determined it was a SDTI. Wound RN- J stated that there should not be a concern with R10's skin assessments because a treatment was done the entire time. Surveyor asked Wound RN- J about the order from the Wound MD to use 1/2 strength Dakins solution to cleanse the wound prior to treatment. Wound RN- J stated that is a mistake, it is supposed to be normal saline solution, I had discussed this with the Wound MD last week. Surveyor verified with Wound RN- J that the last 3 weeks assessments indicated that 1/2 Dakins Solution was being used to cleanse the wound but the treatment order is for normal saline wash. This order was written on 4/27/22 to Apply Santayl to right heel topically one time a say for wound care. Normal Saline to right heel. Surveyor asked Wound RN- J about the observation in the morning on 5/12/22 that R10 had a dressing to the left heel dated 4/28/22. Wound RN- J stated she is not sure why this was there, maybe it was preventative. On 5/12/22, Surveyor conducted a review of R10's physician orders. It was noted that there was never an order obtained for a treatment to R10's left heel. The Treatment Administration Record for April, 2022 showed that on 4/28/22, Wound RN- J signed that she had completed a treatment to R10's right heel. This was also completed on 4/29/22 by Wound RN- J. R10 had a physician order to have a weekly skin check, on bath days ( Mondays) and staff are to document findings and implement interventions as needed. In addition, R10 had an order that staff are to Inspect Feet Daily. Document +/- (positive or negative) for findings. Document findings and implement interventions as needed every evening shift. The plan of care for R10 states that R10 has Diabetes Mellitus and a diabetic foot check is to be conducted every evening by licensed nurse, followed by lotion to bilateral lower extremities. Staff should have noticed that treatment gauze to R10's left foot was dated 4/28/22 when providing the nightly diabetic foot checks. Surveyor requested to view the weekly skin evaluations for R10. On 5/16/22, at 1:58 p.m., Director of Nursing- B stated that she could not provide any evidence that the weekly skin evaluations were completed and that she use to have a folder of the written evaluations but is not sure what happened to R10's. As of the time of exit, there was no further information provided as to why R10's open blister to her right heel (stage #2) was not comprehensively assessed until the area worsened on 4/12/22. R10's area continued to worsen, becoming unstageable and received a debridement treatment. In addition, there was concerns that the location of the area may have changed or even been 2 separate areas, although the assessment did not indicate this. The facility could not provide additional information as to how R10 ended up with a treatment gauze to the left heel, which was observed by the Surveyor and the area appeared to once have been a blister. 2.) R47 was originally admitted to the facility on [DATE] and was readmitted on [DATE] after a hospitalization. R47's diagnosis included muscle spasm, tracheostomy, dysphagia, heart failure, contracture of right knee, depressive disorder, chronic respiratory failure, hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. According to the significant change MDS (Minimum Data Set) dated 3/2/22, R47 had a BIMS (brief interview for mental status) score of 11, indicating moderate impairment for daily decision making. R47 needed extensive assistance of 2-person physical assist with bed mobility. R47 was assessed to be at risk for development of pressure ulcers and at the time of the assessment had no unhealed pressure ulcers. No DTI, (Deep Tissue Injury) no other wounds or skin problems noted. R47 is said to be non-verbal though able to communicate to a degree with nonverbal interaction. Nursing note dated 3/25/2022, at 12:08 p.m., documents: WCC (Wound Care Certified) RN- J called to room to assess darkened area to R47's medial right heel. NP (Nurse Practitioner)-C accompanied RN- J to room. Upon assessment, intact blood blister measuring 2 cm (centimeters) x 1 cm noted to medial right heel. R47 contracted, R leg under left and no noted skin to skin contact between heel and LLE noted. R47 questioned if skin was pinched and nods yes. Area assessed for items that may have pinched skin and consistent with skin being pinched between bed and bedside table. Plan of care updated to ensure bedside table moved away from bed during cares and repositioning. Skin prep orders obtained and processed. The facility obtained a physician order on 3/25/22 for Skin Prep Right to medial heel intact blood blister BID (two times) a day for intact blood blister Review of individual plan of care for R47 documents the following concerns: R47 has potential for pressure injury/ulcer development r/t (related to) Impaired mobility, incontinence, decreased activity, contractures, CVA (Cerbrovascular Accident) with right sided hemiplegia and hemiparesis, hx (history) of pressure ulcer to right medial heel. readmitted [DATE] with unstagable to right elbow (resolved 1/27/22). 02/14/22 area of sheering to right lateral; lower leg (resolved 03/01/22); 3/18/22 fungal rash to R hand between thumb and 1st finger; 3/25/22 Intact blood blister medial R heel. (Date Initiated: 06/18/2019 Revision on: 03/25/2022) Interventions included: R47's skin will be intact, free of redness, blisters or discoloration by/through review date. (Date Initiated: 08/27/2019, Revision on: 03/16/2022, Target Date: 06/18/2022); 1/15/22 weekly skin checks per policy (Date Initiated: 01/18/2022); Avoid positioning R47 on R medial foot (Date Initiated: 06/18/2019 Revision on: 11/26/2019); Daily foot checks by licensed staff (Date Initiated: 08/27/2019); Ensure bedside table moved away from bed with all cares and repositioning (Date Initiated: 03/25/2022); Inspect skin daily with cares-nursing assistant to report any concerns or changes to the nurse (Date Initiated: 08/27/2019); Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate, wound MD to follow (Date Initiated: 06/18/2019 Revision on: 12/14/2021). R47 was sent out to the hospital on 3/27/22 and returned to facility on 4/1/22. Review of the medical record did not show a re-admission skin assessment was completed upon R47's return to the facility. Nursing note dated 4/2/2022. at 8:07 p.m.; R47 A&O x's (Alert and oriented times) 3 and able to make needs known through hand signals. Resident resting quietly in bed this shift. Requires total assist with all cares and transfers. No s/sx (signs and symptoms) of pain or discomfort noted. Cares given every 2 and as needed. Peg tube in place and flushes well. Meds tolerated well. Tx (Treatment) continues to reddened areas and to right hand for fungus. Discoloration to right great toe and right heel remains with skin prep applied. Awaiting antibiotic to be delivered. Nursing note dated 4/3/2022, at 1:30 a.m., F/U (Follow Up) readmit. Alert & responsive. No s/s of pain & disc (discomfort). Color WNL (Within Normal Limits). Skin W&D (Warm and Dry). No cough or SOB (Shortness of Breath). HOB (Head of Bed) elevated. Tolerating TF (Tube Feeding) well. Oxygen continues @ 8L/min. (at 8 liters per minute) via trach mask. GT (Gastrostomy Tube) patent & intact. Abdominal soft. Non tender. Bowel sounds x4 (in all 4 quandrants), blister. Blood to R heel intact. Nursing note dated 4/4/2022, at 1:46 a.m.; F/u readmit. Alert & responsive. No c/o pain & disc. Color WNL. Skin W&D. No cough or SOB. HOB elevated. Tolerating TF well. Abdominal soft. Non tender. Bowel sounds x4. Continues ABT (antibiotic) for c-diff/sepsis. No adverse reaction. No loose stool noted @ present time. Blister R heel intact. TX (treatment) done. Surveyor noted though continued record review R47's medical record did not show any weekly pressure ulcer assessments to the areas to the right heel. Further review of the medical record did not show any evidence that the area to R47's right heel had been comprehensively assessed from 4/4/22- 4/29/22. Surveyor reviewed the physician progress note on 4/26/22 which documented, R47's Right heel wound resolved. Skin intact with no residual noted. currently resting comfortably. Plan: Monitor for pressure points pressure offloading and repositioning as tolerated watch for recurrence of infection: For details please see orders in the chart. Nursing note dated 4/29/22, written by Wound RN- J, documented, in to review intact blood blister to R heel cause by pinched skin. Blister noted dry, intact no drainage, no opening in skin no s/s infection or pain. Skin prep treatment remains appropriate. Surveyor reviewed R47's plan of care which was not updated to include the new skin impairment concerns of the right heel blister or additional interventions put in place. On 05/11/22, at 2:19 PM , Surveyor conducted an interview with Wound RN- J in regards to R47's intact blister to the right heel. Surveyor asked Wound RN- J why R47's area to the right heel was not comprehensively assessed weekly and noted to be a Stage #2 pressure Ulcer per facility policy. Wound RN- J stated the area was deemed to be trauma and did not assess as a pressure ulcer. The staff determined R47's heel was pinched due to the bedside table. Wound RN- J stated she asked R47 if area was pinched and R47 shook head yes. New intervention was to keep side table away from her. Wound RN- J stated she probably did not follow- skin assessment. Wound RN- J stated per my wound doctor I consult with, he does not stage them (blisters), meaning does not stage trauma. Wound RN- J confirmed that R47 is not followed by the Wound MD she consults with but follows what he recommends. Wound RN- J was again asked if there was an assessment of the area and Wound- RN J stated she has not been doing this and the floor nurse should be doing this . Wound RN- J again stated that the area is identified as trauma on risk management notes. Surveyor confirmed that the care plan says blood blister. Wound RN- J stated that the facility did obtain treatment from MD. On 5/11/22, at 2:54 p.m., Surveyor interviewed Wound RN- J who reviewed the risk management notes dated 3/25/22, which documented: IDT (Interdisciplinary Team) reviewed intact blood blister to medial right heel. Intact blood blister measuring 2 x 1 cm noted to medial right heel. R47 contracted, right leg under left and no noted skin to skin contact between heel and lower left extremity noted. R47 questioned if skin was pinched, resident nodded yes. Area assessed for items that may have been pinched skin and consistent with skin being pinched between bed and bedside table. POC (Plan of Care) updated to ensure bedside table moved away from bed during cares and repositioning. Wound RN- J again stated that she has not been assessing this area weekly because it's just an intact blister and treated with skin prep. Wound RN-J stated area is now a dry blister. Surveyor refereed Wound RN- J to facility's wound policy which identifies a Stage #2 may also present as an intact or open/ ruptured serum filled blister. Wound RN- J stated that previously she was only following pressure ulcers, not trauma areas or surgical areas. As of the time of exit, no additional information was provided as to why the facility did not comprehensively assess, per the individual plan of care and facility policy, R47's blister to the right heel.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R88's Quarterly Minimum Data Set with an Annual Reference Date of 1/3/22 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 2 person assist. R88's Care Plan (CP) Focus area initiated 1/2/20 documents: (R88) is at risk for falls r/t (related to) Fall history, impaired balance, psychotropic medication use, behaviors, cognitive loss, fall risk tool score. Interventions include: (R88) needs a safe environment with: Adequate glare-free light; a working and reachable call light, handrails on walls in hallways and bathrooms, personal items within reach - Date Initiated: 1/2/20. Bed in lowest position - Date Initiated: 1/2/20 Anticipate and meet (R88)'s needs - Date Initiated: 1/2/20. Surveyor review of the Facility Reported Incident dated 3/29/22 which indicated R88 sustained a fall from the bed. The report documented: Certified Nursing Assistant (CNA) was providing cares for resident by herself and per CNA, resident lifted her leg swinging it over causing her to fall out of bed on the floor striking her face. Resident was noted to have blood coming from her mouth. She was sent to the ED (Emergency Department) for evaluation. She received sutures for a laceration to her lower lip. She was diagnosed with a UTI (Urinary Tract Infection) and prescribed antibiotics. Imaging that was performed was negative for any fractures. Agency CNA told the DON (Director of Nursing) she had referenced the care card for the resident. The care card was reviewed and indicated resident is assist of 2 for bed mobility and dressing. When asked if she had someone in helping her, the CNA indicated that she did not. CNA was made a do not return to the facility. Her agency was notified by nursing. The ED note dated 3/29/22 documented: Laceration repair lower interior lip - 3 sutures. Laceration repair lower exterior lip - 2 sutures. On 5/9/22 at 3:23 PM Surveyor spoke with Nursing Home Administrator (NHA)-A. NHA-A reported the CNA admitted to her that she was getting the resident dressed when she fell out of bed, and she was alone when the CP indicated 2 person assist. NHA-A reported the CNA was fired after the incident. NHA-A reported facility wide education was completed after the incident and provided evidence of documentation. Surveyor noted the facility completed education with all nursing staff on following the Care Plan. On 5/9/22 at 11:20 AM Surveyor entered R88's room and observed R88 lying in bed, calling out Put some clothes on me. I want some pants on, I'm not wearing any pants, all I got on is my brief. R88 pointed to the closet and said: Clothes are in there. Surveyor noted R88's call light was not on. Surveyor asked R88 if she knew how to use her call light. R88 looked around, felt the bed with her right hand and said I don't know. Surveyor observed R88's call light on the floor near the right side of the head of he bed, not within reach of R88. On 5/9/22 at 2:14 PM Surveyor observed R88 lying in bed on her back, covered to her waist with a blanket. R88 was asleep and snoring. Surveyor observed R88's call light on the floor near the right side of the head of the bed, not within reach of R88. On 5/10/22 at 8:06 AM Surveyor observed R88 lying in bed on her back, with the head of the bed slightly elevated. Surveyor observed R88's call light on the floor, wrapped around the bed frame on the right side near the head of the bed, not within reach of R88. On 5/10/22 at 9:36 AM Surveyor observed R88 lying in bed, asleep, with the head of the bed elevated. R88's breakfast tray was on the table in front of her. Surveyor observed R88's call light was on the floor, wrapped around the bed frame on the right side near the head of the bed, not within reach of R88. On 5/10/22 at 11:15 AM Surveyor observed R88 lying in bed asleep. R88 woke when Surveyor entered room. Surveyor observed R88's call light remained on the floor, wrapped around the bed frame on the right side near the head of the bed, not within reach of R88. On 5/10/22 at 2:10 PM Surveyor observed R88 lying in bed asleep. R88's call light remained on the floor, wrapped around the bed frame on the right side of the bed, not within reach of R88. Surveyor noted R88's bed to be in a high position, at least 3 feet from the floor. No staff was in R88's room. On 5/10/22 at 3:28 PM Surveyor observed R88's call light remained on the floor wrapped around the right side of the bed frame on the right side of the bed, not within reach of R88. R88's bed remained in the high position at least 3 feet from the floor and no staff were in the room. On 5/11/22 at 11:04 AM Surveyor observed R88 lying in bed, which was now in the lowest position, with the call light attached to the left side of the bed within reach of R88. On 5/12/22 at 3:00 PM during the daily exit conference, Surveyor advised NHA-A that R88's Fall care planned P interventions included a working and reachable call light and bed in lowest position. Surveyor advised NHA-A of observations R88's call light not within reach and R88's bed in the high position without staff present in the room. No additional information was provided. Based on observation, record review and interview, the facility did not ensure that 3 (146, R12, & R88) of 8 residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents. * R146 was assessed to be at high risk for falls. R146 was assessed to require 2 staff assistant with bed mobility and toileting. On 3/24/22, cares were provided with 1 staff member and not 2 staff as assessed and as care planned for. On 3/24/22 during the cares provided, R146 fell out of bed sustaining a condyle fracture of lower end of R (right) femur. * R12 was observed to not have his fall interventions in place per his plan of care. R12 also sustained multiple falls (8 falls) that were not thoroughly investigated and did not include a root cause analysis to prevent future falls. * On 3/29/22, a Certified Nursing Assistant (CNA) provided cares to R88 by herself, rather than with the use of 2 staff members as indicated by R88's assessment and care plan. During the cares provided, R88 lifted her leg swinging it over causing R88 to fall out of bed and onto the floor striking her face. R88 was noted to have blood coming from her mouth. R88 was sent to the emergency department where R88 received 3 sutures for a laceration to her lower interior lip and 2 sutures to her lower exterior lip. Facility wide education was completed with all nursing staff on following the care plan however, during the survey, R88's fall preventive care planned interventions dated 1/2/20 was not followed. R88's bed was observed not to be in the lowest position and R88's call light was not within reach. Findings include: 1. R146 was readmitted to the facility on [DATE] with diagnoses that included Dementia with Behavioral Disturbance, Alzheimer's Disease with Late Onset and Chronic Obstructive Pulmonary Disease. R146's Quarterly MDS (Minimum Data Set) dated 2/22/22 documents that R146 has short and long term memory problems. Section C1000 (Cognitive Skills for Daily Decision Making) documents that R146 has severely impaired cognitive skills for daily decision making. Section G (Functional Status) documents that R146 has total dependence on staff and requires a two person physical assist for her bed mobility and toilet use needs. R146's Falls CAA (Care Area Assessment) dated 8/22/21 documents under the Care Plan Considerations section, R146 triggered the falls CAA because she has impaired balance and receives scheduled psychotropic medications. R146's situation is complicated by her advanced Alzheimer's dementia with severe cognitive & communication impairment .The team agrees she continues to have risk for falls and risk for injury if falls occur. Staff will continue to provide assist with ADL's per c.n.a (Certified Nursing Assistant) care card and provide interventions to help reduce her risk for falls. R146's Falls Risk Evaluation assessment dated [DATE] documents a score of 16, indicating that R146 is at high risk for falls. R146's ADL (Activities of Daily Living) care plan dated as initiated on 11/20/17 documents under the Interventions section, TOILET USE: R146 is incontinent of both bowel and bladder and requires check and change q (every) 2-3 hours and prn (as needed) with total assist of 2. R146's nursing note dated 3/24/22 documents, General Nurses Note Text: Writer alerted by CNA (Certified Nursing Assistant) that during care resident rolled over and rolled out of bed and landed on the left side. Resident is unable to say she is in pain or not. [R146] is scream [sic] and yelling thru out the shift which is her baseline. Writer unable to straighten her legs out. Writer inform RN (Registered Nurse) on duty to assess. Updated NP (nurse practitioner) and left message for POA (power of attorney) to return call. R146's nursing note dated 3/24/22 documents, General Nurses Note Text: Res (Resident) returned to facility at 1332 (1:32 p.m.) from .hospital via ambulance .Res (Resident) returned with a condyle fracture of lower end of R (right) femur. R146's hospital discharge documentation dated 3/24/22 documents, Diagnosis: Displaced unspecified codyle fracture of lower end of right femur; Fall- initial encounter. R146's fall investigation dated 3/24/22 documents, R146 .admitted to the facility on [DATE] for long term placement that shows severe cognitive impairment and has a legal guardian in place. She has a history of falls. She has a history of calling out/yelling out when touched or moved. She does have some noted contractures of her lower extremities . On 3/24/2022 at approximately 07:15 (7:15 AM) nursing was notified by the CNA (Certified Nursing Assistant) that the resident rolled out of bed during cares. The resident was assessed by nursing with no obvious s/s (signs and symptoms) of injury noted. Resident was yelling/calling out during assessment. She was transported to the ED (emergency department) for evaluation. Notifications were made. While at the ED, she was diagnosed with a displaced unspecified condyle fracture of lower end of right femur . CNA (Certified Nursing Assistant)-M indicated that she was providing cares for the resident and rolled the resident onto her left side. She stated the resident became combative at that point. She stated she tried to continue with cares so she could roll the resident back, but the resident rolled off the bed. She stated she was performing cares by herself. Administration, DON (Director of Nursing) and Social Services spoke with the CNA in the Administrative office. She was asked how she rolled the resident, and she indicated she rolled the resident away from her. She was asked if she had referred to the resident's care card which indicates she requires 2 people for bed mobility. The CNA indicated she did not look at the care card. CNA was educated at that time to always check the care cards for the residents before doing cares. CNA was suspended pending investigation. The resident returned from the hospital at 13:32 (1:32 P.M.) and was assessed. Orders for ace wrap to right leg/femur fracture and pain medications processed. Education initiated with staff on following and checking care cards. Spot checks for fall interventions and care cards conducted. Involved CNA remained off the schedule during investigation. She admitted to providing cares by herself and not referring to the care card. Involved CNA's employment terminated. R146's fall investigation dated 3/24/22 includes a written statement from CNA-M which documents, I was in [R146's] room getting her dressed and cleaned and when I was cleaning [R146], I rolled her away from me and that's when she (R146) fell on the floor. Surveyor noted per the facility's investigation report, R146 fell during incontinence cares as a result of only having an assist of 1, not 2 as documented in R146's plan of care and R146's assessment. Due to CNA-M no longer being employed at the facility at the time of the survey, Surveyor was unable to interview CNA-M regarding R146's 3/24/22 fall. On 5/16/22 at 9:05 a.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. Surveyor asked NHA-A if R146 fell during incontinence cares as a result of only having an assist of 1, not 2 as documented in R146's plan of care. NHA-A informed Surveyor that R146 should have had an assist of 2 during incontinence cares instead of 1. No additional information was provided as to why R146 did not have adequate interventions in place to prevent accidents. 2. R12 was readmitted to the facility on [DATE] with diagnoses that included Traumatic Brain Injury, Dementia without Behavioral Disturbance, Cerebral Infraction and Monoplegia of Upper Limb. R12's Significant Change MDS (Minimum Data Set) dated 1/27/22 documents a BIMS (Brief Interview for Mental Status) score of 3, indicating that R12 is severely cognitively impaired. Section G (Functional Status) documents that R12 requires extensive assistance and a two person physical assist for his bed mobility and transfer needs. Section G0400 (Functional Limitation in Range of Motion) documents that R12 has impairment to one side of both his upper and lower extremities. R12's Falls CAA (Care Area Assessment) dated 1/27/22 documents under the Care Plan Considerations section, R12 triggered the falls CAA because he has has fallen since readmission, has a history of falls, has impaired balance, and received prn (as needed) antianxiety medication during [NAME]. His situation is further complicated by his impulsiveness and attempts at keeping as much independence as he is able to, when not too lethargic since readmission, he also has hospice orders and received prn narcotic during reference period. Staff completed a fall risk tool on 1/21 and 1/24/22 indicating high risk, see for details. The team agrees he continues to be at risk for falls and risk for injury if falls occur. R12's Falls Risk Evaluation assessments dated 5/8/21 documents a score of 14, indicating that R12 is at moderate risk for falls. A. Observations R12's Falls care plan dated as revised 9/21/20 documents under the Interventions section, Pillows to sides of resident when in bed to define bed parameters. On 5/9/22 at 3:16 p.m., Surveyor observed R12 laying supine in bed. Surveyor observed R12 not to have pillows to the sides of his bed as documented in R12's plan of care. On 5/10/22 at 8:03 a.m., Surveyor observed R12 attempting to get out out bed. Surveyor observed R12 not to have pillows to the sides of his bed as documented in R12's plan of care. On 5/11/22 at 8:11 a.m., Surveyor observed R12 laying supine in bed. Surveyor observed R12 not to have pillows to the sides of his bed as documented in R12's plan of care. On 5/16/22 at 9:05 a.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. No additional information was provided as to why R12 did not have his fall interventions in place to prevent accidents and falls. B. Fall Investigations On 5/11/22 at 8:57 a.m., Surveyor reviewed R12's falls. Fall #1; R12's nursing note dated 11/6/21 documents, General Nurses Note Text: Called to room by roommate that resident had fallen in the bathroom self transferring himself to the toilet. Resident assessed by DON. Vitals stable, ROM (Range of Motion) within baseline limits. Resident transferred to toilet with 2 assist and gait belt then assisted to wheelchair. DON (Director of Nursing), administrator, case manager RN (Registered Nurse), son all updated on fall. R12's fall investigation dated 11/6/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #2; R12's nursing note dated 11/7/21 documents, General Nurses Note Text: Writer was called to resident room, he was laying on the floor in the bathroom on his left side. He was yelling out that his left arm/elbow/wrist and hand are in severe pain. He would not allow staff to assess the left arm at all. He stated I fell NP (nurse practitioner) on call notified of above new order to send to (name of hospital) ER for evaluation. Bell ambulance notified of transport. Administration updated, Guardian message left to return call to update on above. Bell ambulance arrived at 1840 for transportation all paperwork is with ambulance driver. R12's fall investigation dated 11/7/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #3; R12's nursing note dated 11/10/21 documents, General Nurses Note Text: Writer was alerted by patients roommate that patient was on the floor writer asses AROM (adequate range of motion), vitals and, checked skin for any indication of an injury. Patient had no c/o pain. Writer is a graduate RN who assessed under the supervision of DON. Patient Left extremities are at baseline patients Right extremities are unaffected by fall no trouble performing ROM exercises. Patient says he does not know what happened he was trying to get on the toilet and suddenly fell. R12's fall investigation dated 11/10/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #4; R12's nursing note dated 11/18/21 documents, General Nurses Note Text: Per LPN (licensed practical nurse): Floor nurse discovered resident lying on the floor, in supine position in front of resident bathroom door, ROM (range of motion) WNL (within normal limit), denies pain and discomfort at this time, resident denies hitting his head. PERRLA (pupils equal and reactive to light), Resident states, I have to go pee, get me off this floor. Assisted resident to toilet he had a large BM. (bowel movement) Resident is dry, he did not use his call light. Encourage to use his call light for assistant. R12's fall investigation dated 11/18/21 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #5; R12's nursing note dated 11/22/21 documents, Writer was made aware by CNA resident was in the bathroom on his back- Writer entered the bathroom where resident was laying on his back and his wheelchair was being him.[sic] No injuries. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #6; R12's nursing note dated 11/23/21 documents, Patient could be heard yelling help from his room. Nurse entered room and saw patient in his bathroom alone on the floor. He did not have his shoes or left leg brace. Patient had a laceration to the left lateral orbital bone measuring 0.6 x 0.9 cm. Patient stated he was trying to go the bathroom, fell and his [sic] head on the sink. C/o (complains of ) headache. Transport to hospital. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. Fall #7; R12's nursing note dated 1/21/22 documents, General Nurses Note Text: Called to room to assess resident. Resident was found on floor crawling toward the bathroom. Resident was admitted to hospice this AM. Resident is very confused at baseline. Resident unaware that he physically can not walk due to hx (history) of cva (cerebrovascular accident) .No injuries noted at this time. Bed in low position, fall mats in place. R12's fall investigation dated 1/21/22 documents, Staff to begin 3 day bowel and bladder assessment to check for toileting needs Q (every) 2 hours. Surveyor was unable to locate a bowel and bladder assessment dated [DATE] in R12's medical record. Fall #8; R12's nursing note dated 2/6/22 documents, Health Status Note Text: Resident resting in bed quietly with no c/o pain or discomfort voiced. Neuro (neurological) check - and injuries noted from fall on 2/6/22 at 1000. Tolerated med pass well. Will continue to monitor. R12's fall investigation dated 2/6/22 documents, IDT (Interdisciplinary Team): Due to resident impulsivity, falls are unavoidable. Surveyor noted that R12's fall investigation did not include a root cause analysis, when R12 was last seen prior to his fall and what fall interventions were in place prior to R12's fall. Surveyor also noted that R12's fall investigation did not have any new fall interventions put in place and R12's care plan was not updated to reflect R12's fall. On 5/12/22 at 3:28 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. NHA-A and DON-B directed Surveyor to speak with Wound RN (Registered Nurse)-J about R12's falls. On 5/16/22 at 8:46 a.m., Surveyor informed Wound RN-J of the above findings. Surveyor asked Wound RN-J if R12 had a bowel and bladder assessment completed on 1/21/22 as documented in R12's fall investigation, as Surveyor was unable to locate any in R12's medical record. Wound RN-J informed Surveyor that she also could not locate a bowel and bladder assessment dated [DATE] in R12's medical record. Surveyor asked Wound RN-J why R12's above fall investigations were not thoroughly investigated and or why they were missing a root cause analysis and new fall interventions for R12. Wound RN-J informed Surveyor that she could not provide any additional information regarding R12's above fall investigations as she was not employed at the facility at the time of R12's falls. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 1 (R70) residents reviewed. The facility was not monitoring NP-C's notes requesting lab orders starting on 1/13/22. Lab collections were not obtained timely with no follow through on results. The results of labs were not available in R70 medical record so that NP-C could monitor the results. NP-C ordered the labs because R70 was more confused, falling and declining. On 3/6/22, R70 was documented as having a fall. On 3/14/22, R70 had another fall, hitting her head and was sent to the emergency and hospitalized for an altered mental status and severe sepsis. This is evidenced by: The facility Policy titled: Lab (Laboratory) and Diagnostic Test Results - Clinical Protocol, revised October 2010 documents (in part) . 1. The physician will identify, and order diagnostic and lab testing based on diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility. The facility policy titled: Physician/Licensed Prescriber Orders Queued in EMR (Electronic Medical Record), dated 1/2022 documents (in part) .Policy Statement Physician/Licensed orders shall be given by on a person duly licensed and authorized to prescribe such orders in this state. Policy Interpretation and Implementation . 2. All drug, diagnostic and biological orders shall be noted by a person lawfully authorized to give such an order. These orders will be inputted into the electronic medical record (EMR) by the licensed prescriber and queued. These queued orders will serve as a notification to the assigned licensed nurse to confirm in the EMR, which will place the order in an active status. 3. The Director of Nursing (DON) or designee will monitor and confirm any queued orders at the end of the scheduled shift. 4. The Administrator will check to confirm no outstanding queued orders to ensure timely activation of all Licensed Prescriber's orders. R70 admitted to the facility on [DATE], and had diagnoses that included Encephalopathy, acute on chronic Diastolic (Congestive) Heart Failure, Diabetes Mellitus, Malignant Neoplasm of female breast with metastasis, major depressive disorder, anxiety disorder, Stage 3 Pressure Injury to buttock and iron deficiency anemia. R70's Brief Interview for Mental Status (BIMS) score dated 1/14/22 documents a score of 14 - indicating R70 was cognitively intact for daily decision making. R70's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 3/2/22 documented a BIMS score of 13 - indicating R70 was cognitively intact for daily decision making. R70's readmission Minimum Data Set assessment BIMS score dated 3/25/22, documented a score of 7 indicating severe cognitive impairment for daily decision making. Surveyor reviewed the Nurse Practitioner (NP-C)'s progress notes related to R70, which documented: On 1/13/22, Labs as ordered: CBC (Complete Blood Count), CMP (Comprehensive Metabolic Panel), TSH (Thyroid Stimulating Hormone), Hemoglobin (Hg) A1C, lipid panel. The NP-C completed a laboratory order request for these labs including a CPK (Creatine phosphokinase) dated 1/14/22. On 1/17/22, the NP-C documented: Labs ordered previous visit Not completed. On 1/18/22, (Medical Doctor note) documented: Labs as ordered - CBC, electrolytes, renal functions, Liver functions. Surveyor noted none of the above ordered lab results were in R70's medical record. On 1/21/22, NP-C documented: Lab request for CBC, CMP, TSH, Lipid profile, HgA1C. Surveyor noted lab test results dated 1/21/22, were not located in R70's medical record. Nursing Home Administrator (NHA)-A was able to provide this Surveyor with a copy of the lab results after the completion of survey. The lab results documented: CBC, Lipid panel, TSH, CBC, HgA1C as Cancelled. No specimen received. Surveyor was unable to find evidence NP-C was informed the ordered lab tests were cancelled due to no specimen being received. On 1/24/22, NP-C documented, Labs ordered but not resulted please obtain results and placed in chart. On 2/2/22, NP-C documented, Labs ordered but not completed. Labs ordered but not resulted please obtain results and placed in chart. On 2/4/22, NP-C documented, Labs ordered but not completed. Labs ordered but not resulted please obtain results and placed in chart. On 2/7/22, Surveyor noted the lab test results for the CBC, CMP, TSH, Lipid, Hga1C was collected. As of 5/16/22, the day of facility exit, these lab results were not in R70's medical record and was not available to staff includeing NP-C, or DON-B. (On 5/17/22, Surveyor was provided with the lab results that collected on 2/7/22 after the facility's exit on 5/16/22. There was no indication on these lab results that NP-C or the MD were ever notified of these lab results.) In the meantime, NP-C continued to order the labs which NP-C had not received. On 2/10/22, NP-C documented, Will get labs as ordered previously, monitor renal functions while on Metformin. On 2/15/22, NP-C documented: Labs were ordered previously and drawn but not resulted - not available on PCC (Point Click Care). Bilateral 3 to 4+ pitting edema, blistering, no calf tenderness. Start Lasix 40 mg (milligrams) daily. Tubigrips lower extremities. Will get labs as ordered previously, monitor renal functions while on Metformin. On 2/21/22, NP-C documented, Labs were ordered previously (initially ordered 1/13/22) and drawn but not resulted - not available on PCC. Bilateral 3 to 4+ pitting edema, blistering, no calf tenderness. Continue Lasix 40 mg in AM, and 1400 dose daily. Will get labs as ordered previously, monitor renal functions while on Metformin. Surveyor noted these labs were again on collected on 2/21/22. During the survey with an exit of 5/16/22, the results of the labs (CBC, CMP, TSH) were not available in R70's medical record not available to staff. The R70's medical record continues to indicate no lab results, for the CBC, CMP, and TSH. On 2/23/22, R70's lab results document: Potassium this morning 3.2. Not currently supplemented. Labs were ordered previously and drawn but not resulted - not available on PCC. Bilateral 3+ pitting edema, blistering, no calf tenderness. Potassium supplement today with 20 mEq (milliequivalents). Repeat BMP in 1 week. Will get labs as ordered previously, monitor renal functions while on Metformin. On 2/24/22, NP-C documented, Bilateral 3+ pitting edema, blistering, no calf tenderness. Repeat BMP not completed. Surveyor noted lab test results dated as collected on 2/25/22 for urine culture and sensitivity. Orders received on 2/28/22 indicated R70 received a 5-day course of Nitrofurantoin 100 mg (milligrams) twice daily for UTI (urinary tract infection). On 2/28/22, NP-C documented, Bilateral 3+ pitting edema, right ankle blistering, no calf tenderness. DC (discontinue) Fentanyl patch, removed by myself. Start scheduled morphine every 4 hours while awake. Will get labs as ordered previously (CBC, CMP, TSH, HGa1, lipid), monitor renal functions while on Metformin. Surveyor noted the only lab result in R70's medical record was a urine culture and sensitivity which was collected on 2/25/22. Orders received on 2/28/22, indicated R70 received a 5-day course of Nitrofurantoin 100 mg (milligrams) twice daily for UTI (urinary tract infection). Surveyor noted no further lab results were in R70's medical record prior to hospitalization on 3/14/22. R70's record continues to reflect; On 3/1/2022, at 11:12 PM, facility progress notes document: Resident was not herself. She was found multiple times hunched over on the side of the bed falling asleep and out of it. She was able to be re-alerted when her name was called. Resident was oriented but confused. She forgot that her dinner tray came and she did not eat. Her BS (blood sugar) was 90 and her insulin was held for dinner. HS (hour of sleep) her BS (Blood Sugar) was 92, her long-term insulin was held because resident did not want her meal and refused HS snack. Residents vital signs were within normal limits. This behavior has been observed for a couple of days. The NP-C was notified and ordered medication changes, but there has not been a change in this behavior at this time. Resident has +2 pitting edema to BL (bilateral) lower extremities. Supervisor was notified to remind day shift to place tubi-grip in the mornings. Resident did take all medications as ordered without any issues. Subsequent NP-C progress notes documented: On 3/2/22, NP-C documented, Bilateral 3+ pitting edema, right ankle blistering, no calf tenderness. Labs were ordered previously and drawn but not resulted - not available on PCC. Check CBC and CMP Monday. On 3/7/22, NP-C documented, Bilateral 2+ edema, resolving right ankle blistering, no calf tenderness. Check CBC, CMP Monday not done (in bold). On 3/11/22, NP-C documented, Resolved edema, resolved right ankle blistering, no calf tenderness. DC Metolazone, decrease Lasix to once a day. Check CBC, BMP Monday not done (in bold). Surveyor noted none of the above ordered lab results (which were orginally ordered on 1/13/22) were in R70's medical record. On 3/6/22, R70 was documented to have had a fall. The fall investigation documented the resident reported she slid down from the bed. No injuries were documented, and the NP-C was notified. On 3/14/22, R70 was documented to have sustained a fall. The fall investigation documented: Resident calling out for help stating, I'm on the floor, get me off the floor. Nursing staff in to assist, resident found laying on back on floor between wall and nightstand under window. Resident continent at time of incident, denies need to use bathroom, barefoot. When asked what happened, resident states on the floor, over here, over there nonsensical answers to questions which is not resident's baseline. Assessed for injury, none noted. Resident unsure if she hit her head. Pupils equal and reactive. Sent to ED (emergency department) for evaluation due to uncertainty of head injury and AMS (altered mental status). R70 readmitted to the facility on [DATE]. The Hospital Discharge Summary documented: Primary Discharge Diagnoses: Metabolic encephalopathy, severe sepsis, likely secondary to acute Escherichia coli UTI present on admission, hyperactive delirium/improving, volume depletion, likely due to reduced oral intake, acute kidney injury, hypokalemia, severe hypernatremia up to 151/improved. On 5/16/22, at 11:41 AM, Surveyor spoke with NP-C. Surveyor advised NP-C of review of R70's medical record revealed only the one urinalysis lab result. Surveyor asked NP-C if she had difficulty obtaining labs for R70. NP-C stated: Yes, I did have problems with her labs getting done. I was able to get only a few sent from the lab. The facility has PCC and I was told there would be no more paper orders, that I needed to put orders directly into PCC. NP-C stated: It (orders) would flag red pending confirmation and then staff would need to go in and confirm/sign them off, but that was not getting done, I'd come in and my orders would not be done. NP-C stated: I don't know if staff didn't know what to do or what, but now after I put my orders in, I have to send a list of the resident's names to the DON (Director of Nursing) so she can go in and sign them off. I don't understand why they just don't tell the nurses it's their job, and do it themselves - but now the DON does it all. Surveyor asked NP-C if she was aware of R70's cognition changes and falls prior to hospitalization on 3/14/22 and read the hospital discharge diagnoses and lab results. NP-C-C stated: Yes, I know. That's why I was ordering labs because she was more confused, falling and declining. On 5/16/22, at 10:22 AM, Surveyor advised NHA-A of concern that R70 did not have labs consistently completed as ordered since admission and most recently during the weeks prior to hospitalization on 3/14/22, following a fall with AMS. Surveyor advised NHA-A of R70's hospital discharge diagnoses of severe sepsis, hypokalemia and severe hypernatremia. NHA-A reported I'm going to check right now to see if there were any more labs. No additional information provided at that time. NHA-A subsequently provided Surveyor additional lab results after the completion of survey. On 5/17/22, at 1:00 PM, (after survey completion) NHA-A called Surveyor to say she called the lab and has some lab results for Surveyor to review. Surveyor advised NHA-A that Surveyor would review the lab results the facility obtained. Surveyor reminded NHA-A of the concern labs were ordered on 3/2/22 but were not completed prior to R70's fall with AMS. This fall resulted in hospitalization of R70 and diagnoses that included sepsis, hypokalemia, and severe hypernatremia. NHA-A stated, I understand. On 5/17/22, at 3:00 PM, (after survey completion) NHA-A advised Surveyor she looked in the computer and there was no order for a CBP, and CMP put in on 3/2/22. NHA-A reported the NP-C and doctors have to put their own orders in and I went in and looked and there was no order put in on 3/2/22, so we didn't know about the lab order. Surveyor advised NHA-A the NP-C progress notes on 3/2/22 documented the lab order and subsequent NP-C notes on 3/7/22 and 3/11/22 document (in bold) CBC/CMP not done. Surveyor asked NHA-A if anyone at the facility reviews the NP-C notes. NHA-A stated: I don't know, but I went into the computer, and she (NP-C) did not put an order in. Surveyor advised NHA-A the NP-C notes document patient and staff aware and understand. NHA-A stated: I see that she wrote that, but I'm saying she did not put an order in. Surveyor asked again if anyone at the facility reads or reviews NP-C or Physician progress notes. NHA-A stated: That I can't tell you. The NP and MD automatically scan them (progress notes) in (PCC) from their office, we don't even scan them in. On 5/17/22, at 4:55 PM, Surveyor advised NHA-A of concern the facility has no system in place to communicate with the NP or Physician prior to them leaving the facility regarding changes to the plan of care for the residents. Surveyor explained, NPs and Physicians are required to write progress notes, but there is no evidence the facility reviews the progress notes or communicates with the NP to ensure the plan of care and orders are followed. Surveyor advised NHA-A R70 experienced a change in cognition on 3/1/22 and NP-C's progress note on 3/2/22 indicated labs were to be ordered. Subsequent NP progress notes on 3/7/22 and 3/11/22 documented labs were not done (in bold letters). NHA-A stated: That's why I have to have a conversation with (NP-C-C) tomorrow. No additional information was provided.