**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility did not ensure 1 (R13) of 20 sampled residents care plans were revised accordingly.R13's care plan was not revised after R13 had a catheter re-inserted for urine retention.Findings include:The facility policy titled Care Plan Revisions Upon Status Change reviewed/revised 5/2025 documents: Policy: 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: .b. The Minimum Data Set (MDS) coordinator and the Interdisciplinary Team (IDT) will discuss the resident condition and collaborate on intervention options.d. The care plan will be updated with the new or modified interventions. h. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs.R13 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, Dementia, Type 2 Diabetes Mellitus, major depressive disorder, chronic kidney disease stage 3, and Benign Prostatic Hyperplasia (prostate is larger than normal) with lower urinary tract symptoms. R13's admission Minimum Data Set (MDS) dated [DATE] indicated R13 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 0. R13 was admitted to the facility on Hospice care and had a Foley catheter in place.On 8/6/2025, at 9:48 AM, Surveyor observed R13 lying in bed sleeping. Surveyor noted R13 had a catheter bag hanging from the right side of R13's bed.Surveyor reviewed R13's care plan and noted R13 had an indwelling foley catheter care plan initiated on 6/5/2025 that had been resolved on 6/27/2025.Surveyor reviewed R13's progress notes:On 6/26/2025, at 21:32 (9:32 PM), in the progress notes nursing documented (R13) removed catheter . order given to bladder scan (R13) each shift for 24 hours.On 6/27/2025, at 19:16 (7:16 PM), in the progress notes nursing documented . bladder scan for (R13) completed. 596 cc urine present, foley catheter replaced.Surveyor noted R13's foley catheter care plan never got revised/ re- initiated after R13 had R13's catheter re-inserted on 6/27/2025.On 8/12/2025, at 8:35 AM, Surveyor interviewed registered nurse unit manager (RNUM)-D who stated RNUM-D usually updates/ revises the care plans. RNUM-D stated that RNUM-D was not sure why R13's care plan was not revised on 6/27/2025 when R13 got the foley catheter re-inserted because RNUM-D was not employed with the facility at that time. RNUM-D stated care plans do get reviewed in the morning IDT (interdisciplinary team) meetings so it should have been noticed and must have been overlooked. Surveyor asked how often care plans get reviewed in the morning IDT meetings. RNUM-D stated the IDT meetings are every morning and discuss concerns, not all residents get reviewed unless something is happening or a resident is experiencing a change, so R13's should have been revised when the catheter got re-inserted in June.On 8/12/2025, at 11:47 AM, Surveyor shared concern with Director of Nursing (DON)-B that R13's catheter care plan was not revised on 6/27/2025 after R13 has a catheter re-inserted for retention. DON-B stated the care plan should have been revised when R13 had a foley catheter re-inserted and not resolved.

Based on observation and interview the facility did not ensure facility stock medications were not expired in 1 of 2 medication storage rooms.- 1 bottle of Calcium with Vitamin D 600 mg/400 IU with an open date of 11/22 and expiration date of 7/2025.- 2 unopened bottles of Aspirin 325 mg with an expiration date of 6/2025.- 1 bottle of Iron 27 mg with an open date of 1/23/2025 and an expiration date of 4/2025 and 2 unopened bottles of Iron 27 mg with an expiration date of 4/2025.Findings include:On 8/12/2025, at 8:18 AM, Surveyor observed in the 2nd floor medication room (2-East) in the stock medications cabinet the following expired medications:- 1 bottle of Calcium with Vitamin D 600 mg/400 IU with an open date of 11/22 and expiration date of 7/2025.- 2 unopened bottles of Aspirin 325 mg with an expiration date of 6/2025.- 1 bottle of Iron 27 mg with an open date of 1/23/2025 and an expiration date of 4/2025 and 2 unopened bottles of Iron 27 mg with an expiration date of 4/2025.On 8/12/2025, at 8:47 AM, Surveyor interviewed registered nurse unit manager (RNUM)-D who stated RNUM-D looked through the cabinets when RNUM-D started employment at the facility in July 2025 but must have missed those medications. Surveyor asked whose responsibility it is to go through the medications for expired medications. RNUM-D stated anyone can go through the medications to check for expired dates, but ultimately it is up to RNUM-D to make sure that is being completed and check to make sure it is being done. Surveyor asked how often the medications rooms are checked for expired medications. RNUM-D stated was not sure how often but would guess monthly.On 8/12/2025, at 11:47 AM, Surveyor shared concerns with director of nursing (DON)-B that Surveyor observed several expired medications in the 2-East medication room. DON-B stated that medication rooms should be checked often and expired medications should not be left in the medication rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R2) of 5 residents needing assistance with bathing received the necessary services for cares. R2 was admitted to the facility on [DATE] and discharged on 2/8/25. R2 went from 1/25/25 until 2/7/25 without receiving a shower/bath. R2 should have received a shower/bath on 1/31/25 according to the plan of care. Findings include: R2 is a [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses of sepsis, Myasthenia [NAME], subdural hemorrhage, epilepsy, abnormal posture, and colostomy. R2's admission Minimum Data Set (MDS) completed on 1/20/25 documents that R2 is dependent with toileting, showering, dressing and transfers. R2 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R2 has severe cognitive impairment. Surveyor reviewed R2's bathing documentation which documents R2 was to receive showers every Friday on the evening shift. The documentation indicates a shower was not completed for R2 on 1/31/25. Surveyor reviewed R2's nursing notes which documents R2 received a shower on 1/17/25, 1/20/25, 1/24/25, and 2/7/25. Surveyor notes R2 did not receive his scheduled shower on 1/31/25, making it two weeks without receiving a shower/bath per the plan of care. Surveyor interviewed Registered Nurse (RN) Unit Manager- D on 2/18/25, at 11:21 AM, who reviewed R2's shower records and indicated R2 did not receive a shower on 1/31/25. RN Unit Manager- D stated documentation looks like R2 missed his 1/31/25 shower. Surveyor notified RN Unit Manager- D of concerns with R2 missing his 1/31/25 shower and going two weeks without a shower. On 2/19/25, at 11:48 AM, Surveyor notified interim Director of Nursing (DON)- B of concerns with R2 going two weeks without a shower and missing his 1/31/25 shower. Interim DON- B acknowledged these concerns. No additional information was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R7 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, gastro-esophageal reflux disease with esophagitis with bleeding, protein-calorie malnutrition with a gastrostomy tube for all nutrition, anemia, and chronic embolism and thrombosis of deep veins. R7's admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 and had impairment to both arms and legs requiring maximum to total assistance with all activities of daily living and bed mobility. The MDS documented R7 received all nutrition through the gastrostomy tube. The MDS documented R7 had a Deep Tissue Injury that was present upon admission and had a pressure reducing device for the chair and bed and received pressure ulcer care. R7's Skin Impairment Care Plan dated 6/26/2024 documented R7 had deep tissue injuries to the five toes on the left foot. R7's Quarterly MDS assessment dated [DATE] documented R7 did not have any pressure injuries. R7 had an activated Power of Attorney (POA). R7's Skin Impairment Care Plan, initiated 6/25/2024, had the following interventions in place on 10/24/2024: -Apply zinc barrier cream every shift and as needed with incontinence cares. -Encourage good nutrition and hydration in order to promote healthier skin. (Surveyor noted R7 did receive any nutrition orally.) -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Keep linen dry, clean, and free of wrinkles. -Skin will be assessed on a weekly basis on scheduled bath day and document findings on a weekly skin assessment. -Report any skin redness/impaired integrity areas to the nurse. -Use barrier cream to prevent skin impairment issues as needed. R7 was receiving enteral nutrition through a gastrostomy tube. R7 had an order for Osmolyte 1.2 at 75ml/hr from 2:00 PM to 10:00 AM, a total of 20 hours. On 10/24/2024 at 10:24 AM in the progress notes, a Licensed Practical Nurse (LPN) documented a Certified Nursing Assistant (CNA) was giving (R7) a bed bath and noticed (R7) had a scabbed area on the right leg. The LPN documented the area is a dry, scabbed pressure area that measured 1.0 cm x 1.2 cm. The LPN documented the physician, POA, Unit Manager, and the Wound Physician were notified. The LPN documented the area was cleaned with normal saline and was awaiting orders from the wound physician. On 10/24/2024 on the Head to Toe Skin Check form, the LPN documented R7 had a new Unstageable pressure injury to the back of the right lower extremity that measured 1.0 cm x 1.2 cm. On 10/24/2024 at 10:33 AM in the progress notes, Registered Nurse Unit Manager (RN UM)-C documented R7 had a pressure injury to the right calf and R7 was unaware of the breakdown. RN UM-C documented R7 requires extensive assist for bed mobility, total assist for incontinence cares, and total assist of two for Hoyer transfer. RN UM-C documented R7 had a history of cerebral palsy, dysphagia, protein calorie malnutrition, and unilateral osteoarthritis of the right hip. RN UM-C documented R7 would be seen in house by the Wound Physician during wound rounds. RN UM-C documented R7's legs were elevated at the knee to avoid pressure to the site. The POA was updated, and the Care Plan was updated. RN UM-C documented previous intervention in place included heel boots. Surveyor noted heel boots when in bed were on the Treatment Administration Record to be signed off every shift initiated on 6/25/2024. On 10/24/2024 on the Weekly Skin Review, RN UM-C documented R7 had a scabbed area to the right calf, the Wound Physician had been notified, and a treatment order was received. The form was signed by RN UM-C on 10/25/2024. A treatment order for the right calf was to cleanse the wound with normal saline and apply betadine daily. On 10/24/2024 on the Pressure Ulcer/Skin Breakdown Unavoidable Investigation/Review form, RN UM-C documented R7 developed on 10/24/2024 to the right calf, skin breakdown. Primary risk factors include immobility and failure to thrive. No treatments were indicated. No recent lab values were indicated. Clinical signs that increased risk were gradual weight loss, immobility, and total dependence. No non-compliant behavior risk factors were indicated. clinical intervention in place and on the care plan included weekly skin observation, moisture barrier, heel/elbow protectors, and tube feeding. Monitoring included vital signs and weight changes. Education was provided to the POA. The form indicated based on the above clinical findings the pressure ulcer was determined to be unavoidable. The Root Cause portion of the form was blank. Surveyor noted with the information documented on the form, the pressure injury was not unavoidable. R7's Skin Impairment Care Plan was revised on 10/24/2024 with the interventions: -Educate (R7)/family/caregivers of causative factors and measures to prevent skin injury. -Elevate knees with pillow to avoid pressure to calves. Surveyor noted R7 was not seen by the Wound Physician as indicated. On 10/30/2024 on the Head to Toe Skin Check form, RN UM-C documented R7 had an Unstageable pressure injury to the right lower leg (rear) that measured 1.0 cm x 1.2 cm. On 10/30/2024 on the Weekly Skin Review form, an LPN documented R7 had a scabbed area to the right calf. On 10/31/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 2.0 cm x 2.0 cm with no drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type or percentages were documented. On 11/8/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 2.0 cm x 2.5 cm with no drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type or percentages were documented. On 11/14/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 2.0 cm x 2.0 cm with no drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type or percentages were documented. On 11/21/2024, R7 was admitted to the hospital due to a large brown emesis indicating a gastrointestinal bleed. R7 was readmitted to the facility on [DATE]. On 11/22/2024 on the Admit/Readmit Assessment form, an RN completed the Skin Integrity portion of the assessment and documented R7 had a pre-existing open wound to the back of the right lower leg (rear) that measured 1.5 cm x 1.5 cm x 0.2 cm with slough present. Surveyor noted this was the first measurement of depth and description of the tissue in the wound bed. No staging of the pressure injury was documented, and the percentage of slough was not documented. The treatment was changed to cleanse with normal saline, apply betadine, and cover with a foam dressing daily. On 11/27/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.4 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 12/5/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.6 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the Wound Physician would be updated if the condition declines or changes. On 12/12/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.3 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the Wound Physician would be updated if the condition declines or changes. On 12/19/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.3 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the Wound Physician would be updated if the condition declines or changes. On 12/26/2024 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.6 cm x 1.3 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. RN UM-C documented the treatment was changed to manuka honey to the wound bed daily. On 12/26/2024, R7 was admitted to the hospital due to shortness of breath. R7 was readmitted to the facility on [DATE]. On 12/30/2024 on the Admit/Readmit Assessment form, an LPN completed the Skin Integrity portion of the assessment and documented R7 had a wound to the posterior right lower leg. No staging, measurements, or description of the wound was documented. The hospital nutrition orders were for Osmolyte 1.2 at 75ml/hr from 2:00 PM to 12:00 Noon, a total of 22 hours, which is the order continued on readmission to the facility. On 12/30/2024 on the Nutrition Initial/Quarterly/Annual Assessment form, Registered Dietitian (RD)-H documented R7 was a nutritional risk related to past medical history that included cerebral palsy, gastroesophageal reflux disease with esophagitis and bleeding, oropharyngeal dysphagia, protein calorie malnutrition, hyperlipidemia, hypertension, chronic thrombus/embolus, and cognitive communication deficit. RD-H documented R7 was receiving Osmolyte 1.2 for 20 hours a day. RD-H documented R7 had been steadily losing weight since R7 arrived on 6/25/2024. RD-H documented R7's enteral nutrition and Med Pass should be providing sufficient energy: will add Med Pass twice daily and continue to monitor. Surveyor noted RD-H did not document R7 had a pressure injury. Surveyor noted this was the first documentation from a dietitian since R7 developed the Unstageable pressure injury. Surveyor noted RD-H did not document the correct enteral feeding schedule; RD-H documented R7 was getting enteral feeding 20 hours a day when R7 was receiving enteral feeding 22 hours a day so RD-H's calculations were not accurate. On 1/2/2025 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.4 cm x 1.1 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 1/9/2025 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.4 cm x 1.3 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 1/16/2025 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.0 cm x 1.0 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 1/22/2025 at 11:53 AM in the progress notes, RD-H documented R7 was receiving Osmolyte 1.2 at 75ml/hr for 20 hours which meets R7's nutritional needs. Surveyor noted RD-H did not document the correct enteral feeding schedule; RD-H documented R7 was getting enteral feeding 20 hours a day when R7 was receiving enteral feeding 22 hours a day so RD-H's calculations were not accurate. Surveyor noted RD-H did not document R7 had a pressure injury which would alter R7's nutritional needs. On 1/23/2025 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.0 cm x 0.8 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 1/30/2025 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.0 cm x 0.5 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. R7's Skin Impairment Care Plan was revised on 1/30/2025 with the intervention: -Pressure relieving/reducing air mattress to protect the skin while in bed; setting to (R7's) weight or comfort level. On 2/6/2025 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 1.0 cm x 0.5 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 2/13/2025 on the Skin and Wound Evaluation form, RN UM-C documented R7 had an Unstageable pressure injury to the right calf that measured 0.8 cm x 0.5 cm with light serous drainage. RN UM-C documented the pressure injury was Unstageable due to slough and/or eschar. No depth or description of the wound bed tissue type were documented. On 2/12/2025, R7 started Hospice services. On 2/17/2025 on the Nutrition Initial/Quarterly/Annual Assessment form, Registered Dietitian (RD)-H documented R7 was a nutritional risk related to past medical history that included cerebral palsy, gastroesophageal reflux disease with esophagitis and bleeding, oropharyngeal dysphagia, hyperlipidemia, hypertension, chronic thrombus/embolus, cognitive communication deficit, and severe protein calorie malnutrition. RD-H documented R7 was receiving Osmolyte 1.2 for 22 hours a day. RD-H documented (R7) was now on hospice services so (R7) should be monitored for comfort. On 2/18/2025 at 1:17 PM, Surveyor observed R7 in bed on an air mattress. R7 stated R7 was comfortable and agreeable to have Surveyor observe wound care. In an interview on 2/18/2025 at 1:27 PM, Surveyor met with RN UM-C to discuss R7's pressure injury. Surveyor shared with RN UM-C the documentation on 10/24/2024 the Wound Physician was initially going to assess R7 when doing wound rounds. Surveyor asked RN UM-C if the Wound Physician ever assessed R7. RN UM-C stated the Wound Physician had never assessed R7 because the wound is very small. Surveyor asked RN UM-C how R7 developed a pressure injury to the back of the right leg on the calf since that was not a normal pressure point and susceptible to pressure injuries. RN UM-C stated R7 must have at one time broken R7's leg because there is a bony prominence in the middle of R7's calf that would cause the pressure. On 2/18/2025 at 3:57 PM, Surveyor observed LPN-F provide wound care to R7 with the assistance of Certified Nursing Assistant (CNA)-G. R7 was observed to have heel boots on. When the dressing was removed from R7's right calf, Surveyor observed the pressure injury to measure approximately 1 cm x 1 cm x < (less than) 0.1 cm with a pink base. The leg had a bony protuberance at the area of the pressure injury. Manuka honey was applied to the dressing and the dressing was placed over the pressure injury. In an interview on 2/19/2025 at 2:31 PM, Surveyor asked RD-H if RD-H is notified when a resident develops a pressure injury. RD-H stated wound rounds are done every Thursday with the Wound Physician and RD-H can see the Skin and Wound forms in the computer charting after the wound rounds are completed. RD-H stated RD-H is informed shortly after a new admission comes in if they have a wound. Surveyor asked RD-H how involved RD-H is with a resident on enteral feeding. RD-H stated RD-H has a chart showing all the formula breakdowns so she can see the calories and protein for each type of feeding. RD-H stated RD-H had not started anyone on tube feeding. Surveyor asked RD-H why R7's tube feeding was increased in hours. RD-H stated R7 had been losing weight so RD-H increased the tube feeding an additional two hours. Surveyor shared with RD-H that R7 had gone to the hospital and returned on 12/30/2024 with the tube feeding increased at that time. RD-H stated RD-H had added Med Pass to R7's daily intake and then stopped it this month since R7 had gained some weight. Surveyor asked RD-H if RD-H was aware R7 had a pressure injury. RD-H stated RD-H had talked to RN UM-C about R7's pressure injury, so yes, RD-H was aware. RD-H stated RD-H calculated R7's protein and calorie needs and when she did the math, the enteral feed covered R7's needs even with a pressure injury. RD-H stated the Wound Physician's visits get emailed and are put in the wound folder and would make treatment recommendations. Surveyor shared with RD-H the Wound Physician had never seen R7 and did not have any notes in R7's medical record. RD-H stated R7 had been on RD-H's radar because of receiving tube feeding. Surveyor asked RD-H when RD-H became aware of R7 having a pressure injury because Surveyor did not see any documentation by RD-H that R7 had a pressure injury. RD-H reviewed RD-H's documentation and agreed RD-H did not mention a pressure injury. RD-H stated RD-H started employment at the facility in the middle of 10/2024 and October and November 2024 were a little hairy for RD-H because the new food service company started at the same time. RD-H stated it was hard for RD-H the first month knowing who had tube feedings and who had pressure injuries. RD-H agreed RD-H did not document R7 as having a pressure injury. Surveyor asked RD-H if RD-H would have done anything in October 2024 if RD-H had known R7 had a pressure injury. RD-H stated RD-H would have increased R7's protein intake if RD-H was aware of R7's pressure injury. RD-H stated it was triggered in the charting system when R7 readmitted on [DATE] to increase protein. Surveyor shared with RD-H the hospital had increased R7's enteral feeding order from 20 hours a day to 22 hours a day. RD-H was not sure who had increased R7's enteral feeding. In an interview on 2/19/2025 at 3:07 PM, Surveyor asked RN UM-C how R7's pressure injury started. RN UM-C stated on 10/24/2024, there was a scab on the back of the leg, and we started a treatment of betadine. Surveyor asked RN UM-C when did the pressure injury become an open area; Surveyor shared with RN UM-C the documentation did not describe the wound bed. RN UM-C stated RN UM-C did not know when the scab came off. RN UM-C stated the depth should have been documented as <0.1 cm. Surveyor asked RN UM-C who determined the wound was Unstageable. RN UM-C stated the Wound Physician looked at the wound and said it was an Unstageable pressure injury. Surveyor shared with RN UM-C that earlier RN UM-C stated R7 was never seen by the Wound Physician. RN UM-C stated the Wound Physician looked at R7's wound but never officially assessed it and did not document anything. RN UM-C stated the Wound Physician saw R7 in December 2024 and changed the treatment order but did not document. Surveyor shared with RN UM-C the concern the wound bed was never described so how do they know when the scab came off and how do they know if the wound is improving or declining when there is no documentation to compare it to from week to week. RN UM-C agreed RN UM-C could not determine when the scab came off and agreed more needed to be documented about the appearance of the wound bed. RN UM-C stated they have been keeping a towel under R7's knees when R7 is up in a Broda chair. Surveyor asked RN UM-C why an air mattress was not put in place until 1/2025. RN UM-C stated the air mattress was in place prior to them adding it to the care plan on 1/2025 but RN UM-C was unable to verify when the air mattress was placed on R7's bed. On 2/19/2025 at 3:43 PM, Surveyor shared with Director of Nursing (DON)-B the concerns with R7's Unstageable pressure injury; R7 did not have a comprehensive assessment of the wound when discovered, the weekly measurements did not include the measurement of depth, and the wound bed was never documented so staff could not determine if the wound was improving or declining. DON-B agreed there should always be a depth measurement documented. On 2/20/25 the facility submitted information provided to the Surveyor during the survey for additional review and consideration regarding R7. Additional provided included a summary/timeline of MD-L reviewing R7's wound history after Surveyors exited the survey. The detail includes: (Name of MD-L), Wound Care Specialist reviewed (name of R7) wound history and agrees that root cause determined that the wound was unavoidable due to Osteoma, however unable to say categorically or with certainly that this was indeed pressure due to the fact that he has a shorter leg compared to the other and the wheel chair positioning with the foot buddy size may not have caused the shorter leg to have been resting on the foot buddy. Therefore, this could have been trauma versus pressure unable to determine with certainty at this time. Surveyor noted at the time R7 developed the unstageable pressure injury no comprehensive assessment had been documented by MD-L or review of etiology of the wound. There is no indication the facility comprehensively reviewed the etiology of R7's pressure injury that included individual characteristics and risk factors individualized to R7. Based on observation, interview, and record review the facility did not ensure 2 (R6 and R7) of 3 residents reviewed with pressure injuries had the necessary care and treatment to prevent and heal the pressure injuries. * R6 was admitted to the facility on [DATE]. Upon admission, R6 had no open wounds or Pressure Injuries (PI). R6 was assessed to be at risk for pressure injuries and to need assistance with bed mobility upon admission. On 2/7/25, R6 developed a facility acquired Deep Tissue Injury (DTI) to his left heel. On 2/9/25, R6 developed a PI to his sacrum. The facility did not complete a comprehensive assessment of his wounds when discovered. R6 was transferred to the hospital on 2/13/25, with a change in condition and noted to have an unstageable sacral wound. * R7 developed an unstageable PI to the right calf on 10/24/2024. R7 did not have a comprehensive assessment of the wound when discovered, the weekly measurements did not include the measurement of depth, and the wound bed was never documented so staff could not determine if the wound was improving or declining. The unstageable PI has not ever been comprehensively assessed with all the components of a comprehensive assessment: stage, measurements of length, width, and depth, and a complete description of the wound bed. Registered Dietician (RD)-H was not aware of the pressure injury when it was discovered. Findings include: The facility's policy titled, Pressure Injury Prevention and Management, dated 2023, last reviewed/revised 04/2024, documents: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure injury, prevent infection and the development of additional pressure injuries. Avoidable means, that the resident developed a pressure injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Unavoidable means, the resident developed a pressure injury even though the facility had evaluated the resident's clinical condition and risk factors; defined and implemented interventions that are consistent with resident needs, goals, and professional standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Licensed nurses will conduct a pressure injury risk assessment, using the Braden risk assessment, on all residents upon admission. The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Examples of risk factors include but are not limited to: impaired/decreased mobility and decreased functional ability. Cognitive impairment. Exposure of skin to urinary and fecal incontinence. Under nutrition, malnutrition, and hydration deficits. The presence of a previously healed pressure injury. Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse. The staging of pressure injuries will be clearly identified to ensure correct coding on the Minimum Data Set (MDS). Monitoring: The Registered Nurse (RN) unit manager will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance at least weekly. 1.) R6 is an [AGE] year-old resident who was admitted to the facility on [DATE]. R6's diagnoses include bilateral osteoarthritis of the knee and left shoulder, pain in the left shoulder, Chronic Obstructive Pulmonary Disease (COPD), contusion of the left eyelid, difficulty walking, abnormalities of gait and mobility, lack of coordination, abnormal posture, cognitive communication deficit, and glaucoma. R6's admission MDS completed on 2/3/25, documents R6 is dependent with toileting hygiene, dressing, and requires substantial/maximal assistance with showering and rolling left to right. R6 was documented as having a Brief Interview for Mental Status (BIMS) score of 8, indicating R6 has moderate cognitive impairment. The MDS assesses R6 as not demonstrating the behavior of refusing cares. R6's MDS documents no unhealed pressure injuries and is at risk for developing PI's. R6's Care Area Assessment (CAA) for PI documents, R6 has frequent bowel incontinence, is at risk for developing PI's, and requires assistance with Activities of Daily Living (ADL) for movement in bed. R6 requires assistance from rolling left to right. R6 requires assistance from sitting on the side of the bed to lying flat on the bed. R6 requires assistance to safely move from lying on his back to sitting on the side of the bed with feet flat on the floor, and with no back support. R6's CAA documents R6 does not have any pressure ulcers. R6 was admitted to the skilled nursing facility (SNF) after an inpatient stay, treatment for rib pain after a fall at home, and requires assistance with ADL's, including transfers. R6 is frequently incontinent of bowel. R6's care plan, dated 1/28/25, documents: (R6) has actual impairment to skin integrity of the face, hematoma below the left eye with a scab, scattered bruising to extremities related to fall prior to admission, 2/7/25 left heel ruptured blister, now appears unstageable, 2/9/25 moisture acquired skin damage (MASD) now appears unstageable, (dated 1/28/25 with revisions on 1/29/25, 2/8/25, 2/10/25 and 2/13/25). Interventions include: Encourage good nutrition and hydration in order to promote healthier skin (dated 1/28/25). Encourage (R6) to elevate heels (dated 1/28/25). Encourage/assist (R6) with reposition as needed (dated 1/28/25). Low air loss mattress to protect the skin while in bed (dated 1/29/25). (R6's) skin will be assessed on a weekly basis on his scheduled bath day and document findings on a weekly skin assessment (dated 1/28/25). Pressure relieving/reducing cushions to protect the skin while up in chair (dated 1/29/25). Report any skin redness/impaired integrity areas to my nurse (dated 1/28/25). Use barrier cream to prevent skin impairment issues, as needed (dated 1/28/25). Heel lift boots when in bed (dated 2/8/25). Bed rest per wound medical director (MD) (dated 2/13/25). Surveyor noted R6's care plan was not individualized to R6 until 2/13/25 when bedrest, specific to R6, was ordered by the wound MD-L. Surveyor reviewed R6's medical record which documents a Braden Score performed on 2/7/25 and documents a score of 19, indicating R6 is not at risk for pressure injuries. Surveyor notes R6 was assessed rarely being moist on his 2/7/25 Braden Score indicating skin is usually dry and linen only requires changing at routine intervals. R6's medical record documents a progress note on 2/7/25, at 8:56 PM, indicating R6's Certified Nursing Assistant (CNA) notified nursing staff of a ruptured blister on his left heel. There was no drainage, pain, swelling, or erythema noted, and nursing staff notified R6's Medical Director (MD) and facility nurse manager. Treatment orders were obtained and R6 was placed on the 24-hour board for monitoring. Surveyor reviewed R6's Treatment Administration Record (TAR) which documents an order placed on 2/7/25 to apply betadine to the left heel twice daily and apply heel boots when R6 is in bed. R6's medical record documents a Head-to-Toe Assessment completed on 2/7/25, that documents a ruptured blister to the left heel measuring 3 cm x 3 cm x 0 cm. Staging is documented as Not Applicable (N/A) and no further wound description or details are documented. Surveyor notes there is no comprehensive assessment to include staging, wound bed description or, surrounding skin assessment performed. R6's medical record documents a Pressure Ulcer/Skin Breakdown Unavoidable Investigation/Review completed on 2/7/25, by Registered Nurse (RN) Unit Manager (UM)- D documenting the ruptured blister to R6's heel as unavoidable. Documentation includes primary risk factors being immobility and urine and bowel incontinence. Clinical interventions in place on the care plan include daily skin observation, weekly skin observation, frequent turning and repositioning, heel/elbow protectors, protein supplements, pain management, wound MD consult. Comments on the investigation/review form document (R6) is at risk for skin breakdown due to decreased mobility from rib pain and knee pain status post fall prior to admission. The Root Cause portion of the form was blank. Surveyor noted information documented on the unavoidable investigation as clinical interventions in place such as frequent turning and repositioning, heel/elbow protectors were not included on R6's care plan as interventions specific to R6's assessed needs prior to the development of the pressure injuries. Primary risk factors identified to include immobility, and urine and bowel incontinence were not reflected as being addressed individually for R6's potential needs as the care plan, generically, stated encourage/assist with reposition as needed. R6's Braden assessment dated [DATE] did not identify wet/moist skin and linen (which is possible with urine incontinence) as a risk factor for R6. On 2/19/25, at 9:37 AM, Surveyor left a message on RN- I's voicemail to contact Surveyor to discuss the Head-to-Toe Assessment completed on 2/7/25. RN- I did not return the call to Surveyor. R6's medical record documents a Head-to-Toe Assessment completed on 2/9/25, that documents an open area on R6's coccyx measuring 1cm x 1 cm. Surveyor notes there are no descriptive details regarding the open area including possible measurement of depth, staging, wound bed description or surrounding skin description. This was completed by Licensed Practical Nurse (LPN)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 (R4 and R2) of 3 residents reviewed for falls. *R4 had unwitnessed falls on 1/17/2025, 1/19/2025, 2/4/2025, and 2/13/2025. The facility did not thoroughly investigate the falls to determine a root cause of each fall and develop personalized interventions to prevent future falls. *R2 had two unwitnessed falls on 1/17/2025 and 2/7/2025. The facility did not thoroughly investigate these falls. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and a thorough investigation to determine a root cause to determine necessary preventative interventions. Findings include: The facility policy and procedure titled Fall Prevention Program dated 4/2024 documents: Policy Explanation and Compliance Guidelines: 1. The facility utilizes a standardized risk assessment for determining a resident's fall risk. 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 3. The nurse will indicate the resident's fall risk and initiate interventions on the resident's baseline care plan, in accordance with the resident's level of risk. 4. Each resident's risk factors and environmental hazards will be evaluated when developing the resident's comprehensive plan of care. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised as needed. 5. When any resident experiences a fall, the facility will: a. Assess the resident. b. complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident's care plan and update as indicated. f. Document all assessments. 1.) R4 was admitted to the facility on [DATE] with diagnoses of urinary tract infection, chronic kidney disease, diabetes, polymyalgia rheumatica, dementia, depression, difficulty in walking, lack of coordination, and communication deficit. R4's admission Minimum Data Set (MDS) assessment dated [DATE] documented R4 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9, wore glasses, was always incontinent of bladder, frequently incontinent of bowel, needed maximal assistance with toileting hygiene, and needed moderate assistance with transfers. R4's Fall Care Area Assessment with this MDS documented R4 had not had any recent falls, depends on staff to assist with activities of daily living including transfers, has dementia, and becomes confused at times and needs reorientation. R4 was taking psychotropic medication, insulin, and a diuretic which may increase the risk for falls due to side effects. R4 was at risk for falls due to impaired mobility and side effects of medication. R4 did not have an activated Power of Attorney. R4's At Risk for Falls Care Plan was initiated on 1/3/2025 with the intervention: -Be sure (R4's) call light is within reach and encourage (R4) to use it for assistance as needed; (R4) needs prompt response to all requests for assistance. R4 had a Bowel Incontinence Care Plan and a Bladder Incontinence Care Plan initiated on 1/3/2025. No toileting schedule or check and change protocol was initiated. On 1/17/2025 at 7:29 PM in the progress notes, a Registered Nurse (RN) documented a Certified Nursing Assistant (CNA) entered R4's room at 6:05 PM to pick up the dinner tray and found R4 laying on the floor next to the bed. R4 reported R4 had slipped off from the bed while trying to get self into bed. The call light was not activated. R4 did not hit the head. Range of motion was within normal limits, neuro checks were negative, and R4 did not have any injury. R4's spouse, PM supervisor, and physician were notified. The Fall Risk Management form was completed by the RN and documented R4 was oriented to person, place, and situation, predisposing physiological factors were confusion, incontinence, gait imbalance, and weakness/fainted, and predisposing situation factors were using a wheelchair. R4 had intermittent confusion. The Post Fall Assessment form was completed by the RN and documented the fall occurred on 1/17/2025 at 6:05 PM in R4's room. R4 had been up in a wheelchair prior to the fall. R4 did not have a history of falls. R4 had diabetes and unsteady gait. R4 took a diuretic and recently had a new medication of Kevzara injections (used to treat rheumatoid arthritis). R4's functional status included receiving rehab therapy, incontinent of bladder and bowel, unable to toilet self, and can use call light independently. The review of post fall findings documented R4 was attempting to self-transfer from the wheelchair to the bed and slipped off. A referral was made to therapy and the root cause was unsteady gait and did not use the call light. R4's At Risk for Falls Care Plan was revised on 1/17/2025 with the intervention to anticipate and meet R4's needs. R4's Actual Fall Care Plan was initiated on 1/17/2025 with the interventions: -Complete Post Fall Assessment. -Complete Risk Management in PCC (computer charting system). -Initiate neuro checks per facility protocol. -Initiate pain monitoring per facility protocol. -Update physician, nurse practitioner, and responsible party. On 1/19/2025 at 11:20 PM in the progress notes, a Licensed Practical Nurse (LPN) documented R4 had an unwitnessed fall at 9:30 PM. The CNA called the nurse into the room. R4 was found halfway on the bed with the torso bent forward and R4 kneeling on the floor. The wheelchair was unlocked and away from R4 about 3 feet. R4 stated R4 thought R4 locked the wheelchair and then leaned forward towards the bed to reach for the call light but the wheelchair slipped out from under R4 and R4 fell forward onto the bed. R4 stated R4 was there for 5 minutes before R4 was found. The charge nurse was called. Vital signs and neuro checks were obtained and normal. R4 did not have any injuries. R4 was transferred to bed. the physician was notified and R4 declined for emergency contact to be called. Education was provided about locking the wheelchair and process of how post-fall works. The Fall Risk Management form was completed by the LPN and documented R4 had predisposing physiological factors of incontinence, gait imbalance, and medication, and predisposing situation factors of using a wheelchair, on a diuretic, unlocked wheelchair, and lack of coordination. The Post Fall Assessment form was completed by the LPN and documented the fall occurred on 1/19/2025 at 9:30 PM in R4's room when R4 was reaching to get the call light off the bed and thought R4 had locked the wheelchair. Fall interventions in use at the time of the fall were lock wheelchair, call light in reach, and education to R4 about locking the wheelchair and use of the call light for assistance. R4 had 1-3 falls in the past three months. R4 had underlying diseases or conditions of psychiatric or cognitive conditions such as dementia, lack of coordination, and abnormal posture. R4 took hypoglycemic's and diuretics. R4's functional status included problems with mobility, standing and sitting balance, use of assistive/adaptive devices, receiving rehab therapy, incontinent of bowel and bladder, unable to toilet self, and can use call light independently. The new fall prevention intervention to be implemented as a result of the assessment was call light in reach, education about locked wheelchair, and call for assistance if they need to transfer to bed or to wheelchair. The root cause was unlocked wheelchair. On 1/20/2025 at 9:07 AM in the progress notes, RN Unit Manager (RN UM)-C documented the interdisciplinary team (IDT) met to review R4's fall on 1/17/2025 at 6:05 PM and determined R4 would benefit from a Call Don't Fall sign placed in R4's room. Surveyor noted the IDT met three days after the fall and the intervention was implemented after R4 had another fall. On 1/20/2025 at 10:08 AM, RN UM-C documented the IDT met to review R4's fall on 1/19/2025 at 9:30 PM and determined R4 would benefit from staff to ensure call light is within reach prior to leaving R4's room each time. Surveyor noted that intervention was in R4's initial At Risk for Falls Care Plan. R4's At Risk for Falls Care Plan was revised on 1/21/2025 with the intervention Call Don't Fall sign placed in R4's room. R4's At Risk for Falls Care Plan was revised on 1/22/2025 with the intervention to reeducate R4 on locking wheelchair prior to transfers with return demonstration. On 2/4/2025 at 11:17 AM in the progress notes, an LPN documented they heard someone screaming for help from the hallway. The LPN and two CNAs did a walk through and found R4 sitting up on the bathroom floor. R4 verbalized R4 needed to use the toilet and felt weak and out of balance during the self-transfer to the toilet. R4 was assessed for injury and R4 had minimal redness to the buttocks. The unit manager and physician were updated with no new orders. Therapy was updated. R4 was responsible to self. The Fall Risk Management form was completed by the LPN and documented R4 was oriented to person, place, and situation. Predisposing physiological factors were gait imbalance and impaired memory. Predisposing situation factors were improper footwear. The LPN documented R4 self-transferred without grip socks on. The Post Fall Assessment was completed by the LPN and documented the fall occurred on 2/4/2025 at 7:25 AM in R4's bathroom due to a self-transfer. The call light was within reach and the bed was in the lowest position. R4 had a history of 1-3 falls in the last three months. R4 took diuretics. R4's functional status included use of assistive/adaptive devices, receiving rehab therapy, incontinent of bowel and bladder, unable to toilet self, and can use call light independently. The new fall prevention intervention to be implemented as a result of the assessment was to check R4 often, call light within reach, and education provided to R4 about waiting for assistance to arrive prior to transferring self. The root cause was unsteady gait, not utilizing call light for assistance. Surveyor noted the documentation of the fall was unclear as to how R4 got to the bathroom, whether in a wheelchair or ambulating independently. Surveyor noted the fall risk management form does not document follow up or investigation into what type of footwear R4 should have on and whether it was included on the care plan or ask why R4 did not have on gripper socks as identified as a contributing factor in the fall. On 2/5/2025 at 9:56 AM in the progress notes, RN UM-C documented the IDT met to review R4's fall on 2/4/2025 at 7:25 AM and determined R4 would benefit from offering R4 to get up after blood glucose monitoring is completed. Review of the fall shows R4 was attempting to get out of bed unassisted in the early morning after being woken for glucose monitoring. R4's At Risk for Falls Care Plan was revised on 2/5/2025 with the intervention R4 to be offered to get up in the morning after blood glucose monitoring is completed. Surveyor noted R4's toileting care plan was not revised to address R4 needing to use the toilet at the time of the fall and the lack of proper footwear was not addressed. On 2/13/2025 at 12:15 AM in the progress notes, an RN documented the RN heard R4 yelling and found R4 on the floor sitting with no incontinent product on and with R4's walker nearby. R4 had taken the incontinent product off and it was lying on the bed. R4 stated R4 thought it was time to get up so R4 got up to go to the bathroom and slid down. R4 did not have any injuries. The physician and spouse were notified. The Fall Risk Management form was completed by the RN and documented R4 was confused and had impaired memory. R4 was ambulating without assist and had improper footwear. R4 was using a walker. The Post Fall Assessment form was completed by the RN and documented the fall occurred on 2/13/2025 at 12:15 AM in R4's room. R4 had been in bed sleeping prior to the fall. The bed was in low position and the call light was within reach. R4 had 1-3 falls in the last three months. R4 was diabetic. R4 took hypoglycemic's and diuretics. R4's functional status included problems with mobility, standing and sitting balance, use of assistive/adaptive devices, incontinent of bowel, unable to toilet self, and can use call light independently. The new fall prevention intervention to be implemented as a result of the assessment was for R4 to have gripper socks on when in bed. The root cause was confusion. R4's At Risk for Falls Care Plan was revised on 2/13/2025 with the intervention to have bed in low position and gripper socks on when in bed. Surveyor noted R4 did not have appropriate footwear on when R4 fell on 2/4/2025 and was not addressed as an intervention at that time. On 2/14/2025 at 11:57 AM in the progress notes, RN UM-C documented the IDT met to review R4's fall on 2/13/2025 at 12:15 AM and determined R4 would benefit from a night light kept on for assistance with orientation if waking up in the middle of the night. Surveyor noted R4's toileting schedule was not reviewed or revised with R4's need to use the bathroom. R4's At Risk for Falls Care Plan was revised on 2/14/2025 with the intervention night light to be on at night for assistance with orientation in the middle of the night. On 2/17/2025 at 1:21 PM, Surveyor observed R4's room. R4 was not in R4's room at the time. Surveyor observed a Call Don't Fall sign on R4's bulletin board across the room from R4's bed. Surveyor noted multiple items were on the bulletin board such as cards and pictures making the sign very difficult to see. As a fall intervention, the sign was not in R4's line of vision whether in bed or transferring into or out of bed. Surveyor noted R4 required glasses for clear vision and only one sign was observed in R4's room. The call light was attached to R4's pillowcase at the edge of the bed. A walker was up against the wall opposite of the bed. Surveyor asked CNA-M where R4 would be located at that time. CNA-M stated R4's spouse comes regularly to see R4 and wheels R4 downstairs for activities. CNA-M stated R4 does not spend much time in R4's room. Surveyor observed R4 in a wheelchair on the first floor attending the BINGO activity. In an interview on 2/18/2025 at 1:31 PM, Surveyor asked RN UM-C what the facility fall protocol was. RN UM-C stated the CNA would let the nurse know if a resident had fallen and an RN must do the assessment before the resident is moved either to a chair or bed. RN UM-C stated the unit nurse does a skin assessment, a pain assessment, neurological checks, starts the 72-hour post fall follow ups, and does the post fall assessment. The unit nurse notifies the physician and the Power of Attorney or emergency contact. The fall is reported to the unit manager or shift supervisor or the on-call supervisor. RN UM-C stated falls are discussed in morning stand-up and at 1:30 PM stand-down. RN UM-C stated the floor nurse talks to all the staff to get details of the fall. RN UM-C stated if a fall happens on a weekend, therapy is here and can do an assessment at that time and then the IDT meets on Monday after the weekend to come up with interventions. RN UM-C stated the IDT has a group chat, so all are updated timely on any situations. RN UM-C stated for instance, R4 just decided to get out of bed and go to the other bed in the room. Surveyor noted that information was not in R4's fall investigation for the fall that occurred on 2/13/2025. Surveyor asked RN UM-C if the facility uses fall mats as an intervention because Surveyor had not noted any fall mats in use with residents. RN UM-C stated yes, they use fall mats. Surveyor reviewed with RN UM-C R4's four falls for clarification. Surveyor shared the concern with RN UM-C that the documentation does not always follow as to how the intervention is determined, such as the fall on 2/4/2025 did not have any information as to how R4 got into the bathroom, who had seen R4 last, and did R4 walk to the bathroom or was there a wheelchair in the vicinity of the fall. RN UM-C was unable to say how R4 got into the bathroom. Surveyor shared the concern with RN UM-C that R4 had fallen a few times trying to get to the bathroom and toileting was not addressed in any of the root cause evaluations. Surveyor shared with RN UM-C the intervention for R4's fall on 2/13/2025 was to have gripper socks on when in bed and improper footwear was listed in the fall on 2/4/2025 and not followed up on. Surveyor shared with RN UM-C the observation in R4's room of the Call Don't Fall sign; the sign was buried on the bulletin board and would not catch R4's eye to remind them to use the call light. Surveyor shared that Surveyor was actively looking for the sign as a fall intervention and it took a bit to find it. RN UM-C agreed that the interventions needed to be reviewed. On 2/19/2025 at 8:56 AM, Surveyor observed R4's room. R4 was not in the room at the time of the observation. The Call Don't Fall sign was still on the bulletin board covered with cards and pictures. A fall mat was on the floor next to R4's bed. The call light was on the bed under a pillow at the head of the bed. Surveyor noted R4, in a wheelchair, would not be able to get close to the bed to reach the call light to ask for assistance due to the fall mat being placed on the floor next to the bed. On 2/19/2025 at 9:23 AM, Surveyor shared with Director of Nursing (DON)-B the concerns with R4's falls not being thoroughly investigated to implement a personalized fall intervention based on the root cause analysis. Surveyor shared with DON-B the observations of R4's Call Don't Fall sign being buried on the bulletin board where R4 would not be able to see it as well as the need for R4 to have glasses on to see the sign, showing the intervention was not personalized to R4's needs. Surveyor shared with DON-B the observation that morning of a fall mat on R4's floor that was not assessed as a need or put on R4's At Risk for Falls Care Plan and the fact that the floor mat made it impossible for R4 to wheel up to the bed to reach the call light to ask for assistance. In an interview on 2/19/2025 at 10:24 AM, RN UM-C stated Nursing Home Administrator (NHA)-A had purchased fall mats and a nurse saw them and put one in R4's room. RN UM-C stated the fall mat should be put up off the floor when R4 is not in bed. RN UM-C stated RN UM-C added the fall mat to R4's care plan. RN UM-C agreed the Call Don't Fall sign was not placed well. In an interview on 2/19/2025 at 11:49 AM, DON-B agreed the Call Don't Fall sign should have been moved. DON-B stated a nurse on the floor saw the fall mats so put one in R4's room that morning. Surveyor shared with DON-B there was no assessment to show R4 needed a fall mat. DON-B stated the nurse saw it and thought it would be a good idea. DON-B stated the IDT meets and DON-B feels they do a very good job with falls. DON-B stated the sign would have been placed right away and there may not have been anything else on the bulletin board at that time. Surveyor shared with DON-B that interventions are not reviewed to see if they are still effective, such as the Call Don't Fall sign. DON-B agreed interventions need to be reevaluated. On 2/20/25 the facility submitted information provided to the Surveyor during the survey for additional review and consideration regarding R4. 2.) R2 is a [AGE] year-old resident who was admitted to the facility on [DATE] with diagnoses of sepsis, Myasthenia [NAME], subdural hemorrhage, epilepsy, abnormal posture, and colostomy. R2's admission Minimum Data Set (MDS) completed on 1/20/25 documents that R2 is dependent with toileting, showering, dressing and transfers. R2's MDS documents falls since admission to the facility on 1/14/25. R2's MDS documents falls with injury in the last 2-6 months prior to admission. R2 was documented as having a Brief Interview for Mental Status (BIMS) score of 3, indicating that R2 has severe cognitive impairment. R2's care plan, dated 1/14/25, documents: (R2) is at risk for falls related to myasthenia gravis status post Cerebrovascular Accident (CVA) with right sided weakness (date initiated 1/14/25). Interventions include: Be sure (R2's) call light is within reach and encourage the resident to use it for assistance as needed. (R2) needs prompt response to all request for assistance (date initiated 1/14/25). Surveyor notes these are the only interventions for R2 who has a history of falls with injury, right sided weakness post CVA, and severe cognitive impairment prior to his fall on 1/17/25. R2 has an activities of daily living (ADL) self-performance deficit related to myasthenia gravis status post CVA with right sided weakness (date initiated 1/14/25) Interventions include: (R2) requires assistance by one staff with bathing as necessary (date initiated 1/15/25). (R2) requires assistance by one staff to turn and reposition in bed (date initiated 1/14/25). (R2) requires assistance by one staff to dress (date initiated 1/15/25). (R2) requires set up by one staff to eat (date initiated 1/14/25). On 1/17/25, at 1:30 PM, R2 sustained an unwitnessed fall and was found by facility staff sitting on his buttocks on the floor with his back and head against the side of the bed. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and thorough investigation to determine a root cause. Surveyor reviewed the facility fall investigation dated 1/17/25 for R2 which documents the following: (R2) fell in his room on 1/17/25 at 1:30 PM and was sitting in his wheelchair prior to the fall. (R2) sustained a red linear line to the back of his neck, however skin was not broken. (R2's) family, and physician were notified of his fall on 1/17/25. Fall interventions currently in place prior to his fall were documented to keep (R2's) call light within reach. Neuro checks were completed without significant findings. R2's post fall assessment documents R2 having problems with cognition, judgment, memory, and/or safety awareness. (R2) is a new admission to the facility; is alert and oriented but does have decreased safety awareness. There are no environmental factors that may have contributed to R2's fall. (R2) is alert, oriented; did not activate his call light to ask for assistance; (R2) wanted to get into bed and attempted to self-transfer which resulted in a fall due to weakness. New fall prevention interventions included, encourage (R2) to use his call light to ask for assistance into bed from wheelchair and notify therapy. The post fall assessment documents the root cause as weakness and lack of safety awareness. The fall investigation included an incident description which states staff was notified R2 had fallen in his room. Staff entered R2's room and noted him to be sitting on his buttocks, with his back and head against the side of the bed. R2's wheelchair was to the right of him, brakes unlocked. R2's call light was not activated, but within reach. R2 had gripper socks on both feet. No environmental factors noted. R2 is unable to fully verbally state what happened, but did indicate he was trying to get himself into bed. R2 indicated to staff he did not hit his head during the fall. R2's fall investigation indicates a Registered Nurse (RN) assessment was completed. R2 was placed on the 24-hour report board for monitoring. Surveyor notes the Interdisciplinary Team (IDT) met on 1/20/25 which documents (R2) would benefit from a call don't fall visual aid on the wall in his room. The IDT team documents the root cause of the fall being R2 self-transferring. Surveyor notes the fall investigation does not include when R2 was last seen, last toileted, location of where R2 was sitting in his wheelchair prior to his fall, staff statements, and whether R2's call light was within reach at the time of the fall. Surveyor notes the fall investigation did not identify a thorough root cause analysis. R2's care plan was updated after R2's 1/17/25 fall to include: Call don't fall visual aid on the wall in my room (date initiated 1/17/25). Encourage (R2) to use his call light to ask for assistance with transferring to bed from wheelchair, and to wait for assistance (date initiated 1/17/25). Surveyor notes care plan interventions are not personalized interventions for (R2) who has severe cognitive impairment and a BIMS of 3. Fall occurred with no injury (date initiated 1/17/25) Interventions include: Complete a risk assessment in point click care (PCC) (date initiated 1/17/25). If no apparent acute injury, determine and address causative factors of the fall (date initiated 1/17/25). Initiate neuro checks per facility protocol (date initiated 1/17/25). Initiate pain monitoring per facility protocol (date initiated 1/17/25). Complete post fall assessment (date initiated 1/17/25). Complete risk management in PCC (date initiated 1/17/25). Continue interventions on the at risk for falls care plan (date initiated 1/17/25). Update nurse manager, Director of Nursing (DON), Assistant Director of Nursing (ADON) of a fall with significant injury requiring emergency room evaluation (date initiated 1/17/25). Update physician, nurse practitioner, and responsible party (date initiated 1/17/25). On 2/7/25, at 10:15 AM, R2 sustained an unwitnessed fall and was found by facility staff sitting on the floor next to his bed with his back against the side of the bed facing the door. There is no evidence of a comprehensive assessment to determine when R2 was last observed, when R2 was provided toileting cares, staff statements, whether R2's call light was within reach at the time of the fall, and thorough investigation to determine a root cause. Surveyor reviewed the facility fall investigation dated 2/7/25 which documents the following: (R2) fell in his room on 2/7/25 at 10:15 AM with no apparent injury. (R2) was sitting prior to his fall. (R2's) family and physician were notified of R2's fall on 2/7/25. Fall interventions currently in place prior to his fall were documented to keep (R2's) call light within reach. Underlying diseases or conditions were documented as R2 having prior CVA and seizures. (R2) was documented as recently starting a new medication or having a change in medications. (R2) functional status is documented as being incontinent of bowel and bladder. (R2) was documented as having concerns with cognition, judgment, memory and/or safety awareness. There are no environmental factors that may have contributed to R2's fall. Post fall findings document (R2) is alert, oriented, able to use his call light independently, has a history of falls, and weakness. New fall interventions included a sidewall mattress to (R2) bed, notify therapy. The post fall assessment documents R2's fall root cause being weakness. The fall of investigation included an incident description documenting, staff was walking down the hallway and heard (R2) yelling out. Staff noted (R2) to be sitting on the floor next to his bed with his back against the side of the bed. (R2's) call light was not activated. (R2) had gripper socks on his feet and no environmental factors were noted. R2 is alert, oriented, though somewhat aphasic, and did not indicate if he was attempting a transfer or if he slid off the bed. (R2) was assisted back to bed. Vital signs and neuro checks were obtained with no significant findings. No injuries were noted and (R2) denied pain or discomfort. R2's provider, family, and DON were notified. (R2) was placed on the 24-hour board for monitoring. Surveyor notes the IDT team met on 2/7/25 which documents R2 sustained an unwitnessed fall without injury on 2/7/25. The IDT team progress note documents R2 was sitting at bedside when he slid off his mattress onto the floor. Interventions post fall were to place a side wall mattress to aid into finding the perimeter of the mattress. R2's care plan was updated, and the IDT team progress note documents nursing staff will continue to monitor and implement the intervention and evaluate the effectiveness. Surveyor noted the fall investigation does not include when R2 was last seen, last toileted, location of where R2 was sitting prior to the fall, staff statements, whether the call light was within reach at the time of the fall, and further investigation into new medications recently started for R2. Surveyor noted the documentation related to R2's 1/17/25 and 2/7/25 post fall documentation includes documentation to notify therapy. It is unclear if therapy was involved in reviewing R2 for safety as the facility documentation references weakness as a factor in the falls but does not address through investigation to help identify effective interventions to prevent falls for R2. On 2/18/25, at 8:39 AM, Surveyor observed unit one east. Surveyor noted every resident on 1 East having a low bed in the low position. Surveyor observed no fall mats being used throughout 1 East at the time of the observation. On 2/18/25, at 10:14 AM, Surveyor interviewed RN Unit Manager- D who indicates every resident has a low bed. RN Unit Manager- D stated the nurse assigned to the resident starts a fall investigation when a resident falls. The assigned nurse will talk with staff, talk with the resident, obtain a location of where the resident was last seen and when the resident was last seen. RN Unit Manager- D stated statements are verbally given to the nurse and documented in the post fall evaluation. RN Unit Manager- D indicated R2 was very forgetful and would self-transfer. RN Unit Manager- D described R2 as impulsive and indicated R2 told staff he was trying to get into bed at the time of his fall on 1/17/25. RN Unit Manager- D stated this is documented in a nursing progress note. RN Unit Manager- D indicated R2's progress notes document where R2 was last seen, however RN Unit Manager- D was unable to state when R2 was last seen. RN Unit Manager- D indicated the IDT team meets daily in the mornings Monday through Friday and will discuss falls the same day or following day. RN Unit Manager- D stated the default intervention after a resident falls, is to place a call don't fall sign in their room. The IDT team will discuss the fall and unit managers will determine if other interventions are warranted. Surveyor asked RN Unit Manager- D how the facility follows up with interventions placed post fall. RN Unit Manager- D stated, interventions are discussed in the IDT team if another fall occurs. On 2/19/25, at 9:28 AM, Surveyor notified Interim DON- B of concerns discussed above with the fall investigations for R2's unwitnessed falls on 1/17/25 and 2/7/25. Surveyor notified Interim DON- B the facility fall investigations did not determine when R2 was last seen, last toileted, exact location of where R2 was last seen prior to his falls, staff statements, and completion of a thorough investigation to determine a root cause to establish effective interventions to prevent future falls. On 2/19/25, at 11:48 AM, Interim DON- B requested to speak with Surveyor. Interim DON- B reviewed with Surveyor R2's facility progress notes, IDT notes, and post fall investigation. Surveyor notified Interim DON- B of concerns with the facility not completing a thorough fall investigation for R2's falls on 1/17/25 and 2/7/25. Surveyor noted to Interim DON- B the fall investigations lacked a thorough investigation to determine why R2 was attempting to self-transfer or possible causes for R2's falls. On 2/20/25 the facility submitted information provided to the Surveyor during the survey for additional review and consideration regarding R2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained to help prevent the development and transmission of infections during wound care for 1 (R7) of 1 residents observed during wound care. *R7 had a treatment to the right calf pressure injury and hand hygiene was not performed between dirty and clean aspects of the treatment. Findings include: The facility policy and procedure titled Hand Hygiene dated 4/2024 documents: Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. The attached Hand Hygiene Table included, in part, hand hygiene in the following situations: after handling contaminated objects, before performing invasive procedures, before applying and after removing personal protective equipment (PPE) including gloves, before and after handling clean or soiled dressings, after handling items potentially contaminated with blood, body fluids, secretions, or excretions, when during resident care moving from a contaminated body site to a clean body site, and when in doubt. R7 was admitted to the facility on [DATE] with diagnoses of cerebral palsy, gastro-esophageal reflux disease with esophagitis with bleeding, protein-calorie malnutrition with a gastrostomy tube for all nutrition, anemia, and chronic embolism and thrombosis of deep veins. R7's admission Minimum Data Set (MDS) assessment dated [DATE] documented R7 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 4 and had impairment to both arms and legs requiring maximum to total assistance with all activities of daily living and bed mobility. The MDS documented R7 received all nutrition through the gastrostomy tube. The MDS documented R7 had a Deep Tissue Injury that was present upon admission and had a pressure reducing device for the chair and bed and received pressure ulcer care. R7's Skin Impairment Care Plan dated 6/26/2024 documented R7 had deep tissue injuries to the five toes on the left foot. R7's Quarterly MDS assessment dated [DATE] documented R7 did not have any pressure injuries. R7 had an activated Power of Attorney (POA). On 10/24/2024 at 10:24 AM in the progress notes, a Licensed Practical Nurse (LPN) documented a Certified Nursing Assistant (CNA) was giving R7 a bed bath and noticed R7 had a scabbed area on the right leg. The LPN documented the area is a dry, scabbed pressure area that measured 1.0 cm x 1.2 cm. On 2/18/2025 at 1:17 PM, Surveyor observed R7 in bed on an air mattress. R7 stated R7 was comfortable and agreeable to have Surveyor observe wound care. On 2/18/2025 at 3:57 PM, Surveyor observed LPN-F provide wound care to R7 with the assistance of CNA-G. R7 was observed in bed on an air mattress and to have heel boots on. LPN-F washed their hands in the bathroom with soap and water. LPN-F and CNA-G put on isolation gowns and gloves. LPN-F turned R7's feeding tube pump to hold. LPN-F moved the garbage can with gloved hands by grabbing the top edge of the garbage can with the fingertips inside the garbage can. LPN-F removed the lid and protective seal on a bottle of normal saline. LPN-F opened a 4x4 gauze, folded the gauze, and placed it over the open normal saline bottle. With two hands, LPN-F turned the bottle up-side-down so the gauze was on the bottom absorbing the normal saline and then placed the saline soaked gauze on the open gauze packet. LPN-F removed R7's heel boots. CNA-G held R7's right leg under the ankle and knee so LPN-F could access the wound site. LPN-F removed R7's dressing from the back of R7's calf and threw it in the garbage can. LPN-F picked up the saline soaked gauze and washed the wound bed with the gauze. LPN-F took a dry gauze and patted the wound dry. LPN-F removed the gloves and put on a new pair of gloves. LPN-F did not complete any hand hygiene between the use of gloves. LPN-F put manuka honey from a tube onto the middle of the foam gauze. LPN-F placed the foam gauze onto and covering the wound. LPN-F did not perform any hand hygiene after touching the garbage can and before putting normal saline on the gauze. LPN-F did not perform any hand hygiene after removing the heel boots and removing the old dressing. LPN-F did not perform any hand hygiene after removing the old dressing and cleansing the wound with normal saline. LPN-F did not perform any hand hygiene after removing gloves and putting on a new pair of gloves. LPN-F did not perform any hand hygiene after the wound care was completed. Surveyor asked LPN-F if LPN-F normally washes their hands while doing wound care. LPN-F stated LPN-F usually has hand gel (alcohol-based hand sanitizer) in their pocket but today LPN-F did not have any. Surveyor asked LPN-F when LPN-F would use the hand sanitizer. LPN-F stated LPN-F would use it between taking gloves off and putting gloves on. On 2/19/2025 at 7:57 AM, Surveyor shared with Director of Nursing (DON)-B the observation of R7's Unstageable pressure injury wound treatment completed by LPN-F on 2/18/2025. Surveyor shared the concerns with DON-B LPN-F did not perform hand hygiene at critical points throughout the treatment and touched multiple surfaces, such as the garbage can and R7's heel boots, without performing hand hygiene. DON-B agreed hand hygiene should have been performed throughout the wound treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interview, the facility failed to ensure the family member and Activated Responsible Party (FM1) of one Resident (R1) out of nine residents reviewed in the sample was provided with information required to make informed decisions about the residents health care. FM1 was not notified prior to rehabilitation services being discontinued for R1. This failure created the potential for the resident's rehabilitation services to be unnecessarily and/or prematurely discontinued. The findings include: Review of the facility's policy titled, Notification of Changes dated 01/2024 read, in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Review of R1's admission Record, dated 12/06/24 and found in the Electronic Medical Record (EMR) under the Profile Tab, indicated the resident was admitted to the facility on [DATE]. The record indicated family member (FM1) was her activated Medical Power of Attorney (MDPOA)/ Responsible Party. Review of R1's quarterly Minimum Data Set (MDS) found in the EMR under the MDS Tab and with an assessment reference date (ARD) of 12/03/24, revealed the Brief Interview for Mental Status (BIMS) score was 15 out of 15, which indicated the resident was cognitively intact. Review of R1's Power of Attorney for Health Care Statement of Incapacity documentation, dated 08/12/24, signed by two physicians, and found in the EMR under the Miscellaneous Tab, revealed the resident was not capable of making her own health care related decisions and indicated FM1 was activated as R1's legal health care representative. Review of R1's physician's orders found in the EMR under the Orders Tab, revealed an original order dated 09/03/24, for the resident to be evaluated and treated by Occupational Therapy (OT) and Speech Therapy (SLP), and with an original order dated 10/01/24, for the resident to be evaluated and treated by Physical Therapy (PT) under her Medicare B benefit. Review of R1's care plan, most recently dated 09/18/24 and found in the EMR under the Care Plan Tab, revealed the resident planned to remain in the facility for long-term care and indicated, POA- Keep in Contact with (FM1)/Activated Healthcare as needed/requested. Review of R1's skilled therapy documentation dated 09/03/24 through 11/11/24 and provided directly to the surveyor, revealed the resident received skilled OT and PT services consistently per physician's orders during that time period. Review of R1's Advance Beneficiary Notice (ABN) document, dated 11/11/24, signed by R1 herself, and found in the EMR under the Miscellaneous Tab, revealed the resident was provided notification her rehabilitation services were ending. Review of R1's EMR revealed no documentation to indicate FM1 was notified that R1's rehabilitation therapy services were ending or was given the opportunity to appeal to have R1 potentially continue to receive therapy. During an interview with FM1 on 12/04/24 at 1:47 PM, she confirmed she was R1's activated MDPOA and had not been notified that R1's therapy was ended or given an opportunity to appeal the discontinuation of therapy services. She indicated this had been upsetting to her as she felt R1 may have benefited from continued therapy. During an interview with Director of Rehabilitation (DOR) on 12/06/24 at 12:10 PM, she confirmed the ABN notice had been provided and signed by R1 rather than FM1. She stated she should have provided the notice to FM1. During an interview with the Director of Nursing (DON) on 12/06/24 at 2:00 PM, she stated her expectation was the ABN notice should have been provided to FM1 rather than R1 since FM1 was R1's activated MDPOA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and facility policy review, the facility failed to ensure one of nine sample residents (Resident (R) 6) had her preferences honored. Findings include: Review of the facility's policy titled, Accommodation of Needs, provided by the facility, with a revised date of 02/24, revealed The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered. The policy further revealed Based on individual needs and preferences, the facility will assist the resident in maintaining and/or achieving independent functioning, dignity, and well being to the extent possible. Review of R6's admission Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) revealed R6 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated her cognition was intact. The MDS further revealed R6 was admitted to the facility on [DATE]. Review of R6's diagnoses under the Diagnosis tab of the EMR revealed R6 had diabetes and chronic kidney disease stage four. Review of R6's comprehensive Care Plan, dated 08/27/24 and located in the Care Plan tab of the EMR revealed a problem for an activity of daily living (ADL) self-care deficit. Review of the interventions for 08/29/24 included for bathing and showering R6 was totally dependent on one member of staff to provide bathing and showering weekly and as needed. The intervention included no male Certified Nursing Assistants (CNA) was to perform care. Review of the dressing intervention revealed R6 required assistance of one staff and no male CNAs for care. Review of the personal hygiene intervention revealed R6 was totally dependent on staff, but it did not reflect no male CNA to render care. Review of the toilet use intervention revised on 09/09/24 revealed R6 required assistance of two staff but did not specify no male CNA. Review of the problem for functional bladder incontinence revealed peri care was to be completed after each incontinent episode but did not include no male CNA. Review of the care plan with a revised date of 10/10/24 revealed R6 was to not have any male CNAs for any care. During an interview on 10/22/24 at 3:00 PM, CNA3 revealed he had taken care of R6 previously but only to pass her tray and water to her. CNA3 stated he had introduced himself to R6 and her family when she was admitted to the facility. CNA3 stated he was her CNA on 10/10/24 during the night and he had gone into her room around midnight to just check her brief to see if it was yellow or blue and if she needed to be changed, he would go get the female CNA on the other hall, but R6 was dry. CNA3 revealed he went back into R6's room around 4:00 AM to check if R6 was wet. CNA3 revealed R6 was awake, and he pulled the cover back and looked to see if the line on the brief was blue and it was yellow which meant she was still dry. CNA3 stated he knew R6 did not want a male CNA to do certain care. but that was for peri care, and he did not do peri care. CNA3 stated he was just checking R6 for wetness. CNA3 stated he did not go back into the room after Registered Nurse (RN) 2 told him not to. During an interview on 10/22/24 at 6:30 PM, R6 revealed she did not want any male to take care of her because men should not be in a profession where they wiped residents' butts. R6 revealed a male CNA, who she had never seen before, came into her room twice on 10/10/24 and she told the CNA to get out. During an interview on 10/22/24 at 7:15 PM, RN2 revealed she was not aware R6 was not to have a male aid taking care of her. RN2 stated she reviewed the care plan after R6 informed her she did not want a male taking care of her and saw where it was listed to not have a male CNA for peri care and bathing. RN2 stated Unit Manager (UM) 1 scheduled CNA3 to work that shift and she knew about R6 preferring to not have a male CNA. During an interview on 10/23/24 at 9:47 AM, the UM1 revealed CNA3 had taken care of R6 before but only passed water and meal trays to her and did not do peri care or bathing. UM1 stated the son had informed them on admission that R6 preferences was to not have any male CNAs to bathe or do peri care for R6. UM1 revealed she did the scheduling but the nurse on the unit could do the hall assignments. UM1 stated checking the brief was a part of peri care. During an interview on 10/23/24 at 2:09 PM, the Director of Nursing (DON) revealed R6 was care planned to not have a male CNA for bathing and peri care. The DON stated checking the brief for a yellow or blue mark was not a part of peri care. The DON stated CNA3 was just looking at the brief to see if R6 needed care. The DON revealed she had talked to R6, and the resident did not have an issue with a man passing water or a meal tray but did not want a male CNA seeing her nude. The DON stated RN2 should have known that R6 preferred to not have a male CNA because it was on her care plan and the care list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy, the facility failed to ensure one comprehensive care plan for enhanced barrier precautions (EBP) was implemented for one of nine sample residents (Resident (R) 4) reviewed for care plans. This failure had the potential to put R4 and other residents at risk for infections. Findings include: Review of the facility's policy titled, Comprehensive Care Plans provided by the facility with a revised date of 02/24, revealed It was the policy of this facility to develop and implement a comprehensive person-center care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .Resident specific interventions that reflect the resident's needs and preferences. Review of R4's admission Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 10/02/24 revealed R4 was admitted to the facility on [DATE] with diagnoses of Parkinsons, diabetes with a foot ulcer, hypertension, and cerebral vascular accident (CVA). The MDS revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. Review of the comprehensive care plan located in the Care Plan tab of the EMR, initiated 09/27/24, revealed a problem listed for infection control with an intervention that R4 had to be on enhanced barrier precautions. The care plan revealed a gown and gloves should be worn. A problem was identified for impaired skin integrity. Review of the Physicians Orders located under the Orders tab of the EMR, dated 10/16/24, revealed an order for enhanced barrier precautions due to wounds. A wound care treatment observation for R4, on 10/22/24 at 10:04 AM, with Licensed Practical Nurse (LPN) 2, revealed the nurse entered R4's room and did not wash or sanitize his hands before entering the room which had enhanced barrier precautions posted visibly on the door which was opened. During the entire observation on 10/22/24 at 10:15 AM, LPN2 did not wear a gown during the wound treatments to the left heel and buttock. Observation of the signage on the door for R4 revealed enhanced barrier precautions should be used which included hands were to be washed or sanitized before and after entering the room. The signage further revealed the staff must wear gloves and a gown when wound care was done that required a dressing. During an interview on 10/23/24 at 12:38 PM, the MDS Coordinator (MDSC) revealed if the care plan had enhanced barrier precautions on it then enhanced barrier precautions should have been utilized. The MDSC further revealed staff should have worn gloves and a gown if they did any kind of patient care such as wound care treatments. The MDSC stated enhanced barrier precautions helped to prevent transmission of germs to the next patient. During an interview on 10/23/24 at 12:45 PM the Administrator revealed care plans should have been followed and modified as needed. During an interview on 10/23/24 at 1:00 PM, the Director of Nursing (DON) revealed care plans should have been followed to meet the needs of the residents. DON stated the care plan for enhanced barrier precautions should have been implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility policy, the facility failed to follow enhanced barrier precautions (EBP) and infection control for one of nine sample residents (Resident (R) 4) reviewed for infection control precautions. The failure had the potential to put the residents at risk for the spread of an infection. Findings include: Review of the facility's policy titled, Clean Dressing Change, provided by the facility, with an implemented date of 11/23 and reviewed/revised on 09/24, revealed It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physicians' orders will specify type of dressing and frequency of changes. The policy further revealed to set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: a. If the table is soiled, wipe clean. b. Place a disposable cloth or linen saver on the overbed table. c. Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape) .e. Use no-touch techniques to remove ointments and creams from their containers (i.e. use tongue blade or applicator) .Wash hands and put on clean gloves .Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Loosen the tape and remove the existing dressing .Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on clean gloves .Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound (i.e., clean outward from the center of the wound). Pat dry with gauze .Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. Secure dressing. [NAME] with initials and date. Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of R4's admission Minimum Data Set (MDS) located under the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 10/02/24 revealed R4 was admitted to the facility on [DATE] with diagnoses of Parkinson's, diabetes with a foot ulcer, hypertension, and cerebral vascular accident (CVA). The MDS revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. Review of the comprehensive Care Plan located in the Care Plan tab of the EMR, initiated 09/27/24, revealed a problem listed for infection control with an intervention that R4 had to be on enhanced barrier precautions. A problem was identified for impaired skin integrity. Review of the Physicians Orders located under the Orders tab of the EMR, review date 10/16/24, revealed an order, dated 10/17/24, for enhanced barrier precautions due to wounds. The physician orders further revealed Santyl External Ointment 250 unit/grams was to be applied to the sacrum, dated 10/17/24. Another physician order revealed clean the sacrum with ½ Dakin's. Apply skin prep to the peri wound, apply Santyl to the wound base and it was to be followed up with a bordered gauze daily, dated 10/17/24. Another physician's order further revealed the left heel was to be cleansed with saline and skin prep was to be applied, dated 10/17/24. A wound care sacral treatment observation for R4, on 10/22/24 at 10:04 AM, with Licensed Practical Nurse (LPN) 2, revealed he gathered Dakin's Solution (an antiseptic used to treat and prevent infections in wounds), Santyl (an ointment used for debriding ulcers), skin prep, two gauze pads and a bordered gauze and took them into R4's room without washing or sanitizing his hands before entering the room which had a sign visibly posted on the door for enhanced barrier precautions which included washing or sanitizing the hands before going into the room and wearing a gown and gloves when doing care. During the entire observation LPN2 did not wear a gown while doing the wound treatments. During observation on 10/22/24 at 10:04 AM in R4's room, LPN2 did not clean the overbed table before putting the supplies on it and did not put a barrier on the table. Observation further revealed the overbed table had candy bars, Kleenex, a cup, a remote control, and a cell phone lying on it. Observation further revealed LPN2 put gloves on and removed the pillows from behind the resident and under his knees. LPN2 used the lift pad to turn the resident over to his left side and went to remove the brief when he realized R4 had a bowel movement. LPN2 provided appropriate peri care. Observation revealed R4 was not double briefed. The pad and the brief were folded under R4. The dirty washcloth was placed on the side of the garbage can that had a plastic bag in it. Observation revealed LPN2 did not change gloves or wash his hands before he removed the old bandage for the sacral wound. Observation of LPN2 revealed he removed his gloves and applied new gloves but did not wash or sanitize his hands. LPN2 wet the gauze with the Dakin's Solution and cleaned the wound. LPN2 applied Santyl to the wound with the same gloved finger that he had just cleaned the wound with. LPN2 removed the gloves, new gloves were put on, then he applied skin prep around the edges of the wound and applied the border dressing. LPN2 took a pen out of his pocket, signed the dressing, and put the pen back in his pocket. During observation on 10/22/24 at 10:30 AM, LPN2 removed the soiled brief and put it in the garbage can. Peri care to the groin area was completed and a new brief was put on R4. LPN2 removed the pad that was under R4 and placed it on the floor beside the bed and put the dirty washcloth in it. Observation revealed LPN2 removed his gloves and did not wash or sanitize his hands in the room. Observation further revealed LPN2 went down to the small dining room and washed his hands there. During the wound care left heel treatment observation on 10/22/24 at 10:30 AM in R4's room, LPN2 gathered supplies for the left heel wound treatment that consisted of skin prep, normal saline, and a gauze sponge. LPN2 went into R4's room and did not put a gown on. LPN2 placed the supplies on R4's bed. Observation revealed LPN2 removed the old bandage on the foot which did not have any drainage or blood noted. LPN2 placed the old bandage on the bed and did not change gloves. LPN2 cleaned the wound with normal saline and placed that gauze on the bed, put skin prep on the area and placed a sock on the foot. LPN2 removed his gloves but did not wash his hands before he left the room. LPN2 went to the dining area and washed his hands there. During an interview on 10/22/24 at 10:45 AM, LPN2 stated he had training on infection control but just missed it and did not notice that R4 was on enhanced barrier precautions. LPN2 read the enhanced barrier precautions on the door and stated he should have worn a mask, gown, and gloves which he did wear gloves. LPN2 stated he had never been told he had to clean the table off or put a barrier on the table before putting the supplies on the table. LPN2 stated he should not have put the pad on the floor, however he did put the dirty washcloth inside the pad, so it did not touch the floor. During the interview, LPN2 revealed he did change gloves, but he did not wash or sanitize his hands during the wound treatment. LPN2 revealed infection control was to prevent infection from being passed to someone else. During an interview on 10/22/24 at 1:00 PM, the Director of Nursing (DON) revealed for enhanced barrier precautions and doing a wound treatment the nurse should wear gowns and gloves when going into the room. The DON further revealed the surface should be cleaned off and the supplies should be opened there and laid out. The DON stated the old dressing should be removed and put in the garbage can. DON stated the nurses should remove their gloves, clean their hands, put on new gloves, and apply the new dressing after cleaning the wound. The DON stated the gown, and gloves should be removed and placed in garbage bags in the rooms and disposed of. The DON revealed staff should sanitize their hands before going into the room that had enhanced barrier precautions and when leaving the room. The DON revealed the overbed table should be cleaned and all items should be removed from the table. The DON stated the pad that had been under R4 should not have been put on the floor. The DON stated that anytime a staff member removed their gloves they should wash or sanitize their hands. The interview further revealed it was not appropriate for the dirty bandages to be placed on the bed and the bandages should be placed in the garbage. During the interview on 10/22/24 at 1:30 PM, the DON revealed they had a yearly skills fair and they went over enhanced barrier precautions. The DON stated staff were trained in enhanced barrier precautions for wound care, gastrostomy tube (G-tube) care, foley catheter care which consisted of donning a gown and gloves. The DON revealed infection control was utilized to prevent spreading infections. The DON stated the Santyl should have been applied with a Q-Tip and not the gloved finger of the nurse. The DON revealed they have not had any outbreak of infections.

Based on observation, record review, and interview, the facility did not treat residents with dignity when administering insulin for 2 (R33 and R55) of 2 residents observed receiving insulin. Licensed Practical Nurse (LPN)-G administered insulin to R33 in the hallway by the nurses' station with other residents present. LPN-G checked R55's blood sugar and then administered insulin to R55 in the TV room with another resident present. No privacy was provided to R33 or R55. Findings include: The facility policy and procedure entitled Timely Administration of Insulin dated 1/2024 states: Policy Explanation and Compliance Guidelines: . 5. d. Explain procedure and provide privacy. On 5/1/2024 at 8:22 AM, Surveyor observed LPN-G standing at the medication cart next to the nurses' station. LPN-G dialed up the dose on the insulin pen for R33. R33 was in a wheelchair in the middle of the hallway next to the medication cart. Other residents were in the hallway and dining room getting ready for breakfast. The dining room was located across from the nurses' station. LPN-G administered R33's insulin in the right arm. LPN-G did not offer to take R33 to a private area to administer the insulin. LPN-G went into the TV room across from the nurses' station and next to the dining room and tested R55's blood sugar by drawing blood from the finger. R55 was sitting at a table with another resident. LPN-G then administered insulin to R55 in the left arm. LPN-G did not offer to take R55 to a private area to check the blood sugar or administer the insulin. Surveyor reviewed Resident Council minutes from 2/7/2023. A concern was identified at that meeting by residents. The concern was that insulin was being given to residents in the dining room. The recommendation/solution per the minutes was that staff would be educated on giving insulin in the dining room. On 5/1/2024 at 9:48 AM, Surveyor shared with Director of Nursing (DON)-B the observations of LPN-G taking R55's blood sugar in the TV room with another residents present and administering insulin to R33 and R55 in a public space. DON-B stated LPN-G had contacted DON-B after Surveyor had left the unit LPN-G worked on and informed DON-B of the observations. DON-B stated LPN-G was aware blood sugars and insulin should not be obtained or provided to residents in public spaces. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for assessing non-pressure wounds for 2 (R188 and R190) of 2 residents reviewed with non-pressure injuries. R188's non-pressure injuries were not comprehensively assessed on admission. R190's non-pressure injuries were not comprehensively assessed on admission. Findings include: The facility policy and procedure entitled Skin Assessment dated 10/2023 states: 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, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: 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.) R188 was admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit, bacteremia, malnutrition, leukemoid reaction, anemia, anxiety, depression, and epilepsy. R188 had not been a resident of the facility long enough to have a comprehensive Minimum Data Set (MDS) assessment completed. R188 had an activated Power of Attorney (POA). R188's Activities of Daily Living Care Plan was initiated on 4/26/2024 and indicated R188 needed staff assistance of one for bathing/showering, bed mobility, dressing, personal hygiene, and toilet use and staff assistance of two for transferring using a mechanical lift. The Infectious Disease Physician Progress Note dated 4/26/2024 documented R188 had wounds on the dorsal aspect of the left foot and fifth metatarsal (toe) that measured approximately 2 cm x 2 cm and multiple small wounds scattered on bilateral legs and arms. R188's hospital Discharge summary dated [DATE] indicated no wound care was needed. On 4/26/2024, Registered Nurse (RN)-D completed R188's Admit/Readmit Assessment form and Skin & Wound Evaluation forms for the following open areas: -Left flank area skin tear measured 3.2 cm x 1.7 cm (on the Admit/Readmit Assessment form) and left iliac crest abrasion with the same measurements (on the Skin & Wound Evaluation form) with 100% granulation. Surveyor noted no depth of the wound was measured. -Left fourth toe Unstageable pressure injury measured 1.5 cm x 1.5 cm. Surveyor noted no depth was measured and no wound characteristics were documented. Surveyor noted the picture attached to the assessment showed the wound to be on the fifth toe and not the fourth toe. Surveyor noted no wound was documented to the left dorsal foot as noted on the Infections Disease Physician Progress Note dated 4/26/2024. R188's Skin Impairment Care Plan was initiated on 4/26/2024 with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Use barrier cream to prevent skin impairment issues, as needed. R188's Skin Impairment Care Plan was revised on 4/27/2024 with the following interventions: -Encourage to offload heels. -Heel boots on when in bed. -R188 needs an air mattress to protect the skin while in bed. -R188 needs pressure relieving/reducing cushions to protect the skin while up in a chair. On 5/1/2024, Licensed Practical Nurse (LPN)-P completed a Skin & Wound assessment form for the following open area: -Left iliac crest abrasion measured 3.0 cm x 1.9 cm x not applicable. No tissue type was documented for the wound bed and the wound was stable with no other characteristics. On 5/2/2024 at 11:09 AM, Surveyor accompanied Wound Physician-I and RN Unit Manager (UM)-E to assess R188's pressure injuries. RN UM-E stated R188 had a skin tear to the left flank. Wound Physician-I stated the wound to the left fifth toe was due to trauma and not a pressure injury. Surveyor clarified with Wound Physician-I that the wound was on the fifth toe and not the fourth toe as initially documented. Wound Physician-I agreed the wound was on the fifth toe. Surveyor observed a scabbed area to the left dorsal foot. Wound Physician-I stated that wound was caused by trauma. Surveyor observed an open area on the left iliac crest. Wound Physician-I stated the wound to the left iliac crest was possibly due to pulling on the sheets when R188 was repositioned in bed. Surveyor requested a copy of Wound Physician-I's wound assessments. Wound Physician-I's documentation of R188's non-pressure areas on 5/2/2024 had the following assessments: -Left fifth toe trauma measured 1.24 cm x 1.0 cm x 0.1 cm with eschar. -Left dorsal foot trauma measured 1.08 x 1.01 x 0.1 with eschar. -Right posterior superior iliac crest trauma measured 1.88 cm x 1.89 cm x 0.1 cm with 1-25% granulation and 51-75% slough. Surveyor noted the wound was located on the left iliac crest and not the right iliac crest. This was the first comprehensive assessment of the non-pressure areas, six days since admission. In an interview on 5/2/2024 at 3:22 PM, Surveyor asked RN-D what the facility process was when a new resident was admitted to the facility. RN-D stated the nurse on the floor does the initial skin assessment which includes looking at the resident's skin from top to bottom and documenting anything like a scab, bruising, scratches, checking under the breasts and folds for redness or excoriation, and any open areas or Deep Tissue Injuries (DTI) caused by pressure. RN-D stated for any open areas or DTIs, you put a sticker next to the wound and take a picture with the phone; that is connected to the electronic charting system, and it measures the length and width of the wound. RN-D stated the picture is sent to Wound Physician-I or to RN UM-E with the resident's name and what the wound is so they can get a treatment order. RN-D stated the wounds are monitored and they are evaluated weekly on Wednesday. RN-D stated if a treatment needs to be done right away, RN-D will do that and then make sure everything is charted. RN-D stated if the resident has mushy heels, RN-D will get heel boots or pillows if the resident hates the boots. Surveyor asked RN-D if pictures were taken of all skin impairments. RN-D stated scabs, bruises, and blanchable redness just get written into the assessment, but if it is an open area, then they get a picture on the phone. RN-D clarified an open area on the coccyx or anything that gets a deeper assessment will get a picture so Wound Physician-I can get a treatment in place. RN-D stated Wound Physician-I is available every day and answers quickly. RN-D stated RN UM-E and Assistant Director of Nursing (ADON)-C are really good with wounds, so they help with assessments. Surveyor noted the phone picture assessment does not measure depth. Surveyor asked RN-D if any wounds get depth measurements. RN-D stated it depends on the wound if a depth is measured. RN-D stated with a flap off, like a skin tear, the depth is estimated and if it something deeper, then they would take a cotton swab to measure the depth. On 5/6/2024 at 9:31 AM, Surveyor shared with DON-B the concern R188's non-pressure areas were not comprehensively assessed until 5/2/2024, six days after admission, when Wound Physician-I assessed R188's wounds. Surveyor shared with DON-B R188 had a wound to the left fifth toe that was documented as the left fourth toe and determined to be caused by trauma when Wound Physician-I assessed the wound, the left iliac crest wound did not have a depth measurement on admission, and the left dorsal foot wound was not documented on admission. 2.) R190 was admitted to the facility on [DATE] with diagnoses of diabetes, osteomyelitis of the right ankle and foot, chronic obstructive pulmonary disease, cholecystitis, congestive heart failure, diabetic polyneuropathy, coronary artery disease, and anemia. R190 had not been a resident of the facility long enough to have a comprehensive Minimum Data Set (MDS) assessment completed. R190 did not have an activated Power of Attorney. R190's Hospital Wound Care Note dated 4/17/2024 indicated the following non-pressure wounds: -Right lateral foot incision wound from a diabetic ulcer measured 9.9 cm x 3.5 cm x 2 cm with 10% epithelialization, 70% granulation, and 20% slough. -Right distal posterior Achilles leg venous ulcer measured 0.7 cm x 0.8 cm x 0.6 cm with 15% epithelialization, 80% granulation, and 5% slough. -Right foot dorsum incision wound measured 2 cm x 1.6 cm x 0.9 cm with 10% granulation and 90% slough. -Right plantar foot originally a blister measured 0.8 cm x 3 cm x 0.2 cm with 5% epithelialization, 25% slough and 70% eschar. -Bilateral buttocks Suspected Deep Tissue Injury (DTI) with the right buttock DTI measured 0.3 cm x 0.5 cm and the left buttock DTI measured 0.5 cm x 0.5 cm. -Right anterior lower leg Stage 2 pressure injury measured 3 cm x 9 cm with 5% epithelialization. Treatments were ordered for each area including a wound vac to the right lateral foot wound. The Hospital Discharge summary dated [DATE] documented R190 was hospitalized for cholecystitis with elevated liver enzymes. R190 had continuation of a previously treated diabetic foot infection with osteomyelitis of the metatarsal and was placed on intravenous antibiotics. R190's Skin Impairment Care Plan was initiated on 4/18/2024 with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Ensure pressure relieving cushion is used in dialysis chair when resident is in chair for dialysis session. Document if resident refuses to use cushion. (Surveyor noted R190 does not attend dialysis.) -Skin will be assessed on a weekly basis on scheduled bath day and document findings on a weekly skin assessment. -Report any skin redness/impaired integrity areas to the nurse. -R190 needs pressure relieving/reducing cushions to protect the skin while up in chair. -R190 needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. -Use barrier cream to prevent skin impairment issues, as needed. On 4/18/2024 on the Admit/Readmit Assessment form and on the Skin & Wound Evaluation form, Licensed Practical Nurse (LPN)-J documented R190 had the following skin integrity concerns: -Left lateral foot vascular wound measured 10.0 cm x 4.0 cm x 1.7 cm. (Surveyor noted the hospital documentation showed the wound to be on the right foot and not the left foot.) -Bottom of right foot diabetic ulcer measured 1.0 cm x 4.0 cm x 0.2 cm. No wound descriptors were documented. -Right dorsum foot vascular ulcer measured 1.0 cm x 4.0 cm x 0.2 cm. No wound descriptors were documented. -Left buttock Moisture Associated Skin Damage (MASD) measured 0.5 cm x 0.5 cm. No depth or wound descriptors were documented. -Right middle shin venous ulcer measured 4.25 cm x 2.14 cm with 100% granulation. No depth was documented. (Surveyor noted the hospital paperwork indicated this was a pressure area.) -Right medial calf venous ulcer measured 1.58 cm x 1.03 cm with 20% epithelialization and 20% slough. No depth was documented, and the wound descriptors did not equal 100%. -Right medial calf diabetic ulcer measured 1.99 cm x 0.94 cm with 20% granulation and 80% slough. No depth was documented. -Intergluteal cleft MASD measured 0.77 cm x 0.52 cm with 100% granulation. No depth was documented. (Surveyor was unable to determine if the intergluteal cleft MASD was the same area as the left buttock MASD though they did not have the same measurements. Surveyor noted the hospital paperwork indicated this was a pressure area.) -Right lateral midfoot surgical wound measured 9.46 cm x 3.84 cm with 80% granulation and 20% slough. No depth was documented. (Surveyor noted the area was now labeled right instead of left and the length and width measurements were similar.) On 4/25/2024 R190 was seen for the initial visit by Wound Physician-I. Wound Physician-I documented the following wounds: -Right lateral foot surgical wound measured 7.76 cm x 3.19 cm x 1.4 cm with early/partial granulation with the wound bed color descriptions denoted by centimeters squared: red, black, yellow, pink, and other. The tissue types were not documented nor the percentage of wound bed coverage. -Right dorsal foot venous ulcer measured 1.59 cm x 1.2 cm x 0.6 cm with 1-25% granulation and 51-75% slough. -Right plantar foot diabetic ulcer measured 1.49 cm x 2.98 cm x 0.1 cm with 76-100% slough before debridement and 1.25 cm x 2.93 cm x 1.6 cm with 1-25% granulation and 51-75% slough. -Right shin venous ulcer measured 4.63 cm x 2.69 cm x 0.1 cm with 26-50% granulation and 26-50% slough. -Right calf venous ulcer measured 0.87 cm x 1.1 cm x 0.1 cm fully granulated. On 4/25/2024 at 2:40 PM in the progress notes, Registered Nurse Unit Manager (RN UM)-E charted R190's left buttock had healed. On 5/2/2024 at 10:47 AM, Surveyor observed Wound Physician-I along with RN UM-E assess R190's wounds. RN UM-E stated R190's coccyx area had healed since admission and currently has wounds to the lower right leg. Surveyor observed R190's right foot with a Kerlix dressing wrapped around the foot. Yellow drainage had seeped through the bandage on the bottom of the foot. The wound to the bottom of the right foot was macerated. The right lateral foot wound had a wound vac connected which was removed for the assessment. Surveyor observed wounds to the right shin, the right dorsum of the foot, and the right Achilles. Wound Physician-I stated the right Achilles wound had hyper-granulation because of possible tendon involvement. R190 stated R190 had cellulitis to the right foot and because of neuropathy to R190's hands, R190 was unable to change the dressings while at home. R190 stated R190 left the dressing to the right foot on for two weeks and then was in a really bad state and ended up in the hospital. Surveyor requested a copy of Wound Physician-I's wound assessments for that day. Wound Physician-I's documentation of R190's non-pressure areas on 5/2/2024 had the following assessments: -Right lateral foot measured 6.84 cm x 3.11 cm x 0.5 cm with early/partial granulation with the wound bed color descriptions denoted by centimeters squared: red, black, yellow, pink, and other. The tissue types were not documented nor the percentage of wound bed coverage. -Right dorsal foot venous ulcer measured 1.63 cm x 1.12 cm x 0.5 cm with 1-25% granulation and 51=75% slough. -Right plantar foot diabetic ulcer measured 0.76 cm x 5.64 cm x 0.6 cm with 76-100% slough. -Right shin venous ulcer measured 1.03 cm x 0.84 cm x 0.1 cm with 76-100% granulation. -Right calf venous ulcer measured 1.54 cm x 1.57 cm x 0.1 cm with full granulation. In an interview on 5/2/2024 at 3:33 PM, Surveyor asked LPN-J what the facility procedure was for a newly admitted resident. LPN-J stated the majority of new admissions come on second shift, so the floor nurse does the assessment and admission note. LPN-J stated the Unit Manager or the unit secretary may help with orders and getting appointments into the computer system. LPN-J stated the floor nurse has to do the admission in addition to their normal duties and if there are multiple new admissions, then the two floor nurses will split up the admissions so it is an even workload. LPN-J stated the nurse has to get vital signs, do a skin assessment, an admission assessment, and write the admission note. LPN-J stated if the regular nurses are working when there are a lot of new admissions, it is not too bad, but if a nurse does not normally work on that unit, it can be very stressful. Surveyor asked LPN-J to explain what is meant by doing a skin assessment. LPN-J stated the nurse checks for bruising from IVs, open areas, redness, scars, tattoos, or anything else on the skin. LPN-J stated they normally know what they are looking at from the report that is given from the hospital. LPN-J stated the nurse gets measurements of the wounds and takes a picture of the wound that also gets measurements. LPN-J stated the Wound Physician will officially stage any pressure injuries. Surveyor asked LPN-J if the phone picture gets a depth measurement of the wound. LPN-J stated the phone gets a slight depth, but that is where the Wound Physician fills in. LPN-J stated LPN-J does not usually get a depth measurement but knows to use a disposable paper ruler to measure the depth. Surveyor asked LPN-J if LPN-J remembered doing the admission skin assessment for R190. LPN-J stated LPN-J was told to change the dressings that LPN-J could and that R190 was going to have a wound vac to one of the wounds and LPN-J was not going to do the wound vac. LPN-J did not remember getting a depth of the right lateral foot wound. LPN-J stated pictures are taken of the open wounds so the progression of healing can be seen. Surveyor asked LPN-J if any other areas of the skin would have pictures taken. LPN-J stated a picture of a large area of maceration on the buttocks was taken of R190. LPN-J stated LPN-J waits to have someone else look at the wound, so LPN-J does not describe the tissue. LPN-J stated after a picture is taken, the computer gives you option to specify the tissue type and other descriptors, so LPN-J clicks on whatever was seen. LPN-J stated the wound assessment is followed up by RN UM-E. On 5/6/2024 at 9:38 AM, Surveyor shared with Director of Nursing (DON)-B the concerns that R190's wounds on admission were very hard to follow with the documentation; either the wounds did not have a depth measurement, they did not have any description of the tissue type, or they labeled the same areas different names. DON-B stated on the Admit/Readmit Assessment form nurses are not able to add notes such as descriptions of the tissue type. Surveyor stated not all the wounds had Skin & Wound Evaluation forms completed which would allow the nurse to document more descriptors. DON-B stated Wound Physician-I comes after a resident has been in the facility for a few days and Wound Physician-I labels the wound to be at a different location than what the facility picked for the wound, so the facility has to take a new picture or relabel the wound and that makes it look like the wound is a new wound when really it is the same wound just relabeled with the location picked by Wound Physician-I. Surveyor shared the concern most wounds on admission did not have a depth measurement. DON-B stated the nurses will use the depth measurement from Wound Physician-I so they do not have a depth until then. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents with pressure injuries received care consistent with professional standards of practice to promote healing for 4 (R188, R62, R14, and R12) of 5 residents reviewed with pressure injuries. *R188 was admitted to the facility with pressure injuries that were not comprehensively assessed on admission and the air mattress was observed to be not set according to R188's weight. *R62, R14, and R12 had pressure injuries and observations were made of their air mattresses not to be set according to their weight. Findings include: The facility policy and procedure entitled Pressure Injury Prevention and Management dated 10/2023 states: Policy Explanation and Compliance Guidelines: . 3. Assessment of Pressure Injury Risk . c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. 4. Interventions for Prevention and to Promote Healing . c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: . iii. Provide appropriate, pressure-redistributing, support surfaces. The facility policy and procedure entitled Skin Assessment dated 10/2023 states: 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, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 7. Documentation of skin assessment: 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.) R188 was admitted to the facility on [DATE] with diagnoses of pneumonitis due to inhalation of food and vomit, bacteremia, malnutrition, leukemoid reaction, anemia, anxiety, depression, and epilepsy. R188 had not been a resident of the facility long enough to have a comprehensive Minimum Data Set (MDS) assessment completed. R188 had an activated Power of Attorney (POA). R188's Activities of Daily Living Care Plan was initiated on 4/26/2024 and indicated R188 needed staff assistance of one for bathing/showering, bed mobility, dressing, personal hygiene, and toilet use and staff assistance of two for transferring using a mechanical lift. The Infectious Disease Physician Progress Note dated 4/26/2024 documented R188 had wounds on the dorsal aspect of the left foot and fifth metatarsal (toe) that measured approximately 2 cm x 2 cm and multiple small wounds scattered on bilateral legs and arms. R188's hospital Discharge summary dated [DATE] indicated no wound care was needed. On 4/26/2024, Registered Nurse (RN)-D completed R188's Admit/Readmit Assessment form and Skin & Wound Evaluation forms for the following pressure injuries: -Coccyx/Sacrum Stage 3 pressure injury measured 8.1 cm x 6 cm x 0.2 cm with 20% granulation and 80% slough. An additional Skin & Wound Evaluation form was completed for the sacrum Stage 3 pressure injury measured 3.8 cm x 1.4 cm with no depth measurement with 20% granulation and 80% sough. The photos attached to the sacrum assessments revealed three open areas and measurements were for two areas with no description of what was being assessed. The location of the pressure injury was labeled coccyx on the Admit/Readmit Assessment form and was labeled sacrum on the Skin and Wound Evaluation form. -Left heel Unstageable pressure injury measured 2.9 cm x 1.9 cm with 100% eschar. -Left fourth toe Unstageable pressure injury measured 1.5 cm x 1.5 cm. Surveyor noted no depth was measured and no wound characteristics were documented. Surveyor noted the picture attached to the assessment showed the wound to be on the fifth toe and not the fourth toe. R188's Skin Impairment Care Plan was initiated on 4/26/2024 with the following interventions: -Encourage good nutrition and hydration in order to promote healthier skin. -Encourage to elevate heels. -Encourage/assist with reposition as needed. -Use barrier cream to prevent skin impairment issues, as needed. R188's Skin Impairment Care Plan was revised on 4/27/2024 with the following interventions: -Encourage to offload heels. -Heel boots on when in bed. -R188 needs an air mattress to protect the skin while in bed. -R188 needs pressure relieving/reducing cushions to protect the skin while up in a chair. On 4/27/2024 on the Treatment Administration Record (TAR), R188 had an order to check the function of the low airloss mattress every shift. On 5/1/2024, Licensed Practical Nurse (LPN)-P completed a Skin & Wound assessment form for the following pressure injuries: -Sacrum Unstageable pressure injury measured 6.5 cm x 3.3 cm with 90% slough and 10% eschar. Surveyor noted no depth was measured and the photo attached to the assessment showed two open areas. -Sacrum Stage 3 pressure injury had no measurements and no wound description other than the wound was stable. The photo attached to the assessment showed three open areas and had measurements of 0 cm x 0 cm. Surveyor noted the sacrum had open areas and was unable to determine what was being assessed. On 5/2/2024 at 11:09 AM, Surveyor accompanied Wound Physician-I and RN Unit Manager (UM)-E to assess R188's pressure injuries. RN UM-E stated R188 had pressure injuries to the left fourth toe, the left heel and the sacrum. RN UM-E stated R188 had three areas on the sacrum that the picture documentation counted as one area. Surveyor observed R188 in bed on an air mattress. The air mattress setting was at 360 pounds. Surveyor shared the observation of the air mattress setting with Wound Physician-I. Wound Physician-I asked R188 how much R188 weighed. R188 stated R188 weighed 172 pounds the last time R188 was weighed. Wound Physician-I turned the setting on the air mattress down to R188's weight. RN UM-E stated they would reset that air mattress. R188 had bilateral heel boots on. Wound Physician-I stated the wound to the left fifth toe was due to trauma and not a pressure injury. Surveyor clarified with Wound Physician-I that the wound was on the fifth toe and not the fourth toe as initially documented. Wound Physician-I agreed the wound was on the fifth toe. Surveyor observed three open areas on the sacrum and one open area on the left iliac crest. Wound Physician-I stated the sacrum wounds were measured as one area because the tissue surrounding two of the open areas was darkened and had damage below the skin making it one wound with two open areas. Surveyor noted the third open area on the sacrum was not measured or assessed. Wound Physician-I debrided necrotic tissue from the middle and right open areas of the sacral wound. The left heel pressure injury had an eschar cap over the wound. Surveyor requested a copy of Wound Physician-I's wound assessments. Wound Physician-I's documentation of R188's pressure areas on 5/2/2024 had the following assessments: -Sacrum Unstageable pressure injury measured 5.4 cm x 4.51 cm x 0.2 cm with 1-25% granulation and 51-75% slough before debridement and measured 3.97 cm x 5.28 cm x 1.1 cm with 1-25% granulation and 51-75% slough after debridement. Surveyor noted the measurement included two open areas. Surveyor noted the third open area on the sacrum was not assessed. -Left heel Unstageable pressure injury measured 2.16 cm x 1.84 cm x 0.1 cm with eschar. In an interview on 5/2/2024 at 3:22 PM, Surveyor asked RN-D what the facility process was when a new resident was admitted to the facility. RN-D stated the nurse on the floor does the initial skin assessment which includes looking at the resident's skin from top to bottom and documenting anything like a scab, bruising, scratches, checking under the breasts and folds for redness or excoriation, and any open areas or Deep Tissue Injuries (DTI) caused by pressure. RN-D stated for any open areas or DTIs, you put a sticker next to the wound and take a picture with the phone; that is connected to the electronic charting system, and it measures the length and width of the wound. RN-D stated the picture is sent to Wound Physician-I or to RN UM-E with the resident's name and what the wound is so they can get a treatment order. RN-D stated the wounds are monitored and they are evaluated weekly on Wednesday. RN-D stated if a treatment needs to be done right away, RN-D will do that and then make sure everything is charted. RN-D stated if the resident has mushy heels, RN-D will get heel boots or pillows if the resident hates the boots. Surveyor asked RN-D if pictures were taken of all skin impairments. RN-D stated scabs, bruises, and blanchable redness just get written into the assessment, but if it is an open area, then they get a picture on the phone. RN-D clarified an open area on the coccyx or anything that gets a deeper assessment will get a picture so Wound Physician-I can get a treatment in place. RN-D stated Wound Physician-I is available every day and answers quickly. RN-D stated RN UM-E and Assistant Director of Nursing (ADON)-C are really good with wounds, so they help with assessments. Surveyor noted the phone picture assessment does not measure depth. Surveyor asked RN-D if any wounds get depth measurements. RN-D stated it depends on the wound if a depth is measured. RN-D stated with a flap off, like a skin tear, the depth is estimated and if it something deeper, then they would take a cotton swab to measure the depth. Surveyor asked RN-D how air mattresses were set for the amount of pressure. RN-D stated maintenance usually sets that up but was not sure how they determined the amount of pressure. RN-D stated you can tell who needs a mattress, like if the resident has a wound to the back or is frail skin and bones. Surveyor clarified with RN-D who set the pressure on the air mattress. RN-D stated maintenance sets the pressure; nurses never set the pressure. On 5/6/2024 at 8:55 AM, Surveyor observed R188 lying in bed. The air mattress was set to the correct weight and a sticker had been added to the control panel that listed R188's weight as 166.5 pounds. Surveyor reviewed R188's TAR and R188 had an order to check the function of the low airloss mattress every shift. Weight settings: 166.5 had been added on 5/4/2024 to the original order on the TAR. On 5/6/2024 at 9:31 AM, Surveyor shared with DON-B the concern R188's pressure areas were not comprehensively assessed until 5/2/2024, six days after admission, when Wound Physician-I assessed R188's pressure injuries. Surveyor shared with DON-B R188 had three pressure areas on the sacrum and only two open areas were assessed, and those areas were measured as one area even though they were two separate open areas. DON-B stated Wound Physician-I measured those two open areas together because it gets one treatment. Surveyor shared the third open area was never assessed. Surveyor shared with DON-B R188's left heel did not have a depth measurement until 5/2/2024 when Wound Physician-I assessed the left heel. Surveyor shared with DON-B that R188's air mattress was set to 360 pounds when R188 weighed 166.5 pounds. DON-B provided a table that was obtained from the air mattress distributor that gave pound to kilogram conversions for settings on an air mattress, but the settings did not correlate with the air mattress in place on R188's bed. DON-B stated the bed should be set to the resident's weight and the resident's comfort. Surveyor was unable to find any documentation in R188's medical record that a conversation was had about the setting on the air mattress and R188's comfort level. 2.) R12 was admitted to the facility on [DATE] with diagnoses of dementia, type 2 diabetes and CVA (cerebral vascular accident). The significant change MDS (minimum data set) dated 3/22/24 indicates R12 has cognitive impairments and is dependent for hygiene, bed mobility and toileting. R12 has a stage 3 pressure injury to the sacral area. The physician order dated 4/27/22 indicating a low air loss mattress (settings by weight). On 4/22/24 R12 weight was 114 lbs. On 4/30/24 at 9:09 a.m. Surveyor observed R12 in bed and the low air loss mattress was set at 180 lbs. On 5/1/24 at 8:33 a.m. Surveyor observed R12 was in bed and the low air loss mattress was set at 180 lbs . On 5/2/24 at 11:48 a.m. Surveyor observed R12 receive pressure injury treatment and the low air loss mattress was set at 180 lbs. R12's low air loss mattress device is called Proactive. The operating instructions for the Proactive mattress indicates determine the patient's weight and set the control knob to that weight setting on the control unit. On 5/2/24 at 3:00 p.m. during the daily exit meeting with DON (director of nursing)-B and NHA(nursing home administrator)-A, Surveyor explained the concern R12 was observed to be on the low air loss mattress set at 180 lbs when R12 weighs 114 lbs. On 5/6/24 at 10:07 a.m. Regional Consultant-Q stated the mattress representative explained to her that the mattress should be set at the weight and/or resident's comfort level. Surveyor explained what the mattress should be set at is not documented in the medical record. There is no indication an assessment was completed to determine if R12's mattress setting should be set differently from R12's weight. 3.) R14 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis, dementia, paraplegia and anxiety disorder. Significant change MDS dated [DATE] indicate R14 has cognitive impairments and is incontinent of bowel and bladder. R14 has a healing stage 3 pressure injury to the right buttock. The care plan indicates R14 has a low air loss mattress. On 5/2/24 at 12:22 p.m. Surveyor observed R14's pressure injury treatment and the mattress was set at 320 lbs. The mattress is a Proactive device. The operating instructions for the Proactive mattress indicates determine the patient's eight and set the control knob to that weight setting on the control unit. On 4/3/24 R14 weight was 163.5 lbs. On 5/2/24 at 3:00 p.m. during the daily exit meeting with DON (director of nursing)-B and NHA(nursing home administrator)-A, Surveyor explained the concern R14 was observed to be on the low air loss mattress set at 320 lbs when R14 weighs 163.5 lbs. On 5/6/24 at 10:07a.m. Regional Consultant-Q stated the mattress representative explained to her that the mattress should be set at the weight and/or resident's comfort level. Surveyor explained what the mattress should be set at is not documented in the medical record. There is no indication an assessment was completed to determine if R14's mattress setting should be set differently from R14's weight. 4.) R62 was admitted to the facility on [DATE] with diagnoses of dementia, type 2 diabetes and major depression. On 4/30/24 at 9:25 a.m. Surveyor observed R62 in bed and the low air loss mattress was set at 280 lbs. On 5/2/24 at 12:36 p.m. Surveyor observed R62's pressure injury treatment and observed the mattress set between 240 and 280 lbs. On 4/27/24 R62 weighed 190.5 lbs. On 5/2/24 at 3:00 p.m. during the daily exit meeting with DON (director of nursing)-B and NHA(nursing home administrator)-A, Surveyor explained the concern R62 was observed to be on the low air loss mattress set at 240-280 lbs when R62 weighs 190.5 lbs. On 5/6/24 at 10:07 a.m. Regional Consultant-Q stated the mattress representative explained to her that the mattress should be set at the weight and/or resident's comfort level. Surveyor explained what the mattress should be set at is not documented in the medical record. There is no indication an assessment was completed to determine if R62's mattress setting should be set differently from R62's weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility did not ensure that 1 (R29) of 1 Residents reviewed with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. R29 has limitations in range of motion to R29's left upper extremity. The facility did not apply R29's left hand splint as per R29's Care Plan. Findings include: The Facility policy, entitled Prevention of Decline in Range of Motion, dated 2/2023, states, in part: Policy Explanation and Compliance Guidelines: 1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning and preventative care . 3. Appropriate Care planning. A. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motion. B. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: . Appropriate equipment (braces or splints) . C. Care plan interventions will be developed and delivered . D. Interventions will be documented on the resident's person-centered care plan . E. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record . R29 was admitted to the facility on [DATE] and has diagnoses that include Hemiplegia (paralysis of one side of the body) and Spastic Hemiparesis (an abnormal level of muscle stiffness on one side of the body) affecting the left side following a Stroke, Muscle Weakness, and Mild cognitive impairment. R29's Minimum Data Set (MDS) assessment, dated 3/27/24, indicated that R15 is cognitively intact and that R15 has a functional limitation in range of motion impairment to both upper and lower extremities affecting one side. R15 is dependent on staff for upper body and lower body dressing, toileting, and personal hygiene. R15 does not exhibit any rejection of care. R29's Care Plan, dated 5/19/2020 states: Impaired Physical Mobility; actual Related to residual effects of disease process-[Stroke] with [Left sided residual deficits] Intervention, with a revision date of 4/23/24, include: Apply [Left] hand splint when up for 6-8 hours at night. Provide hand hygiene and monitor skin. Surveyor reviewed R29's Medical Doctor (MD) orders with a start date of 1/9/2024 [Left] hand splint-ON for 6-8 [hours] off PM shift; Complete hand hygiene prior to putting on in the morning AND every evening shift. Surveyor reviewed R29's Medication Administration Record (MAR). According to the MAR, the splint is to be placed on R29 at 8 AM, kept on for 6 to 8 hours, and taken off on the PM shift. For the month of February 2024, staff documented that the splint was ON a total of 8 out of 29 days. For the month of March 2024, staff documented that the splint was ON a total of zero out of 31 days. For the month of April 2024, staff documented that the splint was ON a total of one out of 30 days. From May 1st through May 3rd, 2024, staff documented that the splint was ON a total of zero out of 3 days. On 4/30/24 at 10:00 AM Surveyor observed R29 sitting in a wheelchair in R29's room. R29 does not have a splint on R29's left hand. On 5/1/24 at 8:11 AM, Surveyor observed R29 sitting in a wheelchair. R29 does not have a splint on R29's left hand. On 5/1/24 at 2:05 PM, Surveyor observed R29 sitting in a wheelchair in a common area. R29 does not have a splint on R29's left hand. On 5/2/24 at 8:08 AM, Surveyor observed R29 sitting in a wheelchair in the hallway. R29 does not have a splint on R29's left hand. On 5/2/24 at 8:23 AM, Surveyor interviewed Registered Nurse (RN)-H. Surveyor asked RN-H about R29's splint. RN-H indicated that R29 had a recent room change and came from another unit with the splint. RN-H stated that R29 will only wear the splint a couple hours and then will ask for it to be taken off. RN-H stated that R29 does not like the splint. Surveyor asked if Occupational Therapy was aware of R29's dislike of the splint. RN-H indicated that RN-H would have to look into that and would have to follow up with therapy. On 5/2/24 at 8:39 AM, Surveyor interviewed RN-F who is the unit manager on R29's unit. RN-F indicated that R29 does refuse to wear the splint at times. Surveyor asked what staff should do if a resident is refusing to wear a splint. RN-F stated that if a resident refuses 2 or 3 times, a nurse should chart that in a note and notify the physician and/or therapist. On 5/2/24 at 1:21 PM, Surveyor interviewed Occupational Therapist (OT)-N. Surveyor asked how R29 does with R29's splint. OT-N stated that R29 is pretty good about wearing his splint. Surveyor asked if OT-N had noticed any decline in R29's left upper extremity. OT-N stated that R29 is receiving Botox injections to help with R29's contracture and stated that OT-N has not seen any decline. Surveyor asked what could happen if R29 did not wear R29's splint. OT-N stated that R29's contracture could worsen. Surveyor asked if OT-N was aware that R29 had worn the splint a total of 9 days from February 2024 to April 2024. OT-N stated, No. Surveyor asked what staff should do if R29 is not wearing R29's splint. OT-N stated that OT-N would request that staff let OT-N know if R29 is not wearing R29's splint or refusing to wear the splint. On 5/2/24 at 1:39 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what steps staff should take if a resident is not wearing or refusing to wear a splint. DON-B indicated that if a resident is refusing on a daily basis, staff should be notifying the doctor and/or therapist. On 5/2/24 at 3:05 PM, Surveyor shared the following concern to the Nursing Home Administrator (NHA)-A and DON-B: R29 had worn R29's splint a total of 9 times from February 2024 to April 2024 and OT-N was not aware. 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 1 (R75) of 6 residents reviewed for weight received the necessary services to assist with nutritional maintenance. * R75 had a significant weight loss of 23 pounds (LBS) or 10.7% in 8 days which was not addressed by the Dietician or notification given to R75's physician. Findings include: On 5/6/24 the facility's policy titled, Weight Monitoring dated 1/24 was reviewed and read: A significant change in weight is defined as a 5% change in weight in 1 month (30 days). The physician should be informed of a significant weight change. The Registered Dietician should be consulted to assist with intervention: actions are recorded in the nutrition progress notes. R75 was admitted to the facility on [DATE] with diagnoses that included Diabetes Type 2, Dysphasia and Dementia. R75's quarterly Minimum Data Set (MDS) dated [DATE] indicated R75 did not have significant weight loss or gain during the assessment reference period. On 5/5/24 R75's physician orders were reviewed and indicated R75 received tube feeding and nothing by mouth from admission on [DATE] through 10/30/23 when she started a mechanical soft diet along with the tube feeding. On 11/28/23 R75's tube feeding order was changed to receive the tube feeding if she consumes less then 50% of her meal and at the time of the survey was the current order. Daily weights were ordered on 11/29/23 and at the time of the survey was the current order. On 5/5/24 R75's weights were reviewed and were recorded as follows: 5/1/2024 200.0 Lbs Mechanical Lift, 6.98% loss from 4/14/24 4/30/2024 192.0 Lbs Wheelchair 4/29/2024 192.5 Lbs Wheelchair 4/28/2024 192.0 Lbs Wheelchair 4/25/2024 192.0 Lbs Mechanical Lift 4/24/2024 192.0 Lbs Wheelchair 4/23/2024 192.0 Lbs Wheelchair 4/22/2024 192.0 Lbs Wheelchair, 10.7% loss from 4/14/24 4/20/2024 197.2 Lbs Mechanical Lift, 8.28% loss from 4/14/24 4/19/2024 210 Lbs Wheelchair 4/14/2024 215.0 Lbs Wheelchair On 5/5/24 R75's progress notes were reviewed and no notification to R75's physician could be found. R75's last visit from the physician was 4/19/24 and her weight was stable at that time. On 5/6/24 at 10:30 AM Dietician-O was interviewed and indicated R75 had a significant weight loss but this was addressed with the supplemental feeding that was ordered. The Surveyor indicated that the order for supplemental feedings was started on 11/28/23 and R75's significant weight loss was 4/20/24. Dietician-O indicated he would ask for a reweigh for that big of a weight loss but could not find where that was done. Dietician-O indicated he did not assess the new weight loss and the last nutritional assessment for R75 was 3/21/24 and at that time her weight was stable. Dietician-O also indicated the problem could be using 2 different types of scales, (R75 had the same weight using the different scales from 4/20/24 to 4/30/24 and this was never addressed). Dietician-O indicated R75's physician should be called with a significant weight loss. On 5/5/24 R75's nutritional care plan dated 3/21/24 was reviewed and read: at risk for malnutrition goal weight maintenance. The last change to the care plan was 4/19/24 before any significant weight loss as was the goal of will show no nutritional deficits with current diet. Interventions included monitor weight trends which was initiated 8/28/23. On 5/5/24 at 12:15 PM R75 was observed to eat 75% of her lunch meal. The above findings were shared with Administrator-A and Director of Nurses-B on 5/6/24 at 1:00 PM. Additional information was requested if available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure the accurate administration of all drugs and biologicals to meet the needs of each resident for 1 (R15) of 5 residents reviewed for medications. R15 has a Medical Doctor (MD) order for a daily Lantus injection (Lantus is a long-acting insulin used to control blood sugar). Registered Nurse (RN)-K did not follow the MD order on 4/10/24, 4/18/24 and 4/24/24 and the Lantus injection was not given by RN-K. Findings include: The facility policy, entitled Medication Administration, dated April 2024, states, in part: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . R15 was admitted to the facility on [DATE] and has diagnoses that include: Type 2 Diabetes Mellitus. R15's Minimum Data Set (MDS) assessment, dated 2/24/24, indicates that R15 is cognitively intact and that R15 receives insulin injections daily. Surveyor reviewed R15's MD order with a start date of 2/18/24 documents: Lantus SoloStar Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine). Inject 12 units subcutaneously one time a day for [Diabetes Mellitus]. Surveyor reviewed R15's MAR (Medication Administration Record). The MAR indicates on 4/10/24, 4/18/24 and 4/24/24 Lantus was not given by RN-K as ordered. On 5/2/24 at 1:15 PM, Surveyor interviewed RN-K who stated that RN-K was responsible for administering medications to R15 on 4/10/24, 4/18/24 and 4/24/24. Surveyor asked if RN-K would hold Lantus for any reason. RN-K stated that if R15's blood sugar was too low, RN-K would hold the Lantus. Surveyor asked if RN-K would hold the Lantus insulin if there was no direction to do so in the MD order. RN-K stated that RN-K would still hold it even if it wasn't in the MD order and RN-K would use her best judgement. Surveyor asked RN-K to explain why R15's Lantus was held on 4/10/24. RN-K looked in the Electronic Health Record (EHR). RN-K could not locate a nurses note. RN-K stated that RN-K would put a note within the MAR. RN-K looked for the documentation within the MAR. RN-K stated that on 4/10/24, RN-K documented that R15's blood sugar was 62. RN-K gave juice to R15 and documented that RN-K would re-check the blood sugar in 30 minutes. RN-K stated that R15 did not want to eat breakfast that morning. Surveyor asked why R15's Lantus was held on 4/18/24. RN-K stated that on 4/18/24 RN-K documented that R15's blood sugar was 68. RN-K stated that juice was given to R15 and that R15 was eating breakfast. RN-K indicated that RN-K would recheck the blood sugar in 30 minutes. Surveyor asked why R15's Lantus was held on 4/24/24. RN-K stated that R15's blood sugar was 56. RN-K gave juice and stated that R15 was eating breakfast. RN-K indicated that RN-K re-checked R15's blood sugar again and it was at 135. Surveyor asked if RN-K would notify the Physician before not giving the Lantus injection. RN-K stated, I would notify the Physician only if [R15] was symptomatic. Surveyor asked if R15 showed symptoms of low blood sugar on 4/10/24, 4/18/24 and 4/24/24. RN-K stated No. On 5/2/24 at 1:29 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked what the protocol is for administering Lantus. DON-B indicated that nurses should follow the MD order. Surveyor asked if Lantus should be held for any reason. DON-B explained that if a resident did not eat or there were concerns about giving the Lantus, the nurse should notify the Physician and follow the Physician direction. Surveyor asked if DON-B could identify any additional direction within R15's Lantus MD order indicating that Lantus should be held based on a blood sugar result. DON-B stated that there was nothing in the active order indicating that Lantus would be held based on a blood sugar result. DON-B stated that maybe [the nurse] got a verbal order. DON-B continued and stated that a nurse would need to have an order to hold the Lantus insulin. Surveyor reviewed R15's discontinued and completed MD orders. Surveyor did not locate a completed order for the Lantus to be held on 4/10/24, 4/18/24 or 4/24/24. On 5/2/24 at 3:05 PM, Surveyor shared the concern that R15's Lantus was held without an MD order to the Nursing Home Administrator (NHA)-A and DON-B. No further information was provided at that time.

Based on observation, record review, and interview, the facility did not ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Medical equipment was not sanitized between resident use potentially affecting 3 (R36, R15, and R86) of 3 residents reviewed for monitoring of blood sugars and the handling of dirty laundry was not kept separate from the clean laundry potentially affecting all 92 residents in the facility. *An observation was made of Registered Nurse (RN)-K wiping off an EvenCare glucometer with an alcohol wipe. RN-K did not use a disinfectant wipe to clean the glucometer. RN-K had checked blood sugars on R36, R15, and R86 without disinfecting the glucometer between residents potentially exposing those residents to blood borne pathogens. *Observations were made of Laundry Aide-M handling dirty laundry while wearing a gown. The gown was not removed before Laundry Aide-M handled clean linen from the dryer. Findings include: 1.) The facility policy and procedure entitled Blood Glucose Monitoring dated 1/2024 states: Procedure: . 18. Clean and disinfect the glucometer as per manufacturer's instructions. The EvenCare Blood Glucose Monitoring System User's Guide dated 2023 states: Intended Use: . It is indicated to be used for multiple patients in a clinical setting by healthcare professionals, as an aid to monitoring levels in Diabetes Mellitus. Cleaning and Disinfecting Procedures for the Meter: The EvenCare G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. Materials needed: EvenCare G3 Meter, Gloves, A validated disinfecting wipe . Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use. Wipe all external areas of the meter including both front and back surfaces until visibly wet. On 5/1/2024 at 7:46 AM, Surveyor observed Registered Nurse (RN)-K clean off the glucometer with an alcohol pad. Surveyor asked RN-K if residents had their own glucometer or if they shared a glucometer. RN-K stated residents do not have their own individual glucometer's and RN-K uses one glucometer for the residents on that hallway. Surveyor asked RN-K how many residents had their blood sugar checked that morning. RN-K stated three residents, R36, R15, and R86, had their blood sugars checked that morning by RN-K. Surveyor asked RN-K how the glucometer was cleaned between residents. RN-K stated with an alcohol wipe. RN-K stated Surveyor had just watched RN-K clean the glucometer. Surveyor reviewed R36, R15, and R86 diagnosis lists and confirmed none of the affected residents had blood borne pathogens. On 5/1/2024 at 9:48 AM, Surveyor shared with Director of Nursing (DON)-B the observation of RN-K clean the glucometer with an alcohol wipe and not a disinfectant wipe. DON-B stated RN-K should have cleaned the glucometer with the disinfectant wipe. No further information was provided at that time. 2.) Review of the facility's Standard Precautions: For Infection Control, sign posted on the entrance door of the laundry room revealed, .Handwashing, wash hands after touching body fluids .wear gloves before touching body fluids .Gown, wear gown during procedures that may cause splashes .handle linen soiled with body fluids to prevent personal contamination and transfer to other patients . Review of the document provided by the facility titled Attention Housekeeping and Laundry Staff, dated 09/25/19 indicated .LAUNDRY: 1. Wear gown, gloves, mask and goggles when sorting and loading machines .Wash your hands with soap and water. Review of the facility's Laundry Policy dated 01/2023 revealed, .The facility launders linens and clothing under current CDC guidelines to prevent transmission of pathogens .soiled laundry shall be kept separate from clean laundry at all times. During an observation on 05/02/24 at 8:59 AM with the Director of Housekeeping/Laundry (DHL)-L revealed Laundry Aide (LA)-M placed soiled laundry into a washing machine. LA-M was wearing PPE of a yellow gown and gloves. After LA-M placed the soiled clothes in the washer, DHL-L verbally reminded LA-M to remove her PPE before she went to the dryer to retrieve clean linen. LA-M spoke very little English, and DHL-L gestured to LA-M to remove her soiled PPE. Even though LA-M was reminded to remove her PPE, she walked to the dryer and removed the clean linen with the soiled PPE still on. During an interview on 05/02/24 at 9:03 AM, DHL-L stated LA-M did not follow proper PPE procedures related to preventing cross contamination. DHL-L stated it was her expectation LA-M should have removed her soiled gown and gloves before handling the clean laundry. DHL-L also stated it was her expectation LA-M would have followed proper hand hygiene per facility policies. DHL-L further stated that he expected all staff to follow facility policies to eliminate the spread of infections. During an interview on 05/02/24 at 9:41 AM, Administrator (NHA)-A revealed it was his expectation the facility's staff would have followed the facility's policies and procedures for the proper donning and doffing of PPE to prevent the spread of infectious diseases.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure residents were treated with dignity and care that promotes their quality of life. This was observed with 2 (R26 and R151) of 22 residents reviewed. * R26 was observed with their Foley drainage bag uncovered. * R151 was observed with their Foley drainage bag uncovered and did not have their personal clothes to wear for days. Findings include: The facility's policy and procedure for Catheter Care, revised 10/1/22, was reviewed by Surveyor. The policy indicates: Privacy bags will be available and catheter drainage bags will be covered at all times when in use. The facility's policy and procedure for Resident's Personal Inventory, revised 5/2022, was reviewed by Surveyor. The policy indicates the facility will do an inventory list when a resident is admitted and ongoing to protect personal property and prevent loss. 1. On 1/23/23 at 10:03 AM Surveyor observed R26 in their room. R26 had a Foley drainage bag hanging on their nightstand handle as R26 was sitting in their wheelchair. The Foley drainage bag was not covered. R26 did not have any concerns with the Foley, except they have had urinary tract infections. On 1/24/23 at 11:34 AM Surveyor observed R26 In bed. R26 indicated they are not feeling well. The Foley drainage bag was uncovered hanging on the bed frame. On 1/25/22 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns with the Foley drainage bag being uncovered. On 1/26/23 at 9:06 AM DON-B (Director of Nurses) spoke with Surveyor. DON-B indicated the Foley drainage bags are now covered. 2. On 1/23/23 at 10:31 AM Surveyor observed R151 in their bed and has a Foley drainage bag hanging on their walker near the bed. The Foley drainage bag was not covered. R151 was hoping they would take it out. R151 indicates its painful. On 1/24/23 at 11:47 AM Surveyor observed R151 in bed with the Foley drainage bag on bed frame. The Foley drainage bag is not covered. On 1/25/22 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns with the Foley drainage bag not being covered On 1/26/23 at 9:07 AM DON-B (Director of Nurses) spoke with Surveyor. DON-B indicated the Foley drainage bags are now covered. 3. On 1/23/23 at 11:11 AM Surveyor observed R151 in bed. R151 was still in a hospital gown at and did not know when they were getting dressed. R151 indicated they did not have their own clothes to get dressed into yet. Surveyor reviewed R151's medical record. R151 was admitted to the facility on [DATE] for rehab services. On 1/24/23 at 11:42 AM Surveyor observed R151 In bed and with the call light on. R151 indicated staff are looking for their (R151's) clothes. They are bringing clothes up now for R151 to get dressed in. R151 indicated they want their own clothes back. On 1/25/23 at 8:15 AM Surveyor spoke with Laundry Supervisor (LS) -I who indicated a new admissions clothes will get bagged, washed and labeled. The clothes would be returned to the resident within 2 days. LS-I just heard about R151's clothes not yet returned. LS-I indicated R151 was admitted over a the weekend and LS-I wasn't here. LS-I brought R151 clothes from the donation clothing. LS-I just found out about the clothes for R151 and are addressing it now. Resident labeling is completed Monday through Friday. The staff that does the labeling on weekends is on leave, otherwise, would normally be done on the weekend. LS-l stated they do keep a resident clothes inventory and that R151's clothes are in the labeling room to get labeled today. Surveyor noted R151 was admitted on a Tuesday and did not have their personal clothes available for 8 days. Surveyor noted, R151 had not gotten up out of bed on 1/23, 1/24, and 1/15/23 because she did not have her own clothes to wear. On 1/25/22 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns with R151's personal clothes not being available. On 01/26/23 at 11:58 AM Surveyor observed R151 in their wheelchair and dressed. R151 was being wheeled into the Therapy gym. R151 was happy to have their clothes back.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R85 admitted to the facility on [DATE] and has diagnoses that include hemiplegia and hemiparesis following cerebral infarction, dysphagia, hypertensive and chronic kidney disease stage 3 and chronic congestive heart failure. On 1/23/23 at 10:27 AM Surveyor spoke with R85 in his room. He was sitting in his wheelchair, dressed, watching TV. During the interview, R85 stated: Third shift is the worst, I want to get up by 6 AM, but they never get me up, they say they're leaving soon and push it off to first shift. Surveyor asked if he has told anyone of his request to get up by 6 AM. R85 stated: Heck yeah, I've told everyone, but they still don't do it. The first shift even put a sign on my wall to get up on third shift, but they don't. R85 reported if he is not up by 6 AM he has to wait until after breakfast because first shift doesn't have time to get him up before. R85 reported he then has to eat in bed and does not like eating in bed. R85 reported he has not filed any official complaints or grievances. Surveyor observed a sign on the wall above the bed which read: Gets up on 3rd shift. Review of R85's Care Plan did not include interventions for residents' preference to get up by 6 AM. On 1/26/23 at 11:55 AM Surveyor spoke with Scheduler-G and confirmed the Certified Nursing Assistant (C NA) schedule is as follows: AM shift 6:30 AM - 2:30 PM, PM shift 2:30 PM - 10:30 PM, Night shift 10:30 PM - 7:00 AM. On 1/24/23 at 8:17 AM Surveyor observed R85 sitting up in his wheelchair, dressed and well groomed. Surveyor commented he was up early today. R85 stated: Yeah, they got me up this morning. Must be because you're here, because usually it don't happen. Surveyor reviewed R85's nursing progress notes which documented (in part) . 8/18/2022 10:13 AM Resident not up with third shift get ups it seems there was a misunderstanding with get ups, as first shift aid did get in she explained to resident that she had overwhelming circumstances and others that needed her attention first and he would have to get out of bed after breakfast, resident not happy but after writer talked to him and explained the same things with him he was a little better. 9/12/2022 11:12 AM Resident noted to have light on as first shift was getting on the floor/getting report waiting for towels light not on but a few moments and resident was calling the desk, as writer was going down to answer light aid already told him he would be up for breakfast, as resident was still not up for breakfast he turned light on again and was yelling out for the aids, writer did talk to resident and stated there was still plenty of time to be up before breakfast to please wait patiently, resident not happy but did wait and was up for breakfast. 10/2/2022 2:19 PM Resident a little inpatient starting to call the desk as light was not on long resident unable to be up on third shift and needed to wait until after breakfast to get up as there were needs of others that needed to be meet first, resident not happy with this but did get through breakfast .his mother did come to visit and resident much better no further behavior noted. 1/3/2023 11:32 AM Resident did choose to stay in bed this shift as aide walked in the room and asked what resident what would like to wear for the day resident stated well it's very late now what's the point, I will just stay in bed. On 1/24/23 at 1:20 PM Surveyor spoke with Certified Nursing Assistant (CNA)-C who reported she works on R85's unit almost daily, adding: They're my people, I love them. CNA-C reported R85 likes to get up on third shift between 5:00 - 6:00 AM because he likes to go to the dining room to eat, and doesn't like to eat in bed. CNA-C stated: If night shift doesn't get him up, I don't always have time to get him up before breakfast because there's a lot of people, that's why nights is supposed to get up some people who want to get up. Surveyor asked if anyone was aware of R85's request to get up between 5 and 6 AM. CNA-C stated: Yes, everyone is. I even put sign up in his room - it didn't matter, they still don't get him up. CNA-C reported there is an assignment sheet in the book at the nurses station that has the rooms that nights is supposed to get up, but they don't. CNA-C reported she used to write statements and gave them to Nursing Home Administrator (NHA)-A and the Unit Manager (who is no longer employed at the facility). CNA-C reported she has voiced her concerns, but nothing changed, that's why she posted the sign on his wall. CNA-C reported there are a few days R85 is up, but most days they don't get up up and it makes him mad. CNA-C stated: I even told the third shift aides it's OK to leave him in bed after he's washed and dressed and I will get up up. It's an ongoing problem. Surveyor reviewed a red binder at the nurses station which contained a sheet for night shift get up list. The A hall (R85 resides) had 4 rooms listed, one of which is R85's room. The sheet documents: Should not be starting prior to 5 AM unless resident requests. When working short with 1 CNA - the sheet lists 2 rooms to get up, one of which is R85's room. On 1/25/23 at 8:45 AM Surveyor observed R85 dressed and up in his wheelchair in the dining room. Surveyor said good morning and commented it was nice to see him up for breakfast. R85 stated: Yeah, it's nice to be up. R85 asked: How long will you be here? At least I can look forward to getting up when I want because you're here. On 1/25/23 at 3:00 PM during the daily exit meeting with the facility, NHA-A and Director of Nursing (DON)-B were notified of the concern R85 is not consistently up at the time per his preference to eat breakfast in the dining room. On 1/26/23 at 9:50 AM DON-B met with Surveyor. DON-B stated: For the night get up list, we choose people who like to get up early to help day shift. If night shift is not able to get him (R85) up for whatever reason, it's expected that the AM shift should still get him up first, before breakfast. We have educated staff on the unit that is the expectation. On 1/26/23 at 10:20 AM Surveyor met with NHA-A and asked if any staff had written statements or reported R85 had complained about not getting up at the time R85 requested. NHA-A reported he was not aware there was a problem R85 was not getting up at the time requested, and the first he heard about it was yesterday, when Surveyor brought to his attention. NHA-A reported staff on the unit have been educated. No additional information was provided. Based on observation, record review and interview, the facility did not promote or facilitate the residents choice for sleep schedules and health care. This was observed with 2 (R39 and R85) of 22 residents reviewed. * R39 gained weight in the facility and was not offered any alternate dietary diet to assist with weight control and/or loss. * R85 sleep preferences were not implemented by staff. Findings include: 1. On 1/23/23 9:54 AM, Surveyor spoke with R39 in their room. R39 indicated they just do jigsaw puzzles in their room and watches television. R39 is in a wheelchair and indicated they have gained a lot of weight while residing in the facility. On 1/24/23 at 10:59 AM, Surveyor conducted a Resident Group. R39 expressed they have gained a lot of weight in the facility. Their knees hurt and they just eat and sleep here. Surveyor reviewed R39's medical record. R39's Plan of Care for Potential for Weight Change dated 5/21/2020 is related to obesity with unplanned weight gain. The Interventions include: Education about being over weight; Cardiac/regular diet; encourage to limit portions to single serving. R39 admission MDS assessment into the facility completed 5/28/2020 indicates a weight of 146 # On 4/25/21 the Annual MDS assessment indicates 240 # and a significant weight gain. R39's Annual MDS (Minimum Data Set) assessment on 4/1/22 indicates R39 has no weight gain or loss and weight 281 #. The Quarterly MDS assessment on 12/23/22 indicates 314 # and checked for a significant weight gain. R39 has doubled their weight while being in the facility. R39's Physician Progress Note on 11/10/22 indicates R39 has gained significant weight since admission. Has oestoarthritis in both knees and is not a candidate for knee replacements due to weight. A Nutritional Assessment completed on 12/22/22 indicates: Unable to meet with resident at this time. Resident has had a good intake consuming 76-100% of meals. Has weight gain and BMI (body mass index): morbid obesity. Resident snacks frequently and requesting extra portions. Resident has been educated on healthy eating and goal for gradual weight loss. Resident triggers for >5% gain in 1 month (11/14/22 298.9#), >7.5% in 3 months (9/7/22 290#), 10% gain in 6 months (6/8/22 285#). Resident is a independent eater. The Progress Note on 1/12/2023 at 11:15 AM indicates Interdisciplinary Care Conference: Quarterly Comments: R39 has a Brief Interview of Mental Status of 15/15 which indicates no cognitive impairment and a PHQ9 (Patient Health Questionnaire) 0/27, which indicates no depression. R39's current weight is 314 pounds (#); wt loss noted. R39 states she has not been eating as many sweets. R39 continues to have chronic bilateral knee pain; as needed pain medication available for administration. On 1/25/23 at 9:58 AM Surveyor spoke with Social Worker (SW)-M who indicated she (R39) recently lost weight and enjoys to snack and goes to store in the facility. SW-M did not have any additional information at this moment regarding a weight loss program. On 1/25/23 at 12:37 PM Surveyor spoke with Registered Dietician (RD)-J about R39's weight gain. RD-J indicated R39 is big on snacks. RD-J stated having had conversations with weight loss education .We would provide education and a standard general diet. RD-J reported the facility does not offer a low calorie or low fat type diet .They offer portion type snacks. Any low calorie or low fat snacks the family would have to provide. On 1/25/23 at 2:13 PM RD-J spoke with Surveyor. RD-J indicated R39 has been educated about weight reduction risks and benefits. R39 does utilize vending machines in the facility. On 1/25/22 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns with R39 weight gain. On 1/26/23 at 8:57 AM DON-B (Director of Nurses) spoke with Surveyor. The facility had no additional information why R39 was not provided resources to lose weight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R62) of 4 Residents reviewed for weight loss received the necessary care and services to assist with nutritional maintenance. *R62 was admitted on [DATE] and the first weight obtained on R62 was 10/2/22. Further, R62 has a physician's order as of 11/11/22 to obtain daily weights and this was not completed by the facility. Findings Include: Surveyor reviewed the facility weight monitoring policy and procedure dated 10/2022 and noted the following: .Policy: Based on the Resident's comprehensive assessment, the facility will ensure that all Residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the Resident's clinical condition demonstrates that this is not possible or Resident preferences indicate otherwise. Compliance Guidelines: Weight can be useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. 1. The facility will utilize a systemic approach to optimize a Resident's nutritional status. This process includes: a. Identifying and assessing each Resident's nutritional status and risk factors b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring the effectiveness of interventions and revising them as necessary 3. Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the Resident's specific nutritional concerns and preferences. 4. Interventions will be identified, implemented, monitored and modified(as appropriate), consistent with Residents' assessed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status. 5. A weight monitoring schedule will be developed upon admission for all Residents. a. Weights should be recorded at the time obtained. b. Newly admitted Residents-monitor weight weekly for 4 weeks, then monthly unless otherwise directed by the physician. c. Residents with weight loss-monitor weight weekly d. If clinically indicated-monitor weight daily e. All others-monitor weight monthly 6. Weight Analysis: A significant change in weight is defined as: a. 5% change in weight in 1 month*(30 days) b. 7.5% change in weight in 3 months(90 days) c. 10% change in weight in 6 months(180 days) 7. Documentation: f. Observations pertinent to the Resident's weight status should be recorded in the medical record as appropriate. R62 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Stage 4(Severe), Type 2 Diabetes Mellitus, and Depression. R62 is her own person. Surveyor reviewed R62's significant change Minimum Data Set (MDS) dated [DATE]. R62's Brief Interview for Mental Status (BIMS) score of 15 indicates R62 is cognitively intact for daily decision making. R62's MDS documents that R62 requires extensive assistance for bed mobility and transfers, and limited assistance for toileting and hygiene. R62's MDS indicates R62 weighs 147 pounds (#) and had not experienced weight loss or gain. Surveyor reviewed R62's Care Area Assessment(CAA) for nutritional status dated 11/17/22 and noted no specific interventions are documented for R62's weight loss. Surveyor reviewed R62's 'Care Card' as of 1/26/23 and noted it is instructed under monitoring to obtain a weight every day in the AM. Surveyor reviewed R62's comprehensive care plan and noted the following focused problem: Renal diet, Regular / non-modified texture. 9/28/22 wt (weight) 141# skin free of pressure wounds 11/14/22 R62 started dialysis. weight 147#. Skin intact 12/30/22 weight 114# down since October likely due to dialysis, skin intact 1/23/23 weight 111# - >(greater than) 75% wt loss in 3 months - skin intact Interventions Monitor meal intake % of food and fluids - 9/28/22 Offer double portions at dinner - 1/23/22 Offer food preferences - 9/27/22 Offer snacks between meals - 9/23/22 Supplement: Resident declines at this time - 1/23/22 Surveyor reviewed R62's 'Weights and Vitals Summary' since the day of admission on [DATE]. The first documented weight of 143 pounds by mechanical lift is obtained on 10/2/22 which per facility policy and procedure should have been done on 9/27/22. The second documented weight of 144.5 pounds by wheelchair is obtained on 10/15/22. The third documented weight of 147 pounds by wheelchair is obtained on 10/29/22. Per policy and procedure, the facility should have weighed R62 in the week between 10/15/22 and 10/29/22. The policy states to weigh weekly times 4 weeks post admission. Surveyor reviewed R62's active physician orders as of 1/24/23 and noted the following order was effective 11/11/22: .Daily weight (same time of day and same scale everyday) contact MD for weight gain of 3 pounds overnight or 5 pounds in one week. Surveyor reviewed R62's Treatment Administration Record (TAR) for the month of November and noted that daily weights were not obtained on the following dates: 11/13/22, 11/21/22, 11/22/22, 11/25/22, and 11/29/22. There is no documentation that R62 refused to have R62's weight obtained on the above dates. Surveyor reviewed R62's Treatment Administration Record (TAR) for the month of December and noted that daily weights were not obtained on the following dates: 12/1/22, 12/6/22, 12/8/22, 12/9/22, 12/16/22, 12/17/22, 12/18/22, 12/19/22, 12/20/22, 12/25/22, and 12/26/22. There is no documentation that R62 refused to have R62's weight obtained on the above dates. Surveyor also requested R62's TAR for the month of January, however, was not provided it. Surveyor reviewed R62's January weights documented in the 'Weights and Vitals Summary' and noted the following missing daily weights: 1/1/23, 1/2/23, 1/8/23, 1/13/23, 1/15/23, 1/16/23, and 1/18/23 There is no documentation that R62 refused to have R62's weight obtained on the above dates. On 1/25/23 at 12:34 PM, Surveyor interviewed Registered Dietitian (RD-J) in regard to the necessity of obtaining R62's daily weight. RD-J informed Surveyor that RD-J was unaware that R62 had a physician order to weigh R62 every day. Surveyor pointed out to RD-J that the weights were not consistent the method they are obtained. Surveyor shared that the 'Weights and Vital Summary' for R62 documents that staff either obtained R62's weight by wheelchair or standing and the first weight obtained was by mechanical lift. RD-J confirmed it is very important to obtain a weight the same way to eliminate any fluctuations. On 1/25/23 at 1:31 PM, Surveyor interviewed Nurse Manager (NM-E) who confirmed that the expectation is daily weights should be done if there is a physician order for daily weights. NM-E agreed there is no consistent documentation that R62 has refused daily weights to be obtained. On 1/25/23 at 1:47 PM, R62 stated to Surveyor that R62 does not refuse to be weighed because I know it is important. On 1/25/23 at 3:50 PM, Surveyor shared with Administrator (NHA-A) and Interim Director of Nursing(DON-B) the concern that R62 was not weighed on admission and daily weights were not obtained for R62 per physician order effective 11/11/22. No further information was provided by the facility at this time On 1/26/23 at 8:56 AM, DON-B provided documentation to Surveyor that in-service training started effective as of 1/25/23 that includes: 1. Weights need to be completed per physician orders. 2. Admit weight is upon admission, then weekly x 4, then monthly or per MD orders. 3. Daily weights must be completed if Resident refuses please document. 4. If you have an ABNORMAL weight gain or loss of more than 5 pounds it must be reported to the MD. On 1/26/23 9:03 AM, DON-B agreed that a weight was not obtained on admission and daily weights were not obtained for R62.

Based on observation, record review and interview, the facility did not ensure a resident with a gastrostomy tube received the appropriate care and services for a resident with a gastrostomy tube. This was observed with 1 (R90) of 2 residents with a gastrostomy tube. R90 has a gastrostomy tube that was not flushed or care planned after feeding was discontinued. Findings include: The facility's policy and procedure for Care and Treatment of Feeding Tubes, dated 10/2022, was reviewed by Surveyor. The policy includes: the resident's plan of care will address the use of feeding tube, including strategies to prevent complications; Directions for staff for providing care, including water flushes and skin care. On 1/23/23 at 11:31 AM Surveyor observed R90 in their bed. Surveyor observed on the over bed table there are 2 large Styrofoam cups with straws. Surveyor observed there was a large, tan colored and moist appearing area on R90's blanket by their upper abdomen area. There was a tube feeding syringe with a container on the bed side table. Surveyor reviewed R90's medical record and noted R90 is on a general diet. The Progress Note on 1/12/2023 indicates: Writer sent message to (R90's) Physician regarding resident's current gastrostomy tube orders. R90 does not actively receive feeding supplementation or medication administration through gastrostomy tube. New orders received to flush the tube with 200cc's of water three times a day for patency. R90's current Plan of Care does not indicate a gastrostomy tube use and interventions. R90 did not receive water flushes through the tube from 12/22/22 until 1/12/23. On 1/25/23 at 3:00 PM Surveyor requested additional information at the facility Exit Meeting. On 1/26/23 at 8:49 AM DON-B (Director of Nursing) spoke with Surveyor. DON-B indicated R90 had a feeding tube that was resolved on 12/14/22 indicating R90's feeding through the tube was discontinued. On 1/12/23 it was discovered the tube was not being flushed so they started flushing the tube. DON-B provided the Plan of Care for R90 being dependent on tube feeding that was started on 9/9/22 and resolved on 12/22/22. This resolved plan of care included interventions for water flushing and skin care with inspections of the area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not have evidence of ongoing communication and collaboration between the facility and the dialysis center for the care and services of 1 of 1 Residents (R62) reviewed who was receiving dialysis. *R62 did not always have evidence of assessment of R62's condition and monitoring for complications before and after dialysis, specifically obtaining R62's pre-weight by the facility staff and did not have ongoing communication and collaboration with the dialysis center. The form contains documentation from the dialysis center and serves as a communication tool between the facility and the dialysis center. Findings include: Surveyor reviewed the facility's Hemodialysis policy and procedure reviewed/revised 10/2022 and notes the following: .Policy: This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person centered-care plan, and the Resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of Residents receiving hemodialysis. Purpose: The facility will assure that each Resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice. This will include: -The ongoing assessment of the Resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. -Ongoing assessment and oversight of the Resident before, during and after dialysis treatments, including monitoring of the Resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices. -Ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Compliance Guidelines: 2. The facility will coordinate and collaborate with the dialysis facility to assure that: a. The Resident's needs are related to dialysis treatments. b. The provision of the dialysis treatments and care of the Resident meets current standards of practice for the safe administration of the dialysis treatments. c. Documentation requirements are met to assure that treatments are provided as ordered by the nephrologist, attending practitioner and dialysis team. d. There is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. 4. The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form that will include, but not limit itself to: b. Physician/treatment orders, laboratory values and vital signs d. Nutritional/fluid management including documentation of weights, Resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered. R62 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Stage 4(Severe), Type 2 Diabetes Mellitus, and Depression. R62 is her own person. Surveyor reviewed R62's significant change Minimum Data Set (MDS) dated [DATE]. R62's Brief Interview for Mental Status(BIMS) score of 15 indicates R62 is cognitively intact for daily decision making. R62's MDS documents that R62 requires extensive assistance for bed mobility and transfers, and limited assistance for toileting and hygiene. Surveyor reviewed R62's Care Area Assessment (CAA) for nutritional status dated 11/17/22 and notes no specific interventions are documented for R62's weight loss. Surveyor reviewed R62's 'Care Card' as of 1/26/23 and notes it is instructed under monitoring to obtain a weight every day in the AM. Surveyor reviewed R62's comprehensive care plan and notes the following focused problem: The resident needs hemodialysis r/t renal failure: The following interventions are documented Cushion in chair during dialysis - 11/29/22 Do not draw blood or take B/P in arm with graft - 11/29/22 Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis Tues, Thurs, Sat in house - 11/29/22 Monitor for dry skin and apply lotion as needed - 11/29/22 Monitor labs and report to doctor as needed - 11/29/22 Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed - 11/29/22 Monitor/document/report PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage - 11/29/22 Monitor/document/report PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds - 11/29/22 Monitor/document/report PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock - 11/29/22 Surveyor reviewed R62's hospital Discharge summary dated [DATE] and notes it is documented that R62's kidneys did not improve to the point where it was decided R62 would need hemodialysis and R62 was agreeable. Surveyor notes R62 started dialysis on 11/12/22, 3 times a week. Surveyor reviewed R62's dialysis 'Communication Report' and notes the following days of dialysis do not have a pre-weight documented. Surveyor noted the dialysis clinic is including requests for the facility to ensure R62 is weighed by facility staff prior to dialysis. 11/12/22 Please weigh (R62) before dialysis. Thank You. 11/19/22 Please obtain weight before taking (R62) to dialysis. Thank You. 11/29/22 Please weigh (R62) before treatment. Thank You. 12/1/22 Please weigh (R62) before taking to dialysis. Thank You. 12/6/22 12/13/22 Please weigh (R62) before taking to dialysis. Thank You. 1/12/23 Please do not forget to weigh (R62) before taking to dialysis. Each form consistently has the empty spot where the pre-weight should be indicated. Surveyor notes a physician order was added 1/24/23 and became effective to check R62's blood pressure and weight prior to dialysis one time a day every Tues, Thurs, and Sat. On 1/25/23 12:34 PM, Surveyor spoke to Registered Dietitian (RD-J) in regards to importance of pre-weights before dialysis. RD-J stated that RD-J does review the dialysis communication reports for R62 to assist with monitoring of weights and the risk of significant weight loss or gain. RD-J stated that pre-weight is very important to show the amount of fluid taken off. RD-J also confirmed the method of being weighed is equally important. On 1/25/23 at 1:31 PM, Nurse Manager (NM-E) agreed that R62's weight should be obtained prior to going to every dialysis treatment. NM-E agreed that if there is a physician's order to weigh R62 prior to dialysis, the expectation is that R62's weight should have been obtained and documented on R62's dialysis communication report. NM-E agreed there is no documentation that R62 has refused for R62's weight to be obtained. On 1/25/23 at 1:47 PM, Surveyor interviewed R62 who stated that R62 does not refuse to be weighed because I know it is important. On 1/25/23 at 3:50 PM, Surveyor shared the concern that R62's weight was not obtained consistently prior to dialysis treatments with Administrator (NHA-A) and Interim Director of Nursing (DON-B). On 1/26/23 at 12:01 PM, Surveyor interviewed dialysis registered nurse (RN-K) in regards to R62 dialysis treatments and the necessity of pre-weights being obtained by the facility. Surveyor asked RN-K about dialysis for R62. RN-K stated: They are getting better at getting the pre-weights. It has been a significant problem to get the pre-weights for (R62). Sometimes I am able to get the pre-weight if not sent, by using the wheelchair scale outside the dialysis room. RN-K stated that it depends on R62's edema, if lung sounds are bad, I send R62 back to get a pre-weigh, and sometimes I go off of blood pressure instead, which is not what I prefer to do. RN-K further stated, It is concerning that it is not done. I have spoken to NM-E about it several times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R32 admitted to the facility on [DATE] and has diagnoses that include alcohol induced persisting dementia and psychotic disorder, anxiety disorder and cirrhosis of the liver. R32's Physician's Orders documented an order for Ativan (Lorazepam) Tablet 0.5 MG (milligrams) give 0.5 mg by mouth every 24 hours as needed for anxiety. Ordered 6/3/22, discontinued 11/9/22. Surveyor noted the Ativan order did not include the duration for the PRN (as needed) order, or rationale in the resident's medical record to extend beyond 14 days. On 1/25/23 at 9:11 AM Director of Nursing (DON)-B provided R32's pharmacy reviews. Surveyor review of the (name of pharmacy) Recommendation Summary for DON and Medical Director for recommendations created between 10/1/22 and 10/28/22. MRR (Medical Record Review) date 10/11/22 documented: This resident is currently on PRN Lorazepam with the following diagnosis: Anxiety. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order. Please consider discontinue PRN Lorazepam. Surveyor noted an X mark next to Discontinue PRN Lorazepam which was signed by the Physician, but not dated. Surveyor located a (name of pharmacy) Note To Attending Physician/Prescriber, MRR date 10/11/22 which documented: This resident is currently on PRN Lorazepam with the following diagnosis: Anxiety. PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order. Please consider discontinue PRN Lorazepam. Physician/Prescriber response documented a handwritten order: D/C (discontinue) 0.5 mg PRN, which was signed and dated by the physician on 10/20/22. R32's October 2022 Medication Administration Record (MAR) documented an order for Ativan 0.5 MG (Lorazepam) give 0.5 mg by mouth every 24 hours as needed for anxiety - order date 6/3/22, discontinued 11/9/22. Surveyor noted PRN Ativan signed out as administered on 10/11/22, 10/15/22, 10/23/22, 10/30/22 and 10/31/22. R32's November 2022 MAR documented the above PRN order for Ativan until it was discontinued on 11/9/22. No doses were signed out as having been administered. On 1/25/23 at 3:00 PM during the daily exit meeting, Nursing Home Administrator (NHA)-A and DON-B were advised of the concern regarding R32's PRN Ativan order extending beyond 14 days and the delay of discontinuation of the medication after physician ordered. On 1/26/23 at 9:50 AM Surveyor spoke with DON-B who reported she understood the concern regarding the 14 day stop date for the PRN Ativan, but did not think there was a delay in the Ativan order being discontinued. DON-B stated: I get the pharmacy recommendations emailed to me on the 28th. We were in New Jersey for a conference until 11/7/22 and the state knew were away at a conference. It was discontinued on the 9th. Surveyor advised DON-B the physician's order to discontinue the PRN Ativan was written on 10/20/22. DON-B stated: No, that's not right, I don't get the pharmacy recommendation until the 28th. Surveyor showed DON-B the Pharmerica Note To Attending Physician/Prescriber form with the physician's handwritten signed order dated 10/20/22 to discontinue PRN Ativan. DON-B stated: Where did that come from? I didn't even get that. OK, well I never saw that. No additional information was provided. Based on record review and interviews, the facility did not ensure residents receiving psychotropic medications had indications for use, adequately monitored administration and comprehensively assessed need for the medication. This was discovered with 3 (R39, R58 and R32) of 5 resident medication reviews. -R39's psychotropic medication did not indicate the individualized use with non-pharmacological interventions. -R58's psychotropic medication was not comprehensively assessed to identify their individual use and non-pharmacological interventions. -R32's psychotropic medication did not have a definitive stop date and was not discontinued when ordered by the physician. Findings include: The facility's policy and procedure Use of Psychotropic Medication, dated 10/10/22, was reviewed by Surveyor. The policy indicates: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. As needed orders for all psychotropic drugs will include a limited duration. The indications for use of any psychotropic drug will be documented in the medical record. This includes non-pharmacological interventions related to the targeted behavior. 1.) R39's medications were reviewed by Surveyor. R39's Physician Plan Of Care indicates orders for: -Sertraline 75 mg every day for depression with a start date of 5/25/22. -Seroquel 12.5 mg every day for psychosis start date of 10/20/22. -Bupropion 100 mg every day for depression with a start date of 9/17/21. - Monitor side effects for antipsychotic. Resident is on Seroquel. **use legend on Nurses Cart and at Nurses Station. Started 12/3/22. -Monitor side effects for a antidepressant. Resident is on Bupropion and Sertraline. **use legend on Nurses Cart and at Nurses Station. Started 5/21/20. - Behavior monitoring for antidepressants every shift and directs to use legend on Nurses Cart and Nurses Station start date of 5/21/20. -Behavior monitoring for antipsychotic every shift and directs to use legend on Nurses Cart and Nurses Station start date 12/3/22. R39's Quarterly MDS (minimum data set) assessment completed on 12/23/22 does not indicate any behaviors. R39's Plan Of Care does not indicate the targeted behaviors, along with interventions, related to the antidepressant and antipsychotic medication. On 1/25/23 at 12:02 PM Surveyor spoke with (Unit Manager) UM-F. UM-F indicated the medication indication is under the medication physician order. The staff would chart just the behavior from a list of choices. The Nurse Binder (legend for behaviors and interventions) has a list of behaviors and interventions that are not specific to any resident. They indicate the plan of care has the behaviors on it. R39 plan of care was reviewed. They have just the clinical aspect of the psychotropic medication. R39 did not have targeted behaviors, along with non-pharmacological interventions. UM-F indicate the nurse picks an intervention from a list. The Legend used for Behaviors include 38 possible behaviors for any resident on psychotropic medication. The interventions include 12 suggested interventions. Staff chart the behavior exhibited and chose what intervention they attempted. This is not individualized to the resident targeted behaviors and assessed interventions. On 1/25/23 at 12:22 PM Surveyor spoke with (Director of Nurses) DON-B. They indicated the CNA(Certified Nursing Assistant) charting has the specific behaviors related to the legend or the Physician Orders have the specific behavior. On 1/25/23 at 12:55 PM DON-B provided Surveyor with a plan of care for R39. The identified concern is: The resident uses antipsychotic medication related to psychosis. It does not identify R39's psychosis symptoms. The date initiated is 5/21/20. The interventions include to monitor/record occurrence of for targeted behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence, aggression towards staff/others, etc.). Surveyor noted there is not specific behaviors documented related to R39's antipsychotic medication, nor non-pharmacological interventions. The plan of care identified the use of antidepressants due to depression. This was initiated on 5/21/20. The interventions are related to the clinical use of the medication class. The plan of care does not identify R39's symptoms of depression and any interventions to address their depression symptoms. On 1/25/23 at 3:00 PM Surveyor shared the concerns with psychotropic medication use, assessment and monitoring, at the facility Exit Meeting. On 1/26/23 at 9:00 AM DON-B spoke with Surveyor. They did not have any additional information about R39's medication. DON-B indicated that Community Care has had a Counselor see R39 twice a month. They were not aware of this and will obtain visit documentation and revise the plan of care. DON-B provided the last 6 months of Progress Notes and there are no behaviors noted. 2.) R58's medications were reviewed by Surveyor. R58 has not resided in the facility for more then 30 days. R58 was admitted on [DATE] with the following orders: -1/2/23 Bupropion 300 mg every day for depression. This includes behavior monitoring for being on an antidepressant. -1/2/23 Escitalopram 20 mg every day for depression. This includes behavior monitoring for being on an antidepressant. R58's admission MDS (minimum data set) assessment completed on 1/5/23 indicates no behaviors. The Mood section indicates they are currently feeling down, depressed or hopeless 12-14 times over a 2 week period. They are feeing tired or having little energy 7-11 times in a 2 week period. The CAA(Care Area Assessment) for psychotropic medications indicate to refer to the care plan. The CAA does not include any assessment of specific depression symptoms, along with non-pharmacological interventions. The Plan of Care identifies the use of an antidepressant medications for depression. This was initiated 12/31/22. It does not identify R58 depression symptoms, along with interventions. The plan of care lists the clinical side effects of the actual medication. On 1/26/23 at 10:38 AM Surveyor spoke with MDS Nurse-P. They indicated they just look at the medication itself upon admission. They completed the CAA for R58, however did not know the assessment aspect. The care plan is for medication side effects. If the resident would have triggered for the Mood CAA they would let the social worker know. MDS Nurse-P just does the clinical aspects of psychotropic medications. They did not assess R58's use of antidepressant medications. On 1/26/23 at 11:03 AM Surveyor spoke with (Director of Nurses) DON-B and shared concerns with R58's antidepressant medication. DON-B indicated they use the legend to learn the resident's behavior since they are a new admission. DON-B did agree there should be an assessment for why R58 is taking antidepressant medication.

Based on observation, record review and interview, the facility did not implement isolation measures with a resident with potential symptoms of an infection. This was observed with 1 (R39) of 1 residents observed with loose stools that were to be assessed for potential (clostridium difficile) C-Diff. R39 had noted to be experiencing recurring loose stools/diarrhea. The physician was called and ordered testing for C-Diff with an antibiotic based upon test results. R39 was not placed in contact isolation when C-Diff was suspected. Findings include: On 1/23/23 at 9:55 AM Surveyor spoke with R39 in their room. R39 did not have any indications they were on any isolation for infection. R39 indicated the facility just had Covid here and there are just germs everywhere. R39 indicated they caught something with loose stools. Surveyor reviewed R39's medical record. The Progress Notes indicate the following: - 1/22/2023 at 21:56 (9:56 PM) R39 complained of loose stools, per R39 loose stool started a week ago. Writer informed on call Physician of the change in condition. Per Physician start on Vancomycin 250 mg 4x a day for 3 days, as soon as stool specimen has been obtained for C-Diff. If specimen comes back negative for C-Diff start on loperamide 2 mg 4x a day as needed for diarrhea, no more than 7 days. (R39) is aware of new order. At this time (R39) is alert and oriented able to make her needs known. - 1/23/2023 10:16 (10:16 AM) Writer spoke to staff regarding loose stools. Staff stating that (R39) has not had any loose stools noted. (R39) is assist of 1 for bowel and bladder assistance. Writer placed call to Physician regarding clarification on Vancomycin order. Physician in house at this time. Clarification of orders are start Vancomycin following stool specimen collection. Order inputted to collect stool specimen. Isolation bin placed outside of room at this time. -1/23/2023 21:56 (9:56 PM) (R39) had one small diarrhea this shift. C-Diff sample collected. Lab notified. -1/24/23 R39 C-Diff results were negative. R39 was not placed in isolation with potential C-Diff to prevent a possible outbreak until the following day. On 01/25/23 at 1:34 PM Surveyor spoke with the Infection Preventionist (IP)/Unit Manager UM-F, who is training a new IP-O. UM-F indicated they review the antibiotics the following day. They were not notified at the time of R39's symptoms. The facility staff will call the Manager On Call. The Manager On Call happened to be IP-O. IP-O indicated they were not notified and when they discovered the orders on 1/23/23 they placed R39 in isolation. There was no additional information on why R39 was not placed in Isolation when the physician was called. IP-O indicated that staff did not feel R39 had any diarrhea. On 1/25/23 at 3:00 PM Surveyor shared the concerns with isolation at the facility Exit Meeting. Administrator-A indicated IP-O was contacted about R39 and did not have further information.

Based on observation and interview the facility did not ensure safe, clean, comfortable, and homelike environment. This deficient practice was noted for 7 (R61, R52, R18, R26, R90, R32, and R199) of 22 Resident rooms reviewed for cleanliness. Findings include: On 1/26/23 at 12:40 PM, Surveyor interviewed Housekeeping/Laundry Supervisor (HLS)- I in regards to the observations of environmental concerns. HLS-I stated that a daily clean consists of emptying the garbage, wiping down the garbage can, cleaning all touch points like knobs, sweeping and mopping the room floor, cleaning the bathroom including sink and toilet and mopping the bathroom floor. HLS-I stated each Resident room gets a deep clean 2 times per month by moving all the furniture out, windows, and baseboards. HLS-I explained that each housekeeper has 28 Residents they are responsible for housekeeping for plus med rooms and bathrooms in the common area. Surveyor asked HLS-I if the department has been adequately staffed in order to keep the Resident rooms clean and comfortable. HLS-I stated that staffing has been colorful and there has been a high turnover. HLS-I confirmed the department has been running very short a lot. HLS-I stated that the department has been running with only 3 out of 7 staff. HLS-I explained that HLS-I has to be out on the floor now cleaning. HLS-I explained the following for a full staffed department: 3 for the floor 1 for PMs 1 for the common areas 1 for laundry 1 floor tech Weekends 3 housekeepers during the day 1 on PM-clean dining rooms, therapy, offices, dialysis, beauty shop, outside garbage, nurse's station, sweep and mop those areas HLS-I also informed Surveyor that there have been concerns about debris items under the bed by visitors and Residents and when we know about it, we clean it. HLS-I explained some rooms are cleaned a couple of times a day. 1.) On 1/23/23 at 9:52 AM, Surveyor observed R61's wheelchair cushion leaning against the wall with 2 large spots of smeared bowel movement (BM) on it. On 1/24/23 at 7:44 AM, Surveyor observed R61's cushion with 2 large spots of BM smeared on it leaning against the wall. On 1/24/23 at 11:35 AM, Surveyor observed food crumbs on the floor of R61's room. R61's over-bed table appeared to be sticky with some liquid spilled on it. Surveyor observed debris under the bed and a hanger on the floor. R61's soiled wheelchair cushion was observed still leaning against the wall. On 1/25/23 at 10:47 AM, R61 informed Surveyor R61 thought they took the cushion to put it in the washer. Surveyor observed R61's seat of their wheelchair to be very dirty full of food crumbs and dried spills in it. R61 agreed the seat of wheelchair is very dirty and does not remember the last time it has been cleaned. 2.) On 1/24/23 at 11:28 AM, Surveyor observed a large brown stain on the lower part of R52's privacy curtain. 3.) On 1/23/23 at 11:12 AM, R18 informed Surveyor that their toilet has been really dirty for a long time and R18 hates going on it like that. Surveyor observed smeared bowel movement inside of the toilet, smeared bowel movement on the floor, and on the toilet seat. Garbage was on the bathroom floor and various paper products were on the floor under R18's bed. On 1/25/23 at 3:48 PM, Surveyor shared the concern with Administrator(NHA-A) and Interim Director of Nursing(DON-B) the environmental concerns of R61, R18, and R52. No further information was provided by the facility. 6.) On 1/23/23 at 9:46 AM during initial pool observation, Surveyor observed R199's bedside table had 2 red liquid spills which appeared to be dry. On 1/23/23 at 1:01 PM Surveyor observed R199 eating lunch in bed. Surveyor observed the 2 red liquid spills, which appeared to be dry, remained on R199's bedside table. 7.) On 1/23/23 at 9:58 AM during initial pool observation, Surveyor observation of R32's room revealed crumbled crackers, wrappers and a cookie under her bed near the wall. The floor next to the right side of the bed was sticky with the appearance of a dried spill. R32's bedside table was observed to be dirty and sticky. On 1/24/23 at 12:30 PM Surveyor observation of R32's room revealed same crumbled crackers, wrappers and a cookie under her bed near the wall. The floor next to the right side of the bed remained sticky with the appearance of a dried spill. On 1/25/23 at 9:14 AM Surveyor observation of R32's room revealed some cracker crumbs has been cleared from under the bed, however most remained. Surveyor observed another plastic wrapper bag on the floor next to the bed near the wall. R32's floor next to the right side of the bed remained sticky with the appearance of a dried spill. On 1/25/23 at 3:00 PM Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were advised of the above concerns. No additional information was provided. 4.) On 1/23/23 at 10:22 AM Surveyor observed R90 in their bed. Between the wall and their bed was a few straws and a few debris items. On 1/25/23 at 9:39 AM Surveyor observed R90 in bed. There were 4 ceiling tiles by the wall above R90's bed that had brown colored stains. On 1/25/23 at 3:00 PM Surveyor shared the concerns at the facility exit Meeting. 5.) On 1/23/23 at 11:00 AM Surveyor observed R26 in their room. There was talcum powder all over the floor in front of the closet. They indicated the powder fell when staff assisted them with dressing this morning. On 1/25/23 at 3:00 PM Surveyor shared the concerns at the facility exit Meeting.

**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 4 of 7 (R34, R61, R8, and R90) residents reviewed for pressure injuries. *R34 developed a blister on their right heel that was identified on 12/8/2022. There was not a comprehensive assessment completed on R34's right heel pressure injury until 12/20/22. *R61 was identified to be at high risk for developing pressure injuries. R61 was observed without a cushion in their wheelchair during survey. *R8 was observed without their heels floated during survey per their plan of care. R8's air mattress was not being checked for function per shift. *R90 was identified to be at risk for developing pressure injuries. R90 was observed with their heels not floated off the mattress during survey per their plan of care. R90 was also observed with their feet against the foot board of their bed during survey. Findings Include: The Facility Policy and Procedure, entitled Pressure Injury Prevention and Management, dated 10/2022, documents (in part) . Policy: This facility is committed to the prevention of avoidable pressure injuries .and to provide treatment and services to heal the pressure injury/ulcer, prevent infection, and the development of additional pressure injuries. .C. Licensed nurses will conduct a full body skin assessment on all residents . after any newly identified pressure injury. Findings will be documented in the medical record. D. Assessment of pressure injuries will be performed by a licensed nurse and documented. .4. Interventions for Prevention and to Promote Healing 1. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. 2. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 3. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); il. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Provide non-irritating surfaces; and v. Maintain or improve nutrition and hydration status, where feasible. .6. Modifications of Interventions 1. Any changes to the facility's pressure injury prevention and management processes will be communicated to relevant staff in a timely manner. 2. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: ¡. Changes in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure injury development. iii. Lack of progression towards healing. iv. Resident non-compliance. v. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. 1.) R34 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis, Chronic Kidney Disease, and Vascular Dementia. R34's care plan, initiated 11/23/2020, documents, Skin integrity impairment; Actual. Decrease in safety awareness, history of skin problems, immobility, incontinence of bowel, incontinence of urine, history of multiple melanomas. The interventions section documents to assist in keeping my nails short/trimmed, assist me with my general hygiene and comfort measures, barrier cream used with incontinence cares, consult dietary for my nutritional needs, encourage and assist me to elevate my heels of the surface of the bed as needed, encourage and assist with repositioning frequently and as requested, encourage me to have fluids with meals and outside of meal times, encourage me to wear heel boots when in bed on; document refusals and advise nursing, extra encouragement needed to get washed up and changed, I have a Gel cushion/pressure reducing device in my WC, I need a low air loss mattress, keep my linen dry, clean, and free of wrinkles, keep my skin clean and dry, measure and document on skin area as per policy, monitor for all my protective devices that are in place, my skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment, offload pressure to my affected area(s), provide me with treatment as ordered per my orders, report any skin redness/impaired integrity areas to my nurse, and use barrier cream to prevent skin impairment issues, as needed. R34's Significant Change Minimum Data Set (MDS) assessment, dated, 11/3/2022 documents in section C (Cognitive Patterns) that the staff assessment for mental status indicates that R34 is severely cognitively impaired for daily decision-making skills. Section E (Behavior) documents that R34 does not exhibit rejection of care behaviors. Section G (Functional Status) documents that R34 requires extensive assist with one-person physical assist for bed mobility and personal hygiene. Section G also documents that R34 requires total assist with two plus person physical assist with transfers. Section M (Skin Conditions) documents R34 is at risk for developing pressure injuries. R34's Pressure Ulcer/Injury/ CAA (care area assessment), dated 11/3/22, documents that R34 has no pressure wounds. R34 is frequently incontinent of bowel and needs assist with incontinence cares. R34 is wheelchair bound and needs assist with transfers and positioning. Continue with care plan for weekly skin review, pressure reducing devices in place and barrier treatment after incontinence cares. R34's Nurse's Notes, dated 12/08/22, documented that a filled blister to right heel was found on R34 and that the skin was intact on the surrounding area. R34's physician was updated, a treatment was initiated, and R34's plan of care was updated. R34's weekly skin review, dated 12/8/22, documents a check mark next to blisters and that R34 has history of right heel blister which has reoccurred under right heel. R34's blister is filled, and skin is intact. Surveyor noted that there were no measurements of R34's pressure injury completed and there was not staging of R34's pressure injury completed. R34's Pressure Ulcer/Skin Breakdown Unavoidable Investigation/Review, dated 12/8/2022, documented bythe facility that R34's right heel pressure injury as unavoidable. Surveyor noted that there was no documentation of measurements of R34's pressure injury and there was no staging of R34's pressure injury. R34's Weekly Skin Review, dated 12/15/2022, documents a check mark next to blisters and blister to right heel remains. Surveyor noted that there was no documentation of measurements of R34's pressure injury and there was no staging of R34's pressure injury. R34's Weekly Wound evaluation, dated 12/20/22, documents R34 has a Right heel pressure injury, length 9 cm (centimeters) by 9cm. R34's right heel pressure injury is staged as a suspected deep tissue injury. Wound type is described as pressure ulcer identified on 12/8/2022 and documented no exudate and the wound color as Red. Peri wound is described as undefined. The comments section documents that R34 is seen by the nurse practitioner and that R34's chart was pulled to be seen by Wound MD L to assess and treat. Current wound status documents R34's heel pressure injury as being a blood-filled blister that is tender to the touch and that R34 tolerates offloading. Surveyor noted this is the first comprehensive evaluation of R34's pressure injury (12 days after it was identified) as it contains measurements and staging as a DTI (deep tissue injury). On 01/25/23 at 10:31 AM, Surveyor observed wound care provided to R34 with no concerns. On 01/25/23 at 12:07 PM, Surveyor interviewed Nurse Manager F. Nurse Manager F reported that the nurse that found R34's pressure injury on their right heel was an agency nurse. Nurse Manager F reported that the expectation is when a nurse identifies a new pressure injury on a resident, a comprehensive assessment should be completed. Nurse Manager F reported that assessment should include measurements and staging of the pressure injury. On 01/25/23 at 01:02 PM, Surveyor interviewed DON (Director of Nursing) B. DON B reported that the facility has a certified wound nurse, however they are on vacation out of state for 3 months. DON B reported that the expectation is that a comprehensive assessment with measurements and staging would be completed by a nurse when a pressure injury is found. Surveyor shared with DON B that Surveyor noted no measurements or staging of R34's pressure injury on their right heel that was identified on 12/8/22 until 12/20/22. On 01/25/23 at 01:58 PM DON B provided additional information to Surveyor which was the completed pressure ulcer/skin breakdown unavoidable investigation, dated 12/8/22. Surveyor reviewed the document and informed DON B that the provided document does not include measurements and staging of R34's pressure injury on their right heel. On 01/25/23 at 03:08 PM, Surveyor shared with DON B and NHA (Nursing Home Administrator) A regarding concerns that there was not a comprehensive assessment being completed on R34's right heel pressure injury, which was identified on 12/8/22, until 12/20/22. On 01/26/23 at 01:39 PM, Surveyor interviewed Wound MD L. Wound MD L reported to Surveyor that the facility had all interventions in place prior to the development of R34's pressure injury, so they believe that the development of R34's right heel pressure injury has a major arterial component. Wound MD L reported to Surveyor that R34's right heel pressure injury is currently stable. There was no further additional information provided by the facility. 3.) R8 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Chronic Kidney Disease, Stage 3, Type 2 Diabetes Mellitus, Epilepsy, and Adult Failure to Thrive. R8 has an activated Health Care Power of Attorney. Surveyor reviewed R8's admission Minimum Data Set (MDS) dated [DATE] and noted that R8's Brief Interview for Mental Status (BIMS) score of 14 indicates that R8 is cognitively intact for daily decision making. R8's MDS also documents that R8 is at risk for developing pressure injuries. R8's MDS documents that R8 requires extensive assistance for bed mobility, dressing, and hygiene. R8 requires total dependence for transfers and toileting. R8's MDS also documents that R8 has range of motion impairment on upper and lower extremity. Surveyor reviewed R8's signed Care Area Assessment (CAA) for potential for developing pressure injuries dated 11/17/22 and notes no specific interventions are documented. R8's care card as of 1/26/23 instructs certified nursing assistants (CNAs) with Bed Mobility to reposition in bed by using pillow to place R8's head in neutral position, heel protectors both sides, both upper extremities supported on pillows, reposition on a regular basis, may benefit from air mattress as unable to self-reposition, at risk for developing pressure areas. CNAs are also instructed with Resident Care that R8 needs low air mattress to protect the skin while IN BED. Surveyor reviewed R8's comprehensive care plan and notes the following focused problem: (R8) has potential impairment to skin integrity r/t hx (related to history) of pressure injuries, skin dry The following interventions are documented on R8's care plan: Encourage and assist to elevate heels off surface of the bed - 11/7/22 Encourage and assist with frequent repositioning - 11/7/22 Encourage good nutrition and hydration in order to promote healthier skin - 11/4/22 Keep my linen dry, clean, and free of wrinkles - 11/7/22 Keep skin clean and dry. Use lotion on dry skin - 11/7/22, Revised 12/8/22 My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment - 11/4/22 Report any skin redness/impaired integrity areas to my nurse - 11/4/22, Revised 12/8/22 The resident needs low air loss mattress to protect the skin while IN BED - 11/4/22 The resident needs pressure relieving cushion to protect the skin while up IN CHAIR - 12/1/22 Use barrier cream to prevent skin impairment issues, as needed - 11/4/22 Surveyor reviewed R8's current physician orders effective 1/25/22 and noted there is no physician order to check the APM (alternating pressure mattress) mattress function every shift. However, there is an order effective 11/4/22 for R8 to have a pressure relieving mattress to the bed. Surveyor reviewed R8's Treatment Administration Records (TARS) for November, December, and January, and noted there is documentation that R8's air mattress was checked for function every shift. On 1/23/23 at 10:52 AM, Surveyor observed R8's air mattress monitoring device indicating that the mattress was not turned on. R8 informed Surveyor that the air mattress is usually on and can hear it working. Surveyor also noted that R8's heels are not floated. Surveyor observed R8 in bed with the head of bed elevated. On 1/24/23 at 7:57 AM, Surveyor observed R8's air mattress monitoring device indicating that the mattress was not turned on. Surveyor noted the air mattress was not completely flat. Surveyor also noted that R8's heels are not floated. Surveyor observed R8 in bed with the head of bed elevated. Surveyor noted that R8's bare feet are against the foot board. On 1/24/23 at 2:08 PM, Surveyor observed R8's air mattress device setting set to 5. Surveyor also observed the service light was on. Surveyor also noted that R8's heels are not floated. Surveyor observed R8 in bed with the head of bed elevated. Surveyor noted that R8's bare feet are against the foot board. On 1/25/23 at 8:17 AM, Surveyor observed R8's air mattress device setting set to 5. Surveyor also observed the service light is on. Surveyor also noted that R8's heels are not floated and are located directly on the mattress. Surveyor observed R8 in bed with the head of bed elevated. Surveyor noted that R8's bare feet are against the foot board with toes directly on the footboard. R8 informed Surveyor at this time that the air mattress is working much better than it has been and is comfortable On 1/25/23 at 8:25 AM, Certified Nursing Assistant (CNA-H) confirmed that R8's heels are not floated and the air mattress indicates the service light is on. On 1/25/23 at 10:54 AM, Surveyor observed R8's heels not being floated while in bed, the air mattress is set to 5, and R8's bare toes are pushed directly against the footboard. Surveyor interviewed R8 who stated R8's toes pushing against the footboard is very uncomfortable and R8 confirmed they have no open areas. However, R8 did not know they could tell someone about feeling uncomfortable with their toes pressing on the footboard. On 1/25/23 at 1:26 PM, Nurse Manager (NM-E) informed Surveyor that the setting on the air mattress is based on a Resident's weight. NM-E stated that a licensed nurse is supposed to check the functioning of an air mattress, like the one R8 has, every shift and record on the TARS. NM-E confirmed that R8's air mattress function has not been checked and stated it needs to be added to the TARS. On 1/25/23 at 3:50 PM, Surveyor shared the concern of R8's heels not being floated per care plan, R8's air mattress not on during the survey process and not checked for function, and R8's toes resting directly on R8's footboard. Surveyor shared the service light is on on the device for R8's air mattress. Surveyor shared this with Administrator (NHA-A) and Director of Nursing (DON-B). DON-B explained that if the air mattress is turned off, when turned back on, the device will automatically go back to the original setting. No further information was provided at this time and both NHA-A and DON-B understood the concern. On 1/26/23 at 9:16 AM, DON-B provided statements from staff that R8's air mattress was full of air. Surveyor noted that during the survey process, R8's air mattress was not completely flat, however, R8's air mattress device indicated it was not on, on 1/23/23 and the morning of 1/24/23. On the afternoon of 1/24/23 and 1/25/23, R8's air mattress device had the service light not on, indicating the air mattress may not be operating at full capacity. Surveyor noted that the facility has indicated the air mattress function should be documented per shift which R8's electronic medical record (EMR) does not indicate this was done along with R8's heels not being floated according to R8's care plan during the survey process. 4.) R61 was admitted to the facility on [DATE] with diagnoses of Kidney Transplant Status, Chronic Obstructive Pulmonary Disease, Immunodeficiency, Type 2 Diabetes Mellitus with Hyperglycemia, Anorexia, Abnormal Weight Loss, Unspecified Dementia and Depression. R61 has an activated Health Care Power of Attorney (HCPOA). Surveyor reviewed R61's Quarterly Minimum Data Set (MDS) dated [DATE] and noted that R61's Brief Interview for Mental Status (BIMS) documents R61 has a score of 10, indicating that R61 demonstrates moderately impaired skills for daily decision making. R61's MDS also documents that R61 requires extensive assistance for bed mobility, transfers, dressing, and hygiene. R61 requires limited assistance for toileting and R61 has no range of motion impairment. Surveyor reviewed R61's comprehensive care plan and noted R61 has a focused problem for the potential for skin impairment dated 4/8/22 The following interventions are documented on R61's care plan: Encourage and assist with repositioning frequently and as requested - 5/4/22 Encourage good nutrition and hydration in order to promote healthier skin - 4/8/22 Encourage me to off my load heels - 5/4/22 Keep my linen dry, clean, and free of wrinkles - 5/4/22 Keep skin clean and dry. Use lotion on dry skin - 5/4/22 My skin will be assessed on a weekly basis on my scheduled bath day and document findings on a weekly skin assessment - 4/8/22 Report any skin redness/impaired integrity areas to my nurse. The resident needs pressure reducing cushion to protect the skin while up IN CHAIR - 4/20/22 The resident needs pressure reducing mattress to protect the skin while IN BED - 4/20/22. Use barrier cream to prevent skin impairment issues, as needed - 4/8/22 Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface - 6/15/22 Surveyor reviewed R61's 'Care Card' and noted that it instructs CNAs for Resident Care that R61 needs pressure reducing cushion to protect the skin while up IN CHAIR. Surveyor reviewed R61's current physician orders dated 1/26/23 and noted that R61 has an order to apply barrier cream to buttocks as needed for protection, effective 11/28/22. On 1/23/23 at 9:52 AM, Surveyor observed R61's wheelchair cushion leaning against the wall with 2 large spots of smeared bowel movement (BM) on it. Surveyor observed R61 sitting in a wheelchair with no cushion in it. On 1/24/23 at 7:44 AM, Surveyor observed R61's cushion with 2 large spots of BM smeared on it leaning against the wall. On 1/24/23 at 11:35 AM, Surveyor observed R61 in R61's wheelchair, sitting directly on the seat of the wheelchair with no cushion in the wheelchair. On 1/25/23 at 10:47 AM, Surveyor interviewed R61 in regard to their wheelchair cushion. R61 stated the following: I think they took the cushion to put in the washer. R61 stated it is very uncomfortable to be sitting in the wheelchair with no cushion in the chair. On 1/25/23 at 3:48 PM, Surveyor shared the concern with Administrator (NHA-A) and Interim Director of Nursing (DON-B) that R61 has not had a wheelchair cushion to help prevent skin breakdown while up in the wheelchair during the survey process. 2.) On 1/23/23 at 10:17 AM Surveyor observed R90 in their bed. R90 indicated they have a wound on their bottom. Surveyor noted R90 has an air mattress on their bed with their lower extremities uncovered. Surveyor observed R90 has gripper socks on their feet. The right heel is against the mattress and the left foot off of the bed. Surveyor observed the right top of the foot was touching the foot board. On 1/24/23 at 11:31 AM Surveyor observed R90 In bed asleep. R90's feet were exposed and bare. The right heel was against the mattress and the left foot was observed hanging off the mattress. R90's Wound Assessments were reviewed. On 1/12/23 R90 was assessed as having a wound abscess on the left buttock and a stage 3 pressure injury on the sacrum. R90 requires staff assist for positioning in bed. The assessments also indicate to off load heels. On 1/25/23 at 9:19 AM Surveyor observed (Unit Manger) UM-F complete wound treatments on R90 in bed. R90 had their right foot on a pillow with the ball of their foot on the foot board. The left heel was on the side of the mattress. UM-F indicated R90 was on another unit before being transferred to this room. They do not know about an extended bed due to R90's feet touch the foot board. After the treatment UM-F assisted R90 in bed. R90 needed rest periods with any positioning. R90 did boost self up in bed using transfers bars. UM-F raised the head of the bed and raised the lower section. They placed a pillow under both of R90 legs. R90's heels still rested on the mattress and the balls of their feet were touching the foot board. On 1/25/23 at 3:00 PM at the facility Exit Meeting Surveyor shared the concerns with R90's feet. On 1/26/23 at 8:54 AM DON-B (Director of Nurses) spoke with Surveyor sharing they did add a bed extender to R90's bed.

Based on observation, facility policy and procedure review, and interview, the facility did not ensure a safe smoking environment for residents and visitors. This had the potential to effect all 7 (R150, R55, R300, R42, R29, R17 and R54) of 7 assessed resident smokers. This also had the potential to effect anyone that utilized the designated smoking area for the facility. The facility designated smoking area did not include a fire extinguisher, nor did the facility lobby area. There were observations of individuals smoking in the designated area and in front of the facility entrance. Findings include: The facility policy and procedure for Smoking, dated 10/10/22, was reviewed by Surveyor. This procedure includes that there is to be a fire extinguisher in the designated smoking area; and there is to steps to minimize second hand smoke to families, staff, and other residents. On 1/24/23 at 11:29 AM Surveyor observed the designated smoking area. Surveyor did not observe a fire extinguisher. On 1/24/23 at 12:03 PM Surveyor observed a resident and visitor smoking in the designated area. There is no fire extinguisher in the designated area. Surveyor observed R29 and R54 smoking in front of the facility entrance independently in their wheelchairs. There is no fire extinguisher in the front lobby area off the entrance to the facility and R29 and R54 were not utilizing the designated smoking area. On 1/25/23 at 8:13 AM Surveyor spoke with (Housekeeping Supervisor) HS-I. HS-I cleans the smoking area twice a week. Once a month the cigarette butt receptacles are emptied. HS-I has not seen any fire extinguisher and that would be maintenance. On 1/25/23 at 8:38 AM Surveyor spoke, and observed the smoking area, with (Maintenance Director) MD-N. MD-N was not aware of having a fire extinguisher in the smoking area. MD-N shared there is a fire blanket by the front entry way of the facility. It was observed this is hanging above eye level when standing. There is not a fire extinguisher in the front entryway. MD-N indicated they will look for a fire extinguisher and did not know they needed one. On 1/25/23 at 3:18 PM Surveyor shared the smoking concerns at the facility Exit Meeting. Administrator-A indicated they used to have a fire extinguisher in the smoking area and front lobby. They don't know what happened to them and they will replace them today.

Based on observation, interview, and record review, the facility did not ensure medications requiring refrigeration were stored at the appropriate temperature for 2 of 3 medication room refrigerators reviewed. This has the potential to affect 9 (R74, R17, R15, R85, R82, R11, R67, R8, and R39) of 9 residents observed to have medications stored in medication room refrigerators. *Observation of the second-floor east medication room refrigerator temperature log documented the facility was not monitoring the medication room refrigerator temperature daily to ensure proper storage of medications that require refrigeration. Monitoring was not completed for 5 days in the month of January. Surveyor also observed 8 cans of alcoholic beverages being stored in the medication room refrigerator with medications labeled for resident use. *Observation of the first-floor west medication room refrigerator temperature log documented the facility was not monitoring the medication room refrigerator temperature daily to ensure proper storage of medications that require refrigeration. Monitoring was not completed for 17 days in the month of January. Findings Include: The facility policy, entitled Storage of Medication Requiring Refrigeration, with a revision date of 10/2022, states (in part) .: Policy: It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent alteration of the medication by exposure to improper temperature controls . 4. Refrigerators used for the storage of medications and biologicals: a. Used solely for the purpose of storing medications and biologicals that require refrigeration according to manufacturer's instructions. b. Not used for food, blood or blood products or specimen storage. .f. Temperature to be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of person performing the check clearly written . On 01/26/23 at 09:57 AM, Surveyor observed the second-floor east medication room at the facility. Surveyor observed the refrigerator located inside the medication room. Surveyor observed the temperature of the refrigerator to be 38 degrees Fahrenheit. Surveyor noted several medications labeled for resident use including insulin pens. Surveyor noted the temperature log on the cabinet door above the refrigerator. Surveyor noted January 18th, 19th, 21st, 22nd, and 23rd were blank and did not document a temperature of the medication room refrigerator for those dates. Surveyor noted the medication log instructions documented that day shift personnel are to check temperature of refrigerator and record the temperature. Surveyor observed 8 cans of alcoholic beverages being stored in the refrigerator with medications labeled for resident use. Surveyor observed the following medications in the second-floor east medication room refrigerator. Lispro Insulin 100 u/mL (units/milliliter) for R74. Novolog Insulin 100 u/mL for R17. Aspart Insulin 100 u/mL for R15. MMR (Measles, Mumps, and Rubella) vaccine vial for R85. Acetaminophen 650 mg (milligrams) suppositories for R82. On 1/26/23 at 10:15 AM, Surveyor observed the first-floor west medication room at the facility. Surveyor observed the refrigerator located inside the medication room. Surveyor observed the temperature of the refrigerator to be 34 degrees Fahrenheit. Surveyor noted several medications labeled for resident use including insulin pens. Surveyor noted the temperature log on the cabinet door above the refrigerator. Surveyor noted January 4th, 5th, 8th, 9th,10th,11th,13th,14th,16th,17th, 19th, 20th, 21st, 22nd, 23rd, 24th, and 25th were blank and did not document a temperature of the medication room refrigerator for those dates. Surveyor observed the following medications in the first-floor west medication room refrigerator. Omeprazole 2 mg/ml (milligrams/milliliter) for R11. Humalog Insulin 100 u/ml for R67. Lispro Insulin 100 u/ml for R8. Shingrix vial for R39. On 01/26/23 at 10:29 AM, Surveyor interviewed Nurse Manager E who reported that night shift should be checking the temperatures of the medication room refrigerators daily and no other items should be kept in the medication room refrigerators besides medications. On 01/26/23 at 10:35 AM Surveyor interviewed DON (Director of Nursing) B. DON B reported that temperatures of the medication room refrigerators should be checked daily and should be done by night shift. DON B reported that nothing besides medications should be stored in the medication room refrigerators. Surveyor shared concerns with DON B regarding the incomplete temperature logs for the medications room refrigerators on the second floor east and first floor west medication rooms. Surveyor also shared with DON B that alcoholic beverages were observed in the second floor east medication room refrigerator. DON B reported that the unit managers should be checking the medication rooms daily to ensure proper storage. There was no additional information provided by the facility.