**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures when staff did not report an incident of caregiver neglect to the administrator immediately for 1 of 3 residents (R) reviewed for abuse and neglect. (R20) Findings include: R20 was admitted to the facility on [DATE] with diagnoses including, in part, cerebral palsy, unsteadiness on feet, absence epileptic syndrome, and lichen simplex chronicus. R20's Minimum Data Set (MDS) assessment, dated 01/03/24, identified that R20 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R20 had significant cognitive impairment and was unable to perform an accurate BIMS. The MDS assessment also identified R20 required extensive assistance of two people for bed mobility and toileting and was dependent on two people for transfers. R20's care plan included: -Mobility plan: I transfer with the assistance of two and Hoyer lift, 03/12/24. On 06/19/24 at 10:34 AM, Surveyor interviewed Certified Nurse Assistant (CNA) G who indicated that CNA M had transferred R20 by CNA M's self in February and dropped R20 on the floor. CNA G indicated that CNA M had tripped over R20's non-functional leg and dropped R20 on the floor. CNA G indicated that R20 suffered a swollen hip due to the fall but that no one reported the fall to the appropriate personnel. Surveyor asked CNA G if CNA G reported this incident to the administration, and CNA G indicated that CNA G did let DON B know about CNA M dropping R20 on the floor. CNA G indicated that CNA M keeps transferring residents alone who are ordered to be assisted by 2 or mechanical Hoyer lifts instead of receiving assistance with resident transfers. On 06/20/24 at 7:41 AM, Surveyor interviewed CNA M with another Surveyor present and asked to explain the process with R20 and the fall that occurred in February. CNA M indicated that CNA M did drop R20 during a stand pivot transfer in February. CNA M indicated CNA M does not remember the exact day in February that R20 fell but that it was on the day shift. CNA M indicated that CNA M was transferring R20 with a walker and gait belt. R20's foot went dead, CNA tripped on leg and then CNA M and R20 both fell to the ground. CNA M indicated that CNA M reported this to Registered Nurse (RN) L right away. CNA M indicated that RN L came in and assessed R20. CNA M indicated that R20 did not receive any injuries that CNA M was aware of and then therapy came and assessed R20. CNA M indicated that therapy deemed R20 to be a transfer with a Hoyer lift only. On 06/20/24 at 7:52 AM, Surveyor interviewed RN L and asked if RN L was aware of R20's fall in February. RN L indicated that RN L was aware of R20's fall. Surveyor asked RN L if RN L remembers what RN L's process was for post-fall assessment and reporting the fall. RN L indicated that RN L received notice from CNA M that R20 had fallen in R20's room during CNA M transferring R20. RN L was unaware of who helped CNA M transfer R20 as R20 was assist of 2 transfers at that time. On 06/20/24 at 10:01 AM, Surveyor interviewed Physical Therapy Assistant (PTA) N and asked what R20's transfer status was in February 2024. PTA N indicated that R20 has always been an assist of 2 pivot transfer when feeling strong or assist of 2 with mechanical Hoyer lift. On 06/20/24 at 10:53 AM, Surveyor interviewed DON B and asked if staff had reported CNA M transferred R20 alone when R20 needed assist of 2 for R20's fall in February. DON B indicated that DON B was not aware of R20 falling due to improper transfer technique. The only incident that was known was CNA M indicated that CNA M injured CNA M's foot by tripping over the wheelchair pedal in R20's room in February. DON B indicated that if a resident has fallen, staff need to report the fall right away to the charge nurse, charge nurse assesses the resident, provides proper interventions and investigate the root cause. This would determine if caregiver neglect occurred with the transfer. DON B indicated there was no documentation of R20 falling in February, the CNA misconduct was not reported to administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility policy titled General Care of Residents, revised on 06/2018, stated in part . 9. Call Lights a. Staff will respond to call lights timely. b. If responding to a call light and you are assisting another resident, inform the resident you are assisting another resident and will return shortly and turn off call light. c. If other departmental staff answers call lights, let the resident know that you will tell the nursing staff and turn off the call light. R4 was admitted to the facility on [DATE]. Diagnoses included heart failure, cellulitis of upper limb, chronic kidney disease, chronic obstructive pulmonary disease, and shoulder pain. R4 was admitted with a stage 1 pressure injury to right buttock. Minimum Data Set (MDS) assessment, dated 06/06/24, confirmed R4 scored 10/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R4's MDS assessment reported R4 is frequently incontinent of urine and always incontinent of bowel. R4 required substantial assistance with toileting, showering, and dressing, and was dependent on staff for transfers with mechanical hoyer lift. R4's care plan included: -Toileting plan: I am on a toileting schedule. Take me upon rising, before meals, after meals, bedtime, and as needed during the night, 05/31/24. The following occurred on 06/19/24 during a continuous observation from 10:22 AM-11:41 AM, for 79 minutes: -10:22 AM, Surveyor observed R4 in his room, sitting in a Broda chair. Surveyor observed R4's call light was on and R4 was calling out stating he needed to use the bathroom. -Between 10:22 AM and 10:35 AM, Surveyor observed physical therapy staff walk past R4's room twice. Surveyor observed Director of Nursing (DON) B walk past R4's room twice. Surveyor observed Certified Nursing Assistant (CNA) G walk past R4's room twice. -10:41 AM, Surveyor observed Licensed Practical Nurse (LPN) I walk past R4's room. -10:44 AM, Surveyor observed LPN H walk past R4's room. -10:46 AM, Surveyor observed CNA J enter R4's room. R4 stated to CNA J he needed to use the bathroom. CNA J told R4 she would let someone know and she would be back. CNA J left R4's call light on. Surveyor observed CNA J tell CNA G R4 needed to use the bathroom. -10:47 AM, Surveyor observed ADON F walk past R4's room. -10:50 AM, Surveyor observed CNA C and CNA D walk past R4's room. -10:52 AM, Surveyor observed CNA G and CNA J walk past R4's room. -10:54 AM, Surveyor interviewed CNA G. CNA G reported she was not assigned to R4's hall. CNA G stated she is working on the other hallway training CNA J. CNA G stated she assists on R4's hallway as she can as it is a heavy hall, but not all staff assist with answering resident call lights in unassigned areas. CNA G stated, With charting, no, I am not able to complete all of my workload. Surveyor observed CNA G and CNA J walk towards R4's room, where R4's call light was on. Surveyor observed CNA G and CNA J exit the hallway through a door immediately adjacent to R4's room. CNA G stated, We are finally going on break. Surveyor observed R4's call light continued to be on. -10:58 AM, Surveyor observed ADON F walk past R4's room. -11:03 AM, Surveyor observed DON B walk past R4's room. -11:05 AM, Surveyor observed LPN I entered R4's room. R4 stated he needed to use the bathroom. LPN I turned off R4's call light and stated to R4 she would tell the staff. -11:17 AM, Surveyor observed R4's call light was off. Surveyor interviewed R4, R4 stated he needed to use the bathroom, and no one had helped him. Surveyor encouraged R4 to use his call light to request staff assistance. R4 did engage his call light and stated, It doesn't do any good anyway. -11:21 AM, Surveyor observed DON B enter R4's room. R4 stated he needed to use the bathroom. DON B turned off R4's call light and told R4 she would let staff know. Surveyor observed DON B tell CNA C and CNA D R4 needed to use the bathroom. -11:27 AM, Surveyor interviewed LPN I. LPN I stated she told CNA C R4 needed to use the bathroom, after she answered R4's call light at 11:05 AM. -11:34 AM, Surveyor observed R4 was calling out from his room. Surveyor interviewed R4, R4 stated he still needed to use the bathroom. Surveyor encouraged R4 to use his call light to ask for assistance. R4 engaged his call light. -11:35 AM, Surveyor observed DON B enter R4's room. R4 stated he needed to use the bathroom. DON B left R4's call light on, exited his room, and updated CNA C and CNA D R4 needed to use the bathroom. -11:41 AM, Surveyor observed CNA D and CNA G assist R4 with mechanical lift transfer to his bed. Surveyor observed CNA D and CNA G assist R4 with incontinence care of both bowel and bladder. On 06/20/24 at 1:42 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported the facility considers resident acuity when developing staffing patterns. NHA A reported staffing is discussed each morning during the facility's morning meeting, and stated, We move things around based on what is discussed in morning meeting, admissions, discharges, change in condition. Surveyor reported to NHA A the observation of R4 requesting to use the bathroom and not receiving assistance for 79 minutes. NHA A did not make any statements related to the incident. Based on observations, interviews and record reviews, the facility failed to provide the necessary services for 2 of 6 sampled and supplemental sampled residents (R9, R4) to maintain good grooming, toileting and personal hygiene. This is evidenced by: The facility policy and procedure titled General Care For All Residents includes the following directives to staff: - The resident shall be kept clean and dry - Staff will respond to call lights timely Example 1 R9 has medical diagnoses that include but are not limited to, diabetes mellitus type 2, a recent cerebral infarction (3/6/24), unspecified depression and dementia. According to the most recent MDSA (Minimum Data Set Assessment), which was a Significant Change in Status Assessment with an Assessment Reference Date of 3/18/24, R9 has impaired short-term and long-term memory and severely impaired daily decision making abilities. R9 has no behavioral or mood indices. Also according to this assessment, R9 required partial to moderate assistance of staff for moving from sitting to lying and lying to sitting positions to the side of the bed and is dependent on staff for toileting hygiene, upper and lower body dressing and personal hygiene. R9 is transferred with the use of a full body mechanical lift with the assistance of two staff and is frequently incontinent of bladder function and always incontinent of bowel function. Surveyor reviewed the Comprehensive Care Plan (CCP) completed for R9 and noted the following: 1. Activities of Daily Living (initiated 4/17/23 and last revised 4/30/24): Interventions included: - I need staff assist of 1 with dressing. (4/17/23) - I need the assist of two with the Hoyer (3/12/24) - I need partial assist from staff with grooming. (4/17/23) 2. I am both continent and incontinent of bowel and bladder (initiated 4/25/23 and last revised 4/30/24) Interventions for this problem included: - Scheduled toileting: every 2 hours and PRN (as needed) - Staff assist of 2 with hoyer to assist me with transferring on and off toilet/commode. Also noted, staff no longer place R9 on a toilet to allow for normal evacuation of the bladder and bowel. Instead, observations have shown that R9 is a check and change, in which R9 is placed onto the bed and the soiled incontinent brief is changed and perineal cleansing is completed. This was not updated on the CCP. 3. I have impaired mobility . (initiated 4/25/23 and last revised 6/3/24): Interventions for this problem included: - Anticipate needs, such as toileting. - I need assist of 1 with turning and repositioning in bed. - I use a Broda chair to get to destinations. I am dependent on staff with chair mobility 4. I am at risk for falls . (initiated 4/25/23 and last revised 4/30/24): Interventions included: - Anticipate and meet my needs (4/25/23) - Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance (4/25/23) - Assist to eh bathroom every two hours and as needed (6/16/23) 5. The resident had a cerebral vascular accident (3/12/24) Interventions include: - Monitor and document bowel and bladder function. If incontinent, monitor and document for appropriate bowel and bladder training program and implement. A bowel and bladder training program has not yet been attempted for R9. On 6/19/24, Surveyor made the following observation of R9: - At 7:18 AM, R9 was up in the Broda chair in her room. R9 was sitting on the mechanical lift sling and a small blanket covered R9's lap. R9 was positioned at 90 degree angles from back to hips, from hips to legs and from knees to ankles. - At 7:58 AM, R9 was taken to the Main Dining Room (MDR) and placed at a table in preparation for the morning meal. R9 was served her meal at 8:02 AM by Nursing Student (NS) K, who sat beside R9 and fed her the meal. - At 9:10 AM, R9 completed the meal and was propelled to a small television/bird aviary room by NS K. R9 remained here until 10:38 AM, at which time Activity Director (AD) E approached and offered an activity of exercise. R9 affirmed a desire to attend and AD E propelled R9 to the MDR for a small group activity. Surveyor remained throughout this activity to observe R9's participation level and the assistance provided by activity staff. R9 remained in the MDR activity until 11:03 AM. There were no offers yet attempted by staff to assist R9 to the toilet or change the incontinent brief. - At 11:03 AM, AD E propelled R9 to the small activity room for nail care. R9 remained in this activity until 11:40 AM. - At 11:40 AM, Licensed Practical Nurse (LPN) H propelled R9 to her room in order to screen the resident's blood sugar. No attempts to toilet R9 were offered. At 11:43 AM, Surveyor interviewed Certified Nursing Assistant (CNA) C regarding R9's needs with toileting and repositioning. CNA C was one of two staff responsible for R9's care on this day. CNA C stated that R9 was incontinent of bowel and bladder and required total care. CNA C stated R9 is unable to do any activities of daily living on her own and is dependent on staff and required repositioning and toileting every two hours. Surveyor then asked CNA C why R9 was not offered or attempts were made to assist R9 to the toilet yet on this morning. CNA C stated, I am trying, things have been happening down here, extra alarms are going off, I'm just busy. All I can say is that I am trying. CNA C mentioned to the Surveyor that she informed her nurse (LPN H) that they were behind in cares and needed help. Surveyor then interviewed LPN H at 11:48 AM and asked who was responsible to ensure resident's care was being provided according to the written care plan. LPN H stated, It's us, the nurses. I'm sorry. I have been trying to get them to not schedule two new ones (aides) together, but it happens. Surveyor asked LPN H if the CNAs have mentioned anything to her that staff were falling behind in providing cares. LPN H stated that she has been trying to assist the CNAs but, . when I go in to help, the other CNA comes in. No toileting or repositioning was yet completed for R9, even with Surveyor's questioning. - At 11:57 AM, CNA C and CNA D entered R9's room to assist the resident onto the bed with the use of the full body mechanical lift. The resident was assisted onto the bed at 11:59 AM, at which time, staff removed the incontinent brief. The brief was wet with urine and feces. This was 4 hours 41 minutes in which R9 was not offered or assisted with toileting. R9's buttocks was red and wrinkled from the wetness of the urine and feces. Surveyor then asked CNA C and CNA D what the normal staffing was for this hall, in which R9 resides. Both staff indicated there is normally two on this hall and two on the adjacent hall with one additional staff assigned to float between the two halls. Surveyor asked what was different today, in which they could not complete cares as assigned. Both staff indicated they have been on staff for only one month. The two staff also stated there was a call in today and a new staff (CNA J) assigned on the adjacent hall, which was only her third day working. Surveyor then asked who is responsible for staffing the floors to ensure residents are receiving the care they need. Both indicated that Director of Nursing (DON) B completed the staffing schedules. At 12:15 PM, Surveyor interviewed DON B and asked how she decided on the staffing for this date, with three new CNAs and only one seasoned CNA working. DON B stated that CNA C has over 20 years experience as a CNA and she assigned CNA D to work with CNA C, as she needed a strong CNA to guide CNA D, who did not have any experience as a caregiver and required much direction. DON B further stated there are two CNAs assigned to each hall with one additional CNA as a float between the two halls. DON B assigned CNA J to work with CNA G on a less difficult hall, as CNA J is an orientee for the third day. DON B indicated the staffing on this day is normal. DON B further stated that it was the responsibility of the nurses on the hall to ensure residents are receiving care according to their written care plans. DON B also stated that no staff approached her to inform her that the CNAs were behind on cares. Surveyor then asked DON B what the repositioning and toileting needs for R9 were. DON B stated that R9 was to be toileted every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R5 was admitted to the facility on [DATE] with diagnoses including, in part, scoliosis, spastic quadriplegic cerebral palsy, pressure ulcer of the right upper back, dysphagia, and fistula of the intestine. R5's Minimum Data Set (MDS) assessment, dated 06/05/24, identified that R5 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R5 had significant cognitive impairment and was unable to perform an accurate BIMS. The MDS assessment also identified R5 required extensive assistance of two people for bed mobility, and toileting and was dependent on two people for transfers. R5's care plan included: -Mobility plan: I need the assistance of one or two to turn, reposition, and boost in bed, 01/08/24. -Pressure area to Right shoulder plan: Up in chair at 10 am for 1 hour. The following occurred on 06/19/24 during a continuous observation from 9:01 AM-1:05 PM, for 4 hours and 4 minutes. -On 06/19/24 at 9:01 AM, Surveyor observed CNA G enter R5's room. Surveyor observed podus foot protectors on, but the knee pad was located down at the end of R5's bed near R5's feet. CNA G rolled R5 to the right side and washed the peri area. CNA G rolled new chuck and brief under R5. CNA G rolled R5 back to the left side. CNA G cleaned peri area thoroughly and dried it, then applied powder to the area. CNA G attached brief and then boosted R5 up in bed. CNA G turned R5 onto R5's back and placed a pillow semi-under R5's left shoulder. Surveyor observed R5 supine on the back with pressure to the right scapula. CNA G applied covers to R5 and raised the head of the bed. -On 06/19/24 at 11:24 AM, Surveyor observed R5 in a supine position with the right scapula pressing into the bed. On 06/19/24 at 1:05 PM, Surveyor observed Registered Nurse (RN) F and CNA G enter R5's room. Surveyor observed podus foot protectors on, but the knee pad was still down at the end of the bed near R5's feet. CNA G changed R5 and rolled from side to side to change. Surveyor interviewed CNA G on why knee pad was down at the end of R5's feet. CNA G indicated that someone did not place the knee pads between the knees and left the knee pad at the bottom of R5's feet. CNA G then grabbed knee pad and placed in between R5's knees. CNA G placed R5 on the back and placed a pillow semi-under R5's left shoulder. Surveyor observed R5 placed on a supine position on back with pressure to the right scapula. -On 06/19/24 at 1:12 PM, Surveyor interviewed CNA G and asked if CNA G had been in R5's room to reposition or perform incontinent care since the morning at 9:01 AM. CNA G indicated that CNA G has not been in there since CNA G and Surveyor were in R5's room at 9:01 AM on 06/19/24 and then when CNA G went in with RN F to complete wound dressing change. CNA G indicated that CNA G is doing CNA G's best and trying to perform tasks that are needed. CNA G indicated that it is hard when I am alone on a heavy hall and have an orientee who is not fully trained to know what to do with all the residents. On 06/20/24 at 12:52 PM, Surveyor interviewed RN F and asked about the repositioning and roho cushion on R5's bed. RN F indicated that R5 should still be repositioned every two hours as the roho cushion is just an additive measure to help further decrease pressure injury. On 06/20/24 at 1:02 PM, Surveyor interviewed DON B and asked about the expectation of repositioning R5. DON B indicated that staff should reposition R5 at least every two hours. DON B indicated that R5 should be repositioned and off-loaded for at least a couple minutes at a time every 2 hours. DON B indicated that CNA G should have repositioned and performed incontinent care to R5 at least every two hours. Example 3 R27 was admitted to the facility on [DATE] with diagnoses including, in part, infection and inflammatory reaction due to unspecified internal joint prosthesis, urinary tract infection, obstructive and reflux uropathy, type 2 diabetes, unspecified dementia, and pyogenic arthritis. R27's MDS assessment, dated 03/27/24, identified that R27 had a BIMS score of 09. This indicated that R27 had significant cognitive impairment. The MDS assessment also identified R27 required extensive assistance of one to two people for bed mobility, and toileting and was dependent on one person for stand pivot transfers. R27's care plan included: -Mobility plan: I need the assistance of 1 to turn, reposition and boost in bed, 04/30/24. -ADL plan: Before getting out of bed, don podus boot and knee brace to right lower extremity, 02/16/24. -When in bed resident to use blue puffy boots to right lower extremity, 02/16/24. -Potential for pressure ulcer development plan: Immobilizer to the right leg when up, remove every shift to check skin, 04/30/24. -The resident requires an air/float mattress to the bed and, a pressure reduction cushion to a wheel chair. Podus boot to right foot at all times, 02/05/24. R27's physician orders include: - Inspect right heel daily for any breakdown and monitor. - Right heel- Clean with NS, apply Mepilex for prevention of recurrence of pressure ulcer. Monitor heel for any sx recurrence every day shift. On 06/18/24 at 9:55 AM, Surveyor observed R27 lying in bed on R27's back with bilateral heels lying directly on the bed. Surveyor did not observe Podus boot on the right foot. R27's Podus boots were lying in the chair across the room. On 06/18/24 at 12:25 PM, Surveyor observed R27 lying in bed on R27's back with bilateral heels lying directly on the bed. Surveyor did not observe podus boot on the right foot. R27's Podus boots were lying in the chair across the room. On 06/19/24 at 11:01 AM, Surveyor observed R27 sitting in R27's wheelchair with R27's right foot on the pedal of R27's wheelchair. R27's right foot had a gripper sock on, but Surveyor did not observe Podus boot on the right foot. On 06/19/24 at 11:24 AM, Surveyor interviewed Licensed Practical Nurse (LPN) I and asked if R27 is supposed to have Podus boot on R27's right foot. LPN I reviewed physician orders and indicated that R27 is to have Podus boot on at all times. On 06/19/24 at 12:57 PM, Surveyor observed R27's feet bilateral lying flat on the floor while R27 was sleeping in R27's wheelchair. Surveyor did not observe Podus boot on the right foot. Podus boots were across the room lying on a chair. On 06/19/24 at 1:51 PM, Surveyor observed R27 lying in bed with bilateral heels flat on the bed without Podus boots on. Surveyor observed Podus boots in the chair across the room. On 06/19/24 at 1:55 PM, Surveyor interviewed CNA G and asked if R27 was supposed to have Podus boots on while R27 was in bed to protect the heels. CNA G indicated that R27 is supposed to have Podus boots on while in bed and R27 does not at this time. Surveyor observed CNA G enter R27's room and place Podus boots on R27 while in bed. On 06/20/24 at 12:01 PM, DON B handed Surveyor progress notes for skin assessments. Surveyor reviewed that R27's right heel wound healed back in March and then reopened 05/30/24. On 06/20/24 at 1:02 PM, Surveyor interviewed DON B and asked the expectations of R27 wearing Podus boots for heal protection to the right foot. DON B indicated that R27 should have Podus boots in place but sometimes R27 refuses. DON B asked Surveyor if R27 refused Podus boots during Surveyor's observations. Surveyor indicated that Podus boots were not offered to R27 during Surveyor's observations of R27's care. Surveyor indicated to DON B that the Podus boots were located across the room in a chair the whole day. DON B indicated that CNA G should have placed Podus boots on R27 while R27 was in bed. Based on observations, interviews and record reviews, the facility failed to ensure 3 of 3 residents reviewed for high risk of pressure injury (PI) development (R9, R5 and R27), received the necessary treatment and services to promote healing of existing skin impairments or prevent new pressure injuries from developing. - R9 has an active pressure related deep tissue injury to the right heel. R9 remains a high risk for the development of additional PIs related to immobility and bowel and bladder incontinence. An observation of 4 hours 41 minutes was conducted in which repositioning was not offered. Once staff did assist R9 onto the bed for incontinence care, R9's buttocks was red and wrinkled from no pressure redistribution and the incontinence of urine and feces. - R5 is a high risk for PI and has a current PI on the scapula. R5 was not offered or attempts made to reposition R5 off the scapula for over 4 hours. - R27 is a high risk for the development of PIs and has a current PI on the right heel, in which the resident was to wear a Podus boot at all times while in bed. Observations were made in which the Podus boot was not applied to R27. This is evidenced by: Facility policies and procedures for Skin Integrity, Pressure Ulcer Staging and Wound Care Protocol and General Care For All Residents were reviewed. Neither policy gives clear direction to staff on repositioning guidelines for residents either at high risk for the development of PIs or for those with current PIs. There was a section in the Pressure Ulcer Staging and Wound Care Protocol for all wounds that the care plan will be initiated. Also, for any deep tissue injuries to the heel, staff are to place pressure relief boots on at all times. According to the National Pressure Injury Advisory Panel (NPIAP) 2019, page 115, . Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage . According to Wound Care Education Institute (2018), for immobile or bed bound individuals, a full change in position should be conducted a minimum of every two hours. Some individuals require more frequent repositioning due to their high risk status. According to RESNA (Rehabilitation Engineering & Assistive Technology Society of North America) 2015, Position on the Application of Tilt, Recline, and Elevating Leg Rests for Wheel chairs, a lift from a seated position requires at least 2 minutes in order for tissue to return to off-loading levels. (If not, it is only a microshift). RESNA continues to recommend the following for tilt, recline and elevating chairs, such as the Broda: - Tilt, when used alone, must be greater than about 25° to achieve pressure relief and/or tissue perfusion at the ischial tuberosities. - Recline, when used alone, can increase shear but may provide reduction in pressure at the ischial tuberosities at angles greater than 90-100°. - The greatest reductions in pressure are seen when tilt and recline are used together, either at tilt of 35° with recline 100° or tilt of 15-25° with recline of 120°. Example 1 R9 has medical diagnoses that include but are not limited to, diabetes mellitus type 2, a recent cerebral infarction (3/6/24), heart failure, arteriosclerotic heart disease of the native coronary artery, paroxysmal atrial fibrillation, unspecified depression and dementia. According to the most recent MDSA (Minimum Data Set Assessment), which was a Significant Change in Status Assessment with an Assessment Reference Date of 3/18/24, R9 has impaired short-term and long-term memory and severely impaired daily decision making abilities. R9 has no behavioral or mood indices Also according to this assessment, R9 required partial to moderate assistance of staff for moving from sitting to lying and lying to sitting positions to the side of the bed and is dependent on staff for toileting hygiene, upper and lower body dressing, mobility and personal hygiene. R9 is transferred with the use of a full body mechanical lift with the assistance of two staff and is frequently incontinent of bladder function and always incontinent of bowel function. Surveyor reviewed the Comprehensive Care Plan (CCP) completed for R9 and noted the following: 1. Activities of Daily Living (initiated 4/17/23 and last revised 4/30/24): Interventions included: - I need staff assist of 1 with dressing. (4/17/23) - I need the assist of two with the Hoyer (3/12/24) - I need partial assist from staff with grooming. (4/17/23) 2. I am both continent and incontinent of bowel and bladder (initiated 4/25/23 and last revised 4/30/24) Interventions for this problem included: - Scheduled toileting: every 2 hours and PRN (as needed) - Staff assist of 2 with hoyer to assist me with transferring on and off toilet/commode. 3. I have impaired mobility . (initiated 4/25/23 and last revised 6/3/24): Interventions for this problem included: - Anticipate needs, such as toileting. - I need assist of 1 with turning and repositioning in bed. - I use a Broda chair to get to destinations. I am dependent on staff with chair mobility 4. has potential for pressure ulcer development r/t (related to) Immobility, bowel incontinence, bladder incontinence, has SDTI (Suspected deep tissue injury) to right heel. (start 4/25/23; revised 6/3/24) Interventions for this problem include: - Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. - Follow facility policies/protocols for the prevention/treatment of skin breakdown. - Heel lift boots on at all times - Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. - The resident needs assistance of 1 staff to turn/reposition at least every 2 hours, more often as needed or requested. - The resident requires alternating air mattress overlay to bed, Broda chair for pressure reduction when up. Surveyor then reviewed the Braden Scale For Predicting Pressure Sore Risk assessments completed for R9 and noted R9 was scored the following: - 5/5/2024-14 - 6/2/2024-14 - 6/6/2024 -13 - 6/13/2024-13 Note: Scoring for Braden assessments are as follows: - 15-18 indicates individual is at risk for the development of a PI; - scores of 13-14 indicates a moderate risk; - scores of 10-12 indicates a high risk; and - scores of 9 or less indicates a very high risk. Further review of R9's medical record was completed and noted R9 developed an unstageable PI to the right heel on 6/2/24. Interventions were put into place to apply Podus boots at all times and to reposition at least every two hours. Prosource supplements were added as a dietary intervention to promote healing. On 6/19/24, Surveyor made the following observation of R9: - At 7:18 AM, R9 was up in the Broda chair in her room. R9 was seated at 90 degrees from hips to legs and at a straight 90 degrees from hips to back. R9's legs were also at a straight 90 degrees from knees to ankles. R9 was sitting on the mechanical lift sling and a small blanket covered R9's lap. - At 7:58 AM, R9 was taken to the Main Dining Room (MDR) and placed at a table in preparation for the morning meal. R9 was served her meal at 8:02 AM by nursing student (NS) K, who sat beside R9 and fed her the meal. - At 9:10 AM, R9 completed the meal and was propelled to a small television/bird aviary room by NS K. - At 9:59 AM, Certified Nursing Assistant (CNA) G approached R9 and moved the Broda chair closer to the television. CNA G then slightly reclined R9's back in the chair, approximately 25-30 degrees. Note: According to RESNA guidelines, this was a microshift as tilting of the seat was not completed to redistribute pressure, only a slight reclining of the back of the chair. R9 remained here until 10:38 AM, at which time Activity Director (AD) E approached and offered an activity of exercise. R9 affirmed a desire to attend and AD E propelled R9 to the MDR for a small group activity. AD E straightened R9's back in the chair to a 90 degree angle from the hips. Again, no tilting of the seat was completed and no pressure redistribution. Surveyor remained throughout this activity to observe R9's participation level and the assistance provided by activity staff. R9 remained in the MDR activity until 11:03 AM. There were no offers yet attempted by staff to assist R9 for repositioning or offloading. - At 11:03 AM, AD E propelled R9 to the small activity room for nail care. R9 remained in this activity until 11:40 AM. - At 11:40 AM, Licensed Practical Nurse (LPN) H propelled R9 to her room in order to screen the resident's blood sugar. No attempts to toilet or reposition R9 were offered. At 11:43 AM, Surveyor approached CNA C and interviewed regarding R9's needs with toileting and repositioning. CNA C was one of two staff responsible for R9's care on this day. CNA C stated that R9 was incontinent of bowel and bladder and required total care. CNA C stated R9 is unable to do any activities of daily living on her own and is dependent on staff and required repositioning and toileting every two hours. Surveyor then asked CNA C why R9 was not offered, or attempts were made to assist R9 to the toilet or to reposition yet on this morning. CNA C stated, I am trying, things have been happening down here, extra alarms are going off, I'm just busy. All I can say is that I am trying. CNA C mentioned to the Surveyor that she informed her nurse (LPN H) that they were behind in cares and needed help. Surveyor then approached LPN H at 11:48 AM and asked who was responsible to ensure resident's care was being provided according to the written care plan. LPN H stated, It's us, the nurses. I'm sorry. I have been trying to get them to not schedule two new ones (aides) together, but it happens. Surveyor asked LPN H if the CNAs have mentioned anything to her that staff were falling behind in providing cares. LPN H stated that she has been informed and was trying to assist the CNAs but, . when I go in to help, the other CNA comes in. No toileting or repositioning was yet completed for R9, even with Surveyor's questioning. - At 11:57 AM, CNA C and CNA D entered R9's room to assist the resident onto the bed with the use of the full body mechanical lift. The resident was assisted onto the bed at 11:59 AM, at which time, staff removed the incontinent brief. The brief was wet with urine and soiled with feces. This was 4 hours 41 minutes in which R9 was not offered or assisted with repositioning. R9's buttocks was red and wrinkled from the combination of pressure, wetness of the urine and soilage of the feces. Surveyor then asked CNA C and CNA D what the normal staffing was for this hall, in which R9 resides. Both staff indicated there is normally two on this hall and two on the adjacent hall with one additional staff assigned to float between the two halls. Surveyor then asked DON B what the repositioning needs for R9 were to prevent pressure injuries. DON B stated that R9 was to be repositioned every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, 2 of 3 residents (R20 and R27) at risk for falls did not receive adequate supervision and assistance devices to prevent accidents. R20 required the assistance of 2 staff for transfers. CNA M transferred R20 with one person and R20 fell. R27 was at risk for falls. R27's fall interventions included wearing a knee immobilizer to the right knee during all transfers for stability. CNA G was observed transferring R27 from the wheelchair to the bed without using R27's knee immobilizer. Findings include: Example 1: R20 was admitted to the facility on [DATE] with diagnoses including, in part, cerebral palsy, unsteadiness on feet, absence epileptic syndrome, and lichen simplex chronicus. R20's Minimum Data Set (MDS) assessment, dated 01/03/24, identified that R20 had a Brief Interview for Mental Status (BIMS) score of 00. This indicated R20 had significant cognitive impairment and was unable to perform an accurate BIMS. The MDS assessment also identified R20 required extensive assistance of two people for bed mobility and toileting and was dependent on two people for transfers. R20's care plan included: -Mobility plan: I transfer with the assistance of two and Hoyer lift, 03/12/24. On 06/19/24 at 10:34 AM, Surveyor interviewed Certified Nurse Assistant (CNA) G who indicated that CNA M had transferred R20 by CNA M's self in February and dropped R20 on the floor. CNA G indicated that CNA M had tripped over R20's non-functional leg and dropped R20 on the floor. CNA G indicated that R20 suffered a swollen hip due to the fall but that no one reported the fall to the appropriate personnel. Surveyor asked CNA G if CNA G reported this incident to the administration, and CNA G indicated that CNA G did let Director of Nursing (DON) B know about CNA M dropping R20 on the floor. CNA G indicated that CNA M keeps transferring residents alone who are ordered to be assisted by 2 or mechanical Hoyer lifts instead of receiving assistance with resident transfers. On 06/20/24 at 7:41 AM, Surveyor interviewed CNA M with another Surveyor present and asked to explain the process with R20 and the fall that occurred in February. CNA M indicated that CNA M did drop R20 during a stand pivot transfer in February. CNA M indicated CNA M does not remember the exact day in February that R20 fell but that it was on the day shift. CNA M indicated that CNA M was transferring R20 with a walker and gait belt. R20's foot went dead, CNA tripped on leg and then CNA M and R20 both fell to the ground. CNA M indicated that CNA M reported this to Registered Nurse (RN) L right away. CNA M indicated that RN L came in and assessed R20. CNA M indicated that R20 did not receive any injuries that CNA M was aware of and then therapy came and assessed R20. CNA M indicated that therapy deemed R20 to be a transfer with a Hoyer lift only. On 06/20/24 at 7:52 AM, Surveyor interviewed RN L and asked if RN L was aware of R20's fall in February. RN L indicated that RN L was aware of R20's fall. Surveyor asked RN L if RN L remembers what RN L's process was for post-fall assessment and reporting the fall. RN L indicated that RN L received notice from CNA M that R20 had fallen in R20's room during CNA M transferring R20. RN L was unaware of who helped CNA M transfer R20 as R20 was assist of 2 transfers at that time. RN L assessed R20 from head to toe and gathered vitals every 15 minutes for the first half hour, then vitals every 30 minutes for the next 4 hours, and then an hour for the next 24 hours. RN L indicated that all vitals and neuros post-fall are documented on a paper flowsheet located in R20's hard chart. RN L indicated that physician notification was completed and should be in R20's Electronic Health Record (EHR). Surveyor asked RN L to show Surveyor documentation in R20's EHR about the fall incident in February, vitals, neuros, and contact of the physician notification. RN L indicated that RN L could not find any of the documentation in R20's EHR. RN L indicated that RN L thinks RN L had documented it but maybe RN L did not after all. On 06/20/24 at 10:01 AM, Surveyor interviewed Physical Therapy Assistant (PTA) N and asked what R20's transfer status was in February 2024. PTA N indicated that R20 has always been an assist of 2 pivot transfer when feeling strong or assist of 2 with mechanical Hoyer lift. PTA N indicated that R20 has never been an assist of 1 due to the instability of R20's non-functional leg. Surveyor asked if PTA N remembers R20 falling in February and PTA N indicated that PTA N is unaware of a fall in February. On 06/20/24 at 10:53 AM, Surveyor interviewed DON B and asked about any knowledge of R20's fall in February. DON B indicated there was no fall. Surveyor explained to DON B that through several interviews R20 had suffered a fall with minor injury to the right hip. DON B indicated that DON B was not aware of R20 falling and the only incident that was known was CNA M indicated that CNA M injured CNA M's foot by tripping over the wheelchair pedal in R20's room in February. DON B indicated that if a resident has fallen, staff need to report the fall right away to the charge nurse, charge nurse assesses the resident, provides proper interventions to keep the resident safe, documents the fall as an incident, and reports the incident to DON B and the physician. Surveyor asked DON B to find any documentation in R20's EHR about the fall in February. DON B indicated there was no documentation of R20 falling in February. Example 2: R27 was admitted to the facility on [DATE] with diagnoses including, in part, infection and inflammatory reaction due to unspecified internal joint prosthesis, urinary tract infection, obstructive and reflux uropathy, type 2 diabetes, unspecified dementia, and pyogenic arthritis. R27's Minimum Data Set (MDS) assessment, dated 03/27/24, identified that R27 had a Brief Interview for Mental Status (BIMS) score of 09. This indicated that R27 had significant cognitive impairment. The MDS assessment also identified R27 required extensive assistance of one to two people for bed mobility, and toileting and was dependent on one person for stand pivot transfers. R27's care plan included: -Mobility plan: Assist of 1 person pivot transfer with a two-wheeled walker or the transfer pole, use a gait belt, and hold onto it for safety. Needs locking knee brace on right leg for transfers, 04/15/24. -ADL plan: Please put a locking knee brace on the right knee when getting up in the morning, 04/15/24. -Before getting out of bed, don podus boot and knee brace to right lower extremity, 02/16/24. -When in bed resident to use blue puffy boots to right lower extremity, 02/16/24. -Potential for pressure ulcer development plan: Immobilizer to right leg when up, remove every shift to check skin, 04/30/24. -The resident requires air/float mattress to bed, pressure reduction cushion to wheel chair. Podus boot to right foot at all times, 02/05/24. On 06/19/24 at 2:07 PM, Surveyor observed CNA G transfer R27 from the wheelchair to bed without an immobilizer brace on the right leg. On 06/19/24 at 2:14 PM, Surveyor interviewed CNA G and asked if R27 was supposed to have an immobilizer brace on the right leg when transferring to and from bed or wheelchair. CNA G indicated that R27 should have an immobilizer brace on the right leg any time R27 is transferring and ambulating. CNA G indicated CNA G did not place the brace on as CNA G usually puts it on in the a.m. when R27 gets up, but he was sent to the hospital overnight and didn't get back till mid-morning. On 06/19/24 at 2:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN) I and reviewed R27's medical record for transfer status. LPN I indicated that R27 should have an immobilizer brace on the right leg when up and ambulating. On 06/20/24 at 10:01 AM, Surveyor interviewed PTA N and asked what R27's transfer status was. PTA N indicated that R27 is an assist of 1 pivot transfer. PTA N indicated that R27 is to wear an immobilizer brace to the right leg with any transfers and when up for the day for stability post knee surgery to prevent injury. On 06/20/24 at 1:02 PM, Surveyor interviewed DON B and asked the expectation of R27 to wear R27's immobilizer brace to the right knee. DON B indicated that R27 is to always wear the brace once out of bed and transfer to a wheelchair or bathroom. Surveyor indicated observations of CNA G transferring R27 from a wheelchair to a bed without an immobilizer. DON B indicated that CNA G should have transferred R27 with the right immobilizer brace for stability.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure each resident receives necessary respiratory care and services that is in accordance with professional standards of practice for 1 of 1 resident (R) reviewed for respiratory care. (R6) The facility did not clean oxygen filter, change nasal cannula tubing, and ensure R6 received oxygen at the ordered rate according to physician orders. This is evidenced by: R6 was admitted to the facility on [DATE] and has diagnoses that include acute and chronic COPD, congestive heart failure, stroke, stage 5 kidney disease, and is receiving hospice services. On 06/18/24 and 06/19/24, Surveyor observed R6 using oxygen via nasal cannula continuously via a black oxygen concentrator set at 2 liters per minute. Surveyor interviewed R6 on 06/18/24 at 10:17 AM. At that time, R6 stated he had trouble breathing and has been on oxygen continuous for years but does take it off when smoking. R6's medical record reveals physician orders as follows: -Start date: 04/12/24 Oxygen at 3 liters per minute via nasal cannula as needed for shortness of breath -Start date: 12/20/23 Change and label oxygen tubing as needed when Oxygen is in use -Start date: 12/20/23 TAN MACHINE-Clean O2 filter with warm water, dry with towel, and replace BLUE MACHINE-Clean the air intake vents on the back of the machine as needed when oxygen is in use. (R6 is currently using a black oxygen concentrator. Facility did not provide the manufacturer instructions or policy and procedure for oxygen/respiratory care as requested.) On 06/19/24, Surveyor was unable to locate any information within R6's medical record as to when R6's nasal cannula was changed and oxygen concentrator filter was washed. On 06/19/24 at 1:42 PM, Surveyor interviewed Licensed Practical Nurse (LPN) H about the amount of oxygen R6 is to be receiving. LPN H stated, I think R6 is on 2 liters per minute, then looked up the order that read Oxygen at 3l/min via NC as needed. LPN H clarified that R6 has been using oxygen continuously. Surveyor asked if LPN H could tell when R6's tubing was changed and oxygen filters were washed. LPN H reviewed the medical record and stated, No one is signing it out, so I am not sure, I can do this after I finish passing medications. Surveyor saw Director of Nursing (DON) B in hallway and asked DON B to come to R6's room. DON B confirmed R6's oxygen flow rate was at 2 liter per minute instead of the correct order for 3 liters per minute. Surveyor asked how often the tubing is changed and filters are rinsed. DON B stated they are done weekly on the night shift and could not find a date on the nasal canula tubing. Surveyor then removed the filter on the back of the oxygen concentrator and there was visible dust, light beige in color, on the black filter. DON B stated the concentrator is from hospice and R6 only had it about 2 weeks. DON B stated she will address these issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3 R2 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, heart failure, anemia, and hypertension. Minimum Data Set (MDS) assessment dated [DATE] confirmed R2 scored 03/15 during Brief Interview for Mental Status (BIMS), indicating severely impaired cognition. R2's MDS assessment reported R2 is frequently incontinent of urine and always incontinent of bowel. R2 required substantial assistance with toileting, showering, and dressing, and was dependent on staff for transfers. The follow occurred on 06/19/24 during a continuous observation from 1:05 PM-2:14 PM, for 1 hour and 9 minutes. Surveyor observed four facility staff members (Director of Nursing, two licensed nursing staff, and Activities Director) walk by R2's call light. On 06/19/24 at 1:05 PM, Surveyor observed R2's call light on when ambulating down the hallway. Surveyor observed CNA G walk past R2's call light and enter another resident room. On 06/19/24 at 1:06 PM, Surveyor entered into R2's room and asked how R2 was. R2 indicated that R2 had to use the bathroom badly and wanted to get into bed as R2 was tired. On 06/19/24 at 1:25 PM, Surveyor observed R2's call light still on. Surveyor observed CNA J walk by R2's room. On 06/19/24 at 1:41 PM, Surveyor observed R2's call light still on. Surveyor observed Activities Director E walk by R2's room. On 06/19/24 at 1:59 PM, Surveyor observed R2's call light still on. Surveyor observed DON B enter R2's room and ask R2 what R2's needs were. R2 indicated that R2 had to use the bathroom and get into bed. DON B turned the call light off and indicated that DON B would let a staff member know that R2 needed assistance in R2's room. Surveyor observed DON B exit R2's room and walk down the hallway. On 06/19/24 at 2:02 PM, Surveyor observed R2's call light go on again. On 06/19/24 at 2:14 PM, Surveyor observed CNA G entering R2's room. Surveyor interviewed CNA G and asked if DON B had informed CNA G that R2 needed assistance. CNA G indicated no DON B did not let CNA G know of R2's need. CNA G indicated that CNA G now had time to answer R2's call light. Based on observation, staff and resident interview, and record review, the facility did not have sufficient nursing staff to ensure the highest practicable physical, mental, and psychosocial well-being. This occurred for 3 of 12 residents reviewed (R4, R9, R2) This is evidenced by: The Facility Assessment staffing plan updated on 01/2023, indicated licensed nurses providing direct care; 5 (average 40-50 hours), and nurse aides: 12 (average 90-96 hours). Review of facility schedules and daily postings confirmed staff hours aligned with Facility Assessment. Surveyor observations of call light times, mechanical lift transfers, toileting, and hygiene assistance indicated the facility was not adequately staffed to meet resident needs. The facility provided additional information related to resident needs during the survey period from 06/18/24-06/20/24, confirming 33 residents are dependent on staff for needs related to activities of daily living, 15 residents are dependent on staff for mechanical lift transfers. Staff interviews confirmed the facility required two trained staff to assist with mechanical lift transfers. The facility policy titled General Care of Residents, revised on 06/2018, stated in part . 9. Call Lights a. Staff will respond to call lights timely. b. If responding to a call light and you are assisting another resident, inform the resident you are assisting another resident and will return shortly and turn off call light. c. If other departmental staff answers call lights, let the resident know that you will tell the nursing staff and turn off the call light. Example 1 R4 was admitted to the facility on [DATE]. Diagnoses included heart failure, cellulitis of upper limb, chronic kidney disease, chronic obstructive pulmonary disease, and shoulder pain. R4 was admitted with a stage 1 pressure injury to right buttock. Minimum Data Set (MDS) assessment, dated 06/06/24, confirmed R4 scored 10/15 during Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. R4's MDS assessment reported R4 is frequently incontinent of urine and always incontinent of bowel. R4 required substantial assistance with toileting, showering, and dressing, and was dependent on staff for transfers with mechanical hoyer lift. R4's care plan included: -Toileting plan: I am on a toileting schedule. Take me upon rising, before meals, after meals, bedtime, and as needed during the night, 05/31/24. The following occurred on 06/19/24 during a continuous observation from 10:22 AM-11:41 AM, for 79 minutes. Surveyor observed nine facility staff members (Director of Nursing, Assistant Director of Nursing, Physical Therapist, two licensed nursing staff, and four Certified Nursing Assistants), walk past R4's room while his call light was on, or turn off R4's call light without ensuring R4 received assistance. -10:22 AM, Surveyor observed R4 in his room, sitting in a Broda chair. Surveyor observed R4's call light was on and R4 was calling out stating he needed to use the bathroom. -10:54 AM, Surveyor interviewed CNA G. CNA G reported she was not assigned to R4's hall. CNA G stated she is working on the other hallway training CNA J. CNA G stated she assists on R4's hallway as she can as it is a heavy hall, but not all staff assist with answering resident call lights in unassigned areas. CNA G stated, With charting, no, I am not able to complete all of my workload. Surveyor observed CNA G and CNA J walk towards R4's room, where R4's call light was on. Surveyor observed CNA G and CNA J exit the hallway through a door immediately adjacent to R4's room. CNA G stated, We are finally going on break. Surveyor observed R4's call light continued to be on. -11:05 AM, Surveyor observed LPN I entered R4's room. R4 stated he needed to use the bathroom. LPN I turned off R4's call light and stated to R4 she would tell the staff. -11:17 AM, Surveyor observed R4's call light was off. Surveyor interviewed R4, R4 stated he needed to use the bathroom, and no one had helped him. Surveyor encouraged R4 to use his call light to request staff assistance. R4 did engage his call light and stated, It doesn't do any good anyway. -11:41 AM, Surveyor observed CNA D and CNA G assist R4 with mechanical lift transfer to his bed. Surveyor observed CNA D and CNA G assist R4 with incontinence care of both bowel and bladder. On 06/20/24 at 1:42 PM, Surveyor interviewed Nursing Home Administrator (NHA) A. NHA A reported the facility considers resident acuity when developing staffing patterns. NHA A reported staffing is discussed each morning during the facility's morning meeting, and stated, We move things around based on what is discussed in morning meeting, admissions, discharges, change in condition. Surveyor reported to NHA A the observation of R4 requesting to use the bathroom and not receiving assistance for 79 minutes. NHA A did not make any statements related to the incident. Example 2 R9 has an active pressure related deep tissue injury to the right heel. R9 remains a high risk for the development of additional PIs related to comorbidities as well as immobility and bowel and bladder incontinence. On 6/19/24, a continuous observation of 4 hours 41 minutes was conducted (7:18 AM - 11:59 AM) in which toileting and repositioning was not offered. Once staff did assist R9 onto the bed for incontinence care, R9's buttocks was red and wrinkled from no pressure redistribution and the incontinence of urine and feces. Interviews were conducted with staff in which they indicated staffing was insufficient on that day, with three new and one seasoned Certified Nursing Assistant working the two halls in which residents reside. Please refer to F677 and F686 for details.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. The facility did not ensure proper infection control practices were followed during and after resident care. This occurred for 1 of 1 resident (R)1. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that include dementia, cerebral palsy, stroke, type 2 diabetes, epilepsy, and left sided paralysis. R1's Minimum Data Set (MDS), dated [DATE], indicates R1 had a Brief Interview for Mental Status (BIMS) score of 5 indicating severe cognitive impairment. R1's care plan identifies that R1 is unable to walk and requires 2 assist for bed mobility, transfers, and toileting. R1 uses a broda chair and a hoyer lift. On 06/19/24 at 7:36 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA D provide pericare for R1. CNA D provided the peri care, doffed gloves and did not sanitize hands and proceeded to grab hoyer sling, placed under R1, pushed curtain back, grabbed hoyer, attached sling, raised R1 up, placed R1 in a broda chair, donned gloves again, then grabbed R1's dentures. Surveyor stopped CNA D due to failure to sanitize hands after removing gloves following pericare. Surveyor asked CNA D if she forgot anything. CNA D stated she was not sure. Surveyor stated that CNA D should have sanitized her hands after doffing gloves from doing pericare and applying new gloves to then provide R1 denture care. CNA C discarded the soiled water from the wash basin in the sink with R1's denture cup present. Surveyor asked CNA C if it is common practice to discard the soiled water in the sink. CNA C stated she did not know that was a rule and apologized. On 06/19/24 at 8:50 AM, Surveyor interviewed DON B and was asked what the expectation would be for hand hygiene following doffing gloves and where dirty wash basin water should be discarded after use. DON B replied that hand hygiene should be completed every time after doffing gloves and basins should be emptied in the toilet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not develop and implement a comprehensive person-centered care plan addressing medical and nursing needs for a resident with weight loss. This occurred for 1 of 3 residents (R) reviewed for nutrition. (R16) R16 was assessed at nutritional risk on admission and had a 7.37% weight loss in one month. R16's comprehensive care plan did not include problems, goals, or interventions to address nutrition. Findings include: R16 was admitted to the facility on [DATE] following hospitalization for severe sepsis with septic shock. R16 also had the following diagnoses in part, myocardial infarction, chronic kidney disease stage 3, chronic pain syndrome, depression, and acute kidney injury. On 06/26/23 at 2:07 PM, Surveyor observed R16 sitting up in bed with a lunch tray still on the over bed table (OBT). Surveyor noted only a few bites of the food had been eaten. R16 stated they drank the supplement drink that was provided with the tray but was not hungry for much else. On 06/27/23 at 8:12 AM, Surveyor observed Certified Nursing Assistant (CNA) C bring a breakfast tray into R16's room and set it on the OBT beside the bed. R16 was lying down in bed. CNA C informed R16 that breakfast was ready, but did not assist R16 to sit up. At 8:15 AM, Surveyor entered the room and R16 sat up on side of bed to begin eating. R16 was served oatmeal, milk, a supplement drink, a slice of ham, and a blueberry muffin. R16 began eating. At 8:39 AM, Surveyor observed R16 lying down in bed. Surveyor observed the breakfast tray on the OBT. R16 had eaten all of the blueberry muffin and drank the supplement drink, but had not touched the ham or oatmeal. R16 said they were done eating. On 06/27/23 at 12:02 PM, Surveyor observed R16 served tea, a supplement drink and a cup of chocolate ice cream while waiting for lunch in the main dining room. R16 drank all of the supplement and ate all of the ice cream. At 12:18 PM, R16 was served meat balls and noodles with gravy, mixed vegetables, and milk. R16 stated they did not want the food. Director of Nursing (DON) B encouraged R16 to try the food and offered an alternative, but R16 stated they did not want anything else. At 1:12 PM, Surveyor observed R16 leave the dining room. R16's plate of food was still on the table and the food was untouched. Review of R16's medical record identified R16 weighed 179.2 pounds on 05/26/23. On 06/26/23, R16 weighed 166 pounds. This was a 7.37% weight loss in one month. Surveyor reviewed a Nutrition Risk Assessment completed by the Registered Dietician on 05/28/23. The assessment identified R16 was at nutritional risk. Surveyor noted a new order on 06/08/23 for 4 ounce nutritional supplement to be given to R16 three times per day with meals. Surveyor noted R16's comprehensive care plan identified R16 could eat independently. There was no identification that R16 was at nutritional risk and no nutritional interventions included on R16's comprehensive care plan. On 06/27/23 at 2:14 PM, Surveyor interviewed DON B about R16's weight loss. DON B stated they were aware of R16's recent weight loss. DON B stated they were trying to encourage R16 to go out to the dining room for most meals and initiated nutritional supplements three times per day. Surveyor asked if they had developed a nutritional care plan to address nutritional concerns after the Registered Dietician assessed R16 at nutritional risk on 05/28/23. DON B stated they did not develop a nutrition care plan at that time.

Based on observation, interview and record review, the facility did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service for all 42 residents. Dishwasher temperature logs were not complete. Staff touching ready to eat foods with contaminated gloves. Findings include: On 06/26/23 at 9:30 AM, during initial tour of the kitchen with Dietary Manager (DM) G, Surveyor noted the dishwasher temperature log was missing temperature recordings on June 17, 20, 24, 25 and 26th. Surveyor asked for temperature logs for both April and May. DM G led surveyor to the office. DM G found the temperature logs for April and May, and they were also missing temperatures (April 2nd, April 10 through April 21, 25, 29 and 30th and May 5, 9, 13, 14, 19, 23, and 27 through 29th). Surveyor asked DM G for a copy of these logs and a policy on dishwasher temperatures. On 06/27/23 at 10:35 AM, DM G provided Surveyor with policy Dish Machine Temperature and Maintenance Log revised date on 06/26/23 that states in part .5. To verify the sanitizing rinse cycle temperature, a high temperature lipmus paper test must be completed per package instruction. Lipmus paper testing must be completed just once daily or in addition to verify any inaccuracies. 6. Once information has been gathered, it must be transferred to the Dishwasher Temperature Audit provided on the wall next to the dish machine . DM G handed surveyor a copy of the audit that has been started along with education dietary staff must complete. On 06/27/23 at 12:07 PM, Surveyor observed Dietary Staff (DS) F using the same gloves that she plated food for a food cart, pick up a piece of bread and place it in the toaster. DS F then went back to touching scoops in the hot foods, grabbing plates and plating food for the residents in the dining area. Then with the same gloved hands she took the toast out of the toaster and began to butter the toast touching the knife that was in the butter bin. DS F then began plating food touching plates, scoops, and tongs for noodles with the same gloved hands. Surveyor then observed DS F rest her gloved hands on the counter in front of her. DS F then grabbed another piece of bread from the bread bag with the contaminated hands and put it in the toaster and went back to plating food. DS F then grabbed the toast out of the toaster and butter the toast with the same gloved hands. On 06/27/23 at 12:24 PM, Surveyor informed DS F of the observations of touching ready to eat foods with contaminated gloves. Surveyor asked DS F what the process is for touching ready to eat foods. DS F replied I should have used tongs to touch the bread and toast. On 06/27/23 at 12:30 PM, Surveyor informed DM G of the observations of touching ready to eat foods with contaminated gloves. Surveyor asked DM G what the process is for touching ready to eat foods. DM G replied DS F should have used tongs. Surveyor asked for a policy on glove use in the kitchen. On 06/27/23 at 2:26 PM, DM G provided Surveyor with a policy Glove Use dated 10/2008 that states in part .3. Gloves are for single tasks only to avoid cross contamination .7. Employees may use utensils such as deli tissue, spatulas, tongs, or dispensing equipment as an alternative to glove use .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2: R33 was admitted to the facility on [DATE] with a diagnosis of C-difficile. The Minimum Data Set (MDS) dated [DATE] indicated R33 required extensive assistance with toileting and was frequently incontinent of bowel. On 06/26/23 at 11:31am, Surveyor observed incontinent cares being completed for R33. When Surveyor entered R33's room, resident was observed with lower extremities exposed and R33 was lying in a puddle of stool that went down to their knees. CNA C and CNA D entered the room with gown and gloves on. Surveyor observed CNAs wash resident, place clean linens on bed, and dress resident. CNA C performed hand hygiene with ABHR (alcohol based hand rub) and then pulled the Velcro tapes of R33's brief and secured them in front with bare hands. CNA C then pulled R33's pants up bare handed and asked CNA D for help boosting R33 up in the bed. CNA D had already removed her gown but still had her gloves on, came over to R33 and assisted CNA C to boost R33 up in the bed. CNA C removed gown at the sink and CNA D removed gloves at the sink and they both washed their hands with soap and water at the sink. On 06/26/23 at 7:06 AM, Surveyor asked Registered Nurse (RN) E if staff are providing care for residents with contact precautions are they allowed to do any cares bare handed or without a gown. RN E replied no, you are always to go in gown and gloved and remain that way until you leave the room, especially with cares. On 06/27/23 at 9:55 AM, Surveyor interviewed Director of Nursing (DON) B and asked when working with a resident on contact precautions are staff allowed to do any cares bare handed or without a gown. DON B replied no, they need to be using the appropriate PPE with all residents and cares. I am educating all staff on proper hand hygiene use. Surveyor requested a handwashing policy. On 06/27/23 at 10:32 AM, Surveyor received a policy titled Handwashing revised 03/2013 which stated in part under guidelines, .2. Handwashing with antimicrobial soap and water is recommended for most situations when there is prolonged physical contact with any non-infected resident . 5. Except for a true emergency, personnel should always wash their hands: .d. After handling a source that is likely to be contaminated, such as equipment, dressings, and secretions and excretions from residents . During observations, the aides did not complete hand hygiene after touching contaminated items. Based on observation and interview, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection. This had the potential to affect 34 of 42 residents. Staff did not perform proper hand hygiene for residents prior to meals for 34 of 42 residents. The facility staff did not do proper glove changes with hand washing while performing resident cares for R9. Certified Nursing Assistant (CNA) C used Alcohol Based Hand Rub (ABHR) to clean hands while providing cares for Resident (R) 33 who has a diagnosis of Clostridium Difficile (C-Diff is a highly contagious bacterium that causes diarrhea). Example 1: On 6/26/23 at approximately 12 p.m. during the lunch meal, Surveyors observed the main dining area. All residents eat meals, except for one resident who is tube fed. Surveyors observed wet wipes in bowls on top of the dining room tables. During the lunch meal, Surveyors noted that residents were not being offered or provided assistance with wet wipes for hand hygiene prior to eating as they were brought into the dining room. On 06/26/23 at 12:30 PM, Surveyor interviewed CNA J. Surveyor asked when residents are offered hand hygiene. CNA J stated, I am not really sure, if they are in an activity they might do it there, but they don't do it in the dining room. On 06/26/23 at 12:35 PM, Surveyor interviewed CNA K. Surveyor asked when the residents are offered hand hygiene. CNA K stated that some of the CNAs do it before meals. CNA K added, I know I missed a few today. They use the wipes to wash hands after the meal. On 6/28/23 at approximately 9:15 a.m., Surveyor interviewed Director of Nursing (DON) B and asked if she would expect that residents have hand washing prior to eating. DON B stated she would expect that they use the hand wipes. Example 2 On 6/27/23 at approximately 7:20AM, Surveyor observed CNA H and CNA I provide cares for R9. R9 requires 2 staff assist to get up and the staff work in teams for those residents who require the assist of 2 for transfers. CNA H was observed throughout the wash up to change gloves while moving from dirty to clean. CNA H did sanitize hands between glove changes. CNA I, who was the CNA who was primarily washing R9 up, did change gloves when moving from dirty to clean; however, CNA I was observed to not wash or sanitize hands between glove changes. Surveyor interviewed CNA H and CNA I immediately after the cares were completed and asked what had been done wrong. CNA H stated that CNA I did not wash hands in between glove changes. CNA I stated they were not aware they needed to do this. Surveyor interviewed DON B on 6/28/23 at approximately 9:15 a.m. regarding her expectations for hand washing and asked what were her expectations for hand washing. DON B stated she expects that everybody follows standard precautions to keep themselves and residents safe. Surveyor asked if she would expect that staff wash hands in between glove changes and she replied yes. Surveyor asked if she would expect the residents have hand washing prior to eating and she stated she would expect that they use the hand wipes. Surveyor asked DON B what her expectations are when someone is on TBP (transmission based precautions). DON B stated staff should be reading the signs and using the PPE that is suggested on the signs. She added there are instructions on how to don and doff PPE in every resident room who is on TBP and staff have all been educated in the CDC procedures for donning and doffing. The facility policy titled Handwashing that was provided to the survey team by the facility does not state that staff need to wash hands in between glove changes. The CDC guidance found at www.cdc.gov/handhygiene/providers/guideline.html, under Hand Hygiene Guidance in health care settings states the following: Healthcare personnel should use an alcohol based hand rub or wash with soap and water for the following clinical indications. The 6th bullet point states immediately after glove removal. The facility policy does not include washing hands in between glove changes which does not keep with current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example: R15, a [AGE] year old, was admitted to the facility on [DATE]. R15 had diagnoses of Heart Failure, Atrial Fibrillation, and Cerebral Infarction (Stroke). On 6/8/2022, Surveyor observed R15 to have side rails and and an air mattress on their bed. On 6/8/2022, Surveyor reviewed R15's medical record. There was no assessment for the risk of entrapment for the use of side rails in the medical record. There was no consent for the use of the side rails in the medical record. Example: R21, a [AGE] year old, was admitted to the facility on [DATE]. R21 had diagnoses of Pressure injury of the Sacral region, Unspecified Cerebral Vascular disease, and hemiplegia and hemiparesis (loss of strength on one side of the body). On 6/7/2022, Surveyor observed R21 to have assist rails on the bed and to also have an air mattress. On 6/8/2022, Surveyor reviewed R21's medical record. There was no assessment for the risk of entrapment for the use of side rails in the medical record. There was no consent for the use of side rails in the medical record. Based on observation, interview and record review, the facility did not ensure correct use of bed rails, by not ensuring correct installation, use, and maintenance of bed rails for 3 of 4 residents (R) utilizing bed rails. (R135, R15, R21) *The facility did not assess residents for risk of entrapment when utilizing bed rails. *The facility did not review the risks and benefits of bed rails and obtain informed consent prior to the installation of bed rails. *The facility did not follow the manufacturer's recommendations and specifications for installing and maintaining bed rails. Findings include: Surveyor requested the facility policy and procedure on bed rail use, and received the following policy and procedure: Facility Policy and Procedure entitled Physical Device Assessment/Use of Physical Devices, last revised 06/2018, stated in part, .Any device may potentially be a restraint, depending upon how it is used, on whom it is used and the effect upon whom it is used .POLICY If a restraint is used, the positive benefits must outweigh the possible negative effects of strangulation .PROCEDURE 1. A physician's order will be obtained for a restraint .3 .staff will inform the resident or legal representative of the findings of the restraint committee/interdisciplinary team, and the risks vs. benefits of restraints as opposed to other treatment alternatives. The resident or the legal representative will give informed consent to the use of a restraint prior to its use. The resident or legal representative will sign a consent for the restraint .8. Physical Device Assessment should be completed upon admission/readmission, as needed and on a quarterly basis. Example: R135 was admitted to the facility on [DATE], with diagnoses, including in part, prostate cancer, liver cancer, anxiety disorder, osteoarthritis, pain, and a history of falls at home. R135's admission Minimum Data Set (MDS) assessment, dated 06/08/22, in progress, noted R135 required extensive assistance with bed mobility and limited assistance with transfers. R135's Brief Interview for Mental Status score was 08, which indicated R135 had moderate cognitive impairment. The fall risk assessment completed on 06/02/22 indicated R135 was at high risk for falls, had decreased muscle coordination, and had 1-2 falls in the past 5 days. On 06/07/22 at 10:58 AM, Surveyor observed two bed rails on the upper half of R135's bed. There was also an air mattress on the bed. When asked, R135 did not remember anyone talking about risks and benefits of bed rails with an air mattress. R135 did not remember signing a consent form for the use of the bed rails. On 06/08/22 at 8:30 AM, Surveyor reviewed the electronic and paper medical records for R135. Record review identified the following physician order, dated 06/05/22, Bilateral Grab Bars. No directions specified for order. The record review identified no bed rails were noted on R135's care plan, no bed rail assessment with assessment for risk of entrapment, and no signed bed rail consent with risk/benefit discussion was found on the medical record. Surveyor asked for the above documentation. No documentation was received. On 06/08/22 at 1:34 PM, Surveyor interviewed Director of Nursing (DON) B about bed rail use and assessments. DON B stated they had not been doing bed rail assessments with assessment for risk of entrapment, or obtaining informed consent prior to installing bed rails. DON B did not think that the maintenance department was doing any assessment for entrapment risk with measurements of risk zones, or consulting manufacturer's guidelines when installing bed rails to ensure air mattresses and bed rails were compatible. DON B stated they had no documentation of assessment for risk of entrapment, informed consent, or verification of compatibility of equipment used for R135's bed rails and air mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 R15, a [AGE] year old, was admitted to the facility on [DATE]. R15 had diagnoses of Heart Failure, Atrial Fibrillation, and Cerebral Infarction (Stroke). On 6/8/2022, Surveyor observed R15 to have side rails and and an air mattress on their bed. Surveyor asked for routine inspection and maintenance of the side rails. No information was provided. Example 3 R21, a [AGE] year old, was admitted to the facility on [DATE]. R21 had diagnoses of Pressure injury of the Sacral region, Unspecified Cerebral Vascular disease, and hemiplegia and hemiparesis (loss of strength on one side of the body). On 6/7/2022, Surveyor observed R21 to have assist rails on the bed and to also have an air mattress. On 6/8/2022 at approximately 11:00AM, Surveyor interviewed Maintenance Director (MD) C regarding side rails. Surveyor asked if there was documentation of bed/mattress inspections for safety and fit. MD C stated that they did not have any nor had they inspected the bed and mattress for fit and safety. MD C stated that they had been checking to see if the rails were secure on the bed frame but not assessed to see if the mattress and bed were compatible nor had they done any measurements. Based on observation, interview and record review, the facility did not provide routine maintenance of bed rails, mattresses, and bed frames for 3 of 12 residents (R) with bed rails (R135, R21, R15). Example: R135 was admitted to the facility on [DATE], with diagnoses, including in part, prostate cancer, liver cancer, anxiety disorder, osteoarthritis, pain, and a history of falls at home. R135's admission Minimum Data Set (MDS) assessment, dated 06/08/22, in progress, noted R135 required extensive assistance with bed mobility and limited assistance with transfers. R135's Brief Interview for Mental Status score was 08, which indicated R135 had moderate cognitive impairment. The fall risk assessment completed on 06/02/22 indicated R135 was at high risk for falls, had decreased muscle coordination, and had 1-2 falls in the past 5 days. On 06/07/22 at 10:58 AM, Surveyor observed two bed rails on the upper half of R135's bed. There was also an air mattress on the bed. Review of R135's record identified no documentation of routine maintenance of bed, air mattress or bed rails on the electronic or paper chart. On 06/08/22 at 1:34 PM, Surveyor interviewed Director of Nursing (DON) B about bed rail use and assessments. DON B did not think the maintenance department did any scheduled maintenance of beds and bed rails, consulted any manufacturer's guidelines to ensure bed rails, mattresses, and bed frames were compatible.