Every finding on record at Accolade Healthcare Danville

Based on interview and record review, the facility failed to provide the required 30 day notice to a resident discharged involuntarily. This failure affects one resident (R2) out of seven reviewed for discharges on the sample list of eight. Findings include: On 6/9/26 at 9:05 AM, V1, Administrator, stated R2 was still in the hospital. V2 stated R2 was not under an official involuntary discharge process but there was a corporate level decision not to allow R2 to return to the facility. V1 stated the facility could not meet R2's clinical needs and continued to relate conflicts with R2's daughter (V7), an extensive investment of facility resources, direct care staff necessarily providing care to R2 with two staff members to protect themselves against false accusations and allegations from R2 and V7. V1 stated all R2's personal belongings had been packed up and were waiting in her office for someone to come pick the items up. On 6/9/26 at 2:32 PM V7, Family of R2, stated R2 had been sent to the emergency room on 5/21/26 after having a bad day mostly due to her medications. V7 stated R2 had been sent from a local hospital to a more distant hospital to receive treatment. V7 stated R2 had been cleared to be discharged from the hospital for over a week but the facility would not allow R2 to return. V7 stated the hospital had been trying to find another nursing home in the same local area but none were available. V7 stated the hospital was looking in more distant towns for another nursing home. V7 stated the facility had not provided a 30-day notice for R2's discharge from the facility. V7 stated the administrator (V1) told her they couldn't meet R2's needs but the facility was meeting R2's needs prior to being sent to the hospital, and the hospital was seeking another nursing home for R2. V7 stated she had contacted the State Ombudsman (V11) to intervene with the facility, but the Ombudsman had reported back that the administrator told her the same thing, that R2 would not be allowed to return to the facility. R2's Census Detail dated 6/9/26 documents R2 was originally admitted to the facility 6/8/23, then discharged [DATE]. R2 re-admitted to the facility 11/1/23, then discharged [DATE]. R2 was again re-admitted [DATE], experienced 12 short-term hospitalizations with readmissions each time, and discharged [DATE]. R2's Profile Face Sheet dated 6/9/26 documents V7 as R2's legally established power of attorney. R2's Minimum Data Set Resident Assessment (MDS) dated [DATE] documents R2 experienced a range of motion impairment of 1 lower extremity. R2 requires supervision while eating, conducting oral hygiene, upper dressing, and personal hygiene. R2 requires moderate assistance for toileting, showers, lower body dressing, placing footwear, bed mobility, transitions from sitting to lying, and lying to sitting. R2 requires maximum assistance to transition from sitting to standing, to accomplish transfers from chair to bed, toilet, or shower. R2 does not ambulate. R2 required set up to propel her own wheelchair 50 feet to 150 feet. R2 is frequently incontinent of bowel and bladder. R2 had no skin ulcers or associated treatments. All similar conditions to each of the reviewed residents (R1, R3, R4, R5, R6, and R7) who reside at the facility. R2's Nursing Progress Notes dated 6/8/2026 at 3:42 PM document: COMMUNICATION - with Family/NOK (next of kin)/POA (power of attorney). Note Text: Writer attempted to call (R2) two times on 06-08-2026 to find out when she would be picking up her belongings. SSD (Social Services Director) present during phone call attempts. R2 did not answer either call, no message was left due to voice messages not being set up on her phone. R2's Nursing Progress Notes dated 6/1/2026 at 12:11 PM document: COMMUNICATION - with Family/NOK/POA. Late Entry: Note Text: This writer and admissions director attempted to contact (R2) and (V7) via facility phone; both calls when (sic, went) straight to voicemail. Attempted to call (R2) via admissions cellphone; call went to voicemail. Called (V7) via admissions cell phone to discuss when (R2's) items would be picked up. (V7) states that she does not plan to pick (R2's) items up at this time. Informed (V7) that belongings are secured in the Administrators office. This writer present with admissions director for duration of call. R2's Nursing Progress Notes dated 5/30/2026 10:25 AM documents: Nursing Note. Note Text: (V13, unknown reference) here to pick up (R2's) mail. Observed (R2) on the phone with (V13) at the time of mail being picked up. This writer asked if (V13) would be picking up (R2's) personal belongings; (V13) stated that she wanted to talk to (V7) before picking up belongings. Requested corporate number; number given to (V13). On 6/10/26 at 12:28 pm, V1, Administrator, and V9, Regional Consultant, jointly and severally stated R2 has an extensive history of litigation including medical professionals to the point where the facility had to find new surgeon for R2, and R2 has a lot of refusals of insulin. V9 specifically stated she was fully aware the facility had missed the opportunity to do an involuntary discharge notice for R2. Jointly, V1 and V9 stated there were a lot of inaccuracies reported by R2 and V7 during a prior survey which caused the facility to receive citations. On 6/11/26 at11:18 am, V11, Ombudsman, stated she was contacted by R2's daughter (V7) who said the facility had sent R2 to the hospital but now were not allowing R2 to come back. V11 stated she went out to the facility on behalf of R2 and V7 to speak with the administrator who confirmed the facility was not going to allow R2 to return to the facility. V11 stated she asked if the facility had provided a 30 day notice and was told that the situation was past that point. V11 stated she gave all that information to V7 and said from this point it would have to be a phone call to IDPH for more regulatory enforcement. V11 confirmed she had not received the required copy of a 30-day notice of involuntary discharge from the facility. On 6/11/26 at 11:25 AM, V1 confirmed R2 would not be allowed to return to the facility, and there was no 30-day notice issued to R2 or R2's family. The facility's Discharge/ Transfer policy dated 1/2025 documents that involuntary transfers or discharge (discharges against the wishes of the resident or family) will be with proper notification to the resident and family or legal representative by registered or certified mail. A notice of Involuntary Transfer or Discharge and Opportunity for hearing will be provided to the resident/ resident representative. All involuntary discharges will be conducted in accordance with the Nursing Home Care Act. The Clinical Director or CEO (Chief Executive Officer) shall be consulted before any involuntary transfer/ discharge notices are sent. Involuntary transfers or discharges of a resident shall be preceded by a discussion with the resident or responsible party and by a written notice of 30 days. The written notice must be given on a form prescribed by the Illinois Department of Public Health.

Based on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for four (R1, R2, R3, R6) residents of six residents reviewed for call light response in a sample of ten residents.Findings includeThe facility's Call Light Answering policy dated 08/02/2017 documents: All residents will have a staff member that is able to answer/and or see to the residents' request and/or needs. It is the responsibility of the Certified Nursing Assistant (CNA) and or Nurses to answer the call lights/pagers to see what requests or needs the resident may have.R1's undated Care Plan documents an admission date to this facility as 7/31/2024 with the following diagnosis: Type Two Diabetes, Asthma, and Osteoarthritis. R1's care plan contains a focus area regarding R1 having an Activities of Daily Living self-care deficit related to impaired balance and pain with an intervention in place dated 11/3/2025 reading R1 requires moderate assist by one-two staff with gait belt for toileting and that R1 uses incontinence products and another intervention dated 11/19/2025 reading R1 is to use bell to call for assistance.On 5/7/2026 at 10:28 AM, R1 stated R1 experienced an extended wait time for incontinence care on 5/2/2026. R1 stated R1 had an episode of urinary incontinence on the morning of 5/2/2026 around 7:30 AM. R1 reported R1 activated R1's call light around the same time as the episode of incontinence. R1 stated multiple staff had entered R1's room, deactivated R1's call light, and exited without providing incontinent care during this time. R1 stated R1 has feelings of being degraded and disrespected whenever R1 experiences episodes of incontinence due to long call light wait times. R1 stated R1 has also suffered from increased itching, and redness in R1's peritoneal area due to the extended time R1 is forced to remain in urine-soaked incontinence briefs.R2's undated care plan documents R2 with an admission date to the facility as 08/04/2021 with the following diagnosis: Nontraumatic Intracranial Hemorrhage, Hemiplegia and Hemiparesis Following Nontraumatic Subarachnoid Hemorrhage Affecting Left Non-Dominant Side, and Diabetes.R2's undated Care Plan contains a focus area documenting R2 with Activities of daily living self-care performance deficit related to a traumatic brain injury and contractures with an initiation date of 7/23/2021 and an intervention/task documenting R2 uses incontinence products and is to be checked and changed every two hours and as needed.R2's undated Care Plan contains a focus area documenting R2 is moderate risk for falls related to deconditioning and gait/balance problems with an intervention in place to ensure R2's call light is within reach and encourage R2 to use it for assistance as needed. The resident needs prompt response to all requests for assistance.On 5/7/2026 at 10:04 AM, R2 stated R2 sometimes goes a whole shift without getting assistance with incontinence care, but the average call light wait time can be upwards of an hour wait. R2 stated when R2 experiences long wait times, R2 is often left sitting in urine-soaked clothing making R2 feel angry with increased anxiety at times. R2 stated these episodes of incontinence and long call light wait times cause R2 to lose sleep sometimes as well as increased use of R2's as needed anti-anxiety medication.R3's undated Care Plan documents an admission date to the facility as 1/29/2025 with the following diagnosis: Spinal Stenosis, Cervical Region, Hypokalemia, Gastroparesis, Hypertensive Crisis, Unspecified, Cerebral Infarction, Unspecified, Cardiomegaly, and Diabetes. R2's undated Care Plan documents a focus area documenting R2 with an Activities of Daily living self-care performance deficit related to weakness and limited mobility, and diabetic ketoacidosis with an intervention for this focus area, dated 1/30/2025 documenting R2 is to be encouraged to use bell to call for assistance.On 5/7/2026 at 9:46 AM, R3 stated R3 experiences long wait times for call lights to be responded to. R3 stated some staff will come in and shut off the call light without providing care. R3 stated this makes R3 feel insignificant like people don't care about R3 and it makes R3 feel dirty.R6's undated Care Plan documents an admission date to this facility as 5/8/2024 with the following diagnosis: Diabetic Foot Ulcer, Vitamin D Deficiency, Hyperlipidemia, and Diabetes. R6's undated care plan documents a focus area, dated 5/8/2024, documenting R6 with an Activities of Daily Living self-care performance deficit related to deconditioning, diabetic neuropathy, and recent right fifth digit amputation with an intervention dated 5/8/2024 documenting R6 is to use bell to call for assistance.On 5/11/2026 at 1:11PM, R6 stated R6 needs assistance from staff to transfer due to a wound on R6's foot. R6 stated R6 sometimes must wait upwards of 25-30 minutes, sometimes more, for R6's call light to be answered. R6 stated when R6 experiences long wait times for incontinence care R6 feels worthless, like R6 is not important.On 5/11/2026 at 9:53 AM, V4 Auxiliary Aide stated that when V4 works V4 will go into residents rooms to see what the resident needs, turns off call light, and will notify staff of the residents needs after the call light is turned off.Grievance log for the month of April 2026 was reviewed. Call light concerns noted on 4-16-2026 involving R1. Resident/Family Concern Grievance Form dated 4/16/026 contains information regarding R1's concern associated with long wait times for call light response times and untimely incontinence care. This document also addresses R1's concern regarding staff turning off the call light prior to care being provided.Grievance form dated 1/5/2026 documents a concern regarding long call light wait times involving R5. This form documents V4's concern about extended wait times for call lights to be answered.

Based on interview, record review, and facility documentation, the facility failed to thoroughly investigate allegations of abuse and failed to implement timely interventions to protect one (R1) from further potential abuse and emotionally distressing interactions involving Certified Nursing Assistant (CNA) on a Sample list of three residents. The facility failed to adequately respond to prior allegations of degrading behavior, failed to ensure effective follow-up after a care plan meeting addressing resident concerns, failed to remove the alleged staff member from resident care after repeated complaints, and failed to complete a timely and thorough investigation into allegations of verbal abuse and rough handling on 5/2/2026.Findings Include:On 5/6/2026 at 9:24 AM, V11 (R1's) Power of Attorney (POA), stated there had been prior allegations involving V9 CNA degrading and disrespecting R1 approximately two weeks before the incident on 5/2/2026. V11 stated a care plan meeting had been held with R1, V11, and facility staff, including V2 Director of Nursing (DON), where concerns regarding V9's treatment of R1 were discussed. V11 stated R1 expressed that R1 did not want V9 providing care due to feeling degraded and emotionally mistreated. Despite these concerns, V9 continued to enter R1's room and provide care.On 5/6/2026 at 9:24 AM, V11 stated that on 5/2/2026 at approximately 7:00 PM, R1 called V11 crying hysterically, emotionally distressed, and complaining of pain following another interaction with V9 CNA. V11 stated R1 reported V9 became upset during care and forcefully pulled the wheelchair into R1's foot. V11 further stated V11 overheard staff minimize R1's concerns and tell R1 that R1 was overreacting.On 5/6/2026 at 10:00 AM, R1 stated V9 CNA repeatedly raised V9's voice, degraded R1, and treated R1 disrespectfully. R1 stated R1 had previously requested that V9 not provide care to R1 because of prior degrading interactions. R1 stated that on 5/2/2026 V9 again entered (R1's) room, became argumentative during care, and spoke to R1 in a disrespectful and intimidating manner. R1 stated R1 felt humiliated, emotionally distressed, and fearful during the interaction.On 5/6/2026 at 11:18 AM, V9 Certified Nursing Assistant (CNA) admitted V9 yanked the wheelchair from beside the bed and struck R1's foot. V9 also acknowledged stating, thank god you got that all recorded, after leaving the room despite no recording occurring.On 5/6/2026 at 2:15 PM, V10 Licensed Practical Nurse (LPN) confirmed V10 overheard V9 speaking to R1 in a stern voice during care and stated V10 believed V9's comment about recording the interaction was intended to visibly upset R1.On 5/6/2026 at 1:30PM, V8 Assistant Director of Nursing (ADON) stated V8 was notified on 5/2/2026 regarding the incident involving R1's foot; however, V8 acknowledged V8 did not notify the Administrator at that time. Record review revealed the facility did not suspend V9 CNA or initiate formal reporting procedures until 5/5/2026 after the POA came to the facility and met with administration.Record review further revealed no evidence the facility implemented immediate protective interventions following the earlier care plan meeting regarding R1's concerns about V9 CNA. There was no documented evidence that the facility ensured V9 would avoid providing care to R1, monitored staff interactions, or completed a thorough abuse investigation after the earlier allegations of degrading behavior.The facility failed to thoroughly investigate allegations of abuse and mistreatment, failed to implement effective interventions to protect R1 after prior complaints involving the same staff member, and failed to prevent continued contact between R1 and the alleged perpetrator.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one (R1) of three residents reviewed for employee-to-resident verbal abuse on a sample list of three residents. The facility failed to ensure R1 was protected from ongoing verbal abuse, degrading interactions, intimidation, and emotionally distressing treatment. The facility further failed to appropriately respond to prior concerns involving the same staff member and failed to ensure resident dignity and emotional well-being were maintained. These failures resulted in R1 feeling emotional distress, tearfulness, frustration, feelings of being degraded, and disbelieved. On 5/6/2026 at 9:24 AM, V11 (R1's) Power of Attorney (POA) stated that on 5/2/2026 at approximately 7:00 PM, R1 called V11 crying hysterically, upset, and in pain following an interaction with V9 Certified Nursing Assistant (CNA). V11 stated R1 was so emotionally distressed R1 could barely understand what R1 was saying. V11 stated there had been previous allegations involving V9 degrading R1 approximately two weeks prior to the incident. V11 stated a care plan meeting was held with R1, V11, and facility staff, including V2 Director of Nursing (DON), where concerns regarding V9's treatment of R1 were discussed. V11 stated R1 reported feeling degraded and emotionally mistreated by V9 CNA and requested V9 not provide care to R1. V11 stated V2 DON reported the allegations would be investigated; however, V9 continued to enter R1's room and provide care.V11 stated while V11 remained on the phone with R1 on 5/2/2026, V11 overheard V10 Licensed Practical Nurse (LPN) and V7 Registered Nurse (RN) enter the room and discuss the incident with R1. V11 stated V11 heard staff tell R1 the incident was an accident and that V9 would never do that. V11 stated R1 became increasingly upset and asked staff if they were calling R1 a liar. V11 stated staff then told R1 that R1 was overreacting. V11 stated the interaction caused R1 additional emotional distress and made R1 feel dismissed and disbelieved by facility staff. V11 further stated V11 text V3 Social Services Director (SSD) on 5/2/2026 at 8:07 PM regarding the incident and concerns involving V9 CNA. The text message documented, Mom just called and said that one of the nurses rammed a wheelchair into her (R1's) leg. V9 CNA said the wheelchair was stuck under the bed and V9 pulled it out and it ran over her (R1's) foot. V11 stated V11 received no response from facility staff.On 5/6/2026 at 10:00 AM, R1 stated V9 CNA repeatedly raised V9's voice, degraded R1, and treated R1 disrespectfully during care. R1 stated V9 would become argumentative and had previously stated, your kids wouldn't talk to me like that. R1 stated R1 generally got along with other CNAs but consistently experienced problems with V9. R1 stated R1 had previously requested that V9 not provide care to R1 because of degrading interactions on 4/16/26. Record Review documents that Care Plan dated 4/17/26 states R1 makes false accusations, but no behaviors or documentations from grievance logs, behavior logs before the care plan meeting on 4/16/26. R1 stated on the evening of 5/2/2026, V9 CNA entered R1's room despite previous requests that V9 not provide care. R1 stated V9 stood over R1 watching R1 and became argumentative while attempting to provide care. R1 stated R1 requested assistance respectfully; however, V9 raised V9's voice and responded dismissively. R1 stated R1 told V9 that R1 did not want V9 providing care because V9 was disrespectful toward R1. R1 stated V9 responded, you need to respect me. R1 described the interaction as degrading and humiliating and stated, is she (R9) trying to give me (R1) a heart attack? R1 stated R1 felt intimidated, emotionally overwhelmed, and humiliated during the interaction.R1 stated R1 believed staff did not believe R1's allegations and attempted to make R1 appear dishonest. R1 stated staff were asking all kinds of questions suggesting I (R1) was lying. R1 described V9 CNA as pouncing on me (R1) like a cat after prey and stated V9 intentionally attempted to upset and intimidate R1. R1 stated the interactions caused significant emotional distress and made R1 fearful and uncomfortable receiving care from V9.On 5/6/2026 at 11:18 AM, V9 CNA acknowledged R1 became very upset and was yelling during the interaction on 5/2/2026. V9 acknowledged exiting the room and stating to V10 LPN, thank god you got that all recorded, despite no recording occurring. V9 acknowledged R1 overheard the statement.On 5/6/2026 at 2:15 PM, V10 LPN stated V10 overheard V9 CNA speaking to R1 in a stern voice and repeatedly directing R1 to roll over during care. V10 stated after exiting the room, V9 stated, I'm glad you were recording all of that. V10 stated V10 believed the comment was intended to visibly upset R1 further.Record review revealed psychiatric documentation dated 5/7/2026 identified increased sadness, frustration, emotional distress, and conflict with staff following the incident. Documentation noted increased behaviors, emotional escalation, and the need for close psychiatric monitoring following the conflict with staff. Nursing documentation dated 5/11/2026 documented increased episodes of tearfulness and emotional distress requiring an increase in Sertraline medication dosage.Record review further revealed the facility failed to implement new interventions after the earlier care plan meeting regarding R1's concerns involving V9 CNA. There was no documented evidence that the facility ensured V9 would avoid providing care to R1 or monitored interactions between V9 and R1 after allegations of degrading behavior were reported.

Based on interview, record review, and facility documentation, the facility failed to timely report allegations of abuse, neglect, injury of unknown source, and mistreatment involving one resident (R1) in accordance with facility policy and federal regulations on a sample list of three residents. The facility failed to immediately report allegations to the Administrator, physician, and other required officials after staff became aware of allegations involving verbal abuse, rough handling, and injury to R1's left foot by a Certified Nursing Assistant on 5/2/2026.Findings Include: On 5/2/2026, R1 alleged that V9 Certified Nursing Assistant (CNA) forcefully pulled a wheelchair and struck R1's foot during care, causing pain and bruising. R1 further alleged V9 had previously degraded and verbally mistreated R1.On 5/6/2026 at 9:24 AM, V11 (R1's) Power of Attorney (POA), stated R1 called V11 on 5/2/2026 at approximately 7:00 PM crying hysterically and emotionally distressed following the incident. V11 stated V11 subsequently contacted the facility and spoke with V9 CNA, who admitted the wheelchair struck R1's foot while being forcefully removed from beside the bed. V11 provided a text message sent to V3 Social Services Director (SSD) on 5/2/2026 at 8:07 PM documenting the allegation. The text message stated, Mom (R1) just called and said that one of the nurses rammed a wheelchair into her (R1's) leg. The nurse (V9) said the wheelchair was stuck under the bed and she (R9) pulled it out and it ran over her (R1's) foot. V11 stated V11 received no response from facility staff after reporting the allegation.On 5/6/2026 at 11:18 AM, V9 Certified Nursing Assistant (CNA) admitted V9 yanked the wheelchair from under the bed and accidentally struck R1's foot. V9 acknowledged R1 became upset and was yelling following the incident.On 5/6/2026 at 2:15 PM, V10 Licensed Practical Nurse (LPN) stated V9 informed V10 on 5/2/2026 that the wheelchair struck R1's foot. V10 stated V10 notified V8 Assistant Director of Nursing (ADON) regarding the incident and obtained statements from R1 and V9 CNA.On 5/6/2026, V8 Assistant Director of Nursing (ADON) stated V8 received notification from V10 LPN on 5/2/2026 regarding the wheelchair incident involving R1's foot. V8 ADON acknowledged V8 did not report the allegation to the Administrator on the date of the incident.Record review revealed an incident note dated 5/5/2026 documenting that administration, the physician, ombudsman, and local police department were not notified until 5/5/2026 after the POA came to the facility and met with administration. The incident note documented that V9 CNA was suspended pending investigation on 5/5/2026.Record review further revealed Nurse Practitioner documentation dated 5/4/2026 noted R1 reported a CNA hit R1's toe with a wheelchair. Additional documentation dated 5/6/2026 confirmed bruising, pain, and tenderness to the left toe and foot with x-rays ordered due to continued pain. V16 Nurse Practitioner (NP) confirmed on 5/6/2026 at 10:45AM, that physician notification should have occurred on 5/2/2026 when the allegation and injury were first reported.The facility failed to ensure allegations of abuse and injury were immediately reported to administration and other required officials, failed to ensure timely physician notification, and failed to initiate a timely investigation upon receipt of the allegation. These failures had the potential to delay resident protection, investigation, and implementation of interventions to prevent further abuse or mistreatment.

Based on observation, interview, and record review the facility failed to provide incontinence care/catheter care in a timely manner and failed to maintain a urinary catheter bag below the level of the bladder for one resident (R1) and failed to use appropriate hand hygiene for another resident during incontinence care (R5) of three residents reviewed for incontinence care in a sample list of eight residents.Findings Include:R1's Care Plan updated 10/2/25 includes the following diagnoses: Open Wound to the Abdominal Wall, Polyneuropathy, Spondylosis, Severe Obesity, Reduced Mobility, Repeated Falls, Chronic Clostridium Difficile, History of MRSA (Methicillin Resistant Staphylococcus Aureus), and History of Total Knee Replacement.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and totally dependent on staff for mobility and incontinence care.On 11/19/25 at 11:30AM, R1 was observed returning from a doctor's appointment. R1 was brought to R1s room. R1 told V7, Certified Nursing Assistant (CNA) she needs to go to bed to be cleaned as she has diarrhea. There was an odor of feces around R1. At 12:50PM, R1 was in bed with the sling type mechanical lift sling under her and her catheter bag was lying on her abdomen. V7 was in the room alone with R1. R1 stated, They haven't cleaned me since I got back at 11:30AM. V7 stated, We were busy with lunch and I had to get some help. V7 left the room to get help after verifying R1 had not been cleaned since returning from the doctor's appointment.On 11/19/25 at 1:30PM, V2 Director of Nursing verified R1 should have been cleaned up sooner especially given R1 has an open wound to her abdomen.On 11/19/25 at 12:00PM, V6 Certified Nursing Assistant (CNA) was completing incontinence care for R5 following R5 being incontinent of bladder and bowel. V6 first cleaned the urine from R5 and cleansed R5's perineal area. With the assistance of V3 ADON (Assistant Director of Nursing), V6 turned R5 on her left side and cleansed the feces off R5's anal area. V6 failed to complete hand hygiene or change gloves before to applying barrier cream to R5's abdominal fold. When asked, V6 verified she should have completed hand hygiene and donned clean gloves prior to applying the cream to R5's abdominal fold. V3 verified V6 should have performed hand hygiene and changed gloves prior to applying the cream.The facility's policy Toileting and incontinence care Revised 6/25/25 states, All will receive assistance with toileting needs according to their Plan of Care Guidelines. Incontinence care will be provided to keep skin clean, dry, free of irritation and odor. Incontinence care will be provided after each incontinence episode.

Based on interview, observation, and record review the facility failed to assess one resident (R1) for safety to self-medicate of three residents reviewed for self-medication in a sample list of eight residents. Findings Include:R1's Care Plan updated 10/2/25 includes the following diagnoses: Open Wound to the Abdominal Wall, Polyneuropathy, Spondylosis, Severe Obesity, Reduced Mobility, Repeated Falls, Chronic Clostridium Difficile, History of MRSA (Methicillin Resistant Staphylococcus Aureus), and History of Total Knee Replacement.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact and totally dependent on staff for mobility and incontinence care.There is no documentation of a self-medication assessment documented in R1's electronic medical record. R1's Care Plan does not address self-medication. On 11/19/25 at 12:50PM, R1 had a brown capsule on the over the bed table in a medication cup. R1 was not able to verbalize what pill it was but stated, They just leave my medicine and I take it. R1 swallowed the capsule and disposed of the cup. On 11/19/25 at 1:00PM, V5 Registered Nurse (RN) was at the medication cart in the hall outside R1's room. V5 verified V5 is the nurse caring for R1. V5 stated, (R1) is totally with it mentally. I thought she would take it, it's her Gabapentin. R1's Medication Administration Record (MAR) documents R1 has a current order for Gabapentin 300 milligrams four times daily. V5 verified V5 is aware she should watch residents swallow medication and not leave medication at bedside without a specific physician's order to do so.On 11/19/25 at 1:15PM, V2 Director of Nursing verified R1 is not to receive medication without the nurse on duty watching R1 take them. V2 verified R1 is not on a self-medication program and R1 has no physician's order to self-administer any medication.The facility's policy Administration of Medication revised 5/2025 states Self-Administration of medication is permitted when approved by the Intradisciplinary Team (IDT) with a written order by the primary attending physician.

Based on Observation, Interview, and Record Review the facility failed to prevent a fall with injury by failing to provide adequate staff assistance during a therapy session for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1 falling forward out of a bed and landing on the floor and hitting R1's head on the floor. R1 sustained a laceration to the head which required emergency treatment and 15 staples to close. Findings Include:R1's Emergency Department Notes dated 10/31/25 at 6:15PM document R1 has a laceration and received 15 staples to the frontal part of the head due to a fall. R1's Progress Note dated 10/31/25 documents Therapy informed this nurse that resident fell. She reported that she had resident sitting on the side of the bed and she walked to other side of bed. Upon assessment resident was lying on her stomach with her head turned to the left in between both beds. Bleeding present from head. Resident reported she hit her head on her night stand.R1's Minimum Data Set assessment dated [DATE] documents R1 is cognitively intact. R1's Care Plan documents a fall intervention for therapy to have two assist on 10/31/25 when completing sessions. On 11/4/2025 at 12:15PM, R1 was eating lunch at the table. R1 had staples from the middle of R1's head and down the right side of her head. R1 stated that on 10/31/25 the therapist came in after dinner and R1 already had R1's gown on. R1 stated she was tired. R1 stated the therapist seemed very rushed and wanted R1 to sit on the side of the bed and then stand. R1 stated she could not stand, and the therapist had a very hard time getting R1 on the side of the bed. R1 stated she sat on the side of bed and felt like she was going to fall. R1 stated the therapist walked away from R1. R1 stated she fell forward hitting the bedside table and was lying in a pool of blood until the paramedics arrived. R1 stated the therapist was at the end of the bed and just watched R1 fall. On 11/5/2025 at 11:45 AM, R1 was lying in a bariatric bed with approximately three inches of space on each side of R1. Two Certified Nursing Assistants and a nursing student brought in a mechanical lift to transfer R1 from the bed to the wheelchair. R1 required maximum assistant with turning side to side to place the sling underneath R1. On 11/5/2025 at 11:55AM, R4 is cognitively intact per her minimum data set assessment dated [DATE]. R4 stated R4 watched the physical therapist assistant start therapy with R1 (on 10/31/25). R4 stated the therapist watched R1 fall forward and hit her head. R4 stated the physical therapist assistant did not try to help R1. R4 stated there are always two people in the room when getting R1 up to her wheelchair, and throughout the night to help turn R1. On 11/4/2025 at 10:05AM, V3 (Certified Nursing Assistant) stated R1 requires a mechanical lift for transfers and always requires two people for care due to R1's overweight status. R1 requires maximum assistance with turning and repositioning and getting into the wheelchair. On 11/4/25 at 10:20AM, V4 (Physical Therapist) stated she evaluated R1 on 10/28/25 due to R1's functional decline. V4 stated R1's goals were to improve ability to safely transfer from lying on the back to sitting on the side of the bed, with feet flat on the floor. V4 stated R1 is dependent on staff due to R1 being overweight. R1's limited ability and the physical therapist assistant completing therapy on 10/31/25 should have had another person with her due to R1's limited mobility in bed. On 11/4/2025 at 11:35 AM, V6 Physical Therapist Assistant (PTA) stated she was completing therapy with R1 on 10/31/25. V6 stated V6 asked R1 to sit on the side of the bed and had a walker in front of R1 to help stabilize R1. V6 stated R1 is dependent with bed mobility and does not stand. V6 stated she had R1 sitting on the side of the bed, but stated R1 was on the edge of the bed. V6 stated she let go of R1 and was walking to the other side of the bed to try to pull R1 into the middle of the bed when R1 fell forward off the bed and hit the bedside table. R1 fell forward face first. V6 stated before the therapy session started V6 looked outside of the room to see if anyone was available and didn't see anyone so went to work with R1. On 11/5/2025 at 9:37AM, V9 Licensed Practical Nurse (LPN) stated the physical therapist assistant (PTA) came and got her that night and stated there was blood all over the floor. V9 stated she immediately called 911. V9 stated the PTA never asked for assistance with R1. V9 stated due to R1's weight, and needing maximum assistance, the PTA should not have started the therapy session until someone was available to help balance R1. On 11/5/2025 at 11:05AM, V2 Director of Nursing (DON) stated V6 (PTA) should have had two people working with R1 for safety concerns as R1 is dependent and needs help with bed mobility, transfers and dressing. V2 stated V6 (PTA) should have waited to complete the therapy session until somebody could help her. V2 stated that the lack of safety concern and not having two people in with R1 resulted in the fall which caused R1 to need emergency medical treatment and including 14 staples to her head. On 11/4/2025 at 12:45 PM, V10 (R1's Nurse Practitioner) stated R1 has had a decline since R1 was admitted from the last stay. V10 stated R1 has limited mobility and is completely dependent on staff while rolling side to side. R1 also needs maximum assistance with activities of daily living, V10 stated, because R1 requires maximum assistance and weighs 343 pounds. V6 PTA needed someone else to assist with R1 while completing therapy to provide a safe therapy session. V10 stated that R1 is alert and orientated and the therapist walked away from R1 without holding onto R1.The Facility's Safety Policy revised on 9/23 documents that the staff will support the resident's body well during all positioning, transferring and ambulation. Avoid pulling on the resident's extremities. Provide two or more persons to assist when necessary for resident and staff safety.

Based on observation, interview, and record review the facility failed to implement interventions to prevent and treat pressure ulcers and failed to complete initial wound assessments for three residents (R24, R84, R140) of five residents reviewed for pressure ulcers in a sample list of 38. Findings include: 1. R140's current diagnoses list includes the following diagnoses: Type II Diabetes, Morbid Obesity, Congestive Heart Failure, Chronic Kidney Disease Stage III, History of Cerebral Infarction, Major Depression, Difficulty in Walking, Anemia, and Pilonidal Cyst with abscess. R140's Minimum Data Set (MDS) dated [DATE] documents R140 is mildly cognitively impaired and requires a wheelchair for mobility. R140's Care Plan reviewed 4/21/25 documents R140 requires a specialized air mattress and is to be turned and repositioned every two hours and as needed. On 5/18/25 at 10:00AM R140 was seated in his wheelchair beside his bed. R140's sweat pants were soaked down to his knees in the front. R140's bed was stripped and there was no air mattress in place to the bed. R140 stated he hadn't had an air mattress for a while. R140 stated I stay up in the wheelchair from breakfast until after lunch. On 5/19/25 at 12:00PM R140 was again seated beside his bed. R140's bed again did not have a specialized mattress in place. R140 was eating his lunch. V26, R140's family member was assisting and encouraging R140 to eat. V26 stated I visit (R140) at least two or three times a week. (R140) is always constantly up in the wheel chair from before breakfast until after lunch. (R140) has that sore spot on his butt and he hasn't had an air mattress since he got back from the hospital. R140's treatment order dated 4/24/25 documents a current physician's treatment order for Sacrum: Cleanse area with wound cleanser, pat dry, apply Medihoney to wound bed, and cover with dry clean dressing daily and PRN (as needed). R140's Wound Assessment Detail Report dated 5/13/25 at 2:12PM by V11, Assistant Director of Nursing (ADON) documents R140 has a facility acquired infectious full thickness wound on his sacrum measuring 0.50 x 0.30 x 0.10 (Length x Width x Depth) Centimeters. On 5/20/25 at 10:30AM R140's wound was observed during the daily dressing change and noted to appear unchanged from the 5/13/25 assessment. On 5/19/25 at 1:00PM V11 verified (R140) should have a special mattress and hasn't had one for some time and (R140) should be repositioned at least every two hours and kept clean and dry to prevent skin breakdown. 2.) On 5/18/25 at 9:11 AM R24 was lying in bed. R24 stated R24 has a sore on his bottom that isn't getting better. At 10:50 AM, 12:15 PM, 12: 25 PM, 12:50 PM, and 2:26 PM R24 was sitting in his wheelchair. On 5/19/25 at 11:01 AM R24 was sitting in his wheelchair near the third floor elevator. At 12:06 PM R24 was in his wheelchair in the first floor dining room. On 5/19/25 at 1:00 PM R24 was sitting in his wheelchair in his room, R24 was leaning forward and to the left. V22 and V5 Certified Nursing Assistants (CNAs) transferred R24 into bed using a full mechanical lift. On 5/19/25 at 1:30 PM V5 CNA stated R24 was assisted into the wheelchair at 9:30 AM and had not been laid down or offered to lay down prior to 1:00 PM. V5 confirmed R24 is supposed to be repositioned every two hours to offload pressure from R24's bottom. V5 stated usually R24 stays in bed, but R24 was in activities this morning and R24's family likes for R24 to get out of bed. On 5/19/25 at 1:12 PM V11 Assistant Director of Nursing (ADON) and V15 Registered Nurse (RN) entered R24's room and administered R24's pressure ulcer treatment. R24 had a linear, backwards L shaped wound, that contained pink and white/yellow tissue. V11 stated R24's wound is a stage three pressure ulcer that had recently healed in April and then reopened as a stage three. R24's Minimum Data Set (MDS) dated [DATE] documents R24 has moderate cognitive impairment, is dependent on staff assistance for toileting, bed mobility, and transfers; and R24 is always incontinent of bowel and bladder. R24's active Care Plan documents R24 has a stage three coccyx pressure ulcer and includes an intervention dated 2/5/25 for turning and repositioning every two hours and as needed. This care plan does not document that R24 refuses repositioning. R24's May 2025 Treatment Administration Record documents the following: On 5/10/25 a treatment was initiated to cleanse and dry coccyx wound and apply dry dressing daily and as needed (entered by V15 RN). On 5/12/25 R24's coccyx wound treatment was changed to cleanse and dry wound, apply medicated honey, and cover with a dry dressing daily and as needed. R24's Wound Assessment Detail Report dated 4/4/25 documents R24's stage four facility acquired coccyx pressure ulcer was healed. R24's Wound Assessment Detail Report dated 5/12/25 documents R24's facility acquired stage three coccyx pressure ulcer measured 6 centimeters (cm) long by 2.5 cm wide by 0.1 cm deep, and 30% of the wound bed was white, fibrinous slough (dead tissue). There is no documentation in R24's medical record that this wound was measured/assessed on 5/10/25, when first identified, prior to 5/12/25. R24's Wound Assessment and Plan dated 5/14/25, recorded by V24 Wound Physician, documents R24's stage three coccyx pressure ulcer measured 5 cm by 4 cm by 0.1 cm. This plan includes recommendations to offload per facility policy. R24's Wound Assessment and Detail Report dated 5/19/25 documents R24's pressure ulcer measured 6 cm by 2 cm by 0.1 cm, and 40% of the wound bed contained white slough. On 5/20/25 at 10:31 AM V15 RN stated R24's coccyx wound reopened the day V15 entered the order for the dry dressing. V15 stated V15 did not document an assessment of the wound as it was towards the end of his shift. V15 described the wound as being smaller but deeper than it is now. On 5/19/25 at 11:43 AM V11 stated the facility has had prior discussions with R24's family regarding hospice care or a feeding tube. V11 stated R24's family wanted to see what R24's weight is this week before deciding on whether to move forward with hospice. R24's family is leaning more towards hospice since R24 does not want a feeding tube. On 5/20/25 at 12:16 PM V11 stated the floor nurses notify nurse management/wound nurse of newly identified pressure ulcers and the floor nurse should document an initial assessment of the wound in the nursing notes if the wound nurse is not available. V11 stated V11 thought the facility has 72 hours to document a wound assessment for a newly identified wound. At 12:55 PM V11 confirmed there was no documented assessment of R24's reopened coccyx wound prior to 5/12/25. 3.) On 5/18/25 at 2:22 PM V10 CNA Coordinator removed R84's socks. R84 had a small dark scabbed area on the left heel. On 5/19/25 at 1:32 PM R84 was lying in bed and was not wearing pressure relieving boots. R84's heels were directly on the mattress. R84's heel boots were in the wheelchair beside R84's bed. On 5/19/25 at 3:00 PM V25 CNA stated today was the first time V25 was assigned to R84 and V25 was unsure if R84 has a pressure ulcer. V25 stated R84's pressure relieving interventions are turning and repositioning in bed every two hours and using pillows behind R84's back to position R84 on her side. V25 was unsure of any pressure relieving interventions for R84's feet and was unsure if R84 uses pressure relieving boots. V25 stated V25 has access to resident care plans and would look there to determine what pressure interventions should be used. V25 entered R84's room and confirmed R84's heels were directly on the mattress and R84's pressure relieving boots were in R84's wheelchair. R84 allowed V25 to apply R84's boots. R84's MDS dated [DATE] documents R84 is dependent on staff assistance for lower body dressing and uses substantial/maximal assistance for turning in bed. R84's active Care Plan documents R84 has a deep tissue injury of the right heel, and interventions include the use of pressure relieving boots and to monitor and document wound assessments. This care plan does not document R84 refuses pressure relieving boots. R84's Nursing Notes document the following: On 2/7/2025 R84 admitted to the facility following a fall with right femur fracture. R84 discharged home on 4/30/25 and readmitted to the facility on [DATE]. R84's Wound Assessment and Plan dated 3/27/25, recorded by V24 Wound Physician, documents R84's right heel pressure ulcer measured 2 cm by 2 cm and was 100% eschar, dead tissue. This plan includes recommendations for offloading per facility policy and offloading boot was in place. R84's Wound Assessment and Plan dated 4/3/25 documents this pressure ulcer measured 2 cm by 1.5 cm. R84's Wound Assessment and Plan dated 4/24/25 documents this pressure ulcer measured 1 cm by 1 cm and was 100% covered in eschar. This plan documents the facility is contacting R84's family regarding possible hospice as R84 is overall declining. R84's Wound Assessment Detail Report dated 5/5/25 documents R84's right heel pressure ulcer was present on readmission on [DATE]. The wound measured 1 cm by 2 cm by 0.1 cm and the wound photograph shows a dark scabbed area. R84's Wound Assessment Detail Report dated 5/12/25 documents R84's right heel pressure ulcer measured 1 cm by 1 cm by 0.1 cm. R84's Wound Assessment and Plan dated 5/14/25, recorded by V24, documents R84's right heel unstageable pressure ulcer was 1 cm by 1 cm and 100% covered in eschar. R84's Nutrition/Dietary Notes dated 3/30/25, 4/2/25 and 4/16/25 document R84 had significant weight loss with supplements and medications in place to address this weight loss. These notes document R84 had no skin breakdown. R84's March, April and May 2025 Medication and Treatment Administration Records document the following: Pressure relieving boots were initiated 3/12-4/30/25 and 5/5/25. Daily skin protectant to right heel initiated 4/4-4/30/25 and 5/6/25. Multivitamin daily, Zinc 50 milligrams (mg) daily, Prostat 30 milliliters twice daily, and Vitamin C 500 mg twice daily for wound healing scheduled to begin on 4/24/25, but not implemented, and initiated on 5/2/25. On 5/20/25 at 12:16 PM V11 ADON confirmed R84 is supposed to have heel boots on when in bed. V11 stated R84 has had an overall decline related to failure to thrive and there is an upcoming care plan scheduled with R84's family to discuss hospice. V11 stated the facility discussed hospice with R84's family previously, but R84's family decided to take R84 home. V11 stated Vitamin C, Zinc, Multivitamin and Prostat should have been implemented as it is the facility's standard protocol for wound care. At 12:55 PM V11 confirmed there was no documented assessment of R84's right heel pressure ulcer on 5/2/25 when R84 readmitted to the facility, prior to 5/5/25. V11 confirmed R84's right heel wound was initially facility acquired, had not healed, and was present on readmission on [DATE]. On 5/20/25 at 12:42 PM V23 Registered Dietitian stated if V23 was aware of R84's right heel pressure ulcer it would be documented in V23's notes. V23 stated V23 would have ordered Vitamin C, Zinc, Multivitamin with minerals and liquid Prostat to aid in wound healing if V23 was aware of R84's pressure ulcer. The facility's Skin Care Prevention policy dated April 2025 documents residents identified as being at increased risk for skin breakdown shall be repositioned as needed and based on the resident's assessment, and pillows or positioning devices may be used between skin surfaces or to elevate bony prominences and pressure areas off of surfaces. This policy documents pressure redistribution mattresses may be used on beds and in chairs for residents identified to be at risk for skin breakdown. The facility's Pressure Ulcer, Lower Extremity Ulcer Treatment and Documentation policy dated April 2023 documents to notify the wound nurse upon identified skin impairment, and if the wound nurse is not available the floor nurse will document the open area and notify the provider for orders. The wound nurse is responsible for assessing, measuring, and photographing the wound; reviewing the orders; ad updating notes and care plans as appropriate.

Based on observation, interview and record review, the facility failed to provide assistance with fingernail care, eating, and shaving for four of four residents (R24, R26, R190, R38) reviewed for Activities of Daily Living in the sample list of 38. Findings include: 1.) On 05/18/25 at 2:26 PM R24's fingernails were long, approximately 1/4 inch past fingertips, and jagged. On 5/19/25 at 11:01 AM R24's fingernails remained long and jagged. On 5/19/25 at 1:12 PM V11 Assistant Director of Nursing (ADON) confirmed R24's fingernails were long and jagged. V11 stated the Certified Nursing Assistants (CNAs) are supposed to trim and clean fingernails as needed and V11 will have the CNAs trim R24's fingernails. R24's Minimum Data Set (MDS) dated [DATE] documents R24 has moderate cognitive impairment and is dependent on staff assistance for personal hygiene. R24's active care plan does not document R24 refuses nail care. 2.) On 5/18/25 at 8:41 AM R26 was lying in bed and R26's fingernails were long, approximately 1/4 inch past fingertips, and jagged. There was a dark substance underneath R26's fingernails. On 5/19/25 at 2:49 PM R26's fingernails were long, jagged, and had a dark substance underneath. V11 ADON checked R26's fingernails and confirmed they were long, jagged and dirty. V11 stated V11 will follow up with the CNAs to provide nail care. R26's MDS dated [DATE] documents R26 has severe cognitive impairment and is dependent on staff assistance for personal hygiene. R26's active care plan does not document R26 refuses nail care. 3.) On 5/18/25 at 8:48 AM R190 was in bed and had facial hair stubble to upper lip, chin, and cheeks. R190 stated R190's family member was supposed to be bringing R190 a razor since the facility has not offered to shave R190 or provided a razor. R190 stated he would like to be shaved. On 5/19/25 at 10:57 AM R190 still had facial hair stubble. R190 stated R190 is supposed to have a shower today. On 5/19/25 at 2:49 PM V11 ADON stated residents should be shaved on shower days. At 3:04 PM V11 stated R190 had a shower today. V11 entered R190's room and asked R190 if R190 wanted to be shaved. R190 still had facial hair stubble. R190 told V11 that R190 had not been shaved since admitting to the facility and R190 prefers to be clean shaven. R190's Care Plan dated 5/15/25 documents R190 admitted to the facility on [DATE] and requires extensive assistance of one staff person for bathing/showering. R190's Shower Sheet dated 5/19/25 documents R190 received a shower and R190 was not shaved. 4.) On 5/18/25 at 12:15 PM, 12:25 PM, 12:40 PM and 12:50 PM R38 was lying in bed and R38's meal tray was covered on an overbed table in R38's room near the foot of the bed. There was no staff present in R38's room. On 5/18/25 at 12:51 PM V5 CNA stated R38 is not able to feed himself and requires staff to feed R38. V5 stated V5 had not attempted to feed R38 lunch and V7 CNA is assigned to R38's hall. V6 CNA entered R38's room. V6 stated V6 is going to feed R38 lunch now. V6 confirmed V6 had not attempted to feed R38 lunch earlier. V6 uncovered R38's meal, which was untouched, and began feeding R38. At 1:52 PM V7 CNA stated V7 had not served R38's lunch meal tray and had not assisted R38 with lunch. V7 confirmed V7 was assigned to R38's hall and should have been notified when R38's meal was served. On 5/19/25 at 2:49 PM V11 ADON stated the CNAs should assist residents with eating at the time the meal tray is delivered to the resident's room. R38's MDS dated [DATE] documents R38 has severe cognitive impairment and is dependent on staff assistance for eating. The facility's Nail Care (Finger and Toes) policy dated April 2025 documents resident's nails will be kept clean and neat in order to provide cleanliness, prevent spread of infection and skin problems, and for comfort. This policy documents resident refusal of nail care will be documented in the resident's care plan. The facility's Shaving Resident policy dated August 2017 documents facial hair will be shaved by the CNAs on shower days and as needed or requested; and the charge nurse is responsible for ensuring residents who prefer to be shaved are free of facial hair. The facility's Feeding the Dependent Resident policy dated 8/2/17 documents to take the meal tray into the resident's room, place the tray directly in front of the resident, cut the food into small portions, give the resident your complete attention, sit at the same level as the resident while assisting with the meal, and remove the meal tray when the resident is finished eating.

Based on observation, interview and record review, the facility failed to accurately code the minimum data sheet (MDS) for three (R24, R38, R76) of 17 residents reviewed for MDS accuracy in a sample size of 38. Findings include: 1.) R76's MDS dated [DATE] documents R76 has limited range of motion (ROM) in bilateral lower extremities and no impairment in upper extremities ROM. R76's prior MDS dated [DATE] documents no impairment in upper and lower extremities. On 05/20/25 at 09:22 AM R76 used both hands and arms in the hallway. R76 had left hand contracture in a semi-fist position. R76 did not flex fingers on the left hand. 2.) R38's MDS dated [DATE] documents one sided impaired ROM to upper and lower extremity. R38's 10/22/24 and 1/6/25 MDS does not document impaired ROM. R38's 7/1/24 MDS documents one sided impaired ROM to upper and lower extremity. On 05/20/25 at 09:31 AM V19 CNA, stated she does ROM with R38 every morning. V19 stated R38 has been totally dependent on staff for activities of daily living since time of admission and no changes have been seen. V19 stated R38 has upper and lower extremity impaired ROM. 3.) R24's MDS dated [DATE] documents one sided impairment for ROM to upper and lower extremities. R24's previous MDS dated [DATE] documents no impairment to upper and lower extremities. On 05/19/25 at 11:19 AM V5 CNA stated V5 has always used a mechanical lift for R24 for transfer since he admitted to the facility. R24 can move his arms and legs just fine. R24 helps with feeding. R24 can hold his legs up to dress him when he's in bed. On 05/19/25 at 12:58 PM V22 CNA, and V5 CNA entered R24's room. R24 was leaning forward and left in the wheelchair, pillow positioned beside R24. V22 and V5 used a mechanical lift to transfer R24 into bed. R24 demonstrated ability to move legs and left arm. R24's right arm remained at his side. V22 and V5 stated R24 can move both arms. On 05/20/25 at 09:29 AM R24 was holding a coffee cup with his right hand and drinking unassisted. On 5/20/25 at 10:00 AM V16 on 5/20/25, V16 MDS Coordinator stated V16 misunderstood what impaired ROM meant when previously coding MDS's and V16 has since had education regarding what ROM assessments entailed. At 2:00 PM V1 Administrator stated V16 should have completed corrections to any MDS submitted that were inaccurate. The facility's policy titled Resident Assessment Instrument dated August 2017 documents the purpose is to provide guidelines for identifying resident care needs, strengths, and assisting the resident to attain their highest practical level of mental and physical function and well-being. It is the responsibility of all resident care providers under the supervision of the attending physician to ensure that the resident is accurately and thoroughly assessed per MDS 3.0 Manual guidelines.

Based on observation, interview, and record review the facility failed to administer medications as ordered for three of nine residents (R24, R50, R78) reviewed for medication administration in the sample list of 38. This failure resulted in three medication errors out of 25 opportunities, a 12% medication error rate. Findings include: 1.) R24's May 2025 Medication Administration Record (MAR) documents to administer Novolin Regular Insulin per blood glucose (milligrams per deciliter) based sliding scale, with meals, scheduled at 8:00 AM, 12:00 PM, and 5:00 PM. On 5/19/25 at 12:06 PM R24 was in the main dining room eating lunch. On 5/19/25 at 12:30 PM R24 was in R24's room. V15 Registered Nurse (RN) administered 6 units of Novolin Regular Insulin into R24's abdomen. V15 stated V15 checked R24's blood sugar just a few minutes prior, which was 280. V15 confirmed R24 already ate lunch prior to R24's blood glucose check and insulin administration. On 5/20/25 at 1:50 PM V1 Administrator stated blood glucose should be checked prior to meals. V1 confirmed sliding scale insulin should be administered based on blood glucose results obtained prior to meals, unless ordered differently. 2.) R78's May 2025 MAR documents to administer Metoprolol Tartrate 25 milligrams (mg) one half tablet by mouth twice daily, hold for systolic blood pressure less than 130 and heart rate less than 90 beats per minute. On 05/19/25 at 3:45 PM V17 RN checked R78's blood pressure and heart rate which was 136/80 and 72. V17 administered R78's medications, including Metoprolol Tartrate 25 milligrams one half tablet by mouth. The medication card indicated to check blood pressure and heart, hold for systolic blood pressure less than 130 or if heart rate less than 90. At 3:52 PM V17 verified R78's Metoprolol card and physician ordered parameters. V17 confirmed V17 should not have administered this medication since R78's heart rate was less than 90. 3.) R50's May 2025 MAR documents to administer Carvedilol 3.125 mg one tablet by mouth twice daily. Hold for systolic blood pressure less than 110 or heart rate less than 60. On 5/19/25 at 4:02 PM V3 RN administered R50's medications, including Carvedilol 3.125 mg one tablet by mouth. V3 did not check R50's blood pressure or pulse prior to administering this medication. At 4:09 PM V3 stated R50's blood pressure is checked daily. V3 confirmed R50's physician's ordered parameters for Carvedilol. V3 confirmed V3 did not check R50's heart rate and blood pressure prior to administering Carvedilol. The facility's pharmacy policy titled Administration Procedures for All Medications, dated 10/25/14, documents to check the MAR for the order and not any contraindications the resident may have prior to administering the medication. This policy documents to check the label against the order on the MAR and obtain/record any vital signs or other ordered monitoring parameters prior to medication administration.

Based on observation, interview and record review, the facility failed to appropriately label and store medications and account for controlled medications for five of 16 residents (R40, R61, R71, R192, R63) reviewed for medication storage in the sample list of 38. Findings include: The facility's pharmacy policy titled Administration Procedures for all Medications, dated 10/25/14, documents to check the expiration date on package and container prior to medication administration and to label an opened date on multi-dose containers. The facility's Narcotic Count policy dated 9/5/22 documents a physical count of narcotics will be done by the oncoming and off-going nurses at each change of shift to identify discrepancies and to ensure controlled medications are handled, stored, disposed of and accounted for properly. This policy documents the controlled medication record will accompany the controlled medication. The facility's Storage of Medications policy dated April 2025 documents all resident medications should be stored in a locked cabinet, locked medication room, or locked medication cart. The facility's Self Administration of Medication policy dated April 2025 documents the care plan will reflect self-administration of medications and there will be a physician's order. This policy documents medications kept in a resident's room must be done in a way that prevents access by other residents, and only medications approved for self-administration may be left at the bedside. 1.) On 5/18/25 at 2:41 PM the short hall medication cart on the second floor was reviewed with V4 Licensed Practical Nurse. R40's Glargine insulin pen was opened, dated with dispensed date of 3/2/25, and was not labeled with an opened date. R61's Lispro insulin vial was labeled with an opened date of 4/13/25 and discard date of 5/11/25. R71's Lispro insulin vial was labeled with opened date of 4/13/25 and discard date of 5/11/25. V4 confirmed the labeling of these medications. There was a bottle of Clonazepam (controlled medication) 1 milligram tablets labeled with R192's name. The controlled medication binder on the cart did not contain a controlled count sheet for this bottle of Clonazepam. V4 stated R192's bottle of Clonazepam was brought in from home yesterday or the day prior, but there was no count sheet for this medication. V4 stated the nurses are suppose to count the controlled medications and complete a count sheet. On 5/20/25 at 12:16 PM V11 Assistant Director of Nursing (ADON) stated controlled medications brought from home or an outside pharmacy should be counted and documented on a controlled medication form. R40's May 2025 Medication Administration Record (MAR) documents to administer Insulin Glargine 100 units/milliliter (u/ml) give 10 units subcutaneously daily at 6:00 AM as of 3/31/25. R61's May 2025 MAR documents to administer Insulin Lispro 100 u/ml subcutaneously per blood glucose based sliding scale four times daily as of 4/16/25. R71's May 2025 MAR documents to administer Insulin Lispro 100 u/ml 8 units subcutaneously three times daily as of 1/17/25. R192's Census documents R192 admitted to the facility on [DATE]. R192's May 2025 MAR documents to administer Clonazepam 1 mg one tablet by mouth three times daily as of 5/15/25. The Insulin Glargine Highlights of Prescribing Information dated November 2018 documents vials/pens are good for 28 days once opened. The Insulin Lispro Highlights of Prescribing Information dated September 2023 documents vials are good for 28 days once opened. 2.) On 5/18/25 at 8:12 AM and 8:23 AM R63 was in bed asleep with a medication cup in R63's hand that contained several pills. At 8:23 AM V14 Licensed Practical Nurse entered R63's room. V14 stated V14 gave those medications to R63 earlier this morning and usually R63 takes the medications, but R63 must have fallen asleep. V14 woke R63 and instructed R63 to take the medications. R63 stated the nurses leave her medications for her to take because they know R63 will take them. R63's active physician orders and care plan do not document self administration and bedside storage of medications. On 5/20/25 at 12:16 PM V11 ADON confirmed nurses should observe residents consume medications during medication administration and nurses should not leave the medications at the bedside. V11 stated there are currently no residents who are approved to self administer medications.

Based on observation, interview, and record review the facility failed to initiate contact droplet precautions for two residents (R36, R69) and failed to sanitize a blood glucose meter following use to prevent cross contamination for one resident (R24) of 17 residents reviewed for infection control in a sample list of 38. Findings Include: The facility's Glucose Meter Cleaning policy dated July 2019 documents clean and disinfect the blood glucose meter after each use with an Environmental Protection Agency approved cleaner. The facility's policy Transmission Based Precautions revised April of 2025 documents In order to prevent the spread of communicable diseases isolation will be initiated according to CDC (Center for Disease Control) transmission based guidelines. Transmission based guidelines will be used in all cases in which standard precautions does not provide adequate barrier protection. Transmission based guidelines will be used to determine whether airborne, droplet, or contact isolation precautions will be implemented. The CDC's Transmission Based Precautions guidance dated 4/3/24 documents to use contact precautions for patients with known or suspected infections that represent an increased risk for contact transmission, including use of gown and gloves for cares, limiting patient transport, placing the patient in a private room, using dedicated or disposable medical equipment or disinfecting shared medical equipment, and frequent cleaning/disinfection of rooms. This guidance documents to use droplet precautions for patients with known or suspected respiratory pathogens that can be spread through respiratory droplets by coughing, sneezing or talking. These precautions include having the patient wear a mask and follow respiratory hygiene/cough etiquette, preferably placing the patient in a single room, wearing a mask when entering the patient's room, and limiting transportation/movement of the patient. 1. R69's care plan updated 5/16/25 includes the following diagnoses: Mild Persistent Asthma, Type II Diabetes, and Morbid Obesity. R69's Minimum Data Set (MDS) dated [DATE] documents R69 is cognitively intact. R69's Care Plan dated 5/16/25 documents (R69), has Pneumonia, an infection of the respiratory system and receiving Antibiotic therapy thru 05/20/25. On 5/18/25 at 10:15AM R69 was lying in her bed. R69 was coughing frequently with a moist sounding cough. R69 stated, I have pneumonia and I have a bad cough. I cough so hard it hurts and I am worn out. R69's family member was at the bedside and confirmed R69 has pneumonia. R69 was observed to fail to cover her cough. There was no transmission based precaution sign on R69's door and no Personal Protective Equipment was placed outside near R69's room. R69's Advanced Practice Nurse's note dated 5/20/25 at 9:35AM documents, (R69) was sent to the Emergency Department (ED) yesterday due to coughing up blood. Reviewed (R69's) ED paperwork; (R69) received a CT (computed tomography) without contrast, CBC/CMP (Complete Blood Count/Complete Metabolic Panel), D-Dimer, PT/INR (Protime and International Normalized Ratio) and was diagnosed with pneumonia and prescribed azithromycin which she was already diagnosed with and taking. Patient was referred to a local nurse practitioner for follow up. Will refer provider to a local pulmonologist for follow up. 2. R36 is documented on the facility census of 5/18/25 as R69's roommate. R36's's Minimum Data Set (MDS) dated [DATE] documents R36 is severely cognitively impaired. R36's Nurse's Note dated 05/15/2025 at 2:19AM documents (R36) has a non-productive cough and is running a fever 101.6 F (degrees Fahrenheit). Tylenol 650 mg suppository was administered. (R36) refused cough syrup. Given sips of water. Will have Nurse Practitioner assess (R36) in the AM. On 5/18/25 at 10:15AM R36 was lying in her bed. R36 was coughing frequently with a moist sounding cough. R36 was unable to practice any kind of respiratory hygiene and was seen wiping her nose with her right hand and then touching bed linens. There was no transmission based precaution sign on R36's door and no Personal Protective Equipment was placed outside near R36's room. On 5/19/25 at 12:00PM and on 5/20/25 at 12:15PM R36 was seated in a wheelchair at a large table with other residents in the main dining room. R36 was noted to continue to cough. On 5/20/25 V11, Assistant Director of Nursing (ADON) verified that both (R36, R69) are roommates, and both are currently exhibiting respiratory signs and symptoms. V11 stated V11 would place both on contact droplet precautions. 4.) On 5/19/25 at 4:13 PM V3 Registered Nurse used a blood glucose meter, labeled with R24's name, to obtain R24's blood glucose level. V3 did not disinfect R24's blood glucose machine after use. V3 placed R24's blood glucose machine on top of the medication cart, contaminating the top of the cart. On 5/19/25 at 4:26 PM R24's blood glucose meter remained on top of the medication cart. V3 stated V3 was unsure how often blood glucose meters are disinfected. V3 confirmed V3 did not disinfect R24's blood glucose meter after use. On 5/20/25 at 12:16 PM V11 Assistant Director of Nursing stated a bleach wipe should be used to disinfect blood glucose meters after each use.

Based upon observation, interview and record review, the facility failed to maintain or improve range of motion and contractures following recommended restorative program for one (R76) of four residents reviewed in a sample size of 38. Findings include: The facility's policy titled Functional Maintenance Program dated April 2025 documents therapy will provide recommendations for maintenance programing based on therapy outcomes or screenings. Individual tasks will be documented in the Point of Care (POC) in the electronic health record (EHR). Measurable objectives, goals and interventions will be documented in the care plan. On 05/18/25 09:09 AM R76 was in bed and R76's right hand appeared contracted. On 5/20/25 at 9:22 AM R76 used hands and arms in the hallway. R76's left hand appeared contracted in a semi-fist position. R76 did not flex fingers on left hand. R76's face sheet dated 5/20/25 documents an admission date of 3/29/24 with a history of down syndrome, and adult failure to thrive. R76's MDS dated [DATE] documents R76 has limited range of motion (ROM) in bilateral lower extremities and no impairment in upper extremities ROM. R76's care plan dated 4/24/25 documents R76 has a deficit in activities of daily living related to down syndrome and cognitive impairments. Care plan does not document range of motion, contractures, or restorative program. R76's physical therapy discharge date d 1/16/25 documents Restorative Programs Established/Trained for range of motion, transfer program, and bed mobility all educated. On 5/19/25 at 9:42 AM V21 Director of Rehab/Certified Occupational Therapy Assistant stated R76 was discharged from physical therapy on 1/16/25. R76's transfer status was max assist with 75% cues, 2-person transfer. R76 was only able to walk with very maximum assistance and would not be safe for certified nurse aides (CNAs) to walk with her. R76 complained of knee pain which is partly why we stopped doing the walking. R76 stated restoratives were recommended for range of motion (ROM), transfers, and bed mobility, which can all be completed during activities of daily living (ADLs). On 5/20/25 at 11:45am V11 Assistant Director of Nursing stated the facility does not have a restorative program, they have a functional maintenance program. On 5/20/25 at 12:16pm V11 stated V11 did not have any documentation for functional maintenance program for R76 since it is provided by the CNAs as part of ADLs.

Based on observation, interview, and record review the facility failed to check gastric residual volume during gastrostomy tube (g-tube) medication administration for one of two residents (R26) reviewed for g-tubes in the sample list of 38. Findings include: The facility's Tube Feeding (Administration of Medication) policy dated April 2025 documents to stop the feeding, disconnect the tubing, and check the tubing for placement before administering medications. R26's Care Plan dated 2/10/25 documents R26 has a g-tube and to monitor gastric residual volume prior to administering nutrition and medications. On 5/19/25 at 3:06 PM V17 Registered Nurse stopped R26's feeding, disconnected the tubing, and checked g-tube placement using air rush technique with syringe. V17 did not check gastric residual volume prior to administering water flushes, Tylenol, and Vitamin D3 into R26's g-tube. V17 confirmed V17 did not check gastric residual at this time. V17 stated V17 checked R26's gastric residual earlier, at the beginning of his shift. On 5/20/25 at 12:16 PM V11 Assistant Director of Nursing confirmed gastric residual volume should be checked at the time of g-tube medication administration.

Based on observation, interview, and record review, the facility failed to implement a fall prevention intervention according to a resident's care plan. This failure affects one resident (R1) out of three reviewed for fall prevention on the sample list of three. Findings include: On 4/10/25 at 11:24 AM, R1 was lying in bed and did not make any verbal responses to a greeting by name and made no verbal responses to questions. There was an alarm sensor pad underneath R1 with a wire cord leading towards the foot end of R1's bed, however the cord was not plugged in to anything. There was an alarm box module on top of a four drawer bureau across the room approximately eight feet away from R1's bed. On 4/10/25 at 11:29 AM, V5, Registered Nurse, confirmed the alarm sensor was not plugged into the module as it should be. V5 further stated he had knowledge of R1's Care Plan containing a fall prevention intervention that R1 was to have the bed alarm and it should be maintained in a functional condition. R1's Care Plan documents a fall prevention intervention dated as initiated on 3/28/25 for a bed alarm placed for safety, and R1 needs increased supervision when in her room dated as initiated 3/27/25. On 4/10/25 at 11:52 AM, V3, Assistant Director of Nursing, stated she would make sure the nursing staff check R1's alarm. V1 Administrator stated something should be placed on R1's Physician Order Sheet to make sure the nurses check the alarm. V1 stated facility staff do 'Angel Rounds' every morning to check things like alarms. V1 stated R1 will occasionally unplug alarms, but then confirmed R1 would not be able to get the module across the room and on top of the bureau.

Based on observation, interview, and record review, the facility failed to report an injury of unknown origin to the state agency (Illinois Department of Public Health) in the required two hour time frame. This failure affects one resident (R1) out of three reviewed for injuries on the sample list of three. Findings include: On 4/10/25 at 11:24 AM, R1 was lying in bed and did not make any verbal responses to a greeting by name and made no verbal responses to questions. R1's Census Detail dated 4/10/24 documents R1 was admitted to the facility 1/14/25, with a subsequent admission 3/7/25. R1's Diagnoses List dated 4/10/25 documents R1 had surgical repair of a right trochanter (hip) fracture which was present on R1's admission of 1/14/25, and surgical repair of a displaced spiral fracture of the right distal femur (knee area) present on R1's admission of 3/7/25. R1's Minimum Data Set, dated dated dated [DATE] documents R1 received a score of 4 out of a possible 15 during a brief interview for mental status, indicating severe cognitive impairment, inattention, and disorganized thinking. This same Minimum Data Set documents R1 is dependent on staff for toileting, lower body dressing, putting on footwear, all bed mobility, and transfers. R1's Progress Notes dated 2/20/25 documented a facility nurse (V6, Registered Nurse) contacted R1's Power of Attorney (V22) with notification that R1's right leg was shortened and rotated, and that the Nurse Practitioner (V21) had ordered x-rays. R1's Progress Note dated 2/20/25 documents V21, Nurse Practitioner, had assessed R1 at 9:35 AM due to a report from the facility nursing staff that R1 was experiencing a shortened and rotated right leg, wouldn't allow staff to move her leg, and screamed out in pain when V21 manipulated R1's leg. V21 included in this note that R1 had not experienced any falls or trauma and did have the previous surgery of the right hip. V21 also documented she had ordered x-rays for R1. R1's radiological (x-ray) report dated 2/20/25 documents the facility had been informed of the x-ray results at 2:41 PM on 2/20/25. This report documents R1 had experienced a new comminuted (broken pieces) fracture of the distal (by the knee) femur, and that the prior hip fracture was stable and the hip repair hardware intact. R1's Diagnoses List (4/10/25) and hospital Discharge Report (3/7/25) further document this new fracture was a displaced spiral fracture. This hospital Discharge Report documents R1 was at the hospital for surgical repair of the new fracture from 2/21/25 through 3/7/25. On 4/10/25 at 11:52 AM, V3, Assistant Director of Nursing, related the time line of events involved with R1's assessment, x-ray, and results as documented in the nurses notes. V3 further stated the nursing managerial staff, including herself, had not been able to ascertain any cause associated with R1's fracture. V3 stated R1 could not explain anything except to say she had not fallen. V3 stated R1's physician (un-named) had stated the new fracture was pathological related to osteopenia (low bone density). V3 stated V21 thought there might be a fracture associated with the previous surgery site of R1's right hip. On 4/10/25 at 11:52 AM, V1 Administrator, she had conducted an investigation by interviewing staff and there was no evidence that R1 had fallen or twisted her leg. V1 stated the fracture was not reported to the Illinois Department of Public Health at all because the Nurse Practitioner (V21) examined R1 and since there was no bruising there was not a suspicion of abuse. V1 further stated the timeframe from when the nurse first noticed the right leg shortened and rotated to the Nurse Practitioner assessing R1, to the x-rays, to the doctor (un-named) saying the fracture was pathologic, was immediate. R1's Progress Notes dated 2/21/25 document the Director of Nursing (V2) entered a note to document R1's Physician (un-named) had made a statement that the new fracture experienced by R1 was pathological at 9:36 AM on 2/21/25, nineteen hours after the facility received the x-ray report, and 24 hours after V21's assessment. The facility's Abuse Prevention policy dated as revised January 2025 documents injuries should be classified as an injury of unknown source if there was no person who observed the source of the injury or if the resident could not explain the source of the injury, and if the injury is suspicious because of the extent of the injury.

Based on observation, interview, and record review the facility failed to develop and implement skin and pressure relieving interventions, evaluate nutritional status, maintain wound dressings, and accurately document wound assessments for three (R1, R3, R4) of three residents reviewed for pressure ulcers in the sample list of four. These failures resulted in R4 developing a stage two pressure ulcer that deteriorated into an unstageable pressure ulcer. Findings include: The facility's Skin and Wound Management Guidelines dated April 2023 documents preventative measures will be implemented for residents who are at risk for developing wounds and aggressive wound management will be initiated for wounds/pressure ulcers. This guide documents to complete Braden assessments upon admission and then weekly for four weeks, ensure the resident is added to the shower schedule and review shower documentation and weekly skin checks to ensure compliance and identify new wounds at an early stage. This guide documents to assess, measure, photograph and document wounds in the electronic software system, refer to the dietitian for recommendations for wound healing, obtain an order for wound physician consult and update the resident's care plan. The facility's Pressure Injury Preventions Guidelines and Suggested Interventions dated April 2023 documents poor diet may cause pressure injuries and nutrition should be evaluated. This guide documents residents who are dependent on staff for assistance should e assisted to reposition at least every two hours or per plan of care, position the resident at a 30 degree angle when turning on one side or the other, and residents at risk should avoid sitting in a chair for long periods without repositioning. 1.) On 2/18/25 at 10:37 AM V10 and V15 Certified Nursing Assistants (CNAs) entered R4's room and transferred R4 with a full mechanical lift from the bed to the shower chair. R4 had an open, pink/yellow wound, approximately quarter sized, that was not covered with a dressing. V15 stated R4 did not have a dressing over the wound since V15 came on shift and the dressing must have come off sometime on night shift. On 2/18/25 at 11:26 AM V16 Licensed Practical Nurse stated no one had reported that R4's wound dressing had come off prior to R4's shower. V16 stated V16 would expect the CNAs to notify V16 when a dressing has come off so that a new one can be applied. R4's Admission Minimum Data Set (MDS) dated [DATE] documents R4 has moderate cognitive impairment, impaired range of motion to one upper and one lower extremity, is dependent on staff transfers, requires substantial/maximal assistance from staff for turning in bed and bathing/showering, is always incontinent of urine. R4 has no pressure ulcers and is not on a turning and repositioning program. This MDS lists pressure relieving device for chair as the only skin/ulcer intervention. R4's MDS dated [DATE] documents R4 has moderate cognitive impairment, R4 is dependent on staff for turning in bed, transfers and bathing, and R4 has one stage three facility acquired pressure ulcer. R4's Braden assessment dated [DATE] documents R4 is at moderate risk for developing pressure ulcers. R4's Care Plan with initiated date of 12/24/24 and revised date of 2/5/25 documents R4 has potential for skin impairment related to decreased mobility, incontinence, and cerebrovascular accident, and R4 has a coccyx stage three pressure ulcer as of 1/16/25. This care plan documents an intervention dated 2/5/25 for turning and repositioning every two hours and as needed. R4's diagnoses include vascular dementia, type two diabetes mellitus, hemiplegia and cerebrovascular accident. There are no documented implementation of pressure relieving interventions on R4's care plan or in R4's medical record prior to R4 developing a pressure ulcer. R4's ongoing weight log documents R4's weights as follows: 12/23/2024 160.2 pounds (Lbs.) 12/31/2024 150.6 Lbs. (5.99% loss) 1/7/2025 147.5 Lbs. 1/14/2025 145.0 Lbs. (9.49% loss since 12/23/24) 1/21/2025 147.6 Lbs. 1/28/2025 145.4 Lbs. 2/4/2025 150.4 Lbs. 2/11/2025 148.8 Lbs. R4's shower documentation for December 2024 and January 2025 was requested on 2/19/25. R4's Shower Sheets, provided by V2 Director of Nursing (DON) document showers were given/offered on 12/31/24 and then not again until 1/21/25 (3 weeks later). R4's Weekly Skin Assessments dated 12/31/24 and 1/7/25 document R4 had no new skin issues and there are no preventative interventions marked as indicated, which includes a turning schedule, specialized mattress, positioning devices, and seating surface. R4's Weekly Skin assessment dated [DATE] documents R4 had no new skin issues and heels floated was the only preventative intervention documented. R4's Weekly Skin assessment dated [DATE] documents R4 had a 3 centimeter (cm) wide by (x) 1 cm long open sacral wound. R4's Wound Assessment Details Reports document the following: On 1/17/25 R4's coccyx stage two pressure ulcer measured 2.7 cm x 1 cm x 0.1 cm deep. On 1/24/25 R4's stage two pressure ulcer was 1.9 cm x 0.8 cm x 0.1 cm. On 2/6/25 R4's coccyx pressure ulcer as a stage three that measured 2 cm x 0.7 cm x 0.1 cm with 70% slough (dead tissue). On 2/13/25 R4's pressure ulcer as unstageable with 100% slough and the wound measured 1.6 cm x 1 cm x 0.1 cm. There is no documentation that R4's wound was assessed by V4 Wound Physician prior to 1/27/25, when R4's wound had declined to an unstageable pressure ulcer. R4's Wound Assessment and Plan dated 1/27/25, recorded by V4, documents R4's coccyx wound as an unstageable pressure ulcer with 100% slough and the wound measured 2 cm x 1 cm. R4's Wound Assessment and Plan dated 2/10/25, recorded by V4, documents R4's unstageable pressure ulcer was 100% covered with slough and measured 1.6 cm x 1 cm. R4's Physician Order dated 1/28/25 documents to cleanse coccyx wound, pat dry, apply medicated honey gel and cover with a dressing daily and as needed. R4's Albumin (protein found in the blood) level was 3.1 grams per deciliter (normal range 3.5-5) on 12/11/24. There is no documentation in R4's medical record that R4's nutritional status was evaluated by a Registered Dietitian (RD) prior to and after 1/16/25 (when R4's pressure ulcer was identified). R4's Dietary Note dated 1/16/25 at 8:56 PM documents V7 RD evaluated R4's nutritional status and weight loss. This note documents R4 had no skin concerns, R4 was on health shakes twice daily, V7 had no new recommendations and to notify V7 with any significant changes. On 2/18/25 at 11:37 AM V3 Assistant DON/Wound Nurse stated R4's wound was facility acquired and classified as a stage two on 1/17/25 and it worsened on 1/24/25 with slough present, but the 1/24/25 wound assessment incorrectly documents the wound was a stage two. V3 stated the wound was a stage three on 1/24/25, but the electronic software system does not allow amendments to V3's assessments. V3 stated R4's wound is currently an unstageable pressure ulcer. V3 stated R4's poor appetite was the cause of the wound and has contributed to R4's wound decline. On 2/19/25 at 9:58 AM V3 stated R4 should be turned and repositioned every two hours and this should be documented on the CNA task charting and on R4's care plan. V3 stated R4 should have an at risk care plan with pressure relieving interventions if R4's Braden identified R4 to be at risk for pressure ulcers. V3 stated we review wounds weekly with V2 DON and follow up with the RD when wounds decline. V3 stated the RD is sent an electronic mail with any changes in condition. V3 was unsure if R4 has been evaluated by an RD after 1/16/25. V3 stated the facility recently changed RDs within the last month. On 2/19/25 at 1:03 PM V3 stated V3 has been the facility's wound nurse since January 2025. On 2/18/24 at 3:47 PM V18 CNA stated the CNAs can view how much assistance residents need and pressure relieving interventions in their electronic charting system. V18 stated there is also a binder at the nurse's station that documents pressure relieving interventions. This binder was viewed with V18 and confirmed it did not contain information regarding R4. On 2/18/24 between 4:04 PM and 4:13 PM V20 and V21 CNAs stated they would look at the resident's care plan to determine what pressure relieving interventions are used. On 2/19/25 at 10:58 AM V6 MDS/Care Plan Coordinator stated if the Braden determines the resident to be at risk for pressure ulcers, then there should be a care plan for pressure ulcer risk and pressure relieving interventions. V6 viewed R4's care plan and confirmed there were no documented pressure relieving interventions prior to R4's pressure ulcer. V6 confirmed the turning and repositioning intervention was not added until 2/5/25, after R4's wound had deteriorated to an unstageable pressure ulcer. On 2/19/25 at 11:17 AM V2 DON stated V2 has not followed up with the RD for R4's wounds after 1/16/25. V2 confirmed 1/16/25 was the only documented RD evaluation for R4. At 1:45 PM V2 stated V2 had no other shower documentation to provide for R4 and confirmed missed showers between 12/31/24 and 1/22/25. V2 confirmed showers would be part of pressure ulcer prevention. At 3:50 PM V2 stated V4 Wound Physician was at the facility on 1/20/25, but we did not have a consent that day for R4 to be evaluated by V4, so R4 was seen by V4 on 1/27/25. V2 stated V2 would expect a wound consult to be ordered when wounds are showing a decline and no improvement. On 2/19/25 at 11:40 AM V5 Nurse Practitioner stated the facility's RD makes nutritional recommendations and a wound physician for wound evaluation and orders. V5 stated pressure relieving interventions would be individualized and based on the resident's mobility and if they get out of bed. V5 stated R4 should have had turning and repositioning by using wedge/pillows to offload pressure and laid down between meals, and R4's nutrition should have been evaluated prior to R4 developing the pressure ulcer. V5 stated the facility should develop a care plan once a stage one pressure ulcer is identified. V5 stated V5 believes R4's wound deteriorating so quickly into a stage three and unstageable pressure ulcer could have been avoidable. V5 stated not maintaining wound dressings can contribute to wound decline. On 2/19/25 at 12:28 PM V4 Wound Physician stated the facility should follow their protocol when residents are at risk for pressure ulcers, they should develop a care plan and implement pressure relieving interventions. V4 stated it is better to prevent than to treat and pressure relieving interventions should be implemented ahead of time. V4 stated nutrition should be assessed and referred to the dietitian. V4 stated when wounds aren't covered urine and feces can get into the wound which could pose a risk of infection, and the potential of sheering from sheets that could cause a wound to worsen. On 2/19/25 at 1:09 PM V7 RD stated V7 has been the facility's RD from June 2024 until the first week of February 2025. V7 works remotely and does not round at the facility. V7 stated V7 questioned whether there was a change in wound nurses since V7 used to receive updates from the former wound nurse, but in February V7 had to run a wound report and V7 thought R4's wound had improved. V7 stated V7 would appreciate being updated and notified of changes and declines in wounds. V7 confirmed R4's 1/16/25 nutritional evaluation was the only documented nutritional assessment. V7 stated V7 documents nutritional assessments in a progress note. V7 stated if V7 had been notified of R4's wound decline, V7 would have recommended adding double portions of protein during meals and additional protein snacks/foods since V7 was already on protein supplement, zinc, multivitamin, and health shakes. 2.) On 2/19/25 at 9:30 AM V23 CNA assisted V3 Assistant DON with R3's pressure ulcer treatment administration. R3 had one open, pink/yellow wound to the left buttock with two small superficial wounds next to it. R3 had a wound on the coccyx that was deep, and the wound bed had pink and yellow tissue. R3's Wound Summaries dated 2/18/25 document R3's coccyx pressure ulcer and left buttock pressure ulcers were unstageable between 12/18/24 and 2/13/25. These assessments do not match R3's wound assessments completed by V26 and V4 Wound Physicians. R3's Wound Assessment and Plan dated 12/31/24, recorded by V26, documents R3 had a right buttock unstageable pressure ulcer and R3's coccyx wound was initially a stage two that had declined to a stage three. R3's Wound Assessment and Plan dated 1/6/25, recorded by V4, documents R3 had a left buttock unstageable pressure ulcer and R3's coccyx wound was a stage three. On 2/19/25 at 9:58 AM V3 stated R3's coccyx wound was staged by prior wound nurse as unstageable on 12/18/24, but that was incorrect as V4 staged the wound as a stage two on 12/19/24. V3 stated the wound declined to a stage three on 12/31/24. V3 stated V3 completed R3's 12/27/24 coccyx wound assessment and it was a stage two at that time, but because it was previously entered as an unstageable the electronic software system would not allow V3 to change the assessment. V3 stated V26 had R3's left buttock pressure ulcer incorrectly documented as the right buttock. 51951 3.) R1's Wound Assessment and Plan dated 1/6/25 documents an order from V4 wound doctor, to initiate a low air loss mattress on R1's bed. R1's Wound Assessment and Plan dated 1/20/25 documents a preventative wound recommendation for an air mattress. R1's Wound Assessment and Plan dated 1/27/25 documents that an air mattress is recommended for wound prevention. R1's electronic medical record does not include any documentation that the low air mattress was initiated for R1. On 2/18/25 at 11:20 AM, V11, Certified Nursing Assistant (CNA) stated that she cared for R1 on a couple of occasions and doesn't recall if R1 had an air mattress on his bed. On 2/19/25 at 9:19 AM, V12 CNA stated she doesn't remember if there was an air mattress on R1's bed. On 2/19/25 at 2:00 PM, V2 Director of Nursing confirmed there was no documentation that an air mattress was implemented for R1.

Based on observation, interview, and record review the facility failed to ensure a dependent resident received repositioning for one (R2) of three residents reviewed for repositioning on a sample list of 4. Findings include: On 2/18/25 at 9:49 AM, 10:35 AM, 10:48 AM, 11:12 AM, 11:49 AM, 12:01 PM, and 12:30 PM, R2 was in his room sitting upright in a reclining geriatric chair. On 2/18/25 at 1:54, V8 Certified Nursing Assistant stated she did not lay R2 down this morning because he got up later than usual, around 9:30 AM to 9:45 AM and wasn't laid down until 1:15/1:30PM. V8 confirmed R2 was in reclining geriatric chair from around 9:30/9:45 AM to 1:15/1:30 PM. Resident/Family Concern Grievance Form documents that a grievance was made on 1/10/25 by V9 spouse of R2. V9 reported she had concerns that R2 was not being repositioned throughout the day. R2's Care Plan dated 1/17/25 documents R2 requires total assist from staff with transfers and requires repositioning every two hours and as needed.

Based on interview and record review the facility failed to routinely assess and monitor a bruise/hematoma (bruising with blood pooling underneath the skin), update the physician, and assess and measure post-surgical wounds upon readmission for one of three residents (R1) reviewed for wounds in the sample list of four. This failure resulted in R1's left foot bruise/hematoma becoming infected and requiring hospital operative incision and draining (I&D). Findings include: R1's Care Plan dated as reviewed 5/13/24 documents R1's diagnoses include Peripheral Vascular Disease and Type 2 Diabetes Mellitus. R1's Nursing Note dated 6/1/2024 at 9:48 AM documents a fresh, purple bruise was found on the top of R1's left foot that measured 3 centimeters (cm) by 1 cm. R1 reported that R1's foot was likely bumped during R1's mechanical lift transfer yesterday. R1's Weekly Skin assessment dated [DATE] documents R1's anterior foot bruise measured 5 cm by 2.5 cm and there was no break in skin. R1's Weekly Skin Assessments dated 6/11/24 and 6/18/24 document there were no new or worsening skin conditions, but there is no documentation of R1's left foot bruising or a description of this area. R1's electronic medical record (EMR) does not contain documentation that R1's foot bruising was reported to a physician after 6/1/24 or assessed by a physician until R1's hospitalization on [DATE]. There are no documented assessments or monitoring of this bruise after 6/4/24 until after R1 was hospitalized on [DATE]. R1's Hospital History & Physical dated 6/20/24 documents on 6/19/24 R1 presented with left foot swelling, fluctuance (boggy feeling due to buildup of fluid), redness and warmth. R1's admitting diagnoses included septic shock and left foot abscess, and intravenous antibiotics were initiated. R1's Infectious Disease Note dated 6/26/25 documents R1 was in septic shock secondary to gram negative bacteria and the source of the infection is gastrointestinal versus left foot infection. This note documents on 6/23/24 purulence was expressed from R1's abscessed hematoma and a large hematoma was operatively removed. R1's Readmission nursing assessment dated [DATE] documents R1 had multiple stage one pressure ulcers on the right outer foot. There is no documentation to indicate how many wounds, wound characteristics, or measurements. R1's Weekly Skin assessment dated [DATE] documents three pressure sores to left lateral foot/ankle and sutures to the top left foot where a hematoma was prior to hospitalization . This assessment does not document measurements or wound descriptions for these wounds. There are no other documented assessments for these wounds after 7/6/24 until 7/9/24 when R1 was evaluated by V3 Registered Nurse (RN)/Wound Nurse. R1's Wound Assessment Details Report dated 7/9/24 documents the following: R1's left dorsal (top) foot full thickness surgical wound measured 1.5 cm by 1.3 cm. R1's left proximal dorsal vascular wound measured 1.9 cm by 1.3 cm. R1's left distal, lateral (side) unstageable pressure ulcer measured 2.2 cm by 0.9 cm. R1's left proximal, lateral foot unstageable pressure ulcer measured 2.5 cm by 1.3 cm. R1's Wound Assessment and Plan dated 7/11/24, recorded by V18 Wound Physician, documents these wounds are related to an avulsion injury (skin tear), and this was the initial consultation by V18 for R1's left foot hematoma. On 7/29/24 at 10:35 AM V4 RN stated on 7/17/24 R1 had open areas to the left foot and one with sutures due to a hematoma that was lanced during R1's prior hospital stay in June 2024. On 7/29/24 at 11:56 AM V4 confirmed V4 completed R1's skin assessment on 7/7/24. V4 stated at that time R1's left foot wounds were red with callous like tissue and were not open. V4 stated V3 Wound Nurse is responsible for obtaining and documenting wound measurements and assessments. On 7/29/24 at 1:04 PM V4 stated R1's left foot bruising was red/purple in color, was swollen with blood collected forming a bump. V4 stated the area stayed the same from when it was first identified until R1 was hospitalized in June, and the area had not shown any signs of improvement. V4 stated there should be documented monitoring and assessments for this area recorded on the Treatment Administration Record or progress notes. On 7/29/24 at 12:00 PM V5 RN confirmed V5 completed R1's readmission assessment on 7/6/24. V5 stated V5 incorrectly documented R1's left foot wounds as the right foot. V5 stated V5 did not obtain measurements of the wounds which V5 described as multiple stage one pressure ulcers that were reddened and not open. V5 stated V5 was unsure how many wounds were present since V5 did not document that information. V5 stated V5 reported these wounds to V3. V5 stated wounds should be documented on the readmission assessment, but usually V3 obtains and documents the wound assessment. V5 stated if V3 is not here, then V3 completes the assessment the next day. V5 confirmed V3 was not on duty when R1 readmitted to the facility and V5 did not document a thorough assessment of R1's foot wounds. On 7/29/24 at 12:49 PM V3 RN/Wound Nurse stated the nurses should notify V3 of newly identified wounds and when V3 is not in the facility the nurses should notify the physician and document a description/assessment of the wound. V3 stated the protocol is the same for when residents are new admissions or readmissions to the facility. On 7/29/24 at 1:24 PM V3 stated R1 returned from the hospital with two wounds on the lateral and two wounds on the dorsal sides of her foot, which were closed when R1 readmitted . V3 stated R1 also had sutures to the top of her left foot where the hematoma was. V3 stated V3 evaluated R1's wounds on 7/9/23 since R1 readmitted on a Saturday. V3 stated V3 initially thought the wounds were pressure ulcers that were scabbed areas, but V18 classified them as vascular. V3 stated the bruise/hematoma was not in (wound monitoring software) for monitoring prior to R1's return from the hospital, and V3 was not aware of R1's bruise/hematoma since V3 had been on vacation until 6/10/24. V3 stated the nurses should have been monitoring the area and documenting a weekly description on the weekly skin assessments, including color and other characteristics, until it was resolved. V3 confirmed the nurses should have notified the physician if the area was not improving or if it had worsened. V3 stated physician notification is documented in the nursing notes. On 7/29/24 at 3:43 PM V15 Nurse Practitioner stated R1 was hospitalized in June for sepsis that was caused either from the hematoma or bowel related. V15 stated the facility staff should have been monitoring and assessing R1's hematoma, including characteristics, measurements/assessments, and monitoring for fever. V15 stated the area should have been monitored daily and the staff should have made sure it was healing and had no signs of infection. V15 stated V15 was not aware of R1's left foot hematoma prior to R1's hospital I&D and V15 relies heavily on the nurses to report things. V15 stated V18 should have been notified as well of any decline in the wound or if no signs of improvement. V15 would have referred R1 to be seen by V18 if V15 was made aware, and it is a strong possibility that R1's hospital I&D may have been prevented if R1 was evaluated by V18 and antibiotics were ordered. On 7/29/24 at 3:55 PM V18 Wound Physician stated 7/11/24 was V18's initial evaluation of R1's foot wounds and R1 had four left foot wounds at that time. V18 stated R1 had been previously hospitalized for the left foot hematoma and R1's wounds were not pressure related. V18 stated V18 coded the wounds as avulsions which were the result of the hospital I&D. V18 stated the facility should have been monitoring the hematoma and notified V18. V18 stated V18 would have lanced and drained the hematoma at the facility, which could have prevented R1's hospital I&D. R1 stated the nurses should be documenting thorough wound assessments at the time of admission/readmission. On 7/30/24 at 1:00 PM V2 Director of Nursing stated V2 looked through the medical records and has no additional documentation to provide. The facility's Bruises and Rashes policy dated April 2023 documents significant bruises will be monitored in (wound monitoring software) weekly until healed and physician notification will be completed. The facility's (wound monitoring software) policy dated April 2023 documents the admitting nurse will document the presence of wounds on the nursing admission form and obtain a treatment order. This policy documents the wound nurse is responsible for documenting the wound measurements/description and interventions and reviewing treatment orders within 72 hours. The facility's Physician Notification of Resident Change Of Condition dated 8/2/24 documents the charge nurse is responsible for notifying the resident's physician of changes in the resident's condition, and documenting the change and notification in the resident's medical record. This policy documents the resident will be placed on the 24 hour report for close monitoring of condition each shift.

Based on observation, interview and record review the facility failed to implement effective fall interventions in three (R1, R2, and R3) of three residents reviewed for falls. These failures resulted in R1 sustaining a head laceration with an arterial bleed, requiring nine sutures and R2 sustaining bilateral fractured wrists resulting in decreased independence, both as the result of falls. Findings include: The Facility Accidents and Incidents Policy dated 11/2023 documents, The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate intervention to affected parties. 1.) R1's undated diagnosis sheet documents the following diagnoses including: dementia, encephalopathy, neutropenia, history of falls, chronic kidney disease, diabetes mellitus, type 2, congestive heart failure, chronic kidney disease, history of a kidney transplant, hypertension, hyponatremia, and a history of a coronary artery bypass graft. R1's progress note documents admission to the facility on [DATE] and that R1 is forgetful, uses a walker, has an unsteady gait and needs therapy services for strength and stability training. R1's fall assessment dated [DATE] documents R1 as a high fall risk. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as moderately cognitively impaired. R1's fall investigation dated 4/18/24 documents that R1 fell at 6:45AM while sitting at the nurse's station while repeatedly attempting to stand up. The intervention used was to redirect R1. R1 stood up after being reminded that it was unsafe, fell and hit her head. R1 was then sent to the hospital. R1's emergency room notes dated 4/18/24 document that R1 sustained a forehead contusion from the fall and has a history of hyponatremia. R1 was returned to the facility on the same day. R1's care plan dated 4/18/24 documents the intervention to prevent further falls is to check R1's basic metabolic panel weekly. R1's progress notes dated 4/26/24 document R1 as restless and attempting to stand unassisted. R1 was again placed in a chair next to the nurse's station, R1 stood up and fell . A laceration was sustained to R1's forehead that bled substantially. R1 was again sent to the emergency room . R1's emergency room notes dated 4/26/24 document that emergency medical services applied pressure dressings to R1's head due an arterial bleed and that hemostasis was achieved by tying off the vessels in the emergency department. Nine sutures were required to close the wound. R1 was then returned to the facility with orders for Apixaban (blood thinner) 5 milligrams to be administered twice daily. R1's care plan dated 4/26/24 documents the intervention was to obtain a new wheelchair for R1. R1's progress notes dated 4/29/24 document that a staff member walked by R1's room to find her on the floor next to her bed with a new skin tear and a bruise to the right hip. R1's progress notes dated 4/28/24 document that R1's family chose to take R1 home on 5/2/24. On 5/6/24 at 12:00PM, V16 R1's family member said that R1 was always impulsive and determined regardless of reminders both at home and at the facility and that the facility was aware. On 5/6/24 at 2:30PM, V7 Licensed Practical Nurse stated, We had to keep a close eye on her and kept her at the nurse's station a lot but that doesn't mean that we had our eyes on her at all times. On 5/6/24 at 11:00AM, V2 Director of Nursing (DON) said that she understood that if other interventions had been implemented after R1's first fall, the second fall with injury might have been prevented. V2 DON then stated, She was so fast, you can't redirect someone like her, that doesn't work. In an ideal world we would have had her on 1:1s at all times. Even her family was going to get alarms and cameras for when she went home. On 5/6/24 at 3:18PM, V11 Nurse Practitioner said that the second fall that resulted in nine sutures was preventable had more effective interventions been put into place. 2.) On 5/6/24 at 2:20PM, R2 was sitting in front of the nurse's station with bilateral splints applied to her wrists. R2's undated diagnosis sheet documents the following diagnoses including: osteoarthritis, diabetes mellitus type two, anxiety, peripheral vascular disease, bilateral wrist fractures, major depressive disorder and dementia with other behavioral disturbances. R2's undated census sheet documents admission to the facility on [DATE]. R2's fall assessment dated [DATE] documents R2 as a high fall risk. R2's Minimum Data Set, dated dated dated [DATE] documents R2 as moderately cognitively impaired. R2's fall investigation dated 3/16/24 documents that R2 was observed by staff trying to move her walker to the corner of her room, lost her balance and fell . R2 sustained a laceration on the head. R2's care plan dated 3/16/24 documents that the intervention put into place was to move R2's bed farther into the corner of her room. R2's progress notes dated 4/20/24 document R2 was observed by staff falling onto the floor in her room when get to her bed at 8:30AM. R2 used her hands to block her fall. At 3:30PM the same day, R2 complained of bilateral wrist pain. A stat X-ray of R2's wrists was ordered. At 6:09PM of the same day, R2's left wrist was noted to be swollen. R2's progress notes dated 4/21/24 document at 1:06PM, R2's bilateral wrists were swollen. At 1:40PM, the facility provided X-ray service had not yet taken the stat X-rays. R2's progress notes dated 4/22/24 document at 11:22AM, the facility provided X-ray service had not yet taken the stat X-rays. At 2:45PM on the same day, R2 was sent to the hospital for X-rays. R2's radiology results were documented on 4/22/24 with bilateral wrist fractures reported and follow up with orthopedics and bilateral splints ordered. R2's January 2024 minimum data set assessment of activities of daily living document R2 as supervision only for toileting and dressing. R2's April 2024 minimum data set documents that R2 requires partial to moderate assistance with toileting and dressing. On 5/6/24 at 1:23PM, V11 Nurse Practitioner said that R2's X-rays were not performed in a timely manner and should have been obtained sooner. On 5/7/24 at 9:30AM, V15 Certified Nursing Assistant said that since R2 broke her wrists she must have assistance toileting and dressing. 3.) On 5/6/24 at 2:25PM, R3 was laying on his bed. R3 had a large bandage covering his right bicep. On 5/7/24 at 9:45AM, R3 was standing in his room beside his bed. When V13 Licensed Practical Nurse entered the room, she reminded R3 that he wasn't supposed to get up without assistance. Observed a quarter sized skin tear on biceps area and a dime size on R3's elbow. R3's undated diagnoses sheet documents the following diagnoses including: dementia, major depressive disorder, malnutrition, chronic obstructive pulmonary disease, peripheral vascular disease, metabolic encephalopathy, atherosclerosis, cognitive communication deficit, and hypertension. R3's 4/22/24 fall risk assessment documents R3 has a high fall risk. R3's Minimum Data Set, dated dated dated [DATE] documents R3 as severely cognitively impaired. R3's fall investigation dated 4/22/24 documents that at 6:35PM, R3 fell when standing up from the toilet because the toilet grab bar broke resulting in a skin tear on R3's left elbow. R3's fall investigation dated 4/28/24 documents that at 2:44PM, R3 was found on the floor near the foot of his bed resulting in a large skin tear on his left forearm, requiring Steri-strips. R3's care plan dated 4/28/24 documents the fall intervention after the 4/28/24 fall was to obtain a urine culture. R3's urine culture, resulted on 4/30/24, documents no urinary tract infection. On 5/6/24 at 2:30PM, V5 Certified Nursing Assistant said that R3 requires close supervision and lots of reminders to sit down. On 5/6/24 at 2:33PM, V6 Certified Nursing Assistant said R3 requires close supervision because he is always getting up on his own. On 5/7/24 at 10:15AM, V2 Director of Nursing said that other interventions should have been put into place when the urine culture was negative.

Based on observation, interview and record review, the facility failed to provide a safe, functional air mattress to prevent a fall from bed; failed to thoroughly investigate the environment to determine a targeted root cause to repair or replace the air mattress for R2; and failed to safely transfer a resident (R5) by full mechanical lift, from a wheelchair to recliner chair. These failures resulted in R2 sustaining a head injury and laceration requiring emergency medical care at a local hospital and R5 to get hit in forehead with mechanical lift equipment causing mild swelling and abrasion. R2 and R5 are two of five residents reviewed for accidents/accidents on the sample list of 11. Findings Include: 1.) R2's Admission Record documents R2's initial admitted as 11/20/23. It includes the following diagnoses for R2: Diffuse Traumatic Brain Injury with Loss of Consciousness Unspecified Duration, Subsequent Encounter 6/23/23, History of Falling 6/23/23, Post concussion Syndrome dated 11/13/23, Idiopathic Normal Pressure Hydrocephalus 11/13/23 and Ataxia 11/13/23, and Weakness 10/01/23. R2's Skin/Wound Note dated 11/20/2023 at 4:19 pm documents the following: Note Text: Resident is a new admit today. Skin assessment complete. Resident has multiple pressure injuries to bilateral feet/heels, and a pressure injury to her left hip and ischial tuberosity. See wound rounds for full assessments. Resident is on a low air loss mattress; she has contractures to both legs in which she keeps her legs up in a fetal position. Resident does moan in pain when providing care. Will verify that resident has pain medication ordered. Resident also has a g-tube (gastrostomy feeding tube) noted as well and a PIV (Peripheral Venous Intravenous) noted in the left forearm. Areas to feet were swabbed with betadine and left OTA (open to air). Areas to hip were cleansed and a Duoderm applied. Will Consult (V38, Wound Physician). R2's Minimum Data Set, dated dated dated [DATE] documents, R2 had moderate cognitive impairment, one upper and both lower extremity impaired range of motion and required substantial/maximal assistance bed mobility to role from back to side. R2's Care Plan dated 11/20/23 documents: (R2) has an ADL (activity of daily living) selfcare performance deficit r/t (related/to) Confusion, Traumatic Brain Injury, Osteoarthritis, and Post-concussion Syndrome. BED MOBILITY: The resident requires extensive assistance x2 (of two) staff to turn and reposition in bed per facility protocol and as necessary. TRANSFER: The resident requires full mechanical lift, large sling, and 2x staff to move between surfaces as necessary. The same Care Plan documents: (R2 is high risk for falls r/t Confusion, Deconditioning, New Admission. R2's Nursing Note dated 11/24/2023 at 09:45 am signed by V3, Licensed Practical Nurse (LPN) documents the following: Note Text: Alerted to (sic) fall by RA (V27, Hall Assistant). Upon entering the room, resident was noted to be laying on her right side between her bed and the window. Full body assessment completed approx. 1 (one) inch laceration noted to resident's right forehead, bleeding copiously (large quantity). Pressure dressing applied to stop bleeding. EMS (Emergency Medical Service) called for transport. The same note documents a report called to the local hospital emergency department. R2's ED (Emergency Department) Progress Note dated 11/24/23 documents the following: Chief Complaint, Pt (patient) presents with Laceration. The ED (Emergency Department) Progress Note documents: Pt presents to the ED by EMS for head laceration after a falling out of her bed at the nursing home. Patient has significant health history as well as history of TBI (Traumatic Brain Injury). Bleeding is controlled on right forehead laceration. The ED (Emergency Department) Progress Note documents: Patient is severely contracted. The ED (Emergency Department) Progress Note documents R2 required laboratory test and a Computed Tomography (CT scan) diagnostic imaging of R2's head. R2's CT results document R2 sustained a small scalp hematoma in the right frontal region measuring approximately 2.5 centimeters width and 4.4 millimeters in the AP dimension (front to back). Clinical Impression: Fall: Acute, Laceration of Head, Acute, Leukocytosis Unspecified Acute, Thrombocythemia, Acute, Anemia, Unspecified. Leukocytosis Unspecified, Acute. R2's right forehead laceration was cleaned; blood controlled a pressure dressing was applied and R2 was transferred back to the facility. On 01/04/24 at 1:30 pm V27, Hall Assistant stated V27 was down the hall passing water to the residents. R2 was not in her bed. V27 saw R2 on the floor. V27 came out and reported to a V14 LPN. V14 and another nurse (unidentified) came to the resident room. They went in and examined her. Some CNAs (unidentified) went in to help (R2) first. (V27 did not recall if the mattress was deflated. On 01/04/24 at 3:15 pm V3, LPN stated V3, LPN was R2's nurse when R2 fell [DATE]. V3 stated R2's air mattress was already deflated when V3 got to her room. V3 stated, It had happened before, where the cord was pulled out of the socket. V3 stated She (R2) was very contracted and did not generally move much in bed, and for sure could not role over on her own. On 01/5/24 at 9:25 am V2, Director of Nursing (DON) stated, (R2) was in a low bed with a low-air flow mattress. She (R2) could become fidgety when in bed. Though, I had never seen her roll on her own. I was told she rolled out of bed. I don't know if (R2) had side rails. Likely, not since she had an air mattress. I did not check to see if her air mattress was inflated. My investigation should have covered these (air mattress and side rails) as part of the environment assessment. I could have been more thorough. Her fall was not witnessed. I think it was just assumed she rolled on her own, since she was found on the floor next to her bed. I don't recall any staff reporting issues with the mattress. (V21, Certified Nursing Assistant) would have been the last CNA to do bed check and reposition (R2). On 1/5/24 at 10:14 am V17, Licensed Practical Nurse (LPN) stated, I V17 could not figure out how (R2) she fell out of bed. She did not hardly move when I saw her on my shifts. She could not roll without assistance. I worked several shifts before her fall when CNA's (unidentified) reported (R2's) air mattress was deflating. They would alert me. I would assess the mattress. I found her air mattress was not plugged in. The first time it happened I could not figure it out for several minutes. (R2) air mattress was never completely deflated but was deflating fast that night (first unidentified). After that, the plugs were the first place I checked each time the air mattress was deflated. It was not as far as it was that first time. I think (V34, and V35) have both reported (R2) mattress was not holding air. I think it was them. Not for sure. The first time it was (V18, CNA) pretty sure. On 1/5/24 at 10:56 am V21, Certified Nursing Assistant stated, (R2's) feet were wrapped. She was in bed all the time. Therapy was just starting to work with her. (R2) did not roll in bed at all. She was small but it still took two people to reposition her. Her legs were very contracted, and she could not move them at all on her own. She would lay in a fetal position. When we would reposition her, she was always in the same fetal position we left her in. She did not like to be touched. We had to be very easy with her. She could move her arms a little and would put her hands down by her depends on when we changed her. I did have her mattress deflate a couple times. It was never all the way deflated but it was obvious it was not staying plugged in. I started checking the plug when I would come on my shift. On 1/5/24 at 12:55 pm V30, Certified Nursing Assistant stated, (R2's) Air Mattress was problematic and reported several times to nurses before she fell . It was an agency nurse. I can't remember her name. Pretty much when I would come in to work, (R2's) mattress would be deflating. Twice it was almost totally deflated. Several times it was partially deflated. It was not the plug. It was the hose attached to the air mattress machine, at the foot of (R2's) bed. The hose would be pulled away where it is supposed to attach. If not attached tight, the air did not go into the mattress like it was supposed to. Her bed was always in the low position. (R2) could not roll by herself. Rarely would she even move. We needed two people to reposition her and change her. She had contracted legs, so I know she had not knocked the hose off the machine herself. My guess is the hose detached with staff rolled her to do peri-care. I was not here the night (only fall occurred on day shift 11/24/23) she (R2) fell . I do know if the air mattress was a problem before that fall. I know I had warned the nurses before that she was going to fall. It was just a matter of time. I also told them we needed to put floor mats down. That did not happen until after she fell . On 1/5/24 at 3:09 pm V36, Certified Nursing Assistant (CNA) stated, I was the first person in the room after (R2) fell . The Hall Aide (V27) said she (R2) fell . Hall Aides can't give any kind of care to the residents. She just let us know when someone needs something. (R2's) mattress was deflated. We had problems with that mattress deflating all the time. Everybody knew it. It was reported a couple of times by me, and I know by other CNA's (unidentified) too. (R2) was on the floor with her head bleeding. Two CNA's, (V21 and V31) came in right after me. Then I think it was (V3, LPN), (V14, LPN) and (V15, RN wound Nurse). (R2) could not change position on her own. She barely moved from one bed check to the next. The whole two hours between, she was always where we left her. On 1/5/24 at 3:15 pm V31, CNA stated, I saw (R2's) mattress when she fell . It was mostly deflated. (R2's) air mattress deflated many times. It had a short in the cord. It would go off and on. We knew it for several days. We had to move the cord to get it inflated. When she fell , I don't think she rolled but that is what they said was the caused the fall. That didn't make sense because she never changed positions on her own. She just laid in a fetal position all the time. R2's Fall investigation did not document R2's air mattress was assessed as part of the environmental review. The root cause was documented as R2 rolled out of bed. Therefore, R2's Care Plan dated 11/20/23 documents the post-fall 11/24/23 intervention was a fall mat next to bed. The care plan does not document a targeted intervention related to R2's air deflated air mattress. A facility Work Order list dated 11/20/23 at 12:49 pm documents: (R2's room-bed number) needs air mattress and work order was completed. On 01/5/24 at 8:20 am V32, Maintenance Department provided the above work order. V32 stated V32 has had no work orders indicating R2 air mattress needed repaired or replaced. 2.) R5's Diagnoses Sheet dated R5's 9/6/22 documents the following: Unspecified Sequela Cerebral Infarction and Hemiplegia, Unspecified Affecting Left Dominant Side. R5's Minimum Data Set (MDS) dated [DATE] documents R5's Brief Interview of Mental Status score as 12 out of 15 indicating moderate cognitive impairment. The same MDS documents R5 is dependent on staff for transfers. R5's Care Plan dated 12/11 documents the following: (R5) has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) CVA (Cerebral Vascular Accident). TRANSFER: The resident is totally dependent on 2 (two) staff with full mechanical lift and large lift sling for transferring. Please place (R5) in (special brand wheeled) chair for positioning. R5's Incident Note dated 12/31/23 at 5:01 PM documents: Resident struck in L (left) forehead by (full body, mechanical lift) boom during transfer to recliner. Mild swelling and abrasion were noted L forehead. Mild Pain 2/10 9 two out of 10) reported. Immediate Action taken: Resident offered ice for forehead but refused. Injury Type: Abrasion, Top of scalp. The same note documents IDT (Interdisciplinary Team) reviewed. Root cause was resident being transferred to recliner via mechanical lift and the hit him in the head. Intervention is to complete and (sic) with CNA's (Certified Nursing Assistants) on mechanical transfers. There are no documented measurements of left forehead injury. R5's facility Quick Pic dated 1/2/24 documents, Incident and has a picture of a measuring strip laid up against R5's left forehead. The picture displays eight small areas clustered together, that measure approximately four centimeters by three centimeters. Unable to determine if the areas are opened or closed. On 01/04/24 2:25 pm R5 was lying in bed, on an air mattress. R5's left forehead had a pencil eraser sized, red divot area with a thin layer of skin over areas. The reddened area had dry peeling edges. R5 stated, (V16) and (V33), both are CNA's. They were transferring me from my wheelchair to my recliner with the (full body- mechanical lift). They lowered the bar with the hooks on it. They lowered it fast. The bar and hook hit my forehead hard. It was a quick thump. It happened in the evening. I got Norco (narcotic pain medication), scheduled at bedtime, that took care of the pain. On 01/5/24 at 11:12 am V16, Certified Nursing Assistant stated, I was one of the CNA's transferring (R5) with the (full body mechanical lift). (V33) was the other CNA. (V33) was managing the controls. I was holding onto the sling to guide (R5). I think there was too much weight on one side of the sling to balance him (R5). The (full body mechanical lift) totally tilted to one side as we lower (R5) down into his recliner. It was going down real fast. When it tilted. The bar hit his (R5's) head. It all happened in seconds. I have never seen a (full body mechanical lift) do that before. He (R5) had real red scrap on his forehead where it (full body mechanical lift) bar hit. At first, he (R5) said it hurt. Then he said he was fine and gets pain meds (medications) routinely, so he be okay. We felt so bad. On 01/09/24 at 2:55 pm V2, Director of Nursing stated the CNA's that transferred R5 have been educated on safe mechanical lift transfers. V2 stated, The incident should have never happened.

Based on interview and record review the facility failed to safely transfer one (R1) of three residents reviewed for transfers from a total sample list of three. This failure resulted in R1 sustaining a left proximal fibula fracture. Findings include: The facility Transfer Policy dated 1/2020 documents that it is the responsibility of all nursing staff to ensure the use of safe transfer techniques when transferring a resident. To promote the safe transfer for the residents, as well as the staff; gait belts and mechanical lifts will be used unless otherwise specified. The facility Transfer Belts/Gait Belts policy dated 7/2020 documents that if two staff are required for a transfer and a mechanical lift is not required, a gait belt should used. Do not attempt to transfer/lift/ambulate a resident who requires assist, without a gait belt. R1's diagnosis sheet documents diagnoses including; Right Above Knee Amputation, Congestive Obstructive Pulmonary Disease, Type II Diabetes Mellitus, Gastroesophageal Reflux Disease, Chronic Kidney Disease Stage IV requiring Hemodialysis, Fracture of the Left Fibula, and Morbid Obesity. R1's Minimum Data Set, dated dated dated [DATE] documents R1 is cognitively intact and a two person assist for transfer. On 8/15/23 at 1:50PM, V4 Certified Nursing Assistant (CNA) said that on the day of R1's incident, V4 and V6 CNA were taking residents outside to an activity near the front driveway. V4 said, We jumped into the van because the van driver said that (R1) needed to have her (mechanical lift) sling adjusted before she could go back to have dialysis. V4 said they placed their arms under R1's under arms and lifted R1 while she was supposed to put her weight on her left leg. V4 said, We were trying to fix her sling and her knee buckled and she dropped to the floor. We didn't use a gait belt. On 8/16/23 at 9:45AM, V6 CNA confirmed a gait belt was not used during R1's transfer. On 8/15/23 at 2:34PM, V7 Dialysis Registered Nurse said when R1 returned to the facility on the 22nd (July 22) for dialysis, (R1) said they were having her stand on her left leg while they (V4, V6) adjusted the sling and R1 can't stand very long. R1 just normally stands and pivots, so she fell on to her knee. R1 said it hurt and that she knew it was going to swell. V7 stated, We let our doctor know what happened before we went ahead with her treatment. She was completely alert and oriented. R1's fall investigation dated 7/22/23 documents R1 was assisted in the transport van by V4 and V6 Certified Nursing Assistants (CNAs) to adjust a mechanical lift sling underneath of R1 so dialysis could transfer R1 using a mechanical lift. R1 could not sustain standing on her left foot and she went to the floor. V5 Medical Doctor recommended pain medication as needed with continued monitoring. On 8/16/23 at 1:10PM, V12 CNA stated, After she fell , she said that she couldn't stand and pivot, so we used the (mechanical lift). After that, she just complained of occasional pain. On 8/16/23 at 1:20PM, V13 Registered Nurse stated while waiting for the dialysis bus on 7/28/23, R1 mentioned to someone in the lobby that she thought she might need an x-ray. V13 said, They let me know that she said that and I ordered it that day. R1's facility provided x-ray dated 7/28/23, documents an acute proximal fibular fracture of the left leg. R1's emergency room notes dated 7/29/23 document, The patient is a [AGE] year-old female sent here from the nursing home after an x-ray that was done yesterday showed a proximal fibular fracture from a fall one week ago. Patient states, 'They dropped me'. R1's orthopedic surgery appointment note, dated 8/10/23 documents (R1) fell from standing 11 days ago. (R1) was seen in the emergency department and was referred to orthopedics', complaining of knee and ankle pain on the left side with a 4/10 throbbing. This is improved with a non-weight-bearing status. (R1) reports no shortness of breath, or chest pain. (R1's) fall pain is improved with (non-steroidal anti-inflammatory medications) and rest and is worse with activity. On 8/15/23 at 2:00PM, V3 Assistant Director of Nursing stated, No, they didn't use a gait belt and that made it an unsafe transfer. On 8/16/23 at 9:25AM, V2 Director of Nursing said V4 and V6 CNAs should have brought R1 into the facility with more people to help them transfer her and to use a gait belt for leverage. V2 said, It was an unsafe transfer.

Based on observation, interview and record review the facility failed to prevent the development of residents pressure ulcers, administer treatments as ordered, develop/implement pressure relieving interventions, accurately assess risk for developing pressure ulcers, accurately assess pressure ulcers, timely notify the physician to obtain treatment orders, and notify the resident representative of pressure ulcers. These failures affect three of five residents (R37, R64, R51) reviewed for pressure ulcers in the sample list of 55 residents. These failures resulted in R37 developing a left hip deep tissue injury (DTI) that deteriorated to an unstageable wound. Findings include: The facility's Wound Prevention, Identification & Treatment policy revised February 2021 documents: A pressure ulcer is caused from unrelieved pressure and causes damage to underlying tissue. A prevention plan will be implemented for residents who are at high risk for developing wounds and an aggressive treatment plan will be implemented for residents with pressure ulcers. The Charge Nurse/designee is responsible for administering pressure ulcer treatments and obtaining/documenting weekly measurements. Pressure ulcer risk assessments are to be completed upon admissions, then weekly for four weeks, and then quarterly. Pressure ulcers will have assessments and treatments initiated when identified. The physician should be notified when a pressure ulcer develops and when pressure ulcers deteriorate. A deep tissue injury is described as purple/maroon discolored intact skin or a blood filled blister that is due to underlying soft tissue damage from a pressure ulcer or shearing. An unstageable pressure ulcer is described as full thickness tissue loss and the wound is covered by slough and/or eschar. 1. R37 was sitting in a wheelchair on 2/27/23 at 10:30 AM, 10:49 AM, 11:44 AM, 12:05 PM, 2:16 PM, and 2:49 PM. There was a wound vacuum attached to the back of the wheelchair. At 4:06 PM R37 was asleep in bed and lying on R37's right side. R37's bed contained an air mattress. On 2/28/23 at 12:22 PM R37 was lying in bed on R37's back. On 3/01/23 11:29 AM V8 Wound Nurse removed R37's dressing and wound packing from R37's left hip wound. The wound was open, red, and circular with undermining. V8 cleansed the wound, packed the wound with foam, applied an adhesive dressing and attached the wound vacuum. R37 was lying on R37's right side during and after the wound treatment. R37 did not voice complaints of lying on R37's right side or request to be repositioned onto R37's left side. R37's Minimum Data Set (MDS) dated [DATE] documents R37 required assistance of two staff for transfers and bed mobility, had no behaviors of rejecting care in the last 7 days, and had a significant weight loss in 1 or 6 months. R37's MDS dated [DATE] documents: R37 had no behaviors of rejecting care during the 7-day review period, has moderate cognitive impairment, is dependent on the assistance of two staff for bed mobility and transfers, had a significant weight loss in 1 or 6 months, and has one stage 2 and two unstageable pressure ulcers that were facility acquired. R37's Skin Risk Assessments dated 7/15/22 and 10/15/22 document R37 is at high risk for developing pressure ulcers. The 10/15/22 assessment does not correctly identify R37's nutritional risk of poor appetite/weight loss, and records R37's nutrition as adequate. R37's Care Plan dated as revised 2/17/23 documents R37 is at risk for impaired skin integrity related to a history of poor nutrition, history of alcoholism, impaired mobility and aspirin use. R37 has a history of a left shoulder stage 2 pressure ulcer and as of 12/29/22 R37 has a left hip DTI and left hip stage 4 pressure ulcer. The interventions listed do not include frequent turning/repositioning or when R37's air mattress was implemented. R37's Care Plan dated 1/20/23 documents R37 is resistive to care and refuses to reposition off of R37's left side and does not document refusal of care prior to 1/20/23. R37's Nursing Note dated 11/4/22 at 10:37 AM documents R37 has an open area below the left shoulder that measured 1 centimeter (cm) by 1.2 cm surrounded by a red area and measured 4.5 cm by 3.7 cm. R37's Wound Summaries document: On 12/9/22 R37 had a stage II pressure ulcer of the left knee that measured 1.7 cm by 1.3 cm by 0.1 cm, and a Stage II Pressure Ulcer of the right knee that measured 1.5 cm by 2.4 cm by 0.1 cm. These wounds healed on 1/27/23. On 1/6/23 R37's left shoulder wound was a Stage II Pressure Ulcer that measured 1.5 cm long by 0.6 cm wide by 0.1 cm deep and healed on 2/9/23. On 12/29/22 R37 left hip DTI measured 4.2 cm by 5.2 cm and was 100% deep maroon tissue. On 1/6/23 the wound contained 60% slough, is incorrectly staged as a DTI instead of unstageable, and measured 3.3 cm by 3.5 cm. On 1/13/23 the DTI measured 4 cm by 3.5 cm by 1.8 cm and was 80% slough and 20% eschar. On 1/20/23 the DTI measured 3.5 cm by 3.8 cm by 1 cm deep and contained 90% slough. These summaries do not stage R37's wound until 2/10/23, when R37's wound is described as a Stage 4 Pressure Ulcer. There is no documentation that R37 was evaluated by V33 Wound Physician after R37 developed three stage 2 Pressure Ulcers and the left hip DTI until 1/19/23. R37's Wound Evaluation & Management Summaries recorded by V33 document: On 1/19/23 R37's left upper hip pressure ulcer was unstageable, measured 0.3 cm by 1.5 cm and was covered with necrotic (dead) tissue. V33 mechanically debrided (removed dead tissue) the DTI and the wound was Stage 4 after debridement. R37 also had a left lower hip Stage 4 Pressure Ulcer that measured 4 cm by 3.5 cm by 2.5 cm. On 1/20/23 R37's left upper hip Stage 3 Pressure Ulcer, measured 0.5 cm by 1.5 cm by 0.1 cm. The Stage 4 measured 3 cm by 2 cm by 1 cm and contained undermining (open space underneath tissue) of 2.5 cm at 9 o'clock. On 2/24/23 the left upper hip stage 3 healed. The left hip Stage 4 measured 2.5 cm by 2.5 cm by 1 cm with 1.5 cm undermining at 6 o'clock. There is no documentation that a physician was notified and a treatment was initiated for R37's DTI until 1/1/23, 3 days after identified, or that the physician was updated and the treatment was altered when R37's wound deteriorated to an unstageable wound on 1/6/23, until 3 days later 1/9/23. There is no documentation in R37's medical record that V30 (R37's Power of Attorney) was notified of R37's bilateral knee and left hip pressure ulcers at the time they were identified. On 3/01/23 at 9:57 AM V8 Wound Nurse stated R37's left hip wound was facility acquired, started on 12/29/22 as a DTI, and R37 had Stage II Pressure Ulcers to bilateral knees and left shoulder that were facility acquired and present prior to the DTI. V8 stated R37 prefers to lay on R37's left side and does not like to turn off R37's left side, and this was a contributing factor in the development of R37's wounds. V8 did not feel that R37's nutrition was a contributing factor since R37 eats well. V8 acknowledged that R37 had significant weight loss between August and September 2022 and again in November 2022. V8 stated the facility uses the (Skin Risk Assessment) to determine the resident's risk for developing pressure ulcers and confirmed R37's Skin Risk assessment dated [DATE] does not correctly assess R37's nutrition/weight loss. V8 stated residents are referred to V33 depending on the stage of the wounds and the resident's history. If they have a stage 2 or greater facility acquired pressure ulcer then they are referred to be seen by V33. R37's air mattress was implemented after R37's left hip wound declined and should be documented on the care plan when it was implemented. V8 stated air mattresses are implemented when recommended by V33 or when the resident has two or more Stage 2 pressure ulcers. R37's DTI was intact on 12/29/22 and deteriorated to Stage 4 when V33 debrided the wound on 1/19/23. V33 did not evaluate R37's wounds prior to 1/19/23. V8 stated the physician should be notified when wounds are identified. On 3/01/23 at 12:39 PM V8 stated we notify the physician if there is a decline in the wound and confirmed R37's DTI deteriorated to an unstageable wound when slough was noted on 1/6/23. V8 confirmed R37's wound summary incorrectly classified the slough covered wound as a DTI. V8 stated: The physician was notified on 1/9/23 and the treatment was changed to apply collagen. If a resident is determined to be at high risk for developing pressure ulcers, we ensure they have adequate intake, implement a turning and repositioning program, and implement nutritional supplements/vitamins. The repositioning should be documented on the Treatment Record or Certified Nursing Assistant documentation. On 3/01/23 at 12:00 PM V2 Director of Nursing stated V29 Physician was notified of R37's DTI on 1/1/23 and the treatment was implemented at that time. V2 confirmed there was no treatment initiated on 12/29/22 when the wound was identified. V2 stated the air mattress was applied to R37's bed on 1/5/23 and confirmed there is no documentation of this in R37's medical record. On 3/1/23 at 10:55 AM V29 Physician stated: When a resident develops a pressure ulcer the facility should implement interventions such as frequent turning and repositioning and have them evaluated by V33. An air mattress could have possibly prevented R37's DTI, but the facility also should have gotten R37 out of bed as much as possible. On 3/1/23 at 2:33 PM V23 Regional Nurse stated there was no documentation that V30 (R37's Power of Attorney) was notified when R37's knee wounds and DTI were identified. V23 confirmed there was no documentation of turning/repositioning prior to R37's 1/20/23 care plan of refusing to be turned off left side. On 3/02/23 at 9:30 AM V33 stated: R37's risk factors for developing pressure ulcers include rigidity, dementia, and being combative/resistive to care. For someone like R37 who is at high risk for pressure ulcers, the facility should have implemented pressure relieving interventions such as an air mattress, pillows between R37's knees, and repositioning. When V33 first saw the left hip pressure ulcer it was covered with necrosis and unstageable. V33 debrided the wound and it became a Stage 4. If the facility had implemented an air mattress after R37 developed prior Stage 2 pressure ulcers it may have delayed R37 from developing the left hip DTI and have avoided the severity of the wound deteriorating to an unstageable pressure ulcer. 35046 2. On 3/1/23 at 12:28 PM, V19 Licensed Practical Nurse and V3 Registered Nurse assisted R64 with a treatment change. There was a dime size blister to the side of R64's left outer foot. V19 stated she was going to use the skin protectant wipe around the outside edges of the wound. V19 then wiped the outside of the blister but did not wipe the blister itself. V19's Physician order dated 2/25/23 documents an order to, Cleanse area, pat dry, apply skin prep to area, cover with border foam, change every other day and PRN (as needed) if soiled or dislodged one time a day every other day. R64's initial wound assessment dated [DATE] documents R64's wound is a facility acquired deep tissue injury that was caused by pressure. On 2/28/23 at 10:00 AM, V8 Wound Nurse stated R64's wound to the left foot is caused from pressure. V8 stated it is a quarter size blood blister. V8 stated R64 likes to draw her leg up and tuck it under the other leg. The side of her foot lays on the bed and the pressure of it lying on the bed caused the area. V8 stated that she put in an intervention for pressure relieving boots after the area developed. 32853 3. R51's Care Plan dated 12/12/22 documents R51 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Pressure Ulcer of Sacral Region Stage 4, Type 2 Diabetes Mellitus, Obstructive Sleep Apnea and Unsteadiness on Feet. This Care Plan documents R51 has actual impairment to skin integrity of the coccyx with an intervention dated 4/8/21 to provide treatments as ordered by the Physician. R51's Physician's Orders documents an order dated 2/7/23 for the Sacrum wound to cleanse wound with wound cleanser, pat dry, lightly pack wound with Povidone-iodine moistened gauze, cover with an abdominal dressing, and secure with retention tape. Change twice a day and as needed if soiled or dislodged. R51's Treatment Administration Record (TAR) dated 1/1/23 through 1/31/23 documents the treatment order for the Sacrum wound to cleanse wound with wound cleanser, pat dry, apply collagen sheet to wound bed, then lightly pack wound with Povidone-iodine moistened gauze, cover with an abdominal dressing and secure with retention tape. Change twice a day and as needed if soiled or dislodged. Order date 11/14/2022 and discontinued date of 2/07/2023. This TAR documents this treatment was not signed off as completed on 1/1/23 evening shift, 1/7/23 evening shift, 1/19/23 day shift, 1/20/23 evening shift and 1/23/23 day and evening shift. R51's TAR dated 2/1/23 through 2/28/23 documents the treatment order for the Sacrum wound to cleanse wound with wound cleanser, pat dry, apply collagen sheet to wound bed, then lightly pack wound with Povidone-iodine moistened gauze, cover with abdominal dressing, and secure with retention tape. Change twice a day and as needed if soiled or dislodged, dated 11/14/2022 and discontinued on 2/07/2023. This TAR documents this treatment was not signed off as completed on 2/5/23 on the evening shift. R51's TAR dated 2/1/23 through 2/28/23 documents the treatment order for the Sacrum wound to cleanse wound with wound cleanser, pat dry, lightly pack wound with Povidone-iodine moistened gauze, cover with an abdominal dressing, and secure with retention tape. Change twice a day and as needed if soiled or dislodged dated 2/7/2023. This TAR documents this treatment was not signed off as completed on 2/10/23 day shift, 2/13/23 evening shift, 2/15/23 evening shift, 2/17/23 day shift and evening shift, 2/18/23 evening shift and 2/21/23 evening shift. On 2/27/23 at 10:45 AM, R51 stated they don't change R51's wound dressing on R51's bottom when there is only one nurse on the floor. R51 stated they have a nursing shortage and have a hard time keeping nurses. On 3/1/23 at 9:40 AM, V8 Licensed Practical Nurse/Wound Nurse completed R51's Sacrum pressure ulcer dressing change. The wound was pink with some white edges, but appeared to have new skin forming. On 3/2/23 at 8:49 AM, V2 Director of Nursing confirmed there were missing treatment signatures on R51's TAR.

Based on observation, interview, and record review the facility failed to provide supervision to prevent a fall, implement fall interventions, and complete post fall neurological assessments for one resident (R23) reviewed for falls in the sample list for 55 residents. This failure resulted in R23 falling, causing head and facial trauma/bruising, and an emergency room evaluation. Findings include: The facility's Accidents & Incidents policy dated 8/2/17 documents: Resident accidents and incidents will be investigated and immediate, appropriate, interventions will be implemented by the charge nurse. The resident will be monitored for 72 hours following the incident. The facility's undated Neurological Screening Guidelines documents: Neurological assessments should be completed following an unwitnessed fall or when a resident hits their head during a fall. The assessments are completed and documented on the neurological flow sheet every 15 minutes times 4, then hourly times 4, then every 8 hours times nine for a minimum of 72 hours. Abnormal findings should be reported to the physician. R23's Diagnoses List dated 3/2/23 documents R23 has Alzheimer's Disease. R23's Physician's Orders dated 3/2/23 document R23 receives Eliquis (blood thinner) 2.5 milligrams twice daily. R23's Minimum Data Set, dated dated dated [DATE] documents R23 has severe cognitive impairment, requires extensive assistance of two staff for transfers and assistance of one for walking in the corridor. R23 has impaired balance with walking, turning, and surface to surface transfers and requires staff assistance for stabilizing. R23's Care Plan revised on 11/7/22 documents R23 has a self-care deficit with activities of daily living and attempts to self-transfer and ambulate. This care plan includes an intervention for minimal assist to contact guard assist of one for transfers. R23's Care Plan dated 1/18/23 documents R23 has impaired cognition related to Dementia and has disorientation. This care plan includes an intervention to provide cues, reorientation, and supervision as needed. R23's Care Plan dated 12/16/22 documents R23 had a fall without injury related to poor balance. Interventions include the use of a nonskid mat in R23's wheelchair implemented on 1/30/23. R23's Care plan has not been updated with R23's falls and post fall interventions for falls on 1/31/23 and 2/14/23 or include the use of blood thinning medications. R23's Fall Investigation dated 1/27/23 documents R23 was found on the floor of the lounge by an unidentified CNA at 3:18 PM. R23's fall was unwitnessed and R23 stated R23 slid out of R23's wheelchair. The intervention was to use a nonskid mat in R23's wheelchair seat. R23's Fall Investigation dated 1/31/23 at 6:30 AM documents R23's fall was witnessed. R23 stood from R23's wheelchair unassisted, turned, and fell over R23's wheelchair landing head first on the floor. The root cause of the fall was R23's cognitive impairment and the intervention was for Speech Therapy to evaluate for poor safety awareness and impaired cognition. R23's Neurological Assessment form with a start date of 1/28/23 documents neurological assessments were not completed per facility policy and only documented on 1/28/23 at 1:00 PM, 3:00 PM, and 11:00 PM; on 1/29/23 at 7:45 AM, evening shift; and on dayshift and evening shift on 1/30/23. R23's Fall Investigation dated 2/14/23 at 10:25 AM documents R23 had an unwitnessed fall and was found on the floor in front of R23's wheelchair. R23 had a hematoma and swelling noted to the right eye and was sent to the emergency room for evaluation. The root cause of R23's fall is not documented and the post fall intervention was for Occupational Therapy to assess and treat for strengthening and safe transfers. R23's Neurological Assessment form with a start date of 2/14/23 documents neurological assessments are only documented per shift for days, evenings, and nights from 2/14/23-2/16/23, and not per the frequency listed in the facility's policy. R23's Hospital After Visit Summary dated 2/14/23 documents fall as the reason for R23's hospital visit, diagnoses of head and facial trauma, and that a Computed Tomography of the head was completed. On 2/27/23 at 9:47 AM R23 was sitting in a wheelchair in R23's room. R23 had large dark purple bruising to R23's right eye socket, face, and cheek, and a protruding golf ball sized knot to the right forehead. On 2/27/23 at 2:19 PM R23 was lying in bed and R23's wheelchair did not contain a nonskid device (mat on seat). On 2/27/23 at 10:23 AM V39 Registered Nurse was asked what caused R23's facial bruising/hematoma. V39 stated R23 fell in the lounge/dining area on 2/14/23, hit R23's head on the table, and R23's fall was unwitnessed. On 2/27/23 at 2:23 PM V39 stated: V39 has told staff that R23 needs increased supervision, R23 has dementia and fluctuates with R23's ability to self transfer. R23 is very impulsive at times and attempts to self transfer, and R23 uses assistance of one staff person to safely transfer. R23 does not use a nonskid mat in R23's wheelchair. V39 immediately assessed R23 after R23's fall on 2/14/23, transferred R23 to the local emergency room for a head Computed Tomography, which had no abnormalities, and R23 returned to the facility. On 2/28/23 at 4:14 PM V2 Director of Nursing stated: V2 completes fall investigations, and fall interventions are to be updated on the care plan. R23 had an unwitnessed fall on 1/27/23 and was found on the floor in the lounge. The root cause was R23 slid out of the wheelchair and the post fall intervention was a nonskid mat in R23's wheelchair seat. The nonskid mat is a current intervention and should be on top of R23's wheelchair cushion. Neurological assessments should be completed for unwitnessed falls and if the resident hits their head and should be completed every 15 minutes for 4 times, every 30 minutes for 4 times, hourly for 4 times, and then every shift for a total duration of 72 hours post fall. R23 had a witnessed fall on 1/31/23 and the root cause was R23's impaired cognition. Speech Therapy was the post fall intervention. R23 had an unwitnessed fall on 2/14/23 and the intervention was Occupational Therapy. V2 confirmed R23 requires supervision, there was no staff present in the lounge when R23 fell , and if staff were present, it may have prevented R23's fall. V2 reviewed R23's Neurological Assessment forms and confirmed the documented assessments did not follow the frequency per facility policy.

Based on observation, interview and record review the facility failed to prevent weight loss, record meal intakes, implement nutritional recommendations, ensure weight loss was timely evaluated by the dietitian, notify the physician and family, and evaluate the effectiveness of nutritional supplements for three (R37, R18, R50) of five residents reviewed for nutrition in the sample list of 55. This failure resulted in R37 experiencing a significant weight loss of 13.59 % between August and September 2022 and an additional significant weight loss of 8.37% between 11/23/22 and 11/30/22. Findings include: The facility's Weights policy dates as revised July 2021 documents: A resident weight loss of 5% in 1 month or 10% in 6 months will be reported to the Care Plan Coordinator, Dietary Manager, physician, and Registered Dietitian. The Director of Nursing/Designee is responsible for reviewing/monitoring weights and ensuring weight loss is reported to the physician and Registered Dietitian. Dietary should implement an immediate intervention for weight loss. The facility's Hydration policy dated 8/2017 documents, 8. Nursing will monitor and document fluid intake and the Dietitian will be kept informed of the status. 1. On 11/28/23 at 11:40 AM V24 Certified Nursing Assistant was feeding R37 lunch in R37's room. R37's meal tray included ice cream, apple dessert, spaghetti with meat sauce, vegetable blend and lemonade. At 12:01 PM V24 brought R37's meal tray out of R37's room. R37's ice cream was unopened. V24 stated R37 ate 75% of R37's meal. V24 stated V24 did not open/offer R37 the ice cream since R37 drank all of R37's health shake. On 3/01/23 at 11:29 AM V8 Wound Nurse Manager administered R37's left hip stage IV pressure ulcer treatment. R37 appeared thin and R37's hip bone was visible underneath R37's skin. R37's Minimum Data Set (MDS) dated [DATE] documents R37 has moderate cognitive impairment, requires setup/supervision of one staff person for eating, and R37 had a significant weight loss within the last month or six months. R37's Care Plan dated as revised 2/13/23 documents to offer R37 ice cream twice daily. R37's meal intakes dated 9/29/22-12/31/22 document 46 meal intakes were left blank and not recorded. R37's February 2023 meal intake report documents 11 meal intakes were left blank and not recorded. R37's Weight Log documents R37's weights as follows: 130.6 lbs (pounds) on 4/6/22. 130.2 lbs. on 8/5/22. 112.5 lbs on 9/28/22 (13.59% loss since 8/5). 113.5 lbs on 11/23/22. 104 lbs on 11/30/22 (8.37% in one week). 102.5 lbs on 12/22/22. 99.5 lbs on 1/19/23. 98.5 on 2/28/23 (13.22% loss in 3 months and 24.35% loss in 6 months). R37's Dietary Notes document: V27 Registered Dietitian evaluated R37's weight on 8/22/22 and notes weight gain at 3 months and 6 months. R37's weight was stable for the month and R37's health shake was reduced from twice daily to daily. R37 was not evaluated again for nutrition/weight loss until 10/17/22, almost 3 weeks after R37's significant weight loss on 9/28/22. V27 documents R37's weight as stable x 1 month, with significant weight loss of 11% at 3 months and 10.7% at 6 months. R37's diet includes ice cream twice daily and health shake daily. V27 did not recommend any new nutritional interventions. On 10/26/22 V27 noted R37 had a significant weight loss of 14.7 % since August and 11.2 % since May. V27 recommended increasing health shakes to twice daily. On 11/14/22 R37 had a significant weight loss of 11.9% since June, and V27 again recommended to increase health shakes to twice daily. V27 did not assess R37's nutritional status again until 12/22/23, 3 weeks after R37's additional significant weight loss noted between 11/23/22 and 11/30/22. On 12/22/22 V27 again recommended to increase health shakes to twice daily. On 1/16/23 R37 has skin breakdown to bilateral knees, left scapula, and left hip and R37's diet includes ice cream and health shakes twice daily. R37's October, November, and December 2022 Medication Administration Records document R37 received health shakes daily and does not document the percentage/amount consumed. There is no documentation in R37's medical record that V27's recommendation to increase R37's health shake to twice daily was implemented until 1/1/23. There is no documentation that V29 Physician was notified of R37's significant weight loss identified on 9/28/22 and 11/30/22 until 12/19/22. There is no documentation that R37's Power of Attorney (V30) was notified of R37's significant weight loss between September and December 2022 prior to 12/28/22. On 2/28/23 at 4:06 PM V2 Director of Nursing stated V2 is responsible for notifying the resident's family and physician of weight loss and it should be recorded in a progress note. V2 stated V2 would expect staff to open and offer R37's ice cream. On 3/1/23 at 9:32 AM V2 stated: V2 did not have documentation that R37's significant weight loss identified on 9/28/22 and 11/30/22 was reported to the physician and family. Nutritional supplements are recorded on the Medication Administration Record and the amount consumed is not recorded. On 3/1/23 at 1:25 PM V2 confirmed R37's meal intakes are missing entries. On 3/01/23 at 11:13 AM V27 Registered Dietitian stated V27 runs a weekly weight report each week on Mondays to identify weight loss and records residents with significant weight loss. V27 stated V27 is not always able to see all of the residents on V27's list each visit. V27 confirmed V27 did not identify R37's significant weight loss noted 9/28/22 for R37's assessment completed on 10/17/22. V27 stated at that time V27 thought R37's weight had stabilized for the month. V27 ran the weight report the following week and identified R37's significant weight loss on 10/26/22. V27 stated V27 recommended to increase R37's health shake to twice daily on 10/26/22, 11/14/22, and 12/29/22. V27 confirmed V27 did not re-evaluate R37's nutrition/weight loss after 11/14/22 until 12/29/22. V27 stated R37 likes ice cream and the health shakes, and both were recommended for weight loss. The facility is responsible for reporting weight loss and V27's recommendations to the physician, and V27's recommendations should be implemented within a week. V27 confirmed if R37's nutritional shakes were increased as recommended on 10/26/22, R37's weight may have stabilized. On 3/1/23 at 10:55 AM V29 Physician stated: R37's dementia and overall decline contributed to R37's weight loss. The facility should notify the Registered Dietitian of resident weight loss and implement nutritional supplements such as ice cream and shakes. It depends on how well R37 accepted the health shakes on whether it would have prevented R37's additional weight loss. 2. R18's Minimum Data Set, dated dated dated [DATE] documents R18 has moderate cognitive impairment and R18 is dependent on assistance of one staff for eating. R18's weight log documents R18's weights as follows: 139.8 lbs on 8/2/22 and 11/6/22. 132.2 lbs on 1/19/23. 125.5 lbs on 2/2/23 (5.07% loss in 1 month) and 2/22/23 (10.23% loss in 3 and 6 months). 123.6 lbs on 2/22/23 (11.59% since 11/6/22). R18's Dietitian Notes recorded by V27 Registered Dietitian document: On 9/12/22 R18 triggered for a significant weight loss and V27 recommended a frozen nutritional supplement three times daily. On 1/16/23 R18 had sacral skin breakdown and R18's diet includes a frozen nutritional supplement three times daily. On 2/13/23 R18 triggered for a significant weight loss at 1, 3, and 6 months. R18's diet includes a frozen nutritional supplement three times daily. V27 recommended to consider an appetite stimulant for R18. R18's Dietary Card only lists a frozen nutritional supplement for the supper meal, and not for breakfast and lunch. On 02/28/23 at 11:52 AM V34 Certified Nursing Assistant was feeding R18 lunch in R18's room. R18's meal did not include a frozen nutritional supplement. At 12:06 PM V34 removed R18's meal tray from R18's room and stated R18 ate 100% of R18's lunch. V34 confirmed that R18's meal did not include a frozen nutritional supplement. V34 stated sometimes R18 gets a frozen nutritional supplement, but not at every meal. On 3/1/23 at 9:32 AM V2 Director of Nursing stated there is no documentation that R18's Legal Guardian (V36) was notified of R18's significant weight loss identified in February 2023. On 3/1/23 at 11:13 AM V27 stated R18's diet includes a frozen nutritional supplement three times daily for weight loss/nutrition. On 03/01/23 at 2:00 PM V37 Dietary Manager stated the frozen nutritional supplements are served by dietary staff on the meal trays, and R18 only receives the frozen nutritional supplement at supper. V37 checked R18's Diet Card and confirmed it had not been updated to provide the frozen nutritional supplement with breakfast and lunch as recommended by V27 on 9/12/22. 35046 3. On 2/27/23 at 11:53 AM, R50 was sitting up on the side of the bed. There was a Styrofoam container on the bedside table. There was eggs and a bagel barely eaten in the container. On 2/27/23 at 11:30 AM, V35 Certified Nurse's Assistant was taking a lunch tray into R50's room. R50's breakfast was still on the bedside table. R50's eggs in the container and the bagel appeared untouched. V35 stated R50 does not require help with eating or supervision when eating. R50's Quarterly Minimum Data Set assessment dated [DATE] documents R50 requires supervision with meals. R50's Nutrition plan of care with a revision date of 2/6/23 documents R50 has had a significant weight loss but does not document that R50 requires supervision with meals. R50's weight log documents R50 weighed 134.6 on 10/6/22 and weighed 114 pounds on 2/22/23. R50's Nutrition/Dietary Note dated 2/13/23 at 11:01 AM, documents Registered Dietitian weight Note: Ht (height): 62 in (inches), Current Body Weight: 116.5 pounds, Body Mass Index: 21.3 within normal limits. Triggered for significant weight loss (-15.0%, -20.5#) x 3 months and (-13.4%, -18.1#) since October - may be related to varied oral intakes. Diet: regular diet with health shake daily. Per documentation, feeds self with some assist, no chewing/swallowing issues noted. No edema or pressure-related areas noted. Meds reviewed. No recent labs to review. Registered Dietitian recommends increasing health shake to twice a day related to significant weight loss and varied intakes. Current diet with supplement is appropriate to meet estimated needs and support skin integrity. Refer to Registered Dietitian as needed. R50's Medication Administration sheet dated 2/1/23 through 2/28/23 does not document the percentage of health shake that R50 consumed. On 3/1/23 at 9:50 AM, V2 Director of Nursing stated the nurses should be marking whether R50 is drinking her supplement. V2 stated the facility would not be able to evaluate the health shakes effectiveness if this was not documented.

Based on observation, interview and record review the facility failed to provide pain control to one (53) of two residents reviewed for pain from a total sample list of 55. This failure resulted in severe pain for R53 during a wound dressing change. Findings include: The undated facility census sheet documents that R53 was admitted to the facility on [DATE]. R53's undated diagnosis sheet includes diagnoses of: encephalopathy, hemiparesis, hemiplegia, history of a cerebral vascular accident, diabetes mellitus type two, chronic kidney disease, anxiety, pulmonary hypertension and congestive heart failure. R53's Minimum Data Set, dated dated dated [DATE] documents R53 as cognitively intact. R53's Minimum Data Set, dated dated dated [DATE] documents R53's skin as without any foot ulcers or wounds. R53's electronic medical record does not document a daily, weekly or monthly pain assessment. On 2/27/23 at 2:36 PM R53 stated, I didn't have a wound when I came in here, my feet were fine. I got an infection and this happened (pointed to the covered right foot wound) and when it did, it was excruciating. R53's progress notes dated 2/3/23 document R53 reported to the Certified Nursing Assistant (CNA) that his right leg was in pain. The nurse then assessed the resident's right lower leg and it was becoming larger than his baseline with excessive dry skin, redness, and warmth noted. (R53) said that the pain began in his right leg on Monday, but by 2/3/23 it was throbbing, unbearable, his pain was an 8 out of 10, and it interfered with transferring from the bed to the wheelchair and the wheelchair to the bed. The nurse administered pain medication per (R53's) request. R53's progress notes dated 2/7/23 document that R53 was sent to the hospital for evaluation and treatment of the right foot wound. On 3/2/23 at 10:00 AM, V8 Wound Nurse stated, I sent R53 to the hospital on the 7th of February because of the amount and color of the wound drainage. He was hospitalized for several days and given (intravenous antibiotics). R53's care plan dated 2/13/23 does not document pain assessments or evaluations related to the right foot wound and dressing changes. R53's initial wound physician note dated 2/17/23 documents that the wound measures 1 x 2 x 0.8 centimeters. The ordered wound treatment is calcium alginate with silver, covered with gauze and a large pad. On 2/24/23, R53's wound physician note documents that the wound has deteriorated and now measures 1.6 x 2 x 0.1 centimeters. The ordered wound treatment was then changed to packing the wound with gauze moistened with 1/4 bleach solution and covering with a large pad. On 2/28/23 at 9:15 AM V8 Wound Nurse provided wound care to R53. During the dressing change, the packed wound was cleansed with wound cleanser and gauze. The wound had a yellow layer of crust that began bleed while being cleansed out of the wound. During this procedure, R53 took deep breaths and winced while grabbing the wheel chair handles tightly and clenching his jaw. While observing R53's pain, V8 wound nurse stated, Hang on (R53) we are almost done. V8 wound nurse then wiped the bleeding wound with dry gauze and pushed bleach moistened gauze into the wound to pack it. After the wound care was completed, R53 continued to reposition himself, attempting to get comfortable and continuing to wince. On 2/28/23 at 9:25 AM, R53 stated, I didn't have any pain medication before that (wound dressing change) but I would have liked some and I would like some now, my pain is an 8 of 10. On 2/28/23 at 9:30 AM, V8 Wound Nurse stated, I will make sure that he gets pain medication right away. On 3/1/23 at 3:40 PM, R53 stated, I never get pain medicine before my dressing change with the nurse but I would really like that. There were times in the past when they were changing my dressing that it was just excruciating and I am glad to know that I can get some now. On 3/2/23 at 10:03 AM, V8 wound nurse stated, I know that V33 Wound Physician always sprays the wounds with Lidocaine before doing dressing changes, so yes, in the future I will offer premedication, especially if I'm packing it. On 2/28/23 at 11:13 AM, V2 Director of Nursing stated, I would expect pain medication to be offered before every dressing change. The facility Management of Pain policy revised date March 2023 documents that their mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing out residents the means to receive necessary comfort, exercise greater independence and enhance dignity and lift involvement. We will achieve these goals through promptly and accurately assessing and diagnosing pain.

Based on interview and record review the facility failed to ensure one resident (R3) was not subjected to misappropriation of property. This failure caused (R3) to experience financial harm due to the loss of a check book and $53.00 cash and psychosocial harm expressed as fear, worry, and inability to trust care givers. (R3) is one of three residents reviewed for abuse in a sample list of three residents. Findings include: R3's Face sheet printed 7/1/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set (MDS) dated [DATE] documents R3 is cognitively intact and does not exhibit any behavioral symptoms. R3's Grievance/Complaint form dated 5/13/22 documents Resident stated her check book was misplaced. On 7/13/22 at 2:27PM R3 stated On 4/30/22 my check book wallet and $53.00 came up missing. It had to be between 9:00PM and Midnight. I had been balancing my checkbook earlier that evening and I finished around 9:00PM. There were four agency CNA's(Certified Nurse's Aides) in my room. I told them I only need the help of two people, but they were all in here. I keep things on my tray table so I can reach them. I woke up at midnight and noticed things on my tray table looked like they had been moved around and that is when I found my checkbook and $53.00 missing. I know I had $53.00 because I had gotten $55.00 and spent $2.00. I told the nurse that night and I told them several times. I worried all weekend until I could get to the bank Monday 5/2/22 to close the old account and open a new one. I was able to do that 5/2/22 and no checks had come in, so I was out the $53.00. I kept reporting it and wanted to call the police, but the nurses and CNAs all told me 'Oh it will turn up.' It did not get reported until (V17) Social Services Director came to talk to me 5/13/22. Then I finally got to report it to the police. From when it came up missing 4/30/22 until I got to the bank 5/2/22 to change my accounts I was so worried I couldn't stand it. I was thinking my check comes to the bank on the first, what if someone takes my whole check. I honestly think one of those four CNA's who were in here (4/30/22) took it. I take care of my own finances and health care decisions. On 7/13/22 at 3.00PM V1, Administrator stated I was not aware that (R3) was missing her check book until 5/13/22 when (V17) Social Services Director brought it to my attention. I do know, after talking to (R3) that she had reported it to direct care staff beginning 4/30/22 and (R3) closed her bank account and opened a new one on 5/2/22. We searched (R3's) room and did not find the check book. I was not aware of the $53.00 that was missing. It was reported to the police 5/13/22 at (R3's) request. V1 verified R3 does not have a financial or healthcare Power of Attorney and makes her own decisions. On 7/14/22 the (Local) Police Department verified that (R3) had reported on 5/13/22 her checkbook and $53.00 was missing since 4/30/22.

Based on observation, interview, and record review the facility failed to ensure a resident (R1) was transferred in accordance with the resident's plan of care. This failure resulted in R1 being sent to the local emergency room with a left knee laceration that required nine sutures to close the laceration. The facility also failed to develop and implement interventions to prevent reoccurrences of skin injuries for two of three residents (R2, R3) reviewed for skin injuries in the sample list of three. Findings include: The facility's Accidents and Incidents policy revised March 2021, documents the following: All accidents/incidents involving a resident, visitor or volunteer will be investigated, and then recorded on the Confidential Accident/Incident Report Form. It is the responsibility of the D.O.N. (Director of Nursing)/Designee to investigate and ensure appropriate completion, notification, and follow-up on all Accidents and Incidents. The Charge Nurse must conduct an immediate investigation of the accident/incident and implement immediate appropriate interventions to affected parties. The D.O.N./Designee will conduct an investigation of the accident/incident as well. Findings will be indicated on the Accident/Incident Report Form in appropriate area. The IDT (Interdisciplinary Team) will be notified of the accident/incident so that appropriate changes may be made to the care plan as needed. 1. R1's Incident Report dated 10/14/21, documents at 4:40 AM R1 had a left knee laceration. R1 was alert and oriented to person, situation, and place. V3 Agency Certified Nursing Assistant (CNA) Witness Statement documents V3 sat R1 on the side of the bed, and stood and pivoted R1 into the wheelchair. R1 was transported to the shower room and R1 complained of left knee pain. V3 noticed blood and R1's left knee injury. R1's Hospital Notes dated 10/14/21 at 5:44 AM, documents R1 was seen in the emergency room for a laceration to the left knee that was caused during a transfer from the wheelchair to the bed. R1's laceration was 7 centimeters long, had significant loss of tissue requiring undermining of the skin to approximate the wound edges, and required 9 sutures to close the laceration. R1's Minimum Data Set (MDS) dated [DATE] documents: R1 is dependent upon two staff for transfers. R1 is not steady and requires staff assistance to stabilize R1 when moving from seated to standing positions and during surface to surface transfers. R1's Care Plan with a revision date of 4/8/21, documents R1 is at risk for falls secondary to [CONDITION(S)] Accident with left sided weakness. R1's Care Plan revised on 3/26/21 documents R1 requires assistance with Activities of Daily Living related to Activity Intolerance, Confusion, Dementia, Impaired Balance, Spinal Stenosis, and [CONDITION(S)] of bilateral knees. This Care Plan documents an intervention revised on 1/21/21 that R1 requires a full mechanical lift and two staff for transfers. R1's Interview dated 10/15/21 recorded by V2 DON documents: R1 stated the CNA (V3) put R1's legs on the side of the bed and transferred R1 into the wheelchair. R1 stated a lift was not used during R1's transfer. The facility's Report to Illinois Department of Public Health dated 10/21/21 documents a summary of R1's incident as follows: R1's laceration occurred during the transfer from the bed to the wheelchair. R1 was sent to the local emergency room for treatment and received nine sutures to the laceration. Maintenance noted that a screw was sticking out of R1's wheelchair which potentially caused R1's injury, and padding was applied to R1's bed frame and wheelchair. The CNA (V3) stated R1 was transferred by standing and pivoting from the bed to the wheelchair. Transfer education was provided to nursing staff. On 10/25/21 at 11:47 AM R1 was sitting in a wheelchair with a full mechanical lift sling positioned underneath of R1. R1 stated: About a week ago around 4:00 AM, a CNA came in and got R1 out of bed. The CNA self-transferred R1 and did not use a mechanical lift. R1 bumped R1's left knee during the transfer, causing a wound to R1's knee. R1 was transferred to the hospital for stitches. On 10/25/21 at 3:09 PM R1's left knee wound was observed with V10 Licensed Practical Nurse (LPN.) R1's wound sutures were intact. On 10/25/21 at 12:25 PM V3 Agency CNA stated: V3 sat R1 on the side of the bed (on the morning of 10/14/21), and assisted R1 to stand and pivot from the bed to the wheelchair. V3 took R1 to the shower room and R1 complained of knee pain. V3 noticed R1's left knee injury and reported to V7 Licensed Practical Nurse (LPN.) That was the first time V3 was assigned to give R1 a shower and the first time V3 had transferred R1. Usually a CNA lets us know how residents transfer. V3 was not aware that R1 required two staff and a mechanical lift for transfers. On 10/25/21 at 12:42 PM V3 stated R1 seemed heavy during the transfer, and R1 was not standing well. When V3 pivoted R1 into the wheelchair R1's buttocks hit the armrest of the wheelchair before V3 could get R1 onto the seat. If a mechanical lift was used, R1 wouldn't have had mobility of R1's legs and the injury may have been prevented. On 10/25/21 at 2:33 PM V7 LPN stated: During the morning of 10/14/21 V3 notified V7 that R1 was bleeding from R1's knee. R1 had blood running down R1's leg and a puddle of blood was on the floor. R1's left knee had about a 1 inch gash, that was deep, and more than a skin tear. R1 was sent to the hospital and the wound required stitches. V7 traced drops of blood from the shower room to R1's room. V3 was the CNA who had transferred R1 out of bed. No other staff assisted with R1's transfer and V3 did not use a mechanical lift during the transfer. R1 should have been transferred with a full mechanical lift. On 10/25/21 at 12:40 PM V8 Nurse Practitioner stated: V8 would expect staff to follow the resident's transfer status. Agency staff may not know how a resident transfer, but they should be informed. R1's injury probably would have been prevented if the proper lift and transfer status was used. On 10/25/21 at 2:45 PM V2 Director of Nursing stated: Staff are to review the resident's electronic file to determine resident transfer status. The resident's file pulls information from the resident's care plan. Staff are expected to always follow the resident's care plan for transfer status. An all staff in-service was conducted following R1's injury on how to locate and review the resident's file. Sometimes agency staff don't review the resident's file, so we are in the process of implementing laminated cards with the resident's transfer status. The cards will be placed in resident rooms, so staff know how each resident transfers. The root cause of R1's injury was that R1 was improperly transferred by V3 CNA. The facility identified a screw was inserted the wrong way with the end sticking out of the leg rest of R1's wheelchair, causing R1's laceration. R1's injury could have been prevented if R1 was transferred with a full mechanical lift as R1 would have been positioned above the chair and would have avoided contact with the screw. R1 was believed to have grazed the screw during the stand/pivot transfer. The location of the screw aligned with the location of R1's injury. 2. R2's MDS dated [DATE] documents: R2 has short- and long-term memory impairment and requires extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. R2's Nursing Notes document: On 7/22/21 at 6:07 AM, R2 had a skin tear to the right forearm/antecubital that measured 5 centimeters. R2 was combative during incontinence care, attempted to grab staff, and grabbed R2's own arm causing the skin tear. On 8/17/21 at 6:27 AM CNAs were changing R2, and R2 was fighting and hitting the staff. R2 received a large skin tear to the left arm near the elbow, and one on the right wrist. R2's nursing notes do not document interventions were implemented following R2's skin tears. R2's Care Plan with a revision date of 8/17/21 documents: R2 is at risk for impaired skin integrity. On 7/20/21 R2 had a skin tear to the right antecubital during cares. On 8/16/21 R2 had a skin tear to R2's left arm and left wrist. R2's care plan does not document interventions were developed and implemented after R2's skin tears to prevent reoccurrences of skin injuries. R2's Incident Report dated 7/22/21 at 5:59 AM documents R2 received a skin tear during incontinence care when R2 grabbed R2's own forearm causing a 5-centimeter skin tear. This report does not document an investigation of R2's injury was completed, or interventions were developed/implemented to prevent reoccurrence of skin injuries. R2's Incident Investigation dated 8/17/21, documents R2 had a skin tear to the left elbow and right wrist. Two CNAs were attempting to provide cares when R2 became physically aggressive with staff. The CNAs were given verbal reminders to stop care when R2 becomes agitated, allow R2 to calm down and reattempt to provide care for R2. The facility's Incident Log dated 7/1/21-10/25/21 does not document R2's skin tear on 8/17/21. On 10/25/21 at 2:46 PM V14 CNA stated: R2 has Dementia, and we explain and provide cues to R2 during cares. V14 was not sure of any other interventions used to prevent skin injuries for R2. R2 has gotten skin tears. Sometimes R2 bumps the siderails of R2's bed. 3. R3's MDS dated [DATE] documents: R3 has severe cognitive impairment and requires extensive assistance of one staff for bed mobility and dressing, and two staff for transfers and toileting. R3's Care Plan with a revision date of 10/12/21 documents: R3 had a skin tear to the left hand on 9/20/21. R3's care plan does not document interventions were developed/implemented after R3's skin tear to prevent reoccurrences of skin injuries. R3's Incident Report dated 9/21/21 at 5:22 AM documents: R3 had dried blood on the bed sheet and a skin tear to the back of R3's left hand between the thumb and first finger. R3's Nursing Note dated 9/21/21 at 5:35 AM documents dried blood was found on R3's bed sheet and a skin tear were noted to the back of R3's left hand. R3 was unable to say how the skin tear occurred. There is no documentation that interventions were developed/implemented to prevent reoccurrences of skin injuries. On 10/25/21 at 1:28 PM V4 CNA stated V4 was not sure what interventions were used for R3 to prevent skin injuries. On 10/25/21 at 3:40 PM V2 DON stated: Following skin injuries a risk management incident form is completed by the nurse. The nurse should document facts such as if the resident was attempting to self-ambulate at the time the injury was noted. New interventions should be implemented following skin injuries. Interventions are to be documented on the risk management form or on the resident's care plan. V2 was unable to provide documentation that R2's skin tear on 7/22/21 and R3's skin tear on 9/21/21 were investigated and interventions were developed/implemented to prevent reoccurrences.

Based on observation, interview, and record review the facility failed to properly secure a gastrostomy tube by failing to ensure the external retention ring was positioned properly up against the skin and failed to develop and implement behavioral interventions to prevent the removal of a gastrostomy tube for one of one residents (R13) reviewed for gastrostomy tubes on the sample list of 52. These failures resulted in R13 extubating the gastrostomy tube, requiring emergency services and surgery, under anesthesia, to replace R13's gastrostomy tube. Findings include: On 1/24/21 at 10:06 AM, the external retention ring to R13's gastrostomy tube was positioned approximately six inches from R13's stoma site. The skin around R13's stoma site was red and irritated. At that time, V14 Registered Nurse stated the external retention ring should be pushed up against the abdomen. V14 stated the skin around R13's stoma site is red due to R13 pulling on the tube. V14 stated R13 was receiving continuous feeding through the gastrostomy tube but R13 kept pulling on the tube and trying to get out of bed, so the feeding had to be switched to bolus. V14 stated R13 still pulls on the gastrostomy tube. R13's Nutrition/Dietary note dated 1/14/21 documents, Nursing thinks (R13) would benefit from bolus feedings as (R13) has been pulling tubing with continuous feedings and having to stop feedings. R13's plan of care with a revision date of 11/9/20 does not include interventions for R13's behaviors of pulling on the gastrostomy tube. R13's electronic medical record does not include interventions for R13's behaviors of pulling on the gastrostomy tube. R13's nursing notes dated 1/26/2021 at 6:30 AM documents, (R13) was transferred to the (hospital) for re-insertion of (R13's) feeding tube. (R13) was found with (R13's) tube in (R13's) hand. On 1/26/21 at 10:20 AM, V2 ,Director of Nursing stated the external retention ring on R13's gastrostomy tube should be pushed up to the stoma to prevent leakage from the stoma. V2 stated R13 has behaviors of pulling on the gastrostomy tube. V2 confirmed that R13's medical record does not include interventions for R13's behaviors of pulling on the gastrostomy tube. V2 stated R13 went to the hospital this morning due to R13 pulling out R13's gastrostomy tube. R13's hospital admission history and physical report dated 1/26/21 documents under chief complaint that R13's gastrostomy tube could not be replaced in the emergency room due to too much scar tissue and it being scabbed over and that trauma surgery was consulted. This report also documents that R13 was admitted to the hospital on [DATE] at 6:28 AM and documents (R13) who comes from the nursing home with a PEG (percutaneous endoscopic gastrostomy) tube malfunction. Apparently, (R13) might have pulled out (R13's) PEG tube. Unable to replace a new PEG tube in the emergency room . (R13) is agreeable. Consultation at this time for observation. General surgery was consulted in the emergency room . This report also documents an EGD (Esophagogastroduodenoscopy) and anesthesia was required to replace R13's gastrostomy tube.

Based on observation, record review, and interview, the facility failed to protect one (R4) of three residents reviewed for abuse from physical and verbal abuse. This failure resulted in R4 being repeatedly physically forced to sit in the wheelchair causing injury with bleeding to the right lower arm. The finding includes: According to R4's July 2016 Physician order [REDACTED]. R4's 5-4-16 Annual Resident Assessment Instrument (RAI) documents that R4 has a hearing difficulty, has delusions, has behaviors of striking out and has verbal behaviors toward others. R4 is severely cognitively impaired and requires assist of one with all activities of daily living (ADLs), R4 requires assistance with balance and uses a wheelchair. The facility's incident dated 7-1-16 completed by E2, Director of Nurses, documents that E11, a former Laundry Aide, reported to the nurse on 6-29-16 at 8:45 P.M. that E10, Certified Nurse Assistant (CNA) reacted in an inappropriately matter to R4. The incident report stated that it occurred in the Second Floor East Dining Room around 8:00 P.M. E2 was interviewed on 7-13-16 at 8:40 A.M. E2 stated that E2 conducted the investigation. E2 stated that E2 got a call from E12, Licensed Practical Nurse at approximately 9:30 P.M. E12 told E2 of the incident in the dining room. E2 directed E12 to get a statement from E10 and tell E10 to clock out and go home. E2 stated that E2 came to the facility. E2 stated E2 was acting in the absence of E1, Administrator. According to E2 written investigation notes, E2 interviewed E11 on 6-29-16 at 10:55 P.M. E 11 told E2 that at approximately 8:10 P.M., E11 went to the second floor to clean the lounge (dining room) on the east hall, E11 stated that she saw E10 forcefully kick and spin R4's wheelchair around and was smacking at R4 when R4 would try to hit E10. E11 states that E11 witnessed and heard E10 tell R4 to sit down. E10 said it nicely then R4 attempted to stand up again and E10 raised E10's voice and stated in loud voice to R4 Sit down. E11 stated R4 kept trying to stand up so E10 tried to take R4 over to the table. E11 states R4 started hitting E10 on E10's arm and E10 slapped at R4's arm trying to push R4 away. E11 states after E10 got R4 to the table R4 kept trying to move, so E10 forcefully kicked wheelchair and grabbed the handles of wheelchair to spin R4 around so R4 would be facing the opposite direction. E11 stated E11 was unsure if this was abuse or just inappropriate from what E11 witnessed. E11 reported incident to E13, CNA who instructed E11 to go to the nurse. E11 stated E11 then went to E12, LPN within about 30 to 45 minutes to report incident. E2 interviewed E12, LPN on 6-29-16 at 11:00 P.M. E12' interview statement includes that at approximately 9:30 P.M. E11 approached E12 in regards to what E11 believed was inappropriate behavior of E10 towards R4. E12 stated that shortly before E11 approached E12, E14, CNA and E10 reported to E12 that R4 had scratch on R4's right arm. E12 states that E10 brought R4 up to the nurse's station at approximately 8:45 P.M. to tell E12 that R4 had a scratch on her arm. E12 states that when E12 asked E10 what happened to R4's arm, E10 stated E10 had no idea what could have happened. E12 asked R4 and R4 was unable to recall what happened to R4's arm. E12 stated after E11 reported E11's concern, E12 went to explain to E10 that there has been an allegation about E10's behavior towards R4 and E12 will be sending E10 home. E12 states that E10 began trying to explain what happened and stated I was just trying to hold R4's arms down. E12 told E10 to clock out and E12 would be contacting E2. During the interview with E2 on 7-13-16 8:40 A.M., E2 said that E10 did abuse R4 and E10 was terminated. E2 said that E11 was also terminated because of the delay in reporting the allegation. E2 stated that the facility has a video of the abuse. E2 stated that it is hard for E2 to look at the video evidence. E2 offered to show the video evidence to the surveyor. E2 stated that R4 had a long sleeved shirt on and the R4's blood soaked through the sleeves when R4 was taken to E12. The video was viewed on 7-13-16 starting at 11:10 A.M. The time stamp on the video started at about 8:19 P.M. until 8:37 P.M. E11 was not in the dining room the entire time of the video. Beside what was reported by E11, E10 exhibited additional actions toward R4. At least eight times during the video, R4 was seen standing at R4's wheelchair and E10 would pull R4 back down to the wheelchair. E10 would grab the waist in the back of R4's pants. E10 would pull hard enough to force R4 into her wheelchair. E10 pulled R4's wig off of R4's head. At least two times E10 jerked and pushed R4 very firmly. E10 was observed many times pushing and pulling R4's arms. E10 was holding on to R4's from behind R4. The facility's Abuse Prevention policy dated 8-10-11 states that the facility will provide each resident with an environment that is free of abuse.

Based on observation, record review and interview, the facility failed to transfer R1 from the wheelchair to the bed using the appropriately assessed mechanical lift and the recommended number of staff. R1 was dropped out of the lift and onto the floor striking her head on the bed frame. R1 received a laceration and contusion to the scalp. The wound required hospital admission and closure of the wound with skin staples. In addition, the facility failed to visually supervise one of five residents, R10 who was left seated on the toilet unattended. R1 and R10 are two of five residents reviewed for falls on the sample of 19. The findings include: 1. The April 2011 physician's orders [REDACTED]. An Incident/Accident Report dated 4/24/2011 at 9:00 PM reads as follows:"...Patient (R1) fell back out of sit to stand (mechanical lift) and hit head on floor...could not see laceration due to amount of blood..." R1's Care Plan shows an entry on 11/24/2010 that reads, "...Recommend sit to stand lift for all transfers..." An entry on 4/12/2011 shows the method of transferring for R1 is reassesed and changed. The Care Plan reads, "...(mechanical sling lift) for transfers..." E2, Director of Nursing (DON) stated on 5/5/2011 at 1:00 PM that (R1) had been complaining of shoulder pain from arthritis and that is why she was switched from the sit to stand lift to the mechanical sling lift. A witness statement written by E9, Certified Nursing Assistant (CNA) states, "...I was going to put (R1) into bed and she didn't have a (lift sling) under her so I got the sit to stand, hooked it up...as we were going up she let go of one side I told her she needed to hang on. then I looked up (and ) she started to slide through (and) I went to try to catch her it all happened so quick. After she fell she hit her head on the corner of the bed..." E9 confirmed the statement on 5/5/2011 at 1:40 PM. E9 stated, "...I transferred her with a sit to stand (lift). I was transferring her by myself. I transferred her with the wrong lift because she did not have the mechanical lift sling under her; I was not sure how to put it under her. According to facility policy (the) sit to stand lift is a two person transfer. I know I did wrong..." A nurses note dated 4/25/2011 at 2:00 AM states, "...Resident admitted to (Hospital) (with) diagnosis (of Altered Mental Status and Scalp Laceration..." The sit to stand lift owners manual states, "... (the manufacturer) recommends that two assistants be used for ALL lifting preparation, transferring from and transferring to procedures..." E2, Dirctor of Nursing (DON) stated on 5/5/2011 at 1:00 PM that facility policy states that two staff are required for all mechanical lifting procedures. R1 stated on 5/3/2011, "...they dropped me out of the lift when they were trying to transfer me. The girl started lifting me and my shoulder started to hurt very bad. I told her to put me down. I could not hold on...They took me to the hospital and put staples in my head..." Six skin closing staples were observed in the scalp of R1 on 5/6/2011 at 1:40 PM. 2. R10's physician's orders [REDACTED]. R10's Minimum Data Set ( (MDS) dated [DATE] assessed R1 as severely cognitively impaired, requires limited assist of one for transfer, ambulation, and toileting and extensive assist of one for personal hygiene and toileting. R10 is frequently incontinent of urine and occasional incontinent of bowel. R10 is assessed as a high fracture risk, and a high fall risk on 4/17/11. The physical enable assessment for the use of a lap cushion which documented "resident is dependant on staff for all transfers..serves as an enabler..for enhanced posture which enables her to interact in a more dignified manner." On 5/05/11 at 11:15 am, CNA E4 came into room to toilet R10. E4 got gloves, a wet wash cloth and towel and laid them on R10's bed. E4 then gave R10 a walker, applied a gait belt, removed her lap cushion and walked her into the bathroom at 11:28 am. E4 asked the surveyor to hand her a pair of gloves from the bed. E4 stated she would get the rest of supplies in a minute. After R10 was seated on the toilet, E4 stated "I'm going to get the other stuff ready", and at 11:30 am E4 came out of the bathroom, closed the door behind her, washed her hands at the sink in the bedroom and then went over to bed 2 to retrieve the clean incontinent brief, wash cloth and towels. R10 remained seated on the toilet, with a walker in front of her. At 11:31, E4 went back into the toilet room to give R10 incontinent care and a new brief. At 11:35 am, E4 came out of the bathroom again with a bag of soiled linen which she tied shut, and washed her hands at the sink, while R10 stayed seated in the bathroom with the door closed. E4 then assisted R10 off the toilet and walked her back to her wheelchair at the bedside. On 5/05/11 at 11:40 am when asked about leaving R10 alone on the toilet, E4 stated "(R10) sits well on the toilet, I never leave the room, but if I need washcloths or something I will come out of the bathroom to get it." R10's Care Plan dated 1/24/11 documents " (R10) is at Risk for Falls related to diuretic med, incontinent, unsteady gait, diagnosis (DX) of dementia, history of falls, 4/23/11 Unsteady balance, Dx Osteoporosis, and Disorganized Thinking." The goal "(R10) will have no serious injuries related to falls by next review". Approaches include Lap Buddy to be placed on w/c (wheelchair) as an enabler to proper body positioning, bed alarm and low bed for safety awareness. On 5/03/11 at 5/03/11 at 1:05pm R10 was observed in her bed. A personal alarm (PCA)was attached to the 1/2 siderail, but the cord was hanging straight down and was not attached to the resident. The resident remained asleep in her bed during observations at 1:30pm, 2:25pm and 3:25 pm with the cord still hanging down at the side of the bed. On 5/05/11 at 1:45 pm E5 stated anyone who uses a PCA, has bed alarms, or enablers should not be left unattended in the bathroom. On 5/05/11 Director of Nurse's DON stated at 2:00 pm that any resident with a bed alarm, chair alarm, has had falls, lap buddies, tray tables should not be left alone in the bathroom. .