Every finding on record at Addolorata Villa

Based on interview and record review, the facility failed to effectively address R2's behaviors, put effective fall interventions in place, and provide appropriate hands-on ADL care to one resident (R2) who is high risk for falls. This failure resulted in R2 falling out of bed while being provided with care and sustaining multiple lacerations to his face requiring six sutures in total.Findings Include:R2 is a [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: Alzheimer's disease, dysphagia, cognitive communication deficit, muscle weakness, and repeated falls.Facility Reported Incident dated 4/19/2026 states in part but not limited to the following: On 4/19/2026 at 5:20AM, V5 (Certified Nursing Assistant) provided care to R2. V5 was obtaining supplies from the wheelchair that was positioned at the foot of the bed when R2 was observed to be in a sitting position, feet on the ground and was holding onto the grab bar. It was determined that R2 attempted to get out of bed and made contact with the bedside table, resulting in active bleeding and injury to the facial area. Staff reported that R2 has a history of attempting to self-transfer and may exhibit intermittent agitation during care.Hospital record dated 4/19/2026 shows R2 sustained 4 total lacerations to the face which required 6 sutures due to the incident including: two sutures near the right eye, two sutures on the right nose, 1 suture on the right chin, and 1 suture inside the right chin.On 5/26/2026 at 11:57AM, V5 said I was providing incontinent care to R2 in bed. I turned around to grab an incontinent brief from his wheelchair and during this time, R2 rolled over and was hanging on the bed. He must have hit his head on the nightstand because he was bleeding from his face.V5 said R2 has a history behaviors such as trying to stand up without asking for assistance. R2 needs increased supervision and we try and keep him in communal areas to provide supervision.At 11:35AM, V4 (Certified Nursing Assistant) said I work with R2 often and am very familiar with him. R2 is very confused and can become impatient with staff in the middle of care. He will try and move around or stand up while you are providing ADL care to him. He needs increased supervision due to these behaviors of consistently trying to stand up and not asking for assistance.It is to be noted that V2, V3, V6, and V8 all expressed the knowledge of R2 having behaviors such as standing up without assistance or getting impatient with staff during care.On 5/27/2026 at 12:15PM, V2 (Director of Nursing) said after investigating the fall, I did provide one on one education to V5 to ensure that when he is changing R2 he keeps incontinent supplies within reach and puts his hand on the resident while grabbing supplies. We also now provide two person assistance to R2 when providing incontinent care due to his unpredictable behaviors.Inservice education sheet dated 4/22/2026 states in part but not limited to the following: Ensure all necessary supplies and equipment are gathered and within reach prior to initiating resident care to prevent leaving the resident unattended and to promote safety and efficiency. This in-service is noted to be provided by V2 to V5.Care plan for R2 states in part but not limited to the following: R2 is at risk for falls related to Alzheimer's Disease, unaware of safety needs, sleep pattern disturbance, insomnia, and restless at night. R2 has history of falls prior to admission. Interventions include but not limited to the following: anticipate and meet R2's needs, ensure R2 is positioned near staff for closer monitoring and provide redirection; and ensure R2 is properly positioned in the middle of the mattress when in bed.Facility policy titled Fall Prevention and Management Policy with most recent review date of 12/1/2025 states in part but not limited to the following: Fall prevention is achieved through an interdisciplinary approach of education, managing risk factors, and implementing appropriate interventions to reduce the risk of falls. The community will provide adequate supervision to prevent accidents.

Based on interviews and record reviews, the facility failed to implement safety measures during transfer back to wheelchair from standing position resulting in R1's fall, hospitalization and sustaining a facial laceration, nasal fracture and neck fracture (type 2 odontoid fracture) and R1 passing in the facility.Findings Include:On 3/26/2026 at 12:13 PM V6 (Activity Aide/Assistant) stated she witnessed R1 pushing his wheelchair while walking. V6 demonstrated and said she took the wheelchair from R1, turned the wheelchair around by placing it behind R1 and verbally instructed R1 to sit down. In the process of R1 trying to sit back down, R1 fell forward hitting his head and face to the floor. V6 said she positioned herself behind the wheelchair. V6 said there was no gait belt used. V6 screamed and asked for assistance after learning R1 had injuries from the fall. During demonstration, V1(Administrator) was present.On 3/26/2026 at 9:52 AM V1 (Administrator) and V2 (Director of Nursing) stated R1 returned to facility and family opted for hospice care for remainder of his stay.On 3/27/2026 at 11:20AM V12 (Physical Therapy) demonstrated and stated to safely transfer a resident from a standing position to sit back down on the wheelchair, staff should stand in front of the resident not behind, apply gait belt, and assist back to wheelchair. This is important to prevent frontal falling. R1 is not safe to walk by himself, staff should be present during ambulation. During demonstration, V2 (Director of Nursing) was present. V2 stated activity aides are not trained to transfer and should call for assistance. R1 admitted to facility on 7/1/2025. Medical diagnosis included (not a complete list) acute hematogenous osteomyelitis, left ankle and foot, Alzheimer's disease, unspecified dementia, unspecified severity, with agitation, need for assistance with personal care, unspecified osteoarthritis, unspecified site. Care plan report, date initiated, 7/1/2025, read Focus: The resident has an ADL self-care and mobility usual performance deficit r/t dementia with behaviors, OA, cardiomyopathy, heart failure, Afib and s/p left foot toe osteomyelitis and amputation 2/27 readmitted type 2 odontoid fracture, nasal fx s/p fall. Interventions: Chair/bed to chair transfer: mod changed to Max x2. admission Evaluation/ Fall Evaluation, 12/21/2025 read Intervention: Anticipate and meet the resident's needs. MDS - Assessment Information, Target date 2025-12-26 Section GG read E. Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair), substantial/max assistance. Physical Therapy Treatment Encounter Note, date of service 2/26/2026 read R1 ambulated 50' X2 on level surfaces with min assist and w/c (wheelchair) follow with FWW.Policy and Procedure, reviewed date 12/1/2025Subject: Fall Prevention & Management PolicyPolicy:Franciscan Ministries has a Fall Management Program in place to ensure that the community's residents are assessed utilizing a standardized tool for their potential fall risk and to guide in implementing person-centered interventions to decrease the frequency or severity in the event a fall does occur.Fall prevention is achieved through an interdisciplinary approach of education, managing risk factors, and implementing appropriate interventions to reduce the risk of falls.Actions following a fall include:2. Determining what may have caused or contributed to the fall.3. Addressing the factors for the fall.

Based on observation, interview, and record review, the facility failed to follow their menu and provide adequate portions to all residents residing on unit 2-East and all residents receiving a puree diet. This failure applied to all 18 residents currently on the 2East unit of the facility.Findings Include:Per facility census dated 1/12/2026, 18 residents are residing on the 2-East unit.On 1/13/2026 at 9:45AM, V14 (Cook) was observed to be pureeing chicken [NAME] for lunch. V14 said we need 14 servings of puree chicken for lunch today.V14 was observed adding 6 chicken thighs to the blender along with chicken broth. This surveyor asked V14 if he felt that was enough puree to serve 14 servings, in which he said yes.It is to be noted that per diet spread sheet, one full piece of chicken is served to residents on a regular diet.At 11:30AM, V21 (Dietary Server) was observed serving the 2-East unit. V21 was observed serving with a 3-ounce (ivory) spoon for rice and a 4-ounce scoop for the pork peppered steak.Diet spreadsheet for 1/13/2026 shows 4-ounces of rice and 3/4 cup (6-ounces) of the pork peppered steak were to be served.On 1/14/2026 at 12:47PM, V11 (Dining Service Director) said the diet spreadsheets is how we know what portions to serve. It is important to serve the appropriate portions to residents to ensure they are getting proper and adequate nutrition.Facility policy titled Meal/Tray Assembly Procedures with revision date of 01/2025 says Meal service is prompt and accurate to ensure nutrient content of food is preserved. Ensures current diet extension is available and followed at each meal period.

Based on observation, interviews and records review, the facility failed to implement care plan interventions for the treatment and management of pressure ulcers; and failed to ensure multiple sheets are not used on low air loss mattress per manufacturer's guidelines. These deficiencies affect one (R20) of three residents reviewed for pressure ulcers.Findings include: R20 is a [AGE] year-old, female, admitted in the facility on 12/16/2020 with diagnoses of Quadriplegia, Unspecified; Multiple Sclerosis, Unspecified; Alzheimer's Disease, Unspecified; Contracture, Right Hand; and Contracture, Left Hand. MDS (Minimum Data Set) dated 12/10/25 recorded R20's BIMS (Brief Interview for Mental Status) score is 11, which means moderate impairment in cognition. R20's Wound Evaluation and Management Summary recorded the following: 10/23/25: Non-pressure wound of the right buttock, Moisture Associated Skin Damage (MASD), wound size: 0.5 x 0.6 x 0.1 cm (centimeters). Treatment: Alginate calcium with silver, apply once daily and as needed: if saturated, soiled or dislodged; gauze island with border, apply once daily and as needed: if saturated, soiled, or dislodged.11/13/25: Non-pressure wound of the right buttock, Moisture Associated Skin Damage, wound progress - resolved.11/20/25: Non pressure wound of the lower sacrum, Moisture associated skin damage, wound size - 4 x 4 x 0.1 cm. Additional wound detail: Recently healed wound which has reopened. Treatment: calcium alginate with silver, apply once daily and as needed: If saturated, soiled, or dislodged; island gauze, apply once daily and as needed: if saturated, soiled, or dislodged. 12/24/25: Stage 2 pressure wound of the lower sacrum, wound size: 4 x 4 x 0.1 cmAdditional wound detail: Wound originally due to moisture/friction. Wound slow to heal due to multiple factors, including immobility, quadriplegia, multiple sclerosis, dementia. Will change etiology of wound to pressure stage 2. Patient (R20) with all the proper wound protocols in place, including low air loss mattress, turning/repositioning. Treatment: collagen sheet, apply once daily and as needed: if saturated, soiled, or dislodged. Island gauze, apply once daily and as needed: if saturated, soiled, or dislodged. On 01/12/2026 at 11:18 AM, R20 in bed; alert, oriented able to verbalize needs and wants. R20 uses a low air loss mattress. The low air loss mattress was covered with a flat sheet. On top of the flat sheet is a white sheet folded into two. R20 is wearing incontinence brief. Wound care was observed on R20, performed by V9 (Wound Care Nurse), assisted by V8 (Certified Nurse Assistant, CNA). R20 has two open areas, close together on the sacrum, observed with light serous exudates. Wound treatment was observed with no issues noted. R20's skin and Wound Evaluation dated 01/12/26 documented: Lower sacrum, Stage 2, measurements: 3 x 4 x 0.1 cm. On 01/13/2026 at 12:15 PM, R20 was observed in bed, on low air loss mattress. The low air loss mattress was covered with a flat sheet. On top of the flat sheet is a white sheet folded into four. A cloth incontinence pad was also observed on top of the folded white sheet. On 01/14/2026 at 10:20 AM, R20 was sitting in her wheelchair. R20 was asked if she prefers to use multiple sheets on her bed. R20 stated she does not have any preferences when it comes to how many sheets she is using on her mattress. On 01/14/2026 at 10:25 AM, V8 was asked regarding low air loss mattress. V8 stated, For low air loss mattress, we usually put one sheet, and a draw sheet folded into 4. On 01/14/2026 at 10:32 AM, V6 (Registered Nurse, RN) was also asked regarding low air loss mattress. V6 verbalized, She (R20) is using low air loss mattress, only flat sheet and a draw sheet like a one sheet not folded. Because the air mattress would lose its purpose of alternating pressure if multiple sheets were used. On 01/14/2026 at 10:45 AM, V9 was asked regarding R20 and the use of low air loss mattress. V9 stated, She is alert, oriented, able to verbalize needs; forgetful; incontinent of bowel and bladder; total assist. MASD was identified on 10/23/25 on the right buttock. It was treated with calcium alginate with silver. It was resolved on 11/13/25. On 11/20/25, MASD was identified on the lower sacrum. It was treated with calcium alginate with silver. The MASD on the lower sacrum progressed to Stage 2. She was placed on low air loss mattress. When using low air loss mattress, we use flat sheet, and a draw sheet, folded into two. The flat sheet and the draw sheet allow the alternating pressure of the mattress and the air to circulate.V3 (Director of Nursing) also stated during interview on 01/14/2026 at 11:42 AM that a draw sheet and a cloth incontinence pad should be used to cover the low air loss mattress. On 01/14/2026 at 11:48 AM, V4 (Assisted Director of Nursing) also mentioned during interview that flat sheet is used for low air loss mattress and if care planned, an unfolded draw sheet can be used.R20's care plan related to skin breakdown documented:Revision: 01/06/26Interventions:Revision 04/26/24 - The resident needs low air loss mattress, to protect the skin while in bed set to alternating pressure, use flat sheet on mattress and draw sheet for turning and repositioning. R20's care plan did not mention that draw sheet should be folded into two or four. On 01/14/2026 at 2:47 PM, V10 (Wound Physician) was interviewed regarding R20 and how many sheet needed on low air loss mattress. V10 stated, She has a Stage 2 pressure ulcer on the sacrum, it reopened, MASD before on the right buttock, healed, it was okay for a little while and reopened in sacrum in cluster, opened to different areas. She is incontinent, immobile, unable to turn self, very dependent. It's hard to say why it reopened. Albumin is okay but heals slowly. She is on a low air loss mattress, but wound is still slow to heal. Probably because there are some elements to it. Multiple sheets used on low air loss mattress can possibly causing the slow healing. Its standard for mattress company to make sure one sheet is used which makes the mattress effective. One sheet helps relieve the pressure; more layers decrease the effectiveness in dissipating the heat. R20's low air loss mattress manufacturer's guidelines documented in part but not limited to the following: Installation: 10. Patients can directly lie on the mattress or cover with a sheet and tuck loosely, to increase the comfort of the patient. Facility's policy titled Skin Integrity Documentation - SNF (Skilled Nursing Facility) dated 06/01/23, stated in part but not limited to the following: Policy: To assist the community in the documentation related to the occurrence, treatment, and prevention of pressure and non-pressure related wounds. Process: Management nurse/Wound Nurse steps: (page 2) 3. Validate a care plan with appropriate interventions initiated.

Based on observation, interview, and record review, the facility failed to provide a resident with restorative services to aid in maintaining range of motion per resident's plan of care. This failure applied to one (R42) of three residents reviewed for restorative services.Findings include:R42 is an [AGE] year-old male who originally admitted to the facility on [DATE] and continues to reside in the facility. R42 has multiple diagnoses including but not limited to the following: dysphagia, right elbow contracture, urine retention, type II DM, quadriplegia, bell's palsy, and heart failure.On 1/12/2026 at 11:00AM, R42 said the staff does not get me up out of bed. I am in pain in my back and legs.On 1/12/2026 and 1/13/2026, R42 was observed on multiple occasions laying in bed. This surveyor observed resident to have a contracted right arm.On 1/14/2026 at 2:07PM, V20 (Restorative Aide) said I do work with R42. We do passive range of motion exercises to help with his contractures. I'd say on average I work with him about 2-3 times a week.V20 said however, I am the only restorative aide in the building and some days I do get pulled to the floor to work as a CNA. V20 said today there was a call off, so I am working on the floor and unable to do restorative therapy.Master Restorative Program List shows R42 should be getting passive range of motion exercises with restorative therapy five times a week.Restorative Monthly Report shows from 11/26/2025-1/14/2026, R42 received 10 restorative therapy sessions out of the 26 times he should have received them during this time period.Facility policy titled Restorative Nursing dated 8/21/2023 states in part but not limited to the following: It is the policy to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level.

Based on interview and record review, the facility failed to implement care plan interventions during ambulation and transfer which affected one resident (R1) that required hospital transfer. This failure resulted in staff's inability to prevent a fall and R1 sustaining a hip fracture.Findings include:R1 is an [AGE] year-old, originally admitted on [DATE] with medical diagnosis that include and are not limited to: Parkinson's Disease, Dementia and Obstructive and Reflux Uropathy, according to Minimum Data Set (MDS), R1 has a Brief Interview for Mental Status (BIMS) score of 3/15, indicating severe cognitive impairment. According to R1's electronic medical record, care plan dated: 9-9-2025 reads: R1 has an Activities of Daily living (ADL) self-care and mobility usual performance deficit related to Parkinson's dementia with agitation, insomnia and behaviors. Interventions: R1 to ambulate with contact guard in the hallway and a gait belt on for safety with a wheeled walker.On 12-6-2025 AT 3:10 pm V3 (Registered Nurse) said I was the nurse on 11-26-2025 at about 9:30 pm. R1 was observed coming out of his bedroom walking without using the walker and going to next room, I immediately intervened and asked V5 (Certified Nurse Assistant) to stay with R1 while I will get the walker. R1 had a shuffling gait, I walked next to R1 to the main common area in front of the nurse station and I gave R1 ice cream and sat R1 in a recliner chair, R1 ambulated with the walker, R1 did not have any gait belt on, I was having a direct supervision from the nurse station. At about 10:00pm, after R1 ate the ice cream, R1 stood up and walked towards the nurse station, I got up and provided the walker but R1 refused to use it by waving his hands to signal no. I was positioned on R1's right side while walking with him toward his room. After we had taken approximately 5-6 steps away from the nurse's station, R1 leaned to his left, lost his balance, and fell. The fall occurred very quickly, and I was unable to prevent it. R1 was not wearing a gait belt at the time, having a gait belt in place would have assisted me in supporting R1. I assessed R1 and with V5, we transferred R1 to a wheelchair and I kept him by the nurse station, I gave a pain medication, R1 was calm and sleepy, no complaints of pain or discomfort. I called the family, and the medical director received orders to transfer R1 to a local hospital for evaluation.According to local hospital report dated 11-27-2025, R1 will be admitted with left hip fracture.On 12-6-2025 at 2:50 pm V5 (Certified Nurse Assistant) said, R1 is very confused, hard to re-direct, on 11-26-2025 when he had a fall, R1 did not have any gait belt on.On 12-6-2025 at 4:45 pm V2(Director of Nursing) said, I expect for V3 to use the gait belt on R1 since is one of the interventions in the care plan.On 12-6-2025 V1(Administrator) presented policy titled: Gait Belt, dated: 6-1-2023 reads in part: It is the standard of the community to use a gait belt for all residents in accordance with assessed needs, the care plan and standards of practice in order to provide optimal safety. Gait belts are to be used for all transfers that require staff assistance and when assisting residents to ambulate.

Based on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not reporting an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.Findings include: R1 is a [AGE] year-old female with a diagnosis's history of Dementia with Behavioral Disturbance, Chronic Venous Hypertension with Ulcers of Right and Left Lower Extremities, Stage 3 Chronic Kidney Disease, Hypothyroidism, and Recurrent Severe Major Depressive Disorder who was admitted to the facility 05/04/2025. R1's Behavior Progress Note dated 5/21/2025 documents a CNA (Certified Nursing Assistant) informed that R1 went to the bathroom by herself, urine was all over the floor in the bathroom, R1 was then brought to common area and said, The lady abused me. I'm gonna call V7 (Family Member). The facility did not have an abuse investigation report for R1's abuse allegation from 05/21/2025. On 08/13/2025 at 1:34 PM V1 (Administrator) stated if she was aware of any abuse related concerns for R1 she would have addressed them, but she was not aware of these issues for R1. On 08/13/2025 1:53 PM V2 (Director of Nursing) stated R1 had a history of making allegations prior to admission towards caregivers and families, doesn't know if the documentation regarding R1 stating the lady abused me, would be considered an allegation, doesn't know what the writer meant. R1 has impaired cognition this would not change that an allegation was made but may affect V2's perception of what happened, this allegation would still have to be investigated if V2 were made aware of it, this should have been reported to the administrator, if the nurse would have informed V1 or V2 that R1 stated someone abused her V2 would have notified the administrator. If something is reported or seen in the community, we immediately report it to our administrator. The proper protocol would have been followed if she or V1 would have been notified about the allegations of abuse from R1. On 08/14/2025 from 10:26 AM - 11:30 AM V1 (Administrator) stated they spoke to the nurse and aide involved with caring for R1 on 05/21 and the nurse made the clinical decision to document the comment about being abused and wanting to call V7 (Family Member) from R1 to demonstrate her psychiatric behavior in conjunction with other behaviors displayed during that time, and quoted this because the nurse was just attempting to document paranoid and delusional behavior; what we have done for R1 is have multiple care plans in place based on three care plan meetings since she arrived to the facility and have been documenting on her behaviors of paranoia and delusions and consulted with psychiatry to coordinate her care. V1 stated V6 (Certified Nursing Assistant) was the staff being accused by R1 of abusing her on 05/21 and was the aide working with R1 during that time. V6 had informed the nurse that R1 went in the bathroom alone and when V6 went in there to monitor her, R1 didn't want her there and became upset when V6 stated she was there because she didn't want her to slip and fall. When V6 brought R1 out to the common area R1 made the abuse accusation and V6 told V4 (Registered Nurse) what happened and knew that R1 was upset with her for intervening in R1's care. V6 reported to the nurse that there was urine on the floor, and she was assisting R1 because she was engaging in behavior that wasn't safe. On 08/14/2025 12:52 PM V1 (Administrator) stated she followed up with V4 (Registered Nurse) and V4 doesn't recall or remember anyone else being in the room with V6 (Certified Nursing Assistant) on 05/21 when she was caring for R1. When asked by the surveyor how it can be determined R1's report of abuse by V6 occurred if there were no witnesses V1 replied by V6 coming forward and reporting what happened that's how V4 (Registered Nurse) made her judgment that R1's report of abuse was a psychiatric behavior not an allegation of abuse. The facility's Abuse, Neglect and Exploitation Policy received 08/14/2025 states: Franciscan Communities affirms that each resident has the right to be free from abuse. The community must adhere to policies and procedures that include the following components: reporting. Allegations shall be reported immediately to:The Executive Director/Administrator.State Survey and Certification agency through established procedures. The community will utilize of the following recommendations for prevention of abuse of residents:React to all allegations of abuse by residents. The community will consider factors indicating possible abuse including, but not limited to, the following possible indicators:Resident report of abuse.

Based on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not investigating an allegation of abuse for a resident with a history of making abuse allegations. This failure applies to one of four residents (R1) reviewed for abuse.Findings include: R1 is a [AGE] year-old female with a diagnosis's history of Dementia with Behavioral Disturbance, Chronic Venous Hypertension with Ulcers of Right and Left Lower Extremities, Stage 3 Chronic Kidney Disease, Hypothyroidism, and Recurrent Severe Major Depressive Disorder who was admitted to the facility 05/04/2025. R1's Behavior Progress Note dated 5/21/2025 documents a CNA (Certified Nursing Assistant) informed that R1 went to the bathroom by herself, urine was all over the floor in the bathroom. R1 was then brought to common area and said, The lady abused me. I'm gonna call V7 (Family Member). The facility did not have an abuse investigation report for R1's abuse allegation from 05/21/2025. On 08/13/2025 1:53 PM V2 (Director of Nursing) stated R1 had a history of making allegations prior to admission towards caregivers and families, doesn't know if the documentation regarding R1 stating the lady abused me, would be considered an allegation, doesn't know what the writer meant. R1 has impaired cognition this would not change that an allegation was made but may affect V2's perception of what happened. The allegation would still have to be investigated if V2 were made aware of it, this should have been reported to the administrator. If the nurse would have informed V1 or V2 that R1 stated someone abused her V2 would have notified the administrator. If something is reported or seen in the community, we immediately report it to our administrator. The proper protocol would have been followed if she or V1 would have been notified about the allegations of abuse from R1. On 08/14/2025 from 10:26 AM - 11:30 AM V1 (Administrator) stated they spoke to the nurse and aide involved with caring for R1 on 05/21 and the nurse made the clinical decision to document the comment about being abused and wanting to call V7 (Family Member) from R1 to demonstrate her psychiatric behavior in conjunction with other behaviors displayed during that time, and quoted this because the nurse was just attempting to document paranoid and delusional behavior. What we have done for R1 is have multiple care plans in place based on three care plan meetings since she arrived to the facility and have been documenting on her behaviors of paranoia and delusions and consulted with psychiatry to coordinate her care. V1 stated V6 (Certified Nursing Assistant) was the staff being accused by R1 of abusing her on 05/21 and was the aide working with R1 during that time. V6 had informed the nurse that R1 went in the bathroom alone and when V6 went in there to monitor her, R1 didn't want her there and became upset when V6 stated she was there because she didn't want her to slip and fall. When V6 brought R1 out to the common area R1 made the abuse accusation and V6 told V4 (Registered Nurse) what happened and knew that R1 was upset with her for intervening in R1's care. V6 reported to the nurse that there was urine on the floor, and she was assisting R1 because she was engaging in behavior that wasn't safe. When asked by the surveyor once the allegation of abuse was made to V4 what should have been done, V1 responded if someone makes an allegation of abuse the accused staff member is put on leave pending investigation for the safety of that resident and other residents. On 08/14/2025 at 11:42 AM V8 (Medical Director) stated the nurses are trained to quote the patient, the nurse that documented R1's allegation of abuse was quoting the patient not expressing an opinion, just because the patient uses the word abuse the nurse still can use clinical judgment to determine if it's a concern or not, this does not necessarily require investigation if the patient repeats things multiple times. V8 stated there is a certain amount of leeway the facility has and if we investigate every single thing a person is saying we'll be investigating everything, the nurse has the ability to use her clinical judgment to determine whether an investigation of what is being said needs to be done, if someone cries abuse because a band aid is ripped off or says someone was trying to poison them it doesn't necessarily require investigation, R1 has a history of complaining about every little thing and claiming someone quote on quote abused her. On 08/14/2025 at 11:47 AM V1 (Administrator) confirmed that no other staff was present with V6 (Certified Nursing Assistant) when she was monitoring R1 on 05/21 after being found in the bathroom by V6 standing in urine. When asked by the surveyor if there were any other witnesses present to confirm R1's allegation of abuse towards V6 (Certified Nursing Assistant) reported to V4 (Registered Nurse), V1 stated she had not yet had an opportunity to speak with anyone about this and she had not yet investigated this information. On 08/14/2025 12:52 PM V1 (Administrator) stated she followed up with V4 (Registered Nurse) and V4 doesn't recall or remember anyone else being in the room with V6 (Certified Nursing Assistant) on 05/21 when she was caring for R1. When asked by the surveyor how it can be determined R1's report of abuse by V6 occurred if there were no witnesses, V1 replied by V6 coming forward and reporting what happened that's how V4 (Registered Nurse) made her judgment that R1's report of abuse was a psychiatric behavior not an allegation of abuse. The facility's Abuse, Neglect and Exploitation Policy received 08/14/2025 states: Franciscan Communities affirms that each resident has the right to be free from abuse. The community must adhere to policies and procedures that include the following components: investigation and reporting. Allegations shall be reported immediately to:The Executive Director/Administrator.State Survey and Certification agency through established procedures. The community will utilize of the following recommendations for prevention of abuse of residents:React to all allegations of abuse by residents. The community will consider factors indicating possible abuse including, but not limited to, the following possible indicators:Resident report of abuse. When reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and the alleged abuser is removed from the community an initial reporting has occurred, an investigation should be conducted. The community must ensure to protect all residents after alleged abuse. This must include:Responding immediately to protect the alleged victim and the integrity of the investigation.Immediate removal of the alleged perpetrator.

Based on observation, interviews and record reviews, the facility failed to assess and prevent the development of a pressure ulcer for one ((R28) of two residents reviewed for pressure ulcers. This deficiency resulted in R28's intact skin developing a facility acquired Unstageable pressure ulcer. Findings include: R28 is a [AGE] year-old, female, admitted in the facility on 11/22/24 with diagnoses of Heart Failure, Unspecified; and Nondisplaced Fracture of Medial Malleolus of Right Tibia, Subsequent Encounter for Closed Fracture with Routine Healing; Other Fracture of Upper and Lower End of Right Fibula, Subsequent Encounter for Closed Fracture with Routine Healing. MDS (Minimum Data Set) dated 11/28/24 documented R28's BIMS (Brief Interview for Mental Status) score of 11 which means moderate impairment in cognition. MDS also recorded R28 has no pressure ulcer. R28's 11/29/24 Braden score for predicting pressure sore risk was 13, which means moderate risk. R28's progress notes recorded the following in part but not limited to the following: 11/22/24 - came from hospital, admitted due to ankle injury. 11/23/24 - skin/wound note: skin is generally intact 12/04/24 - skin/wound note: noted pressure injury on sacrum 1 x 1.5 cm (centimeters); informed V27 (Nurse Practitioner) V16 (Wound Care Nurse). Cleansed with NSS (normal saline solution), applied silver alginate and foam dressing. Monitored accordingly. All needs attended. Endorsed. 12/07/24 - skin/wound note: received report of pressure injury of sacrum. V17 (Wound Doctor) notified, and treatment obtained, adjusted and carried out. 12/09/24 - changed to air mattress for pressure wound. 12/16/24 - continued to have US (Unstageable) PI (pressure injury) to sacrum (1 x 1.2 x 0.1). R28's POS (Physician Order Sheet) recorded the following: 12/07/24 - low air loss mattress pressure redistribution mattress for PI treatment 12/07/24 - sacrum: cleanse with NSS. Apply santyl ointment and calcium alginate and foam dressing every evening shift every other day and as needed for pressure injury. 12/08/24 - sacrum: cleanse with NSS. Apply santyl ointment and calcium alginate and foam dressing as needed for pressure injury 12/09/24 - sacrum: cleanse with NSS. Apply santyl ointment and calcium alginate and foam dressing every evening shift every other day and as needed for pressure injury. 12/23/24 - sacrum: cleanse with NSS. Apply skin-prep to periwound. Apply silver alginate and foam dressing as needed for pressure injury. 12/23/24 - sacrum: cleanse with NSS. Apply skin-prep to periwound. Apply silver alginate and foam dressing every evening shift every other day for pressure injury. R28's wound notes recorded the following: 12/09/24 - Unstageable (due to necrosis) sacrum- 1 cm x 1.2 cm x not measurable cm 12/17/24 - Stage 3 pressure wound sacrum - 0.8 cm x 0.9 cm x 0.1 cm 12/31/24 - Stage 3 pressure wound sacrum - 0.8 cm x 0.7 cm x 0.1 cm 01/14/25: Stage 3 pressure wound sacrum: 0.3 cm x 0.3 cm x 0.1 cm; alginate calcium with silver apply once daily for 8 days; foam silicone border apply once daily for 23 days; skin prep apply once daily for 23 days. On 01/13/25 at 10:38 AM, R28 was in bed, alert, oriented. Observed a wrapped bandage on right lower leg. R28 stated, she had a recent fall and broke her ankle. R28 also verbalized she was not sure about her pressure ulcers. R28 is currently on physical therapy. On 01/14/25 at 12:56 PM, wound care observed on R28, provided by V22 (Registered Nurse, RN) assisted by V21 (Certified Nurse Assistant, CNA). R28 currently has a Stage 3 pressure ulcer on the sacral area. R28 stated, I haven't heard of my wound until a couple of weeks ago. The sacral wound is small, dry, no discharges. The skin around wound is intact. On 01/15/25 at 12:02 PM, V19 (RN) was asked regarding R28's pressure ulcer on the sacrum. V19 replied, V18 (CNA) told me about it when she was cleaning her (R28). It was a pressure injury already. There was no endorsement from the previous shift that she had any skin alteration or wound. I was shocked when I saw it. The wound was like the size of a pea. It was open, red. I called nurse practitioner and ordered silver alginate. I did the dressing and I also inform V16 and V17. That time she stays in bed most of the time due to injury in her right ankle. On 01/15/25 at 2:35 PM, V18 was also interviewed regarding R28. V18 stated, I worked afternoon shift. During incontinence care, I noticed redness on the lower back. That was the first time I saw the redness. And I reported it V19. R28's Skin Assessment for Care Partner Use (Shower sheets) documented the following: 12/31/24 - no skin alteration. Per progress notes dated 12/04/24, pressure injury was noted on sacrum. There were no other shower sheets provided by facility for R28. On 01/15/25 at 5:52 PM, V16 was asked about what happened to R28's wound on the sacrum. V16 verbalized, I was notified that they noted skin damage on her (R28) skin. When I saw it the next time I was in the facility, it was pressure ulcer, it was Unstageable. She was admitted with intact skin. I notified V17, and he ordered santyl with calcium alginate. Every time I see her (R28) I asked her did you get up; did you sit in the wheelchair. She says she likes to be lying in bed. I was encouraging her to offload. V16 was also asked on her expectations on staff to prevent pressure ulcer development. V16 stated, We have to encourage her to get up and get out of bed; turning every two hours at least; changing the brief as needed as frequently as possible. She (R28) is alert and oriented. Staff when they change the brief, they make sure she is dry, check for any skin abnormalities. I don't have any information regarding her wound because the nurse told me the skin issue when she called me. The skin was already damage. Floor nurses should do treatment as ordered. As soon as I saw her skin damage, I placed her on low air loss mattress. Low air loss mattress is indicated for Stage 3 and higher. Further review of progress noted dated 12/04/24 recorded R28 was noted to have pressure injury on the sacrum. Progress notes dated 12/09/24 documented her (R28) regular mattress was changed to air mattress for pressure wound. POS dated 12/07/24, low air loss mattress pressure redistribution mattress had been ordered for R28's pressure injury treatment. Wound notes dated 12/09/24 recorded an Unstageable sacrum pressure ulcer on R28. R28's care plan dated 12/07/24 documented: Has Stage 3 pressure injury on sacrum related to limited mobility, fragile skin: Interventions - resident (R28) requires air mattress to bed and cushion to wheelchair. On 01/15/25 at 5:37 PM V17 was interviewed regarding R28's pressure ulcer on the sacrum area. V17 mentioned, I have been treating R28's wound since December 2024. I see the wound every week. It was Unstageable pressure ulcer when I first saw it. We have been treating it with santyl. It was measured 1 cm x 1.2 cm at first. Right now, she's on silver alginate. The wound is pretty small now, it measures 0.3 x 0.3. When I first saw it was Unstageable pressure ulcer, not sure the depth of sacrum injury. There was 30% slough on it that is why I could not stage it. She was admitted for rehab, she needs to be gotten out of bed and try to get her mobile. Everyone is at risk to develop pressure ulcer. It is hard to say when the wound developed. Wound treatments should be implemented as ordered. On 01/16/25 at 11:46 AM, V2 (Director of Nursing) was asked regarding expectations on staff in prevention and management of pressure ulcers. V2 stated, Staff perform pericare as needed and frequent monitoring and attending to residents' needs; repositioning; toileting residents in a timely manner. CNAs assess skin during care and notify nurses for skin issues. Nurses assess skin and notify wound doctor and wound nurse for any issues and if there are orders, orders are carried out and implemented until resident is seen. Facility's policy titled, Management and Treatment of Pressure Ulcers, dated 06/01/2023 stated in part but not limited to the following: Policy: The community will have protocols in place in the event a newly identified pressure ulcer is noted. The direct care staff will initiate an appropriate treatment to the wound until the time it is further assessed by the Wound Care Nurse. Any newly identified pressure ulcer will have treatment initiated at the time of discovery. The policy for skin presented by facility did not specifically address assessment and prevention of pressure ulcers.

Based on observation, interviews and record reviews, the facility failed to adequately monitor and supervise a cognitively impaired resident in preventing a fall for one (R120) of five residents reviewed for accidents and supervision. This deficiency resulted in R120 falling from a wheelchair in the common area in the facility and sustaining an acute subcapital femoral neck fracture. R120 underwent a surgical procedure called left hip hemiarthroplasty. Findings include: R120 is a [AGE] year-old female, initially admitted in the facility on 12/11/24 with diagnoses of Dementia in other Diseases Classified Elsewhere, Unspecified Severity with other Behavioral Disturbance; Unspecified Lack of Coordination; and Repeated falls. R120 was readmitted on [DATE] with diagnosis of Displaced Fracture of Base of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing. MDS (Minimum Data Set) dated 01/09/25 documented a BIMS (Brief Interview for Mental Status) score of 3, which means severe impairment in cognition. Fall risk evaluation dated 12/11/24 indicated a fall risk score of 85, which means R120 is a high fall risk. Incident report dated 12/28/24 documented: R120 had a fall from wheelchair. Nurse at nurses' station saw R120 kneeling and assisted her (R120) to the floor. R120 was in her wheelchair and the next time nurse looked up, R120 was kneeling on the floor in front of her wheelchair. R120 was on her left knee with right leg outstretched in front of her and her bottom resting on her left foot. Nurse responded immediately and assisted her to the floor. X-ray was ordered. R120 was sent to the hospital for further evaluation and treatment. R120's Xray report dated 12/28/24 recorded: Conclusion - Acute subcapital femoral neck fracture. Hospital record dated 12/28/24 documented a surgery called left hip hemiarthroplasty was performed on R120 on 12/30/24. R120's progress notes documented the following in part but not limited to the following: 12/18/24 - has exhibited sun downing behavior and will become agitated in the afternoon which occurred last evening on 12/17/24. She yells at the staff and wants to know when she is leaving. Per nurse on duty, she also made attempts to get up without regard to her own safety and needs close monitoring due to poor safety and awareness. 12/18/24 - resident alert and oriented x 1-2, forgetful and confused. Attempts to get up very often without call for help. Resident (R120) needs monitoring all the time. Afternoon became more sundowning. 12/18/24 - Around 4 PM, R120 started to become agitated with several attempts to stand up from her chair. When asked if she needed anything, she stated that she wanted to be away from the rest of the people in the common room and wanted to sit near the window. Done as requested. After several minutes, R120 again starts to stand up. When asked what she wanted, she asked the nurse why she was placed there away from other people. Explained that she requested to sit near the window. 12/22/24 - R120 noted standing up in common area room through shift. NOD (Nurse on Duty) educated R120 on safety. Education noted ineffective, resident non-compliant to education provided by NOD. 12/24/24 - R120 with poor safety awareness continuously attempting to get up from wheelchair without asking for assistance. Resident at times difficult to redirect, provided 1:1 self-directed activity with negative effect. Resident is with another associate for close monitoring. 12/28/24 - At 12:50 PM, this writer (V24, Registered Nurse, RN) was next to the nursing station with the medical cart, when I observed that R120 was trying to walk on the common area, lost her balance and was going on the floor between the big white table and her wheelchair. This writer was able to catch her and lower her on the floor. Her left knee was banded, and LLE (left lower extremity) was toward her right side (she was kneeling on her left side and set down on her left leg). No visible injury noted during head to toe assessment. R120 complained of pain to LLE. STAT (immediate) Xray to LLE and left hip was ordered. 12/29/24: notified the result and advise writer to send out R120 to hospital via regular ambulance. 01/05/25 - readmitted from hospital. On 01/13/25 at 11:00 AM, R120 was observed sitting in her wheelchair in the common area. She is alert, verbal, oriented. She was asked regarding recent fall, stated she does not know what happened. On 01/14/24 at 11:20 AM, V24 was interviewed regarding R120's recent fall incident. V24 stated, On 12/28/24, I was assigned to the first floor. I witnessed the fall. It was weekend, Sunday or Saturday, before new year. I was standing next to the medication cart in the [NAME] Hallway. She (R120) was in the common area, in her wheelchair. There was a space between her and the table. I was by myself. CNAs were putting residents back to their rooms. I remember the phone rang and I answered the phone. After I answered the phone, I noticed her chair was empty and she was sitting on the floor. Her left leg was under her right leg with right leg extended. I called for help, but nobody was there. I put her on the floor. I did head to toe assessment. There were no bruises, no skin tear, no external rotation on lower extremities. No complaint of pain. She did not hit her head. Then she started to move, she has dementia. When we put her in the reclining chair, we noticed that when she moved, she made facial grimaces. We started to ask her if she had pain, she said yes. We asked if its right leg or left leg. She was asked to show us which leg, she pointed left leg. V25 (Physician) was notified and ordered STAT Xray. V24 was asked regarding supervision and monitoring of residents in the common area. V24 mentioned, In the morning, all CNAs put all residents in the common area. When they are eating, CNAs are there. After eating, they have activities. CNA is supposed to stay with the residents in the common area. Activity staff, CNAs, they take turns in staying with residents. R120 always stand up when in the wheelchair. We redirect her, make her busy and she likes to do activities. On 01/14/25 at 10:35 AM, V21 (CNA) was observed in the common area doing computer charting. V21 situated herself closed to the residents. V21 verbalized, Right now, I am watching the residents and charting. Residents are placed here in the common area to watch TV; attend activities like range of motion; playing games. They play cards here, play balloons. This is their common area where they can be together. Usually, we have one person doing the monitoring and stay here with the residents. We make sure someone is watching them closely. On 01/14/25 at 11:00 AM, V23 (Certified Nurse Assistant, CNA) was asked regarding R120. V23 replied, She has dementia, alert and confused. She repeats the same thing you tell her. She doesn't follow directions. She keeps standing up when she's in the wheelchair. We try to have somebody around her and provide activities. If there are no activities, CNAs, nurses do the supervision and monitoring. Most of the time, somebody is in the common area. When we do charting in the computer, we sit with these residents. She (R120) is placed in the common area. If she is in the common area, somebody has to be close to her. If she keeps on standing up, nurse or any staff should run to her and redirect her. We need to sit with her. On 01/14/25 at 11:40 AM, R120 was in the common area, in her wheelchair. She was observed standing up several times. V23 was the staff present in the common area monitoring residents while charting on the computer. V23 approached R120 and asked what she needs. R120 stated she is okay. Subsequently, V23 sat beside R120 for close monitoring and supervision. V22 (Registered Nurse, RN) also stated during interview, R120 is alert, oriented, forgetful, unable to ambulate. She uses wheelchair and always try to get up while in the wheelchair. We redirect her and ask what she needs. We always keep her in the common area. When I am over there, its fine. I supervise them. When I take a break or busy, I call somebody, and they come to help to monitor the residents. R120's care plan documented the following: 1.Behavior: poor safety awareness date initiated 12/18/24: Interventions: Educate family of risks associated with behavior such as falling and/ or obtaining an injury. Encourage to attend programs - likes religious TV, music, reading. Provide frequent cues and reminders to wait for staff assistance. 2.At risk for falls related to left sided weakness status post CVA (Cerebrovascular Accident), dementia date initiated 12/11/24: Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light within reach and encourage the resident (R120) to use it for assistance as needed. The resident (R120) needs prompt response to all requests for assistance. PT (Physical Therapy) evaluate and treat as ordered or PRN (when necessary). The resident (R120) needs a safe environment with: (even floors free from spills and/ or clutter, adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, handrails on walls, personal items within reach) high risk for falls also related to CVA with hemorrhagic conversion. 3.Has left hemiplegia/hemiparesis related to stroke date initiated 12/13/24: Intervention: Reposition/ambulate as tolerated and at least every 2 hours. There were no other interventions formulated for R120 addressing behavior of standing up while in the wheelchair in the common area. On 01/14/25 at 1:44 PM, V25 (Physician) was asked regarding R120 and fall. V25 verbalized, I have been taking care of R120 since admission. She stays in the wheelchair. She is impulsive, she moves around on her own, she should be kept in the nurses' station. She has significant cognitive impairment; alert oriented x 1-2 (alert, oriented to self and place). I was notified regarding her recent fall. I expect staff to do frequent rounding in the TV (television) room/common area on a constant basis keeping an eye on the residents. It could be CNAs, nurses monitoring and supervising her. Facility has to follow their fall protocol. On 01/15/25 at 9:55 AM, V2 (Director of Nursing) was also asked regarding supervision and monitoring of residents in the common area. V2 stated, When there are residents out in the common area, it is supervised either by CNA, nurses or unit secretary and if they have to leave the unit or area, they will notify our scheduler or life enrichment staff who will go out there to supervise. Anybody can sit in the common area and monitor the residents. R120 is alert and has impaired cognition. She is here for short term rehab. Prior to facility admission, she had stroke. She is on extensive assist, incontinent of bowel and bladder. She is high risk for falls. Prior to her recent fall, we make sure we anticipate her needs, and she is to be placed in the common area when she is awake. We do frequent rounding on her and everybody in the common area, we have staff monitoring the common area. She (R120) had a fall incident on 12/28/24 at 12:50 PM. She was attempting to get up from the wheelchair. She was restless, attempting to get up. Her cognition is impaired and unable to let staff know what she needs. She wants to stand up from the wheelchair and she is redirected whenever staff observe it. The staff has to approach her (R120) and ask her what she needs, sit with her and make sure she is safe. The incident happened after lunch, the staff were assisting other residents to go back to their rooms or providing care. The nurse was the only one monitoring the resident and she was by the med cart. Facility's policy titled Fall Prevention & Management Policy, dated 10/23/24 documented in part but not limited to the following:Policy: (Name of organization) has a Fall Management Program in place to ensure that the community's residents are assessed utilizing a standardized tool for their potential fall risk and to guide in implementing person-centered interventions to decrease the frequency or severity in the event a fall does occur. CMS's (Centers for Medicare and Medicaid Services) definition of a Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g. resident pushes another resident). An episode where a resident lost his/her balance and wound have fallen, if not for staff intervention, is considered a fall. All without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Fall prevention is achieved through an interdisciplinary approach of education, managing risk factors, and implementing appropriate interventions to reduce the risk of falls. There is no one medical professional responsible for identifying and managing fall risk. Medical professionals, family members, as well as support staff in the community (housekeeping, maintenance, dietary, etc.) are equally important and can provide insight to managing fall risk. Supervision - The Community will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident.

Based on interview and record reviews, the facility failed to provide bed hold notifications to residents and/or family members when residents were discharged to a local hospital. This failure affected 5 residents (R5, R19, R37, R64 and R120) reviewed for bed hold notification in a total sample of 38. This failure had the potential to affect all residents in the facility. Findings include: R5 originally admitted on [DATE] with diagnosis that include and are not limited to: pneumonia, sepsis, dysphagia and acute kidney failure. Resident was transferred to a local hospital on 1/6/2025 per progress notes. Per record review no bed hold notification on record. R19 originally admitted on [DATE] with most recent readmission on 1/4/2025 with diagnosis that include and are not limited to: pick's disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia and aphasia. Resident was transferred to a local hospital on 11/9/2024 and 12/30/2024 per progress notes. Per record review no bed hold notification on record. R37 originally admitted on [DATE] with most recent readmission on 12/21/2024 with diagnosis that include and are not limited to: calculus of bile duct with acute cholecystitis with obstruction, muscle weakness, difficulty in walking and cognitive communication deficit. Resident was transferred to a local hospital on 10/24/2024, 12/16/2024 and 12/19/2024 per progress notes. Per record review no bed hold notification on record. R64 originally admitted on [DATE] with most recent readmitted d 11/5/2024 with diagnosis that include and are not limited to: Alzheimer's disease, cognitive communication deficit, anemia and generalized anxiety disorder. Resident was transferred to a local hospital on 10/31/2024 per progress notes. Per record review no bed hold notification on record. R120 originally admitted on [DATE] with most recent readmission on 1/5/2025 with diagnosis that include and are not limited to: displaced fracture of base of neck of left femur, hemiplegia and hemiparesis, muscle weakness and dysphagia. Resident was transferred to a local hospital on 12/29/2024 per progress notes. Per record review no bed hold notification on record. On 01/15/25, at 2:41 PM, V1 (Administrator) was asked to provide surveyor the bed holds for the listed 18 discharges from hospital in the last three months. V1 stated, it has not been documented in the records. We are in the process of in-servicing the nursing staff on the proper procedure. On 1/15/2025, at 2:52 PM V2 DON (Director of Nursing) stated, regarding bed hold policy my expectation for the staff moving forward is communication with families and residents. I am not familiar with the bed hold policy. I remember from years ago I remember sending something with the patient when they discharged . The nurses are not aware of bed hold policy. We communicate with the families when they are discharged . We let them know what we are sending them out for, that we got the order. We call for follow up with the hospital. The hospital will usually ask us if they will come back to facility. We leave their belongings the same in their room unless family states that resident expires or are transferring elsewhere. Going forward I have started reviewing something that was given to me and started an in-service with the nurses on our bed hold policy. I am working on the verbiage so families and staff can understand it. Bed hold policy has not been being followed in the whole facility. On 1/15/2025, at 3:11 PM V1 stated, regarding the bed hold policy, it has not been being done in the whole facility. We are in the process of educating staff now. I do not know how this could have gotten overlooked. We do not charge any residents for any bed holds. For Medicare residents, we do not charge a bed hold. Private pay we do charge for the room whether they are here or not if belongings are in room. We do not kick residents out after the 10 days. The resident belongings stay in the room when they are discharged out to hospital. We do not move their belongings. Bed Hold Notices Policy with effective date of 5/1/2019 documents (in part): Policy: Franciscan Ministries supports the resident and/or resident's representative's right to be informed of the policy regarding holding a bed prior to and/or upon a resident's transfer to the hospital, therapeutic leave or discharge, including the duration of the bed hold. Purpose: To ensure a resident has the information regarding his/her rights regarding bed holds. Procedure: Notice Before Transfer 1. The following information is given to the resident and/or resident representative. a. The duration of the State bed-hold, if any during which the resident is permitted to return and resume residence in the nursing community. b. The reserve bed payment policy in the State plan, if any; and c. The community policy regarding bed hold periods to include permitting residents to return. 2. Policy Administration: 3. 2. The Executive Director/Administrator and Director of Nursing share responsibility for the implementation and communication of this policy. 4. 3. The Executive Director and [NAME] President of Clinical Services share responsibility for monitoring and reporting on implementation of this policy. This responsibility includes bringing to the attention of the Senior Management or the Board instances where this policy is not being applied.

Based on observation, interview and record review, the facility failed to perform proper hand hygiene, failed to follow proper food storage practices, and failed to ensure dishwasher maintained proper temperature during final rinsing cycles to prevent the spread of food-borne illness and contamination. These failures have the potential to affect all 87 residents receiving meals from the kitchen. Findings include: On 01/13/25 at 09:25AM during the initial kitchen tour with V4 (Director of Dinning Services), surveyor observed three 50 pound bags of carrots on the floor, half full containers of: flour, salt, sugar, and navy beans without open and used by dates. V4 said, the carrots should not be placed directly on the floor and the flour, salt, sugar, and navy beans must be labeled with the open date and used by date. V4 said, he did not know what happened and that the staff are expected to follow the facility policy to label and date food when it is opened. On 01/14/25 at 09:25AM surveyor checked the temperature for the dishwasher with V4. Surveyor observed final rinse temperature of174 Fahrenheit (F) and repeat of final rinse at 175F. Surveyor requested for the high temperature dishwasher policy and specifications. V4 said, the dishwasher machine the facility uses, the final rinse is expected to be between 180F to 190F and V4 will be calling a local company to come and check the dishwasher machine. On 01/14/25 at 11:36 AM surveyor observed resident dining in [NAME] dining room on first floor. V12(Dietary Server) observed opening refrigerator with gloves on, removed saran wrap from plate of tomato and lettuce, touched the tomato and lettuce and added it to lunch plate for R40 with the same gloved hands. Surveyor did not observe V12 perform hand hygiene. Surveyor asked V12 if she should have washed her hands and changed gloves after touching refrigerator and prior to touching residents' food. V12 said, I think so. On 01/15/2025 at 11:50AM V8 (Local company Account Representative) said, when the dish washer machine final rise temperature was checked on 01/14/2025 at 12:09PM, the temperature of the final rinse was not holding up, and the dishwasher temperature was switched to low temperature with chemical rinse, because there were no parts available to fix the machine at that time and ordered the parts. V8 said that the machine requires 6 elements, and one element was not working. V8 showed pictures of exposed wires to the surveyor. and said, that is why the temperature is not holding up. On 01/15/2025 at 9:50AM V2 (Director of Nursing) said, the staff are expected to wash their hands or use hand sanitizer before and after care, after removing gloves and after touching a soiled or dirty surface. Staff in the dining room are required to wash their hands before putting gloves on and before serving meals, and when hands get soiled and when changing tasks. On 01/15/2025 at 9:55AM V3 (Infection Preventionist) said, staff are expected to wash hands or use hands sanitizers all the time, between patients, before and after using personal protective equipment, before and after serving food, before and after passing medications, and when hands get soiled. V3 said, vegetables or food should not be placed directly on the floor because it can cause cross contamination and cause infection. On 01/15/2025 at 11:04 AM V1 (Administrator) said, she was not aware of any concern with the dishwasher or with the final rinse temperatures and V1 works directly with V4 to fix any equipment that is not working properly. V4 usually makes sure that the kitchen equipment is fixed immediately. V1 said, the staff are expected to follow facility policy and not place food directly on the floor and practice hand washing to prevent infection and residents getting sick. Facility policy titled, Sanitation and Infection Prevention/Control Policy number F006 dated issued:5/95 and revised 1/2025 documents (in part): Policy: To prevent communication of food with infections microorganism, Food and Nutrition Services associate are expected to observe the following Infection Prevention and Control Practices. Procedure: Use a spatula or tongs or wear disposable gloves when handling food, do not touch food with bare hands, do not perform multiple activities while wearing gloves which will be used in food handling. Facility policy titled, Sanitation and infection Prevention/Control: Disposable glove use Policy number F021 dated revised: 1/24 documents (in part): Policies: Disposable, no-latex gloves must be worn at the following times, When handling read-to eat-foods, When handling clean utensils/dishes/equipment, When handling soiled dishware Procedure: Disposable gloves must be changed and handwashed when gloves are dirty or ripped and when moving from one task to another, such as moving from handling dirty dishes to handling clean dishes. Facility policy titled, Sanitation and Infection Prevention/Control Policy number F019 date reviewed (1/24) documents (in part): Policies: Dishmachine wash, and rinse water should be maintained at temperatures that meet the guidelines established by the food and drug administration. Single-tank conveyor, dual temperature machine: Wash temperature 160F. Final rinse temperature 180F-194F. Facility policy titled, Production, Purchasing, Storage; Food and Supply storage policy number B003 revised dated (1/25) documents (in part): Policies: All food, non-food items and supplies used in food preparation [NAME] be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Most but all but not all products contain an expiration date, the words sell by, best by, enjoyed by or used by should precede the date. Food past the used by date, sell by, best by, or enjoyed by date should be discarded. Cover, label, and date unused portion opened packages. Use the medadvantage/fresh date labeling system or complete all section on the [NAME] orange label. Refrigerator Storage: Store items 6 inches above the floor. The bottom shelf must be solid to prevent product from splash and dust. 50036

Based on interview and record review, the facility failed to implement a physician's order for an as soon as possible (STAT) X-ray after one resident (R1) sustained an unwitnessed fall and complained of pain in the right hip area; and the facility failed to document in the medical record after one resident (R1) sustained an unwitnessed fall. This failure affected one resident (R1) who was transferred to a local emergency room ten hours after the unwitnessed fall took place and was diagnosed with a right hip fracture. Findings include: R1 is a [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: dementia without behavioral disturbances, chronic obstructive pulmonary disease, and hypertension. According to the Minimum Data Set (MDS) R1 had a brief interview for mental status (BIMS) dated: 9-26-2024 with a score of 5/15, which indicate impaired cognition. On 12-21-2024 at 2:40 pm V10 (Certified Nurse Assistant) said, on 10-27-2024 I went to R1's room since the call light was pulled. R4 (R1's roommate) pulled the call light and said, I called for help because I heard a noise, I think R1 had a fall. I saw R1 on the floor, R1 was facing the bathroom door on his right side, R1 said he was having pain I think in his right hip and leg area. I immediately called for the nurse, V14 (Nurse) came to see R1, assessed the patient, and told us V11 and V10 (Certified Nurse Assistants) that we could move the patient to the wheelchair. I put the gait belt on R1's waist and we moved R1 to the wheelchair and took him to the toilet then we placed him in his bed, and the nurse told us the doctor ordered an x-ray of the right hip and leg area. On 12-21-2024 at 11:15 am V2 (Director of Nursing) said, V14 is on personal time off outside of the country and unable to be reached. According to my investigation, R1 had a fall on 10-27-2024 at 9:30 pm, V14 contacted V15 (Medical Doctor) at 10:40 pm and received an order for an X-ray of the right hip to be completed as soon as possible (STAT). The X-ray was not taken, and the portable X-ray company never came to the facility. My expectation for a STAT x-ray is 4-6 hours. R1 was sent to a local hospital on 10-28-2024 at 7:40 am (ten hours after the unwitnessed fall). R1's fall assessment dated : 10-18-2024 reads a score of 75- indicating a high risk for falls. R1's care plan reads: anticipate R1's needs, assist when he needs to go to the bathroom, call light within reach, (we do not have any assessment to confirm the ability of the patient to use the call light), remind R1 to ask for assistance and bed in low position. I am not able to find any documentation in R1's medical record for the fall dated 10-27-2024. My expectation is for the documentation to be in the resident's medical record. It is not acceptable that V14 did not complete the documentation. On 12-21-2024 at 11:10 AM V1 (Administrator) said, we have a risk management form completed by V14, it is an internal document that I am not able to share with IDPH. On 12-21-2024 at 2:00 pm V12 (Registered Nurse) said, R1 had a fall on the 3-11 shift. I worked on the 11-7 shift. R1 complained of pain in the right hip, the MD ordered a STAT x-ray, the x-ray company told me that they could not come to do it during the night shift, I told V2 (Director of Nursing). I did not report to the doctor. I documented the vital signs, but I did not document the pulse oximetry, I do not remember if took it or not. I should have done it. I know I have to do neurological (neuro) checks. On 10-28-2024 at 5:00 am R1 was provided incontinence care, R1 complained of pain in the right hip. On 12-21-2024 at 2:50 pm V12 said, I should have called the doctor to let him know the delay on the STAT x-ray and obtain further orders. I need to remember to complete the neuro checks after an unwitnessed fall, I am sorry, it was my fault. On 12-21-2024 at 12:55 pm V7 (Registered Nurse) said, R1 was able to walk using the rolling walker with one person's assistance and the wheelchair the rest of the time, able to feed himself after the tray was set up. R1 was alert and oriented to self and confused. R1 was not able to use the call light, R1 will get anxious very easily and will not have an understanding of his physical limitations. I kept him by the nurse station all the time for people to keep an eye on him since he was a high risk for falls. I do remember on Monday, 10-28-2024 I was working during the first shift, I did my rounds to make sure the patients were doing well when I took reports from the night nurse. R1 was in his bed, I saw that R1 was having labored breathing and difficulty to aroused, his right hip was noted to be red, and R1 complained of pain. I did a pulse oximetry (pulse Ox) and the machine read 66%, according to EMR (electronic medical records) Vitals Blood Pressure 125/65 T 97.7 Heart rate 88 Respirations 26. I increased the oxygen to 10 liters via mask I called the doctor and I sent R1 via 911. V12 (Registered Nurse) from the night shift, said the right hip x-ray was not done because the company was not able to come during the night. We nurses, need to take a full set of vital signs including blood pressure, heart rate, temperature respiratory rate, and oxygen saturation, we need to complete the neurological (neuro)checks to make sure the patient is not having any changes in condition. The neuro checks are done: every 15 min for the first hour, then every 30 min x 2, every hour x 4, and every 8 hours for the remaining time to complete the 72 hours. On 12-21-2024 at 12:20 pm V4 (Registered Nurse) said, when any of my patients have an unwitnessed fall, I am responsible for making sure to evaluate the patient, we are not to move the patient if there is any complaint of pain, we must call 911 as a nursing intervention. I will complete a head-to-toe assessment, if the patient is complaining of hip, or leg pain the nurse needs to make sure the extremities are not having any shortening. I need to take a full set of vital signs including blood pressure, heart rate, temperature respiratory rate, and oxygen saturation, we need to complete the neurological (neuro)checks to make sure the patient is not having any changes in condition. The neuro checks are done: every 15 min for the first hour, then every 30 min x 2, every hour x 4, and every 8 hours for the remaining time. The nurse is responsible for notifying the medical provider: Nurse practitioner or medical doctor and the Director of Nursing if any of the provider's orders cannot be followed. On 12-21-2024 at 12:45 pm V6 (Registered Nurse) said, R1 was confused and forgetful. We as nurses need to make sure to follow the doctor's orders and if we are not able to carry the order out, we need to call and report to the doctor for any further orders. If the patient has an unwitnessed fall, we need to make sure to complete a complete body assessment and start neuro checks, that is the only way to see if the patient is having any change in condition. Neuro check if I remember correctly needs to be done every 15 min for the first hour, then every 30 min x 2, every hour x 4, and every 8 hours. On 12-21-2024 at 1:40 pm V3 (MDS Coordinator) said, if the patient has an unwitnessed fall, the nurse must start neuro checks, complete the fall, and pain assessments, call the medical doctor, and update the care plan. The neuro checks are done to make sure the patient does not have any changes in their mental status. The nurse needs to document in the electronic medical record any changes in condition, falls, incidents, and any monitoring. R1 was a nice patient, very forgetful and unable to use the call light consistently due to his cognitive status. R1's hospital records read: primary diagnosis on 10-28-2024 at 8:03 am Acute and Chronic respiratory failure with hypoxia. X-ray of pelvis dated: 10-28-2024 at 10:59 am indicated pain in the right hip, trauma. findings: there is a fracture through the right lesser trochanter and lucency through the intertrochanteric portion of the hip. Orthopedic note dated: 10-28-2024 at 5:07 pm reads: right lower extremity is externally rotated, mild swelling of the hip and proximal leg. On 12-21-2024 at 3:10 pm V15 (Primary Medical Doctor) said, my expectation is for the nurse at the long-term care facility to call me when a STAT X-ray is not done. I need to be called when I give an order and is not able to be completed. I was never notified that the STAT X-ray was not done for R1. R1 was a very complex patient, he had cardiac and respiratory issues among many other issues. On 12-22-2024 at 5:20 pm V2 (Director of Nursing) said, my expectation for the nurse to document in the medical records when the patient has any falls, to notify the medical provider, to document in the patient's medical record if any new order is received and carried out. The standard of practice requires the nurse to communicate with the doctor if the order is not carried out. It is unacceptable not to have complete medical record including and not limited to when the patient has a fall. The nurse is responsible to take a full set of vital signs and to monitor the patient's condition. We do not have any policy on neurological checks, we do not have any policy on carrying out doctors' orders. V2 presented a policy dated: 3-21-2024 and titled: documentation in medical records reads: documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred.

Based on interview and record review, the facility failed to prevent an incident of resident to resident physical aggression. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 kicking R1 in the leg and R1 sustaining a 7 cm skin tear. Findings Include: Facility Reported Incident reviewed, and reads in part: On 9/2/24 at 2:20PM, R1 was in the common area when R1 began talking in a loud voice at a R3 who was trying to push a table over. R2 approached R1 while R1 was speaking to the R3 and kicked R1 in the left lower leg, resulting in a skin tear. R1 has a diagnosis of Dementia and Restlessness and Agitation. R1's most recent BIMs score conducted on 8/16/2024 was 03/15 indicating severe impairment. R1 has diagnosis of Dementia, R1 exhibits poor safety awareness and poor impulse control. R1 also has a care planned behavior of becoming verbally agitated, which has caused peers to become agitated. R2 has a diagnosis of Dementia and Generalized Anxiety Disorder. R2's most recent BIMs score conducted on 07/02/2024 was 03/15 indicating severe impairment. R2 has a care planned behavior of exhibiting poor impulse control as well as having difficulty with interpreting her environment related to her Dementia. After thorough investigation of residents and staff, it was determined that due to R1's behavior of speaking in a loud manner at R3, R2 was frustrated with R1 and wanted R1 to stop talking and because R2 exhibits poor impulse control related to R2's advanced dementia R2 kicked R1 in response. Both residents were immediately separated and R1's skin tear to R1's left lower leg was immediately treated. On 9/28/24 at 11:40AM, V3 (Nurse on 9/2/24) stated that someone yelled to V3 to come over here, R2 kicked R1 and R1 was bleeding. V3 went and R1 was in the wheelchair located in the common area in front of the nurse's station, noted bleeding on the lower leg. V6 (RN) put pressure on the area of the wound. R1 was wearing short pants, and I could see the lower leg. Noted on left lower leg, shin area has a skin tear over 7cm in size, bleeding continuously. V6 and V3 brought R1 by the treatment cart. R2 was separated from R1, R2 was in the west corridor area after the incident. On 9/28/24 at V4 (CNA) stated V4 was passing by the common area, observed R3 shaking the table, R1 was behind R3 and telling R3 stop doing this, stop it. Stop it. R1 was saying this loud, R1 is hard of hearing, and R1 always talks loud. Suddenly I saw R2 propelling R2's wheelchair towards R1. As R2 was heading to R1, R2 was not saying anything at all. And then suddenly, V4 just passed the common area when V4 heard R1 yelling, She kicked me, she kicked me. And as V4 returned to the common area, V4 saw R2 propelling back close to the window, R2's usual spot. V4 went to check on R1 and then saw blood on R1's leg. V4 removed R1 out of the common area, V4 told the nurse and then 2 nurses assisted with R1's wound. On 9/28/24 at 1:25PM, V6 (RN) stated that V6 was in the nurse's station charting and monitoring R3 in the common area because they are high risk for fall. V6 stated that the common area is right across from the nurse's station. R2 was sitting next to the window. R1 was sitting in the middle of the common area, closer to R3. R3 was trying to move the table, making sounds, and R1 started to talking to him, saying Stop doing it, what are you doing. R1 always talks loud due to being hard of hearing. V6 stated that R2 was sitting in her wheelchair by the window, saying stop yelling too much to R1 and at this time R3 stopped moving the table. V6 stated she did not see R2 head towards R1 because there was a center wide pole wall blocking V6's visual to R2 from where V6 was at the nurse's station, charting. V6 just heard R1 say she kicked me. R2 was closer to R1 at the time. On 9/28/24 at 3PM, V2 (DON) stated that on 9/2/24 the incident was reported by the nurse on the floor. It was reported by the nurse that R2 had kicked R1 in the shin. My question was were they immediately separated? Then the nurse said that V4 (CNA) had taken R2 away and V3 (RN) provided treatment to R1. The facility investigated the incident, and the outcome of the investigation was that both residents have dementia. R1 is hard of hearing and spoke with a deeper louder voice at R3 who was banging on the table. R2 approached R1 and R2 got frustrated with R1. R2 told R1 to stop talking and because of the advance dementia that R2 has, R2 kicked R1 in response because R2 exhibits poor impulse control. It is not uncommon for R2 to propel themself and wanders the unit, and the staff did not anticipate R2 kicking R1. On 9/29/24 at 9:40AM, V9 (Activity Aide) stated that R2 did not attend activity that day. V9 said they have never seen in 10 months that they have been working in the facility that R2 is with any physical aggression; but, has observed R2 at times with verbal aggression towards others, such as staff and residents. R2 would get upset, and based on my own experience, R2 got upset when I was trying remove R2 from the dining room. R2 shouted at me and said, leave me alone, and cursed at me. R1's progress notes dated 9/2/24 at 1520, reads in part: R1 got skin tear on LLE (7cm length) and a little bleeding with surround (sic) hematoma, which was kicked by one of residents (R2) in common area at 2:20PM. Immediately, applied steri-strips after normal saline cleansing with Bacitracin ointment on the site. Then applied Foam dressing. Elevated her LLE on the sofa, also applied ice pack for the pain and hematoma. Await MD's s response. The POA aware. Informed DON as well. Endorsed next shift. Behavior notes for R2 dated 9/2/24 at 1432, reads in part: R2 kicked one of residents at 2:20PM, who got skin tear on LLE with bleeding in common area. R2 was separated from the resident at that time as well. Called her POA, the MD and DON aware. Behavior note for R2 dated 8/7/24 at 1304, reads in part: R2 was yelling and fighting with the other resident for moving sofa. R2 almost hit the resident by left hand. Behavior notes for R2 dated 7/18/23, reads in part: At 8:30PM, three residents R1and R2 are convincing another resident to stay seated because the resident keeps walking and wandering without her walker for so many times. R2 was trying to stop R1 from following another female resident. This female resident getting agitated and verbally rude to R1, R2 feels bad and did not like how this resident treated R1. R2 became impatient or annoyed with the female resident and pushed her walker while standing in front of her causing this female resident to fall on the floor. RN asked why R2 did that, R2 said because she is mean to R1. Staff separated the residents from each other to prevent further harm. Redirected as needed. R2's care plan for Behavior dated 9/4/24 stated R2 exhibits poor impulse control and confusion r/t her Dementia. R2 becomes easily agitated and has difficulty interpreting the environment around her. R2 has attempted to hit staff members as well as peers. Abuse, Neglect and Exploitation policy with a revised date of 1/1/24, reads in part: Franciscan Ministries affirms that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Resident must not be subjected to abuse by anyone, including but not limited to community staff, other residents, consultants, contractor, volunteers, or staff of the other agencies serving the resident, family members, legal guardians, friends, or other individuals. Physical abuse includes, but is not limited to hitting, slapping, punching, and kicking. It also includes controlling behavior through corporal punishment.

Based on interview and record review the facility failed to ensure a resident received her medications as ordered. This applies to 1 of 3 residents (R5) reviewed for medication administration in the sample of 11. The findings include: R5's EMR (Electronic Medical Record) shows that R5's Admission Evaluation was created at 1:47 PM on 5/29/24. R5's Medication Administration Record for May 2024 shows that R5 was admitted to the facility on [DATE]. This same document shows that R5 was ordered to receive Allegra (Allergy) 24hr 1 tablet, Amlodipine (Antihypertensive) 2.5mg, Cefpodoxime Proxetil (Antibiotic) 200mg, Januvia (Antidiabetic) 25mg, Telmisartin (Antihypertensive) 80mg, Bisoprolol Fumarate (Antihypertensive) 10mg, and Preservision (Supplement) 1 tablet. None of these medications are signed out as given. A Pharmacy Manifest Document dated 5/30/24 shows that R5's medications were not delivered until 4:36 AM on 5/30/24. On 7/19/24 at 2:05 PM V23 (RN) stated, (V22) worked the PM shift on the day of admission. I get the orders from the hospital and clarified them with the doctor. Then I send the orders to the pharmacy, and they put them in the computer. Then I verify them again between the computer and the medication list to make sure they are right. On 7/19/24 at 2:15 PM V22 (RN) stated, The family had their own stock of medications. I remember I talked to the family and told them that the medications had not come in yet from the pharmacy. I don't know if the family gave her medications or not, but I didn't have them yet from the pharmacy and I told them that. The resident was very sarcastic, and it was hard for me to tell if she wanted to take medications or not. I had a difficult time with her because she was always sarcastic, and I couldn't tell if she was joking or not. The facility policy entitled Medication Administration dated 6/1/23 states, Medications are administered in accordance with written orders of the prescriber.

40920 Based on observation, interview and record review, the facility failed to protect the residents' right to be free from physical, verbal, and mental abuse by an employee, and failed to follow its abuse policy related to prevention, identification of abuse. These failures affected one (R55) of six residents in the sample of 37 residents reviewed for abuse. These failures resulted in R55 feeling angry, uncomfortable, and humiliated by the employees physical and verbal actions towards R55. R55 is a [AGE] year-old female who has resided at the facility since 6/1/2022 with past medical history including, but not limited to [NAME] ataxia, age-related osteoporosis without current pathological fracture, vitamin D deficiency, thoracogenic scoliosis, thoracic region, overactive bladder, pain in right leg, pain in left hip. Minimum Data Set (MDS) assessment dated [DATE], section C (Cognitive) documented R55 has a BIMs (Brief Interview for mental Status) score of 13, section GG (functional abilities and goals) of the same assessment indicated that R55 requires substantial/maximal assistance from staff for most activities of daily living (ADLS). Abuse and neglect screening for R55 dated 6/15/2023 scored her as low risk for abuse, screening dated 12/15/2023 scored resident as low risk and no history of abuse. R55 does not have any care plan or interventions for abuse. Facility reported incident (initial) dated 12/11/2023 documented R55 reported to her Nurse and the Administrator that a CNA made inappropriate comments to her and slapped her. She could not recall the exact times, but it was over the course of the last few months. The perpetrator was put on administrative leave pending investigation. The final report documented that V1 (Administrator) interviewed R55 on 12/11/2023 and resident stated that V8 (CNA) hit her on her behind and called her a fat ass. Resident stated that the last time V8 hit her on the behind was last Thursday, he used to do it more often, it quit for a while and then started again. R55 added that when V8 called her a fat ass, she said to him, no I am not a fat ass. R55 also reported to V1 that one time she was coming out of the shower with V8, and he said, I was going to kiss you back there, and R55 said no, R55 added that V8 went on to make some kissing noises as they were walking down the hall. On 12/13/2023, V1 received an email from R55's sister indicating that she spoke to R55 last night and she reported that after drying her in the shower, V8 will touch her breast to make sure there was no soap left. V1 followed up with R55 the same day and she stated that while showering, V8 will put his bare hand under her armpit and under her breast to make sure the soap was all gone. R55 added that he made her feel uncomfortable. On 12/12/2023, V1 interviewed V8 who admitted to patting R55 on her bottom, did not consider it inappropriate because R55 wears a sanitary napkin inside her pull up and he pats the area to make sure everything is in its place. V8 denied calling R55 a fat ass but said that he groaned after transferring resident from bed to wheelchair, R55 asked him why he groaned, and he said to resident, your weight is 1/2 of mine, so you are not a light weight, your weight is heavy. V8 denied telling resident that he was going to kiss her or making any kissing noises. On 3/19/2024 at 11:10AM, R55 was observed in her room, awake, alert and oriented and stated that she is doing okay. Surveyor asked the resident about the incident that happened with a staff in December of 2023. R55 said, you mean the guy? Surveyor said, yes. R55 said that this staff will pat her on her bottom after changing her incontinence brief, and she does not think that he should be doing that. Surveyor asked resident how that made her feel. R55 said, it makes her angry, it is not appropriate for him to be doing that. R55 also said, The staff member identified as V8 called her a 'fat ass' and that was wrong of him, no one should be addressed like that. R55 reported the incident to a nurse because it makes her feel uncomfortable. R55 added, she has not seen the staff recently, she thinks he got another job, she has not had any issues with any other residents or staff. On 03/20/24 12:04 PM, V1 (Administrator) said that she investigated the abuse allegation for R55, resident is alert and oriented X3 and has never made any abuse allegation towards any staff or resident. V1 interviewed the resident who told her that staff (V8) called her a fat ass, pats her on her bottom after changing her incontinence brief and touched her breast during showering. V8 was suspended during the investigation, and he did not return to the facility because he was terminated. V1 said that she did not substantiate abuse because the staff (V8) was able to explain the patting on resident's bottom, it is not the appropriate thing to do because it could be interpreted as uncomfortable for the resident, staff are not supposed to make residents uncomfortable. V1 said that she did not consider this abuse, but staff was terminated due to customer service, he could have used better judgement when providing care, and she felt it was better to part ways. On 03/20/24 02:10PM, V4 (Executive Director) said, residents are screened for abuse risk upon admission and every 6 months. Those at risk will be identified and referred to nursing and social worker for follow-up. Those identified at risk will have a care plan, at risk residents are those with psych issues, aggressive behavior, history of abuse and substance abuse. Dependent residents may potentially be at risk for abuse, but they don't have an abuse care plan. If there is an allegation of abuse and it is not substantiated, the resident will not have a care plan because no abuse occurred. The Administrator investigates all abuse and does a good job, if she said abuse did not occur, then there is no abuse. On 03/20/24 02:38 PM, V30 (LPN) said, she is familiar with R55, has worked with her since she was admitted , she was the nurse that the resident reported the abuse to. She came to work on second shift and the resident told her that she wanted to speak to her. R55 said that it was private and asked her to close the door. R55 said to V30, He was here today and helped another staff get me up. V30 asked resident who is he and she mentioned V8 and said that V8 called her a fat ass. V30 immediately called V1 who happened to be on grounds, she came up to the floor and spoke to the resident. V30 stated that she reported the incident immediately to V1 because she considers it abuse. Abuse policy revised /7/2018 states in part that the facility affirms that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, contractor, etc. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Under prevention of abuse, neglect and exploitation, the policy states 1. Assess, monitor, and develop appropriate plan of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with history of aggressive behavior, residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff. Facility's policy titled, Abuse, Neglect and Exploitation dated 03-07-2018 documented in part but not limited to the following: Policy: (Name of Ministries) affirms that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes, but it not limited to: freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to: community staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Purpose: To ensure that a comprehensive program exists in all aspects of community operations involving the prevention, identification, reporting, and investigation of abuse. Prevention of Abuse, Neglect and Exploitation 1. The community will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: k. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, or ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds. l. Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors, residents who have behaviors such as entering other residents' rooms, residents with self-injurious behaviors, residents with communication disorders, and those that require heavy nursing care and/or are totally dependent on staff.

Based on observation, interview, and record review, the facility administration failed to take appropriate action to ensure the safety of 2 (R38, R55) of 3 residents reviewed for abuse in the sample of 69. The facility administration failed to protect residents from harmful actions inflicted by staff, failed to conduct a thorough investigation of allegations of abuse, and failed to honor the requests of the resident(s) to remain safe and free from harm. This failure has the potential to affect all 69 residents currently residing in the facility. Findings include: On 3/18/24 at 9:50 AM, V1 (administrator) presented survey team with a census roster showing 69 total residents. 1. R38 is an alert and oriented [AGE] year old resident with diagnoses including chronic diastolic congestive heart failure, osteoarthritis, scoliosis, and spondylosis with radiculopathy. On 3/18//2024 at 11:55 AM, R38 stated that on 2/6/24 V6/CNA, while giving her a bed bath, was very rough and caused her arm/shoulder pain and possible injury. R38 stated that V6 is usually talking on her earpiece and does not pay attention or focus on her but instead on her phone calls. The resident also asked V6 not to wear them but V6 ignores her repeatedly. R38 stated that she asked V6 to be gentle in moving her body and arms while conducting any care but V6 disregarded her requests with repeated responses of I've been a CNA for [AGE] years and I don't need you to tell me what to do. V6 continued pulling her clothes off over her shoulder in a rushed and rough manner as she screamed in pain during the process, yet V6 continued on. R38 stated she informed her nurse V9 (RN) about the incident after several days of experiencing extreme pain and expected the nurse to report it to her doctor and to administration, but she did not hear anything back from anyone. R38 was expecting that she would get some resolution to the conflict. R38 stated V6 was never removed from her care and continued to care for her numerous times after the incident and that this CNA continued to be careless and rough in her care. R38 stated that she saw herself as an advocate not only for herself, but for others who couldn't speak up for themselves. She worried that V6 acted in the same manner with other residents on the dementia unit where she knew V6 had worked. On 3/19/24 at 2:45 PM, V9 (RN) stated, I know (R38), and she is mostly in her bed. She is alert times 4 (cognitively intact with no confusion). She would complain about care especially if it's someone who doesn't know her routine, if her food is delivered late, she will complain, and if she does not get a bath from certain CNA's. Surveyor asked if the resident's requests seemed reasonable, V9 stated, Yes. Surveyor asked if he recalled R38 complaining about arm/shoulder pain, V9 stated, She complained about her shoulder and that a CNA was rough with her. It was V6 and she's on this floor now if you want to talk with her. Surveyor asked V9 to recall the incident, I recall her shoulder was in a lot of pain and so I asked her what happened, and she told me about it. I asked if she wanted any pain medication for that, so I called the doctor who ordered an x-ray. Surveyor asked what else he did when told of the incident with the CNA, V9 stated, I asked the resident first what happened, if it happened when the CNA turned her and I asked her which CNA and she told me V6, so I also talked to the CNA about what happened. Surveyor asked if he informed anyone else about the incident, V9 stated, I think I told V2 (DON), but I did not document that in the notes, just that I called the doctor. Surveyor asked if any incident like what R38 described what he was supposed to do? V9 stated that if a resident had a problem with a CNA assigned to them, they would just swap out that CNA with another one the resident liked. Surveyor asked when the last time he received abuse training, V9 indicated that he had a refresher this month. Surveyor asked what the facility's procedures were of any suspected or reported abuse, V9 stated, We do an abuse assessment on the resident and report what happened to the DON. We are to report any abuse incident, assess and interview the resident and report it. I missed the reporting part. Surveyor asked if he separated V6 from the resident and V9 stated, No. On 3/19/24 at 2:55 PM, V6/CNA stated to surveyors during interview, I've worked here since September and applied for an open position. Surveyor asked if she used to work as an agency CNA prior to her hire? V6 stated No I haven't. V6's statement however did not align with her personnel file showing her previous position was an agency CNA. Surveyor asked about R38 and if she recalled the incident of 2/6/24 where the resident complained of shoulder pain? V6 stated, Yes I know (R38) and I remember her complaining about her shoulder, so I told the nurse, but I'm not frequent on her floor. I generally work the second floor. Surveyor asked the type of floor the second floor was? V6 stated, It's dementia mostly. Surveyor asked if there was anything she could recall of the incident of 2/6/24 other than the resident complaining of shoulder pain? V6 stated, (R38) is very particular about her care and she verbally tells me how she wants things all the time, she likes her phone to be near her. She's also particular about her sheets going up close to her neck when she's in bed, and she needs her gown changed and clean. Surveyor asked if these were unreasonable requests, V6 indicated they were not. Surveyor asked if she could recall during the incident of 2/6/24 if there was any discussion about slowing down or being gentle with her? V6 stated, I'm always gentle with my residents. Surveyor clarified that the question was if there was any discussion by the resident for her to be gentle when moving her arm or any other body part, V6 stated, Yes I think she mentioned something like that. Surveyor asked when she was told to slow down and be gentle what she did, V6 stated, I don't remember. Surveyor asked if she could recall if the nurse V9 asked her what happened? V6 stated, Yes he just asked me what happened, and I told him she was in pain. Surveyor asked if there was any argument on 2/6/24 with R38 or if the resident asked her not to be too rough with her in any manner, V6 stated, No I never argued with her and like I said she (R38) is very particular with how she wants things. Surveyor asked how long she'd been a CNA, V6 stated, I've been a CNA 11-[AGE] years. Surveyor asked if she ever mentioned this fact to the resident, V6 stated, No, I don't have conversations with residents, I just do my job. Surveyor asked if there was anything out of the ordinary that may have occurred on 2/6/24 during her care of R38 or during anytime she'd been assigned to R38? V6 stated, No, she's not a difficult resident, she's just particular but (R38) has a way she talks to other people in a condescending manner. Surveyor asked how that made her feel, V6 stated, I just try to ignore it. Surveyor asked if she'd had any other issues with any other residents she'd care for, V6 paused and then stated, No but earlier this year one of the resident's family complained about my care so the administrator suspended me and when I got back the DON V2 gave me a 1:1 about general care and respecting patients. Surveyor asked if she knew what the specific complaint was that the family alleged, V6 stated, I don't know. Surveyor asked the rationale for her being provided 1:1 training about general care and respecting residents as she mentioned, V6 stated, I can't answer that. Surveyor asked if she'd been trained on the topic of abuse, V6 stated that she received one upon hire and she did an online training in the past November. On 3/19/24 at 3:35 PM, surveyors asked V2/ DON if she knew about the incident of 2/6/24? V2 stated, I don't recall V9 telling me anything about R38 or I do not recall it. I believe I was not in the building and it may have been my previous assistant; but she no longer works here and I don't know who he spoke to. Surveyor asked if she knew about R38's shoulder/arm pain? V2 stated, I am not aware of anything about her shoulder. (R38) is very alert x 4 and she's able to make her needs known. She's particular and has particular preferences. There's certain staff she gravitates to and likes the normal CNA's or the regular CNA's and does not like any of the agency CNA's we had. She likes CNA's who are assigned to the unit that are the permanent on the unit because over time they have gotten to know her. Surveyor asked if these were reasonable requests, V2 indicated that they were. Surveyor asked about V6 and her work record with residents, V2 stated, I've never had any issues with (V6). Surveyor asked if V6 had any history with any other residents that resulted in any disciplinary action, V2 hesitated and stated, I've never had any issues with her except one time recently I think in January there was something about another resident and their care from V6, so we ended up putting her on administrative leave. Surveyor asked what the administrative leave was about, V2 stated, It was about some customer service issue some family had with V6. Surveyor clarified if that administrative leave was a suspension or personal leave, V2 stated, She was suspended. Surveyor asked what specific customer service issue V6 was suspended for, V2 stated, I think the family alleged that their mom was left cold and wet (urine) and wasn't given a blanket or something like that. Surveyor asked how leaving a resident wet and cold was a customer service issue, V2 stated, Well it was also a care issue. Surveyor asked what units V6 normally worked on, V2 stated that V6 worked all throughout the facility including the dementia unit. Surveyor asked if any of the residents on the dementia unit were interviewable or could voice any concerns to anyone, V2 stated, No most of them are confused. V2 paused and stated, Oh I see what you mean. I gave V6 in-service training, and she's been a CNA for a while, and I trust her. On 3/19/24. 2:00 PM. V13 (Director of Resident Services) stated, I'm responsible for the abuse in service training portion in our skills fair and we had our latest one in November. We try to capture all the staff for the campus in these skills fairs that touch on various subjects, one is abuse which I do. I make it a point during training that anything you hear or see, you have to report immediately to your immediate supervisor, who will then report it to V1(Administrator). I tell them about the 8 types of abuse, and anyone can report abuse including family, the resident themselves, and any staff. I tell staff that even idle gossip staff may hear about regarding residents being mistreated should be reported right away to their supervisor. I know we don't like to gossip but a lot of that gossip may include clues about some staff member that may be abusing a resident. Staff shouldn't determine themselves whether it's just a customer service issue because they should report it and let the supervisor and administrator determine this with their investigation whether it is actual abuse or just a service failure. Surveyor asked V13 a hypothetical question about if a CNA was being rough with a resident and that was reported to the nurse what the next step would be, V13 stated, They should immediately remove that person from the resident, and let their immediate supervisor know and also the administrator so they can investigate. It's not up to that individual to do this, they just need to separate the resident from that individual and report it right away. On 3/19/24 at 2:35 PM, V11 RN stated, I know R38 very well because she is on my unit and it's my permanent floor. Sometime she said she likes mostly the morning people. Sometimes she doesn't like somebody, I try to change CNAs. She mostly complains about them talking on the phone when they are working with the resident. They should not be talking on the phone. I talk to CNA at once if they talk on the phone. Sometimes I hear someone being rough with her (R38) but it's not on my shift. I hear that from the CNA amongst themselves. The CNA's talk that somebody was rough with her and not nice with her. It was a few months ago I think, I heard someone was not nice to her. I know for example who it was generally, and I try to figure out who, so I try to ask CNA's. Sometimes you know when she's not happy, so I tell V12/Administrative Assistant not to schedule a particular CNA (V6). Surveyor asked if she informed the administrator or DON about what she heard, V11 stated, I don't tell administrator or anyone, just V12. If there's any problem with any CNA, I Usually I tell V12. That CNA I hear about is (V6). I hear that she (R38) doesn't like her because the resident told me herself. She tells me V6 doesn't know too much what to do, how to care for her. I heard this again today, but I was busy. Surveyor asked V11 if she told anyone else other than V12, V11 stated, No I don't tell anybody. I don't tell anybody. I'm sorry. V1 (Administrator) and V2 (DON) presented information to survey team indicating that they had met with R38 last night to address the resident's concerns voiced on 2/6/24. This type-written response reads in part (V1) and (V2) met with (R38) at 6:35 PM on 3/19/24. V1 said to R38, I heard you need to report to me about someone hurting you. R38 went on to relay that V6 had given her a bed bath and after the bath she asked V6 to boost her up so she could pull her nightgown down in back. R38 reported that V6 wears earbuds a lot and was not sure how much she heard her. V6 proceeded to grab R38's left arm and pulled it to the side and R38 called out telling V6 she was in pain. R38 reported it to my nurse (V9) and waited until Thursday for V39 (attending physician) to come and examine the resident and then ordered an x-ray. The interview goes on to state that (V6) tends to have an unpleasant attitude with R38. The written report goes on to conclude that R38 stated that she felt V6's actions were unintentional and (V9) received education regarding being fully engaged with residents during care with no external distractions such as cell phones and ear buds and to engage with residents verbally during care regardless of ability to reciprocate. This report fails to indicate any re-inservice education on abuse prevention. On 3/20/24 at 1:30 PM, surveyors re-interviewed R38 to verify the meeting the resident had with V1 and V2. R38 stated to surveyors that V1 Administrator and V2 DON came to see her abruptly after dinner when she was already in bed last night around 7 PM and asked her about V6. R38 indicated that V1 asked if V6 was rough with her, and she told her that she was. R38 stated, the Administrator did most of the talking and I felt pressured to say that the CNA's (V6) actions were not willful because she kept emphasizing and repeating the word willful and that V6's intentions were not willful. R38 indicated to surveyors that she didn't agree with this but in order to pacify administration, R38 stated that she gave in and agreed with them even though she felt V6 intentionally and repeatedly ignored her and was rough each time she came. R38 informed surveyors that she still felt pain in her arm and shoulders after the incident and also every time when V6 returned on numerous occasions. R38 added that yesterday (3/19/24) V6 was assigned to her but was abruptly removed from her assignment which she was relieved to find out. R38 indicated that prior to yesterday, V6 continued to ignore her and provided rough care which caused her more pain. R38 stated that she brought concerns to the administrator on numerous occasions about the quality of staff in general, but the administrator's response would be to pass the buck as a corporate issue. R38 stated that she felt even more vulnerable now with administration by complaining stating, When the administrator came in the room, she had this look on her face that she was annoyed with me and that Oh it's her complaining again, but R38 didn't expect any real changes to come as she'd been dealing with the same issues for a while with no improvement. On 3/21/24 at 4:30 PM V39 (Attending Physician) stated to surveyors, (R38) is a very fragile patient and she has to be handled in a very delicate manner as she is brittle and has a complete rotator cuff tear and underlying severe arthritis that would worsen if it is exacerbated in any way. This was the reason I had ordered X-rays for that day when I got a call from a nurse telling me there was some incident that happened that caused the patient severe pain, so I suspected further injury to her shoulders. Surveyor asked if it was about the 2/6/24 incident? V39 stated, I don't know the exact date, I just know it happened a month ago. Surveyor asked if how he was informed of the incident involving his patient (R38) and V6, V39 stated, I found out from the resident that some staff person was careless and rough with her, but the nurse made no mention of any incident with R38's CNA being rough, it was the resident herself who informed me when I came to see her. 2. R55 is a [AGE] year-old female who has resided at the facility since 6/1/2022 with past medical history including, but not limited to ataxia, age-related osteoporosis, thoracogenic scoliosis, thoracic region, overactive bladder, pain in right leg, pain in left hip. On 3/9/2024 at 11:10 AM, R55 was observed in her room, awake, alert and oriented and stated that she is doing okay. Surveyor asked the resident about the incident that happened with a staff in December of 2023, and she said, you mean the guy? Surveyor said yes and resident said that staff will pat her on her bottom after changing her incontinence brief, she does not think that he should be doing that. Surveyor asked resident how that makes her feel and she said it makes her angry, it is not appropriate for him to be doing that. R55 also said that the staff member identified as V8 (former aide) called her a fat ass and that was wrong of him, no one should be addressed like that. R55 reported the incident to a nurse because it makes her feel uncomfortable. R55 added that she has not seen the staff recently, she thinks he got another job, she has not had any issues with any other resident or staff. Minimum Data Set (MDS) assessment dated [DATE], section C (Cognitive) documented that R55 has a BIMs (Brief Interview for mental Status) score of 13, section GG (functional abilities and goals) of the same assessment indicated that R55 requires substantial/maximal assistance from staff for most activities of daily living (ADLS). Facility reported incident (initial) dated 12/11/2023 documented that R55 reported to her nurse and the administrator that a C.N.A made inappropriate comments to her and slapped her. She could not recall the exact times, but it was over the course of the last few months. The perpetrator put on administrative leave pending investigation. The final report documented that V1 (Administrator) interviewed R55 on 12/11/2023 and resident stated that V8 (C.N.A) hit her on her behind and called her a fat ass. Resident stated that the last time V8 hit her on the behind was last Thursday, he used to do it more often, it quit for a while and then started again. R55 added that when V8 called her a fat ass, she said to him, no I am not a fat ass. R55 also reported to V1 that one time she was coming out of the shower with V8, and he said, I was going to kiss you back there, and R55 said no, R55 added that V8 went on to make some kissing noises as they were walking down the hall. On 12/13/2023, V1 received an email from R55's sister indicating that she spoke to R55 last night and she reported that after drying her in the shower, V8 will touch her breast to make sure there was no soap left. V1 followed up with R55 the same day and she stated that while showering, V8 will put his bare hand under her armpit and under her breast to make sure the soap was all gone. R55 added that he made her feel uncomfortable. 03/20/24 12:04 PM, V1 (Administrator) said that she investigated the abuse allegation for R55, resident is alert and oriented X 3 and has never made any abuse allegation towards any staff or resident. V1 interviewed the resident who told her that staff (V8) called her a fat ass, pats her on her bottom after changing her incontinence brief and touched her breast during shower. V8 was suspended during the investigation, he did not return to the facility because he was terminated. V1 said that she did not substantiate abuse because the staff (V8) was able to explain the patting on resident's bottom, it is not the appropriate thing to do because it could be interpreted as uncomfortable for the resident, staff are not supposed to make residents uncomfortable. V1 said that she did not consider this an abuse, staff was terminated due to customer service, he could have used a better judgement when providing care, and she felt it was better to part ways. 03/20/24 02:10 PM, V4 (Executive Director) said that residents are screened for abuse risk upon admission and every 6 months, those at risk will be identified and referred to nursing and social worker for follow-up. Those identified at risk will have a care plan, at risk residents are those with psych issue, aggressive behavior, history of abuse and substance abuse. Dependent residents may potentially be at risk for abuse, but they don't have an abuse care plan, if there is an allegation of abuse and it is not substantiated, the resident will not have a care plan because no abuse occurred. The administrator will determine whether any abuse is willful and investigates all abuse and does a good job, if she said abuse did not occur, then there is no abuse.

Based on observations, interviews, and records review, the facility failed to ensure stock medications were labeled with open and expiration date, failed to ensure opened vaccine vial, nasal sprays, inhalers, and insulins were labeled with open and discard dates, and failed to store an inhaler with a pharmacy label. These failures affected six (R6, R7, R12, R25, R42, R50) residents reviewed for medication storage and labeling and have the potential to affect residents receiving medications from the second-floor east side medication cart and first-floor rosewood medication cart. On [DATE] at 1:00pm, Surveyor and V40 RN (Registered Nurse) inspected the second-floor medication cart for rooms 201 through 228. The following observations were made: V40 stated, Floor Stock meds should be labeled with open date and manufacturers expiration date. Surveyor asked V40 do you use the manufacturers expiration date if the medication has been opened. V40 stated, yes (referring to the manufactures stamped expiration date). R6, Ipratropium Bromide Nasal Solution, open date [DATE] no expiration date. V40 stated, I go by the manufacturers expiration date which is ,d+[DATE]. R6 open Nasal Saline Bottle with no expiration date Opened Arnuity Ellipta 200 mcg (30 dose) inhaler with no expiration date and without the name of resident on inhaler. R42 opened vial of Genteal Tears mod liq drops no expiration date. R12 Lantus Solostar 100u/ml inj opened [DATE] expiration date [DATE]. V40 stated, I do not give that on my shift, that should not be on the cart. Surveyor asked V40 if medication has expired. V40 stated, yes it should not be on the cart. We put expired medication in a different place. R7 eye drops Brimonidine Tart 0.2% 5ml opened [DATE] expiration date [DATE]. Proheal Critical Care Liq protein 30 fl ounce opened [DATE], no expiration date. V40 stated, it is good until [DATE] (manufacturers date). Surveyor reviewed instructions on back of bottle which shows, discard within 60 days after opening. Medication Room Refrigerator: Tuberculin purified protein derivative, diluted aplisol opened [DATE] no expiration date. V40 stated, it should have an expiration date. On [DATE] at approximately 2:00pm surveyor and V2 (DON) reviewed 1st floor Rosewood 1 HCC medication cart for rooms ,d+[DATE]. Surveyor asked V2 how medication stored on the med cart should be labeled. V2 stated, all meds should be labeled with open date and expiration date. Nurses are expected to put open date and expiration date on all meds. The following observations were made: R25, Fluticasone Propionate 50mcg nasal spray opened. Bottle with date of [DATE]. Surveyor asked V2 does the date of [DATE] refer to open date or expiration date. V2 stated, I am not sure what the date means. R50 Fluticasone 50mcg nasal spray dated [DATE]. V2 stated, I am not sure if that is the open date or the expiration date. Proheal Critical Care Liq protein 30 fl ounce opened ,d+[DATE]/ no year noted, no expiration date. V2 stated, it is good until [DATE] (manufacturers date). Surveyor reviewed instructions on back of bottle which shows, discard within 60 days after opening. V2 stated, nurses should put an open date and expiration date. Facility Policy Medication Labeling and Storage revised February 2023 Policy Interpretation and Implementation Medication Storage in part documents 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medication Labeling 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 2. d. expiration date, when applicable; e. resident's name; 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 8. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on interviews and record reviews, the facility failed to report an allegation of rough handling/mistreatment made by one resident (R38) regarding an employee (CNA/V6); failed to prevent further instances of rough handling/mistreatment initially reported to V9/RN on 2/6/24 who failed to recognize the alleged abuse, failed to report the alleged abuse; and failed to immediately remove alleged abuser from further contact with the resident. This failure affected one resident (R38) of 6 residents reviewed for abuse in the sample of 69. This failure resulted in R38 to experience severe pain to her left shoulder as a result of V6's rough treatment and continues to express feelings of pain, fear, anguish, and intimidation when V6 returns to roughly handle the resident even after repeated requests to be gentle in providing care. Findings include: R38 is an alert and oriented [AGE] year-old resident with diagnoses including chronic diastolic congestive heart failure, osteoarthritis, scoliosis, and spondylosis with radiculopathy. Care Plan dated 2/9/24 reads in part, The resident has limited physical mobility related to disease Process (arthritis, pain, and chronic wounds.) The resident will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Interventions: Invite The resident to activity programs that encourage arm movement or gentle arm exercises as tolerated. Monitor/document/report any signs/symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. Provide gentle range of motion as tolerated with daily care. There were no care plans related to R38's susceptibility to abuse and/or preventing abuse. On 03/18/24 at 11:55 AM, R38 stated that on 2/6/24 during care, V6/CNA was very rough with her, ignored her requests to be slow and gentle in moving her arm as it was painful if done too quickly. V6 ignored her requests to not be handled roughly and snapped back at the resident saying to her that she'd been a CNA for [AGE] years, knows what she is doing, and doesn't need to be told what to do. Resident indicated her shoulder was hurt due to V6's careless actions and caused her extreme pain after the incident of 2/6/24 so she informed V9 (RN) about what had happened to her between V6 and to call her doctor for x-rays. V9 called the doctor who ordered x-rays and pain medication but failed to alert the doctor or immediate supervisor about the incident. R38 indicated that she reported to V9 RN about V6 always wearing and talking on an earpiece and does not pay attention to her but is more focused on her phone calls. Resident said she is afraid if she complained further that they will get another rotating aide that does not know what they are doing and does not want to get on this cycle of aides that she has to orient to her particular care needs, so she tolerates V6 who continues to be rough to cause further pain during care. R28 said that this CNA V6 has been assigned to her numerous times after the 2/6/24 incident even after she reported it to the nurse (V9). R38 indicated she was also concerned about others who can't speak up like the residents on the second floor who she knows V6 floats to. On 3/19/24 at 2:45 PM, V9 (RN) stated, I know (R38), and she is mostly on her bed. She is alert times 4 (cognitively intact with no confusion). Surveyor asked if he recalled R38 complaining about arm/shoulder pain, V9 stated, She complained her shoulder was hurt by V6 CNA because she was rough with her. Surveyor asked to recall the incident of 2/6/24, V9 stated, I recall her shoulder was in a lot of pain, so I asked what happened and she told me that the CNA was rough with her arm and hurt her shoulder. I then asked if she wanted any pain medication, so I called the doctor who ordered x-ray and told him that the resident was in extreme pain. Surveyor asked what he did when R38 told him that V6 was rough and hurt the resident's shoulder, V9 stated, I asked the resident first what happened, if V6 was rough and how it happened whether it was when she was turned in bed or whatever and she said it was during a bed bath I think is what she said. I also talked to (V6) about what happened, and she didn't say anything that the resident was in pain, I just remember that I documented that the CNA told me to see her because she claimed the resident was in pain. Surveyor asked if he informed anyone else about the incident, V9 stated, I can't recall but I think I told V2 (DON), but I did not document that in the notes, just that I called the doctor. Surveyor asked if an incident such as what R38 described and what steps or procedures he should do? V9 stated that if a resident had a problem with a CNA assigned to them, they would just swap out that CNA with another one the resident liked. Surveyor asked if this was what he did in this situation that occurred on 2/6/24, V9 stated, No I didn't do that. Surveyor asked if he perceived this rough handling by V6 as potential abuse, V9 stated, I didn't think that at the time but if the resident told me V6 hurt her, then I guess it was. Surveyor asked when he received any abuse training, V9 indicated that he had a refresher this month. Surveyor asked what the facility's procedures were of any suspected or reported abuse, V9 stated, We do an abuse assessment on the resident and report what happened to the DON. We are to report any abuse incident, assess and interview the resident and report it but I missed the reporting part of it, I'm sorry. Surveyor clarified if V6 finished her shift taking care of R38 or if he reassigned V6, V9 stated, No sir, she finished her shift with R38. After the interview with V9 (RN), Surveyor showed V9 the progress notes he entered pertaining to the incident and to confirm whether he wrote the entry, V9 stated, Yes I wrote that. V9's nursing notes read in part, 2/7/2024 at 21:45 Health Status Note. Note Text: Late entry: Around 4PM yesterday, CNA called NOD (nurse on duty) to report that resident is in pain. Checked resident, noted facial grimace and was holding her shoulder, reporting of pain. When asked what happened, she said that CNA lifted her shoulder when asked to adjust her blouse on the back. Resident requested to have her shoulder massaged, provided relief. Resident informed both NOD and CNA that her both shoulders has limited ROM, especially the left one. Offered pain pill, resident declined. CNA kept resident comfortable. At bedtime, checked resident, she reported that pain is tolerable but still there. She added that she will inform MD about in on Thursday. Surveyor asked if there was anywhere in the documentation, he wrote informing either the DON or any supervisor of the incident involving V6 and the resident R38, V9 stated, No sir. I did not do that, so I didn't put that in there. On 3/19/24 at 2:55 PM, V6/CNA stated to surveyors during interview, I've worked here since September and applied for an open position. Surveyor asked if she used to work as an agency CNA prior to her hire, V6 stated No I haven't. V6's statement however did not align with her personnel file showing her previous position was an agency CNA. Surveyor asked about R38 and if she recalled the incident of 2/6/24 where the resident complained of shoulder pain, V6 stated, Yes I know (R38) and I remember her complaining about her shoulder, so I told the nurse, but I'm not frequent on her floor. I generally work the second floor. Surveyor asked the type of floor the second floor was, V6 stated, It's dementia mostly. Surveyor asked if there was anything she could recall of the incident of 2/6/24 other than the resident complaining of shoulder pain, V6 stated, (R38) is very particular about her care and she verbally tells me how she wants things all the time, she likes her phone to be near her. She's also particular about her sheets going up close to her neck when she's in bed, and she needs her gown changed and clean. Surveyor asked if these were unreasonable requests, V6 indicated they were not. Surveyor asked if she could recall during the incident of 2/6/24 if there was any discussion about slowing down or being gentle with her, V6 stated, I'm always gentle with my residents. Surveyor clarified that the question was if there was any discussion by the resident for her to be gentle when moving her arm or any other body part, V6 stated, Yes I think she mentioned something like that. Surveyor asked when she was told to slow down and be gentle what she did, V6 stated, I don't remember. Surveyor asked if she could recall if the nurse V9 asked her what happened, V6 stated, Yes he just asked me what happened, and I told him she was in pain. Surveyor asked if there was any argument on 2/6/24 with R38 or if the resident asked her not to be too rough with her in any manner, V6 stated, No I never argued with her and like I said she (R38) is very particular with how she wants things. Surveyor asked how long she'd been a CNA, V6 stated, I've been a CNA 11-[AGE] years. Surveyor asked if she ever mentioned this fact to the resident, V6 stated, No, I don't have conversations with residents, I just do my job. Surveyor asked if there was anything out of the ordinary that may have occurred on 2/6/24 during her care of R38 or during anytime she'd been assigned to R38 V6 stated, No, she's not a difficult resident, she's just particular but (R38) has a way she talks to other people in a condescending manner. Surveyor asked how that made her feel, V6 stated, I just try to ignore it. Surveyor asked if she'd had any other issues with any other residents she'd care for, V6 paused and then stated, No but earlier this year one of the resident's family complained about my care so the administrator suspended me and when I got back the DON V2 gave me a 1:1 about general care and respecting patients. Surveyor asked if she knew what the specific complaint was that the family alleged, V6 stated, I don't know. Surveyor asked the rationale for her being provided 1:1 training about general care and respecting residents as she mentioned, V6 stated, I can't answer that. Surveyor asked if she'd been trained on the topic of abuse, V6 stated that she received one upon hire and she did an online training in the past November. On 3/19/24 at 3:35 PM, surveyors asked V2/ DON if she knew about the incident of 2/6/24, V2 stated, I don't recall V9 tell me anything about R38 or I do not recall it. I believe I was not in the building, but it may have been my previous assistant, but she no longer works here but I don't know who he spoke to. Surveyor asked if she knew about R38's shoulder/arm pain, V2 stated, I am not aware of anything about her shoulder. (R38) is very alert x 4 and she's able to make her needs known. She's particular and has particular preferences. There's certain staff she gravitates to and likes the normal CNA's or the regular CNA's and does not like any of the agency CNA's we had. She likes CNA's who are assigned to the unit that are the permanent on the unit because over time they have gotten to know her. Surveyor asked if these were reasonable requests, V2 indicated that they were. Surveyor asked about V6 and her work record with residents, V2 stated, I've never had any issues with (V6). Surveyor asked if V6 had any history with any other residents that resulted in any disciplinary action, V2 hesitated and stated, I've never had any issues with her except one time recently I think in January there was something about another resident and their care from V6, so we ended up putting her on administrative leave. Surveyor asked what the administrative leave was about, V2 stated, It was about some customer service issue some family had with V6. Surveyor clarified if that administrative leave was a suspension or personal leave, V2 stated, She was suspended. Surveyor asked what specific customer service issue V6 was suspended for, V2 stated, I think the family alleged that their mom was left cold and wet (urine) and wasn't given a blanket or something like that. Surveyor asked how leaving a resident wet and cold was a customer service issue, V2 stated, Well it was also a care issue. Surveyor asked what units V6 normally worked on, V2 stated that V6 worked all throughout the facility including the dementia unit. Surveyor asked if any of the residents on the dementia unit were interviewable or could voice any concerns to anyone, V2 stated, No most of them are confused. V2 paused and stated, Oh I see what you mean. I gave V6 in-service training, and she's been a CNA for a while, and I trust her. On 3/19/24. 2:00 PM. V13 (Director of Resident Services) stated, I'm responsible for the abuse in service training portion in our skills fair and we had our latest one in November. We try to capture all the staff for the campus in these skills fairs that touch on various subjects, one is abuse which I do. I make it a point during training that anything you hear or see, you have to report immediately to your immediate supervisor, who will then report it to V1(Administrator). I tell them about the 8 types of abuse, and anyone can report abuse including family, the resident themselves, and any staff. I tell staff that even idle gossip staff may hear about regarding residents being mistreated should be reported right away to their supervisor. I know we don't like to gossip but a lot of that gossip may include clues about some staff member that may be abusing a resident. Staff shouldn't determine themselves whether it's just a customer service issue because they should report it and let the supervisor and administrator determine this with their investigation whether it is actual abuse or just a service failure. Surveyor asked V13 a hypothetical question about if a CNA was being rough with a resident and that was reported to the nurse what the next step would be, V13 stated, They should immediately remove that person from the resident, and let their immediate supervisor know and also the administrator so they can investigate. It's not up to that individual to do this, they just need to separate the resident from that individual and report it right away. On 3/19/24 at 2:35 PM, V11 RN stated, I know R38 very well because she is on my unit and it's my permanent floor. Sometimes she said she likes mostly the morning people. Sometimes if she doesn't like somebody, I try to change CNA. She mostly complains about them talking on the phone when they're working with the resident, but they should not be talking on the phone. I talked to CNA's at once if they talk on the phone. Surveyor asked if she heard about the incident that occurred on 2/6/24 involving R38 and V6, V11 stated, I hear someone was rough with her (R38) but it's not on my shift. I hear that from the CNA amongst themselves too. The CNA's talk that somebody was rough with her and not nice with her. It was a few months ago, I think. I know for example who it was generally, and I try to figure out who, so I try to ask CNA's. Sometimes you know when she's not happy, so I tell V12/Administrative assistant not to schedule a particular CNA (V6). Surveyor asked if she informed the Administrator or DON about what she heard, V11 stated, I don't tell Administrator or anyone, just V12. If there's any problem with any CNA, I Usually I tell V12. Surveyor asked if V12 was her immediate supervisor who she reported problems to, V11 stated, No. Surveyor asked if she discovered who the CNA was, she heard about involved with R38's rough treatment, V11 stated, What I hear was about (V6). I hear that she (R38) doesn't like her because the resident told me herself that (V6) was always rough with her. She tells me V6 doesn't know too much what to do and how to care for her. I heard this again today, but I was busy. Surveyor asked V11 if she told anyone else other than V12, V11 stated, No I don't tell anybody, I'm sorry. On 3/19/24 at 11: 00 am V12, stated. I'm a scheduler for nurses and CNA's but my title is administrative assistant. I recall talking to R38 because I followed up with the resident because of (V6). I try to see residents twice a week but I remember that I followed up with her I think last month about V6 because the resident said that the CNA wasn't familiar with her routines so the resident herself walked through it with the CNA so she can follow the steps. She has a routine that she likes. Surveyor asked if the resident or any other residents complained about the CNA, V12 stated, I'm not sure. I come in at 7 AM and I usually go on the floor and make sure the CNAs are there and then I go in to say hello to most of the residents. I see (R38) because she likes to give me feedback. The only thing she told me about V6 was that she wasn't aware of her routine and that was all she told me. Surveyor asked if R38 requested a different CNA, V12 stated, No but we try not to put (V6) with the resident and she works mostly the second floor or wherever we need her. On 3/20/24 at 11:45 AM, V1 (Administrator) and V2 (DON) presented information to survey team indicating that they had met with R38 last night to address the resident's concerns voiced on 2/6/24. This type-written response reads in part (V1) and (V2) met with (R38) at 6:35 PM on 3/19/24. V1 said to R38, I heard you need to report to me about someone hurting you. R38 went on to relay that V6 had given her a bed bath and after the bath she asked V6 to boost her up so she could pull her nightgown down in back. R38 reported that V6 wears earbuds a lot and was not sure how much she heard her. V6 proceeded to grab R38's left arm and pulled it to the side and R38 called out telling V6 she was in pain. R38 reported it to my nurse (V9) and waited until Thursday for V39 (attending physician) to come and examine the resident and then ordered an x-ray. The interview goes on to state that (V6) tends to have an unpleasant attitude with R38. The written report goes on to conclude that R38 stated that V6's actions were unintentional and received education regarding being fully engaged with residents during care with no external distractions such as cell phones and ear buds and to engage with residents verbally during care regardless of ability to reciprocate. This report fails to indicate any re-in-service education on abuse prevention. On 3/20/24 at 1:30 PM, surveyors re-interviewed R38 to verify the meeting the resident had with V1 and V2. R38 stated to surveyors that V1 Administrator and V2 DON came to see her abruptly after dinner when she was already in bed last night around 7 PM and asked her about V6. R38 indicated that V1 asked if V6 was rough with her, and she told her that she was. R38 stated, the Administrator did most of the talking and I felt pressured to say that the CNA's (V6) actions were not willful because she kept emphasizing and repeating the word willful and that V6's intentions were not willful. R38 indicated to surveyors that she didn't agree with this but in order to pacify administration, R38 stated that she gave in and agreed with them even though she felt V6 intentionally and repeatedly ignored her and was rough each time she came. R38 informed surveyors that she still felt pain in her arm and shoulders after the incident and also every time when V6 returned on numerous occasions. R38 added that yesterday (3/19/24) V6 was assigned to her but was abruptly removed from her assignment which she was relieved to find out. R38 indicated that prior to yesterday, V6 continued to ignore her and provided rough care which caused her more pain. R38 stated that she brought concerns to the administrator on numerous occasions about the quality of staff in general, but the administrator's response would be to pass the buck as a corporate issue. R38 stated that she felt even more vulnerable now with administration by complaining stating, When the Administrator came in the room, she had this look on her face that she was annoyed with me and that Oh it's her complaining again, but R38 didn't expect any real changes to come as she'd been dealing with the same issues for a while with no improvement. On 3/21/24 at 4:30 PM V39 (Attending Physician) stated to surveyors, (R38) is a very fragile patient and she has to be handled in a very delicate manner as she is brittle and has a complete rotator cuff tear and underlying severe arthritis that would worsen if it were exacerbated in any way. This was the reason I had ordered X-rays for that day when I got a call from a nurse telling me there was some incident that happened that caused the patient severe pain, so I suspected further injury to her shoulders. Surveyor asked if it was about the 2/6/24 incident, V39 stated, I don't know the exact date, I just know it happened a month ago. Surveyor asked if how he was informed of the incident involving his patient (R38) and V6, V39 stated, I found out from the resident that some staff person was careless and rough with her, but the nurse made no mention of any incident with R38's CNA being rough, it was the resident herself who informed when I came to see her. Facility policy dated, 3/7/2018 titled Abuse, Neglect, and Exploitation reads in part but not limited to, Facility affirms that each resident has the right to be free from abuse and neglect. Residents must not be subjected to abuse by anyone, including but not limited to community staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Abuse means the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation of an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. Prevention of Abuse: Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. Recognize signs of burnout, frustration and stress in associates that may lead to abuse. Provide education on what constitutes abuse, and neglect. React to all allegations or questions of abuse by residents, family members, associates or visitors. Take appropriate actions when abuse is suspected. Provide instructions to staff on care needs of residents. Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, or ignoring residents while giving care. Identification of alleged abuse, neglect and exploitation: The community will consider factors indicating possible abuse, neglect following possible indicators: Resident, staff or family report of abuse, physical injury of a resident, Verbal abuse of a resident overheard. Physical abuse of a resident observed. Psychological abuse of a resident observed. Failure to provide care needs such as, bathing, dressing, turning and positioning. Response and reporting of abuse, neglect: Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect is suspected, the licensed nurse should: Respond to the needs of the resident and protect them from further incident and document response. Notify the director of nursing and executive director/administrator immediately and document notification. Initiate an investigation immediately. Notify attending physician, resident's family/legal representative and Medical Director and document notification. Prohibit and prevent retaliation.

Based on observation, interview, and record review, the facility failed to implement pressure ulcer prevention interventions to promote wound healing for one of three Residents (R18) reviewed for pressure ulcer and pressure ulcer interventions, in a total sample of 69 residents. Findings include: R18 is a cognitively impaired [AGE] year-old resident with diagnoses listed in part, but not limited to, hemiplegia and hemiparesis, gastrostomy, heart failure, and a stage four pressure ulcer of the sacral region. A wound evaluation and management summary report dated 03/19/2024 showed R18 with a wound described as stage four with a duration greater than 1,049 days and measuring 3.0 x 1.8 x 0.3 cm. The facility pressure injury report dated 01/06/2024 states the wound was acquired, In House. Three skin observation tool forms found in R18's Electronic Health Record, dated 03/02/2024, 03/09/2024, and 03/16/2024 lack any describable wound documentation, such as wound site, type, measurement, and stage; instead containing the words, No new area, No new area noted, and no new skin issue noted. R18's nursing care plan dated 03/15/2024, R18 is to be turned and repositioned, as needed to aid in comfort and provide off-loading. R18's nursing care plan dated 03/15/2024, documents it is the staff's responsibility to keep R18's skin free of moisture. On 03/18/2024 at 10:09am, surveyor observed R18 lying in bed on her air mattress, asleep, her torso raised, and backside facing the wall. After over two hours of continuous observation, at 12:20pm, surveyor observed R18 laying on the air mattress with her backside facing the wall, torso raised, asleep, with no change in position. During continuous observation, surveyor observed R18 with perspiration on her face, and two blankets covering her body. On 3/19/2024 continuous observation from 10:05am to 12:20pm surveyor observed R18 asleep in bed, laying on air mattress, on her back with several blankets atop her body. V10 (CNA) said R18 is a total assist and V10 repositions her every two hours. V10 also said she provides clean sheets for R18 at the start of all her shifts, showers R18 once per week, and gives R18 a bed bath once per week, or as needed. On 03/19/24 at 11:50am V33 (Family Member) said, R18 needs round-the-clock nursing care, being bathed, brushed, and sanitary needs. V33 said R18 struggles in the past at the facility led to bed sores. V33 said bed sores were acquired at the facility five years ago and never closed and R18 uses an air mattress around-the-clock. On 03/20/24 11:45am, V1 (Administrator) said there was an MDS on file that said R18's chronic stage four pressure ulcer was originally a stage one pressure ulcer that R18 had upon arrival at the facility in 2013. V1 did not recall when R18's pressure ulcer changed from a stage one to a four, adding she would have to look through ten years' worth of documentation. On 03/20/2024 at 1:40pm, V11 (RN) said she was performing afternoon wound care, along with V10, for R18, who was laying on her back on her air mattress bed. Surveyor asked to observe R18's wound. V11 and V10 proceeded to move R18 onto her left side to expose the stage four wound site of the sacral region, which was covered with a dressing. As V10 held R18 to the side, V11 took the dressing off, revealing a hole slightly smaller than a golf ball. When asked to describe the area, V11 hesitated and paused, saying it looked a little green. A few seconds later, fluid began to leak from R18's urinary catheter, running vertically down the left buttocks area, near the wound site. The area around R18's wound site was visibly moist. R18 had a linen sheet on top of her air mattress, folded over four times under her back. Surveyor also observed the air mattress pump on static mode. When asked V11 about the air mattress pump, V11 said she did not change the pump's settings at all, preferring to leave it as is. On 03/21/24 at 10:18am, V2 (Director of Nursing) said she was not sure if the wound nurse or the facility's environmental services sets the settings of the air mattress pump, adding the pump has a locking mechanism in place. On 03/21/2024 at 1:46pm, V38 (Medical Director) said R18's wound is not new and has been ongoing for a while. V38 said he discusses only newly acquired wounds with the facility, and that stage three wounds and above are discussed in detail. V38 said he does not usually discuss wounds with the wound doctor, unless it is his patient. V38 said repositioning, offloading, and turning every two hours are considered general principles for pressure wound care. On 03/21/2024 at 3:54pm, V29 (Wound Doctor) said he started seeing R18 in March of 2021 for the wound. V29 said repositioning every two hours, offloading, providing incontinence care, keeping the wound area clean, and following with daily dressing changes is the typical recommendation. V29 also said from his experience, individual repositioning was important to the healing process of pressure wounds, adding some of the aides at long term care facilities won't turn the individual, thinking that the air mattress is doing the turning and the mattress does it on its own. V29 said, standard air mattress bed preparation includes not utilizing fitted sheets, not placing too many pads and diapers, minimal would be advisable. Lastly, V29 said he described R18's stage four pressure wound as, unavoidable based on the lab results from R18's hospitalization in February instead of R18's long term care facility lab results January 11, 2024, which included a pre-albumin result of 23.8, within normal range. V29 said he was referring to what the hospital's admission lab results said to designate R18's wound, unavoidable. Surveyors clarified with V29 if the wound was avoidable or not, V29 affirmed that it was avoidable since R18 was able to heal other wounds. Facility policy with an effective date 06/01/2023, and titled, Management and Treatment of Pressure Ulcers-SNF reads in part, In order to heal any wound, including pressure ulcers, some basic principles need to be followed. These are: Protect the wound from infection, trauma, and cold. Protecting the wound from trauma includes the proper support surface. The air mattresses' owner's manual states in part, it is designed to assist in the prevention and treatment of pressure ulcers. The same manual also indicates there are two modes, alternate and static. Static mode turns off Alternating Pressure Therapy. Multiple layering of linens or under pads beneath the resident can negatively affect the mattresses' pressure management capabilities and should be avoided unless recommended by a caregiver.

Based on interview and record review, the facility failed to provide appropriate supervision and assistive devices to prevent a mechanical fall for a resident with a history of falls and at high risk for falls; and failed to conduct a safe transfer from wheelchair to standing position for 1 (R4) of 4 residents reviewed for accident/hazards in the sample. This failure resulted in R4 sustaining a hip fracture during a therapy session for which she was to receive continued strength training for gait imbalance; and warranted an emergent transfer to the hospital with required surgical intervention. Findings include: R4 is an alert and oriented [AGE] year old with diagnosis of pneumonia, muscle weakness, difficulty walking, and spinal stenosis. Fall risk care plan dated 9/24/23 states, The resident is at high risk for falls related to spinal stenosis, hypertension, neuropathy, dementia, urine and blood infections, and decline in ADLs (Activities of Daily Living). Focus: The resident will be free of falls through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident and caregivers about safety reminders and what to do if a fall occurs. Redirect when making poor safety judgments. On 2/6/24 at 1:00 PM, Surveyor visited the resident in her room to inquire about R4's hospitalization . R4 was seated in a wheelchair in her room with her daughter by her side. R4 was alert and was able to respond to questions appropriately and clearly provided by the surveyor. R4 stated, I'm in a little pain but I'm fine now. I fell while V4 (PTA-Physical Therapy Assistant) was having me do exercises. She told me to get up from my wheelchair and I don't know what happened, but I just felt weak and all of a sudden, I fell over to my left side and hit the floor really hard, and I was in a lot of pain. I think I might have yelled when I hit the ground, but I can't remember because it went so fast. Surveyor asked where V4 was when she fell , R4 stated, Well I guess she was right behind me because that's what she told me and that she had to let go of me. V10 (family member) stated I got a call from V3 (Assistant Director of Nursing) saying that my mom fell during therapy. I was really upset so I called the social worker (V11), and she couldn't explain to me how my mom could fall in therapy where she was supposed to be recovering to get her strength back. Instead, this is a huge setback in her recovery, because now she has to recover from surgery because of her fractured hip. To make matters worse, I spoke to the therapy director (V5), and he told me that my mom's fall was an unexpected accident that he never encountered before. He kind of laughed when explaining this to me because I guess it surprised him that this happened during therapy. I asked him what he found funny and that I didn't find any humor in the situation, as my mom got a fracture due to the actions (or lack thereof) of one of his staff. I also asked about the therapist assistant's (V4) past injury which I found out about from another CNA here. That CNA was questioning why this therapist was even allowed to work with my mom. I asked (V5) and he said he was not aware of V4's past injury as he was the interim therapy director. Needless to say, I wanted to take my mother out of here, but she liked the religious services here. Surveyor asked to reveal who the CNA that claimed V4 was injured, but V10 declined to reveal the identity. On 2/6/24 at 1:20 PM V4 (Physical Therapy Assistant) stated, When (R4) was finished with OT (Occupational Therapy), the resident had about a 10 minute break and she was placed on her wheelchair by the bathroom door. When we were going to do her therapy, her wheelchair was behind her and I was on her left side. We've done it everyday and when she was last doing therapy. She was already considered a minimal transfer for her. She was standing and I'm holding her and as she stood up with her first step, she slipped back in the wheelchair in a complete extension away from me. I was holding her using my left arm and she started falling diagonally and forward away from me. It was a split second. Surveyor asked V4 to clarify whether she slipped back or forward as she initially stated that the resident slipped back in the wheelchair, V4 stated, I meant she fell forward, diagonally but she was going really fast. Surveyor inquired whether she had an existing injury while working on R4, V4 stated, Yes, back in November I had an injury on my left arm and I had muscle spasms. At that time, I was wearing athletic tape to my left arm. Surveyor asked if she used the same left arm to grab on to R4 to try to catch her fall, V4 stated, Yes, I always use my left arm and hand. Surveyor asked why she didn't use both arms and hands to stabilize the resident, V4 indicated she was using her right hand to hold on to the wheelchair. Surveyor asked where her focus was during the exercise, the residents' rolling walker, the wheelchair, or the resident, V4 stated, I had to do all, but this happened so fast. Surveyor asked if R4 fell previously prior to the latest event on 2/1/24, V4 stated, Yes I think she fell recently and that was why she was here to receive therapy. Surveyor asked if R4 had a recent fall, how the resident's ability would be considered only at minimal assist, V4 stated, Well she was able to do exercises before at that level. Surveyor asked if she knew whether R4 was at high risk for falls, V4 stated, I presumed she was, but she definitely is now. Surveyor asked if a resident is considered at high risk for falls, if she'd allow the resident to walk with only minimal assistance, V4 stated, Well, we determined she was minimal assist. Surveyor asked the rationale for R4's therapy sessions, V4 stated, For balance training, training with the rolling walker, sit-to-stand, and to regain overall strength. At 1:30 PM, surveyor went with V4 to the therapy gym so she could demonstrate how the fall incident occurred. V4 stated, The wheelchair was against that wall, the back wheels were locked, and her rolling walker was in front of her (referring to R4). I was to her left side and as she stood up, she just fell forward to her left side. My left hand was holding a gait belt and my right hand was on the wheelchair as we were about to walk with the walker and wheelchair behind her. Then she just fell . Surveyor asked if she had to turn around at anytime and whether she had full control of the resident, V4 stated, I tried to catch her. Surveyor asked if her attention was drawn away from the resident in order to unlock the rear wheelchair locks to start the exercise, V6 paused and stated, No I didn't have to unlock them. Surveyor asked how they could start the exercise if the wheelchair was still in locked position as she previously mentioned, V4 had no response. Surveyor asked how she lost control of the resident if she did not have to turn around to unlock the wheelchair, V4 stated, I had my eyes on her at all times I used my left hand to stabilize the resident and my right hand was on the wheelchair. On 2/7/24 at 11:10 AM, V5 (Therapy director) was asked about R4's fall incident, V5 stated, We had a conversation with the daughter(V10) later in the afternoon at around 11:30 am on 2/1/24 (V5 checking his phone). The social worker (V11) and myself called and we talked about the incident that occurred during therapy and that her mom was in the hospital and had a hip fracture. Surveyor asked why the therapist involved in the incident didn't call the family member directly, V5 stated, I can't answer why she didn't make that call. Surveyor asked what he knew happened, V5 stated, I didn't actually see the incident, but I was informed about it. I was in my office, and I heard a loud noise, a thud, or commotion, so I came out of my office around the corner, and I just saw her (R4) on the ground. I remember going to get the nurse, but the DON was already talking to the resident on the ground. Surveyor asked if he knew if his employee V4 had any prior injuries while working with the resident, V5, stated, I understand that her left arm felt funny, this is what I was told, but she had no restriction with her left arm to return to work. Surveyor asked if he knew anything about the therapist's injury, V5 stated, I don't know what happened to her arm. I am only the interim director. V5 continued on and stated, The patient was seated in the wheelchair and was pushed up against the wall, and a rolling walker was in front of the patient and R4 was wearing a gait belt. V4 (PTA) was holding on to the gait belt with her left hand, and was holding the wheelchair in her right hand. Based on the patient's assessment, her transfer ability was considered a minimum assist. The therapy assistant and patient were going to go for a walk with the rolling walker in front and the wheelchair behind the resident. I was told that she fell all of a sudden during the start of this exercise. Surveyor asked if this incident was preventable had the therapist not relied on R4's perceived ability of only minimal assistance, V5 stated, I would have to agree with you that the fall was preventable in that sense. She was here to receive strength training, so she probably should have been treated more than the level of minimum to moderate assist. At 12:15 PM, V5 returned and provided surveyor with R4's physical therapy assessments. On this assessment, on 1/29/24, V4 (PTA) wrote that the resident Required minimum to moderate assist with moderate tactile, visual, verbal cue for safety, proper body mechanics, and to attend to task. Surveyor asked if he agreed with this assessment, V5 stated, Well, in hindsight I agree with you that the resident needed more than minimal assistance. R4's recent therapy assessment records (12/17/23 to 2/1/24) showed in part, Treatment Diagnosis: Muscle weakness (generalized). Patient is a [AGE] year old female who was referred by the primary care physician for subacute rehab status post pneumonia and sepsis with urine ESBL. Patient exhibiting difficulty performing ADL/functional mobility. The functional deficits are caused by weakness, unsteady balance, poor standing with weight bearing tolerance, unsteady balance low endurance. The patient's clinical presentation is stable. Skilled therapy services are medically necessary in order to address deficits, improve quality of life, and assist patient in returning to prior level of function. Therapy Necessity: Therapy necessary for general strengthening and functional mobility re-training. Without therapy, patient at risk for debility and dependence to care. 12/27/23 note entered by V4 (PTA) stated, Patient instructed on balance strategies and strengthening and range of motion, transfer training with rolling walker. Progression from sitting to standing during ADLs (activities of daily living). Required maximum assist times 1-2 person with maximum tactile, visual, verbal cue for safety, proper body mechanics, and to attend to task. 1/23/2024 note again written by V4 states, Instructed patient on proper sequencing and hand placement to improve bed mobility and sit to stand and stand pivot transfers moderate /maximum assist. Patient tends to get unsteady on transition. On 2/7/24 at 11:30 AM, V2 (DON- Director of Nursing) was asked about R4, V2 stated, She is alert times 3 and she is very 'with it'. I was notified of the first fall incident of 1/26/24 and that fall was from a wheelchair too and is the reason why the resident was transferred to us on the skilled side to get therapy for gait training and balance. Surveyor asked the physical condition of the resident after she had fallen on 1/26/24, V2 stated, I don't really know but the nurse normally taking care of her (V6) said she was more weaker than her baseline, so we felt that it was appropriate for her to get more gait training and strengthening and to get therapy. When we moved her to skilled nursing area, her baseline was a 1- person assist, but physically, she appeared weaker. Surveyor asked what minimum assist means, V2 stated, It means that the resident can do her ADLs (Activities of Daily Living) such as walking, toileting, etc. on her own and with just minimal assistance and supervision. Surveyor asked if R4 would be considered that if she required physical therapy for gait imbalance, V2 stated, From a clinical perspective and as the fall the nurse, (R4) appeared weaker with transfers, so the therapist should have been more careful with her, and from that standpoint I guess it could have been avoidable. Surveyor asked if any residents would be considered minimal assistance and with just supervision if they were residents on the skilled side of the facility, V2 stated, No, that was why R4 was transferred here because she no longer was. On 2/7/24 at 2:10 PM V7 (Restorative Aide) was asked about her statement she provided the administrator pertaining to R4's fall incident. V7 stated, I normally sit at the desk in the therapy gym, and I saw that (R4) was going over. She went sideways to her left and I saw her falling over. She was on the ground, and she said, honey my hip hurts. Surveyor asked if she was certain she saw the actual fall or if she just saw her on the ground, V7 stated, Yes, sorry I did not see the actual action of her falling, she was already on the ground. Surveyor clarified the question again because it was not what was stated on her statement provided to the administrator. V7 stated, Yes, I'm sure. (R4) was already on the ground. V3 (ADON) helped me write my statement. I'm sorry she put that I saw the resident falling because that's not correct. Surveyor asked if she saw any part of the fall incident, V7 stated, No I just saw her already on the ground and everyone came and looked at her and then the paramedics came. On 2/7/24 at 2:30 PM V6 (LPN) stated, I know (R4) very well. She is alert and oriented times 3. She is obese and she cannot walk by herself and she's wheelchair bound. She fell from her wheelchair pretty recently in the shelter area and transferred over to skilled section. Surveyor asked how R4 appeared, V6 stated, She definitely was a lot weaker than her baseline, so that is why she was transferred to skilled nursing and to get therapy. Surveyor asked if she was aware of the most recent fall incident, V6 stated, Yes, I heard she fell during therapy, and I was very surprised that it happened in therapy. She fell from her wheelchair last time too, and I was told she fell getting up from her wheelchair again when she was in therapy so that's why I was surprised because she was getting strength training there. On 2/7/24 at 2:45 PM V9 (RN) stated, I was one of the nurses called in to help by the DON, but she was already assessing the resident. I called the doctor, and he was in the building. The doctor went to therapy to see the resident and I got instructions to call 911 for the resident to be sent out. Surveyor asked if she knew (R4), V9 stated, Yes, I know (R4), she's usually a two-person assist. I remember that she was weak when she came to us from the shelter care side when she fell over there. She was transferred back to skilled nursing, when she fell over. They come over here usually because they need more help. I sometimes help the CNA to help her up because she is not a light person. She was supposed to be getting gait training I think in rehab therapy. The day when she fell in the therapy gym, I remember I passed medications for her, but she didn't appear weak though. I was actually surprised she fell because you would think therapy would be the safest place for a resident because they are there to get stronger. Efforts to reach R4's physician were met with no return calls. On 2/8/24 at 10:50 AM, V9 (NP) stated, I was seeing her routinely. I saw (R4) in the skilled area when she moved from the shelter area. She had bouts of pneumonia, we were treating her for an infection, a fever, and overall, she wasn't feeling well and so she was moved to skilled nursing. I was not directly informed of the incident. I was told her fall occurred the day her doctor was already in the facility. Surveyor asked if she was informed of any details of R4's diagnosis and hospitalization , V9 stated, No I knew she was hospitalized but I wasn't informed she sustained a hip fracture, just now from you. Surveyor asked if she knew R4's overall functioning, V9 stated, From my understanding she was maybe contact guard assist to minimal assistance with transfers, and that was my understanding. My understanding from therapy notes was she was contact guard with supervision. She had a decline in her health, yes, and prior to this latest fall, I know that is the reason she transitioned to skilled nursing. I do recall that she had a fall while in the shelter area too. So I did a full work up after she moved to skilled area. She already had a fall, and she already had a fever, and so I can understand your rationale that she required a higher level of care. Surveyor asked if a resident were to have a change of condition where there was a decline in health that warranted transferring to the skilled nursing area, if that would require more than minimal assist and supervision, V10 stated, I see what you mean about the resident requiring a level of care, so I do agree that she declined. As far as during therapy, other than contact guard assist, the resident probably would not have fallen had the therapist maintained her hold on the resident and not relied on the resident conducting the exercise herself, but I can't speculate on that because we weren't there. Hospital record reads in part, Patient admitted to hospital on 2/1/24 with complaint of hip fracture after mechanical fall. Underwent ORIF (Open Reduction Internal Fixation surgery). Comminuted intertrochanteric fracture of the left femur status post Left hip ORIF, pain control, bowel regimen and DVT (Deep Vein Thrombosis) prophylaxis per ortho. Pain medications listed upon discharge: Oxycodone 5 mg. Take 0.5 tabs by mouth every 6 hours as needed for severe pain (pain scale 8-10); Tramadol 50 mg tab. Take 1 tab by mouth every 6 hours as needed for Moderate pain (pain Scale 4-7) Max Daily. Policy dated 6/1/23 titled Fall Prevention and Management Policy reads in part, A fall management program is in place to ensure that the community's residents are assessed utilizing a standardized tool for their potential fall risk and to guide in implementing person-centered interventions to decrease the frequency or severity in the event a fall does occur. Fall prevention is achieved through an interdisciplinary approach of education, managing risk factors, and implementing appropriate interventions to reduce the risk of falls. An evaluation of the factors also includes reviewing for previous falls, and if so, identifying any similarities. Supervision-The Community will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency based on the individual resident's assessed needs and identified hazards in the resident environment.

Based on interview and record review, the facility failed to follow physician's orders to administer appropriate pain medications for a post- surgical resident experiencing extreme pain over a 13- hour period and failed to assess the severity of pain for 1(R4) of 4 residents reviewed for pain management in the sample. This failure resulted in R4 being unable to sleep due to extreme hip pain from post-surgical hospitalization for a hip fracture due to a fall sustained in the facility. Findings include: R4 is an alert and oriented [AGE] year old with diagnosis of pneumonia, muscle weakness, difficulty walking, and spinal stenosis. On 2/1/24 R4 was receiving continued strength training related to balance and gait issues due to a recent fall that occurred on 1/26/24. The resident, while receiving this therapy session had a mechanical fall leading to the emergent transfer to the hospital where the resident was diagnosed with left hip fracture with surgical intervention (Open Reduction Internal Fixation surgery). Hospital record reads in part, Patient admitted to hospital on 2/1/24 with complaint of hip fracture after mechanical fall. Underwent ORIF (Open Reduction Internal Fixation surgery). Comminuted intertrochanteric fracture of the left femur status post Left hip ORIF, pain control, bowel regimen and DVT (Deep Vein Thrombosis) prophylaxis per ortho. Pain medications listed upon discharge: On 2/4/24 at 6:31 PM, R4 was readmitted back to the facility after surgical operation and with orders for staple removal in 14-17 days. The physician order relayed to the facility included: 1. Acetaminophen Oral Tablet 500 MG. Give 2 tablets by mouth three times a day for pain. Start date 2/4/24. 2. Tramadol HCL Oral Tablet 50 MG. Give 1 tablet by mouth every 6 hours as needed for pain (pain scale 4-7) Maximum Daily Amount 200 MG. Start date 2/4/24. 3. Oxycodone HCL Oral Tablet 5 MG. Give 0.5 tablet by mouth every 6 hours as needed for severe pain (pain scale 8-10) Maximum daily amount 10 MG. Start date 2/4/24. 4. Lidocaine External Patch. Apply to left hip pain topically one time a day for apply 6 AM and remove 6 PM. Start date 2/6/24. On 2/6/24 at 1:00 PM, Surveyor visited the resident in her room to inquire about R4's hospitalization . R4 was seated in a wheelchair in her room with her daughter by her side. R4 was alert and was able to respond to questions appropriately and clearly provided by the surveyor. R4 stated, I'm in a little bit of pain but fine now but I fell while V4 (PTA-Physical Therapy Assistant) was having me do exercises. She told me to get up from my wheelchair and I don't know what happened, but I just felt weak and all of a sudden I fell over to my left side and hit the floor really hard, and I was in a lot of pain. I think I might have yelled when I hit the ground but I can't remember because it went so fast. Surveyor asked when she received her pain medications, R4 stated, I got them earlier, but when I first was admitted here, I had a horrible time. I couldn't sleep because I was in severe pain, and I could not get the nurse to come in to give me my pain medications. I don't remember getting anything for my pain when I first got back from the hospital. I did not see a nurse to see how I was doing later that evening. I remember late at night pulling the call light so I could get something for pain. I remember somebody came in throughout the night, but I guess they may have forgotten about me, so I had to wait until the next day to get something for my pain. Surveyor asked if she recalled the nurse coming back after finally receiving her pain medication the next day to see if her pain was gone, R4 stated, No, otherwise I would have asked for something stronger. Admission Assessment upon R4's readmission on 2/4/24 documented by V12 showed in part, Have you had pain or hurting at any time in the last 5 days? Answer: Yes; How much of the time have you experienced pain or hurting over the last 5 days? Answer: Frequently; Over the past 5 days, has pain made it hard for you to sleep at night? Answer: Yes; Over the past 5 days, have you limited your day-day activities because of pain? Answer: Yes; Verbal Descriptor Scale: Answer: Severe. On 2/7/24 at 11:30 AM, Surveyor asked V2 (DON-Director of Nursing) how the facility managed pain for their residents, V2 stated, As far as reassessment, we assess for pain by seeing if there is grimacing and guarding, visualization, if the resident is not eating, resistance to care, and we get the resident's pain level to see if they have a PRN (as needed) medications, and if they are showing symptoms of pain, we give the PRN, then monitor and reassess. Often times we take the vitals. Surveyor asked about R4's pain medication regimen when the resident returned from the hospital on 2/4/24, V2 stated, (R4) was readmitted in the afternoon on 2/4/24 which was a Sunday by V12 RN, and it looks like nothing was given until the following day Monday the 5th at 3:09 PM by V13 LPN. Surveyor asked about the initial screening tool to assess R4's pain and was asked what the screening tool indicated. V2 stated, It's a screening tool the admitting nurse used when R4 came back, and it says that the resident had pain. Surveyor asked what the nurse recorded on the assessment as to the level of pain the resident had, V2 stated, It says she was in severe pain. Efforts to contact both V12 (RN) and V13 (LPN) were met with unreturned voice messages. Review of R4's MAR (Medication Administration Record) showed on 2/4/24, no pain medications were provided to the resident including the patient's scheduled Tylenol when R4 came back to the facility in the afternoon, and no pain medications throughout the evening and early morning the next day which prevented R4 from sleeping. The following day on 2/5/24, R4 received her scheduled Tylenol medication at 8:00 AM, however did not receive her PRN (as needed) pain medications of Tramadol (for moderate pain) until 15:09 (3:09 PM) that day. Physician orders showed Tramadol to be given for moderate pain; Oxycodone to be given (for severe pain) which the resident expressed upon admission and as stated on V12's initial pain assessment for the resident that she was in extreme pain. On 2/8/24 at 10:50 AM V9 (NP) was asked about pain management, V9 stated, They should assess in general at least every shift and documenting where the pain is, on the rating scale, to see what pain medication is available, and to provide that specific medication as it relates to the pain rating the resident provides the nurse. There's also other measures like repositioning. Nurses should have to reassess the resident and/or provide other techniques to see if it was effective. If the patient says they're in pain, then this should have been addressed to relieve the patient's discomfort. Surveyor asked about R4's post surgically prescribed pain medications and how nurses should treat pain in regards to post surgical pain, V9 stated, Like any pain, it should have been addressed. What the pain rating was, if medication is needed (etc.), but yes the order should be followed as ordered. Policy dated 6/1/23 titled Pain Management reads in part, The community to the extent possible to prevent or manage pain will: 1. Recognize when the resident is experiencing pain and identifies circumstances when pain can be anticipated. 2. Evaluate the existing pain and the causes and 3. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Assessment: The nursing staff will evaluate each individual for pain upon admission to the community, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Staff will evaluate pain using the pain review in point click care. Cause Identification/Treatment: The physician will help identify causes of pain by examining the resident directly, reviewing the resident's history, and via discussion with the resident and staff. For example, a hospital discharge summary may indicate that the resident has a painful condition or was receiving medications that may cause or exacerbate pain. The physician will order appropriate medication interventions to address the individual's pain. Pain medications should be selected based on pertinent treatment guidelines. The staff will evaluate and report how much and how often the individual asks for PRN pain medication.

Based on interviews and record reviews the facility failed to supervise/monitor a resident identified to have a lack of safety awareness. This affected one of three residents (R1) reviewed for supervision and fall prevention. This failure resulted in R1 having a fall incident and sustaining a left intertrochanteric femur fracture. The findings include: R1's diagnosis include but are not limited to Supraventricular Tachycardia, Hyperlipidemia, Dementia, Depressive Disorder, Alzheimer's Disease, and Osteoarthritis. On 8/22/23 at 11:08AM R1 observed in her bed resting and did not acknowledge the surveyor. On 8/22/23 at 12:00PM V1, Dining Services, said there had been an activity in the dining room on 8/3/23 and it was over so she and V2, Dining Services, were setting up for the meal. V1 said only herself, V2, and R1 were in the room. V1 said R1 was sitting in a chair near a table. V1 said I had never met R1 before. V1 said we were left about 15 minutes with R1 in the dining room. V1 said when we walked in there was no staff in the room. V1 said in her department she tries to keep an eye out for all the residents, and she can tell someone to sit down. V1 said she saw R1 was trying to scoot herself up and V1 said I told her to sit down and that someone was coming for her. V1 said R1 was lifting her bottom by using the arm rest on the chair to lift herself. V1 said when I turned back to R1 she was on the ground, V1 said my back had been turned towards R1. V1 said I did not see when R1 stood up from the chair before she fell . V1 said R1 was wondering and asking who was coming back to pick her up. V1 said R1's wheelchair had rolled away from her when she fell . On 8/22/23 at 12:08PM V2, Dining Services, said on 8/3/23 I was in the dining room doing my duties. V2 said I overheard V1 tell R1 to sit down and then I saw R1 on the floor. V2 said I stayed with R1 while V1 went to call for help. V2 said R1 was holding her side and saying ow. V2 said the activity staff were not in the dining room. V2 said she was in the dining room with V1 and R1 about 20 minutes before R1 fell . V2 said R1 was asking about going back to her room. V2 said my back was turned towards R1 and when I turned back to look R1 was falling, V2 said R1 stood up and was trying to bend, and then she was laying on her side on the floor. On 8/22/23 at 12:35PM V3, Life Enrichment Aid, said she had left the dining room on 8/3/23 and when she returned R1 was on the floor. V3 said when I left the room V4, Life Enrichment Aid, was in the room with R1. V3 said when Life Enrichment Aids do an activity someone has to stay with the residents during and after the activity to keep them supervised. V3 said when I came into the dining room only the dining staff were in the room, and I stayed with R1. V3 said R1 was laying completely on the floor. V3 said R1 has a history of trying to get up unassisted, if you leave her alone. V3 said R1 needs help to come to the dining room from her room, on the second floor, and she would need assistance to move her wheelchair. V3 said the practice is not to leave residents unattended. On 8/23/23 at 10:00AM V8, Administrator said the fall incident reports are internal documents and were not provided to the surveyor to review. On 8/23/23 at 10:10 AM V5, Nurse, said on 8/3/23 I was called to see R1, and they said she was on the floor in the first floor dining room. V5 said the activity staff had taken R1 to the activity earlier in her wheelchair. V5 said before the fall R1 has Dementia and is very confused. V5 said R1 cannot walk by herself or get up alone. V5 said R1 has fallen before. V5 said fall risk residents are those with dementia diagnosis, memory problems, and if a fall risk while in the hospital. V5 said we report verbally to staff to let them know who a fall risk resident is. V5 said R1 does not remember what happened that day when she fell . V5 said R1 had surgery after the fall on 8/3/23. On 8/23/23 at 10:30AM V6, Certified Nursing Assistant (CNA), said R1 is confused, needs reminders, and sometimes she does not understand. V6 said R1 will not understand a verbal direction. V6 said when R1 is in her room, she will try to get up and calls out. V6 said R1 needs physical cues/contact to sit down. V6 said R1 will not just sit if told because she tries to get up. V6 said R1 is often calling out and asking for her son if she does not see him (R1 shares a room with her son.) On 8/23/23 at 10:45AM V4, Life Enrichment Aid, said on 8/3/23 the activity ended, and I took R4, R1's son, to the second floor and I left R1 on her own. V4 said on my way back to the dining room I heard code purple and I saw R1 on the floor when I got there. V4 said I was not supposed to leave R1 alone because R1 can't control herself. V4 said I left R1 because I thought I would be back quick. V4 said after an activity we usually stay to supervise a resident. V4 said we don't leave kitchen people in charge of the residents. On 8/23/23 at 11:15AM V9, Director of Nursing, was asked to review the fall incident reports with the surveyor since they were not provided for review. V9 discussed R1's incident report. V9 said on 6/20/23 R1 got up unassisted from her wheelchair after dinner and fell . V9 read the findings and said R1 has a behavior of following her son (R4) when he leaves the room. V9 said R1 tried to get up and follow R4 and R1 fell . V9 said on 8/3/23 she arrived to R1's side once notified R1 had a fall. V9 said R1 was saying I gonna stand up. V9 read off the predisposing factors: has gait imbalance, impaired memory, and confused. V9 said R1 has Dementia, and she may not get it if a verbally instruction is given to her one time. V9 said R1 was sent to the hospital for evaluation and was found to have a left femur head fracture. V9 said V1 and V2 should have been trained on Purposeful Rounding. V9 said staff should know if a resident is in a wheelchair, they should think they are at risk for falls. V9 said everyone is at risk for falls. V9 said I would expect them (staff) to approach the resident and say stay here and calm the resident. V9 was asked what her expectation is if nonclinical staff see a resident trying to get up unassisted. V9 said I would expect staff to stay with the resident and wait until someone from activity returned. On 8/23/23 at 1:01PM V7, Dietary Manager, said Purposeful Rounding is a facility program developed to monitor residents. V7 said V1 and V2 could be assigned to rounding, but they work on the Assisted Living unit and rounding is focused on the long term care side. V7 said V1 and V2 will set up in the dining room for meal services. V7 said dietary staff seldom interact with long term care residents. V7 said the expectation of the dietary staff is to address the resident verbally, communicate the behavior, and control the situation. V7 said dietary staff are not to touch the residents because they are not clinically trained. On 8/23/23 at 1:23PM V8 said we do not have a policy for supervision. V8 said fall prevention is an interdisciplinary team approach, everyone is responsible. V8 said all departments have been educated on fall prevention. V8 said if the resident is displaying these behaviors (i.e., attempting to get up) then staff should try to stop it and call for help. R1 has diagnosis including but not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease, and Osteoarthritis. R1's Fall Scale dated 6/23/23 indicates a score of 55. R1 has fallen before. R1 overestimates or forgets limits. Scoring indicates a High Risk 45 and higher. R1's progress notes dated 6/26/23 notes R1 educated on fall precautions. R1 had unwitnessed fall on 6/21/23 and sustained left superior pubic rami fracture. R1's progress notes dated 7/10/23 states fall prevention in place. R1's progress notes dated 8/3/23, written by V5, sates R1 complained of left hip and left lower back pain . Progress note written by V9 states R1 admitted for left femur head fracture. IDPH report notes R1 is alert and orientated times 1, her cognitive score is 2. Facility provided witness statement from V3 typed and initialed by V3 states V3 told V4 to stay in the room until she returned from taking another resident to another location. V3 responded to a question on her statement saying there has to be someone with them (residents) at all times. If I see I am the last one, I stay until someone else comes in. V3 states she is aware R1 is a high fall risk. V3 said I have been with her (R1) when she tries to stand up and she needs to be reminded to sit down. Facility provided witness statement from V4 typed and initialed by V4 states we started to take residents back to their rooms. We cannot leave the residents alone. V4 left to take R4 to his room. V4 said he left R1 in the dining room and the dining staff was there. V4 stated I did not tell them I was leaving. V4 stated I was not supposed to leave the room, but I thought it would be quick. V4 said he is aware of who is a high fall risk resident, if they are in a wheelchair, they are most likely a fall risk. R1's care plan initiated on 3/28/23 states R1 usually (does not mean always) able to understand others. Care plan further states R1 has a behavior of following her son who shares a room with R1. R1 without safety awareness, tries to ambulate without assistance when her son is not in her sight. Intervention dated 6/26/23 states son is encouraged and educated to request assistance for his mom (R1) before exiting the room. (R1's son is R4, resides in the facility.) Hospital record dated 8/3/23 states Imaging Xray of the pelvis and femur show left intertrochanteric femur fracture. Assessment states fracture due to fall and osteoporosis. Plan Open Reduction Internal Fixation of left intertrochanteric femur fracture. Facility system policy Fall Prevention and Management dated 6/1/23 states Supervision- The community will provide adequate supervision to prevent accidents. Type and frequency will be based on individual assessed needs and identified hazards in the resident environment.

Based on interview and record review the facility failed to monitor/supervise a resident who was assessed to be a high fall risk and has exhibited behaviors of getting up by himself without asking for assistance and has impaired safety awareness. This affected 1 of 3 residents (R1) reviewed for falls and supervision. This failure led to R1 getting out of bed and having a fall incident that resulted in R1 sustaining an abrasion and hematoma to the left posterior head and rib fracture. Findings include: On 5-23-23 at 10:08 AM, V3 (CNA) said R1 was alert and confused. V3 said R1 will usually call when he wants to go to bathroom. V3 said she rounded on R1 at 10:30 PM and 12:00 AM and R1 was sleeping in bed. Around 3:00 AM, another resident called, while tending to the other resident, V3 heard a boom and went to R1. R1 was standing in the bathroom. R1 was bleeding at the back of his head. R1 did not complaint of pain. V3 asked R1 what happened and R1 said he went to bathroom himself without calling. V3 said R1's call light was in reach during her rounds. V3 escorted R1 to his wheelchair and made him comfortable. R1 said he could walk to the wheelchair. V3 called the nurse and the nurse assessed R1 in his wheelchair. Nurse cleansed the wound. Nurse called the paramedics. V3 said R1 is impulsive and will try to get up by himself without asking for help. V3 said R1 is sleeping during the night, and she will check on him 2-3 times a shift. V3 said R1 was not a fall risk because he can call for help. V3 is not aware of fall interventions. V3 is not aware of R1 having any previous fall. On 5-23-23 at 10:26 AM, R1 said he does not remember all the specifics. R1 said he cannot say what happened because it happened so quick. On 5-23-23 at 10:33 AM, V6 (LPN) said R1 is alert, oriented times 3, and able to make his needs known. V6 said R1 has Parkinson's disease which can delay his ability to talk and express himself. V6 said R1 has occasional forgetfulness. V6 said R1 uses the walker for ambulation due to unsteady gait due to Parkinson's disease. V6 is aware of R1's repeated falls as mentioned in his medical history. V6 said R1 had previous falls outside of the facility. On 5-23-23 at 11:08 AM, V5 (CNA) said R1 is alert and oriented times 3, and able to make his needs known. V5 said R1 uses the call light to ask for assistance to go to the bathroom. R1 can be mildly forgetful at times which is not constant confusion. Some days are better than others. R1 is compliant with using the call light 80% of the time. R1 will get up by himself to the bathroom [ROOM NUMBER]% of the time. V5 said R1 is a fall risk, and everyone is a fall risk. V5 said R1 uses the walker to be steady on his feet and R1 has an unsteady gait. V5 said she rounds on R1 every half hour to ensure safety. R1 has impaired safety awareness due to impulsive behaviors (getting up without asking for assistance). On 5-23-23 at 11:25 AM, V7 (Therapy Director) said R1 is alert, oriented times 1-2, and is sometimes able to make his needs known due to Parkinson's disease and fatigue. R1 has periods of confusion at times (d/t Parkinson's and fatigue). V7 is not aware of impulsive behaviors. V7 said R1 has impaired safety awareness noted in therapy sessions (due to Parkinson's disease). V7 said R1 has unsteady gait, requires 1-person physical assistance with transfers and ambulation. R1 is a high fall risk due to diagnosis of Parkinson's and requires 1-person assistance and the use of assistive devices (wheelchair or walker). On 5-23-23 at 11:54 AM, V4 (RN) said R1 is alert, oriented times 2 (at that time), and able to make his needs known (at that time). V4 said R1 has occasional forgetfulness and confusion and has impaired safety awareness due to Parkinson's disease. V4 said R1 is a fall risk and uses a walker and wheelchair due to unsteady balance. V4 said she rounded at 11:30 PM (R1 in bed sleeping) and 1:30 AM (R1 in bed sleeping). CNA called V4 on phone and said R1 had a fall and come to R1's room. V4 said she saw R1 standing and saw blood on back of his head (small amount). R1's blood was on the door frame of the bathroom (smear). V4 did R1's neuro checks, vitals, range of motion, and pain assessment (denied pain). R1 told V4 he wanted to get up and use the bathroom, went to bathroom by himself, lost balance and fell down. R1 told V4 he hit his head on the door frame. V4 cleansed the site with saline and applied ice (skin tear less than 1 inch). V4 called MD and called 911. R1 did not return during V4's shift. On 5-23-23 at 12:15 PM, V2 (DON) said she was not the DON at the facility during this incident. V2 said R1 had an unwitnessed fall where resident hit his head on the door frame and sustained rib fracture. On 5-23-23 at 2:21 PM, V1 (Administrator) said R1 got up from bed without using call light, without asking for assistance, and not using his walker. This was an unwitnessed fall. R1 was discovered already standing after his fall. R1 was strong enough to pick himself up from the floor after his fall. CNA and nurse responded immediately. R1 was noted with bleeding to the back of his head. MD notified and gave order to send out for hospital evaluation. R1 returned to facility with diagnosis of rib fracture. Morse Fall Scale dated 9-12-22 documents: Score: 30 and Category: Moderate Risk for Falling. Morse Fall Scale dated 2-21-23 documents: Score: 55 and Category: High Risk for Falling. Morse Fall Scale dated 5-21-23 documents: Score: 80 and Category: High Risk for Falling. MDS (ARD 2-23-23) documents: BIMS: 11, (Self-performance) Transfer: 3 (extensive assistance), (Support) Transfer: 2. (one-person physical assist), (Self-performance) Walk in room: 3 (extensive assistance), (Support) Walk in room: 2. (one-person physical assist). Balance During Transitions and Walking: 2. Not steady, only able to stabilize with staff assistance, Mobility Devices: Walker, Wheelchair. Active Diagnoses (not limited to): Parkinson's Disease. Progress Note dated 4/3/2023 documents: *Incident Note Text: Nurse on duty got a call from CNA around 2:30 AM. Patient is in wheelchair in his room with small opening on the back of the head and bleeding. Patient is AOx3, vital signs : BP 147/88, P 81 T 97.9 RR 20 O2sat -90% on RA. No c/o pain. No changes in ROM noted, no changes in LOC noted. According to patient he went to bathroom without walker and without using the call light for assistance. He lost his balance and fell ; he hit his head to the frame of the door then he gets up and used the call light for assistance. MD was notified. 911 call placed at 2:45 AM. Patient left facility at 3: 05 AM. He sent out to ER (Local Hospital) for evaluation. POA notified. ADON informed. Initial State Reportable dated 4-3-23 documents: Occurrence Description: On 4-3-23 at 02:30, the CNA assigned to resident informed nurse on duty that resident was on the floor. Nurse responded and observed resident standing near the bathroom door bleeding. Resident verbalized that he attempted to walk to the bathroom without using his walker, lost balance, fell and hit his head on the frame of the door. Resident got up and used call light for assistance. Head to toe assessment was performed and noted resident with skin tear at the back of his head. First aid treatment applied. Range of motion performed on all extremities with no limitation Level of consciousness assessed with no change. Vital signs were within normal limit. Emergency ambulance (911) was called. Primary care physician and family were notified Resident was transferred to the emergency room for further evaluation. At 11:45 AM, resident returned to the facility with diagnosis of: Rib fracture. Final Reportable dated 4-7-23 documents: After thorough investigation, the fall IDT determined that resident is alert and oriented x 3. The resident uses walker for ambulation does make needs known to staff. It was concluded, as per resident's self-report, that the resident did not call for staff assistance and attempted to walk to bathroom without his walker. The resident lost balance, fell , hit the back of his head against the door frame and sustained skin tear. Resident got up and pulled the call light for assistance. CNA assigned to the resident immediately responded to the call light and observed resident standing by the bathroom door with blood at the back of his head and on body. CNA called the nurse in charge. The nurse responded and rendered first aid treatment, carried out head to toe assessment and assisted resident to chair. The resident neurological assessment, vital signs, range of motion were all within normal range. Hospital Record dated 4-3-23 documents: Chief Complaint: Fall. Triage Notes: 85 y/o M pt brought by EMS from nursing home after an unwitnessed fall while getting up to go to the bathroom. Per EMS pt got up on his own and called for assistance after. Pt not on thinners. Pt has two small lacerations to back of head that were bleeding but controlled and not actively bleeding here. Pt denying head or neck pain but has pain in lower L back. Pt denying LOC, dizziness, and EMS pt baseline is slow to response but A&Ox3. Pt able to MAEW. NAD. Respirations even/unlabored. Pt placed onto hovermatt and trauma cart upon arrival to ED. HENT: Comments: Abrasion and hematoma to left posterior head. X-ray Left Ribs with PA Chest: Final Result: Nondisplaced posterior eighth rib fracture. Fall Prevention and Management Policy dated 4-1-23 documents: Supervision: The community will provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency based on the individual resident's assessed needs and identified hazards in the resident environment. Fall Care Plan (revised 4-4-23) documents: Anticipate and meet the resident's needs. (Initiated 1-17-23).

Based on observation, interview and record review, the facility failed to follow the plan of care and procedures for wound prevention to heal a preventable facility-acquired pressure sore for 1 (R16) of 3 residents reviewed in the sample of 36 residents. This failure resulted in R16 sustaining a facility-acquired, clinical stage 4 pressure ulcer to the sacral area. Findings include: R16 is a cognitively impaired [AGE] year old resident with diagnoses listed in part with hemiplegia and hemiparesis, gastrostomy, heart failure, and pressure ulcer of sacral region stage 4. A facility wound surveillance report provided to the survey team on 2/14/23 shows (R16) with a wound type described as Pressure, Subtype: Stage 4: Body location: Sacrum; Measurements: 2.7 centimeters length x 1.6 centimeters width x 0.3 centimeters depth; Acquired: [NAME] (In House Acquired). Physician orders dated 5/24/2022 reads in part: Turn and Reposition every two hours every shift for prevent pressure injury. On 2/14/23 at 10:40 AM, R16 was observed in bed asleep on her back with her torso raised up several inches and lying atop a blue-colored air mattress. There were numerous, white-colored sheets on the bed mattress and a tight fitted sheet appeared to wrap around the mattress compressing the sides of the air mattress. An air pump was dangling precariously with one hook at the foot of the bed and had tubes that were hitting the ground. V7 (RN) was asked about R16 and stated, Yes, she is my patient. She is always in bed. I have two Certified Nurse Assistants (CNA's) today but usually we have 3 on the floor. At 2:20 PM, R16 was observed in the same position on her back with her torso and head slightly raised up as was previously observed at 10:40 AM. On 2/15/23 at 9:20 AM, R16 was observed asleep in bed on her back with her torso raised up several inches. A tightly fitted sheet remained wrapped around R16's air mattress compressing the sides of the air mattress and there were again multiple layers of sheets on the mattress over and under R16's body. The same mattress pump remained dangling at the foot of the bed with one hook and tubing hitting the floor. On 2/15/23 at 11:10 AM, surveyor asked V7 (RN) to come and see R16 with the surveyor. R16 appeared to be in the same position and was observed in bed asleep on her back with her torso raised up several inches. Surveyor asked V7 to describe to the surveyor R16's positioning, V7 stated, She is on her back, and we raise her head up a little bit for comfort. Surveyor asked to describe more about R16, V7 stated, (R16) has a G-tube (gastrostomy tube) and a urinary catheter because she has a pressure ulcer on her sacral area. I don't know if she got the pressure ulcer here or from the hospital, but I think I was told it was from here. The wound nurse (V3) comes every Friday and they do wound rounds with her and the wound doctor, but I don't know anything else about it. The nurses do the wound care every day except Friday when V3 (wound nurse) does it. Wound care is done on the PM shift mostly, so I don't normally do it because I am AM shift nurse. Surveyor asked how R16 appeared to her, V7 stated, She looks uncomfortable, but she looks that way a lot. This is a fitted sheet, and it should not be here, we are supposed to have flat sheet. Surveyor asked why a fitted sheet was not supposed to be used as she said, V7 stated, Because I think they told us it is not good for the air mattress to work. Surveyor asked about the green incontinence pads that were bunched up under R16's sacral area, V7 stated, The CNA's shouldn't be using that much under her I will let the CNA know. Surveyor asked about the dangling mattress pump at the foot of the bed, V7 stated, Oh, I saw that yesterday, I should have let maintenance know about it. I will call them now. Surveyor asked if the mattress pump was functioning properly, V7 stated, I don't know. I don't touch this. I think it's working but I don't know anything about this. Surveyor asked if anyone instructed her on how to operate the mattress pump for R16, V7 stated, No, maintenance takes care of this. At 11:20 AM, V7 called in V8 (CNA) and asked her about R16's bed, V8 stated, I didn't do her bed, that was the night shift that makes her bed. Surveyor asked how many incontinence pads were supposed to be under R16, V8 stated, Those pads shouldn't be under her like that. It was probably when she was turned or something. Surveyor asked when she last turned R16, V8 stated, I did it around 7:30 or 8, I don't remember. Surveyor asked if anyone helped her do this, V8 stated, No, I did it myself and I was going to do it again just now that's why I came in. MDS (minimum data set) dated 12/16/22 shows that R16 as rarely/never understood. Functional status of bed mobility as total dependence and requiring a minimum 2+ person to move from lying position, to turn side to side, and to position body while in bed. Section M on this same MDS assessment showed R16 with one stage 4 pressure ulcer and had 0 number of stage 4 pressure ulcers that were present upon admission/entry or reentry to the facility; Skin and ulcer/treatment interventions show R16 to have pressure reducing device for chair and bed but did not show that R16 was on a turning and repositioning program as ordered by the physician. On 2/15/23 at 2:40 PM, V15 (CNA) was observed in R16's room with the privacy curtain drawn. Surveyor entered the room, and V15 stated, patient care! to deter anyone from coming into the room. Surveyor came into the room, and V15 stated to surveyor, Come here and help me change her. Surveyor identified self and informed V15 that surveyor was unable to comply with her request. Surveyor asked V15 what she was doing, V15 stated, I was about to clean her (R16) up, should I stop? Surveyor answered and said to continue how she normally took care of R16 and left the room. At 2:45 PM, Surveyor approached V14 (RN) and requested to see if he could observe him conduct wound care for R16, V14 stated, Yes. I usually do her anyway on my shift. V14 proceeded to R16's room and saw V15 already in the room and informed her to clean R16 up because he was going to do wound care for R16. V15 was overheard saying, I'm almost done so I will wait for you to do her dressing change. V14 went to his cart and took several supplies with him and placed them in his hand and brought them to the room and placed the supplies onto a bedside table and went into the bathroom to wash his hands and put on gloves. Surveyor asked V14 to explain the procedure to surveyor as he conducted the wound care. V14 stated, (R16) is totally dependent and non-responsive resident. She has a pressure ulcer on the coccyx area, and she got it here in the facility, but it was here before I ever started working here which was about 6 months ago. V14 removed the soiled beige colored bandage/dressing cover that had no date or markings on the bandage to identify when the dressing was changed or who changed the dressing. V14 continued and removed the bandage to reveal the wound. V14 stated, It measures approximately 3 centimeters by 2 centimeters wide and 1 centimeter deep. Surveyor asked to describe the wound size further to the surveyor, V14 stated, I'd say it is smaller than a golf ball size but bigger than a marble. First, I clean it with normal saline solution and then I pack the wound with the silver alginate dressing, then cover it with the foam dressing (bandage cover). As V14 was cleaning R16's wound with the normal saline, R16 twitched her body forward and made a moaning sound. As V14 started packing R16's wound with the silver alginate dressing, R16 retracted her body again and moaned. Surveyor asked about the movements and sounds R16 made, V15 stated, She does that all the time when we change her dressing. V14 added, She is has overall pain, but she gets regular scheduled pain medications later on. Surveyor asked if the movements and sounds R16 made were pain responses and whether he should have stopped the procedure or pre-medicated her before doing the wound care, V14 stated, I think she is like that, but I did it pretty quickly, so I don't think she was in pain. Surveyor asked to clarify what clinical stage R16's wound was, V14 stated, It is a stage 3 pressure sore. Surveyor asked to clarify the staging of the wound, V14 stated, Yes it's a stage 3 not a stage 4, that's what it looks like to me. Surveyor asked why there were no initials or date placed on the dressing cover to denote when the wound dressing was changed, V14 stated, We were told not to do that, but I knew it was changed because I changed it yesterday. Surveyor asked if this was considered best nursing practice to not date wound dressings when they are done, V14 stated, I guess it would be sir, but we never do that here. Surveyor asked whether R16 had any other wounds, V14 stated, Yes, it is on her right trochanter hip area, but it is almost healed. V15 turned R16 to her side to reveal another undated and un-initialed wound dressing on R16's right hip area. V15 proceeded to peel off the wound dressing to show surveyor until surveyor asked V15 to stop what she was doing. Surveyor asked V14 if V15 was a nurse and allowed to do wound care, V14 stated, No. She is not a nurse and should not be doing that because she is not licensed. A wound evaluation report provided to surveyor by V1 (Administrator) and submitted by V18 (Wound Doctor) dated 11/11/2022 shows in part, (R16) Focused wound Exam (site 1) Stage 4 press wound sacrum full thickness. Etiology (quality): Pressure; MDS 3.0 Stage 4; Wound size (Length x Width x Depth) 2.6 x 1.8 x 0.3 cm.; Surface area 4.68 centimeters squared. Wound progress: Deteriorated. A recent wound evaluation report also provided by V1 and submitted by V18 dated 2/10/2023 shows in part, (R16) Focused wound Exam (site 1) Stage 4 press wound sacrum full thickness. Etiology (quality): Pressure; MDS 3.0 Stage 4; Wound size (Length x Width x Depth) 2.7 x 1.6 x 0.3 cm.; Surface area 4.32 centimeters squared. Wound progress: No Change. Plan of care reviewed and addressed. Recommendations: Off-load wound; reposition per facility protocol. Care plan dated 8/4/22 reads in part, The resident has a stage 4 pressure injury on sacrum. Goal: Sacral pressure injury will not increase in size. Interventions: The resident requires the bed as flat as possible to reduce shear; Keep skin free of moisture; Monitor the area for any signs of infection; treat the area as ordered; Treat pain as per ordered prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Another care plan dated 7/5/22 (revised 10/5/22) reads in part, The resident has an ADL (activities of Daily Living) self-care performance deficit related to CVA (Cardiovascular accident) with hemiplegia. Goal: The resident will maintain current level of function through the review dated. Interventions: Bed mobility: The resident needs total assist of 2 staff. Bathing/Showering: The resident needs 2 person assist; Personal hygiene: The resident needs total assist with minimum 2 person assist. On 2/16/23 at 10:40 AM, interview with V3 (ADON/Assistant Director of Nursing and wound care nurse) stated, I am the wound nurse and ADON. I've been the wound nurse since 2021. I am wound care certified. I do rounds with V18 (Wound Doctor) every Friday. Mostly the nurse on the floor does the wound care. They do the wounds everyday except Friday when I do them. Surveyor asked about R16, V3 stated, (R16) she is nonverbal and stays in bed, NPO (nothing by mouth), and she has feeding tube. She requires minimum two people with all ADL's (Activities of Daily Living). She has stage 4 in the sacrum, and it was acquired here in the facility. The wound has remained a stage 4 for two years. It is a chronic wound, and it is not deteriorating, it is stable. Surveyor asked based on her training and clinical knowledge why the wound wasn't healing, V3 stated, She has multiple diagnosis she is anemi,c diabetic, hemiplegia. We are doing daily treatments and wound doctor is overseeing it. The treatment was changed multiple times. She is on air mattress, urinary catheter; We are changing her positions every two hours and the CNA's are repositioning her. Surveyor asked how she monitored compliance with these orders for turning and repositioning, V3 stated, I have seen them turning her. I work here 8-4:30 PM so I eyeball it. It takes two people to reposition her, and they CNAs are doing pericare when she is soiled so they turn and reposition her then and as needed. Surveyor asked if it was important to reposition R16 and whether that had any impact on delayed healing if it was not being done, V3 stated, I don't know. Surveyor asked how many times in the day R16 would require repositioning, V3 stated, they reposition her every shift so 4 times a day she is turned. Surveyor asked about dating and initialing of wound dressings when rendered, V3 stated, We don't date or initial wound dressings because our corporate say not to and it is in our policy. Surveyor asked about the training of the nurses since wound care is done 6 out of the 7 days by the floor nurses, V3 stated, I don't know about their training. I communicate to the nurses the type of wound. Surveyor asked if she directly trained the floor nurses about wound care, V3 stated, No I just tell them about the wound and a year ago in a job fair, I told them. Surveyor asked about the wound training of the agency nurses on the floor, V3 stated, I don't know but they should know. Surveyor asked since she was a Certified wound nurse and based on her own wound training and clinical background whether the wound was an avoidable wound, V3 stated, I think that this wound was preventable because if she would not be on hard surface for a long time or if she could be more up from bed and from the wheelchair or sitting position and changing positions, it could have been prevented. Positioning is important and nutrition. Surveyor asked about pain management of wounds, V3 stated, When we do wound care for (R16), she is not pre medicated for pain. She has scheduled medications, but we don't pre-medicate for pain but if she doesn't have any, but I will do that from now on. On 2/16/23 at 4:00 PM, Surveyor reminded V3 to provide the policy where it indicates to not initial or date the dressing when it is accomplished V3 stated, I thought the DON (V2) gave you that. Surveyor asked V3 if she considered it a best practice to initial and date when a dressing is done, V3 stated, I don't know. I can't answer that. On 2/16/23 at 4:10 PM, V2 (Director of Nursing) was asked about dating and initializing when changing wound dressings, V2 stated, It is considered best practice to initial and date when a wound dressing has been changed. Efforts to reach V18 were unsuccessful and was informed by V1 and V3 that V18 was on vacation and was possibly unreachable because V18 was in the mountains. V1 offered surveyor contact information for R16's primary physician and for the facility's medical director. Efforts to reach the V19 (Primary physician) were met with the answering service informing surveyor that only a covering doctor was available to be paged if there were orders needed by the nursing home facility. On 2/16/23 at 4:30 PM, interview with V24 (Medical Director) stated, I am informed of any acquired wounds as the Medical director, and we go over this topic during our monthly quality assurance meetings. When it comes to pressure ulcers we talk about any facility-acquired pressure sores and especially anything above a stage 2 where we talk about root cause, and we develop interventions to prevent and heal these wounds. Surveyor asked that since they talk about wounds higher than a stage 2, what his feedback was about (R16). V24 stated, I do recall this resident being discussed but please refresh my memory. Surveyor provided brief information about R16 and asked the importance of turning and repositioning for R16 as ordered by the Primary physician (V19). Turning and repositioning is an important preventative measure but once the wound develops however, it is crucial now for turning and repositioning to be done. Surveyor asked about the specialty air mattress and how the bed should be prepared, V24 stated, I really couldn't speak to that however I do know that the bed should be made minimally to prevent over padding of sheets, etc. to prevent pressure area and to attempt better healing. Surveyor asked if nurses should be indicating on the wound dressing who or when the dressing was changed, V24 stated, I am not that familiar with nursing practice however, I do consider it would be best practice to initial and date a wound. Surveyor asked whether, CNAs were allowed to do dressing changes, V24 stated, I would not think they are allowed to do so unless they are licensed nurses. Surveyor asked about pain management during wound care, V24 stated, From what I know about pain management, and assuming that the cognitive impaired resident is unable to ask for pain medications, it would be appropriate and good practice to administer pain medication approximately 30 to 45 minutes before dressing changes are done. If a patient shows signs of discomfort and retracts during wound care then pain medication should have been provided prior to this procedure and if there were signs of moaning or retracting when the procedure was being done, that procedure should have been immediately stopped. Facility policy dated 6/1/21 titled Pressure ulcer-wound assessment and documentation reads in part, Wound assessment is a continuous process that serves to provide information about wound status, staging, its etiology, and the efficacy of the interventions. Purpose: to report and gather data for the purpose of planning and implementing wound (specifically pressure injuries treatment procedures. Procedure: Identify resident, explain procedure, obtain consent for photograph, and ensure privacy. Wash hands before and after procedure. Apply gloves before performing wound assessment. remove and discard dressing and gloves. Wash and apply new gloves. Stage 4 Pressure injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure injury. The staff nurse identifying the wound shall make initial measurements. Measurement of the wound should occur weekly. The wound care/designated staff nurse should assess the resident upon identification of impairment in skin integrity and subsequently with any change in appearance. The staff nurse shall assess the wound weekly and notify the wound care nurse/designated staff nurse and physician of any changes/deterioration.

Based on observation, interview and record review, the facility failed to provide effective pain management to a cognitively impaired resident and failed to identify signs and symptoms of pain for 1(R16) of 5 residents reviewed for pain in the sample of 36 residents. This failure caused (R16) to endure pain during a wound care procedure. Findings include: R16 is a cognitively impaired [AGE] year old resident with diagnoses listed in part with hemiplegia and hemiparesis, gastrostomy, heart failure, and pressure ulcer of sacral region stage 4. MDS (minimum data set) dated 12/16/22 shows that R16 as rarely/never understood. Functional status of bed mobility as total dependence and requiring a minimum 2+ person to move from lying position, to turn side to side, and to position body while in bed. Section M on this same MDS assessment showed R16 with one stage 4 pressure ulcer and had 0 number of stage 4 pressure ulcers that were present upon admission/entry or reentry to the facility; Skin and ulcer/treatment interventions show R16 to have pressure reducing device for chair and bed but did not show that R16 was on a turning and repositioning program as ordered by the physician. Physician orders dated 5/24/22 reads in part, Pain assessment every shift for monitor pain record pain level and location: Acetaminophen: give 20.3 ml via G-tube every 6 hours as needed for mild pain related to chronic pain syndrome. Review of records showed no physician orders to manage/mitigate pain before each wound treatment and most recent pain assessment conducted on 12/15/22 by V25 (RN) for R16. This pain assessment form shows Frequency with which resident complains or shown evidence of pain or possible pain, marked as Not assessed. At 2:45 PM, Surveyor approached V14 (RN) and requested to see if he could observe him conduct wound care for R16, V14 stated, Yes. I usually do her anyway on my shift. V14 proceeded to R16's room and saw V15 (CNA) already in the room and informed her to clean R16 up because he was going to do wound care for R16. V15 was overheard saying, I'm almost done so I will wait for you to do her dressing change. V14 stated, (R16) is totally dependent and non-responsive resident. She has a pressure ulcer on the coccyx area, and she got it here in the facility, but it was here before I ever started working here which was about 6 months ago. V14 removed the soiled beige colored bandage/dressing cover that had no date or markings on the bandage to identify when the dressing was changed or who changed the dressing. V14 continued and removed the bandage to reveal the wound. V14 stated, It measures approximately 3 centimeters by 2 centimeters wide and 1 centimeter deep. Surveyor asked to describe the wound size further to the surveyor, V14 stated, I'd say it is smaller than a golf ball size but bigger than a marble. First, I clean it with normal saline solution and then I pack the wound with the silver alginate dressing, then cover it with the foam dressing (bandage cover). As V14 was cleaning R16's wound with the normal saline, R16 twitched her body forward and made a moaning sound. As V14 started packing R16's wound with the silver alginate dressing, R16 retracted her body again and moaned. Surveyor asked about the movements and sounds R16 made, V15 stated, She does that all the time when we change her dressing. V14 added, She has overall pain, but she gets regular scheduled pain medications later on. Surveyor asked if the movements and sounds R16 made were pain responses and whether he should have stopped the procedure or pre-medicated her before doing the wound care, V14 stated, I think she is like that, but I did it pretty quickly, so I don't think she was in pain. Care plan #1 dated 8/4/22 reads in part, The resident has a stage 4 pressure injury on sacrum. Goal: Sacral pressure injury will not increase in size. Interventions: The resident requires the bed as flat as possible to reduce shear; Keep skin free of moisture; Monitor the area for any signs of infection; treat the area as ordered; Treat pain as per ordered prior to treatment/turning etc. to ensure the resident's comfort. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Care plan #2 dated 7/5/22 (revised 11/30/22) reads in part, The resident has arthritis and chronic pain and is at risk for complications. Goal: The resident will be/remain free of complications related to arthritis related joint impairment. Interventions: Educate resident on joint conservation techniques. Encourage adequate nutrition and hydration. Give analgesics as ordered by physician. Monitor and document for side effects and effectiveness. Heat/cold applications as ordered and as tolerated. Monitor/document/report to MD as needed for signs and symptoms related to arthritis: joint pain, usually worse on wakening. Care plan #3 dated 7/5/22 (revised 11/30/22) reads in part, The resident is at risk for pain related to osteoarthritis, history of CVA with right hemiplegia, dementia, chronic wound. Goal: There resident will experience comfort. Interventions: Medicate per physician orders. Monitor for signs and symptoms of pain. Offer massage; Turn and reposition. Records reviewed showed no other care plans to manage pain during wound care for R16. On 2/16/23 at 10:40 AM, interview with V3 (ADON/Assistant Director of Nursing and Wound care nurse) stated, I am the wound nurse and ADON. I've been the wound nurse since 2021. I am wound care certified. I do rounds with V18 (Wound Doctor) every Friday. Mostly the nurse on the floor does the wound care. They do the wounds everyday except Friday when I do them. Surveyor asked about R16, V3 stated, (R16) she is nonverbal and stays in bed, NPO (nothing by mouth), and she has feeding tube. She requires minimum two people with all ADL's (Activities of Daily Living). She has stage 4 in the sacrum, and it was acquired here in the facility. The wound has remained a stage 4 for two years. It is a chronic wound, and it is not deteriorating, it is stable. Surveyor asked about pain management of wounds, V3 stated, When we do wound care for (R16), she is not pre medicated for pain. She has scheduled medications, but we don't pre-medicate for pain but if she doesn't have any, but I will do that from now on. On 2/16/23 at 4:30 PM, interview with V24 (Medical Director) stated, I am informed of any acquired wounds as the Medical director, and we go over this topic during our monthly quality assurance meetings. When it comes to pressure ulcers we talk about any facility-acquired pressure sores and especially anything above a stage 2 where we talk about root cause, and we develop interventions to prevent and heal these wounds. Surveyor asked about pain management during wound care, V24 stated, From what I know about pain management, and assuming that the cognitive impaired resident is unable to ask for pain medications, it would be appropriate and good practice to administer pain medication approximately 30 to 45 minutes before dressing changes are done. If a patient shows signs of discomfort and retracts during wound care then pain medication should have been provided prior to this procedure and if there were signs of moaning or retracting when the procedure was being done, that procedure should have been immediately stopped. Facility policy dated May 19, 2022, titled Pain assessment, long-term care reads in part, Pain is defined by the International association for the study of pain as an unpleasant sensory and emotional experience associated with (or resembling that associated with) actual or potential tissue damage . It's crucial for nurses to communicated with other health care providers and assess and address resident's pain because residents are more likely to return to baseline with early recognition and treatment of pain. Inadequate treatment of pain is associated with many adverse outcome's among long-term care residents, including falls, disrupted sleep and eating, decreased socialization, reluctance to participate in normal activities, impaired mobility, and symptoms of depression, anxiety or both. The assessment, identification, and treatment of pain are important components of a resident care plan and an ethical part of nursing care. Nurses must conduct comprehensive pain assessments that are consistent with resident's age, medical condition and mental status. In addition, residents have the right to treatments and interventions to reduce pain. Pain is commonly under-treated in residents with cognitive impairments such as dementia. Pain assessment in these residents requires the use of a facility-approved tool, such as the Pain Assessment in Advanced Dementia scale, which focuses on observing the resident's behaviors. An ostomy wound management abstract research paper dated February 2009, titled Pressure Ulcer Pain: A Systemic Literature Review and National Pressure Ulcer Advisory Panel White Paper research article reads in part, Pain is an ever-present problem in patients with pressure ulcers. As an advocate for persons with pressure ulcers, the National Pressure Ulcer Advisory Panel (NPUAP) is concerned about pain. To synthesize available pressure ulcer pain literature, a systematic review was performed of English language literature, specific to human research, 1992 to April 2008, using PubMed and the Cumulative Index in Nursing and Allied Health Literature. Fifteen relevant papers were found; they examined pain assessment tools, topical analgesia for pain management, and/or descriptions of persons with pressure ulcer pain. Studies had small sample sizes and included only adults. The literature established that 1) pressure ulcers cause pain; 2) pain assessment was typically found to be self-reported using different versions of the [NAME] Pain Questionnaire, Faces Rating Scale, or Visual Analog Scale; 3) pain assessment instruments should be appropriate to patient cognitive level and medical challenges; 4) in some cases, topical medications can ease pain and although information on systemic medication is limited, pain medications have been found to negatively affect appetite; and 5) wound treatment is painful, particularly dressing changes. Persons with either Stage III or Stage IV pressure ulcers had significantly (P <0.05) more severe pain (i.e., MPQ total and sensory and affective subscales) than persons with other wounds.

Based on observation, interview and record review the facility failed to safely conduct a resident transfer who required extensive assistance with a minimum two-person assist for 1 (R1) of 3 residents reviewed in the sample; and failed to follow facility fall prevention care plan and guidelines. This failure resulted in R1 being emergently transferred to the hospital's emergency department where he was diagnosed with a [CONDITION(S)] and [CONDITION(S)]. Findings include: R1 is an [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Muscle Weakness, [CONDITION(S)], Repeated Falls, Difficulty Walking, [CONDITION(S)], and Dementia. MDS (Minimum Data Set) dated 02/02/2022 under section C, R1 has BIMS (Brief Interview of Mental Status) score of 6 indicating severely impaired cognition. MDS (Minimum Data Set) dated 08/03/2021, 10/27/2021, 01/21/2022, and 02/02/2022 under section G, all showed R1's functional status for transfers required extensive assistance with minimum two-person staff assist to transfer from bed to chair. Care plan dated 02/28/2022 showed R1 was at risk for falls with interventions: keep call light within reach, encourage use of call light, low bed, physical therapy referral, and side rail for repositioning. Fall risk assessment dated [DATE] showed R1 at very high risk for falls. Alternate fall risk assessment dated [DATE] showed R1 remained at a very high risk for falls. On 6/1/22 at 10:25 AM, surveyor observed R1 sitting in the common area in the reclining chair. R1 was transferred to the room for an interview. There were no fall mats noted on the floor or anywhere stored in the room upon entrance to R1's room and a leaf sign (indicating fall risk) posted by R1's room number. Surveyor asked if R1 remembers what happened on 05/01/2022, R1 stated that he doesn't remember what happened; however, he recalls that he had a leg fracture around that time. Surveyor clarified which leg was affected, R1 pointed to the left leg. On 6/1/22 at 12:00 PM surveyor interviewed V3 (RN, Registered Nurse). Surveyor asked about the fall sustained by R1 on 05/01/2022, V3 stated, R1 fell around 7:00 AM while V4 Certified Nursing Aide (CNA) was trying to get him ready for breakfast. R1 usually needs two-person assist or standing mechanical lift. V4 explained that she was trying to get R1 ready by herself, while she was changing his clothes, she realized he was too heavy, and R1 started to slide off the bed. V4 attempted to lower the bed while R1 was sliding off the bed. I wasn't in the room at the time of an incident. When I came in R1 was sitting on the dresser leaning to the left and his head was leaning against the dresser. R1 is on blood thinners, so I made a full assessment to look for any bleeding, I also checked neurological function and range of motion, I didn't notice any changes. Surveyor asked how many people does R1 require for transfers, V3 stated, R1 always requires two-person assist, he is considered a fall risk resident. Surveyor clarified what does an image of a leaf posted by the R1's room number mean, V3 stated, I don't know what that is. Surveyor's asked V3 to accompany them to R1's room to look at the fall mats in question. Upon arriving in the room, V3 searched for the mats that were to be used for R1 but could not find any mats used or stored anywhere in the room. V3 stated, I'm sorry but I cannot find any floor mats, but we are supposed to use them for R1. Surveyors clarified whether mats were stored anywhere on the unit, V3 stated, No we don't have storage area for the mats, they would be folded up against the wall ready for use or in the closet. On 6/1/22 at 12:20 PM surveyors asked V2 (Director of Nursing) information pertaining to the leaf symbolism observed on various rooms and for fall prevention guidelines. V2 indicated she was not aware of the leaf symbol used by the facility, however, was aware the leaf symbol referred to fall risk residents. V2 was able to provide policy and procedures pertaining to falls but could not find any information regarding the leaf symbol. Surveyors asked how long she was in her position, V2 stated, Over 2 years. Progress note dated 05/01/2022 at 10:50 AM completed by V3 (RN) reads in part, At 07:10 AM, care partner reported that R1 fell on to the floor during transfer from bed to wheelchair. She (V4) realized that resident is heavy and not safe to transfer, so she just assisted him to sit on the floor, but his head hit the wood drawer. Immediately went to the resident's room with another nurse. R1 observed sitting on the floor leaning to the left side. Head to toe assessment done. Observed skin laceration on the left side of the head. Informed MD and she advised to send resident to emergency room hospital for further evaluation and treatment. Resident complained of pain to the left hip and desaturated to 88%. 911 called, R1 picked up at 8:08 AM and transferred to the hospital. Interview with V4 on 6/1/22 at 11:30 AM stated, I was R1's CNA that day he fell but I didn't know this resident (R1) at all, and it was my first time working with him when he fell . I was on orientation from this other CNA. I can't recall her name, but she didn't really tell me much about (R1). I was trying to transfer him from bed to wheelchair close to beginning of my shift (6:30 am) and his feet got stuck on the wheelchair. He was really, really, heavy and he started to fall, and I tried to keep him from falling, but like I said he was heavy so I kind of lowered him to the ground, but he dropped to the ground, and he hit his head on the furniture and was bleeding. He looked like he was in shock or something when he was on the ground, so I shouted to the nurse (V3), and she came right away, and I know she checked him out and they sent him to the hospital. I found out later he had a fracture and I felt bad because no one helped me get this man (R1) out of bed. I didn't know he was a fall risk, and no one told me anything about R1 or any of the residents. Surveyor asked what fall preventative measures she was instructed use with R1 and other residents under her care? V4 stated, I don't know what they do for people who are fall risk because I normally do private duty, that's my regular job. I was not even given instructions on anything for this man (R1). I was just given an assignment, that's it. Surveyor asked if the Director of Nursing (V2) called her to investigate the fall, I never got any call from anyone from the facility, in fact you are the first person (referring to surveyor) that has called me about the fall. Surveyor asked again whether anyone from the facility including the Director of Nursing, Administrator or any other staff left a message or tried calling her to interview and investigate about R1's fall? V4 stated, No. Interview with V5 CNA on 6/1/22 at 10:30 AM stated, I'm agency, I just came in to get the call light because (V2-DON) said to get the call light. I don't know these residents well but what's your question? Surveyor asked which residents were considered fall risk, V5 stated, Like I said I don't know these residents well, I'm agency and I've only worked here a couple of times. Surveyor asked if anyone from the facility informed her of who the residents that are at risk for falls, V5 stated No, they don't tell us anything, they just tell us which section we have and that's it. Surveyor asked if the facility in-serviced (training) her on fall prevention, V5 stated, No. On 6/1/22 at 2:00 PM Surveyor interviewed V7 (Physician). Surveyor asked if V7 remembered the fall that R1 suffered on 05/01/2022, V7 stated, Yes, I remember, R1 was sent to the hospital after he fell where he was diagnosed with hip/femoral fracture. I don't know the details of the fall. The facility said that R1 accidentally fell , and I just gave them an order to send him to the emergency room . R1 was hospitalized for few days to get evaluated by an orthopedic specialist; however, the decision was made not to perform a surgery. R1 is unsteady due to his [CONDITION(S)]. He is also very confused and has dementia. R1 is only able to follow very simple directions and he cannot hold himself standing up. Surveyor clarified if someone with [CONDITION(S)] who is confused and unsteady would be safe to transfer with one-person assist, V7 stated, R1 would probably benefit from two-person assist. [CONDITION(S)] residents are not stable and it's safer to have two-person assist while performing transfers with them. Interview with V6 CNA on 6/1/22 at 2:20 PM stated, Yes, I have R1 today, I put him back to bed. Surveyor asked about the one floor mat observed beside R1's right side, V6 stated, I don't know, I was told by the nurse (V3) to make sure it was there. Surveyor asked why there was only one fall mat on one side of the bed and not the other side, V6 stated, I don't know why. Surveyor asked what would prevent R1 from injury if he fell on the other side of the bed without a mat, V6 stated, I guess you're right, but I was just told to put the mat on this side (pointing to R1's right). Surveyor asked if R1 was considered a fall risk, V6 stated, I guess so because of the fall mat. Surveyor asked what other interventions R1 was placed on to keep him safe from falls? V6 stated, I don't know. Surveyor asked if she received any in-service training to keep her residents safe from falls, V6 stated, I was not told anything about any of the residents except to get them up and answer call lights. On 06/01/2022 at 2:53 PM, Surveyor interviewed V8 (RN, Registered Nurse). Surveyor asked if he is familiar with R1, V8 stated, R1 is alert and oriented to himself, he requires one-person assist, and is on pureed diet. He is a fall risk due to his [CONDITION(S)]. R1 had fracture of the left hip, I readmitted him on 05/04/2022. I was also present at the time of the incident on 05/01/2022. V3 (RN) called me for help when R1 fell . I went to the room, V3 was already there, R1 was sitting on the floor. His head was leaning against the dresser. V3 checked his vital signs and assessed him. R1 had laceration on his head due to the fall, I didn't see any other injuries. We put him back into the bed with mechanical lift. V4 was assisting R1 that morning. Surveyor asked what fall precautions were utilized for R1, V8 stated, We are using quarter (length) bed rails to have him something to hold on to; keep bed in low position; frequent monitoring as often as hourly; we are also utilizing a fall mat on the right side of the bed; and orienting residents to use the call light. Surveyor clarified why only one mat was used on the right side of the bed, V8 indicated that he doesn't know why. Surveyor asked about the meaning of the leaf symbol outside R1's bed, V8 stated, I'm not aware of the leaf posted by the R1's room or what it means. Hospital emergency room record reads in part: admitted d 5/1/22 discharge date d 5/3/22. HPI (history of present illness): (R1) is an [AGE] year-old with medical history significant for [CONDITION(S)], hypersensitivity lung disease, hypertension, [CONDITION(S)] on blood thinners, history of [CONDITION(S)] . with mostly wheelchair bound living at a nursing home into hospital after having witnessed fall while being transferred to wheelchair. (R1) had impact on left side and was noted to have left subcapital fracture of the left femoral neck. Ortho was consulted and he was admitted for further management. Facility progress noted dated 05/04/2022 at 2:47 PM completed by V8 (RN) reads in part, R1 arrived on 05/03/2022 at 6:25 PM from the hospital. On continuous oxygen, two liters per minute. Resident readmitted with diagnosis of closed fracture of the left hip with routine healing. Facility policy dated 10/01/2012 titled Falls and Fall Risk-Managing policy reads in part, It is the policy of the community that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risk and causes to try to prevent the resident from falling and trying to minimize complications from falling. The staff, with the input of attending physician, will identify appropriate interventions to reduce the risk of fall. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling

Based on observation, interview, and record review, the facility failed to protect residents from abuse and neglect by not providing timely incontinence care and by staff speaking to residents in a demeaning manner. This failure applied to two (R1 and R2) out of three residents reviewed for abuse and resulted in R1 and R2 experiencing mental duress and humiliation after having to endure sitting in their own urine and feces for extended periods of time without toileting assistance from staff. Findings include: 1. R1 is an alert and oriented [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Care plan with goal date of 9/29/21 shows R1 requiring extensive assistance with toileting assist from 1-2 people. On 8/14/21 at 9:15 AM, R1 stated upon interview, I was given this handout form and it shows the Director of Nurses (V3) and Administrator (V2) and Resident Care Manager and also somebody called (V4-Assistant Director of Nurses). I have not heard word from any of them and they don't return phone calls. I spoke to the Administrator several months ago about the smell in the halls but recently I've been having problems with the nurses here coming to help me go to the bathroom. They just don't come. There is big problem here with them coming to help me to go to the bathroom or change my brief. When they Certified Nurse's Aid's (CNA) come, they act like they are doing me a favor. I have to use my toileting tickets sparingly because I don't want to run out of them otherwise, I will be sitting in my feces until the next shift comes along. Surveyor asked what toileting tickets were and who created these tickets, R1 stated, No I made that up because I literally have to ration the times, I pull this call light for help because they will not come as they tell me I use it too often. I had a nurse actually snap at me and say, You have to go again? I was afraid to ask for help after that and made me feel that I used my call light too much so I'm afraid that I will run out of toileting tickets but I can't help how my bowels are. It's humiliating to sit in your own feces and urine but that is what I have to do. (R1 was getting visibly emotional and upset). R1 said, Staff here do the least possible work and I have to suffer throughout this, this is not right. I have told every nurse who takes care of me and it just falls on deaf ears, that is why I tried contacting those other people on this list and then I called you (referring to public health). I shouldn't be treated this way, and neither should anyone else that has to live here. At 9:20 AM, R1 asked surveyor to wait to witness the response when she pulled the call light. The light lit up on the wall beside R1's bed and beeped outside another light outside of R1's door which was clearly visible and audible to anyone in the hall; 30 minutes passed, and no staff came to see what R1 needed. Surveyor left R1's room and approached V8 (RN) who was at the nurses station. V8 stated, I take care of this section (pointing to the opposite aisle R1 resided in). That is V9 (LPN) section (referring to the R1's hallway). She's (V9) somewhere around here. She said, Do you need anything? Surveyor asked the level of care the floor R1 was on, V8 stated, This is the skilled care floor. It's a lot of heavy care people, some confused, some not. At 9:55 AM, R1's call light was still beeping and with the light still on with no one observed going in to attend to R1. At 10:10 AM, surveyor observed R1's call light was off and asked R1 how she was doing. R1 stated, Someone finally came and changed me. But see what I mean. You're even here (referring to public health) and it takes them this long to come. Can you imagine the other shifts when you're not here? This is what I've been going through and no one listens to me. I can't take it anymore. I'm going to talk to my daughter to get me out of here. 2. R2 is an alert and oriented [AGE] year old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's most current care plan with goal date of 11/7/21 shows: Toileting, (R2) requires extensive assistance. R2 will have toileting needs met with the assistance of 2 people. On 8/14/21 at 9:55 AM, R2 was observed in bed flat on her back as V6 (Certified nurse's aide) was standing next to her and arguing with R2. V6 was overheard telling R2, You'll have to wait, I got a lot of other people to do! Surveyor entered the room and asked V6 if she said what the surveyor heard, V6 stated, I was just trying to tell her I got too much work and I still got to make this bed here (pointing to R2's roommate bed) and I got more that are waiting to be cleaned up. Surveyor asked whether they were short staffed, V6 stated, Yes, somebody called off, so I got to do more so I tell her that she has to wait. The other shift left a lot of stuff for us to do, they don't do anything (referring to the previous shift before her.) Surveyor asked whether R2 needed to be informed of the facility's staffing issues, V6 stated, I don't know. I just tell her, so she knows why she has to wait. It's too much! V6 then abruptly left the room without indicating whether she was going to assist R2 or not. R2 stated, She's something isn't she (referring to V6). Surveyor asked if she needed to be cleaned up (referring to her incontinence pad), R2 stated, Yes, I've been waiting long. Surveyor asked how long she was waiting, R2 put three fingers up to designate the length of time. Surveyor clarified whether she waited three hours, R2 nodded yes and stated in a slow soft voice, It happens all the time especially in the early morning. You see how she talks down to me like I'm a baby. I have to wait for the next shift until I get changed. It makes me very sad and depressed and also angry. I shouldn't be treated this way, no one should. V2 (Administrator) at 11:55 AM was informed of the concerns of abuse/neglect but did not comment on concerns brought forward except stating, I will look into it. Facility policy dated 1/26/2000 (revised 1/6/2017) titled Abuse and Neglect states in part but not limited to: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to: freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including community staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident. Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents within their hearing distance. Examples of verbal abuse include threats of harm and intimidation. Mental abuse includes humiliation, harassment, threats of punishment or deprivation. Neglect means the failure of the community (facility), its associates, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

Based on interview and record review, the facility failed to use two staff members to reposition one (R1) of three residents reviewed, who require extensive assistance for bed mobility in a total sample of three residents. This failure resulted in R1 sustaining a dislocation and fracture to her left shoulder and pain. Findings include: R1 was admitted to facility on 8/13/19, alert and oriented to person, place and time. [DIAGNOSES REDACTED]. R1's functional assessment dated [DATE] notes she requires extensive assistance with 2 staff for bed mobility and repositioning. On 10/1/19 at 2:05pm, R1 stated that on 9/7/19 around bedtime, I was sitting at the bottom of my bed. V3 (Certified Nursing Assistant, CNA) was going to help me scoot up to the top of the bed. I told her that I usually have 2 staff to help transfer and scoot me up in bed and that I was afraid to get hurt. V3 tilted the head of my bed down then grabbed me by my upper arms and pulled me up in bed. We heard a pop and I was in a lot of pain. V3 asked, What was that? I told her that I thought it was my bone and she said, that's it, I am not touching you anymore and left the room. I did not see her again after that. I waited for a little while to see if the pain would get better but it didn't. I explained to V8 (Registered Nurse, RN) what happened after that. The X-ray showed something and I went to the emergency room for further tests that showed a fracture and dislocation of my left shoulder. I have to wear a sling now and have less upper mobility. I was in a lot of pain. I take [MEDICATION NAME] (pain medication) but it doesn't work as well on me because I have been on that for a long time. On 10/1/19 at 2:25pm, V5 (CNA) stated that we usually use 2 people to boost her up in bed, even before the shoulder injury. She has a lot of pain in her shoulders and you should not grab her upper arms the pull or lift her. On 10/1/19 at 2:50pm, V8 (Registered Nurse, RN) stated that on 9/7/19, V3 told me that R1 had pain but did not describe what happened during the repositioning. I gave R1 [MEDICATION NAME] and it was not until later that night when the next CNA was doing rounds, came and told me what happened. I went and talked to R1 again about 10:30 pm and she told me that during the time she was being changed and moved on the bed this evening, V3 and R1 heard a snap and she was in pain. R1 was in pain and did not want to be touched then. I gave her [MEDICATION NAME] (pain medication) and informed V9 (Medical Doctor). I received an order for [REDACTED]. R1 has [MEDICAL CONDITION] arthritis and pain and we usually use 2 people to move her. V3 did not come and ask me for assistance with R1. On 10/1/19 at 3:30pm, V2 (Director of Nursing, DON) stated that we did an investigation and V3 stated that she put her arms around the resident, under her shoulders and pulled her up in bed by herself. This is not proper body mechanics and not the correct way to lift and reposition this resident. I placed a write up in V3's file for failing to follow safe lifting technique. On 10/1/19 at 3:00pm, V9 (Medical Doctor) stated that I was made aware that R1 was pulled up in bed by her arms and that is what caused the dislocation. On 10/2/19 at 12:30pm, V11 (Minimum Data Set, MDS) Coordinator stated that before R1's shoulder injury, she required extensive assistance with 2 staff members to turn and reposition in bed. On 10/2/19 at 1:12pm, V12 (Physical Therapy Assistant, PTA) stated that R1 has arthritis and deformities on her hands from that. Before her shoulder injury, R1 required extensive assistance from 2 staff members for scooting up in bed. Staff should never put their arms underneath resident's arms or around them to lift and scoot them up. It is not proper body mechanics and could hurt the resident. The safest way is to use 2 staff members and a draw or lift sheet or have them roll side to side. On 9/10/19, R1's X-ray of left shoulder showed dislocation of left total shoulder arthroplasty (shoulder replacement). On 9/10/19, R1's CT (Computed tomography) scan notes a nondisplaced fracture through the base of the coracoid process (part of scapula) and dislocation of the left total shoulder arthroplasty. V9 (Medical Doctor) progress note on 9/9/19 states R1 has pain in left shoulder. The night before last (9/7/19), R1 was being repositioned in bed when she heard a snap in the left shoulder. The shoulder swelled up and she can barely move shoulder due to pain. She missed her oncology appointment today. V9 progress notes on 9/10/19 done during hospital admission notes R1 has a dislocated prosthetic humeral head of left shoulder and a fracture of left coracoid process as well as traumatic bursitis of her left shoulder and R1 was admitted to the hospital for pain control. V8's (RN) progress note on 9/8/19 at 12:44 am notes that at the end of the shift on 9/7/19 around 10:30pm, R1 informed me that when V3 was repositioning or boosting her up in bed, she heard a snap on her left shoulder or arm and it had something to do with her bone. She felt so much pain and that is why she asked me for [MEDICATION NAME] pain medication. The pain pill gave little relief and R1 is afraid that if the pain continues she is sure that something happened and may need to go to the emergency room tomorrow. V8's pain assessment on 9/7/19 notes R1 is experiencing pain, a level 6 in her left shoulder, left elbow and arm and that it is painful when being touched or moved. R1 verbalized it is very painful and the pain can get worse at an 8 out of 10. V10 (RN)'s progress note on 9/8/19 at 7:20 am notes [MEDICATION NAME] given for left shoulder pain at 4:10 am. Pain level was 6/10. V10's progress note and pain assessment on 9/8/19 at 9:15 pm notes R1 verbalized pain on the left arm, left elbow and shoulder especially when doing care and being moved. Left arm observed to be swollen and [MEDICATION NAME] given with little relief. Pain rated 6/10. [MEDICATION NAME] Medication Administration 9/9/19-9/10/19, R1 received [MEDICATION NAME] at 8:50am, 4:10pm and 7:50am for pain levels ranging from 4 to 6 out of 10. On 9/9/19 at 9:29am, V6's (RN) note stated R1 requested to cancel oncology appointment today due to left shoulder pain. R1's MDS dated [DATE] notes R1 requires extensive assistance from 2 staff plus physical assistance with bed mobility.

Based on interview and record review, the facility failed to provide supervision while the resident was on the toilet and failed to follow care plan fall interventions for one of three residents (R1) reviewed for falls in a sample of three residents. This failure resulted in R1 sustaining fractures of the tibia and fibula leading up to hospitalization . Findings include: R1 is a [AGE] year old female admitted to the facility 9/20/2008. R1's face sheet [DIAGNOSES REDACTED]. On 4/6/17 at 10:15am in 2nd floor common area accompanied by E7 (RN-Registered Nurse), R1 was in wheelchair with both legs on the footrests, lower right leg in a cast. E7 stated, The resident is wearing a leg cast for an ankle fracture from a fall. She ambulates in wheel chair and is a 1-2 person assist. R1 is alert and oriented to self only and is hard of hearing. R1's MDS (Minimum Data Set) dated 2/1/17 indicates the following: BIMS (Brief Interview for Mental Status) - 99 (the resident was unable to complete the interview); Transfer 3/3 (Extensive Assistance/Two persons assist), Toilet use 3/2 (Extensive Assist/one person assist), Mobility Device (Wheelchair). R1's fall risk screening tool dated 2/3/17 indicates a total score of 16 (Total score of 10 or above represents high risk). R1's care plan for fall intervention dated 2/20/17 denotes, in part: Remind all staff, resident is total supervision with toileting instructions were provided at the start of the shift and as needed. R1's initial fall incident report to the state agency dated 3/14/17 denotes, in part: On 3/13/2017 around 7:15pm, after dinner assigned CNA (certified Nursing Aide) toileted the resident, after few minutes resident was noted sitting in the bathroom floor facing the toilet Resident was sent to ER (emergency room ) for evaluation and treatment and admitted for right tibia fracture Resident's last fall incident was on 7/6/2014. R1's final incident report to the state agency dated 3/17/17 denotes, in part: Investigation revealed that CNA observed another resident who needed assistance immediately while with this resident. CNA stepped out to assist this other resident and asked the resident to wait for her return, CNA returned within a minute or two and observed the resident on the floor. Resident continues to be at the hospital R1's hospital record dated 3/17/17 indicates R1 was admitted on [DATE], discharged on [DATE]. Diagnosis: [REDACTED]. R1's X ray report dated on 3/15/17 documents, in part: Right ankle pain, status [REDACTED]. There is an acute fracture through the proximal shaft of the fibula. There is some cortical irregularity involving the proximal shaft of the tibia below the tibial plateau adjacent to the proximal portion of the intramedullary nail and a non-displaced fracture in this region is not excluded R1's hospital discharge instruction dated 3/17/17 denotes, in part: No weight bearing right leg. Plan to keep cast to right leg for 1 month. Follow up with specialty in Orthopedic Surgery in 1 month On 4/5/16 at 12:15pm, E2 (Assistant Director of Nursing) stated: When a fall occurs, the nurse gathers reports and starts the investigation, the repots go to me and I talk to the witness and the residents. I feel like the CNA should not have left the resident on the toilet by herself because of the resident's low safety awareness and confusion. One-on-one education was given to the CNA after the incident On 4/6/17 at 1:05pm, E3 (DON - Director of Nursing) stated, Because most of the residents on the 2nd floor are high fall risk with a risk score of 10 or more, it is important that fall interventions are in place for the high fall risks because of the residents' confusion, low safety awareness and impulsivity. Fall intervention is in the residents care plan and is updated quarterly and after significant changes, staff should review care plans to ensure the fall interventions are followed Facility's policy entitled: Falls -Clinical Protocol documents, in part, the staff and physician will identify pertinent interventions to try to prevent subsequent falls The staff and physician will monitor and document the response to the interventions intended to reduce falling or the consequence of falling