Every finding on record at Alden Debes Rehab & HCC

Based on interview and record review the facility failed to administer the facility by failing to ensure a qualified individual was hired as the social service director. This has the potential to affect all 182 residents in the facility.Findings include:On 7/24/26 at 9:12 AM, V1 Administrator stated the requirement for the social services director was to have a minimum of a bachelor's degree and 1 year of experience in social services. V1 stated V4 Social Service Director - SSD is in school for her bachelor's degree; it is not completed. V1 stated the facility has an average daily census between 175-180 residents. V1 stated she does the hiring and hired V4 in collaboration with their consultant.On 7/24/26 at 9:37 AM, V1 Administrator stated she had a behavioral health director that helps with social services at times, has a degree but was not the social service director.The facility's Social Service Director - SSD Job Description (10/2022) showed, job summary - responsible for performing assigned social work duties and responsibilities within the facility. Plan, develop, organize, oversee and run the overall operation of the Social Service Department in accordance with current corporation policies and procedures, federal, state and local standards, guidelines and regulations. Qualifications: High school diploma or general education diploma. Current knowledge of Federal and State Long-Term Care (LTC) Social Service Regulations and/or the ability to understand and interpret. Review of the facility's policy did not show it was in line with current regulatory requirements for the position.The Facility Assessment Tool dated 7/13/26 showed the facility resources needed to provide competent support and care for their resident population every day and during emergencies included a Social Service Director. The staffing plan showed based on their resident population and their needs for care and support, their general approach to staffing to ensure they meet the needs of the resident at any given time including one social service director, one social service designee, and one behavioral health director.The Facility Data Sheet dated 7/24/26 for the facility showed a census of 182 residents.

Based on interview and record review the facility failed to have a qualified full time social service director. This has the potential to affect all 182 residents in the facility.Findings include:On 7/24/26 at 8:34 AM, V4 Social Services Director - SSD stated she has been at the facility for two weeks in this position. V4 stated she was in her first year of her bachelor's degree program. V4 stated she has had 1 year and three months of experience as a social service designee in the past at this facility, moved away, and is back as the SSD. V4 confirmed she does not have any other bachelor's degree in a related field.On 7/24/26 at 9:12 AM, V1 Administrator stated the requirement for the social services director was to have a minimum of a bachelor's degree and 1 year of experience in social services. V1 stated V4 Social Service Director - SSD is in school for her bachelor's degree; it is not completed. V1 stated the facility has an average daily census between 175-180 residents.The facility's Social Service Director - SSD Job Description (10/2022) showed, job summary - responsible for performing assigned social work duties and responsibilities within the facility. Plan, develop, organize, oversee and run the overall operation of the Social Service Department in accordance with current corporation policies and procedures, federal, state and local standards, guidelines and regulations. Qualifications: High school diploma or general education diploma. Current knowledge of Federal and State Long-Term Care (LTC) Social Service Regulations and/or the ability to understand and interpret. Review of the facility's policy did not show it was in line with current regulatory requirements for the position.The Facility Data Sheet dated 7/24/26 for the facility showed a census of 182 residents.

Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 20 of 23 residents (R1-R20) reviewed for medication errors in the sample of 23. This failure resulted in R1 and R2 experiencing insomnia. This failure resulted in R1 experiencing increased pain and discomfort.The findings include:1.R1's current care plan showed R1 received medications for treatment of insomnia, Type 2 Diabetes, neuropathy (nerve pain), and restless leg syndrome. The plan showed facility nursing staff were to administer medications as ordered for treatment of these conditions. The care plan showed R1 was cognitively intact.R1's March 2026 Medication Administration Record (MAR) showed the following physician orders for R1:Lantus Insulin 100 units/milliliters (ml), inject 25 units subcutaneously (SQ) daily at 8:00 PM for treatment of Type 2 Diabetes.Melatonin 3 mg (milligrams), give one tablet daily at 8:00 PM for insomnia.Pregabalin 100 mg, give one tablet daily at 8:00 PM for pain management.R1's MAR showed R1 did not receive these medications on 3/28/26.On 4/8/26 at 8:30 AM, R1 stated, One evening a couple of weeks ago, I didn't get my meds. Our nurse never showed up. I didn't get my insulin. My blood sugar was a little higher the next morning but not awful. It was hard to sleep because I get meds for pain and sleep. In fact, that was one of the nights I didn't sleep at all. I couldn't get comfortable. I had pain in my legs from my neuropathy. 2.R2's current care plan showed R2 received medications for treatment of depression and insomnia. The plan showed facility nursing staff were to administer medications as ordered for treatment of these conditions. R2's March 2026 MAR showed the following physician orders for R2:Trazadone 50 mg, give one tablet daily at 8:00 PM for depression.Melatonin 3 mg, give two tablets daily at 8:00 PM for depression and insomnia.R2's MAR showed R2 did not receive these medications on 3/28/26.On 4/8/26 at 8:30 AM, R2 stated she did not receive her evening medications on 3/28/26 because her nurse did not show up for her shift. R2 stated, I didn't sleep well that night. I kept waking up. I was tired the next day.3.R3's current care plan showed R3 received medications for treatment of hyperlipidemia, insomnia, and pain. The plan showed facility nursing staff were to administer medications as ordered for treatment of these conditions. R3 was cognitively intact.R3's March 2026 MAR showed the following physician orders for R3:Nabumetone 750 mg, give one tablet twice a day, at 8 AM and 8 PM, for joint pain.Entresto 24-26 mg, give one tablet twice a day, at 8 AM and 8 PM, for hyperlipidemia.Trazadone 50 mg, give one tablet daily at 8:00 PM for sleep disturbances.Atorvastatin 20 mg, give one tablet daily at 8:00 PM for hyperlipidemia.R3's MAR showed R3 did not receive her 8:00 PM medications on 3/28/26.On 4/8/26 at 8:15 AM, R3 stated on 3/28/26, I never got my evening meds that night. We didn't have a nurse. My pain wasn't too awful that night.4.R4's current care plan showed R4 had diagnoses including epilepsy, hypertension, depression, and glaucoma. R4's March 2026 MAR showed the following physician orders for R4:Vimpat 100 mg, give one table twice a day, at 8 AM and 8 PM, for treatment of epilepsy.Metoprolol Tartrate 25 mg, give one table twice a day, at 8 AM and 8 PM, for hypertension.Mirtazapine 7.5 mg, give one tablet daily at 8:00 PM for depression.Trazadone 50 mg, give 1/2 tablet daily at 8:00 PM for depression.Latanoprost eye drops 0.0005%, install one drop to both eyes daily at 8:00 PM for glaucoma.R4's MAR showed R4 did not receive her 8:00 PM medications on 3/28/26.On 4/8/26 at 8:20 AM, R4 stated, on 3/28/26, I didn't get my evening meds at all that night.A facility list dated 3/28/26 showed R5-R20 also did not receive their 8:00 PM medications on 3/28/26.On 4/8/26 at 11:20 AM, V2 Director of Nursing stated R1-R20 did not receive their 8:00 PM medications on 3/28/26 because the nurse assigned to their wing from 6 PM-10PM never showed up. V2 stated she was not notified that the nurse did not show up for her shift until 3/29/26. V2 stated each resident in the facility must be assigned to a nurse 24 hours a day, 7 days a week to provide skilled nursing to these residents.On 4/8/26 at 1:30 PM, V1 Administrator stated R1-R20 did not receive their medications on 3/28/26 because the nurse assigned their wing did not show up. V1 stated she was not notified of the incident until 3/29/26. On 4/8/26 at 10:40 AM, V8 Nurse Practitioner stated the expectation is that each resident is under the care of a nurse 24/7 while residing in the facility and resident medications are administered as ordered. V8 stated if residents do not receive pain medications and medications for sleep as ordered, it could potentially cause increased pain and insomnia for residents. V8 stated, (R4) takes Vimpat for seizures so missing a dose could potentially put her at increased risk for seizures.The facility's Medication Pass Guidelines policy dated January 2025 showed resident medications are to be administered at the correct time, as prescribed by physician order, by a licensed nurse. The Facility Assessment Tool dated 4/8/26 showed the facility is to provide skilled nursing care to each resident which includes the provision of care and the administration of medications by a licensed nurse, 24 hours a day, 7 days a week.

Based on interview and record review the facility failed to provide sufficient staff to meet the needs of the residents for 20 of 23 residents (R1-R20) reviewed for staffing in the sample of 23. This failure resulted in R1-R20 not receiving their scheduled evening medications on 3/28/26 due to a lack of a licensed nurse to administer the medications.The findings include:1.R1's March 2026 Medication Administration Record (MAR) showed R1 did not receive her prescribed medication doses of Lantus insulin, Melatonin, and Pregabalin on 3/28/26 at 8:00 PM. On 4/8/26 at 8:30 AM, R1 stated, One evening a couple of weeks ago, I didn't get my meds. Our nurse never showed up.2. R2's March 2026 MAR showed R2 did not receive her prescribed doses of Melatonin and Trazadone on 3/28/26 at 8:00 PM.On 4/8/26 at 8:30 AM, R2 stated she did not receive her evening medications on 3/28/26 because her nurse did not show up for her shift.3. R3's March 2026 MAR showed R3 did not receive her prescribed doses of Nabumetone, Entresto, Trazadone, and Atorvastatin on 3/28/26 at 8:00 PM. On 4/8/26 at 8:15 AM, R3 stated on 3/28/26, I never got my evening meds that night. We didn't have a nurse.4. R4's March 2026 MAR showed R4 did not receive her prescribed doses of Vimpat, Metorprolol Tartrate, Mirtazapine, Trazadone, and Latanoprost eye drops on 3/28/26 at 8:00 PM.On 4/8/26 at 8:20 AM, R4 stated, on 3/28/26, I didn't get my evening meds at all that night.A facility list dated 3/28/26 showed R5-R20 also did not receive their 8:00 PM medications on 3/28/26.On 4/8/26 at 11:20 AM, V2 Director of Nursing stated R1-R20 did not receive their 8:00 PM medications on 3/28/26 because the nurse assigned to their wing from 6 PM-10PM never showed up. The nurse was supposed to be here at 6 PM so I called the nursing agency to find out where the nurse was. The agency told me the nurse was running late but would be at the facility in 12 minutes. She never showed up. Someone from the facility should have notified me immediately. V2 stated she was not notified that the agency nurse did not show up for her shift until 3/29/26. V2 stated each resident in the facility must be assigned to a nurse 24 hours a day, 7 days a week to provide skilled nursing to these residents.On 4/8/26 at 1:30 PM, V1 Administrator stated R1-R20 did not receive their medications on 3/28/26 because the nurse assigned their wing did not show up. V1 stated she was not notified of the incident until 3/29/26. On 4/8/26 at 3:05 PM, V12 Certified Nursing Assistant (CNA) stated she was assigned to R1-R20's wing on 3/28/26. V12 stated, Someone told me around 6 PM that evening that the nurse assigned to my wing was running late. I got busy providing cares to residents. Around 7:30 PM, some of the residents started asking where the nurse was. I just assumed the nurse was still running late. By 9:30 PM, no nurse had shown up. When V12 was asked who she notified, on 3/28/26, that no nurse had shown up to provide cares to these residents, V12 stated, No one. I didn't know who to call. On 4/8/26 at 3:15 PM, V13 CNA stated she was assigned to R1-R20's wing on 3/28/26. V13 stated she did not notice until around 8:00 PM on 3/28/26 that her wing did not have a nurse. V13 stated she did not notify any facility staff or administration that her wing did not have a nurse on 3/28/26 because I just figured everyone else knew about it.On 4/8/26 at 10:55 AM, V10 Licensed Practical Nurse stated on 3/28/26 from 6 PM-10 PM, he was assigned to a different wing in the facility. V10 stated, I didn't know the nurse didn't show up to work (R1-R20's wing) until 10 PM that night. No one reported to me that no nurse was covering that unit. I don't know what happened but when I walked over to (R1-R20's wing) at 10 PM that night, the med cart for that wing had not been touched and was in the same place I saw it at 6 PM. V10 stated he did not notify any facility staff or administration that R1-R20's wing did not have a nurse on 3/28/26.On 4/8/26 at 10:40 AM, V8 Nurse Practitioner stated the expectation is that each resident is under the care of a nurse 24/7 while residing in the facility and resident medications are administered as ordered.The Facility Assessment Tool dated 4/8/26 showed the facility is to provide skilled nursing care to each resident which includes the provision of care and the administration of medications by a licensed nurse, 24 hours a day, 7 days a week.

Based on observation, interview and record review, the facility failed to ensure a resident's medications were secure and not left unattended for 1 of 2 residents (R1) observed for medication administration in the sample of 14.The findings include: On 3/3/26 at 9:10 AM, V5 (Registered Nurse-RN) entered R1's room to check her blood sugar levels and administer R1's insulin. V5 had just prepared the morning medications for R1 prior to entering R1's room. The only medication V5 carried into R1's room at 9:10 AM was R1's insulin. R1's other 19 medications were sitting on top of the medication cart in several different cups. The medication cart was pushed up against the wall past R1's doorway and was not in V5's line of vision. The medications left on top of the medication were the following: Flonase nasal spray, Clonidine hydrochloride (HCl) 0.1 mg (milligram) tablet, Buspirone (HCl) 10 mg tablet, Amlodipine 10 mg tablet, ferrous gluconate 324 mg tablet, Pro T gold (liquid protein for wound healing) 30 ml (milliliters), Glipizide 5 mg tablet, Gabapentin 100 mg capsule, Losartan potassium 50 mg tablet, Lorazepam 0.5 mg tablet, Metformin HCl 1000 mg tablet, Metoprolol Tartrate 100 mg tablet, Oxybutynin Chloride ER 5 mg tablet, Terazosin HCl 2 mg capsule, Sertraline HCl 100 mg tablet, Senna-docusate sodium 8.6-50 mg tablet, Pantoprazole DR 40 mg tablet, Miralax 17 gm (gram) pkt in 120 ml water, and Milk of magnesia 30 ml. V4 ((Licensed Practical Nurse/Infection Preventionist) was coming back up the hall putting supplies in the isolation carts. V4 was asked if it was okay to leave medications on the medication cart when the nurse goes in the room. V4 said it is not acceptable to leave medications on top of the medication cart unattended. On 3/3/26 at 4:15 PM, V4 said since V5 had already prepared R1's medications, she should have put all the medications in the locked medication cart so other residents could not access them or grab them. The facility's 05/2025 policy and procedure titled Storage/Labeling/Packaging of Medications showed resident specific medications are placed in a locked cabinet or cart that is affixed to a wall, in close proximity to a nursing station, or in a locked, well-illiuminated room accessible only to licensed nursing personnel, licensed pharmacy personnel, or staff members lawfully authorized to administer medications.Schedule II controlled medications are stored under a double-lock system accessible only to licensed staff.

Based on observation, interview and record review, the facility failed to ensure staff donned the required personal protection equipment (PPE) when entering a room in which a resident is on contact isolation for 1 of 4 residents (R1) reviewed for infection control in the sample of 14.The findings include:R1's admission Record, provided by the facility on 3/3/26, showed she had diagnoses including, but not limited to, methicillin resistant staphylococcus aureus infection (MRSA-a multidrug-resistant organism), local infection of the skin and subcutaneous tissue, disruption of external surgical wound (chronic kidney disease, stage 3A, chronic pain syndrome, major depressive disorder, generalized anxiety disorder, extracorporeal dialysis catheter, a colostomy, anemia, bilateral osteoarthritis of hip, lower abdominal pain, type II diabetes mellitus, and fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing. R1's skin integrity care plan, provided by the facility on 3/3/26, showed she had an actual alteration in skin integrity: multiple open surgical wounds to abdomen, two surgical wounds to her right lower extremity, and a hematoma to her right lower extremity. The care plans showed R1 has an indwelling urinary catheter, a colostomy, is at increased risk for infection due to indwelling urinary catheter, chronic wounds, is receiving antibiotic therapy with single room isolation contact precautions for treatment of wound infection MRSA. Interventions include for staff to use principles of infection control and universal/standard precautions. Post appropriate isolation outside of the room for staff and visitors. R1's Order Summary Report, provided by the facility on 3/3/26, showed an order for Contact isolation Precautions due to MRSA in wound. On 3/3/26 at 9:10 AM, during the medication administration observation, V5 (Registered Nurse-RN) entered R1's room to check her blood sugar level and administer R1's insulin. Signage outside R1's room showed she was on contact isolation. The sign showed STOP. Contact Precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. V5 entered R1's room wearing only gloves. While checking R1's blood sugar level and giving R1 her insulin injection, V5's sweater was observed touching R1's bedding. V4 (Licensed Practical Nurse-LPN/Infection Preventionist/IP) was coming back up the hall filling the bins that contained the isolation supplies. V4 said V5 should have a gown and gloves on when she is in a contact isolation room to prevent the spread of infection. When V5 was exiting R1's room, V4 told V5 to make sure she was wearing the proper PPE when she went into the room. As V4 was walking away, V5 said in a low voice, Well I did not touch her, so. V5 grabbed the rest of R1's medications that were sitting on top of the medication cart and entered R1's room wearing only gloves. While V5 was administering R1's nasal spray her sweater was again touching R1's bedding. On 3/3/26 at 11:30 AM, V14 (Certified Nursing Assistant/CNA) entered R1's room without wearing any PPE. V14 touched R1's bedside table and the bed rail on the side of R1's bed with her hands while talking with R1. This surveyor performed hand hygiene and donned PPE. R1 gave permission for surveyor to enter. R1 said the staff do not always wear a gown and gloves when they come into her room. R1 said I have an infection in the wound on my stomach, and I am getting an antibiotic for the infection. On 3/3/26 at 4:15 PM, V4 (IP nurse) said V5 should perform hand hygiene, and put a gown and gloves on before going into R1's room. V4 said V5 only had gloves on. V4 confirmed she saw V5's sweater touching R1's bedding. V4 said R1 is on contact isolation for MRSA of her abdominal wound. It is important to wear the appropriate PPE to prevent the spread of infection.The facility's 08/2025 policy and procedure titled Contact Precautions showed the purpose of contact precautions is to prevent transmission of infections that are spread by direct (e.g. person-to-person) or indirect contact with the resident or environment. The policy showed Hand hygiene using alcohol-based hand rub (if hands are not visibly soiled) is performed prior to entering and exiting the resident's room. All individuals entering the resident's room must use PPE appropriately, including gloves and a gown. Donning PPE upon room entry and doffing before exiting the resident's room is done to contain pathogens.

Based on observation, interview, and record review, the facility failed to administer medications at the ordered time. There were 25 opportunities with 20 errors resulting in an 80% medication error rate. This failure affects 1 of 2 residents (R1) observed during medication pass. The findings include:On 3/3/26 between 8:44 AM and 9:18 AM, a medication administration observation was observed. At 9:10 AM, V5 (Registered Nurse-RN) went into R1's room to check her blood sugar level and administer her long-acting insulin. V5 came out to the hallway and grabbed the other 19 medications she had prepared for R1 and re-entered her room. V5 placed the medications on R1's bedside table, then administered R1's Flonase at 9:12 AM. V5 left the rest of R1's medications on the bedside table and exited the room. R1's medications listed in the electronic medication administration record were highlighted in pink/red color indicating they were overdue. V5 marked the medications as being administered and moved the cart further down the hall. R1's medications that were administered late were: : Flonase nasal spray, Clonidine hydrochloride (HCl) 0.1 mg (milligram) tablet, Buspirone (HCl) 10 mg tablet, Amlodipine 10 mg tablet, ferrous gluconate 324 mg tablet, Pro T gold (liquid protein for wound healing) 30 ml (milliliters), Glipizide 5 mg tablet, Gabapentin 100 mg capsule, Losartan potassium 50 mg tablet, Lorazepam 0.5 mg tablet, Metformin HCl 1000 mg tablet, Metoprolol Tartrate 100 mg tablet, Oxybutynin Chloride ER 5 mg tablet, Terazosin HCl 2 mg capsule, Sertraline HCl 100 mg tablet, Senna-docusate sodium 8.6-50 mg tablet, Pantoprazole DR 40 mg tablet, Miralax 17 gm (gram) pkt in 120 ml water, and Milk of magnesia 30 ml.R1's March 2026 Medication Administration Record (MAR), provided by the facility on 3/3/26, showed orders for: Lantus Solostar subcutaneous solution pen-injector 100 unit/ml. Inject 14 units a day, scheduled at 8:00 AMFlonase nasal spray 1 spray in both nostrils daily. Clonidine hydrochloride (HCl) 0.1 mg (milligram) tablet, 1 tablet twice daily, scheduled for 8:00 AM and 8:00 PM.Buspirone (HCl) 10 mg 1 tablet daily scheduled at 8:00 AMAmlodipine 10 mg 1 tablet daily, scheduled for 8:00 AM.ferrous gluconate 324 mg tablet, 1 tablet daily, scheduled for 8:00 AMPro T gold (liquid protein for wound healing) 30 ml (milliliters), twice daily, scheduled 8:00 AM and 8:00 PM.Glipizide 5 mg tablet, 1 tablet twice daily, scheduled for 8:00 AM and 8:00 PM.Gabapentin 100 mg capsule, 1 tablet daily, scheduled for 8:00 AMLosartan potassium 50 mg tablet, 1 tablet daily, scheduled for 8:00 AMLorazepam 0.5 mg tablet, one every AM and at HS, scheduled for 8:00 AM and 8:00 PM. Metformin HCl 1000 mg tablet, 1 tablet daily, scheduled for 8:00 AMMetoprolol Tartrate 100 mg tablet, 1 tablet twice daily, scheduled for 8:00 AM and 8:00 PMOxybutynin Chloride ER 5 mg tablet, 1 tablet daily, scheduled for 8:00 AMTerazosin HCl 2 mg capsule, 1 daily, scheduled for 8:00 AMSertraline HCl 100 mg tablet, 1 tablet twice daily, scheduled at 8:00 AM and 8:00 PMSenna-docusate sodium 8.6-50 mg tablet, 1 tablet twice daily, scheduled at 8:00 AM and 8:00 PM.Pantoprazole DR 40 mg tablet, 1 tablet daily, scheduled for 8:00 AMPolyethylene glycol powder 17 gm (gram) daily, Milk of magnesia 30 ml twice daily, scheduled for 8:00 AM and 8:00 PM. On 3/3/26 at 4:15 PM, V4 (Licensed Practical Nurse/Infection Preventionist) said medications should be administered 1 hour before or 1 hour after the ordered time. if it is an 8:00 AM medication, the nurse has until 9:00 AM to give it. When the medications light up red, they are overdue. medications should be given on time. If a resident's medication is given twice a day, and it is given late, then the next time it is due it would not be spaced out like ordered. It could affect the therapeutic level of medication.The facility's policy and procedure titled Medication Administration showed medications will be administered in accordance with the established policies and procedures. 1.Drugs must be administered in accordance with the written orders of the attending physician. 2. not specifically limited as to the time or number of doses when ordered are controlled by the automatic stop orders.

Based on observation, interview and record review, the facility failed to ensure a resident was supervised while taking medications for 1 of 2 residents (R1) reviewed for medication administration in the sample of 14. The findings include:R1's 2/13/26 facility assessment showed she is cognitively intact, has range of motion limitations to her bilateral upper and lower extremities. The assessment showed R1 is dependent on staff for all other activities of daily living. R1's admission Record, provided by the facility on 3/3/26, showed she had diagnoses including, but not limited to, methicillin resistant staphylococcus aureus infection (MRSA-a multidrug-resistant organism), local infection of the skin and subcutaneous tissue, disruption of external surgical wound (chronic kidney disease, stage 3A, chronic pain syndrome, major depressive disorder, generalized anxiety disorder, extracorporeal dialysis catheter, a colostomy, anemia, bilateral osteoarthritis of hip, lower abdominal pain, type II diabetes mellitus, and fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing. On 3/3/26 at 9:10 AM, V5 (Registered Nurse-RN) administered R1's insulin injection. At 9:12 AM, V5 (RN) entered R1's room again to give her morning medications. V5 placed the medications on R1's bedside table, administered R1's nasal spray, then exited R1's room. The rest of R1's AM medications were in cups on R1's bedside table. V5 did not supervise R1 taking the following 18 medications: Clonidine hydrochloride (HCl) 0.1 mg (milligram) tablet, Buspirone (HCl) 10 mg tablet, Amlodipine 10 mg tablet, ferrous gluconate 324 mg tablet, Pro T gold (liquid protein for wound healing) 30 ml (milliliters), Glipizide 5 mg tablet, Gabapentin 100 mg capsule, Losartan potassium 50 mg tablet, Lorazepam 0.5 mg tablet, Metformin HCl 1000 mg tablet, Metoprolol Tartrate 100 mg tablet, Oxybutynin Chloride ER 5 mg tablet, Terazosin HCl 2 mg capsule, Sertraline HCl 100 mg tablet, Senna-docusate sodium 8.6-50 mg tablet, Pantoprazole DR 40 mg tablet, Miralax 17 gm (gram) pkt in 120 ml water, and Milk of magnesia 30 ml. V5 marked the medications as administered, then moved the medication cart further down the hall. On 3/3/26 at 11:30 AM, R1 was asked about the nurse leaving her medications on her bedside table and not watching her take them. R1 said most of the nurses leave the pills on her bedside table and do not watch her take them. R1 said she does not like that because she has dropped pills before. R1 said some will leave it on the table while she is sleeping and she has bumped the table and the pills spill. R1 said she is clumsy sometimes and drops a pill.R1's Order Summary Report, provided by the facility on 3/3/26 did not show an order for R1 to be able to self-administer her medications. On 3/3/26 at 2:14 PM, V2 (Assistant Administrator) was asked to review R1's orders to verify that she did not have an order to self-administer medications. V2 reviewed R1's orders and said she did not see an order for R1 to self-administer medications.On 3/3/26 at 4:15 PM, V4 (Licensed Practical Nurse/Infection Preventionist) said if a resident is able to self-administer medications, it would be in their physician's orders. V4 said she was not aware of any residents with orders to self-administer medications other than maybe some residents with inhalers or eye drops. V4 said it is very rare. The facility's 08/2023 policy and procedure titled Self-Administration of Medications showed Residents may be allowed to self-administer medication according to physician's order unless such practice for the resident is deemed unsafe.when a resident has an MD (doctor's) order and can safely self-administer, the following conditions will apply: A. The manner of storage will prevent access by other residents. B. Drugs will not be kept after the expiration date on the label. C. Drugs will be kept in original containers unless medication boxes are set-up. D. Inquiries concerning self-administration of drugs should be referred to the nurse or wellness director. E. The resident and/or family is responsible for providing the medications.

Based on observation, interview and record review, the facility failed to ensure a resident received assistance with showers. This applies to 1 of 3 (R2) residents reviewed for activities of daily living in the sample of 4. The findings include: On 2/4/26 at 12:05 PM, R2 was in her room sitting in a chair. There was no contact isolation sign posted outside of her room. R2's hair covering was in place, and she did not have a shower stall in her bathroom. R2 said when she was admitted on [DATE], she was on isolation for a blood infection. She was asking staff if she could shower, staff told her she could not leave the room because she was in isolation. R2 said yesterday 2/3/26, she got off isolation and finally got a shower (11 days later). R2 said she smelled bad and that was the worst not being able to shower that long.On 2/5/26 at 9:08 AM, V11 (Certified Nursing Assistant-CNA) said residents should receive showers twice a week. If a resident is in contact isolation, they can leave their room to shower. On 2/5/26 at 11:24 AM, V9 (CNA) said R2 was in isolation for a while she did not assist R2 with showering and certain residents could leave their room to shower. On 2/5/26 at 11:48 AM, V7 (RN) confirmed R2's contact isolation was discontinued on 2/3/26 and she received a shower. R2 mentioned she had not received a shower prior. R2's current care plan shows she has a deficit (ADL) performance deficit with interventions including assisting with setting up supplies for bathing, assist with personal hygiene, assist with ADL tasks. R2's care plan shows she was on contact isolation precautions. R2's Bath/Shower Report provided on 2/5/26 shows she did not receive showers twice a week. The facilities Bath/Tub or Shower policy dated 7/25 states, To provide cleanliness and comfort to the resident, to assist in bathing . to prevent body odors.

Based on observation, interview and record review the facility failed to ensure safety interventions were in place for a resident at risk for falls. This applies to 1 of 3 (R2) reviewed for safety in the sample of 4. The findings include: R1's face sheet shows she has diagnoses including osteomyelitis, palliative care, type 2 diabetes, heart disease, chronic kidney disease stage 3, hypertension, mild cognitive impairment, and lymphedema. R1's Fall Incident Report dated 2/1/26 documents (R1) observed on the floor on the right side of her bed lying on he left side. CNA at bedside stated she got weak and let go. Right side of forehead lump with swelling, right eye bruising, chin abrasion, right elbow small cut, right ring finger bruise and small cut and left knee bruising. R1's current care plan shows she is at risk for falls, self care deficit performance, requires assistance from staff with bed mobility, interventions include use side rail support, cue resident to grasp side rail for positioning.On 2/4/26 at 12:58 PM, R1 was lying in large bariatric bed, her eyes closed and did not respond to her name after several attempts. A large dark purple/greenish bruise was to the right side of her eye/forehead area and a small laceration to her chin. R1's bedside table was located to the right side of her bed and thick bilateral floor mats on the floor. On 2/4/26 at 1:02 PM, V14 (Certified Nursing Assistant-CNA) said R1 fell from her bed during care. R1 was a one person assist with bed mobility now she is a two person assist. She did not have side rails in place prior to the fall, she can hold on to the side rails for bed mobility and should have both floor mats on the floor. On 2/4/26 at 1:12 PM, V5 (Licensed Practical Nurse-LPN) said she was R1's nurse when she fell on 2/1/26. V10 (CNA) reported R1 fell when she was changing her in the bed. R1 fell towards the right side of her bed where the bedside table was located. I'm guessing she hit her head on the bedside table. The floor mats were not on the floor when she entered the room. R1 sustained a right black eye, scrap to her chin, and bruising to her left knee. V5 said she notified, the physician, hospice and left a message for R1's guardian. R1 did not have side rails in place prior to the fall, they just put them up after the fall. R1 can hold on to the side rails with bed mobility. On 2/5/26 at 8:53 AM, V10 (CNA) said on 2/1/26, she was providing incontinence care to R1. She rolled R1 to her side and she was holding on the bedside table because she did not have side rails in place. V5 said one hand was on R1's body and with the other hand she leaned back trying to get the towel and she left go of the bedside table and rolled off the bed. R1 usually is able to hold on the bedside table but she said she got weak and let go. V10 said she put the floor mats up during cares and R1 needs something to hold for bed mobility.R1's Restorative Nursing assessment dated [DATE] shows R1 is on a bed mobility program. R1 will role side to side during care and repositioning, using side rails as needed . the use of side rails is indicated and serves as an enabler to promote independence. On 2/5/26 at 9:58 AM, V6 (Restorative Nurse) said confirmed R1 is on a bed mobility program and should have side rails for bed mobility. V6 said if side rails are indicated for bed mobility he would in the request order for the side rails. I don't know why side R1 did not have the side rails on. He is not sure who is responsible for making sure side rails are in place. R1's strength levels vary day to day, if she is weak she should have something to hold onto. V6 said it's okay for residents to hold on to the equipment including bed side table, windowsill for extra piece of mind. The facility's Management of Falls Policy states, The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate interventions and revise the resident's plan in order to minimize the risks for fall incidents and/or injuries to the resident.

Based on interview and record review the facility failed to ensure a physician or nurse practitioner were notified promptly of radiology results. This applies to 1 of 8 residents (R1) reviewed for mechanical lift transfers in the sample of 8. The findings include: R1's Radiology Results Report shows that R1's x-ray was performed on 1/5/26 at 6:37 PM. This report also shows the results were reported to the facility on 1/6/26 at 1:43 AM and that V11 (Nurse Practitioner) reviewed the results on 1/6/26 at 4:59 PM. Facility nursing schedule for 1/5/26 and 1/6/26 shows that V4 (RN) and V12 (LPN) were the two nurses to work on R1's hall when the x-rays were ordered and the results received by the facility. On 1/15/26 at 9:46 AM, V12 said V12 checked R1's electronic medical records for any updated x-ray results around 3:30 AM on 1/6/26, but all V12 could see was the results were pending. V12 said nurses are instructed to check for any results at the end of each shift or close to the end of each shift. V12 did not check again for updated x-ray results the rest of V12's shift. V12 said if V12 saw the results came in, V12 would reach out to V11 either by phone call or by sending V11 a text message. V12 said when you get the results, V11 should be notified immediately. On 1/15/26 at 1:45 PM, V4 said V4 could not recall when V4 and V11 spoke about R1's x-ray results, but believed it was in the evening on 1/6/26. V4 said it should be in a progress note. R1's Nurses Note dated 1/6/26 at 5:30 PM, written by V4, states the results were relayed to V11. V11 ordered to send R1 to the local hospital for further evaluation and treatment. On 1/15/26 at 9:00 AM, V11 said no facility staff notified V11 that R1's x-ray results were uploaded to R1's electronic medical records prior to V11 reviewing them at 4:59 PM. V11 said if staff told V11 about receiving R1's x-ray results sooner, V11 would have sent R1 to the local hospital earlier in the day.On 1/15/26 at 10:00 AM, V2 (Director of Nursing) said it is the expectation of the facility that nurses should check for x-ray results at the beginning and end of their shifts. If and when staff see the results, it is the expectation that staff notify V11 so V11 can review the x-ray results and to ensure V11 gets the results. V2 said staff can call or text V11 or when V11 is in the facility, staff can tell V11 in person.

Based on interview and record review the facility failed to ensure the facility was free from abuse to 2 of 3 residents (R2, R1) reviewed for sexual abuse in the sample of 3.Findings include:R2's electronic Face sheet show R2 has diagnoses that include Dementia Alzheimer's disease, metabolic encephalopathy.R1's electronic Face sheet show R1 is a hospice resident with diagnoses that include dementia, atrial fibrillation and atherosclerotic heart disease. The facility Reported Incident dated 11/30/25 with final report dated 12/5/25 documents, R2 and R1 were in the activity, we confirm R2 made physical contact with R1. R2 was observed touching R1 around her diaper area. R2 and R1 were separated. R2 and R1 both have dementia. R2's BIMS score-4 (severely impaired). R1's BIMS score-0 (severely impaired) The residents were interviewed about the interaction with neither being able to provide any details about the occurrence. R2 is placed on one-on-one until further notice, placement to memory care unit has been discussed, option for more appropriate placement. R1 with no signs of injury, R1 remains in stable condition. R1's POA does not want to file a police report.On 12/11/25 at 8:15 AM, R2 was in bed alert, R2 said he was fine and had not bothered anyone. V4 (Certified Nursing Assistant-CNA) said V4 was the CNA assigned to provide 1:1 to R2. V4 said R2 touched another resident.On 12/11/25 at 8:30 AM, R1 was sitting in her wheelchair in activity room, asked how she was doing R1 was not able to respond verbally, R1 was just looking around.On 12/11/25 at 9:30 AM, R3 BIMS of 15 (no cognitive impairment) said she witnessed R2 touching R1. R3 said she was sitting in her wheelchair in the activity room with R1. R3 said she noticed R2 was messing with R1, R2 had his hand inside R1 pants. R3 said hey stop to R2, then I called for the staff who came and kept R2 away from R1.On 12/11/25 at 9:47 AM, V7 said she was the Activity Aide working when the incident happened with R2 and R1. V7 said she was bringing residents to the Activity room when R3 asked me to come over. R3 pointed to R2 who was sitting by R1. R2 had his right hand inside R1 pants in the waist area/ abdominal area. V7 stated It appeared that he (R2) was working his way towards (R1's) private areas when I intervened. V7 said he told R2 to stop you know better than that! R2 looked up to me then R2 immediately pulled his hands out from R1's pants. R2 and R1 were separated. V7 said she informed the Nurse.On 12/11/25 at 12;04 PM, V8 (License Practical Nurse) said she was R1's nurse on 11/30/25. V8 said she was handed a blank body assessment form by V9 (admission Staff) who said, I need you to do a thorough assessment on R1, focus on the private area because another resident had his hand in her pants. On 12/11/25 at 12:11 PM, V9 (admission Director) said she was the MOD (manager on duty) last 11/30/25. V9 said she was informed there was an abuse allegation-one male resident touched a female resident. V9 said this was immediately reported to the Administrator (V1) who was the Abuse Coordinator) V9 said V1 gave instructions to do an assessment to R1. R2 was put on 1:1. On 12/11/25 at 10:43 AM, V3 (Nurse Practitioner) said on 12/1/25 the day after the incident, V1 (Administrator) asked for her to do a follow up assessment on R1. R1 had an incident with another resident whose hand was in (R1's) diaper area. Body Assessment was done, within normal limits. R1 has Alzheimer's dementia and cannot recall what happened.R1's latest care plan (undated) documents R1 is at risk for abuse related to dementia with intervention of R1 will remain safe, calm and free from abuse. On 12/11/25 at 1:50 PM, V1 (Administrator) said the incident between R2 touching R1 was reported to the state agency which was the right thing to do. R1 continues be monitored. R2 was still on 1:1.The facility policy entitled Abuse dated 3/25 documents, the facility affirms the right of our residents to be free from abuse, neglect, misappropriation of residence property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime, this facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and residence secure environment. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Sexual abuse is a nonconsensual sexual contact of any type with a resident this includes but not limited to sexual harassment sexual coercion or sexual assault.

Based on interview and record review, the facility failed to inform a resident of of their plan of care. This failure affects one of three residents (R1) reviewed for resident's rights.Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses including End Stage Renal Disease, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter. R1's Minimum Data Set, dated [DATE] shows R1 is cognitively intact.On 11/24/25 at 10:16 AM, R1 said she doesn't know why her oxycodone (narcotic pain medication) was discontinued; no one discussed it with her. R1 said she asked repeatedly to speak to the nurse practitioner (NP), V8, but she never came. R1 said a nurse told her if someone stops taking a medication for a period of time, they could discontinue it. R1 said V8 just discontinued her oxycodone and all she is offered now is Tylenol.On 11/24/25 at 10:40 AM, V6, Licensed Practical Nurse (LPN), said R1 has oxycodone ordered as a scheduled dose, not as needed. V6 proceeded to look through orders on her computer and then said she didn't see it on R1's medication list. V6 said she wasn't aware of any changes in R1's oxycodone.On 11/24/25 at 2:13 PM, V9, LPN, said she always works on R1's wing. V9 said she doesn't know anything about R1's oxycodone being discontinued. V9 said it wasn't being discussed as a plan for R1. V9 said R1 still had oxycodone available the last time she worked. V9 said R1 also had scheduled Tylenol the last time she worked which was a new order for her. V9 said when she spoke to R1, about the scheduled Tylenol, R1 said she didn't know she was getting scheduled Tylenol. On 11/24/25 at 12:42 PM, V8 said prior to today, she probably last saw R1 in October. V8 said she doesn't think she discussed discontinuing R1's oxycodone at her last visit. V8 said she doesn't think anything specifically happened to trigger her to discontinue R1's oxycodone. V8 said she probably should have gone and discussed discontinuing R1's oxycodone with R1 prior to discontinuing it. V8 said she figured she would just discontinue it and see how it goes. R1's Order Summary shows V8 discontinued R1's oxycodone/acetaminophen 5-325 milligram tablet on 11/14/25 at 12:54 PM.V8's documentation of R1's last two visits dated 8/26/25 and 10/2/25 were reviewed and under the Plan section, both show R1 chart, vital signs, and medication list were reviewed and to continue orders and POC (Plan of Care). Neither visit documents plans to discontinue R1's oxycodone.R1's current care plan provided by the facility shows R1 has the potential to have pain due to weakness, dialysis, chronic pain, and arthritis. R1 has the potential for pain and receives opioid medications.The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (Revised 11/18) shows residents have the right to participate in their own care, should receive the services and/or items included in the plan of care and the facility must make arrangements to meet residents' needs and choices.

Based on interview and record review, the facility failed to ensure prescribed medications were acquired and provided for 1 of 3 residents (R1) in the sample of 3 reviewed for medication administration. Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses including End Stage Renal Disease, hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter.R1's current care plan provided by the facility shows R1 requires long term use of prophylactic antifungal medication (fluconazole) for care and management of chronic healing surgical wounds. It is to be provided per physician's orders.R1's Medication Administration Record (MAR) for 10/1/25 to 10/31/25 shows R1 did not receive several medications in October of 2025 due to having no supply of medications to administer. R1 did not receive cetirizine (an allergy medication) on 10/15/25, 10/16/25, and 10/21/25, and 10/28/25, clonazepam (an anxiety medication) on 10/18/25, 10/19/25, 10/20/25, and 10/22/25 through 10/29/25, diltiazem HCL ER (a medication for R1's heart arrhythmia) on 10/20/25, 10/21/25, 10/22/25, 10/29/25 and 10/30/25, fluconazole (used to prevent surgical wound infection) on 10/20/25, 10/21/25, 10/22/25, 10/25/25, 10/26/25 and 10/28/25, Lyrica on 10/29/25, and amlodipine (a medication for high blood pressure) on 10/26/25 and 10/31/25.R1's Progress Notes dated 10/15/25 at 8:41 AM, 10/16/25 at 11:36 AM, 10/21/25 at 5:21 PM and 10/28/25 at 10:07 AM show cetirizine was not available or on order. R1's Progress Notes dated 10/18/25 at 8:02 PM, 10/19/25 at 10:01 PM, 10/20/25 at 9:03 PM, 10/22/25 at 8:44 PM, 10/23/25 at 8:34 PM, 10/24/25 at 9:14 PM, 10/25/25 at 7:48 PM, 10/28/25 at 7:54 PM, and 10/29/25 at 9:58 PM show R1's clonazepam was not available because it was either on order, waiting for delivery, awaiting delivery, not available, out, or no supply. R1's Progress Notes dated 10/20/25 at 11:24 AM, 10/21/25 at 5:21 PM, 10/22/25 at 9:35 AM, and 10/29/25 at 8:45 AM show R1's diltiazem HCL ER was either on order from pharmacy, on order, or unavailable. R1's Progress Notes dated 10/29/25 at 9:59 PM show R1's Lyrica was waiting for delivery. R1's Progress Notes dated 10/20/25 at 11:24 AM, 10/21/25 at 5:20 PM, 10/22/25 at 9:35 AM, 10/25/25 at 10:24 AM, 10/26/25 at 8:35 AM and 10/28/25 at 10:07 AM show R1's fluconazole was either on order from pharmacy, on order, or not available for administration. R1's Progress Notes dated 10/26/25 at 5:02 PM and 10/31/25 at 12:31 PM show R1's amlodipine was not available.On 11/24/25 at 10:40 AM, V6, Licensed Practical Nurse (LPN), said staff kept reordering R1's medications and they weren't being delivered. V6 said they eventually figured out the pharmacy wasn't sending R1's medications because of her bill.On 11/24/25 at 12:25 PM, V7, Social Services Director, said the nurses received a call from the pharmacy stating they wouldn't fill R1's medications again because she had a bill. V7 said the nurses informed her because she was the manager on duty.On 11/24/25 at 1:09 PM, V2, Assistant Administrator, said the pharmacy did say they were no longer able to provide R1's medications because her bill was so high.On 11/24/25 at 9:32 AM, V4, Assistant Director of Nursing (ADON), said if they don't have the medications, she wouldn't be able to give them.On 11/24/25 at 1:56 PM, V3, Director of Nursing (DON), said V7 informed her that R1 has a huge bill to the pharmacy which was not paid. R1's pharmacy bill was not paid, and they were not sending R1's medications for a period. V2 said she thinks there have been a couple times when R1 has gone without her medications while awaiting delivery from the pharmacy. V3 said R1 is a human being, and she needs her medications. On 11/24/25 at 3:55 PM, V3 said she does not know how long R1 was out of her medications; maybe a few days. V3 could not provide the exact dates. V3 said when the nurses chart a code 9 on the MAR it means they are holding the medication due to a number of different reasons. V9 said she encourages her nurses to put a note in just to make sure they can document what happened. V3 said there isn't much difference between a code 9 and a code 5 when documenting on the MAR; the medication is being held (not given). V9 said the nurse doesn't always put in a progress note when they hold a medication, but she encourages it. V3 said they wouldn't document a 9 if they administered the medication. V3 said she doesn't know if there is a policy on what to do if a resident isn't receiving their medications from the pharmacy.On 11/24/25 at 12:42 PM, V8, Nurse Practitioner (NP), said the facility contacted her and said they were not getting R1's medications from the pharmacy. V8 said the facility should be providing the essentials to the residents, including medications. V8 said she told the facility they need to figure it out as R1 needs her medications.On 11/24/25 at 2:13 PM, V9, LPN, said during nurse-to-nurse report, she was told that the nurses kept reordering R1's medications and they were not being delivered. V9 said she was told the day shift nurse got a call from the pharmacy and the pharmacy said they weren't going to send R1's medications because she had an outstanding balance. V9 said she works the evening shift (2:00 PM to 10:00 PM) and the medications R1 was went without were Klonopin (also known as clonazepam) and Lyrica (used to treat nerve pain). V9 said she cannot give a medication they don't have.On 11/25/25 at 10:01 AM, V1, Administrator, the facility is ethically and legally responsible to provide the care and medications R1 needs regardless of whether R1 was paying her bill or not. The facility's Medication Administration: General Guidelines Policy (dated 01/2022) shows all medications shall be administered as prescribed.

Based on interview and record review, the facility failed to administer cardiac medications as prescribed to 1 of 3 residents (R1) with a heart arrhythmia, heart disease, kidney disease, and hypertension in the sample of 3 reviewed for medications.Findings include:R1's admission Record dated 11/24/25 shows R1's diagnoses include, but are not limited to, End Stage Renal Disease, Hypertensive heart and chronic kidney disease with heart failure, atherosclerotic heart disease, asthma, left kidney malignant neoplasm, paroxysmal atrial fibrillation, generalized anxiety disorder, anemia, insomnia, dependence on renal dialysis, hypertension, pain in right and left knees, osteoarthritis of knee, dorsalgia (pain in the back), chronic kidney disease, left shoulder osteoarthritis, obesity, hypothyroidism, presence of an artificial right knee joint, non-pressure chronic ulcer of the right lower leg, and goiter.On 11/24/25 at 10:40 AM, V6, Licensed Practical Nurse (LPN), said staff kept reordering R1's medications and they weren't being delivered. V6 said they eventually figured out the pharmacy wasn't sending R1's medications because of her bill.On 11/24/25 at 2:13 PM, V9, LPN, said during nurse-to-nurse report, she was told that the nurses kept reordering R1's medications and they were not being delivered. V9 said she was told the day shift nurse got a call from the pharmacy and the pharmacy said they weren't going to send R1's medications because she had an outstanding balance. V9 said she cannot give a medication they don't have.On 11/24/25 at 9:32 AM, V4, Assistant Director of Nursing (ADON), said if they don't have the medications, she wouldn't be able to give them.On 11/24/25 at 1:56 PM, V3, Director of Nursing (DON), said V7 informed her that R1 has a huge bill to the pharmacy which was not paid. R1's pharmacy bill was not paid, and they were not sending R1's medications for a period. V2 said she thinks there have been a couple times when R1 has gone without her medications while awaiting delivery from the pharmacy. V3 said R1 is a human being, and she needs her medications. On 11/24/25 at 3:55 PM, V3 said she does not know how long R1 was out of her medications; maybe a few days. V3 could not provide the exact dates. V3 said when the nurses chart a code 9 on the MAR it means they are holding the medication due to a number of different reasons. V9 said she encourages her nurses to put a note in just to make sure they can document what happened. V3 said there isn't much difference between a code 9 and a code 5 when documenting on the MAR; the medication is being held (not given). V9 said the nurse doesn't always put in a progress note when they hold a medication, but she encourages it. V3 said they would NOT document a 5 or a 9 if they administered the medication. V3 looked up Diltiazem and Amlodipine and said Diltiazem is a blood pressure (BP) medication and Amlodipine can be used for BP, chest pain, and/or coronary artery disease. V3 said those can be significant medications to go without.On 11/24/25 at 12:42 PM, V8, Nurse Practitioner (NP), said the facility contacted her and said they were not getting R1's medications from the pharmacy. V8 said the facility should be providing the essentials to the residents, including medications. V8 said she told the facility they need to figure it out as R1 needs her medications.On 11/25/25 at 10:01 AM, V1, Administrator, the facility is ethically and legally responsible to provide the care and medications R1 needs regardless of whether R1 was paying her bill or not. R1's Medication Administration Record (MAR) for 10/1/25 to 10/31/25 shows R1 did not receive several medications in October of 2025 due to having no supply of medications to administer. R1 did not receive Diltiazem HCL ER (a medication for R1's heart arrhythmia (atrial fibrillation) on 10/20/25, 10/21/25, 10/22/25, 10/29/25 and 10/30/25 and Amlodipine (a medication for high blood pressure) on 10/26/25 and 10/31/25. R1's MAR for 10/1/25 to 10/31/25 shows R1 had an active order written on 10/24/25 for Amlodipine to be administered each evening. That order was discontinued on 10/29/25 and Amlodipine was ordered to be administered each morning on 10/29/25. Diltiazem HCL ER was ordered to be administered once daily on 5/6/25 for atrial fibrillation and scheduled at 8:00 AM.R1's Progress Notes dated 10/20/25 at 11:24 AM, 10/21/25 at 5:21 PM, 10/22/25 at 9:35 AM, and 10/29/25 at 8:45 AM show R1's Diltiazem HCL ER was either on order from pharmacy, on order, or unavailable. R1's Progress Notes dated 10/26/25 at 5:02 PM and 10/31/25 at 12:31 PM show R1's Amlodipine was not available.The facility's Medication Administration Policy (dated 09/2020) shows drugs must be administered in accordance with the written orders of the attending physician.

Based on observation, interview, and record review the facility failed to ensure medications were administered timely as ordered and scheduled for 4 of 5 residents (R58, R111, R184, R73) reviewed for medication administration in the sample of 63.Findings include:On 7/30/25 at 9:11 AM, the surveyor approached V11 (Agency RN (Registered nurse)) to observe medication administration. V11's medication cart was parked in the middle of the hall. R182 was seated in her wheelchair next to the medication cart and R58 was standing behind R182. V11 said she was preparing medications for R182. The surveyor waited while V11 administered the prepared medications to R182. R58 told V11 that he needed something for his stomach. V11 opened her computer to the Medication Administration Screen and numerous residents showed up in red. V11 stated, I know there's a lot of red on the screen. That's because they're considered late. R58 was red on the computer screen. V11 stated, I need to give you your morning medications and I'll see what you have for your stomach. While V11 prepared R58's medications he said he had to go, and walked away. V11 did not have R1's Isosorbide 60 mg (milligrams) (blood pressure medication). V11 said it had been ordered yesterday, so she would need to check with a supervisor to see if it was available in the automated medication dispensing system. V11 prepared Amlodipine 10 mg (for blood pressure), Aripiprazole 20 mg (antipsychotic medication), Aspirin 81 mg, Benztropine (anticholinergic) 1 mg, Losartan 100 mg (for blood pressure), Omeprazole 20 mg (for acid reflux), Venlafaxine 150 mg (antipsychotic), Venlafaxine 37.5 mg, and Colace 100 mg (stool softener). V11 collected R58's two inhalers from the medication cart and the prepared medications and went to R58's room at 9:20 AM. V11 said he's not in here and walked to the other end of the hall to look for R58. At 9:24 AM, V11 returned to R58's room and found him in the bathroom. At 9:27 AM, R58 exited the bathroom and requested applesauce to take his oral medications and said he didn't want to take his inhalers at this time. V11 obtained applesauce and administered R58's oral medications. At 9:30 AM, V11 and the surveyor returned to the medication cart. The surveyor asked V11 if she still had morning medications to pass and she said she still had several residents to finish medication pass on. V11 said she doesn't pick up too many shifts at the facility because the morning medication pass is usually like this (late).2. R58's Facesheet dated 7/30/25 showed he had diagnoses to include, but not limited to: COPD (Chronic Obstructive Pulmonary Disease), vascular dementia, schizoaffective disorder (bipolar type), hypertension, diabetes, and generalized anxiety disorder.R58's Medication Administration Audit Report dated 7/31/25 showed R58's nine (0800) oral medications were administered late at 9:30 AM. R58's Progress Notes were reviewed for July 2025. There were no notes regarding notification of R58's Provider that medications were administered late or not available for administration. On 7/30/25 during the Resident Council Meeting, residents said the medication pass is late on the hall when agency staff are working. They said the regular staff will usually get their 8 AM medications to them by 8:30 AM, but if it's agency it could be 10:30 AM or later. On the afternoon of 7/30/25, R184 was lying in bed, reading a book. The surveyor asked her if her morning medications are given on time. R184 replied, I consider it (0800 meds) on time if I get them by 10:30 AM. R184 smiled and said R184 said if agency is working that's the way it is. If the regular staff are working, the medications are always on time.R184's Medication Administration Audit Report dated 7/31/25 showed R184's 8 AM scheduled medications were administered from 9:53 AM - 9:57 AM. R184's Progress Notes were reviewed for July 2025. There were no notes regarding notification of R184's Provider that medications were administered late.R73's Medication Administration Audit Report dated 7/31/25 showed 8 AM scheduled medications were administered between 9:05 - 9:14 AM on 7/30/25. R73's Progress Notes were reviewed for July 2025. There were no notes regarding notification of R73's Provider that medications were administered late.R111's Medication Administration Audit Report dated 7/31/25 showed 8 AM scheduled medications were administered between 10:13 - 10:14 AM on 7/30/25.R111's Progress Notes were reviewed for July 2025. There were no notes regarding notification of R111's Provider that medications were administered late.On 7/31/25 at 7:57 AM, V4 (DON) said the nurses should follow the 5 rights of medication administration. V4 said the 5 rights include the right time. V4 said the nurses have one hour before and one hour after the scheduled medication time to administer the medications. V4 said 0800 medications would be considered late if they were given after 9 AM. V4 said if medications are given outside the medication administration window then the Provider should be notified and a progress note should be entered. The facility's Medication Administration Policy dated 09/2020 showed, Medications will be administered in accordance with the established policies and procedures. Procedures: 1. Drugs must be administered in accordance with the written orders of the attending physician.

Based on observation, interview and record review, the facility failed to prevent potential cross-contamination by failing to don the proper personal protective equipment (PPE) while providing high-contact resident care for residents requiring enhanced barrier precautions (EBP) and failing to remove gloves and perform hand hygiene after providing incontinence care. These failures affect 3 of 5 residents (R77, R160, R99) reviewed for infection control in the sample of 63. Findings include: 1. R77's admission Record, provided by the facility on 7/31/2025, showed diagnoses including, Hypertensive stage 5 Chronic Kidney Disease, or end-stage renal disease, dependence on renal dialysis, acute angle-closure glaucoma, type II diabetes mellitus, and heart failure. R77's care plans, provided by the facility on 7/31/2025, show R77 requires assistance from staff for transfers, experiences bladder and bowel incontinence, and requires enhanced barrier precautions (EBP) related to use and care of indwelling dialysis device. R77's care plan initiated on 5/9/2024, showed R1 has an ADL (activities of daily living) functional performance deficit and staff should assist with transfers and toileting needs as necessary. On 7/29/2025 at 10:43 AM, V16 (Certified Nursing Assistant-CNA) entered R77's room, applied hand sanitizer to her hands and donned gloves. V16 told R77 she was going to get him up to take him to the bathroom. The signage by R77's door showed he was on enhanced barrier precautions. V16 put R77's shoes on, placed a gait belt around R77, and transferred him from his recliner to his wheelchair. V16 propelled R77 into the bathroom and transferred him from his wheelchair to the toilet. V16 removed R77's soiled brief, then removed her gloves and washed her hands. V16 verified that there was urine in R77's brief. V16 put on clean gloves then put a clean brief on R77. When R77 was done, V16 pulled his brief up, then his pants and transferred him back to his wheelchair. V16 did not clean R77 after removing the urine soiled brief or prior to placing a new brief on R77. V16 did not wear a gown while providing high-contact direct care for R77. The signage on R77's door showed staff should wear a gown and glove when providing high-contact care to a resident on EBP. On 7/30/2025 at 9:19 AM, R77 said the CNA did not wash him yesterday when this surveyor watched care. R77 stated, Sometimes they do and sometimes they don't. He said his brief was wet due to incontinence. R77 said the CNA should have probably washed him up, so he did not get a rash. On 7/30/2025 at 9:35 AM, V17 (Registered Nurse/agency) said R77 is on EBP due to having dialysis. Staff should be wearing a gown and gloves when providing any direct-care activities listed on the signage by his door. On 7/30/2025 at 9:52 AM, V18 (LPN/Infection Preventionist) said R77 is on EBP because he receives dialysis. If a resident is on enhanced barrier precautions, staff need to wear a gown and gloves if touching the resident, transferring, toileting, emptying a resident's catheter, or doing anything with the catheter. 2. R160's admission Record, provided by the facility on 7/31/2025, showed he had diagnoses including, but not limited to, retention of urine, encounter for orthopedic aftercare following surgical amputation, acquired absence of left leg below knee, local infection of the skin and subcutaneous tissue, and need for assistance with personal care. R160's Order Summary Report, printed by the facility on 7/31/2025, showed an order for an indwelling urinary catheter. The report showed an order dated 6/26/2025 for a wound vac to left stump at 125 mmHg (millimeters of mercury) continuous suction. Cut black sponge to fit the size of the wound and cover with draping. Change three times a week. Wash left stump with soap and water during dressing change. The Order Summary Report also shows active orders for EBP for a chronic wound and EBP for use of device care or use of urinary catheter. R160's care plan initiated 7/19/2025 showed he has an increased risk of infection due to chronic care and use of indwelling urinary catheter and management of chronic wound. The care plan showed R160 requires use of enhanced barrier precautions. The care plan showed enhanced barrier precautions will be implemented during high-contact resident care activities. On 7/29/2025 at 10:09 AM, the sign by R160's door showed he was on enhanced barrier precautions. R160 said the nurses do dressing changes to the surgical site for his left above the knee amputation. At 10:33 AM, V14 (CNA unit manager) and V15 (CNA) went to empty R160's catheter urinary drainage bag. V14 held the urinal. V15 emptied the urine from the drainage bag into the urinal. Neither V14, nor V15 put a gown on to empty R160's urinary drainage bag. On 7/31/2025 at 11:50 AM, V4 (Director of Nursing) said enhanced barrier precautions are put in place if a resident has an infection or has anything inserted into the body that is a route to inside the body, such as a port for dialysis. V4 said when a resident is on EBP precautions, staff should wear a gown and gloves whenever providing direct patient care, such as bathing, toileting, emptying a catheter, etc., V4 said when toileting a resident, staff should ask the resident first if they (the CNA) can clean them up, to maintain the resident's dignity. If the resident allows, the CNA should clean the resident up. If the resident does not allow, and is able to do it, the CNA should give the resident the supplies to clean themselves and make sure the resident does not need assistance. V4 said she would expect staff to wear the appropriate PPE that is listed on the signage outside the resident's door. The facility's Enhanced Barrier Precaution signage outside R77 and R160's rooms showed Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound care: Any skin opening requiring a dressing. The facility's 12/2024 policy and procedure titled Enhanced Barrier Precautions showed Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. As well as to prevent multidrug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device.EBP involves gown and glove use during high-contact resident care activities for residents known to be infected or colonized with MDROs when contact precautions do not otherwise apply. As well as residents with a chronic wound and/or indwelling medical device. The policy lists high-contact resident care activities include the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care. 3. R99's electronic face sheet printed on 7/31/25 showed R99 has diagnoses including but not limited to heart failure, chronic kidney disease, dementia without behaviors, and history of falls. R99's facility assessment dated [DATE] showed R99 has moderate cognitive impairment and is incontinent of bowel and bladder. R99's undated care plan showed, (R99) experiences bladder incontinence. On 7/29/25 at 10:08AM, V25 (Certified Nursing Assistant) provided incontinence care for R99. V25 applied clean gloves, removed R99's soiled incontinence brief, provided incontinence care, applied a clean incontinence brief, and dressed R99 in clean clothes without changing her gloves. V25 then removed her gloves, picked up all R99's soiled linens with no gloves on, and carried the linens out into the hallway. V25 came back into the room and applied clean gloves without performing hand hygiene. V25 stated she knew she didn't do what she was supposed to do but it was too late to fix it. On 7/31/25 at 12:45PM, V4 (Director of Nursing) stated, When staff are performing incontinence care, they should be changing their gloves when going from a dirty to clean task to prevent cross contamination. It is our policy that staff wear gloves when handling soiled linen for the same reason. Our policy specifically shows all of this as well as performing hand hygiene in between glove changes. This is nothing new, especially for an aide. She should have known that. The facility's policy titled, Glove Use dated 04/2024 showed, Gloves will be used to prevent the spread of infection and disease to other residents, personnel, and visitors. Gloves will be used when anticipating touching blood, body fluids, secretions, excretions, contaminated items.1. Disposable single-use examination gloves are worn when.c. handling or touching contaminated items or surfaces.5. Procedure guidelines.e. non-sterile gloves are used primarily to prevent contamination of the employee's hands when providing care/services to the resident.h. provide hand hygiene when gloves are removed. The facility's policy titled, Perineal Care dated 09/2020 showed.b. put on gloves.j. remove gloves and wash hands and/or use hand hygiene. K. apply gloves before putting on clean brief.

Based on observation, interview, and record review the facility failed to maintain a residents dignity, by failing to dispose of and clean emesis from a basin from the resident's bedside. This applies to 1 of 1 residents (R2) reviewed for dignity in the sample of 63. Findings include:R2's admission Record (Face Sheet) showed an admission date of 4/24/23 with diagnoses to include heart bypass, morbid obesity, and diabetes type 2.R2's 6/6/25 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R2's 7/25/2025 Nurses' Note from 12:40 showed, Resident had another emesis occurrence. NP (Nurse Practitioner) came to assess. Ordered [nausea medication] 4mg (milligram) PO (by mouth) q4PRN (every four hours as need for pain).On 7/29/25 at 10:26 AM, R2 was asleep in bed. R2 was pale and she did not arouse to a door knock. R2 had a pink basin in front of her on the over-bed table. The basin had a approximately one cup of emesis in the basin. The emesis was chunky, dark brown, with round off-white pieces. At 7/29/25 at 10:26 AM, R114 R2's roommate stated, R2 had been sick that morning and she was not feeling well. On 7/29/25 at 2:10 PM, R2 was as before, asleep with the emesis bin in front of her. The emesis was the same amount of the chunky dark brown emesis with off-white pieces. On 7/29/25 at 2:10 PM, R114 stated staff had entered the room and tried to get R2 to eat lunch but she would not eat. (Staff did not clean the emesis from the basin at lunch.) On 7/29/25 at 2:16 PM, V23 Licensed Practical Nurse (LPN) stated she was aware R2 had been sick at lunch time, however, when she saw R2 at that time she was asleep. On 7/30/2025 at 9:00 AM, R2 stated, I got sick and threw up yesterday. I got too hot. I get overheated and then I throw up. This happens every year when it gets hot, it's not a new thing.They should have taken the vomit instead of leaving it in front of me; it took the nice male nurse in the afternoon to clean it up. It was there since breakfast. I threw up the oatmeal and the eggs that I had for breakfast. On 7/30/2025 at 1:36 PM, R4 Director of Nursing stated staff should be rounding hourly and addressing resident concerns and meeting resident needs when rounding to include emptying urinals and emesis basins. The facility's Residents' Rights policy (11/2017) showed, The facility will respect and uphold residents' rights. The Residents' Rights for People in Long-term Care Facilities (4/2024) showed, Your facility must provide services to keep your physical and mental health, and sense of satisfaction.

Based on observation, interview, and record review, the facility failed to provide bed rails for assistance with bed mobility for 1 of 2 residents (R99) reviewed for activities of daily living (ADL's) in the sample of 63.Findings include:R99's electronic face sheet printed on 7/31/25 showed R99 has diagnoses including but not limited to heart failure, chronic kidney disease, dementia without behaviors, and history of falls.R99's facility assessment dated [DATE] showed R99 has moderate cognitive impairment and does not utilize side rails.R99's undated care plan showed, (R99) has an ADL functional performance deficit.cue resident to grasp side rail and pull self-up to a sitting position or to the side of the bed.R99's document titled, Side Rail Assessment dated 4/25/25 showed, Is the resident able to use a side rail to assist in bed mobility? Yes.the use of side rails is indicated and serves as an enabler to promote independence.R99's document titled, Side Rail Assessment dated 7/22/25 showed, Decision regarding side rail use: One side rail.resident has requested the use of side rails while in bed. The use of side rails is indicated and serves as an enable to promote independence.On 7/29/25 at 10:08AM, V25 (Certified Nursing Assistant) provided incontinence care for R99. R99 attempted multiple times to reach out for something to grab onto during her bed mobility. At one point, R99 grabbed onto her bedside table as she stated, I need something to grab onto so I can turn over. I feel like I'm going to fall if I don't hold something. V25 stated R99 does not have bed rails and as far as she knows, she has never had them. V25 stated R99 does help move herself in bed when she has something to grab onto.On 7/31/25 at 11:21AM, V27 (Restorative Nurse) stated, Side rail assessments are done by the floor nurse. If the resident does seem to need side rails, then it will come to the restorative department and then the interdisciplinary team (IDT) will discuss it. If they need siderails for positioning, then they will bring the rail up during cares and then lower it back down. (R99's) side rail assessment was done 7/22 and shows that she would benefit from 1 side rail. I believe she has one if I'm not mistaken but I can't be positive.On 7/31/25 at 12:45PM, V4 (Director of Nursing) stated, Floor nurse's do the initial side rail assessment and as needed. If a resident is deemed to need side rails and benefit from them then we would discuss it as an IDT. I'm not sure if we have discussed (R99) but I feel like we have. If the assessment shows she could use one, then it would probably be a benefit for her.The facility's undated policy titled, Side Rise Assessment showed, It is the policy of this facility to properly assess a resident's need for side rail use .

Based on observation, interview and record review the facility failed to provide clearly defined target behaviors and failed to provide an appropriate indication for the use of an antipsychotic medication for two (R34, R55) residents with a diagnosis of Dementia of five residents in the sample of 63.Findings include:R55's Physician Order Summary Report indicates R55 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Unspecified Bipolar Disorder. This Order Summary Report indicates R55 has current orders for Seroquel (antipsychotic) 50mg (milligrams) in the morning related to Bipolar Disorder and Seroquel 25mg at bedtime for Bipolar Disorder. (Order date initiated 6/5/25)R55's Medical Diagnosis List indicates R55's diagnosis of Bipolar Disorder was initiated on 10/14/24 and Dementia diagnosis on 7/21/25.On 7/28/25 at 11:10am R55 was seen in bed. R55 stated he was too sick to talk.On 7/29/25 at 9:50am R55 was sitting in a wheelchair in the doorway of his room. R55 was asking everyone who passed by in a loud demanding manner Why are you still here? Your shift was over four hours ago! Don't expect to get a paycheck for staying over. R55 insisted he was the Owner of the building. R55 was argumentative but was able to be engaged if response was not contradictory to his statements. R55 stayed within the area of his room, and was primarily focused on interacting with staff.Progress Notes dated 7/30/25 at 10:17am indicate R55 was referred to a Psychiatric Hospital for evaluation and was later transferred on that date at 2:08pm. Progress Notes do not indicate the behavior R55 was displaying to require hospital evaluation.On 7/31/25 at 11:45pm R55 was seen sitting in a wheelchair in his room. At that time V29, RN (Registered Nurse) stated R55 was sent out for his usual behavior and was sent right back. V29 described R55's usual behavior as believing he is the owner (of the facility) and treating staff like they are his employees. Progress Notes dated 7/23/25 at 5:50am, 7/20/25 at 6:12am, 7/9/25 at 6:04am and 7/5/25 at 5:34am all indicate R55 has behaviors and refuses care at times. R55's Progress Notes do not include a description of behaviors.Current Care Plan indicates R55 receives Quetiapine (Seroquel) for mood issues of insomnia, self isolation and lack of motivation.Behavior Tracking Report dated May 2025, June 2025, and July 2025 indicates R55 is monitored for mood disturbances, lack of motivation and lack of self-initiation; Delusions - confusion about life events and believing he is back in the war. Tracking Report indicates R55 displays the behaviors listed almost daily during the evening hours from 2pm, to 10pm and the interventions of Not arguing are effective and the interventions of Conducting reality testing are not effective in reducing behaviors.On 7/31/25 at 12:30pm V13, Behavioral Health Director acknowledged R55 displays typical behaviors of Dementia including cycling and needs a medical diagnosis review by psychiatry services. V13 stated R55 did have a previous diagnosis of Bipolar however it is unclear if his current delusions are a continuation of Bipolar or related to Dementia. V13 confirmed there was a need for more specific documentation describing R55's delusions and therapeutic goal of antipsychotic use in a resident with a dual diagnosis.2. R34's current Physician Order Summary Report indicates R34 was admitted to the facility 8/4/19 with diagnoses that include Dementia with Other Behavioral Disturbance (9/4/24), Alzheimer's Disease (8/27/19) and Delusional Disorder.R34's Order Summary report indicates R34 receives Quetiapine (antipsychotic) 25mg at bedtime (date initiated 1/7/25) related to Delusional Disorder.On 7/29/25 and 7/30/25 R34 was seen in a wheelchair in the hallway. R34 was pleasant and appropriate during interaction. R34's current Care Plan indicates R34 receives an anti-depressant (Paroxetine) and Quetiapine (antipsychotic) related to the diagnosis of Recurrent Depressive Disorders, Schizoaffective and symptoms of sadness. This Care Plan indicates R34 receives psychotropic anti-psychotic Quetiapine for diagnosis of Delusional Disorders for symptoms of delusions. Date initiated: 6/5/19R34's Care Plan does not include details/descriptions of R34's delusions, the specific symptoms of delusions or targeted behaviors that require monitoring. This Care Plan does not include any non-pharmacological interventions. Behavior Tracking Report dated July 2025 indicates R34 is being monitored for Delusions - fixed false beliefs (example: believing someone is there to take her home; waiting for the bus with her purse to go shopping; believing she is being discharged . This report indicates R34 displayed these behaviors 9 times during the report month (across all three shifts).R34's Psychiatry/Psychologist Note dated 7/31/25 at 2:02pm indicates 'R34 was originally started on Seroquel in 2019 for agitation and delusions and was often found yelling with outbursts related to delusions. Note further indicates On 4/12/23 (R34's) change of condition required involuntary psychiatric admission. Per the petition, (R34) had become physically aggressive with staff evidenced by hitting and kicking staff during ADL's (Activities of Daily Living). Based on this she continues to benefit from this medication (Seroquel/Quetiapine). (R34) needs it for stability and it treats her underlying delusions. Our goal is to have (R34) on the lowest dose possible, but her symptoms make this difficult. R34's Psychiatry Note dated 7/31/25 does not specify any symptoms or description of delusions that require antipsychotic medication use, other than R34 becoming aggressive with staff during ADL's and was yelling out. On 7/31/25 at 2:55pm V31, Nurse Consultant confirmed R34 remains on Seroquel as she is still aggressive with care.The facility Policy/Use of Psychotropic Medications dated 9/2020 documents:A resident will not receive psychotropic medications unless behavioral programming and/or environmental changes have failed to sufficiently modify a resident's target behavioral disturbance. A resident will not receive psychotropic medications unless a medication is needed to treat a specific condition and each medication will be given to treat clearly defined target behaviors.A psychotropic medication will be defined as any medication that is prescribed for the purpose of modifying mood and/or behavior.Prior to the administration of an antipsychotic medication, the following must be documented:An appropriate supporting diagnosis and/or targeted behavioral symptom to be treated.Target behaviors will be identified with supporting documentation in the clinical record.Plan of Care including treatment goals, evaluation of any precipitating factors in the residents environment, and any non-drug approaches to providing care.

Based on observation, interview, and record review the facility failed to serve coffee at a temperature to prevent burns. This failure resulted in R1 receiving a 12-inch, slough filled burn to her left thigh. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. This past compliance occurred from 12/1/2024-12/2/2024. Findings include: R1's Admission Record (Face Sheet) showed she was admitted to the facility on [DATE] with diagnoses to include but not limited to Parkinson's Disease (degenerative brain disorder leading to tremors and a loss of motor function); tremors; depression; diabetes II; COPD (Chronic Obstructive Pulmonary Disorder, progressive lung disease caused by damage to the lungs); and rheumatoid arthritis. R1's 10/14/24 Quarterly Minimum Data Set (MDS) showed she was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The MDS showed she used a wheelchair for mobility. The MDS showed R1 required setup or touching assistance for eating and partial/moderate assistance for oral hygiene. The MDS showed she required substantial/maximal assistance to roll left and right in bed; and she required substantial/maximal assistance to go from siting in bed to lying in bed. The MDS showed R1 does not walk. The facilities incident report from 12/1/24 showed, [R1] is an alert and oriented resident with a BIMS score of 14 on an all-female behavioral health unit. On 12/1/24 [R1] was wheeling down the hall independently per her baseline when she asked her friend to assist in moving her wheelchair. The friend complied and handed [R1] her coffee with a lid attached to hold while she helped her. Once completed [R1] attempted to hand the coffee back to her friend when she dropped the coffee onto her own left leg. The nursing staff on duty assessed the resident with noted redness to the left leg. NP (Nurse Practitioner) was notified with new treatment orders in place. POA notified of the incident and agrees with the current plan of care. [R1] was assessed by wound care MD on 12/2. The investigation started immediately . On 12/13/24 at 8:45 AM, R2 stated the councilors office on her locked behavioral unit had a single serving pod-type coffee maker (hereinafter referred to single-serving coffee maker, SSCM). R2 stated, at around 3:30 PM on 12/1/24, she dispensed a cup of coffee by herself then exited the councilors office. R2 said, as she exited the councilors office R1 was in her wheelchair and stuck against the wall. R2 said R1 requested assistance, so she handed her coffee to R1 then moved R1 away from the wall. R2 said when R1 handed the coffee back to her it spilled on R1. R2 said, .The coffee was fresh. I had just gotten it .The coffee is hot. The stuff I get from the counselors is hot, which is why I like it. The stuff from the kitchen is like bath water. Oh yeah, the stuff from the counselors is hotter, which is why I like it. [R1] yelled out when it spilled on her. After that, I just blanked out. I don't remember who came by; I don't remember who assessed her .[R1] does shake a little (hand tremors) . On 12/13/24 at 9:00 AM, R1 stated .I was stuck against the wall. I asked [R2] to help and I told her I would hold her coffee and I asked her to push me to the dining room. I dropped the coffee, and it ran down my leg. [R2] felt bad. When the coffee hit my leg, it hurt bad because it was hot and burned my leg .The coffee came from the councilor's office; I don't drink coffee. After it spilled, I screamed .Now they can't get coffee (referring to the SSCM removed from the unit) and they are going to get another coffee maker .I haven't seen my leg since then. They change the dressing every day and the wound nurse checks it twice a week. I still have some pain (in that leg). Right now, I would rate it (pain) at a 3 out of 10 . On 12/13/24 at 10:23, V10 Wound Care Nurse began wound care on R1 with the assistance of V11 MDS nurse. V10 removed the dressing to R1's left thigh exposing R1's wound. The wound was 12 to 14 inches in length beginning at just below the left hip and wrapping behind her thigh to above the back of the knee. At its widest point, the wound was 5 to 6 inches wide. R1's wound was nearly 100 percent yellow/white slough (dead tissue) with the border of the wound being bright red. The wound bed appeared to more than superficial and the slough tissue was below the top layer of skin. R1 was medicated for pain prior to the start of wound care; however, during wound care R1 winced and gasped with pain, especially during the cleaning of the wound. On 12/13/24 at 10:45 AM, V10 said (with V2 Director of Nursing sitting in on interview), regarding R1's wound, It was due to the hot coffee. V10 said, It's a third-degree burn .It started as redness, then blistered, then opened . R1's 12/2/24 and 12/9/24 Wound Care assessment completed by V12 Wound Care Physician showed, Wound Related Diagnosis: Burn of third degree of left thigh . (All wound assessments were requested, 12/2/24 was the initial provider assessment.) R1's 12/5/24 Wound Care assessment completed by V13 Wound Care Nurse Practitioner showed, Wound related diagnosis: Burn of third degree of left thigh . R1's 12/12/24 Wound Care Physician assessment (performed by V9 Wound Care Physician) showed, Wound Related Diagnosis: Burn of third-degree of left thigh . V9's assessment showed the left thigh wound was coded as T24.312A (a third-degree burn). The assessment showed, after debridement (removal of dead tissue), the wound was 30 centimeters by 15 centimeters by 0.2 centimeters deep. Prior to debridement the wound measured 30 centimeters by 15 centimeters by 0.1 centimeters deep. The undated Mayo Clinic website titled Burns showed three levels of burns. The website showed the final and most severe burn was a third-degree burn. The website showed a third-degree burn was a burn which involves all of the layers of skin and sometimes the fat and muscle tissue under the skin . On 12/13/24 at 9:17 AM, V5 Psychiatric Rehab Services Coordinator (PRSC, working on the locked women's unit) stated she was working when R2 made her coffee. V5 stated she was assisting another resident when R2 entered the office and made the coffee. V5 stated the SSCM was no longer in the office and had been removed. V5 said R1 does not have any self-harm behaviors. On 12/13/24 at 9:50 AM, V5 stated she does not monitor the temperature of the SSCM. On 12/13/24 at 11:23 AM, V7 Dietary Manager stated the facility has temperature regulated coffee machines in the kitchen which are used to fill carafes for the residents. V7 stated the kitchen's coffee makers dispense coffee at 165 degrees Fahrenheit (F) which ends up being 160 F in the cup. V7 stated, We check the coffee temperature. We check it every time it (coffee) goes out. We check the coffee temperature to avoid burns. We send it out at 145-150 F. We use ice to cool it down and label the pots. Some residents are on 'cool down' so their food and hot beverages must be at a lower temperatures, so we label the coffee if it's 'cool down' which is 135F maximum. V7 said, As far as I know they are not allowed to have coffee pots on the units and if they do, we don't monitor them. I was asked to get the coffee [temperatures] lower because there have been burns at other facilities. I didn't lower temperatures on coffee pots on other units because I didn't know about them. If coffee is hot, it can cause burns, which is part of the reason why we are looking at new coffee machines [for the kitchen.] We were not monitoring the women's unit [SSCM]. On 12/13/24 at 11:18 AM, V6 Psychiatric Unit Manager stated, We don't have any process in place to measure the coffee temperature (from the SSCM). We were not monitoring the coffee temperature. The locked men's unit also had an [SSCM], but we removed that one also. On 12/13/24 at 11:23 AM, V8 [NAME] was preparing coffee for the noon meal. V8 stated, I add ice to get the coffee down to 145F. I have worked here for [AGE] years, and we have been checking coffee temperatures for several years. The 145 F is for regular coffee, 'cool down' coffee is 135 F. On 12/13/24 at 2:00 PM, V7 stated, I'm not sure where the 145-150 F [coffee temperature] came from. Not able to find it [in a policy] it's just the temperature we always serve the regular coffee at as a safe temperature. V7 then retrieved the At RISK Hot Food and Beverage Temperature Service policy (dated 5/2019). V7 stated, while referencing the section of the policy Water Temperature and Time Reference Guide for third degree burn for Elderly; we might have gotten it [150 F maximum coffee temperature] from this chart. The facility's policy, At RISK Hot Food and Beverage Temperature Service policy (dated 5/2019) showed, Food and beverages will be served at a temperature that is safe and palatable. Purpose: To reduce the risk of injury. The policy showed liquids at 155 F can cause a third-degree burn in as little as one second and 140 F liquids can cause third degree burn in 3 seconds. On 12/13/24 at 11:15 AM, V1 Administrator stated they were not able to locate the SSCM from the locked women's unit. V1 and V7 Assistant Administrator found another SSCM, same brand, and dispensed coffee from this SSCM unit into a Styrofoam cup. The coffee measured 174.2 F using a facility thermometer. Approximately 2 minutes later, the coffee was 166 F. On 12/13/24 at 11:42 AM, V9 Wound Care Physician said, The best answer right now is it's an unclassified burn degree because I cannot see the whole wound. This wound will take about three months to heal. I see coffee burns all the time; it is something they (the facility) should be aware of. She does have Parkinson's which can affect her grip strength. V9 said, for normal people, a burn would occur at 160 F. The Consumer Protection Safety Commission publication titled Avoiding Tap Water Scalds showed Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds . Prior to the survey date of 12/17/24, the facility had taken the following action to correct the noncompliance: 1. On 12/1/24 V1 directed staff to cease the use of SSCM machines on both the men's and women's locked units. 2. On 12/1/24 V1 developed a plan of correction. 3. On 12/124 training for staff regarding the safe administration of hot liquids and cool liquid program was initiated. 4. On 12/2/24 R1 was assessed by the therapy department, for safe handling of hot liquids. 5. On 12/2/24 Quality Assurance audits for serving hot liquids in the dining room was initiated for both high risk and low risk resident. The audits will be reviewed at the next scheduled QA Committee meeting. 6. On 12/2/24 an emergency resident council meeting was held and residents were educated on not handing liquids to other residents as well as residents pushing other residents in wheelchairs. 7. New residents are assessed for mealtime safety and their ability to handle hot beverages. 8. The facility will maintain a current list of all residents requiring the cool liquid program.

Based on observation, interview and record review, the facility to ensure a resident's right to be free from neglect for 1 of 3 residents (R1) reviewed for neglect in the sample of 5. This failure resulted in R1 lying in urine for hours causing embarrassment and emotional distress. The findings include: R1's face sheet showed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis of acute cystitis with hematuria, syncope and collapse, acute kidney failure, obstructive sleep apnea, hypertension, history of falling, adult failure to thrive, and urinary tract infection. On 4/18/24 at 10:41 AM, R1 was in her room. R1 became tearful and her crying increased as she spoke about the incident night of 4/9/24. R1 said I done forgot about that girl. She didn't want to help me go to the bathroom. I put the call light on waited hours and started calling out nurse, nurse. She had a nasty remark. She didn't want to be bothered with me. I wet myself. I feel like she was abusive to me. You got to have a decent attitude. I don't think she is qualified to take care of people. Some people got jobs they ain't cut out for, but they think they are. I prayed and hoped I made it through the night. I felt afraid to ask for help. She was the one waiting on me. You don't want to call that person to come back in. I hate to say it but that's the way I feel. I was embarrassed that I had to wet myself. On 4/18/24 at 9:41 AM, V7 (Registered Nurse/RN) said R1 alert and oriented x 3. If I was told a resident had not been changed all night and was upset, I would report it to management. If it's true, then someone did not perform their duties. I would call it neglectful if it's true. On 4/18/24 at 9:48 AM, V8 (Certified Nursing Assistant/CNA) said the morning of 4/10/24, R1 told her nobody changed her all night. I got her up and cleaned up, washed her good. R1's bed was wet all the way to the mattress. I reported it to V1 (Administrator) as soon as I cleaned her up. It felt like that was neglect on the patient. We give report that she gets up to the bathroom. Normally she gets up to the bathroom and doesn't wet herself. She is very aware of her surroundings. She was very upset and embarrassed. Honestly, as wet as she was, I don't think she was changed or toileted at all. I know she is continent, and she lets you know when she needs to use the bathroom. She'll put her call light on. If you leave them in their urine too long their skin can start breaking down and leave bedsores. On 4/18/24 at 2:24 PM, V11 (R1's daughter) said she arrived at the facility around 10:00 AM on 4/10/24. R1 told her that during the night she put her call light on to tell staff she needed to go to the bathroom. R1 said a staff person answered the call light and told her to go (urinate) in her undergarment and moved the call light away from her. She (R1) was angry and embarrassed. V1 (Administrator) was in a meeting, and I had to get back to work so I left a note on V4 (Admissions Director's) desk at 11:10 that morning that I wanted to speak to him about the situation. I also told the nurse on duty about it. This incident has changed her mood. I would not say it was abuse. I would say it was neglect. They neglected to attend to her care needs. On 4/18/24 at 3:08 PM, V8 said when she went in R1's room on 4/10/24, the call light was out of R1's reach. R1's 4/5/24 transfer evaluation showed she required 2 persons to transfer. R1's 4/5/24 care plan showed she was admitted to the facility for a skilled stay requiring physician ordered, medically necessary services including skilled nursing care, management and evaluation of the care plan, observation, and assessment of the patient's condition and/or teaching and training activities related to the reason for the stay or in preparation to transition to a lesser care environment. R1's care plan showed the intended discharge location was home and R1 was unable to turn side to side independently. R1's 4/12/24 facility assessment showed cognitively intact, required partial/moderate assistance to toilet and was occasionally incontinent of bladder and bowel. R1's 4/9/24 antibiotic therapy note showed she was on an antibiotic for a urinary tract infection. The facility's 2/2017 Abuse Policy showed the facility affirms the right of our residents to be free from abuse, neglect .Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a resident's physical or mental condition. The facility's reported incident showed V6 (an unnamed Certified Nursing Assistant/CNA) was investigated for resident neglect as R1 was dissatisfied with care. An interview with a CNA Supervisor showed V6 was not always the most pleasant. An interview with V10 (R1's daughter) was actually done with V11 (R1's other daughter and power of attorney). The investigation showed V11 said R1 was changed during the night (contrary to surveyor interview). An interview with V8 (CNA) showed R1 told her she had been soiled a long time when she was found soiled the morning of 4/10/24. This interview showed R1 was saturated in urine and all linens had to be changed. An interview with R1 showed V6 told R1 to go (urinate) in her brief and she was left in her urine for hours. R1 also said the call light was not within reach. This report showed V6 was let go due to poor performance.

Based on interview and record review the facility failed to identify a declining pressure wound, reassess a declining pressure wound, document changes of a declining pressure wound, and notify the decline to a care provider. This applies to 1 of 5 residents (R1) reviewed for pressure injuries in a sample of 6. These failures resulted in R1's (unstaged) pressure injury declining to a larger unstageable pressure injury, which required R1's hospitalization and extensive surgical debridement of the pressure injury. The findings include: The Immediate Jeopardy began on [DATE] when R1's coccyx pressure injury was identified. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 9:10 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's Facility assessment dated [DATE] showed R1 was a [AGE] year-old female cognitively impaired resident who was at risk for developing pressure injuries. This assessment showed R1 needing maximal assistance and/or dependent on staff for bed turning, transfers, bathing, and personal hygiene. R1's Progress Note dated [DATE] at 8:39 PM showed V4 (Wound Care Nurse) documented on R1's new onset coccyx pressure injury. The measurements documented were 3 centimeters (cm) by 2.5 cm by 0.5 cm, serosanguinous drainage, and a brown/yellow wound bed. This progress note showed no staging classification for the wound, or if the wound had any signs of infection present. On [DATE] at 12:30 PM, V4 stated she could not remember who or how she was notified of R1's pressure wound. V4 stated she put the progress note in, contacted the Nurse Practitioner (NP), received new orders, and placed the dressing on R1. V4 stated she was never notified of R1's wound declining after she had seen it on [DATE]. V4 stated she planned to see R1's wound on [DATE] to take new measurements, but R1 was already discharged out of the facility. V4 stated if there are changes to a pressure wound (bigger, odor, infection, etc.) the nursing staff should notify myself or a provider for new orders. On [DATE] at 3:50 PM V17 (Licensed Practical Nurse/LPN) stated if a wound is new it needs to be assessed and documented. The physician/NP should be notified for orders. V17 stated if a dressing change was new the nurse should check the last wound notes to see if there were any problems with the wound. If it is worse or has signs of infection (odor or discharge) the physician/NP and wound nurse need to be notified to update the treatment orders. The orders may include cultures or labs to verify infection. The changes should be documented in a wound assessment, wound progress note, and/or a progress note of who was being notified. On [DATE] at 10:30 AM, V12 (Certified Nursing Assistant/CNA) stated she remembered R1 had a wound on her butt near the top. The rest of her bottom was red and looked rough. The dressing was wet and fallen off. The wound was white and with a little blood on it. The nurse had to put a new dressing on. V12 stated she did not remember who the nurse was on that day. On [DATE] at 1:00 PM, V10 (CNA) stated when rounding on R1 there was a smell of something coming from R1's room. V10 stated she checked to see if R1 needed to be changed several times due to the odor. V10 stated the smell was one of those fleshy infected smells. V10 stated she let the nurse know at that time. V10 could not remember who the nurse was she reported to. The facility's working schedule dated [DATE]-[DATE] showed V12 worked [DATE] and [DATE] on R1's unit. This showed V10 worked [DATE] on R1's unit. R1's Treatment Administration Record (TAR) printed on [DATE] showed V28 (Agency Nurse) provided R1's dressing change on [DATE] and [DATE]. R1's medical record has no progress notes, wound notes, or documentation completed by V28 referring to R1's wound condition for these dressing changes. On [DATE] at 10:14 AM V28 (Agency Nurse) stated she performed a lot of dressing changes when she worked at the facility. V28 stated if the TAR is checked off it means the dressing change was completed by her. V28 stated she did not remember any specific residents dressing changes. V28 stated if a wound is bad it needs to be documented at the time of the dressing change. Look at the previous wound notes, and if it's different or infected the wound nurse needs to be notified. On [DATE] at 3:40 PM V13 (CNA) stated R1 did have a wound at the top of her bottom before she left. V13 stated at first it was about the size of a quarter. V13 stated later in the week it was bigger, and it had a dark ring around it like it was bruised. The facility's working schedule dated [DATE]-[DATE] showed V13 worked [DATE], [DATE], and [DATE] on R1's unit. R1's TAR printed on [DATE] showed V29 (LPN) provided R1's dressing changes for [DATE] and [DATE]. R1 medical record has no progress notes, wound notes, or documentation completed by V29 referring to R1's wound condition for this dressing change. During the survey, multiple attempts were made to contact V29 by phone. Messages were left to call the facility or surveyor's office. V29 did not call back at any time during the survey. On [DATE] at 1:27 PM, V11 (CNA) stated she worked the night shift the day before R1 was sent to the hospital ([DATE]). V11 stated she was cleaning up R1, and R1's dressing had come off. V11 stated the wound was located at the top R1's buttocks. The wound was about 2 inches across, and the center of the wound was black in color. V11 stated she let V14 (LPN) know the dressing needed to be changed. V11 stated she had turned R1 so V14 could place a dressing on R1's wound. V14 was the only male nurse working that unit at the time. The facility's working schedule showed on [DATE] V14 (LPN) was the night nurse working R1's unit. On [DATE] at 1:22 PM, V14 stated he did not remember a replacing a dressing on R1 during the night shifts. V14 stated if there is a new or worsening wound you check the previous notes and orders. If there is a problem the wound care nurse, following physician/NP, and/or the director of nursing should be notified. The oncoming day shift nurse should be told about the wound to make sure it would be followed up on during the day shift. R1's medical record showed no documentation (assessments, progress notes, wound notes) by V14 referencing R1's wound condition or reapplying a dressing during the [DATE] night shift. On [DATE] at 1:15 PM, V20 (Wound Nurse Practitioner/NP) stated when we get to the facility, we are provided a list of residents with wounds we need to round on. Residents with new wounds should be added to the list. V20 stated I was in the facility on [DATE] but was not notified R1 needed to be seen. V20 stated R1 is a resident they had seen in the past, but she had not seen her since August of 2023. V20 stated she was informed about seeing R1 the next week, but R1 was already admitted to the hospital before I could see her. V20 stated she was not contacted for any wound orders for R1. V20 stated if there are changes to the size of a wound, odor, darkening of color, signs, and symptoms of infection, or increase in discharge somebody should be notified so something can be done for the wound care. V48's (R1's NP) Provider Progress Note dated [DATE] showed V48 was notified of R1's new leg wound, and wound care would be managing the wound care orders. This progress note makes no references to R1 having a new coccyx wound. V48 was unavailable for interview during the survey. On [DATE] at 7:55 PM, V15 (LPN) stated in the early morning ([DATE]) she was notified by a CNA that R1 was not doing well. V15 stated when she assessed R1 she was clammy, slightly short of breath and had swelling on the right side of her neck. V15 stated R1 had a history of parotid gland (neck saliva gland) infections. V15 sent R1 out to a local hospital where she was previously treated. V15 stated it was reported to her R1 had a coccyx wound, but she did not have to change or replace R1's dressing. On [DATE] at 11:50 AM, V9 (Advanced Practice Registered Nurse/APRN at the Emergency Department/ED) stated she was the provider who took care of R1 when R1 arrived to the ED. R1 was symptomatic for sepsis in the ED. When we went to turn R1 on their sides a foul odor started coming from R1. R1 had a ,d+[DATE]-inch round pressure wound on her coccyx. V9 stated when she placed her finger in the edge of the wound, she could touch bone. The wound had purulent dark drainage, and the bottom of the wound was black. R1 had lab values correlating with being septic. R1's white cell count was just over 25.1 (high) and a lactic acid of 4.8 (very high). V9 stated she admitted R1 to the hospital's Intensive Care Unit (ICU) due to the level of infection. R1 was consulted with a general surgeon for a wound debridement. R1's hospital records dated [DATE] showed R1 was seen in the Emergency Department (ED) on [DATE] at 4:36 AM. These records showed R1's ED skin notes having a large unstageable coccyx decubitus pressure ulcer present, with copious purulent drainage and tunneling present. In the ED R1 was started on Cefepime (Maxipime) 2 Grams IV and Clindamycin 900 mg IV antibiotics for sepsis. R1's hospital records showed R1 was admitted to the hospital with the diagnoses: 1. Sepsis, due to unspecified organism, unspecified whether acute organ dysfunction present 2. Atrial flutter with rapid ventricular response. 3. Pressure injury of contiguous region involving back and buttock, unstageable, unspecified laterality. R1's hospital records dated [DATE] showed R1 had a wound debridement procedure on [DATE]. The surgical procedure summary showed: The tissue was dead down to the bone. The wound was 30cm x 10cm x 4cm deep. Approximately 25% of this wound was down to the bone. The other 75% was taken down to the muscle fascia. R1's Death certificate dated [DATE] showed R1 expired on [DATE] with causes of death listed as: Multiple organ failure, sepsis, and coccyx decubitus pressure ulcer. The facility's Pressure Injury Policy dated [DATE] showed Pressure and other injuries will be assessed weekly or as needed by facility staff or consulting clinician by utilizing a WASA (assessment tool) or other consulting clinician's evaluation. A comprehensive pressure injury evaluation will be completed for identified pressure injuries. Also, at lease daily, staff should remain alert for potential changes in the skin condition during resident care. R1's medical record had no entries of any WASAs, or Comprehensive Pressure Injury Evaluations done at the time or after R1's coccyx wound was found on [DATE]. R1's medical record showed no documentation of R1's care plan being reviewed or having updated interventions placed after R1's coccyx wound was found on [DATE]. The Immediate jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: The Interdisciplinary team (IDT) conducted a Facility wide skin sweep to identify any new or declining pressure injuries. Results of the skin sweep will be reviewed by the IDT. Care providers will be notified of any new or worsened wounds identified during the sweep. Any orders obtained will be implemented immediately. The DON or designee will provide education for Nurses and Agency nurses on new skin alteration documentation- Completed [DATE] for all nursing staff on duty, all other nursing staff to receive education by [DATE] PRN and Agency nurses will be educated prior to starting their next shift. In-house CNA staff were educated on weekly skin checks, new/worsening wounds during care, wound prevention and interventions, wound care policy (interventions), signs and symptoms of declining wounds, notification to nurse, and documentation. Goal-CNA staff not on duty on [DATE] will be educated prior to [DATE]. Agency staff will be educated prior to starting their next shift. In-house nursing staff were educated on new skin documentation, interventions for newly identified wounds, wound care policy, wound documentation, provider notification for new/worsening wounds, signs, and symptoms of declining wounds. Goal- Nursing staff not on duty on [DATE] will be educated prior to [DATE]. Agency staff will be educated prior to starting their next shift. The Medical Director has been notified of immediate jeopardy by the Administrator on [DATE]. Responsible staff: V1 Administrator, V2 Director of Nursing, Education: ongoing designee A QA/QI tool has been implemented to ensure compliance with this plan of correction and is monitored by the Administrator and/or designee. The tools are reviewed in monthly QA/QI meetings by the IDT. The results of the monitoring completed under this POC are submitted to the QA/QI Committee for review and follow up. Interventions are identified will be carried out as needed when problems are identified. An impromptu QA meeting is scheduled for [DATE]. Actions to be taken: On going audits of daily wound treatment audits to ensure treatments are being completed and documented appropriately. Daily wound care audits conducted by the DON or designee to visualize completion of treatments. Audit information will be added to the QA/QI tool and reviewed at the next meeting scheduled meetings to review the pressure injury data [DATE]. This program will remain ongoing. Interviews with staff working on [DATE] showed staff have received the education provided by the facility. Staff were able to verbalize the education they received which matched the facility's abatement plan.

Based on interview and record review the facility failed to ensure the necessary care and services were provided to one of ten residents (R1) reviewed for quality of care by not monitoring R1's blood glucose levels and by not administering insulin as ordered. This failure contributed to R1 experiencing an elevated blood glucose level which required an admission to the local hospital. The findings include: R1's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including end stage renal disease, peripheral vascular disease, dependence on renal dialysis, cognitive communication deficit, and type two diabetes mellitus with diabetic neuropathy. R1's discharge/admitting orders from the local hospital to the facility dated August 30, 2023 shows, Check blood sugar fasting, before meal, and bedtime. (Continuous blood glucose monitoring device) receive-Lantus 22 units every day, Humalog three times a day per sliding scale: 9 units bgm 150-250, 11 units 251-350, 13 units blood sugar >350. Adjust mealtime dose per blood glucose level. Insulin syringe-needle-use with Lantus nightly. R1's Medication Administration Record (MAR) dated August 1, 2023-August 31, 2023 shows no insulin was ordered or administered nor was any blood glucose levels performed. R1's Initial Nursing assessment dated [DATE] does not show any continuous blood glucose monitoring machine was noted. R1's electronic MAR notes dated August 31, 2023 shows the (continuous blood glucose monitoring device) was pending delivery. R1's MAR dated September 1, 2023-September 30, 2023 shows no insulin was ordered or administered with the exception of September 5, 2023 (Day that R1 was transferred to the local hospital) when a STAT order for insulin was obtained due to an elevated blood glucose level. There were no blood glucose levels documented. R1's Lab Results Report dated September 5, 2023 shows R1's glucose level was 383. R1's Nurses notes dated September 5, 2023 at 3:18 PM, entered by V6 LPN (License Practical Nurse) shows she placed a call to the provider via telephone related to R1's laboratory results and accucheck of high. R1's Nurses notes dated September 5, 2023 at 3:22 PM, entered by V6 shows the ambulance company was contacted and will send a crew over to transport R1. STAT insulin was given at this time. R1's Progress Notes dated September 5, 2023 at 5:18 PM, entered by V6 shows, This writer placed the (Continuous blood glucose monitoring device) this PM as it arrived evening of August 31, 2023 at change of shift. Same applied initial reading was high. R1's Progress Notes dated September 5, 2023 at 9:47 PM, entered by V6 shows R1 was admitted to the local hospital for hyperglycemia. On October 23, 2023 at 11:28 AM, V6 LPN (Nurse taking care of R1 on the day she was transferred to the local hospital with an elevated blood glucose level.) said that she could not remember taking blood glucose levels on R1 nor did she remember any glucose reading numbers. V6 said that she did not remember the day that V6 sent R1 to the hospital. V6 said she did not remember getting an order for a stat insulin. (This was all found in R1's progress notes entered by V6 on 9/5/23). V6 could not recall any events from the day that she transferred R1 out to the hospital. On October 24, 2023 at 9:05 AM, V14 NP (Nurse Practitioner) said R1 had an order for a continuous blood glucose monitoring device, but V14 did not know if R1 had the device on. V14 said that R1 had a (continuous blood glucose monitoring device) placed at some point because it gave a reading of high. V14 said she gave the nurse a one-time order of insulin STAT and to recheck R1's blood sugar. V14 said that after the insulin, R1's blood sugar still read high. V14 said R1's original admission orders should have been clarified when R1 was admitted to the facility on [DATE]. V14 said if the orders had been clarified she would have ordered Lantus long-acting insulin daily and Humalog sliding scale insulin three times per day with blood glucose monitoring four times per day. At 12:00 PM V14 said if a resident's blood sugar gets too high, diabetic ketoacidosis can occur which could place a resident in a coma. On October 23, 23 at 10:29 AM, V2 (Director of Nursing) said the orders from the hospital did not have blood sugar checks on there or anything about insulin on there. R1's sister mentioned to V2 that R1 wasn't getting blood glucose monitoring done. V2 said she did not know if R1 was admitted to the facility with the (continuous blood glucose monitoring system). V2 said if residents are admitted with (continuous blood glucose monitoring device), blood glucose levels should be checked before meals and at bedtime. V2 said if the nurse performs a blood glucose level for a resident, then it should be documented in the residents' medication administration record. On October 24, 2023 at 12:00 PM, V2 said if a resident's blood glucose level is higher than 450, the machine will read high but not give a numerical value. R1's local hospital emergency room Records dated September 5, 2023 at 7:14 PM shows, Patient apparently has not had blood sugar checks done on a routine basis at the nursing facility. R1's blood glucose level in the local emergency roiagnom on [DATE] was 591 and required insulin treatment. The facility's Diabetes Management policy dated September 2020 shows, Recognize signs and symptoms of hyperglycemia or hypoglycemia. Recognize, treat or prevent complication commonly associated with diabetes. The facility's New Admission policy dated March 2021 shows, Medications for newly admitted residents are ordered, provided by the pharmacy if they are not brought in by the resident, and initiated on a timely basis. The facility nurse will verify all admission/move-in orders provided with the attending physician before they are submitted to pharmacy or entered into an electronic system, per facility policy. For facilities using electronic medication administration records for which pharmacy entered orders automatically transmit through an interface to the facility's electronic system, the nurse will sign and date the admission orders, noting that the order were verified with the attending physician.

Based on observation, interview, and record review the facility failed to supervise a confused resident with a hot tray for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 5. This failure resulted with the resident sustaining first and second degree burns to her neck and chest. The findings include: R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including schizophrenia and dementia. R1's 4/5/23 quarterly assessment documents she has severe cognitive impairment. She requires extensive assistance of two persons for bed mobility and transfers between surfaces. She also requires supervision with eating and drinking after setting up her tray. R1's nursing progress notes for 2/27/23 at 6:29 PM documents R1 had a dinner tray containing hot bouillon broth and was at on the bedside table next to the bed and she was laying down and attempted to drink the broth and spilled on her neck and chest area. The area was the right side of the neck to center part of her chest just above the right breast line was red in color with a small open area, no bleeding noted. On 5/4/23 at 10:30 AM, R1 said she did not recall the incident or if she had any pain associated with the burn. She said V4 (Certified Nursing Assistant/CNA) helped her with breakfast this morning. She had hot coffee but not too hot. And she needs to sit up straight in the bed to eat or drink. R1 was observed sitting up in her geriatric chair with a bedside table next to her. She reached out and picked up her coffee cup from the table and was able to drink on her own. On 5/4/23 at 10:30, V4 said R1 needs to be sitting up straight in bed to eat or drink, and the meal tray is put on the bedside table in front of her. V4 said if she has foods or liquids that are too hot, the tray should be held back until it is cooled down because she is able to reach out and grab at the tray. On 5/4/23 at 2:10 PM, V10 (CNA) said on the evening of 2/27/23 she was passing meal trays and placed R1's tray on the bedside table. She thought the tray was out of R1's reach. She said the tray was placed at a distance because R1 requires supervision when she is eating and needs to be placed in an upright position in bed. V10 said shortly after placing the tray in R1's room she could hear a voice calling out for the nurse. She found R1 had somehow reached out, grabbed her soup, and had spilled it over herself. V10 said she was passing all the trays to the residents and planned on returning to R1 to assist her with the meal, but she had already grabbed and spilled her soup before she could get back to her. On 5/4/23 at 10:45 AM, V5 (Registered Nurse/RN) said R1 can feed herself, after she is positioned straight up in the bed or chair. She recalls the incident of 2/27/23 occurring at the end of her shift. She could hear a voice yelling for the nurse, and she found R1 in bed calling out. V5 said R1 had reached out and grabbed hot liquid from the meal tray and spilled it over her chest. V5 said upon assessment the skin was reddened but no open areas were visible and no blistering. On 3/2/23, V11 (Nurse Practitioner) documents she saw R1 following a nursing report of a new burn injury that occurred when she was in bed and spilled her soup onto her chest. She reached for it off her tray. The assessment shows R1 to have a first degree and area of second degree burn on her anterior (front) chest, blistered and open with pink area. The facility's 9/2020 policy for meal service documents 4. To assure that each resident receives the amount of assistance necessary. Procedure: 1. Assist resident to a comfortable position.

Based on observation, interview, and record review the facility failed to provide services, equipment, and assistance to maintain mobility and range of motion (ROM) for 1 of 4 residents (R64) reviewed for ROM/mobility in the sample of 32. This failure resulted in R64 developing left foot drop and experiencing tightness in her left shoulder and left hand. The findings include: On 9/6/22 at 10:52 AM, R64 was sitting up in her wheelchair, visiting with her roommate (R59). R64's left arm was flaccid and resting in her lap. R64's fingers on her left hand were curled in towards the palm of her hand. R64 stated, I had a stroke, and my left side doesn't work anymore. They call this a rehab facility, but they don't do much rehab here. Nobody has done anything with my hand or arm in a while. I asked to speak to OT (Occupational Therapy) a while ago and I never got to see her. I wanted to ask if there were any tricks make it easier to use just one hand for things. My shoulder socket is getting stuck like this. (Resident demonstrated that her left arm is tight against her left side). And my hand keeps going into a claw, but they won't give me a brace for it. I will tell them about it, and they say, We'll see. My left arm is so tight to my side now. It barely moves. I painfully, open my left hand every day with my right hand and massage it. I don't think I have a Restorative Program. My left ankle is freezing up in one spot. When my shoes are off, it feels like I would walk on the outside of my foot. It's getting really tight. If it curls up at night, then I just use my right foot to straighten out the left foot. Nobody comes in here to do exercises with me. I try to do some myself. I can wheel myself around in this chair, but it's very tiring and hard. I use my right arm to move the wheel and guide with my right leg. I had a doctor at the other rehab facility, and he said that I would be walking again with time. I don't see that happening now. It's very disappointing. It's been 1-2 months since I had PT (Physical Therapy) or OT. I think they check us quarterly for that. I've asked for a walker to practice getting up and sitting down to strengthen my legs, but he wouldn't leave it. I'm not sure why. Maybe because I'm just too weak. If they worked with me, then I would do the exercises. It's the only way to get better. I was hoping to go home, but they said I have to stay here because I need 24-hour care. I was in my own apartment before I had the stroke. On 9/07/22 at 11:36 AM, R64 said she was surprised she wasn't getting more therapy. R64 stated, I was getting it every day at the other place and that doctor told me that I would walk again. Here they tell me I can't walk. R64's lunch tray was in front of her. R64 was having difficulty opening the plastic lid, on a styrofoam cup. R64 became frustrated and stated, I can't get that lid off! The edges of the plastic lid were bent, but the lid was still intact on top of the cup. R64 stated, It's so hard with one hand. I have a lot of trouble. R64's Face sheet dated 9/8/22 showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R64's facility assessment dated [DATE] showed she had moderate cognitive impairment; did not exhibit rejection of care behaviors; required extensive assistance of two or more staff for bed mobility and transfers; required extensive assistance of one staff for dressing, toilet use, and personal hygiene; required supervision of one staff for eating; and had impairment to one upper extremity and both lower extremities. R64's Post-acute Rehabilitation paperwork dated 12/20/21 showed an estimated length of stay (LOS) of 2-3 weeks at the facility and the resident should be able to return home with home health care and assistance in the community. These documents showed R64 had good rehab and medical prognosis. R64 had left [CONDITION(S)] and was very focused on improving facility of left-side motor return as well as incorporation with left extremity in daily tasks. R64 had a deficit in mobility, self-care, and safety. R64 should work with PT and OT to improve bed mobility, transfer, ambulation, and self-care activity. The plan included PT comprehensive evaluation and goal setting to include the following: energy-strength, balance, ROM, and endurance; improve mobility skills in bed, transfer skills, wheelchair, bed, commode, mat activities, weight training with and without assistive device, carpeted surfaces, indoors, outdoors, stair climbing; improve static and dynamic sitting and standing balance; family/caregiver training; and equipment. The plan included OT to include the following: comprehensive evaluation, goal setting; instruct patient on energy conservation, joint-protection skills, upgrade upper limb strength, balance, ROM, and endurance; improve self-care skills including oral/facial hygiene; upper and lower limb dressing, bathing, feeding, toileting; upgrade homemaking and meal prep skills; home-environment evaluations; and family care giver training. R64 was agreeable to all forms of therapy (PT, OT, ST) at post-acute rehab facility. R64's Physical Therapy Notes started 1/8/22 showed, . Patient goals: I want to be functionally independent to get to (assisted living facility). Potential for Achieving Goals: Patient demonstrates excellent rehab potential as evidenced by high PLOF (Prior Level of Function), stable medical condition, motivated to participate and motivation to return to PLOF . Reason for referral: Patient is . admit from (post-acute rehab facility) due to acute multiple left infarct involving [NAME], corpus callosum, external capsule resulting in left sided weakness. Patient referred to PT due to new onset of decrease strength, decrease in functional mobility, increased need for assistance from others and reduced ADL participation placed resident at risk for decreased ability to return to prior level of assistance, falls, further decline in function and increased dependency on caregivers . Prior Living Environment = Patient resided in private residence . Strength/Manual Muscle Testing: LLE strength = 2/5 (Part moves partial range on a gravity eliminated plane). LUE Strength 2/5 . Balance: Static Sitting = Fair (maintains balance unsupported without LOB (loss of balance) or UE (upper extremity) support); Dynamic Sitting = Fair (maintains balance with minimal assist or UE support . Tone and Posture . LE Muscle Tone = Normal (hypotonic muscle tone on LLE) . Gross Motor Coordination = Intact . Clinical Impressions: Patient has new onset left sided weakness due to stroke and is currently needing max-dep assistance in all aspects of mobility and ADLs, currently unable to transfer and ambulate due to impairments, and will be needing skilled services to address needs . Risk Factors: Due to documented physical impairments and associated functional deficits, the patient is at risk for: compromised general health, contracture(s), decreased ability to return to prior level of assistance, decrease in level of mobility, decreased participation with functional tasks, decreased skin integrity, falls, further decline in function, increased dependency upon caregivers and limited out-of-bed activity . R64's Physical Therapy Discharge Summary dated 2/22/22 showed, .Prognosis to Maintain CLOF (Current Level of Function) = Good with consistent staff follow-through . Discharge recommendations: 24-hour care. R64's Physical Therapy Notes started 7/9/22 showed, Resident is in SNF (Skilled Nursing Facility) with a history of [CONDITION(S)] (stroke) resulting in left sided [CONDITION(S)] since January 2022, referred to PT for quarterly evaluation and treatment due to risk for further functional decline, increased caregiver burden, and decreased ability to transfer . Strength/Manual Muscle Testing . LLE (left lower extremity) = 1/5 (Tension is palpated in muscle or feeble contraction is felt but no visible motion occurs in joint). Static Sitting - Poor (maintains balance with max assist and upper extremity support); Dynamic Sitting: Unable (total dependence).Static Standing = Unable (total dependence) . Tone and Posture . LE (Left Extremity) Muscle Tone = Flaccid . Gross Motor Coordination = Impaired . Clinical Impressions: Patient is currently below baseline level of function and has shown significant decline in functional mobility, reduced participation in OOB (out of bed) activities, and increased need for caregiver assistance . (These notes showed a decrease in mobility and ROM from R64's initial Therapy notes). R64's Physical Therapy Discharge Summary dated 7/21/22 showed, Prognosis to Maintain CLOF = Good with consistent staff follow-through . Discharge Recommendations: Patient discharged to LTC (long-term care) with referral to restorative nursing for continued daily bed to/from wheelchair transfers using sit to stand machine . R64's OT Discharge Summary dated 1/9/22 - 2/22/22 showed, . Discharge Recommendations: Assistive device for safe functional mobility, elevated toilet seat/3 in 1 commode, environmental modifications, reacher and long handled sponge. RNP (Restorative Nursing Program): To facilitate patient in maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs has been completed with the IDT (Interdisciplinary Team): bed mobility, dressing, transfers, ROM (Active) and ROM (Passive). R64's Task List printed on 9/8/22 showed the only Restorative Programs R64 had were Bed mobility and Dressing. R64's Restorative Nursing assessment dated [DATE] was not completed. (This would have been a quarterly assessment). R64's Restorative Nursing assessment dated [DATE] showed R64 required a mechanical sit to stand lift for transfers; did not have any orthotic or adaptive equipment in place; and had ROM (Range of Motion) limitations to her left shoulder, wrist, hand, and ankle. This assessment showed, Based on the assessment the Residents priority programs will be: c. Bed mobility/walking . e. dressing/grooming . (the options a. PROM/AROM. b. Splint or Brace Assistance . and d. transfers were not chosen for R64.) This assessment showed no changes were made to R64's Restorative Program. R64's Nursing Rehab: Bed Mobility: R64 will roll side to side during cares and repositioning with use of 1/4 side rails and staff cues and assist as needed Task from 8/10/22 - 9/8/22 showed this program was not documented on 8/20, 8/25, 9/3, or 9/4. R64's Nursing Rehab: Dressing: R64 will dress in clean pants and shirt daily and PRN with staff cues and assist PRN Task from 8/10/22 - 9/8/22 showed this program was not documented on 8/20, 8/25, 9/3, or 9/4. R64's Task did not include AROM or PROM. R64's Care Plan initiated 1/24/22 showed, R64 requires ADL assistance secondary to [CONDITION(S)] (stroke) . Interventions/Tasks: . Provide range of motion (ROM) to affected extremity as ordered . Refer to therapies as indicated . R64's Care Plan initiated 1/16/22 showed, R64 requires assist from staff to dress daily . Interventions/Tasks: . Monitor for changes in ROM when dressing extremities . R64's Provider Notes dated 8/2/22 showed, . The resident is able to express their needs, wants, and answers questions appropriately . Left [CONDITION(S)]/[CONDITION(S)] with footdrop (this was not present on 4/8/22 provider note) .Alert, oriented to person, place, time, speech is clear . Calm, cooperative . Mood and affect at baseline . Assessment: . [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side. Chronic. Continue supportive care. Ok for restorative program and therapy as indicated . R64's Progress Notes were reviewed since admission (1/8/22). There was no documentation of refusals of therapy or Restorative Nursing Programs. On 9/8/22 at 11:42 AM, V12 (CNA - Certified Nursing Assistant) said R64 is alert and oriented but can have some episodes of confusion. R64 is able to make her needs know and uses her call light. R64 isn't able to use her left side because of her stroke, but she does use the right side. R64 uses her right leg to move her left leg. She can't move her left leg. She can't open her left hand herself, but I can open it. I've never seen any splints on R64. She can't lift up her left arm either. I have to lift it up for her, when she gets dressed. The Restorative Aide does the exercises, ROM, and Restorative Programs with the residents. They should chart it in the Tasks. I haven't had R64 refuse any care for me. On 9/8/22 at 11:51 AM, V8 (Restorative Nurse) said Restorative Assessments are completed on admission, 7 days after admission, quarterly, and with any significant change. I'm not sure why R64's 4/14/22 (Quarterly) Restorative Assessment wasn't completed. These assessments are done to evaluate the resident's progress and make changes to their programs, as needed. R64 is a LTC (long-term care) resident. Every resident on LTC should have at least two restorative programs. If a resident is having an issue with a specific ADL or mobility issue, then I will try to tailor their restorative program to their needs the best I can. The restorative programs can improve or maintain the residents' functional abilities. When a resident is discharged from therapy, then I will follow the therapy recommendations. I take their recommendations to heart. This is their lane. I'm going to listen to what they say. I don't know why I didn't place R64 on transfer, AROM or PROM programs (as recommended by OT). AROM and PROM programs would be important for stroke residents with [CONDITION(S)]. The goal is to keep their strength on their good side and prevent contracture on the bad side. The Restorative Aide isn't the only staff that can perform ROM exercises. All programs should be completed at least daily, but the more the better. The additional training will help with muscle memory and the repetition keeps it locked. I was not aware of R64's request for a brace. Braces are usually ordered by therapy for contractures. I don't determine what a contracture is and/or the proper treatment. That is beyond my scope. A hand splint may be appropriate if I notice a contracture, or a closed fist is starting to develop. If I notice this, then we can place a washcloth in the resident's hand without a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . AROM and PROM are helpful for residents with [CONDITION(S)] (R64) to prevent development of contractures and maintain joint mobility. If a resident has foot drop, then a foot/ankle brace may be necessary. I was not aware that R64 had foot drop. (Documented by NP on 8/2/22). The surveyor informed V8 of R64's complaints of, tightness in my hand, shoulder, and ankle; feels like her arm is pinned to her side; and her foot curls out and feels like she would walk on the outside of her foot, especially when her shoe is off. On 9/8/22 at 12:54 PM, V13 (Therapy Director/PTA) said when residents are discharge from therapy, the therapist will make recommendations for Restorative Nursing Programs (RNPs). I'm not familiar with R64, but I can review her records. V13 said R64's notes showed that R64 wished to be independent and got to (an assisted living facility). I don't see any reports of refusal of therapy or non-compliance in R64's therapy notes. R64 saw therapy for a long time after admission. I would assume she was seen so long because she was working. R64 would definitely have a better chance of maintaining her strength and abilities if her RNP programs were implemented and performed. It would be difficult for a resident to perform PROM without assistance. I'm not aware of R64 being evaluated for splints or braces. That information would be in the EMR, not in the therapy computer system. Decreased ROM is a precursor to contractures. R64's left sided flaccidity puts her at risk for contractures, bed sores, and an overall decline in transfer status. I would expect the RNP recommendations from the therapists to be implemented by the Restorative Nurse. On 9/8/22 at 3:07 PM, V14 (Nurse Practitioner) said R64 had left footdrop and tightness in her arm is developing. We talked about stretching and exercises. She acknowledges an understanding, but not sure if she does exercises. I don't remember anyone asking me about braces or splints for R64. I noticed R64's footdrop a few months ago. R64 is on a Restorative Program, and I would expect it to be completed. The residents should be evaluated quarterly by Restorative. If a resident is unable to meet therapy goals, then it is important to do RNPs. It provides the resident with more time to develop a tolerance point to do more therapy. R64's goal was to return home. R64's mobility and functional ability may have been affected by the facility's failure to follow therapy recommendations and complete RNP programs as ordered. The facility's Restorative Nursing Program Policy dated 3/10/22 showed, It is the policy of this facility that a resident is given the appropriate treatment and services to enable residents to maintain or improve his or her abilities and to promote the resident's ability to adapt and adjust to living as independently and safely as possible. Increased independence fosters self-esteem and promotes quality of life for residents . Policy Interpretation: 1. The purpose of a Restorative Nursing Program is to: a. Restore to original status or improve level of independence after a decline in Activities of Daily Living (ADLs), and/or b. Stabilize the primary problem, and/or c. Prevent secondary complications, and/or d. Maintain or improve functional abilities in ADLs, and/or e. Promote ability and wellness and where possible, prevent decline or loss of independence, and/or f. Enable residents to attain or maintain their highest practicable level of functioning. 2. A Restorative Nursing Program may be established: .b. When restorative needs arise during the course of a longer-term stay, or c. In conjunction with formalized rehabilitation therapy. 3. Activities provided by restorative nursing staff include: a. Range of Motion: i. Passive; ii. Active. b. Splint or Brace Assistance; c. Bed mobility; d. transfer; e walking; f. Dressing and/or Grooming . Procedure: 1. Admission and periodic functional assessment (via the RAI schedule) will be conducted by IDT. Findings will assist in determining the resident's potential for maintaining or increasing their functional capabilities . 7. The restorative nurse will review the functional assessment and care plan with involved nursing staff and therapy to assure specific needs are identified, plan implemented, and resident placed in the appropriate restorative program(s) . 9. Program goals will be documented in POC task section. Restorative, nursing, therapy, and/or any other trained personnel will document the resident's participation . 11. The restorative nurse will complete a periodic evaluation at least quarterly that will reflect the resident's tolerance and progress towards goals .

Based on interview and record review the facility failed to fully assess, document and treat a pressure ulcer on a resident's sacrum. This failure resulted in R1 leaving the facility with a large, unstageable, infected pressure ulcer requiring hospital evaluation and treatment with antibiotics upon discharge. This applies to 1 of 3 (R1) residents reviewed for pressure ulcers in a sample of 3. The findings include: R1's EMR (Electronic Medical Record) shows that R1 was admitted to the facility on [DATE] and discharged on [DATE]. R1's Progress Notes dated 4/23/21 state, Has skin alteration. Sacrum wound red wound bed. Scant serosanguineous drainage. [MEDICATION(S)] applied. There is no documentation of wound size, depth, tissue type or stage. R1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/4/21 at 12:00PM V1 (Administrator) stated, We want the wound to be assessed by the nurse practitioner and (R1) discharged before the nurse practitioner could do that. For consistency sake we want the wounds assessed by the same person. On 5/4/21 at 10:30AM V3 (Assistant Director of Nursing) stated, V5 (Wound Nurse) is off on FMLA so I have been one of the people helping to cover for her. (R1) came in with a surgical wound. She developed a pressure sore here and I was not able to assess her before she discharged (6 days). There is no assessment of the wound- I didn't get a chance to do it. (V4- RN) saw the wound initially and she is off on vacation now. On 5/5/21 at 9:50AM V4 (RN) stated, I usually measure the wound when I find them- I don't know why I didn't that day. I don't know what was happening that I didn't do it. We usually just write it in our progress notes and then the wound care nurse fills out the WASA (Weekly Assessment of Skin Alteration) form. On 5/4/21 at 3:00PM V1 stated, I spoke to (V4) and she stated that the wound was about 0.5 cm x 0.5 cm, circular and red. V3 then concurred with that assessment. On 5/6/21 at 11:50AM V11 (Nurse Practitioner) stated, I never saw (R1's) sacrum. She left before I got a chance to see it. I know she always refused to turn and didn't ever want to get up so she was definitely high risk- as I said she was very frail. On 5/6/21 at 12:00PM, V15 (Home Health Case Manager) stated, When the (Home Care Nurse) saw (R1) on 4/30/21 her sacral wound was unstageable. He documented the measurements as : 9cm x 7.5cm .We had no description of the pressure ulcer (upon discharge). We called the doctor and she said to send her to the hospital E.R. for further evaluation. The Hospital documents dated 4/30/21(1 day after discharge) state, [AGE] year old female that presents to the ER with a sacral wound and bilateral skin tears to her shins after being discharged from a local extended care facility yesterday post rehab for hip replacement surgery. She was discharged to home and today while home health was there for evaluation it was noted a sacral wound and they were referred to the ER due to the extensive wound. Sacral Wound approximately 7cm across, redness, tenderness, black base of the wound, foul odor noted. Multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Pressure Ulcer of the sacral region, unstageable. [MEDICATION(S)] (Antibiotic) twice a day for 10 days ordered for infection. R1's Braden Scale (Skin Risk Assessment) form dated 4/20/21 shows that R1 scored a 14 (13-14= Moderate Risk). R1's Braden Scale form dated 4/27/21 shows that R1 scored a 16 (15-18= Mild Risk) R1's Care Plan initiated 4/6/21 does not address R1's pressure ulcer. The facility policy entitled Weekly Assessment of Skin Alteration (WASA) Form dated 3/2021 states, 3. The WASA should be completed weekly and PRN. 5. Based on the findings of the completed WASA form: a. Determine appropriate interventions/ changes and implement as needed on the care plan.

Based on interview and record review the facility failed to ensure a door alarm was activated and failed to supervise a resident that had previous elopement attempts. These failures resulted in R1 exiting the building through the door with an inactivated door alarm unknown to staff on 3/12/21. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy that began on 3/12/21 shortly after 3:10 PM when R1 was last seen in his room. V1 (Administrator) was informed of the Immediate Jeopardy on 3/18/21 at 10:10 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed and the deficient practice corrected on 3/13/21, prior to the start of the survey and was therefore Past Noncompliance. This applies to 1 of 3 residents (R1) reviewed for safety/supervision in the sample of 3. The findings include: The facility's reportable event email sent to the Illinois Department of Public Health showed on 3/12/21 R1 exited the facility. R1's Face Sheet showed R1 had the diagnosis of Alzheimer's disease. Part of R1's Post-acute Rehabilitation Pre-Admission Screening information was a letter from V11 (Nurse Practitioner) and V12 (Physician). The letter was dated 2/2/21 and showed R1 had, Severe dementia and due to this medical condition, R1 cannot live alone. R1's Progress Note dated 3/8/21 showed at 6:03 AM, [R1] attempted to leave the facility. He pushed the back door causing the alarm to sound. Redirected back to room, said he was looking for his car to go home. R1's Progress Note dated 3/8/21 at 2:08 PM, showed, Elopement attempt diverted. [R1] was focused on assisting his wife as he stated she will be moving. He was informed of his long term care status and of his [diagnosis] of Alzheimer's disease . Part of R1's Post-acute Rehabilitation Pre-admission Screening information was a Progress Note from V11 indicating R1's wife passed away in 2012. R1's Progress Note dated 3/8/21 at 7:40 PM, showed R1 verbalized he wanted to leave the facility and was angry with his spouse for taking money. On 3/17/21 at 10:28 AM, V4 (Certified Nursing Assistant) said she was familiar with R1 and that R1 was confused. On 3/17/21 at 10:15 AM, V3 (Licensed Practical Nurse) also said R1 was confused. On 3/17/21 at 10:25 AM, R1 said on 3/12/21 he exited the building through the D wing door. R1 said no alarm sounded when he exited through the door. R1 said he wanted to go outside for a walk and, [He] didn't know where he was going. R1 said he was standing in the south end of the parking lot by the facility's sign near a busy four lane road when the local police picked him up. R1 could not recall what the police said to him or how long he was outside. R1 added the police put him in the police car and brought him back to the facility's entrance. On 3/17/21 at 8:55 AM, V1 (Administrator) said on 3/12/21 R1 exited the building through the D wing door. V1 said the alarm on the D wing door was turned off and did not alarm when R1 exited through the door. V1 said the facility was not aware R1 exited the building. V1 said when the D wing exit door alarm is activated a key is used to turn off/silence it and the key needs to be used to turn the alarm back on. V1 said the local police brought R1 back to the building after the police received a phone call about a confused looking man by [NAME] road. V1 said R1 was back in the building no later than 3:50 PM. On 3/17/21 at 9:43 AM, V2 (Vice President of Operations) said the D wing door alarm should have been active/turned on. V2 said the last time staff saw R1 in the building on 3/12/21 was at 3:10 PM. On 3/17/21 at 12:30 PM, V5 (Police Dispatcher) said on 3/12/21 at 3:27 PM they received a welfare check call for someone near the corner of [NAME] road. and [NAME] road. On 3/17/21 at 10:46 AM, V9 (R1's Daughter) said she received a phone call on 3/12/21 at 3:46 PM from the local police saying they had R1. V9 informed the police R1 was a resident of the facility. V9 said once she hung up the phone she called the facility. On 3/17/21 at 11:38 AM, V6 (Receptionist) said on 3/12/21 she started work at 3:30 PM and shortly after starting work she received a phone call from V9. According to V6, V9 said the police found R1 outside and they were bringing him back. V6 said within 20 seconds of hanging up the police where at the door with R1. A written statement provided by V13 (Maintenance) showed on 3/12/21 after R1 was brought back to the facility by the police a door audit was done. The statement showed the D wing door alarm was found to be turned off. The Immediate Jeopardy immediacy that began on 3/12/21 was removed on 3/13/21 when the facility completed the following: 1. Checked all exterior door for proper alarm and function done on 3/12/21. 2. Additional door alarm added for higher level of auditory recognition by staff done on 3/12/21. 3. Maintenance immediately came and assessed the alarm and supervision of the door was maintained until a root cause could be identified and corrected done on 3/12/21 4. All staff in-serviced by the administrator, social services, and director of nursing (DON) on the need to 1) keep an eye out for any resident loitering around an exit door or other exit seeking behavior and report the behavior immediately for a quick intervention. 2) Immediately report any door that is not alarming correctly. 3) Report these behaviors and malfunctions to the administrator and/or DON done one 3/13/12. 5. All staff in-serviced on the proper procedures for door alarm silencing and rearming done on 3/12/21. 6. Facility wide sweep conducted to ensure that all exit seeking behaviors were identified and assessed with appropriate and received matching plans of care done on 3/12/21. 7. Alarm silencing and rearming instructions posted next to all alarms done 3/12/21. The deficient practice was corrected on 3/13/21 after the facility did the following: 1. Notified R1's family done on 3/12/21. 2. Discussed with the family potential for a specialized dementia unit done on 3/13/21. 3. Police report obtained and reviewed for details on 3/13/21. 4. Body check for R1 was completed with no evidence of harm or injury identified done on 3/12/21. 5. R1's Physician was notified with no new orders done on 3/12/21. 6. R1 was located to another room closer to the nursing station and put on one-to-one supervision until Monday 3/15/21 at 2:00 PM. R1 was reevaluated for further interventions at that point done on 3/12/21. 7. Wanderguard band applied to R1 done on 3/12/21. 8. Elopement Risk Assessments reviewed by Nursing Clinical Managers for everyone in the building. Interventions for each of the high risk people were re-evaluated to ensure that the interventions remained in place and were resident specific and appropriate done on 3/12/21. 9. Wanderguard book with pictures was double checked by the administrator and social services to ensure pictures were current and residents at risk were all in the book done on 3/12/21. 10. All exterior alarmed doors are checked daily and logged into a preventative maintenance log done on 3/12/21. 11. Interviews of staff conducted to ensure that all exit seeking behaviors were identified and assessed with appropriate follow up measures done 3/12/21. 12. Nurses in-serviced by the DON on the need to do a new risk assessment when someone exhibits a new exit seeking behaviors and the need to put an immediate resident specific interventions in place done on 3/12/21. 13. A Joint Commission approved root cause analysis was conducted for the event and resident centered interventions were incorporated into the plan of care. 14. Joint Commission approved environmental rounding completed daily by the administrator and building manager of surrounding the door to ensure environmental safety done on 3/12/21. 15. Staff quizzes done on 3/13/21. 16. Elopement/missing resident drill to be done once a week for the next month done on 3/12/21. 17. Assessments of R1 done by social services to determine if a locked memory care unit is a more appropriate and safe placement done on 3/12/21. 18. Shift to shift head counts have begun immediately with nurses on each shift every day started on 3/12/21.

Based on observation, interview, and record review the facility failed to ensure a hazard free environment for a resident (R1) with a known history of self injurious behaviors. This applies to 1 of 3 (R1) residents reviewed for safety in the sample of 6. This failure resulted in R1 obtaining razor blades and cutting her arms resulting in sutures. The findings include: R1's Face Sheet shows an original admission date of [DATE] with [DIAGNOSES REDACTED]. R1's 7/1/2020 Minimum Data Set showed her to be cognitively intact, with hallucinations and delusions. R1's 8/8/2020 Behavior Assessment showed, Nurse went to see (R1) and found that she had taken a razor and sliced up and down both arms .This writer asked R1 where she got the razor. She stated that a hospitality aide gave her a razor for use in the shower and she did not give it back. She (R1) was asked why and she stated that she had unmet expectations about being discharged soon and she was consumed with depression. She stated she cuts in order to relieve the emotional pain that she has. R1's 8/8/2020 Emergency Department notes showed, Patient has multiple linear abrasions and lacerations above (upper) extremities. About 12 on each upper extremity. She does have 2 lacerations (cuts) requiring suture repair on the left upper extremity of a 3 cm (centimeter) length each . On 8/19/2020 at 1:52 PM, V2 Director of Nursing (DON), stated at approximately 3:30 PM on 8/8/2020 she responded to R1's call light. V2 said R1 wanted her to look at her arms at which time she noted the lacerations to bilateral upper arms. V2 said when she got R1 up to the bathroom she found 3 razors wrapped up in paper towels that was stuffed inside her pants. On 8/19/2020 at 8:45 AM, R1 was observed with multiple lacerations to both of her upper arms. The lacerations were red, scabbed, and some with bandages. R1 also had scars on bilateral arms that matched the appearance of previous self cutting attempt. On 8/19/2020 at 8:55 AM, R1 stated she had a history of [REDACTED]. R1 said, I feel safer when they don't let me have those things. On 8/19/2020 at 11:47 AM, V4 Psychiatric Rehabilitation Services Coordinator (PRSC) stated, In an ideal world, the counselors get the mail for the residents (on behavioral health units) and because of COVID the packages have to sit on a table for 24 hours. Then we (PRSC's) usually go and get the packages and bring it to the person. Packages are opened in front of us to make sure it's not something bad, even food, if the person is diabetic, can be harmful. V4 stated, R1 should not have had a razor in her possession at any time. V4 stated, residents on the behavioral health unit who are safe to have razors are allowed to have them; however, they are monitored and the staff take it back .monitored means when they are in the shower, shaving, you are watching them, so the staff are there with them the whole time until they are done with the razor then they take it back. On 8/19/2020 at 10:30 AM, V5 Behavioral Health Director stated he has known R1 for several years and she had a history of [REDACTED]. V5 stated, R1 should never be given a razor even if being watched and staff should do the shaving for her. V5 said, we believe she got it (razor) from the roommate. V5 said, on the behavioral health unit, residents can ask for razors and are told they need to give it back when they are done. On 8/20/2020 at 9:26 AM, V7 Hospitality Aide stated residents on the behavioral health unit that can have razors, we just have to ask for it (razor) back. V7 said, We just have to kind of remember to get it (razor) back. V7 said, she was not aware of any documentation that let's her know who can or cannot have razors. V7 said that information comes from on the job training. On 8/19/2020 at 1:30 PM, V8 Certified Nursing Assistant stated, packages for residents on the behavioral health unit are supposed to be opened with the resident in the presence of the counselor (PRSC). V8 said, residents who can have razors are given the razor and are told to bring it back otherwise she would have to go get it when the resident was done. V8 said, the facility has no policy on tracking which residents received razors and if they were returned. On 8/19/2020 at 11:25 PM, V9 Licensed Practical Nurse stated the razor policy on the behavioral health unit is, CNA's are supposed to be there. That has always been the policy; that CNA's do the shaving or they stay and monitor. (Inconsistent policy statements amongst behavioral health staff) R1's Care Plan from 3/3/2020 showed, (R1) has numerous scars on her body due to a hx (history) of cutting. All items brought into (R1) will be viewed by staff for safety. The Care Plan also showed, All shaving will be monitored and tool taken back after each use. On 8/19/2020 at 2:35 PM, V2 stated she was unable to find a policy regarding razor use and tracking for the behavioral health unit. On 8/20/20 at 9:00 AM, V6 Family Nurse Practitioner stated an intervention to prevent a resident with a history of cutting from expressing that behavior would be no access to razors.

Based on observation, interview, and record review the facility failed to ensure a resident's wound dressing was in place to prevent wound contamination. The facility failed to put interventions in place after indentifying a deep tissue injury to a resident's heel. The facility failed to reposition a resident to prevent pressure ulcers. This failure contributed to R19's pressure ulcer to her coccyx becoming infected on June 11, 2015. This applies to 2 out of 11 residents (R19, R14) reviewed for pressure ulcers in the sample of 23. The findings include: 1. The electronic medical record for R19's [DIAGNOSES REDACTED]. On June 10, 2015 at 9:52 AM, R19 was sitting on the toilet in the bathroom. She was having diarrhea. E13 (Licensed Practical Nurse-LPN) stated, the CNA (Certified Nursing Assistant-CNA) removed the dressing to her coccyx because it was soiled. E18 (CNA) provided perineal care to R19. E13 stated,E18 can finish cleaning her up, then lay her down, and then we will put the dressing on. E13 did not clean the coccyx wound or put a dressing on the wound. On June 10, 2015 at 9:52 AM, R19's coccyx wound was a dime sized open area with visible depth. The tissue was bright red with white tissue in the middle of the wound. On June 10, 2015 at 9:52 AM, R19 stated,It's very sore down there. On June 11, 2015 at 7:55 AM, Z2 (Wound Care Physician), Z3 (Wound Care Nurse Practitioner), and E9 (Licensed Practical Nurse-LPN) provided wound care to R19's coccyx wound. Z2 stated,We cleaned it (coccyx wound) out and I think it is infected. The Wound Care Evaluation dated June 11, 2015 for R19 shows an unstageable wound to the coccyx measuring 1.5 cm X 1.3 cm X 0.3 cm. The other tissue around the wound was swollen and had an odor. Antibiotic treatment was ordered for the wound infection. On June 11, 2015 at 9:52 AM, Z2 stated,It (coccyx wound) gets infected by incontinence. The Minimum Data Set, dated dated dated [DATE] shows R19 to have no behaviors or refusals of care. The care plan dated 5/15/2015 for R19 shows no behaviors or refusals of care. On June 9, 2015 at 2:49 PM, R19 was in bed sleeping. Her heels were not offloaded. On June 10, 2015 at 1:06 PM, R19 was in bed sleeping. R19's heels were not offloaded and she had slippers on. The facility's wound and skin assessment dated [DATE] showed R19 had a deep tissue injury to the left heel. The wound measured 4cm X 3.5cm with purple tissue. The risk for skin breakdown form dated May 22, 2015 showed R19 to be at moderate risk for skin breakdown. On June 11, 2015 at 7:55 AM, Z1, Z2, and E9 provided wound care to R19. The wound to the left heel was approximately the size of a half dollar. The wound was closed with blackish tissue. The wound care evaluation dated June 11, 2015 shows R19's left heel to measure 4.5cm X 3.8cm with 100% brown tissue. The care plan dated May 15, 2015 for R19 does not address the wound on her heel. The facility's prevention and treatment of [REDACTED]. 2. R14's Minimum data set ((MDS) dated [DATE] shows she requires extensive assistance of two persons for transfers, always incontinent of bowel and bladder, and no rejections of care. On June 9, 2015 at 8:30 AM, R14 was in her wheelchair eating breakfast. At 10:10 AM, R14 was in her wheelchair sleeping. At 2:05 PM, R14 was in her wheelchair in her room. At 2:45 PM, R14 was transferred to bed. On June 9, 2015 at 2:05 PM, E15 (Certified Nursing Assistant-CNA) stated, She (R14) has been up since lunch. On June 11, 2015 at 9:55 AM, E17 (Assistant Director of Nursing) said R14 currently has three open areas. E17 stated, I think she got them from being up all day long. E17 also stated, R14 needs more scheduled rest time. She (R14) does not lie down between meals. R14 gets up in the AM and stays up all day. E17 said this is not currently on R14's care plan. R14's Weekly Assessment of Skin Alterations (WASA) dated May 30, 2015 documented a 3cm x 1cm stage 2 to her left sacral area. No other areas were identified. R14's June 1, 2015 WASA documented a new 3cm x 0.5cm stage 2 pressure ulcer to her gluteal folds. R14's June 4, 2015 WASA documented a new 3cm x 1cm stage 2 pressure ulcer to her coccyx area. R14's June 10, 2015 WASA documented a new 0.3cm x 0.2cm open area to her right medial buttock. R14's May 10, 2015 Care Plan for skin integrity does not document any interventions about how often the reposition the resident. The facility's June, 2013 Prevention and treatment of [REDACTED].

Based on observation, interview and record review the facility failed to eliminate pressure to R1's foot. The failed to assess and document the wound characteristics for R1's pressure area. This applies to 1 of 3 residents (R1) reviewed for pressure ulcers in the sample of 5. The findings include: The facility's electronic [DIAGNOSES REDACTED]. On 5/13/15 at 9:35 AM, R1 had a wound on the plantar (front-bottom) area of his right foot. The wound bed was clean approximately 0.2 cm in depth. The edges of the wound bed were rolled down toward the wound bed. There was (black neurotic tissue) around the edges of the wound. The wound was surrounded by a large white/yellow hard calloused area. R1 had an open area to the tip of the middle toe on the left foot. The wound was red and moist with some granulation tissue. R1 stated the shoes he had been wearing since April (of this year) had been rubbing on his feet --where the wounds are located. On 5/13/15 at 11:58 AM, E3 (Director of Nursing-DON) said R1 was admitted in December with surgical wounds which healed. His current wounds were acquired at the facility. On 5/13/15 at 9:35 AM, R1 said he has had the open area on his right foot since 4/6/15 and the open area on his left foot since 4/29/15. On 5/13/15 at 12:23 PM, E5 (Licensed Practical Nurse-LPN) was asked by this surveyor when R1's wounds opened up. E5 stated, I'm not certain, I don't see any WASA (Wound and Skin Assessment) for him. On 5/13/15 at 12:34 PM, E3 said R1 goes out to see his own doctor for his wounds. I'm not aware why his wounds are not being followed in the facility as pressure ulcers. E3 said when the treatments are being done by the nurses an assessment of the wound characteristics should be made and documented. On 5/13/15 at 3:15 PM, E4 (Vice President of Operations) stated the facility is following the progress of R1's wounds, Through the doctor's progress notes and the new orders. On 5/13/15 at 10:40 AM, E7 (Board Certified Gerontological Nurse Practitioner-Wound Care Nurse) stated, I have not seen him (R1). He is not on my list. On 5/13/15 at 10:30 AM and 11:45 AM, requested any documentation the facility had regarding R1's open areas on both feet from E3. On 5/13/15 at 3:15 PM, the facility provided the Physician's Progress notes of 4/27/15 and 5/6/15. The physician progress notes [REDACTED]. Nurses notes dated 2/15/15 through 5/6/15 showed no documented measurements or characteristics of R1's wounds. On 5/13/15 at 4:30 PM, E4 said the facility did not have any further documents to present.

Based on observation, interview, and record review the facility failed to identify a deep tissue injury and pressure ulcers prior to a stage 3 for residents assessed as mild to moderate risk for skin breakdown. The facility failed to ensure a resident's wound dressing was in place to prevent wound contamination to a stage 4 pressure ulcer. This failure contributed to R6 developing a stage 3 pressure ulcer to his coccyx and sacrum and a deep tissue injury to his right heel on April 23, 2015. This applies to 3 of 3 residents (R4, R5, R6) reviewed for pressure ulcers in the sample of 18. The findings include: 1. The Medication Administration Record [REDACTED]. The Braden Scale for predicting skin breakdown dated March 23, 2015, shows R6 is a mild risk for skin breakdown. On May 5, 2015 at 10:25 AM, E15 (Registered Nurse) changed R6's dressings to his coccyx/sacral area and right heel. R6's right heel is approximately the size of a quarter with irregular borders. It is a deep red, purple color, looking like a blood blister. The coccyx/sacral area is now one area. It is open and approximately dime size with irregular borders. The wound is a whitish gray color. The facility's wound assessment initiated April 23, 2015, shows that a Stage 3 pressure ulcer was found on R6's coccyx and sacral areas. The coccyx wound measured 1 x 1 x 0.2 centimeters (cm). The sacral wound measured 4.5 x 4 x 0.2 cm. The same assessment shows R6 also developed a deep tissue injury to the right heel measuring 4 x 3 cm found with 100% eschar (black tissue). On May 5, 2015 at 9:05 AM, E19 (Behavioral Health Director) stated, R6 got the two pressure ulcers because he was in bed all the time. E19 also stated that R6 was on the behavioral health unit when he developed the pressure ulcers and deep tissue injury. E19 stated, that the unit's goal is to have independent residents. They have a minimum of one staff which does not have to be nursing staff. E19 confirmed that they do not use turn schedules with residents on that unit. 2. The Medication Administration Record [REDACTED]. The Physician Wound Care Evaluation dated April 16, 2015 shows that R5 has a new Stage III pressure ulcer measuring 2 x 1.8 x 0.2 centimeters(cm) with 30% scattered slough (devitalized tissue) identified on April 16, 2015. On May 4, 2015 at 2:30 PM, E3 (RN) stated, A CNA reported it and I looked at it that same morning. I really don't know her that well. Sometimes you find them (pressure ulcers) at a Stage III. On May 4, 2015 at 11:50 AM, R5 was laying in bed with a pillow slightly tucked under her left hip. At 12:00 PM, E20 (CNA) pulled back the dressing on R5's left sacrum and revealed a dime sized open area with a yellow tissue present and a red center. E20 stated, We usually try to get her up for meals but we haven't had time to get her up yet today. We are going as fast as we can but there are only 2 of us down here. On May 5, 2015, R5 was positioned on her back in the bed with her head elevated. R5 stated, I'd really like to get on my side. The Medication Administration Record [REDACTED]. R5's care plan dated May 10, 2013 states, Inspect skin with cares daily. The facility policy entitled Prevention and treatment of [REDACTED]. The facility will implement preventative measures and provide appropriate treatment modalities for skin impairments according to industry standards of care. 3. The Minimum Data Set of April 2, 2015 shows that R4 is dependent on 2 or more staff for transfers and requires extensive assist of 1 staff member for personal hygiene. This same document shows that R4 is occasionally incontinent of bowel. On May 4, 2015 at 11:15 AM, E9-Licensed Practical Nurse (LPN) stated, I have to call over to the sub-acute and find out where the wound is because I didn't see anything. The Nurse's Notes dated May 4, 2015 show that E9 assessed R4's buttocks around 6:45 AM and was unable to locate the wound. At 11:30 AM, E9 assisted R4 to turn onto her side to allow surveyor to observe R4's wound. R4 was incontinent of stool. R4's wound was not covered with a dressing and was caked (filled) with stool. E9 cleaned R4's periarea with disposable wipes to expose the wound. There was a dime sized hole on R4's coccyx between her buttocks. E9 cleansed R4's wound with normal saline, packed it with Mesalt (absorbent dressing), covered the wound with 4x4 gauze square and attempted to secure it with paper tape. The tape did not adhere to R4's skin but E9 continued to reposition R4 onto her right side. On May 4, 2015 at 11:45 AM, E10- Certified Nursing Assistant (CNA) stated that she had cleaned R4's periarea about 10:00 AM after an episode of bowel incontinence and there was no dressing in place at that time. The facility provided an admission wound assessment dated [DATE] that shows R4 has a Stage 4 pressure ulcer on her coccyx. The next facility wound assessment is dated May 4, 2015 (18 days later) and shows that R4 has a Stage 4 pressure ulcer to her coccyx measuring 1.2 cm x 0.8 cm x 4.3 cm. The physician's orders [REDACTED]. Pat dry. Apply Mesalt to wound depth and undermining. Cover with ¼ abdominal pad. May use transparent film to secure dressing in place. R4's care plan initiated May 4, 2015 states, Keep skin clean and dry, Weekly wound progress assessment by nurse and as ordered by doctor. The facility policy entitled Prevention and treatment of [REDACTED].

Based on observation, interview and record review, the facility neglected to have a policy and procedure to ensure continuous 24 hour supervision on the Behavioral Health Secured Units. The facility failed to follow their policy and procedure for initiating CPR (Cardiopulmonary Resuscitation) immediately on a resident who was a full code status. The facility failed to follow their policy to ensure staff were alerted and available when assistance was needed for residents with specialized care needs on a secured unit. This neglect contributed to a delay in identifying a resident requiring life sustaining treatment and failing to initiate treatment which resulted in R19's death. The Immediate Jeopardy began on [DATE] at 9:00 PM. E1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 2:45 PM. The immediacy was removed on [DATE] at 7:30 PM. The facility remains out of compliance at a level 2 due to the need to evaluate the effectiveness of corrective measures put in place, the need to complete the in-servicing plan, to have the call light system updated, and the ability to have enough staff scheduled to ensure one person is on each unit at all times. This applies to 10 of 30 residents (R4, R5, R6, R7, R8, R14, R17, R19, R24 and R27) reviewed with a full resuscitation status and 30 residents (R31-R60) in the supplemental sample. The findings include: A.On [DATE] at 10:52 AM, E12 (Licensed Practical Nurse - LPN) said "there was only one CNA scheduled to cover the A & E Wings (Secured Units) that night ([DATE]). E12 stated the A Wing had been left unattended. On [DATE] at 8:05 AM, E11 said she left the room (A22) about 9:00 PM on [DATE]. E11 stated 9:00 PM is "rounds" time. E11 stated at that time, R19 was lying in his bed facing the wall, "punching at his pillow" as if to get comfortable. E11 said the A Wing was unsupervised from 9:00 PM until 10:15 PM when the night shift CNA came on duty. During interviews between [DATE] and [DATE], E5, E7 and E11 said R19 had not been seen, nor was staff present on the A Wing between 9:00 PM and 10:15 PM on [DATE]. The [DATE] rounds sheets showed R19 was last seen at 9:00 PM. On [DATE] at 11:00 AM, E13 stated she was scheduled to work 10:00 PM to 6:00 AM on [DATE] - [DATE]. E13 said there was no one on the A Wing (Secured Unit). E13 said she entered the wing at about 10:15 PM and was met by R36. E13 said R36 told her he thought a pipe was broken down in the vending room area and wanted her to come and take a look. E13 said she stopped by the nurse ' s station to put down her bags and get organized and then accompanied R36 to the vending/smoke room. E13 stated she saw something leaking under the door that was "black, coffee ground" colored. E13 stated the door lead to the bathroom of A22 so "I thought the toilet was blocked." E13 said she went into A22 and noticed that R19 was not in his bed, so she knocked on the bathroom door. E13 said she made 3 attempts to knock and get a response before opening the door to the bathroom. E13 said, "When I opened the door, (R19) was on the floor with his pants down by his ankles. He was lying on his left side with his face against the smoke (vending) room door. I realized he was already dead so I ran out (off the unit) to get the nurses." E13 stated "I only looked at R19 from the doorway of the bathroom and his face was dark colored, brownish, with stuff coming out of his mouth." When staff returned to the unit and a code blue was called, E13 said, "R19 was moved out of the bathroom and had a lot of liquid coming out of his mouth. E13 left R19 unattended. E13 left the room and the unit prior to calling a code blue or initiating CPR. The nursing note dated [DATE] at 1:57 AM shows the following documentation from E5 (RN): "At 10:15 p.m. ([DATE]) a 'code blue' was called. I responded to code. Upon arrival, I saw the Pt. (R19) on the floor of his bathroom off to the left side of the toilet at 45 degree angle with his pants around his knees and a brown substance that appeared to be coming from his head with a foul odor...Pt (R19) was unresponsive, found no pulse and face was gray...Pt. (R19) had appeared to have even more brown fluid emptying from mouth, ears, nose on repositioning and on compressions. Two hundred cc of brown fluid was suctioned out in addition to numerous towels that had been saturated while Pt's (R19) head was turned to the side between breaths. Paramedics from 911 arrived 22:30; Paramedics applied AED, didn't detect a rhythm and left immediately at 22:39 without taking the patient..." The CNA round sheets document R19 was last seen at 9:00 PM on [DATE] "in his room." After interviews and times from persons on the A Wing the night of [DATE] were obtained, (E11, E13 and R36), R19 had not been seen between 9:00 PM and 10:15 PM. R36 identified the liquid contents from under the door prior to 10:00 PM when the smoke room is locked. This places R19 as having been "down" between 20 to 75 minutes. The facility's policy titled Behavioral Health Program Secured Units, undated, states under #1. "Alarmed doors - As there will be some residents who reside on the Behavioral Health Unit who, due to their disability, would be unsafe to be off the unit and/or outside of the facility on their own, all doors that lead off the unit will be equipped with alarms . . . Staff will be able to bypass the alarm system with either a key or number code access." The facility's policy does not specify the need for the unit to have 24 hour continuous staff supervision. On [DATE], the facility provided a list of A & E Wing residents who were identified as "Full Code" and thus would require life sustaining measures in an emergency. The 39 residents identified were R4-R8, R14, R17, R24, R27 and R31-R60. The facility's policy for Abuse/Neglect, dated ,[DATE], defines neglect as "the failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness, or in the deterioration of a resident's physical or mental condition." On [DATE] at 10:35 AM, E10 (Behavioral Health Unit Coordinator) stated there "should be 1 nurse and 1 CNA (Certified Nursing Assistant) on each wing, (A & E Wings), each shift." E10 stated the units should never be left unattended. On [DATE] at 1:20 PM, E4 (Assistant Director of Nursing-ADON) stated she schedules the CNA's in the facility. E4 stated the staffing should be 1 CNA on the A & E (Secured) Wings for each unit each shift. E4 said that she "tries to have 1 CNA on all wings at any given time but with call off's, the A & E (Secured Wings) sometimes will have to share 1 CNA." E4 stated if there is only 1 CNA between the two wings, the nurse must be on the wing if the CNA needs to leave the unit. On [DATE] at 1:30 PM, R5 stated, "It can take between 5 minutes and 1 hour for a call light to be answered "depending on the shift and staffing. Sometimes at night, there is no one (staff) on the wing." On [DATE] at 1:45 PM, R17 said, "There is no staff at night. It can be bad. We (residents) can wait up to an hour for assistance." R17 said he asked for a pain pill and "but the nurse never came on the floor so I had to wait." R17 said "I waited between ,[DATE] hours for the pain pill." R17 said "the nurses are never on the unit." On [DATE] at 2:00 PM, R8 stated, "there is no one here at night. You have to put on your light and wait or you go to the door at the lobby, (secured wing doors), and knock for help. On [DATE] at 2:00 PM, R27 stated "They (staff) go back and forth between units and sometimes at night no one is on the unit." R27 stated a nurse "forgot to give me my meds. I put on the call button but no one came so I went to the end of the wing and banged on the doors to get someone's attention." Sometimes the wing is left unattended completely." R34 said, after passing the medications, "the nurses leave the unit never to return." R34 said sometimes the residents have to go to the front door of the unit and knock on the door to get the attention of the staff and/or request the attention of a nurse. R34 said, "We never know when we (residents) are going to have 'an episode' (behaviors/agitation), with or without staff so it is a big concern that no staff is on the unit." Interviews conducted between [DATE] and [DATE] with E5 (Registered Nurse - RN), E6 (RN), E7 (LPN), E8 (LPN), E11 (CNA) and E12 all stated, when there are 4 nurses scheduled to cover the 5 long term care wings, the A Wing residents are divided up amongst the 4 nurses to provide the medications. All nurses enter the A Wing at the same time to dispense the medication and then leave the unit and do not return. On [DATE] at 8:05 AM, E11 (CNA) stated she was the only CNA on duty [DATE] from 2:00 PM until 10:00 PM to care for the A & E (Secured) Wings. E11 stated there are times when a unit is left unattended for periods of time. E11 states she is typically the only CNA for both (A & E) wings on her scheduled weekends to work. E7 stated the one nurse/one CNA splitting the A & E Wings occurs approximately 85% of the time on the weekends. E12 said the A Wing is short a nurse "more than we would like." E8 said she works 2 double (16 hour) shifts a week and the staffing is this way, (1 nurse and 1 CNA for the A & E Wings), 50% of the time she works. E5 stated he observed the A Wing to be left unsupervised for extended periods of time on [DATE] during the PM shift. E6 said "there are times when no staff are present on the A Wing at any given time." The schedule for the night of [DATE] showed only one CNA had been scheduled to cover the A & E Wings. The schedule also showed a nurse call off which was not replaced leaving the remaining nurses to split the A Wing with no designated nurse coverage. On [DATE] at 1:30 PM, E2 (Director of Nursing) said staffing is done by "myself and the ADON. E2 said they try to find replacements when people call off but "we can't always find someone." E2 said "if we have to, we split a wing and it is the locked (secured) units." On [DATE] at 9:30 AM, E1 (Administrator) and E3 (Corporate Consultant) verified that the secured units are to have at least one staff member present at all times. B. The facility policy titled Code Blue/Medical Emergency Protocol dated ,[DATE] shows "If unresponsive, initiate CPR (Cardiopulmonary Resuscitation) following American Heart guidelines per resident's code status. Remember the CAB's: Chest Compressions, Airway and Breathing....staff to stay with resident at all times until additional help arrives" On [DATE] at 1:00 PM, R36 stated on Saturday, ([DATE]), he saw brown liquid coming out from under a door into the vending/smoke room before 10:00 PM. R36 said and he was on his way to smoke ,[DATE] of a cigarette he had kept from earlier in the day before the 10:00 PM smoking deadline. R36 stated no staff was on the unit when he went to smoke, and upon his return from smoking, R36 stated he noticed the amount of brown liquid on the floor in/near the vending room had increased. R36 said he headed down the hallway to try to get someone's attention. R36 said about that time, E13 entered the unit. R36 said "I told her I thought a pipe broke and was leaking in the vending room and asked her to come look at it." R36 said E13 went into room A22. R36 said after a short time, E13 came out of the room, quickly went down the hall and off of the unit. R36 said "I guess the guy died ." On [DATE] at 11:30 AM, E7 stated she was the last nurse on the A Wing the night/PM of [DATE]. E7 stated she finished her medication pass to the portion of the A Wing she was covering at 8:20 PM. E7 stated she left the A Wing at 8:20 PM. E7 stated she was unaware of any staff being on the A Wing after she departed at 8:20 PM. E7 stated she had no interaction with R19 and was not his assigned nurse throughout the shift (2:00 PM - 10:00 PM) on [DATE]. E7 stated she and E8 were the first to respond to the wing when E13 "alerted us to the unit." When the bathroom door in room A22 was opened, legs were the first thing to been seen and then R19's "Royal Blue face. It was clear he (R19) had been deceased for sometime. He was covered head to toe in body fluids." E7 stated she was unaware when 911 was called. We had done at least ,[DATE] sets of CPR and suctioning when the ambulance arrived. The ambulance hooked up the AED (Automated External Defibrillator) and there was no rhythm." On [DATE] at 8:05 AM, E11 said she responded to R19's room after the code blue was called [DATE] at 10:15 PM. E11 said R19 had a "blood" substance leaking from his mouth. E11 described the "blood" as "dark feces colored blood with a foul odor." E11 said R19's face was blue in color and his pants were around his ankles. E11 said R19 was lying on the bathroom floor still in a somewhat seated position (45 degree angle). E11 said the left side of R19's face was leaning against the smoke room/bathroom door. On [DATE] at 2:45 PM, E6 stated when she arrived to room A22 on [DATE], "(R19) was placed on his back and his head turned to the side because he was fluid filled. His face was grayish purple. The staff was trying to suction out the rust colored fluid." On [DATE] at 11:45 AM, Z4 (Emergency Medical Systems Coordinator - 911 response team) stated 6 people arrived on scene for the 911 call regarding R19. The ambulance, containing the two primary Paramedics had a response time of 2 minutes and 53 seconds. Z4 stated the report documented R19 was found in a "supine", (on his back), position with CPR in progress by facility staff. Z4 stated it was reported R19 had an "unknown down time." Z4 said the AED was applied showing "asystole" (no heart rhythm). R19's body was "cold to the touch." On [DATE] at 2:30 PM, Z3 (Paramedic) described R19's appearance as "face and neck brown & dusky with a distended abdomen." Z4 stated the AED was applied and showed asystole. Z3 said R19's body was cold to the touch and his pupils were fixed and dilated. Z3 stated the staff could not give any time frame for how long R19 may have been down. Z3 then re-emphasized that R19's skin had "no resemblance of warmth to it. It was cold." Z3 stated he observed a large amount of gastric contents on the floor. On [DATE] at 1:00 PM, Z6 and Z7 (911 response team/paramedics) were interviewed. Z7 stated upon arrival to the facility, R19 was lying on the floor with fluid coming out of his mouth. Z7 stated R19's face was "purple" and "looked as if he had been down a long time." Z6 stated "no one" (staff) "had the same amount of time he, (R19), was last seen" by facility staff. E11 stated she last saw R19 at 9:00 PM. R36 identified seeing the brown liquid contents from under the vending/smoke room door prior to 10:00 PM when the smoke room is locked. E13 states she was notified of the liquid identified by R36 at 10:15 PM. This places R19 as having been "down" between 20 to 75 minutes. On [DATE] at 10:15 AM, Z5 (Nurse Practitioner) stated for residents who are a "Full Code" status, CPR should be initiated as soon as they go down. Z5 said "I would have stayed with the resident and used my phone to call for assistance." Z5 stated any delay in the initiation of CPR could decrease the possibility of recovery. Z5 stated had someone been on the unit and found R19 sooner, CPR could have been initiated sooner and that would give him the best chances for the best possible outcome. Z5 stated, the longer time a person is down before initiation of life sustaining measures, the risk of death increases. Z5 said, "the quicker the response, the increased likelihood of a better outcome." Z5 said when a person requiring life sustaining treatment has no one is available to respond, within minutes, the result could be death. C. The facility policy titled Use of Call Light dated ,[DATE] states the purpose is to "respond promptly to a resident's call for assistance." Under the procedure section the policy states: "All facility personnel must be aware of call lights at all times." On [DATE] at 8:05 AM, E11 said there was no one (staff) on the A Wing so no one would have heard him go down. E11 said if he had his call light on or even was yelling for help, he would not have been heard from outside of the secured doors. E11 said the call lights do not ring or light up in the main (fishbowl) nursing area located off the secured units. E11 said that unless staff "happened" to look down the wing and see a call light on, there would be no way of knowing someone needs assistance. On [DATE] at 8:30 AM, E11 pulled the call light in room A14 which is close to the secured doors at the front of the A-unit. This surveyor stepped off the unit and went to the main nursing area (fishbowl). The light could not be heard nor seen. R19's room (A22) is located at the farthest end of the unit, away from the secured entrance doors. On [DATE] at 11:00 AM, E10 verified that call lights on the secured units do not ring or light up at the main nurse ' s station off the secured units. According to the Long Term Care Nursing Desk Reference, Second Edition, "Brain death begins within four minutes of the time of cardiac or respiratory arrest or occlusion of the airway." Because of the narrow time frame, emergency procedures need to be implemented immediately. Based on observation, interview and record review, the surveyor confirmed the facility took the following actions to remove the immediacy: 1. On [DATE] staff members were being educated on the provision of continuous supervision of the Behavior Health Units prior to returning to work. This included educating staff members on ensuring another staff member is present on the unit before exiting the unit and providing rounds on the unit per protocol. 2. On [DATE], Managers were educated on the scheduling and staffing requirements for the Behavioral Health Units. The scheduling is to include a CNA (Certified Nursing Assistant) scheduled every shift for each unit and in the event of a call off the staff member is to be replaced. Observations of this being followed occurred on [DATE] at 10:00 PM. 3. On [DATE], paperwork was provided showing a contractor was contacted to address the call system and ensure the light and sounders would be activated outside the secured units. The contractor was scheduled to address the call light system on [DATE].

Based on observation, interview and record review the facility failed to ensure residents daily skin checks were completed and that changes in a resident's skin were reported. The facility failed to implement preventative measures to reduce the risk of developing pressure ulcers and failed to ensure wound assessments were completed. This applies to 2 of 6 residents (R11, R12) reviewed for pressure ulcers in a sample of 30. The findings include: 1. R12's Minimum Data Set of 6/11/14 shows R12 has severe cognitive impairment, and requires extensive assistance from two staff members with changing position in bed, and toilet use. The 6/11/14 MDS shows R12 is incontinent of bowel and bladder. R12's 7/24/14 Physician order [REDACTED]. R12's 6/9/14 Skin Assessments shows R12 is at mild risk for acquiring a pressure ulcer. R12's Alteration in Skin Integrity Care Plan initiated on 7/9/14 shows "Weekly wound progress assessment by nurse". R12's 7/24/14 Physician order [REDACTED]. R12's 9/25/13 Wound assessment shows a left buttock stage 2 pressure ulcer 0.6 cm )centimeter) (Length) x 0.2 cm (Width) x 0.1 cm (Depth). R12's 10/23/13 wound assessment shows shows 100% [MEDICATION NAME] (healing) to the left buttock. On 7/23/14 at 9:30 AM, E27 and E28 provided incontinence care to R12. E27 and E28 raised R12 to a standing position with a mechanical stand lift, and E27 washed R12's bottom. E27 said R12 did not have any open areas to her bottom. After care was completed, R12 was noted to have a nickel sized red open area to her left buttock. E27 said "it looks like there was a patch of dry skin and when I wiped, it came off and now it's open". On 7/23/14 at 11:20 AM, E26 (Licensed Practical Nurse- LPN) said R12 had a "scab to her bottom" that the nurses were applying a prescription cream to. E26 said the CNA reported to her the scab came off during care and the area was now open. E26 said the scab was from a previously healed Pressure Ulcer to R12's left buttock. R12' 7/23/14 at 5:17 PM, wound assessment shows stage 2 to left buttock "superficial stage two noted to scar tissue area". No other wound assessments were documented of R12's left buttock, and no documentation was made of a scab to the left buttock prior to it opening on 7/23/14. Weekly assessment for the buttock were not documented, where the prescription cream is applied. No evidence of an assessment or monitoring being done was documented after the 10/23/13 wound assessment. On 7/24/14 at 9:45 AM, E2 (Director of Nursing- DON) said there should be continued monitoring of a pressure sore after it is healed. E2 said if a scab is present the wound is not fully healed and weekly assessments should be documented until completely resolved. E2 said a scab could fall off and the wound could re-open and should be monitored with each application of the cream and assessed and documented on weekly. The facility 6/13 "Prevention and treatment of [REDACTED]. Utilize WASA form for documenting progress of pressure, diabetic, arterial, and venous wounds....Develop a plan of care to promote healing of skin impairments and prevention of wounds..." 2. On 7/23/14 at 9:30 AM, E18 (Licensed Practical Nurse - LPN) changed the pressure ulcer dressings for R11. E18 stated she was the first to assess the wound on R11's left heel about 2 months ago. It had been reported by the CNA to look at his heel. She charted about the open wound. E18 could not recall the size of the wound when she first saw it, but remembered that E18 stated a few days later, an opening on R11 right heel was found. The dressing was removed from the left heel and a strong offensive odor was noted. The dime sized wound was surrounded with pale white macerated tissue and the wound bed was covered with 90% slough. The dressing was changed to the right heel by E18. A small pinpoint size opening was noted without drainage or slough. At the tip of the heel a small ? inch size dark circle was noted on the skin. E18 stated she had not observed the dark area before today. E29 (Certified Nursing Assistant - CNA) assisted E18 with R11's dressing change. On 7/23/14 at 9:45 AM, E29 stated R11 receives a bed bath daily and a shower twice a week. E29 stated any change in a resident's skin condition is immediately reported to the nurse. On 7/23/14 at 9:45 AM, E18 stated the waffle heel boots were initiated after the wounds were identified to relieve pressure. E18 stated the wounds occurred because R11's legs were stiff and he would often push down with his feet into the mattress. The Physician order [REDACTED]. The POS [DIAGNOSES REDACTED]. The POS dated 4/23/14 (admission orders [REDACTED]". The order dated 5/1/14 states, " Keep Heels off of bed every shift " . The first wound treatment orders were dated 6/19/14 (7 days after the wound was initially identified). The Braden Scale Assessment (Score to determine risk of developing pressure) on 4/22/14 was 15 indicating mild risk for R11. The skin integrity care plan initiated on admission (4/23/14) identified R11 has friction due to constant movement, and decreased mobility. There were no specific interventions on admission to reduce the friction on his feet due to constant movement or his decreased mobility. Interventions to float R11's heels as prescribed by the physician on 5/1/14 were not listed. The Minimum Data Set of 5/20/14 shows R11 is at risk for pressure and did not have any unhealed pressure ulcers or healed ulcers since the prior assessment. R11 did not have any venous or arterial wounds. R11 requires extensive assistance of 2 staff for bed mobility and transfers and R11 did not ambulate in his room or corridor. R11 requires extensive assistance from staff for bathing and personal hygiene. R11's BIMS (Brief Interview for Mental Status) score is 12. (8-12 shows moderate impairment). On 7/24/14 at 10:00 AM, R11 and R74 (R11's wife and roommate) were interviewed. R11 stated, " They never put my legs up before I got the sores on my feet. " R74 agreed. R11 stated they brought in the boots after they started putting the dressings on his feet. The initial wound assessment of the Right heel dated 6/12/14 measures the wound size as 3.0 cm x 2.0 cm x 0.2 cm, Stage II. The open wound bed showed 80% [MEDICATION NAME] and 20% granulation tissue. The Right heel assessment dated [DATE] measures the wound size 0.5 cm x 0.5 cm x 0 cm and the wound bed is covered with 100% black eschar. The initial wound assessment of the Left heel dated 6/19/14 measures the wound as 2.0 cm x 1.8 cm and the wound bed was covered with 100% black eschar. The facility policy for prevention and treatment of [REDACTED]. The policy states to implement prevention protocols that are appropriate to address the individualized needs of the resident based on potential risk conditions of the resident. Prevention of skin breakdown includes to inspect the skin every shift with care for signs and symptoms of breakdown, boney prominence susceptible to pressure will be protected.

Based on record review, and interview the facility failed to supervise a resident at risk for falls during ambulation, and transfers. These failures contributed to R6 falling and sustaining a fractured humerous on 4/27/14, and a fractured hip on 4/30/14. This applies to 1 of 3 residents reviewed for falls (R6) in the sample of 8. The findings include: R6's May, 2014 physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment of 4/14/14 shows R6 has moderate cognitive impairment. No behaviors are documented. R6 requires limited assistance of one person for bed mobility, transfer, walking in room. She is dependent on one person for dressing. She requires extensive assistance of one person for toilet use. R6's balance is not steady with moving from seated to standing position, moving on and off the toilet, and surface to surface transfers. R6 uses a walker. She occasionally has mild pain. Other health conditions include shortness of breath with exertion. (walking, bathing, transferring) R6 also has shortness of breath when at rest. No fall history is documented. R6 receives oxygen. The occurrence log (Jan.- April, 2014) shows that R6 had 3 falls. (2/11, 4/27, 4/30) On 2/11/14 it is documented she had a behavior problem. On 2/17/14 the same log shows she was found with a bruise. The occurrence reports show the following: 2/11/14 documents that R6 was self positioning in the bed and rolled out on to the floor. She was sent to the emergency room for evaluation. She sustained a bruise on her knee. The same report documents that "old bruises" were found on her back and arms. 4/27/14 shows that E6 (Certified Nursing Assistant) was ambulating with R6 to the bathroom, she (E6) turned away from the resident to get something (brief) from the dresser. R6 slipped, lost her balance and fell to the floor. R6 said that her shoulder was broken and was unable to move her right arm. She was sent to the emergency room and found to have a Fractured Right Humerus. 4/30/14 documents that R6 transferred herself from a recliner into her bed and fell . No injury was documented. The report shows that R6 had to reach for her call light and her arm was in a sling. (previous fracture on 4/27/14) A hospital emergency room report of 4/15/14 shows that R6 had a fall in her bathroom and struck her head. (R6 receives anticoagulant medications that include Coumadin and Aspirin.) The Physician/Provider Notes shows the following: 3/21/14 documents that R6 has difficulty with ADL's. She has poor judgement and insight. Hypoxemia- COPD exacerbation verses pneumonia. Will titrate oxygen. On 5/6/14 at 12:00 noon, E1 (Administrator) said that one of the falls R6 had, the CNA removed R6's oxygen to take her to the bathroom, so she would not trip on the tubing. E1 said that R6 is not to have the oxygen removed. E1 said that R6 had frequent falls while living at home. On the fall of 4/27/14 the CNA (E6) turned away while ambulating with R6 to the bathroom and R6 fell . Two days after this R6 was found on the floor next to her recliner. She did not have any complaints. The next day when she went to the orthopedic office, I was called and told that she complained of pain in her left hip. I was told she had a fracture of the hip. On 5/7/14 at 10:45 AM E7, (Licensed Practical Nurse) said that she was present when R6 had the last two falls. The first one she was using a walker and going into the bathroom. E6, CNA, turned to get a brief and when turned back R6 was on the floor. She complained she couldn't move her arm, she was moving everything else ok. I saw her walker in the doorway of the bathroom. Sometimes R6 will use the call light and sometimes she will not. The second time she fell , I had just come out of her room. I was a few doors down, and I heard her yelling for help. She was on the floor by her recliner. We lifted her with a mechanical lift and put her in her recliner. She said she was fine. I received a call later while she was out to the Ortho and was told she was complaining of pain in her hip. They found a fracture when they did a CT (Computerized Tomography) scan. I was surprised because she had not complained of any pain the night before. On 5/7/14 at 11:15 AM, E6 (CNA) said that she was walking behind R6 into the bathroom and she turned to get a brief and a towel, and when she looked back R6 was falling. She fell backwards. She said she didn't know what happened. Her shoes "flew" off when she fell , they were like a slip on tennis shoe. I work various halls so I only get report for that day. I wasn't sure about her falls, but I had heard she has fallen a lot before. She did not wear her oxygen, because we were always told she could walk from her bed to the bathroom with out it. We don't want her to get tangled in the tubing. She usually takes herself to the bathroom, I have seen her coming out and going in by herself when I'm walking down the hallway. R6's Care Plan dated through 7/13/14, shows that R6 has an Activities of Daily Living (ADL) deficit due to Dementia, Limited Mobility and Fatigue. The same care plan shows that R6 is at risk for impaired gas exchange due to Chronic Obstructive Pulmonary Disease. The Fall risk care plan documents that R6 is at risk for falls related to the use of an assistive device, poor decision making, psychotropic medications, and impulsive behavior. The fall prevention interventions include non-skid wheel chair cushion, encourage appropriate use of the wheel chair, encourage the resident to report falls, non skid foot wear, supportive shoes, no clogs or slippers, notify family and physician of new falls. According to the facility policy and procedure for Fall Prevention: the facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the resident's care plan in order to minimize the risks fo fall incidents and/or injuries to the resident.

Based on interview, observation and record review the facility failed to ensure call lights are responded to, so residents may be toileted to prevent accidents. The facility failed to have a system in place to prevent residents from sitting in line on the C- wing hallway, for up to 1 hour, waiting to see a physician and failed to ensure that staff speak English when in resident care areas.. This failure resulted in anxiety and tearfulness in one resident (27). This has the potential to affect all 179 residents residing in the facility. The findings include: 1. On 8/10/2011 at 1:00 PM, 6 confidential interviews took place. During the interviews the residents were asked if call lights get answered soon after they put them on. The entire group began laughing. The following comments were made: "They answer the lights immediately. They come into our room, turn off the call light and don't return for at least an hour. They often use the excuse they were looking for a working mechanical lift. One time I needed to go to the bathroom. By the time they returned to help me I was crying because I didn't think I was going to make it to the bathroom before wetting myself." "My roommate is always wet. She puts her call light on, they come in and turn it off, then she wets her bed waiting for them to return to help her." "My roommate has accidents also because she puts her call light on, staff turn it off, but don't take her to the bathroom." The facility's Use of Call Light Procedure dated 5/10 states: "2. Answer all call lights promptly whether or not the staff person is assigned to the resident. 3. Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as you enter the room. 4. Never make the resident feel your are too busy to give assistance; offer further assistance before you leave the room." On 8/11/2011 at 1:00 PM, E9 (Activity Aide) was observed going into R25 and R26's room. The call light was on. E9 went into the room, turned off the call light, and did not ask either resident what they needed. E9 said, "R25 has a pressure call light, she is always leaning on it, turning it on." 2. R38 is a female resident interviewed on 8/10/11 at 1:00 PM. During the interview, R38 described an incident that occurred earlier in the morning. R38 stated she was given a bowel stimulant at bedtime on 8/9/11. Around 3:00 AM on 8/10/11, R38 was having a stomach ache and had to go to the bathroom. R38 stated she put on her call light and "no one came. I went (bowel movement) in my bed. What a mess. I had to get myself into the bathroom. Finally one man came in and he had to get me some clean clothes. What a mess I had! It was TERRIBLE!" 3. R27 is an [AGE] year old female resident with [DIAGNOSES REDACTED]. R27's Minimum Data Set of 4/4/11 identifies her as having no cognitive impairment. On 8/9/11 at 2:15 PM, R27 stated she routinely has to wait for up to an hour for staff to respond to her call light resulting in her wetting the bed. R27 said it used to bother me a lot "but now I just let it happen. I wet." 3. On 8/10/2011 at 1:00 PM, 6 confidential interviews took place. The residents all stated to see Z1 and Z2 (Physicians) they have to "line up" down the C wing hall. The residents said they line up, in their wheel chairs, from the dining room to the C wing conference room. The physician and nurse practitioner see each resident in the conference room. The following comments were made: "All of the wheel chairs take up so much room in the hallway, it makes it difficult for other residents to get through, or for the medication and laundry carts to get down the hallway." "I have waited up to an hour in line waiting to see my doctor." "There is nothing to do when waiting in line, you just sit and wait." 4. On 8/11/2011 at 9:00 AM, E7 (Corporate Registered Nurse) verified the residents wait in a line, down the C wing hall, to see the doctor. 5. On 08/10/11 at 9:45 AM, R140 stated, "I see my doctor here. I have to wait in the hallway from 30 minutes to one hour, and I don't like it." 6. On 08/10/11 between 12:15 PM and 12:40 PM, R8, R13, and R114, stated they had to wait in the hallway until they are seen by Z1 or Z2 7. On 08/10/11 at 12:45 PM, E6 (Case Manager) stated, "Residents have to wait on the C Hall for (Z1) and on the unit for (Z2)." 8. On 08/10/11 at 12:50 PM, E8 (Unit Director) stated, "Don't worry we have staff standing there to supervise the residents from A & H Halls while they are in the C Hallway waiting." 7. On 08/10/11 at 1:00 PM, E13 (CNA) confirmed residents have to wait in the hallway until they are seen by their physician. 9 The CMS form 672, completed by the facility on 8/10/2011, shows the census in the building was 179. On 8/10/2011 at 1:00 PM, 6 confidential interviews took place. The residents were asked if they had topics they would like to discuss. One of the interviewees said, "I don't like it when staff talk in their language, where I can hear them. You never know if they are talking about you." All of the residents in attendance shook their heads in agreement. On all days of the survey (8/9 - 8/11/2011) staff were observed in patient care areas, conversing in a language other than English. The facility had no policy regarding non-English speaking staff.