Every finding on record at Alden Des Plaines Rehab & HC

Based on interviews and record reviews, the facility failed to follow physician's order during administration of pain medication (Hydrocodone Acetaminophen) for one (R1) of four residents in the sample four reviewed for medication.Findings include:R1 is [AGE] year-old female, admitted in the facility on 02/16/26 with diagnoses of Other Displaced Fracture of Upper End of Left Humerus, Subsequent Encounter for Fracture with Nonunion; Presence of Left Artificial Shoulder Joint; and Encounter for Change or Removal of Surgical Wound Dressing. MDS (Minimum Data Set) dated 02/23/26 recorded R1's BIMS (brief interview for mental status) score was 13, which means little to no impairment in cognition.R1's POS (Physician Order Sheet) documented the following:05/04/26: Hydrocodone Acetaminophen oral tablet 5-325mg (milligrams) give one tablet by mouth every four hours as needed for severe pain (7-10) (max 3gm acetaminophen/day from all sources).05/04/26: Hydrocodone Acetaminophen oral tablet 5-325mg (milligrams) give 1 tablet by mouth at bedtime for pain management.02/19/26: Hydrocodone Acetaminophen oral tablet 5-325mg give one tablet by mouth every four hours as needed for severe pain (7-10) (max 3gm acetaminophen/day from all sources).R1's MAR (medication administration record) recorded the administration of Hydrocodone Acetaminophen as follows:March 2026:03/06 at 7:02 PM pain level 4; 03/10 at 10:50 PM pain level 5; 03/12 at 5:29 AM pain level 203/17 at 11:21 PM pain level 5; 03/18 at 8:49 AM pain level 0; 03/25 at 9:02 PM pain level 503/26 at 11:12 AM pain level 6; 03/26 at 7:59 PM pain level 5; 03/27 at 10:22 PM pain level 4; 03/28 at 8PM, pain level 5; 03/29 at 7:32 PM pain level 5; 03/30 at 7:44 PM pain level 5April 2026:04/03 at 9:19PM pain level 4; 04/05 at 10:50 PM pain level 4; 04/07 at 8:27 PM pain level 404 09 at 8:01 PM pain level 3; 04/10 at 7:48 PM pain level 5; 04/11 at 8:37 PM, pain level 5 04/13 at 10:06 PM pain level 4; 04/14 at 8:21 PM pain level 4; 04/16 at 8:40 PM pain level 404/25 at 8:31 PM pain level 0; 04/26 at 8:24 PM pain level 0; 04/29 at 7:23 PM pain level 5 04/30 at 8:06 PM pain level 5On 05/27/26 at 12:46 PM, V3 (Licensed Practical Nurse, LPN) was asked regarding R1 and pain medication. V3 stated, Her (R1) Norco is to be given every four hours for severe pain - 7-10. In the morning, she (R1) will really ask for pain pill, sometimes before therapy or after therapy. I should be following the 7-10 pain but if patient requests, I will give it. I should be notifying MD if parameters less than 7-10.V4 (Registered Nurse, RN) also stated during interview on 05/27/26 at 1:00 PM, We check and follow physician orders before giving pain medications. If they are in pain, I assess and have them rate the pain and I will give it as ordered. I have to follow the parameters, we cannot give it outside parameters, I will ask physician if resident wants to get it.On 05/27/26 at 2:50 PM, V2 (Director of Nursing) was asked regarding administration of pain medication. V2 replied, . If there is an order for a Norco (Hydrocodone Acetaminophen) and the order says to be given for pain 7-10, do not give for pain level at 0-6. If a resident asks for Norco even the pain is less 7, we will give it and notify physician.There was no documentation regarding administration of Hydrocodone Acetaminophen for R1's pain level 0-6. R1's care plan dated 02/16/26 regarding pain documented intervention: Administer pain strategies according to MAR/TAR (treatment administration record).Facility's policy titled Physician's Orders for Medications or Treatments dated 06/2022 documented in part but not limited to the following:Policy: Medications will be dispensed and subsequently administered to a resident only upon the clear, complete, signed order of a lawfully authorized prescriber. Verbal orders will be received only by licensed nurses or pharmacists and subsequently confirmed in writing by the prescribing physician. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. Facility's policy titled Medication Administration: General Guidelines dated 01/2022 stated in part but not limited to the following:A. Policy: To ensure that medications are administered safely as prescribed.C. Policy: All medications shall be administered as prescribed by licensed personnel authorized to do so in accordance with standard nursing practice and current regulations.D. Procedure: 6. If the physician's medication order cannot be followed, the physician should be notified, depending upon the situation.

Based on interview and record review, the facility failed to implement fall preventive measures for a resident who is a 2 person transfer assist due to limited mobility due to surgical site. This deficiency affects one (R1) of three residents reviewed for Falls prevention program. This failure resulted in R1 to have dislocation of the right hip prosthesis requiring hospitalization. Findings include:R1 is an [AGE] year-old with the following diagnosis: periprosthetic fracture around internal prosthetic right hip joint, history of falling, essential hypertension, hyperlipidemia, myelodysplastic syndrome, anemia, orthostatic hypotension, personal history of transient ischemic attack and cerebral infarction without residual deficits, age-related osteoporosis without current pathological fracture, polymyalgia rheumatica, presence of right artificial hip joint. Facility Reported Incident dated 11/24/25 documents during the transfer from toilet to wheelchair, R1 experienced sudden weakness in his right leg and was lowered to the floor by the CNA (Certified Nurse Aide). Head to toe assessment completed and the resident denied pain at the time of the fall. R1 reassessed for pain and stated he has pain in the right hip. MD and daughter were notified. X-ray was completed which revealed dislocation of the right hip prosthesis. R1 was sent to the emergency room for further evaluation. On 12/06/25 at 11:45 am, V2 (Director of Nursing) said that on 11/24/25 when incident occurred with transfer to toilet R1 should have been a 2-person transfer assist. V2 said that the certified nurse aide working with R1 during incident is no longer an employee at the facility for multiple reasons including resident safety. V2 said that R1 was transferred to hospital due to dislocation of right hip prosthesis and has not returned to facility. On 12/06/25 at 12:30 PM, V5 (Registered Nurse) stated that when incident with R1 occurred R1 was being transferred to the toilet by 1 staff assist (certified nurse aide). V5 said R1 is supposed to be a 2-person transfer assist due to R1 being a surgical patient and fall precautions needed to be in place. V5 said that the certified nurse aide called him to the room and V5 observed R1 in a sitting position on the floor. V5 assessed R1 with no change of Level of consciousness and no complaints of pain, V5 and the certified nurse aide assisted R1 back to bed using a gait belt. V5 said he notified the MD, family member and Director of Nursing. V5 said when R1 was reassessed for pain R1 said he was having pain to the right hip. V5 notified MD and received orders for x-rays of the right hip for R1 due to fall and complaint of pain. On 12/06/25 at 1:15pm, V6 (Restorative Nurse) said that R1 is a 2 person assist upon admission due to surgical site and having a wound vac, V6 said that she assessed the resident for transfer status assist upon admission and also refers to physical therapy for recommendation and if agreed then the transfer status is then updated in the residents chart and also in the resident point of care charting and updated in the transfer status binder located at the nurses station. On 12/06/25 at 2:00PM, V1 (Administrator) said that R1 had a fall in the facility and the fall was reported due to injury. V1 said that the certified nurse aide working with R1 during time of incident was suspended pending investigation and eventually was let go of the facility due to multiple factors. The Fall Risk assessment dated [DATE] documents At risk for falls. GG Screener assessment dated [DATE] documents Toileting Hygiene: Dependent transfer. Functional Abilities- admission assessment dated [DATE] documents Chair/bed to chair transfer: Dependent transfer. Toilet transfer: dependent transfer.Restorative Progress note dated 11/21/25 documents staff/patient education to use walker with 2-person assist to transfer using left side/good side for safety. Radiology Progress Note dated 11/25/25 documents Patient X-ray result was with hip dislocated.Physical Therapy Evaluation and Plan of Treatment dated 11/20/25 documents R1 is a Max assist out of bed and total dependence assist with transfers. The Care Plan dated 11/19/25 documents R1 is at high risk for falls d/t generalized muscle weakness, impaired mobility, gait, balance, decreased activity tolerance and medical diagnosis of right pre-prosthetic hip, myelodysplastic syndrome. Interventions in place include encourage appropriate use of walker, bed to chair transfer 2-person assist using rollator walker using good side/left side to transfer. The Care Plan dated 11/21/25 documents R1 has an ADL functional performance deficit due to generalized muscle weakness, impaired mobility, gait, balance, decreased activity tolerance and medical diagnosis of right pre-prosthetic hip, myelodysplastic syndrome. Interventions in place include bed to chair transfer 2-person assist using rollator walker using good side, left side to transfer. Facility Policy on Transfer revision date 2/10/2022Definition: Transfer refers to activities provided to improve or maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices. These activities are individualized to the resident's needs, planned, monitored, evaluated, and documented in the resident's medical record. Considerations:2. Fractures- Follow physician orders regarding movement or weight bearing restrictions and any therapy recommendations when developing individualized programs. General transfer guidelines:1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe transfers of residents. 2. Manual lifting of resident's should be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include:a. Resident's preferences for assistance. b. Resident's mobility (degree of dependency)c. Residents sized. Weight-bearing abilitye. Cognitive statusf. Whether the resident is usually cooperative with staff g. The resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. General Transfer Procedures:3. utilize assistive devices as needed: bedrails, walker, slide board, etc.7. transfer toward the resident stronger side and place the chair/wheelchair at the resident's stronger side when possible. Facility Policy on Management of Falls revision date 8/2020Policy: The facility will assess hazards and risks, develop a plan of care to address hazards and risks, implement appropriate resident interventions, and revise the residents plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Procedure:1. Complete a Fall Risk Assessment upon admission, re-admission, with significant change, post-fall, quarterly, and annually. 3.Develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors may include but are not limited to the following contributing diagnosis/disorders/diseases processes/ active infections/ other comorbidities, history of fall incidents, incontinence, medications (Narcotics, Antihypertensives, etc.), assistance required with ADL's, gait/transfer/balance issues, Behaviors, and /or cognitive status. 4. provide assistive devices for mobility, hearing and vision as appropriate for the resident. 5. Assess appropriateness for resident to participate in skilled therapy or restorative programming in order to maintain or improve physical function or resident.

Based on observation, interview, and record review the facility failed to provide needed care and services in accordance with resident's plan of care, facility's protocol, and professional standard of practice. This deficiency affects one (R1) of three residents reviewed for Quality of care. Findings include: On 9/16/25 at 1:15PM, V4 Insurance Case manager said that she visited R1 last week and presented to her his concerns that last month, he was being helped into bed by CNA and during the transfer, his right foot got caught under the bed and has been having foot pain since. R1 said that the CNA does not know what he is doing. V4 is concern with resident safe transfer. R1 has a right foot bandage. V4 spoke with Agency nurse and told her that R1's toes have ulceration and receiving antibiotics for cellulitis. V4 said that she did not follow up her concern with nursing management and social service in the facility. On 9/16/25 at 9:59AM, Observed R1 up in wheelchair in his room. He is alert and oriented x3. He can verbalize his needs to staff. He has O2 via nasal cannula at 2 liters per minute. He said that his right foot was hurt last month when CNA was transferring him from wheelchair to bed. The CNA and Nurse were aware and applied bandage to his right foot. He said that the CNA who works with him did not know what he is doing. On 9/16/25 at 10:04AM, V5 LPN said that R1 did not complain of pain to her, but he has scheduled pain medications that she administered this morning- Tylenol 500mg 2 tabs and Diclofenac sodium external topical gel to right knee. She said that R1 has a wound dressing on his right foot. R1 just completed oral antibiotics for his right foot wound infection/cellulitis. On 9/16/25 at 10:25AM, V2 ADON (Assistant Director of Nursing) said that R1 sustained bruise and abrasion on his right foot when CNA transferred him from wheelchair to bed on 8/11/25. V2 said, V6 Interim DON/Nurse Consultant did the bruise and abrasion incident investigation and root cause analysis. R1 was started on antibiotics on 9/3/25 due to wound infection. He was seen by wound care physician on 9/3/25 and treated with betadine swab 10% apply to right foot topically every Monday, Wednesday, and Friday. After cleansing with NSS (normal saline solution), paint with betadine then apply xeroform. Cover with abdominal dressing and wrap with kerlix three times a week and as needed. V2 said, the floor nurses do the wound treatment and weekly documentations. On 9/16/25 at 10:29AM, R1 was transferred to bed by V8 CNA (Certified Nurse Assistant) using transfer board. V2 ADON and R1 giving instruction and assistance to V8 in transferring R1. V2 removed R1's right foot shoe and sock. No dressing observed. R1 has dried dark brownish black scab on 2nd and 3rd toe. R1 can't remember when the dressing fell off. V2 cleansed the 2nd and 3rd toe with NSS then painted with betadine swab. She applied xeroform, covered with gauze and wrap with kerlix bandage. V2 said that she will call physician to evaluate wound treatment. The ABD pads is not appropriate wound covering on R1's right foot skin condition. R1 was only seen once by wound care physician for consultation. 12:21pm Review R1's medical records with V1 Administrator and V6 Interim DON/Nursing consultant. R1 is admitted on [DATE] with diagnosis listed in part but not limited to Parkinson's disease, Hypertensive chronic kidney disease, Poly osteoarthritis, Acute respiratory failure, dependence on oxygen. MDS/resident assessment dated [DATE] indicated: Section C- Cognitive pattern BIMS (Brief interview for mental status) score of 13. Section GG Functional abilities Mobility coded 02 substantial/maximal assistance. Helper does more than half of the effort. Helper lifts, holds or support trunk or limbs but provides more than half the effort. Section M Skin conditions. Marked yes for at risk for developing pressure ulcers/injuries. Marked 0 for arterial and venous ulcers. Marked 0 for other ulcers, wound and skin problems. Comprehensive care plan indicated: he has ADLs (Activity of daily living) self-care deficit. Intervention: transfer board for transfer. He has actual alteration of skin integrity. Intervention: weekly wound progress assessment by nurse. He has impaired mobility. He is on restorative program for transfer. He requires assistance from staff for transfers using sliding board. Interventions: 1 staff assist using sliding board and verbal cuing daily. Use gait belt and other transfer aids as needed. Active physician order sheet indicated: Skin check completed every Monday and Friday. Betadine swab sticks 10% apply to right foot topically every day shift Monday, Wednesday and Friday and as needed, after cleansing with NSS, the apply xeroform, cover with ABD (abdominal dressing) and wrap with kerlix. R1's bruise incident report dated 8/11/25 reported by V10 RN indicated: At approximately 2:30AM, R1 reported that his right foot was hurting particularly on great toe and second toe. V10 assessed and observed blue and purple discoloration on both great and second toes. Observed abrasion on 2nd and 3rd toes. R1 said that he was being transferred by CNA when he banged his foot on the bed. R1 was given pain medication and physician was notified. X-ray of right foot was ordered. No wound treatment for abrasion was ordered. V6 Interim DON/Nurse consultant completed the incident investigation and root cause analysis on 8/15/25. R1 is alert and oriented x 3. He needs assistance with ADLs. He reported that on 8/11/25 he accidentally bumped his toes while being transferred. He reported his right toes hurt but did not tell anyone. The x-ray was performed indicated mild tissue swelling, no evidenced of fracture noted. R1 was reminded to let the nurse on duty know for any incident/accident. Care plan reviewed and updated. R1 does not have treatment order for the right foot abrasion. R1's progress notes indicated no documentation of right foot abrasion after the incident occurred on 8/11/25. On 9/3/25 progress notes indicated, R1 reported increased pain to right foot. Upon assessment erythema noted to right foot and skin alteration to 2nd toe and 3rd toe. Physician was notified and ordered Doxycycline 100mg twice a day for 10 days and wound consult. On 9/3/25 wound notes indicated, reddish/brown, right 2nd toe 0.75cm x 0.5cm and right 3rd toe 0.5cm x 0.25cm. On 9/3/25 wound care physician assessment indicated: right foot abrasion, 2cm x 3.5cm x 0 cm, 100% scab dermis, intact, Treatment: cleanse with NSS, Betadine paint/ Xeroform, cover with 2 ABD pads and secure with fluffy kerlix, offload. On 9/4/25 Arterial doppler with ABI (Ankle Brachial index) of both lower extremities report indicated bilateral lower extremity arteries shows generalized atherosclerotic wall changes and plaques causing 80% stenosis. ABI 0.6. Suggested clinical correlation and vascular specialist consultation. On 9/4/25 Infectious disease consultation indicated, diagnosis- right 2nd and 3rd toes cellulitis secondary to wound. No documentation of weekly skin assessment of right and 2nd toes cellulitis wound with wound treatment/dressing.On 9/16/25 at 12:30PM, Informed both V1 Administrator and V6 Interim DON that R1 sustained abrasion/bruise during transfer from wheelchair to bed by V9 Former CNA. The incident occurred on 8/11/25 3-11 shift was not reported until R1 reported right foot pain with bruise and abrasion to the V10 RN on 11-7 shift. Abrasion and bruise incident was investigated and documented root cause analysis on 8/15/25 by V6 but did not document that abrasion and bruise on right foot was happened during transfer with V9 CNA. V6 did not interview R1 because he self-terminated himself after V1 interviewed him the following day of the incident. V6 indicated that care plan was updated but she did not. No new intervention for resident safe transfer to avoid foot injury. R1 sustained abrasion and bruise from wheelchair to bed transfer by CNA but no new intervention documented in care plan. No ongoing skin weekly assessment documentation of right foot abrasion since it was identified on 8/11/25. R1's right foot abrasion worsens to cellulitis wound. Wound treatment provided and completed antibiotics 10 days treatment. Still no ongoing weekly skin assessment of right foot cellulitis wound since it was identified on 9/3/25. R1 was observed for wound care on right foot. No dressing was observed. The wound treatment needs to be evaluated due to current wound condition. On 9/16/25 at 12:45PM, V7 MDS/Care Plan Coordinator said that any changes in resident condition or treatment such as incident of bruise/abrasion sustained from transfer with CNA assistance and worsening of abrasion to cellulitis should be care planned. New intervention should be developed for resident safety to prevent re-occurrence of incident. New intervention for treatment of abrasion to promote healing and prevention of wound infection or deterioration. V7 said that she cannot remember if she updated care plan after the incident. V7 said any nurse- floor nurse or managers who are aware of the incident can update R1's care plan as indicated in physician orders. On 9/16/25 at 1:42PM, Reviewed V9 Former CNA's employee record with V1 Administrator. V9 was hired on 7/10/25. Employee separation notice was on 8/12/25. V1 said that V9 self-terminated himself after interviewing for R1's incident on 8/11/25 bruise/abrasion resulted from transferring from wheelchair to bed. Reviewed July and August 2025 facility's transfer in-service for employees. V9 was not listed in training. V6 Interim DON presented R9's competency transfer training with employee's signature but inconsistent with his signature file in employee's record. Facility's policy on Transfer Techniques 02/2022 indicated: Purpose: To safely transfer the resident from bed to chair or from one location to another. Facility's policy on Incident/Accident Reports 09/2020 indicated: The incident/accident report is completed for all unexplained bruises or abrasions, all accidents, or incidents where there is injury or the potential to result in injury, allegation of theft and abuse registered by residents, visitors, or other and resident to resident altercations. Procedure: An accident refers to any unexpected or unintentional incident, which may result in injury to illness to a resident. 9. An incident/accident report is to be completed and shall include: b. Description and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered and notification of appropriate parties. Facility's policy on Comprehensive care plan 11/2017 indicated: An individualized, person-centered comprehensive care plan including measurable objectives with timetables to meet resident's physical, psychosocial and functional needs, is developed and implemented for each resident. Procedure: 8) Assessment of Resident is ongoing and care plans are revised based on the resident condition, preferences, treatments, and goals change. Facility's policy on Prevention and treatment of Pressure injury and other skin alterations 03/2021 indicates: Policy: 3. Implement preventive measures and appropriate treatment modalities for pressure injuries and or other skin alterations through individualized resident care plan. Procedure: 4. Non-pressure skin alterations i.e.: skin tears, abrasions, surgical wounds, MASD, lesions and rashes will be documented weekly on a skin progress. 5. Develop a care plan for either actual or potential alteration in skin integrity and change as needed8. At least daily, staff should remain alert for potential changes in the skin condition during resident care10. Revised care plan approaches as needed based on resident's response and outcomes.

Based on observation, interview and record review the facility failed to ensure residents who were dependent on staff for clothing change and incontinence care received those services for 1 of 3 residents (R1) reviewed for Activity of Daily Living (ADL) assistance. Findings include:On 9/2/2025 at 10:30am V6(Agency Certified Nursing Assistant-CNA) said that on 7/30/2025 at about 6:30am V7(Nurse) asked V6 to clean up R1 and do incontinence care because he was going out to the hospital. V6 said upon entering the room the smell of emesis, feces and urine was observed. R1 had dried and new emesis with red fluid on his gown, upon removing the top linen R1 had feces and urine soaked on the bed with dried urine and feces rings on the bottom sheet and a red penis, scrotum and buttocks. V6 said she questioned V7 about why R1 was in this condition, V7 said the CNA for R1 had left the facility before she could tell her to clean R1.On 9/2/2025 at 11:40am this writer, V3(Assistant Director of Nursing -ADON), and V5(Certified Nursing Assistant -CNA) observed R1 in the bed with a soiled gown, red scrotum, red bilateral inner thighs, and red buttocks with feces and urine soaked on the bottom bed sheet. On 9/2/2025 at 1:00pm V4(Wound Care Nurse) said R1 has very loose stools and had been treated several times for redness on his scrotum, inner thighs and buttocks. The last treatment was 14 days and ended on 8/30/2025. R1 is now on a barrier cream twice a shift and as needed. I expect the nursing staff to do rounds every one to two hours on residents that are dependent on the staff for care and to inform me when a resident is having skin issues.On 9/2/2025 at 1:10pm V5 said R1 only responds to tactile stimuli and is totally dependent on staff for all care and he could not make his needs known. I do rounds every two hours and I did not change R1's gown, I informed the nurse when I changed R1 that morning that R1 has reddened areas on his scrotum and buttocks. On 9/2/2025 at 1:30pm V7(Nurse) said that on 7/30/2025 she was informed that R1 had an emesis I do not remember who informed me she assessed R1 and observed coffee ground emesis on his gown and top bed linen. V7 said she immediately called the physician and was given orders to send R1 to the local emergency room. V7 said she looked for the CNA for night shift and she was not on the unit, when the day shift CNA arrived, she informed V6 the CNA that was taking over that section to do care on R1 because he was transferring to the hospital. V7 said I did not check to see if R1 needed Peri-care I was concentrating on the coffee ground emesis and calling the ambulance. The CNA staff should make rounds every two hours and as needed, I thought the night CNA made rounds apparently, she did not. On 9/2/2025 at 1:45pm V3 said the bed sheets should not be soaked, I expect the CNA staff to make rounds every two hours and as needed for residents that need more frequent changing. All activity of Daily Living care should be completed for dependent residents. On 7/30/2025 I was informed that R1 had been left in a soiled gown, with urine and feces on the bed linen, and that he was going out to the hospital for having an emesis with blood in it. I did not know the extent until I was told the CNA had complained.On 9/2/2025 at 2:00pm V1(Administrator) said that she was informed about R1's condition of Activity of Daily Living care and incontinence care had not been giving, later that day and the agency CNA could not return to the facility. A resident information document dated 9/2/2025 indicates that R1 has a diagnosis of respiratory failure with hypoxia and hypocapnia, hemiplegia and hemiparesis with a cerebral infarction affecting the left no-dominant side, tracheostomy, gastrostomy, Dysphagia, dependent on supplemental oxygen. A care-plan dated 2/14/2025 for focus that R1 requires total assistance on staff with bed mobility, transfers, and all ADL, incontinence care, A focus of Peri-care after each incontinent episode and monitor for excoriation near peri area. Change clothing PRN as needed after each incontinent episodes dated 2/28/2025.Facility Policy: Perineal Care dated 9/2020Purpose:To cleanse the perineumto prevent infection and odorto maintain skin integrity

Based on observation, interview, and record review, the facility failed to follow the Storage/ Labeling/ Packaging of Medications Policy by failing to remove 1 bottle of expired medication dated 6/2025. This failure has the capacity to affect 15 residents who receive medications from the 3rd floor cart #1. Findings include: On [DATE] at 2:00 PM, surveyor and V6 (Licensed Practical Nurse) observed 1 medication bottle with expiration date of 6/2025 on the 3rd floor cart 1. On [DATE] at 2:00 PM, V6 (Licensed Practical Nurse) said this medication is expired and should be removed based on expiration date (6/2025). On [DATE] at 2:05 PM, V11 (Registered Nurse - Pharmacy Consultant) said best practice would be to remove the medication on [DATE]. V11 said she is not aware of any resident currently using this medication. On [DATE] at 2:04 PM, V12 (Pharmacist) said best practice would be to remove the medication on 6-1-2025. On [DATE] at 8:42 AM, V2 (Director of Nursing) said the significance of the expiration date affects the potency of the medication. V2 said when a medication is expired it should be pulled from the cart. V2 said there are currently no residents using the medication. Storage/ Labeling/ Packaging of Medications Policy dated 12/2023 documents: 10. Medication containers that are damaged, soiled, contaminated, or outdated are immediately removed and either returned or disposed of according to procedure. Reorder from the pharmacy as applicable.

Based on interview and record review, the facility failed to obtain and maintain a copy of the hospice coordinated care plan for one of two residents (R12) reviewed for hospice care in a sample of 22. Findings include:R12 is a [AGE] year-old female admitted in the facility on 01/01/2025 under hospice care with diagnoses of not limited to thalassemia minor, generalized muscle weakness and dependence on oxygen. On 07/22/2025 at 10:35AM during record review with V5 (Assistant Director of Nursing), R12's coordinated plan of care was not on the hospice binder or the scanned documents of R12's electronic health record. On 07/23/2025 at 10:15AM during record review with V6 (Licensed Practical Nurse), R12's coordinated plan of care was not on the hospice binder or the scanned documents of R12's electronic health record. On 07/23/2025 at 10:24AM during record review with V7 (Social Service Director), R12's coordinated plan of care was not on the hospice binder or the scanned documents of R12's electronic health record. On 07/23/2025 at 10:24AM during interview with V7, V7 stated that the hospice company did not provide the facility with R12's coordinated care plan. On 07/23/2025 at 2:55PM during interview with V2 (Interim Director of Nursing), V2 stated that the facility must be provided with a copy of the coordinated care plan by the hospice company, and the facility must keep the copy of the coordinated care plan accessible to staff. Review of R12's facility care plan initiated 01/01/2025 indicated R12 requires hospice care and interventions included to integrate hospice team interventions into resident's plan of care. Review of facility's policy entitled Hospice Program dated 09/2020 indicated the following:Policy: Our facility contracts for hospice services for residents who wish to participate in such programs.Policy Interpretation and Implementation:3. When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. Review of the facility and hospice agreement with effective date of 08/26/2013 indicated the following:III. Responsibilities of Hospice3.6 Provision of Information. Hospice shall promote open and frequent communication with Facility and shall provide Facility with sufficient information to ensure that the provision or Facility Services under this Agreement is in accordance with the Hospice Patient's Plan of Care, assessments, treatment planning and care coordination. Hospice shall be responsible for determining. and modifying as necessary, the appropriate hospice plan of care as specified in 42 C.F.R. 418.112(d). Such hospice plan of care shall encompass alI issues related to the terminal illness and related conditions. Hospice shalI communicate with the Resident, family members, Facility staff, and the attending physician to develop and update the content of the hospice plan of care. At a minimum, Hospice shall provide the following information to Facility for each Hospice Patient residing at Facility: 3.6.1 Plan of Care, Medications and Orders. The current Plan of Care, medication information and physician orders specific to each Hospice Patient residing at Facility;

Based on observation, interview and record review, the facility failed to ensure low air loss mattress devices were on the correct weight setting for residents who are assessed to be at risk for developing pressure injuries. This deficient practice affects three (R12, R38 and R43) out of four residents reviewed for pressure injury prevention and treatment in a final sample of 22 residents. Findings Include: R12 is a [AGE] year-old female who was admitted in the facility on 01/01/2025 under hospice care with diagnoses of not limited to thalassemia minor, generalized muscle weakness and dependence on oxygen. On 07/22/2025 at 9:55AM during unit rounds, R12 had flat sheet and disposable pad underneath her while wearing disposable briefs. R12 was lying on low air loss mattress with setting noted at level 7. On 07/22/2025 at 11:15AM during observation with V5 (Assistant Director of Nursing), R12 was again noted with flat sheet and disposable pad underneath her while wearing disposable briefs. R12 was again lying on low air loss mattress with setting noted at level 7. On 07/22/2025 at 11:16AM during interview with V5, V5 stated that R12 should only have flat sheet and either disposable brief or pad underneath her. V5 stated that R12's low air loss mattress is from the hospice company, and they set it up for R12. V5 stated that there is a QR code that can be scanned on top of the master control unit of the low air loss mattress for instructions on how to navigate the low air loss setting. After watching the video instruction, V5 changed R12's low air loss mattress setting to 4 and performed the hand check method as shown in the video instruction. On 07/22/2025 at 11:21AM during interview with V3 (Wound Nurse), V3 stated that she and her assistant checks the settings of the low air loss mattress every morning. V3 stated that the setting of the low air loss mattress is based on the resident' weight, but V3 stated that R12's bed is from hospice and the setting is different from the facility's low air loss mattress, so she just puts pressure on the low air loss mattress to check the firmness of the bed. Review of R12's Order Summary Report dated 07/23/2025 indicated order for low air loss mattress. Review of R12's Monthly Weight Report indicated that R12's weight was 97.5 lbs. Review of R12's Braden Scale for Predicting Pressure Sore Risk dated 07/08/2025 indicated R12 is moderate risk. Review of R12's Wound Physician Notes dated 07/16/2025 indicated R12 was referred for wound consult as requested by the primary care physician for skin ulcers/lesions at the sacrum. It also indicated that the stage 2 sacral pressure wound was resolved on 07/16/2025. Facility's document entitled Rhythm Multi Suggested Weight Guidelines indicated the following: Please note that the chart below is guideline, not a rule. Because of the different body types, shapes and height, we recommend using the hand check method to ensure that the pressure setting is optimal, and that the patient isn't bottoming out. Suggested weight range: Level P4 – 113 ~ 150 lbs P7 – 208 ~ 294 lbs Hand check method: Unzip cover at the foot of the bed as necessary to access the air cells. With patient laying down, slide your hand vertically between the air cells directly underneath the patient's sacral (tailbone) area. If four fingers of clearance exist, no adjustment is needed. If you can feel the patient's body resting on your hand, adjust the pressure control to a higher setting. Wait 10 minutes and repeat the hand check. If the hand check fails, check that the hoses are not kinked or pinched or schedule service. On 7/22/2025 at 10:28 AM, R38 was laying on air mattress with air mattress setting of 400 lbs. On 7/22/2025 at 10:50 AM, V13 (Registered Nurse) said R38's current weight is 143 lbs. V13 (RN) said the air mattress setting is based off the R38's weight. On 7/22/2025 at 12:00 PM, V3 (Wound Care Nurse) said she was informed of the incorrect mattress setting and V3 corrected the setting on R38's mattress. R38's weight dated 7/17/2025 documents weight = 143.2 lbs. R38's Braden Score documents: High Risk for skin breakdown. R43 is a [AGE] year-old with diagnoses but not limited to: Type 2 Diabetes, Morbid Obesity, and Peripheral Vascular Disease. BIMS of 13 (Cognitively Intact) dated 5/28/25. On 7/22/25 at 1030AM, observed R43 in bed, awake and interviewable. Observed on low air loss mattress and the machine was not on. No light indicator on. Bed deflated. R43 reported it has not been working since yesterday evening. That the staff is aware and that R43 is waiting for someone to fix the bed. R43 reported that R43's been with the deflated mattress since yesterday evening. On 7/22/25 at 10:50AM, returned and observed with V4 that the low air loss mattress now on and is set to 660 lbs. (pounds). Confirmed with V4 (LPN) that the mattress is set to 660 lbs. V4 unable to answer for what setting it should be set to, and reported that V4 will check the order. On 7/22/25 at 10:53AM, observed V3 (Wound Nurse) walked in R43's room and touched the setting of the low air loss mattress. On 7/22/25 at 10:55AM, observed R43's low air loss mattress now set at 290 lbs. On 7/22/25 at 11:00AM, confirmed with V4 that R43's weight recorded as 225.5 lbs. with a documented date of 7/9/25. On 7/22/25 at 12:30PM, interviewed V3 (Wound Nurse), confirmed that V3 adjusted the setting to the correct setting. V3 reported that R43 is high risk for skin alteration and that R43 has an active MASD (skin damage caused by prolonged exposure to moisture) on R43's buttocks and is getting zinc oxide cream. V3 reported that R43 is using the special mattress for preventative measures. On 7/24/25 at 10AM, V3 stated that the specialty mattress setting is based on the residents' current weight. R43's weight record reviewed, and on the latest weight entered was on 7/9/25 reads as 225.5 lbs. Record reviewed. R43's Braden Assessment score is 13 Moderate Risk (total score of 13-14) dated 5/23/25. R43's Physician Order Sheet Reviewed and with order for Low Air Loss Mattress with an order date of 11/2/24. Zinc Oxide Ointment, apply to coccyx, perineum to buttock topically every day and evening shift, and as needed. R43's Skin/Wound Progress Note dated 7/17/25, reads in part: Sacral (Skin Split) MASD. Slight redness, skin still intact treatment is in place. R43's Care Plan with initiated date of 6/11/25, reads in part: R43 has actual for alteration in skin integrity due to history of sacral pressure injury and needs assistance with ADLs due to obesity, DM2 (Diabetes Type 2), CKD (Chronic Kidney Disease) stage 4, difficulty walking, gout and COPD (Chronic Obstructive Pulmonary Disease). Incontinent of Bowel and Bladder. Occasionally refuses shower/bath. 6/11/25-Coccyx-MASD. Braden Scale for Predicting Pressure Injury Risk policy dated 4/2020, reads in part: To be completed for all residents to assess level of risk for developing pressure. Complete Braden Scale on admission and weekly for the first 4 weeks after admission, quarterly and with significant change in status. Skin should be inspected with each risk assessment. Regardless of the resident's total risk score, each risk factor and potential cause(s) should be reviewed individually. Implement intervention according to the resident's Braden Score and/or individual risk factors identified. Special Mattress Operational Manual reads in part: Pressure set up, users can adjust the pressure level of the air mattress to a desired firmness by themselves or according to suggestion from a health care professional. It is recommended to press Auto Firm on the panel when the mattress is first inflated. Users can then easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. Prevention and Treatment of Pressure Injury and other Skin Alteration policy dated 3/2/2021, reads in part: Identify residents at risk for developing pressure injuries. Identify the presence of pressure injuries and/or other skin alterations. Implement preventative measure and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Identify residents at risk for developing pressure injuries utilizing the Braden Scale.

Based on observation, interview, and record review, the facility failed to follow its mechanical lift transfer policy by not having two people assist to a resident transfer. This applies to 1 of 1 resident (R31) reviewed for accidents and supervision in a sample of 22. The findings include:R31 is a [AGE] year-old female having moderate cognitive impairment as per the Minimum Data Set, dated [DATE]. The MDS also documents that R31 is dependent on transferring from a bed to a chair (or wheelchair) and vice versa. On 07/22/2025 at 1:56 PM, V9 (Certified Nursing Assistant/CNA) was transferring R31 from chair to bed by herself. On 7/22/25 at 1:58 PM, V9 stated, The other CNA stepped out to get something. I am sorry, I shouldn't have transferred the resident by myself. 07/23/2025 2:59 PM, V2 (Director of Nursing/DON) stated, The mechanical lift transfer requires two people for safe transfer. V9 should have another staff member to assist with the resident transfer. A review of the mechanical transfer care plan document: Provide 2 staff members for transferring. The facility presented a policy on the Total Mechanical Lift transfer dated 01/14/2021 document Equipment:4, Two caregivers are required to operate the mechanical lift.

Based on observation, interview, and record review, the facility failed to follow its intravenous (IV) care guidelines by not changing the IV dressing as needed. This applies to 1 of 1 resident reviewed (R225) for IV catheter care in a sample of 22. The Findings include:R1 is a [AGE] year-old female with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. On 07/22/2025 at 11:33 AM, R1 was observed with a left upper arm peripheral IV line with a dirty dressing with dry blood around the insertion site, and the tape was peeling off from the bottom. On 07/22/2025 at 11:33 AM, V10 (Licensed Practical Nurse/LPN) stated, R1 is getting daily IV antibiotic for the surgical site infection in her back. The dressing should have been changed as the dressing was coming off, and the insertion site was dry with blood. On 07/23/2025 2:59 PM, V2 (Director of Nursing/DON) stated, The nurses are supposed to change the IV dressing when the dressing is peeling off or having an insertion site with dry blood. A review of the Physician Order Sheet (POS) document that R1 was getting Ceftriaxone 2 gram IV in the morning for surgical wound infection aftercare for 48 days. A review of the facility presented IV Care Reference Guidelines dated 11/21/21 document: Check all IV sites every 8 hours and PRN (as needed)Transparent dressing change for peripheral IV every 96 hours (Q 96H) with site change and PRN

Based on interview and record review, the facility failed to follow their ongoing infection surveillance for one of five residents (R4) reviewed for infection control in a sample of 22. Findings include:R4 is a [AGE] year-old male admitted in the facility on 05/23/2025 with diagnoses of not limited to benign prostatic hyperplasia without lower urinary tract symptoms, incontinence without sensory awareness, and Extended-Spectrum Beta-Lactamase resistance. During record review, R4 had Infection Screening Evaluation dated 07/21/2025 which indicated that R4 presented with urinary frequency and urinary urgency, and Infection Analysis of Suspected UTI (urinary tract infection) without indwelling catheter. R4's Order Summary Report dated 07/23/2025 indicated R4 is on contact precautions for ESBL (Extended-Spectrum Beta-Lactamase) urine with order date of 07/21/2025. On 07/23/2025 at 11:50AM during record review with V2 (Interim Director of Nursing/DON), and V5 (Assistant DON), with V8 (previous DON) on the phone for infection control program, R4's Progress Notes dated 07/15/2025 indicated that a urinalysis result was relayed to Nurse Practitioner (NP) with recommendation to wait for the C/S (culture and sensitivity) result. R4's Progress Notes from 07/01/2025 to 07/15/2025 did not indicate any indication for urine testing. R4's electronic health record did not indicate any assessment or physician notes to indicate the need for urine testing. On 07/23/2025 at 11:50AM during phone interview with V8, V8 stated that the Infection Screening Evaluation is completed when the resident presents with signs and symptoms of a possible infection. V8 stated that the Infection Screening Evaluation then appears in their electronic Infection Control Dashboard for the Infection Control team to monitor the suspected infection. V8 stated that they collect data from staff on any change of condition or suspected infection through but not limited to morning meetings, Infection Screening Evaluation form, physician orders, and progress notes. On 07/23/2025 at 11:50AM during interview with V2, V2 stated that V8 works remotely, and V2 and V5 follow up on the infection control program in-person. V2 stated that the nurses are expected to document the signs and symptoms R4 was presenting, and the need for the urine testing somewhere in R4's electronic health record, either on the progress notes or the assessments, at the time of the observation, the complaint that was made by R4, and/or the urine testing order that was made. Review of R4's Order Summary Report dated 07/24/2025 indicated R4 has order to collect urine for UA (urinalysis) and C/S in the morning with order date of 07/14/2025. Review of facility's policy entitled Infection Prevention and Control Program revised 09/20/2024 indicated the following:Policy: It is the policy that this facility's Infection Prevention and Control Program (IPCP) is based upon information from the Facility Assessment and follows national standards and guidelines to prevent, recognize and control the onset and spread of infection whenever possible. Intent of the Infection Prevention and Control ProgramThe intent of this regulation is to ensure that the facility:- Establishes facility-wide systems for the prevention, identification, investigation and control of infections of residents, staff and visitors. It must include an ongoing system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility and procedures for reporting possible incidents of communicable diseases or infections; (NOTE: staff includes employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility, and students in the facilities nurse aid training programs or from affiliated academic institutions) Elements of the Program include:4. Surveillance, including process and outcome surveillance, will include monitoring, data analysis, documentation and communicable diseases reporting (as required by state and federal law and regulation). Surveillance activities will be conducted to identify practice, infection trends and early identification of new infections and potential outbreak situations. Definitions: Surveillance refers to the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks, to try to reduce morbidity and mortality and to improve resident health status. Review of facilities policy entitled Surveillance copyrighted 2020 indicated the following:Infection Surveillance - OverviewPurpose: Infection prevention begins with routine and ongoing surveillance to identify possible communicable diseases or infections before they can spread to other persons in the facility or have the potential to cause, an outbreak. The facility closely monitors all residents who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, analyzing, and interpretation of data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. Data Collection1. The unit charge nurses will identify residents with symptoms or identified infections and complete the Criteria for Infection Report Forms for the respective type of infection:a. Urinary Tract Infection Identification and Follow-Up of InfectionsThe nurse or nursing supervisor will notify the IP of suspected infections and record the information on the Infection Report Form. If this is an unusual suspected infection, or if the resident's condition is considered critical, the IP will be notified immediately, as well as the Director of Nursing. The physician and family (or responsible part) will be informed of any change in residence condition. Procedure:When a resident exhibits signs/symptoms of suspected infection, the unit nurse or charge nurse will:1. Complete the Infection Report Form.

Based on observation, interview, and record review the facility failed to provide incontinence care to dependent residents in a timely manner. This deficiency affects two (R1 and R4) of three residents reviewed for Activity of daily Living (ADL)-Incontinence care. Findings include: R1 On 5/13/25 at 10:20AM, Surveyor requested skin assessment for R1. Observed V5 WCN (Wound Care Nurse) and V10 CNA (Certified Nurse Assistant) repositioned R1 to side lying position. Observed disposable brief soaked with urine and leaked through the cloth pad underneath her. Observed V10 provided incontinence care to R1. Observed V10 did not change her gloves after cleaning peri anal area and sacral area of R1. V10 took clean disposable brief and applied to R1 with the same gloves. On 5/13/25 at 10:22AM, V11 Agency CNA said that he is assigned to both R1 and R4. V11 said that he has not provided incontinence care or morning care to both residents. V5 WCN said that CNAs should check dependent resident for incontinence every 2 hours. R1 was admitted on [DATE] with diagnosis listed in part but not limited to Traumatic subdural hemorrhage with loss of consciousness, Respiratory failure, Tracheostomy, Gastrostomy, Moderate protein calorie malnutrition, Encephalopathy, Contractures of muscle right upper arm, Mild neurocognitive disorder. Comprehensive care plan indicated: She has an ADL (Activity of daily living) functional performance deficit related to muscle weakness, impaired balance, incontinence, impaired memory, and underlying medical conditions. Intervention: Provide incontinence care/toileting needs as needed. Bowel and Bladder incontinence. Intervention: Provide peri care with episodes of incontinence. R4 On 5/13/25 at 10:33AM, Surveyor requested skin assessment for R4. V10 CNA and V11 CNA repositioned R4 to side lying position. Observed R4 soaked with urine with fecal matter on the disposable brief and rectal area. Observed V10 provided incontinence care to R4. Observed V10 did not change her gloves after cleaning peri anal and sacral area of R4. She took clean disposable brief and applied to R4 with the same gloves. Informed V10 of observation made during incontinence care of using same gloves between soiled and clean briefs for R1 and R4. V10 then changed her gloves and donned on new pair of gloves without hand hygiene. Informed V10 of observation made that she failed to perform hand hygiene before donning new pair of gloves. R4 was admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure with hypoxia, Tracheostomy, Gastrostomy, Type 2 Diabetes Mellitus, Hand contractures, Muscle weakness, Incontinence without sensory awareness, Encephalopathy, Parkinson's Disease. Comprehensive care plan indicated: She has an ADL functional performance deficit related to underlying medical conditions. Intervention: Provide incontinence care/toileting needs as needed. Bowel and Bladder incontinence. Intervention: Provide peri care with episodes of incontinence. On 5/13/25 at 1:38PM, Informed V1 Administrator and V2 DON (Director of Nursing) of above observations and concerns. Requested for policies. Facility unable to provide policy for Activity of daily Livings and Incontinence care procedure guidelines. Facility's policy on Routine checks 9/2020 indicated: Policy interpretation and implementation: 1. To ensure the safety and well-being of our residents, a resident check will be made at least 2 hours throughout each 24-hour shift by nursing service personnel. 2. Routine resident checks involve entering the resident's room to determine if the resident's needs are being met. If there has been a change in the resident's condition, if the resident has any complaints, if the resident is sleeping, needs toileting assistance, etc.

Based on observation, interview, and record review the facility failed to implement its preventive measures and appropriate treatment modalities for skin impairment. The facility also failed to avoid multiple layers of linens when using low air loss mattress as manufacturer's recommendation. This deficiency affects all three (R1, R4 and R5) reviewed for Wound Care Prevention Management. Findings include: R1 On 5/13/25 at 9:48AM, Observed R1 lying in bed with LAL (Low air loss) mattress. She is awake but no verbal response. She has bilateral hand splint and heel protector. She receives enteral feeding via GT (Gastrostomy Tube) connected to feeding pump. Her call light is away from her, placed on bedside dresser. V2 DON (Director of Nursing) lifted the top linen and observed cloth pad and flat sheet over the LAL mattress. R1 is wearing a disposable brief. V2 said that R1 should only have flat sheet over the mattress. V2 said resident on LAL mattress should only have flat sheet over the mattress as manufacturer recommendation. On 5/13/25 at 10:10AM, V5 WCN (Wound Care Nurse) said that R1 acquired MASD (Moisture Associated Skin Disorder) on 4/29/25. V5 unable complete wound assessment because she got busy and R1 was sent out to the hospital on 5/5/25. R1 returned on 5/11/25 but she has not updated R1's wound /Skin care plan. On 5/13/25 at 10:15AM Informed V5 WCN of observation made to R1 with V2 DON of having multiple layers of linens on the LAL mattress. V5 said that R1 should only have flat sheet over the mattress and no cloth pad over it. R1 is wearing disposable brief. V5 said that resident on LAL mattress should have flat sheet only as manufacturer recommendation. Multiple layers of linens over the mattress will impede its purpose. On 5/13/25 at 10:20AM, Surveyor requested skin assessment for R1. Observed V5 WCN and V10 CNA repositioned R1 to side lying position. Observed disposable brief soaked with urine and leaked through the cloth pad underneath her. Observed V10 provided incontinence care to R1. Observed V10 did not change her gloves after cleaning peri anal area and sacral area of R1. V10 took clean disposable brief and applied to R1 with the same gloves. V5 said that R1 has healed MASD. No treatment applied after incontinence care. On 5/13/25 at 10:22AM, V11 Agency CNA said that he is assigned to both R1 and R4. V11 said that he has not provided incontinence care or morning care to both residents. He received both residents with cloth pads and flat sheets over the LAL mattress. He said that he did not know that it's not okay to have both cloth pad and flat sheet over the mattress. V5 WCN informed V11 that resident on LAL mattress should only be on flat sheet over the mattress. On 5/13/25 at 10:33AM, Surveyor informed V5 WCN that she did not apply Treatment order of Zinc oxide ointment or barrier cream after incontinent care as indicated in care plan as part of preventive wound/skin impairment management. R1 is admitted on [DATE] with diagnosis listed in part but not limited to Traumatic subdural hemorrhage with loss of consciousness, Respiratory failure, Tracheostomy, Gastrostomy, Moderate protein calorie malnutrition, Encephalopathy, Contractures of muscle right upper arm, Mild neurocognitive disorder. Active physician order sheet indicated: Low air loss (LAL) mattress. Zinc oxide ointment 20% Cleanse with normal saline and apply to perianal topically every shift and as needed for skin condition. Comprehensive care plan indicated: she has potential for alteration in skin integrity related to Braden scale of 11 (High risk), incontinence, requires assistance with bed mobility/transfers, history of sacral pressure injury and underlying medical conditions. Interventions: Barrier cream to areas exposed to moisture/incontinence. Pressure redistribution support (low air or alternation air) in bed. Progress notes dated 4/29/25 documented by V21 RN indicated: MASD (Moisture associated noted on perineal area. Informed to V5 Wound Care Nurse (WCN) and Nurse Practitioner and carried out treatment order. V5 WCN documented on 4/30/24 indicated: Per V21 RN's request, skin check completed. Noted heavy excoriation, MASD to area of perianal. Nurse Practitioner notified and obtained order for Zinc ointment to be applied twice daily and as needed. V6 Family member notified. V5 did not updated R1's comprehensive care plan regarding acquired MASD on 4/29/25. No comprehensive wound assessment/report was completed when wound was identified. R1 was sent out to the hospital on 5/5/25 due to respiratory distress after decannulation. R1 was readmitted on [DATE], still wound/skin care plan was not updated. R4 On 5/13/25 at 9:51AM, Observed R4 lying in bed with LAL mattress. She is unresponsive. She has tracheostomy connected to vent. She receives enteral feeding via GT (Gastrostomy Tube) connected to feeding pump. Observed visible cloth pad and flat sheet over the mattress. R4 is wearing disposable brief. Showed observation to V2 DON. V2 said that R4 should only have flat sheet. V2 said that resident on LAL mattress should only have flat sheet over the mattress as manufacturer recommendation. On 5/13/25 at 10:15AM Informed V5 WCN of observation made to R4 with V2 DON of having multiple layers of linens on the LAL mattress. V5 said that R4 should only have flat sheet over the mattress and no cloth pad over it. R4 is wearing disposable brief. V5 said that resident on LAL mattress should have flat sheet only as manufacturer recommendation. Multiple layers of linens over the mattress will impede its purpose. On 5/13/25 at 10:33AM, Surveyor requested skin assessment for R4. V10 CNA and V11 CNA repositioned R4 to side lying position. Observed R4 soaked with urine with fecal matter on the disposable brief and rectal area. Observed V10 provided incontinence care to R4. Observed V10 did not change her gloves after cleaning peri anal and sacral area of R4. She took clean disposable brief and applied to R4 with the same gloves. Informed V10 of observation made during incontinence care of using same gloves between soiled and clean briefs for R1 and R4. V10 changed her gloves and donned on new pair of gloves without hand hygiene. Informed V10 of observation made that she failed to perform hand hygiene before donning new pair of gloves. V5 WCN applied Zinc oxide to perianal and sacral area. V5 said that R4 has ordered for Zinc oxide for MASD. V5 said that R4 is being seen by Wound Care Physician for MASD. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure with hypoxia, Tracheostomy, Gastrostomy, Type 2 Diabetes Mellitus, Hand contractures, Muscle weakness, Incontinence without sensory awareness, Encephalopathy, Parkinson's Disease. Most recent Braden scale skin assessment dated [DATE] indicated at high risk for skin impairment. Active physician order sheet indicated: Low air loss mattress. Zinc oxide ointment 20% cleanse with normal saline and apply to buttocks/sacral topically every day and evening shift and as needed. Comprehensive care plan indicated: She has actual alteration in skin integrity related to requires extensive assistance with bed mobility, incontinence, and underlying medical conditions. Wound sites: Buttocks- MASD. Interventions: Low air loss mattress. Barrier cream to areas exposed to moisture/incontinence. Wound care Physician wound/skin report dated 5/6/25 indicated: Buttocks/Sacral, MASD, 100% pink epithelization, wound identified: 1/18/25. R5 On 5/13/25 at 10:56Am, Observed R5 lying in bed with LAL mattress. Observed LAL machine is on the floor. R5 does not have foot board where the LAL mattress is hanged. V13 Family member at bedside. V13 said that R5 has been in the facility for 3 months and he did not have foot board attached to his bed. V5 WCN said he should have foot board for the LAL machine/pump to be secured or hanged. On 5/13/25 at 11:05AM, Surveyor requested skin assessment for R5. V10 CNA repositioned R5 to side lying position. Observed no dressing covered to R5's sacral wound. V5 WCN said that the dressing probably got soiled and the CNA had to remove the dressing. V5 said that the CNA should inform the nurse so the nurse could cover the wound while waiting for wound care nurse. V5 said that she was not notifed that R5's sacral dressing was removed. V5 cleansed the wound. V5 said that R5 has 40% greenish slough formation and 60% reddish tissue granulation. She applied metronidazole for contaminated wound, medi honey, calcium alginate and covered with foam dressing. On 5/13/25 at 11:30AM, Informed V14 Building Manager that R5 does not have foot board. V14 said that he was not aware, and nobody told him. R5 is admitted on [DATE] with diagnosis listed in part but not limited to Stage 4 sacral pressure ulcer, Acute respiratory failure with hypoxia, Anoxic brain damage, Encephalopathy, Necrotizing fasciitis, Tracheostomy, Gastrostomy, Type 2 Diabetes Mellitus. Active physician order sheet indicated: Low air loss mattress. Cleanse sacral stage 4 with normal saline. Apply medihoney paste then maxorb II, metronidazole as needed for contamination and cover with foam dressing daily and as needed. Comprehensive care plan indicated: He has alteration in skin integrity. He is at further risk for skin breakdown due to weakness, requiring total assistance with ADLs, tracheostomy status, incontinence, and underlying diagnosis. Facility is unable to provide policy on Low air loss mattress regarding avoiding of multiple layers of linen as manufacturer recommendation. Facility's policy on Prevention and Treatment of Pressure Injury and other Skin Alterations 3/2/21 indicated: Policy: 3. Implement preventive measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Procedure: 2. Evaluate residents for actual pressure injuries or other skin alterations on admission or re-admission by utilizing the initial nursing assessment. 5. Develop a care plan for either actual or potential alteration in skin integrity and changes as needed. 6. Complete a comprehensive pressure injury evaluation for identified pressure injuries. 8. At least daily, staff should remain alert for potential changes I the skin condition during resident care. 9. Moisture barrier may be applied as needed. 10. Revise care plan approaches as needed based on resident's response and outcomes. Facility's policy on non-sterile dressing change 3/2021 indicated: Guidelines: 1. Non-sterile dressings protect open wounds from contamination and absorb drainage. Facility's policy on Management of Low air loss mattress 3/2024 indicated: 7. Secure pump unit on the foot end of the bed frame

Based on observation, interview, and record review the facility failed to implement physician's order in using red rubber catheter for suctioning resident. The facility failed to implement its policy on suctioning procedure. The facility also failed to have a spare tracheostomy tube, one of the same size and one of a smaller size at bedside that is readily available in case of emergency to ensure resident's airway is secured. This deficiency affects one (R4) of three residents reviewed for Respiratory Care of Resident on Tracheostomy tube. Findings include: On 5/13/25 at 9:51AM, Observed R4 lying in bed. She has tracheostomy tube connected to ventilator. V2 DON (Director of Nursing) unable to locate spare tracheostomy tube set for R4 in her room. V2 called for V8 Respiratory Therapist. On 5/13/25 at 9:53AM, V8 Respiratory Therapist (RT) said that R4 is on trach size Shiley 6. V8 said that they should have a spare tracheostomy set at beside in case of emergency such as accidental decannulation to ensure R4's airway is secured. They should have a replacement tracheostomy tube 1 of the same size and 1 of a smaller size that should be readily available. V8 searched the room but unable to find spare of tracheostomy set in R4's room. On 5/13/25 at 10:26AM, Observed V8 RT suctioned R4 using plastic transparent suction catheter for more than 13 seconds three times (3x), no ventilation provided in between suctioning. R4 gaging/coughing with facial redness as he inserted the catheter. After suctioning, he removes his gloves and donned new pair of gloves without hand hygiene. Then provided tracheostomy care. On 5/13/25 at 10:32AM, V8 RT said that he does not need to provide ventilation in between suctioning because the resident is on ventilator. He said he suctioned R4 for 15 seconds each time. Informed V8 that he removed the oxygen collar mask while suctioning R4 and he suctioned R4 more than 10 seconds each time. He continued suctioning without interval of 30 seconds to 1 minute in between suctioning. On 5/13/25 at 1:38PM, Informed V1 Administrator and V2 DON of above observations and concerns. On 5/14/25 at 11:48AM, V19 Care plan coordinator said that she developed and updated R4's comprehensive care plan. She is not aware that R4 has an order to use a red rubber catheter for suctioning due to tracheal bleeding. R4's care plan was not updated. Informed V1 administrator of above concern that V8 RT did not follow physician order when suctioning R4 and care plan was not updated. Requested to talk with respiratory therapist assigned to R4. On 5/14/25 at 12:20PM, V20 Respiratory Therapist (RT) said that V1 Administrator asked him about the red suction catheter for R4. He was not aware not until the administrator told him about the concern. V20 said that they have to follow physician order. On 5/14/25 at 12:29PM, Rounds made with V20 RT to R4's room. V20 searched R4's room for red rubber suction catheter for suctioning and unable to locate. V20 said that R4 does not have a red rubber suction catheter in her room. R4 is admitted on [DATE] with diagnosis listed in part but not limited to Chronic respiratory failure with hypoxia, Tracheostomy, Gastrostomy, Type 2 Diabetes Mellitus, Hand contractures, Muscle weakness, Incontinence without sensory awareness, Encephalopathy, Parkinson's Disease. Active physician order sheet indicated: Vent orders: AC mode, rate 16, VT350, PEEP 5, FIO2 40%. Vent checks every 6 hours and PRN (as needed). Airvo 40% 60% LPM 34 Celsius every shift for high flow humidified oxygen related to dependence on respirator. Suction every 4 hours and PRN. Use red rubber catheter for suction due to tracheal bleeding. Trach care and collar every shift and PRN. Trach Care: Shiley size 6. In case or emergency, trained nurse may reinsert outer cannula of tracheostomy PRN. Comprehensive care plan indicated: She has potential for complications related to ventilator/respirator use. Intervention: Trach care and suction as ordered. She requires oxygen therapy related to her acute respiratory failure. Facility unable to provide policy on Tracheostomy emergency protocol of having spare replacement tracheostomy tube set of the same size and 1 of a smaller size at bedside readily available in case of emergency to ensure resident's airway is secured. Facility unable to provide Nursing competency skills on Respiratory care such as Tracheostomy care and suctioning. Facility's policy on Physician's order for Medications or Treatments indicated: Policy: Medication will be dispensed and subsequently administered to a resident only upon the clear, complete, signed order of a lawfully authorized prescriber. Each medication order is documented in the resident's medical record with the date and signature of the person receiving the order. Prerequisites: 1. Physician orders for medications 2. Physician order sheet (POS), electronic or paper. Procedure: 2. The nurse will follow order-specific procedures to submit orders to pharmacy appropriately, which may include transcribing any telephone or transfer sheet orders to the POS. Facility's policy on Suctioning: Tracheostomy 9/2020 indicated: Policy: Suctioning of a tracheostomy will be done upon physician's order and as needed by nurse, respiratory therapist, or speech therapist to maintain a patent airway to facilitate the removal of accumulated tracheal secretions. Procedure: 12. Using your non-dominant hand and a manual resuscitation bag, hyperventilate and or hyper oxygenate the resident by delivering 3-6 breaths prior to suctioning (if applicable), hyperventilate and or hyper oxygenate. Pre/post suction is not a routine procedure. 14. Apply suction by intermittently occluding the Y port on the catheter with the thumb of your non dominant hand and gently rotate the catheter as it is being withdrawn. Do not suction for more than 10-15 seconds at a time. 15. If using ambu bag, hyperventilate the resident using your non-dominant hand and a manual resuscitation bag, delivering 3-6 breaths. Replace oxygen delivery device, if applicable in between passes, using your non dominant hand and have resident take several deep breaths. 17. Allow at least a 30 second to 1 minute interval if additional suctioning is needed No more than 3 suction passes should be made per suctioning episode. Encourage resident to cough and deep breathe between suctioning. 18. Perform hand hygiene after removing gloves. Facility's policy on Review of care plans 11/2017 indicated: Each resident's care plan shall be reviewed routinely by the IDT (Interdisciplinary Team). Procedure: 2. The IDT is responsible for periodic review and adjustments to the plan of care: d. When there is a change of treatment plan, goals, or interventions 5. The Resident care coordinator will be responsible to ensure that the plan of care is updated and maintained by all IDT members.

Based on observation, interview, and record review, the facility failed to follow facility-enhanced barrier precautions during tracheostomy care and suctioning, failed to change gloves during suctioning and used soiled gloves to start a sterile procedure, and failed to use a sterile technique when using the sterile catheter. This failure affected one (R1) of three residents reviewed for infection control. Findings include: R2 is a [AGE] year-old resident with diagnoses including but not limited to: metabolic encephalopathy, respiratory failure, spinal cord injury, diabetes, quadriplegia, gastrostomy, and tracheostomy. R2 was admitted to the facility on [DATE]. On 4/30/2025 at 1045 AM Observed V5 (Respiratory Therapist) providing tracheostomy and suctioning care to R2. V5 touched the suctioning tubing hanging around the canister on the wall removed the yanker suction tube with yellow secretion opened to air and removed the sterile suction tubing from the opened sterile package proceeded to connect it to the wall suction tube. V5 used a nondominant hand to remove the tracheostomy oxygen collar and suctioned R2 with the dominant hand, during the procedure the suction tube touched the gown and R2's hand. After suction was completed, there was a moderate amount of secretion outside the tracheostomy on the drain gauze, V5 grabbed the yanker tubing from the bag behind the bed and suctioned R2 and did not change the drain gauze. V5 said, R2 is having a lot of secretions requiring suctioning every two hours and I will be back to change later. V5 did not use a gown to suction R2 and did not change gloves during the process or hand hygiene. V5 stated that it was a clean procedure and did not use a gown because it was a quick procedure. V5 said I was expected to do it when the enhanced barriers precaution was placed on the door and R2 had a tracheostomy. On 4/30/2025 at 2:29 PM V4 (Director of Respiratory Therapy) said, I expect the staff is taking care of a tracheostomy it is considered a clean procedure but during suctioning, if the respiratory therapist used a sterile suction kit, I expect the respiratory therapist to use a sterile technique using the dominant hand and the non-dominant hand to use clean technique and change gloves, hand washing when gloves were dirty. V5 was expected to be using enhanced barriers precaution per facility protocol during suctioning and tracheostomy care. V5 was expected to dispose of the opened suction tubing hanging around the suction canister with secretion before suctioning R2. On 4/30/2025 at 4:10 PM, V2 (Director of Nursing) said, I am the infection control preventionist for the facility. I expect the staff to use enhanced barriers precaution per facility protocol during tracheostomy and suctioning. The respiratory therapist should have changed his gloves when V5 moved from dirty to clean and washed his hands. Suction supplies opened in use should be kept in the bag. On 4/30/2025 at 4:15 PM, V1 (Administrator) said, I expect the staff to use enhanced barrier precautions per facility protocol during tracheostomy, suctioning, and respiratory procedures, and I will work with V2 to educate the staff. Facility provided policy titled, Suctioning Tracheostomy (dated 09/2020), which includes: 8. Remove soiled tracheostomy dressing. 9. Remove exam gloves and wash hands. 10. Open dressings, sterile basins, and other supplies using a clean technique. 11. Pour 50% hydrogen peroxide & 50% NS (per MD orders) into one sterile basin and sterile saline/normal saline into the other sterile basin, using aseptic technique .10. Put on a face shield or goggles and mask (if indicated). Put on sterile gloves. The dominant hand will manipulate the catheter and must remain sterile. The non-dominant hand is considered clean rather than sterile and will control the suction valve (y port) on the catheter. Facility policy titled, Enhanced Barrier Precaution (dated 12/2024) reads: POLICY: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDROs including residents with a chronic wound or an indwelling medical device. 2. Residents that have indwelling medical devices, regardless of MDRO status, will be on EBP. a. Some examples may include central vascular line (including hemodialysis catheter), urinary catheter, feeding tube, tracheostomy, and ventilator (excludes peripheral IVs). Facility policy titled, Hand Hygiene (date 10/2024), reads: c. When caring for a resident, when moving from a soiled body site to a clean body site of the same resident. d. After touching a resident or the resident ' s immediate environment.

Based on observation, interview, and record review, the facility failed to ensure that staff provide oral care for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected three (R1, R2, and R3) of three residents reviewed for ADL care. Findings include: R1 is a [AGE] year-old resident admitted to the facility on [DATE]-[DATE] with diagnoses including but not limited to: cardiac arrest, septic shock, orthostatic hypotension, tracheostomy, gastrostomy, metabolic encephalopathy, and anoxic brain damage. The Care plan initiated on 3/31/2025 has an ADL Functional Performance Deficit related to generalized muscle weakness, immunocompromised and with med dx of metabolic encephalopathy, cardiac arrest, and on tracheostomy and gastrostomy. Intervention reads: Assist resident with oral care daily as needed. R2 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: metabolic encephalopathy, respiratory failure, spinal cord injury, diabetes, quadriplegia, gastrostomy, and tracheostomy. The Care Plan, initiated on 4/26/2025, states that R2 has an ADL functional performance deficit, activity intolerance, and decreased functional ability related to generalized muscle weakness, abnormalities of gait and mobility, immunocompromised condition, quadriplegia, and tracheostomy. In the intervention, read: Assist resident with oral care daily as needed. Assist with personal hygiene as required. On 4/30/2025 at 10:35 AM observed R2 in his room, awake, and did not respond to his name. R2 had dry lips with crusted dry secretion to the right side of the mouth with yellow teeth with residue. On 4/30/2025 at 11:00 AM V7 (Certified Nursing Assistant) said, I did not clean his mouth yet and probably night shift cleaned last, but I can see that R2 needs mouth care done. On 4/30/2025 at 11:06 AM V9 (Licensed Practical Nurse) said, I did not clean R2 ' s mouth yet and do not know when it was cleaned and acknowledged that R2 needed his mouth and teeth cleaned. On 4/30/2025 at 12:08 PM V10 (Family Member) said, the only concern that I have when I come to the building is mouth care, his lips are dry and crusted and his teeth are dirty. R3 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: cerebral infarct, anemia, aortic aneurysm, aortic dissection, aortic valve replacement, tracheostomy, gastrostomy, diabetes, and pressure ulcer. The care plan initiated on 4/23/2025 states, that R3 has ADL self-care performance deficit and decreased functional ability related to fall risk, limited mobility, recent hospitalization , shortness of breath, stroke, weakness/deconditioning, tracheostomy status, anoxic encephalopathy. Interventions read: Assist resident with oral care daily as needed. Assist with personal hygiene as needed. On 4/30/2025 at 11:00 AM V11(Family Member) said, I come to the facility every day to visit my brother and the care is good, but mouth care is a problem, and his teeth are very dirty. V11 opened R3's mouth and showed the surveyor R3's teeth condition, stating look to see for yourself how yellow and crusted his teeth are. On 4/30/2025 at 4:10 PM V2 (Director of Nursing) said, the nursing assistant is responsible for oral care unless a medicated mouthwash is used. Oral care is done every shift or as needed by nursing assistants and residents who require assistance. I expect the staff to provide oral care to prevent build-up and dry-crusted secretion on lips and gums. The facility will work on adding residents to the dentist list. Facility provided policy titled, Oral Care (dated 09/2020), which includes: Procedure: Note: Offer oral care hygiene before breakfast and bedtime. 6. Inspect mouth and gum

Based on interview and record review, the facility failed to ensure that fall interventions were in place for a resident with a history of falls. This failure affected one (R4) of four residents reviewed for falls and resulted in R4 experiencing an unwitnessed fall which resulted in a nasal fracture. Findings include: R4 was admitted to the facility on [DATE] with diagnoses that included: Left humerus fracture (status post fall), dementia, weakness, and lack of coordination. On admission, Minimum Data Set assessment dated [DATE] documents that R4 has severe cognitive impairment and according to notes, was non-verbal, and hard of hearing. Fall incident reports were reviewed relating to R4 experiencing three unwitnessed falls in the facility on 8/26/24, 9/9/24, and 10/10/24. 8/26/24 incident report notes at 12:40 pm a nurse on duty heard a noise and rushed to the dining room. R4 was found on the floor in the dining room laying on R4's back and left side. The nurse notes that just five minutes prior, R4 was assisted with eating lunch. R4 was sent to the hospital for evaluation related to the incident. Interventions updated in the care plan after the fall included Will prevent fall by adding the use of bed alarm and wheelchair alarm to resident fall prevention plan. R4 was admitted to the hospital for evaluation and treated for a urinary tract infection. R4 returned to the facility 9/2/24. The Order Summary Report included an order written 9/3/24: Bed alarm and wheelchair alarm for fall risk patient. On 10/23/24 at 12:26 PM, V7 ADON (Assistant Director of Nursing) said that when a resident is at a risk, or has had multiple falls, the interdisciplinary team meets and discusses the root cause of the fall and updates the care plan right away. The interventions are implemented as soon as the care plan is updated. Once the intervention is implemented, it should either auto-populate or can be added to the CNA (Certified Nursing Assistant) tasks. This ensures proper monitoring and ensuring the chair and bed alarms are functioning and being used appropriately. Fall incident of 9/9/24 occurred at 7:30 pm and was described as follows: (R4) was seated at the nursing station in wheelchair prior to fall. (R4) was observed on the floor, smiling upon the writer's arrival. (R4) unable to give description. Interventions after this fall included evaluating seating system for modifications as needed and evaluate multiple falls to determine commonalities or patterns. Fall incident of 9/10/24 occurred at 2:15 am and Nursing Description includes: 'at 2:15am R4 noted at the door in front of room face down, nosebleed noted. R4 was conscious but confused.' Nursing progress notes relating to this incident, note that R4 was sent to the hospital via 911 and was diagnosed with a nasal fracture. R4 returned to the facility after evaluation in the afternoon on the same day. On 10/23/24 at 10:23 AM, V8 Registered Nurse (Agency) said after arriving to the facility, V8 did rounds at about 1:00AM and saw R4 in the bed. V8 remembers specifically viewing R4, because V8 received in report that R4 had fallen earlier in the day. V8 said there were chairs near R4's room, however V8 did not see any nursing assistants on the unit, and furthermore V8 was answering call lights due to no nursing assistants being available. Shortly after 2:00am, V8 described sitting at the nurse's station on the computer and seeing a flash from the corner of the eye. V8 got up to investigate and found that R4 appeared to have gotten up from the bed and ambulated several feet across the hall before falling in the doorway. V8 called out for help and staff came to assist. V8 said there was no unusual sounds or alarms heard at the time. On 10/22/24 at 3:06 pm, V9 CNA (Certified Nursing Assistant) said they were working the overnight shift at the time R4 fell however, V9 was on break at the time. V9 said R4 was in bed prior to leaving for break, and informed another CNA of leaving the unit, however V9 said that they did not inform the nurse. V9 said another CNA (V10) came to assist after hearing V8 call out, and V10 texted V9 to return to the floor. V9 could not remember if R4 had a bed alarm activated, or on the bed when rounds were performed prior to leaving the unit. R4's care plan was updated 9/4/24 to duplicate the use of pressure alarms while in chair and bed, however after reviewing the Point of Care documentation (CNA tasks), staff did not begin documenting use of pressure alarms until the morning (7am-3pm) shift 9/10/24. Facility Policy Management of Falls revised 8/20 states in part; Policy: 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 plan of care 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 follow physician orders for one resident (R1) in the sample of three. This failure resulted in (R1's) medications not being placed on hold and delay in scheduled surgery. Findings include: R1's diagnosis includes: Acquired Absence of Left Leg Below Knee, Chronic Osteomyelitis with draining sinus, Left Tibia and Fibula, Type 2 Diabetes Mellitus with proliferative Diabetic Retinopathy, Essential (Primary) Hypertension, Anemia Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Long Term (Current) Use of Insulin, Peripheral Vascular Disease, Unspecified R1's BIMS (Brief Interview of Mental Status) dated 7/6/2024 documents score of 15 (cognitively intact). R1's After Visit Summary dated 6/14/2024 at 10:34 am (in part) Today's Visit R1 saw doctor. June 14, 2024 for Pre-Op Exam What's next: June 21, 2024 Revision Below Knee Amputation, Preoperative Instructions You may be also be instructed to stop certain medications 5-7 days prior to surgery and that will also be specified. Additional instructions include: Surgery Med List Medication Multivitamin (Multiple Vitamins) PO tablet Hold prior to surgery For 7 days, ferrous sulfate 325 mg (65mg iron) PO enteric coated tablet Hold prior to surgery For 7 days, aspirin (EC) 81 mg PU TbEC enteric coated tablet Hold prior to surgery For 7 days, IBUprofen (Motrin) 200 mg PO tablet Hold prior to surgery For 7 days, clopidogrel (PLAVIX) 75 mg PO Hold prior to surgery For 7 days R1's June 2024 MAR (Medication Administration Record) documents the following medications given and not put on HOLD as ordered 7 days prior to surgery date of June 21, 2024 Aspirin (EC) 81 mg PU TbEC enteric coated tablet given 6/14/2024 thru 6/20/2024 and not put on hold until 6/21/2024 Clopidogrel (PLAVIX) 75 mg PO given 6/14/2024 thru 6/20/2024 and not put on hold until 6/21/2024 Multivitamin (Multiple Vitamins) PO tablet given 6/14/2024 thru 6/21/2024 and not put on hold until 6/22/2024 IBUprofen (Motrin) 200 mg not put on hold until 6/22/2024 Ferrous Sulfate 325 mg (65 mg iron) PO enteric coated tablet given 6/14/2024 thru 6/21/2024 (morning dose) and not put on hold until 6/21/2024 evening dose R1's Order Summary Report dated Active Orders as of 6/1/2024 (in part) documents does not document any medications to be put on hold. R1's Progress Notes dated 6/20/2024 10:02 documents (in part) Type: Nurses Note Received order from V14 (Surgeon) to hold aspirin and Plavix for 5 days pre op for his upcoming procedure Author (V10 LPN) R1's Order Details dated 6/14/2024 documents (in part) Follow Up Appointment with V14 (revision below knee amputation) 6/21/2024 R1's Appointment Month: June documents (in part) R1's date/pick up time 6/21/2024 4:45 am with V14 7 am, canceled. R1's rescheduled appointment 6/25/2024 pick up 8:30 am with V14 (surgery) 11 am On 7/12/2024 at 2:30 pm, V8 (RN) stated, he has taken care of R1 and R1 is able to make needs known and lets you know if he needs anything. Surveyor asked V8 if R1 brings after visit summary to nurse when R1 returns from medical visits. V8 stated, Yes he always gives us the report. R1 needs little help and can verbalize his care needs. I did not take care of him on 6/14/2024 when he came back from his doctor's visit. On 7/12/2024 at 3:03 pm, V4 (LPN) stated, I am familiar with him. I remember his doctor visit. I believe he had an appointment in June, I sent him out for the day to appointment and he came back with paperwork that I entered into the system as ordered. He had a couple of dates for surgery and different medications to hold. The appointments mostly were for July and I had to hold medications a week prior to July. I put in meds to be held and as far as I know they were put in to be held. V3 (Assistant Director of Nursing - ADON) was assisting me in putting the meds (medications) in on hold. I am not sure if he had surgery, nothing was brought to my attention, but I do believe he had the surgery since then. I believe the med hold was either for 7 days or 14 days depending on which one I was looking at but most between 7 and 14 days. I have not heard anything else about it. R1 is pleasant and able to make his needs known. Surveyor asked V4 if she reviewed the after-summary visit for R1 for 6/14/2024. V4 stated, Yes, R1 gave me the paperwork and I reviewed the after-visit summary. On 7/12/2024 at 3:18 pm, surveyor asked V3 who gets paperwork when resident goes to the doctor and returns with paperwork and orders. V3 stated, the floor nurse. V3 stated, we keep the original and if the resident requests a copy we give them a copy. I am familiar with R1. The nurse (V4) had R1's summary for 6/14/2024. The nurse was V4. We put in whatever orders were on the paperwork in the system. Surveyor asked, were there medication orders that needed to be put in. V3 stated, Yes, meds needed to be put on hold. On 7/12/2024 at 3:35 pm, V3 stated, I reviewed the after-visit summary with V4. When we get the after-visit summary, the nurse will put in the orders. Surveyor asked, were R1's medications put in to be held 7 days prior to 6/21/2024 surgery date. V3 stated, I did not know revision meant surgery. He was to have revision. I (V3) just showed the nurse (V4) how to hold medications. Surveyor asked when should R1's medications been held? V3 stated, 7 days prior to surgery. Medications should have been held 7 days prior to 6/21/2024 which would be 6/14/2024. We put the orders in and followed the papers. If there are any questions regarding the after-summary visit, the nurse would call the clinic. Surveyor asked, was R1's surgery delayed. V3 stated, it was rescheduled. On 7/12/2024 at 4:18 pm, V3 stated, orders stated put on hold 7 days prior to surgery and the surgery was scheduled for June 21, 2024. Surveyor asked V3, when were R1's medications actually put on hold. V3 stated, 6/21/2024 5 days prior to rescheduled surgery of 6/26/2024. V4 actually put in the orders, I showed V4 how to put in the orders. I showed her how to put medications on hold. I looked at orders for hold 7 days prior to surgery. I am not sure how it was put in for July 18. I am not sure how this was found out. The nurse is supposed to read through the after-visit summary when they receive it and place orders that are ordered. On 7/12/2024 at 4:26 pm, V2 (Director of Nursing - DON) stated, I am familiar with R1, he voiced a concern the latter part of June. R1 wanted to know who was on shift I believe, Friday June 14, 2024. He wanted the name of the nurse and ADON. I went to go look and asked R1 what was going on. He said they made a mistake and I would like to speak to them. I (V2) believe R1 spoke to them (V3 and V4). I followed up with R1 to see if he still had concerns. R1 said no and thanked me. Surveyor asked V2 did you hear about his surgery being delayed. V2 stated, I was on a call the following week and he was going to go out on 6/25 pre-op so when I saw this I saw the date was different. My understanding is that the medications were not held in time. The order stated 7 days so they had to obtain another order so they held for 5 days for him to have the revision. His scheduled surgery was rescheduled because the medication was not held. The process from appointment is the resident brings us the after care summary. We check to see if any orders for labs or diagnostics and put in medical record then put in scan box where document is ultimately uploaded. We ask for paperwork. Sometimes the resident will not tell us and hold onto it. We do not have access to hospitals records. R1 notified V10 the nurse on the next shift. He let her (V10) know I think they gave me my medication; I don't know if you know. V10 then called the doctor, rescheduled, and got orders of what to hold prior to surgery. That is when I became involved in the situation. I asked R1 why he did not relay this to me. He said V10 handled it and I did not need to talk to you. R1 did not give the nurse any paperwork, he presented it after. On 7/13/2024 at 9:47 am, V10 (LPN) stated (in part), I am familiar with R1. He used to be on my side. R1 always goes to his appointment at local hospital. R1 makes his own appointments and when he comes back, he always gives me the paper. When we get the paper, we must identify if there is any order and then carry out the order because the doctor will sometimes give an order. We keep a copy and they will usually upload it. The documents go to MISC. I (V10) heard that he was supposed to have meds held when R1 came back from appointment. I was not here on Friday; I am off on Friday. I am not sure what really happened. V10 further stated, after a few days, actually one day prior to scheduled surgery he (R1) told me that he had a scheduled surgery. I told R1 his medication was not held. R1 stated, he would call the doctor himself. I then got a call from the doctor. The doctor told me to hold his aspirin and Plavix for 5 days and they would reschedule the surgery. The process if R1 will bring his summary and the nurse, reviews it to see if there is an order. June 21st was the surgery so we should be holding the meds 7 days prior to surgery. R1 told me it is supposed to be held. I told R1, I only can start today so we have to talk to the doctor. R1 messengered his doctor and the doctor called me back. Under the POS (Physician Order Summary) there is an option to hold and for how many days. R1 always brings back paperwork to us, but if there is nothing new, he will tell me no new order, but he will always give us the paper. I review it to see if there is a new order. The floor nurse is responsible for putting in any new orders from residents visit to doctor. V10 stated, I am not sure, but I think the only order that I saw in the computer was the eye appointments. The doctor just said to hold for 5 days and they would reschedule the surgery. I did not check to see if anything was scanned in the computer. I saw the appointments. The only way to know R1 had any appointments is from looking at the after-visit summary and putting it in record. R1 is very knowledgeable about his care. On 7/13/2024 at 11:26 am, Surveyor asked V2 what the process is when a resident returns from an outside appointment. V2 stated (in part), if the resident is going out on a scheduled visit, normally the nurse will put in a progress note. If going out for a procedure will discharge resident then readmit when resident returns to the facility. Paperwork orders will be entered and documents scanned under miscellaneous. For that appointment (R1's appointment on 6/14/2024) it is an old document, it has not been scanned in R1's chart. Surveyor asked V2 when a resident goes to an appointment, is the after-visit summary scanned into the Electronic Medical Record (EMR). V2 stated, We are supposed to scan in the after-visit summary after each visit. Orders were placed by the nurse on 6/17/2024. R1 did not give us any paperwork. Surveyor asked V2 if R1 has active orders on the 6/14/2024 summary how do you know when R1 has other appointments. V2 stated, We put the order in, it is on the POS (Physician Order Summary). Surveyor asked V2 did that come from the after-visit summary. V2 stated, we did not get the after-visit summary until 6/17/2024 from R1. On 7/13/2024 at 12:11 pm, V12 (Scheduling Coordinator) stated (in part), on 6/21/2024 R1 had a doctor's appointment but it was canceled then rescheduled for 6/25/2024.The nurses get the paperwork and they send me a message in EMR telling me when the resident has an appointment. Facility Policy Description Title Staff Nurse (Registered Nurse/License Practical Nurse) dated 1/2015 documents (in part) I. Job Summary Responsible to provide direct nursing care to the customer, and to supervise the day-to-day nursing activities performed by the nursing assistants. Such supervision must be in accordance with current Federal, State, and local standards, guideline and regulations facility policies. The objective is to endure the highest degree of quality care is maintained at all times. II. Qualifications F. Must possess the ability to make independent decisions when circumstances warrant such action. IV. Essential Functions C. Assume all Nursing procedures and protocols are followed in accordance with established policies. N. Place orders for medications and treatments as necessary V. Perform routine charting duties as required and in accordance with out established Charting and Documentation Policies and Procedures X. Prepare and administer medications and treatments if appropriate as ordered by the physician. Y. Review medication record for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies. BB. Arrange for diagnostic and therapeutic services, as ordered by the physician.

Based on observations, interviews, and record reviews, the facility failed to develop and implement effective interventions to prevent or reduce the risk of falling for residents with history of fall and assessed to require extensive assistance for toileting. This affected two of three residents (R6, R5) reviewed for fall prevention interventions. This failure resulted in R6 falling at night while attempting to self-transfer to commode and sustaining a left comminuted and displaced hip fracture requiring surgical intervention. Findings include: 1. On 11/17/23 at 11:25 AM, this surveyor observed R6 lying in bed with eyes closed. R6 had a floor mat on the right side of bed between the bed and wall. The floor mat for the left side of the bed was folded in half and leaning against the wall. On 11/21/23 at 12:07 PM, R6 stated that R6 fell in R6's room on Friday, 10/20/23, around 8:00-9:00 PM. R6 stated that she was going to use her commode and the commode was half on the floor and half on the floor mat. R6 stated that the commode was uneven and she lost her balance and fell . R6 stated that she injured her leg and went to the hospital. R6 stated she broke her knee in 3 different places. R6 stated that she did not ask for help when she went to the commode. R6 stated that she regrets going to the commode and that if she went to the toilet this accident wouldn't have happened. R6 stated that now she can't use the commode and the staff will assist R6 to the bathroom. R6 stated that she has to call for help and she can't do anything without staff assistance. On 11/22/23 at 10:30 AM, V5 (Restorative Nurse) stated that R6 previously needed only limited assistance with ADLs (activities of daily living). V5 stated that over the past few months R6 has been needing more assistance with ADLs; weakness in both legs has increased. V5 stated that R6 is alert and oriented x 3 but needs reminders to call for toileting assistance. V5 acknowledged that R6 has had three falls at night related to toileting. V5 stated that staff are aware that R6 has a habit of getting up without asking for assistance. V5 stated that staff are aware that R6 needs frequent monitoring and rounding at night; staff round on R6 every two hours during the night. V5 stated that during the night staff should check to see if R6 needs help. V5 stated that staff should not wake R6 up but when round if R6 is awake should ask if she needs help. V5 stated that staff should make sure bedside commode properly placed with all four legs on a hard surface for stability. R6's medical record notes the following: On 6/3/23 at midnight, V10 RN (Registered Nurse) was alerted by CNA (Certified Nurse Aide) on duty that R6 was found sitting on the floor next to her bed and assisted her back to her bed, R6 did not utilize call-light bell. V10 found R6 in her bed. R6 stated that she was trying to get out of bed on her own to use the bathroom and fell from her bed. On 7/5/23 at 1:12 pm, V6 RN noted R6 was found sitting on floor on right side of bed. R6 was observed to have one brief on left ankle and one brief on right ankle. R6 stated that R6 was putting on brief and slipped from the bed landing on her buttocks. On 10/14 10:17 PM, V11 RN noted CNA noted R6 was sitting on the floor at 8.45 PM and called for help. V11 went and saw that R6 was on the floor sitting trying to get up telling V11 that she was fine. On physical examination, R6 was found to have a skin tear on her right elbow and she hit her right cheek and jaw on the commode chair and R6 has a minor cut on her cheek. V11 helped R6 to go to the bed. On 10/20 at 11:20 PM, V7 LPN (Licensed Practical Nurse) noted: R6 had an unwitnessed fall at around 11:30 PM. R6 was found lying down on her back by CNA after being alerted by R6's roommate. Initially R6 did not complain of pain but a few minutes later stated that she was feeling pain in her left hip. R6 was transported to the hospital and diagnosed with left hip fracture, awaiting surgery. R6's hospital record, dated 10/21/23, notes R6 was trying to use comode and fell down as the comode was not fully placed properly. R6 fell on left side and currently has 8 out of 10 left hip pain. R6 is not able to lift both legs off the bed due to pain; can attempt on right side but has considerable pain on the left. Left leg is externally roated and shortened. Left hip x-ray showed a comminuted (bone is broken in more than two pieces) and displaced hip fracture. Left hip surgically repaired on 10/21/23. Physical therapist noted R6 with decreased awareness of deficits and assistance required to compensate for deficits. R6's care plan, dated 12/15/2022, notes R6 is at risk for falls due to muscle weakness, use of assistive device, history of falls, and decreased muscle strength. Interventions identified after fall on 10/14 notes floor mats while R6 is in bed and develop toileting schedule for prompted voiding. This facility's management of falls policy, dated 08/2020, notes this facility will develop a plan of care to include goals and interventions which address resident's risk factors. Risk factors include but are not limited to history of fall incidents, incontinence, and behaviors. Assess and monitor resident's immediate environment to ensure appropriate management of potential hazards. 34069 2. On 11-17-23 at 11:41 AM, R5 said he fell 2 months ago. R5 said staff left his side rails down and he rolled out of bed between the bed and his wheelchair. R5 said the staff is responsible for keeping the siderail up. R5 said he prefers his siderail up for safety. R5 said his bed was in the lowest position and he is able to use the call light. R5 said he makes sure the staff keeps his siderail up when he is sleeping. On 11-21-23 at 11:06 AM, V3 (DON) said R5 had an unwitnessed fall. V3 said R5 said he fell out of his bed. No staff found R5 on the floor, at 5:00 AM, R5 activated his call light to tell Certified Nurse Aide/CNA he rolled out of his bed. R5 was assessed and no pain or injury noted. On 11-21-23 at 2:02 PM, V3 (DON) said R5's care plan was reviewed however it was not modified with new interventions. On 11-17-23 at 12:53 PM, V5 (Fall Nurse) said siderails will protect the resident from falling from bed and assist with bed mobility, turning, and repositioning. V5 said when a resident is sleeping, the bed should be in the lowest position and siderails up to prevent a fall and for safety. It is everyone's responsibility to ensure the the siderails are up. V5 said R5's fall care plan dated 8-31-23 does not document R5's recent fall or new interventions added. Progress Note dated 9-20-23 documents: Pt had fallen at around 5 am with call light within reach and bed in the lowest position. CNA found pt standing next to bed, stated they had fallen. Pt stated rolled off bed while sleeping. Provided education and did neurological evaluation and post occurrence. Notified DON, R5's Doctor and family member. Pt was sent to hospital for further evaluation. Hospital Record Dated 9-20-23 documents: Chief Complaint: 96 y/o M with h/o HTN, HL, asthma, CKD, CHF, atrial fibrillation, pacemaker, on 2 L nasal cannula at baseline who presents for evaluation status post mechanical fall. Patient is awake alert and oriented and answering questions appropriately. He reports at the nursing home they failed to raise his bed rail and he excellently fell out of bed this morning. He did hit his head but did not lose consciousness. Does report currently that he is feeling a little lightheaded but denies any prodrome of dizziness or lightheadedness prior to the fall. MDM: Patient status post mechanical fall. We will CT head and cervical spine to further evaluate. Diagnosis: Fall, initial encounter. Management of Falls Policy dated 8-2020 documents: Policy: 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 plan of care in order to minimize the risks for fall incidents and/or injuries to the resident. Fall Care Plan dated 8-31-23 does not reflect updates of the fall incident dated 9-20-23 nor any newly added fall interventions for the fall of 9-20-23.

Based on observation, interview and record review, the facility failed to keep call lights within resident's reach for a resident at risk for falls for one (R32) of three residents reviewed for call lights in a sample of 20. Findings include: On 10/18/2022 at 10:54 AM, R32 was observed sitting in her wheelchair with her bedside table in front of her and call light on the bed, out of R32's reach. In front of her, there is a posting that says Please Call Don't Fall. Your safety is important to us. If you need to get up, use the call button for assistance. On 10/18/2022 at 11:45 AM, R32 was observed with V4 (Licensed Practical Nurse) and noted call light was out of R32's reach. V4 stated that R32's call light should be within her reach. On 10/19/2022 at 12:27 PM, V2 (Director of Nursing) said that call lights should always be within resident's reach. R32's Order Summary Report dated 10/18/2022 indicated admitted [DATE] and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Fall Risk assessment dated [DATE] indicated R32 scored 8 which is categorized as at risk for fall. Care plan with date initiated of 09/05/2018 indicated focus that R32 has an ADL (Activities of Daily Living) Self Care Performance Deficit due to weakness and interventions include encourage use of call light for assistance when needed. It also indicated focus that R32 is at risk for falls due to generalized muscle weakness, unsteady gait, lack of coordination, Dementia, use of [CONDITION(S)], history of falls and interventions include encourage resident to call, don't fall. Facility Policy: Title: Call Light, Use Of. Dated 9/20. Purpose: 1. To respond promptly to resident's call for assistance. Procedure: 7. Be sure call lights are placed within resident's reach at all times.

Based on observation, interview and record review the facility failed to ensure an additional [CONDITION(S)] was at the bedside for 1 of 1 resident (R56) reviewed for respiratory care in a sample of 20. Findings include: On 10/18/2022 at 11:02 am, R56 was observed with V5 (Respiratory Therapist-RT) in bed with a mechanical ventilator, V5 was unable to locate an additional emergency [CONDITION(S)] at the bedside. On 10/18/2022 at 11:04 am, V5 was asked three times should R56 have an emergency [CONDITION(S)] at the bedside. V5 said yes, R56 should have an emergency [CONDITION(S)] at her bedside it should be easy to locate, and I cannot find one, I will put one there now. On 10/19/2022 at 9:30 am, V2 (Director of Nursing-DON) said R56 should have an emergency [CONDITION(S)] at the bedside. On 10/20/2022, R56 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Order summary report dated October 20, 2022, indicates that R56 has an order dated 10/11/2022 for [CONDITION(S)] care: size number six and to change inner cannula daily and as needed prn. A care-plan dated 3/5/2020 with a focus of, Potential for complications secondary to [CONDITION(S)]. Facility Policy: Revised on 09/2022 [CONDITION(S)] Care Policy: [CONDITION(S)] care will be done on all residents with tracheostomies by a nurse, respiratory therapist, or medical doctor-M.D. Procedure: 17. Replace disposable inner cannula, daily and as needed prn. Code Blue/Medical Emergencies (For Illinois Chicago area& Wisconsin Facilities) Purpose: To ensure residents with medical emergencies will be assessed and appropriately handled. Procedure: 4. First aid and BLS (Basic Life Support) will be administered.

Based on observation, interview and record review, the facility failed to provide direct supervision during a meal and failed to ensure that the incident was immediately reported to the nurse for one resident (R34) of 24 residents reviewed for accidents/incidents in a sample of 37. These failures resulted in R34 sustaining a second degree burn to the left forearm/left elbow and a burn of unspecified degree to the left breast area. Findings include: R34 is a [AGE] year old female that suffered a Cerebral Infarction in February 2021 which resulted in left sided weakness and paralysis. R34's medical record also documents the following pertinent diagnoses: Generalized Muscle Weakness, Lack of Coordination, Need for Assistance with Personal Care, Dysphagia, Muscle Wasting and Atrophy and Diabetes Mellitus. A facility Incident Report documented that R34 experienced a Burn Incident on 5/23/21. The incident report dated 5/23/21 at 12:05pm was authored by V6 (LPN-Licensed Practical Nurse) and documents: This nurse was assisting (R34's) roommate with toileting in the bathroom when this nurse overheard (R34) inform therapist that she spilled her hot drink on her and burned herself. According to the patient, she grab(bed) her coffee from table and once it was on hand, it slipped and it spilled on her left arm and bed. She states feeling pain 5/10. Upon assessment, R34 had visible redness on left lateral arm and forearm. V6 applied a cold compress and obtained an order for [MEDICATION(S)] treatments to start twice a day after notifying V16 (Physician Assistant) of the [CONDITION(S)]. On 6/8/21 at 10:35am, R34 recounted the incident and stated, They brought my tray to me in my room and just left it there. The tea was very hot despite the creamer and the thickener. It was very hot. Hot enough to burn me. The mug slipped from my hand and the whole hot tea spilled on my left side. I already can't feel well on that side because of the stroke. They didn't supervise me. There was no supervision the day that it happened. Generally, it's (V11-Speech Therapist) that supervises me but she was not here that day or maybe she was with another resident. Generally, I was told that someone needs to always supervise me because I spill on myself during meals. R34 continued, The CNA (Certified Nurse Assistant) should stay with me and they didn't. But they have many patients to take care of. If I was supervised, it wouldn't have happened. And then, the CNA didn't change me after I spilled the hot tea. She left me in the wet gown for almost an hour and a half. R34 stated, This never should have happened. Now, despite trying to recover from the stroke and brain surgery, I now have to deal with more treatments and pain for these [CONDITION(S)]. R34 indicated that V7 was aware that she spilled hot tea on herself and also knew that she was eating by herself. The CNA was identified as V7. On 6/9/21 at 2:07pm, V6 (LPN) stated as was documented in R34's incident report that, (V7) came to tell me that (R34) spilled on herself. She did not tell me that it was a hot liquid. She just said, I'll be back to her to change her but have to take care of another patient first. V6 indicated that V7 never reported to her that R34 was burned. V6 indicated that one hour later she was assisting R34's roommate to the bathroom and overheard R34 state that she spilled her drink and got burned. V6 stated, Her gown was still wet from chest to belly. I thought back to when (V7) told me about a spill. V6 performed an assessment and found redness on R34's left arm/forearm and left breast. V6 stated, (R34) is supposed to be direct supervision for meals. So, I'm thinking (V7) didn't stay with her and supervise her. (R34) cannot have hot drinks by herself. V6 indicated that the therapist offered to change R34's gown but requested help so V6 asked V7 to assist. On 6/9/21 at 2:25pm, V7 (CNA) made a statement that was opposite R34 and V6's statement. V7 stated, Another person brought the tray to her. I don't know what happened because I was taking care of another resident. I'm busy in another room. (R34) told me that she spilled on herself. I did not supervise her during lunch because it was delivered and no one told me. R34's Physician Order Sheet (POS) documents an order dated 5/11/21 that reads: Pureed with nectar thick liquid. 1:1 assisted feeding with supervision and feeding assist. A sign above R34's bed reads: direct supervision-double swallow with puree: puree/nectar thick liquids. No talking while eating. On 6/8/21 at 11:00am, V11 (ST-Speech Therapist) stated, Right now (R34) is on a pureed diet with nectar thick liquids. I usually request direct supervision when they go from NPO (nothing by mouth) to a diet for safety reasons. She can't use left side. She holds everything with the right hand but does not have the best grip with cups and utensils. V11 further indicated that R34 requires supervision with hot drinks. R34's ST notes dated 5/20/21 documents: Requires moderate cues to aspiration precautions. On 6/9/21 at 11:24am, V12 (OT-Occupational Therapist) indicated that R34 can self feed but requires a lot of cueing to complete a task. V12 stated, Judgement wise - giving her hot drinks could be a safety issue. V12's OT notes dated 5/21/21 document: Pt requires max verbal and tactile cueing for initiation, sequencing and task completion. On 6/9/21 at 12:00pm, V5 (Dietary Manager) indicated that at the time of R34's burn incident, it was not the protocol of dietary staff to perform temperatures on the hot liquids before they were served. V5 indicated that the coffee or hot water would come straight from the machine to a pot and then to cups for service. V5 stated that once R34's incident occurred, he started temping the hot liquids and found that the hot liquids were 175 degrees Fahrenheit straight from the machine. V5 stated that the process was changed to where he performs temperatures before the hot liquids are served and that the coffee or hot water is allowed to cool off in an airpot before service. R34's progress notes dated 5/24/21 document that R34 developed redness with three blisters on her left forearm and a large blister to left breast. On 5/24/21 at 6:56am, R34's progress notes document that she was experiencing pain at the burn site and was administered [MEDICATION(S)] 5 milligrams. It is documented that R34 continued to complain of pain in both burn sites and required pain medication. On 5/26/21, R34's left forearm burn site measured 4 cm (centimeter) length by 2.5 cm (width) by 0 cm (depth) and R34's left breast burn site measured 2.5 cm by 4 cm by 0 cm. R34's POS documents that [MEDICATION(S)] treatments to R34's left arm and left breast started daily on 5/24/21. On 5/27/21, the wound care team initiated care for R34's [CONDITION(S)]. R34's treatment was changed on 5/28/21 to Dakin's solution, [MEDICATION(S)] ointment and foam dressing every two days for both sites. R34's wound care documentation dated 5/27/21 reads: Burn of unspecified degree of chest wall-left breast and burn of second degree of left elbow-left forearm. On 5/27/21, R34's left breast burn measured 4 cm by 3 cm by 0.1 cm and the left forearm measured 3 cm by 7 cm by 0 cm. Both burn sites increased in size. On 6/9/21, during wound care, two scabbed areas were noted on R34's left breast area and a darker brown area noted on left forearm area. On 6/9/21 at 10:20am, V13 (Wound Care Nurse) stated to R34 while changing the dressing on her left breast, There will be a possible debridement done next week to help healthy tissue come out. There will be pain. He will scrape the top layer of the scab to get to healthy tissue. On 6/10/21 at 10:37am, V15 (Physician) stated, We just assumed care for her in May. Definitely, she should have been supervised when taking meals. She was supervised during her meal, right? V15 was told that R34 was not supervised during the meal at the time of the burn incident. V15 stated, Someone should have been in there. On 6/10/21 at 9:55am, V1 (Administrator) stated, My expectation is that incidents get reported to the nurse right away. On 6/9/21 and 6/10/21, the facility was asked to submit a policy regarding Supervision. There was no policy submitted.

Based on record review and interview, the facility failed to protect a resident from abuse by a staff member (V10) for 1 of 5 residents (R5) reviewed for abuse. As a result, R5 suffered mental abuse and was left to believe she could not get nursing assistance when she needs it. Findings include: According to R5's quarterly Minimun Date Set (MDS) assessmet dated 3/05/2021, R5 is a [AGE] year old resident who has no cognitive impairments, incontient of bladder and requires one to two person nursing assistance with transfering, dressing and personal hygiene. On 6/2/21 at 12:09pm, V9, Certified Nurse Assistant (CNA) indicated that she was aware that R5 had issues with V10 (CNA). V9 stated, There is one resident (R5) that told me a few weeks ago that V10 yelled at her and is not nice to her. R5 said that V10 talks loud at her and screams at her. V9 indicated that she did not tell management or the Abuse Coordinator. On 6/2/21 at 12:40pm, R5 stated, V10 has taken care of me, many times. She's like a truck driver. She's very rough with me when she moves me. And she always screams at me and does not talk nice to me. I tell her, Please, take it easy because I'm hurting and she doesn't. She hurts me. I'm starting to think that it is purposeful. It makes me scared to ask her for help but that's why I'm here. I need help. I've let V1, Administrator/Abuse Coordinator know and I told a few CNA's. V1 says, I'll talk to her and nothing happens. I don't want to be abused. I'm not here to be abused. R5 indicated that V9 is one of the CNA's that she spoke to about V10's abuse towards her. The facility documented abuse investigations showed no abuse investigation conducted for R5's allegations. On 6/2/21 at 2:03pm, V1(Administrator) stated, If a resident states that a staff member is rough with them, I would talk to staff, other residents that may be involved and other staff that may be involved. I follow the abuse protocol if someone complains that staff is rough with them. I have not had anyone come to me about V10 being rough with them. I am not aware of any of the residents stating that V10 was rough with them. It was never reported to me that a resident (R6) complained of being treated roughly by V10. I also was not aware that R5 complained of V10 speaking loudly and disrespectfully to her. Things regarding abuse need to be communicated to me by my staff since I am the Abuse Coordinator and so I can run my protocol. The facility Abuse Policy dated 9/20 reads: Policy: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse or our residents. Abuse Prevention Program: 5. Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway. c. Employees of the facility who have been accused of mistreatment will be removed from resident contact immediately until the results of the investigation has been reviewed by the administrator or designee. e. Employees accused of possible abuse shall not complete the shift as a direct care provider to residents.