Every finding on record at Alden Estates of Naperville

Based on observations, interviews, and record review, the facility failed to ensure that medications were stored appropriately in the medication cart, medication room, or treatment cart.These failures affected 4 residents (R7, R8, R9, and R10) reviewed for medication labeling and storage and had the potential to affect all 28 residents on one dementia unit on the second floor. Findings include:On [DATE], the census on the second-floor dementia unit was 28 residents.On [DATE] at 12:45 PM, a tour of the unit's medication room and nurses' desk was conducted with V22, a Licensed Practical Nurse (LPN). The drawers at the nurses' station contained the following medications and supplies:(1) Two 1,000 mL bags of 5% dextrose IV solution labeled with R9's name.(2) A box containing several 10 mL normal saline flushes.(3) One expired bottle of multivitamin dietary supplement.(4) A box of Relevca lidocaine 4% pain relief patches labeled with R7's name.(5) A tube of B & C ointment for wound dressing labeled with R8's name.(6) Silicone-faced foam and border sacrum dressing labeled with R10's name.(7) TheraHoney gel.(8) Miconazole nitrate cream USP 2% antifungal cream.R7's Electronic Medical Record (EMR) showed that R7 was admitted to the facility on [DATE] with diagnoses including ataxia, dementia, mood disorder, anemia, chronic pain, and psychosis. As of [DATE], R7 had an active order for a 4% lidocaine patch to be applied topically to both knees each morning for bilateral knee pain, left on for 12 hours, then removed for 12 hours per schedule.R8's EMR showed that R8 was admitted to the facility on [DATE] with diagnoses including dementia, stage 3 pressure ulcer of the left buttock, benign prostatic hyperplasia, history of falling, chronic pain, and senile degeneration of the brain. The EMR also showed that R8 died at the facility on [DATE]. A tube of B & C ointment for wound dressing labeled with R8's name remained in the nurses' station drawer.R9's EMR showed that R9 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, chronic kidney disease, benign prostatic hyperplasia, gout, hypothyroidism, and senile degeneration of the brain. The EMR also showed that R9 died at the facility on [DATE]. Two 1,000 mL bags of 5% dextrose IV solution labeled with R9's name remained in the nurses' station drawer.R10's Electronic Medical Record (EMR) showed that R10 was admitted to the facility on [DATE] with diagnoses including dementia, malignant neoplasm of the prostate, thrombocytopenia, stage 3 pressure ulcer, osteoarthritis, and pancytopenia. A box of silicone-faced foam and border sacrum dressing labeled with R10's name was found in the nurses' station drawer.On [DATE] at 12:47 PM, V22 stated that the 5% dextrose IV bags belonged to a deceased resident and should have been discarded. V22 also stated that all nurses working on the unit are responsible for storing medications in either the treatment cart or the nurses' medication cart.On [DATE] at 3:05 PM, V2, the Director of Nursing (DON), stated that medications are stored in the medication rooms and medication carts. V2 further stated that medications are not stored in residents' rooms or at the nurses' stations and are kept in the medication rooms when not in use.On [DATE] at 12:55 PM, V2 (DON) stated that medications should be kept in the nurses' medication cart, wound treatment cart, or medication room. V2 also stated that some of the medications listed above should have been discarded.Review of the facility policy titled Medication Storage, dated 09/2020, showed: When a resident is discharged , all medications shall be stored in one designated area determined by the facility.Review of the facility policy titled Storage/Labelling/Packaging of Medications, dated 12/2023, showed: Each resident's medications are kept separately from others.

Based on observation, interview, and record review the facility failed to ensure that the CPaP (continuous positive airway pressure) machine was changed every three months, failed to keep CPaP parts from environmental contamination, failed to obtain a physician's order for the use of CPaP machine and failed to change a nasal canula every month.These failures affected 2 of 3 (R1 and R3) residents reviewed for respiratory care in the total sample of 10 residents. Findings include: 1. On 05/26/2026 at 11:13am R3's nose piece of R3's CPaP was on the floor. The green tubing connected to the oxygen concentrator and CPaP machine was dated 10/01/2025. V7 (Certified Nursing Assistant) was present and V7 picked up the nose piece of the CPaP and placed it behind the CPaP machine and stated it should not be on the floor. V7 checked the date on the tubing and stated it was dated 10/01/2025. R3 stated she used the CPaP machine at bedtime.On 05/26/2026 at 11:28am, V2 (Director Of Nursing) stated the nose piece of the CPaP should be in the bag when not in use to lower or prevent the risk infection. Oxygen tubing should be changed monthly to lower or prevent the risk of infection also.On 05/26/2026 at 11:30am inside R3's room, V2 to checked the label on R3's tubing which was connected to the oxygen concentrator and the CPaP. V2 unhooked the green oxygen tubing and stated she was going to change the oxygen tubing. V2 was informed of nose piece being found on the floor and that it was placed behind the CPaP machine. R3's admission Record documented that R3 diagnoses include but are not limited to chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and obstructive sleep apnea. R3's (Active Order As Of: 05/27/2026) was reviewed with no order noted for CPaP machine. R3's MDS (Minimum Data Set) assessment of 5/08/2026 documents that R3 is cognitively intact and does not document the use of the CPaP machine. R3's care plan with a target date of 8/06/2026 documents the use of a CPaP machine and to encourage the resident to use the CPaP. 2. On 05/26/2026 at 11:46am R1was in bed with Oxygen being delivered via a nasal cannula. The Oxygen concentrator setting was 2 liters per minute. V8 (Registered Nurse) checked the nasal cannula label and confirmed that no label was present. V8 stated it should be labeled with the date it was changed so they know when the nasal cannula was changed for infection control. R1's admission Record documented that R1's diagnoses include but are not limited to chronic obstructive pulmonary disease, acute on chronic respiratory failure, acute on chronic congestive heart failure, obstructive sleep apnea, and dependence on supplemental oxygen.R1's (Active Order As Of: 05/27/2026) Order summary report documented, in part Respiratory: change O2 (oxygen) tubing monthly and prn (as needed). Respiratory: oxygen per nasal cannula @ 2 liters per minute continuous every shift. The (10/2025) BIPAP policy and procedure documented, in part BIPAP therapy will be administered by a respiratory therapist, or Nurse upon order of a physician. Care of Bipap unit: 4. Tubing will be changed every 3 months and prn. (as needed). The (09/2020) Oxygen Therapy Devices - Nasal Cannula documented, in part Policy: Oxygen delivered per nasal cannula will be used to prevent or reverse hypoxia and improve tissue oxygenation. Procedure: 2. A nasal cannula will be changed monthly and prn (as needed).

Based on interview and record review the facility failed to prevent a resident from cutting his face with a broken razor for 1 of 3 residents (R5) reviewed for safety in the sample of 10. The findings include:On 1/20/26 at 1:02 PM, V19 (R5's POA - Power of Attorney) said on 11/21/25 V20 (R5's family member) went to visit R5 and his face was all scratched up with scabbed blood. V19 said V20 immediately took pictures and sent them to her. V19 said the family (V19 and V20) were constantly aware of R5's razor. V19 said on 11/18/25 the razor was in good condition, but on 11/21/25 it wasn't. V19 said she has pictures of all of this. V19 said the head of R5's razor was damaged and there was a big gouge in the metal part. V19 said it appeared as if the razor had been dropped, but no one reported it. V19 said R5 can't use his right arm, and the staff have to hand him his razor. V19 said the staff shouldn't have given R5 a broken razor. V19 said his face was all cut up because they gave him a razor with metal edges sticking up. V19 said if you try to lightly run your fingers over the damaged area it would scratch you. V19 said she still has the razor. V19 said there was another razor in R5's room that didn't belong to him and she believed the facility was trying to cover up that they damaged R5's razor.R5's Facesheet dated 1/21/26 showed diagnoses to include, but not limited to stroke with right sided weakness, apraxia (motor disorder affecting the brain's ability to coordinate planned, skilled movements), aphasia (language disorder that impairs speaking, understanding, reading and writing), epileptic seizures, and xerosis cutis (severe dry skin). R5's Nurses Note dated 11/21/25 at 4:50 PM, showed R5 had dry spot scratches noted to his left chin and neck due to shaving. This note showed the Nurse Practitioner was notified and orders were received for ointment topically every shift for the scratches until healed. This note showed that V19 (R5's POA) was notified. R5's Concern Form completed by V20 (R5's family member) on 11/21/25 at 8:05 AM showed, R5's razor was dropped, the head of blades was cracked and wasn't working the same. R5's face got all cut up from the broken razor. V20 wrote that staff did not look at R5's face only told him they would replace the razor. This form showed the facility would reimburse V19 (R5's POA) for the razor and the nurse assessed R5 and obtained orders for treatment.The facility's Final Report dated 12/14/25 showed that R5's family alleged it was abuse to give R5 the broken razor to shave his face. The facility did not substantiate abuse. This document showed staff interviews did not reveal how his electric razor broke. This report showed the facility initiated education to staff in regard to personal items that are damaged or broken. The facility's investigation showed that 6 staff members were interviewed, and no one knew how R5's razor broke. The statement from V18 (RN - Registered Nurse) showed that V20 (R5's family member) was screaming at the staff, his face was turning red, and he was scaring the staff. This statement showed that she told V20 she didn't know the razor was broken.The facility's In-Service Meeting Attendance Records dated 12/9/25 showed the in-service covered Personal Belongings Safety. The areas discussed included: 1. Inspect all resident personal belongings before use, including mobility devices, furniture, footwear, and electrical items. 2. Do not allow resident to use any item that appears broken, damaged, unstable or unsafe. 3. If any item is found to be damaged, remove it from use immediately and label it Do Not Use. 4. Notify the nurse manager or supervisor immediately of any broken or unsafe personal item. 5. The manager will arrange repair or replacement or contact the family/POA if the item is privately owned. 6. Document findings and actions taken and communicate concerns during shift report. 6. Immediately report all damaged or broken belongs to the managers. Take them out of circulation if broken. Do not let the resident use broken equipment. On 1/20/26 at 1:58 AM, V15 (CNA - Certified Nursing Assistant) said she regularly works on R5's unit and is familiar with his care. V15 said R5 shaved himself most days and we just hand him the razor and put it away when he is done. V15 said she didn't remember the exact date, but remembered V20 (R5's family member was really upset about R5's razor. V15 said was there when V20 was yelling at the nurse (V18). V15 said V20 said someone dropped the razor, it broke, and R5's face had been cut with the razor. V15 said she didn't recall what R5's face looked like and didn't remember is she went in that day. V15 said R5 does get a small [NAME] under his nose from shaving.On 1/20/26 at 1:05 PM, V18 (RN) said she is regularly assigned to R5. V18 said R5 and his family are very particular about his care. V18 said R5 was insistent on shaving himself and the staff just set him up. V18 said there was a day R5 was cut by the razor. V18 said she didn't remember how many cuts or where they were, but she did enter a progress note. V18 said she didn't know how R5's razor was broken (11/21/25), but the family was very upset. V18 said she called the provider, obtained an order for ointment, and notified management.On 1/21/26 at 10:15 AM, V2 (Director of Nursing) said R5 was encouraged to shave himself and the staff should assist him with getting setup. V2 said the staff hand R5 his razor and he shaved himself. V2 said the staff should check the razor for any damage before handing it to the resident. V2 said if the razor head was damaged there would be an increased risk for cutting their face. V2 said she did not look at the razor to see the damage. V2 said the facility did reimburse R5's family for the damaged razor. V2 said the facility had completed an investigation and reported this incident after V19 (R5's POA) made a comment that it was abuse that R5 was provided a broken razor to shave. V2 said abuse wasn't substantiated, but the in-services were provided to the staff and they couldn't determine how the razor was broken. A policy related to Razor Safety was requested and not received.

Based on interview and record review the facility failed to ensure a resident was provided with transportation to get to medical appointments in a timely manner for 1 of 4 residents (R2) reviewed for Quality of Care in the sample of 10. The findings include: R2's face sheet shows he has diagnoses including Gastroesophageal Reflux Disease (GERD). R2's Physician Order Summary report shows an order was entered on 10/27/25 for R2 to be seen for a GI (Gastroenterologist) consult. On 1/20/26 at 10:41 AM, R2 said he was told that he is supposed to be going out to an appointment to see a GI doctor but has yet to get to see one. On 1/20/26 at 11:24 PM, V4 (Appointment and Transportation Scheduler) said there have been some issues with the transportation company the facility uses and getting residents to appointments on time. V4 said unfortunately there are no back up options that the facility uses to get residents to their appointments. V4 confirmed that she has been trying to get R2 to an appointment with the GI doctor and on 12/23/25 the transportation company called and said they were going to be late and the physician office could not accommodate a late appointment so it was rescheduled to 1/12/25. On 1/12/25 the transportation company went to the wrong facility to pick up R2 so again he missed his appointment. V4 said she has made a new appointment for him today for the GI doctor and they cannot get him in until 3/18/26. On 1/20/26 at 2:38 PM, V5 (Nurse Practitioner) said R2 is going to the GI doctor for previous abdominal pain and acid reflux. V5 said she was not aware that R2 had missed his GI appointments and while they are considered non urgent she would still expect the facility to get the resident transported to the appointment on time. The facility provided Transportation policy dated 9/2020 shows that the facility will assist residents in obtaining transportation to their appointments as needed.

Based on observation, interview, and record review, the facility failed to implement wound care interventions as ordered for a resident with pressure injuries.This applies to 1 of 3 residents (R1) reviewed for pressure injuries.The findings include:On 8/30/2025 at 11:30 AM, R1 was in bed on a regular mattress. V5 (Wound Care Nurse) and V6 (Wound Care Technician) said R1 had multiple wounds identified as present on admission on [DATE], including stage 2 pressure injuries to his right and left buttock areas. V5 said R1's wound care was being managed by the wound physician and R1 required daily dressing changes. V5 continued to say she was concerned because R1's wound showed signs of deterioration today, as evidenced by an increase in size measurement. V5 then assessed R1's pressure injuries, which were open with minor bleeding and had peri-wound irritation. V5 said R1's left buttock wound measured 3 centimeters (cm) x 2 cm x 0.1 cm and the right buttock wound measured 0.6 cm x 0.6 cm x 0.1 cm. V5 said she believed R1 was provided with an air loss mattress upon admission. V5 said R1 had a room change on 8/24/2025 and was unsure why R1 was not currently provided with his ordered specialized mattress. V5 said wound care management interventions should be followed as ordered to prevent skin and wound deterioration.On 8/30/2025 at 2 PM, V2 (Director of Nursing/DON) said wound care interventions should be implemented as ordered, including an air loss mattress.R1's initial wound physician consultation dated 8/18/2025, said R1's left buttock stage 2 pressure wound measured 0.7 cm x 0.7 cm x 0.1 cm, and right buttock stage 2 pressure wound measured 0.7 cm x 0.5 cm x 0.1 cm. The consultation report included an order for low air loss mattress as part of R1's wound management plan.R1's wound physician consultation dated 8/25/2025, said R1's left buttock stage 2 pressure wound measured 0.5 cm x 0.5 cm x 0.1 cm, and right buttock stage 2 pressure wound measured 0.4 cm x 0.5 cm x 0.1 cm.R1's Order Summary Report dated 8/30/2025 showed an active order for Low air Loss Mattress initiated 8/16/2025.R1's care plan said R1 was at risk for further skin breakdown due to his multiple wounds. The care plan had an intervention initiated on 8/25/2025 for pressure redistribution support (low air or alternation air) in bed.The facility's policy titled Prevention and Treatment of Pressure Injury and Other Skin Alterations dated 3/02/2021, said Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan.The facility's policy titled Management of Low Air Loss Mattress dated 03/2024, said Residents who have been assessed as in need of a low air loss mattress will have a mattress set up for their use.

Based on interview and record review, the facility failed to ensure that the QAPI (Quality Assurance and Performance Improvement) committee met quarterly and the required QAPI committee members attended the meetings. This applies to all 151 residents residing in the facility. The findings include: The census roster dated June 10, 2024 showed 151 residents residing in the facility. The facility presented committee meeting attendance records since the last annual survey date of August 30, 2023. The facility provided attendance records dated December 7, 2023, March 14, 2024, and an undated attendance record. The attendance record dated December 7, 2023, did not include the signature of the Infection Preventionist, nor the Medical Director. The attendance record dated March 14, 2024, did not include the signature of the Infection Preventionist, or the Medical Director. The undated attendance record did not contain the signature of the Director of Nursing, the Medical Director, or the Infection Preventionist. On June 12, 2024, at 12:00 PM, V1 (Administrator) stated that the Medical Director has not attended a QAPI meeting since last year. V1 also stated there is no representatives from the Pharmacy and the Laboratory, just quarterly reports submitted to be reviewed. The attendance documents do not support quarterly meetings of the QAPI committee have occurred since the last annual survey. The facility's QAPI Plan dated October of 2019, showed .Authority .2. The Administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements.

Based on observation, interview and record review, the facility failed to store resident's foods in a safe and sanitary manner in a resident's personal refrigerator. This applies to 1 of 1 resident (R106) reviewed for foods brought in from outside in the sample of 30. The findings include: R106's face sheet included diagnoses of malignant neoplasm of head of pancreas, type 2 diabetes mellitus without complications, alcohol dependence with unspecified alcohol-induced disorder, encounter for palliative care, adult failure to thrive. R106's quarterly MDS (minimum data set) dated June 4, 2024 showed that R106 is cognitively intact. On June 10, 2024 at 11:51 AM, R106 stated that he orders in own Indian food from outside as he does not care for food here. There was a small refrigerator at bedside but the same was not checked as R106 was having visitors. On June 12, 2024 at 9:53 AM, R106's refrigerator was checked with resident's permission and noted to have 5 clear plastic containers of cooked food items and another item wrapped in silver foil placed over excessive spills and food debris and miscellaneous brownish black particles. These food items were not labeled or dated. R106 stated that ''a man'' brings the food to the front desk and either that person or the CNAs (Certified Nursing Assistant) place it in the refrigerator. No thermometer was found in the refrigerator, but a temperature monitoring log was found on top of the refrigerator with logs from June 01-June 10, 2024. On June 12, 2024 at 9:55 AM, the refrigerator with its contents were showed to V19 (Licensed Practical Nurse) who stated that R106 orders food from an Indian man from outside the facility. V19 stated that the food items are supposed to be labeled and dated and that there should be a thermometer in the refrigerator. V19 stated that usually it's the night shift nursing staff that checks the refrigerator and monitors and logs the temperatures as well. Facility Policy and Procedure titled Food Safety Information for Families and Visitors Tips to Keeping Food Safe included as follows: Chill food to prevent food poisoning: Keep food in your refrigerator at 41 degrees Fahrenheit or below . Holding Foods: Resident food maybe stored in the refrigerator for 3-5 days. Resident food should be in a tight container labeled with name, food item and date it was prepared.

Based on observation, interview and record review, the facility failed to provide pureed and mechanically altered meatballs with sauce for the lunch meal. This applies to 18 of 18 residents (R1, R9, R10, R12, R16, R23, R39, R47, R65, R68, R84, R92, R94, R102, R118, R145, R452, R455) reviewed for dining in the sample of 30. The findings include: 1. On June 10, 2024 at 9:40 AM, V18 (Cook) was seen putting pureed ground meat with spaghetti sauce that was processed in a blender into serving pans. V18 stated that there are around 13 residents that are on pureed consistency. V18 stated that the item was ready for service after reheating the same. When taste tested the product, there was small lumps of fat and meat particles that were unable to be swallowed without further chewing. V16 (Dietary Supervisor) who was in the vicinity was requested to taste test the same and agreed that the item needs to be processed more. On June 12, 2024 at 9:20 AM, V17 (Dietitian) stated that the pureed foods should have the consistency of mashed potatoes or pudding. Facility Policy titled Puree (dated July 2023) included as follows: Purpose: The puree diet texture consists of pureed, homogenous, and cohesive foods in pudding like consistency. Any foods that require bolus formation, controlled manipulation, or mastication are excluded. Facility Diet Type Report printed on June 10, 2024 showed that R1, R9, R10, R16, R39, R65, R84, R92, R94, R145, R455 were on pureed consistency diets. 2. Facility lunch menu spread sheet for June 10, 2024 (Cycle day 9) included ground meatballs served with #8 scoop (4 ounce) and 1/2 cup of green beans for the residents on mechanical soft diet. On June 10, 2024 at 12:32 PM, the lunch meal service was observed in the 1st floor dining room. V20 (Dietary Aide) was plating the food and noted to serve three whole meatballs to residents on mechanical soft diet and R12, R23, R47, R68, R102, R118,and R452 received the same. V15 (Executive chef) who was in the vicinity stated Our menu spread sheets call for the same. When V15 was shown the menu spreadsheet, he agreed that the residents on mechanical soft diet should have received ground meat as shown on the menu. R452 also received regular consistency romaine lettuce salad and a side order of mixed vegetables that included corn. R452 took only a few bites of the salad and mixed vegetables and stated that he is unable to chew the same. On June 10, 2024 at 12:51 PM, V16 (Dietary Supervisor) stated that R452 should have not received corn and should have received shredded lettuce or mechanically altered coleslaw (steamed) instead of the salad. On June 12,2024 at 9:21 AM, V17 (Dietitian) stated that the facility should follow the spread sheet to serve consistency as shown. V17 stated that residents on mechanical soft diet should not receive raw vegetables. V17 added that hard cooked vegetables like corn should also be avoided for mechanical soft diets and creamed corn served instead. Facility Policy titled Regular Ground/Mechanical Soft (dated July 2023) included as follows: Purpose: The regular mechanical soft diet is for adults who have difficulty chewing. This diet is similar to the regular diet with some modifications to hard to chew foods. Rationale: Foods that are difficult to chew are replaced with foods that have been altered into a form that can be easily swallowed. Food that maybe modified because they are tough and difficult to chew include meats, poultry, fish, raw vegetables, and other fibrous foods. Menu guidelines: Meat, Fish, Nuts -Allow all ground meats . Vegetables-Allow cooked vegetables and moist shredded/chopped lettuce. Avoid hard raw vegetables. Facility Diet Type Report printed on June 10, 2024 showed that R12, R23, R47, R68, R102, R118, R452 were on mechanical soft diet consistency.

Based on interview and record review, the facility failed to follow its policy regarding grievances/complaints and failed to inform the Administrator/designee upon receipt of the grievance and failed to inform the resident of the results of the investigation. This applies to 1 of 1 resident (R138) reviewed for grievances in the sample of 30. The findings include: R138's face sheet showed R138 was admitted to the facility on [DATE], with multiple diagnoses including end stage renal disease with hemodialysis, diabetes mellitus type 2, monoplegia of upper limb following cerebral infarction affecting the right dominant side, and vascular dementia. R138's MDS (Minimum Data Set) showed R138 with moderate cognitive impairment and required assistance with ADLs (Activities of Daily Living) including supervision with eating, oral hygiene, toilet hygiene and bed mobility, set up assistance with upper body dressing and personal hygiene, and transfer, substantial assistance with bathing and dependence on staff for lower body dressing and putting on/taking off footwear. On June 12, 2024, at 9:15 AM, R138 stated he had a concern because 3 days ago he had reported a concern regarding his wallet was missing with forty dollars in it, and his black pants were missing. He stated he is not sure which staff member he reported it to, but he hasn't heard anything about the concern since he reported it. R138's concern was reported to V4 (Nurse) R138's progress note dated June 8, 2024, at 7:10 PM, showed R138 was found walking back and forth in his room looking for his wallet and R138 stated he was unable to find his wallet since he returned from dialysis at 4:30 PM that day. The progress note also stated that V22 (scheduler) was informed regarding the missing wallet. The nurse who authored the note was unable to be contacted during the survey, there was no answer to the phone call. A review of the June 2024 Grievance forms showed two completed concern forms one dated June 5, 2024, and one dated June 6, 2024, neither regarding R138. On June 12, 2024, at 10:55 AM, V1 (Administrator) stated there were no additional grievance forms for the month of June 2024. On June 12, 2024, at 12:00 PM, V1 stated it is her expectation that the manager or supervisor who receives a complaint/grievance or concern to complete the concern form at the time it is received if a resolution has not been found. V1 stated she thought V22 (scheduler) was the manager on duty on June 8, 2024. On June 12, 2024, at 12:34 PM, V22 stated she was not the manager on duty on June 8, 2024, and did not receive a notification regarding R138's missing wallet, and pants. V22 stated V23 (Social Services Director) was the Manager on duty on June 8, 2024. On June 12, 2024, at 12:40 PM, V23 stated she was the manager on duty on June 8, 2024, but did not receive a complaint regarding R138's missing wallet. V23 stated she was made aware of R138's concern on the morning of June 12, 2024, when V1 reported the concern to her. V23 stated she has not followed up with R138 regarding his concern of June 8, 2024. On June 12, 2024, at 3:15 PM, V1 stated she was not made aware of R138's concern regarding the missing items until the morning of June 12, 2024, when V23 told her. V1 also stated she did not have a completed concern form, regarding R138 but she could make one out now. The facility's policy titled Grievance/Complaints dated January 2017, showed .3. Grievances and/or complaints can be submitted verbally or in writing and signed by the resident or the person filing the grievance or complaint on behalf of the resident. The grievance or complaint can be written on the concern from .4. The grievance Official will be the Administrator of the facility and will be responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion the Administrator will provide his or her contact information .in the event an Administrator is not present the Administrator will appoint an interim Grievance official .7. The resident or person filing the grievance or complaint will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Such report will be made in a timely fashion of the filing of the grievance .

Based on observation, interview, and record review, the facility failed to ensure that gastric tube (g-tube) placement was checked prior to flushing the tube and administering medication. The facility also failed to administer g-tube flushes and medications using the proper technique. This applied to 1 of 1 resident (R147) reviewed for g-tube medication administration. The finding included: R147's EMR (Electronic Medical Record) showed R147 was admitted to the facility on [DATE], with diagnoses that included pneumonitis due to inhalation of food/vomit, dysphagia, major depressive disorder, anxiety, protein-calorie malnutrition, Right lung malignant neoplasm, Clostridium Difficile (C-diff) and adult failure to thrive. R147's MDS (Minimum Data Set) dated, May 27, 2024, showed R147 was cognitively intact and had history of coughing or choking during meals when swallowing. R147's care plan showed R147 required tube feeding and stoma site care due to dysphagia (difficulty swallowing). Interventions included . check placement and patency of feeding tube prior to administering medications, feedings, and flushes. On June 11, 2024 at 3:28 PM, V3 (LPN/Licensed Practical Nurse) prepared R147's 4:00 PM medications for administration. There were two pills scheduled to be administered. V3 crushed the first pill in a plastic sleeve and then placed the crushed pill into a plastic medication cup. V3 repeated the same process with the second medication. V3 poured 15 ml of water into each medication with the crushed pill. V3 filled two additional medication cups with 30 ml of water, V3 said she will be using it to flush the g-tube. V3 donned PPE (Personal Protective Equipment) before entering the room due to R147 being in contact isolation for Clostridium Difficile (C-diff). V3 explained to R147 what she was going to do. V3 turned off the tube feeding that was currently running. V3 disconnected the tube feeding from the port and then palpated the abdomen around the insertion site and asked R147 if there was any pain. R147 denied pain and V3 said ok good, I was checking placement. V3 used 30 ml of water and administered a water flush by pushing the water into the tube. V3 said she was making sure the tube was patent. V3 proceeded to administer one medication with 15 ml of water by pushing/injecting the medication into the tube, added another 15 ml of water into the medication cup to get the medication residual still in cup and then administered by pushing/injecting the medication into the tube. Second medication was administered by pushing/injecting the medication with 15 ml of water into tube and finished with 15 ml water flush which she pushed through the tube. On June 12, 2024 at 10:20 AM, V10 (Regional Nurse Consultant) said when administering g-tube medication the nurse needs to check for placement by aspirating for gastric content. Medications and flushes should be administered by gravity, and a 30 ml flush before administrating a medication and after administrating medications. Facility provided their policy titled Medication Pass Guidelines dated September 2022. Their policy showed .10. Preparing Medication or Feedings for GT, NGT, or J-tube Administration, check placement before administering medications (or feedings), flush with 30 ml of water before and after each resident's med pass (the gravity method is recommended) . Always rinse/flush the tube after administering each medication, with a sufficient amount of water to clear it .

Based on observation, interview, and record review the facility failed to follow the proper infection control practice when caring for a resident in contact isolation. This applies to 1 of 1 resident (R147) in sample of 30. The finding included: R147's EMR (Electronic Medical Record) showed R147 was admitted to the facility on [DATE], with diagnoses that included pneumonitis due to inhalation of food/vomit, dysphagia, major depressive disorder, anxiety, protein-calorie malnutrition, Right lung malignant neoplasm, Clostridium Difficile (C-diff) and adult failure to thrive. R147's MDS (Minimum Data Set) dated, May 27, 2024, showed R147 was cognitively intact. R147's care plan showed R147 was in a single room, in contact isolation related to C-Diff. Interventions included educate resident and responsible party on isolation precautions. On June 10, 2024 at 8:14 AM, V7 (LPN/Licensed Practical Nurse) was in R147's room with the door open, From the hallway V7 was seen standing next to R147's bed wearing gloves but had no gown on. R147 was on isolation for C-diff. The contact isolation sign and the isolation cart stocked with PPE (Personal Protective Equipment) including gowns and gloves were present outside the entry into R147's room. V7 came out of the R147's room wearing the same gloves, closed the room door, went to the nurses' station where he removed his gloves, threw them in the garbage, and picked up a cup and took a drink. V7 stated R147 was on isolation for C-diff and staff need to wear gown and gloves when in the room. V7 also said that before leaving the room, hands are to be washed with soap. On June 12, 2024 at 10:20 AM, V10 (Regional Nurse Consultant) said when a resident is in isolation for C-diff, the staff must wear the proper PPE and remove it before leaving the room. The staff are also to wash hands with soap and water. V10 said these precautions are in place to protect not only the residents but also the staff from getting C-diff. Facility provided their policy dated 2020 and titled, Infection Prevention and Control Manual Antibiotic Stewardship & MDROs. The policy shows, It is the policy of this facility that appropriate measures will be utilized for the prevention and control of Clostridium Difficile Infections (CDI) . Procedure: Clostridioides difficile (previously known as Clostridium difficile or C.diff) is considered by the Centers for Disease Control and Prevention as an Urgent Threat in the United States. Clostridioides Difficile is a bacterium that will cause inflammation of the colon and causes life-threatening diarrhea . V. Isolation Precautions: A. Contact precautions should be used for CDI residents with diarrhea. B. Hands should frequently be washed with soap and water. An alcohol-based waterless hand cleaner is not effective against CDI spores.

Based on observation, interview, and record review the facility failed to provide necessary supplies in order to preserve a resident's dignity and privacy needs. This applies to 1 of 30 residents (R40) reviewed for dignity in the sample of 30. The findings include: R40's face sheet showed R40 was admitted to the facility on [DATE], with multiple diagnoses including, chronic diastolic heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, and unspecified dementia, without behavioral disturbance. R40's MDS (Minimum Data Set) dated May 15, 2024, showed R40 was severely cognitively impaired, and required staff assistance with ADLs (Activities of Daily Living) including set up assistance with eating and oral hygiene and partial assistance with bed mobility, transfer, toilet hygiene, bathing, and dressing. R40's care plan initiated on January 30, 2023, interventions for incontinence included .Use adult incontinence products as needed . and provide dignity related to the use of incontinence products. On June 10, 2024, at 10:50 AM, R40 was sitting in the hallway in the second floor Medicare unit, without wearing pants, with his genitals exposed. There was another resident in the hallway sitting in a wheelchair nearby, the maintenance staff was in R40's room, and a housekeeping staff was cleaning the adjacent room. Staff did not respond until the surveyor pointed out the concern to V12 (Restorative Nurse) who was at the nurse's station across the hall from R40's room. On June 10, 2024, at 11:06 AM, V11 (CNA) stated she last saw R40 at 10:00 AM in his room and R40 must have wheeled himself into the hallway. V11 stated there were no pull up briefs in R40's room at that time, for R40 to wear, which is the only incontinence product R40 will use. V11 stated the pull up incontinence product was not available because the family did not bring in more supply. V11 then went to the facility's supply room to retrieve the pull up style of incontinence product and put the package of pull up briefs in R40's room. On June 12, 2024, at 12:20 PM, R40 was observed sitting in his room with V21 (CNA) not wearing any pants, with the room door open. R40 took a brief out of the bedside drawer and put it on himself. V21 assisted R40 by locking the brakes to R40's wheelchair while R40 stood up to pull up the brief. V1 (Administrator) provided a copy of Residents' Rights for people in Long-term Care Facilities from the Illinois Department on Aging, when asked for the facility's policy regarding resident dignity. On page 2 of the undated document, showed .safe and good care .Your facility must provide services to keep your physical and mental health, and sense of satisfaction .and .your medical and personal care are private.

Based on observation, interview, and record review the facility failed to assess and provide appropriate splints and therapy services to maintain and/or prevent further progression of deformities or reduction in range of motion. This applies to 3 of 5 residents (R2, R23, R102) reviewed for Range of Motion (ROM) in the sample of 30. The findings include: 1. R2 has multiple diagnoses including rheumatoid arthritis, unspecified, generalized Osteo Arthritis, and Neuralgia according to the face sheet. R2's MDS (Minimum Data Set) dated March 12, 2024, identifies R2 as cognitively intact. R2 has functional limitations of ROM (Range of Motion) to one side of both upper and lower extremities. The same MDS shows R2 requires maximum to total assistance for most ADLs (Activities of daily living). On June 10, 2024 at 12:32 PM, R2 had contractures to the right hand and no splinting device was noted. R2 stated he uses his left hand to assist his right hand to perform basic tasks. R2 stated he is willing to be evaluated for therapy. On June 11, 2024 at 11:30 AM, V8 (Occupational Therapist) was at the bedside and assessed R2's ROM and determined it appropriate to have Occupational Therapy (O/T) department evaluate efficacy of splinting or other therapeutic options, to maintain or increase R2's use of that hand and fingers. R2's OT evaluation and plan of care dated June 12, 2024, written by V9 shows [R2] is below baseline and would benefit from skilled OT. Based on assessment resident's right hand demonstrates claw hand deformity indicating ulnar nerve injury. [R2] also demonstrates deformities in digits one thru (through) three due to Arthritis. In order to prevent further deformities a figure 8 anti-claw splint is recommended 1 time per day, initially for 30 minutes, and an oval 8 finger splint is recommended three times per day initially for 20 minutes. Both splint times being increased as tolerated. On June 12 2024 at 11:45 AM, V9 stated she noted ulnar nerve damage causing right claw-hand deformity of ring and pinky finger (fingers 4 & 5) and based on her evaluation she will recommend an oval 8 anti-claw splint to be applied daily for 30 minutes per day initially then increasing it to 2 hours over the next 4 weeks to prevent further deformity and move fingers into proper alignment. V9 further stated she will also recommend an oval 8 finger splint to the right pointer and index fingers (fingers 2 & 3) three times per day initially for 20 minutes per day and gradually increasing to 1 hour per day to prevent further deformity and move fingers into proper alignment. V9 stated both splints could be applied simultaneously. V9 also recommended OT three times per week for four weeks. 16746 2. R102 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and aphasia following cerebral infarction, based on the face sheet. R102's significant change MDS dated [DATE] showed that the resident was cognitively impaired. R102 had impairment/functional limitations in range of motion to one side of both upper and lower extremities. The same MDS showed that R102 required moderate to total assistance from the staff with most of her ADLs (activities of daily living). On June 10, 2024 at 12:58 PM, R102 was in bed, alert but nonverbal. R102 uses signs, gestures and sounds to communicate. R102 was eating independently using her left hand while in bed. R102 had weakness on her right arm and right hand. R102 was asked to raise her right arm and to open her right hand, but the resident was not able to perform as requested. R102 kept on pointing to her right arm and hand using her left fingers, while moving her head from side to side to indicate that she cannot move her right upper extremity. On June 11, 2024 at 11:17 AM, R102 was in bed, alert but nonverbal. R102 uses signs, gestures and sounds to communicate. V8 (Registered Nurse/wound care nurse) requested R102 to raise her right arm and to open her right hand but the resident was not able to perform as requested. V8 stated that R102 had weakness to the right arm and right hand. V8 was prompted to request the therapy department to screen and/or evaluate R102 for the need for any splint or device to the right arm/hand and any therapy services. R102's OT (occupational therapy) evaluation and plan of treatment dated June 11, 2024 created by V9 (Occupational Therapist) showed that the resident had right sided paralysis and her right upper extremity was flaccid. The same OT evaluation showed that in order to prevent contracture to R102's right hand, a resting hand splint was recommended to be used daily for one to two hours with frequent skin checks for redness, swelling, discomfort or pain. On June 12, 2024 at 9:40 AM, V9 stated that she had evaluated R102 on June 11, 2024 after lunch, per nursing request. V9 stated that R102 had right upper extremity paralysis (flaccid) and her right hand was in a fisted position, and because of this the resident had increase potential to decline due to rigidity of the right upper extremity. According to V9, based on her evaluation of R102, the resident would benefit from the use of the right resting hand splint daily for one to two hours as tolerated to prevent contracture. V9 added that she also recommended for R102 to receive occupational therapy services three times a week for three weeks. 3. R23 had multiple diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side and polyarthritis, based on the face sheet. R23's quarterly MDS dated [DATE] showed that the resident was severely impaired with cognition. The MDS showed that R23 had impairment/functional limitations in range of motion to both sides of her upper and lower extremities. The same MDS showed that R23 required maximum to total assistance from the staff with most of her ADLs. On June 10, 2024 at 10:41 AM, R23 was in bed, alert, verbally responsive but confused. R23's fingers (left and right hands) were deformed, and some fingers were hyperextended without any splint or device in place. On June 11, 2024 at 11:42 AM, R23 was in bed, alert, verbally responsive but confused. V8 who was in the room acknowledged that the resident's fingers were deformed, and some were hyperextended. V8 also acknowledged that R23 had no splint/device in place. V8 was prompted to have the therapy department evaluate or screen the resident for possible use of splint/device and/or therapy services. R23's OT evaluation and plan of treatment dated June 12, 2024, created by V9 (Occupational Therapist) showed in-part under impressions, Based on assessment, [patient's] [left] hand demonstrate swan neck deformity, PIP (proximal interphalangeal) joints are hyperextended, and DIP (distal interphalangeal) joints are in flexion. [Right] hand is showing signs of deformity occurring PIP joints of the 3rd and 4th digits are hyper extending. In order to prevent further deformity of [left/right] hand, a hand-based thumb spica orthosis and oval-8 finger splints are recommended. Thumb spica orthosis is recommended 1 x a day for 30 minutes and gradually increasing the time to 2 hours. Oval-8 finger splints is recommended 3 x a day for 20 minutes and gradually increasing the time to 1 hour. On June 12, 2024 at 1:05 PM, V9 stated that she had evaluated R23 that morning per nursing request. V9 stated that based on her evaluation of R23, the resident had arthritis of her fingers (both hands) with lots of deformities. V9 stated that she was recommending for R23 to use a right thumb spica splint to immobilize the joints of the right hand to prevent further progression of the deformities and to maintain current motion of the fingers. V9 stated that for R23's left hand she had recommended the use of an oval-8 splint due to the hyperextension of the middle and ring fingers. The oval-8 splint will help prevent further hyperextension of the fingers and prevent further progression of the deformities. According to V9, the right thumb spica splint and the left hand oval-8 splint could be applied at the same time. The right thumb spica splint is recommended to be applied once daily for 30 minutes and gradually increased to two hours as tolerated and the left hand oval-8 splint is recommended to be applied three times a day for 20 minutes and gradually increased to one hour as tolerated by the resident. V9 added that she also had recommended for R23 to receive occupational therapy services three times a week for four weeks.

Based on interview and record review, the facility failed to administer Insulin as ordered by the physician. The failure resulted in R1 having elevated blood sugars and elevated lab values. This applies to 2 of 4 residents (R1, R2) reviewed for improper nursing care in the area of missing medication doses in the sample of 4. The findings include: 1). On April 22, 2024 at 2:20 PM, R1 said, I missed my morning dose of insulin (Humulin R U-500) on April 19, 2024. The evening of April 18, they ran out of the insulin and did not have enough to give me a full dose. On April 19, I was supposed to get a second dose at 2:00 PM and they still did not have the insulin in stock. It finally came at 3:00 PM that day. This happens every month. My blood sugars are all over the place and I should not be missing doses. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, open wound of the right buttock, diabetes, generalized anxiety disorder, chronic kidney disease, encounter for change or removal of surgical wound dressing, localized edema, PVD (Peripheral Vascular Disease) elevated liver enzymes, fatty liver, depressive episodes, psoriasis, acquired absence of left leg below the knee, and iron deficiency anemia. R1's MDS (Minimum Data Set) dated February 14, 2024 shows R1 is cognitively intact, is independent with oral hygiene and toilet hygiene, requires set up assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of urine, and occasionally incontinent of stool. R1's EMAR (Electronic Medication Administration Record) dated April 2024 shows the following physician's orders: - Humalog (Insulin Lispro) 100 units/ml (units per milliliter) inject 24 units SQ (subcutaneously) at 8:00 AM, 28 units at 12 noon, and 32 units at 5:00 PM. This was ordered on dated 10/11/2023. - Humulin R U-500 (500 units/ml) inject 220 units at 8:00 AM, 2:00 PM, and 8:00 PM. This was ordered on 11/21/2023. - Humalog (Insulin Lispro) 100 units/ml inject as per the sliding scale for blood glucose level 150 to 450 mg/dL (milligram per deciliter). This was ordered on 3/4/2024. R1's EMAR dated April 2024 also shows R1 has physician's order to administer Jardiance 25 mg one tablet daily at 9:00 AM and Ozempic 2 mg SQ every Friday for Type 2 Diabetes Mellitus. The EMR shows the following documentation for R1 regarding missing medications: On January 1, 2024 at 10:11 PM, V7 (RN-Registered Nurse) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. (On Order means the medication was not available). The facility does not have documentation to show what R1's blood sugar level was on January 1, 2024 at 10:00 PM. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. The EMR shows R1's next blood sugar reading was obtained on January 2, 2024 at 8:00 AM. R1's blood sugar level was 363 (mg/dL milligrams/deciliter). On February 13, 2024 at 3:15 PM, V8 (RN) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. The EMR shows R1's blood sugar level was 248. Nursing documentation shows R1 was given 165 of the 220 units ordered. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. On February 13, 2024 at 9:40 PM, V9 (Agency Nurse) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. On February 14, 2024 at 8:43 AM, V8 (RN) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. The EMR shows R1's blood sugar level was 282. The EMR continues to show R1's blood sugar level was 384 at 2:00 PM. On April 19, 2024 at 8:36 AM, V11 (RN) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. The facility does not have documentation to show R1's physician was notified the medication was not administered as ordered. The EMR shows the following blood sugar readings for R1 on April 19, 2024: 301 at 8:00 AM, 296 at 12:00 PM, 296 at 2:00 PM, and 315 at 8:00 PM. HBA1C (GlycoHemoglobin) laboratory results show a patient with diabetes has glycemic control of their diabetes if they have a reading of less than 7 percent. R1's HBA1C results for the period January 10, 2024 to April 10, 2024 show: January 10, 2024 - 8.3 percent February 12, 2024 - 7.7 percent February 19, 2024 - 7.7 percent March 11, 2024 - 9.3 percent April 10, 2024 - 9.6 percent On April 23, 2024 at 2:19 PM, V5 (NP-Nurse Practitioner) said, [R1] is a brittle diabetic. She has high blood sugars and receives almost 700 units of insulin a day. When she misses insulin doses, her blood sugars are higher. It is a lot for her to miss even one dose of insulin. We do HBA1C labs to check the control of her diabetes. This gives us a picture of her blood sugar control over the past three months. If that number is high or is going up, then her diabetes is not under control. The nurses are supposed to be calling the pharmacy to get the medications. She should be getting her medications. The assumption by myself and the physician is the patients are getting their medications. 2). The EMR shows R2 was admitted on [DATE] with multiple diagnoses including, hemiplegia and hemiparesis following cerebral infarction, COPD (Chronic Obstructive Pulmonary Disease), diabetes with foot ulcer, morbid obesity, chronic kidney disease, left shoulder rotator cuff tear, adjustment disorder with depressed mood, sleep apnea, PVD (Peripheral Vascular Disease), aphasia, long-term use of insulin, and heart disease. R2's MDS dated [DATE] shows R2 is cognitively intact and requires supervision with all ADLs. R2 is occasionally incontinent of urine, and always continent of stool. The EMR shows the following documentation for R2: On January 25, 2024 at 6:54 PM, V8 (RN) documented, Insulin NPH (Human) (Isophane) Subcutaneous Suspension, inject 76 units subcutaneously two times a day related to Type 2 diabetes. On order. The facility's policy entitled Medication Administration: General Guidelines dated 03/2021 shows: C. Policy: All medications shall be administered as prescribed by personnel authorized to do so in accordance with standard 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 ensure medications were obtained from the pharmacy in a timely manner to prevent residents from missing medication doses as ordered by the physician. This applies to 3 of 4 residents (R1, R2, and R4) reviewed for improper nursing care in the area of missing medication doses in the sample of 4. The findings include: 1. On April 22, 2024 at 2:20 PM, R1 said, I missed my morning dose of insulin (Humulin R U-500) on April 19, 2024. The evening of April 18, they ran out of the insulin and did not have enough to give me a full dose. On April 19, I was supposed to get a second dose at 2:00 PM and they still did not have the insulin in stock. It finally came at 3:00 PM that day. This happens every month. My blood sugars are all over the place and I should not be missing doses. They also ran out of my Vitamin D that I take once a month, and my depression medication. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] with multiple diagnoses including, encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, open wound of the right buttock, diabetes, generalized anxiety disorder, chronic kidney disease, encounter for change or removal of surgical wound dressing, localized edema, PVD (Peripheral Vascular Disease) elevated liver enzymes, fatty liver, depressive episodes, psoriasis, acquired absence of left leg below the knee, and iron deficiency anemia. R1's MDS (Minimum Data Set) dated February 14, 2024 shows R1 is cognitively intact, is independent with oral hygiene and toilet hygiene, requires set up assistance with eating, and supervision with all other ADLs (Activities of Daily Living). R1 is always continent of urine, and occasionally incontinent of stool. The EMR shows the following documentation for R1 regarding missing medications: On January 1, 2024 at 10:11 PM, V7 (RN-Registered Nurse) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. (On order means medication was not available). On January 26, 2024 at 11:42 AM, V8 (RN) documented, Ozempic (diabetes medication) Inject 2 mg. subcutaneously one time a day every Friday related to Type 2 diabetes. On order. On February 13, 2024 at 3:15 PM, V8 (RN) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. On February 13, 2024 at 9:40 PM, V9 (Agency Nurse) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day On order. On February 14, 2024 at 8:43 AM, V8 (RN) documented, Humulin R U-500 Inject 220 units subcutaneously three times a day. On order. On April 5, 2024 at 8:39 AM, V8 (RN) documented, Ozempic Inject 2 mg. subcutaneously one time a day every Friday related to Type 2 diabetes. On order. On April 6, 2024 at 1:50 PM, V13 (LPN-Licensed Practical Nurse) documented, Ergocalciferol Capsule (Vitamin D) 50,000 units, give one capsule by mouth one time a day starting on the 6th and ending on the 6th evening. On order. On April 13, 2024 at 8:25 AM, V8 (RN) documented, Duloxetine HCl (Hydrogen Chloride) oral capsule delayed release particles 30 mg. (milligrams) give 1 capsule by mouth one time a day for MDD (Major Depressive Disorder) total dose 90 mg. daily please give with 60 mg. cap. On order. On April 19, 2024 at 8:36 AM, V11 (RN) documented, Humulin R U-500 (Insulin) Inject 220 units subcutaneously three times a day. On order. 2. The EMR shows R2 was admitted on [DATE] with multiple diagnoses including, hemiplegia and hemiparesis following cerebral infarction, COPD (Chronic Obstructive Pulmonary Disease), diabetes with foot ulcer, morbid obesity, chronic kidney disease, left shoulder rotator cuff tear, adjustment disorder with depressed mood, sleep apnea, PVD (Peripheral Vascular Disease), aphasia, long-term use of insulin, and heart disease. R2's MDS dated [DATE] shows R2 is cognitively intact and requires supervision with all ADLs. R2 is occasionally incontinent of urine, and always continent of stool. The EMR shows the following documentation for R2: On January 25, 2024 at 6:54 PM, V8 (RN) documented, Insulin NPH (Human) (Isophane) Subcutaneous Suspension, inject 76 units subcutaneously two times a day related to Type 2 diabetes. On order. On March 18, 2024, V9 (Agency Nurse) documented, Ozempic Inject 0.5 mg. subcutaneously one time a day every Monday related to Type 2 diabetes. Drug on order. On March 28, 2024, V9 (Agency Nurse) documented, Lidocaine Pain Relief External Patch 4 percent, apply to left shoulder topically in the morning for pain and remove per schedule. On order. On April 3, 2024 at 6:23 Am, V7 (RN) documented, Lidocaine Pain Relief External Patch 4 percent, apply to left shoulder topically in the morning for pain and remove per schedule. On order. On April 12, 2024 at 5:46 AM, V7 (RN) documented, Lidocaine Pain Relief External Patch 4 percent, apply to left shoulder topically in the morning for pain and remove per schedule. On order. On April 21, 2024 at 6:19 AM, V7 (RN) documented, Lidocaine Pain Relief External Patch 4 percent, apply to left shoulder topically in the morning for pain and remove per schedule. On order. 3. The EMR shows R4 was admitted to the facility on [DATE] with multiple diagnoses including, end-stage renal disease, palliative care chronic kidney disease, Type 2 diabetes with hyperglycemia, cerebral infarction affecting the right, dominant side, vascular dementia, heart failure, presence of cardiac pacemaker, and dependence on renal dialysis. On April 13, 2024 at 6:25 AM, V7 (RN) documented, Lidocaine External Patch 4 percent, apply to right foot topically in the morning for pain management. On for 12 hours and off for 12 hours and remove per schedule. On order On April 23, 2024 at 1:21 PM, V6 (Pharmacy Order Entry Clerk) said, The facility is supposed to request refills through their electronic charting system or via FAX. They can also call us for a STAT refill request if they did not follow the process. We provide two medication deliveries to the facility each day. I do the order entry for orders that are received. Someone is here 24 hours a day to enter orders. For [R1], we received a call to have the Humulin R U-500 refilled on April 19, 2024 at 4:06 AM. The insulin was sent to the facility on [DATE] at 3:06 PM. April 2, 2024 was the last time the insulin was sent to the facility, which was enough insulin to take [R1] through April 11, 2024. The Ozempic was requested on April 5, 2024 at 8:00 AM and we sent it on April 5, 2024 at 1:39 PM. For [R2's] Lidocaine patches, the facility requested a refill on April 21, 2024 and we sent the patches on April 22, 2024 at 4:00 AM. [R2's] Ozempic and insulin refills were called in on the same day they were sent to the facility. On April 23, 2024 at 2:19 PM, V5 (NP-Nurse Practitioner) said, The nurses are supposed to be calling pharmacy to get the medications. The assumption by myself and the physician is the patients are getting the medications we order. On April 23, 2024 at 2:50 PM, V2 (DON-Director of Nursing) said facility staff need to request medication refills four or five days ahead of time so residents do not run out of medications. The facility's policy entitled, Reordering Medications (Facilities Ordering Refills on Demand) dated, 2005-2021 shows: Policy/Purpose: Medications are reordered in advance so as not to have lapses in therapy. Procedure: 1. The nursing staff is responsible for reordering medications. 2. Medications should be reordered when, in the judgment of the nurse, a 2-day supply of medication remains. 3. Reorders should be submitted either by: a. Using the re-order function in the facility's eMAR (Electronic Medication Administration Record) system (only if there is a pharmacy interface), or b. Removing the barcode label, affixing it to the reorder sheet, and faxing it - in a fax document carrier - to the pharmacy.

Based on interview and record review the facility failed to ensure nebulizer treatments were completed and signed off on the medication administration record. This applies to 2 of 3 residents (R1, R10) reviewed for nebulizer treatments in the sample of 12. The findings include: 1. On 4/8/24 at 10:00 AM, V21 (R1's family) said on 3/28/24 at 6:00 PM, R1's breathing treatment mask was on the floor and the nebulizer machine was not on. R1's Facesheet dated 4/8/24 shows R1 is diagnosed with chronic obstructive pulmonary disease (COPD) and acute and chronic respiratory failure . R1's Medication Administration Record (MAR) for March 2024 shows that R1 was to receive a treatment of Ipratropium-Albuterol via nebulizer on 3/28/24 at 6:00 AM related to chronic respiratory failure. There are no recorded nurse initials to indicate the medication was provided. 2. On 4/9/24 at 2:53 PM, R10 said that he is supposed to receive nebulizer treatments twice per day. R10 said that staff do not always make sure that he receives two treatments per day. R10's Facesheet dated 4/9/24 shows R10 has COPD. R10's MAR for March 2024 shows that R10 was to receive a treatment of Ipratropium-Albuterol via nebulizer on 3/28/24 at 6:00 AM related to COPD. There are no recorded nurse initials to indicate the medication was provided. On 4/9/24 at 4:00 PM, V2 (Director of Nursing) said that R10 and R1 should have received their nebulizer breathing treatment as ordered and initialed on the MAR that the treatment was provided. Facility Medication Administration: General Guidelines policy dated 03/21 states, . C. All medication shall be administered as prescribed by personnel authorized to do so in accordance with standard practice and current regulations. 5. Each dose administered shall be properly recorded on the resident's MAR, TAR (Treatment Administration Record), or eMAR (electronic Medication Administration Record), immediately following administration.

Based on observation, interview, and record review the facility failed to notify a resident's POA (Power of Attorney) of changes in condition. This applies to 1 of 3 residents (R1) reviewed for policy and procedures. The findings include: On 02/08/24 at 1:00 PM, R1 was in her room in a wheelchair with her daughter at bedside. R1 was alert and confused. R1 said she previously had pneumonia and problems with her bladder. R1 said she was not sick for a long time before going to the hospital. On 02/08/24 at 12:10 PM, V3 (CNA/Certified Nursing Assistant) said she has been the CNA for R1 in the past and is taking care of her today. V3 said when R1 was coughing and had a loss of appetite last month, she reported it to the nurse. On 02/08/24 at 12:48 PM, V4 (LPN/Licensed Practical Nurse) said she takes care of R1 3 days a week. V4 said she was taking care of R1 when she became ill on 01/01/24. V4 said R1 was coughing. V4 said she completed a rapid Covid test on R1 and it was negative. V4 said she called the doctor and received orders for Claritin and Flonase. R1's 1/1/2024 progress notes showed V4 documented R1 had coughing and congestion and the Physician was notified. V4 did not document R1's POA was notified of the change in condition and addition of the new medications. On 02/08/24 at 3:02 PM, V2 (DON/Director of Nursing) said the policy for changes in condition is to update the POA of changes as soon as possible. If it is an emergency, the emergency is handled first and then the POA is notified. V2 said R1 had pneumonia. The facility's Change of Condition policy dated 09/20, showed the attending physician on call/NP (Nurse Practitioner) and responsible party will be notified with changes in a resident's condition.

Based on interview and record review, the facility failed to reorder R3's Vimpat (seizure medication), which led to R3 missing three doses, causing R3 to have a grand mal seizure and hospitalized . This applies to 1 of 4 residents (R3) reviewed for significant medication error. The findings include: On [DATE] at 11:18 AM, V19 (LPN/Licensed Practical Nurse) said R3 was hospitalized due to a seizure from missing her medication. V19 said she believed someone forgot to reorder her Vimpat. On [DATE] at 02:26 PM, V20 (Family Member) said R3 almost died and was in the hospital after having a grand mal seizure at the facility. V20 said R3 was intubated and was in the neuro ICU (Intensive Care Unit) after the seizure. V20 said V2 (DON/Director of Nursing) disclosed to the ICU nurse that R3 had not received her Vimpat. V20 said R3 missed three doses of the medication because they had run out of the Vimpat. On [DATE] at 10:32 AM, V23 (RN/Registered Nurse) said she took care of R3 and from what she remembered, the Vimpat was not available to administer to R3. V23 said the nurse before her did not notify her that the Vimpat was unavailable. On [DATE] at 10:49 AM, V24 (LPN) said she took care of R3, and she documented saying the Vimpat was not available. V24 said the nurse from the shift prior did not notify her the Vimpat was unavailable. On [DATE] at 09:45 AM, V21 (R3's Neurology Specialist) said she was the one who prescribed Vimpat to R3. V21 said R3 had been on Vimpat since ,d+[DATE]. V21 said missing the Vimpat could have caused the seizure. V21 said Vimpat had a shorter half-life, so missing three doses could have led to R3 having a seizure. On [DATE] at 03:35 PM, V2 (DON) said it was not clear whether R3 missing doses of Vimpat caused seizures. R3's face sheet showed R3 was admitted to the facility with diagnoses including epilepsy, cognitive social or emotional deficit following cerebral infarction, muscle weakness, need for assistance with personal care, and peripheral vascular disease. R3's MDS (Minimum Data Set) dated [DATE] showed R3 was moderately impaired. R3 required set up assistance with eating, supervision for oral hygiene, moderate assistance for toileting hygiene, upper body dressing and personal hygiene, and maximal assistance for shower/bathing, lower body dressing, and putting on/taking off footwear. R3's POS (Physician Order Sheet) showed an order for Vimpat 50 mg (Milligram) two times a day for conversion disorder with seizures or convulsions. R3's care plan showed R3 has potential for injury related to seizure disorder with interventions including Administer seizure medications per MD (Medical Doctor) order. The ED (Emergency Department) records dated [DATE] at 10:10 PM documented the following: Patient's daughter who is power of attorney and is giving history at the bedside, patient reportedly was fine yesterday, was awake alert and talking yesterday. Today she had 3 seizures in rapid succession within about ,d+[DATE] hour. The patient reportedly had generalized tonic-clonic movements while at [facility] where she is a resident. Had second episode lasting about 90 seconds at [facility] and a third seizure again with generalized tonic-clonic movements lasting for about 2 minutes for which the patient received Versed while in the back of the ambulance. The patient has had no history of any fever. The patient has had no history of any fall or trauma. The patient reportedly takes Vimpat and Keppra for her seizures, but we are uncertain about the compliance of the patient with medication at this time. The hospital's consult dated [DATE] at 08:40 AM documented the following: Seizures- possibly due to inadvertent noncompliance with meds while at SNF (Skilled Nursing Facility). R3's December MAR (Medication Administration Review) showed R3 did not receive her Vimpat on [DATE] at 9 AM and 5 PM, and [DATE] at 9 AM. The facility's progress notes document the following: On [DATE] at 10:34 PM, the EMR showed a progress note for Vimpat 50 mg- pending delivery. On [DATE] at 11:22 AM, the EMR showed a progress note for Vimpat 50 mg- out of stock. On [DATE] at 04:54 PM, the EMR showed a progress note for Vimpat 50 mg- out of stock. On [DATE] at 11:12 AM, the EMR showed a progress note for Vimpat 50 mg- Medication is out of stock. Writer reordered. On [DATE] at 07:25 PM, a progress note documented the following: This writer was called to room by CNA, resident was not responding, pulse palpable, breathing, started O2 (Oxygen) at 3l (Liters) per nasal cannula, patient tries to respond by opening her mouth but remains limp, not opening her eyes. 7:35 PM- 911 called, meantime, patient had another seizure episode. Seizure precautions observed. EMT here, picked up resident and took to [hospital], POA (Power of Attorney) daughter, DR (doctor) and DON made aware. On [DATE] at 10:48 AM, a progress note documented the following: Writer called family and hospital to clarify medications yesterday. Writer notified hospital and family that she missed 3 doses of Vimpat. The facility's Medication Administration: General Guidelines policy dated ,d+[DATE] showed Ensure that medications are administered safely as prescribed.

Based on interview and record review, the facility failed to reorder medications for residents to prevent missing doses of scheduled medications. The facility also failed to have two licensed professionals sign off the shift-to-shift controlled substance sheet and have two licensed professionals sign off on wasted controlled substances. This applies to 4 of 4 residents (R2, R3, R16, R17) reviewed for pharmacy services. The findings include: 1. On 12/20/23 at 02:26 PM, V20 (Family Member) said R3 missed three doses of the medication because they had run out of the Vimpat. R3's face sheet showed R3 was admitted to the facility with diagnoses including epilepsy, cognitive social or emotional deficit following cerebral infarction, muscle weakness, need for assistance with personal care, and peripheral vascular disease. R3's MDS (Minimum Data Set) dated 12/7/23 showed R3 was moderately impaired. R3 required set up assistance with eating, supervision for oral hygiene, moderate assistance for toileting hygiene, upper body dressing and personal hygiene, and maximal assistance for shower/bathing, lower body dressing, and putting on/taking off footwear. R3's POS (Physician Order Sheet) showed an order for Vimpat 50 mg (Milligram) two times a day for conversion disorder with seizures or convulsions. R3's care plan showed R3 has potential for injury related to seizure disorder with interventions including Administer seizure medications per MD (Medical Doctor) order. R3's December MAR (Medication Administration Review) showed R3 did not receive her Vimpat on 12/6/23 at 9 AM and 5 PM, and 12/7/23 at 9 AM. The facility's progress notes document the following: On 12/5/23 at 10:34 PM, the EMR showed a progress note for Vimpat 50 mg- pending delivery. On 12/6/23 at 11:22 AM, the EMR showed a progress note for Vimpat 50 mg- out of stock. On 12/6/23 at 04:54 PM, the EMR showed a progress note for Vimpat 50 mg- out of stock. On 12/7/23 at 11:12 AM, the EMR showed a progress note for Vimpat 50 mg- Medication is out of stock. Writer reordered. 2. On 12/20/23 at 10:39 AM, R2 said she did not receive her morphine on 12/19/23. R2 said she was told they were unable to find the morphine. R2 said she normally received morphine 60 mg twice a day because she had chronic pain. On 12/20/23 at 12:05 PM, V26 (LPN/Licensed Practical Nurse) said R2's morphine script ended and V2 (DON/Director of Nursing) was calling the doctor to get the script. V26 said R2 told her she had been taking the morphine for a long time. V26 said if there were five pills or less, she would have requested the medication to be refilled. V26 said she was uncertain why the medication was not here and she had requested the morphine this morning. On 12/21/23 at 12:58 PM, V27 (LPN) said if she ran out of the medication, she would call pharmacy to get a stat delivery and she would let the DON know. V27 also said if she was unable to get the medication, she would document accordingly and pass it along to the oncoming nurse. On 12/21/23 at 03:35 PM, V2 (DON) said ideally the staff should be notifying the pharmacy two days before the medication ends. The EMR (Electronic Medical Record) shows R2 was admitted to the facility with diagnoses including displaced fracture of scapula, osteoarthritis, acute kidney failure, chronic kidney disease, muscle weakness, chronic pain syndrome, lack of coordination, anxiety disorder, limitations of activities due to disability, hypothyroidism, and neuromuscular dysfunction of bladder. R2's MDS (Minimum Data Set) dated 12/12/23 showed R2 was cognitively intact. R2 required set up assistance for eating, supervision for oral hygiene, maximal assistance for personal hygiene, upper body dressing, and shower/bathing, and was dependent on staff for toileting hygiene, lower body dressing, putting on/taking off footwear. R2's care plan showed to Monitor wound related pain and administer pain medications as appropriate and Administer medications per MD [Medical Doctor] order. R2's December MAR (Medication Administration Record) showed R2 did not receive her scheduled morphine 60 mg on 12/19/23 at 9 PM and 12/20/23 at 9 AM. R2's EMR showed the following progress note: Lorazepam oral tablet 1 mg. Resident requested medication for anxiety due to she did not receive Morphine today. 3. On 12/19/23 at 01:22 PM, V5's medication cart was reviewed for controlled substances. R16's Controlled Drug Receipt/Record/Disposition Form for Hydrocodone 5-325 mg showed on 12/10/23, one pill was wasted. Only one signature was present on the form. The EMR showed R16 was admitted to the facility with diagnoses including osteoarthritis, gout, chronic pain, restless leg syndrome, and hypothyroidism. R16's MDS dated [DATE] showed R16 was cognitively intact and required set up assistance for eating, oral hygiene, and supervision for toileting hygiene, showers/baths, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. 4. On 12/19/23 at 01:22 PM, V5's medication cart was reviewed for controlled substances. R17's Controlled Drug Receipt/Record/Disposition Form for Hydrocodone 5-325 mg showed on 12/1/23, one pill was wasted. Only one signature was present on the form. The EMR showed R17 was admitted to the facility with diagnoses including atrial fibrillation, hypertension, peripheral vascular disease, pain in right shoulder, gastrostomy status, and dysphagia. R17's MDS dated [DATE] showed R17 had moderate cognitive impairment and was independent with toileting hygiene, required set up assistance for oral hygiene, eating, lower body dressing, putting on/taking off footwear, and personal hygiene. R17 required moderate assistance for showers/baths. 5. The facility's December Controlled Substance Shift Count Documentation (2 Shifts) for the medication carts named Windsor, Ambassador, and Heritage showed multiple days where two nurses were not verifying and signing off on the controlled substances. On 12/19/23 at 02:11 PM, V6 (Consultant Pharmacist) said there needs to be two licensed staff to look at the wasted controlled medication. V6 said this is done to prevent drug diversion and safe disposal. On 12/21/23 at 03:35 PM, V2 (DON) said two signatures are required to sign a wasted controlled substance. V2 said the shift-to-shift handoff for the controlled substances should be signed off by two nurses. V2 also said it is done for verification of receiving and handing off narcotics. The facility's Reordering Medications policy dated 01/2022 showed Medications are reordered in advance so as not to have lapses in therapy. Regularly scheduled oral, solid, and chronic medications will be automatically refilled and delivered with each cycle. The nursing staff is responsible for reordering non-cycled medications. The facility's Controlled Drug Documentation dated 06/2022 showed If a dose is wasted, it should be so written on the proof-of-use form and must be signed by two nurses. Controlled substances must be counted and verified every shift, usually at shift change, by two (2) licensed nurses. Balances are documented on the Shift Count form and must be signed by both nurses performing the count.

Based on observation, interview, and record review, the facility failed to follow infection control measures for a resident during incontinence care, and residents under COVID-19 isolation. This applies to 5 of 7 residents (R11, R12, R15, R13, R14) reviewed for infection control. The findings include: 1. On 12/21/23 at 09:07 AM, V11 (CNA) provided incontinence care for R11. V11 removed R11's dirty brief and wiped R11's urine and stool. V11 did not change gloves or perform hand hygiene. V11 then grabbed R11's clean incontinence brief and incontinence pad and placed it under R11. V11 applied barrier cream using the same gloves. V11 secured the incontinence brief and placed the clean incontinence pad under the resident. The EMR (Electronic Medical Record) shows R11 was admitted with diagnoses including wedge compression fracture of T11-T12 vertebra, encephalopathy, Parkinson's disease, chronic obstructive pulmonary disease, muscle weakness, difficulty in walking, unsteadiness on feet, and lack of coordination. R11's MDS (Minimum Data Set) dated 12/2/23 showed R11 had severe cognitive impairment. R11 required supervision for eating, oral hygiene, and personal hygiene. R11 required maximal assistance for upper body dressing. R11 was totally dependent on staff for toileting hygiene, shower/bathing, lower body dressing, and putting on/taking off footwear. 2. On 12/20/23 at 03:41 PM, V9 (CNA/Certified Nurse Assistant) went into R12's room. R12 was under COVID-19 isolation because R12 had tested positive for COVID-19. V9 entered R12's room with just a surgical mask on. At 03:51 PM, V9 said R12 was on isolation for COVID-19. V9 said she should have worn a gown, N-95 mask, and gloves. The EMR shows R12 was admitted with diagnoses including hemiplegia and hemiparesis, metabolic encephalopathy, pressure ulcers, dysarthria, dysphagia, gastrostomy, need for assistance with personal care, hypertension, and hyperlipidemia. R12's MDS dated [DATE] showed R12 was severely impaired. R12 was dependent on staff for all activities of daily living. 3. On 12/21/23 at 12:54 PM, V22 (LPN/Licensed Practical Nurse) was observed entering R15's room. R15 was under COVID-19 isolation. At 12:56 PM, V22 said R15 was on contact and droplet isolation for COVID-19. V22 said she should have worn a gown, glasses, and an N-95. V22 said she was rushing in to get R15's vitals. The EMR showed R15 was admitted to the facility with diagnoses including hemiplegia and hemiparesis, type 2 diabetes mellitus, hypertension, mild cognitive impairment, and gastro-esophageal reflux disease. R15's MDS dated [DATE] showed R15 was cognitively intact. R15 required set up assistance for eating, supervision for oral hygiene and personal hygiene, moderate assistance for toileting hygiene, upper/lower body dressing, and putting on/taking off footwear. 4. On 12/19/23 at 12:35 PM, V4 (Social Work Intern) went into R13 and R14's room. R13 and R14 were under COVID-19 isolation because R13 and R14 tested positive for COVID-19. V4 entered the room without wearing an N-95 mask and eye protection. At 12:40 PM, V4 said she should have worn an N-95 mask. The EMR shows R13 was admitted to the facility with diagnoses including monoplegia of lower limb, hypertensive heart disease with heart failure, congestive heart failure, atrial fibrillation, cardiomyopathy, dementia, hyperlipidemia, adult failure to thrive, and presence of a cardiac pacemaker. R13's MDS dated [DATE] showed R13 had severe cognitive impairment. R13 required set up help for eating, supervision for upper body dressing, moderate assistance for oral hygiene, toileting hygiene, lower body dressing, putting on/taking off footwear, and personal hygiene. R13 requires maximal assistance for showers/baths. The EMR shows R14 was admitted with diagnoses including atrial fibrillation, chronic kidney disease, congestive heart failure, anemia, gout, and Ogilvie syndrome. R14's MDS dated [DATE] showed R14 was cognitively intact. R14 required supervision for all activities of daily living. On 12/21/23 at 03:35 PM, V2 (DON/Director of Nursing) said the staff should be wearing a gown, gloves, N-95 mask, and face shields before entering rooms under COVID-19 isolation precautions. V2 was unable to give an answer regarding when gloves should be changed, and hand hygiene be performed during incontinence care. The facility's Universal PPE For Staff policy dated 07/2023 showed If a resident is suspected or confirmed to have COVID-19, staff will wear an N95 respirator, eye protection, gown, and gloves. The facility's Perineal Care policy dated 09/2020 showed Remove gloves and wash hands and/or use hand hygiene. Apply gloves before putting on a clean brief.

Based on observation, interview and record review, the facility failed to ensure the safety of a resident during care. This failure resulted in R1 sustaining a traumatic brain bleed and traumatic spiral fracture on R1's left femur requiring surgical intervention to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's electronic medical record accessed on 9/9/21 shows R1 has diagnoses of stroke, hypertension and diabetes at the time of admission on 05/31/2017. R1's facility assessment dated [DATE] shows R1 is severely cognitively impaired and R1 is extensive assist to total dependence for care on bed mobility, transfers and toileting. A progress notes by V3 (License Practical Nurse-LPN) dated 9/2/2021 timed at 2219 (10:19 PM) shows, At about 9pm this night, writer was called in room .to further assess resident as she was c/o pain when turned to her left side. upon further assessment writer noticed that resident left hip down to knee joint was swollen, slightly red and warm on touch, fainted pedal pulse was on affected leg. [R1'S MD] was called and gave order for STAT x-ray of knee and hip. Writer called Tech [xray] and was told tech might come till really late or early in am. Writer called DON and per her .call MD to see if ok to send resident to ER for X-ray. Dr. was contacted and gave ok to send resident to ER. POA was called and requested resident to be sent to [local hospital]. Transport was called and resident left at 10:20pm. POA notified of leaving. Will f/u The local hospital emergency room document dated 9/3/2021 shows The patient is a [AGE] year-old female with a previous history of stroke, high cholesterol, hypertension, diabetes, [CONDITION(S)], brought into the emergency department due to concern about deformity of her left lower extremity. There was no known fall. She has been bedbound .Patient arrives awake, alert, eyes open, but no verbal response. So history is quite limited. The emergency room radiology report of R1's left leg dated 9/3/2021 shows, Spiral fracture involving the left distal femoral shaft with mild displacement. CT scan of head dated 9/3/21 show Tiny foci of acute subarachnoid hemorrhage along the high convexity of the bilateral frontal lobes is likely posttraumatic in nature. Clinical Impression: Subarachnoid hemorrhage (HCC) and displaced spiral fracture of shaft of left femur. Both traumatic in nature. A neurology consult dated 9/3/21 show .a 91 y/o female .who presented to Emergency Department (ED) last night with LLE [left lower leg] deformity. According to ED documentation, patient is normally bedbound. There was no known fall. She has CT brain which showed traumatic SAH (subarachnoid hemorrhage) Family does not want any intervention at this time. R1's surgical report show that on 9/4/21, R1 underwent retrograde intramedullary nailing, left distal third femoral shaft fracture with comminution and displacement. On 9/9/21 at 10:05 AM, R1 was in bed, awake and alert. R1's left leg was wrapped with an ace wrap from calf to midthigh. A dressing is visible at thigh area underneath the ace wrap. When R1 was asked what happened to her left leg, R1 responded, Something happened but I don't know R1 said she does not have any pain at this time. On 9/9/21 at 10:15 AM, V4 (License Practical Nurse-LPN) said she was R1's nurse today. V4 said was not aware that R1 has a fracture. V4 said she is an agency nurse and was not familiar with R1. V4 said all she got from report was R1 was stable. On 9/9/21 at 10:30 AM, V6 (Certified Nursing Assistant-CNA) said she was R1's CNA on 9/1/21. V6 said she came in to work at 6AM. V6 said she saw R1 in bed and she was complaining of left leg pain. V6 said she went and told the night nurse. V6 said at breakfast time, R1 was not eating but only drank her coffee. R1 was again complaining of left leg pain. V6 said she went and reported to the day nurse. (V5) V6 said she was extra careful moving R1 during incontinence care. V6 said she did not get up R1. V6 said R1 also did not eat lunch and dinner. V6 said R1 fights during care. V6 said on 9/1/21 R1 was not fighting at all. On 9/9/21 at 10:20 AM. V5 (License Practical Nurse-LPN) said she was an agency nurse. V5 said she was the day nurse working on 9/1/2021 from 7am- 7pm. V5 said she got report from the night nurse (V10-travelling nurse agency) that R1 was mean and cursing during the night shift. V5 said she was not familiar with R1. V5 said she works all over in the facility. V5 said at around 8AM on 9/1/21, R1 told her she was not feeling well. V5 said she gave R1 Tylenol. V5 said she did not see R1 again until 2:30 PM, R1 again said she was not feeling well. V5 said she gave her Tylenol and R1 slept most of her shift. V5 said she did not assess R1's leg. V5 said cannot recall if V6 (CNA) told her that R1's left leg was hurting. V5 said she only found out about R1's fracture when she came back to work today, V5 said she did not know what happened to R1's left leg. On 9/9/21 at 12:06 PM, V11 (CNA) said she worked day shift (6A-6P) on 9/2/21. V11 said she did not notice anything wrong with R1. V11 said she noticed that R1 was not fighting during care. On 9/9/21 at 12:20 PM, V8 said she was a travelling CNA and had not worked with R1 for almost a month. V8 (CNA) said she came in to work at 10 AM on 9/2/21 and relieved V11 to become R1's CNA. V8 said she worked with V11 taking care of R1. R1 stayed in bed. V8 said she did not notice anything wrong with R1's legs. During care, they were able to turn R1 without R1 putting a fight. R1 normally fights during care. On 9/13/21 at 9:42 AM, V14 said she was an agency CNA assigned to R1 on 9/2/21. V14 said she was working from 6P to 6AM. V14 said V15 (CNA) came to help her on her assignment and V15 noticed R1's swollen left leg. On 9/13/21 at 10AM, V15 said she was a travelling agency CNA and was working in another wing on 9/2/21. V15 said she went to help V14. V15 said she went to R1's room at around 8-8:30 PM. V15 said she noticed R1 was quiet. V15 said it got her attention because R1 is normally resistive, curses and fights during care. V15 said she asked R1 if she was feeling ok. V15 said R1 did not say anything. V15 said when she turned R1 to her side, R1screamed for pain! V15 said she noticed R1's left leg was loose. V15 said she finished cleaning R1 having a bowel movement. When she turned R1 to her back, R1 again screamed! V15 said she can feel R1's bone at the back of R1's thigh. V15 said she suspected that R1 had a broken leg. V15 said she called V14 to let the nurse know so she can check R1. V15 said she does not know what happened to R1. On 9/13/21 at 9: 15 AM, V3 (LPN) said she was the nurse working with R1 on 9/2/21. V3 said she worked a double shift that day- 6AM to 11PM. V3 said she did not notice anything unusual with R1 in AM shift. The CNA's assigned to R1 (V11 and V8) did not report anything unusual about R1 in the morning. At around 9-9:30 PM, V14 (CNA) called her to R1's room, because something was wrong with R1. V3 said when she removed R1's covers, R1's left leg was swollen from hip to knee area. V3 said R1's pedal pulse on the left leg was very faint. V3 said R1's knee joint felt dislocated. V3 said she notified R1's physician with order to get a stat x-ray. X-ray company was not available sooner. R1 was sent to ER via 911. V3 said she was told days later that R1 had a spiral fracture. On 9/9/2021 at 11:45 AM, V2 (Director of Nursing-DON) said being a nurse she knows that a spiral fracture was from trauma like twisting. V2 said something happened to (R1's) leg. V2 said R1's leg might have been caught in a sheet while staff were turning her that caused the fracture. R1 also has bleed in brain that can be attributed to a fall. V2 said R1 cannot get herself up from the floor, R1 is dependent on staff. R1 is confused and said she fell in the kitchen. On 9/9/21 at 9:40 AM, V7 said she was the Unit Manager of the hospitalER on ,d+[DATE] to 9/3/21. V7 said R1 came to the ER at 10:55 PM. V7 said R1 was diagnosed with spiral fracture left femur and brain bleed. Both of these injuries were traumatic in nature. The facility said [R1] did not fall and she is bedbound, confused and combative. V7 the ER physician said both of the injuries are highly questionable. On 9/13/21 at 11: 28 AM V1 (Administrator) said there were no cameras in the residents areas that would have helped in the investigation. On 9/13/21 at 4:04 PM, V2 (DON) said R1's injury happened during care. When staff does not check R1's legs during care, it can get tangled with her sheets in bed that can cause the injury of her left leg. V2 said R1 is combative and when staff rolled her side to side, it was possible her head got bumped in the side rails that's when she got the brain bleed. On 9/13/21 at 5:20 PM, V13 (Physician) said he was R1's physician when R1 was sent to the hospital on 9/2/21. V13 said R1's spiral fracture was caused by trauma. R1's fracture was related to forceful twisting of her leg. V13 said the femur is a strong bone, it takes a lot of strong force to brake this bone. V13 said R1's bilateral bleed was caused by a strong force hitting R1's head against a wall, a floor or side rails. On 9/14/21 at 9:30 AM, V1 (Administrator) said the facility has no policy with regards to safety during care.

Based on interview and record review the facility failed to effectively manage abnormal laboratory results for a resident receiving anti-coagulants. This applies to 1 of 6 residents (R114) reviewed for anti-coagulant use in a sample of 27. This failure resulted in R114 being hospitalized with a [DIAGNOSES REDACTED]. Findings include: The Admission Record documents R114 admitted to the facility on (MONTH) 21, (YEAR) with [DIAGNOSES REDACTED]. R114's Order Summary Report dated (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR) documents R114 receiving two blood thinners, [MEDICATION NAME] Sodium, 9 milligrams, (mg) beginning on (MONTH) 22, (YEAR) and [MEDICATION NAME] Sodium, 40 mg every 12 hours, beginning on (MONTH) 21, (YEAR). The Lab Results Report dated (MONTH) 25, (YEAR) document R114 with an elevated [MEDICATION NAME] Time of 39.8 seconds (normal range 20.2-30.8) and an elevated International Normalized Ratio (INR) of 3.77 (normal range 2.0-3.0). This lab report documents these elevated levels were reported to the facility on (MONTH) 25, (YEAR) at 12:51 PM and does not indicate the physician was notified. R114's Progress Notes dated (MONTH) 25-26, (YEAR) do not document the physician was notified of the elevated levels. On (MONTH) 19, (YEAR) 1:43 PM V22 (Nurse) stated on (MONTH) 28, (YEAR) R114 had blood in her stool at approximately 9 PM which V22 described as melena (dark tarry stools containing decomposing blood). V22 informed V23 (Physician) who provided orders to hold the blood thinners and to complete stat lab work. V22 stated, I called the lab and they didn't show up. They called at 1 AM and they said they couldn't make it until 3 am because they didn't have staff. They didn't come until late, way after 3 am. V22 stated she did not inform V23 this lab work could not be completed stat. V22 stated on (MONTH) 29, (YEAR) at approximately 7 AM R114 had a large amount of blood in her stool again and was sent to the hospital. The Lab Results Report dated (MONTH) 29, (YEAR) document this lab work which was ordered stat on (MONTH) 28, (YEAR) completed at 6 AM. The results document R114 with an elevated [MEDICATION NAME] Time of 65.3 seconds (normal range 20.2-30.8) and an elevated INR of 6.21 (normal range 2.0-3.0). In addition this report documents R114's Red Blood Cell Count was 2.17 cells per cubic millimeter (normal 4.2-5.4), Hemoglobin 6.5 grams per deciliter (normal 12-16) and Hematocrit was 21.5 percent (normal 37-47). R114's Hospital History and Physical dated (MONTH) 29, (YEAR) documents R114 with [MEDICAL CONDITION]. On (MONTH) 19, (YEAR) at 2:05 PM, V2 (Director of Nursing) stated anti-coagulant medications (blood thinners) are to be monitored per physician orders [REDACTED]. V2 stated stat labs are to be completed in 4 hours and if that cannot occur the physician is to be notified. V2 stated, R114's abnormal laboratory results should have been called to V23 and V2 confirmed there is no evidence these abnormal results were called to V23. V2 stated physician notification is documented in the progress notes. On (MONTH) 20, (YEAR) at 9:15 am V23 stated if he had been informed of R114's elevated lab from (MONTH) 25, (YEAR) he would have adjusted the anti-coagulant dosing and ordered monitoring. V23 stated gastrointestinal testing was completed during V23's hospitalization with no significant findings. V23 confirmed the cause of the bleeding was from the anti-coagulants and stated, Yes, it was preventable. V23 stated they should have notified a physician. The facility policy [MEDICATION NAME] ([MEDICATION NAME]) Monitoring Guidelines dated (MONTH) (YEAR) documents all residents receiving [MEDICATION NAME] therapy will receive monitoring per physician orders. This policy further documents upon receipt of the results the physician will be notified.

Based on observation, interview and record review, the facility failed to conduct a comprehensive assessment to analyze the development and the progression of the facility acquired pressure injuries. The facility also failed to develop a plan of care based on the identified risk factors and co morbidities of the residents and to consistently implement the plan of care. This resulted in the development of (1) R138's shearing wound on the sacrum that progressed to an Unstageable (necrotic) pressure injury. (2) R97 Stage 2 pressure injury progressed to a Stage 4 and (3) R8 development of a sacral Stage 4. This applies to 4 of 8 (R183, R8, R97 and R114) resident reviewed for skin alteration in the sample of 27 residents. The findings include: 1. On (MONTH) 17, (YEAR) at 11:44 AM, R183 was in bed lying flat in his back, family members were at bed side. R183 was noted with a gastrostomy feeding and with an indwelling catheter. R183 communicate in non-dominant language (Indian dialect) at 2:37 PM, R183 daughter explained, We stays with him 24 hours so we can translate for him. They (staff) only come once per shift. We turn the light on but no one will come, we need to wait, most of the time 30 minutes or longer, that's our problem here. They do not have enough helper. He developed a big pressure ulcer while here in the facility. One on each buttocks. On (MONTH) 18, (YEAR) at 9:15 AM, R 183 was noted in bed lying on his back, no positioning device noted. R183 family member (brother in law) stated, The staff comes only at the end of the shift to empty his catheter bag. We need to call them but most of the time we wait for a long time (30 minutes to an hour) before they come and help him (R183). He developed this big bedsore after he was admitted here. It is hard to get help here, they need more staff. No, they do not come or asked if he needed help. No, they do not turn him that's probably why he developed this black wound in his buttocks and it's getting worst, now it's bigger and it has a very strong rotten odor! At 11:50 AM, R183 remains in the same position, no off- loading device was noted. The family members at bedside stated there was no staff that came to check and reposition him since 8:00 AM. R183's electronic admission record showed R183 was admitted at the facility on (MONTH) 2, (YEAR) with [MEDICAL CONDITION] and [MEDICAL CONDITION] following non traumatic [MEDICATION NAME] hemorrhage affecting left non dominant side. The Minimum Data Set, dated dated dated (MONTH) 9, (YEAR) showed R183 needing extensive assistance with one staff assist with activities of daily living. R183's electronic skin progress notes presented by V3 (Wound Nurse) dated (MONTH) 3, (YEAR) showed R183 was noted with 8.0 cm L (length) X 8.5 cm W (width) X 0.1 cm D (depth) reddened area on his coccyx. This wound is identified and documented as shear wound. On (MONTH) 17, (YEAR) skin progress notes showed that this progressed to an Unstageable pressure injury and with increased size to 12.0 cm L X 10.5 cm W with presence of 75 % slough (tan color). On (MONTH) 18, (YEAR) during wound assessment with V27 (Wound MD) at 12:00 PM, R183 was noted with necrotic area on the sacrum and on the left buttock and an open area on the right buttocks. These wounds has a very strong foul odor and with moderate amount of brownish drainage. V27 explained, This is the first time I see R183. I was told it started as sheering, now it's Unstageable (black). I am recommending him to go to the hospital for surgery. It has a very foul odor. It smells like it's infected but we won't know that because there's no culture done. On (MONTH) 20, (YEAR) at 1:00 PM, V3 explained that the especial mattress was not implemented until (MONTH) 12, 2013. V3 also stated, that the facility does not evaluate residents for tissue tolerance (specific/individualized repositioning plan). During this week of the survey, the facility was unable to present any documentation that the facility assessed and evaluated R138's root cause for the development R138's pressure injury. The skin plan of care to turn and reposition every two hours was not consistently implemented and the identified risk factors were not address. 2. On (MONTH) 17, (YEAR) at 10:40 AM, R97 was noted lying in bed on his back, with an indwelling catheter. R97's gastrostomy feeding was noted to be empty and the feeding pump/machine was beeping. Staff were observed passing by in R97's room but no one stopping by to respond to the alarm. R97 was noted in the same position (on his back) and the alarm going off until 1:00PM after V28 (Certified Nursing Assistant) was notified. At 1:05 PM, V28 said, We were in his room to clean him around 10:00 AM. V28 identified R97 as confused and totally dependent on staff with all of his activities of daily living and unable to reposition self. V28 verified that R97 was lying on his back and said, As far as I know he does not have any pressure ulcer. The facility pressure injury log showed R97 has a Stage 4 on the sacrum. R97'S Minimum Data Set, dated dated dated (MONTH) 2, (YEAR) showed R97 was admitted at the facility on (MONTH) 12, (YEAR) with [DIAGNOSES REDACTED]. R97 was identified needing extensive assistance with two plus staff assist with transfers and positioning. On (MONTH) 18, (YEAR) at 9:20 AM, R97 was in the room sleeping on his bed, lying on his back. No positioning device was noted. At 11:08 AM, V27 (Wound Doctor) was in the hallway. V27 stated, This is the second time I saw him. I was told that upon admission he had had a Stage 2 pressure ulcer on his sacrum that deteriorated (R97's initial nursing assessment showed that this Stage 2 was 3.5 cm X 6.0 cm X 0.1 cm). He was sent at the hospital and his wounds were debrided. R97's pressure sore is now Stage 4 with visible muscles. Well, in order to heal the wound they need to off load the area and reposition the patient at least every two hours. No, the wound is on his buttocks so they are not supposed to position him on his back. They should only be re positioning him from side to side. On (MONTH) 19, (YEAR) at 9:40 AM, the Therapist were observed assisting R97 to sit at the edge of the bed. While sitting at the edge of the bed with V29 (Physical Therapy Assistant) supporting R97, V31 (Nurse) was observed applying a dressing on R97's left shoulder wound. V31 claimed, It's an old wound. I initially saw it Monday (July 16, (YEAR)). There was no documentation found in R97's electronic records or presented as requested, that the doctor or family were notified, no treatment order was obtained and carried out. During treatment observation on (MONTH) 19, (YEAR) at 10:22 AM with V3 (Wound Nurse) and V28 (Certified Nursing Assistant), R97's dressing was noted saturated with brownish drainage. V3 measured and described R97 wound as follows: Sacral area, Stage 4, muscles are visible. The wound was measured at 15 cm in length X 14 cm width x 4.5 cm depth with undermining from 7 o'clock through 4 o'clock deepest at 12 o'clock with 4 cm. With yellow slough at the center of the wound and the left shoulder blade wound measured at 3.0 cm x 7.3 cm. The most current skin care plan dated (MONTH) 13, (YEAR) shows R97 has excoriation to buttocks. The interventions listed to avoid lying on back, position body with pillows/support devices and turn and reposition every two hours were not implemented on July17, (YEAR). There was no comprehensive assessment conducted by the facility to analyze the root cause of R97's pressure injury deterioration and to revise R97's plan of care based on his identified risk factors and co morbidities. On (MONTH) 19, (YEAR) at 10:08 AM, R97 said, I got 2 sores on my behind (buttocks) because instead of lifting me up, they drag me across the bed. Now, I have a new sore on my left shoulder. It would be easier for them to just drag me across the bed. It hurts when they do that (drag). 3. R8's Face Sheet documents the following pertinent Diagnosis: [REDACTED]. On 7/17/18 at 11:35 AM R8 was sitting in a wheelchair with bilateral heel boots on in the dining room. On 7/17/2018 at 1:52PM R8 was sitting in a wheelchair in the room with a mechanical lift pad underneath R8. On 07/18/18 at 9:08 AM while laying in bed R8 said staff keep me up in my wheelchair and do not help me reposition and when they lay me down they reposition me only once. They should do it more often. R8 said her pressure sore is not doing good. On 7/17/2018 at 3:30PM, R8 was asleep in bed. V8(Certified Nursing Assistant) said he is assigned to care for R8 today and does not know how long R8 has been laying down, but R8 was in bed upon the start of my shift which was 2 PM. On 07/19/18 09:01 AM V7(Restorative Nurse Supervisor) wheeled R8 to the room and V7 exited the room. R8 said I push my self to the bathroom and wait for response from my call cord, I have accidents sometimes because I wait too long and that is not good for my butt sore or me. On 7/19/18 at 9:01 V11(Certified Nursing Assistant) was in the room. V11 said R8 was up in the wheelchair at the start of my shift which was 6 am this morning, the night staff got R8 up and put her in the wheelchair. V11 said R8 has not been toileted today. At this time R8 received requested pain medicine and went to participate in an activity without being toileted. On 7/19/18 at 10:38 AM V11(CNA) and V12(CNA) took R8 to the room and placed R8 in bed. After the transfer V12 exited the room and V11 changed R8's incontinent brief which was heavily soiled. R8 had a pressure dressing to the sacrum area. V11 said R8's incontinent brief should be changed every 2 hours, because R8 urinates a lot in the morning. It was again confirmed by V11 that R8 has not been toileted today; hence R8 has been up in the wheelchair for more than 4 and a 1/2 hours. V3(Wound Care Nurse) entered the room to change the dressing for R8's stage 4 re-opened sacral wound. V3 said said it just re-opened last week. V3 said possible causes for the wound to re-open are mobility issues, nutrition and incontinence. V3 said the wound care doctor examined R8 on 7/18/2018. Wound Care Evaluation Form dated 7/18/2018 written by the physician documents the following pertinent data, has incontinence, reposition every 2 hours and as needed and provide bowel and bladder management. The wound description is stage 4 sacral re-opened pressure sore measuring 0.8 cm in length by 0.5cm in width by 0.3 cm in depth with excoriation to the peri-wound. Wound Care Assessment Data was reviewed. The assessment dated [DATE] document a re-admission of R8 with the stage 4 sacral wound and the assessment dated [DATE] documents the stage 4 sacral wound healed. Wound Care Evaluation Form dated 7/9/2018 documents the re-opening of the sacral wound. Care Plan for Alteration in Skin Integrity initiated on 6/13/2018 states to keep skin clean and dry and turn and re-position every 2 hours as needed. Care Plan for bladder/bowel incontinence initiated on 9/7/2011 says staff to check and change in every 2 hours daily. On 7/20/2018 at 10:50AM, V27(Wound Care Physician) said sitting in incontinence for extended periods of time is not recommended for residents who are high risk for pressure ulcer development. It could potentially cause a re-opening and the facility should be re-positioning and off-loading R38. 4. The Admission Record dated (MONTH) 17, (YEAR) documents R114 admitted on (MONTH) 21, (YEAR) [DIAGNOSES REDACTED]. On (MONTH) 17, (YEAR) at 12:04 PM R114 sat in a wheelchair with an undated wrapped gauze dressing to the right lower extremity and foot. R114 stated she was admitted to the facility for treatment of [REDACTED]. The Wound Care Evaluation Note dated (MONTH) 25, (YEAR) documents R114 with Pressure Ulcers to the coccyx, right and left gluteal folds. The Wound Assessment Form dated (MONTH) 3, (YEAR) documents R114 with venous wounds to the right anterior shin, right plantar heel, right lateral foot, right anterior lower leg and right fifth toe. R114's (MONTH) (YEAR) Treatment Administration Record (TAR) does not document completed treatments for Santyl ointment to right lower extremity ulcers and for [MEDICATION NAME] to right and left gluteal fold and sacral pressure ulcer on (MONTH) 27, (YEAR). R114's (MONTH) (YEAR) TAR does not document completed treatments for [MEDICATION NAME] to the right anterior leg ulcer on July, 10, 12, or 14, (YEAR). R114's (MONTH) (YEAR) TAR does not document completed treatments for [MEDICATION NAME] to the right heel ulcer on July, 10, 12, 14, or 15, (YEAR). R114's (MONTH) (YEAR) TAR does not document completed treatments for Santyl and [MEDICATION NAME] to the right and left gluteal fold ulcers on July, 6, 12, and 14-16, (YEAR). R114's (MONTH) (YEAR) TAR does not document completed treatments for Hydro Blue Foam to the right lateral foot ulcer on July, 12 and 14, (YEAR). R114's (MONTH) (YEAR) TAR does not document completed treatments for Santyl to the right ishium ulcer on July, 10, 12, 14-16, (YEAR). On (MONTH) 19, (YEAR) at 2:27 PM, V3 (Wound Nurse) stated all treatments are documented and signed on the Treatment Administration Record at the time the treatment is completed. The Care Plan dated (MONTH) 23, (YEAR) documents R114 with alterations in skin integrity due to multiple wounds with interventions to include provide treatments as ordered. The Medication Administration: General Guidelines dated (MONTH) (YEAR) documents to record on each residents TAR immediately following administration of medications.

Based on observation, record review and interview the facility failed to: - develop and implement individualized and specific interventions including use of bed and chair alarm; - monitor supervise a resident (R1) to prevent from falling. As a result: R1 who has history of multiple falls, had fallen on 10/09/11 and fractured her left hip. This is for one of four residents (R1) in the sample. Findings include: On 11/3/11 at 11:45 am E4, Certified Nurse Aide (CNA) transferred R1 from her bed to her wheel chair. After E4 was done transferring R1 to her chair, there was no bed alarm on her mattress. R1's wheel chair alarm sounded intermittently without even being in use. E4 stated R1 has no bed alarm. R1's chair alarm needs batteries. R1 on 11/3/11 at 2:30 pm who was able to recall the incident of her falling on 10/9/11. R1 was alert and oriented to time, place and person and able to carry on conversation. R1 stated she has Vertigo. On the night of 10/9/11 R1 indicated she could not wait to go to bath room, she needed to go quickly, other wise bath room accidents happen. R1 indicated she goes to bath room at least two to three times at night. R1 stated on the night of 10/9/11 the accident happened shortly after the midnight. R1 also stated it took a while for the girls to come when she called for help, so she got up herself from her bed, and turned her head quickly after she got up from bed and she felt dizzy from Vertigo and fell . R1 answered there was no bed alarm on the bed and she does not like it any, because it sounds, no one comes, and she looses her sleep. The facility documented six incidents (3/16, 4/14, 4/24, 4/30, 7/26, and 10/9/11). After R1's falling the facility recommendations included: On 3/16/11 and 4/14/11 educate R1 on the call light and asking for assistance. It is unclear as to how the facility will ensure that R1 will follow to call for help. On 4/24/11 it was recommended to place bed alarm as a reminder for resident to ask for assistance during transfer. On 4/30/11 move R1 closer to nurses station; in the details it was there was no alarm. The facility did not evaluate why R1 has no alarm on her bed. On 7/26/11 incident details noted the alarm was not sounding and one of the recommendations ensure bed alarm in place and functioning. Again the facility did not evaluate why the alarm was not sounding. On 10/9/11 incident details noted there was no alarm, the recommendations included to ensure chair alarm in place to help remind resident of need for assistance. Once again the facility failed to ensure the staff did not implement the intervention to have alarm on R1's bed. R1's 10/9/11 incident report noted the staff found her on the floor by her bed, alert and verbally responsive. The facility final incident investigation indicated she sustained left hip fracture after her falling on 10/9/11. R1's 7/6/11 Minimum Data Set (MDS) noted she is alert and oriented, needs one staff assistance from sitting to standing, transferring surface to surface, ambulate, turning, moving on off toilet, and ambulation. The facility conducted a fall risk assessment indicating numerical value for each contributing factor. These assessment scores (1/5, 3/16, 4/14, 4/24, 4/30, 6/29, 7/26, 10/9 and 10/16/11) indicated that R1 was at high risk for falling. The facility did not evaluate these risk factors to indicate if the risk factors could be modified. R1's unsteady gait care plan, dated 1/7/11 which was revised on 3/16, 4/5, 4/14 and 7/11/11, interventions added to 'place bed pad alarm.' On 11/3/11 at 12:30 pm Z1 (R1's physician) stated R1 is clumsy, independent (mentally), she wants to do what ever she wants to do, but she is unsteady and needs assistance. If there is any thing wrong R1 jumps and wants it right away. R1 needs close supervision, that is the only way her falling can be prevented. On 11/3/11 E7, day shift Nurse stated in the presence of E3 (the Clinical Support Nurse) that R1 needed limited assistance of one staff prior to her falling 10/9/11 to take her to bath room, but some times R1 takes herself to bath room without calling for help. E7 indicated the staff has to watch R1, she has to have bed alarm and chair alarm. The staff should hear the alarm and respond immediately. It is clear from the observations on 11/3/11 and the facility incident investigation reports, and staff interview the facility did not follow the recommendations to use bed alarm and have a functional chair alarm. R1's fall on 10/9/11 was preventable.

Based on observation, record review and staff interview the facility failed to follow the facility's policy and procedure for proper use of a safety belt during a transfer, failed to monitor a resident during transfer, failed to prevent a resident from injury while turning and positioning. This was for three of three sampled residents (R1, R2, R3). R1 sustained a right tibial fracture, R2 sustained a laceration to the nose and R3 sustained a right periorbital fracture with bruising. Examples include: R3 was observed on 7/20/11 at 9:30 a.m. R3 resides in a secured unit for residents with Dementia. R3 was alert but disoriented to time and place. R3 was interviewed and stated cant remember anything. She "doesn't know why she can't remember". R3 was asked if she remembered hurting her face. R3 stated again did not remember anything. A large black, purplish to red bruise was observed surrounding the right eye that extended downward into the right cheek. R3 was asked how her face became bruised. R3 stated , "is my face bruised, I did not know that". R3 was asked to place her hand on that area and tell whether it hurt or if pained her. R3 denied pain. There were siderails observed on the right side and left side of R3's bed. The siderails were at the head of the bed and were partial length side rails, stated E1 (administrator). Interviews with E1 administrator, E2 director of nurses on 7/20/11 showed R3 did have a bruise on the right side of face not the left side. E2 said the bruise was found on the morning on 7/17/11 by E11, CNA (certified nursing assistant ). E1 and E2 who were conducting the interview stated they were not sure of the cause but were in the process of investigating. E2 stated the nursing staff began their investigation on Sunday 7/17/11 when a bruise discoloration was found on the right side of R3's face. E2 stated the investigation into how R3 facial bruising began on 7/17/11 after it was reported to her. There were interviews conducted with E4 by the facility staff on 7/17/11 and 7/18/11. E2 documented in the Occurrence Report an interview with E4 conducted on the afternoon of 7/17/11. E4 stated that, R3, "noted to have a bruise under her right eye. I do not know the origin of the bruise nor did I witness any incident that could have been the cause." Bruising was reported to me at the start of my 2-10 shift on 7/17/11. E4 was interviewed on 7/20/11 at 1:30 p.m. E4 admitted to being aware that R3's face hit the bar of the side rail when he turned her on the morning of 7/17/11 between 3 and 4 a.m.. E4 stated R3 yelled out, "Oh, SH--. when he turned her" E4 said he looked at her face and did not see any visible bruises, so he did not report it. E4 stated when he returned to work on the afternoon of 7/17/11 he saw the bruise; however it was already reported so he saw no need to report it. An interview with Z5 (police) on 7/20/11 at 10:40 a.m. verified that E4 was aware of how R3's injury occurred. Z5 stated E4 admitted to him he turned R3 and her face hit the side rail. Z4 (physician) stated during interview on 7/20/11 he was there to conduct a follow up visit from an injury to R3's right side of face . Z4 stated hearing R3 had a possible fracture on the right side of the face. Z4 telephoned the discharging hospital to obtain the medical records (x-ray report) for 7/18/11. The emergency report completed by Z9 (emergency room physician) was reviewed with Z4. The x-ray report showed possible orbit fracture. Z4 stated he spoke with Z9 for clarification of the fracture via telephone on 7/20/11. Z4 stated Z9 felt it was a hairline fracture. Z4 stated, R3 sustained a traumatic injury to the right side of her face. Z4 stated he could not determine the direct cause of the injury but it was caused by trauma. The facility completed their investigation on 7/21/11. E1 presented a copy of the report to the surveyor on 7/22/11. The report read and E1 verified that E4 was responsible for turning R3 into a siderail on 7/17/11. E1 stated this caused the facial bruising to R3's face. E1 stated E4 was not truthful during the interview with her. The facility has a policy and procedure for the staff to report accidents and incidents. E1 and E2 stated E4 did not follow the facility's policy. R2 was observed on 7/20/11 seated in a wheelchair in the television room. R2 was alert and oriented and dozing in and out of sleep during the interview. R2 stated , "No" she could not remember the accident when she fell from her chair one month ago. Interview with E13 (nurse) after speaking with R2 revealed the resident can walk with assistance of one, usually sleeps off and on, has Dementia and confused at times. The facility assessed R2 on 3/1/11 as requiring extensive assistance in transfer and unable to walk unassisted The incident report for R2, date of 5/22/11 was reviewed with E1 (administrator) and E2 (director of nurses) on 7/21/11. The report showed E9 CNA turned around and while facing the opposite direction R2 fell from the wheelchair. E9 was getting the foot rests from behind R2's wheelchair and heard a loud thump. E9 stated he turned around and observed the resident on the floor face down and bleeding from the face R2 sustained a 2 centimeter laceration to the bridge of the nose. The transfer procedure (Transfer From Bed To Wheelchair Resident Unable To Assist) directs the staff to have footrests present on the wheelchair before transfer. The Incident report for R1 (6/3/11) was reviewed with E1 and E2 on 7/21/11. E1 verified the report sent to Illinois Department of Public Health was completed on 6/8/11. E1 sated that R1 complained of pain on 6/3/11 while being examined by Z10 (physician). Z10 ordered, R1 was sent out to the hospital for evaluation. A x-ray report for 6/3/11 of the right leg (tibia and fibula) showed nondisplaced spiral fracture mid tibia. R1 has multiple [DIAGNOSES REDACTED]. R1 has bilateral upper and lower extremity impairments, unsteady gait, requires extensive assistance in the areas of mobility and transfers, history of left hip fracture, total assistance in activity;s daily living and a history of fall, alert and oriented times one to person only. This was documented in the 4/19/11 Minimum Data Set. Review of the facility's assessment for R1 shows the resident requires extensive assist in the areas of mobility and transfers. E1 stated an investigation of the injury began on 6/3/11 and was completed by the facility on 6/8/11. E1 concluded E10 transferred R1 on 6/3/11 into a wheelchair. E1 concluded R1's injury could probably occurred during this transfer. E1 also stated E10 demonstrated to E1 how R1 was transferred. E1 and E2 stated E10 did not follow the correct procedure for transferring a resident. E10 was interviewed in the presence of E1 and E2 on 7/21/11. E10 stated he did transfer R1 on 6/3/11 and she did complain of pain after the transfer. E10 was asked to explain how the transfer procedure was performed to R1 on 6/3/11. E4 stated he picked her up under her arms and grabbed her around her waist and moved her to the wheelchair and then moved her legs after she was in the chair. E10 did not include the use of a gait belt when transferring R1. E10 when queried if a transfer belt was used. E10 stated , No", I did not have it that day. Review of the facility;s policy and procedure for transfer technique was conducted with E1 and E2 on 7/21/11. The transfer procedure (Transfer From Bed To Wheelchair Resident Unable To Assist) directs the staff before transfer to place a gait belt around residents waist before transfer, to straightening your knees and supporting the resident knees inside your knees during the transfer.

Based on observation, interview and record review the facility failed to: comprehensively assess the causes of R 11's pressure ulcer development, develop and implement individualized interventions to attempt to stabilize, reduce or remove R 11 ' s underlying risk factors. The facility also failed to develop a specific repositioning plan for R 11 when up in chair and bed. The facility also failed to a implement specific and individualized plan based on the assessed needs of R 11 and revise as needed to promote healing. These failures resulted in R 11 developing a facility acquired unstageable pressure ulcer on the right ischium and worsening /increasing size of R11 existing wound. This is for 1 (R11) of 3 residents with facility acquired pressure ulcer. Findings include: On 06-22-11 at 10:00 AM, R11's was noted sleeping in bed. At 10:15 AM skin assessment protocol was requested of the treatment nurse (E6). At 10:25 AM, the C.N.A (E7) and E 6 observed R11 ' s adult disposable brief soiled with large amount of semi soft stool. R 11's wound dressing on the right ischium was covered with stool. Incontinence care was provided. R 11's initial nursing assessment dated [DATE] showed R 11's skin is intact. A written note dated 04-18-11 reads: skin assessment rechecked by the wound nurse. No new skin altered integrity observed. On 05-04-11 (17 days after admission) R 11 acquired pressure ulcer from the facility. The weekly assessment of skin alteration form for R 11 dated 05-04-11 showed the following: Site: right buttocks (ischium) Wound Type: Pressure Ulcer (Stage): Unable to stage due to ESCHAR Measurement (cm): Length 1.5 Width 1.0 Margin (wound edges): irregular Peri- wound: intact This weekly assessment of skin alteration form does not match the initial nurses note wound description. The nurse's note dated 05-04-11 -7:00 PM reads: during HS care noted right buttocks OPEN AREA (Stage II). R 11 ' s weekly assessment of skin alteration form dated (1) 05-13-11 showed an increased in sized on her wound, 1.7 cm X1.2 cm. (2) 05-16-11 a written note that reads :Unstageable down to Stage II wound bed observed with granulation tissue. (3) On 06-06-11 note reads: back on unstageable, measurement 1.2 cm X 1.7 cm (4) 06-20-11 measurement showed: 2.7 cm X 3.0 cm. On 06-22-11 at 10:50 AM, during treatment observation, E 6 said R 11's pressure ulcer increased in sized (within two days) it was measured at 3.1 cm X 2.8 cm. R 11 care plan for skin integrity dated 04-17-11 showed R 11 at risk for skin integrity related to: Braden risk factors: moisture, incontinent of bowel and bladder, mobility chair fast, mobility and friction and shear. Other risk factors include assists with activities of daily living & incontinence. A pressure sore on the right buttocks (ischium) on 05-04-11 was added on the plan of care as a problem. There were no revision on R 11's skin care plan and interventions were not specific and individualized based on the assessed needs of R 11. There was no comprehensive assessment developed to analyze whether this facility acquired pressure ulcer on R 11 ' s right ischium was avoidable or unavoidable. At 11:30 AM on 06-24-11, E 6 stated " I don ' t know what happen but the problem is position. " R 11's Minimum (MDS) data set [DATE] showed R 11's needs extensive assistance with Activities of Daily Living and with bed mobility.